Comparing treatment outcomes of various intracranial bifurcation aneurysms locations using the Woven EndoBridge (WEB) device.

BACKGROUND: The Woven EndoBridge (WEB) device has Food and Drug Administration approval for treatment of wide-necked intracranial bifurcation aneurysms. The WEB device has been shown to result in adequate occlusion in bifurcation aneurysms overall, but its usefulness in the individual bifurcation locations has been evaluated separately only in few case series, which were limited by small sample sizes. OBJECTIVE: To compare angiographic and clinical outcomes after treatment of bifurcation aneurysms at various locations, including anterior communicating artery (AComA), anterior cerebral artery (ACA) bifurcation distal to AComA, basilar tip, internal carotid artery (ICA) bifurcation, and middle cerebral artery (MCA) bifurcation aneurysms using the WEB device. METHODS: A retrospective cohort analysis was conducted at 22 academic institutions worldwide to compare treatment outcomes of patients with intracranial bifurcation aneurysms using the WEB device. Data include patient and aneurysm characteristics, procedural details, angiographic and functional outcomes, and complications. RESULTS: A total of 572 aneurysms were included. MCA (36%), AComA (35.7%), and basilar tip (18.9%) aneurysms were most common. The rate of adequate aneurysm occlusion was significantly higher for basilar tip (91.6%) and ICA bifurcation (96.7%) aneurysms and lower for ACA bifurcation (71.4%) and AComA (80.6%) aneurysms (p=0.04). CONCLUSION: To our knowledge, this is the most extensive study to date that compares the treatment of different intracranial bifurcation aneurysms using the WEB device. Basilar tip and ICA bifurcation aneurysms showed significantly higher rates of aneurysm occlusion than other locations.

First multicenter experience using the Silk Vista flow diverter in 60 consecutive intracranial aneurysms: technical aspects.

BACKGROUND: The aim of this study was to assess the technical success and procedural safety of the new Silk Vista device (SV) by evaluating the intraprocedural and periprocedural complication rate after its use in several institutions worldwide. METHODS: The study involved a retrospective review of multicenter data regarding a consecutive series of patients with intracranial aneurysms, treated with the SV between September 2020 and January 2021. Clinical, intra/periprocedural and angiographic data, including approach, materials used, aneurysm size and location, device/s, technical details and initial angiographic aneurysm occlusion, were analyzed. RESULTS: 60 aneurysms were treated with SV in 57 procedures. 66 devices were used, 3 removed and 63 implanted. The devices opened instantaneously in 60 out of 66 (91%) cases and complete wall apposition was achieved in 58 out of 63 (92%) devices implanted. In 4 out of 66 (6%) devices a partial opening of the distal end occurred, and in 5 (8%) devices incomplete apposition was reported. There were 3 (5%) intraprocedural thromboembolic events managed successfully with no permanent neurological morbidity, and 4 (7%) postprocedural events. There was no mortality in this study. The initial occlusion rates in the 60 aneurysms were as follows: O'Kelly-Marotta (OKM) A in 34 (57%) cases, OKM B in 15 (25%) cases, OKM C in 6 (10%) cases, and OKM D in 5 (8%) cases. CONCLUSIONS: Our study demonstrated that the use of the new flow diverter Silk Vista for the treatment of intracranial aneurysms is feasible and technically safe.

LARGE ANEURYSM OF BASILAR ARTERY TIP MIMICKING MIDBRAIN TUMOR AND CAUSING UNILATERAL OBSTRUCTIVE HYDROCEPHALUS: A CASE REPORT AND TECHNICAL NOTE.

Cerebral ventricular system is a sporadic location of intracranial aneurysms including those of basilar artery tip. Treatment of such aneurysms remains challenging regardless of endovascular or microsurgical techniques applied. Basilar tip aneurysm presenting as third ventricular mass is rarely associated with obstructive hydrocephalus, mimicking midbrain expansive process and urging precise diagnostics and prompt treatment. Hence, the management of such patients may be delicate, having an uncertain outcome. We report on a case of a patient with unilateral hydrocephalus caused by large basilar tip aneurysm mimicking a midbrain tumor. We also discuss different operative strategies influencing the outcome, including our own endovascular treatment technical modification. A 62-year-old female patient presented with slightly decreased cognition, minor gait disturbances and urinary incontinence. Computed brain tomography revealed a third ventricle mass with unilateral ventricular dilatation, indicating hypertensive obstructive hydrocephalus. Magnetic resonance and digital subtraction angiography identified the third ventricular mass as a large saccular basilar tip aneurysm. The patient was selected for endovascular treatment followed by cerebrospinal fluid derivation. After aneurysm endovascular occlusion and temporary external ventricular drainage, the symptoms diminished and ventricular dilatation decreased. On post-procedure day 10, the hydrocephalus was relieved and external drainage removed. The patient recovered fully and was discharged without neurological deficit. In conclusion, large basilar tip aneurysms associated with obstructive hydrocephalus are rare and best treated by a combination of endovascular obliteration and cerebrospinal fluid ventricular diversion. The possibility of such an aneurysm should always be considered on the differential diagnosis of cerebral ventricular growths.

LATE ANEURYSM RELAPSE AFTER MICROSURGICAL TREATMENT OF MIDDLE CEREBRAL ARTERY ANEURYSM: A CASE REPORT AND LITERATURE REVIEW OF TREATMENT OPTIONS.

