To study the pathophysiology of early CT signs. Early CT signs, due to an increase in tissue wate... more To study the pathophysiology of early CT signs. Early CT signs, due to an increase in tissue water content, are commonly attributed to cytotoxic edema and development of irreversible injury. This may have important implications for thrombolysis. In patients with acute ischemic stroke in the middle cerebral artery territory, the areas of early CT signs and diffusion weighted imaging (DWI) hypersignal were independently assessed and drawn on a standardized atlas. Then, patients were classified into three groups (early CT signs larger than, similar to or smaller than DWI hypersignal) and compared with perfusion weighted imaging (PWI). Of 16 patients, CT scanning was performed with a median time of 3 h after onset and early CT scan signs were recorded in 10/16 patients (62.5%). DWI signal hyperintensity was present in 15/16 (94%) patients. In 7/16 (43%) patients, the area with early CT scan signs was larger than the DWI lesion ('CT-larger group'). Only in 2/16 (12%) patients wer...
Recanalization of the occluded artery is a powerful predictor of good outcome in acute ischemic s... more Recanalization of the occluded artery is a powerful predictor of good outcome in acute ischemic stroke secondary to large artery occlusions. Mechanical thrombectomy with stent-trievers results in higher recanalization rates and better outcomes compared to previous devices. However, despite successful recanalization rates (Treatment in Cerebral Infarction, TICI, score ≥ 2b) between 70 and 90%, good clinical outcomes assessed by modified Rankin Scale (mRS ≥ 2 is present in 40-50% of patients. We aimed to evaluate predictors of poor outcomes (mRS ≥ 2) despite successful recanalization (TICI ≥ 2b) in the acute stroke patients treated with the Solitaire device of the North American Solitaire Stent Retriever Acute Stroke (NASA) registry.
Peer review of scientific articles submitted for publication has been such an integral component ... more Peer review of scientific articles submitted for publication has been such an integral component of innovation in science and medicine that participants (be they readers, reviewers, or editors) seldom consider its complexity. Not surprisingly, much has been written about scientific peer review. The aim of this report is to share some of the elements of that discourse with readers of the Journal of NeuroInterventional Surgery (JNIS).
The aim of this paper is to describe common complications during neurosurgical interventional pro... more The aim of this paper is to describe common complications during neurosurgical interventional procedures. We describe our experience and review the literature about how to avoid complications during diagnostic cerebral angiography and neurosurgical interventional procedures. Recent technological advances have expanded the therapeutic options of neuroendovascular interventions. However, with higher complexity there is also an increased risk of complications. Common complications include hematoma at the puncture site, arterial dissection and microembolism. Treatment of complex aneurysms and arteriovenous malformations involves a higher complication rate. Standardized training and operator's certification reduces the risk of complications. It is also important to work with specialized ancillary staff and to provide dedicated neurocritical care after the neuroendovascular intervention.
Recent trials suggest that angiotensin-converting enzyme inhibitors (ACEI) are effective in preve... more Recent trials suggest that angiotensin-converting enzyme inhibitors (ACEI) are effective in prevention of ischemic stroke, as measured by reduced stroke incidence. We aimed to compare stroke severity between stroke patients who were taking ACEI before their stroke onset and those who were not, to examine the effects of pretreatment with ACEI on ischemic stroke severity. We retrospectively studied 126 consecutive patients presenting within 24 hours of ischemic stroke onset, as confirmed by diffusion-weighted magnetic resonance imaging (DWI). We calculated the NIHSS score at presentation, as the primary measure of clinical stroke severity, and categorized stroke severity as mild (NIHSS [less than or equal to] 7), moderate (NIHSS 8-13) or severe (NIHSS [greater than or equal to] 14). We analyzed demographic data, risk-factor profile, blood pressure (BP) and medications on admissions, and determined stroke mechanism according to TOAST criteria. We also measured the volumes of admission ...
