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Ma Y, Zhang X, Zhang T, Feng Y, Zhao W, Chen X. Safety and efficacy of dual antiplatelet therapy combining aspirin and ticagrelor in patients with undergoing intracranial stenting procedures. J Neurosurg Sci 2024; 68:598-603. [PMID: 36112120 DOI: 10.23736/s0390-5616.22.05745-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
BACKGROUND Thromboembolic complications are one of the major periprocedural complications following neuroendovascular procedures. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel remain the principal agents for prevention of thromboembolic complications. However, clopidogrel resistance is associated with higher risk of thromboembolic complications. This study investigated the safety and efficacy of DAPT with ticagrelor and aspirin in patients undergoing intracranial stenting procedures. METHODS This retrospective study was based on patients with intracranial aneurysms who undergoing intracranial stenting procedures at our institution between August 2017 and July 2020. These patients received DAPT with ticagrelor and aspirin were included. DAPT with 90 mg ticagrelor twice daily and aspirin 100 mg daily was continued for 3 months after the intracranial stenting procedure and aspirin continued for 1 year. RESULTS In this study, 151 patients were identified. The most common aneurysm location was the internal carotid artery with 127 (71.8%) patients. Of the 151 cases with 160 treated aneurysms, 30 (18.8%) patients were treated by flow diverters (FDs), and 130 (81.2%) by stent-assisted coiling. Five (3.3%) patients had thromboembolic complications. Intraprocedural aneurysmal rupture was observed in one patient because of coil extrusion during coil insertion. None of the patients showed a newly DAPT-related intracerebral hemorrhage. Two patients developed dyspnea, and the symptom resolved without intervention. Furthermore, ecchymoma and gastrointestinal bleeding occurred in one patient respectively. DAPT-related thromboembolic and hemorrhagic complications were not significantly different between the FD group and stent-assisted coiling group. CONCLUSIONS In our study, DAPT combining ticagrelor and aspirin seems to be a safe and efficient treatment for preventing thromboembolic complications in patients with intracranial aneurysms, without any increase in hemorrhagic complications. Ticagrelor may be an effective alternative for patients undergoing neurointervention.
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Affiliation(s)
- Yihui Ma
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiangyu Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Tingbao Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yu Feng
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wenyuan Zhao
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xinjun Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China -
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Rodriguez-Erazú F, Cortez GM, Lopes DK, Gutierrez-Aguirre SF, De Toledo OF, Aghaebrahim A, Sauvageau E, Kallmes DF, Fiehler J, Hanel RA. Braids and beyond: a comprehensive study on pipeline device braid stability from PREMIER data. J Neurointerv Surg 2024:jnis-2024-022350. [PMID: 39357888 DOI: 10.1136/jnis-2024-022350] [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: 08/12/2024] [Accepted: 09/13/2024] [Indexed: 10/04/2024]
Abstract
BACKGROUND The pipeline embolization device (PED) has been increasingly used to treat brain aneurysms; however, concerns have been raised about braid stability with newer drawn filled tubing technology devices. OBJECTIVE To evaluate braid stability of PED early generations using data from the PREMIER trial. METHODS All consecutive intracranial aneurysms treated with PED (Classic and Flex) within the PREMIER trial were reviewed for braid stability (fish mouthing, foreshortening, braid bump, braid collapsing). Immediate postprocedure cone-beam CT and angiography were compared with 1- and 2- years' follow-up. Analyses included safety, measured with the modified Rankin Scale (mRS) score, including +1 mRS point and a good clinical outcome (mRS score 0-2), vessel stenosis ≥50%, effectiveness measured with Raymond-Roy Scale, and re-treatment rates. RESULTS 133/141 aneurysms had a complete dataset. 8/133 (6%) aneurysms showed braid deformations. Inter-reader agreement was excellent (κ=0.83). Braid deformations were statistically significantly associated with in-stent vessel stenosis >50% (P=0.029), without impact on effectiveness or safety. Fish mouthing was found in 1/133 (0.75%) at 1 year, causing >50% vessel stenosis. Foreshortening occurred in 6/133 (4.5%), and braid bump in 1/133 (0.75%) associated with severe in-stent stenosis. Four other cases (3.0%) of asymptomatic in-stent stenosis due to neointimal hyperplasia were seen without braid changes. No new braid stability deformations were found at the 2-year follow-up. CONCLUSION Our study demonstrates excellent braid stability among patients treated with the PED Classic and Flex in the PREMIER trial. Within the uncommon braid changes observed, none affected the PED safety or efficacy. TRIAL REGISTRATION NUMBER NCT02186561.
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Affiliation(s)
- Fernanda Rodriguez-Erazú
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
- Research Department, Jacksonville University, Jacksonville, Florida, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
- Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA
| | - Demetrius K Lopes
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Salvador F Gutierrez-Aguirre
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
- Research Department, Jacksonville University, Jacksonville, Florida, USA
| | - Otavio Frederico De Toledo
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
- Research Department, Jacksonville University, Jacksonville, Florida, USA
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
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Jeken-Rico P, Chau Y, Goetz A, Lannelongue V, Sédat J, Hachem E. Virtual flow diverter deployment and embedding for hemodynamic simulations. Comput Biol Med 2024; 180:109023. [PMID: 39163828 DOI: 10.1016/j.compbiomed.2024.109023] [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: 06/08/2024] [Revised: 08/03/2024] [Accepted: 08/11/2024] [Indexed: 08/22/2024]
Abstract
Flow-diverter stents offer clinicians an effective solution for treating intracranial aneurysms, especially in cases where other devices may be unsuitable. However, strongly deviating success rates among different centres, manufacturers, and aneurysm phenotypes highlight the need for better in-situ studies of these devices. To support research in this area, virtual stenting algorithms have been proposed that, combined with computational fluid dynamics, provide insights into the hemodynamic alterations induced by the device. Yet, many existing algorithms rely on uncertain parameters, such as the forces applied during operation, fail to predict the length of the device after deployment, or lack robust validation steps, raising concerns about their reliability. Therefore, we developed a robust deployment technique that builds upon the geometrical features of the vessel and includes advancements from previous works. The algorithm is detailed and validated against literature examples, in-vitro experiments, and patient data, achieving a mean angular error below 5° in the latter. Furthermore, we describe and demonstrate how the deployed device can be embedded in a computational mesh using open-source tools and anisotropic meshing routines.
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Affiliation(s)
- Pablo Jeken-Rico
- Mines Paris, Université PSL, CEMEF, UMR7635 CNRS, Sophia Antipolis, 06904, France.
| | - Yves Chau
- Department of Neuro-Interventional and Vascular Interventional, University Hospital of Nice, Nice, 06000, France
| | - Aurèle Goetz
- Mines Paris, Université PSL, CEMEF, UMR7635 CNRS, Sophia Antipolis, 06904, France
| | - Vincent Lannelongue
- Mines Paris, Université PSL, CEMEF, UMR7635 CNRS, Sophia Antipolis, 06904, France
| | - Jacques Sédat
- Department of Neuro-Interventional and Vascular Interventional, University Hospital of Nice, Nice, 06000, France
| | - Elie Hachem
- Mines Paris, Université PSL, CEMEF, UMR7635 CNRS, Sophia Antipolis, 06904, France
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Schwab R, Kabbasch C, Goertz L, Kaschner M, Weiss D, Loehr C, Wensing H, Bester M, Simgen A, Kemmling A, Wendl C, Fuchs E, Thormann M, Behme D, Nordmeyer H. The DERIVO 2 Heal Embolization Device in the Treatment of Ruptured and Unruptured Intracranial Aneurysms: a Retrospective Multicenter Study. Clin Neuroradiol 2024:10.1007/s00062-024-01446-8. [PMID: 39172220 DOI: 10.1007/s00062-024-01446-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 07/11/2024] [Indexed: 08/23/2024]
Abstract
BACKROUND The use of flow diverting stents in the treatment of intracranial aneurysms is associated with a risk of neurological morbidity due to their thrombogenicity. To reduce this risk different surface modifications have been developed. The Derivo 2 Embolization Device (Acandis, Pforzheim, Germany) has proven to be a safe and effective flow diverter. To overcome the risk of thrombo-embolism, the device was modified by adding an anti-thrombogenic fibrin-heparin coating. We aimed to assess the safety and effectiveness of the Derivo 2 heal Embolization Device. METHODS Retrospective multicenter data from nine German neurovascular centers between February 2022 until December 2023 were used. Patients treated with the Derivo 2 heal Embolization Device for unruptured or ruptured intracranial aneurysms were included. Peri- and postprocedural adverse events, clinical outcomes, and angiographic follow-up results were evaluated. RESULTS 84 patients (73.8% female; mean age 58.7 years) with 89 aneurysms (mean size 9.8 mm) were included. 87.6% were located in the anterior circulation. Most of them were sidewall aneurysms (88.8%). 96 flow diverters were used. 99.0% were successfully implanted. An in-stent balloon angioplasty was performed in 6.0% of the cases. An additional coiling was performed in 28.6%. Technical difficulties were present in 12.0% of the cases. Thrombotic events occurred in 4.8% with no neurological sequelae. Mortality and morbidity were 0 and 1.2% respectively. Adequate aneurysm occlusion was achieved in 80.7% with a mean follow-up time of 6.6 months. CONCLUSION The Derivo 2 heal Embolization Device showed a satisfying aneurysm occlusion and safety with a low rate of neurological morbidity.
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Affiliation(s)
- Roland Schwab
- University Clinic for Neuroradiology, Medical Faculty and University Hospital, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.
- Research Campus STIMULATE, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.
| | - Christoph Kabbasch
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Lukas Goertz
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Marius Kaschner
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - Daniel Weiss
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - Christian Loehr
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - Hauke Wensing
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Simgen
- Department for Neuroradiology, Westpfalz-Klinikum Kaiserslautern, Kaiserslautern, Germany
| | - André Kemmling
- Department of Neuroradiology, University Marburg, Marburg, Germany
| | - Christina Wendl
- University Hospital Regensburg, Institute of Radiology, Regensburg, Germany
| | - Erelle Fuchs
- University Clinic for Neuroradiology, Medical Faculty and University Hospital, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Maximilian Thormann
- University Clinic for Neuroradiology, Medical Faculty and University Hospital, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Daniel Behme
- University Clinic for Neuroradiology, Medical Faculty and University Hospital, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
- Research Campus STIMULATE, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Hannes Nordmeyer
- Department of Neuroradiology Städtisches Klinikum Solingen, Solingen, Germany
- Medical School, Department of Health, Witten/Herdecke University, Witten, Germany
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Yu J, Du Q, Li X, Wei W, Fan Y, Zhang J, Chen J. Potential role of endothelial progenitor cells in the pathogenesis and treatment of cerebral aneurysm. Front Cell Neurosci 2024; 18:1456775. [PMID: 39193428 PMCID: PMC11348393 DOI: 10.3389/fncel.2024.1456775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Accepted: 07/30/2024] [Indexed: 08/29/2024] Open
Abstract
Cerebral aneurysm (CA) is a significant health concern that results from pathological dilations of blood vessels in the brain and can lead to severe and potentially life-threatening conditions. While the pathogenesis of CA is complex, emerging studies suggest that endothelial progenitor cells (EPCs) play a crucial role. In this paper, we conducted a comprehensive literature review to investigate the potential role of EPCs in the pathogenesis and treatment of CA. Current research indicates that a decreased count and dysfunction of EPCs disrupt the balance between endothelial dysfunction and repair, thus increasing the risk of CA formation. Reversing these EPCs abnormalities may reduce the progression of vascular degeneration after aneurysm induction, indicating EPCs as a promising target for developing new therapeutic strategies to facilitate CA repair. This has motivated researchers to develop novel treatment options, including drug applications, endovascular-combined and tissue engineering therapies. Although preclinical studies have shown promising results, there is still a considerable way to go before clinical translation and eventual benefits for patients. Nonetheless, these findings offer hope for improving the treatment and management of this condition.
