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Krylov VV, Shatokhin TA, Shetova IM, Eliava SS, Belousova OB, Airapetyan AA, Alekseev AG, Asratyan SA, Bakharev EY, Vorobyov IA, Dedkov DS, Dubovoy AV, Eliseev VV, Elfimov AV, Kozhaev ZU, Kolotvinov VS, Kosmachev MV, Kravets LY, Kushniruk PI, Myachin NL, Parfenov VE, Rodionov SV, Semin PA, Khasanshin EM, Shnyakin PG, Yakhontov IS. [Russian study on brain aneurysm surgery: a continuation (RIHA II)]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2024; 88:7-20. [PMID: 38334726 DOI: 10.17116/neiro2024880117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE To assess the main performance indicators of neurosurgical departments in surgical treatment of cerebral aneurysms in the Russian Federation. MATERIAL AND METHODS We analyzed 22 neurosurgical departments (19 regional and 3 federal hospitals) in 2017 and 2021. The study enrolled 6.135 patients including 3.160 ones in 2017 and 2.975 ones in 2021. We studied the features of surgical treatment of cerebral aneurysms in different volume hospitals and factors influencing postoperative outcomes. RESULTS The number of surgeries for cerebral aneurysms decreased from 2.950 in 2017 to 2.711 in 2021. Postoperative mortality rate was 6.3% and 5.6%, respectively. The number of microsurgical interventions decreased from 60% in 2017 to 48% in 2021. The share of endovascular interventions increased from 40% to 52%, respectively. Endovascular embolization was accompanied by stenting in 55% of cases. Simultaneous revascularization was carried out in 2% of cases. In 2021, the number of patients undergoing surgery in acute period of hemorrhage increased to 70% (in 2017 - 61%). The number of hospitals performing more than 50 surgical interventions for cerebral aneurysms annually increased from 14 in 2017 to 17 in 2021. CONCLUSION Certain changes in neurosurgical service occurred in 2021 compared to 2017. Lower number of surgical interventions for cerebral aneurysms, most likely caused by the COVID-19 pandemic, is accompanied by lower postoperative mortality. Endovascular interventions and revascularization techniques became more common. The number of surgeries in acute period after aneurysm rupture and hospitals performing more than 50 surgical interventions for cerebral aneurysms annually increased.
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Affiliation(s)
- V V Krylov
- Pirogov Russian National Research Medical University, Moscow, Russia
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- Neurology Research Center, Moscow, Russia
| | - T A Shatokhin
- Pirogov Russian National Research Medical University, Moscow, Russia
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- Neurology Research Center, Moscow, Russia
| | | | | | | | - A A Airapetyan
- Inozemtsev Moscow City Clinical Hospital, Moscow, Russia
| | - A G Alekseev
- Interregional Clinical Diagnostic Center, Kazan, Russia
| | - S A Asratyan
- Buyanov Moscow City Clinical Hospital, Moscow, Russia
| | - E Yu Bakharev
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - I A Vorobyov
- First Republican Clinical Hospital, Izhevsk, Russia
| | - D S Dedkov
- Semashko Republican Clinical Hospital, Simferopol, Russia
| | - A V Dubovoy
- Federal Center for Neurosurgery, Novosibirsk, Russia
| | - V V Eliseev
- Stavropol Regional Clinical Hospital, Stavropol, Russia
| | - A V Elfimov
- Yaroslavl Regional Clinical Hospital, Yaroslavl, Russia
| | - Z U Kozhaev
- Republican Clinical Hospital, Nalchik, Russia
| | - V S Kolotvinov
- Ekaterinburg City Clinical Hospital No. 40, Ekaterinburg, Russia
| | - M V Kosmachev
- Vladimirtsev Regional Clinical Hospital, Khabarovsk, Russia
| | - L Ya Kravets
- Nizhny Novgorod City Clinical Hospital No. 13, Nizhny Novgorod, Russia
| | - P I Kushniruk
- Volgograd Regional Clinical Hospital No. 1, Volgograd, Russia
| | - N L Myachin
- Baranov Republican Hospital, Petrozavodsk, Russia
| | - V E Parfenov
- Dzhanelidze Research Institute for Emergency Care, St. Petersburg, Russia
| | - S V Rodionov
- Voronezh Regional Clinical Hospital No. 1, Voronezh, Russia
| | - P A Semin
- Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - E M Khasanshin
- Kaliningrad Regional Clinical Hospital, Kaliningrad, Russia
| | | | - I S Yakhontov
- Republican Hospital No. 2-Center for Emergency Care, Yakutsk, Russia
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Wang Z, Jiang C, Yang Z, Song J. How we do it? Performing a protective superficial temporal artery-middle cerebral artery bypass with endoscopic transnasal cavernous sinus lesion operation. Acta Neurochir (Wien) 2023; 165:3729-3735. [PMID: 37382688 DOI: 10.1007/s00701-023-05657-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/25/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND To describe the concept of a protective superficial temporal artery-middle cerebral artery (STA-MCA) bypass performed prior to endoscopic transnasal cavernous sinus (CS) lesion resection in order to reduce the risk of perioperative cerebral ischemia due to internal carotid artery (ICA) vasospasm, occlusion, and even injury. METHOD We illustrated the procedure of a 14-year-old female accepting a protective STA-MCA bypass with endoscopic transnasal CS lesion resection. CONCLUSION A protective bypass may be a prophylactic strategy in selected endoscopic transnasal CS surgery cases, particularly where the diagnosis is uncertain, or the risk of ICA injury or occlusion is high.
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Affiliation(s)
- Zhicheng Wang
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350004, Fujian, China
- Department of Neurosurgery, National Regional Medical Center, The First Affiliated Hospital Binhai Campus, Fujian Medical University, Fuzhou, 350209, Fujian, China
| | - Changzhen Jiang
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350004, Fujian, China
- Department of Neurosurgery, National Regional Medical Center, The First Affiliated Hospital Binhai Campus, Fujian Medical University, Fuzhou, 350209, Fujian, China
| | - Zixiao Yang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China
- Research Unit of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai, 200040, China
| | - Jianping Song
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, 200040, China.
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China.
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China.
- Research Unit of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai, 200040, China.
- Department of Neurosurgery, National Regional Medical Center, Huashan Hospital Fujian Campus, Fudan University, Fuzhou, Fuzhou, 350209, Fujian, China.
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Zhang YB, Yao PS, Wang HJ, Xie BS, Wang JY, Zhu M, Wang DL, Yu LH, Lin YX, Gao B, Zheng SF, Kang DZ. Treatment with a flow diverter-assisted coil embolization for ruptured blood blister-like aneurysms of the internal carotid artery: a technical note and analysis of single-center experience with pooled data. Neurosurg Rev 2023; 46:305. [PMID: 37982900 DOI: 10.1007/s10143-023-02216-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/25/2023] [Accepted: 11/07/2023] [Indexed: 11/21/2023]
Abstract
Treatment of blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA) with flow diverters (FDs) has become widespread in recent years. However, ruptured blood blister-like aneurysm (BBA) of ICA treatment with flow diverter-assisted coil embolization (FDAC) remains controversial. Moreover, limited direct comparative studies have been conducted between the two treatment modalities, FDs and FDAC, for BBAs. The purpose of this study was to document our experience and evaluate the effectiveness and safety of FDAC. We conducted a retrospective analysis of clinical and radiological information from ten patients who experienced ruptured BBAs of the supraclinoid ICA at our center from January 2021 to February 2023. The technical details of FDAC for ruptured BBAs were described, and the technical steps were named "pipeline embolization device (PED)-Individualized shaping(microcatheter)-Semi deploying-Rivet(coils)-Massage(microwire)" as the PEISSERM technique. Clinical outcomes were assessed using the modified Rankin Scale (mRS), whereas radiological results were determined through angiography. A pooled analysis was implemented, incorporating data from literature sources that reported perioperative and long-term clinical and angiographic outcomes of ruptured BBAs treated with FD and FDAC strategies, along with our data. Data in our analysis pool were categorized into FD and FDAC strategy groups to explore the preferred treatment modalities for BBAs. The PEISSERM technique was utilized to treat ten patients, seven males, and three females, with an average age of 41.7 years. A single PED was deployed in conjunction with coils in all ten patients. All PEDs were documented to have good wall apposition. The immediate postoperative angiograms demonstrated Raymond grade I in ten aneurysms. Angiographic follow-up of nine patients at 4-25 months showed total occlusion of the aneurysms. At the most recent follow-up, the mRS scores of nine patients hinted at a good prognosis. Pooled analysis of 233 ICA-BBA cases of FD revealed a technical success rate of 91% [95% confidence interval (CI), 0.88 to 0.95], a rate of complete occlusion of 79% (95% CI, 0.73 to 0.84), a recurrence rate of 2% (95% CI, 0.00 to 0.04), a rebleed rate of 2% (95% CI, 0.00 to 0.04), and the perioperative stroke rate was 8% (95% CI, 0.04 to 0.11). The perioperative mortality was 4% (95% CI, 0.01 to 0.07). The long-term good clinical outcome rate was 85% (95% CI, 0.80 to 0.90). The mortality rate was 6% (95% CI, 0.03 to 0.09). Results from the subgroup analysis illustrated that the FDAC strategy for BBAs had a significantly higher immediate postoperative complete occlusion rate (P < 0.001), total occlusion rate (P = 0.016), and a good outcome rate (P = 0.041) compared with the FD strategy. The FDAC strategy can yield a higher rate of good outcomes than the FD strategy. The PEISSERM technique employed by the FDAC is a reliable and effective treatment approach as it can minimize the hemodynamic burden of BBA's fragile dome, thereby achieving an excellent occlusion rate. The PEISSERM technique in the FDAC strategy contributes to understanding the BBA's treatment and offers a potentially optimal treatment for BBA.
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Affiliation(s)
- Yi-Bin Zhang
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Pei-Sen Yao
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Hao-Jie Wang
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Bing-Sen Xie
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Jia-Yin Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, China
| | - Mei Zhu
- Department of Neurosurgery, The Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, 350005, China
| | - Deng-Liang Wang
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Liang-Hong Yu
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Yuan-Xiang Lin
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
- Fujian Provincial Clinical Research Center for Neurological Diseases, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
| | - Bin Gao
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
| | - Shu-Fa Zheng
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
| | - De-Zhi Kang
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
- Fujian Provincial Clinical Research Center for Neurological Diseases, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Clinical Research and Translation Center, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
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Flow Diverter Device-Assisted Coiling Treatment for Cerebral Blister Aneurysm: A Single-Center Study. Brain Sci 2023; 13:brainsci13030435. [PMID: 36979245 PMCID: PMC10046186 DOI: 10.3390/brainsci13030435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/22/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Although endovascular treatment is a promising approach, blood blister-like aneurysms (BBAs) still present treatment challenges. This study aimed to assess the effectiveness and safety of flow diverter device-assisted coiling (FDDAC) for the treatment of BBAs, which are broad based and friable with a high rebleeding risk. Eight patients (five females and three males) who presented with subarachnoid hemorrhages (SAH) due to BBA ruptures between May 2020 and May 2022 were retrospectively enrolled. All patients were treated by flow diverter device (Tubridge) adjunctive coil embolization using a semi-deploying technique. The demographic information, angiographic data, interval between admission and treatment, materials, therapy, clinical outcomes (including periprocedural and intraprocedural mortality and morbidity), and follow-up results of all patients were reviewed. The mean age of the patients with BBAs was 48.5 years (range 31–62 years); aneurysm sizes ranged from 2.2 × 1.7 mm to 4.6 × 3.2 mm, and the median Hunt–Hess score was 3. All aneurysms were completely closed at follow-up, and all 8 patients had excellent clinical outcomes (modified Rankin scores = 0–2) at discharge. Angiograms showed complete aneurysm occlusion after 6 months to 1 year. In addition, there were no cases of re-rupture, re-treatment, or recurrence of the aneurysms. FDDAC is safe to use in patients with BBAs and provides an alternative treatment option for this disease.
