Preservation Of Parent Artery Research Articles

Endovascular Treatment of Anterior Inferior Cerebellar Artery Aneurysms: A Single-Center Experience and Review of 33 Patients

Objective: The aim of the present article was the demonstration of the institutional experience with the endovascular management of the anterior inferior cerebellar artery (AICA) aneurysms in order to propose a treatment algorithm. Methods: Clinical data were obtained from 33 patients with 37 AICA aneurysms who had been surgically treated at the authors’ hospital between 2010 and 2022. The patients’ medical records, imaging data, and follow-up outcomes were retrospectively analyzed. Results: All 33 patients (10 males, 23 females; mean age 54.88 ± 12.49 years) underwent endovascular therapy for AICA aneurysms. The most common chief complaints were headache (87.9%), nausea and vomiting (57.6%), and alteration of consciousness (27.3%). Thirty-one patients experienced subarachnoid hemorrhage. Regarding the AICA aneurysm location, 23 aneurysms were found at the right side of AICA in digital subtraction angiography images, and there were 6, 9, 16, 6 aneurysms in segments A1-A4, respectively. Coiling (59.5%), Onyx embolization (29.7%), coiling-combined Onyx embolization (5.4%), nonintervention (5.4%) were chosen in the surgical strategy. The length of follow-up was 8.09 ± 5.05 months, and 84.8% of the patients had favorable modified Rankin Scale (mRS) scores. The complete occlusion rates were 94.6%. Postoperative complications occurred in 4 cases (12.1%), including new neurological deficit in 3 cases and cerebral infarction in 1 case. One patient died after follow-up because of the severe pneumonia. Poor initial Hunt and Hess grade (HHG) (p = 0.007) was the risk factor for unfavorable clinical outcome. The rupture status (p = 0.025) and the location (p = 0.021) of the AICA aneurysms are statistically significant in determining which operation strategy to be chosen. Coiling had an advantage over Onyx embolization (p = 0.001) in parent artery preservation. Conclusions: In this study, an algorithm for the treatment of AICA aneurysms was proposed based on the clinical status of the patients before treatment, the anatomical factors of AICA, and the technical conditions of endovascular treatment (EVT). To our knowledge, this is the first study to report more than 30 cases of AICA aneurysms that had been treated by EVT and to advocate a treatment algorithm. EVT of AICA aneurysms is an optional strategy, but decisions are made based on the specific condition, anatomical location, and other factors.

Parent Artery Complex Coil Protection for Side-Branched Wide-Neck Aneurysms.

This study aimed to validate the usefulness of parent artery complex coil protection for the treatment of wide-neck, side-branched, and ruptured aneurysms. A microcatheter was first introduced into the aneurysmal sac, and another microcatheter was introduced into the parent artery or near the orifice of the branch artery. A framing coil was deployed partially from the first microcatheter, and a protection coil was deployed from the second microcatheter to prevent protrusion of the first framing coil to the parent artery and side branches. After the first framing coil insertion, the protection coil was withdrawn to confirm the stability of the framing coil and blood flow. The procedures with this technique were successful for 3 patients. Parent artery complex coil protection can be an effective and safe coil embolization technique for the preservation of parent and side branch arteries and an alternative method for emergent ruptured cases.

Endovascular treatment of anterior inferior cerebellar artery trunk aneurysms.

The anterior inferior cerebellar artery (AICA) is a very slender and anatomically variable artery that gives off many important perforating arteries that feed the brainstem and nerve-related arteries that feed the inner ear and labyrinth. AICA trunk aneurysms are rare entities that are also difficult to manage. At present, endovascular treatment (EVT) is the preferred choice; however, the understanding of EVT for AICA trunk aneurysms is limited. In this article, we present a literature review on EVT for AICA trunk aneurysms. To promote understanding, we would also provide some illustrative educational cases of our institute. Aneurysms along the AICA trunk can occur alone (isolated AICA aneurysm) or secondary to cerebrovascular shunts (flow-related AICA aneurysm). According to their anatomical location, they can also be divided into proximal and distal types. At present, EVT is the mainstream treatment, mainly including selective coiling with parent artery preservation and parent artery occlusion. Both coils and liquid embolization materials can be used. For AICA trunk aneurysms, EVT is a reasonable choice and should be based on the specific anatomical location, pathology, and collateral circulation. However, there is still controversy as to the specific type of treatment that should be chosen.

