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Gaub M, Murtha G, Lafuente M, Webb M, Luo A, Birnbaum LA, Mascitelli JR, Al Saiegh F. Flow Diversion for Endovascular Treatment of Intracranial Aneurysms: Past, Present, and Future Directions. J Clin Med 2024; 13:4167. [PMID: 39064207 PMCID: PMC11278297 DOI: 10.3390/jcm13144167] [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: 06/01/2024] [Revised: 07/04/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Flow diversion for intracranial aneurysms emerged as an efficacious and durable treatment option over the last two decades. In a paradigm shift from intrasaccular aneurysm embolization to parent vessel remodeling as the mechanism of action, the proliferation of flow-diverting devices has enabled the treatment of many aneurysms previously considered untreatable. In this review, we review the history and development of flow diverters, highlight the pivotal clinical trials leading to their regulatory approval, review current devices including endoluminal and intrasaccular flow diverters, and discuss current and expanding indications for their use. Areas of clinical equipoise, including ruptured aneurysms and wide-neck bifurcation aneurysms, are summarized with a focus on flow diverters for these pathologies. Finally, we discuss future directions in flow diversion technology including bioresorbable flow diverters, transcriptomics and radiogenomics, and machine learning and artificial intelligence.
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Affiliation(s)
| | | | | | | | | | | | | | - Fadi Al Saiegh
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7843, San Antonio, TX 78229, USA; (M.G.); (G.M.); (M.L.); (M.W.); (A.L.); (L.A.B.); (J.R.M.)
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Korkmazer B, Karaman AK, Ustundag A, Arslan S, Kızılkılıç O, Koçer N, Islak C. Magnetic resonance perfusion imaging findings following flow diversion in patients with complex middle cerebral artery bifurcation aneurysms: a single-center analysis regarding the jailed cortical branches. J Neurointerv Surg 2023; 16:8-14. [PMID: 36963822 DOI: 10.1136/jnis-2023-020124] [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: 01/24/2023] [Accepted: 03/07/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Flow diverter (FD) devices provide a safe and effective treatment option especially for wide-necked intracranial aneurysms. One of the main concerns in patients treated with FD devices is patency of arterial branches jailed by the stent. However, there are no long-term data from magnetic resonance perfusion (MRP) studies regarding jailed branches. In this study we aimed to reveal the MRP findings in patients with jailed middle cerebral artery (MCA) cortical branches during long-term follow-up after flow diversion. METHODS Patients who underwent FD stent treatment for MCA aneurysms with a resulting jailed cortical branch were included. Follow-up clinical, angiographic, and MRP examination findings were recorded. Different MRP parameters were measured in the MCA territory regarding the jailed branches. RESULTS Eighteen patients treated endovascularly with flow diversion for a total of 20 MCA aneurysms were included. At angiographic follow-up (median 35 months, range 7-95 months) complete occlusion was observed in 13 (65%) aneurysms and partial occlusion was observed in 6 (30%). The mean transit time (MTT) prolongation, MTT ratio, time-to peak (TTP) prolongation, and TTP ratio were 1.34, 1.20, 1.18, and 1.06 s, respectively, when compared with the contralateral side in the MCA territory. MTT, TTP, and cerebral blood volume values of the patients showed statistically significant differences compared with the contralateral side (P<0.05). CONCLUSIONS Flow diversion treatment of complex bifurcation aneurysms can be effective and safe. MRP examination may reveal perfusion changes in the territory vascularized via a jailed branch, and these changes are rarely accompanied by clinical findings.
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Affiliation(s)
- Bora Korkmazer
- Division of Neuroradiology, Department of Radiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Ahmet Kursat Karaman
- Department of Radiology, Sureyyapasa Chest Diseases and Chest Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Ustundag
- Department of Radiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Serdar Arslan
- Division of Neuroradiology, Department of Radiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Osman Kızılkılıç
- Division of Neuroradiology, Department of Radiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Naci Koçer
- Division of Neuroradiology, Department of Radiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Civan Islak
- Division of Neuroradiology, Department of Radiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
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Kim JH, Ko YS, Kwon SM, Kim CH, Lee CY. Predictive Factors of Recurrence after Endovascular Treatment of Unruptured Vertebrobasilar Fusiform Aneurysms. Clin Neuroradiol 2023; 33:73-86. [PMID: 35763061 DOI: 10.1007/s00062-022-01184-9] [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: 02/22/2022] [Accepted: 06/01/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE This study aimed to investigate the predictive factors of recurrence after endovascular treatment (EVT) for unruptured vertebrobasilar fusiform aneurysms (VBFA). METHODS This single-center retrospective study evaluated 36 patients who underwent EVT of unruptured VBFA between 2008 and 2020. Variables influencing recurrence, such as size, type, thrombus, preoperative symptoms, and treatment methods, were analyzed. All patients were followed up using vessel imaging. RESULTS In total, 7 of 36 patients (19.4%) developed recurrence. The mean time from EVT to recurrence was 9.2 months (range 2-26.9 months). Maximum aneurysmal diameter on magnetic resonance imaging was decreased, increased, and remained unchanged in 1, 7, and 28 patients, respectively. Transitional type VBFA, brain compression symptoms, large aneurysmal diameter and length, preoperative modified Rankin Scale (mRS) score ≥ 2, sole stenting technique, and intra-aneurysmal thrombus significantly influenced the risk of recurrence. Post-EVT, 7 (19.4%) patients showed complete occlusion of the aneurysm on the immediate postoperative angiogram, and 22 (61.1%) patients showed complete occlusion on the 1‑year follow-up imaging. Good outcomes were observed in 32 patients (88.9%) at the last follow-up, with a mRS score of 0-1 after EVT. CONCLUSION EVT achieves good outcomes in unruptured VBFA. Transitional type VBFA, brain compression symptoms, large aneurysmal diameter and length, preoperative mRS score ≥ 2, sole stenting technique, and intra-aneurysmal thrombus are risk factors for aneurysm recurrence after EVT.
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Affiliation(s)
- Jae Hyun Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, 1035, Dalgubeol-daero, 42601, Dalseo-gu, Daegu, Korea (Republic of)
| | - Young San Ko
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, 1035, Dalgubeol-daero, 42601, Dalseo-gu, Daegu, Korea (Republic of)
| | - Sae Min Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, 1035, Dalgubeol-daero, 42601, Dalseo-gu, Daegu, Korea (Republic of)
| | - Chang Hyun Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, 1035, Dalgubeol-daero, 42601, Dalseo-gu, Daegu, Korea (Republic of)
| | - Chang Young Lee
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, 1035, Dalgubeol-daero, 42601, Dalseo-gu, Daegu, Korea (Republic of).
