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Griessenauer CJ, Dodier P, Stroh NH, Mercea PA, Bavinzski G, Dorfer C, Rössler K, Gruber A, Gmeiner M, Thomé C, Leber KA, Wolfsberger S, Baghban M, Al-Schameri R, Kral M, Thakur S, Lunzer M, Popadic B, Sherif C, Juráň V, Smrčka M, Netuka D, Štekláčová A, Lipina R, Hrbáč T, Večeřa Z, Fiedler J, Grubhoffer M, Hrabálek L, Krahulík D, Koller L, Kretschmer T, Přibáň V, Mraček J, Sameš M, Hejčl A, Klener J, Šroubek J, Petr O. Open Microsurgical Cerebral Aneurysm Treatment After Failed Endovascular Therapy: An Evaluation of Aneurysm Treatment Frequencies in All Neurovascular Centers Across Austria and the Czech Republic Over 20 Years. Neurosurgery 2024:00006123-990000000-01212. [PMID: 38864626 DOI: 10.1227/neu.0000000000003040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/02/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular treatment of cerebral aneurysms has tremendously advanced over the past decades. Nevertheless, aneurysm residual and recurrence remain challenges after embolization. The objective of this study was to elucidate the portion of embolized aneurysms requiring open surgery and evaluate whether newer endovascular treatments have changed the need for open surgery after failed embolization. METHODS All 15 cerebrovascular centers in Austria and the Czech Republic provided overall aneurysm treatment frequency data and retrospectively reviewed consecutive cerebral aneurysms treated with open surgical treatment after failure of embolization from 2000 to 2022. All endovascular modalities were included. RESULTS On average, 1362 aneurysms were treated annually in the 2 countries. The incidence increased from 0.006% in 2005 to 0.008% in 2020 in the overall population. Open surgery after failed endovascular intervention was necessary in 128 aneurysms (0.8%), a proportion that remained constant over time. Subarachnoid hemorrhage was the initial presentation in 70.3% of aneurysms. The most common location was the anterior communicating artery region (40.6%), followed by the middle cerebral artery (25.0%). The median diameter was 6 mm (2-32). Initial endovascular treatment included coiling (107 aneurysms), balloon-assist (10), stent-assist (4), intrasaccular device (3), flow diversion (2), and others (2). Complete occlusion after initial embolization was recorded in 40.6%. Seventy-one percent of aneurysms were operated within 3 years after embolization. In 7%, the indication for surgery was (re-)rupture and, in 88.3%, reperfusion. Device removal was performed in 16.4%. Symptomatic intraoperative and postoperative complications occurred in 10.2%. Complete aneurysm occlusion after open surgery was achieved in 94%. CONCLUSION Open surgery remains a rare indication for cerebral aneurysms after failed endovascular embolization even in the age of novel endovascular technology, such as flow diverters and intrasaccular devices. Regardless, it is mostly performed for ruptured aneurysms initially treated with primary coiling that are in the anterior circulation.
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Affiliation(s)
- Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Nico H Stroh
- Department of Neurosurgery, Kepler University Hospital Linz, Johannes Kepler University, Linz, Austria
| | - Petra A Mercea
- Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Rössler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital Linz, Johannes Kepler University, Linz, Austria
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital Linz, Johannes Kepler University, Linz, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Klaus A Leber
- Department of Neurosurgery, Medical University of Graz, Graz, Austria
| | | | - Mustafa Baghban
- Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Rahman Al-Schameri
- Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Michael Kral
- Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Som Thakur
- Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Manuel Lunzer
- Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Branko Popadic
- Department of Neurosurgery, University Hospital St. Pölten, St. Pölten, Austria
| | - Camillo Sherif
- Department of Neurosurgery, University Hospital St. Pölten, St. Pölten, Austria
| | - Vilém Juráň
- Department of Neurosurgery, University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Martin Smrčka
- Department of Neurosurgery, University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neuro-Oncology, 1st Medical Faculty, Charles University, Central Military Hospital, Prague, Czech Republic
| | - Anna Štekláčová
- Department of Neurosurgery and Neuro-Oncology, 1st Medical Faculty, Charles University, Central Military Hospital, Prague, Czech Republic
| | - Radim Lipina
- Department of Neurosurgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Tomáš Hrbáč
- Department of Neurosurgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Zdeněk Večeřa
- Department of Neurosurgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jiří Fiedler
- Department of Neurosurgery, Ceske Budejovice Hospital, České Budějovice, Czech Republic
| | - Marek Grubhoffer
- Department of Neurosurgery, Ceske Budejovice Hospital, České Budějovice, Czech Republic
- Department of Neurosurgery, Pilsen University Hospital, Pilsen, Czech Republic
| | - Lumír Hrabálek
- Department of Neurosurgery, University Hospital Olomouc, Olomouc, Czech Republic
| | - David Krahulík
- Department of Neurosurgery, University Hospital Olomouc, Olomouc, Czech Republic
| | - Lukas Koller
- Department of Neurosurgery and Neurorestoration, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Thomas Kretschmer
- Department of Neurosurgery and Neurorestoration, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Vladimír Přibáň
- Department of Neurosurgery, Pilsen University Hospital, Pilsen, Czech Republic
| | - Jan Mraček
- Department of Neurosurgery, Pilsen University Hospital, Pilsen, Czech Republic
| | - Martin Sameš
- Department of Neurosurgery, Usti nad Labem Hospital, Ústí nad Labem, Czech Republic
| | - Aleš Hejčl
- Department of Neurosurgery, Usti nad Labem Hospital, Ústí nad Labem, Czech Republic
| | - Jan Klener
- Unit of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jan Šroubek
- Unit of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
- Department of Neurosurgery, Charles University Hospital, Hradec Kralove, Czech Republic
| | - Ondra Petr
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
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Doron O, Patel AB, Hawryluk GWJ. Neurovascular Interventions for Neurotrauma: From Treatment of Injured Vessels to Treatment of the Injured Brain? Oper Neurosurg (Hagerstown) 2024; 26:247-255. [PMID: 37976141 DOI: 10.1227/ons.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/17/2023] [Indexed: 11/19/2023] Open
Abstract
Traumatic brain injury is often associated with a direct or secondary neurovascular pathology. In this review, we present recent advancements in endovascular neurosurgery that enable accurate and effective vessel reconstruction with emphasis on its role in early diagnosis, the expanding use of flow diversion in pseudoaneurysms, and traumatic arteriovenous fistulas. In addition, future directions in which catheter-based interventions could potentially affect traumatic brain injury are described: targeting blood brain barrier integrity using the advantages of intra-arterial drug delivery of blood brain barrier stabilizers to prevent secondary brain edema, exploring the impact of endovascular venous access as a means to modulate venous outflow in an attempt to reduce intracranial pressure and augment brain perfusion, applying selective intra-arterial hypothermia as a neuroprotection method mitigating some of the risks conferred by systemic cooling, trans-vessel wall delivery of regenerative therapy agents, and shifting attention using multimodal neuromonitoring to post-traumatic vasospasm to further characterize the role it plays in secondary brain injury. Thus, we believe that the potential of endovascular tools can be expanded because they enable access to the "highways" governing perfusion and flow and call for further research focused on exploring these routes because it may contribute to novel endovascular approaches currently used for treating injured vessels, harnessing them for treatment of the injured brain.
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Affiliation(s)
- Omer Doron
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston , Massachusetts , USA
- Department of Biomedical Engineering, The Aldar and Iby Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv , Israel
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Akron General Neuroscience Institute, Cleveland Clinic, Akron , Ohio , USA
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Peng L, Qin H, Liu J, Wu N, Wang X, Han L, Ding X. Neurosurgical clipping versus endovascular coiling for patients with ruptured anterior circulation aneurysms: A systematic review and meta-analysis. Neurosurg Rev 2024; 47:68. [PMID: 38267600 DOI: 10.1007/s10143-024-02304-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/28/2023] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
To compare the safety and efficacy of clipping and coiling in patients with ruptured anterior circulation aneurysms. A systematic search of four databases (PubMed, Web of Science, Cochrane Library, and Embase) was conducted to identify comparative articles on endovascular coiling and surgical clipping in patients with ruptured anterior circulation aneurysms. Meta-analyses were conducted using random-effects models. Nineteen studies, including 1983 patients, were included. The meta-analysis showed that neurosurgical clipping was associated with a lower incidence of retreatment (OR:0.28, 95% CI (0.11, 0.70), P = 0.006) than endovascular coiling, which seemed to be a result of incomplete occlusion (OR:0.22, 95% CI (0.11, 0.45), P < 0.001). Neurosurgical clipping was associated with lower mortality (OR:0.45, 95% CI (0.25, 0.82), P = 0.009) at short-term follow-up than endovascular coiling. However, neurosurgical clipping showed a higher incidence of ischemic infarction (OR:2.28, 95% CI (1.44, 3.63), P < 0.001) and a longer length of stay (LOS) (WMD:6.12, 95% CI (4.19, 8.04), P < 0.001) after surgery than endovascular coiling. Furthermore, the pooled results showed no statistically significant differences between the two groups regarding poor outcome, long-term mortality, rebleeding, vasospasm, and hydrocephalus. Evidence from this systematic review illustrates that neurosurgical clipping may be superior to endovascular coiling for ruptured anterior circulation aneurysms. Large-scale RCTs should be conducted to verify these outcomes and provide results according to patient status.
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Affiliation(s)
- Liangsheng Peng
- Department of Neurosurgery, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Hao Qin
- Department of Neurosurgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Jiahao Liu
- Department of Neurosurgery, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Nuojun Wu
- Department of Internal Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Xiaolong Wang
- Department of Neurosurgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Li Han
- Department of Neurosurgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Xinmin Ding
- Department of Neurosurgery, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China.
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Chon MK, Jung SJ, Seo JY, Shin DH, Park JH, Kim HS, Hahn JY, Kim EK, Lee SW, Park YH, Lee SH, Kim JH. The Development of a Permanent Implantable Spacer with the Function of Size Adjustability for Customized Treatment of Regurgitant Heart Valve Disease. Bioengineering (Basel) 2023; 10:1016. [PMID: 37760118 PMCID: PMC10525886 DOI: 10.3390/bioengineering10091016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/14/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
The Pivot Mandu is an innovative device featuring a leak-tight adjustable 3D balloon spacer, incorporating inner mesh support, an outer e-PTFE layer, and a compliant balloon in the middle layer with a specialized detachable system. To assess its feasibility, proof of concept was rigorously evaluated through bench testing and survival porcine animal experiments. The results demonstrated successful remote inflation of the balloon system, with the balloon spacer exhibiting sustained patent and functional integrity over an extended observation period of up to 6 months. A noteworthy feature of the newly designed 3D balloon spacer is its capability for easy size adjustment during procedures, enhancing its adaptability and practicality in clinical settings. This three-layered 3D balloon spacer, with its established long-term patency, exhibits highly encouraging outcomes that hold promise in overcoming the current limitations of spacer devices for heart valve diseases. Given the compelling results from preclinical investigations, the translation of the Pivot Mandu into human trials is strongly warranted.
