Endovascular Treatment Of Cerebral Aneurysms Research Articles

Effects of Self-Made Bismuth Shield Installation on Entrance surface Dose Reduction during Endovascular Treatment of Cerebral Aneurysms

Effects of Self-Made Bismuth Shield Installation on Entrance surface Dose Reduction during Endovascular Treatment of Cerebral Aneurysms

Introduction: Endovascular Neurosurgery.

Remarkable developments in the field of endovascular neurosurgery have been witnessed in the last decade. The success of endovascular therapy for ischemic stroke treatment is now irrefutable, making it an accepted standard of care. Endovascular treatment of cerebral aneurysms is no longer limited to primary coiling but now includes options such as stent or balloon assistance and flow diversion and applications utilizing neck reconstruction, intrasaccular, and bifurcation-specific devices. Balloons, liquid embolic agents, and flow-directed catheters have revolutionized the treatment of arteriovenous malformations and fistulae. The ongoing development of endovascular tools has led to novel and expanding approaches (for example, transvenous arteriovenous malformation embolization and transradial access). With improved technology, transposterior communicating artery access and other endovascular strategies are being applied successfully across the anterior and posterior circulations and to lesions once deemed only surgically approachable. Yet, we would be remiss to attribute the successes of endovascular strategies only to the development of their tools. Improvements in both noninvasive and angiographic imaging (such as three-dimensional road map guidance) have provided a greater understanding of pathologic entities and allowed the pursuit of endovascular cures.In this issue of Neurosurgical Focus, we present a wide range of endovascular strategies for a variety of neurovascular pathologies. We hope this video supplement will not only demonstrate the applicability of tried-and-true endovascular strategies to difficult clinical situations but also highlight new and developing endovascular technologies. We thank the authors for their outstanding contributions.

Microsurgical Treatment of Cerebral Aneurysms After Previous Endovascular Therapy: Single-Center Series and Systematic Review

Since its introduction in the early 1990s, endovascular treatment of cerebral aneurysms has had a steady upward trend and is the primary mode of treatment for most intracranial aneurysms. Concurrently, the need for retreatment of aneurysms after previous endovascular treatment has continued to increase, some of which can only be treated with microsurgical techniques. The factors that dictate outcomes in this group of patients are incompletely understood. To study factors contributing to patient outcomes after microsurgical treatment of aneurysms with previous endovascular treatment. The records of the senior author (D.L.B.) since 2002 were retrospectively reviewed for aneurysms treated after previous endovascular treatment. Demographics, treatment details, and imaging were reviewed for all patients. A systematic review of the literature on microsurgical treatment of aneurysms previously treated by endovascular therapy was also conducted. A total of 91 patients were identified from the retrospective review. Mean age at the time of initial treatment was 49 ± 12.68 years. Most patients initially presented with subarachnoid hemorrhage before initial endovascular treatment, with only 11 patients (12%) presenting with incidentally discovered lesions. Modified Rankin Scale score at discharge after initial treatment was good (0-3) in 81.4% of cases. Functional outcomes at the last known follow-up showed a modified Rankin Scale score of 0-3 in 77 patients (84.6%). Only aneurysm neck size was found to be a significant predictor of surgical complications (Wald χ2= 10.79; P= 0.0010) with an odds ratio of 2.32 (95% confidence interval, 1.40-3.83) for a 2-mm increase in neck size. Systematic review identified 37 studies who were used to pool data on 370 patients. Although type of surgery was identified as a predictor of poor outcomes, this was significantly confounded by Hunt and Hess grade in the systematic review. Favorable outcomes can be obtained even for highly complex cerebral aneurysms that have failed endovascular treatment at high-volume cerebrovascular centers. Initial presentation grade and aneurysm size are important predictors of final patient outcomes.

Treatment of ruptured and unruptured cerebral aneurysms in the USA: a paradigm shift

BackgroundIntegration of data from clinical trials and advancements in technology predict a change in selection for treatment of patients with cerebral aneurysm.ObjectiveTo describe patterns of use and in-hospital mortality associated...

