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Nevzati E, Rey J, Spiessberger A, Moser M, Roethlisberger M, Grüter BE, Widmer HR, Coluccia D, Marbacher S. Aneurysm healing following treatment with biodegradable embolization materials: assessment in a rat sidewall aneurysm model. J Neurointerv Surg 2024:jnis-2023-021260. [PMID: 38262729 DOI: 10.1136/jnis-2023-021260] [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: 11/14/2023] [Accepted: 01/11/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND Biodegradable materials that dissolve after aneurysm healing are promising techniques in the field of neurointerventional surgery. We investigated the effects of various bioabsorable materials in combination with degradable magnesium alloy stents and evaluated aneurysm healing in a rat aneurysm model. METHODS Saccular aneurysms were created by end-to-side anastomosis in the abdominal aorta of Wistar rats. Untreated arterial grafts were immediately transplanted (vital aneurysms) whereas aneurysms with loss of mural cells were chemically decellularized before implantation. All aneurysms were treated with biodegradable magnesium stents. The animals were assigned to vital aneurysms treated with stent alone or decellularized aneurysms treated with stent alone, detachable coil, or long-term or short-term biodegradable thread. Aneurysm healing, rated microscopically and macroscopically at follow-up days 7 and 21, was defined by both neointima formation and absence of aneurysm volume increase over time. RESULTS Of 56 animals included, significant increases in aneurysm volume 7 days after surgery were observed in aneurysms with vital and decellularized walls treated with a stent only (P=0.043 each group). Twenty-one days after surgery an increase in aneurysm volume was observed in decellularized aneurysms treated with long- and short-term biodegradable threads (P=0.027 and P=0.028, respectively). Histological changes associated with an increase in aneurysm volume were seen for aneurysm wall inflammation, periadventitial fibrosis, and luminal thrombus. CONCLUSIONS An increase in aneurysm volume was associated with an absence of intrasaccular embolization material (early phase) and the breakdown of intrasaccular biodegradable material over time (late phase). Thrombus remnant and aneurysm wall inflammation promote aneurysm volume increase.
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Affiliation(s)
- Edin Nevzati
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
- Neurosurgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
- University of Basel, Faculty of Medicine, Basel, Switzerland
| | - Jeannine Rey
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
- Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Alexander Spiessberger
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
- Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Manuel Moser
- Neurosurgery, Cantonal Hospital of Graubuenden, Chur, Switzerland
| | - Michel Roethlisberger
- University of Basel, Faculty of Medicine, Basel, Switzerland
- Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Basil Erwin Grüter
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
- Division of Neuroradiology, Department of Radiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Hans Rudolf Widmer
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Daniel Coluccia
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
- Neurosurgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Serge Marbacher
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
- Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
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2
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Frączek MJ, Błoński MJ, Kliś KM, Krzyżewski RM, Polak J, Stachura K, Kwinta BM. Predictors of intraoperative intracranial aneurysm rupture in patients with subarachnoid hemorrhage: a retrospective analysis. Acta Neurol Belg 2023; 123:1717-1724. [PMID: 35759212 DOI: 10.1007/s13760-022-02005-z] [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: 04/04/2022] [Accepted: 06/09/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE Intraoperative cerebral aneurysm rupture (IOR) is a common phenomenon with a frequency of around 19%. Research regarding IOR lacks an analysis of its predictors. METHODS We retrospectively examined all saccular aneurysms, in 198 patients with subarachnoid hemorrhage, surgically treated from 2013 to 2019. Operative reports, patient histories, blood test results, discharge summaries, and radiological data were reviewed. IOR was defined as any bleeding from the aneurysm during surgery, preceding putting a clip on its neck, regardless of how trivial. RESULTS The frequency of IOR was 20.20%. Patients with IOR had higher aneurysm dome size (9.43 ± 8.39 mm vs. 4.96 ± 2.57 mm; p < 0.01). The presence of blood clot on the aneurysm dome was significantly associated with IOR (12.50% vs. 2.53%; p < 0.01). We also associated lamina terminalis fenestration during surgery (7.50% vs. 21.52%; p = 0.04) and multiple aneurysms (5.00% vs. 18.35%; p = 0.038) with a lower risk of IOR. Glucose blood levels were also elevated in patients with IOR (7.47 ± 2.78 mmol/l vs. 6.90 ± 2.22 mmol/l; p = 0.04). Multivariate analysis associated that urea blood levels (OR 0.55, 0.33 to 0.81, p < 0.01) and multiple aneurysms (OR 0.04, 0.00 to 0.37, p = 0.014) were protective factors against the occurrence of IOR. CONCLUSION Large dome size of an aneurysm, a blood clot on the aneurysm dome and elevated glucose blood levels can be IOR predictive. Lamina terminalis fenestration, the appearance of multiple aneurysms, and high urea blood levels may be associated with a lower risk of such an event.
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Affiliation(s)
- Maciej J Frączek
- Faculty of Medicine, Jagiellonian University Medical College, Św. Anny 12 Street 31-008, Kraków, Poland.
| | - Miłosz J Błoński
- Faculty of Medicine, Jagiellonian University Medical College, Św. Anny 12 Street 31-008, Kraków, Poland
| | - Kornelia M Kliś
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
| | - Roger M Krzyżewski
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
| | - Jarosław Polak
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
| | - Krzysztof Stachura
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
| | - Borys M Kwinta
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
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3
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Rinaldo L, Arturo Larco JL, Kadirvel R, Kallmes DF. Aneurysm healing after endovascular treatment in the Helsinki sidewall aneurysm model: a systematic review. J Neurointerv Surg 2023; 15:298-302. [PMID: 36220336 DOI: 10.1136/jnis-2022-019448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/19/2022] [Indexed: 11/03/2022]
Abstract
AIMS Intracranial aneurysms are treated with a variety of endovascular devices including coils, stents, and flow diverters. The mechanisms by which these devices result in aneurysm occlusion and subsequent healing have been the subject of significant research using various animal models. The murine Helsinki aneurysm model is a sidewall aneurysm created by the end-to-side anastomosis of a donor aortic graft onto the abdominal aorta of a recipient animal. The aim of this systematic review is to assess the efficacy of different endovascular devices for the treatment of the Helsinki model aneurysm. METHODS We performed a systematic review of Pubmed in accordance with PRISMA guidelines, yielding eight studies detailing the results of endovascular treatment of this preclinical aneurysm model. Studies were included if they provided rates of complete aneurysm occlusion after treatment. RESULTS In these studies, aneurysms were treated with coiling (n=81, 7 studies), stenting (n=67, 3 studies), stent-coiling (n=13, 1 study), and flow diversion (n=49, 2 studies). The results of each individual study are discussed with the goal of providing a measure of the relative efficacy of different endovascular devices for the treatment of this particular model aneurysm. We also pay special attention to insights into the mechanisms underlying aneurysm healing after different forms of endovascular therapy. CONCLUSION The data presented here may be useful to investigators attempting to demonstrate superiority of novel endovascular devices relative to previous device iterations using this preclinical model.
