1
|
Enriquez Marulanda A, Young M, Shutran M, Taussky P, Kicielinski K, Ogilvy CS. Acute Coiling With Delayed Flow Diversion for Posterior Communicating Segment Internal Carotid Artery Aneurysms: A Multicenter Case Series. Neurosurgery 2024; 94:729-735. [PMID: 37931125 DOI: 10.1227/neu.0000000000002720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/22/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In ruptured posterior communicating artery (PcomA) aneurysms, the protection of the aneurysm dome alone with initial subtotal coiling decreases the risk of rerupture in the acute setting but does not provide durable/definitive long-term protection against delayed rupture. Delayed flow diverter (FD) placement can be a potential alternative to definitively secure these aneurysms without increasing the risk of complications and PComA occlusion. We analyzed PComA aneurysms treated with a planned delayed FD after primary coiling and assess radiographic and clinical outcomes. METHODS We performed a retrospective study of prospectively collected data for intracranial aneurysms treated with planned FD at 2 institutions from 2013 to 2022. PComA aneurysms that underwent primary coiling and delayed FD placement were included for analysis. RESULTS There were 29 PComA aneurysms identified that were included in the analysis. Patients were mostly female (79.3%), with a median age of 60 years. The mean aneurysm maximum diameter was 7.2 mm ± (5.3). Immediate Raymond-Roy occlusion grade after primary coiling was I in 48.3%, II in 41.4%, and III in 10.3% of aneurysms. The median time from initial coiling to planned delayed FD placement was 6.3 months (3.2-18.6). A total of 21 (72.4%) aneurysms underwent follow-up radiological imaging. Complete and near-complete occlusion status was achieved in 76.2% of the evaluated aneurysms. There were no retreatments and no evidence of delayed aneurysm rupture. One case (3.5%) presented thromboembolic complications and 1 (3.5%) intracranial hemorrhagic complication after FD placement, which was associated with mortality. Most patients (90.5%) had a modified Rankin scale of ≤2 on the last follow-up. CONCLUSION Primary coiling with planned staged FD placement is effective for treating ruptured PComA aneurysms with high occlusion rates and low complications.
Collapse
Affiliation(s)
- Alejandro Enriquez Marulanda
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| | - Michael Young
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| | - Max Shutran
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| | - Philipp Taussky
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| | - Kimberly Kicielinski
- Neurosurgery Department, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Christopher S Ogilvy
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| |
Collapse
|
2
|
Matsukawa S, Ishii A, Fushimi Y, Terada Y, Natsuhara H, Kikuchi T, Okawa M, Yamao Y, Abekura Y, Sasaki N, Tsuji H, Akiyama R, Miyamoto S, Arakawa Y. Ruptured thrombosed vertebral artery dissecting aneurysm treated with staged flow diverter after prediction of the rupture point by vessel wall MRI. Neuroradiol J 2023:19714009231224420. [PMID: 38148669 DOI: 10.1177/19714009231224420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
The safety and feasibility of using staged flow diverter (FD) for ruptured cerebral aneurysms, in which coil embolization is performed in the acute phase and FD is deployed in the subacute phase, has recently been reported. This strategy requires assuming the rupture point and performing coil embolization. Although vessel wall magnetic resonance imaging (VW-MRI) has been reported to be useful in predicting the rupture point of aneurysms, its use with staged FD has not yet been reported. We report the first case of staged FD with preoperative contrast-enhanced VW-MRI to predict the rupture point for partially thrombosed vertebral artery dissecting large aneurysm involving posterior inferior cerebellar artery (PICA) origin. This approach achieved a very good outcome, not only completely occluding the aneurysm, but also reconstructing the parent artery while maintaining the patency of the PICA.
