Long-term outcomes of carotid stenting in a single neurovascular center: up to 12-year retrospective analysis with a focus on the influence of comorbidities.

BACKGROUND: The aim of this study was to evaluate long-term outcomes in patients who underwent carotid artery stenting (CAS) for symptomatic or asymptomatic high-grade stenosis. METHODS: A total of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522) underwent CAS at our center between 2009 and 2020. A total of 560 patients or contacts (asymptomatic, n = 316; symptomatic, n = 244) were interviewed by telephone to evaluate long-term outcomes with a mean follow-up of 5 years. Mortality from all causes, myocardial infarction, and stroke, as well as comorbidities influencing their occurrence, including overall survival and stroke-free survival, were examined. RESULTS: The overall survival rate for all-cause mortality was 91.6% at 1 year, 77.1% at 5 years, and 55.7% at 10 years. A total of 39 (6.9%) patients had an ischemic stroke during long-term follow-up. The stroke-free survival rates at 1 year, 5 years, and 10 years were 97.9%, 92.7%, and 86.6%, respectively. Stroke-free survival and overall survival did not differ significantly between the symptomatic and asymptomatic groups (overall survival, p = 0.304; stroke-free survival, p = 0.336). Regular physical activity reduced the risk of stroke and death and was associated with better long-term clinical outcomes. Age at treatment and diabetes mellitus were statistically significantly associated with death during follow-up. CONCLUSION: Long-term follow-up data confirmed the effectiveness and durability of CAS as a therapy option for both symptomatic and asymptomatic patients. In patient selection for CAS, special consideration should be paid to patient age, ability to engage in physical activity, and diabetes mellitus.

[The first experience of endovascular treatment of chronic subdural hematomas with non-adhesive embolization materials of various viscosities: Squid 12 and 18]. / Pervyi opyt endovaskulyarnogo lecheniya khronicheskikh subdural'nykh gematom neadgezivnymi emboliziruyushchimi materialami razlichnoi vyazkosti SQUID 12 i 18.

Chronic subdural hematomas (CSH) usually require surgical evacuation via a burr hole or craniotomy. Certain incidence of recurrent postoperative CSH is known. Middle meningeal artery (MMA) embolization has been described as an alternative surgery for new or recurrent CSH or as a preventive measure to reduce the risk of postoperative recurrence. The authors report successful MMA embolization with 2 non-adhesive embolic agents of various viscosities (SQUID 12 and SQUID 18, Balt USA, Irvine, CA, USA) for recurrent postoperative CSH in a 44-year-old woman.

Endovascular treatment of idiopathic intracranial hypertension: retrospective analysis of immediate and long-term results in 51 patients.

PURPOSE: Idiopathic intracranial hypertension (IIH) is a disorder of increased intracranial pressure in the absence of any known causative factor. Sinus stenosis is common in these patients. Stenting of stenotic dural sinuses has gained popularity as a treatment option, since these stenoses may contribute to an obstruction of the venous return, and, thereby may contribute to IIH via an increase in venous sinus pressure. We evaluated the safety and efficacy of endovascular treatment in IIH with venous sinus stenosis. METHODS: Fifty-one patients with IIH underwent stenting. Median age was 40 years. Clinical manifestation was headache in 74.5% of the patients and visual obscurations in 78.5%. Papilledema was present in 50/51 patients (98%), and lumbar puncture documented elevated CSF opening pressure in all but one patient (98%). Sinus stenoses were observed in all patients. RESULTS: Endovascular treatment was successfully performed in all patients. There were no major complications encountered (i.e., live threatening or causing a deterioration of a patient's condition equivalent to mRS 3-6). Improvement or resolution of papilledema was observed in 88% of the patients, and 84% reported improvement or resolution of the headache. Follow-up angiographies were performed in 48 patients at a median interval of 49 months and demonstrated in stent-stenosis or a de novo stenosis in 12 patients, eight of them needed re-treatment. CONCLUSION: Venous sinus stenting is a safe and effective alternative to other invasive treatments (e.g., optic nerve sheath fenestration, CSF diversion) in patients with IIH. The majority of patients have a persistent clinical benefit.

[Mechanical thrombectomy: Acute complications and delayed sequelae]. / Mechanische Thrombektomie : Akutkomplikationen und Spätfolgen.

