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Principles, techniques and applications of high resolution cone beam CT angiography in the neuroangio suite

Raz, Eytan; Nossek, Erez; Sahlein, Daniel H; Sharashidze, Vera; Narayan, Vinayak; Ali, Aryan; Esparza, Rogelio; Peschillo, Simone; Chung, Charlotte; Diana, Francesco; Syed, Safia; Nelson, Peter Kim; Shapiro, Maksim
The aim of this review is to describe the acquisition and reformatting of state of the art high resolution cone beam CT (HR-CBCT) and demonstrate its role in multiple neurovascular conditions as a tool to improve the understanding of disease and guide therapeutic decisions. First, we will review the basic principle of CBCT acquisition, followed by the injection protocols and the reformatting paradigms. Next, multiple applications in different pathological conditions such as aneurysms, arteriovenous malformations, dural arteriovenous fistulas, and stroke will be described. HR-CBCT angiography, widely available, is uniquely useful in certain clinical scenarios to improve the understanding of disease and guide therapeutic decisions. It rapidly is becoming an essential tool for the contemporary neurointerventionalist.AChoAho.
PMID: 35835462
ISSN: 1759-8486
CID: 5269382

Cerebral venous anatomy: implications for the neurointerventionalist

Shapiro, Maksim; Raz, Eytan; Nossek, Erez; Srivatanakul, Kittipong; Young, Matthew; Narayan, Vinayak; Ali, Aryan; Sharashidze, Vera; Esparza, Rogelio; Nelson, Peter Kim
Meaningful contributions to neurointerventional practice may be possible by considering the dynamic aspects of angiography in addition to fixed morphologic information. The functional approach to venous anatomy requires integration of the traditional static anatomic features of the system-deep, superficial, posterior fossa, medullary veins, venous sinuses, and outflow routes into an overall appreciation of how a classic model of drainage is altered, embryologically, or pathologically, depending on patterns of flow-visualization made possible by angiography. In this review, emphasis is placed on balance between alternative venous networks and their redundancy, and the problems which arise when these systems are lacking. The role of veins in major neurovascular diseases, such as dural arteriovenous fistulae, arteriovenous malformations, pulsatile tinnitus, and intracranial hypertension, is highlighted, and deficiencies in knowledge emphasized.
PMID: 35803732
ISSN: 1759-8486
CID: 5280692

An unusual anatomical variant: A transclival artery supplying the vertebrobasilar circulation

Raz, Eytan; Nayak, Gopi; Sharashidze, Vera; Nossek, Erez; Malak, Wassim; Bueno, Hugo; Komiyama, Masaki; Nelson, Peter Kim; Shapiro, Maksim
The persistent carotid-vertebrobasilar anastomoses are arterial communications between the anterior and posterior circulations due to the persistence of embryological connections. We here present an extremely rare instance of a transclival persistent carotid-vertebrobasilar anastomosis in a 10-month-old infant, which does not fit into any of the traditionally described categories, such as the trigeminal artery, hypoglossal artery, or proatlantal artery.
PMID: 37032452
ISSN: 2385-2011
CID: 5464012

Access to cavernous dAVF via occluded superior petrosal Sinus

Raz, Eytan; Sharashidze, Vera; Grossman, Scott; Ali, Aryan; Narayan, Vinayak; Nossek, Erez; Stein, Evan; Nelson, Peter Kim; Shapiro, Maksim
There are multiple treatment alternatives for cavernous dAVFs, with transvenous routes being most common. Among these routes, occluded inferior petrosal sinus is well-described, and, apart from being imaginative and elegant, it is also safe and effective. Herein we describe the application of this method to reach the fistulous pouch of a cavernous dAVF via an occluded superior petrosal sinus.
PMID: 36843545
ISSN: 2385-2011
CID: 5432362

