RESUMO
Distal thrombectomy may be considered in selected patients harboring acute occlusion of distal arterial branches, supplying very eloquent brain areas. In these cases navigation and deployment in tortuous, fragile and very small-caliber arteries is usually involved, potentially increasing the risk of per-procedural vessel wall perforation. We report a case of distal recanalization in a right-handed, fourty-year-old woman with left M3 occlusion, with the use of a novel device with manually adapted, gradual expansion, navigated through a 0.013-inch microcatheter, called the Tigertriever-13 [RapidMedical, Yokneam, Israel]. The device was deployed and retrieved with minimal alteration-straightening of the M3 vessels and complete recanalization was achieved. The patient achieved NIHSS 0 in less than 24â¯h.
Assuntos
Isquemia Encefálica , Acidente Vascular Cerebral , Artérias , Feminino , Humanos , Stents , Trombectomia , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: In this study we tested the effect of antiangiogenics on a swine angiogenesis model that shares some brain AVM histological characteristics. The objective was to determine bevacizumab effects on retia volumes and on vessels' wall. MATERIALS AND METHODS: Fifteen pigs were divided into 3 groups: Five animals served as controls (group A), 5 animals underwent endovascular left external and common carotid artery occlusion (group B) and 5 animals underwent the same procedure and had an intra-arterial in-situ injection of bevacizumab (groupC) 2 months after the occlusion. A DSA associated with 3D-rotational angiography was performed at day 0 and at 3 months in all groups in order to measure rete mirabile volumes. The animals were sacrificed at 3 months and the retia were harvested for pathological and immunohistochemistry examinations. RESULTS: All VEGF-A receptors were blocked at the site of injection and there was a local enhanced endothelial proliferation and apoptosis. The volume of the retia remained unchanged after the bevacizumab injection. Retia vessels presented comparable media thickness, higher endothelial proliferation and apoptosis after the anti-VEGF injection. CONCLUSION: A single in-situ injection of bevacizumab in this swine angiogenesis model showed no change in retia volume and an extensive blockage of VEGF receptors at the site of injection one month later. Rete mirabile vessels presented comparable media thickness, higher endothelial proliferation and apoptosis after the anti-VEGF injection, suggesting that bevacizumab antiangiogenic effect does not fragilize vessel wall. More studies are needed to confirm these preliminary insights of in-situ antiangiogenic effect on vascular malformations.
Assuntos
Angiografia , Animais , Bevacizumab/farmacologia , Injeções Intra-Arteriais , SuínosRESUMO
OBJECTIVE: To determine the diagnostic reliability of magnetic resonance imaging (MRI) sequences in chronic groin pain (CGP) compared to surgery and try to propose a suitable MRI protocol. MATERIALS AND METHODS: Forty-three consecutive patients with resistant clinical CGP underwent a pre-surgical pelvis MRI. Eight MRI sequences were acquired: axial fast spin-echo T1-weighted (FSE T1), coronal FSE T1, axial-oblique (in symphysis plane) proton density weighted with fat saturation (PDFS), coronal PDFS, sagittal PDFS, axial FSE T1 with fat saturation and gadolinium enhancement (FSGE), coronal FSE T1 FSGE and axial FSE T1 with Valsalva maneuver (VM). These sequences were reviewed for pubic symphysis assessment, adductor longus (AL) tendon and abdominal wall (AW) injuries. The same surgeon operated on all of these patients (26 AL and 49 AW). Sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative prospective value (NPV) and accuracy of each sequence and combinations for AL or AW injuries were calculated in comparison to surgical findings. RESULTS: One hundred ninety-two sequences were obtained. Coronal T1 FSGE and axial T1 VM proved to be the most reliable sequences (accuracy: 91.67% in AL and 83.33% in AW). The best sequence combination was coronal T1, axial PDFS, sagittal PDFS and axial T1 VM (accuracy: 77.78%; Se: 100.00%, Sp: 69.23%, PPV: 55.56%, NPV: 100.00%). CONCLUSION: MRI has 77.78% accuracy, 100.00% sensitivity, 69.23% specificity, 55.56% PPV and 100.00% NPV in evaluating CGP, with coronal T1-axial PDFS-sagittal PDFS-axial T1 VM as the optimal protocol in terms of diagnostic performance within a reasonable scan time. Diagnostic performance of MRI was examined in the evaluation of CGP using surgery as reference standard.
