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Eraky AM, Feller C, Tolba H, Porwal M, Sacho RH, Hedayat H. Flow diverter stenting for intracranial aneurysms in the pediatric population: Two case reports and literature review. J Cerebrovasc Endovasc Neurosurg 2024; 26:58-64. [PMID: 37605792 PMCID: PMC10995473 DOI: 10.7461/jcen.2023.e2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/03/2023] [Accepted: 07/12/2023] [Indexed: 08/23/2023] Open
Abstract
The Pipeline Embolization Device (PED) is a flow-diverting intraluminal device that is approved for use in adults 18 years or older with internal carotid artery aneurysms. However, it can also be used off-label in pediatric patients with aneurysms that cannot be resolved with traditional endovascular treatments. Herein, we present two cases of flow diversion in the pediatric population with complete obliteration of the aneurysm and excellent outcomes. Flow diversion has been shown to be a safe endovascular option in treating complex aneurysms in children. Larger-sized, multicenter trials are encouraged to compare outcomes between flow diversion and other aneurysm treatment options given the rarity of pediatric aneurysms.
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Affiliation(s)
- Akram M Eraky
- Department of Neurosurgery, Medical College of Wisconsin, WI, USA
| | - Christina Feller
- Department of Neurosurgery, Medical College of Wisconsin, WI, USA
| | - Hatem Tolba
- Department of Neurology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Mokshal Porwal
- Department of Neurosurgery, Medical College of Wisconsin, WI, USA
| | | | - Hirad Hedayat
- Department of Neurosurgery, Medical College of Wisconsin, WI, USA
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2
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Hosseini EM, Zafarshamspour S, Ghasemi-Rad M, Benndorf G, Rasekhi A, Rafieossadat R. Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature. Childs Nerv Syst 2024; 40:345-357. [PMID: 37750891 DOI: 10.1007/s00381-023-06161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/18/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population. METHOD We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs. RESULTS Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis. CONCLUSION Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.
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Affiliation(s)
| | - Saber Zafarshamspour
- Department of Surgery, Rafsanjan University of Medical Sciences, Rafsanjan, Kerman, Iran
| | - Mohammad Ghasemi-Rad
- Department of Interventional Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Goetz Benndorf
- Department of Radiology, University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Alireza Rasekhi
- Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Rafieossadat
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran.
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3
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Fry L, Brake A, Heskett CA, LeBeau G, De Stefano FA, Alkiswani AR, Lei C, Le K, Peterson J, Ebersole K. Endovascular Management of Pediatric Traumatic Intracranial Pseudoaneurysms: A Systematic Review and Case Series. World Neurosurg 2023; 176:213-226. [PMID: 37059359 DOI: 10.1016/j.wneu.2023.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVE This study aims to systematically review the management and outcomes of pediatric patients who develop intracranial pseudoaneurysm (IPA) following head trauma or iatrogenic injury. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature review was performed. Additionally, a retrospective analysis was conducted on pediatric patients who underwent evaluation and endovascular treatment for IPA originating from head trauma or iatrogenic injury at a single institution. RESULTS Two hundred twenty-one articles in the original literature search. Fifty-one met inclusion criteria resulting in a total of 87 patients with 88 IPAs including our institution. Patients ranged in age from 0.5 months to 18 years. Parent vessel reconstruction was used as first-line treatment in 43 cases, parent vessel occlusion in 26, and direct aneurysm embolization (DAE) in 19. Intraoperative complications were observed in 3.00% of procedures. Complete aneurysm occlusion was achieved in 89.61% of cases. 85.54% of cases resulted in favorable clinical outcomes. The mortality rate after treatment was 3.61%. The DAE group had higher rates of aneurysm recurrence than other treatment strategies (P = 0.009). Patients with SAH had overall worse outcomes compared to patients who did not (P = 0.024). There were no differences in favorable clinical outcomes (P = 0.274) or complete aneurysm occlusion (P = 0.13) between primary treatment strategies. CONCLUSIONS IPAs were successfully obliterated, and favorable neurological outcomes were achieved at a high rate regardless of primary treatment strategy. DAE had a higher rate of recurrence than the other treatment groups. Each described treatment method in our review is safe and viable for the treatment of IPAs in pediatric patients.
