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Article ; Online: SuperDyna: Unlocking the Potential of Post-Treatment Device Evaluation.

Raz, Eytan / Sharashidze, Vera / Nossek, Erez / Sahlein, Daniel H / Rostanski, Sara / Chung, Charlotte Y / Khawaja, Ayaz Mahmood / Nelson, Peter Kim / Shapiro, Maksim

Journal of neurointerventional surgery

2024 Volume 16, Issue 5, Page(s) 512–515

Abstract: Background: Current imaging algorithms for post-device evaluation are limited by either poor representation of the device or poor delineation of the treated vessel. Combining the high-resolution images from a traditional three-dimensional digital ... ...

Abstract	Background: Current imaging algorithms for post-device evaluation are limited by either poor representation of the device or poor delineation of the treated vessel. Combining the high-resolution images from a traditional three-dimensional digital subtraction angiography (3D-DSA) protocol with the longer cone-beam computed tomography (CBCT) protocol may provide simultaneous visualization of both the device and the vessel content in a single volume, improving the accuracy and detail of the assessment. We aim here to review our use of this technique which we termed "SuperDyna". Methods: In this retrospective study, patients who underwent an endovascular procedure between February 2022 and January 2023 were identified. We analyzed patients who had both non-contrast CBCT and 3D-DSA post-treatment and collected information on pre-/post-blood urea nitrogen, creatinine, radiation dose, and the intervention type. Results: In 1 year, SuperDyna was performed in 52 (of 1935, 2.6%) patients, of which 72% were women, median age 60 years. The most common reason for the addition of the SuperDyna was for post-flow diversion assessment (n=39). Renal function tests showed no changes. The average total procedure radiation dose was 2.8 Gy, with 4% dose and ~20 mL of contrast attributed to the additional 3D-DSA needed to generate the SuperDyna. Conclusions: The SuperDyna is a fusion imaging method that combines high-resolution CBCT and contrasted 3D-DSA to evaluate intracranial vasculature post-treatment. It allows for more comprehensive evaluation of the device position and apposition, aiding in treatment planning and patient education.
MeSH term(s)	Humans ; Female ; Male ; Middle Aged ; Retrospective Studies ; Cone-Beam Computed Tomography/methods ; Angiography, Digital Subtraction/methods ; Endovascular Procedures/methods ; Endovascular Procedures/instrumentation ; Aged ; Imaging, Three-Dimensional/methods ; Cerebral Angiography/methods ; Adult ; Stents
Language	English
Publishing date	2024-04-23
Publishing country	England
Document type	Journal Article
ZDB-ID	2514982-9
ISSN	1759-8486 ; 1759-8478
ISSN (online)	1759-8486
ISSN	1759-8478
DOI	10.1136/jnis-2023-020357
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Article ; Online: Technical video: Onyx-18 embolization of spinal epidural arteriovenous Fistula using the scepter-Mini balloon catheter.

Amuluru, Krishna / Denardo, Andrew / Scott, John / Payner, Troy / Kulwin, Charles / Sahlein, Daniel H

Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences

2022 , Page(s) 15910199221138633

Abstract: Spinal arteriovenous fistulas (AVFs) account for approximately 70% of all vascular spinal malformations and commonly develop in the lateral epidural space at the epidural /radicular venous junction. The fistula is located close to the spinal nerve root ... ...

Abstract	Spinal arteriovenous fistulas (AVFs) account for approximately 70% of all vascular spinal malformations and commonly develop in the lateral epidural space at the epidural /radicular venous junction. The fistula is located close to the spinal nerve root where a radiculomeningeal artery shunts to a radicular vein. Increased venous pressure leads to decreased spinal venous drainage and venous congestion causing progressive myelopathy, bowel/bladder incontinence and erectile dysfunction. Treatment consists of surgical occlusion of the intradural vein, or endovascular embolization, which has a reported success rate of 25%-75%.
Language	English
Publishing date	2022-11-10
Publishing country	United States
Document type	Journal Article
ZDB-ID	1354913-3
ISSN	2385-2011 ; 1591-0199 ; 1123-9344
ISSN (online)	2385-2011
ISSN	1591-0199 ; 1123-9344
DOI	10.1177/15910199221138633
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Article ; Online: Endovascular intervention for the treatment of epistaxis: cone beam CT review of anatomy, collateral, and treatment implications/efficacy.

