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Ünsal C, Güçlü G, Olcay AB, Hassankhani A, Bilgin C, Hakyemez B. How Flow Diverter Selection Can Affect the Flow Changes within a Jailed Ophthalmic Artery: A Computational Fluid Dynamics Study. Asian J Neurosurg 2024; 19:426-434. [PMID: 39205892 PMCID: PMC11349421 DOI: 10.1055/s-0044-1787868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Introduction Flow diverter (FD) stents are widely used to treat giant aneurysms by reducing blood flow into the aneurysm sac. However, choosing the optimal FD for a patient can be challenging when a nearby artery, such as the ophthalmic artery (OA), is jailed by the FD placement. This study compares the impact of two FD stents with different effective metal surface area (EMSA) values on OA occlusion. Materials and Methods A numerical model of a 59-year-old female patient with a giant aneurysm in the left internal carotid artery and a jailed OA was created based on clinical data. Two FD stents, FRED4017 and FRED4518, with different EMSA values at the aneurysm neck and OA inlet, were virtually deployed in the model. Blood flow and occlusion amount in the OA were simulated and compared between the two FD stents. Results FRED4017 had higher EMSA values than FRED4518 at the aneurysm neck (35% vs. 24.6%) and lower EMSA values at the OA inlet (15% vs. 21.2%). FRED4017 caused more occlusion in the OA than FRED4518 (40% vs. 28%), indicating a higher risk of ocular ischemic syndrome. Conclusion The EMSA value of FD stents affects the blood flow and occlusion amount in the jailed OA. Therefore, selecting an FD stent with a low EMSA value at the OA inlet may be beneficial for patients with a nearby jailed artery at the aneurysm neck.
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Affiliation(s)
- Can Ünsal
- Numerical Simulation and Spray Targeting Division, Department of Engineering, Bosch, Bursa, Türkiye
| | - Görkem Güçlü
- Department of Mechanical Engineering, Southern Methodist University, Dallas, Texas, United States
| | - Ali Bahadir Olcay
- Department of Mechanical Engineering, Faculty of Engineering, Yeditepe University, Istanbul, Türkiye
| | - Amir Hassankhani
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, United States
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States
| | - Bahattin Hakyemez
- Department of Radiology, Uludag University School of Medicine, Bursa, Türkiye
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Yu Z, Qi J, Wang L, Yang X, Liu Z, Chen X, Xu H, Li Y, Chen Y, Dai C, Gu Z. Managing intraoperative rupture of internal carotid pseudoaneurysms during endoscopic transnasal optic canal decompression: a case report. Front Neurol 2024; 15:1382793. [PMID: 38962479 PMCID: PMC11220115 DOI: 10.3389/fneur.2024.1382793] [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: 02/06/2024] [Accepted: 06/10/2024] [Indexed: 07/05/2024] Open
Abstract
Background Endoscopic transnasal optic canal decompression is widely used in the treatment of traumatic optic neuropathy (TON) following head and craniofacial trauma. Intraoperative hemorrhage is a catastrophic surgical complication during optic canal decompression. Case description We present two cases of patients with TON who suffered unexpected intra-operative massive bleeding during endoscopic transnasal optic canal decompression. After intraoperative hemostasis was achieved, emergent cerebral angiograms demonstrated the formation of internal carotid pseudoaneurysms, which were immediately embolized with coils combined with or without Onyx with balloon assistance. One of these cases was also complicated by a postoperative cerebrospinal fluid leak, which failed to be treated with lumbar drainage but was successfully repaired with endoscopic transnasal surgery. Conclusion The intra-operative rupture of ICA pseudoaneurysm is a rare but catastrophic complication in TON patients. Intraoperative massive bleeding indicates rupture of ICA pseudoaneurysm. Postoperative emergency angiography and endovascular therapy should be arranged to evaluate and repair the cerebral vascular injury. Endoscopic trans-nasal surgery repairing CSF leaks resistant to lumbar drainage could be efficient and safe following pseudoaneurysm embolization.
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Affiliation(s)
- Zeran Yu
- Department of Neurosurgery, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
- Department of Neurosurgery, Beijing Tiantan Hospital Yunnan, Kunming, China
- The Center of Stroke, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Junhui Qi
- Department of Neurosurgery, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
- Department of Neurosurgery, Beijing Tiantan Hospital Yunnan, Kunming, China
- The Center of Stroke, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
| | - Lei Wang
- Department of Neurosurgery, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
- Department of Neurosurgery, Beijing Tiantan Hospital Yunnan, Kunming, China
- The Center of Stroke, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
| | - Xiang Yang
- Department of Obstetrics, The First People’s Hospital of Yunnan, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Zhengqiao Liu
- Department of Neurosurgery, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
- Department of Neurosurgery, Beijing Tiantan Hospital Yunnan, Kunming, China
- The Center of Stroke, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
| | - Xu Chen
- Department of Neurosurgery, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
- Department of Neurosurgery, Beijing Tiantan Hospital Yunnan, Kunming, China
- The Center of Stroke, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
| | - Hongling Xu
- Department of Neurosurgery, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
- Department of Neurosurgery, Beijing Tiantan Hospital Yunnan, Kunming, China
- The Center of Stroke, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
| | - Yajie Li
- Department of Neurosurgery, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
- Department of Neurosurgery, Beijing Tiantan Hospital Yunnan, Kunming, China
- The Center of Stroke, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
| | - Yuyun Chen
- Department of Neurosurgery, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
- Department of Neurosurgery, Beijing Tiantan Hospital Yunnan, Kunming, China
- The Center of Stroke, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
| | - Chengguo Dai
- Department of Neurosurgery, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
- Department of Neurosurgery, Beijing Tiantan Hospital Yunnan, Kunming, China
- The Center of Stroke, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
| | - Zhen Gu
- Department of Neurosurgery, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
- Department of Neurosurgery, Beijing Tiantan Hospital Yunnan, Kunming, China
- The Center of Stroke, The Affiliated Hospital of Yunnan University, Second People’s Hospital of Yunnan, Kunming, China
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You W, Wei D, Gui S, Jiang J, Chen T, Tang Y, Ye W, Lv J, Lin J, Chen P, Wang Z, Gong W, Jin H, Ge H, Jiang Y, Sun Y, Li Y. Quantitative Analysis of Hemodynamic Changes in Branch Arteries Covered by Flow Diverters. Neurosurgery 2024:00006123-990000000-01184. [PMID: 38819159 DOI: 10.1227/neu.0000000000002993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/22/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Understanding post-treatment hemodynamic alterations and their association with the patency of covered branch arteries is limited. This study aims to identify hemodynamic changes after flow diverter stenting and investigate their correlation with the patency status of covered branch arteries. METHODS All patients treated with pipeline embolization device for anterior cerebral artery aneurysms at our center between 2016 and 2020 were screened for inclusion. Quantitative digital subtraction angiography was used to analyze changes in hemodynamic parameters pre- and post-stenting. The patency status of covered branch arteries after stenting was categorized as either patent or flow impairment (defined as artery stenosis or occlusion). RESULTS A total of 71 patients, encompassing 89 covered branch arteries, were enrolled. Flow impairment was observed in 11.2% (10/89) of the branches. The mean transit time and full width at half maximum (FWHM) in covered branches were significantly prolonged post-stenting (P = .004 and .023, respectively). Flow-impaired branch arteries exhibited hemodynamic shifts contrary to those in patent branch arteries. Specifically, flow-impaired branches showed marked reductions in time to peak, FWHM, and mean transit time (decreases of 32.8%, 32.6%, and 29%, respectively; P = .006, .002, and .002, respectively). Further multivariate analysis revealed that reductions in FWHM in the branches (odds ratio = 0.97, 95% CI: 0.95-0.99, P = .007) and smoking (odds ratio = 14.5, 95% CI: 1.39-151.76, P = .026) were independent predictors of flow impairment of covered branches. CONCLUSION Pipeline embolization device stenting can cause a reduction in blood flow in branch arteries. Compared with patent branches, flow-impaired branches exhibit an increase in blood flow velocity after stenting. Smoking and ΔFWHM in the covered branches indicate flow impairment.
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Affiliation(s)
- Wei You
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurointerventional Engineering and Technology (NO: BG0287), Beijing Engineering Research Center, Beijing, China
| | - Dachao Wei
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurointerventional Engineering and Technology (NO: BG0287), Beijing Engineering Research Center, Beijing, China
| | - Siming Gui
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Jia Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Ting Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Yudi Tang
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Wanxing Ye
- Artificial Intelligence Research Center, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jian Lv
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Jun Lin
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Peike Chen
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Ziyao Wang
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wentao Gong
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Hengwei Jin
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Huijian Ge
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yuhua Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yong Sun
- Department of Neurosurgery, The First People's Hospital of Lianyungang, Affiliated Hospital of Kangda College of Nanjing Medical University, Lianyungang, China
| | - Youxiang Li
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurointerventional Engineering and Technology (NO: BG0287), Beijing Engineering Research Center, Beijing, China
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Ni H, Hang Y, Liu S, Jia ZY, Shi HB, Zhao LB. Stent-assisted coiling of unruptured paraclinoid aneurysms with wide neck or unfavorable dome-to-neck ratio: Results of ventral wall vs dorsal wall with propensity score matching analysis. Interv Neuroradiol 2024; 30:147-153. [PMID: 35538879 PMCID: PMC11095348 DOI: 10.1177/15910199221100966] [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: 02/17/2022] [Accepted: 04/28/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the clinical safety and efficacy of stent-assisted coil embolization of unruptured wide-necked paraclinoid aneurysms based on the projection distribution. METHODS Between November 2015 and September 2020, 267 unruptured paraclinod aneurysms in 236 patients were identified with a wide neck or unfavorable dome-to-neck ratio and treated with stent-assisted coiling technique. The classification of this segment aneurysms was simplified to the dorsal group (located on the anterior wall) and ventral group (Non-dorsal). Following propensity score matching analysis, the clinical and radiographic data were compared between the two groups. RESULTS Among 267 aneurysms, 186 were located on the ventral wall and 81 were on the dorsal wall. Dorsal wall aneurysms had a larger size (p < .001), wider neck (p = .001), and higher dome-to-neck ratio (p = .023) compared with ventral wall aneurysms. Propensity score-matched analysis found that dorsal group had a significantly higher likelihood of unfavorable results in immediate (residual sac, 39.4% vs. 18.2%, p = .007) and follow-up angiography (residual sac, 14.8% vs. 1.9%, p = .037) compared with ventral group, with significant difference in recurrence rates (9.3% vs. 0%, p = .028). The rates of procedure-related complications were not significantly different, but one thromboembolic event occurred in the dorsal group with clinical deterioration. CONCLUSIONS Traditional stent-assisted coiling can be given preference in paraclinoid aneurysms located on the ventral wall. The relatively high rate of recurrence in dorsal wall aneurysms with stent assistance may require other treatment options.