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Affiliation(s)
- Lane Fry
- The University of Kansas School of Medicine, Kansas City, Kansas
| | - Aaron Brake
- The University of Kansas School of Medicine, Kansas City, Kansas
| | - Cody A Heskett
- The University of Kansas School of Medicine, Kansas City, Kansas.
| | - Gabriel LeBeau
- The University of Kansas School of Medicine, Kansas City, Kansas
| | - Frank A De Stefano
- Department of Neurological Surgery, University of Kansas Health System, Kansas City, Kansas
| | | | - Catherine Lei
- The University of Kansas School of Medicine, Kansas City, Kansas
| | - Kevin Le
- The University of Kansas School of Medicine, Kansas City, Kansas
| | - Jeremy Peterson
- Department of Neurological Surgery, University of Kansas Health System, Kansas City, Kansas
| | - Koji Ebersole
- Department of Neurological Surgery, University of Kansas Health System, Kansas City, Kansas
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4
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Endovascular treatment of pediatric basilar artery aneurysms: case series and literature review. Childs Nerv Syst 2023; 39:25-34. [PMID: 36318284 DOI: 10.1007/s00381-022-05728-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/25/2022] [Indexed: 02/28/2023]
Abstract
PURPOSE Pediatric basilar artery aneurysms are rare and challenging to treat. Microsurgical options and standard endovascular coiling are often undesirable choices for treatment of this pathology. Additional endovascular strategies are needed. METHODS Presentation, diagnosis, and management of pediatric basilar aneurysms were reviewed, with an emphasis on endovascular treatment strategies. Our case series of 2 patients was presented in detail, one treated with flow diversion and vessel sacrifice and one treated with stent-assisted coiling. An extensive review of the literation was performed to find other examples of pediatric basilar artery aneurysms treated with endovascular techniques. RESULTS Twenty-nine studies met inclusion criteria. Fifty-nine aneurysms in 58 patients were treated using endovascular techniques. Mortality rate was 10.3% (6/58) and a poor outcome (GOS 1-3) occurred in 15.5% (9/58). There were 4 reported recurrences requiring retreatment; however, only 46.5% of patients had reported follow-up of at least 1 year. 71.1% (42/59) were dissecting aneurysms. CONCLUSION Basilar artery aneurysms in the pediatric population are rare, commonly giant and fusiform, and often not amenable to microsurgical or coiling techniques. The surrounding vasculature, location, size, and morphology of the aneurysm along with the durability of treatment must be considered in treatment decisions. With proper patient selection, stent-assisted coiling and flow diversion may increase the durability and safety of endovascular treatment in this population.
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Budohoski KP, Thakrar R, Voronovich Z, Rennert RC, Kilburg C, Grandhi R, Couldwell WT, Brockmeyer DL, Taussky P. Initial experience with Pipeline embolization of intracranial pseudoaneurysms in pediatric patients. J Neurosurg Pediatr 2022; 30:465-473. [PMID: 36057120 DOI: 10.3171/2022.7.peds22195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children. METHODS This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed. RESULTS Six patients with a median age of 12 years (range 7-16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae. CONCLUSIONS Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.
