Endovascular Techniques in the Management of Cerebrovascular Disease

193 Pages·2008·11.94 MB·English

978-1-84184-607-1:291mm x 217mm 30/5/08 08:48 Page 1
Endovascular Techniques
Endovascular Techniques in the Management of
in the Management of
CEREBROVASCULAR DISEASE
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Edited by OMS CEREBROVASCULAR
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Thomas J Masaryk • Peter A Rasmussen FSY
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Henry Woo • David Fiorella OE
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EndovascularTechniquesintheMangementofCerebrovascularDiseaseisaninvaluable
toolforneurologyandneurosurgeryfellows-in-trainingandpracticingclinicianswithan
interestinendovascularproceduresusedinthemanagementofcerebrovasculardisease.
Thishighlyillustratedtextbenefitsfromtheresourcesofamultispecialtycerebrovascular
center,thatunifiesexpertiseindiagnosticneuroradiology,neuroanesthesia,neurosurgical
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intensivecare,strokeneurologyandthebasicneurosciences. n
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The first section of Endovascular Techniques in the Mangement of Cerebrovascular a
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Disease reviews equipment, devices and therapeutic agents such as anti-coagulants B c
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andthrombolytics.Thesecondsectiondescribestheclinicalmanagementofischemic R l
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cerebrovascualr disease, including thrombectomy and stenting; the third section is O
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dedicated to hemorrhagic cerebrovascular disease and deals with aneurysms, V e
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subarachnoid hemorrhage and vascular malformations. A h
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Thetechniquesdescribedareincreasinglyemployedintheendovasculartreatmentfor e
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occlusive cerebrovascular disease, cerebral aneurysms, arteriovenous malformation
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and other extra- and intracranial cerebrovascular diseases. In keeping with the L
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WITH CONTRIBUTIONS FROM: e
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Bryson Borg Thomas J Masaryk n
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David Fiorella Shaye Moskowitz
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Vivek A Gonugunta Peter A Rasmussen
Edited by
Irene Katzan Raymond D Turner IV
Michael E Kelly Henry Woo Thomas J Masaryk
Peter A Rasmussen
Henry Woo
David Fiorella
9 781841 846071 www.informahealthcare.com
Endovascular Techniques
in the Management of
Cerebrovascular Disease
Edited by
Thomas J Masaryk
MD
Director, Section of Neuroradiology
The Imaging Institute;
Center for Cerebrovascular Disease
The Neurological Institute
The Cleveland Clinic
Cleveland, OH
USA
Peter A Rasmussen
MD
Director, Department of Neurological Surgery
Center for Cerebrovascular Disease
The Neurological Institute
The Cleveland Clinic
Cleveland, OH
USA
Henry Woo
MD
Director, Department of Neurological Surgery
Cerebrovascular Center
Stony Brook University Medical Center
Stony Brook, NY
USA
David Fiorella
MDPHD
Section of Neuroradiology
The Imaging Institute
The Center for Cerebrovascular Disease
The Neurological Institute
The Cleveland Clinic
Cleveland, OH
USA
© 2008 Informa UK Ltd
First published in the United Kingdom in 2008 by Informa Healthcare, Telephone House, 69–77 Paul Street, London EC2A 4LQ. Informa
Healthcare is a trading division of Informa UK Ltd. Registered Offi ce: 37/41 Mortimer Street, London W1T 3JH. Registered in England
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Library of Congress Cataloging-in-Publication Data
Data available on application
ISBN-10: 1 84184 607 4
ISBN-13: 978 1 84184 607 1
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Contents
List of contributors v
Preface vii
1. Imaging: informed decision-making 1
Bryson Borg, David Fiorella and Thomas J Masaryk
2. The angiography suite: diagnostic devices and maneuvers 27
David Fiorella and Thomas J Masaryk
3. Therapeutic options: pharmacology 43
David Fiorella and Vivek A Gonugunta
4. Embolic agents and materials, stents, delivery systems and retrieval devices 55
David Fiorella and Raymond D Turner IV
5. The role of endovascular therapies in acute ischemic stroke 71
Thomas J Masaryk, Shaye Moskowitz and Irene Katzan
6. Subacute and elective revascularization of the cerebral vasculature 87
Thomas J Masaryk, Irene Katzan and David Fiorella
7. Intracranial aneurysms and subarachnoid hemorrhage 111
Michael E Kelly, Peter A Rasmussen and Thomas J Masaryk
8. Vascular malformations 133
Henry Woo, David Fiorella, Michael E Kelly and Thomas J Masaryk
9. Venous disease: dural sinus thrombosis and occlusion 157
Raymond D Turner IV and Thomas J Masaryk