Flow Diverter Devices for the Treatment of Unruptured Vertebral Artery Dissecting Aneurysm.

ObjectiveVertebral artery dissecting aneurysm (VADA) is a very rare subtype of intracranial aneurysms; when ruptured, it is associated with significantly high rates of morbidity and mortality. Despite several discussions and debates, the optimal treatment for VADA has not yet been established. In the last 10 years, flow diverter devices (FDD) have emerged as a challenging and new treatment method, and various clinical and radiological results have been reported about their safety and effectiveness. The aim of our study was to evaluate the clinical and radiological results with the use of FDD in the treatment of unruptured VADA. MethodsWe retrospectively evaluated the data of all patients with unruptured VADA treated with FDD between January 2018 and February 2021 at our hybrid operating room. Nine patients with unruptured VADA, deemed hemodynamically unstable, were treated with FDD. Among other parameters, the technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcomes were evaluated. ResultsSuccessful FDD deployment was achieved in all cases, and the immediate follow-up angiography showed intra-aneurysmal contrast stasis with parent artery preservation. A temporary episode of facial numbness and palsy was noted in one patient; however, the symptoms had completely disappeared when followed up at the outpatient clinic 2 weeks after the procedure. The 3–6 months follow-up angiography (n=9) demonstrated complete/near-complete obliteration of the aneurysm in seven patients, and partial obliteration and segmental occlusion in one patient each. In the patient who achieved only partial obliteration, there was a sac 13 mm in size, and there was no change in the 1-year follow-up angiography. In the patient with segmental occlusion, the cause could not be determined. The clinical outcome was modified Rankin Scale 0 in all patients. ConclusionOur preliminary study using FDD to treat hemodynamically unstable unruptured VADA showed that FDD is safe and effective. Our study has limitations in that the number of cases is small, and it is not a prospective study. However, we believe that the study contributes to evidence regarding the safety and effectiveness of FDD in the treatment of unruptured VADA.

Deconstructive versus reconstructive endovascular approaches for intracranial dissecting aneurysms

BackgroundThe annual incidence of the intracranial dissecting aneurysms is about 1 to 1.5 per 100,000. This is a well-known cause of stroke and subarachnoid hemorrhage in young and middle-aged patients (Santos-Franco et al. in Neurosurg Rev, 2008. https://doi.org/10.1007/s10143-008-0124-x). Various surgical and endovascular treatment methods have been proposed for intracranial dissecting aneurysms. All treatment methods aim to reduce the blood flow in the dissected region. Deconstructive techniques sacrifice the parent artery, whereas reconstructive techniques aim to maintain a parent artery (Stéphanie et al. in Lancet Neurol 14(6):640–654, 2015. https://doi.org/10.1016/S1474-4422(15)00009-5). Due to its dissecting nature, wall friability can make surgical clipping difficult and even risky. On the other hand, recanalization after coiling alone is almost certain. Therefore, deconstructive modalities of treatment like trapping or parent vessel occlusion, performed either surgically or endovascularly, have predominated for managing those lesions, usually with good results. Nevertheless, in absence of efficient collateral pathways, the deconstructive technique carries an ischemic risk. In situations in which parent artery preservation is mandatory, the use of stent-assisted techniques may be the most appropriate choice (de Barros Faria et al. in Am J Neuroradiol 32(11):2192–2195, 2011. https://doi.org/10.3174/ajnr.A2671). However, the usage of stent with recently ruptured aneurysms is always perplexing due to the necessity of dual antiplatelet administration. Hence the management of dissecting aneurysms remain challenging.ResultsBetween January 2017 and July 2019, 19 patients presenting with intracranial dissecting aneurysms were referred to our department for endovascular treatment. Among the nineteen patients, 11 cases were treated by parent artery occlusion representing 57.9% of the cases, and 7 cases (36.8%) were treated by artery preserving technique, and only one case (5.3%) was treated by combination of parent artery occlusion and artery preserving technique. One week after the intervention 26.3% of patients had no disability (mRS = 0), 47.4% had no significant disability (mRS = 1), 15.8% had slight disability (mRS = 2) and 10.5% had moderate to severe disability (mRS = 3–4). After three months we found an overall improvement of the clinical outcome, as 57.9% of patients had no disability (mRS = 0), 26.3% had no significant disability (mRS = 1) and 15.8% had mild disability (mRS = 2). Finally, after six months reassessment with angiography showed that 89.5% of patients had stable aneurysmal occlusion, and 10.5% had recurrence of aneurysm.ConclusionsBoth endovascular approaches, whether parent artery occlusion or artery preserving technique showed favorable outcome which indicates the safety and efficacy of both approaches if selected properly according to the morphology of the aneurysm.

