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Rouchaud A, Johnson CR, Thielen EP, Schroeder DJ, Ding YH, Dai D, Cebral J, Kallmes DF, Kadirvel R. Abstract WMP27: Differential Gene Expression in Coiled Versus Flow-diverter Treated Aneurysms: a RNA-Seq Analysis in Rabbit Aneurysm Model. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.wmp27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Numerous endovascular tools exist for the treatment of intracranial aneurysms with an increased use of flow-diverting devices in recent years. However, the biological mechanisms leading to aneurysm healing or potential complications such as delayed aneurysm ruptures after flow-diverter treatment are not yet well established. We used RNA-sequencing technology to identify genes relevant for biological impact of coils and flow-diverters in elastase-induced saccular aneurysms in rabbits and to identify genes and pathways of potential clinical interest.
Methods:
Elastase-induced saccular aneurysms were created at the origin of the right common carotid artery. Aneurysms were treated with coils (n=5) or flow-diverters (Pipeline Embolic Device, Covidien, CA) (n=4). Untreated aneurysms (n=6) were used as controls. Messenger RNA and microRNA were isolated from the aneurysms at 4 weeks following treatment. RNA samples were processed using RNA-seq technology. RNA-seq results were analyzed by using the Ingenuity Pathway Analysis tool.
Results:
Using RNA sequencing for coiled versus non-treated aneurysms, 464 genes were found to be differentially expressed with 58 genes down regulated and 406 genes up regulated. Using the same criteria for the flow-diverter treated aneurysms, 177 genes were found to be differentially expressed with 8 genes down regulated and 169 genes up regulated. Comparing coiled versus flow-diverter treated aneurysms, 13 genes were significantly differentially expressed with 8 down regulated and 5 up regulated genes. Genes identified with the highest interest for aneurysms healing were fibroblast growth factor-23, matrix metalloproteinases (MMP)-1, Scinderin and Basigin (implicated in MMP-2 and MMP-9 regulation). Pathway analysis associated these genes with inflammatory response, cellular migration, and coagulation, among other functions.
Conclusions:
RNA-sequencing analysis of rabbit aneurysms revealed differential regulation of some key pathways, including inflammation and cellular migration that could explain the different biological mechanisms implicated in aneurysms healing either after coiling or flow-diverter treatments and could explain potential device-related complications.
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Park MS, Kilburg C, Taussky P, Albuquerque FC, Kallmes DF, Levy EI, Jabbour P, Szikora I, Boccardi E, Hanel RA, Bonafé A, McDougall CG. Pipeline Embolization Device with or without Adjunctive Coil Embolization: Analysis of Complications from the IntrePED Registry. AJNR Am J Neuroradiol 2016; 37:1127-31. [PMID: 26767709 DOI: 10.3174/ajnr.a4678] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/18/2015] [Indexed: 12/18/2022]
Abstract
Flow diversion to treat cerebral aneurysms has revolutionized neurointerventional surgery. Because the addition of coils potentially increases the time and complexity of endovascular procedures, we sought to determine whether adjunctive coil use is associated with an increase in complications. Patients in the International Retrospective Study of Pipeline Embolization Device registry were divided into those treated with the Pipeline Embolization Device alone (n = 689 patients; n = 797 aneurysms; mean aneurysm size, 10.3 ± 7.6 mm) versus those treated with the Pipeline Embolization Device and concurrent coil embolization (n = 104 patients; n = 109 aneurysms; mean aneurysm size, 13.6 ± 7.8 mm). Patient demographics and aneurysm characteristics were examined. Rates of neurologic morbidity and mortality were compared between groups. The Pipeline Embolization Device with versus without coiling required a significantly longer procedure time (135.8 ± 63.9 versus 96.7 ± 46.2 min; P < .0001) and resulted in higher neurological morbidity (12.5% versus 7.8%; P = .13). These data suggest that either strategy represents an acceptable risk profile in the treatment of complex cerebral aneurysms and warrants further investigation.
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353
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Nasr DM, Brinjikji W, Rouchaud A, Kadirvel R, Flemming KD, Kallmes DF. Imaging Characteristics of Growing and Ruptured Vertebrobasilar Non-Saccular and Dolichoectatic Aneurysms. Stroke 2016; 47:106-12. [DOI: 10.1161/strokeaha.115.011671] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 10/22/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Vertebrobasilar, nonsaccular, and dolichoectatic aneurysms generally have a poor natural history. We performed a study examining the natural history of vertebrobasilar, nonsaccular, and dolichoectatic aneurysms receiving serial imaging and studied imaging characteristics associated with growth and rupture.
Methods—
We included all vertebrobasilar dolichoectatic, fusiform, and transitional aneurysms with serial imaging follow-up seen at our institution over a 15-year period. Two radiologists and a neurologist evaluated aneurysms for size, type, mural T1 signal, mural thrombus, daughter sac, mass effect, and tortuosity. Primary outcomes were aneurysm growth or rupture. Univariate analysis was performed with chi-squared tests for categorical variables and Student’s
t
test or analysis of variance for continuous variables. Multivariate logistic regression analysis was performed to identify variables independently associated with aneurysm growth or rupture.
Results—
One hundred and fifty-two patients with 542 patient-years (mean 3.6±3.5 years) of imaging follow-up were included. Aneurysms were fusiform in 45 cases (29.6%), dolichoectatic in 75 cases (49.3%), and transitional in 32 cases (21.1%). Thirty-five aneurysms (23.0%) grew (growth rate=6.5%/year). Eight aneurysms (5.3%) ruptured (rupture rate=1.5%/year). Variables associated with growth and rupture on univariate analysis were size >10 mm (57.6% versus 16.0%,
P
<0.0001), mural T1 signal (39.7% versus 16.3%,
P
=0.001), daughter sac (56.3% versus 21.3%), and mural thrombus (45.5% versus 13.4%,
P
<0.0001). 26.7% of fusiform aneurysms, 9.3% of dolichoectatic aneurysms, and 59.4% of transitional aneurysms grew or ruptured (
P
<0.0001). The only variable independently associated with rupture was transitional morphology (
P
=0.003).