Hoover, Madeline / Berwanger, Robert / Scott, John A / DeNardo, Andrew / Amuluru, Krishna / Payner, Troy / Kulwin, Charles / Raz, Eytan / Gibson, Daniel / Sahlein, Daniel H

Journal of neurointerventional surgery

2024 Volume 16, Issue 2, Page(s) 192–196

Abstract: Epistaxis is common, impacting more than half the population, and can require procedural intervention in approximately 10% of cases. With an aging population and increasing use of antiplatelets and anticoagulants, severe epistaxis is likely to increase ... ...

Abstract	Epistaxis is common, impacting more than half the population, and can require procedural intervention in approximately 10% of cases. With an aging population and increasing use of antiplatelets and anticoagulants, severe epistaxis is likely to increase in frequency significantly over the next two decades. Sphenopalatine artery embolization is rapidly becoming the most common type of procedural intervention. The efficacy of endovascular embolization is dependent on a refined understanding of the anatomy and collateral physiology of this circulation as well as the impact of temporizing measures such as nasal packing and inflation of a nasal balloon. Likewise, safety is dependent on a detailed appreciation of collateralization with the internal carotid artery and ophthalmic artery. Cone beam CT imaging has the resolution to enable a clear visualization of the anatomy and collateral circulation associated with the arterial supply to the nasal cavity, in addition to assisting with hemorrhage localization. We present a review of epistaxis treatment, a detailed description of anatomic and physiologic considerations informed by cone beam CT imaging, and a proposed protocol for sphenopalatine embolization for which there is currently no standard.
MeSH term(s)	Humans ; Aged ; Epistaxis/diagnostic imaging ; Epistaxis/therapy ; Treatment Outcome ; Embolization, Therapeutic/methods ; Arteries ; Cone-Beam Computed Tomography
Language	English
Publishing date	2024-01-12
Publishing country	England
Document type	Journal Article ; Review
ZDB-ID	2514982-9
ISSN	1759-8486 ; 1759-8478
ISSN (online)	1759-8486
ISSN	1759-8478
DOI	10.1136/jnis-2022-019966
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Article: Adjustment of Malpositioned Woven EndoBridge Device Using Gooseneck Snare: Complication Management Technique.

Amuluru, Krishna / Al-Mufti, Fawaz / Sahlein, Daniel H / Scott, John / Denardo, Andrew

Neurointervention

2021 Volume 16, Issue 3, Page(s) 275–279

Abstract: The Woven EndoBridge (WEB) is an intrasaccular flow-disrupting device for the treatment of wide-necked saccular cerebral aneurysms. As with any neuroendovascular device, complications in the form of malpositioning and migration must be managed quickly ... ...

Abstract	The Woven EndoBridge (WEB) is an intrasaccular flow-disrupting device for the treatment of wide-necked saccular cerebral aneurysms. As with any neuroendovascular device, complications in the form of malpositioning and migration must be managed quickly and safely. Few studies have reported complication management techniques in instances of dislocated or migrated WEB devices. We retrospectively describe a case of a malpositioned WEB device that was successfully adjusted with the use of a gooseneck snare. Multiple other intra-procedural bailout strategies for management of WEB malposition and migration were considered, and are herein discussed. Operators should be aware of the causes of WEB malposition and a variety of bailout strategies.
Language	English
Publishing date	2021-10-12
Publishing country	Korea (South)
Document type	Journal Article
ZDB-ID	2639823-0
ISSN	2233-6273 ; 2093-9043
ISSN (online)	2233-6273
ISSN	2093-9043
DOI	10.5469/neuroint.2021.00318
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Article ; Online: Artificial intelligence aneurysm measurement tool finds growth in all aneurysms that ruptured during conservative management.

