Endovascular Reconstruction of Intracranial Aneurysms with the Pipeline Embolization Device in Pediatric Patients: A Single-Center Series

Pipeline embolization in patients with hemoglobinopathies: A cohort study

IntroductionFlow diversion with the pipeline embolization device (PED) is an effective endovascular treatment. However, the metal surface's thrombogenicity and need for dual antiplatelet therapy (DAPT) are notable limitations. Few prior studies have reported specifically on flow diverters' safety in patients with hemoglobinopathies, a population at increased risk of thrombotic and hemorrhagic complications.MethodsNatural language processing queried our institution's medical records for intracranial embolization procedures from 2014 to 2024, screening for "hemoglobinopathy," "thalassemia," and "sickle cell." Patient charts were retrospectively reviewed.ResultsSixteen procedures in 14 patients were identified in which a mean 2.0 PEDs per patient were used. Most patients were female (71.4%). Median age was 48.8 years. Five patients had sickle cell disease, two had sickle cell trait, two had sickle cell or hemoglobin C trait and alpha thalassemia minor, and five had alpha thalassemia minor. The 14 patients were treated for 20 aneurysms; four treatments covered two distinct aneurysms. Median dome size per treatment was 4.0 mm. Of the 16 aneurysm treatments, five (31.2%) treated an irregular aneurysm. Most (56.2%) treatments used multiple PEDs. All patients were discharged on DAPT after verifying effect with P2Y12 assays. Follow-up DSA, CTA, or MRA was obtained in 12/14 (85.7%) patients at a median 1.6 years. Complete occlusion was achieved in all aneurysms. Clinical follow-up was obtained in all patients at a median 2.2 years. There were no thromboembolic or hemorrhagic complications, neurological deficits, or mortalities.ConclusionPipeline embolization can safely and effectively treat patients with hemoglobinopathies.

The Pipeline embolization device for the treatment of intracranial aneurysms in pediatric patients with tuberous sclerosis complex: illustrative cases

BACKGROUND

Tuberous sclerosis complex (TSC) is a neurocutaneous disorder characterized by the multisystem development of benign tumors. Patients with TSC are also at an increased risk of developing intracranial aneurysms early in life. While aneurysms have historically been treated with open surgical clipping, endovascular approaches are increasingly being used in both pediatric and adult populations.

OBSERVATIONS

In this case series, the authors report the endovascular treatment of three young patients with TSC and fusiform intracranial aneurysms using the Pipeline embolization device (PED) for flow diversion of the affected artery. In all cases, complete aneurysm occlusion was observed, with good parent artery wall reconstruction and no parent artery stenosis or occlusion. All flow diverter stents were deployed successfully, and there were no device-related complications. All patients were maintained on dual antiplatelet therapy.

LESSONS

The PED can serve as a safe and effective endovascular alternative to open surgery for the treatment of intracranial aneurysms in young patients with TSC. This could avoid an additional craniotomy in a population already likely to require surgical intervention for TSC-related tumors or epilepsy. Further studies investigating the use of the PED in the pediatric population must be undertaken to validate its long-term efficacy. https://thejns.org/doi/10.3171/CASE24452.

Giant dissecting aneurysm of basilar artery in a child - treated by flow reversal: A case report

Although intracranial aneurysms are rare in the paediatric population, the proportion of those involving posterior circulation is higher than that of adults (approximately 25% vs. 8%, respectively). Moreover, posterior circulation aneurysms in kids tend to be larger in size, many of them being giant dissecting types, and treatment of them is often challenging. Treatment of giant dissecting aneurysms, especially involving the Basilar artery is difficult due to strategic location and haemodynamic factors. Use of reconstructive techniques viz. flow-diverters and braided stents is difficult in children because of the lack of standard protocol for use of antiplatelet therapy and the need for prolonged use of the same. Continuous growth of parent vessel is also suggested as a pitfall for the use of a flow diverter/ braided stent which has a fixed caliber. Carefully planned endovascular parent or feeder branch artery occlusion (FAO) is a time-tested method to achieve flow reversal or favourable flow modifications in an arterial segment harbouring dissecting aneurysm. Here, in this case report, we describe a case of a ruptured distal giant basilar artery dissecting aneurysm in a 10-year-old boy treated with flow diversion by FAO. The dominant left vertebral artery was occluded, thereby diverting flow from the right vertebral artery towards the left posterior inferior cerebellar artery and decreasing flow through the aneurysm. On 1-year follow-up, the patient was asymptomatic and on check angiography, there was complete involution of the aneurysm with increased flow through bilateral posterior communicating arteries to distal posterior circulation which proved our hypothesis correct.