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Affiliation(s)
- Karol P Budohoski
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Raj Thakrar
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Zoya Voronovich
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Robert C Rennert
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Craig Kilburg
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Ramesh Grandhi
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Douglas L Brockmeyer
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Philipp Taussky
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
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Shlobin NA, Raz E, Shapiro M, Moretti L, Cantrell DR, Lam SK, Hurley MC, Ansari SA, Nossek E, Riina HA, Nelson PK, Jahromi BS, Shaibani A, Potts MB. Pipeline embolization of cerebral aneurysms in pediatric patients: combined systematic review of patient-level data and multicenter retrospective review. J Neurosurg Pediatr 2021; 27:668-676. [PMID: 33892469 DOI: 10.3171/2020.10.peds20324] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 10/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebral aneurysms in the pediatric population are rare and optimal treatment strategies are not as well characterized as in adults. The Pipeline embolization device (PED) is an endoluminal flow diverter that is commonly used to treat aneurysms in adults, but experience with this device in children is limited. The authors sought to further characterize PED use and outcomes in this specific population by performing both a systematic review of patient-level data from studies reporting the use of the PED to treat pediatric aneurysms and a retrospective review of their experience. METHODS A systematic review of the PubMed, Embase, and Scopus databases was performed to identify studies reporting the use of the PED in pediatric patients (age ≤ 18 years). Disaggregated data regarding demographics, aneurysm characteristics, treatment, and outcomes were collected. Retrospective data from the authors' two institutions were also included. RESULTS Thirty studies comprising patient-level data on 43 pediatric patients with 47 aneurysms were identified. An additional 9 patients with 9 aneurysms were included from the authors' institutions for a total of 52 patients with 56 aneurysms. The mean patient age was 11.1 years. Presentations included aneurysm rupture (17.3%) and symptomatic mass effect (23.1%). Aneurysms were located in the anterior circulation in 55.4% of cases, and 73.2% were described as nonsaccular. Imaging follow-up was available for 89.3% with a mean follow-up of 13.3 months. Aneurysm occlusion was reported in 75%, with 1 case each (1.8%) demonstrating significant in-stent stenosis and parent vessel occlusion. Clinical follow-up was reported in 90.4% with a mean follow-up of 14.7 months. Good functional outcomes (modified Rankin Scale score of 0-1 or Glasgow Outcome Scale score of 5) were reported in 65.4% of the total population. Two major complications were reported, including 1 death. CONCLUSIONS Despite substantial differences in aneurysm location and type between published pediatric and adult patient populations treated with the PED, the use of the PED in the pediatric population appears to be safe. While the short-term effectiveness is also similar to that of adults, additional studies are needed to further characterize the long-term outcomes and better define the use of this device in pediatric patients.
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Affiliation(s)
| | - Eytan Raz
- 5Departments of Radiology and Neurological Surgery, New York University Grossman School of Medicine, Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Maksim Shapiro
- 5Departments of Radiology and Neurological Surgery, New York University Grossman School of Medicine, Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Luke Moretti
- 5Departments of Radiology and Neurological Surgery, New York University Grossman School of Medicine, Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Donald R Cantrell
- 2Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago
- 4Department of Medical Imaging, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois; and
| | - Sandi K Lam
- Departments of1Neurological Surgery and
- 3Division of Neurosurgery and
| | - Michael C Hurley
- Departments of1Neurological Surgery and
- 2Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago
- 4Department of Medical Imaging, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois; and
| | - Sameer A Ansari
- Departments of1Neurological Surgery and
- 2Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago
- 4Department of Medical Imaging, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois; and
| | - Erez Nossek
- 5Departments of Radiology and Neurological Surgery, New York University Grossman School of Medicine, Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Howard A Riina
- 5Departments of Radiology and Neurological Surgery, New York University Grossman School of Medicine, Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Peter K Nelson
- 5Departments of Radiology and Neurological Surgery, New York University Grossman School of Medicine, Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Babak S Jahromi
- Departments of1Neurological Surgery and
- 2Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago
| | - Ali Shaibani
- Departments of1Neurological Surgery and
- 2Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago
- 4Department of Medical Imaging, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois; and
| | - Matthew B Potts
- Departments of1Neurological Surgery and
- 2Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago
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7
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Scoville J, Joyce E, Baker C, Dewey J, Grandhi R, Taussky P. Analyzing the Safety and Efficacy of Flow-Diverting Stents in Pediatric Aneurysms: A Systematic Review. Neurosurgery 2021; 89:154-163. [PMID: 33825887 DOI: 10.1093/neuros/nyab120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 02/08/2021] [Indexed: 11/12/2022] Open
Abstract
Ruptured intracranial aneurysms cause 50% of spontaneous subarachnoid hemorrhages in children, resulting in up to 65% mortality when left untreated. Although flow-diverting stents are especially suited to treat the fusiform and giant aneurysms more commonly found in children, the US Food and Drug Administration (FDA) has only approved their use in patients ≥22 years of age. Our objective was to assess the safety of flow-diverting stents in the treatment of pediatric patients with aneurysms through a systematic literature review using the PRISMA criteria. We used PubMed, Embase, and Web of Science to identify all published cases of pediatric aneurysms treated or retreated using flow-diverting stents from 2007 through 2019. Two independent researchers developed a consensus regarding the inclusion of all articles. Patient data were extracted from the identified articles and used to calculate the incidence rate of complications. From 1396 journal articles identified, 24 articles contained data on 37 pediatric patients that met the inclusion criteria. Of these 37 patients, 8 (21.6%) had a complication by last follow-up (death: 2; residual aneurysm: 2; parent artery occlusion: 4). This resulted in an incidence rate of 0.018 complications per patient at-risk month (95% CI 0.008-0.035). These data suggest that the use of flow-diverting stents for treatment of aneurysms in children may be safe and that FDA approval for this use should be evaluated. Although this analysis is comprised of case reports and case series, it represents the best attempt thus far to quantify the risk of using flow-diverting stents in children.
