Initial experience with the PulseRider for the treatment of bifurcation aneurysms: report of first three cases in the USA

Intrasaccular Treatment of Intracranial Aneurysms: A Comprehensive Review

Background: The endovascular treatment of complex intracranial aneurysms, such as wide-neck aneurysms (WNAs), remains a challenge. More established endovascular techniques, which include balloon-assisted coiling, stent-assisted coiling, and flow diversion, all have their drawbacks. Intrasaccular flow disruptor devices have emerged as a useful tool for the neurointerventionalist. Methods: Here, we discuss landmark studies and provide a comprehensive, narrative review of the Woven EndoBridge (WEB; Microvention, Alisa Viejo, CA, USA), Artisse (Medtronic, Irvine, CA, USA), Contour (Stryker, Kalamazoo, MI, USA), Saccular Endovascular Aneurysm Lattice Embolization System (SEAL; Galaxy Therapeutics Inc, Milpitas, CA, USA), Medina (Medtronic, Irvine, CA, USA), and Trenza (Stryker, Kalamazoo, MI, USA) devices. Results: Intrasaccular devices have proven to be effective in treating complex aneurysms like WNAs. Conclusions: Intrasaccular flow disruptors have emerged as a new class of effective endovascular therapy, and results of ongoing clinical studies for the newer devices (e.g., SEAL and Trenza) are much anticipated.

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

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

The pCONUS2 and pCONUS2 HPC Neck Bridging Devices : Results from an International Multicenter Retrospective Study

INTRODUCTION

Bifurcation aneurysms represent an ongoing endovascular challenge with a variety of techniques and devices designed to address them. We present our multicenter series of the pCONUS2 and pCONUS2 HPC devices when treating bifurcation aneurysms.

METHODS

We performed a retrospective review of our prospectively maintained databases at 3 tertiary neurointerventional centers to identify all patients who underwent coil embolization with the pCONUS2 or pCONUS2 HPC device between February 2015 and August 2021. We recorded baseline demographics, aneurysm data, complications, immediate and delayed angiographic results.

RESULTS

We identified 55 patients with 56 aneurysms, median age 63 years (range 42-78 years), 67.3% female (n = 37). The commonest aneurysm location was the MCA bifurcation (n = 40, 71.4%). Average dome height was 8.9 ± 4.2 mm (range 3.2-21.5 mm), average neck width 6.4 ± 2.5 mm (range 2.6-14 mm), and average aspect ratio 1.3 ± 0.6 (range 0.5-3.3). The pCONUS2 was used in 64.3% and the pCONUS2 HPC in 35.7%. The procedural technical success rate was 98.2%. Intraoperative complications occurred in 5 cases (8.9%), 4 of which were related to the coils with partial thrombus formation on the pCONUS2 HPC seen in 1 case that was resolved with heparin. In relation to the procedure and treatment of the aneurysm the overall permanent morbidity was 1.8% (n = 1/55) and mortality 0%. Delayed angiographic follow-up (48 aneurysms) at median 12 months postprocedure (range 3-36 months) demonstrated adequate occlusion of 83.4% of aneurysms.

CONCLUSION

The pCONUS2 and pCONUS2 HPC devices carry a high technical success rate, low complication and retreatment rate, and good rates of adequate occlusion. Larger prospective confirmatory studies are required.

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

BACKGROUND

PulseRider is an endovascular device that can be a useful adjunctive device for wide-necked bifurcation aneurysms. However, its use in distal vessels such as the anterior cerebral artery (ACA) has not been widely reported.

OBSERVATIONS

The authors reported the case of a 75-year-old woman who underwent coiling of a 6.9-mm distal ACA aneurysm with PulseRider assistance. Using a partially intraaneurysmal deployment technique, the wide-necked aneurysm was successfully embolized, resulting in Raymond-Roy class II occlusion without intra- or periprocedural complications.

