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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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Ghaith AK, Greco E, Rios-Zermeno J, El-Hajj VG, Perez-Vega C, Ghanem M, Kashyap S, Fox WC, Huynh TJ, Sandhu SS, Ohlsson M, Elmi-Terander A, Bendok BR, Bydon M, Tawk RG. Safety and efficacy of the pipeline embolization device for treatment of small vs. large aneurysms: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:284. [PMID: 37882896 DOI: 10.1007/s10143-023-02192-0] [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: 09/06/2023] [Revised: 10/06/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023]
Abstract
Flow diversion with the pipeline embolization device (PED) is increasingly used to treat intracranial aneurysms with high obliteration rates and low morbidity. However, long-term (≥ 1 year) angiographic and clinical outcomes still require further investigation. The aim of this study was to compare the occlusion and complication rates for small (< 10 mm) versus large (10-25 mm) aneurysms at long-term following treatment with PED. A systematic review and meta-analysis were performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We conducted a comprehensive search of English language databases including Ovid MEDLINE and Epub Ahead of Print, In-Process, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Our studies included a minimum of 10 patients treated with PED for small vs. large aneurysms and with at least 12 months of follow-up. The primary safety endpoint was the rate of clinical complications measured by the occurrence of symptomatic stroke (confirmed clinically and radiographically), intracranial hemorrhage, or aneurysmal rupture. The primary efficacy endpoint was the complete aneurysm occlusion rate. Our analysis included 19 studies with 1277 patients and 1493 aneurysms. Of those, 1378 aneurysms met our inclusion criteria. The mean age was 53.9 years, and most aneurysms were small (89.75%; N = 1340) in women (79.1%; N = 1010). The long-term occlusion rate was 73% (95%, CI 65 to 80%) in small compared to 84% (95%, CI 76 to 90%) in large aneurysms (p < 0.01). The symptomatic thromboembolic complication rate was 5% (95%, CI 3 to 9%) in small compared to 7% (95%, CI 4 to 13%) in large aneurysms (p = 0.01). The rupture rate was 2% vs. 4% (p = 0.92), and the rate of intracranial hemorrhage was 2% vs. 4% (p = 0.96) for small vs. large aneurysms, respectively; however, these differences were not statistically significant. The long-term occlusion rate after PED treatment is higher in large vs. small aneurysms. Symptomatic thromboembolic rates with stroke are also higher in large vs. small aneurysms. The difference in the rates of aneurysm rupture and intracranial hemorrhage was insignificant. Although the PED seems a safe and effective treatment for small and large aneurysms, further studies are required to clarify how occlusion rate and morbidity are affected by aneurysm size.
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Affiliation(s)
- Abdul Karim Ghaith
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Elena Greco
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Victor Gabriel El-Hajj
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Carlos Perez-Vega
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Marc Ghanem
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Samir Kashyap
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - W Christopher Fox
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Thien J Huynh
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Marcus Ohlsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA.
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Abdulla E, Das K, Luther H, Amuah Wireko A. Blister-like Cerebral Aneurysm after Endovascular Catheterization: A Case Report and Literature Review. Cureus 2023; 15:e39674. [PMID: 37398705 PMCID: PMC10308143 DOI: 10.7759/cureus.39674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/04/2023] Open
Abstract
Endovascular procedures have become a mainstay in the treatment of neurovascular pathologies like arteriovenous malformations and aneurysms. Catheter-induced blister-like aneurysms (BBAs) have not been described so far in the neurosurgical literature. The authors report a rare case of a possible, catheter-induced (iatrogenic) BBA of the supra-ventral wall of the internal carotid artery (ICA) post-endovascular coiling for posterior communicating artery (PComA) aneurysm and bring the rapid progression of BBA and the grade prognosis. A 46-year-old female presented with convulsions. Imaging studies showed diffuse subarachnoid haemorrhage (SAH) and a right saccular PComA aneurysm. Endovascular coiling of the aneurysm was performed, and it was uneventful. The patient had a good outcome (modified Rankin Scale of 1) with no neurological deficits and was discharged home on day five. However, on day nine after the first ictus, she experienced a severe headache at home and was rushed to the emergency room where she collapsed. A cranial computed tomography scan showed intracerebral haemorrhage with intraventricular extension and SAH. A cerebral angiogram showed a BBA of the supra-ventral wall of the ICA. A BBA needs to be considered as a complication of an endovascular procedure that may result in rapid neurological deterioration post-coiling due to rupture. The report also illustrates the rapid and catastrophic presentation of BBA.
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Affiliation(s)
| | - Krishna Das
- Neurosurgery, Salmaniya Medical Complex, Manama, BHR
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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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Vieira E, Netto AU, Cezar AB, Faquini I, Almeida NS, Azevedo-Filho HRC. Blood Blister-Like Aneurysms of the Internal Carotid Artery. Adv Tech Stand Neurosurg 2023; 48:371-383. [PMID: 37770692 DOI: 10.1007/978-3-031-36785-4_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Internal carotid artery blood blister-like aneurysms are challenging lesions that arise from the artery trunk at non-branching sites. They have been recognized since 1969 and are distinct from typical saccular aneurysms. Usually, these aneurysms are broad-based, with no clearly identifiable neck and have extremely friable and fragile walls, thus with a great propensity to cause subarachnoid hemorrhage and to rupture during treatment. Apparently, blister-like aneurysms are formed through an acquired defect of the inner layers (tunica intima and media) of the internal carotid artery wall, probably due to hemodynamic stress in the carotid siphon.Several surgical and endovascular techniques have been described for the treatment of these aneurysms, however, there is still no consensus on the best technique or method, exposing how challenging the treatment of internal carotid artery blister-like aneurysms is, for both neurosurgeons and neurointerventionists. In this chapter, we review the main aspects of the pathogenesis, diagnosis, and therapeutics and report our experience in the microsurgical treatment of these formidable lesions.
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Affiliation(s)
- Eduardo Vieira
- Department of Neurological Surgery, Hospital Da Restauração, Recife, Brazil
| | - Arlindo U Netto
- Department of Neurological Surgery, Hospital Da Restauração, Recife, Brazil
| | - Auricelio B Cezar
- Department of Neurological Surgery, Hospital Da Restauração, Recife, Brazil
| | - Igor Faquini
- Department of Neurological Surgery, Hospital Da Restauração, Recife, Brazil
| | - Nivaldo S Almeida
- Department of Neurological Surgery, Hospital Da Restauração, Recife, Brazil
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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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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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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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Sanchez VE, Haider AS, Rowe SE, Wahood W, Sagoo NS, Ozair A, El Ahmadieh TY, Kan P, Johnson JN. Comparison of Blister Aneurysm Treatment Techniques: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 154:e82-e101. [PMID: 34224880 DOI: 10.1016/j.wneu.2021.06.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Blood blister aneurysms are small, thin-walled, rapidly growing side-wall aneurysms that have proved particularly difficult to treat, and evidence-based guidance for treatment strategies is lacking. A systematic review and meta-analysis was performed to aggregate the available data and compare the 3 primary treatment modalities. METHODS We performed a comprehensive literature search according to PRISMA guidelines followed by an indirect meta-analysis that compares the safety and efficacy of surgical, flow-diverting stents (FDS), and other endovascular approaches for the treatment of ruptured blood blister aneurysms. RESULTS A total of 102 studies were included for quantitative synthesis, with sample sizes of 687 treated surgically, 704 treated endovascularly without FDS, and 125 treated via flow diversion. Comparatively, FDS achieved significantly reduced rates of perioperative retreatment compared with both surgical (P = 0.025) and non-FDS endovascular (P < 0.001). The FDS subgroup also achieved a significantly lower incidence of perioperative rebleed (P < 0.001), perioperative hydrocephalus (P = 0.012), postoperative infarction (P = 0.002), postoperative hydrocephalus (P < 0.001), and postoperative vasospasm (P = 0.002) compared with those patients in the open surgical subgroup. Although no significant differences were found among groups on the basis of functional outcomes, angiographic outcomes detailed by rates of radiographic complete occlusion were highest for surgical (90.7%, 262/289) and FDS (89.1%, 98/110) subgroups versus the non-FDS endovascular subgroup (82.7%, 268/324). CONCLUSIONS Flow diversion seems to be an effective treatment strategy for ruptured blood blister aneurysms, with lower rates of perioperative complications compared with surgical and other endovascular techniques, but studies investigating long-term outcomes after flow diversion warrant further study.
