Flow diverter stent for treatment of cerebral aneurysms: A report of 130 patients with 134 aneurysms

Endovascular Rescue of Previously Treated Carotid Aneurysm: Higher Radial Force 48-Wire Flow Diverter for Salvage of Collapsed 64-Wire Device With Braid Deformation: 2-Dimensional Operative Video

Aneurysm treatment presents various therapeutic options. Flow diverters (FD) stents are a revolutionizing endovascular technique for previously untreatable aneurysms.1 FD stents have documented success rates up to 95% and complication rates as low as 2.3%.2 This modality has proven its effectiveness and safety, but it is critical to consider potential complications. Complications include vascular-related problems such as perforation, occlusion, cerebral hyperperfusion, stent thrombosis, restenosis, and embolic events.3 To date, there is no standardized definition for braid collapse and fish-mouthing; however, braid collapse has been reported to occur at a rate of 1% and the latter at a rate of 3%.4 This technical video presents a case of a 51-year-old woman initially treated with a Surpass Evolve flow diverter (Stryker) for a right ophthalmic aneurysm. Secondary to device malapposition and collapse, she developed recurrent ischemic progressive neurologic impairment symptoms. The braid collapse was treated using a Pipeline Embolization device 3.25 × 20 mm (Medtronic) because this device exhibited a larger partial compressive force when compared with the 64-wire device.5 The procedure was uneventful and significantly improved the patient's neurologic symptoms. This technical video illustrates rescue stenting as a salvage intervention for FD collapse cases. The patient gave informed consent for surgery. Institutional review board approval was deemed unnecessary.

Flow diversion for compressive unruptured internal carotid artery aneurysms with neuro-ophthalmological symptoms: a systematic review and meta-analysis

BACKGROUND

Data on the safety and efficacy of flow diverters (FD) for the treatment of unruptured internal carotid artery (ICA) aneurysms with compressive neuro-ophthalmological symptoms (NOS) are scarce and comprise mainly small case series.

METHODS

We performed a search of three databases and included series with ≥10 patients, with unruptured aneurysms of the ICA and NOS, treated with FD. Random-effects analysis of treatment results and safety was performed.

RESULTS

A total of 22 studies reporting on 594 patients were included. Pooled proportions of NOS recovery, improvement, transient and permanent worsening were: 47.4% (95% CI 35.0% to 60.1%); 74.5% (95% CI 67.9% to 80.2%); 7.1% (95% CI 3.3% to 14.7%); and 4.9% (95% CI 3.2% to 7.4%), respectively. Rates of complete recovery and improvement in patients with isolated visual symptoms were 30.6% (95% CI 12.5% to 57.7%) and 56.6% (95% CI 42.3% to 69.9%). Isolated oculomotor symptoms recovered completely in 47.8% (95% CI 29.9% to 66.3%) and improved in 78% (95% CI 69.2% to 84.9%). Morbidity occurred in 5% (95% CI 2.8% to 9%) and mortality in 3.9% (95% CI 2% to 7.5%) of patients. An increased likelihood of symptom improvement was observed when treatment was performed early (<1 month) after symptom onset (OR=11.22, 95% CI 3.9% to 32.5%).

CONCLUSION

Flow diversion promotes recovery or improvement of compressive symptoms in a large proportion of patients but is associated with significant rates of morbidity and mortality. Transient and permanent NOS worsening is not uncommon. Early treatment is of utmost importance, as it increases the likelihood of symptom improvement more than 10-fold.

A case report: Ruptured aneurysm with a wide neck treated by flow diverter stent and coil embolization

Diagnosis and endovascular treatment for ruptured wide neck aneurysms are challenges in clinics, particularly in developing countries. In the present study, we described a clinical case with a ruptured wide neck aneurysm in Vietnam treated by flow diverter stent and coil embolization. A 77-year-old- female patient had a right droopy eyelid for 2 months. The patient was admitted to hospital on the second day after being presented with a sudden-severe headache. Cerebral computed tomography (CT) and magnetic resonance imaging (MRI) were taken on the second day and fifth day after the onset of the headache. The results showed an aneurysm in the right internal carotid artery but no potential subarachnoid hemorrhage (SAH) was displayed. An uncoagulated blood was found in cerebrospinal fluid indicated by a lumbar puncture test. Digital subtraction angiography provided images with one wide-neck right internal carotid aneurysm. The patient was treated by flow diverter stent and coil embolization and the dual antiplatelet therapy with ticagrelor and aspirin at home. After 45 days, the patient did not face with any complication, no neurological symptoms, and the aneurysm was partially thrombosed indicated by MRI images. These results suggested that a lumbar puncture should be analyzed on the patient with brain aneurysm appeared a sudden severe headache and even no potential SAH on brain MRI or CT was found. The combination of flow diverter stent and coil embolization to treat cases with ruptured wide necked aneurysms should be considered in the future.

