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Barburoglu M, Arat A. Flow Diverters in the Treatment of Pediatric Cerebrovascular Diseases. AJNR Am J Neuroradiol 2016; 38:113-118. [PMID: 27765738 DOI: 10.3174/ajnr.a4959] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/08/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is very limited data concerning utilization of flow diverters in children. Our aim is to report results for the treatment of complex intracranial aneurysms and carotid cavernous fistulas by using flow diverters in children. MATERIALS AND METHODS Retrospective review of children (17 years of age or younger) treated with flow diverters between May 2011 and July 2014 was performed. Clinical and laboratory data and angiographic findings were extracted. Seven patients (6 males, 1 female; mean age, 12.7 years; range, 3-16 years) were included. Two presented with posttraumatic fistulas. The remaining patients presented with traumatic aneurysms of the cavernous carotid artery or fusiform aneurysms of the distal vertebral artery, M1, or A2 segments. All patients were premedicated with clopidogrel (75 mg daily for patients with body weights of >45 kg, 37.5 mg daily for 1 small child with a body weight of <45 kg) and aspirin (300 mg daily for ≥45 kg, 100 mg daily for smaller children). RESULTS VerifyNow and Multiplate Analyzer values were higher than expected. No clinical complications were noted. Imaging performed at 7-52 months after the procedure (mean/median, 22.3/14 months) revealed occlusions of all aneurysms and fistulas. One patient had an asymptomatic occlusion of the parent artery; otherwise, no hemodynamically significant parent artery restenosis was observed. There were no clinically significant neurologic events during follow-up. CONCLUSIONS Although flow-diverter placement appears to be safe and effective on midterm follow-up in children, longer follow-up is critical. The current sizes of flow diverter devices and delivery systems cover the pediatric size range, obviating developing flow diverters specific to children.
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Affiliation(s)
- M Barburoglu
- From the Department of Radiology (M.B.), Istanbul University Medical School, Istanbul, Turkey
| | - A Arat
- Department of Radiology (A.A.), School of Medicine, Hacettepe University, Ankara, Turkey.
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Burrows AM, Brinjikji W, Puffer RC, Cloft H, Kallmes DF, Lanzino G. Flow Diversion for Ophthalmic Artery Aneurysms. AJNR Am J Neuroradiol 2016; 37:1866-1869. [PMID: 27256849 DOI: 10.3174/ajnr.a4835] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 03/23/2016] [Indexed: 12/29/2022]
Abstract
Endovascular treatments of ophthalmic segment aneurysms are commonly used but visual outcomes remain a concern. We performed a retrospective review of patients with carotid-ophthalmic aneurysms treated with flow diversion from June 2009 to June 2015. The following outcomes were studied through chart review: visual outcomes, complications, postoperative stroke and intraparenchymal hemorrhage, and clinical outcomes. Angiographic outcomes were studied with angiography and MRA at 6 months, 1 year, and 3 years. We evaluated 50 carotid-ophthalmic aneurysms in 48 patients, among whom 44 patients with 46 aneurysms underwent treatment. The mean clinical follow-up was 29 ± 22 months (range, 0-65 months). There were no permanent adverse visual outcomes. There was 1 death because of late intraparenchymal hemorrhage (2.2%). Six-month angiography showed complete occlusion in 24 of 37 patients (64.9%), and 3-year angiography results showed occlusion in 24 of 25 patients (96%). In conclusion, flow diversion is a safe and effective treatment for carotid-ophthalmic aneurysms in carefully selected patients. The risk of adverse visual outcomes is low, and most aneurysms progress to complete occlusion.
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Affiliation(s)
- A M Burrows
- From the Departments of Neurologic Surgery (A.M.B., R.C.P., G.L.)
| | - W Brinjikji
- Radiology (W.B., H.C., D.F.K., G.L.), Mayo Clinic, Rochester, Minnesota.
| | - R C Puffer
- From the Departments of Neurologic Surgery (A.M.B., R.C.P., G.L.)
| | - H Cloft
- Radiology (W.B., H.C., D.F.K., G.L.), Mayo Clinic, Rochester, Minnesota
| | - D F Kallmes
- Radiology (W.B., H.C., D.F.K., G.L.), Mayo Clinic, Rochester, Minnesota
| | - G Lanzino
- From the Departments of Neurologic Surgery (A.M.B., R.C.P., G.L.)
- Radiology (W.B., H.C., D.F.K., G.L.), Mayo Clinic, Rochester, Minnesota
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103
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Chen K, Wang L, Wang D, Liu J, Lu J, Qi P. Balloon-in-stent assisted coiling for treatment of intracranial overwide and undertall aneurysms. J Clin Neurosci 2016; 34:202-206. [PMID: 27658574 DOI: 10.1016/j.jocn.2016.08.011] [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] [Received: 05/15/2016] [Revised: 08/03/2016] [Accepted: 08/10/2016] [Indexed: 11/28/2022]
Abstract
This study reports our experience of balloon-in-stent assisted coiling for the treatment of morphologically unfavorable aneurysms located in the internal carotid artery (ICA). From July 2007 to April 2014, twelve patients with twelve aneurysms located in the ICA were coil embolized by simultaneously using balloon and stent assistance. Five aneurysms were ruptured and seven were unruptured. All the aneurysms were overwide (dome-to-neck ratio ⩽1.2) and undertall (aspect ratio ⩽1.2) anatomically. The procedure-related adverse events, clinical and angiographic results were retrospectively analyzed. Intraprocedural aneurysmal bleeding occurred for one unruptured aneurysm but was stopped immediately after the balloon was inflated. Periprocedural thromboembolism occurred for two ruptured aneurysms, leading to death in one patient and severe neurological deficit for the other one. Procedure-related permanent morbidity and mortality rates were 8.3% (1/12) and 8.3% (1/12). Satisfactory (total and subtotal) occlusion was obtained immediately in 11 (91.7%) cases. Nine aneurysms received digital subtraction angiography follow-up (mean 25.1months, range 6-55), and all of them except one were totally obliterated. No aneurysmal bleeding occurred during a mean period of 59.1months, clinical follow-up for eleven patients. Balloon-in-stent assisted coiling might be a therapeutic alternative to prevent growth or rupture of overwide and undertall aneurysms. Nevertheless, it should be used prudently for ruptured ICA aneurysms, for its disadvantage of technical complexity and relatively high rate of adverse events.
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Affiliation(s)
- Kunpeng Chen
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China; Beijing Institute of Geriatrics, Graduate School of Peking Union Medical College, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China
| | - Lijun Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China
| | - Daming Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China; Beijing Institute of Geriatrics, Graduate School of Peking Union Medical College, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China.
| | - Jiachun Liu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China
| | - Jun Lu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China
| | - Peng Qi
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China
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Morales HG, Bonnefous O, Geers AJ, Brina O, Pereira VM, Spelle L, Moret J, Larrabide I. Does Arterial Flow Rate Affect the Assessment of Flow-Diverter Stent Performance? AJNR Am J Neuroradiol 2016; 37:2293-2298. [PMID: 27633810 DOI: 10.3174/ajnr.a4933] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 07/20/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to assess the performance of flow-diverter stents. The pre- and end-of-treatment angiographies are commonly compared. However, the arterial flow rate may change between acquisitions; therefore, a better understanding of its influence on the local intra-aneurysmal hemodynamics before and after flow-diverter stent use is required. MATERIALS AND METHODS Twenty-five image-based aneurysm models extracted from 3D rotational angiograms were conditioned for computational fluid dynamics simulations. Pulsatile simulations were performed at different arterial flow rates, covering a wide possible range of physiologic flows among 1-5 mL/s. The effect of flow-diverter stents on intra-aneurysmal hemodynamics was numerically simulated with a porous medium model. Spatiotemporal-averaged intra-aneurysmal flow velocity and flow rate were calculated for each case to quantify the hemodynamics after treatment. The short-term flow-diverter stent performance was characterized by the relative velocity reduction inside the aneurysm. RESULTS Spatiotemporal-averaged intra-aneurysmal flow velocity before and after flow-diverter stent use is linearly proportional to the mean arterial flow rate (minimum R2 > 0.983 of the linear regression models for untreated and stented models). Relative velocity reduction asymptotically decreases with increasing mean arterial flow rate. When the most probable range of arterial flow rate was considered (3-5 mL/s), instead of the wide possible flow range, the mean SD of relative velocity reduction was reduced from 3.6% to 0.48%. CONCLUSIONS Both intra-aneurysmal aneurysm velocity and flow-diverter stent performance depend on the arterial flow rate. The performance could be considered independent of the arterial flow rates within the most probable range of physiologic flows.
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Affiliation(s)
- H G Morales
- From Medisys-Philips Research (H.G.M., O.Bonnefous), Paris, France
| | - O Bonnefous
- From Medisys-Philips Research (H.G.M., O.Bonnefous), Paris, France
| | - A J Geers
- Centre for Cardiovascular Science (A.J.G.), University of Edinburgh, Edinburgh, Scotland.,Department of Information and Communication Technologies (A.J.G.), Universitat Pompeu Fabra, Barcelona, Spain
| | - O Brina
- Department of Information Neuroradiology (O.Brina), University Hospital of Geneva, Geneva, Switzerland
| | - V M Pereira
- Department of Medical Imaging and Department of Surgery (V.M.P.), University Health Network, Toronto, Ontario, Canada
| | - L Spelle
- Interventional Neuroradiology (L.S., J.M.), Beaujon University Hospital, Clichy, France.,Paris Diderot University (L.S.), Paris, France
| | - J Moret
- Interventional Neuroradiology (L.S., J.M.), Beaujon University Hospital, Clichy, France
| | - I Larrabide
- PLADEMA-CONICET (I.L.), Universidad Nacional del Centro de la Provincia de Buenos Aires, Tandil, Argentina
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105
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Labeyrie PE, Gory B, Sadeh-Gonike U, Huguet N, Sivan-Hoffmann R, Riva R, Courthéoux P, Turjman F. Early angiographic changes of intra-aneurysmal flow after flow-diverter stent treatment are not predictive of therapeutic success. Interv Neuroradiol 2016; 22:682-686. [PMID: 27511818 DOI: 10.1177/1591019916662192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/05/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND PURPOSE Flow-diverter stents (FDS) are new devices for the endovascular treatment of intracranial aneurysms (IAs) promoting progressive aneurysmal thrombosis. To date, the delay of aneurysmal exclusion remains unclear. We evaluated the correlation between angiographic changes in the first 24 hours and 12-month occlusion in aneurysms treated with FDS. METHODS We retrospectively analyzed the intra-aneurysmal flow by evaluating the in-flow and out-flow delays on preoperative, immediate postoperative, 24-hour and 12-month follow-up angiography. Dichotomy of in-flow and out-flow within the aneurysm was considered as the time of contrast filling and time of contrast washing relatively to the parent artery. The delay times were compared and correlated with the therapeutic success of FDS at 12 months of follow-up. RESULTS Out of 14 treated IAs, in 13 consecutive patients, n = 10 (71%) aneurysms showed complete occlusion at 12 months. Between immediate postoperative and 24-hour control, 10 aneurysms (71%) demonstrated in-flow modification, with eight increasing, two decreasing and four having no change. There were no statistical differences in therapeutic success in relation to the different flow-related profiles of intra-aneurysmal flux.Out-flow modifications were found in 11 aneurysms (79%) between immediate postoperative and 24-hour control, with five increasing, six decreasing and three having no change. Similar to the in-flow changes, there were no statistical differences in therapeutic success relative to the flow-related profiles. CONCLUSIONS Early angiographic changes after FDS placement are very frequent, but are not correlated with the 12-month technical success of flow-diversion techniques.