Conclusions—
Vertebrobasilar, nonsaccular, and dolichoectatic aneurysms are associated with a poor natural history with high growth and rupture rates. Further research is needed to determine the best treatments for this disease.
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Rouchaud A, Johnson C, Thielen E, Schroeder D, Ding YH, Dai D, Brinjikji W, Cebral J, Kallmes DF, Kadirvel R. Differential Gene Expression in Coiled versus Flow-Diverter-Treated Aneurysms: RNA Sequencing Analysis in a Rabbit Aneurysm Model. AJNR Am J Neuroradiol 2015; 37:1114-21. [PMID: 26721773 DOI: 10.3174/ajnr.a4648] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 11/10/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE The biologic mechanisms leading to aneurysm healing or rare complications such as delayed aneurysm ruptures after flow-diverter placement remain poorly understood. We used RNA sequencing following implantation of coils or flow diverters in elastase aneurysms in rabbits to identify genes and pathways of potential interest. MATERIALS AND METHODS Aneurysms were treated with coils (n = 5) or flow diverters (n = 4) or were left untreated for controls (n = 6). Messenger RNA was isolated from the aneurysms at 4 weeks following treatment. RNA samples were processed by using RNA-sequencing technology and were analyzed by using the Ingenuity Pathway Analysis tool. RESULTS With RNA sequencing for coiled versus untreated aneurysms, 464/9990 genes (4.6%) were differentially expressed (58 down-regulated, 406 up-regulated). When we compared flow-diverter versus untreated aneurysms, 177/10,041 (1.8%) genes were differentially expressed (8 down-regulated, 169 up-regulated). When we compared flow-diverter versus coiled aneurysms, 13/9982 (0.13%) genes were differentially expressed (8 down-regulated, 5 up-regulated). Keratin 8 was overexpressed in flow diverters versus coils. This molecule may potentially play a critical role in delayed ruptures due to plasmin production. We identified overregulation of apelin in flow diverters, supporting the preponderance of endothelialization, whereas we found overexpression of molecules implicated in wound healing (dectin 1 and hedgehog interacting protein) for coiled aneurysms. Furthermore, we identified metallopeptidases 1, 12, and 13 as overexpressed in coiled versus untreated aneurysms. CONCLUSIONS We observed different physiopathologic responses after endovascular treatment with various devices. Flow diverters promote endothelialization but express molecules that could potentially explain the rare delayed ruptures. Coils promote wound healing and express genes potentially implicated in the recurrence of coiled aneurysms.
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Jamali S, Fahed R, Gentric JC, Letourneau-Guillon L, Raoult H, Bing F, Estrade L, Nguyen TN, Tollard É, Ferre JC, Iancu D, Naggara O, Chagnon M, Weill A, Roy D, Fox AJ, Kallmes DF, Raymond J. Inter- and Intrarater Agreement on the Outcome of Endovascular Treatment of Aneurysms Using MRA. AJNR Am J Neuroradiol 2015; 37:879-84. [PMID: 26659336 DOI: 10.3174/ajnr.a4609] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 09/14/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Patients treated with coiling are often followed by MR angiography. Our objective was to assess the inter- and intraobserver agreement in diagnosing aneurysm remnants and recurrences by using multimodality imaging, including TOF MRA. MATERIALS AND METHODS A portfolio composed of 120 selected images from 56 patients was sent to 15 neuroradiologists from 10 institutions. For each case, raters were asked to classify angiographic results (3 classes) of 2 studies (32 MRA-MRA and 24 DSA-MRA pairs) and to provide a final judgment regarding the presence of a recurrence (no, minor, major). Six raters were asked to independently review the portfolio twice. A second study, restricted to 4 raters having full access to all images, was designed to validate the results of the electronic survey. RESULTS The proportion of cases judged to have a major recurrence varied between 16.1% and 71.4% (mean, 35.0% ± 12.7%). There was moderate agreement overall (κ = 0.474 ± 0.009), increasing to nearly substantial (κ = 0.581 ± 0.014) when the judgment was dichotomized (presence or absence of a major recurrence). Agreement on cases followed-up by MRA-MRA was similarly substantial (κ = 0.601 ± 0.018). The intrarater agreement varied between fair (κ = 0.257 ± 0.093) and substantial (κ= 0.699 ± 0.084), improving with a dichotomized judgment concerning MRA-MRA comparisons. Agreement was no better when raters had access to all images. CONCLUSIONS There is an important variability in the assessment of angiographic outcomes of endovascular treatments. Agreement on the presence of a major recurrence when comparing 2 MRA studies or the MRA with the last catheter angiographic study can be substantial.
