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Duangprasert G, Sukhor S, Ratanavinitkul W, Tantongtip D. Evaluation of flow diverter use in acutely ruptured vertebral artery dissecting Aneurysms: A focus on safety and efficacy for rapid Aneurysm obliteration. Clin Neurol Neurosurg 2024; 242:108345. [PMID: 38788544 DOI: 10.1016/j.clineuro.2024.108345] [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: 03/11/2024] [Revised: 05/10/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE Flow diverter device (FDD) has emerged as the reconstruction technique for treating ruptured dissecting vertebral artery Aneurysms (VADA), but data on feasibility regarding re-rupture risk and timing of Aneurysm obliteration following FDD treatment is still limited. Therefore, this study aimed to evaluate the safety and efficacy of FDD in the treatment of VADAs presenting with subarachnoid hemorrhage (SAH). METHODS We retrospectively reviewed patients with ruptured VADA presenting with subarachnoid hemorrhage who underwent FDD placement at our institution between 2015 and 2023. Patient demographic data, Aneurysm configuration, and occlusion status were analyzed. RESULTS Thirteen patients with SAH from VADA rupture underwent FDD implantation. The average size of the largest diameter of the Aneurysm was 11.2 mm (range 6.5-21 mm). Eight of 13 (61.5 %) patients had their Aneurysms completely obliterated within 2 weeks after the procedure. The small dissecting Aneurysm (d = 0.636, p = 0.002) and degree of intra-Aneurysmal contrast stasis (d = 0.524, p = 0.026) were associated with rapid Aneurysm occlusion, according to the Somer's d coefficient. There were no ischemic or hemorrhagic complications at the average clinical follow-up of 28.4 months (range 5-67 months) and average angiographic follow-up of 20.1 months (range 3-60 months). A favorable outcome (mRS 0-2) was achieved in 12 patients (92.3 %). CONCLUSIONS FDD is safe and effective for the reconstruction of acutely ruptured VADAs. In addition, our study emphasizes that small dissecting Aneurysms tend to be rapidly obliterated after flow diversion, which eliminates the risk of re-rupture during the acute phase of subarachnoid hemorrhage.
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Affiliation(s)
- Gahn Duangprasert
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand.
| | - Sasikan Sukhor
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | - Warot Ratanavinitkul
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | - Dilok Tantongtip
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
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2
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Amoukhteh M, Hassankhani A, Valizadeh P, Jannatdoust P, Ghozy S, Kobeissi H, Kallmes DF. Flow diverters in the treatment of intracranial dissecting aneurysms: a systematic review and meta-analysis of safety and efficacy. J Neurointerv Surg 2024:jnis-2023-021117. [PMID: 38212103 DOI: 10.1136/jnis-2023-021117] [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: 10/10/2023] [Accepted: 12/22/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Intracranial dissecting aneurysms present clinical challenges, demanding immediate intervention due to their high bleeding risk. While traditional treatments have limitations, the potential of flow diverters shows promise but remains a subject of ongoing debate for optimal management. The aim of this study was assess the safety and efficacy of flow diverters in the treatment of intracranial dissecting aneurysms. METHODS A systematic review and meta-analysis was performed following established guidelines. The search encompassed PubMed, Scopus, Web of Science, and Embase databases up to July 20, 2023. Eligible studies reporting outcomes of interest were included, and relevant data were extracted and analyzed using R software. RESULTS The analysis, based on data pooled from 20 included studies involving 329 patients, revealed a favorable functional outcome rate of 89.7% at the last follow-up. The mortality rate during the follow-up period was 2.4%, decreasing to 0.9% when excluding the outlier study. In the final angiographic follow-up, a complete occlusion rate of 71.7% and an adequate occlusion rate of 88.3% were observed. Notably, studies with longer angiographic follow-up times exhibited lower rates of complete (P=0.02) and adequate (P<0.01) occlusion. A minimal aneurysm recurrence/rebleeding rate of 0.1% was noted, while in-stent stenosis/thrombosis occurred at a rate of 1.14%. Additionally, ischemic events/infarctions were seen in 3.3% of cases. The need for retreatment was minimal, with a rate of 0.9%, and the technical success rate was impressively high at 99.1%. CONCLUSION This study highlights the safety and efficacy of flow diverters in treating intracranial dissecting aneurysms. Further research, encompassing larger multicenter studies with extended follow-up periods, is crucial for comprehending occlusion dynamics, refining treatment strategies, improving long-term outcomes, and addressing methodological limitations.
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Affiliation(s)
- Melika Amoukhteh
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Amir Hassankhani
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Parya Valizadeh
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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3
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Matsukawa S, Ishii A, Fushimi Y, Terada Y, Natsuhara H, Kikuchi T, Okawa M, Yamao Y, Abekura Y, Sasaki N, Tsuji H, Akiyama R, Miyamoto S, Arakawa Y. Ruptured thrombosed vertebral artery dissecting aneurysm treated with staged flow diverter after prediction of the rupture point by vessel wall MRI. Neuroradiol J 2023:19714009231224420. [PMID: 38148669 DOI: 10.1177/19714009231224420] [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: 12/28/2023] Open
Abstract
The safety and feasibility of using staged flow diverter (FD) for ruptured cerebral aneurysms, in which coil embolization is performed in the acute phase and FD is deployed in the subacute phase, has recently been reported. This strategy requires assuming the rupture point and performing coil embolization. Although vessel wall magnetic resonance imaging (VW-MRI) has been reported to be useful in predicting the rupture point of aneurysms, its use with staged FD has not yet been reported. We report the first case of staged FD with preoperative contrast-enhanced VW-MRI to predict the rupture point for partially thrombosed vertebral artery dissecting large aneurysm involving posterior inferior cerebellar artery (PICA) origin. This approach achieved a very good outcome, not only completely occluding the aneurysm, but also reconstructing the parent artery while maintaining the patency of the PICA.
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Affiliation(s)
- So Matsukawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Akira Ishii
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Yasutaka Fushimi
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Yukinori Terada
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Hiroki Natsuhara
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Takayuki Kikuchi
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Masakazu Okawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Yukihiro Yamao
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Yu Abekura
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Natsuhi Sasaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Hirofumi Tsuji
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Ryo Akiyama
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Yoshiki Arakawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
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4
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Zhang Y, Zhang F, Turhon M, Huang J, Li M, Peng Q, Zheng Z, Liu J, Zhang Y, Liu J, Zhang H, Li T, Song D, Zhao Y, Aisha M, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Guan S. Treatment of Intracranial Vertebral Artery Dissecting Aneurysms Using Pipeline Embolization Devices : A Multicenter Cohort Study. Clin Neuroradiol 2023; 33:1105-1114. [PMID: 37380901 DOI: 10.1007/s00062-023-01318-7] [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: 01/29/2023] [Accepted: 05/24/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE Intracranial vertebral artery dissecting aneurysm (IVADA) is a rare type of aneurysm with high morbidity and mortality. Recently, the application of pipeline embolization devices (PEDs) has been extended to IVADAs. Here, we aim to investigate the safety and effectiveness of PEDs for IVADAs. METHOD We retrospectively reviewed the PLUS database to identify patients who had IVADAs and were treated with PEDs from 2014 to 2019 at 14 centers across China. Data including patient and aneurysm characteristics, procedure details, angiographic and clinical results, relationship with the ipsilateral posterior inferior cerebellar artery (PICA), and patency of the PICA following PED coverage were analyzed. RESULTS In this study 52 consecutive patients with 52 IVADAs were included. The mean age was 52.33 years and 82.7% were male. With a median follow-up of 10.5 months, the complete occlusion rate was 93.8% (45/48) and no recurrence or in-stent stenosis was detected. The total postoperative complication rate and mortality were 11.5% and 1.9%, respectively. Complications occurred in 9.6% (5/52) of patients within 30 days after the operation, including ischemic stroke in 3 and hemorrhagic stroke in 2. Another patient suffered an ischemic stroke at follow-up, 78.8% (41/52) PICAs were covered by PEDs, 1 case (2.4%) had a functional disability due to PICA occlusion, while 39.0% (16/41) had reduced flow during follow-up but hardly caused any obvious neurological deficits. Patients with IVADA involving PICA had a trend towards more complications (66.7% vs. 51.1%; P = 1). CONCLUSION Treating IVADAs with PEDs may be a safe and effective option, with favorable clinical and angiographic outcomes; however, complications associated with this treatment should not be ignored. REGISTRATION http://www. CLINICALTRIALS gov . Unique identifier: NCT03831672.
