Cloft, Harry J.

Treatment of symptomatic intracranial atherosclerotic stenosis usually involves maximizing medical therapy. In patients with medically refractory symptoms despite maximum pharmacologic therapy, intracranial angioplasty and/or stenting has become an accepted treatment option. The use of percutaneous transluminal angioplasty (PTA) for idiopathic intracranial stenoses has not been reported to date. We describe a case of idiopathic intracranial stenosis which was refractory to medical therapy and was successfully treated with percutaneous transluminal angioplasty. The presenting symptoms included multiple episodes of aphasia and right-sided weakness as well as a left basal ganglia infarct. The patient underwent treatment with two intracranial angioplasty procedures. There was a recurrence of the stenosis and symptoms following the first procedure. However, after a second treatment with a slightly larger balloon, flow in the MCA normalized. Furthermore, the symptoms attributed to her MCA stenosis had essentially resolved. This case suggests that patients with medically refractory idiopathic intracranial stenosis can be successfully treated with percutaneous transluminal angioplasty.

We studied the use of minor and major recurrence classifications with regard to observer variability, which directly affects validity of these terms as outcome measures. Recurrences at the time of a three to six month follow-up angiogram were assessed independently by two experienced observers in 83 cases. Intra- and interobserver concordance is approximately 90% for assessment of minor and major recurrence.

The proliferation of new endovascular devices and therapeutic strategies calls for a prudent and rational evaluation of their clinical benefit. This evaluation must be done in an effective manner and in collaboration with industry. Such research initiative requires organisational and methodological support to survive and thrive in a competitive environment. We propose the formation of an international consortium, an academic alliance committed to the pursuit of effective neurovascular therapies. Such a consortium would be dedicated to the design and execution of basic science, device development and clinical trials. The Consortium is owned and operated by its members. Members are international leaders in neurointerventional research and clinical practice. The Consortium brings competency, knowledge, and expertise to industry as well as to its membership across a spectrum of research initiatives such as: expedited review of clinical trials, protocol development, surveys and systematic reviews; laboratory expertise and support for research design and grant applications to public agencies. Once objectives and protocols are approved, the Consortium provides a stable network of centers capable of timely realization of clinical trials or preclinical investigations in an optimal environment. The Consortium is a non-profit organization. The potential revenue generated from client-sponsored financial agreements will be re-directed to the academic and research objectives of the organization. The Consortium wishes to work in concert with industry, to support emerging trends in neurovascular therapeutic development. The Consortium is a realistic endeavour optimally structured to promote excellence through scientific appraisal of our treatments, and to accelerate technical progress while maximizing patients' safety and welfare.

The venous sinuses commonly found in the margins of the diaphragm and sella are venous interconnections between the bilateral cavernous dural sinuses and are termed intercavernous communications or intercavernous sinuses. They form a venous ring, a single “circular sinus” that extends throughout the skull base. We report the first case to our knowledge of an intercavernous sinus fistula. We emphasize the importance of thorough knowledge of lesion characteristics before considering any interventional procedure. An 84-year-old woman presented with alarming progressive orbital symptoms for one month affecting her left eye. A cerebral angiogram showed an intercavernous sinus fistula supplied by internal and external carotid arterial branches. Transvenous embolization through retrograde catheterization of the right inferior petrosal sinus allowed complete coil occlusion of the lesion. Cerebral angiography confirmed the absence of residual blood flow through the fistula. This report represents the first case of an intercavernous sinus dural arteriovenous fistula successfully treated with transvenous embolization. A detailed awareness of the regional anatomy is essential for treatment approach and favorable outcomes.