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Affiliation(s)
- Heng Ni
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yu Hang
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Sheng Liu
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Zhen-Yu Jia
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
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Liu J, Cao F, Zhenmei N, Guo Y, Li Y, Yuan D, Jiang W, Yan J. Flow-diverter stents in intracranial aneurysm treatment: impact on covered cerebral artery branches. Int J Surg 2024; 110:53-65. [PMID: 37851516 PMCID: PMC10793757 DOI: 10.1097/js9.0000000000000762] [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: 07/20/2023] [Accepted: 09/10/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE Flow diverter stents (FDSs) have attracted interest for intracranial aneurysm (IA) treatment; however, occlusion of side branches and related complications have been reported. This study aimed to investigate the effects of FDSs in IA management when different branches of intracranial arteries are covered. MATERIALS AND METHODS A cross-sectional study was conducted using PUBMED, Embase, Web of Science, and Cochrane databases to include randomized or nonrandomized comparative-designed studies from January 2000 to August 2022 which reported outcomes of occlusion/narrowing of branches after IA treatment using FDSs. The PRISMA guidelines were used for our report. A random-effects meta-analysis was conducted to pool the outcomes, which included incidence rates of occlusion/narrowing of FDS-covered branches, branch occlusion-related symptoms, obliteration of IAs, and ideal clinical outcomes (modified Rankin Scale score ≤2). RESULTS The authors identified 57 studies involving 3789 patients with IA managed by FDSs covering different branches. During the median imaging follow-up at 12 months, the IA obliteration rate was satisfactory (>70%) when covering the ophthalmic artery (OA), posterior communicating artery (PComA), anterior choroidal artery (AChoA) or anterior cerebral artery (ACA), but not the middle cerebral artery-M2 segment (MCA-M2; 69.5%; 95% CI: 60.8-77.5%) and posterior inferior cerebellar artery (PICA; 59.1%, 13/22). The overall ideal clinical outcome was observed in 97.4% of patients (95% CI: 95.5-98.9%). Higher rates of occlusion/narrowing of branches were identified when FDSs covered the ACA (66.6%; 95% CI: 45.1-85.3%), PComA (44.3%; 95% CI: 34.2-54.6%), or MCA-M2 (39.2%; 95% CI: 24.5-54.7%); the risks were lower when covering the OA (11.8%; 95% CI: 8.8-15.1%), PICA (6.8%; 95% CI: 1.5-14.5%), and AchoA (0.5%; 95% CI: 0.0-2.9%). The risk of branch occlusion-related complications was low (incidence rate <5%) for each of the six evaluated branches. CONCLUSIONS Acceptable outcomes were identified following treatment of IAs when FDSs were placed across each of the six studied cerebral arteries. Treatment decisions regarding FDS placement across branch arteries should be made with the risk of complications from branch occlusion in mind.
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Affiliation(s)
- Junyu Liu
- Department of Neurosurgery, XiangYa Hospital
- Department of Pharmacology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Fang Cao
- Department of Epidemiology and Health Statistics, XiangYa School of Public Health, Central South University, Changsha, People’s Republic of China
| | | | - Yuxin Guo
- Department of Epidemiology and Health Statistics, XiangYa School of Public Health, Central South University, Changsha, People’s Republic of China
| | - Yifeng Li
- Department of Neurosurgery, XiangYa Hospital
| | - Dun Yuan
- Department of Neurosurgery, XiangYa Hospital
| | - Weixi Jiang
- Department of Neurosurgery, XiangYa Hospital
| | - Junxia Yan
- Hunan Provincial Key Laboratory of Clinical Epidemiology
- Department of Epidemiology and Health Statistics, XiangYa School of Public Health, Central South University, Changsha, People’s Republic of China
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Rodriguez-Calienes A, Borjas-Calderón NF, Vivanco-Suarez J, Zila-Velasque JP, Chavez-Malpartida SS, Terry F, Grados-Espinoza P, Saal-Zapata G. Endovascular Treatment and Microsurgical Clipping for the Management of Paraclinoid Intracranial Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 178:e489-e509. [PMID: 37516140 DOI: 10.1016/j.wneu.2023.07.108] [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: 06/15/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVE We aimed to compare the efficacy and safety of microsurgical clipping versus endovascular treatment (EVT) for paraclinoid aneurysms. METHODS A systematic search for studies including patients with paraclinoid aneurysms treated with a microsurgical or endovascular technique was conducted in 6 databases from inception to February 2022. Efficacy outcomes included complete angiographic occlusion at last follow-up, favorable functional outcome, and recurrence of the aneurysm. For safety, we assessed a composite of intraoperative and postoperative complications. Data were pooled using a random-effects model. RESULTS A total of 95 studies including 6711 patients, 3029 in the surgical group and 3682 in the EVT group were found. Pooled rates of complete occlusion were 94% (95% CI 91%-96%; I2 = 0%) in the surgical group and 69% (95% CI 63%-74%; I2 = 79%) in the EVT group, respectively. The favorable functional outcome rate was 86% (95% CI 76%-92%; I2 = 72%) with surgical treatment and 95% (95% CI 92%-97%; I2 = 61%) with EVT. The rate of aneurysm recurrence with surgical treatment was 1% (95% CI 0%-4%; I2 = 0%) and 12% (95% CI 9%-16%; I2 = 57%) with EVT. The composite safety outcome rate in the surgical group was 24% (95% CI 18%-30%; I2 = 90%) and 10% (95% CI 8%-13%; I2 = 71%) in the EVT group. CONCLUSIONS Our findings suggest that microsurgical clipping seems to have a higher efficacy than EVT in terms of angiographic occlusion and aneurysm recurrence; however, EVT seems to be safer in terms of intraoperative and postoperative complications. Considering the heterogeneity and low-level evidence of the data available, further prospective randomized studies are warranted to confirm our findings.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA; Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru.
| | - Nagheli Fernanda Borjas-Calderón
- Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru; Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru; Abdulrauf University of Neurosurgery, Simi Valley, California, USA
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - J Pierre Zila-Velasque
- Universidad Nacional Daniel Alcides Carrión, Facultad de Medicina Humana, Pasco, Peru; Red Latinoamericana de Medicina en la Altitud e Investigación (REDLAMAI), Pasco, Peru
| | - Sandra S Chavez-Malpartida
- Universidad Nacional Mayor de San Marcos, Lima, Peru; Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
| | - Fernando Terry
- Department of Neurosurgery, Clínica Internacional, Lima, Peru
| | - Pamela Grados-Espinoza
- Universidad Nacional Daniel Alcides Carrión, Facultad de Medicina Humana, Pasco, Peru; Red Latinoamericana de Medicina en la Altitud e Investigación (REDLAMAI), Pasco, Peru
| | - Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, Lima, Peru; Departament of Neurosurgery, Clinica Angloamericana, Lima, Peru
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Kaiser DPO, Cuberi A, Linn J, Gawlitza M. Flow diversion for compressive unruptured internal carotid artery aneurysms with neuro-ophthalmological symptoms: a systematic review and meta-analysis. J Neurointerv Surg 2023; 15:892-897. [PMID: 35918130 PMCID: PMC10447391 DOI: 10.1136/jnis-2022-019249] [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: 06/08/2022] [Accepted: 07/20/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Data on the safety and efficacy of flow diverters (FD) for the treatment of unruptured internal carotid artery (ICA) aneurysms with compressive neuro-ophthalmological symptoms (NOS) are scarce and comprise mainly small case series. METHODS We performed a search of three databases and included series with ≥10 patients, with unruptured aneurysms of the ICA and NOS, treated with FD. Random-effects analysis of treatment results and safety was performed. RESULTS A total of 22 studies reporting on 594 patients were included. Pooled proportions of NOS recovery, improvement, transient and permanent worsening were: 47.4% (95% CI 35.0% to 60.1%); 74.5% (95% CI 67.9% to 80.2%); 7.1% (95% CI 3.3% to 14.7%); and 4.9% (95% CI 3.2% to 7.4%), respectively. Rates of complete recovery and improvement in patients with isolated visual symptoms were 30.6% (95% CI 12.5% to 57.7%) and 56.6% (95% CI 42.3% to 69.9%). Isolated oculomotor symptoms recovered completely in 47.8% (95% CI 29.9% to 66.3%) and improved in 78% (95% CI 69.2% to 84.9%). Morbidity occurred in 5% (95% CI 2.8% to 9%) and mortality in 3.9% (95% CI 2% to 7.5%) of patients. An increased likelihood of symptom improvement was observed when treatment was performed early (<1 month) after symptom onset (OR=11.22, 95% CI 3.9% to 32.5%). CONCLUSION Flow diversion promotes recovery or improvement of compressive symptoms in a large proportion of patients but is associated with significant rates of morbidity and mortality. Transient and permanent NOS worsening is not uncommon. Early treatment is of utmost importance, as it increases the likelihood of symptom improvement more than 10-fold.
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Affiliation(s)
- Daniel P O Kaiser
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
- EKFZ for Digital Health, Dresden University of Technology, Dresden, Germany
| | - Ani Cuberi
- Department of Radiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jennifer Linn
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Matthias Gawlitza
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
- EKFZ for Digital Health, Dresden University of Technology, Dresden, Germany
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8
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Luzzi S, Giotta Lucifero A, Baldoncini M, Campero A, Galzio R, Lawton MT. Optic Foraminotomy versus Anterior Clinoidectomy for Small Superior-Projecting Paraclinoid Aneurysms: Visual and Angiographic Outcome Evaluation. World Neurosurg 2023; 170:e612-e621. [PMID: 36410704 DOI: 10.1016/j.wneu.2022.11.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/17/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Optic foraminotomy (OF) has been recently proposed as an alternative to anterior clinoidectomy (AC) for selected types of paraclinoid aneurysms. In this study, OF and AC were compared for small superior-projecting paraclinoid aneurysms assuming visual and angiographic results as outcome measures. Indications for OF are also discussed. METHODS Data of patients who underwent surgery for a paraclinoid aneurysm in the last 10 years were collected across 3 tertiary hospitals. Small to regular-size and superior projecting aneurysms were sorted. Multiple and complex aneurysms were excluded. Records of patients who went through OF were compared with those of patients who underwent AC. Neurologic outcome was reported as a modified Rankin Scale. Aneurysm complete occlusion rate and rate of approach-related worsened vision were selected as outcome measures of efficacy and safety, respectively, of the OF versus AC. Unpaired t test and χ2 test were used for numerical and categorical variables, respectively. A P value less than 0.05 was considered statistically significant. RESULTS OF and AC groups involved 18 and 25 patients, respectively. Complication rate, overall neurologic outcome, rate of approach-related worsened vision, and complete occlusion rate did not differ between the groups. The average follow-up was 51 ± 34 and 60 ± 41 months in the OF and AC groups, respectively. CONCLUSIONS Compared to AC, OF did not show either a higher rate of approach-related worsened vision or a lower aneurysm complete occlusion rate. OF can be considered a valid alternative to the AC for small superior-projecting dorsal ICA wall paraclinoid aneurysms.
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Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Matias Baldoncini
- Department of Neurological Surgery, San Fernando Hospital, Buenos Aires, Argentina; Laboratory of Microsurgical Neuroanatomy, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Alvaro Campero
- Department of Neurological Surgery, Padilla Hospital, Tucumán, Argentina
| | - Renato Galzio
- Neurosurgery Unit, Maria Cecilia Hospital, Cotignola, Italy
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Ökçesiz İ, Dönmez H, Polat OA, Alpşahin M, Sönmez HK, Temizyürek Ö. Effect on ophthalmic imaging findings of flow-diverting stent treatment covering the origin of the ophthalmic artery. Photodiagnosis Photodyn Ther 2022; 41:103247. [PMID: 36539005 DOI: 10.1016/j.pdpdt.2022.103247] [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: 11/16/2022] [Revised: 12/12/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Flow-diverting stents are devices that are increasingly used in the treatment of intracranial aneurysms and expand the spectrum of endovascular treatment. The patency of side branches and perforators is a major concern about flow-diverting stent (FDS) treatment. METHODS From 2011 to 2020, seventy-eight patients in whom the orifice of the ophthalmic artery was covered during FDS treatment were evaluated in this study. Bilateral retinal vascular parameters of study subjects were evaluated with OCT and OCTA. The FDS implanted-side eyes of the patients were defined as the procedure group, and the fellow eyes were considered as the control group. RESULTS Twenty-seven patients who were treated with FDS covering the ostium of the ophthalmic artery and who could undergo full ophthalmologic examination were included in the study. There was no statistically significant difference found in terms of visual acuity, retinal vascular parameters, and choroidal thickness between the procedure group and the control group (p>0.05). However, in one case, recanalized retinal artery branch occlusion was detected on the side where the FDS was implanted. CONCLUSION The orifice of the ophthalmic artery is often covered during FDS treatment for carotid-ophthalmic aneurysms; however, this treatment approach has no significant effect on ophthalmic vascular parameters.