LESSONS

This case illustrates a novel approach to treatment for wide-necked distal ACA aneurysms, which can be challenging to treat via traditional endovascular means. PulseRider can be safely used to treat distal ACA aneurysms with minimal residual aneurysm.

Propensity score-adjusted analysis on stent-assisted coiling versus coiling alone for ruptured intracranial aneurysms

Stent-assisted coiling (SAC) for ruptured intracranial aneurysms (RIAs) remains controversial due to an inherent risk of potential thromboembolic and hemorrhagic complications. We compared SAC and coiling alone for the management of RIAs using propensity score-adjustment. Sixty-four patients treated by SAC and 220 by stand-alone coiling were retrospectively reviewed and compared using inverse probability of treatment weighting (IPTW) with propensity scores. Functional outcome, procedure-related and overall complications and angiographic results were analyzed. Aneurysms treated by SAC had a larger diameter, a wider neck and were more frequently located at the posterior circulation. SAC had a higher risk for thromboembolic complications (17.2% vs. 7.7%, p = 0.025), however, this difference did not persist in the IPTW analysis (OR 1.2, 95% CI 0.7-2.3, adjusted p = 0.458). In the adjusted analysis, rates of procedural cerebral infarction (p = 0.188), ventriculostomy-related hemorrhage (p = 0.584), in-hospital mortality (p = 0.786) and 6-month favorable functional outcome (p = 0.471) were not significantly different between the two groups. SAC yielded a higher complete occlusion (80.0% vs. 67.2%, OR 3.2, 95% CI 1.9-5.4, p < 0.001) and a lower recanalization rate (17.5% vs. 26.1%, OR 0.3, 95% CI 0.2-0.6, p < 0.001) than stand-alone coiling at 6-month follow-up. In conclusion, SAC of large and wide-necked RIAs provided higher aneurysm occlusion and similar clinical outcome, when compared to stand-alone coiling.

Early postmarket results with PulseRider for treatment of wide-necked intracranial aneurysms: a multicenter experience

OBJECTIVE

Traditionally, stent-assisted coiling and balloon remodeling have been the primary endovascular treatments for wide-necked intracranial aneurysms with complex morphologies. PulseRider is an aneurysm neck reconstruction device that provides parent vessel protection for aneurysm coiling. The objective of this study was to report early postmarket results with the PulseRider device.

METHODS

This study was a prospective registry of patients treated with PulseRider at 13 American neurointerventional centers following FDA approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and perioperative events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications.

RESULTS

A total of 54 aneurysms were treated, with the same number of PulseRider devices, across 13 centers. Fourteen cases were in off-label locations (7 anterior communicating artery, 6 middle cerebral artery, and 1 A1 segment anterior cerebral artery aneurysms). The average dome/neck ratio was 1.2. Technical success was achieved in 52 cases (96.2%). Major complications included the following: 3 procedure-related posterior cerebral artery strokes, a device-related intraoperative aneurysm rupture, and a delayed device thrombosis. Immediately postoperative Raymond-Roy occlusion classification (RROC) class 1 was achieved in 21 cases (40.3%), class 2 in 15 (28.8%), and class 3 in 16 cases (30.7%). Additional devices were used in 3 aneurysms. For those patients with 3- or 6-month angiographic follow-up (28 patients), 18 aneurysms (64.2%) were RROC class 1 and 8 (28.5%) were RROC class 2.

CONCLUSIONS

PulseRider is being used in both on- and off-label cases following FDA approval. The clinical and radiographic outcomes are comparable in real-world experience to the outcomes observed in earlier studies. Further experience is needed with the device to determine its role in the neurointerventionalist's armamentarium, especially with regard to its off-label use.

