Experience With the Pipeline Embolization Device for Posterior Circulations Aneurysms: A Multicenter Cohort Study.

BACKGROUND: The Pipeline Embolization Device (PED; Medtronic) has been used off-label for the treatment of challenging posterior circulation aneurysms. Data on this modality are primarily limited to small retrospective single-center series. OBJECTIVE: To assess safety and efficacy of this treatment by establishing an international, multicenter collaboration. METHODS: Consecutive posterior circulation aneurysms treated with the PED from 2012 to 2019 across 11 neurovascular centers were retrospectively reviewed. Baseline demographics, aneurysm and treatment characteristics, complications, occlusion status, and functional outcome were assessed. RESULTS: There were 149 posterior circulation aneurysms treated with PED in 146 patients. A total of 24 (16.4%) patients presented with subarachnoid hemorrhage. Most aneurysms were dissecting/blister (36.2%) in morphology, followed by saccular (35.6%) and fusiform (28.2%). The most common locations were the vertebral (51.7%) and basilar arteries (22.8%). Complete or near-complete occlusion (>90%) was achieved in 90.9% of aneurysms at a median follow-up of 12 mo. Dissecting/blister aneurysms were most likely to occlude (P = .06). Symptomatic neurologic complications occurred in 9.4% of aneurysms, associated with larger size, ruptured presentation, presentations with brain stem compression, cranial nerve palsy, or stroke. Favorable functional outcome (modified Rankin Score 0-2) was achieved in 86.2% of patients. There were 6 fatalities of which 4 occurred in aneurysmal subarachnoid hemorrhage patients. CONCLUSION: This multicenter study shows that PED for the treatment of posterior circulation is preferentially used for the treatment of fusiform and dissecting/blister aneurysm morphologies. Despite the challenges presented by these less-common morphologies, flow diversion may be performed with a neurologic complication rate of about 10% and favorable long-term aneurysm occlusion rates.

Diagnosis and Endovascular Embolization of a Sacral Spinal Arteriovenous Fistula with "Holo-Spinal" Venous Drainage.

BACKGROUND: Spinal dural arteriovenous fistulas are the most common spinal vascular pathology, accounting for up to 70% of spinal vascular malformations. They most commonly present with insidious and progressive myelopathy and bowel, bladder, and sexual dysfunction. Although noninvasive imaging (e.g., magnetic resonance imaging, magnetic resonance angiography) may suggest the presence of a spinal arteriovenous fistula (AVF), the diagnosis requires confirmation with spinal angiography. CASE DESCRIPTION: A 65-year-old woman presented with progressive myelopathy. Traditional spinal angiography of the paired radicular arteries failed to demonstrate any vascular malformation. However, injection of the right internal iliac artery demonstrated an AVF arising from the artery of Desproges-Gotteron with retrograde venous drainage to the upper thoracic region. CONCLUSIONS: Selective transarterial catheterization and embolization with n-butyl cyanoacrylate resulted in complete occlusion of the AVF. Clinical improvement was also noted on postprocedural day 1. This case highlights the importance of internal iliac injections as a critical component of spinal angiography during an evaluation for vascular malformation.

Neck Remnants and the Risk of Aneurysm Rupture After Endovascular Treatment With Coiling or Stent-Assisted Coiling: Much Ado About Nothing?