Intraprocedural Rupture During Endovascular Treatment of Intracranial Aneurysm: Clinical Results and Literature Review

Intraprocedural rupture (IPR) during endovascular treatment of cerebral aneurysm is the most feared complication, with high morbidity and mortality. The aim of this study was to estimate the incidence and risk factors of IPR during endovascular treatment of ruptured and unruptured cerebral aneurysms. A total of 235 intracranial aneurysms (80 ruptured and 155 unruptured) in 219 patients who received endovascular treatment in our institution between January 2010 and December 2016 were enrolled in our study. Demographic and radiologic data were analyzed to evaluate risk factors of IPR. We conducted a literature review to estimate the incidence of IPR according to rupture status and aneurysm location. Ten patients (6 ruptured, 4 unruptured) experienced IPR during endovascular treatment. The IPR incidence was 7.5% in ruptured and 2.5% in unruptured aneurysms. Aneurysm size (smaller than 3.58 mm) and anterior communicating artery aneurysm were independent risk factors for IPR. According to the literature review, the overall IPR incidence was 4.47% (393/8791) in ruptured and 1.43% (145/10,131) in unruptured aneurysms. Independent risk factors for IPR during endovascular treatment of intracranial aneurysm were aneurysm size and anterior communicating artery aneurysm. Ruptured aneurysms showed a higher tendency toward IPR than did unruptured aneurysms.

Middle cerebral artery pressure changes following Pipeline flow diversion.

Objective Pipeline embolization devices (PED) are commonly used for endovascular treatment of cerebral aneurysms but changes in intracranial hemodynamics after PED deployment are poorly understood. Here, we assess middle cerebral artery (MCA) and systemic blood pressure before and after PED treatment. Methods Records of patients with cerebral aneurysms proximal to the internal carotid artery terminus treated with PED at our institution between 2015 and 2017 were retrospectively reviewed. Patients were included if ipsilateral MCA pressure measurements were available. Ipsilateral MCA pressure was transduced via the microcatheter before and after PED deployment. Systemic arterial blood pressure was also simultaneously recorded. MCA, systemic blood pressure, and ratios of MCA to systemic blood pressure values were compared before and after treatment among the study cohort using the two-sample paired Student t test. Results Fourteen patients were included. Mean age was 54 years. Among the entire cohort, the ratio of MCA to systemic systolic and mean blood pressure were significantly higher after treatment (respectively 0.76 vs. 0.69, p = 0.01, and 0.94 vs. 0.89, p = 0.03), and the ratio of MCA to systemic diastolic pressures showed an increasing trend (1.08 vs. 1.03, p = 0.09). The percentage of ratio increase was independent of aneurysm size ( r = -0.24, p = 0.42 for systolic ratio; r = -0.09, p = 0.74 for diastolic ratio; r = -0.09; p = 0.76 for mean ratio, respectively). Conclusions Following PED deployment, the ratio of ipsilateral MCA to systemic systolic and mean blood pressure increased. These pressure changes should be further evaluated in a larger sample size.

Evaluation of Endovascular Embolization of Cerebral Aneurysms by Hydrogel Coils.

SummaryBackgroundHydrogel coils were created to improve the chances of an effective endovascular treatment of cerebral aneurysms. Achieving a high packing density of coils in the lumen of aneurysms can decrease the risk of recurrence. The aim of the present study is to report our initial experience on the effectiveness and safety of endovascular treatment of intracranial aneurysms with the use hydrogel coils.Material/MethodsSixty patients (age: 28–72 years) (45 women, 15 men) were treated. In 18 patients (30%), subarachnoid hemorrhage was present. Digital subtraction angiography (DSA) of cerebral vessels with rotational scanning was performed. Image analysis was performed by the Philips Integris 3D RA device,which is a specialized workstation (Three-Dimensional Rotational Angiography). 3D reconstructions of cerebral arteries were created based on the data. Sixty-six cerebral aneurysms were embolized with hydrogel coils, which expand in contact with blood. reaching the maximum diameter in about 20 minutes. In 29 aneurysms (43.9%), the effect of the procedure was confirmed on a follow-up DSA after 8.0±4.1 months from the initial treatment.ResultsA complete embolization was performed in 55 aneurysms (83.3%), and partial embolization in 11 aneurysms (16.7%). In 6 aneurysms (9.1%), re-embolization was necessary and it resulted in a complete embolization of 5 aneurysms. On a follow-up DSA, complete embolization was present in 25 aneurysms (86.2%), and partial embolization in 4 aneurysms (13.8%), respectively.ConclusionsEndovascular embolization with hydrogel coils is an effective and safe treatment method for cerebral aneurysms, although it carries the risk of some complications.

Diagnostic Accuracy of Somatosensory Evoked Potential Monitoring in Evaluating Neurological Complications During Endovascular Aneurysm Treatment.

