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Habibi MA, Mirjani MS, Ahmadzadeh AM, Akbari Javar MT, Karami S, Ahmadvand MH. Safety and efficacy of flow redirection endoluminal device (FRED) for treatment of intracranial aneurysm; A systematic review and meta-analysis. Neuroradiol J 2024:19714009241269460. [PMID: 39102710 DOI: 10.1177/19714009241269460] [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: 08/07/2024] Open
Abstract
BACKGROUND Previous research has shown promising results for treating intracranial aneurysms (IAs) with a flow redirection endoluminal device (FRED). In this systematic review and meta-analysis, we aimed to assess the safety and efficacy of this device by providing pooled estimates using the data from previous studies. METHODS A systematic literature search of Web of Sciences, PubMed, Scopus, and Embase was performed until October 8th, 2023. After selecting the final articles, relevant data were extracted. Parameters relating to safety and efficacy were pooled using STATA software. Heterogeneity was assessed using I-squared and Cochran's Q. Funnel plots and Egger's regression methods were used to evaluate publication bias. Sensitivity analysis was also performed using the leave-one-out method. RESULTS The data of 37 studies were used for meta-analysis. The rates of immediate adequate occlusion and complete occlusion were 0.51 (95% CI: 0.31-0.71) and 0.34 (95% CI: 0.16-0.53), respectively, while the rates of the adequate and complete occlusion at the latest follow-up were 0.90 (95% CI: 0.84-0.94) and 0.75 (95% CI: 0.65-0.84), respectively. The periprocedural complications rate was 0.04 (95% CI: 0.03-0.06), and the overall complications rate was 0.12 (95% CI: 0.09-0.15). The rate of good functional outcome was 0.99 (95% CI: 0.99-1.00) and the successful implantation rate was 1.00 (95% CI: 1.00-1.00). There was substantial heterogeneity among the reports for most of the evaluated parameters. CONCLUSION FRED had high safety and efficacy in treating IAs, as evidenced by its high occlusion and low complication rates.
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Affiliation(s)
- Mohammad Amin Habibi
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Amir Mahmoud Ahmadzadeh
- Department of Radiology, School of Medicine, Mashhad University of Medical Sciences, Qom, Iran
| | | | - Shaghayegh Karami
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Moon E, Park W, Song Y, Lee DH, Ahn JS, Park JC. Mass Effect After Flow Diversion for Unruptured Large and Giant Cavernous or Paraclinoid Internal Carotid Artery Aneurysm. World Neurosurg 2023; 180:e108-e116. [PMID: 37690582 DOI: 10.1016/j.wneu.2023.08.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE The mass effect associated with large or giant intracranial aneurysms is difficult for traditional endovascular treatment. This study investigated whether flow diverters can relieve the aneurysmal mass effect caused by aneurysmal compression symptoms. METHODS Fifty-five patients with unruptured large and giant intracranial aneurysms treated by a flow diverter at our institution from January 2014 to February 2022 were retrospectively evaluated. RESULTS In this study, 53 patients were included. Initially, 27 patients (51.9%), including 10 with compressive optic neuropathy, 12 with third nerve palsy, 2 with facial hyperesthesia, and 11 with sixth nerve palsy, were symptomatic. The symptom duration was shorter in the improved group (n = 2.2 ± 4.0 vs. n = 3.1 ± 3.9, P = 0.49). Thrombus formation following the flow diversion procedure was typically observed on magnetic resonance imaging (MRI) performed immediately and was not significantly associated with symptomatic improvement (OR = 0.395; 95% CI (0.058-2.698), P = 0.343). However, symptomatic improvement was seen in most patients when the aneurysm size decreased on MRI. A reduction in the aneurysm size on the MRI at the 3-month follow-up was correlated with symptomatic improvement in the multivariate analysis (OR = 0.08, 95% CI (0.013-0.485), P < 0.05). CONCLUSIONS A flow diverter might help alleviate compression symptoms caused by large or giant intracranial aneurysms. Shrinkage of the aneurysm within 3 months postoperatively and a shorter duration of symptoms contribute to the favorable outcomes of mass effect. Ultimately, prompt treatment is crucial for improving symptomatic intracranial artery aneurysms.
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Affiliation(s)
- Eunji Moon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yunsun Song
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Deok Hee Lee
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Wang Y, Yang X, Zhu W, Wang X, Yao Y, Lu W, Yang G, Qin L, Liu J, Li M. Verification of software-based preoperative simulation of flow diverters in clinical cases. Interv Neuroradiol 2023; 29:510-519. [PMID: 35505598 PMCID: PMC10549721 DOI: 10.1177/15910199221097264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/24/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The authors sought to verify the use of a preoperative simulation software for the treatment of intracranial aneurysms using flow diverters (FDs) based on three-dimensional rotational angiography (3DRA) data. METHODS Based on 3DRA data, the preoperative simulation software (UKNOW) was used to simulate the deployment of virtual FDs. The length and dimensions of virtual and real devices were compared. The deployment plan recommended by the UKNOW software was preliminarily used to complete implantations in the real world. During the experiment, experienced neurointerventional experts were responsible for supervising and judging information such as the length, dimension, and deployment location of the FDs. RESULTS This study retrospectively analyzed the data of 29 patients who received FD treatment. There was no statistical difference between the length of the real device and the virtual device (p = 0.6). The dimensions of FDs recommended by the software were consistent with the dimensions used in 24 out of the 29 real cases. In four of the remaining five cases, neurointerventional experts found that the FD dimensions recommended by the software were superior to those were actually used. Thus, the accuracy rate for FD dimension recommendations by the UKNOW software was 96.6% (28/29). Procedures performed in five cases using deployment plans recommended by the UKNOW software all achieved good postoperative results; the deployment positions of the device were reasonable, and all devices showed good wall adherence. CONCLUSIONS UKNOW software could accurately simulate the length and deployment position of the real FDs and provide suitable device dimensions.
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Affiliation(s)
- Yixuan Wang
- Department of Neurosurgery, The China-Japan Union Hospital, Jilin University, Changchun, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinlan Wang
- Department of Neurosurgery, The China-Japan Union Hospital, Jilin University, Changchun, China
| | - Yangyang Yao
- UnionStrong (Beijing) Technology Co. Ltd, Beijing, China
| | - Wangsheng Lu
- UnionStrong (Beijing) Technology Co. Ltd, Beijing, China
| | - Guangming Yang
- UnionStrong (Beijing) Technology Co. Ltd, Beijing, China
| | - Lan Qin
- UnionStrong (Beijing) Technology Co. Ltd, Beijing, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Miao Li
- Department of Neurosurgery, The China-Japan Union Hospital, Jilin University, Changchun, China
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Lorga T, Pizzuto S, Coskun O, Sgreccia A, Cavazza M, Rahman MH, Rodesch G, Di Maria F, Consoli A. Reconstruction of the sphenoid sinus erosion or dehiscence after treatment of unruptured intracavernous aneurysms with flow diverter stents. J Neurointerv Surg 2023:jnis-2023-020734. [PMID: 37586819 DOI: 10.1136/jnis-2023-020734] [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: 06/23/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Intracavernous carotid aneurysms (ICCAs) are rare, frequently asymptomatic, with a low rupture risk, which, however, can lead to life-threatening epistaxis. The aim of this study was to assess the effect of the treatment of asymptomatic ICCAs with flow diverters (FD) on sphenoid bone erosion or dehiscence in a selected cohort of patients. METHODS We retrospectively reviewed all asymptomatic ICCAs with sphenoid bone erosion or dehiscence detected on cone beam CT (CBCT) and treated with FD between December 2018 and December 2022. Patients were followed-up with CBCT and bone reconstruction was blindly evaluated by two interventional neuroradiologists and classified as unchanged, partial, or complete. RESULTS A total of 10 patients (women: 90%, mean age 58 years) treated with an FD for an asymptomatic ICCA with associated sphenoid bone erosion or dehiscence were included in this cohort. Sphenoid bone erosion was present in seven patients and dehiscence was observed in the remaining three. After treatment with FD, complete reconstruction of the sphenoid sinus wall occurred in seven cases, and partial reconstruction in two cases. Sphenoid bone erosion remained unchanged after treatment in only one patient. CONCLUSIONS The decision to treat asymptomatic and unruptured ICCAs remains challenging due to their benign natural history and low hemorrhagic risk. The presence of sphenoid sinus erosion or dehiscence should not be overlooked since it could be considered as an indication for prophylactic treatment of life-threatening epistaxis. The mechanisms of bone erosion by the aneurysm and of reconstruction after treatment are still to be fully elucidated.