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Affiliation(s)
- Paul-Emile Labeyrie
- FHU IRIS, Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France
| | - Benjamin Gory
- FHU IRIS, Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France
| | - Udi Sadeh-Gonike
- FHU IRIS, Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France
| | - Nazyed Huguet
- FHU IRIS, Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France
| | - Rotem Sivan-Hoffmann
- FHU IRIS, Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France
| | - Roberto Riva
- FHU IRIS, Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France
| | - Patrick Courthéoux
- Department of Interventional Neuroradiology, Hôpital Cote de Nâcre, CHU de Caen, France
| | - Francis Turjman
- FHU IRIS, Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France
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106
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Daou B, Starke RM, Chalouhi N, Barros G, Tjoumakaris S, Rosenwasser RH, Jabbour P. P2Y12 Reaction Units: Effect on Hemorrhagic and Thromboembolic Complications in Patients With Cerebral Aneurysms Treated With the Pipeline Embolization Device. Neurosurgery 2016; 78:27-33. [PMID: 26571145 DOI: 10.1227/neu.0000000000000978] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The main concern with the use of the pipeline embolization device (PED) in treating cerebral aneurysms is the risk of hemorrhagic and thromboembolic complications. OBJECTIVE To investigate if P2Y12 reaction unit (PRU) values are associated with hemorrhagic and thromboembolic complications after treatment with the PED and to find an optimal range of preprocedural PRU values. METHODS Two hundred thirty-one patients with 248 cerebral aneurysms treated with the PED were retrospectively identified. Patients were started on dual-antiplatelet treatment at least 10 days before the intervention. PRU values were checked. Univariate and multivariate logistic regression were performed. Youden Indices were calculated to determine cutoffs for optimal PRU values. RESULTS Mean patient age was 57 years. Mean last preprocedural PRU was 132 (range: 1-382). The combined rate of major hemorrhagic complications (4%) and major thromboembolic complications (5.6%) was 9.6%. Analysis using Youden indices suggested an optimal PRU range of 70 to 150 with higher odds of complications outside this range (P = .01, odds ratio [OR] = 3 [1.2-7.5]). PRU <60 was a significant predictor of hemorrhagic complications (P = .04, OR = 2.45 [1.01-5.9]) and PRU >240 was a significant predictor of any thromboembolic complication (P = .04, OR = 3.6 [1.04-12]) and cerebral thromboembolic complications (P = .02, OR = 4 [1.2-14]). CONCLUSION Target preoperative PRU values should be between 60 and 240 and ideally between 70 and 150. Values below this range and above it carry higher odds of hemorrhagic and thromboembolic complications, respectively.
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Affiliation(s)
- Badih Daou
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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107
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de Carvalho FM, Caroff J, Pereira Dos Santos Neto E, Chalumeau V, Abdel Khalek H, Neki H, Saliou G, Rouchaud A, Moret J, Spelle L. Flow changes in the posterior communicating artery related to flow-diverter stents in carotid siphon aneurysms. J Neurointerv Surg 2016; 9:674-678. [PMID: 27387710 DOI: 10.1136/neurintsurg-2016-012443] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/09/2016] [Accepted: 06/15/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Flow-diverter stent (FDS) placement for treatment of intracranial aneurysms can cause flow changes in the covered branches. OBJECTIVE To assess the impact of the treatment of carotid siphon aneurysms with FDS on the posterior communicating artery (PComA) flow. MATERIALS AND METHODS Between February 2011 and January 2015, 125 carotid siphon aneurysms were treated with FDS. We retrospectively analyzed all cases with PComA ostial coverage. The circle of Willis anatomy was also studied as the flow changes in PComA postoperatively and during angiographic follow-up. Data from neurological examination were also collected. RESULTS Eighteen aneurysms of the carotid siphon in 17 patients were treated with FDS covering the ostium of the PComA. Based on the initial angiography, patients were divided into two groups: the first with a P1/PComA size ratio >1 (10 cases) and the second with a ratio ≤1 (8 cases). Follow-up angiography (mean time of 10 months) showed 90% of PComA flow changes in group 1 but only 12.5% in group 2. There was a significant difference between the two groups (p=0.002). Nevertheless, no patient had new symptoms related to these flow changes during the follow-up period. CONCLUSIONS In our experience, covering the PComA by FDS when treating carotid siphon aneurysms appeared safe and the P1/PComA ratio is a good predictor of flow changes in PComA.
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Affiliation(s)
- Fernando Mota de Carvalho
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France.,Department of Neurorradiologia Diagnóstica e Terapêutica, Hospital Universitário Pedro Ernesto, Rio de Janeiro, Brazil
| | - Jildaz Caroff
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France
| | | | - Vanessa Chalumeau
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France
| | | | - Hiroaki Neki
- Department of Neurosurgery, Saitama University, Saitama, Japan
| | - Guillaume Saliou
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France
| | - Aymeric Rouchaud
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France
| | - Jacques Moret
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France
| | - Laurent Spelle
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France
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Gentric JC, Fahed R, Darsaut TE, Salazkin I, Roy D, Raymond J. Fatal arterial rupture during angioplasty of a flow diverter in a recurrent, previously Y-stented giant MCA bifurcation aneurysm. Interv Neuroradiol 2016; 22:278-86. [PMID: 26893302 PMCID: PMC4984368 DOI: 10.1177/1591019916631147] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 01/13/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND PURPOSE A patient with a previously Y-stented giant left middle cerebral artery (MCA) bifurcation aneurysm returned with a recurrence. MATERIALS AND METHODS A flow diverter (FD) was deployed through one limb of the high-porosity Y-stenting construction. The proximal FD failed to expand and an attempt at balloon angioplasty led to fatal rupture of the MCA. RESULTS Autopsy demonstrated subarachnoid hemorrhage, vessel rupture and fracture of the proximal high-porosity stent. Microscopic photographs showed that the FD had failed to open because the guiding wire had inadvertently exited and re-entered the proximal segment of the high-porosity stent partially incorporated to the wall of the MCA. Balloon dilatation of the FD which had remained collapsed between the stent and the vessel wall caused fracture of the stent and rupture of the artery. CONCLUSION Angioplasty and flow-diversion of previously Y-stented aneurysms can lead to serious complications.
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Affiliation(s)
- Jean-Christophe Gentric
- Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radiology, Service of Neuroradiology, Canada
| | - Robert Fahed
- Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radiology, Service of Neuroradiology, Canada
| | - Tim E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Department of Surgery, Division of Neurosurgery, Canada
| | - Igor Salazkin
- Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM), Notre-Dame Hospital, Interventional Neuroradiology Research Laboratory, Canada
| | - Daniel Roy
- Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radiology, Service of Neuroradiology, Canada
| | - Jean Raymond
- Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radiology, Service of Neuroradiology, Canada
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Otani N, Wada K, Toyooka T, Fujii K, Ueno H, Tomura S, Tomiyama A, Nakao Y, Yamamoto T, Mori K. Usefulness of Suction Decompression Method Combined with Extradural Temporopolar Approach During Clipping of Complicated Internal Carotid Artery Aneurysm. World Neurosurg 2016; 90:293-299. [DOI: 10.1016/j.wneu.2016.02.120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 02/29/2016] [Accepted: 02/29/2016] [Indexed: 12/30/2022]
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110
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Sherif C, Herbich E, Plasenzotti R, Bergmeister H, Windberger U, Mach G, Sommer G, Holzapfel GA, Haider T, Krssak M, Kleinpeter G. Very large and giant microsurgical bifurcation aneurysms in rabbits: Proof of feasibility and comparability using computational fluid dynamics and biomechanical testing. J Neurosci Methods 2016; 268:7-13. [PMID: 27139738 DOI: 10.1016/j.jneumeth.2016.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/22/2016] [Accepted: 04/22/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Giant aneurysms are challenging lesions with unacceptable high rates of aneurysm recanalization and rerupture following embolization. Reliable in vivo models are urgently needed to test the performance of new more efficient endovascular devices. MATERIALS AND METHODS Aneurysms were created in 11 New Zealand white rabbits (4.5-5.5kg): A long venous pouch (length 25-30mm) mimicking the aneurysm sac was derived from the external jugular vein and sutured into a microsurgically created bifurcation between both common carotid arteries. After 4 weeks the rabbits underwent 3T Magnetic resonance angiography (3T-MRA). Exemplary computational fluid dynamics (CFD) simulations were performed to compare the flow conditions of giant rabbit and human aneurysms. We used species-related boundary conditions, in particular, we measured blood viscosity values. Biaxial mechanical tests were performed for the mechanical characterization and comparison. COMPARISON WITH EXISITING METHOD(S) None. RESULTS No peri- or postoperative mortality was observed. 3T-MRA showed aneurysm patency in 10 out of 11 aneurysms (90.9%). Aneurysm lengths ranged from 21.5-25.6mm and aneurysm necks from 7.3-9.8mm. CFD showed complex flow profiles with multiple vortices in both, rabbit and human aneurysms. Lower blood viscosity values of the rabbit (3.92mPas vs. human 5.34mPas) resulted in considerable lower wall shear stress rates (rabbit 0.38Pa vs. human 1.66Pa). Mechanical tests showed lower stiffness of rabbit aneurysms compared to unruptured human aneurysms. CONCLUSIONS The proposed model showed favorable aneurysm patency rates, low morbidity and good hemodynamic comparability with complex flow patterns. Biomechanical testing suggests that experimental aneurysms might be even more fragile compared to human aneurysms.
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Affiliation(s)
- Camillo Sherif
- Department of Neurosurgery, Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030 Vienna, Austria; Cerebrovascular Research Group, Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030 Vienna, Austria; Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria; Department of Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Erwin Herbich
- Department of Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Roberto Plasenzotti
- Cerebrovascular Research Group, Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030 Vienna, Austria; Department of Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Helga Bergmeister
- Cerebrovascular Research Group, Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030 Vienna, Austria; Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria; Department of Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Ursula Windberger
- Department of Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Georg Mach
- Cerebrovascular Research Group, Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030 Vienna, Austria; Institute for Microelectronics, Vienna University of Technology, Gußhausstraße 27-29, 1040 Vienna, Austria
| | - Gerhard Sommer
- Institute of Biomechanics, Graz University of Technology, Kronesgasse 5/I, 8010 Graz, Austria
| | - Gerhard A Holzapfel
- Institute of Biomechanics, Graz University of Technology, Kronesgasse 5/I, 8010 Graz, Austria
| | - Thomas Haider
- Cerebrovascular Research Group, Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030 Vienna, Austria; University Clinic for Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Martin Krssak
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; High Field MR Centre, Depart of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Guenther Kleinpeter
- Department of Neurosurgery, Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030 Vienna, Austria; Cerebrovascular Research Group, Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030 Vienna, Austria
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Matsukawa H, Tanikawa R, Kamiyama H, Tsuboi T, Noda K, Ota N, Miyata S, Takeda R, Tokuda S. Risk Factors for Visual Impairments in Patients with Unruptured Intradural Paraclinoid Aneurysms Treated by Neck Clipping without Bypass Surgery. World Neurosurg 2016; 91:183-9. [PMID: 27080234 DOI: 10.1016/j.wneu.2016.04.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 04/01/2016] [Accepted: 04/02/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Although paraclinoid aneurysms are now frequently referred for endovascular treatment, the durability of obliteration is still to be determined. Therefore, direct surgery for paraclinoid aneurysms still remains indispensable. The present study aimed to evaluate the risk factors for the visual impairments in patients with unruptured intradural paraclinoid aneurysms. METHODS The data of 133 patients with 136 aneurysms treated by neck clipping without bypass surgery was evaluated. Visual impairments included decreased visual acuity and visual field defect. The aneurysm was classified into superior projecting aneurysm, ventral projecting aneurysm, and carotid cave aneurysm. Plug-in method was defined as filling interspace, which was formed between the internal carotid artery and the sutured dura in case of detachment of the dural ring. RESULTS Postoperative new visual impairments were observed in 30 aneurysms (22%). During the follow-up period (median, 600 days), postoperative new visual impairments continued in 23 aneurysms (17%). Multivariate analysis showed that carotid cave location and plug-in method were related to new visual impairments at 30 days (odds ratio [OR], 2.6; 95% confidence interval [CI] 1.1-6.1; P = 0.031 and OR, 4.1; 95% CI 1.4-12; P = 0.008) and at 6 months (OR, 4.1; 95% CI 1.5-11; P = 0.005 and OR, 3.3; 95% CI 1.1-11; P = 0.045). CONCLUSIONS The present study showed that carotid cave location and plug-in method during dural closures were related to postoperative continued visual impairments. Neurosurgeons should carefully consider the surgical indication for unruptured carotid cave aneurysms and avoid plug-in methods.
