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Rashidi F, Habibi MA, Reyhani M, Fallahi MS, Arshadi MR, Sabahi M, Vakharia K, Rahimi SY. Pipeline Embolization Device and Flow Re-Direction Endoluminal Device for Intracranial Aneurysms: A Comparative Systematic Review and Meta-Analysis Study. World Neurosurg 2024; 189:399-409.e18. [PMID: 38925243 DOI: 10.1016/j.wneu.2024.06.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND When it comes to intracranial aneurysms, the quest for more effective treatments is ongoing. Flow diversion represents a growing advancement in this field. This review seeks to compare 2 variants of the endovascular flow diversion method: the Flow Re-Direction Endoluminal Device (FRED) and the Pipeline Embolization Device (PED). METHODS A systematic review was conducted according to the PRISMA guideline using PubMed, Scopus, Web of Science, and Embase, using appropriate terms to compare PED and FRED in double-arm studies from conception until October 8th, 2023. RESULTS The meta-analysis encompassed 1769 patients, with a predominance of females (75.5%), among whom 973 patients underwent FRED procedures, while 651 received PED interventions. At 6 months, complete occlusion rates were 0.62 for FRED and 0.68 for PED (P = 0.68). At 1 year and the last follow-up, no significant differences were observed between FRED and PED, respectively. Adequate occlusion rates were similar between FRED and PED (0.82 vs. 0.79, P = 0.68). FRED showed a statistically significant higher rate of good mRS scores at follow-up (1.00 vs. 0.97, P = 0.03). Hemorrhage and re-treatment rates were higher in PED (P < 0.01) without considering the rupture status of the aneurysms due to the lack of data. CONCLUSIONS This meta-analysis suggests comparable efficacy but different safety profiles between FRED and PED in treating intracranial aneurysms. FRED demonstrated a higher rate of good modified Rankin scores, while PED showed increased hemorrhage and re-treatment rates. Understanding these differences is crucial for informed decision-making in clinical practice.
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Affiliation(s)
- Farhang Rashidi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mahsa Reyhani
- School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | | | - Mohammadmahdi Sabahi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Kunal Vakharia
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Scott Y Rahimi
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA.
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Habibi MA, Mirjani MS, Ahmadzadeh AM, Akbari Javar MT, Karami S, Ahmadvand MH. Safety and efficacy of flow redirection endoluminal device (FRED) for treatment of intracranial aneurysm; A systematic review and meta-analysis. Neuroradiol J 2024:19714009241269460. [PMID: 39102710 DOI: 10.1177/19714009241269460] [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: 08/07/2024] Open
Abstract
BACKGROUND Previous research has shown promising results for treating intracranial aneurysms (IAs) with a flow redirection endoluminal device (FRED). In this systematic review and meta-analysis, we aimed to assess the safety and efficacy of this device by providing pooled estimates using the data from previous studies. METHODS A systematic literature search of Web of Sciences, PubMed, Scopus, and Embase was performed until October 8th, 2023. After selecting the final articles, relevant data were extracted. Parameters relating to safety and efficacy were pooled using STATA software. Heterogeneity was assessed using I-squared and Cochran's Q. Funnel plots and Egger's regression methods were used to evaluate publication bias. Sensitivity analysis was also performed using the leave-one-out method. RESULTS The data of 37 studies were used for meta-analysis. The rates of immediate adequate occlusion and complete occlusion were 0.51 (95% CI: 0.31-0.71) and 0.34 (95% CI: 0.16-0.53), respectively, while the rates of the adequate and complete occlusion at the latest follow-up were 0.90 (95% CI: 0.84-0.94) and 0.75 (95% CI: 0.65-0.84), respectively. The periprocedural complications rate was 0.04 (95% CI: 0.03-0.06), and the overall complications rate was 0.12 (95% CI: 0.09-0.15). The rate of good functional outcome was 0.99 (95% CI: 0.99-1.00) and the successful implantation rate was 1.00 (95% CI: 1.00-1.00). There was substantial heterogeneity among the reports for most of the evaluated parameters. CONCLUSION FRED had high safety and efficacy in treating IAs, as evidenced by its high occlusion and low complication rates.
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Affiliation(s)
- Mohammad Amin Habibi
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Amir Mahmoud Ahmadzadeh
- Department of Radiology, School of Medicine, Mashhad University of Medical Sciences, Qom, Iran
| | | | - Shaghayegh Karami
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Morrish RE, Chunta AT, Belanger BL, Croney PM, Salam MSA, Thompson C, Eesa M, Wong JH, Mitha AP. Angiographic Safety and Efficacy of the ReSolv Flow-Diverting Stent in a Rabbit Model. Interv Neuroradiol 2024:15910199241260896. [PMID: 38899902 DOI: 10.1177/15910199241260896] [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: 06/21/2024] Open
Abstract
BACKGROUND Bioresorbable polymer-based flow-diverting stents have potential benefits over existing metal devices. This study aimed to evaluate the safety and efficacy of the novel ReSolv device, which is a primarily polymer-based flow-diverting stent, using the in vivo rabbit sidewall saccular aneurysm model. METHODS ReSolv stents were deployed in 14 New Zealand White rabbits that had undergone aneurysm creation procedures. Animals were allocated to follow-up time points of 1, 3, 6, 9, 12, 16, or 18 months. Angiographic images were evaluated by an independent neurointerventionalist blinded to follow-up time points for (1) in-stent stenosis, (2) parent vessel and jailed side branch patency, (3) wall apposition, and (4) aneurysm occlusion using the Raymond-Roy Occlusion Classification (RROC), O'Kelly Marotta grading scale, and the 4F flow diversion predictive score. Primary efficacy outcome was defined as RROC Class I or II. RESULTS At a median follow-up time of 7.5 months, parent vessel (14/14) and jailed side (33/33) branches were patent in all cases. There was no development of thrombus on the stent or cases of significant in-stent stenosis, and all stents had good wall apposition. Adequate occlusion was found in 85.7% (n = 12) of animals, including an RROC Class I in 64.3% (n = 9) and RROC Class II in 21.4% (n = 3). CONCLUSIONS The ReSolv stent shows encouraging angiographic safety and efficacy outcomes after placement in a rabbit sidewall saccular aneurysm model. Longer term studies are ongoing to determine eventual fate of the aneurysm, parent vessel, and jailed side branches after absorption of the polymer component of the stent.
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Affiliation(s)
- Rosalie Ea Morrish
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Alec T Chunta
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Brooke L Belanger
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Paige M Croney
- Department of Biomedical Engineering, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Muneer Eesa
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - John H Wong
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Fluid Biomed, Calgary, Alberta, Canada
| | - Alim P Mitha
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Biomedical Engineering, University of Calgary, Calgary, Alberta, Canada
- Fluid Biomed, Calgary, Alberta, Canada
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Deshmukh AS, Priola SM, Katsanos AH, Scalia G, Costa Alves A, Srivastava A, Hawkes C. The Management of Intracranial Aneurysms: Current Trends and Future Directions. Neurol Int 2024; 16:74-94. [PMID: 38251053 PMCID: PMC10801587 DOI: 10.3390/neurolint16010005] [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: 10/15/2023] [Revised: 11/14/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024] Open
Abstract
Intracranial aneurysms represent a major global health burden. Rupture of an intracranial aneurysm is a catastrophic event. Without access to treatment, the fatality rate is 50% in the first 30 days. Over the last three decades, treatment approaches for intracranial aneurysms have changed dramatically. There have been improvements in the medical management of aneurysmal subarachnoid haemorrhage, and there has been an evolution of treatment strategies. Endovascular therapy is now the mainstay of the treatment of ruptured intracranial aneurysms based on robust randomised controlled trial data. There is now an expansion of treatment indications for unruptured intracranial aneurysms to prevent rupture with both microsurgical clipping and endovascular treatment. Both microsurgical and endovascular treatment modalities have evolved, in particular with the introduction of innovative endovascular treatment options including flow diversion and intra-saccular flow disruption. These novel therapies allow clinicians to treat more complex and previously untreatable aneurysms. We aim to review the evolution of treatment strategies for intracranial aneurysms over time, and discuss emerging technologies that could further improve treatment safety and functional outcomes for patients with an intracranial aneurysm.
