1
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Kalani MYS. Retrosigmoid Craniectomy for Clip Ligation of Flow-Diverted Posterior Inferior Cerebellar Artery Aneurysm. World Neurosurg 2024; 187:65. [PMID: 38608814 DOI: 10.1016/j.wneu.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024]
Abstract
Flow diversion (FD) has revolutionized the treatment of cerebral aneurysms. Since the introduction of the Pipeline Embolization Device, there has been a significant shift in the management of cerebral aneurysms, with increasing emphasis being placed on use of endoluminal reconstruction as a means of long-term, durable treatment of aneurysms. Increasingly, FD stents are being used as primary treatment for aneurysms, including those that present with subarachnoid hemorrhage.1 Improper use of FD stents, however, may create havoc, as access to the aneurysm sac is blocked with the placement of these devices. Aneurysms that are incompletely treated with FD may continue to grow and rupture. The inability to use coils or endosaccular devices for treatment of these aneurysms means the only options for treatment are placement of additional FD devices, deconstructive strategies with or without bypass, or microsurgical clipping,2 thereby making an aneurysm that may have been straightforward to treat with another strategy a complex lesion to treat with the presence of the FD stent. Although deconstructive techniques can be used for treatment of failed aneurysm occlusion with flow diversion, where possible, surgical clipping can result in the simplest, most durable solution. Herein we present (Video 1) a case of a patient with a posterior inferior cerebellar artery aneurysm treated previously with FD using a single pipeline embolization device without aneurysm occlusion over 1 year of follow-up who was treated with retrosigmoid craniotomy and clipping of aneurysm. Nuances of the approach selection, clipping of the aneurysm, and preservation of the stent are discussed.
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Affiliation(s)
- M Yashar S Kalani
- Department of Neurological Surgery, St. John's Neuroscience Institute, Tulsa, OK, USA.
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2
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Goertz L, Hohenstatt S, Vollherbst DF, Weyland CS, Nikoubashman O, Styczen H, Gronemann C, Weiss D, Kaschner M, Pflaeging M, Siebert E, Zopfs D, Kottlors J, Pennig L, Schlamann M, Bohner G, Liebig T, Turowski B, Dorn F, Deuschl C, Wiesmann M, Möhlenbruch MA, Kabbasch C. Safety and efficacy of coated flow diverters in the treatment of ruptured intracranial aneurysms: a retrospective multicenter study. J Neurointerv Surg 2024:jnis-2024-021516. [PMID: 38569886 DOI: 10.1136/jnis-2024-021516] [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: 01/22/2024] [Accepted: 03/07/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND This multicenter study evaluated the safety and efficacy of coated flow diverters (cFDs) for the treatment of ruptured intracranial aneurysms. METHODS Consecutive patients treated with different cFDs for ruptured aneurysms under tirofiban at eight neurovascular centers between 2016 and 2023 were retrospectively analyzed. The majority of patients were loaded with dual antiplatelet therapy after the treatment. Aneurysm occlusion was determined using the O'Kelly-Marotta (OKM) grading scale. Primary outcome measures were major procedural complications and aneurysmal rebleeding during hospitalization. RESULTS The study included 60 aneurysms (posterior circulation: 28 (47%)) with a mean size of 5.8±4.7 mm. Aneurysm morphology was saccular in 28 (47%), blister-like in 12 (20%), dissecting in 13 (22%), and fusiform in 7 (12%). Technical success was 100% with a mean of 1.1 cFDs implanted per aneurysm. Adjunctive coiling was performed in 11 (18%) aneurysms. Immediate contrast retention was observed in 45 (75%) aneurysms. There was 1 (2%) major procedural complication (a major stroke, eventually leading to death) and no aneurysmal rebleeding. A good outcome (modified Rankin Scale 0-2) was achieved in 40 (67%) patients. At a mean follow-up of 6 months, 27/34 (79%) aneurysms were completely occluded (OKM D), 3/34 (9%) had an entry remnant (OKM C), and 4/34 (12%) had residual filling (OKM A or B). There was 1 (3%) severe in-stent stenosis during follow-up that was treated with balloon angioplasty. CONCLUSIONS Treatment of ruptured aneurysms with cFDs was reasonably safe and efficient and thus represents a valid treatment option, especially for complex cases.
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Affiliation(s)
- Lukas Goertz
- Department of Radiology and Neuroradiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Sophia Hohenstatt
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital Aachen, Aachen, Germany
| | - Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | | | - Daniel Weiss
- Department of Neuroradiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marius Kaschner
- Department of Neuroradiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Muriel Pflaeging
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, University Hospital Berlin (Charité), Berlin, Germany
| | - David Zopfs
- Department of Radiology and Neuroradiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Jonathan Kottlors
- Department of Radiology and Neuroradiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Lenhard Pennig
- Department of Radiology and Neuroradiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Marc Schlamann
- Department of Radiology and Neuroradiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Georg Bohner
- Department of Neuroradiology, University Hospital Berlin (Charité), Berlin, Germany
| | - Thomas Liebig
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - Bernd Turowski
- Department of Neuroradiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital Aachen, Aachen, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Kabbasch
- Department of Radiology and Neuroradiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
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Rantamo A, Gallé C, Numminen J, Virta J, Tanskanen P, Lindroos AC, Resendiz-Nieves J, Lehecka M, Niemelä M, Haeren R, Raj R. Flow diversion of ruptured intracranial aneurysms: a single-center study with a standardized antithrombotic treatment protocol. Acta Neurochir (Wien) 2024; 166:130. [PMID: 38467916 PMCID: PMC10927838 DOI: 10.1007/s00701-024-06029-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/28/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND The use of antithrombotic medication following acute flow diversion for a ruptured intracranial aneurysm (IA) is challenging with no current guidelines. We investigated the incidence of treatment-related complications and patient outcomes after flow diversion for a ruptured IA before and after the implementation of a standardized antithrombotic medication protocol. METHODS We conducted a single-center retrospective study including consecutive patients treated for acutely ruptured IAs with flow diversion during 2015-2023. We divided the patients into two groups: those treated before the implementation of the protocol (pre-protocol) and those treated after the implementation of the protocol (post-protocol). The primary outcomes were hemorrhagic and ischemic complications. A secondary outcome was clinical outcome using the modified Ranking Scale (mRS). RESULTS Totally 39 patients with 40 ruptured IAs were treated with flow diversion (69% pre-protocol, 31% post-protocol). The patient mean age was 55 years, 62% were female, 63% of aneurysms were in the posterior circulation, 92% of aneurysms were non-saccular, and 44% were in poor grade on admission. Treatment differences included the use of glycoprotein IIb/IIIa inhibitors (pre-group 48% vs. post-group 100%), and the use of early dual antiplatelets (pre-group 44% vs. 92% post-group). The incidence of ischemic complications was 37% and 42% and the incidence of hemorrhagic complications was 30% and 33% in the pre- and post-groups, respectively, with no between-group differences. There were three (11%) aneurysm re-ruptures in the pre-group and none in the post-group. There were no differences in mortality or mRS 0-2 between the groups at 6 months. CONCLUSION We found no major differences in the incidence of ischemic or hemorrhagic complications after the implementation of a standardized antithrombotic protocol for acute flow diversion for ruptured IAs. There is an urgent need for more evidence-based guidelines to optimize antithrombotic treatment after flow diversion in the setting of subarachnoid hemorrhage.
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Affiliation(s)
- Anni Rantamo
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland.
| | - Camille Gallé
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
- Department of Neurosurgery, Maastricht University Medical Center, PO box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Jussi Numminen
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Jyri Virta
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Päivi Tanskanen
- Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Ann-Christine Lindroos
- Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Julio Resendiz-Nieves
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Martin Lehecka
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Roel Haeren
- Department of Neurosurgery, Maastricht University Medical Center, PO box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
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Sciacca S, Bassiouny A, Mansoor N, Minett T, Balasundaram P, Siddiqui J, Joshi Y, Derakhshani S, Kandasamy N, Booth TC, Lynch J. Early Outcomes of the Pipeline Vantage Flow Diverter : A Multicentre Study. Clin Neuroradiol 2023; 33:887-896. [PMID: 37378843 DOI: 10.1007/s00062-023-01314-x] [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: 01/06/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE The recently introduced Pipeline Vantage Embolization Device with Shield Technology is the fourth generation of Pipeline flow diverter devices. Due to the relatively high rate of intraprocedural technical complications, modifications were subsequently made to the device after a limited release of the device in 2020. This study aimed to evaluate the safety and efficacy of the modified version of this device. METHODS This was a multicentre retrospective series. The primary efficacy endpoint was aneurysm occlusion in the absence of retreatment. The primary safety endpoint was any neurological morbidity or death. Ruptured and unruptured aneurysms were included in the study. RESULTS A total of 52 procedures were performed for 60 target aneurysms. Treatment was performed on 5 patients with ruptured aneurysms. The technical success rate was 98%. The mean clinical follow-up time was 5.5 months. In patients presenting with unruptured aneurysms there were no deaths, 3 (6.4%) major complications and 7 (13%) minor complications. In the five patients presenting with subarachnoid haemorrhage there were 2 (40%) major complications with 1 (20%) of these resulting in death, and 1 (20%) minor complication. Of the patients 29 (56%) had undergone 6‑monthly postprocedural angiographic imaging with a mean time of 6.6 months demonstrating that 83% of patients had achieved adequate occlusion (RROC1/2) of the aneurysm. CONCLUSIONS In this non-industry-sponsored study, the occlusion rates and safety outcomes were similar to those seen in previously published studies with flow diverter devices and earlier generation Pipeline devices. Modifications to the device appear to have improved ease of deployment.
