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Orito K, Hirohata M, Abe T, Tanoue S, Morioka M. Endovascular Treatments for Aneurysms Involving a Major Branch. JOURNAL OF NEUROENDOVASCULAR THERAPY 2024; 18:84-91. [PMID: 38559454 PMCID: PMC10973564 DOI: 10.5797/jnet.ra.2023-0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/25/2024] [Indexed: 04/04/2024]
Abstract
Remarkable advances have been made in the endovascular treatment of intracranial cerebral aneurysms. These advances include various adjunctive techniques, increased indications for endovascular treatment, and improved treatment results. Furthermore, the number of cerebral aneurysm treatments using flow diverters (FDs) is expected to increase. However, the reported long-term rate of branch artery occlusion after FD treatment has been reported is 15.8%. Moreover, the complete aneurysm obliteration rate is low if normal branches arise from an aneurysm neck or dome. Flow diverter placement for ophthalmic artery, posterior communicating artery, and anterior choroidal artery aneurysms is often difficult because these normal branches often arise from the aneurysm neck or dome. Therefore, in many cases, coil embolization, which can occlude the aneurysm while preserving branch vessels, should be selected. Although not yet established, various adjunctive techniques and other endovascular treatments that can be performed safely have been reported. Treatment must be planned after understanding the advantages and disadvantages of each treatment method.
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Affiliation(s)
- Kimihiko Orito
- Department of Neurosurgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Masaru Hirohata
- Department of Neurosurgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Toshi Abe
- Department of Radiology, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Shuichi Tanoue
- Department of Radiology, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
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Tanaka K, Furukawa K, Ishida F, Suzuki H. Hemodynamic differences of posterior communicating artery aneurysms between adult and fetal types of posterior cerebral artery. Acta Neurochir (Wien) 2023; 165:3697-3706. [PMID: 37870661 DOI: 10.1007/s00701-023-05840-y] [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: 06/23/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND The recanalization of posterior communicating artery (PCoA) aneurysms after endovascular treatment has been analyzed by various factors. However, the differences between adult and fetal types of posterior cerebral artery (PCA) have not been fully investigated. The main aim of this study was to investigate hemodynamic differences of PCoA aneurysms between adult and fetal types using computational fluid dynamics (CFD). METHODS Fifty-five PCoA aneurysms were evaluated by 3D CT angiography and divided into unruptured aneurysms with adult-type or fetal-type PCAs (19 cases, UA group; 9 cases, UF group) and ruptured aneurysms with adult-type or fetal-type PCAs (17 cases, RA group; 10 cases, RF group). These native aneurysms were analyzed by CFD regarding morphological and hemodynamic characteristics. To evaluate simulated endovascular treatment of aneurysms, CFD was performed using porous media modeling. RESULTS Morphologically, the RA group had significantly smaller parent artery diameter (2.91 mm vs. 3.49 mm, p=0.005) and higher size ratio (2.54 vs. 1.78, p=0.023) than the RF group. CFD revealed that the UA group had significantly lower oscillatory shear index (OSI) (0.0032 vs. 0.0078, p=0.004) than the UF group and that the RA group had lower WSS (3.09 vs. 11.10, p=0.001) and higher OSI (0.014 vs. 0.006, p=0.031) than the RF group, while the RF group presented significantly higher intra-aneurysmal flow velocity (0.19 m/s vs. 0.061 m/s, p=0.002) than the RA group. Porous media modeling of simulated treatment revealed higher residual flow volume in the fetal-type groups. CONCLUSIONS These results suggested that PCoA aneurysms with fetal-type PCAs had different morphological features and hemodynamic characteristics compared with those with adult-type PCAs, leading to high risks of recanalization.
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Affiliation(s)
- Katsuhiro Tanaka
- Department of Neurosurgery, Kuwana City Medical Center, 3-11, Kotobuki-Cho, Kuwana, Mie, 511-0061, Japan.
| | - Kazuhiro Furukawa
- Department of Neurosurgery, NHO Mie Chuo Medical Center, Tsu, Mie, Japan
| | - Fujimaro Ishida
- Department of Neurosurgery, NHO Mie Chuo Medical Center, Tsu, Mie, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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Vivanco-Suarez J, Rodriguez-Calienes A, Kan PT, Wakhloo AK, Pereira VM, Hanel R, Lopes DK, Galecio-Castillo M, Anil S, Farooqui M, Puri AS, Ortega-Gutierrez S. Flow Diverter Performance in Aneurysms Arising From the Posterior Communicating Artery: A Systematic Review and Meta-Analysis. Neurosurgery 2023; 93:764-772. [PMID: 37171169 DOI: 10.1227/neu.0000000000002517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/10/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Flow diverters (FDs) have demonstrated a safe and effective profile. However, the use of FDs for posterior communicating artery (PComA) aneurysms remains controversial. OBJECTIVE To evaluate the safety and effectiveness of FDs for PComA aneurysms using a systematic review and meta-analysis of the literature. METHODS We performed a systematic search from inception until June 2022 for flow diversion in PComA aneurysms. Primary effectiveness was the rate of complete aneurysm occlusion defined by Raymond-Roy class 1. Primary safety outcomes were treatment-related ischemic/hemorrhagic (composite) events causing morbidity and mortality. Secondary safety was PComA patency at follow-up. Random-effects meta-analyses were used to calculate proportions, and statistical heterogeneity was assessed. RESULTS A total of 13 studies with 397 patients harboring 403 aneurysms were included. Mean age was 48 years, and the mean aneurysm size was 5.3 mm. Most aneurysms were unruptured (65%). Complete occlusion at final follow-up was 73% (CI 66%-79%), and adjunctive coils were used in 10% of aneurysms. Retreatment rate was 2% (CI 0%-9%). The primary safety composite outcome was 4% (CI 3%-7%), and mortality was 1%. PComA patency at final follow-up was 76% (CI 57%-89%). Subgroup analysis, patients with fetal PComAs had a lower complete occlusion rate (42% fetal PComA vs 77%, psubgroupdifference = <.01). CONCLUSION The performance of FDs in PComA aneurysms is comparable with outcomes found in other subtypes of supraclinoid aneurysms. Effectiveness was acceptable and safety favorable. However, effectiveness was suboptimal in patients with fetal-type PComAs; alternative treatments should be considered in these cases.