Assuntos
Dor Crônica/diagnóstico por imagem , Virilha/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Adulto , Dor Crônica/cirurgia , Meios de Contraste , Diagnóstico Diferencial , Feminino , Virilha/cirurgia , Humanos , Masculino , Medição da Dor , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: This is the first cohort study of patients treated with mechanical thrombectomy (MT) for acute ischemic stroke in the French West Indies, with a mothership center and helicopter transfer. OBJECTIVE: To describe the population and to evaluate imaging, clinical, and time metric outcomes, in order to assess the feasibility and adjust the territorial organization. METHODS: In this observational study, we retrospectively analyzed our prospectively collected data of a population of consecutive patients treated with MT for anterior and posterior circulation large vessel occlusions. Primary outcome was 3-month functional independence (modified Rankin Scale score ≤2). Secondary outcomes included aerial and terrestrial times of arrival, in-hospital delays, demographics, imaging and clinical data at onset, discharge, and at 3 months. We compared the results of the mothership and drip-and-ship paradigms. RESULTS: Between January 2020 and December 2021, 223 patients were included (74% mothership, 26% drip-and-ship). Mean National Institutes of Health Stroke Scale (NIHSS) score of the population was 16 before MT, with significant reduction (NIHSS score 6) at discharge (9 mothership, 12 drip-and-ship, P=0.025). There was significant difference in onset-to-operation room times among the two centers (335 min mothership, 500 min drip-and-ship, P=0.004). Successful recanalization (modified Thrombolysis in Cerebral Infarction score 2b-3) was 80.3%. Functional independence at 3 months was 35%, symptomatic intracranial hemorrhage was 11%, and the complication rate was 9.4%, all without statistically significant difference between the two groups. CONCLUSION: The population has distinct risk factors. MT with helicopter transfer is feasible in the French West Indies. Reduction of prehospital and in-hospital times is mandatory; evaluation of the territorial strategy is underway, to avoid over-selection of transferred patients.
RESUMO
The present systematic review aimed to identify all the available literature on awake craniotomy (AC) in patients with arteriovenous malformation (AVM) in order to evaluate its safety, risks, benefits and effectiveness. All available literature on AC in patients with AVM was collected and evaluated in an aim to provide a better understanding of its safety, associated risks and benefits. A systematic search for studies employing AC in patients with AVM was conducted using the PubMed, Scopus and ScienceDirect databases without restrictions on the year of publication, language, or study design, from inception up to May 30, 2021. A total of 11 studies published between 2004 and 2021 with 106 patients who underwent ACs were considered eligible. The rate of complete resection was 93% [95% confidence interval (CI), 82 to 100%; I2 0%]. The intraoperative complication rate was 21% (95% CI, 1 to 41%; I2 55%) and the post-operative complication rate was 33% (95% CI, 19 to 48%; I2 40%). During follow-up, the complication rate was 6% (95% CI, 1 to 10%; I2 30%). The post-operative complication rate was higher in the Spetzler-Martin grade (SMG) III-V group (31%; 95% CI, 21 to 42%; I2 46%) than in the SMG I-II group (12%; 95% CI, 2 to 22%; I2 0%). Similarly, the follow-up complication rate was higher in the SMG III-V group (9%; 95% CI, 2 to 16%; I2 34%) than in the SMG I-II group (0%; 95% CI, 0 to 4%; I2 0%). On the whole, the present study provides preliminary evidence to indicate that AC is a possible and useful option for the resection of AVM in selected patients. Well-designed future studies with long-term follow-up are required however, to investigate various aspects of safety and provide solid data for AC in patients with AVM.