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Affiliation(s)
- İzzet Ökçesiz
- Department of Radiology, Erciyes University School of Medicine, Kayseri, Turkiye.
| | - Halil Dönmez
- Department of Radiology, Erciyes University School of Medicine, Kayseri, Turkiye
| | - Osman Ahmet Polat
- Department of Ophthalmology, Erciyes University School of Medicine, Kayseri, Turkiye
| | - Mehmet Alpşahin
- Department of Radiology, Erciyes University School of Medicine, Kayseri, Turkiye
| | | | - Özge Temizyürek
- Department of Ophthalmology, Erciyes University School of Medicine, Kayseri, Turkiye
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10
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Biberoğlu Çelik E, Haidar H, Eraslan M, Baltacioglu F. Choroidal and retinal anatomical response following treatment of carotid-ophthalmic aneurysms with flow diverter stents. Photodiagnosis Photodyn Ther 2022; 40:103117. [PMID: 36109002 DOI: 10.1016/j.pdpdt.2022.103117] [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: 06/04/2022] [Revised: 08/15/2022] [Accepted: 09/09/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Flow diverter stents(FDSs) are recent additions to the endovascular armament for treating ophthalmic segment aneurysms(OSA). In our study we evaluated the long-term effect of FDS placement on multiple Optical Coherence Tomography(OCT) findings, best corrected visual acuity(BCVA) and intra-ocular pressure(IOP). METHODS A prospective cohort study was conducted in 35 patients treated with a single FDS placement for OSA, between 2013 and 2018. Spectral-domain OCT was used to measure retinal nerve fiber layer thickness, ganglion cell complex thickness, subfoveal choroidal thickness(SFCT), and other stereometric parameters. Choroidal Vascularity Index(CVI) in a 1.5 mm wide subfoveal choroidal area was calculated. BCVA and IOP were also assessed. These measurements, at final follow up, were compared to the untreated fellow eye to evaluate the long-term effect of FDS placement. RESULTS This study included 70 eyes from 35 patients (100% female) with a mean age of 54.9 ± 9.8 years and mean follow-up period of 37.3 ± 18.9 months. No ophthalmic artery occlusion was encountered. The mean CVI was significantly higher in the stented side compared to the fellow normal eye (66.90±1.95 vs 65.05±1.93, p=.001) while mean SFCT was significantly reduced (251.23±68.54 vs 288.78±78.95, p=.037). Differences in the remaining studied parameters did not reach statistical significance. The difference in BCVA between stented and fellow normal eyes was also not significant (0.057±0.213 vs 0.060±0.214, p=.977 in logMAR). CONCLUSION Treatment with FDSs did not cause permanent visual damage. This study is the first to report a decrease in SFCT with a compensatory increase in CVI following FDS placement for OSA.
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Affiliation(s)
- Esra Biberoğlu Çelik
- Department of Ophthalmology, Marmara University Pendik Educational and Research Hospital, Istanbul, Turkey
| | - Hassan Haidar
- School of Medicine, Marmara University, Istanbul, Turkey
| | - Muhsin Eraslan
- Department of Ophthalmology, School of Medicine, Marmara University, Istanbul, Turkey.
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11
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Wang Y, Yu J. Endovascular treatment of aneurysms of the paraophthalmic segment of the internal carotid artery: Current status. Front Neurol 2022; 13:913704. [PMID: 36188411 PMCID: PMC9523143 DOI: 10.3389/fneur.2022.913704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
The paraophthalmic segment of the internal carotid artery (ICA) originates from the distal border of the cavernous ICA and terminates at the posterior communicating artery. Aneurysms arising from the paraophthalmic segment represent ~5–10% of intradural aneurysms. Due to the advent of endovascular treatment (EVT) techniques, specifically flow-diverting stents (FDSs), EVT has become a good option for these aneurysms. A literature review on EVT for paraophthalmic segment aneurysms is necessary. In this review, we discuss the anatomy of the paraophthalmic segment, classification of the paraophthalmic segment aneurysms, EVT principle and techniques, and prognosis and complications. EVT techniques for paraophthalmic segment aneurysms include coil embolization, FDSs, covered stents, and Woven EndoBridge devices. Currently, coiling embolization remains the best choice for ruptured paraophthalmic segment aneurysms, especially to avoid long-term antiplatelet therapy for young patients. Due to the excessive use of antiplatelet therapy, unruptured paraophthalmic segment aneurysms that are easy to coil should not be treated with FDS. FDS is appropriate for uncoilable or failed aneurysms. Other devices cannot act as the primary choice but can be useful auxiliary tools. Both coiling embolization and FDS deployment can result in a good prognosis for paraophthalmic segment aneurysms. The overall complication rate is low. Therefore, EVT offers promising treatments for paraophthalmic segment aneurysms. In addition, surgical clipping continues to be a good choice for paraophthalmic segment aneurysms in the endovascular era.
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12
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Zhou HJ, Wang XY, Zhan RY, Zheng JS, Yu JB, Zheng XJ. Clipping Ophthalmic Segment Artery Aneurysms Using a Modified Subdural Dolenc Approach: Classification and Experience Sharing. Oper Neurosurg (Hagerstown) 2022; 23:154-163. [PMID: 35838455 DOI: 10.1227/ons.0000000000000262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/03/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Ophthalmic segment artery aneurysms (OSAs) are difficult to clip; therefore, improvement of the surgical method is of great significance to the prevention of complications, and the classification of the aneurysms is essential to formulate a reasonable surgical plan. OBJECTIVE To explore the strategies and effects of surgery for OSAs using a modified subdural Dolenc approach. METHODS The clinical data of 38 patients (12 men and 26 women, aged 48-73 years) with OSA were analyzed retrospectively. A total of 44 aneurysms were identified, 40 of which were OSAs. The 40 aneurysms were divided into types Ia1 (n = 2), Ia2 (n = 2), Ib (n = 6), IIa (n = 4), IIb (n = 4), IIIa (n = 0), IIIb (n = 4), IIIc (n = 16), and IV (n = 2) based on preoperative images. Thirty-nine OSAs were operated successfully through pterional craniotomy combined with the modified subdural Dolenc approach, and 1 aneurysm was clipped through the contralateral approach. Clinical outcomes were evaluated using the Glasgow Outcome Scale (GOS). RESULTS Thirty-nine OSAs were clipped, and one was wrapped. Visual dysfunction, headache, and dizziness improved after the operation in 18 patients. One patient had new visual impairment, and there were no deaths. At discharge, the GOS score was 5 in 36 cases, 4 in 1 case, and 3 in 1 case. Thirty-seven patients had a GOS score of 5, and 1 patient had a score of 3 at 6 months after the operation. CONCLUSION The modified subdural Dolenc approach (Zheng approach) for clipping OSAs may be associated with less trauma and good postoperative outcomes.
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Affiliation(s)
- Heng-Jun Zhou
- Department of Neurosurgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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13
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Xu C, Wu P, Sun B, Xu S, Luo B, Yang X, Shi H. Incomplete occlusion and visual symptoms of peri-ophthalmic aneurysm after treatment with a pipeline embolization device: a multi-center cohort study. Acta Neurochir (Wien) 2022; 164:2191-2202. [PMID: 35554695 DOI: 10.1007/s00701-022-05239-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 05/05/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Peri-ophthalmic aneurysm is a special type of aneurysm. We assessed the relationship between ophthalmic artery (OA) origin and aneurysm and examined the effect of a pipeline embolization device (PED, Covidien/Medtronic) with or without coils on aneurysm occlusion rate and visual outcomes. METHODS We retrospectively analyzed 194 peri-ophthalmic aneurysms in 189 patients among 1171 patients treated with a PED in a Chinese post-market multi-center registry study from November 2014 to October 2019. Peri-ophthalmic aneurysms were defined as carotid-ophthalmic segment aneurysms arising from the internal carotid artery dorsal wall at, or distal to, the OA origin, with a superior or superomedial projection. The relationship between OA origin and the aneurysm was classified as follows: type A, OA originating separate from the aneurysm; type B, OA originating from the aneurysm neck or dome. Patients with aneurysm were divided into the PED-only group and the PED + coils group according to treatment. RESULTS The median follow-up time was 6.8 months (range, 5.3-20.2 months). There were 163 occluded aneurysms (84%) and 31 aneurysms with incomplete occlusion (16%). A multivariate analysis showed that type B aneurysm was a risk factor for incomplete occlusion in the PED-only group (odds ratio [OR] 4.854, 95% confidence interval [CI] 1.878-12.548, P = 0.001). Visual symptoms at final follow-up correlated with preoperative visual symptoms (OR 22.777, 95% CI 3.115-166.555, P = 0.002). CONCLUSIONS Type B aneurysm is associated with a lower occlusion rate after PED-only treatment. Patients with preoperative visual symptoms should be treated promptly to avoid permanent visual symptoms.
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Paraclinoid aneurysms: Outcome analysis and technical remarks of a microsurgical series. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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15
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Costa M, Baldoncini M, Tataryn ZL, Demichelis ME, Conde A, Purves C, Giotta Lucifero A, Hernesniemi J, Luzzi S. Microsurgical Clipping of Carotid-Ophthalmic Tandem Aneurysms: Case Report and Surgical Nuances. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:731. [PMID: 34357012 PMCID: PMC8305784 DOI: 10.3390/medicina57070731] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 01/02/2023]
Abstract
Tandem intracranial aneurysms (TandIAs) are rare but inherently complex, and special technical considerations are required for their surgical management. The present case highlights the key surgical aspects of two carotid-ophthalmic TandIAs incidentally found in a 60-year-old female. Both the aneurysms were superiorly projecting, regular in size, and involved the left ophthalmic segment of the internal carotid artery (ICA). The minimum distance between the necks was 3 mm. The patient underwent microsurgery because of the reported major complications rate of the endovascular treatment in the case of a very short minimum distance between the TandIAs. After cervical ICA exposure, both the aneurysms were excluded through a pterional approach. Intradural anterior clinoidectomy and unroofing of the optic canal allowed the mobilization of the left optic nerve. The more distal aneurysm was clipped before the opening of the distal dural ring of the ICA. The proximal aneurysm was clipped with two straight clips stacked perpendicular to the ICA. A small remnant was intentionally left to avoid the stenosis of the ophthalmic artery. Postoperative angiography showed the exclusion of both the aneurysms with a small dog-ear of the more proximal one. The patient was discharged neurologically intact and, after one year, the remnant remained stable. Microsurgical clipping is a definitive and durable treatment for carotid-ophthalmic TandIAs. In the case of a very short minimum distance between the aneurysms, the distal one should be clipped first to make the anterior clinoidectomy, opening of the distal dural ring of the ICA, and clipping of the more proximal aneurysm easier.
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Affiliation(s)
- Matias Costa
- Cerebrovascular Neurosurgery Department, Swedish Neuroscience Institute, Seattle, WA 98122, USA;
| | - Matías Baldoncini
- Department of Neurological Surgery, Hospital San Fernando, Buenos Aires 1646, Argentina; (M.B.); (M.E.D.); (A.C.)
| | - Zachary L. Tataryn
- Spine Department, Swedish Neuroscience Institute, Seattle, WA 98122, USA;
| | | | - Agustin Conde
- Department of Neurological Surgery, Hospital San Fernando, Buenos Aires 1646, Argentina; (M.B.); (M.E.D.); (A.C.)
| | - Cynthia Purves
- Division of Interventional Neuroradiology, Juan A. Fernandez Hospital and Güemes Clinic, Buenos Aires C1425 CABA, Argentina;
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
| | - Juha Hernesniemi
- Juha Hernesniemi International Center for Neurosurgery, Henan Provincial People’s Hospital, Zhengzhou 450003, China;
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
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Hidayat R, Asmaniar F, Priambodo A, Mesiano T, Kurniawan M, Rasyid A, Harris S. Endovascular treatment of an unruptured ophthalmic artery aneurysm with a flow diverter: a case report. MEDICAL JOURNAL OF INDONESIA 2021. [DOI: 10.13181/mji.cr.204899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
An unruptured aneurysm is often asymptomatic or present without neurological deficits, causing severe morbidity. However, the potential of this defect to rupture requires proper management. Herein, we report a case of an unruptured saccular aneurysm of the ophthalmic artery with initial clinical seizures. The patient was treated by flow diversion which redirects the blood flow that normally leads to the protrusion of the aneurysm back to the main vessel. Flow diversion is chosen because it is less risky and has a faster recovery time than other treatment options, but it is more expensive than others. Although this technology is not new, there is no report on its implementation in Indonesia. The patient was prescribed antiplatelet treatment for at least 6 months post-treatment, then she showed no sign of seizure or new focal neurological deficits 4 months post-treatment. The patients were expected to undergo digital subtraction angiography evaluation 6 months after flow diversion treatment, but it has not been performed due to the coronavirus disease 2019 pandemic.
