1
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Zarrintan A, Ghozy S, Maroufi SF, Reda A, Brinjikji W, Kadirvel R, Kallmes DF. Efficacy and safety of flow diverters in retreatment of recurrent intracranial aneurysms-A systematic review and meta-analysis. Interv Neuroradiol 2024:15910199241282713. [PMID: 39275854 DOI: 10.1177/15910199241282713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2024] Open
Abstract
BACKGROUND AND PURPOSE Treatment of recurrent intracranial aneurysms after their initial therapy has been a significant challenge in the field of neurointervention. Recently flow diverters stents are widely used for treating intracranial aneurysms. In this systematic review and meta-analysis, we assessed the safety and efficacy of flow diverter in treating recurrent or recanalized intracranial aneurysms. METHODS This meta-analysis is reported following the PRISMA 2020 guidelines. We conducted a systematic review of literature in the PubMed, Embase, Web of Sciences, and Scopus databases. Pooled prevalence and the corresponding 95% are calculated from extracted data using a random-effect model. RESULTS The systematic literature search included 21 studies involving 411 patients, with 135 (32.8%) being male and 276 (67.2%) being females with a total number of 447 aneurysms. The overall rate of adequate occlusion was 90.67% (95% CI: 84.23%-94.65%), and the rates were comparable between the surgery (93.48%), coiling (91.78%), and stenting (85.77%) groups. The overall pooled rate of complete occlusion was 81.80 (95% CI: 71.14%-89.13%). On doing a subgroup analysis, the complete occlusion rates were 89.68%, 84.39%, and 73.47% for the surgery, coiling, and stenting groups, respectively. The overall mortality rate and achieving modified Rankin scale score of 0-2 was 1.28% (95% CI: 0.45%-3.64%) and (95% CI: 89.92%-97.84%), respectively. No significant heterogeneity is noted in the included studies. CONCLUSION Flow diverter stents are an effective and safe method for retreating recurrent or residual intracranial aneurysms with a high rate of complete and adequate occlusion. The rate of mortality, intracerebral hemorrhage, and overall and procedural complications following using flow diverters for intracranial aneurysms is low.
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Affiliation(s)
- Armin Zarrintan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Abdullah Reda
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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2
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Nguyen VN, Heiferman DM, Dornbos D, Johnson KD, Dawkins DW, Moore KA, Khan NR, Hoit DA, Arthur AS. Sequential Flow Diversion After Nitinol Stent Placement for a Large, Matricidal Cavernous Internal Carotid Artery Aneurysm: Technical Video. Interv Neuroradiol 2024; 30:424-425. [PMID: 36113015 PMCID: PMC11310729 DOI: 10.1177/15910199221127455] [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: 06/27/2022] [Accepted: 09/02/2022] [Indexed: 02/18/2024] Open
Abstract
The Surpass Evolve flow diverter is a novel 64-wire braided intravascular stent approved to treat unruptured large or giant saccular wide-neck or fusiform intracranial aneurysms of the intracranial internal carotid artery.1-3 Flow diverting stents have been used for the treatment of previously stented aneurysms, including residual aneurysms following prior flow diversion.5-8 This patient initially presented with a large symptomatic matricidal cavernous ICA aneurysm4 that was treated with stand-alone Neuroform Atlas stenting at an outside hospital. Here we present a video demonstrating the placement of sequential Surpass Evolve flow diverter stents within a Neuroform Atlas nitinol stent.
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Affiliation(s)
- Vincent N Nguyen
- Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, USA
| | | | - David Dornbos
- Department of Neurosurgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | - Demi W Dawkins
- Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
| | - Kenneth A Moore
- Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, USA
| | - Nickalus R Khan
- Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, USA
| | - Daniel A Hoit
- Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, USA
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3
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Chinnadurai A, Salih M, Taussky P, Ogilvy C. Safety and Outcomes of the Off-Label Treatment of Intracranial Aneurysms with Pipeline Embolization Device: A Systematic Review and Meta-analysis. World Neurosurg 2024; 185:e786-e799. [PMID: 38432507 DOI: 10.1016/j.wneu.2024.02.132] [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: 01/21/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Off-label use of pipeline embolization devices (PEDs) has been increasingly used for endovascular treatment of intracranial aneurysms. Numerous articles have highlighted the safety and effectiveness of PED placement from independent centers for both on- and off-label indications. There remains a paucity of information that considers overall safety and efficacy of off-label PED placement across the existing literature. Our objective is to systematically review the safety and occlusion outcomes of PED off-label use in intracranial aneurysm embolization. METHODS A systematic search of PubMed and Embase was performed to identify studies on off-label use of PED. The selected studies provided relevant information, including study characteristics, patient demographics, clinical outcomes, peri-procedural complications, and long-term outcomes, which were subjected to meta-analysis. RESULTS Twelve studies met the inclusion and exclusion criteria. There were 747 patients and 791 aneurysms included for analysis. Among the patient, 69.2% were female, with an age range of 16 to 80 years. The overall incidence rates for ischemic and hemorrhagic complications were 7% (95% CI: 4%-10%) and 2% (95% CI: 0%-4%), respectively. The mortality rate was 1% (95% CI: 0%-4%). The occlusion rates of aneurysm at initial follow up and 1 year follow-up were 82% (95% CI: 72%-91%) and 81% (95%CI: 75%-86%), respectively. Meta-regression analysis indicated no correlation between occlusion rate and factors such as age, sex, aneurysm size, location, morphology, rupture, or history of treatment. CONCLUSIONS Despite variations in results observed in single-center studies, this meta-analysis provides evidence supporting the safety and efficacy of PED off-label use.
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Affiliation(s)
- Anu Chinnadurai
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Mira Salih
- Neurosurgical Service, Harvard Medical School, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Boston, Massachusetts, USA
| | - Philipp Taussky
- Neurosurgical Service, Harvard Medical School, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Boston, Massachusetts, USA
| | - Christopher Ogilvy
- Neurosurgical Service, Harvard Medical School, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Boston, Massachusetts, USA.
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4
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Enriquez Marulanda A, Young M, Shutran M, Taussky P, Kicielinski K, Ogilvy CS. Acute Coiling With Delayed Flow Diversion for Posterior Communicating Segment Internal Carotid Artery Aneurysms: A Multicenter Case Series. Neurosurgery 2024; 94:729-735. [PMID: 37931125 DOI: 10.1227/neu.0000000000002720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/22/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In ruptured posterior communicating artery (PcomA) aneurysms, the protection of the aneurysm dome alone with initial subtotal coiling decreases the risk of rerupture in the acute setting but does not provide durable/definitive long-term protection against delayed rupture. Delayed flow diverter (FD) placement can be a potential alternative to definitively secure these aneurysms without increasing the risk of complications and PComA occlusion. We analyzed PComA aneurysms treated with a planned delayed FD after primary coiling and assess radiographic and clinical outcomes. METHODS We performed a retrospective study of prospectively collected data for intracranial aneurysms treated with planned FD at 2 institutions from 2013 to 2022. PComA aneurysms that underwent primary coiling and delayed FD placement were included for analysis. RESULTS There were 29 PComA aneurysms identified that were included in the analysis. Patients were mostly female (79.3%), with a median age of 60 years. The mean aneurysm maximum diameter was 7.2 mm ± (5.3). Immediate Raymond-Roy occlusion grade after primary coiling was I in 48.3%, II in 41.4%, and III in 10.3% of aneurysms. The median time from initial coiling to planned delayed FD placement was 6.3 months (3.2-18.6). A total of 21 (72.4%) aneurysms underwent follow-up radiological imaging. Complete and near-complete occlusion status was achieved in 76.2% of the evaluated aneurysms. There were no retreatments and no evidence of delayed aneurysm rupture. One case (3.5%) presented thromboembolic complications and 1 (3.5%) intracranial hemorrhagic complication after FD placement, which was associated with mortality. Most patients (90.5%) had a modified Rankin scale of ≤2 on the last follow-up. CONCLUSION Primary coiling with planned staged FD placement is effective for treating ruptured PComA aneurysms with high occlusion rates and low complications.
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Affiliation(s)
- Alejandro Enriquez Marulanda
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| | - Michael Young
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| | - Max Shutran
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| | - Philipp Taussky
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| | - Kimberly Kicielinski
- Neurosurgery Department, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Christopher S Ogilvy
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
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Srinivasan VM, Jubran JH, Stonnington HO, Catapano JS, Scherschinski L, Hendricks BK, Winkler EA, Rudy RF, Nguyen BA, Dabrowski SJ, Jadhav AP, Ducruet AF, Albuquerque FC. Flow diversion for basilar quadrifurcation aneurysms. J Neurointerv Surg 2024; 16:372-378. [PMID: 37253595 DOI: 10.1136/jnis-2022-019238] [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: 06/02/2022] [Accepted: 05/01/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Flow-diverting devices (FDDs), such as the Pipeline Embolization Device, have been gaining traction for treating challenging posterior circulation aneurysms. Few previous studies have focused on using FDDs to treat aneurysms of the basilar quadrifurcation. METHODS We retrospectively reviewed the use of FDDs to treat patients with basilar quadrifurcation aneurysms. Patients were assessed for aneurysm type, previous aneurysm treatment, technical success, periprocedural complications, and long-term aneurysm occlusion. RESULTS 34 patients were assessed; aneurysms of the basilar apex (n=23) or superior cerebellar artery (SCA) (n=7), or both (n=1), and posterior cerebral artery (PCA) (n=3). The mean (SD) largest aneurysm dimension was 8.7 (6.1) mm (range 1.9-30.8 mm). 14 aneurysms were previously surgically clipped or endovascularly coiled. All aneurysms had a saccular morphology. Complete or near-complete occlusion was achieved in 30 of 34 patients (88%) at final angiographic follow-up, a mean (SD) of 6.6 (5.4) months (range 0-19 months) postoperatively. No patient experienced postoperative symptomatic occlusions of the SCA or PCA; 4 patients developed asymptomatic posterior communicating artery occlusions; 28 patients (82%) experienced no complications; whereas 3 (9%) experienced major complications and 3 (9%) experienced minor complications; and 1 patient died as a result of subarachnoid hemorrhage. CONCLUSION Flow diversion may be a safe and effective option to treat basilar quadrifurcation aneurysms. Previously treated basilar quadrifurcation aneurysms with recurrence or residual lesion may benefit from additional treatment with an FDD. Further prospective studies should be directed toward validating these findings.
