Use of the Woven EndoBridge Device for Sidewall Aneurysms: Systematic Review and Meta-analysis.

BACKGROUND: The Woven EndoBridge device was originally approved to treat intracranial wide-neck saccular bifurcation aneurysms. Recent studies have suggested its use for the treatment of sidewall intracranial aneurysms with variable success. PURPOSE: Our aim was to evaluate the safety and efficacy of the Woven EndoBridge device for sidewall aneurysms using a meta-analysis of the literature. DATA SOURCES: We performed a systematic review of all studies including patients treated with the Woven EndoBridge device for sidewall aneurysms from inception until May 2022 on Scopus, EMBASE, MEDLINE, the Web of Science, and the Cochrane Central Register of Controlled Trials. STUDY SELECTION: Ten studies were selected, and 285 patients with 288 sidewall aneurysms were included. DATA ANALYSIS: A random-effects meta-analysis of proportions using a generalized linear mixed model was performed as appropriate. Statistical heterogeneity across studies was assessed with I2 statistics. DATA SYNTHESIS: The adequate occlusion rate at last follow-up was 89% (95% CI, 81%-94%; I2, = 0%), the composite safety outcome was 8% (95% CI, 3%-17%; I2 = 34%), and the mortality rate was 2% (95% CI, 1%-7%; I2 = 0%). Aneurysm width (OR = 0.5; P = .03) was the only significant predictor of complete occlusion. LIMITATIONS: Given the level of evidence, our results should be interpreted cautiously until confirmation from larger prospective studies is obtained. CONCLUSIONS: The initial evidence evaluating the use of the Woven EndoBridge device for the treatment of wide-neck sidewall intracranial aneurysms has demonstrated high rates of adequate occlusion with low procedural complications. Our findings favor the consideration of the Woven EndoBridge device as an option for the treatment of sidewall aneurysms.

Intra-Arterial Chemotherapy for Retinoblastoma in Infants ≤10 kg: 74 Treated Eyes with 222 IAC Sessions.

BACKGROUND AND PURPOSE: Intra-arterial chemotherapy for retinoblastoma has dramatically altered the natural history of the disease. The remarkable outcomes associated with a high safety profile have pushed the envelope to offer treatment for patients weighing ≤10 kg. The purpose was to determine the efficacy and safety of IAC infusions performed in infants weighing ≤10 kg with intraocular retinoblastoma. MATERIALS AND METHODS: A retrospective chart review was performed for patients diagnosed with retinoblastoma and managed with intra-arterial chemotherapy. RESULTS: The total study cohort included 207 retinoblastoma tumors of 207 eyes in 196 consecutive patients who underwent 658 intra-arterial chemotherapy infusions overall. Of these, patient weights were ≤10 kg in 69 (35.2%) and >10 kg in 127 (64.8%) patients. Comparison (≤10 kg versus >10 kg) revealed that the total number of intra-arterial chemotherapy infusions was 222 versus 436. Periprocedural complications were not significantly different (2 [0.9%] versus 2 [0.5%]; P = .49). Cumulative radiation exposure per eye was significantly lower in infants weighing ≤10 kg (5.0 Gym2 versus 7.7 Gym2; P = .01). Patients weighing ≤10 kg had a greater frequency of complete tumor regression (82.6% versus 60.9%; P = .02). Mean fluoroscopy time was not significantly different (7.5 versus 7.2; P = .71). There was a significant difference in the frequency of enucleation (16 [21.6%] versus 52 [39.1%]; P = .01). Patients weighing ≤10 kg had greater number of aborted procedures (12 [5.4%] versus 7 [1.6%]; P = .01). On multivariate analysis, weight ≤10 kg was not an independent predictor of complications or procedure failure. CONCLUSIONS: Intra-arterial chemotherapy in patients weighing ≤10 kg is a safe and effective treatment.

Pipeline-assisted coiling versus pipeline in flow diversion treatment of intracranial aneurysms.