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Affiliation(s)
- Lorenzo Rinaldo
- Department of Neurosurgery, Mayo Clinic, Rochester, New York, USA .,Department of Neurosurgery, University of California San Francisco, San Francisco, Northern California, USA
| | | | - Ramanathan Kadirvel
- Department of Neurosurgery, Mayo Clinic, Rochester, New York, USA.,Radiology, Mayo Clinic, Rochester, Minnesota, USA
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4
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Cayron AF, Morel S, Allémann E, Bijlenga P, Kwak BR. Imaging of intracranial aneurysms in animals: a systematic review of modalities. Neurosurg Rev 2023; 46:56. [PMID: 36786880 PMCID: PMC9928939 DOI: 10.1007/s10143-023-01953-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/28/2022] [Accepted: 01/23/2023] [Indexed: 02/15/2023]
Abstract
Intracranial aneurysm (IA) animal models are paramount to study IA pathophysiology and to test new endovascular treatments. A number of in vivo imaging modalities are available to characterize IAs at different stages of development in these animal models. This review describes existing in vivo imaging techniques used so far to visualize IAs in animal models. We systematically searched for studies containing in vivo imaging of induced IAs in animal models in PubMed and SPIE Digital library databases between 1 January 1945 and 13 July 2022. A total of 170 studies were retrieved and reviewed in detail, and information on the IA animal model, the objective of the study, and the imaging modality used was collected. A variety of methods to surgically construct or endogenously induce IAs in animals were identified, and 88% of the reviewed studies used surgical methods. The large majority of IA imaging in animals was performed for 4 reasons: basic research for IA models, testing of new IA treatment modalities, research on IA in vivo imaging of IAs, and research on IA pathophysiology. Six different imaging techniques were identified: conventional catheter angiography, computed tomography angiography, magnetic resonance angiography, hemodynamic imaging, optical coherence tomography, and fluorescence imaging. This review presents and discusses the advantages and disadvantages of all in vivo IA imaging techniques used in animal models to help future IA studies finding the most appropriate IA imaging modality and animal model to answer their research question.
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Affiliation(s)
- Anne F Cayron
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, CH-1211, Geneva, Switzerland
- Geneva Center for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Sandrine Morel
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, CH-1211, Geneva, Switzerland
- Geneva Center for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Clinical Neurosciences - Division of Neurosurgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Eric Allémann
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Philippe Bijlenga
- Department of Clinical Neurosciences - Division of Neurosurgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Brenda R Kwak
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, CH-1211, Geneva, Switzerland.
- Geneva Center for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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5
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Wanderer S, Grüter BE, Boillat G, Sivanrupan S, Rey J, Catalano K, vonGunten M, Widmer HR, Andereggen L, Marbacher S. Parent artery-initiated and stent-mediated neointima formation in a rat saccular side wall model. J Neurointerv Surg 2022; 14:1258-1263. [PMID: 35110397 PMCID: PMC9685721 DOI: 10.1136/neurintsurg-2021-018297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/29/2021] [Indexed: 12/05/2022]
Abstract
Background Unlike clipping that forms an immediate barrier of blood flow into intracranial aneurysms, endovascular treatments rely on thrombus organization and neointima formation. Therefore, a continuous endothelial cell layer is crucial to prevent blood flow in the former aneurysm. This study investigates the origin of endothelial cells in the neointima of endovascular treated aneurysms, specifically whether cells from the parent artery play a role in neointima formation. Methods In male rats, decellularized and vital side wall aneurysms were treated by coil (n=16) or stent embolization (n=15). The cell tracer CM-Dil dye was injected into the clamped aorta before aneurysm suture to mark initial endothelial cells in the parent artery and enable tracking of their proliferation during follow-up. Aneurysms were analyzed for growth, thrombus formation, and recurrence. Histological evaluation followed with cell counts for specific regions-of-interest. Results During follow-up, none of the 31 aneurysms ruptured. Macroscopic residual perfusion was observed in 12/16 rats after coiling and in 1/15 after stenting. Amounts of CM-Dil +cells in coiled versus stented decellularized aneurysms significantly decreased in the thrombus on day 7 (p=0.01) and neointima on day 21 (p=0.04). For vital aneurysms, the number of CM-Dil +cells in the neointima on day 21 showed no significant difference. Conclusions Healing patterns were worse in coil-treated than stent-treated aneurysms. Cell migration forming a neointima seemed mainly dependent on the adjacent vessel in decellularized aneurysms, but appeared buoyed by recruitment from aneurysm wall cells in vital aneurysms. Therefore, a cell-rich parent artery might be crucial.
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Affiliation(s)
- Stefan Wanderer
- Neurosurgery, Kantonsspital Aarau AG, Aarau, Switzerland .,Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Basil Erwin Grüter
- Neurosurgery, Kantonsspital Aarau AG, Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Gwendoline Boillat
- Neurosurgery, Kantonsspital Aarau AG, Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Sivani Sivanrupan
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Jeannine Rey
- Neurosurgery, Kantonsspital Aarau AG, Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Kristina Catalano
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | | | | | - Lukas Andereggen
- Neurosurgery, Kantonsspital Aarau AG, Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Serge Marbacher
- Neurosurgery, Kantonsspital Aarau AG, Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
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6
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Wang C, Li M, Chen H, Yang X, Zhang Y, Zhang D. Histopathological analysis of in vivo specimens of recurrent aneurysms after coil embolization. J Neurointerv Surg 2021; 14:734-739. [PMID: 34675128 PMCID: PMC9209694 DOI: 10.1136/neurintsurg-2021-017872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/26/2021] [Indexed: 12/15/2022]
Abstract
Background Aneurysm recurrence after coil embolization remains a challenging problem. Objective To determine the histopathological features of recurrent aneurysm specimens and explore the mechanism of aneurysm recurrence. Methods Nine aneurysm specimens were collected from eight patients who underwent clipping for aneurysm recurrence within 2 years after embolization. All specimens were sectioned and embedded in resin, stained with hematoxylin-eosin (H&E), Masson stain, and immunohistochemical staining for smooth muscle actin (SMA) and CD68+ antibodies, and were examined under light microscopy. Results Five aneurysms were surgically clipped owing to post-embolic subarachnoid hemorrhage, while the other four aneurysms had dangerous recanalization detected on follow-up imaging. Five aneurysms had self-growth and four aneurysms had coil compactions. Gross observation showed that each recurrent aneurysm was wrapped by a thrombus and the aneurysm wall; some coils protruded from the pseudocapsule in some ruptured aneurysms. Microscopically, H&E staining showed that three types of thrombi (fresh thrombus, granulation tissue, and scar tissue) coexisted in one section. In addition, characteristic unstable and unorganized thrombi with empty spaces were found in the neck cavity. Immunohistochemical staining showed that the SMA stain was discontinued and incomplete, and CD68+ antibody and H&E staining revealed inflammatory infiltrate in the aneurysm wall. Conclusion The coexistence of three types of thrombi is the main characteristic of recurrent aneurysms. The formation of stable thrombus may be one of the key points of aneurysm recurrence. Smooth muscle cell damage and infiltration of inflammatory cells in the aneurysm wall probably contribute to the recanalization.
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Affiliation(s)
- Chao Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
| | - Mengxing Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
| | - Huiyuan Chen
- Department of Neuropathology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
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7
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Szatmary Z, Mounier J, Janot K, Cortese J, Couquet C, Chaubet F, Kadirvel R, Bardet SM, Mounayer C, Rouchaud A. Bioactive refinement for endosaccular treatment of intracranial aneurysms. Neuroradiol J 2021; 34:534-541. [PMID: 34210195 DOI: 10.1177/19714009211024631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Endovascular treatment is the first-line therapy for most intracranial aneurysms; however, recanalisation remains a major limitation. Developments in bioengineering and material science have led to a novel generation of coil technologies for aneurysm embolisation that address clinical challenges of aneurysm recurrence. This review presents an overview of modified surface coil technologies and summarises the state of the art regarding their efficacy and limitations based on experimental and clinical results. We also present potential perspectives to develop biologically optimised devices.
