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Hellstern V, Brenner N, Cimpoca A, Albina Palmarola P, Henkes E, Wendl C, Bäzner H, Ganslandt O, Henkes H. Flow diversion for unruptured MCA bifurcation aneurysms: comparison of p64 classic, p64 MW HPC, and p48 MW HPC flow diverter stents. Front Neurol 2024; 15:1415861. [PMID: 39206292 PMCID: PMC11349692 DOI: 10.3389/fneur.2024.1415861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 07/17/2024] [Indexed: 09/04/2024] Open
Abstract
Background MCA bifurcation aneurysms pose treatment challenges because of the complex hemodynamics at the bifurcation and the risk of rupture. FDS implantation has been controversial and there are only limited reports. Therefore, the aim of this study was to assess the efficacy and safety of this treatment strategy using p64 MW HPC and p48 MW HPC FDSs for MCA bifurcation aneurysms, compared with the p64 classic FDS. Materials and methods We retrospectively analyzed our institutional database and identified all patients with saccular, non-ruptured MCA bifurcation aneurysms treated with p64 MW HPC, p48 MW HPC, or p64 classic FDS implantation alone. Aneurysms with implantation of additional devices in the same session, previous treatments, and acutely ruptured and fusiform aneurysms were excluded. Results A total of 79 aneurysms met the inclusion criteria: 23 receiving a p64 MW HPC, 34 receiving a p48 MW HPC, and 22 receiving a p64 classic FDS. The occlusion rate was highest for the p48 MW HPC 2 mm FDS, at 88.9% at FU2, compared with 72.2% for the p64 MW HPC and 70.6% for the p64 classic. The time to aneurysm occlusion was shortest with the p64 MW HPC, at 178.31 days. The highest retreatment rate was observed with the p48 MW HPC 3 mm. Conclusion Treatment of MCA bifurcation aneurysms with a p48 MW HPC 2 mm or p64 MW HPC FDS is a safe and reliable strategy achieving high aneurysm occlusion rates - attributable to their lower porosity in relation to the parent vessel diameter as compared to the p48 MW HPC 3 mm FDS-, with reasonable morbidity and mortality.
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Affiliation(s)
- V. Hellstern
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - N. Brenner
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - A. Cimpoca
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - P. Albina Palmarola
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - E. Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - C. Wendl
- Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Universitätsklinikum Regensburg, Regensburg, Germany
| | - H. Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - O. Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - H. Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Medizinische Fakultät der Universität Duisburg-Essen, Essen, Germany
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Kashkoush A, El-Abtah ME, Petitt JC, Glauser G, Winkelman R, Achey RL, Davison M, Abdulrazzak MA, Hussain SM, Toth G, Bain M, Moore N. Flow diversion for the treatment of intracranial bifurcation aneurysms: a systematic review and meta-analysis. J Neurointerv Surg 2024; 16:921-927. [PMID: 37541838 DOI: 10.1136/jnis-2023-020582] [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: 05/12/2023] [Accepted: 07/19/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Flow diversion (FD: flow diversion, flow diverter) is an endovascular treatment for many intracranial aneurysm types; however, limited reports have explored the use of FDs in bifurcation aneurysm management. We analyzed the safety and efficacy of FD for the management of intracranial bifurcation aneurysms. METHODS A systematic review identified original research articles that used FD for treating intracranial bifurcation aneurysms. Articles with >4 patients that reported outcomes on the use of FDs for the management of bifurcation aneurysms along the anterior communicating artery (AComA), internal carotid artery terminus (ICAt), basilar apex (BA), or middle cerebral artery bifurcation (MCAb) were included. Meta-analysis was performed using a random effects model. RESULTS 19 studies were included with 522 patients harboring 534 bifurcation aneurysms (mean size 9 mm, 78% unruptured). Complete aneurysmal occlusion rate was 68% (95% CI 58.7% to 76.1%, I2=67%) at mean angiographic follow-up of 16 months. Subgroup analysis of FD as a standalone treatment estimated a complete occlusion rate of 69% (95% CI 50% to 83%, I2=38%). The total complication rate was 22% (95% CI 16.7% to 28.6%, I2=51%), largely due to an ischemic complication rate of 16% (95% CI 10.8% to 21.9%, I2=55%). The etiologies of ischemic complications were largely due to jailed artery hypoperfusion (47%) and in-stent thrombosis (38%). 7% of patients suffered permanent symptomatic complications (95% CI 4.5% to 9.8%, I2=6%). CONCLUSION FD treatment of bifurcation aneurysms has a modest efficacy and relatively unfavorable safety profile. Proceduralists may consider reserving FD as a treatment option if no other surgical or endovascular therapy is deemed feasible.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Jordan C Petitt
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Gregory Glauser
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Robert Winkelman
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca L Achey
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Davison
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Mohammad A Abdulrazzak
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Shazam M Hussain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nina Moore
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Schüngel MS, Wohlgemuth WA, Elolf E, Rensch L, Brill R, Schob S. Review: Flow Diversion for the Treatment of Middle Cerebral Artery Aneurysms. ROFO-FORTSCHR RONTG 2024. [PMID: 38977012 DOI: 10.1055/a-2343-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
The invention of flow diverting stents (FDS) is a novel milestone in the field of endovascular aneurysm therapy, promoting physiological healing of the vessel segment contrary to prior deconstructive treatment strategies, such as coiling. The effects of FDS are based on changes in flow patterns, segmental wall stabilization, and the growth of a neointima. Although flow diversion is already well established for cerebral aneurysms in proximal segments, peripheral locations remain challenging. Especially the middle cerebral artery (MCA) with its predominance of non-collateralized perforators and functional end arteries that supply the eloquent areas of the brain is of major concern.The literature was reviewed for flow diversion of the MCA and antiplatelet therapy.Resulting from the special anatomical characteristics of the MCA, FDS implantation in this territory is completely different from the proximal vessel segments. Still, flow diversion represents an effective endovascular strategy, especially in otherwise non-accessible or sufficiently treatable lesions. However, the risk of ischemic adverse events might be increased. Special attention to the individual decision regarding device selection, antiplatelet regimen, and exact definition of the proximal and distal landing zone considering the jailed side branches is essential for a good angiographic and clinical outcome. · MCA aneurysms can be sufficiently treated by FDS.. · The anatomic and hemodynamic characteristics of the MCA result in an increased risk of thromboembolism.. · Individual device selection and antiplatelet regimen are essential for treatment success.. · Schüngel M, Wohlgemuth WA, Elolf E et al. Review: Flow Diversion for the Treatment of Middle Cerebral Artery Aneurysms. Fortschr Röntgenstr 2024; DOI 10.1055/a-2343-0046.
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Affiliation(s)
- Marie-Sophie Schüngel
- Policlinic of Radiology and Interventional Radiology, Department of Neuroradiology, University Hospital Halle, Halle (Saale), Germany
| | - Walter A Wohlgemuth
- Policlinic of Radiology and Interventional Radiology, Department of Neuroradiology, University Hospital Halle, Halle (Saale), Germany
| | - Erck Elolf
- Policlinic of Radiology and Interventional Radiology, Department of Neuroradiology, University Hospital Halle, Halle (Saale), Germany
| | - Leonhard Rensch
- Clinic for Neurosurgery, University Hospital Halle (Saale), Halle, Germany
| | - Richard Brill
- Policlinic of Radiology and Interventional Radiology, Department of Neuroradiology, University Hospital Halle, Halle (Saale), Germany
| | - Stefan Schob
- Policlinic of Radiology and Interventional Radiology, Department of Neuroradiology, University Hospital Halle, Halle (Saale), Germany
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Sharashidze V, Raz E, Nossek E, Kvint S, Riina H, Rutledge C, Baranoski J, Khawaja A, Chung C, Nelson PK, Shapiro M. Comprehensive Analysis of Post-Pipeline Endothelialization and Remodeling. AJNR Am J Neuroradiol 2024; 45:893-898. [PMID: 38663989 DOI: 10.3174/ajnr.a8228] [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: 11/27/2023] [Accepted: 02/06/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND AND PURPOSE Successful post-flow-diverter endoluminal reconstruction is widely believed to require endothelial overgrowth of the aneurysmal inflow zone. However, endothelialization/neointimal overgrowth is a complex process, over which we currently have very limited influence. Less emphasized is vascular remodeling of the target arterial segment, the dynamic response of the vessel to flow-diverter implantation. This process is distinct from flow modifications in covered branches. It appears that basic angiographic methods allow simple and useful observations. The purpose of this article was to quantitatively evaluate observable postimplantation changes in target vessels following deployment of Pipeline endoluminal constructs. MATERIALS AND METHODS One hundred consecutive adults with unruptured, previously untreated, nondissecting aneurysms treated with the Pipeline Embolization Device with Shield Technology and the availability of follow-up conventional angiography were studied with 2D DSA imaging. Target vessel size; Pipeline Embolization Device diameter; endothelial thickness; and various demographic, antiplatelet, and device-related parameters were recorded and analyzed. RESULTS The thickness of neointimal overgrowth (mean, 0.3 [SD, 0.1] mm; range, 0.1-0.7 mm) is inversely correlated with age and is independent of vessel size, smoking status, sex, and degree of platelet inhibition. The decrease in lumen diameter caused by neointimal overgrowth, however, appears counteracted by outward remodeling (dilation) of the target arterial segment. This leads to an increase in the diameter with a corresponding decrease in length (foreshortening) of the implanted Pipeline Embolization Device. This physiologic remodeling process affects optimally implanted devices and is not a consequence of stretching, device migration, vasospasm, and so forth. A direct, linear, statistically significant relationship exists between the degree of observed outward remodeling and the diameter of the implanted Pipeline Embolization Device relative to the target vessel. Overall, remodeled arterial diameters were reduced by 15% (SD, 10%) relative to baseline and followed a normal distribution. Clinically relevant stenosis was not observed. CONCLUSIONS Vessel healing involves both outward remodeling and neointimal overgrowth. Judicial oversizing could be useful in specific settings to counter the reduction in lumen diameter due to postimplant neointimal overgrowth; however, this overszing needs to be balanced against the decrease in metal coverage accompanying the use of oversized devices. Similar analysis for other devices is essential.
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Affiliation(s)
- Vera Sharashidze
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Eytan Raz
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Erez Nossek
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Svetlana Kvint
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Howard Riina
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurology (H.R., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Caleb Rutledge
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Jacob Baranoski
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Ayaz Khawaja
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Charlotte Chung
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Peter Kim Nelson
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Maksim Shapiro
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurology (H.R., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
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Ramirez-Velandia F, Enriquez-Marulanda A, Young M, Orrego-González E, Filo J, Fodor TB, Sconzo D, Shutran M, Ogilvy CS, Taussky P. Thromboembolic Events After the Coverage of Anterior Cerebral Artery with Flow Diversion: A Single Institution Series and Systematic Review. World Neurosurg 2024; 187:e1040-e1053. [PMID: 38754548 DOI: 10.1016/j.wneu.2024.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/08/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Advances in the use of flow diversion (FD) now extend to bifurcation aneurysms; herein, we compare thromboembolic events in patients with internal carotid artery (ICA) aneurysms treated with and without exclusion of the anterior cerebral artery (ACA). METHODS Retrospective analysis of aneurysms in the terminal ICA treated with FD from 2013 to 2023 at a single-center study. Procedures were classified according to the coverage at the origin of the ACA and compared through bivariate-analysis. A review was also carried on PubMed, Web of Science, and EMBASE until April 2024, adhering to the PRISMA reporting guidelines. RESULTS Ninety-five patients harboring 113 aneurysms treated in 102 procedures were evaluated. Fifty-eight were treated covering the ACA origin. Dual antiplatelet regimens included aspirin-clopidogrel (50%), aspirin-ticagrelor (44.1%), and aspirin-prasugrel (4.9%). Thromboembolic events occurred in 6 patients (5.9%), all of which presented with large vessel occlusion of the ICA, but without reaching statistical difference in the 2 treated cohorts (P = 0.46). At a median clinical follow-up of 5.95 months, there were no differences in the functional outcomes in the 2 groups (P = 0.22). Contralateral angiographic runs post-treatment after covering the ACA origin demonstrated increase in the A1 (median: 0.45 mm; IQR = 0.4-1.2) and ICA diameter (median: 0.55 mm; IQR = 0.1-1.2). After pooling data from literature and our cohort, complete side branch occlusion after the coverage of ACA was seen in 25% of branches (95%CI = 0.16-0.36), and thromboembolic events were observed after 3% (95%CI = 0.01-0.04) of procedures. CONCLUSIONS Thromboembolic events can occur in distal ICA aneurysms treated with FD, but no significant association was seen with covering the ACA origin.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | | | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Eduardo Orrego-González
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean Filo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas B Fodor
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Sconzo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Wang J, Deng X, Li D, Yang Z, Guo XB. Pipeline embolization of complex, wide-necked middle cerebral artery bifurcation aneurysms: A single-center experience. Interv Neuroradiol 2024; 30:227-233. [PMID: 35876346 PMCID: PMC11095361 DOI: 10.1177/15910199221115924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To evaluate the performance of Pipeline Embolization Device (PED) in complex, wide-necked middle cerebral artery (MCA) bifurcation aneurysms. METHODS We performed a retrospective review of patients treated with PED for complex, wide-necked MCA bifurcation aneurysms between August 2016 and March 2021. In addition to demographic data, we collected aneurysmal neck width, dome-to-neck ratio, complications, and clinical and angiographic follow-up. The embolization degree of aneurysms was evaluated by O'Kelly-Marotta (OKM) grading scale, and the prognosis was assessed with the modified Rankin Scale (mRS). RESULTS From August 2016 to March 2021, a total of 46 patients with 49 MCA bifurcation aneurysms in our center were enrolled, of whom all received PEDs successfully. The O'Kelly-Marotta (OKM) grading showed that post-procedure 15 patients (32.6%) were grade C, another 8 patients (17.4%) were grade D. Aneurysms with small remnant or complete occlusion were 50%, symptomatic ischemic events occurred in 3 (6.5%), and bleeding events in 1 (2.2%). 41 patients underwent a 6-month angiography follow-up, in which 7 patients (17.1%) remained OKM grade C and 30 patients (73.2%) achieved OKM grade D. Complete occlusion and small remnant aneurysms were up to 90.3%. 40 (97.6%) patients' mRS scores were 0, and 1 (2.4%) patient was 2. No new bleeding and ischemic events occurred during the 6-month. CONCLUSIONS The Pipeline Embolization Device provides a safe and effective treatment alternative for complex, wide-necked MCA aneurysms. A larger number with longer-term follow-up data is needed for further verification.