Collapse
Affiliation(s)
- So Matsukawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Akira Ishii
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Yasutaka Fushimi
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Yukinori Terada
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Hiroki Natsuhara
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Takayuki Kikuchi
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Masakazu Okawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Yukihiro Yamao
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Yu Abekura
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Natsuhi Sasaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Hirofumi Tsuji
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Ryo Akiyama
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| | - Yoshiki Arakawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Japan
| |
Collapse
|
3
|
Wei Y, Zhang X, Zhang R, Zhang G, Shang C, Chen R, Li D, Huyan M, Wu C, Zong K, Feng Z, Dai D, Li Q, Huang Q, Xu Y, Yang P, Zhao R, Zuo Q, Liu J. Staged stenting strategy of acutely wide-neck ruptured intracranial aneurysms: A meta-analysis and systematic review. Front Neurol 2023; 14:1070847. [PMID: 36816566 PMCID: PMC9936144 DOI: 10.3389/fneur.2023.1070847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023] Open
Abstract
Objective In the study, we explored the safety and effectiveness of staged stenting strategy for acutely wide-neck ruptured intracranial aneurysms. Methods Online databases, including PubMed, EMBASE, the Cochrane database, and Web of Science, were retrospectively and systematically searched. The main observation indicators were the procedure-related complication rate, complete occlusion rate, and favorable clinical outcome. Meta-analysis was performed using a random or fixed effect model based on heterogeneity. Results A total of 5 studies with 143 patients were included. The hemorrhagic complication rate of the initial coiling and staged stenting was 2.8% (4 of 143) and 0, respectively. The ischemic complication rate of the coiling and supplemental stenting was 3.5% (5 of 143) and 2.9% (4 of 139), respectively. There were no deaths due to procedure-related complications in two stages. The aneurysm complete occlusion rate was 25% (95% CI, 0.13-0.03; I2 = 4.4%; P = 0.168) after initial coiling, 54% (95% CI, 0.63-0.64; I2 = 0%; P = 0.872) after staged stenting, and 74% (95% CI, 0.66-0.81; I2 = 56.4%; P = 0.562) at follow-up, respectively. Favorable clinical outcome rate 74% (95% CI, 0.61-0.86; I2 = 50.5%; P = 0.133) after discharge of initial coiling treatment, and 86% (95% CI, 0.80-0.92; I2 = 0; P = 0.410) after discharge from stenting, and 97% (95% CI, 0.93-1.01; I2 = 43.8%; P = 0.130) at follow-up. Conclusion Staged stenting treatment of wide-neck RIA with coiling in the acute phase followed by delayed regular stent or flow-diverter stent had high aneurysm occlusion rate, favorable clinical outcome rate and low procedure-related complication rate. A more dedicated and well-designed controlled study is warranted for further evaluation of staged stenting treatment compared to SCA in wide-neck RIA.
Collapse
|
4
|
Jindal G, Almardawi R, Gupta R, Colby GP, Schirmer CM, Satti SR, Pukenas B, Hui FK, Caplan J, Miller T, Cherian J, Aldrich F, Kibria G, Simard JM. Target Ultra and Nano coils in the endovascular treatment of small intracranial aneurysms (ULTRA Registry). J Neurosurg 2023; 138:233-240. [PMID: 35901755 DOI: 10.3171/2022.5.jns2296] [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: 01/28/2022] [Accepted: 05/04/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The ULTRA Registry is a national multicenter prospective study designed to assess aneurysm occlusion rates and safety profiles of the Target Ultra and Nano coils in the treatment of small intracranial aneurysms (IAs). METHODS Patients with small (≤ 5 mm) ruptured and unruptured IAs were treated exclusively with Target Ultra and Nano coils. The primary endpoints were the initial rate of complete or near-complete aneurysm occlusion, aneurysm recurrence, and need for retreatment. Secondary endpoints were device- and procedure-related adverse events, hemorrhage from the coiled aneurysm at any time during follow-up, and clinical outcomes. RESULTS The ULTRA Registry included 100 patients with a mean ± SD age of 56 ± 11.6 years, of whom 75 were women and 48 presented after aneurysm rupture. The mean aneurysm size was (3.5 ± 0.9) × (2.8 ± 0.9) × (3.0 ± 1.0) mm, and the mean packing density was 34.4% ± 16.7%. Posttreatment complete or near-complete occlusion reported by an independent imaging core laboratory was seen in 92% of patients at baseline and in 87%, 87%, and 83% of patients at first, second, and final follow-up, respectively. At first, second, and final follow-up, 10%, 11%, and 15%, respectively, of patients were deemed to require retreatment. There were three procedural-related ischemic strokes and one intracranial hemorrhage from wire perforation of a parent artery not involved by the aneurysm. There were no coil-related adverse events, including no intraoperative aneurysm ruptures and no known aneurysm ruptures after coiling. CONCLUSIONS This assessment of aneurysm occlusion rates and safety profiles in ULTRA Registry study participants demonstrates excellent safety and efficacy profiles for Target Ultra and Nano coils in the treatment of small IAs.
