Parent Artery Stenosis Research Articles

Treatment of Acute Iatrogenic Cerebrovascular Injury Using Flow Diverter Stents

BACKGROUND AND OBJECTIVES: Iatrogenic cerebrovascular injury can cause intracranial hemorrhage and pseudoaneurysm formation, putting patients at high risk for postoperative bleeding. No consensus for management exists. This study describes endovascular treatment of these acute injuries with flow diverter stents. METHODS: Electronic medical records were retrospectively reviewed for injury type and etiology, timing of diagnosis, and endovascular management, including antiplatelet regimens, embolization results, and clinical outcome. RESULTS: Six patients were included. Three suffered an injury to the internal carotid artery, 1 suffered an injury to the left anterior cerebral artery, 1 suffered an injury to the right posterior cerebral artery, and 1 suffered an injury to the basilar artery. Four of the 6 injuries occurred during attempted tumor resection, 1 occurred during cerebrospinal fluid leak repair, and 1 occurred during an ophthalmic artery aneurysm clipping. All injuries resulted in pseudoaneurysm formation. Four were immediately detected on angiography; 2 were initially negative on imaging. Five were treated with a pipeline embolization device, and 1 was treated with a Silk Vista Baby. Two were treated with 2 pipeline embolization devices telescopically overlapped across the pseudoaneurysm. All devices deployed successfully. No pseudoaneurysm recurrence or rebleeding occurred. No parent artery occlusion or stenosis was observed, and complete pseudoaneurysm occlusion was observed in 4 patients (in 2 patients, follow-up imaging could not be obtained). CONCLUSION: With proper antiplatelet regimens, flow diverter stents can be used safely to successfully treat complex acute iatrogenic injuries. Early repeat angiogram is needed when immediate postinjury imaging does not discover the point of vessel injury.

Covered Stent Treatment for Direct Carotid-Cavernous Fistulas: A Meta-Analysis of Efficacy and Safety Outcomes

BackgroundDirect carotid-cavernous fistulas (dCCFs) involve the abnormal shunting of blood between the internal carotid artery and the cavernous sinus. The use of covered stents (CSs) has been reported for the treatment of complex carotid artery lesions. However, the efficacy and safety of CS treatment for dCCFs remain controversial. Thus, we performed a systematic review and meta-analysis to evaluate these efficacy and safety endpoints. MethodsA systematic literature review was performed by comprehensively searching the Medline, Embase, and Web of Science databases to identify studies that were related to CS treatment for dCCFs. Then, a meta-analysis was conducted to pool the efficacy and safety outcomes from these studies based on perioperative and follow-up data. ResultsFourteen non-comparative studies enrolling 156 patients with 160 dCCFs met the inclusion criteria. When analyzing perioperative outcomes, the technical success rate was 98.5% [95% confidence interval (CI), 0.948, 1.000], and the immediate complete occlusion rate was 90.9% (95% CI, 0.862, 0.959). Vasospasm and dissection occurred in 32.2% (95% CI, 0.238, 0.463) and 0.1% (95% CI, 0.000, 0.012) of patients, respectively. The in-stent acute thrombus formation rate was 0.1% (95% CI, 0.000; 0.013). Postoperatively, the mortality rate was 0.1% (95% CI, 0.000, 0.013). Based on available follow-up data, the final complete occlusion and parent artery stenosis rates were 99.3% (95% CI, 0.959, 1.000) and 18.6% (95% CI, 0.125, 0.277), respectively. ConclusionsCS placement can be used to safely and effectively treat dCCFs. These results provide a reference for future clinical trials.

