Balloon assisted Woven endobridge deployment (BAWD): A safety and efficacy study.

BACKGROUND: Balloon-assisted deployment/remodelling is a proven adjunctive technique for coil embolization of intracranial aneurysms, and it may be a helpful adjunct in delivering the Woven EndoBridge (WEB) device. OBJECTIVE: To evaluate the safety, efficacy and feasibility of balloon-assisted WEB deployment in both ruptured and unruptured intracranial aneurysms in both typical and atypical locations. METHODS: Patients who underwent treatment of ruptured and unruptured intracranial aneurysms with the BAWD technique were retrospectively identified from a prospectively maintained database at two neurointerventional centres. Patient demographics, aneurysm characteristics, technical procedure details, clinical and imaging outcomes were reviewed. RESULTS: Thirty-three aneurysms (23 women) were identified with a median age of 58 years. There were 15 (45.5%) ruptured aneurysms, 25 (64.3%) in the anterior circulation and 12 (36.4%) aneurysms having an atypical location for WEB treatment. The average aneurysm size was 6.8 mm (greatest dimension), 4.6 mm (height) and 4.5 mm (width), and 25 (75.8%) aneurysms had a wide neck morphology. One patient died (3.0%) secondary to a procedure-related complication, and there was no procedure-related permanent morbidity. Complete and adequate aneurysm occlusion on mid-term follow-up DSA was 85.2% and 92%, respectively. CONCLUSION: Balloon-assisted WEB deployment appears to be a safe and effective technique that may increase the utility of the WEB device. Further prospective studies on BAWD should be considered.

Urgent computed tomography angiography in paediatric stroke.

AIM: To improve delivery of acute therapies for acute ischaemic stroke (AIS). METHOD: We identified factors influencing the speed of diagnosis and delivery of acute therapies in a prospective cohort of 21 children with suspected AIS (eight with AIS, 13 stroke mimics) and explored them in a retrospective cohort with confirmed AIS. RESULTS: Approximately half of the prospective and total AIS cohorts presented with acute, sustained hemiparesis, and were diagnosed relatively quickly. AIS was suspected and diagnosed more slowly in the half presenting with symptoms other than sustained hemiparesis. Thirty-one out of 51 patients with AIS (19 females, 32 males, mean age 8 years 6 months, SD 5 years 4 months) had arterial abnormalities identified by computed tomography angiography (CTA) or magnetic resonance angiography (MRA): 11 with large vessel occlusion, six with dissection, five with moyamoya disease, nine with other arteriopathies. Among these patients, those initially imaged with CTA were diagnosed more quickly than those with initial magnetic resonance imaging/angiography, which facilitated thrombectomy and thrombolytic therapy. Twenty out of 51 had AIS without arterial abnormalities on CTA or MRA: eight with lenticulostriate vasculopathy and 12 with other small-vessel AIS. Among these patients, 80% were ineligible for thrombolysis for reasons beyond delay to diagnosis, and all showed good outcomes with supportive treatments alone. INTERPRETATION: Clinical features at presentation influence rapidity with which childhood AIS is suspected and diagnosed. Readily available CTA can direct thrombectomy in patients with large vessel occlusion and thrombolysis in most, but not all, eligible patients. WHAT THIS PAPER ADDS: Children with acute ischaemic stroke (AIS) commonly present with symptoms other than sustained hemiparesis. Stroke is more slowly recognized in these patients, which limits potential therapies. Computed tomography angiography (CTA) accurately identifies AIS with large vessel occlusion, enabling timely endovascular thrombectomy. CTA is sufficient to direct thrombolytic therapy in most eligible children. Most childhood AIS without arterial abnormalities identified by CTA had good outcomes.

Thrombectomy in stroke of unknown onset, wake up stroke and late presentations: Australian experience from 2 comprehensive stroke centres.

Two recent randomized controlled trials (RCTs) showed selected patients treated with endovascular thrombectomy (EVT) more than 6 h from acute ischemic stroke (AIS) onset had significant improvement in functional outcome at 90 days compared with standard care alone. Our aim is to determine the outcome and predictors of good outcome in AIS patients undergoing EVT with unknown-onset, or late presentation, stroke after 6 h from time last seen well, or witnessed stroke onset, at two Australian comprehensive stroke centres. A retrospective analysis of functional outcome and mortality at 90-days from a prospective cohort of 56 consecutive patients with unknown-onset, or late presentation, stroke with large vessel occlusion (LVO) in the anterior cerebral circulation undergoing EVT over a 15-month period (2016-2017). We evaluated factors which correlated with good functional outcome defined as a 90-day modified Rankin scale (mRS) 0-2. Recanalization times and symptomatic intracranial haemorrhage (sICH) rates were also examined. A good functional outcome was achieved in 35 patients (62%). Eight patients died (14%). Median time-to-recanalization was 7.6 h. SICH occurred in four patients (7%). Factors which predicted good 90-day functional outcome included baseline National Institutes of Health Stroke Scale (NIHSS) < 16, 24 h NIHSS < 10, baseline Alberta Stroke Program Early CT Score (ASPECTS) ≥ 8, pre-procedural CT perfusion imaging and LVO lesion location. This study shows good 'real world' outcomes, comparable to published RCTs, in patients with unknown-onset, or late presentation, stroke treated with EVT more than 6 h from stroke onset.