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Affiliation(s)
- Hidetoshi Matsukawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan.
| | - Rokuya Tanikawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Hiroyasu Kamiyama
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Toshiyuki Tsuboi
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Kosumo Noda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Nakao Ota
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Shiro Miyata
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Rihei Takeda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Sadahisa Tokuda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
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Tecle NEE, Zammar SG, Hamade YJ, El Ahmadieh TY, Aoun RJN, Nanney AD, Batjer HH, Dumanian GA, Bendok BR. Use of a harvested radial artery graft with preservation of the vena comitantes to reduce spasm risk and improve graft patency for extracranial to intracranial bypass: Technical note. Clin Neurol Neurosurg 2016; 142:65-71. [DOI: 10.1016/j.clineuro.2015.12.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 12/16/2015] [Accepted: 12/27/2015] [Indexed: 10/22/2022]
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113
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Zerroug A, Gascou G, Machi P, Riquelme C, Costalat V, Bonafé A. Facteurs prédictifs d’une occlusion anévrismale inadéquate après un traitement par diversion du flux. J Neuroradiol 2016. [DOI: 10.1016/j.neurad.2016.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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114
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Silk flow diverter in the treatment of complex intracranial aneurysms: a single-center experience with 60 patients. Acta Neurochir (Wien) 2016; 158:247-54. [PMID: 26630988 DOI: 10.1007/s00701-015-2644-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Flow diverters are used to treat complex aneurysms that are not amenable to coiling. The aim of the present work was to retrospectively evaluate our experience with the Silk flow diverter. Technical nuances and complications are specifically discussed. METHODS Retrospectively data was collected on patients treated with Silk between October 2008 and October 2013. RESULTS Sixty patients harboring 67 aneurysms were treated using the Silk. Fifteen aneurysms were located in the posterior circulation and 52 in the anterior. A good angiographic result was achieved in 88 % (53/60) of the aneurysms available for imaging follow-up. There were ten treatment-related complications, 80 % were ischemic. Risk of complications increased with aneurysm size and in aneurysms of the posterior circulation. CONCLUSIONS Silk flow diverters are a good treatment option for aneurysms of the anterior circulation. Additional stents may be required in specific cases due to the Silk's low radial resistance. Treatment of giant fusiform aneurysms of the posterior circulation with Silk flow diverters is associated with a high rate of severe complications.
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115
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Flow Diversion for Treating Middle Cerebral Artery Aneurysms. World Neurosurg 2016; 90:627-629. [PMID: 26780283 DOI: 10.1016/j.wneu.2016.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 11/23/2022]
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116
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Barburoglu M, Aydin K. Rescue Retrieval of a Fully Deployed Low-Profile Intracranial Stent After Acute Occlusion. World Neurosurg 2016; 85:349-52. [DOI: 10.1016/j.wneu.2015.08.066] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 08/28/2015] [Accepted: 08/29/2015] [Indexed: 11/28/2022]
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117
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Neki H, Caroff J, Jittapiromsak P, Benachour N, Mihalea C, Ikka L, Moret J, Spelle L. Patency of the anterior choroidal artery covered with a flow-diverter stent. J Neurosurg 2015; 123:1540-5. [PMID: 26047410 DOI: 10.3171/2014.11.jns141603] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The concept of the flow-diverter stent (FDS) is to induce aneurysmal thrombosis while preserving the patency of the parent vessel and any covered branches. In some circumstances, it is impossible to avoid dangerously covering small branches, such as the anterior choroidal artery (AChA), with the stent. In this paper, the authors describe the clinical and angiographic effects of covering the AChA with an FDS.
METHODS
Between April 2011 and July 2013, 92 patients with intracranial aneurysms were treated with the use of FDSs in the authors’ institution. For 20 consecutive patients (21.7%) retrospectively included in this study, this involved the unavoidable covering of the AChA with a single FDS during endovascular therapy. AChAs feeding the choroid plexus were classified as the long-course group (14 cases), and those not feeding the choroid plexus were classified as the short-course group (6 cases). Clinical symptoms and the angiographic aspect of the AChA were evaluated immediately after stent delivery and during follow-up. Neurological examinations were performed to rule out hemiparesis, hemihypesthesia, hemianopsia, and other cortical signs.
RESULTS
FDS placement had no immediate effect on AChA blood flow. Data were obtained from 1-month clinical follow-up in all patients and from midterm angiographic follow-up in 17 patients (85.0%), with a mean length of 9.8 ± 5.4 months. No patient in either group complained of transient or permanent symptoms related to an AChA occlusion. In all cases, the AChA remained patent without any flow changes.
CONCLUSIONS
The results of this study suggest that when impossible to avoid, the AChA may be safely covered with a single FDS during intracranial aneurysm treatment, irrespective of anatomy and anastomoses.
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Affiliation(s)
- Hiroaki Neki
- Interventional Neuroradiology NEURI Center, Beaujon Hospital, Paris Diderot University, Clichy, France
| | - Jildaz Caroff
- Interventional Neuroradiology NEURI Center, Beaujon Hospital, Paris Diderot University, Clichy, France
| | - Pakrit Jittapiromsak
- Interventional Neuroradiology NEURI Center, Beaujon Hospital, Paris Diderot University, Clichy, France
| | - Nidhal Benachour
- Interventional Neuroradiology NEURI Center, Beaujon Hospital, Paris Diderot University, Clichy, France
| | - Cristian Mihalea
- Interventional Neuroradiology NEURI Center, Beaujon Hospital, Paris Diderot University, Clichy, France
| | - Leon Ikka
- Interventional Neuroradiology NEURI Center, Beaujon Hospital, Paris Diderot University, Clichy, France
| | - Jacques Moret
- Interventional Neuroradiology NEURI Center, Beaujon Hospital, Paris Diderot University, Clichy, France
| | - Laurent Spelle
- Interventional Neuroradiology NEURI Center, Beaujon Hospital, Paris Diderot University, Clichy, France
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Daou B, Starke RM, Chalouhi N, Tjoumakaris S, Hasan D, Khoury J, Rosenwasser RH, Jabbour P. Pipeline Embolization Device in the Treatment of Recurrent Previously Stented Cerebral Aneurysms. AJNR Am J Neuroradiol 2015; 37:849-55. [PMID: 26611991 DOI: 10.3174/ajnr.a4613] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 09/16/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The use of the Pipeline Embolization Device in the management of recurrent previously stented cerebral aneurysms is controversial. The aim of this study was to evaluate the efficacy and safety of the Pipeline Embolization Device in the treatment of recurrent, previously stented aneurysms. MATERIALS AND METHODS Twenty-one patients with previously stented recurrent aneurysms who later underwent Pipeline Embolization Device placement (group 1) were retrospectively identified and compared with 63 patients who had treatment with the Pipeline Embolization Device with no prior stent placement (group 2). Occlusion at the latest follow-up angiogram, recurrence and retreatment rates, clinical outcome, complications, and morbidity and mortality observed after treatment with the Pipeline Embolization Device were analyzed. RESULTS Patient characteristics were similar between the 2 groups. The mean time from stent placement to recurrence was 25 months. Pipeline Embolization Device treatment resulted in complete aneurysm occlusion in 55.6% of patients in group 1 versus 80.4% of patients in group 2 (P = .036). The retreatment rate in group 1 was 11.1% versus 7.1% in group 2 (P = .62). The rate of good clinical outcome at the latest follow-up in group 1 was 81% versus 93.2% in group 2 (P = .1). Complications were observed in 14.3% of patients in group 1 and 9.5% of patients in group 2 (P = .684). CONCLUSIONS The use of the Pipeline Embolization Device in the management of previously stented aneurysms is less effective than the use of this device in nonstented aneurysms. Prior stent placement can worsen the safety and efficacy profile of this device.
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Affiliation(s)
- B Daou
- From the Department of Neurosurgery (B.D., N.C., S.T., J.K., R.H.R., P.J.), Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - R M Starke
- Department of Neurological Surgery (R.M.S.), University of Virginia School of Medicine, Charlottesville, Virginia
| | - N Chalouhi
- From the Department of Neurosurgery (B.D., N.C., S.T., J.K., R.H.R., P.J.), Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - S Tjoumakaris
- From the Department of Neurosurgery (B.D., N.C., S.T., J.K., R.H.R., P.J.), Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - D Hasan
- Department of Neurosurgery (D.H.), University of Iowa, Iowa City, Iowa
| | - J Khoury
- From the Department of Neurosurgery (B.D., N.C., S.T., J.K., R.H.R., P.J.), Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - R H Rosenwasser
- From the Department of Neurosurgery (B.D., N.C., S.T., J.K., R.H.R., P.J.), Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - P Jabbour
- From the Department of Neurosurgery (B.D., N.C., S.T., J.K., R.H.R., P.J.), Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Chalouhi N, Jabbour P, Daou B, Starke RM, Shields B, Hasan DM. A New Protocol for Anticoagulation With Tirofiban During Flow Diversion. Neurosurgery 2015; 78:670-4. [DOI: 10.1227/neu.0000000000001071] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Flow diversion is increasingly used to treat intracranial aneurysms. In previous reports, patients were pretreated with aspirin and clopidogrel before the intervention for the prevention of thromboembolic complications.
OBJECTIVE:
To assess the safety and efficacy of a new protocol for anticoagulation using tirofiban during flow diversion.
METHODS:
All patients received a 0.10–μg.kg−1.min−1 maintenance infusion of tirofiban intraoperatively without a loading dose. All patients were loaded with aspirin (325 mg) and clopidogrel (600 mg) just before the procedure or intraoperatively. No patient was pretreated with aspirin or clopidogrel. Thromboembolic and hemorrhagic complications were recorded.
RESULTS:
A total of 46 patients were treated with this protocol. Six patients (13%) had sustained a subarachnoid hemorrhage and were treated with the Pipeline Embolization Device within 24 hours of aneurysm rupture. The mean number of devices was 1.2 ± 0.66; adjunctive coiling was performed in 3 patients (6.5%). There were 2 complications (4.3%), 1 thromboembolic (2.2%) and 1 hemorrhagic (2.2%; monocular vision loss from occlusion of the central retinal artery in 1 patient and a parenchymal hemorrhage managed conservatively in another patient). No patient developed thrombocytopenia or retroperitoneal, gastrointestinal, or genitourinary bleeding. Of 46 patients, 44 (95.7%) had a modified Rankin Scale score of 0 to 2 at their follow-up visit.
