1
|
Duangprasert G, Sukhor S, Ratanavinitkul W, Tantongtip D. Evaluation of flow diverter use in acutely ruptured vertebral artery dissecting Aneurysms: A focus on safety and efficacy for rapid Aneurysm obliteration. Clin Neurol Neurosurg 2024; 242:108345. [PMID: 38788544 DOI: 10.1016/j.clineuro.2024.108345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/10/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE Flow diverter device (FDD) has emerged as the reconstruction technique for treating ruptured dissecting vertebral artery Aneurysms (VADA), but data on feasibility regarding re-rupture risk and timing of Aneurysm obliteration following FDD treatment is still limited. Therefore, this study aimed to evaluate the safety and efficacy of FDD in the treatment of VADAs presenting with subarachnoid hemorrhage (SAH). METHODS We retrospectively reviewed patients with ruptured VADA presenting with subarachnoid hemorrhage who underwent FDD placement at our institution between 2015 and 2023. Patient demographic data, Aneurysm configuration, and occlusion status were analyzed. RESULTS Thirteen patients with SAH from VADA rupture underwent FDD implantation. The average size of the largest diameter of the Aneurysm was 11.2 mm (range 6.5-21 mm). Eight of 13 (61.5 %) patients had their Aneurysms completely obliterated within 2 weeks after the procedure. The small dissecting Aneurysm (d = 0.636, p = 0.002) and degree of intra-Aneurysmal contrast stasis (d = 0.524, p = 0.026) were associated with rapid Aneurysm occlusion, according to the Somer's d coefficient. There were no ischemic or hemorrhagic complications at the average clinical follow-up of 28.4 months (range 5-67 months) and average angiographic follow-up of 20.1 months (range 3-60 months). A favorable outcome (mRS 0-2) was achieved in 12 patients (92.3 %). CONCLUSIONS FDD is safe and effective for the reconstruction of acutely ruptured VADAs. In addition, our study emphasizes that small dissecting Aneurysms tend to be rapidly obliterated after flow diversion, which eliminates the risk of re-rupture during the acute phase of subarachnoid hemorrhage.
Collapse
Affiliation(s)
- Gahn Duangprasert
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand.
| | - Sasikan Sukhor
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | - Warot Ratanavinitkul
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | - Dilok Tantongtip
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| |
Collapse
|
2
|
Ramirez-Velandia F, Enriquez-Marulanda A, Filo J, Young M, Fodor TB, Sconzo D, Muram S, Granstein JH, Shutran M, Taussky P, Ogilvy CS. Thromboembolic Events in the Posterior Circulation After Flow Diversion-A Closer Look at Coverage of the Posterior Cerebral Artery. World Neurosurg 2024:S1878-8750(24)00764-2. [PMID: 38734173 DOI: 10.1016/j.wneu.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Flow diversion for bifurcation aneurysms requires excluding one of the branches from the parent artery, raising concern for ischemic events. We evaluated thromboembolic events and their relationship with covering the origin of the posterior cerebral artery (PCA). METHODS This retrospective analysis included patients with confirmed basilar and proximal PCA aneurysms treated with flow diversion between 2013 and 2023. Procedures were classified according to the coverage of the origin of the PCA. Thromboembolic events associated with the excluded PCA were evaluated. RESULTS Of the total 28 aneurysms included, 7 were at the basilar tip, 16 in the basilar trunk, and 5 in the first segment of the PCA; 15 were treated by excluding one of the PCAs. Dual antiplatelet therapy included aspirin and ticagrelor (57.1%), aspirin and clopidogrel (35.7%), or aspirin and prasugrel (3.57%). Complete and near-complete aneurysm occlusion was achieved in 80.8% of the aneurysms treated at a median follow-up of 12.31 months. Thromboembolic complications occurred in 3 patients (2 with basilar perforator stroke and 1 with basilar in-stent thrombosis). However, the difference in these events was not statistically significant between patients with PCA coverage and those without (P = 0.46). Diminished flow and a lack of flow was seen in 8 and 7 of the covered vessels, respectively. A modified Rankin scale score of ≤2 was reported for 89.3% of patients at a median clinical follow-up of 5.5 months. CONCLUSIONS The incidence of thromboembolic events is high in distal basilar and proximal PCA aneurysms; however, PCA coverage was not associated with their occurrence. There was no difference in postprocedural disability between patients whose aneurysms were treated by excluding one of the PCAs and those who were not.
Collapse
Affiliation(s)
- Felipe Ramirez-Velandia
- 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
| | - Michael Young
- 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
| | - Sandeep Muram
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin H Granstein
- 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
| | - Philipp Taussky
- 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.
| |
Collapse
|
3
|
Liu C, Wu X, Guo K, Sun Y, Yike C, Hu X, Fang B. Flow-Diverting Devices in the Treatment of Vertebral Artery Aneurysms: Insights into Efficacy and Safety from a Systematic Review and Meta-analysis. Transl Stroke Res 2024:10.1007/s12975-024-01251-y. [PMID: 38602659 DOI: 10.1007/s12975-024-01251-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/18/2024] [Accepted: 04/06/2024] [Indexed: 04/12/2024]
Abstract
The objective of this study is to conduct a systematic review and meta-analysis aimed at evaluating the efficacy and safety of flow-diverting devices (FDs) treatment for intracranial vertebral artery (VA) aneurysms. We searched PubMed, Web of Science, OVID, and Embase for English-language studies up to February 2024 and included clinical studies on FD treatment of intracranial VA aneurysms. Sensitivity analysis evaluated outcome stability. Of 2273 articles, 29 studies involving 541 aneurysms treated with FDs were included. Based on the Methodological Index for Non-Randomized Studies (MINORS), six were high-quality and 23 moderate quality. FD treatment showed a 95% rate of favorable clinical outcomes (95% CI, 89-99%), 81% (95% CI, 74-88%) complete aneurysmal occlusion, 4% (95% CI, 2-7%) ischemic complication incidence, 1% (95% CI, 0-3%) hemorrhagic complication incidence, 95% (95% CI, 87-100%) posterior inferior cerebellar artery (PICA) preservation, and 6% (95% CI, 3-10%) in-stent stenosis or occlusion across clinical and angiographic follow-up periods of 13.62 months (95% CI, 10.72-16.52) and 11.85 months (95% CI, 9.36-14.33), respectively. Subgroup analyses, based on a 12-month angiographic follow-up threshold, indicated no statistically significant differences in rates of complete aneurysm occlusion, PICA preservation, or in-stent stenosis or occlusion incidence (p > 0.05) between subgroups. Moreover, significant differences were observed in clinical and angiographic outcomes between ruptured and unruptured aneurysms, particularly in hemorrhagic complications (p < 0.05), without significant disparity in ischemic complications (p > 0.05). The results' stability was confirmed via sensitivity analysis. FDs treatment for VA aneurysms is efficacious and safe, offering high rates of positive clinical and angiographic outcomes with minimal complications, underscoring FDs' viability as a treatment option for VA aneurysms. The study was registered with PROSPERO (registration number: CRD42024499894).
