1
|
Jee TK, Yeon JY, Kim KH, Kim JS, Jeon P. Evaluation of the Significance of Persistent Remnant Filling and Enlargement After Flow Diversion for Intracranial Aneurysms. World Neurosurg 2024; 184:e144-e153. [PMID: 38253178 DOI: 10.1016/j.wneu.2024.01.073] [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: 12/29/2023] [Accepted: 01/13/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND This study aimed to evaluate the clinical course after flow diversion (FD) treatment with a focus on aneurysms with remnant sac filling, by analyzing angiographic outcomes, aneurysm volume, and clinical events. METHODS We retrospectively reviewed the medical records of 61 patients who underwent FD for intracranial aneurysms between July 2014 and June 2021. RESULTS The majority of aneurysms (52.5%) were located in the internal carotid artery, with a median diameter of 16.6 mm and neck size of 9.3 mm. Remnant filling was observed in 17 aneurysms (27.9%) more than 18 months after FD, 10 (16.4%) of these aneurysms underwent enlargement, which occurred only in cases with subtotal filling or entry remnant states. Eleven patients experienced major adverse events, and three exhibited unfavorable functional outcomes. The incidence of major adverse events and unfavorable functional outcomes was significantly higher in the aneurysm enlargement group than that in the no-filling or stable remnant filling groups (P < 0.001). Aneurysmal diameter and the presence of incorporated branches were independent predictors of aneurysm enlargement, while the presence of incorporated branches was the only independent predictor of persistent remnant filling. CONCLUSIONS Aneurysm enlargement after FD is not uncommon, particularly when the aneurysm is large, has incorporated vessels, or does not undergo occlusion within 12 months, often culminating in major adverse events and unfavorable functional outcomes. In addition to investigating angiographic results, it is necessary to evaluate the changes in aneurysm size and clinical events when assessing the efficacy of FD.
Collapse
Affiliation(s)
- Tae Keun Jee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong-Soo Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
2
|
Kan I, Oishi H, Hyodo A, Nemoto S, Fujimura S, Ishibashi T, Sumita K, Takigawa T, Teranishi K, Kodama T, Kato N, Takao H, Murayama Y. A Novel Braided Stent With Customized Simulation Software for Treatment of Intracranial Aneurysms: Multicenter Prospective Trial Before Unrestricted Clinical Application. Oper Neurosurg (Hagerstown) 2024; 26:180-187. [PMID: 37819087 DOI: 10.1227/ons.0000000000000928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 08/03/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Planning/guidance software became important tools for physicians' presurgical optimal decision-making. However, there are no intracranial stent products with specifically associated simulation software. We report the "premarket" clinical trial of a new braided stent with a customized simulation software. METHODS A stent system with 3 mesh density types (16, 24, and 32 wire mesh) was designed based on computational flow dynamics technology, and a simulation software (virtual stent planner [VSP]) was developed for the optimal stent deployment planning. Stents were selected after simulation on preoperative 3D-processed angioimages, and accuracy of the VSP was evaluated. RESULTS Thirty-three unruptured intracranial aneurysms were successfully treated with VSP guidance. Twenty aneurysms (61%) were anterior circulation aneurysms, and 13 (39%) were posterior circulation aneurysms. The average aneurysm size was 7.1 mm, and the mean follow-up period was 19.2 months (11-39.0). There was no major recurrence or retreatment during follow-up, 2 morbidity cases, and no mortality. VSP planning presented slightly smaller stent dimensions compared with postdeployment: 24.2 vs 25.5 mm average, error -1.3 mm, and difference rate-5.46%. CONCLUSION Based on this result, the new stents and software guidance system were approved by the Ministry of Health and Welfare as a combined medical device. VSP provided precise deployment with minimal error compared with actual stent and can contribute to better stent deployment even for less experienced physicians.
Collapse
Affiliation(s)
- Issei Kan
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo , Japan
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy and Neurosurgery, Juntendo University Faculty of Medicine, Tokyo , Japan
| | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama , Japan
| | - Shigeru Nemoto
- Department of Endovascular surgery, Tokyo Medical and Dental University, Tokyo , Japan
| | - Soichiro Fujimura
- Department of Mechanical Engineering, Tokyo University of Science, Tokyo , Japan
- Division of Innovation for Medical Information Technology, Jikei University School of Medicine, Tokyo , Japan
| | - Toshihiro Ishibashi
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo , Japan
| | - Kazutaka Sumita
- Department of Endovascular surgery, Tokyo Medical and Dental University, Tokyo , Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama , Japan
| | - Kohsuke Teranishi
- Department of Neuroendovascular Therapy and Neurosurgery, Juntendo University Faculty of Medicine, Tokyo , Japan
| | - Tomonobu Kodama
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo , Japan
| | - Naoki Kato
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo , Japan
| | - Hiroyuki Takao
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo , Japan
- Division of Innovation for Medical Information Technology, Jikei University School of Medicine, Tokyo , Japan
| | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo , Japan
| |
Collapse
|
3
|
Yamada K, Imamura H, Ozaki S, Niwa A, Kushi Y, Yamada N, Ikedo T, Hamano E, Mori H, Iihara K, Yoshimura S, Kataoka H. A Review of Current Flow Diverters. JOURNAL OF NEUROENDOVASCULAR THERAPY 2024; 18:59-64. [PMID: 38559452 PMCID: PMC10973566 DOI: 10.5797/jnet.ra.2023-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/28/2023] [Indexed: 04/04/2024]
Abstract
Flow diverter (FD) devices are new-generation stents placed in the parent artery at the aneurysmal neck to obstruct intra-aneurysmal blood flow, thus favoring intra-aneurysmal thrombosis. In Japan, about eight years have passed since health insurance approval was granted for FD devices, and FD placement to treat aneurysms has become widespread. Treatment indications have also been expanded with the introduction of novel devices. At present, three types of FD (Pipeline, FRED, and Surpass Streamline) are available in Japan. This report represents a compilation of available FD technologies and describes the current consensus on this treatment.
Collapse
Affiliation(s)
- Kiyofumi Yamada
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Saya Ozaki
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Akihiro Niwa
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yuji Kushi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naoto Yamada
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Taichi Ikedo
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Eika Hamano
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hisae Mori
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| |
Collapse
|
4
|
Sathya A, Enriquez-Marulanda A, Young M, Shutran M, Taussky P, Ogilvy CS. Flow Diversion for the Treatment of Posterior Inferior Cerebellar Aneurysms: A Novel Classification of Posterior Inferior Cerebellar Artery Origin. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00980. [PMID: 38038473 DOI: 10.1227/ons.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/06/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Flow diversion (FD) for posterior circulation aneurysms, such as proximal posterior inferior cerebellar artery (PICA) aneurysms, remains "off-label" and controversial. Although there are reports of using FD in the vertebral artery (VA) to treat PICA aneurysms, the differences between structural PICA-origin variants have not been explored. We analyzed PICA aneurysms treated with FD, assessed radiographic and clinical outcomes, and presented a novel classification of the PICA origin in relationship to aneurysm anatomy. METHODS We performed a retrospective study of prospective data for intracranial aneurysms treated with FD at a major academic institution from 2013 to 2022. Proximal PICA aneurysms that underwent FD placement in the V4 segment of the vertebral artery were included for analysis. A literature review was performed on PubMed to evaluate previously published cases. The PICA origin was characterized by 4 distinct subtypes. Type 1 describes the PICA originating adjacent/separate to the aneurysm neck, Type 2 with the PICA originating from the aneurysm neck, Type 3 with the PICA originating from the aneurysm dome, and Type 4 (True PICA aneurysm) with the aneurysm located proximally on PICA, distal to the PICA-VA junction. RESULTS Thirteen proximal PICA aneurysms were identified and included in the analysis. Patients were primarily female (76.9%), with a median age of 62 years. The aneurysm median maximum diameter was 5.8 mm. From the total sample (institutional and literature review cases), type 1 had a 100% complete and near-complete occlusion rate, type 2 had 75.0%, type 3 had 88.9%, and type 4 had 75%. The overall complete and near-complete occlusion rate was 83.3% (20/24). CONCLUSION FD in the V4 VA segment is an effective way to treat proximal PICA aneurysms. Exploring the relationship between PICA origin is a helpful method in predicting occlusion rates for proximal PICA aneurysms and may lead to improved treatment considerations.
Collapse
Affiliation(s)
- Anvitha Sathya
- Neurosurgery Department, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Alejandro Enriquez-Marulanda
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Young
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Phillip Taussky
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
5
|
Suzuki Y, Toma N, Inoue K, Ichikawa T, Nishikawa H, Miura Y, Fujimoto M, Yasuda R, Maeda M, Suzuki H. Evaluation of Intra-Aneurysmal Residual Blood Flow with the iMSDE T1-Black Blood Imaging after Flow Diverter Treatment. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:159-166. [PMID: 37609573 PMCID: PMC10442175 DOI: 10.5797/jnet.oa.2023-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/25/2023] [Indexed: 08/24/2023]
Abstract
Objective We aimed to evaluate the efficacy of the "improved motion-sensitized driven-equilibrium (iMSDE)"-prepared T1-weighted black blood (T1-BB) MRI for monitoring treatment effect with a flow diverter (FD) for cerebral aneurysms. Methods Following the exclusion of concomitant coiling and retreatment cases from 60 consecutive cases of cerebral aneurysms treated with FDs at our institution, 32 with imaging data were included in the analysis. Detectability of residual blood flow within the aneurysms was validated as follows: 1) comparison of MRI sequences (iMSDE-prepared T1-BB images, T1-weighted images [ T1WI], and time-of-flight [ TOF]-MRA) in cases of incompletely occluded aneurysms and 2) comparison of angiography and MRI sequences in the same period. Results 1) The probability of diagnosing intra-aneurysmal blood flow was significantly higher with iMSDE-prepared T1-BB (iMSDE-prepared T1-BB vs. T1WI, p <0.001; iMSDE-prepared T1-BB vs. TOF-MRA, p <0.001). 2) The diagnostic accuracy of residual aneurysmal blood flow was significantly higher with iMSDE-prepared T1-BB than that with T1WI (p = 0.032). Furthermore, in cases of incomplete occlusion, the probability of detecting intra-aneurysmal blood flow was significantly higher with iMSDE-prepared T1-BB (iMSDE-prepared T1-BB vs. T1WI, p <0.001; iMSDE-prepared T1-BB vs. TOF-MRA, p = 0.023). Conclusion Our results demonstrated that iMSDE-prepared T1-BB could help distinguish between blood flow and thrombus within the aneurysms after FD treatment, especially in the early stages of FD treatment.
