Multiple overlapping stents as monotherapy in the treatment of 'blister' pseudoaneurysms arising from the supraclinoid internal carotid artery: a single institution series and review of the literature.

Background: The 'blister-type' aneurysm is one of the most devastating cerebrovascular lesions. Flow diversion with stent reconstruction is an emerging treatment and has shown promising initial results.

Objective: To evaluate the experience of one institution using stent reconstruction for pseudoaneurysms of the supraclinoid internal carotid artery and to compare with a review of the literature.

Patterns of aneurysm recurrence after microsurgical clip obliteration.

Background: Microsurgical clip obliteration remains a time-honored and viable option for the treatment of select aneurysms with very low rates of recurrence.

Objective: We studied previously clipped aneurysms that were found to have recurrences to better understand the patterns and configurations of these rare entities.

Methods: A retrospective review was performed of 2 prospectively maintained databases of aneurysm treatments from 2 institutions spanning 14 years to identify patients with recurrence of previously clipped intracranial aneurysms.

Trends in device-assisted aneurysm treatment at a single high-volume tertiary care center.

Introduction: Device developments and evolution in technique over the past decade make the treatment of aneurysms which were previously considered poor candidates for coiling more feasible. The authors describe their experience treating aneurysms at a single high-volume tertiary care center, focusing particularly on the use of adjunctive devices.

Methods: A retrospective review was undertaken of all the aneurysms treated at the Cleveland Clinic between 2003 and 2010.

Headache following intracranial neuroendovascular procedures.

Aims: Predicting who will develop post-procedure headache (PPH) following intracranial endovascular procedures (IEPs) would be clinically useful and potentially could assist in reducing the excessive diagnostic testing so often obtained in these patients. Although limited safety data exist, the use of triptans or dihydroergotamine (DHE) often raise concern when used with pre/post-coiled aneurysms. We sought to determine risk factors for PPH following IEP, to evaluate the utility of diagnostic testing in patients with post-coil acute headache (HA), and to record whether triptans and DHE have been used safely in this clinical setting.

Thromboembolic events associated with endovascular treatment of cerebral aneurysms.

Objective: To evaluate the rate of peri-procedural thromboembolic events after the endovascular treatment of cerebral aneurysms. The rate of diffusion-positive lesions was assessed in relation to selected procedural and technical factors.

Methods: 184 patients treated with coil embolization (198 total procedures) between July 2004 and February 2007 were included.

Stenting of a symptomatic long-segment extracranial vertebral artery occlusion.

We present a 56-year-old man who presented with bilateral vertebral artery occlusions and recurrent transient ischemic attacks and strokes despite maximal medical therapy. A long-segment extracranial right vertebral occlusion was noted and successfully reconstructed with four drug-eluting stents. The patient has been symptom free for 3 months and does not exhibit restenosis on follow-up angiography.

Initial experience with angioplasty of symptomatic M2 MCA atheromatous lesions.

Background And Purpose: Symptomatic intracranial atherosclerosis has been associated with a high rate of recurrent stroke. The safety of treatment of more distal atheromatous lesions with angioplasty has not been systematically reported.

Methods: We retrospectively reviewed our institutional database for all patients treated with intracranial angioplasty and stenting from January 2008 to July 2009.

Microsurgical and endovascular management of pericallosal aneurysms.

Background: Pericallosal, or A2 bifurcation, aneurysms are an infrequently encountered cause of subarachnoid hemorrhage (SAH). While the International Subarachnoid Aneurysm Trial showed improved outcomes for patients with any ruptured anterior circulation aneurysm treated with embolization, there was also a higher recurrence rate for embolized aneurysms. Notably, there were relatively few pericallosal aneurysms.

Balloon-augmented carotid artery sacrifice with Onyx: a proof of concept study in a swine model.

Introduction: Carotid sacrifice remains a valuable tool in the treatment of select vascular lesions. Neurointerventionalists have relied on coil embolization as their primary means of carotid sacrifice, a procedure that can be lengthy and expensive with long fluoroscopy times. We investigated a novel technique for carotid sacrifice in a swine model using temporary balloon occlusion to achieve proximal flow arrest in the carotid artery while embolizing the vessel with a liquid embolic agent.

Experience with coil embolization of previously clipped aneurysms presenting with rupture.

Introduction: Endovascular coil embolization has an established role alongside microsurgical clipping in the treatment of aneurysms. We studied previously clipped aneurysms that presented as subarachnoid hemorrhage and were treated by coil embolization.

Methods: A retrospective review was performed of two prospectively maintained databases from two institutions (Cleveland Clinic, Emory University) that spanned 12 years.

ε-Aminocaproic acid in angiographically negative subarachnoid hemorrhage patients is safe: a retrospective review of 83 consecutive patients.

Background: ε-Aminocaproic acid (EACA) has been used to reduce the rate of cerebral aneurysm rerupture before definitive treatment. In centers administering EACA to patients with a subarachnoid hemorrhage (SAH), patients eventually diagnosed with angiographically negative subarachnoid hemorrhage (ANSAH) may also initially receive EACA, perhaps placing them at increased risk for ischemic complications.

Objective: To evaluate the effect of short-term EACA on outcomes and secondary measures in patients with ANSAH.

Merci retrievers as access adjuncts for reperfusion catheters: the grappling hook technique.

