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Duangprasert G, Sukhor S, Ratanavinitkul W, Tantongtip D. Evaluation of flow diverter use in acutely ruptured vertebral artery dissecting Aneurysms: A focus on safety and efficacy for rapid Aneurysm obliteration. Clin Neurol Neurosurg 2024; 242:108345. [PMID: 38788544 DOI: 10.1016/j.clineuro.2024.108345] [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: 03/11/2024] [Revised: 05/10/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE Flow diverter device (FDD) has emerged as the reconstruction technique for treating ruptured dissecting vertebral artery Aneurysms (VADA), but data on feasibility regarding re-rupture risk and timing of Aneurysm obliteration following FDD treatment is still limited. Therefore, this study aimed to evaluate the safety and efficacy of FDD in the treatment of VADAs presenting with subarachnoid hemorrhage (SAH). METHODS We retrospectively reviewed patients with ruptured VADA presenting with subarachnoid hemorrhage who underwent FDD placement at our institution between 2015 and 2023. Patient demographic data, Aneurysm configuration, and occlusion status were analyzed. RESULTS Thirteen patients with SAH from VADA rupture underwent FDD implantation. The average size of the largest diameter of the Aneurysm was 11.2 mm (range 6.5-21 mm). Eight of 13 (61.5 %) patients had their Aneurysms completely obliterated within 2 weeks after the procedure. The small dissecting Aneurysm (d = 0.636, p = 0.002) and degree of intra-Aneurysmal contrast stasis (d = 0.524, p = 0.026) were associated with rapid Aneurysm occlusion, according to the Somer's d coefficient. There were no ischemic or hemorrhagic complications at the average clinical follow-up of 28.4 months (range 5-67 months) and average angiographic follow-up of 20.1 months (range 3-60 months). A favorable outcome (mRS 0-2) was achieved in 12 patients (92.3 %). CONCLUSIONS FDD is safe and effective for the reconstruction of acutely ruptured VADAs. In addition, our study emphasizes that small dissecting Aneurysms tend to be rapidly obliterated after flow diversion, which eliminates the risk of re-rupture during the acute phase of subarachnoid hemorrhage.
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Affiliation(s)
- Gahn Duangprasert
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand.
| | - Sasikan Sukhor
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | - Warot Ratanavinitkul
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | - Dilok Tantongtip
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
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Amoukhteh M, Hassankhani A, Valizadeh P, Jannatdoust P, Ghozy S, Kobeissi H, Kallmes DF. Flow diverters in the treatment of intracranial dissecting aneurysms: a systematic review and meta-analysis of safety and efficacy. J Neurointerv Surg 2024:jnis-2023-021117. [PMID: 38212103 DOI: 10.1136/jnis-2023-021117] [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: 10/10/2023] [Accepted: 12/22/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Intracranial dissecting aneurysms present clinical challenges, demanding immediate intervention due to their high bleeding risk. While traditional treatments have limitations, the potential of flow diverters shows promise but remains a subject of ongoing debate for optimal management. The aim of this study was assess the safety and efficacy of flow diverters in the treatment of intracranial dissecting aneurysms. METHODS A systematic review and meta-analysis was performed following established guidelines. The search encompassed PubMed, Scopus, Web of Science, and Embase databases up to July 20, 2023. Eligible studies reporting outcomes of interest were included, and relevant data were extracted and analyzed using R software. RESULTS The analysis, based on data pooled from 20 included studies involving 329 patients, revealed a favorable functional outcome rate of 89.7% at the last follow-up. The mortality rate during the follow-up period was 2.4%, decreasing to 0.9% when excluding the outlier study. In the final angiographic follow-up, a complete occlusion rate of 71.7% and an adequate occlusion rate of 88.3% were observed. Notably, studies with longer angiographic follow-up times exhibited lower rates of complete (P=0.02) and adequate (P<0.01) occlusion. A minimal aneurysm recurrence/rebleeding rate of 0.1% was noted, while in-stent stenosis/thrombosis occurred at a rate of 1.14%. Additionally, ischemic events/infarctions were seen in 3.3% of cases. The need for retreatment was minimal, with a rate of 0.9%, and the technical success rate was impressively high at 99.1%. CONCLUSION This study highlights the safety and efficacy of flow diverters in treating intracranial dissecting aneurysms. Further research, encompassing larger multicenter studies with extended follow-up periods, is crucial for comprehending occlusion dynamics, refining treatment strategies, improving long-term outcomes, and addressing methodological limitations.
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Affiliation(s)
- Melika Amoukhteh
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Amir Hassankhani
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Parya Valizadeh
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Deshmukh AS, Priola SM, Katsanos AH, Scalia G, Costa Alves A, Srivastava A, Hawkes C. The Management of Intracranial Aneurysms: Current Trends and Future Directions. Neurol Int 2024; 16:74-94. [PMID: 38251053 PMCID: PMC10801587 DOI: 10.3390/neurolint16010005] [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: 10/15/2023] [Revised: 11/14/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024] Open
Abstract
Intracranial aneurysms represent a major global health burden. Rupture of an intracranial aneurysm is a catastrophic event. Without access to treatment, the fatality rate is 50% in the first 30 days. Over the last three decades, treatment approaches for intracranial aneurysms have changed dramatically. There have been improvements in the medical management of aneurysmal subarachnoid haemorrhage, and there has been an evolution of treatment strategies. Endovascular therapy is now the mainstay of the treatment of ruptured intracranial aneurysms based on robust randomised controlled trial data. There is now an expansion of treatment indications for unruptured intracranial aneurysms to prevent rupture with both microsurgical clipping and endovascular treatment. Both microsurgical and endovascular treatment modalities have evolved, in particular with the introduction of innovative endovascular treatment options including flow diversion and intra-saccular flow disruption. These novel therapies allow clinicians to treat more complex and previously untreatable aneurysms. We aim to review the evolution of treatment strategies for intracranial aneurysms over time, and discuss emerging technologies that could further improve treatment safety and functional outcomes for patients with an intracranial aneurysm.
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Affiliation(s)
- Aviraj S. Deshmukh
- Division of Clinical Sciences, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, ON P3E 2C6, Canada;
| | - Stefano M. Priola
- Division of Neurosurgery, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, ON P3E 2C6, Canada;
| | - Aris H. Katsanos
- Division of Neurology, Hamilton General Hospital, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Gianluca Scalia
- Department of Neurosurgery, Highly Specialized Hospital of National Importance “Garibaldi”, 95126 Catania, Italy;
| | - Aderaldo Costa Alves
- Division of Neurosurgery, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, ON P3E 2C6, Canada;
| | - Abhilekh Srivastava
- Division of Neurology, Hamilton General Hospital, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Christine Hawkes
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M5S 1A1, Canada;
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Duangprasert G, Noiphithak R, Sukhor S, Tantongtip D. Efficacy and predicting factors of multimodal treatment for ruptured intracranial vertebral artery dissecting aneurysms. Neurosurg Rev 2023; 46:321. [PMID: 38040929 DOI: 10.1007/s10143-023-02226-7] [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: 10/11/2023] [Revised: 11/09/2023] [Accepted: 11/23/2023] [Indexed: 12/03/2023]
Abstract
We aimed to investigate the efficacy of our multimodal strategies and propose a treatment algorithm for ruptured vertebral artery dissecting aneurysms (VADAs). This study included 41 patients treated at a single institution between 2015 and 2022. The treatment modalities were justified based on the collateral circulation and aneurysm location related to the posterior inferior cerebellar artery (PICA). Treatment outcomes and complications of each treatment group were analyzed. The association between the collateral blood flow and the postoperative vertebrobasilar ischemia (VBI) was also investigated. There were 17 post-PICA, 10 PICA-involved, 7 pre-PICA, and 7 non-PICA types. Reconstruction techniques included flow diversion devices (n = 11) and stent-assisted coiling (n = 3). Deconstruction techniques included coil trapping (n=17) and microsurgical parent artery occlusion with (n = 8) or without PICA revascularization (n = 2). Five (18.5%) of the deconstruction group had postoperative VBI. Overall favorable outcomes in both groups were observed in 70.7% of patients with a mean follow-up time of 21.5 months. Poor World Federation of Neurosurgical Societies grade (IV-V) was identified as a predictor of unfavorable outcomes (p = 0.003). In addition, the VA4/BA4 ratio > 0.22, the presence of collateral blood flow from the posterior communicating artery (PcomA), and a contralateral VA diameter > 2.5 mm were associated with a lower risk of postoperative VBI. In summary, the proposed strategic treatment in this study is pragmatic, yielding satisfactory results where a deconstructive technique should be used with caution, particularly when there is a flow mismatch or the absence of collateral PcomA in the vertebrobasilar circulation.
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Affiliation(s)
- Gahn Duangprasert
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Khlong Nueng, Pathum Thani, 12120, Thailand
| | - Raywat Noiphithak
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Khlong Nueng, Pathum Thani, 12120, Thailand.
| | - Sasikan Sukhor
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Khlong Nueng, Pathum Thani, 12120, Thailand
| | - Dilok Tantongtip
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Khlong Nueng, Pathum Thani, 12120, Thailand
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Zhou M, Wu Z, Maalim AA, Zeng Y, Guo X, Zhang Z, Yuan X, Enos ZM, Shu K, Lei T, Zhu M. Overlapping Stent Treatment for Ruptured Dissecting Aneurysms in Posterior Circulation. Brain Sci 2023; 13:1507. [PMID: 38002469 PMCID: PMC10669846 DOI: 10.3390/brainsci13111507] [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: 07/23/2023] [Revised: 10/04/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
Ruptured dissecting aneurysms in posterior intracranial circulation present significant clinical challenges and often cause poor prognoses. Our cohort used overlapping stents as the primary treatment. We analyzed the medical records of 27 patients (18 men/nine women) with ruptured posterior circulation dissecting aneurysms (PCDAs). Their average age was 52 years. We selected 11 patients who used Enterprise (EP) and LVIS stents overlappingly and matched them 1:1 with counterparts who received either EP or LVIS stents individually. Overlapping stents was a feasible treatment in all 27 cases. We successfully followed up 26 patients for ≥6 months. Regrettably, one patient died from intracranial hypertension on Day 7 post-procedure. Immediate post-procedure angiographies indicated Raymond grade I, II, and III occlusions of PCDAs in 16 (59.3%), 7 (25.9%), and 4 (14.8%) cases, respectively. At an average follow-up duration of 16.2 months, 25 patients (96.2%) had modified Rankin Scale scores of 0-2, signifying positive outcomes. One patient (3.8%) had a score of 3-4. Recurrence rates for the EP and LVIS stent groups were higher than those of the overlapping stent group (45.45% vs. 9.09%, p = 0.15 and 27.27% vs. 9.09%, p = 0.59, respectively). No significant difference in recurrence rates existed between the overlapping and single-stent groups. Similarly, follow-up outcomes were consistent between the two groups. Overlapping stents could be an efficient method for treating ruptured PCDAs.
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Affiliation(s)
- Minghui Zhou
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zengbao Wu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ali Abdi Maalim
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ying Zeng
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Xiao Guo
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zhenhua Zhang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Xiaohong Yuan
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zacharia Majaliwa Enos
- Department of Neurosurgery, Tongji Tianyou Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430030, China;
| | - Kai Shu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ting Lei
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Mingxin Zhu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
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Sakamoto Y, Kabeya R, Nishihori M. A Case of Bilateral Vertebral Artery Dissecting Aneurysm Treated With Multimodality Therapy Under Superficial Temporal Artery Assistance-Posterior Cerebral Artery Bypass. Cureus 2023; 15:e45326. [PMID: 37849606 PMCID: PMC10577094 DOI: 10.7759/cureus.45326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/19/2023] Open
Abstract
A ruptured bilateral vertebral artery dissecting aneurysm (BVDA) is a challenging vascular disorder. Trapping surgery with bypass assistance could be a potential treatment; however, there is a risk of ischemic complications. Recently, endovascular treatment has been reported, but its long-term outcomes remain uncertain. The patient was a 57-year-old male who presented with subarachnoid hemorrhage. Digital subtraction angiography showed a dilated dominant left vertebral artery (VA) and a narrowed right VA, suggesting a BVDA. First, we performed a right superficial temporal artery-superior cerebellar artery (STA-SCA) insurance bypass. We then performed proximal clipping of the left vertebral VA. The pulsation of the STA-SCA bypass disappeared on day 6. Three-dimensional computed tomography angiography (3DCTA) showed the emergence of a fusiform aneurysm and proximal stenosis of the contralateral VA. On day 31, we performed a superficial temporal artery-posterior cerebral artery (STA-PCA) insurance bypass. Stent-assisted coil embolization was planned for two days after the STA-PCA bypass. However, preoperative angiography showed progression of right proximal VA stenosis, and stenting appeared impossible. There was no change in somatosensory evoked potential (SEP), and angiography showed sufficient retrograde blood flow to the posterior circulation during the right VA balloon occlusion test (BOT). Therefore, internal trapping of the right VA was performed. Postoperative angiography showed perfect patency of the left STA-PCA bypass and retrograde blood flow to the posterior circulation. There was no additional neurological deficit after endovascular treatment. Multimodality therapy could be a potential treatment for bilateral VA dissection.
