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Spontaneous subarachnoid hemorrhage (SAH) long-term risk is not well known. Our aims are: describing long-term vascular event (VE) incidence rates in SAH survivors; describing VE: ischemic and/or hemorrhagic; identifying independent association of factors related to VE; and analyzing the usefulness of factors to increase predictive ability.A prospective cohort study of consecutive patients admitted to Hospital del Mar with a diagnosis of SAH (n = 566) between January 2007 and January 2020 was carried out. They were followed up until January 2021. The study endpoint was a new VE in the follow-up. We calculated both incidence rates and cumulative rates at 5 years. Cox regression survival models including vascular risk factors with and without specific data of SAH disease were developed. We analyzed ROC curves of all multivariate models.The analyzed cohort included 423 non-fatal SAH cases. Total patient-years were 2468.16 years. The average follow-up was 70.03 ± 43.14; range: 1-180 months. There were 49 VE detected in 47 patients, as 2 of them had more than 1 VE. Incidence rate was 0.020 events_per_patient/year, cumulative incidence at 5 years was 11.11%. The more frequent VE that we found were cerebrovascular (28/49), mainly ischemic (21/28). Disability after SAH and the presence of multiple aneurysms were independently associated with a VE risk and improved the predictive capacity of multivariate models (AUC 0.679 vs 0.764; p = 0.0062).We reported a low vascular risk after SAH. We have shown the usefulness of SAH factors to identify patients with a higher risk of VE.

PurposeArteriovenous fistulas of the Vein of Galen region in adults (Ad-VGAVF) are an uncommon entity with specific anatomic features. The aim of this article is to present our experience in the endovascular treatment of this pathology and to propose a therapeutic strategy based precisely on the angioarchitecture of these lesions.Materials and methodsDuring a 20-year period, 10 patients underwent endovascular treatment of Ad-VGAVF. They were nine men and one woman with a mean age of 50 years (23–66 years) treated with the same embolization strategy. Clinical presentation, angiographic characteristics, therapeutic strategy, and clinical outcomes were recorded.ResultsAll patients were treated exclusively by endovascular approach. Transarterial access was performed in eight patients and combined transvenous and transarterial access in two. Complete obliteration of the fistula was obtained in all patients. There were no intraprocedural complications. Post-embolization neurological symptoms occurred in 5 of 10 with complete resolution at six months in all of them.ConclusionArteriovenous fistulas of the Vein of Galen region in adults present uniform angioarchitecture despite their low prevalence. Based on this constant angioarchitecture and especially on the features of its venous drainage, judicious embolization strategy is feasible and effective. Ten cases treated entirely by endovascular approach with excellent clinical and angiographic outcomes show this treatment like a curative alternative for this entity of deep topography and severe prognosis.

IMPORTANCE: It is estimated that only 27% of patients with acute ischemic stroke and large vessel occlusion who undergo successful reperfusion after mechanical thrombectomy are disability free at 90 days. An incomplete microcirculatory reperfusion might contribute to these suboptimal clinical benefits. OBJECTIVE: To investigate whether treatment with adjunct intra-arterial alteplase after thrombectomy improves outcomes following reperfusion. DESIGN, SETTING, AND PARTICIPANTS: Phase 2b randomized, double-blind, placebo-controlled trial performed from December 2018 through May 2021 in 7 stroke centers in Catalonia, Spain. The study included 121 patients with large vessel occlusion acute ischemic stroke treated with thrombectomy within 24 hours after stroke onset and with an expanded Treatment in Cerebral Ischemia angiographic score of 2b50 to 3. INTERVENTIONS: Participants were randomized to receive intra-arterial alteplase (0.225 mg/kg; maximum dose, 22.5 mg) infused over 15 to 30 minutes (n = 61) or placebo (n = 52). MAIN OUTCOMES AND MEASURES: The primary outcome was the difference in proportion of patients achieving a score of 0 or 1 on the 90-day modified Rankin Scale (range, 0 [no symptoms] to 6 [death]) in all patients treated as randomized. Safety outcomes included rate of symptomatic intracranial hemorrhage and death. RESULTS: The study was terminated early for inability to maintain placebo availability and enrollment rate because of the COVID-19 pandemic. Of 1825 patients with acute ischemic stroke treated with thrombectomy at the 7 study sites, 748 (41%) patients fulfilled the angiographic criteria, 121 (7%) patients were randomized (mean age, 70.6 [SD, 13.7] years; 57 women [47%]), and 113 (6%) were treated as randomized. The proportion of participants with a modified Rankin Scale score of 0 or 1 at 90 days was 59.0% (36/61) with alteplase and 40.4% (21/52) with placebo (adjusted risk difference, 18.4%; 95% CI, 0.3%-36.4%; P = .047). The proportion of patients with symptomatic intracranial hemorrhage within 24 hours was 0% with alteplase and 3.8% with placebo (risk difference, −3.8%; 95% CI, −13.2% to 2.5%). Ninety-day mortality was 8% with alteplase and 15% with placebo (risk difference, −7.2%; 95% CI, −19.2% to 4.8%). CONCLUSIONS AND RELEVANCE: Among patients with large vessel occlusion acute ischemic stroke and successful reperfusion following thrombectomy, the use of adjunct intra-arterial alteplase compared with placebo resulted in a greater likelihood of excellent neurological outcome at 90 days. However, because of study limitations, these findings should be interpreted as preliminary and require replication. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03876119; EudraCT Number: 2018-002195-40

Rationale The potential value of rescue intraarterial thrombolysis in patients with large vessel occlusion stroke treated with mechanical thrombectomy has not been assessed in randomized trials. Aim The CHemical OptImization of Cerebral Embolectomy trial aims to establish whether rescue intraarterial thrombolysis is more effective than placebo in improving suboptimal reperfusion scores in patients with large vessel occlusion stroke treated with mechanical thrombectomy. Sample size estimates A sample size of 200 patients allocated 1:1 to intraarterial thrombolysis or intraarterial placebo will have >95% statistical power for achieving the primary outcome (5% in the control versus 60% in the treatment group) for a two-sided (5% alpha, and 5% lost to follow-up). Methods and design We conducted a multicenter, randomized, placebo-controlled, double blind, phase 2b trial. Eligible patients are 18 or older with symptomatic large vessel occlusion treated with mechanical thrombectomy resulting in a modified treatment in cerebral ischemia score 2b at end of the procedure. Patients will receive 20–30 min intraarterial infusion of recombinant tissue plasminogen activator or placebo (0.5 mg/ml, maximum dose limit 22.5 mg). Study outcome(s) The primary outcome is the proportion of patients with an improved modified treatment in cerebral ischemia score 10 min after the end of the study treatment. Secondary outcomes include the shift analysis of the modified Rankin Scale, the infarct expansion ratio, the proportion of excellent outcome (modified Rankin Scale 0–1), the proportion of infarct expansion, and the infarction volume. Mortality and symptomatic intracerebral bleeding will be assessed. Discussion The study will provide evidence whether rescue intraarterial thrombolysis improves brain reperfusion in patients with large vessel occlusion stroke and incomplete reperfusion (modified treatment in cerebral ischemia 2b) at the end of mechanical thrombectomy.