Bifurcation Aneurysm Treatment with PulseRider: Technical Nuances, Device Selection, Positioning Strategies, and Overcoming Geometric Challenges

BACKGROUND

Endovascular therapy is a viable alternative to surgical clipping for the treatment of intracranial aneurysms; however, aneurysms arising at bifurcations remain a challenge. The purpose of this technical report is to share the nuances of treating aneurysms with the PulseRider (PR), including device selection and positioning strategy, from authors who are highly experienced in its use.

METHODS

We offer a comprehensive guide for neuroendovascular surgeons less experienced with PR applications to include design, general coil embolization technique, principles of deployment and detachment, positioning options, and geometric challenges and their solutions.

RESULTS

In our experience, the PR is well suited for addressing the challenges of treating bifurcation aneurysms.

CONCLUSIONS

PR use is intuitive and straightforward for use in bifurcation aneurysms with ideal favorable. PR can also be safely and effectively used to address a much broader and more challenging range of geometries.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

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

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

CONCLUSION

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

Endovascular treatment of visceral artery and renal aneurysms (VRAA) using a constant mesh density flow diverting stent

BACKGROUND

Flow diverting stents have been used safely and effectively for the treatment of intracranial aneurysms, particularly for large and wide necked aneurysms that are not amenable to conventional endovascular treatment with coiling. The Surpass Streamline device (Stryker Neurovascular, MI, USA) is a relatively new and unique flow diverting stent which maintains constant device mesh density over varying vessel diameters. This may potentially provide advantages compared to other flow diverting stents in achieving aneurysmal occlusion.

CASE PRESENTATION

Two patients with VRAA were treated using the Surpass Streamline device. The first patient was a 65-year-old male with an incidental 2.4 cm aneurysm originating from the hepatic artery near the gastroduodenal artery (GDA). The second patient was a 56-year-old male with an incidental 1.9 cm renal aneurysm arising from an anterior inferior segmental branch of the left renal artery. A Surpass flow diverting stent was used to successfully exclude the aneurysm neck in both cases. Reduced flow was achieved in one patient (equivalent to O'Kelly-Marotta [OKM] Grade B1). Preserved flow and stagnation (equivalent to OKM Grade A3) was achieved in the other. There was preserved distal flow in the parent arteries. No immediate complications were encountered in either case. Complete occlusion of both aneurysms was seen on follow up CT angiographic imaging within 8-weeks.

CONCLUSIONS

The Surpass flow diverting stent can be used safely and effectively to treat VRAA. It should be considered in unruptured large and giant wide necked VRAAs aneurysms. Additional large prospective studies are required for further validation.

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

BACKGROUND

Although endovascular coiling of unruptured aneurysms is widely accepted, the endovascular treatment of wide-neck bifurcation aneurysms remains one of the most challenging morphologies. Our purpose was to describe our experience with 24-month follow-up for the treatment of unruptured intracranial bifurcation aneurysms using the PulseRider (Cerenovus, New Brunswick, NJ).

METHODS

This study is a single-center, single-arm registry performed under institutional review board control to evaluate efficacy and safety of the PulseRider. Patients with bifurcation aneurysms were identified and enrolled prospectively. Angiography immediately after treatment and at 6 months, and magnetic resonance imaging and magnetic resonance angiography at 12- and 24-month follow-up were retrospectively analyzed. A modified Rankin score was obtained prior to procedure, at discharge, and at 6-, 12- and 24-month follow-up visits.

RESULTS

Eight patients with a mean age of 66 years were treated with the PulseRider. All patients had bifurcation aneurysms (2 anterior communicating, 2 carotid terminus, and 4 basilar apex). The aneurysm diameters ranged from 4.6 to 13.6 mm (mean 7.4 mm) with dome/neck ratio ranging from 1.4 to 2.2 (mean 1.6). In all cases, the PulseRider was successfully deployed. Complete occlusion was demonstrated at 6-month follow-up on 6 of 8 (75%), near complete occlusion in 1 of 8 (12.5%), and residual aneurysm in 1 of 8 (12.5%) patients. There was no change or recurrence on magnetic resonance angiography, nor clinical complication after the procedure through 24-month follow-up.