BACKGROUND AND PURPOSE: Flow-diversion therapy (FDT) for large and complex intracranial aneurysms is effective and considered superior to primary coil embolization. Data evaluating common treatment with both FDT and coiling continues to emerge, but information on outcomes remains scarce. This study aims to examine further the efficiency and outcomes correlated with joint FDT using pipeline embolization device (PED) and coiling compared to PED-alone in treating intracranial aneurysms. MATERIALS AND METHODS: Comparative review and analysis of aneurysm treatment with PED in 416 subjects were conducted. Joint modality, PED, and coiling were compared to PED-alone for aneurysm occlusion, recurrence, retreatment, thromboembolic or hemorrhagic events, and functional outcome using the modified Rankin Scale. Data on patient demographics, aneurysm characteristics, clinical and angiographic follow up, were also collected. Both univariate analysis and multivariate logistic regression modeling using mixed-effects were performed. RESULTS: Total of 437 aneurysms were treated using PED of which 74 were managed with both PED and coiling. Average patient-age was 56 years, the majority were men (85%), an average aneurysm size was 9 mm, and the majority were saccular aneurysms (84%). Larger aneurysm size was associated with a poor outcome in patients with unruptured aneurysms (OR = 1.06). Adjusted regression analyses revealed no differences between treatment groups in thromboembolic or hemorrhagic events, aneurysm occlusion rate, residual flow on follow up angiography, or functional outcome. CONCLUSIONS: Treatment of intracranial aneurysms with joint PED and coiling was safe with no increase in complications when compared to PED alone. Aneurysm occlusion rates and functional outcome with PED and coiling stays comparable to treatment with PED-alone.

Lack of Association between Statin Use and Angiographic and Clinical Outcomes after Pipeline Embolization for Intracranial Aneurysms.

BACKGROUND AND PURPOSE: Use of statin medications has been demonstrated to improve clinical and angiographic outcomes in patients receiving endovascular stent placement for coronary, peripheral, carotid, and intracranial stenoses. We studied the impact of statin use on long-term angiographic and clinical outcomes after flow-diverter treatment of intracranial aneurysms. MATERIALS AND METHODS: We performed a post hoc analysis from pooled patient-level datasets from 3 Pipeline Embolization Device studies: the International Retrospective Study of the Pipeline Embolization Device, the Pipeline for Uncoilable or Failed Aneurysms Study, and the Aneurysm Study of Pipeline in an Observational Registry. We analyzed data comparing 2 subgroups: 1) patients on statin medication, and 2) patients not on statin medication at the time of the procedure and follow-up. Angiographic and clinical outcomes were compared by using the χ2 test, Fisher exact test, or Wilcoxon rank sum test. RESULTS: We studied 1092 patients with 1221 aneurysms. At baseline, 226 patients were on statin medications and 866 patients were not on statin medications. The mean length of clinical and angiographic follow-up was 22.1 ± 15.1 months and 28.3 ± 23.7 months, respectively. There were no differences observed in angiographic outcomes at any time point between groups. Rates of complete occlusion were 82.8% (24/29) versus 86.4% (70/81) at 1-year (P = .759) and 93.3% (14/15) versus 95.7% (45/47) at 5-year (P = 1.000) follow-up for statin-versus-nonstatin-use groups, respectively. There were no differences in any complication rates between groups, including major morbidity and neurologic mortality (7.5% versus 7.1%, P = .77). CONCLUSIONS: Our study found no association between statin use and angiographic or clinical outcomes among patients treated with the Pipeline Embolization Device.

Risk Factors for Ischemic Complications following Pipeline Embolization Device Treatment of Intracranial Aneurysms: Results from the IntrePED Study.

