Residual Neck Research Articles

Early Termination versus Standard Regimen Duration of Dual Antiplatelet Therapy in Intracranial Aneurysm Patients Treated With Pipeline Embolization Device Flex With Shield Technology: Preliminary Experience of 3 U.S. Centers

Pipeline Flex Embolization Device with Shield Technology (PED-Shield) is a third-generation flow diverter with reduced thromboembolic potential. However, safety profile and dual antiplatelet therapy (DAPT) recommendations with PED-Shield is not well -established. We aim to assess the safety and complication profile with early termination of DAPT with use of PED-Shield. Databases of 3 high-volume cerebrovascular centers were retrospectively reviewed. We identified patients with unruptured and ruptured intracranial aneurysms treated with PED-Shield. Patient demographics, aneurysm characteristics, complications, and angiographic outcomes were extracted. All patients who had early termination of DAPT, defined as <180 days, as well as standard duration were included. A total of 37 patients, totaling 37 aneurysms, had early termination of DAPT and 24 patients with 24 aneurysms received standard duration (>180 days) of DAPT. There was no difference in pre-procedural DAPT regimens between the groups (P= 0.503). Following DAPT termination, o1ne major thromboembolic complication was observed in the early termination group while no major or minor thromboembolic or hemorrhagic complication was noted in the standard duration group. Time of angiographic follow-up was not statistically different (P= 0.063) between the early termination (343 days, interquartile range [IQR] 114-371 days) and the standard duration (175 days, IQR 111-224.5 days) groups. There were no statistically significant differences in complete aneurysm occlusion (P= 0.857), residual neck (P= 0.582), and aneurysm remnant (P= 0.352) rates between the groups on angiography. Early termination of DAPT proves safe after PED-Shield treatment of intracranial aneurysms with comparable complete occlusion rates.

Clipping of Unruptured Anterior Choroidal Artery Aneurysms Together with Small Branches: Safety Confirmation Using Intraoperative Indocyanine Green Video-Angiography and Intraoperative Neurophysiological Monitoring

In treating anterior choroidal artery (AChA) aneurysms, preserving the AChA main trunk is of course necessary to prevent postoperative ischemic complications. However, in practice, complete occlusions are often limited by small branches. We aimed to demonstrate that even in cases where complete occlusion of the AChA aneurysm is complex due to small branches, complete occlusion can be safely achieved using indocyanine green video-angiography and intraoperative neurophysiological monitoring (IONM). We performed a retrospective review of all unruptured AChA aneurysms surgically treated at our institution from 2012 to 2021. All available surgical videos were reviewed to find AChA aneurysms clipped with small branches; clinical and radiological data were collected for these cases. Among 391 cases of unruptured AChA aneurysms treated surgically, 25 AChA aneurysms were clipped with small branches. AChA-related ischemic complications occurred in 2 cases (8%) without retrograde indocyanine green filling to the branches. These 2 cases had changes in IONM. There were no ischemic complications in the remaining cases with retrograde indocyanine green filling to the branches and no change in IONM. During an average follow-up of 47months (12-111months), a small residual neck was observed in 3 cases (12%) and recurrence or progression of the aneurysm was observed in only 1 case (4%). The surgical treatment of AChA aneurysms carries the risk of devastating ischemic complications. Even in cases where complete clip ligation seems impossible due to small branches associated with AChA aneurysms, complete occlusion can be safely achieved using indocyanine green video-angiography and IONM.

Free Tissue Transfer in the Reconstruction of Neck Contractures after Burn Injury: A Case Series

Background: Recent advances in burn care have significantly improved the survival rate of patients with extensive burn injuries, placing greater emphasis on reconstruction to improve the long-term outcomes of scar deformities. Anterior and lateral neck contractures are common after burn injuries; they limit range of motion, complicate airway management and create significant cosmetic deformities. Traditional methods have been used to release contractures and improve function. However, they are subject to variable results, residual neck tightness, recurrence and suboptimal cosmetic appearance. Microvascular free tissue transfer is a more technically challenging and time-consuming method, but it offers the potential to overcome the long-term limitations of simpler options. In this paper, we present our experience with microvascular free flaps for the release of burn scar contractures of the neck as a potential high-quality permanent solution. Methods: Over a 10-year period, nine free flaps were performed on burn patients with total body surface area (TBSA) burns between 20 and 70%, who developed moderate to severe neck contractures. Four anterolateral thigh (ALT) flaps, four radial forearm free flaps (RFFFs) and one ulnar forearm flap were used to release neck contractures. Results: All nine flaps were completed successfully with significant improvement in the neck’s range of motion. Good aesthetic results were achieved with smooth contour and thin coverage. Overall, the patients were satisfied. However, five out of nine cases required at least one secondary procedure for flap defatting to reach optimal results. Conclusion: Post-burn scar contractures of the cervical region compromise the cosmetic appearance and airway security of recovering burn patients, imposing a significant impact on their psychological and functional quality of life. Consequently, cervical contractures can be prioritized when planning reconstruction for burn patients. Free flaps can be considered an important and reliable method of reconstruction for neck contracture deformity following burn injuries.

