Mechanical thrombectomy through a ‘carotid–carotid bypass’

An elderly patient presented with acute-onset right-sided weakness and aphasia. A large penumbra was noted in the left middle cerebral artery (MCA) territory without any infarct core. The patient was noted to have a carotid–carotid bypass. This posed certain technical challenge in accessing the intracranial circulation across the carotid bypass; however, the guiding catheter with soft distal segment was successfully navigated coaxially over the aspiration catheter across the bypass and intracranial circulation was accessed for mechanical thrombectomy. Complete recanalisation and reperfusion were achieved with significant neurological recovery of the patient post-thrombectomy. The aim of this report is to emphasise on this rarely encountered situation in thrombectomy and its successful management. The procedure should not be delayed or deferred due to lack of operator experience.

Rescue Maneuver of Migrated Coil Using the ERIC Device after Previous Attempts with Conventional Stentrievers

Coil prolapse or migration is a rare but potentially serious complication that may occur during aneurysm embolization, with no standard management currently described. Here we describe our experience with the Embolus Retriever with Interlinked Cages (ERIC) device^® (Microvention, Aliso Viejo, CA, USA) for the retrieval of prolapsed or migrated coils in a case series and Flow-Model analysis. First, a retrospective review was performed using our institution database for patients in which coil prolapse or migration occurred during aneurysm embolization, and data was collected and analyzed. Second, an <i>in vitro</i> Flow-Model analysis was performed comparing the ERIC device^® with other stent retrievers for coil retrieval. In 2 cases, the ERIC device^® successfully retrieved the displaced coil from intracranial circulation in 1 pass, after failure with other devices. In the Flow-Model, again the ERIC device^® achieved success for retrieving a detached coil, whereas 2 other different stent retrievers failed to capture the coil after 2 attempts. The ERIC device^® appears to be a safe and effective tool for retrieving a prolapsed or migrated coil from the intracranial circulation.

Effectiveness and safety of endovascular thrombectomy for large versus medium vessel occlusions: a single-center experience

BackgroundThe effectiveness and safety of endovascular thrombectomy (EVT) for medium vessel occlusions (MeVO) in the anterior intracranial circulation for patients with acute ischemic stroke (AIS) has yet to be definitively established. We compared outcomes in patients undergoing EVT for large vessel occlusion (LVO) versus those with MeVO.MethodsThis retrospective cohort study, using an intention to treat design, compared the 90-day modified Rankin Scale (mRS) score between 43 patients with MeVO and 199 with LVO in the anterior intracranial circulation. Secondary outcome measures included vessel recanalization using the Thrombolysis in Cerebral Infarction (TICI) score, procedural complications, post-EVT intracranial hemorrhage (ICH), and infarct size.ResultsThe rate of good functional outcome (90-day mRS 0–2) was higher in patients with LVO than in those with MeVO (32.9% vs 27%), but this was not statistically significant (p=0.19). The rate of EVT procedural complications was also not significantly different between the groups (p=0.10), nor was the rate of ICH (p=0.30). There was also no significant difference in TICI scores between groups (p=0.12). Infarct size was larger in the LVO group (p<0.01). Multivariate analysis showed older age, not receiving recombinant tissue plasminogen activator (r-tPA), and larger infarct size were independent predictors of poor functional outcome at 90 days.ConclusionThe 90-day mRS and rate of periprocedural complications were not significantly different between patients treated for LVO and those treated for MeVO with EVT. Older age, not receiving r-tPA, and larger infarct size were independent predictors of poor outcome at 90 days.

Coaxial Access for Microcatheter Stabilization During Aneurysm Coiling: 2-Dimensional Operative Video

Coaxial support is a fundamental technique utilized by neurointerventionalists to optimize distal catheter control within the intracranial circulation. Here we present a 41-yr-old woman with a previously coiled ruptured anterior communicating artery aneurysm with progressive recurrence harboring tortuous internal carotid anatomy to demonstrate the utility of coaxial support. Raymond-Roy classification of initial aneurysm coiling of class 1 resulted as class 3b over the 21 mo from initial treatment.1 The patient consented to stent-assisted coiling for retreatment of this aneurysm. Coaxial support was advanced as distally as possible in the proximal vasculature to improve catheter control, reducing dead space within which the microcatheter could move, decreasing angulations within proximal vasculature, limiting the movement of the native vessels, and providing a surface of lower friction than the endothelium. As the risk of recurrent subarachnoid hemorrhage in previously treated coiled aneurysms approaches 3%, retreatment occurs in 16.4% within 6 yr2 and in 17.4% of patients within 10 yr.3 Rerupture is slightly higher in patients who underwent coiling vs clipping, with the rerupture risk inversely proportional to the degree of aneurysm occlusion,4 further substantiating that coaxial support provides technical advantage in selected patients where additional microcatheter control is necessary for optimal occlusion. Pitfalls of this technique include vasospasm and vascular injury, which can be ameliorated by pretreatment of the circulation with vasodilators to prevent catheter-induced vasospasm. This case and model demonstration illustrates the technique of coaxial access in the stent-assisted coiling of a recurrent anterior communicating artery aneurysm and identification and management of catheter-induced vasospasm.