BACKGROUND: Neck remnants are not uncommon after endovascular treatment of cerebral aneurysms. Critics of endovascular treatments for cerebral aneurysms cite neck remnants as evidence in favor of microsurgical clipping. However, studies have failed to evaluate the true clinical significance of aneurysm neck remnants following endovascular therapies. OBJECTIVE: To assess the clinical significance of residual aneurysm necks and to determine the rate of subsequent rupture following coiling or stent-assisted coiling of cerebral aneurysms. METHODS: We retrospectively reviewed the records of 1292 aneurysm cases that underwent endovascular treatment at 4 institutions. Aneurysms treated by primary coiling or stent-assisted coiling were included in the study; those treated by flow diversion were excluded Aneurysms with residual filling (i.e., Raymond-Roy Occlusion Classification II, neck remnant; or III, residual aneurysm filling) were assessed for their risk of subsequent rupture. RESULTS: A total of 626 aneurysms were identified as having residual filling immediately posttreatment. Of these, 13 aneurysms (2.1%) ruptured during the follow-up period (mean 7.3 mo; range 1-84 mo). Eleven of the 13 (84.6%) were ruptured at presentation. Rupture at presentation, the size of the aneurysm, and the increasing age of the patient were predictive of posttreatment rupture. CONCLUSION: We found that unruptured aneurysms with residual necks following endovascular treatment posed a very low risk of rupture (0.6%). However, patients presenting with ruptured aneurysms had a higher risk of rerupture from a neck remnant (3.4%). These results highlight the importance of achieving complete angiographic occlusion of ruptured aneurysms.

Use of 4D Computer Tomographic Angiography to Accurately Identify Distal Internal Carotid Artery Occlusions and Pseudo-Occlusions: Technical Note.

BACKGROUND AND PURPOSE: Traditional methods of computed tomographic angiography (CTA) can be unreliable in detecting carotid artery pseudo-occlusions or in accurately locating the site of carotid artery occlusion. With these methods, lack of adequate distal runoff due to pseudo-occlusion or intracranial occlusion can result in the inaccurate diagnoses of complete occlusion or cervical carotid occlusion, respectively. The site of carotid occlusion has important therapeutic and interventional considerations. We present several cases in which 4D CTA was utilized to accurately and noninvasively diagnose carotid pseudo-occlusion and intracranial internal carotid artery (ICA) occlusion. METHODS: We identified five patients who presented to our institute with ischemic stroke symptoms and evaluated images from traditional CTA protocols and 4D CTA protocols in each of these patients, comparing diagnoses rendered by each imaging technique. RESULTS: In two patients, traditional CTA suggested the presence of complete ICA occlusion. However, 4D CTA demonstrated pseudo-occlusion. Similarly, in three patients, traditional CTA demonstrated cervical ICA occlusion, whereas the 4D CTA demonstrated intracranial ICA occlusion. CONCLUSION: 4D CTA may be a more effective noninvasive imaging technique than traditional CTA to detect intracranial carotid artery occlusions and carotid artery pseudo-occlusions. Accurate, rapid, and noninvasive diagnosis of carotid artery lesions may help tailor and expedite endovascular intervention.

Patency of anterior circulation branch vessels after Pipeline embolization: longer-term results from 82 aneurysm cases.

OBJECTIVE The Pipeline Embolization Device (PED) has become increasingly used for the treatment of intracranial aneurysms. Given its high metal surface area coverage, there is concern for the patency of branch vessels that become covered by the device. Limited data exist regarding the patency of branch vessels adjacent to aneurysms that are covered by PEDs. The authors assessed the rate of intracranial internal carotid artery, anterior circulation branch vessel patency following PED placement at their institution. METHODS The authors retrospectively reviewed the records of 82 patients who underwent PED treatment between 2009 and 2014 and in whom the PED was identified to cover branch vessels. Patency of the anterior cerebral, posterior communicating, anterior choroidal, and ophthalmic arteries was evaluated using digital subtraction angiography preoperatively and postoperatively after PED deployment and at longer-term follow-up. RESULTS Of the 127 arterial branches covered by PEDs, there were no immediate postoperative occlusions. At angiographic follow-up (mean 10 months, range 3-34.7 months), arterial side branches were occluded in 13 (15.8%) of 82 aneurysm cases and included 2 anterior cerebral arteries, 8 ophthalmic arteries, and 3 posterior communicating arteries. No cases of anterior choroidal artery occlusion were observed. Patients with branch occlusion did not experience any neurological symptoms. CONCLUSIONS In this large series, the longer-term rate of radiographic side branch arterial occlusion after coverage by a flow diverter was 15.8%. Terminal branch vessels, such as the anterior choroidal artery, remained patent in this series. The authors' series suggests that branch vessel occlusions are clinically silent and should not deter aneurysm treatment with flow diversion.