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5
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Willis covered stent in the treatment of a recurrent blood blister-like aneurysm after pipeline implementation: A case report. J Interv Med 2023. [DOI: 10.1016/j.jimed.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
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Adalid LAC, Herrera VC, Rubio DS, Toro MA, Estrada EE. Surgical treatment of a ruptured internal carotid artery pseudoaneurysm following transsphenoidal surgery. J Cerebrovasc Endovasc Neurosurg 2022; 24:380-385. [PMID: 35837685 PMCID: PMC9829561 DOI: 10.7461/jcen.2022.e2021.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/28/2021] [Indexed: 01/21/2023] Open
Abstract
Development of Internal Carotid Artery pseudoaneurysms (ICAp) after transsphenoidal surgery is extremely rare, occurring only in 0.4% of cases. Surgical treatment of ICAp poses a real challenge to the neurosurgeon as treatment may require parent vessel sacrifice or artery reconstruction with bypass grafting. Furthermore, surgical resolution of these lesions is rarely reported in the literature. The internal carotid artery is prone to iatrogenic injury in transsphenoidal surgery due to its frequent involvement in pituitary adenomas. Intracranial pseudoaneurysms may be at high risk for rupture and increased morbidity and mortality. Here we present a case of a patient with an ICAp rupture two months after transsphenoidal surgery for a pituitary adenoma.
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Affiliation(s)
- Luis Alfonso Castillejo Adalid
- Specialties Hospital, 21st Century National Medical Center, Mexico City, Mexico,Correspondence to Luis Alfonso Castillejo Adalid Specialties Hospital, 21st Century National Medical Center, Cuauhtémoc 333, Doctores Suburb. Mexico City, Mexico Tel +52-55-5701-0874 E-mail
| | | | - Diego Soto Rubio
- Specialties Hospital, 21st Century National Medical Center, Mexico City, Mexico
| | - Miguel Abdo Toro
- Specialties Hospital, 21st Century National Medical Center, Mexico City, Mexico
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Budohoski KP, Thakrar R, Voronovich Z, Rennert RC, Kilburg C, Grandhi R, Couldwell WT, Brockmeyer DL, Taussky P. Initial experience with Pipeline embolization of intracranial pseudoaneurysms in pediatric patients. J Neurosurg Pediatr 2022; 30:465-473. [PMID: 36057120 DOI: 10.3171/2022.7.peds22195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children. METHODS This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed. RESULTS Six patients with a median age of 12 years (range 7-16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae. CONCLUSIONS Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.
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Affiliation(s)
- Karol P Budohoski
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Raj Thakrar
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Zoya Voronovich
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Robert C Rennert
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Craig Kilburg
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Ramesh Grandhi
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Douglas L Brockmeyer
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Philipp Taussky
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
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Liu P, Liu L, Zhang C, Lin S, Wang T, Xie X, Zhou L, Wang C. Treatment of Blood Blister Aneurysms of the Internal Carotid Artery With Pipeline-Assisted Coil Embolization: A Single-Center Experience. Front Neurol 2022; 13:882108. [PMID: 35769367 PMCID: PMC9234106 DOI: 10.3389/fneur.2022.882108] [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: 02/25/2022] [Accepted: 04/20/2022] [Indexed: 11/30/2022] Open
Abstract
Background Blood blister aneurysm (BBA) is a complex and rare aneurysm that presents significant treatment challenges. The application of pipeline embolization device (PED)-assisted coiling in the treatment of ruptured BBA remains controversial. This study aimed to report on our experience and assess the safety and efficacy of this strategy. Methods Between February 2019 and February 2021, 12 patients with ruptured BBAs underwent PED-assisted coil embolization. We collected detailed data about each patient, including demographic information, aneurysmal data, technical details, antiplatelet strategy, operation-related complications, and follow-up outcomes. Results A total of 12 BBA patients were treated with single PED-assisted coil embolization. One patient experienced intraoperative rupture that was controlled by rapid coiling without clinical consequences. All the patients demonstrated complete occlusion on postoperative angiography. A total of three patients had postoperative complications: left hemiparesis, Broca's aphasia, and right hemiplegia due to vasospasm, and transient hemiparesis. Follow-up angiography revealed that all BBAs were completely occluded, except one with neck residue. All patients had favorable outcomes at discharge and the most recent clinical follow-up (mRS score ≤ 2). Conclusion Endovascular treatment of BBAs of the internal carotid artery using PED-assisted coil embolization is a safe and effective strategy. This has contributed to the understanding of BBA therapy and provides a potentially optimal treatment option for this intractable lesion.
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Fang W, Yu J, Liu Y, Sun P, Yang Z, Zhao Z, He Y, Deng J, Zhang T. Application of the Willis Covered Stent in the Treatment of Blood Blister-Like Aneurysms: A Single-Center Experience. Front Neurol 2022; 13:882880. [PMID: 35665046 PMCID: PMC9159856 DOI: 10.3389/fneur.2022.882880] [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: 02/24/2022] [Accepted: 04/12/2022] [Indexed: 11/24/2022] Open
Abstract
Objective To evaluate the effectiveness of the Willis covered stent (WCS) in the treatment of ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA). Method The clinical data of 16 patients consecutively treated with WCSs from December 2015 to January 2019 were retrospectively analyzed. Clinical data and angiographic findings were analyzed by two experienced neuroradiologists and neurosurgeons, including age, sex, Hunt and Hess (H&H) grade at admission, modified Rankin scale (mRS) score, aneurysm size, and location, the diameter of the patent artery in proximal and distal ends, stent size, rate of aneurysm occlusion, procedure-related complications, and follow-up. Results All the 16 patients (five males, 11 females) with ICA BBAs underwent WCS deployment successfully. The median age was 49 years (range, 29–72). All patients had complete aneurysm occlusion on immediate postoperative angiography. Anterior choroidal artery (AChA) was occluded in one patient accidentally while no obvious neurological dysfunction was observed. However, this patient underwent subarachnoid hemorrhage 1 day after the treatment; endoleak and aneurysm recurred, and the patient died 10 days later. Therefore, the effective rate of WCS treatment was 93.8% (15/16), and procedure-related complications rate was 6.3% (1/16). Moreover, one patient was urgently treated because of accidental aneurysm rupture after anesthesia, and external ventricular drainage was then performed postoperatively. Another patient developed coma and hemiplegia 3 days after treatment, with emergency angiography showing in-stent thrombosis and ICA occlusion which was recanalized with arterial rt-PA thrombolysis; the patient recovered completely. The clinical follow-up period was 3–30 months in 14 patients. The mRS scores were 0 in 12 patients (85.7%) and 4 in 1 case (7.1%), while 1 patient (7.1%) died 6 months postoperatively for unknown reasons. Angiographic follow-up was performed in 13 patients, and no recurrence was observed. However, ICA occlusion without neurological deficit was observed in one patient. Conclusion Based on careful preoperative evaluation, appropriate WCS size selection, and precise surgical operation, WCSs may provide an alternative and effective solution for blood BBAs via aneurysm isolation and ICA reconstruction immediately; However, further follow-up studies with larger samples are required.
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Affiliation(s)
- Wei Fang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
- Wei Fang
| | - Jia Yu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Yufeng Liu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Peng Sun
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Zijian Yang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Zhenwei Zhao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Yue He
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianping Deng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
- Jianping Deng
| | - Tao Zhang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
- *Correspondence: Tao Zhang
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Lu D, Ma T, Zhu G, Zhang T, Wang N, Lei H, Sui J, Wang Z, He S, Chen L, Deng J. Willis Covered Stent for Treating Intracranial Pseudoaneurysms of the Internal Carotid Artery: A Multi-Institutional Study. Neuropsychiatr Dis Treat 2022; 18:125-135. [PMID: 35125870 PMCID: PMC8811267 DOI: 10.2147/ndt.s345163] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/16/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE This work aimed to retrospectively analyze Willis covered stent (WCS)'s therapeutic efficacy in intracranial pseudoaneurysms (PSAs) of the internal carotid artery (ICA). METHODS Between June 2018 and July 2021, 56 individuals with intracranial PSAs of the ICA treated with WCS in three centers were included to analyze information regarding medical records, operative parameters, imaging findings and follow-up data. RESULTS All WCSs were successfully targeted to the ICA lesions. Total exclusion of PSA was found in 53 cases (94.6%) right upon surgery, and mild endoleak into the aneurysm remained in 3 cases (5.4%). Intraoperative thrombosis occurred in 1 case (1.8%), and tirofiban was utilized for recanalization. Follow-up by angiography showed total aneurysm occlusion in the total number of individuals, including in the 3 above cases with residual endoleak. In-stent stenosis occurred in 7 (12.5%) patients. No stent-related ischemic event was encountered. Predictive factors of late in-stent stenosis following WCS implantation in this patient group were irregular post-operative antiplatelet treatment (p = 0.015) and C4-C5 segment of the ICA (p = 0.043). CONCLUSION WCSs are effective in treating intracranial PSAs of the ICA.
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Affiliation(s)
- Dan Lu
- Department of Neurosurgery, Xi'an International Medical Center Hospital, Xi'an, People's Republic of China
| | - Tao Ma
- Department of Neurosurgery, Xi'an International Medical Center Hospital, Xi'an, People's Republic of China
| | - Gemin Zhu
- Department of Neurology, Xi'an Central Hospital, Xi'an, People's Republic of China
| | - Tao Zhang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, People's Republic of China
| | - Naibing Wang
- Department of Neurosurgery, Xi'an International Medical Center Hospital, Xi'an, People's Republic of China
| | - Hui Lei
- Department of Neurology, Xi'an Central Hospital, Xi'an, People's Republic of China
| | - Jing Sui
- Department of Neurosurgery, Xi'an International Medical Center Hospital, Xi'an, People's Republic of China
| | - Zhiguo Wang
- Department of Neurosurgery, Xi'an International Medical Center Hospital, Xi'an, People's Republic of China
| | - Shiming He
- Department of Neurosurgery, Xi'an International Medical Center Hospital, Xi'an, People's Republic of China
| | - Lei Chen
- Department of Neurosurgery, Xi'an International Medical Center Hospital, Xi'an, People's Republic of China
| | - Jianping Deng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, People's Republic of China
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11
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Liu A, Rincon-Torroella J, Bender MT, McDougall CG, Tufaro AP, London NR, Coon AL, Reh DD, Gallia GL. Combined Pipeline Embolization Device with Endoscopic Endonasal Fascia Lata/Muscle Graft Repair as a Salvage Technique for Treatment of Iatrogenic Carotid Artery Pseudoaneurysm. J Neurol Surg Rep 2021; 82:e43-e48. [PMID: 34877246 PMCID: PMC8635816 DOI: 10.1055/s-0041-1735284] [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: 09/15/2020] [Accepted: 01/14/2021] [Indexed: 11/16/2022] Open
Abstract
The incidence of internal carotid artery (ICA) injury associated with endoscopic endonasal approaches to the pituitary is less than 1%. While parent vessel sacrifice has historically been the choice of treatment, vessel-preserving endovascular techniques have been reported. Although flow diversion offers endoluminal reconstruction, its major limitation is the delay in obtaining complete occlusion. We describe the use of a combined Pipeline embolization device (PED) with endoscopic endonasal repair using a fascia lata/muscle graft to treat an iatrogenic ICA pseudoaneurysm and report long-term radiographic follow-up. Further investigation into the utility of directed endoscopic endonasal repair of iatrogenic pseudoaneurysms initially treated with PED is necessary, especially given the need of post-PED anticoagulation and the rate of permanent neurological deficit after ICA sacrifice.