Background: Expeditious, stable access in acute ischemic stroke is foundational for mechanical revascularization. Proximal vascular tortuosity and unfavorable anatomy may impede the access necessary for revascularization, particularly when large-caliber catheters are used. We describe an approach using the Merci retriever to gain stable catheter access for aspiration.

Mid-term results of endovascular coiling of wide-necked aneurysms using double stents in a Y configuration.

Background: Double stenting in a Y configuration may be used to treat a subset of wide-necked aneurysms not amenable to reconstruction with a single stent.

Objective: We studied the feasibility, safety, and mid-term angiographic outcome of patients treated using this technique.

Methods: A retrospective review was undertaken of all coil embolizations of wide-necked aneurysms using double stents in a Y configuration.

The versatile distal access catheter: the Cleveland Clinic experience.

Background: Vascular access is fundamental to any endovascular intervention. Concentric Medical has developed the Outreach Distal Access Catheter (DAC), which affords stable access at the target vessel modulating the forces at play within the thrombectomy device complex. The DAC is a device with novel access characteristics useful in a host of other types of clinical scenarios.

An analysis of inflation times during balloon-assisted aneurysm coil embolization and ischemic complications.

Background And Purpose: The introduction of balloon remodeling has revolutionized the approach to coiling of wide-neck aneurysms. We studied the effects of balloon inflation during coil embolization on ischemic complications.

Methods: A retrospective review was undertaken of the most recent 147 patients undergoing balloon remodeling for unruptured intracranial aneurysm coil embolization at a single institution (81 balloon, 66 unassisted).

Endovascular therapy of very small aneurysms of the anterior communicating artery: five-fold increased incidence of rupture.

Background: Intraprocedural rupture is a dangerous complication of endovascular treatment. Small ruptured anterior communicating artery (ACoA) aneurysms and microaneurysms present a challenge for both surgical and endovascular therapies to achieve obliteration. An understanding of the complication rates of treating ruptured ACoA microaneurysms may help guide therapeutic options.

Antithrombotic states and outcomes in patients with angiographically negative subarachnoid hemorrhage.

Background: Antithrombotic states are encountered frequently, either because of medical therapy or by preexistent pathological states, and may affect the severity of hemorrhagic strokes such as angiographically negative subarachnoid hemorrhages.

Objective: To determine the effects of antithrombotic states on the outcomes of patients with angiographically negative subarachnoid hemorrhage by examining data pooled from 2 institutions.

Methods: This is a retrospective review of patients who experienced angiographically negative subarachnoid hemorrhage at 2 institutions over the past 5 years.

Targeted extracranial-intracranial bypass with intra-aneurysmal administration of indocyanine green: case report.

Background And Importance: Early origin of the middle cerebral artery M2 segment is a normal variant. When such a vessel is occluded proximally, the parenchyma distal to the vessel may become ischemic. Targeted extracranial to intracranial bypass to such a specific branch may preserve perfusion to the end organ.

Combined surgical and endovascular approach to a complex dural arteriovenous fistula involving the superior sagittal sinus and torcula.

A complex dural arteriovenous fistula (dAVF) may require complex treatment strategies to achieve successful obliteration. We describe a combined open surgical and endovascular approach to a dAVF involving the superior sagittal sinus (SS) and torcula. A 68-year-old male with Factor V Leiden mutation presented with altered mental status from venous hypertension secondary to a complex, high-flow Borden III dAVF with internal carotid and bilateral external carotid artery feeders draining into the SS and torcula.

Mechanical thrombectomy for acute stroke with the alligator retrieval device.

Background And Purpose: Recanalization of occluded vessels in acute ischemic stroke is associated with improved outcome. Devices that can quickly and safely remove thrombus and promote recanalization are useful in the management of these patients. The Alligator retrieval device, developed for endovascular foreign body retrieval, may also be useful for thrombus removal.

Postoperative complications associated with dural substitutes in suboccipital craniotomies.

Objective: Dural replacements are used in cranial surgery when primary closure of native dura is not possible. The goal is to recreate a watertight barrier to prevent cerebrospinal fluid leakage with few associated complications. We reviewed a single-institution experience with a variety of dural substitutes in posterior fossa neurosurgery, for which higher complication rates are well described.

Revascularization of symptomatic subacute cerebrovascular occlusions with a self-expanding intracranial stent system.

Objective: In some patients, collateral circulation may preserve the viability of brain parenchyma distal to an intracranial arterial occlusion for hours or days after the presenting event. These patients may be good candidates for revascularization, even when they present outside of the accepted 6-hour time window for stroke intervention.

Methods: Three patients were revascularized with the Wingspan stent system (Boston Scientific/Target, Fremont, CA) after presenting with subacute occlusions of intracranial arteries and progressive ischemic symptoms despite maximal medical therapy.

Prehemorrhage statin use and the risk of vasospasm after aneurysmal subarachnoid hemorrhage.

Background And Purpose: Aneurysmal SAH is often followed by delayed ischemic deficits attributable to cerebral vasospasm. Recent studies suggest a positive impact of statin therapy on the incidence of vasospasm. This study was designed to assess whether a history of prior use of statin therapy was associated with a lower risk of vasospasm in patients with SAH.

Benign angiopathy of the central nervous system presenting with intracerebral hemorrhage.

Background: Primary central nervous system vasculitis has traditionally been described as an aggressive condition, with significant morbidity and mortality. A subgroup of patients has been identified who have a similar clinical presentation, but with a benign course. This syndrome of BACNS is successfully treated with low-dose steroids and calcium-channel blockers.