CONCLUSIONS

Our experience with 24-month follow-up demonstrated favorable efficacy in the treatment of intracranial wide-neck bifurcation aneurysms using the PulseRider.

PulseRider Use in Ruptured Basilar Apex Aneurysms

BACKGROUND

The PulseRider (Pulsar Vascular, Inc, Los Gatos, California, USA) device was developed to treat wide-neck aneurysms, and the Adjunctive Neurovascular Support of Wide-neck aneurysm Embolization and Reconstruction (ANSWER) Trial showed efficacy in the treatment of unruptured wide-neck aneurysms. Our case series demonstrates the use of the PulseRider device in the treatment of ruptured wide-neck aneurysms.

CASE DESCRIPTION

The 2 patients in our series presented with subarachnoid hemorrhage secondary to ruptured basilar apex aneurysms. The patients were taken to the neurointervention suite for embolization of their aneurysms with the PulseRider and platinum microcoils.

CONCLUSIONS

In both cases, a Roy Raymond class III embolization was achieved. The patients recovered from their subarachnoid hemorrhage and were discharged with resolution of their symptoms. The presented cases document the safety and efficacy of treating ruptured aneurysms with the PulseRider device.

Endosurgical Remodeling of Wide-Necked Bifurcation Aneurysms

Background: Wide-necked cerebral aneurysms at a bifurcation can be difficult to treat with endovascular techniques despite recent advancements.

Objective: We describe a new technique of micro-scaffold remodeling of the aneurysm neck of wide-necked bifurcation aneurysms by placing one or more microcatheters and/or wires in the efferent vessels. We hypothesize that this technique would be a better choice to change the branch angulation, allowing for an improved configuration to stably deploy coils. We present a retrospective case series to illustrate this technique.

Methods: 17 wide-necked bifurcation aneurysms in 17 patients were coil embolized using this technique during a 3 year study period. Branch-vessel microcatheters and/or microwires were used to remodel the aneurysm neck and support the coil mass. Statistical analysis of the branch angulation and neck-width changes were performed during treatment. Long-term clinical outcome and follow-up angiography was obtained in 8 patients.

Results: Eleven patients had complete occlusion of their aneurysm (Raymond-Roy Class I), and 6 patients had Raymond-Roy Class 2 immediately after treatment. Efferent vessels demonstrated a statistically significant change in angulation with insertion of microcatheters or microwires, while neck width did not change significantly. There were four intraoperative complications and no neurological morbidity in the immediate post-operative period. Complete occlusion was documented for all 10 subjects with long-term follow-up.

Conclusions: The micro-scaffold endosurgical remodeling technique is a useful adjunct in treating wide-necked bifurcation aneurysms. By elevating branch vessels away from the aneurysm neck, this technique allows for dense coil packing while decreasing the need for balloon or stent assistance.

Current Status of the PulseRider in the Treatment of Bifurcation Aneurysms: A Systematic Review

BACKGROUND

The PulseRider is an innovative stent-like device designed for the treatment of intracranial bifurcation aneurysms. The aim of this study was to assess the current evidence on safety and effectiveness of the PulseRider.

METHODS

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following databases were searched: PubMed, Ovid MEDLINE, and Scopus. The search strategy consisted of "pulserider," "bifurcation aneurysm," and "endovascular" in both AND and OR combinations. Studies included were original research articles in peer-reviewed journals. The manuscripts were thoroughly examined for study design, outcomes, and results.

RESULTS

Three studies were identified describing use of the PulseRider device in the treatment of 63 patients with 63 bifurcation aneurysms. We identified 2 multicenter case series and 1 single-arm clinical trial. The majority of aneurysms treated were located at the basilar tip (37, 58.7%). All devices were successfully deployed, and there were 5 intraoperative complications (7.9%), including 2 intraoperative aneurysm ruptures, 1 vessel dissection, and 2 thrombus formations. Immediate complete aneurysm occlusion was achieved in 61.9% (39/63) of cases and at the 6-month imaging follow-up, 66.7% (42/63) achieved complete aneurysm occlusion. One recanalization was reported in 1 of the multicenter case series within the 6-month follow-up.