Willis covered stent treatment for internal carotid artery pseudoaneurysm: A meta-analysis of efficacy and safety

BackgroundPseudoaneurysm (PSA) of internal carotid artery is a rare but severe cerebrovascular disease and difficult to repair surgically. A novel medical device called Willis covered stent (WCS) has been created especially for the treatment of complex cerebrovascular diseases. However, the efficacy and safety of WCS therapy for PSA are still debatable. Additional substantial proof is needed. MethodsTo find research pertaining to WCS treatment for PSA, a systematic review of literature was conducted in the Medline, Embase, Web of Science, CNKI, Wanfang, and CBM databases. The results comprising the data of intraoperative situation, postoperative situation, and follow-up were then included in a meta-analysis. ResultsThe criteria were met by 11 noncomparative studies with 152 patients and 157 PSAs. Technical success rate was nearly 100 % (>0.999 (95 % confidence interval (CI), 0.958, 1.000)), complete occlusion rate was 97.8 % (95 % CI, 0.932, 1.000), and side branch occlusion rate was 0.5 % (95 % CI, 0.001, 0.045). The rates of acute in-stent thrombosis (<0.001 (95 % CI, 0.000, 0.013)) and hemorrhage (<0.001 (95 % CI, 0.000, 0.005)) were both less than 0.1 %. In postoperative situation, surgery-related mortality rate was less than 0.1 % (<0.001 (95 % CI, 0.000, 0.005)). The rates of recurrence (<0.001 (95 % CI, 0.000, 0.002)) and parent artery stenosis (<0.001 (95 % CI, 0.000, 0.008)) were both less than 0.1 %, while late in-stent stenosis occurred in 1.3 % (95 % CI, 0.000, 0.053) of patients. In the end, 98.5 % (95 % CI, 0.943, 1.000) of patients had a good outcome. ConclusionThe application of WCS could be effective and safe for PSAs. The findings of this study could serve as a reference for upcoming clinical trials.

Enhanced vessel wall magnetic resonance imaging in the follow-up of intracranial aneurysms treated with flow diversion.

This study aimed to compare the efficacy of enhanced 3D T1-weighted black-blood fast-spin-echo vessel wall magnetic resonance imaging (eVW-MRI) and time-of-flight magnetic resonance angiography (TOF MRA) for follow-up evaluation of aneurysms treated with flow diversion (FD). Our study enrolled 77 patients harboring 84 aneurysms treated with FD. Follow-up was by MRI (eVW-MRI and TOF MRA) and digital subtraction angiography (DSA). Two radiologists, blinded to DSA examination results, independently evaluated the images of aneurysm occlusion and parent artery patency using the Kamran-Byrne Scale. Interobserver diagnostic agreement and intermodality diagnostic agreement were acquired. Pretreatment and follow-up aneurysm wall enhancement (AWE) patterns were collected. Based on the Kamran-Byrne Scale, the intermodality agreement between eVW-MRI and DSA was better than TOF MRA versus DSA for aneurysm remnant detection (weighted ĸ = 0.891 v. 0.553) and parent artery patency (ĸ = 0.950 v. 0.221). Even with the coil artifact, the consistency of eVW-MRI with DSA for aneurysm remnant detection was better than that of TOF MRA (weighted ĸ = 0.891 v. 0.511). The artifact of adjunctive coils might be more likely to affect the accuracy in evaluating parent artery patency with TOF MRA than with eVW-MRI (ĸ = 0.077 v. 0.788). The follow-up AWE patterns were not significantly associated with pretreatment AWE patterns and aneurysm occlusion. The eVW-MRI outperforms TOF MRA as a reliable noninvasive and nonionizing radioactive imaging method for evaluating aneurysm remnants and parent artery patency after FD. The significance of enhancement patterns on eVW-MRI sequences needs more exploration. The application of enhanced vessel wall magnetic resonance imaging has proven to be a promising tool to depict aneurysm remnant and parent artery stenosis in order to tailor the antiplatelet therapy strategy in patients after flow diversion. • Enhanced vessel wall magnetic resonance imaging has an emerging role in depicting aneurysm remnant and parent artery patency after flow diversion. • With or without the artifact from adjunctive coils, enhanced vessel wall magnetic resonance imaging was better than TOF MRA in detecting aneurysm residual and parent artery stenosis by using DSA imaging as the standard. • Enhanced vessel wall magnetic resonance imaging holds potential to be used as an alternative to DSA for routine aneurysm follow-up after flow diversion.

