Stent-assisted treatment of unruptured and ruptured intracranial aneurysms: clinical and angiographic outcome.

BACKGROUND: Wide-necked and non-saccular aneurysms are difficult to treat with coil embolization. The use of stents has expanded the role of endovascular treatment. METHODS: A retrospective study of 43 patients with wide-necked, fusiform or blister aneurysms treated with stent-assisted coiling or stent alone. The review of medical files and images allowed retrieval of the following patient characteristics: (1) age and gender; (2) aneurysm characteristics (site, size, status (ruptured versus unruptured)); (3) coils used; (4) type of stent; (5) complications (procedural and delayed); (6) degree of aneurysm occlusion; (7) length of follow-up; and (8) clinical outcome (modified Rankin scale). RESULTS: Most of the aneurysms treated were located in the anterior circulation (60.4%), while posterior circulation aneurysms represented 39.5%. There are 38 (88%) saccular aneurysms, 1 (2%) fusiform aneurysm and 4 (9%) blister aneurysms. Unruptured aneurysms represented 65%, while ruptured aneurysms represented 35%, 21% of which were treated with a stent in the acute stage. Stent-coiling was performed in 90.7% of cases. Stent alone was performed in 9.3% of cases. The overall radiographic complication rate was 11.6%. Clinically manifest procedure-related complication rate was 4.7%. A complete or near complete (residual neck) embolization was achieved initially in 60.4% of cases. Of the 28 patients with a mean follow-up of 20 months, 57.1% showed a complete occlusion and 25% showed a remnant neck on follow-up. CONCLUSION: Stenting facilitates the treatment of wide-necked, fusiform or blister aneurysms. There is an increased rate of delayed aneurysmal occlusion with subsequent follow-up. A significantly higher rate of occlusion was also observed in the subgroup of aneurysms coiled by a combination of hydrocoils and bare platinum coils versus bare platinum coils only. Stents may also be used in the acute phase of ruptured aneurysms in carefully selected patients.

Artificial intelligence improves transfer times and ischemic stroke workflow metrics.

INTRODUCTION: Rapid initiation of mechanical thrombectomy (MT) for the treatment of large-vessel occlusion (LVO) critically improves patient outcomes. Artificial intelligence algorithms aid in the identification of LVOs and improve door to puncture times as well as patient transfer times. OBJECTIVES: We aimed to determine whether the implementation of an LVO detection algorithm that provides immediate active notification to the thrombectomy team provider's cell phone would improve ischemic stroke workflow at our institution and aid in patient transfer from outlying hospitals when compared to our prior system of passive computed tomography perfusion software analysis and radiologist interpretation and notification. METHODS: A retrospective review of our institutional thrombectomy registry was performed for all patients who underwent MT between January 2020 and March 2022. Demographic, radiographic, and stroke workflow metrics and notification times were collected. Transfer times and stroke metrics were compared pre- and post-implementation of the Viz.ai (Viz.ai, San Francisco, California, USA) smartphone application. RESULTS: Two hundred sixty-two patients underwent MT during the study period. Door-to-puncture time decreased 15 min (p = 0.009) after the implementation of Viz.ai at our Comprehensive Stroke Center. Transfer time from outside hospitals that implemented Viz.ai was reduced by 37 min (p = 0.04). There was no significant change in transfer time over the same time period in outlying hospitals that did not implement the Viz.ai software. CONCLUSION: Active notification of the neurosurgical team significantly reduces patient transfer time and initiation of MT.

Comparison of pipeline embolization device, flow re-direction endoluminal device and surpass flow diverters in the treatment of intracerebral aneurysms.