CONCLUSIONS

The PulseRider is safe and probably effective for the treatment of intracranial bifurcation aneurysms, sometimes not amenable for stent-assisted coiling. However, current evidence is limited to a small sample and short follow-up. In addition, the device has not been compared with other treatment modalities.

An Update on the Adjunctive Neurovascular Support of Wide-Neck Aneurysm Embolization and Reconstruction Trial: 1-Year Safety and Angiographic Results

BACKGROUND AND PURPOSE

The safety and efficacy of the PulseRider for the treatment of wide-neck, bifurcation aneurysms at the basilar and carotid terminus locations were studied in a prospective trial, the Adjunctive Neurovascular Support of Wide-Neck Aneurysm Embolization and Reconstruction (ANSWER) trial, reporting on initial 6-month angiographic and clinical results. This report provides insight into the longer term durability and safety with 12-month data.

MATERIALS AND METHODS

Aneurysms treated with the PulseRider among enrolled sites were prospectively studied. Updated 12-month data on clinical and imaging end points are included.

RESULTS

Thirty-four patients were enrolled (29 women, 5 men) with a mean age of 60.9 years. The mean aneurysm height ranged from 2.4 to 15.9 mm with a mean neck size of 5.2 mm (range, 2.3-11.6 mm). At 1 year, there were no device migrations or symptomatic in-stent stenoses. Raymond-Roy I occlusion was achieved in 53% of cases at the time of treatment and progressed to 61% and 67% at 6 and 12 months, respectively. Adequate occlusion (Raymond-Roy I/II) progressed from 88% at 6 months to 90% at 12 months. No recanalizations were observed. There was 1 delayed ischemic event. Good outcome (mRS 0-2) was achieved in 90% of patients.

CONCLUSIONS

The updated 1-year results from the ANSWER trial demonstrate aneurysm stability and an acceptable safety profile for aneurysms treated at the basilar apex and carotid terminus. Prospective data from a larger set of aneurysms treated at other locations are required to assess how treatment with PulseRider compares with alternatives for treating wide-neck bifurcation aneurysms.

Development of New Endovascular Devices for Aneurysm Treatment

Since the first use of the Guglielmi detachable coil system for cerebral aneurysm embolization in 1990, various endovascular methods have been developed to treat large numbers of aneurysms. The main strategic and technical modifications introduced to date include balloon-assisted coil embolization, stent-assisted coil embolization, flow diverters, and flow disrupters. The development and introduction of such devices have been so persistent and rapid that new devices are being approved worldwide even before the earlier ones become available in some countries. However, even if some patient populations may possibly benefit from earlier introduction of new devices, the approval authorities should balance the available evidence of the safety and effectiveness of novel devices. This review aims to provide an overview of the recent innovations in endovascular treatment of cerebral aneurysms and a brief review of market access policies and regulations for importing high-risk medical devices, such as those used for endovascular aneurysm management, which correspond to class III devices, as defined by the U.S. Food and Drug Administration. We focus on the current situation in Korea and compare it with that in other Asian countries, such as China and Japan.

Role of preliminary registry data in development of a clinical trial for an innovative device: a small but integral piece of a health policy initiative

Establishing a national health policy at a macro level involves the integration of a series of health initiatives across a spectrum of activities, including clinical care. Evaluation of the safety and efficacy of a new medical device ultimately evolves to testing in humans. The pathway to a formal prospective clinical trial includes a stepwise appreciation of pre-clinical data and detailed analysis of data obtained from preliminary registries, where information about appropriate patient selection and use of the device is obtained. Evaluation of procedural and follow-up efficacy and safety data in a preliminary series of cases, chosen to simulate published data, allows the design and conduct of clinical trials that are required to verify preliminary observations, closing the loop on one aspect of modifying health policy decisions.