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Affiliation(s)
- Zoltan Szatmary
- Department of Radiology, Dupuytren Hospital, Limoges University, France
- XLIM UMR CNRS No. 7252, Limoges University, France
| | | | - Kevin Janot
- XLIM UMR CNRS No. 7252, Limoges University, France
- Regional University Hospital Center Tours, Radiology, Diagnostic and Interventional Neuroradiology, France
| | - Jonathan Cortese
- XLIM UMR CNRS No. 7252, Limoges University, France
- Bicêtre Hospital, Interventionnel Neuroradiology, Paris, France
| | | | - Frédéric Chaubet
- Laboratory for Vascular Translational Science, UMRS 1148, INSERM, Université de Paris, France
- Université Sorbonne Paris Nord- Campus de Bobigny, France
| | | | | | - Charbel Mounayer
- Department of Radiology, Dupuytren Hospital, Limoges University, France
- XLIM UMR CNRS No. 7252, Limoges University, France
| | - Aymeric Rouchaud
- Department of Radiology, Dupuytren Hospital, Limoges University, France
- XLIM UMR CNRS No. 7252, Limoges University, France
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8
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Grüter BE, Wanderer S, Strange F, Boillat G, Täschler D, Rey J, Croci DM, Grandgirard D, Leib SL, von Gunten M, Di Santo S, Widmer HR, Remonda L, Andereggen L, Nevzati E, Coluccia D, Fandino J, Marbacher S. Patterns of Neointima Formation After Coil or Stent Treatment in a Rat Saccular Sidewall Aneurysm Model. Stroke 2021; 52:1043-1052. [PMID: 33504186 DOI: 10.1161/strokeaha.120.032255] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular aneurysm treatment relies on a biological process, including cell migration for thrombus organization and growth of a neointima. To better understand aneurysm healing, our study explores the origin of neointima-forming and thrombus-organizing cells in a rat saccular sidewall aneurysm model. METHODS Saccular aneurysms were transplanted onto the abdominal aorta of male Lewis rats and endovascularly treated with coils (n=28) or stents (n=26). In 34 cases, GFP+ (green fluorescent protein)-expressing vital aneurysms were sutured on wild-type rats, and in 23 cases, decellularized wild-type aneurysms were sutured on GFP+ rats. Follow-up at 3, 7, 14, 21, and 28 days evaluated aneurysms by fluorescence angiography, macroscopic inspection, and microscopy for healing and inflammation status. Furthermore, the origin of cells was tracked with fluorescence histology. RESULTS In animals with successful functional healing, histological studies showed a gradually advancing thrombus organization over time characterized by progressively growing neointima from the periphery of the aneurysm toward the center. Cell counts revealed similar distributions of GFP+ cells for coil or stent treatment in the aneurysm wall (54.4% versus 48.7%) and inside the thrombus (20.5% versus 20.2%) but significantly more GFP+ cells in the neointima of coiled (27.2 %) than stented aneurysms (10.4%; P=0.008). CONCLUSIONS Neointima formation and thrombus organization are concurrent processes during aneurysm healing. Thrombus-organizing cells originate predominantly in the parent artery. Neointima formation relies more on cell migration from the aneurysm wall in coiled aneurysms but receives greater contributions from cells originating in the parent artery in stent-treated aneurysms. Cell migration, which allows for a continuous endothelial lining along the parent artery's lumen, may be a prerequisite for complete aneurysm healing after endovascular therapy. In terms of translation into clinical practice, these findings may explain the variability in achieving complete aneurysm healing after coil treatment and the improved healing rate in stent-assisted coiling.
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Affiliation(s)
- Basil E Grüter
- Department of Neurosurgery (B.E.G., S.W., F.S., G.B., L.A., E.N., D.C., J.F., S.M.), Kantonsspital Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research (B.E.G., S.W., F.S., G.B., D.T., J.R., D.M.C., L.A., E.N., D.C., J.F., S.M.), University of Bern, Switzerland
| | - Stefan Wanderer
- Department of Neurosurgery (B.E.G., S.W., F.S., G.B., L.A., E.N., D.C., J.F., S.M.), Kantonsspital Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research (B.E.G., S.W., F.S., G.B., D.T., J.R., D.M.C., L.A., E.N., D.C., J.F., S.M.), University of Bern, Switzerland
| | - Fabio Strange
- Department of Neurosurgery (B.E.G., S.W., F.S., G.B., L.A., E.N., D.C., J.F., S.M.), Kantonsspital Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research (B.E.G., S.W., F.S., G.B., D.T., J.R., D.M.C., L.A., E.N., D.C., J.F., S.M.), University of Bern, Switzerland
| | - Gwendoline Boillat
- Department of Neurosurgery (B.E.G., S.W., F.S., G.B., L.A., E.N., D.C., J.F., S.M.), Kantonsspital Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research (B.E.G., S.W., F.S., G.B., D.T., J.R., D.M.C., L.A., E.N., D.C., J.F., S.M.), University of Bern, Switzerland
| | - Dominik Täschler
- Cerebrovascular Research Group, Department for BioMedical Research (B.E.G., S.W., F.S., G.B., D.T., J.R., D.M.C., L.A., E.N., D.C., J.F., S.M.), University of Bern, Switzerland
| | - Jeannine Rey
- Cerebrovascular Research Group, Department for BioMedical Research (B.E.G., S.W., F.S., G.B., D.T., J.R., D.M.C., L.A., E.N., D.C., J.F., S.M.), University of Bern, Switzerland
| | - Davide M Croci
- Cerebrovascular Research Group, Department for BioMedical Research (B.E.G., S.W., F.S., G.B., D.T., J.R., D.M.C., L.A., E.N., D.C., J.F., S.M.), University of Bern, Switzerland
| | - Denis Grandgirard
- Neuroinfection Laboratory, Institute for Infectious Diseases (D.G., S.L.L.), University of Bern, Switzerland.,Cluster for Regenerative Neuroscience, Department for BioMedical Research (D.G., S.L.L., S.D.S., H.R.W.), University of Bern, Switzerland
| | - Stephen L Leib
- Neuroinfection Laboratory, Institute for Infectious Diseases (D.G., S.L.L.), University of Bern, Switzerland.,Cluster for Regenerative Neuroscience, Department for BioMedical Research (D.G., S.L.L., S.D.S., H.R.W.), University of Bern, Switzerland
| | | | - Stefano Di Santo
- Cluster for Regenerative Neuroscience, Department for BioMedical Research (D.G., S.L.L., S.D.S., H.R.W.), University of Bern, Switzerland.,Department of Neurosurgery, Bern University Hospital, Inselspital Bern, Switzerland (S.D.S., H.R.W.)
| | - Hans Rudolf Widmer
- Cluster for Regenerative Neuroscience, Department for BioMedical Research (D.G., S.L.L., S.D.S., H.R.W.), University of Bern, Switzerland.,Department of Neurosurgery, Bern University Hospital, Inselspital Bern, Switzerland (S.D.S., H.R.W.)