Background and purpose A well-known classification of dural arteriovenous fistulas (DAVFs) according to the patterns of venous drainage was described in 1977 by Djindjian, Merland et al. and later revised by Cognard, Merland et al. in 1995. They described 5 types of DAVFs assuming that the type of venous drainage is directly correlated with neurologic symptoms and in particular with hemorrhagic risk. We present a series of cases that combines type IV (DAVF with cortical venous drainage associated with venous ectasia) and type V (DAVF with spinal venous drainage), which we named type IV + V. Materials and methods A retrospective study between 2012 and 2020 in 2 Hospitals was performed on patients that met inclusion criteria for a diagnosis of this type of DAVF. Demographics, location, clinical presentation and outcomes of endovascular embolization were studied. Results Five (2,3%) patients out of 220 had a type IV + V DAVF. All cases had an aggressive presentation, either subarachnoid hemorrhage, myelopathy or both. All patients were treated with endovascular transarterial embolization achieving complete angiographic occlusion in one session and total remission of symptoms at 3 months. Conclusions This rare type of DAVF, combines two aggressive venous drainage patterns. For that reason, patients with type IV+V DAVF probably have a more aggressive natural history and worst outcome due to risk of intracranial and/or spinal hemorrhage and myelopathy, thus requiring urgent diagnostic and treatment. Larger studies are needed to better understand this type of DAVF.

BackgroundExperience with the endovascular treatment of unruptured small intracranial aneurysms by flow diverter devices is still limited.ObjectiveTo assess the safety and efficacy of the SILK flow diverter (SFD) in the treatment of small unruptured cerebral aneurysms (MethodsWe performed a retrospective review of a prospectively maintained database of patients treated with a SFD between July 2008 and December 2013 at 4 institutions in Spain to identify all patients with small unruptured aneurysms (ResultsA total of 109 small aneurysms were treated with a SFD in 104 patients (78 women; 26 men; mean, median, and range of age: 55.2, 57.1, and 19–80 years, respectively). A total of 60 patients were asymptomatic (57.7%). All except 7 aneurysms (6.4%) arose from the anterior circulation. The mean size of the aneurysms was 4.7±1.9 mm. At 6 months, the neuromorbidity and neuromortality rates were 2.9% and 0.9%, respectively. Imaging at the 12-month follow-up showed complete occlusion, neck remnants, and residual aneurysm in 88.5% (69/78), 7.7% (6/78), and 3.3% (3/78) of cases, respectively. No delayed hemorrhage occurred.ConclusionsThe findings suggest that the indications for SFD can be safely extended to small intracranial aneurysms.

BACKGROUND Flow-diverter technology has become an important stent-based embolization tool in the treatment of complex cerebrovascular pathology. We report here the experience of 4 Spanish centers with using the SILK flow-diverter (SFD) device. OBJECTIVE To evaluate the safety and efficacy of using the SFD in the endovascular treatment of intracranial aneurysms with complex morphology. METHODS We retrospectively examined a prospectively maintained database of patients treated with SFD devices between July 2008 and December 2013 at 1 of 4 institutions in Spain. Data regarding patient demographics, aneurysm characteristics, and technical procedure were analyzed. Angiographic and clinical findings were recorded during the procedure and at 12 months postoperatively. RESULTS A total of 175 SFD devices were implanted in 157 patients (women/men: 119/38; mean, median, and range of age: 56.2, 56.7, and 19-80 years, respectively), who were treated in a delayed manner (3-6 months from the event) for 180 aneurysms (165 unruptured and 15 ruptured). Adverse events (acute and delayed) were observed in 28.7% of cases (45/157), and most were resolved (19.1%; 30/157). Six months after the procedure, total morbidity and mortality were 9.6% (15/157) and 3.2% (5/157), respectively. Long-term imaging follow-up showed complete occlusion, neck remnants, and residual aneurysm in 78.1% (100/128), 14.0% (18/128), and 7.8% (10/128) of cases, respectively. CONCLUSIONS The SFD device is an effective tool for the treatment of challenging aneurysms, and allows complete occlusion within a year of the procedure in most patients, with morbidity and mortality comparable to those previously reported for similar devices.

Background and Purpose— Our aim was to describe variables associated with initial misdiagnosis of subarachnoid hemorrhage (SAH). We also analyzed the relationship of misdiagnosis with poor outcome and complications in good Hunt and Hess (HH) cases. Methods— In a prospective cohort of 401 patients with SAH, misdiagnosis was defined as failure to correctly identify, at first physician contact, a subsequently documented SAH; this meant no urgent radiological study and lumbar puncture was performed. Poor outcome was defined as modified Rankin Scale score 3 to 6 at 3-month follow-up. We recorded age, sex, hypertension, diabetes mellitus, current smoking, previous antithrombotic treatment, initial HH and radiological severity, presence of aneurysm, first therapeutic procedure, hydrocephalus, delayed cerebral ischemia (DCI), rebleeding, and procedure-related complications. Results— Misdiagnosis was confirmed in 104/401 (25.9%) patients, who also had a longer time-to-admission to hospital. Misdiagnosis was associated with less clinical and radiological severity, compared with a correct diagnosis; the 2 groups did not differ in age or cardiovascular risk factor profile. Poor outcome was registered in 167/401 patients (41.6%). Age, misdiagnosis, and greater clinical and radiological initial severity were independent predictors of poor outcome. In the 236 patients (58.8% of cohort) with HH 1–2, misdiagnosis was associated with poor outcome in univariate and multivariate analysis, respectively (odds ratio=3.89; 95% CI, 1.89–8.01). Delayed cerebral ischemia (odds ratio=2.47; 95% CI, 1.2–5.09) and procedure-related complications (odds ratio=2.27; 95% CI, 1.07–4.82) were independently associated with misdiagnosis. Conclusions— Misdiagnosis is an unresolved problem in SAH, and it is a missed opportunity for good outcome in patients with HH 1–2. The poor outcome is partially explained by a higher risk of delayed cerebral ischemia and procedure-related complications in misdiagnosed patients. There is a need to improve the diagnostic strategy in patients reporting only a headache (HH 1–2) after SAH.