PulseRider for Treatment of Wide-Neck Bifurcation Intracranial Aneurysms: 6-Month Results

BACKGROUND/OBJECTIVE

PulseRider is a new endovascular stent dedicated to treat bifurcation intracranial aneurysms with a wide neck. Our purpose was to evaluate 6-month clinical and anatomic results of the device when used to facilitate endovascular coiling of wide-neck bifurcation aneurysms.

METHODS

Unruptured intracranial aneurysms coiled with PulseRider, in 6 European centers and 1 U.S. center, were retrospectively reviewed from June 2014 to October 2015. Immediate and 6-month results were evaluated independently by using the Raymond classification scale. Recanalization was defined as worsening, and progressive thrombosis was defined as improvement on the Raymond scale.

RESULTS

Nineteen patients (10 women, 9 men; mean age, 63 years) harboring 19 bifurcation aneurysms (mean dome size, 8.8 mm; mean neck size, 5.8 mm) were included. Immediate angiographic outcome showed 11 complete aneurysm occlusions, 6 neck remnants, and 2 residual aneurysms. Follow-up at 6 months, obtained in all patients, included 12 complete aneurysm occlusions (63.1%), 6 neck remnants (31.6%), and 1 residual aneurysm (5.3%). Adequate occlusion (defined as complete occlusion and neck remnant combined) was observed in 94.7%. Progressive thrombosis was observed in 2 cases (10.6%) and recanalization in 1 case (5.3%). There was no in-stent stenosis or jailed branch occlusion. No bleeding was observed during the follow-up period. Permanent morbidity rate was 5.3% (1/19), and the mortality rate was 0% at 6 months.

CONCLUSIONS

The PulseRider allows endovascular treatment of wide-neck bifurcation intracranial aneurysms. Larger series are needed to confirm our preliminary results.

PulseRider-assisted treatment of wide-necked intracranial bifurcation aneurysms: safety and feasibility study

OBJECTIVE The goal of this study was to assess the safety and feasibility of PulseRider, a novel endovascular stent, in the treatment of intracranial bifurcation aneurysms with wide necks. The authors present the initial results of the first 10 cases in which the PulseRider device was used. METHODS Patients whose aneurysms were intended to be treated with the PulseRider device at 2 institutions in the United Kingdom were identified prospectively. Patient demographics, procedural details, immediate neurological and clinical status, and immediate angiographic outcomes and 6-month clinical and imaging follow-up were recorded prospectively. RESULTS At the end of the procedure, all 10 patients showed complete aneurysm occlusion (Raymond Class 1). There were no significant intraprocedural complications except for an occurrence of thromboembolism without clinical sequelae. There was no occurrence of aneurysm rupture or vessel dissection. At 6-month follow-up, 7 and 3 patients had modified Rankin Scale scores of 0 and 1, respectively. All 10 patients had stable aneurysm occlusion (Raymond Class 1) and daughter vessel intraluminal patency on 6-month follow-up catheter angiography. CONCLUSIONS The authors' early experience with the PulseRider device demonstrates that it is a safe and effective adjunct in the treatment of bifurcation aneurysms with wide necks arising at the middle cerebral artery bifurcation, anterior cerebral artery, basilar apex, and carotid terminus. It works by providing a scaffold at the neck of the bifurcation aneurysm, enabling neck remodeling and coil support while maintaining parent vessel intraluminal patency. Early clinical and radiological follow-up showed good functional outcome and stable occlusion rates, respectively. Further data are needed to assess medium- and long-term outcomes with PulseRider.

