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Lee I(TL, Kao YS, Lai YJ, Yen HH. Flow diverter retreatment for intracranial aneurysms: A meta-analysis of efficacy and feasibility. Interv Neuroradiol 2024; 30:37-42. [PMID: 35505615 PMCID: PMC10956466 DOI: 10.1177/15910199221095972] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 04/04/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Recurrent intracranial aneurysm carries a risk of rupture and retreatment is often necessary. However, there is no consensus on the best retreatment modality of choice. Flow diverter has emerged as a promising option for this population in recent years. Given its high cost, patient selection to optimize outcomes is very important. PURPOSE To identify patient factors predisposing to failure of flow diverter retreatment. METHOD We conducted a systematic search on PubMed, Cochrane Library, Embase, Ovid/Medline, and ClinicalTrial.gov from 2000 to 2021. Studies regarding flow diverter retreatment of recurrent aneurysms were analyzed if they meet the inclusion criteria. RESULTS A total of twenty-six studies were identified. Among 374 patients retreated with flow diverters, about 0.86 [0.81; 0.92] were successfully occluded and only 0.06 [0.02; 0.10] had unfavorable neurological outcomes. Major complications included intracranial hemorrhage (n = 7), ischemic stroke or thromboembolic event (n = 12), and death (n = 2). In-stent stenosis was reported in 10 of the cases. Saccular aneurysms are associated with a higher occlusion rate while aneurysm location, size, status, and prior treatment modality have no significant impact on retreatment efficacy. CONCLUSIONS We demonstrated that flow diverter is an effective retreatment strategy except in patients with non-saccular aneurysms. It should be considered as a first-line option for patients with recurrent intracranial aneurysm.
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Affiliation(s)
- Irene (Tai-Lin) Lee
- Division of Medical Imaging, Department of Radiology, Far Eastern Memorial Hospital, New Taipei city
| | - Yung-Shuo Kao
- Department of Radiation Oncology, China Medical University Hospital, Taichung
| | - Yen-Jun Lai
- Division of Medical Imaging, Department of Radiology, Far Eastern Memorial Hospital, New Taipei city
| | - Ho-Hsian Yen
- Division of Medical Imaging, Department of Radiology, Far Eastern Memorial Hospital, New Taipei city
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Young M, Enriquez-Marulanda A, Salih M, Shutran M, Budohoski K, Grandhi R, Taussky P, Ogilvy CS. Management of Intracranial Aneurysms that Do Not Occlude on Initial Follow-up After Treatment With the Pipeline Embolization Device. Neurosurgery 2024; 94:271-277. [PMID: 37655903 DOI: 10.1227/neu.0000000000002655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The pipeline embolization device (PED) has become widely accepted as a safe and efficacious treatment for intracranial aneurysms with high rates of complete occlusion at initial follow-up. For aneurysms that are not completely occluded at initial follow-up, further treatment decision-making is varied. Furthermore, the risk of aneurysmal rupture in these incompletely occluded aneurysms after PED is not known. The objective of this study was to determine treatment decision-making that results in increased occlusion status at final follow-up and to evaluate risk of rupture in those aneurysms that do not go onto occlusion. METHODS This study is a retrospective review of prospective data for intracranial aneurysms treated with PED at two institutions from 2013 to 2019. Aneurysms with near-complete or incomplete occlusion at initial follow-up were included in the statistical analysis. RESULTS There were 606 total aneurysms treated at two academic institutions with PED with incomplete occlusion at initial follow-up in 134 aneurysms (22.1%). Of the 134 aneurysms that were nonoccluded at initial follow-up, 76 aneurysms (56.7%) went on to complete or near complete occlusion with final complete or near complete occlusion in 90.4% of all aneurysms treated. The time to final imaging follow-up was 28.2 months (13.8-44.3) Retreatment with a second flow diverter was used in 28 aneurysms (20.9%). No aneurysms that were incompletely occluded at initial follow-up had delayed rupture. Furthermore, older patient age was statistically significant for incomplete occlusion at initial follow-up ( P = .05). CONCLUSION Intracranial aneurysms treated with the PED that do not occlude at initial follow-up may go on to complete occlusion with continuous observation, alteration in antiplatelet regimens, or repeat treatment. Delayed aneurysmal rupture was not seen in patients with incomplete occlusion.