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Affiliation(s)
- Aviraj S. Deshmukh
- Division of Clinical Sciences, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, ON P3E 2C6, Canada;
| | - Stefano M. Priola
- Division of Neurosurgery, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, ON P3E 2C6, Canada;
| | - Aris H. Katsanos
- Division of Neurology, Hamilton General Hospital, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Gianluca Scalia
- Department of Neurosurgery, Highly Specialized Hospital of National Importance “Garibaldi”, 95126 Catania, Italy;
| | - Aderaldo Costa Alves
- Division of Neurosurgery, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, ON P3E 2C6, Canada;
| | - Abhilekh Srivastava
- Division of Neurology, Hamilton General Hospital, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Christine Hawkes
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M5S 1A1, Canada;
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Majtánová N, Kolář P, Krišková P, Kéri P, Balazs T, Cholevík D, Kurilová V. Improvement of Visual Field Defects after Neuroembolization Treatment of Intracranial Aneurysms. Case Reports. CESKA A SLOVENSKA OFTALMOLOGIE : CASOPIS CESKE OFTALMOLOGICKE SPOLECNOSTI A SLOVENSKE OFTALMOLOGICKE SPOLECNOSTI 2024; 80:42-51. [PMID: 38365581 DOI: 10.31348/2024/8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
PURPOSE Intracranial aneurysms and their hemorrhagic and thromboembolic complications represent a serious nosological unit that significantly endangers those afflicted. They are mostly asymptomatic until rupture occurs. In two case reports, we present our observations of young patients with impaired vision and headaches, in whom we found the presence of intracranial aneurysms. OBSERVATIONS Presentation of two case reports of patients who came to our department with impaired vision and headaches. The patients underwent a complete eye examination at our center, including a visual field examination. Based on the results of the examination, they were referred for an imaging examination of the brain, which revealed the presence of intracranial aneurysms. The patients were subsequently sent to the interventional neuroradiology center, where they underwent a noninvasive endovascular neuroembolization procedure with flow diverter implantation. We continued to monitor the patients after the procedure and document the examination results up to 1 year after the procedure. CONCLUSIONS AND SIGNIFICANCE Thanks to the fast detection, diagnosis, and management of both patients, we prevented the occurrence of aneurysm rupture, thus a life-threatening complication. After endovascular procedures with flow diverter implantation, we observed a significant improvement in visual acuity as well as perimetric findings in both patients. When intracranial aneurysms are found within a week of the onset of eye symptoms and treated within three months, defects in the visual fields improved in our two patients within 6-12 months, and in one of the two patients the defects almost completely disappeared.
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Thuan DD, Nguyet NT, Chi LD, Van Nhat D, Hung DV, Khanh N, Thao PN, Xuan NT. A case report: Ruptured aneurysm with a wide neck treated by flow diverter stent and coil embolization. Radiol Case Rep 2022; 18:862-868. [PMID: 36589494 PMCID: PMC9798131 DOI: 10.1016/j.radcr.2022.11.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/20/2022] [Indexed: 12/24/2022] Open
Abstract
Diagnosis and endovascular treatment for ruptured wide neck aneurysms are challenges in clinics, particularly in developing countries. In the present study, we described a clinical case with a ruptured wide neck aneurysm in Vietnam treated by flow diverter stent and coil embolization. A 77-year-old- female patient had a right droopy eyelid for 2 months. The patient was admitted to hospital on the second day after being presented with a sudden-severe headache. Cerebral computed tomography (CT) and magnetic resonance imaging (MRI) were taken on the second day and fifth day after the onset of the headache. The results showed an aneurysm in the right internal carotid artery but no potential subarachnoid hemorrhage (SAH) was displayed. An uncoagulated blood was found in cerebrospinal fluid indicated by a lumbar puncture test. Digital subtraction angiography provided images with one wide-neck right internal carotid aneurysm. The patient was treated by flow diverter stent and coil embolization and the dual antiplatelet therapy with ticagrelor and aspirin at home. After 45 days, the patient did not face with any complication, no neurological symptoms, and the aneurysm was partially thrombosed indicated by MRI images. These results suggested that a lumbar puncture should be analyzed on the patient with brain aneurysm appeared a sudden severe headache and even no potential SAH on brain MRI or CT was found. The combination of flow diverter stent and coil embolization to treat cases with ruptured wide necked aneurysms should be considered in the future.
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Affiliation(s)
- Do Duc Thuan
- Department of Stroke, 103 Military Hospital, Vietnam Military Medical University, 261 Phung Hung Street, Ha Dong District, Ha Noi city, Vietnam
| | - Nguyen Thi Nguyet
- Department of Stroke, 103 Military Hospital, Vietnam Military Medical University, 261 Phung Hung Street, Ha Dong District, Ha Noi city, Vietnam
| | - Le Duy Chi
- Department of Ultrasound, 103 Military Hospital, Vietnam Military Medical University, 261 Phung Hung Street, Ha Dong District, Ha Noi city, Vietnam
| | - Dao Van Nhat
- Department of Urology, 103 Military Hospital, Vietnam Military Medical University, 261 Phung Hung Street, Ha Dong District, Ha Noi city, Vietnam
| | - Dinh Viet Hung
- Department of Psychiatry, 103 Military Hospital, Vietnam Military Medical University, 261 Phung Hung Street, Ha Dong District, Ha Noi city, Vietnam
| | - Nguyen Khanh
- Department of Thoracic Surgery, 103 Military Hospital, Vietnam Military Medical University, 261 Phung Hung Street, Ha Dong District, Ha Noi city, Vietnam
| | - Pham Ngoc Thao
- Department of Functional Diagnosis, 103 Military Hospital, Vietnam Military Medical University, 261 Phung Hung Street, Ha Dong District, Ha Noi city, Vietnam,Corresponding authors.
| | - Nguyen Thanh Xuan
- Department of Senior Officer, 103 Military Hospital, Vietnam Military Medical University, 261 Phung Hung Street, Ha Dong District, Ha Noi city, Vietnam,Corresponding authors.
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Morrish R, Corcoran R, Cooke J, Eesa M, Wong JH, Mitha AP. Fluoroscopy, CT, and MR imaging characteristics of a novel primarily bioresorbable flow-diverting stent for aneurysms. Interv Neuroradiol 2022; 28:660-667. [PMID: 34787481 PMCID: PMC9706267 DOI: 10.1177/15910199211060979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/18/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Five to ten percent of the global population have unruptured intracranial aneurysms, and ruptured brain aneurysms cause approximately 500,000 deaths a year. Flow-diverting stent treatment is a less invasive intracranial aneurysm treatment that induces aneurysm thrombosis. The imaging characteristics of a novel primarily bioresorbable flow-diverting stent (BFDS) are assessed in comparison to the leading metal stent using fluoroscopy, CT, and MRI. METHODS X-ray/fluoroscopic images of stents were taken using a human cadaveric skull model. CT and MRI were acquired using silicone flow models of residual aneurysms. Images were analyzed with Likert scales in anonymous surveys by neurointerventionalists. Quantitative measurements of radiographic density (CT) and artifact boundary size (CT & MRI) were also obtained. RESULTS Visibility of the BFDS on X-ray was less than the metal stent but deemed adequate for deployment and intraprocedural assessment. The metal stent was more radiopaque than the BFDS on CT, but qualitative assessment was not significantly different for the two stents. MRI imaging was significantly better using the BFDS in terms of overall artifact and intraluminal assessment. CONCLUSIONS The BFDS has adequate visualization on X-ray/fluoroscopy and should be clinically acceptable for fluoroscopic deployment. On MRI, there is less quantitative artifact as well as overall improved qualitative assessment that will allow for more detailed non-invasive imaging follow-up of treated aneurysms, potentially reducing the need for digital subtraction catheter angiography.