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Pattern of changes in cross sectional area of arterial branches after jailing with pipeline embolization device: beyond parent neck artery patency. Clin Imaging 2022; 83:159-165. [DOI: 10.1016/j.clinimag.2021.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 12/18/2021] [Accepted: 12/27/2021] [Indexed: 11/17/2022]
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Jesser J, Alberalar ND, Kizilkilic O, Saatci I, Baltacioglu F, Özlük E, Killer-Oberpfalzer M, Vollherbst DF, Islak C, Cekirge SH, Bendszus M, Möhlenbruch M, Koçer N. Safety and Efficacy of the FRED Jr Flow Re-Direction Endoluminal Device for Intracranial Aneurysms: Retrospective Multicenter Experience With Emphasis on Midterm Results. Front Neurol 2021; 12:722183. [PMID: 34659086 PMCID: PMC8518710 DOI: 10.3389/fneur.2021.722183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/02/2021] [Indexed: 02/03/2023] Open
Abstract
Background and Purpose: Flow diversion is increasingly used as an endovascular treatment for intracranial aneurysms. In this retrospective multicenter study, we analyzed the safety and efficacy of the treatment of intracranial, unruptured, or previously treated but recanalized aneurysms using Flow Re-Direction Endoluminal Device (FRED) Jr with emphasis on midterm results. Materials and Methods: Clinical and radiological records of 150 patients harboring 159 aneurysms treated with FRED Jr at six centers between October 2014 and February 2020 were reviewed and consecutively included. Clinical outcome was measured by using the modified Rankin Scale (mRS). Anatomical results were assessed according to the O'Kelly-Marotta (OKM) scale and the Cekirge-Saatci Classification (CSC) scale. Results: The overall complication rate was 24/159 (16%). Thrombotic-ischemic events occurred in 18/159 treatments (11%). These resulted in long-term neurological sequelae in two patients (1%) with worsening from pre-treatment mRS 0–2 and mRS 4 after treatment. Complete or near-complete occlusion of the treated aneurysm according to the OKM scale was reached in 54% (85/158) at 6-month, in 68% (90/133) at 1-year, and in 83% (77/93) at 2-year follow-up, respectively. The rates of narrowing or occlusion of a vessel branch originating from the treated aneurysm according to the CSC scale were 11% (12/108) at 6-month, 20% (17/87) at 1-year, and 23% (13/57) at 2-year follow-up, respectively, with all cases being asymptomatic. Conclusions: In this retrospective multicenter study, FRED Jr was safe and effective in the midterm occlusion of cerebral aneurysms. Most importantly, it was associated with a high rate of good clinical outcome.
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Affiliation(s)
- Jessica Jesser
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Nilüfer D Alberalar
- Department of Diagnostic and Interventional Radiology, University Hospital of Leipzig, Leipzig, Germany
| | - Osman Kizilkilic
- Department of Neuroradiology, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Isil Saatci
- Interventional Neuroradiology Section, Koru and Bayindir, Private Hospitals, Ankara, Turkey
| | - Feyyaz Baltacioglu
- Department of Radiology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Enes Özlük
- Department of Radiology, Acibadem Atakent Hospital, Istanbul, Turkey
| | | | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Civan Islak
- Department of Neuroradiology, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Saruhan H Cekirge
- Interventional Neuroradiology Section, Koru and Bayindir, Private Hospitals, Ankara, Turkey
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Naci Koçer
- Department of Neuroradiology, Cerrahpasa Medical Faculty, Istanbul, Turkey
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Shrivastava A, Mishra R, Salazar LRM, Chouksey P, Raj S, Agrawal A. Enigma of what is Known about Intracranial Aneurysm Occlusion with Endovascular Devices. J Stroke Cerebrovasc Dis 2021; 30:105737. [PMID: 33774553 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/23/2021] [Accepted: 02/28/2021] [Indexed: 11/16/2022] Open
Abstract
Aneurysmal subarachnoid Hemorrhage is a major cause of neurological morbidity and mortality. Over the years vascular neurosurgery has witnessed technological advances aimed to reduce the morbidity and mortality. Several endovascular devices have been used in clinical practice to achieve this goal in the management of ruptured and unruptured cerebral aneurysms. Recurrence due to recanalization is encountered in all of these endovascular devices as well as illustrated by Barrow Ruptured Aneurysm Trial. Histological and molecular characterization of the aneurysms treated with endovascular devices is an area of active animal and human research studies. Yet, the pathobiology illustrating the mechanisms of aneurysmal occlusion and healing lacks evidence. The enigma of aneurysmal healing following treatment with endovascular devices needs to be de-mystified to understand the biological interaction of endovascular device and aneurysm and thereby guide the future development of endovascular devices aimed at better aneurysm occlusion. We performed a comprehensive and detailed literature review to bring all the known facts of the pathobiology of intracranial aneurysm healing, the knowledge of which is of paramount importance to neurosurgeons, an interventional neuroradiologist, molecular biologist, geneticists, and experts in animal studies. This review serves as a benchmark of what is known and platform for future studies basic science research related to intracranial aneurysms.
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Affiliation(s)
- Adesh Shrivastava
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462020, Madhya Pradesh, India.
| | - Rakesh Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | | | - Pradeep Chouksey
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462020, Madhya Pradesh, India
| | - Sumit Raj
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462020, Madhya Pradesh, India
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462020, Madhya Pradesh, India
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Chung J, Cheol Lim Y, Sam Shin Y. Endovascular Treatment of Intracranial Vertebral Artery Dissection. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:265-280. [PMID: 37501904 PMCID: PMC10370974 DOI: 10.5797/jnet.ra.2020-0150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/23/2020] [Indexed: 07/29/2023]
Abstract
Intracranial vertebral artery dissection (VAD) is the most common arterial dissection in intracranial arteries. Some types of VAD can heal spontaneously after reconstitution of the vessel lumen with excellent prognosis, whereas others can progress to stroke that needs treatment. Recently, endovascular treatment (EVT) has emerged and is suggested as a treatment option for VADs due to perceived low rates of procedure-related morbidity with good efficacy. In the last decade, we have accumulated our strategies to treat those VADs. Here, we try to share our experiences about VADs, including indications and methods of treatment of VADs using EVT. We perform EVT for ruptured VADs presenting with SAH and some of unruptured VADs such as VAD with recurrent or progressive ischemia, dissecting aneurysm larger than 7 mm or with mass effect, early ugly change of VADs in shape and size during follow-up period, involving the basilar artery (BA) and bilateral VADs. We present how we have done in our real practice for the last decade for treating VADs by EVT rather than reviewing and organizing so-far-published literature. We tended to occlude the rupture point by vertebral artery (VA) occlusion in non-dominant VA or stent-assisted coiling in dominant VA for ruptured VADs. We tended to reconstruct original hemodynamics using various stents for unruptured VADs. To decide what to treat and how to treat are very complicated for VADs. However, we believe that EVT is the current mainstay for treating VADs. Each technique of EVT should be determined on a case-by-case basis at the discretion of endovascular neurosurgeons and/or interventional neuroradiologists according to presenting symptoms, hemodynamic status, including sufficiency of the collateral supply and anatomic features of the vertebrobasilar artery as well as the posterior inferior cerebellar artery, anterior spinal artery, and medullary perforators.