Treatment of Traumatic Intracranial Pseudoaneurysms: A Single-Center Experience.

Background and Purpose: As a rare lesion secondary to brain trauma, traumatic intracranial aneurysms (TICAs) lead to high mortality and morbidity, and multiple treatment modalities have been applied for TICAs. All patients diagnosed with TICAs in our institution from 2010 to 2020 were included in the report, and their clinical features, treatment, and outcomes are described in detail. The purpose of this study is to illustrate the characteristic of different therapeutic methods of TICAs, and focus on the endovascular treatment.Methods: A total of 20 patients were included in this study. The 3 patients who declined treatment all died. Five of the other 17 patients were treated surgically, including clipping, wrapping, and trapping with or without EC-IC high-flow bypass, with only 1 case of parent artery preservation. Twelve patients underwent endovascular treatment, including bare coil embolization (1 case), stent-assisted coiling (2 cases), balloon-assisted coils/Onyx glue embolization (1 case) and covered stents (8 cases), with only 1 case of parent artery sacrifice.Results: 20 patients were included in the present study with 17 males, and the mean of age on 27 years (IQR: 22, 44 years). Eight patients presented with epistaxis, followed by 5 patients with coma, 3 patients with visual defects and 2 patients with CSF leakage. There were 18 TICAs located at the internal carotid artery (ICA); The other 2 TICAs located at pericallosal artery and A1 segment anterior cerebral artery (ACA). One case of diplopia occurred due to sacrifice of the ICA. Occlusion of the ophthalmic artery occurred in 3 patients after placement of a covered stent, with 1 patient suffering an irreversible vision decrease. None of the other patients who underwent the treatment have experienced an aggravation of their symptoms since the treatment; During the imaging follow-up, 1 case of recurrence and 1 case of endoleak occurred in this case series.Conclusions: TICAs are associated with significant morbidity and mortality, and endovascular treatment has emerged as a valuable option, which may be promising to improve the clinical outcomes due to their advantages of preserving the parent artery if occlusion of the side branch artery can be avoided.

