Christopher S Ogilvy

Publications of Christopher S Ogilvy

• ONYX versus n-BCA for embolization of cranial dural arteriovenous fistulas.

  Authors: James David Rabinov, Albert J Yoo, Christopher S Ogilvy, Bob S Carter, Joshua A Hirsch

  Journal of neurointerventional surgery. 05/2012;

  PurposeTo evaluate the efficacy of n-butyl-2-cyanoacrylate (Trufill n-BCA) versus ethylene vinyl alcohol copolymer (ONYX) for the embolization of cranial dural arteriovenous fistulasPurposeTo evaluate the efficacy of n-butyl-2-cyanoacrylate (Trufill n-BCA) versus ethylene vinyl alcohol copolymer (ONYX) for the embolization of cranial dural arteriovenous fistulas (DAVF).MethodsFifty-three consecutive patients with cranial dural AVF were treated with liquid embolic agents from November, 2003 to November, 2008. These 53 patients had 56 lesions treated with arterial embolization. Patients embolized to completion underwent follow-up angiography at 3 months to assess for durable occlusion.ResultsTwenty-one lesions were treated with n-BCA. Seven patients treated with n-BCA had initial angiographic occlusion of their DAVF, which were durable at 3 months. Six patients had adjunctive treatment with coils and/or polyvinyl alcohol particles, but none of these were occluded by endovascular treatment alone. Eleven patients underwent post-embolization surgery for closure of their DAVF. There was one death related to intractable status epilepticus at presentation. One patient developed a major stroke from venous sinus thrombosis after embolization. Thirty-five lesions were treated with ONYX in 34 patients. Twenty-nine patients treated with ONYX had initial angiographic occlusion of their DAVF by embolization alone. One patient had recurrence at 3 months and was re-treated out of 27 total follow-ups. Four patients underwent post-embolization surgical obliteration of their lesions. No deaths or major strokes occurred in this cohort.ConclusionInitial angiographic occlusion (p=0.0004) and durable angiographic occlusion (p=0.0018) rates for embolization of cranial DAVF show a statistically significant higher efficacy with ONYX compared with n-BCA. Patients embolized with ONYX underwent surgery less frequently compared with those treated with n-BCA (p=0.0015).

• Principles of posterior fossa surgery.

  Authors: David H Jho, Christopher S Ogilvy

  Journal of neurointerventional surgery. 03/2012;

• Glioblastoma multiforme and cerebral cavernous malformations: intersection of pathophysiologic pathways.

  Authors: Matthew K Mian, Brian V Nahed, Brian P Walcott, Christopher S Ogilvy, William T Curry

  Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 11/2011;

  Cerebral cavernous malformations (CCM) are known to occur in both sporadic and familial forms. To date, there has been no identified association of CCM with glioblastoma multiforme. We present aCerebral cavernous malformations (CCM) are known to occur in both sporadic and familial forms. To date, there has been no identified association of CCM with glioblastoma multiforme. We present a 69-year-old woman with a 14year history of multiple CCM who developed progressive aphasia. She had no radiation exposure and had only undergone a single computed tomography scan in her entire life. MRI demonstrated irregular gadolinium enhancement in the area of a prior stable CCM, suspicious for a high grade tumor. Stereotactic biopsy revealed a glioblastoma multiforme. This is a unique case of glioblastoma multiforme arising from the "site" of a known CCM. We review the literature on the genetics of cavernous malformations and propose a mechanism for the tumorigenic potential of these vascular malformations.

• Planned Two-fraction Proton Beam Stereotactic Radiosurgery for High-risk Inoperable Cerebral Arteriovenous Malformations.

  Authors: Jona A Hattangadi, Paul H Chapman, Marc R Bussière, Andrzej Niemierko, Christopher S Ogilvy, Alison Rowell, Juliane Daartz, Jay S Loeffler, Helen A Shih

  International journal of radiation oncology, biology, physics. 11/2011;

