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Lorga T, Pizzuto S, Coskun O, Sgreccia A, Cavazza M, Rahman MH, Rodesch G, Di Maria F, Consoli A. Reconstruction of the sphenoid sinus erosion or dehiscence after treatment of unruptured intracavernous aneurysms with flow diverter stents. J Neurointerv Surg 2023:jnis-2023-020734. [PMID: 37586819 DOI: 10.1136/jnis-2023-020734] [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: 06/23/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Intracavernous carotid aneurysms (ICCAs) are rare, frequently asymptomatic, with a low rupture risk, which, however, can lead to life-threatening epistaxis. The aim of this study was to assess the effect of the treatment of asymptomatic ICCAs with flow diverters (FD) on sphenoid bone erosion or dehiscence in a selected cohort of patients. METHODS We retrospectively reviewed all asymptomatic ICCAs with sphenoid bone erosion or dehiscence detected on cone beam CT (CBCT) and treated with FD between December 2018 and December 2022. Patients were followed-up with CBCT and bone reconstruction was blindly evaluated by two interventional neuroradiologists and classified as unchanged, partial, or complete. RESULTS A total of 10 patients (women: 90%, mean age 58 years) treated with an FD for an asymptomatic ICCA with associated sphenoid bone erosion or dehiscence were included in this cohort. Sphenoid bone erosion was present in seven patients and dehiscence was observed in the remaining three. After treatment with FD, complete reconstruction of the sphenoid sinus wall occurred in seven cases, and partial reconstruction in two cases. Sphenoid bone erosion remained unchanged after treatment in only one patient. CONCLUSIONS The decision to treat asymptomatic and unruptured ICCAs remains challenging due to their benign natural history and low hemorrhagic risk. The presence of sphenoid sinus erosion or dehiscence should not be overlooked since it could be considered as an indication for prophylactic treatment of life-threatening epistaxis. The mechanisms of bone erosion by the aneurysm and of reconstruction after treatment are still to be fully elucidated.
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Affiliation(s)
- Tiago Lorga
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Neuroradiology, Centro Hospitalar Universitário de Lisboa Central EPE, Lisboa, Portugal
| | - Silvia Pizzuto
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Oguzhan Coskun
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Alessandro Sgreccia
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Martino Cavazza
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Diagnostic and Interventional Radiology, University Hospital Arcispedale Sant'Anna of Ferrara, Cona, Italy
| | - Mohammad Habibur Rahman
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Interventional Neurology, National Institute of Neurosciences and Hospital, Sher-E-Bangla Nagar, Bangladesh
| | - Georges Rodesch
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Federico Di Maria
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Versailles Saint-Quentin-en-Yvelines University, Versailles, France
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2
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Grüter BE, Canzanella G, Hägler J, Rey J, Wanderer S, von Gunten M, Galvan JA, Grobholz R, Widmer HR, Remonda L, Andereggen L, Marbacher S. Topographic distribution of inflammation factors in a healing aneurysm. J Neuroinflammation 2023; 20:182. [PMID: 37533024 PMCID: PMC10394867 DOI: 10.1186/s12974-023-02863-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Healing of intracranial aneurysms following endovascular treatment relies on the organization of early thrombus into mature scar tissue and neointima formation. Activation and deactivation of the inflammation cascade plays an important role in this process. In addition to timely evolution, its topographic distribution is hypothesized to be crucial for successful aneurysm healing. METHODS Decellularized saccular sidewall aneurysms were created in Lewis rats and coiled. At follow-up (after 3 days (n = 16); 7 days (n = 19); 21 days (n = 8)), aneurysms were harvested and assessed for healing status. In situ hybridization was performed for soluble inflammatory markers (IL6, MMP2, MMP9, TNF-α, FGF23, VEGF), and immunohistochemical analysis to visualize inflammatory cells (CD45, CD3, CD20, CD31, CD163, HLA-DR). These markers were specifically documented for five regions of interest: aneurysm neck, dome, neointima, thrombus, and adjacent vessel wall. RESULTS Coiled aneurysms showed enhanced patterns of thrombus organization and neointima formation, whereas those without treatment demonstrated heterogeneous patterns of thrombosis, thrombus recanalization, and aneurysm growth (p = 0.02). In coiled aneurysms, inflammation markers tended to accumulate inside the thrombus and in the neointima (p < 0.001). Endothelial cells accumulated directly in the neointima (p < 0.0001), and their presence was associated with complete aneurysm healing. CONCLUSION The presence of proinflammatory cells plays a crucial role in aneurysm remodeling after coiling. Whereas thrombus organization is hallmarked by a pronounced intra-thrombotic inflammatory reaction, neointima maturation is characterized by direct invasion of endothelial cells. Knowledge concerning topographic distribution of regenerative inflammatory processes may pave the way for future treatment modalities which enhance aneurysm healing after endovascular therapy.