Sahlein, Daniel H / Gibson, Daniel / Scott, John A / DeNardo, Andrew / Amuluru, Krishna / Payner, Troy / Rosenbaum-Halevi, David / Kulwin, Charles

Journal of neurointerventional surgery

2022 Volume 15, Issue 8, Page(s) 766–770

Abstract: Background: Cerebral aneurysm rupture is associated with high rates of morbidity and mortality. Detecting aneurysms at high risk of rupture is critical in management decision making. Rupture risk has traditionally been associated with size-measured as a ...

Abstract	Background: Cerebral aneurysm rupture is associated with high rates of morbidity and mortality. Detecting aneurysms at high risk of rupture is critical in management decision making. Rupture risk has traditionally been associated with size-measured as a maximum dimension. However, aneurysms are morphologically dynamic, a characteristic ignored by large prospective aneurysm risk studies. Manual measurement is challenging and fraught with error. We used an artificial intelligence (AI) measurement tool to study aneurysms that ruptured during conservative management to detect changes in size not appreciated by manual linear measurement. Methods: A single practice database with >5000 aneurysms was queried. Patients followed conservatively for an unruptured aneurysm were identified using appropriate diagnosis codes. This cohort was screened for subsequent rupture using procedure codes. Only patients with two vascular imaging studies before rupture were included. Results: Five patients met the criteria. All patients had aneurysm enlargement, two of which were not detected from manual linear measurements, including adjudication and analysis, during a multidisciplinary neurovascular conference in a high volume practice. Maximum dimension increased at a minimum of 1.8% (range 1.8-63.3%) from the first scan to the last, and aneurysm volume increased at a minimum of 5.9% (5.9-385.5%), highlighting the importance of volumetric measurement. Conclusions: AI-enabled volumetric measurements are more sensitive to changes in size and detected enlargement in all aneurysms that ruptured during conservative management. This finding has major implications for clinical practice and methods used for interval aneurysm measurement in patients being conservatively followed.
MeSH term(s)	Humans ; Prospective Studies ; Artificial Intelligence ; Conservative Treatment ; Aneurysm, Ruptured/diagnostic imaging ; Aneurysm, Ruptured/therapy ; Aneurysm, Ruptured/complications ; Intracranial Aneurysm/diagnostic imaging ; Intracranial Aneurysm/therapy ; Intracranial Aneurysm/complications ; Aneurysm, False ; Risk Factors
Language	English
Publishing date	2022-09-30
Publishing country	England
Document type	Journal Article
ZDB-ID	2514982-9
ISSN	1759-8486 ; 1759-8478
ISSN (online)	1759-8486
ISSN	1759-8478
DOI	10.1136/jnis-2022-019339
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Article ; Online: Racial Disparity in Mechanical Thrombectomy Utilization: Multicenter Registry Results From 2016 to 2020.

Wallace, Adam N / Gibson, Daniel P / Asif, Kaiz S / Sahlein, Daniel H / Warach, Steven J / Malisch, Timothy / Lamonte, Marian P

Journal of the American Heart Association

2022 Volume 11, Issue 4, Page(s) e021865

Abstract: Background Previous studies on racial disparity in mechanical thrombectomy (MT) treatment of acute large vessel occlusion stroke lack individual patient data that influence treatment decision-making. We assessed patient-level data in a large US health ... ...