BACKGROUND AND PURPOSE: Risk factors for acute ischemic stroke following flow-diverter treatment of intracranial aneurysms are poorly understood. Using the International Retrospective Study of Pipeline Embolization Device (IntrePED) registry, we studied demographic, aneurysm, and procedural characteristics associated with postoperative acute ischemic stroke following Pipeline Embolization Device (PED) treatment. MATERIALS AND METHODS: We identified patients in the IntrePED registry with post-PED-treatment acute ischemic stroke. The rate of postoperative acute ischemic stroke was determined by demographics, comorbidities, aneurysm characteristics, and procedure characteristics (including anticoagulation use, platelet testing, number of devices used, sheaths, and so forth). Categoric variables were compared with χ(2) testing, and continuous variables were compared with the Student t test. Odds ratios and 95% confidence intervals were obtained by using univariate logistic regression. Multivariate logistic regression analysis was used to determine which factors were independently associated with postoperative stroke. RESULTS: Of 793 patients with 906 aneurysms, 36 (4.5%) patients had acute ischemic stroke. Twenty-six (72.2%) strokes occurred within 30 days of treatment (median, 3.5 days; range, 0-397 days). Ten patients died, and the remaining 26 had major neurologic morbidity. Variables associated with higher odds of acute ischemic stroke on univariate analysis included male sex, hypertension, treatment of MCA aneurysms, treatment of fusiform aneurysms, treatment of giant aneurysms, and use of multiple PEDs. However, on multivariate analysis, the only one of these variables independently associated with stroke was treatment of fusiform aneurysms (OR, 2.74; 95% CI, 1.11-6.75; P = .03). Fusiform aneurysms that were associated with stroke were significantly larger than those not associated with stroke (mean, 24.5 ± 12.5 mm versus 13.6 ± 6.8 mm; P < .001). CONCLUSIONS: Ischemic stroke following PED treatment is an uncommon-but-devastating complication. Fusiform aneurysms were the only variable independently associated with postoperative stroke.

Pipeline Embolization Device with or without Adjunctive Coil Embolization: Analysis of Complications from the IntrePED Registry.

Flow diversion to treat cerebral aneurysms has revolutionized neurointerventional surgery. Because the addition of coils potentially increases the time and complexity of endovascular procedures, we sought to determine whether adjunctive coil use is associated with an increase in complications. Patients in the International Retrospective Study of Pipeline Embolization Device registry were divided into those treated with the Pipeline Embolization Device alone (n = 689 patients; n = 797 aneurysms; mean aneurysm size, 10.3 ± 7.6 mm) versus those treated with the Pipeline Embolization Device and concurrent coil embolization (n = 104 patients; n = 109 aneurysms; mean aneurysm size, 13.6 ± 7.8 mm). Patient demographics and aneurysm characteristics were examined. Rates of neurologic morbidity and mortality were compared between groups. The Pipeline Embolization Device with versus without coiling required a significantly longer procedure time (135.8 ± 63.9 versus 96.7 ± 46.2 min; P < .0001) and resulted in higher neurological morbidity (12.5% versus 7.8%; P = .13). These data suggest that either strategy represents an acceptable risk profile in the treatment of complex cerebral aneurysms and warrants further investigation.

Pipeline Embolization Device in the Treatment of Recurrent Previously Stented Cerebral Aneurysms.

BACKGROUND AND PURPOSE: The use of the Pipeline Embolization Device in the management of recurrent previously stented cerebral aneurysms is controversial. The aim of this study was to evaluate the efficacy and safety of the Pipeline Embolization Device in the treatment of recurrent, previously stented aneurysms. MATERIALS AND METHODS: Twenty-one patients with previously stented recurrent aneurysms who later underwent Pipeline Embolization Device placement (group 1) were retrospectively identified and compared with 63 patients who had treatment with the Pipeline Embolization Device with no prior stent placement (group 2). Occlusion at the latest follow-up angiogram, recurrence and retreatment rates, clinical outcome, complications, and morbidity and mortality observed after treatment with the Pipeline Embolization Device were analyzed. RESULTS: Patient characteristics were similar between the 2 groups. The mean time from stent placement to recurrence was 25 months. Pipeline Embolization Device treatment resulted in complete aneurysm occlusion in 55.6% of patients in group 1 versus 80.4% of patients in group 2 (P = .036). The retreatment rate in group 1 was 11.1% versus 7.1% in group 2 (P = .62). The rate of good clinical outcome at the latest follow-up in group 1 was 81% versus 93.2% in group 2 (P = .1). Complications were observed in 14.3% of patients in group 1 and 9.5% of patients in group 2 (P = .684). CONCLUSIONS: The use of the Pipeline Embolization Device in the management of previously stented aneurysms is less effective than the use of this device in nonstented aneurysms. Prior stent placement can worsen the safety and efficacy profile of this device.