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Affiliation(s)
- Jingjing Wang
- Department of Neuro-interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Deng
- Department of Neuro-interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dong Li
- Department of Neuro-interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen Yang
- Department of Neuro-interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin-bin Guo
- Department of Neuro-interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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7
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Senol YC, Orscelik A, Bilgin C, Kobeissi H, Ghozy S, Arul S, Kallmes DF, Kadirvel R. Safety and efficacy profile of off-label use of the Pipeline Embolization Device: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107586. [PMID: 38242183 PMCID: PMC10939757 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVE The off-label utilization of the Pipeline Embolization Device (PED) is a common practice in numerous medical centers globally. Therefore, we conducted a systematic review and meta-analysis to evaluate the overall outcomes of this off-label usage of PEDs. METHODS PubMed, Web of Science, Ovid Medline, Ovid Embase, and Scopus were searched up to February 2023 using the Nested Knowledge platform to identify studies assessing the off-label use of PEDs. Any use of PED outside of the FDA-approved indication granted in 2018 is considered off-label use. Overall angiographic occlusion rates, ischemic and hemorrhagic complications, mortality, retreatment rates, and favorable clinic outcomes were included. Statistical analyses were performed to compare the overall outcome rates of anterior cerebral artery(ACA) vs. middle cerebral artery(MCA) and anterior vs posterior circulation subgroups. RESULTS We included 26 studies involving a total of 1,408 patients. The overall rate of complete occlusion was 80.3 % (95 % CI= 76.0-84.1). Subgroup analysis demonstrated a statistically significant difference in the rate of complete occlusion between anterior circulation (78.9 %) and posterior circulation (69.2 %) (p value=0.02). The rate of good clinical outcomes was 92.8 % (95 % CI= 88.8-95.4). The mortality rate was 1.4 % (95 % CI= 0.5-2.7). The overall rate of ischemic complications was 9.5 % (95 % CI= 7.7-11.6), with a comparable difference between anterior circulation (7.7 %) and posterior circulation (12.8 %) (p value=0.07). There was no statistically significant difference in MCA vs ACA subgroups in all parameters. CONCLUSIONS Off-label use of PEDs can be a safe and effective treatment option for intracranial aneurysms. However, there is a need for more prospective, high-quality, non-industry-funded registry studies and randomized trials to test the efficacy and safety of off-label usage of PEDs and to expand its indications.
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Affiliation(s)
- Yigit Can Senol
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Atakan Orscelik
- Department of Neurosurgery, Medical University of South Carolina, SC, USA
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Santhosh Arul
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Ramanathan Kadirvel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Radiology, Mayo Clinic, Rochester, MN, USA
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8
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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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9
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Ma Y, Deng X, Chen J, Fan F, Han K, Guan S, Guo X. Predictors of In-Stent Stenosis Following the Implantation of Pipeline Embolization Devices for the Treatment of Aneurysms Located at or beyond the Circle of Willis in the Anterior Circulation. AJNR Am J Neuroradiol 2024; 45:ajnr.A8144. [PMID: 38388683 PMCID: PMC11288563 DOI: 10.3174/ajnr.a8144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/11/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND PURPOSE In-stent stenosis is commonly observed after stent implantation. There is no consensus on the contributing factors for in-stent stenosis, especially for aneurysms located at or beyond the circle of Willis in the anterior circulation. This study aimed to investigate the morbidity and determinants of in-stent stenosis in distal anterior circulation aneurysms following the implantation of Pipeline Embolization Devices. MATERIALS AND METHODS Patients who underwent Pipeline Embolization Device treatment at our center between January 1, 2018, and June 15, 2023, were enrolled. Distal anterior circulation aneurysms were defined as those occurring at or beyond the circle of Willis, including anterior communicating artery aneurysms, anterior cerebral artery aneurysms, and MCA aneurysms. Baseline information, aneurysm characteristics, and follow-up data of patients were analyzed. Patients were divided into 2 groups: the in-stent stenosis group (patients with a loss of >25% of the lumen diameter of the parent artery) and the non-in-stent stenosis group. Binary logistic regression and restricted cubic spline curves were used to explore risk factors. RESULTS We included 85 cases of 1213 patients treated with flow-diverter devices at our hospital. During an average follow-up period of 9.07 months, the complete occlusion rate was 77.64%. The overall incidence of in-stent stenosis was 36.47% (31/85), of which moderate stenosis accounted for 9.41% (8/85), and severe stenosis, 5.88% (5/85) (triglyceride-glucose index ≥ 8.95; OR = 6.883, P = .006). The difference in diameters between the stent and parent artery of ≥0.09 mm (OR = 6.534, P = .015) and 55 years of age or older (OR = 3.507, P = .036) were risk factors for in-stent stenosis. The restricted cubic spline curves indicated that the risk of in-stent stenosis increased as the difference in diameter between stent and parent artery and the triglyceride-glucose index increased. CONCLUSIONS Compared with the on-label use of Pipeline Embolization Devices, the rate of in-stent stenosis did not obviously increase when treating distal anterior circulation aneurysms with these devices. The incidence of in-stent stenosis was 36.47% when defined as a lumen diameter loss of >25%, and 15.2% when defined as a lumen diameter loss of >50%. Stent-size selection and biochemical indicators can potentially impact the incidence of in-stent stenosis.
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Affiliation(s)
- Yajing Ma
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Xin Deng
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Junfan Chen
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Feng Fan
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Kaihao Han
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Sheng Guan
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
- Neurointerventional Engineering Research Center of Henan Province (S.G.), Henan Province, China
| | - Xinbin Guo
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
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10
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Korkmazer B, Karaman AK, Ustundag A, Arslan S, Kızılkılıç O, Koçer N, Islak C. Magnetic resonance perfusion imaging findings following flow diversion in patients with complex middle cerebral artery bifurcation aneurysms: a single-center analysis regarding the jailed cortical branches. J Neurointerv Surg 2023; 16:8-14. [PMID: 36963822 DOI: 10.1136/jnis-2023-020124] [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: 01/24/2023] [Accepted: 03/07/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Flow diverter (FD) devices provide a safe and effective treatment option especially for wide-necked intracranial aneurysms. One of the main concerns in patients treated with FD devices is patency of arterial branches jailed by the stent. However, there are no long-term data from magnetic resonance perfusion (MRP) studies regarding jailed branches. In this study we aimed to reveal the MRP findings in patients with jailed middle cerebral artery (MCA) cortical branches during long-term follow-up after flow diversion. METHODS Patients who underwent FD stent treatment for MCA aneurysms with a resulting jailed cortical branch were included. Follow-up clinical, angiographic, and MRP examination findings were recorded. Different MRP parameters were measured in the MCA territory regarding the jailed branches. RESULTS Eighteen patients treated endovascularly with flow diversion for a total of 20 MCA aneurysms were included. At angiographic follow-up (median 35 months, range 7-95 months) complete occlusion was observed in 13 (65%) aneurysms and partial occlusion was observed in 6 (30%). The mean transit time (MTT) prolongation, MTT ratio, time-to peak (TTP) prolongation, and TTP ratio were 1.34, 1.20, 1.18, and 1.06 s, respectively, when compared with the contralateral side in the MCA territory. MTT, TTP, and cerebral blood volume values of the patients showed statistically significant differences compared with the contralateral side (P<0.05). CONCLUSIONS Flow diversion treatment of complex bifurcation aneurysms can be effective and safe. MRP examination may reveal perfusion changes in the territory vascularized via a jailed branch, and these changes are rarely accompanied by clinical findings.
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Affiliation(s)
- Bora Korkmazer
- Division of Neuroradiology, Department of Radiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Ahmet Kursat Karaman
- Department of Radiology, Sureyyapasa Chest Diseases and Chest Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Ustundag
- Department of Radiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Serdar Arslan
- Division of Neuroradiology, Department of Radiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Osman Kızılkılıç
- Division of Neuroradiology, Department of Radiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Naci Koçer
- Division of Neuroradiology, Department of Radiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Civan Islak
- Division of Neuroradiology, Department of Radiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
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11
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Zhou Z, Lan W, Yu J. Endovascular treatment of middle cerebral artery aneurysms: current status and future prospects. Front Neurol 2023; 14:1239199. [PMID: 38033773 PMCID: PMC10684741 DOI: 10.3389/fneur.2023.1239199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/20/2023] [Indexed: 12/02/2023] Open
Abstract
Middle cerebral artery (MCA) aneurysms are complex and widely distributed throughout the course of the MCA. Various types of aneurysms can occur in the MCA. Ruptured as well as unruptured MCA aneurysms may require treatment to avoid bleeding or rebleeding. Currently, clipping is regarded as the first-line choice for the treatment of MCA aneurysms. However, endovascular treatment (EVT) is emerging as an alternative treatment in selected cases. EVT techniques vary. Therefore, it is necessary to review EVT for MCA aneurysms. In this review, the following issues were discussed: MCA anatomy and anomalies, classifications of MCA aneurysms, the natural history of MCA aneurysms, EVT status and principle, deployments of traditional coiling techniques and flow diverters (FDs), and deployments and prospects of intrasaccular flow disruptors and stent-like devices. According to the review and our experience, traditional coiling EVT is still the preferred therapy for most MCA aneurysms. FD deployment can be used in selective MCA aneurysms. Parent artery occlusion (PAO) can be used to treat distal MCA aneurysms. In addition, new devices can be used to treat MCA aneurysms, such as intrasaccular flow disruptors and stent-like devices. In general, EVT is gaining popularity as an alternative treatment option; however, there is still a lack of evidence regarding EVT, and longer-term data are not currently available for most EVT devices.