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Affiliation(s)
- Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jubran H Jubran
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Henry O Stonnington
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Benjamin K Hendricks
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Robert F Rudy
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Brandon A Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Stephen J Dabrowski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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6
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Lee I(TL, Kao YS, Lai YJ, Yen HH. Flow diverter retreatment for intracranial aneurysms: A meta-analysis of efficacy and feasibility. Interv Neuroradiol 2024; 30:37-42. [PMID: 35505615 PMCID: PMC10956466 DOI: 10.1177/15910199221095972] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 04/04/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Recurrent intracranial aneurysm carries a risk of rupture and retreatment is often necessary. However, there is no consensus on the best retreatment modality of choice. Flow diverter has emerged as a promising option for this population in recent years. Given its high cost, patient selection to optimize outcomes is very important. PURPOSE To identify patient factors predisposing to failure of flow diverter retreatment. METHOD We conducted a systematic search on PubMed, Cochrane Library, Embase, Ovid/Medline, and ClinicalTrial.gov from 2000 to 2021. Studies regarding flow diverter retreatment of recurrent aneurysms were analyzed if they meet the inclusion criteria. RESULTS A total of twenty-six studies were identified. Among 374 patients retreated with flow diverters, about 0.86 [0.81; 0.92] were successfully occluded and only 0.06 [0.02; 0.10] had unfavorable neurological outcomes. Major complications included intracranial hemorrhage (n = 7), ischemic stroke or thromboembolic event (n = 12), and death (n = 2). In-stent stenosis was reported in 10 of the cases. Saccular aneurysms are associated with a higher occlusion rate while aneurysm location, size, status, and prior treatment modality have no significant impact on retreatment efficacy. CONCLUSIONS We demonstrated that flow diverter is an effective retreatment strategy except in patients with non-saccular aneurysms. It should be considered as a first-line option for patients with recurrent intracranial aneurysm.
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Affiliation(s)
- Irene (Tai-Lin) Lee
- Division of Medical Imaging, Department of Radiology, Far Eastern Memorial Hospital, New Taipei city
| | - Yung-Shuo Kao
- Department of Radiation Oncology, China Medical University Hospital, Taichung
| | - Yen-Jun Lai
- Division of Medical Imaging, Department of Radiology, Far Eastern Memorial Hospital, New Taipei city
| | - Ho-Hsian Yen
- Division of Medical Imaging, Department of Radiology, Far Eastern Memorial Hospital, New Taipei city
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7
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El Naamani K, Saad H, Chen CJ, Abbas R, Sioutas GS, Amllay A, Yudkoff CJ, Carreras A, Sambangi A, Hunt A, Jain P, Dougherty J, Tjoumakaris SI, Gooch MR, Herial NA, Rosenwasser RH, Zarzour H, Schmidt RF, Jabbour PM. Comparison of Flow-Redirection Endoluminal Device and Pipeline Embolization Device in the Treatment of Intracerebral Aneurysms. Neurosurgery 2023; 92:118-124. [PMID: 36170173 DOI: 10.1227/neu.0000000000002148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/14/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The use of flow diverters for treating intracranial aneurysms has been widely used in the past decade; however, data comparing pipeline embolization device (PED; Medtronic Inc) and flow-redirection endoluminal device (FRED; MicroVention) in the treatment of intracranial aneurysms remain scarce. OBJECTIVE To compare the outcomes of PED and FRED in the treatment of intracranial aneurysms. METHODS This is a single-center retrospective review of aneurysms treated with PED and FRED devices. Patients treated with PED or FRED were included. Cases requiring multiple or adjunctive devices were excluded. Primary outcome was complete aneurysm occlusion at 6 months. Secondary outcomes included good functional outcome, need for retreatment, and any complication. RESULTS The study cohort comprised 150 patients, including 35 aneurysms treated with FRED and 115 treated with PED. Aneurysm characteristics including location and size were comparable between the 2 cohorts. 6-month complete occlusion rate was significantly higher in the PED cohort (74.7% vs 51.5%; P = .017) but lost significance after inverse probability weights. Patients in the PED cohort were associated with higher rates of periprocedural complications (3.5% vs 0%; P = .573), and the rate of in-stent stenosis was approximately double in the FRED cohort (15.2% vs 6.9%; P = .172). CONCLUSION Compared with PED, FRED offers modest 6-month occlusion rates, which may be due to aneurysmal and baseline patient characteristics differences between both cohorts. Although not significant, FRED was associated with a higher complication rate mostly because of in-stent stenosis. Additional studies with longer follow-up durations should be conducted to further evaluate FRED thrombogenicity.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hassan Saad
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Georgios S Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Clifford J Yudkoff
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Angeleah Carreras
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abhijeet Sambangi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jaime Dougherty
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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8
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Han J, Liang F, Zhang Y, Zhang Y, Liang S, Zhu H, Chang Y, Ma C, Liu L, Jia Z, Jiang C. Pipeline embolization devices for the treatment of nonsaccular aneurysms in pediatric patients. Front Neurol 2023; 14:1115618. [PMID: 36925937 PMCID: PMC10011091 DOI: 10.3389/fneur.2023.1115618] [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: 12/04/2022] [Accepted: 02/07/2023] [Indexed: 03/08/2023] Open
Abstract
Objective Pediatric nonsaccular aneurysms are rare but challenging lesions; pipeline embolization devices (PEDs) are their potential treatment option. In this study, we aimed to evaluate the safety and efficacy of PEDs for treatment of these aneurysms. Methods We retrospectively selected pediatric patients with nonsaccular aneurysms treated using PEDs between June 2015 and July 2021 from our prospectively maintained database. For each patient, demographics, aneurysm characteristics, procedure details, and clinical and angiographic follow-up data were collected and summarized. Results This study included 16 pediatric patients with 16 nonsaccular aneurysms treated with PEDs. A median clinical follow-up time of 1,376 days was achieved in 93.75% of the patients. The complication rate of the included patients was 25%, with two patients developing mass effect, one patient undergoing major ischemic stroke, and one patient experiencing stent foreshortening after the procedure. The complete occlusion rate of aneurysms without any neurologic sequelae was 93.33%, with a median angiographic follow-up period of 246 days. The mortality rate was 6.25%. Conclusions The use of PEDs to treat pediatric nonsaccular aneurysms is feasible, with a high rate of complete occlusion of the aneurysm and favorable follow-up outcomes.
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Affiliation(s)
- Jintao Han
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Fei Liang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Yuxiang Zhang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Yupeng Zhang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Haoyu Zhu
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuzhou Chang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chao Ma
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Lian Liu
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zichang Jia
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Chuhan Jiang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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9
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Zhang H, Ren J, Wang J, Lv X. The off-label uses of pipeline embolization device for complex cerebral aneurysms: Mid-term follow-up in a single center. Interv Neuroradiol 2022:15910199221148800. [PMID: 36583531 DOI: 10.1177/15910199221148800] [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: 12/31/2022] Open
Abstract
OBJECTIVE To describe the off-label uses of pipeline embolization device for a variety of types of aneurysms including ruptured aneurysms, posterior circulation aneurysms, small aneurysms, distal aneurysms, and recurrent aneurysms. METHODS Clinical and angiographic data of patients who underwent pipeline embolization device treatment on off-label use at our center were retrospectively reviewed. For categorical variables, Fisher's exact test was used, and a two-sample Wilcoxon rank-sum test was used for patients' age to analyze the correlation with outcomes. RESULTS In this study, 121 aneurysms in 107 patients received off-label pipeline embolization device treatments. The overall rate of complete aneurysm occlusion was 77.8% (28/36 in 35 patients) for posterior circulation aneurysms and 95.3% (81/85 in 72 patients) for anterior circulation aneurysms. The posterior circulation aneurysms have a lower rate of aneurysm occlusion (p = 0.0372). The small aneurysms have a higher rate of aneurysm occlusion (p = 0.0104). The patient's sex, age, and aneurismal size were associated with ischemic stroke complications (p = 0.0397, 0.0166, and 0.0178). In posterior circulation aneurysm patients, only two basilar apex aneurysms underwent pipeline embolization device treatment, both of whom died of thrombotic complications. There was no difference in mortality between posterior circulation aneurysm patients (8.6%, 3/35) and anterior circulation aneurysm patients (1.4%, 1/72) (p = 0.1015). Patients of older age have a higher risk of death rate (p = 0.0053). CONCLUSIONS The off-label use of pipeline embolization device is often performed in clinical practice and can achieve efficacy in complex aneurysms. The off-label use of pipeline embolization device was found to carry an increased rate of mortality in older patients. Excluding basilar apex aneurysms, the pipeline embolization device is as safe as anterior circulation aneurysms in the treatment of posterior circulation aneurysms elsewhere.