Collapse
Affiliation(s)
- Yume Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Naoki Toma
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Katsuhiro Inoue
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
| | - Tomonori Ichikawa
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hirofumi Nishikawa
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yoichi Miura
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masashi Fujimoto
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Ryuta Yasuda
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masayuki Maeda
- Department of Neuroradiology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| |
Collapse
|
6
|
Dong L, Liu Q, Chen X, Zhang L, Wang J, Peng Q, Li J, He H, Liu P, Lv M. Methylprednisolone is related to lower incidence of postoperative bleeding after flow diverter treatment for unruptured intracranial aneurysm. Front Aging Neurosci 2023; 15:1029515. [PMID: 37143689 PMCID: PMC10151685 DOI: 10.3389/fnagi.2023.1029515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 03/29/2023] [Indexed: 05/06/2023] Open
Abstract
Background and objectives Regarding the anti-inflammatory effect, methylprednisolone is a candidate to prevent patients with unruptured intracranial aneurysms (UIAs) from postoperative bleeding (PB) after flow diverter (FD) treatment. This study aimed to investigate whether methylprednisolone is related to a lower incidence of PB after FD treatment for UIAs. Methods This study retrospectively reviewed UIA patients receiving FD treatment between October 2015 and July 2021. All patients were observed until 72 h after FD treatment. The patients receiving methylprednisolone (80 mg, bid, for at least 24 h) were considered as standard methylprednisolone treatment (SMT) users, otherwise as non-SMT users. The primary endpoint indicated the occurrence of PB, including subarachnoid hemorrhage, intracerebral hemorrhage, and ventricular bleeding, within 72 h after FD treatment. This study compared the incidence of PB between SMT users and non-SMT users and investigated the protective effect of SMT on PB after FD treatment using the Cox regression model. Finally, after controlling the potential factors related to PB, we performed subgroup analysis to further confirm the protective effect of SMT on PB. Results This study finally included 262 UIA patients receiving FD treatment. PB occurred in 11 patients (4.2%), and 116 patients (44.3%) received SMT postoperatively. The median time from the end of surgery to PB was 12.3 h (range: 0.5-48.0 h). SMT users had a lower incidence of PB comparing with non-SMT users (1/116, 0.9% vs. 10/146, 6.8%, respectively; p = 0.017). The multivariate Cox analysis demonstrated that SMT users (HR, 0.12 [95%CI, 0.02-0.94], p = 0.044) had a lower risk of PB postoperatively. After controlling the potential factors related to PB (i.e., gender, irregular shape, surgical methods [FD and FD + coil] and UIA sizes), the patients receiving SMT still had a lower cumulative incidence of PB, comparing with patients receiving non-SMT (all p < 0.05). Conclusion SMT was correlated with the lower incidence of PB for patients receiving FD treatment and may be a potential method to prevent PB after the FD treatment.
Collapse
Affiliation(s)
- Linggen Dong
- Department of Neurosurgery Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Qingyuan Liu
- Department of Neurosurgery Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiheng Chen
- Department of Neurosurgery Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Longhui Zhang
- Department of Neurosurgery Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Jiejun Wang
- Department of Emergency, The Affiliated Wuxi No. 2 People’s Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - Qichen Peng
- Department of Neurosurgery Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Jiangan Li
- Department of Emergency, The Affiliated Wuxi No. 2 People’s Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - Hongwei He
- Department of Neurosurgery Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Peng Liu
- Department of Neurosurgery Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Peng Liu,
| | - Ming Lv
- Department of Neurosurgery Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- *Correspondence: Ming Lv,
| |
Collapse
|
7
|
Chen X, Gui S, Dong L, Zhang L, Ge H, Liu P, Li Y, Lv M. Case report: Covered stent placement to treat delayed aneurysmal rupture after flow diverter-assisted coil embolization. Front Neurol 2022; 13:964733. [PMID: 36419533 PMCID: PMC9676233 DOI: 10.3389/fneur.2022.964733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/17/2022] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Flow diverter (FD) placement is widely accepted as a treatment for large saccular intracranial aneurysms. Delayed aneurysmal rupture (DAR) after FD placement is potentially catastrophic and difficult to treat. To our knowledge, using a Willis covered stent (WCS) to treat DAR after placement of a Pipeline Flex embolization device (PFED) combined with coiling has not been previously reported. CASE PRESENTATION A 49-year-old woman with an incidental asymptomatic large right supraclinoid internal carotid artery aneurysm was treated with PFED placement and adjunctive coiling. DAR causing subarachnoid hemorrhage occurred 11 hours after the procedure. Treatment using a WCS was successful and resulted in a favorable clinical outcome (modified Rankin scale score 2). CONCLUSION DAR after FD implantation requires isolation of the aneurysm from the cerebral circulation as soon as possible. WCS placement can achieve this immediately and occlude the aneurysm. We hope our case could provide new idea for similar cases in the future.
Collapse
Affiliation(s)
- Xiheng Chen
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
- Beijing Engineering Research Center for Interventional Neuroradiology, Beijing, China
| | - Siming Gui
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
- Beijing Engineering Research Center for Interventional Neuroradiology, Beijing, China
| | - Linggen Dong
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Longhui Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Huijian Ge
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
- Beijing Engineering Research Center for Interventional Neuroradiology, Beijing, China
| | - Peng Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
- Beijing Engineering Research Center for Interventional Neuroradiology, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
- Beijing Engineering Research Center for Interventional Neuroradiology, Beijing, China
| | - Ming Lv
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
- Beijing Engineering Research Center for Interventional Neuroradiology, Beijing, China
| |
Collapse
|
8
|
Tsukagoshi E, Sato H, Kohyama S. Delayed aneurysm rupture in a patient treated with flow redirection endoluminal device: A case report and literature review. Surg Neurol Int 2022; 13:506. [DOI: 10.25259/sni_783_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Background:
Delayed aneurysm rupture after flow-redirection endoluminal device (FRED) implantation is rare. We report a case of internal carotid-cavernous fistula (CCF) caused by a delayed aneurysm rupture of the cavernous portion of the internal carotid artery (ICA) after FRED implantation.
Case Description:
A 75-year-old woman had a gradually enlarging aneurysm at the C4 portion of the left ICA. We performed FRED implantation for the same. The FRED implantation procedure was smooth and the FRED expanded well and attached to the vessel wall. Five days after surgery, the patient developed a strong headache, hyperemia of the left eye, and disturbance of the left eye movement. Magnetic resonance imaging and angiography revealed a left CCF with cortical venous reflux. We performed transarterial aneurysmal and transvenous cavernous sinus embolization. Postoperatively, angiography showed no fistula and complete occlusion of the aneurysm; however, minor eye movement disorder persisted.
Conclusion:
To prevent the development of delayed aneurysm rupture in patients treated with FRED, preoperative consideration of whether to add coil embolization is important, even if the aneurysm is located in the C4 portion of the ICA and there is no risk of subarachnoid hemorrhage, including the size of aneurysm. In this report, we have tried to alert surgeons regarding the risk of delayed aneurysm rupture due to FRED implantation.
Collapse
|
9
|
Marosfoi M, Orrù E, Rabinovich M, Newman S, Patel NV, Wakhloo AK. Endovascular Treatment of Intracranial Aneurysms. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00068-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
10
|
In-silico trial of intracranial flow diverters replicates and expands insights from conventional clinical trials. Nat Commun 2021; 12:3861. [PMID: 34162852 PMCID: PMC8222326 DOI: 10.1038/s41467-021-23998-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 05/25/2021] [Indexed: 01/18/2023] Open
Abstract
The cost of clinical trials is ever-increasing. In-silico trials rely on virtual populations and interventions simulated using patient-specific models and may offer a solution to lower these costs. We present the flow diverter performance assessment (FD-PASS) in-silico trial, which models the treatment of intracranial aneurysms in 164 virtual patients with 82 distinct anatomies with a flow-diverting stent, using computational fluid dynamics to quantify post-treatment flow reduction. The predicted FD-PASS flow-diversion success rates replicate the values previously reported in three clinical trials. The in-silico approach allows broader investigation of factors associated with insufficient flow reduction than feasible in a conventional trial. Our findings demonstrate that in-silico trials of endovascular medical devices can: (i) replicate findings of conventional clinical trials, and (ii) perform virtual experiments and sub-group analyses that are difficult or impossible in conventional trials to discover new insights on treatment failure, e.g. in the presence of side-branches or hypertension. In-silico trials rely on virtual populations and interventions simulated using patient-specific models and may offer a solution to lower costs. Here, the authors present the flow diverter performance assessment in-silico trial, which models the treatment of intracranial aneurysms with a flow-diverting stent.
Collapse
|
11
|
Hou K, Li G, Lv X, Xu B, Xu K, Yu J. Delayed rupture of intracranial aneurysms after placement of intra-luminal flow diverter. Neuroradiol J 2020; 33:451-464. [PMID: 32851918 PMCID: PMC7788679 DOI: 10.1177/1971400920953299] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Though flow diverter is a safe and efficient modality, some patients can experience delayed aneurysmal rupture. The mechanism of delayed rupture is still obscure to us. METHODS We performed a systematic search in the PubMed database for patients with delayed rupture of intracranial aneurysms after flow diverter placement. RESULTS A total of 36 articles reporting on 60 patients were included in the final analysis. Of the 49 patients with description of presenting symptoms, six (12.2%) patients were incidentally diagnosed, 39 (87.8%) patients were admitted for aneurysmal rupture or mass effect. Multiple flow diverters were used in 38.3% (18/47) of the patients. Coil assistance was applied in 13.0% (7/54) of the patients. Delayed aneurysmal rupture led to intracranial hemorrhage or carotid-cavernous sinus fistula (CCF) in 76.8% (43/56) and 23.2% (13/56) of the patients, respectively. Of the 55 patients with description of outcome, 14 (25.5%) patients achieved good recovery, one (1.8%) patient was severely disabled, 40 (72.7%) patients died. All of the patients in the CCF group survived and experienced good recovery. CONCLUSION Increased intra-aneurysmal pressure, destabilization of the aneurysm wall by intra-aneurysmal thrombus, persistent residual intra-aneurysmal flow, characteristics of the specific aneurysm, and mechanical injury by the flow diverter might conjointly contribute to the final delayed rupture. There has been no established preventive measure to decrease the incidence of delayed rupture yet. The treatment and outcome depend on the presentation of delayed rupture. Patients presenting with aneurysm-related intracranial hemorrhage have a dismal outcome. Those presenting with CCFs usually have a satisfactory recovery.