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Affiliation(s)
- Zibo Zhou
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Wenjing Lan
- Department of Radiology, First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
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12
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Hiramatsu R, Yagi R, Kameda M, Nonoguchi N, Furuse M, Kawabata S, Ohnishi H, Miyachi S, Wanibuchi M. Treatment Outcomes of 94 Cases of Pipeline Embolization Device in a Single Center: Predictive Factors of Incomplete Aneurysm Occlusion. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:217-223. [PMID: 37869485 PMCID: PMC10586884 DOI: 10.5797/jnet.oa.2023-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/24/2023] [Indexed: 10/24/2023]
Abstract
Objective This study aimed to report the outcome of an endovascular treatment with a pipeline embolization device (PED) at a single center. We also examined the predictive factors for an incomplete occlusion after the PED placement. Methods The subjects were 94 patients with 109 aneurysms who underwent the PED placement at our single center from June 2015 to September 2022. As treatment outcomes, we investigated the PED placement success rate, perioperative morbidity and mortality, postoperative cranial nerve improvement rate, and the classification of angiographic result at 6 months after the PED placement. Furthermore, the predictors of an incomplete occlusion were investigated in detail. Results One hundred nine aneurysms locations were: C1 (9), C2 (30), C3 (15), C4 (53), and C5 (2) in the internal carotid artery segments. Perioperative morbidity, including the asymptomatic ones, occurred in 10 cases (10.6%). Among these 10 cases, the modified Rankin Scale (mRS) improved to preoperative mRS after 90 days in 9 cases except 1 case. On the other hand, no perioperative mortality was observed. The postoperative cranial nerve improvement rate was 84.4%, and 61.7% of patients had a complete occlusion in the follow-up angiography, 6 months after the PED placement. Predictive factors for an incomplete occlusion after the PED placement were the elderly aged 70 years or older (P-value = 0.0214), the elderly aged 75 years or older (P-value = 0.0009), and the use of anticoagulants (P-value = 0.0388) in an univariate analysis. Further, the multivariate analysis revealed that the elderly aged 75 years or older was a predictive factor of an incomplete occlusion in this study. Conclusion We summarized the outcomes of the PED treatment at our single center. In this study, the elderly aged 75 years or older was a predictive factor of an incomplete occlusion after the PED placement.
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Affiliation(s)
- Ryo Hiramatsu
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Ryokichi Yagi
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masahiro Kameda
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Naosuke Nonoguchi
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Motomasa Furuse
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Shinji Kawabata
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Hiroyuki Ohnishi
- Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Hyogo, Japan
| | - Shigeru Miyachi
- Department of Neurosurgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Masahiko Wanibuchi
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
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13
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Sahoo A, Abdalkader M, Saatci I, Raymond J, Qiu Z, Huo X, Sun D, Weyland CS, Jia B, Zaidat OO, Hu W, Qureshi AI, Miao Z, Nguyen TN. History of Neurointervention. Semin Neurol 2023; 43:454-465. [PMID: 37549692 DOI: 10.1055/s-0043-1771455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
In this review article, we aim to provide a summary of the discoveries and developments that were instrumental in the evolution of the Neurointerventional field. We begin with developments in the advent of Diagnostic Cerebral Angiography and progress to cerebral aneurysm treatment, embolization in AVMs and ischemic stroke treatment. In the process we discuss many persons who were key in the development and maturation of the field. A pivotal aspect to rapid growth in the field has been the multidisciplinary involvement of the different neuroscience specialties and therefore we close out our discussion with excitement about ongoing and future developments in the field with a focus on treatments in the non-cerebrovascular disease realm.
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Affiliation(s)
- Anurag Sahoo
- Department of Neurology/Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Mohamad Abdalkader
- Department of Neurology/Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Isil Saatci
- Department of Interventional Neuroradiology, Private Koru Hospitals, Ankara, Turkey
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Universite de Montreal, Montreal, Canada
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, People's Republic of China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Charlotte S Weyland
- Department of Interventional Neuroradiology, Aachen University Hospital, Aachen, Germany
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Osama O Zaidat
- Department of Neuroscience and Stroke Program, Bon Secours Mercy Health St Vincent Hospital, Toledo, Ohio
| | - Wei Hu
- Division of Life Sciences and Medicine, Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, People's Republic of China
| | - Adnan I Qureshi
- Department of Neurology, Zeenat Qureshi Stroke Institute, University of Missouri, Columbia, Missouri
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Thanh N Nguyen
- Department of Neurology/Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
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14
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Soydemir E, Gündoğmuş CA, Türeli D, Andaç Baltacıoğlu N, Bayri Y, Baltacıoğlu F. Safety and efficacy of flow diverter stents in the treatment of middle cerebral artery aneurysms: a single-center experience and follow-up data. Diagn Interv Radiol 2023; 29:350-358. [PMID: 36988000 PMCID: PMC10679704 DOI: 10.4274/dir.2022.211050] [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: 10/19/2021] [Accepted: 04/04/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE This study aims to evaluate the safety and efficacy of flow diverters (FDs) in the treatment of middle cerebral artery (MCA) aneurysms and share the follow-up (F/U) results. METHODS The treatment and F/U results of 76 MCA aneurysms treated with the flow re-direction endoluminal device (FRED), FRED Jr., and pipeline embolization device (PED) FD stents were evaluated retrospectively. The aneurysm occlusion rates were compared between FDs, and the integrated and jailed branches were evaluated through follow-ups. The oversizing of the stent was compared between occluded/non-occluded aneurysms and integrated branches. RESULTS The mean F/U duration was 32 ± 6.3 months, and the mean aneurysm diameter was 4.45 mm. A total of 61 (80.3%) aneurysms were wide-necked; 73 (96.1%) were saccular; 52 (68.4%) were located at the M1 segment; and 36 (45.6%) FREDs, 23 (29.1%) FRED Jr.s, and 19 (24.1%) PEDs were used for treatment. The overall occlusion rates for the 6-, 12-, 24-, 36-, and 60-month digital subtraction angiographies were 43.8%, 63.5%, 73.3%, 85.7%, and 87.5% respectively. The last F/U occlusion rates were 67.6% for FRED, 66.7% for PED, and 60.6% for FRED Jr. (P = 0.863). An integrated branch was covered with an FD during the treatment of 63 (82.8%) aneurysms. A total of six (10%) of the integrated branches were occluded without any symptoms at the last F/U appointment. The median oversizing was 0.45 (0-1.30) for occluded aneurysms, and 0.50 (0-1.40) for non-occluded aneurysms (P = 0.323). The median oversizing was 0.70 (0.45-1.10) in occluded integrated branches and 0.50 (0-1.40) in non-occluded branches (P = 0.131). In-stent stenosis was seen in 22 (30.1%) of the stents at the 6-month F/U and in only 2 (4.7%) at the 24-month F/U. Thus, none of the patients had any neurological deficits because of the in-stent stenosis. Severe in-stent stenosis was seen in two stents. CONCLUSION MCA aneurysms tend to be complex, with integrated branches and potentially wide necks. FD stents are safe and effective in the treatment of MCA aneurysms, and the patency of the side and jailed branches is preserved in most cases. Higher occlusion and lower in-stent stenosis rates are seen with longer F/U durations.
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Affiliation(s)
- Efe Soydemir
- Department of Radiology, Marmara University Faculty of Medicine, İstanbul, Turkey
| | - Cemal Aydın Gündoğmuş
- Department of Radiology, Marmara University Faculty of Medicine, İstanbul, Turkey
- Department of Radiology, Koç University Hospital, İstanbul, Turkey
| | - Derya Türeli
- Department of Radiology, Marmara University Faculty of Medicine, İstanbul, Turkey
| | | | - Yaşar Bayri
- Department of Neurosurgery, Marmara University Faculty of Medicine, İstanbul, Turkey
| | - Feyyaz Baltacıoğlu
- Department of Radiology, Marmara University Faculty of Medicine, İstanbul, Turkey
- Department of Radiology, VKV Amerikan Hospital, İstanbul, Turkey
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15
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Hanel RA, Cortez GM, Lopes DK, Nelson PK, Siddiqui AH, Jabbour P, Mendes Pereira V, István IS, Zaidat OO, Bettegowda C, Colby GP, Mokin M, Schirmer CM, Hellinger FR, Given C, Krings T, Taussky P, Toth G, Fraser JF, Chen M, Priest R, Kan P, Fiorella D, Frei D, Aagaard-Kienitz B, Diaz O, Malek AM, Cawley CM, Puri AS, Kallmes DF. Prospective study on embolization of intracranial aneurysms with the pipeline device (PREMIER study): 3-year results with the application of a flow diverter specific occlusion classification. J Neurointerv Surg 2023; 15:248-254. [PMID: 35292570 PMCID: PMC9985759 DOI: 10.1136/neurintsurg-2021-018501] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/06/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The pipeline embolization device (PED; Medtronic) has presented as a safe and efficacious treatment for small- and medium-sized intracranial aneurysms. Independently adjudicated long-term results of the device in treating these lesions are still indeterminate. We present 3-year results, with additional application of a flow diverter specific occlusion scale. METHODS PREMIER (prospective study on embolization of intracranial aneurysms with pipeline embolization device) is a prospective, single-arm trial. Inclusion criteria were patients with unruptured wide-necked intracranial aneurysms ≤12 mm. Primary effectiveness (complete aneurysm occlusion) and safety (major neurologic event) endpoints were independently monitored and adjudicated. RESULTS As per the protocol, of 141 patients treated with a PED, 25 (17.7%) required angiographic follow-up after the first year due to incomplete aneurysm occlusion. According to the Core Radiology Laboratory review, three (12%) of these patients progressed to complete occlusion, with an overall rate of complete aneurysm occlusion at 3 years of 83.3% (115/138). Further angiographic evaluation using the modified Cekirge-Saatci classification demonstrated that complete occlusion, neck residual, or aneurysm size reduction occurred in 97.1%. The overall combined safety endpoint at 3 years was 2.8% (4/141), with only one non-debilitating major event occurring after the first year. There was one case of aneurysm recurrence but no cases of delayed rupture in this series. CONCLUSIONS The PED device presents as a safe and effective modality in treating small- and medium-sized intracranial aneurysms. The application of a flow diverter specific occlusion classification attested the long-term durability with higher rate of successful aneurysm occlusion and no documented aneurysm rupture. TRIAL REGISTRATION NCT02186561.
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Affiliation(s)
- Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | | | - Peter Kim Nelson
- Interventional Radiology, NYU Langone Medical Center, New York, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Istvan Szikora István
- Department of Neuroradiology, National Institute of Neurosciences, Budapest, Hungary
| | - Osama O Zaidat
- Neuroscience Institute, Mercy Health Saint Vincent Medical Center, Toledo, Ohio, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Geoffrey P Colby
- Department Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA
| | - Frank R Hellinger
- Department of Radiology, Florida Hospital Neuroscience Institute, Winter Park, Florida, USA
| | - Curtis Given
- Department of Radiology, Baptist Health Lexington, Lexington, Kentucky, USA
| | - Timo Krings
- Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Justin F Fraser
- Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Michael Chen
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Ryan Priest
- Charles T Dotter Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - David Fiorella
- Department of Neurosurgery, Cerebrovascular Center, Stony Brook University, Stony Brook, New York, USA
| | - Donald Frei
- Department of Neuroradiology, Swedish Medical Center, Englewood, Colorado, USA
| | - Beverly Aagaard-Kienitz
- Department of Neurological Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Orlando Diaz
- Cerebrovascular Center, Houston Methodist Research Institute, Houston, Texas, USA
| | - Adel M Malek
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - C Michael Cawley
- Department of Neurointerventional Radiology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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16
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Le K, Heskett C, De Stefano FA, Fry L, Lei C, Dharia A, Brake A, Chatley K, Peterson J, Ebersole K. An Analysis of Landmark Articles Regarding Aneurysms of the Middle Cerebral Artery. World Neurosurg 2023; 171:72-83. [PMID: 36473598 DOI: 10.1016/j.wneu.2022.11.135] [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: 10/18/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Aneurysms located on the middle cerebral artery (MCA) range from 22% to 31.5% in prevalence of all aneurysms in the anterior cerebral circulation. This bibliometric analysis summarizes the most cited articles on MCA aneurysms and highlights the landmark publications that contributed to evidence-based practice. METHODS In the execution of this bibliometric-based review article, the Scopus database was used to perform a title-specific, keyword-based search for all publications until August 2022. The keyword "(middle cerebral artery OR MCA) AND aneurysm" was used. Our results were arranged in descending order based on the citation count of the article. The 100 most cited articles were selected for analysis. Parameters included the following: title, citation count, citations per year, authors, specialty of first author, institution, country of origin, publishing journal, Source Normalized Impact per Paper, and Hirsch index. RESULTS The keyword-based search showed that 1206 articles on MCA aneurysms were published up to August 2022. The top 100 articles were published between 1940 and 2019. The top 100 most cited articles collected a total of 6232 citations with an average of 62.3 citations per article. The rate of self-citations accounted for an average of 5.75% of the total number of citations. CONCLUSIONS The bibliometric analysis provides a quantitative overview of how medical literature and interventions are analyzed in academic medicine. In the present study, we evaluated the global trends in research regarding MCA aneurysms by finding the top 100 most cited articles.