  PURPOSE: To evaluate patients with high-risk cerebral arteriovenous malformations (AVMs), based on eloquent brain location or large size, who underwent planned two-fraction proton stereotacticPURPOSE: To evaluate patients with high-risk cerebral arteriovenous malformations (AVMs), based on eloquent brain location or large size, who underwent planned two-fraction proton stereotactic radiosurgery (PSRS). METHODS AND MATERIALS: From 1991 to 2009, 59 patients with high-risk cerebral AVMs received two-fraction PSRS. Median nidus volume was 23 cc (range, 1.4-58.1 cc), 70% of cases had nidus volume ≥14 cc, and 34% were in critical locations (brainstem, basal ganglia). Median AVM score based on age, AVM size, and location was 3.19 (range, 0.9-6.9). Many patients had prior surgery or embolization (40%) or prior PSRS (12%). The most common prescription was 16 Gy radiobiologic equivalent (RBE) in two fractions, prescribed to the 90% isodose. RESULTS: At a median follow-up of 56.1 months, 9 patients (15%) had total and 20 patients (34%) had partial obliteration. Patients with total obliteration received higher total dose than those with partial or no obliteration (mean dose, 17.6 vs. 15.5 Gy (RBE), p = 0.01). Median time to total obliteration was 62 months (range, 23-109 months), and 5-year actuarial rate of partial or total obliteration was 33%. Five-year actuarial rate of hemorrhage was 22% (95% confidence interval, 12.5%-36.8%) and 14% (n = 8) suffered fatal hemorrhage. Lesions with higher AVM scores were more likely to hemorrhage (p = 0.024) and less responsive to radiation (p = 0.026). The most common complication was Grade 1 headache acutely (14%) and long term (12%). One patient developed a Grade 2 generalized seizure disorder, and two had mild neurologic deficits. CONCLUSIONS: High-risk AVMs can be safely treated with two-fraction PSRS, although total obliteration rate is low and patients remain at risk for future hemorrhage. Future studies should include higher doses or a multistaged PSRS approach for lesions more resistant to obliteration with radiation.

• Dual Ipsilateral Craniotomies Through a Single Incision for the Surgical Management of Multiple Intracranial Aneurysms.

  Authors: Gavin P Dunn, Brian V Nahed, Brian P Walcott, Henry Jung, Travis S Tierney, Christopher S Ogilvy

  World neurosurgery. 11/2011;

  OBJECTIVE: To examine whether multiple aneurysms located in the anterior cerebral artery (ACA), middle cerebral artery (MCA), or internal carotid artery (ICA) could be treated through single-stage,OBJECTIVE: To examine whether multiple aneurysms located in the anterior cerebral artery (ACA), middle cerebral artery (MCA), or internal carotid artery (ICA) could be treated through single-stage, ipsilateral dual craniotomies. METHODS: Investigators reviewed records of nine patients who underwent dual ipsilateral craniotomies through one incision for surgical treatment of multiple aneurysms in the anterior circulation at a single institution from 1994-2010. In all cases, a single-stage pterional and frontal interhemispheric approach through two separate, ipsilateral craniotomies under a single, extended pterional incision was used. RESULTS: Dual craniotomies through one incision were performed on nine patients with multiple aneurysms without complications. This series included eight women and one man with an average age of 57 years. The mean number of aneurysms treated was 2.7 (range 2-5 aneurysms). Most patients underwent elective treatment. The pterional craniotomy approach was used to treat MCA and ICA aneurysms, whereas distal ACA aneurysms were treated through the frontal parasagittal craniotomy approach. All aneurysms were successfully treated via clip ablation. There were no perioperative or postoperative complications at an average follow-up of 29 months (range 1-131 months). CONCLUSIONS: Single-stage, ipsilateral dual pterional and frontal craniotomies through one incision constitute a safe approach that can be employed for the effective surgical treatment of multiple aneurysms in joint unilateral and axial locations with excellent clinical results.

• Cerebral revascularization for the treatment of complex intracranial aneurysms of the posterior circulation: microsurgical anatomy, techniques and outcomes.

  Authors: Jared M Pisapia, Brian P Walcott, Brian V Nahed, Kristopher T Kahle, Christopher S Ogilvy

  Journal of neurointerventional surgery. 09/2011; 3(3):249-54.

  While the trend for endovascular therapy of posterior circulation aneurysms is permeating, cerebrovascular bypass remains essential in the armamentarium for complex lesions not amendable to theseWhile the trend for endovascular therapy of posterior circulation aneurysms is permeating, cerebrovascular bypass remains essential in the armamentarium for complex lesions not amendable to these techniques. This review discusses the microsurgical anatomy of the posterior fossa intracranial circulation, as well as the techniques and outcomes related to cerebrovascular bypass.

• Nicotine replacement therapy after subarachnoid hemorrhage is not associated with increased vasospasm.