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Affiliation(s)
- Victoria E Sanchez
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ali S Haider
- Department of Neurosurgery, Texas A&M University College of Medicine, Bryan, Texas, USA
| | - Scott E Rowe
- Department of Surgery, Nova Southeastern University College of Osteopathic Medicine, Davie, Florida, USA
| | - Waseem Wahood
- Department of Surgery, Nova Southeastern University College of Allopathic Medicine, Davie, Florida, USA
| | - Navraj S Sagoo
- Department of Orthopaedic Surgery, University of Texas Medical Branch School of Medicine, Galveston, Texas, USA
| | - Ahmad Ozair
- Department of Neurosurgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Tarek Y El Ahmadieh
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jeremiah N Johnson
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.
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Mouchtouris N, Khanna O, Al Saiegh F, Jabbour P. Commentary: Microsurgical Clip Trapping of Dorsal Internal Carotid Artery Blister Ruptured Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E246-E247. [PMID: 34131755 DOI: 10.1093/ons/opab212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/09/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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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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Foreman PM, Ilyas A, Cress MC, Vachhani JA, Hirschl RA, Agee B, Griessenauer CJ. Ruptured Intracranial Aneurysms Treated with the Pipeline Embolization Device: A Systematic Review and Pooled Analysis of Individual Patient Data. AJNR Am J Neuroradiol 2021; 42:720-725. [PMID: 33602746 DOI: 10.3174/ajnr.a7002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The Pipeline Embolization Device (PED) is a flow-diverting stent for the treatment of intracranial aneurysms and is used off-label for a subset of ruptured aneurysms not amenable to traditional treatment. PURPOSE Our aim was to evaluate the safety and efficacy of the PED for treatment of ruptured intracranial aneurysms. DATA SOURCES A systematic review of the MEDLINE, EMBASE, and Scopus data bases from January 2011 to March 2020 was performed for articles reporting treatment of ruptured intracranial aneurysms with the PED. STUDY SELECTION A total of 12 studies comprising 145 patients with 145 treated aneurysms were included for analysis. DATA ANALYSIS Individual patient data were collected. Nonparametric tests were used to compare differences among patients. Logistic regression was used to determine an association with outcome variables. DATA SYNTHESIS Mean aneurysm size was 5.9 mm, and most were blister (51.0%) or dissecting (26.9%) in morphology. Three (2.1%) aneurysms reruptured following PED placement. Univariate logistic regression identified larger aneurysm size as a significant predictor of aneurysm rerupture (P = .008). Of patients with radiographic follow-up, 87.5% had complete aneurysm occlusion. Symptomatic neurologic complications occurred in 16.5%. LIMITATIONS Analysis was limited by the quality of the included data, most of which were from small case series representing class III medical evidence. No study assessed outcome in a blinded or independently adjudicated manner. CONCLUSIONS Most ruptured aneurysms treated with the PED were blister or dissecting aneurysms. Treatment was associated with a rerupture rate of 2.1% and a complete occlusion rate of 87.5%.
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Affiliation(s)
- P M Foreman
- From the Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., J.A.V., R.A.H.), Orlando Health, Orlando, Florida
| | - A Ilyas
- Department of Neurosurgery (A.I., B.A.), University of Alabama at Birmingham, Birmingham, Alabama
| | - M C Cress
- From the Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., J.A.V., R.A.H.), Orlando Health, Orlando, Florida
| | - J A Vachhani
- From the Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., J.A.V., R.A.H.), Orlando Health, Orlando, Florida
| | - R A Hirschl
- From the Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., J.A.V., R.A.H.), Orlando Health, Orlando, Florida
| | - B Agee
- Department of Neurosurgery (A.I., B.A.), University of Alabama at Birmingham, Birmingham, Alabama
| | - C J Griessenauer
- Department of Neurosurgery (C.J.G.), Geisinger Health System, Danville, Pennsylvania
- Research Institute of Neurointervention (C.J.G.), Paracelsus Medical University, Salzburg, Austria
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Aboukais R, Tétard MC, Devalckeneer A, Boussemart P, Bourgeois P, Bricout N, Verbraeken B, Menovsky T, Leclerc X, Lejeune JP. Ruptured blood blister like aneurysm: does the best therapeutic option really exist? Neurosurg Rev 2021; 44:2767-2775. [PMID: 33411092 DOI: 10.1007/s10143-020-01463-4] [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: 10/12/2020] [Revised: 12/07/2020] [Accepted: 12/14/2020] [Indexed: 10/22/2022]
Abstract
Our study aimed to evaluate the outcome of patients with ruptured blood-blister like aneurysm (BBLA) in our institution by comparing microsurgical selective treatment to endovascular treatment using flow-diverter stent (FD). Our study included 18 consecutive patients treated for BBLA between 2004 and 2020. Until 2014, microsurgery was preferred in all patients with BBLA (n = 10). Significant postoperative morbi-mortality was recorded at this time and led us to change therapeutic strategy and to favor FD as first-line treatment in all patients (n = 8). Postprocedural complications and BBLA occlusion were recorded. High WFNS score (> 2) was noted in 6 patients of microsurgical group and in 2 of endovascular group. In microsurgical group, ischemic lesions were noted in 6 patients and led to death in 3 patients. Immediate BBLA occlusion was obtained in all patients. Favorable outcome after 3 months (mRS < 3) was recorded in 4 of the 7 survivors. In endovascular group, ischemic lesions were noted in 4 patients. One patient died from early postprocedural BBLA rebleeding. Scarpa hematoma was noted in 3 patients with surgical evacuation in 1. Persistent BBLA at 3 months was recorded in 4 patients without rebleeding, but further FD was required in 1 with growing BBLA. Favorable outcome was noted in 6 of the 7 survivors. Although, rate of morbi-mortality appear lower in patients treated with FD, neurological presentation was better and BBLA diagnosis remains questionable in this group. Moreover, persistent BBLA imaging with potential risk of rebleeding after FD deserves to be discussed.
