Evaluation of multidetector CT Hounsfield unit measurements as a predictor of efficacy and complications in percutaneous vertebroplasty for osteoporotic vertebral compression fractures.

Introduction: More than 30 years after the initial experience of Galibert and Deramond with percutaneous vertebroplasty, the procedure has gone through countless refinements and clinical evaluations. Predictors for the success and failure of the procedure in the literature vary and are focused on the duration of complaints, type of fracture, presence of edema on MRI scans, etc. We propose using a quantitative method based on a standard CT examination of the thoracic or lumbar spine to assess the risks and potential success of performing vertebroplasty. Materials and methods: This is a single-center prospective observational study on 139 patients treated with percutaneous vertebroplasty (pVPL) for a single symptomatic osteoporotic vertebral compression fracture (OVCF). We measured the levels of disability and pain preoperatively and again at the 3-, 6- and 12-month marks using the standardized VAS and ODI questionnaires. Every patient in the study was evaluated with postoperative multidetector CT (MDCT) to determine the presence, extent, and localization of vertebral cement leakage and to measure the adjacent vertebrae's minimal and mean density in Hounsfield units (HUmin and HUmean, respectively). Results: We determined that a slight (r = -0.201) but statistically significant (p = 0.018) correlation existed between HU measurements taken from radiologically intact adjacent vertebrae and the procedure's effect concerning the pain levels at the 3-month follow-up. This correlation failed to reach statistical significance at 12 months (p = 0.072). We found no statistically significant relationship between low vertebral cancellous bone density and cement leakage on postoperative scans (p = 0.6 for HUmin and p = 0.74 for HUmean). Conclusion: We have moderately strong data that show a negative correlation between the mean values of vertebral cancellous bone density in patients with OVCF and the effect of pVPL in reducing pain. Lower bone densities, measured this way, showed no increased risk of cement leakage.

Comaneci stent-angioplasty for the optimization of inadequately deployed flow diverter stents.

BACKGROUND AND PURPOSE: In endovascular procedures, inadequate deployment of a flow diverter stent is a highly concerning technical complication that can lead to acute parent vessel occlusion and ischaemic events. This study aimed to assess the off-label use of the Comaneci device in managing technical difficulties associated with flow diversion. MATERIALS AND METHODS: We conducted an analysis of all flow diverter procedures documented in our prospectively collected database. Our objective was to identify patients with inadequately deployed implants who underwent Comaneci stent-angioplasty. Both Comaneci 17 and Comaneci 21 devices were utilized to address and remediate technical complications related to stent deployment. We reviewed anatomical features, technical details, intraprocedural complications, as well as clinical and angiographic outcomes. RESULTS: Thirty-one Comaneci devices were employed to remediate 31 inadequately deployed flow diverter stents. Successful resolution of technical complications associated with flow diverter placement was achieved in all attempted cases. No clinically significant complications were attributed to the technique, and no mortality was observed during the study. CONCLUSION: Technical issues arising from flow diverter stent deployment are formidable complications. Familiarity with appropriate corrective manoeuvres is essential to achieve successful outcomes. The Comaneci device can be safely and effectively incorporated into the range of techniques used to rectify inadequately deployed stents.

And don't forget your anti in-stent stenosis pill! Commentary on 'Factors associated with in-stent stenosis after cerebral aneurysm embolization using a Pipeline embolization device' by Flores-Milan et al.

In their INR study, Flores-Milan et al. present a retrospective single-centre study that aimed to investigate and determine some of the factors associated with in-stent stenosis (ISS) after intracranial aneurysm (IA) embolization using a commercially available flow diverter stent (FD). The retrospective analyses included ruptured and unruptured intracranial aneurysms treated with standalone flow diverter stent implantation or initial coil obliteration with the FD device placed subsequently two weeks after initial treatment. The article's methodology was carefully tailored to demystify the unknown pathophysiological mechanism behind the entity of interest called in-stent stenosis. Study outcomes also included angiographic evaluation of aneurysm occlusion thrombotic and hemorrhagic events. The authors reported excellent technical and clinical results altogether. The achieved angiographic occlusion rates resonate with the current obliteration results reported in the literature. Mortality and morbidity are congruent with previously published results and were 5.3% and 1.1%, respectively.

Endovascular treatment of wide-necked intracranial aneurysms using the Nautilus Intrasaccular System: initial case series of 41 patients at a single center.