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Affiliation(s)
- Kevin Le
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Cody Heskett
- University of Kansas School of Medicine, Kansas City, Kansas, USA.
| | - Frank A De Stefano
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Lane Fry
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Catherine Lei
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Anand Dharia
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Aaron Brake
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Kevin Chatley
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeremy Peterson
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Koji Ebersole
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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17
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Piano M, Lozupone E, Milonia L, Pero G, Cervo A, Macera A, Quilici L, Visconti E, Valvassori L, Cenzato M, Boccardi E. Flow diverter devices in the treatment of complex middle cerebral artery aneurysms when surgical and endovascular treatments are challenging. J Stroke Cerebrovasc Dis 2022; 31:106760. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/17/2022] [Accepted: 09/04/2022] [Indexed: 11/21/2022] Open
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18
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El Naamani K, Saiegh FA, Chen CJ, Abbas R, Sioutas GS, Amllay A, Shehabeldine M, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Treatment of cerebral aneurysms with the FRED Jr flow-diverting stent: A case series and meta-analysis. Clin Neurol Neurosurg 2022; 223:107483. [DOI: 10.1016/j.clineuro.2022.107483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/29/2022] [Accepted: 10/18/2022] [Indexed: 11/30/2022]
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19
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Abdelkhalek H, Abdelhameed EA, Zakarea A, El Malky I. Predictors of flow diverter stent in large and giant unruptured intracranial aneurysms, single-center experience. Neurol Sci 2022; 43:6399-6405. [PMID: 35984605 PMCID: PMC9616764 DOI: 10.1007/s10072-022-06336-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/07/2022] [Indexed: 11/29/2022]
Abstract
Background Flow diversion with or without coiling has been established as the treatment of choice for large unruptured aneurysms. This study aims to assess possible predictors for radiological and clinical outcome such as location of the aneurysm (anterior or posterior circulation), complexity by a branching artery, bifurcation, and adjuvant coiling. Methods This study was conducted on 65 consecutive patients with 65 large, unruptured intracranial aneurysms (size ≥ 10 mm) treated with flow diverters. Follow-up angiography was done for 60 patients (92.3%) at 12 ± 8.6 months range from 3 to 36 months. Results Complete occlusion was achieved in 50 from 60 aneurysms (83.4%), while 8 aneurysms (13.3%) had neck remnant, and another two aneurysms (3.3%) remained with aneurysmal remnant. Periprocedural complications were encountered in 14 patients (21.5%) with morbidity in six patients (9.2%) and mortality in one patient (1.5%). In a multivariate logistic regression, anterior versus posterior location was less likely associated with worse outcome; adjusted OR (95% CI) of 0.16 (0.07–0.01), p = 0.006. Complete occlusion in complex aneurysms with branching artery was 60% versus 88% in simple aneurysms without branching artery (p-value = 0.04). Conclusions Flow diverter deployment of a large, unruptured aneurysm in the anterior circulation might have a better outcome than one in the posterior circulation. Flow diverter of aneurysms with branching artery or at bifurcation might be associated with aneurysm persistence and complications respectively.
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Affiliation(s)
| | | | - Ayman Zakarea
- Department of Radiology, Kasr Alainy University, Cairo, Egypt
| | - Islam El Malky
- Department of Neurology, South Valley University, Qena, Egypt.
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20
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Lauzier DC, Root BK, Kayan Y, Almandoz JED, Osbun JW, Chatterjee AR, Whaley KL, Tipps ME, Moran CJ, Kansagra AP. Pipeline embolization of proximal middle cerebral artery aneurysms: A multicenter cohort study. Interv Neuroradiol 2022; 28:50-57. [PMID: 33951971 PMCID: PMC8905083 DOI: 10.1177/15910199211015578] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Flow diversion of aneurysms located in the M1 segment and middle cerebral artery bifurcation with Pipeline embolization device is sometimes performed, but further study is needed to support its regular use in aneurysm treatment. Here, we report measures of safety and efficacy for Pipeline embolization in the proximal middle cerebral artery in a multi-center cohort. MATERIALS AND METHODS Clinical and angiographic data of eligible patients were retrospectively obtained from participating centers and assessed for key clinical and angiographic outcomes. Additional details were extracted for patients with complications. RESULTS In our multi-center cohort, complete aneurysm occlusion was achieved in 71% (17/24) of treated aneurysms. There were no deaths or disabling strokes, but non-disabling ischemic strokes occurred in 8% (2/24) of patients. For aneurysms in the M1 segment, complete aneurysm occlusion was observed in 75% (12/16) of aneurysms, aneurysm volume reduction was observed in 100% (16/16) of aneurysms, and non-disabling ischemic strokes occurred in 13% (2/16) of patients. For aneurysms at the middle cerebral artery bifurcation, complete aneurysm occlusion was observed in 63% (5/8) of aneurysms, aneurysm volume reduction occurred in 88% (7/8) of aneurysms, and ischemic or hemorrhagic complications occurred in 0% (0/8) of patients. CONCLUSION Pipeline embolization of cerebral aneurysms in the M1 segment and middle cerebral artery bifurcation demonstrated a 71% rate of complete aneurysm occlusion. There were no deaths or disabling strokes, but there was an 8% rate of non-disabling ischemic strokes.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Brandon K Root
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Yasha Kayan
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Josser E Delgado Almandoz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Joshua W Osbun
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Kayla L Whaley
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Megan E Tipps
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA,Akash P Kansagra, 510 S Kingshighway Blvd, St. Louis, MO 63110, USA.
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21
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Pipeline embolization of MCA aneurysms in the M2-M4 segment: Dual center study and meta-analysis. Clin Neurol Neurosurg 2021; 212:107063. [PMID: 34864490 DOI: 10.1016/j.clineuro.2021.107063] [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: 10/13/2021] [Revised: 11/15/2021] [Accepted: 11/21/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Flow diversion of distal MCA aneurysms in the M2-M4 segments with Pipeline embolization device is promising, but further study is needed. Here, we seek to quantify the safety and efficacy of Pipeline embolization in the M2-M4 region in a dual-center cohort and comprehensive meta-analysis. METHODS Clinical and angiographic data of eligible patients was obtained from participating centers. A systematic review was performed with searches of Pubmed, Scopus, Embase, and the Cochrane Library for articles from inception to May 2021. 86 studies were identified in systematic review. Of these, 7 studies with 46 aneurysms met the inclusion criteria and were aggregated with 8 aneurysms from our dual-center cohort for analysis. RESULTS In our dual-center cohort, complete occlusion was observed in 88% (7/8) of aneurysms, and no patients experienced hemorrhagic or thromboembolic complications. Clinical outcomes were reported for 100% (54/54) of aneurysms included in meta-analysis and angiographic follow-up was available for 91% (49/54). The overall rate of complete aneurysm occlusion was 80% (95% CI, 69-91%), and the overall rate of clinical complication was 9% (95% CI, 2-16%). CONCLUSION Pipeline embolization of cerebral aneurysms of the M2-M4 segments of the MCA was reasonably effective and safe in a small group of selected patients, but further study is needed to validate these preliminary results.
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22
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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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23
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Abbasi M, Savasatano LE, Brinjikji W, Kallmes KM, Mikoff N, Reierson N, Abdelmegeed M, Pederson J, Warren B, Touchette JC, Khan S, Kamrowski S, Barrett A, Kallmes DF, Kadirvel R. Endoluminal flow diverters in the treatment of sidewall and bifurcation aneurysm: A systematic review and meta-analysis of complications and angiographic outcomes. Interv Neuroradiol 2021; 28:229-239. [PMID: 34154429 DOI: 10.1177/15910199211026713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIM The use of endoluminal flow diversion in bifurcation aneurysms has been questioned due to the potential for complications and lower occlusion rates. In this study we assessed outcomes of endovascular treatment of intracranial sidewall and bifurcation aneurysms with flow diverters. METHODS In July 2020, a literature search for all studies utilizing endoluminal flow diverter treatment for sidewall or bifurcation aneurysms was performed. Data were collected from studies that met our inclusion/exclusion criteria by two independent reviewers and confirmed by a third reviewer. Using random-effects meta-analysis the target outcomes including overall complications (hematoma, ischemic events, minor ischemic stroke, aneurysm rupture, side vessel occlusion, stenosis, thrombosis, transient ischemic stroke, and other complications), perioperative complications, and follow-up (long-term) aneurysm occlusion were intestigated. RESULTS Overall, we included 35 studies with 1084 patients with 1208 aneurysms. Of these aneurysms, 654 (54.14%) and 554 (45.86%) were classified as sidewall and bifurcation aneurysm, respectively, based on aneurysm location. Sidewall aneurysms had a similar total complication rate (R) of 27.12% (95% CI, 16.56%-41.09%), compared with bifurcation aneurysms (R, 20.40%, 95% CI, 13.24%-30.08%) (p = 0.3527). Follow-up angiographic outcome showed comparable complete occlusion rates for sidewall aneurysms (R 69.49%; 95%CI, 62.41%-75.75%) and bifurcation aneurysms (R 73.99%; 95% CI, 65.05%-81.31%; p = 0.4328). CONCLUSIONS This meta-analysis of sidewall and bifurcation aneurysms treated with endoluminal flow diverters demonstrated no significant differences in complications or occlusion rates. These data provide new information that can be used as a benchmark for comparison with emerging devices for the treatment of bifurcation aneurysms.
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Affiliation(s)
- Mehdi Abbasi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Luis E Savasatano
- Department of Neurosurgery, 6915Mayo Clinic, Mayo Clinic, Rochester, MN, USA
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24
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Lee JE, Kan P. Commentary: Safety, Efficacy, and Durability of Stent Plus Balloon-Assisted Coiling for the Treatment of Wide-Necked Intracranial Bifurcation Aneurysms. Neurosurgery 2021; 88:E415-E416. [PMID: 33575797 DOI: 10.1093/neuros/nyab006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 12/04/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jae Eun Lee
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
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25
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Bhogal P, Makalanda H, Wong K, Keston P, Downer J, Du Plessis JC, Nania A, Simonato D, Fuschi M, Chong W, O'Reilly S, Rennie I. The Silk Vista Baby - The UK experience. Interv Neuroradiol 2021; 28:201-212. [PMID: 34078155 DOI: 10.1177/15910199211024061] [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] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The Silk Vista Baby (SVB) flow diverter (FDS) is the only FDS deliverable via a 0.017 inch microcatheter and is specifically designed for the distal vasculature. We sought to evaluate the safety and efficacy of the SVB. MATERIALS AND METHODS We performed a retrospective review to identify SVB cases at 4 tertiary neurosurgical centres within the U.K. Clinical, procedural, angiographic and follow-up data were collected. RESULTS We identified 60 patients (35 female, 58%) of average age 54 ± 10.5 (range 30-72) with 61 aneurysms, 50 (81.9%) located in the anterior circulation. The majority of the aneurysms treated were unruptured (46, 75.4%) and saccular (46, 75.4%). Dome size was 6.2 ± 6.2 mm (range 1-36mm) and parent vessel diameter was 2.3 ± 0.4 mm (range 1.2-3.3 mm).An average number of 1.07 devices were implanted. Coils or other devices were implanted in 14 aneurysms (23.3%). At last angiographic follow-up (n = 55), 7.5 ± 4.2 months post-procedure, 32 aneurysms (57.1%) were graded as RRC I, 7 (12.5%) RRC II, and 17 RRC III (30.4%).Clinical complications, excluding death, were seen in 4 patients (6.8%) including 1 delayed aneurysm rupture and 3 symptomatic ischaemic events. Only one patient had permanent morbidity (mRS 1). 3 patients died during follow-up (5.1%); 2 deaths were related to the aneurysms (3.4%) - one ruptured dissecting MCA aneurysm, and one giant partially thrombosed posterior circulation aneurysm. 93% of patients were mRS ≤ 2 at last follow-up. CONCLUSION The SVB has high rates of technical success and an acceptable safety profile. Distal aneurysms may occlude slower due to relative oversizing of the devices.