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Affiliation(s)
- Tiago Lorga
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Neuroradiology, Centro Hospitalar Universitário de Lisboa Central EPE, Lisboa, Portugal
| | - Silvia Pizzuto
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Oguzhan Coskun
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Alessandro Sgreccia
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Martino Cavazza
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Diagnostic and Interventional Radiology, University Hospital Arcispedale Sant'Anna of Ferrara, Cona, Italy
| | - Mohammad Habibur Rahman
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Interventional Neurology, National Institute of Neurosciences and Hospital, Sher-E-Bangla Nagar, Bangladesh
| | - Georges Rodesch
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Federico Di Maria
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Versailles Saint-Quentin-en-Yvelines University, Versailles, France
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Sirakova K, Penkov M, Matanov S, Minkin K, Ninov K, Hadzhiyanev A, Karakostov V, Ivanova I, Sirakov S. Progressive volume reduction and long-term aneurysmal collapse following flow diversion treatment of giant and symptomatic cerebral aneurysms. Front Neurol 2022; 13:972599. [PMID: 36034286 PMCID: PMC9403733 DOI: 10.3389/fneur.2022.972599] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe primary goal of conventional endovascular and microvascular approaches is the clinical and radiological resolution of the symptomatic aneurysm-induced mass effect. This study assessed the volume changes and mass effect reduction due to sac shrinkage after treatment with flow diverter stents (FD) for unruptured cerebral aneurysms.MethodsWe analyzed retrospectively 36 symptomatic aneurysms that were larger or equal to 25 mm in diameter in patients treated at our center from January 2016 to April 2022. Radiological and clinical outcomes were analyzed, including aneurysmal volume changes and resolution of aneurysm-related symptoms.ResultsAt 6 months, 25 aneurysms decreased in size, 2 remained unchanged, and 9 aneurysms demonstrated a post-treatment dimensional increase. At 12 months, 30 aneurysms showed a progressive radiological volume reduction. Either no change or negligible shrinkage was observed in the remaining six aneurysms. At 24 months, 32 aneurysms showed aneurysmal shrinkage by a mean 47% volume loss with respect to baseline. At the last follow-up, all 13 patients who had presented with third cranial nerve palsy showed improvements. Complete reversal of the pretreatment edematous changes was confirmed in all cases. The overall post-treatment complication rate was 8.3%, as 3 patients experienced non-fatal delayed rupture of their aneurysm. There was no mortality in this study.ConclusionFlow diversion could effectively induce progressive aneurysmal shrinkage and resolution of the mass effect associated with giant symptomatic cerebral aneurysms.
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Affiliation(s)
| | - Marin Penkov
- Radiology Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Svetozar Matanov
- Radiology Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Krasimir Minkin
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Kristian Ninov
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Asen Hadzhiyanev
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Vasil Karakostov
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Irena Ivanova
- Clinical Laboratory Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Stanimir Sirakov
- Radiology Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
- *Correspondence: Stanimir Sirakov
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GÜZELDAĞ H, ONAN B, PİŞKİN FC, SÖZÜTOK S. Geniş boyunlu paraoftalmik anevrizmaların akım çevirici stent implantasyonu ile endovasküler tedavisi. CUKUROVA MEDICAL JOURNAL 2021. [DOI: 10.17826/cumj.977944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Zhang M, Tupin S, Li Y, Ohta M. Association Between Aneurysmal Haemodynamics and Device Microstructural Characteristics After Flow-Diversion Treatments With Dual Stents of Different Sizes: A Numerical Study. Front Physiol 2021; 12:663668. [PMID: 34113263 PMCID: PMC8185279 DOI: 10.3389/fphys.2021.663668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/15/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives Treating intracranial aneurysms with flow-diverting stents sometimes requires deployment of a second device. Herein we quantify the sizing effects of devices in dual-stent treatments upon the final stent microstructure and the post-treatment aneurysmal haemodynamics. Methods Fifteen sidewall ICA aneurysm geometries were included. Using a virtual stenting technique, we implanted either one or two stents for each aneurysm treatment considered, with each stent specified as one of two different sizes, yielding a total of two single-stent and fouir dual-stent treatment scenarios for each aneurysm. Three stent microstructural parameters and nine aneurysmal haemodynamic parameters were quantified and systematically compared across the 90 treatment scenarios. Results Deployment of a second stent further reduced the aneurysmal inflow rate (IR) and energy loss (EL) by, respectively, 14 ± 11% (p = 0.001) and 9 ± 12% (p = 0.056), relative to the untreated condition. Sizing effects of the earlier-deployed stent led to largest differences of 6.9% for the final IR reduction and 11.1% for the EL, whereas sizing effects from the later-deployed stent were minor (≤2.1%). The change in stent pore size was the only microstructural parameter demonstrating a strong correlation with the reduction in the post-treatment aneurysmal haemodynamics, in terms of the IR (r = 0.50, p < 0.001) and pressure drop (r = 0.63, p < 0.001). Conclusion Size of the earlier-deployed stent has substantial effects on the final haemodynamic outcomes after dual-stent treatment. The average pore size of stent wires at the aneurysm orifice shows promise as a potential index for predicting the efficacy of flow-diversion treatments.
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Affiliation(s)
- Mingzi Zhang
- Biomedical Flow Dynamics Laboratory, Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Simon Tupin
- Biomedical Flow Dynamics Laboratory, Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Yujie Li
- Biomedical Flow Dynamics Laboratory, Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Makoto Ohta
- Biomedical Flow Dynamics Laboratory, Institute of Fluid Science, Tohoku University, Sendai, Japan.,ElyTMaX, CNRS-Université de Lyon-Tohoku University, International Joint Unit, Tohoku University, Sendai, Japan
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Kellermann R, Serowy S, Beuing O, Skalej M. Deployment of flow diverter devices: prediction of foreshortening and validation of the simulation in 18 clinical cases. Neuroradiology 2019; 61:1319-1326. [PMID: 31473786 DOI: 10.1007/s00234-019-02287-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/26/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE Flow diverter (FD) devices show severe shortening during deployment in dependency of the vessel geometry. Valid information regarding the geometry of the targeted vessel is therefore mandatory for correct device selection, and to avoid complications. But the geometry of diseased tortuous intracranial vessels cannot be measured accurately with standard methods. The goal of this study is to prove the accuracy of a novel virtual stenting method in prediction of the behavior of a FD in an individual vessel geometry. METHODS We applied a virtual stenting method on angiographic 3D imaging data of the specific vasculature of patients, who underwent FD treatment. The planning tool analyzes the local vessel morphology and deploys the FD virtually. We measured in 18 cases the difference between simulated FD length and real FD length after treatment in a landmark-based registration of pre-/post-interventional 3D angiographic datasets. RESULTS The mean value of length deviation of the virtual FD was 2.2 mm (SD ± 1.9 mm) equaling 9.5% (SD ± 8.2%). Underestimated cases present lower deviations compared with overestimated FDs. Flow diverter cases with a nominal device length of 20 mm had the highest prediction accuracy. CONCLUSION The results suggest that the virtual stenting method used in this study is capable of predicting FD length with a clinically sufficient accuracy in advance and could therefore be a helpful tool in intervention planning. Imaging data of high quality are mandatory, while processing and manipulation of the FD during the intervention may impact the accuracy.
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Affiliation(s)
- Robert Kellermann
- Department of Neuroradiology, Otto-von-Guericke University Magdeburg, Leipziger Straße 44, 39112, Magdeburg, Germany
| | - Steffen Serowy
- Department of Neuroradiology, Otto-von-Guericke University Magdeburg, Leipziger Straße 44, 39112, Magdeburg, Germany.
| | - Oliver Beuing
- Department of Neuroradiology, Otto-von-Guericke University Magdeburg, Leipziger Straße 44, 39112, Magdeburg, Germany
| | - Martin Skalej
- Department of Neuroradiology, Otto-von-Guericke University Magdeburg, Leipziger Straße 44, 39112, Magdeburg, Germany
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Wu X, Tian Z, Li W, Liu J, Zhang Y, Zhang Y, Zhou Y, Yang X, Mu S. Patency of Branch Vessels After Pipeline Embolization: Comparison of Various Branches. Front Neurol 2019; 10:838. [PMID: 31440201 PMCID: PMC6694210 DOI: 10.3389/fneur.2019.00838] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 07/19/2019] [Indexed: 01/08/2023] Open
Abstract
Objective: Pipeline embolization devices (PEDs) are widely used to exclude intracranial aneurysms from their parent arteries. Side branches covered by PEDs, however, sometimes experience occlusion and related symptoms. Thus, predictors of branch occlusion and the patency and clinical outcomes of these branches are concerning. Methods: We conducted a retrospective review of consecutive patients who had been treated with PEDs in our institution during 2015–2018 to identify those in whom one or more branches were involved. Pretreatment and follow-up angiograms were assessed to determine patency of the involved branches. Demographic and clinical data, treatment strategies, and comorbidities were collected to investigate their relations with branch occlusion. Results: Altogether, 173 branches [24 (13.9%) occluded), 29 (16.8%) with diminished flow] in 126 patients were studied. Five patients (OphA involved) presented with blurred vision and 1 patient (ACA involved) presented with headache. None of the other patients had neurologic complications or clinical strokes related to branch occlusion. Multivariate analysis identified that small PED diameter [p = 0.003, odds ratio (OR) = 0.168], branches arising from the aneurysm (p = 0.004, OR = 6.614), and involvement of the anterior cerebral artery (ACA) (p < 0.001, OR = 25.656) significantly predicted branch occlusion. Conclusion: Branch occlusion rate after PED deployment was low and most occlusions was asymptomatic. Branches with rich collateral supply were more likely to occlude, especially the ACA. Smaller PED diameter, branches arising from the aneurysm, and ACA involvement were significant predictors of branch occlusion after PED treatment.