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Affiliation(s)
- Juan Vivanco-Suarez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City , Iowa , USA
| | - Aaron Rodriguez-Calienes
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City , Iowa , USA
- Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima , Peru
| | - Peter T Kan
- Department of Neurological Surgery, University of Texas Medical Branch Galveston, Galveston , Texas , USA
| | - Ajay K Wakhloo
- Department of Interventional Neuroradiology, Lahey Hospital & Medical Center, Burlington , Massachusetts , USA
| | - Vitor M Pereira
- Department of Neurosurgery, St Michael's Hospital, Toronto , Ontario , Canada
| | - Ricardo Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville , Florida , USA
| | - Demetrius Klee Lopes
- Department of Neurosurgery, Brain and Spine Institute, Advocate Aurora Health, Park Ridge , Illinois , USA
| | - Milagros Galecio-Castillo
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City , Iowa , USA
| | - Susan Anil
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City , Iowa , USA
| | - Mudassir Farooqui
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City , Iowa , USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester , Massachusetts , USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City , Iowa , USA
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Bilgin C, Kandemirli SG, Ghozy S, Orscelik A, Kobeissi H, Senol YC, Shehata M, Kadirvel R, Brinjikji W, Kallmes DF. Impact of branch arteries on efficacy of endoluminal flow diverters: Insights from posterior communicating artery aneurysms. Interv Neuroradiol 2023:15910199231186036. [PMID: 37437217 DOI: 10.1177/15910199231186036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Flow diverter treatment may inevitably require jailing of the branch vessels. While the patency of covered branch arteries and associated safety risks have been a topic of substantial interest, the question of whether the characteristics of branch vessels affect flow diversion's efficacy remains unanswered. In this study, we aimed to assess the impact of branch arteries on the efficacy of endoluminal flow diverters, specifically focusing on posterior communicating artery (Pcomm) aneurysms. METHODS Following PRISMA guidelines, we systematically searched the MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane databases with predefined keywords. Studies providing data for flow diversion outcomes in Pcomm aneurysms were included. Outcomes of interest included complete and adequate aneurysm obliteration, ischemic and hemorrhagic complications, and Pcomm occlusion in the follow-up period. A random or fixed effects model was used to calculate the odds ratios (ORs) and pooled event rates with their corresponding confidence intervals (CI). RESULTS The overall complete and adequate aneurysm occlusion rates were 72.25% (95% CI: 64.46-78.88%) and 88.37% (95% CI: 84.33-92.6), respectively. Fetal-type Pcomm aneurysms had significantly lower complete aneurysm occlusion rates than the nonfetal-type Pcomm aneurysms (OR: 0.12, 95% CI: 0.05-0.29). Overall ischemic and hemorrhagic complication rates were 2.62% (95% CI = 0.71-5.32) and 0.71% (95% CI: 0-2.24), respectively. There were no significant associations between Pcomm morphology and complications (OR: 3.61, 95% CI = 0.42-31.06 for ischemic complications and OR: 2.31, 95% CI = 0.36-14.6 for hemorrhage). Overall Pcomm occlusion rate was 32.04% (95% CI = 19.96-47.13), and the Pcomm patency was significantly lower in nonfetal-type Pcomm aneurysms (OR: 0.10, 95% CI = 0.02-0.44). CONCLUSION Our meta-analysis suggests that flow diversion is a safe treatment option for Pcomm aneurysms, regardless of fetal-type Pcomm morphology. However, on the other hand, our findings indicate that Pcomm anatomy or the presence of jailed large branches can affect the efficacy of flow diverter treatment.
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Affiliation(s)
- Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Mostafa Shehata
- Department of Radiology, M.D. Anderson Cancer Center, Houston, TX, USA
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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Tatit RT, Ogilvy CS, Shutran MS, Tawk RG, Yasuda TA, Baccin CE. Plasticity of the adult circle of Willis in response to flow diversion stents. Surg Neurol Int 2023; 14:49. [PMID: 36895205 PMCID: PMC9990810 DOI: 10.25259/sni_1139_2022] [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: 12/18/2022] [Accepted: 01/28/2023] [Indexed: 02/12/2023] Open
Abstract
Background We present five patients with remodeling of the adult circle of Willis in response to flow diverter stents (FDSs) at the anterior communicating artery (AComA) and the posterior communicating artery (PComA). The observed changes provide a paradigm of how flow change can institute anatomic changes in the adult circle of Willis vasculature. Case Description In the first two cases, after placement of the FDS covering the AComA, there was an increase in size and flow of the contralateral A1-anterior cerebral artery which had previously been hypoplastic. In one of the cases, this led to the filling of the aneurysm and required placement of coils within the lesion which was curative. In case three, the FDS effect led to asymptomatic occlusion of the PComA and associated aneurysm without change of the ipsilateral P1-segement of posterior-cerebral-artery (P1-PCA) caliber. In the fourth case, the FDS covering an aneurysm with a fetal PCA arising from its neck resulted in significant reduction of the aneurysm size, persistent flow and caliber of the fetal PCA, and the hypoplastic ipsilateral P1-PCA. Finally, in the fifth case, after FDS occlusion of the PComA and aneurysm there was increasement in diameter of the ipsilateral P1-PCA that was previously hypoplastic. Conclusion The use of FDS can affect vessels covered by the device and other arteries of the circle of Willis adjacent to the FDS. The phenomena illustrated in the hypoplastic branches appear to be a compensatory response to the hemodynamic changes induced by the divertor and to the altered flow in the circle of Willis.