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Affiliation(s)
- Yusuke Sakamoto
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, JPN
| | - Ryusuke Kabeya
- Department of Neurosurgery, Ichinomiya Municipal Hospital, Ichinomiya, JPN
| | - Masahiro Nishihori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, JPN
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Celik E, Goertz L, Ozpeynirci Y, Schlamann M, Dorn F, Lehnen N, Siebert E, Liebig T, Kabbasch C. Comparative assessment of woven endobridge embolization and standard coil occlusion for the treatment of ruptured basilar tip aneurysms. Neuroradiology 2023; 65:765-773. [PMID: 36460785 DOI: 10.1007/s00234-022-03096-4] [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: 07/25/2022] [Accepted: 11/26/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE Endovascular coil occlusion represents the standard treatment for basilar tip aneurysms. Recently, this role has been rivalled by intrasaccular flow disruptors across numerous centres. We retrospectively compared WEB embolization and coiling for the treatment of ruptured basilar tip aneurysms. METHODS Patients treated with WEB or coiling at four neurovascular centres were reviewed. Procedure-related complications, clinical outcome, and angiographic results were retrospectively compared. RESULTS The study included 23 patients treated with the WEB (aneurysm size: 6.6 ± 1.9 mm) and 56 by coiling (aneurysm size: 6.7 ± 2.5 mm). Stent-assistance was more often necessary with coiling than with WEB embolization (32% vs. 4%, p = 0.009). A modified Rankin scale score ≤ 2 at discharge had 21 (37.5%) patients in the coiling group and 12 (52.2%) in the WEB group (p = 0.235). Immediate complete and adequate occlusion rates were 52% for the WEB and 87% for coiling. At short-term follow-up, these rates were 87% for the WEB and 72% for coiling, respectively. There was no delayed aneurysm re-bleeding during follow-up. CONCLUSION Both coiling and WEB seem to prevent rebleeding in ruptured BTA aneurysms. WEB embolization required less frequently stent-support than coiling, potentially advantageous for SAH patients to avoid anti-platelet therapy in the light of concomitant procedures like ventricular drainage.
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Affiliation(s)
- Erkan Celik
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany.
| | - Lukas Goertz
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Yigit Ozpeynirci
- Department of Neuroradiology, Ludwig's Maximilian University Munich, Munich, Germany
| | - Marc Schlamann
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Nils Lehnen
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, University Hospital of Berlin (Charité), Berlin, Germany
| | - Thomas Liebig
- Department of Neuroradiology, Ludwig's Maximilian University Munich, Munich, Germany
| | - Christoph Kabbasch
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
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Utility of flow diverters in treatment of acutely ruptured uncoilable aneurysms of the posterior circulation of the brain. Jpn J Radiol 2023:10.1007/s11604-023-01409-y. [PMID: 36920731 DOI: 10.1007/s11604-023-01409-y] [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: 09/13/2022] [Accepted: 02/27/2023] [Indexed: 03/16/2023]
Abstract
PURPOSE Aim of this study is to evaluate safety and efficacy of flow diverters (FDs) in treatment of acutely ruptured posterior circulation aneurysms MATERIALS AND METHODS: Databases of three participating institutions were retrospectively scanned for patients in whom FD placement was attempted for treatment of acutely ruptured vertebrobasilar aneurysms. An interval of 14 days or fewer between the latest ictus and treatment was used as inclusion criterion. Patients with dolichoectasia of vertebrobasilar arteries were excluded. If necessary, adjunctive techniques including coiling or stenting were utilized. Clinical outcomes were graded using mWFNS (modified World Federation of Neurosurgical Societies Scale) and mRS (modified Rankin Scale). Aneurysmal occlusion was defined as Raymond-Roy Class 1. Spearman's (ρ) test was used to assess the correlation between variables. Univariate and multivariate logistic regression were used to assess outcomes. RESULTS 31 patients (25 women, mean age: 52.7 ± 15.2) harboring 32 aneurysms (16 non-saccular, mean size: 11.4 ± 7 mm) were included. Mean number of FDs used was 1.22 ± 0.42. In six cases, adjunctive coiling and in five cases, apposing stent placement were used. Overall mortality rate and procedure-related mortality rates were 22.5% (7/31) and 9.6% (3/31), respectively. At a mean imaging follow-up of 17.2 ± 12.6 months, total occlusion was achieved in 22 aneurysms (91.6%). Univariate analysis showed that mortality was positively correlated with vasospasm (ρ = 0.600, p < 0.05), higher mWFNS Scale (ρ = 0.685, p < 0.05), higher modified Fischer Score (ρ = 0.609, p < 0.05), higher mRS (ρ = 0.594, p < 0.05) on admission and negatively correlated with saccular morphology (ρ = -0.529, p < 0.05). Multivariate logistic regression identified mWFNS on admission as a significant predictor. (OR: 7.148, 95% CI 1.777-28.758, p: 0.01). Adjunctive coiling positively correlated with aneurysm occlusion. (ρ = 0.522, p < 0.05). CONCLUSION The procedure-related morbidity and mortality is not negligible. However, the risks and efficacy associated with FDs are acceptable, especially when adjunctive coiling is possible, given the lack of treatment alternatives.
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Dolas I, Unal TC, Gulsever CI, Sahin D, Huseynov H, Barburoglu M, Ozturk O, Can H, Adiyaman AE, Dagdeviren HE, Sabanci PA, Aydoseli A, Aras Y, Sencer A, Sencer S. Endovascular treatment of posterior circulation aneurysms: Results from a single-team experience of 81 cases including 13 flow diversion treatment. NEUROCIRUGIA (ENGLISH EDITION) 2023:S2529-8496(22)00097-1. [PMID: 36774258 DOI: 10.1016/j.neucie.2022.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/29/2022] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Relatively constant surgical risks and rapid advances in endovascular treatment have caused a major shift toward endovascular management of posterior circulation aneurysms. This paper presents the results of a series of endovascularly treated posterior circulation aneurysms. METHODS A total of 81 patients who underwent endovascular treatment of posterior circulation aneurysms performed by a single team between 2009 and 2019 were included. Demographic, clinical, radiologic, and management details were retrospectively obtained from hospital records. RESULTS Among the included patients, 50 (61.7%) and 31 (38.3%) were female and male, respectively. Subarachnoid hemorrhage was observed in 30 patients (37%). Moreover, 40 (49.3%) aneurysms were treated with stent-assisted coiling, 1 (1.2%) aneurysm was treated with parent artery occlusion, 2 (2.4%) aneurysms were coiled using balloon assistance, 24 (29.6%) aneurysms were coiled primarily, 1 (1.2%) patient had an unsuccessful treatment attempt, and 13 (16.0%) aneurysms were treated with flow-diverter stents or stent monotherapy. During the last follow-up, 57 (83.8%) aneurysms were completely occluded, whereas 6 (8.8%) and 2 (2.9%) aneurysms did and did not have a residual neck, respectively. Flow diversion was used to treat 13 patients, among whom 8 had total occlusion or stable residue. A total of 7 deaths (8.6%) were encountered in this series. CONCLUSION Endovascular treatment should be considered as the primary treatment modality for posterior circulation aneurysms. Despite the high morbidity and mortality rates, promising results can be achieved with correct patient selection. Flow diversion can be a feasible alternative for complex aneurysms that are difficult to treat.
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Affiliation(s)
- Ilyas Dolas
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Tugrul Cem Unal
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Cafer Ikbal Gulsever
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey.
| | - Duran Sahin
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Heydar Huseynov
- Department of Radiology, Istanbul Atlas University, Istanbul, Turkey
| | - Mehmet Barburoglu
- Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Onur Ozturk
- Department of Neurosurgery, Istanbul Bilim University, Istanbul, Turkey
| | - Halil Can
- Department of Neurosurgery, Istanbul Atlas University, Istanbul, Turkey
| | - Ali Ekrem Adiyaman
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Huseyin Emre Dagdeviren
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Pulat Akin Sabanci
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Aydin Aydoseli
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Yavuz Aras
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Altay Sencer
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Serra Sencer
- Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
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10
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Dmytriw AA, Alrashed A, Enriquez-Marulanda A, Medhi G, Mendes Pereira V. Unruptured Intradural Posterior Circulation Dissecting/Fusiform Aneurysms Natural History and Treatment Outcome. Interv Neuroradiol 2023; 29:56-62. [PMID: 34935531 PMCID: PMC9893235 DOI: 10.1177/15910199211068673] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The natural history and outcome of unruptured posterior circulation dissecting fusiform aneurysms is not fully understood. These have a high risk of morbidity and mortality, not only due to natural history but also due to the challenging and controversial treatment approaches currently available compared to other types of intracranial aneurysms. METHODS We performed a retrospective study of a prospectively collected aneurysm database at a quaternary neurovascular hospital. We included consecutive patients with unruptured intradural vertebrobasilar dissecting aneurysms between January 2000 and July 2016 who were followed to 2020. Description of baseline, procedural, and outcomes data was performed. Comparisons of patient who had aneurysm rupture on follow-up, increase in 2 or more points of mRS in follow-up and progression of the aneurysm was performed. RESULTS Seventy patients with 78 fusiform posterior circulation aneurysms were identified. Thirty-nine (55.7%) patients were male with a mean age of 51.7 years (SD ± 17.6). When multiple, aneurysms were more likely to be fusiform (60%) than saccular (40.0%). Baseline diameter (measured on CTA/MRA/DSA), length as well as symptomatic presentation were significantly higher in aneurysms which grew over time. Coronary disease, diabetes and growth were associated an >2 increase in mRS. Diabetes as well as initial symptomatic presentation were associated with rupture. CONCLUSIONS Unruptured dissecting/fusiform aneurysm are associated with a considerable rate of rupture during follow-up. Growth is associated with morbidity even in the absence of rupture. Initial large size, coronary disease, diabetes, and to a lesser extent female gender may merit closer follow-up and/or prophylactic treatment.
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Affiliation(s)
- Adam Andrew Dmytriw
- St Michael's Hospital, Divisions of Neurosurgery and Therapeutic Neuroradiology,
Toronto, ON, Canada
- Neurosurgical Service, Beth Israel Deaconess Medical
Center, Harvard Medical School, Boston, MA, USA
| | - Abdullah Alrashed
- St Michael's Hospital, Divisions of Neurosurgery and Therapeutic Neuroradiology,
Toronto, ON, Canada
| | - Alejandro Enriquez-Marulanda
- St Michael's Hospital, Divisions of Neurosurgery and Therapeutic Neuroradiology,
Toronto, ON, Canada
- Neurosurgical Service, Beth Israel Deaconess Medical
Center, Harvard Medical School, Boston, MA, USA
| | - Gorky Medhi
- St Michael's Hospital, Divisions of Neurosurgery and Therapeutic Neuroradiology,
Toronto, ON, Canada
| | - Vitor Mendes Pereira
- St Michael's Hospital, Divisions of Neurosurgery and Therapeutic Neuroradiology,
Toronto, ON, Canada
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11
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Primary coiling of a wide-neck unruptured aneurysm in the trifurcation of the P2 segment of the posterior cerebral artery: A case report. Radiol Case Rep 2022; 17:4642-4646. [PMID: 36204413 PMCID: PMC9530493 DOI: 10.1016/j.radcr.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/30/2022] [Accepted: 09/04/2022] [Indexed: 11/21/2022] Open
Abstract
Intracranial aneurysms are now treatable with coils, stents, and flow diverters in recent years. For saccular aneurysms with broad necks and short domes, stent-assisted coiling has become a common technique, but over time, the complications—both intraprocedural and in a delayed fashion—occur more frequently than coiling alone. Nonstent or balloon-assisted coiling results in lower aneurysm recanalization, lower aneurysm rupture or re-rupture, or lower aneurysm retreatment. This paper illustrates a successful coiling of wide-neck unruptured aneurysm in the trifurcation of the left P2 posterior cerebral artery done without the assistance of stents or balloons.
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12
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Lee HJ, Cho WC, Choi JH, Kim BS, Shin YS. Comparison of Parent Artery Occlusion and Stent-Assisted Treatments in Ruptured Vertebral Artery Dissecting Aneurysms. World Neurosurg 2022; 167:e533-e540. [PMID: 35977685 DOI: 10.1016/j.wneu.2022.08.047] [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: 04/10/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess clinical outcomes of ruptured vertebral artery dissecting aneurysms, focusing on comparing parent artery occlusion (PAO) with stent-assisted treatments, and to identify risk factors for unfavorable outcomes and postprocedural complications. METHODS This retrospective review included 36 ruptured vertebral artery dissecting aneurysms treated between February 2009 and April 2020. Treatment modalities included PAO without stent and stent-assisted treatments. Stent-assisted treatments included PAO with posterior inferior cerebellar artery (PICA) stenting and stent-assisted coiling. Univariate and multivariate analyses were conducted to evaluate risk factors for unfavorable outcomes and postprocedural complications. RESULTS Patients were treated with PAO only (24, 66.7%), PAO with PICA stenting (4, 11.1%), and PAO with stent-assisted coiling (8, 22.2%). There were only fusiform aneurysms with PICA involvement in the PAO with PICA stenting group. In the stent-assisted coiling group, 4 aneurysms incorporated PICA, and 4 aneurysms involved dominant vertebral artery. Old age (odds ratio [OR] = 1.25, 95% confidence interval [CI] = 1.01-1.56, P = 0.044) and poor Hunt-Hess grade (OR = 537.99, 95% CI = 6.73-42994.1, P = 0.005) were significantly associated with unfavorable clinical outcomes after a mean follow-up of 37.5 ± 32.8 months. Fusiform dilatation shape (OR = 15.97, 95% CI = 1.52-167.38, P = 0.021) and PICA involvement (OR = 13.71, 95% CI = 1.29-145.89, P = 0.030) were independent risk factors for ischemic complications. CONCLUSIONS Unfavorable clinical outcomes were significantly related to old age and poor Hunt-Hess grade. There were no significant differences between treatment groups in clinical outcomes or ischemic complications. Stent-assisted treatments might be effective and safe methods for ruptured vertebral artery dissecting aneurysms.