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Affiliation(s)
- P Bhogal
- The Royal London Hospital, London, UK
| | | | - K Wong
- The Royal London Hospital, London, UK
| | - P Keston
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - J Downer
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - J C Du Plessis
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - A Nania
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - D Simonato
- Department of Interventional Neuroradiology, John Radcliffe Hospital, Oxford, UK
| | - M Fuschi
- Department of Interventional Neuroradiology, John Radcliffe Hospital, Oxford, UK
| | - W Chong
- Department of Interventional Neuroradiology, University Hospitals Coventry and Warwickshire, Warwickshire, UK
| | - S O'Reilly
- Department of Interventional Neuroradiology, The Royal Victoria Hospital, Belfast, UK
| | - I Rennie
- Department of Interventional Neuroradiology, The Royal Victoria Hospital, Belfast, UK
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26
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Hufnagl C, Broussalis E, Cognard C, Grimm J, Hecker C, Oellerer A, Abdallah M, Griessenauer CJ, Killer-Oberpfalzer M. Evaluation of a novel flow diverter, the DiVeRt system, in an animal model. J Neurointerv Surg 2021; 14:384-389. [PMID: 33986108 DOI: 10.1136/neurintsurg-2021-017430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Using a surgical aneurysm model, this study assessed the performance of a new flow diverter (FD), the DiVeRt, and evaluated the angiographic and histologic features at different periods after stent deployment. METHODS Fifteen New Zealand White rabbits were treated 3 days prior to intervention and until euthanization with dual antiplatelets. DiVeRt was implanted in bilateral carotid aneurysms (n=30) as well as in the aorta (n=15). The rate of technical success, assessment of aneurysm occlusion (measured by the O'Kelly-Marotta grading (OKM) scale), and stent patency were examined using angiography and histologic examinations in three groups at 1, 3, and 6 months follow-up (FU). In each FU group one control animal was included and treated with the XCalibur stent (n=3). RESULTS Overall, DiVeRt placement was successful and without apparent intraprocedural complications. In total, four stents in the carotid artery were occluded and in-stent stenosis was registered in two carotid (7%) and one aortic (6%) vessels. Complete or near complete aneurysm occlusion (OKM scale D1 and C3) was seen in 100% in the 1-month FU group, 70% in the 2-month FU group, and 100% in the 3-month FU group. Histology showed loose, organizing fibrous tissue matrix within the sac and adequate neck endothelialization in all vessels. All branches covered by the DiVeRt remained patent. CONCLUSIONS The DiVeRt system appears to be feasible and effective for the treatment of aneurysms with high rates of complete aneurysm occlusion, excellent vessel patency, and evidence of high biocompatibility. Occurrences of parent artery occlusion at follow-up did not result in clinical consequences.
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Affiliation(s)
- Clemens Hufnagl
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Erasmia Broussalis
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Neurology, University Hospital Salzburg, Salzburg, Austria
| | - Christophe Cognard
- Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Jochen Grimm
- Department of Neuroradiology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Constantin Hecker
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Neurology, University Hospital Salzburg, Salzburg, Austria
| | - Andreas Oellerer
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Neuroradiology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Muhammed Abdallah
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Vascular and Endovascular Surgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA
| | - Monika Killer-Oberpfalzer
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria .,Department of Neurology, University Hospital Salzburg, Salzburg, Austria
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27
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Aguilar Pérez M, Henkes E, Hellstern V, Serna Candel C, Wendl C, Bäzner H, Ganslandt O, Henkes H. Endovascular Treatment of Anterior Circulation Aneurysms With the p64 Flow Modulation Device: Mid- and Long-Term Results in 617 Aneurysms From a Single Center. Oper Neurosurg (Hagerstown) 2021; 20:355-363. [PMID: 33469666 PMCID: PMC8133326 DOI: 10.1093/ons/opaa425] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/09/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Flow diverters have become an important tool in the treatment of intracranial aneurysms, especially when dealing with difficult-to-treat or complex aneurysms. The p64 is the only fully resheathable and mechanically detachable flow diverter available for clinical use. OBJECTIVE To evaluate the safety and effectiveness of p64 for the treatment of intracranial saccular unruptured aneurysms arising from the anterior circulation over a long-term follow-up period. METHODS We retrospectively reviewed our prospectively maintained database to identify all patients who underwent treatment for an intracranial saccular (unruptured or beyond the acute hemorrhage phase) aneurysm arising from the anterior circulation with ≥1 p64 between December 2011 and December 2019. Fusiform aneurysms and dissections were excluded. Aneurysms with prior or concomitant saccular treatment (eg, coiling and clipping) were included. Aneurysms with parent vessel implants other than p64 were excluded. Anatomic features, intraprocedural complications, clinical outcome, as well as clinical and angiographic follow-ups were all recorded. RESULTS In total, 530 patients (388 females; median age 55.9 yr) with 617 intracranial aneurysms met the inclusion criteria. The average number of devices used per aneurysm was 1.1 (range 1-3). Mean aneurysm dome size was 4.8 mm (range 1-27 mm). Treatment-related morbimortality was 2.4%. Early, mid-term, and long-term angiographic follow-up showed complete or near-complete aneurysm occlusion in 76.8%, 89.7%, and 94.5%, respectively. CONCLUSION Treatment of intracranial saccular unruptured aneurysms of the anterior circulation using p64 is a safe and effective treatment option with high rate of occlusion at long-term follow-up and low morbimortality.
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Affiliation(s)
- Marta Aguilar Pérez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Elina Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Victoria Hellstern
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Carmen Serna Candel
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Christina Wendl
- Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Medizinische Fakultät der Universität Duisburg-Essen, Essen, Germany
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de Castro-Afonso LH, Nakiri GS, Abud TG, Monsignore LM, de Freitas RK, Abud DG. Aspirin monotherapy in the treatment of distal intracranial aneurysms with a surface modified flow diverter: a pilot study. J Neurointerv Surg 2021; 13:336-341. [PMID: 33514613 DOI: 10.1136/neurintsurg-2020-017024] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/15/2020] [Accepted: 12/23/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Flow diverters (FDs) result in high occlusion rates of aneurysms located distally to the carotid artery. However, the complications reported are not negligible. New modified surface FDs have low thrombogenic properties that may reduce ischemic complications related to the treatment. In addition, a modified surface FD may allow for the use of a single antiplatelet medication to reduce hemorrhagic risk during the procedure. The aim of this study was to assess the safety and efficacy of the p48 MW HPC (phenox, Bochum, Germany) to treat distal intracranial aneurysms under the use of aspirin monotherapy. METHODS The primary endpoint was the incidence of any neurologic deficit after treatment after 6 months of follow-up. The secondary endpoint was the rate of the complete occlusion of the aneurysms at the 6-month follow-up. Enrollment of 20 patients was planned, but after inclusion of seven patients the study was stopped due to safety issues. RESULTS Seven patients with eight aneurysms were included. Among the seven patients, three (42.8%) had ischemic complications on the second day after FD deployment. Two patients experienced complete recovery at discharge (National Institutes of Health Stroke Scale (NIHSS) score=0), while one patient maintained mild dysarthria at discharge (NIHSS score=1) which improved after 6 months (NIHSS score=0). All three patients had no new symptoms during the 6-month follow-up. Complete aneurysm occlusion occurred in six (75%) of the eight aneurysms at the 6-month follow-up. CONCLUSIONS Antiplatelet monotherapy with aspirin for the treatment of distal intracranial aneurysms with this modified surface FD resulted in a significant incidence of ischemic complications after treatment.
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Affiliation(s)
- Luis Henrique de Castro-Afonso
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Guilherme Seizem Nakiri
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Thiago Giansante Abud
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil.,Interventional Neuroradiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Lucas Moretti Monsignore
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Rafael Kiyuze de Freitas
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Daniel Giansante Abud
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
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29
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Dinc H, Saatci I, Oguz S, Baltacioglu F, Yildiz A, Donmez H, Belet U, Onal B, Andic C, Koc O, Kocak O, Koroglu M, Cetin M, Cekirge HS. Long-term clinical and angiographic follow-up results of the dual-layer flow diverter device (FRED) for the treatment of intracranial aneurysms in a multicenter study. Neuroradiology 2021; 63:943-952. [PMID: 33392735 DOI: 10.1007/s00234-020-02627-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Our aim was to determine the long-term safety and efficacy of the Flow Re-Direction Endoluminal Device (FRED) in this multicenter study with prospective design. MATERIALS-METHOD This study included 136 consecutive patients with 155 aneurysms treated between March 2013 and June 2016 in 10 centers. Twenty-two (16.2%) patients presented with rupture of the index aneurysm. Large/giant aneurysms comprised 1/3 of the cohort. Adjuvant coil use during the treatment was 15.5%. The effectiveness measure in the study was the percentage of aneurysms with stable occlusion at follow-up. RESULTS Vascular imaging follow-up was performed at least once in 131/136 (96.3%) patients with 148/155 (95.5%) aneurysms up to 75 months (mean: 37.3 months; median: 36 months according to latest follow-up), and 102/155(65.8%) aneurysms in 90/136 (66.2%) patients had ≥ 24-month control. According to the latest controls, the overall stable occlusion rate was 91.9% (95% CI, 87.5 to 96.3%). Three out of 148 aneurysms with follow-up were retreated (2%, 95% CI 0.0 to 4.3%). Adverse events were noted in 19/136 (14%, 95% CI, 9 to 21%) patients with a morbidity of 1.5% (95% CI, 0.0 to 3.5%). Mortality was 1/136 (0.7%, 95% CI, 0.02 to 2.2%) and was unrelated to aneurysm treatment. In-stent stenosis (ISS) was detected in 10/131 of the patients with follow-up (7.6%, 95% CI; 3.1 to 12.2%), only one being symptomatic. No adverse events have occurred in any of the patients with follow-up after 24 months, except the one resulting from ISS. CONCLUSION In the treatment of cerebral aneurysms which were candidates for flow diversion technique, this study showed long-term efficacy of FRED with good safety and occlusion rates.
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Affiliation(s)
- Hasan Dinc
- Radiology Department, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Isil Saatci
- Interventional Neuroradiology Section, Koru Hospitals, Kizilirmak mah, 1450 sokak 9/19 Cukurambar, 06510, Ankara, Turkey.
| | - Sukru Oguz
- Radiology Department, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Feyyaz Baltacioglu
- Radiology Department, School of Medicine, Marmara University, Istanbul, Turkey
| | - Altan Yildiz
- Radiology Department, School of Medicine, Mersin University, Mersin, Turkey
| | - Halil Donmez
- Radiology Department, School of Medicine, Erciyes University, Kayseri, Turkey
| | - Umit Belet
- Radiology Department, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Baran Onal
- Radiology Department, School of Medicine, Gazi University, Ankara, Turkey
| | - Cagatay Andic
- Radiology Department, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Osman Koc
- Radiology Department, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Omer Kocak
- Radiology Department, Koru Hospitals, Ankara, Turkey
| | - Mert Koroglu
- Interventional Radiology Clinic, Medical Park VM Hospital, Samsun, Turkey
| | - Mustafa Cetin
- Radiology Department, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey
| | - H Saruhan Cekirge
- Interventional Neuroradiology Section, Koru Hospitals, Kizilirmak mah, 1450 sokak 9/19 Cukurambar, 06510, Ankara, Turkey
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30
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Bonney PA, Connor M, Fujii T, Singh P, Koch MJ, Stapleton CJ, Mack WJ, Walcott BP. Failure of Flow Diverter Therapy: Predictors and Management Strategies. Neurosurgery 2020; 86:S64-S73. [PMID: 31838530 DOI: 10.1093/neuros/nyz305] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/15/2019] [Indexed: 11/14/2022] Open
Abstract
Flow diversion is a safe and effective treatment for many types of brain aneurysms. Even so, there remain some aneurysms that persist despite initial treatment. In studies with the longest follow-up (5 yr), at least 5% of aneurysms persist with this treatment modality. As the cumulative experience and clinical indications for flow diversion continue to expand, the anatomic and functional characteristics that are associated with aneurysm persistence are increasingly described. Identification of these factors preoperatively can help to guide initial treatment decisions, enhance monitoring protocols in the follow-up period, and establish best practices for re-treatment when necessary. Herein, we review published clinical series and provide examples to highlight variables implicated in aneurysm persistence after treatment with flow diversion.
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Affiliation(s)
- Phillip A Bonney
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Michelle Connor
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Tatsuhiro Fujii
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Parampreet Singh
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Matthew J Koch
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher J Stapleton
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - William J Mack
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Brian P Walcott
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois.,University of Chicago Pritzker School of Medicine, Chicago, Illinois
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31
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Liang F, Yang Y, Luo L, Liao B, Zhang G, Ou S, Xiao W, Guo N, Qi T. Endovascular treatment of complex middle cerebral artery aneurysms using TuBridge flow diverters. Interv Neuroradiol 2020; 26:539-546. [PMID: 32722987 DOI: 10.1177/1591019920946216] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The safety and efficacy of the TuBridge flow diverter in treating middle cerebral artery aneurysms remains unknown. In this study, we report our preliminary experience treating complex middle cerebral artery aneurysms using the TuBridge flow diverter. METHODS A prospectively maintained database of intracranial aneurysms treated with the TuBridge flow diverter was retrospectively reviewed, and patients with middle cerebral artery aneurysms were included in this study. Demographics, aneurysm features, complications, and clinical and angiographic outcomes were assessed. Evaluation of the angiographic results included occlusion grade of aneurysm (O'Kelly-Marotta grading scale), patency of jailed branch(es), and in-stent stenosis. RESULTS Eight patients with eight middle cerebral artery aneurysms were included in this study. The mean aneurysm size was 11.8 ± 6.8 mm. There were no procedure-related complications and there was no morbidity or mortality at a mean follow-up of 11.3 ± 3.6 months. All patients had follow-up angiograms at a mean of 7.5 ± 4.0 months after surgery. Of the eight patients, there was 1 (12.5%) O'Kelly-Marotta grading scale A, 3 (37.5%) O'Kelly-Marotta grading scale B, 1 (12.5%) O'Kelly-Marotta grading scale C, and 3 (37.5%) O'Kelly-Marotta grading scale D. Of the seven patients with jailed branch, the blood flow of jailed branch was unchanged in 4 (57.1%), decreased in 2 (28.6%), and occluded in 1 (14.3%). In-stent stenosis was mild in 2 (25%) patients and moderate in 1 (12.5%) patient. CONCLUSION Midterm results suggest that endovascular treatment of middle cerebral artery aneurysms using the TuBridge flow diverter is safe and associated with good outcomes. The TuBridge flow diverter may be an option for complex middle cerebral artery aneurysms that are difficult to treat with either clipping or coiling.
