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Bechan RS, Sprengers ME, Majoie CB, Peluso JP, Sluzewski M, van Rooij WJ. Stent-Assisted Coil Embolization of Intracranial Aneurysms: Complications in Acutely Ruptured versus Unruptured Aneurysms. AJNR Am J Neuroradiol 2015; 37:502-7. [PMID: 26405089 DOI: 10.3174/ajnr.a4542] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 07/29/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The use of stents in the setting of SAH is controversial because of concerns about the efficacy and risk of dual antiplatelet therapy. We compare complications of stent-assisted coil embolization in patients with acutely ruptured aneurysms with complications in patients with unruptured aneurysms. MATERIALS AND METHODS Between February 2007 and March 2015, 45 acutely ruptured aneurysms and 47 unruptured aneurysms were treated with stent-assisted coiling. Patients with ruptured aneurysms were not pretreated with antiplatelet medication but received intravenous aspirin during the procedure. Thromboembolic events and early rebleeds were recorded. RESULTS In ruptured aneurysms, 9 of 45 patients had thromboembolic complications. Four patients remained asymptomatic, 4 developed infarctions, and 1 patient died. The permanent complication rate in ruptured aneurysms was 11% (95% CI, 4%-24%). Five of 45 patients (11%; 95% CI, 4%-24%) had an early rebleed from the treated aneurysm after 3-45 days, and in 4, this rebleed was fatal. In 46 patients with 47 unruptured aneurysms, thromboembolic complications occurred in 2. One patient remained asymptomatic; the other had a thalamus infarction. The complication rate in unruptured aneurysms was 2.2% (1 of 46; 95% CI, 0.01%-12%). No first-time hemorrhages occurred in 46 patients with 47 aneurysms during 6 months of follow-up. CONCLUSIONS The complication rate of stent-assisted coiling with early adverse events in ruptured aneurysms was 10 times higher than that in unruptured aneurysms. Early rebleed accounted for most mortality. In ruptured aneurysms, stent-assisted coil embolization is associated with increased morbidity and mortality and should only be considered when less risky options have been excluded.
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Affiliation(s)
- R S Bechan
- From Sint Elisabeth Ziekenhuis (R.S.B., J.P.P., M.S., W.J.v.R.), Tilburg, the Netherlands
| | - M E Sprengers
- Academisch Medisch Centrum (M.E.S., C.B.M.), Amsterdam, the Netherlands
| | - C B Majoie
- Academisch Medisch Centrum (M.E.S., C.B.M.), Amsterdam, the Netherlands
| | - J P Peluso
- From Sint Elisabeth Ziekenhuis (R.S.B., J.P.P., M.S., W.J.v.R.), Tilburg, the Netherlands
| | - M Sluzewski
- From Sint Elisabeth Ziekenhuis (R.S.B., J.P.P., M.S., W.J.v.R.), Tilburg, the Netherlands
| | - W J van Rooij
- From Sint Elisabeth Ziekenhuis (R.S.B., J.P.P., M.S., W.J.v.R.), Tilburg, the Netherlands
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Killory BD, Kilbourn KJ, Ollenschleger M. A Novel Use of Direct Platelet Application During Surgery for Clopidogrel-Associated Intracerebral Hemorrhage. World Neurosurg 2015; 84:2078.e1-4. [PMID: 26316398 DOI: 10.1016/j.wneu.2015.08.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 08/18/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dual antiplatelet therapy is associated with increased rates of intracerebral hemorrhage, especially in the context of subarachnoid hemorrhage. We present a case of a spontaneous hemorrhage in a patient treated with a Pipeline stent for a ruptured dissecting vertebrobasilar aneurysm and the novel use of direct application of platelets during surgery to control bleeding. CASE DESCRIPTION A 54-year-old previously healthy woman presented with an intradural right vertebral artery dissection with a ruptured 6-mm pseudoaneurysm. The patient was started on aspirin and clopidogrel and the vessel was reconstructed with 2 Pipeline Embolization Devices. On postbleed day number 14, she became obtunded with a blown right pupil; computed tomography of the head demonstrated a large right temporal intracerebral hematoma. The patient was taken emergently to the operating room for evacuation of the clot. Intraoperatively, satisfactory control of bleeding was not achieved despite transfusing several units of platelets intravenously. Ultimately, a mixture of Floseal and platelets applied directly to the hematoma wall allowed prompt hemostasis. At 3 months the patient was doing extremely well clinically and angiography demonstrated occlusion of the aneurysm. CONCLUSIONS This is the first reported description of direct application of platelets to achieve intraoperative hemostasis. Platelets are activated by thrombin and collagen and the use of Floseal (a bovine-derived, gelatin matrix and human-derived thrombin) further potentiated the effectiveness of this strategy. With the increased incidence of intracerebral hemorrhage associated with dual antiplatelet therapy, this technique may provide a useful tool in the neurosurgical armamentarium.
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Affiliation(s)
- Brendan D Killory
- Department of Neurosurgery, Hartford Hospital, Hartford, Connecticut, USA.
| | - Kent J Kilbourn
- Department of Neurosurgery, Hartford Hospital, Hartford, Connecticut, USA
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Ryu CW, Park S, Shin HS, Koh JS. Complications in Stent-Assisted Endovascular Therapy of Ruptured Intracranial Aneurysms and Relevance to Antiplatelet Administration: A Systematic Review. AJNR Am J Neuroradiol 2015; 36:1682-8. [PMID: 26138136 DOI: 10.3174/ajnr.a4365] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/11/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Despite the increasing use of stent-assisted coiling for ruptured intracranial aneurysms, there is little consensus regarding the appropriate antiplatelet administration for this. The objectives of this systematic review were to provide an overview of complications and their association with the method of antiplatelet administration in stent-assisted coiling for ruptured intracranial aneurysms. MATERIALS AND METHODS A comprehensive search of the literature in the data bases was conducted to identify studies reporting complications of stent-assisted coiling for ruptured intracranial aneurysms. The pooled event rate of preprocedural thromboembolisms, hemorrhages, and mortality was estimated from the selected studies. Subgroup analyses were performed by the method of antiplatelet administration (pre-, postprocedural, and modified). Meta-analysis was conducted to compare periprocedural complications and mortality between ruptured intracranial aneurysms and unruptured intracranial aneurysms. RESULTS Of the 8476 studies identified, 33 with 1090 patients were included. The event rates of thromboembolism and intra- and postprocedural hemorrhage were 11.2% (95% CI, 9.2%-13.6%), 5.4% (95% CI, 4.1%-7.2%), and 3.6% (95% CI, 2.6%-5.1%), respectively. Subgroup analyses of thromboembolism showed a statistically significant difference between groups (P < .05). In the preprocedural and modified antiplatelet groups, the risk for thromboembolism in stent-assisted coiling for ruptured intracranial aneurysm was not significantly different from that for unruptured intracranial aneurysm, though this risk of the postprocedural antiplatelet group was significantly higher in ruptured intracranial aneurysms than in unruptured intracranial aneurysms. CONCLUSIONS On the basis of current evidence, complications of stent-assisted coiling for ruptured intracranial aneurysm may be affected by the method of antiplatelet administration.