ObjectiveTo describe short-term and 5-year rates of mortality and poor outcome in patients with spontaneous aneurysmal subarachnoid hemorrhage (aSAH) who received repair treatment.MethodsIn this prospective observational study, mortality and poor outcome (modified Rankin Scale score 3–6) were analyzed in 311 patients with aSAH at 3 months, 1 year, and 5 years follow-up. Sensitivity analysis was performed according to treatment modality. In-hospital and 5-year complications were analyzed.ResultsOf 476 consecutive patients with spontaneous subarachnoid hemorrhage, 347 patients (72.9%) had aSAH. Of these, 311 (89.6%) were treated (242 endovascular, 69 neurosurgical), with a mean follow-up of 43.4 months (range, 1 to 145). Three-month, 1-year, and 5-year mortality was 18.4%, 22.9%, and 29.0%, and poor outcome was observed in 42.3%, 36.0%, and 36.0%, respectively. Adjusted poor outcome was lower in endovascular than in neurosurgical treatment at 3 months (odds ratio [OR] 0.36 [95% confidence interval [CI] 0.18-0.74]), with an absolute difference of 15.8% (number needed to treat = 6.3), and at 1 year (OR = 0.40 [95% CI 0.20-0.81]), with an absolute difference of 15.9% (number needed to treat = 6.3). Complications did not differ between the 2 procedures. However, mechanical ventilation was less frequent with the endovascular technique (OR 0.67 [95% CI 0.54–0.84]).ConclusionsPatients with aSAH treated according to current guidelines had a short-term mortality of 18.4% and 5-year mortality of 29%. The majority (64.0%) of patients remained alive without disabilities at 5-year follow-up. Patients prioritized to endovascular treatment had better outcomes than those referred to neurosurgery because endovascular coiling was not feasible.

PurposeTo describe the efficacy and complications of treating cerebral aneurysms with the Flow Re-direction Endoluminal Device (FRED) and to identify predictors for aneurysm occlusion.MethodsA prospective observational registry including all consecutive aneurysms treated with FRED between December 2015 and July 2018 was designed in one therapeutic neuroangiography department. The primary endpoint for treatment efficacy was complete or near-complete occlusion (O’Kelly–Marotta (OKM) C–D), assessed by three-dimensional digital subtraction angiography. Major (all symptomatics) and minor complications were described and those with modified Rankin Scale scores 3–6 were considered clinically relevant. Univariate and multivariate analyses were performed to identify predictors of efficacy.ResultsA total of 185 aneurysms were analyzed in 150 patients (mean age 54.3±11.5 years). Mean follow-up was 18.99±11.32 months (range 0–43). Efficacy was evaluated in 156 (84.32%) cases: 132 (84.6%) had OKM C–D occlusion, 31/47 (66%) within the first year and 101/109 (92.7%) later on. Major complications were observed in 12 (6.5%) cases: three strokes (one transient ischemic accident, two minor strokes), six intra-stent thrombosis, and three with bleeding, but only one (0.5%) was clinically relevant. Minor complications (all asymptomatic) were observed in 10 (5.4%) cases: three shortening/repositioning of stent; two arterial dissection, two arterial occlusion, and three intra-stent stenosis. Independent predictors of occlusion were immediate OKM grade B–C–D (OR 4.01, 95% CI 1.51 to 10.62), single aneurysm (OR 3.29, 95% CI 1.05 to 10.32), and small size aneurysm (OR 4.74, 95% CI 1.57 to 14.30).ConclusionThe FRED stent fully complied with efficacy and safety requirements for treatment of intracranial aneurysms. Three predictors of aneurysm occlusion were identified.

Castleman's disease is a very rare entity in pediatric population and its presentation in the neck is scarcely described in the literature. We present the case of a 10-year-old-girl with an expanding neck mass over several months causing dysphagia and dyspnea. Surgical excision of the mass was performed and the analysis revealed unicentric Castleman's Disease. This is the second largest reported case of neck pediatric CD in the literature, and it presented with a symptomatology that differs from the other cases described. This fact highlights the need to include CD in the differential diagnosis of pediatric neck masses.

BACKGROUND AND PURPOSE: The introduction of liquid embolic agents has revolutionized endovascular approach to cranial vascular malformations. The aim of the study was to retrospectively assess the efficacy and safety of Precipitating Hydrophobic Injectable Liquid (PHIL), a new nonadhesive liquid embolic agent, in the treatment of patients with cranial dural arteriovenous fistulas. The primary end point was the rate of complete occlusion of dural arteriovenous fistulas. Secondary end points included the incidence of adverse events and clinical status at 3-month follow-up. MATERIALS AND METHODS: This was a retrospective multicenter study. Twenty-six consecutive patients with dural arteriovenous fistulas (de novo or previously treated) treated by injection of PHIL only or with PHIL in combination with other embolization products (such as Onyx or detachable coils) were included in the study. Recruitment started in August 2014 and ended in September 2015. RESULTS: Twenty-two (85%) patients were treated with PHIL only, with 3 patients treated with both PHIL and Onyx, and 1, with both PHIL and coils. Immediate complete angiographic occlusion was achieved in 20 (77%) patients. Of the 6 patients with residual fistulas, 3 were retreated with PHIL and 1 achieved angiographic cure. An adverse event was seen in 1 patient who developed worsening of preexisting ataxia due to acute thrombosis of the draining vein. CONCLUSIONS: PHIL appears to be safe and effective for endovascular treatment of cranial dural arteriovenous fistulas. Short-term angiographic and clinical results are comparable with those of Onyx, with the added advantage of easier preparation and improved homogeneous cast visualization. The use of iodine as a radio-opacifier also produces considerably less artifacts on CT compared with tantalum-based embolic materials.

Background and Purpose— Since demonstration of the benefit of endovascular treatment (EVT) in acute ischemic stroke patients with proximal arterial occlusion, stroke care systems need to be reorganized to deliver EVT in a timely and equitable way. We analyzed differences in the access to EVT by geographical areas in Catalonia, a territory with a highly decentralized stroke model. Methods— We studied 965 patients treated with EVT from a prospective multicenter population-based registry of stroke patients treated with reperfusion therapies in Catalonia, Spain (SONIIA). Three different areas were defined: (A) health areas primarily covered by Comprehensive Stroke Centers, (B) areas primarily covered by local stroke centers located less than hour away from a Comprehensive Stroke Center, and (C) areas primarily covered by local stroke centers located more than hour away from a Comprehensive Stroke Center. We compared the number of EVT×100 000 inhabitants/year and time from stroke onset to groin puncture between groups. Results— Baseline characteristics were similar between groups. Throughout the study period, there were significant differences in the population rates of EVT across geographical areas. EVT rates by 100 000 in 2015 were 10.5 in A area, 3.7 in B, and 2.7 in C. Time from symptom onset to groin puncture was 82 minutes longer in group B (312 minutes [245–435]) and 120 minutes longer in group C (350 minutes [284–408]) compared with group A (230 minutes [160–407]; P Conclusions— Accessibility to EVT from remote areas is hampered by lower rate and longer time to treatment compared with areas covered directly by Comprehensive Stroke Centers.