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Affiliation(s)
- Sara Sciacca
- Department of Neuroradiology, King's College Hospital, London, UK.
| | - Ahmed Bassiouny
- Department of Neuroradiology, King's College Hospital, London, UK
- Department of Radiology, Mansoura University, Mansoura, Egypt
| | - Nina Mansoor
- Department of Neuroradiology, King's College Hospital, London, UK
| | - Thais Minett
- Department of Neuroradiology, Addenbrooke's Hospital, Cambridge, UK
| | | | - Juveria Siddiqui
- Department of Neuroradiology, King's College Hospital, London, UK
| | - Yogish Joshi
- Department of Neuroradiology, Addenbrooke's Hospital, Cambridge, UK
| | | | - Naga Kandasamy
- Department of Neuroradiology, King's College Hospital, London, UK
| | | | - Jeremy Lynch
- Department of Neuroradiology, King's College Hospital, London, UK
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Madjidyar J, Keller E, Winklhofer S, Toth D, Barnaure I, Schubert T, Thurner P, Fierstra J, Willms JF, Regli L, Kulcsar Z. Single-antiplatelet regimen in ruptured cerebral blood blister and dissecting aneurysms treated with flow-diverter stent reconstruction. J Neurointerv Surg 2023; 15:953-957. [PMID: 36328478 DOI: 10.1136/jnis-2022-019361] [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: 07/11/2022] [Accepted: 10/08/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Flow diversion treatment of ruptured cerebral aneurysms remains challenging due to the need for double-antiplatelet therapy. We report our experience with flow-diverter stent (FDS) reconstruction with single-antiplatelet therapy of ruptured cerebral blood blister and dissecting aneurysms. METHODS In this case series we performed a retrospective analysis of all patients with ruptured cerebral aneurysms who were treated with a phosphoryl-bonded FDS between 2019 and 2022 in a single center. Periprocedurally, all patients received weight-adapted eptifibatide IV and heparin IV. After 6-24 hours, eptifibatide was switched to oral prasugrel as monotherapy. We analyzed the rate of bleeding complications, thromboembolic events, occlusion rate and clinical outcome. RESULTS Nine patients with subarachnoid hemorrhage were treated, eight within 24 hours of symptom onset. Seven patients were treated with one FDS and two patients received two FDS in a telescopic fashion. Two aneurysms were additionally coil embolized. Fatal re-rupture occurred in one case; eight patients survived and had no adverse events associated with the FDS. Six patients showed complete occlusion of the aneurysm after 3 months (n=2) and 1 year (n=4), respectively. Two patients showed subtotal occlusion of the aneurysm at the last follow-up after 3 months and 6 months, respectively. Favorable clinical outcome was achieved in five patients. CONCLUSIONS Peri-interventional single-antiplatelet therapy with eptifibatide followed by prasugrel was sufficient to prevent thromboembolic events and reduce re-bleeding using an anti-thrombogenic FDS. FDS with single-antiplatelet therapy might be a viable option for ruptured blood blister and dissecting cerebral aneurysms.
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Affiliation(s)
- Jawid Madjidyar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Emanuela Keller
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sebastian Winklhofer
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Daniel Toth
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Isabelle Barnaure
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Tilman Schubert
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Patrick Thurner
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jan Folkard Willms
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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6
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Akimoto T, Ito Y, Akutagawa K, Sato M, Hayakawa M, Marushima A, Takigawa T, Tsuruta W, Kato N, Suzuki K, Uemura K, Yamamoto T, Matsumaru Y. Perioperative and long-term complications following therapeutic internal carotid artery occlusion. Interv Neuroradiol 2023; 29:426-433. [PMID: 35450482 PMCID: PMC10399501 DOI: 10.1177/15910199221095786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 04/04/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Parent artery occlusion (PAO) is an effective treatment for hemorrhagic diseases associated with the internal carotid artery. There are several reports of long-term cerebral infarction or the formation of de novo cerebral aneurysms following PAO. MATERIALS AND METHODS We retrospectively reviewed these complications in 38 patients who underwent PAO for therapeutic treatment. We investigated perioperative cerebral infarctions, long-term cerebral infarctions, and de novo aneurysms. RESULTS The mean age of the patients was 64.0 years, and 25 patients (65.8%) were female. The causative diseases were unruptured (n = 19; 50.0%) and ruptured (n = 8; 21.1%) aneurysms. PAO was performed after ischemic tolerance was assessed with balloon test occlusion (BTO), and BTO was performed in 34 patients, of whom 25 (73.5%) had ischemic tolerance. Twenty-six patients (68.4%) were treated with PAO alone, eight (23.5%) with low-flow bypass, and six (17.6%) with high-flow bypass. Perioperative complications occurred in five patients (13.2%): two of the 26 patients (7.7%) who underwent scheduled treatment and three of the 12 patients (25.0%) who underwent emergency treatment. One patient (2.6%) had long-term de novo aneurysm, and none developed cerebral infarction. CONCLUSIONS These results showed that the assessment of ischemic tolerance by performing BTO and appropriate revascularization in scheduled treatments are important to reduce perioperative and long-term cerebral infarctions. PAO must be performed with greater caution in emergency treatment.
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Affiliation(s)
- Taisuke Akimoto
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- Department of Neurosurgery, Yokomhama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Yoshiro Ito
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kazuki Akutagawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Masayuki Sato
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Aiki Marushima
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University, Saitama Medical Center, Saitama, Japan
| | - Wataro Tsuruta
- Department of Neuroendovascular Therapy, Toranomon Hospital, Tokyo, Japan
| | - Noriyuki Kato
- Department of Neurosurgery, Mito Medical Center Hospital, Ibaraki, Japan
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University, Saitama Medical Center, Saitama, Japan
| | - Kazuya Uemura
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Ibaraki, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokomhama City University, Yokohama, Kanagawa, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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Utility of flow diverters in treatment of acutely ruptured uncoilable aneurysms of the posterior circulation of the brain. Jpn J Radiol 2023:10.1007/s11604-023-01409-y. [PMID: 36920731 DOI: 10.1007/s11604-023-01409-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: 09/13/2022] [Accepted: 02/27/2023] [Indexed: 03/16/2023]
Abstract
PURPOSE Aim of this study is to evaluate safety and efficacy of flow diverters (FDs) in treatment of acutely ruptured posterior circulation aneurysms MATERIALS AND METHODS: Databases of three participating institutions were retrospectively scanned for patients in whom FD placement was attempted for treatment of acutely ruptured vertebrobasilar aneurysms. An interval of 14 days or fewer between the latest ictus and treatment was used as inclusion criterion. Patients with dolichoectasia of vertebrobasilar arteries were excluded. If necessary, adjunctive techniques including coiling or stenting were utilized. Clinical outcomes were graded using mWFNS (modified World Federation of Neurosurgical Societies Scale) and mRS (modified Rankin Scale). Aneurysmal occlusion was defined as Raymond-Roy Class 1. Spearman's (ρ) test was used to assess the correlation between variables. Univariate and multivariate logistic regression were used to assess outcomes. RESULTS 31 patients (25 women, mean age: 52.7 ± 15.2) harboring 32 aneurysms (16 non-saccular, mean size: 11.4 ± 7 mm) were included. Mean number of FDs used was 1.22 ± 0.42. In six cases, adjunctive coiling and in five cases, apposing stent placement were used. Overall mortality rate and procedure-related mortality rates were 22.5% (7/31) and 9.6% (3/31), respectively. At a mean imaging follow-up of 17.2 ± 12.6 months, total occlusion was achieved in 22 aneurysms (91.6%). Univariate analysis showed that mortality was positively correlated with vasospasm (ρ = 0.600, p < 0.05), higher mWFNS Scale (ρ = 0.685, p < 0.05), higher modified Fischer Score (ρ = 0.609, p < 0.05), higher mRS (ρ = 0.594, p < 0.05) on admission and negatively correlated with saccular morphology (ρ = -0.529, p < 0.05). Multivariate logistic regression identified mWFNS on admission as a significant predictor. (OR: 7.148, 95% CI 1.777-28.758, p: 0.01). Adjunctive coiling positively correlated with aneurysm occlusion. (ρ = 0.522, p < 0.05). CONCLUSION The procedure-related morbidity and mortality is not negligible. However, the risks and efficacy associated with FDs are acceptable, especially when adjunctive coiling is possible, given the lack of treatment alternatives.
