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Introduction: Despite pharmacological and practical advantages for tenecteplase (TNK) over alteplase (ALT), no differences were observed in percent of symptomatic intracranial hemorrhage (sICH) in randomized trials (fewer than 900 total patients for either treatment). We compared rates of sICH in patients treated with either drug, using a large, multicenter, international registry. Methods: The CERTAIN collaboration is an ongoing registry of deidentified patient-level data of thrombolytic treated ischemic stroke from various hospitals/programs in New Zealand, Australia, and the United States that have used ALT or TNK since July 1, 2018. Standardized data were abstracted and harmonized from local or regional clinical registries. We defined sICH as clinical worsening of at least 4 points on NIHSS, attributed to parenchymal hematoma, subarachnoid or intraventricular hemorrhage. We used logistic regression for binary variables, adjusting sICH differences for age, baseline NIHSS, thrombectomy, and source hospital network and Mann-Whitney test for continuous baseline variables. Results: A total of 7891 patients were included in the initial analysis. The TNK group was older, more likely to be male, had higher NIHSS, and more frequently underwent mechanical thrombectomy (Table. Sample Characteristics). The sICH rate was 3.71% for ALT and 2.13% for TNK: adjusted OR (95%CI) = 0.49 (0.31-0.76) p=0.002. For patients not undergoing thrombectomy after thrombolytic, the sICH rate was 3.00% for ALT and 1.74% for TNK, adjusted OR (95%CI) = 0.48 (0.27-0.87), p=0.016. For thrombectomy treated cases, sICH rate was 6.80% for ALT and 2.80% for TNK, adjusted OR (95%CI) 0.60 (0.31-1.16), p=0.129. Conclusion: In this preliminary analysis from a large, multicenter registry, ischemic stroke treated with tenecteplase was associated with a lower rate of sICH than with alteplase. An updated analysis with patient data from additional sites will be presented at the Conference.

IntroductionFollowing complicated endovascular or microsurgical treatments, assessment of radiographic outcome can be challenging due to device resolution and metallic artifact. Two-dimensional and three-dimensional angiography can reveal information about flow and aneurysm obliteration, but may be limited by beam hardening, overlapping vessels, and image degradation in the region of metallic implants. In this study, we investigated the combination of a collimated volumetric imaging (volume of interest, VOI) protocol followed by metal artifact reduction (MAR) post-processing to evaluate the correct positioning of stents, flow diverters, coils, and clips while limiting the radiation dose to the patient.Methods9 patients undergoing 10 procedures were included in our study. All patients underwent endovascular or surgical treatment of a cerebral aneurysm involving stents, flow diverting stents, coils, and/or clips followed by either immediate or early postoperative evaluation of our protocol.ResultsImage datasets corrected for metallic artifacts (VOI-MAR) were judged to be better—a statistically significant finding—than image datasets only corrected for field of view truncation (VOI alone). Qualitatively, images were more interpretable and informative with regards to device position and apposition to the vessel wall for those cases involving a pipeline, and with regards to encroachment on the parent artery and possible residual aneurysm, in all cases.ConclusionsVOI acquisition combined with MAR post-processing provides for accurate and informative evaluation of cerebral aneurysm treatment while limiting the radiation dose to patients.

IntroductionThe natural history of acute ischemic stroke (AIS) due to basilar artery occlusion (BAO) is poor. Endovascular reperfusion therapy (EVT) improves recanalization rates in patients with emergent large vessel intracranial occlusion.ObjectiveTo examine the hypothesis that good collateral patterns identified by pretreatment CT angiography (CTA) might be associated with favorable outcomes after EVT.MethodsWe conducted a retrospective chart review of patients presenting with AIS due to BAO in a tertiary care stroke center during a 4-year period. BAO was diagnosed by CTA in all cases. Admission stroke severity was documented using the National Institute of Health Stroke Scale (NIHSS) score. Pretreatment collateral score for posterior circulation was defined as follows: 0, no posterior communicating artery (PCOM); 1, unilateral PCOM; 2, bilateral PCOM. Favorable outcome was defined as modified Rankin Scale score of 0–2 at 3 months.ResultsA total of 21 patients with AIS due to BAO (age range 31–84 years, median admission NIHSS score: 18 points, range 2–38) underwent EVT. Eleven of 21 patients (52.4%) had bilateral PCOMs, while unilateral PCOM was seen in 3 patients (14.3%). Patients with bilateral PCOMs tended (p=0.261) to have less severe stroke at admission than those with absent/unilateral PCOM (median NIHSS score 18 vs 27 points). Neurological improvement during hospitalization (quantified by the median decrease in NIHSS score) and the rate of 3-month functional independence were greater in patients with good collaterals (16 vs 0 points (p=0.016) and 72.7% vs 0% (p=0.001)).ConclusionsThe presence of bilateral PCOMs on pretreatment CTA appears to be associated with more favorable outcomes in BAO treated with EVT.