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Affiliation(s)
- Jin Yu
- Department of Neurosurgery, Wuhan Asia General Hospital, Wuhan, Hubei, China
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Qian Du
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xiang Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Wei Wei
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yuncun Fan
- Department of Respiratory and Critical Care Medicine, Laifeng County People’s Hospital, Enshi, Hubei, China
| | - Jianjian Zhang
- Department of Neurosurgery, Wuhan Asia General Hospital, Wuhan, Hubei, China
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jincao Chen
- Department of Neurosurgery, Wuhan Asia General Hospital, Wuhan, Hubei, China
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
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Uysal A, Cay F, Balcı S, Arat A. Initial Experience with the Derivo 2Heal Flow Diverter under Standard or Reduced-Dose Single Antiplatelet Therapy. AJNR Am J Neuroradiol 2024; 45:1038-1043. [PMID: 39025640 PMCID: PMC11383417 DOI: 10.3174/ajnr.a8292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/09/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND AND PURPOSE Flow diverters with surface modifications or coatings have been recently introduced to clinical practice with the expectation that they can reduce the rate of thromboembolic complications and residual aneurysms. The purpose of this study is to evaluate the utility of the Derivo 2Heal (D2H) device, a new fibrin and heparin-coated flow diverter. MATERIALS AND METHODS Patients treated by a single operator by using the D2H were retrospectively evaluated for demographic data, aneurysm characteristics, procedural variables, and follow-up data. All patients were treated by using a single D2H, monitored by platelet function testing and kept under single antiplatelet therapy with regular or half-dose clopidogrel or prasugrel after the procedure. RESULTS Twenty patients with 26 aneurysms were treated. Three presented acutely with subarachnoid hemorrhage. Adjunctive devices were used in 6 patients. There were no technical failures and 2 periprocedural self-limited nonthrombotic minor adverse events. During follow-up, 1 of the acutely ruptured aneurysms reruptured, and 1 patient had a visual TIA. All patients were doing well clinically (19 with mRS of 0 and 1 with 1) at the last follow-up after discharge. The rates of total occlusion on very early angiographic (MRA/CTA or DSA, mean: 2.4 months), DSA (mean: 5.8 months), and midterm angiographic (mean: 14.5 months) follow-up for all versus uncoiled aneurysms were 68% versus 70%, 77.8% versus 90.0%, and 91.7% versus 90.1%, respectively. CONCLUSIONS The absence of permanent neurologic deficits in the periprocedural period and favorable occlusion rates in this preliminary study suggest that the novel coating comprising fibrin and heparin may have the potential to increase the safety and efficacy of flow diversion and needs to be further studied by comparing the D2H device with its bare counterpart and other coated or surface-modified flow diverters.
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Affiliation(s)
- Aycan Uysal
- From the Hacettepe University Faculty of Medicine (A.U., F.C., S.B, A.A.), Ankara, Turkey
| | - Ferdi Cay
- From the Hacettepe University Faculty of Medicine (A.U., F.C., S.B, A.A.), Ankara, Turkey
| | - Sinan Balcı
- From the Hacettepe University Faculty of Medicine (A.U., F.C., S.B, A.A.), Ankara, Turkey
| | - Anıl Arat
- From the Hacettepe University Faculty of Medicine (A.U., F.C., S.B, A.A.), Ankara, Turkey
- Department of Neurosurgery (A.A.), Yale University, New Haven, Connecticut
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7
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Barros G, Federico E, Fillingham P, Chanana P, Kaneko N, Zheng Y, Kim LJ, Levitt MR. Endothelial Cell Transcription Modulation in Cerebral Aneurysms After Endovascular Flow Diversion. Ann Biomed Eng 2024:10.1007/s10439-024-03591-0. [PMID: 39095638 DOI: 10.1007/s10439-024-03591-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/25/2024] [Indexed: 08/04/2024]
Abstract
PURPOSE Flow diverting stents (FDS) are used to treat cerebral aneurysms, by promoting thrombosis and occlusion of the aneurysm sac. However, retreatment is required in some cases, and the biologic basis behind treatment outcome is not known. The goal of this study was to understand how changes in hemodynamic flow after FDS placement affect aneurysmal endothelial cell (EC) activity. METHODS Three-dimensional models of patient-specific aneurysms were created to quantify the EC response to FDS placement. Computational fluid dynamic simulations were used to determine the hemodynamic impact of FDS. Two identical models were created for each patient; into one a FDS was inserted. Each model was then populated with human carotid ECs and subjected to patient-specific pulsatile flow for 24 h. ECs were isolated from aneurysm dome from each model and bulk RNA sequencing was performed. RESULTS Paired untreated and treated models were created for four patients. Aneurysm dome EC analysis revealed 366 (2.6%) significant gene changes between the untreated and FDS conditions, out of 13909 total expressed genes. Gene set enrichment analysis of the untreated models demonstrated enriched gene ontology terms related to cell adhesion, growth/tensile activity, cytoskeletal organization, and calcium ion binding. In the FDS models, enriched terms were related to cellular proliferation, ribosomal activity, RNA splicing, and protein folding. CONCLUSION Treatment of cerebral aneurysms with FDS induces significant EC gene transcription changes related to aneurysm hemodynamics in patient-specific in vitro 3D-printed models subjected to pulsatile flow. Further investigation is needed into the relationship between transcriptional change and treatment outcome.
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Affiliation(s)
- Guilherme Barros
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Emma Federico
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Patrick Fillingham
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, WA, USA
| | - Pritha Chanana
- Bioinformatics Shared Resource, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Naoki Kaneko
- Division of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Ying Zheng
- Department of Bioengineering, University of Washington, Seattle, WA, USA
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, WA, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, WA, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
- Department of Radiology, University of Washington, Seattle, WA, USA.
- Department of Mechanical Engineering, University of Washington, Seattle, WA, USA.
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, WA, USA.
- Department of Neurology, University of Washington, Seattle, WA, USA.
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Ramirez-Velandia F, Enriquez-Marulanda A, Filo J, Fodor TB, Sconzo D, Mensah E, Young M, Muram S, Granstein JH, Shutran M, Taussky P, Ogilvy CS. A Novel Scoring System Predicting Aneurysm Incomplete Occlusion After Flow Diversion: A 10-Year Experience. World Neurosurg 2024:S1878-8750(24)01323-8. [PMID: 39094933 DOI: 10.1016/j.wneu.2024.07.183] [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: 05/08/2024] [Revised: 07/23/2024] [Accepted: 07/24/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Factors impacting the rate of aneurysm occlusion after flow diversion (FD) have been well described in the literature. In this article, we sought to evaluate those variables to develop and validate a scoring system predicting aneurysm incomplete occlusion after FD. METHODS Retrospective review of patients with intracranial aneurysms treated with FD at a single institution between March 2013 and March 2023. Multivariable logistic regression model was developed using factors associated with aneurysm incomplete occlusion. The ABC scoring system consisted of: Age (<60 years old: 0, 60-69 years: 1, 70-79: 2, and ≥80: 3), Branch coming out of the aneurysm dome/neck (yes: 2, no: 0), and Cigarette smoking history (never smoker: 1, current or past smoker: 0). The scoring system performance was evaluated with receiver operating characteristic curve and calculating the area under the curve. RESULTS A total of 449 patients with 563 aneurysms treated in 482 procedures were evaluated. Most cases were females (81.7%) with a median age of 59 years old. At a median follow-up of 13.2 months, 84.0% of aneurysms were completely or near-complete occluded. The scoring system had an area under the curve of 0.71. A value ≥ 2, reached a sensitivity of 74.4%, a specificity of 60.9%, a likelihood ratio+ of 1.90, and proved to be reliable in predicting the risk of incomplete occlusion (odds ratio = 4.53; 95% confidence interval: 2.73-7.54; P < 0.001). CONCLUSIONS The proposed ABC scoring system can be used to evaluate the risk of aneurysm incomplete occlusion after treatment with FD, identifying patients who would benefit from adjunctive coiling or alternative treatment modalities.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jean Filo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas B Fodor
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Sconzo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Emmanuel Mensah
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sandeep Muram
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin H Granstein
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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9
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Ramirez-Velandia F, Wadhwa A, Mensah E, Sathya A, Pacheco-Barrios N, Filo J, Pettersson SD, Enriquez-Marulanda A, Young M, Granstein JH, Taussky P, Ogilvy CS. Endovascular Treatment of Basilar Apex Aneurysms: An Updated Systematic Review and Meta-Analysis in the Era of Flow Diversion. World Neurosurg 2024:S1878-8750(24)01281-6. [PMID: 39067688 DOI: 10.1016/j.wneu.2024.07.142] [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: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Endovascular options for the treatment of basilar apex aneurysms (BAAs) are heterogeneous, and evidence is limited to retrospective cohorts and case series. We seek to evaluate the efficacy and complications associated with various endovascular treatment methods of BAAs. METHODS Systematic review of PubMed, Embase, and Web of Science adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Retrospective and prospective studies evaluating endovascular treatment of BAAs between January 2010 and July 2024 were included. Relevant information including occlusion rates, aneurysm recurrence, retreatment rates, and complications were subjected to meta-analysis. RESULTS Fifteen studies with 1049 BAAs were included. The median aneurysm diameter was 8.5 mm (range, 4.6-19.75), with a median follow-up of 33.7 months (range, 6.0-117.6). Residual aneurysm filling occurred in 24% after primary coiling (95% CI = 0.16-0.32), 25% after single stent-assisted coiling (s-SAC; 95% CI = 0.04-0.46), 25% after Y-stents (95% CI = 0.12-0.37), and 23% after flow diverter stent (FDS; 95% CI = 0.11-0.35). Recurrence rates were high for primary coiling (27%, 95% CI = 0.18-0.36) and s-SAC (19%, 95% CI = 0.13-0.26), but significantly lower for Y-stents (9%, 95% CI = 0.03-0.15) and FDS (4%, 95% CI = -0.04-0.11). Retreatment rates were 19% for primary coiling (95% CI = 0.12-0.26), 17% for s-SAC (95% CI = 0.07-0.27), 5% for Y-stents (95% CI = -0.03-0.12), and 13% for FDS (95% CI = -0.01-0.27). Meta-regression indicated larger aneurysms had higher complication rates (P = 0.02). Thromboembolic events were most frequent with FDS and Y-stents(12%). CONCLUSIONS Occlusion rates were similar across treatments, but recurrence rates were significantly lower after Y-stents and FDS compared to primary coiling, although they carried a higher number of thromboembolic complications.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurosurgicla Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Aryan Wadhwa
- Neurosurgicla Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Emmanuel Mensah
- Neurosurgicla Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Anvitha Sathya
- Neurosurgicla Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Niels Pacheco-Barrios
- Neurosurgicla Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean Filo
- Neurosurgicla Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel D Pettersson
- Neurosurgicla Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Michael Young
- Neurosurgicla Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin H Granstein
- Neurosurgicla Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Taussky
- Neurosurgicla Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgicla Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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10
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Sharashidze V, Raz E, Nossek E, Kvint S, Riina H, Rutledge C, Baranoski J, Khawaja A, Chung C, Nelson PK, Shapiro M. Comprehensive Analysis of Post-Pipeline Endothelialization and Remodeling. AJNR Am J Neuroradiol 2024; 45:893-898. [PMID: 38663989 DOI: 10.3174/ajnr.a8228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/06/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND AND PURPOSE Successful post-flow-diverter endoluminal reconstruction is widely believed to require endothelial overgrowth of the aneurysmal inflow zone. However, endothelialization/neointimal overgrowth is a complex process, over which we currently have very limited influence. Less emphasized is vascular remodeling of the target arterial segment, the dynamic response of the vessel to flow-diverter implantation. This process is distinct from flow modifications in covered branches. It appears that basic angiographic methods allow simple and useful observations. The purpose of this article was to quantitatively evaluate observable postimplantation changes in target vessels following deployment of Pipeline endoluminal constructs. MATERIALS AND METHODS One hundred consecutive adults with unruptured, previously untreated, nondissecting aneurysms treated with the Pipeline Embolization Device with Shield Technology and the availability of follow-up conventional angiography were studied with 2D DSA imaging. Target vessel size; Pipeline Embolization Device diameter; endothelial thickness; and various demographic, antiplatelet, and device-related parameters were recorded and analyzed. RESULTS The thickness of neointimal overgrowth (mean, 0.3 [SD, 0.1] mm; range, 0.1-0.7 mm) is inversely correlated with age and is independent of vessel size, smoking status, sex, and degree of platelet inhibition. The decrease in lumen diameter caused by neointimal overgrowth, however, appears counteracted by outward remodeling (dilation) of the target arterial segment. This leads to an increase in the diameter with a corresponding decrease in length (foreshortening) of the implanted Pipeline Embolization Device. This physiologic remodeling process affects optimally implanted devices and is not a consequence of stretching, device migration, vasospasm, and so forth. A direct, linear, statistically significant relationship exists between the degree of observed outward remodeling and the diameter of the implanted Pipeline Embolization Device relative to the target vessel. Overall, remodeled arterial diameters were reduced by 15% (SD, 10%) relative to baseline and followed a normal distribution. Clinically relevant stenosis was not observed. CONCLUSIONS Vessel healing involves both outward remodeling and neointimal overgrowth. Judicial oversizing could be useful in specific settings to counter the reduction in lumen diameter due to postimplant neointimal overgrowth; however, this overszing needs to be balanced against the decrease in metal coverage accompanying the use of oversized devices. Similar analysis for other devices is essential.
