[Endovascular treatment of aneurysms associated with cerebral arteriovenous malformations]

There are proximal, distal and intranidal AVM-associated aneurysms (G. Redekop, 1998).

OBJECTIVE

To evaluate treatment outcomes in 120 patients with AVM-associated aneurysms.

MATERIAL AND METHODS

We analyzed treatment outcomes in 639 patients with cerebral AVM who underwent 1992 endovascular procedures between 2010 and 2019. AVM-associated aneurysms were found in 120 (18.8%) cases: 81 (67.5%) patients with 69 proximal and 29 distal aneurysms, 33 (27.5%) AVMs with intranidal aneurysms and 6 (5%) aneurysms without hemodynamic connection with AVM. One hundred and one malformations (16.9%) out of 596 supratentorial AVMs and 19 (44.2%) out of 43 subtentorial AVMs were associated with aneurysms.

RESULTS

Intracranial hemorrhage occurred in 349 (53.3%) out of 639 patients with AVM: 97 (80.8%) out of 120 patients with AVM-associated aneurysms and 252 (48.6%) out of 519 ones with AVM and no aneurysms. All 33 patients with intranidal aneurysms in the AVM structure and 18 (94.7%) out of 19 patients with AVM-associated aneurysms and AVM in posterior cranial fossa had intracranial hemorrhage. There were 98 aneurysms in 81 patients with AVM-associated aneurysms. Eighty-nine (90.8%) ones underwent endovascular treatment, 6 (6.1%) patients with proximal aneurysms required microsurgery. Three distal aneurysms were not repaired. Thirty-four aneurysms were embolized with spirals. Embolization with spirals and balloon assistance was performed for 41 aneurysms, spirals with stent-assistance - for 9 aneurysms (including 1 distal MCA aneurysm in hemorrhagic period). Implantation of a flow-diverting stent was performed for 5 aneurysms (1 distal and 4 proximal aneurysms). There were 8 (8.9%) complications after embolization of 89 AVM-associated aneurysms (5 thromboembolic and 3 hemorrhagic events).

CONCLUSION

According to our data, intranidal aneurysms require exclusion of the parent AVM segment due to high risk of hemorrhage. Treatment of proximal AVM-associated aneurysms should be carried out prior to AVM embolization. Distal aneurysms do not regress after definitive AVM treatment and should be operated on after total AVM embolization.

Case Report: A 62-Year-Old Woman With Contrast-Induced Encephalopathy Caused by Embolization of Intracranial Aneurysm

Contrast-induced encephalopathy (CIE) is a rare complication of endovascular treatment and is extensively reported as a transient and reversible phenomenon. This report describes a 62-year-old woman for embolization of an internal carotid artery (ICA) aneurysm. The operation was successful, but postoperation the patient suffered unconsciousness, blindness, hemiplegia, ophthalmoplegia, fever, and seizures. CT of the brain without the contrast showed widespread edema in the right cerebral hemisphere, which is involved in the frontal, parietal, temporal, and occipital lobes. She was diagnosed with CIE in time and treated with supportive management as soon as possible, and fortunately, the patient improved a benign course and was discharged without any neurological deficits. This study emphasizes the prevention of the CIE and the importance of early diagnosis and symptomatic treatment.

Retrograde trans-posterior communicating artery rescue balloon angioplasty of incompletely expanded pipeline embolization device: complication management

Background: Pipeline embolization device (PED) deployment is a technically demanding procedure. Incomplete device expansion or deployment is one intra-operative risk, especially in patients with significant vascular tortuosity.Case description: We describe the case of a 71-year female with an unruptured left vertebral artery saccular aneurysm. Tortuosity of the arteries proximal to the aneurysm complicated deployment and the proximal end of the PED failed to expand despite several maneuvers. The inadequately expanded PED caused flow limitation in the left vertebral artery and it became imperative to achieve wall apposition of the PED. We salvaged the PED from the left vertebral artery by retrograde trans-right posterior communicating artery balloon angioplasty.Conclusions: Our case documents the successful application of the rarely used salvage strategy - anterior-to-posterior circulation retrograde rescue balloon angioplasty of an unopened PED.