BACKGROUND: Due to the positive evidence for mechanical thrombectomy (mTE), it will be increasingly used in future. Profound knowledge of potential complications, prevention and management of complications is necessary to safely implement mTE into clinical practice. AIM: Description of specific complications of mTE and their clinical relevance, measures for prevention and management. Summary of the current knowledge on long-term side effects of mTE. MATERIAL AND METHODS: Analysis of current trial results and selected case series to address specific topics. Summary of own practical clinical experience. RESULTS: Vascular injury (1-5%) and emboli (5-9%) are the most relevant intraprocedural complications but the clinical outcome is variable. Measures for prevention and management are described in detail. Vasospasms frequently occur (20-26%) but rarely need specific treatment and do not affect the clinical course. In the case of restrictive indications the frequency of symptomatic hemorrhage is similar to that for medicinal treatment (up to 8%). Contrast medium enhancement in the area of the infarction on post-treatment imaging should not be mistaken for hemorrhages. Focal subarachnoid contrast medium enhancement or hemorrhage occurs in up to 24% of cases and is predominantly benign. In follow-up imaging stenoses or occlusions can be detected in 4-10% of the treated vessels, most of which are asymptomatic. They are considered to be caused by microtrauma to the vascular wall. CONCLUSION: Clinically relevant complications of mTE are rare. Preventive measures and effective management of complications may even increase safety. Stenoses occasionally occur as a long-term side effect but are asymptomatic in the majority of cases.

Is Stent Retraction to ReLieve Arterial Cerebral VaSospasm Caused by SAH (Stent-ReLACSS) Using PRELAX the Long-awaited Solution for Treatment of Posthemorrhagic Cerebral Vasospasm? : Treatment of Posthemorrhagic Cerebral Vasospasm with PRESET and PRELAX: Technical Aspects, Efficacy, and Safety Margins in a Case Series.

PURPOSE: Recent observational studies have indicated the efficacy of stent retriever devices for the treatment of posthemorrhagic cerebral vasospasm (CVS), both by deployment and on-site withdrawal into the microcatheter (stent angioplasty, SA) and deployment followed by retraction through the target vessel similar to thrombectomy (Stent Retraction to reLieve Arterial Cerebral vaSospasm caused by SAH, Stent-ReLACSS). This article reports the findings with each application of pRESET and pRELAX in the treatment of CVS. METHODS: We retrospectively enrolled 25 patients with severe CVS following aneurysmal subarachnoid hemorrhage. For the SA group, a stent retriever or a pRELAX was temporarily deployed into a narrow vessel segment and retrieved into the microcatheter after 3 min. For the Stent-ReLACSS group, a pRELAX was temporarily deployed into a narrow vessel and pulled back unfolded into the internal carotid artery. If intra-arterial vasodilators were administered, they were given exclusively after mechanical vasospasmolysis to maximize the effectiveness of the stent treatment. RESULTS: In this study fifteen patients and 49 vessels were treated with SA. All were technically successful without periprocedural complications; however, 8/15 patients (53.3%) required additional treatment of the CVS. A total of 10 patients and 23 vessel segments were treated with Stent-ReLACSS. All maneuvers were technically successful without periprocedural complications and all vessels showed significant angiographic improvement. No recurrent CVS requiring further endovascular treatment occurred in-hospital, and neither territorial ischemia in the treated vessels nor vascular injury were observed in follow-up angiography. CONCLUSION: Based on the presented data it appears that Stent-ReLACSS with pRELAX does not pose any additional risks when used to treat CVS and might be superior to SA, especially concerning mid-term and long-term efficacy. The mechanism of action may be an effect on the endothelium rather than mechanical vasodilation. As many patients with CVS are diagnosed too late, prophylactic treatment of high-risk patients (e.g., poor grade, young, female) is potentially viable.

Flow diversion for unruptured MCA bifurcation aneurysms: comparison of p64 classic, p64 MW HPC, and p48 MW HPC flow diverter stents.