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Affiliation(s)
- Rosalie Morrish
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Muneer Eesa
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - John H Wong
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Alim P Mitha
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Nasra M, Weerakkody D, Maingard JT, Hall J, Mitreski G, Kok HK, Smith PD, Russell JH, Jhamb A, Brooks DM, Asadi H. A Systematic Review of Neuropsychological Outcomes After Treatment of Intracranial Aneurysms. Neurosurgery 2022; 91:831-841. [PMID: 36239513 DOI: 10.1227/neu.0000000000002147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/12/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage is a cause of profound morbidity and mortality. Its effects extend beyond functional neurological status to neurocognitive and psychological functioning. Endovascular treatment is becoming more prevalent after increasing evidence for its safety and efficacy; however, there is a relative paucity of evidence specific to neurocognitive status after treatment. OBJECTIVE To assess and compare neuropsychological outcomes after the treatment of ruptured and unruptured intracranial aneurysms. METHODS A systematic review of the literature was conducted searching for articles assessing the neuropsychological and cognitive outcomes after the treatment of ruptured and unruptured intracranial aneurysms. Inclusion criteria were English language, publication between January 2000 and October 2020, and discussion of neuropsychological outcomes in adequate detail. Outcomes were categorized into 8 domains: 5 Neurocognitive (Language, Executive Function, Complex Attention, Memory and Learning, and Perceptual motor function), Intelligence Quotient, Affect, and Quality of Life. RESULTS Twenty-four articles were included comprising 2236 patients (924 surgical clipping, 1095 endovascular coiling, and 217 controls). These studies reported that most tests revealed no significant difference [n = 356/421 (84.56%)] between treatment modalities. More studies reported significantly superior test scores in the fields of language, executive function, and memory and learning after coiling [n = 53/421 tests (12.59%)] compared with clipping [n = 12/421 tests (2.85%)]. CONCLUSION The current available data and published studies demonstrate a trend toward improved neurocognitive and psychological outcomes after endovascular treatment. Although these findings should be considered when deciding on the optimal treatment method for each patient, drawing definitive conclusions is difficult because of heterogeneity between patients and studies.
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Affiliation(s)
| | | | - Julian Tam Maingard
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia.,Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Australia.,Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Jonathan Hall
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Goran Mitreski
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Australia
| | - Hong Kuan Kok
- Interventional Radiology Service, Northern Health, Epping, Victoria, Australia
| | - Paul D Smith
- Department of Neurosurgery, St Vincent's Hospital, Fitzroy, Victoria, Melbourne, Australia.,Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Melbourne
| | - Jeremy H Russell
- Department of Neurosurgery, Austin Health, Heidelberg, Victoria, Australia
| | - Ashu Jhamb
- Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Duncan Mark Brooks
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Australia.,School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia.,Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Australia.,School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
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Wilfling S, Kilic M, Tsoneva B, Freyer M, Olmes D, Wendl C, Linker R, Schlachetzki F. Recurrent vertebrobasilar strokes and transient-ischemic attacks with challenging workup: Case report. Brain Circ 2022; 8:50-56. [PMID: 35372722 PMCID: PMC8973451 DOI: 10.4103/bc.bc_61_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/06/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022] Open
Abstract
Detecting the stroke etiology in young patients can be challenging. Among others, determining causality between ischemic stroke and patent foramen ovale (PFO) remains a complicated task for stroke neurologists, given the relatively high prevalence of PFOs. Thorough diagnostic workup to identify incidental vascular risk factors and rare embolic sources is crucial to avoid premature PFO closure suggesting successful secondary stroke prevention. In this paper, we report on a 38-year-old patient with recurrent vertebrobasilar territory, especially right posterior inferior cerebellar artery (PICA) territory strokes. After the initial suspicion of a left vertebral artery (VA) dissection was not confirmed by ultrasound and magnetic resonance imaging (MRI) and other major risk factors were excluded, a PFO was detected and closed. Successful PFO closure was confirmed by transesophageal echocardiography, yet recurrent transient-ischemic attacks and vertebrobasilar strokes, especially during nighttime and in the early morning, occurred despite various antiplatelet and antithrombotic regimes and a persistent right-to-left shunt was detected by bubble transcranial Doppler. Finally, MRI after another vertebrobasilar infarction detected a transient left VA occlusion that finally led to the diagnosis of a left VA pseudoaneurysm from an incident emboligenic dissection in the atlas segment. This pseudoaneurysm together with an anatomical variant of the right PICA originating with the right anterior inferior cerebellar artery from the basilar artery finally explained the recurrent ischemic events of the patient. After successful treatment with coil occlusion, the patient suffered no further stroke and recovered completely. In summary, stroke in the young remains a diagnostic challenge. The incidental finding of a PFO should not deter from thorough stroke workup and the follow-up of these patients including PFO closure verification should be performed under the guidance of vascular neurologists.
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Sergeev AV, Savello AV, Cherebillo VU, Kiskaev AI, Chemurzieva F. Sequential approach of internal maxillary-to-middle cerebral artery bypass and endovascular occlusion for giant middle cerebral artery aneurysm: a case report. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00288-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The combined approach to complex brain МСА aneurysm seems to be generally considered viable. Although it is fairly common, the combinations of modalities, which are suggested in different case reports, vary significantly. This case discusses a sequential approach of reconstructive microsurgery with internal maxillary-to-middle cerebral artery bypass followed by the balloon test occlusion and endovascular embolization of the aneurysm and the MCA. The combined approach together with use of maxillary artery helped minimize the intraoperative and postoperative complications.
Case presentation
A 62-year-old female with rare episodes of headache and depression revealed giant middle cerebral artery aneurysm. The patient underwent a combined operation in a hybrid operating room with no serious neurologic deficit after surgery.
Conclusions
Multimodality management in a hybrid operating room should be considered in case of complex fusiform aneurysm of MCA, which is associated with high risks of clipping. Thus, the sequential procedures will improve patient outcomes in treatment of complex МСА aneurysms.