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Affiliation(s)
- Feng Liang
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yibing Yang
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lijuan Luo
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bingye Liao
- Department of Operation Theater, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guofeng Zhang
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Siqi Ou
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Weiping Xiao
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ning Guo
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tiewei Qi
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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32
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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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Microsurgical Clipping Compared with New and Most Advanced Endovascular Techniques in the Treatment of Unruptured Middle Cerebral Artery Aneurysms: A Meta-Analysis in the Modern Era. World Neurosurg 2020; 137:451-464.e1. [DOI: 10.1016/j.wneu.2019.12.118] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 11/19/2022]
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Wagner KM, Srinivasan VM, Srivatsan A, Ghali MGZ, Thomas AJ, Enriquez-Marulanda A, Alturki AY, Ogilvy CS, Mokin M, Kuhn AL, Puri A, Grandhi R, Chen S, Johnson J, Kan P. Outcomes after coverage of lenticulostriate vessels by flow diverters: a multicenter experience. J Neurosurg 2020; 132:473-480. [PMID: 30641842 DOI: 10.3171/2018.8.jns18755] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE With the increasing use of flow diversion as treatment for intracranial aneurysms, there is a concomitant increased vigilance in monitoring complications. The low porosity of flow diverters is concerning when the origins of vessels are covered, whether large circle of Willis branches or critical perforators. In this study, the authors report their experience with flow diverter coverage of the lenticulostriate vessels and evaluate their safety and outcomes. METHODS The authors retrospectively reviewed 5 institutional databases of all flow diversion cases from August 2012 to June 2018. Information regarding patient presentation, aneurysm location, treatment, and outcomes were recorded. Patients who were treated with flow diverters placed in the proximal middle cerebral artery (MCA), proximal anterior cerebral artery, or distal internal carotid artery leading to coverage of the medial and lateral lenticulostriate vessels were included. Clinical outcomes according to the modified Rankin Scale were reviewed. Univariate and multivariate analyses were performed to establish risk factors for lenticulostriate infarct. RESULTS Fifty-two patients were included in the analysis. Postprocedure cross-sectional images were available in 30 patients. Two patients experienced transient occlusion of the MCA during the procedure; one was asymptomatic, and the other had a clinical and radiographic ipsilateral internal capsule stroke. Five patients had transient symptoms without radiographic infarct in the lenticulostriate territory. Two patients experienced in-stent thrombosis, leading to clinical MCA infarcts (one in the ipsilateral caudate) after discontinuing antiplatelet therapy. Discontinuation of dual antiplatelet therapy prior to 6 months was the only variable that was significantly correlated with stroke outcome (p < 0.01, OR 0.3, 95% CI 0-0.43), and this significance persisted when controlled for other risk factors, including age, smoking status, and aneurysm location. CONCLUSIONS The use and versatility of flow diversion is increasing, and safety data are continuing to accumulate. Here, the authors provide early data on the safety of covering lenticulostriate vessels with flow diverters. The authors concluded that the coverage of these perforators does not routinely lead to clinically significant ischemia when dual antiplatelet therapy is continued for 6 months. Further evaluation is needed in larger cohorts and with imaging follow-up as experience develops in using these devices in more distal circulation.
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Affiliation(s)
| | | | | | | | - Ajith J Thomas
- 2Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alejandro Enriquez-Marulanda
- 2Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Abdulrahman Y Alturki
- 2Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- 2Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Maxim Mokin
- 3Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Anna L Kuhn
- 4Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts; and
| | - Ajit Puri
- 5Department of Neurosurgery, University of Texas at San Antonio, Texas
| | - Ramesh Grandhi
- 5Department of Neurosurgery, University of Texas at San Antonio, Texas
| | - Stephen Chen
- 6Radiology, Baylor College of Medicine, Houston, Texas
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Makalanda HLD, Wong K, Bhogal P. Flow-T stenting with the Silk Vista Baby and Baby Leo stents for bifurcation aneurysms - A novel endovascular technique. Interv Neuroradiol 2020; 26:68-73. [PMID: 31451027 PMCID: PMC6998009 DOI: 10.1177/1591019919870618] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/24/2019] [Indexed: 11/15/2022] Open
Abstract
We present the first case using a novel flow diverter, the Silk Vista Baby (Balt, Montmorency, France), in combination with a low-profile braided stent, the Baby Leo (Balt, Montmorency, France), in a T configuration that we term Flow-T. We describe the technical characteristics of the case as well as the early follow-up results. We believe that this combination may provide an alternative to standard T-stenting and alternative to treat bifurcation aneurysms.
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Affiliation(s)
- HLD Makalanda
- Department of Interventional Neuroradiology, The
Royal
London Hospital, London, UK
| | - K Wong
- Department of Interventional Neuroradiology, The
Royal
London Hospital, London, UK
| | - P Bhogal
- Department of Interventional Neuroradiology, The
Royal
London Hospital, London, UK
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Michelozzi C, Darcourt J, Guenego A, Januel AC, Tall P, Gawlitza M, Bonneville F, Cognard C. Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: complications, aneurysm sac occlusion, reabsorption, recurrence, and jailed branch modification at follow-up. J Neurosurg 2019; 131:1751-1762. [PMID: 30579280 DOI: 10.3171/2018.7.jns18654] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/19/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study is to present the authors' medium-term results, with special emphasis on complications, occlusion rate of the aneurysm sac (digital subtraction angiography [DSA] and MRI), and the fate of cortical branches and perforating arteries covered ("jailed") by the flow diverter (FD) stent. METHODS Between January 2010 and September 2017, 29 patients (14 female) with 30 aneurysms were treated with an FD stent. Twenty-one aneurysms were at the middle cerebral artery bifurcation, 8 were in the anterior communicating artery region, and 1 was a pericallosal artery bifurcation. Thirty-five cortical branches were covered. A single FD stent was used in all patients. Symptomatic and asymptomatic periprocedural and delayed complications were reported. DSA and MRI controls were analyzed to evaluate modification of the aneurysm sac and jailed branches. RESULTS Permanent morbidity was 3.4% (1/29), due to a jailed branch occlusion, with a modified Rankin Scale (mRS) score of 2 at the last follow-up. Mortality and permanent complication with poor prognosis (mRS score > 2) rates were 0%. The mean follow-up time for DSA and MRI (mean ± SD) was 21 ± 14.5 months (range 3-66 months) and 19 ± 16 months (range 3-41 months), respectively. The mean time to aneurysm sac occlusion (available for 24 patients), including stable remodeling, was 11.8 ± 6 months (median 13, range 3-27 months). The overall occlusion rate was 82.1% (23/28), and it was 91.7% (22/24) in the group of patients with at least 2 DSA control sequences. One recanalization occurred at 41 months posttreatment. At the time of publication, at the latest follow-up, 7 (20%) of 35 covered branches were occluded, 18 (51.4%) showed a decreased caliber, and the remaining 10 (28.5%) were unchanged. MRI T2-weighted sequences showed complete sac reabsorption in 7/29 aneurysms (24.1%), and the remaining lesions were either smaller (55.2%) or unchanged (17.2%). MRI revealed asymptomatic and symptomatic ischemic events in perforator territories in 7/28 (25%) and 4/28 (14.3%) patients, respectively, which were reversible within 24 hours. CONCLUSIONS Flow diversion of bifurcation aneurysms is feasible, with low rates of permanent morbidity and mortality and high occlusion rates; however, recurrence may occur. Caliber reduction and asymptomatic occlusion of covered cortical branches as well as silent perforator stroke are common. Ischemic complications may occur with no identified predictable factors. MRI controls should be required in all patients to evaluate silent ischemic lesions and aneurysm sac reabsorption over time.
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Affiliation(s)
- Caterina Michelozzi
- 1Service de Neuroradiologie, Hôpital Pierre-Paul Riquet, CHU de Toulouse; and
| | - Jean Darcourt
- 1Service de Neuroradiologie, Hôpital Pierre-Paul Riquet, CHU de Toulouse; and
| | - Adrien Guenego
- 1Service de Neuroradiologie, Hôpital Pierre-Paul Riquet, CHU de Toulouse; and
| | | | - Philippe Tall
- 1Service de Neuroradiologie, Hôpital Pierre-Paul Riquet, CHU de Toulouse; and
| | | | - Fabrice Bonneville
- 1Service de Neuroradiologie, Hôpital Pierre-Paul Riquet, CHU de Toulouse; and
| | - Christophe Cognard
- 1Service de Neuroradiologie, Hôpital Pierre-Paul Riquet, CHU de Toulouse; and
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Tokunaga K, Hatano T, Nakahara I, Ishii A, Higashi E, Kamata T, Funakoshi Y, Hashikawa T, Takita W, Chihara H, Ando M, Sadamasa N, Kitazono T, Nagata I. Factors Associated with Postprocedural Diffusion-Weighted Imaging–Positive Lesions in Endovascular Treatment for Unruptured Cerebral Aneurysms. World Neurosurg 2019; 130:e457-e462. [DOI: 10.1016/j.wneu.2019.06.114] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 11/16/2022]
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38
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Mühl-Benninghaus R, Abboud R, Ding A, Krajewski S, Simgen A, Tomori T, Bomberg H, Yilmaz U, Brochhausen C, Reith W, Cattaneo G. Preclinical Evaluation of the Accero Stent: Flow Remodelling Effect on Aneurysm, Vessel Reaction and Side Branch Patency. Cardiovasc Intervent Radiol 2019; 42:1786-1794. [DOI: 10.1007/s00270-019-02345-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/19/2019] [Indexed: 10/25/2022]
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Wallace AN, Grossberg JA, Almandoz JED, Kamran M, Roy AK, Kayan Y, Austin MJ, Howard BM, Moran CJ, Cawley CM, Cross DT, Dion JE, Kansagra AP, Osbun JW. Endovascular Treatment of Posterior Cerebral Artery Aneurysms With Flow Diversion: Case Series and Systematic Review. Neurosurgery 2019. [PMID: 29528441 DOI: 10.1093/neuros/nyx561] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Flow diversion of posterior cerebral artery (PCA) aneurysms has not been widely reported, possibly owing to concerns regarding parent vessel size and branch vessel coverage. OBJECTIVE To examine the safety and effectiveness of PCA aneurysm flow diverter treatment. METHODS Retrospective review of PCA aneurysms treated with the Pipeline Embolization Device (PED; Medtronic Inc, Dublin, Ireland) at 3 neurovascular centers, including periprocedural complications and clinical and angiographic outcomes. Systematic review of the literature identified published reports of PCA aneurysms treated with flow diversion. Rates of aneurysm occlusion and complications were calculated, and outcomes of saccular and fusiform aneurysm treatments were compared. RESULTS Ten PCA aneurysms in 9 patients were treated with the PED. There were 2 intraprocedural thromboembolic events (20%), including 1 symptomatic infarction and 1 delayed PED thrombosis. Eight of 10 patients returned to or improved from their baseline functional status. Complete aneurysm occlusion with parent vessel preservation was achieved in 75% (6/8) of cases at mean follow-up of 16.7 mo. Eleven of 12 (92%) major branch vessels covered by a PED remained patent. Including the present study, systematic review of 15 studies found a complete aneurysm occlusion rate of 88% (30/34) and complication rate of 26% (10/38), including 5 symptomatic ischemic strokes (13%; 5/38). Fusiform aneurysms more frequently completely occluded compared with saccular aneurysms (100% vs 70%; P = .03) but were associated with a higher complication rate (43% vs 9%; P = .06). CONCLUSION The safety and effectiveness profile of flow diverter treatment of PCA aneurysms may be acceptable in select cases.