Abstract	Background Previous studies on racial disparity in mechanical thrombectomy (MT) treatment of acute large vessel occlusion stroke lack individual patient data that influence treatment decision-making. We assessed patient-level data in a large US health care system from 2016 to 2020 for racial disparities in MT utilization and eligibility. Methods and Results A retrospective study was performed of 34 596 patients admitted to 43 hospitals from January 2016 to September 2020. Data included patient age, sex, race, residential zip code median income and population density, presenting hospital stroke certification, baseline ambulation, and National Institutes of Health stroke scale. The cohort included 26 640 White, non-Hispanic (77.0%), and 7956 African American/Black (23.0%) patients. In multivariable logistic regression, Black patients were less likely to undergo MT (adjusted odds ratio [OR], 0.65; 95% CI, 0.54-0.76), arrive within 5 hours of "last known well" (adjusted OR, 0.73; 95% CI, 0.69-0.78), and have documented anterior circulation large vessel occlusion (adjusted OR, 0.78; 95% CI, 0.64-0.96). Race was not associated with MT rate among patients arriving within 5 hours of last known well with documented acute large vessel occlusion. Conclusions Black patients with stroke underwent MT less frequently than White patients, likely in part because of longer times from last known well to hospital arrival and a lower rate of documented acute large vessel occlusion. Further studies are needed to assess whether extending the MT time window and more aggressive large vessel occlusion screening protocols mitigate this disparity.
MeSH term(s)	Brain Ischemia/diagnosis ; Humans ; Registries ; Retrospective Studies ; Stroke/diagnosis ; Stroke/therapy ; Thrombectomy/methods ; Treatment Outcome
Language	English
Publishing date	2022-02-12
Publishing country	England
Document type	Journal Article ; Multicenter Study
ZDB-ID	2653953-6
ISSN	2047-9980 ; 2047-9980
ISSN (online)	2047-9980
ISSN	2047-9980
DOI	10.1161/JAHA.121.021865
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Article ; Online: Safety and Effectiveness of Mechanical Thrombectomy for Acute Ischemic Stroke Using Single Plane Angiography.

Amuluru, Krishna / Nguyen, Jimmy / Al-Mufti, Fawaz / Denardo, Andrew / Scott, John / Yavagal, Dileep / Sahlein, Daniel H

Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association

2022 Volume 31, Issue 8, Page(s) 106553

Abstract: Objectives: Nearly all data on mechanical thrombectomy for acute ischemic stroke is based on procedures performed on biplane angiography systems. However, thrombectomy may be performed on single-plane systems in situations of triage or limited resources. ...

Abstract	Objectives: Nearly all data on mechanical thrombectomy for acute ischemic stroke is based on procedures performed on biplane angiography systems. However, thrombectomy may be performed on single-plane systems in situations of triage or limited resources. We present the first US study comparing the safety and effectiveness of mechanical thrombectomy performed on single-plane vs. biplane systems. Methods and methods: A retrospective review of a prospectively maintained database identified all patients treated with thrombectomy between July 2020 and July 2021 by a high-volume practice. Patients were dichotomized into those treated on single plane and biplane systems. Demographic, procedural, clinical and follow-up characteristics were compared. Results: Of the 246 patients treated with mechanical thrombectomy, 70 (33%) and 141 (66%) patients were treated on SP and BP systems, respectively. No significant differences were detected in follow-up 'good functional outcome' (mRS ≤ 2; SP 51% vs BP 43%, p = 0.14), successful recanalization (SP 87% vs BP 88%, p = 0.72), intra-procedural vascular injury (SP 3% vs BP 2%, p = 0.96), or time from groin puncture to reperfusion (SP 24 min vs BP 26 min, p = 0.58). Additionally, no significant differences were detected in peri-procedural complications, fluoroscopy times or total radiation. Patients treated on single plane systems required significantly more contrast. Conclusions: Mechanical thrombectomy for acute ischemic stroke performed on single plane angiography systems is as safe and efficacious as when performed on biplane systems. Our results may have implications for increasing stroke care access, both domestically in underserved/rural areas and internationally when considering requirements for stroke care in lower-income countries.
MeSH term(s)	Angiography/adverse effects ; Brain Ischemia/complications ; Brain Ischemia/diagnostic imaging ; Brain Ischemia/therapy ; Humans ; Ischemic Stroke ; Retrospective Studies ; Stroke/complications ; Stroke/diagnostic imaging ; Stroke/therapy ; Thrombectomy/adverse effects ; Thrombectomy/methods ; Treatment Outcome
Language	English
Publishing date	2022-06-08
Publishing country	United States
Document type	Journal Article
ZDB-ID	1131675-5
ISSN	1532-8511 ; 1052-3057
ISSN (online)	1532-8511
ISSN	1052-3057
DOI	10.1016/j.jstrokecerebrovasdis.2022.106553
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Article ; Online: Endovascular Retreatment of Previously Ruptured Coiled Cerebral Aneurysm Remnants Significantly Reduces Rebleed Rate.

