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Oya S, Yoshida S, Saito A, Shojima M, Yoshikawa G, Ota T, Ono H, Kurita H, Kohyama S, Miyawaki S, Koizumi S, Saito N, Matsui T. The optimal management of ruptured basilar artery dissecting aneurysms: a case series and scoping review. Neurosurg Rev 2022; 45:3427-3436. [PMID: 36069955 DOI: 10.1007/s10143-022-01857-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/22/2022] [Accepted: 09/01/2022] [Indexed: 11/29/2022]
Abstract
The natural history of ruptured basilar artery dissecting aneurysms (BADAs) remains unclear compared to that of ruptured vertebral artery dissecting aneurysms (VADAs). In this study, we investigated the natural history and optimal management of ruptured BADAs. We identified 17 patients with ruptured BADA among 4586 patients with aneurysmal subarachnoid hemorrhage (SAH) treated in seven participating hospitals. A scoping literature review was undertaken to investigate prognostic factors. Six patients among the profiled patients (35.3%) died, all with poor SAH grades (World Federation of Neurological Societies Grade IV and V). Rebleeding after admission was observed in three patients (17.6%) with poor SAH grades. Aggressive treatment and conservative management were initiated in seven and ten patients, respectively. Patients with good SAH grades had significantly higher favorable treatment outcomes than those with poor grades (83.3% vs. 9.1%, P = 0.005). Moreover, based on a scoping review of 158 cases with ruptured BADA, including the patients from our series, approximately 90% of patients with good SAH grades had favorable outcomes. A good SAH grade and no rebleeding after admission were favorable prognostic factors (P < 0.0001 and P = 0.002, respectively). The rebleeding rates were 20.2%, 13.3%, and 6.3% for dilated, pearl and string, and stenotic lesions, respectively. We concluded that the natural history of isolated ruptured BADAs may be better than that of VADAs. Although definitive treatment, if possible, is undoubtedly important, conservative management with careful radiological follow-up for morphological changes might be a viable option for patients in good clinical condition and with non-dilated lesions.
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Affiliation(s)
- Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan.
| | - Shinsuke Yoshida
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Akira Saito
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Masaaki Shojima
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | | | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Hideaki Ono
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Shizuoka, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Shinya Kohyama
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
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Abouelleil M, Chehab A, Nabulsi O, Singer J, Mazaris P. Use of Pipeline Flex Flow Diverter in the Treatment of an Internal Carotid Artery Dissection: A Case Report. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Yamamura N, Iwata R, Suyama T, Ueno K, Kawano H, Naito N, Li Q, Miyata M, Li Y, Fukuda A, Hashiba T, Yoshimura K, Nonaka M, Asai A. Stent-Assisted Coil Embolization of Ruptured Blood Blister-Like Aneurysm of the Basilar Artery: A Case Report and Literature Review. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:449-455. [PMID: 37502779 PMCID: PMC10370885 DOI: 10.5797/jnet.cr.2020-0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 10/21/2020] [Indexed: 07/29/2023]
Abstract
Objective Blood blister-like aneurysms (BBA) often develop on the anterior wall of the internal carotid artery, and few cases have been reported at other sites. We report a case of stent-assisted coil embolization in the acute phase for a ruptured BBA of the basilar artery. Case Presentation A 53-year-old woman underwent emergency stent-assisted coil embolization for subarachnoid hemorrhage due to a ruptured BBA in the main trunk of the basilar artery. Seven months after the operation, cerebral angiography confirmed no recurrence and a good clinical course. Conclusion Stent-assisted coil embolization for BBA may be one treatment option.
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Affiliation(s)
- Natsumi Yamamura
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Ryoichi Iwata
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Takehiro Suyama
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Katsuya Ueno
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Haruka Kawano
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Nobuaki Naito
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Qiang Li
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Mayuko Miyata
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Yi Li
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Akihiro Fukuda
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Tetsuo Hashiba
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Kunikazu Yoshimura
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Akio Asai
- Department of Neurosurgery, Kansai Medical University, Hirakata, Osaka, Japan
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AlMatter M, Aguilar Pérez M, Hellstern V, Mitrovic G, Ganslandt O, Bäzner H, Henkes H. Flow Diversion for Treatment of Acutely Ruptured Intracranial Aneurysms : A Single Center Experience from 45 Consecutive Cases. Clin Neuroradiol 2020; 30:835-842. [PMID: 31686121 PMCID: PMC7728654 DOI: 10.1007/s00062-019-00846-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/03/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Reports about the use of flow diverter stents (FDS) in the acute setting of subarachnoid hemorrhage (SAH) are limited. This article presents a single center experiences based on 45 consecutive cases with emphasis on complication rates and clinical and radiologic outcomes. METHODS A prospectively maintained database of all cases treated with FDS as a stand-alone or adjunct device was retrospectively reviewed. All patients treated within 30 days of SAH were included. Records were made of clinical presentation, details of endovascular treatment, procedural complications, clinical outcome, and degree of occlusion on follow-up. RESULTS In this study 45 patients (48.9% females; mean age 58.8 ± 12.4 years) were included. Flow diversion was performed after a median of 4 days. The procedural complication rate was 13.3% resulting in 2.2% permanent morbidities and 4.4% mortalities. No major hemorrhagic complications related to antiplatelet therapy were recorded. Immediate complete occlusion was achieved in 13.3%. Among survivors, complete occlusion was achieved in 94.6%. Excellent clinical outcome was recorded in 68.9% and 81.6% of the total population and survivors, respectively. There were no records of rebleeding from the target lesions. CONCLUSION Flow diversion is an attractive alternative strategy for management of acutely ruptured aneurysms with high rates of delayed complete occlusion and acceptable complication rates.
