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Kaliyev A, Makhambetov Y, Medetov Y, Kulmirzayev M, Dusembayev S, Nurimanov C, Kunakbayev B, Akshulakov S. Management of giant internal carotid aneurysm by extracranial-intracranial bypass and flow diverter stent. Br J Neurosurg 2023; 37:1893-1897. [PMID: 34236251 DOI: 10.1080/02688697.2021.1947974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
Flow diverter stents have become the standard approach to managing intracranial aneurysms; however, in some cases of complex, wide-necked aneurysms, poor outcomes due to stent occlusion have been reported. We report the case of a giant internal carotid artery aneurysm treated by high-flow extracranial-intracranial (EC-IC) bypass with flow diverter deployment. Seven months post-operatively, radiographic imaging demonstrated occlusion of the stent and parent artery, with further ischemic events prevented by collateral flow from the high flow bypass. This case demonstrates the continued utility of EC-IC bypass in the endovascular era, especially as a rescue tool in cases of delayed stent occlusion.
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Affiliation(s)
- Assylbek Kaliyev
- Department of Vascular and Functional Neurosurgery, Nur-Sultan, Kazakhstan
| | - Yerbol Makhambetov
- Department of Vascular and Functional Neurosurgery, Nur-Sultan, Kazakhstan
| | - Yerkin Medetov
- Department of Vascular and Functional Neurosurgery, Nur-Sultan, Kazakhstan
| | - Marat Kulmirzayev
- Department of Vascular and Functional Neurosurgery, Nur-Sultan, Kazakhstan
| | - Serik Dusembayev
- Department of Vascular and Functional Neurosurgery, Nur-Sultan, Kazakhstan
| | - Chingiz Nurimanov
- Department of Vascular and Functional Neurosurgery, Nur-Sultan, Kazakhstan
| | | | - Serik Akshulakov
- Department of Vascular and Functional Neurosurgery, Nur-Sultan, Kazakhstan
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Santoro A, Armocida D, Paglia F, Iacobucci M, Berra LV, D'Angelo L, Cirelli C, Guidetti G, Biraschi F, Cantore G. Treatment of giant intracranial aneurysms: long-term outcomes in surgical versus endovascular management. Neurosurg Rev 2022; 45:3759-3770. [PMID: 36269463 PMCID: PMC9663390 DOI: 10.1007/s10143-022-01884-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/22/2022] [Accepted: 10/11/2022] [Indexed: 10/24/2022]
Abstract
Aneurysms with a major diameter > 25 mm are defined as giant intracranial aneurysms (GIAs). Different clinical, pathological, and radiological factors were revealed as playing a role in choosing the best strategy between surgical and endovascular approaches. Despite the improvement of both techniques, the efficacy and safety of these different management are still debated. We evaluated the differences in clinical and radiological outcomes of GIAs treated with surgical and endovascular techniques in a large retrospective mono-centric study. We compared aneurysm location, clinical, morphological features, treatment outcome, and complications on the ground of treatment technique. The final cohort consisted of 162 patients. All the patients were assigned on the ground of the type of eligible treatment: surgical (118 patients) and endovascular procedure (44 patients). The different treatment strategies were made through a multidisciplinary selection whereas clinical parameters, location, and morphologic features of the aneurysm were considered. The surgical group manifested a greater reduction in performance levels and neurological status in the post-operative phases than the endovascular group (p < 0.01) with a higher incidence of complications (p = 0.012) in contrast to a lower recurrence rate (p > 0.01). There is no significant difference in post-operative mortality and survival between surgical and endovascular groups. The surgical group manifested a higher incidence of complications after treatment. The endovascular group has a better post-operative outcome, but a higher risk of recurrence and the necessity of further treatment.