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8
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Roethlisberger M, Aghlmandi S, Rychen J, Chiappini A, Zumofen DW, Bawarjan S, Stienen MN, Fung C, D'Alonzo D, Maldaner N, Steinsiepe VK, Corniola MV, Goldberg J, Cianfoni A, Robert T, Maduri R, Saliou G, Starnoni D, Weber J, Seule MA, Gralla J, Bervini D, Kulcsar Z, Burkhardt JK, Bozinov O, Remonda L, Marbacher S, Lövblad KO, Psychogios M, Bucher HC, Mariani L, Bijlenga P, Blackham KA, Guzman R. Impact of Very Small Aneurysm Size and Anterior Communicating Segment Location on Outcome after Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2023; 92:370-381. [PMID: 36469672 DOI: 10.1227/neu.0000000000002212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 08/31/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Very small anterior communicating artery aneurysms (vsACoA) of <5 mm in size are detected in a considerable number of patients with aneurysmal subarachnoid hemorrhage (aSAH). Single-center studies report that vsACoA harbor particular risks when treated. OBJECTIVE To assess the clinical and radiological outcome(s) of patients with aSAH diagnosed with vsACoA after aneurysm treatment and at discharge. METHODS Information on n = 1868 patients was collected in the Swiss Subarachnoid Hemorrhage Outcome Study registry between 2009 and 2014. The presence of a new focal neurological deficit at discharge, functional status (modified Rankin scale), mortality rates, and procedural complications (in-hospital rebleeding and presence of a new stroke on computed tomography) was assessed for vsACoA and compared with the results observed for aneurysms in other locations and with diameters of 5 to 25 mm. RESULTS This study analyzed n = 1258 patients with aSAH, n = 439 of which had a documented ruptured ACoA. ACoA location was found in 38% (n = 144/384) of all very small ruptured aneurysms. A higher in-hospital bleeding rate was found in vsACoA compared with non-ACoA locations (2.8 vs 2.1%), especially when endovascularly treated (2.1% vs 0.5%). In multivariate analysis, aneurysm size of 5 to 25 mm, and not ACoA location, was an independent risk factor for a new focal neurological deficit and a higher modified Rankin scale at discharge. Neither very small aneurysm size nor ACoA location was associated with higher mortality rates at discharge or the occurrence of a peri-interventional stroke. CONCLUSION Very small ruptured ACoA have a higher in-hospital rebleeding rate but are not associated with worse morbidity or mortality.
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Affiliation(s)
- Michel Roethlisberger
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Soheila Aghlmandi
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jonathan Rychen
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alessio Chiappini
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel W Zumofen
- Department of Neurological Surgery, Maimonides Medical Center, New York, USA
| | - Schatlo Bawarjan
- Department of Neurosurgery, University Hospital of Göttingen, Göttingen, Germany
| | - Martin N Stienen
- Department of Neurosurgery and Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland.,Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Christian Fung
- Department of Neurosurgery, University Hospital of Freiburg, Freiburg Germany.,Departments of Neurosurgery and Neuroradiology, University Hospital of Bern, Bern Switzerland
| | - Donato D'Alonzo
- Departments of Neurosurgery and Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Nicolai Maldaner
- Department of Neurosurgery and Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland
| | - Valentin K Steinsiepe
- Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marco V Corniola
- Departments of Neurosurgery and Neuroradiology, University Hospital of Geneva, Geneva Switzerland
| | - Johannes Goldberg
- Departments of Neurosurgery and Neuroradiology, University Hospital of Bern, Bern Switzerland
| | - Alessandro Cianfoni
- Departments of Neurosurgery and Neuroradiology, Neurocenter of Southern Switzerland, Ospedale regionale, Lugano, Switzerland
| | - Thomas Robert
- Departments of Neurosurgery and Neuroradiology, Neurocenter of Southern Switzerland, Ospedale regionale, Lugano, Switzerland
| | - Rodolfo Maduri
- Clinique de Genolier, Swiss Medical Network, Genolier, Switzerland
| | - Guillaume Saliou
- Departments of Neurosurgery and Neuroradiology, University Hospital of Lausanne, Switzerland
| | - Daniele Starnoni
- Departments of Neurosurgery and Neuroradiology, University Hospital of Lausanne, Switzerland
| | - Johannes Weber
- Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Martin A Seule
- Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Jan Gralla
- Departments of Neurosurgery and Neuroradiology, University Hospital of Bern, Bern Switzerland
| | - David Bervini
- Departments of Neurosurgery and Neuroradiology, University Hospital of Bern, Bern Switzerland
| | - Zsolt Kulcsar
- Department of Neurosurgery and Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Oliver Bozinov
- Department of Neurosurgery and Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland.,Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Luca Remonda
- Departments of Neurosurgery and Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Serge Marbacher
- Departments of Neurosurgery and Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Karl-Olof Lövblad
- Departments of Neurosurgery and Neuroradiology, University Hospital of Geneva, Geneva Switzerland
| | - Marios Psychogios
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philippe Bijlenga
- Departments of Neurosurgery and Neuroradiology, University Hospital of Geneva, Geneva Switzerland
| | - Kristine A Blackham
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
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9
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Khanna O, Al Saiegh F, Mouchtouris N, Sajja K, Baldassari MP, El Naamani K, Tjoumakaris S, Gooch MR, Rosenwasser RH, Starke RM, Jabbour PM. Coil Embolization with Subsequent Subacute Flow Diversion Before Hospital Discharge as a Treatment Paradigm for Ruptured Aneurysms. World Neurosurg 2022; 167:e583-e589. [PMID: 35987457 DOI: 10.1016/j.wneu.2022.08.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Subtotal coil embolization followed by subsequent flow diversion is often pursued for treatment of acutely ruptured aneurysms. Owing to the need for anti-platelet therapy, the optimal time of safely pursuing flow diversion treatment has not been fully elucidated. In this study, we aim to demonstrate the safety and feasibility of staged treatment of acutely ruptured aneurysms with early coil embolization followed by flow diversion prior to discharge. METHODS A retrospective study to evaluate clinical outcomes of patients who presented with aneurysmal subarachnoid hemorrhage and underwent coil embolization followed by subacute flow diversion treatment during the same hospitalization. RESULTS A total of 18 patients are included in our case series. Eight patients presented with Hunt-Hess (H-H) grade 2 bleed, 6 patients with H-H grade 3, and 2 patients each with H-H grade 4 and H-H grade 1. Eight patients required placement of an external ventricular drain on admission. After initial coil embolization, 12 achieved Raymond-Roy grade 2 occlusion, and 6 attained grade 3a/b occlusion. The mean duration between coil embolization and subsequent flow diversion was 9.83 days (range: 1-30). There were no instances of re-hemorrhage between initial coil embolization and subsequent flow diversion treatment. Sixteen patients had a minimum of 6-month follow-up, of which 15 were found to have complete occlusion, and 1 required subsequent clipping. CONCLUSIONS Subtotal coil embolization followed by definitive treatment using flow diversion during the same hospitalization is feasible and achieves excellent aneurysm occlusion rates while avoiding dual anti-platelet therapy during the initial hemorrhage period.
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Affiliation(s)
- Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kalyan Sajja
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael P Baldassari
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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10
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Russo R, Boghi A, Giorgianni A, Lazzarotti GA, Bozzi A, Chegai F, Saletti A, Gallizioli G, Gavrilovic V, Michelozzi C, Petralia B, Gatti FL, Gorgatti T, Gallesio I, Cristaudo C, Politi MA, Molinaro S, Bergui M. Silk Vista Baby flow diverter stent for ruptured intracranial aneurysms: a retrospective observational study. Neuroradiology 2022; 64:2031-2037. [PMID: 35773522 DOI: 10.1007/s00234-022-03003-x] [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: 04/14/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Flow diversion changed the approach to complex intracranial aneurysms, leading to a widespread use and a rapid technological evolution. Indeed, indications continued to expand, including ruptured intracranial aneurysms in selected cases. Recently, new devices have been designed specifically to target smaller vessels. Therefore, we conducted a multicenter study to evaluate clinical outcome, complications, and occlusion rate of patients with ruptured aneurysms treated with new generation low profile Silk Vista Baby (SVB) flow diverter stent (FD). METHODS We performed a retrospective observational study on consecutive patients who underwent treatment with SVB for ruptured aneurysms at 12 Italian centers. Primary end point was favorable clinical outcome rate, defined as modified ranking score (mRS) of 0-2 at the 3 months. Secondary outcomes were complication rate, aneurysm re-rupture, and complete aneurysm occlusion at last radiological follow-up. RESULTS Twenty-five patients were included; at 3 months' follow-up, 19 patients (79.1%) had favorable clinical outcome (mRS 0-2). Three patients (12.5%) died during follow-up. In-stent thrombosis occurred in two cases (8.3%), managed with glycoprotein IIb/IIIA and intra-stent angioplasty, without clinical consequences. In 18 (85.7%) patients, complete occlusion at 3 months was demonstrated. No rebleeding occurred during follow-up. Presentation with unfavorable World Federation of Neurosurgical Societies grading system (WFNS) and posterior circulation location were both significantly correlated with unfavorable clinical outcome (p = 0.005 and p = 0.02). CONCLUSIONS Our data suggests that low profile FD treatment of ruptured intracranial aneurysms located distally of the circle of Willis is feasible. New generation low profile FD may represent an alternative option in carefully selected cases.
