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Ye Z, Ai X, You C. Letter to the Editor. Complications from the use of flow-diverting devices. Neurosurg Focus 2019; 44:E10. [PMID: 29490549 DOI: 10.3171/2017.11.focus17694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Bhatia KD, Kortman H, Orru E, Klostranec JM, Pereira VM, Krings T. Periprocedural complications of second-generation flow diverter treatment using Pipeline Flex for unruptured intracranial aneurysms: a systematic review and meta-analysis. J Neurointerv Surg 2019; 11:817-824. [DOI: 10.1136/neurintsurg-2019-014937] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/30/2019] [Accepted: 05/06/2019] [Indexed: 12/11/2022]
Abstract
BackgroundFlow diverters are a breakthrough treatment for large and giant intracranial aneurysms but carry a risk of periprocedural death or major stroke. Pipeline Flex is a second-generation device that is thought to have lower complication rates because of improvements in the delivery system as well as increased operator experience. Our objective was to analyze the risk of periprocedural death or major complications using Pipeline Flex for unruptured intracranial aneurysms.MethodsA systematic search of three databases was performed for studies of ≥10 treatments using Pipeline Flex for unruptured intracranial aneurysms (2014–2019) using PRISMA guidelines. Random effects meta-analysis was used to pool the rates of periprocedural (<30 days) death, major ischemic stroke, symptomatic intracranial hemorrhage, and minor stroke/transient ischemic attack.ResultsWe included eight studies reporting 901 treatments in 879 patients. Periprocedural mortality (<30 days) was 0.8% (5/901; 95% CI 0.4% to 1.5%; I2=0%). Rate of major complications (death, major ischemic stroke, or symptomatic intracranial hemorrhage) was 1.8% (14/901; 95% CI 1.0% to 2.7%; I2=0%). Aneurysm size ≥10 mm was a statistically significant predictor of a major complication (OR 6.4; 95% CI 2.0 to 20.7; p=0.002). Risk of a major complication in aneurysms <10 mm was 0.9% (95% CI 0.3% to 1.7%; I2=0%). The meta-analysis was limited by the predominance of anterior circulation aneurysms.ConclusionTreatment of unruptured intracranial aneurysms using the Pipeline Flex flow diverter has a low periprocedural risk of death (0.8%) or major complication (1.8%). The risk of a major complication is significantly higher for large/giant aneurysms (4.4%) and is very low for aneurysms <10 mm (0.9%).
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Nishimura K, Otani K, Mohamed A, Dahmani C, Ishibashi T, Yuki I, Kaku S, Takao H, Murayama Y. Accuracy of Length of Virtual Stents in Treatment of Intracranial Wide-Necked Aneurysms. Cardiovasc Intervent Radiol 2019; 42:1168-1174. [PMID: 31076839 PMCID: PMC6597734 DOI: 10.1007/s00270-019-02230-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/19/2019] [Indexed: 11/25/2022]
Abstract
Background and Purpose Precise stent deployment is important for successful treatment of intracranial aneurysms by stent-assisted coiling (SAC). We evaluated the accuracy of virtual stents generated using commercial stent planning software by comparing the length of virtual and actually deployed intracranial laser cut stents on three-dimensional digital subtraction angiography (3D-DSA) images. Methods We retrospectively analyzed the data of 75 consecutive cases of intracranial wide-necked aneurysms treated with the SAC technique using laser cut stents. Based on 3D-DSA images acquired by C-arm CT, stent sizing and placement were intraoperatively simulated by a commercial software application. The difference in length of the stents was estimated by measuring proximal discrepancies between the end points of the virtual and actually deployed stents on fused pre-procedural and post-procedural 3D-DSA images. Discrepancies between distal stent end points were manually minimized. The Kruskal–Wallis test was applied to test whether stent location, type, and length had an effect on difference in length between virtual and real stent. Results The median difference in length between virtual and real stents was 1.58 mm with interquartile range 1.12–2.12 mm. There was no evidence for an effect of stent location (p = 0.23), stent type (p = 0.33), or stent length (p = 0.53) on difference in length between virtual and real stents. Conclusions Stent planning software allows 3D simulation of laser cut stents overlain on 3D-DSA images of vessels and may thus be useful for stent selection and deployment of laser cut stents during stent-assisted coiling of intracranial aneurysms.
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Affiliation(s)
- Kengo Nishimura
- Division of Endovascular Neurosurgery, Department of Neurosurgery, School of Medicine, Jikei University, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461 Japan
| | - Katharina Otani
- Siemens Healthcare K.K., Gate City Osaki West Tower, 1-11-1 Osaki, Shinagawa-ku, Tokyo, 141-8644 Japan
| | - Ashraf Mohamed
- Siemens Healthcare K.K., Gate City Osaki West Tower, 1-11-1 Osaki, Shinagawa-ku, Tokyo, 141-8644 Japan
| | - Chihebeddine Dahmani
- Siemens Healthcare Pte Ltd, Surgery Business Line, 60 MacPherson Road, Singapore, 348615 Singapore
| | - Toshihiro Ishibashi
- Division of Endovascular Neurosurgery, Department of Neurosurgery, School of Medicine, Jikei University, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461 Japan
| | - Ichiro Yuki
- Division of Endovascular Neurosurgery, Department of Neurosurgery, School of Medicine, Jikei University, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461 Japan
| | - Shogo Kaku
- Division of Endovascular Neurosurgery, Department of Neurosurgery, School of Medicine, Jikei University, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461 Japan
| | - Hiroyuki Takao
- Division of Endovascular Neurosurgery, Department of Neurosurgery, School of Medicine, Jikei University, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461 Japan
| | - Yuichi Murayama
- Division of Endovascular Neurosurgery, Department of Neurosurgery, School of Medicine, Jikei University, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461 Japan
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Maingard J, Lamanna A, Kok HK, Ranatunga D, Ravi R, Chandra RV, Lee MJ, Brooks DM, Asadi H. Endovascular treatment of visceral artery and renal aneurysms (VRAA) using a constant mesh density flow diverting stent. CVIR Endovasc 2019; 2:15. [PMID: 32026177 PMCID: PMC7224242 DOI: 10.1186/s42155-019-0057-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 04/11/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Flow diverting stents have been used safely and effectively for the treatment of intracranial aneurysms, particularly for large and wide necked aneurysms that are not amenable to conventional endovascular treatment with coiling. The Surpass Streamline device (Stryker Neurovascular, MI, USA) is a relatively new and unique flow diverting stent which maintains constant device mesh density over varying vessel diameters. This may potentially provide advantages compared to other flow diverting stents in achieving aneurysmal occlusion. CASE PRESENTATION Two patients with VRAA were treated using the Surpass Streamline device. The first patient was a 65-year-old male with an incidental 2.4 cm aneurysm originating from the hepatic artery near the gastroduodenal artery (GDA). The second patient was a 56-year-old male with an incidental 1.9 cm renal aneurysm arising from an anterior inferior segmental branch of the left renal artery. A Surpass flow diverting stent was used to successfully exclude the aneurysm neck in both cases. Reduced flow was achieved in one patient (equivalent to O'Kelly-Marotta [OKM] Grade B1). Preserved flow and stagnation (equivalent to OKM Grade A3) was achieved in the other. There was preserved distal flow in the parent arteries. No immediate complications were encountered in either case. Complete occlusion of both aneurysms was seen on follow up CT angiographic imaging within 8-weeks. CONCLUSIONS The Surpass flow diverting stent can be used safely and effectively to treat VRAA. It should be considered in unruptured large and giant wide necked VRAAs aneurysms. Additional large prospective studies are required for further validation.