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Affiliation(s)
- Basil E Grüter
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, C/o NeuroResearch Office,Tellstrasse 1, 5001, Aarau, Switzerland.
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland.
| | - Gwendoline Canzanella
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Joshua Hägler
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Jeannine Rey
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Stefan Wanderer
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Michael von Gunten
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
- Institute of Pathology Laenggasse, Ittigen, Switzerland
| | - José A Galvan
- Translational Research Unit (TRU), Institute of Pathology, University of Bern, Bern, Switzerland
| | - Rainer Grobholz
- Institute of Pathology, Kantonsspital Aarau, Aarau, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Hans-Rudolf Widmer
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Luca Remonda
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, C/o NeuroResearch Office,Tellstrasse 1, 5001, Aarau, Switzerland
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Program for Regenerative Neuroscience, Department for BioMedical Research, University of Bern, Bern, Switzerland
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3
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Cayron AF, Morel S, Allémann E, Bijlenga P, Kwak BR. Imaging of intracranial aneurysms in animals: a systematic review of modalities. Neurosurg Rev 2023; 46:56. [PMID: 36786880 PMCID: PMC9928939 DOI: 10.1007/s10143-023-01953-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/28/2022] [Accepted: 01/23/2023] [Indexed: 02/15/2023]
Abstract
Intracranial aneurysm (IA) animal models are paramount to study IA pathophysiology and to test new endovascular treatments. A number of in vivo imaging modalities are available to characterize IAs at different stages of development in these animal models. This review describes existing in vivo imaging techniques used so far to visualize IAs in animal models. We systematically searched for studies containing in vivo imaging of induced IAs in animal models in PubMed and SPIE Digital library databases between 1 January 1945 and 13 July 2022. A total of 170 studies were retrieved and reviewed in detail, and information on the IA animal model, the objective of the study, and the imaging modality used was collected. A variety of methods to surgically construct or endogenously induce IAs in animals were identified, and 88% of the reviewed studies used surgical methods. The large majority of IA imaging in animals was performed for 4 reasons: basic research for IA models, testing of new IA treatment modalities, research on IA in vivo imaging of IAs, and research on IA pathophysiology. Six different imaging techniques were identified: conventional catheter angiography, computed tomography angiography, magnetic resonance angiography, hemodynamic imaging, optical coherence tomography, and fluorescence imaging. This review presents and discusses the advantages and disadvantages of all in vivo IA imaging techniques used in animal models to help future IA studies finding the most appropriate IA imaging modality and animal model to answer their research question.
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Affiliation(s)
- Anne F Cayron
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, CH-1211, Geneva, Switzerland
- Geneva Center for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Sandrine Morel
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, CH-1211, Geneva, Switzerland
- Geneva Center for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Clinical Neurosciences - Division of Neurosurgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Eric Allémann
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Philippe Bijlenga
- Department of Clinical Neurosciences - Division of Neurosurgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Brenda R Kwak
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, CH-1211, Geneva, Switzerland.