The Nimodipine-Sparing Effect of Perioperative Dexmedetomidine Infusion During Aneurysmal Subarachnoid Hemorrhage: A Prospective, Randomized, Controlled Trial

Background: Nimodipine can block the influx of calcium into the vascular smooth muscle cell and prevent secondary ischemia in patients with aneurysmal subarachnoid hemorrhage. However, the reduction of blood pressure after long-term intravenous administration of nimodipine has been associated with neurological deterioration. Yet, no effective solutions have been suggested to address this phenomenon. The use of neuroprotective drug combinations may reduce the risk of sudden blood pressure loss. This prospective, randomized, controlled trial was performed to evaluate the nimodipine-sparing effect of perioperative dexmedetomidine infusion during aneurysmal subarachnoid hemorrhage.

Methods: One hundred nine patients who underwent aneurysm embolization were divided into three groups: group C (n = 35, infused with 0.9% sodium chloride at the same rate as other two groups), group D1 (n = 38, dexmedetomidine infusion at 0.5 µg·kg^–1 for 10 min, then adjusted to 0.2 µg·kg^–1·h^–1), and group D2 (n = 36, dexmedetomidine infusion at 0.5 µg·kg^–1 for 10 min, then adjusted to 0.4 µg·kg^–1·h^–1). Patient-controlled analgesia was given for 48 h after surgery. The primary outcome measure was the total consumption of nimodipine during the first 48 h after surgery. The secondary outcome measures were recovery time at post-anesthesia care unit (PACU), postoperative pain intensity scores, dexmedetomidine and sufentanil consumption, hemodynamic, satisfaction of patients and neurosurgeon, neurologic examination (Glasgow Coma Scale, GCS), Bruggemann comfort scale, and adverse effects. Intraoperative hemodynamics were recorded at the following time-points: arrival at the operating room (T1); before intubation (T2); intubation (T3); 5 min (T4), 10 min (T5), and 15 min (T6) after intubation; suturing of femoral artery (T7); end of surgery (T8); extubation (T9); and 5 min (T10), 10 min (T11), and 15 min (T12) after arrival at the PACU. The level of sedation was recorded at 15 min, 30 min, 1 h, and 2 h after extubation. We also recorded the incidence of symptomatic cerebral vasospasm during 7 days after surgery, Glasgow Outcome Score (GOS) at 3 months, and incidence of cerebral infarction 30 days after surgery.

Results: The consumption of nimodipine during the first 48 h after surgery was significantly lower in group D2 (P < 0.05). Compared with group C, HR and MAP were significantly decreased from T2 to T12 in group D1 and D2 (P < 0.05). Patients in group D2 showed a significantly decreased MAP from T5 to T9 compared with group D1 (P < 0.05). The consumption of sevoflurane, remifentanil, dexmedetomidine, and nimodipine were all significantly reduced in groups D1 and D2 during surgery (P < 0.05). Compared with group C, MAP was significantly decreased in groups D1 and D2 during the first 48 h after surgery (P < 0.05). Compared with group C, consumption of sufentanil and dexmedetomidine at 1 h, pain intensity at 1 h, and 8 h after surgery were significantly decreased in groups D1 and D2 (P < 0.05). FAS was significantly higher in group D2 at 8 h, 16 h, and 24 h after surgery. LOS was significantly lower only in group D2 at 0.5 h after surgery (P < 0.05). Compared with group C, BCS was significantly higher group D2 at 4 h and 8 h after surgery (P < 0.05). There were no significant differences among the three groups in consumption of propofol, cisatracurium, fentanyl, and vasoactive drugs during operation, recovery time at PACU, satisfaction of patients and neurosurgeon, and number of applied urapidil and GCS during the first 48 h after surgery. The incidence of symptomatic cerebral vasospasm during 7 days after surgery, GOS of 3 months, and cerebral infarction after 30 days were also comparable among the three groups.

Conclusions: Dexmedetomidine (infusion at 0.5 µg·kg^–1 for 10 min, then adjusted to 0.4 µg·kg^–1·h^–1 during the surgery) significantly reduced the total consumption of nimodipine during the first 48 h after surgery and promoted early rehabilitation of patients although the incidences of symptomatic cerebral vasospasm, GOS, and cerebral infarction were not reduced.