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Affiliation(s)
- Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Fujunhui Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mirzat Turhon
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiliang Huang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mengxing Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qichen Peng
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhaoxu Zheng
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianmin Liu
- Changhai Hospital Affiliated to Naval Medical University, Shanghai, China
| | - Hongqi Zhang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianxiao Li
- Zhengzhou University People's Hospital, Zhengzhou, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Maimaitili Aisha
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yunyan Wang
- Qilu Hospital of Shandong University, Jinan, China
| | - Wenfeng Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yang Wang
- Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jieqing Wan
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guohua Mao
- Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huaizhang Shi
- First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Barros G, Levitt MR. Treatment of an acutely ruptured complex fusiform middle cerebral artery aneurysm with flow diverting stenting and adjunctive coil embolization. NEUROSURGICAL FOCUS: VIDEO 2022; 7:V5. [PMID: 36425267 PMCID: PMC9664493 DOI: 10.3171/2022.7.focvid2249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/11/2022] [Indexed: 06/16/2023]
Abstract
This technical video demonstrates the treatment of an acutely ruptured, large, complex left fusiform middle cerebral artery (MCA) aneurysm with endovascular flow diversion with adjunctive coiling in a 27-year-old female. Two telescoping flow-diverting stents (Pipeline Flex) were placed, with partial coiling of a saccular portion of the aneurysm. Technical challenges, alternative treatment, intraoperative and postoperative antiplatelet management, vasospasm treatment, and clinical and radiographic follow-up are described. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2249.
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Affiliation(s)
| | - Michael R. Levitt
- Departments of Neurological Surgery
- Radiology
- Mechanical Engineering, and
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington
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6
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Cler SJ, Lauzier DC, Chatterjee AR, Osbun JW, Moran CJ, Kansagra AP. Comparative study of on-label versus off-label treatment of intracranial aneurysms with the Pipeline embolization device. J Neurosurg 2022; 137:685-690. [PMID: 35090133 DOI: 10.3171/2021.11.jns212481] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 11/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Pipeline embolization device (PED) is widely used for the treatment of intracranial aneurysms, including in off-label applications. In this work, the authors compared the real-world efficacy and safety of PED use in on-label and off-label aneurysm treatments. METHODS Clinical and angiographic data of patients who underwent PED placement at a high-volume academic medical center were retrospectively obtained. Treatments were classified as on-label if they fell within the applications approved by the United States Food and Drug Administration as of 2021. Recorded outcomes included aneurysm occlusion, procedural complications, ischemic events, in-stent stenosis, intracranial hemorrhage, postprocedural functional status, and death. RESULTS In total, 416 aneurysms in 330 patients were treated with PED, comprising 256 aneurysms that received on-label treatments and 160 that received off-label treatments. The overall rate of complete aneurysm occlusion was 76.4% for on-label aneurysms and 75.6% for off-label aneurysms (p = 0.898). The risk of ischemic stroke in patients who underwent off-label treatments was 15.2%, which was higher than the 4.2% rate in patients who underwent on-label treatment (p = 0.003). All other clinical complications, procedural complications, and long-term functional status were comparable between the on-label and off-label groups. CONCLUSIONS In real-world practice, off-label use of PED is common and can achieve similar efficacy as on-label use. However, in aggregate, off-label use was found to carry an increased rate of ischemic complications. With judicious attention to safety and individual patient characteristics, these results highlight the scale and general feasibility of off-label PED use by experts.
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Affiliation(s)
- Samuel J Cler
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - David C Lauzier
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Arindam R Chatterjee
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; and
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua W Osbun
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; and
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J Moran
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; and
| | - Akash P Kansagra
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; and
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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7
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Outcomes after Flow Diverter Treatment in Subarachnoid Hemorrhage: A Meta-Analysis and Development of a Clinical Prediction Model (OUTFLOW). Brain Sci 2022; 12:brainsci12030394. [PMID: 35326350 PMCID: PMC8946659 DOI: 10.3390/brainsci12030394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 02/01/2023] Open
Abstract
Background: patients with a subarachnoid hemorrhage (SAH) might need a flow diverter (FD) placement for complex acutely ruptured intracranial aneurysms (IAs). We conducted a meta-analysis and developed a prediction model to estimate the favorable clinical outcome after the FD treatment in acutely ruptured IAs. Methods: a systematic literature search was performed from 2010 to January 2021 in PubMed and Embase databases. Studies with more than five patients treated with FDs within fifteen days were included. In total, 1157 studies were identified. The primary outcome measure was the favorable clinical outcome (mRS 0–2). Secondary outcome measures were complete occlusion rates, aneurysm rebleeding, permanent neurologic deficit caused by procedure-related complications, and all-cause mortality. A prediction model was constructed using individual patient-level data. Results: 26 retrospective studies with 357 patients and 368 aneurysms were included. The pooled rates of the favorable clinical outcome, mortality, and complete aneurysm occlusion were 73.7% (95% CI 64.7–81.0), 17.1% (95% CI 13.3–21.8), and 85.6% (95% CI 80.4–89.6), respectively. Rebleeding occurred in 3% of aneurysms (11/368). The c-statistic of the final model was 0.83 (95% CI 0.76–0.89). All the studies provided a very low quality of evidence. Conclusions: FD treatment can be considered for complex ruptured IAs. Despite high complication rates, the pooled clinical outcomes seem favorable. The prediction model needs to be validated by larger prospective studies before clinical application.
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Giorgianni A, Agosti E, Molinaro S, Terrana AV, Vizzari FA, Nativo L, Garg K, Craparo G, Conti V, Locatelli D, Baruzzi F, Valvassori L, Lanzino G. Flow diversion for acutely ruptured intracranial aneurysms treatment: A retrospective study and literature review. J Stroke Cerebrovasc Dis 2022; 31:106284. [PMID: 35007933 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/19/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Flow diversion is becoming an increasingly established practice for the treatment of acutely ruptured intracranial aneurysms. In this study the authors present a literature review and meta-analysis, adding a retrospective review of institutional registry on emergency treatment of aRIA with flow diverter stent. MATERIALS AND METHODS A systematic search of PubMed, SCOPUS, Ovid MEDLINE, and Ovid EMBASE was performed on April 20th, 2021, extrapolating 35 articles. R language 'meta' and 'metafor' packages were used for data pooling. The DerSimonian-Laird model was used to calculate the pooled effect. The I2 value and Q statistic evaluated study heterogeneity. Additionally, the authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured intracranial aneurysms treated with flow diverter stent placement from May 2010 to November 2020 was performed. RESULTS From the systematic literature review and meta-analysis, the pooled proportion of complete aneurysm occlusion was 78%, with a pooled rate of 79%, 71%, 80%, and 50% for dissecting, saccular, fusiform, and mycotic aneurysms, respectively. The pooled proportion of aneurysm rebleeding and intrastent stenosis was 12% and 15% respectively, for a total of 27% rate. The analysis of authors retrospective register showed an overall mortality rate of 16.7% (3/18), with a low but not negligible postprocedural rebleeding and intrastent thrombosis rates (5.6% and 11.1% respectively). CONCLUSION Although increasingly utilized in the management of selected patients with acutely ruptured intracranial aneurysms, flow diversion for acutely ruptured intracranial aneurysms treatment presents rebleeding and intrastent stenosis rates not negligible.
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Affiliation(s)
- Andrea Giorgianni
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Brescia, Italy.
| | - Stefano Molinaro
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Alberto Vito Terrana
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | | | - Luca Nativo
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Kanwaljeet Garg
- Associate Professor, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Giuseppe Craparo
- Department of Department of Neuroradiology, ARNAS Civico di Palermo, Palermo, Italy
| | - Vinicio Conti
- Department of Anesthesiology and Resuscitation, ASST Sette Laghi, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Fabio Baruzzi
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | | | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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Vergara-Garcia D, Abaunza-Camacho JF, Agudelo-Arrieta M, Riveros WM, Caballero A. Transient third cranial nerve palsy after pipeline shield treatment of a ruptured anterior cerebral artery dissecting aneurysm: Case report. Surg Neurol Int 2021; 12:489. [PMID: 34754539 PMCID: PMC8571181 DOI: 10.25259/sni_764_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/13/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Intracranial dissecting aneurysms (IDAs) are rare vascular lesions usually arising from the posterior circulation. The anterior cerebral artery (ACA) is an unusual location for this pathology. Even rarer is the occurrence of a transient de novo third cranial nerve (CN) palsy after flow-diverting device (FDD) treatment of an ACA dissecting aneurysm. Case Description: A middle-aged man with a prior history of hypertension was admitted to our emergency department with severe headache and loss of consciousness after sexual intercourse. Imaging revealed a subarachnoid hemorrhage with stenosis of the left A1 segment of the ACA. Cerebral digital subtraction angiography confirmed a dissecting aneurysm of the left A1 segment. The aneurysm was treated with an FDD (Pipeline Shield). Transient isolated incomplete third CN palsy was documented 12 h after treatment. No evidence of ischemic or hemorrhagic strokes was found. The condition improved after a few days of empiric steroid treatment. Conclusion: An FDD is a suitable alternative for the treatment of a ruptured IDA of the anterior circulation. Some infrequent complications associated with the device, such as de novo cranial neuropathies, are yet to be studied.
