Lanzino, Giuseppe

Abstract Vascular access for cerebral angiography has traditionally been performed via the common femoral artery. It is crucial to obtain safe access to prevent complications that could lead to limb ischemia, groin hematoma, or retroperitoneal hematoma. This is especially true in neurointervention as many patients are anticoagulated or have received intravenous thrombolytics prior to their intervention. Special attention to anatomic landmarks, both grossly and radiographically, can help to assure safe access. The patient consented for this procedure. This video details rapid but safe femoral artery access in a patient undergoing emergent thrombectomy.

Abstract Management options for carotid stenosis include medical management, carotid endarterectomy, carotid stenting with distal filter protection, or stenting with either flow arrest or flow reversal techniques. 1 Flow reversal with transcarotid artery revascularization (TCAR) technique represents a hybrid approach with surgical access to the common carotid for endovascular placement of a stent in the internal carotid artery. This direct access to the carotid artery avoids navigating the challenging anatomy of the aortic arch with endovascular devices. 2 Compared to transfemoral stenting, TCAR possesses lower risk of transient ischemic attack and stroke, and compared to carotid endarterectomy, there is less risk of cranial neuropathy. 3,4 We present the case of an 87-yr-old man with recurrent severe stenosis (85%) of the right internal carotid artery. The patient had a remote history of bilateral endarterectomies for asymptomatic stenosis and was found with recurrence and progression of right internal carotid artery stenosis. Options were discussed and decision was made to proceed with TCAR after he consented for the procedure. The patient tolerated the procedure well with satisfactory revascularization. Exam remained unremarkable prior to discharge on postoperative day 1 and during follow-up at 1 mo. Patient consented to the publication of their image.

Abstract Cerebral venous sinus stenting has gained popularity in recent years as a safe and efficacious treatment of selected patients with idiopathic intracranial hypertension (IIH) and focal venous sinus stenosis.1–3 - 3 The main goal of treatment is to prevent visual loss, and often patients report resolution of headache and visual symptoms within 21 mo of mean follow-up.4–8 - 8 We present the case of a 57-yr-old woman with medically refractory IIH, bilateral sinus stenosis, and a mass lesion causing stenosis on the left. Venous angiogram with pressure monitoring was completed with the patient awake, which showed a significant pressure gradient on the right (19 mm Hg) and borderline gradient on the left (8 mm Hg). Options were reviewed and decision was made to proceed with the treatment of the right-sided stenosis with stenting and continue with the observation of the lesion on the left to prevent further visual deterioration. The patient consented for the procedure, and she tolerated the procedure well. Neurological exam remained at baseline, and she was discharged home on post-operative day #1. At 2 mo’s follow-up, the patient reported improvement in headaches and remained intact neurologically.

Abstract Giant intracranial aneurysms still represent a serious threat because of high mortality and morbidity and an absence of a widely accepted treatment. Herein, we illustrate the case of a 54-yr-old woman with progressive neurological decline who was found to have an unruptured, giant, partially thrombosed aneurysm of the left supraclinoid portion of internal carotid artery (ICA) with brainstem compression. In this video, we demonstrate the successful stepwise treatment of this lesion with endovascular embolization of the patent portion of the aneurysm, followed by microsurgical debulking and clipping. At 3-yr follow-up, the patient experienced a neurological improvement and performed all normal activity. For patients in which single-modality therapy does not assure a safe treatment option, multimodal management with endovascular and open techniques should be considered as a therapeutic option for complex giant intracranial aneurysms. Consent was given by the patient prior to the surgical procedure. Consent and approval for this operative video, in light of the retrospective nature and use of anonymized material, were waived.

Abstract Wide-necked bifurcation aneurysms pose technical and anatomical challenges to endovascular treatment, which make the simpler assisted (balloon or single stent) coiling techniques less effective. 1 Consequently, unique endovascular solutions to treat such aneurysms have been devised. 2,3 One such device is PulseRider (Cerenovus, New Brunswick, New Jersey), which is designed to provide neck support for a coil mass while protecting the bifurcation. 3 The device comprises a body or stem that is deployed in the parent artery and a saddle component that sits at the aneurysm neck to keep the coil mass away from the bifurcation. There are several technical nuances involved in successful use of the device during positioning, deployment, and detachment. 3 We present a surgical video detailing the steps of PulseRider-assisted coiling of unruptured basilar bifurcation (or basilar apex) aneurysms. The first case highlights index treatment at diagnosis and the second showcases treatment of a recurrent basilar apex aneurysm. Both patients provided informed consent to the procedure. We also briefly discuss the rationale for treating basilar apex aneurysms. 4,5

Abstract Mechanical thrombectomy as a treatment for large vessel occlusion to achieve rapid revascularization is supported in the literature. 1-3 The presenting symptoms will localize to functions of the ischemic area. The middle cerebral artery (MCA) supplies areas of the frontal, temporal, and parietal cortices, as well as the basal ganglia. Occlusion of the MCA will present with contralateral hemiplegia, sensory loss, and, if the dominant hemisphere is involved, language deficits. We present a right-hand-dominant 79-yr-old female with right MCA syndrome—her last known well time was 1.5 h prior to presentation. Her NIH (National Institutes of Health) Stroke Scale was 16, most notable for left hemiplegia. Although the patient presented early in the clinical time course, as part of our institution protocol, a computed tomography (CT) head, CT perfusion, and CT angiogram (CTA) were performed. CT head did not demonstrate acute hemorrhage, so she received intravenous tissue plasminogen activator. CTA demonstrated a right MCA occlusion and CT perfusion suggested a large area of salvageable tissue, so she was taken to the angiography suite for mechanical thrombectomy. Angiography of the right internal carotid artery (ICA) showed MCA occlusion (insular segment). A thrombectomy device was deployed over the area of occlusion and allowed to engage for 5 min. An aspiration catheter was advanced over the stentriever up against the clot. The stentriever device was withdrawn under continuous aspiration and follow-up angiography showed complete reperfusion. The patient demonstrated improvement and was eventually discharged to an inpatient rehabilitation center. Patient provided consent for photography per university protocol. Institutional review board (IRB) approval was not needed for the single-patient data included in this report.

