Future Directions and Innovations in Venous Sinus Stenting

This review explores the future role of venous sinus stenting (VSS) in the management of idiopathic intracranial hypertension and pulsatile tinnitus. Despite its favorable safety profile and clinical outcomes compared with traditional treatments, VSS is not yet the standard of care for these conditions, lacking high-level evidence data and guidelines for patient selection and indications. Current and recently completed clinical trials are expected to provide data to support the adoption of VSS as a primary treatment option. Additionally, VSS shows potential in treating other conditions, such as dural arteriovenous fistula and cerebral venous sinus thrombosis, and it is likely that the procedure will continue to see an expansion of its approved indications. The current lack of dedicated venous stenting technology is being addressed with promising advancements, which may improve procedural ease and patient outcomes. VSS also offers potential for expansion into modulation of brain electrophysiology via endovascular routes, offering exciting possibilities for neurodiagnostics and treatment of neurodegenerative disorders.

Foundations of the Diagnosis and Management of Idiopathic Intracranial Hypertension and Pulsatile Tinnitus

Venous sinus stenosis has garnered increasing academic attention as a potential etiology of idiopathic intracranial hypertension (IIH) and pulsatile tinnitus (PT). The complex anatomy of the cerebral venous sinuses and veins plays a crucial role in the pathophysiology of these conditions. Venous sinus stenosis, often found in the superior sagittal or transverse sinus, can lead to elevated intracranial pressure (ICP) and characteristic IIH symptoms. Stenosis, variations in dural venous anatomy, and flow dominance patterns contribute to aberrant flow and subsequent PT. Accurate imaging plays a vital role in diagnosis, and magnetic resonance (MR) venography is particularly useful for detecting stenosis. Management strategies for IIH and PT focus on treating the underlying disease, weight management, medical interventions, and, in severe cases, surgical or endovascular procedures. Recently, venous sinus stenting has gained interest as a minimally invasive treatment option for IIH and PT. Stenting addresses venous sinus stenosis, breaking the feedback loop between elevated ICP and stenosis, thus reducing ICP and promoting cerebrospinal fluid outflow. The correction and resolution of flow aberrances can also mitigate or resolve PT symptoms. While venous sinus stenting remains an emerging field, initial results are promising. Further research is needed to refine patient selection criteria and evaluate the long-term efficacy of stenting as compared to traditional treatments.

Challenges in the use of Venous Sinus Stenting in the Treatment of Idiopathic Intracranial Hypertension and Pulsatile Tinnitus

Although numerous case series and meta-analyses have shown the efficacy of venous sinus stenting (VSS) in the treatment of idiopathic intracranial hypertension and idiopathic intracranial hypertension-associated pulsatile tinnitus, there remain numerous challenges to be resolved. There is no widespread agreement on candidacy; pressure gradient and failed medical treatment are common indications, but not all clinicians require medical refractoriness as a criterion. Venous manometry, venography, and cerebral angiography are essential tools for patient assessment, but again disagreements exist regarding the best, or most appropriate, diagnostic imaging choice. Challenges with the VSS technique also exist, such as stent choice and deployment. There are considerations regarding postprocedural balloon angioplasty and pharmacologic treatment, but there is insufficient evidence to formalize postoperative decision making. Although complications of VSS are relatively rare, they include in-stent stenosis, hemorrhage, and subdural hematoma, and the learning curve for VSS presents specific challenges in navigating venous anatomy, emphasizing the need for wider availability of high-quality training. Recurrence of symptoms, particularly stent-adjacent stenosis, poses challenges, and although restenting and cerebrospinal fluid-diverting procedures are options, there is a need for clearer criteria for retreatment strategies. Despite these challenges, when comparing VSS with traditional cerebrospinal fluid-diverting procedures, VSS emerges as a favorable option, with strong clinical outcomes, lower complication rates, and cost-effectiveness. Further research is necessary to refine techniques and indications and address specific aspects of VSS to overcome these challenges.