563 Post-Approval Three Year Outcomes Study of the Neuroform Atlas Stent for Treatment of Wide-Neck Intracranial Aneurysms

INTRODUCTION: Favorable safety and effectiveness outcomes were presented previously for the Neuroform Atlas Stent following the completion of its pre-market study (ATLAS trial [Safety and Effectiveness of the Treatment of Wide Neck, Saccular, Intracranial Aneurysms with the Neuroform Atlas Stent System]) in anterior and posterior cohorts. METHODS: The ATLAS post-approval study was a multicenter, prospective, single-arm, open-label study of wide neck (neck ≥ 4mm or dome-to-neck ratio &lt;2) intracranial aneurysms in the anterior and posterior circulations treated with the Neuroform Atlas Stent and approved coils. The primary effectiveness endpoint was complete occlusion (Raymond-Roy class 1) on angiography in the absence of retreatment or significant parent artery stenosis (&gt;50%) through 3 years post-procedure. The primary safety endpoint was occurrence of major stroke, ipsilateral stroke, or neurological death through 3 years post-procedure. Independent adjudication of primary endpoint outcomes was completed by an Imaging Core Laboratory and Clinical Events Committee. RESULTS: A total of 146 anterior and 101 posterior cohort subjects from the pre-market study population were enrolled for continued follow-up. Subject demographics and aneurysm anatomy were representative of pivotal trial findings. For anterior subjects, the mean aneurysm size was 6.1±2.4 mm and the mean dome-to-neck ratio was 1.2±0.3 mm. In posterior subjects, the mean aneurysm size was 7±2.7 mm and the mean dome-to-neck ratio was 1.2±0.4 mm. At 3-year follow-up, the percent of target aneurysm progressive occlusion rated the same or better was 84.4% (95% CI, 67.2% - 94.7%) of anterior subjects and 90.0% (95% CI, 73.5% - 97.9%) of posterior subjects. A primary safety event was reported in 0.7% (1/146) of anterior and 1.0% (1/101) of posterior subjects, respectively, with no neurological deaths. CONCLUSIONS: The results of the ATLAS post-approval study demonstrate durable treatment effectiveness and favorable safety outcomes.

Culprit Plaques of Large Parent Arteries, Rather than Cerebral Small Vessel Disease, Contribute to Early Neurological Deterioration in Stroke Patients with Intracranial Branch Atheromatous Disease

Introduction: Intracranial branch atheromatous disease (BAD) has been applied to occlusions that occur at the origin of large caliber penetrating arteries due to the microatheromas or large parent artery plaques. This study aimed to explore the association between culprit plaques of large parent arteries, neuroimaging markers of cerebral small vessel disease (CSVD), and the risk of early neurological deterioration (END) in stroke patients with BAD. Methods: A total of 97 stroke patients with BAD in the vascular territories of the lenticulostriate arteries or paramedian pontine arteries, diagnosed using high-resolution magnetic resonance imaging, were prospectively recruited in this observational study. A culprit plaque in the middle cerebral artery was defined as the only arterial plaque on the ipsilateral side of an infarction visible on diffusion-weighted imaging. A culprit plaque in the basilar artery (BA) was identified when it was observed within the same axial slices of an infarction or on the adjacent upper or lower slice, whereas a plaque within the BA located in the ventral region was considered non-culprit. If more than one plaque was present in the same vascular territory, the most stenotic plaque was chosen for the analysis. Four CSVD neuroimaging markers, including white matter hyperintensity, lacunes, microbleeds, and enlarged perivascular spaces, were evaluated in accordance with the total CSVD score. The associations between neuroimaging features of lesions within large parent arteries, neuroimaging markers of CSVD, and the risk of END in stroke patients with BAD were investigated using logistic regression analysis. Results: END occurred in 41 stroke patients (42.27%) with BAD. The degree of large parent artery stenosis (p < 0.001), culprit plaques of large parent arteries (p < 0.001), and plaque burden (p < 0.001) were significantly different between the END and non-END groups in stroke patients with BAD. In logistic regression analysis, culprit plaques of large parent arteries (odds ratio, 32.258; 95% confidence interval, 4.140–251.346) were independently associated with the risk of END in stroke patients with BAD. Conclusions: Culprit plaques of large parent arteries could predict the risk of END in stroke patients with BAD. These results suggest that lesions in the large parent arteries, rather than damage to the cerebral small vessels, contribute to END in stroke patients with BAD.

