Treatment of giant intracranial aneurysms: long-term outcomes in surgical versus endovascular management.

Aneurysms with a major diameter > 25 mm are defined as giant intracranial aneurysms (GIAs). Different clinical, pathological, and radiological factors were revealed as playing a role in choosing the best strategy between surgical and endovascular approaches. Despite the improvement of both techniques, the efficacy and safety of these different management are still debated. We evaluated the differences in clinical and radiological outcomes of GIAs treated with surgical and endovascular techniques in a large retrospective mono-centric study. We compared aneurysm location, clinical, morphological features, treatment outcome, and complications on the ground of treatment technique. The final cohort consisted of 162 patients. All the patients were assigned on the ground of the type of eligible treatment: surgical (118 patients) and endovascular procedure (44 patients). The different treatment strategies were made through a multidisciplinary selection whereas clinical parameters, location, and morphologic features of the aneurysm were considered. The surgical group manifested a greater reduction in performance levels and neurological status in the post-operative phases than the endovascular group (p < 0.01) with a higher incidence of complications (p = 0.012) in contrast to a lower recurrence rate (p > 0.01). There is no significant difference in post-operative mortality and survival between surgical and endovascular groups. The surgical group manifested a higher incidence of complications after treatment. The endovascular group has a better post-operative outcome, but a higher risk of recurrence and the necessity of further treatment.

Stent-assisted coiling in ruptured cerebral aneurysms: multi-center experience in acute phase.

INTRODUCTION: The purpose of this study is to report on a multi-center experience of ruptured intracranial aneurysms treated in acute phase with stent-assisted coil embolization, including primary success rates and midterm follow-up results. MATERIALS AND METHODS: Retrospective analysis was performed on a sample of 40 patients (14 men, 26 women, mean age 59.7 years) affected by ruptured saccular aneurysms and treated by stent-assisted coiling in acute phase; double antiplatelet therapy with clopidogrel bisulphate and acetylsalicylic acid was started after the procedure. Angiographic follow-up at 1 year was recorded. RESULTS: 20 % of the aneurysms were located in the posterior circulation, and 85 % presented a wide neck. Mean size of the sac was 7 mm (range 3-22 mm). Complete sac exclusion was obtained in 92.5 % and neck remnant in 7.5 %. The overall complications rate was 15 %. In 7.5 %, stent occlusion occurred intra-procedurally. In 12.5 %, re-bleeding was detected within 3 weeks after the procedure. Ischemic area related to the procedure was observed at follow-up in 7.5 %. Hydrocephalus developed in 15 %. 7.5 % presented with sac re-bleeding between 1 and 5 months after the procedure. In 15 %, the 3-6 months of follow-up revealed aneurysm refilling. 25 % of the patients presented vessel stenosis at the 1-year DSA of control. 33 % of the patients reported sensory-motor deficits. 82.5 % had a favorable outcome (GOS: IV-V), while 17.5 % presented a poor score (GOS: I-III). CONCLUSIONS: Stent-assisted coil embolization is a feasible endovascular treatment option for ruptured intracranial aneurysms, which is difficult to approach with simple coiling; however, neurointerventionalists need to consider a mild increase of post-procedural complications rate.

Effective ADAPT Thrombectomy in a Patient with Acute Stroke due to Cardiac Papillary Elastofibroma: Histological Thrombus Confirmation.

A 75-year-old man with hypertension and atrial fibrillation was admitted to our emergency room with right-sided hemiplegia and complete aphasia (National Institutes of Health Stroke Scale [NIHSS] score = 18). A noncontrast computed tomography scan showed a slight hypodensity in the left insular region and a bright hyperdense sign in the M1 tract of the left middle cerebral artery (MCA). Angio-CT confirmed an occlusion of the M1 tract of the MCA. Magnetic resonance diffusion-weighted imaging/perfusion-weighted imaging was obtained and revealed a mismatch in the left parietal cortical region. Complete revascularization was achieved by thromboaspiration with the A Direct ASPIRATION first PASS TECHNIQUE (ADAPT) technique. Histological examination of the embolic material revealed its nonthrombotic nature: cardiac embolic papillary elastofibroma (PEF). At discharge, good recovery of right-side hemiplegia was observed. This case report is the second in literature in which a histological confirmed cardiac embolic PEF is reported as a cause of embolic stroke. PEF is a rare but potentially treatable cause of embolic stroke. Understanding the nature of the embolic material would help in choosing the best revascularization approach.