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Affiliation(s)
- Rafael Trindade Tatit
- Department of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max S Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Rabih G Tawk
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Thomas A Yasuda
- Department of Interventional Neuroradiology, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Carlos Eduardo Baccin
- Department of Interventional Neuroradiology, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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Duplicated fetal posterior cerebral artery in a patient with a ruptured fetal posterior cerebral artery aneurysm: a cerebrovascular variant. SURGICAL AND RADIOLOGIC ANATOMY : SRA 2023; 45:35-38. [PMID: 36484823 DOI: 10.1007/s00276-022-03052-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The most common neurovascular variant is the fetal posterior cerebral artery (FPCA), in which the P1 branch is absent or hypoplastic, and the majority of P2 supply is derived from the anterior circulation. While there are reports of hyperplastic anterior choroidal arteries (AChA) with supply to the temporo-occipital and calcarine regions, no reports of a duplicated FPCA exist. METHODS This case report describes a patient with a ruptured right FPCA aneurysm. Digital subtraction angiogram (DSA) revealed an artery with origin distal to the FPCA associated with the aneurysm. This was not consistent with a typical AChA. The FPCA associated with the aneurysm had the typical origin, course, and supply of a FPCA. The distal FPCA had a similar course of a typical FPCA with significant supply to the typical PCA territory. The patient underwent successful clipping of the aneurysm, and the duplicated FPCA was identified during the craniotomy. RESULTS The features of this duplicate FPCA, which has not been previously described, are discussed in comparison to another variant, the hyperplastic, anomalous AChA. The artery described in this report does not fit the typical criteria of this AChA variant. Therefore, the authors outline this variant as a duplicated FPCA. CONCLUSION Recognition of variant cerebrovascular anatomy is vital to neurosurgeons and interventional neuroradiology specialists. FPCA aneurysms require special management considerations and are often more challenging to treat. This report discusses a duplicated FPCA. To our knowledge, this is the first description of this variant. A duplicated FPCA carries important management considerations in the management of neurovascular pathology.
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Abdelkhalek H, Abdelhameed EA, Zakarea A, El Malky I. Predictors of flow diverter stent in large and giant unruptured intracranial aneurysms, single-center experience. Neurol Sci 2022; 43:6399-6405. [PMID: 35984605 PMCID: PMC9616764 DOI: 10.1007/s10072-022-06336-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/07/2022] [Indexed: 11/29/2022]
Abstract
Background Flow diversion with or without coiling has been established as the treatment of choice for large unruptured aneurysms. This study aims to assess possible predictors for radiological and clinical outcome such as location of the aneurysm (anterior or posterior circulation), complexity by a branching artery, bifurcation, and adjuvant coiling. Methods This study was conducted on 65 consecutive patients with 65 large, unruptured intracranial aneurysms (size ≥ 10 mm) treated with flow diverters. Follow-up angiography was done for 60 patients (92.3%) at 12 ± 8.6 months range from 3 to 36 months. Results Complete occlusion was achieved in 50 from 60 aneurysms (83.4%), while 8 aneurysms (13.3%) had neck remnant, and another two aneurysms (3.3%) remained with aneurysmal remnant. Periprocedural complications were encountered in 14 patients (21.5%) with morbidity in six patients (9.2%) and mortality in one patient (1.5%). In a multivariate logistic regression, anterior versus posterior location was less likely associated with worse outcome; adjusted OR (95% CI) of 0.16 (0.07–0.01), p = 0.006. Complete occlusion in complex aneurysms with branching artery was 60% versus 88% in simple aneurysms without branching artery (p-value = 0.04). Conclusions Flow diverter deployment of a large, unruptured aneurysm in the anterior circulation might have a better outcome than one in the posterior circulation. Flow diverter of aneurysms with branching artery or at bifurcation might be associated with aneurysm persistence and complications respectively.
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Affiliation(s)
| | | | - Ayman Zakarea
- Department of Radiology, Kasr Alainy University, Cairo, Egypt
| | - Islam El Malky
- Department of Neurology, South Valley University, Qena, Egypt.
