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ABSTRACT: ObjectivesTo determine the safety and tolerability of super-selective intra-arterial magnesium sulfate in combination with intra-arterial
nicardipine in patients with cerebral vasospasm after subarachnoid hemorrhage.
MethodsPatients were treated in a prospective protocol at two teaching medical centers. Emergent cerebral angiography was performed
if there was either clinical, ultrasound, and/or computed tomographic (CT) perfusion deficits suggestive of cerebral vasospasm.
Intra-arterial magnesium sulfate (0.25–1g) was administered via a microcatheter in the affected vessels in combination with
nicardipine (2.5–20.0mg). Mean arterial pressures (MAP) and intracranial pressures (ICP) were monitored during the infusion.
Immediate and sustained angiographic and clinical improvement was determined from post-treatment angiograms and clinical follow-up.
Angiographic and clinical outcomes were compared to two published case series that has used nicardipine alone.
ResultsA total of 58 vessels were treated in 14 patients (mean age 42years; 11 women) with acute subarachnoid hemorrhage. The treatment
was either intra-arterial nicardipine and magnesium sulfate alone or in conjunction with primary angioplasty. Forty vessels
(69%) had immediate angiographic improvement with intra-arterial nicardipine and magnesium sulfate alone and 18 vessels (31%)
required concomitant balloon angioplasty with complete reversal of the vasospasm. Retreatment was required in 13 vessels (22%)
and the median time for retreatment was 2days (range 1–13days). Nicardipine treatment resulted in the reduction of MAP (12.3mmHg,
standard error [SE] 1.34, P-value <0.0001) without any significant change in ICP. Magnesium sulfate infusion was not associated with change in MAP or
ICP. Among 31 procedures, immediate neurological improvement was observed in 22 (71%) procedures. In 12 (86%) patients, there
were no infarctions in the follow-up CT scan acquired between 24 and 48 h. No statistical significant difference was observed
in angiographic and clinical outcome of patients treated with the combination therapy in comparison with historical controls
treated with nicardipine alone.
ConclusionAdministration of intra-arterial magnesium sulfate in combination with nicardipine was well tolerated in patients with subarachnoid
hemorrhage and cerebral vasospasm without a significant change in MAP and ICP. The efficacy of this combination therapy should
be evaluated in a larger, controlled setting.
Neurocritical Care 04/2012; 11(2):190-198. · 2.47 Impact Factor
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ABSTRACT: ABSTRACTOBJECTIVE
Tenecteplase (TNK) is a third-generation thrombolytic agent. We evaluated the safety and feasibility of intra-arterial (IA) administration of TNK in patients with acute ischemic stroke.METHODS
Patients who received endovascular treatment for acute ischemic stroke were identified from prospectively collected databases at three university hospitals. We compared clinical and radiological outcomes of patients treated with TNK to those treated with other IA thrombolytics or mechanical thrombectomy alone. Primary outcome measures were favorable functional outcome at 30 days (modified Rankin Scale score of 0-2), and rate of intracranial hemorrhage (ICH). Early neurological improvement, angiographic recanalization, time to recanalization, and mortality at 30 days were additional outcome measures.RESULTSWe identified 114 patients (mean age 67 ± 15 years, 54 were women). Thirty-three patients received IA TNK, 48 received alteplase (n = 11) or reteplase (n = 37), and 33 patients had mechanical thrombectomy alone. Stroke severity was similar among the three groups. No difference between the groups was found in the secondary outcome measures and ICH. Borderline statistical significance was seen toward favorable functional outcome at 1 month in the TNK-treated patients [odds ratio (OR) = 2.8; 95% confidence interval (CI) .96-8.1, P = .063 vs. other thrombolytics, and OR = 3.0, 95% CI .97-9.5, P = .06 vs. mechanical thrombectomy alone].CONCLUSION
Our study demonstrates that administration of IA TNK in acute stroke is safe and results in rates of favorable outcomes that are comparable to those observed with currently used drugs. Additional studies are needed to further determine the safety and efficacy of IA TNK in acute stroke treatment. J Neuroimaging 2011;XX:1-6.
