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ORIGINAL
RESEARCH
Endovascular Treatment of Ruptured Paraclinoid
Aneurysms: Results, Complications, and
Follow-Up
I. Loumiotis
P.I. D’Urso
R. Tawk
H.J. Cloft
D.F. Kallmes
V. Kairouz
R. Hanel
G. Lanzino
BACKGROUND AND PURPOSE: Paraclinoid aneurysms are an uncommon cause of aneurysmal SAH,
and their treatment is challenging. To assess the effectiveness and safety of endovascular treatment
of ruptured paraclinoid aneurysms, we performed a retrospective analysis of 33 patients.
MATERIALS AND METHODS: Clinical and radiologic information on 33 patients undergoing endovascular
therapy between 1999 and 2010 was retrospectively reviewed. Angiographic results were evaluated
with the modified Raymond grading system, whereas clinical outcomes were evaluated with the mRS
scale.
RESULTS: Seventeen (52%) aneurysms were classified as clinoid segment aneurysms, and 16 (48%),
as ophthalmic segment aneurysms. Twenty-six (79%) aneurysms were small, 6 (18%) were large, 1
was (3%) giant, and 39% were wide-neck. Coiling was done with balloon assistance in 36% of cases
and stent-assistance in 6%. Technical complications occurred in 1 patient, contributing to death. Early
clinical complications causing permanent disability occurred in 3% of cases. One patient (3%) had fatal
rebleeding 18 days after treatment. Overall, procedure-related morbidity and mortality were, respec-
tively, 3% and 6%. Complete occlusion of the aneurysm was achieved in 36% of patients after initial
treatment and in 65% during follow-up (average, 29.3 months). Seven patients had recurrences
requiring retreatment (30%). Clinical outcome (average, 32.9 months) was good in 75% of patients and
poor in 25%. No delayed complications related to treatment and/or the aneurysm occurred.
CONCLUSIONS: Ruptured paraclinoid aneurysms are challenging lesions from an endovascular and
surgical point of view. Despite the high rate of recurrences, good clinical results and protection against
rebleeding can be achieved with current endovascular techniques.
ABBREVIATIONS: GCS ⫽Glasgow Coma Scale; ISAT ⫽International Subarachnoid Aneurysm Trial;
mRS ⫽modified Rankin Scale; WFNS ⫽World Federation of Neurosurgical Societies
The paraclinoid ICA location is common in patients with
unruptured intracranial aneurysms. However, paraclinoid
aneurysms are an uncommon cause of aneurysmal SAH, and
in large series, these represent approximately 1.4%–9.1% of all
patients with ruptured aneurysms.
1-3
Because of their location
in proximity to the skull base, surgery for paraclinoid aneu-
rysms can be challenging and often requires extensive drilling
of the anterior clinoid process and skull base to obtain proxi-
mal control and expose the aneurysm neck in its entirety. Be-
cause of these challenges, paraclinoid aneurysms have been
one of the most common indications for endovascular treat-
ment.
4,5
There is extensive literature on endovascular treat-
ment of unruptured paraclinoid aneurysms. However, due to
their rarity, to our knowledge, little is known about the results
and outcome of patients with ruptured paraclinoid aneurysms
undergoing endovascular treatment. In this article, we sum-
marize our experience with patients with ruptured paraclinoid
aneurysms treated with endovascular techniques at our
institutions.
Materials and Methods
After approval of the institutional review board, a retrospective chart
review of patients treated with coil embolization at our institutions
(Mayo Clinic Rochester from 1999 to 2010 and Mayo Clinic Florida
from 2007 to 2010) was undertaken. Thirty-four patients had rup-
tured aneurysms located in the paraclinoid region. This represents
9% of all ruptured aneurysms treated with endovascular techniques at
Mayo Clinic Rochester between 1999 and 2010. Clinical and radio-
logic information were retrospectively abstracted from the chart. Pa-
tients with dissecting, fusiform, and blisterlike aneurysms were ex-
cluded. Similarly patients who presented with SAH from another
aneurysm and had an unruptured paraclinoid aneurysm were ex-
cluded. Information collected included patient demographics, risk
factors (including a history of ischemic cerebrovascular disease,
smoking, hypertension, and a family history of intracranial aneu-
rysms), and length of hospital stay. Clinical outcomes were reported
by using the mRS scores, which were documented at baseline (before
the SAH based on information collected on admission) and at the last
available clinical follow-up.