  Authors: Raphael A Carandang, Bruce Barton, Guy A Rordorf, Christopher S Ogilvy, John R Sims

  Stroke; a journal of cerebral circulation. 08/2011; 42(11):3080-6.

  A significant number of patients with aneurysmal subarachnoid hemorrhage are active smokers and at risk for acute nicotine withdrawal. There is conflicting literature regarding the vascular effectsA significant number of patients with aneurysmal subarachnoid hemorrhage are active smokers and at risk for acute nicotine withdrawal. There is conflicting literature regarding the vascular effects of nicotine and theoretical concern that it may worsen vasospasm. The literature on the safety of nicotine replacement therapy and its effects on vasospasm is limited. A retrospective analysis was conducted of a prospectively collected database of aneurysmal subarachnoid hemorrhage patients admitted to the neurointensive care unit from 1994 to 2008. Paired control subjects matched for age, sex, Fisher score, aneurysm size and number, hypertension, and current medication were analyzed. The primary outcome was clinical and angiographic vasospasm and the secondary outcome was Glasgow Outcome Score on discharge. Conditional logistic models were used to investigate univariate and multivariate relationships between predictors and outcome. Two hundred fifty-eight active smoking patients were included of which 87 were treated with transdermal nicotine replacement therapy. Patients were well matched for age, sex, gender, Fisher score, aneurysm size and number, hypertension, and current medications, but patients who received nicotine replacement therapy had less severe Hunt-Hess scores and Glasgow coma scores. There was no difference in angiographic vasospasm, but patients who received nicotine replacement therapy were less likely to have clinical vasospasm (19.5 versus 32.8%; P=0.026) and a Glasgow Outcome Score <4 on discharge (62.6% versus 81.6%; P=0.005) on multivariate analysis. Nicotine replacement therapy was not associated with increased angiographic vasospasm and was associated with less clinical vasospasm and better Glasgow Outcome Score scores on discharge.

• Delayed endovascular revascularization in a patient with progressive neurological deterioration from bilateral intracranial vertebral artery occlusions: case report.

  Authors: Christopher S Ogilvy, Alexander A Khalessi, Erik F Hauck, Larry R Shannon, L Nelson Hopkins, Elad I Levy, Adnan H Siddiqui

  Neurosurgery. 07/2011; 69(1):E251-6; discussion E256.

  This article describes delayed endovascular revascularization in a patient with clinical and radiographic evidence of posterior circulation hemodynamic failure in the setting of intracranialThis article describes delayed endovascular revascularization in a patient with clinical and radiographic evidence of posterior circulation hemodynamic failure in the setting of intracranial occlusive lesions. A 48-year-old man presented with a 6-week history of progressive headache, nausea, and ataxia. Bilateral intracranial vertebral artery occlusions and a left posterior inferior cerebellar artery stroke were diagnosed, and the patient began warfarin therapy. Despite these measures, the patient developed dense lower cranial neuropathies, including severe dysarthria, decreased left-sided hearing acuity, and left facial droop. He presented at this point for endovascular evaluation. The patient underwent successful revascularization with intravascular Wingspan stents (Boston Scientific, Natick, Massachusetts) in a delayed fashion (approximately 6 weeks after his initial stroke presentation). His neurological syndrome stabilized and began to improve slowly. Patients with arterial occlusion should be evaluated acutely for potential revascularization. In the posterior circulation, clinical progression may supplant physiological imaging in the assessment of hemodynamic collapse. A subpopulation of patients will present with progressive deficits distinct from extracranial manifestations of vertebrobasilar insufficiency; these patients should be considered for delayed revascularization.

• Early experience with flow diverting endoluminal stents for the treatment of intracranial aneurysms.

  Authors: Brian P Walcott, Jared M Pisapia, Brian V Nahed, Kristopher T Kahle, Christopher S Ogilvy

  Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 07/2011; 18(7):891-4.

