Internal Maxillary Artery Preoperative Embolization Using n-Butyl Cyanoacrylate and Pushable Coils for Temporomandibular Joint Ankylosis Surgery

BACKGROUND: Temporomandibular joint (TMJ) ankylosis causes disability through impaired digestion, mastication, speech, and appearance. Surgical treatment increases range of motion with resultant functional improvement. However, substantial perioperative blood loss can occur (up to 3 L) if the internal maxillary artery (IMAX) is injured as it traverses the ankylotic mass. Achieving hemostasis is difficult because of limited proximal IMAX access and poor visualization. Our aim is to investigate the technical feasibility and preliminary safety of preoperative IMAX embolization in patients undergoing TMJ ankylosis surgery. METHODS: Case series using chart reviews of 2 patients who underwent preoperative embolization before TMJ ankylosis surgery. RESULTS: Both patients were women (28 and 51 years old) who had severely restricted mouth opening. Embolization was performed using general anesthesia with nasal intubation on the same day of TMJ surgery. Both patients underwent bilateral IMAX embolization using pushable coils (Vortex, Boston Scientific) of distal IMAX followed by n-butyl-cyanoacrylate (Trufill, Cordis) embolization from coil mass up to proximal IMAX. There were no complications from the embolization procedures. Both patients had normal neurologic examination results. TMJ surgery occurred with minimal operative blood loss (≤300 mL for each surgery). Maximum postoperative mouth opening was 35 mm and 34 mm, respectively. One patient had a postoperative TMJ wound infection that was managed with antibiotics. CONCLUSIONS: Preoperative IMAX embolization before TMJ ankylosis surgery is technically feasible with encouraging preliminary safety. There were no complications from the embolization procedures and surgeries occurred with low volumes of blood loss

Arteriovenous Malformations in the Pediatric Population: Review of the Existing Literature

Arteriovenous malformations (AVMs) in the pediatric population are relatively rare but reportedly carry a higher rate of rupture than in adults. This could be due to the fact that most pediatric AVMs are only detected after rupture. We aimed to review the current literature regarding the natural history and the clinical outcome after multimodality AVM treatment in the pediatric population, as optimal management for pediatric AVMs remains controversial. A multidisciplinary approach using multimodality therapy if needed has been proved to be beneficial in approaching these lesions in all age groups. Microsurgical resection remains the gold standard for the treatment of all accessible pediatric AVMs. Embolization and radiosurgery should be considered as an adjunctive therapy. Embolization provides a useful adjunct therapy to microsurgery by preventing significant blood loss and to radiosurgery by decreasing the volume of the AVM. Radiosurgery has been described to provide an alternative treatment approach in certain circumstances either as a primary or adjuvant therapy

Clopidogrel plus Aspirin for Symptomatic Intracranial Atherosclerotic Stenosis: A Pilot Study

BACKGROUND AND PURPOSE: There are limited data on the optimal duration of dual antiplatelet therapy for secondary stroke prevention in patients with symptomatic intracranial atherosclerotic disease. METHODS: Consecutive patients presenting with high-grade (70-99%) symptomatic intracranial stenosis from January 1, 2011, to December 31, 2013, and evaluated within 30 days of the index event were eligible for this analysis. All patients underwent treatment with aspirin plus clopidogrel for a target duration of 12 months along with aggressive medical management based on the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) protocol; all patients were given gastrointestinal prophylaxis for the duration of their aspirin and clopidogrel treatment. Clinical and safety outcomes of our cohort were compared with the medical arm of the SAMMPRIS trial cohort (n = 227). RESULTS: Our cohort included 25 patients that met the inclusion criteria. Achievement of blood pressure and LDL cholesterol targets were similar between our cohort and the SAMMPRIS cohort. At 1 year, the rates of stroke, myocardial infarction or vascular death were 0% in our cohort and 16% in the SAMMPRIS cohort (p = 0.03). At 1 year, major bleeding rates were similar between our cohort and the SAMMPRIS cohort (4 vs. 2.2%, p = 1.0). CONCLUSION: A prolonged course of dual antiplatelet therapy for symptomatic intracranial atherosclerotic disease may be associated with less vascular events with no increase in hemorrhagic complications

Longer procedural times are independently associated with symptomatic intracranial hemorrhage in patients with large vessel occlusion stroke undergoing thrombectomy

BACKGROUND: Time to reperfusion is an essential factor in determination of outcomes in acute ischemic stroke (AIS). OBJECTIVE: To establish the effect of the procedural time on the clinical outcomes of patients with AIS. METHODS: Data from all consecutive patients who underwent mechanical thrombectomy between September 2010 and July 2012 were analysed retrospectively. The variable of interest was procedural time (defined as time from groin puncture to final recanalization time). Outcome measures included the rates of symptomatic intracranial hemorrhage (sICH, defined as any parenchymal hematoma-eg, PH-1/PH-2), final infarct volume, 90-day mortality, and independent functional outcomes (modified Rankin Scale 0-2) at 90 days. RESULTS: The cohort included 242 patients with a mean age of 65.5±14.2 and median baseline National Institutes of Health Stroke Scale score 20. 51% of the patients were female. The mean procedure time was significantly shorter in patients with a good outcome (86.7 vs 73.1 min, respectively, p=0.0228). Patients with SICH had significantly higher mean procedure time than patients without SICH (79.67 vs 104.5 min, respectively; p=0.0319), which remained significant when controlling for the previous factors (OR=0.974, 95% CI 0.957 to 0.991). No correlation was found between the volume of infarction and the procedure time (r=0.10996, p=0.0984). No association was seen between procedure time and 90-day mortality (77.8 vs 88.2 min in survivals vs deaths, respectively; p=0.0958). CONCLUSIONS: Our data support an association between the risk of SICH and a longer procedure time, but no association between procedural times and the final infarction volume or long-term functional outcomes was found