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17
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Flow-diverting devices in the treatment of unruptured ophthalmic segment aneurysms at a mean clinical follow-up of 5 years. Sci Rep 2021; 11:9206. [PMID: 33911105 PMCID: PMC8080650 DOI: 10.1038/s41598-021-87498-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 03/31/2021] [Indexed: 12/19/2022] Open
Abstract
A shift toward the endovascular treatment of ophthalmic segment aneurysms is noticeable. However, it is not clear if the long-term treatment results improve with the development of endovascular methods. The aim of this study was to present the outcomes of the treatment of unruptured ophthalmic aneurysms using flow diverting devices (FDD) with or without coiling. This retrospective study included 52 patients with 65 UIAs treated in 2009–2016. The mean aneurysm size was 8.8 mm. Eight aneurysms were symptomatic. Therapeutic procedures included: 5 failed attempts, 55 first sessions with FDD deployment (bilateral procedures in 3) and 3 retreatment procedures. To cover 55 ICAs, 25 Silk, 26 Pipeline, 9 Fred and 1 Surpass FDD were used. FDD with coiling was applied in 19(29.2%), mainly for symptomatic and larger aneurysms. Mean radiological and clinical follow-up was 12 and 61 months, respectively. Postprocedural deterioration was noted in 3(5.8%) patients, but in long-term the modified Rankin Scale grades 0–2 were achieved in 98.1% of patients. One patient died from the treated aneurysm rupture (annual risk—0.07%). Raymond–Roy occlusion classification class I or II was achieved in 98.5% in the long term, with similar results in both groups. Complications occurred in 40.4% of patients and the most frequent were: imperfect FDD deployment (15%), failed attempt of FDD deployment (9.6%) and late FDD stenosis (9.6%). Flow-diverting devices, with additional coiling in selected cases, may offer a very high proportion of satisfactory outcomes. However, in our experience the high risk of complications remains.
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18
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Kamide T, Burkhardt JK, Tabani H, Safaee M, Lawton MT. Microsurgical Clipping Techniques and Outcomes for Paraclinoid Internal Carotid Artery Aneurysms. Oper Neurosurg (Hagerstown) 2021; 18:183-192. [PMID: 31515556 DOI: 10.1093/ons/opz157] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 01/21/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Microsurgical clipping of paraclinoid aneurysms presents unique technical challenges because of the anatomical complexity of the paraclinoid region. OBJECTIVE To analyze microsurgical clipping techniques, complications, and outcomes associated with paraclinoid aneurysms, with a focus on clip selection and clipping technique according to aneurysm location. METHODS From 1997 to 2016, 231 unruptured paraclinoid aneurysms from 216 patients were treated using microsurgical clipping. We retrospectively reviewed patient records to analyze clinical outcomes. RESULTS A total of 80 aneurysms (34.6%) were treated with simple clipping. Among them, fenestrated clips were used with superior hypophyseal artery (SHA) aneurysms, but curved clips were used with most other aneurysms. A total of 151 aneurysms (65.6%) were treated using multiple clips, including tandem clipping for ophthalmic artery (OphA) aneurysms, tandem angled-fenestrated clipping for SHA and ventral carotid aneurysms, stacked clipping for dorsal carotid aneurysms, and various techniques for clinoidal segment/carotid cave aneurysms. Postoperative angiography was performed in 214 aneurysms (92.6%), and complete obliteration was confirmed in 195 aneurysms (91.1%). Using the modified Rankin Scale (mRS), overall functional outcome was good (mRS 0-2) in 99.6% of patients, although 30 cases (13.0%) showed new postoperative visual deficits. CONCLUSION Surgical clipping of paraclinoid aneurysms is an excellent treatment modality with good clinical outcomes and acceptable complication rates, particularly in centers with large experience in the microsurgical management of cerebrovascular disorders. Appropriate clip selection and clipping techniques are required to perform complete and safe clipping.
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Affiliation(s)
- Tomoya Kamide
- Department of Neurological Surgery, University of California, San Francisco, California.,Department of Neurosurgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Halima Tabani
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael Safaee
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, California.,Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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19
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Sugiyama N, Fujii T, Yatomi K, Teranishi K, Oishi H, Arai H. Endovascular Treatment for Lateral Wall Paraclinoid Aneurysms and the Influence of Internal Carotid Artery Angle. Neurol Med Chir (Tokyo) 2021; 61:275-283. [PMID: 33716235 PMCID: PMC8048120 DOI: 10.2176/nmc.oa.2020-0307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Lateral wall paraclinoid aneurysms (LPA) are a rare type of aneurysm located on the lesser curve side of the internal carotid artery (ICA) bend, at the level of the anterior clinoid process. The objective of this study was to assess the influence of flexion of the ICA on the morphology of aneurysms and outcome of endovascular treatment. Between 2003 and 2018, we treated 643 cases of unruptured paraclinoid aneurysms with endovascular therapy in our institution. Of those cases, aneurysms projecting laterally on preoperative angiography were defined as LPA. The degree of bending of the ICA (ICA angle) was measured and statistically analyzed in relation to the aneurysm characteristics and the occlusion status after treatment. In all, 43 aneurysms were identified. ICA angle was positively correlated with the maximum dome size of the aneurysm (P <0.01) and the aspect ratio (P <0.01), and negatively correlated with the volume coil embolization ratio (P <0.01). Complete occlusion (CO) was achieved in 23 cases (53.5%) immediately after treatment, and in 35 cases (81.4%) at follow-up. The mean ICA angle in the incomplete occlusion group was significantly larger than in the CO group (P = 0.01). Larger ICA angle resulted in recurrence, whereas smaller ICA angle was more likely to obtain progressive thrombosis (P = 0.02). Endovascular treatment for LPA was safe and effective. The degree of flexion of the ICA may contribute to the level of hemodynamic stress on the aneurysm, its morphology, and the embolization effect.
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Affiliation(s)
- Natsuki Sugiyama
- Department of Neurosurgery, Juntendo University Faculty of Medicine
| | - Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University Faculty of Medicine
| | - Kosuke Teranishi
- Department of Neurosurgery, Juntendo University Faculty of Medicine
| | - Hidenori Oishi
- Department of Neurosurgery, Juntendo University Faculty of Medicine.,Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University Faculty of Medicine
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20
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Ni H, Zhao LB, Liu S, Jia ZY, Cao YZ, Shi HB. Open-cell stent-assisted coiling for the treatment of paraclinoid aneurysms: traditional endovascular treatment is still not out of date. Neuroradiology 2021; 63:1521-1530. [PMID: 33630124 DOI: 10.1007/s00234-021-02679-x] [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] [Received: 12/04/2020] [Accepted: 02/18/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Before we enter the era of flow diverter stents (FDS), the standard stent-assisted coiling technique is a well-established treatment option for routine paraclinoid aneurysms. We assess the clinical safety and efficacy of stent-assisted coiling with open-cell stent in the treatment of paraclinoid aneurysms and evaluate the association between clinical factors and follow-up aneurysm occlusion. METHODS The clinical and radiographic data of 110 consecutive patients with 122 paraclinoid aneurysms treated with open-cell stent between April 2015 and April 2019 were analyzed retrospectively at our center. We assessed the immediate and progressive occlusion rates, complications, and clinical outcome. Multivariate analysis was performed to investigate the risk factors of angiographic incomplete occlusion. RESULTS Among 110 patients, stent-assisted coiling was successfully performed in all cases. Four (3.6%) thromboembolic events were reported during the procedure, which resulted in transient morbidity. Immediate angiography demonstrated complete occlusion in 64 (52.5%) aneurysms and no occlusion of ophthalmic artery. Angiographic follow-up at 6 months demonstrated an increase in the complete occlusion rate to 92.9%. No delayed in-stent stenosis was observed, and three aneurysms recurred. Clinical follow-up was completed in 102 patients (92.7%), and favorable outcomes were achieved in 101 (99%) patients at 6 months. Multivariate analysis showed that aneurysm size (p < 0.001) was associated with incomplete aneurysm occlusion at follow-up. CONCLUSION Stent-assisted coil embolization with open-cell stents is safe and effective for the treatment of paraclinoid aneurysms and provides progressive occlusion without significant in-stent stenosis events.
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Affiliation(s)
- Heng Ni
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Zhen-Yu Jia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Yue-Zhou Cao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China.
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21
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Michishita S, Ishibashi T, Yuki I, Urashima M, Karagiozov K, Kodama T, Kan I, Nishimura K, Kato N, Ikemura A, Murayama Y. Visual complications after coil embolization of internal carotid artery aneurysms at the ophthalmic segment. Interv Neuroradiol 2021; 27:622-630. [PMID: 33615875 DOI: 10.1177/1591019921996886] [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: 01/10/2023] Open
Abstract
BACKGROUND Coil embolization of aneurysms of the ophthalmic segment of the internal carotid artery (ICA-OphA ANs) has potential risks of visual complications. We analyzed this risk and focused on the relationship of the ophthalmic artery (OphA) origin with the aneurysm neck. METHODS From January 2003 to April 2018, 179 unruptured ICA-OphA ANs were treated with endovascular surgery in our institution. Two ruptured and four aneurysms with missing data were excluded. Finally, 173 unruptured aneurysms were included in this study. The aneurysms were classified into three groups according to the location of the OphA origin: Separate, Shared, and Dome type. We retrospectively assessed visual complications based on the relationship between types of aneurysm and postoperative angiographic findings for the OphA. RESULTS Visual deficits remained permanent in eleven cases (6.4%). In the Dome type, visual complications were significantly more frequent compared to the Separate type. Change in the OphA flow was significantly associated with a higher complication rate of 2.9%, but patients with changed OphA flow had a significant rate of 7.5% (p = 0.020). We found no significant difference in the incidence of visual complications concerning the use of perioperative antithrombotic therapy. CONCLUSIONS The location of OphA origin regarding the aneurysmal neck and postoperative OphA flow were significantly correlated with the visual outcome after coil embolization for ICA-OphA ANs. Post-procedural flow in the OphA was an important factor affecting the rate of ischemic retinal complications. Retinal embolic events occurred with preserved flow in the OphA, albeit at a lower rate.
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Affiliation(s)
- Shotaro Michishita
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toshihiro Ishibashi
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Ichiro Yuki
- Department of Neurological Surgery, University of California Irvine, Irvine, CA, USA
| | - Mitsuyoshi Urashima
- Department of Innovation for Medical Information, The Jikei University School of Medicine, Tokyo, Japan
| | - Kostadin Karagiozov
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Tomonobu Kodama
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Issei Kan
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kengo Nishimura
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoki Kato
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Ayako Ikemura
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
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22
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HOSOO H, TSURUTA W, DOFUKU S, HARA T, ISHIKAWA E, MATSUMARU Y. Delayed Occlusion of the Anterior Choroidal Artery Following Flow Diverter Stent Deployment for Unruptured Aneurysm: A Case Report and Literature Review. NMC Case Rep J 2021; 8:167-175. [PMID: 35079459 PMCID: PMC8769386 DOI: 10.2176/nmccrj.cr.2020-0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/16/2020] [Indexed: 11/20/2022] Open
Abstract
Flow diverter stent has been a promising device for intracranial aneurysm treatment. For treating aneurysms located in the anterior circulation, critical branches may be covered by flow diverter stent. The occlusion incidence of these branches has been reported, and even if branch vessel occlusions occur, associated neurological deficits are extremely rare. We present a 55-year-old woman who had a large saccular aneurysm at the right internal carotid artery (ICA). A developed fetal-type posterior communicating artery (PCOM) originated from the sac. We administered flow diverter stent deployment with coil insertion following surgical anastomosis of the superficial temporal artery to the posterior cerebral artery (STA-PCA) with ligation of the origin of the PCOM. On the seventh morning following the intervention, ischemic complication developed due to anterior choroidal artery occlusion jailed by the flow diverter stent. The occlusion of anterior choroidal artery covered by flow diverter stent is extremely rare. However, if the branch arises from the aneurysm sac, occlusion can transpire and induce serious complication. The most probable cause of occlusion in this case was that the orifice was jailed apart from the stent strut because the branch originated from the sac rather than the neck. Furthermore, the progression rate of intra-aneurysm thrombus formation is also an important factor affecting the side branch occlusion.