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Affiliation(s)
- C-W Ryu
- From the Departments of Radiology (C.-W.R., S.P.)
| | - S Park
- From the Departments of Radiology (C.-W.R., S.P.)
| | - H S Shin
- Neurosurgery (H.S.S., J.S.K.), Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine; Seoul, South Korea
| | - J S Koh
- Neurosurgery (H.S.S., J.S.K.), Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine; Seoul, South Korea
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Chalouhi N, Zanaty M, Whiting A, Tjoumakaris S, Hasan D, Ajiboye N, Hann S, Rosenwasser RH, Jabbour P. Treatment of ruptured intracranial aneurysms with the pipeline embolization device. Neurosurgery 2015; 76:165-72; discussion 172. [PMID: 25549187 DOI: 10.1227/neu.0000000000000586] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pipeline embolization device (PED) has been used for treatment of unruptured aneurysms. Little is known about the use of the PED in ruptured aneurysms. OBJECTIVE To assess the safety and efficacy of the PED in ruptured intracranial aneurysms. METHODS This is a case series with prospective data collection on 20 patients with freshly ruptured aneurysms who were treated with PED (with or without adjunctive coiling) at 2 cerebrovascular centers. Patients were loaded with aspirin and clopidogrel or received an infusion of tirofiban intraoperatively. RESULTS Hunt and Hess grades were I in 7 patients (35%), II in 9 (45%), and III in 4 (20%). The mean duration from hemorrhage to PED placement was 7±7.0 days. A single device was used in all but 1 patient (95%). The procedure was staged in 20%. There was only 1 complication (5%); this was a fatal intraoperative aneurysm dome rupture that occurred during adjunctive coil deployment. Adjunctive coiling was used in 30%. No patient required an invasive procedure after PED placement. Follow-up angiography (mean, 5.3±4.2 months; range, 2-12 months) showed 100% occlusion in 12 (80%) and incomplete occlusion in 3 patients (20%). At latest follow-up, 19 patients achieved a favorable outcome (modified rankin scale 0-2). CONCLUSION In our preliminary experience, treatment of ruptured aneurysms with the PED was associated with low complication rates, high occlusion rates, and favorable outcomes. These findings suggest that PED may be a safe and effective option for patients with favorable Hunt and Hess grades and aneurysms difficult to treat with conventional methods.
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Affiliation(s)
- Nohra Chalouhi
- *Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; ‡Department of Neurosurgery, University of Iowa, Iowa City, Iowa
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Are Flow Diverting Stents a Treatment Option in Acutely Ruptured Complex A1-A2 Junction Aneurysms? Clin Neuroradiol 2015; 26:109-15. [PMID: 26003172 DOI: 10.1007/s00062-015-0407-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 05/06/2015] [Indexed: 10/23/2022]
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Chalouhi N, Zanaty M, Tjoumakaris S, Manasseh P, Hasan D, Bulsara KR, Starke RM, Lawson K, Rosenwasser R, Jabbour P. Preparedness of neurosurgery graduates for neuroendovascular fellowship: a national survey of fellowship programs. J Neurosurg 2015; 123:1113-9. [PMID: 25839924 DOI: 10.3171/2014.10.jns141564] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Endovascular interventions have become an essential part of a neurosurgeon's practice. Whether endovascular procedures have been effectively integrated into residency curricula, however, remains uncertain. The purpose of this study was to assess the preparedness of US neurosurgery graduate trainees for neuroendovascular fellowship. METHODS A multidomain, global assessment survey was sent to all directors/faculty of neuroendovascular fellowship programs involved in training of US neurosurgery graduates. Surveyees were asked to assess trainees as they entered fellowship. RESULTS The response rate was 78% (25/32). Of respondent program directors, 38% reported that new fellows did not know the history and imaging of the patient and 50% were unable to formulate an appropriate treatment plan. As many as 79% of fellows were unfamiliar with endovascular devices and 75% were unfamiliar with angiographic equipment. Furthermore, 58% of fellows were unable to perform femoral access, 54% were unable to perform femoral closure, 79% were unable to catheterize a major vessel, 86% were unable to perform a 4-vessel angiogram, and 100% were unable to catheterize an aneurysm. Additionally, program directors reported that over 50% of fellows could not recognize neurovascular anatomy and 54% could not recognize/classify vascular abnormalities. There was an overall agreement that fellows demonstrated professionalism and interest in research and had good communication/clinical skills. CONCLUSIONS The results of this study suggest potential gaps in the training of neurosurgery residents with regard to endovascular neurosurgery. In an era of minimally invasive therapies, changes in residency curricula may be needed to keep pace with the ever-changing field of neurosurgery.