Collapse
Affiliation(s)
- Changya Liu
- Department of Emergency, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, NO.725 Wanping South Road, Xuhui District, Shanghai, 200032, China
| | - Xinxin Wu
- Central Laboratory, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, 200443, China
| | - Kaikai Guo
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Yuting Sun
- Department of Emergency, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, NO.725 Wanping South Road, Xuhui District, Shanghai, 200032, China
| | - Cai Yike
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Xuebin Hu
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Bangjiang Fang
- Department of Emergency, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, NO.725 Wanping South Road, Xuhui District, Shanghai, 200032, China.
- Chongqing General Hospital, Chongqing University, Chongqing, 401147, China.
- Institute of Emergency and Critical Care Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| |
Collapse
|
4
|
Sathya A, Enriquez-Marulanda A, Young M, Shutran M, Taussky P, Ogilvy CS. Flow Diversion for the Treatment of Posterior Inferior Cerebellar Aneurysms: A Novel Classification of Posterior Inferior Cerebellar Artery Origin. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00980. [PMID: 38038473 DOI: 10.1227/ons.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/06/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Flow diversion (FD) for posterior circulation aneurysms, such as proximal posterior inferior cerebellar artery (PICA) aneurysms, remains "off-label" and controversial. Although there are reports of using FD in the vertebral artery (VA) to treat PICA aneurysms, the differences between structural PICA-origin variants have not been explored. We analyzed PICA aneurysms treated with FD, assessed radiographic and clinical outcomes, and presented a novel classification of the PICA origin in relationship to aneurysm anatomy. METHODS We performed a retrospective study of prospective data for intracranial aneurysms treated with FD at a major academic institution from 2013 to 2022. Proximal PICA aneurysms that underwent FD placement in the V4 segment of the vertebral artery were included for analysis. A literature review was performed on PubMed to evaluate previously published cases. The PICA origin was characterized by 4 distinct subtypes. Type 1 describes the PICA originating adjacent/separate to the aneurysm neck, Type 2 with the PICA originating from the aneurysm neck, Type 3 with the PICA originating from the aneurysm dome, and Type 4 (True PICA aneurysm) with the aneurysm located proximally on PICA, distal to the PICA-VA junction. RESULTS Thirteen proximal PICA aneurysms were identified and included in the analysis. Patients were primarily female (76.9%), with a median age of 62 years. The aneurysm median maximum diameter was 5.8 mm. From the total sample (institutional and literature review cases), type 1 had a 100% complete and near-complete occlusion rate, type 2 had 75.0%, type 3 had 88.9%, and type 4 had 75%. The overall complete and near-complete occlusion rate was 83.3% (20/24). CONCLUSION FD in the V4 VA segment is an effective way to treat proximal PICA aneurysms. Exploring the relationship between PICA origin is a helpful method in predicting occlusion rates for proximal PICA aneurysms and may lead to improved treatment considerations.
Collapse
Affiliation(s)
- Anvitha Sathya
- Neurosurgery Department, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Alejandro Enriquez-Marulanda
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Young
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Phillip Taussky
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
5
|
Duangprasert G, Noiphithak R, Sukhor S, Tantongtip D. Efficacy and predicting factors of multimodal treatment for ruptured intracranial vertebral artery dissecting aneurysms. Neurosurg Rev 2023; 46:321. [PMID: 38040929 DOI: 10.1007/s10143-023-02226-7] [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: 10/11/2023] [Revised: 11/09/2023] [Accepted: 11/23/2023] [Indexed: 12/03/2023]
Abstract
We aimed to investigate the efficacy of our multimodal strategies and propose a treatment algorithm for ruptured vertebral artery dissecting aneurysms (VADAs). This study included 41 patients treated at a single institution between 2015 and 2022. The treatment modalities were justified based on the collateral circulation and aneurysm location related to the posterior inferior cerebellar artery (PICA). Treatment outcomes and complications of each treatment group were analyzed. The association between the collateral blood flow and the postoperative vertebrobasilar ischemia (VBI) was also investigated. There were 17 post-PICA, 10 PICA-involved, 7 pre-PICA, and 7 non-PICA types. Reconstruction techniques included flow diversion devices (n = 11) and stent-assisted coiling (n = 3). Deconstruction techniques included coil trapping (n=17) and microsurgical parent artery occlusion with (n = 8) or without PICA revascularization (n = 2). Five (18.5%) of the deconstruction group had postoperative VBI. Overall favorable outcomes in both groups were observed in 70.7% of patients with a mean follow-up time of 21.5 months. Poor World Federation of Neurosurgical Societies grade (IV-V) was identified as a predictor of unfavorable outcomes (p = 0.003). In addition, the VA4/BA4 ratio > 0.22, the presence of collateral blood flow from the posterior communicating artery (PcomA), and a contralateral VA diameter > 2.5 mm were associated with a lower risk of postoperative VBI. In summary, the proposed strategic treatment in this study is pragmatic, yielding satisfactory results where a deconstructive technique should be used with caution, particularly when there is a flow mismatch or the absence of collateral PcomA in the vertebrobasilar circulation.