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Affiliation(s)
- Joonho Chung
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Cheol Lim
- Department of Neurosurgery, Ajou University College of Medicine and Hospital, Suwon, Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Hohenstatt S, Arrichiello A, Conte G, Craparo G, Caranci F, Angileri A, Levi D, Carrafiello G, Paolucci A. Branch vessel occlusion in aneurysm treatment with flow diverter stent. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020003. [PMID: 33245072 PMCID: PMC8023076 DOI: 10.23750/abm.v91i10-s.10283] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/05/2020] [Indexed: 11/23/2022]
Abstract
Flow diverter placement for treatment of intracranial aneurysms gained growing consensus in the past years. A major concern among professionals is the side branch coverage which leads in some cases to vessel occlusion. However, the lost vessel patency only infrequently is accompanied by a new onset of neurological deficits secondary to ischaemic lesions. A retrospective analysis of all patients treated with flow diversion at our hospital was aimed to better understand this phenomenon in order to formulate a hypothesis about the causes. We concluded that vessel occlusion occurs due to a reduced blood pressure gradient in those vessels with a strong collateral or anastomotic vascularization that refurnishes the same distal vascular territories. Indeed, we detected no new brain infarction since blood flow was always guaranteed.
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Affiliation(s)
- Sophia Hohenstatt
- Operative Unit of Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy. Via Francesco Sforza 35, 20122, Milano, Italy..
| | - Antonio Arrichiello
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy Via Festa del Perdono 7, 20122, Milan, Italy.
| | - Giorgio Conte
- Operative Unit of Neuoradiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy. Via Francesco Sforza 35, 20122, Milano, Italy.
| | | | - Ferdinando Caranci
- Department of Diagnostic Radiology and Radiotherapy, Federico II University of Naples, Naples, Italy.
| | - Alessio Angileri
- Operative Unit of Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy. Via Francesco Sforza 35, 20122, Milano, Italy..
| | - Daniel Levi
- Casa di Cura Le Betulle. Viale Italia 36, 22070. Appiano Gentile (Como) Italia.
| | - Gianpaolo Carrafiello
- Operative Unit of Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy. Via Francesco Sforza 35, 20122, Milano, Italy. Department of Health Sciences, Università degli Studi di Milano, Milan, Italy. Via Festa del Perdono 7, 20122, Milan Italy.
| | - Aldo Paolucci
- Operative Unit of Neuoradiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy. Via Francesco Sforza 35, 20122, Milano, Italy.
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Tang H, Lu Z, Xue G, Li S, Xu F, Yan Y, Liu J, Zuo Q, Luo Y, Huang Q. The development and understanding of intracranial aneurysm based on rabbit model. Neuroradiology 2020; 62:1219-1230. [PMID: 32594185 DOI: 10.1007/s00234-020-02475-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/10/2020] [Indexed: 10/24/2022]
Abstract
In modern society, intracranial aneurysms have seriously affected people's life. To better study and treat intracranial aneurysm, animal models are ideal candidates to perform biological research and preclinical endovascular device testing. Rabbit aneurysm model is one of the most commonly used animal models, and the rabbit aneurysms share similarities in histology, morphology, and hemodynamic aspects with human intracranial aneurysms, which is an ideal model for intracranial aneurysm pre-clinical and basic research. In this review, we will summarize the main methods of establishing rabbit aneurysms model and will further discuss the current biological mechanisms of intracranial aneurysms based on rabbit model. Further improvements of rabbit aneurysm model and more deep studies based on this model are needed to provide new insights into studying and clinical treating intracranial aneurysm.
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Affiliation(s)
- Haishuang Tang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, 200433, People's Republic of China.,Naval Medical Center of PLA, Second Military Medical University, Shanghai, 200050, People's Republic of China
| | - Zhiwen Lu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, 200433, People's Republic of China
| | - Gaici Xue
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, 200433, People's Republic of China
| | - Sisi Li
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, 200433, People's Republic of China
| | - Fengfeng Xu
- Naval Medical Center of PLA, Second Military Medical University, Shanghai, 200050, People's Republic of China
| | - Yazhou Yan
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, 200433, People's Republic of China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, 200433, People's Republic of China
| | - Qiao Zuo
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, 200433, People's Republic of China
| | - Yin Luo
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, 200433, People's Republic of China
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, 200433, People's Republic of China.
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Wagner KM, Srinivasan VM, Srivatsan A, Ghali MGZ, Thomas AJ, Enriquez-Marulanda A, Alturki AY, Ogilvy CS, Mokin M, Kuhn AL, Puri A, Grandhi R, Chen S, Johnson J, Kan P. Outcomes after coverage of lenticulostriate vessels by flow diverters: a multicenter experience. J Neurosurg 2020; 132:473-480. [PMID: 30641842 DOI: 10.3171/2018.8.jns18755] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE With the increasing use of flow diversion as treatment for intracranial aneurysms, there is a concomitant increased vigilance in monitoring complications. The low porosity of flow diverters is concerning when the origins of vessels are covered, whether large circle of Willis branches or critical perforators. In this study, the authors report their experience with flow diverter coverage of the lenticulostriate vessels and evaluate their safety and outcomes. METHODS The authors retrospectively reviewed 5 institutional databases of all flow diversion cases from August 2012 to June 2018. Information regarding patient presentation, aneurysm location, treatment, and outcomes were recorded. Patients who were treated with flow diverters placed in the proximal middle cerebral artery (MCA), proximal anterior cerebral artery, or distal internal carotid artery leading to coverage of the medial and lateral lenticulostriate vessels were included. Clinical outcomes according to the modified Rankin Scale were reviewed. Univariate and multivariate analyses were performed to establish risk factors for lenticulostriate infarct. RESULTS Fifty-two patients were included in the analysis. Postprocedure cross-sectional images were available in 30 patients. Two patients experienced transient occlusion of the MCA during the procedure; one was asymptomatic, and the other had a clinical and radiographic ipsilateral internal capsule stroke. Five patients had transient symptoms without radiographic infarct in the lenticulostriate territory. Two patients experienced in-stent thrombosis, leading to clinical MCA infarcts (one in the ipsilateral caudate) after discontinuing antiplatelet therapy. Discontinuation of dual antiplatelet therapy prior to 6 months was the only variable that was significantly correlated with stroke outcome (p < 0.01, OR 0.3, 95% CI 0-0.43), and this significance persisted when controlled for other risk factors, including age, smoking status, and aneurysm location. CONCLUSIONS The use and versatility of flow diversion is increasing, and safety data are continuing to accumulate. Here, the authors provide early data on the safety of covering lenticulostriate vessels with flow diverters. The authors concluded that the coverage of these perforators does not routinely lead to clinically significant ischemia when dual antiplatelet therapy is continued for 6 months. Further evaluation is needed in larger cohorts and with imaging follow-up as experience develops in using these devices in more distal circulation.