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Affiliation(s)
- Muhammad AlMatter
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.
| | - Marta Aguilar Pérez
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Victoria Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Goran Mitrovic
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurochirurgische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
- Medizinische Fakultät, der Universität Duisburg-Essen, Essen, Germany
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Topiwala KK, Hussain M, Modak J, Kureshi I, Nouh A, Pervez M, Killory B, Lee D. Staged endovascular reconstruction of complex traumatic intracranial carotid artery dissection. Stroke Vasc Neurol 2020; 5:308-310. [PMID: 32994370 PMCID: PMC7548517 DOI: 10.1136/svn-2019-000287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/07/2019] [Accepted: 01/03/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Karan K Topiwala
- Neurology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Mohammed Hussain
- Interventional Neuroradiology, Hartford Hospital, Hartford, Connecticut, USA
| | - Janhavi Modak
- Interventional Neuroradiology, Hartford Hospital, Hartford, Connecticut, USA
| | - Inam Kureshi
- Neurosurgery, Hartford Hospital, Hartford, Connecticut, USA
| | - Amre Nouh
- Neurology, Hartford Hospital, Hartford, Connecticut, USA
| | | | | | - Daniel Lee
- Interventional Neuroradiology, Hartford Hospital, Hartford, Connecticut, USA
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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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Rajah GB, Goodrich DJ, Rangel-Castilla L, Narayanan S. Mid A1 blister aneurysm presenting with subarachnoid hemorrhage: Case report and review. Brain Circ 2018; 4:19-23. [PMID: 30276332 PMCID: PMC6057701 DOI: 10.4103/bc.bc_2_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 11/28/2022] Open
Abstract
Blister aneurysms are uncommon and difficult-to-treat lesions. They are a substantial cause of morbidity and mortality when encountered. Here, we report a blister aneurysm of the mid A1 segment of the anterior cerebral artery presenting with diffuse basal subarachnoid hemorrhage (SAH). The aneurysm was treated by surgical clipping of the parent vessel. Postoperatively, there was no filling of the parent vessel or aneurysm. A treatment algorithm including direct surgical repair and flow diversion for ruptured blister aneurysms is described. A high level of suspicion should be maintained in the setting of angiographic-negative SAH with an asymmetrically diffuse pattern.
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Affiliation(s)
- Gary B Rajah
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Dylan J Goodrich
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | | | - Sandra Narayanan
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
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Girdhar G, Andersen A, Pangerl E, Jahanbekam R, Ubl S, Nguyen K, Wainwright J, Wolf MF. Thrombogenicity assessment of Pipeline Flex, Pipeline Shield, and FRED flow diverters in an in vitro human blood physiological flow loop model. J Biomed Mater Res A 2018; 106:3195-3202. [PMID: 30242950 PMCID: PMC6282594 DOI: 10.1002/jbm.a.36514] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 06/21/2018] [Accepted: 07/05/2018] [Indexed: 12/12/2022]
Abstract
Endovascular treatment of intracranial aneurysms with endoluminal flow diverters (single or multiple) has proven to be clinically safe and effective, but is associated with a risk of thromboembolic complications. Recently, a novel biomimetic surface modification with covalently bound phosphorylcholine (Shield Technology™) has shown to reduce the material thrombogenicity of the Pipeline flow diverter. Thrombogenicity of Pipeline Flex, Pipeline Shield, and Flow Redirection Endoluminal Device (FRED) in the presence of human blood under physiological flow conditions—in addition to relative increase in thrombogenicity with multiple devices—remains unknown and was investigated here. Thrombin generation (mean ± SD; μg/mL; thrombin–antithrombin complex or TAT) was measured as FRED (30.3 ± 2.9), Pipeline (13.9 ± 4.4), Pipeline Shield (0.4 ± 0.3), and negative control (no device; 0.1 ± 0.0). Platelet activation (mean ± SD; IU/μL; beta‐thromboglobulin or βTG) was measured as FRED (148 ± 45), Pipeline (92.8 ± 41), Pipeline Shield (16.2 ± 3.5), and negative control (2.70 ± 0.16). FRED was significantly more thrombogenic than Pipeline and Pipeline Shield (p < 0.05) for TAT. Additionally, Pipeline Shield had significantly lower TAT and βTG than the other devices tested (p < 0.05) and these were comparable to the negative control (p > 0.05). TAT and βTG scaled proportionately with multiple Pipeline devices (N = 6) but was unaffected by multiple Pipeline Shield (N = 6) devices—the latter being statistically similar to negative control (p > 0.05). © 2018 The Authors. Journal Of Biomedical Materials Research Part A Published By Wiley Periodicals, Inc. J Biomed Mater Res Part A: 106A: 3195–3202, 2018.
