Carotid Sacrifice Research Articles

Covered stent graft for treatment of carotid artery stenosis with post-stenotic aneurysm

Several bare metals, self-expanding stents have been approved by the Food and Drug Administration (FDA) to treat carotid stenosis, but no covered stents have been particularly examined or approved for carotid or cerebrovascular applications. Nonetheless, there are a number of potentially useful applications for covered stents in the brachiocephalic, carotid, and even intracranial arteries. As with currently accepted applications for bare metal carotid stents, the use of covered stents in carotid arteries has been reserved for patients who are at high risk for complications with open surgical management of their specific problem. The present case report emphasizes the safety and efficacy of covered stent in complex carotid artery reconstruction entailing stenosis and aneurysmal dilatation and through light on its impact on minimizing the risk of ischemic complications associated with endovascular or surgical carotid sacrifice.

Endovascular treatment of unruptured cavernous carotid aneurysms using flow diverter devices in Vietnam: A single-center prospective study

ObjectiveThis prospective study aims to investigate the safety and effectiveness of flow diverter (FD) in the treatment of unruptured cavernous carotid aneurysms (CCAs) in Vietnam. MethodsA single-center, prospective case series of 32 patients with unruptured CCAs treated by FD at our center from January 2017 to January 2022 was performed. We analyzed the aneurysm characteristics, procedure details, aneurysm occlusion rate, evolution of clinical symptoms, complications, and functional outcomes after treatment. Angiographic study was scheduled at the 6-month and 12-month follow-up. The occlusion rate was evaluated according to the O’Kelly-Marotta (OKM) Scale. Results35 FDs were deployed to treat 32 unruptured CCAs in 32 patients (mean age, 59.25; mean aneurysm size, 12.13 mm). Stent implantation was successful in all patients. Single FD was used in 29 cases (90.6%). Adjunctive coils were placed in five patients (15.6%). Complete aneurysm occlusion was achieved in 61.3% at 6 months and 96.4% at 12 months. Favorable outcome defined as mRS 0–2 was reported in all except one patient. Complete resolution or significant improvement of clinical symptoms was noted in 29 of 30 symptomatic patients (96.7%). Periprocedural complications included vessel perforation with severe SAH leading to death in one case (3.1%), minor vasospasm in four (12.5%), acute in-stent thrombosis in two (6.3%), and puncture-related hematoma in two (6.3%). All of these patients were successfully managed without clinical sequalae after the procedure except for one case. ConclusionFD represents a safe and effective treatment modality that might be considered as a valuable alternative to standard endovascular coiling techniques or carotid sacrifice for unruptured CCAs.

Abstract 1122‐000218: Flow Reversal After Stent Diversion Causes In‐Stent Thrombosis and Anemia‐Driven Ischemia

Introduction : Large symptomatic ICA aneurysms are rare, but present a life threatening risk of rupture that increases with size, female sex, and age >50 at the time of diagnosis, among other risk factors. Historically, large carotid aneurysms have been treated with intentional carotid sacrifice, requiring recruitment of contralateral, posterior, and ECA‐supplied collaterals to provide flow to the anterior circulation previously supplied by the sacrificed ICA, lest the patient experience an iatrogenic stroke. While still a viable option in some cases, flow diverting stents provide an attractive alternative to vessel sacrifice. By providing a channel for blood to bypass the aneurysm, the stent can effectively exclude the aneurism from active circulation while preserving a path for blood to travel to the anterior cerebral circulation it currently provides. Methods : Here, we present a case of a 1.3 cm symptomatic left cavernous ICA aneurysm treated with such a flow diverting stent. Results : The patient presented to the emergency department with left sided ptosis. CTA head and neck revealed the 1.3 cm left sided cavernous ICA aneurysm. She was treated endovascularly under general anesthesia with continuous intra‐operative monitoring. The procedure was complicated by iatrogenic flow reversal through the Circle of Willis at the time of stent deployment and resultant in situ thrombosis of the stent without alteration in electrical signals recorded at the scalp – thus creating a de facto carotid sacrifice without intra‐operative complication. Follow up doppler study revealed a loss of flow through the left ICA and reversal of flow through the ophthalmic artery on the left side, thus confirming ECA collateral supply to the area. Post‐op course was complicated by extensive bleeding from the scalp electrode sites used for intraoperative monitoring due to hyper‐response to aspirin‐ticagrelor dual‐antiplatelet therapy. This gave rise to a symptomatic anemia that manifested as pressure‐dependent left‐sided circulatory failure on exam – specifically hemiparesis and aphasia. The symptoms ultimately resolved with pressure augmentation, blood transfusion, and supportive care in the Neuro ICU. The patient was successfully transitioned to a general neurology floor with subsequent resolution of the anemia and, correspondingly, the symptoms. Conclusions : The patient was discharged to rehab and at 4‐month follow‐up is again living independently with no residual deficits. This case has significance for pre‐operative anti‐platelet optimization for flow diverting stents, management of post‐operative complications of flow‐diverting stent placement including thrombosis and bleeding, and optimal critical care support for patients with pressure‐dependent ischemia. Specifically, the course of the patient’s symptoms and anemia raise the question of optimal hemoglobin targets in the subset of patients with pressure‐dependent ischemia, and how to best reach those targets.

