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Ghorbani M, Keykhosravi E, Vatanparast M, Elyassirad D, Kakhki FT, Gheiji B, Golchin N, Zamani Z, Lafta G, Hasanpour M. Flow diverting stent monotherapy as the best choice in the treatment of intracranial blood blister-like aneurysms: a systematic review. Neurosurg Rev 2024; 47:513. [PMID: 39212745 DOI: 10.1007/s10143-024-02764-8] [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: 02/06/2024] [Revised: 07/15/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To evaluate the effectiveness and safety of flow-diverting stent (FDS) monotherapy in the treatment of intracranial blood blister-like aneurysms (BBAs) through a detailed systematic review. METHODS This review adheres to the PRISMA guidelines, focusing on studies utilizing FDS monotherapy for BBAs, spanning from July 2010 to November 2023. A systematic search across databases including Embase, Medline/PubMed, Scopus, and Google Scholar was conducted. Studies in English that solely used FDS for BBA treatment and assessed perioperative complications were included. Data from 23 studies encompassing 181 cases were systematically analyzed for patient demographics, aneurysm characteristics, treatment specifics, and outcomes. RESULTS The collected data indicates a dominant occurrence of BBAs in the internal carotid artery (86.9%), with a mean patient age of 50.27 years and a higher prevalence in females (73.43%). Treatment timing varied, with 45.9% treated within the first three days, 35.7% were treated between 4 and 14 days, and 18.4% of patients were treated after 14 days. The study found a complete occlusion rate of 88.1% in follow-up imaging and a favorable clinical outcome in 82.2% of cases. Periprocedural complications were reported in 19.2% of patients, with a related mortality rate of 3.9%. CONCLUSIONS The systematic review demonstrates that FDS monotherapy is highly effective and safe in the treatment of intracranial BBAs. It offers a high rate of complete aneurysm occlusion, favorable clinical outcomes, and low complication rates. These results highlight FDS monotherapy as a prominent treatment method, ensuring robust aneurysmal protection while maintaining the patency of the parent artery.
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Affiliation(s)
- Mohammad Ghorbani
- Division of Vascular and Endovascular Neurosurgery, Department of Neurosurgery, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ehsan Keykhosravi
- Department of Neurosurgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahsa Vatanparast
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Danial Elyassirad
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farbod Tabasi Kakhki
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Benyamin Gheiji
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Navid Golchin
- Department of Neurosurgery, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zohreh Zamani
- Department of Neurology, Firoozabadi Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ghazwan Lafta
- Department of Surgery, Faculty of Medicine, University of Al-Ameed, Karbala, Iraq
| | - Mohammad Hasanpour
- Division of Vascular and Endovascular Neurosurgery, Department of Neurosurgery, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
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Zhang YB, Yao PS, Wang HJ, Xie BS, Wang JY, Zhu M, Wang DL, Yu LH, Lin YX, Gao B, Zheng SF, Kang DZ. Treatment with a flow diverter-assisted coil embolization for ruptured blood blister-like aneurysms of the internal carotid artery: a technical note and analysis of single-center experience with pooled data. Neurosurg Rev 2023; 46:305. [PMID: 37982900 DOI: 10.1007/s10143-023-02216-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/25/2023] [Accepted: 11/07/2023] [Indexed: 11/21/2023]
Abstract
Treatment of blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA) with flow diverters (FDs) has become widespread in recent years. However, ruptured blood blister-like aneurysm (BBA) of ICA treatment with flow diverter-assisted coil embolization (FDAC) remains controversial. Moreover, limited direct comparative studies have been conducted between the two treatment modalities, FDs and FDAC, for BBAs. The purpose of this study was to document our experience and evaluate the effectiveness and safety of FDAC. We conducted a retrospective analysis of clinical and radiological information from ten patients who experienced ruptured BBAs of the supraclinoid ICA at our center from January 2021 to February 2023. The technical details of FDAC for ruptured BBAs were described, and the technical steps were named "pipeline embolization device (PED)-Individualized shaping(microcatheter)-Semi deploying-Rivet(coils)-Massage(microwire)" as the PEISSERM technique. Clinical outcomes were assessed using the modified Rankin Scale (mRS), whereas radiological results were determined through angiography. A pooled analysis was implemented, incorporating data from literature sources that reported perioperative and long-term clinical and angiographic outcomes of ruptured BBAs treated with FD and FDAC strategies, along with our data. Data in our analysis pool were categorized into FD and FDAC strategy groups to explore the preferred treatment modalities for BBAs. The PEISSERM technique was utilized to treat ten patients, seven males, and three females, with an average age of 41.7 years. A single PED was deployed in conjunction with coils in all ten patients. All PEDs were documented to have good wall apposition. The immediate postoperative angiograms demonstrated Raymond grade I in ten aneurysms. Angiographic follow-up of nine patients at 4-25 months showed total occlusion of the aneurysms. At the most recent follow-up, the mRS scores of nine patients hinted at a good prognosis. Pooled analysis of 233 ICA-BBA cases of FD revealed a technical success rate of 91% [95% confidence interval (CI), 0.88 to 0.95], a rate of complete occlusion of 79% (95% CI, 0.73 to 0.84), a recurrence rate of 2% (95% CI, 0.00 to 0.04), a rebleed rate of 2% (95% CI, 0.00 to 0.04), and the perioperative stroke rate was 8% (95% CI, 0.04 to 0.11). The perioperative mortality was 4% (95% CI, 0.01 to 0.07). The long-term good clinical outcome rate was 85% (95% CI, 0.80 to 0.90). The mortality rate was 6% (95% CI, 0.03 to 0.09). Results from the subgroup analysis illustrated that the FDAC strategy for BBAs had a significantly higher immediate postoperative complete occlusion rate (P < 0.001), total occlusion rate (P = 0.016), and a good outcome rate (P = 0.041) compared with the FD strategy. The FDAC strategy can yield a higher rate of good outcomes than the FD strategy. The PEISSERM technique employed by the FDAC is a reliable and effective treatment approach as it can minimize the hemodynamic burden of BBA's fragile dome, thereby achieving an excellent occlusion rate. The PEISSERM technique in the FDAC strategy contributes to understanding the BBA's treatment and offers a potentially optimal treatment for BBA.