Recurrence of intracranial aneurysm after initial microsurgical or endovascular treatment is uncommon. Although the exact etiology remains unknown, recurrent aneurysms may be observed in surgical patients with big and multiple aneurysms, arterial hypertension, non-atherosclerotic cerebrovascular arteriopathies, as well as in those with a familial history of the disease. Such recurrence can occur over a wide period ranging from several months to years after the initial aneurysm treatment. Still, the occurrence delayed by more than 20 years is rather unusual. Herein, we present a case of a 70-year-old female patient who developed late intracranial aneurysm relapse 30 years after successful microsurgical clipping of the middle cerebral artery aneurysm. We also provide a brief review of relevant literature, discussing the etiology and pathophysiology of aneurysm reappearance, as well as different treatment options available. In conclusion, one should always consider the possibility of intracranial aneurysm recurrence regardless of the mode and time of primary surgery. In such a case, a multidisciplinary management approach using flow diverting endovascular techniques is advised in selected patients.

THE RISK OF MULTIPLE INTRACRANIAL ANEURYSM FORMATION IN PATIENTS WITH MALIGNANT DISEASE UNDERGOING RADIATION THERAPY: A CASE REPORT AND LITERATURE REVIEW.

Neoplastic etiology of intracranial cerebral aneurysm is rare. Yet, the risk of its development is higher in malignant tumor patients receiving radiation therapy. Due to the possible negative effects of irradiation on intracranial vessel walls, the risk of aneurysm formation after radiation therapy, which is crucial for some types of breast cancer patients, continues to be a matter of debate. The aim of this study was to evaluate the hazard of multiple intracranial aneurysm development in patients with malignant disease undergoing radiation therapy. It is based on literature review and case report of a 77-year-old female patient who underwent surgery for multifocal invasive hormone-receptor positive ductal breast carcinoma of no special type, followed by chemotherapy, adjuvant radiation and hormone therapy. Her comorbidity included arterial hypertension and type 2 diabetes. Six unruptured intracranial aneurysms of different bilateral locations were diagnosed incidentally by multi-slice computed tomography angiography and digital subtraction angiography of cerebral vessels. Due to the bilateral aneurysm multiplicity, tumor characteristics and prognosis, comorbidity and relatively advanced age, the patient was not selected for active endovascular or microsurgical aneurysm treatment but only periodical clinical, oncologic and radiological follow-up was advised. In conclusion, the risk of multiple intracranial aneurysm formation in patients with breast cancer undergoing radiation therapy is low, but still possible. Long-term follow-up and regular cerebral angiographic check-up studies are necessary in selected malignant patients to decrease such a risk and to evade the worst outcome associated with aneurysm rupture.

Periprocedural safety and technical outcomes of the new Silk Vista Baby flow diverter for the treatment of intracranial aneurysms: results from a multicenter experience.

PURPOSE: The aim of our study was to assess the technical success and the safety of this new low-profile flow diverter Silk Vista Baby (SVB) by evaluating the intraprocedural and periprocedural complication rate. MATERIAL/METHODS: Clinical, procedural, and angiographic data were analyzed. RESULTS: 41 consecutive patients (28 women; age average 50.5 years) with 43 aneurysms were treated with SVB. Aneurysm sizes were classified by their maximum diameter, with an average size of 9.5 mm (range 2-30 mm). Thirty-four cases were unruptured. five aneurysms previously ruptured, had recurrence after the initial coiling. There were two ruptured cases. Aneurysms' locations were: M1 segment (five cases), M2 segment (three cases), M3 segment (one case), middle cerebral artery (MCA) bifurcation (six cases), carotid-T (two cases), anterior communicating artery/A1/A2 (11 cases), pericallosal artery (four cases), supraclinoid ICA (two cases), PCom (one case), V4 segment (three cases), PCA (three cases), SCA (one case), and PICA (one case). We had five intraprocedural complications which resolved without clinical consequences and three events postprocedural events. Initial occlusion rates were: eight aneurysms (18.6%) were completely occluded, five aneurysms (11.6%) showed near-complete occlusion, four cases (9.3%) showed incomplete filling, and 26 cases (60.4%) showed persisting filling. The mRS score at discharge from the hospital did not change from the admission mRS score. CONCLUSION: Our study demonstrated that the use of the new low-profile flow diverter, SVB device, for the treatment of intracranial aneurysms is feasible and technically safe.

Preliminary experience with Precipitating Hydrophobic Injectable Liquid (PHIL) in treating cerebral AVMs.

OBJECTIVE: To describe our early experience in treating cerebral arteriovenous malformations (AVMs) with the new Precipitating Hydrophobic Injectable Liquid (PHIL) embolic material. MATERIALS AND METHODS: Between June and August 2015 five patients with cerebral AVMs were treated at two tertiary university hospitals. PHIL was used as complementary treatment to Onyx liquid embolic material or as the sole endovascular treatment. RESULTS: Five patients (average age 39 years (range 19-73)) with ruptured plexiform AVMs were treated. The group included one patient with Spetzler-Martin grade II AVMs, three grade III, and one grade IV. One grade II and two grade III AVMs were cured. A total of nine pedicles were embolized with an average of two pedicles per session. There were no procedural complications. One patient had a seizure after embolization but a brain CT scan showed no hemorrhage. CONCLUSIONS: PHIL is a new embolic agent that can be used for the treatment of cerebral AVMs.