Collapse
Affiliation(s)
- Gaurav Jindal
- 1Department of Radiology, Division of Interventional Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland
| | - Ranyah Almardawi
- 1Department of Radiology, Division of Interventional Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland
| | - Rishi Gupta
- 2Department of Neurosurgery, Wellstar Health System, Marietta, Georgia
| | - Geoffrey P Colby
- 3Department of Neurosurgery, University of California, Los Angeles, California
| | - Clemens M Schirmer
- 4Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania
| | - Sudhakar R Satti
- 5Department of Neurointerventional Surgery, Christiana Care Medical Center, Newark, Delaware
| | - Bryan Pukenas
- 6Department of Radiology, Division of Interventional Neuroradiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ferdinand K Hui
- 7Department of Radiology, Division of Interventional Neuroradiology, and
| | - Justin Caplan
- 8Department of Neurosurgery, Johns Hopkins Hospital, Baltimore
| | - Timothy Miller
- 1Department of Radiology, Division of Interventional Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland
| | - Jacob Cherian
- 9Department of Neurosurgery, University of Maryland Medical Center, Baltimore; and
| | - Francois Aldrich
- 9Department of Neurosurgery, University of Maryland Medical Center, Baltimore; and
| | - Gulam Kibria
- 10Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - J Marc Simard
- 9Department of Neurosurgery, University of Maryland Medical Center, Baltimore; and
| | | |
Collapse
|
5
|
Lv N, Ma H, Zhou Y, Li Z, Zeng Y, Li Q, Zhao R, Fang Y, Yang P, Huang Q, Hong B, Xu Y, Lin Z, Liu J. Coiling followed by staged flow diversion for large and giant intracranial aneurysms. Front Neurol 2022; 13:1024447. [DOI: 10.3389/fneur.2022.1024447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022] Open
Abstract
ObjectiveDelayed aneurysm rupture is a fatal complication after flow diversion treatment for large and giant intracranial aneurysms. This study aimed to investigate the feasibility and safety of coiling first and followed by planned flow diversion to prevent delayed aneurysm rupture.MethodsFrom January 2017 to December 2021 in two institutions, patients with unruptured intracranial aneurysms treated by coiling first and planned flow diversion were retrospectively collected. Data on demographic and aneurysmal characteristics, procedural details, and clinical and angiographic outcomes were reviewed.ResultsThirty patients were included (7 Males and 23 Females; Median age 57 years). Aneurysmal size ranged from 11.8 to 26.8 mm, with a median value of 18.5 mm. All aneurysms were located within the intradural segment of internal carotid arteries. Coiling and planned flow diversion were successfully performed in all patients. The time interval between coiling and flow diversion was 3.9–6.7 weeks, with a median value of 5.2 weeks. No hemorrhagic or ischemic complications occurred during the procedures and follow-up. Complete or subtotal occlusion was achieved in 86.7% (26/30) at the last angiographic follow-up (median 6.7 months).ConclusionThe preliminary data suggested that coiling unruptured intracranial aneurysms followed by planned flow diversion is both safe and effective. Further studies with larger cohorts are needed to verify the effect of this new strategy in preventing delayed rupture after flow diversion.
Collapse
|
6
|
Khanna O, Al Saiegh F, Mouchtouris N, Sajja K, Baldassari MP, El Naamani K, Tjoumakaris S, Gooch MR, Rosenwasser RH, Starke RM, Jabbour PM. Coil Embolization with Subsequent Subacute Flow Diversion Before Hospital Discharge as a Treatment Paradigm for Ruptured Aneurysms. World Neurosurg 2022; 167:e583-e589. [PMID: 35987457 DOI: 10.1016/j.wneu.2022.08.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Subtotal coil embolization followed by subsequent flow diversion is often pursued for treatment of acutely ruptured aneurysms. Owing to the need for anti-platelet therapy, the optimal time of safely pursuing flow diversion treatment has not been fully elucidated. In this study, we aim to demonstrate the safety and feasibility of staged treatment of acutely ruptured aneurysms with early coil embolization followed by flow diversion prior to discharge. METHODS A retrospective study to evaluate clinical outcomes of patients who presented with aneurysmal subarachnoid hemorrhage and underwent coil embolization followed by subacute flow diversion treatment during the same hospitalization. RESULTS A total of 18 patients are included in our case series. Eight patients presented with Hunt-Hess (H-H) grade 2 bleed, 6 patients with H-H grade 3, and 2 patients each with H-H grade 4 and H-H grade 1. Eight patients required placement of an external ventricular drain on admission. After initial coil embolization, 12 achieved Raymond-Roy grade 2 occlusion, and 6 attained grade 3a/b occlusion. The mean duration between coil embolization and subsequent flow diversion was 9.83 days (range: 1-30). There were no instances of re-hemorrhage between initial coil embolization and subsequent flow diversion treatment. Sixteen patients had a minimum of 6-month follow-up, of which 15 were found to have complete occlusion, and 1 required subsequent clipping. CONCLUSIONS Subtotal coil embolization followed by definitive treatment using flow diversion during the same hospitalization is feasible and achieves excellent aneurysm occlusion rates while avoiding dual anti-platelet therapy during the initial hemorrhage period.