Journal of neuroimaging: official journal of the American Society of Neuroimaging 08/2011; · 1.72 Impact Factor
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ABSTRACT: BACKGROUND AND INTRODUCTION: Patients presenting with posterior circulation acute ischemic events are occasionally noted to have occlusion of bilateral vertebral arteries with basilar artery blood flow entirely dependent from the anterior circulation. There is limited data about prognosis of such patients in literature.
Patients with acute posterior circulation ischemic stroke and bilateral vertebral artery occlusion (including contra-lateral hypoplastic vertebral artery without contribution to the basilar artery system) were identified prospectively from two academic centers. Data including clinical presentation, medical management, angiographic findings, recurrent events and outcome were collected and reported.
A total of 4 patients presenting with acute ischemic events in the posterior circulation were identified to have bilateral vertebral artery occlusion at our center. One additional patient had a vertebral artery occlusion and a contra-lateral hypoplastic vertebral artery. In the functional evaluation of the blood flow with catheter angiography, the basilar artery was filling from the anterior circulation, with no antegrade flow from bilateral vertebral arteries injection in all 5 patients. Patients were treated with anti-platelets (n=4) or started on anti-coagulation after failing anti-platelet therapy (n=2). All patients had recurrent ischemic stroke with new ischemic lesions proven by diffusion weighted images on MRI within 2 to 70 days after the initial event.
Patients with acute posterior circulation ischemic stroke and bilateral vertebral artery occlusion are at high risk of having early recurrent ischemic events. Reestablishment of the antegrade vertebro-basilar blood flow through endovascular re-canalization might be an option to decrease stroke recurrence in selected patients with acute posterior circulation stroke and bilateral vertebral artery occlusion.
Journal of vascular and interventional neurology 07/2011; 4(2):9-14.
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ABSTRACT: In the treatment of acute ischemic stroke, intravenous (IV) recombinant tissue plasminogen (rt-PA) and intraarterial (IA) interventions are often combined. However, the optimal dose of IV rt-PA preceding endovascular treatment has not been established.
Studies that used combined IV and IA thrombolysis were identified from a search of the MEDLINE, PubMed, and Cochrane databases. We compared the rates of angiographic recanalization, symptomatic intracerebral hemorrhage (sICH), and favorable functional outcome between patients who had been treated with .6 mg/kg IV rt-PA and those who had received .9 mg/kg rt-PA.
Eleven studies met our criteria. In 7 studies, .6 mg/kg IV rt-PA had been administered to 317 patients, whereas 140 patients in 4 studies had received .9 mg/kg of IV rt-PA. The weighted mean of median National Institutes of Health Stroke Scale score at presentation was 18.3 in the .6 mg/kg group (median range 9-34), and 17.3 in the .9 mg/kg group (median range 4-39). Patients in the .9 mg/kg group had higher rates of favorable outcome [odds ratio (OR)=1.60, 95% confidence interval (CI)=(1.07-2.40), P=.022] and similar rates of sICH [OR=.86 (95% CI .41-1.83), P=.70]. Depending on the statistics used, the higher angiographic recanalization rate among patients treated with .9 mg/kg was significant (P=.03, events/trial syntax logistic regression) or borderline significant (P=.07, random effects model).
Our analysis suggests that using .9 mg/kg IV rt-PA prior to IA thrombolysis is safe and may be associated with higher recanalization rates and better functional outcome at 3 months.
Journal of neuroimaging: official journal of the American Society of Neuroimaging 11/2009; 21(2):113-20. · 1.72 Impact Factor
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ABSTRACT: A large vein of Galen was diagnosed in a 9-month-old boy. This was not treated at birth, as there was no associated congestive heart failure. The patient was followed conservatively and follow-up magnetic resonance imaging showed increase in the size of the vein of Galen malformation. Subsequent cerebral angiogram demonstrated hypertrophied but thrombosed right posterior choroidal artery, suggesting spontaneous thrombosis of the arterial feeder and thus the embolization was not pursued.