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Affiliation(s)
- Riccardo Russo
- Department of Neuroscience, Azienda Ospedaliero Universitaria Città Della Salute E Della Scienza Di Torino, Neuroradiological Unit, University of Turin, Turin, Italy.
| | - Andrea Boghi
- Department of Interventional Radiology and Neuroradiology, S. Giovanni Bosco Hospital, Turin, Italy
| | | | | | - Alessio Bozzi
- Interventional Neuroradiology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Fabrizio Chegai
- Interventional Neuroradiology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Andrea Saletti
- Azienda Ospedaliero Universitaria Di Ferrara Arcispedale Sant Anna, Neuroradiology, Ferrara, Emilia-Romagna, Italy
| | | | - Vladimir Gavrilovic
- Azienda Sanitaria Universitaria Friuli Centrale, Interventional Radiology, Udine, Italy
| | - Caterina Michelozzi
- Interventional Neuroradiology, Vita-Salute San Raffaele University Hospital, Milan, Italy
| | - Benedetto Petralia
- Azienda Sanitaria Alto Adige, Regional Hospital of Bolzano, Radiology Unit, Bolzano, Italy
| | | | - Tommaso Gorgatti
- Azienda Sanitaria Alto Adige, Regional Hospital of Bolzano, Radiology Unit, Bolzano, Italy
| | - Ivan Gallesio
- Department of Radiology, Azienda Ospedaliera SS Antonio E Biagio E C. Arrigo, Alessandria, Italy
| | - Concetto Cristaudo
- Department of Diagnostic and Interventional Neuroradiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Marco Angelo Politi
- Department of Diagnostic and Interventional Neuroradiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | | | - Mauro Bergui
- Department of Neuroscience, Azienda Ospedaliero Universitaria Città Della Salute E Della Scienza Di Torino, Neuroradiological Unit, University of Turin, Turin, Italy
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11
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Outcomes after Flow Diverter Treatment in Subarachnoid Hemorrhage: A Meta-Analysis and Development of a Clinical Prediction Model (OUTFLOW). Brain Sci 2022; 12:brainsci12030394. [PMID: 35326350 PMCID: PMC8946659 DOI: 10.3390/brainsci12030394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 02/01/2023] Open
Abstract
Background: patients with a subarachnoid hemorrhage (SAH) might need a flow diverter (FD) placement for complex acutely ruptured intracranial aneurysms (IAs). We conducted a meta-analysis and developed a prediction model to estimate the favorable clinical outcome after the FD treatment in acutely ruptured IAs. Methods: a systematic literature search was performed from 2010 to January 2021 in PubMed and Embase databases. Studies with more than five patients treated with FDs within fifteen days were included. In total, 1157 studies were identified. The primary outcome measure was the favorable clinical outcome (mRS 0–2). Secondary outcome measures were complete occlusion rates, aneurysm rebleeding, permanent neurologic deficit caused by procedure-related complications, and all-cause mortality. A prediction model was constructed using individual patient-level data. Results: 26 retrospective studies with 357 patients and 368 aneurysms were included. The pooled rates of the favorable clinical outcome, mortality, and complete aneurysm occlusion were 73.7% (95% CI 64.7–81.0), 17.1% (95% CI 13.3–21.8), and 85.6% (95% CI 80.4–89.6), respectively. Rebleeding occurred in 3% of aneurysms (11/368). The c-statistic of the final model was 0.83 (95% CI 0.76–0.89). All the studies provided a very low quality of evidence. Conclusions: FD treatment can be considered for complex ruptured IAs. Despite high complication rates, the pooled clinical outcomes seem favorable. The prediction model needs to be validated by larger prospective studies before clinical application.
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12
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Giorgianni A, Agosti E, Molinaro S, Terrana AV, Vizzari FA, Nativo L, Garg K, Craparo G, Conti V, Locatelli D, Baruzzi F, Valvassori L, Lanzino G. Flow diversion for acutely ruptured intracranial aneurysms treatment: A retrospective study and literature review. J Stroke Cerebrovasc Dis 2022; 31:106284. [PMID: 35007933 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/19/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Flow diversion is becoming an increasingly established practice for the treatment of acutely ruptured intracranial aneurysms. In this study the authors present a literature review and meta-analysis, adding a retrospective review of institutional registry on emergency treatment of aRIA with flow diverter stent. MATERIALS AND METHODS A systematic search of PubMed, SCOPUS, Ovid MEDLINE, and Ovid EMBASE was performed on April 20th, 2021, extrapolating 35 articles. R language 'meta' and 'metafor' packages were used for data pooling. The DerSimonian-Laird model was used to calculate the pooled effect. The I2 value and Q statistic evaluated study heterogeneity. Additionally, the authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured intracranial aneurysms treated with flow diverter stent placement from May 2010 to November 2020 was performed. RESULTS From the systematic literature review and meta-analysis, the pooled proportion of complete aneurysm occlusion was 78%, with a pooled rate of 79%, 71%, 80%, and 50% for dissecting, saccular, fusiform, and mycotic aneurysms, respectively. The pooled proportion of aneurysm rebleeding and intrastent stenosis was 12% and 15% respectively, for a total of 27% rate. The analysis of authors retrospective register showed an overall mortality rate of 16.7% (3/18), with a low but not negligible postprocedural rebleeding and intrastent thrombosis rates (5.6% and 11.1% respectively). CONCLUSION Although increasingly utilized in the management of selected patients with acutely ruptured intracranial aneurysms, flow diversion for acutely ruptured intracranial aneurysms treatment presents rebleeding and intrastent stenosis rates not negligible.
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Affiliation(s)
- Andrea Giorgianni
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Brescia, Italy.
| | - Stefano Molinaro
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Alberto Vito Terrana
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | | | - Luca Nativo
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Kanwaljeet Garg
- Associate Professor, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Giuseppe Craparo
- Department of Department of Neuroradiology, ARNAS Civico di Palermo, Palermo, Italy
| | - Vinicio Conti
- Department of Anesthesiology and Resuscitation, ASST Sette Laghi, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Fabio Baruzzi
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | | | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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13
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Catapano JS, Rumalla K, Karahalios K, Srinivasan VM, Labib MA, Cole TS, Baranoski JF, Rutledge C, Rahmani R, Jadhav AP, Ducruet AF, Albuquerque FC, Zabramski JM, Lawton MT. Intraventricular Tissue Plasminogen Activator and Shunt Dependency in Aneurysmal Subarachnoid Hemorrhage Patients With Cast Ventricles. Neurosurgery 2021; 89:973-977. [PMID: 34460915 DOI: 10.1093/neuros/nyab333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/08/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patients with intraventricular hemorrhage (IVH) are at higher risk of hydrocephalus requiring an external ventricular drain and long-term ventriculoperitoneal shunt placement. OBJECTIVE To investigate whether intraventricular tissue plasminogen activator (tPA) administration in patients with ventricular casting due to IVH reduces shunt dependence. METHODS Patients from the Post-Barrow Ruptured Aneurysm Trial (PBRAT) database treated for aneurysmal subarachnoid hemorrhage (aSAH) from August 1, 2010, to July 31, 2019, were retrospectively reviewed. Patients with and without IVH were compared. A second analysis compared IVH patients with and without ventricular casting. A third analysis compared patients with ventricular casting with and without intraventricular tPA treatment. The primary outcome was chronic hydrocephalus requiring permanent shunt placement. RESULTS Of 806 patients hospitalized with aSAH, 561 (69.6%) had IVH. IVH was associated with a higher incidence of shunt placement (25.7% vs 4.1%, P < .001). In multivariable logistic regression analysis, IVH was independently associated with increased likelihood of shunt placement (odds ratio [OR]: 7.8, 95% CI: 3.8-16.2, P < .001). Generalized ventricular casting was present in 80 (14.3%) patients with IVH. In a propensity-score adjusted analysis, generalized ventricular casting was an independent predictor of shunt placement (OR: 3.0, 95% CI: 1.8-4.9, P < .001) in patients with IVH. Twenty-one patients with ventricular casting received intraventricular tPA. These patients were significantly less likely to require a shunt (OR: 0.30, 95% CI: 0.010-0.93, P = .04). CONCLUSION Ventricular casting in aSAH patients was associated with an increased risk of chronic hydrocephalus and shunt dependency. However, this risk decreased with the administration of intraventricular tPA.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Caleb Rutledge
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joseph M Zabramski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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14
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Scullen T, Mathkour M, Werner C, Zeoli T, Amenta PS. Vertebral artery dissection and associated ruptured intracranial pseudoaneurysm successfully treated with coil assisted flow diversion: A case report and review of the literature. Brain Circ 2021; 7:159-166. [PMID: 34667899 PMCID: PMC8459696 DOI: 10.4103/bc.bc_67_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/01/2021] [Accepted: 04/30/2021] [Indexed: 11/14/2022] Open
Abstract
Dissecting intracranial pseudoaneurysms (IPs) are associated with a high incidence of rupture and poor neurologic outcomes. Lesions in the posterior circulation are particularly malignant and pose even greater management challenges. Traditional management consists of microsurgical vessel sacrifice with or without bypass. Flow diversion (FD) in the setting of subarachnoid hemorrhage (SAH) represents a reconstructive treatment option and can be paired with coil embolization to promote more rapid thrombosis of the lesion. We report a case of a ruptured dissecting vertebral artery (VA) IP successfully acutely treated with coil-assisted FD. A 53-year-old male presented with a right V4 dissection spanning the origin of the posterior inferior cerebellar artery and associated ruptured V4 IP. The patient was treated with coil-assisted FD. Oral dual-antiplatelet therapy (DAPT) was initiated during the procedure, and intravenous tirofiban was used as a bridging agent. Immediate obliteration of the IP was achieved, with near-complete resolution of the dissection within 48 h. The patient made a complete recovery, and angiography at 6 weeks confirmed total IP obliteration, reconstruction of the VA, and a patent stent. The use of FD and DAPT in the setting of acute SAH remains controversial. We believe that coil-assisted FD in carefully selected patients offers significant advantages over traditional microsurgical and endovascular options. The risks posed by DAPT and potential for delayed thrombosis with FD can be effectively mitigated with planning and the development of protocols. We discuss the current literature in the context of our case and review the challenges associated with treating these often devastating lesions.