Aneurysmal bone cysts (ABCs) are destructive cystic lesions of the bone and are common in children. They are expansile in nature and, therefore, may become symptomatic. These have traditionally been treated surgically; but recently, endovascular embolization has shown promise as a stand-alone therapy. The authors describe a case of an ABC highlighting the effectiveness and efficiency of endovascular treatment. A 16-year-old boy was referred for a 4-month history of radiating back pain and urinary hesitancy. Findings from his neurological examination were normal, but he had problems ambulating because of pain. Magnetic resonance imaging and CT scanning showed a cystic mass in the sacrum; a biopsy was performed and diagnosis of ABC was confirmed. Treatment options were then discussed with the family. The patient underwent 2 endovascular embolizations in approximately 1 month: Onyx 18 was involved in the first session, and N-butyl cyanoacrylate glue was used in the second session. After the first treatment, the patient experienced a dramatic decrease in pain and concomitant improvement in function. The patient went from being mildly symptomatic after the first treatment to completely asymptomatic after the second treatment. Clinical and radiographic follow-up obtained at 2, 6, and 18 months after initial treatment revealed the patient to be asymptomatic with progressive ossification. Endovascular treatment can be effective in treating symptomatic cases of ABC in which surgery would carry significant risk. Selective arterial embolization can promote sclerosis and result in an immediate and significant decrease in pain.

Background and purposeHigh admission blood pressure (BP) levels have been associated with lower recanalization rates after endovascular treatment (EVT) for patients with acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO). We sought to evaluate the association of admission BP with early outcomes in patients with ELVO treated with EVT.MethodsConsecutive patients with AIS presenting with ELVO in a tertiary stroke center during a 4-year period were prospectively evaluated. Admission systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured using automated cuff recordings. A blinded neuroradiologist calculated the final infarct volume (FIV) using standardized ABC/2 methodology. A favorable functional outcome (FFO) at 3 months was defined as modified Rankin Scale score of 0–2.ResultsOur study population consisted of 116 patients with AIS (mean age 63±13 years, median NIH Stroke Scale score 17 points (IQR 14–21), median FIV 30 cm3 (IQR 8–94)). Higher admission SBP correlated with higher FIV (r +0.225; p=0.020). Patients with FFO had lower admission SBP (151±24 mm Hg vs 165±28 mm Hg; p=0.010), while admission SBP levels were higher in patients who died during hospitalization (169±34 mm Hg vs 156±24 mm Hg; p=0.043). A 10 mm Hg increment in admission SBP was independently (p=0.010) associated with an increase of 12 cm3 in FIV (95% CI 3 to 21) in multiple linear regression models adjusting for potential confounders. A 10 mm Hg increment in admission SBP was independently (p=0.012) associated with a lower likelihood of FFO at 3 months (OR 0.64; 95% CI 0.45 to 0.91) in multiple logistic regression models adjusting for potential confounders.ConclusionsHigher admission SBP is an independent predictor of increased FIV and lower likelihood of 3-month FFO in patients with ELVO treated with EVT.