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Affiliation(s)
- Vera Sharashidze
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Eytan Raz
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Erez Nossek
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Svetlana Kvint
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Howard Riina
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurology (H.R., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Caleb Rutledge
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Jacob Baranoski
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Ayaz Khawaja
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Charlotte Chung
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Peter Kim Nelson
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Maksim Shapiro
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurology (H.R., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
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11
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Ramirez-Velandia F, Mensah E, Salih M, Wadhwa A, Young M, Muram S, Taussky P, Ogilvy CS. Endothelial Progenitor Cells: A Review of Molecular Mechanisms in the Pathogenesis and Endovascular Treatment of Intracranial Aneurysms. Neuromolecular Med 2024; 26:25. [PMID: 38886284 DOI: 10.1007/s12017-024-08791-4] [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: 02/19/2024] [Accepted: 05/09/2024] [Indexed: 06/20/2024]
Abstract
This comprehensive review explores the multifaceted role of endothelial progenitor cells (EPCs) in vascular diseases, focusing on their involvement in the pathogenesis and their contributions to enhancing the efficacy of endovascular treatments for intracranial aneurysms (IAs). Initially discovered as CD34+ bone marrow-derived cells implicated in angiogenesis, EPCs have been linked to vascular repair, vasculogenesis, and angiogenic microenvironments. The origin and differentiation of EPCs have been subject to debate, challenging the conventional notion of bone marrow origin. Quantification methods, including CD34+ , CD133+ , and various assays, reveal the influence of factors, like age, gender, and comorbidities on EPC levels. Cellular mechanisms highlight the interplay between bone marrow and angiogenic microenvironments, involving growth factors, matrix metalloproteinases, and signaling pathways, such as phosphatidylinositol-3-kinase (PI3K) and mitogen-activated protein kinase (MAPK). In the context of the pathogenesis of IAs, EPCs play a role in maintaining vascular integrity by replacing injured and dysfunctional endothelial cells. Recent research has also suggested the therapeutic potential of EPCs after coil embolization and flow diversion, and this has led the development of device surface modifications aimed to enhance endothelialization. The comprehensive insights underscore the importance of further research on EPCs as both therapeutic targets and biomarkers in IAs.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Emmanuel Mensah
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Aryan Wadhwa
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02215, USA
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Sandeep Muram
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02215, USA.
- Harvard Medical School, Boston, MA, USA.
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12
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Fiehler J, Ortega-Gutierrez S, Anagnostakou V, Cortese J, Cekirge HS, Fiorella D, Hanel R, Kulcsar Z, Lamin S, Liu J, Lylyk P, Marden FA, Pereira VM, Psychogios MN, Rice H, Rouchaud A, Saatci I, Siddiqui AH, Spelle L, Yang P, Grams A, Gounis MJ. Evaluation of flow diverters for cerebral aneurysm therapy: recommendations for imaging analyses in clinical studies, endorsed by ESMINT, ESNR, OCIN, SILAN, SNIS, and WFITN. J Neurointerv Surg 2024:jnis-2023-021404. [PMID: 38830670 DOI: 10.1136/jnis-2023-021404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/02/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Multiple studies and meta-analyses have described the technical and clinical outcomes in large cohorts of aneurysm patients treated with flow diverters (FDs). Variations in evaluation methodology complicate making comparisons among studies, hinder understanding of the device behavior, and pose an obstacle in the assessment of further advances in FD therapy. METHODS A multidisciplinary panel of neurointerventionalists, imaging experts, and neuroradiologists convened with the goal of establishing consensus recommendations for the standardization of image analyses in FD studies. RESULTS A standardized methodology is proposed for evaluating and reporting radiological outcomes of FD treatment of intracranial aneurysms. The recommendations include general imaging considerations for clinical studies and evaluations of longitudinal changes, such as neointimal lining and stenosis. They cover standards for classification of aneurysm location, morphology, measurements, as well as the assessment of aneurysm occlusion, wall apposition, and neck coverage. These reporting standards further define four specific braid deformation patterns: foreshortening, fish-mouthing, braid bump deformation, and braid collapse, collectively termed 'F2B2'. CONCLUSIONS When widely applied, standardization of methods of measuring and reporting outcomes will help to harmonize the assessment of treatment outcomes in clinical studies, help facilitate communication of results among specialists, and help enable research and development to focus on specific aspects of FD techniques and technology.
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Affiliation(s)
- Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Santiago Ortega-Gutierrez
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Vania Anagnostakou
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Jonathan Cortese
- Interventional Neuroradiology, Biĉetre Hospital, Le Kremlin Biĉetre, France
- UMR CNRS No. 7252, XLIM, Limoges, France
| | - H Saruhan Cekirge
- Radiology, Koru Health Group, Ankara, Turkey
- Private Office, Saruhan Cekirge, Ankara, Turkey
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
| | - Ricardo Hanel
- Stroke & Cerebrovascular Center, Baptist Neurological Institute and Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - Zsolt Kulcsar
- Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Saleh Lamin
- Interventional Neuroradiology and Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Neuroradiology, University Hospital Birmingham, Birmingham, UK
| | - Jianmin Liu
- Neurosurgery, Naval Medical University, Shanghai, China
| | - Pedro Lylyk
- Interventional Neuroradiology, Clinical Institute ENERI, Buenos Aires, Argentina
| | | | - Vitor M Pereira
- Department of Neurosurgery, Unity Health Toronto, Toronto, Ontario, Canada
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Hal Rice
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Aymeric Rouchaud
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
- University of Limoges, CNRS, XLIM, UMR 7252, Limoges, France
| | - Isil Saatci
- Radiology, Koru Health Group, Ankara, Turkey
| | - Adnan H Siddiqui
- Neurosurgery and Radiology, and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Laurent Spelle
- Interventional Neuroradiology, NEURI Brain Vascular Center, Biĉetre Hospital, Le Kremlin Biĉetre, France
- Paris-Saclay University Faculty of Medicine, Le Kremlin Biĉetre, France
| | - Pengfei Yang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Astrid Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Matthew J Gounis
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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13
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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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14
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Ma L, Hoz SS, Al-Bayati AR, Nogueira RG, Lang MJ, Gross BA. Flow Diverters with Surface Modification in Patients with Intracranial Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 185:320-326.e17. [PMID: 38160909 DOI: 10.1016/j.wneu.2023.12.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/24/2023] [Accepted: 12/25/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Flow diverters with surface modification (FDSM) are increasingly being used in the treatment of intracranial aneurysms (ANs). We aimed to evaluate the effectiveness and safety across different devices and antiplatelet therapies using a systematic review and meta-analysis. METHODS A systematic review was performed to identify original studies of ≥10 patients with intracranial ANs treated with FDSM from database inception through August 2023. Primary effectiveness outcome was the rate of complete AN occlusion at follow-up ≥6 months. Safety outcomes included ischemic stroke, hemorrhage, and in-stent thrombosis, and were stratified by FDSM devices and antiplatelet therapies. Certainty of evidence was evaluated following the Grading of Recommendations, Assessment, Development, and Evaluations approach. RESULTS Twenty-seven studies were included, yielding 2161 patients with 2373 ANs. A total of 70.5% of the ANs were located on the internal carotid artery (ICA). Total 10.3% were acutely ruptured. The complete AN occlusion rate was 72.3% at follow-up ≥6 months. Sensitivity analysis in the ICA AN cohort yielded comparable occlusion rates between Pipeline Flex Embolization Device-Shield (80.4%) and Phenox-hydrophilic polymer-coated (77.5%, P = 0.54), but a lower 66.2% rate for Flow Redirection Endoluminal Device-X (P = 0.02). The rate of in-stent thrombosis and stenosis tended to be higher in Phenox-hydrophilic polymer-coated (3.4%) and Flow Redirection Endoluminal Device-X (4.3%) versus Pipeline Flex Embolization Device-Shield (0.8%, P = 0.05). CONCLUSIONS FDSM were safe with satisfactory effectiveness for intracranial ANs. More specific investigations are warranted to explore their performance in ANs beyond the ICA and optimal antiplatelet therapy.
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Affiliation(s)
- Li Ma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samer S Hoz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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15
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Zhu Y, Zeng F, Liu J, Mu S, Zhang Y, Yang X. Evaluation of the EMBOPIPE flow diverter device: in vivo and in vitro experiments. Chin Neurosurg J 2024; 10:8. [PMID: 38468329 PMCID: PMC10929142 DOI: 10.1186/s41016-024-00360-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/29/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Although flow diverter device (FDD) has brought revolutionized advances in endovascular treatment of intracranial aneurysms, it also presents considerable drawbacks as well, as the innovation for novel device has never stopped. This preclinical research aims to evaluate the safety and efficacy of a newly developed FDD, the EMBOPIPE, through in vivo and in vitro experiments. METHODS Aneurysms were induced in 20 New Zealand white rabbits which were randomized to three follow-up groups according to the time elapsed after EMBOPIPE implantation (28, 90, and 180 days). Additional EMBOPIPEs were implanted in the abdominal aorta to cover the renal artery in nine rabbits. Angiography was performed immediately after device placement in all groups. Aneurysm occlusion, patency of renal arteries, and pathological outcomes were assessed. For the in vitro experiments, we measured the thrombogenic potential of EMBOPIPEs (n = 5) compared with bare stents (n = 5) using the Chandler loop model. Evaluation indicators were the platelet counts, macroscopic observations and scanning electron microscopy. RESULTS EMBOPIPEs were successfully deployed in 19 of 20 rabbit aneurysms (95.0%). The rates of complete or near-complete aneurysm occlusion were 73.3%, 83.3%, and 100% in the 28-, 90-, and 180-day groups, respectively. All renal arteries covered by EMBOPIPEs remained patent, and the mean difference in renal artery diameter before and after the device placement in the three groups was 0.07 mm, 0.10 mm, and 0.10 mm, respectively (p = 0.77). Renal pathology was normal in all cases. The pathological findings of the aneurysms were as follows: thickened and adequate neointimal coverage at the aneurysm neck, minimal inflammatory response, near-complete smooth muscle cell layer, and endothelialization along the device. In vitro experiments showed that the platelet counts were significantly higher in EMBOPIPE blood samples than in bare stent samples and that platelet adhesion to the device was lower in the EMBOPIPE stent struts compared with bare stent struts through macroscopic observations and scanning electron microscopy. CONCLUSIONS The EMBOPIPE can achieve high rates of aneurysm occlusion while maintaining excellent branch artery patency. It exhibited wonderful pathological results. This novel device with phosphorylcholine surface modification could reduce platelet thrombus attached to the stent struts.
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Affiliation(s)
- Yongnan Zhu
- Department of Beijing Neurosurgical Institute, Fengtai District, Capital Medical University, No. 119, South Fourth Ring West Road, Beijing, 100070, People's Republic of China
| | - Fanyan Zeng
- Fengxian District, Heartcare Medical Technology Co., Ltd, Building 38, No. 356 Zhengbo Road, Shanghai, 200000, People's Republic of China
| | - Jian Liu
- Neurosurgical Institute & Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119, South Fourth Ring West Road, Beijing, 100070, People's Republic of China
| | - Shiqing Mu
- Neurosurgical Institute & Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119, South Fourth Ring West Road, Beijing, 100070, People's Republic of China
| | - Ying Zhang
- Department of Beijing Neurosurgical Institute, Fengtai District, Capital Medical University, No. 119, South Fourth Ring West Road, Beijing, 100070, People's Republic of China.
| | - Xinjian Yang
- Department of Beijing Neurosurgical Institute, Fengtai District, Capital Medical University, No. 119, South Fourth Ring West Road, Beijing, 100070, People's Republic of China.
- Neurosurgical Institute & Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119, South Fourth Ring West Road, Beijing, 100070, People's Republic of China.
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16
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Pineda-Castillo SA, Jones ER, Laurence KA, Thoendel LR, Cabaniss TL, Zhao YD, Bohnstedt BN, Lee CH. Systematic Review and Meta-Analysis of Endovascular Therapy Effectiveness for Unruptured Saccular Intracranial Aneurysms. STROKE (HOBOKEN, N.J.) 2024; 4:e001118. [PMID: 38846323 PMCID: PMC11152505 DOI: 10.1161/svin.123.001118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/13/2023] [Indexed: 06/09/2024]
Abstract
Background Currently, endovascular treatment of intracranial aneurysms (ICAs) is limited by low complete occlusion rates. The advent of novel endovascular technology has expanded the applicability of endovascular therapy; however, the superiority of novel embolic devices over the traditional Guglielmi detachable coils (GDCs) is still debated. We performed a systematic review of literature that reported Raymond-Roy occlusion classification (RROC) rates of modern endovascular devices to determine their immediate and follow-up occlusion effectiveness for the treatment of unruptured saccular ICAs. Methods A search was conducted using electronic databases (PUBMED, Cochrane, ClinicalTrials.gov, Web of Science). We retrieved studies published between 2000-2022 reporting immediate and follow-up RROC rates of subjects treated with different endovascular ICA therapies. We extracted demographic information of the treated patients and their reported angiographic RROC rates. Results A total of 80 studies from 15 countries were included for data extraction. RROC rates determined from angiogram were obtained for 21,331 patients (72.5% females, pooled mean age: 58.2 (95% CI: 56.8-59.6), harboring 22,791 aneurysms. The most frequent aneurysm locations were the internal carotid artery (46.4%, 95% CI: 41.9%-50.9%), the anterior communicating artery (26.4%, 95% CI: 22.5%-30.8%), the middle cerebral artery (24.5%, 95% CI:19.2%-30.8%) and the basilar tip (14.4%, 95% CI:11.3%-18.3%). The complete occlusion probability (RROC-I) was analyzed for GDCs, the Woven EndoBridge (WEB), and flow diverters. The RROC-I rate was the highest in balloon-assisted coiling (73.9%, 95% CI: 65.0%-81.2%) and the lowest in the WEB (27.8%, 95% CI:13.2%-49.2%). The follow-up RROC-I probability was homogenous in all analyzed devices. Conclusions We observed that the coil-based endovascular therapy provides acceptable rates of complete occlusion, and these rates are improved in balloon-assisted coils. Out of the analyzed devices, the WEB exhibited the shortest time to achieve >90% probability of follow-up complete occlusion (~18 months). Overall, the GDCs remain the gold standard for endovascular treatment of unruptured saccular aneurysms.