Ipsilateral chronic carotid occlusion (CCO) can be found in up to 15% of patients with transient ischemic attacks (TIAs) and strokes. 1,2 Cervical occlusion is a morbid diagnosis with a high risk (6%-20%) of recurrent strokes and ipsilateral strokes (2%-9.5%). 3-5 The subgroup of patients with severe hemodynamic compromise with CCO is at a higher risk for such events. 6 The effectiveness of percutaneous transluminal angioplasty and stenting of the extracranial carotid artery is improving as a result of the development of autoexpandable prostheses and new systems of cerebral protection. 7 Currently, this technique constitutes a true alternative to carotid endarterectomy in the treatment of a severe degree of carotid stenosis with a minimum risk of cerebral embolization. 8-10 We attempted endovascular recanalization in select patients with CCO and retrograde ophthalmic artery flow. 11 We present an early report on the safety and efficacy of endovascular recanalization in symptomatic CCO. In this study, we evaluate the safety and efficacy of endovascular recanalization in CCO with severe hemodynamic compromise. METHODS We performed a retrospective review of patients with symptomatic CCO. We identified 39 patients with CCO who were admitted to our institution after suffering an ischemic event, stroke, or TIA. Neurological evaluation included preprocedural and postprocedural clinical examination and neuropsychological tests. 12 In addition to routine neurological examinations, we focused on cognitive function. We used the Rankin Scale to measures disability scores, the National Institutes of Health Stroke Scale to detect focal disorder, and the Barthel Scale to evaluate functional incapacity. Minor stroke was defined as an increase in the National Institutes of Health Stroke Scale score of ,3 with complete resolution or no significant disability at 30 days. Major stroke was defined as an increase in the National Institutes of Health Stroke Scale score of $ 3 with significant disability at 30 days. Neuropsychological tests included global cognitive function (Mini-Mental State Examination of Folstein

Pial arteriovenous fistulas (pAVF) of the posterior fossa are rare and may present with symptoms secondary to mass effect, venous hypertension or hemorrhage, among others. A case is presented of a previously healthy 2-year-old boy with neurological deficit arising from pAVF of the posteroinferior cerebellar artery. The pAVF was successfully treated with endovascular occlusion.

Purpose: In this article, the authors studied the feasibility of estimating regional mechanical properties in cerebral aneurysms, integrating information extracted from imaging and physiological data with generic computational models of the arterial wall behavior. Methods: A data assimilation framework was developed to incorporate patient-specific geometries into a given biomechanical model, whereas wall motion estimates were obtained from applying registration techniques to a pair of simulated MR images and guided the mechanical parameter estimation. A simple incompressible linear and isotropic Hookean model coupled with computational fluid-dynamics was employed as a first approximation for computational purposes. Additionally, an automatic clustering technique was developed to reduce the number of parameters to assimilate at the optimization stage and it considerably accelerated the convergence of the simulations. Severalin silicoexperiments were designed to assess the influence of aneurysm geometrical characteristics and the accuracy of wall motion estimates on the mechanical property estimates. Hence, the proposed methodology was applied to six real cerebral aneurysms and tested against a varying number of regions with different elasticity, different mesh discretization, imaging resolution, and registration configurations. Results: Severalin silicoexperiments were conducted to investigate the feasibility of the proposed workflow, results found suggesting that the estimation of the mechanical properties was mainly influenced by the imagespatial resolution and the chosen registration configuration. According to the in silicoexperiments, the minimal spatial resolution needed to extract wall pulsation measurements with enough accuracy to guide the proposed data assimilation framework was of 0.1 mm. Conclusions: Current routine imaging modalities do not have such a high spatial resolution and therefore the proposed data assimilation framework cannot currently be used onin vivo data to reliably estimate regional properties in cerebral aneurysms. Besides, it was observed that the incorporation of fluid-structure interaction in a biomechanical model with linear and isotropic material properties did not have a substantial influence in the final results.

PMAVFs are rare entities that are formed by a direct communication between an artery that feeds the spinal cord and a vein. The goal of treatment is to occlude the shunt; this is done endovascularly either from an arterial or a venous approach. When these approaches are not possible, direct percutaneous puncture of the draining veins may be attempted to embolize the arteriovenous shunt directly.

There are several cerebral protection devices used for carotid artery stenting (CAS). All of them require manipulation and exchange of two separate materials (cerebral protection device ? dilatation balloon), making the procedure longer and posing possible complications such as vasospasm and embolism. The new system described here is an evolution of the cerebral protection concept and allows temporary occlusion of the distal internal carotid during CAS procedures with both materials in one device. We present our experience using this new device. Between January 2007 and March 2008, consecutive patients sent for CAS (symptomatic, with stenosis C50%, or asymptomatic, with stenosis C70%) were treated using TwinOne as a cerebral protection system. All patients were treated using the "simplified" CAS technique, limiting cerebral protection to the poststenting angioplasty phase. Two hundred nine patients have been treated at our institutions; eight underwent bilateral CAS, for a total of 217 CAS procedures performed using the TwinOne for cerebral protection. There have been four periprocedural (within 3 h of procedure) cases of complications (1.8%): three disabling strokes (one in-stent thrombosis, one presumed clotting, one ipsilateral stroke with uncertain root cause) and one transient ischemic attack attributable to heart failure. There have been two in-hospital complications (0.92%): one disabling stroke of unclear origin and one contralateral transient ischemic attack. No additional adverse event has been reported at 30 days after the CAS procedure. In conclusion, this cerebral protection system is simple to use, allows a quick intervention and short occlusion time, and has a low rate of complications.

The preliminary experience with the Leo microstent in combination with detachable coils for the treatment of patients with wide-necked cerebral aneurysms is reported, and the technical complications and recommendations for optimum placement and deployment are discussed. Thirty two patients identified as harboring wide-necked aneurysm were selected for stent-assisted coiling. Aneurysms were paraophthalmic-cavernous in 13 cases, eight were located at the posterior communicating artery, four at the basilar artery, three at the vertebral arteries, two at the posterior cerebral arteries, one at the right middle artery, and one at the right posterior inferior cerebellar artery. After appropriate antiplatelet therapy, the Leo stent was delivered to the aneurysm site and positioned without difficulty, except in four cases requiring the use of steam to shape the tip of the Vasco microcatheter. Angiographic follow-up was undertaken at six months in 32 patients, at one year in 27 patients, and at two years in 20 patients. Stent placement in the desired position with complete or near complete occlusion of the aneurysm was feasible in all patients. In one patient, the stent was slightly displaced during microwire manipulation for aneurysm microcatheterization. Two-year angiography in 20 patients showed 18 complete occlusions and two aneurysms with a minimal residual neck. The Leo stent represents a significant advancement in the vascular treatment of intracranial aneurysms providing high radial force and an easy delivery system i.e., it is a feasible, secure and effective system.