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Affiliation(s)
- David Vergara-Garcia
- Department of Neurosurgery, Center for Research and Training in Neurosurgery, Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
| | - Juan Felipe Abaunza-Camacho
- Department of Neurosurgery, Center for Research and Training in Neurosurgery, Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
| | - Mariana Agudelo-Arrieta
- Department of Neurosurgery, Center for Research and Training in Neurosurgery, Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
| | - William Mauricio Riveros
- Department of Neurosurgery, Center for Research and Training in Neurosurgery, Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
| | - Alberto Caballero
- Department of Neurosurgery, Center for Research and Training in Neurosurgery, Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
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10
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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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11
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Rupture from cavernous internal carotid artery pseudoaneurysm 11 years after transsphenoidal surgery. J Clin Neurosci 2020; 79:266-268. [PMID: 33070909 DOI: 10.1016/j.jocn.2020.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/16/2020] [Accepted: 06/29/2020] [Indexed: 11/21/2022]
Abstract
Carotid artery pseudoaneurysm is a rare complication of transsphenoidal surgery, usually diagnosed within 90 days post procedure. Sequelae of pseudoaneurysm rupture, such as severe epistaxis or carotid cavernous fistula (CCF), have significant morbidity and mortality. A case of epistaxis from pseudoaneurysm rupture over a decade after transsphenoidal surgery is presented, with staged treatment using coiling, endonasal mucosal flap repair and interval flow-diverting stent insertion. This case illustrates that pseudoaneurysm rupture occurs regardless of time course after transsphenoidal surgery, and treatment strategies using combined endovascular and endonasal techniques are reviewed.
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12
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Pomeraniec IJ, Mastorakos P, Raper D, Park MS. Rerupture Following Flow Diversion of a Dissecting Aneurysm of the Vertebral Artery: Case Report and Review of the Literature. World Neurosurg 2020; 143:171-179. [PMID: 32730963 DOI: 10.1016/j.wneu.2020.07.149] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dissecting aneurysms of the posterior cerebral circulation can wield significant treatment challenges with devastating clinical outcomes. Despite an expanded therapeutic armamentarium, these vascular lesions remain relatively difficult to diagnose and portend high associated morbidity and mortality. METHODS A ruptured, fusiform, dissecting aneurysm of the mid V4 segment of the right vertebral artery (VA) distal to the posterior inferior cerebellar artery origin resulted in a Hunt and Hess grade 5, Fisher scale score 4 subarachnoid hemorrhage. The lesion incorporated 360 degrees of the vessel wall and extended across an area measuring 11 mm in length and 6.8 mm in width at maximum dimension. The vascular lesion was treated with 2 overlapping Pipeline Embolization Devices. RESULTS Digital subtraction angiography demonstrated an origin of the right posterior inferior cerebellar artery mildly stenosed by the dissecting aneurysm. The left VA was markedly hypoplastic. After deployment of 2 overlapping Pipeline Embolization Devices, the aneurysm neck was well covered with appropriate positioning of the stent construct with good apposition to the vessel wall. There was contrast stasis within the aneurysm. The patient was managed with dual antiplatelet therapy. He demonstrated initial clinical and radiographic improvement. However, on the night of the second postprocedure day, the patient succumbed to rerupture of the aneurysm. CONCLUSIONS The literature posits that nonsaccular, fusiform, and dissecting aneurysms of the vertebrobasilar circulation can be occluded with consistency and success using flow diversion techniques. Endovascular treatment of a ruptured dissecting aneurysm of the VA is technically feasible and can be performed with or without parent artery occlusion. Outcomes following flow diversion of the posterior circulation may depend on the location of the dissection and viability of collateral circulation. In the present case, adequate coverage of the aneurysm did not portend a positive outcome.
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Affiliation(s)
- I Jonathan Pomeraniec
- Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Panagiotis Mastorakos
- Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Daniel Raper
- Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA; Department of Interventional Neuroradiology, University of Virginia Health Science Center, Charlottesville, Virginia, USA.
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13
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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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14
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Kaschner MG, Petridis A, Turowski B. Single-center experience with the new generation Derivo Embolization Device in ruptured dissecting and blister aneurysms. Acta Radiol 2020; 61:37-46. [PMID: 31166695 DOI: 10.1177/0284185119852731] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Treatment of ruptured dissecting and blister aneurysms is technically challenging with potentially high morbidity and mortality. The Derivo Embolisation Device (Derivo) is a flow diverter stent designed for the treatment of intracranial aneurysms. Purpose To assess the safety and feasibility of the Derivo in the treatment of ruptured dissecting and blister aneurysms. Material and Methods We retrospectively analyzed all patients with ruptured dissecting and blister aneurysms treated with the Derivo between February 2016 and July 2018. Procedural details, complications, morbidity within 30 days, and angiographic aneurysm occlusion rates, initially and after six months, were assessed. Results In 10 patients 11 ruptured dissecting and blister aneurysms were treated with 12 Derivos as monotherapy. No aneurysm rebleeding was observed at follow-up. One treatment-related complication occurred including a coil perforation of an additionally treated aneurysm. One patient died due to brain edema. Initial digital subtraction angiography revealed complete (O’Kelly–Marotta [OKM] classification D) and favorable (OKM D+C) occlusion rate in three aneurysms. Six-month follow-up for digital subtraction angiography and clinical evaluation was available in 6/9 patients with complete (OKM D) occlusion in all aneurysms (6/6). Favorable (modified Rankin Scale [mRS] ≤ 2) and moderate (mRS 3) clinical outcome after a mean follow-up of 10 months was observed in six and two patients, respectively. Conclusion Endovascular treatment with the Derivo in ruptured dissecting and blister aneurysms revealed a sufficient initial division of aneurysms from the circulation without rebleeding. The Derivo is associated with high procedural and clinical short-term safety.
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Affiliation(s)
- Marius Georg Kaschner
- University Düsseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, Germany
| | | | - Bernd Turowski
- University Düsseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, Germany
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15
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Shields LBE, Shields CB, Ghiassi M, Dashti SR, Yao TL, Zhang YP, Ghiassi M. Pipeline Embolization Device for Treatment of Craniocervical Internal Carotid Artery Dissections: Report of 3 Cases. World Neurosurg 2019; 132:106-112. [PMID: 31491581 DOI: 10.1016/j.wneu.2019.08.183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Dissecting pseudoaneurysms of the craniocervical circulation are uncommon, accounting for only 3% of all cerebral aneurysms. These aneurysms pose a challenge due to their location and anatomic configuration. The Pipeline Embolization Device (PED) is a flow diversion technique that successfully treats aneurysms by diverting blood flow away from the aneurysm and reconstructing the diseased parent artery by altering its hemodynamics. CASE DESCRIPTION We report 3 cases in which the PED was used to treat craniocervical carotid artery dissection with associated pseudoaneurysms. A single PED was used in the first case, 4 PEDs were used in the second case, and 3 PEDs and a PRECISE PRO RX carotid stent were placed in the third case. All 3 patients achieved full neurologic recovery postoperatively. Cerebral angiography performed postoperatively demonstrated revascularization, good laminar flow, and no in-stent or adjacent stenosis. CONCLUSIONS PED placement offers a safe and effective method of treating spontaneous or traumatic craniocervical carotid artery dissections with excellent neurologic outcomes postoperatively and complete long-term aneurysmal occlusion.
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Affiliation(s)
- Lisa B E Shields
- Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky, USA
| | - Christopher B Shields
- Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky, USA; Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Mayshan Ghiassi
- Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky, USA
| | - Shervin R Dashti
- Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky, USA
| | - Tom L Yao
- Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky, USA
| | - Yi Ping Zhang
- Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky, USA
| | - Mahan Ghiassi
- Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky, USA.