Rescue intra-arterial chemotherapy following retinoblastoma recurrence after initial intra-arterial chemotherapy.

PURPOSE: To determine the efficacy of rescue intra-arterial chemotherapy (IAC) for retinoblastoma recurrence following failed initial IAC. METHODS: Retrospective, non-comparative, interventional case series of 12 eyes in 12 patients. INTERVENTION: Rescue IAC employed chemotherapy agents of melphalan (5mg, 7.5mg) alone or with additional topotecan (1mg). MAIN OUTCOME MEASURE: Tumor control and globe salvage. RESULTS: The median patient age at initial presentation was 16 months. At initial examination, the International Classification of Retinoblastoma grouping was group B (n=1), group D (n=7), or group E (n=4). The initial IAC was primary in 5 cases (42%) and secondary following failure of intravenous chemotherapy in 7 (58%). In all cases, initial IAC was delivered using melphalan 3mg (n=3), melphalan 5mg (n=7), or combination melphalan 5mg/topotecan 1mg (n=2) for a median of 3 cycles. The mean interval from initial IAC to recurrence necessitating rescue IAC was 5 months (median 4, range 2-10 months). Of the 12 patients, 3 (25%) had undergone previous enucleation of the opposite eye and the rescue IAC was planned for the only remaining eye. Rescue IAC was delivered for recurrent solid tumor (n=1), recurrent subretinal seeds (n=7), recurrent vitreous seeds (n=1), or combination recurrent subretinal/vitreous seeds (n=3). IAC was technically successful through the ophthalmic artery in 9 cases (75%) or the middle meningeal artery in 3 (25%). Rescue IAC involved median 3 cycles (mean 3, range 2-4 cycles) of higher dose melphalan in 4 cases (33%) or combination melphalan/topotecan in 8 (67%). At mean follow-up of 20 months (median 14 months, range 7-36 months), complete tumor control was achieved in 9 eyes (75%) and globe salvage in 8 eyes (67%). Of the 3 failure eyes, all were initially groups D or E, previously treated with initial IAC, and 2 had previous intravenous chemotherapy. There were 4 eyes that came to enucleation for persistent subretinal/vitreous seeds (n=3) or neovascular glaucoma without viable tumor (n=1). There was no case of cerebrovascular stroke, systemic metastasis, or death. CONCLUSION: Rescue IAC following retinoblastoma recurrence after initial IAC provided tumor control in 75% of cases and globe salvage in 67%. Rescue IAC can be considered in children who fail initial IAC, especially if the opposite eye has been enucleated.

International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study.

BACKGROUND AND PURPOSE: Flow diverters are increasingly used in the endovascular treatment of intracranial aneurysms. Our aim was to determine neurologic complication rates following Pipeline Embolization Device placement for intracranial aneurysm treatment in a real-world setting. MATERIALS AND METHODS: We retrospectively evaluated all patients with intracranial aneurysms treated with the Pipeline Embolization Device between July 2008 and February 2013 in 17 centers worldwide. We defined 4 subgroups: internal carotid artery aneurysms of ≥10 mm, ICA aneurysms of <10 mm, other anterior circulation aneurysms, and posterior circulation aneurysms. Neurologic complications included spontaneous rupture, intracranial hemorrhage, ischemic stroke, permanent cranial neuropathy, and mortality. Comparisons were made with t tests or ANOVAs for continuous variables and the Pearson χ(2) or Fisher exact test for categoric variables. RESULTS: In total, 793 patients with 906 aneurysms were included. The neurologic morbidity and mortality rate was 8.4% (67/793), highest in the posterior circulation group (16.4%, 9/55) and lowest in the ICA <10-mm group (4.8%, 14/294) (P = .01). The spontaneous rupture rate was 0.6% (5/793). The intracranial hemorrhage rate was 2.4% (19/793). Ischemic stroke rates were 4.7% (37/793), highest in patients with posterior circulation aneurysms (7.3%, 4/55) and lowest in the ICA <10-mm group (2.7%, 8/294) (P = .16). Neurologic mortality was 3.8% (30/793), highest in the posterior circulation group (10.9%, 6/55) and lowest in the anterior circulation ICA <10-mm group (1.4%, 4/294) (P < .01). CONCLUSIONS: Aneurysm treatment with the Pipeline Embolization Device is associated with the lowest complication rates when used to treat small ICA aneurysms. Procedure-related morbidity and mortality are higher in the treatment of posterior circulation and giant aneurysms.