BACKGROUND: Endovascular treatment of intracranial wide-necked and bifurcation aneurysms (WNBA) is technically challenging. The Nautilus Intrasaccular System is designed to provide a mechanical barrier at the aneurysm neck to support coil embolization. We report the results of a single-center series of patients treated for intracranial aneurysms with the Nautilus. METHODS: Clinical and radiological data were retrospectively collected for all patients treated with the Nautilus for an unruptured or ruptured intracranial aneurysm at our center between March 2021 and March 2022. Clinical outcomes (modified Rankin Scale (mRS) scores), Raymond-Roy angiographic occlusion, recanalization, and complications were measured immediately post-procedure and at 3-6-month follow-up. RESULTS: A total of 41 patients of mean age 56.7 years (range 37-83 years) were treated with the Nautilus, with 41 saccular aneurysms (18 (43.9%) unruptured and 23 (56.1%) ruptured). The majority of aneurysms (39/41 (95.1%)) were located in the anterior circulation. We experienced no technical complications. One patient had an asymptomatic post-procedural minor stroke related to the procedure. Immediate Class I occlusion was achieved in 30 (73.1%) patients. The rate of all-cause mortality was 7.3% (3/41). One patient was lost to follow-up. At follow-up, 94.5% (35/37) of patients achieved Class I occlusion and 94.5% (35/37) had an mRS score of 0. There were no procedural-related deaths or permanent morbidities at discharge or follow-up. CONCLUSION: This study demonstrates good safety and effectiveness using the Nautilus Intrasaccular System to treat both ruptured and unruptured intracranial aneurysms. Larger studies are needed to confirm these findings.

Mechanical Comaneci 17-stent angioplasty for a sub-optimally deployed flow-diverter stent.

Flow diverter stents are increasingly used as the sole endovascular treatment method for complex or wide-necked intracranial aneurysms.1 Technical complications related to stent deployment are infrequently reported in the literature. During treatment, implant misbehaviors may occur, including incomplete tubular expansion with insufficient aneurysmal coverage and wall apposition, proximal or distal narrowing, and twisting along the axis.2- 4 Little is known about this phenomenon, especially if it relates to the operator experience, deployment techniques, different devices, and implant properties. The management of these complications requires technical precision and is often remediated by "massaging" the stent with the delivery system, balloon angioplasty, or placement of additional self-expandable stents. Lastly, if critically damaged, the stent could be taken out of the vessel with a combination of maneuvers called "stentectomy."5 These techniques often necessitate multiple navigations and the utilization of a larger microcatheter. We aim to highlight the feasibility of Comaneci 17 stent-angioplasty as an effective bailout strategy for inadequately deployed flow diverter stents. The suggested approach's technical aspects, including pros and cons, have been discussed.

Critical Angiographic and Sonographic Analysis of Intra Aneurysmal and Downstream Hemodynamic Changes After Flow Diversion.

Introduction: Successful treatment of intracranial aneurysms after flow diversion (FD) is dependent on the flow modulating effect of the device. We aimed to investigate the intra-aneurysmal and parent vessel hemodynamic changes, as well as the incidence of silent emboli following treatment with various FD devices. Methods: We evaluated the appearance of the eclipse sign in nine distinct phases of cerebral angiography before and immediately after FD placement in correlation with aneurysm occlusion. Angiographic and clinical data of consecutive procedures were analyzed retrospectively. Patients who had successful FD procedure without adjunctive coiling, visible eclipse sign on post embolization angiography, and reliable follow-up angiographic data were included in the analysis. Detailed analysis of hemodynamic data from transcranial doppler after FD was performed in selected patients, such as monitoring for silent emboli. Results: Among all patients (N = 65) who met inclusion criteria, complete aneurysm occlusion at 12 months was achieved in 89% (58/65). Eclipse sign prior to FD was observed in 42% (27/65) with unchanged appearance in 4.6% (3/65) of the treated patients. None of these three patients achieved complete aneurysm occlusion. Among all analyzed variables, such as aneurysm size, device type used, age, and appearance of the eclipse sign pre- and post-FD, the most reliable predictor of permanent aneurysm occlusion at 12 months was earlier, prolonged, and sustained eclipse sign visibility in more than three angiographic phases in comparison to the baseline (p < 0.001). Elevation in flow velocities within the ipsilateral vascular territory was noted in 70% (9/13), and bilaterally in 54% (7/13) of the treated patients. None of the patients had silent emboli. Conclusions: Intra-aneurysmal and parent vessel hemodynamic changes after FD can be reliably assessed by the cerebral angiography and transcranial doppler with important implications for the prediction of successful treatment.

Developmental venous anomaly causing obstructive hydrocephalus due to aqueductal stenosis: а case report.