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Affiliation(s)
- Ann Liu
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | | | - Matthew T Bender
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States
| | - Cameron G McDougall
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Anthony P Tufaro
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Division of Plastic Surgery, Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Nyall R London
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Neurosurgery, Carondelet Neurological Institute, Tucson, Arizona, United States
| | - Douglas D Reh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Otolaryngology-Head and Neck Surgery, Greater Baltimore Medical Center, Baltimore, Maryland, United States
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
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12
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Scullen T, Mathkour M, Werner C, Zeoli T, Amenta PS. Vertebral artery dissection and associated ruptured intracranial pseudoaneurysm successfully treated with coil assisted flow diversion: A case report and review of the literature. Brain Circ 2021; 7:159-166. [PMID: 34667899 PMCID: PMC8459696 DOI: 10.4103/bc.bc_67_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/01/2021] [Accepted: 04/30/2021] [Indexed: 11/14/2022] Open
Abstract
Dissecting intracranial pseudoaneurysms (IPs) are associated with a high incidence of rupture and poor neurologic outcomes. Lesions in the posterior circulation are particularly malignant and pose even greater management challenges. Traditional management consists of microsurgical vessel sacrifice with or without bypass. Flow diversion (FD) in the setting of subarachnoid hemorrhage (SAH) represents a reconstructive treatment option and can be paired with coil embolization to promote more rapid thrombosis of the lesion. We report a case of a ruptured dissecting vertebral artery (VA) IP successfully acutely treated with coil-assisted FD. A 53-year-old male presented with a right V4 dissection spanning the origin of the posterior inferior cerebellar artery and associated ruptured V4 IP. The patient was treated with coil-assisted FD. Oral dual-antiplatelet therapy (DAPT) was initiated during the procedure, and intravenous tirofiban was used as a bridging agent. Immediate obliteration of the IP was achieved, with near-complete resolution of the dissection within 48 h. The patient made a complete recovery, and angiography at 6 weeks confirmed total IP obliteration, reconstruction of the VA, and a patent stent. The use of FD and DAPT in the setting of acute SAH remains controversial. We believe that coil-assisted FD in carefully selected patients offers significant advantages over traditional microsurgical and endovascular options. The risks posed by DAPT and potential for delayed thrombosis with FD can be effectively mitigated with planning and the development of protocols. We discuss the current literature in the context of our case and review the challenges associated with treating these often devastating lesions.
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Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Surgery, Neurosurgery Division, Jazan University, Jazan, Kingdom of Saudi Arabia
| | - Cassidy Werner
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Tyler Zeoli
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Peter S Amenta
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
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13
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Wang T, Richard SA, Li J, Jiao H, Zhang C, Wang C, Lin S, Xie X, You C. Cerebral vasospasm resulted in "stent shortening" after pipeline assisted coil embolization for blood blister aneurysms. Medicine (Baltimore) 2021; 100:e26971. [PMID: 34414968 PMCID: PMC8376338 DOI: 10.1097/md.0000000000026971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/01/2021] [Indexed: 02/05/2023] Open
Abstract
Blood blister aneurysms (BBAs) are intracranial arterial lesions appearing in nonbranching sites of the supraclinoid internal carotid artery as well as the basilar artery. Endovascular treatment of BBAs is still not well established because of the rarity of these lesions. We report incidences of BBAs with associated vasospasms. Treatment of the BBAs and associate vasospasms with single Pipeline Flex embolization device (PLED) assisted coiling resulted in seemly shorting of the PLEDs in 3 patients.A retrospective analysis of patients with BBAs who were treated with single PLED assisted coiling from July 2018 to October 2019 was conducted. Patients' ethnic and medical records, aneurysmal characteristics, intraoperative-rupture, cerebral vasospasm (CVS), postprocedure contrast filling, follow-up imaging, and results were analyzed. Neurological examination at baseline and outcome based on modified Rankin scale (mRS) at discharge as well as follow-ups were also documented.Six patients consisting of 5 females and 1 male, with a mean age of 48.3 years (range from 34-67) were identified during our analysis. All the BBAs were located in nonbranching site of supra-clinoidal segment of internal carotid artery with a mean neck width of 4.5 mm and mean aneurysm size of 4.23 mm. PLED assisted coiling's were performed in all of them. CVS was observed in 3 patients while 1 patient had an intraoperative-rupture of the BBA. Postprocedure contrast filling was still present in 1 patient. All the patients had good outcomes with discharge and follow-up mRS scores ≤ 2 except 1 patient with mRS score = 3 with aphasia.PLED assisted endovascular coiling is very safe and efficient in treating patients with BBAs. Resolution of CVSs after treatment made the PLEDs seemly shorter. Furthermore, a combination of arterial lengthening after gaining their tensile strength back and radical expansion of the PLED could account for the shortening.
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Affiliation(s)
- Ting Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
- Department of Medicine, Princefield University, P. O. Box MA 128, Ho-Volta Region, Ghana
| | - Junrao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - He Jiao
- Department of Radiology, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Changwei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Chaohua Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Sen Lin
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Xiaodong Xie
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, P. R. China
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14
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Giorgianni A, Agosti E, Terrana A, Pozzi F, Sileo G, Nativo L, Balbi S, Motta A, Castelnuovo P, Locatelli D, Turri-Zanoni M. Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-center experience. Acta Neurochir (Wien) 2021; 163:2055-2061. [PMID: 32808087 PMCID: PMC8195932 DOI: 10.1007/s00701-020-04517-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/30/2020] [Indexed: 11/05/2022]
Abstract
Background and objective To describe our single-center experience in the treatment of cavernous internal carotid artery (ICA) acute bleeding with flow diverter stent (FDS), as a single endovascular procedure or combined with an endoscopic endonasal approach. Methods We analyze a case series of 5 patients with cavernous ICA acute bleeding, i.e., 3 iatrogenic, 1 post-traumatic, and 1 erosive neoplastic. After an immediate nasal packing to temporarily bleeding control, patients underwent digital subtraction angiography (DSA) to identify the site of the ICA injury. A concomitant balloon occlusion test (BOT) was performed, to exclude post-occlusive ischemic neurological damage. An FDS was placed with parallel intravenous infusion of abciximab in 3 cases and tirofiban in 2 cases. In two patients, an innovative “sandwich technique” combining the endovascular reconstruction with an extracranial intrasphenoidal cavernous ICA resurfacing with autologous flaps or grafts by endoscopic endonasal approach was performed. Results No patient had periprocedural ischemic-hemorrhagic complications. All patients had a regular clinical evolution, without general complications or new onset of focal neurological deficits. No further bleeding occurred in 3 patients, while 2 cases experienced a mild rebleeding in a period ranging from 5 to 15 days after the endovascular procedure. In these two cases, we proceeded with an endoscopic endonasal procedure to resurface the exposed ICA wall in the sphenoid sinus. Conclusions Although the treatment of choice for cavernous ICA acute bleeding remains the occlusion of the injured vessel, in cases of poor hemodynamic compensation at the BTO, the endovascular FDS emergency placement can be effective. A combined endoscopic endonasal technique to support the extracranial side of the vessel using autologous flaps or grafts can be performed to prevent the risk of rebleeding.
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Affiliation(s)
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Via Guicciardini, 9, 21100, Varese, Italy.
| | - Alberto Terrana
- Department of Neuroradiology, ASST Sette Laghi, Varese, Italy
| | - Fabio Pozzi
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Via Guicciardini, 9, 21100, Varese, Italy
| | - Giorgio Sileo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Luca Nativo
- Department of Neuroradiology, ASST Sette Laghi, Varese, Italy
| | - Sergio Balbi
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Via Guicciardini, 9, 21100, Varese, Italy
| | - Alessandro Motta
- Department of Anesthesiology e Resuscitation, ASST Sette Laghi, Varese, Italy
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Via Guicciardini, 9, 21100, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Mario Turri-Zanoni
- Department of Anesthesiology e Resuscitation, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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15
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Balik V, Takebayashi S, Takizawa K. A Case Series of Double Bypass Technique Used for the Treatment of Internal Carotid Blood Blister-like Aneurysms in Patients in Poor Initial Neurological Condition at the Early Stage of Subarachnoid Hemorrhage. Oper Neurosurg (Hagerstown) 2021; 18:126-135. [PMID: 31232429 DOI: 10.1093/ons/opz107] [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] [Received: 11/05/2018] [Accepted: 01/21/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Optimal surgical treatment of blood-blister aneurysms (BBA) remains controversial. Some surgeons prefer clipping reconstruction while others favor primary bypass with trapping. OBJECTIVE To analyze of benefit of double bypass technique to surgical outcomes in patients with ruptured BBA in poor initial neurological condition (PINC). METHODS Retrospective analysis of clinical, radiological, and surgical data in 9 patients treated between January 2009 and December 2015. Intraoperative middle cerebral artery blood pressure (MCABP) measurement was used for selection of bypass procedure. RESULTS Seven patients presented with World Federation of Neurosurgical Societies (WFNS) subarachnoid hemorrhage (SAH) score 4 or 5. No pulse pressure in the MCA after internal carotid artery (ICA) clamping was found in 3 patients, although their ACoA or PCoA were well visualized on preoperative angiograms. By contrast, only a minimal drop in MCABP following ICA clamping was detected in two cases, although their collaterals were slim/nonvisualized on imaging. Although angiographic vasospasms were not observed in our patients, two of them experienced cerebral infarction, attributable more to the mass effect and postoperative ICA thrombosis than to SAH-induced vasospasm. There were 2 premature intraoperative ruptures, but no perioperative mortality, aneurysm recurrence, or rebleeding. Five patients with WFNS SAH score 4 or 5 achieved favorable outcomes. CONCLUSION Early double bypass technique guided by MCABP measurement and combined with trapping (or rarely clipping) seems to be a safe method with excellent long-term outcomes in patients in PINC. This study may thus contribute to the debate on the optimal treatment strategy for BBA.