| | - Luca Remonda
- Division of Neuroradiology, Department of Radiology (L.R.), Kantonsspital Aarau, Switzerland
| | - Lukas Andereggen
- Department of Neurosurgery (B.E.G., S.W., F.S., G.B., L.A., E.N., D.C., J.F., S.M.), Kantonsspital Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research (B.E.G., S.W., F.S., G.B., D.T., J.R., D.M.C., L.A., E.N., D.C., J.F., S.M.), University of Bern, Switzerland
| | - Edin Nevzati
- Department of Neurosurgery (B.E.G., S.W., F.S., G.B., L.A., E.N., D.C., J.F., S.M.), Kantonsspital Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research (B.E.G., S.W., F.S., G.B., D.T., J.R., D.M.C., L.A., E.N., D.C., J.F., S.M.), University of Bern, Switzerland
| | - Daniel Coluccia
- Department of Neurosurgery (B.E.G., S.W., F.S., G.B., L.A., E.N., D.C., J.F., S.M.), Kantonsspital Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research (B.E.G., S.W., F.S., G.B., D.T., J.R., D.M.C., L.A., E.N., D.C., J.F., S.M.), University of Bern, Switzerland
| | - Javier Fandino
- Department of Neurosurgery (B.E.G., S.W., F.S., G.B., L.A., E.N., D.C., J.F., S.M.), Kantonsspital Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research (B.E.G., S.W., F.S., G.B., D.T., J.R., D.M.C., L.A., E.N., D.C., J.F., S.M.), University of Bern, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery (B.E.G., S.W., F.S., G.B., L.A., E.N., D.C., J.F., S.M.), Kantonsspital Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research (B.E.G., S.W., F.S., G.B., D.T., J.R., D.M.C., L.A., E.N., D.C., J.F., S.M.), University of Bern, Switzerland
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9
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Grüter BE, Marbacher S. The importance of wall degeneration in preclinical aneurysm models. J Neurointerv Surg 2020; 13:200-201. [PMID: 33188154 DOI: 10.1136/neurintsurg-2020-016926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Basil Erwin Grüter
- Department of Neurosurgery, Kantonsspital Aarau AG, Aarau, Aargau, Switzerland .,Department for BioMedical Research, Cerebrovascular Research Group, Bern, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau AG, Aarau, Aargau, Switzerland.,Department for BioMedical Research, Cerebrovascular Research Group, Bern, Switzerland
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Marbacher S, Strange F, Frösén J, Fandino J. Preclinical extracranial aneurysm models for the study and treatment of brain aneurysms: A systematic review. J Cereb Blood Flow Metab 2020; 40:922-938. [PMID: 32126875 PMCID: PMC7181093 DOI: 10.1177/0271678x20908363] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Animal models make an important contribution to our basic understanding of the pathobiology of human brain aneurysms, are indispensable in testing novel treatment approaches, and are essential for training interventional neuroradiologists and neurosurgeons. Researchers are confronted with a broad diversity of models and techniques in various species. This systematic review aims to summarize and categorize extracranial aneurysm models and their characteristics, discuss advantages and disadvantages, and suggest the best use of each model. We searched the electronical Medline/PubMed database between 1950 and 2020 to identify main models and their refinements and technical modifications for creation of extracranial aneurysms. Each study included was assessed for aneurysm-specific characteristics, technical details of aneurysm creation, and histological findings. Among more than 4000 titles and abstracts screened, 473 studies underwent full-text analysis. From those, 68 different techniques/models in five different species were identified, analyzed in detail, and then grouped into one of the five main groups of experimental models as sidewall, terminal, stump, bifurcation, or complex aneurysm models. This systematic review provides a compact guide for investigators in selecting the most appropriate model from a range of techniques to best suit their experimental goals, practical considerations, and laboratory environment.
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Affiliation(s)
- Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Fabio Strange
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Juhana Frösén
- Hemorrhagic Brain Pathology Research Group, Department of Neurosurgery, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.,Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
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11
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Grüter BE, Wanderer S, Strange F, Sivanrupan S, von Gunten M, Widmer HR, Coluccia D, Andereggen L, Fandino J, Marbacher S. Comparison of Aneurysm Patency and Mural Inflammation in an Arterial Rabbit Sidewall and Bifurcation Aneurysm Model under Consideration of Different Wall Conditions. Brain Sci 2020; 10:brainsci10040197. [PMID: 32230757 PMCID: PMC7226569 DOI: 10.3390/brainsci10040197] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 03/15/2020] [Accepted: 03/25/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Biological processes that lead to aneurysm formation, growth and rupture are insufficiently understood. Vessel wall inflammation and degeneration are suggested to be the driving factors. In this study, we aimed to investigate the natural course of vital (non-decellularized) and decellularized aneurysms in a rabbit sidewall and bifurcation model. Methods: Arterial pouches were sutured end-to-side on the carotid artery of New Zealand White rabbits (vital [n = 6] or decellularized [n = 6]), and into an end-to-side common carotid artery bifurcation (vital [n = 6] and decellularized [n = 6]). Patency was confirmed by fluorescence angiography. After 28 days, all animals underwent magnetic resonance and fluorescence angiography followed by aneurysm harvesting for macroscopic and histological evaluation. Results: None of the aneurysms ruptured during follow-up. All sidewall aneurysms thrombosed with histological inferior thrombus organization observed in decellularized compared to vital aneurysms. In the bifurcation model, half of all decellularized aneurysms thrombosed whereas the non-decellularized aneurysms remained patent with relevant increase in size compared to baseline. Conclusions: Poor thrombus organization in decellularized sidewall aneurysms confirmed the important role of mural cells in aneurysm healing after thrombus formation. Several factors such as restriction by neck tissue, small dimensions and hemodynamics may have prevented aneurysm growth despite pronounced inflammation in decellularized aneurysms. In the bifurcation model, rarefication of mural cells did not increase the risk of aneurysm growth but tendency to spontaneous thrombosis.
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Affiliation(s)
- Basil Erwin Grüter
- Department of Neurosurgery, Kantonsspital Aarau, 5000 Aarau, Switzerland; (S.W.); (F.S.); (D.C.); (L.A.); (J.F.); (S.M.)
- Cerebrovascular Research Group, Neurosurgery, Department of BioMedical Research, University of Bern, 3010 Bern, Switzerland;
- Correspondence: ; Tel.: +41-62-838-41-41
| | - Stefan Wanderer
- Department of Neurosurgery, Kantonsspital Aarau, 5000 Aarau, Switzerland; (S.W.); (F.S.); (D.C.); (L.A.); (J.F.); (S.M.)
- Cerebrovascular Research Group, Neurosurgery, Department of BioMedical Research, University of Bern, 3010 Bern, Switzerland;
| | - Fabio Strange
- Department of Neurosurgery, Kantonsspital Aarau, 5000 Aarau, Switzerland; (S.W.); (F.S.); (D.C.); (L.A.); (J.F.); (S.M.)
- Cerebrovascular Research Group, Neurosurgery, Department of BioMedical Research, University of Bern, 3010 Bern, Switzerland;
| | - Sivani Sivanrupan
- Cerebrovascular Research Group, Neurosurgery, Department of BioMedical Research, University of Bern, 3010 Bern, Switzerland;
| | | | - Hans Rudolf Widmer
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inseslspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Daniel Coluccia
- Department of Neurosurgery, Kantonsspital Aarau, 5000 Aarau, Switzerland; (S.W.); (F.S.); (D.C.); (L.A.); (J.F.); (S.M.)
- Cerebrovascular Research Group, Neurosurgery, Department of BioMedical Research, University of Bern, 3010 Bern, Switzerland;
| | - Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, 5000 Aarau, Switzerland; (S.W.); (F.S.); (D.C.); (L.A.); (J.F.); (S.M.)