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Piano M, Valvassori L, Lozupone E, Pero G, Quilici L, Boccardi E. FRED Italian Registry: a multicenter experience with the flow re-direction endoluminal device for intracranial aneurysms. J Neurosurg 2020; 133:174-181. [PMID: 31075778 DOI: 10.3171/2019.1.jns183005] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The introduction of flow-diverter devices (FDDs) has revolutionized the endovascular treatment of intracranial aneurysms. Here the authors present their Italian multicenter experience using the flow re-direction endoluminal device (FRED) in the treatment of cerebral aneurysms, evaluating both short- and long-term safety and efficacy of this device. METHODS Between February 2013 and December 2014, 169 consecutive aneurysms treated using FRED in 166 patients were entered into this study across 30 Italian centers. Data collected included patient demographics, aneurysm location and characteristics, baseline angiography, adverse event and serious adverse event information, morbidity and mortality rates, and pre- and posttreatment modified Rankin Scale scores, as well as angiographic and cross-sectional CT/MRI follow-up at 3-6 months and/or 12-24 months per institutional standard of care. All images were reviewed and adjudicated by an independent core lab. RESULTS Of the 169 lesions initially entered into the study, 4 were later determined to be extracranial or nonaneurysmal by the core lab and were excluded, leaving 165 aneurysms in 162 patients treated in 163 procedures. Ninety-one (56.2%) patients were asymptomatic with aneurysms found incidentally. Of the 165 aneurysms, 150 (90.9%) were unruptured. One hundred thirty-four (81.2%) were saccular, 27 (16.4%) were fusiform/dissecting, and the remaining 4 (2.4%) were blister-like. One hundred thirty-seven (83.0%) arose from the anterior circulation.FRED deployment was impossible in 2/163 (1.2%) cases, and in an additional 4 cases (2.5%) the device was misdeployed. Overall mortality and morbidity rates were 4.3% and 7.3%, respectively, with rates of mortality and morbidity potentially related to FRED of up to 2.4% and 6.2%, respectively. Neuroimaging follow-up at 3-6 months showed complete or nearly complete occlusion of the aneurysm in 94% of cases, increasing to 96% at 12-24 months' follow-up. Aneurysmal sac shrinkage was observed in 78% of assessable aneurysms. CONCLUSIONS This preliminary experience using FRED for endovascular treatment of complex unruptured and ruptured aneurysms showed a high safety and efficacy profile that is comparable to those of other FDDs currently in use.
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Affiliation(s)
| | | | - Emilio Lozupone
- 2UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Guglielmo Pero
- 1ASST Grande Ospedale Metropolitano Niguarda, Milan; and
| | - Luca Quilici
- 1ASST Grande Ospedale Metropolitano Niguarda, Milan; and
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Arleth T, Olsen MH, Orre M, Rasmussen R, Bache S, Eskesen V, Frikke-Schmidt R, Møller K. Hypozincaemia is associated with severity of aneurysmal subarachnoid haemorrhage: a retrospective cohort study. Acta Neurochir (Wien) 2020; 162:1417-1424. [PMID: 32246202 DOI: 10.1007/s00701-020-04310-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 03/23/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hypozincaemia may develop in critically ill patients, including those with acute brain injury in the early phase after hospital admission. The aim of this study was to investigate the prevalence of hypozincaemia after aneurysmal subarachnoid haemorrhage (aSAH) and its association with delayed cerebral ischemia and functional outcome. METHODS We retrospectively analysed a cohort of 384 patients with SAH admitted to the Neurointensive Care Unit at Rigshospitalet, Copenhagen, Denmark, in whom at least one measurement of plasma zinc concentration was done during the hospital stay. Hypozincaemia was defined as at least one measurement of plasma zinc below 10 μmol/L. Potential associations between hypozincaemia, demographic variables and functional outcome after aSAH were analysed in multivariable logistic regression models. RESULTS Hypozincaemia was observed in 67% (n = 257) of all patients and occurred within 7 days in more than 95% of all hypozincaemic patients. In a multivariable model, severe SAH (WFNS 3-5; OR 4.2, CI 2.21-8.32, p < 0.001) and Sequential Organ Failure Assessment (SOFA) score on the day of admission (OR 1.24, CI 1.11-1.40, p < 0.001) were independently associated with hypozincaemia. In another multivariable model, hypozincaemia was independently associated with an unfavourable outcome (defined as a modified Rankin Scale score from 3 to 6) (OR 1.97, CI 1.06-3.68, p = 0.032), as was age (OR 1.03, CI 1.01-1.05, p = 0.015), SOFA score on the day of admission (OR 1.14, CI 1.02-1.29, p = 0.02), a diagnosis of delayed cerebral ischaemia (OR 4.06, CI 2.29-7.31, p < 0.001) and a clinical state precluding assessment for delayed cerebral ischaemia (OR 15.13, CI 6.59-38.03, p < 0.001). CONCLUSION Hypozincaemia occurs frequently after aSAH, is associated with a higher disease severity and independently contributes to an unfavourable outcome.
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Affiliation(s)
- Tobias Arleth
- Department of Neuroanaesthesiology, The Neuroscience Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Matias Orre
- Department of Neuroanaesthesiology, The Neuroscience Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rune Rasmussen
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Bache
- Department of Neuroanaesthesiology, The Neuroscience Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Vagn Eskesen
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ruth Frikke-Schmidt
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, The Neuroscience Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Rice H, Martínez Galdámez M, Holtmannspötter M, Spelle L, Lagios K, Ruggiero M, Vega P, Sonwalkar H, Chapot R, Lamin S. Periprocedural to 1-year safety and efficacy outcomes with the Pipeline Embolization Device with Shield technology for intracranial aneurysms: a prospective, post-market, multi-center study. J Neurointerv Surg 2020; 12:1107-1112. [PMID: 32482834 PMCID: PMC7569365 DOI: 10.1136/neurintsurg-2020-015943] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 01/23/2023]
Abstract
Background The first and second generations of the Pipeline Embolization Device (PED) have been widely adopted for the treatment of intracranial aneurysms (IAs) due to their high associated occlusion rates and low morbidity and mortality. The objective of this study was to evaluate the safety and effectiveness of the third- generation Pipeline Shield device (PED-Shield) for the treatment of IAs. Methods The SHIELD study was a prospective, single-arm, multicenter, post-market, observational study evaluating the PED-Shield device for the treatment of IAs. The primary efficacy endpoint was complete aneurysm occlusion without significant parent artery stenosis or retreatment at 1-year post-procedure and the primary safety endpoint was major stroke in the territory supplied by the treated artery or neurological death. Results Of 205 subjects who consented across 21 sites, 204 subjects with 204 target aneurysms were ultimately treated (mean age 54.8±12.81 years, 81.4% [166/204] female). Technical success (ie, deployment of the PED-Shield) was achieved in 98.0% (200/204) of subjects with a mean number of 1.1±0.34 devices per subject and a single device used in 86.8% (177/204) of subjects. The primary effectiveness endpoint was met in 71.7% (143/200) of subjects while the primary safety endpoint occurred in six (2.9%) subjects, two (1.0%) of which led to neurological death. Conclusions The findings of the SHIELD study support the safety and effectiveness of the PED-Shield for IA treatment, evidenced by high occlusion rates and low rates of neurological complications in the study population. Clinical trial registration-URL http://www.clinicaltrials.gov. Unique identifier: NCT02719522.