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Affiliation(s)
- Hyeong Jin Lee
- Department of Neurosurgery, Seoul St. Mary's Hospital, Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Woo Cheul Cho
- Department of Neurosurgery, Seoul St. Mary's Hospital, Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Jai Ho Choi
- Department of Neurosurgery, Seoul St. Mary's Hospital, Catholic University of Korea College of Medicine, Seoul, South Korea.
| | - Bum-Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St. Mary's Hospital, Catholic University of Korea College of Medicine, Seoul, South Korea
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13
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Oya S, Yoshida S, Saito A, Shojima M, Yoshikawa G, Ota T, Ono H, Kurita H, Kohyama S, Miyawaki S, Koizumi S, Saito N, Matsui T. The optimal management of ruptured basilar artery dissecting aneurysms: a case series and scoping review. Neurosurg Rev 2022; 45:3427-3436. [PMID: 36069955 DOI: 10.1007/s10143-022-01857-6] [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: 05/27/2022] [Revised: 08/22/2022] [Accepted: 09/01/2022] [Indexed: 11/29/2022]
Abstract
The natural history of ruptured basilar artery dissecting aneurysms (BADAs) remains unclear compared to that of ruptured vertebral artery dissecting aneurysms (VADAs). In this study, we investigated the natural history and optimal management of ruptured BADAs. We identified 17 patients with ruptured BADA among 4586 patients with aneurysmal subarachnoid hemorrhage (SAH) treated in seven participating hospitals. A scoping literature review was undertaken to investigate prognostic factors. Six patients among the profiled patients (35.3%) died, all with poor SAH grades (World Federation of Neurological Societies Grade IV and V). Rebleeding after admission was observed in three patients (17.6%) with poor SAH grades. Aggressive treatment and conservative management were initiated in seven and ten patients, respectively. Patients with good SAH grades had significantly higher favorable treatment outcomes than those with poor grades (83.3% vs. 9.1%, P = 0.005). Moreover, based on a scoping review of 158 cases with ruptured BADA, including the patients from our series, approximately 90% of patients with good SAH grades had favorable outcomes. A good SAH grade and no rebleeding after admission were favorable prognostic factors (P < 0.0001 and P = 0.002, respectively). The rebleeding rates were 20.2%, 13.3%, and 6.3% for dilated, pearl and string, and stenotic lesions, respectively. We concluded that the natural history of isolated ruptured BADAs may be better than that of VADAs. Although definitive treatment, if possible, is undoubtedly important, conservative management with careful radiological follow-up for morphological changes might be a viable option for patients in good clinical condition and with non-dilated lesions.
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Affiliation(s)
- Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan.
| | - Shinsuke Yoshida
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Akira Saito
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Masaaki Shojima
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | | | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Hideaki Ono
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Shizuoka, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Shinya Kohyama
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
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14
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Miyamoto S, Yoshioka R, Yamada K, Nishido H, Takeda R, Ino Y, Hoya K. Stent-assisted coil embolization for a pediatric distal posterior cerebral artery aneurysm: A case report and review. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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15
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Dolas I, Unal TC, Gulsever CI, Sahin D, Huseynov H, Barburoglu M, Ozturk O, Can H, Adiyaman AE, Dagdeviren HE, Sabanci PA, Aydoseli A, Aras Y, Sencer A, Sencer S. Endovascular treatment of posterior circulation aneurysms: Results from a single-team experience of 81 cases including 13 flow diversion treatment. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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16
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Ogishima T, Tone O, Sato Y, Tamaki M. Internal Trapping of an Acutely Ruptured Dissecting Aneurysm of a Dominant Vertebral Artery Following Balloon Test Occlusion: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2022; 16:474-480. [PMID: 37502797 PMCID: PMC10370988 DOI: 10.5797/jnet.cr.2021-0105] [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: 12/23/2021] [Accepted: 04/10/2022] [Indexed: 07/29/2023]
Abstract
Objective To report a case of an acutely ruptured vertebral artery dissecting aneurysm (VADA) with a hypoplastic contralateral vertebral artery (VA) successfully treated with internal trapping following the estimation of the collateral flow from anterior circulation. Case Presentation A 46-year-old woman was diagnosed with subarachnoid hemorrhage and acute hydrocephalus. Ventriculostomy was performed under general anesthesia. CTA revealed a left VADA distal to the origin of the left posterior inferior cerebellar artery (PICA). The right VA was hypoplastic, and the right posterior communicating artery (Pcom) was fetal type. We performed balloon test occlusion (BTO) of the VA proximal to the origin of the left PICA and estimated sufficient collateral blood flow via the right Pcom and basilar artery (BA) to the anterior spinal artery (ASA) and the left PICA. Internal trapping of the left VADA was then performed. The angiograms after internal trapping revealed collateral flow from the right Pcom to the BA, and the hypoplastic right VA perfused the proximal BA and ASA. She recovered without any neurological deficits following antiplatelet therapy and vasospasm treatment. She was followed up for 6 years without any neurological events occurring. Conclusion When BTO indicates sufficient collateral flow, internal trapping could be a useful treatment for acutely ruptured VADAs on the dominant side, given a complete understanding of the angioarchitecture and the risk of vasospasm due to subarachnoid hemorrhage.
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Affiliation(s)
- Takahiro Ogishima
- Department of Neurosurgery, Japanese Red Cross Musashino Hospital, Musashino, Tokyo, Japan
| | - Osamu Tone
- Stroke Center, Ome Municipal General Hospital, Ome, Tokyo, Japan
| | - Yohei Sato
- Department of Neurosurgery, Japanese Red Cross Musashino Hospital, Musashino, Tokyo, Japan
| | - Masashi Tamaki
- Department of Neurosurgery, Japanese Red Cross Musashino Hospital, Musashino, Tokyo, Japan
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17
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Outcomes after Flow Diverter Treatment in Subarachnoid Hemorrhage: A Meta-Analysis and Development of a Clinical Prediction Model (OUTFLOW). Brain Sci 2022; 12:brainsci12030394. [PMID: 35326350 PMCID: PMC8946659 DOI: 10.3390/brainsci12030394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 02/01/2023] Open
Abstract
Background: patients with a subarachnoid hemorrhage (SAH) might need a flow diverter (FD) placement for complex acutely ruptured intracranial aneurysms (IAs). We conducted a meta-analysis and developed a prediction model to estimate the favorable clinical outcome after the FD treatment in acutely ruptured IAs. Methods: a systematic literature search was performed from 2010 to January 2021 in PubMed and Embase databases. Studies with more than five patients treated with FDs within fifteen days were included. In total, 1157 studies were identified. The primary outcome measure was the favorable clinical outcome (mRS 0–2). Secondary outcome measures were complete occlusion rates, aneurysm rebleeding, permanent neurologic deficit caused by procedure-related complications, and all-cause mortality. A prediction model was constructed using individual patient-level data. Results: 26 retrospective studies with 357 patients and 368 aneurysms were included. The pooled rates of the favorable clinical outcome, mortality, and complete aneurysm occlusion were 73.7% (95% CI 64.7–81.0), 17.1% (95% CI 13.3–21.8), and 85.6% (95% CI 80.4–89.6), respectively. Rebleeding occurred in 3% of aneurysms (11/368). The c-statistic of the final model was 0.83 (95% CI 0.76–0.89). All the studies provided a very low quality of evidence. Conclusions: FD treatment can be considered for complex ruptured IAs. Despite high complication rates, the pooled clinical outcomes seem favorable. The prediction model needs to be validated by larger prospective studies before clinical application.
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18
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Giorgianni A, Agosti E, Molinaro S, Terrana AV, Vizzari FA, Nativo L, Garg K, Craparo G, Conti V, Locatelli D, Baruzzi F, Valvassori L, Lanzino G. Flow diversion for acutely ruptured intracranial aneurysms treatment: A retrospective study and literature review. J Stroke Cerebrovasc Dis 2022; 31:106284. [PMID: 35007933 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/19/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Flow diversion is becoming an increasingly established practice for the treatment of acutely ruptured intracranial aneurysms. In this study the authors present a literature review and meta-analysis, adding a retrospective review of institutional registry on emergency treatment of aRIA with flow diverter stent. MATERIALS AND METHODS A systematic search of PubMed, SCOPUS, Ovid MEDLINE, and Ovid EMBASE was performed on April 20th, 2021, extrapolating 35 articles. R language 'meta' and 'metafor' packages were used for data pooling. The DerSimonian-Laird model was used to calculate the pooled effect. The I2 value and Q statistic evaluated study heterogeneity. Additionally, the authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured intracranial aneurysms treated with flow diverter stent placement from May 2010 to November 2020 was performed. RESULTS From the systematic literature review and meta-analysis, the pooled proportion of complete aneurysm occlusion was 78%, with a pooled rate of 79%, 71%, 80%, and 50% for dissecting, saccular, fusiform, and mycotic aneurysms, respectively. The pooled proportion of aneurysm rebleeding and intrastent stenosis was 12% and 15% respectively, for a total of 27% rate. The analysis of authors retrospective register showed an overall mortality rate of 16.7% (3/18), with a low but not negligible postprocedural rebleeding and intrastent thrombosis rates (5.6% and 11.1% respectively). CONCLUSION Although increasingly utilized in the management of selected patients with acutely ruptured intracranial aneurysms, flow diversion for acutely ruptured intracranial aneurysms treatment presents rebleeding and intrastent stenosis rates not negligible.
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Affiliation(s)
- Andrea Giorgianni
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Brescia, Italy.
| | - Stefano Molinaro
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Alberto Vito Terrana
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | | | - Luca Nativo
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Kanwaljeet Garg
- Associate Professor, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Giuseppe Craparo
- Department of Department of Neuroradiology, ARNAS Civico di Palermo, Palermo, Italy
| | - Vinicio Conti
- Department of Anesthesiology and Resuscitation, ASST Sette Laghi, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Fabio Baruzzi
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | | | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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19
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Maybaum J, Henkes H, Aguilar-Pérez M, Hellstern V, Gihr GA, Härtig W, Reisberg A, Mucha D, Schüngel MS, Brill R, Quäschling U, Hoffmann KT, Schob S. Flow Diversion for Reconstruction of Intradural Vertebral Artery Dissecting Aneurysms Causing Subarachnoid Hemorrhage-A Retrospective Study From Four Neurovascular Centers. Front Neurol 2021; 12:700164. [PMID: 34276549 PMCID: PMC8280292 DOI: 10.3389/fneur.2021.700164] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/17/2021] [Indexed: 12/20/2022] Open
Abstract
Objective: Dissecting aneurysms (DAs) of the vertebrobasilar territory manifesting with subarachnoid hemorrhage (SAH) are associated with significant morbi-mortality, especially in the case of re-hemorrhage. Sufficient reconstruction of the affected vessel is paramount, in particular, if a dominant vertebral artery (VA) is impacted. Reconstructive options include stent-assisted coiling and flow diversion (FD). The latter is technically less challenging and does not require catheterization of the fragile aneurysm. Our study aims to report a multicentric experience with FD for reconstruction of DA in acute SAH. Materials and Methods: This retrospective study investigated 31 patients (age: 30–78 years, mean 55.5 years) who had suffered from SAH due to a DA of the dominant VA. The patients were treated between 2010 and 2020 in one of the following German neurovascular centers: University Hospital Leipzig, Katharinenhospital Stuttgart, BG Hospital Bergmannstrost Halle/Saale, and Heinrich-Braun-Klinikum Zwickau. Clinical history, imaging, implanted devices, and outcomes were reviewed for the study. Results: Reconstruction with flow-diverting stents was performed in all cases. The p64 was implanted in 14 patients; one of them required an additional balloon-expandable stent to reconstruct severe stenosis in the target segment. One case demanded additional liquid embolization after procedural rupture, and in one case, p64 was combined with a PED. Further 13 patients were treated exclusively with the PED. The p48MW-HPC was used in two patients, one in combination with two additional Silk Vista Baby (SVB). Moreover, one patient was treated with a single SVB, one with a SILK+. Six patients died [Glasgow Outcome Scale (GOS) 1]. Causes of death were periprocedural re-hemorrhage, thrombotic occlusion of the main pulmonary artery, and delayed parenchymal hemorrhage. The remaining three patients died in the acute–subacute phase related to the severity of the initial hemorrhage and associated comorbidities. One patient became apallic (GOS 2), whereas two patients had severe disability (GOS 3) and four had moderate disability (GOS 4). Eighteen patients showed a complete recovery (GOS 5). Conclusion: Reconstruction of VA-DA in acute SAH with flow-diverting stents is a promising approach. However, the severity of the condition is reflected by high overall morbi-mortality, even despite technically successful endovascular treatment.