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Affiliation(s)
- Antonio Santoro
- Rome Human Neurosciences Departmen, AUO "Policlinico Umberto I", Neurosurgery Division, Sapienza University, Via del Policlinico, 155, 00161, Rome, Italy
| | - Daniele Armocida
- Rome Human Neurosciences Departmen, AUO "Policlinico Umberto I", Neurosurgery Division, Sapienza University, Via del Policlinico, 155, 00161, Rome, Italy.
| | - Francesco Paglia
- Rome Human Neurosciences Departmen, AUO "Policlinico Umberto I", Neurosurgery Division, Sapienza University, Via del Policlinico, 155, 00161, Rome, Italy
| | - Marta Iacobucci
- Department of Radiological, Oncological and Anatomopathological Sciences, Unit of Interventional Neuroradiology, Sapienza" University of Rome, Umberto I University Hospital, Rome, Italy
| | - Luigi Valentino Berra
- Rome Human Neurosciences Departmen, AUO "Policlinico Umberto I", Neurosurgery Division, Sapienza University, Via del Policlinico, 155, 00161, Rome, Italy
| | - Luca D'Angelo
- Rome Human Neurosciences Departmen, AUO "Policlinico Umberto I", Neurosurgery Division, Sapienza University, Via del Policlinico, 155, 00161, Rome, Italy
| | - Carlo Cirelli
- Department of Radiological, Oncological and Anatomopathological Sciences, Unit of Interventional Neuroradiology, Sapienza" University of Rome, Umberto I University Hospital, Rome, Italy
| | - Giulio Guidetti
- Department of Radiological, Oncological and Anatomopathological Sciences, Unit of Interventional Neuroradiology, Sapienza" University of Rome, Umberto I University Hospital, Rome, Italy
| | - Francesco Biraschi
- Department of Radiological, Oncological and Anatomopathological Sciences, Unit of Interventional Neuroradiology, Sapienza" University of Rome, Umberto I University Hospital, Rome, Italy
| | - Giampaolo Cantore
- Rome Human Neurosciences Departmen, AUO "Policlinico Umberto I", Neurosurgery Division, Sapienza University, Via del Policlinico, 155, 00161, Rome, Italy
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Hou K, Li G, Lv X, Xu B, Xu K, Yu J. Delayed rupture of intracranial aneurysms after placement of intra-luminal flow diverter. Neuroradiol J 2020; 33:451-464. [PMID: 32851918 PMCID: PMC7788679 DOI: 10.1177/1971400920953299] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Though flow diverter is a safe and efficient modality, some patients can experience delayed aneurysmal rupture. The mechanism of delayed rupture is still obscure to us. METHODS We performed a systematic search in the PubMed database for patients with delayed rupture of intracranial aneurysms after flow diverter placement. RESULTS A total of 36 articles reporting on 60 patients were included in the final analysis. Of the 49 patients with description of presenting symptoms, six (12.2%) patients were incidentally diagnosed, 39 (87.8%) patients were admitted for aneurysmal rupture or mass effect. Multiple flow diverters were used in 38.3% (18/47) of the patients. Coil assistance was applied in 13.0% (7/54) of the patients. Delayed aneurysmal rupture led to intracranial hemorrhage or carotid-cavernous sinus fistula (CCF) in 76.8% (43/56) and 23.2% (13/56) of the patients, respectively. Of the 55 patients with description of outcome, 14 (25.5%) patients achieved good recovery, one (1.8%) patient was severely disabled, 40 (72.7%) patients died. All of the patients in the CCF group survived and experienced good recovery. CONCLUSION Increased intra-aneurysmal pressure, destabilization of the aneurysm wall by intra-aneurysmal thrombus, persistent residual intra-aneurysmal flow, characteristics of the specific aneurysm, and mechanical injury by the flow diverter might conjointly contribute to the final delayed rupture. There has been no established preventive measure to decrease the incidence of delayed rupture yet. The treatment and outcome depend on the presentation of delayed rupture. Patients presenting with aneurysm-related intracranial hemorrhage have a dismal outcome. Those presenting with CCFs usually have a satisfactory recovery.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Guichen Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Xianli Lv
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
- Jinlu Yu, Department of Neurosurgery, The First Hospital of Jilin University, 1 Xinmin Avenue, Changchun 130021, China.