Brainstem melanomas presenting as a cavernous malformation.

BACKGROUND: Melanoma lesions in the brainstem can be difficult to distinguish radiographically and clinically from cavernous malformations. However, the treatment modalities and clinical course of these two diseases differ considerably. We report two cases of melanoma presenting as brainstem hemorrhages. CASE DESCRIPTION: A 69-year-old male was found to have a hemorrhagic lesion of the right dorsal midbrain. After a repeat hemorrhage, the lesion was resected and found to be hyperchromatic. Nonetheless, the patient suffered rebleeding and died 3 months later. A 62-year-old female was similarly found to have an acute pontine hemorrhage. After resection of the lesion, she underwent whole-brain radiation therapy but ultimately died 5.5 months later. The histopathology of both lesions was consistent with melanoma. CONCLUSIONS: Melanoma in the brainstem can mimic cavernous malformations. While management of these lesions includes stereotactic radiosurgery, whole-brain radiation, and surgical resection, metastatic brainstem melanoma follows an aggressive clinical course with a poor prognosis.

A single pipeline embolization device is sufficient for treatment of intracranial aneurysms.

BACKGROUND AND PURPOSE: The Pipeline Embolization Device has emerged as an important treatment option for intracranial aneurysms. The number of devices needed to treat an aneurysm is uncertain and is the subject of vigorous debate. The purpose of this study was to compare rates of complications, aneurysm occlusion, and outcome in patients treated with a single-versus-multiple Pipeline Embolization Devices. MATERIAL AND METHODS: One hundred seventy-eight patients were treated with the Pipeline Embolization Device at our institution. Patients were divided into 2 groups: a single-device group (n = 126) and a multiple-device group (n = 52). RESULTS: There was no statistically significant difference between the 2 groups with respect to baseline characteristics except for age and aneurysm size (higher with multiple Pipeline Embolization Devices). Complications occurred more frequently with multiple (15%) versus a single device (5%, P = .03). In multivariate analysis, the use of multiple devices independently predicted complications. A similar proportion of patients achieved adequate aneurysm obliteration at follow-up in the single-device (84%) and the multiple-device groups (87%, P = .8). In multivariate analysis, age and follow-up time predicted obliteration. At follow-up, a significantly higher proportion of patients treated with a single device (97%) achieved a favorable outcome compared with those treated with multiple devices (89%, P = .03). In multivariate analysis, there was a strong trend for the use of a single device to predict favorable outcomes (P = .06). CONCLUSIONS: Treatment with a single Pipeline Embolization Device provides similar occlusion rates with less complications and better overall outcomes. These findings suggest that a single Pipeline Embolization Device is sufficient for treatment of most intracranial aneurysms.

Coiling of large and giant aneurysms: complications and long-term results of 334 cases.

