Utility of virtual stenting in treatment of cerebral aneurysms by flow diverter devices.

Successful endovascular treatment by stenting of intracranial aneurysms requires proper placement of the device and appropriate choice of its diameter and length. To date, several methods have been employed to achieve these goals, although each has inherent critical issues. Recently developed stent planning software applications can be used to assist interventional neuroradiologists. Based on a 3D-DSA image acquired before stenting, these applications simulate and visualize the final placement of the deployed stent. In this single-centre retrospective study, 27 patients undergoing an intravascular procedure for the treatment of intracranial aneurysms from June 2019 to July 2020 were evaluated according to strict inclusion criteria. Stent virtualization was performed with Syngo 3D Aneurysm Guidance Neuro software. We compared the software-generated stent measurement and measurements taken by the interventional radiologist. Statistical analysis was performed using the STAC web platform. Mean and standard deviations of absolute and relative discrepancies between predicted and implanted stents were recorded. Friedman's nonparametric test was used to refute the null hypotheses, i.e. (I) discrepancies between the size of virtual and implanted stents would occur, and (II) operator influence does not affect the outcome of the virtual stenting process. Based on these observations, it is believed that the virtual stenting process can validly assist interventional neuroradiologists in selecting the appropriate device and reducing peri- and post-procedural complications. The results of our study suggest that virtual reality simulation of devices used for endovascular treatment of intracranial aneurysms is a useful, rapid, and accurate tool for interventional procedure planning.

Efficacy of recanalization therapy for ischemic stroke: multicenter hospital network experience.

PURPOSE: Stroke is a leading cause of long-term disability with high mortality rate in the first year after the event. In Campania, mechanical thrombectomy treatment significantly increases in the last 3 years, as well as hospitals delivering acute stroke treatments. The aim of this study is to demonstrate how a full opening of our stroke network improves stroke management and stroked patients' survival in Campania. MATERIAL AND METHODS: In Federico II University Hospital of Naples acting as a HUB center of 7 peripheral SPOKE hospitals in regional territory, 68 patients with acute ischemic stroke were evaluated with NIHSS and m-RS clinical scores and neuroradiological ASPECT scores, from January 1 to December 31, 2021. At hospital discharge, NIHSS score and three months after m-RS score were re-assessed to evaluate the therapeutic effects. RESULTS: Forty-two of 68 patients (63%) admitted to our hub center had ischemic acute stroke at CT evaluation; 29 patients had ASPECT score > 7 (69%), and 6 a score < 7 (14%). At admission, NIHSS score mean value was 10.75, and m-RS score mean value was 0.74. At discharge, NIHSS score mean value was 7.09. After three months, m-RS score mean value was 0.74. DISCUSSION: The inter-company agreement between Federico II University and several peripheral hospitals allows an absolute and relative increase in endovascular mechanical thrombectomy and intravenous thrombolysis procedures, with a relative prevalence of mechanical thrombectomy. A regional implementation of the stroke multi-disciplinary care system is hardly needed to ensure the optimum treatment for the largest number of patients, improving patient's outcome.

Dissective tandem stroke: an endovascular approach.

Ischemic stroke due to internal carotid artery occlusion is a potential devastating condition. More frequently the occlusions are embolic in nature, but sometimes they are caused by arterial dissection and their treatment is a challenge. We describe an illustrative case where a young patient with middle cerebral artery stroke caused by carotid artery dissection was submitted to endovascular treatment of mechanical thrombectomy and stenting, giving an excellent outcome. We believe that tandem approach is a treatment of choice in these cases.

Basilar Artery Occlusion (BAO) revascularization after more than 12 hours from the onset of symptoms with excellent outcome: Report of a case.

This paper reports a case of basilar artery occlusion (BAO), a relatively rare event associated with high mortality rate and high risk of disability. A 77-year-old man arrived at our Stroke Unit approximately 14 hours after the onset of symptoms (dysarthria and complete left hemiparesis) with progressive worsening up to coma and with a National Institute Health Stroke Scale (NIHSS) of 22. The patient was treated and, at discharge, the modified Rankin scale and NIHSS were 2 and 5, respectively. The aim of this paper is to illustrate how revascularization treatment, also after 12 hours, could be a viable option to ensure survival and a good life quality for the patient. Furthermore, it is essential to encourage the publication of a greater number of trials about the posterior circulation emphasizing how many favorable prognosis indicators are now recognized.