Treatment of unruptured intracranial aneurysms based on critical size and predictive risk factors is generally accepted, but several factors contribute to the clinical outcome in a patient with subarachnoid hemorrhage (SAH) secondary to a ruptured aneurysm. We decided to evaluate other parameters that might contribute to the clinical outcome of patients with a ruptured posterior communicating artery aneurysm. A retrospective review of the medical records of patients diagnosed and/or treated of cerebral aneurysms at our institution was carried out. We selected patients with Pcom aneurysms that presented with SAH and reviewed conventional and tridimensional angiographic images to determine its anatomical orientation and correlated the data with amount of SAH and clinical presentation and outcome. A total of 112 Pcom aneurysms presented with SAH and were included in this study. 92 patients were women and 20 were men, with a mean age of 57 years (range 25–81). According to anatomical orientation, 43 were inferolateral, 30 lateral, 13 superolateral, three inferomedial, two in medial location, two superomedial, 11 inferoposterior, five posterior and three superoposterior. Aneurysms in superolateral location are to be watched carefully, it is likely that this location joins several conditions for these aneurysms to grow faster or have a higher hemodynamic stress which makes them more at risk of rupture and contribute to a worse clinical outcome.

The ultimate goal of endovascular treatment of intracranial aneurysms is complete occlusion of the aneurysm without compromising the parent artery. Several techniques have been described for the treatment of wide-necked aneurysms. An innovative method is proposed for the treatment of wide-necked aneurysms with the neck incorporated in the parent artery.

Temporary balloon occlusion is used as tolerance predictor in patients undergoing vascular occlusion with the aid of clinical assessment during a 30–40 minute temporary occlusion. Several other techniques have been used to help predict each patient's tolerance. Digital cerebral parenchymography (DCP) was originally described to improve our analysis of brain perfusion during ischemic events. We report a case using DCP as tolerance predictor in a patient undergoing sacrifice of the left vertebral artery.

To obtain a better active contention of the lumbosacral spine, a new technique of liposuction of the fat surrounding the atrophied paraspinal muscles is described. A preliminary series of 40 patients presenting low back pain symptoms is presented. The technique, performed on an out patient basis is well tolerated. The MR follow-up controls regularly showed an expansion of the paraspinal muscles. The overall results obtained on this preliminary non uniform series showed encouraging results with 77.5% of very good or good results.

Radial approach (mainly right) has been used in the treatment of 67 supraaortic lesions including 56 carotid, nine vertebral and two subclavian artery stenoses. This approach offers new possibilities and solves most of the remaining technical difficulties or impossibilities encountered in the endovascular treatment of supraaortic lesions. The current technique is described. The results of this first series have been very satisfactory without complication. MR angiography allows selection of patients suitable for radial approach.

Introduction Direct carotid artery puncture (DCP) is employed in patients with tortuous anatomy and peripheral vascular disease when the peripheral arteries are not available for vascular access. Manual compression is the only method of achieving hemostasis following DCP and, till date, the use of a closure device for DCP has been reported in only one patient. In this study we sought to analyze our experience with the use of closure device for DCP. Methods This is a retrospective study of patients in whom Angioseal™ was used following DCP for neuroendovascular procedures. Medical charts and imaging of these patients was reviewed for any abnormalities pertaining to the use of the closure device. Results A total of eight patients were included in the study. Angioseal™ was used in all the patients. There were no complications related to the use of the closure device in any of the eight patients. Immediate post-procedure angiography done in one patient did not show any structural or hemodynamic abnormalities within the carotid artery lumen. At 6 months follow-up imaging, there was no evidence stenosis or vascular wall abnormality in any of the patients. There were no adverse clinical reactions related to the use of closure device. Conclusion In our experience, Angioseal™ may be a safe and off-label effective closure device for patients undergoing DCP for neuroendovascular procedures. It obviates the need for manual compression without causing any structural or hemodynamic changes within the carotid artery. Larger studies with longer follow-up are required to establish its safety in patients undergoing DCP.

Atherosclerotic stenosis of the posterior circulation refractory to medical treatment generally has a poor prognosis resulting in a high morbidity-mortality rate and the recurrence of ischemic events. Extracranial bypass in the vertebrobasilar system is possible but is also associated with high morbidity (3–21%) and mortality (13–55%)1,2, and has not been demonstrated to reduce the risk of stroke. Percutaneous angioplasty alone has also not shown favorable results, and further, has been associated with a remarkable number of complications. The improvement resulting from endovascular therapy has taken the treatment of this pathology to a new dimension. We describe eight patients with severe symptomatic basilar artery stenosis who, in addition to medical therapy, were treated by our service with angioplasty and stent placement. Three of them received urgent treatment. All patients suffering from severe stenosis of the basilar artery were treated by the insertion of balloon expandable stents. The degree of pre-stent stenosis was approximately 80% in all cases, and was reduced to 5–10% after the stent implant. There were no complications during treatment. There has not been a recurrence of symptoms or a new ischemic lesion during the one-year follow-up period. Endovascular therapy with a balloon expandable stent or angioplasty plus stent are presented as improved choices for treatment of patients with severe basilar artery stenosis refractory to medical treatment.

Atheromatous stenoses at the carotid bifurcation were treated by angioplasty and Wallstenting with cerebral protection obtained in most cases by temporary occlusion of the internal carotid artery. 287 carotid stenoses were treated in 233 patients. The stenosis was symptomatic in 79% of cases. All patients presented either a stenosis of >70% with significant impairment of the cerebral circulation (281 cases) or a symptomatic ulcerated plaque (six cases). A self-mounted protection system was used in 177 cases, the Percusurge Guardwire protection device in 98 cases an EPI filter in 12 cases. There was a contralateral internal carotid occlusion in 13% of cases. A combined stenting (vertebral, siphon, subclavian) was performed in 14% of cases. A Rolling membrane Wallstent was used in 84 patients, a first generation Easy Wallstent in 38 cases, a “Carotid” Easy Wallstent 35 in 55 cases and monorail 14 in 110 cases. Full opening of the stenosis was obtained in 98% of patients with correction of the arterial curve and improvement of the cerebral vascular supply. There were 0.7% cases with transient symptomatic neurological complications and 2% with permanent sequelae mainly related to avoidable inadequacy in flushing or to the insufficient radial force of the first generation Easy Wallstent. There were no per and one post-procedural cardiac complication (0.6%) in the s165 cases performed with the “Carotid” Easy Wallstent. Follow-up angiograms showed O.7% of restenoses. Still in evolution, endovascular treatment of atheromatous stenoses at the carotid bifurcation with cerebral protection and stenting is a promising alternative technique to surgery. The association of Carotid Easy Wallstent 14 monorail and Percusurge Guardwire appears to be currently satisfactory.