  We aimed to identify the initial preliminary experience with flow diverting stents (FDS) for the treatment of intracranial aneurysms (IA). A PubMed search was performed to identify studies reportingWe aimed to identify the initial preliminary experience with flow diverting stents (FDS) for the treatment of intracranial aneurysms (IA). A PubMed search was performed to identify studies reporting patients treated with FDS. Selection was made for studies that provided either immediate or short term follow-up data. For each study, the number of patients and IA were identified. Details regarding the aneurysm itself were recorded; such as aneurysm morphology (saccular or fusiform), location, and rupture status. The primary treatment modality and the number of stents used to treat each aneurysm was recorded along with the antiplatelet regimen used. Outcomes such as aneurysm occlusion and complications, including stroke, in-stent thrombosis and stenosis, and death were identified. The average length of follow-up was calculated in weeks. A total of 10 manuscripts reporting 206 IA in 190 patients were identified in the literature. Occlusion rates were variably reported, ranging from 58% to 94% in the larger series. Major complications of treatment included stroke (6.0%), in-stent thrombosis and stenosis (4.9%), and death (3.3%). A phenomenon of delayed aneurysm rupture was also identified. We concluded that flow diverting stents have proven effective in a variety of scenarios. The major complications with FDS have related to perforator artery stroke, aneurysm re-rupture, and in-stent stenosis and thrombosis. Long-term efficacy, optimal antithrombotic agent regimen, and perforator stroke risk are yet to be determined.

• Time-resolved contrast-enhanced magnetic resonance angiography in the investigation of suspected intracranial dural arteriovenous fistula.

  Authors: Benjamin D Schanker, Brian P Walcott, Brian V Nahed, Christopher S Ogilvy, Andrew J M Kiruluta, James D Rabinov, William A Copen

  Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 06/2011; 18(6):837-9.

  Cerebral angiography is widely regarded as the gold standard for the evaluation and diagnosis of neurovascular abnormalities. However, recent improvements in the spatial and temporal resolution ofCerebral angiography is widely regarded as the gold standard for the evaluation and diagnosis of neurovascular abnormalities. However, recent improvements in the spatial and temporal resolution of time-resolved magnetic resonance angiography (MRA) offer clinicians a non-invasive alternative to cerebral angiography. We explored the utility of this technique in an elderly female patient with a suspected intracranial dural arteriovenous fistula (dAVF). A product pulse sequence available from the scanner's manufacturer (time-resolved imaging of contrast kinetics, TRICKS; GE Healthcare, Milwaukee, WI, USA) was used with the following parameters: TR/TE 2.832/TE 1.072 ms, flip angle 25°, receiver bandwidth 31.25 kHz, 0.75 NEX, acceleration factor (ASSET) of 2, field of view 14 cm, matrix size 96 × 96, phase-encoding left-right. Twenty overlapping 8-mm-thick slices were acquired in an axial orientation, with a slice spacing of 4mm. Images were acquired at 48 time points, with a temporal resolution of 0.3s/image. We found that all intracranial venous structures enhanced synchronously. There was no evidence of arteriovenous shunting. Retrograde venous flow explained the signal abnormality seen on time-of-flight MRA. We concluded that time-resolved MRA is useful in the investigation of suspected intracranial dAVF.

• Emergent endovascular recanalization for cervical internal carotid artery occlusion in patients presenting with acute stroke.

  Authors: Erik F Hauck, Sabareesh K Natarajan, Hajime Ohta, Christopher S Ogilvy, L Nelson Hopkins, Adnan H Siddiqui, Elad I Levy

  Neurosurgery. 04/2011; 69(4):899-907; discussion 907.

  Acute proximal (cervical) internal carotid artery (ICA) occlusion may cause ischemia of an entire hemisphere or no ischemia at all, depending on the presence of intracranial collaterals. ToAcute proximal (cervical) internal carotid artery (ICA) occlusion may cause ischemia of an entire hemisphere or no ischemia at all, depending on the presence of intracranial collaterals. To retrospectively analyze the clinical results for emergent endovascular carotid recanalization in patients with acute proximal (cervical) ICA occlusion and to assess predictors of recanalization and clinical, neurological, and functional outcome. Emergent endovascular revascularization was attempted in 22 patients presenting with acute stroke secondary to complete cervical ICA occlusion. Patients with pseudo-occlusion were excluded. Recanalization was assessed with the Thrombolysis in Myocardial Ischemia (TIMI) system: grade 0 (no flow) to grade 3 (normal flow). The median age of the patients was 65 years; mean admission National Institutes of Health Stroke Scale (NIHSS) score was 14. Recanalization (TIMI grade 2/3) occurred in 17 patients (77.3%). Ten patients (45.5%) demonstrated significant clinical improvement during hospitalization (NIHSS improved ≥4 points). Fifty percent of patients had good outcomes (modified Rankin Scale ≤2) after a median follow-up of 3 months. Patient age <70 years and successful recanalization (TIMI grade 2/3) predicted a good outcome (P ≤ .01). Presence of atrial fibrillation, admission NIHSS score ≥20, and complete ICA occlusion at all levels (cervical, petrocavernous, and intracranial) were associated with poor outcomes (P ≤ .05). Patients with complete cervical ICA occlusion but partial distal preservation of the vessel were most likely to benefit from the intervention (recanalization in 88.2%; good outcome in 64.7%). Attempts at emergent endovascular carotid recanalization for acute stroke are encouraged, particularly in younger patients with partial distal preservation of the ICA.