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Affiliation(s)
- Sergio A. Pineda-Castillo
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK, USA
| | - Evan R. Jones
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK, USA
| | - Keely A. Laurence
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK, USA
| | - Lauren R. Thoendel
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK, USA
| | - Tanner L. Cabaniss
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK, USA
| | - Yan D. Zhao
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Bradley N. Bohnstedt
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chung-Hao Lee
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK, USA
- Department of Bioengineering, University of California Riverside, Riverside, CA, USA
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Salem MM, Khorasanizadeh M, Nwajei F, Gomez-Paz S, Akamatsu Y, Jordan N, Maroufi SF, Thomas AJ, Ogilvy CS, Moore JM. Predictors of aneurysmal occlusion following intracranial aneurysms treatment with pipeline embolization device. Acta Neurochir (Wien) 2023; 165:2801-2809. [PMID: 37615726 DOI: 10.1007/s00701-023-05740-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/28/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE Pipeline embolization device (PED) is thought to induce aneurysmal occlusion through diversion of flow away from the aneurysmal sac with subsequent thrombosis and endothelialization. The impact of different factors especially hypertension (HTN)-a known predisposing factor to hypercoagulability and altered endothelial function-on aneurysmal occlusion after flow diversion has not been studied. We sought to determine predictors of aneurysmal occlusion following PED treatment focusing on impact of blood pressure. METHODS Database of patients with cerebral aneurysms treated with PED from 2013 to 2019 at our institution was retrospectively reviewed. Patients were defined as hypertensive if (1) they had a documented history of HTN requiring anti-HTN medications or (2) average systolic blood pressure on three measurements was > 130 mmHg. The primary outcome was aneurysm occlusion status at the last imaging follow-up. Multivariable logistic regression model was constructed to assess the effect of HTN on occlusion, controlling for age, smoking, aneurysmal size, fusiform morphology, posterior circulation location, and incorporated branches. RESULTS A total of 331 aneurysms in 294 patients were identified for this analysis. The mean age was 59 years (79.9% female). Fifty-five percent of the cohort were classified as hypertensive. When controlling for other potential confounders, hypertensive patients trended toward higher odds of achieving complete occlusion compared to non-hypertensive patients (OR = 2.05; 95% CI = 0.99-4.25; p = 0.052). Meanwhile, age (OR = 0.91; 95% CI = 0.88-0.95; p < 0.001) and an incorporated branch into an aneurysm (OR = 0.22; 95% CI = 0.08-0.58; p < 0.002) were associated with decreased odds for complete aneurysmal occlusion. CONCLUSION Hypertensive patients show a trend toward higher odds of achieving complete occlusion when controlling for potential confounders. The HTN-induced hypercoagulable state, enhanced endothelial activation, and altered extracellular matrix regulation might be the contributing factors. Further research is warranted to explore clinical implications of these findings.
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Affiliation(s)
- Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - MirHojjat Khorasanizadeh
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Felix Nwajei
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Yosuke Akamatsu
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Noah Jordan
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Hospital, Camden, NJ, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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18
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Krishnakumar H, Mascitelli J, Hassan A, Leary J, Son C. Treatment of cerebral aneurysms with flow diversion or stent assisted coiling in patients on concurrent oral anticoagulation. Neuroradiol J 2023; 36:464-469. [PMID: 36409963 PMCID: PMC10588601 DOI: 10.1177/19714009221114443] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Flow diversion and stent assisted coiling are increasingly utilized strategies in the endovascular treatment of cerebral aneurysms. Ischemic and hemorrhagic complications play an important role in the outcome following such embolizations. Little is published regarding patients on concurrent oral anticoagulation and undergoing such embolizations and the rates of complications and patient outcomes. MATERIALS AND METHODS Retrospective data for consecutive patients on concurrent oral anticoagulation undergoing flow diversion or stent assisted coiling for cerebral aneurysms was accessed from databases at the participating sites. Patient demographics, comorbidities, antiplatelet regimens, aneurysm characteristics, complications, and radiographic results were recorded and descriptive statistics reported. RESULTS Eleven patients were identified undergoing embolization in the setting of preoperative anticoagulant use and included seven patients undergoing flow diversion and four patients undergoing stent assisted coiling. There was a wide range of antiplatelet and anticoagulant management strategies. There were four major complications in three patients (27.2%) to include two serious bleeding events in addition to ischemic strokes. Both serious bleeding events occurred in patients continued on oral anticoagulation with the addition of antiplatelets. At a mean follow-up of 9.6 months, three aneurysms had continued filling for a good radiographic outcome of 72.7%. CONCLUSIONS Anticoagulant and antiplatelet use in the setting of flow diversion or stent assisted coiling may carry increased risks as compared to historical norms and, for flow diversion, offer decreased efficacy.
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Affiliation(s)
- Hari Krishnakumar
- Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Ameer Hassan
- Department of Neurology, University of Texas Rio Grande Valley Medical School, Harlingen, TX, USA
- Valley Baptist Medical Center, Harlingen, TX, USA
| | - Jonathan Leary
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Colin Son
- Neurosurgical Associates of San Antonio, San Antonio, TX, USA
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX, USA
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19
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Sirakova K, Sirakov A, Ninov K, Minkin K, Sirakov S. Comaneci stent-angioplasty for the optimization of inadequately deployed flow diverter stents. Interv Neuroradiol 2023:15910199231184520. [PMID: 37402394 DOI: 10.1177/15910199231184520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND AND PURPOSE In endovascular procedures, inadequate deployment of a flow diverter stent is a highly concerning technical complication that can lead to acute parent vessel occlusion and ischaemic events. This study aimed to assess the off-label use of the Comaneci device in managing technical difficulties associated with flow diversion. MATERIALS AND METHODS We conducted an analysis of all flow diverter procedures documented in our prospectively collected database. Our objective was to identify patients with inadequately deployed implants who underwent Comaneci stent-angioplasty. Both Comaneci 17 and Comaneci 21 devices were utilized to address and remediate technical complications related to stent deployment. We reviewed anatomical features, technical details, intraprocedural complications, as well as clinical and angiographic outcomes. RESULTS Thirty-one Comaneci devices were employed to remediate 31 inadequately deployed flow diverter stents. Successful resolution of technical complications associated with flow diverter placement was achieved in all attempted cases. No clinically significant complications were attributed to the technique, and no mortality was observed during the study. CONCLUSION Technical issues arising from flow diverter stent deployment are formidable complications. Familiarity with appropriate corrective manoeuvres is essential to achieve successful outcomes. The Comaneci device can be safely and effectively incorporated into the range of techniques used to rectify inadequately deployed stents.
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Affiliation(s)
| | | | - Kristian Ninov
- Neurosurgery Department, UH St Ivan Rilski, Sofia, Bulgaria
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20
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Suzuki Y, Toma N, Inoue K, Ichikawa T, Nishikawa H, Miura Y, Fujimoto M, Yasuda R, Maeda M, Suzuki H. Evaluation of Intra-Aneurysmal Residual Blood Flow with the iMSDE T1-Black Blood Imaging after Flow Diverter Treatment. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:159-166. [PMID: 37609573 PMCID: PMC10442175 DOI: 10.5797/jnet.oa.2023-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/25/2023] [Indexed: 08/24/2023]
Abstract
Objective We aimed to evaluate the efficacy of the "improved motion-sensitized driven-equilibrium (iMSDE)"-prepared T1-weighted black blood (T1-BB) MRI for monitoring treatment effect with a flow diverter (FD) for cerebral aneurysms. Methods Following the exclusion of concomitant coiling and retreatment cases from 60 consecutive cases of cerebral aneurysms treated with FDs at our institution, 32 with imaging data were included in the analysis. Detectability of residual blood flow within the aneurysms was validated as follows: 1) comparison of MRI sequences (iMSDE-prepared T1-BB images, T1-weighted images [ T1WI], and time-of-flight [ TOF]-MRA) in cases of incompletely occluded aneurysms and 2) comparison of angiography and MRI sequences in the same period. Results 1) The probability of diagnosing intra-aneurysmal blood flow was significantly higher with iMSDE-prepared T1-BB (iMSDE-prepared T1-BB vs. T1WI, p <0.001; iMSDE-prepared T1-BB vs. TOF-MRA, p <0.001). 2) The diagnostic accuracy of residual aneurysmal blood flow was significantly higher with iMSDE-prepared T1-BB than that with T1WI (p = 0.032). Furthermore, in cases of incomplete occlusion, the probability of detecting intra-aneurysmal blood flow was significantly higher with iMSDE-prepared T1-BB (iMSDE-prepared T1-BB vs. T1WI, p <0.001; iMSDE-prepared T1-BB vs. TOF-MRA, p = 0.023). Conclusion Our results demonstrated that iMSDE-prepared T1-BB could help distinguish between blood flow and thrombus within the aneurysms after FD treatment, especially in the early stages of FD treatment.
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Affiliation(s)
- Yume Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Naoki Toma
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Katsuhiro Inoue
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
| | - Tomonori Ichikawa
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hirofumi Nishikawa
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yoichi Miura
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masashi Fujimoto
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Ryuta Yasuda
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masayuki Maeda
- Department of Neuroradiology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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21
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Matsukawa H, Uchida K, Rajbhandari S, Shirakawa M, Yoshimura S. Difference in the cumulative incidence of aneurysmal occlusion by Flow Re-direction Endoluminal Device and Pipeline Embolization Device in the treatment of unruptured internal carotid artery aneurysms: a propensity score-matched cohort study. Neurosurg Rev 2023; 46:125. [PMID: 37243833 DOI: 10.1007/s10143-023-02026-z] [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: 04/04/2023] [Revised: 04/24/2023] [Accepted: 05/06/2023] [Indexed: 05/29/2023]
Abstract
The introduction of flow diverters (FDs) has represented a paradigm shift in the management of unruptured cerebral aneurysms (UCA). Flow Re-direction Endoluminal Devices (FREDs) and Pipeline Embolization Devices (PEDs) have gained widespread popularity. We aimed to investigate the cumulative incidence of aneurysm occlusion. A total of 195 patients with 199 UCAs were analyzed retrospectively. The outcomes were aneurysmal occlusion during the follow-up, a modified Rankin Scale score of 0-2 at 90 days, additional treatment, major stroke, and steno-occlusive events of FD. Propensity score-matched analysis was performed, controlling for age, sex, aneurysmal size, and location of the internal carotid artery (ICA) aneurysm. Non-ICA aneurysms were excluded from matching. During the follow-up period (median, 366 days), complete and satisfactory aneurysmal occlusions were observed in 128 (68%) and 148 (78%) of 189 UCAs in the unmatched cohort. The 142 (71 each) propensity score-matched cohort was complied. The FRED group had a higher cumulative incidence of ICA aneurysm occlusion (complete: HR 2.7, 95% CI 1.4-5.1, p = 0.0025; satisfactory: HR 2.4, 95% CI 1.1-5.2, p = 0.025). The proportion of additional treatment was significantly smaller in the FRED group (OR 0.077, 95% CI 0.010-0.57, p = 0.0007). Other outcomes showed no significant differences. Propensity score-matched analysis indicated that FRED might have a higher cumulative incidence of aneurysmal occlusion in the treatment of unruptured ICA aneurysms. Whether a cumulative incidence of aneurysmal occlusion may differ by the type of FDs warrants further investigation.
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Affiliation(s)
- Hidetoshi Matsukawa
- Department of Neurosurgery, Takarazuka City Hospital, Takarazuka, Hyogo, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, 663-8501, Japan
| | - Saujanya Rajbhandari
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, 663-8501, Japan
| | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, 663-8501, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, 663-8501, Japan.
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22
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Kitamura T, Fujii T, Yatomi K, Teranishi K, Mitome-Mishima Y, Oishi H. Safety and efficacy of pipeline embolization device treatments for intradural internal carotid artery aneurysms in a single center in a Japanese population. Surg Neurol Int 2023; 14:92. [PMID: 37025526 PMCID: PMC10070317 DOI: 10.25259/sni_1165_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/25/2023] [Indexed: 03/19/2023] Open
Abstract
Background:
The pipeline embolization device (PED) is the most common flow diverter device in the world. To date, there have been no reports of treatment outcomes specific to intradural internal carotid artery (ICA) aneurysms. The safety and efficacy of the PED treatments for intradural ICA aneurysms are reported.
Methods:
131 patients with 133 aneurysms underwent PED treatments for intradural ICA aneurysms. The mean aneurysm dome size and neck length were 12.7 ± 4.3 mm and 6.1 ± 2.2 mm, respectively. We used adjunctive endosaccular coil embolization for 88 aneurysms (66.2%). A total of 113 aneurysms (85%) were angiographically followed up 6 months following the procedure, and 93 aneurysms (69.9%) were followed up for 1 year.
