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Papers by John Gaughen

Research paper thumbnail of Endovascular treatment of ophthalmic artery aneurysms: ophthalmic artery patency following flow diversion versus coil embolization

Journal of neurointerventional surgery, Jan 9, 2015

The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carot... more The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carotid artery aneurysms while maintaining patency of covered side branches. The purpose of this retrospective matched cohort study is to evaluate the effect of flow diversion on the patency of the ophthalmic artery when treating ophthalmic artery aneurysms. A retrospective review of our prospectively collected institutional database identified 19 ophthalmic artery aneurysms treated with a PED. These were matched according to aneurysm diameter in a 1:2 fashion to ophthalmic artery aneurysms treated via coil embolization, although it is important to note that there was a statistically significance difference in the neck diameter between the two groups (p=0.045). Clinical and angiographic outcomes were recorded and analyzed. On follow-up angiography, decreased flow through the ophthalmic artery was observed in 26% of the PED cohort and 0% of the coil embolization cohort (p=0.003). No ophthalmol...

Research paper thumbnail of Reduced-dose Iodinated Contrast Material Administration Yields Diagnostic Quality CTPA Studies Using 16-MDCT

PURPOSE Patients undergoing CTPA ordered from the emergency department are often lost to follow-u... more PURPOSE Patients undergoing CTPA ordered from the emergency department are often lost to follow-up, making the judicious use of potentially nephrotoxic contrast important in this setting. The purpose of our study was to compare a reduced dose to conventional dose protocol of iodinated contrast material in the evaluation of pulmonary embolism using 16-slice MDCT. METHOD AND MATERIALS In this retrospective case control study, 100 patients undergoing CTPA using 16-MDCT with 350mg/mL iodinated contrast were included. Group 1 (50 patients; age: 59 +/- 14 years; weight: 178 +/- 42 lbs) received a conventional dose of contrast during the scan delay and scan coverage time (mean dose: 84 +/- 12 mL). Group 2 (50 patients; age: 54 +/- 20 years; weight: 171 +/- 45 lbs) received contrast during the scan delay only (mean dose: 55 +/- 17 mL) with a saline flush during the scan. Quantitative analysis included ROI attenuation measurements of the right atrium and main, lobar, and segmental pulmonary ...

Research paper thumbnail of Stenting of symptomatic intracranial stenosis using balloon mounted coronary stents: a single center experience

Journal of neurointerventional surgery, 2015

Intracranial atherosclerotic disease is the cause of up to 10% of ischemic strokes and transient ... more Intracranial atherosclerotic disease is the cause of up to 10% of ischemic strokes and transient ischemic attacks. Intracranial stenting with off-label balloon mounted coronary stents (BMCS) may be a viable alternative for patients with symptomatic intracranial stenosis who fail best medical therapy. Between December 2005 and June 2012, 42 symptomatic intracranial stenoses were treated with a BMCS after failing medical management. Procedural records, clinical outcomes, and imaging follow-up were reviewed. Outcome measurements included technical success rate, morbidity and mortality, long term stent patency, and clinical outcomes, as measured by the modified Rankin Scale. The technical success rate was 98% (41 of 42 lesions). Morbidity within the first 30 days was 7.1% (three of 42 lesions). Overall morbidity, including both periprocedural and long term evaluation, was 9.5% (four of 42 lesions). There were no deaths. Follow-up imaging was available for 30 stents (71%) with an average...

Research paper thumbnail of DynaCT imaging for intraprocedural evaluation of flow-diverting stent apposition during endovascular treatment of intracranial aneurysms

Journal of Clinical Neuroscience, 2014

The treatment of large, complex intracranial aneurysms is being increasingly performed using flow... more The treatment of large, complex intracranial aneurysms is being increasingly performed using flowdiverting stents (FDS) such as the Pipeline Embolization Device (PED; ev3, Irvine, CA, USA). Malapposition of a FDS to the parent artery wall decreases the likelihood of aneurysm obliteration and increases the risk of both immediate and delayed complications. DynaCT scanning (Siemens Medical Solutions, Erlangen, Germany) is a novel imaging modality which uses a flat plane detector to generate CT images using the same C-arm employed for digital subtraction angiography. We present a 40-year-old woman with an unruptured, 11 mm cavernous internal carotid artery aneurysm who was treated with endovascular obliteration using a PED. Intraprocedural DynaCT scan performed after PED deployment demonstrated incomplete stent apposition to the parent vessel which could not be detected on digital subtraction angiography alone. Balloon angioplasty was performed to improve apposition of the stent to the vessel wall. There were no procedural or clinical complications. The aneurysm shrank in size at follow-up angiography 6 months after the procedure and will be monitored for progressive occlusion. While gross stent malapposition is readily evident after stent deployment, minor instances of malapposition may be undetectable by standard angiography. Therefore the use of DynaCT imaging may improve intraprocedural stent visualization and potentially avert long-term endovascular aneurysm treatment complications associated with inadequate stent apposition.