Background: MCA bifurcation aneurysms pose treatment challenges because of the complex hemodynamics at the bifurcation and the risk of rupture. FDS implantation has been controversial and there are only limited reports. Therefore, the aim of this study was to assess the efficacy and safety of this treatment strategy using p64 MW HPC and p48 MW HPC FDSs for MCA bifurcation aneurysms, compared with the p64 classic FDS. Materials and methods: We retrospectively analyzed our institutional database and identified all patients with saccular, non-ruptured MCA bifurcation aneurysms treated with p64 MW HPC, p48 MW HPC, or p64 classic FDS implantation alone. Aneurysms with implantation of additional devices in the same session, previous treatments, and acutely ruptured and fusiform aneurysms were excluded. Results: A total of 79 aneurysms met the inclusion criteria: 23 receiving a p64 MW HPC, 34 receiving a p48 MW HPC, and 22 receiving a p64 classic FDS. The occlusion rate was highest for the p48 MW HPC 2 mm FDS, at 88.9% at FU2, compared with 72.2% for the p64 MW HPC and 70.6% for the p64 classic. The time to aneurysm occlusion was shortest with the p64 MW HPC, at 178.31 days. The highest retreatment rate was observed with the p48 MW HPC 3 mm. Conclusion: Treatment of MCA bifurcation aneurysms with a p48 MW HPC 2 mm or p64 MW HPC FDS is a safe and reliable strategy achieving high aneurysm occlusion rates - attributable to their lower porosity in relation to the parent vessel diameter as compared to the p48 MW HPC 3 mm FDS-, with reasonable morbidity and mortality.

Endovascular management of spinal dural arteriovenous fistulas in 78 patients.

INTRODUCTION: The purpose of this study was the evaluation of the safety and efficiency of the endovascular treatment of spinal dural arteriovenous fistulas (SDAVFs). METHODS: Between May 1992 and August 2012, 78 patients (59 men) with an angiographically proven SDAVF with pial venous drainage were treated by endovascular embolization (n = 61) and/or surgery (n = 31) at three German hospitals by a single team of physicians and according to a uniform therapeutic concept. RESULTS: Endovascular treatment resulted in a complete occlusion of the fistula in 47 cases (77 %). After failed embolization with residual shunt, 14 DAVFs were surgically cured (23 % failure rate). We had one permanent and two minor complications after endovascular therapy. Within a postoperative period of 2 weeks, 73.6 % of patients improved in gait disability, 51.1 % in micturition function, and 70.5 % in paresthesia of the lower extremities. Long-term follow-up data showed further improvement of clinical symptoms confirmed by normalization or resolution of spinal changes on MRI. CONCLUSIONS: An interdisciplinary approach to the management of SDAVFs is mandatory. Patients without a common origin of arteries supplying the spinal cord and the dural fistula, and without a stenosis or occlusion of the concerning segmental artery are potential candidates for endovascular treatment (diluted n-butyl-2-cyanoacrylate). Only occlusion of the "nidus" and the proximal segment of the draining vein can lead to clinical improvement.

Detection and treatment of spinal CSF leaks in idiopathic intracranial hypotension.

INTRODUCTION: This study aimed to evaluate the diagnostic imaging findings and treatment results of patients with idiopathic intracranial hypotension (IIH) due to cerebrospinal fluid (CSF) leaks. METHODS: Between February 2009 and April 2012, 26 IIH patients (15 men, median age 49 years) presenting with orthostatic headache (n = 20) and/or with spontaneous subdural effusions or subarachnoid hemorrhage (n = 19) were enrolled. Twenty-three patients underwent a whole spine CT and MRI myelography, starting 45 min after the intrathecal injection of 9 cc of iomeprol (Imeron 300 M) and 1 cc of gadobutrolum (Gadovist). Three patients only underwent MR myelography after intrathecal gadobutrolum injection. Adjacent to the level(s) of the detected CSF leak(s) along the nerve roots, 20 cc of fresh venous blood with 0.5 cc Gadovist was injected epidurally (blood patch, BP). The distribution of the BP was visualized by MRI the following day. Treatment results were evaluated clinically and by myelography 2 weeks after the application of the BP. Retreatment was offered to patients with persistent symptoms and continued CSF leakage. RESULTS: CSF leaks were detected at the cervical (n = 12), thoracic (n = 25), or lumbar (n = 21) spine. In 23 patients, more than one spinal segment was affected. One patient refused treatment. BP were applied in one (n = 9) or several (n = 16) levels. Clinical and/or radiological improvement was achieved after one (n = 16), two (n = 5), three (n = 3), or five (n = 1) BPs. CONCLUSION: CT and MRI myelography allow the reliable detection of spinal CSF leaks. The targeted and eventually repeated epidural BP procedure is a safe and efficacious treatment.