Abstract Number ‐ 138: Complex symptomatic dissecting pseudoaneurysm with inflow zone stenosis required angioplasty before flow‐diversion‐a technical report.

Introduction 16.4 percent of patients diagnosed with fibromuscular dysplasia (FMD) are found to have internal carotid artery (ICA) dissection [1] which may lead to life threatening ICA dissecting pseudoaneurysm (ICADPA). Endovascular repair of ICADPA may be urgent when ICADPA is symptomatic, potential for rupture with no good alternatives. Tortuous anatomy with FMD and ICADS can represent a significant endovascular challenge, especially if there is an aneurysmal inflow‐zone stenosis.Objective: We present a unique case of right ICADPA with an inflow‐zone parent artery stenosis underwent angioplasty and repair with surpass evolve flow diverter (SEFD). Methods Case report and chart review. Results 49‐year‐old man history of hypertension, hyperlipidemia, and left ICADPA status post stenting/stent‐assisted coiling in 2017, who presented with right‐sided pulsatile tinnitus after a facial injury. Cerebral angiography revealed a tortuous right ICA with FMD, and presence of a right ICADPA at the skull base measuring 16×8 mm with inflow zone stenosis and a post‐stenotic dilatation. An emergency repair was performed with an informed consent under general anesthesia. In order for the SEFD to deploy properly, an angioplasty of inflow‐zone parent artery stenosis was performed with a 3×20mm Maverick balloon. Subsequently, a SEFD measuring 5×40 mm was deployed to cover the dissecting pseudoaneurysm, and a second SEFD measuring 5×20 mm was deployed covering the ICADS resulting in good apposition of SEFD and securement of ICADS.Use of a metal self‐deployable stent prior to flow diversion was not an option due to the presence of extreme tortuosity and acute angulations on the parent artery.patient was discharged home after 24 hours with 325 mg of aspirin and 75 mg of clopidogrel and good blood pressure control. 90‐days follow‐up, demonstrated good recovery with modified Rankin score of 0 with no symptoms. Conclusions ICADPA with aneurysmal inflow zone parent artery stenosis and the presence of extream tortuosity and acute angulations, may require angioplasty prior to the flow diversion for successful repair. Further studies are required.

Abstract Number ‐ 128: Predictors of the effects of flow diversion in very large and giant aneurysms

Introduction The treatment paradigm for very large and giant aneurysms recently changed to flow diversion, in light of the results of the Pipeline for Uncoilable or Failed Aneurysms trial. However, the effects of flow diversion was definitely unknown. We explored this topic and identified predictors of such effects. Methods We retrospectively reviewed 51 patients with unruptured aneurysms admitted to our institution for flow diversion between February 2014 and August 2019. Patients were categorized into an effect group (no filling or remnant entry) and a no‐effect group (subtotal or total filling). We evaluated aneurysm size and shape, incorporation vessel, parent artery stenosis and curvature, stagnation of contrast medium within the aneurysm, use or not of balloon angioplasty, and intra‐aneurysm thrombus, as potential predictors of the effects of flow diversion. Results The effect group comprised 34 patients (66.7%, 34/51; no filling [35.3%, 18/51] and remnant entry [31.4% 16/51]). The no‐effect group comprised 17 patients (33.3%, 17/51; subtotal filling [29.4%, 15/51] and total filling [3.9% 2/51]). The presence of an incorporation vessel (odds ratio 0.13, p = 0.021) and balloon angioplasty (odds ratio 0.05, p = 0.004) were independent risk factors for poor flow diversion (no‐effect group) in multivariate logistic regression analyses. Conclusions Flow diversion is effective for very large and giant aneurysms but the outcomes require further improvement. The results of this study show that an incorporated vessel and excessive balloon angioplasty might compromise flow diversion. Considering this finding can help improve the outcomes of flow diversion.