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Affiliation(s)
- Yi-Bin Zhang
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Pei-Sen Yao
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Hao-Jie Wang
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Bing-Sen Xie
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Jia-Yin Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, China
| | - Mei Zhu
- Department of Neurosurgery, The Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, 350005, China
| | - Deng-Liang Wang
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Liang-Hong Yu
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Yuan-Xiang Lin
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
- Fujian Provincial Clinical Research Center for Neurological Diseases, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
| | - Bin Gao
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
| | - Shu-Fa Zheng
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
| | - De-Zhi Kang
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
- Fujian Provincial Clinical Research Center for Neurological Diseases, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Clinical Research and Translation Center, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
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Flow Diverter Device-Assisted Coiling Treatment for Cerebral Blister Aneurysm: A Single-Center Study. Brain Sci 2023; 13:brainsci13030435. [PMID: 36979245 PMCID: PMC10046186 DOI: 10.3390/brainsci13030435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/22/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Although endovascular treatment is a promising approach, blood blister-like aneurysms (BBAs) still present treatment challenges. This study aimed to assess the effectiveness and safety of flow diverter device-assisted coiling (FDDAC) for the treatment of BBAs, which are broad based and friable with a high rebleeding risk. Eight patients (five females and three males) who presented with subarachnoid hemorrhages (SAH) due to BBA ruptures between May 2020 and May 2022 were retrospectively enrolled. All patients were treated by flow diverter device (Tubridge) adjunctive coil embolization using a semi-deploying technique. The demographic information, angiographic data, interval between admission and treatment, materials, therapy, clinical outcomes (including periprocedural and intraprocedural mortality and morbidity), and follow-up results of all patients were reviewed. The mean age of the patients with BBAs was 48.5 years (range 31–62 years); aneurysm sizes ranged from 2.2 × 1.7 mm to 4.6 × 3.2 mm, and the median Hunt–Hess score was 3. All aneurysms were completely closed at follow-up, and all 8 patients had excellent clinical outcomes (modified Rankin scores = 0–2) at discharge. Angiograms showed complete aneurysm occlusion after 6 months to 1 year. In addition, there were no cases of re-rupture, re-treatment, or recurrence of the aneurysms. FDDAC is safe to use in patients with BBAs and provides an alternative treatment option for this disease.
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Stent-assisted Coiling vs. Flow Diverter for Treating Blood Blister-like Aneurysms : A Proportion Meta-analysis. Clin Neuroradiol 2022; 32:889-902. [PMID: 35403855 DOI: 10.1007/s00062-022-01160-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/09/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Blood blister-like aneurysms (BBAs) are rare vascular lesions and a therapeutic challenge. Although endovascular treatment of BBA is a promising approach, the optimal treatment remains controversial. The purpose of this study was to compare the safety and efficacy of stent-assisted coiling (SAC) and flow diverter (FD) in the management of BBAs. METHODS A proportion meta-analysis including a published series of BBAs treated with endovascular approaches from 2009 to 2020 including SAC and FD was performed by searching English language studies via MEDLINE and EMBASE. RESULTS The 32 studies included 16 based on SAC and 16 involving FD. The long-term complete occlusion rate was higher in FD (89.26%, 95% confidence interval, CI 82.93-94.26%, I2 = 14.42%) than in SAC (70.26%, 95% CI 56.79-82.13%, I2 = 70.60%). The rate of aneurysm recanalization was lower in FD (4.54%, 95% CI 1.72-8.16%, I2 = 0%) than in SAC (25.38%, 95% CI 14.44-38.19%, I2 = 67.31%). Rates of mortality, favorable functional outcome, procedural complications, and rebleeding showed no differences between the two procedures. CONCLUSION In a proportion meta-analysis comparing FD with SAC, the FD was associated with more favorable angiographic outcomes but similar complications and clinical outcomes.
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Russo R, Boghi A, Giorgianni A, Lazzarotti GA, Bozzi A, Chegai F, Saletti A, Gallizioli G, Gavrilovic V, Michelozzi C, Petralia B, Gatti FL, Gorgatti T, Gallesio I, Cristaudo C, Politi MA, Molinaro S, Bergui M. Silk Vista Baby flow diverter stent for ruptured intracranial aneurysms: a retrospective observational study. Neuroradiology 2022; 64:2031-2037. [PMID: 35773522 DOI: 10.1007/s00234-022-03003-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Flow diversion changed the approach to complex intracranial aneurysms, leading to a widespread use and a rapid technological evolution. Indeed, indications continued to expand, including ruptured intracranial aneurysms in selected cases. Recently, new devices have been designed specifically to target smaller vessels. Therefore, we conducted a multicenter study to evaluate clinical outcome, complications, and occlusion rate of patients with ruptured aneurysms treated with new generation low profile Silk Vista Baby (SVB) flow diverter stent (FD). METHODS We performed a retrospective observational study on consecutive patients who underwent treatment with SVB for ruptured aneurysms at 12 Italian centers. Primary end point was favorable clinical outcome rate, defined as modified ranking score (mRS) of 0-2 at the 3 months. Secondary outcomes were complication rate, aneurysm re-rupture, and complete aneurysm occlusion at last radiological follow-up. RESULTS Twenty-five patients were included; at 3 months' follow-up, 19 patients (79.1%) had favorable clinical outcome (mRS 0-2). Three patients (12.5%) died during follow-up. In-stent thrombosis occurred in two cases (8.3%), managed with glycoprotein IIb/IIIA and intra-stent angioplasty, without clinical consequences. In 18 (85.7%) patients, complete occlusion at 3 months was demonstrated. No rebleeding occurred during follow-up. Presentation with unfavorable World Federation of Neurosurgical Societies grading system (WFNS) and posterior circulation location were both significantly correlated with unfavorable clinical outcome (p = 0.005 and p = 0.02). CONCLUSIONS Our data suggests that low profile FD treatment of ruptured intracranial aneurysms located distally of the circle of Willis is feasible. New generation low profile FD may represent an alternative option in carefully selected cases.
