More Innovation. More Validation. Better Outcomes. VOLUME 28 - No. 1 - february 2015 ISSN 1971-4009 Online ISSN 2385-1996
™
Delivering more to transform acute ischemic stroke treatment.
MORE
RIGOROUSLY TESTED
BETTER
NEUROLOGICAL OUTCOMES
LOWEST MORTALITY
With more than 1,000 patients enrolled across 6 different studies, the Solitaire ™ 2 device is the most extensively researched mechanical thrombectomy device available.1-6
In every study, patient outcomes improved across all Modified Rankin Scale, with up to 62% achieving mRS 0-2 at 90 days.1-7
The Solitaire ™ 2 device has been proven to offer the lowest observed mortality rate in any significant prospective study of mechanical thrombectomy devices.1-7
NRJ - THE NEURORADIOLOGY JOURNAL - VOLUME 28, No. 1 - pages 1 - 80, 2015
Solitaire 2 Revascularization Device
Official Journal of: REFERENCES 1. Pereira VM, Gralla J, Davalos A, et al. Prospective, multicenter, single-arm study of mechanical thrombectomy using Solitaire Flow Restoration in acute ischemic stroke. Stroke. 2013;44(10):2802-2807. 2. Saver JL, Jahan R, Levy EI, et al; SWIFT Trialists. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012;380(9849):1241-1249. 3. Jahan R, Liebeskind D, Nogueira R, et al; for SWIFT Investigators. Abstract 163: TICI success rates in SWIFT: comparison between randomized arms and correlation to 90 day neurologic outcome. Stroke. 2013;44:A163. 4. Dávalos A, Pereira VM, Chapot R, et al; Solitaire Group. Retrospective multicenter study of Solitaire FR for revascularization in the treatment of acute ischemic stroke. Stroke. 2012;43(10):2699-2705. 5. Schroth G. Endovascular stroke therapy in Bern: 20 years of experience. Presented at: 12th Congress of the World Federation of Interventional and Therapeutic Neuroradiology; November 9–13, 2013; Buenos Aires, Argentina. 6. Nguyen T, Malisch T, Castonguay A, et al. O-004 Balloon guide catheter improves recanalisation, procedure time, and clinical outcomes with Solitaire in acute stroke: analysis of the NASA Registry. J NeuroIntervent Surg. 2013;5:A2-A3. 7. Nogueira RG, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): A randomised trial. Lancet. 2012:DOI:10.1016/ S0140-6736(12)61299-9. The Solitaire™ 2 Revascularization Device is intended to restore blood flow by removing thrombus from a large intracranial vessel in patients experiencing ischemic stroke within 8 hours of symptom onset. Patients who are ineligible for intravenous tissue plasminogen activator (IV t-PA) or who fail IV t-PA therapy are candidates for treatment. Indications, contraindications, warnings and instructions for use can be found on the product labeling supplied with each device. CAUTION: Federal (USA) law restricts this device to sale by or on the order of a physician. COVIDIEN, COVIDIEN with logo, and Covidien logo are US and internationally registered trademarks of Covidien AG. Other brands are trademarks of a Covidien company. ©2015 Covidien. - EU-15-4300 - 02/2015
AINR - Associazione Italiana di Neuroradiologia
and: The Neuroradiologists of Alpe-Adria ANRS - Albanian Neuroradiological Society PANRS - Pan Arab NeuroRadiology Society Radiological Society of Saudi Arabia, Division of Neuroradiology Egyptian Society of Neuroradiology ISNR - Indian Society of Neuroradiology Indonesian Society of Neuroradiology Neuroradiology Section of the Radiology Society of Iran Israeli Society of Neuroradiology College of Radiology Malaysia
Neuroradiology Section - Pakistan Psychiatry Research Center Section of Neuroradiology - Polish Radiological Society The Neuroradiologists of Romania Section of Neuroradiology of Serbia and Montenegro SILAN - Sociedad Ibero Latino Americana de Neurorradiologia Neuroradiology Section of Singapore Radiological Society Slovenian Society of Neuroradiology The Neuroradiological Society of Taiwan TSNR - Turkish Society of Neuroradiology
Case report
Beware of the Aneurysm in Stealth Mode! Amar Swarnkar1, Raghu Ramaswamy2, David J Padalino2 and Eric M Deshaies2
The Neuroradiology Journal 2015, Vol. 28(1) 76–79 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.15274/NRJ-2014-10109 neu.sagepub.com
Abstract Endovascular treatment is one of the treatment options considered for acute stroke in many primary stroke centers. Outcome from such treatment can be very successful and gratifying if the intervention is timely and patient selection is appropriate. There are however certain pitfalls that need to be kept in mind which, if the interventionalist is not careful, can adversely affect the outcome. We describe such a case where the patient presented with acute stroke due to basilar artery thrombosis but also had an aneurysm in the affected vessel. We also make certain recommendations to reduce the chances of complications arising during treatment of patients with such a condition.