Use of a p64 MW Flow Diverter with Hydrophilic Polymer Coating (HPC) and Prasugrel Single Antiplatelet Therapy for the Treatment of Unruptured Anterior Circulation Aneurysms: Safety Data and Short-term Occlusion Rates.

PURPOSE: To assess the safety and short-term occlusion rates in procedures using the p64 MW hydrophilic polymer-coated (HPC) flow diverter (FD) with prasugrel single antiplatelet therapy (SAPT) for the treatment of anterior circulation saccular aneurysms. METHODS: We retrospectively identified patients who underwent treatment of one or more intracranial anterior circulation saccular aneurysms between March 2020 and December 2021 with a p64 MW HPC FD and prasugrel SAPT with verified P2Y12 platelet receptor inhibition. Patients diagnosed with fusiform, dissecting, or recently ruptured aneurysms were excluded. Periprocedural and postprocedural complications, clinical outcomes, and angiographic follow-up results were evaluated. RESULTS: One hundred and two patients with 132 intracranial aneurysms met the inclusion criteria. Previous or concomitant treatments (e.g., coil occlusion) had been performed on 18 of these aneurysms. The technical success rate (i.e., implantation of the intended FD) was 100% with an average of 1.1 devices implanted per patient. Periprocedural and postprocedural complications occurred in 13.6% and 6.8% of these patients, respectively. No mortality or permanent clinical deterioration (i.e., modified Rankin scale score ≥ 3) were reported. Early follow-up digital subtraction angiography revealed aneurysmal occlusion rates of 72.6% and 83.8% at four and nine months, respectively. CONCLUSIONS: The implantation of a p64 MW HPC FD with prasugrel SAPT is safe and results in rapid, reliable and effective aneurysmal occlusion.

Adenosine-induced Asystole during AVM Embolization : A Case Series.

BACKGROUND: Adenosine induced cardiac standstill has been used intraoperatively for both aneurysm and arteriovenous malformation (AVM) surgery and embolization. We sought to report the results of adenosine induced cardiac standstill as an adjunct to endovascular embolization of brain AVMs. MATERIAL AND METHODS: We retrospectively identified patients in our prospectively maintained database to identify all patients since January 2007 in whom adenosine was used to induce cardiac standstill during the embolization of a brain AVM. We recorded demographic data, clinical presentation, Spetzler Martin grade, rupture status, therapeutic intervention and number of embolization sessions, angiographic and clinical results, clinical and radiological outcomes and follow-up information. RESULTS: We identified 47 patients (22 female, 47%) with average age 42 ± 17 years (range 6-77 years) who had undergone AVM embolization procedures using adjunctive circulatory standstill with adenosine. In total there were 4 Spetzler Martin grade 1 (9%), 9 grade 2 (18%), 15 grade 3 (32%), 8 grade 4 (18%), and 11 grade 5 (23%) lesions. Of the AVMs six were ruptured or had previously ruptured. The average number of embolization procedures per patient was 5.7 ± 7.6 (range 1-37) with an average of 2.6 ± 2.2 (range 1-14) embolization procedures using adenosine. Overall morbidity was 17% (n = 8/47) and mortality 2.1% (n = 1/47), with permanent morbidity seen in 10.6% (n = 5/47) postembolization. Angiographic follow-up was available for 32 patients with no residual shunt seen in 26 (81%) and residual shunts seen in 6 patients (19%). The angiographic follow-up is still pending in 14 patients. At last follow-up 93.5% of patients were mRS ≤2 (n = 43/46). CONCLUSION: Adenosine induced cardiac standstill represents a viable treatment strategy in high flow AVMs or AV shunts that carries a low risk of mortality and permanent neurological deficits.

A ruptured intraorbital ophthalmic artery aneurysm, associated with a dural arteriovenous fistula: combined transarterial and transvenous endovascular treatment.

BACKGROUND: True aneurysms of the ophthalmic artery (OA) are extremely rare and most often arise at the origin of this artery. We present the endovascular management of a ruptured intraorbital OA aneurysm and of an associated dural arteriovenous fistula (dAVF). PATIENT: A patient with a ruptured intraorbital ophthalmic artery aneurysm, associated with a dAVF with cortical drainage presented with acute visual loss and intra- and periorbital hematoma. The aneurysm was treated by endovascular coil occlusion. The dAVF was occluded by transvenous obliteration of the draining basal vein of Rosenthal. Both intraorbital ophthalmic artery aneurysms and their rupture are extremely rare. CONCLUSION: Transvenous treatment of dAVFs is well feasible even with very far going catheterization, in this case to the origin of the basal vein of Rosenthal.