To correlate the findings on diffusion-weighted magnetic resonance (MR) images with the cytologic... more To correlate the findings on diffusion-weighted magnetic resonance (MR) images with the cytologic and histologic findings in ischemic tissue. A photochemical model of cerebral infarction in rats was studied with diffusion- and T2-weighted MR imaging. The development of lesions was followed from 20 minutes to 5 days after the onset of ischemia. Apparent water diffusion coefficient (ADC) maps were calculated and correlated with light and electron microscopic findings. T2-weighted images clearly showed vasogenic edema but did not enable distinction between areas with cellular damage and the surrounding edematous regions. In contrast, the ADC, which was elevated in nonischemic edematous regions, was diminished in areas with histologic evidence of ischemic damage or necrosis. In the core of the infarct, the ADC became elevated when electron microscopy revealed cellular lysis. Diffusion-weighted images may help ascertain the extent of cellular damage and death after stroke.
The aim of our study was to evaluate the safety and eficacy of the Pipeline endovascular device f... more The aim of our study was to evaluate the safety and eficacy of the Pipeline endovascular device for the treatment of anterior circulation aneurysms at the level of circle of Willis and beyond. A consecutive series of 23 patients with unruptured and 1 with ruptured anterior circulation aneurysms treated with Pipeline endovascular device. Complication rates, aneurysm obliteration, modified Rankin Scale (mRS) outcomes were assessed. All devices were placed properly, without technical difficulties. We found 1 minor clinical event (resolved within 7 days from procedure) and 1 major event (symptoms present after 7 days) (table), and no mortality. There were no aneurysm rupture or parenchymal haemorrhage during follow-up. The mRS at 3 and 6 months did not change from prior mRS in all cases but 1. We had 2 asymptomatic periprocedural ischemic events: 1 perforator stroke in the case of a recanalised A1-A2 where we used 2 PEDs, and 1 lacunar stroke. Both cases were discovered incidentally at the control CT predischarge. We had 3 intraprocedural complications, resolved without clinical consequences:1 acute branch occlusion during hypotension state which was solved after TA raise (case 4), 1 slow opacification of the inferior trunk of MCA resolved with intraarterial bolus of reopro (case 20), and 1 focal SAH secondary to distal perforation with the microwire during and exchange manoeuvre which was resolved with coil occlusion and glue at the level of the perforation, with no symptoms (case 14) Six-month follow-up angiograms were obtained in 16 aneurysms, showing complete occlusion in 9 and significantly decreased residual filling in 7. 5 cases are still pending on 6 months DSA and 1 case showed residual filling at the 3 months follow-up. Patency of PEDs and status of branches originating from the aneurysm sacs were evaluated in 17 and 11 angiograms respectively. All PEDs were patent, but we found 4 intrastent stenosis at 6 months DSA where only 1 symptomatic case (an angioplasty was done successfully). In the 11 branches evaluated, 7 were patent, 2 moderate reduced and in 2 cases were occluded asymptomatically. The PED provides a safe and effective solution for aneurysms at and beyond the circle of Willis. Preliminary results are promising but larger series with longer-term follow-up examinations are required to show the long-term safety and durability of this treatment alternative. M. Martínez-Galdámez: 2; C; Covidien. I. Linfante: 2; C; Covidien, Stryker, Codman. E. Lin: None. G. Dabus: 2; C; Covidien, Microvention, Reverse Medical.
Intracranial stenting with the Wingspan system has been used as a revascularization strategy in s... more Intracranial stenting with the Wingspan system has been used as a revascularization strategy in symptomatic patients with intracranial atherosclerotic disease (ICAD). The latest results of the Stenting versus Aggressive Medical Therapy for Intracranial Artery Stenosis (SAMMPRIS) trial challenge this approach. Our experience in the treatment of symptomatic ICAD with the Wingspan system is reported. Patients who underwent stenting for symptomatic ICAD were included in the analysis. Demographic data, periprocedural complications, long term radiological and clinical outcomes are reported. 46 lesions were treated in 45 patients. 13 patients (29%) presented with a transient ischemic attack and 32 (71%) with a stroke. 43 patients (95.5%) failed antithrombotic therapy at presentation. One (2%) symptomatic periprocedural (24 h) complication occurred. The 30 day incidence of stroke and vascular death was 6.6%--a fatal hemorrhagic stroke and two non-fatal hemorrhagic strokes. In-stent stenosis (≥50%) was seen in nine (42.8%) lesions, two were symptomatic. This cohort of patients with symptomatic ICAD who failed antithrombotic medications benefited from angioplasty and stenting with the Wingspan system.