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Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Surgery, Neurosurgery Division, Jazan University, Jazan, Kingdom of Saudi Arabia
| | - Cassidy Werner
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Tyler Zeoli
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Peter S Amenta
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
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15
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Zhong W, Kuang H, Zhang P, Yang X, Luo B, Maimaitili A, Zhao Y, Song D, Guan S, Zhang H, Wang Y, Wang D, Su W, Wang Y. Pipeline Embolization Device for the Treatment of Ruptured Intracerebral Aneurysms: A Multicenter Retrospective Study. Front Neurol 2021; 12:675917. [PMID: 34603179 PMCID: PMC8481592 DOI: 10.3389/fneur.2021.675917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/19/2021] [Indexed: 12/03/2022] Open
Abstract
Background and Purpose: The utilization of flow diversion for ruptured intracerebral aneurysms (IAs) is still limited. We aimed to demonstrate our multicenter experience using the pipeline embolization device (PED) for ruptured IAs that were difficult to treat by clipping and coiling. Methods: Thirty-eight patients with ruptured IAs who underwent PED treatment from 2015 to 2020 were retrospectively reviewed. Factors associated with procedure-related stroke (ischemic and hemorrhagic) and clinical and angiography outcomes were analyzed. Results: There were 14 (36.8%) saccular IAs, 12 (31.6%) blister-like IAs, and 12 (31.6%) dissecting IAs. Perforator involvement was noted in 10 (26.3%) IAs. Early PED placement ( ≤ 15 days) and adjunctive coiling treatment were performed in 27 (71.1%) and 22 (57.9%) cases, respectively. The overall rate of stroke-related complications was 31.6% (12/38) (including rates of 10.5% for procedure-related hemorrhagic complications and 15.8% for procedure-related infarction). The mortality rate was 13.2% (5/38), and 84.2% of patients (32/38) had favorable outcomes. Thirty-two (84.2%) patients underwent follow-up angiographic evaluations; of these, 84.4% (27 patients) had complete occlusion and 15.6% had incomplete obliteration. Multivariate analysis revealed that early PED placement was not associated with a high risk of procedure-related stroke or an unfavorable outcome. Adjunctive coiling exhibited an association with procedure-related stroke (p = 0.073). Procedure-related hemorrhagic complications were significantly associated with an unfavorable outcome (p = 0.003). Immediate contrast stasis in the venous phase was associated with complete occlusion during follow-up (p = 0.050). Conclusion: The PED is a feasible and effective treatment to prevent rebleeding and achieve aneurysm occlusion, but it is associated with a substantial risk of periprocedural hemorrhage and ischemic complications in acute ruptured IAs. Therefore, the PED should be used selectively for acutely ruptured IAs. Additionally, adjunctive coiling might increase procedure-related stroke; however, it may reduce aneurysm rebleeding in acutely ruptured IAs. Patients with immediate contrast stasis in the venous phase were more likely to achieve total occlusion. A prospective study with a larger sample size should be performed to verify our results.
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Affiliation(s)
- Weiying Zhong
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Hong Kuang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Department of Neurosurgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ping Zhang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Xinjian Yang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bin Luo
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongqi Zhang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Donghai Wang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Wandong Su
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Yunyan Wang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
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16
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Treatment of acute aneurysmal subarachnoid haemorrhage with primary flow diversion: 5-year single-centre experience. Clin Radiol 2021; 76:941.e19-941.e24. [PMID: 34548172 DOI: 10.1016/j.crad.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/20/2021] [Indexed: 11/20/2022]
Abstract
AIM To evaluate the safety and efficacy of treatment of patients presenting with acute aneurysmal subarachnoid haemorrhage (SAH) with primary flow-diverting stents (FDS; with or without adjuncts), with comparison to the published literature. MATERIALS AND METHODS A retrospective single-centre review was undertaken of prospectively obtained data on patients treated for SAH over a 60-month period. Of 354 patients treated for SAH during that time period, 24 patients with a total of 25 aneurysms were identified. Baseline patient demographics were recorded and clinical and imaging outcomes assessed. RESULTS Eighty-eight per cent (22/25) of the aneurysms were completely occluded (Raymond-Roy 1) at mean 12-month follow-up. The minor complication rate was 12.5% (3/24) without permanent morbidity. Mortality rate was 4% (1/25) after one patient died following aneurysmal rebleed on day 7 post-procedure. Forty-two per cent (10/24) of patients had a high-pressure shunt placed prior to endovascular treatment, no haemorrhagic complications of neurosurgical intervention were observed. CONCLUSION The necessity of dual antiplatelet therapy (DAPT) therapy when deploying FDS will rightly continue to limit their use in the acutely ruptured setting to a case-by-case basis whereby other treatment options are deemed unsafe. Methods employed to minimise subsequent haemorrhagic risks from DAPT in these patients may be worthy of further investigation.
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17
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Kim S, Park KY, Chung J, Kim YB, Lee JW, Huh SK. Comparative Analysis of Feasibility of the Retrograde Suction Decompression Technique for Microsurgical Treatment of Large and Giant Internal Carotid Artery Aneurysms. J Korean Neurosurg Soc 2021; 64:740-750. [PMID: 34380192 PMCID: PMC8435642 DOI: 10.3340/jkns.2021.0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/12/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Retrograde suction decompression (RSD) is an adjuvant technique used for the microsurgical treatment of large and giant internal carotid artery (ICA) aneurysms. In this study, we analyzed the efficacy and safety of the RSD technique for the treatment of large and giant ICA aneurysms relative to other conventional microsurgical techniques.
Methods The aneurysms were classified into two groups depending on whether the RSD method was used (21 in the RSD group vs. 43 in the non-RSD group). Baseline characteristics, details of the surgical procedure, angiographic outcomes, clinical outcomes, and procedure-related complications of each group were reviewed retrospectively.
Results There was no significant difference in the rates of complete neck-clipping between the RSD (57.1%) and non-RSD (67.4%) groups. Similarly, there was no difference in the rates of good clinical outcomes (modified Rankin Scale score, 0–2) between the RSD (85.7%) and non-RSD (81.4%) groups. Considering the initial functional status, 19 of 21 (90.5%) patients in the RSD group and 35 of 43 (81.4%) patients in the non-RSD group showed an improvement or no change in functional status, which did not reach statistical significance.
Conclusion In this study, the microsurgical treatment of large and giant intracranial ICA aneurysms using the RSD technique obtained competitive angiographic and clinical outcomes without increasing the risk of procedure-related complications. The RSD technique might be a useful technical option for the microsurgical treatment of large and giant intracranial ICA aneurysms.
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Affiliation(s)
- Sunghan Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Whan Lee
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Seung Kon Huh
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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18
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Städt M, Holtmannspötter M, Eff F, Voit-Höhne H. Non-visualizable stent-occlusion after treatment of a fusiform PCA-aneurysm-a case report. Radiol Case Rep 2021; 16:2573-2578. [PMID: 34306290 PMCID: PMC8283140 DOI: 10.1016/j.radcr.2021.06.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 10/25/2022] Open
Abstract
We report the case of a 17-year-old woman with extensive subarachnoidal hemorrhage due to a ruptured fusiform aneurysm of the right PCA (posterior cerebral artery). Endovascular treatment was successfully performed using a LVIS-EVO-Stent (Microvention Incorporation, Tustin, USA) as well as several coils. Short-term angiographic follow-up demonstrated extensive aneurysm progression and dilatation of the coil package, the stent could no longer be visualized and was not passable. Despite excellent distal vascular perfusion, a non-visible stent occlusion was suspected and subsequent occlusion of the patent artery was performed. We conclude that rapid progression of fusiform aneurysms after stent-assisted coiling may lead to expansion of the coil packages and non-assessability of the stent. Even with excellent distal perfusion, a stent-occlusion should be suspected in these cases. Therefore, we suggest short-term angiographic follow-up, especially after deploying multiple coil packages in fusiform aneurysms.
