PulseRider-Assisted Coil Embolization for Treatment of Intracranial Bifurcation Aneurysms: A Single-Center Case Series with 24-Month Follow-up

Some technical options for successful PulseRider procedures

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.

Six-month Outcomes after PulseRider- and Conventional Single Stent-assisted Embolization for Bifurcation Aneurysms: A Propensity-adjusted Comparison

Endovascular treatment of wide-necked bifurcation aneurysms (WNBAs) remains challenging despite using a stent. PulseRider is a novel device specifically designed to treat WNBAs, protecting both daughter branches, but the outcomes have not been compared with conventional single stent-assisted embolization. This study aimed to compare the six-month outcomes of PulseRider and single stent-assisted embolization for intracranial unruptured WNBAs using propensity score adjustment. Between February 2012 and October 2021, 46 unruptured WNBAs (34 basilar and 12 middle cerebral arteries) smaller than 10 mm in diameter were treated with PulseRider-assisted embolization (n = 17) or single stent-assisted embolization (n = 29). The immediate and six-month outcomes were compared using inverse probability of treatment weighting analysis. The immediate adequate occlusion rates for the PulseRider- and single stent-assisted embolization were similar (47.1% vs. 62.1%). At six months, adequate occlusion rates for the two groups were also similar (94.1% vs. 86.2%). However, the complete obliteration rate was significantly high after PulseRider-assisted embolization (88.2% vs. 41.4%, adjusted OR 10.54, 95% CI 1.93-57.63). The angiographical improvement rate was also significantly high after PulseRider-assisted embolization (70.6% vs. 37.9%, adjusted OR 6.06, 95% CI 1.54-23.76). The neurologic thromboembolic complication rate was 0% after PulseRider-assisted embolization and 3.4% after single stent-assisted embolization. PulseRider-assisted embolization of WNBAs smaller than 10 mm in diameter was associated with complete obliteration and angiographical improvement at six months. The unique shape of the PulseRider might contribute to the improved midterm aneurysm occlusion.

Usefulness of Y-shaped PulseRider-assisted coil embolization for basilar artery tip aneurysm with a misaligned axis: A case report

Background

Endovascular treatment of wide-necked bifurcation aneurysms remains challenging. Although the advent of PulseRider and Web has expanded treatment options, aneurysms with a large deviation from the parent artery axis remains difficult to treat. We present the case of a wide-necked bifurcation aneurysm that was misaligned with the angle between the long axis of the parent artery and the aneurysm and was successfully treated with Y-shaped PulseRider-assisted coil embolization.

Case Description

A 64-year-old woman presented with an unruptured basilar tip aneurysm. Cerebral angiography showed a wide-necked aneurysm measuring 8.1 mm × 6.1 mm, neck 5.7 mm. The aneurysm was strongly tilted to the right and posterior relative to the basilar artery, and the bilateral posterior cerebral artery (PCA) and superior cerebellar artery (SCA) diverged from the aneurysm body. PulseRider-assisted coil embolization was performed. A Y-shaped PulseRider was selected to be placed in a hybrid fashion with the right arch in the aneurysm and the left arch in the branch. Adequate coil embolization with preservation of the bilateral PCA and SCA was possible, and cerebral angiography immediately after the treatment showed slight dome filling. Cerebral angiography 6 months after the procedure showed that the embolic status had improved to complete occlusion.

Conclusion

For wide-neck bifurcation aneurysms with a misaligned axis, a Y-shaped PulseRider used in a hybrid fashion, in which the leaflet on the side with the tilted axis is placed in the aneurysm, allows the PulseRider to be deployed more closely to the aneurysm, thereby enabling good coil embolization.

PulseRider-assisted coil embolization for an unruptured internal carotid artery-persistent primitive trigeminal artery aneurysm

A persistent primitive trigeminal artery (PPTA) is a vessel remnant of carotid-vertebrobasilar anastomosis. The aneurysm at the bifurcation of the internal carotid artery (ICA) and PPTA tends to have a broad neck with the branch incorporated into the sac. Because PPTA supplies to the posterior circulation and branches off direct pontine perforators, PPTA preservation should always be considered when treating PPTA aneurysms to avoid ischemic complications.We report a case of the wide-neck ICA-PPTA aneurysm successfully treated with the PulseRider-assisted coil embolization, resulting in complete occlusion with PPTA patency. Relevant anatomy and endovascular strategy of the PPTA aneurysms are discussed.