Results:
The angiographic outcome at 6 months showed that 94 (83.2%) aneurysms had O’Kelly-Marotta (OKM) grade D, 6 (5.3%) had C, 10 (8.8%) had B, and 3 (2.7%) had A. At 1 year, 82 (88.2%) aneurysms had OKM grade D, 6 (6.5%) had C, 3 (3.2%) had B, and 2 (2.2%) had A. Multivariate analysis showed that aneurysm neck size and adjunctive coiling were statistically significant in aneurysm occlusion status. Major morbidity modified Rankin Scale >2 and mortality rates related to procedures were 3.0% and 0%, respectively. Delayed aneurysm ruptures were not observed.
Conclusion:
These results reveal that PED treatment of intradural ICA aneurysms is safe and efficacious. The combined use of adjunctive coil embolization not only prevents delayed aneurysm ruptures but also contributes to an increase in the rate of complete occlusion.
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Affiliation(s)
- Takayuki Kitamura
- Department of Neuroendovascular Therapy and Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Yumiko Mitome-Mishima
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy and Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
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23
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Thormann M, Sillis N, Thoma T, Altenbernd J, Berger B, Cioltan A, Loehr C, Bohner G, Siebert E, Nordmeyer H, Mpotsaris A, Behme D. The DERIVO®2 Embolization Device in the treatment of ruptured and unruptured intracranial aneurysms: A multicenter analysis. Interv Neuroradiol 2022:15910199221142643. [PMID: 36567499 DOI: 10.1177/15910199221142643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Flow diverters are an increasingly used treatment option for intracranial aneurysms. A recent addition to the European market is the DERIVO®2 Embolization Device (DED2), promising improved radiopacity. We aimed to assess the safety and efficacy of the DED2 regarding angiographic and clinical outcomes in ruptured and unruptured cerebral aneurysms. METHODS We performed a multicenter trial at six interventional centers. Data were prospectively collected and all patients treated with the DED2 were included. The primary endpoint was angiographic aneurysm occlusion at 6 months as assessed by the O'Kelly Marotta (OKM) grading scale with a favorable outcome definition of OKM C + D. Clinical outcome was evaluated according to the modified Rankin scale (mRS). RESULTS Between August 2020 and July 2021, 37 patients were treated with the DED2 and were included in our analysis. Five patients presented with ruptured aneurysms. Median age was 60 years, 27 patients were female, and 10 male. Median mRS was 0 (range 0-4). Mean aneurysm size was 8.9 ± 7.1 mm with a mean neck size of 6.5 ± 6.1. The DED2 fully opened at deployment in all cases. Clinical follow-up was available for 30 patients (81%). Twenty-five (83%) had an mRS of 0 or 1. Three patients with ruptured aneurysms died during the follow-up period. No treatment-related major morbidity was observed. Follow-up imaging was available in 27 (90%) patients, with 23 patients (85%) showing satisfactory aneurysm occlusion OKM grade C-D. CONCLUSION In this small cohort, the DED2 provided safe and effective treatment of ruptured and unruptured intracranial aneurysms.
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Affiliation(s)
- Maximilian Thormann
- University Clinic for Neuroradiology, 39067University Hospital Magdeburg, Magdeburg, Germany
| | - Nele Sillis
- University Clinic for Neuroradiology, 39067University Hospital Magdeburg, Magdeburg, Germany
| | - Taina Thoma
- University Clinic for Neuroradiology, 39067University Hospital Magdeburg, Magdeburg, Germany
| | - Jens Altenbernd
- Department of Radiology and Neuroradiology, Gemeinschaftskrankenhaus Herdecke, Herdecke, Germany
| | - Björn Berger
- Department of Neuroradiology, Evangelisches Klinikum Bethel, Universitätsklinikum OWL, Bielefeld, Germany
| | - Andrea Cioltan
- Department of Radiology and Neuroradiology, 39546Klinikum Vest GmbH Behandlungszentrum Knappschaftskrankenhaus Recklinghausen, Recklinghausen, Germany
| | - Christian Loehr
- Department of Radiology and Neuroradiology, Klinikum Vest Knappschaftskrankenhaus Recklinghausen, Recklinghausen, Germany
| | - Georg Bohner
- Institute of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hannes Nordmeyer
- Department of Interventional Neuroradiology Radprax, 39655St Lukas Klinik, Solingen, Germany
- School of Medicine, Department of Health, 12263Witten/Herdecke University, Witten, Germany
| | - Anastasios Mpotsaris
- Department for Diagnostic and Interventional Radiology and Neuroradiology, Munich Clinic Harlaching, Munich, Germany
| | - Daniel Behme
- University Clinic for Neuroradiology, 39067University Hospital Magdeburg, Magdeburg, Germany
- Research Campus STIMULATE, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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24
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El Naamani K, Saiegh FA, Chen CJ, Abbas R, Sioutas GS, Amllay A, Shehabeldine M, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Treatment of cerebral aneurysms with the FRED Jr flow-diverting stent: A case series and meta-analysis. Clin Neurol Neurosurg 2022; 223:107483. [DOI: 10.1016/j.clineuro.2022.107483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/29/2022] [Accepted: 10/18/2022] [Indexed: 11/30/2022]
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25
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Khorasanizadeh M, Shutran M, Schirmer CM, Salem MM, Ringer AJ, Grandhi R, Mitha AP, Levitt MR, Jankowitz BT, Taussky P, Thomas AJ, Moore JM, Ogilvy CS. North American multicenter experience with the Flow Redirection Endoluminal Device in the treatment of intracranial aneurysms. J Neurosurg 2022; 138:933-943. [PMID: 36087324 DOI: 10.3171/2022.7.jns221371] [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: 06/08/2022] [Accepted: 07/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow diverters have revolutionized the endovascular treatment of intracranial aneurysms. Here, the authors present the first large-scale North American multicenter experience using the Flow Redirection Endoluminal Device (FRED) in the treatment of cerebral aneurysms. METHODS Consecutive cerebral aneurysms treated with FRED at 7 North American centers between June 2020 and November 2021 were included. Data collected included patient demographic characteristics, aneurysm characteristics, periprocedural and long-term complications, modified Rankin Scale (mRS) scores, and radiological follow-up. RESULTS In total, 133 aneurysms in 116 patients were treated with 123 FRED deployment procedures and included in this study. One hundred twenty-six aneurysms (94.7%) were unruptured, 117 (88.0%) saccular, and 123 (92.5%) located in anterior circulation. The mean (range) aneurysm maximal width and neck width sizes were 7.2 (1.5-42.5) mm and 4.1 (1.0-15.1) mm, respectively. Successful FRED deployment was achieved in 122 procedures (99.2%). Adjunctive coiling was used in 4 procedures (3.3%). Radiological follow-up was available for 101 aneurysms at a median duration of 7.0 months. At last follow-up, complete occlusion was observed in 55.4% of patients, residual neck in 8.9%, and filling aneurysm in 35.6%; among cases with radiological follow-up duration > 10 months, these values were 21/43 (48.8%), 3/43 (7.0%), and 19/43 (44.2%), respectively. On multivariate regression analysis, age (OR 0.93, p = 0.001) and aneurysm neck size (OR 0.83, p = 0.048) were negatively correlated with odds of complete occlusion at latest follow-up. The retreatment rate was 6/124 (4.8%). The overall complication rate was 31/116 (26.7%). Parent vessel occlusion, covered branch occlusion, and in-stent stenosis were detected in 9/99 (9.1%), 6/63 (9.5%), and 15/99 (15.2%) cases, respectively. The FRED-related, symptomatic, thromboembolic, and hemorrhagic complication rates were 22.4%, 12.9%, 6.9%, and 0.9% respectively. The morbidity rate was 10/116 patients (8.6%). There was 1 death due to massive periprocedural internal carotid artery stroke, and 3.6% of the patients had an mRS score > 2 at the last follow-up (vs 0.9% at baseline). CONCLUSIONS As the first large-scale North American multicenter FRED experience, this study confirmed the ease of successful FRED deployment but suggested lower efficacy and a higher rate of complications than reported by previous European and South American studies on FRED and other flow-diverting devices. The authors recommend judicious use of this device until future studies can better elucidate the long-term outcomes of FRED treatment.
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Affiliation(s)
- MirHojjat Khorasanizadeh
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Max Shutran
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Mohamed M Salem
- 3Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew J Ringer
- 4Mayfield Clinic, TriHealth Neuroscience Institute, Good Samaritan Hospital, Cincinnati, Ohio
| | - Ramesh Grandhi
- 5Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Alim P Mitha
- 6Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Michael R Levitt
- 7Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | - Brian T Jankowitz
- 3Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Philipp Taussky
- 5Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Ajith J Thomas
- 8Department of Neurological Surgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Justin M Moore
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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26
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Zhang H, Li L, Zhang H, Liu J, Song D, Zhao Y, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Luo B, Shao Q, Chang K, Zhang Q, He Y, Zhang P, Yang X, Li TX. Small and Medium-Sized Aneurysm Outcomes Following Intracranial Aneurysm Treatment Using the Pipeline Embolization Device: A Subgroup Analysis of the PLUS Registry. Front Neurol 2022; 13:881353. [PMID: 35711259 PMCID: PMC9197587 DOI: 10.3389/fneur.2022.881353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/25/2022] [Indexed: 11/24/2022] Open
Abstract
Objective The purpose of this work was to summarize the real-world safety and efficacy of Pipeline Embolization Device (PED) therapy for small and medium-sized intracranial aneurysms in China. Methods Patients from the PED in China post-market multi-center registry study (PLUS) with aneurysms smaller than 12 mm were selected. Radiographic outcomes were assessed using digital subtraction angiography. Clinical outcomes included functional outcomes (modified Rankin Scale, MRS) in the early postoperative period ( ≤ 30 days) and early postoperative complications associated with PED therapy. Results A total of 652 patients with a combined 754 aneurysms were included in this study (mean age of 53.9 ± 10.3 years, 68.7% women). Mean aneurysm diameter was 6.78 ± 2.67 mm. Of the 687 stents deployed, 99.7% (685/689) were successfully deployed. In this study, 64.7% (488/754) of aneurysms were treated with only the PED, whereas 35.3% (266/754) were subjected to PED-assisted therapy. Radiographic outcome at the last follow-up (median time: seven months) was available for 64.3% (485/754) of the aneurysms. 82.5% (400/485) of aneurysms demonstrated complete occlusion (Raymond Roy Grade I). 81.4% (395/485) of aneurysms were found to meet the study's primary effectiveness outcome. At the early postoperative period, the mRS score was determined to be 0–2 vs. 3-6 in 98.2% (640/652) vs. 1.8% (12/652) of the cases, respectively. The combined major morbidity and mortality rate was 3.2% (21/652). Conclusion In the largest study of PED therapy for small and medium-sized intracranial aneurysms to date, pipeline-assisted coil embolization was chosen more often than multiple stent implantation for aneurysm treatment, demonstrating good results, high surgical success rates, high occlusion rates, and low morbidity and mortality. Clinical Trial Registration www.ClinicalTrials.gov, identifier: NCT03831672.
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Affiliation(s)
- Hongyun Zhang
- Cerebrovascular Department of Interventional Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China.,Neurosurgery Department of Stroke Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China
| | - Li Li
- Cerebrovascular Department of Interventional Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China.,Neurosurgery Department of Stroke Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China
| | - Hongqi Zhang
- Department of Neurosurgery, International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianmin Liu
- Changhai Hospital Affiliated to Naval Medical University, Shanghai, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Yunyan Wang
- Qilu Hospital of Shandong University, Jinan, China
| | - Wenfeng Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yang Wang
- First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jieqing Wan
- School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Guohua Mao
- Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huaizhang Shi
- First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bin Luo
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiuji Shao
- Cerebrovascular Department of Interventional Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China.,Neurosurgery Department of Stroke Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China
| | - Kaitao Chang
- Cerebrovascular Department of Interventional Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China.,Neurosurgery Department of Stroke Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China
| | - Qianqian Zhang
- Cerebrovascular Department of Interventional Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China.,Neurosurgery Department of Stroke Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China
| | - Yingkun He
- Cerebrovascular Department of Interventional Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China.,Neurosurgery Department of Stroke Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China
| | - Peng Zhang
- Department of Neurosurgery, International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tian Xiao Li
- Cerebrovascular Department of Interventional Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China.,Neurosurgery Department of Stroke Center, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China
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27
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Lee JK, Choi JH, Kim BS, Shin YS. Recovery from Cranial Nerve Symptoms after Flow Diversion without Coiling for Unruptured Very Large and Giant ICA Aneurysms. AJNR Am J Neuroradiol 2022; 43:736-740. [PMID: 35450858 PMCID: PMC9089254 DOI: 10.3174/ajnr.a7498] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Cranial nerve symptoms, including visual impairment and ophthalmoplegia, are one of the most common presentations of very large and giant (≥15 mm) ICA aneurysms. In this study, we evaluated the treatment outcomes of flow diversion and conventional coiling in terms of recovery from cranial nerve symptoms and postoperative complications. MATERIALS AND METHODS Seventy-nine patients with unruptured ICA aneurysms of >15 mm who were treated with flow diversion or conventional coiling between December 2009 and December 2020 were retrospectively evaluated. We compared the radiologic and clinical outcomes, including recovery from cranial nerve symptoms, between the 2 groups. RESULTS Twenty-eight of 49 patients (57.1%) treated with flow diversion and 10 of 30 patients (33.3%) treated with conventional coiling initially presented with cranial nerve symptoms (P = .068). In the clinical follow-up, the symptom recovery rate was significantly higher in those treated with flow diversion (15 [50%] versus 3 [25%] with conventional coiling, P = .046). Multivariate logistic regression analysis demonstrated that flow diversion was significantly associated with symptom recovery (OR, 7.425; 95% CI, 1.091-50.546; P = .040). The overall postoperative complication rate was similar (flow diversion, 10 [20.4%]; conventional coiling, 6 [20.0%], P = .965), though fatal hemorrhagic complications occurred only in patients with intradurally located aneurysms treated with flow diversion (4 [8.2%] versus 0 [0.0%] with coiling, P = .108). CONCLUSIONS Flow diversion without coiling for very large and giant ICA aneurysms yielded a higher rate of recovery from cranial nerve symptoms, but it may be related to an increased hemorrhagic complication rate, especially for intradurally located aneurysms.