BACKGROUND AND PURPOSE: Large and giant intracranial aneurysms are increasingly treated with endovascular techniques. The goal of this study was to retrospectively analyze the complications and long-term results of coiling in large and giant aneurysms (≥ 10 mm) and identify predictors of outcome. MATERIALS AND METHODS: A total of 334 large or giant aneurysms (≥ 10 mm) were coiled in our institution between 2004 and 2011. Medical charts and imaging studies were reviewed to determine baseline characteristics, procedural complications, and clinical/angiographic outcomes. Aneurysm size was 15 mm on average. Two hundred twenty-five aneurysms were treated with conventional coiling; 88, with stent-assisted coiling; 14, with parent vessel occlusion; and 7, with balloon-assisted coiling. RESULTS: Complications occurred in 10.5% of patients, with 1 death (0.3%). Aneurysm location and ruptured aneurysms predicted complications. Angiographic follow-up was available for 84% of patients at 25.4 months on average. Recanalization and retreatment rates were 39% and 33%, respectively. Larger aneurysm size, increasing follow-up time, conventional coiling, and aneurysm location predicted both recurrence and retreatment. The annual rebleeding rate was 1.9%. Larger aneurysm size, increasing follow-up time, and aneurysm location predicted new or recurrent hemorrhage. Favorable outcomes occurred in 92% of patients. Larger aneurysm size, poor Hunt and Hess grades, and new or recurrent hemorrhage predicted poor outcome. CONCLUSIONS: Coiling of large and giant aneurysms has a reasonable safety profile with good clinical outcomes, but aneurysm reopening remains very common. Stent-assisted coiling has lower recurrence, retreatment, and new or recurrent hemorrhage rates with no additional morbidity compared with conventional coiling. Aneurysm size was a major determinant of recanalization, retreatment, new or recurrent hemorrhage, and poor outcome.

Spontaneous delayed migration/shortening of the pipeline embolization device: report of 5 cases.

Five patients were found to have spontaneous delayed migration/shortening of their Pipeline Embolization Devices on follow-up angiography. The device migrated proximally in 4 patients and distally in 1 patient. One patient had a subarachnoid hemorrhage and died as a result of migration of the Pipeline Embolization Device, and another patient presented with complete MCA occlusion and was left severely disabled. Mismatch in arterial diameter between inflow and outflow vessels was a constant finding. Migration of the Pipeline Embolization Device was managed conservatively, with additional placement of the device, or with parent vessel occlusion. Obtaining complete expansion of the embolization device by using a longer device, increasing vessel coverage, using adjunctive aneurysm coiling, and avoiding dragging and stretching of the device are important preventive measures. Neurointerventionalists should be aware of this potentially fatal complication and take all necessary preventive measures.

Stent-assisted coiling versus balloon remodeling of wide-neck aneurysms: comparison of angiographic outcomes.

BACKGROUND AND PURPOSE: Stent-assisted coiling and balloon-assisted coiling are 2 well-established techniques for treatment of wide-neck intracranial aneurysms. A direct comparative analysis of angiographic outcomes with the 2 techniques has not been available. We compare the angiographic outcomes of wide-neck aneurysms treated with stent-assisted coiling versus balloon-assisted coiling. MATERIALS AND METHODS: A retrospective review was conducted on 101 consecutive patients treated at our institution, 69 with stent-assisted coiling and 32 with balloon-assisted coiling. Two multivariate logistic regression analyses were performed to determine predictors of aneurysm obliteration and predictors of progressive aneurysm thrombosis at follow-up. RESULTS: The 2 groups were comparable with respect to all baseline characteristics with the exception of a higher proportion of ruptured aneurysms in the balloon-assisted coiling group (65.6%) than in the stent-assisted coiling group (11.5%, P < .001). Procedural complications did not differ between the stent-assisted coiling group (6%) and the balloon-assisted coiling group (9%, P = .5). The rates of complete aneurysm occlusion (Raymond score 1) at the most recent follow-up were significantly higher for the stent-assisted coiling group (75.4%) compared with the balloon-assisted coiling group (50%, P = .01). Progressive occlusion of incompletely coiled aneurysms was noted in 76.6% of aneurysms in the stent-assisted coiling group versus 42.8% in the balloon-assisted coiling group (P = .02). Retreatment rates were significantly lower with stent-assisted coiling (4.3%) versus balloon-assisted coiling (15.6%, P = .05). In multivariate analysis, stented aneurysms independently predicted both complete aneurysm obliteration and progression of occlusion. CONCLUSIONS: Stent-assisted coiling may yield lower rates of retreatment and higher rates of aneurysm obliteration and progression of occlusion at follow-up than balloon-assisted coiling with a similar morbidity rate.