The Italian Registry of Endovascular Treatment in Acute Stroke: rationale, design and baseline features of patients.

Endovascular treatment (ET) showed to be safe in acute stroke, but its superiority over intravenous thrombolysis is debated. As ET is rapidly evolving, it is not clear which role it may deserve in the future of stoke treatments. Based on an observational design, a treatment registry allows to study a broad range of patients, turning into a powerful tool for patients' selection. We report the methodology and a descriptive analysis of patients from a national registry of ET for stroke. The Italian Registry of Endovascular Treatment in Acute Stroke is a multicenter, observational registry running in Italy from 2010. All patients treated with ET in the participating centers were consecutively recorded. Safety measures were symptomatic intracranial hemorrhage, procedural adverse events and death rate. Efficacy measures were arterial recanalization and 3-month good functional outcome. From 2008 to 2012, 960 patients were treated in 25 centers. Median age was 67 years, male gender 57 %. Median baseline NIHSS was 17. The most frequent occlusion site was Middle cerebral artery (46.9 %). Intra-arterial thrombolytics were used in 165 (17.9 %) patients, in 531 (57.5 %) thrombectomy was employed, and 228 (24.7 %) patients received both treatments. Baseline features of this cohort are in line with data from large clinical series and recent trials. This registry allows to collect data from a real practice scenario and to highlight time trends in treatment modalities. It can address unsolved safety and efficacy issues on ET of stroke, providing a useful tool for the planning of new trials.

Brain AVMs: an endovascular, surgical, and radiosurgical update.

Brain arteriovenous malformations (bAVMs) are complex vascular lesions. Despite multiple studies, several classifications, and a great interest of the scientific community, case selection in AVM patients remains challenging. During the last few years, tremendous advancements widened therapeutic options and improved outcomes spreading indications for patients harboring lesions deemed inoperable in the past. Anatomical and biological case specific features, and natural history with a focus on presenting symptoms should be evaluated case by case and always kept in mind while planning a therapeutic management for a bAVMs. A multidisciplinary approach is strongly recommended when dealing with bAVMs and should involve physicians expertise in this kind of challenging lesions. The goal of this paper is to provide a focused review of the most recent acquisitions and therapeutic strategies regarding surgical, endovascular, and radiosurgical treatment.

Italian multicenter experience with flow-diverter devices for intracranial unruptured aneurysm treatment with periprocedural complications--a retrospective data analysis.

INTRODUCTION: We report the experiences of 25 Italian centers, analyzing intra- and periprocedural complications of endovascular treatment of intracranial aneurysms using Silk (Balt Extrusion, Montmorency, France) and pipeline embolization devices (EV3 Inc, Irvine California). METHODS: Two hundred seventy-three patients with 295 cerebral aneurysms, enrolled in 25 centers in Italy and treated with the new flow-diverter devices, were evaluated; 142 patients were treated with Silk and 130 with pipeline (in one case, both devices were used). In 14 (5.2 %) cases devices were used with coils. Aneurysm size was >15 mm in 46.9 %, 5-15 mm in 42.2 %, and <5 mm in 10.8 %. Aneurysm locations were supraclinoid internal carotid artery (ICA) in 163 cases (55.2 %), cavernous ICA in 76 (25.7 %), middle cerebral artery in 11 (3.7 %), PCoA in 6 (2 %), and ACoA in 2 (0.7 %); the vertebrobasilar system accounted for 32 cases (10.8 %) and PCA in 5 (1.7 %). RESULTS: Technical adverse events occurred with 59 patients (21.6 %); 5 patients died after ischemic events, 10 to hemorrhagic complications, and 1 from external ventricular drain positioning. At 1 month, morbidity and mortality rates were 3.7 % and 5.9 %, respectively CONCLUSION: Our retrospective study confirms that morbidity and mortality rates in treatment with FDD of unruptured wide-neck or untreatable cerebral aneurysms do not differ from those reported in the largest series.