Abstract As capabilities for endovascular treatment of intracranial vascular pathologies continue to expand, the need for access to the distal internal carotid artery with rigid support catheter systems continues to increase. One of the dominant factors limiting this access is patient anatomy, specifically vessel tortuosity. Increased tortuosity of the carotid siphon is a frequently encountered anatomic variant and may complicate endovascular procedures in adults and children. 1,2 Failed attempts to navigate the carotid siphon with a distal access catheter carry a risk of vessel injury and treatment failure. For this reason, techniques that aid in supporting safe advancement of a distal access catheter across a tortuous carotid siphon are essential. 3,4 In this video, we demonstrate 2 ways in which this may be accomplished. The first technique uses a larger diameter microcatheter, such as the AXS Offset catheter (Stryker, Kalamazoo, Michigan), to increase support for the distal access catheter, while the second uses a buddy wire technique to accomplish this increased support. Both of these techniques can help increase the safety of navigating a tortuous carotid siphon and increase the likelihood of successful treatment. The procedures shown were performed with the informed consent of the patients.

Introduction: High-resolution vessel wall imaging (HR-VWI) of the intracranial vasculature may aid in the diagnosis and management of Moyamoya Disease (MMD). The patterns of HR-VWI findings of the cerebral vasculature of MMD patients remains uncertain, however. We sought to describe HR-VWI findings in a single-center cohort of MMD patients. Methods: Consecutive patients who were evaluated at a Midwest American medical center with a HR-VWI exam were included. Fourteen anterior circulation arterial segments in each patient were analyzed: proximal and distal supraclinoid Internal Carotid Artery, proximal M1 segment of the Middle Cerebral Artery, mid-portion of the M1, distal M1, proximal A1 segment of the Anterior Cerebral Artery and distal A1. Imaging variables that were collected from each segment included the presence of wall thickening (concentric vs eccentric), degree and pattern (concentric or eccentric) of contrast enhancement, and presence of positive or negative vessel remodeling. The total number and percentage of vessel segments demonstrating these characteristics were calculated. The number and percentage of patients with at least one segment demonstrating these characteristics were calculated. Results: Thirty-six patients (32 females, 88.9%) with a diagnosis of MMD were included. Overall, 221 of 504 segments (43.8%) demonstrated negative remodeling in 29 (75%) patients. Ninety-eight segments (19.4%) demonstrated wall enhancement (71 concentric, 27 eccentric; 22 high grade, 76 low grade) in 32 (88.9%) patients. Eighty-seven segments (17.3%) demonstrated wall thickening (52 concentric, 35 eccentric) in 32 patients (88.9%). Conclusions: Negative remodeling was the most-commonly observed vessel wall abnormality in all segments analyzed. However, a high percentage of patients had at least one segment demonstrating wall enhancement, wall thickening and negative remodeling. Continued study is necessary to further elucidate the HR-VWI patterns of the cerebral arterial system in MMD patients.

Background: Accurate and reliable models of intracranial hemorrhage (ICH) risk in the untreated course of brain arteriovenous malformation (BAVM) patients are needed to help weigh the risk-benefit of treatment. We present preliminary estimates of rates and risk factors for ICH or death in the Multicenter AVM Research Study (MARS), which is the largest individual patient data meta-analysis (IPDMA) of cohort studies of unruptured BAVM. Methods: Longitudinal data from 9 cohorts comprising 2,839 unruptured BAVM at time of diagnosis were included: UCSF (n=557), Macquarie (n=462), Kaiser Permanente Northern California (n=354), Columbia (n=335), Barrow Neurological Institute (n=324), Tiantan Hospital (n=303), Mayo Clinic-Rochester (n=244), Scottish Intracranial Vascular Malformation Study (n=194), and Toronto Western Hospital (n=66). Clinical and angiographic data were collected using standardized definitions across cohorts. Cox proportional hazards analysis of time-to-event (ICH or death) in the untreated course after diagnosis was performed, censoring at first treatment or last visit. Baseline hazard rates were stratified by cohort to account for different rates and follow-up times. Results: The combined cohort was 49% female, 72% white race, and 17% Hispanic ethnicity; mean age at diagnosis was 37±17 years and mean follow-up was 3.4±7.0 years. The most common presenting symptom was seizures (43%). Mean AVM size was 3.5±1.9 cm and 46% were Spetzler-Martin grade I-II. Overall, 123 ICH and 131 deaths occurred over 9,608 person-years (PY) for an event rate of 2.64 per 100 PY [95% CI: 2.34-2.99]. Cox regression analyses adjusting for age at diagnosis (HR=1.67 [1.54, 1.82], P<0.001) identified cerebellar location (HR=1.73 [1.03-2.93], P=0.040) and exclusively deep venous drainage (HR=1.83 [1.09-3.09], P=0.022) as predictors. Conclusion: Our current model identified increasing age, exclusively deep venous drainage, and cerebellar location as risk factors for ICH or death in the untreated course of unruptured bAVM patients. Review of imaging data, multiple imputation of missing angioarchitectural data, and additional data from pending cohorts will provide greater power to search for additional risk factors in this ongoing IPDMA.