Background: Among the acute ischemic stroke patients with large vessel occlusions and contraindications for the use of IV thrombolysis, mainly on oral anticoagulation or presenting too late, primary endovascular therapy is often performed as an alternative to the standard therapy even though evidence supporting the use of endovascular reperfusion therapies is not yet established. Using different statistical approaches, we compared the functional independence rates at 3 months among patients undergoing primary endovascular therapy and patients treated only with IV thrombolysis. Methods: We used data from a prospective, government-mandated and externally audited registry of reperfusion therapies for ischemic stroke (January 2011 to November 2012). Patients were selected if treated with either IV thrombolysis alone (n = 1,582) or primary endovascular thrombectomy (n = 250). A series of exclusions were made to homogenize the clinical characteristics among the two groups. We then carried out multivariate logistic regression and propensity score matching analyses on the final study sample (n = 1,179) to compare functional independence at 3 months, as measured by the modified Rankin scale scores 0-2, between the two groups. Results: The unadjusted likelihood of good outcome was poorer among the endovascular group (OR: 0.69; 95% CI: 0.47-1.0). After adjustment, no differences by treatment modality were seen (OR: 1.51; 95% CI: 0.93-2.43 for primary endovascular therapy). Patients undergoing endovascular thrombectomy within 180-270 min (OR: 2.89; 95% CI: 1.17-7.15) and patients with severe strokes (OR: 1.84; 95% CI: 1.02-3.35) did better than their intravenous thrombolysis counterparts. The propensity score-matched analyses with and without adjustment by additional covariates showed that endovascular thrombectomy was as effective as intravenous thrombolysis alone in achieving functional independence (OR for unadjusted propensity score matched: 1.35; 95% CI: 0.9-2.02, OR for adjusted propensity score matched: 1.45; 95% CI: 0.91-2.32). Conclusion: This comparative effectiveness study shows that in ischemic stroke patients with contraindications for IV thrombolysis, primary endovascular treatment might be an alternative therapy at least as effective as IV thrombolysis alone. Randomized controlled trials are urgently needed.

Purpose: To report the efficacy and complications of intra-ophthalmic artery melphalan (IAM) for treatment of patients with advanced intra-ocular retinoblastoma. Methods: Patients with newly diagnosed, unilateral, group D retinoblastoma were included in a phase II protocol. Children with relapsed-refractory disease after systemic chemoreduction were later treated under the same guidelines. Melphalan (3–5 mg/procedure) was injected through a 1.2 F microcatheter placed into the ophthalmic artery every 21 days. Results: Eleven patients (12 eyes, eight as primary treatment) received 33 IAM procedures. The phase II protocol closed prematurely because of low accrual. The IAM technique was overall safe and could be performed successfully in 31 of 33 (94%) attempts. After the second administration of IAM, very good partial response was achieved in all treated eyes. With a median follow-up time of 29.5 months (range 6–57), ocular salvage was achieved in 7 of 12 (58%) eyes. No systemic adverse events were observed. Two patients developed diffuse arteriolar sclerosis, hyperpigmentation of the retinal pigment epithelium and partial retinal atrophy after the second IAM. Both eyes were preserved with no tumour activity, good motility and perception of light, 56 and 30 months after the last IAM treatment. Multinucleated macrophages with intracytoplasmic foreign material were found in the choroid and the retina in 2 of 5 enucleated eyes. Conclusion: Our study reports the activity and reproducibility of IAM in advanced retinoblastoma but also underlines the challenges of performing prospective studies on this treatment modality. Toxicity was limited to only ocular vascular events.

Background and Purpose —We sought to quantitatively and qualitatively evaluate the release of atheromatous plaque debris induced by carotid stenting procedures. Methods —Eight patients with severe carotid atheromatous stenoses were treated by stent implantation under distal balloon protection. Blood samplings were obtained after stent deployment in the blood pooled below the inflated protection balloon. The samples were centrifuged and evaluated for plaque debris with the use of light microscopy. The debris release was quantitatively estimated by dividing the total volume of debris obtained by the mean debris size. Five patients without endovascular procedure were used as a control group. Results —The 2 main debris types found were nonrefringent cholesterol crystals (4 to 389 μm; 115 to 8697 in number) and lipoid masses (7 to 600 μm; 341 to 34 000 in number). There was a statistically significant difference compared with the samples obtained in the control group ( P =0.017). Conclusions —Blood samples collected during stent implantation procedures contain a large quantity of atheromatous plaque debris. This emphasizes the role of distal protection techniques in avoiding migration of this plaque material into the cerebral circulation.

New therapies are needed to improve current results in diffuse intrinsic pontine glioma. We present here the initial experience of administering Celyvir, autologous mesenchymal stem cells infected with ICOVIR-5, an oncolytic adenovirus that selectively replicates in cancer cells, by means of superselective intra-arterial delivery, in a patient diagnosed of diffuse intrinsic pontine glioma. Feasibility, safety, and morbidity rates of the superselective catheterization technique are comparable with those of diagnostic angiography. The intra-arterial approach warrants a greater contact of the mesenchymal stem cells with the tumor mass, and minimizes hemorrhages or vascular disruption. The tolerance to the 2 administrations was excellent, with no acute or delayed adverse effect, underscoring the feasibility of this technique for the delivery of virotherapies and/or cellular therapies in this location.

To assess effectiveness of endovascular treatment of carotid artery stenosis by means of angioplasty with cerebral protection and stent placement.Angioplasty was performed for carotid artery stenosis in 259 patients. Cerebral protection (triple coaxial catheter) was used in 136 cases of atherosclerotic stenosis in the internal carotid artery or in the carotid bifurcation and was not used in 123 cases. A stent was placed in 69 patients when images obtained immediately after angioplasty showed signs of dissection or insufficient arterial opening.No procedure-related complications occurred in the 71 cases of nonatherosclerotic stenosis and in the 14 cases of proximal carotid artery and siphon atherosclerotic stenosis. Among the 38 patients who underwent angioplasty without cerebral protection, dissection occurred in two (5%) and embolic complication occurred in three (8%) during the procedure. Among 136 patients in whom cerebral protection was used, no embolic complications occurred during angioplasty, and two (1%) occurred during or after stent placement without protection. No residual flaps were found after stents were placed, and the restenosis rate decreased from 16% to 4%.Endovascular treatment can be considered for all types of carotid artery stenosis. Cerebral protection is mandatory to eliminate embolic complication in cases of atherosclerotic stenosis in the internal carotid artery or carotid bifurcation. Stent placement has eliminated the risk of immediate dissection and reduced the risk of delayed restenosis.