Placement of a Pipeline Embolization Device: 2-Dimensional Operative Video.

Flow diversion has been a game-changer in the treatment of wide-neck large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms as well as large vertebral artery aneurysms. Prior to their existence, carotid sacrifice or clipping with or without external to internal carotid artery bypass was the mainstay of treatment. Prior to flow diversion, endovascular coil embolization was often not effective as a stand-alone treatment because of the fact that many of these aneurysms present with symptoms created by mass effect on the cavernous sinus cranial nerves by the aneurysm. Packing the aneurysm with coils did nothing to alleviate the mass effect and did not prevent flow from entering the aneurysm. The continued flow causes coil compaction and aneurysm enlargement. Flow diversion addressed both these issues by diverting flow from the aneurysm while allowing the aneurysm to slowly thrombose and shrink. The video is a step-by-step account of this procedure in a 72-yr-old male with a large recurrence of a previously coiled cavernous ICA aneurysm. The procedure was performed following informed consent.

Penumbra Occlusion Device for neurovascular vessel sacrifice: Feasibility and application

PurposeThe purpose of this study is to describe the use of the Penumbra Occlusion Device (POD), which is a coil with an enhanced anchor segment, along with standard coils for carotid and vertebral artery sacrifice, and to assess its feasibility, safety, and efficacy. MethodsThis is a retrospective chart review of patients with vessel sacrifices who were treated using POD. For the procedure, a balloon test occlusion was performed prior to permanent arterial sacrifice. Following this, a POD was deployed followed by subsequent angiography to confirm occlusion. Secondary PODs or standard coils were deployed as necessary. ResultsA total of 5 internal carotid arteries and 5 vertebral arteries were treated in 10 patients. The mean vessel diameter of the vessel sacrificed was 4 mm (range 2.9–7.7 mm). The total mean number of coils required for vessel sacrifice was 7 (range 3–17). The mean number of PODs used for vessel sacrifice was 2.4 (range, 1–6). The mean number of additional standard coils used was 4.1 (range, 0–13). 9/10 (90%) parent arteries were successfully occluded. One patient had slow flow distal to the occluded segment. One (10%) of the patients had a delayed ischemic event. There were no immediate periprocedural complications including coil migrations or vessel dissections. 6/10 patients had follow-up imaging and no patients developed recanalization during the follow-up period. ConclusionParent vessel sacrifice using a combination of PODs and standard coils appear to be a feasible, safe and effective alternative to the traditional vessel sacrifice techniques.

Delayed massive epistaxis from traumatic cavernous carotid false aneurysms: A report of two unusual cases

Introduction Blunt head trauma can injure the cavernous segment of the internal carotid artery (ICA). This may result in a carotid cavernous fistula (CCF). Rarely, a traumatic aneurysm may bleed medially causing massive epistaxis. Case presentation We present two cases of traumatic intracavernous carotid pseudoaneurysms with delayed massive epistaxis. The patients were managed with endovascular treatment involving coil embolization with parent vessel sparing and detachable balloon occlusion with carotid sacrifice. Early clinical outcome was good in both patients. Wherever possible, the CARE1 guidelines were followed in the reporting. Conclusion These cases illustrate the delayed nature of traumatic aneurysms and the need for a high index of suspicion in the presence of skull base fractures. The use of endovascular detachable balloon occlusion and coil embolization treatment with parent vessel preservation is shown.

Clinical Features, Management Considerations and Outcomes in Case Series of Patients with Parasellar Intracranial Aneurysms Undergoing Anterior Skull Base Surgery.

