Preliminary experience with intra-arterial nicardipine as a treatment for cerebral vasospasm

BACKGROUND AND PURPOSE: Papaverine is the primary intra-arterial (IA) treatment for vasospasm after aneurysmal subarachnoid hemorrhage (SAH); however, is it limited in effect and by adverse effects. We prospectively studied the use of IA nicardipine as a treatment for vasospasm. METHODS: Over 12 months, all patients with SAH who required interventional treatment for vasospasm were given IA nicardipine with or without angioplasty. Vasospasm was determined by serial clinical assessments and/or daily transcranial Doppler (TCD) imaging and confirmed by angiography. Doses of IA nicardipine per vessel were 0.5-6 mg. All patients were monitored for increased intracranial pressure (ICP) and change in cardiovascular or neurologic status. RESULTS: Forty-four vessels in 18 patients with vasospasm were treated with IA nicardipine alone. TCD data for 38 vessels (15 cases) were available. All vessels demonstrated immediate angiographic dilatation after IA nicardipine. No sustained cardiovascular changes were after treatment. ICP was transiently elevated in five patients and persistently elevated in one. Mean peak systolic velocities at TCD imaging were significantly reduced from pretreatment values in all treated vessels for 4 days after infusion (268.9 +/- 77.8 vs 197.6 +/- 74.1 cm/s, P <.001). Neurologic improvement after IA nicardipine occurred in eight (42.1%) patients. No clinical deterioration was noted. CONCLUSION: As shown by TCD imaging, IA nicardipine has an immediate and sustained effect on vasospasm. It does not appear to have sustained effect on ICP or cardiovascular status. This treatment warrants further study to determine its safety and efficacy.     

Efficacy of intra-arterial nimodipine in the treatment of cerebral vasospasm complicating subarachnoid haemorrhage

AIM: To examine the efficacy and safety of nimodipine as an alternative to papaverine for the treatment of cerebral vasospasm following subarachnoid haemorrhage. METHODS: We retrospectively reviewed the procedure reports, anaesthetic records, clinical charts and CT and angiographic images of 9 patients who had received intra-arterial nimodipine; 1 of these patients received both nimodipine and papaverine. The difference in arterial luminal diameter before and after treatment was calculated as a percentage change. RESULTS: The average dose of nimodipine administered per vessel was 3.3mg. The mean increase in arterial diameter was 66.6% in the vasospastic segment. There was no significant change in blood pressure of any of the subjects during endovascular treatment of vasospasm. CONCLUSION: Intra-arterial nimodipine is effective in improving angiographic vasospasm complicating subarachnoid haemorrhage. Further studies aimed at examining the clinical benefits of nimodipine are warranted, particularly in view of the low risk of adverse side effects of nimopidine when compared with papaverine.     

Angiographic evaluation of the effect of intra-arterial milrinone therapy in patients with vasospasm from aneurysmal subarachnoid hemorrhage

Introduction  

Several methods have been used to treat cerebral vasospasm, which is a major cause of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). Here, we examined the effectiveness and safety of intra-arterial injection of milrinone for the treatment of vasospasm.     

Ultrasound-accelerated thrombolysis for the treatment of deep vein thrombosis: initial clinical experience

PURPOSE: To evaluate the success of lysis and clinical outcomes in patients treated with ultrasound (US)-accelerated thrombolysis for deep vein thrombosis (DVT). MATERIALS AND METHODS: Forty-seven patients with 53 cases of DVT were treated with US-accelerated thrombolysis at eight centers in the United States. Sixty percent of the occlusions were in the lower extremity, 36% were in the upper extremity, and 4% were hepatic. The clot was acute (< or =14 days) in 47% of cases, subacute (15-28 d) in 8%, chronic (>28 d) in 17%, acute-on-chronic in 17%, and not specified in 11%. Patients were treated with urokinase (UK), tissue plasminogen activator (tPA), recombinant plasminogen activator (rPA), or tenecteplase. RESULTS: Complete lysis (> or =90%) was seen in 37 of 53 cases (70%) and overall lysis (complete plus partial) was seen in 48 (91%). No lysis occurred in five cases (9%), four of which were chronic. The median thrombolysis infusion time was 22.0 hours. Major complications (hematoma at site of earlier surgery) occurred in only two patients (3.8%), with no incidence of intracranial or retroperitoneal hemorrhage. US-accelerated thrombolysis exhibited comparable or better lysis with a lower average drug dose and shorter median treatment times than reported in the National Venous Registry and a more recently published study of standard catheter-directed thrombolysis. CONCLUSIONS: US-accelerated thrombolysis was shown to be a safe and efficacious treatment for DVT in this multicenter experience. The addition of US reduces total infusion time and provides a greater incidence of complete lysis with a reduction in bleeding rates.     

