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Gaub M, Murtha G, Lafuente M, Webb M, Luo A, Birnbaum LA, Mascitelli JR, Al Saiegh F. Flow Diversion for Endovascular Treatment of Intracranial Aneurysms: Past, Present, and Future Directions. J Clin Med 2024; 13:4167. [PMID: 39064207 PMCID: PMC11278297 DOI: 10.3390/jcm13144167] [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: 06/01/2024] [Revised: 07/04/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Flow diversion for intracranial aneurysms emerged as an efficacious and durable treatment option over the last two decades. In a paradigm shift from intrasaccular aneurysm embolization to parent vessel remodeling as the mechanism of action, the proliferation of flow-diverting devices has enabled the treatment of many aneurysms previously considered untreatable. In this review, we review the history and development of flow diverters, highlight the pivotal clinical trials leading to their regulatory approval, review current devices including endoluminal and intrasaccular flow diverters, and discuss current and expanding indications for their use. Areas of clinical equipoise, including ruptured aneurysms and wide-neck bifurcation aneurysms, are summarized with a focus on flow diverters for these pathologies. Finally, we discuss future directions in flow diversion technology including bioresorbable flow diverters, transcriptomics and radiogenomics, and machine learning and artificial intelligence.
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Affiliation(s)
| | | | | | | | | | | | | | - Fadi Al Saiegh
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7843, San Antonio, TX 78229, USA; (M.G.); (G.M.); (M.L.); (M.W.); (A.L.); (L.A.B.); (J.R.M.)
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Kanazawa R, Uchida T, Higashida T, Watanabe S, Kono T. Some technical options for successful PulseRider procedures. Surg Neurol Int 2023; 14:403. [PMID: 38053696 PMCID: PMC10695450 DOI: 10.25259/sni_656_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/19/2023] [Indexed: 12/07/2023] Open
Abstract
Background Unlike other conventional neck bridge stents, when using the PulseRider (PR), it is not necessary to introduce a microcatheter for stent delivery into the daughter branches from the neck, and it has less intraluminal metal. However, in some cases, securely introducing both leaflets into daughter vessels may be difficult, leading to coil herniation. This study aimed to present some technical issues in PR deployment. Methods Fourteen PR procedures were performed in our institution between August 2021 and June 2023, and T-type PRs were used in all procedures. Four technical points during PR procedures are presented from our experience, as "technical options (Options 1-4)". All procedures were carried out with T-type PR implants. Results The PR was successfully placed in all interventions; however, in seven cases (50%), some technique trials were necessary because the leaflets did not unfold in the optimal directions. In Option 1, an introduction procedure with transposition of the daughter artery using a microcatheter is presented. In Option 2, the method for correction of the unfolded leaflet angle is demonstrated. In Option 3, another method for correction of the leaflets is shown. In Option 4, an effective method for neck protection during PR procedures is shown. Conclusion Various options should be considered to achieve appropriate apposition of PR leaflets. These technical options may be safe and effective for successful PR deployment.
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Santos-Franco JA, Cruz-Argüelles CA, Abrego-Salinas AA, Casas-Martínez MR, DeFont-Reaulx Rojas E. [Brain aneurysms treatment with pCONus2 device. Initial experience at IMSS]. REVISTA MEDICA DEL INSTITUTO MEXICANO DEL SEGURO SOCIAL 2023; 61:265-273. [PMID: 37216405 PMCID: PMC10437233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 09/08/2022] [Indexed: 05/24/2023]
Abstract
Background pCONus2 device has been used in some countries as coadyuvant in the treatment of wide-neck bifurcation aneurysms with coils. Objective To present the first series of brain aneurysms treated with pCONus2 in the Mexican Institute for Social Security (IMSS). Material and methods We retrospectively present the first 13 aneurysms treated from October 2019 to February 2022 with pCONus2 device at a third level hospital. Results 6 aneurysms located at anterior communicating artery, 3 at middle cerebral artery bifurcation, 2 at internal carotid artery bifurcatión, and 2 at the tip of basilar artery were treated. Device deployment was performed without complications and it was possible to embolize aneurysms with coils in 12 patients (92%), while on an internal carotid bifurcation aneurysm (8%) there was an incident of a pCONus2 petal migration toward vascular lumen caused by coils mesh pressure, situation that was solved by placing an nitinol self-expandable microstent. In 7 cases (54%) we performed coiling technique after microcatheter passage through pCONus2, while in 6 cases (46%) we used the jailing technique without complications. Conclusions pCONus2 is a useful device for wide-neck bifurcation aneurysms embolization. In Mexico our experience is yet limited; however, the first cases have been successful. Furthermore, we showed the first cases treated using jailing technique. Much more cases are required in order to carry out a statistically conclusive analysis and to establish the effectiveness and safety of the device.