Collapse
Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Guichen Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Xianli Lv
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
- Jinlu Yu, Department of Neurosurgery, The First Hospital of Jilin University, 1 Xinmin Avenue, Changchun 130021, China.
| |
Collapse
|
12
|
Ocal O, Arat A. The Exchange-Free Technique: A Novel Technique for Enhancing Surpass Flow Diverter Placement. Asian J Neurosurg 2020; 15:620-626. [PMID: 33145216 PMCID: PMC7591168 DOI: 10.4103/ajns.ajns_374_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/26/2020] [Accepted: 04/18/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Following flow diverter placement, approximately 20% of intracranial aneurysms remain as residual aneurysms at 1 year. Device malapposition is a cause of residual aneurysms after flow diversion. We present a new and straightforward technique (exchange-free technique [EFT]) to enhance apposition of the surpass flow diverter (SFD), the only over-the-wire flow diverter currently available. Materials and Methods: We deployed laser-cut mini stents through the inner deployment catheter of the SFD. This maneuver was performed simply by withdrawing the micro-guidewire from its lumen and replacing it with a mini-stent (stents deliverable through microcatheters with inner diameter of 0.0165 inches), without a need to re-cross the deployed SFD or an exchange maneuver. All aneurysms in which this technique was utilized were retrospectively reviewed. Results: Twenty-eight patients (20 females) with 30 treated aneurysms were identified. The mean aneurysm diameter was 10.2 ± 6.6 mm. Technical success rate was 96.6% (29/30 aneurysms). There was no mortality or permanent morbidity related to the procedures. Except for the patient treated for an iatrogenic, surgery-related internal carotid artery pseudoaneurysm who died secondary to consequences of multiple surgeries, no cases of mortality or permanent morbidity were noted. Complete aneurysm occlusion rates were 78.2%, 82.1%, and 95.2% at 0–3, 3–6, and 9–12 months, respectively. None of the patients were re-treated. Conclusion: EFT is a simple and fast technique which was not associated with adverse effects in our series. The higher aneurysm obliteration rate obtained with EFT is probably the result of better wall apposition of the SFD.
Collapse
Affiliation(s)
- Osman Ocal
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Anıl Arat
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| |
Collapse
|
13
|
Fujii T, Oishi H, Teranishi K, Yatomi K, Suzuki K, Arai H. Outcome of flow diverter placement for intracranial aneurysm with dual antiplatelet therapy and oral anticoagulant therapy. Interv Neuroradiol 2020; 26:532-538. [PMID: 32727310 PMCID: PMC7645175 DOI: 10.1177/1591019920947878] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/14/2020] [Indexed: 10/24/2023] Open
Abstract
PURPOSE Antiplatelet therapy initiated before flow diverter placement is effective for the prevention of ischemic complications. However, the effectiveness of oral anticoagulant treatment is unclear. This retrospective study evaluated the complications and obliteration rates after flow diverter placement in patients taking anticoagulants. METHODS A total of 155 cases were treated by Pipeline Flex placement for unruptured large and giant cerebral aneurysms in our hospital between October 2015 and June 2019. The groups of 8 patients taking anticoagulants before operation and 147 patients not taking anticoagulants were compared. RESULTS Clopidogrel oral dose (P = 0.002) was significantly lower in the anticoagulant group. Delayed aneurysm rupture (P = 0.002) and additional treatment (P = 0.009) rates were significantly higher and complete obliteration rate (P = 0.011) was lower in the anticoagulant group. CONCLUSIONS Additional oral anticoagulant administration before flow diverter placement does not reduce ischemic complications compared to dual antiplatelet therapy, but does increase hemorrhagic complications, especially delayed aneurysm rupture. Complete obliteration of the cerebral aneurysm is difficult to achieve in patients taking anticoagulants.
Collapse
Affiliation(s)
- Takashi Fujii
- Department of Neuroendovascular Therapy, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy, Faculty of Medicine, Juntendo University, Tokyo, Japan
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kenji Yatomi
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kazumoto Suzuki
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Hajime Arai
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| |
Collapse
|
14
|
Kühn AL, Gounis MJ, Puri AS. Introduction: History and Development of Flow Diverter Technology and Evolution. Neurosurgery 2019; 86:S3-S10. [DOI: 10.1093/neuros/nyz307] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/15/2019] [Indexed: 11/12/2022] Open
Abstract
AbstractThe introduction of flow diverter technology to the field of neurointervention has revolutionized the treatment of intracranial aneurysms. The therapy approach has shifted from intrasaccular aneurysm treatment to exclusion of the aneurysm from the blood circulation with remodeling of the parent artery. Previously, “difficult”-to-treat aneurysms including fusiform and blister aneurysms, but also aneurysms arising from a diseased vessel segment, can now be safely and permanently treated with flow diverters. A little over a decade ago, after extensive bench testing and refinement of the flow diverter concept, the device was eventually available for clinical use and today it has become a standard treatment for intracranial aneurysms. Currently, United States Food and Drug Administration (FDA)-approved flow diverters are the Pipeline Embolization Device (Medtronic) and the Surpass Streamline Flow Diverter (Stryker). The devices can either be delivered or deployed via a standard femoral artery approach or a radial artery approach. Other considerations for catheter setup and device deployment strategies depending on aneurysm location or vessel anatomy are described.
Collapse
Affiliation(s)
- Anna Luisa Kühn
- Division of Neuroradiology, Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Matthew J Gounis
- Division of Neuroimaging and Intervention, New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Ajit S Puri
- Division of Neuroimaging and Intervention, New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| |
Collapse
|
15
|
Ting W, Richard SA, Changwei Z, Chaohua W, Xiaodong X. Delayed spontaneous rupture of cavernous segment of the internal carotid artery following dual ophthalmic segment aneurysms treatment with pipeline embolization device: A case report. Medicine (Baltimore) 2019; 98:e18420. [PMID: 31876716 PMCID: PMC6946193 DOI: 10.1097/md.0000000000018420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/31/2019] [Accepted: 11/14/2019] [Indexed: 11/29/2022] Open
Abstract
RATIONALE The incidence of double aneurysms on the ophthalmic segment of the internal carotid artery (ICA) is very rare. Nevertheless, delayed rupture of a parent artery instead of the aneurysmal sac following pipeline embolization device (PLED) is unusual. PATIENT CONCERNS We present a 72-year-old female who was admitted at our facility with gradual onset of nonspecific visual changes. DIAGNOSIS Conventional angiography revealed 2 aneurysms located at the ophthalmic segment of the left ICA. INTERVENTIONS Both aneurysms were successfully treated with PLED. OUTCOMES Two months after discharge, the patient was rushed into the emergency with bilateral conjunctival congestion. Computed tomography revealed intracranial hemorrhage at left temporal lobe while digital subtraction angiography established a left direct carotid cavernous fistula. We utilized stent (Solitaire 6*30) assisted coils to occlude the fistula. The patient is well and go about her normal duties. LESSIONS Manipulation of the tortuous parent artery resulted in a focal traumatic weakness in the artery and subsequently a delay tear. We are of the view that, endovascular surgeons should be on the lookout for this complication following flow deviation treatment modalities.
Collapse
Affiliation(s)
- Wang Ting
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P.R. China
- Department of Medicine, Princefield University, Ghana West Africa
| | - Zhang Changwei
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Wang Chaohua
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Xie Xiaodong
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P.R. China
| |
Collapse
|
16
|
Flow Diversion for Treatment of Partially Thrombosed Aneurysms: A Multicenter Cohort. World Neurosurg 2019; 135:e164-e173. [PMID: 31760188 DOI: 10.1016/j.wneu.2019.11.084] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Partially thrombosed intracranial aneurysms (PTIA) represent a unique subset of intracranial aneurysms with an ill-defined natural history, posing challenges to standard management strategies. This study aims to assess the efficacy of flow diversion in the treatment of this pathology. METHODS A retrospective review of patients with flow-diverted PTIA at 6 cerebrovascular centers was performed. Clinical and radiographic data were collected from the medical records, with the primary outcome of aneurysmal occlusion and secondary outcomes of clinical status and complications. RESULTS Fifty patients with 51 PTIA treated with flow diversion were included. Median age was 56.5 years. Thirty-three (64.7%) aneurysms were saccular and 16 (31.4%) were fusiform/dolichoectatic. The most common location was the internal carotid artery (54.9%) followed by the vertebral and basilar arteries (17.7% and 17.7%, respectively). Last imaging follow-up was performed at a median of 25.1 (interquartile range, 12.8-43) months. Complete occlusion at last radiographic follow-up was achieved in 37 (77.1%) aneurysms. Pretreatment aneurysm thrombosis of >50% was associated with a significantly lower rate of complete aneurysm occlusion (58.8 vs. 87.1%, P = 0.026) with a trend toward better functional outcome (modified Rankin scale <2) at last follow-up in patients with <50% pretreatment aneurysm thrombosis (96.8 vs. 82.4; P = 0.08). Ischemic complications occurred in 5 (9.8%) patients, producing symptoms in 4 (7.8%) and resultant mortality in 2 (4.2%) patients. CONCLUSIONS Flow diversion treatment of PTIA has adequate efficacy along with a reasonable safety profile. Aneurysms harboring large amounts of pretreatment thrombus were associated with lower rates of complete occlusion.
Collapse
|
17
|
Li W, Tian Z, Zhu W, Zhang YS, Wang K, Zhang Y, Wang Y, Yang X, Liu J. Hemodynamic Analysis of Postoperative Rupture of Unruptured Intracranial Aneurysms after Placement of Flow-Diverting Stents: A Matched Case-Control Study. AJNR Am J Neuroradiol 2019; 40:1916-1923. [PMID: 31624118 DOI: 10.3174/ajnr.a6256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/23/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Postoperative rupture of intracranial aneurysm has been reported as a fatal complication after flow-diverter placement. We assessed several hemodynamic variables to explore risk factors in the postoperative rupture process. MATERIALS AND METHODS We enrolled 10 patients with intracranial aneurysms, treated with flow diverters between September 2014 and December 2018, who experienced postoperative aneurysm rupture (postoperative aneurysm rupture group). We matched these subjects 1:2 with 20 patients with postoperative unruptured (postoperative unruptured group) intracranial aneurysms based on clinical and morphologic factors. Using computational fluid dynamics, we assessed hemodynamic changes pre- and posttreatment between the 2 groups on a number of qualitative and quantitative parameters. RESULTS In the postoperative aneurysm rupture group, the proportion of patients with aneurysms with an unstable flow pattern increased to 60.0% after treatment, while the proportion in the postoperative unruptured group decreased to 20.0%, a significant difference between the 2 groups (P = .028). Energy loss in the postoperative unruptured group decreased after treatment but increased in the postoperative aneurysm rupture group. The reduction ratio of energy loss showed a significant difference between the 2 groups (22.73% ± 53.59% for postoperative unruptured versus -158.81% ± 183.95% for postoperative aneurysm rupture, P = .02). Other parameters and changes of pre- and posttreatment hemodynamic parameters showed no significant difference between 2 groups. CONCLUSIONS Compared with pretreatment, unstable flow pattern and higher energy loss after Pipeline Embolization Device placement for intracranial aneurysm may be the important hemodynamic risk factors related to delayed aneurysm rupture.