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Affiliation(s)
- Huachen Zhang
- Department of Neurosurgery, 589702Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jiyang Ren
- Center for Statistical Science and Department of Industrial Engineering, Tsinghua University, Beijing, China
| | - Jiangdian Wang
- Center for Statistical Science and Department of Industrial Engineering, Tsinghua University, Beijing, China
| | - Xianli Lv
- Department of Neurosurgery, 589702Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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10
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Khanna O, Al Saiegh F, Mouchtouris N, Sajja K, Baldassari MP, El Naamani K, Tjoumakaris S, Gooch MR, Rosenwasser RH, Starke RM, Jabbour PM. Coil Embolization with Subsequent Subacute Flow Diversion Before Hospital Discharge as a Treatment Paradigm for Ruptured Aneurysms. World Neurosurg 2022; 167:e583-e589. [PMID: 35987457 DOI: 10.1016/j.wneu.2022.08.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Subtotal coil embolization followed by subsequent flow diversion is often pursued for treatment of acutely ruptured aneurysms. Owing to the need for anti-platelet therapy, the optimal time of safely pursuing flow diversion treatment has not been fully elucidated. In this study, we aim to demonstrate the safety and feasibility of staged treatment of acutely ruptured aneurysms with early coil embolization followed by flow diversion prior to discharge. METHODS A retrospective study to evaluate clinical outcomes of patients who presented with aneurysmal subarachnoid hemorrhage and underwent coil embolization followed by subacute flow diversion treatment during the same hospitalization. RESULTS A total of 18 patients are included in our case series. Eight patients presented with Hunt-Hess (H-H) grade 2 bleed, 6 patients with H-H grade 3, and 2 patients each with H-H grade 4 and H-H grade 1. Eight patients required placement of an external ventricular drain on admission. After initial coil embolization, 12 achieved Raymond-Roy grade 2 occlusion, and 6 attained grade 3a/b occlusion. The mean duration between coil embolization and subsequent flow diversion was 9.83 days (range: 1-30). There were no instances of re-hemorrhage between initial coil embolization and subsequent flow diversion treatment. Sixteen patients had a minimum of 6-month follow-up, of which 15 were found to have complete occlusion, and 1 required subsequent clipping. CONCLUSIONS Subtotal coil embolization followed by definitive treatment using flow diversion during the same hospitalization is feasible and achieves excellent aneurysm occlusion rates while avoiding dual anti-platelet therapy during the initial hemorrhage period.
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Affiliation(s)
- Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kalyan Sajja
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael P Baldassari
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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11
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Han YF, Jiang P, Tian ZB, Chen XH, Liu J, Wu ZX, Gao BL, Ren CF. Risk factors for repeated recurrence of cerebral aneurysms treated with endovascular embolization. Front Neurol 2022; 13:938333. [PMID: 36247772 PMCID: PMC9556764 DOI: 10.3389/fneur.2022.938333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 09/02/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose To explore the risk factors of recurrence after second endovascular embolization of recurrent aneurysms and the characteristics of recurrent refractory aneurysms to help clinical decision-making. Materials and methods Forty-nine patients with recurrent aneurysms who underwent repeated embolization were retrospectively enrolled and divided into the recurrent and non-recurrent group. The risk factors of recurrence, complications and follow-up results of repeated embolization, and characteristics of recurrent refractory aneurysms were analyzed. Results Among the 49 patients with the second embolization, 5 were lost to follow-up, 9 recurred, and 35 did not. Univariate analysis showed that aneurysm size (P = 0.022), aneurysm classification (P = 0.014), and Raymond-Roy grade after the second embolization (P = 0.001) were statistically different between the two groups. Multivariate analysis demonstrated the Raymond-Roy grade as an independent risk factor for the recurrence of aneurysms after the second embolization (P = 0.042). The complication rate after the second embolization was 4%. There were five recurrent refractory aneurysms with an average aneurysm size of 23.17 ± 10.45 mm, including three giant aneurysms and two large aneurysms. To achieve complete or near-complete embolization of the recurrent refractory aneurysms, multiple treatment approaches were needed with multiple stents or flow diverting devices. Conclusion Aneurysm occlusion status after the second embolization is an independent risk factor for the recurrence of intracranial aneurysms. Compared with near-complete occlusion, complete occlusion can significantly reduce the risk of recurrence after second embolization. In order to achieve complete or near-complete occlusion, recurrent refractory aneurysms need multiple treatments with the use of multiple stents or flow diverting devices.
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Affiliation(s)
- Yong-Feng Han
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Shijiazhuang People's Hospital, Shijiazhuang, China
| | - Peng Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Peng Jiang
| | - Zhong-Bin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xi-Heng Chen
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhong-Xue Wu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bu-Lang Gao
- Department of Neurosurgery, Shijiazhuang People's Hospital, Shijiazhuang, China
| | - Chun-Feng Ren
- Zhengzhou University First Affiliated Hospital, Zhengzhou, China
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12
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Crinnion W, Jackson B, Sood A, Lynch J, Bergeles C, Liu H, Rhode K, Mendes Pereira V, Booth TC. Robotics in neurointerventional surgery: a systematic review of the literature. J Neurointerv Surg 2022; 14:539-545. [PMID: 34799439 PMCID: PMC9120401 DOI: 10.1136/neurintsurg-2021-018096] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/24/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Robotically performed neurointerventional surgery has the potential to reduce occupational hazards to staff, perform intervention with greater precision, and could be a viable solution for teleoperated neurointerventional procedures. OBJECTIVE To determine the indication, robotic systems used, efficacy, safety, and the degree of manual assistance required for robotically performed neurointervention. METHODS We conducted a systematic review of the literature up to, and including, articles published on April 12, 2021. Medline, PubMed, Embase, and Cochrane register databases were searched using medical subject heading terms to identify reports of robotically performed neurointervention, including diagnostic cerebral angiography and carotid artery intervention. RESULTS A total of 8 articles treating 81 patients were included. Only one case report used a robotic system for intracranial intervention, the remaining indications being cerebral angiography and carotid artery intervention. Only one study performed a comparison of robotic and manual procedures. Across all studies, the technical success rate was 96% and the clinical success rate was 100%. All cases required a degree of manual assistance. No studies had clearly defined patient selection criteria, reference standards, or index tests, preventing meaningful statistical analysis. CONCLUSIONS Given the clinical success, it is plausible that robotically performed neurointerventional procedures will eventually benefit patients and reduce occupational hazards for staff; however, there is no high-level efficacy and safety evidence to support this assertion. Limitations of current robotic systems and the challenges that must be overcome to realize the potential for remote teleoperated neurointervention require further investigation.
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Affiliation(s)
- William Crinnion
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Ben Jackson
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Avnish Sood
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Jeremy Lynch
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Christos Bergeles
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Hongbin Liu
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Kawal Rhode
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Thomas C Booth
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, UK
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13
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Enriquez-Marulanda A, Penumaka A, Ogilvy CS, Thomas AJ, Moore JM. Safety and Efficacy of the Off-Label Use of Pipeline Embolization Device Based on the 2018 Food and Drug Administration-Approved Indications for Intracranial Aneurysms: A Single-Center Retrospective Cohort Study. Neurosurgery 2022; 90:700-707. [PMID: 35319533 DOI: 10.1227/neu.0000000000001891] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pipeline embolization device (PED; ev3/Covidien) has proven safe and effective for treating selected intracranial aneurysms. This device's versatility and popularity have driven increased interest in expanding the latest 2018 Food and Drug Administration-approved indications. OBJECTIVE To compare "off-label" and "on-label" PED treatment. METHODS Retrospective analysis of aneurysms treated with PED at a single center from 2013 to 2019. Comparisons were made based on the 2018 Food and Drug Administration-approved indications. RESULTS A total of 492 treated aneurysms were included (65.2% on-label and 34.8% off-label). Aneurysm complete and near-complete occlusion rate was nonsignificantly lower in the off-label group (80.9% vs 85.7%; P = .19). Off-label treatment had higher rate of poor functional outcomes (modified Rankin Scale [mRS] >2: 10.3% vs 3.5%; P = .002). Although pretreatment mRS was already higher in the off-label group (5.3% vs 0.3%; P < .001) and there were no differences in mRS worsening during follow-up (5.5% vs 2.9%; P = .15). We also found a trend to a higher rate of intracranial hemorrhagic complications in the off-label group (4.7% vs 1.6%; P = .05), but there were no differences in hemorrhages requiring surgical intervention (1.8% vs 1.3%; P = .65). There were no differences in retreatment, thromboembolic complications, and mortality rates. CONCLUSION Off-label PED treatment may be considered for select aneurysms, which are challenging to treat with other techniques. These cases have similar complete and near-complete occlusion rates compared with on-label cases. There are, however, higher risks of poor functional outcomes despite similar rates of thromboembolic and hemorrhagic complications. This is partly explained by the significantly higher pretreatment mRS score in the off-label group.
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14
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Abbas R, El Naamani K, Sweid A, Birkenstock L, Ruiz R, Tjoumakaris S, Gooch MR, Herial NA, Rosenwasser RH, Jabbour P. Retreatment Strategies in Aneurysm Woven Endobridge Recurrences: A Case Series. Oper Neurosurg (Hagerstown) 2022; 22:201-207. [PMID: 35240675 DOI: 10.1227/ons.0000000000000115] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The treatment of wide-necked and bifurcation aneurysms has become a common indication for the Woven Endobridge (WEB) device. In many instances, WEB embolization fails and retreatment strategies for the recanalized aneurysms have not been established and may be challenging. OBJECTIVE To report an experience with retreatment strategies after WEB failure in 7 cases involving various aneurysm shapes, sizes, and location using multiple strategies including endovascular modalities and microsurgical clip ligation. METHODS Data were retrospectively collected from 1 high-volume cerebrovascular center for 7 patients treated with a WEB device for an aneurysm who subsequently required retreatment for that same aneurysm from 2015 through January 2021. RESULTS We identified 7 patients with WEB recurrences over a period of 6 years. Four patients initially presented with incidental findings, whereas 3 patients presented with subarachnoid hemorrhage. One patient was lost to follow-up and presented with a rerupture, whereas the 6 other patients were diagnosed with routine follow-up. Two patients received clip ligation, 2 had simple coil embolization, 1 had stent-assisted coil embolization, 1 had a flow-diverting stent, and 1 patient required 2 retreatments; he received stent-assisted coil embolization for the first retreatment and a simple coil embolization for the second retreatment. All patients had excellent angiographic outcomes and no complications. CONCLUSION The authors conclude that aneurysm recurrence after WEB is very diverse, and no single modality can properly address all recurrences. Rather, an individualized approach based on aneurysm features, neurointerventionalist expertise, and patient preference should be implemented.
