Pigtail catheter exchange technique for the Simmons catheter formation in transradial cerebral angiography.

BACKGROUND: The transradial approach (TRA) has become popular for diagnostic cerebral angiography. However, this approach is still used less often because of problematic formation of the Simmons catheter. The purpose of this study was to introduce a pigtail catheter exchange technique for Simmons catheter formation to improve the success rates with a shorter operation time and without increasing complications. METHODS: This retrospective study included consecutive patients eligible for right TRA cerebral angiography at our institution from 2021. To introduce the technique, the cerebral angiogram of formation of the Simmons catheter in the type II aortic arch was constructed. Patient demographic and angiographic data were collected. RESULTS: In total, 295 cerebral angiographies were evaluated. There were 155 (52.5 %), 83 (28.1 %), 39 (13.2 %), and 18 (6.1 %) patients with types I, II, and III aortic arches and bovine arch, respectively. The total fluoroscopy time, operation time and radiation exposure were 6.3 ± 4.4 min, 17.7 ± 8.3 min and 559.2 ± 197.3 mGy, respectively. The Simmons catheter was successfully formed in 294 of 295 patients, with a success rate of 99.6 %, confirming an effective technique for right TRA cerebral angiography. No severe complications were observed in any patient. CONCLUSIONS: Pigtail catheter exchange may be an effective and safe technique for right TRA cerebral angiography. The findings of this report prompted institutions to apply this technique clinically and can serve as a basis for future trials focused on TRA cerebral angiography.

The "distal-to-proximal" strategy for the treatment of posterior circulation tandem occlusions: a single-centre experience.

PURPOSE: Data on posterior circulation tandem occlusions in acute ischemic stroke are scarce: recognition may be challenging and little is known about optimal treatment strategy. We report our endovascular treatment strategy for posterior circulation tandem occlusion. METHODS: Consecutive patients with posterior circulation tandem occlusions in our centre were enrolled retrospectively. The preferred strategy was "distal-to-proximal" strategy, which means opening the distal occlusion first followed by treatment of the proximal pathology. The imaging characteristics, treatment strategy, clinical outcomes, and complications of patients with posterior circulation tandem occlusions were analyzed. RESULTS: In total, 21 patients with posterior circulation tandem occlusions were enrolled in the study, which accounted for 23.6% of patients with posterior circulation stroke in our centre. The mean age was 60 years (range 32 to 80), and median pre-procedure NIHSS score was 28 (interquartile range: 13-31). Eighteen patients (85.7%) had vertebrobasilar artery tandem occlusions and 3 (14.3%) had basilar artery to basilar artery tandem occlusions. All distal occlusions were successfully recanalized (modified TICI 2b/3). Two (9.5%) of the proximal lesions were not treated. A total of 57.1% of the patients had stents implanted on the proximal occlusions. The rate of mRS 0-3 at 3 months was 57.1% and the mortality rate was 19.0%. CONCLUSION: In patients with acute ischaemic stroke caused by posterior circulation tandem occlusions, we favor "distal-to-proximal" strategy based on the positive results in this small series. Nevertheless, a more extensive study is required to explore the optimal treatment strategy further.

Outcome and Prognostic Factors of Ruptured Middle Cerebral Artery Aneurysms Treated via Endovascular Approach: A Single-Center 11-Year Experience.

OBJECTIVE: To investigate outcomes and prognostic factors of ruptured middle cerebral artery (MCA) aneurysms, treated via endovascular approach, with improving treatment materials and techniques. PATIENTS AND METHODS: A total of 185 consecutive patients, admitted with acutely ruptured MCA aneurysms and treated by endovascular methods between 2006 and 2016, were retrospectively reviewed. Their baseline characteristics, procedure-related complications, and angiographic and clinical outcomes were collected. Univariate analysis and logistic regression analysis were completed to identify any association between procedure-related complications or clinical outcomes and potential risk factors. RESULTS: Procedure-related complications occurred in 28 patients (15.1%), including aneurysm rebleeding in 7 (3.8%), hematoma expansion in 10 (5.4%), and ischemia in 13 (7.0%) (concurrent hemorrhage and ischemia in 2 patients), which resulted in morbidity/mortality of 7% and 1.4%. Final evaluations indicated that 153 patients (82.7%, 153/185) had a good outcome (modified Rankin Scale score 0-2). Among 120 (69.4%) who underwent angiographic follow-up, 89 (74.2%) were completely occluded and 20/120 (16.7%) were recanalized. Multivariate analysis of clinical outcome indicated that a high preoperative Hunt and Hess grade (IV-V), intrasylvian/intracerebral hematoma, and early period treatment (2006-2013) were associated with unfavorable outcomes. CONCLUSIONS: Endovascular treatment for patients with ruptured middle cerebral artery aneurysms may offer favorable clinical and angiographic outcomes. With the evolution of treatment materials and updated techniques, treatment complications have become less common than previously reported in literature, and clinical outcomes have been improved in recent years.