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Affiliation(s)
- Min-Ku Chon
- Department of Cardiology, School of Medicine, Pusan National University, Cardiovascular Center, Yangsan Hospital, Yangsan 50612, Republic of Korea; (M.-K.C.); (Y.-H.P.); (S.-H.L.)
| | - Su-Jin Jung
- Department of Research Strategy Team, R&D Center, TAU MEDICAL Inc., Yangsan 50612, Republic of Korea; (S.-J.J.); (J.-Y.S.)
| | - Jae-Young Seo
- Department of Research Strategy Team, R&D Center, TAU MEDICAL Inc., Yangsan 50612, Republic of Korea; (S.-J.J.); (J.-Y.S.)
| | - Dong-Hoon Shin
- Department of Pathology, School of Medicine, Yangsan Hospital, Pusan National University, Yangsan 50612, Republic of Korea;
| | - Jun-Hui Park
- Major of Human Bioconvergence, Division of Smart Healthcare, Pukyong National University, Busan 48513, Republic of Korea;
| | - Hyun-Sook Kim
- Division of Cardiology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea;
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (J.-Y.H.); (E.-K.K.)
| | - Eun-Kyoung Kim
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (J.-Y.H.); (E.-K.K.)
| | - Seung-Whan Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea;
| | - Yong-Hyun Park
- Department of Cardiology, School of Medicine, Pusan National University, Cardiovascular Center, Yangsan Hospital, Yangsan 50612, Republic of Korea; (M.-K.C.); (Y.-H.P.); (S.-H.L.)
| | - Sang-Hyun Lee
- Department of Cardiology, School of Medicine, Pusan National University, Cardiovascular Center, Yangsan Hospital, Yangsan 50612, Republic of Korea; (M.-K.C.); (Y.-H.P.); (S.-H.L.)
| | - June-Hong Kim
- Department of Cardiology, School of Medicine, Pusan National University, Cardiovascular Center, Yangsan Hospital, Yangsan 50612, Republic of Korea; (M.-K.C.); (Y.-H.P.); (S.-H.L.)
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Hartquist CM, Lee JV, Qiu MY, Suskin C, Chandrasekaran V, Lowe HR, Zayed MA, Osbun JW, Genin GM. Stability of navigation in catheter-based endovascular procedures. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.06.02.543219. [PMID: 37333419 PMCID: PMC10274636 DOI: 10.1101/2023.06.02.543219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Endovascular procedures provide surgeons and other interventionalists with minimally invasive methods to treat vascular diseases by passing guidewires, catheters, sheaths and treatment devices into the vasculature to and navigate toward a treatment site. The efficiency of this navigation affects patient outcomes, but is frequently compromised by catheter "herniation", in which the catheter-guidewire system bulges out from the intended endovascular pathway so that the interventionalist can no longer advance it. Here, we showed herniation to be a bifurcation phenomenon that can be predicted and controlled using mechanical characterizations of catheter-guidewire systems and patientspecific clinical imaging. We demonstrated our approach in laboratory models and, retrospectively, in patients who underwent procedures involving transradial neurovascular procedures with an endovascular pathway from the wrist, up in the arm, around the aortic arch, and into the neurovasculature. Our analyses identified a mathematical navigation stability criterion that predicted herniation in all of these settings. Results show that herniation can be predicted through bifurcation analysis, and provide a framework for selecting catheter-guidewire systems to avoid herniation in specific patient anatomy.
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Sidiq M, Scheidecker E, Potreck A, Neuberger U, Weyland CS, Mundiyanapurath S, Bendszus M, Möhlenbruch MA, Seker F. Aortic Arch Variations and Supra-aortic Arterial Tortuosity in Stroke Patients Undergoing Thrombectomy : Retrospective Analysis of 1705 Cases. Clin Neuroradiol 2023; 33:49-56. [PMID: 35695910 PMCID: PMC10014756 DOI: 10.1007/s00062-022-01181-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/16/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Unfavorable vascular anatomy can impede thrombectomy in patients with acute ischemic stroke. The aim of this study was to determine the prevalence of aortic arch types, aortic arch branching patterns and supra-aortic arterial tortuosity in stroke patients with large vessel occlusion. METHODS Computed tomography (CT) and magnetic resonance (MR) images of all stroke patients in an institutional thrombectomy registry were retrospectively reviewed. Aortic arch types and branching patterns of all patients were determined. In patients with anterior circulation stroke, the prevalence of tortuosity (elongation, kinking or coiling) of the supra-aortic arteries of the affected side was additionally assessed. RESULTS A total of 1705 aortic arches were evaluated. Frequency of aortic arch types I, II and III were 777 (45.6%), 585 (34.3%) and 340 (19.9%), respectively. In 1232 cases (72.3%), there was a normal branching pattern of the aortic arch. The brachiocephalic trunk and the left common carotid artery had a common origin in 258 cases (15.1%). In 209 cases (12.3%), the left common carotid artery arose from the brachiocephalic trunk. Of 1598 analyzed brachiocephalic trunks and/or common carotid arteries, 844 (52.8%) had no vessel tortuosity, 592 (37.0%) had elongation, 155 (9.7%) had kinking, and 7 (0.4%) had coiling. Of 1311 analyzed internal carotid arteries, 471 (35.9%) had no vessel tortuosity, 589 (44.9%) had elongation, 150 (11.4%) had kinking, and 101 (7.7%) had coiling. CONCLUSION With 20%, type III aortic arches are found in a relevant proportion of stroke patients eligible for mechanical thrombectomy. Nearly half of the stroke patients present with supra-aortic arterial tortuosity, mostly arterial elongation.
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Affiliation(s)
- Maiwand Sidiq
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Emilia Scheidecker
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Arne Potreck
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Ulf Neuberger
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Charlotte S Weyland
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | | | - Martin Bendszus
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Fatih Seker
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Endovascular Treatment of Ruptured Blood Blister-like Aneurysms Using the LVIS EVO Stents. J Clin Med 2023; 12:jcm12031089. [PMID: 36769737 PMCID: PMC9918215 DOI: 10.3390/jcm12031089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
Blood blister-like aneurysms (BBAs) are rare cerebrovascular lesions that face serious challenges in surgical as well as endovascular treatment. In this paper, we present our experience in treating BBAs using the LVIS EVO stents. A total of 10 patients (mean age of 56.1 years) with 13 BBAs, who were admitted to our university hospital between April 2020 and November 2021 with a subarachnoid hemorrhage (SAH) due to aneurysm rupture, were treated using the LVIS EVO stents. Treatment of the BBAs consisted of stent-assisted coiling in four patients and stenting in six patients. The aneurysms were located within ICA (84.6%), VA (7.7%), and MCA (7.7%). Placement of the LVIS EVO stents was successful in all patients. No technical complications were observed. One in-stent thrombotic event occurred during the procedure. MRA for one-year follow-up was performed in nine patients. One patient died (Hunt and Hess Grade IV). LVIS EVO stents may be a beneficial treatment option for BBAs, as they provide high occlusion rates. However, the long-term efficacy remains uncertain.
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Haeren R, Hafez A, Korja M, Raj R, Niemelä M. Fast Transition from Open Surgery to Endovascular Treatment of Unruptured Anterior Communicating Artery Aneurysms-A Retrospective Analysis of 128 Patients. World Neurosurg 2022; 165:e668-e679. [PMID: 35779751 DOI: 10.1016/j.wneu.2022.06.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Anterior communicating artery aneurysms (ACoAAs) are challenging to treat both surgically and endovascularly. In this study, we evaluate the treatment-related morbidity and clinical outcome of microsurgical clipping and endovascular treatment for a consecutive series of unruptured ACoAAs while the treatment paradigm was in transition from surgical to endovascular first. METHODS We retrospectively reviewed clinical and radiologic data of adult patients who underwent microsurgical clipping or endovascular treatment of an unruptured ACoAA at a high-volume academic neurovascular center (Helsinki University Hospital) during 2012-2019. During this period, a transition from microsurgical clipping to endovascular treatment took place. Regarding outcome, we focused on treatment-related complications, discharge-to-home rates, functional performance (modified Rankin Scale score), and obliteration rates. RESULTS Of 128 treated ACoAAs, 81 (64%) were treated surgically and 47 (36%) endovascularly. There was no difference in major complications, intracranial hemorrhagic complications or ischemic complications, discharge-to-home rates, or functional performance between the surgically and endovascularly treated patients. With time, a decrease in major complications was observed in the surgical cases (from 29% to 17%), whereas the major complication rate increased in the endovascularly patients (from 0% to 25%). Cerebral ischemia was the most frequent complication in both groups. The risk for permanent neurologic deficit remained low in both groups (9% for endovascular and 5% for surgery). CONCLUSIONS We did not find any major differences regarding complications and outcomes after the treatment paradigm shift from clipping to endovascular of unruptured ACoAAs. Prospective studies evaluating durability of treatments are needed to compare overall effectiveness.
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Affiliation(s)
- Roel Haeren
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland; Department of Neurosurgery, Maastricht University Medical Center, Maastricht, the Netherlands.
| | - Ahmad Hafez
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Miikka Korja
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
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Labib MA, Rumalla K, Karahalios K, Srinivasan VM, Nguyen CL, Rahmani R, Catapano JS, Zabramski JM, Lawton MT. Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis. Neurosurgery 2022; 91:470-476. [PMID: 35876676 DOI: 10.1227/neu.0000000000002061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 04/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In specialized neurosurgical centers, open microsurgery is routinely performed for aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE To compare the cost of endovascular vs microsurgical treatment for aSAH at a single quaternary center. METHODS All patients undergoing aSAH treatment from July 1, 2014, to July 31, 2019, were retrospectively reviewed. Patients were grouped based on primary treatment (microsurgery vs endovascular treatment). The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis. RESULTS Of 384 patients treated for an aSAH, 234 (61%) were microsurgically treated and 150 (39%) were endovascularly treated. The mean cost of index hospitalization for these patients was marginally higher ($9504) for endovascularly treated patients ($103 980) than for microsurgically treated patients ($94 476) ( P = .047). For the subset of patients with follow-up data available, the mean total cost was $45 040 higher for endovascularly treated patients ($159 406, n = 59) than that for microsurgically treated patients ($114 366, n = 105) ( P < .001). After propensity scoring (adjusted for age, sex, comorbidities, Glasgow Coma Scale score, Hunt and Hess grade, Fisher grade, aneurysms, and type/size/location), linear regression analysis of patients with follow-up data available revealed that microsurgery was independently associated with healthcare costs that were $37 244 less than endovascular treatment costs ( P < .001). An itemized cost analysis suggested that this discrepancy was due to differences in the rates of aneurysm retreatment and long-term surveillance. CONCLUSION Microsurgical treatment for aSAH is associated with lower total healthcare costs than endovascular therapy. Aneurysm surveillance after endovascular treatments, retreatment, and device costs warrants attention in future studies.
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Affiliation(s)
- Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Chen CJ, Dabhi N, Snyder MH, Ironside N, Abecassis IJ, Kellogg RT, Park MS, Ding D. Intrasaccular flow disruption for brain aneurysms: a systematic review of long-term outcomes. J Neurosurg 2022; 137:360-372. [PMID: 34952523 DOI: 10.3171/2021.9.jns211706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 09/27/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The long-term safety and efficacy of intrasaccular flow disruption (IFD) for the treatment of brain aneurysms remain unclear. With accumulating experience and increasing use of IFD devices, recent studies have provided additional data regarding their outcomes. This review summarizes the long-term outcomes of IFD-treated brain aneurysms. METHODS A systematic literature review was performed on May 23, 2021, in PubMed, Web of Science, and Ovid MEDLINE for aneurysm treatment outcomes with IFD devices. Procedural details, including use of adjunctive devices and complications, were collected. The quality of studies was assessed using the Downs and Black checklist. Angiographic outcomes were classified as complete occlusion, residual neck, and residual aneurysm. Other outcomes included need for retreatment, permanent neurological deficit, and mortality. Pooled analyses were performed. RESULTS The final analysis comprised 1217 patients with 1249 aneurysms from 22 studies. The mean aneurysm diameter and neck width were 6.9 and 4.5 mm, respectively, and 27.6% of aneurysms were ruptured. The complete occlusion rates at 12 months and final follow-up (pooled mean duration 15.7 months) were 50.1% and 58.2%, respectively. Adjunctive devices were used in 6.4% of cases. The rates of hemorrhage, symptomatic infarction, permanent neurological deficit, and mortality were 1.2%, 2.8%, 1.0%, and 2.6%, respectively. CONCLUSIONS IFD is a very safe treatment for appropriately selected brain aneurysms with low complication and neurological deterioration rates. However, complete occlusion is achieved in only half of IFD-treated aneurysms at 1 year with a modest increase beyond this time point. As the majority of the studies were single arm, the pooled data are subject to selection and reporting biases. Future device developments, increased operator experience, and direct comparisons with alternative endovascular strategies and surgical clipping may clarify the role of IFD in aneurysm management.