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Affiliation(s)
- Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Lyena Birkenstock
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ramon Ruiz
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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15
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Abstract
The treatment of intracranial aneurysms (IA) began in the late 19th century. Some degree of controversy has always surrounded the best treatment modality for IA. Cushing and Dandy debated about cervical carotid ligation as the only surgical alternative before the introduction of microsurgical clipping. In the early 21st century, the debate has centered on surgical versus^ endovascular techniques. With the advent of newer endovascular techniques and devices, there has been a dramatic shift in treatment paradigms toward endovascular intervention that is preferred by both physicians and patients. However, there will always be a need for microsurgical cerebrovascular expertise since some aneurysms cannot or should not be embolized. This creates a difficult conundrum as only the most complex of aneurysms will require open surgery, but the lack of volume and training will be a challenge in teaching and maintaining the surgical expertise required to safely treat them. The purpose of this review is to discuss the history of IA treatment and critically evaluate the current state of the art of IA treatment, with a specific focus on the necessary role microsurgical clipping continues to play in the current treatment landscape.
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Affiliation(s)
- Pablo Harker
- From the Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Justin Vranic
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Aman B Patel
- From the Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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16
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Diestro JDB, Adeeb N, Dibas M, Boisseau W, Harker P, Brinjikji W, Xiang S, Joyce E, Shapiro M, Raz E, Parra-Farinas C, Pickett G, Alotaibi NM, Regenhardt RW, Bernstock JD, Spears J, Griessenauer CJ, Burkhardt JK, Hafeez MU, Kan P, Grandhi R, Taussky P, Nossek E, Hong T, Zhang H, Rinaldo L, Lanzino G, Stapleton CJ, Rabinov JD, Patel AB, Marotta TR, Roy D, Dmytriw AA. Flow Diversion for Middle Cerebral Artery Aneurysms: An International Cohort Study. Neurosurgery 2021; 89:1112-1121. [PMID: 34624100 DOI: 10.1093/neuros/nyab365] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 08/06/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Open surgery has traditionally been preferred for the management of bifurcation middle cerebral artery (MCA) aneurysms. Flow diverting stents present a novel endovascular strategy for aneurysm treatment. OBJECTIVE To add to the limited literature describing the outcomes and complications in the use of flow diverters for the treatment of these complex aneurysms. METHODS This is a multicenter retrospective review of MCA bifurcation aneurysms undergoing flow diversion. We assessed post-treatment radiological outcomes and both thromboembolic and hemorrhagic complications. RESULTS We reviewed the outcomes of 54 aneurysms treated with flow diversion. Four (7.4%) of the aneurysms had a history of rupture (3 remote and 1 acute). Fourteen (25.9%) of the aneurysms already underwent either open surgery or coiling prior to flow diversion. A total of 36 out of the 45 aneurysms (80%) with available follow-up data had adequate aneurysm occlusion with a median follow-up time of 12 mo. There were no hemorrhagic complications but 16.7% (9/54) had thromboembolic complications. CONCLUSION Flow diverting stents may be a viable option for the endovascular treatment of complex bifurcation MCA aneurysms. However, compared to published series on the open surgical treatment of this subset of aneurysms, flow diversion has inferior outcomes and are associated with a higher rate of complications.
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Affiliation(s)
- Jose Danilo Bengzon Diestro
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada.,Département de Radiologie, Radio-oncologie et Médecine Nucléaire, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Nimer Adeeb
- Departments of Neurosurgery & Interventional Neuroradiology, LSU Shreveport School of Medicine, Shreveport, Louisiana, USA
| | - Mahmoud Dibas
- Departments of Neurosurgery & Interventional Neuroradiology, LSU Shreveport School of Medicine, Shreveport, Louisiana, USA
| | - William Boisseau
- Département de Radiologie, Radio-oncologie et Médecine Nucléaire, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Pablo Harker
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Waleed Brinjikji
- Departments of Radiology & Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sishi Xiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Evan Joyce
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Maksim Shapiro
- Departments of Radiology and Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Eytan Raz
- Departments of Radiology and Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Carmen Parra-Farinas
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada
| | - Gwynedd Pickett
- Department of Neurosurgery, Queen Elizabeth II Health Science Centre, Dalhousie Medical School, Halifax, Nova Scotia, Canada
| | - Naif M Alotaibi
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua D Bernstock
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian Spears
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Muhammad U Hafeez
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Houston, Texas, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Erez Nossek
- Departments of Radiology and Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lorenzo Rinaldo
- Departments of Radiology & Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Departments of Radiology & Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher J Stapleton
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James D Rabinov
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas R Marotta
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada
| | - Daniel Roy
- Département de Radiologie, Radio-oncologie et Médecine Nucléaire, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Adam A Dmytriw
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada.,Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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17
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Jumaa MA, Salahuddin H, Burgess R. The Future of Endovascular Therapy. Neurology 2021; 97:S185-S193. [PMID: 34785617 DOI: 10.1212/wnl.0000000000012807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 04/13/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article summarizes a broad range of the most recent advances and future directions in stroke diagnostics, endovascular robotics, and neuromodulation. RECENT FINDINGS In the past 5 years, the field of interventional neurology has seen major technological advances for the diagnosis and treatment of cerebrovascular diseases. Several new technologies became available to aid in complex prehospital stroke triage, stroke diagnosis, and interpretation of radiologic findings. Robotics and neuromodulation promise to expand access to established treatments and broaden neuroendovascular indications. SUMMARY Mobile applications offer a solution to simplify prehospital diagnostic and transfer decisions. Several prehospital devices are also under development to improve the accuracy of detection of large vessel occlusion (LVO). Artificial intelligence is now routinely used in early diagnosis of LVO and for detecting salvageability of the affected brain parenchyma. Technological advances have also paved the way to incorporate endovascular robotics and neuromodulation into practice. This may expand the deliverability of established treatments and facilitate the development of cutting-edge treatments for other complex neurologic diseases.
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Affiliation(s)
- Mouhammad A Jumaa
- From the Department of Neurology, ProMedica Neurosciences Institute; and Department of Neurology, University of Toledo College of Medicine, OH.
| | - Hisham Salahuddin
- From the Department of Neurology, ProMedica Neurosciences Institute; and Department of Neurology, University of Toledo College of Medicine, OH
| | - Richard Burgess
- From the Department of Neurology, ProMedica Neurosciences Institute; and Department of Neurology, University of Toledo College of Medicine, OH
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18
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Salem MM, Sweid A, Kuhn AL, Dmytriw AA, Gomez-Paz S, Maragkos GA, Waqas M, Parra-Farinas C, Salehani A, Adeeb N, Brouwer P, Pickett G, Ku J, X D Yang V, Weill A, Radovanovic I, Cognard C, Spears J, Cuellar-Saenz HH, Renieri L, Kan P, Limbucci N, Mendes Pereira V, Harrigan MR, Puri AS, Levy EI, Moore JM, Ogilvy CS, Marotta TR, Jabbour P, Thomas AJ. Repeat Flow Diversion for Cerebral Aneurysms Failing Prior Flow Diversion: Safety and Feasibility From Multicenter Experience. Stroke 2021; 53:1178-1189. [PMID: 34634924 DOI: 10.1161/strokeaha.120.033555] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Aneurysmal persistence after flow diversion (FD) occurs in 5% to 25% of aneurysms, which may necessitate retreatment. There are limited data on safety/efficacy of repeat FD-a frequently utilized strategy in such cases. METHODS A series of consecutive patients undergoing FD retreatment from 15 centers were reviewed (2011-2019), with inclusion criteria of repeat FD for the same aneurysm at least 6 months after initial treatment, with minimum of 6 months post-retreatment imaging. The primary outcome was aneurysmal occlusion, and secondary outcome was safety. A multivariable logistic regression model was constructed to identify predictors of incomplete occlusion (90%-99% and <90% occlusion) versus complete occlusion (100%) after retreatment. RESULTS Ninety-five patients (median age, 57 years; 81% women) harboring 95 aneurysms underwent 198 treatment procedures. Majority of aneurysms were unruptured (87.4%), saccular (74.7%), and located in the internal carotid artery (79%; median size, 9 mm). Median elapsed time between the first and second treatment was 12.2 months. Last available follow-up was at median 12.8 months after retreatment, and median 30.6 months after the initial treatment, showing complete occlusion in 46.2% and near-complete occlusion (90%-99%) in 20.4% of aneurysms. There was no difference in ischemic complications following initial treatment and retreatment (4.2% versus 4.2%; P>0.99). On multivariable regression, fusiform morphology had higher nonocclusion odds after retreatment (odds ratio [OR], 7.2 [95% CI, 1.97-20.8]). Family history of aneurysms was associated with lower odds of nonocclusion (OR, 0.18 [95% CI, 0.04-0.78]). Likewise, positive smoking history was associated with lower odds of nonocclusion (OR, 0.29 [95% CI, 0.1-0.86]). History of hypertension trended toward incomplete occlusion (OR, 3.10 [95% CI, 0.98-6.3]), similar to incorporated branch into aneurysms (OR, 2.78 [95% CI, 0.98-6.8]). CONCLUSIONS Repeat FD for persistent aneurysms carries a reasonable success/safety profile. Satisfactory occlusion (100% and 90%-99% occlusion) was encountered in two-thirds of patients, with similar complications between the initial and subsequent retreatments. Fusiform morphology was the strongest predictor of retreatment failure.