Factors Predicting De Novo Formation of Fistulas After Dural Fistula Embolization Using Venous Sinus Balloon Protection.

BACKGROUND: Endovascular embolization with transvenous sinus preservation using balloon is at present the preferred modality for dural arteriovenous fistulas involving venous sinuses (sagittal, transverse, and sigmoid) with potential drainage function. The aim of the study was to evaluate the necessity and medium-term efficacy of this technique. METHODS: Patients with dural arteriovenous fistulas involving large sinuses who underwent vascular embolization with transvenous balloon protection technique at our center from December 2012 to July 2017 were retrospectively reviewed. The clinical symptoms, postoperative and mid-term follow-up imaging results, perioperative complications, and follow-up clinical outcomes were analyzed. RESULTS: Eighteen patients (8 women and 10 men) with mean age 49 years were included in this study. Complete (16 of 18) or near-complete (1 of 18) occlusion of original fistula was achieved in 17 patients (94.4%). Recurrence of original fistula (1 of 18) or de novo fistula (3 of 18) occurred in 4 patients (22.2%). The patency rate of balloon-protected sinus was 72.2% (13 of 18) during the follow-up, and the involved sinuses were eventually occluded in 5 patients (27.8%). The frequency of de novo fistulas was higher in patients with sinus occlusion (P < 0.05). Stenosis of the involved sinus was more likely related to balloon-protected sinus occlusion (P < 0.05). After a mean follow-up of 17.6 months, 17 patients (94.4%) achieved remission of the original symptoms. CONCLUSIONS: Transvenous balloon protection technique maintains sinus patency in most cases, and preoperative stenosis increases the probability of sinus occlusion. De novo fistula is related to sinus occlusion during the follow-up.

Transvenous embolization of brain arteriovenous malformations: a systematic review and meta-analysis.

INTRODUCTION: The safety and efficacy of transvenous embolization of brain arteriovenous malformations (AVM) remains relatively poorly understood. We performed a systematic review of the literature to determine outcomes of transvenous embolization of brain AVMs. EVIDENCE ACQUISITION: Data sources include Ovid MEDLINE, Ovid EMBASE and the Web of Science. All case series with four or more patients receiving transvenous embolization of brain AVMs published before September 2017 were included. EVIDENCE SYNTHESIS: A total of 8 series with 66 patients were included. All-cause mortality rate was 6.0% (95% CI: 0.0-11.0%). There were no cases of treatment related mortality. Overall good functional outcome rates were 89.0% (95% CI: 82.0-96.0%). Complete occlusion rates were 96.0% (95% CI: 91.0-100.0%). Technical complications rates were 8.0% (95% CI: 2.0-14.0%). Additional treatment rates were 6.0% (95% CI: 0.0-11.0%). CONCLUSIONS: Patients receiving transvenous embolization of AVMs experience good long-term clinical outcomes in nearly 90% of highly selected cases. Further large case series are needed to confirm the result.