Collapse
Affiliation(s)
- W Li
- From the Department of Interventional Neuroradiology (W.L., Z.T., W.Z., Y.S.Z., K.W., Y.Z., X.Y., J.L.), Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Z Tian
- From the Department of Interventional Neuroradiology (W.L., Z.T., W.Z., Y.S.Z., K.W., Y.Z., X.Y., J.L.), Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - W Zhu
- From the Department of Interventional Neuroradiology (W.L., Z.T., W.Z., Y.S.Z., K.W., Y.Z., X.Y., J.L.), Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Y S Zhang
- From the Department of Interventional Neuroradiology (W.L., Z.T., W.Z., Y.S.Z., K.W., Y.Z., X.Y., J.L.), Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - K Wang
- From the Department of Interventional Neuroradiology (W.L., Z.T., W.Z., Y.S.Z., K.W., Y.Z., X.Y., J.L.), Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Y Zhang
- From the Department of Interventional Neuroradiology (W.L., Z.T., W.Z., Y.S.Z., K.W., Y.Z., X.Y., J.L.), Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Y Wang
- Department of Neurosurgery (Y.W.), The First Affiliated Hospital of Nanchang University, Nanchang University, Nanchang, China
| | - X Yang
- From the Department of Interventional Neuroradiology (W.L., Z.T., W.Z., Y.S.Z., K.W., Y.Z., X.Y., J.L.), Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - J Liu
- From the Department of Interventional Neuroradiology (W.L., Z.T., W.Z., Y.S.Z., K.W., Y.Z., X.Y., J.L.), Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
18
|
Sarrami-Foroushani A, Lassila T, Hejazi SM, Nagaraja S, Bacon A, Frangi AF. A computational model for prediction of clot platelet content in flow-diverted intracranial aneurysms. J Biomech 2019; 91:7-13. [PMID: 31104921 DOI: 10.1016/j.jbiomech.2019.04.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 03/14/2019] [Accepted: 04/30/2019] [Indexed: 01/30/2023]
Abstract
Treatment of intracranial aneurysms with flow-diverting stents is a safe and minimally invasive technique. The goal is stable embolisation that facilitates stent endothelialisation, and elimination of the aneurysm. However, it is not fully understood why some aneurysms fail to develop a stable clot even with sufficient levels of flow reduction. Computational prediction of thrombus formation dynamics can help predict the post-operative response in such challenging cases. In this work, we propose a new model of thrombus formation and platelet dynamics inside intracranial aneurysms. Our novel contribution combines platelet activation and transport with fibrin generation, which is key to characterising stable and unstable thrombus. The model is based on two types of thrombus inside aneurysms: red thrombus (fibrin- and erythrocyte-rich) can be found in unstable clots, while white thrombus (fibrin- and platelet-rich) can be found in stable clots. The thrombus generation model is coupled to a CFD model and the flow-induced platelet index (FiPi) is defined as a quantitative measure of clot stability. Our model is validated against an in vitro phantom study of two flow-diverting stents with different sizing. We demonstrate that our model accurately predicts the lower thrombus stability in the oversized stent scenario. This opens possibilities for using computational simulations to improve endovascular treatment planning and reduce adverse events, such as delayed haemorrhage of flow-diverted aneurysms.
Collapse
Affiliation(s)
- Ali Sarrami-Foroushani
- Centre for Computational Imaging and Simulation Technologies in Biomedicine (CISTIB), School of Computing, University of Leeds, Leeds, UK
| | - Toni Lassila
- Centre for Computational Imaging and Simulation Technologies in Biomedicine (CISTIB), School of Computing, University of Leeds, Leeds, UK
| | - Seyed Mostafa Hejazi
- Department of Electronic and Electrical Engineering, The University of Sheffield, Sheffield, UK
| | | | - Andrew Bacon
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, UK
| | - Alejandro F Frangi
- Centre for Computational Imaging and Simulation Technologies in Biomedicine (CISTIB), School of Computing, University of Leeds, Leeds, UK; Biomedical Imaging Department, Leeds Institute for Cardiovascular and Metabolic Medicine (LICAMM), School of Medicine, University of Leeds, Leeds, UK.
| |
Collapse
|
19
|
Ocal O, Arat A. Intra-aneurysmal air after flow diversion treatment in intracranial aneurysms: incidence, characteristics and clinical significance. Jpn J Radiol 2019; 37:549-554. [PMID: 31062213 DOI: 10.1007/s11604-019-00842-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 04/27/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To describe the rate and characteristics of air bubble retention (ABR) within cerebral aneurysms treated by flow diversion. METHODS Procedural flat detector CT (FDCT) studies were scrutinized for the presence of air bubbles (density < - 200 HU) in patients treated by flow diversion. Patients with intrasaccular treatment or previous clipping were excluded. Clinical outcomes, procedural angiograms, aneurysm characteristics and imaging features of air within the aneurysm were evaluated. RESULTS Bubbles were noted in 17.1% of 105 aneurysms in 85 FDCTs. Aneurysms with ABR were significantly larger (mean diameter: 18.9 versus 7.5 mm, P < 0.0001). There was a trend for the use of multiple devices during the treatment of these aneurysms (72.2% vs 49.4%, P = 0.071). All of the bubbles were located rostrally in the aneurysm sac and were smaller than 6 mm (mean diameter: 2.1 ± 1.3 mm). None of the patients had post-procedural neurological deterioration. The air had spontaneously disappeared on follow-up CT images (available in 12 patients) obtained at a mean follow-up duration of 48 h. CONCLUSIONS ABR is not infrequent in cerebral flow diversion procedures. It is a clinically silent and self-limited technical complication. We propose air entrapment or filtration through the flow diverter as causative factors.
Collapse
Affiliation(s)
- Osman Ocal
- Department of Radiology, Faculty of Medicine, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Anıl Arat
- Department of Radiology, Faculty of Medicine, School of Medicine, Hacettepe University, Ankara, Turkey.
| |
Collapse
|
20
|
Atallah E, Saad H, Li J, Kumar A, Tjoumakaris S, Chalouhi N, Hasan D, Zarzour H, Herial N, Gooch MR, Rosenwasser RH, Jabbour P. The Experience With Flow Diverters in the Treatment of Posterior Inferior Cerebellar Artery Aneurysms. Oper Neurosurg (Hagerstown) 2019; 17:8-13. [DOI: 10.1093/ons/opy301] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 09/12/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Hassan Saad
- Department of Neurological Surgery, Arkansas Neuroscience Institute, CHI St. Vincent, Little Rock, Arkansas
| | - Jonathan Li
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Ayan Kumar
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- Department of Neurological Surgery, Iowa University Hospital and Clinics, Iowa City, Iowa
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nabeel Herial
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Michael Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| |
Collapse
|
21
|
Helthuis JHG, Bhat S, van Doormaal TPC, Kumar RK, van der Zwan A. Proximal and Distal Occlusion of Complex Cerebral Aneurysms-Implications of Flow Modeling by Fluid-Structure Interaction Analysis. Oper Neurosurg (Hagerstown) 2018; 15:217-230. [PMID: 29281095 DOI: 10.1093/ons/opx236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 10/10/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In complex cerebral aneurysms, adequate treatment by complete occlusion is not always possible. Partial occlusion by either proximal or distal occlusion is an alternative. However, the hemodynamic consequences of these partial occlusion options are often not easily predictable. OBJECTIVE To assess the feasibility of fluid-structure interaction (FSI) analysis to investigate the hemodynamic changes after partial occlusion in cerebral aneurysms. METHODS Two patients were analyzed. One was treated by proximal occlusion and 1 by distal occlusion. In both, flow replacement bypass surgery was performed. Three-dimensional models were constructed from magnetic resonance angiography (MRA) scans and used for FSI analysis. A comparative study was done for pre- and postoperative conditions. Postoperative thrombosis was modeled and analyzed for the distal occlusion. FSI results were compared to postoperative angiograms and computed tomography (CT)-scans. RESULTS Proximal occlusion resulted in reduction of velocity, wall shear stresses, and disappearance of helical flow patterns in the complete aneurysm. Distal occlusion showed a decrease of velocity and wall shear stress in the dome of the aneurysm. Results were validated against postoperative CT-scans and angiograms at 1-, 7-, and 9-mo follow-up. Addition of thrombus to the distal occlusion model showed no change in velocities and luminal pressure but resulted in decrease in wall tension. CONCLUSION This pilot study showed hemodynamic changes in 2 patients with proximal and distal occlusion of complex cerebral aneurysms. The FSI results were in line with the follow-up CT scans and angiograms and indicate the potential of FSI as a tool in patient-specific surgical interventions.
Collapse
Affiliation(s)
- Jasper H G Helthuis
- Department of Neurology and Neuro-surgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.,Brain Technology Institute, Utrecht, The Netherlands
| | - Sindhoor Bhat
- Department of Engineering Design, Indian Institute of Technology Madras, Chennai, India
| | - Tristan P C van Doormaal
- Department of Neurology and Neuro-surgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.,Brain Technology Institute, Utrecht, The Netherlands
| | | | - Albert van der Zwan
- Department of Neurology and Neuro-surgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.,Brain Technology Institute, Utrecht, The Netherlands
| |
Collapse
|
22
|
Fahed R, Darsaut TE, Kotowski M, Salazkin I, Raymond J. Re-treatment of residual aneurysms after flow diversion: An experimental study. Neuroradiol J 2018. [PMID: 29513077 DOI: 10.1177/1971400918763198] [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: 10/17/2022] Open
Abstract
Aim Flow diverters are increasingly used to treat aneurysms, but treatment is not always effective. The management of aneurysms that fail to occlude following flow diversion is problematic. We aimed to reproduce failures in an animal model and study re-treatment with additional flow diverters alone or with flow diverters and liquid embolic agent. Material and methods Twenty wide-necked aneurysms were created at the carotid-lingual bifurcation in 10 dogs, and were treated with flow diverters 4-6 weeks later. Follow-up angiography was performed at three months. Suitable residual aneurysms were randomly allocated: re-treatment with flow diverters alone ( n = 6), or with the injection of liquid embolic between two layers of flow diverters ( n = 4) or no re-treatment ( n = 2). Angiography was repeated three months later, followed by euthanasia, photography and pathology. Results Patent wide-necked aneurysms were produced in 17/20 attempts (85%); three months after flow diversion there were 15/17 (88%) residual aneurysms. In three cases, re-treatment was not possible because the flow diverter had prolapsed into the aneurysm, leaving 12 aneurysms to study. Re-treated aneurysms showed improved angiographic results at six months (median score of 2; P = 0.03), but residual aneurysms were present in all cases. Parent artery occlusion occurred in two aneurysms treated with flow diverter plus liquid embolic. At pathology, aneurysms were only partially filled with thrombus; leaks through the flow diverters were found in the neointima connecting the arterial lumen to residual aneurysms. Conclusion Re-treatment of residual flow-diverted experimental aneurysms with additional flow diverters did not lead to aneurysm occlusion.