The coincidence of parasellar aneurysms (IAs) and anterior skull base (ASB) lesions, while rare, presents a management challenge. IAs embedded within, or adjacent to, ASB lesions are at risk in the perioperative period and may have unique presentations, natural histories, and outcomes. The objective of this study was to outline management options and nuances in patients with coexisting IAs and ASB lesions. We retrospectively evaluated all patients who presented for management of IAs and ASB lesions from January 2006 to January 2014. Medical charts and imaging were reviewed for patient, tumor and IA characteristics, pathology, operative findings, complications, and outcomes. Of 13 patients included in the study, 11 had histologically proven or presumed pituitary macroadenomas. The majority of cases presented with visual and endocrine deficits, and the median maximal tumor diameter was 3.1 cm. There were 17 IAs, all located in the parasellar area. Endovascular treatment of the IA was performed before tumor resection in 2 cases. Transsphenoidal resection was performed before IA occlusion in 1 case, and intraoperative vascular injury occurred in 2 cases. The median follow-up was 36 months. Management decisions for patients with coincident IA and ASB lesions require careful, individualized treatment plans. Coil embolization is well tolerated and does not delay surgery, except in cases requiring stent placement. Inadvertent intraoperative rupture of an adjacent IA during anterior skull base surgery may be treated with emergent coil embolization, flow diversion, or carotid sacrifice, but adequate preoperative planning can reduce this risk.

First experience of combined penumbra occlusion device (POD) associated to pc-400 coils in carotid artery sacrifice: Efficacy, safety and technical note

Introduction L’occlusion carotidienne est un traitement classique en pathologie neuroravasculaire dans des indications selectionnees, malgre le developpement recent des stents flow-diverters . L’occlusion de vaisseau porteur est habituellement realisee par coiling : ce type d’intervention necessite un grand nombre de coils afin d’obtenir une occlusion complete. Ceci prolonge donc la duree procedurale et est donc associe a une irradiation scopique peroperatoire et un surcout economique notables. Un nouveau dispositif d’occlusion - le Penumbra Occlusion Device ® (POD) - a ete recemment developpe. Ce coil d’un diametre de 0,020 inches est compose de deux segments distincts: une portion initiale relativement rigide fonctionnant comme une ancre distale puis une portion plus souple, plus longue, aux spires de diametre legerement plus faible, destinee a occlure le vaisseau en formant un maillage compact. Veritable coil-plug , ce dispositif apparait novateur. Par ailleurs, les coils PC-400 sont des coils de remplissage de 0,020 inches . Nous proposons ici d’evaluer l’efficacite de la combinaison de ces deux types de coils dans l’occlusion carotidienne pour le traitement des anevrismes geants du siphon carotidien. Materiel et methodes Nous presentons ici notre experience institutionnelle d’occlusion d’artere parente en utilisant cette combinaison specifique de coils (un coil POD puis coils PC-400). L’indication d’occlusion carotidienne etait retenue en cas d’anevrisme geant carotido-caverneux symptomatique (paralysie oculomotrice, cephalee) apres evaluation de la fonctionnalite du polygone de Willis et discussion de l’alternative therapeutique par flow-diversion . Les possibilites de sacrifice de l’artere porteuse etaient evaluees par test de clampage carotidien clinique et angiographique, avec epreuve d’hypotension arterielle. Les donnees cliniques, angiographiques et procedurales etaient collectees prospectivement. Les patients etaient revus en consultation avec arteriographie cerebrale a trois mois apres l’intervention. Resultats Entre avril et aout 2015, trois patients ont beneficie d’une occlusion carotidienne par systeme POD associe a 2 a 3 coils PC-400. Le traitement endovasculaire permettait une occlusion complete et rapide dans tous les cas. Aucune complication notamment thromboembolique peroperatoire n’etait constatee. A trois mois, tous les patients presentaient une evolution clinique satisfaisante avec regression des symptomes dans tous les cas. Les arteriographies de controle confirmaient l’occlusion complete et perenne des arteres parentes. Conclusion Il s’agit du premier rapport de l’utilisation du dispositif POD dans une indication neurovasculaire. Tous nos patients ont beneficie d’une occlusion carotidienne dans le traitement d’anevrismes carotido-caverneux geants symptomatiques. Aucune complication ni recanalisation tardive n’a ete decelee. Nous pensons que le deploiement d’un coil POD associe a quelques coils PC-400 est sur et efficace pour les traitements par occlusion carotidienne. Ce dispositif souleve des benefices important sur la reduction de la duree des interventions, des doses d’irradiation peroperatoires et des couts economiques.