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Affiliation(s)
- Rabih Aboukais
- Department of Neurosurgery, Lille University Hospital, rue E. Laine, 59037, Lille cedex, France.
| | - Marie Charlotte Tétard
- Department of Neurosurgery, Saint-Etienne University Hospital, Saint-Priest-en-Jarez, France
| | - Antoine Devalckeneer
- Department of Neurosurgery, Lille University Hospital, rue E. Laine, 59037, Lille cedex, France
| | - Pierre Boussemart
- Neurosurgical Intensive Care Department, Lille University Hospital, Lille, France
| | - Philippe Bourgeois
- Department of Neurosurgery, Lille University Hospital, rue E. Laine, 59037, Lille cedex, France
| | - Nicolas Bricout
- Department of Neuroradiology, Lille University Hospital, Lille, France
| | - Barbara Verbraeken
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
| | - Tomas Menovsky
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
| | - Xavier Leclerc
- Department of Neuroradiology, Lille University Hospital, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, Lille University Hospital, rue E. Laine, 59037, Lille cedex, France
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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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Möhlenbruch MA, Seker F, Özlük E, Kizilkilic O, Broussalis E, Killer-Oberpfalzer M, Griessenauer CJ, Bendszus M, Kocer N. Treatment of Ruptured Blister-Like Aneurysms with the FRED Flow Diverter: A Multicenter Experience. AJNR. AMERICAN JOURNAL OF NEURORADIOLOGY 2020; 41:2280-2284. [PMID: 33122212 DOI: 10.3174/ajnr.a6849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/05/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Treatment of ruptured blister-like aneurysms is technically challenging. This study aimed at analyzing the safety and efficacy of the Flow-Redirection Endoluminal Device (FRED) in the treatment of ruptured blister-like aneurysms. MATERIALS AND METHODS In a retrospective multicenter study, all patients treated with the FRED due to a ruptured intracranial blister-like aneurysm between January 2013 and May 2019 were analyzed. The primary end points for clinical safety were mRS 0-2 at 6 months after treatment and the absence of major ipsilateral stroke or death. The primary end points for efficacy were the absence of rebleeding after treatment and complete angiographic occlusion according to the O'Kelly-Marotta classification at 6 months after treatment. RESULTS In total, 30 patients with 30 ruptured blister-like aneurysms were treated. Immediate complete aneurysm obliteration (O'Kelly-Marotta classification D) with the FRED was achieved in 10 patients (33%). Of the 26 patients with follow-up, complete obliteration was achieved in 21 patients (80%) after 6 months and in 24 patients (92%) in the final follow-up (median, 22 months). Twenty-three patients (77%) achieved mRS 0-2 at 6 months. Major stroke or death occurred in 17%. Two patients died due to pneumonia, and 2 patients died due to infarction following cerebral vasospasm. There was no case of rebleeding after FRED implantation. There was 1 case of delayed asymptomatic stent occlusion. CONCLUSIONS Treatment of ruptured blister-like aneurysms with the FRED is safe and effective.
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Affiliation(s)
- M A Möhlenbruch
- From the Department of Neuroradiology (M.A.M., F.S., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - F Seker
- From the Department of Neuroradiology (M.A.M., F.S., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - E Özlük
- Department of Radiology (E.Ö.), Acibadem University Atakent International Hospital, Istanbul, Turkey
| | - O Kizilkilic
- Division of Neuroradiology (O.K., N.K.), Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - E Broussalis
- Research Institute of Neurointervention (E.B., M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria
| | - M Killer-Oberpfalzer
- Research Institute of Neurointervention (E.B., M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria
| | - C J Griessenauer
- Research Institute of Neurointervention (E.B., M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria
| | - M Bendszus
- From the Department of Neuroradiology (M.A.M., F.S., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - N Kocer
- Division of Neuroradiology (O.K., N.K.), Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Incandela F, Craparo G, Abrignani S, Tessitore A, Pitrone A, Caranci F, Arrichiello A, Paolucci A. Flow diverting devices in acute ruptured blood blister aneurysms: a three centric retrospective study. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020011. [PMID: 33245069 PMCID: PMC8023071 DOI: 10.23750/abm.v91i10-s.10261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/07/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Blood blister aneurysms (BBAs) are a rare tiny subset of intracranial aneurysms, located at the nonbranching site of an artery, representing a therapeutic challenge from both surgical and endovascular approach. Flow-diverting efficacy, by preserving flow through the parent artery, was approved for its use in unruptured cerebral aneurysms, but no consensus was reached on its use for BBAs ruptured in the acute setting. We report a multicenter experience of use of flow diversion in acute setting of ruptured BBA, to analyze the safety and efficacy of these devices. METHODS We performed a retrospective study of 6 consecutive intracranial BBAs treated with flow diverter devices (FDD) between 2018 and 2020 at 3 italian institutions. Materials, therapy used, complications, clinical and radiographic outcomes were reviewed. RESULTS We used different FDD, in all cases immediate change in contrast opacification at the end of the procedure was reported. Intraprocedural IIb/IIIa inhibitor agent was the major antiplatelet protocol administered. Any complications occurred. All patients showed complete BBA obliteration at 3 months follow-up. 5/6 patients achieved good clinical outcome (0-2 mRS) at 3 months, all of which were presented with low grade SAH (Hunt Hess I-III) and a lower Fisher grade. CONCLUSION Our data support this endovascular technique as a safe and effective therapeutic modality for this pathology in the acute setting.
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Affiliation(s)
- Francesca Incandela
- 1. Section of Radiological Sciences, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy.
| | - Giuseppe Craparo
- Neuroradiology Unity of diagnostic and intervention, A.R.N.A.S. Civico-Di Cristina-Benfratelli, Palermo, Italy.
| | - Sergio Abrignani
- Department of Diagnostic Radiology and Radiotherapy, Federico II University of Naples, Naples, Italy.
| | | | - Antonio Pitrone
- Neuroradiology Unit, A.O.U. Policlinico "G.Martino" - Messina, Italy .
| | - Ferdinando Caranci
- Department of Diagnostic Radiology and Radiotherapy, Federico II University of Naples, Naples, Italy.
| | - Antonio Arrichiello
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan.
| | - Aldo Paolucci
- Operative Unit of Neuroradiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy.
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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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Kan P, Sweid A, Srivatsan A, Jabbour P. Expanding Indications for Flow Diverters: Ruptured Aneurysms, Blister Aneurysms, and Dissecting Aneurysms. Neurosurgery 2019; 86:S96-S103. [DOI: 10.1093/neuros/nyz304] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/26/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
The safety and efficacy of flow diversion (FD) in the treatment of cerebral aneurysms have been reported by many studies. FD has enabled the treatment of complex aneurysms and aneurysms that were previously untreatable by conventional means. It has achieved high rates of obliteration with essentially no recanalization, and its indications have continued to expand, now including ruptured aneurysms, blister aneurysms, and dissecting aneurysms.
OBJECTIVE
To provide a review on the outcomes of studies covering the use of FD in the settings of ruptured, blister, and dissecting aneurysms. In addition, to discuss dual antiplatelet therapy (DAPT) used in preparation for FD deployment in these scenarios, including associated complications with DAPT use in the acute rupture setting.
METHODS
References for this topical review were identified by PubMed searches between January 2000 and January 2019. The search terms “aneurysm”, “flow diverter”, “stent”, “pipeline”, “ruptured”, “blister”, and “dissecting aneurysms” were used.
RESULTS
FD carries a higher complication rate in the acute rupture setting than for unruptured aneurysms. Patient selection is of paramount importance for achieving good functional and angiographic outcomes. DAPT still remains challenging, especially in ruptured aneurysms. Advancements in surface modification of flow diverters can reduce the risk of thromboembolism and perhaps lead to a safer antiplatelet regimen.
CONCLUSION
In summary, FD shows promise to be an effective treatment for ruptured, blister, and dissecting aneurysms.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Aditya Srivatsan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Flow diverter embolization device for endovascular treatment of ruptured blister and wide necked very small aneurysms. Heliyon 2019; 5:e02241. [PMID: 31687529 PMCID: PMC6819851 DOI: 10.1016/j.heliyon.2019.e02241] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/03/2019] [Accepted: 08/02/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose Ruptured blood blisters (BBA) and very small, wide necked aneurysms (VSA) remain challenging lesions to treat due to their small size, wide necks, and thin, fragile walls. In the present study, we reviewed our experience with these aneurysms treated by flow diversion. Methods A total of 18 patients with hemorrhage due to a ruptured BBAs and VSAs, treated with flow diversion between July 2014 and March 2016 were included in this study. We analyzed clinical and radiographic outcomes. Results A total of 12 (66.7%) VSAs and 6 (33.3%) BBAs were treated with flow diversion. Fifteen (83.3%) and three (16.7%) aneurysms were located on the internal carotid artery and the basilar artery, respectively. On admission, a GCS score of 15 and WFNS grade 1 were found in 14 (77.7%) patients, 3 patients had an admission GCS of 13 and WFNS grade 2, one had an admission GCS of 8 and WFNS of 4. Fisher CT grades 2, 3, and 4 were observed in 11 (61.1%), 1 (5.6%), and 6 (33.3%) patients, respectively. Flow diversion was performed on average 5.6 days after onset of hemorrhage. 6 months post-intervention angiography showed complete obliteration of the aneurysms in all patients. Conclusion Our findings indicate that flow diversion in the acute and subacute phase of hemorrhage is a reliable treatment for reducing complications in patients with BBAs and VSAs. In patients with poor clinical presentation it might be reasonable to delay treatment until the first signs of recovery become apparent.