Somatosensory evoked potential (SSEP) monitoring is used extensively for early detection and prevention of neurological complications in patients undergoing many different neurosurgical procedures. However, the predictive ability of SSEP monitoring during endovascular treatment of cerebral aneurysms is not well detailed. To evaluate the performance of intraoperative SSEP in the prediction postprocedural neurological deficits (PPNDs) after coil embolization of intracranial aneurysms. This population-based cohort study included patients ≥18 years of age undergoing intracranial aneurysm embolization with concurrent SSEP monitoring between January 2006 and August 2012. The ability of SSEP to predict PPNDs was analyzed by multiple regression analyses and assessed by the area under the receiver operating characteristic curve. In a population of 888 patients, SSEP changes occurred in 8.6% (n = 77). Twenty-eight patients (3.1%) suffered PPNDs. A 50% to 99% loss in SSEP waveform was associated with a 20-fold increase in risk of PPND; a total loss of SSEP waveform, regardless of permanence, was associated with a greater than 200-fold risk of PPND. SSEPs displayed very good predictive ability for PPND, with an area under the receiver operating characteristic curve of 0.84 (95% CI 0.76-0.92). This study supports the predictive ability of SSEPs for the detection of PPNDs. The magnitude and persistence of SSEP changes is clearly associated with the development of PPNDs. The utility of SSEP monitoring in detecting ischemia may provide an opportunity for neurointerventionalists to respond to changes intraoperatively to mitigate the potential for PPNDs.

Development of New Endovascular Devices for Aneurysm Treatment.

Since the first use of the Guglielmi detachable coil system for cerebral aneurysm embolization in 1990, various endovascular methods have been developed to treat large numbers of aneurysms. The main strategic and technical modifications introduced to date include balloon-assisted coil embolization, stent-assisted coil embolization, flow diverters, and flow disrupters. The development and introduction of such devices have been so persistent and rapid that new devices are being approved worldwide even before the earlier ones become available in some countries. However, even if some patient populations may possibly benefit from earlier introduction of new devices, the approval authorities should balance the available evidence of the safety and effectiveness of novel devices. This review aims to provide an overview of the recent innovations in endovascular treatment of cerebral aneurysms and a brief review of market access policies and regulations for importing high-risk medical devices, such as those used for endovascular aneurysm management, which correspond to class III devices, as defined by the U.S. Food and Drug Administration. We focus on the current situation in Korea and compare it with that in other Asian countries, such as China and Japan.

Safety Assessment of Endovascular Treatment of Cerebral Aneurysms in Patients with Fibromuscular Dysplasia

Background: The prevalence of cerebral aneurysms is increased in fibromuscular dysplasia (FMD). The presence of FMD may serve as discouragement to elective endovascular aneurysm treatment. Outcomes of endovascular intervention for aneurysms through vessels affected by FMD have not been reported. Methods: A prospectively maintained database of patients undergoing intracranial embolization was reviewed for patients with FMD who underwent endovascular aneurysm treatment. Results: A total of 1,025 patients were screened and 31 (3.0%) had cerebrovascular FMD. These patients underwent a total of 43 embolization procedures; 27 of these procedures were performed through an affected vessel. All but 1 patient were female and the average age was 62 years. “String-of-pearls”-type FMD was the most common subtype (90%). The internal carotid arteries were more commonly affected (65%) than the vertebral arteries (48%). All patients underwent treatment of cerebral aneurysms, most of which (87%) were incidentally discovered; 6 patients (19%) also had incidental vessel dissection. The average aneurysm size was 7.1 mm. The morphology was saccular in 93% of the cases, and 86% were in the anterior circulation. The most commonly performed treatment was flow diversion (67%), in the majority of cases by pipeline embolization. Other procedures performed were coiling (19%), stent-coiling (12%), and intrasaccular flow disruption (2%). All but 1 procedure (98%) were successful. There were no major complications; 1 patient experienced a transient ischemic attack. Follow-up angiography was performed in 88% of the cases, without evidence for disease progression after treatment. The average time to last angiographic follow-up was 17 months (±13). Conclusions: Elective embolization of intracranial aneurysms can be performed safely through vessels affected by FMD.

Intracranial contrast transit times on digital subtraction angiography decrease more in patients with delayed intraparenchymal hemorrhage after Pipeline