Intracranial aneurysms treated with stent-assisted coil embolization: evaluation with four-dimensional ultrashort-TE MR angiography.

As a novel follow-up method for intracranial aneurysms treated with stent-assisted coil embolization (SACE), we developed four-dimensional magnetic resonance angiography (MRA) with minimized acoustic noise utilizing ultrashort-echo time (4D mUTE-MRA). We aimed to assess whether 4D mUTE-MRA is useful for the evaluation of intracranial aneurysms treated with SACE. This study included 31 consecutive patients with intracranial aneurysm treated with SACE who underwent 4D mUTE-MRA at 3T and digital subtraction angiography (DSA). For 4D mUTE-MRA, five dynamic MRA images with a spatial resolution of 0.5 × 0.5 × 0.5 mm3 were obtained every 200ms. Two readers independently reviewed the 4D mUTE-MRA images to evaluate the aneurysm occlusion status (total occlusion, residual neck, and residual aneurysm) and the flow in the stent using a 4-point scale (from 1 [not visible] to 4 [excellent]). The interobserver and intermodality agreement was assessed using κ statistics. On DSA images, 10 aneurysms were classified as total occlusion, 14 as residual neck, and 7 as residual aneurysm. In terms of aneurysm occlusion status, the intermodality and interobserver agreement was excellent (κ = 0.92 and κ = 0.96, respectively). For the flow in the stents on 4D mUTE-MRA, the mean score was significantly higher for single stents than multiple stents (p < .001) and for open-cell type stents than closed-cell type (p < .01). 4D mUTE-MRA is a useful tool with a high spatial and temporal resolution for the evaluation of intracranial aneurysms treated with SACE. • In the evaluation of intracranial aneurysms treated with SACE on 4D mUTE-MRA and DSA, the intermodality and interobserver agreement in aneurysm occlusion status was excellent. • 4D mUTE-MRA shows good to excellent visualization of flow in the stents, especially for cases treated with a single or open-cell stent. • 4D mUTE-MRA can provide hemodynamic information related to embolized aneurysms and the distal arteries to stented parent arteries.

Additional rescue stenting with Neuroform Atlas stents during stent-assisted coiling of saccular aneurysms

ObjectiveOverlapping stenting is sometimes attempted during endovascular treatment of cerebral aneurysm as a rescue for coil herniation, stent mal-positioning, or in-stent thrombosis. We retrospectively evaluated the efficacy and safety of additional rescue stenting (ARS) in telescoping fashion with Neuroform Atlas stent (NAS) during stent-assisted coiling of saccular aneurysms. MethodsWe collected clinical and radiological data of patients with saccular aneurysms treated with ARS using NASs between March 2018 and December 2021. Y or X-stent-assisted coiling technique was excluded. ResultsEighteen unruptured and 5 ruptured aneurysms in 23 patients were treated with ARS using NASs. Sizes of aneurysms ranged from 2.0 mm to 10.0 mm (mean: 5.0 mm). Immediate angiographic results were complete occlusion in 11 aneurysms, residual neck in 4 aneurysms, and residual sac in 8 aneurysms. Peri-operative morbidity was 4.3 %. Nineteen of 23 patients underwent follow-up conventional angiography (mean, 9.9 months). Results showed progressive occlusion in 10 (52.6 %) cases and asymptomatic in-stent stenosis in 3 (15.8 %) cases. At the end of the observation period (mean, 17.4 months), all 18 patients without subarachnoid hemorrhage had excellent clinical outcomes (mRS of 0), except one (mRS of 1). Of five patients with subarachnoid hemorrhage, four had a favorable outcome (mRS of 0–1), while the other one was dependent (mRS of 4). ConclusionIn this report on 23 patients, ARS with NASs for treating saccular aneurysms showed good technical safety with favorable clinical and angiographic outcomes. However, delayed in-stent stenosis was not uncommon. Thus, regular imaging follow-up is required.

396 North American Multicenter Experience of the Flow-Redirection Endoluminal Device (FRED) in the Treatment of Intracranial Aneurysms

INTRODUCTION: Flow-diverters have revolutionized the endovascular treatment of intracranial aneurysms. The evidence on the Flow Re-direction Endoluminal Device (FRED) is limited compared to some counterparts that have been available for clinical use longer. METHODS: Between June 2020 and November 2021, consecutive cerebral aneurysms treated using FRED were included across 7 North American centers. Data collected included patient demographics, aneurysm characteristics, peri-procedural and long-term complications, modified Rankin Scale (mRS) scores, and radiologic follow-up. RESULTS: 133 aneurysms in 116 patients treated in 123 FRED deployment procedures were included. One hundred twenty-six aneurysms (94.7%) were unruptured, 117 (88.0%) were saccular, and 123 (92.5%) aneurysms were located in the anterior circulation. Mean aneurysm maximal width and neck sizes were 7.2 mm and 4.1 mm, respectively. Successful FRED deployment was achieved in 122 (99.2%) procedures. Radiologic follow-up was available for 101 aneurysms at a median duration of 7.0 months. At the last follow-up, complete occlusion was observed in 55.4%, residual neck in 8.9%, and filling aneurysm in 35.6%. On multivariate regression analysis, age (OR = 0.93; p = 0.001) and aneurysm neck size (OR = 0.83; p = 0.048) negatively correlated with odds of complete occlusion. The retreatment rate was 6/124 (4.8%). The overall complication rate was 31/116 (26.7%). Parent vessel occlusion, covered branch occlusion, and in-stent stenosis were detected in 9/99 (9.1%), 6/63 (9.5%), and 15/99 (15.2%) of the cases, respectively. FRED-related, symptomatic, thromboembolic, and hemorrhagic complication rates were 22.4%, 12.9%, 6.9%, and 0.9% respectively. The morbidity rate was 10/116 (8.6%). CONCLUSIONS: As the first large-scale North American multi-center FRED experience, this study confirms FRED’s ease of successful deployment but suggests a lower efficacy and higher rate of complications compared to previous European and South American FRED studies and other flow diverting devices.