Research paper thumbnail of A method for complete angiographic obliteration of a brain arteriovenous malformation in a single session through a single pedicle

Journal of Clinical Neuroscience, 2015

Historically, the endovascular treatment of arteriovenous malformations (AVM) has largely been re... more Historically, the endovascular treatment of arteriovenous malformations (AVM) has largely been relegated to an adjunctive role to open surgical and radiosurgical methods. In this article, we describe a novel endovascular approach to the treatment of brain AVM using Onyx (ev3 Endovascular, Plymouth, MN, USA), which may allow for a complete angiographic obliteration in a single treatment session. Twelve patients underwent Onyx embolization of an AVM using a novel "reverse plug and push" technique in which a plug is formed around the treatment catheter prior to injecting Onyx into the AVM. The plug mitigates the risk of backflow and catheter entrapment, thereby allowing the user to inject higher volumes of Onyx at higher injection rates. Patient demographics, AVM characteristics, and treatment details were reviewed. Using the "reverse plug then push" technique, an average of 8.8 mL of Onyx was injected into the AVM in a single session. In every case, the microcatheter was removed easily with minimal traction pressure. Complete angiographic obliteration was achieved in 83% of patients after a single treatment. Morbidity and mortality were 8% each. The "reverse plug then push" technique allows for a more rapid injection of Onyx due to the formation of a well-controlled plug prior to treatment, mitigating the risk of catheter entrapment by Onyx reflux. With further refinement, this technique may present a viable curative option for treatment of select brain AVM.

Research paper thumbnail of Early Postmarket Results After Treatment of Intracranial Aneurysms With the Pipeline Embolization Device

Neurosurgery, 2012

The pipeline embolization device (PED) is the latest technology available for intracranial aneury... more The pipeline embolization device (PED) is the latest technology available for intracranial aneurysm treatment. To report early postmarket results with the PED. This study was a prospective registry of patients treated with PEDs at 7 American neurosurgical centers subsequent to Food and Drug Administration approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and periprocedural events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications. Sixty-two PED procedures were performed to treat 58 aneurysms in 56 patients. Thirty-seven of the aneurysms (64%) treated were located from the cavernous to the superior hypophyseal artery segment of the internal carotid artery; 22% were distal to that segment, and 14% were in the vertebrobasilar system. A total of 123 PEDs were deployed with an average of 2 implanted per aneurysm treated. Six devices were incompletely deployed; in these cases, rescue balloon angioplasty was required. Six periprocedural (during the procedure/within 30 days after the procedure) thromboembolic events occurred, of which 5 were in patients with vertebrobasilar aneurysms. There were 4 fatal postprocedural hemorrhages (from 2 giant basilar trunk and 2 large ophthalmic artery aneurysms). The major complication rate (permanent disability/death resulting from perioperative/delayed complication) was 8.5%. Among 19 patients with 3-month follow-up angiography, 68% (13 patients) had complete aneurysm occlusion. Two patients presented with delayed flow-limiting in-stent stenosis that was successfully treated with angioplasty. Unlike conventional coil embolization, aneurysm occlusion with PED is not immediate. Early complications include both thromboembolic and hemorrhagic events and appear to be significantly more frequent in association with treatment of vertebrobasilar aneurysms.

Research paper thumbnail of Persistent trigeminal artery: In situ thrombosis and associated perforating vessel infarction

Journal of Clinical Neuroscience, 2014

We report a patient with progressive brainstem infarction despite medical therapy. The patient wa... more We report a patient with progressive brainstem infarction despite medical therapy. The patient was transferred to our institution for potential angioplasty of basilar stenosis. Imaging review demonstrated persistent trigeminal artery in situ thrombosis and associated perforating vessel infarction. Persistent trigeminal arteries are commonly associated with an atretic basilar artery and interventional treatment can result in significant morbidity and mortality.

Research paper thumbnail of Endovascular treatment of ophthalmic artery aneurysms: ophthalmic artery patency following flow diversion versus coil embolization

Journal of neurointerventional surgery, Jan 9, 2015

The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carot... more The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carotid artery aneurysms while maintaining patency of covered side branches. The purpose of this retrospective matched cohort study is to evaluate the effect of flow diversion on the patency of the ophthalmic artery when treating ophthalmic artery aneurysms. A retrospective review of our prospectively collected institutional database identified 19 ophthalmic artery aneurysms treated with a PED. These were matched according to aneurysm diameter in a 1:2 fashion to ophthalmic artery aneurysms treated via coil embolization, although it is important to note that there was a statistically significance difference in the neck diameter between the two groups (p=0.045). Clinical and angiographic outcomes were recorded and analyzed. On follow-up angiography, decreased flow through the ophthalmic artery was observed in 26% of the PED cohort and 0% of the coil embolization cohort (p=0.003). No ophthalmol...