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Affiliation(s)
- Mohamed M Salem
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Ahmad Sweid
- Department of Neurosurgery, University of Alabama at Birmingham (A.S., M.R.H.)
| | - Anna L Kuhn
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester (A.L.K., A.S.P.)
| | - Adam A Dmytriw
- Department of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, ON, Canada (A.A.D., I.R., V.M.P.)
| | - Santiago Gomez-Paz
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Georgios A Maragkos
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (M.W., E.I.L.)
| | - Carmen Parra-Farinas
- Department of Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.).,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.)
| | - Arsalaan Salehani
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA (A.S., P.J.)
| | - Nimer Adeeb
- Department of Neurosurgery, Ochsner-Louisiana State University Hospital, Shreveport (N.A., H.H.C.-S.)
| | - Patrick Brouwer
- Department of Neuroradiology, Karolinska Universitetssjukhuset, Stockholm, Sweden (P.B.)
| | - Gwynedd Pickett
- Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada (G.P.)
| | - Jerry Ku
- Department of Neuroradiology and Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K., V.X.D.Y.)
| | - Victor X D Yang
- Department of Neuroradiology and Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K., V.X.D.Y.)
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, QC, Canada (A.W.)
| | - Ivan Radovanovic
- Department of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, ON, Canada (A.A.D., I.R., V.M.P.)
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.)
| | - Julian Spears
- Department of Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.).,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.)
| | - Hugo H Cuellar-Saenz
- Department of Neurosurgery, Ochsner-Louisiana State University Hospital, Shreveport (N.A., H.H.C.-S.)
| | - Leonardo Renieri
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy (L.R., N.L.)
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX (P.K.)
| | - Nicola Limbucci
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy (L.R., N.L.)
| | - Vitor Mendes Pereira
- Department of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, ON, Canada (A.A.D., I.R., V.M.P.)
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama at Birmingham (A.S., M.R.H.)
| | - Ajit S Puri
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester (A.L.K., A.S.P.)
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (M.W., E.I.L.)
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Thomas R Marotta
- Department of Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.).,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.)
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA (A.S., P.J.)
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
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19
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Zheng Y, Zheng L, Sun Y, Lin D, Wang B, Sun Q, Bian L. Surgical Clipping of Previously Coiled Recurrent Intracranial Aneurysms: A Single-Center Experience. Front Neurol 2021; 12:680375. [PMID: 34621232 PMCID: PMC8490643 DOI: 10.3389/fneur.2021.680375] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 08/12/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: This study reviews our experiences in surgical clipping of previously coiled aneurysms, emphasizing on recurrence mechanism of intracranial aneurysms (IAs) and surgical techniques for different types of recurrent IAs. Method: We performed a retrospective study on 12 patients who underwent surgical clipping of aneurysms following endovascular treatment between January 2010 and October 2020. The indications for surgery, surgical techniques, and clinical outcomes were analyzed. Result: Twelve patients with previously coiled IAs were treated with clipping in this study, including nine females and three males. The reasons for the patients having clipping were as follows: early surgery (treatment failure in two patients, postoperative early rebleeding in one patient, and intraprocedural aneurysm rupture during embolization in one patient) and late surgery (aneurysm recurrence in five patients, SAH in one, mass effect in one, and aneurysm regrowth in one). All aneurysms were clipped directly, and coil removal was performed in four patients. One patient died (surgical mortality, 8.3%), 1 patient (8.3%) experienced permanent neurological morbidity, and the remaining 10 patients (83.4%) had good outcomes. Based on our clinical data and previous studies, we classified the recurrence mechanism of IAs into coil compaction, regrowth, coil migration, and coil loosening. Then, we elaborated the specific surgical planning and timing of surgery depending on the recurrence type of IAs. Conclusion: Surgical clipping can be a safe and effective treatment strategy for the management of recurrent coiled IAs, with acceptable morbidity and mortality in properly selected cases. Our classification of recurrent coiled aneurysms into four types helps to assess the optimal surgical approach and the associated risks in managing them.
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Affiliation(s)
- Yongtao Zheng
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lili Zheng
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuhao Sun
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dong Lin
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Baofeng Wang
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qingfang Sun
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Liuguan Bian
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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20
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da Silva Júnior NR, Trivelato FP, Nakiri GS, Rezende MTS, de Castro-Afonso LH, Abud TG, Vanzin JR, Manzato LB, Ulhôa AC, Abud DG, Giannetti AV. Endovascular treatment of residual or recurrent intracranial aneurysms after surgical clipping. J Cerebrovasc Endovasc Neurosurg 2021; 23:221-232. [PMID: 34470100 PMCID: PMC8497721 DOI: 10.7461/jcen.2021.e2021.03.001] [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: 03/16/2020] [Accepted: 04/19/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Total aneurysm occlusion is crucial for the prevention of rebleeding of a ruptured aneurysm or to avoid rupture of an unruptured lesion. Both surgical and endovascular embolization fail to achieve complete aneurysm occlusion in all the cases. The objective of the study was to establish the safety and efficacy of endovascular treatment for previously clipped residual or recurrent aneurysms. METHODS This was an observational, retrospective study of patients harboring incompletely occluded intracranial aneurysms after clipping who underwent endovascular treatment. Patients were treated using 4 different techniques: (1) simple coiling, (2) balloon remodeling, (3) stent-assisted coiling, and (4) flow diversion. Analyses were performed to identify predictors of total aneurysm occlusion, recanalization and complications. RESULTS Between May 2010 and September 2018, 70 patients harboring incompletely occluded intracranial aneurysms after clipping met the inclusion criteria in 5 centers. The mean residual aneurysm size was 7.5 mm. Fifty-nine aneurysms were unruptured. Total aneurysm occlusion was achieved in 75.3% of the aneurysms after 1 year. All aneurysms treated with flow diversion revealed complete occlusion according to control angiography. Recanalization was observed in 14.5%. Permanent morbidity and mortality occurred in 2.9% and 1.4% of the patients, respectively. CONCLUSIONS Endovascular treatment of recurrent or residual aneurysms after surgical clipping was safe and efficacious. Flow diversion seems to be associated with better anatomical results. A more rigid study, a larger group of patients, and longterm follow-up are required to provide stronger conclusions about the best approach for residual clipped aneurysms.
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Affiliation(s)
| | - Felipe Padovani Trivelato
- Division of Interventional Neuroradiology, Felício Rocho Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - Guilherme Seizem Nakiri
- Division of Interventional Neuroradiology, Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Luís Henrique de Castro-Afonso
- Division of Interventional Neuroradiology, Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Thiago Giansante Abud
- Division of Interventional Neuroradiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - José Ricardo Vanzin
- Division of Interventional Neuroradiology, Hospital de Clínicas, Passo Fundo, Rio Grande do Sul, Brazil
| | - Luciano Bambini Manzato
- Division of Interventional Neuroradiology, Hospital de Clínicas, Passo Fundo, Rio Grande do Sul, Brazil
| | - Alexandre Cordeiro Ulhôa
- Division of Interventional Neuroradiology, Felício Rocho Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - Daniel Giansante Abud
- Division of Interventional Neuroradiology, Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Alexandre Varella Giannetti
- Department of Neurosurgery, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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21
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Cooper JB, Li B, Kaur G, Gandhi CD, Santarelli JG. Pipeline embolization of ruptured, previously coiled cerebral aneurysms: Case series and considerations for management. Brain Circ 2021; 7:111-117. [PMID: 34189354 PMCID: PMC8191537 DOI: 10.4103/bc.bc_59_20] [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: 11/03/2020] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/05/2022] Open
Abstract
PURPOSE: Aneurysmal recurrence represents a significant drawback of endovascular coiling, particularly in aneurysms that have previously ruptured. Given the high recurrence rate of coiled aneurysms and particularly the risk of posttreatment rupture in previously ruptured aneurysms that have been treated by coiling, the question of how best to treat ruptured aneurysms that recur postcoiling remains. MATERIALS AND METHODS: We conducted a retrospective analysis of twenty patients who underwent pipeline embolization of previously ruptured, coiled cerebral aneurysms. RESULTS: Pipeline embolization device (PED) treatment resulted in complete aneurysmal occlusion in 10 patients (62.5%) at first angiographic follow-up, and 11 patients (68.75%) at last follow-up. No PED-related complications were encountered and there were no peri-procedural or postprocedural hemorrhages, or symptomatic ischemic events following flow diversion. CONCLUSIONS: PED as a second-line treatment is a safe and effective modality for achieving aneurysmal occlusion in recurrent, previously ruptured, primarily coiled aneurysms. Additionally, a staged coil-to-PED approach may be considered for the management of acutely ruptured aneurysms to achieve aneurysmal obliteration in an effort to mitigate recurrence, and reduce the amount of postprocedural studies.