6,7
The mRS score has been considered a
well-accepted measure of outcomes for aneurysm repair.
8
A “good”
outcome was defined as an mRS score of 0 –2; a “poor” outcome was
defined as an mRS score of 3– 6. The patient admission status was
codified according to the WFNS score, and the GCS score was re-
corded. The amount of blood on CT was defined according to the
Fisher grade. The total number of aneurysms identified on cerebral
angiograms along with the location and size of each was analyzed.
Paraclinoid aneurysms were classified according to Bouthillier et al.
9
Transitional, carotid cave, posterior carotid wall, and superior hypo-
Received April 20, 2011; accepted after revision June 21.
From the Departments of Neurosurgery (I.L., P.I.D., G.L.) and Radiology (H.J.C., D.F.K.),
Mayo Clinic, Rochester Minnesota; and Department of Neurosurgery (R.T., V.K., R.H.), Mayo
Clinic, Jacksonville, Florida.
Please address correspondence to Giuseppe Lanzino, MD, Department of Neurosurgery,
Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: Lanzino.Giuseppe@mayo.edu
http://dx.doi.org/10.3174/ajnr.A2825
632 Loumiotis 兩AJNR 33 兩Apr 2012 兩www.ajnr.org
physeal aneurysms were considered “clinoid segment” (C5) aneu-
rysms; and ophthalmic aneurysms, “ophthalmic segment” (C6)
aneurysms.
Information about treatment, including the need for balloon as-
sistance or stent assistance, was collected. Stents became available at
both centers in September 2002. Technical complications including
perforation, coil prolapse, coil migration, endoluminal thrombus for-
mation, and distal emboli were recorded. Coil prolapse was subclas-
sified into no flow-limiting and flow-limiting, and information was
acquired about whether systemic and/or intra-arterial administration
of glycoprotein IIB/IIIA inhibitors (eptifibatide [Integrilin] or abcix-
imab [ReoPro]) was used. Early neurologic complications were de-
fined as any thromboembolic or hemorrhagic complication occur-
ring within 1 month. SAH-related complications such as vasospasm
or hydrocephalus were also recorded. Non-neurologic complications,
including access site hematoma (defined as any hematoma requiring
prolonged immobilization, blood transfusion, or surgical repair),
were recorded. Aneurysm occlusion was graded by using a 3-point
mRS.
10
Radiologic follow-up information for every aneurysm was re-
corded at various intervals and at the last radiologic follow-up. We
prescribe routine follow-up imaging at 6 months in all patients with
ruptured aneurysms, but earlier angiography is sometimes performed
if there is concern for early recurrence. Specifically, we recorded oc-
clusion rates and whether conventional angiography or MRA studies
were performed. Information was also extracted about whether the
aneurysm had been retreated and the occlusion rate after retreatment.
Clinical information collected at the last follow-up included that re-
garding any occurrence of rebleeding, delayed ischemic symptoms
related to possible thromboembolism induced by the coils and/or
stent, mRS score, and, if applicable, the cause of worsening. Rates of
balloon-assisted and stent-assisted coiling, immediate angiographic
obliteration, and recurrence were compared with those encountered
in the overall institutional experience with endovascular treatment of
ruptured aneurysms in other locations. Data about postprocedural
single or double antiplatelet therapy (aspirin and/or clopidogrel)
were considered. The institutional policies regarding antiplatelet
medication for ruptured aneurysms are generally not to routinely use
periprocedural aspirin in ruptured aneurysms. However, aspirin and
clopidogrel are administered when using adjunctive stents. For these
comparisons, only Mayo Clinic Rochester data were used because
overall data from Mayo Clinic Florida were not available.
The
2
test was used for comparison of proportions, and the
2-sided ttest, for comparison of means. Results were considered sig-
nificant for Pvalues ⱕ.05.
Patients treated in the first half of the study period (from 1999 to
2004) were compared with patients treated during the second half
(from 2005 to 2010). Continuous data are presented as mean ⫾SD.
All statistical analyses were performed with JMP software, Version
9.0.1 (SAS Institute, Cary, North Carolina).
