Rangel-Castilla, Leonardo

Abstract Mechanical thrombectomy has become the standard of care for management of most acute large-vessel occlusion (LVO) strokes. Most intracranial occlusions are located in the middle cerebral and internal carotid arteries. We present a unique case of acute occlusion of an azygous anterior cerebral artery (ACA). A 59-yr-old man with known hypertension and alcoholism presented with right hemiparesis, right facial palsy, aphasia, and dysarthria. His initial National Institutes of Health Stroke Scale (NIHSS) score was 20. Computed tomographic angiography and perfusion imaging demonstrated acute bilateral ACA occlusion with viable penumbra and preserved cerebral blood volume. The patient was not a candidate for intravenous tissue plasminogen activator because he presented with a wake-up stroke. After consent was obtained from his family, the patient was taken urgently for endovascular recanalization. Digital subtraction angiography confirmed acute azygous ACA occlusion. Under conscious sedation, the patient underwent mechanical thrombectomy with a stent retriever and a large-bore aspiration catheter. Successful revascularization (thrombolysis in cerebral infarction [TICI] grade 3) of the azygous ACA and both A2 arteries was obtained after 2 attempts and the use of a different stent retriever (first a 3 × 30 mm Trevo [Stryker Neurovascular, Kalamazoo, Michigan] and then a 4 × 40 mm Solitaire Platinum [Medtronic, Dublin, Ireland]). A reperfusion catheter was used during both attempts. No procedure-related complications occurred. The patient was discharged to a rehabilitation facility 3 d after the procedure with an NIHSS score of 2. In this video, we present the operative nuances of an uncommon location of LVO and its endovascular management.

OBJECTIVE De novo aneurysms are rare entities periodically discovered during follow-up imaging. Little is known regarding the frequency with which these lesions form or the time course. This systematic review and meta-analysis was undertaken to estimate the incidence of de novo aneurysms and to determine risk factors for aneurysm formation. METHODS The authors searched multiple databases for studies of patients with unruptured and ruptured aneurysms describing the rate of de novo aneurysm formation. The primary outcome was incidence of de novo aneurysm formation. A meta-analysis was performed using a random-effects model. The authors examined the associations of multiple aneurysms, prior subarachnoid hemorrhage, smoking, sex, age at presentation, and hypertension with de novo aneurysm formation. RESULTS The meta-analysis included 14,968 aneurysm patients who received imaging follow-up from 35 studies. The overall incidence of de novo aneurysm formation was 2% (95% CI 2%–3%) over a mean follow-up time of 8.3 years. The estimated incidence density was 0.3%/patient-year. There was no statistically significant difference in rates of de novo aneurysm formation between patients who had ruptured aneurysms and those with unruptured aneurysms. In 8 studies, 11.2% of de novo aneurysms were found in patients with ≤ 5 years of follow-up and 88.8% were found at > 5 years. The mean time to rupture for de novo aneurysms was 10 years. CONCLUSIONS This systematic review demonstrates that formation of de novo aneurysms is rare. Overall, routine screening for de novo aneurysms is likely to be of low yield and could be performed at time intervals of at least 5 to 10 years.

Abstract We present a case of tandem stenosis of the great vessels (cervical internal carotid artery [ICA] and brachiocephalic trunk ostium [BTO]) treated with stenting and balloon angioplasty of both lesions under flow arrest. A 70-yr-old woman with a history of hypertension, hyperlipidemia, coronary artery disease, and previous strokes presented with recurrent transient ischemic attacks of the left upper and lower extremities over the last 6 mo. She underwent right cervical endarterectomy (CEA) 16 yr prior. Neurological examination was unremarkable. Carotid Doppler ultrasonography revealed severely increased velocities of the right ICA. Cervical magnetic resonance angiography demonstrated 80% right ICA stenosis and 50% BTO stenosis. Digital subtraction cerebral angiography showed 80% right ICA stenosis and 70% BTO stenosis. The patient was not a candidate for standard carotid artery stenting because the BTO precluded endovascular access or for CEA because of the previous CEA; therefore, direct carotid access and flow reversal was an alternative. Under general anesthesia and systemic heparinization, the patient underwent right carotid artery surgical exposure. Under flow reversal using the Enroute System (Silk Road Medical, Sunnyvale, California), anterograde right ICA stenting angioplasty and retrograde BTO stenting and angioplasty were performed. Successful revascularization of the right ICA and BTO was obtained. No procedure-related complications occurred. The patient was discharged home 2 d postprocedure, neurologically intact. Direct carotid access with flow reversal is a safe and effective therapeutic alternative for patients with ICA (or common carotid artery) stenosis who cannot undergo CEA or when endovascular access from the aortic arch is not possible. Patient consent was obtained prior to performing the procedure. Institutional board approval is not required for the report of a single case.

Abstract We present a case of a traumatic skull base internal carotid artery (ICA) pseudoaneurysm treated with endovascular flow diversion stenting. The patient was a 27-year-old male who was involved in a motorcycle accident suffering multiple traumatic injuries including a large skull base fracture that extended through the carotid canal. Computed tomography angiography revealed a 2-cm right ICA pseudoaneurysm. Once the patient was stable, a digital subtraction angiography demonstrated enlargement of the pseudoaneurysm. After his other injuries were addressed by trauma and orthopedic surgery, at day 9 after his initial injury, the patient was loaded with aspirin and clopidrogel in preparation for stent reconstruction of his ICA injury. Under conscious sedation and systemic heparinization, the patient underwent endovascular reconstruction of the large pseudoaneurysm using telescoping flow diversion stents. Immediate intra-aneurysm flow stasis was observed. No procedure-related complications occurred. The patient did well and at last follow-up remained neurologically intact.

Abstract BACKGROUND Neck remnants are not uncommon after endovascular treatment of cerebral aneurysms. Critics of endovascular treatments for cerebral aneurysms cite neck remnants as evidence in favor of microsurgical clipping. However, studies have failed to evaluate the true clinical significance of aneurysm neck remnants following endovascular therapies. OBJECTIVE To assess the clinical significance of residual aneurysm necks and to determine the rate of subsequent rupture following coiling or stent-assisted coiling of cerebral aneurysms. METHODS We retrospectively reviewed the records of 1292 aneurysm cases that underwent endovascular treatment at 4 institutions. Aneurysms treated by primary coiling or stent-assisted coiling were included in the study; those treated by flow diversion were excluded Aneurysms with residual filling (i.e., Raymond–Roy Occlusion Classification II, neck remnant; or III, residual aneurysm filling) were assessed for their risk of subsequent rupture. RESULTS A total of 626 aneurysms were identified as having residual filling immediately posttreatment. Of these, 13 aneurysms (2.1%) ruptured during the follow-up period (mean 7.3 mo; range 1-84 mo). Eleven of the 13 (84.6%) were ruptured at presentation. Rupture at presentation, the size of the aneurysm, and the increasing age of the patient were predictive of posttreatment rupture. CONCLUSION We found that unruptured aneurysms with residual necks following endovascular treatment posed a very low risk of rupture (0.6%). However, patients presenting with ruptured aneurysms had a higher risk of rerupture from a neck remnant (3.4%). These results highlight the importance of achieving complete angiographic occlusion of ruptured aneurysms.