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Affiliation(s)
- Hisayuki HOSOO
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Wataro TSURUTA
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Shogo DOFUKU
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Takayuki HARA
- Department of Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Eiichi ISHIKAWA
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yuji MATSUMARU
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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23
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Muram S, Eesa M, Belanger BL, Almekhlafi M, Goyal M, Morrish W, Wong JH, Gomez-Paz S, Akamatsu Y, Salem MM, Robinson TM, Moore JM, Thomas AJ, Ogilvy CS, Mitha AP. A Novel Parameter to Predict Supraclinoid Aneurysm Persistence After Flow Diversion with the Pipeline Embolization Device. World Neurosurg 2020; 145:e216-e223. [PMID: 33065343 DOI: 10.1016/j.wneu.2020.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/01/2020] [Accepted: 10/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Aneurysm recurrence after Pipeline Embolization Device (PED) placement can be caused by oversizing of the stent as well as poor wall apposition, both of which can lead to elongation. The objective of this study was to assess whether a novel parameter for measuring device elongation based on two-dimensional imaging could be predictive for persistent aneurysm filling after treatment with the PED. METHODS A retrospective cohort analysis was initially completed on 41 aneurysms from institution A, examining demographic, aneurysmal, and device measurements. Device measurements, including the ratio of the measured length to the nominal length (ML/NL) of the PED, were taken by reviewers blinded to the primary end point, which was aneurysm occlusion status on 6 month catheter angiogram. Findings were then externally validated against 30 aneurysms (supraclinoid only) from institution B. RESULTS Data from institution A showed 61% complete aneurysm occlusion at 6 months, and were lower for aneurysms in the supraclinoid region. For supraclinoid aneurysms alone, combined data from both institutions showed higher rates of nonocclusion with aneurysm neck size >4 mm (P = 0.008) and a trend toward significance in aneurysms with a branch vessel (P = 0.051). The mean ML/NL ratio was significantly larger in the nonoccluded group compared with the occluded group at both institution A (ratio, 1.37 versus 1.10; P < 0.001) and institution B (ratio, 1.36 vs. 1.11; P = 0.002). CONCLUSIONS Our data suggest that a novel parameter based on two-dimensional angiography may serve as a rapid technique to measure device elongation and predict occlusion of supraclinoid aneurysms after PED placement.
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Affiliation(s)
- Sandeep Muram
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada; Department of Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Muneer Eesa
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Brooke L Belanger
- Department of Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - William Morrish
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - John H Wong
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada; Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Yosuke Akamatsu
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy M Robinson
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- 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
| | - Alim P Mitha
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada; Department of Radiology, University of Calgary, Calgary, Alberta, Canada; Department of Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.
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24
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Narata AP, Moura F, Larrabide I, Chapot R, Cognard C, Januel AC, Velasco S, Bouakaz A, Patat F, Marzo A. Role of distal cerebral vasculature in vessel constriction after aneurysm treatment with flow diverter stents. J Neurointerv Surg 2020; 12:818-826. [PMID: 31900352 DOI: 10.1136/neurintsurg-2019-015447] [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: 09/13/2019] [Revised: 12/04/2019] [Accepted: 12/04/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Treatment of intracranial aneurysms with flow diverter stent (FDS) procedures can lead to caliber changes of jailed vessels. The reason some branches remain unchanged and others are affected by narrowing remains unknown. OBJECTIVE To investigate the influence of resistance to flow from distal vasculature on stent-induced hemodynamic modifications affecting bifurcating vessels. MATERIALS AND METHODS Radiological images and demographic data were acquired for 142 aneurysms treated with a FDS. Vascular resistance was estimated from patient-specific anatomic data. Correlation analysis was used to identify correspondence between anatomic data and clinical outcome. Computational Fluid Dynamics was performed on a typical patient-specific model to evaluate the influence of FDS on flow. Relevant hemodynamic variables along the bifurcating vessels were quantitatively analyzed and validated with in vitro data obtained using power Doppler ultrasound. RESULTS Statistical analysis showed a correlation between clinical outcome and FDS resistance to flow considering overall jailed vessel vascular resistance (r=0.5, P<0.001). Computational predictions of blood flow showed that hemodynamics is minimally affected by FDS treatment in the ophthalmic artery. CONCLUSIONS Jailed vessels are affected by narrowing when resistance to flow from the FDS constitutes a larger proportion of the overall vessel resistance to flow. This knowledge may contribute to better understanding of intracranial hemodynamics after a FDS procedure and reinforce indications for flow diversion in the treatment of intracranial aneurysms.
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Affiliation(s)
- Ana Paula Narata
- Department of Neuroradiology, University Hospital of Tours, Tours, France
| | - Fernando Moura
- Federal University of the ABC Engineering Modeling and Applied Social Sciences Center Sao Bernardo do Campo, Sao Bernardo do Campo, Brazil
| | - Ignacio Larrabide
- PLADEMA-CONICET, Universidad Nacional del Centro de la Provincia de Buenos Aires, Tandil, Argentina
| | - René Chapot
- Department of Neurointerventional Therapy, Krupp Krankenhaus, Germany, Essen, Germany
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Purpan, Toulouse, France
| | | | - Stéphane Velasco
- Department of Radiology, CHU de Poitiers, Poitiers, Vienne, France
| | - Ayache Bouakaz
- Department of Neuroradiology, University Hospital of Tours, Tours, France
| | - Frederic Patat
- Department of Neuroradiology, University Hospital of Tours, Tours, France
| | - Alberto Marzo
- Department of Mechanical Engineering, Insigneo Institute for in silico medicine, The University of Sheffield, Sheffield, UK
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25
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Ting W, Richard SA, Changwei Z, Chaohua W, Xiaodong X. Delayed spontaneous rupture of cavernous segment of the internal carotid artery following dual ophthalmic segment aneurysms treatment with pipeline embolization device: A case report. Medicine (Baltimore) 2019; 98:e18420. [PMID: 31876716 PMCID: PMC6946193 DOI: 10.1097/md.0000000000018420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/31/2019] [Accepted: 11/14/2019] [Indexed: 11/29/2022] Open
Abstract
RATIONALE The incidence of double aneurysms on the ophthalmic segment of the internal carotid artery (ICA) is very rare. Nevertheless, delayed rupture of a parent artery instead of the aneurysmal sac following pipeline embolization device (PLED) is unusual. PATIENT CONCERNS We present a 72-year-old female who was admitted at our facility with gradual onset of nonspecific visual changes. DIAGNOSIS Conventional angiography revealed 2 aneurysms located at the ophthalmic segment of the left ICA. INTERVENTIONS Both aneurysms were successfully treated with PLED. OUTCOMES Two months after discharge, the patient was rushed into the emergency with bilateral conjunctival congestion. Computed tomography revealed intracranial hemorrhage at left temporal lobe while digital subtraction angiography established a left direct carotid cavernous fistula. We utilized stent (Solitaire 6*30) assisted coils to occlude the fistula. The patient is well and go about her normal duties. LESSIONS Manipulation of the tortuous parent artery resulted in a focal traumatic weakness in the artery and subsequently a delay tear. We are of the view that, endovascular surgeons should be on the lookout for this complication following flow deviation treatment modalities.
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Affiliation(s)
- Wang Ting
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P.R. China
- Department of Medicine, Princefield University, Ghana West Africa
| | - Zhang Changwei
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Wang Chaohua
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Xie Xiaodong
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P.R. China
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26
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Otani N, Mori K, Wada K, Tomiyama A, Toyooka T, Takeuchi S, Nakao Y, Yamamoto T, Arai H. Limited Indications for Clipping Surgery of Paraclinoid Aneurysm Based on Long-Term Visual Morbidity. World Neurosurg 2019; 134:e153-e161. [PMID: 31629143 DOI: 10.1016/j.wneu.2019.09.147] [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: 06/13/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Clipping of paraclinoid aneurysm is still challenging because of poor visual morbidity. The extradural temporopolar approach was applied to clip paraclinoid aneurysms, with the expectation of reducing visual morbidity. Factors related to poor visual morbidity were evaluated, to assess the results for clipping of paraclinoid aneurysms. METHODS A series of 40 unruptured paraclinoid aneurysms in 38 patients were clipped via extradural temporopolar approach. Preoperative and postoperative states of visual cognitive function and radiological outcomes were investigated. Aneurysms were classified into dorsal type or non-dorsal type, and small (<9 mm) or not-small (≥9 mm), respectively, to identify factors correlated with visual morbidity. RESULTS Complete clipping rate was 90.0% without any recurrence (mean: 5.2 years). Visual morbidity was unexpectedly high at 28.9%, including 2.7% of blindness immediately after the operation, and 23.7% and 2.7% at the final examination (mean: 3.6 years). Multivariate analysis showed aneurysm size was significantly correlated with worse visual outcome. Visual morbidity was 13.3% and 11.1% for dorsal and the non-dorsal small aneurysms, respectively, and all these cases showed visual field defect limited to the nasal quadrant without decreased visual acuity. In contrast, the non-dorsal not-small aneurysms showed significantly worse visual morbidity (60%) with decreased visual acuity. CONCLUSIONS Clipping via extradural temporopolar approach can achieve durable treatment for small unruptured paraclinoid aneurysms with acceptable visual morbidity. Visual morbidity of the not-small non-dorsal type, however, was poor. The indications for clipping of paraclinoid aneurysm should be limited to small aneurysms, especially the dorsal type in young patients.
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Affiliation(s)
- Naoki Otani
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan.
| | - Kentaro Mori
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan; Department of Neurosurgery, Tokyo General Hospital, Tokyo, Japan
| | - Kojiro Wada
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Arata Tomiyama
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Terushige Toyooka
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Satoru Takeuchi
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yasuaki Nakao
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University Hospital, Tokyo, Japan
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27
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Rubio RR, Gandhi S, Vigo V, Tabani H, Meybodi AT, Abla AA, Lawton MT, Benet A. An Anatomic Feasibility Study for Revascularization of the Ophthalmic Artery, Part I: Intracanalicular Segment. World Neurosurg 2019; 133:e893-e901. [PMID: 31541753 DOI: 10.1016/j.wneu.2019.08.260] [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: 06/18/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The anatomico-functional complexity of the ophthalmic segment aneurysms is attributable to the presence of critical neurovascular structures in the surgical field. Surgical clipping of the ophthalmic artery (OpA) aneurysms can result in postoperative visual deficit due to the complexity of the aneurysm, vasospasm, or optic nerve manipulation. In this study, we aimed to characterize the feasibility of an intracanalicular OpA (iOpA) revascularization with 2 donor vessels: an intracranial-intracranial (IC-IC) bypass using the anterior temporal artery (ATA) and an extracranial-intracranial (EC-IC) bypass using the superficial temporal artery (STA). We further discuss their potential role in "unclippable" OpA aneurysms. METHODS Twenty cadaveric specimens were used to evaluate the operative exposure of the intradural and intracanalicular OpA segments using an extradural-intradural intracanalicular approach. The arterial caliber and length at the anastomotic sites and required donor artery lengths were measured. The feasibility of the bypass using both donors was assessed. RESULTS The average length of the intradural and intracanalicular segment of the OpA was 9.5 ± 1.6 mm. The mean caliber of the iOpA was 1.5 ± 0.2 mm. The mean ATA length required for an ATA-OpA anastomosis was 26.7 ± 8.9 mm, with a mean caliber of 1.0 ± 0.1 mm. The mean length of STA required for the bypass was 89.9 ± 9.7 mm, with a mean caliber of 1.92 ± 0.4 mm. CONCLUSIONS This study confirms the feasibility of iOpA revascularization using IC-IC and EC-IC bypasses. These techniques could potentially be used for prophylactic or therapeutic neuroprotection from retinal ischemic injury while treating complex OpA aneurysms, infiltrative tumors, or intraoperative arterial injuries.