Risk of acute kidney injury associated with neuroimaging obtained during triage and treatment of patients with acute ischemic stroke symptoms.

BACKGROUND: Combining non-contrast CT (NCCT), CT angiography (CTA), and CT perfusion (CTP) imaging (referred to as a CT stroke study, CTSS) provides a rapid evaluation of the cerebrovascular axis during acute ischemic stroke. Iodinated contrast-enhanced CT imaging is not without risk, which includes renal injury. If a patient's CTSS identifies vascular pathology, digital subtraction angiography (DSA) is often performed within 24-48 h. Such patients may receive multiple administrations of iodinated contrast material over a short time period. OBJECTIVE: We aimed to evaluate the incidence of acute kidney injury (AKI) in patients who underwent a CTSS and DSA for evaluation of acute ischemic symptoms or for stroke intervention within a 48 h period between August 2012 and December 2014. METHODS: We identified 84 patients for inclusion in the analysis. Patients fell into one of two cohorts: AKI, defined as a rise in the serum creatinine level of ≥0.5 mg/dL from baseline, or non-AKI. Clinical parameters included pre- and post-imaging serum creatinine level, time between CTSS and DSA, and type of angiographic procedure (diagnostic vs intervention) performed. RESULTS: Four patients (4.7%) experienced AKI, one of whom had baseline renal dysfunction (defined as baseline serum creatinine level ≥1.5 mg/dL). The mean difference between baseline and peak creatinine values was found to be significantly greater in patients with AKI than in non-AKI patients (1.65 vs -0.09, respectively; p=0.0008). CONCLUSIONS: This study provides preliminary evidence of the safety and feasibility of obtaining CTSS with additional DSA imaging, whether for diagnosis or intervention, to identify possible acute ischemic stroke.

To Treat or Not to Treat M2 Occlusions? The Question (and Answer) From a Single Institution.

BACKGROUND: Occlusions of the M2 segment of the middle cerebral artery may cause significant clinical effects, especially when occurring in the dominant cerebral hemisphere, yet endovascular treatment of these lesions remains controversial. OBJECTIVE: To examine the safety and efficacy of endovascular treatment of M2 occlusions at our institution. METHODS: We retrospectively examined radiographic and clinical data of 53 patients presenting with M2 occlusions to our institution. RESULTS: Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b or 3) was achieved in 40 patients (76.9%). No symptomatic intracranial hemorrhage occurred. The mean National Institutes of Health Stroke Scale score at discharge was 6.4 (median, 5.5). In the 38 patients who had follow-up after discharge, the mean follow-up duration was 11.1 months (range, 0.5-36.5 months) and mean National Institutes of Health Stroke Scale score was 3.5 (median, 1). CONCLUSION: The results of our single-institution experience suggest that endovascular therapy for M2 occlusions is safe and effective. Additional evaluation with randomized, controlled studies is warranted. ABBREVIATIONS: ADAPT, direct aspiration first-pass techniqueECASS, European-Australasian Cooperative Acute Stroke StudyICH, intracranial hemorrhageIMS, Interventional Management of StrokeMERCI, Mechanical Embolus Removal in Cerebral IschemiamRS, modified Rankin ScaleNIHSS, National Institutes of Health Stroke ScalePROACT, Prolyse in Acute Cerebral ThromboembolismTICI, Thrombolysis in Cerebral Infarctiont-PA, tissue-type plasminogen activator.

Importance of repeat angiography in the diagnosis of iatrogenic anterior cerebral artery territory pseudoaneurysm following endoscopic sinus surgery.

