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Wathen C, Santangelo G, Muhammad N, Ellens N, Catanzaro S, Singh A, Dagli MM, Petrov D, Ozturk AK, Bender M, Stone JJ, Schuster J. Management and outcomes of cerebrovascular injuries after gunshot wounds to the cervical spine. Clin Neurol Neurosurg 2024; 243:108376. [PMID: 38865803 DOI: 10.1016/j.clineuro.2024.108376] [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: 03/06/2024] [Revised: 06/05/2024] [Accepted: 06/06/2024] [Indexed: 06/14/2024]
Abstract
STUDY DESIGN This study was a multicenter retrospective analysis of cervical spine gunshot wound (GSW) patients. OBJECTIVE The present study was conducted to evaluate the management and outcomes of vascular injuries following GSW involving the cervical spine. SUMMARY OF BACKGROUND DATA Gunshot wounds (GSW) injuring the cervical spine are associated with high rates of vascular injury. METHODS Charts of patients with GSW involving the cervical spine at two Level 1 trauma centers were reviewed from 2010 to 2021 for demographics, injury characteristics, management and follow-up. Statistical analysis included T tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables, non-parametric tests were used when indicated. Beta-binomial models were used to estimate the probabilities outcomes. Bayesian regression models were utilized to compute risk ratios (RR) and their 95 % confidence intervals (CI) to enhance the inferential robustness. RESULTS 40 patients with cervical spine GSW and associated cerebrovascular injury were included in our analysis. 15 % of patients had Biffl grade (BG) V injuries, 50 % grade IV, and 35 % grade III-I. Angiography was performed in 35 % of patients. 5 of these patients (BG V-III) required endovascular treatment for pseudoaneurysm obliteration or parent vessel sacrifice. 7 patients (22 %) showed evidence of progression. 70 % of patients were placed on antiplatelet therapy for stroke prevention. Bayesian regression models with a skeptical prior for cerebral ischemia revealed a mean RR of 4.82 (95 % CI 1.02-14.48) in the BG V group, 0.75 (95 % CI 0.13-2.26) in the BG IV group, and 0.61 (95 % CI 0.06-2.01) in the combined BG III-I group. For demise the mean RR was 3.41 (95 % CI 0.58-10.65) in the BG V group and 1.69 (95 % CI 0.29-5.97) in the BG IV group. In the high BG (V, IV) group, 54.55 % of patients treated with antiplatelet therapy had complications. None of the patients that were treated with antiplatelet therapy in the low BG (III-I) group had complications. CONCLUSIONS Cervical spine GSWs are associated with high-grade vascular injuries and may require early endovascular intervention. Additionally, a high rate of injury progression was seen on follow up imaging, requiring subsequent intervention. Reintervention and demise were common and observed in high BG (V, IV) groups. The incidence of stroke was low, especially in low BG (I-III) groups, suggesting that daily aspirin prophylaxis is adequate for long-term stroke prevention.
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Affiliation(s)
- Connor Wathen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Gabrielle Santangelo
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Najib Muhammad
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nathaniel Ellens
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Sandra Catanzaro
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Aman Singh
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Mert Marcel Dagli
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dmitry Petrov
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ali K Ozturk
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew Bender
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Jonathan J Stone
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - James Schuster
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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2
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Tuan NHN, Van Khoa L, Van Tien Bao N, Tu PD, Van Phuoc L. Endovascular management of giant post-traumatic pseudoaneurysm in cavernous sinus: A case report. Radiol Case Rep 2023; 18:2514-2518. [PMID: 37214327 PMCID: PMC10199404 DOI: 10.1016/j.radcr.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 04/12/2023] [Indexed: 05/24/2023] Open
Abstract
A 20-year-old male was admitted with the history of a traumatic head injury after traffic accident. The physical examination revealed blurred vision, swelling of the right face, and minor epistaxis. CT and MRI findings revealed a giant pseudoaneurysm of cavernous carotid artery. The patient was enrolled endovascular coils embolization of the internal carotid artery. After the procedure, the patient recovered well. Endovascular treatment is an effective therapy in cavernous carotid pseudoaneurysm.
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3
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Han JW, Lee JI, Hwangbo L. [Endovascular Treatment for Head and Neck Trauma]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:792-808. [PMID: 37559799 PMCID: PMC10407061 DOI: 10.3348/jksr.2023.0034] [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: 04/02/2023] [Revised: 06/09/2023] [Accepted: 07/08/2023] [Indexed: 08/11/2023]
Abstract
Trauma to the head and neck region can have serious consequences for vital organs such as the brain, and injuries to blood vessels can cause permanent neurological damage or even death. Thus, prompt treatment of head and neck vessels is crucial. Although the level of evidence is moderate, an increasing amount of research indicates that endovascular treatments can be a viable alternative to traditional surgery or medical management. Embolization or reconstructive endovascular procedures can significantly improve patient outcomes. This article provides an overview of various endovascular options available for specific clinical scenarios, along with examples of cases in which they were employed.
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4
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Theocharidou A, Spanou A, Alexandratou M, Michas V, Lamprou V, Psoma E, Finitsis S. An off-label use of flow-diverter stent as a successful treatment of a postoperative middle cerebral artery pseudoaneurysm. Radiol Case Rep 2023; 18:2219-2223. [PMID: 37123043 PMCID: PMC10139864 DOI: 10.1016/j.radcr.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/24/2023] [Accepted: 03/07/2023] [Indexed: 05/02/2023] Open
Abstract
A pseudoaneurysm or false aneurysm is the result of the disruption of the vessel wall and the formation of a hematoma in communication with the vascular lumen, restrained by perivascular connective tissue. Intracranial pseudoaneurysms represent a rare entity mainly because of trauma, iatrogenic causes, infectious disease, radiation exposure, connective tissue disease and sometimes spontaneous occurrence. We present a 35-year-old female patient with a history of multiple low-grade glioma debulking surgeries. During the last procedure, laceration of the left middle cerebral artery (MCA) occurred with diffuse subarachnoid hemorrhage. Imaging studies showed the formation of a pseudoaneurysm of the left MCA which was successfully treated with the implantation of a flow diverter across the lesion neck and excellent mid- to long- term results. Flow diverter implantation may be a promising technique for the therapeutic management of cerebral pseudoaneurysms.
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5
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Duangprasert G, Sukhor S, Kaewprasert T, Tantongtip D. Traumatic Supraclinoid Internal Carotid Artery Pseudoaneurysm associated with Carotid-Cavernous Fistula and Contralateral Anterior Cerebral Artery Pseudoaneurysm Treated by Surgical Trapping with High-Flow Bypass and A3-A3 Bypass: A Case Report and Literature Review. Asian J Neurosurg 2023; 18:184-190. [PMID: 37056887 PMCID: PMC10089730 DOI: 10.1055/s-0043-1761239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
AbstractTraumatic pseudoaneurysms of the supraclinoid internal carotid artery (ICA) are uncommon, particularly associated with carotid-cavernous fistulas (CCF) or multiple traumatic aneurysms. This report describes a patient with a ruptured left ICA dissecting pseudoaneurysm that caused a direct CCF and a right anterior cerebral artery (ACA) pseudoaneurysm. To eliminate the aneurysm and fistula, we followed the universal bypass strategy by performing an ICA trapping with high-flow bypass, followed by an ACA trapping with A3-A3 side-to-side bypass. Herein, we report the first successful surgical trapping and revascularization of supraclinoid ICA pseudoaneurysm associated with a direct carotid-cavernous fistula.
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6
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Adalid LAC, Herrera VC, Rubio DS, Toro MA, Estrada EE. Surgical treatment of a ruptured internal carotid artery pseudoaneurysm following transsphenoidal surgery. J Cerebrovasc Endovasc Neurosurg 2022; 24:380-385. [PMID: 35837685 PMCID: PMC9829561 DOI: 10.7461/jcen.2022.e2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/28/2021] [Indexed: 01/21/2023] Open
Abstract
Development of Internal Carotid Artery pseudoaneurysms (ICAp) after transsphenoidal surgery is extremely rare, occurring only in 0.4% of cases. Surgical treatment of ICAp poses a real challenge to the neurosurgeon as treatment may require parent vessel sacrifice or artery reconstruction with bypass grafting. Furthermore, surgical resolution of these lesions is rarely reported in the literature. The internal carotid artery is prone to iatrogenic injury in transsphenoidal surgery due to its frequent involvement in pituitary adenomas. Intracranial pseudoaneurysms may be at high risk for rupture and increased morbidity and mortality. Here we present a case of a patient with an ICAp rupture two months after transsphenoidal surgery for a pituitary adenoma.
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Affiliation(s)
- Luis Alfonso Castillejo Adalid
- Specialties Hospital, 21st Century National Medical Center, Mexico City, Mexico,Correspondence to Luis Alfonso Castillejo Adalid Specialties Hospital, 21st Century National Medical Center, Cuauhtémoc 333, Doctores Suburb. Mexico City, Mexico Tel +52-55-5701-0874 E-mail
| | | | - Diego Soto Rubio
- Specialties Hospital, 21st Century National Medical Center, Mexico City, Mexico
| | - Miguel Abdo Toro
- Specialties Hospital, 21st Century National Medical Center, Mexico City, Mexico
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7
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Budohoski KP, Thakrar R, Voronovich Z, Rennert RC, Kilburg C, Grandhi R, Couldwell WT, Brockmeyer DL, Taussky P. Initial experience with Pipeline embolization of intracranial pseudoaneurysms in pediatric patients. J Neurosurg Pediatr 2022; 30:465-473. [PMID: 36057120 DOI: 10.3171/2022.7.peds22195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children. METHODS This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed. RESULTS Six patients with a median age of 12 years (range 7-16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae. CONCLUSIONS Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.