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Affiliation(s)
- Michael Städt
- Institute of Radiology und Neuroradiology, Paracelsus Medical University, Nuremberg South Hospital, Germany
| | - Markus Holtmannspötter
- Institute of Radiology und Neuroradiology, Paracelsus Medical University, Nuremberg South Hospital, Germany
| | - Florian Eff
- Institute of Radiology und Neuroradiology, Paracelsus Medical University, Nuremberg South Hospital, Germany
| | - Heinz Voit-Höhne
- Institute of Radiology und Neuroradiology, Paracelsus Medical University, Nuremberg South Hospital, Germany
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19
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Porto GBF, Al Kasab S, Sattur MG, Almallouhi E, Lajthia O, Casey MA, Starke RM, Lanzino G, Ogilvy CS, Thomas AJ, Kim L, James RF, Levitt M, Spiotta AM. Endovascular Management of Distal Anterior Cerebral Artery Aneurysms: A Multicenter Retrospective Review. World Neurosurg 2021; 154:e421-e427. [PMID: 34284157 DOI: 10.1016/j.wneu.2021.07.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/12/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Distal anterior cerebral artery aneurysms (DACAA) are a rare and difficult entity to manage. Endovascular treatment has evolved for safe and durable treatment of these lesions. The objective of this study is to report the safety, efficacy, and outcomes of endovascular treatment of DACAA. METHODS A retrospective review of DACAA endovascularly treated at 5 different institutions was performed. Data included demographics, rupture status, radiographic features, endovascular technique, complication rates, and long-term angiographic and clinical outcomes. A primary endpoint was a good clinical outcome (modified Rankin scale 0-2). Secondary endpoints included complications and radiographic occlusion at follow-up. RESULTS A total of 84 patients were reviewed. The mean age was 56, and 64 (71.4%) were female. Fifty-two (61.9%) aneurysms were ruptured. A good functional outcome was achieved in 59 patients (85.5%). Sixty (71.4%) aneurysms were treated with primary coiling, and the remaining 24 were treated with flow diversion. Adequate occlusion was achieved in 41 (95.3%) aneurysms treated with coiling, and 17 (89.5%) with flow diversion. There were total 11 (13%) complications. In the flow diversion category, there were 2, both related to femoral access. In the coiling category, there were 9: 5 thromboembolic, 3 ruptures, and 1 related to femoral access. CONCLUSION Endovascular treatment, and in particular, flow diversion for DACAA, is safe, feasible, and associated with good long-term angiographic and clinical outcomes.
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Affiliation(s)
- Guilherme B F Porto
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
| | - Sami Al Kasab
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mithun G Sattur
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eyad Almallouhi
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Orgest Lajthia
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael A Casey
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert M Starke
- Department of Neurosurgery, Division of Neuroendovascular Surgery, University of Miami, Miami, Florida, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher S Ogilvy
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Louis Kim
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Robert F James
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Michael Levitt
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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20
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Alpay K, Hinkka T, Lindgren AE, Isokangas JM, Raj R, Parkkola R, Sinisalo M, Numminen J, Pienimäki JP, Saari P, Seppänen J, Palosaari K, Rautio R. Finnish flow diverter study: 8 years of experience in the treatment of acutely ruptured intracranial aneurysms. J Neurointerv Surg 2021; 14:699-703. [PMID: 34266906 PMCID: PMC9209683 DOI: 10.1136/neurintsurg-2021-017641] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/01/2021] [Indexed: 11/30/2022]
Abstract
Background Flow diversion of acutely ruptured intracranial aneurysms (IAs) is controversial due to high treatment-related complication rates and a lack of supporting evidence. We present clinical and radiological results of the largest series to date. Methods This is a nationwide retrospective study of acutely ruptured IAs treated with flow diverters (FDs). The primary outcome was the modified Rankin Scale (mRS) score at the last available follow-up time. Secondary outcomes were treatment-related complications and the aneurysm occlusion rate. Results 110 patients (64 females; mean age 55.7 years; range 12–82 years) with acutely ruptured IAs were treated with FDs between 2012 and 2020 in five centers. 70 acutely ruptured IAs (64%) were located in anterior circulation, and 47 acutely ruptured IAs (43%) were blister-like. A favorable functional outcome (mRS 0–2) was seen in 73% of patients (74/102). Treatment-related complications were seen in 45% of patients (n=49). Rebleeding was observed in 3 patients (3%). The data from radiological follow-ups were available for 80% of patients (n=88), and complete occlusion was seen in 90% of aneurysms (79/88). The data from clinical follow-ups were available for 93% of patients (n=102). The overall mortality rate was 18% (18/102). Conclusions FD treatment yields high occlusion for acutely ruptured IAs but is associated with a high risk of complications. Considering the high mortality rate of aneurysmal subarachnoid hemorrhage, the prevention of rebleeding is crucial. Thus, FD treatment may be justified as a last resort option.
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Affiliation(s)
- Kemal Alpay
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Tero Hinkka
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Antti E Lindgren
- Neurosurgery, Kuopio University Hospital, Kuopio, Pohjois-Savo, Finland.,Department of Clinical Radiology, Kuopio University Hospital, Kuopip, Finland.,University of Eastern Finland, Institute of Clinical Medicine, Kuopio, Finland
| | | | - Rahul Raj
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Uusimaa, Finland
| | - Riitta Parkkola
- Department of Radiology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Matias Sinisalo
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Jussi Numminen
- Helsinki University Central Hospital, Helsinki, Uusimaa, Finland
| | | | - Petri Saari
- Kuopio University Hospital, Kuopio, Pohjois-Savo, Finland
| | - Janne Seppänen
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | | | - Riitta Rautio
- Department of Radiology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
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21
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Gopinathan A, Jain S, Lwin S, Teo K, Yang C, Nga V, Yeo TT. Flow Diversion in Acute Sub Arachnoid Haemorrhage: A Single Centre Five Year Experience. J Stroke Cerebrovasc Dis 2021; 30:105910. [PMID: 34119748 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The role of flow-diversion in acute sub-arachnoid haemorrhage (SAH) is controversial. Many of the published data warns of high rates of procedure-related complications and aneurysmal rebleed. This study evaluates the safety, efficacy, clinical and angiographic outcomes of acute flow-diversion at our institute. METHODS The institutional database from June 2015 to June 2020 was retrospectively reviewed for aneurysmal SAH (aSAH) treated with flow diversion. Clinical presentation, procedural details, complications, anti-platelet usage, rebleeding and aneurysm occlusion rates and outcomes were recorded. RESULTS 22 (59% females; median age 56 years) consecutive patients were identified. None of them were on regular antiplatelets/anticoagulation in the 15-days preceding the treatment. The mean aneurysm diameter was 5.4 mm and the median delay to flow-diversion was 2 days. Almost 73% (16/22) of patients had adjunctive coiling in the same session. There was no aneurysmal rebleed at a median follow up of 8.5 months and 86.3% (19/22 patients) had good clinical outcomes (3-month MRS 0-2). Adverse events related to the flow diversion procedure were seen in 3 patients; none of them had a medium to long-term clinical consequence. Three patients died from complications of SAH, unrelated to the procedure. Vascular imaging follow-up was available for 20 patients and the complete aneurysm occlusion rate was 95%. CONCLUSION Flow-diversion could be a reasonably safe and effective technique for treating ruptured aneurysms in appropriately selected patients when conventional options of surgical clipping and coiling are considered challenging.
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Affiliation(s)
- Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore.
| | - Swati Jain
- Division of Neurosurgery, University Surgical Cluster, National University Health System, Singapore.
| | - Sein Lwin
- Division of Neurosurgery, University Surgical Cluster, National University Health System, Singapore.
| | - Kejia Teo
- Division of Neurosurgery, University Surgical Cluster, National University Health System, Singapore.
| | - Cunli Yang
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore.
| | - Vincent Nga
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore.
| | - Tseng Tsai Yeo
- Division of Neurosurgery, University Surgical Cluster, National University Health System, Singapore.