Utility of low-profile visualized intraluminal support (LVIS™) stent for treatment of acutely ruptured bifurcation aneurysms: A single-center study.

Stent-assisted coiling has been increasingly used in the treatment of intracranial aneurysms. However, its application in ruptured bifurcation aneurysms remains controversial and challenging. This study aimed to present the safety and feasibility of low-profile visualized intraluminal support (LVIS™, LVIS, and LVIS Jr.) stent for acutely ruptured bifurcation aneurysms. A total of 41 patients with acutely ruptured intracranial aneurysms arising at the bifurcation were treated with LVIS™ stent-assisted coiling in our hospital between January 2017 and December 2021. The clinical data and angiographic results of the patients were analyzed. Among these patients, all stents were successfully implanted. According to the immediate angiographic results, 29 aneurysms (70.7%) were completely occluded. Intraoperative thrombosis and hemorrhage occurred in two and one cases, respectively. No post-operative thrombosis or rebleeding events were observed. The clinical follow-up of all patients revealed that 38 (92.7%) cases had favorable outcomes (modified Rankin scale: 0-2). The angiographic results available for the 36 patients during the follow-up period revealed complete occlusion was achieved in 30 patients (83.3%) and residual neck in six patients. The LVIS™ stent-assistant coiling is a safe and feasible option for acutely ruptured bifurcation aneurysms. Further studies with a prospective design, a larger sample size, and long-term follow-up are needed to validate these findings.

Abstract Number ‐ 135: Surpass Evolve® Flow Diversion for Embolization of Unruptured Anterior Circulation Aneurysms: 6‐month Obliteration Rates

Introduction The Surpass Evolve flow diverter (FD) is a 64‐wire cobalt‐chromium device with improved ease of deployment and conformability, compared to its predecessor. Data on procedural outcomes and aneurysm obliteration rate remain limited. The objective of this study was to describe the procedural outcomes, including 6‐month obliteration rates, for patients who underwent Surpass Evolve FD embolization of an unruptured anterior circulation aneurysm. Methods All consecutive patients with an unruptured anterior circulation aneurysm who were treated with the Surpass Evolve FD between Aug 2020 and May 2022 were included. Patients with a ruptured or posterior circulation aneurysm were excluded. Demographic and clinical features, aneurysm morphology, arterial access, and procedural factors and outcome were extracted from our departmental neurointerventional database. Summary statistics included frequencies, and measures of central tendency and dispersion as appropriate. Results Sixty patients (82% female, mean age 57.9 years ± 15.5) underwent elective Surpass Evolve flow diversion for an unruptured anterior circulation aneurysm. In 47 (78%) patients, a native aneurysm was flow‐diverted, and in 13 (22%) patients, FD was performed for a recurrent aneurysm. Distribution of aneurysm location was: supraclinoid ICA (65%), cavernous ICA (12%), cervical ICA (10%) and anterior cerebral artery (13%). Thirty‐nine (65%) patients underwent left‐sided intervention. Mean aneurysm maximal diameter was 8.7 ± 5.7 mm. The majority of patients (49, 82%) underwent radial arterial access. Balloon angioplasty or J‐wire manipulation was used to enhance apposition in 37 (62%) cases. To date, thirty‐five (58%) patients have had a follow up angiogram (mean 0.65 years ± 0.2 from intervention); in 5 patients, there was mild non‐flow‐limiting stenosis. Based on the Raymond‐Roy Occlusion Classification, 25 (71%) had complete occlusion, 1 (2%) had a residual neck, and 9 (26%) had residual aneurysm. Conclusions The Surpass Evolve FD is safe and associated with favorable occlusion rates at six months. In our early experience, complication rates are well within the acceptable limits.