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Affiliation(s)
- Xinzhi Wu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongbin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yangyang Zhou
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shiqing Mu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Podlasek A, Al Sultan AA, Assis Z, Kashani N, Goyal M, Almekhlafi MA. Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis. J Neurointerv Surg 2019; 12:148-155. [DOI: 10.1136/neurintsurg-2019-014996] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/30/2019] [Accepted: 06/02/2019] [Indexed: 01/15/2023]
Abstract
BackgroundThromboembolic complications are not uncommon in patients undergoing neurointerventional procedures. The use of flow diverting stents is associated with higher risks of these complications despite current dual antiplatelet regimens.ObjectiveTo explore contemporary evidence on the safety of emerging dual antiplatelet regimens in flow diverting stenting procedures.MethodsWe performed a systematic review and meta-analysis to identify relevant articles in electronic databases, and relevant references. Studies reporting the complications and mortality of flow diverting stenting procedures using acetyl salicylic acid (ASA) + ticagrelor or ASA + prasugrel compared with ASA + clopidogrel were included.ResultsOf 452 potentially relevant studies, we identified 49 studies (2526 patients) which reported the safety of ticagrelor or prasugrel for pooled analysis, and five studies (1005 patients) for meta-analysis. The pooled overall mortality in all studies was 2.14%, ischemic complications 6.89%, and hemorrhagic complications 3.68%. The use of ticagrelor or prasugrel was associated with a lower risk of mortality compared with clopidogrel (RR=4.57, 95% CI 1.23 to 16.99; p=0.02). Considering ischemic events, ASA + clopidogrel was as safe as ASA + prasugrel (RR=0.55, 95% CI 0.11 to 2.74; p=0.47) and ASA + ticagrelor (RR=0.74, 95% CI 0.32 to 1.74; p=0.49). ASA +ticagrelor was not associated with a higher risk of hemorrhagic complications (RR=0.92, 95% CI 0.27 to 3.16; p=0.89).ConclusionsEvidence suggests that dual antiplatelet regimens including ticagrelor or prasugrel are safe for patients undergoing flow diversion procedures. Regimens using ticagrelor were associated with better survival than those using clopidogrel in the included studies.
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Wu X, Tian Z, Liu J, Zhang Y, Li W, Zhang Y, Chen J, Zhou Y, Yang X, Mu S. Patency of Posterior Circulation Branches Covered by Flow Diverter Device: A Hemodynamic Study. Front Neurol 2019; 10:658. [PMID: 31275237 PMCID: PMC6593048 DOI: 10.3389/fneur.2019.00658] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/04/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: Flow diverter devices are increasingly used in the treatment of posterior circulation aneurysms, sometimes necessarily involving ostia of side branches and perforators. The aim of this study was to identify the hemodynamic influence of flow diverters on side branches and perforators of the posterior circulation. Methods: We performed a retrospective study of consecutive patients treated by a flow diverter device for posterior circulation aneurysms with anterior inferior cerebellar artery (AICA) or posterior inferior cerebellar artery (PICA) involvement. Computational fluid dynamics (CFD) were used to discern hemodynamic changes of branches after deployment of the flow diverter. Results: We studied 18 branches from 17 patients (mean age, 50.72 ± 8.17 years). No branches were occluded on immediate angiography and later follow-up. Average flow velocity in aneurysms decreased from 0.077 ± 0.065 m/s to 0.025 ± 0.025 m/s (p < 0.01). Average flow velocity in branch ostia decreased from 0.29 ± 0.14 m/s to 0.27 ± 0.16 m/s (p = 0.189). The difference in flow velocity reduction ratio between aneurysms and branches was statistically significant (68.8 vs. 9.5%; p < 0.001). The mean pressure in branch ostia increased from 10,717.4 ± 489.0 to 10,859.0 ± 643.4 Pa (p < 0.01). Conclusion: While a flow diverter device is capable of slowing down aneurysmal inflow, it is unable to block the flow into branches and perforators when used in the treatment of posterior circulation aneurysms; flow velocity in branches even increased in some cases. With a low branch occlusion ratio, it may be acceptable to cover posterior circulation branches and perforators if unavoidable.
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Affiliation(s)
- Xinzhi Wu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongbin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junfan Chen
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yangyang Zhou
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shiqing Mu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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12
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Kaschner MG, Petridis A, Turowski B. Single-center experience with the new-generation Derivo embolization device for ruptured and unruptured intracranial aneurysms. J Neurosurg Sci 2019; 64:353-363. [PMID: 31079436 DOI: 10.23736/s0390-5616.19.04678-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study is to evaluate safety and efficacy of the new-generation Derivo embolization device in complex ruptured (RIA) and unruptured (UIA) intracranial aneurysms. METHODS Retrospective analysis of 32 patients with complex RIAs and UIAs treated with Derivo at our hospital from November 2015 to December 2018. Clinical safety was defined as absence of death, transient attack, absence of minor and major stroke, and Derivo associated hemorrhage. Treatment efficacy was assessed angiographically (DSA) immediately after treatment and at 6-month follow-up according to the O'Kelly-Marotta (OKM) Grading Scale (from A=total filling to D=no filling; prolongation of stasis 1=arterial to 3=venous phase). RESULTS Thirty-two patients with 39 aneurysms were treated with 42 Derivos. In five aneurysms, additional coiling was performed. Deployment was technically successful in all cases. Two patients developed a procedure related minor stroke (one transient). In one patient bleeding due to an inflammatory aneurysmatic wall process occurred 20 days after retreatment and in one patient a stroke due to in-stent thrombosis occurred when dual platelet inhibition (PI) was switched to permanent single PI 12 month after FD treatment. No treatment related deaths were observed. Initial DSA revealed three OKM D, six OKM C, five OKM B, and 25 OKM A. Six-month follow-up for DSA and clinical evaluation was available in 20/32 patients (62.5%), 26 of 39 aneurysms (66.7%) and revealed 73.1% complete and 3.8% subtotal occlusion (OKM D: 19 of 26, OKM C3: one of 26). CONCLUSIONS Treatment of complex RIAs and UIAs with the new-generation Derivo appeared to be safe and effective in this single-center case series for ruptured and unruptured intracranial aneurysms. Immediate DSA revealed a significant flow modulation; and 6-month follow-up showed a high occlusion rate.
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Affiliation(s)
- Marius G Kaschner
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany -
| | - Athanasios Petridis
- Department of Neurosurgery, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Bernd Turowski
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
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Maingard J, Lamanna A, Kok HK, Ranatunga D, Ravi R, Chandra RV, Lee MJ, Brooks DM, Asadi H. Endovascular treatment of visceral artery and renal aneurysms (VRAA) using a constant mesh density flow diverting stent. CVIR Endovasc 2019; 2:15. [PMID: 32026177 PMCID: PMC7224242 DOI: 10.1186/s42155-019-0057-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 04/11/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Flow diverting stents have been used safely and effectively for the treatment of intracranial aneurysms, particularly for large and wide necked aneurysms that are not amenable to conventional endovascular treatment with coiling. The Surpass Streamline device (Stryker Neurovascular, MI, USA) is a relatively new and unique flow diverting stent which maintains constant device mesh density over varying vessel diameters. This may potentially provide advantages compared to other flow diverting stents in achieving aneurysmal occlusion. CASE PRESENTATION Two patients with VRAA were treated using the Surpass Streamline device. The first patient was a 65-year-old male with an incidental 2.4 cm aneurysm originating from the hepatic artery near the gastroduodenal artery (GDA). The second patient was a 56-year-old male with an incidental 1.9 cm renal aneurysm arising from an anterior inferior segmental branch of the left renal artery. A Surpass flow diverting stent was used to successfully exclude the aneurysm neck in both cases. Reduced flow was achieved in one patient (equivalent to O'Kelly-Marotta [OKM] Grade B1). Preserved flow and stagnation (equivalent to OKM Grade A3) was achieved in the other. There was preserved distal flow in the parent arteries. No immediate complications were encountered in either case. Complete occlusion of both aneurysms was seen on follow up CT angiographic imaging within 8-weeks. CONCLUSIONS The Surpass flow diverting stent can be used safely and effectively to treat VRAA. It should be considered in unruptured large and giant wide necked VRAAs aneurysms. Additional large prospective studies are required for further validation.