Cerebral developmental venous anomalies are asymptomatic benign cerebrovascular malformations that are commonly found accidentally on brain magnetic resonance imaging. It is not uncommon for cerebrospinal fluid flow to be obstructed at the level of the aqueduct of Sylvius, causing an obstructive non-communicating hydrocephalus. Most notable reasons for such an obstruction at that level are tumors, congenital etiology, or post-inflammatory gliotic atresia.

Nautilus-assisted coil embolization for a complex AcomA wide-necked aneurysm in the setting of acute subarachnoid hemorrhage.

Numerous devices and sophisticated strategies have been developed to further increase the number of aneurysms amenable to endovascular treatment.1-4 Despite the superfluity of available neurovascular armamentarium, wide-necked bifurcation aneurysms can still pose a significant technical challenge to the treating clinician.5-7 Neck bridging is a conceptually new approach, which provides increased occlusion rates with lower recurrence and complications rates.8-10 The Nautilus (EndoStream Medical) is an intrasaccular bridging device intended to assist in coil embolization of wide-necked cerebral aneurysms. This CE-marked device, available in various sizes, consists of flexible-layers, and is a nitinol-based, detachable implant. The device is delivered through a standard microcatheter with a minimal 0.0165" inner diameter and is fully radiopaque and completely resheathable.Owing to its unique 'tornado' like shape the device entirely reconstructs the aneurysmal neck, which facilitates the following coil embolization. In this video 1, we demonstrate the use of Nautilus - assisted coil embolization for a complex anterior communicating artery (AcomA) wide-necked aneurysm in the setting of acute subarachnoid hemorrhage. neurintsurg;14/3/310/V1F1V1Video 1.

Diversion-p64: results from an international, prospective, multicenter, single-arm post-market study to assess the safety and effectiveness of the p64 flow modulation device.

BACKGROUND: The use of flow diversion to treat intracranial aneurysms has increased in recent years. OBJECTIVE: To assess the safety and angiographic efficacy of the p64 flow modulation device. METHODS: Diversion-p64 is an international, prospective, multicenter, single-arm, study conducted at 26 centers. The p64 flow modulation device was used to treat anterior circulation aneurysms between December 2015 and January 2019. The primary safety endpoint was the incidence of major stroke or neurologic death at 3-6 months, with the primary efficacy endpoint being complete aneurysm occlusion (Raymond-Roy Occlusion Classification 1) on follow-up angiography. RESULTS: A total of 420 patients met the eligibility criteria and underwent treatment with the p64 flow modulation device (mean age 55±12.0 years, 86.2% female). Mean aneurysm dome width was 6.99±5.28 mm and neck width 4.47±2.28 mm. Mean number of devices implanted per patient was 1.06±0.47, with adjunctive coiling performed in 14.0% of the cases. At the second angiographic follow-up (mean 375±73 days), available for 343 patients (81.7%), complete aneurysm occlusion was seen in 287 (83.7%) patients. Safety data were available for 413 patients (98.3%) at the first follow-up (mean 145±43 days) with a composite morbidity/mortality rate of 2.42% (n=10). CONCLUSIONS: Diversion-p64 is the largest prospective study using the p64 flow modulation device. The results of this study demonstrate that the device has a high efficacy and carries a low rate of mortality and permanent morbidity.

Nautilus-Assisted Coiling of an Unruptured Wide-Necked Aneurysm of the Posterior Communicating Artery.

A variety of recently introduced devices have allowed more complex aneurysms to be rendered for endovascular embolization. Tiny and sophisticated implants are nowadays designed to provide further either temporary or permanent remodeling of the wide-necked aneurysms and improve coil occlusion rates.1-4 Such improvements in the technical armamentarium include the Woven EndoBridge (Sequent Medical, California, USA), the Medina Embolic Device (Medtronic, Irvine, California, USA), The Contour Neurovascular System (Cerus Endovascular, Fremont, California, USA), and pCONUS 2 HPC (Phenox, GmbH, Bohum, Germany).5-7 Intrasaccular neck bridging is a conceptually new technique descending from the theoretical combination of intrasaccular flow diversion and temporary-stent assisted coiling.8 The Nautilus (EndoStream Medical, Tel Aviv, Israel) is an intrasaccular bridging device that offers complete neck reconstruction in coil embolization of wide-neck cerebral aneurysms. It has been granted a CE mark by the European Union. The detachable intrasaccular implant comprises flexible and "tornado-like"-shaped Nitinol-based layers. The device is compatible with a standard microcatheter with minimal 0.0165″ inner diameter and is fully radiopaque and fully resheathable. The device's intrasaccular nature and the fact that it does not harbor any intraluminal satellite parts suggest that the implant can be safely used in both unruptured and ruptured case scenarios without the need for dual antiplatelet therapy. This is what we consider a great advantage of the proposed technique over the alternative options of intrasaccular and intraluminal flow diversion. This technical video (Video 1) demonstrates the successful obliteration of a complex posterior communicating artery aneurysm with Nautilus-assisted endovascular coiling. To our knowledge, this is the first technical video demonstrating an in-vivo and step-by-step implementation of this novel device.