A new self-expandable nitinol stent for the treatment of wide-neck aneurysms: initial clinical experience

BACKGROUND AND PURPOSE: Stent systems for intracranial use are continuously improved. We report our initial experience using a new self-expanding easy-to-place nitinol stent (Enterprise) in the treatment of wide-neck intracranial aneurysms.MATERIALS AND METHODS: Between January and October 2007, 16 aneurysms in 15 patients were treated with stent assistance. Aneurysm size was a mean of 13.2 mm (median, 12 mm; range, 7–30 mm). Eight aneurysms had reopened after prior coiling, and 8 aneurysms were primarily treated, 1 after acute subarachnoid hemorrhage. Response to antiplatelet premedication was tested with a P2Y12 assay before stent placement. On a 3D angiographic workstation, stent placement was simulated to assess vessel caliber and appropriate stent length.RESULTS: In all aneurysms, the stent could be placed at the exact location as predicted from the computer simulation. Stent placement proved to be technically easy without the need for recapture in all patients. Although placement of the microcatheter through the stent struts and subsequent coil placement was challenging in some patients, coiling after stent placement resulted in complete or near-complete occlusion in all aneurysms. There were no technical or clinical complications. At 6 months, angiographic follow-up in 14 aneurysms revealed 4 aneurysms recanalized to 80% occlusion, 3 of which were additionally coiled.CONCLUSION: In this small series, delivery and deployment of the Enterprise stent was technically easy. There were no technical or clinical complications. The device was valuable in the treatment of wide-neck aneurysms. The need for antiplatelet medication in patients treated with this and other stents remains a significant disadvantage.

Endovascular coil embolization of wide-neck intracranial aneurysms is technically challenging. Several treatment strategies are available to prevent coil migration into the parent vessel. The most widely used technique is balloon-assisted treatment, in which a balloon is temporarily inflated across the aneurysm neck during coil insertion.^1,2 A permanent neck-bridge device (TriSpan; Boston Scientific, Natick, Mass) may be used to prevent coil migration in wide-neck bifurcation aneurysms.^3,4 In recent years, stents for intracranial use became available. The first-generation stents were balloon expandable (INX/AVE; Medtronic, Santa Rosa, Calif), but limited flexibility was a major drawback. Later, the first self-expandable stents with an open or closed cell design became available for intracranial use.^5,6 With some stent systems, the microcatheter has to be exchanged for the stent over a 300-cm microguidewire. The new Enterprise stent (Cordis Neurovascular, Miami Lakes, Fla) is a highly flexible nitinol stent, which can be delivered through a standard microcatheter, which is technically easier than the exchange procedure.^7–9In this study, we report our initial clinical experience with this new stent system in the treatment of 16 wide-neck intracranial aneurysms.     

Intra-arterial colforsin daropate for the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage

Introduction

Cerebral vasospasm (CV) remains a major cause of mortality and morbidity in patients with subarachnoid hemorrhage (SAH). Here, we examined the effectiveness and safety of intra-arterial injection of colforsin daropate hydrochloride (CDH).

Methods

A consecutive series of 29 patients with angiographically confirmed CV received intra-arterial CDH (IAC) therapy. Angiographic changes in spastic vessels and the cerebral circulation time (CCT) were assessed before and after IAC treatment, together with the change in clinical status.

Results

IAC treatment was performed in 53 procedures in 29 patients. Angiographic improvement was observed following all procedures (100%), and clinical improvement was observed following 36 of 42 procedures (86%) in symptomatic cases. CCT improved significantly. At the 3-month follow-up, 19 patients (66%) showed good recovery or moderate disability on the Glasgow Outcome Scale. Major adverse effects were headache and increased heart rate.

Conclusions

IAC treatment was effective and safe for the treatment of CV after SAH     

Intra-arterial nimodipine for the treatment of symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage: preliminary results

BACKGROUND AND PURPOSE: Cerebral vasospasm remains a major problem in patients recovering from aneurysmal subarachnoid hemorrhage despite advances in medical, surgical, and endovascular care. Our purpose was to assess the efficacy of intra-arterial nimodipine, a calcium-channel blocker acting mainly on cerebral vessels, in preventing delayed neurologic deficits in patients with symptomatic vasospasm. METHODS: Clinical charts of 25 consecutively treated patients were retrospectively reviewed. A multifactorial decision tree was used to determine the indication for angiography and subsequent endovascular treatment. Nimodipine was infused intra-arterially via a diagnostic catheter in the internal carotid artery or vertebral artery at a rate of 0.1 mg/min. Angiographic vasospasm before endovascular treatment, immediate vessel caliber modifications, and short- and long-term clinical efficacy of the procedure were assessed. RESULTS: Thirty procedures were performed in 25 patients. Clinical improvement was observed in 19 (76%), 16 of whom improved after the first endovascular procedure, two after the second intra-arterial treatment, and one after the third. Of these 19 patients, only 12 (63%) had notable vascular dilatation at postprocedural angiography. Dilatation of infused vessels occurred in only 13 (43%) of 30 procedures. After follow-up of 3-6 months, 18 (72%) of 25 patients had a favorable outcome (Glasgow outcome scale score of 1-2 and modified Rankin scale score of 0-2). No complications were observed. CONCLUSION: Intra-arterial nimodipine is effective and safe for the treatment of symptomatic vasospasm after subarachnoid hemorrhage. Further prospective randomized studies of cerebral blood flow are needed to confirm these results.     