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Affiliation(s)
- Ching-Jen Chen
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Nisha Dabhi
- 2Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - M Harrison Snyder
- 3Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts; and
| | - Natasha Ironside
- 2Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Isaac Josh Abecassis
- 4Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Ryan T Kellogg
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Min S Park
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Dale Ding
- 4Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
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11
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Wang K, Tan G, Tian R, Zhou H, Xiang C, Pan K. Circular RNA circ_0021001 regulates miR-148b-3p/GREM1 axis to modulate proliferation and apoptosis of vascular smooth muscle cells. Metab Brain Dis 2022; 37:2027-2038. [PMID: 35689751 DOI: 10.1007/s11011-022-01014-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/23/2022] [Indexed: 10/18/2022]
Abstract
Intracranial aneurysm (IA) is an abnormal expression in the intracranial arteries, which is related to the growth and apoptosis of vascular smooth muscle cells (VSMCs). Circular RNA (circRNA) circ_0021001 (also named circARFIP2) has been identified to mediate the regulation of VSMCs proliferation. However, the molecular mechanism of circ_0021001 involved in VSMC dysfunction in IA is poorly defined. The expression levels of circ_0021001, microRNA-148b-3p (miR-148b-3p), and Gremlin 1 (GREM1) were detected by real-time quantitative polymerase chain reaction (RT-qPCR). Cell viability, proliferation, cell cycle progression, and apoptosis were detected by Cell Counting Kit-8 (CCK-8), 5-ethynyl-2'-deoxyuridine (EdU), and flow cytometry assays. Protein levels of proliferating cell nuclear antigen (PCNA), p21, B-cell lymphoma-2 (Bcl-2), Bcl-2 related X protein (Bax), and GREM1 were examined by western blot assay. The binding relationship between miR-148b-3p and circ_0021001 or GREM1 was predicted by StarBase and then verified using a dual-luciferase reporter assay. The expression levels of circ_0021001 and GREM1 were increased, and that of miR-148b-3p was decreased in IA tissues and HUASMCs. Moreover, the downregulation of circ_0021001 could repress proliferation ability and induce apoptosis of HUASMCs. The mechanical analysis uncovered that circ_0021001 served as a sponge of miR-148b-3p to regulate GREM1 expression. Circ_0021001 silencing could suppress cell growth and induce apoptosis of HUASMCs partially through modulating the miR-148b-3p/GREM1, presented circ_0021001 as a promising therapeutic target for IA.
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Affiliation(s)
- Kui Wang
- Department of Neurosurgery, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, 158 Wuyang Avenue, Enshi, Hubei, 445000, China
| | - Gaofeng Tan
- Department of Neurosurgery, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, 158 Wuyang Avenue, Enshi, Hubei, 445000, China
| | - Renfu Tian
- Department of Neurosurgery, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, 158 Wuyang Avenue, Enshi, Hubei, 445000, China
| | - Han Zhou
- Department of Neurosurgery, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, 158 Wuyang Avenue, Enshi, Hubei, 445000, China
| | - Chunhui Xiang
- Department of Neurosurgery, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, 158 Wuyang Avenue, Enshi, Hubei, 445000, China
| | - Ke Pan
- Department of Neurosurgery, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, 158 Wuyang Avenue, Enshi, Hubei, 445000, China.
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12
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Vaithialingam B, Vankayalapati S. Anterior Circulation Infarct Following the Placement of Flow-Diverting Stent for Basilar Artery Aneurysm - A Conundrum. Neurol India 2022; 70:1740-1741. [PMID: 36076714 DOI: 10.4103/0028-3886.355092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Balaji Vaithialingam
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Sriharish Vankayalapati
- Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
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13
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Delora A, Ezzeldin O, Ali U, El-Ghanem M, Ezzeldin M. Ultra-Short-Term Dual Antiplatelet Therapy in Treating Unruptured Brain Aneurysm With the Pipeline Flex-Shield Embolization Device. Cureus 2022; 14:e25516. [PMID: 35800802 PMCID: PMC9245062 DOI: 10.7759/cureus.25516] [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] [Accepted: 05/31/2022] [Indexed: 11/25/2022] Open
Abstract
Ruptured cerebral aneurysms can cause significant morbidity and mortality. Endoluminal devices to treat aneurysms such as the Pipeline™ Flex Embolization Device with Shield Technology (PFES) (Medtronic, Dublin, Ireland) integrate phosphorylcholine on the surface of the device in order to reduce platelet adherence that causes periprocedural thromboembolic events and subsequent long-term intrastent stenosis. In addition to the Shield Technology, patients are commonly placed on dual antiplatelet therapy (DAPT) for six months to reduce thromboembolic events and subsequent long-term intrastent stenosis. There is a strong positive correlation between the length of DAPT use and bleeding. Here, we present a case of a 66-year-old female with a right supraclinoid internal carotid artery (ICA) aneurysm treated with a PFES who was placed on dual antiplatelet therapy for the first 31 days postoperative and subsequently maintained on aspirin (ASA) 81 mg monotherapy. At two months, a follow-up diagnostic cerebral angiogram showed complete occlusion of the aneurysm with a patent stent. Our case sets the stage for further research into the optimal length of dual antiplatelet therapy required in PFES to prevent short and long-term thromboembolic events. This report indicates that it may be safe for patients with PFES to intermittently halt the use of DAPT to manage bleeding complications or perform surgery.
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14
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Kim Y, Genevriere E, Harker P, Choe J, Balicki M, Regenhardt RW, Vranic JE, Dmytriw AA, Patel AB, Zhao X. Telerobotic neurovascular interventions with magnetic manipulation. Sci Robot 2022; 7:eabg9907. [PMID: 35417201 PMCID: PMC9254892 DOI: 10.1126/scirobotics.abg9907] [Citation(s) in RCA: 58] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Advances in robotic technology have been adopted in various subspecialties of both open and minimally invasive surgery, offering benefits such as enhanced surgical precision and accuracy with reduced fatigue of the surgeon. Despite the advantages, robotic applications to endovascular neurosurgery have remained largely unexplored because of technical challenges such as the miniaturization of robotic devices that can reach the complex and tortuous vasculature of the brain. Although some commercial systems enable robotic manipulation of conventional guidewires for coronary and peripheral vascular interventions, they remain unsuited for neurovascular applications because of the considerably smaller and more tortuous anatomy of cerebral arteries. Here, we present a teleoperated robotic neurointerventional platform based on magnetic manipulation. Our system consists of a magnetically controlled guidewire, a robot arm with an actuating magnet to steer the guidewire, a set of motorized linear drives to advance or retract the guidewire and a microcatheter, and a remote-control console to operate the system under real-time fluoroscopy. We demonstrate our system's capability to navigate narrow and winding pathways both in vitro with realistic neurovascular phantoms representing the human anatomy and in vivo in the porcine brachial artery with accentuated tortuosity for preclinical evaluation. We further demonstrate telerobotically assisted therapeutic procedures including coil embolization and clot retrieval thrombectomy for treating cerebral aneurysms and ischemic stroke, respectively. Our system could enable safer and quicker access to hard-to-reach lesions while minimizing the radiation exposure to physicians and open the possibility of remote procedural services to address challenges in current stroke systems of care.
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Affiliation(s)
- Yoonho Kim
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Emily Genevriere
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Pablo Harker
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jaehun Choe
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Xuanhe Zhao
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA.,Department of Civil and Environmental Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
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15
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Hudson JS, Lang MJ, Gross BA. Novel Innovation in Flow Diversion. Neurosurg Clin N Am 2022; 33:215-218. [DOI: 10.1016/j.nec.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Belavadi R, Gudigopuram SVR, Raguthu CC, Gajjela H, Kela I, Kakarala CL, Hassan M, Sange I. Surgical Clipping Versus Endovascular Coiling in the Management of Intracranial Aneurysms. Cureus 2021; 13:e20478. [PMID: 35047297 PMCID: PMC8760002 DOI: 10.7759/cureus.20478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 01/16/2023] Open
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17
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Zhang M, Li Y, Sugiyama SI, Verrelli DI, Matsumoto Y, Tominaga T, Qian Y, Tupin S, Anzai H, Ohta M. Incomplete stent expansion in flow-diversion treatment affects aneurysmal haemodynamics: a quantitative comparison of treatments affected by different severities of malapposition occurring in different segments of the parent artery. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2021; 37:e3465. [PMID: 33847467 DOI: 10.1002/cnm.3465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/23/2021] [Accepted: 04/10/2021] [Indexed: 06/12/2023]
Abstract
Incomplete stent expansion (IncSE) is occasionally seen in flow-diversion (FD) treatment of intracranial aneurysms; however, its haemodynamic consequences remain inconclusive. Through a parametric study, we quantify the aneurysmal haemodynamics subject to different severities of IncSE occurring in different portions of the stent. Two patient cases with IncSE confirmed in vivo were studied. To investigate a wider variety of IncSE scenarios, we modelled IncSE at two severity levels respectively located in the proximal, central, or distal segment of a stent, yielding a total of 14 treatment scenarios (including the ideal deployment). We examined stent wire configurations in 14 scenarios and resolved aneurysm haemodynamics through computational fluid dynamics (CFD). A considerable degradation of aneurysm flow-reduction performance was observed when central or distal IncSE occurred, with the maximal elevations of the inflow rate (IR) and energy loss (EL) being 10% and 15%. The underlying mechanism might be the increased resistance for flow to remain within the FD stent, which forces more blood to leak into the aneurysm sac. Counter-intuitively, a slight reduction of aneurysm inflow was associated with proximal IncSE, with the maximal further reduction of the IR and EL being 5% and 8%. This may be due to the disruption of the predominant parent-artery flow by the collapsed wires, which decreased the strength and altered the direction of aneurysmal inflow. The effects of IncSE vary greatly with the location of occurrence, revealing the importance of performing individualised, patient-specific risk assessment before treatment.