Internal Carotid Artery Blister Aneurysm: Review of Endovascular Techniques

AbstractCerebral blister aneurysms are very difficult vascular lesions in terms of accurate diagnosis as well as proper management strategy for vascular neurosurgeons and neurointerventionists. Histopathological analysis has revealed their nature to be more akin to pseudoaneurysms in comparison to the typical berry aneurysms. This explains their fragile nature, with high probability of rerupture and regrowth during the follow-up if not addressed properly. Even though surgical approaches have evolved over the years to minimize intraprocedural rupture and recurrence, they still have relatively high morbidity as well as mortality in comparison to endovascular treatment. Over the last few years, endovascular treatment has evolved significantly, with introduction of new devices and techniques. Focus of the endovascular management has shifted from the deconstructive techniques to reconstructive ones with parent artery preservation. Recent introduction of flow diverter technology has enabled neurointerventionists to manage these difficult lesions with more confidence in terms of avoiding rerupture and recurrence. Flow diverter (FD) use in blister aneurysm resulted in high-technical success, complete aneurysm occlusion, and less complications in comparison to other reconstructive techniques like simple coiling, stent assisted coiling, and overlapping/monotherapy stent placement. Few debatable issues like use of dual antiplatelets in the setting of acute subarachnoid hemorrhage (SAH), timing of drugs in relation to procedures, single/overlapping devices, and concerns during cerebral vasospasm phase need further detailed analysis and standardized protocols. In this article, we have done a review of different endovascular treatment options in the management of internal carotid artery blister aneurysms with special focus on FD and issues related to it.

Endovascular treatment of a small ruptured non-traumatic internal carotid artery aneurysm presenting with repeated massive epistaxis

ObjectiveWe encountered a rare case of massive epistaxis resulting from a small ruptured non-traumatic cavernous internal carotid artery aneurysm associated a bony defect in the wall of the posterior lateral wall of the sphenoid sinus. We presented successful diagnosis and treatment with a balloon-assisted neck-plasty coil embolization. Case PresentationA 74-year-old Japanese man was admitted following recurrent massive epistaxis. There was no history of trauma, surgery, radiotherapy, infection, or tumor. Radiographic imaging demonstrated a bony defect in the wall of the posterior lateral wall of the sphenoid sinus that allowed the aneurysm to ruptured into the nasal cavity rather than intracranially. After rupture, the patient presented with epistaxis that resulted in systemic hypotension. This aneurysm can be managed rapidly using endovascular techniques of a balloon-assisted neck-plasty coil embolization. ConclusionThe present case report highlights the rarity of a small non-traumatic cavernous ICA aneurysm causing massive epistaxis. Clinicians should be aware of this possibility, as a high index of suspicion is required for proper diagnosis. Internal carotid angiography should be performed, particularly in patients with refractory epistaxis. Aneurysms in this location are usually amenable to endovascular treatment. Coil embolization using a microballoon-assisted neck-plasty technique can result in immediate hemostasis, parent artery preservation, and successful long-term aneurysm occlusion.

Internal carotid artery occlusion may affect long-term quality of life in patients with high-flow carotid cavernous fistulas

To investigate the mid- and long-term effects of parent artery occlusion on the carotid cavernous fistula and on the quality of life of patients. One hundred and twenty-six patients with high-flow direct carotid cavernous fistulas were enrolled. The modified Rankin scale scores, the headache impact test and the short form health survey scores were used to evaluate the patients' clinical status. Fifty-two patients had parent artery occlusion, while the rest of the 74 patients had embolization of carotid cavernous fistulas with parent artery preservation. No periprocedural complications occurred. Eighteen patients in the parent artery occlusion group had low perfusion symptoms within two weeks following embolization, and three patients had Horner's syndrome on the ipsilateral side. At two months' follow-up, the patients with parent artery occlusion had a significantly (P < 0.05) greater proportion of headache than patients with parent artery preservation. At 12 months, no significant (P > 0.05) difference existed in the headache impact test scores in both groups. At 36 months' follow-up, the patients with parent artery occlusion had decreased SF-30 scores in all the eight health domains compared with patients treated with parent artery preservation, with a significant (P < 0.05) lower score in general health, vitality and bodily pain in the parent artery occlusion compared with the parent artery preservation group. No recurrence was shown in patients with parent artery occlusion, but nine (12.2%) patients were recurrent in patients with parent artery preservation. Parent artery occlusion may affect the quality of life of patients with carotid cavernous fistulas despite being an effective treatment option for high-flow direct fistulas.