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22
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Bhogal P, Makalanda H, Wong K, Keston P, Downer J, Du Plessis JC, Nania A, Simonato D, Fuschi M, Chong W, O'Reilly S, Rennie I. The Silk Vista Baby - The UK experience. Interv Neuroradiol 2021; 28:201-212. [PMID: 34078155 DOI: 10.1177/15910199211024061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The Silk Vista Baby (SVB) flow diverter (FDS) is the only FDS deliverable via a 0.017 inch microcatheter and is specifically designed for the distal vasculature. We sought to evaluate the safety and efficacy of the SVB. MATERIALS AND METHODS We performed a retrospective review to identify SVB cases at 4 tertiary neurosurgical centres within the U.K. Clinical, procedural, angiographic and follow-up data were collected. RESULTS We identified 60 patients (35 female, 58%) of average age 54 ± 10.5 (range 30-72) with 61 aneurysms, 50 (81.9%) located in the anterior circulation. The majority of the aneurysms treated were unruptured (46, 75.4%) and saccular (46, 75.4%). Dome size was 6.2 ± 6.2 mm (range 1-36mm) and parent vessel diameter was 2.3 ± 0.4 mm (range 1.2-3.3 mm).An average number of 1.07 devices were implanted. Coils or other devices were implanted in 14 aneurysms (23.3%). At last angiographic follow-up (n = 55), 7.5 ± 4.2 months post-procedure, 32 aneurysms (57.1%) were graded as RRC I, 7 (12.5%) RRC II, and 17 RRC III (30.4%).Clinical complications, excluding death, were seen in 4 patients (6.8%) including 1 delayed aneurysm rupture and 3 symptomatic ischaemic events. Only one patient had permanent morbidity (mRS 1). 3 patients died during follow-up (5.1%); 2 deaths were related to the aneurysms (3.4%) - one ruptured dissecting MCA aneurysm, and one giant partially thrombosed posterior circulation aneurysm. 93% of patients were mRS ≤ 2 at last follow-up. CONCLUSION The SVB has high rates of technical success and an acceptable safety profile. Distal aneurysms may occlude slower due to relative oversizing of the devices.
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Affiliation(s)
- P Bhogal
- The Royal London Hospital, London, UK
| | | | - K Wong
- The Royal London Hospital, London, UK
| | - P Keston
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - J Downer
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - J C Du Plessis
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - A Nania
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - D Simonato
- Department of Interventional Neuroradiology, John Radcliffe Hospital, Oxford, UK
| | - M Fuschi
- Department of Interventional Neuroradiology, John Radcliffe Hospital, Oxford, UK
| | - W Chong
- Department of Interventional Neuroradiology, University Hospitals Coventry and Warwickshire, Warwickshire, UK
| | - S O'Reilly
- Department of Interventional Neuroradiology, The Royal Victoria Hospital, Belfast, UK
| | - I Rennie
- Department of Interventional Neuroradiology, The Royal Victoria Hospital, Belfast, UK
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23
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Fries F, Tomori T, Schulz-Schaeffer WJ, Jones J, Yilmaz U, Kettner M, Simgen A, Reith W, Mühl-Benninghaus R. Treatment of experimental aneurysms with a GPX embolic agent prototype: preliminary angiographic and histological results. J Neurointerv Surg 2021; 14:286-290. [PMID: 33947771 PMCID: PMC8862012 DOI: 10.1136/neurintsurg-2021-017308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/08/2021] [Accepted: 04/19/2021] [Indexed: 11/29/2022]
Abstract
Background Recently, liquid embolic agents have emerged for the endovascular treatment of cerebral aneurysms. Here we describe the in vivo performance of a novel liquid embolization agent (GPX Embolic Device). Methods Elastase-induced aneurysms were embolized with a GPX prototype under balloon assistance. Digital subtraction angiography was performed pre-deployment and immediately after, and at 5, 10, and 30 min post-deployment in 10 rabbits and at 1 month in 8 rabbits. The early post-deployment intra-aneurysmal flow was graded as unchanged, moderately diminished, or completely absent. At 1 month the status of aneurysm occlusion was evaluated. Adhesion to catheter material and migration of GPX was assessed. Results The mean aneurysm neck diameter, width, and height were 3.6±1.0 mm, 3.0±0.8 mm, and 7.4±1.4 mm, respectively. The mean dome-to-neck ratio was 0.9±0.2. Complete stagnation of intra-aneurysmal flow was observed in 9 of 10 aneurysms (90%) within 30 min of device deployment. One aneurysm showed moderately diminished intra-aneurysmal flow at 30 min. At 1 month, 8 aneurysms were completely occluded. There was no evidence of GPX adhesion to the catheter material. Histologically, a leukocyte and foreign body reaction to GPX was detectable 28 days after embolization. Conclusions This is the first preclinical study reporting the performance of a protype version of the GPX Embolic Device in a wide-neck aneurysm model. GPX showed promising results by achieving and maintaining high rates of complete angiographic occlusion, but may induce an inflammatory reaction.
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Affiliation(s)
- Frederik Fries
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Toshiki Tomori
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Walter J Schulz-Schaeffer
- Department of Neuropathology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Joshua Jones
- Engeneering and Development, FLUIDX Medical Technology, Salt Lake City, Utah, USA
| | - Umut Yilmaz
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Michael Kettner
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Andreas Simgen
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Ruben Mühl-Benninghaus
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
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24
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Lobsien D, Clajus C, Behme D, Ernst M, Riedel CH, Abu-Fares O, Götz FG, Fiorella D, Klisch J. Aneurysm Treatment in Acute SAH with Hydrophilic-Coated Flow Diverters under Single-Antiplatelet Therapy: A 3-Center Experience. AJNR Am J Neuroradiol 2021; 42:508-515. [PMID: 33446495 DOI: 10.3174/ajnr.a6942] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/05/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE In certain clinical circumstances, dual-antiplatelet therapy can be problematic in patients with acute SAH. In some aneurysms, however, flow-diverting stents are the ideal therapeutic option. We report our experience with ruptured intracranial aneurysms treated with flow diverters with hydrophilic coating (p48 MW HPC and p64 MW HPC) under single-antiplatelet therapy. MATERIALS AND METHODS Patients were treated with either flow-diverter placement alone or a flow diverter and additional coiling. Due to the severity of the hemorrhage, the potential for periprocedural rehemorrhage, and the potential for additional surgical interventions, a single-antiplatelet regimen was used in all patients. RESULTS Thirteen aneurysms were treated in 10 patients. The median age was 62 years; 5 patients were male. All had acute SAH due to aneurysm rupture. Four blood-blister, 2 dissecting, and 7 berrylike aneurysms were treated. Seven aneurysms were adjunctively coiled. Eight of the 10 patients received a single-antiplatelet protocol of aspirin, 1 patient was treated with prasugrel only, and 1 patient was treated with tirofiban first and then switched to the aspirin single-antiplatelet protocol. One device-related complication occurred, a thrombosis of an overstented branch. All stents, however, remained open at DSA, CTA, or MRA follow-up. CONCLUSIONS The implantation of flow diverters with reduced thrombogenicity due to hydrophilic surface coating under single-antiplatelet therapy seems to be an option in carefully selected cases of SAH due to aneurysm rupture.
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Affiliation(s)
- D Lobsien
- From the Institute for Diagnostic and Interventional Neuroradiology (D.L., C.C., J.K.), Helios Klinikum Erfurt, Erfurt, Germany
| | - C Clajus
- From the Institute for Diagnostic and Interventional Neuroradiology (D.L., C.C., J.K.), Helios Klinikum Erfurt, Erfurt, Germany
| | - D Behme
- Institute for Diagnostic and Interventional Neuroradiology (D.B., M.E., C.H.R.), University Medical Center Göttingen, Göttingen, Germany
- Department for Neuroradiology (D.B.), University Hospital Magdeburg, Magedeburg, Germany
| | - M Ernst
- Institute for Diagnostic and Interventional Neuroradiology (D.B., M.E., C.H.R.), University Medical Center Göttingen, Göttingen, Germany
| | - C H Riedel
- Institute for Diagnostic and Interventional Neuroradiology (D.B., M.E., C.H.R.), University Medical Center Göttingen, Göttingen, Germany
| | - O Abu-Fares
- Institute for Diagnostic and Interventional Neuroradiology (O.A.-F., F.G.G.), Hanover Medical School, Hannover, Germany
| | - F G Götz
- Institute for Diagnostic and Interventional Neuroradiology (O.A.-F., F.G.G.), Hanover Medical School, Hannover, Germany
| | - D Fiorella
- Cerebrovascular Center (D.F.), Stony Brook Hospital, Stony Brook, New York
| | - J Klisch
- From the Institute for Diagnostic and Interventional Neuroradiology (D.L., C.C., J.K.), Helios Klinikum Erfurt, Erfurt, Germany
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25
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Kang H, Luo B, Liu J, Zhang H, Li T, Song D, Zhao Y, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Wang K, Yang X. Mortality after treatment of intracranial aneurysms with the Pipeline Embolization Device. J Neurointerv Surg 2021; 14:neurintsurg-2020-017002. [PMID: 33627503 DOI: 10.1136/neurintsurg-2020-017002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/12/2021] [Accepted: 01/22/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The Pipeline Embolization Device (PED) is reported to be a safe treatment tool for aneurysms. However, mortality occurs in a few cases, and this has not been clearly studied. We conducted a multicenter study to retrospectively evaluate the causes of, and risk factors for, mortality in patients with intracranial aneurysms treated with the PED. METHODS We retrospectively reviewed the prospectively maintained databases of patients with intracranial aneurysms treated by PED placement at 14 academic institutions from 2014 to 2019. Patients' data, including clinical and radiographic information, were analyzed with an emphasis on mortality-related complications. RESULTS A total of 1171 consecutive patients underwent 1319 PED procedures to treat 1322 intracranial aneurysms. The mortality rate was 1.5% (17/1171), and in 1.3% of the patients (15/1171), deaths were caused by delayed aneurysmal rupture, distal intraparenchymal hemorrhage, and neurological compression symptoms associated with PED procedures. Multivariate analysis showed that previous treatment (OR, 12.657; 95% CI, 3.189 to 50.227; P<0.0001), aneurysm size ≥10 mm (OR, 4.704; 95% CI, 1.297 to 17.068; P=0.019), aneurysm location (basilar artery) (OR, 10.734; 95% CI, 2.730 to 42.207; P=0.001), and current subarachnoid hemorrhage (OR, 4.505; 95% CI, 0.991 to 20.474; P=0.051) were associated with neurological complications resulting in mortality. CONCLUSIONS Delayed aneurysm rupture, distal intraparenchymal hemorrhage, and neurological compression were the main causes of mortality in patients with intracranial aneurysms treated with the PED. Large basilar aneurysms are associated with an increased risk of postoperative death and require increased attention and caution.