• Complete preoperative embolization of hemangioblastoma vessels with Onyx 18.

  Authors: Denes B Horvathy, Erik F Hauck, Christopher S Ogilvy, L Nelson Hopkins, Elad I Levy, Adnan H Siddiqui

  Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 03/2011; 18(3):401-3.

  The authors present a preliminary experience with ethyl-enevinylalcohol copolymer (Onyx) for hemangioblastoma vessel embolization before surgical resection. The patient presented with neck pain,The authors present a preliminary experience with ethyl-enevinylalcohol copolymer (Onyx) for hemangioblastoma vessel embolization before surgical resection. The patient presented with neck pain, dizziness, blurred vision, vomiting, and loss of balance. Diagnostic imaging revealed a posterior fossa cystic mass with a nodular component. Angiography demonstrated a significant vascular blush with arteriovenous shunting that was characteristic of a hemangioblastoma. Tumor vessels originating off the left posterior inferior cerebellar artery were embolized before surgery using Onyx 18 (ev3, Covidien Vascular Therapies, Mansfield, MA, USA). This resulted in complete obliteration of all tumor vessels, transforming a highly vascular tumor into an avascular mass. A safe and uneventful surgical resection was performed the next day. Onyx is a valuable embolic agent for preoperative hemangioblastoma vessel embolization. Because of its low viscosity, Onyx penetrates deeply into the tumor vasculature and allows complete obliteration of tumor vessels. Risks of the intervention have to be carefully weighed against the benefits. If preoperative embolization is indicated, the use of Onyx should be strongly considered.

• Arterial tortuosity syndrome with multiple intracranial aneurysms: a case report.

  Authors: Matthew R Naunheim, Brian P Walcott, Brian V Nahed, Calum A MacRae, John R Levinson, Christopher S Ogilvy

  Archives of neurology. 03/2011; 68(3):369-71.

  To report a new manifestation of the rare connective tissue disorder arterial tortuosity syndrome in the absence of skin and soft-tissue abnormalities and with bilateral, giant fusiform intracranialTo report a new manifestation of the rare connective tissue disorder arterial tortuosity syndrome in the absence of skin and soft-tissue abnormalities and with bilateral, giant fusiform intracranial aneurysms. Case report. University teaching hospital. A 67-year-old man with a history of hypertension presented to medical attention after a syncopal episode. Imaging revealed incidental, bilateral, giant fusiform intracranial aneurysms of the internal carotid artery at their junction of the circle of Willis. There was also aneurysmal dilatation of the left main coronary artery ectasia and aneurysmal dilation of the aorta and bilateral iliac arteries, suggestive of arterial tortuosity syndrome. The patient's syncope was attributed to transient complete heart block for which a permanent pacemaker was placed. The patient started taking aspirin for stroke prevention and losartan potassium for blood pressure control. To our knowledge, we present the first case of arterial tortuosity syndrome with marked bilateral intracranial artery dilation in the absence of concurrent skin and soft tissue abnormalities. Workup may include systemic vascular imaging to characterize the extent of disease. Antiplatelet therapy can be used for stroke prevention by reducing the risk of clot formation in ectatic vessels with altered hemodynamics and subsequent embolism. Losartan is known to inhibit transforming growth factor β signaling and may be a specific modulator of disease expression in this syndrome.

• Stent-assisted coiling of paraclinoid aneurysms: risks and effectiveness.

  Authors: Christopher S Ogilvy, Sabareesh K Natarajan, Shady Jahshan, Yuval Karmon, Xinyu Yang, Kenneth V Snyder, L Nelson Hopkins, Adnan H Siddiqui, Elad I Levy

  Journal of neurointerventional surgery. 03/2011; 3(1):14-20.