Stent deployment protocol for optimized real-time visualization during endovascular neurosurgery

Successful application of endovascular neurosurgery depends on high-quality imaging to define the pathology and the devices as they are being deployed. This is especially challenging in the treatment of complex cases, particularly in proximity to the skull base or in patients who have undergone prior endovascular treatment. The authors sought to optimize real-time image guidance using a simple algorithm that can be applied to any existing fluoroscopy system. Exposure management (exposure level, pulse management) and image post-processing parameters (edge enhancement) were modified from traditional fluoroscopy to improve visualization of device position and material density during deployment. Examples include the deployment of coils in small aneurysms, coils in giant aneurysms, the Pipeline embolization device (PED), the Woven EndoBridge (WEB) device, and carotid artery stents. The authors report on the development of the protocol and their experience using representative cases. The stent deployment protocol is an image capture and post-processing algorithm that can be applied to existing fluoroscopy systems to improve real-time visualization of device deployment without hardware modifications. Improved image guidance facilitates aneurysm coil packing and proper positioning and deployment of carotid artery stents, flow diverters, and the WEB device, especially in the context of complex anatomy and an obscured field of view.

Surgical flow modification of the anterior cerebral artery-anterior communicating artery complex in the management of giant aneurysms of internal carotid artery bifurcation: An alternative for a difficult clip reconstruction

BACKGROUND

Internal carotid artery bifurcation (ICAb) aneurysms account for about 2-15% of all intracranial aneurysms. In giant and complex cases, treatment may be difficult and dangerous, once some aneurysms have wide neck and anterior cerebral artery (ACA) and middle cerebral artery (MCA) may arise from the aneurysm itself. Clip reconstruction may be difficult in such cases. Whenever possible, the occlusion of ACA transform the bifurcation in a single artery reconstruction (ICA to MCA), much easier than a bifurcation reconstruction.

METHODS

In patients with giant and complex ICAb aneurysms, we propose routine preoperative angiography with anatomical evaluation of anterior communicating artery (ACoA) patency during cervical common carotid compression with concomitant contralateral carotid artery injection. This allowed visualization of the expected reversal of flow in the A1 segment-ACoA complex. When test is positive, we can perform ipsilateral ACA (A1 segment) clip occlusion and flow modification of the ACA-ACoA complex transforming a three vessel (ICA, ACA, and MCA) reconstruction into a two vessel (ICA and MCA) reconstruction.

RESULTS

Two patients were treated, with 100% of occlusion and good outcome.

CONCLUSIONS

Surgical treatment of giant and complex ICAb may be achieved with acceptable morbidity.

PulseRider Stent-Assisted Coiling of Wide-Neck Bifurcation Aneurysms: Periprocedural Results in an International Series

The PulseRider is a novel endovascular device specifically designed to treat bifurcation intracranial aneurysms with wide necks. In an international series, we report the results of PulseRider stent-assisted coiling of 15 patients (9 women and 6 men; mean age, 62.6 years) with 15 unruptured wide-neck (median dome size, 8 mm; median neck size, 5 mm) bifurcation aneurysms. Failure of PulseRider treatment occurred in 1 case, and 1 intraprocedural thromboembolic complication was observed. There was no mortality or neurologic permanent morbidity at discharge and at 1 month. Immediate angiographic outcome showed 12 complete occlusions and 2 neck remnants. Follow-up at 6 months was available for 3 aneurysms and demonstrated 2 complete aneurysm occlusions and 1 growing neck remnant. In this small series of selected patients, PulseRider stent-assisted coiling of wide-neck bifurcation aneurysms was feasible with low procedural complication rates. Angiographic follow-up will be required to evaluate the efficacy of the PulseRider device.

Single-center experience in the endovascular treatment of wide-necked intracranial aneurysms with a bridging intra-/extra-aneurysm implant (pCONus)

Purpose

To retrospectively evaluate the safety and efficacy of the endovascular treatment of wide-necked intracranial aneurysms assisted by a novel intra-/extra-aneurysm stent-like implant (pCONus).