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Affiliation(s)
- Julian Maingard
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Melbourne, Victoria 3084 Australia
- Interventional Neuroradiology Service, Radiology Department, Austin Hospital, Melbourne, Australia
- Faculty of Health, School of Medicine, Deakin University, Waurn Ponds, Australia
| | - Anthony Lamanna
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Melbourne, Victoria 3084 Australia
| | - Hong Kuan Kok
- Faculty of Health, School of Medicine, Deakin University, Waurn Ponds, Australia
- Interventional Radiology Service, Department of Radiology, Northern Hospital, Melbourne, Australia
| | - Dinesh Ranatunga
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Melbourne, Victoria 3084 Australia
| | - Rajeev Ravi
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Melbourne, Victoria 3084 Australia
| | - Ronil V. Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Michael J. Lee
- Interventional Radiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Duncan Mark Brooks
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Melbourne, Victoria 3084 Australia
- Interventional Neuroradiology Service, Radiology Department, Austin Hospital, Melbourne, Australia
- Faculty of Health, School of Medicine, Deakin University, Waurn Ponds, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Hamed Asadi
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Melbourne, Victoria 3084 Australia
- Interventional Neuroradiology Service, Radiology Department, Austin Hospital, Melbourne, Australia
- Faculty of Health, School of Medicine, Deakin University, Waurn Ponds, Australia
- Interventional Neuroradiology Unit, Monash Imaging, Melbourne, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
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Al-Mufti F, Cohen ER, Amuluru K, Patel V, El-Ghanem M, Nuoman R, Majmundar N, Dangayach NS, Meyers PM. Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms. INTERVENTIONAL NEUROLOGY 2018; 8:38-54. [PMID: 32231694 DOI: 10.1159/000489016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/06/2018] [Indexed: 12/21/2022]
Abstract
Background Flow-diverting stents (FDS) have revolutionized the endovascular management of unruptured, complex, wide-necked, and giant aneurysms. There is no consensus on management of complications associated with the placement of these devices. This review focuses on the management of complications of FDS for the treatment of intracranial aneurysms. Summary We performed a systematic, qualitative review using electronic databases MEDLINE and Google Scholar. Complications of FDS placement generally occur during the perioperative period. Key Message Complications associated with FDS may be divided into periprocedural complications, immediate postprocedural complications, and delayed complications. We sought to review these complications and novel management strategies that have been reported in the literature.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA.,Departments of Neurology and Neurosurgery, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Eric R Cohen
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh-Hamot, Erie, Pennsylvania, USA
| | - Vikas Patel
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Mohammad El-Ghanem
- Department of Neurology and Medical Imaging, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Rolla Nuoman
- Department of Neurology, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA
| | - Neil Majmundar
- Departments of Neurology and Neurosurgery, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Neha S Dangayach
- Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Philip M Meyers
- Departments of Radiology and Neurosurgery and Columbia University Medical Center, New York, New York, New York, USA
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Beydoun HA, Azarbaijani Y, Cheng H, Anderson-Smits C, Marinac-Dabic D. Predicting Successful Treatment of Intracranial Aneurysms with the Pipeline Embolization Device Through Meta-Regression. World Neurosurg 2018; 114:e938-e958. [DOI: 10.1016/j.wneu.2018.03.120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/17/2018] [Accepted: 03/17/2018] [Indexed: 10/17/2022]
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Al-Mufti F, Amuluru K, Cohen ER, Patel V, El-Ghanem M, Wajswol E, Dodson V, Al-Marsoummi S, Majmundar N, Dangayach NS, Nuoman R, Gandhi CD. Rescue Therapy for Procedural Complications Associated With Deployment of Flow-Diverting Devices in Cerebral Aneurysms. Oper Neurosurg (Hagerstown) 2018; 15:624-633. [DOI: 10.1093/ons/opy020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 03/15/2018] [Indexed: 12/12/2022] Open
Abstract
Abstract
Flow diverting devices (FDDs) have revolutionized the treatment of morphologically complex intracranial aneurysms such as wide-necked, giant, or fusiform aneurysms. Although FDDs are extremely effective, they carry a small yet significant risk of intraprocedural complications. As the implementation of these devices increases, the ability to predict and rapidly treat complications, especially those that are iatrogenic or intraprocedural in nature, is becoming increasingly more necessary.
Our objective in this paper is to provide a descriptive summary of the various types of intraprocedural complications that may occur during FDDs deployment and how they may best be treated. A systematic and qualitative review of the literature was conducted using electronic databases MEDLINE and Google Scholar. Searches consisted of Boolean operators “AND” and “OR” for the following terms in different combinations: “aneurysm,” “endovascular,” “flow diverter,” “intracranial,” and “pipeline.”
A total of 94 papers were included in our analysis; approximately 87 of these papers dealt with periprocedural endovascular (mainly related to FDDs) complications and their treatment; 7 studies concerned background material. The main categories of periprocedural complications encountered during deployment of FDDs are failure of occlusion, parent vessel injury and/or rupture, spontaneous intraparenchymal hemorrhage, migration or malposition of the FDDs, thromboembolic or ischemic events, and side branch occlusion
Periprocedural complications occur mainly due to thromboembolic events or mechanical issues related to device deployment and placement. With increasing use and expanding versatility of FDDs, the understanding of these complications is vital in order to effectively manage such situations in a timely manner.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Neuro-surgery, and Radiology, Robert Wood Johnson Medical School, Rutgers Uni-versity, New Brunswick, New Jersey
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh Medical Center Hamot, Erie, Pennsylvania
| | - Eric R Cohen
- Department of Radiology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Vikas Patel
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
- Department of Neurology, New Jersey Medical School, Rutgers University, Newark, New Jersey
| | - Mohammad El-Ghanem
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Ethan Wajswol
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Vincent Dodson
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Sarmad Al-Marsoummi
- Department of Neuroscience, University of North Dakota, Grand Forks, North Dakota
| | - Neil Majmundar
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Neha S Dangayach
- Department of Neurology and Neurosurgery, Ichan School of Medicine at Mount Sinai, New York, New York
| | - Rolla Nuoman
- Department of Neurology, New Jersey Medical School, Rutgers University, Newark, New Jersey
| | - Chirag D Gandhi
- Department of Neurosurgery, New York Medical College, Westchester Medical Center, New York, New York
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17
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Giorgianni A, Pellegrino C, Minotto R, Mercuri A, Frattini L, Baruzzi F, Valvassori L. Flow-diverter stenting of post-traumatic bilateral anterior cerebral artery pseudoaneurysm: A case report. Interv Neuroradiol 2018; 21:23-8. [PMID: 25934771 DOI: 10.1177/1591019915575441] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The use of flow-diverter (FD) stents in recent years has positively changed the therapeutic approach to some vascular diseases, especially of certain types of aneurysms. This paper describes the case of a young patient after a major head trauma causing multiple skull fractures. The trauma occasioned two pseudoaneurysms from the A1 segment of the right anterior cerebral artery and from the A2 segment of the left anterior cerebral artery. Both lesions were treated with two Pipeline devices (ev3, Irvine, CA, USA) in two different sessions. The CT study and angiographic investigations performed in the following month showed a complete resolution of the post-traumatic pseudoaneurysmal lesions. Although the use of FD stents is described in the literature, particularly in the treatment of selected aneurysms, this paper shows good technical results in the use of these stents in cases of intracranial post-traumatic pseudoaneurysms with clinical improvement.