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Affiliation(s)
- Karol P Budohoski
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Raj Thakrar
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Zoya Voronovich
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Robert C Rennert
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Craig Kilburg
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Ramesh Grandhi
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Douglas L Brockmeyer
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Philipp Taussky
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
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8
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Panther E, Lucke-Wold B, Laurent D, Osorno-Cruz C, Mehkri Y, Turner R, Polifka A, Koch M, Hoh B, Chalouhi N. Treatment of Dissecting Vertebral Pseudoaneurysms: A Single-Center Experience. ANNALS OF NEUROLOGY AND NEUROSCIENCE 2022; 1:1002. [PMID: 36468934 PMCID: PMC9717722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Background Dissecting vertebral artery pseudoaneurysms represent a unique clinical challenge with careful appreciation for location of the posterior inferior cerebellar artery. Limited data is available in terms of outcomes regarding the various treatment modalities. Methods 11 patients with dissecting pseudoaneurysms were identified from 2013-2021. Pseudoaneurysm size and morphology, clinical presentation, and treatment approach was collected. Success of treatment was recorded based on post-operative imaging as well as documented overall patient outcomes. Three primary treatment modalities emerged: coil embolization, stent assisted coiling, and flow diversion. Results Of the 11 patients, 5 were female and 6 were male with an age from 36 to 69.7. 7 had ruptured pseudoaneurysms at time of treatment. Size of pseudoaneurysm ranged from 3 to 6 mm. 8 were on the right and 3 were on the left vertebral artery. 8 were proximal to PICA and 3 were distal. Co-dominance of vertebral filling was seen in 5 patients, 5 with dominance through right vertebral artery, and 1 with dominance through left vertebral artery. Variability existed in treatment approaches with 4 patients undergoing coil occlusion, 5 patients undergoing flow diversion stenting, and 2 patients undergoing flow diversion stenting with jailed coiling. 1 patient had enlargement of pseudoaneurysm while inpatient and required a second flow diversion device. 1 patient had two flow diversion devices placed initially at time of treatment due to morphology of PA. 6 patients had repeat angiograms between 6 to 9 months with complete occlusion. 3 had CTA or MRA with complete occlusion for those that had flow diversion, they were transitioned from aspirin and clopidogrel to aspirin monotherapy after first repeat angiogram. 6 patients required shunt placement for hydrocephalus. 1 patient died prior to discharge due to sepsis. 2 patients died post discharge: 1 with myocardial infarction and the 2nd due to urosepsis.Dissecting vertebral pseudoaneurysm has high morbidity and mortality if rupture occurs. Location of PICA origin influences treatment approach. Patients with poor Hunt/Hess scores upon arrival had increased risk for systemic infection and mortality.
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Affiliation(s)
- E Panther
- Department of Neurosurgery, University of Florida, Gainesville
| | - B Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville
| | - D Laurent
- Department of Neurosurgery, University of Florida, Gainesville
| | - C Osorno-Cruz
- Department of Neurosurgery, University of Iowa, Des Moines
| | - Y Mehkri
- Department of Neurosurgery, University of Florida, Gainesville
| | - R Turner
- Department of Neurosurgery, West Virginia University, Morgantown
| | - A Polifka
- Department of Neurosurgery, University of Florida, Gainesville
| | - M Koch
- Department of Neurosurgery, University of Florida, Gainesville
| | - B Hoh
- Department of Neurosurgery, University of Florida, Gainesville
| | - N Chalouhi
- Department of Neurosurgery, University of Florida, Gainesville
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9
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Treatment of Traumatic Internal Carotid Artery Aneurysm by Flow-Diverter: A Single-Center Experience. Neurochirurgie 2022; 68:e60-e67. [PMID: 36028352 DOI: 10.1016/j.neuchi.2022.07.011] [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: 03/23/2022] [Revised: 07/07/2022] [Accepted: 07/26/2022] [Indexed: 11/20/2022]
Abstract
AIM Traumatic intracranial aneurysm (TICA) is a rare vascular lesion with various etiologies and a high mortality rate when diagnosed late. In this study, we present our cases of TICA, which we treated with flow-diverter stents due to different etiological factors. METHODS Clinical data were recorded for 8 patients: age, gender, etiological factors, aneurysm location, aneurysm type, rupture, main artery status, and postoperative complications. RESULTS 75% (n:6) of the patients were male and 25% (n:2) female. Etiologically, there was intracranial tumor surgery in 3 cases (37.5%), fall from height in 2 (25%), road accident in 2 (25%), and blunt trauma in 1 (12.5%). Reconstruction used a flow-diverting stent in all cases. One patient experienced intraoperative iatrogenic rupture of the distal arterioles due to a microwire. Mean angiographic follow-up was 17.8 months (range, 6-32 months). During follow-up, none of the patients required renewed endovascular treatment. CONCLUSION Traumatic aneurysm is a vascular lesion with high mortality when diagnosed late. In case of suspected vascular injury after trauma or intracranial surgery, further evaluation should be performed without delay. TICA can be safely treated with flow-diverter stents, conserving the main artery.
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10
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Liu A, Rincon-Torroella J, Bender MT, McDougall CG, Tufaro AP, London NR, Coon AL, Reh DD, Gallia GL. Combined Pipeline Embolization Device with Endoscopic Endonasal Fascia Lata/Muscle Graft Repair as a Salvage Technique for Treatment of Iatrogenic Carotid Artery Pseudoaneurysm. J Neurol Surg Rep 2021; 82:e43-e48. [PMID: 34877246 PMCID: PMC8635816 DOI: 10.1055/s-0041-1735284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/14/2021] [Indexed: 11/16/2022] Open
Abstract
The incidence of internal carotid artery (ICA) injury associated with endoscopic endonasal approaches to the pituitary is less than 1%. While parent vessel sacrifice has historically been the choice of treatment, vessel-preserving endovascular techniques have been reported. Although flow diversion offers endoluminal reconstruction, its major limitation is the delay in obtaining complete occlusion. We describe the use of a combined Pipeline embolization device (PED) with endoscopic endonasal repair using a fascia lata/muscle graft to treat an iatrogenic ICA pseudoaneurysm and report long-term radiographic follow-up. Further investigation into the utility of directed endoscopic endonasal repair of iatrogenic pseudoaneurysms initially treated with PED is necessary, especially given the need of post-PED anticoagulation and the rate of permanent neurological deficit after ICA sacrifice.
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Affiliation(s)
- Ann Liu
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | | | - Matthew T Bender
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States
| | - Cameron G McDougall
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Anthony P Tufaro
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Division of Plastic Surgery, Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Nyall R London
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Neurosurgery, Carondelet Neurological Institute, Tucson, Arizona, United States
| | - Douglas D Reh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Otolaryngology-Head and Neck Surgery, Greater Baltimore Medical Center, Baltimore, Maryland, United States
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
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11
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Athanasiou S, Aslanidi C, Mamalis V, Markogiannakis G, Tsanis A, Arhontakis E. Endovascular management of spontaneous intracranial pseudoaneurysms in a pediatric patient with Noonan syndrome. A mere coincidence or a possible association with the disorder? Surg Neurol Int 2021; 12:537. [PMID: 34754587 PMCID: PMC8571254 DOI: 10.25259/sni_837_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/30/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Noonan syndrome (NS) is a rare autosomal-dominant neurodevelopmental disorder, which typically develops abnormalities of the craniofacial development and congenital heart defects. A number of cerebrovascular anomalies have also been occasionally described previously in the setting of NS. The assumption that NS can induce the formation of intracranial pseudoaneurysm (IAP) or the rupture of an already existing abnormality is yet unknown. CASE DESCRIPTION We encountered a rare case of a 9-year-old NS patient with two IAPs presenting with episodes of intracerebral hemorrhage that were successfully managed with endovascular embolization. CONCLUSION This case represents a possible association between NS and the presence of ruptured IAPs.
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Affiliation(s)
- Sofia Athanasiou
- Department of Interventional Radiology, Red Cross Hospital, Athens, Greece
| | - Christina Aslanidi
- Department of Interventional Radiology, Red Cross Hospital, Athens, Greece
| | - Vasileios Mamalis
- Department of Interventional Radiology, Red Cross Hospital, Athens, Greece
| | | | - Antonios Tsanis
- Department of Interventional Radiology, Red Cross Hospital, Athens, Greece
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12
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Scullen T, Mathkour M, Werner C, Zeoli T, Amenta PS. Vertebral artery dissection and associated ruptured intracranial pseudoaneurysm successfully treated with coil assisted flow diversion: A case report and review of the literature. Brain Circ 2021; 7:159-166. [PMID: 34667899 PMCID: PMC8459696 DOI: 10.4103/bc.bc_67_20] [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: 11/29/2020] [Revised: 02/01/2021] [Accepted: 04/30/2021] [Indexed: 11/14/2022] Open
Abstract
Dissecting intracranial pseudoaneurysms (IPs) are associated with a high incidence of rupture and poor neurologic outcomes. Lesions in the posterior circulation are particularly malignant and pose even greater management challenges. Traditional management consists of microsurgical vessel sacrifice with or without bypass. Flow diversion (FD) in the setting of subarachnoid hemorrhage (SAH) represents a reconstructive treatment option and can be paired with coil embolization to promote more rapid thrombosis of the lesion. We report a case of a ruptured dissecting vertebral artery (VA) IP successfully acutely treated with coil-assisted FD. A 53-year-old male presented with a right V4 dissection spanning the origin of the posterior inferior cerebellar artery and associated ruptured V4 IP. The patient was treated with coil-assisted FD. Oral dual-antiplatelet therapy (DAPT) was initiated during the procedure, and intravenous tirofiban was used as a bridging agent. Immediate obliteration of the IP was achieved, with near-complete resolution of the dissection within 48 h. The patient made a complete recovery, and angiography at 6 weeks confirmed total IP obliteration, reconstruction of the VA, and a patent stent. The use of FD and DAPT in the setting of acute SAH remains controversial. We believe that coil-assisted FD in carefully selected patients offers significant advantages over traditional microsurgical and endovascular options. The risks posed by DAPT and potential for delayed thrombosis with FD can be effectively mitigated with planning and the development of protocols. We discuss the current literature in the context of our case and review the challenges associated with treating these often devastating lesions.
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Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Surgery, Neurosurgery Division, Jazan University, Jazan, Kingdom of Saudi Arabia
| | - Cassidy Werner
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Tyler Zeoli
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Peter S Amenta
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
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13
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Iatrogenic Middle Cerebral Artery Ruptured Pseudoaneurysm Successfully Treated With a Pipeline Embolization Device. Ochsner J 2021; 21:190-193. [PMID: 34239381 PMCID: PMC8238105 DOI: 10.31486/toj.19.0122] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Endovascular advances have shifted the treatment algorithms for traumatic intracranial pseudoaneurysms (IPs) from vessel sacrifice to reconstruction. The Pipeline embolization device (PED) is a flow-diverting stent that promotes endothelialization across the lesion and reconstitutes the parent vessel lumen. Case Report: A 66-year-old male with a history of a right orbital apex lesion presented for biopsy with ophthalmology. Ophthalmology performed a right lateral orbitotomy complicated by brisk arterial bleeding from a proximal right middle cerebral artery (MCA) pseudoaneurysm. The MCA pseudoaneurysm was treated endovascularly with a PED, resulting in immediate stasis of contrast within the lesion without compilation. Interval follow-up angiograms 6 weeks and 6 months after the procedure showed no evidence of recurrence and a widely patent stent. Conclusion: The PED provided a rapid, minimally invasive, and durable treatment option for an acutely ruptured IP. We illustrate that endovascular management with flow diversion can be effectively used in select cases and provides a way to reconstruct the damaged vessel lumen and obliterate the aneurysm.