Collapse
Affiliation(s)
- Robert Fahed
- 1 Interventional Neuroradiology Research Laboratory, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, Canada.,2 Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Tim E Darsaut
- 3 Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Canada
| | - Marc Kotowski
- 1 Interventional Neuroradiology Research Laboratory, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, Canada.,4 Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Igor Salazkin
- 1 Interventional Neuroradiology Research Laboratory, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, Canada
| | - Jean Raymond
- 1 Interventional Neuroradiology Research Laboratory, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, Canada.,4 Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| |
Collapse
|
23
|
McDonald RJ, McDonald JS, Kallmes DF, Lanzino G, Cloft HJ. Periprocedural safety of Pipeline therapy for unruptured cerebral aneurysms: Analysis of 279 Patients in a multihospital database. Interv Neuroradiol 2018; 21:6-10. [PMID: 25934768 DOI: 10.1177/1591019915576289] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The relative safety of unruptured aneurysm treatment with coiling versus flow diversion therapy is unknown. Most data available on flow diversion reflect highly focused patient groups and very experienced operators. We evaluated a national, multihospital patient database to examine periprocedural morbidity and mortality in patients treated with endovascular flow diversion therapy. The Premier Perspective database was used to identify patients hospitalized between May 2011 and March 2013 for unruptured aneurysm who underwent flow diversion therapy with a Pipeline embolization device. The risk of in-hospital mortality and morbidity was determined using ICD 9 codes. A total of 279 unruptured aneurysm patients at 18 medical centers underwent endovascular therapy with a Pipeline device. Adverse outcomes included in-hospital mortality in two cases (0.7%), discharge to long-term care in 22 cases (7.9%), ischemic complications in 14 cases (5.0%), hemorrhagic complications in four cases (1.4%), and postoperative neurological complications in nine cases (3.2%). This study of a large cohort of patient hospitalizations in the United States provides preliminary data on flow diversion in a "real world" scenario and demonstrates that the periprocedural morbidity and mortality is not negligible and must be considered in the context of the natural history of the aneurysms that are being treated.
Collapse
Affiliation(s)
| | | | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Harry J Cloft
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
24
|
Dmytriw AA, Adeeb N, Kumar A, Griessenauer CJ, Phan K, Ogilvy CS, Foreman PM, Shallwani H, Limbucci N, Mangiafico S, Michelozzi C, Krings T, Pereira VM, Matouk CC, Zhang Y, Harrigan MR, Shakir HJ, Siddiqui AH, Levy EI, Renieri L, Cognard C, Thomas AJ, Marotta TR. Flow Diversion for the Treatment of Basilar Apex Aneurysms. Neurosurgery 2018. [DOI: 10.1093/neuros/nyx628] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Adam A Dmytriw
- Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, Ontario, Canada
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Nimer Adeeb
- Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Ashish Kumar
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christoph J Griessenauer
- Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Kevin Phan
- Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Christopher S Ogilvy
- Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Paul M Foreman
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Hussain Shallwani
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, New York
| | - Nicola Limbucci
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy
| | - Salvatore Mangiafico
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy
| | - Caterina Michelozzi
- Department of Diagnostic and Therapeutic Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Timo Krings
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Vitor Mendes Pereira
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Charles C Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Yuchen Zhang
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Hakeem J Shakir
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, New York
| | - Leonardo Renieri
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Ajith J Thomas
- Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Thomas R Marotta
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
25
|
ReXiaTi N, AiKeReMu R, KaDeEr K, Fan YD, Feng ZH, Wang K, SuErTanNiYa T, Dou TT, Wu HQ, AiSha M, Cheng XJ. Short-term efficacy of pipeline embolization device for treating complex intracranial aneurysms. Biomed Mater Eng 2018; 29:137-146. [PMID: 29457589 DOI: 10.3233/bme-171718] [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: 10/18/2022]
Abstract
OBJECTIVE To observe the short-term efficacy of Pipeline embolization divice (PED) for the treatment of complex intracranial aneurysms. METHODS The clinical data of 29 consecutive patients with 32 intracranial aneurysms treated with PED between April 2015 to September 2016 were analyzed retrospectively. There were 3 small aneurysm, 15 large aneurysms, 8 giant aneurysms, 5 fusiform ayneurysms and 1 recidivation. The vessels include 25 anterior circulation and 4 posterior circulation. RESULTS We treated 31 aneurysms with 30 PEDs and all of the stents were implanted successfully. 1 case of single aneurysm was multiple divices implanted and 1 case of 3 aneurysms were treated by single PED. 12 of the 29 patients were implanted PED only, 17 were implanted PED with coils, 2 underwent balloon remodeling after the PED implanted. The ostia of 19 ophthalmic arteries, 10 posterior communicating arteries, 4 posterior inferior cerebellar arteries and 1 anterior cerebral artery were covered by PED during procedures; 1 ophthalmic arteries and 1 posterior communicating artery disappeared, no branch vessels occlusion and parent artery stenosis occurred.Hemorrhagic complacations occurred in 2 patients, 2 hours and 5 days after procedure respectively. Radiographic follow-up examnations were carried out in 24 patients and revealed complete occlusion in 21 patients, uncomplete occlusion in 3 patients. No neurological injure occurred in 27 patients who received a clinical follow-up. CONCLUSION PED provide a safe and effective methord for the treatment of intracranial complex aneurysms like wide-neck aneurysms, fusiform aneurysms, giant aneurysms in low risk of procedural complications and high rates of aneurysm occlusion.
Collapse
Affiliation(s)
- NiZaMiDingJiang ReXiaTi
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - ReXiDan AiKeReMu
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - KaHeErMan KaDeEr
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Yan-Dong Fan
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Zhao-Hai Feng
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Kai Wang
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - TeWuErBaTi SuErTanNiYa
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Tao-Tao Dou
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Hai-Qiang Wu
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - MaiMaiTiLi AiSha
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| | - Xiao-Jiang Cheng
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, China
| |
Collapse
|
26
|
Capo G, Vescovi MC, Toniato G, Petralia B, Gavrilovic V, Skrap M. Giant vertebral aneurysm: A case report detailing successful treatment with combined stenting and surgery. Surg Neurol Int 2018; 9:6. [PMID: 29416903 PMCID: PMC5791511 DOI: 10.4103/sni.sni_170_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 10/10/2017] [Indexed: 01/20/2023] Open
Abstract
Background Giant aneurysms (>25 mm) arising from the vertebral artery (VA) often present with slow progression of symptoms and signs because of gradual brainstem and cranial nerve compression. The underlying pathophysiology is not well understood, and treatment, wherever possible, is tailored to each singular case. Endovascular management does not usually solve the problem of mass compression, whereas surgical treatment involves several complications. Case Description A 58-year-old woman presented with a continuously growing giant right VA aneurysm, partially thrombosed, even after endovascular treatment (placement of two diversion flow stents). Operative partial aneurysmectomy and intraoperative placement of an endovascular balloon allowed removal from circulation without significant bleeding with a good neurological outcome. Conclusions The variability of VA thrombosed giant aneurysms implies a customized therapeutic strategy. Combined endovascular techniques and surgical clipping allow safe and successful trapping and aneurysmectomy. This case highlights the benefits of treating similar pathologies with a combination of both techniques.
Collapse
Affiliation(s)
- Gabriele Capo
- Department of Neurosurgery, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Maria C Vescovi
- Department of Neurosurgery, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Giovanni Toniato
- Department of Neurosurgery, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Benedetto Petralia
- Department of Neuroradiology, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Vladimir Gavrilovic
- Department of Neuroradiology, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Miran Skrap
- Department of Neurosurgery, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| |
Collapse
|
27
|
Srinivasan VM, Ghali MGZ, Reznik OE, Cherian J, Mokin M, Dumont TM, Gaughen JR, Grandhi R, Puri AS, Chen SR, Johnson JN, Kan P. Flow diversion for the treatment of posterior inferior cerebellar artery aneurysms: a novel classification and strategies. J Neurointerv Surg 2017; 10:663-668. [DOI: 10.1136/neurintsurg-2017-013427] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 11/04/2022]
Abstract
BackgroundThe pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, treatment of posterior inferior cerebellar artery (PICA) aneurysms with flow diversion (FD) has not been specifically described or discussed. While there are reports of treating PICA aneurysms using placement of FD stents in the vertebral artery, there are no reports of treating these lesions by placement of flow diverting stents in the PICA vessel itself. Due to the unique anatomy and morphology of these aneurysms, it requires special attention. We assessed our multi-institutional experience treating these lesions, including the first reported cases of the PED placed within the PICA.MethodsInstitutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with the PED. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases of PICA aneurysms treated with the PED. PICA aneurysms were defined as aneurysms that involved the PICA. Vertebral aneurysms without disease in the PICA were excluded from the study.Results10 PICA aneurysms were treated during the study period. These were classified based on their morphology and location into two main types and five total subtypes for consideration of treatment with flow diversion. All aneurysms were successfully treated, with 8/10 completely obliterated and 2 with a partial reduction in size. Three patients had the PED placed entirely in the PICA and no patient suffered from a medullary or cerebellar stroke. All PEDs were patent and all patients were independent at the last follow-up.ConclusionsThe PED may be used successfully to treat select aneurysms of the PICA. We present the first described cases of successful PED treatment of PICA aneurysms with direct placement of the PED in the PICA vessel itself. The proposed classification system aids in that selection.