  Stent assistance for treatment of wide-based aneurysms is becoming rapidly accepted. Cases of aneurysms arising in the paraclinoid location of the internal carotid artery treated with intracranialStent assistance for treatment of wide-based aneurysms is becoming rapidly accepted. Cases of aneurysms arising in the paraclinoid location of the internal carotid artery treated with intracranial stents and/or bare platinum coils were analyzed retrospectively from our prospectively collected database. We identified 70 aneurysms treated with stent assistance (including one stenting-alone case) and 24 aneurysms treated with coiling alone. Stenting-assisted coiling was achieved either as a one-time treatment or as a two-step maneuver with the stent placed several weeks before coiling, or stent-assisted coiling was used as a second maneuver in aneurysms that recanalized after previous coiling. In aneurysms treated with stent assistance, 60% had ≥95% occlusion at treatment completion, a result comparing favorably with the 54.2% rate of ≥95% occlusion associated with coiling alone. At last follow-up, 60 aneurysms treated with stent assistance had a 66.7% incidence of ≥95% occlusion, with no in-stent stenosis; 75% of patients treated with coiling alone had ≥95% aneurysm occlusion. Thrombus occurred during stent deployment in two patients, one with and one without neurologic sequelae; stent displacement occurred in one patient without neurologic sequelae. At last follow-up, 57 of 62 patients (91.9%) treated with stent-assisted coiling experienced excellent/good outcomes (modified Rankin scale score ≤2). These results compared favorably with those for the coiling-alone group in which 23 of 24 (95.8%) had good outcomes. Stent-assisted coiling of paraclinoid aneurysms did not add significantly to morbidity; overall effectiveness was comparable to that of bare coiling of paraclinoid aneurysms. These results require confirmation by a prospective controlled trial.

• Microsurgical retrieval of an endovascular microcatheter trapped during Onyx embolization of a cerebral arteriovenous malformation.

  Authors: Brian P Walcott, Jason L Gerrard, Raul G Nogueira, Brian V Nahed, Anna R Terry, Christopher S Ogilvy

  Journal of neurointerventional surgery. 03/2011; 3(1):77-9.

  Cerebral arteriovenous malformations (AVMs) are vascular lesions that are amenable to various treatment modalities including stereotactic radiosurgery, fractionated radiotherapy, endovascularCerebral arteriovenous malformations (AVMs) are vascular lesions that are amenable to various treatment modalities including stereotactic radiosurgery, fractionated radiotherapy, endovascular embolization, microsurgical obliteration or combined modality treatment. A potential complication of endovascular therapy with embolization material is microcatheter entrapment. We report on a patient for whom surgery was combined with endovascular embolization to obliterate an AVM and retrieve an entrapped endovascular microcatheter. A 52-year-old woman suffered a left parietal hemorrhage from an AVM. She underwent staged endovascular embolization of the lesion using Onyx material. During the second stage of the embolization, the microcatheter (Marathon Flow Directed Microcatheter; eV3 Neurovascular, Inc., Irvine, CA, USA) was retained in the Onyx plug. It was decided to section the microcatheter at the groin and proceed with microsurgical obliteration of the AVM, with removal of the entrapped microcatheter remnant. The AVM was dissected circumferentially allowing the meticulous obliteration of the feeding vessels. A single remaining feeding vessel originating from the distal anterior cerebral artery was identified and suspected to contain the entrapped microcatheter. The location was confirmed using stereotactic guidance (BrainLab, Munich, Germany) and the vessel was then sectioned allowing complete removal of the AVM. The microcatheter (102 cm) was then extracted cranially using gentle traction. This demonstrates the first incidence of microcatheter removal after procedural entrapment in Onyx embolization material.

• Unruptured cerebral aneurysms do not shrink when they rupture: multicenter collaborative aneurysm study group.

  Authors: Maryam Rahman, Christopher S Ogilvy, Gregory J Zipfel, Colin P Derdeyn, Adnan H Siddiqui, Ketan R Bulsara, Louis J Kim, Howard A Riina, J Mocco, Brian L Hoh

  Neurosurgery. 01/2011; 68(1):155-60; discussion 160-1.