Research paper thumbnail of Randomized controlled trial of vertebroplasty versus kyphoplasty in the treatment of vertebral compression fractures

Journal of neurointerventional surgery, Jan 24, 2015

We present the results of a randomized controlled trial evaluating the efficacy of vertebroplasty... more We present the results of a randomized controlled trial evaluating the efficacy of vertebroplasty versus kyphoplasty in treating vertebral body compression fractures. Patients with vertebral body compression fractures were randomly assigned to treatment with kyphoplasty or vertebroplasty. Primary endpoints were pain (0-10 scale) and disability assessed using the Roland-Morris Disability Questionnaire (RMDQ). Outcomes were assessed at 3 days, 1 month, 6 months, and 1 year following the procedure. 115 subjects were enrolled in the trial with 59 (51.3%) randomly assigned to kyphoplasty and 56 (48.7%) assigned to vertebroplasty. Mean (SD) pain scores at baseline, 3 days, 30 days, and 1 year for kyphoplasty versus vertebroplasty were 7.4 (1.9) vs 7.9 (2.0), 4.1 (2.8) vs 3.7 (3.0), 3.4 (2.5) vs 3.6 (2.9), and 3.0 (2.8) vs 2.3 (2.6), respectively (p>0.05 at all time points). Mean (SD) RMDQ scores at baseline, 3 days, 30 days, 180 days, and 1 year were 17.3 (6.6) vs 16.3 (7.4), 11.8 (7.9...

Research paper thumbnail of 009 The necessity of intensive care unit monitoring following elective endovascular treatment of unruptured intracranial aneurysms

Journal of NeuroInterventional Surgery, 2009

Research paper thumbnail of P-006 Safety and Efficacy of Endovascular Treatment of Paraophthalmic Internal Carotid Artery Aneurysms

Journal of NeuroInterventional Surgery, 2013

Research paper thumbnail of E-017 Intracranial Stenting with Balloon Mounted Stents: Initial Safety and Long Term Follow up

Journal of NeuroInterventional Surgery, 2013

Research paper thumbnail of Direct comparison of Neuroform and Enterprise stents in the treatment of wide-necked intracranial aneurysms

Clinical radiology, 2014

To compare the complications and outcomes of Neuroform and Enterprise stents in the treatment of ... more To compare the complications and outcomes of Neuroform and Enterprise stents in the treatment of unruptured wide-necked aneurysms. Under the auspices of the institutional review board, a review of a prospectively collected patient log identified 130 patients who underwent elective stent-assisted coil embolization of a wide-necked aneurysm, including 53 patients treated with an Enterprise stent and 77 patients treated with a Neuroform stent. Immediate and long-term clinical and radiographic outcomes were recorded for all patients. All patient data were handled in accordance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. The technical success rate was 94%. Overall morbidity was 15% with Enterprise stents and 3% with Neuroform stents (p = 0.020). However, the type of stent used was not predictive of clinical outcomes as measured by the modified Rankin scale. In a multivariate analysis, the use of a Neuroform stent was one of the predictors of retr...

Research paper thumbnail of E-049 Intraprocedural Diagnosis of Flow-Diverting Stent Malapposition during Endovascular Aneurysm Treatment with DynaCT Imaging

Journal of neurointerventional surgery, 2014

The treatment of large, complex intracranial aneurysms is being increasingly performed using flow... more The treatment of large, complex intracranial aneurysms is being increasingly performed using flow-diverting stents (FDS) such as the Pipeline Embolization Device (PED). Malapposition of a FDS to the parent artery wall decreases the likelihood of aneurysm obliteration and increases the risk of both immediate and delayed complications. DynaCT is a novel imaging modality which uses a flat plane detector to generate computed tomography images using the same C-arm employed for digital subtraction angiography. We present a case of a 40 year-old female with a large, unruptured, cavernous internal carotid artery (ICA) aneurysm who was treated with endovascular obliteration using a PED. A 6 French Chaperon guide catheter was navigated into the left ICA through which subsequent control angiograms could be performed. Cerebral angiography showed a lobular, cavernous ICA aneurysm measuring 11 mm in maximal diameter with a wide 7.5 mm neck. An Excelsior XT-27 microcatheter advanced over an Asahi ...

Research paper thumbnail of E-038 CTA Protocol Optimization for Improved Stent Visualization

Journal of neurointerventional surgery, 2014

Evaluation of stents using noninvasive imaging can be difficult. Artefact from the metallic strut... more Evaluation of stents using noninvasive imaging can be difficult. Artefact from the metallic struts often limits visibility within the stent on computed tomography angiograms (CTA). Special techniques developed for visualization of cardiac stents using CTA can be adapted for cervical and intracranial stent evaluation. All studies were performed on a 64 slice GE Discovery 750HD CT scanner (GE Healthcare, Little Chalfont, Buckinghamshire, United Kingdom). The standard arterial phase imaging protocol is performed with 100 mL of contrast administered at a rate of 5 ml/sec. Scan acquisition is triggered when contrast arrives in the aortic arch. Scan coverage extends from the carina to the vertex of the head. Slice thickness is 0.625. Pitch is 1.375:1. Rotation time is 0.5 sec. Tube voltage is 120 kv with a dynamic tube current ranging from 200-350 mA. The raw images are then reconstructed through the stent using a bone plus algorithm at 0.625 mm x 0.3 mm and a field of view of 20 mm. Thre...