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356
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McDonald RJ, McDonald JS, Kallmes DF, Jentoft ME, Murray DL, Thielen KR, Williamson EE, Eckel LJ. Response. Radiology 2015; 277:925. [PMID: 26929976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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357
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Brinjikji W, Lanzino G, Cloft HJ, Siddiqui AH, Kallmes DF. Risk Factors for Hemorrhagic Complications following Pipeline Embolization Device Treatment of Intracranial Aneurysms: Results from the International Retrospective Study of the Pipeline Embolization Device. AJNR Am J Neuroradiol 2015; 36:2308-13. [PMID: 26251427 DOI: 10.3174/ajnr.a4443] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 05/10/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intraparenchymal hemorrhage is a dreaded complication of unknown etiology following flow-diversion treatment. Using the International Retrospective Study of the Pipeline Embolization Device registry, we studied demographic, aneurysm, and procedural characteristics associated with intraparenchymal hemorrhage following Pipeline Embolization Device treatment. MATERIALS AND METHODS We identified patients in the International Retrospective Study of the Pipeline Embolization Device registry with intraparenchymal hemorrhage unrelated to index aneurysm rupture post-Pipeline Embolization Device treatment. The rate of intraparenchymal hemorrhage was determined by baseline demographics, comorbidities, aneurysm characteristics, and procedural characteristics (including anticoagulation use, platelet testing, number of devices used, sheaths, catheters, and guidewires). Categoric variables were compared with χ(2) testing, and continuous variables were compared with the Student t test. RESULTS Of 793 patients with 906 aneurysms, 20 (2.5%) had intraparenchymal hemorrhage. Fifteen intraparenchymal hemorrhages (75.0%) occurred within 30 days of treatment (median, 5 days; range, 0-150 days). Nine patients with intraparenchymal hemorrhage (45.0%) died, 10 (50.0%) had major neurologic morbidity, and 1 had minor neurologic morbidity (5.0%). Intraparenchymal hemorrhage was ipsilateral to the Pipeline Embolization Device in 16 patients (80%) and contralateral in 3 patients (15.0%). Variables associated with higher odds of intraparenchymal hemorrhage included treatment of ruptured aneurysms (OR, 4.44; 95% CI, 1.65-11.94; P = .005) and the use of ≥ 3 Pipeline Embolization Devices (OR, 4.10; 95% CI, 1.34-12.58; P = .04). The Shuttle sheath was not associated with intraparenchymal hemorrhage (OR, 0.97; 95% CI, 0.38-2.45; P = .95). CONCLUSIONS Spontaneous intraparenchymal hemorrhage following Pipeline Embolization Device treatment is a rare-but-devastating complication, with nearly all patients having morbidity or mortality. Variables associated with intraparenchymal hemorrhage included the use of multiple Pipeline Embolization Devices and treatment of ruptured aneurysms. The Shuttle, a device that was previously thought to be associated with intraparenchymal hemorrhage, was not associated with it.
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358
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Rouchaud A, Brinjikji W, Cloft HJ, Kallmes DF. Endovascular Treatment of Ruptured Blister-Like Aneurysms: A Systematic Review and Meta-Analysis with Focus on Deconstructive versus Reconstructive and Flow-Diverter Treatments. AJNR Am J Neuroradiol 2015; 36:2331-9. [PMID: 26381557 DOI: 10.3174/ajnr.a4438] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/09/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Various endovascular techniques have been applied to treat blister-like aneurysms. We performed a systematic review to evaluate endovascular treatment for ruptured blister-like aneurysms. MATERIALS AND METHODS We performed a comprehensive literature search and subgroup analyses to compare deconstructive versus reconstructive techniques and flow diversion versus other reconstructive options. RESULTS Thirty-one studies with 265 procedures for ruptured blister-like aneurysms were included. Endovascular treatment was associated with a 72.8% (95% CI, 64.2%-81.5%) mid- to long-term occlusion rate and a 19.3% (95% CI, 13.6%-25.1%) retreatment rate. Mid- to long-term neurologic outcome was good in 76.2% (95% CI, 68.9%-8.4%) of patients. Two hundred forty procedures (90.6%) were reconstructive techniques (coiling, stent-assisted coiling, overlapped stent placement, flow diversion) and 25 treatments (9.4%) were deconstructive. Deconstructive techniques had higher rates of initial complete occlusion than reconstructive techniques (77.3% versus 33.0%, P = .0003) but a higher risk for perioperative stroke (29.1% versus 5.0%, P = .04). There was no difference in good mid- to long-term neurologic outcome between groups, with 76.2% for the reconstructive group versus 79.9% for the deconstructive group (P = .30). Of 240 reconstructive procedures, 62 (25.8%) involved flow-diverter stents, with higher rates of mid- to long-term complete occlusion than other reconstructive techniques (90.8% versus 67.9%, P = .03) and a lower rate of retreatment (6.6% versus 30.7%, P < .0001). CONCLUSIONS Endovascular treatment of ruptured blister-like aneurysms is associated with high rates of complete occlusion and good mid- to long-term neurologic outcomes in most patients. Deconstructive techniques are associated with higher occlusion rates but a higher risk of perioperative ischemic stroke. In the reconstructive group, flow diversion carries a higher level of complete occlusion and similar clinical outcomes.
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359
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Brinjikji W, Zhu YQ, Lanzino G, Cloft HJ, Murad MH, Wang Z, Kallmes DF. Risk Factors for Growth of Intracranial Aneurysms: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2015; 37:615-20. [PMID: 26611992 DOI: 10.3174/ajnr.a4575] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 07/21/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Understanding risk factors for intracranial aneurysm growth is important for patient management. We performed a meta-analysis examining risk factors for intracranial aneurysm growth in longitudinal studies and examined the association between aneurysm growth and rupture. MATERIALS AND METHODS We searched the literature for longitudinal studies of patients with unruptured aneurysms. We examined the associations of demographics, multiple aneurysms, prior subarachnoid hemorrhage, family history of aneurysm or subarachnoid hemorrhage, smoking, and hypertension; and aneurysm shape, size, and location with aneurysm growth. We studied the association between aneurysm growth and rupture. A meta-analysis was performed by using a random-effects model by using summary statistics from included studies. RESULTS Twenty-one studies including 3954 patients with 4990 aneurysms with 13,294 aneurysm-years of follow-up were included. The overall proportion of growing aneurysms was 3.0% per aneurysm-year (95% CI, 2.0%-4.0%). Patient risk factors for growth included age older than 50 years (3.8% per year versus 0.9% per year, P < .01), female sex (3.2% per year versus 1.3% per year, P < .01), and smoking history (5.5% per year versus 3.5% per year, P < .01). Characteristics associated with higher growth rates included cavernous carotid artery location (14.4% per year), nonsaccular shape (14.7% per year versus 5.2% per year for saccular, P < .01), and aneurysm size (P < .01). Aneurysm growth was associated with a rupture rate of 3.1% per year compared with 0.1% per year for stable aneurysms (P < .01). CONCLUSIONS Observational evidence provided multiple clinical and anatomic risk factors for aneurysm growth, including age older than 50 years, female sex, smoking history, and nonsaccular shape. These findings should be considered when counseling patients regarding the natural history of unruptured intracranial aneurysms.