Collapse
Affiliation(s)
- Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kalyan Sajja
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael P Baldassari
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
7
|
Mascitelli JR, Lawton MT, Hendricks BK, Hardigan TA, Yoon JS, Yaeger KA, Kellner CP, De Leacy RA, Fifi JT, Bederson JB, Albuquerque FC, Ducruet AF, Birnbaum LA, Caron JLR, Rodriguez P, Mocco J. Endovascular Therapy Versus Microsurgical Clipping of Ruptured Wide Neck Aneurysms (EVERRUN Registry): a multicenter, prospective propensity score analysis. J Neurosurg 2022; 137:87-94. [PMID: 34740187 DOI: 10.3171/2021.7.jns211323] [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: 05/25/2021] [Accepted: 07/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Randomized controlled trials have demonstrated the superiority of endovascular therapy (EVT) compared to microsurgery (MS) for ruptured aneurysms suitable for treatment or when therapy is broadly offered to all presenting aneurysms; however, wide neck aneurysms (WNAs) are a challenging subset that require more advanced techniques and warrant further investigation. Herein, the authors sought to investigate a prospective, multicenter WNA registry using rigorous outcome assessments and compare EVT and MS using propensity score analysis (PSA). METHODS Untreated, ruptured, saccular WNAs were included in the analysis. A WNA was defined as having a neck ≥ 4 mm or a dome/neck ratio (DNR) < 2. The primary outcome was the modified Rankin Scale (mRS) score at 1 year posttreatment, as assessed by blinded research nurses (good outcome: mRS scores 0-2) and compared using PSA. RESULTS The analysis included 87 ruptured aneurysms: 55 in the EVT cohort and 32 in the MS cohort. Demographics were similar in the two cohorts, including Hunt and Hess grade (p = 0.144) and modified Fisher grade (p = 0.475). WNA type inclusion criteria were similar in the two cohorts, with the most common type having a DNR < 2 (EVT 60.0% vs MS 62.5%). More anterior communicating artery aneurysms (27.3% vs 18.8%) and posterior circulation aneurysms (18.2% vs 0.0%) were treated with EVT, whereas more middle cerebral artery aneurysms were treated with MS (34.4% vs 18.2%, p = 0.025). Within the EVT cohort, 43.6% underwent stand-alone coiling, 50.9% balloon-assisted coiling, 3.6% stent-assisted coiling, and 1.8% flow diversion. The 1-year mRS score was assessed in 81 patients (93.1%), and the primary outcome demonstrated no increased risk for a poor outcome with MS compared to EVT (OR 0.43, 95% CI 0.13-1.45, p = 0.177). The durability of MS was higher, as evidenced by retreatment rates of 12.7% and 0% for EVT and MS, respectively (p = 0.04). CONCLUSIONS EVT and MS had similar clinical outcomes at 1 year following ruptured WNA treatment. Because of their challenging anatomy, WNAs may represent a population in which EVT's previously demonstrated superiority for ruptured aneurysm treatment is less relevant. Further investigation into the treatment of ruptured WNAs is warranted.