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Affiliation(s)
- J K Lee
- From the Departments of Neurosurgery (J.K.L., J.H.C., Y.S.S.)
| | - J H Choi
- From the Departments of Neurosurgery (J.K.L., J.H.C., Y.S.S.)
| | - B-S Kim
- Radiology (B.-S.K.), Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Y S Shin
- From the Departments of Neurosurgery (J.K.L., J.H.C., Y.S.S.)
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28
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Enriquez-Marulanda A, Penumaka A, Ogilvy CS, Thomas AJ, Moore JM. Safety and Efficacy of the Off-Label Use of Pipeline Embolization Device Based on the 2018 Food and Drug Administration-Approved Indications for Intracranial Aneurysms: A Single-Center Retrospective Cohort Study. Neurosurgery 2022; 90:700-707. [PMID: 35319533 DOI: 10.1227/neu.0000000000001891] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pipeline embolization device (PED; ev3/Covidien) has proven safe and effective for treating selected intracranial aneurysms. This device's versatility and popularity have driven increased interest in expanding the latest 2018 Food and Drug Administration-approved indications. OBJECTIVE To compare "off-label" and "on-label" PED treatment. METHODS Retrospective analysis of aneurysms treated with PED at a single center from 2013 to 2019. Comparisons were made based on the 2018 Food and Drug Administration-approved indications. RESULTS A total of 492 treated aneurysms were included (65.2% on-label and 34.8% off-label). Aneurysm complete and near-complete occlusion rate was nonsignificantly lower in the off-label group (80.9% vs 85.7%; P = .19). Off-label treatment had higher rate of poor functional outcomes (modified Rankin Scale [mRS] >2: 10.3% vs 3.5%; P = .002). Although pretreatment mRS was already higher in the off-label group (5.3% vs 0.3%; P < .001) and there were no differences in mRS worsening during follow-up (5.5% vs 2.9%; P = .15). We also found a trend to a higher rate of intracranial hemorrhagic complications in the off-label group (4.7% vs 1.6%; P = .05), but there were no differences in hemorrhages requiring surgical intervention (1.8% vs 1.3%; P = .65). There were no differences in retreatment, thromboembolic complications, and mortality rates. CONCLUSION Off-label PED treatment may be considered for select aneurysms, which are challenging to treat with other techniques. These cases have similar complete and near-complete occlusion rates compared with on-label cases. There are, however, higher risks of poor functional outcomes despite similar rates of thromboembolic and hemorrhagic complications. This is partly explained by the significantly higher pretreatment mRS score in the off-label group.
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Roloff C, Berg P. Effect of flow diverter stent malposition on intracranial aneurysm hemodynamics—An experimental framework using stereoscopic particle image velocimetry. PLoS One 2022; 17:e0264688. [PMID: 35235597 PMCID: PMC8890739 DOI: 10.1371/journal.pone.0264688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/15/2022] [Indexed: 12/04/2022] Open
Abstract
Background Flow-diverting stents are increasingly used for the minimally-invasive treatment of intracranial aneurysms. However, a correct positioning of such devices can be challenging due to varying vessel diameters as well as the complex anatomy of the neurovasculature. As a consequence, unsuccessful treatment outcomes are increasingly reported requiring an improvement of the understanding of stent-induced flow modification. Methods To evaluate the effect of different degrees of flow diverter stent malposition on intra-aneurysmal hemodynamic changes, a controlled hemodynamic configuration was created using an idealized intracranial aneurysms model. Afterwards, four different treatment scenarios were reproduced comprising of 1) the ideal treatment, 2) an insufficient wall apposition in the region of the ostium, 3) a distorted device migrating into the aneurysm sac and 4) an inaccurately deployed stent due to wrong release location. For the assessment of the individual flow modifications, high-resolution stereoscopic particle image velocimetry (PIV) measurements were carried out. Results The analysis of the precise in-vitro PIV measurements reveals that in all cases a considerable reduction of the cycle-averaged and peak-systolic velocity was obtained. Compared to the untreated aneurysm configuration, the flow reduction ranged from 63% (scenario 4) up to 89% (scenario 3). The ideal treatment reached a reduction of 78%, which is known to be sufficient for a successful therapy. However, inaccurate device positioning leads to increased oscillating flow towards the lateral directions reducing the chances of sufficient thrombus formation. Conclusions High-resolution in-vitro PIV measurements enable an accurate quantification of the treatment efficacy for flow-diverting devices. Furthermore, insufficient treatment outcomes can be reproduces allowing for an assessment of intra-aneurysmal hemodynamic changes.
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Affiliation(s)
- Christoph Roloff
- Laboratory of Fluid Dynamics and Technical Flows, University of Magdeburg, Magdeburg, Germany
| | - Philipp Berg
- Laboratory of Fluid Dynamics and Technical Flows, University of Magdeburg, Magdeburg, Germany
- Research Campus STIMULATE, University of Magdeburg, Magdeburg, Germany
- * E-mail:
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30
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Berod A, Chnafa C, Mendez S, Nicoud F. A heterogeneous model of endovascular devices for the treatment of intracranial aneurysms. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2022; 38:e3552. [PMID: 34806847 DOI: 10.1002/cnm.3552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/25/2021] [Accepted: 07/31/2021] [Indexed: 06/13/2023]
Abstract
Numerical computations of hemodynamics inside intracranial aneurysms treated by endovascular braided devices such as flow-diverters contribute to understanding and improving such treatment procedures. Nevertheless, these simulations yield high computational and meshing costs due to the heterogeneity of length scales between the dense weave of the fine struts of the device and the arterial volume. Homogeneous strategies developed over the last decade to circumvent this issue substitute local dissipations due to the wires with a global effect in the form of a pressure-drop across the device surface. However, these methods cannot accurately reproduce the flow-patterns encountered near the struts, the latter strongly dictating the intra-saccular flow environment. In this work, a versatile theoretical framework which aims at correctly reproducing the local flow heterogeneities due to the wires while keeping memory consumption, meshing and computational times as low as possible is introduced. This model reproduces the drag forces exerted by the device struts onto the fluid, thus producing local and heterogeneous effects on the flow. Extensive validation for various flow and geometric configurations using an idealized device is performed. To further illustrate the method capabilities, a real patient-specific aneurysm endovascularly treated with a flow-diverter is used, enabling quantitative comparisons with classical approaches for both intra-saccular velocities and computational costs reduction. The proposed heterogeneous model endeavors to bridge the gap between computational fluid dynamics and clinical applications and ushers in a new era of numerical treatment planning with minimally costing computational tools.
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Affiliation(s)
- Alain Berod
- IMAG, Univ Montpellier, CNRS, Montpellier, France
- Sim&Cure, Montpellier, France
| | | | - Simon Mendez
- IMAG, Univ Montpellier, CNRS, Montpellier, France
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31
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Gegenschatz-Schmid K, Buzzi S, Grossmann J, Roschitzki B, Urbanet R, Heuberger R, Glück D, Zucker A, Ehrbar M. Reduced thrombogenicity of surface-treated Nitinol implants steered by altered protein adsorption. Acta Biomater 2022; 137:331-345. [PMID: 34673227 DOI: 10.1016/j.actbio.2021.10.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 12/19/2022]
Abstract
Blood-contacting medical implants made of Nitinol and other titanium alloys, such as neurovascular flow diverters and peripheral stents, have the disadvantage of being highly thrombogenic. This makes the use of systemic (dual) anti-platelet/anticoagulant therapies inevitable with related risks of device thrombosis, bleeding and other complications. Meeting the urgent clinical demand for a less thrombogenic Nitinol surface, we describe here a simple treatment of standard, commercially available Nitinol that renders its surface ultra-hydrophilic and functionalized with phosphate ions. The efficacy of this treatment was assessed by comparing standard and surface-treated Nitinol disks and braids, equivalent to flow diverters. Static and dynamic (Chandler loop) blood incubation tests showed a drastic reduction of thrombus formation on treated devices. Surface chemistry and proteomic analysis indicated a key role of phosphate and calcium ions in steering blood protein adsorption and avoiding coagulation cascade activation and platelet adhesion. A good endothelialization of the surface confirmed the biocompatibility of the treated surface. STATEMENT OF SIGNIFICANCE: Titanium alloys such as Nitinol are biocompatible and show favorable mechanical properties, which led to their widespread use in medical implants. However, in contact with blood their surface triggers the activation of the intrinsic coagulation cascade, which may result in catastrophic thrombotic events. The presented results showed that a phosphate functionalization of the titanium oxide surface suppresses the activation of both coagulation cascade and platelets, avoiding the subsequent formation of a blood clot. This novel approach has therefore a great potential for mitigating the risks associated to either thrombosis or bleeding complications (due to systemic anticoagulation) in patients with cardiovascular implants.
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32
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Winters H, Schüngel MS, Scherlach C, Mucha D, Thalwitzer J, Härtig W, Donitza A, Bailis N, Maybaum J, Hoffmann KT, Quäschling U, Schob S. First Experience of Three Neurovascular Centers With the p64MW-HPC, a Low-Profile Flow Diverter Designed for Proximal Cerebral Vessels With Antithrombotic Coating. Front Neurol 2021; 12:724705. [PMID: 34594297 PMCID: PMC8476967 DOI: 10.3389/fneur.2021.724705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/12/2021] [Indexed: 12/23/2022] Open
Abstract
Background: In the last decade, flow diversion (FD) has been established as hemodynamic treatment for cerebral aneurysms arising from proximal and distal cerebral arteries. However, two significant limitations remain—the need for 0.027” microcatheters required for delivery of most flow diverting stents (FDS), and long-term dual anti-platelet therapy (DAPT) in order to prevent FDS-associated thromboembolism, at the cost of increasing the risk for hemorrhage. This study reports the experience of three neurovascular centers with the p64MW-HPC, a FDS with anti-thrombotic coating that is implantable via a 0.021” microcatheter. Materials and methods: Three neurovascular centers contributed to this retrospective analysis of patients that had been treated with the p64MW-HPC between March 2020 and March 2021. Clinical data, aneurysm characteristics, and follow-up results, including procedural and post-procedural complications, were recorded. The hemodynamic effect was assessed using the O'Kelly–Marotta Scale (OKM). Results: Thirty-two patients (22 female, mean age 57.1 years) with 33 aneurysms (27 anterior circulation and six posterior circulation) were successfully treated with the p64MW-HPC. In 30/32 patients (93.75%), aneurysmal perfusion was significantly reduced immediately post implantation. Follow-up imaging was available for 23 aneurysms. Delayed aneurysm perfusion (OKM A3: 8.7%), reduction in aneurysm size (OKM B1-3: 26.1%), or sufficient separation from the parent vessel (OKM C1-3 and D1: 65.2%) was demonstrated at the last available follow-up after a mean of 5.9 months. In two cases, device thrombosis after early discontinuation of DAPT occurred. One delayed rupture caused a caroticocavernous fistula. The complications were treated sufficiently and all patients recovered without permanent significant morbidity. Conclusion: Treatment with the p64MW-HPC is safe and feasible and achieves good early aneurysm occlusion rates in the proximal intracranial circulation, which are comparable to those of well-established FDS. Sudden interruption of DAPT in the early post-interventional phase can cause in-stent thrombosis despite the HPC surface modification. Deliverability via the 0.021” microcatheter facilitates treatment in challenging vascular anatomies.