COManeci MechANical dilation for vasospasm (COMMAND): multicenter experience

Salem, Mohamed M; Khalife, Jane; Desai, Sohum; Sharashidze, Vera; Badger, Clint; Kuhn, Anna L; Monteiro, Andre; Salahuddin, Hisham; Siddiqui, Adnan H; Singh, Jasmeet; Levy, Elad I; Lang, Michael; Grandhi, Ramesh; Thomas, Ajith J; Lin, Li-Mei; Tanweer, Omar; Burkhardt, Jan-Karl; Puri, Ajit S; Gross, Bradley A; Nossek, Erez; Hassan, Ameer E; Shaikh, Hamza A; Jankowitz, Brian T
BACKGROUND:We report the largest multicenter experience to date of utilizing the Comaneci device for endovascular treatment of refractory intracranial vasospasm. METHODS:Consecutive patients undergoing Comaneci mechanical dilatation for vasospasm were extracted from prospectively maintained registries in 11 North American centers (2020-2022). Intra-arterial vasodilators (IAV) were allowed, with the Comaneci device utilized after absence of vessel dilation post-infusion. Pre- and post-vasospasm treatment scores were recorded for each segment, with primary radiological outcome of score improvement post-treatment. Primary clinical outcome was safety/device-related complications, with secondary endpoints of functional outcomes at last follow-up. RESULTS:A total of 129 vessels in 40 patients (median age 52 years; 67.5% females) received mechanical dilation, 109 of which (84.5%) exhibited pre-treatment severe-to-critical vasospasm (ie, score 3/4). Aneurysmal subarachnoid hemorrhage was the most common etiology of vasospasm (85%), with 65% of procedures utilizing Comaneci-17 (92.5% of patients received IAV). The most treated segments were anterior cerebral artery (34.9%) and middle cerebral artery (31%). Significant vasospasm drop (pre-treatment score (3-4) to post-treatment (0-2)) was achieved in 89.9% of vessels (96.1% of vessels experienced ≥1-point drop in score post-treatment). There were no major procedural/post-procedural device-related complications. Primary failure (ie, vessel unresponsive) was encountered in one vessel (1 patient) (1/129; 0.8%) while secondary failure (ie, recurrence in previously treated segment requiring retreatment in another procedure) occurred in 16 vessels (7 patients) (16/129; 12.4%), with median time-to-retreatment of 2 days. Favorable clinical outcome (modified Rankin Scale 0-2) was noted in 51.5% of patients (median follow-up 6 months). CONCLUSIONS:The Comaneci device provides a complementary strategy for treatment of refractory vasospasm with reasonable efficacy/favorable safety. Future prospective trials are warranted.
PMID: 36002289
ISSN: 1759-8486
CID: 5338272

Tumor Embolization through Meningohypophyseal and Inferolateral Trunks is Safe and Effective

Raz, E; Cavalcanti, D D; Sen, C; Nossek, E; Potts, M; Peschillo, S; Lotan, E; Narayan, V; Ali, A; Sharashidze, V; Nelson, P K; Shapiro, M
BACKGROUND AND PURPOSE/OBJECTIVE:Skull base tumors are commonly supplied by dural branches of the meningohypophyseal and inferolateral trunks. Embolization through these arteries is often avoided due to technical challenges and inherent risks; however, successful embolization can be a valuable surgical adjunct. We aimed to review the success and complications in our series of tumor embolizations through the meningohypophyseal and inferolateral trunks. MATERIALS AND METHODS/METHODS:We performed a retrospective review of patients with tumor treated with preoperative embolization at our institution between 2010 and 2020. We reviewed the following data: patients' demographics, tumor characteristics, endovascular embolization variables, and surgical results including estimated blood loss, the need for transfusion, and operative time. RESULTS:= 4) trunk. In this group of patients, on average, 79% of tumors were embolized. No mortality or morbidity from the embolization procedure was observed in this subgroup of patients. The average estimated blood loss in the operation was 395 mL (range, 200-750 mL). None of the patients required a transfusion, and the average operative time was 7.3 hours. CONCLUSIONS:Some skull base tumors necessitate embolization through ICA branches such as the meningohypophyseal and inferolateral trunks. Our series demonstrates that an effective and safe embolization may be performed through these routes.
PMID: 35902121
ISSN: 1936-959x
CID: 5276862

Balloon anchoring technique for thrombectomy in hostile craniocervical arterial anatomy