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Affiliation(s)
- Jens Maybaum
- Institute of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Katharinenhospital Stuttgart, Stuttgart, Germany
| | | | - Victoria Hellstern
- Neuroradiological Clinic, Katharinenhospital Stuttgart, Stuttgart, Germany
| | | | - Wolfgang Härtig
- Paul Flechsig Institute for Brain Research, University of Leipzig, Leipzig, Germany
| | - André Reisberg
- Department of Diagnostic Imaging and Interventional Radiology, Bergbau-Berufsgenossenschaft Hospital Bergmannstrost Halle, Halle, Germany
| | - Dirk Mucha
- Department of Radiology, Interventional Radiology and Neuroradiology, Heinrich-Braun-Klinikum, Zwickau, Germany
| | | | - Richard Brill
- Department of Neuroradiology, Radiology and Policlinic of Radiology, University Hospital Halle (Saale), Halle, Germany
| | - Ulf Quäschling
- Institute of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | | | - Stefan Schob
- Department of Neuroradiology, Radiology and Policlinic of Radiology, University Hospital Halle (Saale), Halle, Germany
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20
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Gopinathan A, Jain S, Lwin S, Teo K, Yang C, Nga V, Yeo TT. Flow Diversion in Acute Sub Arachnoid Haemorrhage: A Single Centre Five Year Experience. J Stroke Cerebrovasc Dis 2021; 30:105910. [PMID: 34119748 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The role of flow-diversion in acute sub-arachnoid haemorrhage (SAH) is controversial. Many of the published data warns of high rates of procedure-related complications and aneurysmal rebleed. This study evaluates the safety, efficacy, clinical and angiographic outcomes of acute flow-diversion at our institute. METHODS The institutional database from June 2015 to June 2020 was retrospectively reviewed for aneurysmal SAH (aSAH) treated with flow diversion. Clinical presentation, procedural details, complications, anti-platelet usage, rebleeding and aneurysm occlusion rates and outcomes were recorded. RESULTS 22 (59% females; median age 56 years) consecutive patients were identified. None of them were on regular antiplatelets/anticoagulation in the 15-days preceding the treatment. The mean aneurysm diameter was 5.4 mm and the median delay to flow-diversion was 2 days. Almost 73% (16/22) of patients had adjunctive coiling in the same session. There was no aneurysmal rebleed at a median follow up of 8.5 months and 86.3% (19/22 patients) had good clinical outcomes (3-month MRS 0-2). Adverse events related to the flow diversion procedure were seen in 3 patients; none of them had a medium to long-term clinical consequence. Three patients died from complications of SAH, unrelated to the procedure. Vascular imaging follow-up was available for 20 patients and the complete aneurysm occlusion rate was 95%. CONCLUSION Flow-diversion could be a reasonably safe and effective technique for treating ruptured aneurysms in appropriately selected patients when conventional options of surgical clipping and coiling are considered challenging.
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Affiliation(s)
- Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore.
| | - Swati Jain
- Division of Neurosurgery, University Surgical Cluster, National University Health System, Singapore.
| | - Sein Lwin
- Division of Neurosurgery, University Surgical Cluster, National University Health System, Singapore.
| | - Kejia Teo
- Division of Neurosurgery, University Surgical Cluster, National University Health System, Singapore.
| | - Cunli Yang
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore.
| | - Vincent Nga
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore.
| | - Tseng Tsai Yeo
- Division of Neurosurgery, University Surgical Cluster, National University Health System, Singapore.
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21
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Korai M, Kanematsu Y, Yamaguchi I, Yamaguchi T, Yamamoto Y, Yamamoto N, Miyamoto T, Shimada K, Satomi J, Hanaoka M, Matsuzaki K, Satoh K, Takagi Y. Subarachnoid Hemorrhage Due to Rupture of Vertebral Artery Dissecting Aneurysms: Treatments, Outcomes, and Prognostic Factors. World Neurosurg 2021; 152:e86-e93. [PMID: 34051365 DOI: 10.1016/j.wneu.2021.05.018] [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: 01/30/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Mortality rate after subarachnoid hemorrhage due to rupture of vertebral artery dissecting aneurysms (VADAs) is high; endovascular coil trapping is the first-line therapy to prevent rerupture. To select optimal treatments, the positional relationship between the VADA and posterior inferior cerebellar artery (PICA) and the morphology of the contralateral vertebral artery must be considered, and outcome predictors of different treatment methods and their possible complications must be identified. METHODS We retrospectively studied 44 patients with ruptured VADAs who had undergone endovascular or surgical treatment. VADA morphology was assessed on conventional preoperative angiograms, and VADAs were categorized based on their site in relation to the PICA. VADA site, treatment method, and complications were used to identify prognostic factors. RESULTS The sites of the 44 VADAs were PICA-proximal (n = 3), PICA-distal (n = 22), PICA-absent (n = 7), and PICA-involved (n = 12). Treatments included internal coil trapping (n = 30), proximal coil occlusion (n = 5), and stent placement (n = 3); surgical flow alteration via an occipital artery-PICA bypass and ligation at the proximal vertebral artery and the PICA origin was performed in 6 patients. Periprocedural rebleeding was associated with a poor outcome. Internal coil trapping prevented the rerupture of PICA-proximal and PICA-absent VADAs, and flow alteration prevented rerupture of PICA-involved VADAs; there were no complications directly attributable to these procedures. CONCLUSIONS Periprocedural rebleeding was a poor prognostic factor. Internal trapping of PICA-proximal and PICA-absent VADAs and flow alteration in PICA-involved VADAs prevented rerupture.
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Affiliation(s)
- Masaaki Korai
- Department of Neurosurgery, Tokushima University, Tokushima, Japan.
| | | | - Izumi Yamaguchi
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Tadashi Yamaguchi
- Department of Neurosurgery, Tokushima Red Cross Hospital, Tokushima, Japan
| | - Yuki Yamamoto
- Department of Neurology, Tokushima University, Tokushima, Japan
| | | | - Takeshi Miyamoto
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Kenji Shimada
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Junichiro Satomi
- Department of Neurosurgery, Kitajima Taoka Hospital, Tokushima, Japan
| | - Mami Hanaoka
- Department of Neurosurgery, Tokushima Red Cross Hospital, Tokushima, Japan
| | - Kazuhito Matsuzaki
- Department of Neurosurgery, Tokushima Red Cross Hospital, Tokushima, Japan
| | - Koichi Satoh
- Department of Neurosurgery, Tokushima Red Cross Hospital, Tokushima, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
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Catapano JS, Ducruet AF, Cadigan MS, Farhadi DS, Majmundar N, Nguyen CL, Baranoski JF, Cole TS, Wilkinson DA, Fredrickson VL, Srinivasan VM, Albuquerque FC. Endovascular treatment of vertebral artery dissecting aneurysms : a 20-year institutional experience. J Neurointerv Surg 2021; 14:257-261. [PMID: 33906940 DOI: 10.1136/neurintsurg-2020-017089] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 04/09/2021] [Accepted: 04/16/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The ideal treatment for unruptured vertebral artery dissecting aneurysms (VADAs) and ruptured dominant VADAs remains controversial. We report our experience in the management and endovascular treatment of patients with VADAs. METHODS Patients treated endovascularly for intradural VADAs at a single institution from January 1, 1999, to December 31, 2019, were retrospectively reviewed. Primary neurological outcomes were assessed using modified Rankin Scale (mRS) scores, with mRS >2 considered a poor neurological outcome. Additionally, any worsening (increase) in the mRS score from the preoperative neurological examination was considered a poor outcome. RESULTS Ninety-one patients of mean (SD) age 53 (11.6) years (48 (53%) men) underwent endovascular treatment for VADAs. Fifty-four patients (59%) presented with ruptured VADAs and 44 VADAs (48%) involved the dominant vertebral artery. Forty-seven patients (51%) were treated with vessel sacrifice of the parent artery, 29 (32%) with flow diversion devices (FDDs), and 15 (17%) with stent-assisted coil embolization (stent/coil). Rates of procedural complications and retreatment were significantly higher with stent/coil treatment (complications 4/15; retreatment 6/15) than with vessel sacrifice (complications 1/47; retreatment 2/47) or FDD (complications 2/29; retreatment 4/29) (p=0.008 and p=0.002, respectively). Of 37 patients with unruptured VADAs treated, only two (5%) had mRS scores >2 on follow-up. CONCLUSION Endovascular FDD treatment of VADAs appears to be associated with lower retreatment and complication rates than stenting/coiling, although further study is required for confirmation. Endovascular treatment of unruptured VADAs was safe and was associated with favorable angiographic and neurological outcomes.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Megan S Cadigan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dara S Farhadi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Neil Majmundar
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Candice L Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Vance L Fredrickson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Lobsien D, Clajus C, Behme D, Ernst M, Riedel CH, Abu-Fares O, Götz FG, Fiorella D, Klisch J. Aneurysm Treatment in Acute SAH with Hydrophilic-Coated Flow Diverters under Single-Antiplatelet Therapy: A 3-Center Experience. AJNR Am J Neuroradiol 2021; 42:508-515. [PMID: 33446495 DOI: 10.3174/ajnr.a6942] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/05/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE In certain clinical circumstances, dual-antiplatelet therapy can be problematic in patients with acute SAH. In some aneurysms, however, flow-diverting stents are the ideal therapeutic option. We report our experience with ruptured intracranial aneurysms treated with flow diverters with hydrophilic coating (p48 MW HPC and p64 MW HPC) under single-antiplatelet therapy. MATERIALS AND METHODS Patients were treated with either flow-diverter placement alone or a flow diverter and additional coiling. Due to the severity of the hemorrhage, the potential for periprocedural rehemorrhage, and the potential for additional surgical interventions, a single-antiplatelet regimen was used in all patients. RESULTS Thirteen aneurysms were treated in 10 patients. The median age was 62 years; 5 patients were male. All had acute SAH due to aneurysm rupture. Four blood-blister, 2 dissecting, and 7 berrylike aneurysms were treated. Seven aneurysms were adjunctively coiled. Eight of the 10 patients received a single-antiplatelet protocol of aspirin, 1 patient was treated with prasugrel only, and 1 patient was treated with tirofiban first and then switched to the aspirin single-antiplatelet protocol. One device-related complication occurred, a thrombosis of an overstented branch. All stents, however, remained open at DSA, CTA, or MRA follow-up. CONCLUSIONS The implantation of flow diverters with reduced thrombogenicity due to hydrophilic surface coating under single-antiplatelet therapy seems to be an option in carefully selected cases of SAH due to aneurysm rupture.
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Affiliation(s)
- D Lobsien
- From the Institute for Diagnostic and Interventional Neuroradiology (D.L., C.C., J.K.), Helios Klinikum Erfurt, Erfurt, Germany
| | - C Clajus
- From the Institute for Diagnostic and Interventional Neuroradiology (D.L., C.C., J.K.), Helios Klinikum Erfurt, Erfurt, Germany
| | - D Behme
- Institute for Diagnostic and Interventional Neuroradiology (D.B., M.E., C.H.R.), University Medical Center Göttingen, Göttingen, Germany
- Department for Neuroradiology (D.B.), University Hospital Magdeburg, Magedeburg, Germany
| | - M Ernst
- Institute for Diagnostic and Interventional Neuroradiology (D.B., M.E., C.H.R.), University Medical Center Göttingen, Göttingen, Germany
| | - C H Riedel
- Institute for Diagnostic and Interventional Neuroradiology (D.B., M.E., C.H.R.), University Medical Center Göttingen, Göttingen, Germany
| | - O Abu-Fares
- Institute for Diagnostic and Interventional Neuroradiology (O.A.-F., F.G.G.), Hanover Medical School, Hannover, Germany
| | - F G Götz
- Institute for Diagnostic and Interventional Neuroradiology (O.A.-F., F.G.G.), Hanover Medical School, Hannover, Germany
| | - D Fiorella
- Cerebrovascular Center (D.F.), Stony Brook Hospital, Stony Brook, New York
| | - J Klisch
- From the Institute for Diagnostic and Interventional Neuroradiology (D.L., C.C., J.K.), Helios Klinikum Erfurt, Erfurt, Germany
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Lam J, Ravina K, Rennert RC, Russin JJ. Cerebrovascular bypass for ruptured aneurysms: A case series. J Clin Neurosci 2021; 85:106-114. [PMID: 33581780 DOI: 10.1016/j.jocn.2020.12.029] [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: 08/24/2020] [Revised: 12/07/2020] [Accepted: 12/25/2020] [Indexed: 10/22/2022]
Abstract
In patients with aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for endovascular or traditional open surgical techniques, surgical revascularization strategies comprise one of remaining limited options. There is nonetheless a paucity of data on the safety and efficacy of bypass in aSAH. In this study, we aimed to investigate complications and outcomes in a cohort of patients with aSAH treated with bypass. A prospective single-surgeon database of consecutive patients treated for aSAH between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge were recorded and analyzed for the patients that underwent bypass surgery. Forty patients with aSAH were treated with bypass surgery (23 extracranial-intracranial; 17 intracranial-intracranial). All-cause perioperative mortality was 13% (6 patients). At discharge and at mean 14-month follow up, respectively, 16/40 (40%) and 16/25 (64%) of patients achieved a Glasgow Outcome Score of 4-5. All-cause, in-hospital complications occurred in 28 patients (70%), of which any ischemic complication occurred in 20 patients (50%), 7 (18%) being open surgical complications. This work represents the largest modern series of bypass for aSAH to date. In cases of aSAH unfavorable for endovascular intervention or traditional open surgical techniques, bypass remains a viable option in this complex group of patients.