- Cerebrovascular Research Group, Neurosurgery, Department of BioMedical Research, University of Bern, 3010 Bern, Switzerland;
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, 5000 Aarau, Switzerland; (S.W.); (F.S.); (D.C.); (L.A.); (J.F.); (S.M.)
- Cerebrovascular Research Group, Neurosurgery, Department of BioMedical Research, University of Bern, 3010 Bern, Switzerland;
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, 5000 Aarau, Switzerland; (S.W.); (F.S.); (D.C.); (L.A.); (J.F.); (S.M.)
- Cerebrovascular Research Group, Neurosurgery, Department of BioMedical Research, University of Bern, 3010 Bern, Switzerland;
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12
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Marbacher S, Wanderer S, Strange F, Grüter BE, Fandino J. Saccular Aneurysm Models Featuring Growth and Rupture: A Systematic Review. Brain Sci 2020; 10:brainsci10020101. [PMID: 32069946 PMCID: PMC7071455 DOI: 10.3390/brainsci10020101] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 01/25/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Most available large animal extracranial aneurysm models feature healthy non-degenerated aneurysm pouches with stable long-term follow-ups and extensive healing reactions after endovascular treatment. This review focuses on a small subgroup of extracranial aneurysm models that demonstrated growth and potential rupture during follow-up. METHODS The literature was searched in Medline/Pubmed to identify extracranial in vivo saccular aneurysm models featuring growth and rupture, using a predefined search strategy in accordance with the PRISMA guidelines. From eligible studies we extracted the following details: technique and location of aneurysm creation, aneurysm pouch characteristics, time for model creation, growth and rupture rate, time course, patency rate, histological findings, and associated morbidity and mortality. RESULTS A total of 20 articles were found to describe growth and/or rupture of an experimentally created extracranial saccular aneurysm during follow-up. Most frequent growth was reported in rats (n = 6), followed by rabbits (n = 4), dogs (n = 4), swine (n = 5), and sheep (n = 1). Except for two studies reporting growth and rupture within the abdominal cavity (abdominal aortic artery; n = 2) all other aneurysms were located at the neck of the animal. The largest growth rate, with an up to 10-fold size increase, was found in a rat abdominal aortic sidewall aneurysm model. CONCLUSIONS Extracranial saccular aneurysm models with growth and rupture are rare. Degradation of the created aneurysmal outpouch seems to be a prerequisite to allow growth, which may ultimately lead to rupture. Since it has been shown that the aneurysm wall is important for healing after endovascular therapy, it is likely that models featuring growth and rupture will gain in interest for preclinical testing of novel endovascular therapies.
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Affiliation(s)
- Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau 5000, Switzerland (B.E.G.)
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern 3000, Switzerland
- Correspondence: ; Tel.: +41-62-838-5970
| | - Stefan Wanderer
- Department of Neurosurgery, Kantonsspital Aarau, Aarau 5000, Switzerland (B.E.G.)
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern 3000, Switzerland
| | - Fabio Strange
- Department of Neurosurgery, Kantonsspital Aarau, Aarau 5000, Switzerland (B.E.G.)
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern 3000, Switzerland
| | - Basil E. Grüter
- Department of Neurosurgery, Kantonsspital Aarau, Aarau 5000, Switzerland (B.E.G.)
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern 3000, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau 5000, Switzerland (B.E.G.)
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern 3000, Switzerland
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13
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Morel S, Karol A, Graf V, Pelli G, Richter H, Sutter E, Braunersreuther V, Frösen J, Bijlenga P, Kwak BR, Nuss KM. Sex-related differences in wall remodeling and intraluminal thrombus resolution in a rat saccular aneurysm model. J Neurosurg 2019; 134:58-71. [PMID: 31881533 DOI: 10.3171/2019.9.jns191466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 09/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intracranial aneurysms (IAs) are more often diagnosed in women. Hormones and vessel geometry, which influences wall shear stress, may affect pathophysiological processes of the arterial wall. Here, the authors investigated sex-related differences in the remodeling of the aneurysm wall and in intraluminal thrombus resolution. METHODS A well-characterized surgical side-wall aneurysm model was used in female, male, and ovariectomized rats. Decellularized grafts were used to model highly degenerated and decellularized IA walls and native grafts to model healthy IA walls. Aneurysm growth and thrombus composition were analyzed at 1, 7, 14, and 28 days. Sex-related differences in vessel wall remodeling were compared with human IA dome samples of men and pre- and postmenopausal women. RESULTS At 28 days, more aneurysm growth was observed in ovariectomized rats than in males or non-ovariectomized female rats. The parent artery size was larger in male rats than in female or ovariectomized rats, as expected. Wall inflammation increased over time in all groups and was most severe in the decellularized female and ovariectomized groups at 28 days compared with the male group. Likewise, in these groups the most elastin fragmentation was seen at 28 days. In female rats, on days 1, 7, and 14, the intraluminal thrombus was mainly composed of red blood cells and fibrin. On days 14 and 28, macrophage and smooth muscle cell invasion inside the thrombus was shown, leading to the removal of red blood cells and deposition of collagen and elastin. On days 14 and 28, similar profiles of thrombus reorganization were observed in male and ovariectomized female rats. However, collagen content in thrombi and vessel wall macrophage content were higher in aneurysms of male rats at 28 days than in those of female rats. On day 28, thrombus coverage by endothelial cells was lower in ovariectomized than in female or male rats. Finally, analysis of human IA domes showed that endothelial cell coverage was lower in men and postmenopausal women than in younger women. CONCLUSIONS Aneurysm growth and intraluminal thrombus resolution show sex-dependent differences. While certain processes (endothelial cell coverage and collagen deposition) point to a strong hormonal dependence, others (wall inflammation and aneurysm growth) seem to be influenced by both hormones and parent artery size.
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Affiliation(s)
- Sandrine Morel
- 1Department of Pathology and Immunology and
- 2Division of Neurosurgery, Department of Clinical Neurosciences, Faculty of Medicine, and
| | | | | | | | - Henning Richter
- 4Diagnostic Imaging Research Unit, Vetsuisse Faculty, University of Zürich, Switzerland; and
| | | | | | - Juhana Frösen
- 6Hemorrhagic Brain Pathology Research Group, Department of Neurosurgery, Kuopio University Hospital, Kuopio, Finland
| | - Philippe Bijlenga
- 2Division of Neurosurgery, Department of Clinical Neurosciences, Faculty of Medicine, and
| | - Brenda R Kwak
- 1Department of Pathology and Immunology and
- 7Department of Medical Specializations-Cardiology, Faculty of Medicine, University of Geneva
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14
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Nevzati E, Rey J, Coluccia D, Grüter BE, Wanderer S, vonGunten M, Remonda L, Frosen J, Widmer HR, Fandino J, Marbacher S. Aneurysm wall cellularity affects healing after coil embolization: assessment in a rat saccular aneurysm model. J Neurointerv Surg 2019; 12:621-625. [DOI: 10.1136/neurintsurg-2019-015335] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 11/04/2022]
Abstract
Background and purposeDespite significant technical advances, recanalization rates after endovascular therapy of ruptured intracranial aneurysms (IAs) remain a clinical challenge. A histopathological hallmark of ruptured human IA walls is mural cell loss. Mural smooth muscle cells (SMCs) are known to promote intraluminal healing in thrombosed experimental aneurysms. In this rat model we assess the natural history and healing process after coil embolization in SMC-rich and decellularized aneurysms.MethodsSaccular aneurysms were created by end-to-side anastomosis of an arterial graft from the descending thoracic aorta of a syngeneic donor rat to the infrarenal abdominal aorta of recipient male Wistar rats. Untreated arterial grafts were immediately transplanted, whereas aneurysms with loss of mural cells were chemically decellularized before implantation. Aneurysms underwent coil implantation during aneurysm anastomosis. Animals were randomly assigned either to the non-decellularized or decellularized group and underwent macroscopic and histological analyses on days 3, 7, 21, or 90 post-coil implantation.ResultsA total of 55 rats underwent macroscopic and histologic analysis. After coil embolization, aneurysms with SMC-rich walls showed a linear course of thrombosis and neointima formation whereas decellularized aneurysms showed marked inflammatory wall degeneration with increased recanalization rates 21 days (p=0.002) and 90 days (p=0.037) later. The SMCs showed the ability to actively migrate into the intra-aneurysmal thrombus and participate in thrombus organization.ConclusionsCoil embolization of aneurysms with highly degenerated walls is prone to further wall degeneration, increased inflammation, and recanalization compared with aneurysms with vital SMC-rich walls.