Multiple pipeline embolization devices improves aneurysm occlusion without increasing morbidity: A single center experience of 140 cases

INTRODUCTION

Rates of aneurysm occlusion with the pipeline embolization device (PED) has varied widely in the literature from 55.7% to 93.3% at 6 months, which may reflect a difference in technique including sizing and number of devices used.

METHODS

140 cases at our institution were retrospectively reviewed, and aneurysms treated with a single PED vs. multiple were compared.

RESULTS

Complete aneurysm occlusion was achieved in 86.9% at 6 months, 91.8% at 1 year, and 97.6% at longest follow-up. Retreatment with an additional device was required in 7 (5.1%). Major and minor complication rate within 30 days was 1.4% and 5.0%, and at greater than 30 days was 0.8% and 3.1%. Patients treated with multiple PEDs had significantly higher rates of aneurysm occlusion at 6 months (92.9% vs. 75.6%, p = 0.017) and 12 months (98.4% vs. 81.1%, p = 0.014), with no difference in complications. The two groups were similar aside from a higher number of ophthalmic and paraophthalmic aneurysms treated with multiple PEDs (23.4% vs. 6.5%, p = 0.004; and 35.1% vs. 17.4%, p = 0.020), and more posterior communicating artery and recurrent aneurysms treated with a single PED (28.3% vs. 3.2%, p = 0.001; 23.9% vs. 8.5%, p = 0.031). The use of multiple PEDs was found to be an independent predictor of aneurysm occlusion in a multivariate analysis (p = 0.015).

CONCLUSIONS

The use of multiple PEDs for intracranial aneurysms leads to significantly higher occlusion rates without added morbidity. This benefit is particularly appropriate for ophthalmic segment aneurysms, while more distal segments with eloquent perforating branches should be managed with caution.

Intracranial Aneurysms: Does Size Really Matter?

BACKGROUND

To stratify the risk of aneurysmal rupture, size remains the primary criterion as proposed by 2 ISUIA (International Study of Unruptured Intracranial Aneurysms) trials that recommend the observation of ≤7 mm aneurysms because of their low propensity to rupture. These recommendations are controversial, given the severe outcomes following hemorrhage.

OBJECTIVE

To retrospectively assess whether size correlates with aneurysmal rupture, and to analyze outcomes of endovascular and microsurgical procedures.

METHODS

All aneurysms presenting between 2016 and 2019 were reviewed. Age, gender, comorbidities, ruptured status, modes of treatment, and their outcomes were noted. Regression analysis was performed to correlate size with rupture. The type of intervention was based on clinical and aneurysmal characteristics and the likelihood of obliteration.

RESULTS

Of the 668 aneurysms, 116 had ruptured. In size groups 0 to 6 mm,  7 to 12 mm,  13 to 18 mm,  18 to 24 mm, and giant, the ruptured aneurysms were 60.3%, 30.2%, 1.7%, 0.9%, and 6.9%, respectively. The majority (423) were managed endovascularly, of which 84 (19.9%) were ruptured. A total of 97 (14.5%) underwent clipping, of which 31 were ruptured. The mean modified Rankin Scale for both treated groups was zero. One death in each group and a single brainstem stroke in the coiled group were noted. A total of 139 were followed, of which none had ruptured. The mean modified Raymond-Roy classification for endovascular therapy was 1.1, with 380 completely occluded; 15 had a score of 2, and 28 of score 3.

CONCLUSION

The ruptured aneurysms were mostly smaller than reported previously. Surgical clipping was at equipoise with endovascular treatments. Further studies to correlate aneurysmal characteristics to the risk of rupture are needed.

Double Stent-Assisted (Y and X) Coil Embolization of Unruptured Intracranial Saccular Aneurysms using the Low-Profile Visualized Intraluminal Support Device-Single Center Experience

PURPOSE

To study the feasibility, safety, and durability of the dual stent-assisted coil embolization (DSCE) technique using low-profile visualized intraluminal support (LVIS) device.