Intracranial aneurysms in pediatric population treated with flow diverters: A single-center experience

Background:

Pediatric intracranial aneurysms (PIAs) are uncommon. Flow diverters (FDs) have shown to be effective on treatment of selected aneurysms.

Methods:

We describe 10 cases of PIAs treated with FDs at one medical center in Mexico, from April 2015 to April 2020.

Results:

Out of 230 patients treated with FDs, 10 (4.3%) were pediatric. Average age was 9.4 years old (R: 6–15). Two patients (20%) had subarachnoid hemorrhage, 3 had epilepsy (30%), 3 (30%) had clinical signs of cranial nerve compression, and 4 (40%) had only headache. Two patients were in 1a grade of Hunt and Kosnik scale. Out of the nonruptured aneurysms, 7 (70%) were in 15 points of Glasgow Coma Scale and 1 patient (10%) was in 13 points. Treatment was performed without complications; nevertheless, appropriate distal deployment was not achieved in one case. At discharge, nine patients had 5 points of Glasgow Outcome Scale. All patients underwent computed tomography angiography or digital subtraction angiography at 1, 3, 6, and 12 months, 2 patients (20%) had a 2-year follow-up, and 3 patients (30%) had a 3-year follow-up. According to Kamran grading scale, 9 patients (90%) were classified as Grade 4 and 1 patient (10%) as Grade 3.

Conclusion:

Even though it is a small series, as this is an uncommon disease, we may suggest that FDs are useful to treat properly selected PIAs. Our study has consecutive imaging assessment at least a year of follow-up in which aneurysm stable occlusion was observed in 90% of patients.

Flow diversion for acutely ruptured intracranial aneurysms treatment: A retrospective study and literature review

OBJECTIVE

Flow diversion is becoming an increasingly established practice for the treatment of acutely ruptured intracranial aneurysms. In this study the authors present a literature review and meta-analysis, adding a retrospective review of institutional registry on emergency treatment of aRIA with flow diverter stent.

MATERIALS AND METHODS

A systematic search of PubMed, SCOPUS, Ovid MEDLINE, and Ovid EMBASE was performed on April 20^th, 2021, extrapolating 35 articles. R language 'meta' and 'metafor' packages were used for data pooling. The DerSimonian-Laird model was used to calculate the pooled effect. The I² value and Q statistic evaluated study heterogeneity. Additionally, the authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured intracranial aneurysms treated with flow diverter stent placement from May 2010 to November 2020 was performed.

RESULTS

From the systematic literature review and meta-analysis, the pooled proportion of complete aneurysm occlusion was 78%, with a pooled rate of 79%, 71%, 80%, and 50% for dissecting, saccular, fusiform, and mycotic aneurysms, respectively. The pooled proportion of aneurysm rebleeding and intrastent stenosis was 12% and 15% respectively, for a total of 27% rate. The analysis of authors retrospective register showed an overall mortality rate of 16.7% (3/18), with a low but not negligible postprocedural rebleeding and intrastent thrombosis rates (5.6% and 11.1% respectively).

CONCLUSION

Although increasingly utilized in the management of selected patients with acutely ruptured intracranial aneurysms, flow diversion for acutely ruptured intracranial aneurysms treatment presents rebleeding and intrastent stenosis rates not negligible.

A case report of pericallosal aneurysm successfully treated with flow diverter stents

Pericallosal artery aneurysm (PAA) is a relatively uncommon type of intracranial aneurysm that tends to rupture more frequently and cause higher mortality rates than other types of cerebral aneurysms. Surgery to address PAA is difficult due to its deep-seated location, the size of the aneurysmal sac, and the limited surgical field. In recent years, with the development of percutaneous interventions, endovascular treatment has become the preferred, minimally invasive intervention method for the treatment of pericallosal aneurysms. In this article, we present a case of PAA that was successfully treated with flow diversion therapy in a 51-year-old male.