OBJECTIVES: The use of flow diversion for the treatment of intracranial aneurysms has gained broad acceptance. Three flow-diverting stents are approved by the Food and Drug Administration for use in the United States. We sought to compare the outcomes and safety profiles between the three devices at our institution. METHODS: A retrospective review of aneurysms treated with pipeline embolization device (PED), flow re-direction endoluminal device (FRED), and SURPASS was performed for aneurysms treated between 2018 and 2022 at our institution. RESULTS: The study cohort consisted of 142 patients. Precisely, 86 aneurysms were treated with a pipeline, 33 aneurysms were treated with FRED, and 23 aneurysms were treated with SURPASS. The 1-year complete occlusion rates were 59.4%, 60%, and 65%, respectively (0.91). Linear regression models found that only adjunctive coiling predicted aneurysm occlusion at 6 months (p = 0.02), but this effect was lost at 1 year and beyond. There was no significant difference in acute thrombotic or acute hemorrhagic complications between the three cohorts. There was a higher rate of delayed hemorrhagic complications in the SURPASS cohort (10%) compared to the PED (1.3%) and FRED (0%) cohorts (p = 0.04). There was also a higher rate of in-stent stenosis in the SURPASS cohort (20%) compared to the PED (5%) and FRED (3.1%) cohorts (p < 0.01). CONCLUSIONS: Treatment with PED, FRED, and SURPASS all resulted in similar complete occlusion rates at 6 months and 1 year. SURPASS was associated with higher in-stent stenosis as well as delayed hemorrhagic complications. Additional future studies evaluating the newest generation of flow-diverting stents with long-term follow-up will be necessary to make any definitive conclusions.

Use of intravenous cangrelor in the treatment of ruptured and unruptured cerebral aneurysms: an updated single-center analysis and pooled analysis of current studies.

BACKGROUND: Intracranial stent placement for the treatment of cerebral aneurysms is increasingly utilized in both ruptured and unruptured scenarios. Intravenous (IV) cangrelor is a relatively new antiplatelet agent that was initially approved for coronary interventions. In addition to our institution, five other centers have published their results using IV cangrelor in neurointerventional procedures. This article combines the aneurysm treatment data from all prior studies to provide insight into the safety and efficacy of cangrelor for intracranial aneurysm treatment. METHODS: A prospectively maintained database was reviewed to identify all cases of IV cangrelor administration during aneurysm embolization. 20 additional patients were identified who had not been previously published. In addition, a literature search was performed to identify prior publications regarding cangrelor in neurointervention. The data from these were combined with our institutional results in a pooled-analysis. RESULTS: Overall, 85 patients who received IV cangrelor during aneurysm embolization were identified, including 46 ruptured and 39 unruptured cases. The asymptomatic and symptomatic intracranial hemorrhage rates were 4% (2/46) for ruptured cases and 2.6% (1/39) for unruptured cases. The rate of retroperitoneal hematoma and gastrointestinal bleeding was 0%. There were no incidents of intraprocedural thromboembolic complication or intraprocedural in-stent thrombosis in either cohort. One subject suffered an ischemic stroke at 24 hours secondary to in-stent thrombosis in a ruptured case. CONCLUSIONS: IV cangrelor during aneurysm embolization appears to be safe, with a symptomatic intracranial hemorrhage rate of 4% in ruptured cases and 2.6% in unruptured cases. More research is needed to determine the ideal dosing regimen.

A Transcriptomic Comparative Study of Cranial Vasculature.

In genetic studies of cerebrovascular diseases, the optimal vessels to use as controls remain unclear. Our goal is to compare the transcriptomic profiles among 3 different types of control vessels: superficial temporal artery (STA), middle cerebral arteries (MCA), and arteries from the circle of Willis obtained from autopsies (AU). We examined the transcriptomic profiles of STA, MCA, and AU using RNAseq. We also investigated the effects of using these control groups on the results of the comparisons between aneurysms and the control arteries. Our study showed that when comparing pathological cerebral arteries to control groups, all control groups presented similar responses in the activation of immunological processes, the regulation of intracellular signaling pathways, and extracellular matrix productions, despite their intrinsic biological differences. When compared to STA, AU exhibited upregulation of stress and apoptosis genes, whereas MCA showed upregulation of genes associated with tRNA/rRNA processing. Moreover, our results suggest that the matched case-control study design, which involves control STA samples collected from the same subjects of matched aneurysm samples in our study, can improve the identification of non-inherited disease-associated genes. Given the challenges associated with obtaining fresh intracranial arteries from healthy individuals, our study suggests that using MCA, AU, or paired STA samples as controls are feasible strategies for future large-scale studies investigating cerebral vasculopathies. However, the intrinsic differences of each type of control should be taken into consideration when interpreting the results. With the limitations of each control type, it may be most optimal to use multiple tissues as controls.

Comparison of hydrogel coils versus bare platinum coils for the treatment of anterior communicating artery aneurysms.