- Geneva Center for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Lu T, Liu Z, Guo D, Ma C, Duan L, He Y, Jia R, Guo C, Xing Z, Liu Y, Li T, He Y. Transcriptome-Based Dissection of Intracranial Aneurysms Unveils an “Immuno-Thermal” Microenvironment and Defines a Pathological Feature-Derived Gene Signature for Risk Estimation. Front Immunol 2022; 13:878195. [PMID: 35711443 PMCID: PMC9194475 DOI: 10.3389/fimmu.2022.878195] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/19/2022] [Indexed: 12/16/2022] Open
Abstract
Immune inflammation plays an essential role in the formation and rupture of intracranial aneurysm (IA). However, the current limited knowledge of alterations in the immune microenvironment of IA has hampered the mastery of pathological mechanisms and technological advances, such as molecular diagnostic and coated stent-based molecular therapy. In this study, seven IA datasets were enrolled from the GEO database to decode the immune microenvironment and relevant biometric alterations. The ssGSEA algorithm was employed for immune infiltration assessment. IAs displayed abundant immune cell infiltration, activated immune-related pathways, and high expression of immune-related genes. Several immunosuppression cells and genes were also coordinately upregulated in IAs. Five immune-related hub genes, including CXCL10, IL6, IL10, STAT1, and VEGFA, were identified from the protein-protein interaction network and further detected at the protein level. CeRNA networks and latent drugs targeting the hub genes were predicted for targeted therapy reference. Two gene modules recognized via WCGNA were functionally associated with contractile smooth muscle loss and extracellular matrix metabolism, respectively. In blood datasets, a pathological feature-derived gene signature (PFDGS) for IA diagnosis and rupture risk prediction was established using machine learning. Patients with high PFDGS scores may possess adverse biological alterations and present with a high risk of morbidity or IA rupture, requiring more vigilance or prompt intervention. Overall, we systematically unveiled an “immuno-thermal” microenvironment characterized by co-enhanced immune activation and immunosuppression in IA, which provides a novel insight into molecular pathology. The PFDGS is a promising signature for optimizing risk surveillance and clinical decision-making in IA patients.
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Affiliation(s)
- Taoyuan Lu
- Department of Cerebrovascular Disease, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
| | - Zaoqu Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dehua Guo
- Department of Cerebrovascular Disease, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
| | - Chi Ma
- Department of Cerebrovascular Disease, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
| | - Lin Duan
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
- Department of Cerebrovascular Disease, Henan University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Yanyan He
- Department of Cerebrovascular Disease, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
- Department of Cerebrovascular Disease, Henan University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Rufeng Jia
- Department of Cerebrovascular Disease, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
| | - Chunguang Guo
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhe Xing
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yiying Liu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
- Department of Cerebrovascular Disease, Henan University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- *Correspondence: Yingkun He, ; Tianxiao Li,
| | - Yingkun He
- Department of Cerebrovascular Disease, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
- Department of Cerebrovascular Disease, Henan University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- *Correspondence: Yingkun He, ; Tianxiao Li,
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5
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Laurent D, Lucke-Wold B, Dodd WS, Martinez M, Chowdhury MAB, Hosaka K, Motwani K, Hoh B. Combination release of chemokines from coated coils to target aneurysm healing. J Neurointerv Surg 2022:neurintsurg-2022-018710. [PMID: 35609975 PMCID: PMC10116990 DOI: 10.1136/neurintsurg-2022-018710] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/13/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Monocyte chemoattractant protein 1 (MCP-1) and osteopontin (OPN) have been identified separately as key mediators of the aneurysm healing process following coil embolization in the rodent model. The ability of protein coated coils to accelerate this process is currently unknown.To create coils coated with both MCP-1 and OPN to target aneurysm healing. METHODS We uses a polymer (poly(glycolide-co-caprolactone)) (Rao pharmaceuticals) (CG910) to test whether coils could be dual coated with active proteins with sequential reliable release. Coils were coated with poly-DL-lactic glycolic acid (PLGA), CG910, and subsequently dipped with protein OPN (inner layer for delayed release) and MCP-1 (outer layer for initial release). Release assays were used to measure protein elution from coils over time. To test in vivo feasibility, coated coils were implanted into carotid aneurysms to determine the effect on aneurysm healing. RESULTS The in vitro protein release assay demonstrated, a significant amount of OPN and MCP-1 release within 2 days. Using a 200 µg/µL solution of MCP-1 in phosphate-buffered saline, we showed that CG910 coated coils provide effective release of MCP over time. In the carotid aneurysm model, MCP-1 and OPN coated coils significantly increased tissue ingrowth (74% and 80%) compared with PLGA and CG910 coated coils alone (58% and 53%). To determine synergistic impact of dual coating, we measured ingrowth for MCP-1/OPN coils (63%) as well as overlap coefficients for NOX4 and NFκB with CD31. CONCLUSIONS This study demonstrates that MCP-1 and OPN coated coils are viable and may promote early aneurysm healing. Dual coated coils may have synergistic benefit given different location of protein interaction measured in vivo. Further work is warranted.