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15
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Thompson JW, Elwardany O, McCarthy DJ, Sheinberg DL, Alvarez CM, Nada A, Snelling BM, Chen SH, Sur S, Starke RM. In vivo cerebral aneurysm models. Neurosurg Focus 2019; 47:E20. [DOI: 10.3171/2019.4.focus19219] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/09/2019] [Indexed: 11/06/2022]
Abstract
Cerebral aneurysm rupture is a devastating event resulting in subarachnoid hemorrhage and is associated with significant morbidity and death. Up to 50% of individuals do not survive aneurysm rupture, with the majority of survivors suffering some degree of neurological deficit. Therefore, prior to aneurysm rupture, a large number of diagnosed patients are treated either microsurgically via clipping or endovascularly to prevent aneurysm filling. With the advancement of endovascular surgical techniques and devices, endovascular treatment of cerebral aneurysms is becoming the first-line therapy at many hospitals. Despite this fact, a large number of endovascularly treated patients will have aneurysm recanalization and progression and will require retreatment. The lack of approved pharmacological interventions for cerebral aneurysms and the need for retreatment have led to a growing interest in understanding the molecular, cellular, and physiological determinants of cerebral aneurysm pathogenesis, maturation, and rupture. To this end, the use of animal cerebral aneurysm models has contributed significantly to our current understanding of cerebral aneurysm biology and to the development of and training in endovascular devices. This review summarizes the small and large animal models of cerebral aneurysm that are being used to explore the pathophysiology of cerebral aneurysms, as well as the development of novel endovascular devices for aneurysm treatment.
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Affiliation(s)
- John W. Thompson
- Departments of 1Neurological Surgery and
- 3The University of Miami Cerebrovascular Initiative, University of Miami; and
| | - Omar Elwardany
- Departments of 1Neurological Surgery and
- 3The University of Miami Cerebrovascular Initiative, University of Miami; and
| | - David J. McCarthy
- Departments of 1Neurological Surgery and
- 3The University of Miami Cerebrovascular Initiative, University of Miami; and
| | - Dallas L. Sheinberg
- Departments of 1Neurological Surgery and
- 3The University of Miami Cerebrovascular Initiative, University of Miami; and
| | - Carlos M. Alvarez
- Departments of 1Neurological Surgery and
- 3The University of Miami Cerebrovascular Initiative, University of Miami; and
| | - Ahmed Nada
- Departments of 1Neurological Surgery and
- 3The University of Miami Cerebrovascular Initiative, University of Miami; and
| | - Brian M. Snelling
- Departments of 1Neurological Surgery and
- 3The University of Miami Cerebrovascular Initiative, University of Miami; and
- 4Marcus Neuroscience Institute, Boca Raton Regional Hospital, Boca Raton, Florida
| | - Stephanie H. Chen
- Departments of 1Neurological Surgery and
- 3The University of Miami Cerebrovascular Initiative, University of Miami; and
| | - Samir Sur
- Departments of 1Neurological Surgery and
- 3The University of Miami Cerebrovascular Initiative, University of Miami; and
| | - Robert M. Starke
- Departments of 1Neurological Surgery and
- 2Radiology, University of Miami
- 3The University of Miami Cerebrovascular Initiative, University of Miami; and
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Gruszka W, Zbroszczyk M, Komenda J, Gruszczyńska K, Baron J. The role of inflammation and potential pharmacological therapy in intracranial aneurysms. Neurol Neurochir Pol 2018; 52:662-669. [PMID: 30190209 DOI: 10.1016/j.pjnns.2018.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 06/29/2018] [Accepted: 08/03/2018] [Indexed: 10/28/2022]
Abstract
Intracranial aneurysms remain important clinical concern. There is relatively low risk of rupture of symptomless aneurysms incidentally found in MRA or CTA performed due to other indications. Not all of the intracranial aneurysms should or can be treated with neurosurgery intervention or endovascular embolization. Clinical strategy for small, symptomless, unruptured aneurysms is still questionable. Mechanisms underlying aneurysms formation, progression and rupture are poorly understood. Inflammation is one of the factors suspected to participate in these processes. Therefore the aim of this manuscript is to present current state of knowledge about the role of inflammation in the formation and progression of intracranial aneurysms and in their rupture process. Current knowledge about possible pharmacological treatment of intracranial aneurysms will also be presented. Macrophages infiltration seems to participate in the formation of intracranial aneurysms. Inhibition of signals sent by macrophages may prevent the aneurysms formation. Inflammation present in the wall of the aneurysm seems to be also related to the aneurysm's rupture risk. However it does not seem to be the only cause of the degeneration, but it can be a possible target of drug therapy. Some preliminary studies in humans indicate the potential role of aspirin as a factor that decrease the level of inflammation and lower the risk of rupture of intracranial aneurysms. However further research including a greater number of subjects and a prospective randomized design are necessary to assess the role of aspirin in preventing strategy for small, symptomless, unruptured intracranial aneurysms.
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Affiliation(s)
- Wojciech Gruszka
- Department of Radiology and Interventional Radiology, Medical University of Silesia, Katowice, Poland; Pathophysiology Unit, Department of Pathophysiology, Medical Faculty in Katowice, Medical University of Silesia, Katowice, Poland.
| | - Miłosz Zbroszczyk
- Department of Radiology and Interventional Radiology, Medical University of Silesia, Katowice, Poland
| | - Jacek Komenda
- Department of Radiology and Interventional Radiology, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Gruszczyńska
- Department of Radiology and Interventional Radiology, Medical University of Silesia, Katowice, Poland
| | - Jan Baron
- Department of Radiology and Interventional Radiology, Medical University of Silesia, Katowice, Poland
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Nevzati E, Rey J, Coluccia D, D'Alonzo D, Grüter B, Remonda L, Fandino J, Marbacher S. Biodegradable Magnesium Stent Treatment of Saccular Aneurysms in a Rat Model - Introduction of the Surgical Technique. J Vis Exp 2017. [PMID: 28994804 DOI: 10.3791/56359] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The steady progess in the armamentarium of techniques available for endovascular treatment of intracranial aneurysms requires affordable and reproducable experimental animal models to test novel embolization materials such as stents and flow diverters. The aim of the present project was to design a safe, fast, and standardized surgical technique for stent assisted embolization of saccular aneurysms in a rat animal model. Saccular aneurysms were created from an arterial graft from the descending aorta.The aneurysms were microsurgically transplanted through end-to-side anastomosis to the infrarenal abdominal aorta of a syngenic male Wistar rat weighing >500 g. Following aneurysm anastomosis, aneurysm embolization was performed using balloon expandable magnesium stents (2.5 mm x 6 mm). The stent system was retrograde introduced from the lower abdominal aorta using a modified Seldinger technique. Following a pilot series of 6 animals, a total of 67 rats were operated according to established standard operating procedures. Mean surgery time, mean anastomosis time, and mean suturing time of the artery puncture site were 167 ± 22 min, 26 ± 6 min and 11 ± 5 min, respectively. The mortality rate was 6% (n=4). The morbidity rate was 7.5% (n=5), and in-stent thrombosis was found in 4 cases (n=2 early, n=2 late in stent thrombosis). The results demonstrate the feasibility of standardized stent occlusion of saccular sidewall aneurysms in rats - with low rates of morbidity and mortality. This stent embolization procedure combines the opportunity to study novel concepts of stent or flow diverter based devices as well as the molecular aspects of healing.