Abstract Number ‐ 33: Patients Treated with The Pipeline Shield Flow Diverter Enrolled Within the INSPIRE Study: Primary analysis

Introduction The INSPIRE study collects post‐market data on multiple devices from more than 40 centers world‐wide. One of these devices is the PipelineTM Flex flow diverter with Shield TechnologyTM (Pipeline Shield) for the treatment of intracranial aneurysms. The Shield surface modification is designed to enhance endothelization of the device with low thromboembolic risks. We analyze the efficacy and safety outcomes after Pipeline Shield therapy at the 1‐year follow‐up in a large prospective study. Methods INSPIRE is a prospective, multicenter, single arm study. Patients are followed for 1‐year post‐procedure and results are adjudicated by an independent Clinical Events Committee and Imaging Core Laboratory. All patients were treated per their hospital’s standard of care. The primary safety endpoint was neurological death or major stroke in the treated vascular area. The primary efficacy endpoint was complete aneurysm occlusion without significant parent artery stenosis (&gt;50%) or retreatment. For this analysis, the last‐available observation was carried forward to overcome differences between centers’ imaging schedules. Results A total of 537 patients were enrolled, with 504 patients with 488 aneurysms included in the analysis (mean age 53.8±12.2, 77.0% [388/504] female). The majority of aneurysms were located in the ICA (74.2%, 362/488). Of the remaining aneurysms, 16.0% (78/488) were in the anterior circulation and 9.8% (48/488) were in the posterior circulation. The majority of aneurysms were saccular (89.3% [436/488]). A total of 47.1% of aneurysms were small (&lt; 7mm, 230/488), 30.9% were medium (7‐&lt; 13 mm, 151/488), 16.8% were large (13‐&lt; 25 mm, 82/488), and 5.1% were giant (&gt; = 25 mm, 25/488). Adjunctive devices were used in 20.9% (102/488) of cases, including balloon (42.2% [19/43]), coil (63.7%, [65/102]), stent (5.9% [6/102]), or flow diverter (9.8% [10/102]). At 1‐year post‐procedure, complete occlusion (Raymond Roy Class I) was achieved in 74.9% (326/435) aneurysms. The primary safety endpoint occurred in 2.2% (11/504) patients. The primary endpoint was achieved in 73.2% (290/396) cases; reasons for primary endpoint failure included residual neck (5.8% [23/396]), residual aneurysm (19.4% [77/396]), stenosis &gt;50% (1.0% [4/396]), and re‐treatment (1.5% [6/396]). Among ICA aneurysms, complete occlusion was achieved in 78.1% (249/319). The primary safety endpoint occurred in 2.0% (7/356) patients. The primary endpoint was achieved in 77.1% (225/292) cases; reasons for primary endpoint failure among ICA aneurysms included residual neck (5.5% [16/292]), residual aneurysm (16.4% [48/292]), stenosis &gt;50% (0.7% [2/292]), and re‐treatment (1.4% [67/292]). Conclusions INSPIRE data suggests good rates of complete occlusion, efficacy, and safety among a large cohort of patients with aneurysms in a variety of challenging locations and sizes treated with the Pipeline Shield device, with adjudication by CEC and Imaging Core Lab ensuring high quality of these data.

Endovascular treatment of posterior circulation aneurysms: Results from a single-team experience of 81 cases including 13 flow diversion treatment

IntroductionRelatively constant surgical risks and rapid advances in endovascular treatment have caused a major shift toward endovascular management of posterior circulation aneurysms. This paper presents the results of a series of endovascularly treated posterior circulation aneurysms. MethodsA total of 81 patients who underwent endovascular treatment of posterior circulation aneurysms performed by a single team between 2009 and 2019 were included. Demographic, clinical, radiologic, and management details were retrospectively obtained from hospital records. ResultsAmong the included patients, 50 (61.7%) and 31 (38.3%) were female and male, respectively. Subarachnoid hemorrhage was observed in 30 patients (37%). Moreover, 40 (49.3%) aneurysms were treated with stent-assisted coiling, 1 (1.2%) aneurysm was treated with parent artery occlusion, 2 (2.4%) aneurysms were coiled using balloon assistance, 24 (29.6%) aneurysms were coiled primarily, 1 (1.2%) patient had an unsuccessful treatment attempt, and 13 (16.0%) aneurysms were treated with flow-diverter stents or stent monotherapy. During the last follow-up, 57 (83.8%) aneurysms were completely occluded, whereas 6 (8.8%) and 2 (2.9%) aneurysms did and did not have a residual neck, respectively. Flow diversion was used to treat 13 patients, among whom 8 had total occlusion or stable residue. A total of 7 deaths (8.6%) were encountered in this series. ConclusionEndovascular treatment should be considered as the primary treatment modality for posterior circulation aneurysms. Despite the high morbidity and mortality rates, promising results can be achieved with correct patient selection. Flow diversion can be a feasible alternative for complex aneurysms that are difficult to treat.