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14
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Giorgianni A, Agosti E, Terrana A, Pozzi F, Sileo G, Nativo L, Balbi S, Motta A, Castelnuovo P, Locatelli D, Turri-Zanoni M. Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-center experience. Acta Neurochir (Wien) 2021; 163:2055-2061. [PMID: 32808087 PMCID: PMC8195932 DOI: 10.1007/s00701-020-04517-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/30/2020] [Indexed: 11/05/2022]
Abstract
Background and objective To describe our single-center experience in the treatment of cavernous internal carotid artery (ICA) acute bleeding with flow diverter stent (FDS), as a single endovascular procedure or combined with an endoscopic endonasal approach. Methods We analyze a case series of 5 patients with cavernous ICA acute bleeding, i.e., 3 iatrogenic, 1 post-traumatic, and 1 erosive neoplastic. After an immediate nasal packing to temporarily bleeding control, patients underwent digital subtraction angiography (DSA) to identify the site of the ICA injury. A concomitant balloon occlusion test (BOT) was performed, to exclude post-occlusive ischemic neurological damage. An FDS was placed with parallel intravenous infusion of abciximab in 3 cases and tirofiban in 2 cases. In two patients, an innovative “sandwich technique” combining the endovascular reconstruction with an extracranial intrasphenoidal cavernous ICA resurfacing with autologous flaps or grafts by endoscopic endonasal approach was performed. Results No patient had periprocedural ischemic-hemorrhagic complications. All patients had a regular clinical evolution, without general complications or new onset of focal neurological deficits. No further bleeding occurred in 3 patients, while 2 cases experienced a mild rebleeding in a period ranging from 5 to 15 days after the endovascular procedure. In these two cases, we proceeded with an endoscopic endonasal procedure to resurface the exposed ICA wall in the sphenoid sinus. Conclusions Although the treatment of choice for cavernous ICA acute bleeding remains the occlusion of the injured vessel, in cases of poor hemodynamic compensation at the BTO, the endovascular FDS emergency placement can be effective. A combined endoscopic endonasal technique to support the extracranial side of the vessel using autologous flaps or grafts can be performed to prevent the risk of rebleeding.
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Affiliation(s)
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Via Guicciardini, 9, 21100, Varese, Italy.
| | - Alberto Terrana
- Department of Neuroradiology, ASST Sette Laghi, Varese, Italy
| | - Fabio Pozzi
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Via Guicciardini, 9, 21100, Varese, Italy
| | - Giorgio Sileo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Luca Nativo
- Department of Neuroradiology, ASST Sette Laghi, Varese, Italy
| | - Sergio Balbi
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Via Guicciardini, 9, 21100, Varese, Italy
| | - Alessandro Motta
- Department of Anesthesiology e Resuscitation, ASST Sette Laghi, Varese, Italy
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Via Guicciardini, 9, 21100, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Mario Turri-Zanoni
- Department of Anesthesiology e Resuscitation, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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15
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Johnson RM, Young M, Guglielmi GN, Farhat H. Proximal basilar artery hemorrhage after submaximal angioplasty for intracranial atherosclerotic disease presenting as a large vessel occlusion treated with pipeline embolization device. J Cerebrovasc Endovasc Neurosurg 2021; 23:145-151. [PMID: 34134445 PMCID: PMC8256018 DOI: 10.7461/jcen.2021.e2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/16/2020] [Indexed: 11/23/2022] Open
Abstract
Iatrogenic vessel perforation from endovascular intervention is a devastating complication that commonly is treated with vessel sacrifice. We present a unique case of an iatrogenic proximal basilar artery perforation after submaximal angioplasty in a 67-year-old male presenting with an acute basilar artery occlusion with underlying intracranial atherosclerotic disease. Telescoping flow-diverting stents were then deployed to reconstruct the vessel wall with resulting active hemorrhage resolution. Our case documents a successful deployment of flow-diverting stents with resolution of active hemorrhage after an iatrogenic basilar artery perforation.
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Affiliation(s)
- Ryan M Johnson
- Department of Neurosurgery, Carle BroMenn Medical Center, Normal, IL, USA
| | - Michael Young
- Department of Neurosurgery, Carle BroMenn Medical Center, Normal, IL, USA
| | - Gina N Guglielmi
- Department of Neurosurgery, Carle BroMenn Medical Center, Normal, IL, USA
| | - Hamad Farhat
- Department of Neurosurgery, Advocate Christ Medical Center, Oak Lawn, IL, USA
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16
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Wang W, Liang X, Chen G, Yang P, Zhang J, Liu H, Zhao S, Li Y, Sun B, Kang J. Treatment of Intracranial Pseudoaneurysms With a Novel Covered Stent: A Series of 19 Patients With Midterm Follow-Up. Front Neurol 2020; 11:580877. [PMID: 33324325 PMCID: PMC7723868 DOI: 10.3389/fneur.2020.580877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/21/2020] [Indexed: 01/04/2023] Open
Abstract
Background: The optimal treatment for intracranial pseudoaneurysm is unclear. This study aims to analyze the outcome of treating intracranial pseudoaneurysm with a novel covered stent. Materials and Methods: The institutional imaging and clinical databases were retrospectively reviewed for patients with intracranial pseudoaneurysms treated with Willis covered stent from January 2017 to December 2019. The clinical presentations, etiology, intraoperative complications, and immediate and follow-up outcomes were analyzed. Results: A total of 19 patients with 20 pseudoaneurysms were enrolled for analysis. Seventeen patients presented with vision loss and two with epistaxis. Nineteen Willis covered stents were used with one for each patient without technical failure. Intraoperative thrombosis was encountered in one patient (5.3%), which was recanalized by tirofiban. During clinical follow-up, no further epistaxis occurred, and visual acuity improved in three (17.6%) patients. Endoleak occurred in seven (36.8%) patients after the initial balloon inflation and persisted in one (5.3%) patient after balloon re-inflation. This endoleak disappeared at 8 month follow-up. Finally, during angiographic follow-up (median 13 months), parent artery occlusion and in-stent stenosis occurred in one (5.3%) patient. No stent-related ischemic event was encountered. Conclusions: The Willis covered stent is feasible, safe, and efficient in treating intracranial pseudoaneurysms.
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Affiliation(s)
- Wei Wang
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Xihong Liang
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Guangli Chen
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Peng Yang
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Jialiang Zhang
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Haocheng Liu
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Shangfeng Zhao
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Yong Li
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Bowen Sun
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Jun Kang
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
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17
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Ghorbani M, Griessenauer CJ, Shojaei H, Wipplinger C, Hejazian E. Endovascular reconstruction of iatrogenic internal carotid artery injury following endonasal surgery: a systematic review. Neurosurg Rev 2020; 44:1797-1804. [PMID: 32860104 DOI: 10.1007/s10143-020-01379-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/30/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
The objective of this study is to provide an update on endovascular treatments for iatrogenic internal carotid artery (ICA) injuries following endonasal surgery. A systematic review of the literature was performed by using Medline, Cochrane library, and Scopus from 1999 to 2019. We used a combination of the MeSH terms "internal carotid artery," "iatrogenic disease," and "endovascular procedure." Twenty-six articles including 46 patients were identified for in this systematic review. The mean age of the patients was 49 years (CI: ± 4.2). The most common site of ICA injury was in cavernous segment (18 patients; 39%). The most common type of iatrogenic ICA injury was a traumatic pseudoaneurysm documented in 28 patients (60%). Endoluminal reconstruction was performed using covered stents in 28 patients, the Pipeline embolization device (PED) in 13 patients, the Surpass flow diverter device in three, the SILK flow diverter in one, and one case was treated using a combined approach of a covered stent and a PED. Flow diversion and covered stents resulted in a good clinical outcome in 94% and 89% of patients, respectively. This difference did not reach statistical significance (p = 1.0). Even though this systematic review was limited due to articles of small sample sizes and considerable heterogeneity, the results indicate that flow diverting devices and covered stents are good therapeutic options for endoluminal reconstruction of iatrogenic ICA injuries following endonasal surgery.
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Affiliation(s)
- Mohammad Ghorbani
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Hamidreza Shojaei
- Department of Neurosurgery, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
| | | | - Ebrahim Hejazian
- Department of Neurosurgery, Babol University of Medical Sciences, Babol, Mazandaran, Iran
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18
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Zheng Y, Lu Z, Shen J, Xu F. Intracranial Pseudoaneurysms: Evaluation and Management. Front Neurol 2020; 11:582. [PMID: 32733358 PMCID: PMC7358534 DOI: 10.3389/fneur.2020.00582] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/20/2020] [Indexed: 12/04/2022] Open
Abstract
Intracranial pseudoaneurysms account for about 1% of intracranial aneurysms with a high mortality. The natural history of intracranial pseudoaneurysm is not well-understood, and its management remains controversial. This review provides an overview of the etiology, pathophysiology, clinical presentation, imaging, and management of intracranial pseudoaneurysms. Especially, this article emphasizes the factors that should be considered for the most appropriate management strategy based on the risks and benefits of each treatment option.
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Affiliation(s)
- Yongtao Zheng
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Zheng Lu
- Department of Neurosurgery, Hai'an People's Hospital, Nantong, China
| | - Jianguo Shen
- Department of Neurosurgery, Second Affiliated Hospital of Jiaxiang University, Jiaxing, China
| | - Feng Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China.,Department of Neurosurgery, Kashgar Prefecture Second People's Hospital, Kashgar, China
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19
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Deng Q, Feng WF. Efficacy of pipeline endovascular device and Willis stent graft in the treatment of traumatic pseudo intracranial aneurysms. J Interv Med 2020; 3:45-48. [PMID: 34805906 PMCID: PMC8562160 DOI: 10.1016/j.jimed.2020.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the advantages and effects of pipeline embolization device (PED) or Willis stent, in treating traumatic pseudoaneurysms. Traumatic pseudo intracranial aneurysms (TPIA) can be caused by either direct trauma or iatrogenic injuries, usually caused by direct arterial wall injury or shear due to acceleration. We describe a series of patients with TPIA who received a PED or Willis stent. MATERIALS AND METHODS Retrospective analysis was performed on nine patients with TPIA admitted to the southern hospital of Southern Medical University from December 2017 to June 2019, of whom four were treated with PED and five were implanted with six Willis covered stents. The occlusive rate and complication in the two kinds of stents were compared by postoperative follow-up and modified rankin score (MRS). RESULTS After the implantation of PED, four patients showed an immediate stagnation of blood flow or a decreased filling in aneurysms, three out of four patients exhibited complete occlusion, and the remaining patient had nearly complete occlusion. Four out of five cases of Willis stent implantation were associated with immediate complete occlusion of aneurysms, and the modified rankin score of these patients ranged from 0 to 1. One patient died of unassociated complications. CONCLUSION For different types of TPIA in the internal carotid artery (ICA), PED and Willis stents provide significant advantages in treatment, with fewer postoperative complications and prognosis well.