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Affiliation(s)
- Riccardo Russo
- Department of Neuroscience, Azienda Ospedaliero Universitaria Città Della Salute E Della Scienza Di Torino, Neuroradiological Unit, University of Turin, Turin, Italy.
| | - Andrea Boghi
- Department of Interventional Radiology and Neuroradiology, S. Giovanni Bosco Hospital, Turin, Italy
| | | | | | - Alessio Bozzi
- Interventional Neuroradiology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Fabrizio Chegai
- Interventional Neuroradiology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Andrea Saletti
- Azienda Ospedaliero Universitaria Di Ferrara Arcispedale Sant Anna, Neuroradiology, Ferrara, Emilia-Romagna, Italy
| | | | - Vladimir Gavrilovic
- Azienda Sanitaria Universitaria Friuli Centrale, Interventional Radiology, Udine, Italy
| | - Caterina Michelozzi
- Interventional Neuroradiology, Vita-Salute San Raffaele University Hospital, Milan, Italy
| | - Benedetto Petralia
- Azienda Sanitaria Alto Adige, Regional Hospital of Bolzano, Radiology Unit, Bolzano, Italy
| | | | - Tommaso Gorgatti
- Azienda Sanitaria Alto Adige, Regional Hospital of Bolzano, Radiology Unit, Bolzano, Italy
| | - Ivan Gallesio
- Department of Radiology, Azienda Ospedaliera SS Antonio E Biagio E C. Arrigo, Alessandria, Italy
| | - Concetto Cristaudo
- Department of Diagnostic and Interventional Neuroradiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Marco Angelo Politi
- Department of Diagnostic and Interventional Neuroradiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | | | - Mauro Bergui
- Department of Neuroscience, Azienda Ospedaliero Universitaria Città Della Salute E Della Scienza Di Torino, Neuroradiological Unit, University of Turin, Turin, Italy
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Liu P, Liu L, Zhang C, Lin S, Wang T, Xie X, Zhou L, Wang C. Treatment of Blood Blister Aneurysms of the Internal Carotid Artery With Pipeline-Assisted Coil Embolization: A Single-Center Experience. Front Neurol 2022; 13:882108. [PMID: 35769367 PMCID: PMC9234106 DOI: 10.3389/fneur.2022.882108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/20/2022] [Indexed: 11/30/2022] Open
Abstract
Background Blood blister aneurysm (BBA) is a complex and rare aneurysm that presents significant treatment challenges. The application of pipeline embolization device (PED)-assisted coiling in the treatment of ruptured BBA remains controversial. This study aimed to report on our experience and assess the safety and efficacy of this strategy. Methods Between February 2019 and February 2021, 12 patients with ruptured BBAs underwent PED-assisted coil embolization. We collected detailed data about each patient, including demographic information, aneurysmal data, technical details, antiplatelet strategy, operation-related complications, and follow-up outcomes. Results A total of 12 BBA patients were treated with single PED-assisted coil embolization. One patient experienced intraoperative rupture that was controlled by rapid coiling without clinical consequences. All the patients demonstrated complete occlusion on postoperative angiography. A total of three patients had postoperative complications: left hemiparesis, Broca's aphasia, and right hemiplegia due to vasospasm, and transient hemiparesis. Follow-up angiography revealed that all BBAs were completely occluded, except one with neck residue. All patients had favorable outcomes at discharge and the most recent clinical follow-up (mRS score ≤ 2). Conclusion Endovascular treatment of BBAs of the internal carotid artery using PED-assisted coil embolization is a safe and effective strategy. This has contributed to the understanding of BBA therapy and provides a potentially optimal treatment option for this intractable lesion.
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Outcomes after Flow Diverter Treatment in Subarachnoid Hemorrhage: A Meta-Analysis and Development of a Clinical Prediction Model (OUTFLOW). Brain Sci 2022; 12:brainsci12030394. [PMID: 35326350 PMCID: PMC8946659 DOI: 10.3390/brainsci12030394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 02/01/2023] Open
Abstract
Background: patients with a subarachnoid hemorrhage (SAH) might need a flow diverter (FD) placement for complex acutely ruptured intracranial aneurysms (IAs). We conducted a meta-analysis and developed a prediction model to estimate the favorable clinical outcome after the FD treatment in acutely ruptured IAs. Methods: a systematic literature search was performed from 2010 to January 2021 in PubMed and Embase databases. Studies with more than five patients treated with FDs within fifteen days were included. In total, 1157 studies were identified. The primary outcome measure was the favorable clinical outcome (mRS 0–2). Secondary outcome measures were complete occlusion rates, aneurysm rebleeding, permanent neurologic deficit caused by procedure-related complications, and all-cause mortality. A prediction model was constructed using individual patient-level data. Results: 26 retrospective studies with 357 patients and 368 aneurysms were included. The pooled rates of the favorable clinical outcome, mortality, and complete aneurysm occlusion were 73.7% (95% CI 64.7–81.0), 17.1% (95% CI 13.3–21.8), and 85.6% (95% CI 80.4–89.6), respectively. Rebleeding occurred in 3% of aneurysms (11/368). The c-statistic of the final model was 0.83 (95% CI 0.76–0.89). All the studies provided a very low quality of evidence. Conclusions: FD treatment can be considered for complex ruptured IAs. Despite high complication rates, the pooled clinical outcomes seem favorable. The prediction model needs to be validated by larger prospective studies before clinical application.
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Giorgianni A, Agosti E, Molinaro S, Terrana AV, Vizzari FA, Nativo L, Garg K, Craparo G, Conti V, Locatelli D, Baruzzi F, Valvassori L, Lanzino G. Flow diversion for acutely ruptured intracranial aneurysms treatment: A retrospective study and literature review. J Stroke Cerebrovasc Dis 2022; 31:106284. [PMID: 35007933 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/19/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Flow diversion is becoming an increasingly established practice for the treatment of acutely ruptured intracranial aneurysms. In this study the authors present a literature review and meta-analysis, adding a retrospective review of institutional registry on emergency treatment of aRIA with flow diverter stent. MATERIALS AND METHODS A systematic search of PubMed, SCOPUS, Ovid MEDLINE, and Ovid EMBASE was performed on April 20th, 2021, extrapolating 35 articles. R language 'meta' and 'metafor' packages were used for data pooling. The DerSimonian-Laird model was used to calculate the pooled effect. The I2 value and Q statistic evaluated study heterogeneity. Additionally, the authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured intracranial aneurysms treated with flow diverter stent placement from May 2010 to November 2020 was performed. RESULTS From the systematic literature review and meta-analysis, the pooled proportion of complete aneurysm occlusion was 78%, with a pooled rate of 79%, 71%, 80%, and 50% for dissecting, saccular, fusiform, and mycotic aneurysms, respectively. The pooled proportion of aneurysm rebleeding and intrastent stenosis was 12% and 15% respectively, for a total of 27% rate. The analysis of authors retrospective register showed an overall mortality rate of 16.7% (3/18), with a low but not negligible postprocedural rebleeding and intrastent thrombosis rates (5.6% and 11.1% respectively). CONCLUSION Although increasingly utilized in the management of selected patients with acutely ruptured intracranial aneurysms, flow diversion for acutely ruptured intracranial aneurysms treatment presents rebleeding and intrastent stenosis rates not negligible.