Collapse
Affiliation(s)
- Gahn Duangprasert
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Khlong Nueng, Pathum Thani, 12120, Thailand
| | - Raywat Noiphithak
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Khlong Nueng, Pathum Thani, 12120, Thailand.
| | - Sasikan Sukhor
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Khlong Nueng, Pathum Thani, 12120, Thailand
| | - Dilok Tantongtip
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Khlong Nueng, Pathum Thani, 12120, Thailand
| |
Collapse
|
6
|
Goroshchenko SA. [Diagnosis and treatment of non-saccular vertebrobasilar aneurysms]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:109-114. [PMID: 35758086 DOI: 10.17116/neiro202286031109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To systematize the data on diagnosis and treatment of non-saccular vertebrobasilar aneurysms. MATERIAL AND METHODS We have analyzed modern and fundamental studies in the PubMed database for the period 1969-2020. The following keywords were used: non-saccular aneurysm, dolichoectasia, vertebrobasilar pool. Fifty-nine studies including 1 meta-analysis, 9 case reports, 24 reviews and 25 original articles were selected. RESULTS Analysis of literature data indicates various unresolved problems associated with difficult diagnosis and choice of treatment that results high rates of disability and mortality. CONCLUSION Data on anatomical features of non-saccular aneurysms, such as presence or absence of perforating arteries within the affected arterial segment, analysis of electrophysiological changes following brainstem compression by aneurysm can serve as factors that will improve treatment outcomes in these patients.
Collapse
Affiliation(s)
- S A Goroshchenko
- Polenov Russian Research Neurosurgical Institute - Branch of the Almazov National Medical Research Center, St. Petersburg, Russia
| |
Collapse
|
7
|
Fu W, Ge H, Luo G, Meng X, Wang J, Jin H, Li Y. Treatment of Unruptured Vertebral Artery Aneurysm Involving Posterior Inferior Cerebellar Artery With Pipeline Embolization Device. Front Neurol 2021; 12:622457. [PMID: 34177754 PMCID: PMC8222993 DOI: 10.3389/fneur.2021.622457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 04/20/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Treatment of unruptured vertebral artery aneurysm involving posterior inferior cerebellar artery (PICA) is challenging. The experience of pipeline embolization device (PED) therapy for these lesions is still limited. Objective: To evaluate the safety and efficacy of the PED for unruptured vertebral artery aneurysm involving PICA. Methods: Thirty-two patients with unruptured vertebral artery aneurysm involving PICA underwent treatment with PED were retrospectively identified. Procedure-related complications, PICA patency, clinical, and angiographic outcomes were analyzed. Results: Thirty-two aneurysms were successfully treated without any procedure-related complications. Images were available in 30 patients (93.8%) during a period of 3–26 months follow-up (average 8.4 months), which confirmed complete occlusion in 17 patients (56.5%), near-complete occlusion in 9 patients (30%), and incomplete occlusion in one patient (3.3%). Parent artery occlusion (PAO) was occurred in 3 patients (10%). Twenty-eight of 30 PICA remained patent. The two occlusions of PICA were secondary to PAO. At a mean of 20.7 months (range 7–50 months) clinical follow-up, all the patients achieved a favorable outcome without any new neurological deficit. Conclusion: PED seems to be a safe and effective alternative endovascular option for patients with unruptured vertebral artery aneurysm involving PICA.
Collapse
Affiliation(s)
- Weiqi Fu
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Fushun Central Hospital, Fushun, China
| | - Huijian Ge
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gang Luo
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiangyu Meng
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiejun Wang
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Bejing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
8
|
Kumar A, Dmytriw AA, Salem MM, Kuhn AL, Phan K, Bharatha A, Spears J, Thomas A, Puri A, Marotta TR. Reconstructive vs Deconstructive Endovascular Approach to Intradural Vertebral Artery Aneurysms: A Multicenter Cohort Study. Neurosurgery 2021; 87:383-393. [PMID: 32022238 DOI: 10.1093/neuros/nyaa005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 12/01/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Parent vessel sacrifice (PVS) has been a traditional way of treating complex aneurysms of the intradural vertebral artery (VA). Flow diversion (FD) has emerged as an alternative reconstructive option. OBJECTIVE To compare the long-term clinical and radiographic outcomes of intradural VA aneurysms following PVS or FD. METHODS We retrospectively reviewed and evaluated 43 consecutive patients between 2009 and 2018 with ruptured and unruptured intradural VA aneurysms treated by PVS or FD. Medical records including clinical and radiological details were reviewed. RESULTS A total of 43 intradural VA aneurysms were treated during this period. In the 14 PVS patients, the mean follow-up was 19.5 mo, and 71.4% of cases achieved modified Rankin scale (mRS) ≤2 at the last follow-up. A total of 86.5% of cases achieved complete occlusion. There was a 14.3% (2 cases) mortality rate, 14.3% (2 cases) postoperative ischemic complication rate, and 0% postoperative hemorrhaging rate. Retreatment was required in 1 case (7.1%). In the 29 FD patients, the mean follow-up was 21.8 mo, and 89.7% of cases achieved mRS ≤2 at the final follow-up. There was a 3.2% (1 case) mortality rate, 19.4% (6 cases) of postoperative ischemic complications, and 6.5% (2 cases) of postoperative hemorrhagic complications. Complete occlusion was seen in 86.5% patients. No cases required retreatment. Mortality and complication rates were not significantly different between PVS and PED (Pipeline Embolization Device) groups. CONCLUSION PVS was associated with comparable intraprocedural complications for VA aneurysms as compared to FD in the largest multicenter study to date. Both procedures have good long-term clinical and radiological outcomes.
Collapse
Affiliation(s)
- Ashish Kumar
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Adam A Dmytriw
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anna L Kuhn
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Kevin Phan
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Aditya Bharatha
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Julian Spears
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Ajith Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajit Puri
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Thomas R Marotta
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| |
Collapse
|
9
|
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: 16] [Impact Index Per Article: 4.0] [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.