RESUMO
INTRODUCTION: The aim of this study was to compare the sensitivity of intra-aortic computed tomography angiography (IA-CTA) to that of regular spinal digital subtraction angiography for the presurgical location of the Adamkiewicz artery (AKA). METHODS: Thirty patients (21 males, 9 females; mean age 64 years) had an IA-CTA for the location of the AKA before surgery of aneurysm (n = 24) or dissection (n = 6) of the thoracoabdominal aorta. After femoral artery puncture, a pigtail catheter was positioned at the origin of the descending aorta. CT acquisition was performed with an intra-aortic iodinated contrast media injection (15 mL/s, 120 mL). The visualization of the AKA and the location of the feeder(s) to the AKA were independently evaluated by two observers. Interrater agreement was calculated using a kappa test. Spinal angiogram by selective catheterization was systematically performed to confirm the results of the IA-CTA. RESULTS: The AKA was visualized by the IA-CTA in 27/30 cases (90 %); in 26/31 (84 %) cases, the continuity with the aorta was satisfactorily seen. Interrater agreement was good for the visualization of the AKA and its feeder(s): 0.625 and 0.87, respectively. In 75 % of the cases for which the AKA was visualized, the selective catheterization confirmed the results of the IA-CTA. In the remaining 25 % of the cases, the selective catheterization could not be performed due to marked vessels' tortuosity or ostium stenosis. CONCLUSION: IA-CTA is a feasible technique in a daily practice that presents a good sensitivity for the location of the AKA.
Assuntos
Aneurisma Roto/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aortografia/métodos , Cuidados Pré-Operatórios/métodos , Radiografia Intervencionista/métodos , Tomografia Computadorizada por Raios X/métodos , Idoso , Idoso de 80 Anos ou mais , Aneurisma Roto/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Embolization of extra-axial tumors has shown its effectiveness in reducing perisurgical blood loss. However, the complication rate of this procedure is poorly reported. We aimed to evaluate the rate of procedure-related complications and their risk factors. METHODS: From 1998 to 2011, 193 consecutive patients (141 females, 52 males; mean age = 52.9 years) were referred to our institution for presurgical embolization of an extra-axial tumor (meningiomas: n = 178; solitary fibrous tumors: n = 3; other: n = 12). Of 193 patients, 137 (71 %) underwent 141 embolizations (by microparticles: n = 133; by glue: n = 8). The remaining 56 patients (29 %) were not embolized due to unstable catheterization or dangerous anastomosis. Occurrence of neurological deficit was systematically assessed during and after embolization. The risk factors of procedure-related neurological complications were evaluated. RESULTS: Neither intratumoral hemorrhage nor procedure-related death was reported. Two of the 137 patients (1.5 %) had ischemic events with permanent neurological deficit after microparticles embolization. One patient had cortical blindness and one had hemiparesis. Both complications involved the vertebrobasilar system. The first patient had direct intratumoral anastomosis between the middle and the posterior meningeal arteries (PMA); the second one had reflux in the vertebral artery during particles injection in the PMA. Occurrence of ischemic complication was not related to the size of the microparticles. CONCLUSIONS: Though embolization of meningeal tumors is considered as a safe technique, serious neurological complications may occur. Opening of dangerous anastomosis or uncontrolled reflux caused two neurological complications (1.5 %). The size of the microparticles was not associated with the occurrence of neurological event.
Assuntos
Artérias/cirurgia , Neoplasias Encefálicas/terapia , Embolização Terapêutica/métodos , Meningioma/terapia , Neovascularização Patológica/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artérias/patologia , Neoplasias Encefálicas/patologia , Feminino , Humanos , Masculino , Meningioma/irrigação sanguínea , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Fatores de Risco , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND AND IMPORTANCE: Direct puncture may offer an alternative access for embolization of intracranial aneurysms in patients presenting with tortuous vessels. Nevertheless, major complications such as compressive hematoma and arterial dissection can occur with this technique. CLINICAL PRESENTATION: A tight common carotid artery (CCA) dissection was seen secondary to direct puncture in a 72-year-old patient who presented with a ruptured anterior communicating artery (ACom) aneurysm. After regular coiling of the aneurysm and using a femoral approach, an Angio-Seal™ device (St Jude Medical, Saint Paul, MN, USA) was placed and a carotid wallstent (Stryker Neurovascular, Fremont, CA, USA) successfully deployed at the dissected CCA, which was followed by good clinical and angiographic outcomes. CONCLUSION: A combined rescue technique combining Angio-Seal insertion and stent deployment was safe and effective for managing iatrogenic carotid artery dissection.