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Affiliation(s)
- Dimitri Laurent
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Brandon Lucke-Wold
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - William S Dodd
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Melanie Martinez
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | | | - Koji Hosaka
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Kartik Motwani
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Brian Hoh
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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Fujii T, Teranishi K, Yatomi K, Suzuki K, Mitome-Mishima Y, Kondo A, Oishi H. Long-term Follow-up Results after Flow Diverter Therapy Using the Pipeline Embolization Device for Large or Giant Unruptured Internal Carotid Artery Aneurysms: Single-center Retrospective Analysis in the Japanese Population. Neurol Med Chir (Tokyo) 2021; 62:19-27. [PMID: 34707069 PMCID: PMC8754679 DOI: 10.2176/nmc.oa.2021-0203] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Flow diverter (FD) therapy using Pipeline embolization device (PED) has become an important alternative to treat internal carotid artery (ICA) aneurysms. Herein, we report the long-term outcome for 3 years after FD therapy using PED for ICA aneurysms in Japan. The patients who underwent angiographical and/or clinical follow-up for 3 years after the FD therapy using PED of large or giant unruptured ICA aneurysms from December 2012 at our university hospital are the subjects of this study. We retrospectively reviewed the in- and outpatients’ medical charts, and written operative and radiological records. There were 84 patients with 90 aneurysms who could be clinically and/or angiographically followed up for 3 years. Of these, 7 aneurysms were only available for clinical follow-up. Of the remaining 83 aneurysms, 6 aneurysms had vessel occlusion due to stent thrombosis or parent artery occlusion, and 60 of the remaining 77 (77.9%) had complete occlusion. In multivariate analysis, older age (>70 years), wide neck, and non-adjunctive coiling contributed statistically significantly to incomplete occlusion. Of the 84 patients, 2 patients (2.4%) had delayed complications between 6 months and 3 years after the initial FD placement. Three patients (3.6%) had poor outcome due to postoperative major stroke complications, 2 of which were acute complications. The long-term results after FD therapy are good both angiographically and clinically. Endothelialization of the aneurysmal neck and intra-aneurysmal thrombosis contribute to complete occlusion. The primary reason for the somewhat low complete occlusion in Japan may be the patients are generally older.
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Affiliation(s)
- Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University, Graduate School of Medicine
| | - Kohsuke Teranishi
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | - Kazumoto Suzuki
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | | | - Akihide Kondo
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy, Juntendo University, Graduate School of Medicine.,Department of Neurosurgery, Juntendo University, Graduate School of Medicine
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7
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Ravindran K, Casabella AM, Cebral J, Brinjikji W, Kallmes DF, Kadirvel R. Mechanism of Action and Biology of Flow Diverters in the Treatment of Intracranial Aneurysms. Neurosurgery 2020; 86:S13-S19. [PMID: 31838528 PMCID: PMC6911734 DOI: 10.1093/neuros/nyz324] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/30/2019] [Indexed: 12/19/2022] Open
Abstract
Flow diverters have drastically changed the landscape of intracranial aneurysm treatment and are now considered first-line therapy for select lesions. Their mechanism of action relies on intrinsic alteration in hemodynamic parameters, both at the parent artery and within the aneurysm sac. Moreover, the device struts act as a nidus for endothelial cell growth across the aneurysm neck ultimately leading to aneurysm exclusion from the circulation. In silico computational analyses and investigations in preclinical animal models have provided valuable insights into the underlying biological basis for flow diverter therapy. Here, we review the present understanding pertaining to flow diverter biology and mechanisms of action, focusing on stent design, induction of intra-aneurysmal thrombosis, endothelialization, and alterations in hemodynamics.