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Affiliation(s)
| | - Carlo Pellegrino
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Renzo Minotto
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Anna Mercuri
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Lara Frattini
- Departement of Anesthesiology, Ospedale di Circolo, Varese, Italy
| | - Fabio Baruzzi
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Luca Valvassori
- Departement of Neuroradiology, Ospedale Niguarda Ca' Granda, Milan, Italy
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18
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Voigt P, Schob S, Jantschke R, Nestler U, Krause M, Weise D, Lobsien D, Hoffmann KT, Quäschling U. Stent-Assisted Coiling of Ruptured and Incidental Aneurysms of the Intracranial Circulation Using Moderately Flow-Redirecting, Braided Leo Stents-Initial Experience in 39 Patients. Front Neurol 2017; 8:602. [PMID: 29184531 PMCID: PMC5694479 DOI: 10.3389/fneur.2017.00602] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 10/30/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Flow diversion (FD)-a young technique using stents with highly increased surface coverage-was introduced to treat complex aneurysms without intra-aneurysmal material placement and has amended the spectrum of endovascular techniques such as stent-assisted coil occlusion considerably. However, ischemic complications, a common side effect in FD, occur more frequently compared with the conventional endovascular approaches and certainly limit the indication of this technique. Our study aimed to investigate the feasibility and efficacy of stent-assisted coiling using low profile self-expandable stents, which exhibit only moderate flow-redirecting properties and therefore represent a combination of hemodynamic endovascular and occlusive endosaccular therapy. MATERIALS AND METHODS 39 Patients were included in our retrospective study. Occlusion rates were assessed 6 months after the procedure in a total of 27 cases using the Raymond scale. RESULTS Complete occlusion (Raymond I) was achieved in 24/27 aneurysms. Small neck remnants (Raymond II) were evident in 3/27 aneurysms. There were no cases with sac remnant or complete persistence of aneurysmal filling (Raymond III and IV). CONCLUSION Our study demonstrates interventional treatment of intracranial aneurysms using flow-redirecting stent-assisted coiling to be technically feasible and highly effective in aneurysmal occlusion. We believe that this approach is outstanding in the prevention of long-term aneurysmal reperfusion and exhibits a more acceptable risk profile than highly efficient FD techniques.
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Affiliation(s)
- Peter Voigt
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
| | - Stefan Schob
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
| | - Robert Jantschke
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
| | - Ulf Nestler
- Department of Neurosurgery, Leipzig University Hospital, Leipzig, Germany
| | - Matthias Krause
- Department of Neurosurgery, Leipzig University Hospital, Leipzig, Germany
| | - David Weise
- Department of Neurology, Leipzig University Hospital, Leipzig, Germany
| | - Donald Lobsien
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
| | | | - Ulf Quäschling
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
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19
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Emerging Technologies in Flow Diverters and Stents for Cerebrovascular Diseases. Curr Neurol Neurosci Rep 2017; 17:96. [DOI: 10.1007/s11910-017-0805-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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20
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Mahboobani NR, Chong WH, Lam SSK, Siu JCW, Tan CB, Wong YC. Treatment of Intracranial Aneurysms with Flow Re-direction Endoluminal Device - A Single Centre Experience with Short-term Follow-up Results. Neurointervention 2017; 12:11-19. [PMID: 28316865 PMCID: PMC5355456 DOI: 10.5469/neuroint.2017.12.1.11] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 01/02/2017] [Indexed: 11/30/2022] Open
Abstract
Purpose A flow diverter (FD) is an effective treatment option for intracranial aneurysms. The Flow Re-direction Endoluminal Device (FRED) is a relatively new flow diverter with a unique dual-layer design. We report our experience and short-term results with the FRED. Materials and Methods We did a retrospective review of all consecutive cases in which the FRED was used to treat intracranial aneurysms at a single institution from March 2014 till December 2015. Clinical parameters, aneurysm characteristics, technical results and short-term outcomes were reviewed. Results Eleven intracranial aneurysms were treated with the FRED in 11 patients. The technical device deployment success rate was 100%. Immediate reduction in intra-aneurysmal flow after deployment was noted in 10 cases. The aneurysm occlusion rate at 6 months was 75%. There was 1 complication of in-stent thrombosis immediately after deployment. There was no side branch occlusion, delayed aneurysm rupture, stroke, or intraparenchymal haemorrhage. There was no neurological deficit, morbidity, or mortality. Conclusion The FRED is a new FD. It has shown to be safe and effective in our series. The unique dual-layer design of the device renders it to have technical advantages over other FDs. The 6-month aneurysm occlusion rate and complication profile of FRED are similar to other FDs.
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Affiliation(s)
| | - Wing Ho Chong
- Department of Radiology, Tuen Mun Hospital, Hong Kong
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Luecking H, Engelhorn T, Lang S, Goelitz P, Kloska S, Roessler K, Doerfler A. FRED Flow Diverter: A Study on Safety and Efficacy in a Consecutive Group of 50 Patients. AJNR Am J Neuroradiol 2017; 38:596-602. [PMID: 28104636 DOI: 10.3174/ajnr.a5052] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 10/23/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular flow diverters are increasingly used for the treatment of cerebral aneurysms. We assessed the safety and efficacy of the Flow-Redirection Endoluminal Device (FRED) in a consecutive series of 50 patients. MATERIALS AND METHODS Inclusion criteria were wide-neck, blister-like, or fusiform/dissecting aneurysms independent of size, treated with the FRED between February 2014 and May 2015. Assessment criteria were aneurysm occlusion, manifest ischemic stroke, bleeding, or death. The occlusion rate was assessed at 3 months with flat panel CT and at 6 months with DSA by using the Raymond classification and the O'Kelly-Marotta grading scale. RESULTS Fifty patients with 52 aneurysms were treated with 54 FREDs; 20 patients were treated with the FRED and coils. Aneurysm size ranged from 2.0 to 18.5 mm. Deployment of the FRED was successful in all cases. There were no device-associated complications. One patient developed mild stroke symptoms that fully receded within days. There have been no late-term complications so far and no treatment-related mortality. Initial follow-up at 3 months showed complete occlusion in 72.3% of the overall study group, Six-month follow-up showed total and remnant-neck occlusion in 87.2% of patients, distributed over 81.5% of the FRED-only cases and 95.0% of the cases with combined treatment. CONCLUSIONS The FRED flow diverter is a safe device for the treatment of cerebral aneurysms of various types. Our data reveal high occlusion rates at 3 and 6 months, comparable with those in other flow diverters. Long-term occlusion rates are expected.
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Affiliation(s)
- H Luecking
- From the Departments of Neuroradiology (H.L., T.E., S.L., P.G., S.K., A.D.)
| | - T Engelhorn
- From the Departments of Neuroradiology (H.L., T.E., S.L., P.G., S.K., A.D.)
| | - S Lang
- From the Departments of Neuroradiology (H.L., T.E., S.L., P.G., S.K., A.D.)
| | - P Goelitz
- From the Departments of Neuroradiology (H.L., T.E., S.L., P.G., S.K., A.D.)
| | - S Kloska
- From the Departments of Neuroradiology (H.L., T.E., S.L., P.G., S.K., A.D.)
| | - K Roessler
- Neurosurgery (K.R.), University of Erlangen-Nuremberg, Erlangen, Germany
| | - A Doerfler
- From the Departments of Neuroradiology (H.L., T.E., S.L., P.G., S.K., A.D.)
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Akgul E, Onan HB, Akpinar S, Balli HT, Aksungur EH. The DERIVO Embolization Device in the Treatment of Intracranial Aneurysms: Short- and Midterm Results. World Neurosurg 2016; 95:229-240. [DOI: 10.1016/j.wneu.2016.07.101] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 07/23/2016] [Accepted: 07/27/2016] [Indexed: 11/26/2022]
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23
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Zanaty M, Daou B, Chalouhi N, Starke RM, Samaniego E, Derdeyn C, Jabbour P, Hasan D. Same-Day Discharge After Treatment with the Pipeline Embolization Device Using Monitored Anesthesia Care. World Neurosurg 2016; 96:31-35. [PMID: 27565476 DOI: 10.1016/j.wneu.2016.08.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/10/2016] [Accepted: 08/12/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The Pipeline Embolization Device (PED) has been used and shown to be safe under monitored anesthesia care (MAC). We present the results of the first study, to our knowledge, assessing the safety and feasibility of same-day discharge in patients undergoing treatment with the PED, using MAC. METHODS A total of 130 patients with 143 cerebral aneurysms (CAs) were identified. Patients were treated under MAC with the PED. All of the patients were counseled preoperatively about the elective nature of the procedure and the same-day discharge. RESULTS The mean age of the participants was 60.7 ± 12.12 years. Men constituted 27.69% (36/130) of the population. The number of procedures was 138. All of our patients elected to return home the same day, whereas only 6.15% (8/130) of them changed their mind in the postoperative setting and elected to stay overnight out of convenience (late discharge, patient preference, or living alone at home). Overall discharge home on the same day occurred after 90.6% of procedures (125/138) and in 91.53% (119/130) of the patients. All same-day discharges took place within 4-6 hours after the procedures. The rate of major complications was 0.75% (1/134). The mortality rate was 0%. CONCLUSIONS PED treatment under MAC is feasible and safe. This has brought forth an era of outpatient treatment of CAs where patients are discharged home 6 hours after the procedure.
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Affiliation(s)
- Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Badih Daou
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Edgar Samaniego
- Department of Neurology and Interventional Radiology, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Colin Derdeyn
- Department of Radiology and Interventional Radiology, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - David Hasan
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA.