A comparison of functional and physical properties of self-expanding intracranial stents [Neuroform3, Wingspan, Solitaire, Leo+, Enterprise].

PURPOSE: 5 self-expanding intracranial stents Neuroform (N), Wingspan (W), Solitaire (S), Leo(+) (L), and Enterprise (E) were subjected to an in vitro examination and comparison of their physical features and functional properties in order to better understand the clinical advantages and potential limitations of each device. MATERIAL AND METHODS: The following features were examined for each stent: visual appearance, radial strength, wall apposition, bending stiffness, gator backing, kink resistance, ovalization, vessel wall coverage, cell size, ease of delivery. RESULTS: Given are rankings for the 5 stents: radial force at 50% oversizing: L

Carotid Stenting as Definitive Treatment for Free Floating Thrombus-Review of 7 Cases.

BACKGROUND AND PURPOSE: Free floating thrombus (FFT) is a rare condition. The optimal treatment strategy is yet to be determined although medical management with anticoagulation is the mainstay. This article reports experience of treating FFT with carotid stenting. METHODS: A retrospective analysis of a prospectively maintained database was performed to identify all patients with FFT treated with carotid stenting. For each patient the demographic data, clinical presentation, location of the thrombus, type of stent and use of adjunctive devices, e.g. balloon guide catheters, clinical and radiological follow-up information as well as complications were recorded. RESULTS: A total of 7 patients, 4 female, with mean age of 55.6 ± 14.5 years were identified. The median National Institutes of Health Stroke Scale (NIHSS) was 7 (range 0-13) at presentation. Free floating thrombus was seen on the left in the majority of cases (n = 6, 85.7%). None of the patients had intracranial large vessel occlusion. The FFT was located in the CCA in 2 cases (28.6%) and the proximal ICA in the remaining 5 cases (71.4%). The Wallstent was used in 5 patients and a cGuard stent used in 2 patients. In 1 patient 2 overlapping stents were used but a single stent was used in the remaining patients. In 6 cases a distal filter wire was used and in 2 cases a balloon guide catheter was used as embolic protection. There were no intraoperative complications and no cases of distal clot migration or intracranial large vessel occlusion during the procedure. At last follow-up (n = 7) 6 patients were recorded as modified Rankin Scale (mRS) ≤2 and 1 patient was mRS 3. CONCLUSION: Free floating thrombus of the carotid arteries can be managed with stenting.

The p48MW Flow Diverter-Initial Human Experience.

BACKGROUND AND PURPOSE: The use of flow diverters to treat aneurysms arising from small caliber parent vessels has been reported. This article reports the results of the first in experiences with the p48MW (p48 Movable Wire) in humans, a device specifically designed to target vessels 1.75-3 mm in diameter. METHODS: This monocentric study retrospectively reviewed the prospectively maintained database to identify all patients treated with the p48MW device between January 2017 and January 2019 at this institution. Patient demographics, aneurysm characteristics, angiographic and clinical follow-up were recorded as well as complications. RESULTS: A total of 25 patients (20 female) with an average age of 55 ± 12.9 years (range 34-84) with 25 aneurysms were identified. The majority of the aneurysms was located in the anterior circulation (19/25, 76%). The average aneurysm dome width was 3.98 ± 3.6 mm (range 1.2-13 mm). Complete occlusion was seen in 18/24 (75%) aneurysms with neck remnants in 1/24 (4.2%) and continued aneurysm filling seen in the remaining cases (5/24, 20.8%). Adequate occlusion was seen in 79.2% of aneurysms (Raymond Roy Classification [RRC] grade I or II) during the follow-up period. There was a single technical complication with inappropriate deployment of the first p48MW. There was a single clinical complication (4%); however, the patient made a complete recovery (modified Rankin Scale [mRS] 0) and one patient died secondary to uncontrollable status epilepticus following acute subarachnoid hemorrhage unrelated to the treatment. CONCLUSION: The p48MW is safe and effective for the treatment of aneurysms including those arising from distal vessels.

Anomalous origin of the middle meningeal artery from the inferolateral trunk with an arterial circle around a hypoplastic internal carotid artery in an infant with a dural arteriovenous fistula.