Journal of neuroimaging: official journal of the American Society of Neuroimaging 07/2009; 21(1):87-8. · 1.72 Impact Factor
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ABSTRACT: Symptomatic occlusive lesions at the origins of the supra-aortic vessels pose challenges for treatment. Endovascular angioplasty and stent placement via the transfemoral approach is possible, but obtaining a stable position for the guide catheter via this approach is technically difficult. The authors describe the case of a 56-year-old man presenting with symptomatic occlusion of a previously placed stent at the origin of the left common carotid artery (CCA). An endovascular revascularization of the left CCA was planned. However, the absence of a lumen proximal to the stent prevented stable placement of a guide catheter via the transfemoral route. Consequently, the authors used a combined surgical and endovascular approach to gain access to the lesion. The left CCA was exposed surgically distal to the occlusion and clamped just proximal to its bifurcation to preserve flow from the external to the internal carotid artery (ICA) and to prevent embolism into the ICA. A wire was passed retrograde through the occlusive lesion and then was subsequently advanced proximally into the femoral sheath. This allowed transfemoral advancement of the appropriate endovascular devices to perform an angioplasty and placement of a stent. The patient remained neurologically stable, and postoperative studies showed improvement in cerebral perfusion. This case demonstrates the feasibility of distal-to-proximal stent delivery with a combined endovascular and surgical approach.
Journal of Neurosurgery 01/2009; 110(5):935-8. · 2.96 Impact Factor
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ABSTRACT: To report our initial experience in setting up a neuroendovascular service in a university-based comprehensive stroke center.
We determined the rates of referral path, procedural type, and independently adjudicated 1-month outcomes (actual rates) in first 150 procedures (120 patients) and subsequently compared with rates derived from pertinent clinical trials after adjustment for procedural type (predicted rates).
The patients were referred from the emergency department (n= 44), transferred from another hospital (n= 13), or admitted for elective procedures from the clinic (n= 63). The procedures included treatment of acute ischemic stroke (n= 12); extracranial carotid stent placement (n= 33); extracranial vertebral artery stent placement (n= 13); intracranial angioplasty and/or stent placement (n= 12); embolization for intracranial aneurysms (n= 35), arteriovenous malformations (n= 5), and tumors (n= 10); cerebral vasospasm treatment (n= 26); and others (n= 4). The technical success rate was 100% for intracranial aneurysm obliteration and extracranial carotid artery stent placement, and 95% for those undergoing intracranial or vertebral artery stent placements; and partial or complete recanalization was achieved in 72% of patients undergoing intra-arterial thrombolysis. After adjusting for procedural type, the actual adverse event rate of 3% compared favorably with the predicted rate of 7% based on the results of clinical trials.
We provide estimates of procedure volumes and outcomes observed in the initial phase of setting up a neuroendovascular service with an active training program.
Journal of neuroimaging: official journal of the American Society of Neuroimaging 07/2008; 19(1):72-9. · 1.72 Impact Factor
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Journal of neurosurgical anesthesiology 05/2008; 20(2):154-5. · 2.41 Impact Factor
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ABSTRACT: Non-traumatic or spontaneous intracerebral hemorrhage (ICH) is defined as intra-parenchymal bleeding with or without extension into the ventricles and rarely into the subarachoid space. Primary ICH in most cases is associated with chronic hypertension. Acute hypertension is associated with hematoma expansion, and poor neurological outcome. The treatment of hypertension in acute ICH is a topic of controversy. Experiments have shown an area of ischemia around the hematoma, with the reduction of regional cerebral blood flow (CBF) secondary to compression of microvasculature. Not all scientific results agree with the above findings. Recent studies have shown that CBF decreases in the perihematoma region but with concomitant reduction of cerebral metabolism, which would argue against an area of ischemia in the perihematoma region. Based on the above result, there have been several clinical trials looking at clinical outcome and decrease in hematoma expansion rates with reduction of blood pressure acutely after ICH. The parameters for the blood pressure control are still under investigation. The American Heart Association has put forward guidelines for blood pressure control which have been adopted in the centers around the country. We have described the protocol we use at our center for the blood pressure control in patients with acute ICH.