Assessment of balloon remodeling techniques in endovascular treatment of wide-neck intracranial aneurysms (WN-IAs)

ABSTRACT Objectives To evaluate the clinical, technical, and angiographic results in endovascular management of wide-neck intracranial aneurysms (WN-IAs) using the balloon-remodeling technique. Methods This study was a prospective, single-center study that was carried out over a period of three years from January 2019 to December 2021 at the Neuro-Interventional Unit at our hospital. Patients who presented with WNIAs and were eligible for endovascular treatment using the balloon-remodeling approach were included in the study. Results We included 37 patients with a mean age of 49.7 ± 12.3 years. About 91.9% of the participants had SAH, 5.4% had unruptured aneurysms, and 2.7% had intracranial hemorrhage. The mean time to treatment was 6.97 ± 7.35 days, the mean aneurysm diameter was 5.7 ± 1.7 mm, and the mean neck diameter was 3.8 ± 1.0 mm. The majority of the patients had a dom-to-neck ratio of less than 2 (89.2%). We have used hyper form balloons in 48.6%, hyper glide in 43.2%, Copernic balloons in 5.4%, and eclipse in 2.7%. According to the Raymond-Roy occlusion classification, 86.5% of the patients had complete obliteration, 10.8% had residual neck, and 2.7% had a residual aneurysm. Almost 91.9% had no complications, 2.7% had ischemia, and 5.4% had mild rupture by wire, treated by 5 min hyperinflation of the balloon till hemorrhage stopped. Conclusions Balloon-assisted detachable coiling is an important option in the treatment of WN-IAs. We found that this technique allowed safe and efficient treatment of aneurysms when conventional treatment had failed due to WN. Endovascular coiling using the balloon remodeling technique of wide neck showed a high technical success rate and good short-term clinical outcomes. A good selection of patients with WN-IAs treated by endovascular coiling using balloon remodeling technique and a good selection of materials used help in decreasing the complications.

Ultrashort Echo Time Magnetic Resonance Angiography as an Alternative Tool to Digital Subtraction Angiography in the Follow-up of Stent-Assisted Coil Embolization Outcomes.

Follow-up of aneurysms treated with stent-assisted coil embolization has been performed using digital subtraction angiography (DSA) because in time-of-flight magnetic resonance angiography, metal artifacts from the stent often affect visualization. To confirm whether ultrashort echo time (TE) MRA may be an alternative for DSA during follow-up. Patients with unruptured aneurysms initially treated with stent-assisted coil embolization between April 2019 and March 2021 were enrolled. After 3 months of treatment, follow-up DSA and ultrashort TE MRA were performed. All images were independently reviewed by neurosurgeons to evaluate in-stent flow and rated from 1 (not visible) to 4 (excellent). Aneurysmal embolization status was assessed as complete obliteration, residual neck, or residual aneurysm. Ultrashort TE MRA findings were classified as evaluative or nonevaluative state based on the presence of metal artifacts. We investigated the types of aneurysms that were evaluative and the agreement between ultrashort TE and DSA. Overall, 89 aneurysms were examined, of which 74% (n = 66) were classified as evaluative on ultrashort TE. Significant differences were observed in size and stent type. Evaluative cases had an aneurysm size of <7 mm ( P = .0007) and a higher rate of Neuroform Atlas ( P = .0006). The rate of agreement between ultrashort TE with evaluative state and DSA was 95%. Ultrashort TE MRA could evaluate an embolization status treated with stenting, and the findings are in excellent agreement with those of DSA. Aneurysms measuring <7 mm and treated with Neuroform Atlas are evaluative on ultrashort TE, and DSA might not be necessary.

BEST (Bolster Equalization Suture Technique) Neck: Optimization of Skin Redraping Following Necklift Surgery.

Skin laxity of the neck is a primary concern of patients seeking facial rejuvenation. Traditional methods for redraping neck skin have well-described shortcomings. To optimize skin redraping after necklift surgery while reducing risk, the BEST (Bolster Equalization Suture Technique) was developed as described. At the conclusion of the facelift and necklift, 3 external quilting sutures are placed with protective bolsters. The first suture is placed at the midline, advancing the skin posteriorly toward the hyoid and anchoring the skin to the platysma. The second and third are placed in the cervicomandibular groove over the sternocleidomastoid muscle, advancing the skin posteriorly. Complications such as skin necrosis, skin ischemia, dimpling, hypopigmentation, hyperpigmentation, and scarring were documented. A control group of 20 patients who underwent the same surgery without the BEST was compared to the next 20 patients using the technique. Preoperative and postoperative photographs were blindly reviewed by two plastic surgeons. The photographs were analyzed for residual central neck skin laxity and cervicomental angle improvement and surveyed using the pertinent sections of the FACE-Q. In necklift patients who received the BEST, cervicomental angle improvement and decreased central skin laxity were statistically significant. Patient perceived age on the visual analogue scale was 2.5 years younger in the BEST group. The BEST is a safe and efficient method which can be used to improve cervical skin redraping and contour. The BEST creates a more defined cervicomental angle while reducing central skin neck laxity with minimal complications.

Effects of stent-assisted coiling in comparison with flow diversion on intracranial aneurysms.