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Affiliation(s)
- Jonathan Scoville
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Evan Joyce
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Cordell Baker
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Jesse Dewey
- Rocky Vista University College of Osteopathic Medicine, Ivins, Utah, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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8
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LoPresti MA, Srinivasan VM, North RY, Ravindra VM, Johnson J, Burkhardt JK, Lam SK, Kan P. Endovascular stenting for rescue of a failed donor graft during superficial temporal artery to middle cerebral artery bypass surgery: case report. J Neurosurg Pediatr 2019; 24:572-576. [PMID: 31398698 DOI: 10.3171/2019.5.peds1977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/30/2019] [Indexed: 11/06/2022]
Abstract
Direct bypass has been used to salvage failed endovascular treatment; however, little is known of the reversed role of endovascular management for failed bypass.The authors report the case of a 7-year-old patient who underwent a superficial temporal artery to middle cerebral artery (STA-MCA) bypass for treatment of a giant MCA aneurysm and describe the role of endovascular rescue in this case. Post-bypass catheter angiogram showed occlusion of the proximal extracranial STA donor with patent anastomosis, possibly due to STA dissection. A self-expanding Neuroform Atlas stent was deployed across the dissection flap, and follow-up images showed revascularization of the STA with good MCA runoff.This case demonstrates that direct extracranial-intracranial bypass failure can infrequently originate from the STA donor vessel and that superselective angiogram can be useful for identification and treatment in such cases. With more advanced endovascular techniques the tide has turned in the treatment of complex cerebrovascular cases, with this case being an early example of successful rescue stenting for endovascular management of a failed donor after STA-MCA bypass.
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Affiliation(s)
- Melissa A LoPresti
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Visish M Srinivasan
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Robert Y North
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Vijay M Ravindra
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jeremiah Johnson
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jan-Karl Burkhardt
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi K Lam
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- 1Division of Neurosurgery, Texas Children's Hospital, Houston; and
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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9
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Cherian J, Srinivasan V, Froehler MT, Grossberg JA, Cawley CM, Hanel RA, Puri A, Dumont T, Ducruet AF, Albuquerque F, Arthur A, Cheema A, Spiotta A, Anadani M, Lopes D, Saied A, Kim L, Kelly CM, Chen PR, Mocco J, De Leacy R, Powers CJ, Grandhi R, Fargen KM, Chen SR, Johnson JN, Lam S, Kan P. Flow Diversion for Treatment of Intracranial Aneurysms in Pediatric Patients: Multicenter Case Series. Neurosurgery 2019; 87:53-62. [DOI: 10.1093/neuros/nyz380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 07/02/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Though the Pipeline Embolization Device (Medtronic) is approved for use in adults 22 yr and older, the high efficacy and long-term durability of the device is attractive for treatment of intracranial aneurysms in younger patients who often have aneurysms less amenable to traditional endovascular treatments.
OBJECTIVE
To report technical, angiographic, and clinical outcomes in patients aged 21 or below undergoing flow-diversion treatment for intracranial aneurysms.
METHODS
Retrospective review across 16 institutions identified 39 patients aged 21 or below undergoing 46 treatment sessions with Pipeline Embolization Device placement between 2012 and 2018. A total of 50 intracranial aneurysms were treated. Details regarding patient demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed in a multicenter database.