CONCLUSION:
A protocol of anticoagulation with tirofiban during flow diversion has an excellent safety profile. This protocol provides a reasonable alternative to pretreatment with aspirin and clopidogrel and is useful in patients with ruptured aneurysms or when the use of a stent is unexpected.
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Affiliation(s)
- Nohra Chalouhi
- 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
| | - Badih Daou
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M. Starke
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Bridget Shields
- Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - David M. Hasan
- Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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Comparison of the flow diverter and stent-assisted coiling in large and giant aneurysms: safety and efficacy based on a propensity score-matched analysis. Eur Radiol 2015; 26:2369-77. [PMID: 26471273 DOI: 10.1007/s00330-015-4052-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 09/23/2015] [Accepted: 09/29/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The flow diverter (FD) is a device aimed at reconstructing the parent artery and occluding an aneurysm. We performed a propensity score-matched analysis to compare safety and efficacy between the FD and stent-assisted coiling. METHODS A database review was conducted to identify patients with large and giant unruptured aneurysms (aneurysms located in the ACA, MCA, or PCA were excluded) treated with the FD or stent-assisted coiling. A propensity score, representing the probability of using the FD, was generated for each aneurysm using the relevant patient and aneurysmal variables. Angiographic results, complications, and clinical outcomes were compared. RESULTS Forty-five aneurysms treated with the FD (FD alone: 32; FD+Coils: 13) and 45 treated with stent-assisted coiling were matched. The rate of complete occlusion was significantly (P = 0.0002) higher in the FD cohort than the conventional stent cohort at the 6-month follow-up. The FD cohort achieved greater improvement (P < 0.0001) and a lower rate of recurrence (P = 0.0001). The rate of periprocedural complications was similar, as was the proportion of patients who attained mRS ≤ 2 at discharge and at the 6-month follow-up. CONCLUSIONS Our findings provide reliable evidence demonstrating that the FD may be a preferred treatment option for large and giant unruptured aneurysms. KEY POINTS • Flow Diverter provided a higher complete occlusion rate at 6-month follow-up. • Flow Diverter achieved more progress occlusion and less recurrence. • Compared with the conventional stents, procedure-related morbidity of Flow Diverter was similar. • Flow Diverter is a preferred treatment for large and giant unruptured aneurysms.
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121
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Extraintracranial Bypass as a Rescue Therapy for Symptomatic Flow Diverter Thrombosis. Case Rep Neurol Med 2015; 2015:204387. [PMID: 26457212 PMCID: PMC4589589 DOI: 10.1155/2015/204387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 09/06/2015] [Indexed: 11/17/2022] Open
Abstract
A 56-year-old female with a giant partially thrombosed unruptured carotid-ophthalmic aneurysm was treated with a Pipeline flow diverter. Three months after the procedure, in concomitance with the discontinuation of one of the antiplatelet medications, the patient suffered from a minor stroke and relapsing transient ischemic attacks. The angiography demonstrated the occlusion of the internal carotid artery, and a perfusion-weighted CT scan showed a condition of hypoperfusion. The patient underwent a double-barrel extraintracranial bypass. The postoperative course was uneventful and she has experienced no further ischemic events to date.
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122
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Park W, Park JC, Han K, Ahn JS, Kwun BD. Anterior Optic Pathway Compression Due to Internal Carotid Artery Aneurysms: Neurosurgical Management and Outcomes. J Stroke 2015; 17:344-53. [PMID: 26438000 PMCID: PMC4635711 DOI: 10.5853/jos.2015.17.3.344] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 07/16/2015] [Accepted: 08/03/2015] [Indexed: 01/09/2023] Open
Abstract
Background and Purpose Compression of the anterior optic pathway results in visual deficits that can lead to the detection of unruptured aneurysms in the internal carotid artery (ICA). The general types of treatment modalities for aneurysms and visual deficits include surgery and endosaccular coiling. This study retrospectively analyzed and compared the resolution of visual deficits following surgery or endosaccular coiling. Methods We reviewed data on 33 patients with unruptured ICA aneurysms who presented with visual field deficits caused by mass effects over the anterior optic pathway. Statistical analyses were performed to identify the variables associated with the recovery of visual symptoms. Results Eighteen patients underwent aneurysm clipping, 2 underwent bypass surgery with endovascular trapping, and 2 underwent endovascular trapping without bypass surgery (group A). Ten patients received endosaccular coiling (group B). The visual outcomes included the following: in group A, 17 patients (73.9%) demonstrated improvement and 6 patients (26.1%) demonstrated no changes or worse outcomes; in group B, 2 patients (20.0%) demonstrated improvement and 8 patients (80.0%) demonstrated no changes or worse outcomes. Group A was associated with a higher rate of favorable outcome than group B (P = 0.007). According to the multivariate analysis, treatment without endosaccular coiling (group A) was the only variable significantly associated with improvement of visual outcome (P = 0.005; OR = 28.523; 95% CI = 2.683-303.171). Conclusions Treatment modality was the only predictor of improvement in visual deficits. Treatment without endosaccular coiling resulted in visual improvement significantly more often in comparison with endosaccular coiling.
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Affiliation(s)
- Wonhyoung Park
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical center, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical center, Seoul, Korea
| | - Kyunghwa Han
- Biostatistics Collaboration Unit, Gangnam Medical Research Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical center, Seoul, Korea
| | - Byung Duk Kwun
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical center, Seoul, Korea
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Caroff J, Neki H, Mihalea C, D'Argento F, Abdel Khalek H, Ikka L, Moret J, Spelle L. Flow-Diverter Stents for the Treatment of Saccular Middle Cerebral Artery Bifurcation Aneurysms. AJNR Am J Neuroradiol 2015; 37:279-84. [PMID: 26405085 DOI: 10.3174/ajnr.a4540] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 06/12/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The flow-diverter stent has been proved a feasible, safe, and efficient technique, particularly for the treatment of large and broad-neck carotid siphon aneurysms. Wide-neck bifurcation aneurysms remain, in some cases, a challenge for neurointerventionalists. We report the outcomes of the treatment of saccular middle cerebral artery bifurcation aneurysms with flow diversion in our institution. MATERIALS AND METHODS From the institution data base, all saccular, nondissecting MCA bifurcation aneurysms, treated with flow-diverter stents, were retrospectively reviewed. Technical issues, immediate posttreatment and follow-up angiographic findings, and clinical outcomes were assessed. RESULTS Fourteen patients with 15 aneurysms were included in the study. Ischemic complications, as confirmed by MR imaging, occurred in 6 patients (43%). Procedure-related morbidity and mortality at last follow-up were 21% and 0%, respectively. Angiographic follow-up was available for 13 aneurysms, with a mean follow-up of 16 months. Complete occlusion was obtained for 8 aneurysms (62%). CONCLUSIONS Compared with other available therapeutic options, the flow-diverter stent does not appear to be a suitable solution for the treatment of saccular MCA bifurcation aneurysms.
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Affiliation(s)
- J Caroff
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France
| | - H Neki
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France Department of Neurosurgery (H.N.), Saitama University, Saitama, Japan
| | - C Mihalea
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France Department of Neurosurgery (C.M.), University of Medicine and Pharmacy "Victor Babes," Timisoara, Romania
| | - F D'Argento
- Department of Bioimaging and Radiological Sciences (F.D.), Policlinico "A. Gemelli," Rome, Italy
| | - H Abdel Khalek
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France Department of Neuropsychiatry (H.A.K.), Tanta University Hospital, Tanta, Egypt
| | - L Ikka
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France
| | - J Moret
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France
| | - L Spelle
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France
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Fischer S, Aguilar-Pérez M, Henkes E, Kurre W, Ganslandt O, Bäzner H, Henkes H. Initial Experience with p64: A Novel Mechanically Detachable Flow Diverter for the Treatment of Intracranial Saccular Sidewall Aneurysms. AJNR Am J Neuroradiol 2015; 36:2082-9. [PMID: 26272970 DOI: 10.3174/ajnr.a4420] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 03/17/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow diverters are important tools for the treatment of intracranial aneurysms. We report a retrospective evaluation of the safety and efficacy of p64, a fully resheathable, detachable flow diverter, in the endovascular treatment of intracranial sidewall aneurysms. MATERIALS AND METHODS Results of 121 patients with 130 aneurysms (median neck size, 3 mm; median fundus size, 4 mm), treated from April 2012 through October 2014, were analyzed. Aneurysms were unruptured or beyond the acute SAH phase. Thirteen aneurysms were located in the posterior circulation. Twenty-three aneurysms had previous saccular treatment but no previous parent vessel stent placement. In 19 aneurysms, a combination of coiling and flow diversion was performed. RESULTS Successful p64 deployment was achieved in 127/130 aneurysms. The average number of p64s used was 1.1 per aneurysm. The rates of transient and permanent morbidity and mortality were 5%, 1.7%, and 0.8%, respectively. Three-month DSA follow-up in 123/130 aneurysms showed complete occlusion in 58.5%. Nine-month DSA follow-up in 93/106 (87.7%) eligible aneurysms showed complete occlusion in 79.6%. Late follow-up (median, 496 days) has already been performed in 35 aneurysms, showing complete occlusion in 30 (85.7%). CONCLUSIONS p64 offers an efficacious treatment option for intracranial sidewall aneurysms with a high aneurysm occlusion and an acceptable complication rate. The possibility of repositioning or removing the device was an advantage. The higher attenuation may lead to fewer devices per case and early aneurysm occlusion. Long-term follow-up data are pending.
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Affiliation(s)
- S Fischer
- From the Neuroradiologische Klinik (S.F., M.A.-P., E.H., W.K., H.H.) the Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie und Nuklearmedizin (S.F.), Universitätsklinikum Knappschaftskrankenhaus, Bochum, Germany
| | - M Aguilar-Pérez
- From the Neuroradiologische Klinik (S.F., M.A.-P., E.H., W.K., H.H.)
| | - E Henkes
- From the Neuroradiologische Klinik (S.F., M.A.-P., E.H., W.K., H.H.)
| | - W Kurre
- From the Neuroradiologische Klinik (S.F., M.A.-P., E.H., W.K., H.H.)
| | | | - H Bäzner
- Neurologische Klinik (H.B.), Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- From the Neuroradiologische Klinik (S.F., M.A.-P., E.H., W.K., H.H.)
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125
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van der Marel K, Gounis MJ, Weaver JP, de Korte AM, King RM, Arends JM, Brooks OW, Wakhloo AK, Puri AS. Grading of Regional Apposition after Flow-Diverter Treatment (GRAFT): a comparative evaluation of VasoCT and intravascular OCT. J Neurointerv Surg 2015. [DOI: 10.1136/neurintsurg-2015-011843] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BackgroundPoor vessel wall apposition of flow diverter (FD) stents poses risks for stroke-related complications when treating intracranial aneurysms, necessitating long-term surveillance imaging. To facilitate quantitative evaluation of deployed devices, a novel algorithm is presented that generates intuitive two-dimensional representations of wall apposition from either high-resolution contrast-enhanced cone-beam CT (VasoCT) or intravascular optical coherence tomography (OCT) images.MethodsVasoCT and OCT images were obtained after FD implant (n=8 aneurysms) in an experimental sidewall aneurysm model in canines. Surface models of the vessel wall and FD device were extracted, and the distance between them was presented on a two-dimensional flattened map. Maps and cross-sections at potential locations of malapposition detected on VasoCT-based maps were compared. The performance of OCT-based apposition detection was evaluated on manually labeled cross-sections using logistic regression against a thresholded (≥0.25 mm) apposition measure.ResultsVasoCT and OCT acquisitions yielded similar Grading of Regional Apposition after Flow-Diverter Treatment (GRAFT) apposition maps. GRAFT maps from VasoCT highlighted 16 potential locations of malapposition, of which two were found to represent malapposed device struts. Logistic regression showed that OCT could detect malapposition with a sensitivity of 98% and a specificity of 81%.ConclusionsGRAFT delivered quantitative and visually convenient representations of potential FD malapposition and occasional acute thrombus formation. A powerful combination for future neuroendovascular applications is foreseen with the superior resolution delivered by intravascular OCT.