Iatrogenic intracranial pseudoaneurysm formation and rupture are rare complications following endoscopic sinus surgery. Given the propensity for devastating neurologic injury after a relatively routine procedure, swift diagnosis and treatment is essential. The authors present a patient who experienced bifrontal intracranial hemorrhage and subarachnoid hemorrhage due to a ruptured iatrogenic frontopolar artery pseudoaneurysm caused during routine endoscopic sinus surgery. The pseudoaneurysm was not present on initial angiograms but became apparent radiographically 19 days after the endoscopic procedure. Endovascular treatment consisted of coil and Onyx embolization for sacrifice of the parent vessel proximal to the lesion. Early recognition of iatrogenic intracranial vascular injury is important to allow for rapid treatment. Initial radiographic studies may be unreliable in excluding the presence of a pseudoaneurysm so delayed repeat angiographic assessment is necessary, particularly in the presence of a high index of clinical suspicion. Endovascular techniques may provide an effective and safe option for the treatment of iatrogenic anterior cerebral artery distribution pseudoaneurysms.

Experience with vertebral artery origin stenting and ostium dilatation: results of treatment and clinical outcomes.

BACKGROUND: The vertebral artery (VA) ostium (VAO) is a common stenosis site. Most patients with VAO stenosis refractory to medical treatment are treated endovascularly using stenting. To optimally cover the ostial plaque, which frequently extends into the adjacent subclavian artery, part of the stent must overhang in the subclavian artery. This configuration makes subsequent VA access very challenging in cases of in-stent or distal vertebrobasilar pathology; it also obstructs the distal subclavian artery. OBJECTIVE: To determine whether angioplasty at the ostium with a dual balloon (Flash Ostial) specially designed to allow the subclavian end of the stent to flare might circumvent these problems and, most importantly, provide optimal plaque coverage around the vertebral ostium. METHODS: Between June 2012 and July 2014, 11 patients with symptomatic VAO stenosis refractory to best medical therapy were treated with stenting and dual balloon Flash angioplasty. Demographics, results, and outcomes were reviewed. RESULTS: A total of 12 VAO stenting-dual balloon angioplasty procedures were performed (mean stenosis, 83.6%; range, 78-90%). Nine patients had mild-to-moderate (40-60%) contralateral VAO stenosis. The initial average modified Rankin Scale (mRS) score was 1.25. In all cases, immediate postangioplasty angiography showed excellent stent apposition against the VA and around the ostium in the subclavian artery. No permanent perioperative complications or deaths occurred. At a mean follow-up of 10.8 months (range 2-24), all patients had symptom resolution and no evidence of symptomatic restenosis on neuroimaging/Doppler studies; the average mRS score was 0.66. Three patients continued to have previously diagnosed mid-cervical VA stenosis; one of them had postprocedure dissection and an asymptomatic in-stent stenosis at 8 months. CONCLUSIONS: Safety and feasibility were demonstrated using the Ostial Flash system for VAO stenting and angioplasty. No permanent perioperative complications were seen.

Feasibility, Safety, and Periprocedural Complications of Pipeline Embolization for Intracranial Aneurysm Treatment Under Conscious Sedation: University at Buffalo Neurosurgery Experience.

BACKGROUND: Endovascular Pipeline Embolization Device (PED) placement for intracranial aneurysms is performed under general anesthesia at most centers because of perceived improved image quality and patient safety. OBJECTIVE: To report the feasibility, safety, and outcomes associated with the use of the PED for intracranial aneurysms performed in awake patients after the administration of conscious sedation (CS) and a local anesthetic. METHODS: Between March 2012 and September 2014, 130 patients with 139 intracranial aneurysms (8 ruptured) were treated with the PED under CS at our institution. Procedure details and time (including duration, radiation exposure, and fluoroscopy) and procedure-related complications were retrospectively reviewed. RESULTS: A total of 155 PED deployment procedures were performed under CS. Treatment was successfully completed in all cases. Anesthesia was converted from CS to general anesthesia during 5 procedures. Mean interval from patient entry at the endovascular suite to procedure initiation was 18 minutes (range, 5 minutes-1 hour 10 minutes). Mean procedure length was 1 hour 25 minutes (range, 30 minutes-3 hours 51 minutes). Mean ± SD values for fluoroscopy time and radiation exposure were 36.17 ± 18.4 minutes and 1367 ± 897 mGy, respectively. The mean amount of contrast material administered was 211.37 ± 83.5 mL. Permanent neurological complications were seen in 4 patients (3%). CONCLUSION: In our experience, CS for PED placement for intracranial aneurysm treatment is feasible and safe. Procedure and fluoroscopy times and amount of radiation exposure are similar to or less than described in reports of PED placement under general anesthesia. CS allows direct neurological evaluation and earlier detection of and response to intraprocedural complications.