RESULTS
A total of 70% of patients were male. Nonsaccular morphology was seen in half of identified aneurysms. Six aneurysms were giant, and five patients were treated acutely after ruptured presentation. Eight patients were younger than 10 yr of age. Complete aneurysm occlusion was seen in 74% of treated aneurysms. Three aneurysms (6%) were retreated. A total of 83% of patients had a modified Rankin Scale scores of ≤2 at last clinical follow-up. There were 2 early mortalities (4.3%) in the immediate postprocedure period because of rerupture of a treated ruptured aneurysm. No recanalization of a previously occluded aneurysm was observed.
CONCLUSION
Flow-diversion treatment is a safe and effective treatment for intracranial aneurysms in patients younger than 22 yr. Rates of complete aneurysm occlusion and adverse events are comparable for rates seen in older patients.
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Affiliation(s)
- Jacob Cherian
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Visish Srinivasan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Ricardo A Hanel
- Department of Neurosurgery, Jacksonville Baptist, Jacksonville, Florida
| | - Ajit Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Travis Dumont
- Department of Neurosurgery, University of Arizona, Tucson, Arizona
| | - Andrew F Ducruet
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Felipe Albuquerque
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Adam Arthur
- Department of Neurosurgery, Semmes Murphy, Memphis, Tennessee
| | - Ahmed Cheema
- Department of Neurosurgery, Semmes Murphy, Memphis, Tennessee
| | - Alejandro Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Mohammad Anadani
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Demetrius Lopes
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Ahmed Saied
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
- Neurology Department, Mansoura University, Mansoura, Egypt
| | - Louis Kim
- Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Cory M Kelly
- Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Peng Roc Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ciarán J Powers
- Department of Neurological Surgery, The Ohio State Wexner Medical Center, Columbus, Ohio
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Kyle M Fargen
- Department of Neurological Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Stephen R Chen
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Sandi Lam
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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10
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Wang J, Zhang Y, Lv M, Yang X, Tian Z, Liu J, Liu P, Miao Z, Jia L, Chen J, Ding X, Zhang Y, Zhu W, Li W, Wang K, Wang Z. Application of the Pipeline Embolization Device for Giant Vertebrobasilar Dissecting Aneurysms in Pediatric Patients. Front Neurol 2019; 10:179. [PMID: 30915016 PMCID: PMC6421298 DOI: 10.3389/fneur.2019.00179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 02/12/2019] [Indexed: 11/22/2022] Open
Abstract
Objective: To evaluate the feasibility and effectiveness of the pipeline embolization device (PED) for the treatment of pediatric giant vertebrobasilar dissecting aneurysms (VBDAs). Methods: We retrospectively reviewed our institutional clinical database and identified 2,706 patients who presented with a diagnosis of intracranial aneurysms from January 2016 to June 2018. Among this group, 153 patients were diagnosed with VBDAs, and 54 of these patients underwent PED therapy. The PED technique was used in four patients who were 18 years old or younger at the time of presentation (two males, two females; mean age 9.25 years; age range 8–11 years). Results: All four included pediatric patients were managed with the PED. One patient (25%) was treated with the PED alone, while three (75%) were treated with the PED and coils. One patient died from brainstem infarction or compression of the brainstem, while follow-up of the other three patients revealed favorable outcomes. The mass effect was reduced in cases 1, 2, and 3 on follow-up MRI performed 6 months after the PED procedure. Conclusions: PEDs could be feasible in the treatment of pediatric giant VBDAs. However, the safety and efficacy of this method have not been clarified in this special pediatric population, and long-term follow-up is still necessary.