Keywords stroke, aneurysm, thrombolysis, hyperdensity
Introduction Endovascular treatment is one of the treatment options considered for acute stroke in many primary stroke centers. Outcome from such treatment can be very successful and gratifying if the intervention is timely and patient selection is appropriate. There are however certain pitfalls that need to be kept in mind which, if the interventionalist is not careful, can adversely affect the outcome. We describe such a case where the patient presented with acute stroke due to basilar artery thrombosis but also had an aneurysm in the affected vessel. We also make certain recommendations to reduce the chances of complications arising during treatment of patients with such a condition.
Case Report A 53-year-old woman was found unresponsive and quadriparetic with right-side affected more than the left. Her NIHSS score was 20 on admission. She underwent plain CT head scan which ruled out intracranial hemorrhage and showed hyperdensity of the distal basilar artery. She then underwent CT angiogram of her brain and neck including the aortic arch which showed thrombosis of distal basilar artery (BA) with no filling of either posterior cerebral artery (PCA). It also showed occlusion of the right vertebral artery (VA) with significant stenosis of the dominant left VA (L-VA) origin. She was then transferred to the endovascular suite for treatment of the BA thrombosis. Her initial cerebral angiogram showed complete occlusion of the hypoplastic right VA origin with some reconstitution distally at C4/5 level but with no filling of intracranial VA or BA.
Angiogram of left common carotid artery (CCA) and left subclavian artery showed significant stenosis of her left internal carotid artery (ICA) (80% as per North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria) and L-VA at the origin (90% measured as per NASCET study). To improve flow and facilitate access to basilar artery she underwent left VA angioplasty and stenting using a 4X12mm balloon mounted Multilink stent (Abbott Vascular, Abott park, IL, USA). There was 25% residual stenosis of L-VA origin post stenting/ angioplasty. We accessed the distal left VA/BA using a synchro 2 soft microwire and Prowler select micro catheter (Codman & Shurtleff, Raynham, MA, USA). When we attempted to pass the microwire into one of the P1 branches we noticed that the microwire was looping in the midline instead of going into one of the PCAs. At this point we abandoned further attempts to negotiate the microwire distal to the thrombus as we were unsure of the anatomic path the microwire was taking. We decided to review the plain CT head prior to attempting any further intervention. On reviewing her plain CT head we noticed that the hyperdensity at the BA apex was bulbous suggesting a possible aneurysm in that location (Figure 1). We suspected that the 1
Department of Radiology Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
2
Corresponding author: Raghu Ramaswamy, MD, Department of Neurosurgery, 750 East Adams Street, Syracuse, NY 13210 USA. Email: [email protected]
Swarnkar et al.
77
Figure 1. Hyperdense, thrombosed normal-sized basilar artery (left) and thrombosed, bulbous basilar apex (right).
aneurysm at the BA apex was causing the microcatheter to loop in the midline instead of going into either of the PCAs. We decided to thrombolyze the clot from the proximal end with intra-arterial tissue plasminogen activator (tPA) as mechanical thrombectomy could have been hazardous. After thrombolysis we noticed both PCAs filling and also noticed some linear contrast extension in the midline between both PCAs (Figure 2). This was interpreted as filling of the now partially thrombosed BA aneurysm and not as perforation of the vessel as the patient was neurologically and hemodynamically stable. Having established antegrade flow in BA and both PCAs and residual thrombus in the aneurysm we stopped the intervention at that point. She received a loading dose of Plavix 300 mg during the procedure and Plavix 75 mg/day and Aspirin 81 mg/day was continued after the procedure. Over the next few days the patient remained stable but developed right-sided transient ischemic attack (TIA) secondary to her left ICA stenosis. As she had developed TIA in spite of being treated with dual antiplatelet therapy she underwent a repeat cerebral angiogram and stenting of the left ICA stenosis. During that procedure a small (
™
Delivering more to transform acute ischemic stroke treatment.
