pCONus Device for the Endovascular Treatment of Wide-Neck Middle Cerebral Artery Aneurysms

BACKGROUND AND PURPOSE

Endovascular treatment of bifurcation middle cerebral artery aneurysms with a wide neck could be challenging, and many lesions are still treated by a surgical approach. The pCONus is a newly emerging device for wide-neck bifurcation intracranial aneurysms. To date, a single report on the treatment of intracranial aneurysms including all locations has been published. We report our experience with pCONus in the treatment of wide-neck MCA aneurysms.

MATERIALS AND METHODS

MCA aneurysms treated with pCONus in 4 European centers were retrospectively reviewed.

RESULTS

Forty MCA aneurysms (mean dome size, 7.7 mm; mean neck size, 5.6 mm) were treated in 40 patients (mean age, 62 years). Aneurysm coiling was performed after deployment of 1 pCONus in 95% (38/40) of cases and after deployment of 2 pCONus devices in 5% (2/40). No procedural angiographic complications were observed. Reversible neurologic complications were noted in 5% (2/40), and permanent neurologic complication, in 2.5% (1/40) at 1 month. There was no mortality. No aneurysms bled or rebled after treatment. Immediate angiographic results were complete aneurysm occlusion in 25% (10/40), neck remnant in 47.5% (19/40), and aneurysm remnant in 27.5% (11/40). Follow-up (mean, 6.8 months) was available for 33 aneurysms (82.5%). Stable or improved results were observed in all except 3 cases, including 48.5% complete occlusions (16/33), 30.3% neck remnants (10/33), and 21.2% aneurysm remnants (7/33). There was no in-stent stenosis or jailed branch occlusion. There was no angiographic recurrence of initially totally occluded aneurysms.

CONCLUSIONS

MCA aneurysms with a wide neck are amenable to treatment with pCONus.

Endovascular treatment of bifurcation intracranial aneurysms with the WEB SL/SLS: 6-month clinical and angiographic results

BACKGROUND

The WEB device is a recent intrasaccular flow disruption technique developed for the treatment of wide-necked intracranial aneurysms. To date, a single report on the WEB Single-Layer (SL) treatment of intracranial aneurysms has been published with 1-months' safety results. The aim of this study is to report our experience and 6-month clinical and angiographic follow-up of endovascular treatment of wide-neck aneurysm with the WEB SL.

METHODS

Ten patients with 10 unruptured wide-necked aneurysms were prospectively enrolled in this study. Feasibility, intraoperative and postoperative complications, and outcomes were recorded. Immediate and 6-month clinical and angiographic results were evaluated.

RESULTS

Failure of WEB SL placement occurred in two cases. Eight aneurysms were successfully treated using one WEB SL without additional treatment. Three middle cerebral artery, four anterior communicating artery, and one basilar artery aneurysms were treated. Average dome width was 7.5 mm (range 5.4-10.7 mm), and average neck size was 4.9 mm (range 2.6-6.5 mm). No periprocedural complication was observed, and morbi-mortality at discharge and 6 months was 0.0%. Angiographic follow-up at 6 months demonstrated complete aneurysm occlusion in 2/8 aneurysms, neck remnant in 5/8 aneurysms, and aneurysm remnant in 1/8 aneurysm.

CONCLUSIONS

From this preliminary study, treatment of bifurcation intracranial aneurysms using WEB SL is feasible. WEB SL treatment seems safe at 6 months; however, the rate of neck remnants is not negligible due to compression of the WEB SL. Further technical improvements may be needed in order to ameliorate the occlusion in the WEB SL treatment.

Endovascular treatment of wide-neck anterior communicating artery aneurysms using WEB-DL and WEB-SL: short-term results in a multicenter study

BACKGROUND AND PURPOSE

Endovascular treatment of wide-neck anterior communicating artery aneurysms can often be challenging. The Woven EndoBridge (WEB) device is a recently developed intrasaccular flow disrupter dedicated to endovascular treatment of intracranial aneurysms. The aim of this study was to investigate the feasibility, safety, and efficacy of the WEB Dual-Layer and WEB Single-Layer devices for the treatment of wide-neck anterior communicating artery aneurysms.