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Affiliation(s)
| | | | | | | | - Ajith J Thomas
- 2Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alejandro Enriquez-Marulanda
- 2Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Abdulrahman Y Alturki
- 2Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- 2Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Maxim Mokin
- 3Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Anna L Kuhn
- 4Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts; and
| | - Ajit Puri
- 5Department of Neurosurgery, University of Texas at San Antonio, Texas
| | - Ramesh Grandhi
- 5Department of Neurosurgery, University of Texas at San Antonio, Texas
| | - Stephen Chen
- 6Radiology, Baylor College of Medicine, Houston, Texas
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Computational methods applied to analyze the hemodynamic effects of flow-diverter devices in the treatment of cerebral aneurysms: Current status and future directions. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2019. [DOI: 10.1016/j.medntd.2019.100018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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12
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The p64 Flow Diverter-Mid-term and Long-term Results from a Single Center. Clin Neuroradiol 2019; 30:471-480. [PMID: 31399749 DOI: 10.1007/s00062-019-00823-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/19/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE The p64 is a flow modulation device designed to be used in endovascular treatment of intracranial aneurysms. There is limited data on the long-term effectiveness of the device. This study sought to determine the safety and long-term efficacy of this device. METHODS A retrospective review of a prospectively maintained database was performed to identify all patients treated with a p64 between March 2015 and November 2018 at University Hospital St. Ivan Rilski. Anatomical features, intraprocedural complications, clinical, and angiographic outcomes were also taken into account and reviewed. RESULTS A total of 72 patients with 72 aneurysms who met the inclusion criteria were identified. Device placement was successful in all patients. Follow-up angiographic imaging at 6 months showed complete occlusion (O'Kelly-Marotta scale [OKM] D) in 55 (76.3%) patients, subtotal aneurysmal filling (OKM B) in 10 (13.8%) patients, and neck remnant (OKM C) in 7 (9.7%) patients. Catheter angiography at 12 months was available for 70 patients (97.2%) and of these patients 91.4% of the aneurysms were completely occluded (OKM D) (64/72). Delayed angiography at 24 months was available for 68 patients (94.4%) and of these 98.5% (67/68) had completely occluded aneurysms. A 36-month angiography was available for 61 patients (84.4%) by which point all aneurysms had been completely occluded (100%). Permanent morbidity due to delayed aneurysmal rupture occurred in one patient (1.38%). The mortality rate was 0%. Self-limiting mild intimal hyperplasia was seen in 2 patients (2.72%). CONCLUSION Treatment of intracranial aneurysms with a p64 flow modulation device is safe and effective with a high success rate and only infrequent complications.
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Multiple Aneurysms AnaTomy CHallenge 2018 (MATCH): Phase I: Segmentation. Cardiovasc Eng Technol 2018; 9:565-581. [DOI: 10.1007/s13239-018-00376-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022]
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Berg P, Saalfeld S, Janiga G, Brina O, Cancelliere NM, Machi P, Pereira VM. Virtual stenting of intracranial aneurysms: A pilot study for the prediction of treatment success based on hemodynamic simulations. Int J Artif Organs 2018; 41:698-705. [PMID: 29783867 DOI: 10.1177/0391398818775521] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular treatment of intracranial aneurysms using flow-diverting devices has revolutionized the treatment of large and complex lesions due to its minimally invasive nature and potential clinical outcomes. However, incomplete or delayed occlusion and persistent intracranial aneurysm growth are still an issue for up to one-third of the patients. We evaluated two patients with intracranial aneurysm located at the internal carotid artery who were treated with flow-diverting devices and had opposite outcomes. Both patients presented with similar aneurysms and were treated with the same device, but after a 1-year follow-up, one case presented with complete occlusion (Case 1) and the other required further treatment (Case 2). To reproduce the interventions, virtual stents were deployed and blood flow simulations were carried out using the respective patient-specific geometries. Afterward, hemodynamic metrics such as aneurysmal inflow reduction, wall shear stresses, oscillatory shear, and inflow concentration indices were quantified. The hemodynamic simulations reveal that for both cases, the neck inflow was clearly reduced due to the therapy (Case 1: 19%, Case 2: 35%). In addition, relevant hemodynamic parameters such as time-averaged wall shear stress (Case 1: 35.6%, Case 2: 57%) and oscillatory shear (Case 1: 33.1%, Case 2: 26.7%) were decreased considerably. However, although stronger relative reductions occurred in the unsuccessful case, the absolute flow values in the successful case were approximately halved. The findings demonstrate that a high relative effect of endovascular devices is not necessarily associated with the desired treatment outcome. Instead, it appears that a successful intracranial aneurysm therapy requires a certain patient-specific inflow threshold.
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Affiliation(s)
- Philipp Berg
- 1 Department of Fluid Dynamics and Technical Flows, University of Magdeburg, Magdeburg, Germany.,2 Forschungscampus STIMULATE, Magdeburg, Germany
| | - Sylvia Saalfeld
- 2 Forschungscampus STIMULATE, Magdeburg, Germany.,3 Department of Simulation and Graphics, University of Magdeburg, Magdeburg, Germany
| | - Gábor Janiga
- 1 Department of Fluid Dynamics and Technical Flows, University of Magdeburg, Magdeburg, Germany.,2 Forschungscampus STIMULATE, Magdeburg, Germany
| | - Olivier Brina
- 4 Interventional Neuroradiology Unit, University Hospital of Geneva, Geneva, Switzerland
| | - Nicole M Cancelliere
- 5 Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Paolo Machi
- 4 Interventional Neuroradiology Unit, University Hospital of Geneva, Geneva, Switzerland
| | - Vitor M Pereira
- 5 Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.,6 Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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Influence of overlapping pattern of multiple overlapping uncovered stents on the local mechanical environment: A patient-specific parameter study. J Biomech 2017; 60:188-196. [PMID: 28712543 DOI: 10.1016/j.jbiomech.2017.06.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 06/05/2017] [Accepted: 06/25/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Multiple overlapping uncovered stents (MOUS) system has shown potentials in managing complex aortic aneurysms with side branches involvement. It promotes the development of thrombus by modulating local flow pattern that reduces the wall tension, while maintaining patency of side branches. However the modulation of local hemodynamic parameters depends on various factors that have not been assessed comprehensively. METHODS Aneurysm 3D geometry was reconstructed based on CT images. One-way fluid-structure interaction analysis was performed to quantify structural stress concentration in the wall, and changes of blood velocity, wall shear stress (WSS), oscillatory shear index (OSI), relative residence time (RRT) and pressure in the sac due to the stent deployment. RESULTS High structural stress concentration due to stent deployment was found in the landing zone and it increased linearly with the number of stents deployed. The wall tension in the sac was unaffected by the stent deployment. Stress within the wall was insensitive to the different overlapping pattern. After one stent was deployed, the mean flow velocity in the sac reduced by 36.4%. The deployment of the 2nd stent further reduced the mean sac velocity by 10%. WSS decreased while both OSI and RRT increased after stent deployment, however pressure in the sac remained nearly unchanged. Except for the cases with complete stents struts alignment, different overlapping pattern had little effect on flow parameters. CONCLUSIONS Mechanical parameters modulated by the MOUS are insensitive to different overlapping pattern suggesting that endovascular procedure can be performed with less attention to the overlapping pattern.