Background Giant perimedullary arteriovenous fistulas (GPMAVFs) located in the cervical region are a rare pathology with distinctive characteristics. Objective To evaluate clinical presentation and different endovascular treatment options of cervical GPMAVFs and review previously published data in the literature regarding cervical GPMAVFs. Methods Six patients with cervical GPMAVFs were found in the spinal vascular malformations database of our group collected between 1990 and 2009. Endovascular techniques and treatment outcomes were evaluated and compared with other published series. Results Clinical presentations were progressive motor deficit (5 patients), hematomyelia (1 patient), meningeal syndrome (1 patient), and respiratory arrest and gait apraxia (1 patient). Three patients were treated by the transarterial approach. One patient was treated by the transvenous approach due to previous embolizations resulting in a proximal occlusion and preventing a safe transarterial approach. A transvenous approach was used in another patient due to complex arterial anatomy. In 1 patient, direct percutaneous puncture of the venous pouch was necessary because of previous proximal occlusion of the arteries. All embolizations resulted in complete occlusions with clinical improvement, and there was no recanalization during a mean follow-up of 21 months. Conclusion Transarterial embolization of cervical GPMAVFs is safe and effective when it is done in highly experienced centers. Cervical GPMAVFs that cannot be accessed by the transarterial technique due to their complex angioarchitecture can be treated by transvenous embolization or direct puncture of the venous pouch.

BACKGROUND AND PURPOSE: Endovascular coiling is a well-established therapy for treating intracranial aneurysms. Nonetheless, postoperative hemodynamic changes induced by this therapy remain not fully understood. The purpose of this work is to assess the influence of coil configuration and packing density on intra-aneurysmal hemodynamics. MATERIALS AND METHODS: Three 3D rotational angiography images of 3 intracranial aneurysms before and after endovascular coiling were used. For each aneurysm, a 3D representation of the vasculature was obtained after the segmentation of the images. Afterward, a virtual coiling technique was used to treat the aneurysm geometries with coil models. The aneurysms were coiled with 5 packing densities, and each was generated by using 3 coil configurations. Computational fluid dynamics analyses were carried out in both untreated and treated aneurysm geometries. Statistical tests were performed to evaluate the relative effect of coil configuration on local hemodynamics. RESULTS: The intra-aneurysmal blood flow velocity and wall shear stress were diminished as packing density increased. Aneurysmal flow velocity was reduced >50% due to the first inserted coils (packing density .01) were found in the hemodynamics due to coil configuration for high packing densities (near 30%). A damping effect was observed on the intra-aneurysmal blood flow waveform after coiling. CONCLUSIONS: Intra-aneurysmal hemodynamics are altered by coils. Coil configuration might reduce its influence on intra-aneurysmal hemodynamics as the packing density increases until an insignificant influence could be achieved for high packing densities.

Carotid artery stenting is usually performed by a femoral approach. When the patient's anatomy forbids this or other distal access to the carotids, a direct access by percutaneous puncture may be used. We present two cases in which a successful stenting of the carotids with the use of a cerebral protection device was performed.

This study investigates the efficacy of chemonucleolysis using RGE in the treatment of cervical disk hernias in a small sample of patients who had cervical diskogenic or radicular pain secondary to disk herniations. Results were satisfactory in 89.5% patients, with no adverse events recorded during the procedure or after. The use of RGE shows promising results and might be a feasible and safe alternative in the treatment of cervical disk hernias.

Neurotoxicity from contrast media used in angiography is a rare complication from these procedures. The infrequency with which it is encountered makes it a diagnostic challenge. We present the case of a 51-year-old male who, 30 min after successful angiography for treatment of a right carotid-ophthalmic fusiform aneurysm with a stent, developed psychomotor agitation, disorientation, and progressive left faciobrachial hemiparesis (4/5). An emergency nonenhanced CT showed marked cortical enhancement and edema in the right cerebral hemisphere. Cortical enhancement is thought to be secondary to contrast extravasation due to disruption of the blood-brain barrier. Angiography was performed immediately, without any pathologic findings. After this procedure there was an increase in the left faciobrachial hemiparesis (3/5), right gaze deviation, Gerstmann syndrome, and left anosognosia and left homonymous hemianopsia. Endovenous dexamethasone and mannitol were initiated. Twenty-four hours later an MRI showed no signs of acute infarct, just gyriform signal increase in the right cerebral hemisphere on FLAIR and a decrease in the edema observed before. The patient had progressive improvement of his neurological deficit. A control MRI done 5 days later was normal. The patient recovered completely and was discharged. This rare entity should be kept in mind but diagnosed only when all other causes have been ruled out, because more important and frequent causes, such as acute infarct, must be excluded promptly.

Endovascular treatment of intracranial aneurysms is a minimally-invasive technique recognized as a valid alternative to surgical clipping. However, endovascular treatment can be associated to aneurysm recurrence, either due to coil compaction or aneurysm growth. The quantification of coil compaction or aneurysm growth is usually performed by manual measurements or visual inspection of images from consecutive follow-ups. Manual measurements permit to detect large global deformation but might have insufficient accuracy for detecting subtle or more local changes between images. Image inspection permits to detect a residual neck in the aneurysm but do not differentiate aneurysm growth from coil compaction. In this paper, we propose to quantify independently coil compaction and aneurysm growth using non-rigid image registration. Local changes of volume between images at successive time points are identified using the Jacobian of the non-rigid transformation. Two different non-rigid registration strategies are applied in order to explore the sensitivity of Jacobian-based volume changes against the registration method, FFD registration based on mutual information and Demons. This volume-variation measure has been applied to four patients of which a series of 3D Rotational Angiography (3DRA) images obtained at different controls separated from two months to two years were available. The evolution of coil and aneurysm volumes along the period has been obtained separately, which allows distinguishing between coil compaction and aneurysm growth. On the four cases studied in this paper, aneurysm recurrence was always associated to aneurysm growth, as opposed to strict coil compaction.

Prospective clinical trial.Demonstrate the safety and efficacy of gelified ethanol in the percutaneous treatment of lumbar disk hernias.After the commercial withdrawal of Chymopapain, the need for new substances to treat intervertebral disk hernias was evident. Good results were obtained with pure ethanol, but this substance was difficult to handle. We decided to use a similar substance mixed with ethylcellulose to increase its viscosity and enhanced with radiopaque material.Two hundred seventy-six consecutive patients sent to be treated of a lumbar intervertebral disk hernia percutaneously were included in this preliminary study and treated with radiopaque gelified ethanol (RGE) and intra-articular steroids. Three groups were set, group A for patients to be treated only with RGE and groups B and C for difficult cases presenting a narrow canal, foraminal hernia, or hiperalgic sleepless hernia, treated with RGE plus another intradiscal technique, automatized percutaneous diskectomy for group B and radiofrequency nucleoplasty for group C.Very good or good results were obtained in 202 (91.4%) of the 221 patients in group A. Of the 44 patients in group B, 37 patients (84%) presented very good or good results and in 9 (82%) of the 11 patients of group C, we obtained similar results. There was no allergic complication in any of our patients. Short-term follow-up with magnetic resonance showed little or no changes in the intervertebral disk but there was discordance with clinical signs. Long-term follow-up magnetic resonance showed a dramatic reduction in hernia volume.This preliminary study shows the efficacy and inocuity of this new substance that could take over the Chymopapain therapeutic field.

