Flow Diversion for Acutely Ruptured Intracranial Aneurysms Treatment: A Retrospective Study and Literature Review.

OBJECTIVE: Flow diversion is becoming an increasingly established practice for the treatment of acutely ruptured intracranial aneurysms. In this study the authors present a literature review and meta-analysis, adding a retrospective review of institutional registry on emergency treatment of aRIA with flow diverter stent. MATERIALS AND METHODS: A systematic search of PubMed, SCOPUS, Ovid MEDLINE, and Ovid EMBASE was performed on April 20th, 2021, extrapolating 35 articles. R language 'meta' and 'metafor' packages were used for data pooling. The DerSimonian-Laird model was used to calculate the pooled effect. The I2 value and Q statistic evaluated study heterogeneity. Additionally, the authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured intracranial aneurysms treated with flow diverter stent placement from May 2010 to November 2020 was performed. RESULTS: From the systematic literature review and meta-analysis, the pooled proportion of complete aneurysm occlusion was 78%, with a pooled rate of 79%, 71%, 80%, and 50% for dissecting, saccular, fusiform, and mycotic aneurysms, respectively. The pooled proportion of aneurysm rebleeding and intrastent stenosis was 12% and 15% respectively, for a total of 27% rate. The analysis of authors retrospective register showed an overall mortality rate of 16.7% (3/18), with a low but not negligible postprocedural rebleeding and intrastent thrombosis rates (5.6% and 11.1% respectively). CONCLUSION: Although increasingly utilized in the management of selected patients with acutely ruptured intracranial aneurysms, flow diversion for acutely ruptured intracranial aneurysms treatment presents rebleeding and intrastent stenosis rates not negligible.

Ruptured Proximal Anterior Cerebral Artery Aneurysm Treated with Flow Diverter.

AIM: To discuss the use of flow modulation in treating ruptured aneurysms of the proximal segment of the anterior cerebral artery (A1 aneurysms). A1 aneurysms are rare, constituting approximately 1% of all intracranial aneurysms. CASE REPORT: We report a left A1 aneurysm with a wide neck and small sac (3 × 1.8 mm). In order to treat the lesion, a flow diverter (4 × 12?18 mm, FRED, Microvention) was placed from M1 to the proximal end of the paraophthalmic internal carotid artery, without directly covering the neck of the aneurysm. No procedural bleeding occurred. During stent deployment, abciximab was infused. A day after the procedure, double antiplatelet therapy was initiated for 1 month, followed by single antiplatelet therapy for another 3 months. Due to the aneurysm morphology, we opted for a competitive flow diversion, covering the parent artery origin and leaving the A1A neck uncovered. A decreased flow into the aneurysmal parent artery gradually promoted aneurysm sac thrombosis. Both digital subtraction angiography at a 12-month follow-up and computed tomography angiography 24-month follow-up confirmed the regular patency of the stent and resolution of the aneurysm. In addition, the competitive modulation of flow in the ipsilateral anterior cerebral artery results in the narrowing of the vessel. CONCLUSION: A1 aneurysm endovascular treatment is often challenging. Coiling or assisted coiling is the most frequently employed. Although flow diverter stent (FDS) is a consolidated technique for treating ruptured intracranial blister-like and dissecting aneurysms, its role in treating intracranial saccular ruptured aneurysms has to be elucidated. However, more number of case studies is needed to confirm the efficacy and safety of an FDS in treating ruptured A1 aneurysms.

Comaneci-Assisted Coiling of Wide-Necked Intracranial Aneurysm: A Single-Center Preliminary Experience.

BACKGROUND: Wide-necked aneurysms remain challenging for both coiling and microsurgical clipping. They often require additional techniques to prevent coil prolapse into the parent artery, such as balloon- and stent-assisted coiling. Comaneci is an expandable and removable stent that acts as a bridging device and does not interfere with the blood flow of the parent artery. METHODS: We retrospectively reviewed our institutional radiological and clinical chart of patients treated for saccular intracranial aneurysm via endovascular Comaneci-assisted coiling. The aim of the study was to report our preliminary experience in Comaneci-assisted coiling of wide-necked intracranial aneurysms. RESULTS: We included 14 patients in the study. Of these, 11 had a ruptured intracranial aneurysm and were treated with Comaneci-assisted coiling. We registered five minor intraprocedural complications and two intraprocedural failures of the device. At one-year follow-up, a satisfying aneurysm occlusion was observed in 85% of the cases. CONCLUSIONS: Though long-term follow-up data and larger case series are needed, this preliminary study showed the feasibility of the Comaneci-assisted coiling method for both ruptured and unruptured wide-neck intracranial aneurysms, with similar occlusion rates as balloon-assisted coiling. However, we registered high incidence of thromboembolic complications; these were probably related to the lack of heparin administration. The main advantageous application of this technique is likely in cases of ruptured intracranial aneurysms, as there is no need for post-procedural antiplatelet therapy.

Twenty Years of Experience in Juvenile Nasopharyngeal Angiofibroma (JNA) Preoperative Endovascular Embolization: An Effective Procedure with a Low Complications Rate.

Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor of the nasal cavity that predominantly affects young boys. Surgical removal remains the gold standard for the management of this disease. Preoperative intra-arterial embolization (PIAE) is useful for reductions in intraoperative blood loss and surgical complications. In our series of 79 patients who underwent preoperative embolization from 1999 to 2020, demographics, procedural aspects, surgical management and follow-up outcome were analyzed. Embolization was performed in a similar fashion for all patients, with a superselective microcatheterization of external carotid artery (ECA) feeders and an injection of polyvinyl alcohol (PVA) particles, followed, in some cases, by the deployment of coils . Procedural success was reached in 100% of cases, with no complications such as bleeding or thromboembolic occlusion, and surgical intraoperative blood loss was significantly decreased. In conclusion, PIAE is a safe and effective technique in JNA treatment, minimizing intraoperative bleeding.

Comaneci-Assisted Coiling Embolization of a Posttraumatic Carotid-Cavernous Fistula.

BACKGROUND: A direct carotid-cavernous fistula (CCF) is a rare complication that typically occurs in closed head injuries. The balloon-assisted occlusion is the most used treatment. However, this technique requires multiple inflation/deflations, which could be problematic in a vessel with acute vessel injury. CASE DESCRIPTION: In this study we reported a case of 72-year-old male patient with posttraumatic CCF, treated endovascularly with a transarterial Comaneci-assisted coiling embolization, highlighting the advantages and pitfalls of this innovative endovascular treatment. CONCLUSIONS: The Comaneci-assisted coiling technique has proven to be advantageous both in the microcatheterization of the CCF and during coiling with remodeling technique. In addition, this device does not interrupt the vascular flow compared to balloon-assisted coiling and does not require long-term antiaggregation therapy with respect to the stent placement.