Endovascular treatment of intracranial infectious aneurysms in eloquent cortex with super-selective provocative testing: Case series and literature review

Intracranial infectious aneurysms (IIAs) are a rare subgroup of intracranial aneurysms. Often erroneously termed mycotic aneurysms, these lesions most often result from infectious endocarditis and involve the distal anterior cortical circulation. Diagnosis typically follows headaches or septic infarcts, although increasing numbers of lesions are found incidentally, during screening protocols for infectious endocarditis. Open surgical treatment was previously the mainstay of treatment; however, these IIAs are often fusiform and quite fragile, making open surgical obliteration difficult and typically requiring lesion trapping. Current treatment techniques more commonly involve endovascular coil embolization or parent vessel occlusion. Many of these lesions occur distally, in or around the eloquent cortex, making embolization potentially dangerous. We present cases that highlight the use of super-selective provocative testing with sodium amobarbital and lidocaine, to help clarify and predict the risk of parent vessel occlusion in IIAs located in the eloquent cortex.

Early surgical removal of migrated coil/stent after failed embolization of intracranial aneurysm

OBJECT

Distal coil or stent migration is a rare, but potentially morbid complication of intracranial aneurysm embolization. At present, there is no established standard of surgical evacuation of displaced material-in particular, there is no consensus on the optimum time for such intervention. The authors report their positive experiences with an ultra-early surgical evacuation of 2 migrated coils and a flow-diverter stent.

METHODS

Uncontrolled coil or stent migration occurred in 3 (0.75%) of approximately 400 patients treated between 1999 and 2012 in the authors' institution. In all 3 cases, the materials moved from their intended position to the middle cerebral artery (MCA). Surgical evacuation was started immediately (within half an hour) after a futile attempt of removing them via intraarterial route, under the same anesthesia and with no active reversal of heparinization.

RESULTS

No excessive bleeding was observed. Displaced coils were extracted through an incision of a branch of MCA-the anterior temporal artery, the stent was removed through a direct incision of MCA. Recombinant tissue plasminogen activator (rtPA) was injected to the stem of the internal carotid artery toward the end of the procedure, with no discernible adverse effects. Two patients were discharged with no deficit (Glasgow Outcome Scale [GOS] Score 5); the other patient was conscious with mild hemiparesis (GOS Score 4) at discharge.

CONCLUSIONS

The experiences of these 3 cases suggest that immediate removal of a migrated stent/coil is feasible and may be effective. Indirect access to the MCA through its branch helps to shorten the time of temporary clipping of the artery to a minimum. Maintaining active heparinization and direct intraarterial injection of rtPA are helpful in promoting blood flow in the MCA.

Neuroophthalmological outcomes associated with use of the Pipeline Embolization Device: analysis of the PUFS trial results

OBJECT

Neuroophthalmological morbidity is commonly associated with large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms. The authors sought to evaluate the neuroophthalmological outcomes after treatment of these aneurysms with the Pipeline Embolization Device (PED).

METHODS

The Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial was an international, multicenter prospective trial evaluating the safety and efficacy of the PED. All patients underwent complete neuroophthalmological examinations both before the PED procedure and at a 6-month follow-up. All examinations were performed for the purpose of this study and according to study criteria.

RESULTS

In total, 108 patients were treated in the PUFS trial, 98 of whom had complete neuroophthalmological follow-up. Of the patients with complete follow-up, 39 (40%) presented with a neuroophthalmological baseline deficit that was presumed to be attributable to the aneurysm, and patients with these baseline deficits had significantly larger aneurysms. In 25 of these patients (64%), the baseline deficit showed at least some improvement 6 months after PED treatment, whereas in 1 patient (2.6%), the deficits only worsened. In 5 patients (5%), new deficits had developed at the 6-month follow-up, while in another 6 patients (6%), deficits that were not originally assumed to be related to the aneurysm had improved by that time. A history of diabetes was associated with failure of the baseline deficits to improve after the treatment. The aneurysm maximum diameter was significantly larger in patients with a new deficit or a worse baseline deficit at 6 months postprocedure.