Collapse
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
| |
Collapse
|
10
|
Pomeraniec IJ, Mastorakos P, Raper D, Park MS. Rerupture Following Flow Diversion of a Dissecting Aneurysm of the Vertebral Artery: Case Report and Review of the Literature. World Neurosurg 2020; 143:171-179. [PMID: 32730963 DOI: 10.1016/j.wneu.2020.07.149] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dissecting aneurysms of the posterior cerebral circulation can wield significant treatment challenges with devastating clinical outcomes. Despite an expanded therapeutic armamentarium, these vascular lesions remain relatively difficult to diagnose and portend high associated morbidity and mortality. METHODS A ruptured, fusiform, dissecting aneurysm of the mid V4 segment of the right vertebral artery (VA) distal to the posterior inferior cerebellar artery origin resulted in a Hunt and Hess grade 5, Fisher scale score 4 subarachnoid hemorrhage. The lesion incorporated 360 degrees of the vessel wall and extended across an area measuring 11 mm in length and 6.8 mm in width at maximum dimension. The vascular lesion was treated with 2 overlapping Pipeline Embolization Devices. RESULTS Digital subtraction angiography demonstrated an origin of the right posterior inferior cerebellar artery mildly stenosed by the dissecting aneurysm. The left VA was markedly hypoplastic. After deployment of 2 overlapping Pipeline Embolization Devices, the aneurysm neck was well covered with appropriate positioning of the stent construct with good apposition to the vessel wall. There was contrast stasis within the aneurysm. The patient was managed with dual antiplatelet therapy. He demonstrated initial clinical and radiographic improvement. However, on the night of the second postprocedure day, the patient succumbed to rerupture of the aneurysm. CONCLUSIONS The literature posits that nonsaccular, fusiform, and dissecting aneurysms of the vertebrobasilar circulation can be occluded with consistency and success using flow diversion techniques. Endovascular treatment of a ruptured dissecting aneurysm of the VA is technically feasible and can be performed with or without parent artery occlusion. Outcomes following flow diversion of the posterior circulation may depend on the location of the dissection and viability of collateral circulation. In the present case, adequate coverage of the aneurysm did not portend a positive outcome.
Collapse
Affiliation(s)
- I Jonathan Pomeraniec
- Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Panagiotis Mastorakos
- Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Daniel Raper
- Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA; Department of Interventional Neuroradiology, University of Virginia Health Science Center, Charlottesville, Virginia, USA.
| |
Collapse
|
11
|
Chen JA, Garrett MC, Mlikotic A, Ausman JI. Treatment of intracranial vertebral artery dissecting aneurysms involving the posterior inferior cerebellar artery origin. Surg Neurol Int 2019; 10:116. [PMID: 31528452 PMCID: PMC6744774 DOI: 10.25259/sni-281-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 05/02/2019] [Indexed: 02/07/2023] Open
Abstract
Background Vertebral artery dissecting aneurysm (VADA) involving the origin of the posterior inferior cerebellar artery (PICA) is a complex disease entity in which the dual goals of preventing future rebleeding and maintaining perfusion of the lateral medulla must be considered. We present an illustrative case and review the literature surrounding treatment strategies. Case Description We report a patient presenting with extensive subarachnoid hemorrhage due to rupture of an intracranial VADA involving the PICA origin. After consideration of the patient's cerebral vasculature and robustness of collaterals, a flow-diverting stent was placed with angiographic resolution of the lesion and maintenance of antegrade PICA flow. Ultimately, the patient experienced a contralateral intraparenchymal hemorrhage leading to death. Review of the literature identified 124 cases of VADA involving the PICA origin described over the past decade. The methods of surgical and endovascular treatment of these cases were reviewed, with particular focus on the rationale of treatment, outcomes, and complications. Conclusion Numerous treatment options for VADA involving PICA have been reported with different risk and benefit profiles. Flow-diverting stents appear to offer the most favorable balance of securing the aneurysm and avoiding medullary infarction, but the risks and optimal anti-thrombotic treatment strategy are incompletely understood. In select cases, in which the surgical risk is low or in which the anatomy is favorable (e.g., nondominant parent vessel or robust collateral circulation in the involved territories), parent artery trapping with or without microsurgical revascularization can be considered.
Collapse
Affiliation(s)
- Jason A Chen
- Department of Neurosurgery, University of California, Los Angeles
| | | | - Anton Mlikotic
- Department of Radiology, Harbor-UCLA Medical Center, Torrance, California, USA
| | - James I Ausman
- Department of Neurosurgery, University of California, Los Angeles
| |
Collapse
|
12
|
Raper DMS, Chen CJ, Kumar J, Kalani MY, Park MS. Predicting Outcomes for Cerebral Aneurysms Treated with Flow Diversion: A Comparison Between 4 Grading Scales. World Neurosurg 2019; 128:e209-e216. [PMID: 31004852 DOI: 10.1016/j.wneu.2019.04.099] [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: 01/13/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Despite the development of 4 grading scales of angiographic outcome after flow diversion for cerebral aneurysms, none have been widely adopted in the neurosurgical literature, nor have any been validated in an independent dataset. We evaluated the reported grading scales for their ability to predict aneurysm occlusion at follow-up. METHODS Four reported grading scales were applied in a retrospective analysis of our prospectively maintained institutional database of patients with intracranial aneurysms treated with flow-diverting stents. Analysis of patient factors, aneurysm factors, and outcomes was made to compare the grading scales' ability to predict aneurysm occlusion. RESULTS Ninety-nine aneurysms in 90 patients treated at our institution between 2011 and 2018 were included in the analysis. Lower Flow-Diverting Stent Score (FDSS) scores were associated with higher rates of aneurysm occlusion at final follow-up (P=0.004). The OKM, Kamran-Byrne, and SMART scales scores were not associated with aneurysm occlusion at final follow-up even after adjustments for baseline differences. Area under the receiver operating characteristic curve for the FDSS was 0.675 (0.534-0.816). CONCLUSIONS Although the FDSS was the only reported grading scale that was significantly associated with occlusion at follow-up, its ability to predict occlusion fell below the typical level for widespread clinical utility. The high rate of eventual occlusion of most aneurysms after flow diversion likely limits the clinical utility of a grading score for this application.