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Tureli D, Sabet S, Senol S, Andac N, Donmez H, Geyik S, Baltacioglu F, Cekirge S. Stent-assisted coil embolization of challenging intracranial aneurysms: initial and mid-term results with low-profile ACCLINO devices. Acta Neurochir (Wien) 2016; 158:1545-53. [PMID: 27250849 DOI: 10.1007/s00701-016-2839-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 05/10/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Stent-assisted coiling using low-profile, self-expandable and retrievable stents is a valid option in endovascular treatment of challenging intracranial aneurysms. This study aims to evaluate the feasibility and efficacy of ACCLINO 1.9 F and ACCLINO Flex stent systems, designed for use as adjunctive products in coil embolization of intracranial aneurysms. METHODS Case files of 47 patients, and 52 aneurysms in total, treated with at least one ACCLINO 1.9 F or ACCLINO Flex stent were retrospectively evaluated. Technical success, complications, and angiographic outcomes were assessed based on immediate post-procedural controls along with 6th and 12th month angiograms. RESULTS Mechanical untoward event rate, including asymptomatic complications, is 9.6 % (five out of 52 aneurysms). Failed dual-stenting attempt rate is 15.4 % (two out of 13). Overall procedure-related morbidity is 4.2 % with no neurologic sequelae. Initial occlusion rate is 90.4 % (47 aneurysms). One patient had residual filling in the aneurysm neck, which was stable throughout follow-up. The remaining four cases had spontaneous follow-up occlusion. Recanalization rate at 6th month is 2.1 % with one aneurysm requiring retreatment. One patient was lost to follow-up. There is no mortality associated with treatment. CONCLUSIONS Stent-assisted coil embolization with ACCLINO stents in single or dual configurations is a feasible treatment option for challenging intracranial aneurysms. Follow-up results are encouraging; techniques were effective in complex cases and there were no clinically significant adverse outcomes.
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Affiliation(s)
- Derya Tureli
- Department of Radiology, Umraniye Training and Research Hospital, Elmalıkent M, Adem Yavuz C. #1, 34760, Umraniye, Istanbul, Turkey.
| | - Soheil Sabet
- Department of Radiology, Marmara University School of Medicine, Istanbul, Turkey
| | - Serkan Senol
- Department of Radiology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Nurten Andac
- Radiology Clinic, VKV Amerikan Hospital, Istanbul, Turkey
| | - Halil Donmez
- Department of Radiology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Serdar Geyik
- Interventional Neuroradiology Clinic, Memorial Healthcare Group Hospitals, Istanbul, Turkey
| | - Feyyaz Baltacioglu
- Department of Radiology, Marmara University School of Medicine, Istanbul, Turkey
| | - Saruhan Cekirge
- Interventional Radiology Clinic, Koru Hospital, Ankara, Turkey
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Al-Mufti F, Amuluru K, Gandhi CD, Prestigiacomo CJ. Flow Diversion for Intracranial Aneurysm Management: A New Standard of Care. Neurotherapeutics 2016; 13:582-9. [PMID: 27160270 PMCID: PMC4965406 DOI: 10.1007/s13311-016-0436-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Endovascular treatment of intracranial aneurysms with complex morphologies such as giant, wide-necked, or fusiform aneurysms is challenging. Stent-assisted coiling and balloon-assisted coiling are alternative techniques to treat such complex aneurysms, but studies have shown less-than-expected efficacy, as suggested by their high rate of recanalization. The management of complex aneurysms via microsurgery or conventional neuroendovascular strategies has traditionally been poor. However, over the last few years, flow-diverting stents (FDS) have revolutionized the treatment of such aneurysms. FDS are implanted within the parent artery rather than the aneurysm sac. By modifying intra-aneurysmal and parent-vessel flow dynamics at the aneurysm/parent vessel interface, FDS trigger a cascade of gradual intra-aneurysmal thrombosis. As endothelialization of the FDS is complete, the parent vessel reconstructs while preserving the patency of normal perforators and side branch vessels. As with any intervention, the practice and application of flow-diversion technology is inherent, with risks that include vessel rupture or perforation, in-stent thrombosis, perforator occlusion, procedural and delayed hemorrhages, and perianeurysmal edema. Herein, we review the devices, their mechanisms of actions, clinical applications, complications, and ongoing studies.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurosurgery, Rutgers University School of Medicine, Newark, NJ, USA.
| | - Krishna Amuluru
- Department of Neurosurgery, Rutgers University School of Medicine, Newark, NJ, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Rutgers University School of Medicine, Newark, NJ, USA
- Department of Neurology, Rutgers University School of Medicine, Newark, NJ, USA
- Department of Radiology, Rutgers University School of Medicine, Newark, NJ, USA
| | - Charles J Prestigiacomo
- Department of Neurosurgery, Rutgers University School of Medicine, Newark, NJ, USA
- Department of Neurology, Rutgers University School of Medicine, Newark, NJ, USA
- Department of Radiology, Rutgers University School of Medicine, Newark, NJ, USA
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Bouillot P, Brina O, Yilmaz H, Farhat M, Erceg G, Lovblad KO, Vargas MI, Kulcsar Z, Pereira VM. Virtual-versus-Real Implantation of Flow Diverters: Clinical Potential and Influence of Vascular Geometry. AJNR Am J Neuroradiol 2016; 37:2079-2086. [PMID: 27365325 DOI: 10.3174/ajnr.a4845] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/24/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial stents have become extremely important in the endovascular management of complex intracranial aneurysms. Sizing and landing zone predictions are still very challenging steps in the procedure. Virtual stent deployment may help therapeutic planning, device choice, and hemodynamic simulations. We aimed to assess the predictability of our recently developed virtual deployment model by comparing in vivo and virtual stents implanted in a consecutive series of patients presenting with intracranial aneurysms. MATERIALS AND METHODS Virtual stents were implanted in patient-specific geometries of intracranial aneurysms treated with the Pipeline Embolization Device. The length and cross-section of virtual and real stents measured with conebeam CT were compared. The influence of vessel geometry modifications occurring during the intervention was analyzed. RESULTS The virtual deployment based on pre- and poststent implantation 3D rotational angiography overestimated (underestimated) the device length by 13% ± 11% (-9% ± 5%). These differences were highly correlated (R2 = 0.67) with the virtual-versus-real stent radius differences of -6% ± 7% (5% ± 4%) for predictions based on pre- and poststent implantation 3D rotational angiography. These mismatches were due principally to implantation concerns and vessel-shape modifications. CONCLUSIONS The recently proposed geometric model was shown to predict accurately the deployment of Pipeline Embolization Devices when the stent radius was well-assessed. However, unpredictable delivery manipulations and variations of vessel geometry occurring during the intervention might impact the stent implantation.
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Affiliation(s)
- P Bouillot
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland.,Laboratory for Hydraulic Machines (P.B., M.F.), École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - O Brina
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland
| | - H Yilmaz
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland
| | - M Farhat
- Laboratory for Hydraulic Machines (P.B., M.F.), École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - G Erceg
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland
| | - K-O Lovblad
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland
| | - M I Vargas
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland
| | - Z Kulcsar
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland
| | - V M Pereira
- Division of Neuroradiology (V.M.P.), Department of Medical Imaging .,Division of Neurosurgery (V.M.P.), Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Gentric JC, Fahed R, Darsaut TE, Salazkin I, Roy D, Raymond J. Fatal arterial rupture during angioplasty of a flow diverter in a recurrent, previously Y-stented giant MCA bifurcation aneurysm. Interv Neuroradiol 2016; 22:278-86. [PMID: 26893302 PMCID: PMC4984368 DOI: 10.1177/1591019916631147] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 01/13/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND PURPOSE A patient with a previously Y-stented giant left middle cerebral artery (MCA) bifurcation aneurysm returned with a recurrence. MATERIALS AND METHODS A flow diverter (FD) was deployed through one limb of the high-porosity Y-stenting construction. The proximal FD failed to expand and an attempt at balloon angioplasty led to fatal rupture of the MCA. RESULTS Autopsy demonstrated subarachnoid hemorrhage, vessel rupture and fracture of the proximal high-porosity stent. Microscopic photographs showed that the FD had failed to open because the guiding wire had inadvertently exited and re-entered the proximal segment of the high-porosity stent partially incorporated to the wall of the MCA. Balloon dilatation of the FD which had remained collapsed between the stent and the vessel wall caused fracture of the stent and rupture of the artery. CONCLUSION Angioplasty and flow-diversion of previously Y-stented aneurysms can lead to serious complications.