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Affiliation(s)
- Julian Maingard
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Melbourne, Victoria 3084 Australia
- Interventional Neuroradiology Service, Radiology Department, Austin Hospital, Melbourne, Australia
- Faculty of Health, School of Medicine, Deakin University, Waurn Ponds, Australia
| | - Anthony Lamanna
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Melbourne, Victoria 3084 Australia
| | - Hong Kuan Kok
- Faculty of Health, School of Medicine, Deakin University, Waurn Ponds, Australia
- Interventional Radiology Service, Department of Radiology, Northern Hospital, Melbourne, Australia
| | - Dinesh Ranatunga
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Melbourne, Victoria 3084 Australia
| | - Rajeev Ravi
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Melbourne, Victoria 3084 Australia
| | - Ronil V. Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Michael J. Lee
- Interventional Radiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Duncan Mark Brooks
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Melbourne, Victoria 3084 Australia
- Interventional Neuroradiology Service, Radiology Department, Austin Hospital, Melbourne, Australia
- Faculty of Health, School of Medicine, Deakin University, Waurn Ponds, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Hamed Asadi
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Melbourne, Victoria 3084 Australia
- Interventional Neuroradiology Service, Radiology Department, Austin Hospital, Melbourne, Australia
- Faculty of Health, School of Medicine, Deakin University, Waurn Ponds, Australia
- Interventional Neuroradiology Unit, Monash Imaging, Melbourne, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
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Malhotra A, Wu X, Brinjikji W, Miller T, Matouk CC, Sanelli P, Gandhi D. Pipeline Endovascular Device vs Stent-Assisted Coiling in Small Unruptured Aneurysms: A Cost-Effectiveness Analysis. Neurosurgery 2019; 85:E1010-E1019. [DOI: 10.1093/neuros/nyz130] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 12/24/2018] [Indexed: 11/13/2022] Open
Abstract
AbstractBACKGROUNDBoth stent-assisted coiling (SAC) and flow diversion with the Pipeline Embolization device (PED; Medtronic Inc) have been shown to be safe and clinically effective for treatment of small (<10 mm) unruptured aneurysms. However, the economic impact of these different techniques has not been established.OBJECTIVETo analyze the cost-effectiveness between stent-assisted coiling and flow diversion using PED, including procedural costs, long-term outcomes, and aneurysm recurrence.METHODSA decision-analytical study was performed with Markov modeling methods to simulate patients undergoing SAC or PED for treatment for unruptured aneurysms of sizes 5 and 7 mm. Input probabilities were derived from prior literature, and 1-way, 2-way, and probabilistic sensitivity analyses (PSA) were performed.RESULTSIn base case calculation and PSA, PED was the dominant strategy for both the size groups, with and without consideration of indirect costs. One-way sensitivity analyses show that the conclusion remained robust when varying the retreatment rate of SAC from 0% to 50%, and only changes when the retreatment rate of PED > 49%. PED remained the more cost-effective strategy when the morbidity and mortality of PED increased by <55% and when those of SAC decreased by <37%. SAC only became cost-effective when the total cost of PED is >$73000 more expensive than the total cost of SAC.CONCLUSIONWith increasing use of PED for treatment of small unruptured anterior circulation aneurysms, our study indicates that PED is cost-effective relative to stent coiling irrespective of aneurysm size. This is due to lower aneurysm recurrence rate, as well as better health outcomes.
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Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Waleed Brinjikji
- Department of Radiology and Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Timothy Miller
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles C Matouk
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Pina Sanelli
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Dheeraj Gandhi
- Interventional Neuroradiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
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Huang YC, Tsuang FY, Lee CW, Wu CY, Lin YH. Assessing Vascularity of Osseous Spinal Metastases with Dual-Energy CT-DSA: A Pilot Study Compared with Catheter Angiography. AJNR Am J Neuroradiol 2019; 40:920-925. [PMID: 30948377 DOI: 10.3174/ajnr.a6023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/06/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Spine debulking surgery in patients with hypervascular spinal metastasis is associated with massive intraoperative blood loss, but currently, the vascularity of tumor is determined by invasive conventional angiography or dynamic contrast MR imaging. We aimed to investigate the usefulness of noninvasive dual-energy CT-DSA, comparing it with conventional angiography in evaluating the vascularity of spinal metastasis. MATERIALS AND METHODS We conducted a retrospective study from January to December 2018. A total of 15 patients with spinal metastasis undergoing dual-energy CT, conventional DSA, and subsequent debulking surgery were included. CT-DSA images were produced after rigid-body registration and subtraction between CT phases. Qualitative and quantitative assessments of tumor vascularity were conducted. Correlations between CT-DSA and conventional DSA results were evaluated using the Spearman coefficient. The mean enhancement in the estimated tumor volume and surgical blood loss was compared between hypervascular and nonhypervascular groups using the Wilcoxon rank sum test. RESULTS The CT-DSA and DSA results were strongly correlated, with ρ = 0.87 (P < .001). The DSA and the quantitative enhancement index also showed a strong correlation with ρ = 0.83 (P < .001). Wilcoxon rank sum testing between hypervascular and nonhypervascular CT-DSA groups showed a difference in enhancement indices (P = .0003). The blood loss between the hypervascular and nonhypervascular groups was nonsignificant (P = .09). CONCLUSIONS Dual-energy CT-DSA correlates well with conventional DSA in assessing the vascularity of spinal metastasis. It may serve as a noninvasive preoperative evaluation option before debulking surgery.
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Affiliation(s)
- Y-C Huang
- From the Department of Medical Imaging (Y.-C.H., C.-W.L., Y.-H.L.)
| | - F-Y Tsuang
- Division of Neurosurgery (F.-Y.T.), Department of Surgery
| | - C-W Lee
- From the Department of Medical Imaging (Y.-C.H., C.-W.L., Y.-H.L.)
| | - C-Y Wu
- Department of Anesthesiology (C.-Y.W.), National Taiwan University Hospital, Taipei, Taiwan
| | - Y-H Lin
- From the Department of Medical Imaging (Y.-C.H., C.-W.L., Y.-H.L.)