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Rouchaud A, Brinjikji W, Gunderson T, Caroff J, Gentric JC, Lanzino G, Cloft HJ, Kallmes DF. Validity of the Meyer Scale for Assessment of Coiled Aneurysms and Aneurysm Recurrence. AJNR Am J Neuroradiol 2015; 37:844-8. [PMID: 26564443 DOI: 10.3174/ajnr.a4616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 09/18/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Both the Meyer and Raymond scales are commonly used to report angiographic outcomes following coil embolization of intracranial aneurysms. The objectives of this study were the following: 1) to assess the interobserver agreement of the Meyer and Raymond scales, and 2) to evaluate and compare their performance in predicting major recurrence at follow-up. MATERIALS AND METHODS A retrospective series of 120 coiled aneurysms was included. Four investigators independently graded DSA images immediately posttreatment and at follow-up according to the Meyer and Raymond scales. On follow-up DSA, readers also evaluated recurrence outcome. Interobserver agreement was assessed via the intraclass correlation coefficient. The ability of posttreatment Meyer and Raymond scales to predict major recurrence was modeled by using logistic regression and assessed by using receiver operating characteristic analysis. RESULTS For the Meyer scale, interobserver intraclass correlation coefficients were 0.58 (95% CI, 0.46-0.68) on posttreatment and 0.78 (95% CI, 0.72-0.83) on follow-up evaluations. For the Raymond scale, interobserver intraclass correlation coefficients were 0.50 (95% CI, 0.39-0.61) and 0.69 (95% CI, 0.62-0.76), respectively, for posttreatment and follow-up. The areas under the curve for the receiver operating characteristic analyses regarding the performance to predict major recurrence at follow-up were 0.69 (95% CI, 0.60-0.79) for the Meyer and 0.70 (95% CI, 0.61-0.78) for the Raymond scale. CONCLUSIONS The Meyer scale appears consistent and reliable with observer agreement as high or higher than that of the Raymond scale. Performance of both scales in predicting the risk of major recurrence at follow-up is adequate, with no statistical difference between the scales.
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361
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McDonald JS, Katzberg RW, McDonald RJ, Williamson EE, Kallmes DF. Is the Presence of a Solitary Kidney an Independent Risk Factor for Acute Kidney Injury after Contrast-enhanced CT? Radiology 2015; 278:74-81. [PMID: 26523492 DOI: 10.1148/radiol.2015142676] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE To determine whether patients with a solitary kidney are at higher risk for contrast material-induced acute kidney injury (AKI) than matched control patients with bilateral kidneys. MATERIALS AND METHODS This retrospective study was HIPAA compliant and approved by the institutional review board. Adult patients with bilateral kidneys or a solitary kidney from unilateral nephrectomy who underwent contrast material-enhanced computed tomography (CT) at this institution from January 2004 to August 2013 were identified. The effects of contrast material exposure on the rate of AKI--defined as an increase in maximal observed serum creatinine (SCr) level of either (a) ≥0.5 mg/dL (44.2 μmol/L) or (b) ≥0.3 mg/dL (26.52 μmol/L) or 50% over baseline within 24-72 hours of exposure--and 30-day post-CT emergent dialysis and death were determined after propensity score-based 1:3 matching of patients with solitary kidneys and control patients with bilateral kidneys. Differences in clinical characteristics and outcomes between the solitary and bilateral kidney groups were assessed by using the Wilcoxon rank sum test or Pearson χ(2) test prior to matching and by using conditional logistic regression after matching. RESULTS Propensity score matching yielded a cohort of 247 patients with solitary kidneys and 691 patients with bilateral kidneys. The rate of AKI was similar between the solitary and bilateral kidney groups (SCr ≥ 0.5 mg/dL AKI definition odds ratio = 1.11 [95% confidence interval {CI}: 0.65, 1.86], P = .70; SCr ≥ 0.3 mg/dL or 50% over baseline AKI definition odds ratio = 0.96 [95% CI: 0.41, 2.07], P = .99). The rate of emergent dialysis was rare and also similar between cohorts (odds ratio = 1.87 [95% CI: 0.16, 16.4], P = .61). Although the rate of mortality was higher in the solitary kidney group (odds ratio = 1.70 [95% CI: 1.06, 2.71], P = .0202), chart review showed that no death was attributable to AKI. CONCLUSION Our study did not demonstrate any significant differences in the rate of AKI, dialysis, or death attributable to contrast-enhanced CT in patients with a solitary kidney versus bilateral kidneys.
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362
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Brinjikji W, Shahi V, Cloft HJ, Lanzino G, Kallmes DF, Kadirvel R. Could Statin Use Be Associated with Reduced Recurrence Rates following Coiling in Ruptured Intracranial Aneurysms? AJNR Am J Neuroradiol 2015; 36:2104-7. [PMID: 26272974 DOI: 10.3174/ajnr.a4422] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 04/12/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE A number of studies have examined the role of matrix metalloproteinases in aneurysm healing following endovascular coiling. Because ruptured aneurysms are known to express higher levels of matrix metalloproteinases, we hypothesized that patients with subarachnoid hemorrhage who were on a statin at the time of coil embolization would have lower aneurysm recanalization and retreatment rates than patients not on statins. MATERIALS AND METHODS We performed a retrospective chart review of patients who underwent intrasaccular coil embolization of ruptured intracranial aneurysms of ≤10 mm with at least 6 months of imaging follow-up. Patients were separated into 2 groups: 1) those on an oral statin medication at the time of coiling, and 2) those who were not. Outcomes studied were aneurysm recurrence and aneurysm retreatment after endovascular coiling. Student t and χ(2) tests were used for statistical significance of differences between groups. RESULTS One hundred thirty-two patients with 132 ruptured aneurysms were included in our study. Sixteen were on statins (12.1%) and 116 were not (87.9%). The recurrence rate was 6.3% in the statin group (1/16) and 36.2% in the nonstatin group (42/107) (P = .02). Unplanned retreatment rates were 6.3% (1/16) for the statin group and 25.9% (30/116) for the nonstatin group (P = .08). CONCLUSIONS Statins were associated with a lower rate of aneurysm recurrence following endovascular coiling of small- and medium-sized ruptured aneurysms in this small retrospective study. Further studies are needed to confirm this finding to determine whether statins can be used to reduce recurrence rates in these aneurysms.