Background & Purpose: High pre-treatment systolic blood pressure (SBP) levels have been associated with lower recanalization rates after endovascular treatment (EVT) for acute ischemic stroke (AIS) patients with emergent large vessel occlusion (ELVO). We sought to evaluate the association of of pre-treatment SBP with other outcome measures after EVT including final infarct volume (FIV) and favorable outcome (FO) at three-months. Methods: We conducted a retrospective cohort study evaluating AIS patients presenting with anterior circulation ELVO in a tertiary care stroke center during a 4-year period. Admission stroke severity was documented using NIHSS-score. Pre-treatment SBP and DBP were measured using automated cuff. Two investigators calculated the FIV using ABC/2 methodology. FO was defined as mRS score of 0-2 at 3 months. Results: Our study population consisted of 116 patients with anterior circulation ELVO (mean age 63±13 years, 51% male, median admission NIHSS-score: 17 points, IQR 14-21, median FIV: 30cm3, IQR: 8-94) who were treated with EVT. Systemic thrombolysis was administered in 75 patients (65%). A total of 38 patients (33%) achieved FO, while in-hospital and three-month mortalities were 27% and 31% respectively. Higher pre-treatment SBP was positively correlated to increased FIV (r: +0.225; p=0.020). Patients with FFO had lower pretreatment SBP (151±24mmHg vs 165±28mmHg; p= 0.010), while pretreatment SBP levels were higher in patients who died during hospitalization (169±34mmHg vs 156±24mmHg; p=0.043). A 10mmHg increment in pretreatment SBP was independently (p=0.010) associated with an increase of 12cm3 in FIV (95%CI: 3-21) in multiple linear regression models adjusting for demographics, vascular risk factors, pretreatment DBP, admission NIHSS, intravenous thrombolysis, onset to revascularization and successful revascularization. A 10mmHg increment in pretreatment SBP was independently (p=0.012) associated with a lower likelihood of FFO at three months (OR: 0.64; 95%CI: 0.45-0.91) in multiple logistic regression models adjusting for multiple confounders. Conclusion: Higher pretreatment SBP is an independent predictor of increased FIV and lower likelihood of three-month FFO in patients with ELVO who undergo EVT.

BackgroundRecent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center.MethodsA retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria.Results126 patients receiving MT from January 2012 to June 2015 were included (age 31–89 years, National Institutes of Health Stroke Scale (NIHSS) score 2–38); 62 (49%) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score 360 min (58%). 26 (42%) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45% in those lacking top tier evidence compared with 26% (p=0.044), and 3 month mRS score 0–2 was 33% versus 46%, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (β −8.2; 95% CI −24.6 to −8.2; p=0.321), 3 month mortality (OR=0.38; 95% CI 0.08 to 1.41), or 3 month favorable mRS (OR=0.97; 95% CI 0.28 to 3.35).ConclusionsOur study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted.

Endovascular therapy of cerebral venous thrombosis using modern approaches to intracranial recanalization, such as stent retrievers and aspiration thrombectomy, is not well described. We performed a retrospective review of data for consecutive patients with venous sinus thrombosis who underwent endovascular treatment between 1 January 2010 and 31 December 2013 at participating institutions. We identified a total of 13 patients with a diagnosis of cerebral venous thrombosis. The most frequently utilized type of endovascular intervention was the Penumbra aspiration system (Penumbra Inc., Alameda, California, USA) (nine cases), followed by local infusion of tissue plasminogen activator (bolus and/or drip in six cases) and stent retrievers (Solitaire FR (Covidien, Irvine, California, USA) in three cases and Trevo (Stryker, Kalamazoo, Michigan, USA) in one case). Overall, multimodality treatment (two or more different types of devices or approaches) was performed in 62% of cases. Follow-up data were available for 11 patients; of those, five had a favorable clinical outcome (defined as modified Rankin Scale score of 0–2) and three patients died. Various endovascular approaches are utilized in current clinical practice. A multimodal approach to endovascular therapy for the treatment of cerebral venous thrombosis resulted in partial or complete restoration of flow in all cases, yet the mortality rate of 27% indicates the need for improvement in recanalization strategies for this disorder.

Background: Residual aneurysm after microsurgical clipping carries a risk of aneurysm growth and rupture. Digital subtraction angiography (DSA) remains the standard to determine the adequacy of clipping. Intraoperative indocyanine green (ICG) angiography is increasingly utilized to confirm optimal clip positioning across the neck and to evaluate the adjacent vasculature. Objective: We evaluated the correlation between ICG and DSA in clipped intracranial aneurysms. Methods: A retrospective study of patients who underwent craniotomy and microsurgical clipping of intracranial aneurysms with ICG for 2 years. Patient characteristics, presentation details, operative reports, and pre- and postclipping angiographic images were reviewed to determine the adequacy of the clipping. Results: Forty-seven patients underwent clipping with ICG and postoperative DSA: 57 aneurysms were clipped; 23 patients (48.9%) presented with subarachnoid hemorrhage. Nine aneurysms demonstrated a residual on DSA not identified on ICG (residual sizes ranged from 0.5 to 4.3 mm; average size: 1.8 mm). Postoperative DSA demonstrated no branch occlusions. Conclusion: Intraoperative ICG is useful in the clipping of intracranial aneurysms to ensure a gross patency of branch vessels; however, the presence of residual aneurysms and subtle changes in flow in branch vessels is best seen by DSA. This has important clinical implications with regard to follow-up imaging and surgical/endovascular management.