Endosaccular Treatment of Very Large and Giant Intracranial Aneurysms with Parent Artery Preservation : Single Center Experience with Long Term Follow-up.

ObjectiveVery large (20–25 mm) and giant (≥25 mm) intracranial aneurysms have an extremely poor natural course, and treatment of these aneurysms remains a challenge for endovascular and surgical strategies. This study was undertaken to describe our experiences of endosaccular treatment of very large and giant intracranial aneurysms with parent artery preservation. MethodsFrom January 2005 to October 2016, twenty-four very large or giant aneurysms in 24 patients were treated by endosaccular coil embolization with parent artery preservation. Nine (37.5%) aneurysms were ruptured and 15 were unruptured, and of these 15, 11 were symptomatic cases and 4 were incidentally discovered. The cohort comprised 17 women and 7 men of mean age 58.5 years (range, 26–82). Mean aneurysm size was 26.0 mm (range, 20–39) and 13 of the 24 aneurysms were giant. ResultsImmediate angiographic results were complete occlusion in nine (37.5%) cases, remnant neck in six (25.0%), and remnant sac in nine (37.5%). Overall procedural related morbidity and mortality rates were 12.5% and 4.2%, respectively. Angiographic follow-up was available in 16 patients (66.7%). Mean and median follow-up periods were 27.2 (range, 2–77) and 10.5 months, respectively. In 12 cases (12/16, 75%) stable occlusion was achieved, four cases (4/16, 25%) had recanalized, and two of these were retreated with additional coiling. At clinical follow-up of the nine ruptured cases, three patients (33.3%) achieved a good clinical outcome (Glasgow outcome scale [GOS] score of 4 or 5), two (22.2%) a poor outcome (GOS score of 2 or 3), and four patients (44.4%) expired (GOS 1). On the other hand, of the 15 unruptured cases, 13 patients (86.7%) achieved a good clinical outcome (GOS 4 or 5), one patient a poor outcome (GOS score of 2 or 3), and one patient expired (GOS 1). ConclusionThe present study shows endosaccular treatment of very large or giant intracranial aneurysms with parent artery preservation is both feasible and effective with acceptable morbidity and mortality.

Recurrence risk factors in detachable balloon embolization of traumatic direct carotid cavernous fistulas in 188 patients

PurposeTo investigate the effects of detachable balloons in embolizing traumatic carotid cavernous fistulas (TCCFs) and the risk factors for recurrence after balloon embolization.Materials and methods188 patients with TCCFs were enrolled,...

Clinical analysis of endovascular strategies in the treatment of vertebrobasilar dissecting aneurysms

Objective: To evaluate the efficacy and safety of endovascular strategies for vertebrobasilar dissecting aneurysm (VBDA) and analyze advantages and disadvantages of different endovascular methods for the treatment of VBDA through long-term follow-up. Methods: Retrospectively analyzing was used for the clinical information of 45 cases of vertebrobasilar dissecting aneurysms treated with endovascular methods in our department from January 2007 to December 2015. The treatment modalities were classified into reconstructive surgery and destructive surgery that were based on parent artery preservation. Reconstructive surgery included stent-assisted coil embolization (24 patients) and the placement of single or multiple overlapping stents (8 patients). Destructive surgery was coil embolization combined with proximal coil trapping of the dissected segment of the parent artery (CE+ PT, 13 patients). Results: The incidence of perioperative complications was 11.4%, and the mortality associated with these complications was 4.4%. In the patients undergoing reconstructive surgery, one patient suffered from aneurysm rerupture and died, one patient had intraoperative thrombi in the parent artery and resulted in a complete patency after thrombolysis was performed with Tirofiban. Both perioperative complications occurred in patients treated with stent-assisted coil embolization. No complications occurred in patients treated with single or multiple overlapping stents placements. Perioperative brainstem ischemia occurred in three patients who were treated with destructive surgery, and caused one death and two severe disabilities. Clinical outcome evaluations were performed using the Modified Rankin Scale and resulted in the following scores: 0-2 for 41 patients, 3-6 for 4 patients. The prognosis of reconstructive group was better than that of destructive group, with statistical differences (P<0.05). The incidence of perioperative complications in reconstructive group was lower than that in destructive group, without significant differences (P>0.05). Conclusions: Endovascular treatment is effective and safe for VBDAs. The incidence of perioperative complication in reconstructive group is lower and the prognosis is better than that in destructive group.