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Affiliation(s)
- Jiejun Wang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yisen Zhang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Lv
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongbin Tian
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zefeng Miao
- Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Luqiong Jia
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junfan Chen
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinghuan Ding
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Zhang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Zhu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenqiang Li
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kun Wang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongxiao Wang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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11
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Kim M, Lee HS, Lee S, Park JC, Ahn JS, Kwon DH, Kwun BD, Park W. Pediatric Intracranial Aneurysms: Favorable Outcomes Despite Rareness and Complexity. World Neurosurg 2019; 125:e1203-e1216. [PMID: 30794975 DOI: 10.1016/j.wneu.2019.01.280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/27/2019] [Accepted: 01/30/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Pediatric intracranial aneurysms (IAs) are rare and differ from their adult counterparts in terms of their aneurysmal characteristics, presentation, treatment, and outcomes. Their treatment is often more difficult and complex compared with that of adults. However, studies outlining the clinical effect of pediatric IAs remain sparse. METHODS We retrospectively reviewed the data from patients aged ≤18 years admitted to our hospital from 2000 to 2017 with a diagnosis of IAs. RESULTS From the sample of 8207 patients with an IA diagnosis, 26 patients with 33 IAs were involved. Our cohort included 17 males and 9 females, with a mean age of 12.5 years. The mean follow-up duration was 4 years and 3 months. Seven patients (26.92%) were assumed to have a traumatic origin for their IAs. Ruptured aneurysms were more common than unruptured ones (61.53% vs. 38.46%). Complex features were observed in 14 aneurysms (42.42%). Initially, microsurgical and endovascular treatment were both performed in 10 patients (38.46%). A good recovery was obtained in 16 patients (61.54%) as determined by the Glasgow outcome scale scores at the 6-month follow-up visits. The complete obliteration of aneurysms was observed in 17 patients (65.38%). Endovascular treatment was the initial treatment in 3 patients with incomplete obliteration. CONCLUSIONS The treatment of pediatric IAs is challenging and technically demanding owing to their discrete nature compared with adult IAs and the need for greater surgical skills. We found a male predominance, with internal carotid artery bifurcation as the most frequent location of the aneurysms. Despite the greater incidence of ruptured and complex aneurysm cases, many patients had experienced a good recovery at the 6-month follow-up examinations.
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Affiliation(s)
- Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Heui Seung Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seungjoo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Do Hoon Kwon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byung Duk Kwun
- Department of Neurosurgery, School of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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12
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Ares WJ, Tonetti DA, Greene S, Sharma MS, Xavier F, Jankowitz BT, Jadhav A. Pipeline Embolization of an Infectious Basilar Artery Aneurysm in a 2-Year-Old Child: Case Report, Discussion of the Literature and Perioperative Considerations. Oper Neurosurg (Hagerstown) 2019; 17:E224-E228. [DOI: 10.1093/ons/opz002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/11/2019] [Indexed: 11/13/2022] Open
Abstract
AbstractBACKGROUND AND IMPORTANCEFlow diversion of intracranial aneurysms has been rarely described in the pediatric population. Here we discuss the technical and perioperative complexities inherent in the flow diversion of an infectious basilar apex aneurysm in a 2-yr-old child with significant medical comorbidities.CLINICAL PRESENTATIONFollowing judicious oral administration of dual anti-platelet agents and intra-arterial administration of calcium channel blockers to treat vasospasm, standard endovascular procedures were used to place a flow diverting stent across the neck of a rapidly enlarging infectious aneurysm of the basilar apex.Following the uncomplicated procedure, the patient demonstrated progressive thrombosis of the previously noted basilar apex aneurysm over a 3-mo period. The patient was therefore felt to be safe to proceed with, and eventually underwent, uncomplicated orthotopic heart transplant.CONCLUSIONFlow diversion of complex intracranial aneurysms in pediatric patients with significant medical comorbidities is feasible and safe; however, considerations have to be made in the pre- and perioperative care of these patients given the propensity for low-weight and complicated systemic disease processes.