Background & Purpose: The outcomes of patients with acute ischemic stroke (AIS) due to basilar artery occlusion (BAO) are poor. Endovascular therapy (EVT) improves rates of recanalization. We hypothesized that good collateral patterns by pre-treatment CT Angiography (CTA) would predict favorable outcome after EVT. Methods: We conducted a retrospective chart review of patients presenting with AIS due to BAO in a tertiary care stroke center during a four-year period. BAO was diagnosed by CTA in all cases, who received EVT as standard of care. Admission stroke severity was documented using NIHSS-score. Pretreatment collateral score (CS) for posterior circulation was defined as follows: 0 - no posterior communicating artery (PCOM), 1- unilateral PCOM, 2- bilateral PCOM. Complete recanalization was defined by Thrombolysis in Cerebral Infarction (TICI) scores of 2b or 3. Favorable outcome was defined as modified Rankin Scale score (mRS) of 0-2 at three months. Results: Our study population consisted of 15 AIS patients (age range; 31-84 years, median admission NIHSS-score: 21, range 2-38 points) who underwent EVT. Systemic thrombolysis was administered in 4 patients (27%). Seven of 15 patients (47%) had bilateral PCOMs, while unilateral PCOM was diagnosed in 2 cases (13%). Patients with bilateral PCOMs tended to have less severe stroke (p=0.199) at admission in comparison to patients with absent/unilateral PCOM (median NIHSS-score 18 vs. 28 points). The rate of favorable outcome was higher in patients with bilateral PCOMs (71%) in comparison to patients with absent or unilateral PCOM (0%; p=0.014). Patients with bilateral PCOMs tended to have higher recanalization in comparison with patients with absent/unilateral PCOM (86% vs. 33%, p= 0.076). CONCLUSION: Presence of bilateral PCOMs on pre-treatment CTA is associated with lower baseline stroke severity, higher rates of complete recanalization and favorable outcome in patients with AIS due to BAO who are treated with EVT. Future prospective studies including a larger sample of patients are required to define the potential association of posterior circulation collateral status with favorable outcome in this subgroup of ischemic stroke patients.

Objective Flexible large lumen aspiration catheters and stent retrievers have recently become available in the USA for the revascularization of large vessel occlusions presenting within the context of acute ischemic stroke (AIS). We describe a multicenter experience using a combined aspiration and stent retrieval technique for thrombectomy. Design A retrospective analysis to identify patients receiving combined manual aspiration and stent retrieval for treatment of AIS between August 2012 and April 2013 at six high volume stroke centers was conducted. Outcome variables, including recanalization rate, post-treatment National Institutes of Health Stroke Scale (NIHSS) score, symptomatic intracranial hemorrhage, discharge 90 day modified Rankin Scale (mRS) score, and mortality were evaluated. Results 105 patients were found that met the inclusion criteria for this retrospective study. Successful recanalization (Thrombolysis in Cerebral Infarction score 2B) was achieved in 92 (88%) of these patients. 44% of patients had favorable (mRS score 0–2) outcomes at 90 days. There were five (4.8%) symptomatic intracerebral hemorrhages and three procedure related deaths (2.9%). Conclusions Mechanical thrombectomy utilizing combined manual aspiration with a stent retriever is an effective and safe strategy for endovascular recanalization of large vessel occlusions presenting within the context of AIS.

Aneurysmal bone cysts (ABCs) are destructive cystic lesions of the bone and are common in children. They are expansile in nature and, therefore, may become symptomatic. These have traditionally been treated surgically; but recently, endovascular embolization has shown promise as a stand-alone therapy. The authors describe a case of an ABC highlighting the effectiveness and efficiency of endovascular treatment. A 16-year-old boy was referred for a 4-month history of radiating back pain and urinary hesitancy. Findings from his neurological examination were normal, but he had problems ambulating because of pain. Magnetic resonance imaging and CT scanning showed a cystic mass in the sacrum; a biopsy was performed and diagnosis of ABC was confirmed. Treatment options were then discussed with the family. The patient underwent 2 endovascular embolizations in approximately 1 month: Onyx 18 was involved in the first session, and N-butyl cyanoacrylate glue was used in the second session. After the first treatment, the patient experienced a dramatic decrease in pain and concomitant improvement in function. The patient went from being mildly symptomatic after the first treatment to completely asymptomatic after the second treatment. Clinical and radiographic follow-up obtained at 2, 6, and 18 months after initial treatment revealed the patient to be asymptomatic with progressive ossification. Endovascular treatment can be effective in treating symptomatic cases of ABC in which surgery would carry significant risk. Selective arterial embolization can promote sclerosis and result in an immediate and significant decrease in pain.