METHODS

Retrospective review of our aneurysm database to identify all the patients treated with LVIS stent-assisted embolization between July 2015 and June 2017 was performed. 15% of the patients with Y- or X-configuration DSCE constituted the study population. Patient demographics, clinical presentation, aneurysm characteristics (location, dome, and dome/neck ratio), periprocedural complications, immediate and follow-up angiographic and clinical outcomes were reported.

RESULTS

Twelve patients (15%) with unruptured, wide-necked branching aneurysms underwent DSCE using LVIS Junior stents. M:F-1:11. Mean age of 60 ± 11 years. 75% (n = 9) aneurysms are located in anterior circulation. Recurrent aneurysms were treated in 17% (n = 2). Mean aneurysm diameter was 8 ± 3.4 mm and the dome/neck ratio was 1.6 ± 0.4. Periprocedural complications were noted in 25% (n = 3; transient in-stent thrombus = 2 and iatrogenic rupture = 1) with no clinical sequelae. Immediate aneurysm obliteration following DSCE was noted in all (100%) patients. Mean time-of-flight (TOF) magnetic resonance angiography (MRA) follow-up was 10 ± 6 months (Range: 5-19 months). Mean clinical follow-up was 12 ± 6 months (Range: 5-21 months). Stable neck recurrence was demonstrated in 25% (n = 3). The average modified Rankin Score (mRS) at prestent, 24-hour poststent, and last clinical follow-up were: 0.5 (Range: 0-1), 0.75 (Range: 0-1), and 0.5 (Range: 0-1), respectively.

CONCLUSION

We report the first dedicated DSCE experience with LVIS Junior stents in the literature. DSCE with LVIS Junior stents for intracranial complex wide-neck branching aneurysms is feasible, safe, and effective with good clinical outcomes.

Pelvic cardiovascular magnetic resonance venography: venous changes with patient position and hydration status

BACKGROUND

To determine the effect of hydration as well as prone versus supine positioning on the pelvic veins during cardiovascular magnetic resonance (CMR) venography.

METHODS

Under institutional review board approval, 8 healthy subjects were imaged with balanced steady state free precession, non-contrast CMR venography to measure common and external iliac vein volumes and common femoral vein cross-sectional area in the supine, prone and decubitus positions after dehydration and again following re-hydration. CMR venography from 23 patients imaged both supine and prone were retrospectively reviewed and measurements of common femoral and iliac veins areas were compared using Wilcoxon test.

RESULTS

Common femoral vein area on CMR venography increased with prone positioning (83 ± 35 mm2) compared to supine positioning (59 ± 21 mm2) (p = 0.02) and further increased with hydration to 123 ± 44 mm2 (p < 0.01). With right and left side down decubitus positioning, the common femoral vein area on dehydration increased from 29 ± 17 mm2 in the ante-dependent position to 134 ± 36 mm2 in the dependent position (p < 0. 001). Similarly, common and external iliac veins increased in volume with prone, 5.4 ± 1.9 cm3 and 5.8 ± 1.9 cm3 compared to supine positioning 4.6 ± 1.8 cm3 and 4.5 ± 1.9 cm3 (p = 0.01) and further increase with hydration to 6.7 ± 2.1 cm3 and 6.3 ± 1.9 cm3 (p = 0.01). CMR venography on patients also demonstrated an increase in mean common femoral vein luminal area from 103 ± 44 mm2 in supine position to 151 ± 52 mm2 with prone positioning (p < 0.001) as well as increases in common and external iliac vein volumes from 6.5 ± 2.6 cm3 and 8.0 ± 3.4 cm3 in the supine position to 7.5 ± 2.5 cm3 and 9.3 ± 3.6 cm3 with prone positioning (p < 0.01).

CONCLUSIONS

Common femoral and common/external iliac vein size on CMR venography may be affected by position and hydration status. Routine clinical CMR venography of the pelvis could include prone positioning and avoiding dehydration to maximize pelvic vein distension.