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Affiliation(s)
- Mingzi Zhang
- Institute of Fluid Science, Tohoku University, Sendai, Japan
- Department of Biomedical Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Yujie Li
- Institute of Fluid Science, Tohoku University, Sendai, Japan
- Department of Biomedical Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Shin-Ichiro Sugiyama
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Neuroanesthesia, Kohnan Hospital, Sendai, Japan
| | - David I Verrelli
- Department of Biomedical Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yi Qian
- Department of Biomedical Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Simon Tupin
- Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Hitomi Anzai
- Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Makoto Ohta
- Institute of Fluid Science, Tohoku University, Sendai, Japan
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18
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Hartquist CM, Chandrasekaran V, Lowe H, Leuthardt EC, Osbun JW, Genin GM, Zayed MA. Quantification of the flexural rigidity of peripheral arterial endovascular catheters and sheaths. J Mech Behav Biomed Mater 2021; 119:104459. [PMID: 33887627 DOI: 10.1016/j.jmbbm.2021.104459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 02/28/2021] [Accepted: 03/10/2021] [Indexed: 11/18/2022]
Abstract
Endovascular catheter-based technologies have revolutionized the treatment of complex vascular pathology. Catheters and endovascular devices that can be maneuvered through tortuous arterial anatomy have enabled minimally invasive treatment in the peripheral arterial system. Although mechanical factors drive an interventionalist's choice of catheters and sheaths, these decisions are mostly made qualitative and based on personal experience and procedural pattern recognition. However, a definitive quantitative characterization of endovascular tools that are best suited for specific peripheral arterial beds is currently lacking. To establish a foundation for quantitative tool selection in the neurovascular and lower extremity peripheral arterial beds, we developed a nonlinear beam theory method to quantify catheter and sheath flexural rigidity. We applied this assessment to a sampling of commonly utilized commercially available peripheral arterial catheters and sheaths. Our results demonstrated that catheters and sheaths adopted for existing practice patterns to treat peripheral arterial disease in the lower extremities and neurovascular system have different but overlapping ranges of flexural rigidities that were not sensitive to luminal diameters within each procedure type. Our approach provides an accurate and effective method for characterization of flexural rigidity properties of catheters and sheaths, and a foundation for developing future technologies tailored for specific peripheral arterial systems.
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Affiliation(s)
- Chase M Hartquist
- Center for Innovation in Neuroscience and Technology, Washington University in St. Louis, Missouri, USA; McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri, USA; Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Vinay Chandrasekaran
- Center for Innovation in Neuroscience and Technology, Washington University in St. Louis, Missouri, USA; McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri, USA; Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Halle Lowe
- Center for Innovation in Neuroscience and Technology, Washington University in St. Louis, Missouri, USA; McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri, USA; Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Eric C Leuthardt
- Center for Innovation in Neuroscience and Technology, Washington University in St. Louis, Missouri, USA; McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri, USA; Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joshua W Osbun
- Center for Innovation in Neuroscience and Technology, Washington University in St. Louis, Missouri, USA; Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Guy M Genin
- Center for Innovation in Neuroscience and Technology, Washington University in St. Louis, Missouri, USA; McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri, USA; Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - Mohamed A Zayed
- Center for Innovation in Neuroscience and Technology, Washington University in St. Louis, Missouri, USA; McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri, USA; Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
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19
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Shrivastava A, Mishra R, Salazar LRM, Chouksey P, Raj S, Agrawal A. Enigma of what is Known about Intracranial Aneurysm Occlusion with Endovascular Devices. J Stroke Cerebrovasc Dis 2021; 30:105737. [PMID: 33774553 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/23/2021] [Accepted: 02/28/2021] [Indexed: 11/16/2022] Open
Abstract
Aneurysmal subarachnoid Hemorrhage is a major cause of neurological morbidity and mortality. Over the years vascular neurosurgery has witnessed technological advances aimed to reduce the morbidity and mortality. Several endovascular devices have been used in clinical practice to achieve this goal in the management of ruptured and unruptured cerebral aneurysms. Recurrence due to recanalization is encountered in all of these endovascular devices as well as illustrated by Barrow Ruptured Aneurysm Trial. Histological and molecular characterization of the aneurysms treated with endovascular devices is an area of active animal and human research studies. Yet, the pathobiology illustrating the mechanisms of aneurysmal occlusion and healing lacks evidence. The enigma of aneurysmal healing following treatment with endovascular devices needs to be de-mystified to understand the biological interaction of endovascular device and aneurysm and thereby guide the future development of endovascular devices aimed at better aneurysm occlusion. We performed a comprehensive and detailed literature review to bring all the known facts of the pathobiology of intracranial aneurysm healing, the knowledge of which is of paramount importance to neurosurgeons, an interventional neuroradiologist, molecular biologist, geneticists, and experts in animal studies. This review serves as a benchmark of what is known and platform for future studies basic science research related to intracranial aneurysms.
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Affiliation(s)
- Adesh Shrivastava
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462020, Madhya Pradesh, India.
| | - Rakesh Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | | | - Pradeep Chouksey
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462020, Madhya Pradesh, India
| | - Sumit Raj
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462020, Madhya Pradesh, India
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462020, Madhya Pradesh, India
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20
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Pflaeging M, Kabbasch C, Schlamann M, Pennig L, Juenger ST, Grunz JP, Timmer M, Brinker G, Goldbrunner R, Krischek B, Goertz L. Microsurgical Clipping versus Advanced Endovascular Treatment of Unruptured Middle Cerebral Artery Bifurcation Aneurysms After a "Coil-First" Policy. World Neurosurg 2021; 149:e336-e344. [PMID: 33607288 DOI: 10.1016/j.wneu.2021.02.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Although intracranial aneurysms are increasingly treated endovascularly, microsurgical clipping has been the standard approach for middle cerebral artery (MCA) aneurysms. We compared microsurgical clipping and state-of-the-art endovascular treatment of unruptured MCA bifurcation aneurysms treated at a neurovascular center following a "coil-first" policy. METHODS This single-center study included 148 patients treated for 160 unruptured MCA bifurcation aneurysms. Technical success, complications, clinical outcome, and angiographic results were retrospectively compared. RESULTS Microsurgical clipping was performed for 120 MCA aneurysms (75%) and endovascular treatment for 40 (25%; conventional coiling: 8, stent-assisted coiling: 16, balloon-assisted coiling: 3, and flow-disruption: 13). Technical treatment success was higher in the clipping group (100%) than in the endovascular group (92.5%, P = 0.015). Overall, complications occurred in 16.7% for clipping and in 20.0% for endovascular treatment (P = 0.631). Major ischemic stroke rates were 4.2% in the clipping group and 7.5% in the endovascular group (P = 0.414). At 6 months, a favorable outcome was obtained by 99.2% after clipping and 95.0% after endovascular treatment (P = 0.154). The 6-month complete aneurysm occlusion rates were by trend higher in the clipping group (89.2%) than in the endovascular group (75.9%, P = 0.078). CONCLUSIONS Microsurgical clipping was associated with a higher technical success rate and tendentially higher complete occlusion than endovascular treatment, with no additional morbidity and similar clinical outcome. On the basis of these results, clipping proves to be the standard treatment option for MCA bifurcation aneurysms. However, endovascular treatment represents a safe and efficient alternative treatment option for patients.
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Affiliation(s)
- Muriel Pflaeging
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Marc Schlamann
- Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lenhard Pennig
- Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Stephanie Theresa Juenger
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan-Peter Grunz
- Institute for Diagnostic and Interventional Radiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Marco Timmer
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gerrit Brinker
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Boris Krischek
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Department of Neurosurgery, Hôpitaux Robert Schuman, Luxembourg, Luxembourg
| | - Lukas Goertz
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
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21
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Starke RM, Thompson J, Pagani A, Choubey A, Wainwright JM, Wolf MF, Jahanbekam R, Girdhar G. Preclinical safety and efficacy evaluation of the Pipeline Vantage Embolization Device with Shield Technology. J Neurointerv Surg 2020; 12:981-986. [PMID: 32487767 PMCID: PMC7509525 DOI: 10.1136/neurintsurg-2020-016043] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/05/2020] [Accepted: 05/09/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND The Pipeline Vantage Embolization Device with Shield Technology is a next generation flow diverter developed to improve aneurysm occlusion and implant endothelialization in addition to lowering thrombogenicity. We report here the in vivo biocompatibility and in vitro hemocompatibility performance of the Pipeline Vantage Embolization Device with Shield Technology (Vantage) compared with the Pipeline Flex Embolization Device (Flex). METHODS Biocompatibility (via histology), aneurysm occlusion and vessel patency (via angiography), and endothelial coverage (via scanning electron microscopy (SEM)) for the Vantage and Flex devices were assessed in the rabbit elastase aneurysm model at 90 days (n=29) and 180 days (n=27). In vitro thrombogenicity for Flex and Vantage (n=16) was assessed using a human blood flow loop model at low heparin concentration (0.6 U/mL) with thrombin generation, platelet activation and thrombus visualization as outputs. RESULTS Raymond Roy Occlusion Classification grade 1 was higher for Vantage (61%) compared with Flex (46%), but was not statistically significant (p>0.05). All branch vessels were patent. Histological measures for both devices were similar (p>0.05). Endothelial coverage of the implant was significantly better for Vantage compared with Flex (p<0.05). In vitro measurements of thrombin generation (thrombin-antithrombin complex (µg/mL): Vantage 0.49±0.45; Flex 10.57±9.84) and platelet activation (β-thromboglobulin (IU/µl): Vantage 0.41±0.19; Flex 4.14±2.38) were both statistically lower (p<0.05) for Vantage compared with Flex. High resolution microscopy showed less accumulation of thrombus on Vantage as compared with Flex. CONCLUSION Vantage improved aneurysm occlusion and implant endothelialization and had significantly lower thrombogenicity as compared with Flex, while preserving the biocompatibility safety profile of Flex.
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Affiliation(s)
- Robert M Starke
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - John Thompson
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ariana Pagani
- Neurovascular, Medtronic plc, Irvine, California, USA
| | | | | | - Michael F Wolf
- Core Technologies, Medtronic plc, Minneapolis, Minnesota, USA
| | - Reza Jahanbekam
- Core Technologies, Medtronic plc, Minneapolis, Minnesota, USA
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22
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Mohammaden MH, English SW, Stapleton CJ, Khedr E, Shoyb A, Hegazy A, Elbassiouny A. Safety and efficacy of ticagrelor as single antiplatelet therapy in prevention of thromboembolic complications associated with the Pipeline Embolization Device (PED): multicenter experience. J Neurointerv Surg 2020; 12:1113-1116. [PMID: 32471826 DOI: 10.1136/neurintsurg-2020-015978] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/08/2020] [Accepted: 04/10/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Flow diversion (FD) is a common treatment modality for complex intracranial aneurysms. A major concern regarding the use of FD is thromboembolic events (TEE). There is debate surrounding the optimal antiplatelet regimen to prevent TEE. We aim to evaluate the safety and efficacy of ticagrelor as a single antiplatelet therapy (SAPT) for the prevention of TEE following FD for complex aneurysm treatment. METHODS A retrospective review of a prospectively maintained neuroendovascular database at three endovascular centers was performed. Patients were included if they had an intracranial aneurysm that was treated with FD between January 2018 and September 2019 and were treated with ticagrelor as SAPT. Primary outcomes included early (within 72 hours post-procedure) and late (within 6 months) ischemic events. RESULTS A total of 24 patients (mean age 47.7 years) with 36 aneurysms were eligible for analysis, including 15 (62.5%) females. 14 (58.3%) patients presented with subarachnoid hemorrhage. 35 aneurysms arose from the anterior circulation and 1 from the posterior circulation. 23 aneurysms had a saccular morphology, whereas 7 were fusiform and 6 were blister. For the treatment of all 36 aneurysms, 30 procedures were performed with 32 FD devices. Procedural in-stent thrombosis occurred in 2 cases and was treated with intra-arterial tirofiban without complications. Aneurysm re-bleeding was reported in 1 (4.2%) patient. There were no reported early or late TEE. Three patients discontinued ticagrelor due to systemic side effects. CONCLUSION Ticagrelor is a safe and effective SAPT for the prevention of TEE after FD. Large multicenter prospective studies are warranted to validate our findings.