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Goto S, Izumi T, Nishihori M, Ishida M, Ishida T, Otawa M, Kawaguchi T, Oshima R, Kropp A, Ikezawa M, Wakabayashi T. Cardiac Arrest Induced by Carotid Sinus Reflex Activation During Flow-Diverter Stent Deployment. World Neurosurg 2019; 124:22-24. [PMID: 30615992 DOI: 10.1016/j.wneu.2018.12.136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 12/16/2018] [Accepted: 12/18/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND A 60-year-old female with multiple carotid aneurysms underwent endovascular treatment with a Pipeline Flex embolization device (PED) under local anesthesia via femoral puncture. CASE DESCRIPTION Cardiac arrest occurred when the delivery systems were pushed to promote adequate opening and apposition of the PED against the vessel wall and was recovered to sinus rhythm in approximately 30 seconds by pulling down the microcatheter. The carotid sinus reflex was suspected as the cause of this temporary asystole. Delivery of the PED was accompanied by application of forward pressure on the delivery system. This resulted in buckling of the delivery systems in the neck and likely excessive pressure on the carotid sinus. The procedure was continued and successfully completed with care not to excessively push the system and with the additional use of atropine. CONCLUSIONS Although it was a rare complication, the phenomenon and its mechanisms were known in the carotid artery stenting procedure. To the best of our knowledge, this is the first report of cardiac arrest induced by a carotid sinus reflex during PED deployment. It is important for an operator of PED deployment to recognize its possibility. Vital signs should be closely checked during PED deployment, particularly while pushing the catheter.
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Affiliation(s)
- Shunsaku Goto
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Izumi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Masahiro Nishihori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mamoru Ishida
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tetsuya Ishida
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Otawa
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Kawaguchi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryosuke Oshima
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Asuka Kropp
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mizuka Ikezawa
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshihiko Wakabayashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Zhang X, Zuo Q, Tang H, Xue G, Yang P, Zhao R, Li Q, Fang Y, Xu Y, Hong B, Huang Q, Liu J. Stent assisted coiling versus non-stent assisted coiling for the management of ruptured intracranial aneurysms: a meta-analysis and systematic review. J Neurointerv Surg 2019; 11:489-496. [PMID: 30842307 DOI: 10.1136/neurintsurg-2018-014388] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 11/14/2018] [Accepted: 11/19/2018] [Indexed: 11/03/2022]
Abstract
PURPOSE To compare the safety and efficiency of stent assisted coiling (SAC) with non-SAC for the management of ruptured intracranial aneurysms. METHODS A meta-analysis that compared SAC with coiling alone and balloon assisted coiling was conducted by database searching. The primary outcomes of this study were immediate occlusion and progressive thrombosis rate, overall perioperative complication rate, and angiographic recurrence. Secondary outcomes included mortality at discharge, hemorrhagic and ischemic complications, and favorable clinical outcome at discharge and at follow-up. RESULTS Eight retrospective cohort studies with 1408 ruptured intracranial aneurysms (SAC=499; non-SAC=909) were included. The SAC group tended to show a lower immediate complete occlusion rate than the non-SAC group (54.3% vs 64.2%; RR 0.90; 95% CI 0.83 to 0.99; I2=17.4%) and achieved a significantly higher progressive complete rate at follow-up (73.4% vs 61.0%; RR 1.30; 95% CI 1.16 to 1.46; I2=40.5%) and a lower recurrence rate (4.8% vs 16.6%; RR 0.28; 95% CI 0.16 to 0.50; I2=0.0%). With respect to safety concerns, overall perioperative complications in the SAC group were significantly higher (20.2% vs 13.1%; RR 1.70; 95% CI 1.36 to 2.11; I2=0.0%). However, no significant difference was found for mortality rate at discharge (6.3% vs 6.2%; RR 1.29; 95% CI 0.86 to 1.94; I2=0.0%), or favorable clinical outcome rate at discharge (73.4% vs 74.2%; RR 0.95; 95% CI 0.88 to 1.02; I2=12.1%) and at follow-up (85.6% vs 87.9%; RR 0.98; 95% CI 0.93 to 1.02; I2=0.0%; P=0.338). CONCLUSIONS SAC has a lower recurrence rate than non-SAC. Nevertheless, further validation by well designed prospective studies is warranted for determining whether stents improve angiographic outcome without an increased complication rate or unfavorable clinical outcome.
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Affiliation(s)
- Xiaoxi Zhang
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiao Zuo
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Haishuang Tang
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Gaici Xue
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Rui Zhao
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiang Li
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yibin Fang
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
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Flores BC, White JA, Batjer HH, Samson DS. The 25th anniversary of the retrograde suction decompression technique (Dallas technique) for the surgical management of paraclinoid aneurysms: historical background, systematic review, and pooled analysis of the literature. J Neurosurg 2019; 130:902-916. [PMID: 29726776 DOI: 10.3171/2017.11.jns17546] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 11/04/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Paraclinoid internal carotid artery (ICA) aneurysms frequently require temporary occlusion to facilitate safe clipping. Brisk retrograde flow through the ophthalmic artery and cavernous ICA branches make simple trapping inadequate to soften the aneurysm. The retrograde suction decompression (RSD), or Dallas RSD, technique was described in 1990 in an attempt to overcome some of those treatment limitations. A frequent criticism of the RSD technique is an allegedly high risk of cervical ICA dissection. An endovascular modification was introduced in 1991 (endovascular RSD) but no studies have compared the 2 RSD variations. METHODS The authors performed a systematic review of MEDLINE/PubMed and Web of Science and identified all studies from 1990-2016 in which either Dallas RSD or endovascular RSD was used for treatment of paraclinoid aneurysms. A pooled analysis of the data was completed to identify important demographic and treatment-specific variables. The primary outcome measure was defined as successful aneurysm obliteration. Secondary outcome variables were divided into overall and RSD-specific morbidity and mortality rates. RESULTS Twenty-six RSD studies met the inclusion criteria (525 patients, 78.9% female). The mean patient age was 53.5 years. Most aneurysms were unruptured (56.6%) and giant (49%). The most common presentations were subarachnoid hemorrhage (43.6%) and vision changes (25.3%). The aneurysm obliteration rate was 95%. The mean temporary occlusion time was 12.7 minutes. Transient or permanent morbidity was seen in 19.9% of the patients. The RSD-specific complication rate was low (1.3%). The overall mortality rate was 4.2%, with 2 deaths (0.4%) attributable to the RSD technique itself. Good or fair outcome were reported in 90.7% of the patients.Aneurysm obliteration rates were similar in the 2 subgroups (Dallas RSD 94.3%, endovascular RSD 96.3%, p = 0.33). Despite a higher frequency of complex (giant or ruptured) aneurysms, Dallas RSD was associated with lower RSD-related morbidity (0.6% vs 2.9%, p = 0.03), compared with the endovascular RSD subgroup. There was a trend toward higher mortality in the endovascular RSD subgroup (6.4% vs 3.1%, p = 0.08). The proportion of patients with poor neurological outcome at last follow-up was significantly higher in the endovascular RSD group (15.4% vs 7.2%, p < 0.01). CONCLUSIONS The treatment of paraclinoid ICA aneurysms using the RSD technique is associated with high aneurysm obliteration rates, good long-term neurological outcome, and low RSD-related morbidity and mortality. Review of the RSD literature showed no evidence of a higher complication rate associated with the Dallas technique compared with similar endovascular methods. On a subgroup analysis of Dallas RSD and endovascular RSD, both groups achieved similar obliteration rates, but a lower RSD-related morbidity was seen in the Dallas technique subgroup. Twenty-five years after its initial publication, RSD remains a useful neurosurgical technique for the management of large and giant paraclinoid aneurysms.