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Affiliation(s)
- Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Alejandro Enriquez-Marulanda
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Karol Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
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Kashkoush A, El-Abtah ME, Davison MA, Toth G, Moore N, Bain M. Repeat Flow Diversion for Retreatment of Incompletely Occluded Large Complex Symptomatic Cerebral Aneurysms: A Retrospective Case Series. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01027. [PMID: 38251895 DOI: 10.1227/ons.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/01/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Data regarding radiographic occlusion rates after repeat flow diversion after initial placement of a flow diverter (FD) in large intracranial aneurysms are limited. We report clinical and angiographic outcomes on 7 patients who required retreatment with overlapping FDs after initial flow diversion for large intracranial aneurysms. METHODS We performed a retrospective review of a prospectively maintained database of cerebrovascular procedures performed at our institution from 2017 to 2021. We identified patients who underwent retreatment with overlapping FDs for large (>10 mm) cerebral aneurysms after initial flow diversion. At last angiographic follow-up, occlusion grade was evaluated using the O'Kelly-Marotta (OKM) grading scale. RESULTS Seven patients (median age 57 years) with cerebral aneurysms requiring retreatment were identified. The most common aneurysm location was the ophthalmic internal carotid artery (n = 3) and basilar trunk (n = 3). There were 4 fusiform and 3 saccular aneurysms. The median aneurysm width was 18 mm; the median neck size for saccular aneurysms was 7 mm; and the median dome-to-neck ratio was 2.8. The median time to retreatment was 9 months, usually due to symptomatic mass effect. After retreatment, the median clinical follow-up was 36 months, MRI/magnetic resonance angiography follow-up was 15 months, and digital subtraction angiography follow-up was 14 months. Aneurysm occlusion at last angiographic follow-up was graded as OKM A (total filling, n = 1), B (subtotal filling, n = 2), C (early neck remnant, n = 3), and D (no filling, n = 0). All patients with symptomatic improvement were OKM C, whereas patients with worsened symptom burden were OKM A or B. Two patients required further open surgical management for definitive management of the aneurysm remnant. CONCLUSION Although most patients demonstrated a decrease in aneurysm remnant size, many had high-grade persistent filling (OKM grades A or B) in this subset of mostly large fusiform aneurysms. Larger studies with longer follow-up are warranted to optimize treatment strategies for atypical aneurysm remnants after repeat flow diversion.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mohamed E El-Abtah
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mark A Davison
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nina Moore
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mark Bain
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Lee RP, Bhimreddy M, Kim J, Wicks RT, Xu R, Bender M, Yang W, Sattari SA, Hung A, Jackson CM, Gonzalez LF, Huang J, Tamargo R, McDougall CG, Caplan JM. No Delayed Ruptures on Long-Term Follow-Up of a Case Series of Persistently Filling Saccular Internal Carotid Artery Aneurysms After Flow Diversion With the Pipeline Embolization Device. Neurosurgery 2023; 93:994-999. [PMID: 37255292 DOI: 10.1227/neu.0000000000002521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/20/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Flow diversion of intracranial aneurysms results in high occlusion rates. However, 10% to 20% remain persistently filling at 1 year. Often, these are retreated, but benefits of retreatment are not well established. A better understanding of the long-term rupture risk of persistently filling aneurysms after flow diversion is needed. METHODS Our institutional database of 974 flow diversion cases was queried for persistently filling saccular aneurysms of the clinoidal, ophthalmic, and communicating segments of the internal carotid artery treated with the pipeline embolization device (PED, Medtronic). Persistent filling was defined as continued flow into the aneurysm on 1 year catheter angiogram. The clinical record was queried for retreatments and delayed ruptures. Clinical follow-up was required for at least 2 years. RESULTS Ninety-four persistent aneurysms were identified. The average untreated aneurysm size was 5.6 mm. A branch vessel originated separately in 55% of cases from the body of the aneurysm in 10.6% of cases and from the neck in 34% of cases. Eighteen percent of aneurysms demonstrated >95% filling at 1 year, and 61% were filling 5% to 95% of their original size. The mean follow-up time was 4.9 years, including 41 cases with >5 years. No retreatment was undertaken in 91.5% of aneurysms. There were no cases of delayed subarachnoid hemorrhage. CONCLUSION Among saccular internal carotid artery aneurysms treated with PED that demonstrated persistent aneurysm filling at 1 year, there were no instances of delayed rupture on long-term follow-up. These data suggest that observation may be appropriate for continued aneurysm filling at least in the first several years after PED placement.