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16
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Lopes DK, Jang DK, Cekirge S, Fiorella D, Hanel RA, Kallmes DF, Levy EI, Lylyk P. Morbidity and Mortality in Patients With Posterior Circulation Aneurysms Treated With the Pipeline Embolization Device: A Subgroup Analysis of the International Retrospective Study of the Pipeline Embolization Device. Neurosurgery 2019; 83:488-500. [PMID: 28945879 DOI: 10.1093/neuros/nyx467] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 08/10/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The safety of PipelineTM Embolization Device (PED; Medtronic Inc, Dublin, Ireland) in posterior circulation aneurysms is still controversial. OBJECTIVE To study complications associated with the treatment of posterior circulation aneurysms by conducting a subgroup analysis from the International Retrospective Study of PED registry. METHODS Data from 91 consecutive patients with 95 posterior circulation aneurysms at 17 centers between July 2008 to February 2013 were analyzed. The primary endpoint was defined as any complication leading to neurological morbidity or death. The outcome predictors were calculated using Kaplan-Meier and Cox regression methods. RESULTS The mean aneurysm size was 13.8 mm. Aneurysm types were saccular (36.8%), fusiform (29.5%), dissecting (28.4%), and others (5.3%). The median follow-up was 21.1 mo. Twelve (13.2%) patients encountered a primary endpoint event. In multivariate analysis for the primary endpoint, use of ≥3 PEDs and fusiform shape compared with other shapes had hazard ratios (HRs) of 7.77 (95% confidence interval [CI], 2.48-25.86; P = .0007) and 3.48 (95% CI, 1.06-13.39; P = .0488), respectively. The multivariate HR of aneurysm size for neurological morbidity after PED implantation was 1.11 (95% CI, 1.04-1.18; P = .0015), and HRs of ruptured aneurysm and age for neurological mortality were 8.1 (95% CI, 1.31-41.26; P = .0197) and 1.07 (95% CI, 1.02-1.15; P = .0262), respectively. Basilar artery aneurysm had an HR of 3.54 (95% CI, 1.12-14.18, P = .0529) in the univariate analysis for major outcomes. CONCLUSION PED implantation may be considered for the treatment of posterior circulation aneurysms, especially of saccular or dissecting type. Our major complications appear to be comparable to those reported previously after clipping and coiling in the literature. Neurointerventionists should consider the shape, size, rupture, and location of complex posterior circulation aneurysms as well as age and PED number before the PED placement.
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Affiliation(s)
- Demetrius K Lopes
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Dong-Kyu Jang
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea
| | - Saruhan Cekirge
- Department of Radiology Koru Hospital and Bayindir Hospital, Ankara, Turkey
| | - David Fiorella
- Department of Neurosurgery, Cerebrovascular Center, Stony Brook University Medical Center, Stony Brook, New York
| | - Ricardo A Hanel
- Stroke and Cerebrovascular Surgery, Lyerly Neurosurgery/Baptist Neurological Institute, Jacksonville, Florida
| | | | - Elad I Levy
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, New York
| | - Pedro Lylyk
- Department of Neurosurgery, ENERI-Clinica La Sagrada Familia, Buenos Aires, Argentina
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17
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Kaschner MG, Kraus B, Petridis A, Turowski B. Endovascular treatment of intracranial 'blister' and dissecting aneurysms. Neuroradiol J 2019; 32:353-365. [PMID: 31271334 DOI: 10.1177/1971400919861406] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Blister and dissecting aneurysms may have a different pathological background but they are commonly defined by instability of the vessel wall and bear a high risk of fatal rupture and rerupture. Lack of aneurysm sack makes treatment challenging. PURPOSE The purpose of this study was to assess the safety and feasibility of endovascular treatment of intracranial blister and dissecting aneurysms. METHODS We retrospectively analysed all patients with ruptured and unruptured blister and dissecting aneurysms treated endovascularly between 2004-2018. Procedural details, complications, morbidity/mortality, clinical favourable outcome (modified Rankin Scale ≤2) and aneurysm occlusion rates were assessed. RESULTS Thirty-four patients with endovascular treatment of 35 aneurysms (26 dissecting aneurysms and 9 blister aneurysms) were included. Five aneurysms were treated by parent vessel occlusion, and 30 aneurysms were treated by vessel reconstruction using stent monotherapy (n = 9), stent-assisted coiling (n = 7), flow diverting stents (n = 13) and coiling + Onyx embolization (n = 1). No aneurysm rebleeding and no procedure-related major complications or deaths occurred. There were five deaths in consequence of initial subarachnoid haemorrhage. Complete occlusion (79.2%) was detected in 19/24 aneurysms available for angiographic follow-up, and aneurysm recurrence in 2/24 (8.3%). The modified Rankin Scale ≤2 rate at mean follow-up of 15.1 months was 64.7%. CONCLUSION Treatment of blister and dissecting aneurysms developed from coil embolization to flow diversion with multiple stents to the usage of flow diverting stents. Results using modern flow diverting stents encourage us to effectively treat this aneurysm entity endovascularly by vessel reconstruction. Therefore, we recommend preference of vessel reconstructive techniques to parent vessel occlusion.
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Affiliation(s)
- Marius G Kaschner
- 1 Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Bastian Kraus
- 1 Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Athanasios Petridis
- 2 Department of Neurosurgery, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Bernd Turowski
- 1 Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
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18
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Daou B, Atallah E, Chalouhi N, Starke RM, Oliver J, Montano M, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Aneurysms with persistent filling after failed treatment with the Pipeline embolization device. J Neurosurg 2019; 130:1376-1382. [PMID: 29726765 DOI: 10.3171/2017.12.jns163090] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/14/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Pipeline embolization device (PED) has become a valuable tool in the treatment of cerebral aneurysms. Although failures with PED treatment have been reported, the characteristics and course of these aneurysms remain a topic of uncertainty. METHODS Electronic medical records and imaging studies were reviewed for all patients treated with the PED between July 2010 and March 2015 to identify characteristics of patients and aneurysms with residual filling after PED treatment. RESULTS Of 316 cases treated at a single institution, 281 patients had a long-term follow-up. A total of 52 (16.4%) aneurysms with residual filling were identified and constituted the study population. The mean patient age in this population was 58.8 years. The mean aneurysm size was 10.1 mm ± 7.15 mm. Twelve aneurysms were fusiform (23%). Of the aneurysms with residual filling, there were 20 carotid ophthalmic (CO) aneurysms (20% of all CO aneurysms treated), 10 other paraclinoid aneurysms (16.4% of all paraclinoid aneurysms), 7 posterior communicating artery (PCoA) aneurysms (21.9% of all PCoA aneurysms), 7 cavernous internal carotid artery (ICA) aneurysms (14.9% of all cavernous ICA aneurysms), 4 vertebrobasilar (VB) junction aneurysms (14.8% of all VB junction aneurysms), and 3 middle cerebral artery (MCA) aneurysms (25% of all MCA aneurysms). Eleven patients underwent placement of more than one PED (21.2%), with a mean number of devices of 1.28 per case. Eight of 12 aneurysms were previously treated with a stent (15.4%). Nineteen patients underwent re-treatment (36.5%); the 33 patients who did not undergo re-treatment (63.5%) were monitored by angiography or noninvasive imaging. In multivariate analysis, age older than 65 years (OR 2.65, 95% CI 1.33-5.28; p = 0.05), prior stent placement across the target aneurysm (OR 2.94, 95% CI 1.15-7.51; p = 0.02), aneurysm location in the distal anterior circulation (MCA, PCoA, and anterior choroidal artery: OR 2.72, 95% CI 1.19-6.18; p = 0.017), and longer follow-up duration (OR 1.06, 95% CI 1.03-1.09; p < 0.001) were associated with incomplete aneurysm occlusion. CONCLUSIONS While the PED can allow for treatment of large, broad-necked aneurysms with high efficacy, treatment failures do occur (16.4%). Aneurysm size, shape, and previous treatment may influence treatment outcome.