Assuntos
Dissecação da Artéria Carótida Interna/etiologia , Dissecação da Artéria Carótida Interna/terapia , Embolização Terapêutica/instrumentação , Embolização Terapêutica/métodos , Hemostáticos/administração & dosagem , Punções/efeitos adversos , Stents , Idoso , Aneurisma Roto/complicações , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/cirurgia , Dissecação da Artéria Carótida Interna/diagnóstico por imagem , Terapia Combinada/instrumentação , Terapia Combinada/métodos , Humanos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Masculino , Radiografia , Resultado do TratamentoRESUMO
INTRODUCTION: This is a multi-center, hospital-based study aiming to estimate social factors influencing pre-hospital times of arrival in acute ischemic stroke, with a perspective of finding ways to reduce arrival time and to augment the number of patients eligible for intra-arterial thrombolysis. METHODS: Acute ischemic stroke patients who presented at the emergency units of four major general public hospitals were registered. We assessed information concerning demographics, time of presentation, clinical situation, imaging, treatment, and socioeconomic factors. The sample was divided in two sub-samples, based on the time of arrival since onset of symptoms, and was statistically analyzed. RESULTS: During one calendar year (2005), 907 patients were registered. Among them 34.6% arrived in the first 6 h from symptom onset, 38.7% arrived between 6 and 24 h, 18.1% after 24 h and for 8.6% the time of onset was unknown. Younger age (P = 0.007), transfer with ambulatory service (Ρ = 0.002), living with a mate (Ρ = 0.004), and higher educational level (P < 0.005) were factors which correlated significantly with early arrival at the hospital. CONCLUSIONS: Instructing patients at high risk for stroke to live with a housemate appears beneficial for timely arrival at the hospital. The establishment of dedicated acute stroke call and transportation center should improve the percentage of early arrival. A national information campaign is needed to increase the level of awareness of the population concerning beneficial social behaviors and optimal reaction to symptoms of acute ischemic stroke.
Assuntos
Isquemia Encefálica/diagnóstico , Isquemia Encefálica/tratamento farmacológico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Neuroimagem/métodos , Admissão do Paciente/normas , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/tratamento farmacológico , Isquemia Encefálica/patologia , Distribuição de Qui-Quadrado , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Socioeconômicos , Estatísticas não Paramétricas , Acidente Vascular Cerebral/patologia , Terapia Trombolítica , Fatores de TempoRESUMO
BACKGROUND: The technique of endovascular transvenous embolization for brain arteriovenous malformations (AVMs) has emerged in the last 8 years as a very promising therapeutic alternative for otherwise incurable cases. Selective temporary flow arrest during transvenous endovascular embolization (TFATVE) is a novel adaptation of our previously described transvenous approach, which employs hyper-compliant balloons intra-arterially for the selective occlusion of arterial feeders during ethylene vinyl copolymer (EVOH) injection, in order to reduce intra-nidal pressure and increase nidi occlusion rates. METHODS: We performed a feasibility study of the TFATVE technique between January 2016 and April 2020. Consecutive patients were included. All patients had at least one axial brain MRI or CT in the first 48 hours following intervention, and at least one brain MRI scan within the first postoperative month, in order to detect both silent and clinically evident adverse events. Patients' demographics, angio-architectural characteristics, total injection and procedure times, angiographic and clinical outcomes were analyzed. RESULTS: 22 patients underwent TFATVE during transvenous endovascular treatment of brain AVMs. Among them, 86.4% were high Spetzler-Martin's grade. Good clinical outcome (modified Rankin Scale <2) was achieved in 95.5% of the cases, with 0% of procedure-related mortality and 4.5% of clinically significant, procedure-related morbidity. Total occlusion of the nidus was achieved in >90% of the cases at the end of the procedure and angiographic stability was achieved in all cases; 100% of the cases had angiographic cure at follow-up. CONCLUSIONS: TFATVE seems a safe and effective technique when conducted in carefully selected patients in highly specialized centers.