Impaired drainage of vein of Labbé following venous sinus stenting for idiopathic intracranial hypertension

PURPOSE

The impact of venous sinus stenting (VSS) on vein of Labbé (VOL) drainage is poorly understood. The purpose of the study is to examine the incidence and potential high risk factors of impaired VOL drainage among idiopathic intracranial hypertension (IIH) patients following VSS.

MATERIALS AND METHODS

Institutional review board approved prospective evaluation of all IIH patients who underwent VSS over a 5 year period (January 2012 to December 2017) at Weill Cornell Medical Center constituted the study population. Patient demographics, procedural details (laterality of stenting, balloon angioplasty, number of stents, and stent diameters), morphology of the VOL and changes in the flow in the VOL, type of sinus stenosis, and transverse sinus symmetry were evaluated. We used χ² analysis to evaluate impaired VOL drainage against other variables. Statistical significance was set at 0.05.

RESULTS

70 consecutive patients (67 women, 3 men) with a mean age of 31±9.8 years underwent VSS. Stenosis was extrinsic in 63% (n=44) and intrinsic in 37% (n=26) of patients. Impaired drainage of the VOL was detected in 9/70 (13%) patients. Ipsilateral VOL was recognized as dominant in 20% (n=14), co-dominant in 51% (n=36), and non-dominant in 29% (n=20) of patients. Impaired VOL drainage was significantly associated with ipsilateral VOL dominance (P=0.001) and stent diameter of ≥9 mm (P=0.042). All patients demonstrated widely patent VOL on follow-up contrast enhanced MR venography at 3 months and 24 months.

CONCLUSION

Impaired drainage of the ipsilateral VOL is a potential consequence of VSS with 13% incidence, and has significant association with ipsilateral superficial cortical venous drainage via dominant VOL and stent diameter of ≥9 mm.

CLINICAL TRIAL REGISTRATION

NCT01407809.

Anatomic measurements of cerebral venous sinuses in idiopathic intracranial hypertension patients

Purpose

Magnetic resonance venography (MRV) has not been validated in pre-operative planning of the dural venous sinus stenting (VSS) among idiopathic intracranial hypertension (IIH) patients. We aim to prospectively evaluate dural venous sinus measurement in IIH patient population on two-dimensional time-of-flight (2D-TOF) MRV and Three-dimensional contrast-enhanced (3D-CE) MRV acquisitions and compare them against real-time endoluminal measurements with intravascular ultrasound (IVUS), served as the reference.

Materials and methods

The study has been approved by the Weill Cornell Medicine institutional review board. All patients signed written informed consent approved by IRB. Prospective evaluation of forty-five consecutive IIH patients treated with VSS at our institution were evaluated. Patients with pre-stent magnetic resonance venography (MRV) ≤ 6-months of VSS and intravascular ultrasound (IVUS) during VSS constituted the study population. Maximum diameter (in mm), Area (in cm2) and Perimeter (in cm) were measured at posterior 1/3rd of superior sagittal sinus (SSS), proximal transverse sinus (PTS), proximal sigmoid sinus (PSS) and mid sigmoid sinus (MSS) on 2D-TOF-MRV, 3D-CE-MRV and IVUS. Statistical analysis performed using box and whisker plots, Bland-Altman analysis and paired sample t-test.

Results

Twenty (n = 20) patients constituted our study population. The mean age was 30±11 years (7–59 years) and 18 out of 20 were female patients. Mean weight and BMI (range) were 86.3±18.3 kilograms (30.8–107.5 kgs) and 32.9±6.8 kg/M2 (16.4–48.3kg/M2) respectively. The CE-MRV significantly oversized the cerebral venous sinuses compared to TOF-MRV (Dmax: +2.0±1.35 mm, p<0.001; Area: +13.31±10.92 mm2, p<0.001 and Perimeter: +4.79±3.4 mm, p<0.001) and IVUS (Dmax: +1.52±2.16 mm, p<0.001; Area: +10.03±21.5 mm2, p<0.001 and Perimeter: +4.15±3.27 mm, p<0.001). The TOF-MRV sinus measurements were in good agreement with the IVUS measurements with no significant variation (Dmax: +.21±2.23 mm, p = 0.49; Area: +2.51±20.41mm2, p = 0.347 and Perimeter: +.001±1.11 mm, p = 0.991).