Endovascular reconstruction of unruptured intradural vertebral artery dissecting aneurysms with the Pipeline embolization device

BackgroundDissecting aneurysms of the vertebral artery (VA) are difficult to treat using current surgical and endovascular techniques.ObjectiveTo analyze retrospectively the efficacy and safety of flow diverters in the treatment of...

E-131 endovascular reconstruction of intradural vertebral artery fusiform dissecting aneurysms with the pipeline embolization device

Introduction/purpose Dissecting aneurysms of the vertebral artery (VA) are difficult to treat using current surgical and endovascular techniques. Currently, there is no consensus on management strategies of dissecting VA aneurysms. The characteristics of flow diverter stents appear to have ideal requirements for the treatment of dissecting VA aneurysms. In this study, we retrospectively analyzed the efficacy and safety of flow diverters in the treatment of such lesions. Materials and methods We identified six patients with six VA dissecting aneurysms either arising from the V4 or V3–V4 junction that were treated with the pipeline embolization device (PED) at our institution from July 2012 to February 2015. Among other parameters, technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcome were evaluated. Results Six patients, 3 females and 3 males, with a mean age of 52.8 years (age range 39–63 years) were identified. Vascular risk factors included hypertension (4/6), dyslipidemia (2/6), fibromuscular dysplasia (1/6) and smoking (1/6). The aneurysms were incidental findings in 3 cases, whereas the other 3 patients presented with neurological symptoms such as visual changes, ataxia, facial numbness or vertigo. Diagnostic angiography confirmed the presence of fusiform dissecting aneurysms centered at the V4 segment in 5 cases and at the vertebral V3–V4 junction in one case. PED placement was achieved in all cases and immediate angiography follow-up demonstrated intra-aneurysmal contrast stasis with parent artery preservation. A temporary episode of dysarthria was noted in one patient. Major procedure-related complications were not observed. 6-month follow-up (n = 5) demonstrated complete/near complete aneurysm obliteration in 4 and partial obliteration in 1 patient. At 1-year follow-up (n = 4) stable complete aneurysm occlusion was seen in 2 patients. One patient demonstrated progression from near complete to complete occlusion and the previously noted partial occlusion remained stable. No aneurysmal bleeding, in-stent stenosis or thromboembolic complication was observed. NIHSS and mRS scores remained unchanged from admission to discharge. Conclusion Our preliminary experience with endoluminal reconstruction of intradural dissecting VA aneurysms with the PED confirms this treatment approach to be feasible and safe with good short-term angiographic and clinical outcomes. Long-term and larger cohort studies will need to provide further information on durable aneurysm obliteration in response to hemodynamic intravascular flow changes and the occurrence of delayed hemorrhage and in-stent thrombosis. The promising results obtained so far, however, appear to support the use of flow diverter in the treatment of dissecting intracranial VA aneurysms; especially in circumstances where maintaining parent artery and side branch patency is required. Disclosures A. Kuhn: None. F. Massari: None. J. Lozano: None. S. Hou: None. M. Howk: None. M. Perras: None. C. Brooks: None. P. Kan: None. M. Gounis: 1; C; NIH, Philips Healthcare, Covidien/eV3 Neurovascular, Codman Neurovascular, Stryker Neurovascular, Wyss Institute, Tay Sachs Foundation. 2; C; fee-per-hour consultation, Stryker Neurovascular. A. Wakhloo: 1; C; Philips Medical. 2; C; Stryker Neurovascular. 3; C; Harvard Postgraduate Course and Miami Baptist Vascular Institute. A. Puri: None.