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Affiliation(s)
- Hal Rice
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Mario Martínez Galdámez
- Endovascular Neurosurgery/Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Castilla y León, Spain
| | | | - Laurent Spelle
- Interventional Neuroradiology, Hôpital Bicêtre, Le Kremlin-Bicetre, Île-de-France, France
| | - Konstantinos Lagios
- Interventional Neuroradiology, 251 Air Force General Hospital, Athens, Attica, Greece
| | - Maria Ruggiero
- Neuroradiology, Maurizio Bufalini Hospital, Cesena, Emilia-Romagna, Italy
| | - Pedro Vega
- Radiology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Hemant Sonwalkar
- Neuroradiology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - René Chapot
- Department of Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Ruttenscheid, Essen, Nordrhein-Westfalen, Germany
| | - Saleh Lamin
- Interventional Neuroradiology. Radiology, Queen Elizabeth Hospital, Birmingham, Birmingham, UK
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Olsen MH, Orre M, Leisner ACW, Rasmussen R, Bache S, Welling K, Eskesen V, Møller K. Delayed cerebral ischaemia in patients with aneurysmal subarachnoid haemorrhage: Functional outcome and long-term mortality. Acta Anaesthesiol Scand 2019; 63:1191-1199. [PMID: 31173342 DOI: 10.1111/aas.13412] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/23/2019] [Accepted: 05/01/2019] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Delayed cerebral ischaemia (DCI) is one of the most frequent complications of aneurysmal subarachnoid haemorrhage (aSAH). The purpose of the present retrospective cohort study of patients with aSAH was to identify the association between DCI, functional outcome and 4-year mortality. METHODS Patients admitted to the Neurointensive Care Unit at Rigshospitalet, Copenhagen, with aSAH from 1 January 2010, through 31 December 2013 were registered. Patients were categorized into 3 groups: (a) those with DCI, defined as either a decline in consciousness or focal neurological deficits lasting ≥1 hour without any other detectable cause, (b) those without DCI, or (c) those who were unassessable for DCI. Functional neurological outcome after 6 months, as measured by the modified Rankin Scale (mRS), was dichotomized into good (mRS 0-2) and poor (mRS 3-6). Kaplan-Meier survival curves were constructed, and incidence risk rates were calculated both to determine the association between DCI and mortality. RESULTS Four hundred ninety-two cases of aSAH were recorded in the study period. DCI occurred in 23% of all patients, corresponding to 33% of assessable patients. Patients without DCI had the best functional outcome (mRS) compared to patients with DCI and patients who were unassessable; furthermore, the latter had worse outcomes than patients with DCI. Patients diagnosed with DCI had significantly higher mortality than those without DCI, even ignoring the first 14 days after admission. CONCLUSION DCI may be associated with both short- and long-term morbidity and mortality in patients with aSAH.
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Affiliation(s)
- Markus Harboe Olsen
- Department of Neuroanaesthesiology Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Matias Orre
- Department of Neuroanaesthesiology Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Anna Cold Winge Leisner
- Department of Neuroanaesthesiology Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Rune Rasmussen
- Department of Neurosurgery Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Søren Bache
- Department of Neuroanaesthesiology Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Karen‐Lise Welling
- Department of Neuroanaesthesiology Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Vagn Eskesen
- Department of Neurosurgery Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology Rigshospitalet, University of Copenhagen Copenhagen Denmark
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Liang B, Lesley WS, Robinson TM, Chen W, Benardete EA, Huang JH. Off-Label Application of Pipeline Embolization Device for Intracranial Aneurysms. Neurointervention 2019; 14:116-124. [PMID: 31302986 PMCID: PMC6736497 DOI: 10.5469/neuroint.2019.00073] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 05/22/2019] [Accepted: 06/03/2019] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The Pipeline embolization device (PED) is approved in the USA for treating giant and large aneurysms arising from the petrous to superior hypophyseal segments of the internal carotid artery in patients older than 21 years of age. This study investigates off-label PED results in a large cohort. MATERIALS AND METHODS Retrospective, single-center review of all patients who had off-label PED surgery. RESULTS Sixty-two aneurysms (48 patients) underwent off-label PED treatment from 2012- 2017. There were 44 females and four males (age 21 to 75 years; mean/median, 54.3/55.0 years). The most common presenting symptom was headache (47/62, 75.8%). All aneurysms were in the anterior circulation. Aneurysm size ranged from 1.4 to 25.0 mm (mean/median, 7.6/6.9 mm). Fifty-two aneurysms had post-operative imaging with total/near-complete occlusion of 84.6% (44/52). Aneurysm-based operative near-term complication rate was 9.7% while there were no permanent complications. For aneurysms and headache, 86.7% improved/resolved after embo-surgery, and were four times more likely to have a better clinical outcome (resolved or improved symptoms) after surgery (odds ratio [OR], 4.333; P=0.0325). Left-sided aneurysms had a higher occlusion rate (OR, 20; P=0.0073). Hypertension (OR, 4.2; P=0.0332) and smoking (OR, 7; P=0.0155) were more prone towards aneurysm occlusion. Patients without a family history were 14 times more likely to have favorable imaging outcome (P=0.0405). There is no difference of occlusion rates between untreated and previously treated aneurysms (P=0.6894). Overall, occlusion rate decreased by 14% with an increase of aneurysm size by 1 mm (P=0.0283). CONCLUSION For anterior circulation aneurysms, the off-label application of PED is as effective and safe as reported for on-label intracranial aneurysms.
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Affiliation(s)
- Buqing Liang
- Department of Neurosurgery, Baylor Scott & White Health, Temple, TX, USA
- Texas A&M University HSC-COM, Temple, TX, USA
| | - Walter S. Lesley
- Department of Neurosurgery, Baylor Scott & White Health, Temple, TX, USA
- Texas A&M University HSC-COM, Temple, TX, USA
| | - Timothy M. Robinson
- Department of Neurosurgery, Baylor Scott & White Health, Temple, TX, USA
- Texas A&M University HSC-COM, Temple, TX, USA
| | - Wencong Chen
- Department of Biostatistics, Baylor Scott & White Research Institute, Temple, TX, USA
| | - Ethan A. Benardete
- Department of Neurosurgery, Baylor Scott & White Health, Temple, TX, USA
- Texas A&M University HSC-COM, Temple, TX, USA
| | - Jason H. Huang
- Department of Neurosurgery, Baylor Scott & White Health, Temple, TX, USA
- Texas A&M University HSC-COM, Temple, TX, USA
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Treatment of ruptured blood blister-like aneurysms of the internal carotid artery with flow-diverting stents: Case report and review of pharmacological management. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Al-Mufti F, Cohen ER, Amuluru K, Patel V, El-Ghanem M, Nuoman R, Majmundar N, Dangayach NS, Meyers PM. Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms. INTERVENTIONAL NEUROLOGY 2018; 8:38-54. [PMID: 32231694 DOI: 10.1159/000489016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/06/2018] [Indexed: 12/21/2022]
Abstract
Background Flow-diverting stents (FDS) have revolutionized the endovascular management of unruptured, complex, wide-necked, and giant aneurysms. There is no consensus on management of complications associated with the placement of these devices. This review focuses on the management of complications of FDS for the treatment of intracranial aneurysms. Summary We performed a systematic, qualitative review using electronic databases MEDLINE and Google Scholar. Complications of FDS placement generally occur during the perioperative period. Key Message Complications associated with FDS may be divided into periprocedural complications, immediate postprocedural complications, and delayed complications. We sought to review these complications and novel management strategies that have been reported in the literature.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA.,Departments of Neurology and Neurosurgery, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Eric R Cohen
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh-Hamot, Erie, Pennsylvania, USA
| | - Vikas Patel
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Mohammad El-Ghanem
- Department of Neurology and Medical Imaging, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Rolla Nuoman
- Department of Neurology, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA
| | - Neil Majmundar
- Departments of Neurology and Neurosurgery, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Neha S Dangayach
- Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Philip M Meyers
- Departments of Radiology and Neurosurgery and Columbia University Medical Center, New York, New York, New York, USA
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Racial and Ethnic Disparities in Treatment Outcomes of Patients with Ruptured or Unruptured Intracranial Aneurysms. J Racial Ethn Health Disparities 2018; 6:345-355. [PMID: 30264335 DOI: 10.1007/s40615-018-0530-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The aim of this study is to examine how health outcomes varied by treatment selection and race/ethnicity among hospitalized US patients with ruptured or unruptured IAs. METHODS A retrospective cohort study was conducted using a sample of 62,224 hospital discharges from the 2002-2012 Nationwide Inpatient Sample. Logistic regression models evaluated treatment selection as predictor of in-hospital survival (IHS: "yes," "no") and length of stay (LOS ≤ 7 days, > 7 days), overall and across racial/ethnic groups, taking hospital- and patient-level confounders into account, while stratifying by IA rupture status. RESULTS Compared to surgical clipping, endovascular coiling was associated with better IHS, after controlling for confounders. Compared to surgical clipping, LOS ≤ 7 days was less likely in patients with combination of treatments and more likely among patients with endovascular coiling as well as balloon- or stent-assisted coiling. Observed relationships varied significantly by race and ethnicity for IHS, but not for LOS ≤ 7 days. Whereas combination of treatments were associated with worse IHS than surgical clipping among Blacks alone, endovascular coiling was associated with better IHS than surgical clipping among White and Other racial/ethnic subgroups. These relationships were for the most part consistent among patients with and without IA rupture. CONCLUSIONS Racial and ethnic subgroups of IA patients experienced differential IHS by treatment selection, irrespective of IA rupture status. Prospective cohort studies are needed to further elucidate these racial and ethnic disparities, while collecting data on IA size, location, and morphology as well as Hunt and Hess grade for ruptured IA.