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Affiliation(s)
- Jared B Cooper
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Boyi Li
- School of Medicine, School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Gurmeen Kaur
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Justin G Santarelli
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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22
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Li W, Zhu W, Sun X, Liu J, Wang Y, Wang K, Zhang Y, Yang X, Zhang Y. Retreatment With Flow Diverters and Coiling for Recurrent Aneurysms After Initial Endovascular Treatment: A Propensity Score-Matched Comparative Analysis. Front Neurol 2021; 12:625652. [PMID: 34149588 PMCID: PMC8209336 DOI: 10.3389/fneur.2021.625652] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Flow diverters and conventional coiling are established modalities for the retreatment of intracranial recurrent aneurysms after initial endovascular treatment. We aimed to compare the efficacy of these techniques. Methods: We retrospectively analyzed data for patients with recurrent aneurysms after initial endovascular treatment retreated in our center with either a pipeline embolization device (PED) or conventional coil embolization from January 2012 to July 2020. We performed 1:2 propensity score matching (PSM) using the nearest neighbor method. We controlled for: initial treatment strategy, aneurysm size, neck diameter, symptom presentation, history of aneurysm rupture, age, sex, fusiform-dissecting aneurysm, bifurcation aneurysm, and aneurysm location. The clinical and morphological factors of all patients at initial treatment and the angiographic and clinical results at the second treatment were collected and compared between the propensity-matched pairs. Results: A total of 105 intracranial aneurysms were identified; 18 patients (17.1%) were treated with a PED, and 87 (82.9%) were treated via conventional coil embolization. PSM resulted in 12 matched pairs (12 patients in the PED group and 24 in the coiling group). There was no significant difference of ischemic and hemorrhagic complications between the groups, the obliteration rate of branches covered by stent, or modified Rankin Scale scores at the last clinical follow-up. Importantly, the retreatment strategy in the PED group provided significantly different results vs. the coiling group (P < 0.001), with a lower recurrence rate (0.0 vs. 29.2%, respectively; P = 0.037). However, the procedural failure rate and the parent artery stenosis were more frequently in PED group compared with coiling group (both were 16.7 vs. 0.0%; P = 0.040). Conclusions: Endovascular retreatment for recurrent aneurysms after initial endovascular treatment might be safe and effective. Flow diverters might be associated with reduced risk of recanalization and an increased risk of procedural failure and mild parent artery stenosis.
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Affiliation(s)
- Wenqiang Li
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinguo Sun
- Department of Neurosurgery, Binzhou People's Hospital, Binzhou, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kun Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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23
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Hassan AE, Burke EM, Monayao M, Tekle WG. Utilization of the Ballast Long Guiding Sheath for Neuroendovascular Procedures: Institutional Experience in 68 Cases. Front Neurol 2021; 12:578446. [PMID: 34025546 PMCID: PMC8137819 DOI: 10.3389/fneur.2021.578446] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 04/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The rise of neurointerventional devices has created a demand for guide systems capable of navigating to the carotid artery consistently regardless of tortuosity. The shift toward large distal access catheters (DACs) and desire for greater trackability have inspired the creation of flexible, supportive, large-lumen long guiding sheaths. Recently, the Ballast long guiding sheath was introduced to provide stability and flexibility while navigating neurointerventional devices through tortuous intracranial anatomy. Objective: To report our experience using the Ballast long guiding sheath in a series of patients undergoing a variety of neuroendovascular procedures. Methods: We retrospectively identified all patients who underwent neuroendovascular treatment with a long guiding sheath were selected from a prospectively maintained endovascular database from January 2019 to November 2019. Baseline clinical characteristics and procedural details were collected. Results: A total of 68 patients were included, mean patient age 67.6 ± 13.6 years. Of the patients treated, 52.9% (36/68) presented with stenosis, 25% (17/68) with aneurysms, 13.2% (9/68) with stroke or emboli, 1.5% (1/68) with a tumor, 1.5% (1/68) with an arteriovenous fistula (AVF), and 4.4% (3/68) with a carotid web. Of the patients with stenosis, 20/36 (55.6%) were extracranial, and 16/36 (44.4%) were intracranial. The Ballast long guiding sheath was used to deliver treatment devices for stenting (37/68, 54.4%), flow diversion (12/68, 17.6%), mechanical thrombectomy (8/68, 11.8%), endovascular coiling (5/68, 7.4%), liquid embolization (3/68, 4.4%), balloon angioplasty (2/68, 2.9%), and balloon angioplasty with stenting (1/68, 1.5%). No Ballast-related complications or adverse events were encountered. Conclusions: We demonstrate the feasibility of the Ballast long guiding sheath to successfully deliver modern neurointerventional treatment devices through tortuous anatomy.
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Affiliation(s)
- Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX, United States.,Department of Neuroscience, Valley Baptist Neuroscience Institute, Harlingen, TX, United States
| | - Elizabeth M Burke
- Department of Biological Sciences, The Ohio State University, Columbus, OH, United States
| | - Marlon Monayao
- Department of Neuroscience, Valley Baptist Neuroscience Institute, Harlingen, TX, United States
| | - Wondwossen G Tekle
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX, United States.,Department of Neuroscience, Valley Baptist Neuroscience Institute, Harlingen, TX, United States
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24
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Beaman CB, Kaneko N, Meyers PM, Tateshima S. A Review of Robotic Interventional Neuroradiology. AJNR Am J Neuroradiol 2021; 42:808-814. [PMID: 33541906 PMCID: PMC8115357 DOI: 10.3174/ajnr.a6976] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/26/2020] [Indexed: 12/20/2022]
Abstract
Robotic interventional neuroradiology is an emerging field with the potential to enhance patient safety, reduce occupational hazards, and expand systems of care. Endovascular robots allow the operator to precisely control guidewires and catheters from a lead-shielded cockpit located several feet (or potentially hundreds of miles) from the patient. This has opened up the possibility of expanding telestroke networks to patients without access to life-saving procedures such as stroke thrombectomy and cerebral aneurysm occlusion by highly-experienced physicians. The prototype machines, first developed in the early 2000s, have evolved into machines capable of a broad range of techniques, while incorporating newly automated maneuvers and safety algorithms. In recent years, preliminary clinical research has been published demonstrating the safety and feasibility of the technology in cerebral angiography and intracranial intervention. The next step is to conduct larger, multisite, prospective studies to assess generalizability and, ultimately, improve patient outcomes in neurovascular disease.
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Affiliation(s)
- C B Beaman
- Department of Neurology (C.B.B.), Columbia University Irving Medical Center, New York, New York
| | - N Kaneko
- Department of Radiological Sciences (N.K., S.T.), David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - P M Meyers
- Department of Radiology and Neurological Surgery (P.M.M.), Columbia University Irving Medical Center, New York, New York
| | - S Tateshima
- Department of Radiological Sciences (N.K., S.T.), David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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25
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Piao J, Luan T, Qu L, Yu J. Intracranial post-clipping residual or recurrent aneurysms: Current status and treatment options (Review). MEDICINE INTERNATIONAL 2021; 1:1. [PMID: 36698683 PMCID: PMC9855273 DOI: 10.3892/mi.2021.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 04/08/2021] [Indexed: 01/28/2023]
Abstract
Following the clipping of intracranial aneurysms, post-clipping residual or recurrent aneurysms (PCRRAs) can occur. In recent years, the incidence of PCRRAs has increased due to a prolonged follow-up period and advanced imaging techniques. However, several aspects of intracranial PCRRAs remain unclear. Therefore, the present study performed an in-depth review of the literature on PCRRAs. Herein, a summary of PCRRAs that can be divided into the following two categories is presented: i) Those occurring after the incomplete clipping of an aneurysm, where the residual aneurysm regrows into a PCRRA; and ii) those occurring after the complete clipping of an aneurysm, in which a de novo aneurysm occurs at the original aneurysm site. Currently, digital subtracted angiography remains the gold standard for the imaging diagnosis of PCRRAs as it can eliminate metallic clip artifacts. Intracranial symptomatic PCRRAs should be actively treated, particularly those that have ruptured. A number of methods are currently available for the treatment of intracranial PCRRAs; these mainly include re-clipping, endovascular treatment (EVT) and bypass surgery. Currently, re-clipping remains the most effective method used to treat PCRRAs; however, it is a very difficult procedure to perform. EVT can also be used to treat intracranial PCRRAs. EVT methods include coiling (stent- or balloon-assisted) and flow-diverting stents (or coiling-assisted). Bypass surgery can be selected for difficult-to-treat, complex PCRRAs. On the whole, following appropriate treatment, the majority of intracranial PCRRAs achieve a high occlusion rate and a good prognosis.
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Affiliation(s)
- Jianmin Piao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Tengfei Luan
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Lai Qu
- Department of Intensive Care, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China,Correspondence to: Dr Jinlu Yu, Department of Neurosurgery, The First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, Jilin 130021, P.R. China
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26
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Kang H, Luo B, Liu J, Zhang H, Li T, Song D, Zhao Y, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Wang K, Yang X. Mortality after treatment of intracranial aneurysms with the Pipeline Embolization Device. J Neurointerv Surg 2021; 14:neurintsurg-2020-017002. [PMID: 33627503 DOI: 10.1136/neurintsurg-2020-017002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/12/2021] [Accepted: 01/22/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The Pipeline Embolization Device (PED) is reported to be a safe treatment tool for aneurysms. However, mortality occurs in a few cases, and this has not been clearly studied. We conducted a multicenter study to retrospectively evaluate the causes of, and risk factors for, mortality in patients with intracranial aneurysms treated with the PED. METHODS We retrospectively reviewed the prospectively maintained databases of patients with intracranial aneurysms treated by PED placement at 14 academic institutions from 2014 to 2019. Patients' data, including clinical and radiographic information, were analyzed with an emphasis on mortality-related complications. RESULTS A total of 1171 consecutive patients underwent 1319 PED procedures to treat 1322 intracranial aneurysms. The mortality rate was 1.5% (17/1171), and in 1.3% of the patients (15/1171), deaths were caused by delayed aneurysmal rupture, distal intraparenchymal hemorrhage, and neurological compression symptoms associated with PED procedures. Multivariate analysis showed that previous treatment (OR, 12.657; 95% CI, 3.189 to 50.227; P<0.0001), aneurysm size ≥10 mm (OR, 4.704; 95% CI, 1.297 to 17.068; P=0.019), aneurysm location (basilar artery) (OR, 10.734; 95% CI, 2.730 to 42.207; P=0.001), and current subarachnoid hemorrhage (OR, 4.505; 95% CI, 0.991 to 20.474; P=0.051) were associated with neurological complications resulting in mortality. CONCLUSIONS Delayed aneurysm rupture, distal intraparenchymal hemorrhage, and neurological compression were the main causes of mortality in patients with intracranial aneurysms treated with the PED. Large basilar aneurysms are associated with an increased risk of postoperative death and require increased attention and caution.