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Affiliation(s)
- Qiao Deng
- Department of Neurosurgery, Nanfang Hospital of Southern Medical University, Guangzhou, 510515, China
| | - Wen feng Feng
- Department of Neurosurgery, Nanfang Hospital of Southern Medical University, Guangzhou, 510515, China
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20
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Zaki Ghali G, George Zaki Ghali M, Zaki Ghali E, Lahiff M, Coon A. Clinical utility and versatility of the petrous segment of the internal carotid artery in revascularization. J Clin Neurosci 2020; 73:13-23. [PMID: 31987635 DOI: 10.1016/j.jocn.2019.11.005] [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: 09/29/2018] [Revised: 09/03/2019] [Accepted: 11/09/2019] [Indexed: 10/25/2022]
Abstract
Direct approaches to high cervical lesions, including tumors and aneurysms, carry significant risks. This renders alternative approaches desirable, with vascular disease amenable to exclusion and revascularization to the intracranial circulation, including the petrous or supraclinoid segments of the internal carotid artery (ICA). The cervicopetrous ICA bypass via saphenous venous grafting has proven an effective strategy for treating and excluding these lesions. In current practice, this is performed via an extradural subtemporal approach to access the petrous segment of the ICA and a cervical incision for access to the cervical ICA. The venous graft is alternately tunneled subcutaneously or in situ through the cervical ICA, with the latter eschewing external compression, kinking, and torsion, which increases risk of graft thrombosis with the former. Maxillary or middle meningeal arteries may also serve as donors to the petrous ICA. Moreover, the petrous ICA may be used as a donor in revascularization procedures, to the supraclinoid segment of the ICA and the middle cerebral artery, with petrous supraclinoid and petrous-MCA bypasses described. Clinical utility and operative approaches bypassing to or from the petrous ICA in revascularization procedures are reviewed and discussed.
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Affiliation(s)
- George Zaki Ghali
- United States Environmental Protection Agency, Arlington, VA, United States; Department of Toxicology, Purdue University, West Lafayette, IN, United States
| | - Michael George Zaki Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, TX, United States; Department of Neurobiology and Anatomy, Drexel University College of Medicine, 2900 W Queen Lane, Philadelphia, PA 19129, United States.
| | - Emil Zaki Ghali
- Department of Medicine, Inova Alexandria Hospital, Alexandria, United States; Department of Urological Surgery, El Gomhoureya General Hospital, Alexandria, Egypt
| | - Marshall Lahiff
- Walton Lantaff Schoreder and Carson LLP, 9350 S Dixie Highway, Miami, FL 33156, United States
| | - Alexander Coon
- Department of Neurosurgery, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, United States
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21
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Akinduro OO, Gopal N, Hasan TF, Nourollah-Zadeh E, Vakharia K, De Leacy R, Burkhardt JK, Yamamoto J, Mocco J, Castilla LR, Tze Man Kan P, Boulos A, Levy E, Tawk RG. Pipeline Embolization Device for Treatment of Extracranial Internal Carotid Artery Pseudoaneurysms: A Multicenter Evaluation of Safety and Efficacy. Neurosurgery 2020; 87:770-778. [DOI: 10.1093/neuros/nyz548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 11/04/2019] [Indexed: 12/20/2022] Open
Abstract
Abstract
BACKGROUND
There is a paucity of literature regarding treatment options for extracranial pseudoaneurysms of the internal carotid artery (ICA). To date, Pipeline Embolization Device (PED; Medtronic Inc) use for the treatment of extracranial pseudoaneurysms of the ICA has only been reported from single-center case series.
OBJECTIVE
To evaluate the safety and efficacy of PED for the treatment of extracranial ICA pseudoaneurysms.
METHODS
This is a multicenter retrospective study involving 6 high-volume tertiary academic institutions in the United States. We analyzed patients with extracranial ICA pseudoaneurysms treated with PED between January 1, 2011, and January 1, 2019. Clinical assessment was performed pre- and postintervention using the modified Rankin Scale (mRS) and National Institution of Health Stroke Scale (NIHSS) at a minimum of 4-mo follow-up.
RESULTS
A total of 28 pseudoaneurysms with a mean diameter of 17.7 mm (range: 4.1-52.5 mm) were treated with PED in 24 patients at 6 participating centers. The mean age was 52.1 yr (17-73) ± 14.3 with 14 females and 10 males. At a mean of 21-mo (range 4-66 mo) follow-up, complete occlusion was achieved in 89% (n = 25/28), with near-complete occlusion (>90% occlusion) in the remainder. There were no periprocedural complications. Postprocedure NIHSS was 0 in 88% (n = 21/24) and 1 in 12% (n = 3/24) of patients, and mRS was 0 in 83% (n = 20/24) and 1 in 17% (n = 4/24) of patients.
CONCLUSION
The treatment of extracranial ICA pseudoaneurysms with PED is safe and effective in selected patients. Randomized controlled trials and prospective cohort studies are needed to establish the role of flow diversion for ICA pseudoaneurysms.
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Affiliation(s)
| | - Neethu Gopal
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | | | - Kunal Vakharia
- Department of Neurological Surgery, University at Buffalo, Buffalo, New York
| | - Reade De Leacy
- Department of Neurological Surgery, Mount Sinai, New York, New York
| | - Jan-Karl Burkhardt
- Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas
| | - Junichi Yamamoto
- Department of Neurological Surgery, Albany Medical Center, Albany, New York
| | - J Mocco
- Department of Neurological Surgery, Mount Sinai, New York, New York
| | | | - Peter Tze Man Kan
- Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas
| | - Alan Boulos
- Department of Neurological Surgery, Albany Medical Center, Albany, New York
| | - Elad Levy
- Department of Neurological Surgery, University at Buffalo, Buffalo, New York
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
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22
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Niu Y, Zhou S, Tang J, Miao H, Zhu G, Chen Z. Treatment of traumatic intracranial aneurysm: Experiences at a single center. Clin Neurol Neurosurg 2019; 189:105619. [PMID: 31812032 DOI: 10.1016/j.clineuro.2019.105619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 11/19/2019] [Accepted: 11/24/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To report the treatment and outcome of traumatic intracranial aneurysm (TICA) cases at the Southwest Hospital, Army Medical University in China. PATIENTS AND METHODS All patients diagnosed with TICA at our institution from January 1, 1977, to October 31, 2018, and meeting the inclusion/exclusion criteria were included in the study. Cases were reported separately for those diagnosed before 1998 and those after 1998. RESULTS A total of 25 patients were included in the study. Ten were diagnosed with TICA prior to 1998. Seven of these 10 patients were treated surgically with parent artery sacrificed, including aneurysmectomy, trapping, and bypass. The mean Glasgow Outcome Scale (GOS) score for the 7 patients with surgical treatment was 3.1. Three of the 10 patients died of severe complications, including intracranial infection, delayed bleeding, and deadly injury. After 1998, 15 patients were diagnosed with TICA. Thirteen presented with head trauma and two with iatrogenic TICA following ventricle drainage or sphenoid ridge meningioma resection. Thirteen were treated with endovascular treatment, including coil alone, glue, coil-associated glue, stent alone, stent-assisted coil embolization, one with clipping, and one with conservative treatment. The 13 patients with endovascular treatment achieved a mean GOS score of 4.5. Among the 13 patients, one died from intracranial infection, one suffered recurrence, and one had intraoperative rupture. CONCLUSION Although the treatment of TICA has traditionally been surgical, endovascular treatment with different techniques, such as endovascular patch, provides a valuable alternative. Currently, the flow diverter is a popular embolization device and may represent another valid treatment option for TICA.
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Affiliation(s)
- Yin Niu
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, People's Republic of China
| | - Sheng Zhou
- Department of Neurosurgery, Chongqing Qianjiang Central Hospital, Chengxi RD. Qianjiang District, Chongqing, 409000, People's Republic of China
| | - Jun Tang
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, People's Republic of China
| | - Hongping Miao
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, People's Republic of China
| | - Gang Zhu
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, People's Republic of China
| | - Zhi Chen
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, People's Republic of China.
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23
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Nariai Y, Kawamura Y, Takigawa T, Hyodo A, Suzuki K. Pipeline embolization for an iatrogenic intracranial internal carotid artery pseudoaneurysm after transsphenoidal pituitary tumor surgery: Case report and review of the literature. Interv Neuroradiol 2019; 26:74-82. [PMID: 31505983 DOI: 10.1177/1591019919874943] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Intracranial pseudoaneurysms are uncommon and among the most difficult lesions to treat with surgery or endovascular means without parent artery sacrifice. Here, we report on a patient who underwent successful treatment using a flow-diverting stent for an iatrogenic intracranial internal carotid artery pseudoaneurysm following a vessel injury after endoscopic pituitary tumor resection via the transsphenoidal approach. A 62-year-old man with a Rathke's cleft cyst presenting with bitemporal hemianopia and progressive decline of left visual acuity underwent endoscopic transsphenoidal pituitary tumor resection. During dura incision, brisk arterial bleeding was encountered from the right internal carotid artery. Immediate packing was performed, and hemostasis was achieved. Three days after the vessel injury, an angiography revealed a pseudoaneurysm (2.9 × 2.1 mm) at the cavernous segment of the right internal carotid artery, which showed enlargement on follow-up magnetic resonance imaging at six days postoperatively. Pipeline embolization was performed nine days after the vessel injury. Angiography performed one month after Pipeline embolization revealed significant stagnation but not complete occlusion of blood flow inside the pseudoaneurysm cavity. Dual antiplatelet therapy was replaced with single antiplatelet therapy. Follow-up angiograms three months after Pipeline embolization confirmed complete obliteration of the pseudoaneurysm and successful endoluminal reconstruction of the damaged vessel. Despite the possibility of short-term bleeding and the need for dual antiplatelet therapy administration for a certain period, the use of flow-diverting stents is a feasible vessel-sparing option in the management of intracranial internal carotid artery pseudoaneurysms resulting from transsphenoidal surgery injuries if intraoperative hemodynamic stability can be achieved with effective packing.