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Affiliation(s)
| | | | | | | | - Samantha Ubl
- Medtronic Core Technologies, Minneapolis, Minnesota
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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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Giorgianni A, Pellegrino C, Minotto R, Mercuri A, Frattini L, Baruzzi F, Valvassori L. Flow-diverter stenting of post-traumatic bilateral anterior cerebral artery pseudoaneurysm: A case report. Interv Neuroradiol 2018; 21:23-8. [PMID: 25934771 DOI: 10.1177/1591019915575441] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The use of flow-diverter (FD) stents in recent years has positively changed the therapeutic approach to some vascular diseases, especially of certain types of aneurysms. This paper describes the case of a young patient after a major head trauma causing multiple skull fractures. The trauma occasioned two pseudoaneurysms from the A1 segment of the right anterior cerebral artery and from the A2 segment of the left anterior cerebral artery. Both lesions were treated with two Pipeline devices (ev3, Irvine, CA, USA) in two different sessions. The CT study and angiographic investigations performed in the following month showed a complete resolution of the post-traumatic pseudoaneurysmal lesions. Although the use of FD stents is described in the literature, particularly in the treatment of selected aneurysms, this paper shows good technical results in the use of these stents in cases of intracranial post-traumatic pseudoaneurysms with clinical improvement.
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Affiliation(s)
| | - Carlo Pellegrino
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Renzo Minotto
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Anna Mercuri
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Lara Frattini
- Departement of Anesthesiology, Ospedale di Circolo, Varese, Italy
| | - Fabio Baruzzi
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Luca Valvassori
- Departement of Neuroradiology, Ospedale Niguarda Ca' Granda, Milan, Italy
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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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12
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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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13
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Wang A, Santarelli J, Stiefel MF. Pipeline embolization device as primary treatment for cervical internal carotid artery pseudoaneurysms. Surg Neurol Int 2017; 8:3. [PMID: 28217382 PMCID: PMC5288989 DOI: 10.4103/2152-7806.198730] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 11/15/2016] [Indexed: 12/16/2022] Open
Abstract
Background: Limited data exists on the durability and occlusion rate of treating extracranial cervical internal carotid artery pseudoaneurysms using the pipeline embolization device (PED) flow-diverting stent. Methods: Three patients presenting with dissecting cervical internal carotid artery pseudoaneurysms were treated with the PED as the sole treatment modality. Results: In all three patients, successful aneurysmal occlusion and parent vessel reconstruction occurred on immediate angiography and continued on 6-month follow-up. No immediate or delayed complications were seen, and all patients remained neurologically intact. Conclusion: Complete aneurysmal occlusion and long-term angiographic occlusion can occur after PED treatment of cervical carotid pseudoaneurysms. In select patients, the PED can be a suitable primary treatment modality with good neurological outcome for cervical carotid pseudoaneurysms.
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Affiliation(s)
- Arthur Wang
- Department of Neurosurgery, New York Medical College, Valhalla, New York, USA
| | - Justin Santarelli
- Department of Neurosurgery, New York Medical College, Valhalla, New York, USA; NeuroVascular Institute, Westchester Medical Center, Valhalla, New York, USA
| | - Michael F Stiefel
- Capital Institute for Neurosciences, Stroke and Cerebrovascular Center, Capital Health System, Trenton, NJ, USA
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14
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Bhogal P, Pérez MA, Ganslandt O, Bäzner H, Henkes H, Fischer S. Treatment of posterior circulation non-saccular aneurysms with flow diverters: a single-center experience and review of 56 patients. J Neurointerv Surg 2016; 9:471-481. [PMID: 27836994 PMCID: PMC5520279 DOI: 10.1136/neurintsurg-2016-012781] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 10/19/2016] [Accepted: 10/21/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Non-saccular aneurysms of the posterior fossa are an uncommon pathology with no clear treatment strategy. The use of flow-diverting stents (FDS) has had mixed results. We sought to evaluate our experience of FDS for the treatment of this pathology. METHODS We retrospectively reviewed our database of prospectively collected information for all patients treated only with flow diversion for an unruptured non-saccular aneurysm of the posterior circulation between February 2009 and April 2016. The aneurysms were classified as dolichoectasia, fusiform or transitional, and imaging characteristics including maximal diameter, disease vessel segment, MRI features (intra-aneurysmal thrombus, T1 hyperintensity in the aneurysmal wall, infarctions in the territory of the posterior circulation, and mass effect) were recorded alongside clinical and follow-up data. RESULTS We identified 56 patients (45 men) with 58 aneurysms. The average age of the patients was 63.5 years. Twenty-two patients were symptomatic from the aneurysms at presentation. The majority of the lesions were vertebrobasilar in location (44.8%) with isolated vertebral lesions representing 29.3% of aneurysms. Transitional aneurysms were the most common (48.2%). The mean maximal diameter of the aneurysms was 11 mm. Angiographic exclusion of the aneurysms was seen in 57.4% of aneurysms with follow-up (n=47). During the follow-up period nine patients died. CONCLUSIONS Treatment of non-saccular aneurysms of the posterior fossa is technically possible. Early treatment, particularly of the fusiform and transitional subtypes, is recognized, as is treatment prior to the development of symptoms. A 'watch and wait' strategy with regular imaging follow-up could be employed for asymptomatic dolichoectasia.