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Affiliation(s)
- Ryan P Lee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Meghana Bhimreddy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jennifer Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Robert T Wicks
- Miami Neuroscience Institute, Baptist Health South Florida, Miami , Florida , USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Matthew Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester , New York , USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Alice Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Rafael Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Cameron G McDougall
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle , Washington , USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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Salem MM, Khorasanizadeh M, Lay SV, Renieri L, Kuhn AL, Sweid A, Massari F, Moore JM, Tjoumakaris SI, Jabbour P, Puri AS, Ogilvy CS, Jankowitz BT, Burkhardt JK, Kan P, Limbucci N, Cognard C, Thomas AJ. Endoluminal flow diverting stents for middle cerebral artery bifurcation aneurysms: multicenter cohort. J Neurointerv Surg 2021; 14:1084-1089. [PMID: 34732531 DOI: 10.1136/neurintsurg-2021-018224] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/20/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Data regarding the safety and efficacy of flow diverting stents (FDS) in the treatment of middle cerebral artery (MCA) bifurcation aneurysms are scarce and limited to small single center series, with particular concern for increased risk of ischemic complications with jailing one of the M2 branches. METHODS Prospectively-maintained databases at six North American and European centers were queried for patients harboring MCA bifurcation aneurysms undergoing treatment with FDS (2011-2018). The pertinent clinical and radiographic data were collected and analyzed. RESULTS 87 patients (median age 60 years, 69% females) harboring 87 aneurysms were included. The majority of aneurysms were unruptured (79%); 75.9% were saccular with a median maximal diameter of 8.5 mm. Radiographic imaging follow-up was available in 88.5% of cases at a median of 16.3 months post-treatment, showing complete occlusion in 59% and near complete occlusion (90-99%) in 18% of aneurysms. The overall rate of ischemic and hemorrhagic complications was 8% and 1.1%, respectively. Symptomatic and permanent complications were encountered in 5.7% and 2.3% of patients respectively, with retreatment pursued in 2.3% of patients. Jailed branch occlusion was detected in 11.5% of cases, with clinical sequelae in 2.3%. Last follow-up modified Rankin Scale of 0-2 was noted in 96.8% of patients. On multivariate analysis, male sex was the only independent predictor of aneurysmal persistence at last follow-up imaging (p=0.019). CONCLUSION FDS treatment for MCA bifurcation aneurysms is feasible, with comparable safety and efficacy profiles to other available endovascular options when utilized in carefully selected aneurysms. Jailing of M2 branches was not associated with a higher risk of post-procedural ischemic complications.
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Affiliation(s)
- Mohamed M Salem
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Mirhojjat Khorasanizadeh
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sovann V Lay
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Leonardo Renieri
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy
| | - Anna L Kuhn
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Francesco Massari
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ajit S Puri
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Nicola Limbucci
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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6
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Salem MM, Salih M, Nwajei F, Gomez-Paz S, Thomas AJ, Ogilvy CS, Moore JM. Cost-Effectiveness Analytic Comparison of Neuroimaging Follow-Up Strategies After Pipeline Embolization Device Treatment of Unruptured Intracranial Aneurysms. World Neurosurg 2021; 158:e206-e213. [PMID: 34757210 DOI: 10.1016/j.wneu.2021.10.154] [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: 09/17/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Flow diversion via a Pipeline embolization device (PED [Medtronic, Dublin, Ireland]) is one of the established modalities for the treatment of unruptured intracranial aneurysms that require a robust follow-up regimen. However, to date, no consensus has been reached regarding the optimal imaging modality and timing intervals for such a strategy. We studied the cost-effectiveness of different neuroimaging follow-up strategies after flow diversion with the PED. METHODS A decision-analytical study using Markov modeling was performed to compare 5 commonly used multistep follow-up strategies with different combinations of digital subtraction angiography (DSA) and magnetic resonance angiography (MRA): 1) DSA at 6 months and MRA at 12 and 24 months; 2) DSA at 6, 12, and 24 months; 3) MRA at 6, 12, and 24 months; 4) DSA at 6 and 12 months and MRA at 24 months; and 5) DSA at 12 months and MRA at 24 months. The input parameters were mainly collected from the latest meta-analysis, and 1-way, 2-way, and probabilistic sensitivity analyses were conducted to assess the robustness of our model. RESULTS Strategy 5, incorporating DSA at 12 months and MRA at 24 months, was the most cost-effective strategy for >99% of the 10,000 iterations in the probabilistic sensitivity analysis at a willingness-to-pay threshold of $100,000/quality-adjusted life-year. The result remained robust in the 1- and 2-way sensitivity analyses. CONCLUSIONS Given the current data, delayed imaging follow-up at 1 year with DSA and 2 years with MRA after PED treatment of unruptured intracranial aneurysms is more cost-effective than early follow-up at 6 months.
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Affiliation(s)
- Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Felix Nwajei
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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