Collapse
Affiliation(s)
| | | | - Oleg E Reznik
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jacob Cherian
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Maxim Mokin
- Departments of Neurology and Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Travis M Dumont
- Division of Neurosurgery, University of Arizona, Tucson, Arizona, USA
| | - John R Gaughen
- Sentara Martha Jefferson Medical and Surgical Associates, Charlottesville, Virginia, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Texas at San Antonio, San Antonio, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Stephen R Chen
- Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremiah N Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
28
|
Becske T, Potts MB, Shapiro M, Kallmes DF, Brinjikji W, Saatci I, McDougall CG, Szikora I, Lanzino G, Moran CJ, Woo HH, Lopes DK, Berez AL, Cher DJ, Siddiqui AH, Levy EI, Albuquerque FC, Fiorella DJ, Berentei Z, Marosföi M, Cekirge SH, Nelson PK. Pipeline for uncoilable or failed aneurysms: 3-year follow-up results. J Neurosurg 2017; 127:81-88. [DOI: 10.3171/2015.6.jns15311] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe long-term effectiveness of endovascular treatment of large and giant wide-neck aneurysms using traditional endovascular techniques has been disappointing, with high recanalization and re-treatment rates. Flow diversion with the Pipeline Embolization Device (PED) has been recently used as a stand-alone therapy for complex aneurysms, showing significant improvement in effectiveness while demonstrating a similar safety profile to stent-supported coil treatment. However, relatively little is known about its long-term safety and effectiveness. Here the authors report on the 3-year safety and effectiveness of flow diversion with the PED in a prospective cohort of patients with large and giant internal carotid artery aneurysms enrolled in the Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial.METHODSThe PUFS trial is a prospective study of 107 patients with 109 aneurysms treated with the PED. Primary effectiveness and safety end points were demonstrated based on independently monitored 180-day clinical and angiographic data. Patients were enrolled in a long-term follow-up protocol including 1-, 3-, and 5-year clinical and imaging follow-up. In this paper, the authors report the midstudy (3-year) effectiveness and safety data.RESULTSAt 3 years posttreatment, 74 subjects with 76 aneurysms underwent catheter angiography as required per protocol. Overall, complete angiographic aneurysm occlusion was observed in 71 of these 76 aneurysms (93.4% cure rate). Five aneurysms were re-treated, using either coils or additional PEDs, for failure to occlude, and 3 of these 5 were cured by the 3-year follow-up. Angiographic cure with one or two treatments of Pipeline embolization alone was therefore achieved in 92.1%. No recanalization of a previously completely occluded aneurysm was noted on the 3-year angiograms. There were 3 (2.6%) delayed device- or aneurysm-related serious adverse events, none of which led to permanent neurological sequelae. No major or minor late-onset hemorrhagic or ischemic cerebrovascular events or neurological deaths were observed in the 6-month through 3-year posttreatment period. Among 103 surviving patients, 85 underwent functional outcome assessment in which modified Rankin Scale scores of 0–1 were demonstrated in 80 subjects.CONCLUSIONSPipeline embolization is safe and effective in the treatment of complex large and giant aneurysms of the intracranial internal carotid artery. Unlike more traditional endovascular treatments, flow diversion results in progressive vascular remodeling that leads to complete aneurysm obliteration over longer-term follow-up without delayed aneurysm recanalization and/or growth.Clinical trial registration no.: NCT00777088 (clinicaltrials.gov)
Collapse
Affiliation(s)
| | - Matthew B. Potts
- Departments of 1Radiology,
- 3Neurological Surgery, Neurointerventional Service, NYU School of Medicine, NYU Langone Medical Center, New York, New York
| | | | | | | | - Isil Saatci
- 5Department of Radiology, Bayindir Hospital, Ankara, Turkey
| | - Cameron G. McDougall
- 6Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | | | - Christopher J. Moran
- 8Division of Interventional Neuroradiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Henry H. Woo
- 9Department of Neurosurgery, Stony Brook Hospital, Stony Brook, New York
| | - Demetrius K. Lopes
- 10Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | | | | | - Adnan H. Siddiqui
- 13Departments of Neurological Surgery and Radiology, University of Buffalo, Buffalo, New York
| | - Elad I. Levy
- 13Departments of Neurological Surgery and Radiology, University of Buffalo, Buffalo, New York
| | - Felipe C. Albuquerque
- 6Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - David J. Fiorella
- 9Department of Neurosurgery, Stony Brook Hospital, Stony Brook, New York
| | | | | | | | - Peter K. Nelson
- Departments of 1Radiology,
- 3Neurological Surgery, Neurointerventional Service, NYU School of Medicine, NYU Langone Medical Center, New York, New York
| |
Collapse
|
29
|
McDougall CM, Khan K, Saqqur M, Jack A, Rempel J, Derksen C, Xi Y, Chow M. Ultrasound for the evaluation of stenosis after flow diversion. J Neurointerv Surg 2017; 10:297-300. [DOI: 10.1136/neurintsurg-2017-013049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/10/2017] [Accepted: 04/22/2017] [Indexed: 11/03/2022]
Abstract
Background and purposeFlow diversion is a relatively new strategy used to treat complex cerebral aneurysms. The optimal method for radiographic follow-up of patients treated with flow diverters has not been established. The rate and clinical implications of in-stent stenosis for these devices is unclear. We evaluate the use of transcranial Doppler ultrasound (TCD) for follow-up of in-stent stenosis.Materials and methodsWe analyzed 28 patients treated with the Pipeline embolization device (PED) over the course of 42 months from January 2009 to June 2012. Standard conventional cerebral angiograms were performed in all patients. TCD studies were available in 23 patients.ResultsAngiographic and TCD results were compared and found to correlate well.ConclusionsTCD is a potentially useful adjunct for evaluating in-stent stenosis after flow diversion.
Collapse
|
30
|
Ishii A, Chihara H, Kikuchi T, Arai D, Ikeda H, Miyamoto S. Contribution of the straightening effect of the parent artery to decreased recanalization in stent-assisted coiling of large aneurysms. J Neurosurg 2016; 127:1063-1069. [PMID: 28009233 DOI: 10.3171/2016.9.jns16501] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The durability of embolization of large aneurysms is enhanced by use of the neck-bridging stent. However, it remains unclear what factors contribute to decreased recanalization. The purpose of this study was to demonstrate the contribution of the straightening effect of the parent artery to the durability of stent-assisted coiling for large aneurysms. METHODS Of the 182 aneurysms treated by embolization since the introduction of the neurovascular stent, 82 consecutive unruptured aneurysms with a diameter greater than 7 mm were selected. There were 52 aneurysms treated with a stent (Group S) and 30 treated without a stent (Group NS). Occlusion status was evaluated 12 months after embolization with digital subtraction angiography. The vascular angle of the parent artery was measured before, immediately after, and 12 months after embolization. The rates of recanalization were compared between Group S and Group NS. In Group S, the rates of recanalization were further compared between those aneurysms with and without a significant angle change. RESULTS The rate of major recanalization was 9.6% in Group S and 26.7% in Group NS. The volume embolization ratio was 32.6% in Group S and 31.6% in Group NS, with no statistically significant difference. However, the angulation change before and after coiling was significantly higher in Group S (10.6°) than in Group NS (0.9°). The difference in the angulation was more evident 12 months after coiling (19.1° in Group S and 1.5° in Group NS). In Group S, recanalization was found in 14.3% of 35 stented aneurysms without a significant angular change when a significant angular change was defined as more than 20°. In contrast, all 17 aneurysms with ≥ 20° of angular change remained occluded. CONCLUSIONS Significant angular change of ≥ 20° most likely leads to decreased recanalization following stent-assisted embolization of large aneurysms.
Collapse
Affiliation(s)
- Akira Ishii
- Department of Neurosurgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Hideo Chihara
- Department of Neurosurgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Takayuki Kikuchi
- Department of Neurosurgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Daisuke Arai
- Department of Neurosurgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Hiroyuki Ikeda
- Department of Neurosurgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| |
Collapse
|
31
|
An Intraoperative Look at Failure of Flow Diversion: When Additional or Alternative Treatments Should Be Considered. World Neurosurg 2016; 93:486.e7-486.e12. [DOI: 10.1016/j.wneu.2016.06.131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 11/17/2022]
|
32
|
Hemodynamic Effect of Flow Diverter and Coils in Treatment of Large and Giant Intracranial Aneurysms. World Neurosurg 2016; 89:199-207. [DOI: 10.1016/j.wneu.2016.01.079] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/27/2016] [Accepted: 01/27/2016] [Indexed: 11/19/2022]
|
33
|
|
34
|
Raychev R, Tateshima S, Vinuela F, Sayre J, Jahan R, Gonzalez N, Szeder V, Duckwiler G. Predictors of thrombotic complications and mass effect exacerbation after pipeline embolization: The significance of adenosine diphosphate inhibition, fluoroscopy time, and aneurysm size. Interv Neuroradiol 2015; 22:34-41. [PMID: 26537850 DOI: 10.1177/1591019915609125] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/03/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The mechanisms leading to delayed rupture, distal emboli and intraparenchymal hemorrhage in relation to pipeline embolization device (PED) placement remain debatable and poorly understood. The aim of this study was to identify clinical and procedural predictors of these perioperative complications. METHODS We conducted a retrospective review of consecutive patients who underwent PED placement. We utilized a non-commercial platelet aggregation method measuring adenosine diphosphate (ADP)% inhibition for evaluation of clopidogrel response. To our knowledge, this is the first study to test ADP in neurovascular procedures. Multivariable regression analysis was used to identify the strongest predictor of three separate outcomes: (1) thrombotic complications, (2) hemorrhagic complications, and (3) aneurysm mass effect exacerbation RESULTS Permanent complication-related morbidity and mortality at 3 months was 6% (3/48). No specific predictors of hemorrhagic complications were identified. In the univariate analysis, the strongest predictors of thrombotic complications were: ADP% inhibition<49 (p=0.01), aneurysm size (p=0.04) and fluoroscopy time (p=0.002). In the final multivariate analysis, among all baseline variables, fluoroscopy time exceeding 52 min was the only factor associated with thrombotic complications (p=0.007). Aneurysm size≥18 mm was the single predictor of mass effect exacerbation (p=0.039). CONCLUSIONS Procedural complexity, reflected by fluoroscopy time, is the strongest predictor of thrombotic complications in this study. ADP% inhibition is a reliable method of testing clopidogrel response in neurovascular procedures and values of <50% may predict thrombotic complications. Interval mass effect exacerbation after PED placement may be anticipated in large aneurysms exceeding 18 mm.
Collapse
|
35
|
Ikeda H, Ishii A, Kikuchi T, Ando M, Chihara H, Arai D, Hattori E, Miyamoto S. Delayed aneurysm rupture due to residual blood flow at the inflow zone of the intracranial paraclinoid internal carotid aneurysm treated with the Pipeline embolization device: Histopathological investigation. Interv Neuroradiol 2015; 21:674-83. [PMID: 26500232 DOI: 10.1177/1591019915609121] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/30/2015] [Indexed: 11/17/2022] Open
Abstract
Cerebral aneurysm rupture is a serious complication that can occur after flow diverter (FD) placement, but the underlying mechanisms remain unclear. We encountered a case in which direct stress on the aneurysm wall caused by residual blood flow at the inflow zone near the neck during the process of thrombosis after FD placement appeared associated with aneurysm rupture. The patient was a 67-year-old woman with progressive optic nerve compression symptoms caused by a large intracranial paraclinoid internal carotid aneurysm. The patient had undergone treatment with a Pipeline embolization device (PED) with satisfactory adherence between the PED and vessel wall. Surgery was completed without complications, and optic nerve compression symptoms improved immediately after treatment. Postoperative clinical course was satisfactory, but the patient suddenly died 34 days postoperatively. Autopsy confirmed the presence of subarachnoid hemorrhage caused by rupture of the internal carotid aneurysm that had been treated with PED. Although the majority of the aneurysm lumen including the outflow zone was thrombosed, a non-thrombosed area was observed at the inflow zone. Perforation was evident in the aneurysm wall at the inflow zone near the neck, and this particular area of aneurysm wall was not covered in thrombus. Macrophage infiltration was not seen on immunohistochemical studies of the aneurysm wall near the perforation. A hemodynamically unstable period during the process of complete thrombosis of the aneurysm lumen after FD placement may be suggested, and blood pressure management and appropriate management with antiplatelet therapy may be important.