Research paper thumbnail of E-037 single center comparison of ophthalmic aneurysm treatment using pipeline embolization device versus coil embolization

Journal of neurointerventional surgery, 2014

Aneurysms arising from the ophthalmic segment of the internal carotid artery (ICA) account for ap... more Aneurysms arising from the ophthalmic segment of the internal carotid artery (ICA) account for approximately 5% of all intracranial aneurysms. The Pipeline Embolization Device (PED) is a relatively new device available for treatment of these aneurysms. Here, we compare our experience with PED versus coil embolization in the treatment of unruptured ophthalmic artery aneurysms. A review of our prospectively collected patient log identified 106 patients who had undergone endovascular treatment of an unruptured ophthalmic artery aneurysm. Blinded to outcome, PED and coil patients were matched in a 1:2 fashion, respectively, based on aneurysm size. Matched analysis was carried out with marched t-test, Wilcoxon rank sum test, and McNamara's test as appropriate. P-values of ≤ 0.05 were considered statistically significant. Statistical analysis was carried out with Stata 10.0 (College Station, TX). After matching the patients in a 1:2 fashion, there were 20 patients treated with PED and...

Research paper thumbnail of Vision outcomes and major complications after endovascular coil embolization of ophthalmic segment aneurysms

AJNR. American journal of neuroradiology

As aneurysms arising from the ophthalmic segment of the internal carotid artery increase in size,... more As aneurysms arising from the ophthalmic segment of the internal carotid artery increase in size, they can compress the optic nerve, prompting patients to present with visual disturbances. The purpose of this article is to describe the clinical and angiographic results with an emphasis on visual outcomes following the endovascular treatment of ophthalmic segment ICA aneurysms. The records of 1254 patients who presented for endovascular treatment of a cerebral aneurysm were retrospectively reviewed to identify 65 consecutive patients who underwent coil embolization of an ophthalmic segment ICA aneurysm. The clinical records, treatment reports, and imaging were reviewed with a focus on visual outcomes. Twenty-two of the 65 patients (34%) who presented for treatment of an ophthalmic aneurysm reported a visual disturbance at presentation. Fifteen of the 22 patients (68%) experienced an improvement in their symptoms after treatment. Overall, patients with visual symptoms were significant...

Research paper thumbnail of The therapeutic benefit of repeat percutaneous vertebroplasty at previously treated vertebral levels

AJNR. American journal of neuroradiology

Recurrent pain after vertebroplasty is relatively common, usually representing a new fracture at ... more Recurrent pain after vertebroplasty is relatively common, usually representing a new fracture at a different vertebral level. In a small cohort described herein, clinical and imaging findings indicated that recurrent pain arose from abnormality of the previously treated level. Our purpose was to demonstrate that repeat percutaneous vertebroplasty performed within the same fractured vertebra can offer therapeutic benefit for patients with recurrent pain after initial treatment. We conducted a retrospective review of consecutive vertebroplasty procedures performed at our institution to define a patient population that underwent repeat vertebroplasty for recurrent pain at previously treated vertebral levels. We identified six such patients over an 8-year period, and clinical outcomes were assessed through quantitative measurements of pre- and postoperative levels of pain and mobility. Initial vertebroplasty resulted in substantial improvement in pain in all six patients. Patients devel...

Research paper thumbnail of Lack of preoperative spinous process tenderness does not affect clinical success of percutaneous vertebroplasty

Journal of vascular and interventional radiology : JVIR, 2002

Some operators use the lack of point tenderness over compression fractures to exclude patients fr... more Some operators use the lack of point tenderness over compression fractures to exclude patients from undergoing percutaneous vertebroplasty procedures. The purpose of this study was to determine whether this lack of tenderness portends a poorer clinical outcome after vertebroplasty than is achieved in patients with such tenderness. The authors conducted a retrospective review of consecutive percutaneous vertebroplasty procedures performed at their institution to define two populations. Group 1 included 90 patients with tenderness to palpation over the spinous process of the fractured vertebra, whereas group 2 included 10 patients without such tenderness. This second group presented with back pain and demonstrated tenderness distant from the fracture (n = 5), tenderness lateral to the fracture (n = 4), or no focal tenderness at all (n = 1). All were treated because of edema seen on magnetic resonance (MR) imaging and/or increased activity on bone scan. Clinical outcomes were assessed ...

Research paper thumbnail of Relevance of antecedent venography in percutaneous vertebroplasty for the treatment of osteoporotic compression fractures

AJNR. American journal of neuroradiology, 2002

Controversy exists regarding the utility of antecedent venography in percutaneous vertebroplasty.... more Controversy exists regarding the utility of antecedent venography in percutaneous vertebroplasty. Our purpose was to determine whether antecedent venography improves clinical outcomes and/or decreases extravertebral cement extravasation in these procedures. We retrospective reviewed outcomes of consecutive percutaneous vertebroplasty procedures performed at our institution to define two populations, each consisting of 24 patients treated at 42 vertebral levels. Group 1 included patients who underwent antecedent venography, and group 2 included patients treated without venography. Clinical outcomes were assessed with quantitative measurements of pain and mobility. Venograms and postprocedural radiographs were interpreted to evaluate the number of vertebrae with extravertebral cement extravasation, degree of extravasation at each level, and correlation between venography and vertebroplasty. Pain improved in 19 of 20 group 1 patients, compared with 21 of 22 group 2 patients; mean posto...

