59 e-Letters

  • No thromboembolic complications after Pipeline Embolization Device with Shield Technology treatment: the possible role of aneurysm size

    To the editor,

    With great interest we read the recent paper by Martinez-Galdámez et al. regarding the periprocedural outcomes and early safety after placement of a Pipeline Embolization Device with Shield Technology (PEDshield) (1). Evaluation of new endovascular devices, such as PEDshield, is of the utmost importance to give future users a chance to objectively review possible benefits for their clinical practice.

    In the study of Martinez-Galdámez et al. 76% of the target aneurysms were small (< 10 mm). It is known that small aneurysms are associated with a lower probability of thromboembolisms and ischemic stroke after flow diverter treatment than large and giant aneurysms (2,3). The size of the treated aneurysms, and not the PEDshield, might therefore explain the lack of thromboembolic complications reported in the study of Martinez-Galdámez et al. Selection bias might thus have led to the conclusion that the early safety of the PEDshield device is warranted.

    Furthermore, it is hard to understand why only 21 out of 50 patients (42%) underwent platelet reactivity testing, especially since the primary outcome measure focused on identifying thromboembolic complications in the territory supplied by the treated artery. To make matters worse: when platelet reactivity tests revealed the presence of hyporesponders, anti-platelet therapy was left unchanged in most cases. If thromboembolic complications do occur in the 6-month and 1-year follow-up of this...

    Show More
  • Interest of a balloon guide catheter in association with the CAPTIVE technique

    We have read with great interest the article describing the CAPTIVE technique for endovascular acute ischemic treatment by McTaggart et al.1. Firstly, we would like to commend the great clarity they used to describe the combination of distal aspiration and stent retriever to perform mechanical thrombectomy. Notably, they illustrated the rationale for aspiration prior to stent deployment as well as the removal of both distal aspiration catheter and stent as a single unit to decrease possible clot fragmentation.
    We adopt a very similar approach for most of our cases, although we would like to emphasize a slight variant that appears clinically interesting.

    In combination with stent retrievers, the balloon guide catheter (BGC) has been shown to improve the effectiveness of mechanical thrombectomy2, 3. In our experience, we typically use the CAPTIVE technique in association with a BGC which presents several potential advantages.
    Firstly, in cases of tortuous anatomy it provides excellent support for navigating the distal aspiration catheter. In addition, the balloon can be temporarily inflated at this stage to provide an anchoring effect in order to avoid potential push back of the guiding catheter4.
    Secondly, McTaggart et al. reported 5% embolization to new territory with the CAPTIVE technique; an equivalent rate to previous reports on distal aspiration with no stent retriever5. In an in vitro study, Chueh et al.6 demonstrated a significant decrease o...

    Show More
  • Aspiration with distal filter protection: an effective management for carotid floating thrombus

    To the editor,

    Giragani S et al. (published online 25 January 2017) described a remarkable case of recurrent transient ischemic attacks (TIA) due to carotid free floating thrombus. They successfully used stentriever with distal filter protection in retrieving the thrombus.

    Here we share a similar case of TIA with right common carotid artery (CCA) floating thrombus that was effectively managed with distal filter protection and aspiration. A 48-year-male with recurrent ischemic symptoms detected to have right CCA long segment floating thrombus (approximately 4.5 cm) extending upto right proximal external carotid artery.* Under general anaesthesia through right femoral route long sheath guiding catheter (Neuron Max 6F088; Penumbra, Inc. Alameda, USA) was placed in right proximal CCA. After parking the filter device (Spider FX 6mm; eV3, Plymouth, Minnesota, USA) at distal cervical segment, thrombus was aspirated using penumbra system (5MAX ACE, 132 cm; Penumbra, Inc. Alameda, USA).* Final check angiography showed 80 % reduction in clot burden .*

    Placing the filter protection device in the distal cervical segment does not protect thrombus migration to ECA, although it primarily prevent intracranial shower. In our index case thrombus fragment migrated to ECA, although it did not cause any neurological deficit. These cases highlight a novel technique to treat free floating thrombus.