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Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Mario Zanaty
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Philip Manasseh
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa; and
| | - Ketan R Bulsara
- Department of Neurosurgery, Yale and New Haven Hospital, New Haven, Connecticut
| | - Robert M Starke
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Kevin Lawson
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Yang P, Zhao K, Zhou Y, Zhao R, Zhang L, Zhao W, Hong B, Xu Y, Huang Q, Krings T, Liu J. Stent-assisted Coil Placement for the Treatment of 211 Acutely Ruptured Wide-necked Intracranial Aneurysms: A Single-Center 11-Year Experience. Radiology 2015; 276:545-52. [PMID: 25822469 DOI: 10.1148/radiol.2015140974] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate the safety and angiographic and clinical outcome of stent-assisted coil placement (SACP) for acutely ruptured wide-necked intracranial aneurysms treated in a single center during an 11-year period. MATERIALS AND METHODS According to an institutional review board-approved protocol, the angiographic and clinical data of 211 patients (52 men, 159 women; median age, 56 years; age range, 31-83 years) with acutely ruptured wide-necked intracranial aneurysms (neck > 4 mm and/or dome-to-neck ratio ≤ 2) treated with SACP from September 2000 to December 2011 were reviewed retrospectively. Baseline characteristics, procedure-related complications, angiographic follow-up results, and clinical outcome were analyzed statistically. A Mann-Whitney U test was performed for non-normally distributed continuous variables. A Pearson χ(2) or Fisher exact test was performed for categorical variables. Univariate analysis and logistic regression analysis were performed to determine the association of procedure-related complications and clinical outcome with potential risk factors. RESULTS Procedure-related complications occurred in 30 patients (14.2%). They were more common in the anterior communicating artery (26.7%, 12 of 45) and middle cerebral artery bifurcation (40%, four of 10) aneurysms than in aneurysms at other locations (9.0%, 14 of 156). Clinical outcome (median, 33 months) was good in 175 patients (82.9%) with a modified Rankin Scale score of up to 2. Older age (P = .013, odds ratio = 1.054) and higher Hunt and Hess grade (P < .001, odds ratio = 15.876) were independent risk factors for unfavorable outcome. One hundred fifty-two of 190 patients who survived (80%) underwent angiographic follow-up at least once (median, 12 months). The complete occlusion rate improved from an immediate 45.5% to 75.7% at follow-up (115 of 152 patients). CONCLUSION Angiographic and clinical outcomes in our series were comparable to those reported by using coil placement alone or balloon-assisted coil placement techniques. SACP for the treatment of acutely ruptured middle cerebral artery bifurcation and anterior communicating artery aneurysms was associated with a significantly higher incidence of complications than was the case for treatment of aneurysms at other locations.
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Affiliation(s)
- Pengfei Yang
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Rd, Shanghai 200433, People's Republic of China (P.Y., K.Z., Y.Z., R.Z., L.Z., W.Z., B.H., Y.X., Q.H., J.L.); and Division of Neuroradiology, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (T.K.)
| | - Kaijun Zhao
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Rd, Shanghai 200433, People's Republic of China (P.Y., K.Z., Y.Z., R.Z., L.Z., W.Z., B.H., Y.X., Q.H., J.L.); and Division of Neuroradiology, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (T.K.)
| | - Yu Zhou
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Rd, Shanghai 200433, People's Republic of China (P.Y., K.Z., Y.Z., R.Z., L.Z., W.Z., B.H., Y.X., Q.H., J.L.); and Division of Neuroradiology, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (T.K.)
| | - Rui Zhao
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Rd, Shanghai 200433, People's Republic of China (P.Y., K.Z., Y.Z., R.Z., L.Z., W.Z., B.H., Y.X., Q.H., J.L.); and Division of Neuroradiology, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (T.K.)
| | - Lei Zhang
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Rd, Shanghai 200433, People's Republic of China (P.Y., K.Z., Y.Z., R.Z., L.Z., W.Z., B.H., Y.X., Q.H., J.L.); and Division of Neuroradiology, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (T.K.)
| | - Wenyuan Zhao
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Rd, Shanghai 200433, People's Republic of China (P.Y., K.Z., Y.Z., R.Z., L.Z., W.Z., B.H., Y.X., Q.H., J.L.); and Division of Neuroradiology, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (T.K.)
| | - Bo Hong
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Rd, Shanghai 200433, People's Republic of China (P.Y., K.Z., Y.Z., R.Z., L.Z., W.Z., B.H., Y.X., Q.H., J.L.); and Division of Neuroradiology, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (T.K.)
| | - Yi Xu
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Rd, Shanghai 200433, People's Republic of China (P.Y., K.Z., Y.Z., R.Z., L.Z., W.Z., B.H., Y.X., Q.H., J.L.); and Division of Neuroradiology, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (T.K.)
| | - Qinghai Huang
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Rd, Shanghai 200433, People's Republic of China (P.Y., K.Z., Y.Z., R.Z., L.Z., W.Z., B.H., Y.X., Q.H., J.L.); and Division of Neuroradiology, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (T.K.)
| | - Timo Krings
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Rd, Shanghai 200433, People's Republic of China (P.Y., K.Z., Y.Z., R.Z., L.Z., W.Z., B.H., Y.X., Q.H., J.L.); and Division of Neuroradiology, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (T.K.)
| | - Jianmin Liu
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Rd, Shanghai 200433, People's Republic of China (P.Y., K.Z., Y.Z., R.Z., L.Z., W.Z., B.H., Y.X., Q.H., J.L.); and Division of Neuroradiology, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada (T.K.)
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Chung J, Suh SH, Hong CK, Joo JY, Lim YC, Shin YS, Kim YB. Preliminary experience with self-expanding closed-cell stent placement in small arteries less than 2 mm in diameter for the treatment of intracranial aneurysms. J Neurosurg 2015; 122:1503-10. [PMID: 25555078 DOI: 10.3171/2014.11.jns14435] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to report the authors' preliminary experience using self-expanding closed-cell stents deployed in small arteries (< 2 mm in diameter) to treat intracranial aneurysms. METHODS A total of 31 patients were studied. All subjects met the following criteria: 1) they received an Enterprise stent for treatment of a wide-necked aneurysm or a dissecting aneurysm or as part of a stent-salvage procedure; and 2) they had an Enterprise stent deployed in a small parent artery (< 2 mm in diameter) that had no atherosclerotic stenosis. Procedure-related complications and follow-up sizes of the parent arteries were evaluated for safety and patency. RESULTS There were 16 ruptured aneurysms and 15 unruptured aneurysms. Three (9.7%) of the 31 patients experienced procedure-related complications, and they all were asymptomatic. Follow-up angiography was performed in 27 patients (87.1%) (at a mean 15.5 months after surgery). Parent arteries with 2 acute angles (n = 4) were occluded in 3 cases (75.0%), and those with no acute angles (n = 13) or 1 acute angle (n = 6) showed 100% patency on follow-up angiography. There was a significant difference between the follow-up sizes (mean 1.72 ± 0.30 mm) of parent arteries and their sizes (mean 1.59 ± 0.26 mm) before treatment (95% CI - 0.254 to - 0.009 mm; p = 0.037, paired-samples t-test). CONCLUSIONS In the current series the deployment of self-expanding closed-cell stents in small arteries was safe and resulted in good patency, especially when the stents were deployed in segments of the parent artery with no acute angles or only 1 acute angle.