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Beydoun HA, Azarbaijani Y, Cheng H, Anderson-Smits C, Marinac-Dabic D. Predicting Successful Treatment of Intracranial Aneurysms with the Pipeline Embolization Device Through Meta-Regression. World Neurosurg 2018; 114:e938-e958. [DOI: 10.1016/j.wneu.2018.03.120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/17/2018] [Accepted: 03/17/2018] [Indexed: 10/17/2022]
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Adeeb N, Moore J, Griessenauer CJ, Gupta R, Fazelat AA, Ogilvy CS, Thomas AJ. Acute retinal hemorrhage after Pipeline embolization device placement for treatment of ophthalmic segment aneurysm: A case report. Interv Neuroradiol 2018; 24:383-386. [PMID: 29754516 DOI: 10.1177/1591019918771929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Ophthalmic segment aneurysms may present with visual symptoms due to direct compression of the optic nerve. Treatment of these aneurysms with the Pipeline embolization device (PED) often results in visual improvement. Flow diversion, however, has also been associated with occlusion of the ophthalmic artery and visual deficits in a small subset of cases. Case report A 49-year-old Caucasian female presented with subarachnoid hemorrhage due to a ruptured anterior communicating artery aneurysm. On follow-up imaging, the patient was found to have a right asymptomatic ophthalmic segment aneurysm. Due to the irregular shape of the aneurysm and history of aneurysmal subarachnoid hemorrhage, the decision was made to treat the aneurysm with a PED. Postoperatively, the patient complained of floaters in the right eye. Detailed ophthalmologic examination showed retinal hemorrhage and cotton-wool spots on the macula. Such complication after PED placement has never been reported in the literature. Conclusion Visual complications after PED placement for treatment of ophthalmic segment aneurysms are rare. It is thought that even in cases where the ophthalmic artery occludes, patients remain asymptomatic due to the rich collateral supply from the external carotid artery branches. Here we report a patient who developed an acute retinal hemorrhage after PED placement.
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Affiliation(s)
- Nimer Adeeb
- 1 Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Justin Moore
- 1 Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Christoph J Griessenauer
- 1 Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Raghav Gupta
- 1 Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | | | - Christopher S Ogilvy
- 1 Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Ajith J Thomas
- 1 Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
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Srinivasan VM, Kaufmann A, Kan P, Duckworth EA. Surgical Reconstruction to Allow Endovascular Access for Flow Diversion of Giant Cavernous Aneurysm: A Combined Approach. Cureus 2018; 10:e2381. [PMID: 29850376 PMCID: PMC5973504 DOI: 10.7759/cureus.2381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Giant cavernous aneurysms of the internal carotid artery (ICA) are challenging lesions associated with high surgical morbidity. Prior to the past several years, these were treated by surgical reconstruction, proximal ligation, or stent-assisted coiling techniques. Flow diversion has become the standard of care for these lesions, providing a high rate of obliteration with a much better safety profile. However, flow diverters rely upon a navigable vasculature and, usually, a tri-axial support system. Cases in which such access is difficult require unique approaches to combine the strengths of both surgical and endovascular therapy. A woman with a giant cavernous ICA aneurysm and an ophthalmic artery aneurysm presented for treatment, but access was challenging due to cervical ICA tortuosity and pseudoaneurysms. We elected a staged, combined approach with surgical reconstruction of the cervical ICA followed by flow diverter placement for the intracranial aneurysms. Our case features an “outside-the-box” approach that synergistically applied both microsurgical and endovascular techniques to treat a challenging pathology. Classic microsurgical techniques remain important in cases that are refractory or not amenable to endovascular therapy alone.
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Affiliation(s)
| | | | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine
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Das S, Gupta AK, Ramalingiah AH. Kinking of Flow Diverter in a Giant Wide-Necked Supraclinoid Internal Carotid Artery Aneurysm. Neurointervention 2018. [PMID: 29535900 PMCID: PMC5847892 DOI: 10.5469/neuroint.2018.13.1.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We report here a rare complication in the form of kinking of flow diverter in a case of giant wide-necked supraclinoid internal carotid artery (ICA) aneurysm 48 hours after the procedure. This 28-year female presented with giant wide-necked right supraclinoid ICA aneurysm which was managed by flow diversion. On 2nd post-op day, patient developed weakness of left side with altered sensorium - angiography and CT showed kinking of flow diverter at the neck of the aneurysm with poor distal flow. Eventually, the patient developed right middle cerebral artery infarct for which decompressive hemicraniectomy was done. The likely cause of development of kink is because the aneurysm was wide-necked, the hemodynamic forces have resulted in inward buckling of the flow diverter at the aneurysm neck. This case shows that kinking of flow diverter can still happen 48 hours post-procedure.
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Affiliation(s)
- Soumik Das
- Department of Neuroimaging and Interventional Radiology, NIMHANS, Bangalore - 29, India
| | - Arun Kumar Gupta
- Department of Neuroimaging and Interventional Radiology, NIMHANS, Bangalore - 29, India
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Volker M, Anastasios M, Jan B, Nuran A, Thomas L, Franziska D, Pantelis S, De-Hua C, Christoph K. Treatment of Intracranial Aneurysms with the Pipeline Embolization Device Only: a Single Center Experience. Neurointervention 2018. [PMID: 29535896 PMCID: PMC5847888 DOI: 10.5469/neuroint.2018.13.1.32] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose The aim of this study was to evaluate the technical feasibility and rate of mid-term occlusion in aneurysms treated solely with the Pipeline Embolization Device (PED) in a German tertiary care university hospital. Materials and Methods Forty-nine non-consecutive intracranial aneurysms underwent endovascular treatment using the PED exclusively between March 2011 and May 2017 at our institution. Primary endpoint was a favorable aneurysm occlusion defined as OKM C1-3 and D (O'Kelly Marotta Scale). Secondary endpoints were retreatment rate and delayed complications. Median follow-up was 200 days. Results The mean aneurysm size was 7.1 ± 5.3 mm. Forty-four aneurysms were located in the anterior circulation (90%). Ten aneurysms were ruptured (20%). Branching vessels from the sac were observed in 11 aneurysms (22%). Favorable obliteration immediately after PED placement was seen in 13/49 aneurysms (27%), of those nine aneurysms were completely occluded (18%). Angiographic and clinical follow-up was available for 45 cases (92%); 36/45 aneurysms (80%) were occluded completely and 40/45 aneurysms (89%) showed a favorable occlusion result. A branching vessel arising from the aneurysm sac was associated with incomplete occlusion (P < .05). All electively treated patients had good outcome (mRS 0). Three aneurysms (6%) required additional treatment due to aneurysm recurrence. Conclusion In our series, treatment of intracranial aneurysms with the PED was associated with favorable occlusion rates and low complication rates at mid-term follow-up. The presence of branching vessels arising from the aneurysms sac was predictive for an incomplete occlusion.