Mendenhall, Stephen K / Shapiro, Scott A / Cohen-Gadol, Aaron A / Sahlein, Daniel H

World neurosurgery

2020 Volume 147, Page(s) e382–e387

Abstract: Objective: Treatment of ruptured cerebral aneurysms by endovascular coiling is associated with a better neurologic outcome when compared with neurosurgical clipping but has a higher risk for target aneurysm rebleeding after treatment. We hypothesize ... ...

Abstract	Objective: Treatment of ruptured cerebral aneurysms by endovascular coiling is associated with a better neurologic outcome when compared with neurosurgical clipping but has a higher risk for target aneurysm rebleeding after treatment. We hypothesize that aggressive retreatment of coiled aneurysms will lead to fewer recurrent hemorrhages as compared with historical values of 2.3%-3.0%. Methods: All first-time Guglielmi detachable coil-embolized cerebral aneurysms were retrospectively reviewed at a single institution from 2004 to 2015. Aneurysm retreatment after first-time embolization was recorded as well as time to retreatment. Retreatment at our institution is routinely performed for incomplete coiling with etiologies including incomplete initial coiling, coil compaction, and aneurysmal dilatation. Aneurysm rerupture was treated with additional coiling. Kaplan-Meier survival analysis was performed to evaluate embolization durability. Results: There were 214 aneurysms that met inclusion criteria. Mean (standard deviation) follow-up was 2.74 (2.24) years. Aneurysms that were patent or recanalized were retreated. Mean (standard deviation) time to retreatment was 9 (9) months. Overall, 46 (21.5%) aneurysms required retreatment. Retreatment was performed for coil compaction/remnant growth, recanalization, persistent remnant, and rebleed. Two (0.9%) patients had recurrent aneurysm hemorrhage and both were treated with additional coil embolization. There were no new long-term neurologic deficits caused by aneurysm retreatment. Conclusions: Aggressive retreatment of previously ruptured, coiled cerebral aneurysms for persistent aneurysm patency reduces the recurrent hemorrhage risk to that historically seen in neurosurgically clipped aneurysms with minimal additional morbidity. This study validates a large body of literature demonstrating the significance of post-treatment aneurysm remnants and their association with recurrent hemorrhage.
Language	English
Publishing date	2020-12-19
Publishing country	United States
Document type	Journal Article
ZDB-ID	2534351-8
ISSN	1878-8769 ; 1878-8750
ISSN (online)	1878-8769
ISSN	1878-8750
DOI	10.1016/j.wneu.2020.12.063
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Article ; Online: Safety and efficacy of endovascular versus microsurgical treatment of unruptured wide-necked middle cerebral artery aneurysms: a propensity score-matched analysis of the NeuroVascular Quality Initiative Quality Outcomes Database Cerebral Aneurysm Registry.

Padmanaban, Varun / Zhu, Junjia / Zhou, Shouhao / Ansari, Sameer A / Howington, Jay U / Sahlein, Daniel H / Tejada, Juan G / Wilkinson, D Andrew / Simon, Scott D / Cockroft, Kevin M / Church, Ephraim W

Journal of neurosurgery

2023 , Page(s) 1–9

Abstract: Objective: Unruptured, wide-necked middle cerebral artery (WN-MCA) aneurysms have traditionally been considered ideal candidates for microsurgery (MS), although endovascular treatment (EVT) has dramatically increased in popularity with the advent of ... ...