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Lauzier DC, Root BK, Kayan Y, Almandoz JED, Osbun JW, Chatterjee AR, Whaley KL, Tipps ME, Moran CJ, Kansagra AP. Pipeline embolization of proximal middle cerebral artery aneurysms: A multicenter cohort study. Interv Neuroradiol 2022; 28:50-57. [PMID: 33951971 PMCID: PMC8905083 DOI: 10.1177/15910199211015578] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Flow diversion of aneurysms located in the M1 segment and middle cerebral artery bifurcation with Pipeline embolization device is sometimes performed, but further study is needed to support its regular use in aneurysm treatment. Here, we report measures of safety and efficacy for Pipeline embolization in the proximal middle cerebral artery in a multi-center cohort. MATERIALS AND METHODS Clinical and angiographic data of eligible patients were retrospectively obtained from participating centers and assessed for key clinical and angiographic outcomes. Additional details were extracted for patients with complications. RESULTS In our multi-center cohort, complete aneurysm occlusion was achieved in 71% (17/24) of treated aneurysms. There were no deaths or disabling strokes, but non-disabling ischemic strokes occurred in 8% (2/24) of patients. For aneurysms in the M1 segment, complete aneurysm occlusion was observed in 75% (12/16) of aneurysms, aneurysm volume reduction was observed in 100% (16/16) of aneurysms, and non-disabling ischemic strokes occurred in 13% (2/16) of patients. For aneurysms at the middle cerebral artery bifurcation, complete aneurysm occlusion was observed in 63% (5/8) of aneurysms, aneurysm volume reduction occurred in 88% (7/8) of aneurysms, and ischemic or hemorrhagic complications occurred in 0% (0/8) of patients. CONCLUSION Pipeline embolization of cerebral aneurysms in the M1 segment and middle cerebral artery bifurcation demonstrated a 71% rate of complete aneurysm occlusion. There were no deaths or disabling strokes, but there was an 8% rate of non-disabling ischemic strokes.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Brandon K Root
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Yasha Kayan
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Josser E Delgado Almandoz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Joshua W Osbun
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Kayla L Whaley
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Megan E Tipps
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA,Akash P Kansagra, 510 S Kingshighway Blvd, St. Louis, MO 63110, USA.
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Pipeline embolization of MCA aneurysms in the M2-M4 segment: Dual center study and meta-analysis. Clin Neurol Neurosurg 2021; 212:107063. [PMID: 34864490 DOI: 10.1016/j.clineuro.2021.107063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/15/2021] [Accepted: 11/21/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Flow diversion of distal MCA aneurysms in the M2-M4 segments with Pipeline embolization device is promising, but further study is needed. Here, we seek to quantify the safety and efficacy of Pipeline embolization in the M2-M4 region in a dual-center cohort and comprehensive meta-analysis. METHODS Clinical and angiographic data of eligible patients was obtained from participating centers. A systematic review was performed with searches of Pubmed, Scopus, Embase, and the Cochrane Library for articles from inception to May 2021. 86 studies were identified in systematic review. Of these, 7 studies with 46 aneurysms met the inclusion criteria and were aggregated with 8 aneurysms from our dual-center cohort for analysis. RESULTS In our dual-center cohort, complete occlusion was observed in 88% (7/8) of aneurysms, and no patients experienced hemorrhagic or thromboembolic complications. Clinical outcomes were reported for 100% (54/54) of aneurysms included in meta-analysis and angiographic follow-up was available for 91% (49/54). The overall rate of complete aneurysm occlusion was 80% (95% CI, 69-91%), and the overall rate of clinical complication was 9% (95% CI, 2-16%). CONCLUSION Pipeline embolization of cerebral aneurysms of the M2-M4 segments of the MCA was reasonably effective and safe in a small group of selected patients, but further study is needed to validate these preliminary results.
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Hanel RA, Monteiro A, Nelson PK, Lopes DK, Kallmes DF. Predictors of incomplete aneurysm occlusion after treatment with the Pipeline Embolization Device: PREMIER trial 1 year analysis. J Neurointerv Surg 2021; 14:1014-1017. [PMID: 34716215 DOI: 10.1136/neurintsurg-2021-018054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/04/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Flow diverters have revolutionized the treatment of intracranial aneurysms. Nevertheless, some aneurysms fail to occlude with flow diversion. The Prospective Study on Embolization of Intracranial Aneurysms with the Pipeline Device (PREMIER) was a prospective, multicenter and single-arm trial of small and medium wide-necked unruptured aneurysms. In the current study, we evaluate the predictors of treatment failure in the PREMIER cohort. METHODS We analyzed PREMIER patients who had incomplete occlusion (Raymond-Roy >1) at 1 year angiographic follow-up and compared them with those who achieved Raymond-Roy 1, aiming to identify predictors of treatment failure. RESULTS 25 aneurysms demonstrated incomplete occlusion at 1 year. There was a median reduction of 0.9 mm (IQR 0.41-2.43) in maximum diameter between pre-procedure and 1 year measurements, with no aneurysmal hemorrhage. Patients with incomplete occlusion were significantly older than those with complete occlusion (p=0.011). Smoking (p=0.045) and C6 segment location (p=0.005) were significantly associated with complete occlusion, while location at V4 (p=0.01) and C7 (p=0.007) and involvement of a side branch (p<0.001) were significantly associated with incomplete occlusion. In multivariable logistic regression, significant predictors of incomplete occlusion were non-smoker status (adjusted OR 4.49, 95% CI 1.11 to 18.09; p=0.03) and side branch involvement (adjusted OR 11.68, 95% CI 3.84 to 35.50; p<0.0001), while C6 location had reduced odds of incomplete occlusion (adjusted OR 0.29, 95% CI 0.10 to 0.84; p=0.02). CONCLUSIONS The results of our study are consistent with previous retrospective series and warrant consideration for technique adaptations to achieve higher occlusion rates. Further follow-up is needed to assess progression of aneurysm occlusion and clinical behavior in these cases.