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Affiliation(s)
- Roberto Rodriguez Rubio
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA.
| | - Sirin Gandhi
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Vera Vigo
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Halima Tabani
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ali Tayebi Meybodi
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Arnau Benet
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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28
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Touzé R, Gravellier B, Rolla-Bigliani C, Touitou V, Shotar E, Lenck S, Boch AL, Degos V, Sourour NA, Clarençon F. Occlusion Rate and Visual Complications With Flow-Diverter Stent Placed Across the Ophthalmic Artery's Origin for Carotid-Ophthalmic Aneurysms: A Meta-Analysis. Neurosurgery 2019; 86:455-463. [DOI: 10.1093/neuros/nyz202] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 02/11/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Romain Touzé
- Interventional Neuroradiology Unit, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, Paris, France
| | - Bastien Gravellier
- Advanced Scientific Statistics Unit, University of Paris-Saclay, Paris, France
| | - Claudia Rolla-Bigliani
- Interventional Neuroradiology Unit, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Valérie Touitou
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne University of Paris 6, Paris, France
| | - Eimad Shotar
- Interventional Neuroradiology Unit, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne University of Paris 6, Paris, France
| | - Stéphanie Lenck
- Interventional Neuroradiology Unit, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Anne-Laure Boch
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Vincent Degos
- Department of Anesthesiology, Pitié-Salpêtrère Hospital, Paris, France
- Neuro-Intensive Care Unit, Pitié-Salpêtrière Hospital, Paris, France
| | - Nader-Antoine Sourour
- Interventional Neuroradiology Unit, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Frédéric Clarençon
- Interventional Neuroradiology Unit, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne University of Paris 6, Paris, France
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29
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Xin WQ, Xin QQ, Yuan Y, Chen S, Gao XL, Zhao Y, Zhang H, Li WK, Yang XY. Comparison of Flow Diversion and Coiling for the Treatment of Unruptured Intracranial Aneurysms. World Neurosurg 2019; 128:464-472. [PMID: 31132489 DOI: 10.1016/j.wneu.2019.05.149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/16/2019] [Accepted: 05/17/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND To systematically assess the efficacy and safety between flow diversion and coiling for patients with unruptured intracranial aneurysms. METHODS Potential academic articles were identified from Cochrane Library, Medline, PubMed, EMBASE, ScienceDirect, and other databases. The time range we retrieved from was the inception of electronic databases to February 2019. Gray studies were identified from the references of included literature reports. STATA version 11.0 was used to analyze the pooled data. RESULTS A total of 11 articles (10 retrospective studies and 1 prospective study) were involved in our study. The overall participants of the coiling group were 611, whereas 576 were in the flow diversion group. Our meta-analysis showed that flow diversion was preferable for unruptured intracranial aneurysms as its lower value of total cost per case (weighted mean difference, 5705.906; 95% confidence interval [CI], [4938.536, 6473236]; P < 0.001), fluoroscopy time per case (weighted mean difference, 25.786; 95% CI, 17.169-34.377; P < 0.001), and retreatment rates (odds ratio [OR], 7.127; 95% CI, [3.525, 14.410]; P < 0.001), at the same time, a higher rate of immediate completed occlusion (OR, 0.390; 95% CI, [0.224, 0.680]; P = 0.001) and follow-up completed occlusion (OR, 0.173; 95% CI, [0.080, 0.375]; P < 0.001) was demonstrated in the flow diversion group. There was no difference on intraoperative complication rates (P = 0.070), procedure-related mortality (P = 0.609) and rupture rates (P = 0.408), modified Rankin Scale (mRS) 0-2 at discharge (P = 0.077), and mRS 0-2 at follow-up (P = 0.484). CONCLUSIONS The use of flow diversion for the treatment of unruptured intracranial aneurysms may reduce total cost per case, fluoroscopy time per case, retreatment rates, and increases immediate completed occlusion and follow-up completed occlusion rates without affecting the results of mRS and intraoperative complication.
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Affiliation(s)
- Wen-Qiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Qi-Qiang Xin
- Department of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, People's Republic of China
| | - Yan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Shi Chen
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Xiang-Liang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Yan Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Hao Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Wen-Kui Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Xin-Yu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China.
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30
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Chua MMJ, Silveira L, Moore J, Pereira VM, Thomas AJ, Dmytriw AA. Flow diversion for treatment of intracranial aneurysms: Mechanism and implications. Ann Neurol 2019; 85:793-800. [PMID: 30973965 DOI: 10.1002/ana.25484] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 03/31/2019] [Accepted: 04/07/2019] [Indexed: 12/31/2022]
Abstract
Flow diverters are new generation stents that have recently garnered a large amount of interest for use in treatment of intracranial aneurysms. Flow diverters reduce blood flow into the aneurysm, with redirection along the path of the parent vessel. Flow stagnation into the aneurysm and neck coverage with subsequent endothelialization are the important synergistic mechanisms by which the therapy acts. Several studies have examined the mechanisms by which flow diverters subsequently lead to aneurysm occlusion. This review aims to provide a general overview of the flow diverters and their mechanism of action and potential implications. ANN NEUROL 2019;85:793-800.
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Affiliation(s)
| | | | - Justin Moore
- Boston University School of Medicine, Boston, MA.,Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vitor M Pereira
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adam A Dmytriw
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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31
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Cagnazzo F, Lefevre PH, Mantilla D, Rouchaud A, Morganti R, Perrini P, Carlo DD, Dargazanli C, Gascou G, Riquelme C, Bonafe A, Costalat V. Patency of the supraclinoid internal carotid artery branches after flow diversion treatment. A meta-analysis. J Neuroradiol 2019; 46:9-14. [DOI: 10.1016/j.neurad.2018.07.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 03/15/2018] [Accepted: 07/26/2018] [Indexed: 10/28/2022]
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32
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Granja MF, Cortez GM, Aguilar-Salinas P, Agnoletto GJ, Imbarrato G, Jaume A, Aghaebrahim A, Sauvageau E, Hanel RA. Stent-assisted coiling of cerebral aneurysms using the Y-stenting technique: a systematic review and meta-analysis. J Neurointerv Surg 2019; 11:683-689. [PMID: 30610070 DOI: 10.1136/neurintsurg-2018-014517] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/08/2018] [Accepted: 11/26/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Bifurcation aneurysms can be treated with stent-assisted coiling using two stents in a Y-configuration. We aim to investigate the angiographic and clinical outcomes of Y-stent constructs for the treatment of intracranial aneurysms. METHODS A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE databases was conducted based on PRISMA guidelines. The study selection was performed using the 'Ryyan' application. Our analysis included 18 studies with 327 patients. Inclusion criteria were: articles published from January 2000 to November 2017, English language, including cerebral aneurysms treated via Y-stenting, and ≥5 cases with radiographic/clinical outcomes. Technical notes, editorials, reviews, and animal studies were excluded. A random-effect meta-analysis was performed on angiographic and clinical outcomes, including aneurysm occlusion, modified Rankin Scale, neurological outcome, and procedure-related mortality. 95% CIs and event rates were estimated. Statistical heterogeneity was assessed using I2 statistics. RESULTS The procedure-related good outcome rate was 92% and complete occlusion rate was 91%. The permanent neurological deficit rate was 4% and procedure-related mortality was 2%. The procedure-related stroke rate was 12%. A total of 28/146 (19%) patients had ruptured aneurysms. At long-term follow-up, overall stroke rate was 9% in patients with unruptured aneurysm. The mortality rate was higher in cases with ruptured aneurysms than in those with unruptured aneurysms (18% vs 0.8%; p<0.001). CONCLUSIONS Y-stenting for bifurcation aneurysms yields a high rate of complete occlusion and low rates of mortality and stroke. Careful patient selection is needed.
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Affiliation(s)
- Manuel F Granja
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | | | | | - Gregory Imbarrato
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | | | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
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Raymond SB, Koch MJ, Rabinov JD, Leslie-Mazwi TM, Torok CM, Stapleton CJ, Patel AB. The Role of Collateral Circulation in Branch Vessel Occlusion After Flow Diversion. World Neurosurg 2018; 124:S1878-8750(18)32887-0. [PMID: 30593960 DOI: 10.1016/j.wneu.2018.12.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 12/05/2018] [Accepted: 12/07/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Flow diversion for treatment of intracranial aneurysms frequently necessitates covering adjacent branch vessels. Although branch vessel occlusion is common, associated clinical deficits are rare. It has been hypothesized that clinically silent branch vessel occlusion is due to underlying collateral circulation. To study the role of collateral circulation in covered branch vessel occlusion, we assessed collateral vessels and altered branch vessel flow on transfemoral catheter angiography in patients undergoing flow diversion of intracranial aneurysms. METHODS Angiograms obtained before treatment, immediately after treatment, and during follow-up were evaluated for branch vessel flow patterns and associated collateral circulation in a consecutive retrospective cohort of 84 patients from 2011 to 2017 with branch vessel coverage related to aneurysm flow diversion using the Pipeline embolization device. RESULTS We identified 142 branch vessels covered by the Pipeline device construct for treatment of 89 aneurysms, predominately in the anterior circulation (>90%). Collateral circulation was observed in approximately one third of these vessels and was associated with diminished (P < 0.001) or absent (P < 0.001) flow on follow-up angiography. Only 2 of 80 terminal branch vessels (no collaterals) were occluded, and these occurred in a patient with Pipeline device construct thrombosis. Altered branch vessel flow was not associated with vascular risk factors, treatment technique, or outcome measures, including new or worsening neurologic deficit. CONCLUSIONS Altered flow in branch vessels covered during flow diversion reflects underlying collateral circulation and is not associated with downstream ischemic deficits.
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Affiliation(s)
- Scott B Raymond
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Matthew J Koch
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Kamide T, Tabani H, Safaee MM, Burkhardt JK, Lawton MT. Microsurgical clipping of ophthalmic artery aneurysms: surgical results and visual outcomes with 208 aneurysms. J Neurosurg 2018; 129:1511-1521. [PMID: 29372879 DOI: 10.3171/2017.7.jns17673] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/14/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEWhile most paraclinoid aneurysms can be clipped with excellent results, new postoperative visual deficits are a concern. New technology, including flow diverters, has increased the popularity of endovascular therapy. However, endovascular treatment of paraclinoid aneurysms is not without procedural risks, is associated with higher rates of incomplete aneurysm occlusion and recurrence, and may not address optic nerve compression symptoms that surgical debulking can. The increasing endovascular management of paraclinoid aneurysms should be justified by comparisons to surgical benchmarks. The authors, therefore, undertook this study to define patient, visual, and aneurysm outcomes in the most common type of paraclinoid aneurysm: ophthalmic artery (OphA) aneurysms.METHODSResults from microsurgical clipping of 208 OphA aneurysms in 198 patients were retrospectively reviewed. Patient demographics, aneurysm morphology (size, calcification, etc.), clinical characteristics, and patient outcomes were recorded and analyzed.RESULTSDespite 20% of these aneurysms being large or giant in size, complete aneurysm occlusion was accomplished in 91% of 208 cases, with OphA patency preserved in 99.5%. The aneurysm recurrence rate was 3.1% and the retreatment rate was 0%. Good outcomes (modified Rankin Scale score 0-2) were observed in 96.2% of patients overall and in all 156 patients with unruptured aneurysms. New visual field defects (hemianopsia or quadrantanopsia) were observed in 8 patients (3.8%), decreased visual acuity in 5 (2.4%), and monocular blindness in 9 (4.3%). Vision improved in 9 (52.9%) of the 17 patients with preoperative visual deficits.CONCLUSIONSThe most important risk associated with clipping OphA aneurysms is a new visual deficit. Meticulous microsurgical technique is necessary during anterior clinoidectomy, aneurysm dissection, and clip application to optimize visual outcomes, and aggressive medical management postoperatively might potentially decrease the incidence of delayed visual deficits. As the results of endovascular therapy and specifically flow diverters become known, they warrant comparison with these surgical benchmarks to determine best practices.