MORE
RIGOROUSLY TESTED
BETTER
NEUROLOGICAL OUTCOMES
LOWEST MORTALITY
With more than 1,000 patients enrolled across 6 different studies, the Solitaire ™ 2 device is the most extensively researched mechanical thrombectomy device available.1-6
In every study, patient outcomes improved across all Modified Rankin Scale, with up to 62% achieving mRS 0-2 at 90 days.1-7
The Solitaire ™ 2 device has been proven to offer the lowest observed mortality rate in any significant prospective study of mechanical thrombectomy devices.1-7
NRJ - THE NEURORADIOLOGY JOURNAL - VOLUME 28, No. 1 - pages 1 - 80, 2015
Solitaire 2 Revascularization Device
Official Journal of: REFERENCES 1. Pereira VM, Gralla J, Davalos A, et al. Prospective, multicenter, single-arm study of mechanical thrombectomy using Solitaire Flow Restoration in acute ischemic stroke. Stroke. 2013;44(10):2802-2807. 2. Saver JL, Jahan R, Levy EI, et al; SWIFT Trialists. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012;380(9849):1241-1249. 3. Jahan R, Liebeskind D, Nogueira R, et al; for SWIFT Investigators. Abstract 163: TICI success rates in SWIFT: comparison between randomized arms and correlation to 90 day neurologic outcome. Stroke. 2013;44:A163. 4. Dávalos A, Pereira VM, Chapot R, et al; Solitaire Group. Retrospective multicenter study of Solitaire FR for revascularization in the treatment of acute ischemic stroke. Stroke. 2012;43(10):2699-2705. 5. Schroth G. Endovascular stroke therapy in Bern: 20 years of experience. Presented at: 12th Congress of the World Federation of Interventional and Therapeutic Neuroradiology; November 9–13, 2013; Buenos Aires, Argentina. 6. Nguyen T, Malisch T, Castonguay A, et al. O-004 Balloon guide catheter improves recanalisation, procedure time, and clinical outcomes with Solitaire in acute stroke: analysis of the NASA Registry. J NeuroIntervent Surg. 2013;5:A2-A3. 7. Nogueira RG, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): A randomised trial. Lancet. 2012:DOI:10.1016/ S0140-6736(12)61299-9. The Solitaire™ 2 Revascularization Device is intended to restore blood flow by removing thrombus from a large intracranial vessel in patients experiencing ischemic stroke within 8 hours of symptom onset. Patients who are ineligible for intravenous tissue plasminogen activator (IV t-PA) or who fail IV t-PA therapy are candidates for treatment. Indications, contraindications, warnings and instructions for use can be found on the product labeling supplied with each device. CAUTION: Federal (USA) law restricts this device to sale by or on the order of a physician. COVIDIEN, COVIDIEN with logo, and Covidien logo are US and internationally registered trademarks of Covidien AG. Other brands are trademarks of a Covidien company. ©2015 Covidien. - EU-15-4300 - 02/2015
AINR - Associazione Italiana di Neuroradiologia
and: The Neuroradiologists of Alpe-Adria ANRS - Albanian Neuroradiological Society PANRS - Pan Arab NeuroRadiology Society Radiological Society of Saudi Arabia, Division of Neuroradiology Egyptian Society of Neuroradiology ISNR - Indian Society of Neuroradiology Indonesian Society of Neuroradiology Neuroradiology Section of the Radiology Society of Iran Israeli Society of Neuroradiology College of Radiology Malaysia
Neuroradiology Section - Pakistan Psychiatry Research Center Section of Neuroradiology - Polish Radiological Society The Neuroradiologists of Romania Section of Neuroradiology of Serbia and Montenegro SILAN - Sociedad Ibero Latino Americana de Neurorradiologia Neuroradiology Section of Singapore Radiological Society Slovenian Society of Neuroradiology The Neuroradiological Society of Taiwan TSNR - Turkish Society of Neuroradiology
Case report
Beware of the Aneurysm in Stealth Mode! Amar Swarnkar1, Raghu Ramaswamy2, David J Padalino2 and Eric M Deshaies2
The Neuroradiology Journal 2015, Vol. 28(1) 76–79 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.15274/NRJ-2014-10109 neu.sagepub.com
Abstract Endovascular treatment is one of the treatment options considered for acute stroke in many primary stroke centers. Outcome from such treatment can be very successful and gratifying if the intervention is timely and patient selection is appropriate. There are however certain pitfalls that need to be kept in mind which, if the interventionalist is not careful, can adversely affect the outcome. We describe such a case where the patient presented with acute stroke due to basilar artery thrombosis but also had an aneurysm in the affected vessel. We also make certain recommendations to reduce the chances of complications arising during treatment of patients with such a condition.