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Affiliation(s)
- Ricardo A Hanel
- Cerebrovascular and Endovascular Surgery, Lyerly Neurosurgery and Baptist Medical Center, Jacksonville, FL, USA
| | - Andre Monteiro
- Cerebrovascular and Endovascular Surgery, Lyerly Neurosurgery and Baptist Medical Center, Jacksonville, FL, USA
| | - Peter K Nelson
- Radiology, NYU Langone Medical Center Neuroradiology Section, New York, New York, USA
| | - Demetrius K Lopes
- Brain and Spine Institute, Advocate Aurora Health, Park Ridge, Illinois, USA
| | - David F Kallmes
- Interventional Neuroradiology, Mayo Clinic, Rochester, Minnesota, USA
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Remodeling of the Posterior Cerebral Artery P1-Segment after Pipeline Flow Diverter Treatment of Posterior Communicating Artery Aneurysms. Neurol Int 2021; 13:195-201. [PMID: 34066972 PMCID: PMC8162531 DOI: 10.3390/neurolint13020020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/08/2021] [Accepted: 04/08/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction: Flow diverters such as the pipeline embolization device (PED) cause hemodynamic changes of the treated vessel segment. In posterior communicating artery (PcomA), aneurysms’ unique anatomic consideration have to be taken in account due to the connection between the anterior and posterior circulation. We hypothesize that in conjunction with PcomA remodeling, there will also be remodeling of the ipsilateral P1 segment of the posterior cerebral artery (PCA) after PED treatment for PcomA aneurysms. Methods: We retrospectively collected radiological as well as clinical data of PcomA aneurysm patients treated with PED including PcomA and P1 vessel diameters before and after treatment as well as patient and aneurysm characteristics. Results: Overall, 14 PcomA aneurysm patients were included for analysis and PED treatment was performed without complications in all patients. In 10 out of 14 patients (71%), a decrease in PcomA diameter was observed and there was a significant mean decrease of 0.78 mm in PcomA diameter on angiographic last follow-up (LFU) (p = 0.003). In the same patient population (10 out of 14 patients), there was meanwhile a significant mean increase of 0.43 mm in the ipsilateral P1 segment diameter observed (p = 0.015). These vessel remodeling effects were in direct correlation with aneurysm occlusion since all of these patients showed aneurysm occlusion at LFU while 29% showed only partial occlusion without vessel remodeling effects. A decrease in PcomA diameter was directly associated with aneurysm occlusion (p = 0.042). There were no neurologic complications on LFU. Conclusion: In the treatment of PcomA aneurysms with PED, the P1 segment of the PCA increases in diameter while the PcomA diameter decreases. Our results suggest that this remodeling effect is associated with aneurysm occlusion and decrease of PcomA is hemodynamically compensated for by an increase in the ipsilateral P1 diameter.
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12
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Limitations of Flow Diverters in Posterior Communicating Artery Aneurysms. Brain Sci 2021; 11:brainsci11030349. [PMID: 33803427 PMCID: PMC8001829 DOI: 10.3390/brainsci11030349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/04/2021] [Accepted: 03/07/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Treatment of intracranial aneurysms with flow diverters (FDs) showed promising results. However, a subset of patients treated for posterior communicating artery (PComA) aneurysms has variable occlusion rates. Especially the fetal type-associated PComA aneurysms seemed to respond differently to treatment. We analyze our series of fetal type PComA aneurysms treated with a FD. The literature on this subject is reviewed. Methods: Data from patients treated with FD for all PComA aneurysms at the RadboudUMC Nijmegen were retrospectively analysed. Primary end-point was complete aneurysm occlusion at six months. Secondary end-points were clinical outcome, treatment safety, and results of secondary treatment after non-closure. The results for the fetal PComA aneurysms were compared to the literature. Results: Nineteen consecutive patients harboring 21 PComA aneurysms were treated. Three aneurysms had ipsilateral fetal type PCA (14.3%). Overall, none of the fetal type PcomA aneurysm showed complete occlusion versus 77.8% of the others (p = 0.03). Mortality and permanent morbidity rates were respectively 5.3% and 0%. Conclusions: FD treatment for PComA aneurysm with fetal type circulation seemed to be less effective compared to other types of PComA aneurysms. Flow characteristics at the PComA bifurcation are thought to be causative Alternative strategies should be considered as first line treatment.
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13
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Bonney PA, Connor M, Fujii T, Singh P, Koch MJ, Stapleton CJ, Mack WJ, Walcott BP. Failure of Flow Diverter Therapy: Predictors and Management Strategies. Neurosurgery 2020; 86:S64-S73. [PMID: 31838530 DOI: 10.1093/neuros/nyz305] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/15/2019] [Indexed: 11/14/2022] Open
Abstract
Flow diversion is a safe and effective treatment for many types of brain aneurysms. Even so, there remain some aneurysms that persist despite initial treatment. In studies with the longest follow-up (5 yr), at least 5% of aneurysms persist with this treatment modality. As the cumulative experience and clinical indications for flow diversion continue to expand, the anatomic and functional characteristics that are associated with aneurysm persistence are increasingly described. Identification of these factors preoperatively can help to guide initial treatment decisions, enhance monitoring protocols in the follow-up period, and establish best practices for re-treatment when necessary. Herein, we review published clinical series and provide examples to highlight variables implicated in aneurysm persistence after treatment with flow diversion.