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Enriquez-Marulanda A, Ravindran K, Salem MM, Ascanio LC, Kan P, Srinivasan VM, Griessenauer CJ, Schirmer CM, Jain A, Moore JM, Ogilvy CS, Thomas AJ, Alturki AY. Evaluation of Radiological Features of the Posterior Communicating Artery and Their Impact on Efficacy of Saccular Aneurysm Treatment with the Pipeline Embolization Device: A Case Series Study. World Neurosurg 2019; 125:e998-e1007. [PMID: 30771544 DOI: 10.1016/j.wneu.2019.01.228] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Posterior communicating artery segment aneurysms are one of the most frequent intracranial aneurysms. Currently, limited data have described the use of the pipeline embolization device (PED) in these aneurysms. METHODS We conducted a multicenter retrospective review of 3 prospectively collected databases of patients treated with the PED from January 2013 to December 2017. The primary objective was to assess the efficacy and safety of the PED in the treatment of saccular posterior communicating artery (PComA) aneurysms. We also assessed the effect of anatomical variations on the angiographic and clinical outcomes, including the presence of fetal PComA, vessel origin relationship to the aneurysm, and patency after PED placement. RESULTS We identified 57 patients with 60 saccular aneurysms; Their mean age was 60.5 years, and 49 were female (86.0%). A total of 55 aneurysms (91.7%) were unruptured. The median imaging follow-up duration was 8.5 months. Complete occlusion at the last imaging follow-up study was 84.0%. At the last follow-up examination, 94.5% of patients had a modified Rankin scale score of ≤2. The presence of fetal PComA, origin type, and patency during follow-up did have a significant effect on aneurysm occlusion (P = 0.61, P = 0.40, and P = 0.14, respectively). CONCLUSIONS PED use for treatment of PComA aneurysms resulted in acceptable occlusion rates. The present study did not find that fetal PComA, its origin, or its patency during follow-up had an effect on aneurysm occlusion.
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Affiliation(s)
| | - Krishnan Ravindran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Luis C Ascanio
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA; Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | | | - Abhi Jain
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Abdulrahman Y Alturki
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia.
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111
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Ospel JM, Gascou G, Costalat V, Piergallini L, Blackham KA, Zumofen DW. Comparison of Pipeline Embolization Device Sizing Based on Conventional 2D Measurements and Virtual Simulation Using the Sim&Size Software: An Agreement Study. AJNR Am J Neuroradiol 2019; 40:524-530. [PMID: 30733254 DOI: 10.3174/ajnr.a5973] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/04/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The Sim&Size software simulates case-specific intraluminal Pipeline Embolization Device behavior, wall apposition, and device length in real-time on the basis of rotational angiography DICOM data. The purpose of this multicenter study was to evaluate whether preimplantation device simulation with the Sim&Size software results in selection of different device dimensions than manual sizing. MATERIALS AND METHODS In a multicenter cohort of 74 patients undergoing aneurysm treatment with the Pipeline Embolization Device, we compared apparent optimal device dimensions determined by neurointerventionalists with considerable Pipeline Embolization Device experience based on manual 2D measurements taken from rotational angiography with computed optimal dimensions determined by Sim&Size experts blinded to the neurointerventionalists' decision. Agreement between manually determined and computed optimal dimensions was evaluated with the Cohen κ. The significance of the difference was analyzed with the Wilcoxon signed rank test. RESULTS The agreement index between manual selection and computed optimal dimensions was low (κ for diameter = 0.219; κ for length = 0.149, P < .01). Computed optimal device lengths were significantly shorter (median, 14 versus 16 mm, T = 402, r = -0.28, P < .01). No significant difference was observed for device diameters. CONCLUSIONS Low agreement between manually determined and computed optimal device dimensions is not proof, per se, that virtual simulation performs better than manual selection. Nevertheless, it ultimately reflects the potential for optimization of the device-sizing process, and use of the Sim&Size software reduces, in particular, device length. Nevertheless, further evaluation is required to clarify the impact of device-dimension modifications on outcome.