Results
Thirty-three patients were admitted with SAH from aneu-
rysms located in the paraclinoid region. Twenty-six patients
(79%) were treated within 24 hours from the SAH; 2 patients
(6%), after 24 and within 48 hours; and 5 (15%), after 48
hours. Demographic and clinical data of these patients are
summarized in Table 1. Twenty-six (79%) aneurysms were
small (⬍10 mm), 6 (18%) were large (10 to 25 mm), and 1
(3%) was giant (⬎25 mm) (Table 2). The mean size of the
aneurysm fundus was 8.17 ⫾6.11, and the mean size of the
aneurysm neck was 3.88 ⫾1.89. Thirteen (39%) aneurysms
were wide-neck (neck ⬎4 mm). Forty-seven percent of pa-
tients had multiple aneurysms, and 9 (27%) patients had bi-
lateral paraclinoid aneurysms. Only in 1 case could a history of
SAH from rupture of another aneurysm be elicited. Table 3
summarizes clinical and CT findings on admission.
Fifteen (45%) patients were treated between 1999 and
2004, and 18 (55%), between 2005 and 2010. No significant
differences were observed within these subgroups in relation
to aneurysm size (P⫽.669) and aneurysm neck size
(P⫽.545).
Treatment
All aneurysms were treated with reconstructive therapy.
Twenty-six aneurysms required only 1 endovascular proce-
dure. Because of recurrence, 6 aneurysms required 2 proce-
dures, and 1 aneurysm, 3. Recurrences were managed with
recoiling in 5 patients and flow-diverter deployment in 2 pa-
tients. No significant difference between recurrences and post-
procedural use of antiplatelet medication was observed
(P⫽.942). The recurrence rate in this population was 30%,
higher than that of ruptured aneurysms in other locations ob-
served in our endovascular series (30% versus 18%, P⫽.166,
Mayo Clinic Rochester dataset). Twelve patients (36%) un-
derwent balloon-assisted coiling, 7 of whom had broad-neck
aneurysms, while in 2 patients (6%), the procedure was stent-
assisted; these percentages are significantly higher compared
with those of balloon- and stent-assistance observed in our
endovascular series of ruptured aneurysms in other locations
(34% versus 15%, P⫽.015, Mayo Clinic Rochester dataset).
Table 1: Patients characteristics
Ruptured
Paraclinoid
Sex
F 27 (82%)
M 6 (18%)
F/M 4.5
Mean age (yr) 52.9 ⫾14.3
Risk factors
Hypertension 41%
Diabetes mellitus 3%
Tobacco abuse
Current 55%
Prior 3%
Personal history of stroke 9%
Family history of intracranial aneurysm 11%
History of SAH 3%
Pretreatment mRS (before SAH)
0 52%
1 42%
33%
43%
Interval between SAH and treatment
⬍24 Hr 26 (79%)
ⱖ24 ⱕ48 Hr 2 (6%)
ⱖ48 Hr 5 (15%)
Length of hospital stay (days) 16.1 ⫾11.9
INTERVENTIONAL ORIGINAL RESEARCH
AJNR Am J Neuroradiol 33:632–37 兩Apr 2012 兩www.ajnr.org 633
Periprocedural Complications
In 1 patient (3%), a 47-year-old with a grade V SAH from a
very large carotid-ophthalmic aneurysm, aneurysm perfora-
tion occurred during coiling. The patient died as a result of this
complication combined with the effects of the primary SAH.
Clinical Complications
Early clinical complications (related either to the procedure or
to SAH), causing transient neurologic symptoms and signs,
occurred in 6 patients (18%), while permanent disability oc-
curred only in 1 patient (3%). Transient neurologic worsening
was related to hydrocephalus (3 patients), vasospasm (3 pa-
tients, with 1 patient having neurologic worsening attributed
to both vasospasm and hydrocephalus). Permanent disability
was observed in 1 patient admitted with a Fisher grade 4 SAH
and associated intraparenchymal and subdural hematoma,
both requiring surgical evacuation after coiling.
Mortality following treatment within 30 days after admis-
sion and not related to technical complications occurred in 2
patients (6%). One patient had a rebleeding 18 days after com-
plete coiling of a posterior carotid wall aneurysm; another
patient, admitted with a poor-grade SAH, died the day follow-
ing admission from complications related to the SAH.
In conclusion, procedural mortality was 3%, and the re-
bleeding rate following endovascular treatment was 3%, while
there was no permanent morbidity attributed to treatment.
However, as previously specified, 1 patient (3%) had perma-
nent morbidity from sequelae of the original bleed.
Angiographic Outcome
All patients had immediate postoperative angiography, which
demonstrated complete aneurysm obliteration (class 1) in 12
patients (36%); this rate was lower compared with that ob-
served in ruptured aneurysms in other locations (31% versus
43%, P⫽.194, Mayo Clinic Rochester dataset).