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Affiliation(s)
- Phillip A Bonney
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Michelle Connor
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Tatsuhiro Fujii
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Parampreet Singh
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Matthew J Koch
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher J Stapleton
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - William J Mack
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Brian P Walcott
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois.,University of Chicago Pritzker School of Medicine, Chicago, Illinois
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14
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Martínez-Galdámez M, Schüller-Arteaga M, Galván-Fernández J, Kalousek V, Petra E, Pabón B, Ortega-Gutiérrez S, Jiménez-Arribas P, Rodríguez-Arias C. Transcirculation Silk Vista Baby-assisted coiling in half-T configuration for the treatment of posterior communicating artery aneurysms associated with a fetal posterior circulation: An alternative flow diversion strategy. Interv Neuroradiol 2020; 27:230-234. [PMID: 32967502 DOI: 10.1177/1591019920961889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Flow diverter devices have become a routine first-line option for treatment of an increasing population of intracranial aneurysms at many neurovascular centers. Despite the promising results of flow diverter stents on anterior circulation, incomplete occlusion on the presence of fetal posterior circulation has been described on several reports. Here we describe a novel technical alternative to conventional flow diversion approach for this specific subgroup of aneurysms using the low-profile flow diverter, Silk Vista Baby. The device was selectively placed into the fetal type posterior cerebral artery in half-T configuration for the treatment of a posterior communicating aneurysm using a transcirculation approach through the anterior communicating artery. This represents a useful and effective technique and should be considered when encountering the above-described situation.
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Affiliation(s)
- Mario Martínez-Galdámez
- Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Miguel Schüller-Arteaga
- Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Jorge Galván-Fernández
- Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Vladimir Kalousek
- Interventional Neuroradiology, Department of Radiology, Clinical Hospital Center "Sestre Milosrdnice," Zagreb, Croatia
| | - Ezequiel Petra
- Interventional Neuroradiology, Hospital Español de Mendoza, Mendoza, Argentina
| | - Boris Pabón
- Interventional Neuroradiology, Angioteam-Angiosur, Medellín, Colombia
| | - Santiago Ortega-Gutiérrez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Carver College of Medicine, Iowa, USA
| | - Paloma Jiménez-Arribas
- Neurosurgery Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Carlos Rodríguez-Arias
- Neurosurgery Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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15
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Chen X, Li H, Wang MZ, Li MG, Cao Y, Zhang D, Zhang Y, Wang H, Wang S. Clinical features and outcomes of PComA aneurysms originating from fetal posterior communicating arteries in a single institution. Chin Neurosurg J 2020; 6:23. [PMID: 32922952 PMCID: PMC7398228 DOI: 10.1186/s41016-020-00200-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 04/30/2020] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study was to retrospectively analyze our experience with the patients who underwent surgical treatment of posterior communicating artery (PComA) aneurysms originating from fetal posterior cerebral artery (fPCA) and analyze the risk factors for the postoperative radiological infarction and outcome. Methods From 2011 to 2020, we retrospectively reviewed 74 PComA aneurysms originating from fPCA in terms of the clinical and radiological features and obtained the follow-up data from the Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University. The relationships between these features and follow-up data were assessed with the univariate and multivariate analysis. Results In this series, 74 aneurysms were occurring at the origin of fPCAs. All the patients showed complete obliteration of their aneurysms. Full fPCA type tends to be a predictive factor for radiological infarction (univariate χ2 = 5.873, P = 0.027; multivariate OR = 0.264, P = 0.060). Postoperative radiological infarction (univariate χ2 = 12.611, P = 0.001; multivariate OR = 6.033, P = 0.043), rupture (univariate χ2 = 4.514, P = 0.047; multivariate OR = 57.966, P = 0.044), and hypertension (univariate χ2 = 5.301, P = 0.024; multivariate OR = 24.462, P = 0.029) tend to be the independent predictive factors for poor prognosis at 3 months after discharge. Conclusions In conclusion, we report a series of patients harboring aneurysms originating from the fPCA. Surgical clipping is a reliable strategy. Full fPCA type is related to postsurgical infarction. Postoperative radiological infarction, rupture, and hypertension tend to be the independent predictive factor for poor prognosis at 3 months after discharge.
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Affiliation(s)
- Xin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070 China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, 100070 China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100070 China
| | - Hao Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070 China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, 100070 China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100070 China
| | - Ming-Ze Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070 China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, 100070 China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100070 China
| | - Mao-Gui Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070 China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, 100070 China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100070 China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070 China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, 100070 China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100070 China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070 China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, 100070 China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100070 China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070 China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, 100070 China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100070 China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070 China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, 100070 China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100070 China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070 China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, 100070 China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100070 China
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16
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Thiarawat P, Jahromi BR, Kozyrev DA, Intarakhao P, Teo MK, Choque-Velasquez J, Niemelä M, Hernesniemi J. Are Fetal-Type Posterior Cerebral Arteries Associated With an Increased Risk of Posterior Communicating Artery Aneurysms? Neurosurgery 2020; 84:1306-1312. [PMID: 29788502 DOI: 10.1093/neuros/nyy186] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 04/11/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Fetal-type posterior cerebral arteries (F-PCAs) might result in alterations in hemodynamic flow patterns and may predispose an individual to an increased risk of posterior communicating artery aneurysms (PCoAAs). OBJECTIVE To determine the association between PCoAAs and the presence of ipsilateral F-PCAs. METHODS We retrospectively reviewed the radiographic findings from 185 patients harboring 199 PCoAAs that were treated at our institution between 2005 and 2015. Our study population consisted of 4 cohorts: (A) patients with 171 internal carotid arteries (ICAs) harboring unilateral PCoAAs; (B) 171 unaffected ICAs in the same patients from the first group; (C) 28 ICAs of 14 patients with bilateral PCoAAs; and (D) 180 ICAs of 90 patients with aneurysms in other locations. We then determined the presence of ipsilateral F-PCAs and recorded all aneurysm characteristics. RESULTS Group A had the highest prevalence of F-PCAs (42%) compared to 19% in group B, 3% in group C, and 14% in group D (odds ratio A : B = 3.041; A : C = 19.626; and A : D = 4.308; P < .001). PCoAAs were associated with larger diameters of the posterior communicating arteries (median value 1.05 vs 0.86 mm; P = .001). The presence of F-PCAs was associated with larger sizes of the aneurysm necks (median value 3.3 vs 3.0 mm; P = .02). CONCLUSION PCoAAs were associated with a higher prevalence of ipsilateral F-PCAs. This variant was associated with larger sizes of the aneurysm necks but was not associated with the sizes of the aneurysm domes or with their rupture statuses.