    *Representative image available.

  • Transcranial antegrade approach for the treatment of dural sinus thrombosis

    With interest, I read this article and the authors' claim that their technique has not been previously described. A cursory search using PubMed would have shown that we described this approach almost 30 years ago:

    Treatment of dural sinus thrombosis with local urokinase infusion. Case report. Scott JA, Pascuzzi RM, Hall PV, Becker GJ. J Neurosurg. 1988 Feb;68(2):284-7.

  • Re: Letter to the Editor
    Felipe C. Albuquerque

    We appreciate the letter in response to our study and would like to offer the following. First and foremost, it is obvious the authors of the letter feel that this study is an indictment of chiropractic care or spinal manipulation. To the neurosurgical and neurointerventional community, it should be clear that this study downplays any potential causality between chiropractic care and extracranial vessel dissection, as the study...

    Show More
  • Letter to the Editor
    Peter Tuchin

    To the editor,

    We would like to raise some issues regarding the Moon et al article "Stroke prevention by endovascular treatment of carotid and vertebral artery dissections", recently published in Neurointerventional Surgery.1 We commend the authors for conducting research in the important area of cervical artery dissection. Their study confirms that cervical artery dissection is a very rare condition, with the...

    Show More
  • Comment on “Delayed enhancing lesions after coil embolization of aneurysms: clinical experience and benchtop analyses”

    We read with interest the article entitled: “Delayed enhancing lesions after coil embolization of aneurysms: clinical experience and benchtop analyses” by Oh et al [1]. This interesting case series deals with a recently described complication of intracranial endovascular procedures [2–8]: delayed enhancing lesions (DELs), also known as NICE (non-ischemic cerebral enhancing) lesions [8]. This rare complication consists in delayed appearance of cortical leptomeningeal enhancement associated with vasogenic subcortical edema [8]. The authors describe 3 more cases, in addition to the 19 previously reported [8]. We congratulate the authors for their efforts to understand the mechanism of this rare complication by performing benchtop tests.
    Numerous hypotheses have been proposed to explain this complication.
    First, an allergic reaction to nickel has been suggested [4,7]. In a series we recently published in Neuroradiology [8], we did not find any allergic reaction to the devices used for the embolization of the patients who presented NICE lesions. The fact that, in the series of Oh et al [1], none of the three patients had an allergic background, seems to confirm the absence of any relationship between these lesions and allergy.
    The second hypothesis is a reaction to foreign bodies (catheter coating) released during the embolization. We do believe that, according to our experience [8] and to the data of the literature [2,3,5,6], these lesions are more likely to...

    Show More
  • Re:Comment on The Medina Embolic Device: early clinical experience from a single center
    Marta Aguilar Perez

    We would like to thank our colleagues for reading our publication and for the thorough review of the paper. We greatly look forward to reading their own experience and believe that it will add substantially to the literature on this new and interesting device.

    At the outset we would like to make it clear that we stand by our initial comment in saying that we believe the combination of a MED and other devices,...

    Show More
  • Thrombectomy in low NIHSS stroke - a diagnostic and therapeutic challenge
    Anselm Angermaier

    We read with great interest the article of Haussen et al. 1 outlining the problem of identifying patients with minor stroke symptoms (low NIHSS) despite proximal vessel occlusion who should undergo thrombectomy. Intension-to-treat analysis showed significantly higher reduction of stroke severity in the primary thrombectomy group compared to the medical group. But more interestingly, per-protocol analysis revealed a high propo...

    Show More
  • Use of flat panal angio CT for navigation through a stent
    Gerhard Schroth

    Thank you for your technical considerations regarding stent in stent placement without hooking the first stent.

    Use of 3 D Roadmap may be helpful. Moreover, following passage of the microwire, reconstructions of a second flat panel angioCT with the microwire in place clearly outlines the relationship between the microwire and the struts of the first stent, especially if reconstructions perpendicular to the orientati...

    Show More