Assuntos
Embolização Terapêutica , Malformações Arteriovenosas Intracranianas , Humanos , Malformações Arteriovenosas Intracranianas/diagnóstico por imagem , Malformações Arteriovenosas Intracranianas/terapia , Estudos de Viabilidade , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/métodos , Encéfalo , Imageamento por Ressonância Magnética , Resultado do TratamentoRESUMO
INTRODUCTION: Vein of Galen malformations (VOGMs) represent a rare pathologic entity with often catastrophic natural history. The advances in endovascular treatment in recent years have allowed for a paradigm shift in the treatment and outcome of these high-flow shunts, even though their pathogenetic mechanisms and evolution remain in part obscure. AREAS COVERED: The overall management of VOGMs requires a tailored case-to-case approach, starting with in utero detection and reserving endovascular treatment for indicated cases. Lately, the advances in translational research with whole-genome sequencing and the coupling with cellular-level hemodynamics attempt to shed more light in the pathogenesis and evolution of these lesions. At the same time the advances in endovascular techniques allow for more safety and tailored technical strategy planning. Furthermore, the advances in MRI techniques allow a better understanding of their vascular anatomy. In view of these recent advances and by performing a PUBMED literature review of the last 15 years, we attempt a review of the evolutions in the imaging, management, endovascular treatment and understanding of underlying mechanisms for VOGMs. EXPERT OPINION: The progress in the fields detailed in this review appears very promising in better understanding VOGMs and expanding the available therapeutic arsenal.
Assuntos
Embolização Terapêutica , Procedimentos Endovasculares , Malformações da Veia de Galeno , Humanos , Imageamento por Ressonância Magnética , Malformações da Veia de Galeno/terapia , VeiasRESUMO
Introduction: Despite numerous advances in the endovascular treatment of intracranial aneurysms (IAs), treatment in cases of wide-neck, complex configurations or branching locations remains challenging. Apart from the paradigm shift introduced by flow diverters, several other devices have seen the light or are under development in order to address these challenges.Areas covered: We performed a review of the novel implantable endovascular devices which have been introduced for the treatment of IAs, from 1 January 2014 to 1 September 2019, excluding classic flow diverter and intracranial stent designs.Expert opinion: Alternative designs have been proposed for the treatment of IAs at branching positions, which do not jail the side branches, with or without flow diversion effect, most of which with good initial outcomes. Endosaccular devices have also been proposed, some of which with lower initial total occlusion rates. Alternative materials such as biopolymers have also been proposed and are under bench research. Despite the challenges in the exploitation of some of the new devices, most of them seem to provide solutions to some current technical shortcomings. The exploitation of the biological phenomena and the physical properties of the devices will allow us to expand the therapeutic armamentarium for more complex IA cases.
Assuntos
Procedimentos Endovasculares/instrumentação , Equipamentos e Provisões , Aneurisma Intracraniano/terapia , Embolização Terapêutica/instrumentação , Humanos , Stents , Resultado do TratamentoRESUMO
INTRODUCTION: Intracranial aneurysms in distal locations are sometimes difficult to treat due to their branching locations and the presence of blister-like or very wide-necked aneurysms. Braided intracranial stents, including flow diverters (FDs) and low-profile braided intracranial stents (LPBSs) may provide additional advantages, due to their flow-diverting properties. AREAS COVERED: The use of FDs in off-label, distal intracranial locations has been increasing with promising outcomes and has given rise to the LPBS, which has less flow-diverting properties, allowing for easier use in distal branching sites through 0.017' microcatheters. These devices have shifted the interest from the aneurysm's sac filling to the regional remodeling through the effect of flow diversion. The purpose of this article is to discuss their functionality, safety, performance, and perspectives through a critical review of important publications of the last 11.5 years (January 2007 to July 2018) on the use of these devices at and beyond the circle of Willis. EXPERT OPINION: FDs modify the regional anatomy thus careful pre-procedural consideration of the regional hemodynamic equilibrium is mandatory, as well as effective antiplatelet regimen. LPBSs provide moderate flow-diversion effect, which may be an advantage, especially for very distal and small aneurysms.