Carotid Cavernous Fistulas and Dural Arteriovenous Fistulas of the Cavernous Sinus: Validation of a New Classification According to Venous Drainage.

BACKGROUND: Multiple carotid cavernous fistula (CCF) classifications have been proposed. However, they lacked predictive factors for the clinical presentation, natural history, and hemorrhagic risk. Our aim was to externally validate a new classification according to venous drainage (i.e., the Thomas classification [TC]) to assess its relationship with symptoms, endovascular treatment, and outcomes. METHODS: We performed a multicenter retrospective review of CCFs at 2 major academic institutions. The CCFs were classified using the Barrow classification (BC) and TC systems. RESULTS: The data from 94 patients with a diagnosis of CCF were collected during a study period 23 years, 4 months. Of these 94 patients, 89 had undergone CCF treatment and 5 had experienced spontaneous occlusion. Complete occlusion was achieved in 89.9% of the treated patients. Complications occurred in 5.3% of the patients, including permanent deficits in 2.1%. TC type 4 was associated with cortical symptoms compared with type 2 (P = 0.003) and type 3 (P < 0.001). The BC was not able to detect significant differences among the symptom types. Significant differences were found using the TC for the transarterial-only, transvenous anterior-only, and transvenous posterior-only approaches (P < 0.001, P = 0.03, and P = 0.001, respectively). The transvenous posterior and transvenous anterior approach were significantly associated with type 2 and 3 TC, respectively. Excluding direct CCFs, the BC was not related to the treatment approach. No significant differences in the outcomes were found. However, a trend toward a lower occlusion rate for TC type 4 compared with type 3 was observed. CONCLUSION: The TC provided useful information regarding the fistula anatomy and venous hemodynamics, which correlated with the clinical symptoms and treatment strategy.

Mid-term and long-term follow-up of intracranial aneurysms treated by the p64 Flow Modulation Device: a multicenter experience.

BACKGROUND: Experience with the endovascular treatment of cerebral aneurysms using the p64 Flow Modulation Device is still limited. This study discusses the results and complications of this new flow diverter device. METHODS: 40 patients (30 women, 10 men) with 50 cerebral aneurysms treated in six Italian neurointerventional centers with the p64 Flow Modulation Device between April 2013 and September 2015 were retrospectively reviewed. RESULTS: Complete occlusion was obtained in 44/50 aneurysms (88%) and partial occlusion in 3 (6%). In the other three aneurysms (6%), two cases of asymptomatic in-stent thrombosis and one intraprocedural occlusion of the parent vessel occurred. Technical complications were observed in eight procedures (16%). Permanent morbidity due to acute in-stent thrombosis and consequent ischemic stroke occurred in one patient (2.5%). No delayed aneurysm rupture, subarachnoid or intraparenchymal hemorrhage, or ischemic complications occurred and there were no deaths. CONCLUSIONS: Endovascular treatment with the p64 Flow Modulation Device is a safe treatment for unruptured cerebral aneurysms, resulting in a high rate of occlusion. As with other flow diverter devices, we recommend this treatment mainly for large-necked aneurysms of the internal carotid artery siphon. However, endovascular treatment with the p64 device should also be encouraged in difficult cases such as aneurysms of the posterior circulation and beyond the circle of Willis.

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

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

Flow diverter device for the treatment of small middle cerebral artery aneurysms.

PURPOSE: Experience with the endovascular treatment of middle cerebral artery (MCA) aneurysms by flow diverter devices (FDD) is still limited. This study examines the results and complications of FDD for small aneurysms at this location. METHODS: From February 2010 to December 2013, 14 patients (10 women; mean age 59 years) with 15 small MCA aneurysms were treated with FDD. All procedures were performed with the Pipeline embolization device (PED). RESULTS: Complete occlusion was obtained in 12/15 aneurysms (80%) and partial occlusion in 3 (20%). Among 13 aneurysms with a side branch, this was patent at the angiographic control in 4 cases, showed decreased filling in 6, and was occluded in 3 (with neurological deficits in 2). All PEDs were patent at follow-up. Post-procedural ischemic complications occurred in 4 (27%) procedures with permanent neurological deficit (modified Rankin score 2) in 3 (21%). No early or delayed aneurysm rupture, no subarachnoid or intraparenchymal hemorrhage and no deaths occurred. CONCLUSIONS: Endovascular treatment with FDD is a relatively safe treatment for small MCA aneurysms resulting in a high occlusion rate. The findings of this study suggest that complete occlusion after endovascular treatment with FDD can be delayed (>6 months). Ischemic complications may occur as early or delayed, particularly at clopidogrel interruption.