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Affiliation(s)
- J M Ospel
- From the Diagnostic and Interventional Neuroradiology Section (J.M.O., K.A.B., D.W.Z.), Department of Radiology and Nuclear Medicine
| | - G Gascou
- Department of Neuroradiology (G.G., V.C., L.P.), Hôpital Gui de Chauliac, Centre Hospitalier Universitaire de Montpellier, University of Montpellier, Montpellier, France
| | - V Costalat
- Department of Neuroradiology (G.G., V.C., L.P.), Hôpital Gui de Chauliac, Centre Hospitalier Universitaire de Montpellier, University of Montpellier, Montpellier, France
| | - L Piergallini
- Department of Neuroradiology (G.G., V.C., L.P.), Hôpital Gui de Chauliac, Centre Hospitalier Universitaire de Montpellier, University of Montpellier, Montpellier, France.,Postgraduation School of Radiodiagnostics (L.P.), Università degli Studi di Milano, Milan, Italy
| | - K A Blackham
- From the Diagnostic and Interventional Neuroradiology Section (J.M.O., K.A.B., D.W.Z.), Department of Radiology and Nuclear Medicine
| | - D W Zumofen
- From the Diagnostic and Interventional Neuroradiology Section (J.M.O., K.A.B., D.W.Z.), Department of Radiology and Nuclear Medicine.,Department of Neurosurgery (D.W.Z.), University Hospital Basel, University of Basel, Basel, Switzerland
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Iosif C, Biondi A. Braided stents and their impact in intracranial aneurysm treatment for distal locations: from flow diverters to low profile stents. Expert Rev Med Devices 2019; 16:237-251. [DOI: 10.1080/17434440.2019.1575725] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Christina Iosif
- Department of Neuroradiology and Endovascular Treatment, Jean-Minjoz University Hospital, Besancon, France
- Department of Interventional Neuroradiology, Erasmus University Hospital, Brussels, Belgium
- Associate Professor in Radiology, European University of Cyprus, Nicosia, Cyprus
| | - Alessandra Biondi
- Department of Neuroradiology and Endovascular Treatment, Jean-Minjoz University Hospital, Besancon, France
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Zhu Y, Zhang H, Zhang Y, Wu H, Wei L, Zhou G, Zhang Y, Deng L, Cheng Y, Li M, Santos HA, Cui W. Endovascular Metal Devices for the Treatment of Cerebrovascular Diseases. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2019; 31:e1805452. [PMID: 30589125 DOI: 10.1002/adma.201805452] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/20/2018] [Indexed: 06/09/2023]
Abstract
Cerebrovascular disease involves various medical disorders that obstruct brain blood vessels or deteriorate cerebral circulation, resulting in ischemic or hemorrhagic stroke. Nowadays, platinum coils with or without biological modification have become routine embolization devices to reduce the risk of cerebral aneurysm bleeding. Additionally, many intracranial stents, flow diverters, and stent retrievers have been invented with uniquely designed structures. To accelerate the translation of these devices into clinical usage, an in-depth understanding of the mechanical and material performance of these metal-based devices is critical. However, considering the more distal location and tortuous anatomic characteristics of cerebral arteries, present devices still risk failing to arrive at target lesions. Consequently, more flexible endovascular devices and novel designs are under urgent demand to overcome the deficiencies of existing devices. Herein, the pros and cons of the current structural designs are discussed when these devices are applied to the treatment of diseases ranging broadly from hemorrhages to ischemic strokes, in order to encourage further development of such kind of devices and investigation of their use in the clinic. Moreover, novel biodegradable materials and drug elution techniques, and the design, safety, and efficacy of personalized devices for further clinical applications in cerebral vasculature are discussed.
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Affiliation(s)
- Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Hongbo Zhang
- Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, P. R. China
- Department of Pharmaceutical Sciences Laboratory, Åbo Akademi University, Turku, FI-20520, Finland
- Turku Center for Biotechnology, University of Turku and Åbo Akademi University, Turku, FI-20520, Finland
| | - Yiran Zhang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Huayin Wu
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, 02138, USA
| | - Liming Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Gen Zhou
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Yuezhou Zhang
- Department of Pharmaceutical Sciences Laboratory, Åbo Akademi University, Turku, FI-20520, Finland
- Turku Center for Biotechnology, University of Turku and Åbo Akademi University, Turku, FI-20520, Finland
| | - Lianfu Deng
- Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, P. R. China
| | - Yingsheng Cheng
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Minghua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Hélder A Santos
- Drug Research Program, Division of Pharmaceutical Chemistry and Technology, Faculty of Pharmacy, University of Helsinki, FI-00014, Helsinki, Finland
- Helsinki Institute of Life Science, University of Helsinki, FI-00014, Helsinki, Finland
| | - Wenguo Cui
- Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, P. R. China
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Nishi H, Ishii A, Satow T, Iihara K, Sakai N. Parent Artery Occlusion for Unruptured Cerebral Aneurysms: Results of the Japanese Registry of Neuroendovascular Therapy 3. Neurol Med Chir (Tokyo) 2018; 59:1-9. [PMID: 30531152 PMCID: PMC6350003 DOI: 10.2176/nmc.st.2018-0190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although the current standard treatment for unruptured aneurysms comprises surgical clipping or endovascular coiling, these techniques are not suitable for some cases, such as large, giant, and fusiform aneurysms. Endovascular parent artery occlusion (PAO), which includes internal trapping and proximal occlusion, is a well-established alternative treatment for such cases. Here, we retrospectively reviewed PAO cases from the Japanese Registry of Neuroendovascular Therapy 3, a nation-wide survey of all neuroendovascular therapy cases between 2010 and 2014. This dataset included 274 procedures with a mean patient age of 57.1 years and 55.4% female patients. For the treatment strategy, internal trapping was selected in 213 aneurysm cases (77.7%) and proximal occlusion in 61 aneurysm cases (22.2%). Most of the procedures were successfully completed (272/274: 99.2%). Immediately after treatment, angiographical complete occlusion was achieved in 248 cases (90.5%). Although the feasibility of this technique was excellent, there were 60 periprocedural complications (21.8%), including 48 ischemic complications (17.5%), seven hemorrhagic complications (2.5%). Overall, morbidity and mortality at 30 days postoperative were 5.8% and 0.7%, respectively. Among the pretreatment variables, a patient age of 70 and older was associated with ischemic complications [odds ratio (OR); 2.34, 95% confidence interval (CI); 1.02-5.25; P = 0.04] and a small aneurysm size (<5 mm) was associated with hemorrhagic complications (OR; 9.85, 95% CI; 1.07-221.0; P = 0.04) by multivariate analysis. In conclusion, PAO for unruptured cerebral aneurysms is feasible, but is associated with a complication rate of approximately 20%. Various alternative treatment options should be carefully considered with deconstructive strategies.
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Affiliation(s)
- Hidehisa Nishi
- Department of Neurosurgery, Graduate School of Medicine, Kyoto University
| | - Akira Ishii
- Department of Neurosurgery, Graduate School of Medicine, Kyoto University
| | - Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
| | - Nobuyuki Sakai
- Department of Neuroendovascular Therapy, Institute of Biomedical Research and Innovation.,Department of Neurosurgery, Kobe City Medical Center General Hospital
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Endovascular management of spontaneous delayed migration of the flow-diverter stent. J Neuroradiol 2018; 47:38-45. [PMID: 30513289 DOI: 10.1016/j.neurad.2018.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 10/31/2018] [Accepted: 11/22/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous delayed migration of the flow-diverter stent (FD) is an unusual complication that can be fatal. The purpose of this study is to report our experience and review the literature for the management of delayed FD migration. MATERIALS AND METHODS Between November 2013 and June 2017, 122 patients treated by FD at our institution were enrolled. We also performed a comprehensive review of the literature. RESULTS Six patients (4.9%) were found to have spontaneous delayed migration of their FD. The device migrated proximally in 4 patients and distally in 2 patients. One patient had temporal lobe infarction due to stent migration, and another had subarachnoid haemorrhage (SAH). Three patients were treated with a 2nd or 3rd FD, while 2 were treated with stent-assisted coiling, and one was treated with sacrifice of the parent internal carotid artery. According to our results and the literature, the prevalence rate of delayed FD migration ranges from 2.2% to 4.9%, and the mortality and morbidity rate of delayed FD migration is 40%. CONCLUSIONS Neuro-interventionalists should be aware of this complication and be familiar with risk factors, preventive methods and treatment options. If there is any concern regarding the size or position of the FD, early imaging follow-up and endovascular treatment should be indicated.