E-017 endovascular management of iatrogenic anterior communication artery pseudoaneurysm

Introduction Traumatic intracranial pseudoaneurysm following transphenoidal surgery has been described, but these typically involve the internal carotid artery and avulsion of the anterior communicating artery (AComm) is a very unusual complication. We present a case managed with endovascular repair. Case presentation A 80 year-old man underwent endoscopic transphenoidal surgery for endocrinologically-active pituitary adenoma. This patient had received pre- and post-op CTA. On postoperative CT angiography, the patient was noted to have a dramatic conformation change of the ACOM complex with splaying and a small new A1/A2 junction pseudoaneurysm indicating iatrogenic avulsion of the ACOM as the probable cause. The pseudoaneurysm had a narrow neck, therefore we elected to coil it. Other options including sacrifice of the A1/A2, flow diversion and surgery were considered and the pros and cons of these treatment options discussed. Under biplane fluoroscopic guidance, the pseudoaneurysm was accessed via microcatheter technique and coil embolization was performed. Following completion angiography to confirm no residual pseudoaneurysm, the patient was transferred in stable condition to the neuro-intensive care unit. At 6 month follow-up, the patient is well and possesses no neurological deficit. MR angiography showed no coil migration or residual pseudoaneurysm. Discussion Traditionally, this type of injury might be treated by vessel sacrifice or surgical intervention. Flow diversion might also be considered. We report here successful repair with conventional coiling approach with parent artery preservation for this very unusual iatrogenic injury. Disclosures A. Dmytriw: None. D. Sarma: None. W. Montanera: None. M. Cusimano: None. A. Bharatha: None.

Deconstructive and Reconstructive Techniques in Treatment of Vertebrobasilar Dissecting Aneurysms: A Systematic Review and Meta-Analysis.

Various endovascular techniques have been applied to the treatment of vertebrobasilar dissecting aneurysms, including parent artery preservation with coiling, stent placement or flow diverter placement, and trapping and proximal occlusion. We performed a systematic review and meta-analysis to study clinical and angiographic outcomes of patients undergoing endovascular treatment of vertebrobasilar dissecting aneurysms. We performed a comprehensive literature search for studies on the endovascular treatment of vertebrobasilar dissecting aneurysms. From each study we abstracted the following data: immediate occlusion, long-term occlusion, long-term good neurologic outcome, perioperative morbidity, perioperative mortality, rebleed (ruptured only), recurrence, and retreatment. We performed subgroup analyses of patients undergoing deconstructive-versus-reconstructive techniques. Meta-analysis was performed by using a random effects model. Seventeen studies with 478 patients were included in this analysis. Sixteen studies had at least 6 months of clinical/angiographic follow-up. Endovascular treatment was associated with high rates of long-term occlusion (87.0%; 95% CI, 74.0%-94.0%) and low recurrence (7.0%; 95% CI, 5.0%-10.0%) and retreatment rates (3.0%; 95% CI, 2.0%-6.0%). Long-term good neurologic outcome was 84.0% (95% CI, 65.0%-94.0%). Deconstructive techniques were associated with higher rates of long-term complete occlusion compared with reconstructive techniques (88.0%; 95% CI, 35.0%-99.0% versus 81.0%; 95% CI, 64.0%-91.0%; P < .0001). Deconstructive and reconstructive techniques were both associated with high rates of good neurologic outcome (86.0%; 95% CI, 68.0%-95.0% versus 92.0%; 95% CI, 86.0%-95.0%; P = .10). Endovascular treatment of vertebrobasilar dissecting aneurysms is associated with high rates of complete occlusion and good long-term neurologic outcomes. Deconstructive techniques are associated with higher occlusion rates. There was no statistical difference in neurologic outcomes between groups, possibly due to low power.