Radiologic follow-up information was available for 14 pa-
tients within 6 months and for 12 patients within 12 months,
while in 13 patients, radiologic follow-up longer than 1 year
was available, with some patients having multiple angio-
graphic follow-ups at various intervals (Table 4). In 66% of
cases, angiographic follow-up was obtained with DSA, while
in 34% of cases, with MRA. The mean length of radiologic
follow-up was 29.3 ⫾26.7 (range, 2–94 months).
After subgroup analysis, 6/15 (40%) patients treated be-
tween 1999 and 2004 and 6/18 (33%) patients treated between
2005 and 2010 had complete aneurysm occlusion immediately
following endovascular treatment (P⫽.692). Six of 11 (55%)
patients treated between 1999 and 2004 and 9/12 (75%)
treated between 2005 and 2010 had complete occlusion at fol-
low-up (P⫽.301). The higher rate of complete occlusion in
the second half of the study was related to the higher chance of
complete occlusion achieved in patients treated with balloon-
assistance between 2005 and 2010 (P⫽.022).
Seven patients required retreatment for recurrences
deemed to be clinically important in relation to the increased
risk of rebleeding (Fig 1). Overall, at the end of the radiologic
follow-up period, complete obliteration (including retreat-
ment) was achieved in 16 of 24 patients (67%) (Tables 5 and
6). No significant differences in recurrence rate were observed
between the 1999 –2004 and the 2005–2010 subgroups (20%
versus 22%, P⫽.876).
Clinical Outcome and Long-Term Morbidity
Clinical follow-up longer than 3 months was available in 26 of
the 30 survivors (average length of clinical follow up, 32.9 ⫾
26.4 months; range, 3–94 months). Three patients died. A 47-
year-old man, admitted with a grade V SAH from a very large
carotid-ophthalmic aneurysm, experienced aneurysm perfo-
ration during coiling and died due to the combined effects of
the primary bleed and the periprocedural rupture. A 48-year-
old man had rebleeding 18 days after the procedure despite
initial complete angiographic occlusion of a posterior carotid
wall aneurysm. The third patient, a 64-year-old woman ad-
mitted with a poor-grade SAH from a small posterior carotid
wall aneurysm, died the day following the treatment from
complications related to the SAH.
Of the patients available for follow-up, 22/26 (85%) had a
good outcome, while 4/26 patients (15%) had an overall poor
outcome. In 2 patients, permanent disability was related to
SAH, while 2 patients recovered to their pre-SAH baseline but
they had pre-existing (due to the SAH) disabilities which af-
fected the follow-up mRS score. Time elapsing between SAH
and aneurysm treatment was not significantly related to over-
all outcome (P⫽.250). No cases of delayed worsening or
death occurred during follow-up. No late (⬎1 month after
treatment) rebleedings were reported. When patients who
Table 2: Distribution of the subtypes of paraclinoid aneurysm and size
Aneurysm Location
Size
Small (⬍10 mm) Large (10–25 mm) Giant (⬎25 mm) Total
Clinoid segment (C5) 15 1 1 52%
Ophthalmic segment (C6) 11 5 0 48%
Table 3: Clinical and radiologic admission grade
Scale Grade
WFNS
I 20 (61%)
II 4 (12%)
III 2 (6%)
IV 3 (9%)
V 4 (12%)
Fisher Grade
1 3 (9%)
2 4 (12%)
3 17 (52%)
4 9 (27%)
Table 4: Angiographic outcome at various intervals
Occlusion
Grade Immediate 6 Mo 12 Mo
Last
Follow-Up
Class 1 12/33 (36%) 7/14 (50%) 5/12 (42%) 9/13 (69%)
Class 2 16/33 (48%) 5/14 (36%) 6/12 (50%) 4/13 (31%)
Class 3 5/33 (15%) 2/14 (14%) 1/12 (8%) –
634 Loumiotis 兩AJNR 33 兩Apr 2012 兩www.ajnr.org
died within the first month of treatment are included, overall
rates of good and poor outcome were 75% (22/29) and 25%
(7/29), respectively.