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Affiliation(s)
- Jean-Christophe Gentric
- Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radiology, Service of Neuroradiology, Canada
| | - Robert Fahed
- Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radiology, Service of Neuroradiology, Canada
| | - Tim E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Department of Surgery, Division of Neurosurgery, Canada
| | - Igor Salazkin
- Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM), Notre-Dame Hospital, Interventional Neuroradiology Research Laboratory, Canada
| | - Daniel Roy
- Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radiology, Service of Neuroradiology, Canada
| | - Jean Raymond
- Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radiology, Service of Neuroradiology, Canada
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Failure of the Pipeline Embolization Device in Posterior Communicating Artery Aneurysms Associated with a Fetal Posterior Cerebral Artery. Case Rep Vasc Med 2016; 2016:4691275. [PMID: 27069709 PMCID: PMC4812271 DOI: 10.1155/2016/4691275] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/21/2016] [Accepted: 02/28/2016] [Indexed: 12/13/2022] Open
Abstract
The pipeline embolization device has emerged as an important endovascular option. This is in part due to safety, efficacy, and possibly the ability to shorten the operative time considerably. With this new technology, some limitations are emerging as experience accumulates. We report three cases of posterior communicating (PCOM) artery aneurysms associated with fetal posterior cerebral artery where pipeline embolization was unsuccessful in obliterating the aneurysms. PCOM artery aneurysms associated with a fetal PCA should be managed either by microsurgical clipping or coiling when feasible.
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29
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Safain MG, Roguski M, Heller RS, Malek AM. Flow Diverter Therapy With the Pipeline Embolization Device Is Associated With an Elevated Rate of Delayed Fluid-Attenuated Inversion Recovery Lesions. Stroke 2016; 47:789-97. [DOI: 10.1161/strokeaha.115.010522] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 11/20/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Mina G. Safain
- From the Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Marie Roguski
- From the Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Robert S. Heller
- From the Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Adel M. Malek
- From the Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
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Yu SCH, Lee KT, Lau TWW, Wong GKC, Pang VKY, Chan KY. Intravenous C-Arm Conebeam CT Angiography following Long-Term Flow-Diverter Implantation: Technologic Evaluation and Preliminary Results. AJNR Am J Neuroradiol 2016; 37:481-6. [PMID: 26585252 DOI: 10.3174/ajnr.a4558] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 07/29/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE A noninvasive investigation with high spatial resolution and without metal artifacts is necessary for long-term imaging follow-up after flow-diverter implantation. We aimed to evaluate the diagnostic value of conebeam CT angiography with intravenous contrast enhancement in the assessment of vascular status following implantation of the Pipeline Embolization Device and to analyze the preliminary results of vascular status following long-term Pipeline Embolization Device implantation. MATERIALS AND METHODS This was an ongoing prospective study of consecutive patients with intracranial aneurysms treated with the Pipeline Embolization Device. Patients with a modified Rankin Scale score of 4-5 were excluded. The median and interquartile range of the time interval of Pipeline Embolization Device implantation to conebeam CT angiography with intravenous contrast enhancement were 56.6 and 42.9-62.4 months, respectively. Conebeam CT angiography with intravenous contrast enhancement was performed with the patient fully conscious, by using a C-arm CT with a flat panel detector. RESULTS There were 34 patients and 34 vascular segments. In all 34 cases, contrast effect and image quality were good and not substantially different from those of intra-arterial conebeam CTA. Metal artifacts occurred in all 14 cases with coil masses; the Pipeline Embolization Device was obscured in 3 cases. In all 34 cases, there was no residual aneurysm, no vascular occlusion, 1 vascular stenosis (50%), good Pipeline Embolization Device apposition to the vessel, and no Pipeline Embolization Device-induced calcification. All 28 Pipeline Embolization Device-covered side branches were patent. CONCLUSIONS Conebeam CT angiography with intravenous contrast enhancement is potentially promising and useful for effective evaluation of the vascular status following intracranial flow diverters. The Pipeline Embolization Device for intracranial aneurysms is probably safe and promising for long-term placement, with favorable morphologic outcome and without delayed complications.
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Affiliation(s)
- S C H Yu
- From the Department of Imaging and Interventional Radiology (S.C.H.Y., K.T.L., T.W.W.L.)
| | - K T Lee
- From the Department of Imaging and Interventional Radiology (S.C.H.Y., K.T.L., T.W.W.L.)
| | - T W W Lau
- From the Department of Imaging and Interventional Radiology (S.C.H.Y., K.T.L., T.W.W.L.)
| | - G K C Wong
- Division of Neurosurgery (G.K.C.W.), Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR
| | - V K Y Pang
- Department of Neurosurgery (V.K.Y.P.), Pamela Youde Nethersole Eastern Hospital, Hong Kong, SAR
| | - K Y Chan
- Department of Neurosurgery (K.Y.C.), Kwong Wah Hospital, Yaumatei, Kowloon, Hong Kong, SAR
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Amuluru K, Al-Mufti F, Singh IP, Prestigiacomo C, Gandhi C. Flow Diverters for Treatment of Intracranial Aneurysms: Technical and Clinical Updates. World Neurosurg 2015; 85:15-9. [PMID: 26679259 DOI: 10.1016/j.wneu.2015.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Krishna Amuluru
- Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
| | - Inder Paul Singh
- Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA; Department of Neurology, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
| | - Charles Prestigiacomo
- Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA; Department of Neurology, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA; Department of Radiology, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA; Department of Neurology, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA; Department of Radiology, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
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32
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Al-Ali F. Editorial: Balloon and Stent for Ischemic and Hemorrhagic Stroke: A New Trend for Stroke Prevention and Management. Front Neurol 2015; 6:218. [PMID: 26539156 PMCID: PMC4609842 DOI: 10.3389/fneur.2015.00218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 09/28/2015] [Indexed: 11/18/2022] Open
Affiliation(s)
- Firas Al-Ali
- Department of Neuro Interventional Surgery, Akron General Medical Center , Akron, OH , USA
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Comparison of the flow diverter and stent-assisted coiling in large and giant aneurysms: safety and efficacy based on a propensity score-matched analysis. Eur Radiol 2015; 26:2369-77. [PMID: 26471273 DOI: 10.1007/s00330-015-4052-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 09/23/2015] [Accepted: 09/29/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The flow diverter (FD) is a device aimed at reconstructing the parent artery and occluding an aneurysm. We performed a propensity score-matched analysis to compare safety and efficacy between the FD and stent-assisted coiling. METHODS A database review was conducted to identify patients with large and giant unruptured aneurysms (aneurysms located in the ACA, MCA, or PCA were excluded) treated with the FD or stent-assisted coiling. A propensity score, representing the probability of using the FD, was generated for each aneurysm using the relevant patient and aneurysmal variables. Angiographic results, complications, and clinical outcomes were compared. RESULTS Forty-five aneurysms treated with the FD (FD alone: 32; FD+Coils: 13) and 45 treated with stent-assisted coiling were matched. The rate of complete occlusion was significantly (P = 0.0002) higher in the FD cohort than the conventional stent cohort at the 6-month follow-up. The FD cohort achieved greater improvement (P < 0.0001) and a lower rate of recurrence (P = 0.0001). The rate of periprocedural complications was similar, as was the proportion of patients who attained mRS ≤ 2 at discharge and at the 6-month follow-up. CONCLUSIONS Our findings provide reliable evidence demonstrating that the FD may be a preferred treatment option for large and giant unruptured aneurysms. KEY POINTS • Flow Diverter provided a higher complete occlusion rate at 6-month follow-up. • Flow Diverter achieved more progress occlusion and less recurrence. • Compared with the conventional stents, procedure-related morbidity of Flow Diverter was similar. • Flow Diverter is a preferred treatment for large and giant unruptured aneurysms.
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Zanaty M, Chalouhi N, Barros G, Schwartz EW, Saigh MP, Starke RM, Whiting A, Tjoumakaris SI, Hasan D, Rosenwasser RH, Jabbour P. Flow-diversion for ophthalmic segment aneurysms. Neurosurgery 2015; 76:286-9; discussion 289-90. [PMID: 25584955 DOI: 10.1227/neu.0000000000000607] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The use of flow-diversion to treat ophthalmic segment aneurysms (OSA) has not been well evaluated. OBJECTIVE To assess the visual outcomes, the obliteration rate, and the need for retreatment of OSA treated by the pipeline embolization device (PED). METHODS Patients who underwent treatment with PED for OSA from 2009 to 2014 were selected and retrospectively reviewed. Patient's age, sex, mode of presentation, and aneurysm size were recorded. The complication rates, the need for retreatment (due to recurrence of the aneurysm or worsening symptoms), the aneurysm occlusion rates, the evolution of visual symptoms, and the evolution of headache/retro-orbital pain were registered. RESULTS Forty-one patients harboring 44 OSA treated by flow-diversion were identified. Females constituted 87.80% (37/41) of the cohort. The mean age was 59.16 ± 12.54 years. At final angiographic follow-up, 77.27% (34/44) had complete occlusion, 6.81% (3/44) had near-complete occlusion, and 15.90% (7/44) had incomplete occlusion. Of the 22 symptomatic OSA, complete resolution or significant improvement was noted in 72.72% (16/22), while worsening of symptoms occurred in 4.54% (1/22). Five patients out of 22 (22.72%; 5/22) had no significant changes in their symptoms. The complication rate was 2.27% (1/44). The mortality rate was 0%. CONCLUSION The low complication rate, the high obliteration rate, and the high rate of improvement in the visual symptoms make flow-diversion an appealing option for the treatment of OSA.