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116
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Macdonald IR, Shankar JJS. Delayed parent artery occlusions following use of SILK flow diverters for treatment of intracranial aneurysms. J Neurointerv Surg 2018; 11:690-693. [DOI: 10.1136/neurintsurg-2018-014354] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/31/2018] [Accepted: 11/05/2018] [Indexed: 11/03/2022]
Abstract
BackgroundThe efficacy of SILK flow diverters (SFD) in the management of cerebral aneurysms has been established. However, the risk of complications with parent artery occlusion (PAO) remains to be fully elucidated. The purpose of our study was to analyze intracranial aneurysms treated with SFDs and assess for occurrences and potential risk factors for PAO.Materials and methodsBetween September 2010 and September 2017, 34 patients were treated for intracranial aneurysms using SFDs at a Canadian institution. This database was retrospectively analyzed for frequency of PAOs and statistical analysis performed for potential contributing factors.ResultsFollowing treatment with SFDs, average clinical and imaging follow-ups were 31 and 22 months, respectively. PAOs were identified in 21% (7/34) of patients and occurred between 8 days and 1.5 years from intervention but only in 11.8% in those compliant to anti-platelet medications. These were all associated with anterior circulation aneurysms (P=0.131) and had no associated neurological deficits. Of these, 57% (4/7) had a fusiform morphology compared with only 19% (5/27) in non-occluded patients (P=0.039). The presence of clinical symptoms at the time of initial SFD intervention was significantly associated with PAO (P=0.021).ConclusionDelayed PAO is not an uncommon outcome of flow diverter deployment and could be seen up to 1.5 years after treatment with no associated neurological deficits. Anti-platelet non-adherence remains a risk factor for PAO. Fusiform morphology of the aneurysm and symptoms at the time of intervention were associated with subsequent occlusion.
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Sullivan S, Aguilar-Salinas P, Santos R, Beier AD, Hanel RA. Three-dimensional printing and neuroendovascular simulation for the treatment of a pediatric intracranial aneurysm: case report. J Neurosurg Pediatr 2018; 22:672-677. [PMID: 30215588 DOI: 10.3171/2018.6.peds17696] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 06/13/2018] [Indexed: 11/06/2022]
Abstract
The use of simulators has been described in a variety of fields as a training tool to gain technical skills through repeating and rehearsing procedures in a safe environment. In cerebrovascular surgery, simulation of skull base approaches has been used for decades. The use of simulation in neurointervention to acquire and enhance skills before treating a patient is a newer concept, but its utilization has been limited due to the lack of good models and deficient haptics. The advent of 3D printing technology and the development of new training models has changed this landscape. The prevalence of aneurysms in the pediatric population is much lower than in adults, and concepts and tools sometimes have to be adapted from one population to another. Neuroendovascular rehearsal is a valid strategy for the treatment of complex aneurysms, especially for the pediatric population. The authors present the case of an 8-year-old boy with a fusiform intracranial aneurysm and documented progressive growth, who was successfully treated after the authors rehearsed the placement of a flow diverter using a patient-specific 3D-printed replicator system model.
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Affiliation(s)
- Sean Sullivan
- 1Lyerly Neurosurgery, Baptist Neurological Institute; and
| | | | - Roberta Santos
- 1Lyerly Neurosurgery, Baptist Neurological Institute; and
| | - Alexandra D Beier
- 2Division of Pediatric Neurosurgery, University of Florida Health Science Center, Jacksonville, Florida
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Ravindran K, Salem MM, Enriquez-Marulanda A, Alturki AY, Moore JM, Thomas AJ, Ogilvy CS. Quantitative Assessment of In-Stent Stenosis After Pipeline Embolization Device Treatment of Intracranial Aneurysms: A Single-Institution Series and Systematic Review. World Neurosurg 2018; 120:e1031-e1040. [DOI: 10.1016/j.wneu.2018.08.225] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/18/2018] [Accepted: 08/20/2018] [Indexed: 12/18/2022]
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Kolumam Parameswaran P, Dai D, Ding YH, Urban MW, Manlove L, Sathish V, Cebral JR, Kallmes DF, Kadirvel R. Downstream vascular changes after flow-diverting device deployment in a rabbit model. J Neurointerv Surg 2018; 11:523-527. [PMID: 30415228 DOI: 10.1136/neurintsurg-2018-014123] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 10/05/2018] [Accepted: 10/20/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Flow diverters (FDs) are increasingly used in the treatment of intracranial aneurysms, and carry the risk of thromboembolic complications, even in patients treated with dual antiplatelet therapy. The effect of FDs on the downstream vascular is unknown. The aim of the study was to investigate vascular wall pulse wave velocity (PWV) and contractility changes following FD treatment in a rabbit model. METHODS FDs (Pipeline Embolic Device, Medtronic Inc., Irvine, California, USA) were implanted in the aorta of normal rabbits and sham-operated aorta were used as controls (n=6 per group). Pulse wave imaging with ultra-fast ultrasound at 1600 frames per second (Vantage, Verasonics, Inc., Kirkland, WA) was performed in the vessel wall distal to FD prior to device implantation and at 8- week follow-up to measure the PWV. Force contraction vascular reactivity studies were conducted in the aortic rings using an organ bath. RESULTS The difference in mean PWV in the follow-up compared with pre-implantation was significantly higher in the distal vessels compared with sham controls (1.18 m/s [SD=0.54] vs. 0.37 m/s [SD=1.09], P=0.03). Conversely, the aortic segments distal to the FD exhibited a 55% increase in vascular contractility compared with proximal segments (P=0.002). We observed a significant positive correlation between mean PWV and mean vascular contractility. CONCLUSION Implantation of FD was associated with increased PWV and vascular contractility, suggesting that FD implantation causes changes to the vascular wall. Further studies are needed to understand the clinical implication of changes in vascular PWV and contractility.