Research paper thumbnail of Endovascular treatment of ophthalmic artery aneurysms: ophthalmic artery patency following flow diversion versus coil embolization

Journal of neurointerventional surgery, Jan 9, 2015

The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carot... more The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carotid artery aneurysms while maintaining patency of covered side branches. The purpose of this retrospective matched cohort study is to evaluate the effect of flow diversion on the patency of the ophthalmic artery when treating ophthalmic artery aneurysms. A retrospective review of our prospectively collected institutional database identified 19 ophthalmic artery aneurysms treated with a PED. These were matched according to aneurysm diameter in a 1:2 fashion to ophthalmic artery aneurysms treated via coil embolization, although it is important to note that there was a statistically significance difference in the neck diameter between the two groups (p=0.045). Clinical and angiographic outcomes were recorded and analyzed. On follow-up angiography, decreased flow through the ophthalmic artery was observed in 26% of the PED cohort and 0% of the coil embolization cohort (p=0.003). No ophthalmol...

Research paper thumbnail of Reduced-dose Iodinated Contrast Material Administration Yields Diagnostic Quality CTPA Studies Using 16-MDCT

PURPOSE Patients undergoing CTPA ordered from the emergency department are often lost to follow-u... more PURPOSE Patients undergoing CTPA ordered from the emergency department are often lost to follow-up, making the judicious use of potentially nephrotoxic contrast important in this setting. The purpose of our study was to compare a reduced dose to conventional dose protocol of iodinated contrast material in the evaluation of pulmonary embolism using 16-slice MDCT. METHOD AND MATERIALS In this retrospective case control study, 100 patients undergoing CTPA using 16-MDCT with 350mg/mL iodinated contrast were included. Group 1 (50 patients; age: 59 +/- 14 years; weight: 178 +/- 42 lbs) received a conventional dose of contrast during the scan delay and scan coverage time (mean dose: 84 +/- 12 mL). Group 2 (50 patients; age: 54 +/- 20 years; weight: 171 +/- 45 lbs) received contrast during the scan delay only (mean dose: 55 +/- 17 mL) with a saline flush during the scan. Quantitative analysis included ROI attenuation measurements of the right atrium and main, lobar, and segmental pulmonary ...

Research paper thumbnail of Stenting of symptomatic intracranial stenosis using balloon mounted coronary stents: a single center experience

Journal of neurointerventional surgery, 2015

Intracranial atherosclerotic disease is the cause of up to 10% of ischemic strokes and transient ... more Intracranial atherosclerotic disease is the cause of up to 10% of ischemic strokes and transient ischemic attacks. Intracranial stenting with off-label balloon mounted coronary stents (BMCS) may be a viable alternative for patients with symptomatic intracranial stenosis who fail best medical therapy. Between December 2005 and June 2012, 42 symptomatic intracranial stenoses were treated with a BMCS after failing medical management. Procedural records, clinical outcomes, and imaging follow-up were reviewed. Outcome measurements included technical success rate, morbidity and mortality, long term stent patency, and clinical outcomes, as measured by the modified Rankin Scale. The technical success rate was 98% (41 of 42 lesions). Morbidity within the first 30 days was 7.1% (three of 42 lesions). Overall morbidity, including both periprocedural and long term evaluation, was 9.5% (four of 42 lesions). There were no deaths. Follow-up imaging was available for 30 stents (71%) with an average...

Research paper thumbnail of DynaCT imaging for intraprocedural evaluation of flow-diverting stent apposition during endovascular treatment of intracranial aneurysms

Journal of Clinical Neuroscience, 2014

The treatment of large, complex intracranial aneurysms is being increasingly performed using flow... more The treatment of large, complex intracranial aneurysms is being increasingly performed using flowdiverting stents (FDS) such as the Pipeline Embolization Device (PED; ev3, Irvine, CA, USA). Malapposition of a FDS to the parent artery wall decreases the likelihood of aneurysm obliteration and increases the risk of both immediate and delayed complications. DynaCT scanning (Siemens Medical Solutions, Erlangen, Germany) is a novel imaging modality which uses a flat plane detector to generate CT images using the same C-arm employed for digital subtraction angiography. We present a 40-year-old woman with an unruptured, 11 mm cavernous internal carotid artery aneurysm who was treated with endovascular obliteration using a PED. Intraprocedural DynaCT scan performed after PED deployment demonstrated incomplete stent apposition to the parent vessel which could not be detected on digital subtraction angiography alone. Balloon angioplasty was performed to improve apposition of the stent to the vessel wall. There were no procedural or clinical complications. The aneurysm shrank in size at follow-up angiography 6 months after the procedure and will be monitored for progressive occlusion. While gross stent malapposition is readily evident after stent deployment, minor instances of malapposition may be undetectable by standard angiography. Therefore the use of DynaCT imaging may improve intraprocedural stent visualization and potentially avert long-term endovascular aneurysm treatment complications associated with inadequate stent apposition.