Carotid Artery Sacrifice and Reconstruction in the Setting of Advanced Head and Neck Cancer.

To determine oncological and neuromorbidity outcomes in patients with advanced head and neck cancer (stage IVB) requiring sacrifice and reconstruction of the carotid artery. Case series with chart review. Tertiary care referral center. Overall, 51 patients underwent carotid artery sacrifice during surgical treatment of the neck, in both the primary and salvage setting. All patients underwent autogenous in-line carotid artery bypass grafting with either saphenous vein or the deep femoral vein in conjunction with vascular surgery. In all, the study included 39 males and 12 female subjects, with age ranging from 39 to 82 (mean, 62.7). Two patients (3.9%) had a cerebral vascular accident in the immediate postoperative period. The remaining 49 patients (96%) had no neurologic sequela. Serial ultrasonic evaluation revealed 4 patients with intra-luminal thrombus within the site of reconstruction. Perioperative mortality occurred in a single patient. Disease-related mortality occurred in 9.8% (5) of patients, with an overall 2-year survival of 82%. We presently report the largest series of surgical treatment for advanced head and neck cancer with carotid artery involvement. We document an overall 2-year survival of 82% in the setting of low perioperative neuromorbidity and mortality rates. We therefore consider carotid artery sacrifice and autogenous vein graft reconstruction in the absence of distant metastatic disease as a viable treatment option for what was once thought to be a palliative procedure.

Carotid artery occlusion secondary to retropharyngeal abscess treated with endovascular carotid sacrifice

Introduction: Carotid occlusion is a rare but serious complication of retropharyngeal abscess (RPA). Management questions that must be addressed include the choice between reconstruction and occlusion in the setting of an active infectious process. Case Report: A 4 year old female presented with hoarseness, shortness of breath, and a right-sided Horner’s syndrome. A CT scan confirmed the diagnosis of RPA, and contrast studies showed no filling in the right internal carotid artery (ICA). Surgical exploration of the abscess disrupted the occluded artery, causing deep, uncontrolled bleeding. Emergent angiographic evaluation was completed, and the decision was made to sacrifice the ICA. The patient recovered on antibiotics, but the Horner’s syndrome persisted. Discussion: The presence of a carotid artery occlusion must be ruled out in the setting of a RPA. When suspected, it should be investigated further. Therapeutic decisions regarding sacrifice or reconstruction of the carotid artery are burdened by risks associated with the setting of an infection, notably infection and systemic dissemination. Conclusion: The presence of a carotid occlusion is a serious complication resulting from a RPA that can lead to permanent neurological deficit. Endovascular vessel sacrifice is a viable treatment option for carotid occlusion in the setting of a retropharyngeal abscess, but must be considered on a case-by-case basis.

Covered Stents for the Prevention and Treatment of Carotid Blowout Syndrome.

Carotid blowout syndrome (CBS) is a life-threatening emergency resulting from compromise of the carotid artery caused by malignancy in the head and neck. To report our experience with covered stents for the prevention or treatment of carotid blowout syndrome secondary to head and neck cancer to ascertain the safety and efficacy of this technique. We reviewed the characteristics and outcome of all patients who underwent covered stent placement in the extracranial carotid artery in the setting of head and neck malignancy between 2006 and 2013 at the University of Miami. Patient demographics, presenting symptoms, devices used, perioperative complications, imaging, and follow-up data were reviewed. Seventeen carotids in 15 patients, whose ages ranged from 20 to 84 years (mean, 70.4 years), were treated with 20 covered nitinol (Viabahn Endoprosthesis, Gore, Flagstaff, Arizona) stents. Three patients were treated acutely for bleeding from carotid blowout, and 12 were treated prophylactically for threatened carotid blowout. All patients were given periprocedural dual antiplatelet therapy. No thromboembolic or ischemic complications were noted. Hemorrhage after treatment occurred in 4 patients. In 2 patients, the hemorrhage was from a source not covered by the stent. The use of covered stents is a simple, safe, and effective method for treating or preventing carotid blowout syndrome in patients with head and neck malignancy. Carotid artery reconstruction with covered stents may minimize the risk of ischemic complications associated with endovascular or surgical carotid sacrifice.