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Bhogal P, Ganslandt O, Bäzner H, Henkes H, Pérez MA. The Fate of Side Branches Covered by Flow Diverters-Results from 140 Patients. World Neurosurg 2017; 103:789-798. [PMID: 28438653 DOI: 10.1016/j.wneu.2017.04.092] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Flow diverter stents (FDS) are a recognized treatment option for intracranial aneurysms. There remain ongoing concerns regarding the safety of FDS, especially regarding the fate of covered side branches. We report the patency of side branches covered by FDS. METHODS We retrospectively reviewed our database of prospectively collected information for all patients treated with FDS for an unruptured saccular aneurysm of the clinoid, ophthalmic, and terminating segments of the internal carotid artery between September 2009 and July 2016. The aneurysm location, fundus size, and the state of covered branches at last angiography were recorded compared with preoperative angiography. RESULTS We identified 140 patients, with 147 aneurysms, who met our inclusion criteria. Five patients had bilateral aneurysms. There were 31 male patients in our cohort (21.9%) and the mean average age was 56.2 ± 13.7 years. Sixty-seven aneurysms arose from the communicating, 58 from the ophthalmic, and 22 from the clinoidal segments. At last follow-up (mean, 22.3 months) 116 aneurysms were completely occluded (78.3%). On the most recent angiogram, 7 ophthalmic (5.3%), 20 posterior communicating (42.6%), 0 anterior choroidal (0%), and 2 anterior cerebral arteries (14.3%) were completely occluded. Reduced vessel caliber was seen in 11 ophthalmic (8.3%), 3 posterior communicating (6.4%), 0 anterior choroidal, and 6 anterior cerebral arteries (42.9%). One patient died during follow-up. CONCLUSIONS The side branch occlusion rate was 20% and included ophthalmic, posterior communicating, and anterior cerebral arteries. Consistent with other studies, we did not see occlusion of the anterior choroidal artery.
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Affiliation(s)
- Pervinder Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.
| | - Oliver Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany; Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Marta Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
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Dholakia R, Sadasivan C, Fiorella DJ, Woo HH, Lieber BB. Hemodynamics of Flow Diverters. J Biomech Eng 2017; 139:2569375. [DOI: 10.1115/1.4034932] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Indexed: 01/17/2023]
Abstract
Cerebral aneurysms are pathological focal evaginations of the arterial wall at and around the junctions of the circle of Willis. Their tenuous walls predispose aneurysms to leak or rupture leading to hemorrhagic strokes with high morbidity and mortality rates. The endovascular treatment of cerebral aneurysms currently includes the implantation of fine-mesh stents, called flow diverters, within the parent artery bearing the aneurysm. By mitigating flow velocities within the aneurysmal sac, the devices preferentially induce thrombus formation in the aneurysm within hours to days. In response to the foreign implant, an endothelialized arterial layer covers the luminal surface of the device over a period of days to months. Organization of the intraneurysmal thrombus leads to resorption and shrinkage of the aneurysm wall and contents, eventually leading to beneficial remodeling of the pathological site to a near-physiological state. The devices' primary function of reducing flow activity within aneurysms is corollary to their mesh structure. Complete specification of the device mesh structure, or alternately device permeability, necessarily involves the quantification of two variables commonly used to characterize porous media—mesh porosity and mesh pore density. We evaluated the flow alteration induced by five commercial neurovascular devices of varying porosity and pore density (stents: Neuroform, Enterprise, and LVIS; flow diverters: Pipeline and FRED) in an idealized sidewall aneurysm model. As can be expected in such a model, all devices substantially reduced intraneurysmal kinetic energy as compared to the nonstented case with the coarse-mesh stents inducing a 65–80% reduction whereas the fine-mesh flow diverters induced a near-complete flow stagnation (∼98% reduction). We also note a trend toward greater device efficacy (lower intraneurysmal flow) with decreasing device porosity and increasing device pore density. Several such flow studies have been and are being conducted in idealized as well as patient-derived geometries with the overarching goals of improving device design, facilitating treatment planning (what is the optimal device for a specific aneurysm), and predicting treatment outcome (will a specific aneurysm treated with a specific device successfully occlude over the long term). While the results are generally encouraging, there is poor standardization of study variables between different research groups, and any consensus will only be reached after standardized studies are conducted on collectively large datasets. Biochemical variables may have to be incorporated into these studies to maximize predictive values.
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Affiliation(s)
- Ronak Dholakia
- Department of Neurological Surgery, Stony Brook University Medical Center, Stony Brook, NY 11794
| | - Chander Sadasivan
- Department of Neurological Surgery, Stony Brook University Medical Center, Stony Brook, NY 11794
| | - David J. Fiorella
- Department of Neurological Surgery, Stony Brook University Medical Center, Stony Brook, NY 11794
| | - Henry H. Woo
- Department of Neurological Surgery, Stony Brook University Medical Center, Stony Brook, NY 11794
| | - Baruch B. Lieber
- Professor Department of Neurological Surgery, Stony Brook University Medical Center, HSC T12, Room 080, 100 Nicolls Road, Stony Brook, NY 11794-8122 e-mail:
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Iosif C, Berg P, Ponsonnard S, Carles P, Saleme S, Pedrolo-Silveira E, Mendes G, Waihrich E, Trolliard G, Couquet CY, Yardin C, Mounayer C. Role of terminal and anastomotic circulation in the patency of arteries jailed by flow-diverting stents: animal flow model evaluation and preliminary results. J Neurosurg 2016; 125:898-908. [DOI: 10.3171/2015.8.jns151296] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The authors describe herein the creation of an animal model capable of producing quantifiable data regarding blood flow rate and velocity modifications in terminal and anastomotic types of cerebrofacial circulation. They also present the preliminary results of a translational study aimed at investigating the role of terminal and anastomotic types of circulation in arterial branches jailed by flow-diverting stents as factors contributing to arterial patency or occlusion.
METHODS
Two Large White swine were used to validate a terminal-type arterial model at the level of the right ascending pharyngeal artery (APhA), created exclusively by endovascular means. Subsequently 4 Large White swine, allocated to 2 groups corresponding to the presence (Group B) or absence (Group A) of terminal-type flow modification, underwent placement of flow-diverting stents. Blood flow rates and velocities were quantified using a dedicated time-resolved 3D phase-contrast MRA sequence before and after stenting. Three months after stent placement, the stented arteries were evaluated with digital subtraction angiography (DSA) and scanning electron microscopy (SEM). Patent (circulating) ostia quantification was performed on the SEM images.
RESULTS
Terminal-type flow modification was feasible; an increase of 75.8% in mean blood velocities was observed in the right APhAs. The mean blood flow rate for Group A was 0.31 ± 0.19 ml/sec (95% CI −1.39 to 2.01) before stenting and 0.21 ± 0.07 ml/sec (95% CI −0.45 to 0.87) after stenting. The mean blood flow rate for Group B was 0.87 ± 0.32 ml/sec (95% CI −1.98 to 3.73) before stenting and 0.76 ± 0.13 ml/sec (95% CI −0.41 to 1.93) after stenting. Mean flow rates after stenting showed a statistically significant difference between Groups A and B (Welch test). Mean and maximal blood velocities were reduced in Group A cases and did not decrease in Group B cases. Control DSA and SEM findings showed near occlusion of the jailed APhAs in both cases of anastomotic circulation (mean patent ostium surface 32,776 μm2) and patency in both cases of terminal-type circulation (mean patent ostium surface 422,334 μm2).