Research paper thumbnail of A method for complete angiographic obliteration of a brain arteriovenous malformation in a single session through a single pedicle

Journal of Clinical Neuroscience, 2015

Historically, the endovascular treatment of arteriovenous malformations (AVM) has largely been re... more Historically, the endovascular treatment of arteriovenous malformations (AVM) has largely been relegated to an adjunctive role to open surgical and radiosurgical methods. In this article, we describe a novel endovascular approach to the treatment of brain AVM using Onyx (ev3 Endovascular, Plymouth, MN, USA), which may allow for a complete angiographic obliteration in a single treatment session. Twelve patients underwent Onyx embolization of an AVM using a novel "reverse plug and push" technique in which a plug is formed around the treatment catheter prior to injecting Onyx into the AVM. The plug mitigates the risk of backflow and catheter entrapment, thereby allowing the user to inject higher volumes of Onyx at higher injection rates. Patient demographics, AVM characteristics, and treatment details were reviewed. Using the "reverse plug then push" technique, an average of 8.8 mL of Onyx was injected into the AVM in a single session. In every case, the microcatheter was removed easily with minimal traction pressure. Complete angiographic obliteration was achieved in 83% of patients after a single treatment. Morbidity and mortality were 8% each. The "reverse plug then push" technique allows for a more rapid injection of Onyx due to the formation of a well-controlled plug prior to treatment, mitigating the risk of catheter entrapment by Onyx reflux. With further refinement, this technique may present a viable curative option for treatment of select brain AVM.

Research paper thumbnail of Early Postmarket Results After Treatment of Intracranial Aneurysms With the Pipeline Embolization Device

Neurosurgery, 2012

The pipeline embolization device (PED) is the latest technology available for intracranial aneury... more The pipeline embolization device (PED) is the latest technology available for intracranial aneurysm treatment. To report early postmarket results with the PED. This study was a prospective registry of patients treated with PEDs at 7 American neurosurgical centers subsequent to Food and Drug Administration approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and periprocedural events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications. Sixty-two PED procedures were performed to treat 58 aneurysms in 56 patients. Thirty-seven of the aneurysms (64%) treated were located from the cavernous to the superior hypophyseal artery segment of the internal carotid artery; 22% were distal to that segment, and 14% were in the vertebrobasilar system. A total of 123 PEDs were deployed with an average of 2 implanted per aneurysm treated. Six devices were incompletely deployed; in these cases, rescue balloon angioplasty was required. Six periprocedural (during the procedure/within 30 days after the procedure) thromboembolic events occurred, of which 5 were in patients with vertebrobasilar aneurysms. There were 4 fatal postprocedural hemorrhages (from 2 giant basilar trunk and 2 large ophthalmic artery aneurysms). The major complication rate (permanent disability/death resulting from perioperative/delayed complication) was 8.5%. Among 19 patients with 3-month follow-up angiography, 68% (13 patients) had complete aneurysm occlusion. Two patients presented with delayed flow-limiting in-stent stenosis that was successfully treated with angioplasty. Unlike conventional coil embolization, aneurysm occlusion with PED is not immediate. Early complications include both thromboembolic and hemorrhagic events and appear to be significantly more frequent in association with treatment of vertebrobasilar aneurysms.

Research paper thumbnail of Persistent trigeminal artery: In situ thrombosis and associated perforating vessel infarction

Journal of Clinical Neuroscience, 2014

We report a patient with progressive brainstem infarction despite medical therapy. The patient wa... more We report a patient with progressive brainstem infarction despite medical therapy. The patient was transferred to our institution for potential angioplasty of basilar stenosis. Imaging review demonstrated persistent trigeminal artery in situ thrombosis and associated perforating vessel infarction. Persistent trigeminal arteries are commonly associated with an atretic basilar artery and interventional treatment can result in significant morbidity and mortality.

Research paper thumbnail of Endovascular treatment of ophthalmic artery aneurysms: ophthalmic artery patency following flow diversion versus coil embolization

Journal of neurointerventional surgery, Jan 9, 2015

The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carot... more The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carotid artery aneurysms while maintaining patency of covered side branches. The purpose of this retrospective matched cohort study is to evaluate the effect of flow diversion on the patency of the ophthalmic artery when treating ophthalmic artery aneurysms. A retrospective review of our prospectively collected institutional database identified 19 ophthalmic artery aneurysms treated with a PED. These were matched according to aneurysm diameter in a 1:2 fashion to ophthalmic artery aneurysms treated via coil embolization, although it is important to note that there was a statistically significance difference in the neck diameter between the two groups (p=0.045). Clinical and angiographic outcomes were recorded and analyzed. On follow-up angiography, decreased flow through the ophthalmic artery was observed in 26% of the PED cohort and 0% of the coil embolization cohort (p=0.003). No ophthalmol...