Importance of repeat angiography in the diagnosis of iatrogenic anterior cerebral artery territory pseudoaneurysm following endoscopic sinus surgery.

Iatrogenic intracranial pseudoaneurysm formation and rupture are rare complications following endoscopic sinus surgery. Given the propensity for devastating neurologic injury after a relatively routine procedure, swift diagnosis and treatment is essential. The authors present a patient who experienced bifrontal intracranial hemorrhage and subarachnoid hemorrhage due to a ruptured iatrogenic frontopolar artery pseudoaneurysm caused during routine endoscopic sinus surgery. The pseudoaneurysm was not present on initial angiograms but became apparent radiographically 19 days after the endoscopic procedure. Endovascular treatment consisted of coil and Onyx embolization for sacrifice of the parent vessel proximal to the lesion. Early recognition of iatrogenic intracranial vascular injury is important to allow for rapid treatment. Initial radiographic studies may be unreliable in excluding the presence of a pseudoaneurysm so delayed repeat angiographic assessment is necessary, particularly in the presence of a high index of clinical suspicion. Endovascular techniques may provide an effective and safe option for the treatment of iatrogenic anterior cerebral artery distribution pseudoaneurysms.

Endovascular treatment of a temporal bone pseudoaneurysm presenting as bloody otorrhea.

Objective This case report is designed to illustrate an uncommon presentation of osteoradionecrosis (ORN) of the temporal bone and a treatment method for bloody otorrhea from a pseudoaneurysm of the internal carotid artery (ICA). Design This is a single patient case report Setting University of Missouri-Columbia Hospital and Clinics. Participants The report describes a patient with a history of hypopharyngeal squamous cell carcinoma (SCCA) who was previously treated with chemoradiation therapy and salvage bilateral neck dissections and then presented in a delayed fashion with profuse, episodic bloody otorrhea. Computed tomography (CT) was consistent with ORN of the temporal bone. The patient underwent emergent cerebral angiography. A pseudoaneurysm of the cervicopetrous ICA was confirmed to be the source of the patient's bloody otorrhea. The lesion was treated by endovascular sacrifice of the ICA using the two-catheter coiling technique. Results The patient had no neurologic sequelae or further bleeding after treatment. Conclusions Bloody otorrhea is an uncommon presentation of ORN. Sacrifice of the internal carotid can be considered as a treatment when the source is pseudoaneurysmal.

Oncogenic brain metazoan parasite infection.

Multiple observations suggest that certain parasitic infections can be oncogenic. Among these, neurocysticercosis is associated with increased risk for gliomas and hematologic malignancies. We report the case of a 71-year-old woman with colocalization of a metazoan parasite, possibly cysticercosis, and a WHO grade IV neuroepithelial tumor with exclusively neuronal differentiation by immunohistochemical stains (immunopositive for synaptophysin, neurofilament protein, and Neu-N and not for GFAP, vimentin, or S100). The colocalization and temporal relationship of these two entities suggest a causal relationship.

Cerebral edema associated with ventricular reservoirs in two patients: a case report.

Placement of ventricular reservoirs is a common practice to treat various tumors of the central nervous system (CNS). Ventricular catheter-reservoir-associated edema has been noted in the literature, but a thorough review of this literature identified no articles that examine this particular complication in neurooncology patients, specifically. We report two cases of ventricular catheter-reservoir-associated edema in patients receiving treatment for CNS metastasis.