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Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.
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Affiliation(s)
- Stanlies D'Souza
- Department of Neuroanesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
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127
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Kan P, Mokin M, Puri AS, Wakhloo AK. Republished: Successful treatment of a giant pediatric fusiform basilar trunk aneurysm with surpass flow diverter. J Neurointerv Surg 2015; 8:e23. [DOI: 10.1136/neurintsurg-2015-011718.rep] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2015] [Indexed: 11/04/2022]
Abstract
Fusiform aneurysms present a unique challenge to traditional microsurgical and endovascular treatment because of the lack of a discernible neck and the involvement of parent vessel. Flow diversion has increasingly become the treatment of choice for fusiform aneurysms in the anterior circulation, but its results in the posterior circulation are variable. We report successful treatment of a giant fusiform upper basilar trunk aneurysm with the Surpass flow diverter in an adolescent, and discuss the potential advantages of this emerging technology in the treatment of fusiform posterior circulation aneurysms.
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128
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Kan P, Mokin M, Puri AS, Wakhloo AK. Successful treatment of a giant pediatric fusiform basilar trunk aneurysm with surpass flow diverter. BMJ Case Rep 2015; 2015:bcr-2015-011718. [PMID: 26040828 DOI: 10.1136/bcr-2015-011718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Fusiform aneurysms present a unique challenge to traditional microsurgical and endovascular treatment because of the lack of a discernible neck and the involvement of parent vessel. Flow diversion has increasingly become the treatment of choice for fusiform aneurysms in the anterior circulation, but its results in the posterior circulation are variable. We report successful treatment of a giant fusiform upper basilar trunk aneurysm with the Surpass flow diverter in an adolescent, and discuss the potential advantages of this emerging technology in the treatment of fusiform posterior circulation aneurysms.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, USF, Tampa, Florida, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Ajay K Wakhloo
- Department of Radiology, New England Center for Stroke Research and Division Neuroimaging and Intervention, Worcester, Massachusetts, USA Division of Neuroimaging and Intervention, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Gawlitza M, Januel AC, Tall P, Bonneville F, Cognard C. Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: a single-center series with special emphasis on covered cortical branches and perforating arteries. J Neurointerv Surg 2015; 8:481-7. [PMID: 25878068 DOI: 10.1136/neurintsurg-2015-011682] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 03/13/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Data regarding anatomic and clinical results of flow diversion treatment in complex bifurcation aneurysms of the anterior circulation are scarce. OBJECTIVE To present our results of treatment of these lesions with special emphasis on the fate of 'jailed' cortical branches and perforating arteries. METHODS Seventeen patients were treated with flow diverters (FDs) for 18 aneurysms of the middle cerebral artery bifurcation (n=13) and the anterior communicating artery complex (n=5). Nineteen cortical branches were covered. A single FD was used in all patients. RESULTS At latest follow-up (mean 7.9 months; range 3-36; median 4.0) 2/19 (10.5%) of the covered branches were occluded, 9/19 (47.4%) showed a decreased caliber and the remaining branches were unchanged. All branch modifications were clinically asymptomatic. Mortality and permanent morbidity were 0%. Symptomatic ischemic events in perforator territories occurred in three patients (17.6%), which were reversible in all of them within 24 h. Follow-up MRI disclosed asymptomatic lacunar defects corresponding to covered perforating artery territories in five patients (29.4%). Altogether, perforator lesions-symptomatic and asymptomatic-occurred in 7/17 patients (41.2%). 33.3% of the aneurysms were occluded at latest follow-up; decreased diameters were seen in the other 66.7%. CONCLUSIONS Flow diversion of bifurcation aneurysms is feasible with low rates of permanent morbidity and mortality. Caliber reduction and asymptomatic occlusion of covered cortical branches seems to be common, yet ischemic complications are rather linked to perforator occlusions. Our results on aneurysm occlusion rates are preliminary and longer follow-up periods are warranted.
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Affiliation(s)
- Matthias Gawlitza
- Department of Neuroradiology, CHU Toulouse, Toulouse, France Department of Diagnostic and Interventional Radiology, Leipzig University Hospital, Leipzig, Germany
| | | | - Philippe Tall
- Department of Neuroradiology, CHU Toulouse, Toulouse, France
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Spranger K, Ventikos Y. Which spring is the best? Comparison of methods for virtual stenting. IEEE Trans Biomed Eng 2015; 61:1998-2010. [PMID: 24956618 DOI: 10.1109/tbme.2014.2311856] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This paper presents a methodology for modeling the deployment of implantable devices used in minimally invasive vascular interventions. Motivated by the clinical need to perform preinterventional rehearsals of a stent deployment, we have developed methods enabling virtual device placement inside arteries, under the constraint of real-time application. This requirement of rapid execution narrowed down the search for a suitable method to the concept of a dynamic mesh. Inspired by the idea of a mesh of springs, we have found a novel way to apply it to stent modeling. The experiments conducted in this paper investigate properties of the stent models based on three different spring types: lineal, semitorsional, and torsional springs. Furthermore, this paper compares the results of various deployment scenarios for two different classes of devices: a stent graft and a flow diverter. The presented results can be of a high-potential clinical value, enabling the predictive evaluation of the outcome of a stent deployment treatment.
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Brinjikji W, Kallmes DF, Cloft HJ, Lanzino G. Patency of the anterior choroidal artery after flow-diversion treatment of internal carotid artery aneurysms. AJNR Am J Neuroradiol 2015; 36:537-41. [PMID: 25339646 DOI: 10.3174/ajnr.a4139] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Treatment of cerebral aneurysms with flow diverters often mandates placement of the device across the ostia of major branches of the internal carotid artery. We determined the patency rates of the anterior choroidal artery after placement of flow-diversion devices across its ostium. MATERIALS AND METHODS We analyzed a consecutive series of patients in whom a Pipeline Embolization Device was placed across the ostium of an angiographically visible anterior choroidal artery while treating the target aneurysm. Patency of the anterior choroidal artery after Pipeline Embolization Device placement was determined at immediate postoperative and follow-up angiography. Data on pretreatment aneurysm rupture status, concomitant coiling, number of Pipeline Embolization Devices used, neurologic status at follow-up, and follow-up MR imaging/CT findings were collected. RESULTS Fifteen patients with 15 treated aneurysms were included in this study. In the immediate postprocedural setting, the anterior choroidal artery was patent on posttreatment angiography for all 15 patients. Of the 14 patients with follow-up angiography at least 6 months after Pipeline Embolization Device placement, 1 (7%) had occlusion of the anterior choroidal artery and 14 had a patent anterior choroidal artery (93%). No patients had new neurologic symptoms or stroke related to anterior choroidal artery occlusion at follow-up. Of the 9 patients with follow-up CT or MR imaging, none had infarction in the vascular territory of the anterior choroidal artery. CONCLUSIONS In this small study, placement of a Pipeline Embolization Device across the anterior choroidal artery ostium resulted in occlusion of the artery in only 1 patient. It was not associated with ischemic changes in the distribution of the anterior choroidal artery in any patient.
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Affiliation(s)
- W Brinjikji
- From the Departments of Radiology (W.B., D.F.K., H.J.C., G.L.)
| | - D F Kallmes
- From the Departments of Radiology (W.B., D.F.K., H.J.C., G.L.) Neurosurgery (D.F.K., H.J.C., G.L.), Mayo Clinic, Rochester, Minnesota
| | - H J Cloft
- From the Departments of Radiology (W.B., D.F.K., H.J.C., G.L.) Neurosurgery (D.F.K., H.J.C., G.L.), Mayo Clinic, Rochester, Minnesota
| | - G Lanzino
- From the Departments of Radiology (W.B., D.F.K., H.J.C., G.L.) Neurosurgery (D.F.K., H.J.C., G.L.), Mayo Clinic, Rochester, Minnesota
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Rouchaud A, Leclerc O, Benayoun Y, Saleme S, Camilleri Y, D'Argento F, Boncoeur MP, Robert PY, Mounayer C. Visual outcomes with flow-diverter stents covering the ophthalmic artery for treatment of internal carotid artery aneurysms. AJNR Am J Neuroradiol 2015; 36:330-6. [PMID: 25339649 DOI: 10.3174/ajnr.a4129] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow-diverting stents can be used to treat intracranial aneurysms that are not amenable to treatment with coils. We analyzed ophthalmic consequences due to coverage of the origin of the ophthalmic artery by flow-diverting stents for the treatment of internal carotid artery aneurysms. MATERIALS AND METHODS From April 2009 to April 2013, the clinical and angiographic outcomes of all 28 patients treated for aneurysms with flow-diverting stents covering the origin of the ophthalmic artery were prospectively collected. The origin of the ophthalmic artery in relation to the target aneurysm was classified by using a 4-type classification. A complete ophthalmic examination was performed by a single ophthalmologist 48 hours before and 1 week after covering the ophthalmic artery. RESULTS Ophthalmic artery patency was normal at the end of endovascular treatment in 24/28 cases (85.7%). With extensive ophthalmic examinations, 11 patients (39.3%) showed new ophthalmic complications. Patients with the ophthalmic artery originating from the aneurysm sac were at high risk for retinal emboli (4/5, 80%). Patients with the ophthalmic artery originating from the inner curve of the carotid siphon were at high risk for optic nerve ischemic atrophy (3/4, 75%). CONCLUSIONS This prospective study shows that covering the ophthalmic artery with a flow-diverting stent is not without potential complications. Ophthalmic complications can occur but are often not diagnosed. The anatomic disposition of the ophthalmic artery in relation to the carotid siphon and aneurysm should be clearly understood because some configurations have a higher risk. When not required, covering of the ophthalmic artery by flow-diverting stents should be avoided.
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Affiliation(s)
- A Rouchaud
- From the Departments of Interventional Neuroradiology (A.R., S.S., Y.C., M.-P.B., C.M.)
| | - O Leclerc
- Ophthalmology (O.L., Y.B., P.-Y.R.), Centre Hospitalier et Universitaire Dupuytren, Limoges, France
| | - Y Benayoun
- Ophthalmology (O.L., Y.B., P.-Y.R.), Centre Hospitalier et Universitaire Dupuytren, Limoges, France
| | - S Saleme
- From the Departments of Interventional Neuroradiology (A.R., S.S., Y.C., M.-P.B., C.M.)
| | - Y Camilleri
- From the Departments of Interventional Neuroradiology (A.R., S.S., Y.C., M.-P.B., C.M.)
| | - F D'Argento
- Institute of Radiology (F.D.), Policlinico Agostino Gemelli, Catholic University, Rome, Italy
| | - M-P Boncoeur
- From the Departments of Interventional Neuroradiology (A.R., S.S., Y.C., M.-P.B., C.M.)
| | - P-Y Robert
- Ophthalmology (O.L., Y.B., P.-Y.R.), Centre Hospitalier et Universitaire Dupuytren, Limoges, France
| | - C Mounayer
- From the Departments of Interventional Neuroradiology (A.R., S.S., Y.C., M.-P.B., C.M.)