Collapse
Affiliation(s)
- Daniel M S Raper
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jeyan Kumar
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - M Yashar Kalani
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
| |
Collapse
|
13
|
Zhang Y, Liang F, Zhang Y, Yan P, Liang S, Ma C, Jiang C. Exploring the Feasibility of Pipeline Embolization Device Compared With Stent-Assisted Coiling to Treat Non-saccular, Unruptured, Intradural Vertebral Artery Aneurysms. Front Neurol 2019; 10:275. [PMID: 30972007 PMCID: PMC6443633 DOI: 10.3389/fneur.2019.00275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 03/04/2019] [Indexed: 11/15/2022] Open
Abstract
Object: The pipeline embolization device (PED) has been used to treat non-saccular, unruptured, intradural vertebral artery aneurysms at some institutions. However, there is an absence of large controlled studies validating the feasibility of this treatment. This study aimed to explore the therapeutic feasibility of PED by comparing PED treatment with controlled stent-assisted coiling (SAC). Materials and Methods: Thirty-two PED procedures were matched in a 1:2 manner with 64 SAC procedures based on patient age, sex, aneurysm size, and aneurysm location. Technical factors, procedural complications, angiographic results, and clinical outcomes were analyzed and compared. Results: There was no statistically significant difference in technical factors and procedural complications between the two groups (PED vs. SAC, 9.4 vs. 4.7%, P = 0.397). In multivariate analysis, smoking and therapeutic modality were identified as independent predictors of occlusion. Smoking was a risk factor for aneurysm obliteration [hazard ratio (HR) 0.53; 95% confidence interval (CI), 0.31–0.89; P = 0.018]. Aneurysms treated with PED were more likely to achieve obliteration over time compared with aneurysms treated with SAC (HR 2.97; 95% CI, 1.79–4.93; P < 0.001). The rate of favorable clinical outcomes (modified Rankin Scale (mRS), 0–2) was similar between the two groups (PED vs. SAC, 100 vs. 96.9%, P = 0.551). In the SAC group, one patient had neurological deficit with an mRS of four at the latest follow-up. There was no mortality in either group. Conclusions: The PED and SAC groups showed similar technical factors, procedural complications, angiographic results, and favorable clinical outcomes. Aneurysms treated with PED were more prone to obliteration over time than aneurysms treated with SAC. These outcomes suggest, based on short-term follow-up, PED is a safe and feasible strategy for the treatment of non-saccular, unruptured, intradural vertebral artery aneurysms.
Collapse
Affiliation(s)
- Yupeng Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fei Liang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuxiang Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Yan
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Chao Ma
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuhan Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
14
|
Chen X, Sun Z, Shi L, Xu L, Yu J, Fang B, Zheng J, Xu J, Zhang J. Endovascular management of ruptured distal posterior inferior cerebellar artery aneurysms: A retrospective cohort study. Medicine (Baltimore) 2018; 97:e13300. [PMID: 30544389 PMCID: PMC6310559 DOI: 10.1097/md.0000000000013300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Distal posterior inferior cerebellar artery (PICA) aneurysm is a kind of rare intracranial aneurysm with controversial evidence in managements. The main purposes of this research are to study the safety and effectiveness of parent artery occlusion (PAO) compared with selective aneurysm coiling (SAC) as well as figure out factors that affect the outcomes.All characteristics of patients that diagnosed with ruptured distal PICA aneurysm and treated with endovascular management in our hospital from July 2009 to February 2016 were retrospectively collected. Details include complete occlusion rate, procedure-related complications and Modified Rankin Scale (mRS) of 31 months (mean) follow-up.Total 36 patients finally met the criterions and were included in the present study. New imaging infarction was observed in 12 (33.33%) patients. And 10 of them showed no apparent neurological dysfunctions after 34 months (mean) follow-up; 1 remained coma status since the symptom onset; and 1 patient died. 27 (75%) patients got a mRS ≤ 2 at the discharge while 20 (86.96%) patients with 3-year follow-up after the operation. There is no significant difference between patients treated with SAC and PAO in both complications and functional recovery in 3-years follow-up period. Hunt&Hess classification (H&H), age, and hydrocephalus are risk factors for functional recovery at discharge.PAO is safe and efficient in the management of distal PICA aneurysms while complications and outcomes are similar with SAC. H&H, age, and hydrocephalus are predicting factors for the mRS at discharge. Further prospective study is still needed to confirm the results of present study.
Collapse
Affiliation(s)
- Xianyi Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Zeyu Sun
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Ligen Shi
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Liang Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Jun Yu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Bing Fang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Jingwei Zheng
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Jing Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
- Brain Research Institute
- Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou, Zhejiang, China
| |
Collapse
|
15
|
Kilburg C, Kalani MYS, Park MS. Posterior communicating artery occlusion and recanalization through a fusiform aneurysm after flow diversion. J Clin Neurosci 2018; 55:97-99. [PMID: 30042068 DOI: 10.1016/j.jocn.2018.06.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/25/2018] [Indexed: 11/18/2022]
Abstract
Occlusion of branch vessels is a known potential sequela of the treatment of intracranial aneurysms with flow diversion. We present a case of occlusion and distal reconstitution of the origin of the posterior communicating artery through a fusiform aneurysm of the internal carotid artery after flow diversion. A 56-year-old woman was incidentally found to have a large fusiform aneurysm of the posterior communicating segment of the internal carotid artery incorporating the origin of the posterior communicating artery. The aneurysm was treated with placement of a Pipeline flow diverter. Follow-up computed tomography angiogram at 7 months demonstrated no change in aneurysm filling. A follow-up digital subtraction angiogram at 12 months demonstrated occlusion of the native origin of the posterior communicating artery with distal reconstitution through two accessory channels through the aneurysm. The remainder of the aneurysm was thrombosed. The patient had not had any clinical symptoms during this event. The unorganized nature of the thrombus within aneurysms after flow diversion may allow accessory vascular channels to form in the event of occlusion of a side branch.