Collapse
Affiliation(s)
- Hiroyuki Ikeda
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan
| | - Akira Ishii
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan
| | - Takayuki Kikuchi
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan
| | - Mitsushige Ando
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan
| | - Hideo Chihara
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan
| | - Daisuke Arai
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan
| | - Etsuko Hattori
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan
| |
Collapse
|
36
|
Aneurysmal and Perianeurysmal Changes After Endovascular Treatment: from Inflammation to Microbleed. A Case Report. Clin Neuroradiol 2015; 26:239-42. [PMID: 26227620 DOI: 10.1007/s00062-015-0442-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 07/15/2015] [Indexed: 10/23/2022]
|
37
|
McGuinness BJ, Memon S, Hope JK. Prospective Study of Early MRI Appearances following Flow-Diverting Stent Placement for Intracranial Aneurysms. AJNR Am J Neuroradiol 2015; 36:943-8. [PMID: 25767184 PMCID: PMC7990576 DOI: 10.3174/ajnr.a4335] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 11/03/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE MR imaging findings of aneurysm enlargement, aneurysm wall enhancement, perianeurysmal edema, and embolic phenomena following deployment of flow-diverting stents may be relevant to those patients who subsequently experience procedure-related intracranial hemorrhage. We sought to document the routine early postoperative MR imaging findings following flow-diverting stent insertion. MATERIALS AND METHODS Patients requiring flow-diverting stent placement for treatment or retreatment of cerebral aneurysms were prospectively included in the study during a 26-month period. Early postprocedural MR imaging studies were obtained and compared with preoperative imaging. Patient clinical outcome data were also collected. RESULTS There were 34 stent-placement procedures during the study period. Aneurysm mural enhancement and mild new perianeurysmal edema were present in 50% and 14%, respectively. Any DWI lesion was present in 57% of cases. New or possibly new foci of susceptibility effect were found ipsilateral to the stent and not associated with diffusion restriction in 66% of cases. There were 2 cases (6%) of parenchymal hemorrhage and 2 major clinical complications (6%) causing permanent morbidity. CONCLUSIONS Asymptomatic aneurysm mural enhancement is frequently seen following flow-diverting stent placement and should not necessarily be interpreted as a sign of impending aneurysm rupture. This finding often persists despite complete aneurysm occlusion. New small brain parenchymal susceptibility foci following stent placement have not previously been reported, to our knowledge, but were common in our series.
Collapse
Affiliation(s)
- B J McGuinness
- From the Department of Radiology (B.J.M., J.K.H.), Auckland City Hospital, Auckland, New Zealand
| | - S Memon
- Department of Radiology (S.M.), Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - J K Hope
- From the Department of Radiology (B.J.M., J.K.H.), Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
38
|
Chalouhi N, Jabbour P, Starke RM, Zanaty M, Tjoumakaris S, Rosenwasser RH, Gonzalez LF. Treatment of a basilar trunk perforator aneurysm with the pipeline embolization device: case report. Neurosurgery 2015; 74:E697-701; discussion 701. [PMID: 24492662 DOI: 10.1227/neu.0000000000000308] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Basilar trunk perforator (BTP) aneurysms are rare lesions that pose significant challenges to microsurgical clipping and endovascular coiling. We present the intriguing case of a ruptured BTP aneurysm that was successfully treated with the Pipeline Embolization Device (PED). CLINICAL PRESENTATION An elderly woman presenting with subarachnoid hemorrhage was found to have a 1.5-mm aneurysm arising from the proximal portion of a thin midbasilar perforator. The decision was made to treat this aneurysm with flow diversion in an attempt to preserve the patency of the perforator and to avoid the hazards associated with parent vessel trapping. A 3 × 12-mm PED was successfully deployed in the basilar trunk across the neck of the aneurysm, causing stasis in the aneurysm, with continuous flow through the parent vessel. The procedure and postoperative course were uneventful. A follow-up angiogram 2 weeks later showed complete disappearance of the aneurysm with preservation of the patency of the perforator. At the 6-month follow-up, the patient was asymptomatic and remained neurologically intact. CONCLUSION We present the first case of a BTP aneurysm treated with the PED. The aneurysm was successfully occluded, and the patency of the feeding vessel was preserved. In light of the limitations of coiling and the hazards associated with microsurgery and parent vessel trapping, the PED may be a valuable option for BTP aneurysms.
Collapse
Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | | | | | | | | | | | | |
Collapse
|
39
|
Duckworth EAM, Nickele C, Hoit D, Belayev A, Moran CJ, Arthur AS. Republished: The first North American use of the Pipeline Flex flow diverter. J Neurointerv Surg 2015; 8:e8. [DOI: 10.1136/neurintsurg-2014-011548.rep] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2014] [Indexed: 11/03/2022]
Abstract
Flow diversion for the management of intracranial aneurysms represents a paradigm shift in how aneurysms are managed. The Pipeline embolization device (PED) is, to date, the only flow diverter approved for use in the USA by the Food and Drug Administration. Limitations and complications with new treatment strategies are inevitable, and with the PED there have been reports of complications, most commonly with challenging deployments. Once deployment has been initiated, the device is ‘one-way’; it can only be deployed further or removed. Yet, situations arise in which the ability to recapture or reposition the device would be advantageous. A second-generation Pipeline has been developed that addresses these concerns. We report the first use in North America of this second-generation Pipeline device: the Pipeline Flex. We discuss our rationale for using the device, our impressions of its operation, and the relevant literature concerning the current state of flow diversion.
Collapse
|
40
|
Duckworth EAM, Nickele C, Hoit D, Belayev A, Moran CJ, Arthur AS. The first North American use of the Pipeline Flex flow diverter. BMJ Case Rep 2015; 2015:bcr-2014-011548. [PMID: 25636625 DOI: 10.1136/bcr-2014-011548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Flow diversion for the management of intracranial aneurysms represents a paradigm shift in how aneurysms are managed. The Pipeline embolization device (PED) is, to date, the only flow diverter approved for use in the USA by the Food and Drug Administration. Limitations and complications with new treatment strategies are inevitable, and with the PED there have been reports of complications, most commonly with challenging deployments. Once deployment has been initiated, the device is 'one-way'; it can only be deployed further or removed. Yet, situations arise in which the ability to recapture or reposition the device would be advantageous. A second-generation Pipeline has been developed that addresses these concerns. We report the first use in North America of this second-generation Pipeline device: the Pipeline Flex. We discuss our rationale for using the device, our impressions of its operation, and the relevant literature concerning the current state of flow diversion.
Collapse
Affiliation(s)
- Edward A M Duckworth
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Christopher Nickele
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Daniel Hoit
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Andrey Belayev
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Christopher J Moran
- Department of Neuroradiology, Mallinkrodt Institute, St Louis, Missouri, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| |
Collapse
|
41
|
Fox B, Humphries WE, Doss VT, Hoit D, Elijovich L, Arthur AS. Rupture of giant vertebrobasilar aneurysm following flow diversion: mechanical stretch as a potential mechanism for early aneurysm rupture. J Neurointerv Surg 2014; 7:e37. [PMID: 25361560 DOI: 10.1136/neurintsurg-2014-011325.rep] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2014] [Indexed: 11/04/2022]
Abstract
A patient with a giant symptomatic vertebrobasilar aneurysm was treated by endoscopic third ventriculostomy for obstructive hydrocephalus followed by treatment of the aneurysm by flow diversion using a Pipeline Embolization Device. After an uneventful procedure and initial periprocedural period, the patient experienced an unexpected fatal subarachnoid hemorrhage 1 week later. Autopsy demonstrated extensive subarachnoid hemorrhage and aneurysm rupture (linear whole wall rupture). The patent Pipeline Embolization Device was in its intended location, as was the persistent coil occlusion of the distal left vertebral artery. The aneurysm appeared to rupture in a linear manner and contained a thick large expansile clot that seemed to disrupt or rupture the thin aneurysm wall directly opposite the basilar artery/Pipeline Embolization Device. We feel the pattern of aneurysm rupture in our patient supports the idea that the combination of flow diversion and the resulting growing intra-aneurysmal thrombus can create a mechanical force with the potential to cause aneurysm rupture.
Collapse
Affiliation(s)
- Benjamin Fox
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | | | - Vinodh T Doss
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA
| | | | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| |
Collapse
|
42
|
Fox B, Humphries WE, Doss VT, Hoit D, Elijovich L, Arthur AS. Rupture of giant vertebrobasilar aneurysm following flow diversion: mechanical stretch as a potential mechanism for early aneurysm rupture. BMJ Case Rep 2014; 2014:bcr-2014-011325. [PMID: 25355741 DOI: 10.1136/bcr-2014-011325] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A patient with a giant symptomatic vertebrobasilar aneurysm was treated by endoscopic third ventriculostomy for obstructive hydrocephalus followed by treatment of the aneurysm by flow diversion using a Pipeline Embolization Device. After an uneventful procedure and initial periprocedural period, the patient experienced an unexpected fatal subarachnoid hemorrhage 1 week later. Autopsy demonstrated extensive subarachnoid hemorrhage and aneurysm rupture (linear whole wall rupture). The patent Pipeline Embolization Device was in its intended location, as was the persistent coil occlusion of the distal left vertebral artery. The aneurysm appeared to rupture in a linear manner and contained a thick large expansile clot that seemed to disrupt or rupture the thin aneurysm wall directly opposite the basilar artery/Pipeline Embolization Device. We feel the pattern of aneurysm rupture in our patient supports the idea that the combination of flow diversion and the resulting growing intra-aneurysmal thrombus can create a mechanical force with the potential to cause aneurysm rupture.