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Jarvik JG, Comstock BA, James KT, Avins AL, Bresnahan BW, Deyo RA, Luetmer PH, Friedly JL, Meier EN, Cherkin DC, Gold LS, Rundell SD, Halabi SS, Kallmes DF, Tan KW, Turner JA, Kessler LG, Lavallee DC, Stephens KA, Heagerty PJ. Lumbar Imaging With Reporting Of Epidemiology (LIRE)--Protocol for a pragmatic cluster randomized trial. Contemp Clin Trials 2015; 45:157-163. [PMID: 26493088 PMCID: PMC4674321 DOI: 10.1016/j.cct.2015.10.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/09/2015] [Accepted: 10/11/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Diagnostic imaging is often the first step in evaluating patients with back pain and likely functions as a "gateway" to a subsequent cascade of interventions. However, lumbar spine imaging frequently reveals incidental findings among normal, pain-free individuals suggesting that treatment of these "abnormalities" may not be warranted. Our prior work suggested that inserting the prevalence of imaging findings in patients without back pain into spine imaging reports may reduce subsequent interventions. We are now conducting a pragmatic cluster randomized clinical trial to test the hypothesis that inserting this prevalence data into lumbar spine imaging reports for studies ordered by primary care providers will reduce subsequent spine-related interventions. METHODS/DESIGN We are using a stepped wedge design that sequentially randomizes 100 primary care clinics at four health systems to receive either standard lumbar spine imaging reports, or reports containing prevalence data for common imaging findings in patients without back pain. We capture all outcomes passively through the electronic medical record. Our primary outcome is spine-related intervention intensity based on Relative Value Units (RVUs) during the following year. Secondary outcomes include subsequent prescriptions for opioid analgesics and cross-sectional lumbar spine re-imaging. DISCUSSION If our study shows that adding prevalence data to spine imaging reports decreases subsequent back-related RVUs, this intervention could be easily generalized and applied to other kinds of testing, as well as other conditions where incidental findings may be common. Our study also serves as a model for cluster randomized trials that are minimal risk and highly pragmatic.
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364
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Jagani M, Brinjikji W, Rouchaud AM, Cloft HJ, Kallmes DF. Capillary Index Score in acute ischemic stroke: interobserver reliability and correlation with neurological outcomes. J Neurosurg Sci 2015; 62:116-120. [PMID: 26512765 DOI: 10.23736/s0390-5616.17.03528-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Collateral blood flow has been identified as a possible factor to evaluate when predicting neurological outcomes or selecting patients for endovascular therapy in acute ischemic stroke. The Capillary Index Score (CIS) has recently been proposed as a tool to select patients with sufficient collateral blood flow for vascularization and to predict good neurological outcomes. We investigated the inter-rater agreement among reviewers of CIS and compared consensus scores to neurological outcomes. METHODS We conducted a retrospective review of 29 randomly selected patients undergoing endovascular therapy for an occlusion in the middle cerebral artery or intracranial internal carotid artery. Patients' angiograms were reviewed by four reviewers of varying experience levels and given a CIS ranging from 0-3. A favorable CIS was 2 or 3 and an unfavorable CIS was 0 or 1. The inter-agreement of the reviewers was calculated using the κ statistic. A consensus CIS was compared with good neurological outcome, defined as modified Rankin Scale scores (mRS≤2) at 90 days. RESULTS The agreement between reviewers for the CIS ranged from κ=0.66-0.97, indicating good to very good agreement. 92% of patients with favorable CIS had a positive neurological outcome compared to only 14% of unfavorable CIS patients. The number of patients with a favorable neurological outcome (mRS≤2) at 90 days was higher in the favorable CIS group (P<0.0001). CONCLUSIONS CIS was a reproducible metric among physicians of varying experiences. Favorable CIS scores were a predictor of good neurological outcome and lower rates of intracranial hemorrhage. We believe that the Capillary Index Score can be used alongside other tools to improve patient selection for endovascular treatment.
