Factors associated with in-stent stenosis after cerebral aneurysm embolization using a Pipeline embolization device

Background Flow-diverting (FD) stents, with or without coiling, are a mainstay in endovascular treatment of intracranial aneurysms (IAs). One observed complication from flow diverter stent (FDS) insertion has been in-stent stenosis. Though previously studied in the short-term period, the long-term history of this complication has yet to be described. Methods We performed a retrospective cohort study of consecutive IAs treated with Pipeline Embolization Device (PED), with or without coiling, at our centre between September 2014 and December 2018 that had at least one digital subtraction angiogram (DSA) during follow-up. In-stent stenosis was measured from DSA images, and associated patient and procedural characteristics were analysed. Results 94 patients treated with PED for IA were identified. On initial DSA during follow-up, 52 patients (55.3%) had in-stent stenosis within the PED. Of these 52 patients, 17 had a second DSA during follow-up. In this 2nd DSA, improvement and/or stable in-stent stenosis was seen 16 patients (94.1%). One patient in this group had worsening in-stent stenosis had a vertebrobasilar junction FD stent. Of the patients without in-stent stenosis on initial DSA, 15 had a second DSA during follow-up. Only one of these patients (6.7%) had new appearance of in-stent stenosis (measuring 5%). Multivariate analysis found statin use to be predictive of in-stent stenosis (p = 0.020, Odds ratio = 0.279 and 95% confidence interval = 0.095–0.821). Conclusions In-stent stenosis after FDS placement was seen in 53.2% of cases, which had between 1–50% of stenosis. 82.4% had resolution/improvement of their stenosis. Statin use was protective of in-stent stenosis.

Management of significant atherosclerotic carotid artery disease: review of literature

Stroke is the third leading cause of death and disability in the world. Carotid artery stenosis due to atherosclerosis accounts for 20 to 30% of all strokes. The patients can be asymptomatic or present with a transient ischemic attack or stroke. Diagnosis is based primarily on imaging modalities like carotid Doppler, CT (Computed tomography) angiogram, MR (Magnetic resonance) angiogram or DSA (Digital subtraction angiogram). Treatment options include optimal medical therapy, carotid endarterectomy-touted as the gold standard for treating significant carotid stenosis; and carotid artery stenting, whose safety and efficacy have undergone significant improvements due to technological advances in the field. We presented a review of the literature outlining the various aspects of atherosclerotic carotid stenosis and the findings of several randomized controlled trials conducted to settle the debate between endarterectomy and stenting for carotid stenosis.

Abstract 1122‐000013: Spinal Dural Arterio‐Venous Fistula: A Masquerade as a Longitudinal Myelitis

Introduction : SDAVF are rare and frequently misdiagnosed due to their nonspecific symptomatology and delay of presentation on imaging. Spinal digital subtraction angiogram is the gold standard diagnostic test. Delayed diagnosis and treatment of SDAVF can lead to irreversible neurologic damage. Methods : None Results : Two female patients, 69 and 74 years old, each developed recurrent episodes of subacute worsening myelopathy and urinary retention. The subacute onset of symptoms and longitudinal appearance on cord imaging raised concern for inflammatory myelitis. Despite a negative CSF analysis, and the absence of serum inflammatory, metabolic and infectious markers, the working diagnosis was seronegative neuromyelitis optica spectrum disorder. In accordance, both patients were treated with plasma exchange and IV rituximab, initially displaying stabilization on imaging. However, further worsening and extension of the myelopathy alongside the presence of flow voids in one patient’s repeat MRI nine months post‐presentation raised the question of an alternate etiology. A spinal angiogram was ordered for the patient, revealing SDAVF. Subsequently, the patient underwent complete Onyx embolization of the right L2 feeder and surgical clipping of the right L1 feeder. This resulted in stabilization and improvement of symptoms. Although the second patient did not display flow voids in their MRI, they were ordered a spinal angiogram due to their similar clinical course, indeed confirming SDAVF. The patient underwent successful complete embolization of the L3 segmental artery on the right resulting in improvement of symptoms. Conclusions : Clinicians should have a high index of suspicion for SDAVF when a patient presents with a longitudinally extensive transverse myelitis negative for inflammatory markers and is unresponsive to treatment. While the appearance of flow voids on imaging is a helpful diagnostic feature, these may not be present in patients.

Carotid blowout syndrome: endovascular management of a lesser known oncological emergency: case report

Background Carotid blowout syndrome (CBS) refers to a fatal hemorrhagic complication of cervical carotid arteries that occurs due to rupture of the extracranial carotid artery or one of its major branches in patients treated for head and neck malignancy. In this article, we will discuss two different spectrum of CBS and endovascular approach. Case presentation Two cases of per oral bleeding presented in the emergency department. After patients were hemodynamically stabilized, CT angiography was done which showed type II CBS and type III CBS, respectively. This was followed by transfemoral supra-aortic digital subtraction angiogram coil embolization with scaffolding and anchoring technique, respectively, for the patients. Conclusions Early recognition of the predictors of CBS by a multidisciplinary team is critical. The endovascular treatment approach is relatively safe and effective with low rates of morbidity and mortality compared to surgical approach in CBS.