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Affiliation(s)
- Helge Winters
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany.,Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Germany
| | | | - Cordula Scherlach
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Dirk Mucha
- Institut für Radiologie und Neuroradiologie, Heinrich-Braun- Klinikum, Zwickau, Germany
| | - Jörg Thalwitzer
- Institut für Radiologie und Neuroradiologie, Klinikum Chemnitz gGmbH, Chemnitz, Germany
| | - Wolfgang Härtig
- Paul-Flechsig-Institut für Hirnforschung, Universität Leipzig, Leipzig, Germany
| | - Aneta Donitza
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle, Halle (Saale), Germany
| | - Nikolaos Bailis
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Jens Maybaum
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Karl Titus Hoffmann
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Ulf Quäschling
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Stefan Schob
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle, Halle (Saale), Germany
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33
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Li L, Yongjie M, Dmytriw AA, Jian R, Hongqi Z. Evaluation of Vessel Wall Apposition for Stent-Assisted Coiling in Treatment of Vertebral Artery Aneurysms Using Optical Coherence Tomography. Clin Neuroradiol 2021; 32:565-570. [PMID: 34427701 DOI: 10.1007/s00062-021-01070-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/15/2021] [Indexed: 01/02/2023]
Affiliation(s)
- Li Li
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, No. 45 Changchun Street, Xicheng District, 100053, Beijing, China
- Department of Neurosurgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Ma Yongjie
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, No. 45 Changchun Street, Xicheng District, 100053, Beijing, China
| | - Adam A Dmytriw
- Neuroradiology & Neurointervention Service, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ren Jian
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, No. 45 Changchun Street, Xicheng District, 100053, Beijing, China
| | - Zhang Hongqi
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, No. 45 Changchun Street, Xicheng District, 100053, Beijing, China.
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34
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Nawka MT, Broocks G, McDonough R, Fiehler J, Bester M. Woven EndoBridge (WEB) Width at the Aneurysm Neck Level Affects Early Angiographic Aneurysm Occlusion. Clin Neuroradiol 2021; 32:89-97. [PMID: 34089083 PMCID: PMC8894173 DOI: 10.1007/s00062-021-01034-0] [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] [Received: 10/27/2020] [Accepted: 04/28/2021] [Indexed: 11/03/2022]
Abstract
Purpose Endovascular therapy with the Woven EndoBridge (WEB) device is a safe treatment approach, whereby neoendothelialization at the neck area is a crucial element for aneurysm occlusion. We hypothesized that WEB sizing at the aneurysmal neck level has an impact on early aneurysm occlusion. Methods Patients with short-term follow-up digital subtraction angiography following WEB treatment of unruptured aneurysms were included. Aneurysms were categorized according to the Bicêtre Occlusion Scale Score (BOSS) as adequately (BOSS 0, 0′, 1) or partially occluded (BOSS 2, 3, 1 + 3). The WEB device dimensions, including the average aneurysm diameter (AADi) and the average neck diameter (ANDi) as well as baseline patient characteristics were documented. Results In this study 75 patients with 76 aneurysms were included and 65 aneurysms showed adequate occlusion at short-term follow-up (86%). In univariable logistic regression analysis, smaller differences in WEB size to ANDi (D-ANDi) were significantly associated with adequate aneurysm occlusion (odds ratio, OR = 0.41, 95% confidence interval, CI 0.23–0.71, p = 0.002). Receiver operating characteristic (ROC) curve analyses displayed higher discriminative power for the D‑ANDi (AUC = 0.77, 95% CI 0.66–0.86, cut-off ≤2.9 mm) compared to the difference in WEB size to the average aneurysm diameter (D-AADi, AUC = 0.65, 95% CI 0.53–0.75, cut-off ≤1.0 mm). Conclusion Smaller differences between the WEB width and ANDi were associated with adequate early aneurysm occlusion and might thus have a higher impact on the results than the traditional device sizing considering the mean aneurysm diameter. D‑ANDi ≤2.9 mm served as an optimal cut-off to classify occlusion after WEB treatment at the short-term follow-up. Further external validation is warranted. Supplementary Information The online version of this article (10.1007/s00062-021-01034-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marie Teresa Nawka
- Department of Neuroradiology, University Hospital Eppendorf, Hamburg, Germany.
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35
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Oishi H, Mishima Y, Yatomi K, Teranishi K, Suzuki K, Fujii T. Defective Endothelialization of Pipeline Embolization Device after Flow Diverter Therapy: An Autopsy Case Report. NMC Case Rep J 2021; 8:33-37. [PMID: 34012746 PMCID: PMC8116919 DOI: 10.2176/nmccrj.cr.2020-0107] [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] [Received: 04/08/2020] [Accepted: 04/30/2020] [Indexed: 11/20/2022] Open
Abstract
The authors report a rare autopsy case. A 59-year-old woman underwent flow diverter (FD) therapy using a pipeline embolization device (PED) for a large paraclinoid internal carotid artery aneurysm. Follow-up magnetic resonance (MR) examinations were performed 6 months after the treatment. Although the T2-weighted images showed progressive thrombosis of the aneurysm, the silent MR angiography (MRA) clearly showed the residual blood flow within the aneurysm. The patient committed suicide 2 months after the follow-up MR examinations. An autopsy specimen showed a small section of the defective membranes with the PED that matched the entry point of residual blood flow seen clearly in the silent MRA. Macroscopic photograph and hematoxylin and eosin stained sections showed defective endothelialization. In contrast, complete endothelialization was observed in membranes covering the PED. The autopsy findings after FD therapy showed defective endothelialization that perfectly matched and corroborated the silent MRA findings.
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Affiliation(s)
- Hidenori Oishi
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan.,Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yumiko Mishima
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kosuke Teranishi
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kazumoto Suzuki
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine, Tokyo, Japan
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Shrivastava A, Mishra R, Salazar LRM, Chouksey P, Raj S, Agrawal A. Enigma of what is Known about Intracranial Aneurysm Occlusion with Endovascular Devices. J Stroke Cerebrovasc Dis 2021; 30:105737. [PMID: 33774553 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105737] [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: 10/13/2020] [Revised: 02/23/2021] [Accepted: 02/28/2021] [Indexed: 11/16/2022] Open
Abstract
Aneurysmal subarachnoid Hemorrhage is a major cause of neurological morbidity and mortality. Over the years vascular neurosurgery has witnessed technological advances aimed to reduce the morbidity and mortality. Several endovascular devices have been used in clinical practice to achieve this goal in the management of ruptured and unruptured cerebral aneurysms. Recurrence due to recanalization is encountered in all of these endovascular devices as well as illustrated by Barrow Ruptured Aneurysm Trial. Histological and molecular characterization of the aneurysms treated with endovascular devices is an area of active animal and human research studies. Yet, the pathobiology illustrating the mechanisms of aneurysmal occlusion and healing lacks evidence. The enigma of aneurysmal healing following treatment with endovascular devices needs to be de-mystified to understand the biological interaction of endovascular device and aneurysm and thereby guide the future development of endovascular devices aimed at better aneurysm occlusion. We performed a comprehensive and detailed literature review to bring all the known facts of the pathobiology of intracranial aneurysm healing, the knowledge of which is of paramount importance to neurosurgeons, an interventional neuroradiologist, molecular biologist, geneticists, and experts in animal studies. This review serves as a benchmark of what is known and platform for future studies basic science research related to intracranial aneurysms.
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Affiliation(s)
- Adesh Shrivastava
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462020, Madhya Pradesh, India.
| | - Rakesh Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | | | - Pradeep Chouksey
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462020, Madhya Pradesh, India
| | - Sumit Raj
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462020, Madhya Pradesh, India
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462020, Madhya Pradesh, India
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Dinc H, Saatci I, Oguz S, Baltacioglu F, Yildiz A, Donmez H, Belet U, Onal B, Andic C, Koc O, Kocak O, Koroglu M, Cetin M, Cekirge HS. Long-term clinical and angiographic follow-up results of the dual-layer flow diverter device (FRED) for the treatment of intracranial aneurysms in a multicenter study. Neuroradiology 2021; 63:943-952. [PMID: 33392735 DOI: 10.1007/s00234-020-02627-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Our aim was to determine the long-term safety and efficacy of the Flow Re-Direction Endoluminal Device (FRED) in this multicenter study with prospective design. MATERIALS-METHOD This study included 136 consecutive patients with 155 aneurysms treated between March 2013 and June 2016 in 10 centers. Twenty-two (16.2%) patients presented with rupture of the index aneurysm. Large/giant aneurysms comprised 1/3 of the cohort. Adjuvant coil use during the treatment was 15.5%. The effectiveness measure in the study was the percentage of aneurysms with stable occlusion at follow-up. RESULTS Vascular imaging follow-up was performed at least once in 131/136 (96.3%) patients with 148/155 (95.5%) aneurysms up to 75 months (mean: 37.3 months; median: 36 months according to latest follow-up), and 102/155(65.8%) aneurysms in 90/136 (66.2%) patients had ≥ 24-month control. According to the latest controls, the overall stable occlusion rate was 91.9% (95% CI, 87.5 to 96.3%). Three out of 148 aneurysms with follow-up were retreated (2%, 95% CI 0.0 to 4.3%). Adverse events were noted in 19/136 (14%, 95% CI, 9 to 21%) patients with a morbidity of 1.5% (95% CI, 0.0 to 3.5%). Mortality was 1/136 (0.7%, 95% CI, 0.02 to 2.2%) and was unrelated to aneurysm treatment. In-stent stenosis (ISS) was detected in 10/131 of the patients with follow-up (7.6%, 95% CI; 3.1 to 12.2%), only one being symptomatic. No adverse events have occurred in any of the patients with follow-up after 24 months, except the one resulting from ISS. CONCLUSION In the treatment of cerebral aneurysms which were candidates for flow diversion technique, this study showed long-term efficacy of FRED with good safety and occlusion rates.
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Affiliation(s)
- Hasan Dinc
- Radiology Department, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Isil Saatci
- Interventional Neuroradiology Section, Koru Hospitals, Kizilirmak mah, 1450 sokak 9/19 Cukurambar, 06510, Ankara, Turkey.
| | - Sukru Oguz
- Radiology Department, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Feyyaz Baltacioglu
- Radiology Department, School of Medicine, Marmara University, Istanbul, Turkey
| | - Altan Yildiz
- Radiology Department, School of Medicine, Mersin University, Mersin, Turkey
| | - Halil Donmez
- Radiology Department, School of Medicine, Erciyes University, Kayseri, Turkey
| | - Umit Belet
- Radiology Department, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Baran Onal
- Radiology Department, School of Medicine, Gazi University, Ankara, Turkey
| | - Cagatay Andic
- Radiology Department, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Osman Koc
- Radiology Department, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Omer Kocak
- Radiology Department, Koru Hospitals, Ankara, Turkey
| | - Mert Koroglu
- Interventional Radiology Clinic, Medical Park VM Hospital, Samsun, Turkey
| | - Mustafa Cetin
- Radiology Department, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey
| | - H Saruhan Cekirge
- Interventional Neuroradiology Section, Koru Hospitals, Kizilirmak mah, 1450 sokak 9/19 Cukurambar, 06510, Ankara, Turkey
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Therapeutic Potential of Heme Oxygenase-1 in Aneurysmal Diseases. Antioxidants (Basel) 2020; 9:antiox9111150. [PMID: 33228202 PMCID: PMC7699558 DOI: 10.3390/antiox9111150] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/15/2022] Open
Abstract
Abdominal aortic aneurysm (AAA) and intracranial aneurysm (IA) are serious arterial diseases in the aorta and brain, respectively. AAA and IA are associated with old age in males and females, respectively, and if rupture occurs, they carry high morbidity and mortality. Aneurysmal subarachnoid hemorrhage (SAH) due to IA rupture has a high rate of complication and fatality. Despite these severe clinical outcomes, preventing or treating these devastating diseases remains an unmet medical need. Inflammation and oxidative stress are shared pathologies of these vascular diseases. Therefore, therapeutic strategies have focused on reducing inflammation and reactive oxygen species levels. Interestingly, in response to cellular stress, the inducible heme oxygenase-1 (HO-1) is highly upregulated and protects against tissue injury. HO-1 degrades the prooxidant heme and generates molecules with antioxidative and anti-inflammatory properties, resulting in decreased oxidative stress and inflammation. Therefore, increasing HO-1 activity is an attractive option for therapy. Several HO-1 inducers have been identified and tested in animal models for preventing or alleviating AAA, IA, and SAH. However, clinical trials have shown conflicting results. Further research and the development of highly selective HO-1 regulators may be needed to prevent the initiation and progression of AAA, IA, or SAH.