The aim of this study was to investigate the efficacy and complications of stent-assisted coiling in comparison with flow diversion for wide-necked intracranial aneurysms. Patients with wide-necked intracranial aneurysms who were treated with stent-assisted coiling or flow diversion were respectively, enrolled into the stent-assisted coiling or flow diversion treatment group. The clinical and angiographic data were analyzed. A total of 61 patients with intracranial aneurysms underwent stent-assisted coiling, including 35 (57.4%) female and 26 (42.6%) male patients with 21 (34.4%) ruptured and 40 (65.6%) unruptured aneurysms. Also, 53 patients underwent deployment of flow-diverting devices, including 30 (56.6%) female and 23 (43.4%) male patients with 25 (47.2%) ruptured and 28 (52.8%) unruptured aneurysms. Stent-assisted coiling was performed successfully in 60 patients with 63 stents deployed, and immediate aneurysm occlusion was complete occlusion in 38 (62.3%) aneurysms, residual neck in 12 (19.7%), and residual aneurysm in 10 (16.4%). Procedure-related complications included in-stent thrombosis in three (4.9%) patients, coil protrusion in three (4.9%), and re-rupture of one (1.6%) aneurysm, with a total complication rate of 11.5%. In the flow diversion group, a pipeline embolization device alone was deployed in each of the 24 (45.3%) patients, adjunctive coiling combined with a pipeline device in 29 (54.7%), and double pipeline devices in each of the 6 (11.3%) patients. Immediately after treatment, complete occlusion was achieved in 3 (5.7%) patients with adjunctive coiling, residual neck in 3 (5.7%), and residual aneurysm in 47 (88.7%). Procedure-related complications included aneurysm rebleeding in one patient (1.9%). Clinical and angiographic follow-up was performed 13-49 months (median 29) after the procedure for 49 (80.3%) patients with stent-assisted coiling, with complete aneurysm occlusion in 27 (55.1%) aneurysms, residual neck in 3 (6.1%), residual aneurysm in 5 (10.2%), and recurrence in 14 (28.6%). Follow-up was performed for 14-37 (median 25) months in 45 (84.9%) patients with flow diversion treatment, with complete occlusion in 39 (86.7%) patients, residual neck in 5 (11.1%), residual aneurysm in 1 (2.2%), and no aneurysm recurrence. Stent-assisted coiling comes with more complications but fewer permanent aneurysm occlusions than flow diverters, and flow diverters are superior to stent-assisted coiling in the treatment of wide-necked intracranial aneurysms, especially in the long-term effect.

Stent-alone treatment of unruptured vertebral artery fusiform aneurysms: A comparison of flow diverter and conventional stents.

Treatment of vertebral artery fusiform aneurysms (VAFAs) is complex and controversial. This study aimed to compare the safety and efficacy between flow diverter and conventional stents in patients with VAFAs undergoing endovascular stent-alone treatment (SAT). Thirty-six patients with 36 VAFAs who underwent SAT between January 2014 and December 2018 were retrospectively analyzed. Patient and aneurysm characteristics, procedural details, complications, and angiographic and clinical outcomes were compared between flow diverter stent patients (n = 22) and conventional stent patients (n = 14). More branches covered with stent were found in the conventional stent group (88.9 vs. 33.3%; p = 0.008). The number of stents placed was significantly higher in the conventional stent group (1.57 ± 0.76 vs. 1.09 ± 0.29; p = 0.016). The proportion of patients with significant or moderate stasis within the aneurysm immediately after stent placement was higher in the flow diverter stent group (95.5 vs. 57.1%; p = 0.004). The proportion of patients with complete obliteration or only a residual neck on follow-up angiography was significantly higher in the flow diverter stent group (86.3 vs 50.0%; p = 0.047). However, the incidence of parent artery stenosis or occlusion was also higher in the flow diverter stent group (27.3% vs. zero; p = 0.032). The rate of complications did not significantly differ between the groups. SAT was safe and effective in patients with VAFAs. Flow diverter stents are associated with a significantly better complete occlusion rate than conventional stents; however, they are also associated with an increased risk of parent artery stenosis.

Comparative effectiveness of stent-assisted coiling and Woven EndoBridge embolization for the treatment of unruptured wide-neck bifurcation intracranial aneurysms.

Woven EndoBridge (WEB) intrasaccular flow disruptors and stent-assisted coiling (SAC) are viable endovascular treatment options for wide-neck bifurcation intracranial aneurysms (WNBAs). Data directly comparing these two treatment options are limited. The authors aimed to compare radiographic occlusion rates and complication profiles between patients who received WEB and those who received SAC for WNBAs. Retrospective review of a prospectively maintained cerebrovascular procedural database was performed at a single academic medical center between 2017 and 2021. Patients were included if they underwent WEB embolization or SAC of an unruptured WNBA. SAC patients were propensity matched to WEB-embolized patients on the basis of aneurysm morphology. Complete and adequate (complete occlusion or residual neck remnant) occlusion rates at last angiographic follow-up, as well as periprocedural complications, were compared between the two groups. A cost comparison was performed for a typical 5-mm WNBA treated with WEB versus SAC by using manufacturer-suggested retail prices. Thirty-five WEB and 70 SAC patients were included. Aneurysm width, neck size, and dome-to-neck ratio were comparable between groups. Follow-up duration was significantly longer in the SAC group (median [interquartile range] 545 [202-834] days vs 228 [177-494] days, p < 0.001, Mann-Whitney U-test). Complete (66% of WEB patients vs 69% of SAC patients) and adequate (94% WEB vs 91% SAC) occlusion rates were similar between groups at the last available angiographic follow-up (p = 0.744, chi-square test). Complete occlusion rates were comparable on Cox regression analysis after correction for follow-up duration (hazard ratio 1.5, 95% CI 0.8-3.1). Average time to residual aneurysm or neck formation was not statistically different between treatment groups (613 days for SAC patients vs 347 days for WEB patients, p = 0.225, log-rank test). Periprocedural complications trended higher in the SAC group (0% WEB vs 9% SAC, p = 0.175, Fisher exact test), although this finding was not significant. The equipment costs for a typical SAC case were estimated at $18,950, whereas the costs for a typical WEB device case were estimated at $18,630. Midterm complete and adequate occlusion rates were similar between patients treated with WEB and those treated with SAC. Given these comparable outcomes, there may be equipoise in treatment options for WNBAs.