Conclusion

We report baseline cerebral venous sinus measurements (maximum diameter, area and perimeter) in patients with idiopathic intracranial hypertension. In our experience, TOF-MRV is a reliable representation of endoluminal cerebral venous sinus dimensions, and CE-MRV measurements reflected an overestimation of the endoluminal sinus dimensions when compared against the real time IVUS measurements.

Pressure variations in cerebral venous sinuses of idiopathic intracranial hypertension patients

PURPOSE

To evaluate the alteration of pressure characteristics in the cerebral venous sinuses before and after venous sinus stenting (VSS) using mean sinus pressures (MSPs), sinus pressure gradient (SPG), and sinus pressure pulsatility (SPP) parameters among the idiopathic intracranial hypertension (IIH) patients.

MATERIALS AND METHODS

Prospective evaluation of 45 consecutive IIH patients who underwent VSS at our institution. A written informed consent approved by the Weill Cornell Institutional Review Board was signed by the study participants. All patients (n = 45) were evaluated for MSPs and SPG. In a subgroup of 12 (n = 12) consecutive patients, SPP was measured. MSP was measured using microcatheter at superior sagittal sinus (SSS), transverse sinus (TS), and sigmoid sinus (SS). SPG was measured as trans-stenotic gradient and trans-torcular gradient. SPP was recorded in the dominant TS with a six French intermediate catheter. Statistical analysis was performed using paired student t-test and two sample t-tests tested for both equal and unequal variances. P values below 0.05 were considered significant.

RESULTS

The mean age of the study population was 30.6 ± 10 years (7-59 years) and 43 out of 45 are female patients. The mean weight and BMI of the study population were 96 ± 24.7 kg (30.8-144 kg) and 35.6 ± 8.3 kg/M² (16.4-51.4 kg/M²), respectively. VSS in IIH patients resulted in immediate reduction of MSP in the SSS {Δ Mean: -8.1 mm Hg [95% confidence interval (CI): -5.0-11.7 mm Hg], p < 0.001} and TS [Δ Mean: -11.8 mm Hg (95% CI: -7.5 to 13.4 mm Hg), p < 0.001] and increase of MSP in SS [Δ Mean: 7.5 mm Hg (95% CI: 6-10.1 mm Hg), p < 0.001]. Significant reduction of trans-stenotic SPG reduction [Δ Mean: -15.7 mm Hg (95% CI: -13.6-17.8 mm Hg), p < 0.001] and SPP [Δ Mean: -8 mm Hg (95% CI: -2.5-13.4 mm Hg), p < 0.05] was observed following VSS.

CONCLUSION

VSS resulted in immediate alteration of the cerebral venous sinus pressure measurements in patients with IIH.

Contrast enhanced magnetic resonance venography in the follow-up evaluation of idiopathic intracranial hypertension patients with cerebral venous sinus stenting

PURPOSE

Role of contrast-enhanced magnetic resonance venography (CE-MRV) in the follow-up of venous sinus stenting (VSS) among the idiopathic intracranial hypertension (IIH) patients.

MATERIALS AND METHODS

Prospective evaluation of VSS patients with CE-MRV, DRCV and DSA for follow-up of clinically suspected recurrent stenosis. CE-MRV was evaluated against DRCV and DSA.

RESULTS

Ten patients with twelve episodes of recurrent symptoms. Sensitivity, specificity, PPV, NPV and accuracy of the CE-MRV for the detection of recurrent stenosis were: 100%, 33.33%, 81.82%, 100% and 83.3% respectively.

CONCLUSION

CE-MRV was a reliable first-line investigation for the detection of recurrent stenosis following VSS.