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Affiliation(s)
- Jorge Arturo Santos-Franco
- Instituto Mexicano del Seguro Social, Centro Médico Nacional La Raza, Hospital de Especialidades “Dr. Antonio Fraga Mouret”, Departamento de Neurocirugía y Terapia Endovascular Neurológica. Ciudad de México, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Carlos Antonio Cruz-Argüelles
- Instituto Mexicano del Seguro Social, Centro Médico Nacional La Raza, Hospital de Especialidades “Dr. Antonio Fraga Mouret”, Departamento de Neurocirugía y Terapia Endovascular Neurológica. Ciudad de México, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Adrián Alejandro Abrego-Salinas
- Instituto Mexicano del Seguro Social, Centro Médico Nacional La Raza, Hospital de Especialidades “Dr. Antonio Fraga Mouret”, Departamento de Neurocirugía y Terapia Endovascular Neurológica. Ciudad de México, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Martín Roberto Casas-Martínez
- Instituto Mexicano del Seguro Social, Centro Médico Nacional La Raza, Hospital de Especialidades “Dr. Antonio Fraga Mouret”, Departamento de Neurocirugía y Terapia Endovascular Neurológica. Ciudad de México, MéxicoInstituto Mexicano del Seguro SocialMéxico
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Suzuki R, Takigawa T, Nagaishi M, Hyodo A, Suzuki K. Impact of size ratio on thromboembolic events based on diffusion-weighted imaging after coil embolization for unruptured basilar apex aneurysm. Clin Neurol Neurosurg 2023; 228:107699. [PMID: 37023486 DOI: 10.1016/j.clineuro.2023.107699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/24/2023] [Accepted: 03/25/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE Coil embolization is one of the main endovascular treatment for basilar apex aneurysms (BAAs), and thromboembolic events are important complications of coil embolization. Even in small aneurysms, there is a risk of rupture, and aggressive treatment should be considered for unruptured BAAs. Using diffusion-weighted imaging (DWI), the study aimed to investigate thromboembolic events after coil embolization for unruptured BAAs by focusing on the absolute aneurysm size and relative aneurysm size (size ratio [SR]). METHODS To evaluate the predictors of thromboembolic events, patients were divided into those with and without hyperintensity on DWI after coil embolization. Patient and radiographic characteristics were compared between the two groups. SR was defined as the maximum aneurysm diameter divided by the average parent artery diameter. RESULTS Fifty-six unruptured BAAs in 56 patients were investigated. The mean aneurysm size and SR were 7.61 ± 2.18 mm and 2.74 ± 1.45, respectively. Postprocedural hyperintensity on DWI was detected in 17 patients (30.4%). SR was significantly larger in the group with hyperintensity on DWI (3.75 ± 1.97 vs. 2.3 ± 0.82, P < 0.01) in the univariate analysis. Multivariate analysis revealed that SR> 3.0 was a significant predictor of thromboembolic events after coil embolization for unruptured BAAs (odds ratio: 12.15; 95% confidence interval: 2.95-49.98; P < 0.01). CONCLUSIONS This study showed that SR is a predictor of thromboembolic events after coil embolization for unruptured BAAs. Therefore, if even in small BAAs, if the BAAs dome height is large compared to the diameter of the posterior cerebral artery (e.g., there is a large SR), preoperative evaluation of the use of antiplatelet therapy is important, particularly to prevent thromboembolic events.
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Affiliation(s)
- Ryotaro Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya City, Saitama 343-8555, Japan.
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya City, Saitama 343-8555, Japan
| | - Masaya Nagaishi
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya City, Saitama 343-8555, Japan
| | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya City, Saitama 343-8555, Japan
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya City, Saitama 343-8555, Japan
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Kim MJ, Park KY, Kim YB, Chung J. Risk factors for recanalization of basilar tip aneurysm after endovascular treatment: a retrospective cohort study. Neurol Res 2023; 45:276-282. [PMID: 36208455 DOI: 10.1080/01616412.2022.2132459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2022]
Abstract
OBJECTIVES Endovascular treatment (EVT) of basilar tip aneurysms (BTAs) is arduous because of the lesions' angioarchitecture and the relatively high recanalization rate after EVT. In this study, we aimed to report the clinical characteristics of BTAs and evaluate the incidence of and risk factors for recanalization. METHODS One hundred twenty-five patients with BTAs (11 ruptured, 114 unruptured) treated with EVT between 2009 and 2019 at one institution were retrospectively reviewed. Among them, 113 patients were included in statistical analyses. The anatomical parameters of the aneurysms and clinical data were analyzed. Univariate (chi-square test and t-test) and multivariate (multiple logistic regression) analyses were performed to identify risk factors for recanalization. RESULTS Recanalization of the BTA occurred in 15 patients (13.3%). One patient (0.9%) was retreated endovascularly. The mean follow-up duration was 49.8 months. Neck size, posterior cerebral artery (PCA) angle, maximum diameter, and the rupture rate differed significantly between the recanalization and non-recanalization groups (P=.007, P<.001, P=.006, and P=.048, respectively). The maximum diameter (odds ratio, 1.483 per mm; 95% confidence interval, 1.145-1.919; P=.003) and PCA angle (odds ratio, 1.020 per degree; 95% confidence interval, 1.001-1.039; P=.036) were independently associated with recanalization. CONCLUSIONS Of all investigated BTAs, 96.8% were wide-neck aneurysms. The recanalization rate of BTAs after EVT was 13.3%. The PCA angle and maximal aneurysmal diameter were independently associated with recanalization; no associations were observed regarding vertebral artery dominance or modality of treatment. As such, BTA patients with wide PCA angles should be carefully monitored over time.
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Affiliation(s)
- Min Jeoung Kim
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Webb M, Riina H, Mascitelli J. Wide-Neck and Bifurcation Aneurysms. Neurosurg Clin N Am 2022; 33:359-369. [DOI: 10.1016/j.nec.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: 10/14/2022]
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Shimizu T, Naito I, Miyamoto N, Aihara M, Asakura K, Yoshimoto Y. Long-Term Durability and Recurrence Patterns After Endovascular Treatment for Basilar Tip Aneurysms. World Neurosurg 2022; 163:e482-e492. [PMID: 35398572 DOI: 10.1016/j.wneu.2022.04.015] [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: 03/01/2022] [Revised: 04/02/2022] [Accepted: 04/04/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Treating recurrence after coil embolization of basilar tip aneurysm remains challenging even with the development of endovascular procedures. The present study evaluated long-term durability and recurrence patterns after endovascular treatment of basilar tip aneurysms. METHODS Data of 116 consecutive patients treated with endovascular therapy at 3 regional hospitals from 2002-2019 were retrospectively analyzed. Aneurysms were ruptured in 51 cases and unruptured in 65 cases, with a mean maximal diameter of 7.8 mm (>15 mm in 14 patients) and a mean follow-up period of 5.8 ± 4.3 years. RESULTS Recurrence was observed in 24 of the 116 patients (21%), and 14 patients were retreated. The 5-year recurrence-free survival rate was 75.3%. Cox proportional hazards analysis found that recurrence correlated significantly with maximal aneurysm diameter >10 mm (P = 0.001; hazard ratio: 3.95, 95% confidence interval: 1.76-8.90) and incomplete occlusion (P = 0.003; hazard ratio: 4.43, 95% confidence interval: 1.63-12.00). Recurrence pattern was classified into 3 types: neck type (9 patients), regrowth type (10 patients), and regrowth type of initially thrombosed aneurysms (3 patients). Rerupture occurred in neck type with de novo aneurysm formation adjacent to the neck (n = 3) and regrowth type with dome filling (n = 4). CONCLUSIONS Recurrence after coil embolization for basilar tip aneurysms is associated with large aneurysms and incomplete occlusion at initial embolization. Understanding the patterns of recurrence is useful for predicting recurrence and selecting treatment strategies.