Collapse
Affiliation(s)
- Justin R Mascitelli
- 1Department of Neurosurgery, University of Texas Health Science Center at San Antonio, Texas
| | - Michael T Lawton
- 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Trevor A Hardigan
- 3Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Health System, New York, New York; and
| | - James S Yoon
- 4Yale School of Medicine, New Haven, Connecticut
| | - Kurt A Yaeger
- 3Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Health System, New York, New York; and
| | - Christopher P Kellner
- 3Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Health System, New York, New York; and
| | - Reade A De Leacy
- 3Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Health System, New York, New York; and
| | - Johanna T Fifi
- 3Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Health System, New York, New York; and
| | - Joshua B Bederson
- 3Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Health System, New York, New York; and
| | | | - Andrew F Ducruet
- 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Lee A Birnbaum
- 1Department of Neurosurgery, University of Texas Health Science Center at San Antonio, Texas
| | - Jean Louis R Caron
- 1Department of Neurosurgery, University of Texas Health Science Center at San Antonio, Texas
| | - Pavel Rodriguez
- 1Department of Neurosurgery, University of Texas Health Science Center at San Antonio, Texas
| | - J Mocco
- 3Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Health System, New York, New York; and
| |
Collapse
|
8
|
Zhong W, Kuang H, Zhang P, Yang X, Luo B, Maimaitili A, Zhao Y, Song D, Guan S, Zhang H, Wang Y, Wang D, Su W, Wang Y. Pipeline Embolization Device for the Treatment of Ruptured Intracerebral Aneurysms: A Multicenter Retrospective Study. Front Neurol 2021; 12:675917. [PMID: 34603179 PMCID: PMC8481592 DOI: 10.3389/fneur.2021.675917] [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: 03/04/2021] [Accepted: 07/19/2021] [Indexed: 12/03/2022] Open
Abstract
Background and Purpose: The utilization of flow diversion for ruptured intracerebral aneurysms (IAs) is still limited. We aimed to demonstrate our multicenter experience using the pipeline embolization device (PED) for ruptured IAs that were difficult to treat by clipping and coiling. Methods: Thirty-eight patients with ruptured IAs who underwent PED treatment from 2015 to 2020 were retrospectively reviewed. Factors associated with procedure-related stroke (ischemic and hemorrhagic) and clinical and angiography outcomes were analyzed. Results: There were 14 (36.8%) saccular IAs, 12 (31.6%) blister-like IAs, and 12 (31.6%) dissecting IAs. Perforator involvement was noted in 10 (26.3%) IAs. Early PED placement ( ≤ 15 days) and adjunctive coiling treatment were performed in 27 (71.1%) and 22 (57.9%) cases, respectively. The overall rate of stroke-related complications was 31.6% (12/38) (including rates of 10.5% for procedure-related hemorrhagic complications and 15.8% for procedure-related infarction). The mortality rate was 13.2% (5/38), and 84.2% of patients (32/38) had favorable outcomes. Thirty-two (84.2%) patients underwent follow-up angiographic evaluations; of these, 84.4% (27 patients) had complete occlusion and 15.6% had incomplete obliteration. Multivariate analysis revealed that early PED placement was not associated with a high risk of procedure-related stroke or an unfavorable outcome. Adjunctive coiling exhibited an association with procedure-related stroke (p = 0.073). Procedure-related hemorrhagic complications were significantly associated with an unfavorable outcome (p = 0.003). Immediate contrast stasis in the venous phase was associated with complete occlusion during follow-up (p = 0.050). Conclusion: The PED is a feasible and effective treatment to prevent rebleeding and achieve aneurysm occlusion, but it is associated with a substantial risk of periprocedural hemorrhage and ischemic complications in acute ruptured IAs. Therefore, the PED should be used selectively for acutely ruptured IAs. Additionally, adjunctive coiling might increase procedure-related stroke; however, it may reduce aneurysm rebleeding in acutely ruptured IAs. Patients with immediate contrast stasis in the venous phase were more likely to achieve total occlusion. A prospective study with a larger sample size should be performed to verify our results.
Collapse
Affiliation(s)
- Weiying Zhong
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Hong Kuang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Department of Neurosurgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ping Zhang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Xinjian Yang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bin Luo
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongqi Zhang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Donghai Wang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Wandong Su
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Yunyan Wang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| |
Collapse
|
9
|
Alpay K, Hinkka T, Lindgren AE, Isokangas JM, Raj R, Parkkola R, Sinisalo M, Numminen J, Pienimäki JP, Saari P, Seppänen J, Palosaari K, Rautio R. Finnish flow diverter study: 8 years of experience in the treatment of acutely ruptured intracranial aneurysms. J Neurointerv Surg 2021; 14:699-703. [PMID: 34266906 PMCID: PMC9209683 DOI: 10.1136/neurintsurg-2021-017641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/01/2021] [Indexed: 11/30/2022]
Abstract
Background Flow diversion of acutely ruptured intracranial aneurysms (IAs) is controversial due to high treatment-related complication rates and a lack of supporting evidence. We present clinical and radiological results of the largest series to date. Methods This is a nationwide retrospective study of acutely ruptured IAs treated with flow diverters (FDs). The primary outcome was the modified Rankin Scale (mRS) score at the last available follow-up time. Secondary outcomes were treatment-related complications and the aneurysm occlusion rate. Results 110 patients (64 females; mean age 55.7 years; range 12–82 years) with acutely ruptured IAs were treated with FDs between 2012 and 2020 in five centers. 70 acutely ruptured IAs (64%) were located in anterior circulation, and 47 acutely ruptured IAs (43%) were blister-like. A favorable functional outcome (mRS 0–2) was seen in 73% of patients (74/102). Treatment-related complications were seen in 45% of patients (n=49). Rebleeding was observed in 3 patients (3%). The data from radiological follow-ups were available for 80% of patients (n=88), and complete occlusion was seen in 90% of aneurysms (79/88). The data from clinical follow-ups were available for 93% of patients (n=102). The overall mortality rate was 18% (18/102). Conclusions FD treatment yields high occlusion for acutely ruptured IAs but is associated with a high risk of complications. Considering the high mortality rate of aneurysmal subarachnoid hemorrhage, the prevention of rebleeding is crucial. Thus, FD treatment may be justified as a last resort option.