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Affiliation(s)
- Peeraphong Thiarawat
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland.,De-partment of Surgery, Naresuan University, Phitsanulok, Thailand
| | | | - Danil A Kozyrev
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland.,Department of Paediatric Neurology and Neurosurgery, North-western State Medical University, St. Petersburg, Russia
| | - Patcharin Intarakhao
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland.,Department of Anesthesiology, Naresuan University, Phitsanulok, Thailand
| | - Mario K Teo
- Bristol Institute of Clinical Neurosciences, North Bristol University Hospital, Bristol, United Kingdom
| | | | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
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17
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Choi HH, Cho YD, Yoo DH, Lee HS, Kim SH, Jang D, Lee SH, Cho WS, Kang HS, Kim JE. Impact of fetal-type posterior cerebral artery on recanalization of posterior communicating artery aneurysms after coil embolization: matched-pair case-control study. J Neurointerv Surg 2020; 12:783-787. [PMID: 31915206 DOI: 10.1136/neurintsurg-2019-015531] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/26/2019] [Accepted: 12/29/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND It is well known that hemodynamic stress may impact the recanalization of coiled aneurysms. One of the most common sites for aneurysms to develop is the posterior communicating artery (PcoA), the variants of which are defined by diameter ratios (PcoA/P1 segment). OBJECTIVE This study was undertaken to investigate the impact of a fetal-type posterior cerebral artery (PCA) on recanalization of PcoA aneurysms after coil embolization based on matched-pair (fetal vs non-fetal PCA) analysis. METHODS A total of 480 consecutive PcoA aneurysms (PCA: fetal, n=156; non-fetal, n=324) subjected to coil embolization between January 2007 and June 2017 were selected for study. All lesions were followed for ≥6 months via radiologic imaging, grouped by adjacent PCAs as fetal (PcoA/P1 >1) or non-fetal (PcoA/P1 ≤1) type. Paired subjects were matched (1:1) for several relevant variables. RESULTS Of the 480 coiled aneurysms, 159 (33.1%) showed recanalization (minor, 76; major, 83) in the course of follow-up (mean 33.8±21.9 months), developing significantly more often in fetal (37.8%) than in non-fetal (26.9%; p=0.020) PCA types. Once matched, however, 6-month and cumulative recanalization rates did not differ significantly by group (p=0.531 and p=0.568, respectively). Complications (hemorrhage, p=0.97; thromboembolism, p=0.94) during endovascular coil embolization also showed similar rates in these groups. CONCLUSIONS The chances of recanalization after coil embolization seem to be greater in PcoA aneurysms than in intracranial aneurysms overall, thus calling for careful follow-up monitoring. Surprisingly, PcoA type appeared unrelated in this regard.
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Affiliation(s)
- Hyun Ho Choi
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Yoo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Heui Seung Lee
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung-Hyun Kim
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Donghwan Jang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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18
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Kwon HJ, Cho YD, Lim JW, Koh HS, Yoo DH, Kang HS, Han MH. Retrograde stenting through anterior communicating artery in coil embolization of the posterior communicating artery aneurysm: contralateral approach. J Neuroradiol 2019; 48:21.e1-21.e5. [PMID: 31229579 DOI: 10.1016/j.neurad.2019.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/29/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
Abstract
During coil embolization of wide-necked posterior communicating artery (PcomA) aneurysms, stent assistance is sometimes limited if PcomA is acutely angled at its origins from saccular neck. Herein, we present two instances where retrograde stenting was used for coil embolization of PcomA aneurysms. Both procedures involved a contralateral approach via anterior communicating artery (AcomA). To achieve this, the stent-delivery microcatheter was inserted retrograde from contralateral to ipsilateral internal carotid artery (ICA) across AcomA, arriving at ipsilateral PcomA. A separate microcatheter, passed through ipsilateral ICA, was then used to select the aneurysm sac for coil delivery. Coil embolization ultimately took place under protection of a horizontally placed stent extending from PcomA to terminal ICA. Each aneurysm was properly coiled and occluded, without procedural complications. This stenting technique is a reasonable option, offering a means of strategic coil embolization in wide-necked PcomA aneurysms and providing complete neck coverage through contralateral access.