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Linfante I, Andreone V, Ravelo N, Starosciak AK, Arif B, Shallwani H, Tze Man Kan P, McDermott MW, Dabus G. Endovascular Treatment of Giant Intracranial Aneurysms. Cureus 2020; 12:e8290. [PMID: 32601564 PMCID: PMC7317134 DOI: 10.7759/cureus.8290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective Giant intracranial aneurysms (GIAs) are associated with a high risk of rupture and have a high mortality rate when they rupture (65-100%). The traditional microsurgical approach to secure these lesions is challenging, and as such endovascular embolization has been increasingly selected as a treatment option. Methods We performed a retrospective analysis of consecutive patients with ruptured and unruptured GIAs at three medical centers from October 2008 to April 2016. Clinical follow-up and digital subtraction angiography were conducted at six months post-treatment. Chi-square analysis was used to determine differences in outcomes between anterior and posterior circulation aneurysms and if a pipeline embolization device (PED) provided favorable outcomes in unruptured GIAs. Results A total of 45 consecutive patients (mean/median age = 57/59; range: 16-82 years) were included. The mean/median aneurysm size was 29.9/28.3 mm (range: 25-50 mm). Eight (18%) patients presented with aneurysmal subarachnoid hemorrhage and 37 (82%) with unruptured GIAs. Twenty-eight (62%) were treated with a PED: 11 (24.4%) with one PED, 1 (2.2%) with PED + coils, 11 (24.4%) with more than one PED, and 5 (13.5%) with multiple PED + coils. The overall mortality rate was 3/45 (6.7%). No deaths were procedure-related. Five (11.1%) patients experienced ischemic stroke but only 2 had a 90-day modified Rankin Scale (mRS) score of ≥3. Of 33 patients available for six-month angiography, Raymond scale (RS) scores were 1, 2, and 3 for 23/45 (70%), 7/45 (20.9%), and 3/45 (9.1%), respectively. Chi-square test demonstrated that overall, anterior circulation GIAs had better clinical (mRS score) and radiographic (RS score) outcomes than posterior GIAs. PED alone provided similar clinical mRS outcomes but had a higher rate of complete occlusion at six months compared with PED + coils and coils alone in unruptured GIAs (p < 0.05). Conclusions Endovascular embolization using PED or PED + coils appears to be a moderately safe and effective treatment option for patients with GIAs.
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Affiliation(s)
- Italo Linfante
- Neurology, Miami Cardiac & Vascular Institute/Miami Neuroscience Institute, Baptist Health South Florida, Miami, USA
| | | | - Natalia Ravelo
- Neuroscience, Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | - Amy K Starosciak
- Neurology, Miami Neuroscience Institute, Baptist Health South Florida, Miami, USA
| | - Bilal Arif
- Neuroscience, Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | - Hussain Shallwani
- Neurosurgery, University at Buffalo - The State University of New York, Buffalo, USA
| | | | | | - Guilherme Dabus
- Radiology, Miami Cardiac & Vascular Institute/Miami Neuroscience Institute, Miami, USA
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Bhogal P, AlMatter M, Hellstern V, Ganslandt O, Bäzner H, Henkes H, Aguilar-Pérez M. The Combined Use of Intraluminal and Intrasaccular Flow Diversion for the Treatment of Intracranial Aneurysms: Report of 25 Cases. Neurointervention 2018; 13:20-31. [PMID: 29535895 PMCID: PMC5847887 DOI: 10.5469/neuroint.2018.13.1.20] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 02/23/2018] [Accepted: 02/26/2018] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The Medina Embolic Device (MED) is a new intrasaccular device with promising early results. Previously we documented our initial experience of this device both alone and in combination with other devices including flow diverter stents (FDS). We sought to determine the effect of the MED + FDS strategy for the treatment of selected aneurysms. MATERIALS AND METHODS We performed a retrospective analysis of prospectively collected data to identify all patients with aneurysms treated using both the MED and intraluminal FDS. We present our technical success rate, early and mid-term angiographic follow-up, and clinical outcome data. RESULTS We identified 25 non-consecutive patients. The treatment was staged in 9 patients and in a single session 16 patients. The average age was 61±12.8 years (range 40-82). The average fundus height was 11±3.6 mm and average fundus width was 10.1±3.4 mm. In the staged cohort (n=9) at delayed angiography (mean 10 mths) 8 aneurysms (89%) showed complete exclusion (mRRC 1) and in one patient there was a parent vessel occlusion. In the simultaneous cohort delayed angiography (n=10, mean 8.1 months) demonstrated complete occlusion (mRRC 1) in 6 aneurysms (60%), 3 neck remnants (mRRC 2) (30%) and 1 patient (10%) showed persistent aneurysmal filling (mRRC 3a). There were 5 complications with permanent morbidity (mRS >2) in two patients. There were no mortalities. CONCLUSION The MED can be successfully used in combination with intraluminal FDS and in selected aneurysms this may represent an alternative to FDS and adjunctive coiling.