Endovascular treatment of middle cerebral artery aneurysms: A single center experience with a focus on thromboembolic complications

Background Endovascular treatment of middle cerebral artery (MCA) aneurysms has traditionally been considered difficult due to complex branching patterns, frequent involvement of parent vessels within the aneurysm neck, and a high incidence of thromboembolic complications. Methods The cases of 93 MCA aneurysms treated with endovascular intervention at our institution between 2003 and 2015 were retrospectively reviewed. Demographic, clinical, and radiographic variables were recorded and analyzed. Results Immediate complete or near-complete occlusion was achieved in 81 (90%) cases. At the longest follow up of 6 months or greater, 83.3% of the aneurysms were stable-to-improved in the Raymond occlusion classification, 8.3% were found to have minor recanalization not requiring retreatment, and 8.3% required retreatment due to significant recanalization. Thromboembolic events occurred in 18 (19.3%) of cases, but only 1 resulted in permanent vessel occlusion and only 1 resulted in permanent neurologic impairment. Thrombus was resolved with intra-arterial thrombolysis or mechanical thrombectomy in 17 of the 18 cases. There were only two cases resulting in morbidity (2.15%). There was no statistically significant correlation between aneurysm location, size, morphology, or use of adjuvant device with radiographic outcome or thromboembolic event. Conclusions While the rate of thromboembolic events in our series was 19%, the overall morbidity was only 2%. This highlights the fact that even complex MCA aneurysms can safely and effectively be treated by endovascular means with or without the use of balloon or stent assistance, as long as the interventionalist is astutely aware of the possibility of thrombus formation and acts accordingly with thrombolytic therapy when necessary.

Selective ophthalmic artery chemosurgery (SOAC) for retinoblastoma: fluoroscopic time and radiation dose parameters. A baseline study

OBJECTIVE

To evaluate fluoroscopic time and radiation dose parameters, and factors affecting these parameters, during selective ophthalmic artery chemosurgery (SOAC) for retinoblastoma.

MATERIALS AND METHODS

Retrospective review from the prospective database of all patients with retinoblastoma treated with SOAC over a 5-year period (September 2009-January 2015) at a single institution after receiving institutional review board approval. Patient demographics, arterial approach, access device, side of treatment, number of SOAC cycles/patient, number of drugs/SOAC, and radiation parameters (outcome variables), including the fluoroscopic time, dose-area product (DAP), and total radiation dose, were obtained from the database. Generalized linear regression was used for univariate and multivariate analysis of the outcome variables.

RESULTS

In 218 patients (M:F=94:124), 272 eyes were treated by 833 SOAC infusions during 792 procedures. Mean age, weight, SOAC cycle/patient, and drugs/cycle were 19±19.5 months, 11.4±6.4 kg, 2.72±1.6, and 2.48±0.8, respectively. Mean fluoroscopic time, DAP, and doses were 10.2±8.4 min, 218.7±240.8 cGy.cm², and 42.3±41.4 mGy, respectively. Radiation parameters (fluoroscopic time, DAP, and dose) were significantly lower (p<0.001) for the ophthalmic artery (OA) approach (7.5±5.4; 147.7±138.4; 28.5±29.4) than with middle meningeal artery (13.4±5.6; 242±138; 51.4±27) and balloon-assisted infusion in the internal carotid artery (ICA; 17.8±11.5; 449.8±361; 81.8±63.3). Radiation parameters for microcatheter access (8.6±7.1; 193.4±181.3; 42.3±37) were significantly lower (p<0.001) than with the ICA (17.8±11.5; 449.8±361; 81.8±63.3). Radiation parameters for bilateral IA chemotherapy (IAC; 16.8±11.6; 320.7±268.7; 60.8±45.6) were significantly higher (p<0.001) than for unilateral IAC (8.9±6.6; 212.7±247; 42±41).

CONCLUSIONS

In SOAC for retinoblastoma, the OA approach, microcatheter access, and unilateral treatment were associated with significantly lower radiation parameters. We established benchmark radiation parameters for retinoblastoma SOAC in our patient cohort.