INTRODUCTION: While endovascular coiling has been shown to be a safe treatment option for intracranial aneurysms, there remains concern regarding increased recurrence and retreatment rates. Preliminary studies evaluating hydrogel coated coils have demonstrated decreased recurrence rates compared to bare metal coils. METHODS: A retrospective chart review was done on all patients with anterior communicating artery aneurysms (ACoAAs) treated with endovascular coiling between 2014 and 2018. Treatment groups were divided into hydrogel coated coils or bare metal coils. Patients were categorized into the hydrogel group when ≥ 70% of the coil length was hydrogel coated. RESULTS: Eighty-four ACoAAs were treated with coil embolization between 2014 and 2018. Postoperative imaging was available for 68 patients. Twenty-six patients were categorized into the hydrogel treatment group. Aneurysm recurrence was seen in 7.7% (2/26) of patients treated with hydrogel coated coils compared to 33.3% (14/42) of those treated with bare metal coils (P = 0.03). Subanalysis of patients with ruptured aneurysms revealed decreased recurrence rates in patients treated with hydrogel coated coils at 5.9% (1/17) compared to patients treated with bare metal coils at 39.4% (13/33) (P = 0.01). CONCLUSIONS: Hydrogel-coated coils may reduce recurrence rates in the treatment of both ruptured and unruptured ACoAAs.

Does Pre-existing Anticoagulation or Antiplatelet Therapy Increase the Risk of Traumatic Subarachnoid Hemorrhage Progression?

BACKGROUND: Isolated traumatic subarachnoid hemorrhage (tSAH) is a common finding in mild traumatic brain injury that often results in transfer to a tertiary center. Patients prescribed blood-thinning medications (BTs) are believed to be at higher risk of clinical or radiographic worsening. OBJECTIVE: To compare the rates of radiographic progression and need for neurosurgical intervention in patients with tSAH who are on anticoagulation (AC) and antiplatelet (AP) therapies with those who are not. METHODS: Analysis using a retrospective cohort design identified patients older than 18 years with isolated tSAH and a Glasgow Coma Scale of 15 on admission. Clinical information including use of BTs, administration of reversal agents, radiographic progression, and need for neurosurgical intervention was collected. Patients on BTs were divided into AP, AC, and AP/AC groups based on drug type. RESULTS: Three hundred eighty-four patients were included with 203 in the non-BT group and 181 in the BT group. Overall, 2.1% had worsening scans, and none required operative intervention. There was no difference in radiographic worsening between the non-BT and BT groups (2.4% vs 1.6%; P = 1.00). Crosswise comparison revealed no difference between the non-BT group and each BT subtype (AP, AP/AC, or AC). The non-BT group was more likely to have radiographic improvement than the BT group (45.8% vs 30.9%; P = .002). CONCLUSION: Neurologically intact patients on BTs with isolated tSAH are not at increased risk of radiographic progression or neurosurgical intervention. The presence of BTs should not influence management decisions for increased surveillance.

Developing a fast-track discharge protocol for patients with cerebral aneurysms treated via neuroendovascular techniques.

INTRODUCTION: As we emerge from the current pandemic, hospitals, staff, and resources will need to continue to adjust to meet ongoing healthcare demands. Lessons learned during past shortages can be used to optimize peri-procedural protocols to safely improve the utilization of hospital resources. METHODS: Retrospective review of patients who underwent elective endovascular intracranial aneurysm treatment was performed. Multivariable logistic regression was used to identify factors associated with patients who were able to be discharged within 24 h of elective procedures. Rates of complications (particularly readmission) were determined. RESULTS: 330 patients underwent elective endovascular aneurysm treatment with 86 (26.1%) discharged within 24 h. Factors associated with earlier discharge included procedure years (2019-2021) and male sex. Patients were more likely to be discharged later (after 24 h) if they underwent stent-coil embolization or flow-diversion. There was no association between discharge timing and likelihood of readmission. DISCUSSION: Our review highlights the safety of earlier discharge and allowed us to prepare a fast-track protocol for same-day discharge in these patients. This protocol will be studied prospectively in the next phase of this study. As we gain more comfort with emerging, minimally invasive endovascular therapies, we hope to safely achieve same-day discharge on a protocolized and routine basis, reducing the demand of elective aneurysm treatments on our healthcare system. CONCLUSION: We retrospectively demonstrate that early discharge following elective aneurysm treatment is safe in our cohort and provide a fast-track pathway based on these findings for other centers developing similar protocols.

Somatic Variants in SVIL in Cerebral Aneurysms.