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Affiliation(s)
| | - Sang Hyun Suh
- 2Radiology, Gangnam Severance Hospital, Yonsei University, Seoul
| | | | | | - Yong Cheol Lim
- 3Department of Neurosurgery, Ajou University School of Medicine, Suwon; and
| | - Yong Sam Shin
- 4Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
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Shin JH, Park SH, Kim CH, Lee CY. Very late stent thrombosis after sole stent-assisted coiling at the paraclinoid giant aneurysm : could prophylactic antiplatelet therapy be ceased at the only 1 year after procedure? J Korean Neurosurg Soc 2014; 56:344-7. [PMID: 25371786 PMCID: PMC4219194 DOI: 10.3340/jkns.2014.56.4.344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 02/21/2014] [Accepted: 09/29/2014] [Indexed: 01/01/2023] Open
Abstract
Stent thrombosis is a major limitation of stent-assisted coiling, which is an effective method for treating wide-necked aneurysms. Although early in-stent thrombosis has been reported, very late stent thrombosis (VLST) (>1 year) has not been reported following implantation of a single self-expandable stent designed for coiling. Herein, the authors present a case of VLST that occurred 14 months after single stent implantation in a large paraclinoid aneurysm with an ultra-wide neck involving the parent artery circumferentially. This case indicates the need for establishing guidelines regarding the optimal duration of prophylactic antiplatelet therapy following stent-assisted coiling, which remains undefined in the neuroendovascular field.
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Affiliation(s)
- Jung-Hoon Shin
- Department of Neurosurgery, Keimyung University School of Medicine, Daegu, Korea
| | - Seong-Ho Park
- Department of Neurosurgery, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Young Lee
- Department of Neurosurgery, Keimyung University School of Medicine, Daegu, Korea
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Vasquez C, Hubbard M, Jagadeesan BD, Tummala RP. Transfundal stent placement for treatment of complex basilar tip aneurysm: technical note. J Neurointerv Surg 2014; 7:e33. [PMID: 25352580 DOI: 10.1136/neurintsurg-2014-011288.rep] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2014] [Indexed: 11/03/2022]
Abstract
We describe a case where a complex unruptured basilar tip aneurysm was treated with a unique method of stent-assisted coil embolization. The aneurysm was considered to have a complex anatomy since both the left posterior cerebral artery and left superior cerebellar artery originated from the dome of the aneurysm. Also, the right posterior cerebral artery was incorporated in the aneurysm neck and needed to be protected prior to coil embolization. This case describes placement of a stent across the span of the aneurysm fundus in order to preserve the two branches arising from it, and the aneurysm dome was coiled without any complication. Using modifications of existing strategies for stent-assisted coil embolization, the aneurysm was treated without any complications and all of the vessels at risk were preserved.
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Affiliation(s)
- Ciro Vasquez
- Department of Neurosurgery, Univeristy of Minnesota, Minneapolis, Minnesota, USA
| | - Molly Hubbard
- Department of Neurosurgery, Univeristy of Minnesota, Minneapolis, Minnesota, USA
| | | | - Ramachandra Prasad Tummala
- Department of Neurosurgery, Univeristy of Minnesota, Minneapolis, Minnesota, USA University of Minnesota, Minneapolis, Minnesota, USA
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Vasquez C, Hubbard M, Jagadeesan BD, Tummala RP. Transfundal stent placement for treatment of complex basilar tip aneurysm: technical note. BMJ Case Rep 2014; 2014:bcr-2014-011288. [PMID: 25336546 DOI: 10.1136/bcr-2014-011288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe a case where a complex unruptured basilar tip aneurysm was treated with a unique method of stent-assisted coil embolization. The aneurysm was considered to have a complex anatomy since both the left posterior cerebral artery and left superior cerebellar artery originated from the dome of the aneurysm. Also, the right posterior cerebral artery was incorporated in the aneurysm neck and needed to be protected prior to coil embolization. This case describes placement of a stent across the span of the aneurysm fundus in order to preserve the two branches arising from it, and the aneurysm dome was coiled without any complication. Using modifications of existing strategies for stent-assisted coil embolization, the aneurysm was treated without any complications and all of the vessels at risk were preserved.
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Affiliation(s)
- Ciro Vasquez
- Department of Neurosurgery, Univeristy of Minnesota, Minneapolis, Minnesota, USA
| | - Molly Hubbard
- Department of Neurosurgery, Univeristy of Minnesota, Minneapolis, Minnesota, USA
| | | | - Ramachandra Prasad Tummala
- Department of Neurosurgery, Univeristy of Minnesota, Minneapolis, Minnesota, USA University of Minnesota, Minneapolis, Minnesota, USA
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Administration of eptifibatide during endovascular treatment of ruptured cerebral aneurysms reduces the rate of thromboembolic events. Neuroradiology 2014; 57:197-203. [PMID: 25326169 DOI: 10.1007/s00234-014-1452-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Thromboembolic complications are the most frequent complications of endovascular treatment of ruptured intracranial aneurysms. The optimal protocol to prevent thromboembolic complications during coil embolization does not yet exist. The aim of this study was to investigate the effectiveness and safety of eptifibatide for the prevention of thromboembolic complications during elective coil embolization of ruptured cerebral aneurysms. METHODS A consecutive series of 100 patients (group 1) with ruptured intracranial aneurysm were treated using endovascular coil embolization. At the beginning of the procedure, all patients received an intra-arterial bolus (0.2 mg/kg) of eptifibatide. The following data were collected: degree of aneurysmal occlusion after treatment, thromboembolic and hemorrhagic complications and other intraoperative adverse events. The results were compared with those from a control group (group 2) which were analyzed retrospectively. Group 2 consisted of 100 previous patients with ruptured aneurysm managed with coil embolization who had received heparin and/or aspirin at the beginning of the procedure. RESULTS (1) Patient populations in groups 1 and 2 were considered statistically comparable, except that group 1 (eptifibatide) included more wide-necked aneurysms (p = 0.011). (2) There were less thromboembolic complications in group 1 (p = 0.011): seven intraoperative complications in group 1 versus 20 in group 2. (3) Intraoperative hemorrhagic complications were statistically comparable in both groups (p = 1). CONCLUSION Eptifibatide was effective in lowering the intraoperative thromboembolic complication rate in ruptured aneurysms treated with coil embolization and did not increase the hemorrhagic risk.