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Affiliation(s)
- Huibin Kang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bin Luo
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, 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
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yunyan Wang
- Qilu Hospital of Shandong University, Jinan, China
| | - Wenfeng Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yang Wang
- First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 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
| | - Kun Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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27
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Akgul E, Onan HB, Islek I, Tonge M, Durmus Y, Barburoglu M, Azizova A, Erol C, Hakyemez B, Sencer S, Aydin K, Arat A. Flow diverter stents in the treatment of recanalized intracranial aneurysms. Interv Neuroradiol 2021; 27:481-489. [PMID: 33509011 DOI: 10.1177/1591019921990507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We assessed the safety and efficacy of flow diverter stents (FDSs) in the treatment of recanalized or residual intracranial aneurysms treated endovascularly. MATERIALS & METHODS Patients whose recanalized or residual aneurysms were treated with FDSs in five tertiary hospitals were reviewed retrospectively. The patients' demographic data, aneurysm characteristics, types of previous treatment, and clinical complications, or serious adverse events associated with FDSs, as well as the results of neurological and angiographic follow-up assessments, were recorded. RESULTS Eighty-six patients (37 males) with 87 aneurysms were included in this study. Eighty (91.9%) aneurysms were in the anterior and seven (8.1%) in the posterior circulation. The initial treatment methods were the primary coiling or balloon remodeling technique in 69 (79.3%) and stent-assisted coiling in 18 (20.7%) aneurysms. The endovascular procedure was successful in all patients. Complications occurred in four patients, for a total complication rate of 4.6%. A technical complication developed in one patient (1.2%). An in-stent thrombosis treated with tirofiban was seen in two cases. Late in-stent stenosis exceeding 50% was treated with balloon angioplasty in one patient. The mean length of follow-up was 21.0 months. The first angiographic follow-up (3-6 months) revealed the complete occlusion of 74 aneurysms (85.1%). While 76 aneurysms (87.4%) were occluded at the last angiographic follow-up (mean: 26.0 months), 11 aneurysms (12.6%) were still filling. Morbimortality was zero. CONCLUSION The drawback of endovascular treatment is aneurysmal remnants or recurrences, which is safely and durably amenable to flow diversion.
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Affiliation(s)
- Erol Akgul
- Interventional Neuroradiology Section, Radiology Department, International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Hasan Bilen Onan
- Radiology Department, School of Medicine, Cukurova University, Adana, Turkey
| | - Irem Islek
- Radiology Department, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Mehmet Tonge
- Neurosurgery Department, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Yavuz Durmus
- Radiology Department, Bursa Yuksek Ihtisas Education and Research Hospital, Bursa, Turkey
| | - Mehmet Barburoglu
- Department of Neuroradiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aynur Azizova
- Radiology Department, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Cengiz Erol
- Radiology Department, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Bahattin Hakyemez
- Radiology Department, School of Medicine, Uludag University, Bursa, Turkey
| | - Serra Sencer
- Department of Neuroradiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Kubilay Aydin
- Department of Neuroradiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.,Department of Interventional Neuroradiology, Faculty of Medicine, Koc University, Istanbul, Turkey
| | - Anil Arat
- Radiology Department, School of Medicine, Hacettepe University, Ankara, Turkey
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28
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Limbucci N, Leone G, Renieri L, Nappini S, Cagnazzo F, Laiso A, Muto M, Mangiafico S. Expanding Indications for Flow Diverters: Distal Aneurysms, Bifurcation Aneurysms, Small Aneurysms, Previously Coiled Aneurysms and Clipped Aneurysms, and Carotid Cavernous Fistulas. Neurosurgery 2020; 86:S85-S94. [PMID: 31838532 PMCID: PMC6911737 DOI: 10.1093/neuros/nyz334] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 06/06/2019] [Indexed: 11/23/2022] Open
Abstract
Flow diverter devices have gained wide acceptance for the treatment of unruptured intracranial aneurysms. Most studies are based on the treatment of large aneurysms harboring on the carotid syphon. However, during the last years the “off-label” use of these stents has widely grown up even if not supported by randomized studies. This review examines the relevant literature concerning “off-label” indications for flow diverter devices, such as for distal aneurysms, bifurcation aneurysms, small aneurysms, recurrent aneurysms, and direct carotid cavernous fistulas.
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Affiliation(s)
- Nicola Limbucci
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Giuseppe Leone
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy.,Department of Neuroradiology, Cardarelli Hospital, Naples, Italy
| | - Leonardo Renieri
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Sergio Nappini
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Federico Cagnazzo
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Antonio Laiso
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Mario Muto
- Department of Neuroradiology, Cardarelli Hospital, Naples, Italy
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29
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Rotim K, Raguž M, Rotim A, Splavski B, Kalousek V. LATE ANEURYSM RELAPSE AFTER MICROSURGICAL TREATMENT OF MIDDLE CEREBRAL ARTERY ANEURYSM: A CASE REPORT AND LITERATURE REVIEW OF TREATMENT OPTIONS. Acta Clin Croat 2020; 59:532-538. [PMID: 34177065 PMCID: PMC8212637 DOI: 10.20471/acc.2020.59.03.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Recurrence of intracranial aneurysm after initial microsurgical or endovascular treatment is uncommon. Although the exact etiology remains unknown, recurrent aneurysms may be observed in surgical patients with big and multiple aneurysms, arterial hypertension, non-atherosclerotic cerebrovascular arteriopathies, as well as in those with a familial history of the disease. Such recurrence can occur over a wide period ranging from several months to years after the initial aneurysm treatment. Still, the occurrence delayed by more than 20 years is rather unusual. Herein, we present a case of a 70-year-old female patient who developed late intracranial aneurysm relapse 30 years after successful microsurgical clipping of the middle cerebral artery aneurysm. We also provide a brief review of relevant literature, discussing the etiology and pathophysiology of aneurysm reappearance, as well as different treatment options available. In conclusion, one should always consider the possibility of intracranial aneurysm recurrence regardless of the mode and time of primary surgery. In such a case, a multidisciplinary management approach using flow diverting endovascular techniques is advised in selected patients.
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Affiliation(s)
| | - Marina Raguž
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Ante Rotim
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Bruno Splavski
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Vladimir Kalousek
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
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30
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Moubark M, Allah AEKA, Yosef H, Abdel-Tawab M, Panos P, Othman M. Flow diverter devices in the treatment of posterior communicating artery aneurysms: mid-term clinical and radiological outcomes. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00241-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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31
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Han Y, Liu J, Tian Z, Lv M, Yang X, Wu Z, Gao BL. Factors affecting recurrence and management of recurrent cerebral aneurysms after initial coiling. Interv Neuroradiol 2020; 26:300-308. [PMID: 31992106 DOI: 10.1177/1591019919901037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate factors affecting recurrence and effects and safety of endovascular retreatment for aneurysms recurrent after embolization. METHODS Among 815 aneurysms treated with embolization, recurrence was in 114 aneurysms (14.0%). Forty-three recurrent aneurysms were managed with re-embolization. Procedural complications, angiographic, and clinical results of retreatment were analyzed. RESULTS Patients with recurrent aneurysms were significantly (P < 0.01) younger than without recurrence (51.09 ± 10.46 vs. 53.88 ± 9.61 years). Recurrent aneurysms (n = 114) were significantly (P = 0.00) greater (11.12 ± 8.35 vs. 5.81 ± 3.44 mm) with a significantly (P = 0.00) greater neck (4.34 ± 2.26 vs. 2.90 ± 1.44 mm) than without recurrence. The rupture status of aneurysms significantly (P = 0.00) affected recurrence at follow-up. Significantly (P = 0.00) more aneurysms without recurrence were treated with advanced embolization techniques (81.0% vs. 62.3%) and got complete occlusion at the first embolization than those with recurrence (93.7% vs. 36.8%). In treating 43 recurrent aneurysms, stent-assisted recoiling was used in 48.8% in the first retreatment and 50% in the second and third retreatment procedures. Angiographic follow-up in 38 (88.4%) cases showed complete or near complete occlusion in 30 aneurysms, with the rest eight aneurysms experiencing a second recurrence (21.1%). Of the eight aneurysms with the second recurrence, five underwent the second endovascular retreatment, with complete aneurysm occlusion achieved in three cases (60%), near-complete occlusion in one (20%), and incomplete occlusion in one case at immediate angiography and six-month follow-up. Procedure-related complications occurred in three patients. CONCLUSIONS Endovascular retreatment of recurrent previously coiled aneurysms is safe and effective even though advanced embolization techniques are frequently involved especially for large and giant aneurysms.
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Affiliation(s)
- Yongfeng Han
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Shijiazhuang First Hospital, Shijiazhuang, Hebei, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongbin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Lv
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongxue Wu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bu-Lang Gao
- Department of Neurosurgery, Shijiazhuang First Hospital, Shijiazhuang, Hebei, China
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Kutty RK, Kumar A, Yamada Y, Tanaka R, Kannan S, Ravisankar V, Musara A, Miyatani K, Higashiguchi S, Takizawa K, Kawase T, Kato Y. Management of Recurrent Aneurysms after Endovascular Coiling: A Fujita Experience. Asian J Neurosurg 2020; 14:1151-1156. [PMID: 31903355 PMCID: PMC6896644 DOI: 10.4103/ajns.ajns_105_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction: Microsurgical clipping and Endovascular coiling (EC) are both effective alternatives in the management of intracranial aneurysms. EC has been shown to be associated with the risk of recurrent aneurysm (RA) growth. Considering the minimally invasive nature of this procedure, the management of intracranial aneurysms has been skewed toward EC, especially in the developed world. In this scenario, there has been an upsurge of RAs after EC. Since the optimal management of these RAs has not been defined, they pose a unique challenge to the treating surgeons. Aims and Objectives: The aim of this study is to elucidate the optimal management of RAs after EC. Materials and Methods: Medical records of all patients who underwent surgery for RAs were reviewed from the period January 2014 to March 2019. The demographic and angiographic patterns of the patients and operative techniques and complications were studied. The outcome was dichotomized into good and bad depending on the Glasgow outcome scale (GOS). Results: There were four cases of RAs operated in our institution between the above-mentioned period. There were varied differences between the initial coiling and time to recurrences. All four patients were operated under neuromonitoring. Three underwent clipping and one patient underwent clipping with bypass. All four patients had good outcome with a GOS of 5/5. Conclusion: Operations for RAs constitute many technical challenges and require a lot of expertise. Such surgeries are recommended in high-volume centers, with sufficient experience in both clipping and cerebral bypass.