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Affiliation(s)
- William J Ares
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Daniel A Tonetti
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephanie Greene
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mahesh S Sharma
- Division of Pediatric Cardiothoracic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Frederico Xavier
- Division of Pediatric Hematology/Oncology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian T Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ashutosh Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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13
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Colby GP, Jiang B, Bender MT, Beaty NB, Westbroek EM, Xu R, Lin LM, Campos JK, Tamargo RJ, Huang J, Cohen AR, Coon AL. Pipeline-assisted coil embolization of a large middle cerebral artery pseudoaneurysm in a 9-month-old infant: experience from the youngest flow diversion case. J Neurosurg Pediatr 2018; 22:532-540. [PMID: 30141750 DOI: 10.3171/2018.6.peds18165] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/04/2018] [Indexed: 11/06/2022]
Abstract
Intracranial aneurysms in the pediatric population are rare entities. The authors recently treated a 9-month-old infant with a 19-mm recurrent, previously ruptured, and coil-embolized left middle cerebral artery (MCA) pseudoaneurysm, which was treated definitively with single-stage Pipeline-assisted coil embolization. The patient was 5 months old when she underwent resection of a left temporal Grade 1 desmoplastic infantile ganglioglioma at an outside institution, which was complicated by left MCA injury with a resultant 9-mm left M1 pseudoaneurysm. Within a month, the patient had two aneurysmal rupture events and underwent emergency craniectomy for decompression and evacuation of subdural hematoma. The pseudoaneurysm initially underwent coil embolization; however, follow-up MR angiography (MRA) revealed aneurysm recanalization with saccular enlargement to 19 mm. The patient underwent successful flow diversion-assisted coil embolization at 9 months of age. At 7 months after the procedure, follow-up MRA showed complete aneurysm occlusion without evidence of in-stent thrombosis or stenosis. Experience with flow diverters in the pediatric population is still in its early phases, with the youngest reported patient being 22 months old. In this paper the authors report the first case of such a technique in an infant, whom they believe to be the youngest patient to undergo cerebral flow diversion treatment.
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Affiliation(s)
- Geoffrey P Colby
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
- 2Department of Neurosurgery, UCLA Medical Center, Los Angeles, California; and
| | - Bowen Jiang
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Matthew T Bender
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Narlin B Beaty
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Erick M Westbroek
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Risheng Xu
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Li-Mei Lin
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
- 3Department of Neurosurgery, UC Irvine Medical Center, Orange, California
| | - Jessica K Campos
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Judy Huang
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alan R Cohen
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alexander L Coon
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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14
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Ocal O, Yilmaz M, Peynircioglu B, Bilginer B, Peker A, Arat A. Hybrid vascular intervention for a giant cervical carotid artery aneurysm in a clopidogrel-hyporesponsive child. J Neurosurg Pediatr 2018; 22:265-269. [PMID: 29932366 DOI: 10.3171/2018.3.peds17669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Aneurysms of the extracranial internal carotid artery (ICA) in pediatric patients are rare and mostly treated surgically. The authors present the case of a child with a giant extracranial ICA aneurysm presenting with gradual airway compression. A plan was made to explore the aneurysm surgically and straighten the associated carotid artery kinks during the operation to enable further endovascular treatment if primary reconstruction of the carotid artery proved not to be possible. Finally, the aneurysm was successfully treated with staged hybrid intervention, which consisted of surgical correction of parent artery kinks followed by endovascular implantation of stent grafts. The child tolerated the procedure well without adverse events. A craniocervical CT angiogram at 5 months showed patency of the stent construct and relief of airway compression. However, a follow-up CT angiogram at 14 months showed total occlusion of the ipsilateral carotid artery without clinical sequelae and complete cessation of airway compression. The management of this was unique since the patient is the first reported case of clopidogrel hyporesponsiveness in a child undergoing neurovascular intervention with prasugrel monotherapy. Point-of-care testing-based adjustment of prasugrel necessitated education of the patient's family regarding the loss of effect of the prasugrel tablets upon crushing and contact with air.
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Affiliation(s)
| | | | | | - Burcak Bilginer
- 3Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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15
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Pipeline Embolization Device Flow Diversion for a Dissecting Ruptured Posterior Cerebral Artery Aneurysm in a Pediatric Patient. World Neurosurg 2018; 117:255-260. [DOI: 10.1016/j.wneu.2018.06.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/04/2018] [Accepted: 06/05/2018] [Indexed: 11/21/2022]
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16
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Ghali MG, Srinivasan VM, Cherian J, Wagner KM, Chen SR, Johnson J, Lam SK, Kan P. Multimodal Treatment of Intracranial Aneurysms in Children: Clinical Case Series and Review of the Literature. World Neurosurg 2018; 111:e294-e307. [DOI: 10.1016/j.wneu.2017.12.057] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/07/2017] [Accepted: 12/09/2017] [Indexed: 12/18/2022]
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