Background and Objectives: While somatic mutations have been well-studied in cancer, their roles in other complex traits are much less understood. Our goal is to identify somatic variants that may contribute to the formation of saccular cerebral aneurysms. Methods: We performed whole-exome sequencing on aneurysm tissues and paired peripheral blood. RNA sequencing and the CRISPR/Cas9 system were then used to perform functional validation of our results. Results: Somatic variants involved in supervillin (SVIL) or its regulation were found in 17% of aneurysm tissues. In the presence of a mutation in the SVIL gene, the expression level of SVIL was downregulated in the aneurysm tissue compared with normal control vessels. Downstream signaling pathways that were induced by knockdown of SVIL via the CRISPR/Cas9 system in vascular smooth muscle cells (vSMCs) were determined by evaluating changes in gene expression and protein kinase phosphorylation. We found that SVIL regulated the phenotypic modulation of vSMCs to the synthetic phenotype via Krüppel-like factor 4 and platelet-derived growth factor and affected cell migration of vSMCs via the RhoA/ROCK pathway. Discussion: We propose that somatic variants form a novel mechanism for the development of cerebral aneurysms. Specifically, somatic variants in SVIL result in the phenotypic modulation of vSMCs, which increases the susceptibility to aneurysm formation. This finding suggests a new avenue for the therapeutic intervention and prevention of cerebral aneurysms.

Characterization of antiplatelet response to low-dose cangrelor utilizing platelet function testing in neuroendovascular patients.

STUDY OBJECTIVES: The optimal antiplatelet therapy for emergent neuroendovascular stenting is uncertain. Cangrelor is an intravenous P2Y12 inhibitor that is an attractive option due its favorable pharmacokinetic profile and ease of measurability but optimal dosing remains unclear. The primary objective of this study is to characterize the dose response of low dose cangrelor (<2 mcg/kg/min) with the utilization of platelet function testing (PFT). DESIGN: A retrospective review of all patients treated with cangrelor for either procedural stenting or bridging was conducted between January 1st, 2019 and October 31st, 2020. Seventy-two patients met inclusion criteria. An in-depth analysis of dose response to low dose cangrelor based on PFT was performed. PATIENTS: Neuroendovascular patients treated with cangrelor. SETTING: Albany Medical Center Hospital. INTERVENTION AND MAIN RESULTS: Patients who underwent procedural stenting were given a bolus of 5 mcg/kg and an initial infusion rate of either 0.75 mcg/kg/min or 1 mcg/kg/min. Patients who were bridged with cangrelor were administered an initial infusion rate of 0.75 mcg/kg/min or 1 mcg/kg/min. Twelve patient's doses were titrated to achieve a platelet reactivity unit (PRU) between 50-150; three patient's doses were titrated multiple times. Based on initial PFT results, utilizing the 1 mcg/kg/min maintenance dose resulted in more patients being in the acceptable (10-180) and desired (50-150) PRU range than the 0.75 mcg/kg/min dose (47% vs 56% and 70% vs 80%, respectively). Final recorded PRU results showed that 64% of patients had PRUs in the optimal range (50-150) and 88% of patients had PRUs in the desire range (10-180). CONCLUSIONS: Utilizing low doses of cangrelor with platelet function testing is an option during emergent neuroendovascular stenting and bridging. Cangrelor demonstrates significant variability in response at low doses and exhibits a dose response relationship when PFT is utilized.

Cangrelor dose titration using platelet function testing during cerebrovascular stent placement.

BACKGROUND: Optimal antiplatelet inhibition is vital during cerebrovascular stenting procedures, yet no standardized recommendation exists for antithrombotic therapy in these scenarios. Cangrelor is an intravenous P2Y12 inhibitor with a favorable pharmacokinetic profile for use during neuroendovascular stenting. METHODS: A retrospective review of all neuroendovascular patients who underwent stenting between 1 January 2019 and 22 March 2020 and were treated with cangrelor was conducted. Thirty-seven patients met inclusion criteria. RESULTS: All patients were administered a bolus of 5 mcg/kg of cangrelor followed by a maintenance infusion. Antiplatelet effects of cangrelor were monitored using platelet reactivity units (PRU). Based on the initial PRU, seven patients' doses were adjusted with subsequent PRUs in or near the goal range of 50-150. One patient experienced an acute intraprocedural occlusion likely related to a subtherapeutic PRU which subsequently resolved with cangrelor dose adjustment and intra-arterial tirofiban administration, and one patient experienced a post-procedure stent occlusion which required a thrombectomy and intra-arterial tirofiban administration. No hemorrhagic complications occurred. DISCUSSION: Cangrelor utilization during neuroendovascular stenting with maintenance doses of <2 mcg/kg/min with dose adjustments based on platelet function testing has not been previously described. Cangrelor presents many advantages compared to standard therapy in patients undergoing stent placement related to its pharmacokinetic profile, rapid onset of action, ease of transition to oral P2Y12 antiplatelet agents, and measurability. CONCLUSION: Cangrelor is a promising alternative to currently available therapies, especially in patients with a high hemorrhagic risk.