International Journal of Pediatric Otorhinolaryngology Extra, 2011
ABSTRACT Tonsillectomy is a common surgical procedure performed in children. Post-tonsillectomy h... more ABSTRACT Tonsillectomy is a common surgical procedure performed in children. Post-tonsillectomy hemorrhage (PTH) may occur in 3% of surgeries. We report a case of PTH due to a pseudoaneurysm of the tonsillar branch of the ascending palatine artery. The pseudoaneurysm was identified by angiography and was treated by superselective embolization.
Arteriovenous fistulas of the scalp (S-AVFs) are rare lesions and may occur spontaneously or seco... more Arteriovenous fistulas of the scalp (S-AVFs) are rare lesions and may occur spontaneously or secondary to trauma. The use of Onyx for the treatment of S-AVFs is not well established at this time. We discuss three cases of traumatic S-AVFs treated successfully with Onyx embolization alone or in association with coils. The database of patients treated at the Baptist Cardiac and Vascular Institute, Miami, Florida, was reviewed. All patients with traumatic S-AVFs treated with Onyx were included. Two men and one woman with progressive enlarging pulsatile mass with bruit or tinnitus had angiographic evidence of S-AVF and were treated. In two patients the S-AVFs were secondary to hair transplantation. They were treated with Onyx-18 embolization as the single treatment modality. One patient with S-AVF resulting from temporomandibular joint arthroscopy was treated with coils and subsequent Onyx-34 embolization. In one patient, transarterial microcatheterization and injection of Onyx-18 was performed. In another patient, the intra-arterial approach was prevented by arterial vessel tortuosity. Therefore, access to the fistula was obtained through direct puncture of a large frontal vein; contrast injection confirmed the positioning of the needle within the draining vein of the AVF and Onyx-18 was then injected while the outflow vein was compressed. In the third patient in this series, coils were deployed to allow safer and more controlled injection of Onyx-34. No procedure related complications were noted. Post-embolization angiography demonstrated successful and complete occlusion of the AVF immediately after treatment. Follow-up revealed complete resolution of the symptoms. Our experience in this small series indicates that endovascular treatment of S-AVFs with Onyx is rapid, safe, and highly effective.
Carotid-basilar anastomoses are remnants of the fetal circulation and although rare, they may bec... more Carotid-basilar anastomoses are remnants of the fetal circulation and although rare, they may become symptomatic and should be recognized during cerebral angiography. Two patients are described with non-aneurysmal subarachnoid hemorrhage and persistent trigeminal arteries (PTA) found on cerebral angiography. In the first patient, the PTA ended in the anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery. The second patient had a PTA terminating in the AICA and superior cerebellar artery. These rare anatomical PTA variants should be recognized on cerebral angiography.
The clinical presentation and imaging of venous congestive encephalopathy (VCE) can mimic several... more The clinical presentation and imaging of venous congestive encephalopathy (VCE) can mimic several neurological conditions, making the diagnosis challenging. We report a patient with end stage renal disease on dialysis who presented with a right occipital infarction. The patient developed progressive encephalopathy and increased intracranial pressure. Extensive imaging, electroencephalography and serum analysis did not explain the cause of his infarction and progressive neurological deterioration. Finally, cerebral angiography and venography demonstrated severe generalized VCE due to arterial shunting from a right upper extremity arteriovenous graft (AVG) and an occluded right innominate venous trunk. The right arm shunt resulted in severe cerebral venous hypertension due to ipsilateral occlusion of the innominate venous trunk. After the AVG was repaired, the cerebral venous hypertension resolved and the patient returned to baseline.