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Affiliation(s)
- Mahmoud H Mohammaden
- Department of Neurology, Faculty of Medicine, South Valley University, Qena, Egypt.,Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stephen W English
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eman Khedr
- Department of Neurology, Assiut University Faculty of Medicine, Assiut, Egypt
| | - Ahmed Shoyb
- Department of Neurology, Faculty of Medicine, Aswan University, Sahary City, Egypt
| | - Ahmed Hegazy
- Department of Neurosurgery, Cairo University Kasr Alainy Faculty of Medicine, Cairo, Egypt
| | - Ahmed Elbassiouny
- Department of Neurology, Ain Shams University Faculty of Medicine, Cairo, Egypt
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23
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Raper DMS, Caldwell J, Brew S, Buell TJ, Liu JY, Savage JJ, McGuinness B. A comparison of endovascular strategies in the treatment of ruptured vertebral artery aneurysms. J Clin Neurosci 2020; 75:168-175. [PMID: 32222429 DOI: 10.1016/j.jocn.2019.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 07/06/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Contemporary management of ruptured vertebral artery dissecting aneurysms (VADA) has evolved beyond proximal parent artery occlusion (PPAO) to include endovascular trapping (ET) of the diseased segment and vessel preserving stent treatments. The aim of this retrospective cohort study was to assess the outcomes of patients with ruptured VADAs who underwent endovascular management with trapping of the diseased segment as the first-line treatment approach. METHODS We evaluated an institutional database of patients with ruptured VADAs who were treated at Auckland City Hospital from 1998 to 2017. Baseline and outcomes data were analyzed. High-grade SAH was defined as a World Federation of Neurological Surgeons or a Hunt and Hess grade of IV-V. Favorable outcome was defined as a modified Rankin Scale of 0-2. RESULTS The study cohort was comprised of 45 ruptured VADA patients with a mean age of 50 years. The mean follow-up duration was 12.9 months. ET of the diseased segment was performed in 32 cases (71.1%), PPAO of the VA was performed in 12 cases (26.7%) and reconstruction using a flow diverting stent was performed in 1 case (2.2%). The overall procedural complication rate was 13%, including procedural neurological morbidity in 4.4%. At last follow-up, no further aneurysm filling was seen in any case, and 77.8% had a favorable outcome. CONCLUSION ET affords a favorable risk to benefit profile for patients with ruptured VADAs. ET remains a reasonable option for ruptured VADAs in patients with sufficient collateral supply to the vertebrobasilar system.
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Affiliation(s)
- Daniel M S Raper
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA; Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | - James Caldwell
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Stefan Brew
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Thomas J Buell
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA; Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | - Jing Yi Liu
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Jesse J Savage
- Department of Neurosurgery, Indiana University, Indianapolis, IN, USA
| | - Ben McGuinness
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
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24
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Luther E, McCarthy DJ, Brunet MC, Sur S, Chen SH, Sheinberg D, Hasan D, Jabbour P, Yavagal DR, Peterson EC, Starke RM. Treatment and diagnosis of cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era: trends and outcomes. J Neurointerv Surg 2020; 12:682-687. [PMID: 31959634 DOI: 10.1136/neurintsurg-2019-015418] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Following publication of the International Subarachnoid Aneurysm Trial (ISAT), treatment paradigms for cerebral aneurysms (CAs) shifted from open surgical clipping to endovascular embolization as primary therapy in a majority of cases. However, comprehensive analyses evaluating more recent CA diagnosis patterns, patient populations and outcomes as a function of treatment modality remain rare. METHODS The National Inpatient Sample from 2004 to 2014 was reviewed. Aneurysmal subarachnoid hemorrhages (aSAHs) and unruptured intracranial aneurysms (UIAs) with a treatment of surgical clipping or endovascular therapy (EVT) were identified. Time trend series plots were created. Linear and logistic regressions were utilized to quantify treatment changes. RESULTS 114 137 aSAHs and 122 916 UIAs were reviewed. aSAH (+732/year, p=0.014) and UIA (+2550/year, p<0.0001) discharges increased annually. The annual caseload of surgical clippings for aSAH decreased (-264/year, p=0.0002) while EVT increased (+366/year, p=0.0003). For UIAs, the annual caseload for surgical clipping remained stable but increased for EVT (+615/year, p<0.0001). The rate of incidentally diagnosed UIAs increased annually (+1987/year; p<0.0001). Inpatient mortality decreased for clipping (p<0.0001) and EVT in aSAH (p<0.0001) (2004 vs 2014-clipping 13% vs 11.7%, EVT 15.8% vs 12.7%). Mortality rates for clipped UIAs decreased over time (p<0.0001) and remained stable for EVT (2004 vs 2014-clipping 1.57% vs 0.40%, EVT 0.59% vs 0.52%). CONCLUSION Ruptured and unruptured CAs are increasingly being treated with EVT over clipping. Incidental unruptured aneurysm diagnoses are increasing dramatically. Mortality rates of ruptured aneurysms are improving regardless of treatment modality, whereas mortality in unruptured aneurysms is only improving for surgical clipping.
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Affiliation(s)
- Evan Luther
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David J McCarthy
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA .,Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Marie-Christine Brunet
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Samir Sur
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stephanie H Chen
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Dallas Sheinberg
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David Hasan
- Neurological Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Dileep R Yavagal
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eric C Peterson
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert M Starke
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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Initial Experience in a Pig Model of Robotic-Assisted Intracranial Arteriovenous Malformation (AVM) Embolization. Oper Neurosurg (Hagerstown) 2019; 19:205-209. [DOI: 10.1093/ons/opz373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/02/2019] [Indexed: 11/15/2022] Open
Abstract
Abstract
BACKGROUND
Robotic assistance for coronary and peripheral vascular pathologies is steadily gaining popularity. However, it has yet to be applied to neurovascular intervention.
OBJECTIVE
To establish the feasibility of the CorPath® GRX robotic-assisted platform (Corindus Inc, Waltham, Massachusetts) for intracranial arteriovenous malformation (AVM) embolization.
METHODS
This robotic system was used to embolize intracranial AVMs (n = 4) in 2 anesthetized pigs, under controlled conditions appropriate for clinical intervention. Initially, a catheter was manually introduced into the common carotid artery (CCA). Then, the robotic system was used to advance the catheter into the ascending pharyngeal artery (APA) towards the rete mirabilis, which was used as a model for an AVM, using 0.014 in guidewires and 2.4F/1.7F microcatheters. After doing a pre-embolization APA run, which demonstrated good visualization of the rete, dimethyl sulfoxide (DMSO) was instilled into the microcatheter. A negative roadmap was then done, and Onyx was used to embolize the rete.
RESULTS
All 4 AVMs were completely obliterated with no complications, including no contrast extravasation, dissection, thrombosis, or other vascular injury.
CONCLUSION
This study is the first to demonstrate the feasibility of a robotic-assisted platform for intracranial AVM embolization.
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26
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Britz GW, Panesar SS, Falb P, Tomas J, Desai V, Lumsden A. Neuroendovascular-specific engineering modifications to the CorPath GRX Robotic System. J Neurosurg 2019; 133:1830-1836. [PMID: 31783367 DOI: 10.3171/2019.9.jns192113] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 09/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate new, neuroendovascular-specific engineering and software modifications to the CorPath GRX Robotic System for their ability to support safer and more effective cranial neurovascular interventions in a preclinical model. METHODS Active device fixation (ADF) control software, permitting automated manipulation of the guidewire relative to the microcatheter, and a modified drive cassette suitable for neuroendovascular instruments were the respective software and hardware modifications to the current CorPath GRX robot, which was cleared by the FDA for percutaneous coronary and peripheral vascular intervention. The authors then trialed the modified system in a live porcine model with simulated neuroendovascular pathology. Femoral access through the aortic arch to the common carotid artery was accomplished manually (without robotic assistance), and the remaining endovascular procedures were performed with robotic assistance. The system was tested for the enhanced ability to navigate and manipulate neurovascular-specific guidewires and microcatheters. The authors specifically evaluated the movement of the wire forward and backward during the advancement of the microcatheter. RESULTS Navigation of the rete mirabile and an induced aneurysm within the common carotid artery were successful. The active device fixation feature enabled independent advancement and retraction of the guidewire and working device relative to the microcatheter. When ADF was inactive, the mean forward motion of the guidewire was 5 mm and backward motion was 0 mm. When ADF was active, the mean forward motion of the guidewire was 0 mm and backward motion was 1.5 mm. The modifications made to the robotic cassette enabled the system to successfully manipulate the microcatheter and guidewire safely and in a manner more suited to neuroendovascular procedures than before. There were no occurrences of dissection, extravasation, or thrombosis. CONCLUSIONS The robotic system was originally designed to navigate and manipulate devices for cardiac and peripheral vascular intervention. The current modifications described here improved its utility for the more delicate and tortuous neurovascular environment. This will set the stage for the development of a neurovascular-specific robot.
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Affiliation(s)
- Gavin W Britz
- 1Department of Neurological Surgery and Neurological Institute, and
| | - Sandip S Panesar
- 1Department of Neurological Surgery and Neurological Institute, and
| | | | | | - Virendra Desai
- 1Department of Neurological Surgery and Neurological Institute, and
| | - Alan Lumsden
- 3Department of Cardiovascular Surgery, Houston Methodist Hospital, Texas Medical Center, Houston, Texas; and
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27
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Ding D, Buell TJ, Chen CJ, Raper DM, Liu KC, Vollmer DG. Staged Multimodality Treatment of a Large Ruptured Fusiform Supraclinoid Internal Carotid Artery Aneurysm: Microsurgical Clip-assisted Endovascular Coiling. J Neurosci Rural Pract 2019; 8:668-671. [PMID: 29204037 PMCID: PMC5709900 DOI: 10.4103/jnrp.jnrp_293_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
In the contemporary era of aneurysm management, large fusiform aneurysms presenting with subarachnoid hemorrhage (SAH) remain particularly challenging lesions to successfully manage. We describe a staged, multimodal treatment strategy for a 71-year-old patient who presented with a large ruptured fusiform aneurysm of the supraclinoid internal carotid artery (ICA) and a fetal posterior communicating artery which originated from the inferomedial aspect of the aneurysm. In the first stage, we performed a partial microsurgical clip reconstruction of the fusiform aneurysm and secured its rupture site, which was identified intraoperatively. This left two residual saccular components of the aneurysm, which were targeted with endovascular coiling in the same hospitalization after the patient had convalesced from the SAH and was beyond the vasospasm window. We believe that this combined approach of clip-assisted coiling can be employed instead of endovascular flow diversion or microsurgical bypass for appropriately selected patients with ruptured fusiform ICA aneurysms.
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Affiliation(s)
- Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ 85013, USA
| | - Thomas J Buell
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22908, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22908, USA
| | - Daniel M Raper
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22908, USA
| | - Kenneth C Liu
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22908, USA
| | - Dennis G Vollmer
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22908, USA
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28
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Britz GW, Tomas J, Lumsden A. Feasibility of Robotic-Assisted Neurovascular Interventions: Initial Experience in Flow Model and Porcine Model. Neurosurgery 2019; 86:309-314. [DOI: 10.1093/neuros/nyz064] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 04/03/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Gavin W Britz
- Department of Neurological Surgery and Neurological Institute, Houston Methodist, Houston, Texas
| | | | - Alan Lumsden
- Department of Cardiovascular Surgery, Texas Medical Center, Houston, Texas
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29
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Zhu Y, Zhang H, Zhang Y, Wu H, Wei L, Zhou G, Zhang Y, Deng L, Cheng Y, Li M, Santos HA, Cui W. Endovascular Metal Devices for the Treatment of Cerebrovascular Diseases. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2019; 31:e1805452. [PMID: 30589125 DOI: 10.1002/adma.201805452] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/20/2018] [Indexed: 06/09/2023]
Abstract
Cerebrovascular disease involves various medical disorders that obstruct brain blood vessels or deteriorate cerebral circulation, resulting in ischemic or hemorrhagic stroke. Nowadays, platinum coils with or without biological modification have become routine embolization devices to reduce the risk of cerebral aneurysm bleeding. Additionally, many intracranial stents, flow diverters, and stent retrievers have been invented with uniquely designed structures. To accelerate the translation of these devices into clinical usage, an in-depth understanding of the mechanical and material performance of these metal-based devices is critical. However, considering the more distal location and tortuous anatomic characteristics of cerebral arteries, present devices still risk failing to arrive at target lesions. Consequently, more flexible endovascular devices and novel designs are under urgent demand to overcome the deficiencies of existing devices. Herein, the pros and cons of the current structural designs are discussed when these devices are applied to the treatment of diseases ranging broadly from hemorrhages to ischemic strokes, in order to encourage further development of such kind of devices and investigation of their use in the clinic. Moreover, novel biodegradable materials and drug elution techniques, and the design, safety, and efficacy of personalized devices for further clinical applications in cerebral vasculature are discussed.