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Affiliation(s)
- Badih Daou
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Elias Atallah
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Nohra Chalouhi
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Robert M Starke
- Departments of2Neurosurgery and
- 3Radiology, University of Miami, Florida
| | - Jeffrey Oliver
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Maria Montano
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Robert H Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Stavropoula I Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
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19
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Dossani RH, Patra DP, Kosty J, Jumah F, Kuybu O, Mohammed N, Waqas M, Riaz M, Cuellar H. Early Versus Delayed Flow Diversion for Ruptured Intracranial Aneurysms: A Meta-Analysis. World Neurosurg 2019; 126:41-52. [PMID: 30822578 DOI: 10.1016/j.wneu.2019.02.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/03/2019] [Accepted: 02/05/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The use and timing of flow diversion for aneurysmal subarachnoid hemorrhage is controversial. The objective of this study is to perform a meta-analysis and systematic review to compare overall complication rate between early versus delayed flow diversion for ruptured aneurysms. METHODS A literature search for all eligible articles was performed using PubMed, Cochrane, and Web of Science databases. The primary outcome was the overall complication rate (any complication in the perioperative period), and secondary outcomes were 1) hemorrhage and 2) stroke/death (all hemorrhagic/ischemic strokes and/or death). RESULTS Thirteen articles including 142 patients met inclusion criteria. Eighty-nine (62.7%) patients underwent early deployment of flow diverters (i.e., 2 days or less). The odds ratio for overall complication rate with early versus delayed flow diversion was 0.95 (95% confidence interval [CI] 0.36-2.49, P = 0.42). The odds ratio for the secondary outcome of hemorrhagic complication for early versus delayed flow diversion was 1.44 (95% CI 0.45-4.52, P = 0.87) and of stroke/death was 1.67 (95% CI 0.5-4.9, P = 0.69). The odds ratio of early versus delayed flow diversion for blister/dissecting/fusiform aneurysms was 0.82 (95% CI 0.29-2.30) and for saccular/giant aneurysms was 2.23 (95% CI 0.17-29.4). At last follow-up, 71.6% of patients had good performance status (modified Rankin Scale score 0-2), and the rate of angiographic aneurysm occlusion was 90.2%. CONCLUSIONS This meta-analysis did not show a difference in overall complication rate between early versus delayed flow diversion for ruptured aneurysms. Early flow diversion for ruptured blister/fusiform/dissecting aneurysms carries a lower risk of aneurysm rerupture and overall complications as compared with that for ruptured saccular/giant aneurysms.
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Affiliation(s)
- Rimal Hanif Dossani
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
| | - Devi P Patra
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Jennifer Kosty
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Fareed Jumah
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Okkes Kuybu
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Nasser Mohammed
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Muhammad Waqas
- Section of Neurosurgery, The Aga Khan University Hospital, Karachi, Pakistan
| | - Muhammad Riaz
- Section of Neurosurgery, The Aga Khan University Hospital, Karachi, Pakistan
| | - Hugo Cuellar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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20
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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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21
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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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Cagnazzo F, di Carlo DT, Cappucci M, Lefevre PH, Costalat V, Perrini P. Acutely Ruptured Intracranial Aneurysms Treated with Flow-Diverter Stents: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2018; 39:1669-1675. [PMID: 30049721 DOI: 10.3174/ajnr.a5730] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 05/25/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND The implantation of flow-diverter stents for the treatment of ruptured intracranial aneurysms required further investigation. PURPOSE Our aim was to analyze the outcomes after flow diversion of ruptured intracranial aneurysms. DATA SOURCES A systematic search of 3 databases was performed for studies published from 2006 to 2018. STUDY SELECTION According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies (from 2010 to 2018) reporting acutely ruptured intracranial aneurysms treated with flow diversion. DATA ANALYSIS Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, rebleeding, and factors influencing the studied outcomes. DATA SYNTHESIS We included 20 studies evaluating 223 patients with acutely ruptured intracranial aneurysms treated with flow-diverter stents. Immediate angiographic occlusion was obtained in 32% (29/86; 95% CI, 15.4%-48%; I2 = 79.6%) of aneurysms, whereas long-term complete/near-complete aneurysm occlusion was 88.9% (162/189; 95% CI, 84%-93.5%; I2 = 20.9%) (mean radiologic follow-up of 9.6 months). The treatment-related complication rate was 17.8% (42/223; 95% CI, 11%-24%; I2 = 52.6%). Complications were higher in the posterior circulation (16/72 = 27%; 95% CI, 14%-40%; I2 = 66% versus 18/149 = 11.7%; 95% CI, 7%-16%; I2 = 0%) (P = .004) and after treatment with multiple stents (14/52 = 26%; 95% CI, 14%-45%; I2 = 59%) compared with a single stent (20/141 = 10%; 95% CI, 5%-15%; I2 = 0%) (P = .004). Aneurysm rebleeding after treatment was 4% (5/223; 95% CI, 1.8%-7%; I2 = 0%) and was higher in the first 72 hours. LIMITATIONS Small and retrospective series. CONCLUSIONS Flow-diversion treatment of ruptured intracranial aneurysms yields a high rate of long-term angiographic occlusion with a relatively low rate of aneurysm rebleeding. However, treatment is associated with a complication rate of 18%. When coiling or microsurgical clipping are not feasible strategies, anterior circulation ruptured aneurysms can be effectively treated with a flow-diversion technique, minimizing the number of stents deployed. Given the 27% rate of complications, flow diversion for ruptured posterior circulation aneurysms should be considered only in selected cases not amenable to other treatments.
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Affiliation(s)
- F Cagnazzo
- From the Department of Neurosurgery (F.C., D.T.d.C., P.P.), University of Pisa, Pisa, Italy
| | - D T di Carlo
- From the Department of Neurosurgery (F.C., D.T.d.C., P.P.), University of Pisa, Pisa, Italy
| | - M Cappucci
- Radiology Department (M.C.), University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - P-H Lefevre
- Neuroradiology Department (P.-H.L., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalo-Universitaire de Montpellier, Montpellier, France
| | - V Costalat
- Neuroradiology Department (P.-H.L., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalo-Universitaire de Montpellier, Montpellier, France
| | - P Perrini
- From the Department of Neurosurgery (F.C., D.T.d.C., P.P.), University of Pisa, Pisa, Italy
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23
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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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24
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Sami MT, Gattozzi DA, Soliman HM, Reeves AR, Moran CJ, Camarata PJ, Ebersole KC. Use of Pipeline™ embolization device for the treatment of traumatic intracranial pseudoaneurysms: Case series and review of cases from literature. Clin Neurol Neurosurg 2018; 169:154-160. [PMID: 29698879 DOI: 10.1016/j.clineuro.2018.04.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 04/03/2018] [Accepted: 04/07/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Intracranial traumatic pseudoaneurysms (PSA) are a rare but dangerous subtype of cerebral aneurysm. Reports documenting use of flow-diverting stents to treat traumatic intracranial PSAs are few and lack long-term follow-up. To our knowledge, this is the largest case-series to date demonstrating use of Pipeline Endovascular Device (PED) for traumatic intracranial PSAs. PATIENTS AND METHODS Retrospective review of 8 intracranial traumatic PSAs in 7 patients treated using only PED placement. Patients were followed clinically and angiographically for at least 6 months. RESULTS Seven patients with a mean age of 37 years were treated for 8 intracranial pseudo-aneurysms between 2011-2015. Six aneurysms were the result of blunt trauma; 2 were from iatrogenic injury during transsphenoidal surgery. Mean clinical and angiographic follow-up in surviving patients was 15.2 months. In patients with angiographic follow-up, complete occlusion was achieved in all but one patient, who demonstrated near-complete occlusion. No ischemic events or stent-related stenosis were observed. One patient developed a carotid-cavernous fistula after PED, which was successfully retreated with placement of a second PED. There were two mortalities. One was due to suspected microwire perforation remote from the target aneurysm resulting in SAH/IPH. The other was due to a traumatic SDH and brainstem hemorrhage from an unrelated fall during follow-up interval. CONCLUSIONS Use of PED for treatment of intracerebral PSAs following trauma or iatrogenic injury showed good persistent occlusion, and acceptable complication rate for this high-risk pathology. Risks of this procedure and necessary antiplatelet therapy require appropriate patient selection. Larger prospective studies are warranted.