CONCLUSIONS
Terminal-type arterial modification in swine APhAs is feasible. Sufficient data were acquired to perform an a priori analysis for further research. Flow diversion at the level of the APhA ostium resulted in significant stenosis in cases of anastomotic circulation, while sufficient patency was observed in terminal-type circulation.
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Affiliation(s)
- Christina Iosif
- Departments of 1Interventional Neuroradiology and
- 2Applied Medical Research Team (ERMA)
| | - Philipp Berg
- 3Laboratory of Fluid Dynamics and Technical Flows, University of Magdeburg “Otto von Guerike,” Magdeburg, Germany
| | | | - Pierre Carles
- 5Science of Ceramic Processes and Surface Treatments, CNRS, UMR 7315, European Ceramic Center, University of Limoges
| | | | | | | | | | - Gilles Trolliard
- 5Science of Ceramic Processes and Surface Treatments, CNRS, UMR 7315, European Ceramic Center, University of Limoges
| | | | - Catherine Yardin
- 2Applied Medical Research Team (ERMA)
- 7Department of Histology, Cytology, Cellular Biology and Cytogenetics, Mother and Child (HME) University Hospital, Limoges, France; and
| | - Charbel Mounayer
- Departments of 1Interventional Neuroradiology and
- 2Applied Medical Research Team (ERMA)
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Iosif C, Ponsonnard S, Roussie A, Saleme S, Carles P, Ponomarjova S, Pedrolo-Silveira E, Mendes G, Waihrich E, Couquet C, Yardin C, Mounayer C. Jailed Artery Ostia Modifications After Flow-Diverting Stent Deployment at Arterial Bifurcations. Neurosurgery 2016; 79:473-80. [DOI: 10.1227/neu.0000000000001311] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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20
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Iosif C, Berg P, Ponsonnard S, Carles P, Saleme S, Ponomarjova S, Pedrolo-Silveira E, Mendes GAC, Waihrich E, Trolliard G, Couquet CY, Yardin C, Mounayer C. Role of terminal and anastomotic circulation in the patency of arteries jailed by flow-diverting stents: from hemodynamic changes to ostia surface modifications. J Neurosurg 2016; 126:1702-1713. [PMID: 27203141 DOI: 10.3171/2016.2.jns152120] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The outcome for jailing arterial branches that emerge near intracranial aneurysms during flow-diverting stent (FDS) deployment remains controversial. In this animal study, the authors aimed to elucidate the role of collateral supply with regard to the hemodynamic changes and neointimal modifications that occur from jailing arteries with FDSs. To serve this purpose, the authors sought to quantify 1) the hemodynamic changes that occur at the jailed arterial branches immediately after stent placement and 2) the ostia surface values at 3 months after stenting; both parameters were investigated in the presence or absence of collateral arterial flow. METHODS After an a priori power analysis, 2 groups (Group A and Group B) were created according to an animal flow model for terminal and anastomotic arterial circulation; each group contained 7 Large White swine. Group A animals possessed an anastomotic-type arterial configuration to supply the territory of the right ascending pharyngeal artery (APhA), while Group B animals possessed a terminal-type arterial configuration to supply the right APhA territory. Subsequently, all animals underwent FDS placement, thereby jailing the right APhAs. Mean flow rates and velocities inside the jailed branches were quantified using time-resolved 3D phase-contrast MR angiography before and after stenting. Three months after stent placement, the jailed ostia surface values were quantified on scanning electron micrographs. The data were analyzed using descriptive statistics and group comparisons with parametric and nonparametric tests. RESULTS The endovascular procedures were feasible, and there were no findings of in situ thrombus formation on postprocedural optical coherence tomography or ischemia on postprocedural diffusion-weighted imaging. In Group A, the mean flow rate values at the jailed right APhAs were reduced immediately following stent placement as compared with values obtained before stent placement (p = 0.02, power: 0.8). In contrast, the mean poststenting flow rates for Group B remained similar to those obtained before stent placement. Three months after stent placement, the mean ostia surface values were significantly higher for Group B (527,911 ± 306,229 μm2) than for Group A (89,329 ± 59,762 μm2; p < 0.01, power: 1.00), even though the initial dimensions of the jailed ostia were similar between groups. A statistically significant correlation was found between groups (A or B), mean flow rates after stent placement, and ostia surface values at 3 months. CONCLUSIONS When an important collateral supply was present, the jailing of side arteries with flow diverters resulted in an immediate and significant reduction in the flow rate inside these arteries as compared with the prestenting values. In contrast, when competitive flow was absent, jailing did not result in significant flow rate reductions inside the jailed arteries. Ostium surface values at 3 months after stent placement were significantly higher in the terminal group of jailed arteries (Group B) than in the anastomotic group (Group A) and strongly correlated with poststenting reductions in the velocity value.
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Affiliation(s)
- Christina Iosif
- Departments of 1 Interventional Neuroradiology and.,Applied Medical Research Team and
| | - Philipp Berg
- Laboratory of Fluid Dynamics and Technical Flows, University of Magdeburg "Otto von Guerike," Magdeburg, Germany
| | | | - Pierre Carles
- Science of Ceramic Processes and Surface Treatments, CNRS, UMR 7315, European Ceramic Center, University of Limoges
| | | | | | | | | | | | - Gilles Trolliard
- Science of Ceramic Processes and Surface Treatments, CNRS, UMR 7315, European Ceramic Center, University of Limoges
| | | | - Catherine Yardin
- Applied Medical Research Team and.,Department of Histology, Cytology, Cellular Biology, and Cytogenetics, Mother and Child (HME) University Hospital, Limoges, France; and
| | - Charbel Mounayer
- Departments of 1 Interventional Neuroradiology and.,Applied Medical Research Team and
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Dai D, Ding YH, Kelly M, Kadirvel R, Kallmes D. Histopathological findings following pipeline embolization in a human cerebral aneurysm at the basilar tip. Interv Neuroradiol 2016; 22:153-7. [PMID: 26842611 DOI: 10.1177/1591019915622165] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 11/08/2015] [Indexed: 11/15/2022] Open
Abstract
We report histopathological findings from a human cerebral aneurysm following treatment with a flow diverter. A 75-year-old male underwent flow diversion treatment (Pipeline Embolization Device (PED)) and coil embolization for treatment of an aneurysm at the basilar tip. At four months, angiography showed complete aneurysm occlusion; at 12 months angiography demonstrated that the aneurysm had reopened. The patient expired from brainstem compression. The aneurysm cavity was primarily filled with unorganized thrombus. Thick, interrupted neointima crossed the neck interface indicating blood flow into aneurysm through small channels. Along the parent artery the PED was covered by neointima having a measured thickness of 0.19 ± 0.01 mm; the maximal stenosis of the proximal parent artery was 27%. The perforating arteries that were crossed by the PED remained patent. Findings in this human case are similar to those in the elastase-induced aneurysms in rabbits.