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Podlasek A, Al Sultan AA, Assis Z, Kashani N, Goyal M, Almekhlafi MA. Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis. J Neurointerv Surg 2019; 12:148-155. [DOI: 10.1136/neurintsurg-2019-014996] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/30/2019] [Accepted: 06/02/2019] [Indexed: 01/15/2023]
Abstract
BackgroundThromboembolic complications are not uncommon in patients undergoing neurointerventional procedures. The use of flow diverting stents is associated with higher risks of these complications despite current dual antiplatelet regimens.ObjectiveTo explore contemporary evidence on the safety of emerging dual antiplatelet regimens in flow diverting stenting procedures.MethodsWe performed a systematic review and meta-analysis to identify relevant articles in electronic databases, and relevant references. Studies reporting the complications and mortality of flow diverting stenting procedures using acetyl salicylic acid (ASA) + ticagrelor or ASA + prasugrel compared with ASA + clopidogrel were included.ResultsOf 452 potentially relevant studies, we identified 49 studies (2526 patients) which reported the safety of ticagrelor or prasugrel for pooled analysis, and five studies (1005 patients) for meta-analysis. The pooled overall mortality in all studies was 2.14%, ischemic complications 6.89%, and hemorrhagic complications 3.68%. The use of ticagrelor or prasugrel was associated with a lower risk of mortality compared with clopidogrel (RR=4.57, 95% CI 1.23 to 16.99; p=0.02). Considering ischemic events, ASA + clopidogrel was as safe as ASA + prasugrel (RR=0.55, 95% CI 0.11 to 2.74; p=0.47) and ASA + ticagrelor (RR=0.74, 95% CI 0.32 to 1.74; p=0.49). ASA +ticagrelor was not associated with a higher risk of hemorrhagic complications (RR=0.92, 95% CI 0.27 to 3.16; p=0.89).ConclusionsEvidence suggests that dual antiplatelet regimens including ticagrelor or prasugrel are safe for patients undergoing flow diversion procedures. Regimens using ticagrelor were associated with better survival than those using clopidogrel in the included studies.
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Blister aneurysms of the internal carotid artery: Surgical treatment and management outcome from a single center experience. Clin Neurol Neurosurg 2019; 182:136-141. [PMID: 31121473 DOI: 10.1016/j.clineuro.2019.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/15/2019] [Accepted: 05/09/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) are rare entities, but clinically important cause of subarachnoid hemorrhage (SAH). Several surgical and endovascular strategies have been attempted for these heterogeneous lesions. In this study, the authors analyzed the treatment strategy and outcomes in a series of cases of ICA blister aneurysms treated microsurgically. PATIENTS AND METHODS We retrospectively reviewed 15 consecutive cases of patients harboring ruptured BBAs, microsurgically treated at our institution between 2014 and 2018. We performed an analysis of the clinical and surgical aspects, as well as post-operative angiograms and outcomes. RESULTS Fifteen patients were identified; 9 (60%) were female. The mean age of presentation was 43,8 years. Most patients presented in good clinical conditions (Hunt-Hess 1-3 = 86%). The most common Fisher grade at presentation was 3 (60% of cases). All patients underwent digital subtraction angiography (DSA), revealing broad-based aneurysms at non-branching sites on the dorsal wall of the ICA. Intraoperatively, BBAs were confirmed in all cases. The lesions were approached through pterional (11-73%) or lateral supraorbital (4-27%) craniotomy. Direct clipping was performed in all but one lesion, in which case the clip-wrapping technique was used. Final angiographic control revealed complete occlusion in 14 cases. One patient required reoperation due to residual aneurysm filling. At discharge, a good outcome (Glasgow Outcome Scale [GOS] 4 or 5) was observed in 12 (80%) patients. Three patients were discharged with a GOS of 3. CONCLUSION Blood-blister-type aneurysms are rare and challenging lesions. Preoperative knowledge and careful surgical planning can prevent poor clinical outcomes. Surgical treatment remains an effective and safe option in this context.
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Liu J, Gao G, Zhang S, Huang Y, Wu J, Hu X, Lu J, Zhang Q, Zhou L, Huang Y. Cotton-Assisted Surgical Clipping of Very Small Aneurysms: A Two-Center Study. World Neurosurg 2019; 127:e242-e250. [PMID: 30885863 DOI: 10.1016/j.wneu.2019.02.227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/24/2019] [Accepted: 02/25/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Very small intracranial aneurysms (VSIAs) are challenging to treat because aneurysm tearing and clip slippage can occur during neurosurgical clipping. In this study, we introduce and share our experience with cotton-assisted clipping of VSIAs. METHODS We retrospectively analyzed the data of 20 patients with 24 VSIAs treated with cotton-assisted clipping between February 2008 and December 2014 in the Neurosurgery Departments of the First Affiliated Hospital, Soochow University and Taizhou People's Hospital. During surgery, 2 aneurysm necks were torn. To treat the tears, we wrapped rectangular cotton pads around the parental arteries at the site of rupture. The remaining 22 aneurysms were clipped after being wrapped in cotton pads. RESULTS The 2 aneurysm ruptures were successfully repaired with cotton-assisted clipping. In the remaining 22 aneurysms, no cases of aneurysm clip slippage or aneurysm rupture occurred. Patients were followed up on average for 59.0 months (range, 30-113 months). Of the 20 patients, the 16 patients with preoperative Hunt-Hess grades of 1-3 recovered well after the surgery (Glasgow Outcome Scale [GOS] score, 5). Of the 4 patients with Hunt-Hess grades of 4-5, 3 had a good recovery (GOS scores, 4-5), and 1 patient died of heart disease 6 months after being discharged from the hospital; this patient had a GOS score of 4 at the time of discharge. CONCLUSIONS Cotton-assisted clipping could prevent aneurysm clip slipping and aneurysm rupture and facilitate the repair of aneurysm neck tears. This technique is a useful alternative therapy for VSIAs.