Basilar artery (BA) thrombosis is a severe condition that has a high percentage of mortality if no treatment is performed. Recanalization is the most successful way of reducing mortality and improving outcome in patients with BA thrombosis. We present a case of a patient that presented to our hospital 12 h after onset of symptoms in which a combination of techniques were used to perform a vertebrobasilar recanalization.

Although the incidence of ruptured cerebral aneurysms is relatively small, when rupture occurs, morbidity and mortality are exceptionally high. The understanding of the pathological and physiological forces driving aneurysmal pathogenesis and progression is crucial. In this paper we analyze the occurrence of mirror cerebral aneurysms in 8 patients and speculate on the effect of haemodynamics on the localization and course of the disease. By mirror cerebral aneurysms we indicate two aneurysms in the same patient and at the same location in the cerebral vasculature but symmetrically with respect to a sagittal plane. In particular we focus on cases of mirror cerebral aneurysms where only one of the two aneurysms presented subarachnoid hemorrhage (SAH). Anatomical information is extracted from 3D rotational angiography (3DRA) images and haemodynamic information is obtained through blood flow simulation in patientspecific anatomical models. The distribution of Wall Shear Stress (WSS) and the flow patterns through the vessels and inside the aneurysms are reported. By combining clinical observations on asymmetry of the cerebral vasculature and aneurysmal shape and size with computed information on blood flow patterns we explore the causes behind a specific localization and a different outcome of disease progression.

Spinal arteriovenous shunts are rare and present at a rate of approximately 1:10 with cerebral arteriovenous shunts. Spinal dural arteriovenous fistulas (SDAVF) are the most common type of spinal vascular malformation in the adult and account for about 60% of all, with a marked male predominance (5:1). Endovascular treatment has gained force as the treatment of choice in recent years. We reviewed the patients sent to our service at Clinica del Rosario in Madrid and Hospital General de Cataluña in Barcelona between January 1991 and December 2005 with a diagnosis of SDAVF made clinically or by imaging for possible endovascular treatment. Location, presenting symptoms, and clinical outcome according to treatment were analyzed. A total of 104 patients were diagnosed and treated for a SDAVF, 85 were men and 19 women aged between 23 and 79 years (average 58). Seventy-six were treated with embolization alone (73%), 21 with a combination of endovascular therapy and surgery (20.1%) and seven patients had surgery alone (6.7%). Of the embolization group, 62 patients were cured (81.5%), 11 improved (14.4%) and three (3.9%) worsened. Of the group with combined therapy, 13 (61.9%) were cured, five (23.8%) improved and three (14.2%) worsened. Among the surgery group, four (57.2%) were cured and three (42.8%) worsened. Endovascular approach with liquid adhesive is gaining more acceptance as the treatment of choice for SDAVF if the conditions allow a super selective catheterization of the shunt. These patients benefit most when diagnosis is made early in the course of the pathology and have a better chance of a complete remission of symptoms.

The authors report the complications that occurred in their experience with performing recanalization procedures in the internal carotid artery and present their treatment strategies. The complications can be classified into those that were periprocedural and those that were postprocedural. The former include complications related to the vascular-approach access site of and those associated with the dilation and stenting procedure. Other complications observed included embolic events, dissection, vascular spasm, bradycardia, inappropriate dilation, occlusion of the external carotid artery, and rare, unusual complications such as the occurrence of iatrogenic cavernous carotid fistula. Postprocedure complications occurred in the hours and days following the procedure in the form of embolic and occlusive events, and hypotension and bradycardia were seen as late complications in the months following the procedure. The authors discuss how such complications occur and provide suggestions on how to avoid them. The role of stent placement and the potential use of protective devices are explored. Overall, adequate use of currently available systems allows for safe application of endovascular treatment techniques that avoid altogether or treat these potential complications. A reduced incidence of complications related to the initial individual learning curve may be obtained with preclinical training, in which use of invitro models should be considered. Surgical standby no longer seems required; however, early posttreatment surveillance in intensive care unit is mandatory to avoid the remaining primary complications.

A measurement system is proposed to evaluate reconstructive effects of carotid stents on the geometry of the carotid bifurcation and the course of the internal carotid artery. To describe deviations of the stenotic internal carotid artery (ICA) from the extended axis of the common carotid artery (CCA) the CCA-ICA angle is measured between the CCA midaxis and the midaxis of the stenotic ICA segment. Maximal extensions of ICA tortuosities perpendicular to the course of the CCA axis are defined as ICA offset. The measurements were applied to DSA images of 224 carotid stenoses to evaluate variation and correlation between the two parameters. Comparative pre- and post-stent evaluation was performed in two series of 55 and 31 carotid stenoses treated with Wallstents and in a historic control group of 35 stenoses treated with Strecker stents. Straight course of the ICA was associated with low angle and low offset values, whereas tortuous course of the ICA showed larger angle and offset. A moderate linear correlation between the two parameters was found. Corresponding to a straightening of the stented segment, Wallstents reduced mean angle and offset values significantly. In five cases of the second series of Wallstents, transferrals of curves above the distal stent end associated with kinks were observed, and offset remained constant or increased. Strecker stent implantation caused no significant changes of bifurcational geometry. The proposed parameters corresponded to visual aspects of ICA tortuosity and detected reconstructive effects of self-expanding Wallstents on the ICA course. The measurement system may provide a basis for geometric evaluation of different stent types or implantation concepts with the aim: to optimize anatomic recanalization results in tortuous high angle-high offset bifurcations.

Background: Epidemiological studies suggest that raised plasma concentrations of total homocysteine (tHcy) may be a common, causal and treatable risk factor for atherothromboembolic ischaemic stroke. Although tHcy can be lowered effectively with small doses of folic acid, vitamin B12 and vitamin B6, it is not known whether lowering tHcy, by means of multivitamin therapy, can prevent stroke and other major atherothromboembolic vascular events. Purpose: To determine whether vitamin supplements (folic acid 2 mg, B6 25 mg, B12 500 µg) reduce the risk of stroke, and other serious vascular events, in patients with recent stroke or transient ischaemic attacks of the brain or eye (TIA). Methods: An international, multi-centre, randomised, double-blind, placebo-controlled clinical trial. Results: As of November 2001, more than 1,400 patients have been randomised from 10 countries in four continents. Conclusion: VITATOPS aims to recruit and follow up 8,000 patients between 2000 and 2004, and provide a reliable estimate of the safety and effectiveness of dietary supplementation with folic acid, vitamin B12, and vitamin B6 in reducing recurrent serious vascular events among a wide range of patients with TIA and stroke.