Sharashidze, Vera; Nogueira, Raul G; Al-Bayati, Alhamza R; Grossberg, Jonathan A; Haussen, Diogo C
BACKGROUND:Craniocervical catheter access in large vessel occlusion acute ischemic strokes can be challenging in cases of unfavorable aortic arch/cervical vascular anatomy, leading to lower recanalization rates, increased procedural time and worse clinical outcomes. We aim to demonstrate the feasibility of the balloon-anchoring technique (BAT) that can be attempted before switching to alternative access sites. METHODS:Retrospective review of prospectively collected information on 11 patients in which two variants of the BAT (proximal anchoring: balloon guide catheter (BGC) is inflated to provide support for distal access; distal anchoring: compliant balloon is inflated in an intracranial artery to allow advancement of the support system) were utilized to facilitate craniocervical access due to failure of conventional maneuvers. RESULTS:Ten patients had anterior and one patient had posterior circulation large vessel occlusions. Mean age was 81 years and 81% were females. Type 3 arches were found in 82% and a 9 French balloon guide catheter was used in 82%. Proximal anchoring with BGC was used in four cases while distal anchoring was used in seven patients to allow access to the target vessel, avoiding the need to puncture alternative access sites. Successful reperfusion (modified treatment in cerebral ischemia 2b-3) was achieved in all cases and no complications were observed. CONCLUSION/CONCLUSIONS:BAT is safe and feasible. It can be considered as a rescue maneuver in order to avoid switching to a different access during thrombectomy in individuals with unfavorable aortic arch/craniocervical anatomy.
PMID: 32015181
ISSN: 1759-8486
CID: 4950722

Markers of coagulation and hemostatic activation aid in identifying causes of cryptogenic stroke

Nahab, Fadi; Sharashidze, Vera; Liu, Michael; Rathakrishnan, Priyadharshi; El Jamal, Sleiman; Duncan, Alexander; Hoskins, Michael; Marmarchi, Fahad; Belagaje, Samir; Bianchi, Nicolas; Belair, Trina; Henriquez, Laura; Monah, Kaslyn; Rangaraju, Srikant
OBJECTIVE:To test the hypothesis that markers of coagulation and hemostatic activation (MOCHA) help identify causes of cryptogenic stroke, we obtained serum measurements on 132 patients and followed them up to identify causes of stroke. METHODS:Consecutive patients with cryptogenic stroke who met embolic stroke of undetermined source (ESUS) criteria from January 1, 2017, to October 31, 2018, underwent outpatient cardiac monitoring and the MOCHA profile (serum D-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, and fibrin monomer) obtained ≥2 weeks after the index stroke; abnormal MOCHA profile was defined as ≥2 elevated markers. Prespecified endpoints monitored during routine clinical visits included new atrial fibrillation (AF), malignancy, venous thromboembolism (VTE), or other defined hypercoagulable states (HS). RESULTS:= 0.79). The combination of 4 normal MOCHA and normal left atrial size (n = 30) had 100% sensitivity for ruling out the prespecified endpoints. CONCLUSION:The MOCHA profile identified patients with cryptogenic stroke more likely to have new malignancy, VTE, or HS during short-term follow-up and may be useful in direct evaluation for underlying causes of cryptogenic stroke.
PMID: 32291293
ISSN: 1526-632x
CID: 4950732

Acute Neurological Deterioration in Large Vessel Occlusions and Mild Symptoms Managed Medically