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.

Pipeline Flex with Shield Technology Placement for Small- and Medium-sized Aneurysms Achieves Early Complete Occlusion.

The flow diverter has been shown to be a safe and effective device for large cerebral aneurysms in the proximal internal carotid artery (ICA). Recently, its indication has been expanded to small- and medium-sized cerebral aneurysms in the distal segment of the ICA. In this study, we report a single-center, retrospective investigation of the safety and efficacy of the Pipeline Flex device to treat these aneurysms. Of the patients who underwent Pipeline implantation for small- and medium-sized ICA aneurysms (≤12 mm) at our hospital between July 2013 and October 2021, 102 patients with 104 aneurysms were included in this study. The mean age of the patients was 57.7 ± 12.1 years, and 94 (90.4%) were female. The mean aneurysmal dome diameter was 9.2 ± 2.3 mm, the mean neck diameter was 5.3 ± 1.6 mm, and the mean dome-to-neck ratio was 1.8 ± 0.5. Twenty-five patients (24.0%) had incorporated vessels from the aneurysm. Complete occlusion of the aneurysms was obtained in 96 patients (92.3%). There were no cases of parent artery stenosis or major stroke after the procedure. Absence of incorporated vessel from the aneurysm dome and adjunctive coil embolization are statistically significant factors indicating complete occlusion in multivariate analysis. The time to complete occlusion was determined earlier with the use of the Pipeline Shield (p = 0.0386) and with adjunctive coils (p = 0.0025). We showed that Pipeline implantation for small- and medium-sized aneurysms was safe and highly effective.

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.

A multicenter retrospective controlled study of the Pipeline™ and Tubridge™ Flow Diverter devices for intracranial wide-necked aneurysms.

PurposeTo compare the safety and efficacy of PipelineTM and TubridgeTM Flow Diverter devices (FDs) in the treatment of intracranial wide-necked aneurysms.MethodsWe retrospectively analyzed the clinical data of 92 patients with intracranial wide-necked aneurysms who were treated with those two flow-diverter devices (FDs) at four participating centers between July 2012 and December 2020.ResultsThis study included 92 patients who underwent endovascular therapy using either Pipeline™ (n = 39) or TubridgeTM (n = 53) for treating intracranial wide-necked aneurysms. The periprocedural complication developed in 2.56% (1/39) patients of Pipeline group and 3.77% (2/53) patients of the TubridgeTM group. During perioperative period, one patient in Pipeline™ group showed subarachnoid hemorrhage (2.56%, 1/39) and two ischemic complications in the Tubridge™ group (3.77%, 2/53). Follow-up assessments were conducted on 31 patients (79.49%) in the Pipeline™ group (the mean follow-up period was 9.7 ± 3.3 months). The rate of complete aneurysm occlusion at the final angiographic follow-up was 77.42%. Patients with a modified Rankin scale (mRS) score of 0.44 ± 0.31. Follow-up assessments were conducted on 42 patients (79.25%) in the TubridgeTM group (the mean follow-up period was 9.1 ± 4.4 months). The rate of complete aneurysm occlusion at the final angiographic follow-up was 85.71%. Patients with mRS score of 0.52 ± 0.28. Three patients showed parent artery stenosis, and one showed parent artery occlusion.ConclusionBoth the PipelineTM and TubridgeTM are safe and effective for the treatment of intracranial wide-necked aneurysms, with no significant difference in the rate of complete aneurysm occlusion and perioperative complications between the two FDs.

Treatment of giant intracranial aneurysms using the Pipeline flow-diverting stent: Long-term results from the International Retrospective Study of the Pipeline Embolization Device (IntrePED) study.