Risk factors for repeated recurrence of cerebral aneurysms treated with endovascular embolization

Purpose

To explore the risk factors of recurrence after second endovascular embolization of recurrent aneurysms and the characteristics of recurrent refractory aneurysms to help clinical decision-making.

Materials and methods

Forty-nine patients with recurrent aneurysms who underwent repeated embolization were retrospectively enrolled and divided into the recurrent and non-recurrent group. The risk factors of recurrence, complications and follow-up results of repeated embolization, and characteristics of recurrent refractory aneurysms were analyzed.

Results

Among the 49 patients with the second embolization, 5 were lost to follow-up, 9 recurred, and 35 did not. Univariate analysis showed that aneurysm size (P = 0.022), aneurysm classification (P = 0.014), and Raymond-Roy grade after the second embolization (P = 0.001) were statistically different between the two groups. Multivariate analysis demonstrated the Raymond-Roy grade as an independent risk factor for the recurrence of aneurysms after the second embolization (P = 0.042). The complication rate after the second embolization was 4%. There were five recurrent refractory aneurysms with an average aneurysm size of 23.17 ± 10.45 mm, including three giant aneurysms and two large aneurysms. To achieve complete or near-complete embolization of the recurrent refractory aneurysms, multiple treatment approaches were needed with multiple stents or flow diverting devices.

Conclusion

Aneurysm occlusion status after the second embolization is an independent risk factor for the recurrence of intracranial aneurysms. Compared with near-complete occlusion, complete occlusion can significantly reduce the risk of recurrence after second embolization. In order to achieve complete or near-complete occlusion, recurrent refractory aneurysms need multiple treatments with the use of multiple stents or flow diverting devices.

Therapeutic dilemmas regarding giant aneurysms of the intracranial vertebral artery causing medulla oblongata compression

BACKGROUND

Giant aneurysms of the intracranial vertebral artery are very rare cerebrovascular lesions. Due to the rarity of these aneurysms, we know little about them.

METHODS

We performed a systematic review of the English literature by searching the PubMed database. The inclusion criteria were as follows: (a) the full text was available and (b) complete clinical data were available.

RESULTS

A total of 45 articles were identified, containing 53 patients (53 aneurysms). The patients were aged from 5 to 77 years (48.8 ± 20.8 years). Four patients receiving conservative treatment died. The remaining 49 patients were divided into the aneurysm removal group (n = 17) and the aneurysm reserve group (n = 32). The outcomes of the 49 treated cases could be obtained in 45 cases, 31 of which (68.9%, 31/45) had a Glasgow outcome scale score of 4-5.

CONCLUSIONS

It is still difficult to treat intracranial giant vertebral artery aneurysms, regardless of the treatment selected. Because of the malignant natural history, aggressive treatment is still advocated.

Pipeline embolization of cerebral aneurysms in pediatric patients: combined systematic review of patient-level data and multicenter retrospective review

OBJECTIVE

Cerebral aneurysms in the pediatric population are rare and optimal treatment strategies are not as well characterized as in adults. The Pipeline embolization device (PED) is an endoluminal flow diverter that is commonly used to treat aneurysms in adults, but experience with this device in children is limited. The authors sought to further characterize PED use and outcomes in this specific population by performing both a systematic review of patient-level data from studies reporting the use of the PED to treat pediatric aneurysms and a retrospective review of their experience.

METHODS

A systematic review of the PubMed, Embase, and Scopus databases was performed to identify studies reporting the use of the PED in pediatric patients (age ≤ 18 years). Disaggregated data regarding demographics, aneurysm characteristics, treatment, and outcomes were collected. Retrospective data from the authors' two institutions were also included.

