Background: The utilization of flow diverters (FDs) in the treatment of high-flow Type A carotid cavernous fistulas (CCFs) has been described before mainly as an adjunct to the traditional endovascular techniques and rarely as a stand-alone treatment. In this study, we retrospectively evaluated our experience with FDs as the solo nonadjunctive treatment of Type A CCF with severe cortical venous reflux (CVR). Methods: A retrospective review was performed of patients with Type A CCFs who were treated using FDs' patch technique (PT). Patients' demographics, clinical data, and preoperative and postoperative ocular examination were recorded. The procedure technique, pipeline embolization device (PED) diameters, and immediate and late procedure outcomes were described. Results: Three patients were included in this case series. All patients had history of trauma and presented with decreased visual acuity, cranial nerve II deficit, limited extraocular muscles' movement, and increased intraocular pressure (IOP). Diagnostic angiography was performed, which confirmed high-flow Type A CCF. Endovascular treatment was performed through distal radial access in 2 patients and femoral access in 1 patient by deploying 4 sequentially enlarging PEDs with immediate resolution of the ocular symptoms. Follow-up angiography confirmed complete resolution of CCF in 2 patients. One patient was lost to follow-up; however, angiogram at 4 months demonstrated residual small CCF with significant improvement from postprocedure angiogram. Conclusions: The patch technique using sequentially enlarging FDs is a reasonable alternative solo technique for the treatment of direct CCF symptoms and results in immediate resolution of CVR while preserving the cavernous sinus anatomy.
Introduction: Atherosclerotic cervical ICA disease is one of the major causes of ischemic stroke. The risk of stroke from mild to moderate stenoses (i.e., <50% stenosis) might be underestimated. Further investigation is mandated to describe the association between high-risk plaque features and ESUS. Methods: This was a retrospective observational study. Using the stroke registry of our hospital's system between June 20th 2016 and June 20th 2021, we reviewed data for patients diagnosed with ESUS according to previously published definition criteria. Using CTA, we analyzed laterality of high-risk plaque features in relation to the stroke side, and then we identified the incidence of recurrent stroke events. Results: Out of 1779 patients with cryptogenic ischemic stroke, only 152 met the inclusion criteria for ESUS. We Compared high-risk plaque features ipsilateral to stroke side as to contralaterally. There were significantly more ulcerations defined as >1 mm depression (19.08% vs 5.26%, p<.0001), plaque thickness >3 mm (19.08% vs 7.24%, p=0.001), and plaque length >1cm (13.16% vs 5.92%, p=0.0218). Also, there was a significant difference in stenosis of ipsilateral to stroke when compared contralaterally, especially for stenoses of 10-30% and 31-49% (17.76% vs 10.53% and 5.26% vs 2.63%, respectively. p=0.0327). There was also a significant difference in plaque component; both components (soft and calcified) and only soft plaque (42.76% vs 23.68% and 17.76% vs 9.21%, respectively. p<.0001) were more prevalent ipsilaterally. In total, 17 patients were found to have a recurrent stroke event, 8 patients had an ipsilateral stroke to the index event, 7 had a bilateral and 2 had a contralateral event. Conclusion: ESUS is more commonly found ipsilateral to high-risk plaque features. The small number of our sample is definitely a limitation. Further large and multicenter studies aiming to form precise prediction models and scoring systems are needed to help guide treatment.
Introduction Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e., < 50% stenosis) might be underestimated, and further investigation is mandated to describe the association between high‐risk plaque features and ESUS. Methods This was a retrospective observational study. Using the stroke registry of our hospital’s system between June 20th 2016 and June 20th 2021. We reviewed data for patients diagnosed with ESUS according to previously published definition criteria. Using computed tomography angiography (CTA), we analyzed laterality of high‐risk plaque features in relation to the stroke side, and then we identified the incidence of recurrent stroke events. Results Out of 1779 patients with cryptogenic ischemic stroke, only 152 met the inclusion criteria for ESUS. We Compared high‐risk plaque features ipsilateral to stroke side as to contralaterally. There were significantly more ulcerations defined as >1 mm depression (19.08% vs 5.26%, p< .0001), plaque thickness >3 mm (19.08% vs 7.24%, p = 0.001), and plaque length >1cm (13.16% vs 5.92%, p = 0.0218).Also, there was a significant difference in stenosis of ipsilateral to stroke when compared contralaterally, especially for stenoses of 10–30% and 31–49% (17.76% vs 10.53% and 5.26% vs 2.63%, respectively. p = 0.0327). There was also a significant difference in plaque component; both components (soft and calcified) and only soft plaque (42.76% vs 23.68% and 17.76% vs 9.21%, respectively. p< .0001) were more prevalent ipsilaterally. In total, 17patients were found to have a recurrent stroke event, 8 patients had an ipsilateral stroke to the index event, 7 had a bilateral and 2 had a contralateral event. Conclusions ESUS is more commonly found ipsilateral to high‐risk plaque features. Qualitative assessment of plaque features using CTA could be easily implemented in clinical practice. The small number of our sample is definitely a limitation. Further large and multicenter studies aiming to form precise prediction models and scoring systems are needed to help guide treatment with carotid artery stenting or carotid endarterectomy versus maximizing medical therapy.
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