Research paper thumbnail of Randomized controlled trial of vertebroplasty versus kyphoplasty in the treatment of vertebral compression fractures

Journal of neurointerventional surgery, Jan 24, 2015

We present the results of a randomized controlled trial evaluating the efficacy of vertebroplasty... more We present the results of a randomized controlled trial evaluating the efficacy of vertebroplasty versus kyphoplasty in treating vertebral body compression fractures. Patients with vertebral body compression fractures were randomly assigned to treatment with kyphoplasty or vertebroplasty. Primary endpoints were pain (0-10 scale) and disability assessed using the Roland-Morris Disability Questionnaire (RMDQ). Outcomes were assessed at 3 days, 1 month, 6 months, and 1 year following the procedure. 115 subjects were enrolled in the trial with 59 (51.3%) randomly assigned to kyphoplasty and 56 (48.7%) assigned to vertebroplasty. Mean (SD) pain scores at baseline, 3 days, 30 days, and 1 year for kyphoplasty versus vertebroplasty were 7.4 (1.9) vs 7.9 (2.0), 4.1 (2.8) vs 3.7 (3.0), 3.4 (2.5) vs 3.6 (2.9), and 3.0 (2.8) vs 2.3 (2.6), respectively (p>0.05 at all time points). Mean (SD) RMDQ scores at baseline, 3 days, 30 days, 180 days, and 1 year were 17.3 (6.6) vs 16.3 (7.4), 11.8 (7.9...

Research paper thumbnail of 009 The necessity of intensive care unit monitoring following elective endovascular treatment of unruptured intracranial aneurysms

Journal of NeuroInterventional Surgery, 2009

Research paper thumbnail of P-006 Safety and Efficacy of Endovascular Treatment of Paraophthalmic Internal Carotid Artery Aneurysms

Journal of NeuroInterventional Surgery, 2013

Research paper thumbnail of E-017 Intracranial Stenting with Balloon Mounted Stents: Initial Safety and Long Term Follow up

Journal of NeuroInterventional Surgery, 2013

Research paper thumbnail of Direct comparison of Neuroform and Enterprise stents in the treatment of wide-necked intracranial aneurysms

Clinical radiology, 2014

To compare the complications and outcomes of Neuroform and Enterprise stents in the treatment of ... more To compare the complications and outcomes of Neuroform and Enterprise stents in the treatment of unruptured wide-necked aneurysms. Under the auspices of the institutional review board, a review of a prospectively collected patient log identified 130 patients who underwent elective stent-assisted coil embolization of a wide-necked aneurysm, including 53 patients treated with an Enterprise stent and 77 patients treated with a Neuroform stent. Immediate and long-term clinical and radiographic outcomes were recorded for all patients. All patient data were handled in accordance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. The technical success rate was 94%. Overall morbidity was 15% with Enterprise stents and 3% with Neuroform stents (p = 0.020). However, the type of stent used was not predictive of clinical outcomes as measured by the modified Rankin scale. In a multivariate analysis, the use of a Neuroform stent was one of the predictors of retr...

Research paper thumbnail of E-049 Intraprocedural Diagnosis of Flow-Diverting Stent Malapposition during Endovascular Aneurysm Treatment with DynaCT Imaging

Journal of neurointerventional surgery, 2014

The treatment of large, complex intracranial aneurysms is being increasingly performed using flow... more The treatment of large, complex intracranial aneurysms is being increasingly performed using flow-diverting stents (FDS) such as the Pipeline Embolization Device (PED). Malapposition of a FDS to the parent artery wall decreases the likelihood of aneurysm obliteration and increases the risk of both immediate and delayed complications. DynaCT is a novel imaging modality which uses a flat plane detector to generate computed tomography images using the same C-arm employed for digital subtraction angiography. We present a case of a 40 year-old female with a large, unruptured, cavernous internal carotid artery (ICA) aneurysm who was treated with endovascular obliteration using a PED. A 6 French Chaperon guide catheter was navigated into the left ICA through which subsequent control angiograms could be performed. Cerebral angiography showed a lobular, cavernous ICA aneurysm measuring 11 mm in maximal diameter with a wide 7.5 mm neck. An Excelsior XT-27 microcatheter advanced over an Asahi ...

Research paper thumbnail of E-038 CTA Protocol Optimization for Improved Stent Visualization

Journal of neurointerventional surgery, 2014

Evaluation of stents using noninvasive imaging can be difficult. Artefact from the metallic strut... more Evaluation of stents using noninvasive imaging can be difficult. Artefact from the metallic struts often limits visibility within the stent on computed tomography angiograms (CTA). Special techniques developed for visualization of cardiac stents using CTA can be adapted for cervical and intracranial stent evaluation. All studies were performed on a 64 slice GE Discovery 750HD CT scanner (GE Healthcare, Little Chalfont, Buckinghamshire, United Kingdom). The standard arterial phase imaging protocol is performed with 100 mL of contrast administered at a rate of 5 ml/sec. Scan acquisition is triggered when contrast arrives in the aortic arch. Scan coverage extends from the carina to the vertex of the head. Slice thickness is 0.625. Pitch is 1.375:1. Rotation time is 0.5 sec. Tube voltage is 120 kv with a dynamic tube current ranging from 200-350 mA. The raw images are then reconstructed through the stent using a bone plus algorithm at 0.625 mm x 0.3 mm and a field of view of 20 mm. Thre...