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Affiliation(s)
- Tatsuya Shimizu
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Isao Naito
- Department of Neurosurgery, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan
| | - Naoko Miyamoto
- Department of Neurosurgery, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan
| | - Masanori Aihara
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Ken Asakura
- Department of Neurosurgery, Japanese Red Cross Maebashi Hospital, Maebashi, Gunma, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Horizontal stent deployment via extracranial-intracranial bypass in coil embolization of basilar apex aneurysms: technical report. Acta Neurochir (Wien) 2022; 164:1281-1285. [PMID: 34817629 DOI: 10.1007/s00701-021-05070-0] [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: 09/09/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The endovascular treatment of large, wide-necked basilar apex aneurysms (BAAs) remains challenging. Although horizontal stent deployment across both P1 segments of the posterior cerebral arteries (PCAs) would be an optimal strategy in coil embolization of wide-necked BAAs, this is only feasible in cases with anatomically favorable access. In rare circumstances, large-diameter conduits of extracranial-intracranial (EC-IC) bypass can also provide a good access route for endovascular treatment of complex intracranial aneurysms. METHODS We describe the technique of accessing the PCA via EC-IC bypass grafts and deploying a stent horizontally across the neck of BAA and its coil embolization. We provide a detailed technical review and describe some pitfalls of the procedure. RESULTS Two patients underwent EC-IC bypass surgery prior to the treatment of a large, wide-necked BAA. The radial artery and saphenous vein were used as grafts, respectively. To facilitate coil embolization for a large BAA, a PCA-to-PCA horizontal stent was deployed via the bypass graft. Trans-cell and jailing techniques were used, respectively. Both aneurysms were completely occluded, and the patients were discharged without any neurological deficit. CONCLUSION Horizontal stent deployment via EC-IC bypass grafts can be performed safely, providing proper closure of the aneurysmal neck and apposition to both PCAs, facilitating complete coil embolization.
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Dang H, Cotton P, Lazaro T, Khan AB, Hoang AN, Tanweer O, Raper DMS. PulseRider-assisted embolization of a distal anterior cerebral artery bifurcation aneurysm: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE2216. [PMID: 36303500 PMCID: PMC9379709 DOI: 10.3171/case2216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/23/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND PulseRider is an endovascular device that can be a useful adjunctive device for wide-necked bifurcation aneurysms. However, its use in distal vessels such as the anterior cerebral artery (ACA) has not been widely reported. OBSERVATIONS The authors reported the case of a 75-year-old woman who underwent coiling of a 6.9-mm distal ACA aneurysm with PulseRider assistance. Using a partially intraaneurysmal deployment technique, the wide-necked aneurysm was successfully embolized, resulting in Raymond-Roy class II occlusion without intra- or periprocedural complications. LESSONS This case illustrates a novel approach to treatment for wide-necked distal ACA aneurysms, which can be challenging to treat via traditional endovascular means. PulseRider can be safely used to treat distal ACA aneurysms with minimal residual aneurysm.
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Affiliation(s)
- Huy Dang
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Patrick Cotton
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Tyler Lazaro
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - A. Basit Khan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Alex N. Hoang
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Results of the pToWin Study: Using the pCONUS Device for the Treatment of Wide-Neck Intracranial Aneurysms. J Clin Med 2022; 11:jcm11030884. [PMID: 35160333 PMCID: PMC8836830 DOI: 10.3390/jcm11030884] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 12/03/2022] Open
Abstract
Coil embolization has become a well-established option for the treatment of intracranial aneurysms. Yet, wide-neck bifurcation aneurysms (WNBAs) remain a challenge. The pCONUS is the first generation of a stent-like implant for the bridging of WNBAs to enable coiling. The pToWin study was a prospective, single-arm, multicenter study conducted to analyze the safety and efficacy of the pCONUS in the treatment of WNBAs. The primary effectiveness endpoint was the rate of adequate occlusion of the aneurysm at 3–6 and 7–12 months. The primary safety endpoint was the occurrence of major ipsilateral stroke or neurological death during the follow-up. A total of 115 patients were included. Aneurysm locations were the middle cerebral artery in 52 (45.2%), the anterior communicating artery in 35 (30.4%), the basilar artery in 23 (20%), the internal carotid artery terminus in three (2.6%), and the pericallosal artery in two (1.7%) patients. Treatment was successfully performed in all but one patient. The morbi-mortality rate was 1.9% and 2.3% at 3–6 and 7–12 months, respectively. Of the aneurysms, 75.0% and 65.6% showed adequate occlusion at 3–6 and 7–12 months, respectively. pCONUS offers a safe and reasonably effective treatment of WNBAs, demonstrated by acceptable adequate aneurysm occlusion and low rates of adverse neurologic events.