Fluoroscopic-guided lumbar puncture: fluoroscopic time and implications of body mass index--a baseline study

BACKGROUND AND PURPOSE

Fluoroscopic-guided lumbar puncture is an effective alternative to bedside lumbar puncture in challenging patients. However, no published guidelines are available for an acceptable range of fluoroscopic time for this procedure. The purpose of this study was to set department benchmark fluoroscopic times for lumbar puncture, accounting for body mass index in our patient population.

MATERIALS AND METHODS

We identified and reviewed all patients who underwent fluoroscopic-guided lumbar puncture at 4 hospitals during a 2-year period (July 2011 to June 2013). Data collection included patient information (demographics, body mass index, history of prior lumbar surgery and/or lumbar hardware, scoliosis); procedure details (fluoroscopic time, level of access, approach, needle gauge and length); level of operator experience; and hospital site. A generalized linear model was used to test whether body mass index influenced fluoroscopic time while controlling other factors.

RESULTS

Five hundred eighty-four patients (mean age, 47.8 ± 16.2 years; range, 16-92 years; 33% male) had successful fluoroscopic-guided lumbar puncture s. Mean body mass index and fluoroscopic time were higher in female patients (34.4 ± 9.9 kg/m(2) and 1.07 minutes; 95% CI, 0.95-1.20) than in male patients (29.2 ± 7.3 kg/m(2) and 0.91 minutes; 95% CI, 0.79-1.03). Body mass index (P = .001), hospital site (P < .001), and level of experience (P = .03) were factors significantly affecting fluoroscopic time on multivariate analysis. Benchmark fluoroscopic times in minutes were the following: 0.48 (95% CI, 0.40-0.56) for normal, 0.61 for overweight (95% CI, 0.52-0.71), 0.63(95% CI, 0.58-0.73) for obese, and 0.86 (95% CI, 0.74-1.01) in extremely obese body mass index categories.

CONCLUSIONS

In patients undergoing fluoroscopic-guided lumbar punctures, fluoroscopy time increased with body mass index We established benchmark fluoroscopic-guided lumbar puncture time ranges as related to body mass index in our patient population.

Contrast-enhanced time-resolved MRA for follow-up of intracranial aneurysms treated with the pipeline embolization device

BACKGROUND AND PURPOSE

Endovascular reconstruction and flow diversion by using the Pipeline Embolization Device is an effective treatment for complex cerebral aneurysms. Accurate noninvasive alternatives to DSA for follow-up after Pipeline Embolization Device treatment are desirable. This study evaluated the accuracy of contrast-enhanced time-resolved MRA for this purpose, hypothesizing that contrast-enhanced time-resolved MRA will be comparable with DSA and superior to 3D-TOF MRA.

MATERIALS AND METHODS

During a 24-month period, 37 Pipeline Embolization Device-treated intracranial aneurysms in 26 patients underwent initial follow-up by using 3D-TOF MRA, contrast-enhanced time-resolved MRA, and DSA. MRA was performed on a 1.5T unit by using 3D-TOF and time-resolved imaging of contrast kinetics. All patients underwent DSA a median of 0 days (range, 0-68) after MRA. Studies were evaluated for aneurysm occlusion, quality of visualization of the reconstructed artery, and measurable luminal diameter of the Pipeline Embolization Device, with DSA used as the reference standard.

RESULTS

The sensitivity, specificity, and positive and negative predictive values of contrast-enhanced time-resolved MRA relative to DSA for posttreatment aneurysm occlusion were 96%, 85%, 92%, and 92%. Contrast-enhanced time-resolved MRA demonstrated superior quality of visualization (P = .0001) and a higher measurable luminal diameter (P = .0001) of the reconstructed artery compared with 3D-TOF MRA but no significant difference compared with DSA. Contrast-enhanced time-resolved MRA underestimated the luminal diameter of the reconstructed artery by 0.965 ± 0.497 mm (27% ± 13%) relative to DSA.

CONCLUSIONS

Contrast-enhanced time-resolved MRA is a reliable noninvasive method for monitoring intracranial aneurysms following flow diversion and vessel reconstruction by using the Pipeline Embolization Device.