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Affiliation(s)
- P Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - M Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - H Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Duisburg, Germany
| | - S Fischer
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie, Nuklearmedizin, Knappschaftskrankenhaus Bochum-Langendreer Universtätsklinik, Bochum, Germany
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15
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Brouillard AM, Sun X, Siddiqui AH, Lin N. The Use of Flow Diversion for the Treatment of Intracranial Aneurysms: Expansion of Indications. Cureus 2016; 8:e472. [PMID: 26973807 PMCID: PMC4772997 DOI: 10.7759/cureus.472] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Flow diversion is a novel concept for treating anatomically challenging intracranial aneurysms and has gained increasing acceptance. Flow diverter stents, such as the Pipeline Embolization Device (PED) (ev3-Covidien, Irvine, CA, USA), are approved for treating unruptured large and giant aneurysms from the internal carotid artery between the superior hypophyseal and cavernous segments. However, technological advances and recent clinical results suggest that flow diversion can be safely and effectively used in treating ruptured aneurysms, posterior circulation aneurysms, and distal anterior circulation aneurysms. In this brief review, we aim to investigate the recent evidence on the utilization of PEDs in these controversial vascular territories and to discuss whether the indications for flow diversion can be expanded.
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Affiliation(s)
- Adam M Brouillard
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - Xingwen Sun
- Department of Neurosurgery, Weill Cornell Medical College ; New York Presbyterian Hospital
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - Ning Lin
- Department of Neurosurgery, Weill Cornell Medical College
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16
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Saliou G, Power S, Krings T. Flow diverter placement for management of dissecting ruptured aneurysm in a non-fused basilar artery. Interv Neuroradiol 2015; 22:58-61. [PMID: 26628453 DOI: 10.1177/1591019915617324] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 10/01/2015] [Indexed: 12/25/2022] Open
Abstract
Intracranial vertebral artery dissection can be associated with subarachnoid hemorrhage (SAH) and pseudoaneurysm formation. Dissecting aneurysms have a high risk of rebleeding in the acute phase. To our knowledge, the management of an acute vertebrobasilar junction dissecting aneurysm associated with a basilar non-fusion has not been previously reported. We report here a case of SAH due to rupture of a dissecting aneurysm involving the vertebrobasilar junction and extending to involve the right limb and proximal junction of a non-fused basilar artery, managed by insertion of a flow-diverting stent with excellent clinical outcome and long-term patency of the flow diverter.
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Affiliation(s)
| | - Sarah Power
- Neuroradiology, Toronto Western Hospital & University Health Network, Canada
| | - Timo Krings
- Neuroradiology, Toronto Western Hospital & University Health Network, Canada
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17
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Endovascular management of adjacent tandem intracranial aneurysms: utilization of stent-assisted coiling and flow diversion. Acta Neurochir (Wien) 2015; 157:379-87. [PMID: 25572632 DOI: 10.1007/s00701-014-2318-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 12/17/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Tandem intracranial aneurysms are aneurysms located along a single intracranial vessel. Adjacent tandem aneurysms arise within the same vascular segment and their presence often suggests diffuse parent vessel anomaly. Endovascular management of these rare lesions has not been well studied. In this retrospective observational study, we describe our experience treating adjacent tandem intracranial aneurysms with endovascular embolization. METHODS We retrospectively reviewed records of patients with these lesions who underwent endovascular treatment between 2008 and 2013. RESULTS Thirteen patients (mean age 60.8 years; 12 women) with 28 adjacent tandem aneurysms were treated during the study timeframe. Aneurysms were located along the clinoidal, ophthalmic, and communicating segments of the internal carotid artery in 12 patients and at the basilar apex in one patient. Average size was 8.4 mm. Six patients (12 aneurysms) were treated by flow diversion via the Pipeline embolization device (PED) and seven (16 aneurysms) by stent-assisted coiling, with coils successfully placed in 11 aneurysms. Clinical follow-up was available for an average of 26.1 months; postprocedural angiography was performed for 12 patients. Complete occlusion was achieved in nine of ten (90 %) PED-treated aneurysms and eight of 11 (72.7 %) treated by stent-assisted coiling (p = 0.44). Two patients treated by stent-assisted coiling required re-coiling for aneurysm recanalization. Overall, modified Rankin scale scores were 0-1 for 12 patients and 3 for one patient. CONCLUSIONS Adjacent tandem intracranial aneurysms can be safely and effectively treated by either stent-assisted coiling or flow diversion. We prefer PED flow diversion due to better parent vessel reconstruction and lower recanalization risk.