Keywords stroke, aneurysm, thrombolysis, hyperdensity
Introduction Endovascular treatment is one of the treatment options considered for acute stroke in many primary stroke centers. Outcome from such treatment can be very successful and gratifying if the intervention is timely and patient selection is appropriate. There are however certain pitfalls that need to be kept in mind which, if the interventionalist is not careful, can adversely affect the outcome. We describe such a case where the patient presented with acute stroke due to basilar artery thrombosis but also had an aneurysm in the affected vessel. We also make certain recommendations to reduce the chances of complications arising during treatment of patients with such a condition.
Case Report A 53-year-old woman was found unresponsive and quadriparetic with right-side affected more than the left. Her NIHSS score was 20 on admission. She underwent plain CT head scan which ruled out intracranial hemorrhage and showed hyperdensity of the distal basilar artery. She then underwent CT angiogram of her brain and neck including the aortic arch which showed thrombosis of distal basilar artery (BA) with no filling of either posterior cerebral artery (PCA). It also showed occlusion of the right vertebral artery (VA) with significant stenosis of the dominant left VA (L-VA) origin. She was then transferred to the endovascular suite for treatment of the BA thrombosis. Her initial cerebral angiogram showed complete occlusion of the hypoplastic right VA origin with some reconstitution distally at C4/5 level but with no filling of intracranial VA or BA.
Angiogram of left common carotid artery (CCA) and left subclavian artery showed significant stenosis of her left internal carotid artery (ICA) (80% as per North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria) and L-VA at the origin (90% measured as per NASCET study). To improve flow and facilitate access to basilar artery she underwent left VA angioplasty and stenting using a 4X12mm balloon mounted Multilink stent (Abbott Vascular, Abott park, IL, USA). There was 25% residual stenosis of L-VA origin post stenting/ angioplasty. We accessed the distal left VA/BA using a synchro 2 soft microwire and Prowler select micro catheter (Codman & Shurtleff, Raynham, MA, USA). When we attempted to pass the microwire into one of the P1 branches we noticed that the microwire was looping in the midline instead of going into one of the PCAs. At this point we abandoned further attempts to negotiate the microwire distal to the thrombus as we were unsure of the anatomic path the microwire was taking. We decided to review the plain CT head prior to attempting any further intervention. On reviewing her plain CT head we noticed that the hyperdensity at the BA apex was bulbous suggesting a possible aneurysm in that location (Figure 1). We suspected that the 1
Department of Radiology Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
2
Corresponding author: Raghu Ramaswamy, MD, Department of Neurosurgery, 750 East Adams Street, Syracuse, NY 13210 USA. Email: [email protected]
Swarnkar et al.
77
Figure 1. Hyperdense, thrombosed normal-sized basilar artery (left) and thrombosed, bulbous basilar apex (right).
aneurysm at the BA apex was causing the microcatheter to loop in the midline instead of going into either of the PCAs. We decided to thrombolyze the clot from the proximal end with intra-arterial tissue plasminogen activator (tPA) as mechanical thrombectomy could have been hazardous. After thrombolysis we noticed both PCAs filling and also noticed some linear contrast extension in the midline between both PCAs (Figure 2). This was interpreted as filling of the now partially thrombosed BA aneurysm and not as perforation of the vessel as the patient was neurologically and hemodynamically stable. Having established antegrade flow in BA and both PCAs and residual thrombus in the aneurysm we stopped the intervention at that point. She received a loading dose of Plavix 300 mg during the procedure and Plavix 75 mg/day and Aspirin 81 mg/day was continued after the procedure. Over the next few days the patient remained stable but developed right-sided transient ischemic attack (TIA) secondary to her left ICA stenosis. As she had developed TIA in spite of being treated with dual antiplatelet therapy she underwent a repeat cerebral angiogram and stenting of the left ICA stenosis. During that procedure a small (