Atypical Manifestation of Direct Low-Flow Carotid-Cavernous Fistula: Case Report and Review of the Literature.

BACKGROUND: Carotid cavernous fistula (CCF) is a rare type of arteriovenous shunt that develops within the cavernous sinus (CS). Direct CCFs entail a direct communication between the cavernous internal carotid artery and the CS and are typically high-flow lesions. Most CCFs drain into the ophthalmic veins (typical venous drainage pattern), leading to the pathognomic ocular clinical triad associated with a CCF. When an obstruction of the typical venous outflow is present, the arterial pressure generated by the fistula is transmitted into the cerebral venous system via the sphenoparietal sinus, which might lead to intracerebral hemorrhage. We present a rare case of posttraumatic, direct, low-flow CCF associated with cerebral hemorrhage, a typical venous drainage pattern, and without ocular symptoms at presentation. CASE DESCRIPTION: A 76-year-old woman was hospitalized for a posttraumatic frontotemporopolar hemorrhage associated with multiple fractures of the maxillofacial and cranial base skeleton and midline shift >10 mm. On neurologic examination the Glasgow Coma Scale was 8 and right anisocoria was present. Immediate surgical evacuation of the hematoma was performed. Severe arterial bleeding from the anterior third of the middle cranial fossa floor was controlled intraoperatively. Postoperative brain angio-magnetic resonance imaging and digital subtraction angiography showed a direct CCF without theft phenomenon. Ocular symptoms, and ultimately loss of function of the right eye, appeared 2 weeks from surgery. Endovascular treatment of the CCF was attempted attaining partial closure of the shunt using coils. CONCLUSIONS: Direct low-flow CCFs are exceedingly rare lesions. Five cases have been described in the literature, 4 of which were associated with spontaneous rupture of a cavernous carotid aneurysm while only 1 case was associated with posttraumatic rupture of a cavernous internal carotid artery pseudoaneurysm. In addition, despite our patient having developed an intraparenchymal hemorrhage most probably correlated to the CCF, the latter was associated with a typical venous drainage via the superior ophthalmic vein, which is uncommonly correlated to intraparenchymal bleeding.

The only case of mycotic aneurysm of the PICA: Clinical-radiological remarks and review of literature.

We present the first and only case, reported in literature, of a 67-years-old man with a mycotic aneurysm (MA) of the left posterior inferior cerebellar artery (PICA), caused by group B Streptococcus, that we surgically treated, performing neck aneurysm clipping, preserving patency of parent vessel. Moreover the peculiarity of this case is represented by the fact that the MA is originated from a tooth abscess, treated about two years before. To date, there have been only 10 cases of association between MA with either tooth pathologies or dental surgical procedures and our case is the only one originating from PICA. Therefore an extensive literature analysis was performed. Hence if we observe a patient with a fusiform aneurysm in posterior intracranial circulation and clinical history of fever and/or persistent neck swelling after dental pathologies, it is mandatory to consider the possibility of a MA, for a correct differential diagnosis. If the diagnosis is confirmed, it is necessary to research the origin of infection and to set the specific antibiotics therapy.

Reconstructive endovascular treatment of a ruptured blood blister-like aneurysm of anterior communicating artery.