10. The decision-making process: treatment planning for cerebrovascular disease 171
Peter A Rasmussen
Index 181

Contributors
Bryson Borg M D Thomas J Masaryk M D
Department of Neuroradiology Section of Neuroradiology
Keesler Air Force Base The Imaging Institute
Biloxi, MS Center for Cerebrovascular Disease
USA The Neurological Institute
The Cleveland Clinic
David Fiorella MD PHD Cleveland, OH
Section of Neuroradiology USA
The Imaging Institute
Center for Cerebrovascular Disease Shaye Moskowitz MD PhD
The Neurological Institute Endovascular Surgical Neuroradiology
The Cleveland Clinic Center for Cerebrovascular Disease
Cleveland, OH The Neurological Institute
USA The Cleveland Clinic
Cleveland OH
USA
Vivek A Gonugunta M D FRCS
Endovascular Surgical Neuroradiology
Peter A Rasmussen MD
Center for Cerebrovascular Disease
Department of Neurological Surgery
The Neurological Institute
Center for Cerebrovascular Disease
The Cleveland Clinic
The Neurological Institute
Cleveland, OH
The Cleveland Clinic
USA
Cleveland, OH
USA
Irene Katzan M D
Department of Neurology Raymond D Turner IV M D
Center for Cerebrovascular Disease Endovascular Surgical Neuroradiology
The Neurological Institute Center for Cerebrovascular Disease
The Cleveland Clinic The Neurological Institute
Cleveland, OH The Cleveland Clinic
USA Cleveland, OH
USA
Michael E Kelly MD FRCSC
Endovascular Surgical Neuroradiology Henry Woo MD
Center for Cerebrovascular Disease Department of Neurological Surgery
The Neurological Institute Cerebrovascular Center
The Cleveland Clinic Stony Brook University Medical Center
Cleveland, OH Stony Brook, NY
USA USA

Preface
I n his biography of Cleveland native Harvey Cushing, John link between imaging and computers was strikingly powerful. . .
Fulton describes the fortuitous series of circumstances that my father had me hooked. I was extraordinarily fortunate to
conspired to create the specialty of neurological surgery. The continue to benefit from this confluence of technology with
compulsive and competitive Dr Cushing trained as a surgeon the help of Dr Ralph Alfidi and my colleagues Jeff Ross, Paul
under the precise tutelage of William Hallsted. On the recom- Ruggieri, and Mike Modic, and perhaps more importantly the
mendation of his friend and mentor, William Osler, Cushing indulgence of my wife, Midge, and our four daughters.
spent the year following completion of his surgical residency I ngenious innovators such as Serbinenko, Engleson, Guglielmi
traveling Europe. It was then, under the guidance of Professor and others have helped transform imaging from diagnostic
Theodor Kocher in the laboratory of Professor Hugo Kronecker adjunct to sophisticated guidance for definitive treatments (in a
in Berne, Switzerland, that Cushing described the relationship fashion analogous to the evolution of neurosurgical management
between intracranial pressure and systemic blood pressure hemostasis and intracranial pressure). Therapeutic devices will
regulated by the vasomotor center in the medulla that would continue to develop in parallel with advances in image guided
ultimately be known as the ‘Cushing reflex’. Prior to this time, techniques. Presently, many of these are complimentary to con-
vital signs (and in particular blood pressure) were not routinely ventional, open, neurosurgical procedures. As some techniques
charted during surgical procedures. Cushing continued his replace surgery, it seems unrealistic for radiologists to presume
experiments as he toured Europe, performing studies in dogs that surgeons will either watch idly or that, as imagers, they
in Professor Angelo Mosso’s laboratory in Turin, Italy. While can remain uninvolved in pre- and post-procedure care and
in Italy, Cushing was serendipitously introduced to Scipione follow-up. In this respect I have been blessed to work as a true
Riva-Rocci’s elegantly simple sphygmomanometer, which he team with Peter, Henry, and David as well as the dedicated nurses
promptly recognized as a significant addition to the operating and technologists in the angiography suite and the operating
room. Upon his return home the combination of his compulsive room at the Cleveland Clinic. Each contributes a unique and
personality, watchful (albeit indirect) management of systemic valuable skill set based on their training background; everyone
and intracranial pressure, and career-long obsession with hemo- recognizes that as a whole, the team functions better because
stasis (Cushing developed the silver hemoclip, and, with physicist of it . . . and (I truly believe) patients do better. In 2003 the
W Bovie, introduced electrocoagulation) precipitated the begin- group established the second formally credentialed fellowship in
ning of neurosurgical practice. Endovascular Surgical Neuroradiology. In our own way, we each
In 1979, I came to Cushing’s home town as a medical student felt that a new specialty had arrived.
at the suggestion of my father. A local medical imaging company, To each and every one, our sincerest thanks.