Assuntos
Prótese Vascular , Aneurisma Intracraniano/cirurgia , Desenho de Prótese , Stents , Prótese Vascular/efeitos adversos , Humanos , Complicações Pós-Operatórias/etiologia , Stents/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: The treatment of low grade Spetzler-Martin (SM) brain arteriovenous malformations (AVMs) has been debated in unruptured cases. Nevertheless, in clinical practice there are cases where treatment is preferred; in these cases a very low complication rate is mandatory. In ruptured cases, early and complete obliteration of the nidus is the preferred strategy. OBJECTIVE: To achieve curative embolization, ideally in a single session, by dual microcatheterization techniques with arterial and/or venous access, according to the angioarchitecture. MATERIALS AND METHODS: This is a prospective, single-center study carried out between January 2008 and January 2016. Patients with ruptured and unruptured brain AVMs, with SM grades I and II, treated by endovascular means, were included. Demographics, clinical presentation, angioarchitecture, and procedure-related complications were analyzed. Angiographic and clinical results were reported. RESULTS: Seventy-three patients, aged 40.5±17.8 years, were included. More than 60% of the patients presented with ruptured AVMs. Initial SM grades were I for 22% and II for 78% of the patients. Preprocedural modified Rankin Scale (mRS) score was 0-2 for 53 (72.6%), 3 for 12 (16.4%), 4 for 5 (6.8%) and 5 for 3 (4.1%) patients. Procedure-related morbidity was 2.7% and procedure-related mortality was 0%. Ninety percent (90.5%) of the patients were independent in their everyday lives (mRS score 0-2) at 6 months. In all but one case (95%) the embolization was curative. CONCLUSION: Stand-alone endovascular treatment for SM grade I and II brain AVMs seems safe and effective, allowing for complete obliteration of the nidus, with low complication rates. A study of larger cohorts is needed.
Assuntos
Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/cirurgia , Procedimentos Endovasculares/métodos , Malformações Arteriovenosas Intracranianas/diagnóstico por imagem , Malformações Arteriovenosas Intracranianas/cirurgia , Adolescente , Adulto , Idoso , Angiografia/métodos , Encéfalo/anormalidades , Encéfalo/diagnóstico por imagem , Encéfalo/cirurgia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: Stent-assisted coiling (SAC) has widened indications of endovascular treatment of intracranial aneurysms (wide-neck, fusiform aneurysms); moreover, it is associated with more stable anatomical results. Besides the development of other techniques such as flow diverter stents, bifurcation stents, or intrasaccular flow disruptors, SAC remains one of the most used endovascular techniques because it provides good clinical and anatomical results for most aneurysms. Several devices based on the same principle are available and have undergone many adaptations and developments over 20 years of intracranial stenting. AREAS COVERED: The purpose of this article is to review and compare intrinsic properties of available devices and their anatomical and clinical performance. EXPERT COMMENTARY: Based on this review and our experience of SAC, we will discuss the behavior and performance of those devices in different anatomic and clinical situations.