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Affiliation(s)
- Tomoya Kamide
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Halima Tabani
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Michael M Safaee
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Jan-Karl Burkhardt
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Michael T Lawton
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
- 2Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital & Medical Center, Phoenix, Arizona
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Cagnazzo F, Cappucci M, Dargazanli C, Lefevre PH, Gascou G, Riquelme C, Morganti R, Mazzotti V, Bonafe A, Costalat V. Flow-Diversion Effect of LEO Stents: Aneurysm Occlusion and Flow Remodeling of Covered Side Branches and Perforators. AJNR Am J Neuroradiol 2018; 39:2057-2063. [PMID: 30287459 DOI: 10.3174/ajnr.a5803] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/30/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Flow diversion with intermediate-porosity stents (braided stents) has been recently reported for distally located small aneurysms. The aim of this study was to evaluate the flow-diversion effect of LEO stents on covered vessels and for aneurysms treated with sole stent-placement therapy. MATERIALS AND METHODS We retrospectively evaluated the following outcomes: 1) remodeling of covered side branches and perforators (extra-aneurysmal flow remodeling), and 2) the occlusion rate of aneurysms treated with sole stent-placement therapy (intra-aneurysmal flow remodeling). RESULTS Seventy-six patients with 98 covered vessels were studied. Overall, 89 covered arteries (91%) were normal, 7 showed narrowing (7%), and 2 (2%) were occluded (1 posterior communicating artery and 1 MCA) without related complications (mean DSA follow-up, 14 months). Univariate and multivariate analyses highlighted smoking (P = .03) and the length of follow-up (P = .002) as factors associated with arterial remodeling. Of the 17 Sylvian (lenticulostriate arteries) and 7 basilar perforators, 1 (4%) group of Sylvian perforators covered with double stents had asymptomatic remodeling. Ten aneurysms (mean size, 3.5 mm) were treated with LEO stents as stent monotherapy (5 recanalized after coiling and 5 directly treated with the LEO). Complete occlusion (Raymond-Roy I) was achieved in 70% of aneurysms (mean follow-up, 14 months). The Raymond-Roy I occlusion rate among recanalized aneurysms and those directly treated with LEO stents was 80% and 60%, respectively (P = .9). CONCLUSIONS The rate of flow remodeling on the covered arteries and perforators was 9% and 4%, respectively, and was clinically irrelevant in all cases. Complete occlusion of aneurysms treated with sole stent-placement therapy was 70%. These data stress the flow-diversion properties of LEO stents.
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Affiliation(s)
- F Cagnazzo
- From the Neuroradiology Department (F.C., M.C., C.D., P.-H.L., G.G., C.R., A.B., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - M Cappucci
- From the Neuroradiology Department (F.C., M.C., C.D., P.-H.L., G.G., C.R., A.B., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - C Dargazanli
- From the Neuroradiology Department (F.C., M.C., C.D., P.-H.L., G.G., C.R., A.B., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - P-H Lefevre
- From the Neuroradiology Department (F.C., M.C., C.D., P.-H.L., G.G., C.R., A.B., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - G Gascou
- From the Neuroradiology Department (F.C., M.C., C.D., P.-H.L., G.G., C.R., A.B., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - C Riquelme
- From the Neuroradiology Department (F.C., M.C., C.D., P.-H.L., G.G., C.R., A.B., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - R Morganti
- Section of Statistics (R.M., V.M.), University Hospital of Pisa, Pisa, Italy
| | - V Mazzotti
- Section of Statistics (R.M., V.M.), University Hospital of Pisa, Pisa, Italy
| | - A Bonafe
- From the Neuroradiology Department (F.C., M.C., C.D., P.-H.L., G.G., C.R., A.B., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - V Costalat
- From the Neuroradiology Department (F.C., M.C., C.D., P.-H.L., G.G., C.R., A.B., V.C.), University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
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Kraus B, Goertz L, Turowski B, Borggrefe J, Schlamann M, Dorn F, Kabbasch C. Safety and efficacy of the Derivo Embolization Device for the treatment of unruptured intracranial aneurysms: a multicentric study. J Neurointerv Surg 2018; 11:68-73. [DOI: 10.1136/neurintsurg-2018-013963] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 04/14/2018] [Accepted: 04/18/2018] [Indexed: 11/04/2022]
Abstract
BackgroundThe Derivo Embolization Device (DED) is a novel flow diverter stent that provides increased x-ray visibility, an improved delivery system, and potentially reduced thrombogenicity. The objective of this study was to evaluate the early safety and efficacy of the second-generation DED.MethodsWe retrospectively analyzed all patients with unruptured intracranial aneurysms (UIAs) treated with the DED between November 2015 and December 2017 in three German tertiary care centers. Procedural details, complications, and morbidity within 30 days after treatment, as well as the aneurysm occlusion rates after 6 months (O’Kelly–Marotta scale, OKM), were evaluated.ResultsImplantation of the DED was attempted in 42 patients with 42 aneurysms. All procedures were technically successful. Multiple DEDs were used in three aneurysms (7.2%) and adjunctive coiling in 11 (26.2%). Procedure-related complications occurred in four cases (9.5%) including three thromboembolic events and one aneurysm perforation. The morbidity rate was 2.4% and there was no mortality. One patient suffered an ischemic stroke with persistent aphasia at 30-day follow-up due to a thromboembolic infarct (modified Rankin Scale score 1). Among 33 patients (78.6%) available for angiographic follow-up, complete (OKM D) and favorable (OKM C+D) aneurysm occlusion was obtained in 72.7% (24/33) and 87.9% (29/33), respectively.ConclusionsEndovascular treatment of UIAs with the DED is associated with high procedural safety and adequate occlusion rates. Examinations at 1- and 2-year follow-up will provide data on the long-term safety and angiographic outcomes of this device.
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Touzé R, Touitou V, Shotar E, Gabrieli J, Drir M, Mathon B, Sourour NA, Clarençon F. Long-term visual outcome in patients treated by flow diversion for carotid-ophthalmic aneurysms. J Neurointerv Surg 2018; 10:1067-1073. [PMID: 29572267 DOI: 10.1136/neurintsurg-2017-013684] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/12/2018] [Accepted: 02/20/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Flow-diverter stents (FDSs) are an upgrade in the treatment of intracranial aneurysms. However, complications concerning covered branches have been reported, especially the ophthalmic artery (OA). The purpose of our study was to evaluate the long-term ophthalmic complication rate of carotid-ophthalmic aneurysms (COA) without visual pathways compression, treated by a FDS covering the OA by performing an exhaustive ophthalmic examination. MATERIAL AND METHODS Retrospective analysis of a single-center database screening the patients treated from October 2009 to April 2015 for an intracranial aneurysm with a FDS. The patients treated for a non-compressive COA with coverage of the OA by the device were studied (n=30). Among these patients, 15 (50%) were excluded. The remaining 15 patients underwent a systematic and extensive ophthalmic examination at least 2 years after the stent placement by two ophthalmologists. RESULTS Fifteen patients with 16 COAs treated with a FDS were included. Mean follow-up was 4.1±2 years. Six patients (40%), presented ophthalmic complications, including three fugax amauroses (18.8%) and four significant visual field defects (25%). After comparing each eye's visual field's patients, we observed a significant difference between the eye on the FDS side compared with the contralateral eye, with a mean deviation of -1.58 dB versus -0.67 dB respectively (P=0.003). Visual acuity was preserved in all patients. CONCLUSION Patients treated by FDS for COA have a good long-term clinical ophthalmic outcome. However, extensive ophthalmic examination shows a high percentage of minor ophthalmic modifications. Interventional neuroradiologists should be aware of these possible complications when choosing to treat these aneurysms with FDS.
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Affiliation(s)
- Romain Touzé
- Departement of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France.,Departement of Ophthalmology, Pitié-Salpêtrière Hospital, Paris, France
| | - Valérie Touitou
- Departement of Ophthalmology, Pitié-Salpêtrière Hospital, Paris, France.,Paris VI University, Pierre et Marie Curie, Paris, France
| | - Eimad Shotar
- Departement of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France.,Paris VI University, Pierre et Marie Curie, Paris, France
| | - Joseph Gabrieli
- Departement of Interventional Neuroradiology, Padova University Hospital, Padova, Italy
| | - Mehdi Drir
- Departement of Anesthesiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Bertrand Mathon
- Paris VI University, Pierre et Marie Curie, Paris, France.,Departement of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France.,Paris VI University, Pierre et Marie Curie, Paris, France
| | | | - Frédéric Clarençon
- Departement of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France.,Paris VI University, Pierre et Marie Curie, Paris, France
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Bhogal P, Hellstern V, Bäzner H, Ganslandt O, Henkes H, Aguilar Pérez M. The Use of Flow Diverting Stents to Treat Para-Ophthalmic Aneurysms. Front Neurol 2017; 8:381. [PMID: 28824537 PMCID: PMC5545935 DOI: 10.3389/fneur.2017.00381] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 07/18/2017] [Indexed: 11/13/2022] Open
Abstract
Background and purpose Few publications have dealt exclusively with the use of flow diverter stents for the treatment of para-ophthalmic aneurysms. We sought to determine the efficacy of flow diverting stents (FDSs) to treat aneurysms in this specific location. Methods We retrospectively reviewed our database of prospectively collected information for all patients treated with flow diversion for an unruptured saccular para-ophthalmic aneurysm between September 2009 and January 2016. The aneurysm fundus size, neck size, number and type of FDS, complications, and follow-up data were recorded. Results We identified 74 patients that matched our inclusion criteria. Of these patients, 18 patients were male (24.3%). The average fundus size was 4.8 mm, 11 aneurysms had previous coil occlusions and 63 were treated solely with flow diversion. At an initial angiographic follow-up (mean avg. 3.2 months), 71.8% of the aneurysms were occluded, and at the last follow-up (mean avg. 31.8 months), 88.9% of aneurysms were occluded. One patient suffered permanent morbidity (1.36%) secondary to interruption of the antiplatelet medication and another died (1.36%) secondary to in-stent thrombosis that was also due to an interruption in the antiplatelet medication. Conclusion Treatment of saccular para-ophthalmic aneurysms with FDS is feasible and carries a high degree of technical success with low complication rates and excellent rates of aneurysm exclusion.
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Affiliation(s)
| | | | | | | | - Hans Henkes
- Neurocentrum, Klinikum Stuttgart, Stuttgart, Germany
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Asaid M, O'Neill AH, Bervini D, Chandra RV, Lai LT. Unruptured Paraclinoid Aneurysm Treatment Effects on Visual Function: Systematic Review and Meta-analysis. World Neurosurg 2017; 106:322-330. [PMID: 28669879 DOI: 10.1016/j.wneu.2017.06.135] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 06/22/2017] [Accepted: 06/24/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Postoperative visual outcomes following repair of unruptured paraclinoid aneurysms (UPAs) are not well defined. We aim to investigate the influence of treatment modality on visual function. METHODS A systematic literature analysis using the Ovid Medline and EMBASE databases was performed, encompassing English language studies (published between 1996 and 2016) reporting treatment outcomes for UPAs. Rates of visual morbidity (new, permanent postoperative deficit, worsening preoperative deficit); angiographic (occlusion, recurrence, retreatment) and clinical outcomes (death, disability, post-treatment subarachnoid hemorrhage) were recorded. Random effects meta-analysis was performed. RESULTS Twenty-eight studies reported visual outcomes, with data for 1013 endovascular and 691 microsurgical patients. In patients with normal vision undergoing elective repair of UPAs, rates of postoperative visual morbidity were higher following microsurgical (10.8%; 95% confidence interval [CI] 8.5-13.7) than endovascular (2.0%; 95% CI 1.2-3.2) interventions, P < 0.001. In those presenting with preoperative visual impairment, surgery was associated with a modest advantage in visual recovery compared with endovascular therapies (65.2% vs. 48.9%, P < 0.03). There were no differences in visual morbidity following treatment with any of the endovascular modalities. Meta-analysis of comparative studies suggested a trend toward poor visual (ES = 0.42; 95% CI 0.08-2.09) and clinical outcomes (ES = 0.57; 95% CI 0.07-4.44) following microsurgery and a trend toward angiographic recurrence (ES = 2.52; 95% CI 0.80-7.90) and retreatment (ES = 1.62; 95% CI 0.46-5.67) after endovascular interventions. CONCLUSION In patients with normal vision undergoing repairs for UPAs, there is a positive correlation between visual outcomes and endovascular treatments. When visual compromise is present, surgery provided modest advantage in visual recovery. However, definitive conclusions were not possible due to data heterogeneity.