Presentation and outcomes of patients with thoracic and lumbosacral spinal epidural arteriovenous fistulas: a systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Thoracolumbar and sacral spinal epidural arteriovenous fistulas (SEDAVFs) are an increasingly recognized form of spinal vascular malformation. The purpose of this study was to perform a systematic review of the demographics, clinical presentation and treatment results of thoracolumbar SEDAVFs. MATERIALS AND METHODS: Pubmed, Scopus and Web of Science databases were searched from January 2000 to January 2018 for articles on treatment of SEDAVFs. Pooled data of individual patients were analyzed for demographic and clinical features of SEDAVFs as well as treatment outcomes. RESULTS: There were 125 patients from 11 studies included. Mean age was 63.5 years. There was a male sex predilection (69.6%). Sensory symptoms including pain or numbness were the most frequently presenting symptoms. Fistula location was the lumbosacral spine in 79.2% and the thoracic spine in 20.8%. Involvement of intradural venous drainage was more common than extradural venous drainage only (89.6% vs 10.4%). Of the 123 treated patients, endovascular therapy was performed in 67.5% of patients, microsurgery in 23.6%, and combined treatment in 8.9%. The overall complete obliteration rate was 83.5% and did not differ between groups. Clinical symptoms improved in 70.7% of patients, were stable in 25%, and worsened in 1.7% with no difference between treatment modalities. CONCLUSIONS: Thoracic and lumbosacral SEDAVFs often present with symptoms secondary to congestive myelopathy or compressive symptoms. Both endovascular and microsurgical treatments were associated with high obliteration rates and good clinical outcomes.

Endovascular treatment of intracranial vertebrobasilar artery dissecting aneurysms: Parent artery occlusion versus flow diverter.

PURPOSE: To compare the safety and efficacy of endovascular parent artery occlusion (PAO) and flow diverter (FD) treatment in treating vertebrobasilar dissecting aneurysms (VBDAs). METHODS: A review of a prospective aneurysm database at our institution was performed to identify all consecutive patients with intracranial VBDAs managed with endovascular treatment, which were either PAO or FD. Clinical and imaging findings were compared between the two groups. RESULTS: A total of 25 consecutive patients with 27 VBDAs were included. Seventeen VBDAs were treated by PAO, and 11 VBDAs were treated with FDs. Immediate total occlusion rate after initial treatment was higher in the PAO group than in the FD group (62.5% v.s. 9.1%, p = .018). Complete occlusion on follow-up at 18 months was more frequently observed in the PAO group (81.8%) compared to the FD group (55.6%), although the difference was not statistically significant (p = .433). Procedure related complication rate and mortality for the whole case series was 28% and 24% respectively, and were comparable in the two groups. Excellent outcome at discharge was achieved in 77.8% and 40% of patients treated with FD and PAO respectively, which was not statistically significant (p = .169). Excellent outcome at followed-up was comparable as well. CONCLUSIONS: PAO and FD treatment are both feasible options for treatment of VBDAs. PAO provide higher immediate complete occlusion rate compared to FD. Despite low initial complete occlusion rates, FD group presented a comparable long-term outcome and similar perioperative events rate compared to the PAO group.

Reconstructive endovascular treatment of vertebral artery dissecting aneurysms with the Low-profile Visualized Intraluminal Support (LVIS) device.

INTRODUCTION: The Low-profile Visualized Intraluminal Support (LVIS) device is a new generation of self-expanding braided stent recently introduced in China for stent assisted coiling of intracranial aneurysms. The aim of our study is to evaluate the feasibility, safety, and efficacy of the LVIS device in reconstructive treatment of vertebral artery dissecting aneurysms (VADAs). METHODS: We retrospectively reviewed the neurointerventional database of our institution from June 2014 to May 2016. Patients who underwent endovascular treatment of VADAs with LVIS stents were included in this study. Clinical presentation, aneurysmal characteristics, technical feasibility, procedural complications, and angiographic and clinical follow-up results were evaluated. RESULTS: 38 patients with VADAs who underwent treatment with LVIS stent were identified, including 3 ruptured VADAs. All VADAs were successfully treated with reconstructive techniques including the stent-assisted coiling (n = 34) and stenting only (n = 4). Post-procedural complications developed in 3 patients (7.9%) including two small brainstem infarctions and one delayed thromboembolic event. Complications resulted in one case of minor permanent morbidity (2.6%). There was no procedure-related mortality. The follow-up angiogram was available in 30 patients at an average of 8.3 months (range, 2 to 30 months), which revealed complete occlusion in 23 patients (76.7%), residual neck in five patients (16.7%), and residual sac in two patients (6.7%). The follow-up of 25 aneurysms with incomplete immediate occlusion revealed 22 aneurysms (88%) with improvement in the Raymond class. One aneurysm (3.3%) showed recanalization and required retreatment. Clinical followed-up at 5-28 months (mean 14.1 months) was achieved in 36 patients because two patients died of pancreatic cancer and basal ganglia hemorrhage, respectively. No new neurologic deterioration or aneurysm (re)bleeding was observed. CONCLUSIONS: Our preliminary experience with reconstruction of VADAs with the LVIS device demonstrates that this treatment approach is feasible with good short-term angiographic and clinical outcomes. Long-term and larger cohort studies are necessary to determine long-term outcomes of this therapy.