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Affiliation(s)
- Jiangang Liu
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Guangzhong Gao
- Department of Neurosurgery, Taizhou People's Hospital, Taizhou, Jiangsu Province, China
| | - Shiming Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
| | - Yabo Huang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jiang Wu
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xiaohui Hu
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jun Lu
- Department of Neurosurgery, Taizhou People's Hospital, Taizhou, Jiangsu Province, China
| | - Qin Zhang
- Department of Neurosurgery, Taizhou People's Hospital, Taizhou, Jiangsu Province, China
| | - Lei Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Yulun Huang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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Zhu Y, Zhang H, Zhang Y, Wu H, Wei L, Zhou G, Zhang Y, Deng L, Cheng Y, Li M, Santos HA, Cui W. Endovascular Metal Devices for the Treatment of Cerebrovascular Diseases. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2019; 31:e1805452. [PMID: 30589125 DOI: 10.1002/adma.201805452] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/20/2018] [Indexed: 06/09/2023]
Abstract
Cerebrovascular disease involves various medical disorders that obstruct brain blood vessels or deteriorate cerebral circulation, resulting in ischemic or hemorrhagic stroke. Nowadays, platinum coils with or without biological modification have become routine embolization devices to reduce the risk of cerebral aneurysm bleeding. Additionally, many intracranial stents, flow diverters, and stent retrievers have been invented with uniquely designed structures. To accelerate the translation of these devices into clinical usage, an in-depth understanding of the mechanical and material performance of these metal-based devices is critical. However, considering the more distal location and tortuous anatomic characteristics of cerebral arteries, present devices still risk failing to arrive at target lesions. Consequently, more flexible endovascular devices and novel designs are under urgent demand to overcome the deficiencies of existing devices. Herein, the pros and cons of the current structural designs are discussed when these devices are applied to the treatment of diseases ranging broadly from hemorrhages to ischemic strokes, in order to encourage further development of such kind of devices and investigation of their use in the clinic. Moreover, novel biodegradable materials and drug elution techniques, and the design, safety, and efficacy of personalized devices for further clinical applications in cerebral vasculature are discussed.
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Affiliation(s)
- Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Hongbo Zhang
- Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, P. R. China
- Department of Pharmaceutical Sciences Laboratory, Åbo Akademi University, Turku, FI-20520, Finland
- Turku Center for Biotechnology, University of Turku and Åbo Akademi University, Turku, FI-20520, Finland
| | - Yiran Zhang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Huayin Wu
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, 02138, USA
| | - Liming Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Gen Zhou
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Yuezhou Zhang
- Department of Pharmaceutical Sciences Laboratory, Åbo Akademi University, Turku, FI-20520, Finland
- Turku Center for Biotechnology, University of Turku and Åbo Akademi University, Turku, FI-20520, Finland
| | - Lianfu Deng
- Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, P. R. China
| | - Yingsheng Cheng
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Minghua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Hélder A Santos
- Drug Research Program, Division of Pharmaceutical Chemistry and Technology, Faculty of Pharmacy, University of Helsinki, FI-00014, Helsinki, Finland
- Helsinki Institute of Life Science, University of Helsinki, FI-00014, Helsinki, Finland
| | - Wenguo Cui
- Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, P. R. China
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Sorimachi T, Osada T, Hirayama A, Shigematsu H, Srivatanakul K, Matsumae M. Preservation of Anterior Choroidal Artery Blood Flow During Trapping of the Internal Carotid Artery for a Ruptured Blood Blister-Like Aneurysm with High-Flow Bypass. World Neurosurg 2019; 122:e847-e855. [DOI: 10.1016/j.wneu.2018.10.162] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 10/27/2022]
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Delayed Treatment (≥5 Days) by Flow Diversion of Ruptured Blister-Like Cerebral Aneurysms. Clin Neuroradiol 2019; 30:287-296. [DOI: 10.1007/s00062-019-00758-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/08/2019] [Indexed: 11/26/2022]
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Clipping on Crossed Wrapping Method for Ruptured Blood Blister-Like Aneurysm of the Internal Carotid Artery: Technical Note and Long-Term Results. World Neurosurg X 2019; 2:100005. [PMID: 31218280 PMCID: PMC6580898 DOI: 10.1016/j.wnsx.2018.100005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/13/2018] [Indexed: 12/13/2022] Open
Abstract
Background We have been performing the clipping on crossed wrapping (COCW) method using 2 strips of cotton on patients with an internal carotid artery blood blister-like aneurysm (IC-BLA). This method is reliable in preventing the clips from slipping off and the aneurysm walls from being damaged during clipping, and it enables more appropriate and safer clipping. Here we report the technical details of this method and the long-term outcomes of patients receiving this procedure. Methods Fifteen of 1275 (1.5%) patients with a ruptured cerebral aneurysm who received treatment at the Saiseikai Kumamoto Hospital during the period from January 1, 1999, to December 31, 2016, had an IC-BLA. All 15 patients were treated with COCW, except for the first patient, who was treated using a single strip of cotton. The long-term outcome of the treatment was analyzed. Results The mean follow-up period was 74 months. The first patient experienced rerupture of an aneurysm 10 days after the operation. No complications or regrowth of an aneurysm were observed in the remaining 14 patients during the follow-up period, except for 1 patient who received a reoperation for the regrowth of an aneurysm. As the final outcome, the numbers of patients with a Modified Rankin Score of 0, 3, and 6 were 13, 1, and 1, respectively. Conclusions It is suggested that COCW is a treatment that enables safe and long-term management of lesions in IC-BLAs.
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Key Words
- 3D-CTA, Three-dimensional computed tomographic angiography
- AchA, Anterior choroidal artery
- BBA, Blood blister-like aneurysm
- Blood blister-like aneurysm
- COCW, Clipping on crossed wrapping
- COW, Clipping on wrapping
- CT, Computed tomography
- Clipping on crossed wrapping
- Clipping on wrapping
- Direct surgery
- IC, Internal carotid
- IC-BBAs, BBAs of the ICA
- ICA, Internal carotid artery
- Internal carotid artery aneurysm
- PcomA, Posterior communicating artery
- SAH, Subarachnoid hemorrhage
- mRS, Modified Rankin Scale
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Aguilar-Salinas P, Agnoletto GJ, Brasiliense LBC, Santos R, Granja MF, Gonsales D, Aghaebrahim A, Sauvageau E, Hanel RA. Safety and efficacy of cangrelor in acute stenting for the treatment of cerebrovascular pathology: preliminary experience in a single-center pilot study. J Neurointerv Surg 2018; 11:347-351. [PMID: 30552167 DOI: 10.1136/neurintsurg-2018-014396] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/16/2018] [Accepted: 10/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Treatment of acute cerebrovascular pathology, such as acute ischemic stroke or intracranial aneurysms, presents a challenge if an extracranial or intracranial stent is required; immediate platelet inhibition is vital. To date, there is no standardized approach for antiplatelet inhibition in an acute setting. OBJECTIVE To report our preliminary experience and lessons learnt using cangrelor in acute neurointervention. METHODS A single-arm pilot study was performed to assess the safety and efficacy of cangrelor plus aspirin for platelet inhibition in patients who require acute stenting in the setting of neuroendovascular treatment. RESULTS Eight patients were enrolled between October 2017 and August 2018. Median age was 71 years (53-86). Seven patients were treated in an acute setting according to the stroke protocol at our institution, while one patient was treated for a symptomatic, unruptured aneurysm with flow diversion and coiling. At admission, the median National Institutes of Health Stroke Scale score for the patients with stroke was 12.5 (range 2-22.3). Cangrelor was infused and all patients achieved adequate platelet inhibition (<200 PRU (P2Y12 reaction units)). Six of seven patients with ischemic stroke had a carotid stent placed and one had an intracranial stent deployed in the middle cerebral artery. None of the patients experienced intraprocedural thromboembolic complications, intraprocedural in-stent thrombosis, hemorrhagic complications, or stroke within 24 hours after the intervention. The majority of patients (6/8) had a good clinical outcome at discharge (modified Rankin Scale score 0-2). CONCLUSIONS Our findings suggest that cangrelor is a promising alternative in acute stenting for the treatment of cerebrovascular pathology. However, further studies with larger samples are required to accurately elucidate its safety and effectiveness in neuroendovascular procedures.