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Affiliation(s)
- Pervinder Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | | | | | | | - Hansjörg Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Germany
- Medical Faculty, University Duisburg-Essen, Germany
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Aguilar-Salinas P, Brasiliense LBC, Gonsales D, Mitchell B, Lima A, Sauvageau E, Hanel R. Evaluation of Pipeline Flex delivery system for the treatment of unruptured aneurysms. Expert Rev Med Devices 2016; 13:885-897. [PMID: 27647130 DOI: 10.1080/17434440.2016.1231573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Refinements in endovascular technology have revolutionized the treatment of intracranial aneurysms (IAs) with the development of flow-diversion technology. The first generation of the Pipelin Embolization Device (PED) has demonstrated its safety and efficacy. However, the deployment technique was a difficult task that often led to complex maneuvers. The Pipeline Flex Embolization Device (PED Flex) is the second generation and its introduction has arrived with high expectations due to a completely redesigned delivery system that intends to overcome deployment difficulties seen in the previous generation. Areas covered: Preclinical studies, mechanism of action of flow-diverters, technical aspects and deployment system of the PED Flex, and clinical outcomes with both PED generations. Expert commentary: Flow diversion has allowed us to treat lesions that would be otherwise challenging for surgical clipping or unsuitable for other endosaccular strategies. Although the experience with PED Flex is limited, initial results suggest its safety and short-term efficacy.
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Affiliation(s)
| | | | - Douglas Gonsales
- a Lyerly Neurosurgery , Baptist Health , Jacksonville , FL , USA
| | - Bartley Mitchell
- a Lyerly Neurosurgery , Baptist Health , Jacksonville , FL , USA
| | - Andrey Lima
- a Lyerly Neurosurgery , Baptist Health , Jacksonville , FL , USA
| | - Eric Sauvageau
- a Lyerly Neurosurgery , Baptist Health , Jacksonville , FL , USA
| | - Ricardo Hanel
- a Lyerly Neurosurgery , Baptist Health , Jacksonville , FL , USA
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Martinez-Moreno R, Aguilar M, Wendl C, Bäzner H, Ganslandt O, Henkes H. Fatal Thrombosis of a Flow Diverter due to Ibuprofen-related Antagonization of Acetylsalicylic Acid. Clin Neuroradiol 2015; 26:355-8. [PMID: 26631399 PMCID: PMC5025486 DOI: 10.1007/s00062-015-0487-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 11/17/2015] [Indexed: 11/27/2022]
Affiliation(s)
- R. Martinez-Moreno
- Neuroradiological Clinic, Katharinenhospital, Klinikum Stuttgart, Kriegsbergstraße 60, 70174 Stuttgart, Germany
| | - M. Aguilar
- Neuroradiological Clinic, Katharinenhospital, Klinikum Stuttgart, Kriegsbergstraße 60, 70174 Stuttgart, Germany
| | - C. Wendl
- Neuroradiological Clinic, Katharinenhospital, Klinikum Stuttgart, Kriegsbergstraße 60, 70174 Stuttgart, Germany
| | - H. Bäzner
- Neurological Clinic, Klinikum Stuttgart, Stuttgart, Germany
| | - O. Ganslandt
- Neurosurgical Clinic, Klinikum Stuttgart, Stuttgart, Germany
| | - H. Henkes
- Neuroradiological Clinic, Katharinenhospital, Klinikum Stuttgart, Kriegsbergstraße 60, 70174 Stuttgart, Germany
- Medical Faculty, University of Duisburg-Essen, Essen, Germany
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Aneurysmal and Perianeurysmal Changes After Endovascular Treatment: from Inflammation to Microbleed. A Case Report. Clin Neuroradiol 2015; 26:239-42. [PMID: 26227620 DOI: 10.1007/s00062-015-0442-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 07/15/2015] [Indexed: 10/23/2022]
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