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Post-angioplasty and stenting angiogram shows recanalization of the right vertebral artery with significantly improved flow through the posterior circulation with normalization of flow through the anterior spinal artery.
Source publication
This is the first in a set of documents intended to standardize techniques, procedures, and practices in the field of endovascular surgical neuroradiology. Standards are meant to define core practices for peer review, comparison, and improvement. Standards and guidelines also form the basic dialogue, reporting, and recommendations for ongoing pract...
Context in source publication
Context 1
... there was slow, delayed, retrograde flow into the left posterior cerebral artery and the top of the basilar artery via pial collaterals from the middle cerebral artery to the posterior cerebral artery ( figure 1C). The patient underwent successful right vertebral artery stenting resulting in markedly improved flow through the posterior circulation ( figure 2). Following the procedure the patient's neurological exam significantly improved. ...
Citations
... The used approaches and devices need to be tailored to the clinico-radiological characteristics of each lesion. Considering the likelihood of institutional reporting biases and the variability of reported parameters/outcomes across the literature, our pooled findings should be judged with some caution, warranting a standardization of reporting methods and treatment guidelines [55]. Though not generalizable, this meta-analysis supports the demand to design future prospective trials and/or multi-institutional registries targeting the management of BAS. ...
Purpose:
Basilar artery stenosis (BAS) carries high morbidity and mortality, with variable outcomes after endovascular treatments. We systematically reviewed the literature on percutaneous transluminal angioplasty and/or stenting (PTAS) for BAS.
Methods:
PubMed, EMBASE, Web-of-Science, Scopus, and Cochrane were searched upon the PRISMA guidelines to include prospective/retrospective cohort studies describing PTAS for BAS. Pooled rates of intervention-related complications and outcomes were analyzed with random-effect model meta-analyses.
Results:
We included 25 retrospective cohort studies comprising 1016 patients. All patients were symptomatic, presenting with transient ischemic attack or ischemic stroke. BAS frequently involved the middle basilar artery (51.4%), mostly classified as Mori-B (57.4%). PTAS for BAS was indicated in severe (≥ 50-70%), symptomatic BAS refractory to dual antiplatelet therapy. Patients underwent angioplasty (95.5%) and/or stenting (92.2%), preferably using Wingspan or Apollo stents. Median baseline BAS was 81% (range, 53-99%), while median post-intervention BAS was 13% (0-75%). Actuarial rates of successful intervention and "good" final outcome were 100% (95% CI: 100-100%) and 89% (95% CI: 85-93%). Intervention-related recurrent ischemic stroke occurred in 85 patients (8.3%) with actuarial rates of 5% (95% CI: 4-7%), differentiated into perforator (5.4%), in-stent (2.6%), and embolic (0.4%). Actuarial rates of intervention-related dissection, restenosis, and death were 0% (95% CI: 0-0%), 1% (95% CI: 0-1%), and 0% (95% CI: 0-2%).
Conclusion:
Elective PTAS appears to be safe and effective in selected patients with medically refractory, severe, symptomatic, and non-acute BAS. Different stent types and angioplasty-assisted procedures should be considered based on specific clinico-radiological characteristics of the lesions. Future randomized controlled trials are required to corroborate these findings.
... A preprocedural checklist of materials and information is critical in the pediatric outpatient setting for diagnostic procedures [51]: ...
Purpose of review:
The scope of procedures conducted by neurointerventionalists is expanding quickly, with lacking consensus over the best anesthesia modality. Although the procedures involve all age groups, the interventions may be complex and lengthy and may be provided in hospitals currently not yet familiar with the field. Here we review current literature addressing elective outpatient neurointerventional procedures and aim to provide an update on the management of intervention-specific crises, address special patient populations, and provide key learning points for everyday use in the neurointerventional radiology suite.
Recent findings:
Various studies have compared the use of different anesthesia modalities and preinterventional and postinterventional care. Monitored anesthesia care is generally recommended for elderly patients, whereas children are preferably treated with general anesthesia. Additional local anesthesia is beneficial for procedures, such as percutaneous kyphoplasty and vascular access.
Summary:
Combining different anesthetic modalities is a valuable approach in the neurointerventional radiology suite. More interventional and patient population-specific studies are needed to improve evidence-based perioperative management.
... Despite a resulting quantitative increase in cases, faster TT only helps reduce direct and indirect staffing costs and has little effect on revenue [21]. On the other hand, adequate capacity planning during the tactical DM stage can lower costs and increase the quality of care [22]. ...
Efficient operating room (OR) management is a constant balancing act between optimal OR
capacity, allocation of ORs to surgeons, assignment of staff, ordering of materials, and
reliable scheduling, while keeping patient safety highest priority. We provide an overview of
common concepts in OR management, specifically addressing the areas of strategic,
tactical and operational decision making (DM), and parameters to measure OR efficiency.
For optimal OR productivity, a surgical suite needs to define its main stakeholders, identify
and create strategies to meet their needs, and ensure staff and patient satisfaction. OR
planning should be based on real life data at every stage, and should apply newly developed
algorithms.