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Affiliation(s)
- Mairaj T Sami
- Department of Neurosurgery, University of Kansas Medical Center, Mail Stop 3021, Kansas City, KS, 66160, USA
| | - Domenico A Gattozzi
- Department of Neurosurgery, University of Kansas Medical Center, Mail Stop 3021, Kansas City, KS, 66160, USA.
| | - Hesham M Soliman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alan R Reeves
- Department of Radiology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160 USA
| | - Christopher J Moran
- Department of Radiology, Washington University School of Medicine, Barnes-Jewish Hospital Mallinckrodt Institute of Radiology, 510 South Kingshighway Boulevard, St. Louis, MO, 63100, USA
| | - Paul J Camarata
- Department of Neurosurgery, University of Kansas Medical Center, Mail Stop 3021, Kansas City, KS, 66160, USA
| | - Koji C Ebersole
- Department of Neurosurgery, University of Kansas Medical Center, Mail Stop 3021, Kansas City, KS, 66160, USA
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25
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Ozaki T, Nishida T, Fujita Y, Kishima H, Kinoshita M. Coil and Single-Stent Placement for Ruptured Dissecting Aneurysm of Middle Cerebral Artery: A Case Report. World Neurosurg 2018; 113:208-211. [PMID: 29499426 DOI: 10.1016/j.wneu.2018.02.117] [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: 12/18/2017] [Revised: 02/18/2018] [Accepted: 02/19/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Ruptured dissecting aneurysms located at the middle cerebral artery (MCA) are rare, and their standard treatment has not been defined. Furthermore, lenticulostriate artery involvement in the dissecting segment makes treatment extremely difficult, and no previous reports have described successful treatment for such conditions. CASE DESCRIPTION We herein report the case of a 74-year-old woman who presented with sudden severe headache from subarachnoid hemorrhage due to dissection in the proximal M1 segment of left MCA involving lenticulostriate arteries. Digital subtraction angiography on day 6 showed that the dissecting aneurysm had enlarged despite strict blood pressure control. On day 8, the patient was treated successfully with a self-expanding closed cell stent and coil embolization, preserving blood flow in the lenticulostriate arteries as well as the MCA. CONCLUSIONS Follow-up digital subtraction angiography performed 5 weeks after endovascular therapy showed healing of the dissecting lesion, and the patient was discharged neurologically intact.
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Affiliation(s)
- Tomohiko Ozaki
- Department of Neurosurgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan.
| | - Takeo Nishida
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yuya Fujita
- Department of Neurosurgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Manabu Kinoshita
- Department of Neurosurgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
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26
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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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Maus V, Mpotsaris A, Dorn F, Möhlenbruch M, Borggrefe J, Stavrinou P, Abdullayev N, Barnikol UB, Liebig T, Kabbasch C. The Use of Flow Diverter in Ruptured, Dissecting Intracranial Aneurysms of the Posterior Circulation. World Neurosurg 2017; 111:e424-e433. [PMID: 29277587 DOI: 10.1016/j.wneu.2017.12.095] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 12/12/2017] [Accepted: 12/14/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Acute dissecting aneurysms of the posterior circulation are a rare cause of subarachnoid hemorrhage. Established endovascular treatment options include parent artery occlusion and stent-assisted coiling, but appear to be associated with an increased risk of ischemic stroke. Vessel reconstruction with flow diverters is an alternative treatment option; however, its safety and efficacy in the acute stage remains unclear. METHODS This is a multicentric retrospective analysis of 15 consecutive acutely ruptured dissecting posterior circulation aneurysms treated with flow diverters. The primary end point was favorable aneurysm occlusion, defined as OKM C1-3 and D (O'Kelly Marotta scale). Secondary end points were procedure-related complications and clinical outcome. RESULTS Nine of 15 aneurysms (60%) arose from the intradural portion of the vertebral artery, 3 were located on the posterior inferior cerebellar artery and 1 each on the anterior inferior cerebellar artery, posterior cerebral artery, and basilar artery. Flow diverter placement was technically successful in 14 of 15 cases (93%). After endovascular treatment, none of the ruptured aneurysms rebled. Median clinical follow-up was 217 days and median angiographic follow-up was 203 days. Favorable occlusion was observed in 7 of 14 aneurysms (50%) directly after flow diverter placement; of those, 5 were completely occluded (36%). Seven patients (47%) with poor-grade subarachnoid hemorrhage died in the acute phase. Favorable clinical outcome (modified Rankin scale ≤2) was observed in 4 of 15 patients (27%) and a moderate outcome (modified Rankin scale 3/4) was observed in 5 of 15 patients (33%). All aneurysms showed complete occlusion at follow-up. CONCLUSIONS Flow diverters might be a feasible, alternative treatment option for acutely ruptured dissecting posterior circulation aneurysms and may effectively prevent rebleeding. Larger cohort studies are required to validate these results.
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Affiliation(s)
- Volker Maus
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany.
| | | | - Franziska Dorn
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan Borggrefe
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Pantelis Stavrinou
- Department of Neurosurgery, University Hospital Cologne, Cologne, Germany
| | - Nuran Abdullayev
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Utako Birgit Barnikol
- Clearing Unit Ethics, Medical Faculty of Cologne & Research Unit Ethics, Department of Child and Adolescence Psychiatry, University Hospital Cologne, Cologne, Germany
| | - Thomas Liebig
- Department of Neuroradiology, Charite, Berlin, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
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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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Aihara M, Naito I, Shimizu T, Matsumoto M, Asakura K, Miyamoto N, Yoshimoto Y. Predictive factors of medullary infarction after endovascular internal trapping using coils for vertebral artery dissecting aneurysms. J Neurosurg 2017; 129:107-113. [PMID: 28799869 DOI: 10.3171/2017.2.jns162916] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The first choice of treatment in cases of vertebral artery dissecting aneurysms (VADAs) is endovascular internal trapping (EIT) of the dissecting segment using coils. However, this procedure carries the risk of medullary infarction, and the risk factors for this complication are not well understood. This study investigated the risk factors causing medullary infarction. METHODS One hundred patients who underwent EIT for VADAs were included in this study. Ninety-three patients presented with subarachnoid hemorrhage. In cases involving the posterior inferior cerebellar artery (PICA), partial internal trapping targeting the ruptured site was performed to preserve the PICA. The VADAs were classified into the distal VA stump group, proximal VA stump group, and entire VA stump group, according to the location of VA segments without adequate flow-out vessels (such as the PICA [VA stump]) at risk of delayed thrombosis. The occurrence of medullary infarction was examined in each group using diffusion-weighted MRI and/or clinical symptoms. Various measurements were performed on digital subtraction angiography, and the risk factors for medullary infarction were analyzed. RESULTS Medullary infarction occurred in 30 patients, affecting the posterolateral medulla in 27 patients and the anteromedial medulla in 3 patients. Medullary infarction occurred in 3 of 47 patients (6%) in the distal VA stump group, 10 of 19 patients (53%) in the proximal VA stump group, and 17 of 34 patients (50%) in the entire VA stump group. The length of trapping was significantly longer in the infarction group than in the noninfarction group but did not differ among the 3 groups. Total length (length of trapping plus VA stump) was a risk factor for medullary infarction in the proximal VA stumps. CONCLUSIONS The primary risk factor for medullary infarction after EIT is not the length of trapping; rather, it is the anatomical location of the VADAs. The risk of medullary infarction is low in cases with distal VA stumps, but the symptoms are severe. Preservation of the origin of the anterior spinal artery can reduce the risk of medullary infarction. The risk of medullary infarction is high in cases with proximal VA stumps, but the symptoms are mild. A shorter length of trapping, although less likely to lead to complications, cannot prevent medullary infarction because the total length depends on the anatomical location of the PICA and not on the surgical technique. Reconstructive therapy should be indicated for patients with ruptured VADAs at high risk of severe ischemic complications (e.g., patients with hypoplasia of the contralateral VA or cases involving the PICA or anterior spinal artery, which are inappropriate for partial internal trapping) or for patients with unruptured VADAs.
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Affiliation(s)
- Masanori Aihara
- 1Department of Neurosurgery, Gunma University Graduate School of Medicine
| | - Isao Naito
- 2Department of Neurosurgery, Geriatrics Research Institute and Hospital
| | - Tatsuya Shimizu
- 1Department of Neurosurgery, Gunma University Graduate School of Medicine
| | - Masahiro Matsumoto
- 3Department of Neurosurgery, Tatebayashi Kosei Hospital, Tatebayashi, Gunma, Japan
| | - Ken Asakura
- 4Department of Neurosurgery, Maebashi Red Cross Hospital, Maebashi; and
| | - Naoko Miyamoto
- 2Department of Neurosurgery, Geriatrics Research Institute and Hospital
| | - Yuhei Yoshimoto
- 1Department of Neurosurgery, Gunma University Graduate School of Medicine
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30
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Murai Y, Matano F, Yokobori S, Onda H, Yokota H, Morita A. Treatment Strategies of Subarachnoid Hemorrhage from Bilateral Vertebral Artery Dissection: A Case Report and Literature Review Focusing on the Availability of Stent Placement. World Neurosurg 2017; 106:1050.e11-1050.e20. [PMID: 28710044 DOI: 10.1016/j.wneu.2017.06.167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/26/2017] [Accepted: 06/29/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Bilateral vertebral artery dissection (VAD) may result in subarachnoid hemorrhage (SAH). However, a variety of factors contribute to the difficulties with treating SAH. We report a case of bilateral VAD with SAH, as well as a literature review. CASE DESCRIPTION A 32-year-old woman developed headache. Computed tomography demonstrated diffuse SAH, and 3-dimensional computed tomography indicated bilateral VAD. Her left vertebral artery was severely stenosed, and the basilar artery retrogradely flowed via the posterior communicating artery. Her bilateral VAD was trapped with the use of staged craniotomy. The postoperative course was uneventful for 13 days; however, severe neurologic deterioration remained in the area of the cerebral infarction, due to vasospasm of the internal carotid artery. This is the first report of hemorrhagic bilateral VAD treated with bilateral trapping and aggressive spasm treatment in the acute phase. However, the treatment was not successful. CONCLUSIONS Because of the increasing use of stent therapy, there has been a shift toward this treatment choice. For cases in which stents cannot be used, treatment methods based on prestenting protocols are helpful. A literature review indicated that conservative treatment for 2 weeks, in which vasospasm and rebleeding are controlled, may be considered compared with acute-stage stent treatment. Following our literature review, in situations in which stents cannot be used, only the ruptured side should be trapped with strict blood pressure control and detailed radiological images should be observed for 2 weeks. In conclusion, patient selection is essential to subject the patient to open surgery in such cases.