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18
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Kerolus M, Kasliwal MK, Lopes DK. Persistent aneurysm growth following pipeline embolization device assisted coiling of a fusiform vertebral artery aneurysm: a word of caution! Neurointervention 2015; 10:28-33. [PMID: 25763295 PMCID: PMC4355643 DOI: 10.5469/neuroint.2015.10.1.28] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 12/17/2014] [Indexed: 11/24/2022] Open
Abstract
The complex morphology of vertebrobasilar fusiform aneurysms makes them one of the most challenging lesions treated by neurointerventionists. Different management strategies in the past included parent vessel occlusion with or without extra-intracranial bypass surgery and endovascular reconstruction by conventional stents. Use of flow diversion has emerged as a promising alternative option with various studies documenting its efficacy and safety. However, there are various caveats associated with use of flow diversion in patients with fusiform vertibrobasilar aneurysms especially in patients presenting with acute subarachnoid hemorrhage (SAH). We report a rare case of persistent aneurysmal growth after coiling and placement of the Pipeline Embolization Device (PED; ev3, Irvine, California, USA) for SAH from a fusiform vertebral artery aneurysm. As consequences of aneurysm rupture can be devastating especially in patients with a prior SAH, the clinical relevance of recognizing and understanding such patterns of failure cannot be overemphasized as highlighted in the present case.
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Affiliation(s)
- Mena Kerolus
- Department of Neurosurgery, Rush University Medical Center, Chicago, U.S.A
| | - Manish K Kasliwal
- Department of Neurosurgery, Rush University Medical Center, Chicago, U.S.A
| | - Demetrius K Lopes
- Department of Neurosurgery, Rush University Medical Center, Chicago, U.S.A
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19
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Martin AR, Cruz JP, O'Kelly C, Kelly M, Spears J, Marotta TR. Small pipes: preliminary experience with 3-mm or smaller pipeline flow-diverting stents for aneurysm repair prior to regulatory approval. AJNR Am J Neuroradiol 2014; 36:557-61. [PMID: 25395659 DOI: 10.3174/ajnr.a4170] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Flow diversion has become an established treatment option for challenging intracranial aneurysms. The use of small devices of ≤3-mm diameter remains unapproved by major regulatory bodies. A retrospective review of patients treated with Pipeline Embolization Devices of ≤3-mm diameter at 3 Canadian institutions was conducted. Clinical and radiologic follow-up data were collected and reported. Twelve cases were treated with ≥1 Pipeline Embolization Device of ≤3-mm diameter, including 2 with adjunctive coiling, with a median follow-up of 18 months (range, 4-42 months). One patient experienced a posttreatment minor complication (8%) due to an embolic infarct. No posttreatment hemorrhage or delayed complications such as in-stent stenosis/thrombosis were observed. Radiologic occlusion was seen in 9/12 cases (75%) and near-occlusion in 2/12 cases (17%). Intracranial aneurysm treatment with small-diameter flow-diverting stents provided safe and effective aneurysm closure in this small selected sample. These devices should be further studied and considered for regulatory approval.
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Affiliation(s)
- A R Martin
- From the Division of Neurosurgery (A.R.M., J.S.), Department of Surgery
| | - J P Cruz
- Department of Radiology (J.P.C., T.R.M.), University of Toronto, Toronto, Ontario, Canada
| | - C O'Kelly
- Division of Neurosurgery (C.O.), Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - M Kelly
- Division of Neurosurgery (M.K.), Department of Surgery, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - J Spears
- From the Division of Neurosurgery (A.R.M., J.S.), Department of Surgery
| | - T R Marotta
- Department of Radiology (J.P.C., T.R.M.), University of Toronto, Toronto, Ontario, Canada
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20
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Chan RSK, Mak CHK, Wong AKS, Chan KY, Leung KM. Use of the pipeline embolization device to treat recently ruptured dissecting cerebral aneurysms. Interv Neuroradiol 2014; 20:436-41. [PMID: 25207906 DOI: 10.15274/inr-2014-10042] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 02/08/2014] [Indexed: 11/12/2022] Open
Abstract
The Pipeline embolization device (PED) is one of the flow-diverting stents approved for the treatment of unruptured large or wide-necked cerebral aneurysms in 2011(1). Its use has now been extended to the treatment of recently ruptured dissecting cerebral aneurysm, carotid pseudoaneurysm from radiation injury, and blister aneurysms(2,3). We aimed to evaluate the effectiveness of utilizing the PED as a primary treatment for ruptured dissecting intracranial aneurysms. A single center retrospective review was conducted for all patients primarily treated with PED for acute subarachnoid hemorrhage (SAH) from ruptured dissecting cerebral aneurysms between December 2010 and February 2013. Patients were followed up with CT angiogram (CTA) or digital subtraction angiogram (DSA). Eight patients with a total of eight dissecting aneurysms were identified. The mean duration from SAH to treatment was 2.5 days. Six of the aneurysms arose from vertebral arteries and two from the basilar artery. Immediate check-DSA confirmed satisfactory contrast stasis in all eight cases, and complete aneurysmal obliteration was achieved at six months. There were two (25%) procedure-related complications, but no major procedure-related complications, such as thromboembolic events or rebleeding from aneurysm were encountered. The PED is a feasible treatment option for ruptured dissecting cerebral aneurysms in acute phase. According to our experience, using PED as flow-diverters in acute SAH does not significantly increase the complication risks or mortality rate if the antiplatelet regime is carefully monitored. Future studies shall evaluate the optimal antiplatelet regimen for using the PED in the acute phase.