... The merits of such an approach have been widely debated [23,24]. Part of the debate stems from the fact that formal standards for NIR training and practice are not as well developed as those for older and more established subspecialties [25]. ...
... Publications from various clinical neuroscience societies [25,26] have started to pave the way for this type of formal NIR training but have a way to go before widespread acceptance and universal adoption. ...
Objective:
Neurofibromatosis type 1 (NF1) is a multisystemic genetic disease in which patients develop benign tumors including optic nerve gliomas (ONG). Optic nerve thickening and tortuosity are radiologic markers of tumors but can also be present in children with NF1 who do not have gliomas, thus complicating screening and diagnosis. We undertook this study to retrospectively determine quantitative and qualitative diagnostic criteria using MRI of the orbits for ONG in children with NF1.
Materials and methods:
MR images of the orbits obtained from 2003 to 2016 for children with and without NF1 were reviewed. Optic nerves were divided into three groups: NF1 with glioma (n = 71 nerves), NF1 without glioma (n = 151 nerves), and healthy control subjects (n = 66 nerves). The diameter of each nerve was measured at multiple locations. Two radiologists assessed tortuosity using validated criteria, and subarachnoid dilatation was quantified. Last, a composite score using both optic nerve diameter and tortuosity was proposed.
Results:
The mean diameter of the optic nerve was significantly larger in patients with NF1 with glioma compared with those with NF1 without glioma and with control subjects at all locations. Maximal nerve diameter greater than 2 SD above the mean maximal diameter for control nerves was considered abnormally enlarged. The tortuosity parameters were all significantly associated with ONG compared with absence of ONG in NF1. A scoring system derived from these data were highly reliable in differentiating ONG from absence of ONG in NF1.
Conclusion:
The radiologic diagnosis of ONG in patients with NF1 is challenging. The scoring systems we describe provide a framework for simple radiologic criteria for ONG in these patients.
... It is assumed that the radiation exposure to the patient and medical staff is justified by the disease state for which the patient is undergoing treatment, so long as it is kept "as low as reasonably achievable." 311,312 Neurointerventional procedures commonly fall into the category of high-exposure fluoroscopic procedures. It is possible that the radiation exposure would become so significant that alternative surgical procedures should be considered, especially for patients with unruptured aneurysms who have a long potential life expectancy with appropriate treatment. ...
... Although radiation exposure has not commonly been accounted for during neurointerventional procedures, some authors have considered radiation dose and exposure. 311,[313][314][315] Significant radiation exposure may occur from 30 minutes of fluoroscopy or a series of DSA acquisitions. 316 When a kerma area product, or dose-area product, of at least 500 Gy cm 2 has been reached, follow-up evaluation for signs of radiation injury may be necessary. ...
The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms.
Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.
© 2015 American Heart Association, Inc.
... A task force team (TFT) was organized in August 2010 to develop training programs and certification. TFT members conducted research on programs and systems in other countries1,2,3,4,5,6,8,9,10,11,12,13,14,15,16,17,18,19,20,21) and conceptualized the programs that would best suit Korea. After 1 year of effort, a rough draft of the ENS training and certification regulations was prepared, and the standard training program title was decided. ...
The need for standard endovascular neurosurgical (ENS) training programs and certification in Korea cannot be overlooked due to the increasing number of ENS specialists and the expanding ENS field. The Society of Korean Endovascular Neurosurgeons (SKEN) Certification Committee has prepared training programs and certification since 2010, and the first certificates were issued in 2013. A task force team (TFT) was organized in August 2010 to develop training programs and certification. TFT members researched programs and systems in other countries to develop a program that best suited Korea. After 2 years, a rough draft of the ENS training and certification regulations were prepared, and the standard training program title was decided. The SKEN Certification Committee made an official announcement about the certification program in March 2013. The final certification regulations comprised three major parts: certified endovascular neurosurgeons (EN), certified ENS institutions, and certified ENS training institutions. Applications have been evaluated and the results were announced in June 2013 as follows: 126 members received EN certification and 55 hospitals became ENS-certified institutions. The SKEN has established standard ENS training programs together with a certification system, and it is expected that they will advance the field of ENS to enhance public health and safety in Korea.
... The working group was composed of members of the Society for NeuroInterventional Surgery Standards and Guidelines Committee (see general document), and the recommendations presented represent a consensus statement from this working group. 31 May 2011 was conducted. Search terms included 'intracranial', 'atherosclerosis', 'stenosis', 'cerebral', 'stroke', 'transient ischemic attack', 'stent', 'angioplasty', 'stent assisted angioplasty', in various combinations. ...
Background:
Symptomatic intracranial atherosclerotic disease (ICAD) worldwide represents one of the most prevalent causes of stroke. When severe, studies show that it has a very high risk for recurrent stroke, highlighting the need for effective preventative strategies. The mainstay of treatment has been medical therapy and is of critical importance in all patients with this disease. Endovascular therapy is also a possible therapeutic option but much remains to be defined in terms of best techniques and patient selection. This guideline will serve as recommendations for diagnosis and endovascular treatment of patients with ICAD.