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Chalouhi N, Zanaty M, Whiting A, Yang S, Tjoumakaris S, Hasan D, Starke RM, Hann S, Hammer C, Kung D, Rosenwasser R, Jabbour P. Safety and efficacy of the Pipeline Embolization Device in 100 small intracranial aneurysms. J Neurosurg 2015; 122:1498-502. [PMID: 25635478 DOI: 10.3171/2014.12.jns14411] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Flow diverters are increasingly used for treatment of intracranial aneurysms. In most series, the Pipeline Embolization Device (PED) was used for the treatment of large, giant, complex, and fusiform aneurysms. Little is known about the use of the PED in small aneurysms. The purpose of this study was to assess the safety and efficacy of the PED in small aneurysms (≤ 7 mm). METHODS A total of 100 consecutive patients were treated with the PED at the authors' institution between May 2011 and September 2013. Data on procedural safety and efficacy were retrospectively collected. RESULTS The mean aneurysm size was 5.2 ± 1.5 mm. Seven patients (7%) had sustained a subarachnoid hemorrhage. All except 5 aneurysms (95%) arose from the anterior circulation. The number of PEDs used was 1.2 per aneurysm. Symptomatic procedure-related complications occurred in 3 patients (3%): 1 distal parenchymal hemorrhage that was managed conservatively and 2 ischemic events. At the latest follow-up (mean 6.3 months), 54 (72%) aneurysms were completely occluded (100%), 10 (13%) were nearly completely occluded (≥ 90%), and 11 (15%) were incompletely occluded (< 90%). Six aneurysms (8%) required further treatment. Increasing aneurysm size (OR 3.8, 95% CI 0.99-14; p = 0.05) predicted retreatment. All patients achieved a favorable outcome (modified Rankin Scale Score 0-2) at follow-up. CONCLUSIONS In this study, treatment of small aneurysms with the PED was associated with low complication rates and high aneurysm occlusion rates. These findings suggest that the PED is a safe and effective alternative to conventional endovascular techniques for small aneurysms. Randomized trials with long-term follow-up are necessary to determine the optimal treatment that leads to the highest rate of obliteration and the best clinical outcomes.
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Affiliation(s)
- Nohra Chalouhi
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Mario Zanaty
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Alex Whiting
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Steven Yang
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- 2Department of Neurosurgery, University of Iowa, Iowa City, Iowa; and
| | - Robert M Starke
- 3Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Shannon Hann
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Christine Hammer
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Kung
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Gascou G, Lobotesis K, Brunel H, Machi P, Riquelme C, Eker O, Bonafé A, Costalat V. Extra-aneurysmal flow modification following pipeline embolization device implantation: focus on regional branches, perforators, and the parent vessel. AJNR Am J Neuroradiol 2014; 36:725-31. [PMID: 25523592 DOI: 10.3174/ajnr.a4191] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 09/19/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow-diverter technology has proved to be a safe and effective treatment for intracranial aneurysm based on the concept of flow diversion allowing parent artery and collateral preservation and aneurysm healing. We investigated the patency of covered side branches and flow modification within the parent artery following placement of the Pipeline Embolization Device in the treatment of intracranial aneurysms. MATERIALS AND METHODS Sixty-six aneurysms in 59 patients were treated with 96 Pipeline Embolization Devices. We retrospectively reviewed imaging and clinical results during the postoperative period at 6 and 12 months to assess flow modification through the parent artery and side branches. Reperfusion syndrome was assessed by MR imaging and clinical evaluation. RESULTS Slow flow was observed in 13 of 68 (19.1%) side branches covered by the Pipeline Embolization Device. It was reported in all cases of anterior cerebral artery coverage, in 3/5 cases of M2-MCA coverage, and in 5/34 (14.7%) cases of ophthalmic artery coverage. One territorial infarction was observed in a case of M2-MCA coverage, without arterial occlusion. One case of deep Sylvian infarct was reported in a case of coverage of MCA perforators. Two ophthalmic arteries (5.9%) were occluded, and 11 side branches (16.2%) were narrowed at 12 months' follow-up; patients remained asymptomatic. Parent vessel flow modification was responsible for 2 cases (3.4%) of reperfusion syndrome. Overall permanent morbidity and mortality rates were 5.2% and 6.9%, respectively. We did not report any permanent deficit or death in case of slow flow observed within side branches. CONCLUSIONS After Pipeline Embolization Device placement, reperfusion syndrome was observed in 3.4%, and territorial infarction, in 3.4%. Delayed occlusion of ophthalmic arteries and delayed narrowing of arteries covered by the Pipeline Embolization Device were observed in 5.9% and 16.2%, respectively. No permanent morbidity or death was related to side branch coverage at midterm follow-up.
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Affiliation(s)
- G Gascou
- From the Department of Neuroradiology (G.G., P.M., C.R., O.E., A.B., V.C.), CHU Gui de Chauliac, Montpellier, France
| | - K Lobotesis
- Department of Imaging (K.L.), Imperial College Healthcare NHS Trust, Charing Cross Hospital, United Kingdom
| | - H Brunel
- Department of Neuroradiology (H.B.), CHU La Timone, Marseille, France
| | - P Machi
- From the Department of Neuroradiology (G.G., P.M., C.R., O.E., A.B., V.C.), CHU Gui de Chauliac, Montpellier, France
| | - C Riquelme
- From the Department of Neuroradiology (G.G., P.M., C.R., O.E., A.B., V.C.), CHU Gui de Chauliac, Montpellier, France
| | - O Eker
- From the Department of Neuroradiology (G.G., P.M., C.R., O.E., A.B., V.C.), CHU Gui de Chauliac, Montpellier, France
| | - A Bonafé
- From the Department of Neuroradiology (G.G., P.M., C.R., O.E., A.B., V.C.), CHU Gui de Chauliac, Montpellier, France
| | - V Costalat
- From the Department of Neuroradiology (G.G., P.M., C.R., O.E., A.B., V.C.), CHU Gui de Chauliac, Montpellier, France
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Technology developments in endovascular treatment of intracranial aneurysms. J Neurointerv Surg 2014; 8:135-44. [DOI: 10.1136/neurintsurg-2014-011475] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 11/04/2014] [Indexed: 11/03/2022]
Abstract
Advances in the management and endovascular treatment of intracranial aneurysms are progressing at a tremendous rate. Developments in novel imaging technology may improve diagnosis, risk stratification, treatment planning, intraprocedural assessment, and follow-up evaluation. Evolution of devices, including microwires, microcatheters, balloons, stents, and novel scaffolding devices, has greatly expanded the potential to treat difficult aneurysms. Although developments in technology have greatly improved the efficiency and efficacy of treatment of neurovascular disorders, novel devices do not always improve outcomes and may be associated with unique complications. As such, it is paramount to have an in-depth understanding of new devices and the implications of their introduction into clinical practice. This review provides an update on developments in endovascular treatment of intracranial aneurysms.
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Hodis S, Ding YH, Dai D, Lingineni R, Mut F, Cebral J, Kallmes D, Kadirvel R. Relationship between aneurysm occlusion and flow diverting device oversizing in a rabbit model. J Neurointerv Surg 2014; 8:94-8. [PMID: 25387731 DOI: 10.1136/neurintsurg-2014-011487] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 10/24/2014] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Implanted, actual flow diverter pore density is thought to be strongly influenced by proper matching between the device size and parent artery diameter. The objective of this study was to characterize the correlation between device sizing, metal coverage, and the resultant occlusion of aneurysms following flow diverter treatment in a rabbit model. METHODS Rabbit saccular aneurysms were treated with flow diverters (iso-sized to proximal parent artery, 0.5 mm oversized, or 1.0 mm oversized, respectively, n=6 for each group). Eight weeks after implantation, the angiographic degree of aneurysm occlusion was graded (complete, near-complete, or incomplete). The ostium of the explanted aneurysm covered with the flow diverter struts was photographed. Based on gross anatomic findings, the metal coverage and pore density at the ostium of the aneurysm were calculated and correlated with the degree of aneurysm occlusion. RESULTS Angiographic results showed there were no statistically significant differences in aneurysm geometry and occlusion among groups. The mean parent artery diameter to flow diverter diameter ratio was higher in the 1.0 mm oversized group than in the other groups. Neither the percentage metal coverage nor the pore density showed statistically significant differences among groups. Aneurysm occlusion was inversely correlated with the ostium diameter, irrespective of the size of the device implanted. CONCLUSIONS Device sizing alone does not predict resultant pore density or metal coverage following flow diverter implantation in the rabbit aneurysm model. Aneurysm occlusion was not impacted by either metal coverage or pore density, but was inversely correlated with the diameter of the ostium.
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Affiliation(s)
- Simona Hodis
- Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Yong-Hong Ding
- Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Daying Dai
- Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Ravi Lingineni
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Fernando Mut
- Center for Computational Fluid Dynamics, College of Sciences, George Mason University, Fairfax, Virginia, USA
| | - Juan Cebral
- Center for Computational Fluid Dynamics, College of Sciences, George Mason University, Fairfax, Virginia, USA
| | - David Kallmes
- Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota, USA
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Mrak G, Paladino J, Stambolija V, Nemir J, Sekhar LN. Treatment of giant and large fusiform middle cerebral artery aneurysms with excision and interposition radial artery graft in a 4-year-old child: case report. Neurosurgery 2014; 10 Suppl 1:E172-7; discussion E177. [PMID: 24509498 DOI: 10.1227/neu.0000000000000168] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE We report an unusual case of complex giant and large fusiform aneurysms not amenable for clipping or coiling in a 4-year-old child managed with aneurysm resection and radial artery interposition graft. CLINICAL PRESENTATION A 4-year-old child presented with repeated severe headache and vomiting. Computed tomography, magnetic resonance imaging, and magnetic resonance angiography and digital subtraction angiography showed a giant fusiform aneurysm on the right middle cerebral artery (MCA). Because of the complex shape, endovascular treatment or clip reconstruction was not possible, and a bypass procedure was planned. Right frontotemporal craniotomy and orbitotomy was performed. Two aneurysms involving the M1 segment of the MCA were found in line, 1 giant, and the other large in size. The aneurysms were resected and treated with short radial artery interposition graft, which was narrower than the proximal or distal MCA. The child recovered normally, and the bypass was patent after 1 year. CONCLUSION Large fusiform MCA aneurysms may be difficult to treat, but there are treatment options that include a bypass procedure. Resection and short interposition radial artery graft is an excellent but rare treatment option in a very young child. This was a very successful treatment in this child.