Saleem, Yasir; Nogueira, Raul G; Rodrigues, Gabriel M; Kim, Song; Sharashidze, Vera; Frankel, Michael; Al-Bayati, Alhamza; Bianchi, Nicolas; Haussen, Diogo C
Background and Purpose- It is unclear which factors predict acute neurological deterioration in patients with large vessel occlusion and mild symptoms. We aim to evaluate the frequency, timing, and potential predictors of acute neurological deterioration ≥4 National Institutes of Health Stroke Scale (NIHSS) points in medically managed patients with large vessel occlusion and mild presentation. Methods- Single-center retrospective study of patients with consecutive minor stroke (defined as NIHSS score of ≤5 on presentation) and large vessel occlusion from January 2014 to December 2017. Primary outcome was acute neurological deterioration ≥4 NIHSS points during the hospitalization. Secondary outcomes included ΔNIHSS (defined as discharge minus admission NIHSS score). Results- Among 1133 patients with acute minor strokes, 122 (10.6%) had visible occlusions on computed tomography angiography/magnetic resonance angiography. Twenty-four (19.7%) patients had ≥4 points deterioration on NIHSS at a median of 3.6 (1-16) hours from arrival. No clinical or radiological predictors of acute neurological deterioration ≥4 NIHSS points were observed on multivariable analysis. Rescue endovascular thrombectomy was performed more often in the ones with acute neurological deterioration ≥4 NIHSS points compared with patients with no deterioration (54% versus 0%; P<0.001). Acute neurological deterioration ≥4 NIHSS points was associated with ΔNIHSS ≥4 points (33% versus 4.9%; P<0.01) and a trend toward lower independence rates at discharge (50% versus 70%; P=0.06) compared with the group with no deterioration. In patients with any degree of neurological worsening, patients who underwent rescue thrombectomy were more likely to be independent at discharge (73% versus 38%; P=0.02) and to have a favorable ΔNIHSS (-2 [-3 to 0] versus 0 [-1 to 6]; P=0.05) compared with the ones not offered rescue thrombectomy. Conclusions- Acute neurological deterioration ≥4 NIHSS points was observed in a fifth of patients with large vessel occlusion and mild symptoms, occurred very early in the hospital course, impacted functional outcomes, and could not be predicted by any of the studied clinical and radiological variables. Rescue thrombectomy was associated with improved clinical outcomes at discharge in patients with neurological deterioration.
PMID: 32295503
ISSN: 1524-4628
CID: 4950742

Coagulation markers and echocardiography predict atrial fibrillation, malignancy or recurrent stroke after cryptogenic stroke

Ellis, Deandrea; Rangaraju, Srikant; Duncan, Alexander; Hoskins, Michael; Raza, Syed Ali; Rahman, Haseeb; Winningham, Melanie; Belagaje, Samir; Bianchi, Nicolas; Mohamed, Ghada A; Obideen, Mahmoud; Sharashidze, Vera; Belair, Trina; Henriquez, Laura; Nahab, Fadi
We evaluated the utility of left atrial volume index (LAVI) and markers of coagulation and hemostatic activation (MOCHA) in cryptogenic stroke (CS) patients to identify those more likely to have subsequent diagnosis of atrial fibrillation (AF), malignancy or recurrent stroke during follow-up.Consecutive CS patients who met embolic stroke of undetermined source (ESUS) who underwent transthoracic echocardiography and outpatient cardiac monitoring following stroke were identified from the Emory cardiac registry. In a subset of consecutive patients, d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer (MOCHA panel) were obtained ≥2 weeks post-stroke and repeated ≥4 weeks later if abnormal; abnormal MOCHA panel was defined as ≥2 elevated markers which did not normalize when repeated. We assessed the predictive abilities of LAVI and the MOCHA panel to identify patients with subsequent diagnosis of AF, malignancy, recurrent stroke or the composite outcome during follow-up.Of 94 CS patients (mean age 64 ± 15 years, 54% female, 63% non-white, mean follow-up 1.4 ± 0.8 years) who underwent prolonged cardiac monitoring, 15 (16%) had new AF. Severe LA enlargement (vs normal) was associated with AF (P < .06). In 42 CS patients with MOCHA panel testing (mean follow-up 1.1 ± 0.6 years), 14 (33%) had the composite outcome and all had abnormal MOCHA. ROC analysis showed LAVI and abnormal MOCHA together outperformed either test alone with good predictive ability for the composite outcome (AUC 0.84).We report the novel use of the MOCHA panel in CS patients to identify a subgroup of patients more likely to have occult AF, occult malignancy or recurrent stroke during follow-up. A normal MOCHA panel identified a subgroup of CS patients at low risk for recurrent stroke on antiplatelet therapy. Further study is warranted to evaluate whether the combination of an elevated LAVI and abnormal MOCHA panel identifies a subgroup of CS patients who may benefit from early anticoagulation for secondary stroke prevention.
PMID: 30572550
ISSN: 1536-5964
CID: 4950712