Pipeline shield with single antiplatelet therapy in aneurysmal subarachnoid haemorrhage: multicentre experience.

BACKGROUND: The Pipeline Embolisation Device with Shield technology (PED-Shield) is suggested to have reduced thrombogenicity. This reduced thrombogenicity may make it possible to use safely in the acute treatment of aneurysmal subarachnoid haemorrhage (aSAH) on single antiplatelet therapy (SAPT). OBJECTIVE: To evaluate the safety and efficacy of the off-label use of PED-Shield with SAPT for the acute treatment of aSAH. METHODS: Patients who underwent acute treatment of ruptured intracranial aneurysms with the PED-Shield with SAPT were retrospectively identified from prospectively maintained databases at three Australian neurointerventional centres. Patient demographics, aneurysm characteristics, clinical and imaging outcomes were reviewed. RESULTS: Fourteen patients were identified (12 women), median age 64 (IQR 21.5) years. Aneurysm morphology was saccular in seven, fusiform in five, and blister in two. Aneurysms arose from the anterior circulation in eight patients (57.1%). Six (42.9%) patients were poor grade (World Federation of Neurological Societies grade ≥IV) SAH. Median time to treatment was 1 (IQR 0.5) day. Complete or near complete aneurysm occlusion (Raymond-Roy <3) was achieved in 12 (85.7%) patients at the end of early-acute follow-up (median day 7 after SAH). Permanent, treatment-related morbidity occurred in one (7.1%) patient and one (7.1%) treatment-related death occurred. The use of a postoperative heparin infusion (n=5) was associated with a higher rate of all complications (80.0% vs 11.1%, p=0.023) and symptomatic complications (60% vs 0.0%, p=0.028). No symptomatic ischaemic or haemorrhagic complications were observed in the patients who did not receive a post-operative heparin infusion. Nine (64.3%) patients were functionally independent on discharge from the treatment centre. CONCLUSION: The PED-Shield may be safe to use in the acute treatment of ruptured intracranial aneurysms with SAPT. Further investigation with a formal treatment registry is needed.

Long term follow-up of bifurcation aneurysms treated with braided stent assisted coiling and complex T- and Y- stent constructs.

BACKGROUND: Stent assisted coil embolization (SACE) of bifurcation aneurysms is challenging. Heterogeneous results have been achieved to date, but largely for laser cut stents. While braided stents offer multiple technical advantages, their long term efficacy has yet to be validated. OBJECTIVE: To report the first long term 18 month results for the durability of bifurcation aneurysms treated with braided stents. MATERIALS AND METHODS: Over a 4 year period, 59 consecutive patients with 60 bifurcation aneurysms underwent elective braided SACE across three Australian neurovascular centers. 17 of these aneurysms underwent T- or Y-shaped stent constructs. All patients had immediate, 6 month and 18 month clinical and radiological follow-up. Radiological assessment was made on modified Raymond-Roy occlusion scores while clinical assessment was based on the modified Rankin Scale. Subgroup analysis of 17 aneurysms treated with multi-stent constructs was conducted. RESULTS: 6 month follow-up data were available for 59 aneurysms and 18 month follow-up data for 58 aneurysms. Satisfactory aneurysm occlusion was achieved in 97% at inception and at 6 months, and 98% at 18 months. Good neurological outcomes were achieved in 95% at 18 months. Similar satisfactory results were achieved with the multi-stent construct cohort. Intraprocedural thromboembolic events were recorded in 5% and delayed events in 2%. Technical complications were found in 5%. All complication rate was 13%. CONCLUSION: Braided SACE was safe, efficacious, and durable at the long term 18 month follow-up, including for multi-stent constructs. Preliminary results indicate favorable clinical and radiological outcomes compared with laser cut stents.

Long-term follow-up of aneurysms treated electively with woven stent-assisted coiling.