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Affiliation(s)
- Andrea Giorgianni
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Brescia, Italy.
| | - Stefano Molinaro
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Alberto Vito Terrana
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | | | - Luca Nativo
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Kanwaljeet Garg
- Associate Professor, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Giuseppe Craparo
- Department of Department of Neuroradiology, ARNAS Civico di Palermo, Palermo, Italy
| | - Vinicio Conti
- Department of Anesthesiology and Resuscitation, ASST Sette Laghi, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Fabio Baruzzi
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | | | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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Tanburoglu A, Andic C. Early Treatment of Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery With Flow Diverters Using Single Antiplatelet Therapy: A Single-Center Experience With Long-Term Follow-Up. Front Neurol 2021; 12:708411. [PMID: 34630284 PMCID: PMC8492904 DOI: 10.3389/fneur.2021.708411] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Blood Blister-like aneurysms (BBAs) of the internal carotid artery (ICA) are rare entities of cerebral aneurysms. FD use in acutely ruptured aneurysms, timing of treatment and antiplatelet regimen are main debate topics in clinical practice when the treatment decision is flow diversion. The aim of this study is to report the safety and efficacy of a single-center FD treatment for ruptured BBAs in the early phase of SAH using the SAPT regimen. Material and Method: This study involved a retrospective analysis of a prospectively collected database. Records of patients admitted to our clinic and treated by endovascular route on ruptured BBA between January 2013 and December 2020 were reviewed. Ruptured supraclinoid ICA BBAs treated with FD devices with SAPT within 48 h from ictus of SAH are included. BBA of atypical anatomic locations, other endovascular techniques performed, and delayed admissions (>48 h) were excluded from the study. Demographic, clinical and angiographic features of patients and aneurysms, FD types and numbers, periprocedural complications, immediate and follow-up angiographic and clinical outcomes were recorded. Results: A total of six patients with ruptured BBAs treated via FDs within 48 h and used SAPT were included in the study. The mean age was 41.6 years (range from 34 to 45 years), and four of six patients were female. All patients were treated within 48 h after ictus, and the mean treatment day was 1.33 days. One patient received ticagrelor, and five patients received prasugrel as SAPT for one year after treatment. No procedure-related death and rebleeding were recorded. One (16.7 %) treatment responsive procedure-related complication occurred (transient ischemia). Overall good outcome rate was 83.3%. One patient died due to pneumonia. The immediate control angiograms showed complete occlusions of BBAs in one patient (16.6%). The complete occlusion rate was 100 % for five survivors at the control angiogram. The median follow-up was 49.5 months. Conclusion: This single-center experience suggests that early treatment (<2 days) within SAH of ruptured BBAs with FDs using SAPT is safe and effective in terms of clinical and radiological long-term outcomes.
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Affiliation(s)
| | - Cagatay Andic
- Radiology Department, Başkent University, Adana, Turkey
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Zhong W, Kuang H, Zhang P, Yang X, Luo B, Maimaitili A, Zhao Y, Song D, Guan S, Zhang H, Wang Y, Wang D, Su W, Wang Y. Pipeline Embolization Device for the Treatment of Ruptured Intracerebral Aneurysms: A Multicenter Retrospective Study. Front Neurol 2021; 12:675917. [PMID: 34603179 PMCID: PMC8481592 DOI: 10.3389/fneur.2021.675917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/19/2021] [Indexed: 12/03/2022] Open
Abstract
Background and Purpose: The utilization of flow diversion for ruptured intracerebral aneurysms (IAs) is still limited. We aimed to demonstrate our multicenter experience using the pipeline embolization device (PED) for ruptured IAs that were difficult to treat by clipping and coiling. Methods: Thirty-eight patients with ruptured IAs who underwent PED treatment from 2015 to 2020 were retrospectively reviewed. Factors associated with procedure-related stroke (ischemic and hemorrhagic) and clinical and angiography outcomes were analyzed. Results: There were 14 (36.8%) saccular IAs, 12 (31.6%) blister-like IAs, and 12 (31.6%) dissecting IAs. Perforator involvement was noted in 10 (26.3%) IAs. Early PED placement ( ≤ 15 days) and adjunctive coiling treatment were performed in 27 (71.1%) and 22 (57.9%) cases, respectively. The overall rate of stroke-related complications was 31.6% (12/38) (including rates of 10.5% for procedure-related hemorrhagic complications and 15.8% for procedure-related infarction). The mortality rate was 13.2% (5/38), and 84.2% of patients (32/38) had favorable outcomes. Thirty-two (84.2%) patients underwent follow-up angiographic evaluations; of these, 84.4% (27 patients) had complete occlusion and 15.6% had incomplete obliteration. Multivariate analysis revealed that early PED placement was not associated with a high risk of procedure-related stroke or an unfavorable outcome. Adjunctive coiling exhibited an association with procedure-related stroke (p = 0.073). Procedure-related hemorrhagic complications were significantly associated with an unfavorable outcome (p = 0.003). Immediate contrast stasis in the venous phase was associated with complete occlusion during follow-up (p = 0.050). Conclusion: The PED is a feasible and effective treatment to prevent rebleeding and achieve aneurysm occlusion, but it is associated with a substantial risk of periprocedural hemorrhage and ischemic complications in acute ruptured IAs. Therefore, the PED should be used selectively for acutely ruptured IAs. Additionally, adjunctive coiling might increase procedure-related stroke; however, it may reduce aneurysm rebleeding in acutely ruptured IAs. Patients with immediate contrast stasis in the venous phase were more likely to achieve total occlusion. A prospective study with a larger sample size should be performed to verify our results.