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Goto S, Izumi T, Nishihori M, Araki Y, Yokoyama K, Uda K, Saito R. Atypical Incomplete Detachment Following PulseRider Deployment. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 16:409-412. [PMID: 37502632 PMCID: PMC10370634 DOI: 10.5797/jnet.cr.2021-0095] [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: 10/12/2021] [Accepted: 11/22/2021] [Indexed: 07/29/2023]
Abstract
Objective Owing to the limited time since the introduction of the PulseRider (PR), inconsequential or rare complications that clinicians should be aware of remain unreported yet. Here, we report a rare complication of incomplete detachment. Case Presentation A 50-year-old male underwent PR-assisted coil embolization for a basilar tip aneurysm. Coiling was completed, and the detachment procedure was performed using a detachment machine; the success signal was observed. The delivery microcatheter was subsequently advanced back up to the proximal markers, and no reapproximation of the proximal markers, which indicates successful detachment, was observed. However, only one of the proximal markers returned to the microcatheter, and incomplete detachment of only one leg was detected. Ultimately, electrical detachment was not possible, and physical separation by tension was achieved. Conclusion Our case report presents a rare case of a detachment problem in the PR. The PR could not be detached, although the signal revealed successful detachment. Therefore, careful withdrawal of the delivery wire by checking not only the proximal markers but also the behavior of the entire PR and coil complex is important.
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Affiliation(s)
- Shunsaku Goto
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takashi Izumi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masahiro Nishihori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yoshio Araki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kinya Yokoyama
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kenji Uda
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Abbasi M, Savasatano LE, Brinjikji W, Kallmes KM, Mikoff N, Reierson N, Abdelmegeed M, Pederson J, Warren B, Touchette JC, Khan S, Kamrowski S, Barrett A, Kallmes DF, Kadirvel R. Endoluminal flow diverters in the treatment of sidewall and bifurcation aneurysm: A systematic review and meta-analysis of complications and angiographic outcomes. Interv Neuroradiol 2021; 28:229-239. [PMID: 34154429 DOI: 10.1177/15910199211026713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIM The use of endoluminal flow diversion in bifurcation aneurysms has been questioned due to the potential for complications and lower occlusion rates. In this study we assessed outcomes of endovascular treatment of intracranial sidewall and bifurcation aneurysms with flow diverters. METHODS In July 2020, a literature search for all studies utilizing endoluminal flow diverter treatment for sidewall or bifurcation aneurysms was performed. Data were collected from studies that met our inclusion/exclusion criteria by two independent reviewers and confirmed by a third reviewer. Using random-effects meta-analysis the target outcomes including overall complications (hematoma, ischemic events, minor ischemic stroke, aneurysm rupture, side vessel occlusion, stenosis, thrombosis, transient ischemic stroke, and other complications), perioperative complications, and follow-up (long-term) aneurysm occlusion were intestigated. RESULTS Overall, we included 35 studies with 1084 patients with 1208 aneurysms. Of these aneurysms, 654 (54.14%) and 554 (45.86%) were classified as sidewall and bifurcation aneurysm, respectively, based on aneurysm location. Sidewall aneurysms had a similar total complication rate (R) of 27.12% (95% CI, 16.56%-41.09%), compared with bifurcation aneurysms (R, 20.40%, 95% CI, 13.24%-30.08%) (p = 0.3527). Follow-up angiographic outcome showed comparable complete occlusion rates for sidewall aneurysms (R 69.49%; 95%CI, 62.41%-75.75%) and bifurcation aneurysms (R 73.99%; 95% CI, 65.05%-81.31%; p = 0.4328). CONCLUSIONS This meta-analysis of sidewall and bifurcation aneurysms treated with endoluminal flow diverters demonstrated no significant differences in complications or occlusion rates. These data provide new information that can be used as a benchmark for comparison with emerging devices for the treatment of bifurcation aneurysms.
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Affiliation(s)
- Mehdi Abbasi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Luis E Savasatano
- Department of Neurosurgery, 6915Mayo Clinic, Mayo Clinic, Rochester, MN, USA
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Larson AS, Mehta T, Grande AW. Neurosurgical management of aneurysms of the vertebrobasilar system: increasing indications for endovascular therapy with a continued role for open microneurosurgery. Neurosurg Rev 2021; 44:2469-2476. [PMID: 33409762 DOI: 10.1007/s10143-020-01460-7] [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: 07/31/2020] [Revised: 11/16/2020] [Accepted: 12/09/2020] [Indexed: 11/26/2022]
Abstract
Aneurysms of the vertebrobasilar system remain among the most challenging subsets of aneurysms to treat with an open surgical approach. Since Charles Drake's pioneering work in the 1960s, several advances in microsurgical techniques have improved outcomes and feasibility in the open surgical management of these aneurysms. In parallel, the field of endovascular neurosurgery has provided several safe and effective treatment options. Multiple trials have suggested that endovascular therapy for aneurysms of the vertebrobasilar system is superior to open surgical management in most cases. In some instances, however, open surgical management likely represents a more effective and durable option relative to endovascular therapy. Therefore, continued training of future cerebrovascular specialists in open surgery of vertebrobasilar aneurysms remains crucial. With widespread utilization of endovascular techniques, however, proper exposure of trainees to such aneurysms is growing increasingly difficult. In this review, we discuss the recent advances in the endovascular management of vertebrobasilar aneurysms while also emphasizing the continued importance of open microneurosurgery in such cases.