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Affiliation(s)
- Hyon Jo Kwon
- Department of Neurosurgery, Regional Cerebrovascular Center, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Jeong Wook Lim
- Department of Neurosurgery, Regional Cerebrovascular Center, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hyeon-Song Koh
- Department of Neurosurgery, Regional Cerebrovascular Center, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Dong Hyun Yoo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Moon Hee Han
- Department of Radiology, Veterans Health Service Medical Center, Seoul, Korea
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Kühn AL, Kan P, Henninger N, Srinivasan V, de Macedo Rodrigues K, Wakhloo AK, Gounis MJ, Puri AS. Impact of age on cerebral aneurysm occlusion after flow diversion. J Clin Neurosci 2019; 65:23-27. [PMID: 31072739 DOI: 10.1016/j.jocn.2019.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/28/2019] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to evaluate safety and efficacy of the pipeline embolization device (PED) in different patient age groups with unruptured intracranial aneurysms (UIA). All patients with UIA treated with the PED between 2011 and 2017 were included. Based on their age, patients were trichotomized to: young (≤45 years), middle-aged (46 to <65 years) and older (≥65 years) groups. Patient's vascular risk factors, presenting symptoms and mRS on admission were collected. Follow-up imaging was evaluated for presence/absence of aneurysm occlusion. Clinical outcome at discharge, 3-9 months and 12-18 months was also documented when available. A total of 260 patients harboring 307 aneurysms (young = 57, middle-age = 144 and older age group = 64). Most aneurysms were located in the anterior circulation (94.8%). Overall morbidity and mortality was 2.3% each (6/260). At 3-9 months near complete to complete aneurysm occlusion was 82.5% (47/57) in the young age group, 82.6% (100/121) in the middle age, and 70.2% (40/57) in the older age group. At 12-18-month, near complete to complete occlusion was 100% in the young age group (32/32), 91.4% (64/70) in the middle age, and 78.4% (29/37) in the older age group. After adjustment for potential confounders, older age patients less frequently achieved near complete to complete occlusion by 3 years than younger subjects (p = 0.009, HR 1.34 95%, CI 1.08-1.66). Our results indicate feasibility and safety of PED across different age groups. Further study is required to determine age-related factors relating to aneurysm occlusion after PED to improve outcome and patient counseling.
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Affiliation(s)
- Anna Luisa Kühn
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts, Worcester, MA, USA
| | - Visish Srinivasan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Katyucia de Macedo Rodrigues
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA
| | - Ajay K Wakhloo
- Lahey Clinic and Medical Center, Department of Neurointerventional Radiology, Burlington, MA, USA
| | - Matthew J Gounis
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA
| | - Ajit S Puri
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA.
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20
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Effect of Fetal Posterior Circulation on Efficacy of Flow Diversion for Treatment of Posterior Communicating Artery Aneurysms: A Multi-Institutional Study. World Neurosurg 2019; 127:e1232-e1236. [PMID: 31009780 DOI: 10.1016/j.wneu.2019.04.112] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Flow diversion (FD) has emerged as an effective treatment modality for aneurysms of the posterior communicating artery (PCOM). Whether or not a fetal posterior circulation (FPC) affects PCOM aneurysm occlusion rates after FD remains undetermined. METHODS We performed a retrospective cohort study in which treatment outcomes for FD of PCOM aneurysms from multiple institutions were reviewed. The primary outcome of interest was complete aneurysm occlusion at last follow-up. The presence of a FPC, defined as a PCOM diameter larger than that of the P1 segment, was noted and its relationship to complete aneurysm occlusion was investigated using a Cox proportional hazards model. RESULTS There were 49 patients with 49 PCOM aneurysms treated with FD who met inclusion criteria for analysis. A FPC was present in 16 patients (32.7%). Complete aneurysm occlusion was observed in 34 patients (69.4%). Complete occlusion was less common for patients with a FPC (43.7% vs. 81.8%; P = 0.007). For patients with and without a FPC, median time to occlusion was 51 and 6 months, respectively (P = 0.002). Using a multivariable Cox proportional hazards model, a FPC was associated with reduced odds of complete occlusion on last follow-up (risk ratio 0.35, 95% confidence interval 0.14-0.89; P = 0.029). CONCLUSIONS Our results indicate reduced efficacy of FD for the treatment of PCOM aneurysms associated with a FPC. These findings may influence treatment selection for aneurysms at this location.
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21
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Enriquez-Marulanda A, Salem MM, Ascanio LC, Maragkos GA, Gupta R, Moore JM, Thomas AJ, Ogilvy CS, Alturki AY. No differences in effectiveness and safety between pipeline embolization device and stent-assisted coiling for the treatment of communicating segment internal carotid artery aneurysms. Neuroradiol J 2019; 32:344-352. [PMID: 30998116 DOI: 10.1177/1971400919845368] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Aneurysms arising from the communicating segment (C7) of the internal carotid artery (ICA) are one of the most frequent locations of intracranial aneurysms. Stent-assisted coiling (SAC) and flow diversion therapies are both endovascular strategies used for the treatment of ICA aneurysms occurring at the C7 segment. OBJECTIVE The aim of this study is to compare both methods' angiographic and functional outcomes, and procedural complications. To our knowledge, this is the first study to compare both modalities for aneurysms at this location. METHODS A retrospective review was performed of our prospectively collected database from 2008 until 2017 for patients treated with SAC and from 2013 until 2017 for patients treated with pipeline embolization devices (PEDs). RESULTS We identified 35 patients for this cohort with 38 aneurysms; 17 treated with SAC and 21 with PED. Mean age was 59 years, and 30 patients were female (86%). Complete occlusion at last follow-up occurred in 70.6% of patients in the SAC group and in 81% in the PED group (p = 0.45). Posterior communicating artery patency at last follow-up did not differ significantly between the two groups (94.1% vs 85.7%; p = 0.40). Good functional outcome at last follow-up (mRS 0-2) was achieved in 100% and 88.2% of patients, respectively. Additionally, there was no significant difference between the two groups for retreatment rates, procedural hemorrhagic, or thromboembolic complications. CONCLUSION SAC and PED are two equally efficacious modalities for endovascular treatment of ICA aneurysms arising at the communicating segment of the ICA.
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Affiliation(s)
| | - Mohamed M Salem
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Luis C Ascanio
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Georgios A Maragkos
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Raghav Gupta
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Justin M Moore
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ajith J Thomas
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Abdulrahman Y Alturki
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,2 Department of Neurosurgery, The National Neuroscience Institute, Riyadh, Saudi Arabia
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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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