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Affiliation(s)
- Mina Asaid
- Department of Neurosurgery, Monash Health, Melbourne, Australia
| | - Anthea H O'Neill
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Monash Neurovascular Institute, Melbourne, Australia
| | - David Bervini
- Department of Neurosurgery, University Hospital Inselspital and University of Bern, Bern, Switzerland
| | - Ronil V Chandra
- Department of Surgery, Monash University, Melbourne, Australia; Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Australia; Monash Neurovascular Institute, Melbourne, Australia
| | - Leon T Lai
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia; Monash Neurovascular Institute, Melbourne, Australia.
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Abstract
BACKGROUND Intracranial saccular aneurysms are acquired lesions that often present with neuro-ophthalmologic symptoms and signs. Recent advances in neurosurgical techniques, endovascular treatments, and neurocritical care have improved the optimal management of symptomatic unruptured aneurysms, but whether the chosen treatment has an impact on neuro-ophthalmologic outcomes remains debated. EVIDENCE ACQUISITION A review of the literature focused on neuro-ophthalmic manifestations and treatment of intracranial aneurysms with specific relevance to neuro-ophthalmologic outcomes was conducted using Ovid MEDLINE and EMBASE databases. Cavernous sinus aneurysms were not included in this review. RESULTS Surgical clipping vs endovascular coiling for aneurysms causing third nerve palsies was compared in 13 retrospective studies representing 447 patients. Complete recovery was achieved in 78% of surgical patients compared with 44% of patients treated with endovascular coiling. However, the complication rate, hospital costs, and days spent in intensive care were reported as higher in surgically treated patients. Retrospective reviews of surgical clipping and endovascular coiling for all ocular motor nerve palsies (third, fourth, or sixth cranial nerves) revealed similar results of complete resolution in 76% and 49%, respectively. Improvement in visual deficits related to aneurysmal compression of the anterior visual pathways was also better among patients treated with clipping than with coiling. The time to treatment from onset of visual symptoms was a predictive factor of visual recovery in several studies. Few reports have specifically assessed the improvement of visual deficits after treatment with flow diverters. CONCLUSIONS Decisions regarding the choice of therapy for intracranial aneurysms causing neuro-ophthalmologic signs ideally should be made at high-volume centers with access to both surgical and endovascular treatments. The status of the patient, location of the aneurysm, and experience of the treating physicians are important factors to consider. Although a higher rate of visual recovery was reported with neurosurgical clipping, this must be weighed against the potentially longer intensive care stays and increased early morbidity.
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Silva MA, See AP, Dasenbrock HH, Patel NJ, Aziz-Sultan MA. Vision outcomes in patients with paraclinoid aneurysms treated with clipping, coiling, or flow diversion: a systematic review and meta-analysis. Neurosurg Focus 2017; 42:E15. [DOI: 10.3171/2017.3.focus1718] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVEPatients with paraclinoid aneurysms commonly present with visual impairment. They have traditionally been treated with clipping or coiling, but flow diversion (FD) has recently been introduced as an alternative treatment modality. Although there is still initial aneurysm thrombosis, FD is hypothesized to reduce mass effect, which may decompress the optic nerve when treating patients with visually symptomatic paraclinoid aneurysms. The authors performed a meta-analysis to compare vision outcomes following clipping, coiling, or FD of paraclinoid aneurysms in patients who presented with visual impairment.METHODSA systematic literature review was performed using the PubMed and Web of Science databases. Studies published in English between 1980 and 2016 were included if they reported preoperative and postoperative visual function in at least 5 patients with visually symptomatic paraclinoid aneurysms (cavernous segment through ophthalmic segment) treated with clipping, coiling, or FD. Neuroophthalmological assessment was used when reported, but subjective patient reports or objective visual examination findings were also acceptable.RESULTSThirty-nine studies that included a total of 2458 patients (520 of whom presented with visual symptoms) met the inclusion criteria, including 307 visually symptomatic cases treated with clipping (mean follow-up 26 months), 149 treated with coiling (mean follow-up 17 months), and 64 treated with FD (mean follow-up 11 months). Postoperative vision in these patients was classified as improved, unchanged, or worsened compared with preoperative vision. A pooled analysis showed preoperative visual symptoms in 38% (95% CI 28%–50%) of patients with paraclinoid aneurysms. The authors found that vision improved in 58% (95% CI 48%–68%) of patients after clipping, 49% (95% CI 38%–59%) after coiling, and 71% (95% CI 55%–84%) after FD. Vision worsened in 11% (95% CI 7%–17%) of patients after clipping, 9% (95% CI 2%–18%) after coiling, and 5% (95% CI 0%–20%) after FD. New visual deficits were found in patients with intact baseline vision at a rate of 1% (95% CI 0%–3%) for clipping, 0% (95% CI 0%–2%) for coiling, and 0% (95% CI 0%–2%) for FD.CONCLUSIONSTo the authors’ knowledge, this is the first meta-analysis to assess vision outcomes after treatment for paraclinoid aneurysms. The authors found that 38% of patients with these aneurysms presented with visual impairment. These data also demonstrated a high rate of visual improvement after FD without a significant difference in the rate of worsened vision or iatrogenic visual impairment compared with clipping and coiling. These findings suggest that FD is an effective option for treatment of visually symptomatic paraclinoid aneurysms.
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Bhogal P, Aguilar Pérez M, Sauder G, Bäzner H, Ganslandt O, Henkes H. [Management of paraophthalmic aneurysms : Review of endovascular treatment strategies]. Ophthalmologe 2017; 115:114-122. [PMID: 28439656 DOI: 10.1007/s00347-017-0497-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Aneurysms of the cerebral vessels are relatively common and aneurysms of the ophthalmic segment of the internal carotid artery (ICA) represent approximately 10% of intradural aneurysms. ANATOMICAL ASPECTS The ophthalmic segment of the ICA extends from the origin of the ophthalmic artery to the origin of the posterior communicating artery. Aneurysms can originate from the ophthalmic artery itself or directly from the ICA at a distance from the ophthalmic artery. The various anatomic configurations can alter the risks of treatment. SURGICAL TREATMENT Surgical treatment of aneurysms of the ophthalmic segment poses unique challenges for the neurosurgeon, given the deep location and complex nearby structures and optic nerve. The necessity to remove the clinoid process can make the operation technically challenging. ENDOVASCULAR TREATMENT Endovascular treatment of paraophthalmic aneurysms includes coil occlusion, and also stent- or balloon-assisted coil occlusion. More recently, hemodynamically active flow diverter stents improved the treatment results. CONCLUSION The management of paraophthalmic aneurysms is associated with specific risks. Careful consideration of the available techniques is necessary before each invention. Coil-occlusion remains the first choice for ruptured paraophthalmic aneurysms. For unruptured paraophthalmic aneurysms flow diversion offers improved results. The overall complication rates of these procedures are low; however, cerebral ischemia, intracranial hemorrhage and visual complications must be considered in advance and the patient must be informed of the risks.
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Affiliation(s)
- P Bhogal
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland.
| | - M Aguilar Pérez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland
| | - G Sauder
- Charlottenklinik, Stuttgart, Deutschland
| | - H Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Deutschland
| | - O Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Deutschland
| | - H Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland.,Medizinische Fakultät, Universität Duisburg-Essen, Essen, Deutschland
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Bhogal P, Ganslandt O, Bäzner H, Henkes H, Pérez MA. The Fate of Side Branches Covered by Flow Diverters-Results from 140 Patients. World Neurosurg 2017; 103:789-798. [PMID: 28438653 DOI: 10.1016/j.wneu.2017.04.092] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Flow diverter stents (FDS) are a recognized treatment option for intracranial aneurysms. There remain ongoing concerns regarding the safety of FDS, especially regarding the fate of covered side branches. We report the patency of side branches covered by FDS. METHODS We retrospectively reviewed our database of prospectively collected information for all patients treated with FDS for an unruptured saccular aneurysm of the clinoid, ophthalmic, and terminating segments of the internal carotid artery between September 2009 and July 2016. The aneurysm location, fundus size, and the state of covered branches at last angiography were recorded compared with preoperative angiography. RESULTS We identified 140 patients, with 147 aneurysms, who met our inclusion criteria. Five patients had bilateral aneurysms. There were 31 male patients in our cohort (21.9%) and the mean average age was 56.2 ± 13.7 years. Sixty-seven aneurysms arose from the communicating, 58 from the ophthalmic, and 22 from the clinoidal segments. At last follow-up (mean, 22.3 months) 116 aneurysms were completely occluded (78.3%). On the most recent angiogram, 7 ophthalmic (5.3%), 20 posterior communicating (42.6%), 0 anterior choroidal (0%), and 2 anterior cerebral arteries (14.3%) were completely occluded. Reduced vessel caliber was seen in 11 ophthalmic (8.3%), 3 posterior communicating (6.4%), 0 anterior choroidal, and 6 anterior cerebral arteries (42.9%). One patient died during follow-up. CONCLUSIONS The side branch occlusion rate was 20% and included ophthalmic, posterior communicating, and anterior cerebral arteries. Consistent with other studies, we did not see occlusion of the anterior choroidal artery.
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Affiliation(s)
- Pervinder Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.
| | - Oliver Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany; Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Marta Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
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Chalouhi N, Daou B, Barros G, Starke RM, Chitale A, Ghobrial G, Dalyai R, Hasan D, Gonzalez LF, Tjoumakaris S, Rosenwasser RH, Jabbour P. Matched Comparison of Flow Diversion and Coiling in Small, Noncomplex Intracranial Aneurysms. Neurosurgery 2017; 81:92-97. [DOI: 10.1093/neuros/nyw070] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 08/15/2016] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND: Flow diversion is typically reserved for large, giant, or morphologically complex aneurysms. Coiling remains a first-line treatment for small, morphologically simple aneurysms.
OBJECTIVE: To compare coiling and flow diversion in small, uncomplicated intracranial aneurysms (typically amenable to coiling).
METHODS: Forty patients treated with the pipeline embolization device (PED) for small (<10 mm), morphologically simple aneurysms that would have also been amenable to coiling were identified. These patients were matched in a 1:1 fashion with 40 patients with comparable aneurysms treated with coiling. Matching was based on age, gender, aneurysm size, and aneurysm morphology.
RESULTS: The 2 groups were comparable with regard to baseline characteristics including age, gender, and aneurysm size. The complication rate did not differ between the 2 groups (2.5% with coiling vs 5% with PED; P = .6). Multivariate analysis did not identify any predictor of complications. Complete occlusion (100%) at follow-up was significantly higher in patients treated with PED (70%) than coiling (47.5%, P = .04). In multivariate analysis, treatment with PED predicted aneurysm obliteration (P = .04). A significantly higher proportion of coiled patients (32.5%) required retreatment compared with flow diversion (5%, P = .003). In multivariate analysis, coiling predicted retreatment (P = .006). All patients achieved a favorable outcome (modified Rankin Scale: 0-2) regardless of group.
CONCLUSION: This matched analysis suggests that flow diversion provides higher occlusion rates, lower retreatment rates, and no additional morbidity compared with coiling in small, simple aneurysms amenable to both techniques. These results suggest a potential benefit for flow diversion over coiling even in small, uncomplicated aneurysms.
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Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Badih Daou
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Guilherme Barros
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M. Starke
- Department of Neuro-surgery & Radiology, Miami Miller School of Medicine, Miami University Hospital
| | - Ameet Chitale
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - George Ghobrial
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Richard Dalyai
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa
| | - L. Fernando Gonzalez
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H. Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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