To study the pathophysiology of early CT signs. Early CT signs, due to an increase in tissue wate... more To study the pathophysiology of early CT signs. Early CT signs, due to an increase in tissue water content, are commonly attributed to cytotoxic edema and development of irreversible injury. This may have important implications for thrombolysis. In patients with acute ischemic stroke in the middle cerebral artery territory, the areas of early CT signs and diffusion weighted imaging (DWI) hypersignal were independently assessed and drawn on a standardized atlas. Then, patients were classified into three groups (early CT signs larger than, similar to or smaller than DWI hypersignal) and compared with perfusion weighted imaging (PWI). Of 16 patients, CT scanning was performed with a median time of 3 h after onset and early CT scan signs were recorded in 10/16 patients (62.5%). DWI signal hyperintensity was present in 15/16 (94%) patients. In 7/16 (43%) patients, the area with early CT scan signs was larger than the DWI lesion ('CT-larger group'). Only in 2/16 (12%) patients wer...
Recanalization of the occluded artery is a powerful predictor of good outcome in acute ischemic s... more Recanalization of the occluded artery is a powerful predictor of good outcome in acute ischemic stroke secondary to large artery occlusions. Mechanical thrombectomy with stent-trievers results in higher recanalization rates and better outcomes compared to previous devices. However, despite successful recanalization rates (Treatment in Cerebral Infarction, TICI, score ≥ 2b) between 70 and 90%, good clinical outcomes assessed by modified Rankin Scale (mRS ≥ 2 is present in 40-50% of patients. We aimed to evaluate predictors of poor outcomes (mRS ≥ 2) despite successful recanalization (TICI ≥ 2b) in the acute stroke patients treated with the Solitaire device of the North American Solitaire Stent Retriever Acute Stroke (NASA) registry.
Peer review of scientific articles submitted for publication has been such an integral component ... more Peer review of scientific articles submitted for publication has been such an integral component of innovation in science and medicine that participants (be they readers, reviewers, or editors) seldom consider its complexity. Not surprisingly, much has been written about scientific peer review. The aim of this report is to share some of the elements of that discourse with readers of the Journal of NeuroInterventional Surgery (JNIS).
The aim of this paper is to describe common complications during neurosurgical interventional pro... more The aim of this paper is to describe common complications during neurosurgical interventional procedures. We describe our experience and review the literature about how to avoid complications during diagnostic cerebral angiography and neurosurgical interventional procedures. Recent technological advances have expanded the therapeutic options of neuroendovascular interventions. However, with higher complexity there is also an increased risk of complications. Common complications include hematoma at the puncture site, arterial dissection and microembolism. Treatment of complex aneurysms and arteriovenous malformations involves a higher complication rate. Standardized training and operator's certification reduces the risk of complications. It is also important to work with specialized ancillary staff and to provide dedicated neurocritical care after the neuroendovascular intervention.
Recent trials suggest that angiotensin-converting enzyme inhibitors (ACEI) are effective in preve... more Recent trials suggest that angiotensin-converting enzyme inhibitors (ACEI) are effective in prevention of ischemic stroke, as measured by reduced stroke incidence. We aimed to compare stroke severity between stroke patients who were taking ACEI before their stroke onset and those who were not, to examine the effects of pretreatment with ACEI on ischemic stroke severity. We retrospectively studied 126 consecutive patients presenting within 24 hours of ischemic stroke onset, as confirmed by diffusion-weighted magnetic resonance imaging (DWI). We calculated the NIHSS score at presentation, as the primary measure of clinical stroke severity, and categorized stroke severity as mild (NIHSS [less than or equal to] 7), moderate (NIHSS 8-13) or severe (NIHSS [greater than or equal to] 14). We analyzed demographic data, risk-factor profile, blood pressure (BP) and medications on admissions, and determined stroke mechanism according to TOAST criteria. We also measured the volumes of admission ...