Assuntos
Procedimentos Endovasculares/métodos , Aneurisma Intracraniano/terapia , Stents , Animais , Procedimentos Endovasculares/instrumentação , HumanosRESUMO
BACKGROUND: Flow-diverter stent (FDS) deployment can cause morphological and hemodynamic changes in the carotid siphon (CS), influencing the occlusion rate of aneurysms in this location. OBJECTIVE: To evaluate morphological changes to the CS after FDS deployment and their relationship with the rate of occlusion of intracranial aneurysms. METHODS: A cohort of 183 patients with CS aneurysms were treated by deployment of Pipeline® FDS (Medtronic Inc, Dublin, Ireland). Their CSs were classified as type U, V, C, or S, depending on morphology. The posterior and anterior bend angles were measured on strict lateral cerebral angiogram with digital subtraction before FDS deployment, immediately after deployment, and at 6 mo. Differences between angles were analyzed to identify any correlations with rates of aneurysm occlusion, using the O'Kelly-Marotta classification. RESULTS: FDS deployment was associated with immediate changes in CS morphology. The mean anterior angle increased from 3.97 ± 25.06° to 22.05 ± 25.18° (P < .001) and the mean posterior angle increased from 71.98 ± 31.27° to 79.43 ± 31.80° (P < .001). Multivariate analysis revealed a progressive, statistically significant increase in frequency of complete (grade D) occlusion at 6-mo follow-up with increasing anterior bend angle (prevalence ratios (PR) = 1.42 for increases between 5.3° and 12°, P = .017; PR = 1.56 for increases between 12.1° and 27.6°, P = .002; PR = 1.83 for increases >27.6°, P < .001, all vs increases <5.3°). CONCLUSION: FDS deployment induces changes in CS morphology. Specifically, increases in mean anterior angle are associated with better radiological results on 6-mo follow-up digital subtraction angiography.
Assuntos
Artéria Carótida Interna/diagnóstico por imagem , Aneurisma Intracraniano/diagnóstico por imagem , Adulto , Idoso , Angiografia Digital , Prótese Vascular , Artéria Carótida Interna/cirurgia , Angiografia Cerebral , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Feminino , Hemodinâmica , Humanos , Aneurisma Intracraniano/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents , Resultado do TratamentoRESUMO
OBJECTIVE Even though published data exist concerning the prevalence of ischemic lesions detected by diffusion-weighted imaging (DWI) following endovascular treatment of intracranial aneurysms, a single-center cross-evaluation of the different endovascular techniques has been lacking. The authors sought to prospectively evaluate the prevalence and clinical significance of ischemic lesions occurring after endovascular treatment of intracranial aneurysms and to compare the safety and effectiveness of a broad spectrum of currently accepted endovascular techniques in a single-center setting. METHODS This was a prospective cohort study involving consecutive patients treated for intracranial aneurysms exclusively by endovascular means, excluding treatments in the acute rupture phase, in a center featuring an endovascular-only treatment policy for intracranial aneurysms. All patients underwent MRI, including a 3-directional DWI sequence, before treatment, 24 hours postprocedure, and 6 months following endovascular embolization. Selective angiography was performed at 6 months' follow-up. RESULTS From January 2012 through December 2013, 164 aneurysms were treated in 128 consecutive patients. Endovascular techniques included coiling (14.6%), balloon-assisted coiling (20.1%), stent-assisted coiling (3.7%), low-profile stent-assisted coiling, flow diversion (38.4%), and very complex treatments (6.1%) involving 2 stents in Y or T configurations. On postprocedure MRI, the rates of occurrence of new DWI-positive lesions were 64.3% for coiling, 54.5% for remodeling, 61.1% for stent-assisted coiling, 53.7% for flow-diverting stents, and 75% for very complex treatments (p = 0.4962). The 6-month procedure-related morbidity and mortality rates were 6.25% and 0%, respectively. At 6 months' follow-up, 93% of the patients had modified Rankin Scale (mRS) scores of 0-2. Very complex treatments offered a higher complete occlusion rate (100%) than all other techniques (66.7%-88.9%). Age and length of procedure were independent factors for DWI lesion occurrence. The diameter of DWI lesions on 24-hour postprocedure MRI was positively correlated with mRS score at discharge. Among the DWI-positive lesions measuring less than 2 mm in diameter on the 24-hour MRI, 44.12% had regressed at 6 months. CONCLUSIONS Procedure-related DWI lesions are far more often encountered in silent forms than they are clinically evident. They do not seem to be significantly correlated with procedure-related complications, nor do they seem to impair clinical outcome, regardless of the endovascular technique. Small lesions (< 2 mm in diameter) may regress within 6 months. The use of the most adapted technique, in terms of aneurysm configuration, results in significant total occlusion rates, with acceptable safety.