Deviations from normal embryologic development can manifest in different anatomical variants of the ophthalmic artery. We present a case of an infant treated for a high-flow dural arteriovenous fistula of the superior sagittal sinus, in whom an arterial circle involving the ophthalmic artery, the middle meningeal artery, the inferolateral trunk and a hypoplastic segment of the internal carotid artery was found. The embryologic development is briefly reviewed with emphasis on the possible genesis of this interesting constellation.

Comparison of the Thrombogenicity of a Bare and Antithrombogenic Coated Flow Diverter in an In Vitro Flow Model.

BACKGROUND: Dual antiplatelet therapy is a pre-requisite for flow diverter (FD) implantation. The purpose of this study was to assess the thrombogenicity of the p48 FD, coated with the newly developed phenox Hydrophilic Polymer Coating (p48_HPC, phenox GmbH, Germany) in comparison with uncoated p48 FDs in an in vitro flow model (Chandler Loop). METHODS: p48 and p48_HPC FDs were implanted into silicon tubes filled with whole human blood and incubated at 37 °C under pulsating flow. After 120 min, platelet count was determined in the blood. Platelet activation markers (PAR1) and formation of microparticles were analyzed in a flow cytometer. Fluorescence microscopy of CD42a positive cells and scanning electron microscopy was used to detect adherent platelets on the wire surface. RESULTS: Platelets in contact with the uncoated p48 FDs are significantly more activated than those incubated with p48_HPC (73 ± 9% vs. 65 ± 6%, p < 0.05) and release more microparticles (1.8 ± 0.5 vs. 1.4 ± 0.4, p < 0.05). The platelet count after 120-min circulation in the Chandler Loop was significantly lower for the uncoated p48 compared to the p48_HPC indicating significantly greater adherence of the platelets to the p48 (71 ± 8% vs. 87 ± 5%, p < 0.05). SEM and fluorescent antibody imaging revealed minimal platelet adherence to the surface of the p48_HPC compared to the uncoated p48. CONCLUSION: The pHPC coating significantly reduces thrombogenicity of the p48 FD. This may help to reduce the risk of thromboembolic complications when using these devices. A reduction in antiplatelet therapy may be possible.

Endovascular management of dural arteriovenous fistulas of the transverse and sigmoid sinus in 150 patients.

INTRODUCTION: This study aimed to evaluate the safety and efficiency of the endovascular treatment of transverse-sigmoid sinus dural arteriovenous fistulas (TS_dAVF). METHODS: A total of 150 consecutive patients and 348 procedures were evaluated. RESULTS: Pulsatile tinnitus (81%), headache (15%), and intracranial hemorrhage (10%) were the most frequent manifestations of the TS_dAVFs. More than half of the affected sinuses were partially or completely thrombosed. Access-wise treatment was performed transarterial (n = 33), transvenous (n = 21), or a combination thereof (n = 96). A mean of 2.4 procedures per patient was required. Immediate postprocedural occlusion rate after transarterial embolization was 30% only. Transvenous treatment alone resulted in an early occlusion rate of 81%, with delayed complete obliteration of half of the remaining fistulas. After combined transarterial/transvenous treatment, the angiographic cure rate was 54%. At follow-up, 88% of patients with residual shunt after the treatment showed complete occlusion. The cumulative complication rate was 9% (n = 13), with minor adverse events in ten patients (7%) and major complications in three patients (2%). CONCLUSION: Transvenous coil occlusion of the sinus segment with the adjacent dAVF site, eventually combined with transarterial occlusion of supplying arteries, is a very effective and well-tolerated treatment method. In selected patients, variations of these methods (e.g., sinus stenting, compartmental sinus occlusion) can be useful.

Treatment of Wide-Necked Bifurcation Aneurysms : Initial Results with the pCANvas Neck Bridging Device.