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Affiliation(s)
- Yasuhiko Nariai
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Yosuke Kawamura
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
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24
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AlBayar A, Sullivan PZ, Blue R, Leonard J, Kung DK, Ozturk AK, Chen HI, Schuster JM. Risk of Vertebral Artery Injury and Stroke Following Blunt and Penetrating Cervical Spine Trauma: A Retrospective Review of 729 Patients. World Neurosurg 2019; 130:e672-e679. [PMID: 31279109 DOI: 10.1016/j.wneu.2019.06.187] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cervical spine trauma (CST) may result in vertebral artery injury (VAI), increasing the risk of developing stroke. Stroke risk following CST is poorly reported. METHODS In total, 729 patients with CST were retrospectively analyzed, including rates of VAI, age at injury, cause of injury, cardiovascular history, smoking history, substance abuse history, embolization therapy, and antiplatelet or anticoagulant therapy prior or after injury. VAIs were identified and graded following the Modified Denver Criteria for Blunt Cerebrovascular Injury using magnetic resonance angiography and computed tomography angiography. Brain scans were reviewed for stroke rates and statistically significant variations. RESULTS Thirty-three patients suffered penetrating trauma, whereas 696 patients experienced blunt trauma. In total, 81 patients met the criteria for analysis with confirmed VAI. VAI was more common in penetrating injury group compared with blunt injury group (64% vs. 9%, P < 0.0005). However, low-grade VAI (less than grade III) was more common in blunt injury group versus penetrating group (37% vs. 14%, P < 0.05). The frequency of posterior circulation strokes did not vary significantly between groups (26.3% vs. 13.8%, P = 0.21). Cardiovascular comorbidities were significantly more common in the blunt group (50%, P = 0.0001) compared with the penetrating group (0%). CONCLUSIONS VAI occurs with a high incidence in penetrating CST. Although stroke risk following penetrating and blunt CST did not vary significantly, they resulted in serious complications in a group of patients. Further study of this patient population is required to provide high-level, evidence-based preventions for VAI complications.
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Affiliation(s)
- Ahmed AlBayar
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Patricia Zadnik Sullivan
- Department of Neurosurgery, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Rachel Blue
- Department of Neurosurgery, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Jennifer Leonard
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - David K Kung
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ali K Ozturk
- Department of Neurosurgery, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - H Isaac Chen
- Department of Neurosurgery, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - James M Schuster
- Department of Neurosurgery, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
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25
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Chen SH, McCarthy DJ, Sheinberg D, Hanel R, Sur S, Jabbour P, Atallah E, Chalouhi N, Dumont A, Amenta P, Hasan D, Raper D, Liu K, Jane JA, Crowley RW, Aguilar-Salinas P, Bentley J, Monteith S, Mitchell BD, Yavagal DR, Peterson EC, Starke RM. Pipeline Embolization Device for the Treatment of Intracranial Pseudoaneurysms. World Neurosurg 2019; 127:e86-e93. [PMID: 30849553 DOI: 10.1016/j.wneu.2019.02.135] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Intracranial pseudoaneurysms (PSAs) are associated with high rupture and mortality rates and have traditionally been treated by parent vessel sacrifice. There has been recent interest in using flow-diverting devices for treatment of these complex lesions while preserving flow through the parent artery. The objective of this study is to examine the safety and efficacy of these devices in the treatment of intracranial PSA. METHODS We performed a multi-institutional retrospective study of intracranial PSAs treated with the Pipeline Embolization Device (PED) between 2014 and 2017 at 7 institutions. Complications and clinical and radiographic outcomes were reviewed. RESULTS A total of 19 patients underwent PED placement for intracranial PSA. Iatrogenic injury and trauma comprised most etiologies in our series. The mean pseudoaneurysm diameter was 8.8 mm, and 18 of 19 PSAs (95%) involved the internal carotid artery (ICA). Multiple PEDs were deployed in a telescoping fashion in 7 patients (37%). Of the 18 patients with follow up imaging, 14 (78%) achieved complete pseudoaneurysm obliteration and 2 achieved near-complete obliteration (11%). Two patients (11%) were found to have significant pseudoaneurysm progression on short-term follow-up and required ICA sacrifice. No patients experienced new neurologic deficits or deterioration secondary to PED placement. No patients experienced bleeding or rebleeding from PSA. CONCLUSIONS In well-selected patients, the use of flow-diverting stents may be a feasible alternative to parent vessel sacrifice. Given the high morbidity and mortality associated with PSA, we recommend short- and long-term radiographic follow-up for patients treated with flow-diverting stents.
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Affiliation(s)
- Stephanie H Chen
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - David J McCarthy
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA.
| | - Dallas Sheinberg
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Ricardo Hanel
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA; Department of Neurological Surgery, Baptist Health, Miami, Florida, USA
| | - Samir Sur
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elias Atallah
- Department of Neurological Surgery, Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, Jefferson University, Philadelphia, Pennsylvania, USA
| | - Aaron Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - Peter Amenta
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - David Hasan
- Department of Neurological Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Daniel Raper
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Kenneth Liu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - John A Jane
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - R Webster Crowley
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Josh Bentley
- Department of Neurological Surgery, Swedish Health, Seattle, Washington, USA
| | - Stephen Monteith
- Department of Neurological Surgery, Swedish Health, Seattle, Washington, USA
| | - Bartley D Mitchell
- Department of Neurological Surgery, Methodist Institute, Houston, Texas, USA
| | - Dileep R Yavagal
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Eric C Peterson
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
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Yan Y, Wu Y, Zhao K, Pan Y, Huang Q. Endovascular treatment of traumatic carotid pseudoaneurysm with Tubridge flow diverter: A case report. Interv Neuroradiol 2019; 25:685-687. [PMID: 31169434 DOI: 10.1177/1591019919855862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Traumatic pseudoaneurysm is a rare lesion with a high risk of rupture, and represents one of the most difficult lesions to treat, either surgically or endovascularly. Herein, we describe the case of a 32-year-old man with a traumatic pseudoaneurysm of the internal carotid artery, which was treated by overlapped flow diverters (Tubridge). The patient recovered well, and the follow-up angiography at four months showed complete occlusion of the pseudoaneurysm and patency of the internal carotid artery and the ophthalmic artery.
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Affiliation(s)
- Yazhou Yan
- Department of Neurosurgery, Changhai Hospital affiliated to the Naval Military Medical University, Shanghai, P.R. China
| | - Yina Wu
- Department of Neurosurgery, Changhai Hospital affiliated to the Naval Military Medical University, Shanghai, P.R. China
| | - Kaijun Zhao
- Department of Neurosurgery, Changhai Hospital affiliated to the Naval Military Medical University, Shanghai, P.R. China
| | - Yuan Pan
- Department of Neurosurgery, 971 Hospital of PLA, Qingdao, P.R. China
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital affiliated to the Naval Military Medical University, Shanghai, P.R. China
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Bassi ST, Noronha V, Halbe S. A Time Bomb Defused, In Time! A Traumatic Optic Neuropathy To Be Wary Of. Neuroophthalmology 2019; 43:32-35. [PMID: 30723522 DOI: 10.1080/01658107.2018.1458886] [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: 11/03/2017] [Revised: 02/28/2018] [Accepted: 03/26/2018] [Indexed: 10/28/2022] Open
Abstract
Authors describe a case of traumatic pseudoaneurysm of cavernous internal carotid artery in a young male who presented with complaints of progressive decrease in vision, inability to move the eye, and delayed epistaxis 8 months after the head injury sustained during a motor vehicle accident. The presence of optic atrophy and epistaxis in the setting of head trauma alerted the authors to look for this potentially life-threatening condition. Timely intervention in the form of endovascular coil occlusion of the internal carotid artery was performed and the epistaxis stopped without any ischaemic or thromboembolic sequaelae.
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Affiliation(s)
| | - Veena Noronha
- Department of Radiology, Sankara Nethralaya, Chennai, India
| | - Swatee Halbe
- Department of Radiology and Imaging Services, Senior Interventional Radiologist Apollo Hospitals, Chennai, India
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28
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Grandhi R, Brasiliense LBC, Williamson R, Zwagerman NT, Sauvageau E, Hanel RA. Delayed Pipeline Embolization of a Ruptured True Internal Carotid Artery Aneurysm Presenting with Epistaxis: Case Report and Review of the Literature. World Neurosurg 2019; 125:273-276. [PMID: 30716493 DOI: 10.1016/j.wneu.2019.01.126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 01/11/2019] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Massive epistaxis from rupture of an intracavernous internal carotid artery aneurysm is a potentially fatal event. Although rare, this presentation is seen most often in patients after trauma or iatrogenic injury secondary to transsphenoidal surgery or radiation therapy. CASE DESCRIPTION We present our unusual case of a patient with no significant risk factors who had recurrent epistaxis owing to a ruptured true cavernous internal carotid artery aneurysm. The patient was treated initially with coil embolization followed by placement of a Pipeline embolization device. The patient had complete resolution of her bleeding events. A follow-up arteriogram performed 14 months later confirmed aneurysm obliteration, with parent artery preservation and no evidence of in-stent stenosis. CONCLUSIONS Our case highlights the importance of evaluating for intracranial pathological conditions in patients who present with refractory epistaxis. In selected patients, the use of flow-diversion technology as an adjunct or alternative to primary coil embolization for treatment should be considered.