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Affiliation(s)
| | - Daying Dai
- Applied Neuroradiology Research Laboratory, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yong-Hong Ding
- Applied Neuroradiology Research Laboratory, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew W Urban
- Division of Radiology Research, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Logan Manlove
- Pulmonary Cell Biology Laboratory, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Venkatachalem Sathish
- Department of Pharmaceutical Sciences, North Dakota State University, Fargo, North Dakota, USA
| | - Juan R Cebral
- Department of Bioengineering, George Mason University, Fairfax, Virginia, USA
| | - David F Kallmes
- Applied Neuroradiology Research Laboratory, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ramanathan Kadirvel
- Applied Neuroradiology Research Laboratory, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Mascitelli JR, Lawton MT, Hendricks BK, Nakaji P, Zabramski JM, Spetzler RF. Analysis of Wide-Neck Aneurysms in the Barrow Ruptured Aneurysm Trial. Neurosurgery 2018; 85:622-631. [DOI: 10.1093/neuros/nyy439] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/13/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Ruptured wide-neck aneurysms (WNAs) are difficult to treat and few publications have compared clipping to coiling.
OBJECTIVE
To determine, using Barrow Ruptured Aneurysm Trial (BRAT) data: (1) How many aneurysms had a wide neck? (2) Did wide-neck status influence treatment? (3) How did clipping compare to coiling for WNAs?
METHODS
A post hoc analysis was conducted of saccular WNAs in the BRAT. A WNA was defined as maximum neck width ≥ 4 mm or maximum aneurysm dome-diameter–to–neck-width ratio < 2. Both intent-to-treat and as-treated analyses were performed.
RESULTS
Of the 327 patients analyzed, 177 (54.1%) had a WNA. WNAs were more likely to occur in older patients (P = .03) with worse presenting clinical grade (P = .02), were more likely to arise from the middle cerebral artery, basilar tip, or internal carotid artery other than the junction with the posterior communicating artery (P = .001) and were associated with worse clinical outcomes at all time points (P ≤ .01). WNAs were equally distributed in assigned treatment groups (clip 56.6% vs coil 51.8%; P = .38), but were overrepresented in the actual clipping group (clip 62.4% vs coil 37.6%, P < .001). Most patients (76.7%) in the coil-to-clip crossover group had a WNA. Comparing clipping to coiling, there was no difference in clinical outcomes at any time point in either analysis (P ≥ .33). The aneurysm obliteration rate was lower (P < .001) and the retreatment rate higher (P < .001) in the actual coiling group.
CONCLUSION
Wide-neck status significantly impacted treatment strategy in the BRAT, favoring clipping. Clipping and coiling of ruptured WNAs resulted in statistically similar long-term clinical outcomes.
10.1093/neuros/nyy439 Video Abstract 10.1093.neuros.nyy439 5850292551001
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Affiliation(s)
- Justin R Mascitelli
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Benjamin K Hendricks
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Joseph M Zabramski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Aydin K, Barburoglu M, Oztop Cakmak O, Yesilot N, Vanli ENY, Akpek S. Crossing Y-Solitaire thrombectomy as a rescue treatment for refractory acute occlusions of the middle cerebral artery. J Neurointerv Surg 2018; 11:246-250. [DOI: 10.1136/neurintsurg-2018-014288] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/14/2018] [Accepted: 08/16/2018] [Indexed: 12/13/2022]
Abstract
BackgroundMechanical thrombectomy using a stent retriever has become the standard of care for acute large-vessel occlusions in the anterior circulation. Clots that are refractory to single stent retriever thrombectomy remain a challenge for neurointerventionalists.ObjectiveTo assess the efficacy and safety of double stent retriever (crossing Y-Solitaire) thrombectomy as a rescue treatment for acute middle cerebral artery (MCA) occlusions that are refractory to single stent retriever thrombectomy.MethodsWe retrospectively reviewed the databases of our hospitals to identify patients who presented with an acute MCA occlusion and were treated with crossing Y-Solitaire thrombectomy. The angiographic (Thrombolysis in Cerebral Infarction (TICI) scale) and clinical outcomes (National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores) and complications were assessed.ResultsTen patients were included in the study. The median initial NIHSS score and Alberta Stroke Program Early CT Score (ASPECTS) were 19.0 and 9.6, respectively. Crossing Y-Solitaire thrombectomy was performed as a rescue technique after unsuccessful single Solitaire thrombectomy passes in all cases. Successful recanalization (TICI 2b/3) was achieved in 8 (80%) patients. We observed asymptomatic reperfusion hemorrhages in 2 (20%) patients. No procedural related complications were seen other than reversible vasospasms in 5 (50%) patients. Sixty percent of the patients had a mRS score of between 2 and 0 at 90 days after the procedure. There was no mortality.ConclusionCrossing Y-Solitaire thrombectomy seems to be an effective and safe alternative rescue technique to treat refractory MCA bifurcation occlusions that are refractory to standard thrombectomy procedures.
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Delayed Posttreatment Residual Flow into Aneurysm After Flow Diverter Placement. World Neurosurg 2018; 116:205-208. [PMID: 29852305 DOI: 10.1016/j.wneu.2018.05.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/18/2018] [Accepted: 05/18/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Inflow into an aneurysm sac immediately following flow diverter (FD) treatment is an assumed cause of delayed aneurysmal rupture. The significance of delayed posttreatment residual flow occurring months after FD treatment is unknown. CASE DESCRIPTION A 76-year-old woman with a large intracranial aneurysm measuring 23.0 × 18.1 mm in the cavernous segment of the right internal carotid artery was treated with placement of a single FD (Pipeline Embolization Device, Covidien, Irvine, California, USA). Postprocedure digital subtraction angiography (DSA) demonstrated flow stagnation inside the aneurysm dome. The patient was discharged 9 days post procedure without new neurologic deficits. A 6-month follow-up DSA demonstrated delayed posttreatment residual flow into the aneurysm sac. Although she was scheduled for additional FD placement because of concern for aneurysmal rupture, the operation was not conducted due to an interim motor vehicle accident. Oral treatment with aspirin (100 mg/day) and clopidogrel (75 mg/day) was continued during her recovery. DSA performed 12 months post procedure showed that the aneurysm had completely thrombosed. CONCLUSIONS Our findings suggest that delayed post-treatment residual flow into an aneurysm may form part of the normal clinical course post FD placement and may not preclude eventual thrombosis of the aneurysm. Larger studies are needed to determine whether more frequent follow-up DSAs after FD placement are necessary and whether all patients exhibiting delayed post-treatment residual flow into an aneurysm require additional FD placement or if watchful waiting is a more suitable course.