RESULTS

Thirty studies comprising patient-level data on 43 pediatric patients with 47 aneurysms were identified. An additional 9 patients with 9 aneurysms were included from the authors' institutions for a total of 52 patients with 56 aneurysms. The mean patient age was 11.1 years. Presentations included aneurysm rupture (17.3%) and symptomatic mass effect (23.1%). Aneurysms were located in the anterior circulation in 55.4% of cases, and 73.2% were described as nonsaccular. Imaging follow-up was available for 89.3% with a mean follow-up of 13.3 months. Aneurysm occlusion was reported in 75%, with 1 case each (1.8%) demonstrating significant in-stent stenosis and parent vessel occlusion. Clinical follow-up was reported in 90.4% with a mean follow-up of 14.7 months. Good functional outcomes (modified Rankin Scale score of 0-1 or Glasgow Outcome Scale score of 5) were reported in 65.4% of the total population. Two major complications were reported, including 1 death.

CONCLUSIONS

Despite substantial differences in aneurysm location and type between published pediatric and adult patient populations treated with the PED, the use of the PED in the pediatric population appears to be safe. While the short-term effectiveness is also similar to that of adults, additional studies are needed to further characterize the long-term outcomes and better define the use of this device in pediatric patients.

Analyzing the Safety and Efficacy of Flow-Diverting Stents in Pediatric Aneurysms: A Systematic Review

Ruptured intracranial aneurysms cause 50% of spontaneous subarachnoid hemorrhages in children, resulting in up to 65% mortality when left untreated. Although flow-diverting stents are especially suited to treat the fusiform and giant aneurysms more commonly found in children, the US Food and Drug Administration (FDA) has only approved their use in patients ≥22 years of age. Our objective was to assess the safety of flow-diverting stents in the treatment of pediatric patients with aneurysms through a systematic literature review using the PRISMA criteria. We used PubMed, Embase, and Web of Science to identify all published cases of pediatric aneurysms treated or retreated using flow-diverting stents from 2007 through 2019. Two independent researchers developed a consensus regarding the inclusion of all articles. Patient data were extracted from the identified articles and used to calculate the incidence rate of complications. From 1396 journal articles identified, 24 articles contained data on 37 pediatric patients that met the inclusion criteria. Of these 37 patients, 8 (21.6%) had a complication by last follow-up (death: 2; residual aneurysm: 2; parent artery occlusion: 4). This resulted in an incidence rate of 0.018 complications per patient at-risk month (95% CI 0.008-0.035). These data suggest that the use of flow-diverting stents for treatment of aneurysms in children may be safe and that FDA approval for this use should be evaluated. Although this analysis is comprised of case reports and case series, it represents the best attempt thus far to quantify the risk of using flow-diverting stents in children.

A history of the path towards imaging of the brain: From skull radiography through cerebral angiography

This publication reviews the steps in the path towards obtaining a complete image of the brain. Up to the 1920s, plain X-ray films could demonstrate only calcified tumors, shifts in midline position of a calcified pineal gland due to a mass in the cranium, or foreign metallic objects within the skull. Walter Dandy reported in 1918 that he visualized cerebral ventricles by introducing air as a contrast agent through a trocar into one of the occipital lobes or the right frontal horn of the ventricular system. Dandy localized lesions that distorted or shifted the ventricles. In 1920, Dandy placed air by lumbar puncture into the spinal subarachnoid space that could visualize the brain and entire ventricles. Antonio Egas Moniz with the assistance of his neurosurgeon colleague, Almeida Lima, obtained X-ray images of cerebral arteries of dogs and decapitated human heads from corpses after injecting strontium bromide into their carotid arteries. Satisfied by these experiments, Moniz injected strontium bromide directly into carotid arteries of five patients which failed to show intracranial vessels. In the sixth patient, intracranial arteries were outlined but that patient died of cerebral thrombosis presumably due to the hyper-osmolality of that contrast agent. Finally, on June 18, 1927, Moniz injected 22% sodium iodine into a 20-year-old man and obtained clear visualization of his carotid artery and intracerebral branches after temporarily occluding the artery with a ligature. Direct percutaneous puncture of the cervical carotid artery remained the primary technique unto the 1960s to visualize intracranial blood vessels until Seldinger's technique was introduced in 1953. Computerized axial tomography (CAT) and magnetic resonance imaging (MRI) replaced cerebral arteriography for localizing tumors and epidural or subdural hemorrhage. However, angiography is used currently for embolization of aneurysms and removal of thrombi or emboli in patients with acute stroke.