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Affiliation(s)
- Daying Dai
- Neuroradiology Research Laboratory, Mayo Clinic, Rochester, USA
| | - Yong-Hong Ding
- Neuroradiology Research Laboratory, Mayo Clinic, Rochester, USA
| | - Michael Kelly
- Division of Neurosurgery, Department of Surgery, College of Medicine, University of Saskatchewan, Canada
| | | | - David Kallmes
- Neuroradiology Research Laboratory, Mayo Clinic, Rochester, USA
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22
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Flow Diversion for Treating Middle Cerebral Artery Aneurysms. World Neurosurg 2016; 90:627-629. [PMID: 26780283 DOI: 10.1016/j.wneu.2016.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 11/23/2022]
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23
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Berg P, Iosif C, Ponsonnard S, Yardin C, Janiga G, Mounayer C. Endothelialization of over- and undersized flow-diverter stents at covered vessel side branches: An in vivo and in silico study. J Biomech 2016; 49:4-12. [DOI: 10.1016/j.jbiomech.2015.10.047] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 10/28/2015] [Accepted: 10/31/2015] [Indexed: 11/28/2022]
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Mazur MD, Kilburg C, Wang V, Taussky P. Pipeline embolization device for the treatment of vertebral artery aneurysms: the fate of covered branch vessels. J Neurointerv Surg 2015; 8:1041-7. [DOI: 10.1136/neurintsurg-2015-012040] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 09/29/2015] [Indexed: 11/04/2022]
Abstract
IntroductionPreliminary studies suggest that flow-diverting stents may be suitable for the treatment of aneurysms of the posterior circulation. The safety and efficacy of using flow-diverting stents for vertebral artery (VA) aneurysms is not well defined.ObjectiveTo examine the fate of covering the posterior inferior cerebellar artery (PICA) in patients undergoing placement of a flow-diverting stent for VA aneurysm.MethodsConsecutive patients who underwent placement of a Pipeline Embolization Device (PED) for treatment of an aneurysm of the V4 segment of the VA between April 2012 and June 2015 at our institution were retrospectively evaluated. Angiograms were reviewed to determine the patency of the PICA when the vessel origin was covered by the PED.Results11 patients with VA aneurysms who underwent treatment with the PED were identified. In each case the device covered the origin of the PICA. Follow-up angiography in eight patients demonstrated thrombosis of the aneurysm with patency of the PICA.ConclusionsFlow-diverting stents can be used for the treatment of VA aneurysms. When appropriately sized to the vessel wall and positioned in the VA, the device may cover the origin of the PICA without impairing flow through the branching artery.
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25
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Holcomb M, Ding YH, Dai D, McDonald RJ, McDonald JS, Kallmes DF, Kadirvel R. RNA-Sequencing Analysis of Messenger RNA/MicroRNA in a Rabbit Aneurysm Model Identifies Pathways and Genes of Interest. AJNR Am J Neuroradiol 2015; 36:1710-5. [PMID: 26228879 DOI: 10.3174/ajnr.a4390] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 01/30/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Rabbit aneurysm models are used for the testing of embolization devices and elucidating the mechanisms of human intracranial aneurysm growth and healing. We used RNA-sequencing technology to identify genes relevant to induced rabbit aneurysm biology and to identify genes and pathways of potential clinical interest. This process included sequencing microRNAs, which are important regulatory noncoding RNAs. MATERIALS AND METHODS Elastase-induced saccular aneurysms were created at the origin of the right common carotid artery in 6 rabbits. Messenger RNA and microRNA were isolated from the aneurysm and from the control left common carotid artery at 12 weeks and processed by using RNA-sequencing technology. The results from RNA sequencing were analyzed by using the Ingenuity Pathway Analysis tool. RESULTS A total of 9396 genes were analyzed by using RNA sequencing, 648 (6.9%) of which were found to be significantly differentially expressed between the aneurysms and control tissues (P < .05; false-discovery rate, <0.01; fold change, >2 or <.5). Of these genes, 614 were mapped successfully, 143 were down-regulated, and 471 were up-regulated in the aneurysms as compared with controls. Using the same criteria for significance, 3 microRNAs were identified as down-regulated and 5 were identified as up-regulated. Pathway analysis associated these genes with inflammatory response, cellular migration, and coagulation, among other functions and pathologies. CONCLUSIONS RNA-sequencing analysis of rabbit aneurysms revealed differential regulation of some key pathways, including inflammation and antigen presentation. ANKRD1 and TACR1 were identified as genes of interest in the regulation of matrix metalloproteinases.
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Affiliation(s)
- M Holcomb
- From the Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Y-H Ding
- From the Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota
| | - D Dai
- From the Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota
| | - R J McDonald
- From the Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota
| | - J S McDonald
- From the Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota
| | - D F Kallmes
- From the Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota
| | - R Kadirvel
- From the Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota.
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Gawlitza M, Januel AC, Tall P, Bonneville F, Cognard C. Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: a single-center series with special emphasis on covered cortical branches and perforating arteries. J Neurointerv Surg 2015; 8:481-7. [PMID: 25878068 DOI: 10.1136/neurintsurg-2015-011682] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 03/13/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Data regarding anatomic and clinical results of flow diversion treatment in complex bifurcation aneurysms of the anterior circulation are scarce. OBJECTIVE To present our results of treatment of these lesions with special emphasis on the fate of 'jailed' cortical branches and perforating arteries. METHODS Seventeen patients were treated with flow diverters (FDs) for 18 aneurysms of the middle cerebral artery bifurcation (n=13) and the anterior communicating artery complex (n=5). Nineteen cortical branches were covered. A single FD was used in all patients. RESULTS At latest follow-up (mean 7.9 months; range 3-36; median 4.0) 2/19 (10.5%) of the covered branches were occluded, 9/19 (47.4%) showed a decreased caliber and the remaining branches were unchanged. All branch modifications were clinically asymptomatic. Mortality and permanent morbidity were 0%. Symptomatic ischemic events in perforator territories occurred in three patients (17.6%), which were reversible in all of them within 24 h. Follow-up MRI disclosed asymptomatic lacunar defects corresponding to covered perforating artery territories in five patients (29.4%). Altogether, perforator lesions-symptomatic and asymptomatic-occurred in 7/17 patients (41.2%). 33.3% of the aneurysms were occluded at latest follow-up; decreased diameters were seen in the other 66.7%. CONCLUSIONS Flow diversion of bifurcation aneurysms is feasible with low rates of permanent morbidity and mortality. Caliber reduction and asymptomatic occlusion of covered cortical branches seems to be common, yet ischemic complications are rather linked to perforator occlusions. Our results on aneurysm occlusion rates are preliminary and longer follow-up periods are warranted.