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Affiliation(s)
| | - Calvin H K Mak
- Department of Neurosurgery, Kwong Wah Hospital; Hong Kong
| | - Alain K S Wong
- Department of Neurosurgery, Kwong Wah Hospital; Hong Kong
| | - Kwong Yau Chan
- Department of Neurosurgery, Kwong Wah Hospital; Hong Kong
| | - Kar Ming Leung
- Department of Neurosurgery, Kwong Wah Hospital; Hong Kong
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21
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Successful Treatment of Growing Basilar Artery Dissecting Aneurysm by Pipeline Flow Diversion Embolization Device. J Stroke Cerebrovasc Dis 2014; 23:1713-6. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.11.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 10/06/2013] [Accepted: 11/20/2013] [Indexed: 11/24/2022] Open
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22
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Borota L, Gál G, Jonasson P, Ridderheim PÅ. Successful treatment of a ruptured aneurysm at the vertebral artery-posterior inferior cerebellar artery junction and simultaneous treatment of the stenotic vertebral artery with a single flow-diverting stent: a case report. J Med Case Rep 2014; 8:172. [PMID: 24886040 PMCID: PMC4096498 DOI: 10.1186/1752-1947-8-172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 04/14/2014] [Indexed: 11/20/2022] Open
Abstract
Introduction This is the first report on the simultaneous successful treatment of a large ruptured saccular aneurysm and stenotic parent artery with a single flow-diverting stent. Case presentation We report the case of a 68-year-old Caucasian man with occlusion of the right vertebral artery and a ruptured aneurysm at the junction of the left posterior inferior cerebellar artery-left vertebral artery that was successfully treated by the deployment of a single flow-diverting stent in the stenotic left vertebral artery. Stent deployment was complicated by thrombotic occlusion of the basilar artery, which was successfully reopened. The patient recovered completely, and follow-up angiography at 4 months and 1 year showed patent vertebral artery with gradual shrinkage of the aneurysm. Conclusions This report contributes to the literature on treatment of large ruptured aneurysms localized in stenotic arteries and in areas of the endocranium where a mass of embolic material in the aneurysm (coils) might compromise the circulation in the parent blood vessel or compress vital brain structures.
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Affiliation(s)
- Ljubisa Borota
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden.
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23
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Giorgianni A, Pellegrino C, Minotto R, Mercuri A, Frattini L, Baruzzi F, Valvassori L. Flow-Diverter Stenting of Post-Traumatic Bilateral Anterior Cerebral Artery Pseudoaneurysm. Interv Neuroradiol 2014. [DOI: 10.15274/inr-2014-10100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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24
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Rouchaud A, Saleme S, Gory B, Ayoub D, Mounayer C. Endovascular exclusion of the anterior communicating artery with flow-diverter stents as an emergency treatment for blister-like intracranial aneurysms. A case report. Interv Neuroradiol 2013; 19:471-8. [PMID: 24355152 DOI: 10.1177/159101991301900411] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 06/22/2013] [Indexed: 11/16/2022] Open
Abstract
Blood blister-like aneurysms (BLAs) are rare lesions, associated with diffuse subarachnoid hemorrhage (SAH). BLAs tend to rebleed quickly after first bleeding and must be treated as an emergency. Acute treatment is challenging using surgical and endovascular approaches due to the fragile aneurysm wall and small sac. Flow-diverter stents (FDSs) may offer a new option for the treatment of difficult small aneurysms. We describe a case of a ruptured BLA on the anterior communicating artery (AComA) treated in the acute phase of SAH by endovascular exclusion of the AComA with deployment of two FDSs in the A1/A2 junctions of both anterior cerebral arteries (ACAs). A 61-year-old man was admitted for diffuse SAH with a focal interhemispheric hematoma. Angiography revealed multiple arterial wall irregularities on the AComA and both ACAs. We performed an endovascular shunt of the AComA by deploying two FDSs in both A1/A2 junctions. Immediate control injections confirmed flow diversion in the A1/A2 segments of the ACAs with decreased blood flow in the AComA. The patient's course in hospital was uneventful. A three-month follow-up angiogram confirmed complete exclusion of the aneurysms, complete exclusion of the AComA, and patency of the two ACAs without any persistent arterial wall irregularity. Endovascular bypass using an FDS for a ruptured BLA has never been described. It establishes a new therapeutic option despite the need for antiplatelet therapy. Endovascular AComA exclusion using an FDS may be a solution when no other treatment is available for a ruptured BLA.
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Affiliation(s)
- Aymeric Rouchaud
- Department of Interventional Neuroradiology, CHU Dupuytren; Limoges, France. -
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25
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Dornbos D, Pillai P, Sauvageau E. Flow diverter assisted coil embolization of a very small ruptured ophthalmic artery aneurysm. BMJ Case Rep 2013; 2013:bcr-2013-010876. [PMID: 24319025 DOI: 10.1136/bcr-2013-010876] [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: 11/04/2022] Open
Abstract
Small ruptured aneurysms present a unique problem to endovascular therapy. We report a case in which a patient presented with subarachnoid hemorrhage and a very small ruptured ophthalmic artery aneurysm, for which endovascular therapy was preferred secondary to severe cardiac comorbidities. Due to the aneurysm size, a small 1.5 mm coil was needed, but presented a significant risk of migration. Conventional stent assisted coiling was considered suboptimal as the small coil could have easily migrated through the strut. We present a novel technique of flow diverter assisted coil embolization in which a coil was placed within the aneurysm and a pipeline embolization device was then partially deployed, jailing the microcatheter and coil mass. Once in place, the coil was detached, securing the aneurysm, and preventing coil migration. Through the use of a flow diverter, some degree of aneurysm protection would still be expected in the event of coil migration toward the ophthalmic artery origin.