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Affiliation(s)
- Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, Salt Lake City, Utah, USA.
| | | | - Richard Williamson
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Nathan T Zwagerman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
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29
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Letter to the Editor Regarding "Pediatric Intracranial Pseudoaneurysms: Report of 15 Cases and Review of the Literature". World Neurosurg 2018; 121:282-283. [PMID: 30557927 DOI: 10.1016/j.wneu.2018.08.246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/31/2018] [Indexed: 12/26/2022]
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30
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Emergency placement of a Flow Diverter Stent for an Iatrogenic Internal Carotid Artery Injury During Endoscopic Pituitary Surgery. World Neurosurg 2018; 122:376-379. [PMID: 30439523 DOI: 10.1016/j.wneu.2018.10.234] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/29/2018] [Accepted: 10/31/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Internal carotid artery (ICA) injury is 1 of the most feared complications in endoscopic pituitary surgery. Different endovascular techniques are available for the management of early and delayed ICA injuries. CASE REPORT We report a case of emergency endovascular treatment with a flow diverter stent for an ICA injury that occurred during endoscopic transphenoidal surgery for pituitary macroadenoma in a 66-year-old man. Effective intraoperative hemostasis was achieved by direct packing of the sphenoid sinus. Digital subtraction angiography demonstrated extravasation of the contrast agent into the sphenoidal sinus from the anterior genu of the intracavernous portion of the right ICA. Balloon test occlusion resulted in a prominent delay in the venous phase in the right hemisphere during occlusion of the right ICA. Taking into account the hemodynamic stability and the absence of intracranial bleeding, we considered the ICA injury as if it were a pseudoaneurysm. Therefore, an emergency release of a flow diverter stent was performed, in association with antiplatelet therapy. No periprocedural complications occurred. The patient was discharged without neurologic deficits. The last follow-up studies at 6 months (digital subtraction angiography and magnetic resonance imaging) confirmed the regular placement of the stent and vessel reconstruction. CONCLUSIONS Despite the presence of acute hemorrhage and the need for antiplatelet therapy, a flow diverter stent can be used as emergency treatment of ICA injury in selected circumstances.
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31
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Al-Mufti F, Cohen ER, Amuluru K, Patel V, El-Ghanem M, Nuoman R, Majmundar N, Dangayach NS, Meyers PM. Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms. INTERVENTIONAL NEUROLOGY 2018; 8:38-54. [PMID: 32231694 DOI: 10.1159/000489016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/06/2018] [Indexed: 12/21/2022]
Abstract
Background Flow-diverting stents (FDS) have revolutionized the endovascular management of unruptured, complex, wide-necked, and giant aneurysms. There is no consensus on management of complications associated with the placement of these devices. This review focuses on the management of complications of FDS for the treatment of intracranial aneurysms. Summary We performed a systematic, qualitative review using electronic databases MEDLINE and Google Scholar. Complications of FDS placement generally occur during the perioperative period. Key Message Complications associated with FDS may be divided into periprocedural complications, immediate postprocedural complications, and delayed complications. We sought to review these complications and novel management strategies that have been reported in the literature.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA.,Departments of Neurology and Neurosurgery, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Eric R Cohen
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh-Hamot, Erie, Pennsylvania, USA
| | - Vikas Patel
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Mohammad El-Ghanem
- Department of Neurology and Medical Imaging, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Rolla Nuoman
- Department of Neurology, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA
| | - Neil Majmundar
- Departments of Neurology and Neurosurgery, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Neha S Dangayach
- Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Philip M Meyers
- Departments of Radiology and Neurosurgery and Columbia University Medical Center, New York, New York, New York, USA
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32
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Griauzde J, Ravindra VM, Chaudhary N, Gemmete JJ, Mazur MD, Roark CD, Couldwell WT, Park MS, Taussky P, Pandey AS. Use of the Pipeline embolization device in the treatment of iatrogenic intracranial vascular injuries: a bi-institutional experience. Neurosurg Focus 2018; 42:E9. [PMID: 28565993 DOI: 10.3171/2017.3.focus1735] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow-diverting devices have been used for the treatment of complex intracranial vascular pathology with success, but the role of these devices in treating iatrogenic intracranial vascular injuries has yet to be clearly defined. Here, the authors report their bi-institutional experience with the use of the Pipeline embolization device (PED) for the treatment of iatrogenic intracranial vascular injuries. METHODS The authors reviewed a retrospective cohort of patients with iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2012 and 2016. Data collection included demographic data, indications for treatment, number and sizes of PEDs used, and immediate and follow-up angiographic and clinical outcomes. RESULTS Four patients with a mean age of 47.5 years (range 18-63 years) underwent PED placement for iatrogenic vessel injuries. In 3 patients, the intracranial internal carotid artery (ICA) was injured during transnasal tumor resection. In 1 patient, a basilar apex injury occurred during endoscopic third ventriculostomy. Three patients had a pseudoaneurysm as a result of vessel injury, and 1 patient had frank ICA laceration and extravasation. All 3 pseudoaneurysms were successfully treated with PED deployment. The ICA laceration was refractory to PED placement, and the vessel was subsequently occluded endovascularly. All 4 patients had a good clinical outcome (modified Rankin Scale score of 0 or 1). CONCLUSIONS The use of the PED is feasible in the management of iatrogenic pseudoaneurysms of the intracranial vasculature. In cases of frank vessel perforation, an alternative strategy such as covered stent placement should be considered. Endovascular or surgical vessel occlusion remains the definitive treatment in cases of refractory hemorrhage.
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Affiliation(s)
| | - Vijay M Ravindra
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah; and
| | | | - Joseph J Gemmete
- Departments of 1 Radiology.,Neurosurgery, and.,Otolaryngology, University of Michigan Health System, Ann Arbor, Michigan
| | - Marcus D Mazur
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah; and
| | - Christopher D Roark
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - William T Couldwell
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah; and
| | - Min S Park
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah; and
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah; and
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33
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Young M, Imbarrato G, Gordhan A. Symptomatic Post Endarterectomy Common Carotid Artery Pseudoaneurysm Treated with Combination of Flow Diverter Implantation and Carotid Stenting. Neurointervention 2018. [PMID: 29535899 PMCID: PMC5847891 DOI: 10.5469/neuroint.2018.13.1.54] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 74-year-old male developed cervical carotid artery psuedoaneurysm 8 months after carotid endarterectomy. The patient was successfully managed with dual implantation of flow-diverter and conventional carotid stent. Flow-diverter was placed across the neck of pseudoaneurysm to provide flow diversion while carotid stent was implanted within the lumen of the expanded flow-diverter to approximate and hold the flow diverter proximal and distal to the pseudoaneurysm. Follow-up ultrasonography revealed complete resolution of the pseudoaneurysm.
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Affiliation(s)
- Michael Young
- Department of Neurosurgery, Advocate Health Care, Normal, IL, USA
| | - Greg Imbarrato
- Department of Neurosurgery, Advocate Health Care, Normal, IL, USA
| | - Ajeet Gordhan
- Department of Neurointerventional Radiology, Advocate Health Care, Normal, IL, USA
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34
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Giorgianni A, Pellegrino C, Minotto R, Mercuri A, Frattini L, Baruzzi F, Valvassori L. Flow-diverter stenting of post-traumatic bilateral anterior cerebral artery pseudoaneurysm: A case report. Interv Neuroradiol 2018; 21:23-8. [PMID: 25934771 DOI: 10.1177/1591019915575441] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The use of flow-diverter (FD) stents in recent years has positively changed the therapeutic approach to some vascular diseases, especially of certain types of aneurysms. This paper describes the case of a young patient after a major head trauma causing multiple skull fractures. The trauma occasioned two pseudoaneurysms from the A1 segment of the right anterior cerebral artery and from the A2 segment of the left anterior cerebral artery. Both lesions were treated with two Pipeline devices (ev3, Irvine, CA, USA) in two different sessions. The CT study and angiographic investigations performed in the following month showed a complete resolution of the post-traumatic pseudoaneurysmal lesions. Although the use of FD stents is described in the literature, particularly in the treatment of selected aneurysms, this paper shows good technical results in the use of these stents in cases of intracranial post-traumatic pseudoaneurysms with clinical improvement.
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Affiliation(s)
| | - Carlo Pellegrino
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Renzo Minotto
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Anna Mercuri
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Lara Frattini
- Departement of Anesthesiology, Ospedale di Circolo, Varese, Italy
| | - Fabio Baruzzi
- Departement of Neuroradiology, Ospedale di Circolo, Varese, Italy
| | - Luca Valvassori
- Departement of Neuroradiology, Ospedale Niguarda Ca' Granda, Milan, Italy
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35
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Patel PD, Chalouhi N, Atallah E, Tjoumakaris S, Hasan D, Zarzour H, Rosenwasser R, Jabbour P. Off-label uses of the Pipeline embolization device: a review of the literature. Neurosurg Focus 2017; 42:E4. [DOI: 10.3171/2017.3.focus1742] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The Pipeline embolization device (PED) is the most widely used flow diverter in endovascular neurosurgery. In 2011, the device received FDA approval for the treatment of large and giant aneurysms in the internal carotid artery extending from the petrous to the superior hypophyseal segments. However, as popularity of the device grew and neurosurgeons gained more experience, its use has extended to several other indications. Some of these off-label uses include previously treated aneurysms, acutely ruptured aneurysms, small aneurysms, distal circulation aneurysms, posterior circulation aneurysms, fusiform aneurysms, dissecting aneurysms, pseudoaneurysms, and even carotid-cavernous fistulas. The authors present a literature review of the safety and efficacy of the PED in these off-label uses.
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Affiliation(s)
- Purvee D. Patel
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
- 2Department of Neurological Surgery, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey; and
| | - Nohra Chalouhi
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Elias Atallah
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- 3Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Hekmat Zarzour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Shakir HJ, Rooney PJ, Rangel-Castilla L, Yashar P, Levy EI. Treatment of iatrogenic V2 segment vertebral artery pseudoaneurysm using Pipeline flow-diverting stent. Surg Neurol Int 2017; 7:104. [PMID: 28168090 PMCID: PMC5223396 DOI: 10.4103/2152-7806.196235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/27/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Iatrogenic injury to the vertebral artery is a rare but potential complication of cervical spine surgery. Previous authors have commented on the use of flow-diverting stents for treatment of aneurysms of the V3 segment of the vertebral artery. CASE DESCRIPTION Here, we report a case in which injury occurred at the V2 segment of the vertebral artery with the development of a pseudoaneurysm, which was found on angiography. After decompressing the spinal cord from an epidural hematoma, the pseudoaneurysm was treated by deploying two Pipeline flow-diverting stents (Medtronic, Minneapolis, MN). Obliteration of the pseudoaneurysm was noted on follow-up angiography 4 days after the treatment. CONCLUSION This case highlights a unique treatment at a region which, to our knowledge, has not been mentioned in the literature.