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Affiliation(s)
- Goran Mrak
- *Department of Neurosurgery, Clinical Hospital Centre Zagreb- Rebro, School of Medicine Zagreb, Zagreb, Croatia; ‡Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, Washington
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Keskin F, Erdi F, Kaya B, Poyraz N, Keskin S, Kalkan E, Ozbek O, Koc O. Endovascular treatment of complex intracranial aneurysms by pipeline flow-diverter embolization device: a single-center experience. Neurol Res 2014; 37:359-65. [PMID: 25310354 DOI: 10.1179/1743132814y.0000000450] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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139
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Intra-aneurysmal thrombus modification after flow-diversion. J Clin Neurosci 2014; 22:105-10. [PMID: 25192591 DOI: 10.1016/j.jocn.2014.05.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 05/28/2014] [Indexed: 11/22/2022]
Abstract
Flow diversion has been successfully used to treat large and giant intracranial aneurysms that present with mass effect. We conducted a retrospective review, evaluating the modification of thrombi in this aneurysm type after treatment with the Pipeline Embolization Device (ev3 Endovascular, Plymouth, MN, USA) and the effects of these modifications on symptoms. Eight patients, seven of whom were female, harbored eight partially thrombosed large or giant aneurysms. Five of the eight aneurysms presented with symptomatic mass effect. At 1 year follow-up, complete occlusion occurred in 75% (6/8) of patients. On average, the longest thrombus diameter measured 22.31 mm before treatment and 14.05 mm 1 year afterwards. Seven of the eight thrombi regressed, as did their aneurysms. All six patients with shrunken thrombi had tremendous symptom improvement and became asymptomatic in the following year. The current findings seem to reflect the size variation of the intra-aneurysmal thrombus rather than the size of the aneurysm itself.
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Jeong HW, Seo JH, Kim ST, Jung CK, Suh SI. Clinical practice guideline for the management of intracranial aneurysms. Neurointervention 2014; 9:63-71. [PMID: 25426300 PMCID: PMC4239410 DOI: 10.5469/neuroint.2014.9.2.63] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 08/05/2014] [Indexed: 11/29/2022] Open
Abstract
Purpose An intracranial aneurysm, with or without subarachnoid hemorrhage (SAH), is a relevant health problem. The rupture of an intracranial aneurysm is a critical concern for individual health; even an unruptured intracranial aneurysm is an anxious condition for the individual. The aim of this guideline is to present current and comprehensive recommendations for the management of intracranial aneurysms, with or without rupture. Materials and Methods We performed an extensive literature search, using Medline. We met in person to discuss recommendations. This document is reviewed by the Task Force Team of the Korean Society of Interventional Neuroradiology (KSIN). Results We divided the current guideline for ruptured intracranial aneurysms (RIAs) and unruptured intracranial aneurysms (UIAs). The guideline for RIAs focuses on diagnosis and treatment. And the guideline for UIAs focuses on the definition of a high-risk patient, screening, principle for treatment and selection of treatment method. Conclusion This guideline provides practical, evidence-based advice for the management of patients with an intracranial aneurysm, with or without rupture.
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Affiliation(s)
- Hae Woong Jeong
- Department of Radiology, Busan Paik Hospital, Inje University, Busan, Korea
| | - Jung Hwa Seo
- Department of Neurology, Busan Paik Hospital, Inje University, Busan, Korea
| | - Sung Tae Kim
- Department of Neurosurgery, Busan Paik Hospital, Inje University, Busan, Korea
| | - Cheol Kyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Il Suh
- Department of Radiology, Korea University Guro Hospital, Seoul, Korea
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Chalouhi N, Zanaty M, Jabbour PM, Starke RM, Tjoumakaris SI, Rosenwasser RH, Gonzalez LF. Intracerebral hemorrhage after pipeline embolization: Management of antiplatelet agents and the case for point-of-care testing—Case reports and review of literature. Clin Neurol Neurosurg 2014; 124:21-4. [DOI: 10.1016/j.clineuro.2014.06.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 05/28/2014] [Accepted: 06/14/2014] [Indexed: 10/25/2022]
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The 'Sphere': A Dedicated Bifurcation Aneurysm Flow-Diverter Device. Cardiovasc Eng Technol 2014; 5:334-347. [PMID: 25400707 PMCID: PMC4226933 DOI: 10.1007/s13239-014-0188-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 07/15/2014] [Indexed: 11/03/2022]
Abstract
We present flow-based results from the early stage design cycle, based on computational modeling, of a prototype flow-diverter device, known as the 'Sphere', intended to treat bifurcation aneurysms of the cerebral vasculature. The device is available in a range of diameters and geometries and is constructed from a single loop of NITINOL® wire. The 'Sphere' reduces aneurysm inflow by means of a high-density, patterned, elliptical surface that partially occludes the aneurysm neck. The device is secured in the healthy parent vessel by two armatures in the shape of open loops, resulting in negligible disruption of parent or daughter vessel flow. The device is virtually deployed in six anatomically accurate bifurcation aneurysms: three located at the Basilar tip and three located at the terminus bifurcation of the Internal Carotid artery (at the meeting of the middle cerebral and anterior cerebral arteries). Both steady state and transient flow simulations reveal that the device presents with a range of aneurysm inflow reductions, with mean flow reductions falling in the range of 30.6-71.8% across the different geometries. A significant difference is noted between steady state and transient simulations in one geometry, where a zone of flow recirculation is not captured in the steady state simulation. Across all six aneurysms, the device reduces the WSS magnitude within the aneurysm sac, resulting in a hemodynamic environment closer to that of a healthy vessel. We conclude from extensive CFD analysis that the 'Sphere' device offers very significant levels of flow reduction in a number of anatomically accurate aneurysm sizes and locations, with many advantages compared to current clinical cylindrical flow-diverter designs. Analysis of the device's mechanical properties and deployability will follow in future publications.
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Burrows AM, Cloft H, Kallmes DF, Lanzino G. Periprocedural and mid-term technical and clinical events after flow diversion for intracranial aneurysms. J Neurointerv Surg 2014; 7:646-51. [PMID: 25082803 DOI: 10.1136/neurintsurg-2014-011184] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 07/11/2014] [Indexed: 11/03/2022]
Abstract
OBJECT Flow diversion has emerged as a promising treatment alternative for cerebral aneurysms. As a new device, treatment-related events and complications are currently being characterized. METHODS Data on 100 consecutive procedures with the intention to use flow diversion were prospectively collected and analyzed retrospectively. RESULTS Ninety-five aneurysms were treated in 93 patients during 100 consecutive procedures in which the intention was to treat an intracranial aneurysm with flow diversion. Death occurred in 1% and permanent morbidity in 1%. However, periprocedural technical complications occurred in 35% of the procedures and included proximal device migration in 12%, incomplete device expansion in 9%, catheter-induced vasospasm in 6%, and artery perforation from the wire in 3%. Perioperative clinical events were seen in 28% (thromboembolism and access site complications were the most common, being observed in 6.5% of patients). Worsened extraocular motility was seen in 5.4% and resolved in 4/5 patients. Mean clinical follow-up was 17 months. There were no late clinical or technical issues resulting in permanent deficits, although one patient suffered worsening ataxia. Overall, using very strict angiographic criteria, complete angiographic obliteration was 50% at 6 months and 69% after 1 year. CONCLUSIONS Flow diversion for intracranial aneurysms is a safe and effective treatment. Technical and clinical events are common in the perioperative period. Careful perioperative care and proper management of technical and clinical events encountered is key to achieving low morbidity and mortality. Late clinical events can occur but are unlikely to result in permanent complications.
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Affiliation(s)
- Anthony M Burrows
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Harry Cloft
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Gentric JC, Darsaut TE, Makoyeva A, Salazkin I, Raymond J. The success of flow diversion in large and giant sidewall aneurysms may depend on the size of the defect in the parent artery. AJNR Am J Neuroradiol 2014; 35:2119-24. [PMID: 24970546 DOI: 10.3174/ajnr.a4010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow diverters are designed to occlude aneurysms while preserving flow to jailed arterial branches. We postulated that treatment success depended on the size of the aneurysm ostium or defect in the parent artery. MATERIALS AND METHODS Flow diverter expansion and deformation were studied in silicone tubes with wall apertures of various sizes. Large and giant canine sidewall aneurysms, featuring a branch located immediately opposite the aneurysm, and a smaller 6- to 8-mm (group A, n = 6) or a larger 10- to 16-mm (group B, n = 6) ostium were created to study the effects of ostium size on aneurysm or branch occlusion by flow diverters. Angiographic results after deployment and at 3 months were scored by using an ordinal scale. The amount of neointima formation on the segment of the device overlying the aneurysm or the branch ostia was determined by specimen photography. RESULTS The fusiform deformation of flow diverters was maximal with larger defects in silicone tubes. At 3 months, group B aneurysms showed worse angiographic results than group A aneurysms, with larger residual aneurysm volumes (P = .002). Neointimal coverage of the aneurysm ostia was more complete in group A compared with group B (P = .002). CONCLUSIONS The effects of flow diversion may vary with the size of the aneurysm ostium.
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Affiliation(s)
- J C Gentric
- From the Department of Radiology (J.C.G., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada Groupe d'étude de la Thrombose en Bretagne Occidentale (J.C.G.), Université de Bretagne Occidentale, Brest, France
| | - T E Darsaut
- Division of Neurosurgery (T.E.D.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - A Makoyeva
- Laboratory of Interventional Neuroradiology (A.M., I.S., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Centre, Montreal, Quebec, Canada
| | - I Salazkin
- Laboratory of Interventional Neuroradiology (A.M., I.S., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Centre, Montreal, Quebec, Canada
| | - J Raymond
- From the Department of Radiology (J.C.G., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada Laboratory of Interventional Neuroradiology (A.M., I.S., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Centre, Montreal, Quebec, Canada.
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145
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Zanaty M, Khan MB, Chalouhi N, Tjoumakaris SI, Rosenwasser RH, Jabbour P. Development of normal pressure hydrocephalus after the placement of a pipeline embolization device for the treatment of a large aneurysm: case report. Clin Neurol Neurosurg 2014; 122:116-9. [PMID: 24908229 DOI: 10.1016/j.clineuro.2014.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 03/08/2014] [Accepted: 04/09/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Mario Zanaty
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Muhammad Babar Khan
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
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Morales-Valero SF, Brinjikji W, Murad MH, Wald JT, Lanzino G. Endovascular treatment of internal carotid artery bifurcation aneurysms: a single-center experience and a systematic review and meta-analysis. AJNR Am J Neuroradiol 2014; 35:1948-53. [PMID: 24904050 DOI: 10.3174/ajnr.a3992] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular coiling of internal carotid artery bifurcation aneurysms can be challenging due to unfavorable morphologic features. With improvements in endovascular techniques, several series have detailed the results and complications of endovascular treatment of aneurysms at this location. We performed a systematic review and meta-analysis of published series on the endovascular treatment of ICA bifurcation aneurysms, including a tertiary referral center experience. MATERIALS AND METHODS We performed a comprehensive literature search for reports on contemporary endovascular treatment of ICA bifurcation aneurysms from 2000 to 2013, and we reviewed our experience. We extracted information regarding periprocedural complications, procedure-related morbidity and mortality, immediate angiographic outcome, long-term clinical and angiographic outcome, and retreatment rate. Event rates were pooled across studies by using random-effects meta-analysis. RESULTS Including our series of 37 patients, 6 studies with 158 patients were analyzed. Approximately 60% of the aneurysms presented as unruptured; 88.0% (95% CI, 68.0%-96.0%) of aneurysms showed complete or near-complete occlusion at immediate postoperative angiography compared with 82.0% (95% CI, 73.0%-88.0%) at last follow-up. The procedure-related morbidity and mortality were 3.0% (95% CI, 1.0%-7.0%) and 3.0% (95% CI, 1.0%-8.0%), respectively. The retreatment rate was 14.0% (95% CI, 8.0%-25.0%). Good neurologic outcome was achieved in 93.0% (95% CI, 86.0%-97.0%) of patients. CONCLUSIONS Endovascular treatment of ICA bifurcation aneurysms is feasible and effective and is associated with high immediate angiographic occlusion rates. However, retreatment rates and procedure-related morbidity and mortality are non-negligible.