蛛网膜下腔出血后症状性血管痉挛的检测:单次和连续动脉自旋标记的初步应用

目的采用动脉自旋标记(ASL)检测蛛网膜下腔出血术后的症状半球。方法研究包括18例动脉瘤所致蛛网膜下腔出血的病人,4例术后出现症状性血管痉挛。全部病人在第9～10天进行ASL检查(单次ASL)。9例病人分别在第1～2天、9～10天和13～21天进行连续ASL检查(连续ASL),7例病人在第4～7天也进行了检查。测量大脑中动脉供血区后部的脑血流量(CBF),估算同侧/对侧的CBF比例。通过受试者操作特征(ROC)曲线分析症状半球和其他部位之间的差异。结果单次ASL显示,CBF第9～10天和CBF同侧/对侧第9～10天在症状半球明显低于非症状半球(P<0.001)。连续ASL显示,CBF第4～7天较CBF第1～2天明显降低,CBF第9～10天较CBF第4～7天明显降低,而CBF第13～21天较CBF第9～10天明显升高。单次ASL的ROC分析显示CBF第9～10天的曲线下面积为0.95,明显高于CBF同侧/对侧第9～10天(P<0.001)。连续ASL的ROC分析显示CBF第9～10天的曲线下面积为0.93,明显高于CBF第9～10天/第1～2天和CBF同侧/对侧第9～10天(P<0.001)。结论单次ASL显示症状半球较非症状半球CBF明显减低。连续ASL可显示蛛网膜下腔出血后CBF随时间的变化。     

Detection of symptomatic vasospasm after subarachnoid haemorrhage: initial findings from single time-point and serial measurements with arterial spin labelling

Objectives

To detect symptomatic hemispheres during the postoperative course of subarachnoid haemorrhage (SAH) using arterial spin labelling (ASL).

Methods

Eighteen patients with aneurysmal SAH were included; four exhibited symptomatic vasospasm postoperatively. All patients underwent ASL on days 9–10 (single time-point ASL). Nine patients underwent serial measurements of ASL (serial ASL) on days 1–2, 9–10 and 13–21, and seven patients also underwent imaging on days 4–7. CBF in the posterior part of the MCA territory was measured, and the ipsilateral/contralateral ratio of CBF was calculated. Differences between symptomatic hemispheres and others underwent ROC analysis.

Results

Single time-point ASL revealed that CBF_day9-10 and CBF_{i/c_day9-10} were significantly lower in symptomatic hemispheres than in asymptomatic hemispheres (P?<?0.001). Serial ASL was significantly decreased on CBF_day4-7 compared with CBF_day1-2 and on CBF_day9-10 compared with CBF_day4-7, and significantly increased on CBF_day13-21 compared with CBF_day9-10. ROC analysis of single time-point ASL revealed that AUC for CBF_day9-10 was 0.95, significantly higher than CBF_{i/c_day9-10} (P?<?0.001). ROC analysis of serial ASL showed that AUC for CBF_day9-10 was 0.93 and significantly higher than CBF_{day9-10/day1-2} and CBF_{i/c_day9-10} (P?<?0.001).

Conclusions

Single time-point ASL revealed significant CBF reduction in symptomatic hemispheres compared with asymptomatic hemispheres. Serial ASL showed time-dependent CBF changes after SAH.

Key Points

? MR arterial spin labelling (ASL) can non-invasively assess cerebral blood flow (CBF) ? ASL revealed significant CBF reduction in symptomatic hemispheres compared with asymptomatic hemispheres ? Serial ASL measurements enable observation of time-dependent CBF changes after SAH ? ASL is non- invasive and suitable for serial repeated examinations     

Gelatin microspheres: initial clinical experience for the transcatheter arterial embolization

PURPOSE: The purpose of this study is to evaluate the embolization effects of gelatin microspheres (GMSs) when used as an embolic material for transcatheter arterial embolization (TAE) for several organs. MATERIALS AND METHODS: We prepared GMSs that dissolves in 5 days in extravasuclar tissue. GMSs were used in five cases in total, four cases with multiple liver tumors and one case with a pelvic bone tumor. RESULTS: In all five cases, it was possible to treat the targeted tumors by TAE with GMSs. In the contrast-enhanced CT performed 2-4 weeks later, the embolized tumors did not show an enhancement effect. Passage of GMSs in the microcatheter was excellent. CONCLUSION: GMSs showed sufficient potential to be used as an embolic material.     