Blood blister-like aneurysms (BBA) consist of focal wall defects covered with thin fibrous tissue correlated with the marked fragility of their wall; this concept is very important for deciding the right treatment of the latter. Until 2008, it was thought that this type of aneurysm almost exclusively affected the internal carotid artery, and in particular, of its dorsal portion. Subsequently, it was discovered that the BBA may also be present on the anterior communicating artery and on the posterior cranial fossa vessels. In this article, we present a case of anterior communicating artery (AComA) BBA and discuss the unique diagnostic and therapeutic aspects of this vascular lesion. Treatment requires an experienced team of vascular and endovascular neurosurgeons to treat this hazardous group of aneurysms; endovascular stenting techniques avoid maneuvres on the aneurysm itself and should therefore be judged as the lowest risk and first-choice procedures available. We found no reports in the English-language literature of BBA that arose from the AComA treated by a Flow-diverter stent (FDS) in the acute phase. BBA constitute technically challenging lesions that may occur at the AComA. Endovascular treatment offers a lower morbidity-mortality compared with surgical approaches; FDS appear to be a promising strategy.

Endovascular Treatment of Large and Giant Carotid Aneurysms with Flow-Diverter Stents Alone or in Combination with Coils: A Multicenter Experience and Long-Term Follow-up.

BACKGROUND: Although flow diverters (FDs) have been widely accepted by neurointerventionists, their safety has yet to be fully defined. Stratification by aneurysm size and location is essential for correct evaluation of treatment outcomes and risks of flow diversion. OBJECTIVE: To compare neurological and anatomic outcomes and evaluate the risk of complications after endovascular treatment of large or giant internal carotid artery (ICA) aneurysms with FD/FDs alone or together with coil embolization. METHODS: We reviewed all patients with large or giant, ruptured or unruptured ICA aneurysms who underwent endovascular treatment with flow diversion alone (group A) or with concomitant coiling (group B) in 4 international institutions between 2010 and 2015. Anatomic outcome was evaluated using the Byrne scale on digital subtraction angiography and/or angioMRI and/or angioCT scans 3, 6, 12, and 24 months postoperatively. RESULTS: We collected 44 patients with large or giant ICA aneurysms. Four patients (9%) presented with aneurysmal subarachnoid hemorrhage (SAH). FD/FDs were used alone in 26 patients and in combination with coil embolization in the 18 remaining patients. The mortality rate due to procedure-related and/or neurological complications was 2.2%. Twelve months after the procedure, 88.6% (n = 39) of patients had a favorable neurological outcome. One year after the procedure, the aneurysm was completely occluded in 72.7% of patients: 61.5% (16/18) in group A and 88.9% (16/26) in group B. CONCLUSION: Clinical outcomes and rates of intraoperative and postoperative complications did not differ significantly between the groups. Better anatomic results using FD/FDs combined with coils were documented 6 months after the procedure; this option seems to provide a higher aneurysm occlusion rate and reduce the need for retreatment.

Surgical treatment of pial cerebellar arteriovenous fistulas with aneurysm of the main feeding artery.

BACKGROUND: Intracranial pial arteriovenous fistulas (pAVFs) are rare vascular lesions only recently considered distinct from arteriovenous malformations. Conservative management was associated with a high mortality rate. The abnormality of the lesion arises from its high-flow nature. The authors present a case of a cerebellar pAVF associated with aneurysms of the main feeding artery that was surgically treated. CASE DESCRIPTION: A 54-year-old woman was referred to us after an attack of severe headache and vomiting. Computerized tomography scan visualized a hematoma of the fourth ventricle. Digital subtraction angiography (DSA) revealed a cerebellar pAVF mainly fed by the right posteroinferior cerebellar artery (PICA) and with drainage into one of the superior cerebellar veins. The PICA presented a saccular aneurysm on its fourth segment and a fusiform dilatation on its third segment. The patient underwent surgical operation via a midline suboccipital craniotomy. The fusiform dilatation was wrapped and the saccular aneurysm was clipped. The most fistulous connections were closed. The draining vein at the level of torcular herophili was closed by application of a clip. Control DSA demonstrated exclusion of both the aneurysms and the fistula from the circulation. At 1-year follow-up, the patient was neurologically intact. CONCLUSIONS: The association of a cerebellar pAVF and an aneurysm is rare. Surgical treatment of multiple-channel arteriovenous fistulas by closure of venous varix should guarantee the exclusion from the circulation and avoid recruitment of new arterial connections and recurrence. Attention must be paid to normal venous channels draining into the varix.