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Affiliation(s)
- Pedro Aguilar-Salinas
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA.,Division of Neurosurgery, University of Arizona, Tucson, Arizona, USA
| | | | | | - Roberta Santos
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA
| | - Manuel F Granja
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA
| | - Douglas Gonsales
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA
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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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Bhogal P, Henkes E, Schob S, AlMatter M, Hellstern V, Bäzner H, Ganslandt O, Henkes H, Pérez MA. The use of flow diverters to treat small (≤5 mm) ruptured, saccular aneurysms. Surg Neurol Int 2018; 9:216. [PMID: 30505618 PMCID: PMC6219287 DOI: 10.4103/sni.sni_243_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 08/30/2018] [Indexed: 11/08/2022] Open
Abstract
Background: There is limited published literature on the use of flow diverting stents (FDS) to treat ruptured intracranial aneurysms in the acute stage. We present our experience of using FDS to treat small (≤5 mm) ruptured aneurysms. Methods: We retrospectively identified all patients with ≤5 mm ruptured aneurysms treated exclusively with FDS between February 2009 and February 2016. We recorded demographic data, the Hunt and Hess score, aneurysm location and size, therapeutic intervention, immediate angiographic and clinical result, and clinical and radiological follow-up information. Results: We identified seven patients (four females) with average age 59.8 ± 10 years (range 48–75). The average aneurysm fundus size was 2.7 ± 0.76 mm (range 1–4 mm). The average time from ictus to treatment was 6.3 days (range 1–14 days) and there were no cases of repeat rupture prior to treatment or intraoperative rupture. Angiographic follow-up was available in five patients. At initial follow-up, aneurysms (100%) were completely occluded raymond roy classification 1 (RRC 1). None of the aneurysms re-ruptured following treatment. Clinically, six patients were discharged with good functional outcome modified Rankin Score (mRS ≤2). There were no mortalities. Conclusion: The use of FDS to treat small, ruptured, saccular aneurysms is feasible; however, the use of FDS should not be considered first-line treatment. Further studies are required to determine the safety and efficacy of the use of FDS in the acute situation.
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Affiliation(s)
- Pervinder Bhogal
- Department of Neuroradiology, The Royal London Hospital, London, UK
| | - Elina Henkes
- Neuroradiological Clinic, Neurocenter, Leipzig, Germany
| | - Stefan Schob
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | | | | | | | - Oliver Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Leipzig, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Leipzig, Germany.,Medical Faculty, University Duisburg-Essen, Duisburg, Germany
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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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Mahajan A, Das B, Narang KS, Jha AN, Singh VP, Sapra H, Goel G. Surpass Flow Diverter in the Treatment of Ruptured Intracranial Aneurysms-A Single-Center Experience. World Neurosurg 2018; 120:e1061-e1070. [PMID: 30213677 DOI: 10.1016/j.wneu.2018.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/30/2018] [Accepted: 09/02/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Use of a Surpass flow diverter (FD) device in the treatment of acutely ruptured aneurysm has not been well studied and reported in the literature. METHODS We retrospectively reviewed patients with subarachnoid hemorrhage who were treated by Surpass FD placement at our hospital between June 2016 and March 2018. Detailed analysis of medical records was performed to obtain patient age, gender, clinical history, Hunt and Hess grade, Fisher grade, results of radiographic and procedural details including technical success and complication, clinical outcome, and follow-up angiographic results. RESULTS Our search identified 16 patients with 16 aneurysms who were treated with Surpass FD, of which 13 aneurysms (81%) were in the anterior circulation and 3 (19%) were in the posterior circulation. Aneurysm size ranged from 1.1 to 16 mm, with a mean of 4 mm. The mean delay between subarachnoid hemorrhage and endovascular treatment was 5 days (range, 3-20 days). Only 1 Surpass FD was used in each patient, ranging in size from 3 × 25 mm to 4 × 50 mm. Fifteen patients (94%) achieved favorable clinical outcome (modified Rankin Scale score 0-1) at 3 months. One patient died of invasive fungal infection. Angiographic follow-up results were assessed by O'Kelly-Marotta grading scale in 15 surviving patients and showed a grade D result (no filling) in 13/15 aneurysms (87%) at 3 and 6 months. CONCLUSIONS A Surpass FD device is a feasible option for the treatment of ruptured intracranial aneurysms that are difficult to treat by conventional clipping and coiling; however, larger and comparative studies with long-term follow-up are needed to confirm its safety and efficacy.
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Affiliation(s)
- Anshu Mahajan
- Department of Neurointerventional surgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Biplab Das
- Department of Neurointerventional surgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Karanjit Singh Narang
- Department of Neurosurgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Ajaya Nand Jha
- Department of Neurosurgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Varindera Paul Singh
- Department of Neurosurgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Harsh Sapra
- Department of Neuroanaesthesia and Critical Care, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Gaurav Goel
- Department of Neurointerventional surgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India.
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Extracranial-Intracranial Bypass for Treatment of Blister Aneurysms: Efficacy and Analysis of Complications Compared with Alternative Treatment Strategies. World Neurosurg 2018; 117:e417-e424. [DOI: 10.1016/j.wneu.2018.06.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 06/05/2018] [Accepted: 06/06/2018] [Indexed: 11/24/2022]
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34
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Beydoun HA, Azarbaijani Y, Cheng H, Anderson-Smits C, Marinac-Dabic D. Predicting Successful Treatment of Intracranial Aneurysms with the Pipeline Embolization Device Through Meta-Regression. World Neurosurg 2018; 114:e938-e958. [DOI: 10.1016/j.wneu.2018.03.120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/17/2018] [Accepted: 03/17/2018] [Indexed: 10/17/2022]
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35
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Walcott BP, Koch MJ, Stapleton CJ, Patel AB. Blood Flow Diversion as a Primary Treatment Method for Ruptured Brain Aneurysms-Concerns, Controversy, and Future Directions. Neurocrit Care 2018; 26:465-473. [PMID: 27844465 DOI: 10.1007/s12028-016-0318-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Flow diversion is a novel treatment for brain aneurysms that works by redirecting blood flow away from the aneurysm. Immediately after placement of the stent, blood flow stagnates within the aneurysm dome and it undergoes thrombosis. Over time, a new endothelium develops across the neck, thereby reconstructing the parent vessel and curing the aneurysm. The use of this treatment method for ruptured aneurysms has two specific concerns: 1) risk of hemorrhage from the aneurysm after treatment because of potential delayed aneurysm occlusion; and 2) hemorrhagic complications from antiplatelet use, which is required to prevent thromboembolic complications from the device. In this review, we explore these two concerns based on the emerging published literature. Optimal peri-procedural management of these issues in the neurocritical care setting is vital to improving outcomes. We also identify ongoing clinical trials of flow diversion for the treatment of ruptured aneurysms. Flow diversion is an alternative to clipping or coiling for many ruptured aneurysms and may be potentially more efficacious in certain aneurysm subtypes.
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Affiliation(s)
- Brian P Walcott
- Department of Neurological Surgery, University of Southern California, USC Healthcare Center II, 1520 San Pablo St #3800, Los Angeles, CA, 90033, USA.
| | - Matthew J Koch
- Department of Neurological Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Christopher J Stapleton
- Department of Neurological Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Department of Neurological Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
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Parthasarathy R, Gupta V, Gupta A. Safety of Prasugrel loading in ruptured blister like aneurysm treated with a Pipeline device. Br J Radiol 2018; 91:20170476. [PMID: 29509490 DOI: 10.1259/bjr.20170476] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Blister like aneurysm (BLA) is extremely challenging to treat; endoluminal reconstruction has emerged as the most promising treatment method. When to treat after the ictus, the timing of administration of antiplatelet and causal relationship between platelet function testing results and thrombo-embolism is unclear. We theorized that Prasugrel with a lower incidence of resistance may be a safe suitable alternative to clopidogrel in patients treated with a flow diverter (FD). METHODS Prospectively collected data from consecutive patients treated for a ruptured blister with an FD was reviewed. Device deployment was timed to be at 2 h following Prasugrel loading. Thrombo-embolic and hemorrhagic complications, and occlusion rates were documented. RESULTS Nine patients were included. Most were females (55%); the median age was 55 (43, 65). The median Fischer grade was 3 (2, 4). A single pipeline device was deployed in all within 24 h of admission; the median time from ictus to device deployment was 4 days (2, 30). There were no thrombo-embolic or hemorrhagic complication. Complete occlusion was noted in 89% (n = 9). CONCLUSION Prasugrel loading timed 2 h prior to stent delivery did not increase thrombo-embolic or hemorrhagic complications. Single stent that is well apposed against the wall appears to be an effective treatment strategy to treat BLA. Advances in knowledge: Treatment of acutely ruptured BLA with a single pipeline device deployed at 2 h after Prasugrel loading appears to be safe.