Simultaneous revascularization of the occluded internal carotid artery using the Solitaire as a workhorse wire during acute ischemic stroke intervention.

INTRODUCTION: Tandem lesions involving a large vessel occlusion intracranially with concomitant cervical carotid critical stenosis or occlusion are a common presentation of acute ischemic stroke. These lesions are both challenging and time-consuming but can be extremely beneficial for patients when successful. We present a technique utilizing the pusher wire of the stent retriever used for intracranial thrombectomy as the workhorse wire for carotid intervention using a monorail system to perform cervical carotid angioplasty. METHODS: We reviewed four successive patients who presented with a tandem occlusion and underwent thrombectomy and simultaneous carotid artery intervention using this technique. RESULTS: All four patients had radiographically successful intracranial thrombectomy and cervical carotid revascularization. Time from groin puncture to intracranial stent retriever deployment was 63 min on average. Then, using the pusher wire as a monorail workhorse, time from stent retriever deployment to carotid angioplasty was on average 6 min. DISCUSSION: This technique allows for cervical carotid revascularization to begin during the recommended 5-min wait time after stent retriever deployment, allowing for rapid near-simultaneous revascularization across both lesions. This technique has been reported briefly in the past for management of a cervical dissection. There is continued debate regarding the management of tandem occlusions, as to which lesion should be managed first. CONCLUSION: As the management paradigms of tandem occlusions continue to evolve, this technique may improve outcomes by expediting endovascular intervention. Using the stent retriever wire provides a method of expediting the management of the proximal lesion after addressing the more distal intracranial occlusion first.

Peri-operative medical management of cerebral vasospasm.

INTRODUCTION: The physiological mechanism of cerebral vasospasm after aneurysmal subarachnoid hemorrhage remains elusive and its treatment can be challenging. Traditionally, 'triple-H' therapy and the calcium channel blocker, nimodipine, are used to treat cerebral vasospasm. However, as the etiology of vasospasm is unraveled, investigative pharmaceutical agents that stop the development and attenuate the severity of cerebral vasospasm, are being investigated in clinical trials. METHODS: In this manuscript, we review the clinical presentation and characteristics of cerebral vasospasm after aneurysmal subarachnoid hemorrhage and the utility of hyperdynamic therapy and pharmacotherapies. RESULTS: Triple-H therapy improves cerebral perfusion and improves neurological outcome during clinically evident cerebral vasospasm. Nimodipine is the accepted standard medication used to reduce the incidence of cerebral vasospasm, but more importantly, has a neuroprotective effect during hypoxia. Other medications such as magnesium sulfate, HMG-CoA reductase inhibitors and enoxaparin, are also being trialed with some promising results. CONCLUSION: Endovascular administration of intra-arterial anti-spasmodic agents and balloon angioplasty are becoming more commonly utilized at institutions where endovascular therapy is available. However, triple-H therapy and nimodipine remain the accepted first-line of treatment for cerebral vasospasm after aneurysmal subarachnoid hemorrhage.

Evidence-based pharmacotherapy for cerebral vasospasm.

INTRODUCTION: The vast amount of literature on the pharmaceutical treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage remains daunting. Optimal treatment regimens for patients can be obscured by studies not statistically powered to draw evidenced-based conclusions. METHODS: In this chapter, we reviewed the English literature using the National Library of Medicine for studies regarding pharmacotherapies for the treatment of cerebral vasospasm. These studies were then categorized according to the US Preventative Services Task Force ranking system for evidence based medicine and reviewed each pharmacotherapy for its efficacy in the treatment of cerebral vasospasm. RESULTS: Nimodipine (Nimotop), HMG Co-A reductase inhibitor (statins) and enoxaparin (Lovenox) were the only drugs with level-1 evidence available for the treatment of vasospasm from aneurysmal subarachnoid hemorrhage as defined by the US Preventative Services Task Force. CONCLUSION: As the understanding of the pathophysiological mechanisms of vasospasm after aneurysmal subarachnoid hemorrhage evolves in the basic science laboratory, novel medications are being trialed in humans. However, significantly more work must be carried out in this area before we have an effective medical treatment that can prevent or reverse the devastating events of cerebral vasospasm.