Endovascular treatment of posterior communicating artery aneurysms with oculomotor nerve palsy: clinical outcomes and predictors of nerve recovery.

BACKGROUND AND PURPOSE: ONP is a well-known presentation of PcomA aneurysms. Reports on recovery of ONP with endovascular coiling have been limited to small case series. We assessed the safety and efficacy of endovascular therapy in a series of PcomA aneurysms with ONP. MATERIALS AND METHODS: We reviewed 37 patients with ONP who underwent endovascular treatment in our institution between 2005 and 2011. Published studies were also reviewed to determine the overall rate of ONP recovery with endovascular therapy. RESULTS: Nineteen patients (51.4%) presented with complete ONP, and 18 (48.6%), with partial ONP. Conventional coiling was performed in 31 (83.8%) patients; stent-assisted coiling, in 4 (10.8%); and balloon remodeling, in 2 (5.4%). There was 1 (2.7%) procedural complication (a transient thromboembolic event). Twenty-seven (73%) patients were treated within 3 days from symptom onset. At the last available clinical follow-up, ONP resolution was complete in 14 (37.8%) patients and partial in 19 (51.4%). Only 4 (10.8%) patients showed no signs of nerve recovery. In multivariate analysis, partial ONP and longer follow-up durations were predictors of complete nerve recovery. Treatment timing, type of endovascular embolization, subarachnoid hemorrhage, and initial degree of aneurysm occlusion were not predictors of nerve recovery. Of 169 patients reported in the literature (including ours), ONP resolved completely in 73 (43.2%) patients and partially in 73 (43.2%). CONCLUSIONS: Endovascular therapy is a safe and highly efficient alternative to surgical clipping for PcomA aneurysms with ONP.

Intracranial vertebral artery dissections: evolving perspectives.

Intracranial vertebral artery dissection (VAD) represents the underlying etiology in a significant percentage of posterior circulation ischemic strokes and subarachnoid hemorrhages. These lesions are particularly challenging in their diagnosis, management, and in the prediction of long-term outcome. Advances in the understanding of underlying processes leading to dissection, as well as the evolution of modern imaging techniques are discussed. The data pertaining to medical management of intracranial VADs, with emphasis on anticoagulants and antiplatelet agents, is reviewed. Surgical intervention is discussed, including, the selection of operative candidates, open and endovascular procedures, and potential complications. The evolution of endovascular technology and techniques is highlighted.

Superior hypophyseal artery aneurysms have the lowest recurrence rate with endovascular therapy.

BACKGROUND AND PURPOSE: Given the challenges posed by surgical clipping, endovascular techniques have been increasingly used to treat SHA aneurysms. The purpose of this study was to assess the safety and efficacy of endovascular techniques in the treatment of SHA aneurysms. MATERIALS AND METHODS: Medical charts and initial and follow-up angiograms were reviewed retrospectively for all patients treated with endovascular procedures at our institution between January 2006 and February 2011. RESULTS: We identified 87 patients with SHA aneurysms who were treated with endovascular techniques. Of these patients, 79 were women and only 8 were men (90.8% female predominance). Thirty-five patients were treated with coil embolization; 45, with stent-assisted coiling; 4, with balloon-assisted coil embolization; and 3, with a flow-diversion technique. Minor complications occurred in 2 patients (2.2%). None of the patients had a major complication. The mortality and permanent morbidity rates related to the procedure were 0%. Imaging follow-up was available for 89.4% of patients (DSA in 65, MRA in 11 patients) at a mean time point of 10.4 months (range, 6-60 months). Of the 76 patients with available follow-up, 3 patients had a recurrence (3.9%) and only 1 required further intervention (1.3%). Stent-assisted coiling was associated with lower recurrence rates than simple coil embolization. CONCLUSIONS: SHA aneurysms have the lowest recurrence rate with endovascular treatment compared with aneurysms in other locations by using historical data. Because of its safety and efficacy, endovascular therapy should be considered the procedure of choice for the treatment of SHA aneurysms.