Discussion
We report our experience with ruptured paraclinoid aneu-
rysms treated with endovascular embolization. In our series,
complete aneurysm occlusion was achieved in 35% of cases at
the end of the original procedure. Eventually, complete angio-
graphic obliteration (including those patients requiring re-
treatment) was achieved in 67% of patients at the last angio-
graphic follow-up (range, 3–94 months). Subgroup analysis of
patients treated in the first-and second-half intervals of our
study showed that higher rates of aneurysm occlusion were
observed in recent years, and this difference was related to a
higher incidence of complete occlusion achieved in the second
half of the study period in those patients treated with balloon
assistance (despite the incidence of balloon-assisted coiling
being similar in the 2 periods). This difference suggests a pos-
itive role of experience with this adjunctive technique in
achieving better packing attenuation as well as a possible pos-
itive role of better coil designs in the latter part of the series.
Although better packing attenuation and complete occlusion
rates may be achieved with stent-assisted coiling, only 2 pa-
tients in the present series were treated with such techniques.
In general, we try to avoid stent-assisted coiling in patients
with ruptured aneurysms because of the need for dual anti-
platelet therapy and the higher incidence of complications.
11
Approximately 40% of the aneurysms treated had a wide
neck (ⱖ4 mm), which may explain the low rate of immediate
angiographic occlusion compared with other series. Wide-
neck aneurysms are a challenge for an endovascular approach
and may require balloon or stent assistance to accomplish sat-
isfactory anatomic results in terms of occlusion. We use bal-
loon- or stent-assisted coiling selectively. In our experience,
balloon and stent assistance (36% and 6%, respectively, total
Fig 1. A, This 50-year-old woman was admitted with a WFNS grade I SAH with a thick clot localized around the right carotid cistern (axial noncontrast CT scan). Band C, She was found
to have a 9-mm elongated right superior hypophyseal aneurysm (B, oblique projection) for which coil embolization was performed with near-complete occlusion (C, oblique projection). D,
A follow-up DSA 6 months later showed recurrence of the aneurysm (oblique projection). The recurrence was treated with a Pipeline Embolization Device (PED, Chestnut Medical
Technologies, Menlo Park, California). Eand F, Oblique projections, early arterial phase (E) and late venous phase (F) after PED deployment, show stasis of contrast within the recurrent
portion of the neck.
Table 5: Angiographic outcome
a
Occlusion Grade
(Raymond class) Immediate Follow-Up
Class 1 7/23 (30%) 15/23 (65%)
Class 2 13/23 (57%) 7/23 (31%)
Class 3 3/23 (13%) 1/23 (4%)
Occlusion grade scored with Raymond class.
a
Comparative results between immediate and delayed angiographic occlusion grade in a
restricted subgroup of patients with radiology at any time during the follow-up.
Table 6: Number of retreatments
a
Within 6 Mo Within 12 Mo At the Last Follow-Up
322
a
Retreatment interval since initial intervention for 7 patients during the follow-up.
AJNR Am J Neuroradiol 33:632–37 兩Apr 2012 兩www.ajnr.org 635
42%) were more commonly used in the treatment of ruptured
paraclinoid aneurysms than in the treatment of ruptured an-
eurysms in other locations. Sherif et al
12
analyzed a series of
ruptured paraclinoid aneurysms treated with embolization
and achieved complete obliteration in 76.3% of the aneurysms
on the immediate postoperative angiograms and 82.9% at fol-
low-up. However, only 21% of their patients had wide-neck
aneurysms compared with 40% in our series, and this differ-
ence may partially explain the discrepancy in the immediate
obliteration rates between the 2 series.
Repeat embolization because of insufficient obliteration
was performed in 7 patients (30%), most whom were retreated
within 12 months of the first embolization procedure. This
rate is higher compared with the recurrence rate observed in
ruptured aneurysms in other locations of our series. The avail-
ability of flow diverters will most likely improve the rate of
complete angiographic obliteration. We foresee a near-future
in which ruptured paraclinoid aneurysms are treated with cur-
rent endovascular techniques in the acute phase to achieve
acceptable protection against immediate rebleeding. A few
weeks later, once patients are past the acute phase, flow divert-
ers will be used to supplement the original treatment and in-
crease the likelihood of complete angiographic occlusion.
One of the main reasons for treating acutely ruptured an-
eurysms causing SAH is to “secure” these aneurysms and pro-
tect the patient from subsequent bleeding that could be fatal.
In our series, early rebleeding following successful coil embo-
lization occurred in 1 patient with a posterior carotid wall
aneurysm. Although the aneurysm was judged as completely
coiled at the end of the procedure, rebleeding occurred 18 days
after the procedure. The rebleeding rate observed in our series
is comparable with that reported from the ISAT study (early
rebleeding rate, 1.9%).