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Affiliation(s)
- Weiying Zhong
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Hong Kuang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Department of Neurosurgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ping Zhang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Xinjian Yang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bin Luo
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongqi Zhang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Donghai Wang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Wandong Su
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Yunyan Wang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
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11
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Khan NR, Elarjani T, Cajigas I, Chen S, Morcos JJ. Microsurgical Clip Trapping of Dorsal Internal Carotid Artery Blister Ruptured Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E244-E245. [PMID: 34097734 DOI: 10.1093/ons/opab196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/04/2021] [Indexed: 11/15/2022] Open
Abstract
Dorsal internal carotid artery (ICA) blister aneurysms are an uncommon aneurysm variant constituting 0.3% to 1% of intracranial aneurysms and can be due to ulceration, atherosclerosis, or dissection.1-3 Despite its rarity, it carries a high risk of rupture with an estimation of 0.9% to 6.5% among intracranial aneurysms.1,2 Blister aneurysms are small in size, have no distinguishable neck, and have a friable wall that can easily rupture if manipulated, hence the difficulty in its treatment utilizing both microsurgical and endovascular techniques.1,2,4-6 Endovascular coiling of these lesions may not be adequate due to the broad-based size; stenting requires the use of antiplatelet medications, which could lead to rebleeding; flow diversion takes longer to exert its treatment effect.1,4 Conversely, microsurgical management carries a higher intraoperative rupture rate.2 Microsurgical options include clipping, clip reconstruction, trapping with bypass, and wrapping.4,7 We present a case of a 38-yr-old man who presented with a ruptured right dorsal ICA blister aneurysm treated with microsurgical trapping with intraoperative flow measurements. We demonstrate how the use of quantitative intraoperative flow measurements allows confident sacrifice of the supraclinoid ICA. We also demonstrate in contrast another case example of utilizing a clip-graft repair. The patient remained unchanged with an intact neurological exam, and postoperative imaging showed no aneurysm remnant and patent anterior choroidal artery. We review the literature and management of dorsal ICA aneurysms.8-15 We also review the technical nuances and different endovascular and microsurgical treatments that can be used for this condition. The patient gave informed consent for the procedure and verbal consent to the publication.
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Affiliation(s)
- Nickalus R Khan
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Turki Elarjani
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ian Cajigas
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stephanie Chen
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jacques J Morcos
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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12
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Gupta V, Londhe S, Parthasarathy R. Internal Carotid Artery Blister Aneurysm: Review of Endovascular Techniques. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1726166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AbstractCerebral blister aneurysms are very difficult vascular lesions in terms of accurate diagnosis as well as proper management strategy for vascular neurosurgeons and neurointerventionists. Histopathological analysis has revealed their nature to be more akin to pseudoaneurysms in comparison to the typical berry aneurysms. This explains their fragile nature, with high probability of rerupture and regrowth during the follow-up if not addressed properly. Even though surgical approaches have evolved over the years to minimize intraprocedural rupture and recurrence, they still have relatively high morbidity as well as mortality in comparison to endovascular treatment. Over the last few years, endovascular treatment has evolved significantly, with introduction of new devices and techniques. Focus of the endovascular management has shifted from the deconstructive techniques to reconstructive ones with parent artery preservation. Recent introduction of flow diverter technology has enabled neurointerventionists to manage these difficult lesions with more confidence in terms of avoiding rerupture and recurrence. Flow diverter (FD) use in blister aneurysm resulted in high-technical success, complete aneurysm occlusion, and less complications in comparison to other reconstructive techniques like simple coiling, stent assisted coiling, and overlapping/monotherapy stent placement. Few debatable issues like use of dual antiplatelets in the setting of acute subarachnoid hemorrhage (SAH), timing of drugs in relation to procedures, single/overlapping devices, and concerns during cerebral vasospasm phase need further detailed analysis and standardized protocols. In this article, we have done a review of different endovascular treatment options in the management of internal carotid artery blister aneurysms with special focus on FD and issues related to it.
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Affiliation(s)
- Vipul Gupta
- Departement of Interventional Neuroradiology, Artemis Hospital, Gurgaon, Haryana, India
| | - Shrikant Londhe
- Departement of Interventional Neuroradiology, Artemis Hospital, Gurgaon, Haryana, India
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13
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Chen S, Chen X, Ning B, Cao Y, Wang S. Supraclinoid internal carotid artery blister-like aneurysms: hypothesized pathogenesis and microsurgical clipping outcomes. Chin Neurosurg J 2021; 7:10. [PMID: 33517915 PMCID: PMC7849078 DOI: 10.1186/s41016-020-00226-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 12/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Blister-like aneurysms (BLAs) on the supraclinoid segment of the internal carotid artery (ICA) are an enigma of cerebrovascular disease. Neither has a definite pathogenesis been so far identified, nor have uniform treatment guidelines been established for them. Our aim was to develop a hypothesis regarding the evolution of BLAs according to their macroscopic morphologies and to evaluate the efficacy of microsurgical clipping. METHODS The clinical data and morphological features of 15 consecutive patients with 16 BLAs on the supraclinoid ICA were retrospectively reviewed. The treatment strategies were analyzed, and functional outcomes were evaluated using the modified Rankin scale (mRS). Favorable outcomes were defined as a mRS score of 0-2. RESULTS Morphologically, aneurysm growth with expansion of the aneurysm neck before the surgical procedure occurred in two ruptured and one unruptured aneurysm. Daughter bleb formation was observed in two ruptured and five unruptured aneurysms. A varied degree of parent artery sclerosis was observed in nine patients. Thirteen patients were treated with direct surgical clipping, one patient was treated with clipping and wrapping, and the remaining patient was treated with an encircling clipping graft. Favorable and unfavorable outcomes were observed in 13 and two cases, respectively. Follow-up angiograms revealed 4 cases of stenosis with respective degree of mild, 30%, 50%, and 80% without any neurological dysfunction. CONCLUSIONS We suggest a hypothesis that BLAs on the supraclinoid ICA may share different evolving mechanisms between ruptured and unruptured lesions. A majority of them can be reliably and safely obliterated by direct clipping technique, except for the aneurysms accompanied with severely atherosclerotic parent walls.
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Affiliation(s)
- Shanwen Chen
- Department of Neurosurgery, the Hospital of Shunyi District, No.3 Guangming Nan Street, Shunyi District, Beijing, 101300, China
| | - Xin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100050, China
| | - Bo Ning
- Department of Neurosurgery, Guangzhou Red Cross Hospital, Jinan University, No. 396 Tongfu Zhong Road, Haizhu District, Guangzhou, 510220, Guangdong, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100050, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100050, China.