Intraoperative blood flow monitor for aneurysm clipping

Background: Both indocyanine green videoangiography (ICG-VA) and flowmetry were considered beneficial in preventing parent artery compromise during aneurysm surgery. However, the appropriate strategy that should be used remains controversial. The objective of the study is to assess the outcomes of aneurysm clipping through flowmetry or ICG-VA monitoring. Materials and Methods: This retrospective cohort study included 75 patients who underwent aneurysm clipping with vascular patency monitoring. In total, 42 patients underwent flowmetry monitoring and 33 ICG-VA monitoring. Preoperative disease severity and functional outcomes were assessed using the World Federation of Neurosurgical Societies (WFNS) grading system and the modified Rankin scale, respectively. Results: As compared with ICG-VA, flowmetry group had nonsignificant higher incidence of clip modification (31.7% vs. 18.2%, P = 0.29) and residual neck (22% vs. 10%, P = 0.218). Besides Fisher grade, flowmetry monitoring (Crude odds ratio [OR] = 0124, P = 0.015), young age, and anterior communicating artery location were the independent risk factors for vasospasm based on multivariate analysis. The incidence of parent artery compromise did not differ between both groups. Old age, poor preoperative WFNS grade, low Glasgow coma scale (GCS) score, left-side location, and long hospital stay were associated with poor functional outcomes in the univariate analysis. However, only the GCS score was considered a prognostic factor in the multivariate analysis (Adjusted OR = 0.03, P = 0.034). Conclusion: Both monitoring methods have similar functional outcomes. Although not influencing outcome, the flowmetry group has a higher incidence of angiographic vasospasm than the ICG-VA group. The vessel preparation for flowmetry monitoring is more complicated than that for ICG-VA; thus, we recommend ICG-VA for routine monitoring. Flowmetry may be applicable in distal aneurysms when hemodynamic insufficiency in a parent artery is suspected.

LBODP097 Malignant Struma Ovarii: Long Term Successful Treatment. Outcome

Abstract 18 year old African American female saw her GYN in 9/2008 for abdominal pain. CT: bilateral adnexal masses (10×8 cm left; 6.3×3.1 cm right). Surgical pathology reported a left benign cystic teratoma and right corpus luteum cyst. Pain recurred in 2010. MRI showed: 9×7.5×4 cm right adnexal mass. Repeat surgery was done. Pathology: benign cystic teratoma with focal thyroid tissue - "Struma Ovarii". Abdominal pain recurred yet again in 2012. Sonography revealed a mixed solid/cystic pelvic mass measuring 10.6×7.9×7.6 cm. Exploratory laparotomy 9/2012 revealed a right adnexal mass and widespread peritoneal nodules. Pathology reported follicular tissue with colloid in the nodules - "Peritoneal Strumatosis" suggesting benignity. Upon further review was reclassified as metastatic well differentiated follicular thyroid cancer of ovarian origin with follicular thyroid tissue identified in peritoneal lymph nodes, spleen, bladder and rectal wall. The patient was then referred to endocrinology at our facility. On exam she was clinically euthyroid without thyromegaly or nodularity. Thyroid hormone levels were normal. Antithyroid antibodies were absent. Serum Thyroglobulin (Tg): elevated (229; normal 2-35 ng/ml) as was CA125 (64; normal &amp;lt;21 U/ml). Immunohistochemistry: positive for Tg and Thyroid transcription factor-1. Molecular markers: no mutations in BRAF, RAS, or TP53. In preparation for radioactive iodine (RAI) therapy, total thyroidectomy was performed 4/13/2013 and reported as normal thyroid tissue. Dosimetry findings: very iodine avid tissue with prolonged retention (33% at 6 days). Maximum tolerated dose: 200 mCi. A 62.8 mCi RAI was administered 7/13/2013. Post RAI whole body scan (WBS): numerous focal areas of increased uptake in abdomen and pelvis consistent with metastatic disease. Treatment with L-thyroxine was given to suppress TSH. Follow up WBS 12/26/2013 showed persistent increased uptake in abdomen and pelvis. Serum Tg was high (198. 0). A second RAI dose of 104.8 mCi was given. Post RAI WBS confirmed multiple areas of metastatic disease in abdomen and pelvis. Subsequent serum Tg levels down trended. WBS 11/12/2014: only two residual abnormal foci in the lower neck and one inferior to the liver without abdominal or pelvic foci. Given the dosimetry issue and the reassuring serum Tg levels, surveillance was continued. WBS 9/25/2015: unchanged. Now age 27, WBS 1/26/2022: only residual faint lower neck uptake, resolution of the focus inferior to the liver and no distant foci. Stimulated Tg was normal at 2.2 ng/ml with stimulated TSH &amp;gt;110. 0 uIU/ml. Presentation: No date and time listed