BACKGROUND: Recently, numerous devices dedicated to the treatment of wide-necked aneurysms have become available. We present our initial experience with the pCANvas device and present the technical success rate, clinical outcome and immediate angiographic occlusion rates. OBJECTIVE: We sought to determine the efficacy of flow with the pCANvas for the treatment of unruptured intracranial aneurysms. METHODS: We performed a retrospective review of our prospectively collected data to identify patients treated with the pCANvas device between February 2015 and February 2017. The patient demographics, aneurysm characteristics, immediate and delayed clinical and radiographic follow-up data were recorded. RESULTS: We identified 17 patients (13 female) treated only with the pCANvas device. The average age of the patients was 60.5 ± 13.3 years (range 25-75 years). The average dome width was 7.6 ± 3.2 mm (range 3-15.8 mm), dome height 7.1 ± 3.2 mm (range 3-12.9 mm) and neck width 5.4 ± 3.2 (range 3-16.3 mm). The average aspect ratio was 1.5 ± 0.8 (range 0.6-3.7). At the end of the procedure 15 aneurysms continued complete filling of the aneurysm (Raymond Roy Classification[RRC] 3) with 2 aneurysms showing only filling of the neck of the aneurysm (RRC 2). Early follow-up angiography was available for 16 patients and at this stage 11 aneurysms showed persistent and complete filling of the aneurysm (RRC 3), 5 aneurysms showed complete occlusion of the aneurysm (RRC 1) and 7 aneurysms underwent repeat treatment with coiling. CONCLUSION: The early results on the use of the pCANvas are promising; however, longer term follow-up and larger studies are required.

Treatment of Unruptured, Tandem Aneurysms of the ICA with a Single Flow Diverter.

BACKGROUND AND PURPOSE: Intracranial adjacent tandem lesions of the internal carotid artery (ICA) are rare and the optimal treatment strategy is unknown. This study was carried out to determine whether a single flow diverter stent (FDS) could be successfully used to treat these lesions. METHODS: The prospectively maintained database was retrospectively carried out to identify patients treated between February 2009 and February 2018 with multiple unruptured, tandem ICA aneurysms and treated with a single FDS. Demographic data, clinical presentation, aneurysm characteristics, treatment data, clinical result and clinical and radiological follow-up information were recorded. RESULTS: A total of 69 patients (62 female, 89.8%) with average age 55 ± 14.8 years were identified. In total there were 169 aneurysms and the majority of patients (n = 47, 68.1%) had only 2 tandem aneurysms. The largest aneurysms measured 7.69 ± 5.3 mm (range 1.5-26 mm) in height, 6.64 ± 4.71 mm (range 1.5-23 mm) in width and the smaller aneurysm measured 2.61 ± 1.32 mm (range 0.8-9.5 mm) in height and 2.32 ± 1.12 mm (range 0.7-8 mm) in width. In 36 patients the p64 was used, the PED in 28 patients and Surpass in 5 patients. Follow-up was available in 54 patients (130 aneurysms). At initial follow-up (7.2 ± 4.2 months) 45 (83.3%) of the larger aneurysms and 66 (86.8%) of the smaller aneurysms were satisfactorily occluded (Raymond-Roy classification RRC 1 or 2). At delayed follow-up (18 ± 14.6 months) 48 of the larger aneurysms (88.9%) and 71 of the smaller aneurysms (93.4%) were satisfactorily occluded. There were three complications including one death. CONCLUSION: A single FDS can be used to successfully treat multiple tandem aneurysms of the ICA with a high rate of aneurysm exclusion and an acceptable risk profile.

Treatment of Unruptured, Saccular, Anterior Choroidal Artery Aneurysms with Flow Diversion : A Single Centre Experience.

BACKGROUND: The region of the brain supplied by the anterior choroidal artery (AChoA) is exquisitely eloquent. Aneurysms arising at or close to the origin of the vessel are not uncommon and damage or occlusion to the vessel can result in devastating consequences. The optimal treatment strategy is yet to be determined. OBJECTIVE: We sought to determine the efficacy of flow diversion for the treatment of unruptured AChoA aneurysms. METHOD: A retrospective review of our prospectively maintained database was performed to identify all patients with unruptured aneurysms of the AChoA between March 2009 and May 2017. The fundus size, number and type of flow-diverting stent (FD), complications and follow-up data were recorded. RESULTS: We identified 30 patients (60% female), average age 52.8 ± 10.8 years (range 27-73), with 30 aneurysms. The aneurysms were generally small with a mean fundus diameter of 3.4 mm (range 1-7 mm). Early angiographic follow-up data were available for all patients at which point 15 aneurysms were completely occluded (50%). Delayed angiographic follow-up was available in 24 patients and occlusion was seen in 21 patients (87.5%). Of the patients one developed transient ischemic symptoms after interruption of the antiplatelet medication and another patient had a small embolic infarct with transient symptoms in the periprocedural period. CONCLUSION: Flow diversion can be used to successfully treat aneurysms of the AChoA. The treatment carries a high rate of technical and radiological success with a good safety profile.