Intractable bleeding: the role of embolization in a resource-limited country

Transarterial catheter embolization is novel in Ghana, even though it has been practiced over three decades in certain parts of the world. The procedure is safer with the advent of new catheter techniques and embolic agents which place interventional radiology at the forefront of the treatment of bleeding due to myriad of indications. It is fast, safe, and minimally invasive relative to open surgery, especially when other conventional minimally invasive procedures such as endoscopic banding and sclerotherapy fail. This paper presents two cases involving pre-and post-embolization digital subtraction angiogram (DSA) of gastroduodenal artery and bilateral iliac arteries. Findings of DSA of the gastroduodenal artery and bilateral iliac arteries showed florid extravasation and extensive neovascularity. Post embolization DSA showed absent extravasation and near total devascularization. The inclusion of embolization to the management protocols of upper gastrointestinal bleeding and intractable haematuria is recommended

On the Modal Analysis of Blood Flow Dynamics in Brain Aneurysms

Complex, unstable inflow jet has been linked to aneurysm growth and rupture. However, methodologies to characterize this inflow jet have not been well established. Our previous works (Le et al., J. Biomech. Engr., 2010 and Le et al., Annals Biomedical Eng., 2013) have shown a possible transition from the stable mode (cavity) to the unstable mode (vortex ring) of this jet. We have proposed the use of a non-dimensional index called Aneurysm Number to characterize this transition (Le et al., 2013). However, the quantification of such a transition is lacking. Currently, there have no efforts in quantifying unstable flows in intracranial aneurysms, which is essential in stratifying rupture risks. In this work, the aneurysmal geometries from three patients at Sanford Health, North Dakota are reconstructed from Magnetic Resonance Angiogram and Digital Subtraction Angiogram data. Using our in-house CFD code (Virtual Flow Simulator), high-resolution flow data is obtained via numerical simulation. We perform modal analysis of blood flow dynamics for these cases using Proper Orthogonal Decomposition. Our results show that there are up to five dominant modes in the flow arising from the interaction of the incoming jet and the aneurysm dome. The spatial distribution of these modes reflect the characteristics of the inflow jet and can be used to quantify flow unsteadiness. Future works will be needed to apply the same procedure for a larger population of patients to examine its relevance in clinical practice.

Symptomatic Extracranial Carotid Artery Thrombus: An Indian Experience

ABSTRACT Introduction: Symptomatic intraluminal carotid artery thrombus (ICT) is an uncommon finding, whose incidence increases with the percentage of stenosis. The optimal treatment modality to address carotid artery thrombus is not well established. We present our data of medical management of carotid artery thrombus with antiplatelet and anticoagulation. Methods: We reviewed our data from January 1, 2016 to December 31, 2017. Patients with extracranial carotid artery thrombus underwent a catheter digital subtraction angiogram to confirm the presence of thrombus. Medical management was done with dual antiplatelets along with low-molecular-weight heparin, and a check angiogram was done after 14 days. Factors contributing to the persistence of thrombus were analyzed. Results: A total of 21 patients diagnosed with acute ischemic stroke and extracranial carotid artery thrombus. Three patients opted for endarterectomy. Eighteen patients underwent medical management. Nine (50%) had a resolution of thrombus. Those with persistent thrombus were significantly older (average age 64 vs. 43 years, P = 0.008). They also had significantly higher proportions of hypertension (100% vs. 44%, P = 0.029), diabetes mellitus (89% vs. 11%, P = 0.003), and underlying carotid stenosis (100% vs. 33%, P = 0.009). Conclusion: Our regimen of dual antiplatelets plus short-term anticoagulation is safe and effective in the management of ICT. Large-scale studies are warranted to determine the optimal regimen and duration of medical treatment.

Challenges of Management of Stunned Myocardium Associated with Acute Subarachnoid Hemorrhage: A Case Report

A 40 year old lady presented with headache and vomiting having no past history of hyper-tension, diabetes, smoking, alcohol or drug abuse. Computed Tomography (CT) scan of brain revealed sub-arachnoid haemorrhage in parasaggital frontal and lt. Sylvian fissure. Digital Subtraction Angiogram (DSA) was performed and revealed a small aneurysm (4x 2.5 x 2) mm in anterior communicating artery. After 12 hours of DSA patient complaints of sudden severe headache followed by unconsciousness. Repeat CT performed and revealed new onset rt. fronto-basal intra-cranial hematoma consistent with rebleed. On admission the patient was with normal Glasgow Coma Scale (GCS-15), Blood pressure (BP125/80mm/Hg), ECG & Echocardiogram. After rebleed patient developed low BP (50/35mmHg), GCS down gread (05), ECG showed sinus tachycardia with poor progression of R(V1-V3) wave, elevated cardiac Troponin –I(-4919.6 Pg). Then patient was given a regimen of ionotropic agent noradrenalin at dose 5mcg/kg/h. From day 3th of rebleed the patient was clinically improving, BP(120/84mmHg), GCS( 8), ECG normal, Cardiac Troponin-I- (790.8 Pg/dl). Then emergency endovascular ACOM coil embolization was done.Journal of National Institute of Neurosciences Bangladesh, 2018;4(2): 150-153