Enterprise Treatment for Recurrent Basilar Tip Aneurysm after PulseRider-assisted Coil Embolization: A Case Report

PulseRider (Cerenovus, Irvine, CA, USA) is a relatively novel device used for the treatment of wide-neck aneurysms with a coil-assisted effect. However, treatment options for recurrent aneurysms after PulseRider-assisted coil embolization remain controversial. Here we report a case of recurrent basilar tip aneurysm (BTA) treated with Enterprise 2 after PulseRider-assisted coil embolization. A woman in her 70s underwent coil embolization for a subarachnoid hemorrhage with ruptured BTA 16 years ago. Recurrence was detected at 6-year follow-up, and an additional coil embolization was performed. Nevertheless, gradual recurrence still occurred, and PulseRider-assisted coil embolization was performed without any complications 9 years after the second treatment. However, recurrence was detected once more at 6-month follow-up. Thus, stent-assisted coil embolization using Enterprise 2 (Cerenovus) through PulseRider was selected for angular remodeling. Enterprise 2 was deployed between the right P2 segment of the posterior cerebral artery (PCA) and basilar artery (BA) after an effective coil embolization, which achieved effective angular remodeling between the right PCA and BA. The patient's postoperative course was uneventful, and no recanalization was detected after half a year. Although PulseRider is effective for wide-neck aneurysm treatment, recurrence remains a possibility. Additional treatment using Enterprise 2 is safe and effective with the expectation of angular remodeling.

Long-term outcomes of Y-stent-assisted coil embolization using Low-profile Visualized Intraluminal Support Junior (LVIS Jr) for intracranial bifurcation aneurysms

OBJECTIVE

Y-stent-assisted coil embolization is indicated for the treatment of complex intracranial bifurcation aneurysms. However, the long-term outcomes associated with this technique remain unclear. The purpose of this study was to evaluate the long-term outcomes of Y-stent-assisted coil embolization using the Low-profile Visualized Intraluminal Support Junior (LVIS Jr) device.

METHODS

We retrospectively reviewed our databases to identify patients treated with Y-stent-assisted coiling using LVIS Jr. Digital subtraction angiography, silent magnetic resonance angiography (MRA), and time-of-flight MRA were performed at 1 year after the procedure. Patients also received an annual follow-up using MRA. Aneurysm occlusion status was classified into complete occlusion (CO), neck remnant (NR), and body filling (BF). Clinical outcomes were assessed using the modified Rankin Scale.

RESULTS

Twenty-one patients (22 aneurysms) were included in this study. All procedures were performed successfully. Immediate postprocedural angiograms showed CO in 13 aneurysms (59.1%), NR in two aneurysms (9.1%), and BF in seven aneurysms (31.8%). One-year follow-up angiograms revealed CO in 86.4% of patients. Only one patient had a major recurrence and required retreatment. The mean follow-up duration was 43.5 months. The last angiographic studies demonstrated CO in 18 aneurysms (81.8%), NR in three aneurysms (13.6%), and BF in one aneurysm (4.5%). Periprocedural and delayed complications occurred in two patients and one patient, respectively. There was no permanent morbidity or death. The modified Rankin Scale scores at last clinical follow-up were equal to those before the procedures in all patients.

CONCLUSION

Y-stent-assisted coil embolization using LVIS Jr for intracranial bifurcation aneurysms has favorable long-term angiographic and clinical outcomes.

Non-contrast-enhanced silent magnetic resonance angiography for assessing cerebral aneurysms after PulseRider treatment

Purpose

Conventional time-of-flight (TOF) magnetic resonance angiography (MRA) failed to depict clear visualization of coiled cerebral aneurysms with PulseRider due to metal-induced susceptibility artifacts. Our aim was to overcome the metal artifact using a novel imaging technique of non-contrast-enhanced ultrashort echo-time magnetic resonance angiography (UTE-MRA).

Materials and methods

Five unruptured intracranial aneurysms were treated using PulseRider and the patients underwent silent MRA (UTE-MRA). The images were compared with TOF-MRA and digital subtraction angiography (DSA).

Results

Silent MRA can visualize the residual cavity of the coiled aneurysms, which was not well visualized and rather defective when using TOF-MRA. While a segment of the proximal marker composed of stainless steel was poorly visualized, the other parts of the parent artery and the arteries of bifurcation, including the aneurysmal neck, were clearly visualized, equivalent to that of DSA.

Conclusions

UTE-MRA achieves better visualization of cerebral aneurysms after PulseRider treatment than TOF-MRA.

PulseRider-assisted embolization of a distal anterior cerebral artery bifurcation aneurysm: illustrative case

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.

Brainstem Infarctions Caused by a Proximal Marker of the PulseRider Device Obstructing the Origin of a Perforator

The PulseRider (Cerenovus, Johnson & Johnson Medical Devices, New Brunswick, NJ, USA) is a neck reconstruction device that is used for the treatment of unruptured wide-necked bifurcation aneurysms. Herein, we describe the case of a 51-year-old male patient with a basilar apex aneurysm who was treated with PulseRider but had post-procedural brainstem infarctions caused by one of the proximal markers covering the origin of a perforator. In such cases, repositioning of the PulseRider should be performed to avoid infarctions.