Retrospective analysis of parenteral magnesium sulfate administration in decreased incidence of clinical and neuroradiological cerebral vasospasm: a single center experience.

OBJECTIVE: Experimental work suggests a neuroprotective role for magnesium sulfate in aneurysmal subarachnoid hemorrhage. We retrospectively review the incidence of clinically relevant vasospasm in patients treated or not with continuous magnesium infusion after onset of subarachnoid hemorrhage. METHODS: All patient records in Albany Medical Center with the diagnosis of SAH between January 1999 and June 2004 were reviewed. Patients who presented to the emergency department within 72 hours of onset were entered in the study. Patients were defined as in clinical vasospasm if there was an acute neurological change in association with abnormal trancranial Doppler (TCD), CT angiogram (CTA) or digital subtraction angiography (DSA). RESULTS: A total of 85 patients were selected. Magnesium sulfate was infused in 43 patients. When compared with patients who did not receive MgSO(4), there was a statistically significant lower incidence of clinical and radiological vasospasm in those who had the continuous infusion of magnesium sulfate (p<0.01). There was no statistically significant difference between patients who were coiled or clipped. CONCLUSION: Continuous magnesium sulfate infusion for the management of clinically significant cerebral vasospasm is safe and reduces the incidence of clinically significant cerebral vasospasm. Large, multicenter, controlled studies should be performed in order to determine the true effectiveness of the treatment in a controlled setting.

Delayed stenosis as a consequence of angioplasty for subarachnoid hemorrhage-induced vasospasm. Case report.

The authors report a case of restenosis in the bilateral internal carotid arteries (ICAs) following angioplasty for cerebral vasospasm. This 53-year-old woman suffering subarachnoid hemorrhage due to a ruptured posterior communicating artery aneurysm had severe vasospasm and underwent angioplasty of the left and right ICAs and middle cerebral arteries. Two months later, a follow-up CT angiogram revealed bilateral ICA stenoses. Transluminal angioplasty leads to long-term connective tissue damage in the medial and adventitial layers from the disruption of the arrangement of collagen fibers due to stretching and tearing, resulting in loss of transmission of contractile forces. Furthermore, following endothelial cell denudation and stretching and rupture of internal elastic lamina from angioplasty, reendothelialization of the intimal layer composed of smooth muscle cells may also explain the contractile properties of restenosis. Other factors such as macrophage-induced inflammation and reactive oxygen species accumulation may also contribute to restenosis. This is the second reported case of restenosis following angioplasty to treat vasospasm, although restenosis is a known complication of angioplasty for treatment of atherosclerosis. In addition, this is the first case of restenosis in the bilateral ICAs following angioplasty for vasospasm. This report presents an illustrative case study and reviews the pathophysiology of angioplasty and restenosis.

Transient Episode of Alice in Wonderland Syndrome After Ventriculoatrial Shunt Revision.

BACKGROUND: Visual misperceptions as a result of neurosurgical disorders are well documented. Alice in Wonderland syndrome (AWS) typically is reported in neurologic and psychiatric disorders. We present a patient who developed symptoms of AWS postoperatively. CASE DESCRIPTION: A 48-year-old man presented in shunt failure, attributed to a proximal catheter occlusion. Operative revision with replacement of the proximal catheter was performed without incident. Postoperatively, he complained of visual disturbances, including the perception that people had small heads on full-sized bodies. Symptoms resolved postoperatively. The patient's symptoms were diagnosed as a transient episode of AWS. This was attributed to manipulation of the parieto-occipital cortex during the revision. The local inflammatory response from manipulation of that area is thought to have caused our patient's symptoms. CONCLUSIONS: Visual disturbances caused by lesions along the optic radiations are common findings for neurosurgery patients, although AWS after surgical intervention has not been reported previously.