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Affiliation(s)
- Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Hongbo Zhang
- Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, P. R. China
- Department of Pharmaceutical Sciences Laboratory, Åbo Akademi University, Turku, FI-20520, Finland
- Turku Center for Biotechnology, University of Turku and Åbo Akademi University, Turku, FI-20520, Finland
| | - Yiran Zhang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Huayin Wu
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, 02138, USA
| | - Liming Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Gen Zhou
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Yuezhou Zhang
- Department of Pharmaceutical Sciences Laboratory, Åbo Akademi University, Turku, FI-20520, Finland
- Turku Center for Biotechnology, University of Turku and Åbo Akademi University, Turku, FI-20520, Finland
| | - Lianfu Deng
- Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, P. R. China
| | - Yingsheng Cheng
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Minghua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Hélder A Santos
- Drug Research Program, Division of Pharmaceutical Chemistry and Technology, Faculty of Pharmacy, University of Helsinki, FI-00014, Helsinki, Finland
- Helsinki Institute of Life Science, University of Helsinki, FI-00014, Helsinki, Finland
| | - Wenguo Cui
- Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, P. R. China
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Sharma M, Ugiliweneza B, Fortuny EM, Khattar NK, Andaluz N, James RF, Williams BJ, Boakye M, Ding D. National trends in cerebral bypass for unruptured intracranial aneurysms: a National (Nationwide) Inpatient Sample analysis of 1998–2015. Neurosurg Focus 2019; 46:E15. [DOI: 10.3171/2018.11.focus18504] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 11/08/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe development and recent widespread dissemination of flow diverters may have reduced the utilization of surgical bypass procedures to treat complex or giant unruptured intracranial aneurysms (UIAs). The aim of this retrospective cohort study was to observe trends in cerebral revascularization procedures for UIAs in the United States before and after the introduction of flow diverters by using the National (Nationwide) Inpatient Sample (NIS).METHODSThe authors extracted data from the NIS database for the years 1998–2015 using the ICD-9/10 diagnostic and procedure codes. Patients with a primary diagnosis of UIA with a concurrent bypass procedure were included in the study. Outcomes and hospital charges were analyzed.RESULTSA total of 216,212 patients had a primary diagnosis of UIA during the study period. The number of patients diagnosed with a UIA increased by 128% from 1998 (n = 7718) to 2015 (n = 17,600). Only 1328 of the UIA patients (0.6%) underwent cerebral bypass. The percentage of patients who underwent bypass in the flow diverter era (2010–2015) remained stable at 0.4%. Most patients who underwent bypass were white (51%), were female (62%), had a median household income in the 3rd or 4th quartiles (57%), and had private insurance (51%). The West (33%) and Midwest/North Central regions (30%) had the highest volume of bypasses, whereas the Northeast region had the lowest (15%). Compared to the period 1998–2011, bypass procedures for UIAs in 2012–2015 shifted entirely to urban teaching hospitals (100%) and to an elective basis (77%). The median hospital stay (9 vs 3 days, p < 0.0001), median hospital charges ($186,746 vs $66,361, p < 0.0001), and rate of any complication (51% vs 17%, p < 0.0001) were approximately threefold higher for the UIA patients with bypass than for those without bypass.CONCLUSIONSDespite a significant increase in the diagnosis of UIAs over the 17-year study period, the proportion of bypass procedures performed as part of their treatment has remained stable. Therefore, advances in endovascular aneurysm therapy do not appear to have affected the volume of bypass procedures performed in the UIA population. The authors’ findings suggest a potentially ongoing niche for bypass procedures in the contemporary treatment of UIAs.
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Setlur Nagesh SV, Fennel V, Krebs J, Ionita C, Davies J, Bednarek DR, Mokin M, Siddiqui AH, Rudin S. High-Definition Zoom Mode, a High-Resolution X-Ray Microscope for Neurointerventional Treatment Procedures: A Blinded-Rater Clinical-Utility Study. AJNR Am J Neuroradiol 2019; 40:302-308. [PMID: 30591511 DOI: 10.3174/ajnr.a5922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/12/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Quality of visualization of treatment devices during critical stages of endovascular interventions, can directly impact their safety and efficacy. Our aim was to compare the visualization of neurointerventional procedures and treatment devices using a 194-μm pixel flat panel detector mode and a 76-μm pixel complementary metal oxide semiconductor detector mode (high definition) of a new-generation x-ray detector system using a blinded-rater study. MATERIALS AND METHODS Deployment of flow-diversion devices for the treatment of internal carotid artery aneurysms was performed under flat panel detector and high-definition-mode image guidance in a neurointerventional phantom simulating patient cranium and tissue attenuation, embedded with 3D-printed intracranial vascular models, each with an aneurysm in the ICA segment. Image-sequence pairs of device deployments for each detector mode, under similar exposure and FOV conditions, were evaluated by 2 blinded experienced neurointerventionalists who independently selected their preferred image on the basis of visualization of anatomic features, image noise, and treatment device. They rated their selection as either similar, better, much better, or substantially better than the other choice. Inter- and intrarater agreement was calculated and categorized as poor, moderate, and good. RESULTS Both raters demonstrating good inter- and intrarater agreement selected high-definition-mode images with a frequency of at least 95% each and, on average, rated the high-definition images as much better than flat panel detector images with a frequency of 73% from a total of 60 image pairs. CONCLUSIONS Due to their higher resolution, high-definition-mode images are sharper and visually preferred compared with the flat panel detector images. The improved imaging provided by the high-definition mode can potentially provide an advantage during neurointerventional procedures.
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Affiliation(s)
- S V Setlur Nagesh
- From the Canon (formerly Toshiba) Stroke and Vascular Research Center (S.V.S.N., J.K., C.I., D.R.B., A.H.S., S.R.)
- Departments of Neurosurgery (S.V.S.N., V.F., C.I., J.D., D.R.B., A.H.S.)
| | - V Fennel
- Department of Neurosurgery (V.F., J.D.), Gates Vascular Institute at Kaleida Health, Buffalo, New York
- Departments of Neurosurgery (S.V.S.N., V.F., C.I., J.D., D.R.B., A.H.S.)
| | - J Krebs
- From the Canon (formerly Toshiba) Stroke and Vascular Research Center (S.V.S.N., J.K., C.I., D.R.B., A.H.S., S.R.)
| | - C Ionita
- From the Canon (formerly Toshiba) Stroke and Vascular Research Center (S.V.S.N., J.K., C.I., D.R.B., A.H.S., S.R.)
- Departments of Biomedical Engineering (C.I., S.R.)
- Departments of Neurosurgery (S.V.S.N., V.F., C.I., J.D., D.R.B., A.H.S.)
| | - J Davies
- Department of Neurosurgery (V.F., J.D.), Gates Vascular Institute at Kaleida Health, Buffalo, New York
- Departments of Neurosurgery (S.V.S.N., V.F., C.I., J.D., D.R.B., A.H.S.)
- Bioinformatics (J.D.)
- Jacobs Institute (J.D., A.H.S.), Buffalo, New York
| | - D R Bednarek
- From the Canon (formerly Toshiba) Stroke and Vascular Research Center (S.V.S.N., J.K., C.I., D.R.B., A.H.S., S.R.)
- Departments of Neurosurgery (S.V.S.N., V.F., C.I., J.D., D.R.B., A.H.S.)
- Radiology (D.R.B., A.H.S., S.R.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - M Mokin
- Department of Neurosurgery and Brain Repair (M.M.), University of South Florida, Tampa, Florida
| | - A H Siddiqui
- From the Canon (formerly Toshiba) Stroke and Vascular Research Center (S.V.S.N., J.K., C.I., D.R.B., A.H.S., S.R.)
- Departments of Neurosurgery (S.V.S.N., V.F., C.I., J.D., D.R.B., A.H.S.)
- Radiology (D.R.B., A.H.S., S.R.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
- Jacobs Institute (J.D., A.H.S.), Buffalo, New York
| | - S Rudin
- From the Canon (formerly Toshiba) Stroke and Vascular Research Center (S.V.S.N., J.K., C.I., D.R.B., A.H.S., S.R.)
- Departments of Biomedical Engineering (C.I., S.R.)
- Mechanical and Aerospace Engineering (S.R.)
- Electrical Engineering (S.R.), University at Buffalo, State University of New York; Buffalo, New York
- Radiology (D.R.B., A.H.S., S.R.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
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Girdhar G, Ubl S, Jahanbekam R, Thinamany S, Belu A, Wainwright J, Wolf MF. Thrombogenicity assessment of Pipeline, Pipeline Shield, Derivo and P64 flow diverters in an in vitro pulsatile flow human blood loop model. eNeurologicalSci 2019; 14:77-84. [PMID: 30723811 PMCID: PMC6350389 DOI: 10.1016/j.ensci.2019.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/07/2019] [Indexed: 12/11/2022] Open
Abstract
Flow diversion is a disruptive technology for the treatment of intracranial aneurysms. However, these intraluminal devices pose a risk for thromboembolic complications despite dual antiplatelet therapy. We report the thrombogenic potential of the following flow diversion devices measured experimentally in a novel human blood in-vitro pulsatile flow loop model: Pipeline™ Flex Embolization Device (Pipeline), Pipeline™ Flex Embolization Device with Shield Technology™ (Pipeline Shield), Derivo Embolization Device (Derivo), and P64 Flow Modulation Device (P64). Thrombin generation (Mean ± SD; μg/mL) was measured as: Derivo (28 ± 11), P64 (21 ± 4.5), Pipeline (21 ± 6.2), Pipeline Shield (0.6 ± 0.1) and Negative Control (1.5 ± 1.1). Platelet activation (IU/μL) was measured as: Derivo (4.9 ± 0.7), P64 (5.2 ± 0.7), Pipeline (5.5 ± 0.4), Pipeline Shield (0.3 ± 0.1), and Negative Control (0.9 ± 0.7). We found that Pipeline Shield had significantly lower platelet activation and thrombin generation than the other devices tested (p < .05) and this was comparable to the Negative Control (no device, p > .05). High resolution scanning electron microscopy performed on the intraluminal and cross-sectional surfaces of each device showed the lowest accumulation of platelets and fibrin on Pipeline Shield relative to Derivo, P64, and Pipeline. Derivo and P64 also had higher thrombus accumulation at the flared ends. Pipeline device with Phosphorylcholine surface treatment (Pipeline Shield) could mitigate device material related thromboembolic complications.