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Affiliation(s)
- David Dornbos
- Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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26
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Walsh KM, Moskowitz SI, Hui FK, Spiotta AM. Multiple overlapping stents as monotherapy in the treatment of ‘blister’ pseudoaneurysms arising from the supraclinoid internal carotid artery: a single institution series and review of the literature. J Neurointerv Surg 2013; 6:184-94. [DOI: 10.1136/neurintsurg-2013-010648] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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27
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Brisman JL. What's coming down the pipe--and should we be excited, concerned, or both? AJNR Am J Neuroradiol 2013. [PMID: 23179650 DOI: 10.3174/ajnr.a3425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- J L Brisman
- Department of NeurosurgeryWinthrop University Hospital, Mineola, New York, USA
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28
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Leung GKK, Tsang ACO, Lui WM. Pipeline embolization device for intracranial aneurysm: a systematic review. Clin Neuroradiol 2012; 22:295-303. [PMID: 23124329 PMCID: PMC3505532 DOI: 10.1007/s00062-012-0178-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 10/04/2012] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The pipeline embolization device (PED) is a new endovascular stent designed for the treatment of challenging intracranial aneurysms (IAs). Its use has been extended to nonruptured and ruptured IAs of a variety of configurations and etiologies in both the anterior and posterior circulations. METHODS We conducted a systematic review of ten eligible reports on its clinical efficacy and safety. RESULTS There were 414 patients with 448 IAs. The majority of the IAs were large (40.2 %), saccular or blister-like (78.3 %), and were located mostly in the anterior circulation (83.5 %). The regimens of antiplatelet therapy varied greatly between and within studies. The mean number of the PED used was 2.0 per IA. Deployment was successful in around 95 % of procedures. Aneurysm obliteration was achieved in 82.9 % of IAs at 6-month. The overall incidences of periprocedural intracranial vascular complication rate and mortality rate were 6.3 and 1.5 %, respectively. CONCLUSION The PED is a safe and effective treatment for nonruptured IAs. Its use in the context of acute subarachnoid hemorrhage (SAH) should be cautioned. Its main limitations include the need for prolonged antiplatelet therapy, as well as the potential risks of IA rupture and non-IA-related intracerebral hemorrhages (ICH). Future studies should aim at identifying factors that predispose to incomplete obliteration, delayed rupture, and thromboembolic complications.
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Affiliation(s)
- G K K Leung
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, China.
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29
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Cruz JP, O'Kelly C, Kelly M, Wong JH, Alshaya W, Martin A, Spears J, Marotta TR. Pipeline embolization device in aneurysmal subarachnoid hemorrhage. AJNR Am J Neuroradiol 2012; 34:271-6. [PMID: 23064594 DOI: 10.3174/ajnr.a3380] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The PED is an FDS designed for the treatment of intracranial aneurysms. Data regarding the use of this device in acute or subacute aSAH is limited to a few case reports or small series. We aimed to demonstrate the feasibility of using an FDS, the PED, for the treatment of ruptured intracranial aneurysms with challenging morphologies. MATERIALS AND METHODS We conducted a retrospective review of all known patients treated with the PED for aSAH at 4 institutions between June 2008 and January 2012. Pertinent clinical and radiologic information was submitted by individual centers for central collation. The decision to treat with the PED was made on a case-by-case basis by a multidisciplinary team under compassionate use. RESULTS Twenty patients (15 women; median age, 54.5 years; IQR, 8.0 years) were found. There were 8 blister, 8 dissecting or dysplastic, 2 saccular, and 2 giant aneurysms. Median time to treatment was 4 days (range, 1-90 days; IQR, 12.75 days) from rupture. Three patients had previous failed treatment. Procedure-related symptomatic morbidity and mortality were 15%, with 1 (5%) procedure-related death. Two patients died relative to medical complications, and 1 patient was lost to follow-up. Sixteen patients were available for follow-up, 81% had a GOS of 5, and 13% had a GOS of 4 attributed to a poorer initial clinical presentation. One patient died of urosepsis at 4 months. Occlusion rates were 75% and 94% at 6 months and 12 months, respectively. There were 3 delayed complications (1 silent perforator infarct, 2 moderate asymptomatic in-stent stenoses). No symptomatic delayed complications or rehemorrhages occurred. CONCLUSIONS The FDS may be a feasible treatment option in the acute or subacute setting of selected ruptured aneurysms, especially blister aneurysms. Ruptured giant aneurysms remain challenging for both surgical and endovascular techniques; at this stage, FDSs should be used with caution in this aneurysm subtype.