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Affiliation(s)
- Jordan Lam
- Neurorestoration Centre, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, 1333 San Pablo Street, Room B51 McKibben Hall, Los Angeles, CA 90033, USA
| | - Kristine Ravina
- Neurorestoration Centre, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, 1333 San Pablo Street, Room B51 McKibben Hall, Los Angeles, CA 90033, USA
| | - Robert C Rennert
- Department of Neurological Surgery, University of California San Diego, San Diego, CA, USA
| | - Jonathan J Russin
- Neurorestoration Centre, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, 1333 San Pablo Street, Room B51 McKibben Hall, Los Angeles, CA 90033, USA.
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25
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Shindo K, Ogino T, Endo H, Fukuda M, Matsuda M, Yamashita D, Yamaguchi D, Yoshihara R, Morishita M, Tatsuta Y, Sakurai S, Kyono M, Goto D, Asanome T, Osato T, Nakamura H. Target Embolization of Dilated Post-PICA Segment for Ruptured PICA-Involved Type Vertebral Artery Dissecting Aneurysm. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:565-573. [PMID: 37501752 PMCID: PMC10370790 DOI: 10.5797/jnet.oa.2020-0157] [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: 08/11/2020] [Accepted: 11/27/2020] [Indexed: 07/29/2023]
Abstract
Objective In parent artery occlusion (PAO) for ruptured vertebral artery dissecting aneurysms (RVADA), target embolization using coils in a short segment to occlude only the vasodilated area containing the rupture point is selected as a first-choice procedure at our institute. We focused on RVADA involving the posterior inferior cerebellar artery (PICA) and evaluated the treatment results. Methods This study consisted of eight cases with RVADA involving the PICA which were treated between October 2007 and January 2020. Based on radiological findings such as the bleb, the rupture points were located at the affected vertebral artery (VA) distal to PICA in all cases. Target embolization, by which only coiling at the dilated segment distal to the VA was performed. We aimed to preserve blood flow to the PICA. The incidence and extent of medullary infarctions, and neurological outcome were retrospectively assessed. Results Regarding the diameter of bilateral VA, there were no differences in six cases while the affected VA with RVADA were larger in the remaining two cases. PICA was preserved in all cases but one in which occlusion of complementary PICA was observed. Postoperative medullary infarction was not noted. There was no rebleeding during the follow-up period. However, recanalization of the VA was observed in four cases and additional coil embolization was performed. All patients were discharged with a good outcome (modified Rankin Scale [mRS] 0; seven patients, mRS 2; one patient). Conclusion Target embolization preserving the PICA in PICA-involved type RVADA was considered to be an effective treatment method for cases whose rupture point was located in the VA distal to PICA orifice.
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Affiliation(s)
- Koichiro Shindo
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Tatsuya Ogino
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Hideki Endo
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Department of Neurosurgery, Nakamura Memorial South Hospital, Sapporo, Hokkaido, Japan
| | - Mamoru Fukuda
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Megumi Matsuda
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Daisuke Yamashita
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Daishi Yamaguchi
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Ryunosuke Yoshihara
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Masahiro Morishita
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Yasuyuki Tatsuta
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Suguru Sakurai
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Masanori Kyono
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Daigo Goto
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Taku Asanome
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Toshiaki Osato
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Hirohiko Nakamura
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
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Chung J, Cheol Lim Y, Sam Shin Y. Endovascular Treatment of Intracranial Vertebral Artery Dissection. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:265-280. [PMID: 37501904 PMCID: PMC10370974 DOI: 10.5797/jnet.ra.2020-0150] [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: 07/22/2020] [Accepted: 08/23/2020] [Indexed: 07/29/2023]
Abstract
Intracranial vertebral artery dissection (VAD) is the most common arterial dissection in intracranial arteries. Some types of VAD can heal spontaneously after reconstitution of the vessel lumen with excellent prognosis, whereas others can progress to stroke that needs treatment. Recently, endovascular treatment (EVT) has emerged and is suggested as a treatment option for VADs due to perceived low rates of procedure-related morbidity with good efficacy. In the last decade, we have accumulated our strategies to treat those VADs. Here, we try to share our experiences about VADs, including indications and methods of treatment of VADs using EVT. We perform EVT for ruptured VADs presenting with SAH and some of unruptured VADs such as VAD with recurrent or progressive ischemia, dissecting aneurysm larger than 7 mm or with mass effect, early ugly change of VADs in shape and size during follow-up period, involving the basilar artery (BA) and bilateral VADs. We present how we have done in our real practice for the last decade for treating VADs by EVT rather than reviewing and organizing so-far-published literature. We tended to occlude the rupture point by vertebral artery (VA) occlusion in non-dominant VA or stent-assisted coiling in dominant VA for ruptured VADs. We tended to reconstruct original hemodynamics using various stents for unruptured VADs. To decide what to treat and how to treat are very complicated for VADs. However, we believe that EVT is the current mainstay for treating VADs. Each technique of EVT should be determined on a case-by-case basis at the discretion of endovascular neurosurgeons and/or interventional neuroradiologists according to presenting symptoms, hemodynamic status, including sufficiency of the collateral supply and anatomic features of the vertebrobasilar artery as well as the posterior inferior cerebellar artery, anterior spinal artery, and medullary perforators.
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Affiliation(s)
- Joonho Chung
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Cheol Lim
- Department of Neurosurgery, Ajou University College of Medicine and Hospital, Suwon, Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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27
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Chen CC, Chen CT, Huang YH, Hsieh PC, Wu YM, Yeap MC, Wang YC, Chang CH, Yi-Chou Wang A. Modified Balloon-in-Stent Technique for Circumferential Vertebral Artery Dissecting Aneurysm. World Neurosurg 2021; 147:e552-e558. [PMID: 33412323 DOI: 10.1016/j.wneu.2020.12.120] [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: 11/29/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Treatment for circumferential vertebral artery dissecting aneurysms (VADAs) remains challenging. Stent-assisted coil embolization is the most common treatment technique. However, this approach presents high rates of incomplete occlusion and recurrence, often requiring the addition of second or third stents for reconstruction. A flow diverter may achieve favorable clinical outcomes, but it cannot result in immediate aneurysm occlusion and is limited by strict antiplatelets and expensive price. We report excellent results of a 1-stage modified balloon-in-stent technique for circumferential VADA. METHODS A total of 12 patients were treated with the modified balloon-in-stent technique for VADAs. A homogeneous coil was used to fill the aneurysm sac, followed by deployment of 1 self-expandable stent and in-stent Scepter balloon angioplasty. Clinical presentations, outcomes, and imaging results were evaluated over at least 2 years of follow-up. RESULTS Our 12 patients were examined during a mean follow-up period of 36.2 months (range, 2-5 years). The initial symptoms presented included subarachnoid hemorrhage (5 of 12; 41.7%), ischemia (3 of 12; 25.0%), and nonischemia (4 of 12; 33.3%). The modified BIS technique and coil embolization were successful in all patients. No technique-related complications or recanalization occurred during follow-up. CONCLUSIONS We demonstrated an innovative modified BIS technique to treat circumferential VADA by using a coiling basket followed by the deployment of a self-expandable stent and in-stent Scepter balloon angioplasty. This strategy is safe, feasible, and cost effective and was not associated with recurrence or complications over at least 2 years of follow-up.
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Affiliation(s)
- Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taipei City, Taiwan; New Taipei Municipal Tu-Cheng Hospital, New Taipei City, Taiwan.
| | - Chun-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taipei City, Taiwan
| | - Yu-Hsuan Huang
- Department of Ophthalmology, National Taiwan University Hospital, Taipei City, Taiwan
| | - Po-Chuan Hsieh
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taipei City, Taiwan; New Taipei Municipal Tu-Cheng Hospital, New Taipei City, Taiwan
| | - Yi-Ming Wu
- Department of Radiology, Division of Neuroradiology, Linkou Chang Gung Memorial Hospital & Chang Gung University, Taoyuan City, Taiwan
| | - Mun-Chun Yeap
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taipei City, Taiwan
| | - Yu-Chi Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taipei City, Taiwan; New Taipei Municipal Tu-Cheng Hospital, New Taipei City, Taiwan
| | - Chien-Hung Chang
- Department of Neurology, Linkou Chang Gung Memorial Hospital & Chang Gung University, Taoyuan City, Taiwan
| | - Alvin Yi-Chou Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taipei City, Taiwan
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Maus V, Weber W, Berlis A, Maurer C, Fischer S. Initial Experience with Surpass Evolve Flow Diverter in the Treatment of Intracranial Aneurysms. Clin Neuroradiol 2020; 31:681-689. [DOI: 10.1007/s00062-020-00972-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/17/2020] [Indexed: 11/29/2022]
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29
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Kong X, Sun Z, Ling C, Xu L, Qian C, Yu J, Xu J. Endovascular treatment for ruptured vertebral dissecting aneurysms involving PICA: Reconstruction or deconstruction? Experience from 16 patients. Interv Neuroradiol 2020; 27:163-171. [PMID: 33115297 DOI: 10.1177/1591019920970030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Ruptured vertebral dissecting aneurysms (VDAs) with posterior inferior cerebellar artery (PICA) involved require an optimal method to isolate the dissection and prevent the symptomatic infraction. This study aims to present our experience with both parent artery occlusion (PAO) and stent-assisted coiling (SAC), and provide a favorable strategy to the management of ruptured VDAs with PICA involved. METHODS We retrospectively reviewed patients with subarachnoid hemorrhage in our database from March 2013 to December 2018, suffering from dissecting aneurysms of the intradural vertebral arteries and endovascularly treated. A total of 16 cases with PICA involved were included. Basic information, aneurysm characteristics, procedure related complications and outcomes of patients were analyzed. RESULTS 10 (62.5%) aneurysms were managed with PAO containing 3 proximal occlusion and 8 targeted-trapping preserved the PICA. 5 (31.3%) aneurysms were treated with SAC and one 6.3%) treated with vertebral artery to PICA stenting and trapping. Two (12.5%) patients died in the acute phase. Good clinical outcomes (modified Rankin Scale 0 to 3) were observed in 13(81.5%) cases in 30 days follow-up. PICA territory infraction was happened in one patient without any dysfunction. Favorable occlusion was observed in 9 of 12 (75%) which were free of further treatment. CONCLUSIONS For patients with good contralateral circulation, PAO could be a first line management for ruptured VDAs with PICA involved. Targeted-trapping with either reserved PICA or proximal occlusion with moderate coiling in aneurysm are promising modalities to prevent severe PICA infraction.
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Affiliation(s)
- Xiangjie Kong
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zeyu Sun
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chenhan Ling
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Liang Xu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Cong Qian
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jun Yu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jing Xu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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30
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Cimflova P, Özlük E, Korkmazer B, Ahmadov R, Akpek E, Kizilkilic O, Islak C, Kocer N. Long-term safety and efficacy of distal aneurysm treatment with flow diversion in the M2 segment of the middle cerebral artery and beyond. J Neurointerv Surg 2020; 13:631-636. [PMID: 33082291 DOI: 10.1136/neurintsurg-2020-016790] [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: 08/25/2020] [Revised: 10/01/2020] [Accepted: 10/04/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Indications for flow diversion stent (FDS) treatment are expanding. However, there is still a lack of evidence for the long-term outcome in distally located aneurysms in the M2 segment of the middle cerebral artery (MCA) and beyond. METHODS Consecutive subjects (from June 2013 to August 2020) with MCA aneurysms in the M2 segment or beyond treated with FDS were reviewed retrospectively. The primary endpoints for clinical safety were the absence of mortality, stroke event, re-rupture of the aneurysm, and worsening of clinical symptoms. The primary endpoint for treatment efficacy was complete/near-complete occlusion at follow-up after 12 months. RESULTS 23 patients were identified: 7 aneurysms were located in the M2 segment of the MCA, 4 in the M2-M3 bifurcation, 2 in M3, 3 in M3-4 branching, and 2 in M4; 5 aneurysms were located in M2 with extension into the M1-M2 bifurcation. 13 aneurysms were of fusiform morphology, 8 sacculofusiform, and 2 saccular. 16 aneurysms were of highly suspected dissecting etiology. The median diameter of the parent vessel was 2.1 mm proximally and 2 mm distally. The median time of the follow-up was 30 months (range 16 months to 6 years). Complete/near complete occlusion was observed in 14/20 patients (70%) and one stable remodeling (5%) was seen at 12 months. 22 patients (95.6%) had an excellent clinical outcome (mRS 0-1) at 6 months. Technical challenges associated with the deployment of FDS occurred in 8.7% of cases. Severe complications, intraparenchymal hemorrhage and re-rupture of the aneurysm occurred in 2 patients (8.7%). CONCLUSION Flow diversion of distally located aneurysms is technically feasible with low morbidity and mortality.
