An Overview of Antithrombotics in Ischemic Stroke

The use of antithrombotic medications is an important component of ischemic stroke treatment and prevention. This article reviews the evidence for best practices for antithrombotic use in stroke with focused discussion on the specific agents used to treat and prevent stroke

A method for complete angiographic obliteration of a brain arteriovenous malformation in a single session through a single pedicle

Historically, the endovascular treatment of arteriovenous malformations (AVM) has largely been relegated to an adjunctive role to open surgical and radiosurgical methods. In this article, we describe a novel endovascular approach to the treatment of brain AVM using Onyx (ev3 Endovascular, Plymouth, MN, USA), which may allow for a complete angiographic obliteration in a single treatment session. Twelve patients underwent Onyx embolization of an AVM using a novel “reverse plug and push” technique in which a plug is formed around the treatment catheter prior to injecting Onyx into the AVM. The plug mitigates the risk of backflow and catheter entrapment, thereby allowing the user to inject higher volumes of Onyx at higher injection rates. Patient demographics, AVM characteristics, and treatment details were reviewed. Using the “reverse plug then push” technique, an average of 8.8mL of Onyx was injected into the AVM in a single session. In every case, the microcatheter was removed easily with minimal traction pressure. Complete angiographic obliteration was achieved in 83% of patients after a single treatment. Morbidity and mortality were 8% each. The “reverse plug then push” technique allows for a more rapid injection of Onyx due to the formation of a well-controlled plug prior to treatment, mitigating the risk of catheter entrapment by Onyx reflux. With further refinement, this technique may present a viable curative option for treatment of select brain AVM

Persistent trigeminal artery: in situ thrombosis and associated perforating vessel infarction

We report a patient with progressive brainstem infarction despite medical therapy. The patient was transferred to our institution for potential angioplasty of basilar stenosis. Imaging review demonstrated persistent trigeminal artery in situ thrombosis and associated perforating vessel infarction. Persistent trigeminal arteries are commonly associated with an atretic basilar artery and interventional treatment can result in significant morbidity and mortality

DynaCT imaging for intraprocedural evaluation of flow-diverting stent apposition during endovascular treatment of intracranial aneurysms

The treatment of large, complex intracranial aneurysms is being increasingly performed using flow-diverting stents (FDS) such as the Pipeline Embolization Device (PED; ev3, Irvine, CA, USA). Malapposition of a FDS to the parent artery wall decreases the likelihood of aneurysm obliteration and increases the risk of both immediate and delayed complications. DynaCT scanning (Siemens Medical Solutions, Erlangen, Germany) is a novel imaging modality which uses a flat plane detector to generate CT images using the same C-arm employed for digital subtraction angiography. We present a 40-year-old woman with an unruptured, 11mm cavernous internal carotid artery aneurysm who was treated with endovascular obliteration using a PED. Intraprocedural DynaCT scan performed after PED deployment demonstrated incomplete stent apposition to the parent vessel which could not be detected on digital subtraction angiography alone. Balloon angioplasty was performed to improve apposition of the stent to the vessel wall. There were no procedural or clinical complications. The aneurysm shrank in size at follow-up angiography 6months after the procedure and will be monitored for progressive occlusion. While gross stent malapposition is readily evident after stent deployment, minor instances of malapposition may be undetectable by standard angiography. Therefore the use of DynaCT imaging may improve intraprocedural stent visualization and potentially avert long-term endovascular aneurysm treatment complications associated with inadequate stent apposition

Single-center experience with a dual microcatheter technique for the endovascular treatment of wide-necked aneurysms

The endovascular treatment of wide-necked aneurysms can be technically challenging due to distal coil migration or impingement of the parent vessel. In this paper, the authors illustrate an alternative method for the treatment of wide-necked intracranial aneurysms using a dual microcatheter technique. The authors' first 100 consecutive patients who underwent coil embolization of a wide-necked aneurysm using a dual microcatheter technique are reported. With this technique, 2 microcatheters are used to introduce coils into the aneurysm. The coils are deployed either sequentially or concurrently to form a stable construct and prevent coil herniation or migration. Angiographic and clinical outcomes are reported. The technical success rate of the dual microcatheter technique is 91% with a morbidity and mortality of 1% and 2%, respectively. Clinical outcomes are excellent with 93% of patients demonstrating a modified Rankin Scale score of 0-2 at long-term follow-up regardless of their score at presentation. Retreatment rates are 18%. The dual microcatheter technique may be a safe and efficacious first line of treatment for widenecked aneurysms

Stenting of symptomatic intracranial stenosis using balloon mounted coronary stents: a single center experience

Objective Intracranial atherosclerotic disease is the cause of up to 10% of ischemic strokes and transient ischemic attacks. Intracranial stenting with off-label balloon mounted coronary stents (BMCS) may be a viable alternative for patients with symptomatic intracranial stenosis who fail best medical therapy. Design Between December 2005 and June 2012, 42 symptomatic intracranial stenoses were treated with a BMCS after failing medical management. Procedural records, clinical outcomes, and imaging follow-up were reviewed. Outcome measurements included technical success rate, morbidity and mortality, long term stent patency, and clinical outcomes, as measured by the modified Rankin Scale. Results The technical success rate was 98% (41 of 42 lesions). Morbidity within the first 30 days was 7.1% (three of 42 lesions). Overall morbidity, including both periprocedural and long term evaluation, was 9.5% (four of 42 lesions). There were no deaths. Follow-up imaging was available for 30 stents (71%) with an average follow-up time of 35.1 months. Restenosis (>50%) and retreatment were observed in 20% and 10% of cases, respectively. Clinical evaluation by a neurologist ≥30 days postprocedure was available in 40 of 42 cases (95%) with an average of 32.1 months. At presentation, 55% of patients had a modified Rankin Scale (mRS) score of ≤2. At follow-up, 74% of patients were found to have an mRS score of ≤2. Conclusions This study suggests that BMCS may benefit patients with symptomatic intracranial stenosis who experience stroke or transient ischemic attack in spite of best medical therapy

Retrograde venous perfusion with hypothermic saline and adenosine for protection of the ischemic spinal cord

Purpose: Spinal cord injury and the resultant postoperative paraplegia are devastating complications of thoracic aortic surgery, for which no widely accepted protective interventions exist. We hypothesized that retrograde venous perfusion-cooling of the spinal cord with a hypothermic saline and adenosine solution would protect it from ischemic injury caused by thoracic aortic occlusion