Collapse
Affiliation(s)
- Kemal Alpay
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Tero Hinkka
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Antti E Lindgren
- Neurosurgery, Kuopio University Hospital, Kuopio, Pohjois-Savo, Finland.,Department of Clinical Radiology, Kuopio University Hospital, Kuopip, Finland.,University of Eastern Finland, Institute of Clinical Medicine, Kuopio, Finland
| | | | - Rahul Raj
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Uusimaa, Finland
| | - Riitta Parkkola
- Department of Radiology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Matias Sinisalo
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Jussi Numminen
- Helsinki University Central Hospital, Helsinki, Uusimaa, Finland
| | | | - Petri Saari
- Kuopio University Hospital, Kuopio, Pohjois-Savo, Finland
| | - Janne Seppänen
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | | | - Riitta Rautio
- Department of Radiology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| |
Collapse
|
10
|
Limbucci N, Leone G, Renieri L, Nappini S, Cagnazzo F, Laiso A, Muto M, Mangiafico S. Expanding Indications for Flow Diverters: Distal Aneurysms, Bifurcation Aneurysms, Small Aneurysms, Previously Coiled Aneurysms and Clipped Aneurysms, and Carotid Cavernous Fistulas. Neurosurgery 2020; 86:S85-S94. [PMID: 31838532 PMCID: PMC6911737 DOI: 10.1093/neuros/nyz334] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 06/06/2019] [Indexed: 11/23/2022] Open
Abstract
Flow diverter devices have gained wide acceptance for the treatment of unruptured intracranial aneurysms. Most studies are based on the treatment of large aneurysms harboring on the carotid syphon. However, during the last years the “off-label” use of these stents has widely grown up even if not supported by randomized studies. This review examines the relevant literature concerning “off-label” indications for flow diverter devices, such as for distal aneurysms, bifurcation aneurysms, small aneurysms, recurrent aneurysms, and direct carotid cavernous fistulas.
Collapse
Affiliation(s)
- Nicola Limbucci
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Giuseppe Leone
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy.,Department of Neuroradiology, Cardarelli Hospital, Naples, Italy
| | - Leonardo Renieri
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Sergio Nappini
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Federico Cagnazzo
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Antonio Laiso
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Mario Muto
- Department of Neuroradiology, Cardarelli Hospital, Naples, Italy
| | | |
Collapse
|
11
|
Ospel JM, Brouwer P, Dorn F, Arthur A, Jensen ME, Nogueira R, Chapot R, Albuquerque F, Majoie C, Jayaraman M, Taylor A, Liu J, Fiehler J, Sakai N, Orlov K, Kallmes D, Fraser JF, Thibault L, Goyal M. Antiplatelet Management for Stent-Assisted Coiling and Flow Diversion of Ruptured Intracranial Aneurysms: A DELPHI Consensus Statement. AJNR Am J Neuroradiol 2020; 41:1856-1862. [PMID: 32943417 DOI: 10.3174/ajnr.a6814] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/30/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE There is a paucity of data regarding antiplatelet management strategies in the setting of stent-assisted coiling/flow diversion for ruptured intracranial aneurysms. This study aimed to identify current challenges in antiplatelet management during stent-assisted coiling/flow diversion for ruptured intracranial aneurysms and to outline possible antiplatelet management strategies. MATERIALS AND METHODS The modified DELPHI approach with an on-line questionnaire was sent in several iterations to an international, multidisciplinary panel of 15 neurointerventionalists. The first round consisted of open-ended questions, followed by closed-ended questions in the subsequent rounds. Responses were analyzed in an anonymous fashion and summarized in the final manuscript draft. The statement received endorsement from the World Federation of Interventional and Therapeutic Neuroradiology, the Japanese Society for Neuroendovascular Therapy, and the Chinese Neurosurgical Society. RESULTS Data were collected from December 9, 2019, to March 13, 2020. Panel members achieved consensus that platelet function testing may not be necessary and that antiplatelet management for stent-assisted coiling and flow diversion of ruptured intracranial aneurysms can follow the same principles. Preprocedural placement of a ventricular drain was thought to be beneficial in cases with a high risk of hydrocephalus. A periprocedural dual, intravenous, antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor was preferred as a standard approach. The panel agreed that intravenous medication can be converted to oral aspirin and an oral P2Y12 inhibitor within 24 hours after the procedure. CONCLUSIONS More and better data on antiplatelet management of patients with ruptured intracranial aneurysms undergoing stent-assisted coiling or flow diversion are urgently needed. Panel members in this DELPHI consensus study preferred a periprocedural dual-antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor.