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Affiliation(s)
| | - Samantha Ubl
- Medtronic Core Technologies, Minneapolis, MN, United States
| | | | | | - Anna Belu
- Medtronic Core Technologies, Minneapolis, MN, United States
| | | | - Michael F Wolf
- Medtronic Core Technologies, Minneapolis, MN, United States
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Sokolowski JD, Ilyas A, Buell TJ, Taylor DG, Chen CJ, Ding D, Raper DMS, Liu KC. SMART coils for intracranial aneurysm embolization: Follow-up outcomes. J Clin Neurosci 2018; 59:93-97. [PMID: 30414808 DOI: 10.1016/j.jocn.2018.10.132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 10/27/2018] [Indexed: 11/19/2022]
Abstract
The SMART coil (Penumbra Inc., Alameda, CA, USA) is a new microcoil designed to enhance deliverability. Although prior studies have described its perioperative safety and efficacy, the follow-up outcomes after embolization of intracranial aneurysms using SMART coils have not been reported. Therefore, the aim of this retrospective cohort study is to assess the angiographic outcomes at interim follow-up after aneurysm embolization with SMART coils. We reviewed data from consecutive patients with intracranial aneurysms who underwent endovascular treatment using SMART coils between June 2016 and August 2017. Baseline data and follow-up angiographic outcomes using the modified Raymond-Roy classification (MRRC) were recorded. The study cohort comprised 33 patients with 34 aneurysms who underwent SMART coil embolization and had sufficient follow-up data. The mean age was 57 years, and 82% were female. The mean aneurysm maximum diameter and neck width were 6.1 ± 2.2 mm and 3.2 ± 1.2 mm, respectively, and 14.7% of aneurysms were ruptured. The overall complication rate was 12%. Initial mean coil packing density was 26%, and the initial MRRC was I, II, IIIa, and IIIb in 24%, 26%, 35%, and 15%, respectively. At last follow-up (mean duration 7.7 ± 3.2 months), the MRRC was I, II, IIIa, and IIIb in 62%, 26%, 3%, and 9%, respectively. The retreatment rate was 14.7%. The SMART coil is efficacious for the treatment of appropriately selected aneurysms, with an acceptable risk profile. The majority of residual aneurysms after the initial embolization procedure will progress to complete or near-complete occlusion at interim follow-up.
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Affiliation(s)
- Jennifer D Sokolowski
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States.
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Davis G Taylor
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, KY, United States
| | - Daniel M S Raper
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Kenneth C Liu
- Department of Neurological Surgery, Pennsylvania State University, Hershey, PA, United States
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Al-Mufti F, Cohen ER, Amuluru K, Patel V, El-Ghanem M, Nuoman R, Majmundar N, Dangayach NS, Meyers PM. Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms. INTERVENTIONAL NEUROLOGY 2018; 8:38-54. [PMID: 32231694 DOI: 10.1159/000489016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/06/2018] [Indexed: 12/21/2022]
Abstract
Background Flow-diverting stents (FDS) have revolutionized the endovascular management of unruptured, complex, wide-necked, and giant aneurysms. There is no consensus on management of complications associated with the placement of these devices. This review focuses on the management of complications of FDS for the treatment of intracranial aneurysms. Summary We performed a systematic, qualitative review using electronic databases MEDLINE and Google Scholar. Complications of FDS placement generally occur during the perioperative period. Key Message Complications associated with FDS may be divided into periprocedural complications, immediate postprocedural complications, and delayed complications. We sought to review these complications and novel management strategies that have been reported in the literature.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA.,Departments of Neurology and Neurosurgery, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Eric R Cohen
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh-Hamot, Erie, Pennsylvania, USA
| | - Vikas Patel
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Mohammad El-Ghanem
- Department of Neurology and Medical Imaging, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Rolla Nuoman
- Department of Neurology, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA
| | - Neil Majmundar
- Departments of Neurology and Neurosurgery, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Neha S Dangayach
- Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Philip M Meyers
- Departments of Radiology and Neurosurgery and Columbia University Medical Center, New York, New York, New York, USA
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Girdhar G, Andersen A, Pangerl E, Jahanbekam R, Ubl S, Nguyen K, Wainwright J, Wolf MF. Thrombogenicity assessment of Pipeline Flex, Pipeline Shield, and FRED flow diverters in an in vitro human blood physiological flow loop model. J Biomed Mater Res A 2018; 106:3195-3202. [PMID: 30242950 PMCID: PMC6282594 DOI: 10.1002/jbm.a.36514] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 06/21/2018] [Accepted: 07/05/2018] [Indexed: 12/12/2022]
Abstract
Endovascular treatment of intracranial aneurysms with endoluminal flow diverters (single or multiple) has proven to be clinically safe and effective, but is associated with a risk of thromboembolic complications. Recently, a novel biomimetic surface modification with covalently bound phosphorylcholine (Shield Technology™) has shown to reduce the material thrombogenicity of the Pipeline flow diverter. Thrombogenicity of Pipeline Flex, Pipeline Shield, and Flow Redirection Endoluminal Device (FRED) in the presence of human blood under physiological flow conditions—in addition to relative increase in thrombogenicity with multiple devices—remains unknown and was investigated here. Thrombin generation (mean ± SD; μg/mL; thrombin–antithrombin complex or TAT) was measured as FRED (30.3 ± 2.9), Pipeline (13.9 ± 4.4), Pipeline Shield (0.4 ± 0.3), and negative control (no device; 0.1 ± 0.0). Platelet activation (mean ± SD; IU/μL; beta‐thromboglobulin or βTG) was measured as FRED (148 ± 45), Pipeline (92.8 ± 41), Pipeline Shield (16.2 ± 3.5), and negative control (2.70 ± 0.16). FRED was significantly more thrombogenic than Pipeline and Pipeline Shield (p < 0.05) for TAT. Additionally, Pipeline Shield had significantly lower TAT and βTG than the other devices tested (p < 0.05) and these were comparable to the negative control (p > 0.05). TAT and βTG scaled proportionately with multiple Pipeline devices (N = 6) but was unaffected by multiple Pipeline Shield (N = 6) devices—the latter being statistically similar to negative control (p > 0.05). © 2018 The Authors. Journal Of Biomedical Materials Research Part A Published By Wiley Periodicals, Inc. J Biomed Mater Res Part A: 106A: 3195–3202, 2018.
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Affiliation(s)
| | | | | | | | - Samantha Ubl
- Medtronic Core Technologies, Minneapolis, Minnesota
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Optical Coherence Tomography. Stroke 2018; 49:1044-1050. [DOI: 10.1161/strokeaha.117.019818] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/22/2017] [Accepted: 01/09/2018] [Indexed: 11/16/2022]
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Paisan GM, Ding D, Xu Z, Liu KC. Effect of Dual Antiplatelet Therapy on Shunt Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Matched Cohort Pilot Study. Cureus 2018; 10:e2383. [PMID: 29850378 PMCID: PMC5973489 DOI: 10.7759/cureus.2383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objective: The aim of this retrospective, matched cohort study is to determine the effect of dual antiplatelet therapy (DAPT) on shunt-related complications and long-term functional outcomes in endovascularly treated aneurysmal subarachnoid hemorrhage (aSAH) patients. Materials and Method: We retrospectively analyzed an institutional database of aSAH patients from 2000-2015. Patients who underwent endovascular treatment with stent-assisted coiling (DAPT cohort) were matched in a 1:4 ratio to those who underwent coiling alone (no-DAPT cohort) based on the presenting patient and aneurysm factors. A favorable outcome was defined as a modified Rankin scale of <2. Statistical analyses were performed to compare the shunt-related and functional outcomes between the DAPT and no-DAPT cohorts. Results: After applying the selection criteria and performing the matching process, the overall study cohort comprised 25 aSAH patients who underwent endovascular treatment, including five in the DAPT and 20 in the no-DAPT cohorts. The mean age, World Federation of Neurological Surgeons grade, aneurysm size, and follow-up duration of the overall study cohort were 52.3 years, 2.9, 7.4 mm, and 32.7 months, respectively. The mean time from aSAH to shunt placement was significantly higher for patients in the DAPT cohort (5.6 vs. 0.7 months; p=0.026). The shunt complication rates (p=0.562) and functional outcomes at last follow-up (p=0.924) were not significantly different between the two cohorts. Conclusion: Patients receiving DAPT after the stent-assisted coiling of acutely ruptured aneurysms do not have an increased risk of shunt-related complications or unfavorable long-term functional outcomes compared to endovascularly treated aSAH patients not taking DAPT. These results suggest that further study is warranted.
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Affiliation(s)
- Gabriella M Paisan
- Department of Neurological Surgery, University of Virginia, Charlottesville, USA
| | - Dale Ding
- Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, USA
| | - Kenneth C Liu
- Department of Neurological Surgery, University of Virginia, Charlottesville, USA
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Ilyas A, Buell TJ, Chen CJ, Ding D, Raper DMS, Taylor DG, Sokolowski JD, Liu KC. SMART coils for intracranial aneurysm embolization: Initial outcomes. Clin Neurol Neurosurg 2017; 164:87-91. [PMID: 29216501 DOI: 10.1016/j.clineuro.2017.11.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 11/11/2017] [Accepted: 11/29/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Endovascular technology for the treatment of intracranial aneurysms continues to rapidly evolve. The SMART coil (Penumbra Inc., Alameda, CA, USA) is a novel microcoil designed to enhance deliverability. The aim of this single-center, retrospective cohort study is to assess the initial outcomes after aneurysm embolization using SMART coils. PATIENTS AND METHODS We reviewed consecutive patients with intracranial aneurysms who underwent endovascular embolization using SMART coils from June 2016 to January 2017. Baseline and initial outcomes data were analyzed. RESULTS The study cohort was comprised of 32 patients with 33 aneurysms. The mean age was 55.8 years. The majority (85%) of aneurysms were located in the anterior circulation. The mean aneurysm maximum diameter and neck width were 6.0mm and 3.1mm, respectively. Dome irregularity and fusiform aneurysm morphology were noted in 33% and 9% of aneurysms, respectively, and 15% presented with subarachnoid hemorrhage. No serious procedural complications occurred, including microcatheter prolapse, intraprocedural aneurysm rupture, or thromboembolism. Device malfunction occurred in one case (3%). The mean packing density was 25%, and the degree of immediate post-embolization aneurysm occlusion was a modified Raymond-Roy grade I, II, IIIa, and IIIb in 48%, 27%, 18%, and 6%, respectively. CONCLUSION Our preliminary findings suggest that the SMART coil has a favorable initial risk to benefit profile for the embolization of appropriately selected aneurysms. Additional studies of larger cohorts are necessary to determine the mid-term and long-term clinical and angiographic outcomes of aneurysm patients treated with the SMART coil.
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Affiliation(s)
- Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Daniel M S Raper
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Davis G Taylor
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Jennifer D Sokolowski
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Kenneth C Liu
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
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Paisan GM, Ding D, Starke RM, Crowley RW, Liu KC. Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: Predictors and Long-Term Functional Outcomes. Neurosurgery 2017; 83:393-402. [DOI: 10.1093/neuros/nyx393] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 06/16/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Although chronic hydrocephalus requiring shunt placement is a known sequela of aneurysmal subarachnoid hemorrhage (aSAH), its effect on long-term functional outcomes is incompletely understood.
OBJECTIVE
To identify predictors of shunt-dependent hydrocephalus and shunt complications after aSAH and determine the effect of shunt dependence on functional outcomes in aSAH patients.
METHODS
We evaluated a database of patients treated for aSAH at a single center from 2000 to 2015. Favorable and unfavorable outcomes were defined as modified Rankin Scale grades 0 to 2 and 3 to 6, respectively. We performed statistical analyses to identify variables associated with shunt-dependent hydrocephalus, unfavorable outcome, and shunt complication.