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Liu JM, Zhou Y, Li Y, Li T, Leng B, Zhang P, Liang G, Huang Q, Yang PF, Shi H, Zhang J, Wan J, He W, Liang C, Zhu G, Xu Y, Hong B, Yang X, Bai W, Tian Y, Zhang H, Li Z, Li Q, Zhao R, Fang Y, Zhao K. Parent Artery Reconstruction for Large or Giant Cerebral Aneurysms Using the Tubridge Flow Diverter: A Multicenter, Randomized, Controlled Clinical Trial (PARAT). AJNR Am J Neuroradiol 2018; 39:807-816. [PMID: 29599173 DOI: 10.3174/ajnr.a5619] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/26/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Although flow diverters have been reported with favorable clinical and angiographic outcomes in various literatures, randomized trials determining their true effectiveness and safety are still in lack. The Parent Artery Reconstruction for Large or Giant Cerebral Aneurysms Using the Tubridge Flow Diverter (PARAT) trial was designed to evaluate the safety and efficacy of the Tubridge flow diverter in the treatment of large or giant aneurysms in comparison with Enterprise stent-assisted coiling. MATERIALS AND METHODS This prospective, multicenter, randomized trial was conducted at 12 hospitals throughout China. Enrolled adults with unruptured large/giant intracranial aneurysms were randomly assigned (1:1) to receive either Enterprise stent-assisted coiling or Tubridge flow diverter implantation. The primary end point was complete occlusion at 6-month follow-up, while secondary end points included technical success, mortality, target vessel-related stroke, aneurysm bleeding, in-stent stenosis, parent artery occlusion, and the frequency of all adverse events. RESULTS Among 185 enrolled subjects, 41 withdrew before procedure initiation. Overall, 82 subjects underwent Tubridge implantation, and 62 subjects were primarily treated with stent-assisted coiling. The results of 6-month follow-up imaging included complete occlusion rates of 75.34% versus 24.53% for the Tubridge and stent-assisted coiling groups, respectively, with a calculated common odds ratio of 9.4 (95% confidence interval, 4.14-21.38; P < .001). There was a higher, nonsignificant frequency of complications for Tubridge subjects. Multivariate analysis showed a decreased stroke rate at the primary investigational site, with a marginal P value (P = .051). CONCLUSIONS This trial showed an obviously higher rate of large and giant aneurysm obliteration with the Tubridge FD over Enterprise stent-assisted coiling. However, this higher obliteration rate came at the cost of a nonsignificantly higher rate of complications. Investigational site comparisons suggested that a learning curve for flow-diverter implantation should be recognized and factored into trial designs.
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Affiliation(s)
- J-M Liu
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - Y Zhou
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - Y Li
- Department of Neurosurgery (Y.L., X.Y.), Tiantan Hospital, Beijing, China
| | - T Li
- Department of Interventional Radiology (T.L., W.B.), Henan Provincial People's Hospital, Henan Province, China
| | - B Leng
- Department of Neurosurgery (B.L., Y.T.), Huashan Hospital, Shanghai, China
| | - P Zhang
- Department of Neurosurgery (P.Z., H.Z.), Xuanwu Hospital, Beijing, China
| | - G Liang
- Department of Neurosurgery (G.L., Z.L.), General Hospital of Shenyang Military, Shenyang Province, China
| | - Q Huang
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - P-F Yang
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - H Shi
- Department of Neurosurgery (H.S.), First Clinical Hospital affiliated with Harbin Medical University, Heilongjiang Province, China
| | - J Zhang
- Department of Neurosurgery (J.Z.), Second Affiliated Hospital of Zhejiang University, Hangzhou Municipality, Zhejiang, China
| | - J Wan
- Department of Neurosurgery (J.W.), Renji Hospital, Shanghai, China
| | - W He
- Department of Neurosurgery (W.H.), Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - C Liang
- Department of Neurosurgery (C.L.), First Hospital of China Medical University, Shenyang Municipality, Liaoning, China
| | - G Zhu
- Department of Neurosurgery (G.Z.), Southwest Hospital, Chongqing Municipality, China
| | - Y Xu
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - B Hong
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - X Yang
- Department of Neurosurgery (Y.L., X.Y.), Tiantan Hospital, Beijing, China
| | - W Bai
- Department of Interventional Radiology (T.L., W.B.), Henan Provincial People's Hospital, Henan Province, China
| | - Y Tian
- Department of Neurosurgery (B.L., Y.T.), Huashan Hospital, Shanghai, China
| | - H Zhang
- Department of Neurosurgery (P.Z., H.Z.), Xuanwu Hospital, Beijing, China
| | - Z Li
- Department of Neurosurgery (G.L., Z.L.), General Hospital of Shenyang Military, Shenyang Province, China
| | - Q Li
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - R Zhao
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - Y Fang
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - K Zhao
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
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Xu D, Zhang C, Wang T, Wang C, Kallmes DF, Lanzino G, You C, Xie X. Evaluation of Enterprise Stent-Assisted Coiling and Telescoping Stent Technique as Treatment of Supraclinoid Blister Aneurysms of the Internal Carotid Artery. World Neurosurg 2017; 110:e890-e896. [PMID: 29191548 DOI: 10.1016/j.wneu.2017.11.119] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 11/19/2017] [Accepted: 11/22/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Supraclinoid blister aneurysms (BAs) of the internal carotid artery are uncommon and deadly, and appropriate treatment is controversial. Endovascular reconstruction may allow treatment through aneurysm isolation. We report a single-institution experience in the use of Enterprise stent-assisted coiling (ESAC) for treating BAs to appraise the safety and efficacy of this technique. METHODS Patients treated with ESAC for a BA at our institution between 2013 and 2016 were retrospectively included in this study. Patients' aneurysm characteristics, progression status, aneurysm occlusion on follow-up angiography, and modified Rankin Scale (mRS) score were recorded and analyzed. Occlusion rates and neurologic outcomes were compared between patients treated with a single stent and those treated with multiple telescoping stents. RESULTS Forty-four patients were included (17 males; average age, 47.3 years), and ESAC was successfully performed in all patients. Immediate postprocedure angiography revealed complete occlusion in 23 patients (52.3%), residual neck in 15 (34.1%), and residual aneurysm in 6 (13.6%). Twenty patients (45.5%) suffered perioperative cerebral vasospasm, and 3 (6.8%) died of secondary ischemic stroke. The duration of follow-up ranged from 2.5 to 27 months (mean, 11.59 ± 5.76 months). One patient with recurrence was treated with additional coiling, and another patient was treated with a covered stent. The use of telescoping stents was associated with a better complete aneurysm occlusion rate compared with the use of single stents (84.4% [27 of 34] vs. 44.4% [4 of 9]; P = 0.04). Follow-up mRS score was ≤1 for 32 of 41 patients (78.4%). CONCLUSIONS ESAC to treat BAs is safe, effective, and provides good clinical outcomes. ESAC with telescoping stents has a higher follow-up complete occlusion rate compared with ESAC with single stents.
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Affiliation(s)
- Ding Xu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Changwei Zhang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ting Wang
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Chaohua Wang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Chao You
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiaodong Xie
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
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