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Affiliation(s)
- Mario Zanaty
- *Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; ‡Department of Neurosurgery, University of Virginia, Charlottesville, Virginia; §Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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35
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Chalouhi N, Zanaty M, Whiting A, Tjoumakaris S, Hasan D, Ajiboye N, Hann S, Rosenwasser RH, Jabbour P. Treatment of ruptured intracranial aneurysms with the pipeline embolization device. Neurosurgery 2015; 76:165-72; discussion 172. [PMID: 25549187 DOI: 10.1227/neu.0000000000000586] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pipeline embolization device (PED) has been used for treatment of unruptured aneurysms. Little is known about the use of the PED in ruptured aneurysms. OBJECTIVE To assess the safety and efficacy of the PED in ruptured intracranial aneurysms. METHODS This is a case series with prospective data collection on 20 patients with freshly ruptured aneurysms who were treated with PED (with or without adjunctive coiling) at 2 cerebrovascular centers. Patients were loaded with aspirin and clopidogrel or received an infusion of tirofiban intraoperatively. RESULTS Hunt and Hess grades were I in 7 patients (35%), II in 9 (45%), and III in 4 (20%). The mean duration from hemorrhage to PED placement was 7±7.0 days. A single device was used in all but 1 patient (95%). The procedure was staged in 20%. There was only 1 complication (5%); this was a fatal intraoperative aneurysm dome rupture that occurred during adjunctive coil deployment. Adjunctive coiling was used in 30%. No patient required an invasive procedure after PED placement. Follow-up angiography (mean, 5.3±4.2 months; range, 2-12 months) showed 100% occlusion in 12 (80%) and incomplete occlusion in 3 patients (20%). At latest follow-up, 19 patients achieved a favorable outcome (modified rankin scale 0-2). CONCLUSION In our preliminary experience, treatment of ruptured aneurysms with the PED was associated with low complication rates, high occlusion rates, and favorable outcomes. These findings suggest that PED may be a safe and effective option for patients with favorable Hunt and Hess grades and aneurysms difficult to treat with conventional methods.
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Affiliation(s)
- Nohra Chalouhi
- *Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; ‡Department of Neurosurgery, University of Iowa, Iowa City, Iowa
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Shankar JJS, Tampieri D, Iancu D, Cortes M, Agid R, Krings T, Wong J, Lavoie P, Ghostine J, Shettar B, Ritchie K, Weill A. SILK flow diverter for complex intracranial aneurysms: a Canadian registry. J Neurointerv Surg 2015; 8:273-8. [PMID: 25987591 DOI: 10.1136/neurintsurg-2015-011708] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/24/2015] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The SILK flow diverter (SFD) is used for the treatment of complex intracranial aneurysms. Small case series have been reported in the literature but few studies with a large number of patients have been published. We present our experience with the SFD for the treatment of intracranial aneurysms in Canada. METHODS Centers across Canada using SFDs were contacted to fill out a case report form for patients treated with an SFD in their center. Individual centers were responsible for approval from their ethics committee. Image analysis was performed by individual operators. The case report forms were collected and the final analysis was performed. RESULTS A total of 92 patients were treated with SFDs in eight centers in Canada between January 2009 and August 2013. The aneurysms were located in the posterior circulation in 16 patients and in the anterior circulation in 76 patients. Most aneurysms (75%) were saccular in shape; 22% were fusiform and 3% were blister aneurysms. The size of the aneurysms varied from 2 to 60 mm with the neck varying from 2 to 60 mm. Perioperative morbidity and mortality were 8.7% and 2.2%, respectively. At the last available follow-up, 83.1% of the aneurysms were either completely or near-completely occluded. The rate of complications was higher for fusiform aneurysms (p<0.001). CONCLUSIONS The SFD appears to be an important tool for the treatment of complex intracranial aneurysms. Treatment outcomes and complication rates remain a problem, but should be considered in the context of available alternative interventions. Ongoing analysis of flow-diverting stents for radiographic and clinical performance is required.
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Affiliation(s)
- Jai Jai Shiva Shankar
- Division of Neuroradiology, Department of Diagnostic Imaging, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Donatella Tampieri
- Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, Montreal, Quebec, Canada
| | - Daniela Iancu
- Division of Neuroradiology, Department of Diagnostic Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Maria Cortes
- Department of Radiology, Montreal Neurological Hospital and Institute, Montreal, Quebec, Canada
| | - Ronit Agid
- Division of Neuroradiology, Department of Diagnostic Imaging, Toronto Western Hospital and University Health Network, Toronto, Ontario, Canada
| | - Timo Krings
- Department of Radiology, University of Toronto, Toronto Western Hospital and University Health Network, Toronto, Ontario, Canada
| | - John Wong
- Department of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Jimmy Ghostine
- Department of Radiology, CHUM, Hopital Notre-Dame, Montreal, Quebec, Canada
| | - Basavraj Shettar
- Division of Neuroradiology, Department of Diagnostic Imaging, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Krsita Ritchie
- Interdisciplinary Research Team, IWK, Dalhousie Universtiy, Halifax, Nova Scotia, Canada
| | - Alain Weill
- Department of Radiology, CHUM, Hopital Notre-Dame, Montreal, Quebec, Canada
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Zander T, Medina S, Montes G, Nuñez-Atahualpa L, Valdes M, Maynar M. Endoluminal occlusion devices: technology update. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2014; 7:425-36. [PMID: 25489252 PMCID: PMC4257107 DOI: 10.2147/mder.s49540] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Endoluminal occlusion has been performed since the early beginning of interventional radiology. Over recent decades, major technological advances have improved the techniques used and different devices have been developed for changing conditions. Most of these occlusion devices have been implemented in the vascular territory. Early embolization materials included glass particles, hot contrast, paraffin, fibrin, and tissue fragments such as muscle fibers and blood clots; today, occlusion materials include metallic devices, particles, and liquid materials, which can be indicated for proximal or distal occlusion, high-flow and low-flow situations, and in large-caliber and small-caliber vessels, based on need. Technological progress has led to a decreased size of delivery catheters, and an increase in safety due to release systems that permit the withdrawing and replacement of embolization material. Furthermore, bioactive embolization materials have been developed to increase the efficacy of embolization or the biological effect of medication. Finally, materials have been modified for changing indications. Intravascular stents were initially developed to keep an artery open; however, by adding a covering membrane, these stents can be used to occlude the wall of a vessel or other endoluminal structures. This article gives an overview of the devices most utilized for occlusion of endoluminal structures, as well as their major purpose in the endovascular territory.
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Affiliation(s)
- Tobias Zander
- Endoluminal/Vascular Department, Hospiten Hospital Group, Santa Cruz de Tenerife, Spain
| | - Samantha Medina
- Endoluminal/Vascular Department, Hospiten Hospital Group, Santa Cruz de Tenerife, Spain
| | - Guillermo Montes
- Endoluminal/Vascular Department, Hospiten Hospital Group, Santa Cruz de Tenerife, Spain
| | | | - Michel Valdes
- Endoluminal/Vascular Department, Hospiten Hospital Group, Santa Cruz de Tenerife, Spain
| | - Manuel Maynar
- Endoluminal/Vascular Department, Hospiten Hospital Group, Santa Cruz de Tenerife, Spain ; University of Las Palmas de Gran Canarias, Las Palmas, Canary Island, Spain
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Zanaty M, Chalouhi N, Starke RM, Barros G, Saigh MP, Schwartz EW, Ajiboye N, Tjoumakaris SI, Hasan D, Rosenwasser RH, Jabbour P. Flow Diversion Versus Conventional Treatment for Carotid Cavernous Aneurysms. Stroke 2014; 45:2656-61. [DOI: 10.1161/strokeaha.114.006247] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mario Zanaty
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Nohra Chalouhi
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Robert M. Starke
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Guilherme Barros
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Mark Philip Saigh
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Eric Winthrop Schwartz
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Norman Ajiboye
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Stavropoula I. Tjoumakaris
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - David Hasan
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Robert H. Rosenwasser
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Pascal Jabbour
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
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Giorgianni A, Pellegrino C, Minotto R, Mercuri A, Frattini L, Baruzzi F, Valvassori L. Flow-Diverter Stenting of Post-Traumatic Bilateral Anterior Cerebral Artery Pseudoaneurysm. Interv Neuroradiol 2014. [DOI: 10.15274/inr-2014-10100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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