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McDonald RJ, McDonald JS, Carter RE, Hartman RP, Katzberg RW, Kallmes DF, Williamson EE. Response. Radiology 2015; 277:306-307. [PMID: 26668855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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366
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O'Keeffe DT, Mikhail MA, Lanzino G, Kallmes DF, Weinshenker BG. Corticosteroid-Induced Paraplegia—A Diagnostic Clue for Spinal Dural Arterial Venous Fistula. JAMA Neurol 2015; 72:833-4. [PMID: 26167899 DOI: 10.1001/jamaneurol.2015.0757] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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367
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Jagani M, Brinjikji W, Rabinstein AA, Pasternak JJ, Kallmes DF. Hemodynamics during anesthesia for intra-arterial therapy of acute ischemic stroke. J Neurointerv Surg 2015; 8:883-8. [DOI: 10.1136/neurintsurg-2015-011867] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 08/31/2015] [Indexed: 11/03/2022]
Abstract
Background and purposeMany studies have suggested a relationship between the type of anesthesia provided during intra-arterial therapy for acute ischemic stroke and patient outcomes. Variability in blood pressure and hypotension have previously been identified as possible reasons for worse outcomes in acute stroke. Our aim was to investigate hemodynamic parameters and neurological outcomes of patients receiving either general anesthesia or conscious sedation for intra-arterial therapy of acute stroke.MethodsWe performed a retrospective review of patients undergoing intra-arterial therapy from December 2008 to March 2015. Demographic data, baseline National Institutes of Health Stroke Scale score, preoperative physiological variables, procedural details, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate, and modified Rankin Scale scores were recorded.Results99 patients were included in the study, with 38 receiving general anesthesia and 61 receiving conscious sedation. Patients who received general anesthesia had a lower maximum SBP (p=0.02), minimum SBP (p<0.0001), minimum DBP (p<0.0001), and minimum MAP (p<0.0001). On multivariate analysis, general anesthesia was associated with lower minimum SBP (p=0.04), DBP (p=0.02), and MAP (p=0.007). Conscious sedation was associated with more favorable neurological outcomes (p=0.02). Patients with favorable neurological outcomes had a lower maximum variability in SBP (p=0.01) and MAP (p=0.03), as well as a higher minimum DBP (p=0.03).ConclusionsPatients with acute ischemic stroke undergoing intra-arterial therapy with general anesthesia had lower minimum SBP, DBP, and MAP, greater fluctuations in blood pressure, and less favorable outcomes. More studies are needed to examine the implications of variable and reduced blood pressures and neurological outcomes.
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368
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Brinjikji W, Rabinstein A, Cloft HJ, Lanzino G, Kallmes DF. Recently Published Stroke Trials: What the Radiologist Needs to Know. Radiology 2015; 276:8-11. [PMID: 26101918 DOI: 10.1148/radiol.2015150422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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369
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Brinjikji W, Diehn FE, Jarvik JG, Carr CM, Kallmes DF, Murad MH, Luetmer PH. MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2015; 36:2394-9. [PMID: 26359154 DOI: 10.3174/ajnr.a4498] [Citation(s) in RCA: 306] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/07/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Imaging features of spine degeneration are common in symptomatic and asymptomatic individuals. We compared the prevalence of MR imaging features of lumbar spine degeneration in adults 50 years of age and younger with and without self-reported low back pain. MATERIALS AND METHODS We performed a meta-analysis of studies reporting the prevalence of degenerative lumbar spine MR imaging findings in asymptomatic and symptomatic adults 50 years of age or younger. Symptomatic individuals had axial low back pain with or without radicular symptoms. Two reviewers evaluated each article for the following outcomes: disc bulge, disc degeneration, disc extrusion, disc protrusion, annular fissures, Modic 1 changes, any Modic changes, central canal stenosis, spondylolisthesis, and spondylolysis. The meta-analysis was performed by using a random-effects model. RESULTS An initial search yielded 280 unique studies. Fourteen (5.0%) met the inclusion criteria (3097 individuals; 1193, 38.6%, asymptomatic; 1904, 61.4%, symptomatic). Imaging findings with a higher prevalence in symptomatic individuals 50 years of age or younger included disc bulge (OR, 7.54; 95% CI, 1.28-44.56; P = .03), spondylolysis (OR, 5.06; 95% CI, 1.65-15.53; P < .01), disc extrusion (OR, 4.38; 95% CI, 1.98-9.68; P < .01), Modic 1 changes (OR, 4.01; 95% CI, 1.10-14.55; P = .04), disc protrusion (OR, 2.65; 95% CI, 1.52-4.62; P < .01), and disc degeneration (OR, 2.24; 95% CI, 1.21-4.15, P = .01). Imaging findings not associated with low back pain included any Modic change (OR, 1.62; 95% CI, 0.48-5.41, P = .43), central canal stenosis (OR, 20.58; 95% CI, 0.05-798.77; P = .32), high-intensity zone (OR = 2.10; 95% CI, 0.73-6.02; P = .17), annular fissures (OR = 1.79; 95% CI, 0.97-3.31; P = .06), and spondylolisthesis (OR = 1.59; 95% CI, 0.78-3.24; P = .20). CONCLUSIONS Meta-analysis demonstrates that MR imaging evidence of disc bulge, degeneration, extrusion, protrusion, Modic 1 changes, and spondylolysis are more prevalent in adults 50 years of age or younger with back pain compared with asymptomatic individuals.
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McDonald RJ, Schwartz KM, Eckel LJ, Diehn FE, Hunt CH, Bartholmai BJ, Erickson BJ, Kallmes DF. The effects of changes in utilization and technological advancements of cross-sectional imaging on radiologist workload. Acad Radiol 2015. [PMID: 26210525 DOI: 10.1016/j.acra.2015.05.007] [Citation(s) in RCA: 209] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
RATIONALE AND OBJECTIVES To examine the effect of changes in utilization and advances in cross-sectional imaging on radiologists' workload. MATERIALS AND METHODS All computed tomography (CT) and magnetic resonance imaging (MRI) examinations performed at a single institution between 1999 and 2010 were identified and associated with the total number of images for each examination. Annual trends in institutional numbers of interpreted examinations and images were translated to changes in daily workload for the individual radiologist by normalizing to the number of dedicated daily CT and MRI work assignments, assuming a 255-day/8-hour work day schedule. Temporal changes in institutional and individual workload were assessed by Sen's slope analysis (Q = median slope) and Mann-Kendall test (Z = Z statistic). RESULTS From 1999 to 2010, a total of 1,517,149 cross-sectional imaging studies (CT = 994,471; MRI = 522,678) comprising 539,210,581 images (CT = 339,830,947; MRI = 199,379,634) were evaluated at our institution. Total annual cross-sectional studies steadily increased from 84,409 in 1999 to 147,336 in 2010, representing a twofold increase in workload (Q = 6465/year, Z = 4.2, P < .0001). Concomitantly, the number of annual departmental cross-sectional images interpreted increased from 9,294,140 in 1990 to 94,271,551 in 2010, representing a 10-fold increase (Q = 8707876/year, Z = 4.5, P < .0001). Adjusting for staffing changes, the number of images requiring interpretation per minute of every workday per staff radiologist increased from 2.9 in 1999 to 16.1 in 2010 (Q = 1.7/year, Z = 4.3, P < .0001). CONCLUSIONS Imaging volumes have grown at a disproportionate rate to imaging utilization increases at our institution. The average radiologist interpreting CT or MRI examinations must now interpret one image every 3-4 seconds in an 8-hour workday to meet workload demands.