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Affiliation(s)
- Maus Volker
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Mpotsaris Anastasios
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Borggrefe Jan
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Abdullayev Nuran
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Liebig Thomas
- Department of Neuroradiology, Charité, Berlin, Germany
| | - Dorn Franziska
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - Stavrinou Pantelis
- Department of Neurosurgery, University Hospital Cologne, Cologne, Germany
| | - Chang De-Hua
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Kabbasch Christoph
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
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Al-Mufti F, Alkanaq A, Amuluru K, Nuoman R, Abdulrazzaq A, Sami T, Nuoaman H, Hayes-Rosen C, Prestigiacomo CJ, Gandhi CD. Genetic Insights into Cerebrovascular Disorders: A Comprehensive Review. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2017; 9:21-32. [PMID: 29163746 PMCID: PMC5683023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Fawaz Al-Mufti
- Rutgers University - Robert Wood Johnson Medical School, Department of Neurology, Division of Neuroendovascular Surgery and Neurocritical Care, New Brunswick, New Jersey, USA
- Rutgers University - New Jersey Medical School, Department of Neurosurgery, Newark, New Jersey, USA
| | - Ahmed Alkanaq
- Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Krishna Amuluru
- University of Pittsburgh Medical Center- Hamot, Department of Neurointerventional Radiology, Erie, Pennsylvania, USA
| | - Rolla Nuoman
- Rutgers University - New Jersey Medical School, Department of Neurology, Division of Child Neurology, Newark, New Jersey, USA
| | - Ahmed Abdulrazzaq
- Rutgers University - School of Dental Medicine, Newark, New Jersey, USA
| | - Tamarah Sami
- Rutgers University - Robert Wood Johnson Medical School, Department of Neurology, New Brunswick, New Jersey, USA
| | - Halla Nuoaman
- Rutgers University - Robert Wood Johnson Medical School, Department of Neurology, New Brunswick, New Jersey, USA
| | - Caroline Hayes-Rosen
- Rutgers University - New Jersey Medical School, Department of Neurology, Division of Child Neurology, Newark, New Jersey, USA
| | - Charles J Prestigiacomo
- Rutgers University - New Jersey Medical School, Department of Neurosurgery, Newark, New Jersey, USA
| | - Chirag D Gandhi
- Westchester Medical Center, New York Medical College, Department of Neurosurgery, Valhalla, New York, USA
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Abstract
BACKGROUND Intracranial saccular aneurysms are acquired lesions that often present with neuro-ophthalmologic symptoms and signs. Recent advances in neurosurgical techniques, endovascular treatments, and neurocritical care have improved the optimal management of symptomatic unruptured aneurysms, but whether the chosen treatment has an impact on neuro-ophthalmologic outcomes remains debated. EVIDENCE ACQUISITION A review of the literature focused on neuro-ophthalmic manifestations and treatment of intracranial aneurysms with specific relevance to neuro-ophthalmologic outcomes was conducted using Ovid MEDLINE and EMBASE databases. Cavernous sinus aneurysms were not included in this review. RESULTS Surgical clipping vs endovascular coiling for aneurysms causing third nerve palsies was compared in 13 retrospective studies representing 447 patients. Complete recovery was achieved in 78% of surgical patients compared with 44% of patients treated with endovascular coiling. However, the complication rate, hospital costs, and days spent in intensive care were reported as higher in surgically treated patients. Retrospective reviews of surgical clipping and endovascular coiling for all ocular motor nerve palsies (third, fourth, or sixth cranial nerves) revealed similar results of complete resolution in 76% and 49%, respectively. Improvement in visual deficits related to aneurysmal compression of the anterior visual pathways was also better among patients treated with clipping than with coiling. The time to treatment from onset of visual symptoms was a predictive factor of visual recovery in several studies. Few reports have specifically assessed the improvement of visual deficits after treatment with flow diverters. CONCLUSIONS Decisions regarding the choice of therapy for intracranial aneurysms causing neuro-ophthalmologic signs ideally should be made at high-volume centers with access to both surgical and endovascular treatments. The status of the patient, location of the aneurysm, and experience of the treating physicians are important factors to consider. Although a higher rate of visual recovery was reported with neurosurgical clipping, this must be weighed against the potentially longer intensive care stays and increased early morbidity.
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Surgical Resection and Histopathological Analysis of a Thrombosed Giant Fusiform MCA Aneurysm After Initial Treatment with a Flow Diversion Construct. World Neurosurg 2017; 103:348-354. [PMID: 28433850 DOI: 10.1016/j.wneu.2017.04.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 04/08/2017] [Accepted: 04/10/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND We describe the histopathology of an unruptured giant calcified left middle cerebral artery (MCA) fusiform aneurysm initially treated with endovascular flow diversion. The flow diversion construct underwent postoperative in-stent thrombosis, necessitating surgical resection of the aneurysm to eliminate mass effect. METHODS A 75-year-old woman with a known left MCA aneurysm presented to the emergency department with moderate right hemibody weakness. Owing to the clinical and radiographic progression of the aneurysm, the patient was offered treatment. She was initially offered open surgical management of the lesion but declined it, indicating that she would consider only endovascular treatment. The patient underwent endovascular reconstruction of the aneurysmal segment with an overlapping pipeline construct. Postoperatively, the patient experienced in-stent thrombosis of the pipeline construct. The thrombosed aneurysm exerted a progressive local mass effect, necessitating en bloc surgical resection of the aneurysm and stent construct. The aneurysm was submitted for pathological analysis, which demonstrated chronologically older thrombus outside the flow diversion construct. RESULTS Postsurgical imaging demonstrated a left MCA territory stroke. The patient gradually gained strength in her right hemibody. The histopathological analysis indicated that the degrees of platelet activation and clot formation in this case were dependent on the aggregate surface area of the thrombus and surface area of the pipeline device used in the reconstruction. CONCLUSIONS This technical report with histopathological analysis provides useful insight into the mechanism of aneurysmal thrombosis after flow diversion. It also raises new questions regarding the roles of thrombus formation, platelet aggregation, and stent construct surface area in the maintenance of vessel patency.
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Shakir HJ, Rooney PJ, Rangel-Castilla L, Yashar P, Levy EI. Treatment of iatrogenic V2 segment vertebral artery pseudoaneurysm using Pipeline flow-diverting stent. Surg Neurol Int 2017; 7:104. [PMID: 28168090 PMCID: PMC5223396 DOI: 10.4103/2152-7806.196235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/27/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Iatrogenic injury to the vertebral artery is a rare but potential complication of cervical spine surgery. Previous authors have commented on the use of flow-diverting stents for treatment of aneurysms of the V3 segment of the vertebral artery. CASE DESCRIPTION Here, we report a case in which injury occurred at the V2 segment of the vertebral artery with the development of a pseudoaneurysm, which was found on angiography. After decompressing the spinal cord from an epidural hematoma, the pseudoaneurysm was treated by deploying two Pipeline flow-diverting stents (Medtronic, Minneapolis, MN). Obliteration of the pseudoaneurysm was noted on follow-up angiography 4 days after the treatment. CONCLUSION This case highlights a unique treatment at a region which, to our knowledge, has not been mentioned in the literature.