Stent-assisted coil embolization of complex wide-necked bifurcation cerebral aneurysms using the "waffle cone" technique. A review of ten consecutive cases.

Endovascular treatment of complex, wide-necked bifurcation cerebral aneurysms is challenging.  Intra/extra-aneurysmal stent placement, the "waffle cone" technique, has the advantage of using a single stent to prevent coil herniation without the need to deliver the stent to the efferent vessel. The published data on the use of this technique is limited. We present our initial and follow-up experience with the waffle cone stent-assisted coiling (SAC) of aneurysms to evaluate the durability of the technique. We retrospectively identified ten consecutive patients who underwent SAC of an aneurysm using the waffle cone technique from July 2009 to March 2011. Clinical and angiographic outcomes after initial treatment and follow-up were evaluated. Raymond Class I or II occlusion of the aneurysm was achieved in all cases with the waffle cone technique. No intraoperative aneurysm rupture was noted. The parent arteries were patent at procedure completion. Clinical follow-up in nine patients (median 12.9 months) revealed no aneurysm rupture. Two patients had a transient embolic ischemic attack at 18 hours and three months after treatment, respectively. Catheter angiography or MRA at six-month follow-up demonstrated persistent occlusions of aneurysms in seven out of eight patients. Another patient had stable aneurysm occlusion at three-month follow-up study. Our experience in the small series suggests the waffle cone technique could be performed on complex, wide-necked aneurysms with relative safety, and it allowed satisfactory occlusions of the aneurysms at six months in most cases.

Congenital absence of the internal carotid artery in a patient with spinal cord injury: case report.

STUDY DESIGN: Case report. OBJECTIVE: To describe a rare case of congenital absence of the internal carotid artery (ICA) in the setting of acute spinal cord injury and review the existing literature. SETTING: Regional Spinal Cord Injury Center of the Delaware Valley, Philadelphia, PA, USA. CLINICAL PRESENTATION: We report on a 47-year-old male who presented as a T2 ASIA A spinal cord injury with a T2-T3 fracture dislocation injury after a 25-feet fall from a tree. Magnetic resonance angiography imaging of the neck carried out as per routine spinal trauma protocol suggested an acute traumatic injury to the carotid artery. Therefore, computed tomographic angiography imaging of the neck was performed, which revealed absence of the left ICA and a diminutive left carotid canal at the skull base, suggesting congenital absence. Follow-up magnetic resonance imaging of the brain to evaluate for acute infarct showed no diffusion restriction contributing to the evidence that this was a congenital anomaly and not traumatic occlusion of the artery. CONCLUSION: Congenital absence or hypoplasia of the ICA is a rare anomaly. It should be considered in the differential in patients who have absent or diminished carotid arteries on radiologic imaging in the setting of trauma.

Barré-Lieou syndrome and the problem of the obsolete eponym.

BACKGROUND: Eponym lists in major sources can give an aura of legitimacy to discredited diagnoses, as exemplified by the case of Barré-Lieou syndrome, a 'rare' vestibular disorder. METHODS: A literature review for information on the posterior cervical syndrome of Barré-Lieou. RESULTS: Barré-Lieou syndrome includes very common symptoms--tinnitus, dizziness, and head or neck pain--attributed to ischaemia caused by cervical sympathetic nerve compression. Its original description brings together many unrelated disorders, and its causative mechanism has been discredited. However, it appears credulously in a number of eponym lists, and references to the syndrome are steadily increasing on the internet in general and on alternative medicine and legal profession websites in particular. CONCLUSION: By inclusion in eponym lists, without a disclaimer, a syndrome can be given legitimacy before the general public. A syndrome, such as Barré-Lieou syndrome, that is useless to the medical profession can unfortunately prove to be very useful for litigants and disability claimants.