Blister-like Aneurysms in Atypical Locations: A Single-Center Experience and Comprehensive Literature Review.

OBJECTIVE: Blister-like aneurysms (BLAs) were originally described to arise typically along the nonbranching segment of the dorsal wall of the internal carotid artery (ICA); however, BLAs located in areas other than the dorsal ICA have been described more recently. We present a case series of "atypical" BLAs and a systematic review of the literature on this subject. METHODS: We conducted a literature search using the key word "blister-like aneurysm." Studies reporting BLAs in locations other than the dorsal ICA wall were selected. Clinical presentation, treatment modality, complications, and outcomes (modified Rankin Scale for neurologic outcomes and Roy scale for radiologic outcomes) were extracted from each study. We also reviewed our single-institution experience with atypical BLAs and analyzed the topography and outcomes of all the atypical BLAs according to each specific treatment modality. RESULTS: Atypical BLAs were observed in the anterior communicating, middle cerebral, basilar, posterior cerebral, anterior cerebral, and posterior inferior cerebellar arteries. Surgery was the treatment in 65% of patients, an endovascular approach was used in 30%, and a combined approach was used in 5%. A good outcome (modified Rankin Scale 0-1-2) was experienced by 88% and 55% of the patients in the endovascular and surgical groups, respectively. There were 4 deaths, 2 in the endovascular group and 2 in the surgical group. CONCLUSIONS: Endovascular treatment of BLAs seems to be associated with reduced morbidity and mortality and to provide a better outcome compared with surgical approaches. Further prospective studies are needed to confirm these results. It is important for clinicians to remember that BLAs may also occur in sites other than the typical ICA location.

Curative Reconstruction of Giant Fusiform Intracranial Aneurysms with Flow-Diverter and Self-expanding Stents.

OBJECTIVE AND IMPORTANCE: To demonstrate the curative reconstruction of two giant fusiform aneurysms using a combination of flow-diverter stents and self-expanding stents for intracranial use. CLINICAL PRESENTATION: Two cases that would have been difficult to manage with standard methods: one patient with deficiencies of cranial nerves VI and VII on the left, acute diplopia, and an aneurysm of the vertebrobasilar bifurcation, the other with diplopia, deficiencies of cranial nerves III and VI, and an aneurysm of the intracavernous internal carotid artery. INTERVENTION OR TECHNIQUE: Complete reconstruction was achieved using a combination of flow-diverter and self-expandable stents. Follow-up investigations at 6 months demonstrated the complete reconstruction of the arteries and angiographically determined disappearance of the aneurysms with resolution of the clinical profile. The patients' outcome was excellent (modified Rankin Scale: 0). CONCLUSION: This technique enables safe and definitive treatment of lesions that would be difficult to manage with other methods. The greater metal surface does not seem to interfere with the perforating arteries originating from the segments involved.

Bypass combined with embolization via a venous graft in a patient with a giant aneurysm in the posterior communicating artery and bilateral idiopathic occlusion of the internal carotid artery in the neck.

The authors describe the case of a patient with a symptomatic giant aneurysm of the posterior communicating artery (PCoA) associated with bilateral idiopathic occlusion of the internal carotid artery (ICA). The presence of severe tortuosity of the vertebral arteries (VAs), both at their origin from the subclavian artery and at the level of the third segment, impeded navigation of the catheter for embolization of the aneurysm with Guglielmi detachable coils (GDCs). A direct surgical approach was considered to be a high-risk procedure because of the bilateral occlusion of the ICAs and the size of the aneurysm. The following therapeutic strategy was therefore adopted: 1) balloon occlusion test of the left VA; 2) vertebro-vertebral bypass with saphenous vein graft to provide a pathway for subsequent embolization; 3) ICA-left middle cerebral artery bypass to ensure blood flow in the event that embolization resulted in closure of the PCoA; and 4) GDC embolization of the aneurysm via the posterior circulation graft to ensure complete exclusion of the lesion from the arterial circulation and preservation of the PCoA. At 3-month follow-up review the patient did not present with any neurological deficits; at 1-year control examination, magnetic resonance (MR) imaging and MR angiography both confirmed complete exclusion of the aneurysm and patency of the two bypasses.