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Affiliation(s)
- Vladimir Balik
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University and Faculty Hospital Olomouc, Olomouc, Czech Republic.,Department of Neurosurgery, Japanese Red Cross Asahikawa Hospital, Asahikawa, Hokkaido, Japan
| | - Seiji Takebayashi
- Department of Neurosurgery, Japanese Red Cross Asahikawa Hospital, Asahikawa, Hokkaido, Japan
| | - Katsumi Takizawa
- Department of Neurosurgery, Japanese Red Cross Asahikawa Hospital, Asahikawa, Hokkaido, Japan
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16
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Hou K, Li G, Lv X, Xu B, Xu K, Yu J. Delayed rupture of intracranial aneurysms after placement of intra-luminal flow diverter. Neuroradiol J 2020; 33:451-464. [PMID: 32851918 PMCID: PMC7788679 DOI: 10.1177/1971400920953299] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Though flow diverter is a safe and efficient modality, some patients can experience delayed aneurysmal rupture. The mechanism of delayed rupture is still obscure to us. METHODS We performed a systematic search in the PubMed database for patients with delayed rupture of intracranial aneurysms after flow diverter placement. RESULTS A total of 36 articles reporting on 60 patients were included in the final analysis. Of the 49 patients with description of presenting symptoms, six (12.2%) patients were incidentally diagnosed, 39 (87.8%) patients were admitted for aneurysmal rupture or mass effect. Multiple flow diverters were used in 38.3% (18/47) of the patients. Coil assistance was applied in 13.0% (7/54) of the patients. Delayed aneurysmal rupture led to intracranial hemorrhage or carotid-cavernous sinus fistula (CCF) in 76.8% (43/56) and 23.2% (13/56) of the patients, respectively. Of the 55 patients with description of outcome, 14 (25.5%) patients achieved good recovery, one (1.8%) patient was severely disabled, 40 (72.7%) patients died. All of the patients in the CCF group survived and experienced good recovery. CONCLUSION Increased intra-aneurysmal pressure, destabilization of the aneurysm wall by intra-aneurysmal thrombus, persistent residual intra-aneurysmal flow, characteristics of the specific aneurysm, and mechanical injury by the flow diverter might conjointly contribute to the final delayed rupture. There has been no established preventive measure to decrease the incidence of delayed rupture yet. The treatment and outcome depend on the presentation of delayed rupture. Patients presenting with aneurysm-related intracranial hemorrhage have a dismal outcome. Those presenting with CCFs usually have a satisfactory recovery.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Guichen Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Xianli Lv
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
- Jinlu Yu, Department of Neurosurgery, The First Hospital of Jilin University, 1 Xinmin Avenue, Changchun 130021, China.
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17
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Bafaquh M, Khairy S, Alyamany M, Alobaid A, Alzhrani G, Alkhaibary A, Aldhafeeri WF, Alaman AA, Aljohani HN, Elahi BN, Alghabban FA, Orz Y, Alturki AY. Classification of internal carotid artery injuries during endoscopic endonasal approaches to the skull base. Surg Neurol Int 2020; 11:357. [PMID: 33194290 PMCID: PMC7656006 DOI: 10.25259/sni_188_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/20/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Internal carotid artery (ICA) injuries are a major complication of endoscopic endonasal approaches (EEAs), which can be difficult to manage. Adding to the management difficulty is the lack of literature describing the surgical anatomical classification of these types of injuries. This article proposing a novel classification of ICA injuries during EEAs. Methods: The classification of ICA injuries during EEAs was generated from the review of the literature and analysis of the main author observation of ICA injuries in general. All published cases of ICA injuries during EEAs in the literature between January 1990 and January 2020 were carefully reviewed. We reviewed all patients’ demographic features, preoperative diagnoses, modes of injury, cerebral angiography results, surgical and medical management techniques, and reported functional outcomes. Results: There were 31 papers that reported ICA injuries during EEAs in the past three decades, most studies did not document the type of injury, and few described major laceration type of it. From that review of the literature, we classified ICA injuries into three main categories (Types I-III) and six sub-types. Type I is ICA branch injury, Type II is a penetrating injury to the ICA, and Type III is a laceration of the ICA wall. The functional neurological outcome was found to be worse with Type III and better with Type I. Conclusion: This is a novel classification system for ICA injuries during EEAs; it defines the patterns of injury. It could potentially lead to advancements in the management of ICA injuries in EEAs and facilitate communication to develop guidelines.
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Affiliation(s)
- Mohammed Bafaquh
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Sami Khairy
- Division of Neurosurgery, Department of Surgery, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mahmoud Alyamany
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Abdullah Alobaid
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Gmaan Alzhrani
- Division of Neurosurgery, Department of Surgery, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ali Alkhaibary
- Division of Neurosurgery, Department of Surgery, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Wafa F Aldhafeeri
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Areej A Alaman
- Division of Neurosurgery, Department of Surgery, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hanan N Aljohani
- Department of Neurosciences, Division of Neurosurgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Basim Noor Elahi
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Fatimah A Alghabban
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Yasser Orz
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman Y Alturki
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
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18
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Möhlenbruch MA, Seker F, Özlük E, Kizilkilic O, Broussalis E, Killer-Oberpfalzer M, Griessenauer CJ, Bendszus M, Kocer N. Treatment of Ruptured Blister-Like Aneurysms with the FRED Flow Diverter: A Multicenter Experience. AJNR. AMERICAN JOURNAL OF NEURORADIOLOGY 2020; 41:2280-2284. [PMID: 33122212 DOI: 10.3174/ajnr.a6849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/05/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Treatment of ruptured blister-like aneurysms is technically challenging. This study aimed at analyzing the safety and efficacy of the Flow-Redirection Endoluminal Device (FRED) in the treatment of ruptured blister-like aneurysms. MATERIALS AND METHODS In a retrospective multicenter study, all patients treated with the FRED due to a ruptured intracranial blister-like aneurysm between January 2013 and May 2019 were analyzed. The primary end points for clinical safety were mRS 0-2 at 6 months after treatment and the absence of major ipsilateral stroke or death. The primary end points for efficacy were the absence of rebleeding after treatment and complete angiographic occlusion according to the O'Kelly-Marotta classification at 6 months after treatment. RESULTS In total, 30 patients with 30 ruptured blister-like aneurysms were treated. Immediate complete aneurysm obliteration (O'Kelly-Marotta classification D) with the FRED was achieved in 10 patients (33%). Of the 26 patients with follow-up, complete obliteration was achieved in 21 patients (80%) after 6 months and in 24 patients (92%) in the final follow-up (median, 22 months). Twenty-three patients (77%) achieved mRS 0-2 at 6 months. Major stroke or death occurred in 17%. Two patients died due to pneumonia, and 2 patients died due to infarction following cerebral vasospasm. There was no case of rebleeding after FRED implantation. There was 1 case of delayed asymptomatic stent occlusion. CONCLUSIONS Treatment of ruptured blister-like aneurysms with the FRED is safe and effective.
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Affiliation(s)
- M A Möhlenbruch
- From the Department of Neuroradiology (M.A.M., F.S., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - F Seker
- From the Department of Neuroradiology (M.A.M., F.S., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - E Özlük
- Department of Radiology (E.Ö.), Acibadem University Atakent International Hospital, Istanbul, Turkey
| | - O Kizilkilic
- Division of Neuroradiology (O.K., N.K.), Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - E Broussalis
- Research Institute of Neurointervention (E.B., M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria
| | - M Killer-Oberpfalzer
- Research Institute of Neurointervention (E.B., M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria
| | - C J Griessenauer
- Research Institute of Neurointervention (E.B., M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria
| | - M Bendszus
- From the Department of Neuroradiology (M.A.M., F.S., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - N Kocer
- Division of Neuroradiology (O.K., N.K.), Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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19
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Ghorbani M, Griessenauer CJ, Shojaei H, Wipplinger C, Hejazian E. Endovascular reconstruction of iatrogenic internal carotid artery injury following endonasal surgery: a systematic review. Neurosurg Rev 2020; 44:1797-1804. [PMID: 32860104 DOI: 10.1007/s10143-020-01379-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/30/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
The objective of this study is to provide an update on endovascular treatments for iatrogenic internal carotid artery (ICA) injuries following endonasal surgery. A systematic review of the literature was performed by using Medline, Cochrane library, and Scopus from 1999 to 2019. We used a combination of the MeSH terms "internal carotid artery," "iatrogenic disease," and "endovascular procedure." Twenty-six articles including 46 patients were identified for in this systematic review. The mean age of the patients was 49 years (CI: ± 4.2). The most common site of ICA injury was in cavernous segment (18 patients; 39%). The most common type of iatrogenic ICA injury was a traumatic pseudoaneurysm documented in 28 patients (60%). Endoluminal reconstruction was performed using covered stents in 28 patients, the Pipeline embolization device (PED) in 13 patients, the Surpass flow diverter device in three, the SILK flow diverter in one, and one case was treated using a combined approach of a covered stent and a PED. Flow diversion and covered stents resulted in a good clinical outcome in 94% and 89% of patients, respectively. This difference did not reach statistical significance (p = 1.0). Even though this systematic review was limited due to articles of small sample sizes and considerable heterogeneity, the results indicate that flow diverting devices and covered stents are good therapeutic options for endoluminal reconstruction of iatrogenic ICA injuries following endonasal surgery.
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Affiliation(s)
- Mohammad Ghorbani
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Hamidreza Shojaei
- Department of Neurosurgery, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
| | | | - Ebrahim Hejazian
- Department of Neurosurgery, Babol University of Medical Sciences, Babol, Mazandaran, Iran
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20
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Zheng Y, Lu Z, Shen J, Xu F. Intracranial Pseudoaneurysms: Evaluation and Management. Front Neurol 2020; 11:582. [PMID: 32733358 PMCID: PMC7358534 DOI: 10.3389/fneur.2020.00582] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/20/2020] [Indexed: 12/04/2022] Open
Abstract
Intracranial pseudoaneurysms account for about 1% of intracranial aneurysms with a high mortality. The natural history of intracranial pseudoaneurysm is not well-understood, and its management remains controversial. This review provides an overview of the etiology, pathophysiology, clinical presentation, imaging, and management of intracranial pseudoaneurysms. Especially, this article emphasizes the factors that should be considered for the most appropriate management strategy based on the risks and benefits of each treatment option.
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Affiliation(s)
- Yongtao Zheng
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Zheng Lu
- Department of Neurosurgery, Hai'an People's Hospital, Nantong, China
| | - Jianguo Shen
- Department of Neurosurgery, Second Affiliated Hospital of Jiaxiang University, Jiaxing, China
| | - Feng Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China.,Department of Neurosurgery, Kashgar Prefecture Second People's Hospital, Kashgar, China
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21
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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22
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Zhang Y, Tian Z, Li C, Liu J, Zhang Y, Yang X, Zhang Y. A modified endovascular treatment protocol for iatrogenic internal carotid artery injuries following endoscopic endonasal surgery. J Neurosurg 2020; 132:343-350. [PMID: 30684942 DOI: 10.3171/2018.8.jns181048] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 08/28/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) are catastrophic complications. Alongside the advancements in medical instrumentation and material, there is a need to modify previous treatment modalities and principles. METHODS A retrospective review of 3658 patients who underwent EES performed at the authors' institution between January 2012 and December 2017 was conducted. Ultimately, 20 patients (0.55%) with ICA injury following EES were enrolled for analysis. Data collection included demographic data, preoperative diagnosis, injury setting, repair method, and immediate and follow-up angiographic and clinical outcomes. RESULTS Among the 20 patients, 11 received immediate endovascular therapy and 9 were treated only with packing. Of the 11 patients who received endovascular treatment, 6 were treated by covered stent and 5 by parent artery occlusion (PAO). The preservation rate of injured ICA increased from 20.0% (1 of 5) to 83.3% (5 of 6) after the Willis covered stent graft became available in January 2016. Of the 20 patients in the study, 19 recovered well and 1 patient-who had a pseudoaneurysm and was treated by PAO with a detachable balloon-suffered epistaxis after the hemostat in her nasal cavity was removed in ward, and she died later that day. The authors speculated that the detachable balloon had shifted to the distal part of ICA, although the patient could not undergo a repeat angiogram because she quickly suffered shock and could not be transferred to the catheter room. After the introduction of a hybrid operating room (OR), one patient whose first angiogram showed no ICA injury was found to have a pseudoaneurysm. He received endovascular treatment when he was brought for a repeat angiogram 5 days later in the hybrid OR after removing the hemostat in his nasal cavity. Of the 4 surviving patients treated with PAO, no external carotid artery-ICA bypass was required. The authors propose a modified endovascular treatment protocol for ICA injuries suffered during EES that exploits the advantage of the covered stent graft and the hybrid OR. CONCLUSIONS The endovascular treatment protocol used in this study for ICA injuries during EES was helpful in the management of this rare complication. Willis stent placement improved the preservation rate of injured ICA during EES. It would be highly advantageous to manage this complication in a hybrid OR or by a mobile C-arm to get a clear intraoperative angiogram.