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Affiliation(s)
- J P Cruz
- Division of Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada, M5B1W8
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30
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Phillips TJ, Wenderoth JD, Phatouros CC, Rice H, Singh TP, Devilliers L, Wycoco V, Meckel S, McAuliffe W. Safety of the pipeline embolization device in treatment of posterior circulation aneurysms. AJNR Am J Neuroradiol 2012; 33:1225-31. [PMID: 22678845 PMCID: PMC7965498 DOI: 10.3174/ajnr.a3166] [Citation(s) in RCA: 166] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 04/05/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The published results of treating internal carotid artery aneurysms with the PED do not necessarily apply to its use in the posterior circulation because disabling brain stem infarcts can be caused by occlusion of a single perforator. In this multicenter study, we assessed the safety of PED placement in the posterior circulation. MATERIALS AND METHODS A prospective case registry was maintained of all posterior circulation aneurysms treated with PEDs at 3 Australian neurointerventional centers during a 27-month period. The objective was to assess the complications and aneurysm occlusion rates associated with posterior circulation PEDs. RESULTS Thirty-two posterior circulation aneurysms were treated in 32 patients. No deaths or poor neurologic outcomes occurred. Perforator territory infarctions occurred in 3 (14%) of the 21 patients with basilar artery aneurysms, and in all 3, a single PED was used. Two asymptomatic intracranial hematomas were recorded. No aneurysm rupture or PED thrombosis was encountered. The overall rate of permanent neurologic complications was 9.4% (3/32); all 3 patients had very mild residual symptoms and a good clinical outcome. Aneurysm occlusion was demonstrated in 85% of patients with >6 months of follow-up and 96% of patients with >1 year of follow-up. CONCLUSIONS The PED is effective in the treatment of posterior circulation aneurysms that are otherwise difficult or impossible to treat with standard endovascular or surgical techniques, and its safety is similar to that of stent-assisted coiling techniques. A higher clinical perforator infarction rate may be associated with basilar artery PEDs relative to the internal carotid artery.
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Affiliation(s)
- T J Phillips
- Department of Neurological Intervention and Imaging Western Australia, Sir Charles Gairdner Hospital, Perth, Australia.
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31
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Ducruet AF, Crowley RW, Albuquerque FC, McDougall CG. Reconstructive endovascular treatment of a ruptured vertebral artery dissecting aneurysm using the Pipeline embolization device. J Neurointerv Surg 2012; 5:e20. [PMID: 22717921 DOI: 10.1136/neurintsurg-2012-010358] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The Pipeline embolization device has been used successfully to treat intracranial aneurysms with difficult morphologies. However, the need for dual antiplatelet therapy has limited its use after subarachnoid hemorrhage. CASE REPORT A 42-year-old woman with a ruptured dissecting aneurysm of her dominant vertebral artery (V4) was successfully treated by Pipeline embolization with preservation of flow through a covered posterior inferior cerebellar artery. This strategy preserved endovascular access for the treatment of severe posterior circulation vasospasm. She was a non-responder to thienopyridine agents and was thus maintained on aspirin and heparin, which was transitioned to warfarin following ventricular drain removal. The aneurysm remains angiographically obliterated at 6 months. Despite a moribund presentation and an extended hospitalization, she has made a remarkable neurological recovery. CONCLUSIONS Pipeline embolization may be used to treat a ruptured dissecting aneurysm in selected cases where parent vessel preservation is paramount.
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Affiliation(s)
- Andrew F Ducruet
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Rizzi M, De Benedictis A, Marras CE, Palma P, Desiderio F, Rollo M. Ruptured dissecting vertebrobasilar aneurysm in childhood: what is the therapeutic strategy? Pediatr Neurosurg 2012; 48:313-8. [PMID: 23860364 DOI: 10.1159/000351578] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 04/18/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Pediatric aneurysms are rare, accounting for 0.5-4.6% of all intracranial aneurysms. Dissecting vertebrobasilar aneurysms (DVBA) are more frequently observed among children than adults. Cases acutely presenting with subarachnoid hemorrhage need a prompt treatment because of the higher mortality related to untreated cases. Options for an active DVBA management depend on the features of the malformation and include endovascular and surgical approaches. METHODS We refer to an 8-year-old healthy female, who presented with a sudden severe headache and vomit, followed by a half-hour loss of consciousness. A CT scan revealed subarachnoid hemorrhage, and brain MR angiography showed a lesion with mass effect on bulbar structures, suggestive of an aneurysm of the vertebrobasilar junction. The intracranial angiography confirmed this diagnosis and showed a relevant revascularization coming from the anterior cerebral circulation. RESULTS Endovascular treatment was considered as a suitable option and occlusion of both vertebral arteries, saving the left posterior inferior cerebellar artery, was performed. No neurological deficits appeared after embolization, and the patient was clinically stable at 18 months of follow-up. CONCLUSION In the 'stent era', parent vessel deconstruction throughout endovascular balloon or coil occlusion could be considered in patients with a sound collateral circulation and when cerebellar hemisphere and encephalic trunk feeding is not compromised.
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Affiliation(s)
- Michele Rizzi
- Division of Neurosurgery, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, University of Milan, Milan, Italy.
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