  The International Study of Intracranial Aneurysms found that for patients with no previous history of subarachnoid hemorrhage, small (< 7 mm) anterior circulation and posterior circulation aneurysmsThe International Study of Intracranial Aneurysms found that for patients with no previous history of subarachnoid hemorrhage, small (< 7 mm) anterior circulation and posterior circulation aneurysms had a 0% and 2.5% risk of subarachnoid hemorrhage over 5 years, respectively. To determine whether cerebral aneurysms shrink with rupture. The clinical databases of 7 sites were screened for patients with imaging of cerebral aneurysms before and after rupture. Inclusion criteria included documented subarachnoid hemorrhage by imaging or lumbar puncture and intracranial imaging before and after cerebral aneurysm rupture. The patients were evaluated for aneurysm maximal height, maximal width, neck diameter, and other measurement parameters. Only a change of ≥ 2 mm was considered a true change. Data on 13 patients who met inclusion criteria were collected. The median age was 60, and 11 of the 13 patients (84.6%) were female. Only 5 patients had posterior circulation aneurysms. None of the aneurysms had a significant decrease in size. One aneurysm decreased by 1.8 mm in maximum size after rupture (7.7%). Six aneurysms had an increase in maximum size of at least 2 mm after rupture (46.2%) with a mean increase of 3.5 mm (± 0.5 mm). Unruptured aneurysms do not shrink when they rupture. The large percentage of ruptured small aneurysms in previous studies were likely small before they ruptured.

• Neurointerventional procedures for unruptured intracranial aneurysms under procedural sedation and local anesthesia: a large-volume, single-center experience.

  Authors: Christopher S Ogilvy, Xinyu Yang, Osama A Jamil, Erik F Hauck, L Nelson Hopkins, Adnan H Siddiqui, Elad I Levy

  Journal of neurosurgery. 01/2011; 114(1):120-8.

  In this paper, the authors' goal was to report the outcome of patients with unruptured intracranial aneurysms undergoing endovascular treatment under conscious sedation (local anesthesia). BetweenIn this paper, the authors' goal was to report the outcome of patients with unruptured intracranial aneurysms undergoing endovascular treatment under conscious sedation (local anesthesia). Between November 5, 2001, and February 5, 2009, the authors treated 340 patients with 358 unruptured aneurysms by using neurointerventional procedures at Millard Fillmore Gates Hospital (Buffalo, New York). The data were retrospectively reviewed for periprocedural safety and long-term follow-up. A total of 496 procedures were performed under local anesthesia. Of those, 370 procedures (74.6%) were completed successfully. In 82 procedures (16.5%), an associated medical or technical event occurred. Forty-four procedures (8.9%) were aborted. Rates of overall procedure-related morbidity and mortality were 1.2% (6 of 496) and 0.6% (3 of 496), respectively. The average hospital stay was 1.5 ± 2.5 days. Long-term follow-up was available in 261 (82.1%) of 318 patients whose procedures were performed with local anesthesia. Of those, 246 patients (94.3%) had a good outcome (modified Rankin Scale score ≤ 2), 6 patients (2.3%) had an unfavorable outcome, not related to the procedure, and 9 patients (3.4%) had a poor outcome (modified Rankin Scale score > 2) as a result of the intervention. Interventional treatment under conscious sedation (local anesthesia) can be effectively performed in most patients with unruptured intracranial aneurysms and is associated with a short hospital stay and low morbidity and mortality.

• Surgical treatment of a large fusiform distal anterior cerebral artery aneurysm with In Situ end-to-side A3-A3 bypass graft and aneurysm trapping: case report and review of the literature.

  Authors: Gavin P Dunn, Jason L Gerrard, David H Jho, Christopher S Ogilvy

  Neurosurgery. 12/2010; 68(2):E587-91; discussion E591.

  Large fusiform aneurysms of the distal anterior cerebral territory are extremely rare and can be particularly challenging to treat. The circumferential pathology of fusiform lesions rendersLarge fusiform aneurysms of the distal anterior cerebral territory are extremely rare and can be particularly challenging to treat. The circumferential pathology of fusiform lesions renders stand-alone clip or coil ablation unsatisfactory, and the deep, narrow corridor augments the difficulty of surgical approaches. In this setting, bypass procedures may be used to both treat the aneurysm definitively and preserve distal parent artery flow. We report a rare case of a large fusiform A3 aneurysm treated with trapping and concomitant end-to-side A3:A3 bypass. A 52-year-old man was evaluated after losing consciousness and experiencing a fall. A noncontrast computed tomography scan revealed a focal area of hemorrhage above the body of the corpus callosum, and computed tomography angiography showed a fusiform aneurysm of the right A3 artery. To treat the aneurysm definitively and preserve distal vessel flow, the patient was taken to surgery in anticipation of aneurysm ablation and cerebrovascular bypass. A large, fusiform right A3 aneurysm was identified. Intraoperative flow measurement demonstrated poor collateral circulation. The aneurysm was trapped with clips, and a right-to-left A3:A3 end-to-side in situ bypass was performed. Aneurysm occlusion and preserved distal vessel flow were confirmed with intraoperative angiography. Large fusiform aneurysms in the distal anterior cerebral artery region are rare, and the anatomy of these lesions and their vascular location render stand-alone surgical management technically challenging. End-to-side A3:A3 bypass combined with aneurysm trapping represents a feasible treatment strategy for lesions in this location.