Acutely ruptured basilar artery bifurcation aneurysm, treated with simultaneous Cascade and Comaneci temporary-assisted coiling.

Temporary stent-assisted coiling is an eligible approach for the treatment of acutely ruptured complex cerebral aneurysms. Improved material properties and industrial advances in braiding technology have led to the introduction of new stent-like devices to augment endovascular coil embolization. Such technology includes the Cascade and Comaneci neck-bridging devices. Both devices are manually controlled, non-occlusive and fully retrievable neck-bridging temporary implants. The braided nature and the ultra-thin wire, compliant structure of their bridging meshes helps maintain target vessel patency during coil embolization. In this video (video 1) we demonstrate the straightforward combination of two temporary neck-bridging devices for the embolization of an acutely ruptured aneurysm of the basilar artery. Technical success and complete embolization of the aneurysm were recorded at the final angiography. In this technical video we discuss the technical nuances of the Comaneci and Cascade coil embolization. neurintsurg;13/2/196/V1F1V1Video 1.

The p48 MW flow modulation device for treatment of unruptured, saccular intracranial aneurysms: a single center experience from 77 consecutive aneurysms.

BACKGROUND: The p48 MW Flow Modulation Device (phenox, Bochum Germany) is a low profile flow diverter stent (FDS), designed for implantation into intracranial arteries with a diameter of less than 3.5 mm. OBJECTIVE: To evaluate the safety and efficacy of the p48 MW FDS in the treatment of unruptured aneurysms located at intracranial arteries with less than 3.5 mm diameter based on a retrospective analysis from a single tertiary neurovascular center. METHODS: A prospectively maintained database was retrospectively reviewed to identify all cases of intracranial saccular aneurysms treated electively with the p48 MW device. Records were made of basic demographics, aneurysmal characteristics, interventional procedures, adverse events, clinical outcomes and occlusion rates on angiographic follow-ups. RESULTS: A total of 77 aneurysms and 74 patients were included. The mean size of the treated aneurysms was 3.5 ± 2.4 mm and the mean aspect ratio was 1.3 ± 0.4. A total of 80 endovascular procedures were performed with a total of 12 (15%) adverse events leading to two (2.5%) permanent morbidities/mortalities. Technical issues were encountered in 3 (3.9%) cases. Adequate occlusion of the treated aneurysm was recorded in 55.6% and 63.9% on the first and latest available DSA follow-ups, respectively. There were no cases of side-branch occlusion. CONCLUSIONS: The p48 MW is an easy-to-use implant with very good safety margins. Side branch occlusion and significant in-stent stenosis are infrequently encountered. The time from implantation to sufficient aneurysm occlusion takes longer than with FDS with lower porosity.

Endovascular treatment of patients with intracranial aneurysms: feasibility and successful employment of a new low profile visible intraluminal support (LVIS) EVO stent.

BACKGROUND AND PURPOSE: Low-profile self-expandable stents have increased the number of intracranial aneurysms treated by endovascular means. The new low-profile visible intraluminal support device LVIS EVO (Microvention), the successor of LVIS Jr, is a self-expandable and retrievable microstent system, designed for implantation into intracranial arteries with a diameter up to 2.0 mm. In this retrospective study we aimed to elucidate the technical feasibility and clinical safety of the novel LVIS EVO stent for stent-assisted coil embolisation of intracranial aneurysms. MATERIALS AND METHODS: A single centre technical report of the first six consecutive cases of stent-assisted coil embolisation with the novel LVIS EVO stent for the treatment of unruptured or recanalised intracranial aneurysms. Records were made of basic demographics, aneurysmal characteristics, device properties and related technical details, adverse events, clinical outcomes and occlusion rates on available radiological follow-up. RESULTS: Six LVIS EVO devices were successfully implanted in all subjects to treat a total number of six intracranial aneurysms. No device-related intraprocedural complications were seen. At early clinical follow-up six out of six (100%) patients had a modified Ranking score of 0-1. Early angiographic and cross-sectional radiological follow-up, available in five out of six (83.3%) of the patients confirmed unchanged aneurysmal occlusion rates. A minor, transitory neurological deficit was recorded in one of the six (16.6%) patients. Mortality was 0%. CONCLUSIONS: Preliminary experience in this subset of our patients confirms a notably improved technical behaviour of the novel LVIS EVO stent system when compared to its ancestor LVIS Jr. The enhanced visibility of the stent and the refined delivery/retrieval capabilities of the stent further increase the safety margins of the devices profile, especially in cases of tortuous anatomy.