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Affiliation(s)
- Hakeem J Shakir
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Patrick J Rooney
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Leonardo Rangel-Castilla
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Parham Yashar
- California Neurosurgical Institute, Valencia, California, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
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37
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Wang A, Santarelli J, Stiefel MF. Pipeline embolization device as primary treatment for cervical internal carotid artery pseudoaneurysms. Surg Neurol Int 2017; 8:3. [PMID: 28217382 PMCID: PMC5288989 DOI: 10.4103/2152-7806.198730] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 11/15/2016] [Indexed: 12/16/2022] Open
Abstract
Background: Limited data exists on the durability and occlusion rate of treating extracranial cervical internal carotid artery pseudoaneurysms using the pipeline embolization device (PED) flow-diverting stent. Methods: Three patients presenting with dissecting cervical internal carotid artery pseudoaneurysms were treated with the PED as the sole treatment modality. Results: In all three patients, successful aneurysmal occlusion and parent vessel reconstruction occurred on immediate angiography and continued on 6-month follow-up. No immediate or delayed complications were seen, and all patients remained neurologically intact. Conclusion: Complete aneurysmal occlusion and long-term angiographic occlusion can occur after PED treatment of cervical carotid pseudoaneurysms. In select patients, the PED can be a suitable primary treatment modality with good neurological outcome for cervical carotid pseudoaneurysms.
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Affiliation(s)
- Arthur Wang
- Department of Neurosurgery, New York Medical College, Valhalla, New York, USA
| | - Justin Santarelli
- Department of Neurosurgery, New York Medical College, Valhalla, New York, USA; NeuroVascular Institute, Westchester Medical Center, Valhalla, New York, USA
| | - Michael F Stiefel
- Capital Institute for Neurosciences, Stroke and Cerebrovascular Center, Capital Health System, Trenton, NJ, USA
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38
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Jung SH, Kim SH, Kim TS, Joo SP. Surgical Treatment of Traumatic Intracranial Aneurysms: Experiences at a Single Center over 30 Years. World Neurosurg 2016; 98:243-250. [PMID: 27836703 DOI: 10.1016/j.wneu.2016.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 11/01/2016] [Accepted: 11/01/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Traumatic intracranial aneurysm (tIA) is rare and is associated with high rates of morbidity and mortality. We describe our experiences with tIA at our institution. METHODS We retrospectively reviewed records from patients who underwent treatment for tIA between January 1986 and December 2015. RESULTS Data from 5532 patients with cerebral aneurysms between January 1986 and December 2015 were reviewed. Of these, 13 cases (0.23%) were tIA. Most occurred after blunt brain trauma (12/13; 92%). The most common location was the distal anterior cerebral artery (7/13; 53%) followed by the internal carotid artery (5/13; 38%). One patient had a tIA in the distal middle cerebral artery. Delayed intracerebral hemorrhage was the major presentation at the time of aneurysmal rupture (70%). Most patients underwent surgical treatment (10/12; 83.3%), which included clipping (5/10), trapping (3/10), aneurysmal excision and bypass (1/10), and aneurysmal excision and coagulation (1/10). In 2 cases, tIA located in the internal carotid artery was treated with coil embolization and detachable balloon occlusion, respectively. Most patients had good recovery (5/12; 41.7%); 3 patients and 1 patient had moderate and severe disability, respectively; 1 patient was in a vegetative state; and 2 patients died. CONCLUSIONS tIA is an uncommon complication of head trauma. tIA should be considered when unexpected new symptoms develop in patients with head trauma. Early diagnosis and prompt treatment could help to improve final clinical outcomes.
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Affiliation(s)
- Seung-Hoon Jung
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Sung-Hyun Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Tae-Sun Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea.
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Tsang ACO. Letter to the Editor: Internal carotid artery injuries secondary to endonasal surgery. J Neurosurg 2016; 125:1315-1317. [PMID: 27540906 DOI: 10.3171/2016.4.jns16936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Raper DMS, Ding D, Peterson EC, Crowley RW, Liu KC, Chalouhi N, Hasan DM, Dumont AS, Jabbour P, Starke RM. Cavernous carotid aneurysms: a new treatment paradigm in the era of flow diversion. Expert Rev Neurother 2016; 17:155-163. [DOI: 10.1080/14737175.2016.1212661] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Daniel M. S. Raper
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eric C. Peterson
- Department of Neurosurgery, University of Miami Miller School of Medicine, University of Miami Hospital, Jackson Memorial Hospital, Miami Children’s Hospital, Miami, FL, USA
| | | | - Kenneth C. Liu
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - David M. Hasan
- Department of Neurological Surgery, University of Iowa, Iowa City, IA, USA
| | - Aaron S. Dumont
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert M. Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, University of Miami Hospital, Jackson Memorial Hospital, Miami Children’s Hospital, Miami, FL, USA
- Department of Radiology, University of Miami Miller School of Medicine, University of Miami Hospital and Jackson Memorial Hospital, Miami, FL, USA
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Madhusudhan KS, Venkatesh HA, Gamanagatti S, Garg P, Srivastava DN. Interventional Radiology in the Management of Visceral Artery Pseudoaneurysms: A Review of Techniques and Embolic Materials. Korean J Radiol 2016; 17:351-63. [PMID: 27134524 PMCID: PMC4842855 DOI: 10.3348/kjr.2016.17.3.351] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 01/25/2016] [Indexed: 12/15/2022] Open
Abstract
Visceral artery pseudoaneurysms occur mostly as a result of inflammation and trauma. Owing to high risk of rupture, they require early treatment to prevent lethal complications. Knowledge of the various approaches of embolization of pseudoaneurysms and different embolic materials used in the management of visceral artery pseudoaneurysms is essential for successful and safe embolization. We review and illustrate the endovascular, percutaneous and endoscopic ultrasound techniques used in the treatment of visceral artery pseudoaneurysm and briefly discuss the embolic materials and their benefits and risks.
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Affiliation(s)
| | | | - Shivanand Gamanagatti
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Pramod Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Deep Narayan Srivastava
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
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Cobb MIPH, Nimjee S, Gonzalez LF, Jang DW, Zomorodi A. Direct Repair of Iatrogenic Internal Carotid Artery Injury During Endoscopic Endonasal Approach Surgery With Temporary Endovascular Balloon-Assisted Occlusion: Technical Case Report. Neurosurgery 2016; 11 Suppl 3:E483-6; discussion E486-7. [PMID: 26284353 DOI: 10.1227/neu.0000000000000863] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Iatrogenic internal carotid artery (ICA) injuries during endoscopic endonasal approach (EEA) surgeries are associated with a high morbidity and mortality, with few acceptable methods described for repair. CLINICAL PRESENTATION A 13-year-old girl with a large anterior and central skull base osteoblastoma incurred an iatrogenic cavernous ICA injury during a staged EEA approach. Intraoperative angiogram was performed with balloon-assisted EEA primary microsurgical repair of the lacerated ICA. CONCLUSION By integrating current techniques commonly used in open aneurysm surgeries and in endovascular procedures, we developed a rapid, safe technique to repair an EEA-associated iatrogenic ICA injury.
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Affiliation(s)
- Mary In-Ping Huang Cobb
- *Duke University Hospitals, Department of Neurosurgery, Durham, North Carolina; ‡The Ohio State University Hospitals, Department of Neurosurgery, Columbus, Ohio; §Duke University Hospitals, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Durham, North Carolina
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Sylvester PT, Moran CJ, Derdeyn CP, Cross DT, Dacey RG, Zipfel GJ, Kim AH, Uppaluri R, Haughey BH, Tempelhoff R, Rich KM, Schneider J, Chole RA, Chicoine MR. Endovascular management of internal carotid artery injuries secondary to endonasal surgery: case series and review of the literature. J Neurosurg 2016; 125:1256-1276. [PMID: 26771847 DOI: 10.3171/2015.6.jns142483] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Internal carotid artery (ICA) injury is a rare but severe complication of endonasal surgery. The authors describe their endovascular experience managing ICA injuries after transsphenoidal surgery; they review and summarize the current literature regarding endovascular techniques; and they propose a treatment algorithm based on the available evidence. METHODS A retrospective review of 576 transsphenoidal pituitary adenoma resections was performed. Cases of ICA injury occurring at our institution and transfers from other hospitals were evaluated. Endovascular treatments for ICA injury reported in the literature were also reviewed and summarized. RESULTS Seven cases were identified from the institutional cohort (mean age 46.3 years, mean follow-up 43.4 months [1-107 months]) that received endovascular treatment for ICA injury. Five injuries occurred at our institution (5 [0.9%] of 576), and 2 injuries occurred at outside hospitals. Three patients underwent ICA sacrifice by coil placement, 2 underwent lesion embolization (coil or stent-assisted coil placement), and 2 underwent endoluminal reconstruction (both with flow diversion devices). Review of the literature identified 98 cases of ICA injury treated with endovascular methods. Of the 105 total cases, 46 patients underwent ICA sacrifice, 28 underwent lesion embolization, and 31 underwent endoluminal reconstruction. Sacrifice of the ICA proved a durable solution in all cases; however, the rate of persistent neurological complications was relatively high (10 [21.7%] of 46). Lesion embolization was primarily performed by coil embolization without stenting (16 cases) and stent-assisted coiling (9 cases). Both techniques had a relatively high rate of at least some technical complication (6 [37.5%] of 16 and 5 [55.6%] of 9, respectively) and major technical complications (i.e., injury, new neurological deficit, or ICA sacrifice) (5 [31.3%] of 16 and 2 [22.2%] of 9, respectively). Endoluminal reconstruction was performed by covered stent (24 cases) and flow diverter (5 cases) placement. Covered stents showed a reasonably high rate of technical complications (10 [41.7%] of 24); however, 8 of these problems were resolved, leaving a small percentage with major technical complications (2 [8.3%] of 24). Flow diverter placement was also well tolerated, with only 1 minor technical complication. CONCLUSIONS Endovascular treatments including vessel sacrifice, coil embolization (with or without stent assistance), and endoluminal reconstruction offer a tailored approach to ICA injury management after endonasal surgery. Vessel sacrifice remains the definitive treatment for acute, uncontrolled bleeding; however, vessel preservation techniques should be considered carefully in select patients. Multiple factors including vascular anatomy, injury characteristics, and risk of dual antiplatelet therapy should guide best treatment, but more study is needed (particularly with flow diverters) to refine this decision-making process. Ideally, all endovascular treatment options should be available at institutions performing endonasal surgery.