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Affiliation(s)
- Rajsrinivas Parthasarathy
- 1 Department of Neurointerventional Surgery, Artemis Agrim Institute of Neuroscience , Haryana , India
| | - Vipul Gupta
- 1 Department of Neurointerventional Surgery, Artemis Agrim Institute of Neuroscience , Haryana , India
| | - Aditya Gupta
- 2 Department of Neurosurgery, Artemis Agrim Institute of Neuroscience , Haryana , India
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Mokin M, Chinea A, Primiani CT, Ren Z, Kan P, Srinivasan VM, Hanel R, Aguilar-Salinas P, Turk AS, Turner RD, Chaudry MI, Ringer AJ, Welch BG, Mendes Pereira V, Renieri L, Piano M, Elijovich L, Arthur AS, Cheema A, Lopes DK, Saied A, Baxter BW, Hawk H, Puri AS, Wakhloo AK, Shallwani H, Levy EI, Siddiqui AH, Dabus G, Linfante I. Treatment of blood blister aneurysms of the internal carotid artery with flow diversion. J Neurointerv Surg 2018; 10:1074-1078. [DOI: 10.1136/neurintsurg-2017-013701] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/07/2018] [Accepted: 02/08/2018] [Indexed: 11/03/2022]
Abstract
BackgroundBlood blister aneurysms (BBA) are a rare subset of intracranial aneurysms that represent a therapeutic challenge from both a surgical and endovascular perspective.ObjectiveTo report multicenter experience with flow diversion exclusively for BBA, located at non-branching segments along the anteromedial wall of the supraclinoidal internal carotid artery (ICA).MethodsConsecutive cases of BBA located at non-branching segments along the anteromedial wall of the supraclinoidal ICA treated with flow diversion were included in the final analysis.Results49 patients with 51 BBA of the ICA treated with devices to achieve the flow diversion effect were identified. 43 patients with 45 BBA of the ICA were treated with the pipeline embolization device and were included in the final analysis. Angiographic follow-up data were available for 30 patients (32 aneurysms in total); 87.5% of aneurysms (28/32) showed complete obliteration, 9.4% (3/32) showed reduced filling, and 3.1% (1/32) persistent filling. There was no difference between the size of aneurysm (≤2 mm vs >2 mm) or the use of adjunct coiling and complete occlusion of the aneurysm on follow-up (P=0.354 and P=0.865, respectively). Clinical follow-up data were available for 38 of 43 patients. 68% of patients (26/38) had a good clinical outcome (modified Rankin scale score of 0–2) at 3 months. There were 7 (16%) immediate procedural and 2 (5%) delayed complications, with 1 case of fatal delayed re-rupture after the initial treatment.ConclusionsOur data support the use of a flow diversion technique as a safe and effective therapeutic modality for BBA of the supraclinoid ICA.
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Fang YB, Lin A, Kostynskyy A, Agid R, Tymianski M, Radovanovic I, Krings T, Pereira VM. Endovascular treatment of intracranial vertebrobasilar artery dissecting aneurysms: Parent artery occlusion versus flow diverter. Eur J Radiol 2018; 99:68-75. [DOI: 10.1016/j.ejrad.2017.12.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/06/2017] [Accepted: 12/13/2017] [Indexed: 11/15/2022]
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Endovascular Treatment of Ruptured Vertebrobasilar Dissecting Aneurysms Using Flow Diversion Embolization Devices: Single-Institution Experience. World Neurosurg 2018; 109:e164-e169. [DOI: 10.1016/j.wneu.2017.09.125] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 11/18/2022]
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Ren Y, Liu L, Sun H, Liu Y, Li H, Ma L, Zhang CW, Xie XD, He M, You C, Li J. Microsurgical versus Endovascular Treatments for Blood-Blister Aneurysms of the Internal Carotid Artery: A Retrospective Study of 83 Patients in a Single Center. World Neurosurg 2018; 109:e615-e624. [DOI: 10.1016/j.wneu.2017.10.048] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/06/2017] [Accepted: 10/09/2017] [Indexed: 01/02/2023]
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Nishikawa H, Shimizu S, Nakajima H, Kitano Y, Sano T, Mouri G, Miya F, Suzuki H. Characteristics of Blood Blister-Like Aneurysms with a Saccular-Shape Appearance. World Neurosurg 2017; 108:595-602. [DOI: 10.1016/j.wneu.2017.09.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/09/2017] [Indexed: 10/18/2022]
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Mazur MD, Taussky P, MacDonald JD, Park MS. Rerupture of a Blister Aneurysm After Treatment With a Single Flow-Diverting Stent. Neurosurgery 2017; 79:E634-E638. [PMID: 27759680 DOI: 10.1227/neu.0000000000001412] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE As the use of flow-diverting stents (FDSs) for intracranial aneurysms expands, a small number of case reports have described the successful treatment of blister aneurysms of the internal carotid artery with flow diversion. Blister aneurysms are uncommon and fragile lesions that historically have high rates of morbidity and mortality despite multiple treatment strategies. We report a case of rebleeding after treatment of a ruptured blister aneurysm with deployment of a single FDS. CLINICAL PRESENTATION A 29-year-old man presented with subarachnoid hemorrhage and a ruptured dorsal variant internal carotid artery aneurysm. Despite a technically successful treatment with a single FDS, a second catastrophic hemorrhage occurred during the course of his hospitalization. CONCLUSION This case highlights the risk of hemorrhage during the period after deployment of a single FDS. Ruptured aneurysms, especially of the blister type, are at risk for rehemorrhage while the occlusion remains incomplete after flow diversion. ABBREVIATIONS FDS, flow-diverting stentICA, internal carotid arterySAH, subarachnoid hemorrhage.