Case Report: Management of Traumatic Carotid-Cavernous Fistulas in the Acute Setting of Penetrating Brain Injury

Traumatic carotid-cavernous fistulas (tCCFs) after penetrating brain injury (PBI) have been uncommonly described in the literature with little guidance on optimal treatment. In this case series, we present two patients with PBI secondary to gunshot wounds to the head who acutely developed tCCFs, and we review the lead-up to diagnosis in addition to the treatment of this condition. We highlight the importance of early cerebrovascular imaging as the clinical manifestations may be limited by poor neurological status and possibly concomitant injury. Definitive treatment should be attempted as soon as possible with embolization of the fistula, flow diversion via stenting of the fistula site, and, finally, vessel sacrifice as possible therapeutic options

Embolization in Juvenile Nasopharyngeal Angiofibroma Surgery: A Systematic Review and Meta-Analysis

Objective: To compare outcomes of juvenile nasopharyngeal angiofibroma (JNA) resection between embolized and non-embolized cohorts, and between transarterial embolization (TAE) and direct puncture embolization (DPE). Data sources: Per PRISMA guidelines, PubMed, Embase, Web of Science, Scopus, and Cochrane databases were searched for publications prior to or in 2021. Materials and methods: Original English manuscripts investigating the resection of JNA with and without preoperative embolization were included. Embolization type, recurrence rate, complication rates, blood loss, and transfusions were extracted. Risk of bias was assessed by the Risk of Bias in Non-randomized Studies-of Interventions method. Results: There were 61 studies with 917 patients included. Preoperative embolization was performed in 79.3% of patients. Of those embolized, 75.8% (N = 551) underwent TAE and 15.8% (N = 115) underwent DPE. JNA recurrence in embolized patients was lower than in non-embolized patients (9.3% vs. 14.4%; odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.35, 1.06). DPE resulted in lower rates of disease recurrence (0% vs. 9.5%; OR: 0.066, 95% CI: 0.016, 0.272) and complications (1.8% vs. 21.9%; OR: 0.07, 95% CI: 0.02, 0.3) than TAE. A random effects Bayesian model was performed to analyze the difference in mean blood loss in 6 studies that included both embolized and non-embolized patients. This analysis showed a mean reduction in blood loss of 798 mL in the embolized group. Conclusions: We found embolization decreases blood loss in JNA resection. DPE led to improved recurrence and complication rates when compared to TAE, but future prospective studies are needed to further evaluate which embolization technique can optimize outcomes in JNA. Level of evidence: NA Laryngoscope, 2023.</p

Prehospital comprehensive stroke center vs primary stroke center triage in patients with suspected large vessel occlusion stroke

Importance: Endovascular therapy (EVT) improves functional outcomes in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Whether implementation of a regional prehospital transport policy for comprehensive stroke center triage increases use of EVT is uncertain. Objective: To evaluate the association of a regional prehospital transport policy that directly triages patients with suspected LVO stroke to the nearest comprehensive stroke center with rates of EVT. Design, Setting, and Participants: This retrospective, multicenter preimplementation-postimplementation study used an interrupted time series analysis to compare treatment rates before and after implementation in patients with AIS arriving at 15 primary stroke centers and 8 comprehensive stroke centers in Chicago, Illinois, via emergency medical services (EMS) transport from December 1, 2017, to May 31, 2019 (9 months before and after implementation in September 2018). Data were analyzed from December 1, 2017, to May 31, 2019. Interventions: Prehospital EMS transport policy to triage patients with suspected LVO stroke, using a 3-item stroke scale, to comprehensive stroke centers. Main Outcomes and Measures: Rates of EVT before and after implementation among EMS-transported patients within 6 hours of AIS onset. Results: Among 7709 patients with stroke, 663 (mean [SD] age, 68.5 [14.9] years; 342 women [51.6%] and 321 men [48.4%]; and 348 Black individuals [52.5%]) with AIS arrived within 6 hours of stroke onset by EMS transport: 310 of 2603 (11.9%) in the preimplementation period and 353 of 2637 (13.4%) in the postimplementation period. The EVT rate increased overall among all patients with AIS (preimplementation, 4.9% [95% CI, 4.1%-5.8%]; postimplementation, 7.4% [95% CI, 7.5%-8.5%]; P \u3c .001) and among EMS-transported patients with AIS within 6 hours of onset (preimplementation, 4.8% [95% CI, 3.0%-7.8%]; postimplementation, 13.6% [95% CI, 10.4%-17.6%]; P \u3c .001). On interrupted time series analysis among EMS-transported patients, the level change within 1 month of implementation was 7.15% (P = .04) with no slope change before (0.16%; P = .71) or after (0.08%; P = .89), which indicates a step rather than gradual change. No change in time to thrombolysis or rate of thrombolysis was observed (step change, 1.42%; P = .82). There were no differences in EVT rates in patients not arriving by EMS in the 6- to 24-hour window or by interhospital transfer or walk-in, irrespective of time window. Conclusions and Relevance: Implementation of a prehospital transport policy for comprehensive stroke center triage in Chicago was associated with a significant, rapid, and sustained increase in EVT rate for patients with AIS without deleterious associations with thrombolysis rates or times