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Affiliation(s)
- Yisen Zhang
- Departments of1Interventional Neuroradiology and
| | | | - Chuzhong Li
- 2Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University.,3Key Laboratory of Central Nervous System Injury Research, Beijing.,4Beijing Institute for Brain Disorders Brain Tumor Center; and.,5China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jian Liu
- Departments of1Interventional Neuroradiology and
| | - Ying Zhang
- Departments of1Interventional Neuroradiology and
| | - Xinjian Yang
- Departments of1Interventional Neuroradiology and
| | - Yazhuo Zhang
- 2Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University.,3Key Laboratory of Central Nervous System Injury Research, Beijing.,4Beijing Institute for Brain Disorders Brain Tumor Center; and.,5China National Clinical Research Center for Neurological Diseases, Beijing, China
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23
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Akinduro OO, Gopal N, Hasan TF, Nourollah-Zadeh E, Vakharia K, De Leacy R, Burkhardt JK, Yamamoto J, Mocco J, Castilla LR, Tze Man Kan P, Boulos A, Levy E, Tawk RG. Pipeline Embolization Device for Treatment of Extracranial Internal Carotid Artery Pseudoaneurysms: A Multicenter Evaluation of Safety and Efficacy. Neurosurgery 2020; 87:770-778. [DOI: 10.1093/neuros/nyz548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 11/04/2019] [Indexed: 12/20/2022] Open
Abstract
Abstract
BACKGROUND
There is a paucity of literature regarding treatment options for extracranial pseudoaneurysms of the internal carotid artery (ICA). To date, Pipeline Embolization Device (PED; Medtronic Inc) use for the treatment of extracranial pseudoaneurysms of the ICA has only been reported from single-center case series.
OBJECTIVE
To evaluate the safety and efficacy of PED for the treatment of extracranial ICA pseudoaneurysms.
METHODS
This is a multicenter retrospective study involving 6 high-volume tertiary academic institutions in the United States. We analyzed patients with extracranial ICA pseudoaneurysms treated with PED between January 1, 2011, and January 1, 2019. Clinical assessment was performed pre- and postintervention using the modified Rankin Scale (mRS) and National Institution of Health Stroke Scale (NIHSS) at a minimum of 4-mo follow-up.
RESULTS
A total of 28 pseudoaneurysms with a mean diameter of 17.7 mm (range: 4.1-52.5 mm) were treated with PED in 24 patients at 6 participating centers. The mean age was 52.1 yr (17-73) ± 14.3 with 14 females and 10 males. At a mean of 21-mo (range 4-66 mo) follow-up, complete occlusion was achieved in 89% (n = 25/28), with near-complete occlusion (>90% occlusion) in the remainder. There were no periprocedural complications. Postprocedure NIHSS was 0 in 88% (n = 21/24) and 1 in 12% (n = 3/24) of patients, and mRS was 0 in 83% (n = 20/24) and 1 in 17% (n = 4/24) of patients.
CONCLUSION
The treatment of extracranial ICA pseudoaneurysms with PED is safe and effective in selected patients. Randomized controlled trials and prospective cohort studies are needed to establish the role of flow diversion for ICA pseudoaneurysms.
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Affiliation(s)
| | - Neethu Gopal
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | | | - Kunal Vakharia
- Department of Neurological Surgery, University at Buffalo, Buffalo, New York
| | - Reade De Leacy
- Department of Neurological Surgery, Mount Sinai, New York, New York
| | - Jan-Karl Burkhardt
- Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas
| | - Junichi Yamamoto
- Department of Neurological Surgery, Albany Medical Center, Albany, New York
| | - J Mocco
- Department of Neurological Surgery, Mount Sinai, New York, New York
| | | | - Peter Tze Man Kan
- Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas
| | - Alan Boulos
- Department of Neurological Surgery, Albany Medical Center, Albany, New York
| | - Elad Levy
- Department of Neurological Surgery, University at Buffalo, Buffalo, New York
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
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24
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Enriquez-Marulanda A, Thomas AJ. Commentary: Expanding Indications for Flow Diverters: Ruptured Aneurysms, Blister Aneurysms, and Dissecting Aneurysms. Neurosurgery 2020; 86:S104-S105. [PMID: 31838523 DOI: 10.1093/neuros/nyz409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 08/06/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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25
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Kobets AJ, Scoco A, Nakhla J, Brook AL, Kinon MD, Baxi N, Altschul D. Flow-Diverting Stents for the Obliteration of Symptomatic, Infectious Cavernous Carotid Artery Aneurysms. Oper Neurosurg (Hagerstown) 2019; 14:681-685. [PMID: 28961750 DOI: 10.1093/ons/opx166] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 06/30/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Intracavernous aneurysms constitute up to 9% of all intracranial aneurysms and 6% are infectious (IIA). First line therapy is a protracted antibiotic course, yet with failure, surgery and endovascular parent vessel sacrifice have been utilized. Reconstructive endovascular therapies have emerged for aneurysm control and may demonstrate a safer therapeutic alternative. OBJECTIVE To present an IIA treated with a flow-diverting Pipeline stent (ev3 Neurovascular, Irvine, California). METHODS A 41-yr-old female presented with visual loss, ophthalmoplegia, and cavernous sinus thrombosis with an associated phlegmon. Transsphenoidal evacuation was performed without complication or bleeding and she continued on medical therapy. Two weeks postoperatively, she developed a worsening right third cranial nerve palsy and MRA demonstrated a 1-cm right IIA, not evident on postoperative MRI. Three days of dual antiplatelet therapy preceded successful pipeline embolization. Angiography demonstrated aneurysm obliteration at 3 mo and her right ophthalmoplegia resolved. RESULTS A literature review identified 6 reported cases of IIAs treated with stent embolization. Only 1 documented a flow-diverting Silk stent used in a child. All lesions were obliterated at follow-up without neurological sequelae. No complication arose with implantation in the setting of infection, and as few as 3 d of dual antiplatelet therapy was sufficient for preprocedural prophylaxis, although in Vivo antiplatelet activity may be more significant. CONCLUSION We report the first case of an IIA treated with a flow-diverting pipeline stent. These devices preserve native vasculature and neurological function compared to surgical and endovascular vessel sacrifice strategies. They appear to be safe management options for the treatment of IIAs.
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Affiliation(s)
- Andrew Joshua Kobets
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Aleka Scoco
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Jonathan Nakhla
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Allan Leonard Brook
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York.,Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Merritt Drew Kinon
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Nrupen Baxi
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - David Altschul
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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26
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Nariai Y, Kawamura Y, Takigawa T, Hyodo A, Suzuki K. Pipeline embolization for an iatrogenic intracranial internal carotid artery pseudoaneurysm after transsphenoidal pituitary tumor surgery: Case report and review of the literature. Interv Neuroradiol 2019; 26:74-82. [PMID: 31505983 DOI: 10.1177/1591019919874943] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Intracranial pseudoaneurysms are uncommon and among the most difficult lesions to treat with surgery or endovascular means without parent artery sacrifice. Here, we report on a patient who underwent successful treatment using a flow-diverting stent for an iatrogenic intracranial internal carotid artery pseudoaneurysm following a vessel injury after endoscopic pituitary tumor resection via the transsphenoidal approach. A 62-year-old man with a Rathke's cleft cyst presenting with bitemporal hemianopia and progressive decline of left visual acuity underwent endoscopic transsphenoidal pituitary tumor resection. During dura incision, brisk arterial bleeding was encountered from the right internal carotid artery. Immediate packing was performed, and hemostasis was achieved. Three days after the vessel injury, an angiography revealed a pseudoaneurysm (2.9 × 2.1 mm) at the cavernous segment of the right internal carotid artery, which showed enlargement on follow-up magnetic resonance imaging at six days postoperatively. Pipeline embolization was performed nine days after the vessel injury. Angiography performed one month after Pipeline embolization revealed significant stagnation but not complete occlusion of blood flow inside the pseudoaneurysm cavity. Dual antiplatelet therapy was replaced with single antiplatelet therapy. Follow-up angiograms three months after Pipeline embolization confirmed complete obliteration of the pseudoaneurysm and successful endoluminal reconstruction of the damaged vessel. Despite the possibility of short-term bleeding and the need for dual antiplatelet therapy administration for a certain period, the use of flow-diverting stents is a feasible vessel-sparing option in the management of intracranial internal carotid artery pseudoaneurysms resulting from transsphenoidal surgery injuries if intraoperative hemodynamic stability can be achieved with effective packing.
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Affiliation(s)
- Yasuhiko Nariai
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Yosuke Kawamura
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
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27
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Chen SH, McCarthy DJ, Sheinberg D, Hanel R, Sur S, Jabbour P, Atallah E, Chalouhi N, Dumont A, Amenta P, Hasan D, Raper D, Liu K, Jane JA, Crowley RW, Aguilar-Salinas P, Bentley J, Monteith S, Mitchell BD, Yavagal DR, Peterson EC, Starke RM. Pipeline Embolization Device for the Treatment of Intracranial Pseudoaneurysms. World Neurosurg 2019; 127:e86-e93. [PMID: 30849553 DOI: 10.1016/j.wneu.2019.02.135] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Intracranial pseudoaneurysms (PSAs) are associated with high rupture and mortality rates and have traditionally been treated by parent vessel sacrifice. There has been recent interest in using flow-diverting devices for treatment of these complex lesions while preserving flow through the parent artery. The objective of this study is to examine the safety and efficacy of these devices in the treatment of intracranial PSA. METHODS We performed a multi-institutional retrospective study of intracranial PSAs treated with the Pipeline Embolization Device (PED) between 2014 and 2017 at 7 institutions. Complications and clinical and radiographic outcomes were reviewed. RESULTS A total of 19 patients underwent PED placement for intracranial PSA. Iatrogenic injury and trauma comprised most etiologies in our series. The mean pseudoaneurysm diameter was 8.8 mm, and 18 of 19 PSAs (95%) involved the internal carotid artery (ICA). Multiple PEDs were deployed in a telescoping fashion in 7 patients (37%). Of the 18 patients with follow up imaging, 14 (78%) achieved complete pseudoaneurysm obliteration and 2 achieved near-complete obliteration (11%). Two patients (11%) were found to have significant pseudoaneurysm progression on short-term follow-up and required ICA sacrifice. No patients experienced new neurologic deficits or deterioration secondary to PED placement. No patients experienced bleeding or rebleeding from PSA. CONCLUSIONS In well-selected patients, the use of flow-diverting stents may be a feasible alternative to parent vessel sacrifice. Given the high morbidity and mortality associated with PSA, we recommend short- and long-term radiographic follow-up for patients treated with flow-diverting stents.