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Rosenwasser RH, Chalouhi N, Tjoumakaris S, Jabbour P. Open vs Endovascular Approach to Intracranial Aneurysms. Neurosurgery 2014; 61 Suppl 1:121-9. [DOI: 10.1227/neu.0000000000000377] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Robert H. Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Ikeda DS, Marlin ES, Shaw A, Sauvageau E, Powers CJ. Endovascular Management of Anterior Communicating Artery Aneurysms. Neurosurg Clin N Am 2014; 25:437-54. [DOI: 10.1016/j.nec.2014.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Chung J, Lim YC, Suh SH, Shim YS, Kim YB, Joo JY, Kim BS, Shin YS. Stent-assisted coil embolization of ruptured wide-necked aneurysms in the acute period: incidence of and risk factors for periprocedural complications. J Neurosurg 2014; 121:4-11. [PMID: 24834945 DOI: 10.3171/2014.4.jns131662] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED OBJECT.: The purpose of this study was to report the authors' experiences in stent-assisted coil embolization (SAC) of ruptured wide-necked aneurysms in the acute period and to evaluate the incidence of and risk factors for periprocedural complications. METHODS A total of 72 patients were recruited for this study between March 2007 and June 2012. All patients met the following criteria: 1) the presence of ruptured intracranial wide-necked saccular aneurysms, and 2) the patient underwent SAC for treatment of those aneurysms within 72 hours of rupture. All of the patients with clinically poor grades or acute hydrocephalus underwent external ventricular drainage (EVD) before SAC. The incidence of and risk factors for periprocedural complications were retrospectively evaluated. RESULTS Of the 72 patients included in this study, periprocedural complications occurred in 14 (19.4%), including asymptomatic complications in 4 (5.6%) and symptomatic complications in 10 (13.9%); there were symptomatic thromboembolic complications in 5 patients (6.9%), and symptomatic hemorrhagic complications in 5 (6.9%). The authors observed no subacute or delayed thromboembolic complications during the follow-up period of 18.8 months. Use of EVD (OR 1.413, 95% CI 0.088-2.173; p = 0.046) was the only independent risk factor for periprocedural complications on multivariate logistic regression analysis. CONCLUSIONS The periprocedural complication rate during SAC was 19.4% among 72 patients. Because of the high complication rate, microsurgical clipping or endovascular treatment with another technique (multiple-microcatheter or balloon-assisted technique) may be a more appropriate option for first-line treatment than SAC, especially in patients requiring EVD.
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Nerva JD, Morton RP, Levitt MR, Osbun JW, Ferreira MJ, Ghodke BV, Kim LJ. Pipeline Embolization Device as primary treatment for blister aneurysms and iatrogenic pseudoaneurysms of the internal carotid artery. J Neurointerv Surg 2014; 7:210-6. [PMID: 24578484 DOI: 10.1136/neurintsurg-2013-011047] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Blood blister type aneurysms (BBAs) and pseudoaneurysms create a unique treatment challenge. Despite many advances in open surgical and endovascular techniques, this subset of patients retains relatively high rates of morbidity and mortality. Recently, BBAs have been treated with flow-diverting stents such as the Pipeline Embolization Device (PED) with overall positive results. METHODS Four patients presented with dissecting internal carotid artery (ICA) aneurysms treated with the PED (two BBAs presenting with subarachnoid hemorrhage (SAH), two pseudoaneurysms after injury during endoscopic trans-sphenoidal tumor surgery). RESULTS Three patients had a successful angiographic and neurological outcome. One patient with a BBA re-ruptured during initial PED placement, again in the postoperative period, and later died. Primary PED treatment involved telescoping stents in two patients and coil embolization supplementation in one patient. CONCLUSIONS The PED should be used selectively in the setting of acute SAH. Dual antiplatelet therapy can complicate hydrocephalus management, and the lack of immediate aneurysm occlusion creates the risk of short-term re-rupture. PED treatment for iatrogenic ICA pseudoaneurysms can provide a good angiographic and neurological outcome.
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Affiliation(s)
- John D Nerva
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Ryan P Morton
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Joshua W Osbun
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Manuel J Ferreira
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Basavaraj V Ghodke
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA Department of Radiology, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Louis J Kim
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA Department of Radiology, Harborview Medical Center, University of Washington, Seattle, Washington, USA
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Zanaty M, Chalouhi N, Tjoumakaris SI, Rosenwasser RH, Jabbour PM. Endovascular management of cerebral aneurysm : review of the literature. Transl Stroke Res 2013; 5:199-206. [PMID: 24323730 DOI: 10.1007/s12975-013-0311-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 11/06/2013] [Accepted: 11/08/2013] [Indexed: 10/26/2022]
Abstract
Management of intracranial aneurysms remains controversial. For unruptured aneurysms, many factors should be taken into account before deciding the type of treatment and whether to treat or not. Ruptured aneurysms on the other hand are almost always treated. Still, the question remains what are the indicators that one must rely on to decide what treatment suits the patient best. We present a review on the management of intracranial aneurysm while focusing on endovascular aspects.
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Affiliation(s)
- Mario Zanaty
- Department of Neurological Surgery, Division of Neurovascular Surgery and Endovascular Neurosurgery, Thomas Jefferson University, 909 Walnut St., 2nd Floor, Pennsylvania, PA, 19107, USA
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Mahaney KB, Chalouhi N, Viljoen S, Smietana J, Kung DK, Jabbour P, Bulsara KR, Howard M, Hasan DM. Risk of hemorrhagic complication associated with ventriculoperitoneal shunt placement in aneurysmal subarachnoid hemorrhage patients on dual antiplatelet therapy. J Neurosurg 2013; 119:937-42. [DOI: 10.3171/2013.5.jns122494] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The use of an intracranial stent requires dual antiplatelet therapy to avoid in-stent thrombosis. In this study, the authors sought to investigate whether the use of dual antiplatelet therapy is a risk factor for hemorrhagic complications in patients undergoing permanent ventriculoperitoneal (VP) shunt for hydrocephalus following aneurysmal subarachnoid hemorrhage (aSAH).
Methods
Patients were given 325 mg acetylsalicylic acid and 600 mg clopidogrel during the coil/stent procedure, and they were maintained on dual antiplatelet therapy with acetylsalicylic acid 325 mg daily and clopidogrel 75 mg daily during hospitalization and for 6 weeks posttreatment. Patients underwent placement of VP shunt at a later time during initial hospitalization, usually between 7 and 21 days following aSAH. Postoperative CT scans obtained in each study patient were reviewed for hemorrhages related to placement of the VP shunt.
Results
A total of 206 patients were admitted to the University of Iowa Hospitals and Clinics with aSAH between July 2009 and October 2010. Thirty-seven of these patients were treated with a VP shunt for persistent hydrocephalus. Twelve patients (32%) had previously undergone stent-assisted coiling and were on dual antiplatelet therapy with acetylsalicylic acid and clopidogrel. The remaining 25 patients (68%) had undergone surgical clipping or aneurysm coiling and were not receiving antiplatelet therapy at the time of surgery.