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14
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Scerrati A, Visani J, Flacco ME, Ricciardi L, Trungu S, Raco A, Dones F, De Bonis P, Sturiale CL. Endovascular Treatment of Ruptured Intracranial Blister Aneurysms: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2020; 42:538-545. [PMID: 33361375 DOI: 10.3174/ajnr.a6924] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 09/29/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Endovascular treatment of blister aneurysms is a promising approach, even though they are vascular lesions challenging to treat due to their angioarchitectural characteristics. PURPOSE Our aim was to investigate clinical and radiologic outcomes after endovascular treatment of ruptured blister aneurysms. DATA SOURCES PubMed, Ovid MEDLINE, Ovid EMBASE, Scopus, and the Web of Science were screened. STUDY SELECTION We performed a comprehensive review of the literature from 2010 to 2019 reporting series of patients with blister aneurysms treated with an endovascular approach. DATA ANALYSIS Event rates were pooled across studies using a random effects meta-analysis. DATA SYNTHESIS A total of 32 studies reporting on 684 patients (707 aneurysms) were included. Stent placement, stent-assisted coiling, and flow diversion were the most commonly described treatments (282, 256, and 155 patients, respectively). The long-term complete occlusion rate was 76.9% (95% CI, 69.2%-83.9%). The perioperative complication rate was 8.9%, and clinical outcome at final follow-up was mRS <2 in 76.6% (95% CI, 68.2%-84.2%) of patients. The mortality rate was 4.7% (95% CI, 2.30%-7.80%). Among the different techniques, stent-assisted coiling is the one that had the higher rate of immediate occlusion (63.4%); however, the occlusion rate at the final follow-up was comparable among the different techniques. LIMITATIONS Different techniques were described and data were reported in a nonhomogeneous way, possibly representing a bias in the present study. CONCLUSIONS This study suggests that endovascular treatment of blister aneurysms is associated with good long-term occlusion rates and reasonable complication and mortality rates. There is no consensus on the best endovascular techniques in blister aneurysm management.
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Affiliation(s)
- A Scerrati
- From the Department of Neurosurgery (A.S., J.V., F.D., P.D.B.), S. Anna University Hospital, Ferrara, Italy.,Departments of Morphology, Surgery, and Experimental Medicine (A.S., P.D.B.)
| | - J Visani
- From the Department of Neurosurgery (A.S., J.V., F.D., P.D.B.), S. Anna University Hospital, Ferrara, Italy
| | - M E Flacco
- Medical Sciences (M.E.F.), University of Ferrara, Ferrara, Italy
| | - L Ricciardi
- Unità operativa di Neurochirurgia (L.R., S.T.), Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, Lecce, Italy .,Unità operativa complessa di Neurochirurgia (L.R., S.T., A.R.), Dipartimento di Neuroscienze Salute Mentale e Organi di Senso, Azienda Ospedaliera Sant'Andrea, Sapienza, Rome, Italy
| | - S Trungu
- Unità operativa di Neurochirurgia (L.R., S.T.), Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, Lecce, Italy.,Unità operativa complessa di Neurochirurgia (L.R., S.T., A.R.), Dipartimento di Neuroscienze Salute Mentale e Organi di Senso, Azienda Ospedaliera Sant'Andrea, Sapienza, Rome, Italy
| | - A Raco
- Unità operativa complessa di Neurochirurgia (L.R., S.T., A.R.), Dipartimento di Neuroscienze Salute Mentale e Organi di Senso, Azienda Ospedaliera Sant'Andrea, Sapienza, Rome, Italy
| | - F Dones
- From the Department of Neurosurgery (A.S., J.V., F.D., P.D.B.), S. Anna University Hospital, Ferrara, Italy
| | - P De Bonis
- From the Department of Neurosurgery (A.S., J.V., F.D., P.D.B.), S. Anna University Hospital, Ferrara, Italy.,Departments of Morphology, Surgery, and Experimental Medicine (A.S., P.D.B.)
| | - C L Sturiale
- Department of Neurosurgery (C.L.S.), Fondazione Policlinico Universitario A. Gemelli Istituto di ricovero e cura a carattere scientifico, Rome, Italy
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15
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Youssef PP, Dornbos Iii D, Peterson J, Sweid A, Zakeri A, Nimjee SM, Jabbour P, Arthur AS. Woven EndoBridge (WEB) device in the treatment of ruptured aneurysms. J Neurointerv Surg 2020; 13:443-446. [PMID: 32719167 DOI: 10.1136/neurintsurg-2020-016405] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Wide-necked bifurcation aneurysms (WNBAs) present unique challenges for endovascular treatment. The Woven EndoBridge (WEB) device is an intrasaccular braided device, recently approved by the FDA for treatment of WNBAs. While treatment of intracranial aneurysms with the WEB device has been shown to yield an adequate occlusion rate of 85% at 1 year, few data have been published for patients with ruptured aneurysms. OBJECTIVE To present a multi-institutional series depicting the safety and efficacy of using the WEB device as the primary treatment modality in ruptured intracranial aneurysms. METHODS A multi-institutional retrospective analysis was conducted, assessing patients presenting with aneurysmal subarachnoid hemorrhage treated with the WEB between January 2014 and April 2020. Baseline demographics, aneurysm characteristics, adverse events, and long-term outcomes (occlusion, re-treatment, functional status) were collected. A descriptive analysis was performed, and variables potentially associated with aneurysm recurrence or re-treatment were assessed. RESULTS Forty-eight patients were included. Anterior communicating artery aneurysms were the most common (35.4%) location for treatment, followed by middle cerebral artery (20.8%) and basilar apex (16.7%). Procedural success was noted in 95.8% of patients, and clinically significant periprocedural adverse events occurred in 12.5%. After a median follow-up of 5.5 months, 54.2% of patients had follow-up angiographic imaging. Complete occlusion was seen in 61.5% of cases with adequate occlusion in 92.3%. Re-treatment was required in only 4.2% of patients during the study period. Tobacco use was significantly higher in patients with aneurysm recurrence (88.9% vs 35.7%; p=0.012). No other characteristics were associated with recurrence/re-treatment. At 30 days, 81.1% were functionally independent (modified Rankin Scale score ≤2). CONCLUSION Treatment of acutely ruptured aneurysms with the WEB device demonstrates both safety and efficacy on par with rates of conventional treatment strategies.
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Affiliation(s)
- Patrick P Youssef
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA
| | - David Dornbos Iii
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Jeremy Peterson
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Amanda Zakeri
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Shahid M Nimjee
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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16
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Sonobe S, Yoshida M, Niizuma K, Tominaga T. Ruptured Basilar Artery Dissection Diagnosed Using Magnetic Resonance Vessel Wall Imaging and Treated with Coil Embolization with Overlapping LVIS Stents: A Case Report. NMC Case Rep J 2020; 7:75-79. [PMID: 32322456 PMCID: PMC7162815 DOI: 10.2176/nmccrj.cr.2019-0141] [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: 06/20/2019] [Accepted: 10/28/2019] [Indexed: 11/20/2022] Open
Abstract
The diagnosis and treatment of patients with ruptured basilar artery dissection (rBAD) are often difficult. We present a case of rBAD diagnosed with magnetic resonance vessel wall imaging (MR-VWI) and treated with coil embolization with overlapping low-profile visualized intraluminal support (LVIS) stents. The case is of a 49-year-old woman with subarachnoid hemorrhage. digital subtraction angiography (DSA) showed irregularity in an anterior wall of the middle portion of the basilar artery, indicating the presence of a false lumen. MR-VWI showed local enhancement in an arterial wall, which was consistent with the wall irregularity observed in DSA. Overlapping stents (two LVIS stents) was performed in the basilar artery and coils were placed in the false lumen. The false lumen was completely thrombosed, and anterograde blood flow of the basilar artery was preserved. Dual antiplatelet therapy was administered, and the patient underwent an uneventful postoperative course. DSA performed 6 months later showed a white-collar sign. MR-VWI has attracted attention as a useful modality for detecting a ruptured lesion in patients with subarachnoid hemorrhage. This is the first report, to the best of our knowledge, describing the practical use of MR-VWI for rBAD. MR-VWI is suggested to improve diagnostic accuracy for rBAD. There are no established treatments for rBAD; reconstructive endovascular treatments comprising stent placement and coil embolization of a false lumen are promising. The LVIS stent has a braided design and high metal coverage ratio and is considered to be reasonable for use in rBAD. Coil embolization of a false lumen with overlapping LVIS stents may be effective for rBAD.