Methods

Initial and follow-up angiographic and clinical results are presented of 25 patients with 25 unruptured and ruptured wide-necked intracranial aneurysms treated by reconstruction of the aneurysm neck using the pCONus implant followed by coil occlusion of the fundus.

Results

Successful intra-/extra-aneurysm deployment of the pCONus with coil occlusion of the fundus was achieved in all but one case. Procedure-related ischemic complications were observed in three cases with permanent deterioration in one. Acceptable aneurysm occlusion was achieved in all cases. Follow-up angiography revealed sufficient occlusion in 81.0% of the aneurysms. Intimal hyperplasia in the stented segment of the parent artery or device migration has not been observed to date.

Conclusions

The pCONus device offers a promising treatment option for complex wide-necked bifurcation intracranial aneurysms. Acute or delayed dislocations of coils into the parent artery are successfully avoided.

Republished: Treatment of wide-necked basilar tip aneurysm not amenable to Y-stenting using the PulseRider device

Endovascular treatment of broad-necked bifurcation aneurysms remains challenging. Stent-assisted coiling has been successful but requires catheterization of the branches off the parent vessel. We present the case of a patient who failed primary and stent-assisted coiling of a large basilar tip aneurysm because the morphology of the aneurysm precluded successful distal catheterization of the posterior cerebral artery (PCA) branches. Using the PulseRider device, which does not require catheterization of bifurcation branches, we were able to treat the aneurysm successfully.

pCONus Device for the Endovascular Treatment of Wide-Neck Middle Cerebral Artery Aneurysms

BACKGROUND AND PURPOSE

Endovascular treatment of bifurcation middle cerebral artery aneurysms with a wide neck could be challenging, and many lesions are still treated by a surgical approach. The pCONus is a newly emerging device for wide-neck bifurcation intracranial aneurysms. To date, a single report on the treatment of intracranial aneurysms including all locations has been published. We report our experience with pCONus in the treatment of wide-neck MCA aneurysms.

MATERIALS AND METHODS

MCA aneurysms treated with pCONus in 4 European centers were retrospectively reviewed.

RESULTS

Forty MCA aneurysms (mean dome size, 7.7 mm; mean neck size, 5.6 mm) were treated in 40 patients (mean age, 62 years). Aneurysm coiling was performed after deployment of 1 pCONus in 95% (38/40) of cases and after deployment of 2 pCONus devices in 5% (2/40). No procedural angiographic complications were observed. Reversible neurologic complications were noted in 5% (2/40), and permanent neurologic complication, in 2.5% (1/40) at 1 month. There was no mortality. No aneurysms bled or rebled after treatment. Immediate angiographic results were complete aneurysm occlusion in 25% (10/40), neck remnant in 47.5% (19/40), and aneurysm remnant in 27.5% (11/40). Follow-up (mean, 6.8 months) was available for 33 aneurysms (82.5%). Stable or improved results were observed in all except 3 cases, including 48.5% complete occlusions (16/33), 30.3% neck remnants (10/33), and 21.2% aneurysm remnants (7/33). There was no in-stent stenosis or jailed branch occlusion. There was no angiographic recurrence of initially totally occluded aneurysms.

CONCLUSIONS

MCA aneurysms with a wide neck are amenable to treatment with pCONus.

Treatment of wide-necked basilar tip aneurysm not amenable to Y-stenting using the PulseRider device

Endovascular treatment of broad-necked bifurcation aneurysms remains challenging. Stent-assisted coiling has been successful but requires catheterization of the branches off the parent vessel. We present the case of a patient who failed primary and stent-assisted coiling of a large basilar tip aneurysm because the morphology of the aneurysm precluded successful distal catheterization of the posterior cerebral artery (PCA) branches. Using the PulseRider device, which does not require catheterization of bifurcation branches, we were able to treat the aneurysm successfully.