Long-term follow-up of the pCONus device for the treatment of wide-neck bifurcation aneurysms

PURPOSE

Wide-neck bifurcation aneurysms remain challenging for the neurointerventionist and/or neurosurgeon despite many recent advances. The pCONus (Phenox, Bochum, Germany) is an emerging device for endovascular neck protection, we report the first long-term results of this device.

METHODS

We performed a retrospective analysis of all consecutive intracranial wide-neck bifurcation aneurysms treated with the pCONus. Patients' characteristics were reviewed, procedural complications, angiographic (Roy-Raymond scale) and clinical outcomes were documented.

RESULTS

Between January 2016 and September 2019, 43 patients (74% female, median age 56 [49-66] years) with 43 wide-neck bifurcation aneurysms (mean width of 6.8 ± 2.1 mm, dome/neck ratio of 1.3 ± 0.2 and neck of 5.2 ± 1.3 mm) were included. A procedural angiographic complication was reported in five patients (12%), no patient presented a post-operative neurological deficit or long-term complication, mortality rate was 0%. At last follow-up (median of 46.5 months [38.3-51.7]), an adequate occlusion (complete and neck remnant) was observed in 37/43 patients (86%) and an aneurysm remnant in 6/43 (14%). Four patients (9%) needed retreatment. No in-stent stenosis or branch occlusion was depicted.

CONCLUSION

pCONus device provides a safe and efficient alternative for endovascular wide-neck bifurcation aneurysms management, with long-term stability.

PulseRider Treated Aneurysm with Significant Artifact on Postoperative Magnetic Resonance Angiography: A Case Report and Literature Review

The PulseRider is a neuroendovascular adjunct for wide-necked intracranial aneurysms. The decreased metal burden of the PulseRider theoretically reduces artifact on radiologic imaging. However, we report here on a case of a patient who underwent PulseRider-assisted stent-coiling of a basilar tip aneurysm. He returned 19 months later for intermittent diplopia and darkening of vision but was neurologically intact on exam. Both contrast-enhanced and time-of-flight magnetic resonance angiography (MRA) demonstrated absence of signal in the basilar artery in the proximal anchors of the PulseRider. Given his lack of reproducible symptoms and high functional status, it is presumed that the imaging reflected artifact and not thrombosis/stenosis. Although the PulseRider is a useful treatment option for wide-necked intracranial aneurysms, the clinician should be aware that even contrast-enhanced MRA can produce artifact that resembles thrombosis/stenosis. Non-angiogram radiologic imaging modalities may be appropriate for evaluation for residual aneurysm but not patency of the parent artery.

Neurosurgical management of aneurysms of the vertebrobasilar system: increasing indications for endovascular therapy with a continued role for open microneurosurgery

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.

Initial Experience with LVIS EVO Stents for the Treatment of Intracranial Aneurysms

Background: Over the years, a variety of intracranial stents have been developed, which has expanded the therapy options available for cerebral aneurysms. The Low profile visible intraluminal support (LVIS) EVO stents are new devices, which officially appeared on the market in 2020. The purpose of the study is to report the initial technical and clinical experience with the new stent in the treatment of intracranial aneurysms. Materials and Methods: Between February and September 2020, 30 patients with 35 intracranial aneurysms (29 unruptured and 6 ruptured) were treated using the LVIS EVO stent in our department. The aneurysms were located within internal carotid artery (ICA) (42.9%), middle cerebral artery (MCA) (31.4%), anterior communicating artery (AComA) (11.4%), basilar artery (BA) (11.4%) and anterior cerebral artery (ACA) (2.9%). Stent-assisted coil embolization was performed in all cases. Results: All stents were deployed successfully in the desired position. Immediate complete occlusion of the treated aneurysms, described as Raymond–Roy occlusion classification (RROC) class 1, was achieved in all cases. No technical complications were observed. One thromboembolic complication occurred in the group of unruptured aneurysms and one patient died due to cerebral edema from aneurysms rupture group. Conclusion: In our observation, the showed a satisfactory safety profile LVIS EVO stents seem to be very flexible, can be safely maneuvered and deployed in tortuous vessels. They showed a good initial occlusion rate when used for treating intracranial aneurysms with SAC (stent-assisted coiling).

Evaluation of the Accero Stent for Stent-Assisted Coiling of Unruptured Wide-Necked Intracranial Aneurysm Treatment with Short-Term Follow-Up

BACKGROUND

Stent-assisted coiling is an effective method of treating intracranial aneurysms. The aim of the study was to assess the safety and efficacy of the new Accero stent for the treatment of intracranial aneurysms.

MATERIALS AND METHODS

It was a retrospective, single-center study. Eighteen unruptured intracranial aneurysms were treated using the stent-assisted coiling method with the Accero stent. Patient demographics, aneurysm characteristics, procedural parameters, grade of occlusion, complications, and clinical results were analyzed. Follow-up magnetic resonance (MR) was performed 6 months after intervention.