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Affiliation(s)
- Shinya Sonobe
- Department of Neurosurgery, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Masahiro Yoshida
- Department of Neurosurgery, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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17
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Binh NT, Luu VD, Thong PM, Cuong NN, Anh NQ, Tuan TA, Linh LT, Thien NT, Uddin MJ, Dinh TC, Chu DT. Flow diverter stent for treatment of cerebral aneurysms: A report of 130 patients with 134 aneurysms. Heliyon 2020; 6:e03356. [PMID: 32055743 PMCID: PMC7005424 DOI: 10.1016/j.heliyon.2020.e03356] [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: 03/11/2019] [Revised: 09/03/2019] [Accepted: 01/31/2020] [Indexed: 10/25/2022] Open
Abstract
Background This study aims to report our experience with cerebral aneurysms, which may improve in the treatment with the flow-diverter stent and follow up. Methods This study was conducted in a consecutive series of 130 patients. 134 procedures were performed for treating these patients in Hanoi Medical University Hospital and Bach Mai Hospital from January 2012 to April 2017. 143 flow diverter stents (Pipeline, FRED and SILK) were used. Aneurysm morphology, stent patency and cerebral parenchyma before and after intervention were analyzed on images of digital subtraction angiography (DSA), computed tomography (CT) and magnetic resonance (MR). The follow-up data after 3-6 months and 12 months were recorded. Results In 130 patients (31 men, 99 women), aneurysms of internal carotid artery were mostly common (92.6%), especially in cavernous (35.1%) and in para-ophthalmic (40.3%) segments. 83 cases (61.9%) had wide-neck aneurysms, and 16 cases (11.9%) had multiple aneurysms, and only 5 cases (3.7%) had blister-liked aneurysms. Endovascular treatment was successfully performed at rate of 94.8%. In 3 patients, the stent could not be delivered. Mortality and morbidity rates were 1.5% and 3.7%, respectively. MRI and MSCT follow-up at 3 months showed complete or incomplete occlusions of aneurysms was 7.4% or 17.5%, respectively. 3 patients experienced a thromboembolic event (4.3%). Conclusions Intracranial aneurysms of cavernous and para-ophthalmic segments of internal carotid artery are mostly common with wide-neck and multi aneurysms. Deployment of flow diverter stent is safe and effective with high rate of successful and low procedural complications.
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Affiliation(s)
- Nguyen Thai Binh
- Radiology Department, Hanoi Medical University Hospital, Hanoi, Viet Nam.,Hanoi Medical University, Hanoi, Viet Nam
| | - Vu Dang Luu
- Hanoi Medical University, Hanoi, Viet Nam.,Bach Mai Hospital, Hanoi, Viet Nam
| | - Pham Minh Thong
- Hanoi Medical University, Hanoi, Viet Nam.,Bach Mai Hospital, Hanoi, Viet Nam
| | - Nguyen Ngoc Cuong
- Radiology Department, Hanoi Medical University Hospital, Hanoi, Viet Nam
| | - Nguyen Quang Anh
- Hanoi Medical University, Hanoi, Viet Nam.,Bach Mai Hospital, Hanoi, Viet Nam
| | | | - Le Tuan Linh
- Radiology Department, Hanoi Medical University Hospital, Hanoi, Viet Nam.,Hanoi Medical University, Hanoi, Viet Nam
| | | | - Md Jamal Uddin
- College of Pharmacy, Ewha Womans University, Seoul, South Korea
| | - Thien Chu Dinh
- Institute for Research and Development, Duy Tan University, 03 Quang Trung, Danang, Viet Nam
| | - Dinh-Toi Chu
- Hanoi National University of Education, Hanoi, Viet Nam.,School of Odonto Stomatology, Hanoi Medical University, Hanoi, Viet Nam
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18
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ten Brinck MFM, Jäger M, de Vries J, Grotenhuis JA, Aquarius R, Mørkve SH, Rautio R, Numminen J, Raj R, Wakhloo AK, Puri AS, Taschner CA, Boogaarts HD. Flow diversion treatment for acutely ruptured aneurysms. J Neurointerv Surg 2019; 12:283-288. [DOI: 10.1136/neurintsurg-2019-015077] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 08/04/2019] [Accepted: 08/07/2019] [Indexed: 11/04/2022]
Abstract
Background and purposeFlow diverters are sometimes used in the setting of acutely ruptured aneurysms. However, thromboembolic and hemorrhagic complications are feared and evidence regarding safety is limited. Therefore, in this multicenter study we evaluated complications, clinical, and angiographic outcomes of patients treated with a flow diverter for acutely ruptured aneurysms.MethodsWe conducted a retrospective observational study of 44 consecutive patients who underwent flow diverter treatment within 15 days after rupture of an intracranial aneurysm at six centers. The primary end point was good clinical outcome, defined as modified Rankin Scale score (mRS) 0–2. Secondary endpoints were procedure-related complications and complete aneurysm occlusion at follow-up.ResultsAt follow-up (median 3.4 months) 20 patients (45%) had a good clinical outcome. In 20 patients (45%), 25 procedure-related complications occurred. These resulted in permanent neurologic deficits in 12 patients (27%). In 5 patients (11%) aneurysm re-rupture occurred. Eight patients died resulting in an all-cause mortality rate of 18%. Procedure-related complications were associated with a poor clinical outcome (mRS 3–6; OR 5.1(95% CI 1.0 to 24.9), p=0.04). Large aneurysms were prone to re-rupture with rebleed rates of 60% (3/5) vs 5% (2/39) (p=0.01) for aneurysms with a size ≥20 mm and <20 mm, respectively. Follow-up angiography in 29 patients (median 9.7 months) showed complete aneurysm occlusion in 27 (93%).ConclusionFlow diverter treatment of ruptured intracranial aneurysms was associated with high rates of procedure-related complications including aneurysm re-ruptures. Complications were associated with poor clinical outcome. In patients with available angiographic follow-up, a high occlusion rate was observed.