Assuntos
Isquemia Encefálica/epidemiologia , Procedimentos Endovasculares , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/cirurgia , Adulto , Fatores Etários , Idoso , Prótese Vascular , Isquemia Encefálica/mortalidade , Angiografia Cerebral , Estudos de Coortes , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Prevalência , Estudos Prospectivos , Stents , Resultado do TratamentoRESUMO
BACKGROUND: Curative transvenous embolization is an emerging strategy for treatment of cerebral arteriovenous malformations (AVMs). OBJECTIVE: To assess contemporary outcomes of transvenous embolization as a stand-alone therapy for cerebral AVMs. METHODS: We prospectively followed 40 patients with 41 AVMs who underwent transvenous endovascular therapy between January 2008 and January 2015. Patient demographics, AVM characteristics, endovascular techniques used, angiographic results, clinical outcomes, and complications were assessed independently. RESULTS: Thirty-eight of 41 (92.6%) AVMs were anatomically cured. The mean patient age was 37.7 yr (range, 18-69 yr) and 55% were female. Twenty-seven (67.5%) patients presented with hemorrhage. The mean size of the AVM nidus was 2.8 ± 1.2 cm, and low Spetzler-Martin grade AVMs comprised 41.5% of lesions. The majority of patients were treated in 1 session (56%; n = 23). The mean follow-up period was 28.4 (range, 6-106 mo). There was 1 (2.5%) hemorrhagic complication related to microcatheter navigation and 1 (2.5%) venous infarction was observed without clinical consequences. At 6-mo follow-up, 1 (2.5%) patient had significant disability. There were no recurrences during the follow-up period. Overall mortality was 2.5% and procedure-related mortality was 0%. CONCLUSION: This prospective contemporary series demonstrates a high rate of complete AVM obliteration and excellent functional outcomes in patients with both ruptured and unruptured AVMs treated with transvenous embolization. This approach is promising and warrants further investigation as a treatment for select AVMs.
Assuntos
Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Malformações Arteriovenosas Intracranianas/terapia , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND AND PURPOSE: To evaluate the safety and effectiveness of the low-profile braided intracranial stents called the Low Profile Visualized Intraluminal Support (LVIS) devices for stent-assisted coil embolization of wide-necked intracranial aneurysms. MATERIALS AND METHODS: This was a prospective, multicenter, observational study of unruptured and ruptured intracranial aneurysms treated with the LVIS devices. Imaging and clinical data were independently analyzed respectively by CoreLab and Clinical Event Committee. Primary endpoints were clinical safety, effectiveness, and angiographic stability of the results at 6 and 18 months. RESULTS: Ten centers participated in the study; 102 patients were included and 90 patients (42.2% men, 57.8% women) were eventually analyzed, among which 27 (30.0%) had multiple aneurysms. Twenty-three (25.6%) were ruptured aneurysms, four of which (4.4%) were treated in the acute phase. One aneurysm was treated per patient; 92 LVIS and LVIS Jr devices were placed overall. The total aneurysm occlusion rate was 91.0% on immediate post-procedure angiograms, which remained unchanged at 6-month follow-up and was 92.4% at 18-month follow-up. One patient (1.1%) underwent retreatment between 6 and 18 months of follow-up. A modified Rankin score of 0 was documented for most cases immediately after the procedure (86.7%) and at 6-month (86.8%) and 18-month (83.3%) follow-up. The overall permanent morbidity rate at 18 months was 5.6% and the overall rate of events with sequelae related to the stent was 2.2%. The 18-month procedure-related mortality rate was 3.3%. No patient was deemed to require retreatment at 18-month follow-up. CONCLUSION: The LVIS/LVIS Jr endovascular devices are safe and effective in the treatment of ruptured and unruptured intracranial aneurysms, with acceptable complication rates, very high immediate total occlusion rates, and stable angiographic results.