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Affiliation(s)
- Anthony S Larson
- Department of Neurosurgery, University of Minnesota Medical School, 420 Delaware St SE., Minneapolis, MN, 55455, USA.
| | - Tapan Mehta
- Department of Neurosurgery, University of Minnesota Medical School, 420 Delaware St SE., Minneapolis, MN, 55455, USA
- Department of Interventional Neuroradiology and Neurology, Ayer Neuroscience Institute, Hartford Healthcare, West Hartford, CT, USA
| | - Andrew W Grande
- Department of Neurosurgery, University of Minnesota Medical School, 420 Delaware St SE., Minneapolis, MN, 55455, USA
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Srinivasan VM, Srivatsan A, Spiotta AM, Hendricks BK, Ducruet AF, Albuquerque FC, Puri A, Amans MR, Hetts SW, Cooke DL, Ogilvy CS, Thomas AJ, Enriquez-Marulanda A, Rai A, Boo S, Carlson AP, Crowley RW, Rangel-Castilla L, Lanzino G, Chen PR, Diaz O, Bohnstedt BN, O'Connor KP, Burkhardt JK, Johnson JN, Chen SR, Kan P. Early postmarket results with PulseRider for treatment of wide-necked intracranial aneurysms: a multicenter experience. J Neurosurg 2020; 133:1756-1765. [PMID: 31703202 DOI: 10.3171/2019.5.jns19313] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 05/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traditionally, stent-assisted coiling and balloon remodeling have been the primary endovascular treatments for wide-necked intracranial aneurysms with complex morphologies. PulseRider is an aneurysm neck reconstruction device that provides parent vessel protection for aneurysm coiling. The objective of this study was to report early postmarket results with the PulseRider device. METHODS This study was a prospective registry of patients treated with PulseRider at 13 American neurointerventional centers following FDA approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and perioperative events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications. RESULTS A total of 54 aneurysms were treated, with the same number of PulseRider devices, across 13 centers. Fourteen cases were in off-label locations (7 anterior communicating artery, 6 middle cerebral artery, and 1 A1 segment anterior cerebral artery aneurysms). The average dome/neck ratio was 1.2. Technical success was achieved in 52 cases (96.2%). Major complications included the following: 3 procedure-related posterior cerebral artery strokes, a device-related intraoperative aneurysm rupture, and a delayed device thrombosis. Immediately postoperative Raymond-Roy occlusion classification (RROC) class 1 was achieved in 21 cases (40.3%), class 2 in 15 (28.8%), and class 3 in 16 cases (30.7%). Additional devices were used in 3 aneurysms. For those patients with 3- or 6-month angiographic follow-up (28 patients), 18 aneurysms (64.2%) were RROC class 1 and 8 (28.5%) were RROC class 2. CONCLUSIONS PulseRider is being used in both on- and off-label cases following FDA approval. The clinical and radiographic outcomes are comparable in real-world experience to the outcomes observed in earlier studies. Further experience is needed with the device to determine its role in the neurointerventionalist's armamentarium, especially with regard to its off-label use.
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Affiliation(s)
| | | | - Alejandro M Spiotta
- 2Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | | | - Andrew F Ducruet
- 3Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Ajit Puri
- 4Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Matthew R Amans
- 5Department of Radiology, University of California at San Francisco, San Francisco, California
| | - Steven W Hetts
- 5Department of Radiology, University of California at San Francisco, San Francisco, California
| | - Daniel L Cooke
- 5Department of Radiology, University of California at San Francisco, San Francisco, California
| | - Christopher S Ogilvy
- 6Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- 6Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Ansaar Rai
- 7Department of Radiology, West Virginia University Hospital, Morgantown, West Virginia
| | - SoHyun Boo
- 7Department of Radiology, West Virginia University Hospital, Morgantown, West Virginia
| | - Andrew P Carlson
- 8Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - R Webster Crowley
- 9Department of Neurosurgery, Rush Medical College, Chicago, Illinois
| | | | | | - Peng Roc Chen
- 11Department of Neurosurgery, University of Texas Health Science Center, Houston, Texas
| | - Orlando Diaz
- 12The Cerebrovascular Center, Houston Methodist Hospital, Houston, Texas; and
| | - Bradley N Bohnstedt
- 13Department of Neurosurgery, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Kyle P O'Connor
- 13Department of Neurosurgery, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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15
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Krupa K, Brzegowy P, Kucybała I, Łasocha B, Urbanik A, Popiela TJ. Endovascular embolization of wide-necked bifurcation aneurysms with the use of pCONus device: A systematic review and meta-analysis. Clin Imaging 2020; 70:81-88. [PMID: 33130244 DOI: 10.1016/j.clinimag.2020.10.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/24/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The following study aimed to summarize the overall safety and efficacy of the pCONus device in the treatment of wide-necked bifurcation aneurysms. MATERIAL AND METHODS Major electronic medical databases were thoroughly searched to identify relevant studies. Data regarding the type of included studies, type of aneurysm and its location, treatment results measured in Raymond-Roy Occlusion Class (RROC) and its complications, as well as patients' neurological outcome at the discharge were extracted from the eligible studies and included in the meta-analysis. The subgroup analyses dependent on the aneurysm rupture status were also conducted. RESULTS A total of 8 studies (198 patients with 200 aneurysms) were included in this meta-analysis. The most common localization of the treated aneurysms was the middle cerebral artery with its pooled prevalence estimate (PPE) of 44.5%. Immediately after the procedure, RROC I (complete obliteration of the aneurysm) was observed in 46.8%, RROC II in 32.9%, while RROC III (residual aneurysm) in 20.3% of the patients. In a short-term follow-up, PPE of RROC I was 55.0%, RROC II 29.0%, and RROC III 16.1%. The PPE of intraprocedural complications was 17.3%, the most frequent were thromboembolic events, which were observed in 12.1% of all procedures. Poor neurological outcome at the discharge was noted with PPE of 9.6%. CONCLUSIONS The effectiveness and safety of wide-necked bifurcation aneurysm treatment utilizing the pCONus device is moderate. There is still a need for a consensus regarding the effective antiplatelet regimen in furtherance of diminishing the rate of thromboembolic events.