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Brinjikji W, Lanzino G, Cloft HJ, Siddiqui AH, Hanel RA, Kallmes DF. Platelet Testing is Associated with Worse Clinical Outcomes for Patients Treated with the Pipeline Embolization Device. AJNR Am J Neuroradiol 2015; 36:2090-5. [PMID: 26251435 DOI: 10.3174/ajnr.a4411] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/24/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The necessity for platelet-inhibition testing before aneurysm treatment in patients premedicated with antiplatelet agents is controversial. Using the International Retrospective Study of Pipeline Embolization Device registry, we studied complication rates in groups of patients who underwent platelet testing and those who did not undergo platelet testing to determine if these test results were associated with improved outcomes. MATERIALS AND METHODS Patients in the International Retrospective Study of Pipeline Embolization Device registry with an unruptured aneurysm were categorized as those who underwent platelet testing before Pipeline embolization device treatment or those who did not. Complication rates were compared by using the Fisher exact or Pearson χ(2) test. Multivariate analysis was performed to determine if platelet function testing was independently associated with poor outcomes after adjusting for age, number of devices and aneurysms, aneurysm location and size, and practitioner and center volume. RESULTS Compared with the patients who received a Pipeline embolization device without platelet testing, those who underwent platelet testing and Pipeline embolization device placement experienced higher rates of intracranial hemorrhage (0 of 187 [0.0%] vs 12 of 511 [2.3%], respectively; P = .04), neurologic morbidity (4 of 187 [2.1%] vs 42 of 511 [8.2%], respectively; P < .01), and combined neurologic morbidity and mortality (6 of 187 [3.2%] vs 45 of 511 [8.8%], respectively; P = .01). More patients in the platelet testing and Pipeline embolization device group were treated with multiple devices (227 [38.0%] vs 56 [27.8] patients, respectively; P = .01). On multivariate analysis, the group of patients who underwent platelet testing and Pipeline embolization device placement had higher odds of neurologic morbidity (OR, 3.25 [95% CI, 1.10-9.61]; P = .03). CONCLUSIONS Platelet testing in patients who undergo Pipeline embolization device placement is associated with higher rates of morbidity. Additional prospective studies are needed to determine if and when platelet testing in these patients is appropriate.
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McDonald JS, McDonald RJ, Lieske JC, Carter RE, Katzberg RW, Williamson EE, Kallmes DF. Risk of Acute Kidney Injury, Dialysis, and Mortality in Patients With Chronic Kidney Disease After Intravenous Contrast Material Exposure. Mayo Clin Proc 2015; 90:1046-53. [PMID: 26250726 PMCID: PMC4550308 DOI: 10.1016/j.mayocp.2015.05.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 05/08/2015] [Accepted: 05/22/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine the effect of intravenous iodinated contrast material administration on the subsequent development of acute kidney injury (AKI), emergent dialysis, and short-term mortality using a propensity score-adjusted analysis of computed tomographic scan recipients with chronic kidney disease (CKD). PATIENTS AND METHODS In this institutional review board-approved retrospective study, all patients with CKD who received a contrast-enhanced (contrast group) or unenhanced (noncontrast group) computed tomographic scan from January 1, 2000, to August 1, 2013 were identified. Patients were subdivided into CKD stage III (baseline estimated glomerular filtration rate, 30-59 mL/min per 1.73 m(2)) and CKD stage IV-V (baseline estimated glomerular filtration rate, <30 mL/min per 1.73 m(2)) subgroups and separately underwent propensity score generation, stratification, and 1:1 matching. Rates of AKI, 30-day emergent dialysis, and mortality were compared between contrast and noncontrast groups. Sensitivity analyses examining only patients with stable prescan serum creatinine levels and incorporating intravenous fluid administration at the time of the CT scan into the model were also performed. RESULTS A total of 6902 patients (4496 CKD stage III, matched: 1220 contrast and 1220 noncontrast; 2086 CKD stage IV-V, matched: 491 contrast and 491 noncontrast) were included in the study. After propensity score adjustment, rates of AKI, emergent dialysis, and mortality were not significantly higher in the contrast group than in the noncontrast group in either CKD subgroup (CKD stage III: OR, 0.65-1.00; P<.001-.99 and CKD stage IV-V: OR, 0.93-2.33; P=.22-.99). Both sensitivity analyses revealed similar results. CONCLUSION Intravenous contrast material administration was not associated with an increased risk of AKI, emergent dialysis, and short-term mortality in a cohort of patients with diminished renal function.