Background Pipeline embolization devices (PEDs) are used for endovascular treatment of cerebral aneurysms but can be associated with delayed ipsilateral intraparenchymal hemorrhage (DIPH). Changes in intracranial hemodynamics after PED are poorly understood. Objective Here, we assess hemodynamic changes after PED in patients and compare these changes in patients with and without DIPH (DIPH+ and DIPH-). Methods Records of patients with distal internal carotid artery (ICA) aneurysms treated with PED at our institution between 2012 and 2017 were retrospectively reviewed. Regions of interest were selected proximally to PED over the cavernous ICA and distally over the middle cerebral artery (MCA), and then transit times were determined using syngo iFlow software (Siemens). Ratio of MCA to ICA transit time was compared before, after treatment, and at follow-up. Ratios were also compared between DIPH+ and DIPH- subgroups. Correlations between aneurysm size, age, and ratios were investigated. Results Fifty-three patients were included. The ratio of MCA to ICA transit time decreased significantly after PED deployment (1.13 vs. 1.22, p < 0.01). The ratio in the DIPH + subgroup ( n = 4) was significantly lower (1.00 vs. 1.14, p = 0.01) and decreased significantly more (21% vs. 4.4%, p = 0.02) compared to the DIPH- subgroup ( n = 49). The ratio tended to be higher in larger aneurysms at baseline ( r = 0.25, p = 0.07) but not after PED treatment ( r = 0.11, p = 0.15). Age did not correlate with ratio. Conclusion The ratio of MCA to ICA transit time decreases following PED treatment and decreases more in patients with DIPH. These contrast transit time changes can be detected in real time immediately after PED deployment.

The Impact of the Endovascular Treatment of Cerebral Aneurysms on Headaches.

The co-occurrence of headaches and cerebral aneurysms is common in clinical practice, although a clear causal relationship has not been ascertained. We aimed to investigate the impact of endovascular obliteration of aneurysms on headaches using a cross-sectional, prospective, open-label protocol. We also sought to characterize the preexisting headaches in patients harboring cerebral aneurysms using the International Classification of Headache Disorders criteria. A total of 33 patients were recruited into the study and underwent endovascular treatment for obliteration of their aneurysms. A standardized survey was administered before and 3 to 6 months after the procedure, documenting the HIT-6 scores as well as the headache frequency. The study cohort included 25 women and 8 men. In 61% of cases, the aneurysms were located in the posterior circulation. We achieved grade 0 or 1 obliteration of aneurysms in 100% of cases and there were no complications. The mean for HIT-6 scores were 52.3 at baseline and 49.6 postprocedure (student t test, P<0.047). The headache frequency measured as total headache days per month did not demonstrate statistical significance. Our data indicated that more than half of our cohort had preexisting headaches which fulfilled the criteria for a primary headache disorder. These individuals showed a more robust response to the intervention compared with the remainder of the group, although the P-value per se was not considered statistically significant due to the small sample size. Endovascular treatment of the aneurysms mitigates the headache-related disability.

Middle cerebral artery flow velocity increases more in patients with delayed intraparenchymal hemorrhage after Pipeline

ObjectivePipeline Embolization Devices (PED) are commonly used for endovascular treatment of cerebral aneurysms but can be associated with delayed ipsilateral intraparenchymal hemorrhage (DIPH). The role that altered intracranial hemodynamics may...

Abstract TP422: Platelet Transfusion In Patients Presenting With Aneurysmal Subarachnoid Hemorrhage Does Not Improve Outcome

Introduction: The effect of platelet transfusion (PT) has been studied in patients with intracerebral hemorrhage, but has not been reported for aneurysmal subarachnoid hemorrhage (aSAH). We investigated the effect of PT on the outcome of patients with aSAH. Methods: We retrospectively evaluated 84 patients admitted with aSAH to a Comprehensive Stroke Center in the United States between 2011 and 2015. Charts were reviewed for variables including length of hospitalization, 3-month modified Rankin Scale (mRS), and complications related to endovascular treatment of cerebral aneurysm. Intergroup differences were evaluated with the Chi-squared and Student’s t-test. mRS was evaluated using multivariate ordinal logistic regression. Variables with a univariate p-value &lt;0.2 association with 3 month mRS were included in the ordinal logistic regression model. Results: Patient demographics and clinical variables are seen in Table 1. 30% of patients received PT. PT was associated with male gender, Hunt-Hess score, Fisher Score, external ventricular drain placement, and longer hospital length of stay. After multivariate ordinal regression, PT was associated with higher mRS and there was a trend for association with Hunt-Hess score (Table 2). Conclusion: Our findings suggest that platelet transfusion is common in patients presenting with aSAH. Platelet transfusion in these patients is associated with longer hospital stay and a significantly lower rate of good clinical outcome, with a nearly 4- to 6-fold higher odds of a one-point increase in mRS at 3 months. The association of platelet transfusion to worse outcome in patients with aSAH warrants further study.

Balloon-assisted Catheterization Technique under Proximal Flow Control with Balloon Guiding Catheter in Endovascular Treatment of Cerebral Aneurysm

Balloon-assisted Catheterization Technique under Proximal Flow Control with Balloon Guiding Catheter in Endovascular Treatment of Cerebral Aneurysm

Endovascular Treatment of Cerebral Aneurysm: Report of five cases and review of the literature

Endovascular Treatment of Cerebral Aneurysm: Report of five cases and review of the literature

Quantitative assessment of parent vessel and distal intracranial hemodynamics following pipeline flow diversion.