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Affiliation(s)
- Petra Cimflova
- Department of Medical Imaging, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University Brno, Brno, Czech Republic.,Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Enes Özlük
- Department of Radiology, Acibadem Atakent Hospital, Istanbul, Turkey
| | - Bora Korkmazer
- Department of Neuroradiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ramiz Ahmadov
- Department of Neurosurgery, Acibadem Atakent Hospital, Istanbul, Turkey
| | - Elif Akpek
- Department of Anaestesiology and Reanimation, Acibadem Universitesi Medical Faculty, Istanbul, Turkey
| | - Osman Kizilkilic
- Department of Neuroradiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Civan Islak
- Department of Neuroradiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Naci Kocer
- Department of Neuroradiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Kim DJ, Heo Y, Byun J, Park JC, Ahn JS, Lee DH, Kwun BD, Park W. Role of microsurgery for treatment of posterior circulation aneurysms in the endovascular era. J Cerebrovasc Endovasc Neurosurg 2020; 22:141-155. [PMID: 32971573 PMCID: PMC7522389 DOI: 10.7461/jcen.2020.22.3.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/04/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- Dong Jin Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Yeon Heo
- Department of Neurosurgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Joonho Byun
- Department of Neurosurgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Deok Hee Lee
- Department of Radiology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Byung Duk Kwun
- Department of Neurosurgery, Kyunghee University School of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
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Pomeraniec IJ, Mastorakos P, Raper D, Park MS. Rerupture Following Flow Diversion of a Dissecting Aneurysm of the Vertebral Artery: Case Report and Review of the Literature. World Neurosurg 2020; 143:171-179. [PMID: 32730963 DOI: 10.1016/j.wneu.2020.07.149] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dissecting aneurysms of the posterior cerebral circulation can wield significant treatment challenges with devastating clinical outcomes. Despite an expanded therapeutic armamentarium, these vascular lesions remain relatively difficult to diagnose and portend high associated morbidity and mortality. METHODS A ruptured, fusiform, dissecting aneurysm of the mid V4 segment of the right vertebral artery (VA) distal to the posterior inferior cerebellar artery origin resulted in a Hunt and Hess grade 5, Fisher scale score 4 subarachnoid hemorrhage. The lesion incorporated 360 degrees of the vessel wall and extended across an area measuring 11 mm in length and 6.8 mm in width at maximum dimension. The vascular lesion was treated with 2 overlapping Pipeline Embolization Devices. RESULTS Digital subtraction angiography demonstrated an origin of the right posterior inferior cerebellar artery mildly stenosed by the dissecting aneurysm. The left VA was markedly hypoplastic. After deployment of 2 overlapping Pipeline Embolization Devices, the aneurysm neck was well covered with appropriate positioning of the stent construct with good apposition to the vessel wall. There was contrast stasis within the aneurysm. The patient was managed with dual antiplatelet therapy. He demonstrated initial clinical and radiographic improvement. However, on the night of the second postprocedure day, the patient succumbed to rerupture of the aneurysm. CONCLUSIONS The literature posits that nonsaccular, fusiform, and dissecting aneurysms of the vertebrobasilar circulation can be occluded with consistency and success using flow diversion techniques. Endovascular treatment of a ruptured dissecting aneurysm of the VA is technically feasible and can be performed with or without parent artery occlusion. Outcomes following flow diversion of the posterior circulation may depend on the location of the dissection and viability of collateral circulation. In the present case, adequate coverage of the aneurysm did not portend a positive outcome.
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Affiliation(s)
- I Jonathan Pomeraniec
- Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Panagiotis Mastorakos
- Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Daniel Raper
- Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA; Department of Interventional Neuroradiology, University of Virginia Health Science Center, Charlottesville, Virginia, USA.
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Youssef PP, Dornbos Iii D, Peterson J, Sweid A, Zakeri A, Nimjee SM, Jabbour P, Arthur AS. Woven EndoBridge (WEB) device in the treatment of ruptured aneurysms. J Neurointerv Surg 2020; 13:443-446. [PMID: 32719167 DOI: 10.1136/neurintsurg-2020-016405] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Wide-necked bifurcation aneurysms (WNBAs) present unique challenges for endovascular treatment. The Woven EndoBridge (WEB) device is an intrasaccular braided device, recently approved by the FDA for treatment of WNBAs. While treatment of intracranial aneurysms with the WEB device has been shown to yield an adequate occlusion rate of 85% at 1 year, few data have been published for patients with ruptured aneurysms. OBJECTIVE To present a multi-institutional series depicting the safety and efficacy of using the WEB device as the primary treatment modality in ruptured intracranial aneurysms. METHODS A multi-institutional retrospective analysis was conducted, assessing patients presenting with aneurysmal subarachnoid hemorrhage treated with the WEB between January 2014 and April 2020. Baseline demographics, aneurysm characteristics, adverse events, and long-term outcomes (occlusion, re-treatment, functional status) were collected. A descriptive analysis was performed, and variables potentially associated with aneurysm recurrence or re-treatment were assessed. RESULTS Forty-eight patients were included. Anterior communicating artery aneurysms were the most common (35.4%) location for treatment, followed by middle cerebral artery (20.8%) and basilar apex (16.7%). Procedural success was noted in 95.8% of patients, and clinically significant periprocedural adverse events occurred in 12.5%. After a median follow-up of 5.5 months, 54.2% of patients had follow-up angiographic imaging. Complete occlusion was seen in 61.5% of cases with adequate occlusion in 92.3%. Re-treatment was required in only 4.2% of patients during the study period. Tobacco use was significantly higher in patients with aneurysm recurrence (88.9% vs 35.7%; p=0.012). No other characteristics were associated with recurrence/re-treatment. At 30 days, 81.1% were functionally independent (modified Rankin Scale score ≤2). CONCLUSION Treatment of acutely ruptured aneurysms with the WEB device demonstrates both safety and efficacy on par with rates of conventional treatment strategies.
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Affiliation(s)
- Patrick P Youssef
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA
| | - David Dornbos Iii
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Jeremy Peterson
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Amanda Zakeri
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Shahid M Nimjee
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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Sonobe S, Yoshida M, Niizuma K, Tominaga T. Ruptured Basilar Artery Dissection Diagnosed Using Magnetic Resonance Vessel Wall Imaging and Treated with Coil Embolization with Overlapping LVIS Stents: A Case Report. NMC Case Rep J 2020; 7:75-79. [PMID: 32322456 PMCID: PMC7162815 DOI: 10.2176/nmccrj.cr.2019-0141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/28/2019] [Indexed: 11/20/2022] Open
Abstract
The diagnosis and treatment of patients with ruptured basilar artery dissection (rBAD) are often difficult. We present a case of rBAD diagnosed with magnetic resonance vessel wall imaging (MR-VWI) and treated with coil embolization with overlapping low-profile visualized intraluminal support (LVIS) stents. The case is of a 49-year-old woman with subarachnoid hemorrhage. digital subtraction angiography (DSA) showed irregularity in an anterior wall of the middle portion of the basilar artery, indicating the presence of a false lumen. MR-VWI showed local enhancement in an arterial wall, which was consistent with the wall irregularity observed in DSA. Overlapping stents (two LVIS stents) was performed in the basilar artery and coils were placed in the false lumen. The false lumen was completely thrombosed, and anterograde blood flow of the basilar artery was preserved. Dual antiplatelet therapy was administered, and the patient underwent an uneventful postoperative course. DSA performed 6 months later showed a white-collar sign. MR-VWI has attracted attention as a useful modality for detecting a ruptured lesion in patients with subarachnoid hemorrhage. This is the first report, to the best of our knowledge, describing the practical use of MR-VWI for rBAD. MR-VWI is suggested to improve diagnostic accuracy for rBAD. There are no established treatments for rBAD; reconstructive endovascular treatments comprising stent placement and coil embolization of a false lumen are promising. The LVIS stent has a braided design and high metal coverage ratio and is considered to be reasonable for use in rBAD. Coil embolization of a false lumen with overlapping LVIS stents may be effective for rBAD.
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Affiliation(s)
- Shinya Sonobe
- Department of Neurosurgery, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Masahiro Yoshida
- Department of Neurosurgery, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Kan P, Sweid A, Srivatsan A, Jabbour P. Expanding Indications for Flow Diverters: Ruptured Aneurysms, Blister Aneurysms, and Dissecting Aneurysms. Neurosurgery 2019; 86:S96-S103. [DOI: 10.1093/neuros/nyz304] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/26/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
The safety and efficacy of flow diversion (FD) in the treatment of cerebral aneurysms have been reported by many studies. FD has enabled the treatment of complex aneurysms and aneurysms that were previously untreatable by conventional means. It has achieved high rates of obliteration with essentially no recanalization, and its indications have continued to expand, now including ruptured aneurysms, blister aneurysms, and dissecting aneurysms.
OBJECTIVE
To provide a review on the outcomes of studies covering the use of FD in the settings of ruptured, blister, and dissecting aneurysms. In addition, to discuss dual antiplatelet therapy (DAPT) used in preparation for FD deployment in these scenarios, including associated complications with DAPT use in the acute rupture setting.
METHODS
References for this topical review were identified by PubMed searches between January 2000 and January 2019. The search terms “aneurysm”, “flow diverter”, “stent”, “pipeline”, “ruptured”, “blister”, and “dissecting aneurysms” were used.
RESULTS
FD carries a higher complication rate in the acute rupture setting than for unruptured aneurysms. Patient selection is of paramount importance for achieving good functional and angiographic outcomes. DAPT still remains challenging, especially in ruptured aneurysms. Advancements in surface modification of flow diverters can reduce the risk of thromboembolism and perhaps lead to a safer antiplatelet regimen.
CONCLUSION
In summary, FD shows promise to be an effective treatment for ruptured, blister, and dissecting aneurysms.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Aditya Srivatsan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Imahori T, Shose H, Okamura Y, Kohmura E. Deploying 5 Overlapping Enterprise Stents and Coiling for Treating Hemorrhagic Vertebral Artery Dissecting Aneurysm. World Neurosurg 2019; 132:177-181. [PMID: 31505281 DOI: 10.1016/j.wneu.2019.08.226] [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: 08/01/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Reconstructive endovascular treatment is a method that can ameliorate vertebral artery dissecting aneurysm (VADA) and preserve the parent artery. Recently, 2 or 3 overlapping stents have been used to treat VADAs through the flow-diversion effect. However, little is known about the use of >3 overlapping stents for acute treatment of hemorrhagic VADA. CASE DESCRIPTION A 69-year-old woman was admitted to our institute with the sudden onset of a headache. Brain computed tomography revealed a subarachnoid hemorrhage. Cerebral angiography revealed a VADA in the right intracranial vertebral artery. The contralateral vertebral artery was hypoplastic; thus we performed a reconstructive endovascular procedure using multiple overlapping stents combined with coiling. We used 5 overlapping stents with the aim of preventing coil herniation, fixing the jailed microcatheter, and reinforcing flow diversion and achieved immediate occlusion of the aneurysmal component. Postoperative imaging showed no apparent infarction in the brainstem. Six months after the treatment, angiography revealed complete occlusion of the aneurysm. Therefore in this case, hemorrhagic VADA was successfully treated in the acute setting by 5 overlapping Enterprise stents and coiling, which also preserved the parent artery. CONCLUSIONS Reconstructive endovascular treatment using multiple overlapping stents and coiling may be a beneficial therapy for hemorrhagic VADA, especially when the contralateral vertebral artery is aplastic or hypoplastic. Using >3 overlapping stents may represent a promising, feasible technique for achieving immediate occlusion by increasing flow diversion.
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Affiliation(s)
- Taichiro Imahori
- Department of Neurosurgery, Toyooka Hospital, Kobe University Graduate School of Medicine, Toyooka, Hyogo, Japan.
| | - Hiroyasu Shose
- Department of Neurosurgery, Toyooka Hospital, Kobe University Graduate School of Medicine, Toyooka, Hyogo, Japan
| | - Yusuke Okamura
- Department of Neurosurgery, Toyooka Hospital, Kobe University Graduate School of Medicine, Toyooka, Hyogo, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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ten Brinck MFM, Jäger M, de Vries J, Grotenhuis JA, Aquarius R, Mørkve SH, Rautio R, Numminen J, Raj R, Wakhloo AK, Puri AS, Taschner CA, Boogaarts HD. Flow diversion treatment for acutely ruptured aneurysms. J Neurointerv Surg 2019; 12:283-288. [DOI: 10.1136/neurintsurg-2019-015077] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 08/04/2019] [Accepted: 08/07/2019] [Indexed: 11/04/2022]
Abstract
Background and purposeFlow diverters are sometimes used in the setting of acutely ruptured aneurysms. However, thromboembolic and hemorrhagic complications are feared and evidence regarding safety is limited. Therefore, in this multicenter study we evaluated complications, clinical, and angiographic outcomes of patients treated with a flow diverter for acutely ruptured aneurysms.MethodsWe conducted a retrospective observational study of 44 consecutive patients who underwent flow diverter treatment within 15 days after rupture of an intracranial aneurysm at six centers. The primary end point was good clinical outcome, defined as modified Rankin Scale score (mRS) 0–2. Secondary endpoints were procedure-related complications and complete aneurysm occlusion at follow-up.ResultsAt follow-up (median 3.4 months) 20 patients (45%) had a good clinical outcome. In 20 patients (45%), 25 procedure-related complications occurred. These resulted in permanent neurologic deficits in 12 patients (27%). In 5 patients (11%) aneurysm re-rupture occurred. Eight patients died resulting in an all-cause mortality rate of 18%. Procedure-related complications were associated with a poor clinical outcome (mRS 3–6; OR 5.1(95% CI 1.0 to 24.9), p=0.04). Large aneurysms were prone to re-rupture with rebleed rates of 60% (3/5) vs 5% (2/39) (p=0.01) for aneurysms with a size ≥20 mm and <20 mm, respectively. Follow-up angiography in 29 patients (median 9.7 months) showed complete aneurysm occlusion in 27 (93%).ConclusionFlow diverter treatment of ruptured intracranial aneurysms was associated with high rates of procedure-related complications including aneurysm re-ruptures. Complications were associated with poor clinical outcome. In patients with available angiographic follow-up, a high occlusion rate was observed.