Combined Balloon Test Occlusion and SPECT Analysis for Carotid Sacrifice: Angiographic Predictors for Success or Failure?

Objectives To evaluate angiographic patterns that may predict the success or failure of carotid artery balloon test occlusion (BTO) and single-photon emission computed tomography (SPECT) analysis for carotid sacrifice. Study Design This is a retrospective nonrandomized study. Study Setting Conducted at the University of California Davis Medical Center, Sacramento, California. Patients A total of 31 patients, ranging from 24 to 83 years of age, with a mean age of 61 years (22 men, 9 women) with head and neck cancer (26 patients), malignant glomus tumor (1 patient) or giant carotid aneurysms (4 patients) as possible candidates for surgical carotid artery sacrifice were evaluated from September 2005 to September 2012. Methods All patients underwent unilateral internal carotid artery balloon test occlusion with SPECT analysis (20 mCi technetium 99m-hexamethyl propyleneamine oxime [HMPAO]) imaging before and during carotid occlusion. Carotid angiography with carotid cross-compression (manual compression of the cervical artery contralateral to the side of contrast injection) was used to analyze filling through the anterior communicating artery to the contralateral hemisphere. Intervention The balloon occlusion was terminated in two patients because of deterioration of the neurologic exam. Main Outcome Measures All patients who passed the neurologic examination during BTO and also passed the SPECT occlusive study underwent successful carotid sacrifice without neurologic sequelae. Patients failing the occlusive neurologic examination and/or the SPECT study elected chemoradiation, with the exception of one patient who underwent a successful carotid bypass graft and carotid resection. Results The success of carotid sacrifice in patients passing both the occlusive test and the SPECT analysis for carotid sacrifice was 100%. Three patients failed both the BTO and the SPECT, with two demonstrating no anterior circulation cross-fill, but one showed some cross-fill. Six additional patients passed the BTO but failed the SPECT, with poor cross-fill in five patients. In addition, three patients who had excellent cross-fill through the anterior communicating artery to the contralateral hemisphere failed the SPECT examination in two cases and failed both tests in another case.

Carotid sacrifice with a single Penumbra occlusion device: a feasibility study in a swine model

IntroductionCarotid sacrifice is a valuable tool in the treatment of select vascular lesions. Traditional coil embolization as the primary means of carotid sacrifice can be expensive, with high radiation exposure....

Value of Tc-99m-Bicisate (ECD) Balloon Test Occlusion in Preoperative Assessment of Stroke Risk Prior to Carotid Artery Sacrifice.

Value of Tc-99m-Bicisate (ECD) Balloon Test Occlusion in Preoperative Assessment of Stroke Risk Prior to Carotid Artery Sacrifice.

Balloon-augmented Onyx endovascular ligation: initial human experience and comparison with coil ligation

IntroductionCarotid artery sacrifice remains an important procedure for cerebral vascular disorders despite the development of new endovascular devices. Conventional carotid artery sacrifice with detachable coils alone often requires numerous coils...

Incidence and mechanisms of stroke after permanent carotid artery occlusion following temporary occlusion testing

Background and purposePatients who require sacrifice of the internal carotid artery (ICA) have a substantial risk of stroke, despite preoperative testing with temporary balloon occlusion (TBO). The purpose of this...

Treatment of Cavernous Sinus Aneurysms with Flow Diversion: Results in 44 Patients

Aneurysms of the cavernous segment of the ICA are difficult to treat with standard endovascular techniques, and ICA sacrifice achieves a high rate of occlusion but carries an elevated level of surgical complications and risk of de novo aneurysm formation. We report rates of occlusion and treatment-related data in 44 patients with cavernous sinus aneurysms treated with flow diversion. Patients with cavernous segment aneurysms treated with flow diversion were selected from a prospectively maintained data base of patients from 2009 to the present. Demographic information, treatment indications, number/type of flow diverters placed, outcome, complications (technical or clinical), and clinical/imaging follow-up data were analyzed. We identified 44 patients (37 females, 7 males) who had a flow diverter placed for treatment of a cavernous ICA aneurysm (mean age, 57.2; mean aneurysm size, 20.9 mm). The mean number of devices placed per patient was 2.2. At final angiographic follow-up (mean, 10.9 months), 71% had complete occlusion, and of those with incomplete occlusion, 40% had minimal remnants (<3 mm). In symptomatic patients, complete resolution or significant improvement in symptoms was noted in 90% at follow-up. Technical complications (which included, among others, vessel perforation in 4 patients, groin hematoma in 2, and asymptomatic carotid occlusion in 1) occurred in approximately 36% of patients but did not result in any clinical sequelae immediately or at follow-up. Our series of flow-diversion treatments achieved markedly greater rates of complete occlusion than coiling, with a safety profile that compares favorably with that of carotid sacrifice.