RESULTS

Seventeen patients with 18 incidental unruptured aneurysms were electively treated with coiling and the Accero stent. The aneurysms were located on internal carotid artery (ICA), middle cerebral artery (MCA) and basilar artery (BA). All stents were deployed successfully. Immediate complete occlusion rate Raymond-Roy occlusion classification (RROC) class I was achieved in 13 cases and class II in 4 cases. Complications occurred in 2/17 treatments and included guidewire stent perforation with subarachnoid hemorrhage (SAH) and stent deformation. Vascular spasm in the subarachnoid hemorrhage (SAH) patient subsided before discharge. Ninety days after intervention, the modified Rankin Scale (mRS) value was 0. RROC class I was observed in 88.23% of cases in follow-up.

CONCLUSION

The Accero stent provides excellent support for coil mass. It constitutes an efficacious device with good initial occlusion rate for treating wide-necked unruptured intracranial aneurysms.

Efficacy and safety of PulseRider for treatment of wide-necked intracranial aneurysm-A systematic review and meta-analysis

OBJECTIVE

PulseRider is a novel self-expanding nickel-titanium (nitinol) stent for treatment of wide-necked aneurysms, which is commonly located at the arterial branches in the brain. This systematic review and meta-analysis aims to assess the efficacy and safety of PulseRider for treatment of wide-necked intracranial aneurysm.

METHOD

We performed a systematic literature search on articles that evaluate the efficacy and safety of PulseRider-assisted coiling of the wide-necked aneurysm from several electronic databases. The primary endpoint was adequate occlusion, defined as Raymond-Roy Class I + Raymond-Roy Class II upon immediate angiography and at six-month follow-up.

RESULTS

There were a total of 157 subjects from six studies. The rate of adequate occlusion on immediate angiography was 90% (95% CI, 85%-94%) and 91% (95% CI, 85%-96%) at six-month follow-up. Of these, Raymond-Roy Class I can be observed in 48% (95% CI, 41%-56%) of aneurysms immediately after coiling, and 64% (95% CI, 55%-72%) of aneurysms on six-month follow-up. Raymond-Roy Class II was found in 30% (95% CI, 23%-37%) of aneurysms immediately after coiling, and 25% (17-33) after six-month follow-up. Complications occur in 5% (95% CI, 1%-8%) of the patients. There were three intraoperative aneurysm rupture, three thrombus formation, three procedure-related posterior cerebral artery strokes, one vessel dissection, and one delayed device thrombosis. There was no procedure/device-related death.

CONCLUSIONS

PulseRider-assisted coiling for treatment of patients with wide-necked aneurysm reached 90% adequate occlusion rate that rises up to 91% at sixth month with 5% complication rate.

Recent advances in stent-assisted coiling of cerebral aneurysms

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.

Y-Stenting Versus PulseRider-Assisted Coiling in the Treatment of Wide-Neck Bifurcation Aneurysms: Role of Anatomical Features on Midterm Results

BACKGROUND

Y-stenting is an effective but challenging approach for wide-neck aneurysms. PulseRider (PR) (Pulsar/Cerenovus) is a new device designed to provide scaffolding during coiling but has never been compared with other techniques.

OBJECTIVE

To compare the immediate and 6-mo results of Y-stenting vs PR assisted coiling.

METHODS

A total of 105 consecutive patients were retrospectively divided into 2 groups (73 Y-stenting and 32 PR). All underwent angiographic 6-mo follow-up. We evaluated if some anatomical features could influence treatment results.

RESULTS

The groups were homogeneous. Immediate adequate occlusions as well as complication rates were similar in Y-stenting and PR group (94.5% vs 96.9% and 8.2% vs 6.2%, respectively). At 6 mo, adequate occlusion was 93.1% after Y-stenting and 84.3% after PR (P = .28), complete occlusion was significantly higher after Y-stenting: 90.3% vs 62.5% (P = .0017). Occlusion grade worsening occurred in 6.9% of Y-stenting and 18.7% of PR patients (P = .09).

Neck size was associated with occlusion grade in both groups. Maximal aneurysm size was associated with occlusion grade in the PR group (P = .023) but not in the Y-stenting group (P = .06). After PR, 6-mo occlusion rate was higher in small (< 10 mm) than in large aneurysms (P = .0094); this was not observed after Y-stenting (P = .54).

Location did not significantly affect the mid-term occlusion rate in both the groups. After PR, occlusion was more stable in basilar than anterior or middle cerebral artery aneurysms.

CONCLUSION

Y-stenting and PR are both effective with similar immediate and mid-term results. However, treatment stability seems higher after Y-stenting. Aneurysm size seems to negatively affect PR results.