Abstract Number ‐ 111: Endovascular embolization of traumatic vessel injury using n‐butyl cyanoacrylate: A case series

Introduction There is limited evidence on the use of N‐butyl cyanoacrylate (n‐BCA) liquid embolic in endovascular embolization of traumatic face and neck vessel injuries. We sought to investigate the safety and effectiveness of n‐BCA in treating traumatic vessel injuries. Methods In a prospectively maintained database, we retrospectively analyzed consecutive patients who presented with a vessel injury caused by either a penetrating or blunt injury in a large academic Level 1 trauma center between April 2021 and July 2022. We included patients aged ≥ 18 years with any vessel injury in the face and neck circulation. The primary endpoint was effectiveness of n‐BCA by immediate control of the active bleeding post‐embolization. Results A total of 10 patients required neuro‐endovascular embolization of traumatic vessel injury via n‐BCA. The mean age of patients was 41.10 (95%CI 28.41, 53.79), with a male predominance (n = 8, 80.0%). The mean Glasgow Coma Scale score on presentation was 10 (95% CI 6.20, 14.40). One patient had concomitant brain injury having subdural and subarachnoid hemorrhages. The mean score for Biffl classification was 5.00. Eight patients suffered penetrating gunshot wound injuries, and two patients suffered blunt injuries. Injured vessels included facial artery (n = 4, 40.0%), buccal branch artery (n = 2, 20.0%), internal maxillary artery (n = 2, 20.0%), cervical segment of the internal carotid artery (n = 1, 10.0%), and the V2 segment of the vertebral artery (n = 1, 10.0%). All patients were successfully treated with 2:1 n‐BCA to ethiodol with immediate extravasation control. Balloon guide catheter was used in 3 patients (30.0%). There was no recurrence of bleeding via vessel imaging or need for retreatment. One patient died in‐hospital (10.0%). Most patients were discharged home (n = 5, 50.0%), one discharged home with day rehab (n = 1, 10.0%), and one to an acute rehab facility (n = 1, 10.0%). One patient developed a right posterior cerebral artery territory infarct with hemorrhagic transformation post‐embolization. Conclusions To the best of our knowledge, this is the first study demonstrating the safety and effectiveness of n‐BCA liquid embolic in traumatic vessel injuries, especially penetrating gunshot wound injuries. Further research is needed to investigate the safety and efficacy in this population

Abstract 1122‐000083: Endovascular Therapy Delay for Acute LVO is Associated with Worse Functional Outcome and Increased Mortality

Introduction: The importance of early mechanical thrombectomy (MT) has shown to improve functional outcomes for patients with acute large vessel occlusion (LVO). As well, prior studies have shown that earlier MT resulted in reduced hospital stay, more home‐time, and more desirable living situation in the 90 days after stroke. We hypothesized that delay in MT in patients with LVO would result in worse clinical outcome and increased mortality. Methods: We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between 01/2018 and 05/2021. We compared outcomes including in‐hospital mortality and 90‐day modified Rankin Scale (mRS) based on time from door‐to‐puncture and door‐to‐reperfusion, adjusting for relevant covariates using logistic regression. Results: Patients that had shorter door‐to‐puncture time were found to have higher probability of a lower modified Rankin Scale (mRS 0–2) at discharge (p = 0.03). Patients with door‐to‐puncture less than 60 minutes had a probability of 50% of achieving a good outcome. Longer door‐to‐puncture times were associated with lower probability of achieving mRS 0–2 at discharge. A similar finding was seen in patients that had shorter times to reperfusion (p = 0.05). Adjusting for age, baseline NIHSS score, and final TICI score, delayed door‐to‐reperfusion time in minutes was an independent predictor of increased mortality at 90 days of 9% for every 10 minutes delay (OR 1.009, 95% CI 1.003‐1.016, p = 0.006). Every 10 minutes delay in door‐to‐reperfusion time had 7% higher chance of poor functional outcome at 90 days (OR 1.007, 95% CI 1.004‐1.019, p = 0.015). Conclusions: Shorter times to MT and reperfusion impact functional outcome and mortality in LVO stroke patients. This indicates that an adequate hospital protocol and continuous education may lead to faster and more efficient stroke activations leading to a shorter time to MT and eventual reperfusion. Goals of door‐to‐puncture must be established in order to achieve better outcomes