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Affiliation(s)
- Hakeem J Shakir
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Patrick J Rooney
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Leonardo Rangel-Castilla
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Parham Yashar
- California Neurosurgical Institute, Valencia, California, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
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Jiang B, Paff M, Colby GP, Coon AL, Lin LM. Cerebral aneurysm treatment: modern neurovascular techniques. Stroke Vasc Neurol 2016; 1:93-100. [PMID: 28959469 PMCID: PMC5435202 DOI: 10.1136/svn-2016-000027] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 07/26/2016] [Accepted: 07/28/2016] [Indexed: 11/18/2022] Open
Abstract
Endovascular treatment of cerebral aneurysm continues to evolve with the development of new technologies. This review provides an overview of the recent major innovations in the neurointerventional space in recent years.
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Affiliation(s)
- Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Michelle Paff
- Department of Neurosurgery, University of California, Irvine School of Medicine, UC Irvine Medical Center, Orange, California, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Li-Mei Lin
- Department of Neurosurgery, University of California, Irvine School of Medicine, UC Irvine Medical Center, Orange, California, USA
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Adeeb N, Griessenauer CJ, Moore J, Stapleton CJ, Patel AB, Gupta R, Patel AS, Thomas AJ, Ogilvy CS. Pipeline Embolization Device for Recurrent Cerebral Aneurysms after Microsurgical Clipping. World Neurosurg 2016; 93:341-5. [DOI: 10.1016/j.wneu.2016.06.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 10/21/2022]
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30
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Al-Mufti F, Amuluru K, Gandhi CD, Prestigiacomo CJ. Flow Diversion for Intracranial Aneurysm Management: A New Standard of Care. Neurotherapeutics 2016; 13:582-9. [PMID: 27160270 PMCID: PMC4965406 DOI: 10.1007/s13311-016-0436-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Endovascular treatment of intracranial aneurysms with complex morphologies such as giant, wide-necked, or fusiform aneurysms is challenging. Stent-assisted coiling and balloon-assisted coiling are alternative techniques to treat such complex aneurysms, but studies have shown less-than-expected efficacy, as suggested by their high rate of recanalization. The management of complex aneurysms via microsurgery or conventional neuroendovascular strategies has traditionally been poor. However, over the last few years, flow-diverting stents (FDS) have revolutionized the treatment of such aneurysms. FDS are implanted within the parent artery rather than the aneurysm sac. By modifying intra-aneurysmal and parent-vessel flow dynamics at the aneurysm/parent vessel interface, FDS trigger a cascade of gradual intra-aneurysmal thrombosis. As endothelialization of the FDS is complete, the parent vessel reconstructs while preserving the patency of normal perforators and side branch vessels. As with any intervention, the practice and application of flow-diversion technology is inherent, with risks that include vessel rupture or perforation, in-stent thrombosis, perforator occlusion, procedural and delayed hemorrhages, and perianeurysmal edema. Herein, we review the devices, their mechanisms of actions, clinical applications, complications, and ongoing studies.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurosurgery, Rutgers University School of Medicine, Newark, NJ, USA.
| | - Krishna Amuluru
- Department of Neurosurgery, Rutgers University School of Medicine, Newark, NJ, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Rutgers University School of Medicine, Newark, NJ, USA
- Department of Neurology, Rutgers University School of Medicine, Newark, NJ, USA
- Department of Radiology, Rutgers University School of Medicine, Newark, NJ, USA
| | - Charles J Prestigiacomo
- Department of Neurosurgery, Rutgers University School of Medicine, Newark, NJ, USA
- Department of Neurology, Rutgers University School of Medicine, Newark, NJ, USA
- Department of Radiology, Rutgers University School of Medicine, Newark, NJ, USA
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31
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Murthy SB, Shah J, Mangat HS, Stieg P. Treatment of Intracranial Aneurysms With Pipeline Embolization Device: Newer Applications and Technical Advances. Curr Treat Options Neurol 2016; 18:16. [PMID: 26923606 DOI: 10.1007/s11940-016-0399-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OPINION STATEMENT Pipeline embolization device (PED) is a flow diverter used in the endovascular treatment of intracranial aneurysms, particularly those with unfavorable configurations. It works by causing progressive flow redirection leading to thrombosis within the aneurysm. PED was initially approved for adults with large or giant wide-necked (≥4 mm or no discernible neck) aneurysms of the internal carotid artery (ICA) from the petrous to the superior hypophyseal segments. Studies have shown a superior aneurysm occlusion rate of 85 % at 6 months for the PED and mortality ranging from 2.6 to 4 %. There appears to be a knowledge gap in terms of the duration of dual antiplatelet therapy and efficacy of assessing platelet inhibition. However, increasing operator experience and favorable longer-term outcome data have led to the exploration of PED for a wide array of off-label uses. Given the paucity of good-quality studies comparing PED with other endovascular/surgical treatment options, several multicenter randomized trials are currently underway to answer these important questions.
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Affiliation(s)
- Santosh B Murthy
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA. .,Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA.
| | - Jharna Shah
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Halinder S Mangat
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA.,Department of Neurosurgery, Weill Cornell Medical College, New York, NY, USA
| | - Philip Stieg
- Department of Neurosurgery, Weill Cornell Medical College, New York, NY, USA
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Safety and efficacy of microsurgical treatment of previously coiled aneurysms: a systematic review and meta-analysis. Acta Neurochir (Wien) 2015; 157:1623-32. [PMID: 26166207 DOI: 10.1007/s00701-015-2500-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 06/23/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND We conducted a systematic review of the literature to evaluate the safety and efficacy of surgical treatment of previously coiled aneurysms. METHODS A comprehensive review of the literature for studies on surgical treatment of previously coiled aneurysms was conducted. For each study, the following data were extracted: patient demographics, initial clinical status, location and size of aneurysms, time interval between initial/last endovascular procedure and surgery, surgical indications, and microsurgical technique. We performed subgroup analyses to compare direct clipping versus coil removal and clipping versus parent vessel occlusion, early (<4 weeks post-coiling) versus late surgery and anterior versus posterior circulation. RESULTS Twenty-six studies with 466 patients and 471 intracranial aneurysms were included. All of the studies were retrospective and non-comparative case-series. Patients undergoing direct clipping had lower perioperative morbidity (5.0 %, 95 % CI = 2.6-7.4 %) when compared to those undergoing coil removal and clipping (11.1 %, 95 % CI = 5.3-17.0 %) or parent vessel occlusion (13.1 %, 95 % CI = 4.6-21.6 %) (p = 0.05). Patients receiving early surgery (<4 weeks post-coiling) had significantly lower rates of good neurological outcome (77.1 %, 95 % CI = 69.3-84.8 %) when compared to those undergoing late surgery (92.1 %, 95 % CI = 89.0-95.2 %) (p < 0.01). There were higher rates of long-term neurological morbidity in the posterior circulation group (23.1 vs. 4.7 %, p < 0.01) as well as long-term neurological mortality (4.4 vs. 2.8 %, p < 0.01). CONCLUSIONS Our meta-analysis suggests that surgical treatment is safe and effective. Our data indicate that aneurysms that are amenable to direct clipping have superior outcomes. Late surgery was also associated with better clinical outcomes. Surgery of recurrent posterior circulation aneurysms was associated with high rates of morbidity and mortality. Given the characteristics of the included studies, the quality of evidence of this meta-analysis is limited.
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