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Affiliation(s)
- Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan.
| | - Fumihiro Matano
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Hidetaka Onda
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
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31
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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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32
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Patel PD, Chalouhi N, Atallah E, Tjoumakaris S, Hasan D, Zarzour H, Rosenwasser R, Jabbour P. Off-label uses of the Pipeline embolization device: a review of the literature. Neurosurg Focus 2017; 42:E4. [DOI: 10.3171/2017.3.focus1742] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The Pipeline embolization device (PED) is the most widely used flow diverter in endovascular neurosurgery. In 2011, the device received FDA approval for the treatment of large and giant aneurysms in the internal carotid artery extending from the petrous to the superior hypophyseal segments. However, as popularity of the device grew and neurosurgeons gained more experience, its use has extended to several other indications. Some of these off-label uses include previously treated aneurysms, acutely ruptured aneurysms, small aneurysms, distal circulation aneurysms, posterior circulation aneurysms, fusiform aneurysms, dissecting aneurysms, pseudoaneurysms, and even carotid-cavernous fistulas. The authors present a literature review of the safety and efficacy of the PED in these off-label uses.
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Affiliation(s)
- Purvee D. Patel
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
- 2Department of Neurological Surgery, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey; and
| | - Nohra Chalouhi
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Elias Atallah
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- 3Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Hekmat Zarzour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Cerejo R, Bain M, Moore N, Hardman J, Bauer A, Hussain MS, Masaryk T, Rasmussen P, Toth G. Flow diverter treatment of intracranial vertebral artery dissecting pseudoaneurysms. J Neurointerv Surg 2017; 9:1064-1068. [PMID: 28438894 DOI: 10.1136/neurintsurg-2017-013020] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/19/2017] [Accepted: 03/27/2017] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Intracranial vertebral dissecting pseudoaneurysms are a rare, but increasingly recognized, cause of subarachnoid hemorrhage and ischemic stroke. The risks of aneurysm re-rupture and associated morbidity are high. The use of flow diverter stents for the treatment of these aneurysms has not been well studied. OBJECTIVE To report our data and provide a summarized review of literature using flow diverter stents for the treatment of intracranial vertebral artery dissecting pseudoaneurysms. METHODS We performed a retrospective analysis of flow diverter stents used for the treatment of intracranial vertebral artery dissecting pseudoaneurysms. Clinical, imaging, procedural, and follow-up data were collected. RESULTS We identified eight vertebral dissecting pseudoaneurysms in seven patients (5 (71.4%) female; median age 47 years (IQR 46-52)) who had undergone treatment with flow diverter stents. In 4/7 patients (57.1%) the aneurysm had ruptured; however, only one was treated in the acute phase. Median size of the largest diameter of the aneurysm was 6.3 mm (IQR 4.2-8.8), and 7/8 aneurysms (87.5%) were treated with a single flow diverter device. Three aneurysms were concurrently coiled. Angiographic complete occlusion was seen in 6/8 (75%) aneurysms at a median follow-up of 14 months (IQR 7.7-20.2). Two patients had periprocedural strokes with transient neurologic deficits. All patients had a good clinical outcome (modified Rankin Scale score ≤2). There were no re-treatments or aneurysm ruptures during the follow-up period. CONCLUSIONS Our experience suggests that flow diverter stent treatment of intracranial vertebral artery dissecting pseudoaneurysms is safe, and associated with good occlusion rates and favorable clinical outcomes.
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Affiliation(s)
- Russell Cerejo
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark Bain
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nina Moore
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Julian Hardman
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andrew Bauer
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Thomas Masaryk
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Peter Rasmussen
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
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Derelle AL, Barbier C, Tonnelet R, Liao L, Anxionnat R, Bracard S. Three Cases of Ruptured Basilar Artery Dissection: From Diagnosis to Endovascular Treatment. World Neurosurg 2016; 91:676.e1-7. [PMID: 27155379 DOI: 10.1016/j.wneu.2016.04.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Ruptured basilar artery dissections are rare, and prognosis is often disastrous. CASE DESCRIPTION We report 3 recent cases of ruptured dissection from imaging diagnosis to endovascular treatment, presenting 3 different types of dissection and 3 different treatment approaches. These 3 patients presented major subarachnoid hemorrhage (Fisher grade 4): 2 of them were in a coma (World Federation of Neurosurgical Societies Grading System [WFNS] 5), and 1 patient presented with headache only (WFNS 1). Two of the 3 dissections presented a dilated pseudoaneurysm responsible for the bleeding (1 large and 1 small), and the remaining dissection was extensive. The dissection with the larger pseudoaneurysm was treated with coils, resulting in early recanalization requiring another endovascular treatment with coils and a flow diverter stent. The patient with the small pseudoaneurysm was treated with a flow diverter only. These 2 patients had a favorable outcome. The remaining patient with a large tear of the basilar artery had 3 overlapping stents, and fatal rebleeding occurred prematurely. CONCLUSIONS These 3 cases illustrate different patient management strategies. We discuss this challenging condition and the current position of endovascular therapeutic techniques.
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Affiliation(s)
- Anne-Laure Derelle
- Department of Interventional and Diagnostic Neuroradiology, CHU Nancy, Nancy, France.
| | - Charlotte Barbier
- Department of Interventional and Diagnostic Neuroradiology, CHU Nancy, Nancy, France
| | - Romain Tonnelet
- Department of Interventional and Diagnostic Neuroradiology, CHU Nancy, Nancy, France; Université de Lorraine, France
| | - Liang Liao
- Department of Interventional and Diagnostic Neuroradiology, CHU Nancy, Nancy, France
| | - René Anxionnat
- Department of Interventional and Diagnostic Neuroradiology, CHU Nancy, Nancy, France; Université de Lorraine, France; IADI-INSERM U947, France
| | - Serge Bracard
- Department of Interventional and Diagnostic Neuroradiology, CHU Nancy, Nancy, France; Université de Lorraine, France; IADI-INSERM U947, France
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Linfante I, Mayich M, Sonig A, Fujimoto J, Siddiqui A, Dabus G. Flow diversion with Pipeline Embolic Device as treatment of subarachnoid hemorrhage secondary to blister aneurysms: dual-center experience and review of the literature. J Neurointerv Surg 2016; 9:29-33. [DOI: 10.1136/neurintsurg-2016-012287] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 03/11/2016] [Accepted: 03/18/2016] [Indexed: 11/03/2022]
Abstract
BackgroundAneurysmal subarachnoid hemorrhage (aSAH) secondary to blister-type aneurysms (BAs) is associated with high morbidity and mortality. Microsurgical clipping or wrapping and/or use of traditional endovascular techniques to repair the lesion result in frequent regrowth and rebleeds and ultimately high fatality rates. Because of the purely endoluminal nature of arterial reconstruction, flow diversion may represent an ideal option to repair ruptured BAs.MethodsWe performed a retrospective analysis of our database including all consecutive patients with aSAH secondary to BAs treated with the Pipeline Embolic Device (PED) between November 2013 and November 2015 in two institutions. We collected basic patient demographics, aneurysm size, location, number and sizes of PEDs used, use of coiling, 30-day modified Rankin Scale (mRS) score, and follow-up imaging data.ResultsTen cases of aSAH were found as a result of a ruptured BA. Patients had a mean age of 47.2 years (range 27–68). Mean Hunt and Hess score was 1.6 (range 1–4). Lesions were predominantly left-sided, mostly along the dorsal aspect of the internal carotid artery, either paraclinoid or paraophthalmic (8/10). In two patients the BA was located in the left middle cerebral artery. All lesions were very small (mean 1.4×1.5 mm; range 0.75–2.1 mm). Placement of a single PED resulted in immediate occlusion or near-occlusion of the BA in 9 out of 10 patients. Nine patients did very well; eight had a 90-day mRS score of 0 and one had a 90-day mRS score of 1. Follow-up digital subtraction angiography was performed in all patients (mean 15 months; range 7–24). In the surviving nine patients there was complete occlusion of the BA on long-term follow-up angiography.ConclusionsRepair of ruptured BA with PED may be a safe and durable option.