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Affiliation(s)
- Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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Flow diverter treatment of cerebral blister aneurysms. Neuroradiology 2017; 59:1285-1290. [DOI: 10.1007/s00234-017-1936-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 10/09/2017] [Indexed: 11/26/2022]
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Delgado Almandoz JE, Kayan Y, Tenreiro A, Wallace AN, Scholz JM, Fease JL, Milner AM, Mulder M, Uittenbogaard KM, Tenreiro-Picón O. Clinical and angiographic outcomes in patients with intracranial aneurysms treated with the pipeline embolization device: intra-procedural technical difficulties, major morbidity, and neurological mortality decrease significantly with increased operator experience in device deployment and patient management. Neuroradiology 2017; 59:1291-1299. [PMID: 28986614 DOI: 10.1007/s00234-017-1930-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/19/2017] [Indexed: 12/31/2022]
Abstract
PURPOSE Flow diversion constitutes a pivotal advancement in endovascular intracranial aneurysm treatment, but requires development of a new skill set. The aim of this study is to determine whether outcomes after treatment with the Pipeline Embolization Device improve with experience. METHODS We retrospectively reviewed all patients with intracranial aneurysms treated with Pipeline at two centers over a 4.5-year period. Baseline patient and aneurysm characteristics, complications, and angiographic outcomes were analyzed. RESULTS One hundred forty patients underwent 150 Pipeline procedures to treat 167 intracranial aneurysms during the study period, 109 women, mean age 55.4 years. One hundred twenty-six aneurysms were ICA, mean size 10.2 mm and mean neck 6.4 mm. Intra-procedural technical difficulties were higher during the first 75 procedures compared with the subsequent 75 (13.3 vs 2.7%; p = 0.03), as combined major morbidity and neurological mortality (14.7 vs 4%; p = 0.046). In multivariate regression analysis, increased operator experience with Pipeline remained an independent predictor of intra-procedural technical difficulties (p = 0.02, odds ratio (OR) 0.015, 95% CI 0.0004-0.55) and combined major morbidity and neurological mortality (p = 0.03, OR 0.16, 95% CI 0.03-0.84). At last follow-up, 123 aneurysms were completely occluded (81.5%, mean 24 months). In our cohort, age ≤ 53 years was an independent predictor of complete aneurysm occlusion at last follow-up (p = 0.001, OR 0.92, 95% CI 0.88-0.97). Five aneurysms were retreated (3.3%). CONCLUSION The Pipeline embolization device is an effective treatment for intracranial aneurysms. The risk of intra-procedural technical difficulties and combined major morbidity and neurological mortality decreases significantly with increased operator experience in Pipeline deployment and patient management.
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Affiliation(s)
- Josser E Delgado Almandoz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA.
| | - Yasha Kayan
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Andrea Tenreiro
- Division of Interventional Neuroradiology, Clínica El Ávila, Caracas, Venezuela
| | - Adam N Wallace
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Jill M Scholz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Jennifer L Fease
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Anna M Milner
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Maximilian Mulder
- Division of Critical Care Medicine, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Kyle M Uittenbogaard
- Division of Neurological Surgery, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
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Brasiliense LBC, Walter CM, Avila MJ, Dumont TM. Letter: Rerupture of a Blister Aneurysm After Treatment With a Single Flow-Diverting Stent. Neurosurgery 2017; 81:E40. [PMID: 28499020 DOI: 10.1093/neuros/nyx275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | - Travis M Dumont
- Division of Neurosurgery University of Arizona Tucson, Arizona
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Results of Early High-Flow Bypass and Trapping for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery. World Neurosurg 2017; 105:470-477. [DOI: 10.1016/j.wneu.2017.06.033] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/02/2017] [Accepted: 06/05/2017] [Indexed: 11/18/2022]
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Texakalidis P, Bekelis K, Atallah E, Tjoumakaris S, Rosenwasser RH, Jabbour P. Flow diversion with the pipeline embolization device for patients with intracranial aneurysms and antiplatelet therapy: A systematic literature review. Clin Neurol Neurosurg 2017; 161:78-87. [PMID: 28863286 DOI: 10.1016/j.clineuro.2017.08.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/01/2017] [Accepted: 08/07/2017] [Indexed: 11/17/2022]
Abstract
Flow diversion with the Pipeline Embolization Device (PED) is reported as a safe and efficient treatment for patients with intracranial aneurysms; however, literature discussing the antiplatelet (APT) regimen used before and after the PED is limited. Our aim was to systematically review and summarize available data regarding the APT regimen and the platelet function test (PFT) that was used. We also sought to provide an overview of the aneurysm morphologies and adverse event rates associated with the PED use. This systematic review was conducted according to the PRISMA statement and eligible studies were identified through search of the PubMed and Cochrane databases. We reviewed 28 studies, involving 1556 patients that underwent aneurysm treatment with the PED. The preprocedural aspirin (ASA) 300- 325mg (2-14days) combined with clopidogrel 75mg (3 to >10days) were used as a treatment strategy in 61.7% of patients and ASA 81mg with clopidogrel 75mg for 5-10days for 27%. Patients who received low versus high dose pre-PED ASA, were at less risk for a hemorrhagic event (0.7% versus 3.3%, p=0.053); however no statistical significance was reached. There was also lack of relationship between patients that received low versus high preprocedural ASA in terms of thromboembolic events. Regarding postprocedural APT, ASA (>6months) and clopidogrel (3- 12 months) was the regimen of choice for 93% of patients. Most studies conducted at least one PFT, most common being the VerifyNow. The most frequently reported target P2Y12 Reaction unit (PRU) and Aspirin Reaction Unit (ARU) values were <230 and <550 respectively. There was no statistically demonstrable difference in regards to thrombotic events between centers that conducted at least one PFT and centers that did not test their patients with a PFT. The overall rates of symptomatic thrombotic episodes were 6.6% and hemorrhagic were 3%. The pre- and post-PED APT dose and duration varies across different institutions. More prospective studies are needed to compare the efficacy of different APT agents and reach conclusions regarding use of PFT and platelet reaction values in order to decrease hemorrhagic and thromboembolic complications associated with the PED.
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Affiliation(s)
- Pavlos Texakalidis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kimon Bekelis
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Elias Atallah
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.
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Overlapped Stenting Combined with Coiling for Blood Blister-Like Aneurysms: Comparison of Low-Profile Visualized Intraluminal Support (LVIS) Stent and Non-LVIS Stent. World Neurosurg 2017; 104:729-735. [DOI: 10.1016/j.wneu.2017.03.092] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/18/2017] [Accepted: 03/20/2017] [Indexed: 11/30/2022]
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Yang C, Vadasz A, Szikora I. Treatment of ruptured blood blister aneurysms using primary flow-diverter stenting with considerations for adjunctive coiling: A single-centre experience and literature review. Interv Neuroradiol 2017; 23:465-476. [PMID: 28758550 DOI: 10.1177/1591019917720805] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective The objective of this article is to conduct a single-centre evaluation and quick literature review of the effectiveness of primary flow-diverter (FD) treatment of ruptured blood blister aneurysms (BBAs), with additional relevance of adjunctive coiling. Methods Patients presenting with subarachnoid haemorrhage (SAH) due to ruptured BBAs and subsequently treated with FDs were retrospectively selected from June 2010 to January 2017. Treatment techniques, angiographic data on occlusion rates and procedural success as well as clinical outcomes using the modified Rankin Scale (mRS) were collated. Cross-reference of results were made with available literature. Results Thirteen patients harbouring 14 BBAs were recruited. Of the 14 aneurysms, five (35.7%) showed immediate complete occlusion after the procedure (four of these five patients had adjunctive coiling). All of the aneurysms showed complete occlusion by the six- to nine-month control diagnostic angiogram. No rebleed or retreatment was experienced. Twelve of 13 (92%) patients had an mRS score of 0-1 at the last clinical follow-up. From the pooled data of the literature review, eventual aneurysm occlusion was achieved in 48/56 patients, with five patients requiring further endovascular treatment. In the clinical follow-up period, an mRS of 0-2 was recorded for 83.3% (45/54) of patients. Conclusion Endovascular reconstruction of BBAs using FD treatment is an effective method with good final clinical outcomes. Adjunctive use of coiling achieves higher incidence of immediate complete occlusion of BBAs.
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Affiliation(s)
- Cunli Yang
- Department of Neurointerventions, National Institute of Neurosciences, Budapest, Hungary
| | - Agnes Vadasz
- Department of Neurointerventions, National Institute of Neurosciences, Budapest, Hungary
| | - István Szikora
- Department of Neurointerventions, National Institute of Neurosciences, Budapest, Hungary
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Natarajan SK, Shallwani H, Fennell VS, Beecher JS, Shakir HJ, Davies JM, Snyder KV, Siddiqui AH, Levy EI. Flow Diversion after Aneurysmal Subarachnoid Hemorrhage. Neurosurg Clin N Am 2017; 28:375-388. [DOI: 10.1016/j.nec.2017.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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