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Affiliation(s)
- Adam N Wallace
- Division of Neurointerventional Radi-ology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota.,Department of Radiology, University of Iowa, Iowa City, Iowa
| | | | - Josser E Delgado Almandoz
- Division of Neurointerventional Radi-ology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Mudassar Kamran
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri
| | - Anil K Roy
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Yasha Kayan
- Division of Neurointerventional Radi-ology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Matthew J Austin
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri
| | - Brian M Howard
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri.,Department of Neurosurgery, Washington University, St. Louis, Missouri
| | | | - DeWitte T Cross
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri.,Department of Neurosurgery, Washington University, St. Louis, Missouri
| | - Jacques E Dion
- Department of Radiology, Emory University, Atlanta, Georgia
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri.,Department of Neurosurgery, Washington University, St. Louis, Missouri.,Department of Neurology, Washington University, St. Louis, Missouri
| | - Joshua W Osbun
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri.,Department of Neurosurgery, Washington University, St. Louis, Missouri.,Department of Neurology, Washington University, St. Louis, Missouri
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Bhogal P, Bleise C, Chudyk J, Lylyk I, Viso R, Perez N, Henkes H, Lylyk P. The p48MW Flow Diverter-Initial Human Experience. Clin Neuroradiol 2019; 31:135-145. [PMID: 31435722 PMCID: PMC7943536 DOI: 10.1007/s00062-019-00827-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/30/2019] [Indexed: 02/06/2023]
Abstract
Background and Purpose The use of flow diverters to treat aneurysms arising from small caliber parent vessels has been reported. This article reports the results of the first in experiences with the p48MW (p48 Movable Wire) in humans, a device specifically designed to target vessels 1.75–3 mm in diameter. Methods This monocentric study retrospectively reviewed the prospectively maintained database to identify all patients treated with the p48MW device between January 2017 and January 2019 at this institution. Patient demographics, aneurysm characteristics, angiographic and clinical follow-up were recorded as well as complications. Results A total of 25 patients (20 female) with an average age of 55 ± 12.9 years (range 34–84) with 25 aneurysms were identified. The majority of the aneurysms was located in the anterior circulation (19/25, 76%). The average aneurysm dome width was 3.98 ± 3.6 mm (range 1.2–13 mm). Complete occlusion was seen in 18/24 (75%) aneurysms with neck remnants in 1/24 (4.2%) and continued aneurysm filling seen in the remaining cases (5/24, 20.8%). Adequate occlusion was seen in 79.2% of aneurysms (Raymond Roy Classification [RRC] grade I or II) during the follow-up period. There was a single technical complication with inappropriate deployment of the first p48MW. There was a single clinical complication (4%); however, the patient made a complete recovery (modified Rankin Scale [mRS] 0) and one patient died secondary to uncontrollable status epilepticus following acute subarachnoid hemorrhage unrelated to the treatment. Conclusion The p48MW is safe and effective for the treatment of aneurysms including those arising from distal vessels.
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Affiliation(s)
- P Bhogal
- The Royal London Hospital, Whitechapel Road, E1 1BB, London, UK.
| | - C Bleise
- Neuroradiological Clinic, Clinica Sagrada Familia, ENERI, Buenos Aires, Argentina
| | - J Chudyk
- Neuroradiological Clinic, Clinica Sagrada Familia, ENERI, Buenos Aires, Argentina
| | - I Lylyk
- Neuroradiological Clinic, Clinica Sagrada Familia, ENERI, Buenos Aires, Argentina
| | - R Viso
- Neuroradiological Clinic, Clinica Sagrada Familia, ENERI, Buenos Aires, Argentina
| | - N Perez
- Neuroradiological Clinic, Clinica Sagrada Familia, ENERI, Buenos Aires, Argentina
| | - H Henkes
- Medical Faculty, University Duisburg-Essen, Essen, Germany.,Neuroradiological Clinic, Klinikum Stuttgart, Stuttgart, Germany
| | - P Lylyk
- Neuroradiological Clinic, Clinica Sagrada Familia, ENERI, Buenos Aires, Argentina
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Lu P, Zhang Y, Niu H, Wang Y. Comparison of endovascular treatment for middle cerebral artery aneurysm with a low-profile visualized intraluminal support stent or pipeline embolization device. Exp Ther Med 2019; 18:2072-2078. [PMID: 31410163 PMCID: PMC6676140 DOI: 10.3892/etm.2019.7775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 04/12/2019] [Indexed: 11/10/2022] Open
Abstract
The aim of the present study was to evaluate the safety and effectiveness of low-profile visualized intraluminal support (LVIS) stent and the pipeline embolization device (PED) for middle cerebral artery (MCA) aneurysm treatment. Data of patients with MCA aneurysms who received endovascular treatment with LVIS stent or PED added to the hospital's database between August 2016 and March 2018 were retrospectively collected, and the clinical results and angiographic outcomes were evaluated. A total of 43 patients were included in the study, of whom 23 received LVIS stents and 20 received PED. The rate of complete occlusion was similar in the two groups at 6 months post-treatment (90.9 vs. 88.9%; P=0.832). Peri-operative complications were more frequent in the PED group; however, the LVIS group had more ischemic symptoms during the long-term follow-up. A larger aneurysm size (P=0.032) was associated with recanalization in the two groups. In conclusion, the LVIS stent and PED had acceptable rates of complete occlusion and aneurysm size was an independent predictor for recanalization. LVIS is more effective during the peri-operative period, while PED appears to have higher long-term safety.
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Affiliation(s)
- Peng Lu
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
| | - Ye Zhang
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
| | - Huanjiang Niu
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
| | - Yirong Wang
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
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Podlasek A, Al Sultan AA, Assis Z, Kashani N, Goyal M, Almekhlafi MA. Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis. J Neurointerv Surg 2019; 12:148-155. [DOI: 10.1136/neurintsurg-2019-014996] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/30/2019] [Accepted: 06/02/2019] [Indexed: 01/15/2023]
Abstract
BackgroundThromboembolic complications are not uncommon in patients undergoing neurointerventional procedures. The use of flow diverting stents is associated with higher risks of these complications despite current dual antiplatelet regimens.ObjectiveTo explore contemporary evidence on the safety of emerging dual antiplatelet regimens in flow diverting stenting procedures.MethodsWe performed a systematic review and meta-analysis to identify relevant articles in electronic databases, and relevant references. Studies reporting the complications and mortality of flow diverting stenting procedures using acetyl salicylic acid (ASA) + ticagrelor or ASA + prasugrel compared with ASA + clopidogrel were included.ResultsOf 452 potentially relevant studies, we identified 49 studies (2526 patients) which reported the safety of ticagrelor or prasugrel for pooled analysis, and five studies (1005 patients) for meta-analysis. The pooled overall mortality in all studies was 2.14%, ischemic complications 6.89%, and hemorrhagic complications 3.68%. The use of ticagrelor or prasugrel was associated with a lower risk of mortality compared with clopidogrel (RR=4.57, 95% CI 1.23 to 16.99; p=0.02). Considering ischemic events, ASA + clopidogrel was as safe as ASA + prasugrel (RR=0.55, 95% CI 0.11 to 2.74; p=0.47) and ASA + ticagrelor (RR=0.74, 95% CI 0.32 to 1.74; p=0.49). ASA +ticagrelor was not associated with a higher risk of hemorrhagic complications (RR=0.92, 95% CI 0.27 to 3.16; p=0.89).ConclusionsEvidence suggests that dual antiplatelet regimens including ticagrelor or prasugrel are safe for patients undergoing flow diversion procedures. Regimens using ticagrelor were associated with better survival than those using clopidogrel in the included studies.
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Amuluru K, Al-Mufti F, Romero CE. Flow diversion treatment of anterior communicating artery region aneurysms. J Neuroradiol 2019; 48:391-396. [PMID: 31229575 DOI: 10.1016/j.neurad.2019.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE Reports on flow diversion treatment of aneurysms beyond the Circle of Willis are limited, with few series dedicated to anterior communicating artery region aneurysms. The purpose of this study is to evaluate the safety and effectiveness of the pipeline embolization device in the treatment of anterior communicating artery region aneurysms. MATERIALS AND METHODS The neuro-interventional database of a single institution was retrospectively reviewed for anterior communicating artery aneurysms treated with the pipeline embolization device between November 2016 and December 2018. Data on clinical presentation, aneurysm location, type, vessel size, procedural complications, clinical and imaging follow-up were analyzed. RESULTS Ten patients with 11 anterior communicating artery aneurysms were included. Procedural success was achieved in 9/10 patients (90%). Flow diversion with the pipeline embolization device yielded occlusion in 100% of patients at 6.5 months. Symptomatic ischemic complications occurred in 2/10 patients (20%); only one of who had permanent symptoms. Hemorrhagic groin complications were encountered in 2/10 patients (20%). There were no deaths and no cerebral hemorrhagic complications. CONCLUSIONS Flow diversion therapy may provide a feasible solution for anterior communicating artery region aneurysms that are not amenable to traditional surgical or endovascular modalities.
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Affiliation(s)
- Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Division of Interventional Neuroradiology, Indianapolis IN, United States; Department of Interventional Neuroradiology, University of Pittsburgh Medical Center-Hamot, 300 State St, Suite 4100 Erie, 16550 PA, United States.
| | - Fawaz Al-Mufti
- Westchester Medical Center, Department of Endovascular Neurosurgery and Neurocritical Care, Valhalla, NY, United States
| | - Charles Edward Romero
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Division of Interventional Neuroradiology, Indianapolis IN, United States
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Tejada JG, Lopez GV, Koovor JM, Riley K, Martinez M. Mid-term follow-up of staged bilateral internal carotid artery aneurysm treatment with Pipeline embolization. Interv Neuroradiol 2019; 25:664-670. [PMID: 31159632 DOI: 10.1177/1591019919853586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Endovascular treatment of large complex morphology aneurysms is challenging. High recanalization rates have been reported with techniques such as stent-assisted coiling and balloon-assisted coiling. Flow diverter devices have been introduced to improve efficacy outcomes and recanalization rates. Thromboembolic complications and in-device stenosis are certainly more worrisome when treatment of bilateral internal carotid arteries has been performed. This study aimed to report our experience with mid-term imaging follow-up of staged bilateral Pipeline embolization device placement for the treatment of bilateral internal carotid artery aneurysms. METHODS We reviewed the clinical, angiographic, and follow-up imaging data in all consecutive patients treated with bilateral internal carotid artery aneurysms who underwent elective Pipeline embolization. RESULTS Six female patients were treated, harboring a total of 13 aneurysms. Of these, 60% were asymptomatic. Diplopia and headache were the most common symptoms. The most common location was the paraclinoid segment (6/13), including by cavernous segment (4/13) and ophthalmic segment (2/13). Successful delivery of the device was achieved in 12 cases. Difficult distal access precluded the deployment of the device in one case. The treatment was always staged with at least eight weeks' difference between the two procedures. All aneurysm necks were covered completely. There were no periprocedural complications. Angiographic follow-up ranged between 3 and 12 months, and computed tomography angiogram follow-up ranged between 2 and 24 months. Complete aneurysm occlusion was achieved in all cases. CONCLUSION In our series, Pipeline deployment for the treatment of bilateral internal carotid artery aneurysms in a staged fashion is safe and feasible. Mid-term imaging follow-up showed permanent occlusion of all the treated aneurysms.
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Stent-Assisted Coil Embolization of MCA Bifurcation Aneurysms at a Hypoplastic M1 Branch by Use of Hook Technique. World Neurosurg 2019; 128:e615-e620. [PMID: 31054347 DOI: 10.1016/j.wneu.2019.04.219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND We describe the Hook technique enabling coil embolization in unfavorable M1 bifurcation aneurysms and analyze the morphologic variations in M1 bifurcation to evaluate how often such aneurysms can be seen. METHODS Among 42 MCA aneurysms treated by stent-assisted coil embolization, aneurysms arising at the acute-angled hypoplastic M1 branch (n = 14) were treated by the Hook technique, in which a short stent was deployed only to protect the aneurysm neck after microcatheter selection of the hypoplastic M2, followed by subsequent coiling of the aneurysm. Outcome was evaluated, including Raymond classification, coil packing density, final modified Rankin Scale (mRS), and recurrence. Separately, 100 middle cerebral artery (MCA) bifurcation aneurysms were analyzed to assess the proportion of such unfavorable aneurysms. RESULTS Procedural success of the Hook technique was obtained in 13 of 14 patients (93%). A mean packing density of 30% was achieved. Magnetic resonance angiographic follow-up at a median 4 months (range, 1-26 months) showed complete occlusion in 11 patients and residual neck filling in 3 patients. There was no clinical event (mRS = 0) over a median 17 months (range, 2-26 months) of clinical follow-up. One patient had a thrombotic occlusion during the procedure, which was resolved after tirofiban infusion, without evidence of an infarct or deficit. Of the 100 MCA bifurcation aneurysms, aneurysm arising in asymmetric hypoplastic M2 division was the most common type (48%). CONCLUSIONS The Hook technique enabled stent-assisted coiling of M1 bifurcation aneurysm with extension along the asymmetric hypoplastic M2 division and also securing the M2 branch.