Free floating thrombus of the carotid artery (FFT) is defined as n elongated thrombus attached to the arterial wall with circumerential blood flow at its distal most aspect, with cyclical motion elating to cardiac cycles. FFT is a rare condition and the actual ncidence is not known. It is more frequently reported in men than omen, with a ratio of nearly 2:1. The internal carotid artery is he most commonly affected (75%), with atherosclerosis being the ost common associated pathology [1]. The guidelines for treatment of FFT are not clear due to the rarty of this condition and the lack of comparative studies between edical management (anticoagulation and/or antiplatelet) and urgical management (stenting, carotid endarterectomy or carotid ypass surgery). Anecdotal evidence supports early initiation f intravenous unfractionated heparin (IV-UFH) to prevent troke recurrence in certain situations including acquired or nherited hypercoagulable states, extracranial cervicocephalic rterial dissection, and intraluminal arterial thrombus [2]. Urgent ndarterectomy or endovascular embolectomy has both been eported as successful treatments for this condition [1,3].

BACKGROUND: The presence of residual aneurysm after microsurgical clipping carries a risk of aneurysm growth and rupture. Digital subtraction angiography (DSA) is the gold standard to determine the adequacy of clipping post-operatively. Intra-operative Indocyanine green (ICG) angiography is increasingly utilized to confirm optimal clip positioning across the neck and to evaluate adjacent vasculature. We evaluated the correlation between ICG and DSA in clipped intracranial aneurysms. METHODS: This is a retrospective study of patients who underwent craniotomy and microsurgical clipping of intracranial aneurysms with ICG between January 2010 and May 2011. A chart review was performed to abstract the baseline characteristics and details of presentation of patients, details of the operative reports of clipping were reviewed, and pre and post clipping angiographic images were reviewed to determine the adequacy of clipping. Post-clipping DSA was evaluated by two physicians not involved in the care of the patient for the presence of residual aneurysm and patency of branch vessels/parent artery. RESULTS: Twelve patients (58 % female, mean age 53.6) underwent clipping of intracranial aneurysms with ICG and had post-operative DSA. Operative reports indicated complete clipping of all aneurysms without compromise of branch vessels. Postoperative DSA was performed in follow-up ranging from 1 day to 6 months. Seventeen aneurysms were clipped, seven patients (58.3%) presented with subarachnoid hemorrhage. Thirteen aneurysms were located in the anterior circulation (avg. size 7.3mm) and four in the posterior circulation (avg. size 6.6mm). Four patients had two aneurysms clipped in the same setting. Of the 17 aneurysms treated 5 aneurysms demonstrated a residual on DSA not identified on ICG. The residual sizes ranged from 0.8-4.3 mm with an average size of 1.2mm. There was no apparent predilection to location; three were in the anterior and two in the posterior circulation. Post-operative DSA demonstrated no branch occlusions, two patients demonstrated slow flow in the posterior communicating artery, and there was no compromise of the parent vessel in any cases. CONCLUSION: Intra-operative ICG is useful in the microsurgical clipping of intracranial aneurysms to ensure patency of branch vessels. However, the presence of residual aneurysm and subtle changes in flow in branch vessels is best seen by DSA. This has important clinical implications in regards to immediate post-operative management, the need for delayed follow-up imaging, and decisions to re-treat incompletely clipped aneurysms.

A patient with a giant symptomatic vertebrobasilar aneurysm was treated by endoscopic third ventriculostomy for obstructive hydrocephalus followed by treatment of the aneurysm by flow diversion using a Pipeline Embolization Device. After an uneventful procedure and initial periprocedural period, the patient experienced an unexpected fatal subarachnoid hemorrhage 1 week later. Autopsy demonstrated extensive subarachnoid hemorrhage and aneurysm rupture (linear whole wall rupture). The patent Pipeline Embolization Device was in its intended location, as was the persistent coil occlusion of the distal left vertebral artery. The aneurysm appeared to rupture in a linear manner and contained a thick large expansile clot that seemed to disrupt or rupture the thin aneurysm wall directly opposite the basilar artery/Pipeline Embolization Device. We feel the pattern of aneurysm rupture in our patient supports the idea that the combination of flow diversion and the resulting growing intra-aneurysmal thrombus can create a mechanical force with the potential to cause aneurysm rupture.