Effect of Baseline Characteristics on the Outcome of Stent Retriever-Based Thrombectomy in Acute Basilar Artery Occlusions: A Single-Center Experience and Pooled Data Analysis.

OBJECTIVES: To explore the association of baseline characteristics and the outcome of patients with acute basilar artery occlusion (BAO) after stent retriever-based thrombectomy (SRT). METHODS: Clinical and imaging information of consecutive SRT-treated patients with BAO from a comprehensive stroke center and up-to-date literature were reviewed respectively. The impact of baseline variables toward favorable outcome was evaluated using subgroup analysis and odds ratio (OR) extracted from published data together with single-center records using pooled analysis. RESULTS: Nineteen cases from our center and 15 published studies involving 487 cases were included. Estimated pooled favorable outcome rate was 0.3746 (95% confidence interval [CI], 0.3165-0.4327), mortality was 0.2950 (95% CI, 0.2390-0.3510). Pooled estimates showed that successful reperfusion (modified thrombolysis in cerebral ischemia scale 2b or 3) gained by SRT alone was 0.7317 (95% CI, 0.6532-0.8102) and final successful reperfusion rate with or without additional reperfusion procedures was 0.8834 (95% CI, 0.8279-0.9390). Univariate analysis indicated that patients with successful reperfusion (OR, 2.05; P = 0.05), distal segment occlusion (OR, 2.03; P = 0.03), and cardioembolus origin (OR, 2.13; P = 0.01) were more likely to have favorable outcome (modified Rankin Scale score ≤2 at 3 months). Study series that applied intra-arterial thrombolysis, angioplasty, or stenting as rescuing therapy had higher successful reperfusion rate but they did not show a higher rate of favorable outcome. CONCLUSIONS: SRT with or without additional treatment appeared to be effective for the treatment of BAO. Successful reperfusion, distal segment occlusion, and cardiac embolism were associated with favorable outcome. The overall benefit of lesions requiring additional reperfusion therapy was unclear.

Angiographic Characteristics and Endovascular Treatment of Anterior Cerebral Artery A1 Segment Aneurysms.

OBJECTIVE: This report aimed to review the angiographic characteristics and evaluate the safety and feasibility of endovascular treatment of A1 aneurysms. METHODS: Nineteen ruptured and 13 unruptured A1 aneurysms treated endovascularly were evaluated in this study. The angiographic and clinical records were retrospectively reviewed. RESULTS: Endovascular treatments were successfully applied in all 32 aneurysms. Conventional coiling was performed in 24 aneurysms, stent-assisted coiling in 7, and solo stenting in 1. The immediate angiographic result was 1 aneurysm in 15, two aneurysms in 10, and 3 in 7 aneurysms according to the Raymond grade. Intraoperative rupture was detected in 1 case without clinical consequence, and no other procedure-related complication occurred. Angiographic follow-up (mean, 12 months; range, 2-42 months) of 25 aneurysms showed total occlusion in 20, improvement in 1, stability in 3, and recurrence in 1. The only recurrence was detected in a case treated using conventional coiling, and it was retreated with stent-assisted coiling. Clinical follow-up (mean, 25 months; range, 6-93 months) was available in 24 of 30 patients, and the modified Rankin Scale score was 0-1 in 22 patients. CONCLUSIONS: Endovascular treatment is technically feasible and safe for A1 aneurysms.

Endovascular Embolization of Intracranial Aneurysms: To Use Stent(s) or Not? Systematic Review and Meta-analysis.

