Dissecting spinal aneurysms: conservative management as a therapeutic option.

OBJECTIVE: Isolated dissecting spinal aneurysms are rare lesions that pose a therapeutic challenge. We report our experience in the management of four patients with dissecting spinal aneurysms. METHODS: After institutional review board approval was obtained, the neurointerventional databases of the two participating institutions were retrospectively reviewed. Aneurysms in the anterior spinal artery, posterior spinal artery, or in a radiculomedullary artery were included in the analysis. Flow-related aneurysms were excluded. Data on clinical presentation, hemorrhage location, aneurysm size, location, angiographic follow-up, re-hemorrhage, and clinical outcome were obtained and analyzed. RESULTS: Four patients with five spinal dissecting aneurysms met the inclusion criteria. There were two women and the mean age was 63 years (range 36-64). All patients presented with hemorrhage. Three radiculomedullary arteries in two different patients had one lesion each; the other two involved the anterior spinal artery and a posterior spinal artery in different patients. All four patients were managed conservatively. Follow-up angiography (5.5 months) demonstrated occlusion of all five aneurysms. There was no re-hemorrhage and all patients had a good outcome at the last follow-up (modified Rankin Scale score 0-2). CONCLUSIONS: Conservative management of ruptured spontaneous dissecting spinal aneurysms is a reasonable therapeutic option capable of achieving favorable angiographic and clinical outcomes.

Flow Diverters for Treatment of 160 Ophthalmic Segment Aneurysms: Evaluation of Safety and Efficacy in a Multicenter Cohort.

BACKGROUND: Treatment of ophthalmic segment aneurysms (OSA) remains challenging. Flow diverter stents (FDS) have evolved as a promising endovascular treatment option for aneurysms of the internal carotid artery and are associated with high occlusion rates and a favorable morbidity and mortality profile. OBJECTIVE: To determine safety and efficacy of FDS for OSA in a large, multicenter cohort. METHODS: A retrospective analysis of prospectively maintained databases of 127 consecutive patients harboring 160 OSA treated with FDS was performed. Aneurysms were classified based on location and morphology. Follow-up with digital subtraction angiography (DSA) was performed 6 to 18 months after treatment. RESULTS: Follow-up DSA was available for 101 (63.1%) aneurysms with a mean follow-up of 18 months. Complete occlusion was observed in 90 aneurysms (89.1%), near-complete occlusion (>95%) in 3 (3%), and incomplete occlusion (<95%) in 8 aneurysms (7.9%). One aneurysm was retreated with another FDS (0.9%). No risk factors for incomplete occlusion were identified. The OA was occluded at the latest follow-up in 6 cases (7.1%). Permanent morbidity occurred in 4 patients (3.1%), and there was no mortality related to the FDS procedure. CONCLUSION: Treatment of OSA with FDS was found to be safe and effective. The retreatment rate was extremely low and aneurysms that occluded did not reanalyze.

Neurovascular reconstruction with flow diverter stents for the treatment of 87 intracranial aneurysms: Clinical results.

BACKGROUND: Flow diverter stents represent a new endovascular tool to treat complex aneurysms, such as giant, large, wide-necked and fusiform. The highly dense mash of these stents reduces inflow and outflow inside the aneurysm, resulting in intra aneurysmal thrombosis and stent endothelialization. OBJECTIVES: To present the results of treatment of intracranial aneurysms with flow diverter stents in a single center. METHODS: Retrospective review of 77 patients with 87 aneurysms treated using two different types of flow diverter stent, the Pipeline Embolization Device and SILK stent, between October 2010 and September 2013 in an interventional neuroradiology center. RESULTS: Flow diverter stent placement was successful in 98% of the lesions and resulted in an immediate major stasis within most of the treated aneurysms. The overall aneurysm occlusion rate at six months and 18 months was 80% and 84% respectively. Symptomatic complications occurred in 11 patients (14.3%) with morbidity in eight (10.4%) and mortality in three patients (3.9%). CONCLUSION: Flow diversion is a promising technique for treatment of challenging intracranial aneurysms with acceptable morbidity. A high rate of complete occlusion for small large necked aneurysms, a low morbidity and mortality rate and no recanalization encourage their use in these aneurysms. Further studies accessing long-term aneurysm occlusion and recanalization are required.

Evaluation of Onyx HD-500 embolic system in the treatment of 84 wide-neck intracranial aneurysms.