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Kühn AL, Kan P, Henninger N, Srinivasan V, de Macedo Rodrigues K, Wakhloo AK, Gounis MJ, Puri AS. Impact of age on cerebral aneurysm occlusion after flow diversion. J Clin Neurosci 2019; 65:23-27. [PMID: 31072739 DOI: 10.1016/j.jocn.2019.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/28/2019] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to evaluate safety and efficacy of the pipeline embolization device (PED) in different patient age groups with unruptured intracranial aneurysms (UIA). All patients with UIA treated with the PED between 2011 and 2017 were included. Based on their age, patients were trichotomized to: young (≤45 years), middle-aged (46 to <65 years) and older (≥65 years) groups. Patient's vascular risk factors, presenting symptoms and mRS on admission were collected. Follow-up imaging was evaluated for presence/absence of aneurysm occlusion. Clinical outcome at discharge, 3-9 months and 12-18 months was also documented when available. A total of 260 patients harboring 307 aneurysms (young = 57, middle-age = 144 and older age group = 64). Most aneurysms were located in the anterior circulation (94.8%). Overall morbidity and mortality was 2.3% each (6/260). At 3-9 months near complete to complete aneurysm occlusion was 82.5% (47/57) in the young age group, 82.6% (100/121) in the middle age, and 70.2% (40/57) in the older age group. At 12-18-month, near complete to complete occlusion was 100% in the young age group (32/32), 91.4% (64/70) in the middle age, and 78.4% (29/37) in the older age group. After adjustment for potential confounders, older age patients less frequently achieved near complete to complete occlusion by 3 years than younger subjects (p = 0.009, HR 1.34 95%, CI 1.08-1.66). Our results indicate feasibility and safety of PED across different age groups. Further study is required to determine age-related factors relating to aneurysm occlusion after PED to improve outcome and patient counseling.
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Affiliation(s)
- Anna Luisa Kühn
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts, Worcester, MA, USA
| | - Visish Srinivasan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Katyucia de Macedo Rodrigues
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA
| | - Ajay K Wakhloo
- Lahey Clinic and Medical Center, Department of Neurointerventional Radiology, Burlington, MA, USA
| | - Matthew J Gounis
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA
| | - Ajit S Puri
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA.
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Dayawansa S, Sulhan S, Huang JH, Noonan PT. Endosurgical Remodeling of Wide-Necked Bifurcation Aneurysms. Front Neurol 2019; 10:245. [PMID: 30949119 PMCID: PMC6435532 DOI: 10.3389/fneur.2019.00245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 02/25/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Wide-necked cerebral aneurysms at a bifurcation can be difficult to treat with endovascular techniques despite recent advancements. Objective: We describe a new technique of micro-scaffold remodeling of the aneurysm neck of wide-necked bifurcation aneurysms by placing one or more microcatheters and/or wires in the efferent vessels. We hypothesize that this technique would be a better choice to change the branch angulation, allowing for an improved configuration to stably deploy coils. We present a retrospective case series to illustrate this technique. Methods: 17 wide-necked bifurcation aneurysms in 17 patients were coil embolized using this technique during a 3 year study period. Branch-vessel microcatheters and/or microwires were used to remodel the aneurysm neck and support the coil mass. Statistical analysis of the branch angulation and neck-width changes were performed during treatment. Long-term clinical outcome and follow-up angiography was obtained in 8 patients. Results: Eleven patients had complete occlusion of their aneurysm (Raymond-Roy Class I), and 6 patients had Raymond-Roy Class 2 immediately after treatment. Efferent vessels demonstrated a statistically significant change in angulation with insertion of microcatheters or microwires, while neck width did not change significantly. There were four intraoperative complications and no neurological morbidity in the immediate post-operative period. Complete occlusion was documented for all 10 subjects with long-term follow-up. Conclusions: The micro-scaffold endosurgical remodeling technique is a useful adjunct in treating wide-necked bifurcation aneurysms. By elevating branch vessels away from the aneurysm neck, this technique allows for dense coil packing while decreasing the need for balloon or stent assistance.
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Affiliation(s)
- Samantha Dayawansa
- Department of Neurosurgery, Baylor Scott & White Health Neuroscience Institute, Temple, TX, United States.,College of Medicine, Texas A&M University, Temple, TX, United States
| | - Suraj Sulhan
- Department of Neurosurgery, Baylor Scott & White Health Neuroscience Institute, Temple, TX, United States.,College of Medicine, Texas A&M University, Temple, TX, United States
| | - Jason H Huang
- Department of Neurosurgery, Baylor Scott & White Health Neuroscience Institute, Temple, TX, United States.,College of Medicine, Texas A&M University, Temple, TX, United States
| | - Patrick T Noonan
- Neuroendovascular Surgery, Department of Neurosciences, Doctors Hospital at Renaissance, Edinburg, TX, United States
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Wallace AN, Madaelil TP, Kamran M, Miller TR, Delgado Almandoz JE, Grossberg JA, Kansagra AP, Gandhi D, Kayan Y, Cawley CM, Moran CJ, Jindal G, CreveCoeur T, Howard BM, Cross DT, Kole MJ, Roy AK, Dion JE, Osbun JW. Pipeline Embolization of Vertebrobasilar Aneurysms—A Multicenter Case Series. World Neurosurg 2019; 124:e460-e469. [PMID: 30610980 DOI: 10.1016/j.wneu.2018.12.116] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Pipeline Embolization Device (PED) has been increasingly used for the treatment of posterior circulation aneurysms. The purpose of the present study was to examine the clinical and angiographic outcomes of patients with vertebrobasilar aneurysms treated with the PED. METHODS We performed a retrospective review of vertebrobasilar aneurysms treated with the PED at 4 high-volume neurovascular centers. Patient, aneurysm, and procedural data were collected, including perioperative and delayed complications. Aneurysm occlusion on follow-up imaging studies was defined as complete (100%), near-complete (>90%), or incomplete (<90%) occlusion. RESULTS The cohort included 35 patients with 37 vertebrobasilar aneurysms who underwent 36 treatment sessions. Of the 35 patients, 10 were men (29%), and the mean patient age was 54.1 years (range, 32-75). Eight patients (23%) underwent urgent treatment because of a ruptured aneurysm (n = 6), brainstem perforator stroke (n = 1), or post-traumatic pseudoaneurysm (n = 1). Of the 37 aneurysms, 22 arose from the vertebral artery (59%) and 15 from the basilar artery (41%). Also, 19 were saccular aneurysms (51%), with a mean size of 7.7 mm (range, 1.7-38.0); 17 were fusiform aneurysms (46%), with a mean size of 11.0 mm (range, 4.3-34); and 1 was a 2.9-mm blister aneurysm. The overall procedural complication rate was 14% (5 of 36), including 3 neurologically symptomatic complications. At a mean follow-up period of 14 months (range, 3-59), 24 of 34 aneurysms (71%) were completely occluded and 29 of 34 (85%) were completely or near-completely occluded. CONCLUSION Our results show that Pipeline embolization of vertebrobasilar aneurysms is associated with acceptable occlusion and complication rates.
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Affiliation(s)
- Adam N Wallace
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA; Department of Radiology, University of Iowa, Iowa City, Iowa, USA.
| | | | - Mudassar Kamran
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri, USA
| | - Timothy R Miller
- Department of Radiology, University of Maryland, Baltimore, Maryland, USA
| | - Josser E Delgado Almandoz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | | | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri, USA; Department of Neurosurgery, Washington University, St. Louis, Missouri, USA; Department of Neurology, Washington University, St. Louis, Missouri, USA
| | - Dheeraj Gandhi
- Department of Radiology, University of Maryland, Baltimore, Maryland, USA
| | - Yasha Kayan
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri, USA; Department of Neurosurgery, Washington University, St. Louis, Missouri, USA
| | - Gaurav Jindal
- Department of Neurology, University of Maryland, Baltimore, Maryland, USA; Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Travis CreveCoeur
- Department of Neurosurgery, Washington University, St. Louis, Missouri, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - DeWitte T Cross
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri, USA; Department of Neurosurgery, Washington University, St. Louis, Missouri, USA
| | - Matthew J Kole
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Anil K Roy
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Jacques E Dion
- Department of Radiology, Emory University, Atlanta, Georgia, USA
| | - Joshua W Osbun
- Department of Neurosurgery, Washington University, St. Louis, Missouri, USA; Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri, USA; Department of Neurology, Washington University, St. Louis, Missouri, USA
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Bhogal P, Wong K, Uff C, Wadley J, Makalanda HL. The Silk Vista Baby: Initial experience and report of two cases. Interv Neuroradiol 2019; 25:530-538. [PMID: 30931672 DOI: 10.1177/1591019919839196] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
In this report, we present two cases using a novel flow diverter, the Silk Vista Baby, to treat aneurysms successfully, both ruptured and unruptured, that would have been difficult to treat using alternative flow diverters. We describe the clinical and radiological features, outcome and the unique features of the Silk Vista Baby flow diverter.
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Affiliation(s)
- Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - Ken Wong
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - Christopher Uff
- Department of Neurosurgery, The Royal London Hospital, London, UK
| | - John Wadley
- Department of Neurosurgery, The Royal London Hospital, London, UK
| | - Hegoda Ld Makalanda
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
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Atallah E, Saad H, Mouchtouris N, Bekelis K, Walker J, Chalouhi N, Tjoumakaris S, Smith M, Rosenwasser RH, Zarzour H, Herial N, Feghali J, Gooch MR, Missios S, Sweid A, Jabbour P. Pipeline for Distal Cerebral Circulation Aneurysms. Neurosurgery 2019; 85:E477-E484. [DOI: 10.1093/neuros/nyz038] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 01/27/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Pipeline embolization device (PED; Medtronic, Dublin, Ireland) utilization is not limited to the treatment of giant wide-necked aneurysms. It has been expanded to handle small blisters, fusiforms, and dissecting intracranial aneurysms.
OBJECTIVE
To report the use of the PED in various off-label distal cerebral circulation (DCC) arteries with a follow-up to assess clinical outcomes.
METHODS
Between 2011 and 2016, of 437 consecutive patients, 23 patients with aneurysms located in DCCs were treated with PED. Data on patient presentation, aneurysm characteristics, procedural outcomes, postoperative course, and aneurysm occlusion were gathered. To control confounding, we used multivariable logistic regression and propensity score conditioning.
RESULTS
A total of 437 patients (mean age 52.12 years; 62 women [14.2%]) underwent treatment with PED in our institution. Twenty-three of 437 (5.2%) received a pipeline in a distal artery: 11/23 middle cerebral artery, 6/23 posterior cerebral artery, 3/23 anterior cerebral artery (A1/A2, pericallosal artery), and 3/23 posterior inferior cerebellar artery. Twenty percent of the aneurysms were treated in the past, 10% had previously ruptured, and 5.9% ruptured at presentation to our hospital. The mean aneurysm size was 9.0 ± 6 mm. The mean follow-up was 12 mo (SD = 12.5). In multivariable logistic regression, no associations were found between PED deployment in DCCs and aneurysm occlusion or thromboembolic complications. PED use in DCC was associated with a good clinical outcome. Twenty-two people of 23 (95%) had a good clinical outcome in the latest follow-up.
CONCLUSION
Treatment of DCC aneurysms with PED is technically challenging mainly because of the small caliber and tortuosity of the parent arteries. The results of this study further support the safety of flow diverters in the treatment of various distal aneurysms.
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Affiliation(s)
- Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Hassan Saad
- Department of Neurological Surgery, Arkansas Neurosciences Institute, Little Rock, Arkansas
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Kimon Bekelis
- Department of Neurological Surgery, Good Samaritan Hospital Medical Center, West Islip, New York
| | - Jackson Walker
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Michelle Smith
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nabeel Herial
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - James Feghali
- Department of Neurosurgery, American University of Beirut, Beirut, Lebanon
| | - Michael Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Symeon Missios
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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