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Affiliation(s)
| | | | - Juan Cebral
- Bioengineering Department, George Mason University, Fairfax, Virginia
| | | | | | - Ram Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
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8
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Maragkos GA, Ascanio LC, Salem MM, Gopakumar S, Gomez-Paz S, Enriquez-Marulanda A, Jain A, Schirmer CM, Foreman PM, Griessenauer CJ, Kan P, Ogilvy CS, Thomas AJ. Predictive factors of incomplete aneurysm occlusion after endovascular treatment with the Pipeline embolization device. J Neurosurg 2019; 132:1598-1605. [PMID: 31026827 DOI: 10.3171/2019.1.jns183226] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Pipeline embolization device (PED) is a routine choice for the endovascular treatment of select intracranial aneurysms. Its success is based on the high rates of aneurysm occlusion, followed by near-zero recanalization probability once occlusion has occurred. Therefore, identification of patient factors predictive of incomplete occlusion on the last angiographic follow-up is critical to its success. METHODS A multicenter retrospective cohort analysis was conducted on consecutive patients treated with a PED for unruptured aneurysms in 3 academic institutions in the US. Patients with angiographic follow-up were selected to identify the factors associated with incomplete occlusion. RESULTS Among all 3 participating institutions a total of 523 PED placement procedures were identified. There were 284 procedures for 316 aneurysms, which had radiographic follow-up and were included in this analysis (median age 58 years; female-to-male ratio 4.2:1). Complete occlusion (100% occlusion) was noted in 76.6% of aneurysms, whereas incomplete occlusion (≤ 99% occlusion) at last follow-up was identified in 23.4%. After accounting for factor collinearity and confounding, multivariable analysis identified older age (> 70 years; OR 4.46, 95% CI 2.30-8.65, p < 0.001); higher maximal diameter (≥ 15 mm; OR 3.29, 95% CI 1.43-7.55, p = 0.005); and fusiform morphology (OR 2.89, 95% CI 1.06-7.85, p = 0.038) to be independently associated with higher rates of incomplete occlusion at last follow-up. Thromboembolic complications were noted in 1.4% and hemorrhagic complications were found in 0.7% of procedures. CONCLUSIONS Incomplete aneurysm occlusion following placement of a PED was independently associated with age > 70 years, aneurysm diameter ≥ 15 mm, and fusiform morphology. Such predictive factors can be used to guide individualized treatment selection and counseling in patients undergoing cerebrovascular neurosurgery.
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Affiliation(s)
- Georgios A Maragkos
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Luis C Ascanio
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mohamed M Salem
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Santiago Gomez-Paz
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Abhi Jain
- 3Department of Neurosurgery, Geisinger, Danville, Pennsylvania.,5Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | | | - Paul M Foreman
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christoph J Griessenauer
- 3Department of Neurosurgery, Geisinger, Danville, Pennsylvania.,4Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; and
| | - Peter Kan
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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9
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Adeeb N, Moore JM, Wirtz M, Griessenauer CJ, Foreman PM, Shallwani H, Gupta R, Dmytriw AA, Motiei-Langroudi R, Alturki A, Harrigan MR, Siddiqui AH, Levy EI, Thomas AJ, Ogilvy CS. Predictors of Incomplete Occlusion following Pipeline Embolization of Intracranial Aneurysms: Is It Less Effective in Older Patients? AJNR Am J Neuroradiol 2017; 38:2295-2300. [PMID: 28912285 DOI: 10.3174/ajnr.a5375] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 07/08/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow diversion with the Pipeline Embolization Device (PED) for the treatment of intracranial aneurysms is associated with a high rate of aneurysm occlusion. However, clinical and radiographic predictors of incomplete aneurysm occlusion are poorly defined. In this study, predictors of incomplete occlusion at last angiographic follow-up after PED treatment were assessed. MATERIALS AND METHODS A retrospective analysis of consecutive aneurysms treated with the PED between 2009 and 2016, at 3 academic institutions in the United States, was performed. Cases with angiographic follow-up were selected to evaluate factors predictive of incomplete aneurysm occlusion at last follow-up. RESULTS We identified 465 aneurysms treated with the PED; 380 (81.7%) aneurysms (329 procedures; median age, 58 years; female/male ratio, 4.8:1) had angiographic follow-up, and were included. Complete occlusion (100%) was achieved in 78.2% of aneurysms. Near-complete (90%-99%) and partial (<90%) occlusion were collectively achieved in 21.8% of aneurysms and defined as incomplete occlusion. Of aneurysms followed for at least 12 months (211 of 380), complete occlusion was achieved in 83.9%. Older age (older than 70 years), nonsmoking status, aneurysm location within the posterior communicating artery or posterior circulation, greater aneurysm maximal diameter (≥21 mm), and shorter follow-up time (<12 months) were significantly associated with incomplete aneurysm occlusion at last angiographic follow-up on univariable analysis. However, on multivariable logistic regression, only age, smoking status, and duration of follow-up were independently associated with occlusion status. CONCLUSIONS Complete occlusion following PED treatment of intracranial aneurysms can be influenced by several factors related to the patient, aneurysm, and treatment. Of these factors, older age (older than 70 years) and nonsmoking status were independent predictors of incomplete occlusion. While the physiologic explanation for these findings remains unknown, identification of factors predictive of incomplete aneurysm occlusion following PED placement can assist in patient selection and counseling and might provide insight into the biologic factors affecting endothelialization.