MATERIALS AND METHODS

Patients with anterior communicating artery aneurysms treated with the WEB device between June 2013 and March 2014 in 5 French centers were analyzed. Procedural success, technical complications, clinical outcome at 1 month, and immediate and 3- to 6-month angiographic follow-up results were analyzed.

RESULTS

Ten patients with unruptured anterior communicating artery aneurysms with a mean neck diameter of 5.4 mm were treated with the WEB. Treatment failed in 3 of the 10 aneurysms without further clinical complications. One patient developed a procedural thromboembolic event, and the other 6 had normal neurologic examination findings at 1-month follow-up. Immediate anatomic outcome evaluation showed adequate occlusion (total occlusion or neck remnant) in 6 of 7 patients. Angiographic control was obtained in all patients, including 6 adequate aneurysm occlusions (3 complete occlusions and 3 neck remnants) at short-term follow-up.

CONCLUSIONS

In our small series, treatment of wide-neck anterior communicating artery aneurysms with the WEB device was feasible and safe. However, patient selection based on the aneurysm and initial angiographic findings in the parent artery is important due to the limitations of the WEB device navigation.

Intracranial dural arteriovenous fistulas: a review of their current management based on emerging knowledge

Intracranial dural arteriovenous fistulas are a rarely diagnosed type of vascular malformations, yet they are clinically relevant in a subspecialized neurovascular setting because a misdiagnosis may lead to permanent morbidity and mortality. Modern brain imaging techniques such as flat panel detector computed tomographic angiography and magnetic resonance imaging angiography have a significant role in the preoperative work-up, still digital subtraction angiography remains the neuroimaging mainstay. The most important factor guiding their management is the presence of cortical venous reflux, significantly associated with aggressive symptoms due to cerebral or spinal cord venous congestion and hemorrhage. Cutting-edge developments in endovascular and neurosurgical treatment of these vascular malformations, which should be undertaken in specialized referral centers, have substantially improved their prognosis. While transarterial or transvenous endovascular techniques represent frequently the therapy of choice, surgery remains a very valuable option both as a first line treatment and after partial embolization has been carried out. A significant neurosurgical advance is the introduction of indocyanine green video angiography, which allows precise identification of the arterialized draining vein of the dural fistula to be disconnected and confirms interruption of the arteriovenous shunt. Stereotactic radiosurgery may be considered in case of intracranial dural arteriovenous fistulas without cortical venous drainage for which surgical and endovascular options have been consumed or for palliation.

Endovascular treatment of 404 intracranial aneurysms treated with nexus detachable coils: short-term and mid-term results from a prospective, consecutive, European multicenter study

BACKGROUND

Aneurysm recanalization remains a limitation of endovascular treatment. A new type of bioactive coil, the polyglycolic/polylactic acid-covered platinum microfilaments Nexus coil (ev3/Covidien, Irvine, CA, USA), has been proposed. The objective is to evaluate the safety and short-term and mid-term efficacy of Nexus coils in the endovascular treatment of intracranial aneurysms.

METHODS

The ENDECOR (European Nexus Detachable Coil Registry) is the first prospective, consecutive, multicenter non-randomized registry. After providing informed consent, 390 patients (238 women and 152 men; mean age, 51.6 years) with 404 ruptured or unruptured aneurysms were enrolled at 34 centers. Treatment was performed with at least 75 % of coil length as Nexus coils. Clinical and technical complications were systematically reported. An independent core laboratory evaluated angiographic results by using the Raymond Grading Scale.

RESULTS

Complete occlusion was seen in 181 aneurysms (48 %); neck remnant in 86 aneurysms (22 %) and aneurysm remnant in 111 aneurysms (30 %). Technical and clinical complications related to the procedure occurred in 33 patients (8.5 %). At discharge, overall mortality and permanent-morbidity were 4.1 % (16/390) and 5.6 % (14/251), respectively. Angiographic mean follow-up of 13.3 months was obtained in 233 of 390 patients (64.4 %) harboring 247 aneurysms. Recanalization was observed in 44 aneurysms (17.7 %), and progressive thrombosis was observed in 53 aneurysms (21.6 %).

CONCLUSIONS

Endovascular treatment of intracranial aneurysms with Nexus coils was associated with low morbidity and mortality rates. Efficacy of Nexus coils was comparable to published series of intracranial aneurysms treated with bare platinum coils, but their efficacy to prevent aneurysm recanalization was not demonstrated.