Introduction Following complex endovascular or microsurgical treatment of aneurysms, volumetric assessment of the surgical outcome in the angiography suite can be challenging due to device resolution and metallic artefact. We investigated a collimated volumetric imaging protocol followed by metal artefact suppression post processing to evaluate the correct positioning of stents, flow diverting devices, coils, and clips. Methods Under an IRB approved study protocol, ten patients who underwent endovascular or surgical treatment of a cerebral aneurysm involving stents, flow-diverting devices, coils, and/or clips, underwent angiography. This consisted of conventional 2D diagnostic imaging, followed by the acquisition of a volume of interest (VOI) collimated DynaCT. Such an acquisition yielded high-spatial resolution of implanted devices, by reducing the radiation burden depending on illuminated detector fraction. Volumetric images were reconstructed, accounting for the truncated images and artefact from dense metallic objects. Blinded readers were presented with VOI 3D images, processed with and without correction for metal artefact, and asked to score overall image quality, visibility of surrounding vasculature and aneurysm inflow, and diagnostic value. Scores were evaluated for statistical significance using a student’s T-test, testing the hypothesis that VOI + MAR is better than VOI alone. Results VOI images processed with metal artefact correction were judged better with 95% (p = 0.05) significance for overall image quality and 99% (p = 0.01) for the other three categories. Particular advantage was seen with the identification of residual aneurysm inflow as well as the ability to identify surrounding vasculature. Analysis of VOI scan dose area product (DAP) showed an average reduction of 85% compared to conventional DynaCT. Conclusion Combining VOI imaging with metal artefact suppression allows for clear imaging of complex aneurysm repair in the presence of dense metallic objects, while significantly reducing patient radiation exposure. Disclosures E. Duckworth: None. D. Hoit: 1; C; Seimens. L. Elijovich: 1; C; Seimens. 2; C; Microvention, Stryker, Codman. V. Doss: None. W. Humphries: None. S. Schafer: 5; C; Seimens Medical Solutions USA. S. Bauer: 5; C; Seimens Medical Solutions USA. A. Arthur: 1; C; Seimens, Terumo. 2; C; Seimens, Johnson and Johnson, Sequent Medical, Covidian, Stryker, Terumo.

Carotid endarterectomy (CEA) is the established standard to treat occlusive extracranial atherosclerotic carotid disease. Complications of CEA must be recognized and dealt with efficiently due to the potentially catastrophic neurologic sequelae. A 67-year-old African American man was transferred from an outside hospital for an acute stroke. He had initially presented with a small right frontal subcortical infarct and had undergone a right CEA 2 days prior to transfer. He had a fluctuating examination with left-sided hemiplegia to slight hemiparesis and inconsistent neglect. Head CT demonstrated a watershed infarct of the right hemisphere. CT angiography demonstrated high grade stenosis at the distal aspect of the CEA anastomosis. He was promptly taken for angiography and underwent acute stenting of the right internal carotid artery. This case demonstrates that carotid artery stenting is a safe management strategy for the treatment of complications associated with failed distal anastomosis during CEA.

Parenchymal blood volume (PBV) mapping with flat panel detectors may provide real-time estimates of tissue perfusion during endovascular ischemic stroke procedures. We present two cases of acute middle cerebral artery (MCA) occlusion to demonstrate how PBV may: (1) be used in acute stroke; (2) influence intraprocedural decision-making; and (3) potentially serve as a predicator of clinical outcome. Both cases were successfully recanalized with endovascular embolectomy. Intraprocedural PBV maps were obtained immediately before and after recanalization. Pre-intervention reductions in PBV were seen throughout the MCA territory in both cases, with significant improvement in PBV in one case with good radiographic and clinical outcome and a lack of improvement in PBV in the second case with a large infarct volume. PBV deficit normalization may occur with recanalization of the parent artery and probably represents successful reperfusion. Baseline PBV maps should therefore be interpreted with caution and not interpreted to represent irreversible core infarct.