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Affiliation(s)
- Kamil Krupa
- Department of Radiology, Jagiellonian University Medical College, 19 Kopernika Street, 31-501 Krakow, Poland; International Evidence-Based Anatomy Working Group (iEBA-WG), 12 Kopernika Street, 31-034 Krakow, Poland
| | - Paweł Brzegowy
- Department of Radiology, Jagiellonian University Medical College, 19 Kopernika Street, 31-501 Krakow, Poland
| | - Iwona Kucybała
- Department of Radiology, Jagiellonian University Medical College, 19 Kopernika Street, 31-501 Krakow, Poland.
| | - Bartłomiej Łasocha
- Department of Radiology, Jagiellonian University Medical College, 19 Kopernika Street, 31-501 Krakow, Poland
| | - Andrzej Urbanik
- Department of Radiology, Jagiellonian University Medical College, 19 Kopernika Street, 31-501 Krakow, Poland
| | - Tadeusz J Popiela
- Department of Radiology, Jagiellonian University Medical College, 19 Kopernika Street, 31-501 Krakow, Poland
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16
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Ozpeynirci Y, Hutschenreuter B, Forbrig R, Brückmann H, Liebig T, Dorn F. Endovascular treatment of basilar tip aneurysms in the era of endosaccular flow disruption: a comparative study. Neuroradiology 2020; 63:619-626. [PMID: 32968826 PMCID: PMC7966124 DOI: 10.1007/s00234-020-02555-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/09/2020] [Indexed: 11/26/2022]
Abstract
Purpose This study aims to compare endosaccular flow disruptor (EFD) for treatment of basilar tip aneurysm (BTA) with coiling in terms of safety and efficacy. Methods We retrospectively reviewed patients treated with an EFD for BTAs at our institution between 2013 and 2019 to standard coiling from the same period (control group). Patient demographics, aneurysm characteristics, procedural data, complications and clinical and angiographic outcome were compared between groups. Results Twenty-three (56%) patients were treated with an EFD and eighteen (44%) patients were treated with coiling. Average aneurysm size was 8 mm in the EFD group and 6.9 mm in the coiling group, respectively (P = 0.2). Average fluoroscopy time, treatment DAP and air kerma were 33 min, 76 Gycm2 and 1.7 Gy in the EFD group and 81 min, 152 Gycm2 and 3.8 Gy in the coiling group, respectively (P < 0.001). In the EFD group, clinically relevant thromboembolic complications occurred in one patient (4%) vs. in 5 patients (28%) in the coiling group (P = 0.07). In each group, 4 patients had an unfavourable outcome at discharge (P = 0.7). Adequate occlusion rates were 96% in the EFD group and 100% and coiling group. Six (26%) patients were prescribed long-term antiplatelet therapy in the EFD group vs. eleven (61%) patients in the coiling group (P = 0.02). Conclusion Both treatment concepts provided similar technical success and safety. However, procedure time, radiation exposure and a need for long-term antiaggregation were lower with EFD.
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Affiliation(s)
- Yigit Ozpeynirci
- Department of Neuroradiology, Ludwig Maximilian University, Munich, Germany.
| | | | - Robert Forbrig
- Department of Neuroradiology, Ludwig Maximilian University, Munich, Germany
| | - Hartmut Brückmann
- Department of Neuroradiology, Ludwig Maximilian University, Munich, Germany
| | - Thomas Liebig
- Department of Neuroradiology, Ludwig Maximilian University, Munich, Germany
| | - Franziska Dorn
- Department of Neuroradiology, Ludwig Maximilian University, Munich, Germany
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17
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Oushy S, Rinaldo L, Brinjikji W, Cloft H, Lanzino G. Recent advances in stent-assisted coiling of cerebral aneurysms. Expert Rev Med Devices 2020; 17:519-532. [PMID: 32500761 DOI: 10.1080/17434440.2020.1778463] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Stent-assisted coiling (SAC) of intracranial aneurysms paved the way for endovascular coiling of wide-neck and bifurcation aneurysms, improving rates of aneurysm obliteration and recurrence. In this review, we provide a comprehensive review of the most recent advances related to stent-assisted coiling of intracranial aneurysm. AREAS COVERED The authors have made an attempt to cover the inception, applications, and limitations of SAC of intracranial aneurysms. Special focus is given to 1) the current and recently introduced SAC techniques, 2) most recent advances in device technology, and 3) outcome data for the discussed techniques and devices. The authors also discuss the potential future direction of SAC. EXPERT OPINION technical refinements in the field of SAC should continue to focus on device development and addressing the limitations of SAC, namely aneurysm recurrence and need of antiplatelet agents. Although the recurrence rate of SAC has not been shown to be inferior to flow diverters, the use of intrasaccular and intravascular flow diverters are likely to expand in the future at the expense of SAC.
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Affiliation(s)
- Soliman Oushy
- Department of Neurosurgery, Mayo Clinic , Rochester, MN, USA
| | - Lorenzo Rinaldo
- Department of Neurosurgery, Mayo Clinic , Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic , Rochester, MN, USA.,Department of Radiology, Mayo Clinic , Rochester, MN, USA
| | - Harry Cloft
- Department of Neurosurgery, Mayo Clinic , Rochester, MN, USA.,Department of Radiology, Mayo Clinic , Rochester, MN, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic , Rochester, MN, USA.,Department of Radiology, Mayo Clinic , Rochester, MN, USA
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18
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Campos JK, Lien BV, Wang AS, Lin LM. Advances in endovascular aneurysm management: coiling and adjunctive devices. Stroke Vasc Neurol 2020; 5:14-21. [PMID: 32411403 PMCID: PMC7213502 DOI: 10.1136/svn-2019-000303] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/15/2020] [Accepted: 02/27/2020] [Indexed: 01/30/2023] Open
Abstract
Endovascular coil embolisation continues to evolve and remains a valid modality in managing ruptured and unruptured cerebral aneurysms. Technological advances in coil properties, adjunctive devices and interventional techniques continue to improve long-term aneurysm occlusion rates. This review elaborates on the latest advances in next-generation endovascular coils and adjunctive coiling techniques for treating cerebral aneurysms.