Collapse
Affiliation(s)
- Craig Kilburg
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132 USA.
| | - M Yashar S Kalani
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132 USA.
| | - Min S Park
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132 USA.
| |
Collapse
|
16
|
Awad AW, Moon K, Yoon N, Mazur MD, Kalani MYS, Taussky P, McDougall CG, Albuquerque FC, Park MS. Flow diversion of tandem cerebral aneurysms: a multi-institutional retrospective study. Neurosurg Focus 2018; 42:E10. [PMID: 28565979 DOI: 10.3171/2017.2.focus1731] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow diversion has proven to be an efficacious means of treating cerebral aneurysms that are refractory to other therapeutic means. Patients with tandem aneurysms treated with flow diversion have been included in larger, previously reported series; however, there are no dedicated reports on using this technique during a single session to treat this unique subset of patients. Therefore, the authors analyzed the outcomes of patients who had undergone single-session flow diversion for the treatment of tandem aneurysms. METHODS The authors conducted a retrospective review of flow diversion with the Pipeline embolization device (PED) for the treatment of tandem aneurysms in a single session at 2 participating medical centers: University of Utah, Salt Lake City, Utah, and Barrow Neurological Institute, Phoenix, Arizona. Patient demographic data, aneurysm characteristics, treatment strategy and results, complications, and follow-up data were collected from the medical record and analyzed. RESULTS Between January 2011 and December 2015, 17 patients (12 female, 5 male) with a total of 38 aneurysms (mean size 4.7 ± 2.7 mm, mean ± SD) were treated. Sixteen patients had aneurysms in the anterior circulation, and 1 patient had tandem aneurysms in the posterior circulation. Twelve patients underwent only placement of a PED, whereas 5 underwent adjunctive coil embolization of at least 1 aneurysm. One PED was used in each of 9 patients, and 2 PEDs were required in each of 8 patients. There were 2 intraprocedural complications; however, in both instances, the patients were asymptomatic at the last follow-up. The follow-up imaging studies were available for 15 patients at a mean of 7 months after treatment (216 days, range 0-540 days). The mean initial Raymond score after treatment was 2.7 ± 0.7, and the mean final score was 1.3 ± 0.7. CONCLUSIONS In this series, the use of flow diversion for the treatment of tandem cerebral aneurysms had an acceptable safety profile, indicating that it should be considered as an effective therapy for this complicated subset of patients. Further prospective studies must be performed before more definitive conclusions can be made.
Collapse
Affiliation(s)
- Al-Wala Awad
- Department of Neurosurgery, University of Utah Health Care, Salt Lake City, Utah
| | - Karam Moon
- Barrow Neurological Institute, Phoenix, Arizona; and
| | - Nam Yoon
- Department of Neurosurgery, University of Utah Health Care, Salt Lake City, Utah
| | - Marcus D Mazur
- Department of Neurosurgery, University of Utah Health Care, Salt Lake City, Utah
| | - M Yashar S Kalani
- Department of Neurosurgery, University of Utah Health Care, Salt Lake City, Utah
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah Health Care, Salt Lake City, Utah
| | | | | | - Min S Park
- Department of Neurosurgery, University of Utah Health Care, Salt Lake City, Utah
| |
Collapse
|
17
|
Srinivasan VM, Ghali MGZ, Reznik OE, Cherian J, Mokin M, Dumont TM, Gaughen JR, Grandhi R, Puri AS, Chen SR, Johnson JN, Kan P. Flow diversion for the treatment of posterior inferior cerebellar artery aneurysms: a novel classification and strategies. J Neurointerv Surg 2017; 10:663-668. [DOI: 10.1136/neurintsurg-2017-013427] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 11/04/2022]
Abstract
BackgroundThe pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, treatment of posterior inferior cerebellar artery (PICA) aneurysms with flow diversion (FD) has not been specifically described or discussed. While there are reports of treating PICA aneurysms using placement of FD stents in the vertebral artery, there are no reports of treating these lesions by placement of flow diverting stents in the PICA vessel itself. Due to the unique anatomy and morphology of these aneurysms, it requires special attention. We assessed our multi-institutional experience treating these lesions, including the first reported cases of the PED placed within the PICA.MethodsInstitutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with the PED. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases of PICA aneurysms treated with the PED. PICA aneurysms were defined as aneurysms that involved the PICA. Vertebral aneurysms without disease in the PICA were excluded from the study.Results10 PICA aneurysms were treated during the study period. These were classified based on their morphology and location into two main types and five total subtypes for consideration of treatment with flow diversion. All aneurysms were successfully treated, with 8/10 completely obliterated and 2 with a partial reduction in size. Three patients had the PED placed entirely in the PICA and no patient suffered from a medullary or cerebellar stroke. All PEDs were patent and all patients were independent at the last follow-up.ConclusionsThe PED may be used successfully to treat select aneurysms of the PICA. We present the first described cases of successful PED treatment of PICA aneurysms with direct placement of the PED in the PICA vessel itself. The proposed classification system aids in that selection.
Collapse
Affiliation(s)
| | | | - Oleg E Reznik
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jacob Cherian
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Maxim Mokin
- Departments of Neurology and Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Travis M Dumont
- Division of Neurosurgery, University of Arizona, Tucson, Arizona, USA
| | - John R Gaughen
- Sentara Martha Jefferson Medical and Surgical Associates, Charlottesville, Virginia, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Texas at San Antonio, San Antonio, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Stephen R Chen
- Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremiah N Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
18
|
Mascitelli JR, Yaeger K, Wei D, Kellner CP, Oxley TJ, De Leacy RA, Fifi JT, Patel AB, Naidich TP, Bederson JB, Mocco J. Multimodality Treatment of Posterior Inferior Cerebellar Artery Aneurysms. World Neurosurg 2017; 106:493-503. [DOI: 10.1016/j.wneu.2017.07.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/03/2017] [Accepted: 07/06/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Justin R Mascitelli
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Kurt Yaeger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel Wei
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas J Oxley
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Reade A De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas P Naidich
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
19
|
Mohammad LM, Coon AL, Carlson AP. Resolution of giant basilar artery aneurysm compression and reversal of sensorineural hearing loss with use of a flow diverter: case report. J Neurosurg Pediatr 2017; 20:81-85. [PMID: 28452658 DOI: 10.3171/2016.9.peds16428] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present an unusual case of a 15-year-old boy in whom sensorineural hearing loss and disequilibrium developed in the setting of a giant basilar artery aneurysm. This patient was treated with a flow-diverting stent and had complete resolution of his clinical symptoms including hearing loss. This case demonstrates the efficacy of flow diversion in select pediatric patients with posterior circulation aneurysms. The features that are thought to result in successful treatment are discussed.