Four cases (10.8%) of new intracranial hemorrhages associated with VP shunt placement were observed. All 4 hemorrhages (33%) occurred in patients on dual antiplatelet therapy for stent-assisted coiling. No new intracranial hemorrhages were observed in patients not receiving dual antiplatelet therapy. The difference in hemorrhagic complications between the 2 groups was statistically significant (4 [33%] of 12 vs 0 of 25, p = 0.0075]). All 4 hemorrhages occurred along the tract of the ventricular catheter. Only 1 hemorrhage (1 [8.3%] of 12) was clinically significant as it resulted in occlusion of the proximal shunt catheter and required revision of the VP shunt. The patient did not suffer any permanent morbidity related to the hemorrhage. The remaining 3 hemorrhages were not clinically significant.
Conclusions
This small clinical series suggests that placement of a VP shunt in patients on dual antiplatelet therapy may be associated with an increased, but low, rate of symptomatic intracranial hemorrhage. It appears that in patients who are poor candidates for open surgical clipping and have aneurysms amenable to stent-assisted coiling, the risk of symptomatic hemorrhage may be an acceptable trade-off for avoiding risks associated with discontinuation of antiplatelet therapy. The authors' results are preliminary, however, and require confirmation in larger studies.
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Affiliation(s)
- Kelly B. Mahaney
- 1Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Nohra Chalouhi
- 2Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Stephanus Viljoen
- 1Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Janel Smietana
- 1Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - David K. Kung
- 1Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Pascal Jabbour
- 2Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Ketan R. Bulsara
- 3Department of Neurosurgery, Yale Medical School, New Haven, Connecticut
| | - Matthew Howard
- 1Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - David M. Hasan
- 1Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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Solitaire AB stent-assisted coiling of wide-necked intracranial aneurysms: short-term results from a prospective, consecutive, European multicentric study. Neuroradiology 2013; 55:1373-8. [PMID: 24057085 DOI: 10.1007/s00234-013-1277-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 08/23/2013] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Solitaire AB stent-assisted coiling facilitates the endovascular treatment of wide-necked intracranial aneurysms. Solitaire Aneurysm Remodeling is the first prospective, consecutive, European multicentric study whose main objective was to evaluate the safety, short-, and long-term efficacy of the Solitaire AB stent. This first analysis is focused on the short-term results. METHODS After exclusion of one patient, 66 Solitaire AB stents were used to treat via endovascular approach 64 aneurysms (63 patients) in seven European centers. Technical and clinical complications were recorded. A core laboratory evaluated the angiographic efficacy by using the Raymond classification scale. RESULTS The mean width of aneurysm sac was 7.5 mm, and the mean diameter of aneurysm neck was 4.7 mm. Complete occlusion was achieved in 27 aneurysms (42.2 %); neck remnant was seen in 25 aneurysms (39.1 %) and aneurysm remnant in 12 aneurysms (18.7 %). Technical and clinical complications related to the procedure were encountered in eight patients (12.7 %). Postprocedural modification of the clinical status was observed in one patient (1.6 %). No patients died (0 %); one had a permanent deficit (1.6 %), and one had a transient deficit (1.6 %). Treatment-related mortality was 0 %, and permanent morbidity was 1.6 %. CONCLUSION The Solitaire AB stent has an excellent rate of technical success navigation with the absence of dislodgement. The safety and short-term efficacy are comparable to those previously reported with coiling alone. Mid- and long-term follow-up will be required to elucidate the impact of the Solitaire AB stent on recanalization rate.
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Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a catastrophic neurologic event. Early triage of patients with SAH should include cardiopulmonary stabilization, neurologic assessment, and imaging. Conventional angiography with 3-dimensional rendering is necessary to accurately assess aneurysm morphology and location, so that treatment can be planned appropriately. Current evidence suggests that coil embolization can be beneficial for aneurysms amenable to endovascular treatment. The use of remodeling techniques has expanded the range of aneurysms treatable by endovascular means. Balloon remodeling can be a powerful technique for treating ruptured aneurysms with unfavorable morphology. However, stent-assisted technique is associated with significantly higher complication rates in ruptured aneurysms and requires dual antiplatelet agents, and should therefore be considered with great caution for ruptured aneurysms. Complications of ruptured aneurysm embolization include aneurysm perforation, which should be addressed with immediate occlusion of the aneurysm, and thromboembolism, which can be managed most effectively with glycoprotein IIb/IIIa inhibitors.
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Affiliation(s)
- Michael T Froehler
- Vascular Neurology and Neuro Interventional Service, University of Iowa, Carver College of Medicine, Department of Neurology, University of Iowa Hospital, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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Heller RS, Dandamudi V, Calnan D, Malek AM. Neuroform Intracranial Stenting for Aneurysms Using Simple and Multi-stent Technique Is Associated With Low Risk of Magnetic Resonance Diffusion-Weighted Imaging Lesions. Neurosurgery 2013; 73:582-90; discussion 590-1. [DOI: 10.1227/neu.0000000000000053] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Detection of procedural thromboembolism by diffusion-weighted magnetic resonance imaging (MR-DWI+) can help identify and mitigate endovascular risk factors. Data remain scant on procedural MR-DWI+ following the use of the Neuroform open-cell design stent in aneurysm embolization.
OBJECTIVE:
We sought to evaluate the incidence of MR-DWI+ in Neuroform simple and multi-stent construct stenting for intracranial aneurysms in an attempt to delineate baseline risk and identify possible associated procedural factors.
METHODS:
Seventy-six patients receiving 97 Neuroform stents in the treatment of intracranial aneurysm were identified from a prospective database and eligible for inclusion in the study. Diffusion-weighted magnetic resonance imaging (MR-DWI) was obtained in all patients within 48 hours of the procedure and reviewed for the presence of MR-DWI+ with patient records reviewed for analysis of factors predisposing to these lesions.
RESULTS:
Patients were treated with single-stent Neuroform constructs in 57 cases (73%) and multi-stent Neuroform constructs in 21 cases (27%). Y-stent technique was used in 16 cases. MR-DWI+ was identified in 7 of 78 cases (9.0%), with MR-DWI+ in 0 of 10 subarachnoid hemorrhage cases. No MR-DWI lesions led to a permanent neurological deficit at discharge. There was no MR-DWI+ in patients treated with Y-stenting or multi-stent Neuroform constructs. The only factor associated with ipsilateral MR-DWI+ was target aneurysm location on an arterial sidewall over bifurcation (P = .01).