Journal of the Neurological Sciences 11/2007; 261(1-2):74-9. · 2.35 Impact Factor
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ABSTRACT: Anomalous courses, anastomoses, and origins of the middle meningeal artery have often been described in the literature; however origin from the basilar artery or its branches is exceedingly rare with only five previous reports. We describe a middle meningeal artery originating from a large lateral pontine branch of the basilar artery. The lateral pontine branch also supplied most of the cerebellar hemispheric territory normally vascularized by both the anterior inferior cerebellar artery and posterior inferior cerebellar artery. We discuss the anatomy and possible embryological development of middle meningeal origin from the basilar artery.
Journal of Neuroimaging 08/2007; 17(3):261-3. · 1.51 Impact Factor
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ABSTRACT: Percutaneous stenting techniques are becoming more commonly used for treatment of carotid artery disease. One outcome of particular concern is in-stent restenosis. Indications for treatment of in-stent restenosis are not clearly defined. Use of traditional balloon angioplasty with or without stent placement is still considered the first option. Cutting balloon angioplasty has recently been used as an alternative treatment option for revascularization of in-stent restenosis with higher procedural success rates and without the use of additional stents. We report our experience with cutting balloon angioplasty in treating 2 patients with carotid in-stent restonosis, and review previous cases reported in the literature. A total of 16 patients have been treated with cutting balloon angioplasty. Among 11 patients for whom the clinical and angiographic information were available, 63% of patients were asymptomatic at the time of treatment, and more than 90% of patients showed either complete angiographic resolution or residual stenosis of less than 30%. Additional stent placement or angioplasty was required in only half of the patients, and 1 patient had recurrent stenosis. The review suggests that the procedure is safe and effective.
Journal of neuroimaging: official journal of the American Society of Neuroimaging 02/2007; 18(4):428-32. · 1.72 Impact Factor
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ABSTRACT: To report experience with intra-arterial (IA) calcium channel blocker (nicardipine) in patients with acute ischemic stroke with and without reteplase, mechanical thrombectomy (snare), and primary angioplasty to achieve maximal recanalization. Selective delivery of calcium channel blocker may improve perfusion and possibly provide neuroprotection in cerebral ischemia.
We performed a retrospective study to determine the angiographic and clinical outcomes among patients treated with IA nicardipine administered as 2.5-5 mg dose either alone or adjunct to intra-arterial thrombolysis. Mean arterial pressure and heart rate were recorded throughout the injection. Angiographic severity of initial occlusion and recanalization was assessed using the Qureshi grading scheme. Neurological examinations and computed tomographic scans were performed prior to, immediately, and 24 h after thrombolysis for each patient, to assess the neurological improvement and symptomatic or asymptomatic intracranial hemorrhages.
Ten patients median age of 60 years (age range: 35-93 years) were administered IA nicardipine. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 14 (range 6-19). All patients received IA nicardipine either in combination with thrombolytics (n = 6) or as monotherapy (n = 4). The average decrease in mean arterial pressure (MAP) was 10 mmHg; except one patient who had an asymptomatic decline of 34 mm Hg, which responded to fluid resuscitation. None of the patients suffered any procedural and post-procedural complication. Overall recanalization (improvement in one grade or greater) was observed in 2 of 10 patients with IA nicardipine with or without thrombolytic treatment. Other angiographic changes observed included improvement in collateral flow (n = 2), increase in transit time (n = 1), and vasodilation of distal arteries and branches (n = 4). No patient demonstrated any worsening from the baseline grade in response to IA nicardipine. Of the two patients who underwent serial magnetic resonance imaging (MRI) and one patient demonstrated reversal of pretreatment restricted diffusion. Neurological improvement defined by a decrease of four points or greater was observed in four patients at 24 h following treatment.
Intra-arterial delivery of nicardipine in doses up to 5 mg is well tolerated among patients with acute ischemic stroke. Further studies are required to determine the potential efficacy of this approach with or without thrombolytics.
Neurocritical Care 02/2007; 7(1):53-7. · 2.47 Impact Factor