Collapse
Affiliation(s)
- Laila M Mohammad
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico ; and
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico ; and
| |
Collapse
|
20
|
Wang CC, Fang YB, Zhang P, Zhu X, Hong B, Xu Y, Liu JM, Huang QH. Reconstructive endovascular treatment of vertebral artery dissecting aneurysms with the Low-profile Visualized Intraluminal Support (LVIS) device. PLoS One 2017; 12:e0180079. [PMID: 28662097 PMCID: PMC5491116 DOI: 10.1371/journal.pone.0180079] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/11/2017] [Indexed: 12/26/2022] Open
Abstract
Introduction The Low-profile Visualized Intraluminal Support (LVIS) device is a new generation of self-expanding braided stent recently introduced in China for stent assisted coiling of intracranial aneurysms. The aim of our study is to evaluate the feasibility, safety, and efficacy of the LVIS device in reconstructive treatment of vertebral artery dissecting aneurysms (VADAs). Methods We retrospectively reviewed the neurointerventional database of our institution from June 2014 to May 2016. Patients who underwent endovascular treatment of VADAs with LVIS stents were included in this study. Clinical presentation, aneurysmal characteristics, technical feasibility, procedural complications, and angiographic and clinical follow-up results were evaluated. Results 38 patients with VADAs who underwent treatment with LVIS stent were identified, including 3 ruptured VADAs. All VADAs were successfully treated with reconstructive techniques including the stent-assisted coiling (n = 34) and stenting only (n = 4). Post-procedural complications developed in 3 patients (7.9%) including two small brainstem infarctions and one delayed thromboembolic event. Complications resulted in one case of minor permanent morbidity (2.6%). There was no procedure-related mortality. The follow-up angiogram was available in 30 patients at an average of 8.3 months (range, 2 to 30 months), which revealed complete occlusion in 23 patients (76.7%), residual neck in five patients (16.7%), and residual sac in two patients (6.7%). The follow-up of 25 aneurysms with incomplete immediate occlusion revealed 22 aneurysms (88%) with improvement in the Raymond class. One aneurysm (3.3%) showed recanalization and required retreatment. Clinical followed-up at 5–28 months (mean 14.1 months) was achieved in 36 patients because two patients died of pancreatic cancer and basal ganglia hemorrhage, respectively. No new neurologic deterioration or aneurysm (re)bleeding was observed. Conclusions Our preliminary experience with reconstruction of VADAs with the LVIS device demonstrates that this treatment approach is feasible with good short-term angiographic and clinical outcomes. Long-term and larger cohort studies are necessary to determine long-term outcomes of this therapy.
Collapse
Affiliation(s)
- Chuan-Chuan Wang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi-Bin Fang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Ping Zhang
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Xuan Zhu
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jian-Min Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
- * E-mail: (QHH); (JML)
| | - Qing-Hai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- Changhai Stroke Center, Changhai Hospital, Second Military Medical University, Shanghai, China
- * E-mail: (QHH); (JML)
| |
Collapse
|
21
|
Kilburg C, Taussky P, Kalani MYS, Park MS. Novel use of flow diversion for the treatment of aneurysms associated with arteriovenous malformations. Neurosurg Focus 2017; 42:E7. [PMID: 28565984 DOI: 10.3171/2017.2.focus1755] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The use of flow-diverting stents for intracranial aneurysms has become more prevalent, and flow diverters are now routinely used beyond their initial scope of approval at the proximal internal carotid artery. Although flow diversion for the treatment of cerebral aneurysms is becoming more commonplace, there have been no reports of its use to treat flow-related cerebral aneurysms associated with arteriovenous malformations (AVMs). The authors report the cases of 2 patients whose AVM-associated aneurysms were managed with flow diversion. A 40-year-old woman presented with a history of headaches that led to the identification of an unruptured Spetzler-Martin Grade V, right parietooccipital AVM associated with 3 aneurysms of the ipsilateral internal carotid artery. Initial attempts at balloon-assisted coil embolization of the aneurysms were unsuccessful. The patient underwent placement of a flow-diverting stent across the diseased vessel; a 6-month follow-up angiogram demonstrated complete occlusion of the aneurysms. In the second case, a 57-year-old man presented with new-onset seizures, and an unruptured Spetzler-Martin Grade V, right frontal AVM associated with an irregular, wide-necked anterior communicating artery aneurysm was identified. The patient underwent placement of a flow-diverting stent, and complete occlusion of the aneurysm was observed on a 7-month follow-up angiogram. These 2 cases illustrate the potential for use of flow diversion as a treatment strategy for feeding artery aneurysms associated with AVMs. Because of the need for dual antiplatelet medications after flow diversion in this patient population, however, this strategy should be used judiciously.
Collapse
Affiliation(s)
- Craig Kilburg
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - M Yashar S Kalani
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Min S Park
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| |
Collapse
|
22
|
Awad AJ, Mascitelli JR, Haroun RR, De Leacy RA, Fifi JT, Mocco J. Endovascular management of fusiform aneurysms in the posterior circulation: the era of flow diversion. Neurosurg Focus 2017; 42:E14. [DOI: 10.3171/2017.3.focus1748] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Fusiform aneurysms are uncommon compared with their saccular counterparts, yet they remain very challenging to treat and are associated with high rates of rebleeding and morbidity. Lack of a true aneurysm neck renders simple clip reconstruction or coil embolization usually impossible, and more advanced techniques are required, including bypass, stent-assisted coiling, and, more recently, flow diversion. In this article, the authors review posterior circulation fusiform aneurysms, including pathogenesis, natural history, and endovascular treatment, including the role of flow diversion. In addition, the authors propose an algorithm for treatment based on their practice.