p64 Flow Modulation Device in the treatment of intracranial aneurysms: initial experience and technical aspects.

BACKGROUND: Experience with the endovascular treatment of cerebral aneurysms by flow diverter devices (FDDs) is limited to four devices (Pipeline, Covidien; FRED, Microvention; Silk, Balt Extrusion; Surpass, Stryker), as reported in different studies. OBJECTIVE: To describe the initial experience and the technical innovations of a new-generation FDD (p64 Flow Modulation Device, Phenox, Bochum, Germany). METHODS: Between December 2014 and February 2015, six intracranial aneurysms in five patients (four women, one man; mean age 63 years) were treated with the p64 Flow Modulation Device. RESULTS: Immediate post-treatment angiography showed reduced flow into all aneurysms. No long-term angiographic data are available. The device may be easily deployed and totally retrieved with a unique mechanical detachment. No periprocedural technical complications occurred. No early or delayed aneurysm rupture, no ischemic or hemorrhagic complications, and no neurological morbidity or death were seen. CONCLUSIONS: Treatment of cerebral aneurysms with the p64 Flow Modulation Device is a safe procedure with no technical complications. The mechanical detachment and the 100% retrievability are significant advantages of this new device. However, large prospective studies with long-term clinical and angiographic follow-up are necessary to assess the role of the p64 in the endovascular treatment of intracranial aneurysms.

Mechanical Thrombectomy in the Treatment of Distal Occlusions during Coil Embolization of Ruptured Intracranial Aneurysms.

The experience in the management of thromboembolic complications of distal vessels during coil embolization using stent-retrievers in the setting of subarachnoid hemorrhage (SAH) is still limited. We report a case of 58-year-old woman with a ruptured small anterior communicating aneurysm who experienced during coil embolization a thromboembolic occlusion of the upper post-bifurcation branch of the middle cerebral artery. Mechanical thrombectomy with a stent-retriever (Solitaire, Covidien, Neurovascular) resulted in complete recanalization of the occluded branch with no ischemic complication. This case should encourage the use of the Solitaire device as an effective rescue strategy in the treatment of distal artery occlusions in the setting of SAH.

Endovascular treatment of cerebral aneurysms using flow-diverter devices: A systematic review.

BACKGROUND: Flow-diverter devices (FDDs) are new-generation stents placed in the parent artery at the level of the aneurysm neck to disrupt the intra-aneurysmal flow thus favoring intra-aneurysmal thrombosis. OBJECTIVE: The objective of this review article is to define the indication and results of the treatment of intracranial aneurysms by FDD, reviewing 18 studies of endovascular treatment by FDDs for a total of 1704 aneurysms in 1483 patients. METHODS: The medical literature on FDDs for intracranial aneurysms was reviewed from 2009 to December 2014. The keywords used were: "intracranial aneurysms," "brain aneurysms," "flow diverter," "pipeline embolization device," "silk flow diverter," "surpass flow diverter" and "FRED flow diverter." RESULTS: The use of these stents is advisable mainly for unruptured aneurysms, particularly those located at the internal carotid artery or vertebral and basilar arteries, for fusiform and dissecting aneurysms and for saccular aneurysms with large necks and low dome-to-neck ratio. The rate of aneurysm occlusion progressively increases during follow-up (81.5% overall rate in this review). The non-negligible rate of ischemic (mean 4.1%) and hemorrhagic (mean 2.9%) complications, the neurological morbidity (mean 3.5%) and the reported mortality (mean 3.4%) are the main limits of this technique. CONCLUSION: Treatment with FDDs is a feasible and effective technique for unruptured aneurysms with complex anatomy (fusiform, dissecting, large neck, bifurcation with side branches) where coiling and clipping are difficult or impossible. Patient selection is very important to avoid complications and reduce the risk of morbidity and mortality. Further studies with longer follow-up are necessary to define the rate of complete occlusion.