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Hellstern V, Aguilar-Pérez M, AlMatter M, Bhogal P, Henkes E, Ganslandt O, Henkes H. Microsurgical clipping and endovascular flow diversion of ruptured anterior circulation blood blister-like aneurysms. Interv Neuroradiol 2018; 24:615-623. [PMID: 30001647 PMCID: PMC6259333 DOI: 10.1177/1591019918785911] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/06/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Detection and treatment of blister-like intracranial aneurysms as a source of subarachnoid hemorrhage (SAH) can be challenging. In the past the results of both microsurgical and endovascular treatment were difficult. We present our experience with the treatment of blister-like aneurysms in the acute phase of SAH using microsurgical clipping, endovascular parent vessel occlusion or flow diversion. METHODS A retrospective analysis of the cases of eight consecutive patients presenting in the acute phase after SAH from an intracranial blister aneurysm was performed. The demographic data of the patients, aneurysm characteristics, the clinical results of the treatment and the follow-up examinations were recorded. Procedural safety margins and aneurysm occlusion on follow-up digital subtraction angiography were the main interest of this evaluation. RESULTS Between January 2012 and November 2017 a total of eight ruptured blister aneurysms were treated in our center, six patients endovascularly. Five patients were treated in the acute phase of SAH, four by flow diversion. All endovascular procedures were feasible and no procedure-related complications were observed, especially no recurrent hemorrhage. In the first angiographic follow-up all blood blister-like aneurysms were completely occluded; two of the six patients treated by flow diverter implantation showed mild, transient intimal hyperplasia without clinical symptoms or the need for treatment. CONCLUSIONS Endovascular flow diversion is a viable option in the acute phase after SAH due to the rupture of a blister aneurysm. Implants with reduced thrombogenicity, obviating dual-platelet function inhibition, and flow diverters for vessel bifurcations would extend the indications for this treatment modality.
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Affiliation(s)
- V Hellstern
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - M Aguilar-Pérez
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - M AlMatter
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - P Bhogal
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - E Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
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Treatment of ruptured blood blister-like aneurysms of the internal carotid artery with flow-diverting stents: Case report and review of pharmacological management. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Zhu D, Yan Y, Zhao P, Duan G, Zhao R, Liu J, Huang Q. Safety and Efficacy of Flow Diverter Treatment for Blood Blister–Like Aneurysm: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 118:e79-e86. [DOI: 10.1016/j.wneu.2018.06.123] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022]
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Cagnazzo F, di Carlo DT, Cappucci M, Lefevre PH, Costalat V, Perrini P. Acutely Ruptured Intracranial Aneurysms Treated with Flow-Diverter Stents: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2018; 39:1669-1675. [PMID: 30049721 DOI: 10.3174/ajnr.a5730] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 05/25/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND The implantation of flow-diverter stents for the treatment of ruptured intracranial aneurysms required further investigation. PURPOSE Our aim was to analyze the outcomes after flow diversion of ruptured intracranial aneurysms. DATA SOURCES A systematic search of 3 databases was performed for studies published from 2006 to 2018. STUDY SELECTION According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies (from 2010 to 2018) reporting acutely ruptured intracranial aneurysms treated with flow diversion. DATA ANALYSIS Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, rebleeding, and factors influencing the studied outcomes. DATA SYNTHESIS We included 20 studies evaluating 223 patients with acutely ruptured intracranial aneurysms treated with flow-diverter stents. Immediate angiographic occlusion was obtained in 32% (29/86; 95% CI, 15.4%-48%; I2 = 79.6%) of aneurysms, whereas long-term complete/near-complete aneurysm occlusion was 88.9% (162/189; 95% CI, 84%-93.5%; I2 = 20.9%) (mean radiologic follow-up of 9.6 months). The treatment-related complication rate was 17.8% (42/223; 95% CI, 11%-24%; I2 = 52.6%). Complications were higher in the posterior circulation (16/72 = 27%; 95% CI, 14%-40%; I2 = 66% versus 18/149 = 11.7%; 95% CI, 7%-16%; I2 = 0%) (P = .004) and after treatment with multiple stents (14/52 = 26%; 95% CI, 14%-45%; I2 = 59%) compared with a single stent (20/141 = 10%; 95% CI, 5%-15%; I2 = 0%) (P = .004). Aneurysm rebleeding after treatment was 4% (5/223; 95% CI, 1.8%-7%; I2 = 0%) and was higher in the first 72 hours. LIMITATIONS Small and retrospective series. CONCLUSIONS Flow-diversion treatment of ruptured intracranial aneurysms yields a high rate of long-term angiographic occlusion with a relatively low rate of aneurysm rebleeding. However, treatment is associated with a complication rate of 18%. When coiling or microsurgical clipping are not feasible strategies, anterior circulation ruptured aneurysms can be effectively treated with a flow-diversion technique, minimizing the number of stents deployed. Given the 27% rate of complications, flow diversion for ruptured posterior circulation aneurysms should be considered only in selected cases not amenable to other treatments.
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Affiliation(s)
- F Cagnazzo
- From the Department of Neurosurgery (F.C., D.T.d.C., P.P.), University of Pisa, Pisa, Italy
| | - D T di Carlo
- From the Department of Neurosurgery (F.C., D.T.d.C., P.P.), University of Pisa, Pisa, Italy
| | - M Cappucci
- Radiology Department (M.C.), University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - P-H Lefevre
- Neuroradiology Department (P.-H.L., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalo-Universitaire de Montpellier, Montpellier, France
| | - V Costalat
- Neuroradiology Department (P.-H.L., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalo-Universitaire de Montpellier, Montpellier, France
| | - P Perrini
- From the Department of Neurosurgery (F.C., D.T.d.C., P.P.), University of Pisa, Pisa, Italy
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Management of Blood Blister–Like Aneurysms of the Internal Carotid Artery: Lessons Learned from Direct Clipping in 22 Cases. World Neurosurg 2017; 108:618-626. [DOI: 10.1016/j.wneu.2017.09.080] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/11/2017] [Accepted: 09/13/2017] [Indexed: 11/23/2022]
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