A prospective single-center analysis of the safety and efficacy of the hydrocoil embolization system for the treatment of intracranial aneurysms.

OBJECT: The HydroCoil embolization system is a helical platinum coil coated with a polymeric hydrogel that expands when it contacts aqueous solutions to increase filling volumes, improve mesh stability, and possibly elicit a healing response within the aneurysm. In this paper, the authors report the 1-year recurrence and complication rates of 67 aneurysms embolized with the HydroCoil system. METHODS: Sixty-four consecutive patients (67 total aneurysms) with small (< or =7 mm), large (8-15 mm), very large (16-24 mm), and giant (> or =25 mm) aneurysms in the anterior and posterior intracranial circulations were treated with HydroCoils between March 2003 and September 2004. All aneurysms were embolized by the senior author (A.S.B) with HydroCoils alone or in combination with bare platinum coils, until either there was no further angiographic contrast filling of the aneurysm or the microcatheter was pushed out of the dome by the coil mass. Balloon assistance was used in three cases and combined Neuroform stent-coil embolization in eight other cases. To evaluate the safety and 1-year efficacy of the HydroCoil system, periprocedural complications were recorded, and angiographic recurrences were categorized using the Raymond-Roy Occlusion Classification (RROC) system. The 1-year aneurysm recurrence rate independent of size was 15% in patients treated with HydroCoils. Seventy percent of the patients had stable occlusions. The recurrence rate for small aneurysms was 3.7%, and the combined recurrence rate for small and large aneurysms was 6%. Fifteen percent of the aneurysms initially categorized as RROC Type 2 or 3 with stasis of contrast material at the time of initial embolization improved in RROC type, allowing the authors to develop the aneurysm embolization grade to predict recurrence. The neurological complication rate was 14.9%, of which 4.5% represented permanent neurological deficits. CONCLUSIONS: The HydroCoil embolization system is safe and provides excellent 1-year occlusion of small and large aneurysms with initial RROC Type 1, as well as those with RROC Types 2 and 3 with stasis of contrast material at the time of embolization. Very large and giant aneurysms were not as successfully occluded with this system. Treatment of large and giant internal carotid artery aneurysms was more likely to result in cranial nerve palsies and postembolization headaches than treatment in other locations. The aneurysm embolization grade the authors developed using the results of this study accurately predicted 1-year recurrence rates based on the immediate postembolization angiographic characteristics of the treated aneurysm.

Treatment of Distal Anterior Circulation Aneurysms With the Pipeline Embolization Device: A US Multicenter Experience.

BACKGROUND: Utilization of the Pipeline embolization device (PED) to treat distal carotid circulation aneurysms has not been well studied. OBJECTIVE: To report the collective experience of using PED to treat distal anterior circulation aneurysms. METHODS: We retrospectively reviewed clinical and radiographic records of all patients who underwent Pipeline embolization of distal anterior circulation aneurysms at 10 US neurosurgical centers between 2011 and 2013. RESULTS: Twenty-eight patients (mean age 51.7 years; 18 women) with 28 aneurysms were included in the analyses. Fifteen aneurysms were fusiform, 5 dissecting, and 8 saccular. Average aneurysm size was 12.3 mm; 7 were giant. Twenty aneurysms were located along the middle cerebral artery, 6 along the anterior cerebral artery, and 2 along the anterior communicating artery. PED deployment was successful in 27 patients, with coils utilized in 6 cases. Clinical follow-up was available for an average of 10.7 months (range 3-26). Twenty-seven patients had follow-up neurovascular imaging: 21 aneurysms had complete occlusion, 4 had residual neck filling, and 2 had residual dome filling. Periprocedural complications (<30 days) occurred in 3 patients (10.7%), including 1 case of device failure resulting in stroke. Outcomes were good (modified Rankin Scale score 0 to 2) in 27 patients (96.4%) and fair (modified Rankin Scale 3) in 1. CONCLUSION: PED can be utilized in the treatment of distal anterior circulation aneurysms with difficult anatomy for conventional surgical or endovascular techniques. Larger-scale studies with long-term follow-up are needed to further elucidate the durability of PED treatment and its effect on perforator-rich vascular segments. ABBREVIATIONS: ACA, anterior cerebral arteryAcomA, anterior communicating arteryDSA, digital subtraction angiographyMCA, middle cerebral arterymRS, modified Rankin scalePED, Pipeline embolization device.