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Affiliation(s)
- Jessica K Campos
- Department of Neurological Surgery, University of California Irvine Medical Center, Orange, California, USA
| | - Brian V Lien
- Department of Neurological Surgery, University of California Irvine Medical Center, Orange, California, USA
| | - Alice S Wang
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, California, USA
| | - Li-Mei Lin
- Carondelet Neurological Institute, St. Joseph's Hospital, Carondelet Health Network, Tucson, AZ, United States
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19
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Iosif C. Neurovascular devices for the treatment of intracranial aneurysms: emerging and future technologies. Expert Rev Med Devices 2020; 17:173-188. [PMID: 32141395 DOI: 10.1080/17434440.2020.1733409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Despite numerous advances in the endovascular treatment of intracranial aneurysms (IAs), treatment in cases of wide-neck, complex configurations or branching locations remains challenging. Apart from the paradigm shift introduced by flow diverters, several other devices have seen the light or are under development in order to address these challenges.Areas covered: We performed a review of the novel implantable endovascular devices which have been introduced for the treatment of IAs, from 1 January 2014 to 1 September 2019, excluding classic flow diverter and intracranial stent designs.Expert opinion: Alternative designs have been proposed for the treatment of IAs at branching positions, which do not jail the side branches, with or without flow diversion effect, most of which with good initial outcomes. Endosaccular devices have also been proposed, some of which with lower initial total occlusion rates. Alternative materials such as biopolymers have also been proposed and are under bench research. Despite the challenges in the exploitation of some of the new devices, most of them seem to provide solutions to some current technical shortcomings. The exploitation of the biological phenomena and the physical properties of the devices will allow us to expand the therapeutic armamentarium for more complex IA cases.
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Affiliation(s)
- Christina Iosif
- School of Medicine, European University of Cyprus, Nicosia, Cyprus.,Department of Interventional Neuroradiology, Henry Dunant Hospital, Athens, Greece.,Department of Interventional Neuroradiology, Iaso Hospital, Athens, Greece
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20
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Akhunbay-Fudge CY, Deniz K, Tyagi AK, Patankar T. Endovascular treatment of wide-necked intracranial aneurysms using the novel Contour Neurovascular System: a single-center safety and feasibility study. J Neurointerv Surg 2020; 12:987-992. [PMID: 31974281 PMCID: PMC7509519 DOI: 10.1136/neurintsurg-2019-015628] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/23/2019] [Accepted: 01/04/2020] [Indexed: 11/05/2022]
Abstract
Background and purpose Wide-necked bifurcation aneurysms pose a significant challenge to the treating clinician. The Contour Neurovascular System embolization device is a novel tool for the treatment of such intracranial aneurysms. We report on our experience with this device. Methods Prospective clinical and radiological data were collected for all patients treated with the Contour device at our center. All our patients were treated on an elective basis. Results We have treated 11 patients successfully with the Contour device to date. All patients were women with a mean (SD) age of 65.0 (6.4) years. In total, four basilar tip, two internal carotid artery, three middle cerebral artery, one anterior communicating artery, and one superior cerebellar artery aneurysms were treated. At 1-year follow-up, complete occlusion (Raymond Class 1) was seen in 55.56% (5/9) of cases, with 44.44% (4/9) having small neck remnants (Raymond Class 2). One patient declined 1-year catheter angiography and another had no further follow-up due to an unrelated medical condition. For six patients, 2-year radiological follow-up is available and shows stability. At 6 weeks, nine of the 11 patients had a modifed Rankin Scale score of 0, with two patients scoring 1 for headaches. Two patients had thromboembolic events, but there were no complications leading to permanent neurological disability or death. We additionally had three patients where the Contour device was attempted but was unable to be successfully used. Conclusion Initial results are promising although larger case numbers and longer follow-up are necessary to draw further conclusions on the utility and risk profile of this new device.
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Affiliation(s)
- Christopher Yusuf Akhunbay-Fudge
- Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Interventional Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kenan Deniz
- Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Tufail Patankar
- Interventional Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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21
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Sakai N, Imamura H, Arimura K, Funatsu T, Beppu M, Suzuki K, Adachi H, Okuda T, Matsui Y, Kawabata S, Akiyama R, Horiuchi K, Tani S, Adachi H, Sakai C, Kaneko N, Tateshima S. PulseRider-Assisted Coil Embolization for Treatment of Intracranial Bifurcation Aneurysms: A Single-Center Case Series with 24-Month Follow-up. World Neurosurg 2019; 128:e461-e467. [PMID: 31042599 DOI: 10.1016/j.wneu.2019.04.177] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/19/2019] [Accepted: 04/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although endovascular coiling of unruptured aneurysms is widely accepted, the endovascular treatment of wide-neck bifurcation aneurysms remains one of the most challenging morphologies. Our purpose was to describe our experience with 24-month follow-up for the treatment of unruptured intracranial bifurcation aneurysms using the PulseRider (Cerenovus, New Brunswick, NJ). METHODS This study is a single-center, single-arm registry performed under institutional review board control to evaluate efficacy and safety of the PulseRider. Patients with bifurcation aneurysms were identified and enrolled prospectively. Angiography immediately after treatment and at 6 months, and magnetic resonance imaging and magnetic resonance angiography at 12- and 24-month follow-up were retrospectively analyzed. A modified Rankin score was obtained prior to procedure, at discharge, and at 6-, 12- and 24-month follow-up visits. RESULTS Eight patients with a mean age of 66 years were treated with the PulseRider. All patients had bifurcation aneurysms (2 anterior communicating, 2 carotid terminus, and 4 basilar apex). The aneurysm diameters ranged from 4.6 to 13.6 mm (mean 7.4 mm) with dome/neck ratio ranging from 1.4 to 2.2 (mean 1.6). In all cases, the PulseRider was successfully deployed. Complete occlusion was demonstrated at 6-month follow-up on 6 of 8 (75%), near complete occlusion in 1 of 8 (12.5%), and residual aneurysm in 1 of 8 (12.5%) patients. There was no change or recurrence on magnetic resonance angiography, nor clinical complication after the procedure through 24-month follow-up. CONCLUSIONS Our experience with 24-month follow-up demonstrated favorable efficacy in the treatment of intracranial wide-neck bifurcation aneurysms using the PulseRider.