Research paper thumbnail of E-037 single center comparison of ophthalmic aneurysm treatment using pipeline embolization device versus coil embolization

Journal of neurointerventional surgery, 2014

Aneurysms arising from the ophthalmic segment of the internal carotid artery (ICA) account for ap... more Aneurysms arising from the ophthalmic segment of the internal carotid artery (ICA) account for approximately 5% of all intracranial aneurysms. The Pipeline Embolization Device (PED) is a relatively new device available for treatment of these aneurysms. Here, we compare our experience with PED versus coil embolization in the treatment of unruptured ophthalmic artery aneurysms. A review of our prospectively collected patient log identified 106 patients who had undergone endovascular treatment of an unruptured ophthalmic artery aneurysm. Blinded to outcome, PED and coil patients were matched in a 1:2 fashion, respectively, based on aneurysm size. Matched analysis was carried out with marched t-test, Wilcoxon rank sum test, and McNamara's test as appropriate. P-values of ≤ 0.05 were considered statistically significant. Statistical analysis was carried out with Stata 10.0 (College Station, TX). After matching the patients in a 1:2 fashion, there were 20 patients treated with PED and...

Research paper thumbnail of Vision outcomes and major complications after endovascular coil embolization of ophthalmic segment aneurysms

AJNR. American journal of neuroradiology

As aneurysms arising from the ophthalmic segment of the internal carotid artery increase in size,... more As aneurysms arising from the ophthalmic segment of the internal carotid artery increase in size, they can compress the optic nerve, prompting patients to present with visual disturbances. The purpose of this article is to describe the clinical and angiographic results with an emphasis on visual outcomes following the endovascular treatment of ophthalmic segment ICA aneurysms. The records of 1254 patients who presented for endovascular treatment of a cerebral aneurysm were retrospectively reviewed to identify 65 consecutive patients who underwent coil embolization of an ophthalmic segment ICA aneurysm. The clinical records, treatment reports, and imaging were reviewed with a focus on visual outcomes. Twenty-two of the 65 patients (34%) who presented for treatment of an ophthalmic aneurysm reported a visual disturbance at presentation. Fifteen of the 22 patients (68%) experienced an improvement in their symptoms after treatment. Overall, patients with visual symptoms were significant...

Research paper thumbnail of The therapeutic benefit of repeat percutaneous vertebroplasty at previously treated vertebral levels

AJNR. American journal of neuroradiology

Recurrent pain after vertebroplasty is relatively common, usually representing a new fracture at ... more Recurrent pain after vertebroplasty is relatively common, usually representing a new fracture at a different vertebral level. In a small cohort described herein, clinical and imaging findings indicated that recurrent pain arose from abnormality of the previously treated level. Our purpose was to demonstrate that repeat percutaneous vertebroplasty performed within the same fractured vertebra can offer therapeutic benefit for patients with recurrent pain after initial treatment. We conducted a retrospective review of consecutive vertebroplasty procedures performed at our institution to define a patient population that underwent repeat vertebroplasty for recurrent pain at previously treated vertebral levels. We identified six such patients over an 8-year period, and clinical outcomes were assessed through quantitative measurements of pre- and postoperative levels of pain and mobility. Initial vertebroplasty resulted in substantial improvement in pain in all six patients. Patients devel...

Research paper thumbnail of Lack of preoperative spinous process tenderness does not affect clinical success of percutaneous vertebroplasty

Journal of vascular and interventional radiology : JVIR, 2002

Some operators use the lack of point tenderness over compression fractures to exclude patients fr... more Some operators use the lack of point tenderness over compression fractures to exclude patients from undergoing percutaneous vertebroplasty procedures. The purpose of this study was to determine whether this lack of tenderness portends a poorer clinical outcome after vertebroplasty than is achieved in patients with such tenderness. The authors conducted a retrospective review of consecutive percutaneous vertebroplasty procedures performed at their institution to define two populations. Group 1 included 90 patients with tenderness to palpation over the spinous process of the fractured vertebra, whereas group 2 included 10 patients without such tenderness. This second group presented with back pain and demonstrated tenderness distant from the fracture (n = 5), tenderness lateral to the fracture (n = 4), or no focal tenderness at all (n = 1). All were treated because of edema seen on magnetic resonance (MR) imaging and/or increased activity on bone scan. Clinical outcomes were assessed ...

Research paper thumbnail of Relevance of antecedent venography in percutaneous vertebroplasty for the treatment of osteoporotic compression fractures

AJNR. American journal of neuroradiology, 2002

Controversy exists regarding the utility of antecedent venography in percutaneous vertebroplasty.... more Controversy exists regarding the utility of antecedent venography in percutaneous vertebroplasty. Our purpose was to determine whether antecedent venography improves clinical outcomes and/or decreases extravertebral cement extravasation in these procedures. We retrospective reviewed outcomes of consecutive percutaneous vertebroplasty procedures performed at our institution to define two populations, each consisting of 24 patients treated at 42 vertebral levels. Group 1 included patients who underwent antecedent venography, and group 2 included patients treated without venography. Clinical outcomes were assessed with quantitative measurements of pain and mobility. Venograms and postprocedural radiographs were interpreted to evaluate the number of vertebrae with extravertebral cement extravasation, degree of extravasation at each level, and correlation between venography and vertebroplasty. Pain improved in 19 of 20 group 1 patients, compared with 21 of 22 group 2 patients; mean posto...