Implantation of two flow diverter devices in a child with a giant, fusiform vertebral artery aneurysm: case report

BACKGROUND

Intracranial aneurysms in children and adolescents are uncommon; they account for 0.5% to 4.6% of the total intracranial aneurysms cases.

METHODS

A 15-year-old boy presented with a 6-month history of occipital headache that worsened over time. A magnetic resonance imaging scan revealed a giant, fusiform aneurysm of the V4 segment of the right vertebral artery with mass effect but no signs of hemorrhage. This lesion was confirmed by the catheter digital subtraction angiography. The posterior inferior cerebellar artery arose from the distal part of the aneurysm. Two flow-diverter devices were implanted in the V4 segment of the right vertebral artery. Follow-up angiograms performed 1 and 2 years after the procedure revealed a total aneurysm occlusion.

CONCLUSION

Flow-diverter device implantation may be a viable alternative to parent artery occlusion in a symptomatic, giant, fusiform vertebral artery aneurysm in a child.

Endovascular exclusion of the anterior communicating artery with flow-diverter stents as an emergency treatment for blister-like intracranial aneurysms. A case report

Blood blister-like aneurysms (BLAs) are rare lesions, associated with diffuse subarachnoid hemorrhage (SAH). BLAs tend to rebleed quickly after first bleeding and must be treated as an emergency. Acute treatment is challenging using surgical and endovascular approaches due to the fragile aneurysm wall and small sac. Flow-diverter stents (FDSs) may offer a new option for the treatment of difficult small aneurysms. We describe a case of a ruptured BLA on the anterior communicating artery (AComA) treated in the acute phase of SAH by endovascular exclusion of the AComA with deployment of two FDSs in the A1/A2 junctions of both anterior cerebral arteries (ACAs). A 61-year-old man was admitted for diffuse SAH with a focal interhemispheric hematoma. Angiography revealed multiple arterial wall irregularities on the AComA and both ACAs. We performed an endovascular shunt of the AComA by deploying two FDSs in both A1/A2 junctions. Immediate control injections confirmed flow diversion in the A1/A2 segments of the ACAs with decreased blood flow in the AComA. The patient's course in hospital was uneventful. A three-month follow-up angiogram confirmed complete exclusion of the aneurysms, complete exclusion of the AComA, and patency of the two ACAs without any persistent arterial wall irregularity. Endovascular bypass using an FDS for a ruptured BLA has never been described. It establishes a new therapeutic option despite the need for antiplatelet therapy. Endovascular AComA exclusion using an FDS may be a solution when no other treatment is available for a ruptured BLA.

Temporary solitaire stent-assisted coiling: a technique for the treatment of acutely ruptured wide-neck intracranial aneurysms

BACKGROUND AND PURPOSE

Wide-neck intracranial aneurysms in patients with acute SAH are often challenging lesions to treat by neurosurgical and endovascular approaches. The aim of this study was to investigate the feasibility, safety, and efficacy of the use of temporary Solitaire AB stent-assisted technique with coiling for the treatment of acutely ruptured wide-neck aneurysms without perioperative antiplatelet therapy.

MATERIALS AND METHODS

A retrospective review of our endovascular data base identified all patients treated in the acute phase with a temporary stent-assisted technique by use of a fully resheathable Solitaire AB stent and coiling. One-year clinical and angiographic outcomes were evaluated.

RESULTS

Eight patients (5 women and 3 men; mean age, 57.5 years) with 8 ruptured wide-neck aneurysms were treated. There were 3 complications without clinical impact. Postoperative complete occlusion was achieved in 5 aneurysms, and 3 had a neck remnant. Three patients had an mRS score of 0, and 1 an mRS score of 3. Among the 4 patients admitted with a World Federation of Neurological Societies grade of V, 1 died, 1 improved to an mRS score of 1, and the other 2 achieved mRS scores of 4 and 5. Five had a stable occlusion, and 2 of the 3 incompletely occluded aneurysms underwent recanalization.

CONCLUSIONS

In this small series, temporary placement of the Solitaire AB stent during coiling was a feasible and effective treatment for acutely ruptured wide-neck aneurysms. This technique, avoiding the need for perioperative antiplatelet therapy, could be a valuable option for the treatment of such lesions when the balloon remodeling technique is either not an option or unsuccessful.