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Caroff J, King RM, Ughi GJ, Marosfoi M, Langan ET, Raskett C, Puri AS, Gounis MJ. Longitudinal Monitoring of Flow-Diverting Stent Tissue Coverage After Implant in a Bifurcation Model Using Neurovascular High-Frequency Optical Coherence Tomography. Neurosurgery 2020; 87:1311-1319. [PMID: 32463884 PMCID: PMC7666887 DOI: 10.1093/neuros/nyaa208] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/19/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tissue growth over covered branches is a leading cause of delayed thrombotic complications after flow-diverter stenting (FDS). Due to insufficient resolution, no imaging modality is clinically available to monitor this phenomenon. OBJECTIVE To evaluate high-frequency optical coherence tomography (HF-OCT), a novel intravascular imaging modality designed for the cerebrovascular anatomy with a resolution approaching 10 microns, to monitor tissue growth over FDS in an arterial bifurcation model. METHODS FDS were deployed in a rabbit model (n = 6), covering the aortic bifurcation. The animals were divided in different groups, receiving dual antiplatelet therapy (DAPT) (n = 4), aspirin only (n = 1), and no treatment (n = 1). HF-OCT data were obtained in vivo at 3 different time points in each animal. For each cross-sectional image, metal and tissue coverage of the jailed ostium was quantified. Scanning electron microscopy images of harvested arteries were subsequently obtained. RESULTS Good quality HF-OCT data sets were successfully acquired at implant and follow-up. A median value of 41 (range 21-55) cross-sectional images were analyzed per ostium for each time point. Between 0 and 30 d after implant, HF-OCT analysis showed a significantly higher ostium coverage when DAPT was not given. After 30 d, similar growth rates were found in the DAPT and in the aspirin group. At 60 d, a coverage of 90% was reached in all groups. CONCLUSION HF-OCT enables an accurate visualization of tissue growth over time on FDS struts. The use of FDS in bifurcation locations may induce a drastic reduction of the jailed-branch ostium area.
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Affiliation(s)
| | | | | | | | | | | | | | - Matthew J Gounis
- Correspondence: Matthew J. Gounis, PhD, Department of Radiology, New England Center for Stroke Research, University of Massachusetts, 55 Lake Ave N, SA-107R, Worcester MA 01655, USA.
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Fujii T, Oishi H, Teranishi K, Yatomi K, Suzuki K, Arai H. Outcome of flow diverter placement for intracranial aneurysm with dual antiplatelet therapy and oral anticoagulant therapy. Interv Neuroradiol 2020; 26:532-538. [PMID: 32727310 PMCID: PMC7645175 DOI: 10.1177/1591019920947878] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/14/2020] [Indexed: 10/24/2023] Open
Abstract
PURPOSE Antiplatelet therapy initiated before flow diverter placement is effective for the prevention of ischemic complications. However, the effectiveness of oral anticoagulant treatment is unclear. This retrospective study evaluated the complications and obliteration rates after flow diverter placement in patients taking anticoagulants. METHODS A total of 155 cases were treated by Pipeline Flex placement for unruptured large and giant cerebral aneurysms in our hospital between October 2015 and June 2019. The groups of 8 patients taking anticoagulants before operation and 147 patients not taking anticoagulants were compared. RESULTS Clopidogrel oral dose (P = 0.002) was significantly lower in the anticoagulant group. Delayed aneurysm rupture (P = 0.002) and additional treatment (P = 0.009) rates were significantly higher and complete obliteration rate (P = 0.011) was lower in the anticoagulant group. CONCLUSIONS Additional oral anticoagulant administration before flow diverter placement does not reduce ischemic complications compared to dual antiplatelet therapy, but does increase hemorrhagic complications, especially delayed aneurysm rupture. Complete obliteration of the cerebral aneurysm is difficult to achieve in patients taking anticoagulants.
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Affiliation(s)
- Takashi Fujii
- Department of Neuroendovascular Therapy, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy, Faculty of Medicine, Juntendo University, Tokyo, Japan
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kenji Yatomi
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kazumoto Suzuki
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Hajime Arai
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
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Kocur D, Paździora P, Baron J, Rudnik A. Role of transcranial Doppler ultrasonography in assessing stenosis after flow diversion. Clin Neurol Neurosurg 2020; 198:106219. [PMID: 32932030 DOI: 10.1016/j.clineuro.2020.106219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 08/23/2020] [Accepted: 09/05/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Patients after implantation of flow diverters (FD) due to intracranial aneurysms require radiological and clinical follow-up in view of in-stent stenosis. The aim of the study was to evaluate transcranial Doppler ultrasonography (TCD) as an alternative to more invasive digital subtraction angiography in monitoring patients with FD. PATIENTS AND METHODS Twenty-five patients after FD deployment due to internal carotid artery (ICA) aneurysms were reviewed. The degree stenosis found on TCD was compared with the results of catheter angiography. The TCD examinations were recorded from two sides at the extracranial ICA and the most proximal and distal segment of intracranial ICA. Analyzed TCD factors included: peak systolic blood flow velocity, end diastolic velocity, mean velocity, pulsatility index, and resistivity index. The side-to-side differences and ratios between particular TCD indices were calculated. RESULTS The cumulative frequency of angiographic in-stent stenosis was 5 of 25 (20 %). The analysis showed that pulsatility index measured on the most proximal intracranial segment of ICA is a predictor for angiographic instent stenosis (AUC = 0.854; p = 0.04; 95 % CI 0.59-1.00). The threshold of pulsatility index separating stenosis and non-stenosis groups was 1.05 with a sensitivity of 50 % and a specificity of 100 %. As the cut-off threshold of PI was set 0.75 the sensitivity and specificity was 100 % and 16.7 %, respectively. CONCLUSIONS The increased TCD-derived pulsatility index measured on the most proximal intracranial segment of ICA is associated with in-stent stenosis demonstrated on angiograms.
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Affiliation(s)
- Damian Kocur
- Medical University of Silesia, School of Medicine in Katowice, Department of Neurosurgery, Katowice, Poland.
| | - Piotr Paździora
- Medical University of Silesia, School of Medicine in Katowice, Department of Neurosurgery, Katowice, Poland
| | - Jan Baron
- Medical University of Silesia, School of Medicine in Katowice, Department of Radiology and Nuclear Medicine, Katowice, Poland
| | - Adam Rudnik
- Medical University of Silesia, School of Medicine in Katowice, Department of Neurosurgery, Katowice, Poland
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Pasarikovski CR, Ku JC, Priola SM, da Costa L, Yang VXD. Endovascular optical coherence tomography imaging in cerebrovascular disease. J Clin Neurosci 2020; 80:30-37. [PMID: 33099363 DOI: 10.1016/j.jocn.2020.07.064] [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: 05/19/2020] [Revised: 07/18/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
Endovascular optical coherence tomography (OCT) is the highest resolution imaging modality currently available with spatial resolution of 10 µm. Although originally developed for interventional cardiology, the ability to visualize the luminal environment and anatomy, along with the stent-vessel interaction could be of great utility for various cerebrovascular diseases, and the adoption of endovascular OCT imaging in the evolving field of interventional neuroradiology seems instinctive. The purpose of this study is to conduct a systematic review of the literature regarding applications of endovascular OCT in the diagnosis and treatment of cerebrovascular diseases. In addition, the authors report their institutional experience with the use of OCT in carotid atherosclerotic disease, cerebral aneurysms, and acute ischemic stroke. A systematic review of the literature was undertaken. Peer-reviewed articles were collected through MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) searches through March 2020. A total of 34 studies with 598 patients were included in the qualitative synthesis. These include 23 studies of carotid atherosclerotic disease, 7 studies of cerebral aneurysms, and 4 studies of non-aneurysmal posterior circulation pathology. OCT imaging was feasible in 94% of patients with 0.6% complication rate. Endovascular OCT appears to be safe and feasible, allowing clinicians to visualize stent-vessel interactions, aneurysmal healing, and vulnerable atherosclerotic plaque features. OCT carries great promise, however additional investigations are needed before any imposing statement can be made about the role of OCT in cerebrovascular imaging.
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Affiliation(s)
| | - Jerry C Ku
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stefano M Priola
- Division of Neurosurgery, Department of Surgery, Health Sciences North, Sudbury, Ontario, Canada; Norther Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Leodante da Costa
- Division of Neurosurgery, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Victor X D Yang
- Division of Neurosurgery, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada; Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Mahmoud M, Farag A, Farid M, Elserwi A, Abdelsamad A, Guergues W, Hassan F. Application of flow diverters in the treatment of aneurysms in the internal carotid artery bifurcation region. Neuroradiol J 2020; 33:297-305. [PMID: 32419609 DOI: 10.1177/1971400920924840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION The treatment of aneurysms in the internal carotid bifurcation region (ICABR), including aneurysms of the true internal carotid artery (ICA) terminus, those inclined on the proximal A1 or M1 segments or at the most distal pre-bifurcation (ICA) segment, is often challenging in microsurgical clipping and endovascular surgery. Few reports had discussed flow diversion as a therapeutic option for this group. METHODS This was a retrospective study analysing flow diversion in treating ICABR aneurysms. Seven patients harbouring eight aneurysms in the ICABR were treated with flow diversion. Five aneurysms were inclined on the proximal A1 segment, and three were located at the most distal pre-bifurcation segment. Patients' demographics, presentation, procedure technical description, angiographic and clinical follow-up were recorded. PubMed and Ovid MEDLINE were also reviewed for articles published in English, including case series or case reports, for ICABR aneurysms treated with flow diverters. RESULTS All patients except one underwent angiographic follow-up. The Karman-Byrne occlusion scale was used to determine the occlusion rate. All six patients with documented angiographic follow-up had a class IV occlusion score. No permanent or transient neurological or non-neurological complications were encountered in this study. CONCLUSION Treating ICABR aneurysms using flow diversion is feasible, with a promising angiographic occlusion rate. Further studies are needed to analyse long-term clinical and angiographic results.
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Affiliation(s)
| | - Ahmed Farag
- Radiology Department, Ain Shams University Hospital, Egypt
| | - Mostafa Farid
- Radiology Department, Ain Shams University Hospital, Egypt
| | - Ahmed Elserwi
- Radiology Department, Ain Shams University Hospital, Egypt
| | - Amr Abdelsamad
- Radiology Department, Ain Shams University Hospital, Egypt
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Poupart O, Schmocker A, Conti R, Moser C, Nuss KM, Grützmacher H, Mosimann PJ, Pioletti DP. In vitro Implementation of Photopolymerizable Hydrogels as a Potential Treatment of Intracranial Aneurysms. Front Bioeng Biotechnol 2020; 8:261. [PMID: 32318555 PMCID: PMC7146053 DOI: 10.3389/fbioe.2020.00261] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/13/2020] [Indexed: 12/19/2022] Open
Abstract
Intracranial aneurysms are increasingly being treated with endovascular therapy, namely coil embolization. Despite being minimally invasive, partial occlusion and recurrence are more frequent compared to open surgical clipping. Therefore, an alternative treatment is needed, ideally combining minimal invasiveness and long-term efficiency. Herein, we propose such an alternative treatment based on an injectable, radiopaque and photopolymerizable polyethylene glycol dimethacrylate hydrogel. The rheological measurements demonstrated a viscosity of 4.86 ± 1.70 mPa.s, which was significantly lower than contrast agent currently used in endovascular treatment (p = 0.42), allowing the hydrogel to be injected through 430 μm inner diameter microcatheters. Photorheology revealed fast hydrogel solidification in 8 min due to the use of a new visible photoinitiator. The addition of an iodinated contrast agent in the precursor contributed to the visibility of the precursor injection under fluoroscopy. Using a customized light-conducting microcatheter and illumination module, the hydrogel was implanted in an in vitro silicone aneurysm model. Specifically, in situ fast and controllable injection and photopolymerization of the developed hydrogel is shown to be feasible in this work. Finally, the precursor and the polymerized hydrogel exhibit no toxicity for the endothelial cells. Photopolymerizable hydrogels are expected to be promising candidates for future intracranial aneurysm treatments.
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Affiliation(s)
- Oriane Poupart
- Laboratory of Biomechanical Orthopedics, EPFL, Lausanne, Switzerland
| | - Andreas Schmocker
- Laboratory of Applied Photonics Devices, EPFL, Lausanne, Switzerland
- Department of Chemistry and Applied Biosciences, ETH, Zurich, Switzerland
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Riccardo Conti
- Department of Chemistry and Applied Biosciences, ETH, Zurich, Switzerland
| | - Christophe Moser
- Laboratory of Applied Photonics Devices, EPFL, Lausanne, Switzerland
| | - Katja M. Nuss
- Musculoskeletal Research Unit, Department of Molecular Mechanisms of Disease, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | | | - Pascal J. Mosimann
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
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Ravindran K, Casabella AM, Cebral J, Brinjikji W, Kallmes DF, Kadirvel R. Mechanism of Action and Biology of Flow Diverters in the Treatment of Intracranial Aneurysms. Neurosurgery 2020; 86:S13-S19. [PMID: 31838528 PMCID: PMC6911734 DOI: 10.1093/neuros/nyz324] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/30/2019] [Indexed: 12/19/2022] Open
Abstract
Flow diverters have drastically changed the landscape of intracranial aneurysm treatment and are now considered first-line therapy for select lesions. Their mechanism of action relies on intrinsic alteration in hemodynamic parameters, both at the parent artery and within the aneurysm sac. Moreover, the device struts act as a nidus for endothelial cell growth across the aneurysm neck ultimately leading to aneurysm exclusion from the circulation. In silico computational analyses and investigations in preclinical animal models have provided valuable insights into the underlying biological basis for flow diverter therapy. Here, we review the present understanding pertaining to flow diverter biology and mechanisms of action, focusing on stent design, induction of intra-aneurysmal thrombosis, endothelialization, and alterations in hemodynamics.
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Affiliation(s)
| | | | - Juan Cebral
- Bioengineering Department, George Mason University, Fairfax, Virginia
| | | | | | - Ram Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
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