Collapse
Affiliation(s)
- Benjamin Fox
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | | | - Vinodh T Doss
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA
| | | | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| |
Collapse
|
43
|
Wakhloo AK, Gounis MJ. Revolution in Aneurysm Treatment: Flow Diversion to Cure Aneurysms: A Paradigm Shift. Neurosurgery 2014; 61 Suppl 1:111-20. [DOI: 10.1227/neu.0000000000000392] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ajay K. Wakhloo
- Division Neuroimaging and Intervention and New England Center for Stroke Research Departments of Radiology, Neurology and Neurosurgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Matthew J. Gounis
- Division Neuroimaging and Intervention and New England Center for Stroke Research Departments of Radiology, Neurology and Neurosurgery, University of Massachusetts Medical School, Worcester, Massachusetts
| |
Collapse
|
44
|
Briganti F, Leone G, Napoli M, Lauriola W, Florio F, Maiuri F. Early Fatal Hemorrhage After Endovascular Treatment of a Giant Aneurysm with Flow Diverter Device and Coils. Clin Neuroradiol 2014; 25:201-5. [DOI: 10.1007/s00062-014-0310-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 04/25/2014] [Indexed: 11/29/2022]
|
45
|
Mine B, Pierot L, Lubicz B. Intrasaccular flow-diversion for treatment of intracranial aneurysms: the Woven EndoBridge. Expert Rev Med Devices 2014; 11:315-25. [PMID: 24694000 DOI: 10.1586/17434440.2014.907741] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endovascular approach is now the first option for the treatment of most intracranial aneurysms (IA). However, remaining limitations are the suboptimal stability of aneurysm occlusion and the treatment of complex IA. The use of conventional and flow diverter stents has partially addressed these limitations. Nevertheless, as intraluminal devices, stents require aggressive antiplatelet therapy and are associated with higher thromboembolic (TE) complication rates. Intrasaccular flow disrupters (IFD) are newly developed braided-wire devices designed to achieve flow disruption at the neck without placing material in the parent vessel and without the need of antiplatelet therapy. First clinical series have shown promising anatomical and clinical results. Our purpose is to describe the available IFD and to review the literature about their efficacy, safety, limitations, and developments.
Collapse
Affiliation(s)
- Benjamin Mine
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Route de Lennik 808, 1070 Brussels, Belgium
| | | | | |
Collapse
|
46
|
Chalouhi N, Zanaty M, Tjoumakaris S, Gonzalez LF, Hasan D, Kung D, Rosenwasser RH, Jabbour P. Treatment of Blister-Like Aneurysms With the Pipeline Embolization Device. Neurosurgery 2014; 74:527-32; discussion 532. [DOI: 10.1227/neu.0000000000000309] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Endovascular vessel reconstruction with the pipeline embolization device (PED) has become common practice. Data on the safety and efficacy of the PED in blister-like aneurysms (BLAs) are limited.
OBJECTIVE:
To retrospectively present our experience with use of the PED in BLAs.
METHODS:
A total of 8 patients harboring 8 BLAs were treated with the PED at our institution between November 2011 and April 2013.
RESULTS:
Aneurysm size was 2.5 mm on average. Five patients had sustained a subarachnoid hemorrhage (SAH), 1 patient presented with sentinel headaches, and in 2 patients the aneurysm was incidentally discovered. Seven aneurysms arose from the ICA and 1 from the basilar artery. Placement of the PED was successful in all 8 patients. There were no procedural or perioperative complications in any of the patients. At the latest follow-up, all 8 patients achieved a favorable outcome (mRS 0-2). Angiographic follow-up was available for 6 patients at a mean time point of 3.9 months. Follow-up angiography showed 100% aneurysm occlusion in 5 patients and marked decrease in aneurysm size in 1 patient.
CONCLUSION:
The findings of this study suggest that the PED may be a safe and effective treatment for BLAs. Given the limitations of other treatment modalities and the challenging nature of BLAs, flow diversion may be a valuable option for these lesions.
Collapse
Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Mario Zanaty
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - L. Fernando Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa
| | - David Kung
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H. Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| |
Collapse
|
47
|
Chalouhi N, Tjoumakaris S, Dumont AS, Gonzalez LF, Randazzo C, Starke RM, Rosenwasser RH, Jabbour P. Treatment of posterior circulation aneurysms with the pipeline embolization device. Neurosurgery 2014; 72:883-9. [PMID: 23407289 DOI: 10.1227/neu.0b013e31828ba984] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Treatment of complex intracranial aneurysms with the pipeline embolization device (PED) has become common practice in neurovascular centers. Very few studies have assessed the safety and efficacy of PED treatment for posterior circulation aneurysms. OBJECTIVE To retrospectively present our experience with use of the PED in the posterior circulation. METHODS A total of 7 patients harboring 7 posterior circulation aneurysms were treated with the PED at our institution between November 2011 and July 2012. RESULTS Aneurysm size was 14.1 mm on average. All patients had unruptured aneurysms. Three aneurysms arose from the vertebral artery, 2 from the basilar artery, and 2 from the vertebrobasilar junction. A single stent was used in 4 patients, 2 stents in 2 patients, and 3 stents in 1 patient. Treatment was successful in all 7 patients. No procedural complications or perforator infarcts were noted in the series. No patient experienced new neurological symptoms related to PED treatment during the follow-up period. Angiographic follow-up was available for 6 patients at a mean time point of 5.5 months. Follow-up angiography showed 100% aneurysm occlusion in 3 patients, marked decrease in aneurysm size in 2 patients, and no change in 1 patient. CONCLUSION In our initial experience, it appears that PED treatment in select patients with vertebrobasilar aneurysms may have a reasonable safety-efficacy profile. Larger studies are needed to confirm our findings.
Collapse
Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania 19107, USA
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Zhang Z, Lv X, Wu Z, Li Y, Yang X, Jiang C, Xu R, Shen C. Clinical and angiographic outcome of endovascular and conservative treatment for giant cavernous carotid artery aneurysms. Interv Neuroradiol 2014; 20:29-36. [PMID: 24556297 PMCID: PMC3971137 DOI: 10.15274/inr-2014-10005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 09/13/2013] [Indexed: 02/07/2023] Open
Abstract
This study evaluated the outcome of endovascular and conservative treatment for giant cavernous carotid artery aneurysms (CCAAs). We retrospectively reviewed a series of 35 consecutive giant CCAAs treated with endovascular and conservative treatment. All patients were evaluated by balloon occlusion test (BOT) before treatment. Patients who could tolerate BOT were treated by parent artery occlusion (PAO), those who could not tolerate BOT were treated by stent/coil or conservative methods. Eight patients were treated conservatively, symptoms were worsened in four patients (50%), unchanged in three, and improved in one at 33.6±19.9 months (6~65 months) follow-up. In 27 aneurysms treated with endovascular methods, 17 aneurysms were treated by PAO, eight aneurysms were treated with stent-assisted coil embolization, and two aneurysms were embolized with coils. The initial post-procedure angiogram revealed complete occlusion, neck remnant, and incomplete occlusion in 81.5 %, 11.1 %, and 7.4 %, respectively. Procedure-related mortality and morbidity were 0 and 7.4 %, respectively. At 33.1±17.4 months (4~71 months) follow-up, a good clinical outcome (mRS 0-1) was observed in 25 (92.6%) patients, symptoms were resolved or improved in 20 (74.1%). Statistical analysis showed that risk factors for poor clinical outcome included age of 60 years and older (P=0.006), and conservative treatments (P=0.038). Risk factors for poor clinical outcome of giant CCAAs included conservative treatment and age older than 60 years. A symptomatic giant cavernous carotid aneurysm should be treated. The outcome of endovascular treatment of giant CCAAs is promising.
Collapse
Affiliation(s)
- Zhenhai Zhang
- Affiliated Bayi Brain Hospital, Military General Hospital of Beijing PLA; Beijing, China
- />Zhongxue Wu, MD and Xianli Lv, MD - Beijing Neurosurgical Institute and Beijing Tiantan Hospital - Tiantan, Xili, 6, Dongcheng - Beijing,100050, China - Tel.: +86 10 67098850 - Fax: +86 10 67018349 - E-mail: -
| | - Xianli Lv
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University; Beijing, China
| | - Zhongxue Wu
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University; Beijing, China
| | - Youxiang Li
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University; Beijing, China
| | - Xinjian Yang
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University; Beijing, China
| | - Chuhan Jiang
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University; Beijing, China
| | - Ruxiang Xu
- Affiliated Bayi Brain Hospital, Military General Hospital of Beijing PLA; Beijing, China
| | - Chunsen Shen
- Affiliated Bayi Brain Hospital, Military General Hospital of Beijing PLA; Beijing, China
| |
Collapse
|
49
|
McDonald RJ, McDonald JS, Kallmes DF, Lanzino G, Cloft HJ. Periprocedural Safety of Pipeline Therapy for Unruptured Cerebral Aneurysms. Interv Neuroradiol 2014. [DOI: 10.15274/inr-2014-10087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
50
|
Ishii A, Miyamoto S, Ito Y, Fujinaka T, Sakai C, Sakai N. Parent artery occlusion for unruptured cerebral aneurysms: the Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2. Neurol Med Chir (Tokyo) 2013. [PMID: 24305030 PMCID: PMC4508702 DOI: 10.2176/nmc.oa2013-0185] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Parent artery occlusion (PAO) is an alternative to surgical clipping or endovascular endosaccular coil embolization for the management of cerebral aneurysms. Most giant and fusiform aneurysms are not amenable to endosaccular coil embolization due to anatomical considerations, such as a broad-neck. However, majority of reports regarding the safety of PAO are based on case series involving a relatively small number of patients. In the present study, a total of 381 consecutive patients with unruptured cerebral aneurysms who were treated with PAO were extracted from the Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and JR-NET2 database, which are nationwide surveys conducted by the Japanese Society of Neuroendovascular Therapy. The mean age of the 381 patients was 58.1 years, and 59.3% were female. The aneurysmal location included the vertebral artery (42%) and the cavernous portion of internal carotid artery (32%). The aneurysm size and shape consisted of fusiform (45%), giant (25%), and large (22%). Symptomatic lesions were present in 59.8% of the population. Technical success was achieved in 98.4%. The 30-day morbidity and mortality rates were 3.1% and 1.0%, respectively. The most frequent procedure-related complication was ischemic stroke, which occurred in 12.9% (distal embolism, 6.0%; branch occlusion, 3.9%). The 30-day morbidity and mortality rates related to ischemic strokes were 2.1% and 0.3%, respectively. PAO for unruptured aneurysms is feasible with a high technical success rate. Peri-procedural management of ischemic stroke is the key to enhance the safety of this treatment option.
Collapse
Affiliation(s)
- Akira Ishii
- Department of Neurosurgery, Graduate School of Medicine, Kyoto University
| | | | | | | | | | | | | |
Collapse
|