• Elective stenting for intracranial stenosis under conscious sedation.

  Authors: Andrea J Chamczuk, Christopher S Ogilvy, Kenneth V Snyder, Hajime Ohta, Adnan H Siddiqui, L Nelson Hopkins, Elad I Levy

  Neurosurgery. 11/2010; 67(5):1189-93; discussion 1194.

  Elective stenting for intracranial stenosis is under study as an effective means of reducing stroke risk. At most institutions, these procedures are performed and monitored after the induction ofElective stenting for intracranial stenosis is under study as an effective means of reducing stroke risk. At most institutions, these procedures are performed and monitored after the induction of general anesthesia. To report our success with elective intracranial stenting and angioplasty performed in conscious patients after the administration of mild sedatives and local anesthetic agents. We retrospectively evaluated data from 66 patients who underwent elective intracranial stenting for atherosclerosis. Sixty-one procedures were performed under local anesthesia with mild sedation; 3 were performed under general anesthesia, and 2 were converted from local to general anesthesia during the procedure. Intraprocedural neurological changes were monitored and led to reevaluation of technique, immediate reimaging, modifying the endovascular procedure itself, or possibly mandating conversion to general anesthesia. Thirty-nine anterior and 27 posterior circulation stenotic segments were treated. Angiographic success was achieved in 95.5% of patients with an overall reduction in stenosis of 75.5 to 22.3%. Percutaneous angioplasty and stenting were used in 58 cases; 8 patients were treated with stenting alone. Three patients (4.9%) developed neurological deficits mandating alteration or adjustment of endovascular technique or immediate postoperative management to avoid permanent sequelae. A total of 8 periprocedural complications occurred, 2 of which resulted in permanent neurological deficit. The overall mortality rate was 3.2%. Stenting of intracranial atherosclerosis performed under conscious sedation is associated with complication rates and effectiveness similar to historical rates for general anesthesia. Conscious sedation confers the additional benefit of continuous neurological assessment during the procedure.

• Direct endovascular recanalization of chronic carotid occlusion: should we do it? Case report.

  Authors: Erik F Hauck, Christopher S Ogilvy, Adnan H Siddiqui, L Nelson Hopkins, Elad I Levy

  Neurosurgery. 10/2010; 67(4):E1152-9; discussion E1159.

  Patients with chronic carotid artery occlusion face a significant risk of stroke. It is believed that treatment is indicated if medical therapy fails or even as prophylaxis in high-risk patients.Patients with chronic carotid artery occlusion face a significant risk of stroke. It is believed that treatment is indicated if medical therapy fails or even as prophylaxis in high-risk patients. Direct surgical repair with carotid endarterectomy has a considerable failure rate and significant associated risks. Indirect repair with an extracranial-to-intracranial bypass has become the mainstay of surgical treatment. In this case study, the authors assess the feasibility of direct endovascular recanalization in the setting of chronic carotid occlusion, and discuss technical nuances and indications in comparison with the world literature and alternative options. Two patients presented with symptomatic, chronic, complete occlusion of the proximal carotid artery. The duration of documented occlusion exceeded 3 years in one patient and 6 months in the other. Endovascular recanalization was attempted using extracranial and intracranial stenting with proximal protection (flow arrest/reversal). Both patients had an excellent radiographic result, improving from Thrombolysis in Cerebral Infarction (TICI) grade 0 (no perfusion) to grade 3 (complete perfusion). The first patient's clinical symptoms resolved. The second patient remained unchanged with a mild facial droop. These preliminary results show potential for the endovascular management of this complicated disease. Long-term results and more data will determine the ultimate place of endovascular recanalization for symptomatic chronic carotid occlusion among other therapies.