BACKGROUND: Preliminary short-term results for stent-assisted coil embolization (SACE) using woven/braided stents have been promising. However, evidence supporting mid- to long-term efficacy and durability is lacking. OBJECTIVE: To report the long-term results for the durability of elective intracranial aneurysms treated with woven stents. MATERIALS AND METHODS: Between May 2012 and May 2015, 98 consecutive patients with 103 aneurysms underwent elective woven SACE across three Australian neurovascular centres. All patients had immediate, 6- and 18-month clinical and radiological follow-up. Radiological assessment was performed with modified Raymond-Roy occlusion scores based on angiography results, while clinical assessment was based on the modified Rankin Scale. RESULTS: Six-month follow-up was available in 100 aneurysms, and an 18-month follow-up in 97 aneurysms. Total occlusion rates of 82% were achieved at inception, 82% at 6 months, and 90% at 18 months. Satisfactory occlusion with small neck remnants was present in 17% at inception, 16% at 6 months, and 9% at 18 months. Good neurological outcomes were achieved in 95% at 18 months. Intraprocedural thromboembolic events were recorded in 3% and delayed events in 1% (all in patients taking clopidogrel). Aneurysm recurrence occurred in one patient (1%). Technical complications occurred in 5%. The total complication rate was 10%. CONCLUSIONS: Woven SACE is safe, efficacious, and durable at long-term 18-month follow-up, with very low recurrence and re-treatment rates. Preliminary results appear better than those for traditional laser-cut stents.

Cost analysis of intracranial aneurysmal repair by endovascular coiling versus flow diversion: at what size should we use which method?

INTRODUCTION: Flow diverters enable intracranial aneurysmal repair without the need to enter the aneurysm sac. Concerns, however, have been raised regarding the cost compared with coiling techniques. The aim of this study was to evaluate the relative costs for different aneurysm sizes to ascertain if different sizes are more cost-effectively treated by a particular method. METHODS: Patients undergoing aneurysmal repair at two neurovascular referral centres between September 2005 and August 2010 were included; patients who underwent coiling for recurrences of prior microneurosurgical clipping were excluded. These aneurysms were stratified into three size groups. The average and median number of coils or flow diverters and the average and median costs of treatment of each size category were calculated. RESULTS: Four hundred twenty-nine aneurysms were treated. Of these, 409 were coiled with or without assist devices. Forty-eight percent fell under Group A (<7 mm), 36% under Group B (7-12 mm) and 16% under Group C (>12 mm). Twenty aneurysms were flow diverted. Of these, 14 were treated de novo, five previously coiled and one previously clipped. Twenty percent belonged in Group A, 25% in Group B and 55% in Group C. The highest procedural costs in the coiling group were Group C aneurysms requiring stent assistance, with an average of $24 563 (median $23 860). Using flow diversion, the average was $24 650 (median $16 490). CONCLUSION: Given the price parity threshold crossed for aneurysms >12 mm requiring stent assistance and the relative ease of the flow diverter technique, we suggest that flow diversion should be considered the first-line treatment for aneurysms in this category.

Successful endovascular and surgical treatment of spinal extradural metameric arteriovenous malformation. Case report.

A report of successful combined endovascular and surgical management of an unusual case of metameric (juvenile) spinal arteriovenous malformation (AVM) is presented. The malformation had extradural and paraspinal components, but no intradural elements. It had caused rapid neurological deterioration to near-complete paraplegia prior to treatment (American Spinal Injury Association [ASIA] Grade C). A combination of endovascular occlusion of major feeding vessels and excision of the malformation resulted in a complete neurological recovery (ASIA Grade E). The authors conclude that selected metameric AVMs can be successfully treated with multimodal therapy. This case further illustrates the fact that not all spinal vascular malformations are easily categorized.

Catastrophic delayed rupture of a traumatic aneurysm of the distal superior cerebellar artery in a child.

Traumatic aneurysms of the superior cerebellar artery are rare, especially in children. We report a 3-year-old boy who had a catastrophic delayed rupture of a traumatic aneurysm arising from the superior vermian branch of the left superior cerebellar artery. The aneurysm was likely caused by arterial wall laceration following contusion against the free edge of the tentorium. The aneurysm and the superior vermian artery were successfully embolised endovascularly, but the child never recovered and died 3 days later. The pathogenesis, natural history and treatment options of these aneurysms are discussed.

Neuroapplication of amplatzer vascular plug for therapeutic sacrifice of major craniocerebral arteries: an initial clinical experience.