Methods:
A literature review was performed to extract published literature regarding ICAD, published from 2000 to 2011. Evidence was evaluated and classified according to American Heart Association (AHA)/American Stroke Association standard. Recommendations are made based on available evidence assessed by the Standards Committee of the Society of NeuroInterventional Surgery. The assessment was based on guidelines for evidence based medicine proposed by the American Academy of Neurology (AAN), the Stroke Council of the AHA and the University of Oxford, Centre for Evidence Based Medicine (CEBM).
Results:
59 publications were identified. The SAMMPRIS study is the only prospective, randomized, controlled trial available and is given an AHA level B designation, AAN class II and CEBM level 1b. The Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial arteries (SSYLVIA) trial was a prospective, non-randomized study with the outcome assessment made by a non-operator study neurologist, allowing an AHA level B, AAN class III and CEBM level 2. The remaining studies were uncontrolled or did not have objective outcome measurement, and are thus classified as AHA level C, AAN class IV and CEBM level 4.
Conclusion:
Medical management with combination aspirin and clopidogrel for 3 months and aggressive risk factor modification is the firstline therapy for patients with symptomatic ICAD. Endovascular angioplasty with or without stenting is a possible therapeutic option for selected patients with symptomatic ICAD. Further studies are necessary to define appropriate patient selection and the best therapeutic approach for various subsets of patients.
Interventional neuroradiology has advanced by leaps and bounds in the current decade due to advancements in both hardware and imaging. The scope of neurovascular intervention in children is important as even though pediatric brain malformations are rare (0.06–0.11%), the risk of rupture is higher than in adults and is the most common cause of spontaneous intracranial hemorrhage and recurrent debilitating seizures in this age group. For the neuroanesthesiologist, it brings to the table the issues of maintaining physiology of the brain and difficulties of administering anesthesia in the unfamiliar non-operative environment along with the usual challenges of a pediatric patient. The commonly encountered pediatric neurointerventional procedures may be diagnostic or therapeutic.
Endovascular therapy as any other specialty has continuously been developed since 1904, but acceptability among neurosurgeons remains low despite being other subspecialties and techniques, like endoscope and for that matter microscope also, being adopted very rapidly. From injecting particles for vascular lesions to balloons for fistulas and arteriovenous malformations and embolizing agents to detachable coils for aneurysm coiling, it has come a long way. Old generations of neurosurgeons used to perform carotid puncture for diagnosing mass lesions, but once CT/MRI came in to the picture, this procedure was stopped and handed over to radiologists. A debate continues among neurosurgeons about the feasibility of aneurysm coiling since international subarachnoid aneurysm trial (ISAT) and doubts about the long-term efficacy of this novel treatment cost a subspecialty. With the recent addition of endovascular treatment of stroke and long-term efficacy of endovascular treatment of aneurysm, there is a lot of debate among clinicians and nonclinicians about who will be the true heir of this sub specialty.
Objective:
The purposes of this study were to document recent trends in stroke intervention at a tertiary-care facility with a comprehensive stroke center and to analyze current procedure volumes and the employment of specialty providers in neurointerventional radiology (NIR).
Materials and methods:
Institutional trends in the volume of mechanical thrombectomy were analyzed on the basis of the number of patients who underwent mechanical thrombectomy from 2013 to 2017. To evaluate the current status of mechanical thrombectomy volumes in the United States, the number of patients in the Medicare fee-for-service database who underwent mechanical thrombectomy in 2016 was assessed. The specialty backgrounds of the various providers who performed mechanical thrombectomy were analyzed. Procedure volumes for intracranial stenting, embolization, and vertebral augmentation procedures were assessed.
Results:
From 2013 to 2017, the total numbers of mechanical thrombectomy procedures for acute ischemic stroke were 19 in 2013 and 111 in 2017. The total volume of mechanical thrombectomy procedures in the Medicare fee-for-service population in 2016 was 7479. For intracranial endovascular procedures, 20,850 were performed in the U.S. Medicare population in 2015 and 22,511 in 2016. Radiologists performed 45% of procedures in 2016; neurosurgeons, 41%; and neurologists, 11%. When the total numbers of percutaneous brain and spine procedures were combined, radiologists performed 41%; neurosurgeons, 23%; and neurologists, 3%. In 2016, there were a total of 220 active NIR staff at the NIR programs with rotating residents or fellows. In these programs, 49% of staff members were neuroradiologists, 41% were neurosurgeons, and 10% were neurologists. Of the 72 NIR departments with confirmed rotating fellows or residents, 14 had only neuroradiologists on staff, six had only neurosurgeons, and one had only neurologists.
Conclusion:
Increasing radiology resident interest and participation in NIR should ensure a steady influx of radiologists into the field, continuing the strong tradition of radiology participation, leadership, and innovation in NIR.