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Affiliation(s)
- Stephanie H Chen
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - David J McCarthy
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA.
| | - Dallas Sheinberg
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Ricardo Hanel
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA; Department of Neurological Surgery, Baptist Health, Miami, Florida, USA
| | - Samir Sur
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elias Atallah
- Department of Neurological Surgery, Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, Jefferson University, Philadelphia, Pennsylvania, USA
| | - Aaron Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - Peter Amenta
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - David Hasan
- Department of Neurological Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Daniel Raper
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Kenneth Liu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - John A Jane
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - R Webster Crowley
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Josh Bentley
- Department of Neurological Surgery, Swedish Health, Seattle, Washington, USA
| | - Stephen Monteith
- Department of Neurological Surgery, Swedish Health, Seattle, Washington, USA
| | - Bartley D Mitchell
- Department of Neurological Surgery, Methodist Institute, Houston, Texas, USA
| | - Dileep R Yavagal
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Eric C Peterson
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
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28
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Hanihara M, Yoshioka H, Kanemaru K, Hashimoto K, Shimizu M, Nishigaya K, Fukamachi A, Kinouchi H. Long-Term Clinical and Angiographic Outcomes of Wrap-Clipping for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery Using Advanced Monitoring. World Neurosurg 2019; 126:e439-e446. [DOI: 10.1016/j.wneu.2019.02.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
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29
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Chen H, Chen R, Yang H, Li H, Wang J, Yu J. Outcome of a Blood Blister-Like Aneurysm Treated by Clip-Reinforced Wrapping Technique Using Y-Shaped Temporalis Fascia for Perforator Protection. World Neurosurg 2019; 128:376-380. [PMID: 30986585 DOI: 10.1016/j.wneu.2019.04.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND The optimal approach of blood blister-like aneurysms (BBAs) is debated. Wrapping has been reported to be an effective strategy, but artificial materials have often been used. In addition, perforator protection is difficult using this technique. In this case, we report a ruptured BBA of the left internal carotid artery (ICA) treated with a clip-reinforced wrapping technique using Y-shaped autologous temporalis fascia to protect the posterior communicating artery (PComA). The outcome was favorable. CASE DESCRIPTION A 48-year-old woman was admitted for subarachnoid hemorrhage. Digital subtraction angiography (DSA) revealed a BBA located opposite the PComA origin. A frontotemporal craniotomy was performed. The temporalis fascia was isolated from the temporalis muscle, and then tailored into a Y shape for the PComA to pass through. The diseased segment and the BBA were then wrapped by the Y-shaped temporalis fascia circumferentially. Two clips were applied to the fascia to reinforce the wrapping to fit snugly enough around the parent artery subsequently. DSA and computed tomography angiography scan postoperation showed that the BBA had not recurred, the supraclinoid segment of the left ICA had reconstructed well, and the PComA was unobstructed. The patient recovered without any sequelae during the 1-year follow-up period. CONCLUSIONS A clip-reinforced wrapping technique using Y-shaped temporalis fascia may be an effective method for treating BBAs located opposite the PComA origin. Long-term follow-up and large sample size studies, however, are necessary to validate this approach.
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Affiliation(s)
- Hao Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China
| | - Rudong Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China
| | - Hongkuan Yang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China
| | - Hua Li
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China
| | - Junhong Wang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China
| | - Jiasheng Yu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China.
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Hellstern V, Aguilar-Pérez M, AlMatter M, Bhogal P, Henkes E, Ganslandt O, Henkes H. Microsurgical clipping and endovascular flow diversion of ruptured anterior circulation blood blister-like aneurysms. Interv Neuroradiol 2018; 24:615-623. [PMID: 30001647 PMCID: PMC6259333 DOI: 10.1177/1591019918785911] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/06/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Detection and treatment of blister-like intracranial aneurysms as a source of subarachnoid hemorrhage (SAH) can be challenging. In the past the results of both microsurgical and endovascular treatment were difficult. We present our experience with the treatment of blister-like aneurysms in the acute phase of SAH using microsurgical clipping, endovascular parent vessel occlusion or flow diversion. METHODS A retrospective analysis of the cases of eight consecutive patients presenting in the acute phase after SAH from an intracranial blister aneurysm was performed. The demographic data of the patients, aneurysm characteristics, the clinical results of the treatment and the follow-up examinations were recorded. Procedural safety margins and aneurysm occlusion on follow-up digital subtraction angiography were the main interest of this evaluation. RESULTS Between January 2012 and November 2017 a total of eight ruptured blister aneurysms were treated in our center, six patients endovascularly. Five patients were treated in the acute phase of SAH, four by flow diversion. All endovascular procedures were feasible and no procedure-related complications were observed, especially no recurrent hemorrhage. In the first angiographic follow-up all blood blister-like aneurysms were completely occluded; two of the six patients treated by flow diverter implantation showed mild, transient intimal hyperplasia without clinical symptoms or the need for treatment. CONCLUSIONS Endovascular flow diversion is a viable option in the acute phase after SAH due to the rupture of a blister aneurysm. Implants with reduced thrombogenicity, obviating dual-platelet function inhibition, and flow diverters for vessel bifurcations would extend the indications for this treatment modality.
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Affiliation(s)
- V Hellstern
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - M Aguilar-Pérez
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - M AlMatter
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - P Bhogal
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - E Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
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Treatment of ruptured blood blister-like aneurysms of the internal carotid artery with flow-diverting stents: Case report and review of pharmacological management. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Emergency placement of a Flow Diverter Stent for an Iatrogenic Internal Carotid Artery Injury During Endoscopic Pituitary Surgery. World Neurosurg 2018; 122:376-379. [PMID: 30439523 DOI: 10.1016/j.wneu.2018.10.234] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/29/2018] [Accepted: 10/31/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Internal carotid artery (ICA) injury is 1 of the most feared complications in endoscopic pituitary surgery. Different endovascular techniques are available for the management of early and delayed ICA injuries. CASE REPORT We report a case of emergency endovascular treatment with a flow diverter stent for an ICA injury that occurred during endoscopic transphenoidal surgery for pituitary macroadenoma in a 66-year-old man. Effective intraoperative hemostasis was achieved by direct packing of the sphenoid sinus. Digital subtraction angiography demonstrated extravasation of the contrast agent into the sphenoidal sinus from the anterior genu of the intracavernous portion of the right ICA. Balloon test occlusion resulted in a prominent delay in the venous phase in the right hemisphere during occlusion of the right ICA. Taking into account the hemodynamic stability and the absence of intracranial bleeding, we considered the ICA injury as if it were a pseudoaneurysm. Therefore, an emergency release of a flow diverter stent was performed, in association with antiplatelet therapy. No periprocedural complications occurred. The patient was discharged without neurologic deficits. The last follow-up studies at 6 months (digital subtraction angiography and magnetic resonance imaging) confirmed the regular placement of the stent and vessel reconstruction. CONCLUSIONS Despite the presence of acute hemorrhage and the need for antiplatelet therapy, a flow diverter stent can be used as emergency treatment of ICA injury in selected circumstances.
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Bhogal P, Henkes E, Schob S, AlMatter M, Hellstern V, Bäzner H, Ganslandt O, Henkes H, Pérez MA. The use of flow diverters to treat small (≤5 mm) ruptured, saccular aneurysms. Surg Neurol Int 2018; 9:216. [PMID: 30505618 PMCID: PMC6219287 DOI: 10.4103/sni.sni_243_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 08/30/2018] [Indexed: 11/08/2022] Open
Abstract
Background: There is limited published literature on the use of flow diverting stents (FDS) to treat ruptured intracranial aneurysms in the acute stage. We present our experience of using FDS to treat small (≤5 mm) ruptured aneurysms. Methods: We retrospectively identified all patients with ≤5 mm ruptured aneurysms treated exclusively with FDS between February 2009 and February 2016. We recorded demographic data, the Hunt and Hess score, aneurysm location and size, therapeutic intervention, immediate angiographic and clinical result, and clinical and radiological follow-up information. Results: We identified seven patients (four females) with average age 59.8 ± 10 years (range 48–75). The average aneurysm fundus size was 2.7 ± 0.76 mm (range 1–4 mm). The average time from ictus to treatment was 6.3 days (range 1–14 days) and there were no cases of repeat rupture prior to treatment or intraoperative rupture. Angiographic follow-up was available in five patients. At initial follow-up, aneurysms (100%) were completely occluded raymond roy classification 1 (RRC 1). None of the aneurysms re-ruptured following treatment. Clinically, six patients were discharged with good functional outcome modified Rankin Score (mRS ≤2). There were no mortalities. Conclusion: The use of FDS to treat small, ruptured, saccular aneurysms is feasible; however, the use of FDS should not be considered first-line treatment. Further studies are required to determine the safety and efficacy of the use of FDS in the acute situation.
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Affiliation(s)
- Pervinder Bhogal
- Department of Neuroradiology, The Royal London Hospital, London, UK
| | - Elina Henkes
- Neuroradiological Clinic, Neurocenter, Leipzig, Germany
| | - Stefan Schob
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | | | | | | | - Oliver Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Leipzig, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Leipzig, Germany.,Medical Faculty, University Duisburg-Essen, Duisburg, Germany
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Mahajan A, Das B, Narang KS, Jha AN, Singh VP, Sapra H, Goel G. Surpass Flow Diverter in the Treatment of Ruptured Intracranial Aneurysms-A Single-Center Experience. World Neurosurg 2018; 120:e1061-e1070. [PMID: 30213677 DOI: 10.1016/j.wneu.2018.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/30/2018] [Accepted: 09/02/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Use of a Surpass flow diverter (FD) device in the treatment of acutely ruptured aneurysm has not been well studied and reported in the literature. METHODS We retrospectively reviewed patients with subarachnoid hemorrhage who were treated by Surpass FD placement at our hospital between June 2016 and March 2018. Detailed analysis of medical records was performed to obtain patient age, gender, clinical history, Hunt and Hess grade, Fisher grade, results of radiographic and procedural details including technical success and complication, clinical outcome, and follow-up angiographic results. RESULTS Our search identified 16 patients with 16 aneurysms who were treated with Surpass FD, of which 13 aneurysms (81%) were in the anterior circulation and 3 (19%) were in the posterior circulation. Aneurysm size ranged from 1.1 to 16 mm, with a mean of 4 mm. The mean delay between subarachnoid hemorrhage and endovascular treatment was 5 days (range, 3-20 days). Only 1 Surpass FD was used in each patient, ranging in size from 3 × 25 mm to 4 × 50 mm. Fifteen patients (94%) achieved favorable clinical outcome (modified Rankin Scale score 0-1) at 3 months. One patient died of invasive fungal infection. Angiographic follow-up results were assessed by O'Kelly-Marotta grading scale in 15 surviving patients and showed a grade D result (no filling) in 13/15 aneurysms (87%) at 3 and 6 months. CONCLUSIONS A Surpass FD device is a feasible option for the treatment of ruptured intracranial aneurysms that are difficult to treat by conventional clipping and coiling; however, larger and comparative studies with long-term follow-up are needed to confirm its safety and efficacy.
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Affiliation(s)
- Anshu Mahajan
- Department of Neurointerventional surgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Biplab Das
- Department of Neurointerventional surgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Karanjit Singh Narang
- Department of Neurosurgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Ajaya Nand Jha
- Department of Neurosurgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Varindera Paul Singh
- Department of Neurosurgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Harsh Sapra
- Department of Neuroanaesthesia and Critical Care, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Gaurav Goel
- Department of Neurointerventional surgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India.