Neuroplastic changes in the brain: a case of two successive adaptive changes within the motor cortex.

We describe a case of neuroplasticity associated with both arteriovenous malformation (AVM) and stroke, which occurred in two successive events in the same patient. Functional magnetic resonance imaging (fMRI) during right-hand movement in a young man with a left rolandic AVM detected activation of a region corresponding to the left premotor cortex. The AVM was embolized. A few hours after the last embolization session, the patient sustained an ischemic complication in the left subcortical white matter. A second fMRI detected a lower degree of left premotor cortex activation and strong activation of the contralesional right primary motor cortex and bilateral supplementary motor areas. One month later, in association with clinical recovery, the fMRI activation returned to that observed in the first fMRI, ie, selective activation of the ipsilesional left premotor cortex. This is, to our knowledge, the first description of two distinct functional cortical changes determined by an AVM and a stroke within the motor network.

Surgical treatment of giant intracranial aneurysms: current viewpoint.

OBJECTIVE: Despite new endovascular techniques and technological advances in microsurgery, the treatment of giant intracranial aneurysms is still a daunting neurosurgical task. Many of these aneurysms have a large, calcified neck, directly involve parent and collateral branches, and are partly thrombosed. In this retrospective review, we focused our analysis on the indications for high-flow, extracranial-intracranial (EC-IC) bypass surgery using a saphenous vein graft. METHODS: A series of 130 patients were treated between 1990 and 2004; 31 patients were managed endovascularly, and 99 patients were treated microsurgically (surgical clipping in 58 patients and high-flow EC-IC bypass followed by aneurysm trapping in 41 patients). We examined the patients' clinical records and pre- and postoperative case notes for cerebral angiographic examinations. Graft patency was verified with cerebral angiography, computed tomographic angiography, Doppler ultrasound, or graft palpation. RESULTS: The high-flow EC-IC bypass was used for all surgically treated prepetrous aneurysms (3 patients), intracavernous aneurysms (1 patient), intracavernous aneurysms with subarachnoid extension (23 patients), as well as for some supraclinoid aneurysms (12 of the 32 patients). It was also used for 1 of the 9 aneurysms located in the carotid bifurcation and 2 of 5 vertebrobasilar circulation aneurysms. Of the 58 patients managed by surgical clipping, 4 (6.9%) died, and 51 (94.4%) improved. Of the 41 patients managed with high-flow EC-IC bypass, 4 (9.8%) died and 34 (91.9%) improved. Graft patency at the follow-up examination was 92.7%. CONCLUSION: The "gold standard" for the treatment of giant aneurysms remains surgical clipping. When direct surgical clipping or endovascular repair is contraindicated, the high-flow EC-IC bypass is a viable surgical option.

The Guglielmi detachable coil "crescent" in the endovascular treatment of peripheral brain aneurysms: technical case report.

OBJECTIVE: Peripheral brain aneurysms arise from the distal segments of cerebral arteries. They can be treated by surgery or by an endovascular approach. We present our experience of endovascular treatment of peripheral brain aneurysms with a novel endovascular device, the Guglielmi detachable coil (GDC) "crescent." METHODS: The GDC "crescent" is a 5-mm long, curved coil steerable beyond the tip of a microcatheter and detachable at a distance. The GDC "crescent" was used in three cases of intracranial peripheral aneurysms to occlude their parent vessel. RESULTS: Three peripheral brain aneurysms in three patients were successfully treated with parent vessel occlusion using the prototype GDC "crescent" coils, thereby excluding the aneurysms from the brain circulation. No complications were encountered. CONCLUSION: From this limited experience, the GDC "crescent" seems particularly suitable for the controlled endovascular occlusion of the often-narrow parent artery of distal brain aneurysms.