INTRODUCTION: Clinical use of the Amplatzer vascular plug in the cardiopulmonary and peripheral vasculatures has been described extensively in the literature. We present our initial experience in adapting this device for therapeutic sacrifice of major craniocerebral arteries. MATERIALS AND METHODS: Between July 2007 and November 2008, 8 patients (mean age 59.1 years; range 18 to 82 years) underwent therapeutic occlusion of major craniocerebral arteries using the device, for direct caroticocavernous fistula (1 patient), symptomatic unruptured giant cavernous internal carotid aneurysms (2 patients), and preoperative embolisation before surgical resections of skull base tumours that had encroached upon the internal carotid or vertebral artery (5 patients). The plugs were used alone or in conjunction with detachable platinum coils. The applications of the device, as well as the angiographic and clinical results of the procedures were evaluated. RESULTS: Applications of the plugs were straightforward and successful in all cases, with hermetic occlusions of all target arteries. When used without additional coils, several plugs were deployed in tandem to achieve complete occlusion of the artery. No migration of the device was seen. No patient developed untoward neurological deficits following the procedures, and the 3- and/or 6-month follow-up showed stable results. CONCLUSION: The Amplatzer vascular plug could be a valuable addition to the neurointerventional armamentarium, particularly in therapeutic occlusion of major craniocerebral arteries. Rigidity of the delivery system limits its current use to vessels below the skull base. The potential risk of distal thromboembolism also requires further evaluation.

Successful treatment of six cases of indirect carotid-cavernous fistula with ethylene vinyl alcohol copolymer (Onyx) transvenous embolization.

BACKGROUND: Endovascular transvenous treatments have become the mainstay in the management of indirect carotid-cavernous fistulas (CCFs). However, the standard coil techniques are associated with a substantial failure and complication rate. The ethylene vinyl alcohol copolymer (Onyx) Liquid Embolization System has advantages over coils, including the ability to penetrate and occlude vessels of small caliber or with difficult access. METHODS: This was a review of 5 consecutive patients with indirect type D CCFs who underwent 6 procedures using the Onyx system alone at the Prince of Wales Hospital, Sydney, between December 2005 and May 2007. The cavernous sinus was catheterized with MTI Echelon-10 or Rebar-14 microcatheters via the femoral vein using an inferior petrosal approach to the cavernous sinus in 5 procedures and directly via the superior ophthalmic vein in 1 procedure. RESULTS: All 5 patients had complete closure of the fistulas as seen on imaging and full reversal of ophthalmic manifestations without lingering complications and with substantially shorter procedure times than with conventional approaches. CONCLUSIONS: The Onyx system is a safe and useful method of closing indirect CCFs transvenously. This is the first series report of the use of the Onyx system alone in the treatment of these vascular abnormalities.

Selective embolization and resection of a large noninvoluting congenital hemangioma of the lower eyelid.

PURPOSE: To present a combined interventional radiologic and resection technique for the management of a large amblyogenic, highly vascular lesion of the lower eyelid associated with severe mechanical ectropion, conjunctival pyogenic granuloma, and recurrent, spontaneous conjunctival bleeding. METHODS: Preoperative selective embolization and coil placement were followed by resection of the tumor. RESULTS: Embolization, coil placement, and resection were uneventful with cosmetic and functional visual improvement obtained. Pathology indicated a noninvoluting congenital hemangioma. CONCLUSIONS: To the authors' knowledge, this is the first surgical technique reported in the ophthalmic literature for the selective embolization of a noninvoluting congenital hemangioma prior to its resection. Such a technique should be considered in the management of large lesions of this type.

Ruptured fusiform aneurysm of fenestrated A1 segment of the anterior cerebral artery. Case report and review of the literature.

We present a case report of a 56-year-old woman with a ruptured fusiform aneurysm of a fenestrated A(1) segment of the anterior cerebral artery (ACA). Fenestrated A(1) segments are rare and only a few case reports have been published of a saccular type aneurysm formation. To the best of our knowledge, there have been no documented cases of fusiform aneurysms in these segments.

Incidental discovery of a dural arteriovenous fistula in a patient with activated protein C resistance.

A dural arteriovenous fistula was discovered incidentally in a 58-year-old man with activated protein C resistance who underwent routine outpatient cerebral angiography for workup of multiple intracranial aneurysms.

Basilar trunk occlusion during endovascular treatment of giant and fusiform aneurysms of the basilar artery.

Giant and fusiform aneurysms of the basilar artery (BA) are difficult to manage surgically, and they still present a challenge for the neurosurgeon despite progress in posterior fossa surgery. Guglielmi detachable coils have provided an alternative approach to treatment, but they have their own difficulties. We present a series of three patients with BA aneurysms treated with endovascular occlusion of the aneurysm and basilar trunk. Our experience suggests that, in select cases, BA occlusion may be not only safe but also necessary for the effective treatment of these aneurysms.