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Affiliation(s)
- Huibin Kang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bin Luo
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianmin Liu
- Changhai Hospital Affiliated to Naval Medical University, Shanghai, China
| | - Hongqi Zhang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianxiao Li
- Zhengzhou University People's Hospital, Zhengzhou, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yunyan Wang
- Qilu Hospital of Shandong University, Jinan, China
| | - Wenfeng Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yang Wang
- First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jieqing Wan
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guohua Mao
- Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huaizhang Shi
- First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Kun Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Wu Q, Li L, Shao Q, Xu T, Chang K, Li T, He Y. Intracranial aneurysms managed by parent artery reconstruction using Tubridge: Study protocol for a prospective, multicenter, post-market clinical trial. Interv Neuroradiol 2020; 27:490-496. [PMID: 33236687 DOI: 10.1177/1591019920976233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND As a new endovascular reconstruction technique, flow diverter (FD) shows excellent efficacy and safety for treatment of intracranial aneurysms. In a previous multicenter, randomized, controlled, pre-market study, Tubridge FD showed remarkably higher complete occlusion rate compared with traditional stent-assisted coiling. However, a nonsignificant higher complication rate in the Tubridge group was noted. Considering the learning curve, the safety, and long-term outcomes of Tubridge FD should be verified in new prospective, real world, multicenter, post-market trials. METHODS This study is a prospective, multicenter, single-arm, post-market clinical trial that evaluates the safety and efficacy of Tubridge in the treatment of patients with intracranial aneurysms by reconstructing parent artery. We expect 200 participants who meet the inclusion and exclusion criteria to be included. Clinical information and angiographic results (Raymond-Roy grading scale, RRGS) will be recorded objectively. The primary endpoint will be the complete occlusion rate of the target aneurysm (RRGS 1) at 12-month follow-up. Secondary endpoints will include the adequate occlusion rate (RRGS 1 & 2) and the rate of major in-stent stenosis (>50%) at 12-month follow-up, technique success rate, changes of modified Rankin Scale before and after the procedure, the rate of aneurysm related disability, neurological mortality, and all-cause mortality within follow-up period. DISCUSSION This post-market, prospective trial may offer more information on the safety and long-term outcomes of Tubridge FD. When the study is complete, the results may provide us a new strategy for the treatment of intracranial aneurysms.Trial registration: WHO-Chinese Clinical Trial Registry: ChiCTR2000032282.
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Affiliation(s)
- Qiaowei Wu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Li Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Qiuji Shao
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Tianming Xu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Kaitao Chang
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Yingkun He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
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27
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Sirakov A, Minkin K, Penkov M, Ninov K, Karakostov V, Sirakov S. Comaneci-Assisted Coiling as a Treatment Option for Acutely Ruptured Wide Neck Cerebral Aneurysm: Case Series of 118 Patients. Neurosurgery 2020; 87:1148-1156. [PMID: 32453823 PMCID: PMC7666901 DOI: 10.1093/neuros/nyaa200] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 03/19/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Wide-necked cerebral aneurysms in the setting of acute subarachnoid hemorrhage (SAH) remain difficult to treat with endovascular methods despite recent progress in the neuroendovascular field. OBJECTIVE To evaluate the effectiveness and safety of the Comaneci device (Rapid Medical, Israel) in endovascular coil embolization of acutely ruptured, wide-necked sidewall, or bifurcation cerebral aneurysms. METHODS We retrospectively reviewed 45 anterior communicating artery, 24 internal carotid artery, 21 middle cerebral artery bifurcation, 15 anterior cerebral artery, and 13 posterior circulation aneurysms, which were treated using Comaneci-assisted coil embolization from August 2017 to January 2019. We evaluated procedural complications, clinical outcomes, and mid-term angiographic follow-up. Immediate and 90 d-clinical outcome and radiological follow-up were obtained in all patients. RESULTS Comaneci-assisted coil embolization was performed in 118 acutely ruptured aneurysms. The technique was carried out successfully in all cases. Simultaneous application of 2 separated Comaneci devices was performed in 8/118 cases (6.77%). Periprocedural thromboembolic complications related to the device were seen in 7/118 cases (5.93%) and severe vasospasm of the parent artery after manipulation of the Comaneci device occurred in 5/118 cases (4.2%). The procedural-related morbidity rate was 2.54%, and there was no procedural related mortality. Among the available survivors, angiographic follow-ups were obtained at 3 and 6 mo, and complete aneurysmal obliteration was confirmed in 81/112 (72.3%) and 75/112 (66.9%) cases, respectively. Mid-term follow-up reviewed total recanalization rate of 14.28%. CONCLUSION Comaneci-assisted embolization of wide-necked intracranial aneurysms in patients presenting with acute SAH is associated with high procedural safety and adequate occlusion rates. Furthermore, dual antiplatelet therapy can be safely avoided in this patient group.
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Affiliation(s)
| | | | | | | | | | - Stanimir Sirakov
- Correspondence: Stanimir Sirakov, MD, PhD UH St Ivan Rilski, Radiology Department, Bul. Akad. Ivan Geshov 15, Sofia, Bulgaria 1431.
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28
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Rutledge C, Raper D, Abla AA. In reply to the Letter to the Editor Regarding "Small Aneurysms with Low PHASES Scores Account for a Majority of Subarachnoid Hemorrhage Cases". World Neurosurg 2020; 140:438. [PMID: 32797963 DOI: 10.1016/j.wneu.2020.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/03/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Daniel Raper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
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Simonato D, Gargalas S, Cox PJ, Young V, Corkill R, Kuker W, Fuschi M, Houdart E, Labeyrie MA. Aneurysms of the communicating segment of the internal carotid artery with posterior communicating artery agenesis are associated with perforator infarction after embolization. J Neurointerv Surg 2020; 13:347-352. [PMID: 32546633 DOI: 10.1136/neurintsurg-2020-016083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/16/2020] [Accepted: 05/21/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND While anatomic features associated with the risk of posterior communicating artery (PcoA) occlusion after embolization of aneurysms of the PcoA segment of the internal carotid artery (ICA) are well known, the link between perforator origin and perforator infarction has only been reported following neurosurgical clipping. The aim of this study was to determine the origin of anterior thalamic perforators and correlate it with risk of perforator infarction after embolization of PcoA segment aneurysms. METHODS One-hundred-and-ninety consecutive patients treated for PcoA segment aneurysms between 2017 and 2019 were included. PcoA and anterior thalamic perforator origin anatomy was assessed with computed tomography (CT) angiography, digital subtracted angiography, and high-resolution three-dimensional rotational cone-beam CT angiography (CBCT-A) by two independent interventional neuroradiologists. The presence of perforator infarction after embolization was ascertained from the patient's notes and follow-up imaging. RESULTS CBCT-A was superior in demonstrating the origin of perforators (P<0.001). The prevalence of perforator origin was estimated at 86% (95% CI 81%-92%) for PcoA, 8% (95% CI 4%-13%) for aneurysm wall, and 5% (95% CI 2%-9%) for ICA. The aneurysm wall origin was exclusively associated with PcoA agenesis, as well as higher risk of perforator infarction after aneurysm coiling compared with other variants (OR=14, 95% CI 2-88, P=0.006). CONCLUSIONS Our study suggests that anterior thalamic perforators may arise from aneurysm wall when there is no PcoA. Anatomic association between PcoA agenesis and perforator arising from ICA could underlie such findings, and careful consideration is essential before aneurysm repair to anticipate the risk of thalamic infarction in such cases.
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Affiliation(s)
- Davide Simonato
- Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Sergios Gargalas
- Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Pete J Cox
- Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Victoria Young
- Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Rufus Corkill
- Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Wilhelm Kuker
- Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK.,Nuffield Department of Clinical Neurosciences, Oxford Brookes University Faculty of Health and Life Sciences, Oxford, UK
| | - Maurizio Fuschi
- Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Emmanuel Houdart
- Interventional Neuroradiology, Groupe hospitalier Lariboisiere Fernand-Widal, Université de Paris, Paris, France
| | - Marc-Antoine Labeyrie
- Interventional Neuroradiology, Groupe hospitalier Lariboisiere Fernand-Widal, Université de Paris, Paris, France
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