OBJECTIVE: We report our results using Onyx HD-500 (Micro Therapeutics, Inc., Irvine, CA) in the endovascular treatment of wide-neck intracranial aneurysms, which have a high rate of incomplete occlusion and recanalization with platinum coils. METHODS: Sixty-nine patients with 84 aneurysms were treated. Most of the aneurysms were located in the anterior circulation (80 of 84 aneurysms), were unruptured (74 of 84 aneurysms), and were incidental. Ten presented with subarachnoid hemorrhage, and 15 were symptomatic. All aneurysms had wide necks (neck >4 mm and/or dome-to-neck ratio <1.5). Fifty aneurysms were small (<12 mm), 30 were large (12 to <25 mm) and 4 were giant. Angiographic follow-up was available for 65 of the 84 aneurysms at 6 months, for 31 of the 84 aneurysms at 18 months, and for 5 of the 84 aneurysms at 36 months. RESULTS: Complete aneurysm occlusion was seen in 65.5% of aneurysms on immediate control, in 84.6% at 6 months, and in 90.3% at 18 months. The rates of complete occlusion were 74%, 95.1%, and 95.2% for small aneurysms and 53.3%, 70%, and 80% for large aneurysms at the same follow-up periods. Progression from incomplete to complete occlusion was seen in 68.2% of all aneurysms, with a higher percentage in small aneurysms (90.9%). Aneurysm recanalization was observed in 3 patients (4.6%), with retreatment in 2 patients (3.3%). Procedural mortality was 2.9%. Overall morbidity was 7.2%. CONCLUSION: Onyx embolization of intracranial wide-neck aneurysms is safe and effective. Morbidity and mortality rates are similar to those of other current endovascular techniques. Larger samples and longer follow-up periods are necessary.

Intracranial arterial aneurysm vasculopathies: targeting the outer vessel wall.

The pathogenesis of intracranial arterial aneurysms (AA) remains unclear, despite their clinical importance. An improved understanding of this disease is important in choosing therapeutic options. In addition to the "classical" berry-type aneurysm, there are various other types of intracranial AA such as infectious, dissecting or giant, partially-thrombosed aneurysms. From the clinician's perspective, the hypothesis that some of these intracranial AA might be due to abluminal factors has been proposed for several years. Indeed, this hypothesis and the empirical use of anti-inflammatory drugs in giant intracranial aneurysms have been confirmed by recent studies reporting that an enzyme involved in the inflammatory cascade (5-lipoxygenase or 5-LO) promotes the pathogenesis of specific aneurysms in humans. 5-LO generates different forms of leukotrienes which are potent mediators of inflammation. Adventitial inflammation leads to a weakening of the media from the abluminal part of the vessel wall due to the release of proinflammatory factors that invade the media, thereby degrading the extracellular matrix, the elastic lamina of the vascular wall, and, finally, the integrity of the vessel lumen. This in turn results in a dilation of the vessel and aneurysm formation. Moreover, neoangiogenesis of vasa vasorum is found in close proximity to 5-LO activated macrophages. In addition to this biological cascade, we argue that repeated subadventitial haemorrhages from the new vasa vasorum play an important role in aneurysm pathogenesis, due to a progressive increase in size mediated by the apposition of new layers of intramural haematoma within the vessel wall. Intracranial giant AA can therefore be regarded as a proliferative disease of the vessel wall induced by extravascular activity. Considering certain aneurysmal vasculopathies as an abluminal disease might alter current therapeutic strategies. Therapy should not only be aimed at the intraluminal repair of the artery, but also cross the vessel wall to reach the vasa vasorum. Drug-eluting stents placed proximal to the lesion and targeted to the origin of the vasa vasorum could be considered as a potential future option. "Intelligent" MRI contrast agents (i.e., macrophage marking) could be used to detect vasa vasorum proliferation and weakening of the vessel wall in vivo.

Embolizaçäo das artérias hipogástricas no tratamento de sangramento dos órgäos pélvicos / Embolization of the hypogastric arteries in the treatment of pelvic bleeding

O método de embolizaçäo arterial transcateter que foi inicialmente utilizado para o tratamento de hemorragia maciça secundária a trauma pélvico é hoje usado para controle de hemorragia pélvica de diversas causas, sendo neoplasia de bexiga/neoplasias ginecológicas e seqüelas pós-radioterapia de órgäos pélvicos as mais freqüentes. Em muitas ocasiöes torna-se a única opçäo para pacientes que näo têm condiçöes cirúrgicas e que apresentam hemorragia pélvica incontrolável clinicamente. O presente estudo baseia-se na revisäo dos casos de hemorragia pélvica tratados no serviço, através de embolizaçäo arterial transcateter, no período de março de 1977 a abril de 1985. Foram levantados 30 casos, sendo que a causa mais freqüente de hemorragia pélvica foi neoplasia de bexica em 19 pacientes. Desde 19, 11 apresentavam cistite actínica. Quatro tiveram hemorragia pós-prostatectomia, quatro pacientes sangraram por tumores uterinos e um por tumor de próstata. Houve um sangramento pós-histerctomia via vaginal e outro caso de sangramento puerperal. Obteve-se controle imediato da hemorragia em 28 dos 30 pacientes. Um paciente voltou a sangrar, porém näo foi possível sua reembolizaçäo devido à oclusäo proximal das artérias hipogástricas com molas de Gianturco no primeiro procedimento. Em outro paciente optou-se pela näo embolizaçäo, uma vez que foram identificadas artérias radículo-medulares conectadas à circulaçäo das hipogástricas, o que poderia eventualmente levar a complicaçöes neurológicas se realizada a embolizaçäo; este paciente continuou sangrando. Näo houve complicaçöes sérias ou permanentes em nenhum dos casos, embora tenham ocorrido complicaçöes menores em três casos