Traditional endovascular treatments of giant intracranial aneurysms are associated with high rates of complications and retreatment. Our objective was to examine the safety and long-term efficacy of the Pipeline Embolization Device for treatment of these aneurysms. This retrospective study using the IntrePED database included all patients with giant intracranial aneurysms treated with the Pipeline device between July 2008 and February 2013. Efficacy outcomes were stratified by using the Raymond-Roy Occlusion Classification. Predefined safety outcomes included spontaneous rupture of the target aneurysm; ipsilateral intracranial hemorrhage; ischemic stroke; parent artery stenosis; and sustained cranial neuropathy. Sixty-six embolizations were performed to treat 63 giant intracranial aneurysms (including 2 ruptured): 49 (77.8%) in the anterior and 14 (22.2%) in the posterior circulation. The median follow-up was 22.4 (0.1-60.5) months. Class I angiographic occlusion was achieved in 72.0% (36/50). The neurological morbidity/mortality rate was 23.8% (15/63), with higher rates in the posterior circulation than in the anterior circulation (22.4% vs. 28.6%). Among seven deaths, five had neurological causes. The procedure-related neurological morbidity and mortality rates were 22.7% (15/66) and 7.6% (5/66), respectively. The spontaneous rupture rate was 4.5% (3/66). Two spontaneous ruptures (1 death), 4/4 postprocedural intracranial hemorrhages, and 6/9 ischemic events occurred within 30 days. In-stent stenosis and new-onset cranial neuropathy were not observed during the angiographic follow-up period. Although procedure-related neurological morbidity/mortality rates were not insignificant, this study confirms the feasibility and long-term efficacy of the Pipeline Embolization Device to treat giant intracranial aneurysms.

Y‐Stent–Assisted Coiling of Wide‐Necked Intracranial Aneurysms With the Neuroform Atlas Stent System

Background Endovascular management of wide‐necked bifurcation aneurysms poses a therapeutic challenge, as coiling often requires the use of multiple adjunctive stent constructs to achieve successful embolization without compromising parent vessel integrity. The Neuroform Atlas Stent System is a novel low‐profile, intraluminal remodeling device. The study aims to investigate the safety and efficacy of Y‐stent–assisted coiling configuration constructs using the next generation stent for aneurysm coil embolization. Methods Subjects undergoing Y‐stent–assisted coiling in the ATLAS IDE (Safety and Effectiveness of the Treatment of Wide Neck, Saccular Intracranial Aneurysms with the Neuroform Atlas Stent System Investigational Device Exception) trial were identified for subgroup analysis. Enrollment in the trial was not stratified on the basis of the procedural stenting technique used. The primary efficacy end point was complete aneurysm occlusion (Raymond–Roy class 1) on 12‐month angiography, in the absence of re‐treatment or parent artery stenosis (&gt;50%) at the target location. The primary safety end point was any major stroke or ipsilateral stroke or neurological death within 12 months. Adjudication of the primary end points was performed by an independent imaging core laboratory and the clinical events committee. Results A total of 60 subjects were identified. The mean age was 59, and 28.3% were men. The median aneurysm size was 6.7 mm, with a median neck size of 4.3 mm. Frequently reported aneurysm locations included the basilar apex (56.7%), anterior communicating artery (20.0%), and middle cerebral artery bifurcation (11.7%). The composite primary efficacy end point was achieved in 81.1% of subjects. Overall, 1.7% of subjects experienced a primary safety endpoint of major ipsilateral stroke or neurological death. Conclusion In the ATLAS IDE aneurysm cohort premarket approval study, Y‐stent–assisted coiling with Neuroform demonstrated high rates of complete aneurysm occlusion at 12 months, with low rates of morbidity.

Endovascular treatment of intracranial vertebral artery unruptured dissecting aneurysms: Comparison of flow diversion and stent-assisted coiling or stenting alone.