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Affiliation(s)
| | | | - M H Murad
- Center for Science of Healthcare Delivery (M.H.M.), Mayo Clinic, Rochester, Minnesota
| | | | - G Lanzino
- From the Departments of Neurologic Surgery (S.F.M.-V., G.L.) Radiology (W.B., J.T.W., G.L.)
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Briganti F, Napoli M, Leone G, Marseglia M, Mariniello G, Caranci F, Tortora F, Maiuri F. Treatment of intracranial aneurysms by flow diverter devices: long-term results from a single center. Eur J Radiol 2014; 83:1683-90. [PMID: 24985339 DOI: 10.1016/j.ejrad.2014.05.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 04/28/2014] [Accepted: 05/15/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Flow-Diverter Devices (FDD) are a new generation stents designed for the treatment of the intracranial aneurysms. This article reports the long-term results (2-4 years) of this treatment from a single-center. METHODS From November 2008 to January 2012, 35 patients (29 females and 6 males; mean age 53.9 y) with 39 intracranial aneurysms were treated by FDD. Five patients (14.3%) had ruptured aneurysms and 30 (85.7%) had no previous hemorrhage. The procedures were performed in 5 patients (14.3%) with SILK and in 30 (85.7%) with PED. In 3 patients FDDs were used as a second treatment after failure of previous coiling (2 cases) or stenting (one case). The 39 aneurysms were in supraclinoid ICA in 26 (66.7%), cavernous ICA in 2 (5.1%), PCoA in 4 (10.2%), MCA in 5 (12.9%), SCA in 1 (2.6%) and PICA in 1 (2.6%). The aneurysms were small (<10mm) in 32 cases (82%), large (11-25mm) in 6 (15.3%) and giant in 1 (2.6%). The occlusion rate according to the aneurysm location, size and neck and the complications were evaluated. RESULTS Peri-procedural complications included transient dysarthria (2 patients), vasospasm with acute intra-stent aggregation (one), microwire rupture (one) and failure of the stent opening (one). The follow-up was made between 24 and 62 months (mean 41 months); clinical examination and CTA were performed at 1, 3, 6 and 12 months after the procedure. The complete occlusion was confirmed by CTA and DSA. MRI with angiographic-studies was taken every year. Complete occlusion was obtained in 35 aneurysms (92.1%) and subtotal in 3 (7.9%). Complete occlusion occurred at 3 months in 24 cases (68.6%), within 3 and 6 months in 9 (25.7%). The rate and time of complete occlusion were not correlated with the aneurysm size. MCA aneurysms mainly showed partial occlusion (2/3 cases). Besides, large-neck aneurysms and those with a vessel arising from the sac mainly showed late (>6 months) or partial occlusion. CONCLUSION FDD are a safe and efficacious treatment of intracranial aneurysms, resulting in high occlusion rate and low incidence of complications. It should be the treatment of choice for the large-neck aneurysm of the ICA.
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148
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Ma D, Xiang J, Choi H, Dumont TM, Natarajan SK, Siddiqui AH, Meng H. Enhanced aneurysmal flow diversion using a dynamic push-pull technique: an experimental and modeling study. AJNR Am J Neuroradiol 2014; 35:1779-85. [PMID: 24763414 DOI: 10.3174/ajnr.a3933] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Neurovascular flow diverters are flexible, braided stent-meshes for intracranial aneurysm treatment. We applied the dynamic push-pull technique to manipulate the flow-diverter mesh density at the aneurysm orifice to maximize flow diversion. This study investigated the hemodynamic impact of the dynamic push-pull technique on patient-specific aneurysms by using the developed high-fidelity virtual-stenting computational modeling technique combined with computational fluid dynamics. MATERIALS AND METHODS We deployed 2 Pipeline Embolization Devices into 2 identical sidewall anterior cerebral artery aneurysm phantoms by using the dynamic push-pull technique with different delivery-wire advancements. We then numerically simulated these deployment processes and validated the simulated mesh geometry. Computational fluid dynamics analysis was performed to evaluate detailed hemodynamic changes by deployed flow diverters in the sidewall aneurysm and a fusiform basilar trunk aneurysm (deployments implemented previously). Images of manipulated flow diverter mesh from sample clinical cases were also evaluated. RESULTS The flow diverters deployed in silico accurately replicated in vitro geometries. Increased delivery wire advancement (21 versus 11 mm) by using a dynamic push-pull technique produced a higher mesh compaction at the aneurysm orifice (50% metal coverage versus 36%), which led to more effective aneurysmal inflow reduction (62% versus 50% in the sidewall aneurysm; 57% versus 36% in the fusiform aneurysm). The dynamic push-pull technique also caused relatively lower metal coverage along the parent vessel due to elongation of the flow diverter. High and low mesh compactions were also achieved for 2 real patients by using the dynamic push-pull technique. CONCLUSIONS The described dynamic push-pull technique increases metal coverage of pure braided flow diverters over the aneurysm orifice, thereby enhancing the intended flow diversion, while reducing metal coverage along the parent vessel to prevent flow reduction in nearby perforators.
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Affiliation(s)
- D Ma
- From the Toshiba Stroke and Vascular Research Center (D.M., J.X., A.H.S., H.M.) Departments of Mechanical and Aerospace Engineering (D.M., J.X., H.M.)
| | - J Xiang
- From the Toshiba Stroke and Vascular Research Center (D.M., J.X., A.H.S., H.M.) Departments of Mechanical and Aerospace Engineering (D.M., J.X., H.M.) Neurosurgery (J.X., S.K.N., A.H.S., H.M.)
| | - H Choi
- Department of Neurosurgery (H.C.), Upstate Medical University, The State University of New York, Syracuse, New York
| | - T M Dumont
- Department of Surgery (T.M.D.), The University of Arizona; Tucson, Arizona
| | | | - A H Siddiqui
- From the Toshiba Stroke and Vascular Research Center (D.M., J.X., A.H.S., H.M.) Neurosurgery (J.X., S.K.N., A.H.S., H.M.) Radiology (A.H.S.), University at Buffalo, The State University of New York, Buffalo, New York
| | - H Meng
- From the Toshiba Stroke and Vascular Research Center (D.M., J.X., A.H.S., H.M.) Departments of Mechanical and Aerospace Engineering (D.M., J.X., H.M.) Neurosurgery (J.X., S.K.N., A.H.S., H.M.)
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Derrey S, Penchet G, Thines L, Lonjon M, David P, Bataille B, Emery E, Lubrano V, Laguarrigue J, Bresson D, Pelissou I, Irthum B, Lejeune JP, Proust F. French collaborative group series on giant intracranial aneurysms: Current management. Neurochirurgie 2014; 61:371-7. [PMID: 24647149 DOI: 10.1016/j.neuchi.2013.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 08/31/2013] [Accepted: 11/13/2013] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Giant intracranial aneurysms represent a major therapeutic challenge for each surgical team. The aim of our study was to extensively review the French contemporary experience in treating giant intracranial aneurysms in order to assess the current management. PATIENTS AND METHODS This retrospective multicenter study concerned consecutive patients treated for giant intracranial aneurysms (2004-2008) in different French university hospitals (Bordeaux, Caen, Clermont-Ferrand, Lille, Lyon, Nice, Paris-Lariboisière, Rouen et Toulouse). Different variables were analyzed: the diagnostic circumstances, the initial clinical status based on the WFNS scale, aneurysmal features and exclusion procedure. At 6 months, the outcome was evaluated according to the modified Rankin Scale (mRS): favorable (mRS 0-2) and unfavorable (mRS 3-6). A multivariate logistic regression model included all the independent variables with P<0.25 in the univariate analysis (P<0.05). RESULTS A total of 79 patients with a mean age of 51.5 ± 1.6 years (median: 52 years; range: 16-79) were divided into two groups, with the ruptured group (n=26, 32.9%) significantly younger (P<0.05, Student's-t-test) than the unruptured group (n=53, 67.1%). After SAH, the initial clinical status was good in 12 patients (46.2%), and in the unruptured group, the predominant diagnosis circumstance was a pseudo-tumor syndrome occurring in 22 (41.5%). The first procedure of aneurysm treatment in the global population was endovascular in 42 patients (53.1%), microsurgical in 29 (36.7%) and conservative in 8 (10.2). An immediate neurological deterioration was reported in 38 patients (48.1%) after endovascular treatment in 19 (45.2% of endovascular procedures), after miscrosurgical in 15 (51.7% of microsurgical procedures) and after conservative in 4 (the half). At 6 months, the outcome was favorable in 45 patients (57%) and after multivariate analysis, the predictive factors of favorable outcome after management of giant cerebral aneurysm were the initial good clinical status in cases of SAH (P<0.002), the endovascular treatment (P<0.005), and the absence of neurological deterioration (P<0.006). The endovascular procedure was obtained as a predictive factor because of the low risk efficacy of indirect procedures, in particular a parent vessel occlusion. CONCLUSION The overall favorable outcome rate concerned 57% of patients at 6 months despite 53.8% of poor initial clinical status in cases of rupture. The predictive factors for favorable outcome were good clinical status, endovascular treatment and the absence of postoperative neurological deterioration. Endovascular treatment should be integrated into the therapeutic armenmatarium against giant cerebral aneurysms but the durability of exclusion should be taken into account during the multidisciplinary discussion by the neurovascular team.
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Affiliation(s)
- S Derrey
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - G Penchet
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - L Thines
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - M Lonjon
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - P David
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - B Bataille
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - E Emery
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - V Lubrano
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - J Laguarrigue
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - D Bresson
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - I Pelissou
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - B Irthum
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - J-P Lejeune
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - F Proust
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France.
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150
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Patency of the posterior communicating artery after flow diversion treatment of internal carotid artery aneurysms. Clin Neurol Neurosurg 2014; 120:84-8. [PMID: 24731582 DOI: 10.1016/j.clineuro.2014.02.018] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 02/20/2014] [Accepted: 02/23/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral aneurysm treatment with the Pipeline Embolization Device (PED) often mandates device placement across the ostia of arteries of the Circle of Willis. We determined the patency rates of the posterior communicating artery (Pcomm) after placement across its ostium a PED and studied neurologic outcomes in these patients. METHODS We analyzed, retrospectively, a consecutive series of patients in whom a PED was placed across the ostium of Pcomm while treating the target aneurysm. Pcomm arterial flow after PED placement was graded on a 3-point scale at post-operative angiography and follow-up angiography. Data on pretreatment aneurysm rupture status, concomitant coiling, number of PEDs used, and neurologic status at follow-up were collected. RESULTS Eleven patients with 13 aneurysms were included in this study. All patients had an ipsilateral posterior cerebral artery arising from the basilar artery (P1). In the immediate post-procedural setting, four patients (36%) had diminished Pcomm flow rates. After a mean follow-up of 12.6±6.7 months, three Pcomm arteries (27%) were occluded and two Pcomm arteries (18%) had diminished flow. Of patients with diminished flow/occluded Pcomm at follow-up, 80% (4/5) had diminished flow at initial post-procedure angiography compared to none of the six patients without diminished/occluded flow immediately post treatment. No patients suffered new neurologic symptoms at follow-up. CONCLUSIONS Approximately one half of Pcomm arteries demonstrated occlusion or decreased flow at follow-up if the ostia are covered with a flow diversion device. Covering the Pcomm ostium in patients with a P1 did not result in any neurologic deficits.
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