Collapse
Affiliation(s)
- J M Ospel
- Department of Clinical Neurosciences (J.M.O., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Radiology (J.M.O.), University Hospital of Basel, Basel, Switzerland
| | - P Brouwer
- Department of Interventional Neuroradiology (P.B.), Karolinksa Hospital, Stockholm, Sweden
- University NeuroVascular Center (P.B.), Leiden University Medical Center, Haaglanden Medical Center, Leiden, the Netherlands
| | - F Dorn
- Institute of Neuroradiology (F.D.), University of Bonn, Bonn, Germany
| | - A Arthur
- Department of Neurosurgery (A.A.), Semmes-Murphey Clinic/University of Tennessee, Memphis, Tennessee
| | - M E Jensen
- Departments of Neurological Surgery, Radiology, and Medical Imaging (M.E.J.), University of Virginia Health, Charlottesville, Virginia
| | - R Nogueira
- Marcus Stroke & Neuroscience Center (R.N.), Grady Health System, Atlanta, Georgia
- Department of Neurology (R.N.), Emory University School of Medicine, Atlanta, Georgia
| | - R Chapot
- Department of Neuroradiology (R.C.), Alfred Krupp Krankenhaus Essen, Essen, Germany
| | - F Albuquerque
- Department of Neurosurgery (F.A.), Barrow Neurological Institute, Phoenix, Arizona
| | - C Majoie
- Department of Radiology (C.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - M Jayaraman
- Departments of Diagnostic Imaging, Neurology, and Neurosurgery (M.J.), Warren Alpert School of Medicine at Brown University, Providence, Rhode Island
| | - A Taylor
- Groote Schuur Hospital (A.T.), University of Cape Town, Cape Town, South Africa
| | - J Liu
- Department of Neurosurgery (J.L.), Changhai Hospital Naval Medical University, Shanghai, China
| | - J Fiehler
- Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - N Sakai
- Department of Neurosurgery (N.S.), Kobe City Medical Center General Hospital, Kobe, Japan
| | - K Orlov
- Meshalkin National Medical Research Center (K.O.), Novosibirsk, Russian Federation
| | - D Kallmes
- Department of Radiology (D.K.), Mayo Clinic, Rochester, Minnesota
| | - J F Fraser
- Departments of Neurosurgery, Neurology, Radiology, and Neuroscience (J.F.F.), University of Kentucky, Lexington, Kentucky
| | - L Thibault
- Member of the Scientific Committee of the World Federation of Interventional and Therapeutic Neuroradiology (L.T.)
| | - M Goyal
- Department of Clinical Neurosciences (J.M.O., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Diagnostic Imaging (M.G.), University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
12
|
Howard BM, Hu R, Barrow JW, Barrow DL. Comprehensive review of imaging of intracranial aneurysms and angiographically negative subarachnoid hemorrhage. Neurosurg Focus 2020; 47:E20. [PMID: 31786554 DOI: 10.3171/2019.9.focus19653] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/20/2019] [Indexed: 11/06/2022]
Abstract
Intracranial aneurysms confer the risk of subarachnoid hemorrhage (SAH), a potentially devastating condition, though most aneurysms will remain asymptomatic for the lifetime of the patient. Imaging is critical to all stages of patient care for those who harbor an unruptured intracranial aneurysm (UIA), including to establish the diagnosis, to determine therapeutic options, to undertake surveillance in patients who elect not to undergo treatment or whose aneurysm(s) portends such a low risk that treatment is not indicated, and to perform follow-up after treatment. Neuroimaging is equally as important in patients who suffer an SAH. DSA remains the reference standard for imaging of intracranial aneurysms due to its high spatial and temporal resolution. As noninvasive imaging technology, such as CTA and MRA, improves, the diagnostic accuracy of such tests continues to increasingly approximate that of DSA. In cases of angiographically negative SAH, imaging protocols are necessary not only for diagnosis but also to search for an initially occult vascular lesion, such as a thrombosed, ruptured aneurysm that might be detected in a delayed fashion. Given the crucial role of neuroimaging in all aspects of care for patients with UIAs and SAH, it is incumbent on those who care for these patients, including cerebrovascular neurosurgeons, interventional neurologists and neuroradiologists, and diagnostic radiologists and neurointensivists, to understand the role of imaging in this disease and how individual members of the multispecialty team use imaging to ensure best practices to deliver cutting-edge care to these often complex cases. This review expounds on the role of imaging in the management of UIAs and ruptured intracranial aneurysms and in the workup of angiographically negative subarachnoid hemorrhage.