To correlate the findings on diffusion-weighted magnetic resonance (MR) images with the cytologic... more To correlate the findings on diffusion-weighted magnetic resonance (MR) images with the cytologic and histologic findings in ischemic tissue. A photochemical model of cerebral infarction in rats was studied with diffusion- and T2-weighted MR imaging. The development of lesions was followed from 20 minutes to 5 days after the onset of ischemia. Apparent water diffusion coefficient (ADC) maps were calculated and correlated with light and electron microscopic findings. T2-weighted images clearly showed vasogenic edema but did not enable distinction between areas with cellular damage and the surrounding edematous regions. In contrast, the ADC, which was elevated in nonischemic edematous regions, was diminished in areas with histologic evidence of ischemic damage or necrosis. In the core of the infarct, the ADC became elevated when electron microscopy revealed cellular lysis. Diffusion-weighted images may help ascertain the extent of cellular damage and death after stroke.
The aim of our study was to evaluate the safety and eficacy of the Pipeline endovascular device f... more The aim of our study was to evaluate the safety and eficacy of the Pipeline endovascular device for the treatment of anterior circulation aneurysms at the level of circle of Willis and beyond. A consecutive series of 23 patients with unruptured and 1 with ruptured anterior circulation aneurysms treated with Pipeline endovascular device. Complication rates, aneurysm obliteration, modified Rankin Scale (mRS) outcomes were assessed. All devices were placed properly, without technical difficulties. We found 1 minor clinical event (resolved within 7 days from procedure) and 1 major event (symptoms present after 7 days) (table), and no mortality. There were no aneurysm rupture or parenchymal haemorrhage during follow-up. The mRS at 3 and 6 months did not change from prior mRS in all cases but 1. We had 2 asymptomatic periprocedural ischemic events: 1 perforator stroke in the case of a recanalised A1-A2 where we used 2 PEDs, and 1 lacunar stroke. Both cases were discovered incidentally at the control CT predischarge. We had 3 intraprocedural complications, resolved without clinical consequences:1 acute branch occlusion during hypotension state which was solved after TA raise (case 4), 1 slow opacification of the inferior trunk of MCA resolved with intraarterial bolus of reopro (case 20), and 1 focal SAH secondary to distal perforation with the microwire during and exchange manoeuvre which was resolved with coil occlusion and glue at the level of the perforation, with no symptoms (case 14) Six-month follow-up angiograms were obtained in 16 aneurysms, showing complete occlusion in 9 and significantly decreased residual filling in 7. 5 cases are still pending on 6 months DSA and 1 case showed residual filling at the 3 months follow-up. Patency of PEDs and status of branches originating from the aneurysm sacs were evaluated in 17 and 11 angiograms respectively. All PEDs were patent, but we found 4 intrastent stenosis at 6 months DSA where only 1 symptomatic case (an angioplasty was done successfully). In the 11 branches evaluated, 7 were patent, 2 moderate reduced and in 2 cases were occluded asymptomatically. The PED provides a safe and effective solution for aneurysms at and beyond the circle of Willis. Preliminary results are promising but larger series with longer-term follow-up examinations are required to show the long-term safety and durability of this treatment alternative. M. Martínez-Galdámez: 2; C; Covidien. I. Linfante: 2; C; Covidien, Stryker, Codman. E. Lin: None. G. Dabus: 2; C; Covidien, Microvention, Reverse Medical.
Intracranial stenting with the Wingspan system has been used as a revascularization strategy in s... more Intracranial stenting with the Wingspan system has been used as a revascularization strategy in symptomatic patients with intracranial atherosclerotic disease (ICAD). The latest results of the Stenting versus Aggressive Medical Therapy for Intracranial Artery Stenosis (SAMMPRIS) trial challenge this approach. Our experience in the treatment of symptomatic ICAD with the Wingspan system is reported. Patients who underwent stenting for symptomatic ICAD were included in the analysis. Demographic data, periprocedural complications, long term radiological and clinical outcomes are reported. 46 lesions were treated in 45 patients. 13 patients (29%) presented with a transient ischemic attack and 32 (71%) with a stroke. 43 patients (95.5%) failed antithrombotic therapy at presentation. One (2%) symptomatic periprocedural (24 h) complication occurred. The 30 day incidence of stroke and vascular death was 6.6%--a fatal hemorrhagic stroke and two non-fatal hemorrhagic strokes. In-stent stenosis (≥50%) was seen in nine (42.8%) lesions, two were symptomatic. This cohort of patients with symptomatic ICAD who failed antithrombotic medications benefited from angioplasty and stenting with the Wingspan system.