RESULTS
Of the 888 aSAH patients, 116 had shunt-dependent hydrocephalus (13%). Older age (P = .001), intraventricular hemorrhage (IVH) (P = .004), higher World Federation of Neurological Surgeons (WFNS) grade (P < .001), surgical aneurysm treatment (P = .002), and angiographic vasospasm (P = .005) were independent predictors of shunt-dependent hydrocephalus in multivariable analysis. Functional outcome was evaluable in 527 aSAH patients (mean follow-up 18.6 mo), with an unfavorable outcome rate of 17%. Shunt placement (P < .001), shunt infection (P = .041), older age (P < .001), and higher WFNS grade (P = .043) were independently associated with an unfavorable outcome in multivariable analysis. Of the shunt-dependent patients, 18% had a shunt-related complication. Higher WFNS grade (P = .011), posterior circulation aneurysm (P = .018), and angiographic vasospasm (P = .008) were independent predictors of shunt complications in multivariable analysis.
CONCLUSION
aSAH patients with shunt-dependent hydrocephalus have significantly poorer long-term functional outcomes. Patients with risk factors for post-aSAH shunt dependence may benefit from increased surveillance, although the effect of such measures is not defined in this study.
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Affiliation(s)
| | - Dale Ding
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, Florida
| | - R Webster Crowley
- Department of Neurological Surgery, Rush University, Chicago, Illinois
| | - Kenneth C Liu
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Ding D, Starke RM, McGuinness B, Brew S. Double-barrel Y-configuration Stenting for Flow Diversion of a Giant Recurrent Basilar Apex Aneurysm with the Pipeline Flex Embolization Device. J Neurosci Rural Pract 2017; 7:S99-S102. [PMID: 28163518 PMCID: PMC5244076 DOI: 10.4103/0976-3147.196439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Giant basilar apex aneurysms are extremely challenging to successfully manage. The Pipeline Flex embolization device (PFED) is a new generation flow-diverting stent with a modified delivery system which allows resheathing of the stent after partial deployment. We describe a case of double-barrel Y-configuration stenting of a giant, recurrent basilar apex aneurysm using the PFED. A 73-year-old male was previously treated for an unruptured 11-mm basilar apex aneurysm with stent-assisted coiling using a Neuroform stent. The aneurysm was retreated twice with repeat coiling. After the third recurrence and persistent aneurysm growth into a giant, symptomatic lesion, we decided to proceed with flow diversion. We performed Y-stenting of the basilar bifurcation using three PFEDs, and was recoiled the aneurysm sac. Due to the low porosity of the flow diverters, a side-by-side double-barrel configuration was necessary in the basilar artery. Without the PFED's resheathable capability, it would not have been possible to perform Y-stenting with flow diverters.
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Affiliation(s)
- Dale Ding
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22908, USA; Department of Neurosurgery, Auckland City Hospital, Auckland 1142, New Zealand
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, FL 33136, USA
| | - Ben McGuinness
- Department of Radiology, Auckland City Hospital, Auckland 1142, New Zealand
| | - Stefan Brew
- Department of Radiology, Auckland City Hospital, Auckland 1142, New Zealand
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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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Ding D. Surgical treatment of unruptured middle cerebral artery aneurysms: Complication avoidance. Clin Neurol Neurosurg 2016; 153:107-108. [PMID: 27836403 DOI: 10.1016/j.clineuro.2016.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 11/02/2016] [Accepted: 11/03/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Dale Ding
- University of Virginia, Department of Neurosurgery, P.O. Box 800212, Charlottesville, VA 22908, United States.
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Hagen MW, Girdhar G, Wainwright J, Hinds MT. Thrombogenicity of flow diverters in an ex vivo shunt model: effect of phosphorylcholine surface modification. J Neurointerv Surg 2016; 9:1006-1011. [PMID: 27799376 PMCID: PMC5629931 DOI: 10.1136/neurintsurg-2016-012612] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/25/2016] [Accepted: 08/29/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Flow diverters offer a promising treatment for cerebral aneurysms. However, they have associated thromboembolic risks, mandating chronic dual antiplatelet therapy (DAPT). Shield Technology is a phosphorylcholine surface modification of the Pipeline Embolization Device (PED) flow diverter, which has shown significant reductions in material thrombogenicity in vitro. OBJECTIVE To compare the thrombogenicity of PED, PED with Shield Technology (PED+Shield), and the Flow-Redirection Endoluminal Device (FRED)-with and without single antiplatelet therapy and DAPT-under physiological flow. METHODS An established non-human primate ex vivo arteriovenous shunt model of stent thrombosis was used. PED, PED+Shield, and FRED were tested without antiplatelet therapy, with acetylsalicylic acid (ASA) monotherapy, and with DAPT. Radiolabeled platelet deposition was quantified over 1 hour for each device and total fibrin deposition was also quantified. RESULTS Cumulative statistical analysis showed significantly lower platelet deposition on PED compared with FRED. The same statistical model showed significant decreases in platelet deposition when ASA, clopidogrel, or Shield Technology was used. Direct comparisons of device performances within antiplatelet conditions showed consistent significant decreases in platelet accumulation on PED+Shield relative to FRED. PED+Shield showed significant reductions in platelet deposition compared with unmodified PED without antiplatelet therapy and with DAPT. PED accumulated minimal fibrin with and without Shield Technology. CONCLUSIONS In this preclinical model, we have shown that the Shield Technology phosphorylcholine modification reduces the platelet-specific thrombogenicity of a flow diverter under physiologically relevant flow with and without DAPT. We have further identified increased fibrin-driven thrombogenicity associated with FRED relative to PED.
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Affiliation(s)
- Matthew W Hagen
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | - Monica T Hinds
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
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Konishi Y, Takeuchi M, Fukasaku K. Optimum coil insertion speed of various coils in brain aneurysm embolization in vitro. Interv Neuroradiol 2016; 22:506-11. [PMID: 27353635 DOI: 10.1177/1591019916653250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 04/16/2016] [Indexed: 11/15/2022] Open
Abstract
A coil must comprise material with shape memory to perform optimal coil embolization. To achieve this, the alloy characteristics of the coil (hardness, shape, and thickness) must be understood. In this experiment, a catheter was fixed in the bright position and the movement of the coil was observed under a constant rate of insertion; the optimal insertion rate during clinical use was investigated. The first coil insertion speed was evaluated using simulated aneurysms in an in vivo arterial model. The results showed that the insertion force relates to the deployment shape of the coil, that the feedback through the force indicator using sound is very effective, and that the recorder is useful for analysis of coil embolization. The inserted coils during aneurysm embolization were able to wind uniformly within the aneurysm due to a variety of factors (guiding or micro-catheter position and kick-back phenomenon such as delivery wire). Optimal speed is achieved with proper coil design, which allows the coil to be inserted into the aneurysm. The shape and size of the aneurysm can help determine the necessary size and design of the coil that should be used during the optimal speed range. Aneurysm wall and coil characteristics are considered, along with the friction state of the coil (hardness, shape, and thickness), leading to improvements in safety during the insertion procedure at optimum speed.
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Ding D, Starke RM, Manka D, Crowley RW, Liu KC. Endovascular coil embolization of a spinal epidural arteriovenous fistula with associated cord compression from an enlarging venous varix. Interv Neuroradiol 2015; 21:738-41. [PMID: 26464290 DOI: 10.1177/1591019915609132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 07/09/2015] [Indexed: 11/15/2022] Open
Abstract
Spinal arteriovenous fistulas (AVFs) completely isolated to the epidural compartment are exceedingly rare. As such, the optimal management of these lesions is poorly defined. The aim of this technical note is to describe our endovascular technique for the occlusion of a purely epidural AVF of the thoracic spine associated with cord compression from an associated enlarging venous varix. A 40-year-old male presented with severe right-sided back pain and anterior thigh numbness after a sports-related back injury six months previously. Spinal magnetic resonance imaging (MRI) showed an enhancing, extradural mass lesion at T12. Spinal angiography revealed an epidural AVF supplied by a radicular branch of the right T12 subcostal artery and draining into the paravertebral lumbar veins, as well as an adjacent 20 × 13 mm(2) contrast-filling sac, compatible with a dilated venous varix. There was no evidence of intradural venous drainage. We elected to proceed with endovascular treatment of the lesion. At the time of embolization five days later, the venous varix had enlarged to 26 × 16 mm(2). The T12 epidural AVF was completely occluded with two coils, without residual or recurrent AVF on follow-up angiography one month later. The patient made a full recovery, and complete resolution of the venous varix and cord compression were noted on MRI at three months follow-up. Endovascular coil embolization can be successfully employed for the treatment of appropriately selected spinal epidural AVFs. Cord compression from an enlarging venous varix can be treated concurrently with endovascular occlusion of an associated spinal epidural AVF.
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Affiliation(s)
- Dale Ding
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - David Manka
- HemoShear Therapeutics, Charlottesville, VA, USA
| | - R Webster Crowley
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Kenneth C Liu
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
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Yang P, Schafer S, Royalty K, Ahmed A, Niemann D, Strother C. Measurement in the angiography suite: evaluation of vessel sizing techniques. J Neurointerv Surg 2015; 8:965-8. [PMID: 26453606 DOI: 10.1136/neurintsurg-2015-011920] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/26/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Accurate vessel size measurement is important for neurointervention. Modern angiographic equipment offers various two-dimensional (2D) and 3D measurement methods that have not been systematically evaluated for accuracy and reliability. OBJECTIVE To evaluate these methods using anthropomorphic vessel phantoms. MATERIALS AND METHODS Tubing of known sizes (2-5 mm, 1 mm increments) was embedded in 3D-printed skulls to simulate the middle cerebral artery, internal carotid artery, and basilar artery. Each phantom was imaged to gain 3D DSA, 2D DSA, and DynaCT images. Three identical measurement locations were identified on each simulated vessel. Eight measurement methods (four 2D, three 3D, and one DynaCT) were evaluated. Measurements were performed by three independent experienced users on three separate occasions. Intraclass correlation and independent non-parametric analysis were carried out to evaluate the reliability and accuracy of these measurement methods. RESULTS Better reliability was noted for the automatic measurement methods than for the corresponding manual measurement methods. The mean differences with the ground truth for all methods ranged from -0.12 to 0.03 with small SEs (0.02-0.03) and SDs (0.10-0.18). The smallest absolute mean differences were achieved in two automatic measurement methods based on 2D manual calibration and 3D images. In comparison with these two methods, results of measurements based on 2D autocalibration were statistically different. CONCLUSIONS In our study, automatic analysis using 3D or 2D was the preferred measurement method. Manual calibration on 2D angiograms is necessary to improve the measurement accuracy. It is not known how our results may pertain to other angiographic systems.
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Affiliation(s)
- Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China Department of Radiology, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Kevin Royalty
- Siemens Medical Solutions, Inc, Hoffman Estates, Illinois, USA
| | - Azam Ahmed
- Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin, USA
| | - David Niemann
- Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Charles Strother
- Department of Radiology, University of Wisconsin, Madison, Wisconsin, USA
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Developments in Neurovascular Diseases and Treatments. ScientificWorldJournal 2015; 2015:608607. [PMID: 26417611 PMCID: PMC4568361 DOI: 10.1155/2015/608607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 04/19/2015] [Indexed: 01/19/2023] Open
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Ding D. Management of intracranial atherosclerotic disease: current roles of medical therapy versus stent-assisted revascularization. Neurol Sci 2015; 36:1531-2. [PMID: 25868599 DOI: 10.1007/s10072-015-2214-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 04/09/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Dale Ding
- Department of Neurosurgery, University of Virginia, P.O. Box 800212, Charlottesville, VA, 22908, USA,
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Modern management of paraclinoid aneurysms: rise of flow diversion and fall of microsurgery. Clin Neurol Neurosurg 2015; 131:90-1. [PMID: 25662782 DOI: 10.1016/j.clineuro.2015.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 01/17/2015] [Indexed: 11/23/2022]
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