CONCLUSION:
The Neuroform stent carries a very low risk of MR-DWI+ compared with its closed-cell design counterpart. Subarachnoid hemorrhage and deployment of multiple stents in the same anatomical region in configurations such as the Y-stent construct did not increase the risk of acute procedural thromboembolism.
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Affiliation(s)
- Robert S. Heller
- Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Venkata Dandamudi
- Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Daniel Calnan
- Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Adel M. Malek
- Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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Chalouhi N, Starke RM, Koltz MT, Jabbour PM, Tjoumakaris SI, Dumont AS, Rosenwasser RH, Singhal S, Gonzalez LF. Stent-assisted coiling versus balloon remodeling of wide-neck aneurysms: comparison of angiographic outcomes. AJNR Am J Neuroradiol 2013; 34:1987-92. [PMID: 23639562 DOI: 10.3174/ajnr.a3538] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Stent-assisted coiling and balloon-assisted coiling are 2 well-established techniques for treatment of wide-neck intracranial aneurysms. A direct comparative analysis of angiographic outcomes with the 2 techniques has not been available. We compare the angiographic outcomes of wide-neck aneurysms treated with stent-assisted coiling versus balloon-assisted coiling. MATERIALS AND METHODS A retrospective review was conducted on 101 consecutive patients treated at our institution, 69 with stent-assisted coiling and 32 with balloon-assisted coiling. Two multivariate logistic regression analyses were performed to determine predictors of aneurysm obliteration and predictors of progressive aneurysm thrombosis at follow-up. RESULTS The 2 groups were comparable with respect to all baseline characteristics with the exception of a higher proportion of ruptured aneurysms in the balloon-assisted coiling group (65.6%) than in the stent-assisted coiling group (11.5%, P < .001). Procedural complications did not differ between the stent-assisted coiling group (6%) and the balloon-assisted coiling group (9%, P = .5). The rates of complete aneurysm occlusion (Raymond score 1) at the most recent follow-up were significantly higher for the stent-assisted coiling group (75.4%) compared with the balloon-assisted coiling group (50%, P = .01). Progressive occlusion of incompletely coiled aneurysms was noted in 76.6% of aneurysms in the stent-assisted coiling group versus 42.8% in the balloon-assisted coiling group (P = .02). Retreatment rates were significantly lower with stent-assisted coiling (4.3%) versus balloon-assisted coiling (15.6%, P = .05). In multivariate analysis, stented aneurysms independently predicted both complete aneurysm obliteration and progression of occlusion. CONCLUSIONS Stent-assisted coiling may yield lower rates of retreatment and higher rates of aneurysm obliteration and progression of occlusion at follow-up than balloon-assisted coiling with a similar morbidity rate.
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Affiliation(s)
- N Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Chalouhi N, Jabbour P, Singhal S, Drueding R, Starke RM, Dalyai RT, Tjoumakaris S, Gonzalez LF, Dumont AS, Rosenwasser R, Randazzo CG. Stent-assisted coiling of intracranial aneurysms: predictors of complications, recanalization, and outcome in 508 cases. Stroke 2013; 44:1348-53. [PMID: 23512976 DOI: 10.1161/strokeaha.111.000641] [Citation(s) in RCA: 294] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Self-expanding stents are increasingly used for treatment of complex intracranial aneurysms. We assess the safety and the efficacy of intracranial stenting and determine predictors of treatment outcomes. METHODS A total of 508 patients with 552 aneurysms were treated with Neuroform and Enterprise stents between 2006 and 2011 at our institution. A multivariate analysis was conducted to identify predictors of complications, recanalization, and outcome. RESULTS Of 508 patients, 461 (91%) were treated electively and 47 (9%) in the setting of subarachnoid hemorrhage. Complications occurred in 6.8% of patients. In multivariate analysis, subarachnoid hemorrhage, delivery of coils before stent placement, and carotid terminus/middle cerebral artery aneurysm locations were independent predictors of procedural complications. Angiographic follow-up was available for 87% of patients at a mean of 26 months. The rates of recanalization and retreatment were, respectively, 12% and 6.4%. Older age, previously coiled aneurysms, larger aneurysms, incompletely occluded aneurysms, Neuroform stent, and aneurysm location were predictors of recanalization. Favorable outcomes were seen in 99% of elective patients and 51% of subarachnoid hemorrhage patients. Patient age, ruptured aneurysms, and procedural complications were predictors of outcome. CONCLUSIONS Stent-assisted coiling of intracranial aneurysms is safe, effective, and provides durable aneurysm closure. Higher complication rates and worse outcomes are associated with treatment of ruptured aneurysms. Stent delivery before coil deployment reduces the risk of procedural complications. Staging the procedure may not improve procedural safety. Closed-cell stents are associated with significantly lower recanalization rates.
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Affiliation(s)
- Nohra Chalouhi
- Department of Neurological Surgery, Division of Neurovascular Surgery and Endovascular Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
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Chitale R, Chalouhi N, Theofanis T, Starke RM, Amenta P, Jabbour P, Tjoumakaris S, Dumont AS, Rosenwasser RH, Gonzalez LF. Treatment of Ruptured Intracranial Aneurysms: Comparison of Stenting and Balloon Remodeling. Neurosurgery 2013; 72:953-9. [DOI: 10.1227/neu.0b013e31828ecf69] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Stent-assisted coiling (SAC) and balloon-assisted coiling (BAC) are 2 well-established techniques for the treatment of complex and wide-necked intracranial aneurysms. Most clinicians are reluctant to perform SAC in the setting of subarachnoid hemorrhage because of the need for dual antiplatelet therapy.
OBJECTIVE:
To compare the safety and efficacy of SAC and BAC in acutely ruptured complex and wide-necked aneurysms.
METHODS:
Forty-four patients underwent SAC and 40 underwent BAC. Patients treated with SAC received antiplatelet medications. Perioperative adverse events and outcomes at follow-up (mean, 7.4 months) were retrospectively studied.
RESULTS:
The 2 groups were statistically comparable with respect to all baseline characteristics except for older age in SAC patients (65.6 vs 56.5 years; P = .009). A higher proportion of SAC patients also had poor Hunt and Hess grades (III-V; 70.5% vs 55%; P = .l4). Hemorrhagic, thromboembolic, and overall procedural complications occurred in 6.8%, 11.4%, and 18.2% of the SAC group vs 2.5%, 7.5%, and 10% of the BAC group, respectively (P = .5, P = .6, P = .3, respectively). Favorable outcomes (modified Rankin Scale score 0-2) at follow-up were seen in 61.0% of the SAC group vs 77% of the BAC group (P = .1). In multivariable analysis, after controlling for differences in baseline characteristics, the type of treatment was not a predictor of procedural complications or clinical outcome.