International Journal of Pediatric Otorhinolaryngology Extra, 2011
ABSTRACT Tonsillectomy is a common surgical procedure performed in children. Post-tonsillectomy h... more ABSTRACT Tonsillectomy is a common surgical procedure performed in children. Post-tonsillectomy hemorrhage (PTH) may occur in 3% of surgeries. We report a case of PTH due to a pseudoaneurysm of the tonsillar branch of the ascending palatine artery. The pseudoaneurysm was identified by angiography and was treated by superselective embolization.
Arteriovenous fistulas of the scalp (S-AVFs) are rare lesions and may occur spontaneously or seco... more Arteriovenous fistulas of the scalp (S-AVFs) are rare lesions and may occur spontaneously or secondary to trauma. The use of Onyx for the treatment of S-AVFs is not well established at this time. We discuss three cases of traumatic S-AVFs treated successfully with Onyx embolization alone or in association with coils. The database of patients treated at the Baptist Cardiac and Vascular Institute, Miami, Florida, was reviewed. All patients with traumatic S-AVFs treated with Onyx were included. Two men and one woman with progressive enlarging pulsatile mass with bruit or tinnitus had angiographic evidence of S-AVF and were treated. In two patients the S-AVFs were secondary to hair transplantation. They were treated with Onyx-18 embolization as the single treatment modality. One patient with S-AVF resulting from temporomandibular joint arthroscopy was treated with coils and subsequent Onyx-34 embolization. In one patient, transarterial microcatheterization and injection of Onyx-18 was performed. In another patient, the intra-arterial approach was prevented by arterial vessel tortuosity. Therefore, access to the fistula was obtained through direct puncture of a large frontal vein; contrast injection confirmed the positioning of the needle within the draining vein of the AVF and Onyx-18 was then injected while the outflow vein was compressed. In the third patient in this series, coils were deployed to allow safer and more controlled injection of Onyx-34. No procedure related complications were noted. Post-embolization angiography demonstrated successful and complete occlusion of the AVF immediately after treatment. Follow-up revealed complete resolution of the symptoms. Our experience in this small series indicates that endovascular treatment of S-AVFs with Onyx is rapid, safe, and highly effective.
Carotid-basilar anastomoses are remnants of the fetal circulation and although rare, they may bec... more Carotid-basilar anastomoses are remnants of the fetal circulation and although rare, they may become symptomatic and should be recognized during cerebral angiography. Two patients are described with non-aneurysmal subarachnoid hemorrhage and persistent trigeminal arteries (PTA) found on cerebral angiography. In the first patient, the PTA ended in the anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery. The second patient had a PTA terminating in the AICA and superior cerebellar artery. These rare anatomical PTA variants should be recognized on cerebral angiography.
The clinical presentation and imaging of venous congestive encephalopathy (VCE) can mimic several... more The clinical presentation and imaging of venous congestive encephalopathy (VCE) can mimic several neurological conditions, making the diagnosis challenging. We report a patient with end stage renal disease on dialysis who presented with a right occipital infarction. The patient developed progressive encephalopathy and increased intracranial pressure. Extensive imaging, electroencephalography and serum analysis did not explain the cause of his infarction and progressive neurological deterioration. Finally, cerebral angiography and venography demonstrated severe generalized VCE due to arterial shunting from a right upper extremity arteriovenous graft (AVG) and an occluded right innominate venous trunk. The right arm shunt resulted in severe cerebral venous hypertension due to ipsilateral occlusion of the innominate venous trunk. After the AVG was repaired, the cerebral venous hypertension resolved and the patient returned to baseline.
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Papers by Italo Linfante