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Holcomb M, Ding YH, Dai D, McDonald RJ, McDonald JS, Kallmes DF, Kadirvel R. RNA-Sequencing Analysis of Messenger RNA/MicroRNA in a Rabbit Aneurysm Model Identifies Pathways and Genes of Interest. AJNR Am J Neuroradiol 2015; 36:1710-5. [PMID: 26228879 DOI: 10.3174/ajnr.a4390] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 01/30/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Rabbit aneurysm models are used for the testing of embolization devices and elucidating the mechanisms of human intracranial aneurysm growth and healing. We used RNA-sequencing technology to identify genes relevant to induced rabbit aneurysm biology and to identify genes and pathways of potential clinical interest. This process included sequencing microRNAs, which are important regulatory noncoding RNAs. MATERIALS AND METHODS Elastase-induced saccular aneurysms were created at the origin of the right common carotid artery in 6 rabbits. Messenger RNA and microRNA were isolated from the aneurysm and from the control left common carotid artery at 12 weeks and processed by using RNA-sequencing technology. The results from RNA sequencing were analyzed by using the Ingenuity Pathway Analysis tool. RESULTS A total of 9396 genes were analyzed by using RNA sequencing, 648 (6.9%) of which were found to be significantly differentially expressed between the aneurysms and control tissues (P < .05; false-discovery rate, <0.01; fold change, >2 or <.5). Of these genes, 614 were mapped successfully, 143 were down-regulated, and 471 were up-regulated in the aneurysms as compared with controls. Using the same criteria for significance, 3 microRNAs were identified as down-regulated and 5 were identified as up-regulated. Pathway analysis associated these genes with inflammatory response, cellular migration, and coagulation, among other functions and pathologies. CONCLUSIONS RNA-sequencing analysis of rabbit aneurysms revealed differential regulation of some key pathways, including inflammation and antigen presentation. ANKRD1 and TACR1 were identified as genes of interest in the regulation of matrix metalloproteinases.
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Brinjikji W, White PM, Nahser H, Wardlaw J, Sellar R, Gholkar A, Cloft HJ, Kallmes DF. HydroCoils Are Associated with Lower Angiographic Recurrence Rates Than Are Bare Platinum Coils in Treatment of "Difficult-to-Treat" Aneurysms: A Post Hoc Subgroup Analysis of the HELPS Trial. AJNR Am J Neuroradiol 2015; 36:1689-94. [PMID: 26228887 DOI: 10.3174/ajnr.a4349] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 01/30/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The HydroCoil Endovascular Aneurysm Occlusion and Packing Study was a randomized controlled trial that compared HydroCoils to bare platinum coils. Using data from this trial, we performed a subgroup analysis of angiographic and clinical outcomes of patients with "difficult-to-treat" aneurysms, defined as irregularly shaped and/or having a dome-to-neck ratio of <1.5. MATERIALS AND METHODS Separate subgroup analyses comparing outcomes of treatment with HydroCoils to that of bare platinum coils were performed for the following: 1) irregularly shaped aneurysms, 2) regularly shaped aneurysms, 3) aneurysms with a dome-to-neck ratio of <1.5, and 4) aneurysms with a dome-to-neck ratio of ≥1.5. For each subgroup analysis, the following outcomes were studied at the last follow-up (3-18 months): 1) any recurrence, 2) major recurrence, 3) re-treatment, and 4) an mRS score of ≤2. Multivariate logistic regression analysis was performed to determine if the HydroCoil was independently associated with improved outcomes in these subgroups. RESULTS Among the patients with an irregularly shaped aneurysm, the HydroCoil was associated with lower major recurrence rates than the bare platinum coils (17 of 66 [26%] vs 30 of 69 [44%], respectively; P = .046). Among the patients with an aneurysm with a small dome-to-neck ratio, the HydroCoil was associated with lower major recurrence rates than the bare platinum coils (18 of 73 [24.7%] vs 32 of 76 [42.1%], respectively; P = .02). No difference in major recurrence was seen between HydroCoils and bare platinum coils for regularly shaped aneurysms (42 of 152 [27.6%] vs 52 of 162 [32.1%], respectively; P = .39) or aneurysms with a large dome-to-neck ratio (41 of 145 [28.3%] vs 50 of 155 [32.3%], respectively; P = .53). CONCLUSIONS This unplanned post hoc subgroup analysis found that HydroCoils are associated with improved angiographic outcomes in the treatment of irregularly shaped aneurysms and aneurysms with a dome-to-neck ratio of <1.5. Because this was a post hoc analysis, these results are not reliable and absolutely should not alter clinical practice but, rather, may inform the design of future randomized controlled trials.
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Sahlein DH, Fouladvand M, Becske T, Saatci I, McDougall CG, Szikora I, Lanzino G, Moran CJ, Woo HH, Lopes DK, Berez AL, Cher DJ, Siddiqui AH, Levy EI, Albuquerque FC, Fiorella DJ, Berentei Z, Marosfoi M, Cekirge SH, Kallmes DF, Nelson PK. Neuroophthalmological outcomes associated with use of the Pipeline Embolization Device: analysis of the PUFS trial results. J Neurosurg 2015; 123:897-905. [PMID: 26162031 DOI: 10.3171/2014.12.jns141777] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Neuroophthalmological morbidity is commonly associated with large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms. The authors sought to evaluate the neuroophthalmological outcomes after treatment of these aneurysms with the Pipeline Embolization Device (PED). METHODS The Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial was an international, multicenter prospective trial evaluating the safety and efficacy of the PED. All patients underwent complete neuroophthalmological examinations both before the PED procedure and at a 6-month follow-up. All examinations were performed for the purpose of this study and according to study criteria. RESULTS In total, 108 patients were treated in the PUFS trial, 98 of whom had complete neuroophthalmological follow-up. Of the patients with complete follow-up, 39 (40%) presented with a neuroophthalmological baseline deficit that was presumed to be attributable to the aneurysm, and patients with these baseline deficits had significantly larger aneurysms. In 25 of these patients (64%), the baseline deficit showed at least some improvement 6 months after PED treatment, whereas in 1 patient (2.6%), the deficits only worsened. In 5 patients (5%), new deficits had developed at the 6-month follow-up, while in another 6 patients (6%), deficits that were not originally assumed to be related to the aneurysm had improved by that time. A history of diabetes was associated with failure of the baseline deficits to improve after the treatment. The aneurysm maximum diameter was significantly larger in patients with a new deficit or a worse baseline deficit at 6 months postprocedure. CONCLUSIONS Patients treated with the PED for large and giant ICA aneurysms had excellent neuroophthalmological outcomes 6 months after the procedure, with deficits improving in most of the patients, very few deficits worsening, and few new deficits developing.
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