CONCLUSION:
In this study, procedural complications and clinical outcomes did not differ significantly between SAC and BAC in patients with acutely ruptured aneurysms. SAC may be an acceptable alternative to BAC for complex aneurysms in the acute phase of subarachnoid hemorrhage.
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Affiliation(s)
- Rohan Chitale
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Thana Theofanis
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M. Starke
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Peter Amenta
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Aaron S. Dumont
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H. Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - L. Fernando Gonzalez
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Chalouhi N, Jabbour P, Gonzalez LF, Dumont AS, Rosenwasser R, Starke RM, Gordon D, Hann S, Tjoumakaris S. Safety and efficacy of endovascular treatment of basilar tip aneurysms by coiling with and without stent assistance: a review of 235 cases. Neurosurgery 2013; 71:785-94. [PMID: 22743359 DOI: 10.1227/neu.0b013e318265a416] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endovascular therapy is now the preferred treatment option for basilar tip aneurysms (BTAs). OBJECTIVE To compare the safety and efficacy of common endovascular techniques in the treatment of BTAs. METHODS A retrospective review was conducted of 235 patients with BTAs treated with endovascular means in our institution between 2004 and 2011. Categorization was based on the presence and type of stent assistance (none, single, and Y stenting). The rates of perioperative complications, recanalization, rehemorrhage, and retreatment were analyzed. RESULTS A total of 147 patients were treated with coil embolization and 88 patients with stent-assisted coiling (72 single stents, 16 Y stents). Thromboembolic complications occurred in 6.8% of patients in both groups. There was no associated mortality. Angiographic follow-up (mean, 23.5 months) was available in 172 patients (77.1%). Stented patients had significantly lower recanalization (17.2% vs 38.9%; P=.003) and retreatment (7.8% vs 27.8%; P=.002) rates compared with nonstented patients. Four rehemorrhages (2.7%) occurred in the coiled group, whereas none were noted in the stented group (P=.3). In paired comparisons, lower recanalization (8.3% vs 19.2%; P=.21) and retreatment (0% vs 9.6%; P=.19) rates were seen in the Y-stent group compared with the single-stent group. Thromboembolic complications occurred in 6.9% and 6.2% of patients in the single-stent and Y-stent groups, respectively (P=.91). In multivariate analysis, larger aneurysms, nonstented aneurysms, incomplete initial occlusion, and subarachnoid hemorrhage were predictors of aneurysm recanalization. CONCLUSION Stent-assisted coiling has significantly lower recurrence, retreatment, and rehemorrhage rates than coiling alone for the treatment of BTAs. Y stenting has the highest efficacy with low complication rates.
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Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania 19107, USA
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Chung J, Kim YB, Hong CK, Joo JY, Shin YS, Lim YC. Stent salvage using the Enterprise stent for procedure-related complication during coil embolization of ruptured intracranial aneurysms. Acta Neurochir (Wien) 2013; 155:223-9. [PMID: 23149588 DOI: 10.1007/s00701-012-1528-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 10/11/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite accumulated experience and improved understanding of the tools, endovascular treatment of intracranial aneurysms continues to have risks linked to the technique itself, and induces procedure-related complications. The purpose of this study was to report our series of stent salvage using the Enterprise stent for procedure-related complication during coil embolization in patients with ruptured intracranial aneurysms. METHODS Parent artery thrombosis, parent artery dissection, and coil protrusion were considered to be the procedure-related complications. There were 18 consecutive cases (3 unruptured and 15 ruptured aneurysms) with procedure-related complications rescued by the Enterprise stent from December 2008 to December 2011. Follow-up angiography was performed in 14 of the 15 patients with ruptured aneurysms between 6 and 30 months (mean 14.6 months) after the procedure. RESULTS The procedure-related complications were parent artery dissection (n = 1), parent artery thrombosis (n = 4), and coil protrusion (n = 10). There was no complication related to delivering or deploying of the Enterprise stent. Initial radiographic results showed 8 cases of complete occlusion and 7 cases of neck remnant. There was no change in the angiographic results during the follow-up periods. CONCLUSIONS Facing with procedure-related complications during coil embolization of ruptured intracranial aneurysms, the closed-cell designed Enterprise stent might be a useful option for the salvage technique by restoring blood flow and minimizing thromboembolic events.
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Affiliation(s)
- Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, College of Medicine, Yonsei University, Seoul, Republic of Korea
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Chalouhi N, Jabbour P, Kung D, Hasan D. Safety and efficacy of tirofiban in stent-assisted coil embolization of intracranial aneurysms. Neurosurgery 2013; 71:710-4; discussion 714. [PMID: 22668886 DOI: 10.1227/neu.0b013e31826213f9] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Thromboembolic complications are a major concern in stent-assisted coiling of intracranial aneurysms that may be prevented with adequate antiplatelet therapy. OBJECTIVE To assess the safety and efficacy of tirofiban in stent-assisted coiling. METHODS Two protocols were used. In the initial protocol, tirofiban was administered intravenously as a 0.4 μg/kg per min bolus for 30 minutes followed by 0.10 μg·kg min maintenance infusion. The revised protocol consisted of a 0.10 μg·kg min maintenance infusion alone. RESULTS Sixty-seven patients received tirofiban, 16 under the initial protocol and 51 under the revised protocol. Thirty (44.8%) patients had sustained a subarachnoid hemorrhage (SAH). Tirofiban infusion was initiated after thromboembolic events in 9 (13.4%) patients and prophylactically in 58 (86.6%). Four (6.0%) intracranial hemorrhages were noted. Three (18.8%) intracranial hemorrhages occurred with the initial protocol in patients treated electively and were fatal in 2 (66.7%) cases. The only complication (1.9%) under the revised protocol was a subclinical worsening of the computed tomographic appearance of an SAH. There was no tirofiban-related morbidity or deaths with the revised protocol. Of 9 patients that received tirofiban as a rescue treatment, 7 (77.8%) had complete and 2 (22.2%) had partial arterial recanalization. No thromboembolic events occurred in patients receiving prophylactic tirofiban. CONCLUSION A bolus followed by a maintenance dose of tirofiban appears to have a high risk of cerebral hemorrhage. A maintenance infusion without an initial bolus, however, has an exceedingly low risk of hemorrhage and appears to be very safe and effective, even in the setting of SAH.
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Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
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