MR colonography with barium-based fecal tagging: initial clinical experience

PURPOSE: To assess a strategy for fecal tagging with barium sulfate as an inexpensive tagging agent in conjunction with magnetic resonance (MR) colonography in patients suspected of having colorectal lesions. MATERIALS AND METHODS: Twenty-four patients suspected of having colonic lesions because of rectal bleeding, positive fecal occult blood test results, or altered bowel habits underwent MR colonography and subsequent conventional colonoscopy. A 200-mL dose of a barium sulfate-containing contrast agent was ingested with each of four low-fiber meals, beginning 36 hours before the examination. For MR colonography, the colon was filled with tap water. Gadobenate dimeglumine was injected intravenously. Images were acquired 75 seconds after gadobenate dimeglumine administration by using only a T1-weighted three-dimensional gradient-echo sequence. Images were reviewed by two radiologists blinded to conventional colonoscopic data. By using colonoscopy as the reference standard, sensitivity and specificity of MR colonography were determined for detecting colorectal masses. RESULTS: On the basis of MR colonography, 15 polyps of 5-20 mm and 10 carcinomas were detected and later confirmed with conventional colonoscopy. Conventional colonoscopy depicted three additional lesions less than 8 mm in diameter. Thus, sensitivity of MR colonography was 89.3% (25 of 28) for lesions and 91.7% (22 of 24) for patients. CONCLUSION: Barium-tagged MR colonography obviates bowel cleansing and depicts all lesions exceeding 8 mm in diameter.     

Vessel occlusion with transcatheter electrocoagulation: initial clinical experience.

Transcatheter electrocoagulation (TCEC) was used for vessel occlusion in combination with embolization by Gelfoam and/or Ivalon in six patients in whom other interventional or surgical techniques were considered dangerous or unfeasible. The technique was effective in decreasing or obliterating the blood supply to variously located lesions in all cases. The only complications were small skin burns in one patient and a small ulceration of the upper lip in another.     

Real-time MR with TrueFISP for the detection of acute pulmonary embolism: initial clinical experience

The feasibility and diagnostic value of real-time magnetic resonance imaging (RT-MRI) for the diagnosis of acute pulmonary embolism (PE) was evaluated by comparing RT-MRI and magnetic resonance angiography (MRA). In 39 consecutive patients with suspected PE real-time true fast imaging with steady-state precession (TrueFisp) was prospectively compared with contrast-enhanced MRA on a 1.5-T MR scanner. The TrueFisp sequence used allowed acquisition of T2-weighted images at 0.4 s per image so that the pulmonary vasculature could be visualized in three orientations in <3 min without the need for breath holding or contrast media application. Results of additional scintigraphic pulmonary perfusion examinations were available from 17 patients. All 39 primary RT examinations (100%) and 30 of 39 MRA examinations (77%) were of diagnostic quality. The reasons underlying failure to achieve diagnostic quality for MRA were breathing artifacts among dyspneic patients in all 9 cases. Compared with MRA, the sensitivities and specificities of RT sequences for PE were 93 and 100% (per examination), 96 and 100% (lobar artery PE), and 97 and 100% (segmental artery PE), respectively. Compared with scintigraphy, the sensitivity and specificity of RT-MRI were 83 and 100%, respectively. The MRA reached 100% sensitivity and specificity in this subgroup. The RT-MRI proved to be very robust and undisturbed by respiratory movements and patient cooperation. Its image quality assured fast diagnostic examinations, and its sensitivity and specificity, compared with MRA and scintigraphy, were sufficient to allow the diagnosis of acute central, lobar, and segmental PE; therefore, the emergency diagnosis of PE using RT-MRI is feasible and reliable.     

Intracranial angioplasty for treatment of vasospasm after subarachnoid hemorrhage: technique and modifications to improve branch access

Angioplasty of the proximal portions of major cerebral arteries at the base of the brain has shown promise as a therapy for symptomatic vasospasm after subarachnoid hemorrhage. The blind-ended, single-lumen balloon-dilatation catheter most widely used to date lacks steerability, limiting its application to unbranched stems and single branches at bi- or trifurcation points. To extend the capabilities of cerebral angioplasty, we describe two modifications of the basic technique that have allowed increased selectivity and successful angioplasty of multiple branches, both proximal and distal, involved by vasospasm. Of four patients treated, three showed early improvement in their clinical condition, likely attributable to the angioplasty procedure. Our modifications to the basic angioplasty technique enhanced its success. Further refinement of this technique in the treatment of vasospasm will make it safer in treating this serious and widespread disorder.