Transvenous Embolization of a Ruptured Arteriovenous Malformation.

Transvenous embolization is a not so widely used technique for treatment of arteriovenous malformations.1,2 However, in the reported cases and series in the literature, it is proven to be a safe and efficient method that can lead to total occlusion of the formation in 1 procedure.2-5 The transvenous approach is reserved for small, deeply localized formations with a single draining vein.2-4 In this video, we present a case of a successful single-session transvenous embolization of a ruptured arteriovenous malformation with Onyx. Prior to the injection of the liquid embolic agent, coils were deployed at the proximal part of the draining vein. A balloon was inflated at the arterial part to decrease the pressure inside the nidus, therefore ensuring better penetration of the embolic agent. Control angiogram at the end of the procedure showed total occlusion of the nidus of the arteriovenous malformation.

Comaneci-Assisted Coiling as a Treatment Option for Acutely Ruptured Wide Neck Cerebral Aneurysm: Case Series of 118 Patients.

BACKGROUND: Wide-necked cerebral aneurysms in the setting of acute subarachnoid hemorrhage (SAH) remain difficult to treat with endovascular methods despite recent progress in the neuroendovascular field. OBJECTIVE: To evaluate the effectiveness and safety of the Comaneci device (Rapid Medical, Israel) in endovascular coil embolization of acutely ruptured, wide-necked sidewall, or bifurcation cerebral aneurysms. METHODS: We retrospectively reviewed 45 anterior communicating artery, 24 internal carotid artery, 21 middle cerebral artery bifurcation, 15 anterior cerebral artery, and 13 posterior circulation aneurysms, which were treated using Comaneci-assisted coil embolization from August 2017 to January 2019. We evaluated procedural complications, clinical outcomes, and mid-term angiographic follow-up. Immediate and 90 d-clinical outcome and radiological follow-up were obtained in all patients. RESULTS: Comaneci-assisted coil embolization was performed in 118 acutely ruptured aneurysms. The technique was carried out successfully in all cases. Simultaneous application of 2 separated Comaneci devices was performed in 8/118 cases (6.77%). Periprocedural thromboembolic complications related to the device were seen in 7/118 cases (5.93%) and severe vasospasm of the parent artery after manipulation of the Comaneci device occurred in 5/118 cases (4.2%). The procedural-related morbidity rate was 2.54%, and there was no procedural related mortality. Among the available survivors, angiographic follow-ups were obtained at 3 and 6 mo, and complete aneurysmal obliteration was confirmed in 81/112 (72.3%) and 75/112 (66.9%) cases, respectively. Mid-term follow-up reviewed total recanalization rate of 14.28%. CONCLUSION: Comaneci-assisted embolization of wide-necked intracranial aneurysms in patients presenting with acute SAH is associated with high procedural safety and adequate occlusion rates. Furthermore, dual antiplatelet therapy can be safely avoided in this patient group.

Early clinical experience with Cascade: a novel temporary neck bridging device for embolization of intracranial aneurysms.

BACKGROUND: Temporary placement of a retrievable neck bridging device, allowing parent vessel flow, is an attractive alternative to balloon remodeling for treatment of ruptured intracranial aneurysms. OBJECTIVE: To present, in a single-center study, our initial experience with Cascade (Perflow, Israel) in the treatment of ruptured intracranial aneurysms. METHODS: During a period of 1.5 months, 12 patients with aneurysmal subarachnoid hemorrhage underwent coil embolization in conjunction with Cascade in our center. Retrospective analysis of prospectively collected angiographic and clinical data was conducted to assess the safety and efficacy of the device. RESULTS: Among all treated patients, 41.7% (5/12) were female, the median age was 55 (47-77) years, the median aneurysm dome size was 5.75 mm (3-9.1), and the median neck size was 3.55 mm (2.3-7.9). Complete obliteration (Raymond 1) was achieved in 75% (9/12) of cases, and intentional residual neck (Raymond 2) was left in three cases (25%). None of the patients received any oral or intravenous antiplatelet therapy perioperatively. No thromboembolic complications, device-related spasm, vessel perforation, or coil entanglement were detected in any of the treated patients. CONCLUSIONS: In our initial experience, treatment of wide-neck ruptured intracranial aneurysms with Cascade is safe and effective, without the need for adjuvant antiplatelet therapy. Long-term follow-up data in larger cohorts are needed to confirm these preliminary findings.