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Hao X, Li G, Ren J, Li J, He C, Zhang HQ. Endovascular Patch Embolization for Blood Blister–Like Aneurysms in Dorsal Segment of Internal Carotid Artery. World Neurosurg 2018; 113:26-32. [DOI: 10.1016/j.wneu.2018.01.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 01/01/2018] [Accepted: 01/04/2018] [Indexed: 11/16/2022]
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36
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Griauzde J, Ravindra VM, Chaudhary N, Gemmete JJ, Mazur MD, Roark CD, Couldwell WT, Park MS, Taussky P, Pandey AS. Use of the Pipeline embolization device in the treatment of iatrogenic intracranial vascular injuries: a bi-institutional experience. Neurosurg Focus 2018; 42:E9. [PMID: 28565993 DOI: 10.3171/2017.3.focus1735] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow-diverting devices have been used for the treatment of complex intracranial vascular pathology with success, but the role of these devices in treating iatrogenic intracranial vascular injuries has yet to be clearly defined. Here, the authors report their bi-institutional experience with the use of the Pipeline embolization device (PED) for the treatment of iatrogenic intracranial vascular injuries. METHODS The authors reviewed a retrospective cohort of patients with iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2012 and 2016. Data collection included demographic data, indications for treatment, number and sizes of PEDs used, and immediate and follow-up angiographic and clinical outcomes. RESULTS Four patients with a mean age of 47.5 years (range 18-63 years) underwent PED placement for iatrogenic vessel injuries. In 3 patients, the intracranial internal carotid artery (ICA) was injured during transnasal tumor resection. In 1 patient, a basilar apex injury occurred during endoscopic third ventriculostomy. Three patients had a pseudoaneurysm as a result of vessel injury, and 1 patient had frank ICA laceration and extravasation. All 3 pseudoaneurysms were successfully treated with PED deployment. The ICA laceration was refractory to PED placement, and the vessel was subsequently occluded endovascularly. All 4 patients had a good clinical outcome (modified Rankin Scale score of 0 or 1). CONCLUSIONS The use of the PED is feasible in the management of iatrogenic pseudoaneurysms of the intracranial vasculature. In cases of frank vessel perforation, an alternative strategy such as covered stent placement should be considered. Endovascular or surgical vessel occlusion remains the definitive treatment in cases of refractory hemorrhage.
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Affiliation(s)
| | - Vijay M Ravindra
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah; and
| | | | - Joseph J Gemmete
- Departments of 1 Radiology.,Neurosurgery, and.,Otolaryngology, University of Michigan Health System, Ann Arbor, Michigan
| | - Marcus D Mazur
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah; and
| | - Christopher D Roark
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - William T Couldwell
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah; and
| | - Min S Park
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah; and
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah; and
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Walcott BP, Koch MJ, Stapleton CJ, Patel AB. Blood Flow Diversion as a Primary Treatment Method for Ruptured Brain Aneurysms-Concerns, Controversy, and Future Directions. Neurocrit Care 2018; 26:465-473. [PMID: 27844465 DOI: 10.1007/s12028-016-0318-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Flow diversion is a novel treatment for brain aneurysms that works by redirecting blood flow away from the aneurysm. Immediately after placement of the stent, blood flow stagnates within the aneurysm dome and it undergoes thrombosis. Over time, a new endothelium develops across the neck, thereby reconstructing the parent vessel and curing the aneurysm. The use of this treatment method for ruptured aneurysms has two specific concerns: 1) risk of hemorrhage from the aneurysm after treatment because of potential delayed aneurysm occlusion; and 2) hemorrhagic complications from antiplatelet use, which is required to prevent thromboembolic complications from the device. In this review, we explore these two concerns based on the emerging published literature. Optimal peri-procedural management of these issues in the neurocritical care setting is vital to improving outcomes. We also identify ongoing clinical trials of flow diversion for the treatment of ruptured aneurysms. Flow diversion is an alternative to clipping or coiling for many ruptured aneurysms and may be potentially more efficacious in certain aneurysm subtypes.
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Affiliation(s)
- Brian P Walcott
- Department of Neurological Surgery, University of Southern California, USC Healthcare Center II, 1520 San Pablo St #3800, Los Angeles, CA, 90033, USA.
| | - Matthew J Koch
- Department of Neurological Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Christopher J Stapleton
- Department of Neurological Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Department of Neurological Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
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Mazur MD, Taussky P, MacDonald JD, Park MS. Rerupture of a Blister Aneurysm After Treatment With a Single Flow-Diverting Stent. Neurosurgery 2017; 79:E634-E638. [PMID: 27759680 DOI: 10.1227/neu.0000000000001412] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE As the use of flow-diverting stents (FDSs) for intracranial aneurysms expands, a small number of case reports have described the successful treatment of blister aneurysms of the internal carotid artery with flow diversion. Blister aneurysms are uncommon and fragile lesions that historically have high rates of morbidity and mortality despite multiple treatment strategies. We report a case of rebleeding after treatment of a ruptured blister aneurysm with deployment of a single FDS. CLINICAL PRESENTATION A 29-year-old man presented with subarachnoid hemorrhage and a ruptured dorsal variant internal carotid artery aneurysm. Despite a technically successful treatment with a single FDS, a second catastrophic hemorrhage occurred during the course of his hospitalization. CONCLUSION This case highlights the risk of hemorrhage during the period after deployment of a single FDS. Ruptured aneurysms, especially of the blister type, are at risk for rehemorrhage while the occlusion remains incomplete after flow diversion. ABBREVIATIONS FDS, flow-diverting stentICA, internal carotid arterySAH, subarachnoid hemorrhage.
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Affiliation(s)
- Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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Guo Y, Zhang J, Chen H, Xu K, Yu J. Suturing and Dural Wrapping for a Blood Blister-Like Aneurysm on the Supraclinoid Segment of the Internal Carotid Artery due to Dissection. World Neurosurg 2017; 109:165-170. [PMID: 28987850 DOI: 10.1016/j.wneu.2017.09.186] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/25/2017] [Accepted: 09/26/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Internal carotid artery (ICA) reconstruction is still the most effective treatment for a blood blister-like aneurysm (BBA) on the supraclinoid segment of the ICA, and clipping after wrapping has the most precise effects. However, the materials used are most often artificial. This study examined the use of autologous dura to replace the artificial materials used for wrapping after suturing a BBA. CASE DESCRIPTION A 38-year-old man was hospitalized for subarachnoid hemorrhage. Computed tomography angiography of the head and digital subtraction angiography showed a BBA on the dorsal supraclinoid segment of the ICA. A right frontotemporal craniotomy with extradural resection of the anterior clinoid was adopted. The aneurysm was trapped with temporary clips and was found to be derived from dissection of the ICA. The separated adventitia and vascular wall were sutured to reconstruct the vascular wall first, and then the dura was cut and shaped to wrap the supraclinoid segment of the ICA. The dura was sutured onto the ICA wall to prevent dislocation. A 6-month follow-up digital subtraction angiography review showed that the supraclinoid segment of the ICA was well reconstructed, the vascular cavity exhibited slight stenosis, and BBA did not recur. Postoperative follow-up magnetic resonance imaging showed satisfying images. CONCLUSIONS The method we adopted is new and showed satisfactory curative results, suggesting that ICA suturing with dura mater wrapping may become a method for the treatment of a BBA on the supraclinoid segment. The dura could potentially replace the artificial materials used for wrapping the ICA.
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Affiliation(s)
- Yunbao Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, P. R. China
| | - Jinzhu Zhang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, P. R. China
| | - Hao Chen
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, P. R. China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, P. R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, P. R. China.
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Heit JJ, Telischak NA, Do HM, Dodd RL, Steinberg GK, Marks MP. Pipeline embolization device retraction and foreshortening after internal carotid artery blister aneurysm treatment. Interv Neuroradiol 2017; 23:614-619. [PMID: 28758549 DOI: 10.1177/1591019917722514] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Subarachnoid hemorrhage (SAH) secondary to rupture of a blister aneurysm (BA) results in high morbidity and mortality. Endovascular treatment with the pipeline embolization device (PED) has been described as a new treatment strategy for these lesions. We present the first reported case of PED retraction and foreshortening after treatment of a ruptured internal carotid artery (ICA) BA. Case description A middle-aged patient presented with SAH secondary to ICA BA rupture. The patient was treated with telescoping PED placement across the BA. After 5 days from treatment, the patient developed a new SAH due to re-rupture of the BA. Digital subtraction angiography revealed an increase in caliber of the supraclinoid ICA with associated retraction and foreshortening of the PED that resulted in aneurysm uncovering and growth. Conclusions PED should be oversized during ruptured BA treatment to prevent device retraction and aneurysm regrowth. Frequent imaging follow up after BA treatment with PED is warranted to ensure aneurysm occlusion.
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Affiliation(s)
- Jeremy J Heit
- 1 Department of Radiology, Neuroimaging and Neurointervention Division, Stanford University Medical Center, Stanford, CA, USA
| | - Nicholas A Telischak
- 1 Department of Radiology, Neuroimaging and Neurointervention Division, Stanford University Medical Center, Stanford, CA, USA
| | - Huy M Do
- 1 Department of Radiology, Neuroimaging and Neurointervention Division, Stanford University Medical Center, Stanford, CA, USA
| | - Robert L Dodd
- 2 Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| | - Gary K Steinberg
- 2 Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| | - Michael P Marks
- 1 Department of Radiology, Neuroimaging and Neurointervention Division, Stanford University Medical Center, Stanford, CA, USA
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Yang C, Vadasz A, Szikora I. Treatment of ruptured blood blister aneurysms using primary flow-diverter stenting with considerations for adjunctive coiling: A single-centre experience and literature review. Interv Neuroradiol 2017; 23:465-476. [PMID: 28758550 DOI: 10.1177/1591019917720805] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective The objective of this article is to conduct a single-centre evaluation and quick literature review of the effectiveness of primary flow-diverter (FD) treatment of ruptured blood blister aneurysms (BBAs), with additional relevance of adjunctive coiling. Methods Patients presenting with subarachnoid haemorrhage (SAH) due to ruptured BBAs and subsequently treated with FDs were retrospectively selected from June 2010 to January 2017. Treatment techniques, angiographic data on occlusion rates and procedural success as well as clinical outcomes using the modified Rankin Scale (mRS) were collated. Cross-reference of results were made with available literature. Results Thirteen patients harbouring 14 BBAs were recruited. Of the 14 aneurysms, five (35.7%) showed immediate complete occlusion after the procedure (four of these five patients had adjunctive coiling). All of the aneurysms showed complete occlusion by the six- to nine-month control diagnostic angiogram. No rebleed or retreatment was experienced. Twelve of 13 (92%) patients had an mRS score of 0-1 at the last clinical follow-up. From the pooled data of the literature review, eventual aneurysm occlusion was achieved in 48/56 patients, with five patients requiring further endovascular treatment. In the clinical follow-up period, an mRS of 0-2 was recorded for 83.3% (45/54) of patients. Conclusion Endovascular reconstruction of BBAs using FD treatment is an effective method with good final clinical outcomes. Adjunctive use of coiling achieves higher incidence of immediate complete occlusion of BBAs.
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Affiliation(s)
- Cunli Yang
- Department of Neurointerventions, National Institute of Neurosciences, Budapest, Hungary
| | - Agnes Vadasz
- Department of Neurointerventions, National Institute of Neurosciences, Budapest, Hungary
| | - István Szikora
- Department of Neurointerventions, National Institute of Neurosciences, Budapest, Hungary
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42
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Natarajan SK, Shallwani H, Fennell VS, Beecher JS, Shakir HJ, Davies JM, Snyder KV, Siddiqui AH, Levy EI. Flow Diversion after Aneurysmal Subarachnoid Hemorrhage. Neurosurg Clin N Am 2017; 28:375-388. [DOI: 10.1016/j.nec.2017.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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43
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Patel PD, Chalouhi N, Atallah E, Tjoumakaris S, Hasan D, Zarzour H, Rosenwasser R, Jabbour P. Off-label uses of the Pipeline embolization device: a review of the literature. Neurosurg Focus 2017; 42:E4. [DOI: 10.3171/2017.3.focus1742] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The Pipeline embolization device (PED) is the most widely used flow diverter in endovascular neurosurgery. In 2011, the device received FDA approval for the treatment of large and giant aneurysms in the internal carotid artery extending from the petrous to the superior hypophyseal segments. However, as popularity of the device grew and neurosurgeons gained more experience, its use has extended to several other indications. Some of these off-label uses include previously treated aneurysms, acutely ruptured aneurysms, small aneurysms, distal circulation aneurysms, posterior circulation aneurysms, fusiform aneurysms, dissecting aneurysms, pseudoaneurysms, and even carotid-cavernous fistulas. The authors present a literature review of the safety and efficacy of the PED in these off-label uses.