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Affiliation(s)
- Raja K Kutty
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Ambuj Kumar
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Yasuhiro Yamada
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Riki Tanaka
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Satish Kannan
- Department of Neurosurgery, MGM Hospital, Chennai, Tamil Nadu, India
| | | | - Aaron Musara
- Department of Neurosurgery, College of Health Sciences, Harare, Zimbabwe
| | - Kyosuke Miyatani
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Saeko Higashiguchi
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Katsumi Takizawa
- Department of Neurosurgery, Asahikawa Redcross Hospital, Hokkaido, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
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33
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Kim ST, Baek JW, Jin SC, Park JH, Kim JS, Kim HY, Jeong HW, Jeong YG. Coil Embolization in Patients with Recurrent Cerebral Aneurysms Who Previously Underwent Surgical Clipping. AJNR Am J Neuroradiol 2018; 40:116-121. [PMID: 30573462 DOI: 10.3174/ajnr.a5909] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/10/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Surgical revision of recurrent cerebral aneurysms is technically difficult. Therefore, coil embolization has been used as an alternative in these cases. The aim of this study was to evaluate the clinical and angiographic outcomes of coil embolization in patients with recurrent cerebral aneurysms after microsurgical clipping. MATERIALS AND METHODS Between May 1999 and February 2016, nineteen patients with 19 recurrent aneurysms who previously underwent surgical clipping were treated by coil embolization. RESULTS Nine patients presented with subarachnoid hemorrhage (47.4%). The interval between surgical clipping and coil embolization was 143.5 ± 66.1 months (range, 43-276 months). Single- or double-catheter coil embolization was performed in 16 patients. A balloon (n = 1) and stents (n = 2) were used to assist the coil embolization in 3 patients. Immediate radiologic findings after coil embolization showed complete occlusion in 10 patients, a residual neck in 8 patients, and a residual sac in 1 patient. Procedure-related permanent morbidity occurred in 1 patient. The mean clinical follow-up was 58.3 ± 38.8 months. Poor clinical outcomes (modified Rankin Scale score = ≥3) at the end of the clinical follow-up were reported in 5 patients (26.3%). Angiographic follow-up was available for 12 patients (63.2%). Major recurrence was detected in 5 patients (41.7%), and a tendency for aneurysm regrowth rather than coil compaction was noted in all cases. CONCLUSIONS In our series, coil embolization for recurrent aneurysms after surgical clipping was feasible but had a high recurrence rate and tended to result in aneurysm regrowth rather than coil compaction.
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Affiliation(s)
- S-T Kim
- From the Departments of Neurosurgery (S.-T.K., J.H.P., Y.G.J.)
| | - J W Baek
- Diagnostic Radiology (J.W.B., H.W.J.), Busan Paik Hospital, Inje University, College of Medicine, Busan, Republic of Korea
| | - S-C Jin
- Department of Neurosurgery (S.-C.J., J.S.K., H.Y.K.), Haeundae Paik Hospital, Inje University, College of Medicine, Busan, Republic of Korea.
| | - J H Park
- From the Departments of Neurosurgery (S.-T.K., J.H.P., Y.G.J.)
| | - J S Kim
- Department of Neurosurgery (S.-C.J., J.S.K., H.Y.K.), Haeundae Paik Hospital, Inje University, College of Medicine, Busan, Republic of Korea
| | - H Y Kim
- Department of Neurosurgery (S.-C.J., J.S.K., H.Y.K.), Haeundae Paik Hospital, Inje University, College of Medicine, Busan, Republic of Korea
| | - H W Jeong
- Diagnostic Radiology (J.W.B., H.W.J.), Busan Paik Hospital, Inje University, College of Medicine, Busan, Republic of Korea
| | - Y G Jeong
- From the Departments of Neurosurgery (S.-T.K., J.H.P., Y.G.J.)
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34
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Bender MT, Vo CD, Jiang B, Campos JK, Zarrin DA, Xu R, Westbroek EM, Caplan JM, Huang J, Tamargo RJ, Lin LM, Colby GP, Coon AL. Pipeline Embolization for Salvage Treatment of Previously Stented Residual and Recurrent Cerebral Aneurysms. INTERVENTIONAL NEUROLOGY 2018; 7:359-369. [PMID: 30410513 DOI: 10.1159/000489018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/06/2018] [Indexed: 11/19/2022]
Abstract
Introduction This study assessed the safety and effectiveness of the Pipeline embolization device (PED) for persistent and recurrent aneurysms previously treated with either a vascular reconstruction device (VRD) or a flow diverter (FD). Methods A prospective, IRB-approved database was analyzed for patients treated with PED for aneurysms previously treated with a stent. Results Twenty procedures were performed on 18 patients, 11 with prior FD, 7 with VRD, and 2 previously treated with both. Overall, 15 aneurysms were saccular (75%), and size was 13.5 ± 7.6 mm. Location was internal carotid artery (ICA) in 14 cases (70%) and posterior circulation in 6 cases (30%). Average prior treatments were 1.7. Previously FD cases were re-treated at an average of 18.1 months from most recent treatment. Each case used 1 device, 82% with distal coverage and 82% with proximal coverage of prior stent. Balloon remodeling was performed in 3 cases (27%) and no in-stent thrombosis was observed. Previously VRD stent-coiled cases were re-treated at an average of 87.5 months. These cases used on average 1.9 devices, 89% with distal and 100% proximal coverage. Adjunctive coiling was performed in 1 case (11%), balloon remodeling in 5 cases (56%), and 2 cases (28%) developed thrombosis that resolved with abciximab. Re-VRD cases were longer (59.1 vs. 33.7 min, p = 0.02) than re-FD. Angiographic follow-up was available for 16 cases (80%). In re-FD, occlusion was complete in 56% and partial progressive in 33% at 17.1 months digital subtraction angiography. In re-VRD, occlusion was complete in 57% and partial progressive in 27% at 8.1 months. Two complications occurred (10%), including one asymptomatic cervical ICA occlusion and one stent occlusion with associated mortality (5%). Clinical follow-up was 17.8 months on average (range 0.5-51.9). Conclusions Salvage flow diversion for previously stented aneurysms is technically challenging but offers good prospects of aneurysm obliteration with acceptable complication rates.
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Affiliation(s)
- Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chau D Vo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica K Campos
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David A Zarrin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Li-Mei Lin
- Department of Neurosurgery, University of California Irvine, Orange, California, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Romagna A, Ladisich B, Schwartz C, Winkler PA, Rahman ASA. Flow-diverter stents in the endovascular treatment of remnants in previously clipped ruptured aneurysms: a feasibility study. Interv Neuroradiol 2018; 25:144-149. [PMID: 30370818 DOI: 10.1177/1591019918805774] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The rate of intracranial aneurysm remnants/recurrences after microsurgical clipping varies widely. The optimal management for these patients remains a matter of debate. Repeat surgery in particular bears a high risk of periprocedural complications due to anatomical distortion from prior procedures. This study aims to evaluate the risk-benefit profile of flow-diverter stents in these patients. METHODS The patient database of our neurovascular centre was queried to identify patients with clipped aneurysms who subsequently underwent endovascular treatment with intraluminal flow-diverter stents. The outcome analysis consisted of an assessment of clinical parameters (modified Rankin scale) and the post-interventional angiographic occlusion status (according to the Raymond-Roy occlusion classification). RESULTS Six patients underwent endovascular treatment with flow-diverter stents of recurrent aneurysms after clipping. Treatment was necessary in two patients due to progressive neurological deficits, and due to angiographic proof of an increasing aneurysm size in the other four patients. Median aneurysm size was 0.45 cm. All patients had a prior history of subarachnoid haemorrhage. The time from primary clipping to recurrence was 10.6 years. Complete radiological aneurysm occlusion was feasible in five out of six cases. Two patients who had experienced pre-interventional neurological deficits showed a complete remission of symptoms on last follow-up. No periprocedural morbidity or mortality was recorded and no patient required retreatment within the median follow-up. CONCLUSION This case series suggests that endovascular treatment with flow-diverter stents of aneurysm remnants after previous microsurgical clipping is a feasible treatment concept with a low-risk profile, which might prevent the treatment burden and risks of repeat surgery.
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Affiliation(s)
- Alexander Romagna
- 1 Division of Neurosurgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (current address).,2 Department of Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, Austria
| | - Barbara Ladisich
- 2 Department of Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, Austria
| | - Christoph Schwartz
- 2 Department of Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, Austria
| | - Peter A Winkler
- 2 Department of Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, Austria
| | - Al-Schameri Abdul Rahman
- 2 Department of Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, Austria
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36
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Safety and Efficacy of Endovascular Treatment of Previously Clipped Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 114:e137-e150. [DOI: 10.1016/j.wneu.2018.02.103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 02/16/2018] [Accepted: 02/17/2018] [Indexed: 01/04/2023]
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