Carotid and vertebral artery sacrifice with a combination of Onyx and coils: technical note and case series

Permanent vessel sacrifice has become a routine for the management of aneurysms, pseudoaneurysms, tumors, and carotid blowouts. The purpose of this study is to describe a new technique for carotid and vertebral artery sacrifice using a combination of Onyx and coils and to assess its feasibility, safety, and efficacy. The technique consists of deploying a few coils in the parent vessel under proximal flow arrest followed by Onyx embolization directly into the coil mass. A total of 41 patients underwent carotid/vertebral artery sacrifice using this technique in our institution. A total of 26 internal carotid arteries and 15 vertebral arteries were treated. In all but one patient, a balloon test occlusion was performed prior to permanent arterial sacrifice. The mean number of coils used was 6.8 (range, 2-19). The total volume of Onyx used was 1.3 ml on average (range, 0.2-5.2 ml). All 41 (100%) parent arteries were successfully occluded. No distal migration of Onyx or coils was noted. Periprocedural complications occurred in 14.6% (6/41) of cases causing permanent morbidity in 7.3% (3/41). No patient developed a recurrence during the follow-up period (mean, 14 months). Parent vessel sacrifice with a combination of Onyx and coils appears to be feasible, safe, and effective and may be an alternative to the traditional deconstruction technique with coils alone. The risk of thromboembolism exists with this technique, but there were no instances of Onyx migration.

Editorial: Ophthalmic segment aneurysms

Very large and giant paraclinoid aneurysms are a therapeutic challenge. The goal of treatment is prevention of aneurysm growth/rupture and, in those patients with visual symptoms related to mass effect, stabilization and possible improvement of the visual deficits. Better understanding of the 3D relationships of the anterior clinoid/optic nerve/aneurysm–internal carotid artery (ICA) complex has resulted in good surgical outcomes being reported in several series. Traditional endovascular methods (coiling with or without the adjunct of balloon and stent assistance) provide an effective treatment for most small paraclinoid aneurysms with a very low complication rate.1 However, until the development of flow diverters, ICA-preserving endovascular solutions for very large and giant aneurysms were less than ideal with a very high recurrence rate. Carotid sacrifice is a valid option in many patients with very large and giant paraclinoid aneurysms, but concerns exist about the development of flow-related aneurysms and long-term effects. In their article, Mattingly and coworkers4 detail visual and clinical outcomes in a series of 17 patients (with clipped aneurysms) with challenging ophthalmic segment aneurysms. This report is an honest assessment of the results that particularly pertain to visual symptoms. Of the 14 patients presenting with visual symptoms, 79% experienced improvement in their vision at follow-up, while 21% experienced worsening in the ipsilateral eye. When visual acuity is considered, 53% of patients improved and 16% worsened. The authors used a modification of the suction-decompression technique and do a nice job in discussing the technical nuances. The value of this detailed study is to provide a benchmark (especially in relation to visual outcome) against which results of modern series can be evaluated. This is of special importance at a time when the development of flow diverters may represent a major paradigm shift and may soon become the treatment of choice for these challenging lesions.3,5 In the Pipeline for Uncoilable or Failed Aneurysms (PUFS) study, a detailed preand postoperative neuroophthalmological assessment was part of the study protocol. In the PUFS study, 17 patients had optic neuropathy (defined as a visual field deficit, decreased visual acuity, or an afferent pupillary defect) related to the aneurysm. Six months after treatment, 53% of the patients experienced improvement of their visual symptoms, 41% were stable, and only 1 patient (6%) experienced worsening.2 Thus, although not as good as the results reported in this series, it appears that visual outcomes after flow diversion are fairly close. (http://thejns.org/doi/abs/10.3171/2012.12.JNS121401)

Pipeline embolization device and subsequent vessel sacrifice for treatment of a bleeding carotid pseudoaneurysm at the skull base: a case report

An attempt at parent vessel reconstruction with Pipeline embolization devices to treat a mycotic pseudoaneurysm of the internal carotid artery at the skull base is presented. A 50-year-old woman with...