CONCLUSIONS

Patients treated with the PED for large and giant ICA aneurysms had excellent neuroophthalmological outcomes 6 months after the procedure, with deficits improving in most of the patients, very few deficits worsening, and few new deficits developing.

Initial experience with the coaxial dual-lumen ascent balloon catheter for wide-neck aneurysm coil embolization

Introduction: Techniques for coil embolization of wide-neck cerebral aneurysms include the use of stents and temporary occlusion with compliant non-detachable balloons to safely allow dense packing of the aneurysm lumen with detachable coils. We describe the use of a new balloon device for assisting in wide-neck aneurysm coil treatment. Methods: A single institution neuroendovascular database was accessed to identify cases in which the Ascent balloon (Codman Neurovascular, Raynham, MA, USA) was used for aneurysm coil embolization. Clinical, demographic, and angiographic data were obtained through chart review. Results: Eleven cerebral aneurysm cases were treated using the Ascent balloon during the first 12-month period that the new device was available at our institution. Three of the patients presented with ruptured aneurysms. All aneurysms were large (maximum diameter 6 mm or greater), with an average maximum diameter of 9.4 mm, and an average neck diameter of 5.5 mm. Complete occlusion with coil embolization (Raymond class I) was achieved in all cases. The Ascent balloon was successfully positioned across the neck of the aneurysm in nine patients. Conclusion: This initial experience demonstrates the feasibility and immediate outcomes of the coaxial dual-lumen design Ascent balloon catheter used as an assistive device in coil embolization of wide-neck cerebral aneurysms. This device contributes to the growing number of assistive devices for the treatment of complex cerebral aneurysms.

A comparison between magnetic resonance angiography at 3 Teslas (time-of-flight and contrast-enhanced) and flat-panel digital subtraction angiography in the assessment of embolized brain aneurysms

PURPOSE

To compare the time-of-flight and contrast-enhanced- magnetic resonance angiography techniques in a 3 Tesla magnetic resonance unit with digital subtraction angiography with the latest flat-panel technology and 3D reconstruction in the evaluation of embolized cerebral aneurysms.

INTRODUCTION

Many embolized aneurysms are subject to a recurrence of intra-aneurismal filling. Traditionally, imaging surveillance of coiled aneurysms has consisted of repeated digital subtraction angiography. However, this method has a small but significant risk of neurological complications, and many authors have advocated the use of noninvasive imaging methods for the surveillance of embolized aneurysms.

METHODS

Forty-three aneurysms in 30 patients were studied consecutively between November 2009 and May 2010. Two interventional neuroradiologists rated the time-of-flight-magnetic resonance angiography, the contrast-enhanced-magnetic resonance angiography, and finally the digital subtraction angiography, first independently and then in consensus. The status of aneurysm occlusion was assessed according to the Raymond scale, which indicates the level of recanalization according to degrees: Class 1: excluded aneurysm; Class 2: persistence of a residual neck; Class 3: persistence of a residual aneurysm. The agreement among the analyses was assessed by applying the Kappa statistic.

RESULTS

Inter-observer agreement was excellent for both methods (K = 0.93; 95 % CI: 0.84-1). Inter-technical agreement was almost perfect between time-of-flight-magnetic resonance angiography and digital subtraction angiography (K = 0.98; 95 % CI: 0.93-1) and between time-of-flight-magnetic resonance angiography and contrast-enhanced-magnetic resonance angiography (K = 0.98; 95% CI: 0.93-1). Disagreement occurred in only one case (2.3%), which was classified as Class I by time-of-flight-magnetic resonance angiography and Class II by digital subtraction angiography. The agreement between contrast-enhanced-magnetic resonance angiography and digital subtraction angiography was perfect (K = 1; 95% CI: 1-1). In three patients, in-stent stenosis was identified by magnetic resonance angiography but not confirmed by digital subtraction angiography.

CONCLUSION

Digital subtraction angiography and both 3T magnetic resonance angiography techniques have excellent reproducibility for the assessment of aneurysms embolized exclusively with coils. In those cases also treated with stent remodeling, digital subtraction angiography may still be necessary to confirm eventual parent artery stenosis, as identified by magnetic resonance angiography.