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Affiliation(s)
- Purvee D. Patel
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
- 2Department of Neurological Surgery, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey; and
| | - Nohra Chalouhi
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Elias Atallah
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- 3Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Hekmat Zarzour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Abstract
Blister aneurysms are rare cerebrovascular lesions for which the treatment methods are reviewed here, with a focus on endovascular options. The reported pathogenesis of blister aneurysms varies, and hemodynamic stress, arterial dissection, and arteriosclerotic ulceration have all been described. There is consensus on the excessive fragility of blister aneurysms and their parent vessels, which makes clipping technically difficult. Open surgical treatment is associated with high rates of complications, morbidity, and mortality; endovascular treatment is a promising alternative. Among endovascular treatment options, deconstructive treatment has been associated with higher morbidity compared with reconstructive methods such as direct embolization, stent- or balloon-assisted direct embolization, stent monotherapy, and flow diversion. Flow diversion has been associated with higher technical success rates and similar clinical outcomes compared with non–flow diverting treatment methods. However, delayed aneurysm occlusion and the need for antiplatelet therapy are potential drawbacks to flow diversion that must be considered when choosing among treatment methods for blister aneurysms.
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Park KS, Kang DH, Son WS, Park J, Kim YS, Kim BM. A Case of Ruptured Blood Blister-like Aneurysm Treated with Pipeline Embolization Device: Clinical Significance of Fetal-type Posterior Communicating Artery. Neurointervention 2017; 12:40-44. [PMID: 28316868 PMCID: PMC5355460 DOI: 10.5469/neuroint.2017.12.1.40] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/02/2017] [Indexed: 11/24/2022] Open
Abstract
Blood-blister like aneurysms (BBAs) are challenging lesions because of their wide fragile neck. Flow-diverting stents (FDSs), such as the Pipeline Embolization Device (PED), have been applied to treat BBAs less amenable to more established techniques of treatment. However, the use of FDSs, including the PED, in acute subarachnoid hemorrhage (SAH) still remains controversial. We report a case of aneurysm regrowth following PED application for a ruptured BBA that overlapped the origin of the dominant posterior communicating artery (PCoA), which was successfully treated after coil trapping of the origin of the fetal-type PCoA. And, we discuss the clinical significance of the fetal-type PCoA communicating with a BBA in terms of PED failure.
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Affiliation(s)
- Ki-Su Park
- Department of Neurosurgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Dong-Hun Kang
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea.; Department of Radiology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Won-Soo Son
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jaechan Park
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Young-Sun Kim
- Department of Radiology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Byung Moon Kim
- Department of Radiology, Younsei University College of Medicine, Seoul, South, Korea
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Owen CM, Montemurro N, Lawton MT. Blister Aneurysms of the Internal Carotid Artery: Microsurgical Results and Management Strategy. Neurosurgery 2017; 80:235-247. [DOI: 10.1227/neu.0000000000001259] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 02/29/2016] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND: Blister aneurysms of the supraclinoid internal carotid artery (ICA) are challenging lesions with high intraoperative rupture rates and significant morbidity. An optimal treatment strategy for these aneurysms has not been established.
OBJECTIVE: To analyze treatment strategy, operative techniques, and outcomes in a consecutive 17-year series of ICA blister aneurysms treated microsurgically.
METHODS: Seventeen patients underwent blister aneurysm treatment with direct clipping, bypass and trapping, or clip-reinforced wrapping.
RESULTS: Twelve aneurysms (71%) were treated with direct surgical clipping. Three patients required bypass: 1 superficial temporal artery to middle cerebral artery bypass, 1 external carotid artery to middle cerebral artery bypass, and 1 ICA to middle cerebral artery bypass. One patient was treated with clip-reinforced wrapping. Initial treatment strategy was enacted 71% of the time. Intraoperative rupture occurred in 7 patients (41%), doubling the rate of a poor outcome (57% vs 30% for patients with and without intraoperative rupture, respectively). Severe vasospasm developed in 9 of 16 patients (56%). Twelve patients (65%) were improved or unchanged after treatment, and 10 patients (59%) had good outcomes (modified Rankin Scale scores of 1 or 2).
CONCLUSION: ICA blister aneurysms can be cautiously explored and treated with direct clipping as the first-line technique in the majority of cases. Complete trapping of the parent artery with temporary clips and placing permanent clip blades along normal arterial walls enables clipping that avoids intraoperative aneurysm rupture. Trapping/bypass is used as the second-line treatment, maintaining a low threshold for bypass with extensive or friable pathology of the carotid wall and in patients with incomplete circles of Willis.
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Affiliation(s)
- Christopher M. Owen
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Nicola Montemurro
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Michael T. Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Wang A, Santarelli J, Stiefel MF. Pipeline embolization device as primary treatment for cervical internal carotid artery pseudoaneurysms. Surg Neurol Int 2017; 8:3. [PMID: 28217382 PMCID: PMC5288989 DOI: 10.4103/2152-7806.198730] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 11/15/2016] [Indexed: 12/16/2022] Open
Abstract
Background: Limited data exists on the durability and occlusion rate of treating extracranial cervical internal carotid artery pseudoaneurysms using the pipeline embolization device (PED) flow-diverting stent. Methods: Three patients presenting with dissecting cervical internal carotid artery pseudoaneurysms were treated with the PED as the sole treatment modality. Results: In all three patients, successful aneurysmal occlusion and parent vessel reconstruction occurred on immediate angiography and continued on 6-month follow-up. No immediate or delayed complications were seen, and all patients remained neurologically intact. Conclusion: Complete aneurysmal occlusion and long-term angiographic occlusion can occur after PED treatment of cervical carotid pseudoaneurysms. In select patients, the PED can be a suitable primary treatment modality with good neurological outcome for cervical carotid pseudoaneurysms.
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Affiliation(s)
- Arthur Wang
- Department of Neurosurgery, New York Medical College, Valhalla, New York, USA
| | - Justin Santarelli
- Department of Neurosurgery, New York Medical College, Valhalla, New York, USA; NeuroVascular Institute, Westchester Medical Center, Valhalla, New York, USA
| | - Michael F Stiefel
- Capital Institute for Neurosciences, Stroke and Cerebrovascular Center, Capital Health System, Trenton, NJ, USA
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48
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Ji T, Guo Y, Huang X, Xu B, Xu K, Yu J. Current status of the treatment of blood blister-like aneurysms of the supraclinoid internal carotid artery: A review. Int J Med Sci 2017; 14:390-402. [PMID: 28553172 PMCID: PMC5436482 DOI: 10.7150/ijms.17979] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 02/26/2017] [Indexed: 11/05/2022] Open
Abstract
Currently, the treatment of blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA) is challenging and utilizes many therapeutic methods, including direct clipping and suturing, clipping after wrapping, clipping after suturing, coil embolization, stent-assisted coil embolization, multiple overlapping stents, flow-diverting stents, covered stents, and trapping with or without bypass. In these therapeutic approaches, the optimal treatment method for BBAs has not yet been defined based on the current understanding of BBAs of the supraclinoid ICA. Therefore, in this study, we aimed to review the literature from PubMed to discuss and analyze the pros and cons of the above approaches while adding our own viewpoints to the discussion. Among the surgical methods, direct clipping was the easiest method if the compensation of the collateral circulation of the intracranial distal ICA was sufficient or direct clipping did not induce stenosis in the parent artery. In addition, the clipping after wrapping technique should be chosen as the optimal surgical modality to prevent rebleeding from these lesions. Among the endovascular methods, multiple overlapping stents (≥3) with coils may be a feasible alternative for the treatment of ruptured BBAs. In addition, flow-diverting stents appear to have a higher rate of complete occlusion and a lower rate of retreatment and are a promising treatment method. Finally, when all treatments failed or the compensation of the collateral circulation of the intracranial distal ICA was insufficient, the extracranial-intracranial (EC-IC) arterial bypass associated with surgical or endovascular trapping, a complex and highly dangerous method, was used as the treatment of last resort.
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Affiliation(s)
- Tiefeng Ji
- Department of Radiology, The First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Yunbao Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Xiuying Huang
- Department of Operation, The First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, P.R. China
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Madaelil TP, Moran CJ, Cross DT, Kansagra AP. Flow Diversion in Ruptured Intracranial Aneurysms: A Meta-Analysis. AJNR Am J Neuroradiol 2016; 38:590-595. [PMID: 28007770 DOI: 10.3174/ajnr.a5030] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/11/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Flow diversion is now an established technique to treat unruptured intracranial aneurysms not readily amenable to endovascular coil embolization or open microsurgical occlusion. The role of flow-diverting devices in treating ruptured aneurysms is less clear. PURPOSE To estimate rates of angiographic occlusion and good clinical outcome in patients with ruptured intracranial aneurysms treated with flow-diverting devices. DATA SOURCES Systematic review of Ovid MEDLINE, PubMed, Cochrane databases, and EMBASE from inception to December 2015 for articles that included ruptured aneurysms treated with flow diversion. STUDY SELECTION One hundred seventy-two records were screened, of which 20 articles contained sufficient patient and outcome data for inclusion. DATA ANALYSIS Clinical and radiologic characteristics, procedural details, and outcomes were extracted from these reports. Aggregated occlusion rates and clinical outcomes were analyzed by using the Fisher exact test (statistical significance, α = .05). DATA SYNTHESIS Complete occlusion of the aneurysm was achieved in 90% of patients, and favorable clinical outcome was attained in 81%. Aneurysm size greater than 7 mm was associated with less favorable clinical outcomes (P = .027). Aneurysm size greater than 2 cm was associated with a greater risk of rerupture after treatment (P < .001). LIMITATIONS Observational studies and case reports may be affected by reporting bias. CONCLUSIONS Although not recommended as a first-line treatment, the use of flow diverters to treat ruptured intracranial aneurysms may allow high rates of angiographic occlusion and good clinical outcome in carefully selected patients. Aneurysm size contributes to treatment risk because the rerupture rate following treatment is higher for aneurysms larger than 2 cm.
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Affiliation(s)
- T P Madaelil
- From the Mallinckrodt Institute of Radiology (T.P.M., C.J.M., D.T.C., A.P.K.)
| | - C J Moran
- From the Mallinckrodt Institute of Radiology (T.P.M., C.J.M., D.T.C., A.P.K.).,Department of Neurosurgery (C.J.M., D.T.C., A.P.K.), Washington University School of Medicine, St. Louis, Missouri
| | - D T Cross
- From the Mallinckrodt Institute of Radiology (T.P.M., C.J.M., D.T.C., A.P.K.).,Department of Neurosurgery (C.J.M., D.T.C., A.P.K.), Washington University School of Medicine, St. Louis, Missouri
| | - A P Kansagra
- From the Mallinckrodt Institute of Radiology (T.P.M., C.J.M., D.T.C., A.P.K.).,Department of Neurosurgery (C.J.M., D.T.C., A.P.K.), Washington University School of Medicine, St. Louis, Missouri
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50
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Tsang ACO. Letter to the Editor: Internal carotid artery injuries secondary to endonasal surgery. J Neurosurg 2016; 125:1315-1317. [PMID: 27540906 DOI: 10.3171/2016.4.jns16936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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