Technicare, had just installed their first commercial digital
subtraction angiography system at the Cleveland Clinic. Drs Paul
Duscheneau, Mickey Weinstein, and Michael Modic were furiously Thomas J Masaryk
imaging patients with the new device and publishing papers. The 2008
T eam photo. Front row: Dr Harvey Cushing. Back row (left to right): Drs Peter Rasmussen, David Fiorella, Thomas Masaryk,
Henry Woo.
1
Imaging: informed decision-making
Bryson Borg , D avid Fiorella and Thomas J Masaryk
N eurosurgery and neuroradiology have historically been CT scanning
complementary specialties: neurosurgery demands logical deci-
sion making and accurate therapeutic planning while diagnostic S hortly following Roentgen’ s discovery of the X-ray at the end
neuroradiology supplies ever more clinical data points through of the 19th century, Johan Rand, a Czech mathematician, began
the evolution and application of digital imaging technologies. publishing his treatises on line integrals. Allan Cormack postu-
Endovascular surgical neuroradiology (also known as endovascu- lated, and documented, that the attenuation of X-rays through an
lar neurosurgery) combines the clinical needs of the former with object could be represented by such mathematical modeling.7 , 8
the technical sophistication of the latter in a single specialty. The With the subsequent development and refinement of the analog-
importance of mastery of the imaging concepts as a prerequisite to-digital converter and the application of evolving computer
to expeditious, yet thoughtful, decision making and safe clinical technology, Godfrey Hounsfield produced the first transaxial
practice cannot be underestimated. tomographic maps of X-ray attenuation utilizing filtered back-
This is perhaps best exemplified in the setting of acute projection reconstruction in the early 1970s.9 In 1979 Hounsfield
stroke, where the operative word is indeed ‘expeditious ’ . and Cormack were awarded the Nobel Prize in Medicine.
Intravenous thrombolysis using simple, single-slice CT scanning W hile the basic principles of CT have remained the same,
became the only approved therapy in the USA for acute the engineering refinements have been impressive. Specifically,
ischemic stroke within the first 3 hours of onset on the basis the X-ray source and opposing detector continue to be mechani-
of the National Institute of Neurological Disorders and Stroke cally rotated about the patient but with broader coverage by the
rt-PA Stroke Study Group (the NINDS rt-PA Trial).1 Similar beam and detector at ever faster speeds of rotation. Eventually,
trials performed in Europe demonstrated no benefit to throm- data acquisition became so fast that the patient could be simply
bolytic therapy.2 – 4 A major difference in the trials was the time ‘pulled through ’ the scanner during rotation and completely
window for treatment: 3 hours in the North American study, isotropic three-dimensional data sets could be acquired utilizing
6 hours in Europe. Indeed, review of the US data demonstrates special ‘spiral reconstruction ’ methods. 10 Recent innovations
significantly better outcomes the sooner patients are treated using this technology have included small portable scanners
( Figure 1.1 ).5 designed for neurologic intensive care units, which move to
H ence the first caveat of acute stroke imaging: patients the bedside, and multi-row spiral scanners ( Figure 1.2a ).1 1 , 12
should be emergently transported to a facility with immediate Another exciting innovation is the high-end, vascular scanner
imaging capability and a mechanism in place for rapid, accurate with two X-ray sources and two sets of multi-row detectors.
interpretation. Pre-emptive warning should be provided to Such scanners may not only permit faster scanning, but also
the radiology department to facilitate imaging as rapidly as dual energy (‘subtracted ’ ) angiographic studies ( Figure 1.2b ).1 3
possible, regardless of the modality employed. National guide-
lines developed by the NINDS and adopted by the American
Heart Association (AHA) suggest that acute stroke patients
should be imaged within 20 minutes of initial arrival in the
emergency department. The importance of efficient, detailed,
CT scanning of the brain for
and accurate communication among the transport team, clinical
services, and radiology personnel cannot be overemphasized.
cerebrovascular disease
(Indeed, the medical – legal implications are so great that the
American College of Radiology has explicit recommendations
There are advantages and disadvantages to the use of CT scanning
regarding the documentation of the imaging and interpretation
in cerebrovascular disease. Advantages include:
process and the communication to the requesting service.)6
Familiarity with frequently used clinical scoring scales (Glasgow ■ ready accessibility
Coma Scale, National Institutes of Health Stroke Scale, Hunt – ■ rapid acquisition
Hess Grade) by the imaging service and conversely the imaging ■ high sensitivity to acute blood
signposts (hyperdense middle cerebral artery, decreased ■ h igh-quality vascular imaging of occlusions, stenoses, and
attenuation in greater than one-third of the vascular territory, aneurysms is obtainable with contemporary scanners
Fisher Score) by the clinical services greatly facilitate the decision- ■ three-dimensional stereotactic targeting
making process. ■ targeted relative perfusion maps.