Surgical clipping of a dissecting aneurysm of the precommunicating segment of the anterior cerebral artery: a case report and review of the literature.

INTRODUCTION: Dissecting aneurysms of the cerebral arteries are uncommon vascular malformations. Neurosurgical treatment remains critical in the management of patients with such vascular pathologies. CASE PRESENTATION: A 20-year-old Caucasian woman presented with a sudden onset of severe headache and loss of consciousness. Computed tomography revealed diffuse subarachnoid hemorrhage, while a computed tomography disclosed a dissecting aneurysm of the precommunicating segment of the right anterior cerebral artery. Cerebral carotid angiography confirmed the presence of the dissecting aneurysm. Due to the peculiar anatomic configuration, endovascular treatment was excluded and surgery was selected. As the left circulation perfused both postcommunicating segments of the anterior cerebral artery and the distal right precommunicating segment was hypoplastic, direct clipping of the right precommunicating segment, close to its origin from the internal carotid artery, was carried out. She recovered after surgery and a late angiography showed the correct positioning of the clip, with regular perfusion of both right and left postcommunicating segments. CONCLUSIONS: The management of dissecting aneurysms of the cerebral arteries is still controversial. With this report we highlight a possible neurosurgical option among therapeutic strategies for these uncommon vascular lesions.

Treatment of intracranial aneurysms by flow diverter devices: long-term results from a single center.

OBJECTIVES: Flow-Diverter Devices (FDD) are a new generation stents designed for the treatment of the intracranial aneurysms. This article reports the long-term results (2-4 years) of this treatment from a single-center. METHODS: From November 2008 to January 2012, 35 patients (29 females and 6 males; mean age 53.9 y) with 39 intracranial aneurysms were treated by FDD. Five patients (14.3%) had ruptured aneurysms and 30 (85.7%) had no previous hemorrhage. The procedures were performed in 5 patients (14.3%) with SILK and in 30 (85.7%) with PED. In 3 patients FDDs were used as a second treatment after failure of previous coiling (2 cases) or stenting (one case). The 39 aneurysms were in supraclinoid ICA in 26 (66.7%), cavernous ICA in 2 (5.1%), PCoA in 4 (10.2%), MCA in 5 (12.9%), SCA in 1 (2.6%) and PICA in 1 (2.6%). The aneurysms were small (<10mm) in 32 cases (82%), large (11-25mm) in 6 (15.3%) and giant in 1 (2.6%). The occlusion rate according to the aneurysm location, size and neck and the complications were evaluated. RESULTS: Peri-procedural complications included transient dysarthria (2 patients), vasospasm with acute intra-stent aggregation (one), microwire rupture (one) and failure of the stent opening (one). The follow-up was made between 24 and 62 months (mean 41 months); clinical examination and CTA were performed at 1, 3, 6 and 12 months after the procedure. The complete occlusion was confirmed by CTA and DSA. MRI with angiographic-studies was taken every year. Complete occlusion was obtained in 35 aneurysms (92.1%) and subtotal in 3 (7.9%). Complete occlusion occurred at 3 months in 24 cases (68.6%), within 3 and 6 months in 9 (25.7%). The rate and time of complete occlusion were not correlated with the aneurysm size. MCA aneurysms mainly showed partial occlusion (2/3 cases). Besides, large-neck aneurysms and those with a vessel arising from the sac mainly showed late (>6 months) or partial occlusion. CONCLUSION: FDD are a safe and efficacious treatment of intracranial aneurysms, resulting in high occlusion rate and low incidence of complications. It should be the treatment of choice for the large-neck aneurysm of the ICA.

Bilateral mirror aneurysms at the origin of the posteroinferior cerebellar artery: case report and review of the literature.

We report an exceptional case of symmetrical mirror aneurysms at the origin of the posterior inferior cerebellar arteries treated by endovascular occlusion. Questions related to a correct diagnosis and treatment at this localization are discussed.