Showing papers by "David Fiorella published in 2004"

Preliminary experience using the Neuroform stent for the treatment of cerebral aneurysms.

Abstract: Introduction The Neuroform microstent-a flexible, self-expandable, microcatheter-delivered, nitinol stent designed for the treatment of cerebral aneurysms-was recently approved for use in patients. We present the results of our initial experience in using the Neuroform stent to treat patients with cerebral aneurysms, with an emphasis on potential applications, technical aspects of deployment, and associated intra- and periprocedural complications. Methods The records of all patients treated with the Neuroform stent were entered prospectively into a database. We assessed the clinical history, indications for stent use, aneurysm dimensions, and technical details of the procedures, including any difficulties with stent placement and/or deployment, degree of aneurysm occlusion, and complications. Results During a 5-month period, 19 patients with 22 aneurysms were treated with the Neuroform stent. Twenty-five stents were deployed. Five patients had multiple stents placed. Five patients had ruptured aneurysms at the time of treatment. The indications for use were broad-necked aneurysms (n = 13; average neck length, 5.1 mm; average aneurysm size, 9 mm), fusiform or dissecting aneurysms (n = 3), salvage and/or bailout (n = 1), and giant aneurysms (n = 2). Technical problems included difficulty in deploying the stent (n = 6), inability to deploy the stent (n = 1), stent displacement (n = 2), inadvertent stent deployment (n = 1), and coil stretching (n = 1). Twenty-one of the 22 aneurysms were treated. Four aneurysms were stented without additional treatment, and 17 aneurysms were stented and coiled. Of the coiled aneurysms, complete or nearly complete (more than 95%) occlusion was achieved in 6 aneurysms, and partial occlusion was achieved in 11. Two clinically significant adverse events occurred, both of which were sequelae of periprocedural thromboembolic complications. One patient died after thrombolysis was attempted. The other patient made an excellent functional recovery after undergoing successful thrombolysis of a thrombosed basilar artery stent. Conclusion The Neuroform stent is a useful device for the treatment of patients with aneurysms that may not otherwise be amenable to endovascular therapy. In the majority of cases, the stent can be deployed accurately, even within the most tortuous segments of the cerebral vasculature. Although delivery and deployment may be technically challenging, clinically significant complications are uncommon.

Comparison of routine and selective use of intraoperative angiography during aneurysm surgery: a prospective assessment.

Abstract: Object Whether routine intraoperative angiography is necessary for cerebral aneurysm surgery is currently under debate. In this study the authors prospectively assessed the cerebrovascular surgeon's accuracy in predicting the need for intraoperative angiography. Methods Between January 2002 and January 2003, 200 consecutive patients (141 female and 59 male patients, mean age 52.8 years) with 235 aneurysms underwent routine intraoperative angiography. Before the operation, the surgeons indicated whether they believed that intraoperative angiography was necessary. Their responses were recorded as “intraoperative angiography necessary” or “intraoperative angiography unnecessary.” Regardless of the response, all patients underwent intraoperative angiography after the aneurysm had been clipped. Changes in treatment resulting from intraoperative angiography were compared with surgeons' preoperative predictions of the need for intraoperative angiography. Intraoperative angiography was predicted to be necessary i...

Assessment of the reproducibility of postprocessing dynamic CT perfusion data.

Abstract: BACKGROUND AND PURPOSE: Commercially available software programs for the conversion of dynamic CT perfusion (CTP) source data into cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transit time (MTT) maps require operators to subjectively define parameters that are used in subsequent postprocessing calculations. Our purpose was to define the variability of CBV, CBF, and MTT values derived from CTP maps generated from the same source data postprocessed by three different CT technologists (CTTs). METHODS: Raw data derived from dynamic CTP examinations performed in 20 subjects were postprocessed seven times by three experienced CTTs. Parenchymal regions of interest derived from each map (CBV, CBF, and MTT) were compared. The CBF maps generated by each technologist were also qualitatively assessed. Decisions made by each analyzer during postprocessing were assessed. RESULTS: The intraclass correlation coefficients were 0.73 (95% CI, 0.64–0.81), 0.87 (0.83–0.91) and 0.89 (0.85–0.93), for the CBV, CBF, and MTT parenchymal regions of interest, respectively. All individual correlation coefficients between data sets were significant to a P value P CONCLUSION: There is a high degree of correlation between parenchymal regions of interest derived from CBV, CBF, and MTT maps generated from the same dynamic CTP source data postprocessed by different operators. The level of agreement, however, may not be sufficient to incorporate quantitative values into clinical decision making. Quantitative differences between parenchymal regions of interest were not infrequently manifest as significant differences in the qualitative appearance of the CBF maps. It is likely that, with optimization of postprocessing parameter selection, the degree of variability may be substantially reduced.

Strategies for the management of intraprocedural thromboembolic complications with abciximab (ReoPro).

Abstract: OBJECTIVE Most complications related to endovascular neurointerventional procedures are thromboembolic. The objective of this study was to determine whether abciximab, a glycoprotein IIb/IIIa inhibitor, is a safe and effective agent for the treatment of thromboembolic complications encountered during interventional neuroradiological procedures. METHODS A search of a prospectively maintained database identified 13 patients who were treated for intraprocedural thromboembolic complications with abciximab, either alone or in combination with tissue plasminogen activator, during a 22-month period. RESULTS Of the 13 patients in our series (10 with aneurysms, 3 with arteriovenous malformations), 12 presented with unsecured vascular lesions, and in 9 cases the lesions were either acutely (<10 d) or subacutely (<6 mo) hemorrhagic. After the identification of a thromboembolic complication, each patient was treated with either intra-arterial (n = 5) or intravenous (n = 8) abciximab. Abciximab was administered intravenously as a 0.25-mg/kg bolus (n = 2), a 0.25-mg/kg bolus followed by a 12-hour 0.125-microg/kg/min infusion (n = 5), or a 12-hour 0.125-microg/kg/min infusion alone (n = 1). Intra-arterial abciximab (3.5-10 mg) was administered directly through a microcatheter positioned in the vicinity of the thrombus (n = 5). Five patients also were administered alteplase. Complete (n = 7) or partial (n = 6) resolution of thrombus was observed in all cases. Five patients had small infarcts in the distribution of the thromboembolic complication. In no case was new or increased hemorrhaging observed after thrombolysis. CONCLUSION Abciximab (ReoPro), administered either intravenously or intra-arterially, is a viable option for the management of thromboembolic complications encountered during endovascular therapeutic procedures.

Vertical atlantoaxial distraction injuries: radiological criteria and clinical implications.

Abstract: Object. The authors sought to establish radiological criteria for the diagnosis of C1–2 vertical distraction injuries. Methods. Conventional radiography, computerized tomography (CT), and magnetic resonance (MR) imaging findings in five patients with a C1–2 vertical distraction injury were correlated with their clinical history, operative findings, and autopsy findings. The basion—dens interval (BDI) and the C-1 and C-2 lateral mass interval (LMI) were measured in 93 control patients who underwent CT angiography; these measurements were used to define the normal BDI and LMI. The MR imaging results obtained in 30 healthy individuals were used to characterize the normal signal intensity of the C1–2 joint. The MR imaging results were compared with MR images obtained in five patients with distraction injuries. In the 93 patients, the BDI averaged 4.7 mm (standard deviation [SD] 1.7 mm, range 0.6–9 mm) and the LMI averaged 1.7 mm (SD 0.48 mm, range 0.7–3.3 mm). Based on CT scanning in the five patients with di...