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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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Treatment strategies for dissecting aneurysms of the posterior cerebral artery. Acta Neurochir (Wien) 2015; 157:1633-43. [PMID: 26259621 DOI: 10.1007/s00701-015-2526-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/28/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Dissecting aneurysms of the posterior cerebral artery (PCA) are rare and difficult to treat because of their deep and unfamiliar locations and unusual shapes. Although several treatment modalities have been proposed, none have generated satisfying results. Our experiences with PCA-dissecting aneurysms are reviewed and the treatment strategies discussed. METHODS All consecutive patients with PCA-dissecting aneurysm who were treated in a tertiary referral hospital between January 1998 and March 2014 were identified by retrospective review. Their clinical characteristics, radiological findings, treatment modalities and outcomes were documented. RESULTS Of the 21 patients with 21 PCA-dissecting aneurysms, 9 had subarachnoid hemorrhage and 3 had acute infarction of the thalamus at presentation. The aneurysms involved P1 (n = 4), the P1-2 junction (n = 3), mid-P2 (n = 6), P2A (n = 3), P2P (n = 1) and the P2-3 junction (n = 4). The aneurysm shapes were as follows: fusiform (n = 12), partially thrombosed (n = 8) and blood blister-like aneurysms (n = 1). The mean size was 16.6 ± 9.7 mm. Parent artery occlusion (PAO) without bypass (n = 15), PAO with bypass (n = 2), stent-assisted endosaccular coiling (n = 3) and stent placement only (n = 1) were performed. All three patients who underwent stent-assisted endosaccular coiling and the single patient who underwent PAO without bypass developed aneurysm recurrence. Six of the ten patients who received a PAO without a balloon test occlusion (BTO) experienced PCA territory infarction, whereas only one of the five patients who received a PAO after passing the BTO experienced an infarction. CONCLUSIONS PAO for PCA-dissecting aneurysm was effective in preventing recurrence. In addition, BTO before PAO was helpful in identifying candidates who truly needed surgical revascularization.
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Madaelil TP, Wallace AN, Chatterjee AN, Zipfel GJ, Dacey RG, Cross DT, Moran CJ, Derdeyn CP. Endovascular parent vessel sacrifice in ruptured dissecting vertebral and posterior inferior cerebellar artery aneurysms: clinical outcomes and review of the literature. J Neurointerv Surg 2015; 8:796-801. [DOI: 10.1136/neurintsurg-2015-011732] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 07/06/2015] [Indexed: 11/04/2022]
Abstract
BackgroundRuptured intracranial dissecting aneurysms must be secured quickly to prevent re-hemorrhage. Endovascular sacrifice of the diseased segment is a well-established treatment method, however postoperative outcomes of symptomatic stroke and re-hemorrhage rates are not well reported, particularly for the perforator-rich distal vertebral artery or proximal posterior inferior cerebellar artery (PICA).MethodsWe retrospectively reviewed cases of ruptured distal vertebral artery or PICA dissecting aneurysms that underwent endovascular treatment. Diagnosis was based on the presence of subarachnoid hemorrhage on initial CT imaging and of a dissecting aneurysm on catheter angiography. Patients with vertebral artery aneurysms were selected for coil embolization of the diseased arterial segment based on the adequacy of flow to the basilar artery from the contralateral vertebral artery. Patients with PICA aneurysms were generally treated only if they were poor surgical candidates. Outcomes included symptomatic and asymptomatic procedure-related cerebral infarction, recurrent aneurysm rupture, angiographic aneurysm recurrence, and estimated modified Rankin Scale (mRS).ResultsDuring the study period, 12 patients with dissecting aneurysms involving the distal vertebral artery (n=10) or PICA (n=2) were treated with endovascular sacrifice. Two patients suffered an ischemic infarction, one of whom was symptomatic (8.3%). One patient (8.3%) died prior to hospital discharge. No aneurysm recurrence was identified on follow-up imaging. Ten patients (83%) made a good recovery (mRS ≤2). Median clinical and imaging follow-up periods were 41.7 months (range 0–126.4 months) and 14.3 months (range 0.03–88.6 months), respectively.ConclusionsIn patients with good collateral circulation, endovascular sacrifice may be the preferred treatment for acutely ruptured dissecting aneurysms involving the distal vertebral artery.
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Nam DH, Park SK. Endovascular Treatment in Ruptured Middle Cerebral Artery Dissection Preservation of Arterial Continuity. J Cerebrovasc Endovasc Neurosurg 2015; 17:108-12. [PMID: 26157690 PMCID: PMC4495084 DOI: 10.7461/jcen.2015.17.2.108] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 01/23/2015] [Accepted: 04/03/2015] [Indexed: 11/23/2022] Open
Abstract
Rupture of spontaneous dissecting aneurysms of the middle cerebral artery (MCA) is rare and its etiology remains obscure, although the risk of rebleeding is greater than with saccular aneurysms. Most reports concerning the treatment of a ruptured dissecting aneurysm of the anterior circulation involve surgical trapping or wrapping. Here, we report on a case of an MCA dissecting rupture treated with endovascular procedures. A 22-year-old female presented with sudden stuporous mental change following severe headache and left side hemiparesis. A computed tomography scan showed a diffuse subarachnoid hemorrhage and diffusion MR showed diffusion restriction at the right putamen and internal capsule. A 3-hour follow-up digital subtraction angiography (DSA) showed a dissecting aneurysm, which was not seen on an initial DSA. A stent assisted coil embolization was performed and double stents were applied to achieve flow diversion effects. A small remnant area of the dissecting aneurysm had disappeared at 60-day and was not observed on 12-month follow-up DSA.
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Affiliation(s)
- Dong Hyuk Nam
- Department of Neurosurgery, Kimpo Woori Hospital, Kimpo, Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
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Bhogal P, Brouwer PA, Söderqvist ÅK, Ohlsson M, Andersson T, Holmin S, Söderman M. Patients with subarachnoid haemorrhage from vertebrobasilar dissection: treatment with stent-in-stent technique. Neuroradiology 2015; 57:605-14. [PMID: 25740790 DOI: 10.1007/s00234-015-1505-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 02/20/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Vertebrobasilar dissection is an uncommon cause of subarachnoid haemorrhage (SAH) that carries a high risk for early repeat haemorrhage. The need for rapid treatment of this disease entity is without question; however, the best method for treatment is still undetermined. Here, we present our results using the stent-in-stent technique, without coiling, for these patients and propose that it is a viable treatment strategy. METHODS We identified in our local database for neurointerventional therapy, between 1st October 2000 and 1st January 2014, 93 patients with potential subarachnoid haemorrhage secondary to vertebrobasilar pathology. After review of the clinical notes and imaging, 15 were found to have presented with subarachnoid haemorrhage and treated with stents alone. All dissections were spontaneous with no history of preceding trauma. The ages ranged between 46 and 71 years (mean 61 years). RESULTS All patients presented with Fischer grade 4 SAH and had a visible pseudoaneurysm. The pre-operative GCS varied with two patients scoring 3, one patient scoring 6 and the remaining 12 patients scoring 8 or above. All cases were subjected to stent-in-stent treatment alone. We did not experience any intra-procedural complications. In our series, eight patients had full recovery with a Glasgow Outcome Scale (GOS) of 5, three had moderate disability (GOS 4), one had severe disability (GOS 3), and three patents died, one patient from stent thrombosis or re-bleeding and two from their initial SAH. CONCLUSION The stent-in-stent technique represents a viable reconstructive endovascular surgical technique with a low risk of intra-procedural complication and post-operative repeat haemorrhage.
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Affiliation(s)
- Pervinder Bhogal
- Department of Neuroradiology, The Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden,
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