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Affiliation(s)
- Edin Nevzati
- Department of Neurosurgery, Kantonsspital Aarau; Neuro Lab, Research Group for Experimental Neurosurgery and Neurocritical Care, Department of Intensive Care Medicine, University Hospital and University of Bern;
| | - Jeannine Rey
- Neuro Lab, Research Group for Experimental Neurosurgery and Neurocritical Care, Department of Intensive Care Medicine, University Hospital and University of Bern
| | - Daniel Coluccia
- Department of Neurosurgery, Kantonsspital Aarau; Neuro Lab, Research Group for Experimental Neurosurgery and Neurocritical Care, Department of Intensive Care Medicine, University Hospital and University of Bern
| | - Donato D'Alonzo
- Department of Neurosurgery, Kantonsspital Aarau; Neuro Lab, Research Group for Experimental Neurosurgery and Neurocritical Care, Department of Intensive Care Medicine, University Hospital and University of Bern
| | - Basil Grüter
- Department of Neurosurgery, Kantonsspital Aarau; Neuro Lab, Research Group for Experimental Neurosurgery and Neurocritical Care, Department of Intensive Care Medicine, University Hospital and University of Bern
| | - Luca Remonda
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau; Neuro Lab, Research Group for Experimental Neurosurgery and Neurocritical Care, Department of Intensive Care Medicine, University Hospital and University of Bern
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau; Neuro Lab, Research Group for Experimental Neurosurgery and Neurocritical Care, Department of Intensive Care Medicine, University Hospital and University of Bern
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18
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Recurrence of endovascularly and microsurgically treated intracranial aneurysms—review of the putative role of aneurysm wall biology. Neurosurg Rev 2017; 42:49-58. [DOI: 10.1007/s10143-017-0892-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/10/2017] [Accepted: 08/04/2017] [Indexed: 10/19/2022]
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19
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Sénémaud J, Caligiuri G, Etienne H, Delbosc S, Michel JB, Coscas R. Translational Relevance and Recent Advances of Animal Models of Abdominal Aortic Aneurysm. Arterioscler Thromb Vasc Biol 2017; 37:401-410. [DOI: 10.1161/atvbaha.116.308534] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 12/21/2016] [Indexed: 01/11/2023]
Abstract
Human abdominal aortic aneurysm (AAA) pathophysiology is not yet completely understood. In conductance arteries, the insoluble extracellular matrix, synthesized by vascular smooth muscle cells, assumes the function of withstanding the intraluminal arterial blood pressure. Progressive loss of this function through extracellular matrix proteolysis is a main feature of AAAs. As most patients are now treated via endovascular approaches, surgical AAA specimens have become rare. Animal models provide valuable complementary insights into AAA pathophysiology. Current experimental AAA models involve induction of intraluminal dilation (nondissecting AAAs) or a contained intramural rupture (dissecting models). Although the ideal model should reproduce the histological characteristics and natural history of the human disease, none of the currently available animal models perfectly do so. Experimental models try to represent the main pathophysiological determinants of AAAs: genetic or acquired defects in extracellular matrix, loss of vascular smooth muscle cells, and innate or adaptive immune response. Nevertheless, most models are characterized by aneurysmal stabilization and healing after a few weeks because of cessation of the initial stimulus. Recent studies have focused on ways to optimize existing models to allow continuous aneurysmal growth. This review aims to discuss the relevance and recent advances of current animal AAA models.
Visual Overview—
An online visual overview is available for this article.
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Affiliation(s)
- Jean Sénémaud
- From the UMR 1148, Inserm-Paris7 - Denis Diderot University, Xavier Bichat Hospital, Paris, France (J.S., G.C., H.E., S.D., J.-B.M., R.C.); UMR 1173, Inserm-Paris11 - Faculty of Health Sciences Simone Veil, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Montigny-le-Bretonneux, France (R.C.); Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France (R.C.); and UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines
| | - Giuseppina Caligiuri
- From the UMR 1148, Inserm-Paris7 - Denis Diderot University, Xavier Bichat Hospital, Paris, France (J.S., G.C., H.E., S.D., J.-B.M., R.C.); UMR 1173, Inserm-Paris11 - Faculty of Health Sciences Simone Veil, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Montigny-le-Bretonneux, France (R.C.); Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France (R.C.); and UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines
| | - Harry Etienne
- From the UMR 1148, Inserm-Paris7 - Denis Diderot University, Xavier Bichat Hospital, Paris, France (J.S., G.C., H.E., S.D., J.-B.M., R.C.); UMR 1173, Inserm-Paris11 - Faculty of Health Sciences Simone Veil, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Montigny-le-Bretonneux, France (R.C.); Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France (R.C.); and UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines
| | - Sandrine Delbosc
- From the UMR 1148, Inserm-Paris7 - Denis Diderot University, Xavier Bichat Hospital, Paris, France (J.S., G.C., H.E., S.D., J.-B.M., R.C.); UMR 1173, Inserm-Paris11 - Faculty of Health Sciences Simone Veil, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Montigny-le-Bretonneux, France (R.C.); Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France (R.C.); and UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines
| | - Jean-Baptiste Michel
- From the UMR 1148, Inserm-Paris7 - Denis Diderot University, Xavier Bichat Hospital, Paris, France (J.S., G.C., H.E., S.D., J.-B.M., R.C.); UMR 1173, Inserm-Paris11 - Faculty of Health Sciences Simone Veil, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Montigny-le-Bretonneux, France (R.C.); Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France (R.C.); and UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines
| | - Raphaël Coscas
- From the UMR 1148, Inserm-Paris7 - Denis Diderot University, Xavier Bichat Hospital, Paris, France (J.S., G.C., H.E., S.D., J.-B.M., R.C.); UMR 1173, Inserm-Paris11 - Faculty of Health Sciences Simone Veil, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Montigny-le-Bretonneux, France (R.C.); Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France (R.C.); and UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines
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20
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Rouchaud A, Brinjikji W, Dai D, Ding YH, Gunderson T, Schroeder D, Spelle L, Kallmes DF, Kadirvel R. Autologous adipose-derived mesenchymal stem cells improve healing of coiled experimental saccular aneurysms: an angiographic and histopathological study. J Neurointerv Surg 2017; 10:60-65. [PMID: 28077523 DOI: 10.1136/neurintsurg-2016-012867] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 01/06/2023]
Abstract
PURPOSE Long-term occlusion of coiled aneurysms frequently fails, probably because of poor intrasaccular healing and inadequate endothelialization across the aneurysm neck. The purpose of this study was to determine if attachment of autologous mesenchymal stem cells (MSCs) to platinum coils would improve the healing response in an elastase-induced aneurysm model in rabbits. MATERIALS AND METHODS With approval from the institutional animal care and use committee, aneurysms were created in rabbits and embolized with control platinum coils (Axium; Medtronic) (n=6) or coils seeded ex vivo with autologous adipose-tissue MSCs (n=7). Aneurysmal occlusion after embolization was evaluated at 1 month with angiography. Histological samples were analyzed by gross imaging and graded on the basis of neck and dome healing on H&E staining. Fibrosis was evaluated using a ratio of the total area presenting collagen. Endothelialization of the neck was quantitatively analyzed using CD31 immunohistochemistry. χ2 and Student's t-test were used to compare groups. RESULTS Healing score (11.5 vs 8.0, p=0.019), fibrosis ratio (10.3 vs 0.13, p=0.006) and endothelialization (902 262 μm2 vs 31 810 μm2, p=0.041) were significantly greater in the MSC group. The MSC group showed marked cellular proliferation and thrombus organization, with a continuous membrane bridging the neck of the aneurysm. Angiographic stable or progressive occlusion rate was significantly lower in the MSC group (0.00, 95% CI 0.00 to 0.41) compared with controls (0.67, 95% CI 0.22 to 0.96) (p=0.02). CONCLUSIONS Autologous MSCs attached to platinum coils significantly improve histological healing, as they result in improved neck endothelialization and collagen matrix formation within the aneurysm sac.