PurposeTo investigate the effect and safety of flow diverters in the treatment of unruptured dissecting intracranial aneurysms of the vertebral artery in comparison with stent-assisted coiling or stenting alone.Materials and methodsPatients with unruptured dissecting intracranial aneurysms of the vertebral artery treated with the flow diverter, stent-assisted coiling, or stenting alone were retrospectively enrolled. The clinical data were analyzed and compared.ResultsTwenty-five patients were enrolled in the flow diversion group and 42 patients in the stenting group. Twenty-six flow diverters were deployed in the flow diversion group. Immediate angiography revealed contrast agent retention within the aneurysm cavity in all patients. In the stenting group, 48 stents were deployed, and immediate angiographic outcome showed O'Kelly-Marotta (OKM) grade D in 18 (42.9%) aneurysms, grade C in 16 (38.1%), and grade B in 8 (19.0%). Periprocedural ischemic complications of thrombosis occurred in two (4.8%) patients and were treated with thrombolysis. In the flow diversion group, 19 (76%) patients underwent angiographic follow-up 3–46 (median 24) months after the procedure, with the OKM grade D in 11 (57.9%) patients, C in two (10.5%), and B in six (31.6%). The aneurysm recurrence rate was zero, and all diverters remained patent. Asymptomatic instent stenosis occurred in two (10.5%) patients. In seven of the ten patients with mild or moderate parent artery stenosis before the procedure who experienced angiographic follow-up, the stenosis was improved in five (71.4%) patients. In the stenting group, angiographic follow-up was carried out in 33 (78.6%) patients 6–58 months (median 34) after the procedure, with OKM grade D in 22 (66.7%) patients, grade C in five (15.2%), grade B in three (9.1%), and aneurysm recurrence (grade B, with increased contrast agent into the aneurysm cavity) in three (9.1%). Five (16.7%) patients experienced asymptomatic instent stenosis, and six of the 12 patients (50%) with parent artery stenosis were improved.ConclusionFlow diverters with or without selective adjunctive coiling for the treatment of unruptured dissecting intracranial aneurysms of the vertebral artery may be safe and effective with good occlusion effects not inferior to those of stent-assisted coiling and stenting alone even though the long-term effect still warrants confirmation.

Application of hybrid surgery in the clipping of large complex paraclinoid aneurysms

Nine patients with large complex paraclinoid aneurysms were treated by hybrid surgery in the Second Affiliated Hospital of Zhejiang University between January 2016 and July 2021. Intraoperative angiography was conducted for real-time evaluation of the aneurysm and its clipping efficacy. A total of 8 aneurysms were clipped under temporary proximal control with balloon occlusion. Suction decompression was simultaneously applied in 2 of these cases. After surgery, 2 patients developed symptomatic cerebral infarction, 3 patients developed transient oculomotor nerve palsy, but no patients had vision deterioration. Postoperative follow-up showed that small neck residue occurred in 1 case, but with the rest of aneurysms were completely occluded without parent artery stenosis. Hybrid surgery was proved to be advantageous in real-time assessment of aneurysm morphology and clipping efficacy. Combination of temporary proximal balloon occlusion and suction decompression technique can help in reducing the difficulty of aneurysm exposure and remodeling, thereby improving the outcome and decreasing the complications.

Effect of Proximal Parent Artery Stenosis on the Outcomes of Posterior Communicating Artery Aneurysms: A Preliminary Study Based on Case-Specific Hemodynamic Analysis

The objective of the study was to evaluate the effect of proximal parent artery stenosis on the hemodynamics of aneurysms in the internal carotid artery-posterior communicating artery (ICA-Pcom). A retrospective study of 74 patients with aneurysms in the ICA-Pcom who underwent treatment at the Department of Neurosurgery of Changhai Hospital was conducted between January and June 2018. Patients with proximal parent artery stenosis were included. Case-specific three-dimensional images were reconstructed, and software-based simulations of different stenosis morphologies were performed, focusing on stenosis severity and the distance from the aneurysm to the stenosis. The wall shear stress (WSS) of the aneurysms and blood flow velocity of the aneurysm neck plane were calculated. We performed simulations to evaluate the outcomes of postballoon angioplasty by considering a virtual operation group. To further assess whether WSS after balloon angioplasty increases the risk of aneurysm rupture, a control group of ruptured ICA-Pcom aneurysms without parent artery stenosis was matched with the virtual operation group based on sex, age, history of hypertension, and aneurysm size. Thereafter, the normalized WSS of the 2 groups was calculated. Eight patients with parent artery stenosis were included (2 men and 6 women; average age: 64±15years). The patients were divided into eccentric and concentric stenosis groups according to the stenotic morphologies, with 4 patients in each group. In both groups, the average WSS of the aneurysm and average blood flow velocity at the neck plane increased with the severity of parent artery stenosis, whereas the WSS did not correlate with distance. In the concentric stenosis group, the average blood flow velocity generally decreased as the distance between stenosis and aneurysm increased; however, no such trend was observed in the eccentric stenosis group. The normalized WSS of aneurysms after virtual balloon angioplasty was higher than that of the ruptured aneurysms (0.599 [0.548, 0.800] vs. 0.367 [0.324, 0.407]; P=0.007). Intensified severity of proximal stenosis increases the blood flow velocity and aneurysmal WSS, which may lead to the progression of ICA-Pcom aneurysms. Treatment of the stenosis can reduce the WSS of aneurysms; however, its effect on the prognosis of ICA-Pcom aneurysms requires more concrete evidence.