Collapse
Affiliation(s)
- Brian M Howard
- 1Department of Neurosurgery, and.,2Department of Radiology and Imaging Sciences, Division of Interventional Neuroradiology, Emory University School of Medicine, Atlanta; and
| | - Ranliang Hu
- 2Department of Radiology and Imaging Sciences, Division of Interventional Neuroradiology, Emory University School of Medicine, Atlanta; and
| | - Jack W Barrow
- 3Mercer University School of Medicine, Savannah, Georgia
| | | |
Collapse
|
13
|
Schob S, Hoffmann KT, Richter C, Bhogal P, Köhlert K, Planitzer U, Ziganshyna S, Lindner D, Scherlach C, Nestler U, Meixensberger J, Quäschling U. Flow diversion beyond the circle of Willis: endovascular aneurysm treatment in peripheral cerebral arteries employing a novel low-profile flow diverting stent. J Neurointerv Surg 2019; 11:1227-1234. [PMID: 31088939 PMCID: PMC6902074 DOI: 10.1136/neurintsurg-2019-014840] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/02/2019] [Accepted: 04/08/2019] [Indexed: 11/05/2022]
Abstract
Background Flow diversion (FD) has emerged as superior minimally invasive therapy for cerebral aneurysms. However, aneurysms of small peripheral vessel segments have not yet been adequately treatable. More specifically, currently established devices necessitate large microcatheters which impede atraumatic maneuvering. The Silk Vista Baby (SVB), a novel flow diverter, offers the as yet unique feature of deliverability via a 0.017 inch microcatheter. This study reports our first experience with the SVB in challenging intracranial vessels employing a vessel-specific tailored microcatheter strategy. Materials and methods 25 patients (27 aneurysms) were prospectively included. A total of 30 SVBs were employed, predominantly targeting demanding aneurysms of the anterior communicating artery complex. The efficacy of the FD was assessed using two-dimensional vector-based perfusion and conventional digital subtraction angiography (DSA) after implantation and at the first follow-up at 3 months. The first follow-up was available in 22 patients. Results All devices were implanted without technical or clinical complications. Eleven treatments were performed using the recommended Headway 17. In 14 interventions the even more maneuverable Excelsior SL10 was used, which was previously tried and tested for safety ’in vitro’ as an alternative delivery system. Aneurysmal influx was strongly reduced after implantation. All parent vessels remained patent. 17/27 aneurysms were completely occluded at first follow-up (∼2.7 months), 6/27 aneurysms showed decreased influx or delayed washout and one remained unchanged. In three cases follow-up DSAs are remaining. Conclusions SVB provides enhanced controllability in vulnerable segments beyond the circle of Willis. Smaller variants (2.25 mm and 2.75 mm) can safely be implanted via the superiorly navigable Excelsior SL10. Hence, the SVB represents the next evolutionary step in minimally invasive treatment of cerebral aneurysms.
Collapse
Affiliation(s)
- Stefan Schob
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Karl-Titus Hoffmann
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Cindy Richter
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London Hospital, London, UK
| | - Katharina Köhlert
- Department for Neurosurgery, University Hospital Leipzig, Leipzig, Saxony, Germany
| | - Uwe Planitzer
- Department for Neurosurgery, University Hospital Leipzig, Leipzig, Saxony, Germany
| | - Svitlana Ziganshyna
- Department for Anesthesiology, University Hospital Leipzig, Leipzig, Germany
| | - Dirk Lindner
- Department for Neurosurgery, University Hospital Leipzig, Leipzig, Saxony, Germany
| | - Cordula Scherlach
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Ulf Nestler
- Department for Neurosurgery, University Hospital Leipzig, Leipzig, Saxony, Germany
| | - Jürgen Meixensberger
- Department for Neurosurgery, University Hospital Leipzig, Leipzig, Saxony, Germany
| | - Ulf Quäschling
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| |
Collapse
|
14
|
Albuquerque FC. Happy New Year. J Neurointerv Surg 2018; 11:1-2. [PMID: 30559324 DOI: 10.1136/neurintsurg-2018-014616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2018] [Indexed: 11/03/2022]
|