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Kaschner MG, Kraus B, Petridis A, Turowski B. Endovascular treatment of intracranial 'blister' and dissecting aneurysms. Neuroradiol J 2019; 32:353-365. [PMID: 31271334 DOI: 10.1177/1971400919861406] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Blister and dissecting aneurysms may have a different pathological background but they are commonly defined by instability of the vessel wall and bear a high risk of fatal rupture and rerupture. Lack of aneurysm sack makes treatment challenging. PURPOSE The purpose of this study was to assess the safety and feasibility of endovascular treatment of intracranial blister and dissecting aneurysms. METHODS We retrospectively analysed all patients with ruptured and unruptured blister and dissecting aneurysms treated endovascularly between 2004-2018. Procedural details, complications, morbidity/mortality, clinical favourable outcome (modified Rankin Scale ≤2) and aneurysm occlusion rates were assessed. RESULTS Thirty-four patients with endovascular treatment of 35 aneurysms (26 dissecting aneurysms and 9 blister aneurysms) were included. Five aneurysms were treated by parent vessel occlusion, and 30 aneurysms were treated by vessel reconstruction using stent monotherapy (n = 9), stent-assisted coiling (n = 7), flow diverting stents (n = 13) and coiling + Onyx embolization (n = 1). No aneurysm rebleeding and no procedure-related major complications or deaths occurred. There were five deaths in consequence of initial subarachnoid haemorrhage. Complete occlusion (79.2%) was detected in 19/24 aneurysms available for angiographic follow-up, and aneurysm recurrence in 2/24 (8.3%). The modified Rankin Scale ≤2 rate at mean follow-up of 15.1 months was 64.7%. CONCLUSION Treatment of blister and dissecting aneurysms developed from coil embolization to flow diversion with multiple stents to the usage of flow diverting stents. Results using modern flow diverting stents encourage us to effectively treat this aneurysm entity endovascularly by vessel reconstruction. Therefore, we recommend preference of vessel reconstructive techniques to parent vessel occlusion.
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Affiliation(s)
- Marius G Kaschner
- 1 Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Bastian Kraus
- 1 Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Athanasios Petridis
- 2 Department of Neurosurgery, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Bernd Turowski
- 1 Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
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Liang F, Zhang Y, Yan P, Ma C, Liang S, Jiang C. Outcomes and Complications After the Use of the Pipeline Embolization Device in the Treatment of Intracranial Aneurysms of the Posterior Circulation: A Systematic Review and Meta-Analysis. World Neurosurg 2019; 127:e888-e895. [DOI: 10.1016/j.wneu.2019.03.291] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 11/24/2022]
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40
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Chua MMJ, Silveira L, Moore J, Pereira VM, Thomas AJ, Dmytriw AA. Flow diversion for treatment of intracranial aneurysms: Mechanism and implications. Ann Neurol 2019; 85:793-800. [PMID: 30973965 DOI: 10.1002/ana.25484] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 03/31/2019] [Accepted: 04/07/2019] [Indexed: 12/31/2022]
Abstract
Flow diverters are new generation stents that have recently garnered a large amount of interest for use in treatment of intracranial aneurysms. Flow diverters reduce blood flow into the aneurysm, with redirection along the path of the parent vessel. Flow stagnation into the aneurysm and neck coverage with subsequent endothelialization are the important synergistic mechanisms by which the therapy acts. Several studies have examined the mechanisms by which flow diverters subsequently lead to aneurysm occlusion. This review aims to provide a general overview of the flow diverters and their mechanism of action and potential implications. ANN NEUROL 2019;85:793-800.
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Affiliation(s)
| | | | - Justin Moore
- Boston University School of Medicine, Boston, MA.,Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vitor M Pereira
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adam A Dmytriw
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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Schob S, Becher A, Bhogal P, Richter C, Hartmann A, Köhlert K, Arlt F, Ziganshyna S, Hoffmann KT, Nestler U, Meixensberger J, Quäschling U. Segment Occlusion vs. Reconstruction-A Single Center Experience With Endovascular Strategies for Ruptured Vertebrobasilar Dissecting Aneurysms. Front Neurol 2019; 10:207. [PMID: 30918497 PMCID: PMC6424888 DOI: 10.3389/fneur.2019.00207] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 02/18/2019] [Indexed: 12/30/2022] Open
Abstract
Objective: Ruptured dissecting aneurysms of the intracranial vertebral arteries exhibit an extraordinarily high risk for morbidity and mortality and are prone to re-rupture. Therefore, early treatment is mandatory to induce stagnation of the critical dynamic mural process. Appropriate endovascular approaches are segment sacrifice and reconstruction, however, both carry specific risks and benefits. To date most studies discuss only one of these approaches and focus on one specific device or technique. Therefore, our study aimed to present our experiences with both techniques, providing a considered approach on when to perform endovascular reconstruction or sacrifice. Materials and Methods: We retrospectively reviewed patients with subarachnoid hemorrhage in our database, suffering from dissecting aneurysms of the intradural vertebral arteries and treated endovascularly in the acute setting. A total of 16 cases were included. Clinical history, radiologic findings and outcomes were analyzed. Results: In 7 patients a reconstructive approach was chosen with 4 of them receiving stent-assisted coiling as primary strategy. One of the 7 patients suffered early re-bleeding due to progression of the dissection and therefore treatment was augmented with implantation of 2 flow diverters. The remaining 2 patients were primarily treated with flow diverters in telescoping technique. In 9 patients a deconstructive approach was followed: 6 patients were treated with proximal coil-occlusion of the V4 segment, 3 patients received distal coiling of the V4 segment. Two patients died (GOS 1) in the subacute stage due to sequelae of recurrent episodes of raised intracranial pressure and parenchymal hemorrhage. Two patients kept severe disability (GOS 3), six patients had moderate disability (GOS 4) and seven patients showed full recovery (GOS 5). None of the patients suffered from a procedural or postprocedural ischemic stroke. Conclusions: In patients with good collateral vascularization, proximal, or distal partial segment sacrifice via with endovascular coil occlusion seems to yield the best risk-benefit ratio for treatment of ruptured dissecting V4 aneurysms, especially since no continued anticoagulation is required and possibly essential surgery remains feasible in this scenario. If possible, PICA occlusion should be avoided—although even proximal PICA occlusion can become necessary, when weighing against the risk of an otherwise untreated ruptured V4 dissecting aneurysm. Contrarily, if the dominant V4 segment is affected, the hemodynamic asymmetry prohibits occlusion and necessitates reconstruction of the respective segment. For this, implants with high metal coverage treating the entire affected segment appear to be the most promising approach.
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Affiliation(s)
- Stefan Schob
- Abteilung für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Anett Becher
- Abteilung für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, London, United Kingdom
| | - Cindy Richter
- Abteilung für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany.,Klinik für Neuroradiologie, Klinikum Stuttgart, Stuttgart, Germany
| | - Anna Hartmann
- Abteilung für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Katharina Köhlert
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Felix Arlt
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Svitlana Ziganshyna
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Karl-Titus Hoffmann
- Abteilung für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Ulf Nestler
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Jürgen Meixensberger
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Ulf Quäschling
- Abteilung für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
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Dossani RH, Patra DP, Kosty J, Jumah F, Kuybu O, Mohammed N, Waqas M, Riaz M, Cuellar H. Early Versus Delayed Flow Diversion for Ruptured Intracranial Aneurysms: A Meta-Analysis. World Neurosurg 2019; 126:41-52. [PMID: 30822578 DOI: 10.1016/j.wneu.2019.02.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/03/2019] [Accepted: 02/05/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The use and timing of flow diversion for aneurysmal subarachnoid hemorrhage is controversial. The objective of this study is to perform a meta-analysis and systematic review to compare overall complication rate between early versus delayed flow diversion for ruptured aneurysms. METHODS A literature search for all eligible articles was performed using PubMed, Cochrane, and Web of Science databases. The primary outcome was the overall complication rate (any complication in the perioperative period), and secondary outcomes were 1) hemorrhage and 2) stroke/death (all hemorrhagic/ischemic strokes and/or death). RESULTS Thirteen articles including 142 patients met inclusion criteria. Eighty-nine (62.7%) patients underwent early deployment of flow diverters (i.e., 2 days or less). The odds ratio for overall complication rate with early versus delayed flow diversion was 0.95 (95% confidence interval [CI] 0.36-2.49, P = 0.42). The odds ratio for the secondary outcome of hemorrhagic complication for early versus delayed flow diversion was 1.44 (95% CI 0.45-4.52, P = 0.87) and of stroke/death was 1.67 (95% CI 0.5-4.9, P = 0.69). The odds ratio of early versus delayed flow diversion for blister/dissecting/fusiform aneurysms was 0.82 (95% CI 0.29-2.30) and for saccular/giant aneurysms was 2.23 (95% CI 0.17-29.4). At last follow-up, 71.6% of patients had good performance status (modified Rankin Scale score 0-2), and the rate of angiographic aneurysm occlusion was 90.2%. CONCLUSIONS This meta-analysis did not show a difference in overall complication rate between early versus delayed flow diversion for ruptured aneurysms. Early flow diversion for ruptured blister/fusiform/dissecting aneurysms carries a lower risk of aneurysm rerupture and overall complications as compared with that for ruptured saccular/giant aneurysms.
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Affiliation(s)
- Rimal Hanif Dossani
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
| | - Devi P Patra
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Jennifer Kosty
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Fareed Jumah
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Okkes Kuybu
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Nasser Mohammed
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Muhammad Waqas
- Section of Neurosurgery, The Aga Khan University Hospital, Karachi, Pakistan
| | - Muhammad Riaz
- Section of Neurosurgery, The Aga Khan University Hospital, Karachi, Pakistan
| | - Hugo Cuellar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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Oğuz Ş, Dinc H. Treatment of posterior inferior cerebellar artery aneurysms using flow-diverter stents: A single-center experience. Interv Neuroradiol 2019; 25:407-413. [PMID: 30803331 DOI: 10.1177/1591019918824003] [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: 11/15/2022] Open
Abstract
INTRODUCTION The effectiveness and reliability of flow-diverter stents, which are commonly used in aneurysms of the anterior circulation, have been demonstrated previously. However, the use of these devices is associated with higher rates of perforator and branch ischemia following the treatment of aneurysms of the posterior circulation. METHODS This work involved a single-center; retrospective study reviewing eight patients who had aneurysms related to the posterior inferior cerebellar artery (PICA) and who were treated with flow-diverter stents from September 2013 to May 2017. RESULTS The mean aneurysm diameter was 7.6 mm (range, 5 to 11 mm). The types of aneurysm included five aneurysms that were saccular, two that were fusiform, and one that was dissecting. All saccular aneurysms in the neck involved the PICA origin, and one dissecting aneurysm was localized in the proximal part of the PICA. Procedural success was 100% (8/8), and there were no ischemic complications. One patient with subarachnoid hemorrhage died because of rebleeding (modified Rankin Scale (mRS), 6). Other than this patient all of the patients' mRS scores were zero at discharge and at the clinical follow-up period (mean, 2.5 years). All of the aneurysms were completely occluded according to the latest angiographic controls (mean follow-up period of 19.5 months). CONCLUSIONS Treatment of PICA aneurysms with flow-diverter stents showed positive results with a high rate of technical success and low complication and mortality rates. The use of flow-diverter stents in the treatment of PICA aneurysms should be considered a safe and effective endovascular treatment option.
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Affiliation(s)
- Şükrü Oğuz
- Department of Radiology, Karadeniz Technical University Medical Faculty, Trabzon, Turkey
| | - Hasan Dinc
- Department of Radiology, Karadeniz Technical University Medical Faculty, Trabzon, Turkey
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Hosogai M, Matsushige T, Shimonaga K, Kawasumi T, Kurisu K, Sakamoto S. Stent-Assisted Coil Embolization for Ruptured Intracranial Dissecting Aneurysms Involving Essential Vessels. World Neurosurg 2018; 119:e728-e733. [DOI: 10.1016/j.wneu.2018.07.254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/27/2018] [Accepted: 07/28/2018] [Indexed: 11/28/2022]
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Goertz L, Dorn F, Kraus B, Borggrefe J, Schlamann M, Forbrig R, Turowski B, Kabbasch C. Safety and efficacy of the Derivo Embolization Device for the treatment of ruptured intracranial aneurysms. J Neurointerv Surg 2018; 11:290-295. [DOI: 10.1136/neurintsurg-2018-014166] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 07/14/2018] [Accepted: 07/18/2018] [Indexed: 11/03/2022]
Abstract
BackgroundThe Derivo Embolization Device (DED) is a novel flow diverter with advanced X-ray visibility, potentially lower thrombogenicity, and an improved delivery system.ObjectiveTo evaluate the safety and efficacy of the DED for emergency treatment of ruptured intracranial aneurysms.MethodsBetween February 2016 and March 2018, 10 patients (median age 54.5 years, seven women) with 11 aneurysms were treated with the DED at three neurovascular centers. Procedural details, complications, morbidity, and aneurysm occlusion (O’Kelly-Marotta scale, OKM) were retrospectively reviewed.ResultsAmong 11 aneurysms treated, there were nine anterior circulation and two posterior circulation aneurysms. Aneurysm morphology was saccular in four cases, dissecting in three, blister-like in three, and fusiform in one. In each case, a single DED was implanted and deployment was technically successful without exception. Adjunctive coiling was performed in two aneurysms. We observed one in-stent thrombosis, presumably due to low response to clopidogrel 4 days after the procedure, which remained with a mild hemiparesis after aspiration thrombectomy. No further thromboembolic or hemorrhagic events occurred. Favorable outcome (modified Rankin scale score ≤2) at last follow-up was achieved in all patients. Among 10 aneurysms available for angiographic follow-up, complete aneurysm occlusion (OKM D) was obtained in nine cases (90.0%).ConclusionsIn this pilot study, endovascular treatment of ruptured intracranial aneurysms with the DED was feasible and not associated with any incidence of rebleeding. Larger series with longer follow-up are warranted to reach a definite conclusion about this device.
