Multiple Telescoping Flow Diverter Technique in Endovascular Treatment of a Giant Petrous and Cavernous Carotid Aneurysm

Endovascular flow diversion reconstruction of petrocervical dissections with the proximal anchoring technique: Experience in 31 consecutive cases

INTRODUCTION

Flow diverting stents (FDS) are routinely used to reconstruct the arteries of the head and neck. When placed into the mobile cervical internal carotid artery (cICA) segment, the FDS runs the risk of post-procedure stent migration and proximal intimal hyperplasia reaction from physiologic movement of the neck. We report our experience using a novel proximal anchoring technique during endovascular flow reconstruction of complex petrocervical dissections to prevent this potentially deleterious result.

METHODS

We reviewed a prospectively maintained IRB-approved institutional database of the senior authors to identify cases of FDS treatment in the mobile petrocervical segments which had the proximal FDS "anchored" with a nitinol stent.

RESULTS

The proximal anchoring technique was successfully performed in the mobile cervical segment in a total of 31 cases over the study period. Each case involved a complex ICA dissection with 68% (n = 21) having an accompanying pseudoaneurysm. Fifty-two percent (n = 16) were female. Surpass Streamline and Evolve FDS were utilized in all cases. An average of 2.2 ± 0.1 FDS devices were utilized (range 2-4 FDS), with each case utilizing a laser-cut nitinol carotid stent as the proximal anchor. The average stent diameter was 5.64 ± 0.2 mm (range 4-8 mm) and length of 30.1 ± 1.5 mm (range 20-60 mm). On last follow-up angiography, there were no instances of stent migration or proximal neointimal hyperplasia.

CONCLUSION

Utilization of the proximal anchoring technique on FDS constructs in the mobile cICA may provide additional protection from post-procedure stent migration and intimal reaction attributed to patient neck movement resulting in augmentation of successful healing.

Telescoping Flow Diverters for the Treatment of Brain Aneurysms: Indications and Outcome

OBJECTIVE

Few studies have reported the impact of telescoping flow diverters (FDs) in intracranial aneurysm treatment. Our study compared aneurysms treated using telescoping FDs to those treated with a single FD and identified predictors of telescoping.

METHODS

This was a single-center retrospective review of a prospectively maintained database of aneurysms treated with FDs between 2011 and 2023. All patients who were treated with FDs for intracranial aneurysms were included in the study.

RESULTS

The study comprised 750 patients with 750 aneurysms treated using 871 FDs. The study cohort was divided into 85 patients requiring telescoping FDs and 655 who did not. Rates of hemorrhage (7.1% vs. 1.8%, P < 0.001), symptomatic stroke (5.9% vs. 2.6, P < 0.001), and asymptomatic stroke (1.2% vs. 0.8%, P < 0.001) were significantly higher in the telescoping cohorts. At final follow-up, the rate of nonocclusion (9.8% vs. 5.1%, P = 0.029) and the rate of complete occlusion (88.5% vs. 81.1%, P = 0.029) were significantly higher in the telescoping cohort. On multivariate analysis, fusiform morphology (odds ratio [OR]: 2.4, 95% confidence interval [CI] 1.0-5.0, P = 0.03), increasing aneurysm height (OR: 1.0, 95% CI 1.0-1.1, P= 0.034), and the use of the Pipeline Embolization Device FD (OR: 2.4, 95% CI 1.3-4.4, P = 0.005) were independent predictors of telescoping.

CONCLUSIONS

Aneurysms with fusiform morphology, increasing aneurysm height and those that underwent flow diversion using Pipeline Embolization Device had higher odds for telescoping. Significantly higher rates of angiographic occlusion with the use of telescoping FD add to the literature on its efficacy in treating aneurysms of varying morphology.

Reconstructive endovascular treatment of petrous ICA pseudoaneurysm in skull base osteomyelitis: a hidden catastrophe

Skull base osteomyelitis can be more life-threatening in immunocompromised patients and patients with diabetes. Here, we present a case of a petrous internal carotid artery pseudoaneurysm resulting from skull base osteomyelitis in a diabetic male in his 50s. This case report highlights the need to be conscious of the various complications associated with skull base osteomyelitis, be proficient in detecting them and treat them as early as possible for better outcomes. After adequate control of the disease process with medical treatment, immediate management of the aneurysm with balloon angioplasty and stenting was done. Acknowledging the trivial nasal and ear bleed, radiological evaluation is necessary to rule out rare complications like pseudoaneurysms in a diagnosed case of skull base osteomyelitis. In the discussion, we have cited the various treatment methods and similar cases of pseudoaneurysm caused by osteomyelitis. Currently, the patient continues to live a disease and disability-free life.

Multiple telescoping flow diverter technique in endovascular treatment of a vertebrobasilar dissecting aneurysm: case report

A 64-year-old man presented with headache and dizziness. A vertebrobasilar dissecting aneurysm was identified via computed tomography angiography and high resolution magnetic resonance imaging. Perioperatively, standard oral dual antiplatelet drugs were given. Two flow diverters were telespcoped for endovascular treatment of the aneurysm. Postoperatively, there were no signs of cerebral infarction and no new symptoms. At the 6-month follow-up, digital subtraction angiography showed that the aneurysm was almost completely occluded, with no other complications. This case serves as a reference for using the multiple telescoping flow diverter technique to treat vertebrobasilar dissecting aneurysm.

Petrous internal carotid artery aneurysm: A cause of chronic otitis

BACKGROUND

Aneurysm of the petrous segment of the internal carotid artery (pICA) is a rare pathology presenting with extracranial and especially oto-rhinological symptoms that can be misleading and delay diagnosis.

METHODS

We report the case of a giant pICA aneurysm compressing the Eustachian tube (ET), presenting with hearing loss due to chronic serous otitis. A PRISMA review of the literature was performed to find similar cases. In addition, relevant anatomical sources were screened.

RESULTS

Five reports about 7 cases of middle-ear effusion caused by pICA aneurysm compressing the ET were identified. Median age at diagnosis was 18.5 years. After endovascular treatment, overall outcome was favorable, with no mortality, although outcome was sometimes impaired by neurological comorbidities and unclear prognosis of hearing-loss recovery.

DISCUSSION

These reports, though rare, offer relevant insights into the poorly known regional anatomy of the pICA, in the borderland between neurosurgery and ENT. Within the petrous bone, the osseous separation between the ET and the pICA is narrow, when not dehiscent. This leads to a risk of any pathological process in either the pICA or the ET impinging on the other.

CONCLUSION

Giant pICA aneurysm is a rare cause of hearing loss, due to compression of the ET, leading to chronic serous otitis. This co-dependency between pICA and ET should be kept in mind, as it underlines the necessity of multidisciplinary management and could facilitate earlier diagnosis and therapeutic management when facing atypical clinical situations.