13
More recent studies have suggested
negligible rates of early and midterm rebleeding,
1,14
implying
that with increasing experience and improved devices, the rate
of early rebleeding after coil embolization may be decreasing.
In accordance with the ISAT study, coil embolization confers
long-term protection because no rebleeding was observed af-
ter a mean clinical follow-up of 28 months.
13
Rates of neurologic morbidity and mortality related to the
procedure have progressively improved after coil emboliza-
tion of ruptured aneurysms. Our series confirms the safety of
the endovascular strategy, even in the case of challenging and
often wide-neck paraclinoid aneurysms, which often require
advanced endovascular techniques. One patient had an in-
traprocedural rupture following perforation of a giant paracli-
noid aneurysm and died as a result of the effects of the original
hemorrhage (his WFNS score was V on admission) combined
with the deleterious effects of the perforation. No other per-
manent morbidity was observed. In analyzing the results of
this series, one should consider that patients treated with en-
dovascular techniques were not ideal surgical candidates be-
cause of aneurysm- and patient-related factors and, therefore,
represent a selected high-risk population not necessarily rep-
resentative of the overall population of patients with ruptured
paraclinoid aneurysms seen at our institution. Our results are
in line with those in other studies on the outcome after endo-
vascular treatment of paraclinoid aneurysms, reporting pro-
cedure-related morbidity and mortality rates ranging between
3% and 8.3%, and 0% and 1.5%, respectively (though most of
these studies included mainly patients with unruptured aneu-
rysms).
4,12,15-18
Our series confirms the observation that mul-
tiple (and often bilateral) aneurysms are present in patients
with paraclinoid aneurysms. This association is probably re-
lated to the fact that development of paraclinoid aneurysms
can be related to an intrinsic weakness of the carotid wall in
this specific region, which, in turn, predisposes patients to
mirror aneurysms.
Our study has some limitations related to its retrospective
nature and the variable follow-up (common to most series
dealing with ruptured aneurysms because many of these pa-
tients have limited resources and are often noncompliant with
follow-up recommendations). In addition, the population
studied is a selected group of patients deemed not to be ideal
surgical candidates, and we do not have the overall denomi-
nator of patients from which the pool described is obtained.
Nevertheless, unlike most other series on paraclinoid aneu-
rysms in the literature, this study gives a snapshot of current
endovascular results for ruptured paraclinoid aneurysms and
provides a “modern” comparison against which more ad-
vanced endovascular methods can be compared.
Conclusions
Although unruptured aneurysms of the paraclinoid carotid
artery are very common, these aneurysms represent only a
minority of aneurysms presenting with SAH. Ruptured para-
clinoid aneurysms are challenging lesions from an endovascu-
lar and surgical point of view. Acceptable clinical outcomes
and protection against rebleeding can be achieved with cur-
rent endovascular techniques, though retreatment is not un-
common due to clinically significant recurrences. Given the
protection against rebleeding in the acute phase with coil em-
bolization alone, it is conceivable that in the near future, more
and more patients will be treated with a “staged” endovascular
strategy of coil embolization in the acute phase after SAH fol-
lowed by a second stage during which a flow diverter is placed
across the coiled aneurysm to ensure higher rates of complete
obliteration.
Disclosures: Harry J. Cloft—RELATED:Grant: MicroVention, Comments: enrolling center for
Gel the Neck registry sponsored by MicroVention; UNRELATED:Board Membership:
Medtronic, Comments: serve on the Data Safety and Monitoring Board for the Kyphoplasty
and Vertebroplasty in the Augmentation and Restoration of Vertebral Body Compression
Fractures trial; Grants/Grants Pending: Cordis,* Mindframe.* David Kallmes—UNRELATED:
Royalties: University of Virginia patent foundation, Comments: spine-fusion device; Pay-
ment for Development of Educational Presentations: eV3,* CareFusion.* Ricardo Hanel—
UNRELATED:Board Membership: Neurovasx, Comments: scientific advisory board; Payment
for Lectures, Including Service on Speaker Bureaus: Codman; Other: eV3,* Comments:
support travel expenses for Pipeline training. Giuseppe Lanzino—UNRELATED:Expert
Testimony: Chestnut Medical/Covidien,* Comments: testified in front of FDA panel for
approval of Pipeline embolization device; Grants/Grants Pending: eV3,* Synthes,* Com-
ments: testified in front of FDA panel for approval of Pipeline embolization device. *Money
to the institution.
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