Willis covered stent for paraclinoid aneurysms:efficacy and mid-long-term follow-up results

The clinical data and follow-up results of 27 paraspinoid aneurysms treated by Willis covered stent (WCS) in Department of Neurosurgery, Army Medical University from May 2014 to January 2021 were retrospectively analyzed. Among them, 17 cases (63.0%) were treated with WCS alone, and 10 cases (37.0%) were assisted with coiling embolization. During the follow-up, postoperative internal leakage occurred in 2 patients(7%), of which 1(type Ⅰ) wasself-healing and the other 1 (type Ⅲ) was cured by WCS implantation again. The remaining patients had no aneurysm recurrence, unobstructed parent artery, stent displacement and internal stenosis. 92.6% (25/27) of the improved mRS scores were good. WCS is a safe and effective method for the treatment of parabedinal aneurysms.

Prognosis and antiplatelet therapy of small single subcortical infarcts in penetrating artery territory: a post hoc analysis of the Third China National Stroke Registry

BackgroundSmall single subcortical infarction (SSSI) may be classified as parent artery disease-related or only branch involved according to the stenosis of parent artery. The study aimed to evaluate short-term and...

Mild Luminal Stenosis of Parent Artery and Neurologic Deterioration After Acute Lacunar Stroke

Background Early neurologic deterioration (END) occurs in a quarter of acute lacunar infarcts, but the underlying pathophysiological features are poorly understood. We sought to determine the association between luminal stenosis (&lt;50%) of the parent artery and END. Methods This observational study included consecutive patients with lacunar stroke from the ischemic stroke registries of New York University Langone Health and Brown University. All included patients were admitted for acute lacunar stroke, which was defined as a subcortical infarct &lt;1.5 cm on computed tomography or &lt;2 cm on diffusion‐weighted imaging without significant stenosis (&gt;50%) in the parent vessel and no cardioembolic source. We defined END as any neurologic deterioration referable to the acute lacunar stroke and not related to a medical or noncerebrovascular neurological complication. We used univariate and logistic regression analyses to determine associations between luminal stenosis (&lt;50%) and the odds of END. Furthermore, we attempted to validate findings using the Columbia University Medical Center stroke registry and perform a meta‐analysis combining the derivation and validation groups because of the expected small samples and event rates. Results The New York University Langone Health and Brown University sample included 205 patients, of whom 41 (20%) had END. In adjusted models, we found no definite association between luminal stenosis (&lt;50%) and END (adjusted odds ratio [OR], 1.74; 95% CI, 0.73–4.14). From Columbia University Medical Center, 361 total patients were included, of whom 59 (16%) had END. In adjusted models, we found an association between luminal stenosis (&lt;50%) and END (adjusted OR, 2.28; 95% CI, 1.15–4.50). Meta‐analysis of both cohorts found luminal stenosis (&lt;50%) associated with END (relative risk, 1.69; 95% CI, 1.17–2.43). Conclusions In this multicenter study, luminal stenosis (&lt;50%) may be associated with END following an acute lacunar infarct. Larger studies using vessel wall imaging are needed to validate our findings.