Faculty Bibliography

PURPOSE: Our objective is to identify the effect of prothrombin complex concentrate (PCC) in acute intracranial hemorrhage (ICH) by evaluating intraparenchymal hematoma expansion between initial and follow-up head CT at 5-24 h, in those with positive CTA spot sign (CTASS). CTASS is an independent predictor of hematoma growth (1). Acute ICH, regardless of etiology, can present with quick mental status decline often resulting in irreversible brain damage. Hematoma expansion appears to be a modifiable predictor of clinical outcome and an appropriate target for medical therapy. PCC is a procoagulant which is the agent of choice in warfarin-related ICH. We explore utility of PCC in all patients regardless of warfarin status. MATERIALS AND METHODS: We retrospectively reviewed patients with ICH at our NY State designated Stroke Center from Nov 2013 to Dec 2015. Twenty-three of the 85 patients with ICH received PCC, of which 8 had positive CTASS (E = 8). Four of the 62 patients without PCC, had a positive CTASS (C = 4). Interval change in ICH volume at 5-24 h was measured using ABC/2 formula, which is an accurate predictor of ICH volume (5). RESULTS: Control group (C) showed increase in mean ICH volume of 46% (SD = 37.3%), whereas experimental group (E) showed a decrease of 13% (SD = 29.9%) (p value = 0.012). CONCLUSIONS: We found a strong statistical correlation favoring our hypothesis. Use of PCC in active ICH with positive CTASS resulted in overall decrease in the mean hematoma size at 24 h, whereas the control group showed an overall increase.

Acute hemorrhage relating to an expanding pseudoaneurysm of the carotid artery is referred to as carotid blowout syndrome (CBS). CBS is associated with a high morbidity and mortality. We describe the case of a patient who presented with dysphagia and a pulsatile mass in the neck. Imaging revealed a pseudoaneurysm originating from the bifurcation of the distal right common carotid artery. On neuroangiography the patient lacked sufficient collaterals to allow for vessel sacrifice. A decision was made to use covered stents to prevent flow into the pseudoaneurysm while maintaining vessel patency. Despite placement of multiple covered stents there was residual slow filling of the pseudoaneurysm. We augmented this therapy with direct percutaneous thrombin injection into the pseudoaneurysm. This resulted in complete thrombosis of the pseudoaneurysm. For recalcitrant lesions in which the usual methods of stopping blood flow to the pseudoaneurysmal sac fail, an adjuvant approach with thrombin should be considered.

Acute hemorrhage relating to an expanding pseudoaneurysm of the carotid artery is referred to as carotid blowout syndrome (CBS). CBS is associated with a high morbidity and mortality. We describe the case of a patient who presented with dysphagia and a pulsatile mass in the neck. Imaging revealed a pseudoaneurysm originating from the bifurcation of the distal right common carotid artery. On neuroangiography the patient lacked sufficient collaterals to allow for vessel sacrifice. A decision was made to use covered stents to prevent flow into the pseudoaneurysm while maintaining vessel patency. Despite placement of multiple covered stents there was residual slow filling of the pseudoaneurysm. We augmented this therapy with direct percutaneous thrombin injection into the pseudoaneurysm. This resulted in complete thrombosis of the pseudoaneurysm. For recalcitrant lesions in which the usual methods of stopping blood flow to the pseudoaneurysmal sac fail, an adjuvant approach with thrombin should be considered.

ABSTRACT: Neurovascular stents have revolutionized the endovascular treatment of wide-necked and fusiform aneurysms; however, potential in-stent thrombosis-resulting in devastating strokes-complicates their use. Interventionalists using these devices must be aware of treatment options for such events. We present the case of a 46-year-old man who underwent stent-supported embolization of an incidental basilar aneurysm followed by in-stent thrombosis 6 weeks later. Though he presented at that time after 24 h of symptom onset with complete occlusion of the basilar artery, delayed thrombectomy and thrombolysis resulted in a good clinical outcome. LIST OF ABBREVIATIONS: IVintravenousACTactivated coagulation timeDWI MRIdiffusion weighted magnetic resonance imagingIAintra-arterialtPAtissue plasminogen activatorICHintracranial hemorrhage. LIST OF PROPRIETARY DEVICES CITED IN TEXT: Enterprise Vascular Reconstructive Device (R), Codman Neurovascular, Raynham, MA Excelsior SL 10 microcatheter, Target Therapeutics/Stryker, Fremont, CA Prowler Plus Select microcatheter, Codman Neurovascular MPD Envoy catheter, Codman Neurovascular Penumbra .032" Reperfusion catheter, Penumbra Inc., San Leandro, CA Transend .014" microwire, Target/Stryker Merci Concentric Retriever (R), Concentric Medical/Stryker, Mountainview, CA.

We present a complex case of a splanchnic arterioportal vein fistula in a patient who presented with weight loss, abdominal pain, diarrhea, and pancreatitis. We report successful use of the Guglielmi Detachable Coil (GDC) and N-butyl cyanoacrylate glue for the therapeutic embolization of the fistula between the superior mesenteric artery, the common hepatic artery, and the portal vein. On the day following the procedure, the patient reported total remission of the abdominal pain and diarrhea. These results were maintained at 3 months follow-up.