Background Pipeline embolization devices (PEDs) are commonly used for endovascular treatment of cerebral aneurysms but can be associated with delayed ipsilateral intraparenchymal hemorrhage. Although intra-aneurysmal hemodynamic changes have been studied, parent vessel and intracranial hemodynamics after PED use are unknown. We examine the impact of flow diversion on parent artery and distal intracranial hemodynamics. Method Patients with internal carotid cerebral aneurysms treated with PED who had flow volume rate, flow velocities, pulsatility index, resistance index, Lindegaard ratio, and wall shear stress (WSS) obtained after treatment using quantitative magnetic resonance angiography were reviewed. Means were compared between ipsilateral and contralateral internal carotid artery (ICA) and middle cerebral artery (MCA) using paired t tests. Results A total of 18 patients were included. Mean flow volume rate was lower in the ipsilateral versus contralateral ICA ( p = 0.04) but tended to be higher in the ipsilateral versus contralateral MCA ( p = 0.08). Lindegaard ratio was higher ipsilateral to the PED in diastole ( p = 0.05). Although there was no significant difference in flow velocities, pulsatility or resistance indices, and WSS, the two cases in our cohort with hemorrhagic complications did display significant changes in MCA flows and MCA WSS. Conclusion PED placement appears to alter the elasticity of the stented ICA segment, with lower flows in the ipsilateral versus contralateral ICA. Conversely, MCA flows and MCA WSS are higher in the ipsilateral MCA among patients with hemorrhage after PED placement, suggesting the role of disrupted distal hemodynamics in delayed ipsilateral intraparenchymal hemorrhage.

Lazic Aneurysm Clip System for Microsurgical Clipping of Cerebral Aneurysms: Transition to a New Aneurysm Clip System in an Established Cerebrovascular Practice

In an era of continued advancements in endovascular treatment of cerebral aneurysms, novel developments concerning microsurgical clipping are sparse. The Lazic aneurysm clip system represents such an advancement. The applier has a malleable shaft and is designed to minimally obstruct the view of the surgical field. The purpose of this study was to illustrate the transition to this new aneurysm clip system in an established cerebrovascular practice. We retrospectively reviewed all aneurysms treated with microsurgical clipping using the Lazic aneurysm clip system in 1 cerebrovascular practice in the United States from January 2009 to June2016. Between 2009 and 2016, a total of 973 aneurysms underwent surgical clipping. The Lazic clip system was used in 191 (19.6%) aneurysms (maximum diameter, 5.6 ± 3.8 mm) in 181 patients. The middle cerebral artery was the most frequent location (25.7%) followed by posterior communicating artery (20.9%). There was a continuous increase in the percentage of aneurysms treated with the Lazic clip system from 6% in 2009 to 98% in 2016. The proportion of posterior circulation aneurysms treated with Lazic clips decreased, whereas the middle cerebral artery location increased. There were a total of 11 complications (5.8%), but no instances of clip malfunction. In the largest series to date, the Lazic clip system proved to be safe and efficacious and presents an interesting alternative to established aneurysm clip systems. This study illustrates the transition of an established cerebrovascular practice to the Lazic clip system.

Cerebral aneurysm treatment: modern neurovascular techniques

Endovascular treatment of cerebral aneurysm continues to evolve with the development of new technologies. This review provides an overview of the recent major innovations in the neurointerventional space in recent...

Safety and efficacy of flow re-direction endoluminal device (FRED) in the treatment of cerebral aneurysms: a single center experience.

Experience with the endovascular treatment of cerebral aneurysms by the Flow Re-Direction Endoluminal Device (FRED) is still limited. The aim of this study is to discuss the results and complications of this new flow diverter device (FDD). Between November 2013 and April 2015, 20 patients (15 female and five male) harboring 24 cerebral aneurysms were treated with FRED FDD in a single center. Complete occlusion was obtained in 20/24 aneurysms (83%) and partial occlusion in four (17%). Intraprocedural technical complication occurred in one case (4%) and post-procedural complications in three (12%). None reported neurological deficits (mRS = 0). All FRED were patent at follow-up. No early or delayed aneurysm rupture, no subarachnoid (SAH) or intraparenchymal hemorrhage (IPH) no ischemic complications and no deaths occurred. Endovascular treatment with FRED FDD is a safe treatment for unruptured cerebral aneurysms, resulting in a high rate of occlusion. The FRED is substantially equivalent to the other known FDDs, which show similar functions and technical profiles.