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Affiliation(s)
- Aymeric Rouchaud
- Applied Neuroradiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA.,Department of Interventional Neuroradiology, NEURI Center, Le Kremlin-Bicetre, France
| | | | - Daying Dai
- Applied Neuroradiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Yong-Hong Ding
- Applied Neuroradiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Tina Gunderson
- Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, USA
| | - Dana Schroeder
- Applied Neuroradiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Laurent Spelle
- Department of Interventional Neuroradiology, NEURI Center, Le Kremlin-Bicetre, France
| | - David F Kallmes
- Applied Neuroradiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
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21
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Fennell VS, Kalani MYS, Atwal G, Martirosyan NL, Spetzler RF. Biology of Saccular Cerebral Aneurysms: A Review of Current Understanding and Future Directions. Front Surg 2016; 3:43. [PMID: 27504449 PMCID: PMC4958945 DOI: 10.3389/fsurg.2016.00043] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 07/06/2016] [Indexed: 12/24/2022] Open
Abstract
Understanding the biology of intracranial aneurysms is a clinical quandary. How these aneurysms form, progress, and rupture is poorly understood. Evidence indicates that well-established risk factors play a critical role, along with immunologic factors, in their development and clinical outcomes. Much of the expanding knowledge of the inception, progression, and rupture of intracranial aneurysms implicates inflammation as a critical mediator of aneurysm pathogenesis. Thus, therapeutic targets exploiting this arm of aneurysm pathogenesis have been implemented, often with promising outcomes.
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Affiliation(s)
- Vernard S Fennell
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center , Phoenix, AZ , USA
| | - M Yashar S Kalani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center , Phoenix, AZ , USA
| | - Gursant Atwal
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center , Phoenix, AZ , USA
| | - Nikolay L Martirosyan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center , Phoenix, AZ , USA
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center , Phoenix, AZ , USA
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22
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Abstract
Most of cerebral aneurysms (CAs) are incidentally discovered without any neurological symptoms and the risk of rupture of CAs is relatively higher in Japanese population. The goal of treatments for patients with CAs is complete exclusion of the aneurysmal rupture risk for their lives. Since two currently available major treatments, microsurgical clipping and endovascular coiling, have inherent incompleteness to achieve cure of CAs with some considerable treatment risks, and there is no effective surgical or medical intervention to inhibit the formation of CAs in patients with ruptured and unruptured CAs, new treatment strategies with lower risk and higher efficacy should be developed to prevent the formation, growth, and rupture of CAs. Preemptive medicine for CAs should be designed to prevent or delay the onset of symptoms from CAs found in an asymptomatic state or inhibit the de novo formation of CAs, but we have no definite methods to distinguish rupture-prone aneurysms from rupture-resistant ones. Recent advancements in the research of CAs have provided us with some clues, and one of the new treatment strategies for CAs will be developed based on the findings that several inflammatory pathways may be involved in the formation, growth, and rupture of CAs. Preemptive medicine for CAs will be established with specific biomarkers and imaging modalities which can sensor the development of CAs.
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Affiliation(s)
- Tomohiro Aoki
- Innovation Center for Immunoregulation Technologies and Drugs, Kyoto University Graduate School of Medicine
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23
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Understanding flow patterns and inflammatory status in intracranial aneurysms: Towards a personalized medicine. J Neuroradiol 2016; 43:141-7. [DOI: 10.1016/j.neurad.2015.09.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 08/02/2015] [Accepted: 09/08/2015] [Indexed: 02/06/2023]
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24
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Adibi A, Sen A, Mitha AP. Cell Therapy for Intracranial Aneurysms: A Review. World Neurosurg 2015; 86:390-8. [PMID: 26547001 DOI: 10.1016/j.wneu.2015.10.082] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 01/16/2023]
Abstract
One in five patients undergoing endovascular coiling (the current standard of care for treating intracranial aneurysms) experience a recurrence of the aneurysm as a result of improper healing. Recurrence remains the only major drawback of the coiling treatment and has been the focus of many studies over the last two decades. Cell therapy, a novel treatment modality in which therapeutic cells are introduced to the site of the injury to promote tissue regeneration, has opened up new possibilities for treating aneurysms. The healing response that ensues aneurysm embolization includes several cellular processes that can be targeted with cell therapy to prevent the aneurysm from recurring. Ten preclinical studies involving cell therapy to treat aneurysms were published between 1999 and 2014. In this review, we summarize the results of these studies and discuss advances, shortcomings, and the future of cell therapy for intracranial aneurysms.
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Affiliation(s)
- Amin Adibi
- Pharmaceutical Production Research Facility (PPRF), Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada; Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Arindom Sen
- Pharmaceutical Production Research Facility (PPRF), Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Alim P Mitha
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada.
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25
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Inflammatory mediators in vascular disease: identifying promising targets for intracranial aneurysm research. Mediators Inflamm 2015; 2015:896283. [PMID: 25922566 PMCID: PMC4397479 DOI: 10.1155/2015/896283] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/18/2015] [Accepted: 03/19/2015] [Indexed: 12/21/2022] Open
Abstract
Inflammatory processes are implicated in many diseases of the vasculature and have been shown to play a key role in the formation of intracranial aneurysms (IAs). Although the specific mechanisms underlying these processes have been thoroughly investigated in related pathologies, such as atherosclerosis, there remains a paucity of information regarding the immunopathology of IA. Cells such as macrophages and lymphocytes and their effector molecules have been suggested to be players in IA, but their specific interactions and the role of other components of the inflammatory response have yet to be determined. Drawing parallels between the pathogenesis of IA and other vascular disorders could provide a roadmap for developing a mechanistic understanding of the immunopathology of IA and uncovering useful targets for therapeutic intervention. Future research should address the presence and function of leukocyte subsets, mechanisms of leukocyte recruitment and activation, and the role of damage-associated molecular patterns in IA.
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