Onyx embolization in distal dissecting posterior inferior cerebellar artery aneurysms

BackgroundDissecting aneurysms located along the distal segments of the posterior inferior cerebellar artery (PICA) are extremely rare, accounting for only 0.5–0.7% of all intracranial aneurysms. Treatment of these aneurysms is...

Endoscopic Fluorescence Angiography with Indocyanine Green : A Preclinical Study in the Swine.

ObjectiveMicroscopic indocyanine green (ICG) angiography is useful for identifying the completeness of aneurysm clipping and the preservation of parent arteries and small perforators. Neuroendoscopy is helpful for visualizing structures beyond the straight line of the microscopic view. We evaluated our prototype of endoscopic ICG fluorescence angiography in swine, which we developed in order to combine the merits of microscopic ICG angiography and endoscopy.MethodsOur endoscopic ICG system consists of a camera, a light source, a display and software. This system can simultaneously display real-time visible and near infrared fluorescence imaging on the same monitor. A commercially available endoscope was used, which was 4 mm in diameter and had an angle of 30°. A male crossbred swine was used.ResultsUnder general anesthesia, a small craniotomy was performed and the brain surface of the swine was exposed. ICG was injected via the ear vein with a bolus dose of 0.3 mg/kg. Visible and ICG fluorescence images of cortical vessels were simultaneously observed on the display monitor at high resolution. The real-time merging of the visible and fluorescent images corresponded well.ConclusionSimultaneous visible color and ICG fluorescent imaging of the cortical vessels in the swine brain was satisfactory. Technical improvement and clinical implication are expected.

Extra-aneurysmal flow modification following pipeline embolization device implantation: focus on regional branches, perforators, and the parent vessel.

Flow-diverter technology has proved to be a safe and effective treatment for intracranial aneurysm based on the concept of flow diversion allowing parent artery and collateral preservation and aneurysm healing. We investigated the patency of covered side branches and flow modification within the parent artery following placement of the Pipeline Embolization Device in the treatment of intracranial aneurysms. Sixty-six aneurysms in 59 patients were treated with 96 Pipeline Embolization Devices. We retrospectively reviewed imaging and clinical results during the postoperative period at 6 and 12 months to assess flow modification through the parent artery and side branches. Reperfusion syndrome was assessed by MR imaging and clinical evaluation. Slow flow was observed in 13 of 68 (19.1%) side branches covered by the Pipeline Embolization Device. It was reported in all cases of anterior cerebral artery coverage, in 3/5 cases of M2-MCA coverage, and in 5/34 (14.7%) cases of ophthalmic artery coverage. One territorial infarction was observed in a case of M2-MCA coverage, without arterial occlusion. One case of deep Sylvian infarct was reported in a case of coverage of MCA perforators. Two ophthalmic arteries (5.9%) were occluded, and 11 side branches (16.2%) were narrowed at 12 months' follow-up; patients remained asymptomatic. Parent vessel flow modification was responsible for 2 cases (3.4%) of reperfusion syndrome. Overall permanent morbidity and mortality rates were 5.2% and 6.9%, respectively. We did not report any permanent deficit or death in case of slow flow observed within side branches. After Pipeline Embolization Device placement, reperfusion syndrome was observed in 3.4%, and territorial infarction, in 3.4%. Delayed occlusion of ophthalmic arteries and delayed narrowing of arteries covered by the Pipeline Embolization Device were observed in 5.9% and 16.2%, respectively. No permanent morbidity or death was related to side branch coverage at midterm follow-up.

E-042 Use of Flow Diverters in Vessels less than 2.5 mm during Intracranial Aneurysm Treatment

Introduction/purposePipeline Embolization Device (PED) is currently indicated for treatment of large and complex intracranial aneurysms centerd along the cavernous/intradural segment of the internal carotid artery (ICA) proximal to the Posterior...