Endovascular Treatment in the Subclavian Steal Syndrome: Series of 29 Patients

Subclavian steal syndrome is a group of symptoms resulting from retrograde flow in the vertebral artery, “stealing” blood from the posterior intracranial circulation and other territories, caused by stenosis or occlusion of the subclavian artery proximal to the origin of the same vertebral artery, or even of the brachiocephalic trunk. Most of the time, it is an incidental finding in patients with other conditions or cerebrovascular risk factors. We report a series of 29 patients with an angiographic diagnosis, in which 7 received treatment (all endovascular), all with symptoms directly related to this condition. Advanced age, systemic arterial hypertension, diabetes mellitus, smoking and stroke were comorbidities frequently related. Six patients improved completely after the procedure and one remained with vertigo.

Posthemorrhagic Hydrocephalus With Decompensation Of Cerebrospinal Fluid Dynamics In Newborns: New In Treatment Tactics

Background ― Posthemorrhagic hydrocephalus in newborns with occlusion of cerebrospinal fluid leads to decompensation of cerebrospinal fluid dynamics. There is no single method that meets all the criteria for the effectiveness and safety of treatment. The study goal was to investigate the use of coronary translambdoid subarachnoid ventriculostomy (CTSV) and ventricular subarachnoid stenting (VSS) in the treatment of neonatal hydrocephalus. Material and Methods ― The analysis of the posthemorrhagic hydrocephalus treatment in 327 newborns for the period of 2000-2018 in Crimea. Two groups have been identified. In the Group 1, 184 children underwent standard treatment according to the ‘LVV protocol’ with lumbar and ventricular punctures with 20-22G needles, while with progression of hydrocephalus, with ventriculosubgaleal drainage and ventriculoperitoneal shunt. In 143 children with occlusion and ventricular block, the treatment complex included CTSV – RF Patent No. 2715535, and ventricular drainage by the ventricular subarachnoid stenting (VSS) – RF Patent No. 2721455. Results ― An increase in the treatment radicality under CTSV is achieved through the use of the cerebral needles of a larger diameter (14G) and puncture access zones, elimination of occlusion, while under VSS, restoration of intracranial circulation and absorption of cerebrospinal fluid is ensured by prolonged sanitation with a saline solution of cerebrospinal fluid spaces. A positive outcome with compensation for hydrocephalus was achieved in 75.4% of cases versus 28.2% under the conventional protocol (p<0.001). In other cases, the imbalance of production and absorption of cerebrospinal fluid remained, which required the integration of the VSS with the peritoneal segment of the shunt, without further replacement and reinstallation of the system. Conclusion ― Our results allow us to consider the effectiveness of CTSV and VSS inclusion in the contemporary algorithm for the treatment of decompensated posthemorrhagic hydrocephalus in newborns.

Dangerous Extracranial–Intracranial Anastomoses: What the Interventionalist Must Know

The extracranial and intracranial circulations are richly interconnected at numerous locations, a functional connectivity which underlies their impressive capacity for adaptive plasticity in the setting of vasoocclusive disease. While evolutionarily beneficial, these connections can also result in inadvertent communication with the intracranial circulation during embolization of extracranial vessels, potentially resulting in stroke or cranial nerve palsy. While these anastomoses are always present to a certain extent, flow through them occurs under predictable circumstances, and thus embolization of the extracranial vasculature can be performed safely when knowledge of functional anatomy is combined with adherence to basic principles. Herein, we will review the anatomy of known extracranial–intracranial anastomoses and strategies for avoidance of unwanted intracranial embolization. We will also review the vascular supply to cranial nerves most at risk during common neurointerventional procedures, as well as blood supply to mucosal structures.