Endovascular treatment of middle cerebral artery aneurysms for 120 nonselected patients: a prospective cohort study

BACKGROUND AND PURPOSE

Multiple technologies have developed the endovascular approach to MCA aneurysms. We assess the safety and the efficacy of a systematic endovascular approach in nonselected patients with MCA aneurysms and determine predictors of treatment outcomes.

MATERIALS AND METHODS

We analyzed data collected between January 2007 and January 2012 in a prospective clinical registry. All patients with MCA aneurysms treated by means of the endovascular approach were included. A multivariate analysis was conducted to identify predictors of complications, recanalization, and outcome.

RESULTS

A total of 120 patients with 131 MCA aneurysms were included. Seventy-nine patients (65.8%) were treated electively and 41 (34.2%) in the setting of subarachnoid hemorrhage. Thirty-three of 131 aneurysms (25.2%) were treated with simple coiling, 79 aneurysms (60.3%) with balloon-assisted coiling, and 19 aneurysms (14.5%) with stent-assisted coiling. Complications occurred in 13.7% of patients. Stent-assisted coiling was significantly associated with more complications (P = .002; OR: 4.86; 95% CI, 1.60-14.72). At 1 month after treatment, both the permanent morbidity (mRS ≤2) and mortality rates were 3.3%, without any significant difference according to the endovascular techniques. Mean angiographic follow-up was 16.3 months. The rate of recanalization was 15.6% without a statistical difference, according to the technique. Larger aneurysms were a predictor of recanalization (P = .016; OR: 1.183; 95% CI, 1.02-1.36). Retreatment was performed in 10 of 131 aneurysms (7.6%).

CONCLUSIONS

Even though stent-assisted coiling significantly increases the risk of procedural complications, endovascular treatment of MCA aneurysms is safe, effective, and provides durable aneurysm closure in nonselected patients.

Embolization of spinal dural arteriovenous fistula via the retrocorporeal artery: case report

BACKGROUND AND IMPORTANCE

The goal of spinal dural arteriovenous fistula (DAVF) treatment is to permanently occlude the proximal draining vein and the fistula itself, which can be achieved by open surgery or endovascular treatment. The endovascular approach is currently the primary treatment, but it requires the presence of an access as close to the site of the fistula as possible. This case illustrates that the retrocorporeal artery may be an alternative option in case of previous embolization failure with proximal occlusion of the radicular arteries.

CLINICAL PRESENTATION

A 54-year-old man presented with an 18-month history of progressive paraparesis secondary to right L2 spinal DAVF. The first endovascular treatment failed to achieve occlusion of the fistula via the ipsilateral L2 and L3 radicular arteries. Given the proximal occlusion of these feeders during the first embolization, the dilated retrocorporeal arteries were approached via the contralateral L2 and L3 radicular arteries. Complete occlusion of the fistula was achieved with Onyx in a single session with progressive improvement of preoperative neurological deficit.

CONCLUSION

The retrocorporeal artery may provide a safe alternative approach to spinal DAVFs in cases in which a conventional endovascular approach failed, thus avoiding invasive surgical treatment.

A novel Swine model to evaluate arterial vessel injury after mechanical endovascular thrombectomy

Few animal models have been reported to evaluate and compare mechanical endovascular thrombectomy (MET) devices used to treat human ischemic stroke. These models may contribute to the understanding of arterial injury induced by a MET device and potentially by extrapolation to human intracranial arteries. We have developed a novel swine model for MET that allows visualization of the thrombus/device interaction and characterization of mechanical impact on the vessel wall. Twenty superficial femoral arteries were occluded with radiopaque thrombus, and 20 without thrombus were treated with thrombectomy devices. Acute histopathological changes were evaluated. The swine femoral artery, which is comparable in size to the human middle cerebral artery or basilar artery, may offer a useful animal model for the study of histologic alterations induced by MET.

Histopathologic evaluation of arterial wall response to 5 neurovascular mechanical thrombectomy devices in a swine model

BACKGROUND AND PURPOSE

Five commercial devices are available for mechanical thrombectomy in acute ischemic stroke. This study evaluated and compared the resultant arterial damage from these devices.