ODP446 Where's the Nodule?: Atypical Presentation of an Occult Metastatic Papillary Thryoid Carcinoma

Abstract Papillary thyroid Carcinoma (PTC) with apparent distant metastasis but lacking a primary thyroid cancer on pre-operative ultrasonographic examination, is referred by some as occult PTC. In most cases, primary carcinomas are identified after careful pathologic examination of the specimen but in some rare cases the primary tumors were not detected. Hereby, we describe the rare case of a patient with metastatic PTC without initial visualization on imaging of primary tumor location along with inconsistent pathology results between fine needle aspiration (FNA) biopsy and gross specimen pathology results. A 60-year-old female with past medical history of Diabetes Mellitus type 2 and Hypothyroidism presenting for follow-up visit after being found with neck nodules on head and neck CT scan. Thyroid and neck Ultrasound (US) were performed finding three right irregularly shaped hypoechoic lymph nodes (LN's) measuring &amp;gt; 1 cm, concerning for metastatic disease, but no thyroid nodules were noted. Patient denies family history of thyroid cancer, and no head and neck radiation exposure. Physical examination did not reveal goiter or palpable nodules. Laboratory results: TSH: 2.95 and Total T4: 9.32, both within normal range. Cervical LN's FNA biopsy was performed, yielding results consistent with PTC tall cell variant. Chest CT scan showed suspicious lesions for pulmonary micrometastasis. Total thyroidectomy was performed and gross pathology findings showed an infiltrating, follicular variant PTC with multifocal tiny primary tumors of the thyroid, with lesions measuring up to 0.2 cm, dimension which explains why nodules could not be identified on imaging studies. LN's FNA biopsy results and thyroid pathology did not correlate. Thyroid gross pathology was clearly PTC with follicular variant, infiltrating a small area away from greatest dimension tumor, with cells with apparent dedifferentiation to tall cell cytologic features. Due to high risk of recurrence, radioactive iodine therapy was recommended as adjunctive therapy for metastatic disease and eradication of residual neck disease to be started with levels of TSH&amp;gt;30 mU/ml. Postopertative Thyroglobulin level (Tg) was adequate &amp;lt; 0. 01 ng/ml but unreliable based on above normal range antithyroglobulin antibody &amp;gt; 1000 IU/ml, which increases risk of recurrence. Whole body scan also done showing bilateral lung metastasis and small neck metastatic disease. Repeated postoperative thyroid US also demonstrated a suspicious cystic lymph node in right central neck for which FNA with saline washout of aspirate for Tg measurement was ordered. Metastatic thyroid carcinoma without primary tumor after extensive thyroid sampling is a rare but existent phenomenon that can be encountered in daily practice. Genotyping or immunostaining mestastatic lesions could help direct the Pathologist to the source of the metastasis. Patients with a higher risk of recurrence are monitored more aggressively as it is believed that early detection of recurrent disease offers the best opportunity for effective treatment. Presentation: No date and time listed

Preliminary Experience of the Surpass Streamline Flow Diverter for Large and Giant Unruptured Internal Carotid Artery Aneurysms.

As of January 2021, the Surpass Streamline (SS) is the most recently approved flow diverter in Japan. A total of 28 Japanese patients, including 9 clinical trial patients, with 28 large or giant unruptured internal carotid artery (ICA) aneurysms, underwent SS embolization at Juntendo University Hospital. Procedural failure occurred in two patients due to the difficulty to navigate the device in the tortuous parent artery. Therefore, 26 patients with 26 aneurysms were available for clinical and anatomical assessments. Patients' mean age was 62.6 years (range 46-86), and 24 patients (92.3%) were female. Mean aneurysm size and neck width were 15.4 mm and 7.7 mm, respectively, with 20 saccular and 6 fusiform aneurysms. Seven aneurysms were symptomatic due to the aneurysmal mass effect. Twenty patients underwent a 6-month follow-up angiography to evaluate the degree of occlusion. Anatomical outcomes were 12 (60%) complete occlusion (CO), 4 (20%) residual neck (RN), and 4 (20%) residual aneurysm. Favorable aneurysm occlusion consisted of CO, and RN was achieved in 16 (80.0%). There were no significant device stenoses. Aneurysmal mass effect improved in one and was unchanged in eight patients. There were three device-related complications, namely, delayed aneurysm rupture, minor ischemic stroke, and device occlusion (11.5%). One patient with minor ischemic stroke fully recovered before 30 days, and our series showed 7.7% risk of major ipsilateral stroke and neurological death at 30 days. The SS embolization for large and giant unruptured ICA aneurysms offers satisfactory anatomical and clinical outcomes with a low risk of device-related complications.