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Affiliation(s)
- N Adeeb
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Neurosurgery (N.A.), Louisiana State University, Shreveport, Louisiana
| | - J M Moore
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - M Wirtz
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - C J Griessenauer
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - P M Foreman
- Department of Neurosurgery (P.M.F., M.R.H.), University of Alabama at Birmingham, Birmingham, Alabama
| | - H Shallwani
- Department of Neurosurgery (H.S., A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - R Gupta
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - A A Dmytriw
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - R Motiei-Langroudi
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - A Alturki
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - M R Harrigan
- Department of Neurosurgery (P.M.F., M.R.H.), University of Alabama at Birmingham, Birmingham, Alabama
| | - A H Siddiqui
- Department of Neurosurgery (H.S., A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - E I Levy
- Department of Neurosurgery (H.S., A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - A J Thomas
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - C S Ogilvy
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Emerging Technologies in Flow Diverters and Stents for Cerebrovascular Diseases. Curr Neurol Neurosci Rep 2017; 17:96. [DOI: 10.1007/s11910-017-0805-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Concomitant coiling reduces metalloproteinase levels in flow diverter-treated aneurysms but anti-inflammatory treatment has no effect. J Neurointerv Surg 2016; 9:307-310. [DOI: 10.1136/neurintsurg-2015-012207] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 02/10/2016] [Accepted: 02/22/2016] [Indexed: 11/03/2022]
Abstract
Background and purposeFlow diverters (FD) can cause rare but devastating delayed aneurysm ruptures in which matrix metalloproteinases (MMPs) have been potentially implicated. Concomitant coiling or anti-inflammatory medications have been proposed to prevent the risk of delayed ruptures. The aim of this study was to evaluate concomitant coiling and ciclosporin in regulating the expression of MMPs in FD-treated aneurysms.Materials and methodsElastase-induced aneurysms were created in 20 rabbits. Aneurysms were treated with (1) FD alone; (2) FD with concomitant coiling; (3) FD+ ciclosporin; or (4) left untreated as controls. At sacrifice, MMP levels were analyzed by zymography. Kruskal–Wallis one-way non-parametric ANOVA was performed for each enzyme. If significant results were observed for the Kruskal–Wallis test, pairwise group comparisons were performed using Dunn's test with Bonferroni multiple-testing correction.ResultsSignificant differences were observed among groups for pro-MMP9 (p=0.0337). Pairwise comparison demonstrated higher levels of pro-MMP9 with concomitant coiling compared with untreated aneurysms (p=0.012), with higher though not significantly different levels of pro-MMP9 in FD with concomitant coiling versus FD alone. While not statistically significant, trends were noted regarding differences in active-MMP9 across groups, with a lower level of active-MMP9 with concomitant coiling compared with the other FD groups. No significant differences were observed for pro- or active-MMP2 across groups, or for FD + ciclosporin compared with FD alone.ConclusionsFD implantation increases the level of pro-MMP9 expression in aneurysms. Provocative trends regarding modulation of active-MMP9 expression with concomitant coiling suggest the need for larger confirmatory preclinical studies. Anti-inflammatory treatment with ciclosporin appears to have a minimal biological effect.Trial registration numberR01NS076491