MATERIALS AND METHODS

Wall damage after 4 wall-contact devices (the Merci retriever, Catch thromboembolectomy system, and Solitaire FR revascularization devices of 4 and 6 mm) and 1 aspiration device (the Penumbra System) was evaluated in the superficial femoral arteries of 20 male swine. Each device was tested with and without intraluminal clot. Twenty control vessels were not subjected to any intervention. Acute histopathologic changes were evaluated.

RESULTS

In the device samples, endothelial denudation (72.8 ± 29.4% versus 0.9 ± 1.9%, P < .0001), medial layer edema (52 ± 35.9% versus 18.1 ± 27.8%, P = .004), and mural thrombus (5.3 ± 14.2% versus 0%, P = .05) were found to a greater extent compared with the control samples. The aspiration device provoked more intimal layer (100 ± 79.1% versus 58.8 ± 48.9%, P = .27) and medial layer (75 ± 35.4% versus 46.3 ± 34.8%, P = .13) edema than the wall-contact devices.

CONCLUSIONS

All devices caused vascular injuries extending into the medial layer. The aspiration device was associated with more intimal and medial layer edema, compared with the wall-contact devices except for the Catch thromboembolectomy system.

Initial experience of intracranial aneurysm embolization using the balloon remodeling technique with Scepter C, a new double-lumen balloon

The balloon remodeling technique (BRT) was designed for endovascular treatment of wide-necked intracranial aneurysms. To date, the balloon catheters available have had a single lumen and suitable guidewires ranging from 0.010 to 0.012 inches. We describe the first case of aneurysm embolization using the BRT with the new double-lumen balloon catheter, Scepter C(®), navigable on a 0.014-inch wire, and discuss the benefit of such a device.

Treatment of ruptured intra-cranial internal carotid artery dissection using a flow-diverter stent

In the presence of associated subarachnoid hemorrhage, the treatment of arterial dissection can be classified as either deconstructive (involving occlusion or sacrifice of the parent vessel) or reconstructive (preserving blood-flow through the parent vessel). In both treatment strategies, the main goal is to prevent any further risk of rebleeding. However, reconstructive treatment is reserved only for those patients in whom occlusion of the parent vessel is not feasible due to an insufficient collateral supply. This report is of a case of intra-cranial carotid artery dissection treated by a reconstructive endovascular approach, with deployment of a flow-diverter stent, for the management of an associated subarachnoid hemorrhage. This is, to the authors' knowledge, the first report of the use of a flow-diverter device as the main treatment of a ruptured supraclinoid carotid artery dissection.

Use of the enterprise™ intracranial stent for revascularization of large vessel occlusions in acute stroke

BACKGROUND AND PURPOSE

Major cerebral thromboembolism often resists recanalization with currently available techniques. The authors present their initial experience with a self-expanding stent for use in intracranial vascular reconstruction, permitting immediate recanalization of acute thromboembolic occlusions of the anterior circulation.

PATIENTS AND METHODS

Patients treated with the Cordis Enterprise™ self-expanding intracranial stent system for acute thromboembolic occlusion of the major anterior cerebral arteries were included. Treatment comprised systemic and intraarterial thrombolysis, mechanical thrombectomy, and stent placement. Stent deployment, recanalization rate by means of Thrombolysis In Cerebral Infarction (TICI) scores and the clinical outcome were all assessed.

RESULTS

Six patients presenting with acute carotid T (n = 2) or proximal middle cerebral artery occlusion (n = 4) were treated. The mean National Institutes of Health Stroke Scale (NIHSS) score at presentation was 14; the mean age was 57 years. Successful stent deployment and immediate recanalization were achieved in all six with a TICI score of ≥ 2. Neither distal emboli nor any procedure-related complications were encountered. One patient developed symptomatic intracerebral hemorrhage and two patients needed decompressive craniectomy after treatment. The mean NIHSS score at 10 days was 10, but only one patient showed a complete recovery at 3 months.

CONCLUSION

Intracranial placement of the Enterprise™ self-expanding stent has proven to be feasible and efficient in achieving immediate recanalization of occluded main cerebral arteries. The use of antiplatelet therapy after treatment may, however, increase the risk of reperfusion intracerebral hemorrhage.