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Affiliation(s)
| | - Christopher J Moran
- Division of Neuroradiology, Mallinckrodt Institute, Washington University School of Medicine, St. Louis, Missouri
| | - Colin P Derdeyn
- Departments of 1 Neurosurgery.,Division of Neuroradiology, Mallinckrodt Institute, Washington University School of Medicine, St. Louis, Missouri
| | - DeWitte T Cross
- Division of Neuroradiology, Mallinckrodt Institute, Washington University School of Medicine, St. Louis, Missouri
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Al-Jehani HM, Alwadaani HA, Almolani FM. Traumatic intracranial internal carotid artery pseudoaneurysm presenting as epistaxis treated by endovascular coiling. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2016; 21:60-3. [PMID: 26818170 PMCID: PMC5224415 DOI: 10.17712/nsj.2016.1.20150514] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Traumatic intracranial pseudoaneurysm is a rare complication of blunt trauma. It is even more rare when it presents as epistaxis. Massive epistaxis of a ruptured intracranial internal carotid artery pseudoaneurysm is a major cause of mortality, which requires emergency intervention. We report a case of traumatic intracranial internal carotid artery pseudoaneurysm secondary to skull base fracture, which presented with delayed onset of epistaxis. This was successfully treated by primary endovascular coil embolization. We discuss endovascular treatment options and review the literature.
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Affiliation(s)
- Hosam M. Al-Jehani
- From the Departments of Neurosurgery and Interventional Radiology (Al-Jehani), King Fahad Hospital of the University, University of Dammam, Diagnostic and Interventional Neuroradiology (Alwadaani, Almolani), the Department of Medical Imaging, King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia,Address correspondence and reprint request to: Dr. Hosam M. Al-Jehani, Department of Neurosurgery, King Fahad Hospital of the University, Alkhobar, Kingdom of Saudi Arabia.
| | - Hassan A. Alwadaani
- From the Departments of Neurosurgery and Interventional Radiology (Al-Jehani), King Fahad Hospital of the University, University of Dammam, Diagnostic and Interventional Neuroradiology (Alwadaani, Almolani), the Department of Medical Imaging, King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia
| | - Fadhel M. Almolani
- From the Departments of Neurosurgery and Interventional Radiology (Al-Jehani), King Fahad Hospital of the University, University of Dammam, Diagnostic and Interventional Neuroradiology (Alwadaani, Almolani), the Department of Medical Imaging, King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia
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Safety, efficacy, and short-term follow-up of the use of Pipeline™ Embolization Device in small (<2.5mm) cerebral vessels for aneurysm treatment: single institution experience. Neuroradiology 2015; 58:267-75. [DOI: 10.1007/s00234-015-1630-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 12/04/2015] [Indexed: 10/22/2022]
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Moon TH, Kim SH, Lee JW, Huh SK. Clinical Analysis of Traumatic Cerebral Pseudoaneurysms. Korean J Neurotrauma 2015; 11:124-30. [PMID: 27169077 PMCID: PMC4847513 DOI: 10.13004/kjnt.2015.11.2.124] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 10/13/2015] [Accepted: 10/19/2015] [Indexed: 11/17/2022] Open
Abstract
Objective Traumatic pseudoaneurysms are rare but life-threatening lesions. We investigated the patients with these lesions to clarify their clinical characteristics and therapeutic strategies and we also reviewed the literatures on the treatment principles, possible options, and outcomes. Methods There were a total of 8 patients who were treated with traumatic intracranial pseudoaneurysms between April 1980 and January 2009. Medical charts and the imaging studies were reviewed for analysis. The outcome was measured with modified Rankin Scale (mRS) score at 6 months after treatment. Results All 8 patients were male and the mean age was 25 years old. Six of those were located at the cavernous segment of the internal carotid artery (ICA) and the other 2 was located at the M2 segment of middle cerebral artery. The causes of trauma were car accidents in 6, penetrating injury through the orbit in 1, and slip down injury in 1 patient. Massive epistaxis or hematemesis occurred in all patients with a pseudoaneurysm at the cavernous and ophthalmic segment of the ICA. All 6 patients of the cavernous and ophthalmic ICA group showed favorable outcome of mRS 0 to 1. The outcome of patients with middle cerebral artery pseudoaneurysm was mRS 2 to 3. Conclusion Upon prompt diagnosis and proper treatment planning, it is possible to achieve favorable outcome in these patients. Lesions located at the cavernous segment of the ICA favored endovascular treatment while those at the middle cerebral artery favored surgical treatment.
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Affiliation(s)
- Tae Hun Moon
- Department of Neurosurgery, Stroke Center, College of Medicine, Yonsei University, Severance Hospital, Seoul, Korea
| | - Sung Han Kim
- Department of Neurosurgery, Stroke Center, College of Medicine, Yonsei University, Severance Hospital, Seoul, Korea
| | - Jae Whan Lee
- Department of Neurosurgery, Stroke Center, College of Medicine, Yonsei University, Severance Hospital, Seoul, Korea
| | - Seung Kon Huh
- Department of Neurosurgery, Stroke Center, College of Medicine, Yonsei University, Severance Hospital, Seoul, Korea
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Dolati P, Eichberg DG, Thomas A, Ogilvy CS. Application of Pipeline Embolization Device for Iatrogenic Pseudoaneurysms of the Extracranial Vertebral Artery: A Case Report and Systematic Review of the Literature. Cureus 2015; 7:e356. [PMID: 26623211 PMCID: PMC4658329 DOI: 10.7759/cureus.356] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Traumatic pseudoaneurysms of the vertebral artery (VA) are uncommon vascular lesions and definitive management is often challenging. Between 0% and 8% of craniocervical fusions are complicated by VA injury. In these cases, preserving the vertebral artery while treating the pseudoaneurysm is the goal of any treatment option. We describe the second known case of a patient with and iatrogenic extracranial vertebral artery pseudoaneurysm treated effectively using the Pipeline Embolization Device (PED) (Ev3 Neurovascular, Irvine, CA). Although there have been only two cases reported, the use of flow-diverting stents appears to be efficacious for the treatment of non-actively bleeding traumatic pseudoaneurysms.
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Zanaty M, Chalouhi N, Jabbour P, Starke RM, Hasan D. The unusual angiographic course of intracranial pseudoaneurysms. Asian J Neurosurg 2015; 10:327-30. [PMID: 26425168 PMCID: PMC4558815 DOI: 10.4103/1793-5482.162721] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Although rare, traumatic intracranial pseudoaneurysms remain one of the most difficult vascular lesions to diagnose and treat. A 55-year-old male patient underwent endoscopic endonasal transphenoidal resection for a pituitary macroadenoma. The operation was complicated by an arterial bleed. The initial angiogram revealed pseudoaneurysm of the anterior choroidal artery. Although the pseudoaneurysm completely disappeared on the second angiogram, it was surprisingly found to have enlarged on the third angiogram. The lesion was successfully treated with flow-diversion using a pipeline embolization device. The present case demonstrates that the natural history of iatrogenic pseudoaneurysms may be unpredictable and misleading. Traumatic pseudoaneurysms should, therefore, be carefully followed when conservative treatment is elected or when the lesion seems to have spontaneously regressed. Flow-diversion seems to be a reasonable treatment option.
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Affiliation(s)
- Mario Zanaty
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia, School of Medicine, Charlottesville, Virginia, USA
| | - David Hasan
- Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Successful treatment of iatrogenic vertebral pseudoaneurysm using pipeline embolization device. Case Rep Vasc Med 2014; 2014:341748. [PMID: 25276469 PMCID: PMC4167810 DOI: 10.1155/2014/341748] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 08/27/2014] [Indexed: 11/17/2022] Open
Abstract
Traumatic pseudoaneurysms are uncommon and one of the most difficult lesions to treat. Traditional treatment methods have focused on parent vessel sacrifice with or without revascularization. We report the case of a patient who underwent successful treatment of an iatrogenic extracranial vertebral artery pseudoaneurysm using the Pipeline Embolization Device. A 47-year-old man sustained an inadvertent injury to the left vertebral artery during C1-C2 fixation. Subsequent imaging revealed an iatrogenic vertebral artery pseudoaneurysm. Immediate angiogram was normal. A repeat angiogram done after 3 days of the surgery revealed a vertebral artery pseudoaneurysm. He underwent aneurysm exclusion and vascular reconstruction using the Pipeline Embolization Device. Although flow-diverting stents are currently not being used for treating traumatic pseudoaneurysms, their use may be considered in such cases if active bleeding has ceased. In our case, the patient did well and the aneurysm was excluded from circulation while reconstructing the vessel wall.
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50
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Chan RSK, Mak CHK, Wong AKS, Chan KY, Leung KM. Use of the pipeline embolization device to treat recently ruptured dissecting cerebral aneurysms. Interv Neuroradiol 2014; 20:436-41. [PMID: 25207906 DOI: 10.15274/inr-2014-10042] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 02/08/2014] [Indexed: 11/12/2022] Open
Abstract
The Pipeline embolization device (PED) is one of the flow-diverting stents approved for the treatment of unruptured large or wide-necked cerebral aneurysms in 2011(1). Its use has now been extended to the treatment of recently ruptured dissecting cerebral aneurysm, carotid pseudoaneurysm from radiation injury, and blister aneurysms(2,3). We aimed to evaluate the effectiveness of utilizing the PED as a primary treatment for ruptured dissecting intracranial aneurysms. A single center retrospective review was conducted for all patients primarily treated with PED for acute subarachnoid hemorrhage (SAH) from ruptured dissecting cerebral aneurysms between December 2010 and February 2013. Patients were followed up with CT angiogram (CTA) or digital subtraction angiogram (DSA). Eight patients with a total of eight dissecting aneurysms were identified. The mean duration from SAH to treatment was 2.5 days. Six of the aneurysms arose from vertebral arteries and two from the basilar artery. Immediate check-DSA confirmed satisfactory contrast stasis in all eight cases, and complete aneurysmal obliteration was achieved at six months. There were two (25%) procedure-related complications, but no major procedure-related complications, such as thromboembolic events or rebleeding from aneurysm were encountered. The PED is a feasible treatment option for ruptured dissecting cerebral aneurysms in acute phase. According to our experience, using PED as flow-diverters in acute SAH does not significantly increase the complication risks or mortality rate if the antiplatelet regime is carefully monitored. Future studies shall evaluate the optimal antiplatelet regimen for using the PED in the acute phase.
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Affiliation(s)
| | - Calvin H K Mak
- Department of Neurosurgery, Kwong Wah Hospital; Hong Kong
| | - Alain K S Wong
- Department of Neurosurgery, Kwong Wah Hospital; Hong Kong
| | - Kwong Yau Chan
- Department of Neurosurgery, Kwong Wah Hospital; Hong Kong
| | - Kar Ming Leung
- Department of Neurosurgery, Kwong Wah Hospital; Hong Kong
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