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Affiliation(s)
- Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Koichi Arimura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takayuki Funatsu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Mikiya Beppu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Keita Suzuki
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hiromasa Adachi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tomohiro Okuda
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yuichi Matsui
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shuhei Kawabata
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ryo Akiyama
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kazufumi Horiuchi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shoichi Tani
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hidemitsu Adachi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Chiaki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Naoki Kaneko
- Division of Interventional Neuroradiology, Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
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22
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O'Connor KP, Strickland AE, Bohnstedt BN. PulseRider Use in Ruptured Basilar Apex Aneurysms. World Neurosurg 2019; 127:346-349. [PMID: 30980983 DOI: 10.1016/j.wneu.2019.04.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The PulseRider (Pulsar Vascular, Inc, Los Gatos, California, USA) device was developed to treat wide-neck aneurysms, and the Adjunctive Neurovascular Support of Wide-neck aneurysm Embolization and Reconstruction (ANSWER) Trial showed efficacy in the treatment of unruptured wide-neck aneurysms. Our case series demonstrates the use of the PulseRider device in the treatment of ruptured wide-neck aneurysms. CASE DESCRIPTION The 2 patients in our series presented with subarachnoid hemorrhage secondary to ruptured basilar apex aneurysms. The patients were taken to the neurointervention suite for embolization of their aneurysms with the PulseRider and platinum microcoils. CONCLUSIONS In both cases, a Roy Raymond class III embolization was achieved. The patients recovered from their subarachnoid hemorrhage and were discharged with resolution of their symptoms. The presented cases document the safety and efficacy of treating ruptured aneurysms with the PulseRider device.
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Affiliation(s)
- Kyle P O'Connor
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Allison E Strickland
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Bradley N Bohnstedt
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
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23
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Cagnazzo F, Limbucci N, Nappini S, Renieri L, Rosi A, Laiso A, Tiziano di Carlo D, Perrini P, Mangiafico S. Y-Stent-Assisted Coiling of Wide-Neck Bifurcation Intracranial Aneurysms: A Meta-Analysis. AJNR Am J Neuroradiol 2018; 40:122-128. [PMID: 30523146 DOI: 10.3174/ajnr.a5900] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 10/15/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Y-stent-assisted coiling for wide-neck intracranial aneurysms required further investigation. PURPOSE Our aim was to analyze outcomes after Y-stent placement in wide-neck aneurysms. DATA SOURCES We performed a systematic search of 3 data bases for studies published from 2000 to 2018. STUDY SELECTION According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting Y-stent-assisted coiling of wide-neck aneurysms. DATA ANALYSIS Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, and factors influencing the studied outcomes. DATA SYNTHESIS We included 27 studies and 750 aneurysms treated with Y-stent placement. The immediate complete/near-complete occlusion rate was 82.2% (352/468; 95% CI, 71.4%-93%; I2 = 92%), whereas the long-term complete/near-complete occlusion rate was 95.4% (564/598; 95% CI, 93.7%-97%; I2 = 0%) (mean radiologic follow-up of 14 months). The aneurysm recanalization rate was 3% (20/496; 95% CI, 1.5%-4.5%; I2 = 0%), and half of the recanalized aneurysms required retreatment. The treatment-related complication rate was 8.9% (63/614; 95% CI, 5.8%-12.1%; I2 = 44%). Morbidity and mortality after treatment were 2.4% (18/540; 95% CI, 1.2%-3.7%; I2 = 0%) and 1.1% (5/668; 95% CI, 0.3%-1.9%; I2 = 0%), respectively. Crossing Y-stent placement was associated with a slightly lower complication rate compared with the kissing configuration (56/572 = 8.4%; 95% CI, 5%-11%; I2 = 46% versus 4/30 = 12.7%; 95% CI, 3%-24%; I2 = 0%). Occlusion rates were quite comparable among Enterprise, Neuroform, and LVIS stents, whereas the Enterprise stent was associated with lower rates of complications (8/89 = 6.5%; 95% CI, 1.6%-11%; I2 = 0%) compared with the others (20/131 = 14%; 95% CI, 5%-26%; I2 = 69% and 9/64 = 11%; 95% CI, 3%-20%; I2 = 18%). LIMITATIONS This was a small, retrospective series. CONCLUSIONS Y-stent-assisted coiling yields high rates of long-term angiographic occlusion, with a relatively low rate of treatment-related complications. Y-stent placement with a crossing configuration appears to be associated with better outcomes. Although Y-configuration can be obtained using many types of stents with comparable occlusion rates, the Enterprise stent is associated with lower complication rates.
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Affiliation(s)
- F Cagnazzo
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| | - N Limbucci
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| | - S Nappini
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| | - L Renieri
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| | - A Rosi
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| | - A Laiso
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| | - D Tiziano di Carlo
- Department of Neurosurgery (D.T.d.C., P.P.), Cisanello Hospital, University of Pisa, Pisa, Italy
| | - P Perrini
- Department of Neurosurgery (D.T.d.C., P.P.), Cisanello Hospital, University of Pisa, Pisa, Italy
| | - S Mangiafico
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
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