SUMMARY: Five patients were found to have spontaneous delayed migration/shortening of their Pipeline Embolization Devices on follow-up angiography. The device migrated proximally in 4 patients and distally in 1 patient. One patient had a subarachnoid hemorrhage and died as a result of migration of the Pipeline Embolization Device, and another patient presented with complete MCA occlusion and was left severely disabled. Mismatch in arterial diameter between inflow and outflow vessels was a constant finding. Migration of the Pipeline Embolization Device was managed conservatively, with additional placement of the device, or with parent vessel occlusion. Obtaining complete expansion of the embolization device by using a longer device, increasing vessel coverage, using adjunctive aneurysm coiling, and avoiding dragging and stretching of the device are important preventive measures. Neurointerventionalists should be aware of this potentially fatal complication and take all necessary preventive measures. ABBREVIATIONS:PED ϭ Pipeline Embolization Device; SHA ϭ superior hypophyseal artery

BACKGROUND AND PURPOSE:Large and giant intracranial aneurysms are increasingly treated with endovascular techniques. The goal of this study was to retrospectively analyze the complications and long-term results of coiling in large and giant aneurysms (Ն10 mm) and identify predictors of outcome.

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BACKGROUND AND PURPOSE:The Pipeline Embolization Device has emerged as an important treatment option for intracranial aneurysms. The number of devices needed to treat an aneurysm is uncertain and is the subject of vigorous debate. The purpose of this study was to compare rates of complications, aneurysm occlusion, and outcome in patients treated with a single-versus-multiple Pipeline Embolization Devices.

Intracranial vertebral artery dissection (VAD) represents the underlying etiology in a significant percentage of posterior circulation ischemic strokes and subarachnoid hemorrhages. These lesions are particularly challenging in their diagnosis, management, and in the prediction of long-term outcome. Advances in the understanding of underlying processes leading to dissection, as well as the evolution of modern imaging techniques are discussed. The data pertaining to medical management of intracranial VADs, with emphasis on anticoagulants and antiplatelet agents, is reviewed. Surgical intervention is discussed, including, the selection of operative candidates, open and endovascular procedures, and potential complications. The evolution of endovascular technology and techniques is highlighted.

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IntroductionDiffusion weighted imaging (DWI) has its limitations, as evidenced in the literature by reports of variable sensitivity and accuracy. Increasingly, reports of the utility of CT perfusion (CTP) are being made in predicting acceptable thrombolysis candidates. This is being done by evaluating infarct core and discriminating ischemic territory from penumbra in the acute setting.MethodsA single institution, retrospective review of 21 patients who underwent multimodal endovascular intervention for stroke from January 2010 to 2011 was conducted after institutional review board approval. Immediate CTP of the head and neck was obtained in all cases upon admission. Posterior circulation stroke, lacunar infarcts, and those unable to undergo MRI post-operatively were excluded. Calculated volumes of the penumbra from CTP data were compared to post-operative MRI volumetric calculations of the completed infarct. This data was contrasted to 21 control patients that were excluded from intervention, but had CTP and MRI in the acute setting.ResultsEleven patients in the interventional group and 10 patients in the control group received intravenous tissue plasminogen activator. In both the control group and interventional groups, DWI studies obtained after multimodal recanalization in all patients demonstrated diffusion restriction in the infarct core. Varying volumes of diffusion restriction were seen in the penumbra. The mean difference calculated between the mismatch area on CTP and the correlating diffusion restriction on MRI was a decrease of 43.01 cm3 (p<0.05). In the interventional group, the area of restriction was less than the predicted mismatch area calculated. In the control group, 7 of the 21 patients (33%) had a net increase in the stroke territory. The calculated mean difference between the mismatch on CTP and the diffusion restriction on MRI was a decrease of 14.12 cm3 (p<0.05).ConclusionsDWI and CTP are useful tools in the assessment of ischemic stroke patients in the acute interventional setting. By comparing mismatch on CTP to MRI diffusion restriction after endovascular intervention, we show a decreased conversion of penumbra to stroke than in the patients undergoing medical management alone. Larger, prospective studies with quantitative metrics are necessary for further evaluation of stroke patients.Competing interestsNone.

outcome was defined as 1-3 months modified Rankin Scale (mRS). All patients were divided into three group based on their follow up mRS. Patients with mRS 0-2, patients with mRS 3-5 and patients with mRS 6. Results A total of 66 patients with stenosis or occlusion of posterior circulation presenting with acute ischemic stroke were identified. Out of 66, complete imaging review of 52 patients was completed. Out of 52, no BAO occlusion or high grade stenosis was identified in 11 patients on vascular imaging. In 8 patients, there was no follow up mRS score or baseline vascular imaging available. Thirty two patients were included in the final analysis, out of which, 10 patients were mRS 0-2 group, 6 patients were in mRS 3-5 group and 16 patient were in mRS 6 group (see Table 1). Mean age in both groups was 64.7, 51.6 and 69.2 years respectively with male predominance. Hypertension was the most common baseline comorbidity in all groups. In mRS 6 group, 37.5% had occlusion in vertebrobasilar junction. Thrombectomy was performed in 40%, 33.3% and 37.6% patients repectively. The last known well (LKW) to groin puncture time was increased in patients with mRS 6. Conclusion This retrospective analysis of BAO database depicts that older age, presence of HTN, history of prior stroke, location of clot at vertebrobasilar junction, and absence of bilateral posterior communicating arteries is associated with higher mortality. Moreover, delayed time to groin puncture was also observed in patients with higher mortality. Large scale studies are needed to validate these findings. Disclosures A.