Collapse
Affiliation(s)
- Ahmed J. Awad
- 1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; and
- 2Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Justin R. Mascitelli
- 1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; and
| | - Reham R. Haroun
- 1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; and
| | - Reade A. De Leacy
- 1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; and
| | - Johanna T. Fifi
- 1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; and
| | - J Mocco
- 1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; and
| |
Collapse
|
23
|
Abstract
Atherosclerotic disease of the cerebral vasculature is a major cause of stroke worldwide. Atherosclerosis that is refractory to best medical management may require revascularization. In these instances, endovascular treatment provides a popular and safe alternative to open surgical techniques. The authors provide an overview of stent technology in the treatment of ischemic stroke, discussing the major studies evaluating stenting for extracranial carotid artery, vertebral artery, and intracranial atherosclerotic disease. The authors describe the commonly used stents with respect to their individual characteristics and technical limitations. Current and future developments in stent technology are also discussed, with areas for further innovation and clinical research.
Collapse
Affiliation(s)
- Nam K Yoon
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Al-Wala Awad
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - M Yashar S Kalani
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Min S Park
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| |
Collapse
|
24
|
Park MS, Mazur MD, Moon K, Nanaszko MJ, Kestle JRW, Shah LM, Winegar B, Albuquerque FC, Taussky P, McDougall CG. An outcomes-based grading scale for the evaluation of cerebral aneurysms treated with flow diversion. J Neurointerv Surg 2016; 9:1060-1063. [DOI: 10.1136/neurintsurg-2016-012688] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 09/23/2016] [Accepted: 09/29/2016] [Indexed: 11/04/2022]
|
25
|
de Carvalho FM, Caroff J, Pereira Dos Santos Neto E, Chalumeau V, Abdel Khalek H, Neki H, Saliou G, Rouchaud A, Moret J, Spelle L. Flow changes in the posterior communicating artery related to flow-diverter stents in carotid siphon aneurysms. J Neurointerv Surg 2016; 9:674-678. [PMID: 27387710 DOI: 10.1136/neurintsurg-2016-012443] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/09/2016] [Accepted: 06/15/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Flow-diverter stent (FDS) placement for treatment of intracranial aneurysms can cause flow changes in the covered branches. OBJECTIVE To assess the impact of the treatment of carotid siphon aneurysms with FDS on the posterior communicating artery (PComA) flow. MATERIALS AND METHODS Between February 2011 and January 2015, 125 carotid siphon aneurysms were treated with FDS. We retrospectively analyzed all cases with PComA ostial coverage. The circle of Willis anatomy was also studied as the flow changes in PComA postoperatively and during angiographic follow-up. Data from neurological examination were also collected. RESULTS Eighteen aneurysms of the carotid siphon in 17 patients were treated with FDS covering the ostium of the PComA. Based on the initial angiography, patients were divided into two groups: the first with a P1/PComA size ratio >1 (10 cases) and the second with a ratio ≤1 (8 cases). Follow-up angiography (mean time of 10 months) showed 90% of PComA flow changes in group 1 but only 12.5% in group 2. There was a significant difference between the two groups (p=0.002). Nevertheless, no patient had new symptoms related to these flow changes during the follow-up period. CONCLUSIONS In our experience, covering the PComA by FDS when treating carotid siphon aneurysms appeared safe and the P1/PComA ratio is a good predictor of flow changes in PComA.
Collapse
Affiliation(s)
- Fernando Mota de Carvalho
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France.,Department of Neurorradiologia Diagnóstica e Terapêutica, Hospital Universitário Pedro Ernesto, Rio de Janeiro, Brazil
| | - Jildaz Caroff
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France
| | | | - Vanessa Chalumeau
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France
| | | | - Hiroaki Neki
- Department of Neurosurgery, Saitama University, Saitama, Japan
| | - Guillaume Saliou
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France
| | - Aymeric Rouchaud
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France
| | - Jacques Moret
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France
| | - Laurent Spelle
- Department of Neuroradiologie Interventionnelle, Hôpital Bicetre, Le Kremlin-Bicetre, île-de-France
| |
Collapse
|
26
|
Walcott BP, Reinshagen C, Stapleton CJ, Choudhri O, Rayz V, Saloner D, Lawton MT. Predictive modeling and in vivo assessment of cerebral blood flow in the management of complex cerebral aneurysms. J Cereb Blood Flow Metab 2016; 36:998-1003. [PMID: 27009946 PMCID: PMC4908629 DOI: 10.1177/0271678x16641125] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 02/25/2016] [Indexed: 11/15/2022]
Abstract
Cerebral aneurysms are weakened blood vessel dilatations that can result in spontaneous, devastating hemorrhage events. Aneurysm treatment aims to reduce hemorrhage events, and strategies for complex aneurysms often require surgical bypass or endovascular stenting for blood flow diversion. Interventions that divert blood flow from their normal circulation patterns have the potential to result in unintentional ischemia. Recent developments in computational modeling and in vivo assessment of hemodynamics for cerebral aneurysm treatment have entered into clinical practice. Herein, we review how these techniques are currently utilized to improve risk stratification and treatment planning.
Collapse
Affiliation(s)
- Brian P Walcott
- Department of Neurological Surgery, University of California, San Francisco, USA
| | - Clemens Reinshagen
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Christopher J Stapleton
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Omar Choudhri
- Department of Neurological Surgery, University of California, San Francisco, USA
| | - Vitaliy Rayz
- College of Engineering and Applied Science, University of Wisconsin, Milwaukee, USA Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, USA
| | - David Saloner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, USA
| |
Collapse
|