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Cagnazzo F, di Carlo DT, Cappucci M, Lefevre PH, Costalat V, Perrini P. Acutely Ruptured Intracranial Aneurysms Treated with Flow-Diverter Stents: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2018; 39:1669-1675. [PMID: 30049721 DOI: 10.3174/ajnr.a5730] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 05/25/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND The implantation of flow-diverter stents for the treatment of ruptured intracranial aneurysms required further investigation. PURPOSE Our aim was to analyze the outcomes after flow diversion of ruptured intracranial aneurysms. DATA SOURCES A systematic search of 3 databases was performed for studies published from 2006 to 2018. STUDY SELECTION According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies (from 2010 to 2018) reporting acutely ruptured intracranial aneurysms treated with flow diversion. DATA ANALYSIS Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, rebleeding, and factors influencing the studied outcomes. DATA SYNTHESIS We included 20 studies evaluating 223 patients with acutely ruptured intracranial aneurysms treated with flow-diverter stents. Immediate angiographic occlusion was obtained in 32% (29/86; 95% CI, 15.4%-48%; I2 = 79.6%) of aneurysms, whereas long-term complete/near-complete aneurysm occlusion was 88.9% (162/189; 95% CI, 84%-93.5%; I2 = 20.9%) (mean radiologic follow-up of 9.6 months). The treatment-related complication rate was 17.8% (42/223; 95% CI, 11%-24%; I2 = 52.6%). Complications were higher in the posterior circulation (16/72 = 27%; 95% CI, 14%-40%; I2 = 66% versus 18/149 = 11.7%; 95% CI, 7%-16%; I2 = 0%) (P = .004) and after treatment with multiple stents (14/52 = 26%; 95% CI, 14%-45%; I2 = 59%) compared with a single stent (20/141 = 10%; 95% CI, 5%-15%; I2 = 0%) (P = .004). Aneurysm rebleeding after treatment was 4% (5/223; 95% CI, 1.8%-7%; I2 = 0%) and was higher in the first 72 hours. LIMITATIONS Small and retrospective series. CONCLUSIONS Flow-diversion treatment of ruptured intracranial aneurysms yields a high rate of long-term angiographic occlusion with a relatively low rate of aneurysm rebleeding. However, treatment is associated with a complication rate of 18%. When coiling or microsurgical clipping are not feasible strategies, anterior circulation ruptured aneurysms can be effectively treated with a flow-diversion technique, minimizing the number of stents deployed. Given the 27% rate of complications, flow diversion for ruptured posterior circulation aneurysms should be considered only in selected cases not amenable to other treatments.
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Affiliation(s)
- F Cagnazzo
- From the Department of Neurosurgery (F.C., D.T.d.C., P.P.), University of Pisa, Pisa, Italy
| | - D T di Carlo
- From the Department of Neurosurgery (F.C., D.T.d.C., P.P.), University of Pisa, Pisa, Italy
| | - M Cappucci
- Radiology Department (M.C.), University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - P-H Lefevre
- Neuroradiology Department (P.-H.L., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalo-Universitaire de Montpellier, Montpellier, France
| | - V Costalat
- Neuroradiology Department (P.-H.L., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalo-Universitaire de Montpellier, Montpellier, France
| | - P Perrini
- From the Department of Neurosurgery (F.C., D.T.d.C., P.P.), University of Pisa, Pisa, Italy
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Laukka D, Rautio R, Rahi M, Rinne J. Acute Treatment of Ruptured Fusiform Posterior Circulation Posterior Cerebral, Superior Cerebellar, and Posterior Inferior Cerebellar Artery Aneurysms With FRED Flow Diverter: Report of 5 Cases. Oper Neurosurg (Hagerstown) 2018; 16:549-556. [DOI: 10.1093/ons/opy194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/01/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Flow diverter (FD) treatment of ruptured fusiform posterior cerebral artery (PCA), posterior inferior cerebellar artery (PICA), and superior cerebellar artery (SCA) aneurysms are limited to single reports.
OBJECTIVE
To study the safety and efficacy of FD treatment for ruptured fusiform aneurysms of the PCA, SCA, and PICA.
METHODS
Five patients with ruptured posterior circulation fusiform aneurysms and treated with a Flow-Redirection Endoluminal Device (FRED/FRED Jr; Microvention, Tustin, California) stent in the acute phase of subarachnoid hemorrhage between 2013 and 2016 were included and reviewed retrospectively.
RESULTS
Two aneurysms located on the PICA, 2 on PCA, and 1 on the SCA. Mean treatment time with FD was 5.8 d (range, 0-11 d) from ictus. The technical success rate was 100%. On admission 2 patients were Hunt and Hess grade 1, 2 patients grade 3, and 1 patient grade 4. At discharge, 4 patients (80%) were independent (modified Ranking Scale (mRS) ≤2) and 1 patient had severe disability (mRS 4). None of the patients had aneurysmal rebleeding. All 5 aneurysms were completely occluded on angiographic follow-up (range, 3-22 mo). One patient had permanent intraprocedural in stent thrombosis and brain infarction. One patient had spontaneous nonaneurysmal intracerebral hemorrhage 1 mo after FD treatment. External ventricular drainage was inserted in 3 patients and ventriculoperitoneal shunt in 2 patients without hemorrhagic complications despite dual antiplatelet therapy.
CONCLUSION
FD could be considered as a treatment option for ruptured fusiform aneurysms located on PCA, PICA, or SCA when other treatment options are challenging.
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Affiliation(s)
- Dan Laukka
- Department of Neurosurgery, Turku University Hospital, University of Turku, Turku, Finland
| | - Riitta Rautio
- Department of Radiology and Interventional Radiology, Turku University Hospital, Turku, Finland
| | - Melissa Rahi
- Department of Neurosurgery, Turku University Hospital, University of Turku, Turku, Finland
| | - Jaakko Rinne
- Department of Neurosurgery, Turku University Hospital, University of Turku, Turku, Finland
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Cagnazzo F, Di Carlo DT, Petrella G, Perrini P. Ventriculostomy-related hemorrhage in patients on antiplatelet therapy for endovascular treatment of acutely ruptured intracranial aneurysms. A meta-analysis. Neurosurg Rev 2018; 43:397-406. [PMID: 29968172 DOI: 10.1007/s10143-018-0999-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 05/13/2018] [Accepted: 06/18/2018] [Indexed: 12/15/2022]
Abstract
The risk of ventriculostomy-related hemorrhage among patients requiring antiplatelet therapy (AT) for the endovascular treatment of acutely ruptured intracranial aneurysms needed further investigation. The authors performed a systematic review and meta-analysis of the literature examining the EVD-related hemorrhage rate among patients with and without AT (controls). According to PRISMA guidelines, a comprehensive review of studies published between January 1990 and April 2018 was carried out. The authors identified series with > 5 patients reporting the EVD-associated hemorrhage rate among the AT group and the control group. Variables influencing outcomes were analyzed using a random-effects meta-analysis model. We included 13 studies evaluating 516 (with AT) and 647 (without AT) patients requiring ventriculostomy. EVD-related hemorrhage rates were higher among the AT group (125/516 = 20.9%, 95% CI = 11.9-30%, I2 = 90% vs 57/647 = 9%, 95% CI = 5.5-12.5%, I2 = 45.8%) (p < 0.0001). Major EVD-associated hemorrhage rates were low in both the AT and control group (25/480 = 4.4%, 95% CI = 1.7-7.7%, I2 = 53.9% vs 6/647 = 0.7%, 95% CI = 0.03-1.7%, I2 = 0%) (p < 0.0001). Ventriculostomy before embolization and intraprocedural AT were associated with lower rates of EVD-related bleeding (32/230 = 9.6%, 95% CI = 2.1-17.1%, I2 = 75.4% vs 6/24 = 25.1%, 95% CI = 8.8-41%, I2 = 0%) (p < 0.02). The rate of major hemorrhage was higher after dual AT (CP + ASA) compared to single AT (ASA or CP) used as an intraprocedural loading dose (13/173 = 7%, 95% CI = 3.3-10.7%, I2 = 0% vs 6/210 = 1.7%, 95% CI = 0.1-3.4%, I2 = 0%) (p < 0.009). AT during endovascular treatment of acutely ruptured intracranial aneurysms increases the risk of EVD-related hemorrhages, although most of them are small and asymptomatic. When ventriculostomy is performed before endovascular procedures requiring antiplatelet administration, the hemorrhagic risk is minimized. A single antiplatelet therapy is associated with a lower rate of major bleeding than a dual therapy.
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Affiliation(s)
- Federico Cagnazzo
- Department of Neurosurgery, University of Pisa, Via Paradisa 2, 56100, Pisa, Italy.
| | | | | | - Paolo Perrini
- Department of Neurosurgery, University of Pisa, Via Paradisa 2, 56100, Pisa, Italy
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Ozaki T, Nishida T, Fujita Y, Kishima H, Kinoshita M. Coil and Single-Stent Placement for Ruptured Dissecting Aneurysm of Middle Cerebral Artery: A Case Report. World Neurosurg 2018; 113:208-211. [PMID: 29499426 DOI: 10.1016/j.wneu.2018.02.117] [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: 12/18/2017] [Revised: 02/18/2018] [Accepted: 02/19/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Ruptured dissecting aneurysms located at the middle cerebral artery (MCA) are rare, and their standard treatment has not been defined. Furthermore, lenticulostriate artery involvement in the dissecting segment makes treatment extremely difficult, and no previous reports have described successful treatment for such conditions. CASE DESCRIPTION We herein report the case of a 74-year-old woman who presented with sudden severe headache from subarachnoid hemorrhage due to dissection in the proximal M1 segment of left MCA involving lenticulostriate arteries. Digital subtraction angiography on day 6 showed that the dissecting aneurysm had enlarged despite strict blood pressure control. On day 8, the patient was treated successfully with a self-expanding closed cell stent and coil embolization, preserving blood flow in the lenticulostriate arteries as well as the MCA. CONCLUSIONS Follow-up digital subtraction angiography performed 5 weeks after endovascular therapy showed healing of the dissecting lesion, and the patient was discharged neurologically intact.
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Affiliation(s)
- Tomohiko Ozaki
- Department of Neurosurgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan.
| | - Takeo Nishida
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yuya Fujita
- Department of Neurosurgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Manabu Kinoshita
- Department of Neurosurgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
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Volker M, Anastasios M, Jan B, Nuran A, Thomas L, Franziska D, Pantelis S, De-Hua C, Christoph K. Treatment of Intracranial Aneurysms with the Pipeline Embolization Device Only: a Single Center Experience. Neurointervention 2018. [PMID: 29535896 PMCID: PMC5847888 DOI: 10.5469/neuroint.2018.13.1.32] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose The aim of this study was to evaluate the technical feasibility and rate of mid-term occlusion in aneurysms treated solely with the Pipeline Embolization Device (PED) in a German tertiary care university hospital. Materials and Methods Forty-nine non-consecutive intracranial aneurysms underwent endovascular treatment using the PED exclusively between March 2011 and May 2017 at our institution. Primary endpoint was a favorable aneurysm occlusion defined as OKM C1-3 and D (O'Kelly Marotta Scale). Secondary endpoints were retreatment rate and delayed complications. Median follow-up was 200 days. Results The mean aneurysm size was 7.1 ± 5.3 mm. Forty-four aneurysms were located in the anterior circulation (90%). Ten aneurysms were ruptured (20%). Branching vessels from the sac were observed in 11 aneurysms (22%). Favorable obliteration immediately after PED placement was seen in 13/49 aneurysms (27%), of those nine aneurysms were completely occluded (18%). Angiographic and clinical follow-up was available for 45 cases (92%); 36/45 aneurysms (80%) were occluded completely and 40/45 aneurysms (89%) showed a favorable occlusion result. A branching vessel arising from the aneurysm sac was associated with incomplete occlusion (P < .05). All electively treated patients had good outcome (mRS 0). Three aneurysms (6%) required additional treatment due to aneurysm recurrence. Conclusion In our series, treatment of intracranial aneurysms with the PED was associated with favorable occlusion rates and low complication rates at mid-term follow-up. The presence of branching vessels arising from the aneurysms sac was predictive for an incomplete occlusion.
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Affiliation(s)
- Maus Volker
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Mpotsaris Anastasios
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Borggrefe Jan
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Abdullayev Nuran
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Liebig Thomas
- Department of Neuroradiology, Charité, Berlin, Germany
| | - Dorn Franziska
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - Stavrinou Pantelis
- Department of Neurosurgery, University Hospital Cologne, Cologne, Germany
| | - Chang De-Hua
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Kabbasch Christoph
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
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