Abstract	Objective: Unruptured, wide-necked middle cerebral artery (WN-MCA) aneurysms have traditionally been considered ideal candidates for microsurgery (MS), although endovascular treatment (EVT) has dramatically increased in popularity with the advent of novel devices such as intrasaccular flow disruptors. The purpose of this study was to evaluate the safety and efficacy of MS versus EVT for unruptured WN-MCA aneurysms. Methods: The NeuroVascular Quality Initiative Quality Outcomes Database (NVQI-QOD) Cerebral Aneurysm Registry, a multiinstitutional, prospectively collected procedural database, was queried for cases of unruptured WN-MCA aneurysms treated with MS or EVT between 2015 and 2022. A wide neck was defined as an aneurysm neck ≥ 4 mm or a dome/neck ratio ≤ 2. Demographics and aneurysm characteristics were queried. Propensity score matching (PSM) was utilized to match aneurysm size, number of aneurysms treated, patient age, and aneurysm status. Safety outcomes were evaluated including intraoperative and postoperative complication rates. Aneurysm occlusion status and clinical outcomes using the modified Rankin Scale (mRS) score at discharge and the last follow-up were also assessed. Results: Of 671 unruptured MCA aneurysms, 319 were wide necked. Thirty cases were excluded, as the aneurysm had been previously treated. Two hundred eighty-nine operations (203 EVT, 86 MS) in 282 patients satisfied inclusion criteria. After PSM, there were 86 operations in each group for analysis. The mean aneurysm width was 5.0 (EVT) versus 4.9 mm (MS; p = 0.285). Safety data showed similar intraoperative (7.0% EVT vs 3.5% MS, p = 0.496) and postoperative (4.7% vs 7%, p = 0.746) complication rates. The MS patients were more likely to have complete aneurysm occlusion at discharge (90.4% vs 58.8%, p < 0.001). In a limited subset of patients (52.9%) for whom outcome data were available, the EVT patients were more likely to have an mRS score 0 at discharge (50/59 [84.7%] vs 29/54 [53.7%], p < 0.0003] and at the last follow-up (36/55 [65.5%] vs 13/36 [36.1%], p = 0.006). Conclusions: This study describes a large, modern cohort of propensity score-matched patients who underwent treatment of unruptured WN-MCA aneurysms. Safety data on intraoperative and postoperative complication rates were similar in both treatment groups. MS was more likely to result in complete aneurysm occlusion at discharge. In a subset of patients with available outcome data, EVT was associated with better functional outcomes at discharge and the last follow-up. Given the lack of complete follow-up data and rates of retreatment, these results should be interpreted cautiously.
Language	English
Publishing date	2023-12-29
Publishing country	United States
Document type	Journal Article
ZDB-ID	3089-2
ISSN	1933-0693 ; 0022-3085
ISSN (online)	1933-0693
ISSN	0022-3085
DOI	10.3171/2023.10.JNS231659
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Article: The Use of a Pipeline Embolization Device for Treatment of a Ruptured Dissecting Middle Cerebral Artery M3/M4 Aneurysm: Challenges and Technical Considerations.

Berwanger, Robert P / Hoover, Madeline C / Scott, John A / DeNardo, Andrew J / Amuluru, Krishna / Payner, Troy D / Kulwin, Charles G / Sahlein, Daniel H

Neurointervention

2022 Volume 17, Issue 2, Page(s) 126–130

Abstract: Prompt, effective treatment is necessary following aneurysmal subarachnoid hemorrhage to prevent recurrent rupture, which is thought to double mortality. Atypical ruptured aneurysms, such as blister or dissecting pseudoaneurysms, or those that are ... ...

Abstract	Prompt, effective treatment is necessary following aneurysmal subarachnoid hemorrhage to prevent recurrent rupture, which is thought to double mortality. Atypical ruptured aneurysms, such as blister or dissecting pseudoaneurysms, or those that are unusually distal in the middle cerebral artery (MCA) are challenging to treat with either open or endovascular options, though the pipeline embolization device (PED) has shown promise in multiple case series. We present a case of a ruptured dissecting pseudoaneurysm in the distal MCA (distal M3/proximal M4) prefrontal division in an healthy young patient (<60 years) successfully treated with a PED. The PED was chosen both as the only vessel sparing option in the young patient as well as for its potential as a vessel sacrifice tool if the pseudoaneurysm was felt to be incompletely treated, which in this case was not necessary-though would have leveraged the thrombogenicity of the device as a therapeutic advantage.
Language	English
Publishing date	2022-04-07
Publishing country	Korea (South)
Document type	Case Reports
ZDB-ID	2639823-0
ISSN	2233-6273 ; 2093-9043
ISSN (online)	2233-6273
ISSN	2093-9043
DOI	10.5469/neuroint.2022.00045
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