Thrombus organization in canine carotid arteries occluded with platinum microcoils was studied to determine if endothelial injury created with a Xenon Chloride Excimer Laser (XEL) could acclerate endovascular fibrosis. Ten common carotid artery stumps were created in ten dogs. Each of four stumps were schematically divided into four longitudinally contiguous injury zones (thermal ablation injury, non-ablative injury, proximal and distal non-injury zones) to test the effects of ablative and non-ablative injury and to establish a set of internal controls that would account for proximity to circulating blood at the ostium of the occluded artery. Following XEL irradiation of the endothelium through an arteriotomy, each stump was embolized with microcoils. Four control stumps were subjected to sham laser procedures, and embolized in an identical fashion. Two additional stumps were embolized in the absence of sham surgery. Angiographic, gross and histologic analysis was performed after four weeks. Specimens of freshly clotted whole blood mixed with microcoils were used as an additional control. In irradiated stumps and non-irradiated stumps (sham and embolization only), angiography revealed no evidence of coil compaction or recanalization. In all irradiated stumps the thermal ablation zone contained fibrous tissue and neovascularity without unorganized thrombus. The other zones in the irradiated stumps were indistingnishable from each other and from all zones in the non-irradiated sham stumps, containing primarily unorganized thrombus. Stumps embolized in the absence of sham surgery were filled with material that was grossly and microscopically identical to specimens of freshly clotted whole blood containing microcoils. The results indicate that thermal ablation injury of the endothelium accelerates thrombus organization in canine carotid arteries occluded with platinum microcoils.

Perforation of intracranial aneurysms during endovascular treatment with platinum micro-coils is a well-known and serious complication reported to occur in 2–4% of patients. Inflation of a remodelling balloon across the aneurysm neck or within the proximal parent vessel is an additional technique that theoretically might be useful to reduce flow within the aneurysm and achieve hemostasis. In the case reports that follow, we present our experience using this technique for managing intraprocedural aneurysm rupture.

Background Patients with an acute ischemic stroke (AIS) due to large vessel occlusion often require transfer to an endovascular center for treatment. Objective To assess the effect of hospital transfer on outcomes after endovascular revascularization. Methods Outcomes of endovascular revascularization were compared between directly admitted and transferred patients using data from a national database and our own institution. Results 118 institutions within the database reported outcomes of 8533 inpatient admissions for endovascular treatment of AIS. Mortality rate (14.9% vs 18.6%; p=0.049) and mortality index (1.1 vs 1.6; p=0.048) were significantly lower among directly admitted patients than among transferred patients. Within our institutional cohort of 140 patients who underwent endovascular therapy, directly admitted patients had a significantly faster time to revascularization than transferred patients (277.4 vs 420.4 min; p≤0.0001). Among transferred patients, an increasing distance of transferred hospital to our home institution was associated with an increasing risk of mortality (unit OR=1.26, 95% CI 1.07 to 1.54; p=0.0061). Conclusions Outcomes of revascularization may improve with methods to identify patients with large vessel occlusion before hospital admission, thus increasing the likelihood of initial triage to a comprehensive stroke center for patients eligible for endovascular intervention.

Abstract Rationale There is sparse published literature on the causes and outcomes of hospitalization of patients with hereditary hemorrhagic telangiectasia (HHT). Objectives To evaluate rates of various complications, comorbidities, and in-hospital outcomes of patients with HHT using a large, multihospital inpatient database. Methods We identified patients with HHT in the U.S. Nationwide Inpatient Sample between 2000 and 2012. Rates of hemorrhagic, neurological, hepatic, and cardiopulmonary complications among hospitalized patients with HHT were evaluated. We also studied procedure use rates for blood transfusion, endoscopy, and epistaxis treatment. Hospitalization outcomes, including in-hospital mortality, discharge status, charges, and length of stay, were evaluated. Measurements and Main Results: We identified 10,293 patients with HHT. The mean age of the HHT population was 60.7 years. Sixty percent of patients were female. More than 75% of HHT hospitalizations occurred in those older than 50 years of age. Patients with HHT had high rates of bleeding-related complications, including anemia (53.3%), epistaxis (16.2%), and gastrointestinal bleeding (10.8%). Overall, bleeding complications accounted for 62.7% of HHT-related complications. Thirty-eight percent of hospitalized patients with HHT received one or more transfusions of a blood product. Cardiopulmonary complications were present in 41.0% of the cases. Congestive heart failure was the second most common individual complication among patients with HHT, affecting 19.9% of patients. The in-hospital mortality rate was 1.9%. Conclusions In this large, nationwide study, we found that nearly two-thirds of patients hospitalized with HHT experienced a bleeding-related complication. Nearly 40% of hospitalized patients with HHT required transfusion of blood products. Cardiopulmonary complications, including congestive heart failure, were the second most common complication. The high burden of bleeding-related complications points to a significant unmet clinical need for these patients.