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Rouchaud A, Johnson C, Thielen E, Schroeder D, Ding YH, Dai D, Brinjikji W, Cebral J, Kallmes DF, Kadirvel R. Differential Gene Expression in Coiled versus Flow-Diverter-Treated Aneurysms: RNA Sequencing Analysis in a Rabbit Aneurysm Model. AJNR Am J Neuroradiol 2015; 37:1114-21. [PMID: 26721773 DOI: 10.3174/ajnr.a4648] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 11/10/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE The biologic mechanisms leading to aneurysm healing or rare complications such as delayed aneurysm ruptures after flow-diverter placement remain poorly understood. We used RNA sequencing following implantation of coils or flow diverters in elastase aneurysms in rabbits to identify genes and pathways of potential interest. MATERIALS AND METHODS Aneurysms were treated with coils (n = 5) or flow diverters (n = 4) or were left untreated for controls (n = 6). Messenger RNA was isolated from the aneurysms at 4 weeks following treatment. RNA samples were processed by using RNA-sequencing technology and were analyzed by using the Ingenuity Pathway Analysis tool. RESULTS With RNA sequencing for coiled versus untreated aneurysms, 464/9990 genes (4.6%) were differentially expressed (58 down-regulated, 406 up-regulated). When we compared flow-diverter versus untreated aneurysms, 177/10,041 (1.8%) genes were differentially expressed (8 down-regulated, 169 up-regulated). When we compared flow-diverter versus coiled aneurysms, 13/9982 (0.13%) genes were differentially expressed (8 down-regulated, 5 up-regulated). Keratin 8 was overexpressed in flow diverters versus coils. This molecule may potentially play a critical role in delayed ruptures due to plasmin production. We identified overregulation of apelin in flow diverters, supporting the preponderance of endothelialization, whereas we found overexpression of molecules implicated in wound healing (dectin 1 and hedgehog interacting protein) for coiled aneurysms. Furthermore, we identified metallopeptidases 1, 12, and 13 as overexpressed in coiled versus untreated aneurysms. CONCLUSIONS We observed different physiopathologic responses after endovascular treatment with various devices. Flow diverters promote endothelialization but express molecules that could potentially explain the rare delayed ruptures. Coils promote wound healing and express genes potentially implicated in the recurrence of coiled aneurysms.
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Affiliation(s)
- A Rouchaud
- From the Applied Neuroradiology Laboratory (A.R., C.J., E.T., D.S., Y.-H.D., D.D., W.B., D.F.K., R.K.)
| | - C Johnson
- From the Applied Neuroradiology Laboratory (A.R., C.J., E.T., D.S., Y.-H.D., D.D., W.B., D.F.K., R.K.)
| | - E Thielen
- From the Applied Neuroradiology Laboratory (A.R., C.J., E.T., D.S., Y.-H.D., D.D., W.B., D.F.K., R.K.)
| | - D Schroeder
- From the Applied Neuroradiology Laboratory (A.R., C.J., E.T., D.S., Y.-H.D., D.D., W.B., D.F.K., R.K.)
| | - Y-H Ding
- From the Applied Neuroradiology Laboratory (A.R., C.J., E.T., D.S., Y.-H.D., D.D., W.B., D.F.K., R.K.)
| | - D Dai
- From the Applied Neuroradiology Laboratory (A.R., C.J., E.T., D.S., Y.-H.D., D.D., W.B., D.F.K., R.K.)
| | - W Brinjikji
- From the Applied Neuroradiology Laboratory (A.R., C.J., E.T., D.S., Y.-H.D., D.D., W.B., D.F.K., R.K.) Department of Radiology (W.B., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - J Cebral
- Department of Bioengineering (J.C.), George Mason University, Fairfax, Virginia
| | - D F Kallmes
- From the Applied Neuroradiology Laboratory (A.R., C.J., E.T., D.S., Y.-H.D., D.D., W.B., D.F.K., R.K.) Department of Radiology (W.B., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - R Kadirvel
- From the Applied Neuroradiology Laboratory (A.R., C.J., E.T., D.S., Y.-H.D., D.D., W.B., D.F.K., R.K.)
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