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Affiliation(s)
- Matthias Gawlitza
- Department of Neuroradiology, CHU Toulouse, Toulouse, France Department of Diagnostic and Interventional Radiology, Leipzig University Hospital, Leipzig, Germany
| | | | - Philippe Tall
- Department of Neuroradiology, CHU Toulouse, Toulouse, France
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Raz E, Shapiro M, Becske T, Zumofen DW, Tanweer O, Potts MB, Riina HA, Nelson PK. Anterior choroidal artery patency and clinical follow-up after coverage with the pipeline embolization device. AJNR Am J Neuroradiol 2015; 36:937-42. [PMID: 25572948 DOI: 10.3174/ajnr.a4217] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 10/29/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endoluminal reconstruction with the Pipeline Embolization Device is an effective treatment option for select intracranial aneurysms. However, concerns for the patency of eloquent branch arteries covered by the Pipeline Embolization Device have been raised. We aimed to examine the patency of the anterior choroidal artery and clinical sequelae after ICA aneurysm treatment. MATERIALS AND METHODS We prospectively analyzed all patients among our first 157 patients with ICA aneurysms treated by the Pipeline Embolization Device who required placement of at least 1 device across the ostium of the anterior choroidal artery. The primary outcome measure was angiographic patency of the anterior choroidal artery at last follow-up. Age, sex, type of aneurysm, neurologic examination data, number of Pipeline Embolization Devices used, relationship of the anterior choroidal artery to the aneurysm, and completeness of aneurysm occlusion on follow-up angiograms were also analyzed. RESULTS Twenty-nine aneurysms requiring placement of at least 1 Pipeline Embolization Device (median = 1, range = 1-3) across the anterior choroidal artery ostium were identified. At angiographic follow-up (mean = 15.1 months; range = 12-39 months), the anterior choroidal artery remained patent, with antegrade flow in 28/29 aneurysms (96.5%), while 24/29 (82.7%) of the target aneurysms were angiographically occluded by 1-year follow-up angiography. Anterior choroidal artery occlusion, with retrograde reconstitution of the vessel, was noted in a single case. A significant correlation between the origin of the anterior choroidal artery from the aneurysm dome and failure of the aneurysms to occlude following treatment was found. CONCLUSIONS After placement of 36 Pipeline Embolization Devices across 29 anterior choroidal arteries (median = 1 device, range = 1-3 devices), 1 of 29 anterior choroidal arteries was found occluded on angiographic follow-up. The vessel occlusion did not result in persistent clinical sequelae. Coverage of the anterior choroidal artery origin with the Pipeline Embolization Device, hence, may be considered reasonably safe when deemed necessary for aneurysm treatment.
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Affiliation(s)
- E Raz
- From the Bernard and Irene Schwartz Interventional Neuroradiology Section (E.R., M.S., T.B., D.W.Z., M.P.B., H.A.R., P.K.N.), Department of Radiology
| | - M Shapiro
- From the Bernard and Irene Schwartz Interventional Neuroradiology Section (E.R., M.S., T.B., D.W.Z., M.P.B., H.A.R., P.K.N.), Department of Radiology Departments of Neurology (M.S., T.B.)
| | - T Becske
- From the Bernard and Irene Schwartz Interventional Neuroradiology Section (E.R., M.S., T.B., D.W.Z., M.P.B., H.A.R., P.K.N.), Department of Radiology Departments of Neurology (M.S., T.B.)
| | - D W Zumofen
- From the Bernard and Irene Schwartz Interventional Neuroradiology Section (E.R., M.S., T.B., D.W.Z., M.P.B., H.A.R., P.K.N.), Department of Radiology Neurosurgery (D.W.Z., O.T., M.B.P., H.A.R., P.K.N.), New York University School of Medicine, New York, New York
| | - O Tanweer
- Neurosurgery (D.W.Z., O.T., M.B.P., H.A.R., P.K.N.), New York University School of Medicine, New York, New York
| | - M B Potts
- Neurosurgery (D.W.Z., O.T., M.B.P., H.A.R., P.K.N.), New York University School of Medicine, New York, New York
| | - H A Riina
- From the Bernard and Irene Schwartz Interventional Neuroradiology Section (E.R., M.S., T.B., D.W.Z., M.P.B., H.A.R., P.K.N.), Department of Radiology Neurosurgery (D.W.Z., O.T., M.B.P., H.A.R., P.K.N.), New York University School of Medicine, New York, New York
| | - P K Nelson
- From the Bernard and Irene Schwartz Interventional Neuroradiology Section (E.R., M.S., T.B., D.W.Z., M.P.B., H.A.R., P.K.N.), Department of Radiology Neurosurgery (D.W.Z., O.T., M.B.P., H.A.R., P.K.N.), New York University School of Medicine, New York, New York.
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Hodis S, Ding YH, Dai D, Lingineni R, Mut F, Cebral J, Kallmes D, Kadirvel R. Relationship between aneurysm occlusion and flow diverting device oversizing in a rabbit model. J Neurointerv Surg 2014; 8:94-8. [PMID: 25387731 DOI: 10.1136/neurintsurg-2014-011487] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 10/24/2014] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Implanted, actual flow diverter pore density is thought to be strongly influenced by proper matching between the device size and parent artery diameter. The objective of this study was to characterize the correlation between device sizing, metal coverage, and the resultant occlusion of aneurysms following flow diverter treatment in a rabbit model. METHODS Rabbit saccular aneurysms were treated with flow diverters (iso-sized to proximal parent artery, 0.5 mm oversized, or 1.0 mm oversized, respectively, n=6 for each group). Eight weeks after implantation, the angiographic degree of aneurysm occlusion was graded (complete, near-complete, or incomplete). The ostium of the explanted aneurysm covered with the flow diverter struts was photographed. Based on gross anatomic findings, the metal coverage and pore density at the ostium of the aneurysm were calculated and correlated with the degree of aneurysm occlusion. RESULTS Angiographic results showed there were no statistically significant differences in aneurysm geometry and occlusion among groups. The mean parent artery diameter to flow diverter diameter ratio was higher in the 1.0 mm oversized group than in the other groups. Neither the percentage metal coverage nor the pore density showed statistically significant differences among groups. Aneurysm occlusion was inversely correlated with the ostium diameter, irrespective of the size of the device implanted. CONCLUSIONS Device sizing alone does not predict resultant pore density or metal coverage following flow diverter implantation in the rabbit aneurysm model. Aneurysm occlusion was not impacted by either metal coverage or pore density, but was inversely correlated with the diameter of the ostium.
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Affiliation(s)
- Simona Hodis
- Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Yong-Hong Ding
- Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Daying Dai
- Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Ravi Lingineni
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Fernando Mut
- Center for Computational Fluid Dynamics, College of Sciences, George Mason University, Fairfax, Virginia, USA
| | - Juan Cebral
- Center for Computational Fluid Dynamics, College of Sciences, George Mason University, Fairfax, Virginia, USA
| | - David Kallmes
- Neuroradiology Research Laboratory, Mayo Clinic, Rochester, Minnesota, USA
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