OBJECTIVES: We sought to review the literature concerning stent-assisted coiling (SAC) in comparison with coiling without stents for treating intracranial aneurysms and to evaluate the safety and effectiveness of SAC by conducting a meta-analysis of published studies. METHODS: According to the methods and guidelines for meta-analysis, PubMed, Embase, and Cochrane Database were searched. All articles that compared SAC and coiling without stent were reviewed. The data extracted were the rates of immediate occlusion, progressive thrombosis, angiographic occlusion, angiographic recurrence, overall complications, ischemic stroke, and hemorrhagic stroke. RESULTS: Sixteen studies with 4294 aneurysms were analyzed. SAC was performed for 1466 aneurysms; and coiling without stent was performed for 2828 aneurysms. No significant difference in immediate occlusion rate was found between the 2 groups (odds ratio [OR] = 1.01; 95% confidence interval [CI], 0.73-1.39, P = 0.96). However, SAC had an advantage in terms of angiographic occlusion rate during follow-up (OR = 1.62, 95% CI: 1.16-2.26, P < 0.01), progressive thrombosis rate (OR = 2.54, 95% CI: 2.00-3.24, P < 0.01), and reduction in recurrence rate (OR = 0.46; 95% CI, 0.35-0.59, P < 0.01). No significant differences were shown in overall complication rate (OR = 1.30, 95% CI: 086-1.96, P = 0.21) and hemorrhagic stroke rate (OR = 0.72, 95% CI: 0.43-1.20, P = 0.21). Ischemic strokes were more common in the SAC patients than in the non-stent-assisted patients (OR = 1.66; 95% CI: 1.05-2.63, P = 0.03). CONCLUSION: Compared with coiling without stent, stent-assisted coiling of intracranial aneurysms achieved satisfactory results, with higher long-term angiographic occlusion rate and lower recurrence rate. However, ischemic stroke remains a problem that cannot be ignored.

Treatment of fenestrated vertebrobasilar junction-related aneurysms with endovascular techniques.

Fenestrated vertebrobasilar junction-related aneurysms (fVBJ-AN) are uncommon and endovascular management strategies have become the first options for the treatment of these lesions. This clinical study aimed to report our experience in the endovascular management of these lesions and to review the literature. We retrospectively reviewed 10 consecutive patients harboring 12 fVBJ-AN between January 2007 and December 2014. The demographic, angiographic and clinical data were reviewed. Additionally, a literature review was performed. Endovascular management strategies were successfully applied in all 10 patients. Post-procedural angiograms indicated total occlusion in eight (66.7%) aneurysms, a residual neck in one (8.3%) aneurysm, and three residual aneurysms (25%). No procedure-related complications were observed. Follow-up angiograms were obtained in eight patients and revealed nine occluded aneurysms and one improved aneurysm; two patients were lost to angiographic follow-up. Clinical follow-ups were obtained in all patients (until July 2015), and the modified Rankin Scale scores at 69.5months (range 17-101months) of follow-up were 0 in eight patients and 1 in two patients. Endovascular management strategies provided a high occlusion rate and an acceptable complication rate and are thus efficacious in the treatment of fVBJ-AN. Further studies are necessary to validate the utility of these treatments due to the low incidence of fVBJ-AN.

Parametric Digital Subtraction Angiography Imaging for the Objective Grading of Collateral Flow in Acute Middle Cerebral Artery Occlusion.

PURPOSE: To report the feasibility of parametric color-coded digital subtraction angiography (DSA) in complementing the traditional, subjective way of leptomeningeal collateral assessment in acute middle cerebral artery (MCA) occlusions. METHODS: Thirty-three consecutive patients with acute MCA occlusion who received endovascular treatment were recruited for investigation. Eighteen of 33 consecutive patients were included. The target downstream territory (TDT) of MCA and reference point at terminal internal carotid artery of each patient was contoured by 5 raters independently on the basis of anteroposterior 2-dimensional DSA. Two parameters of relative maximum density of TDT (rDensitymax) and peak time interval (ΔPT) between reference and TDT were extracted by the use of parametric DSA analysis software. Interrater reliability was tested with intraclass correlation coefficients. Parameters with sufficient interrater reliability entered validity evaluation. Then, the correlation test with the American Society of Interventional and Therapeutic Neuroradiology collateral grading system and efficacy in predicting favorable clinical outcome was evaluated. RESULTS: The intraclass correlation coefficient of rDensitymax and ΔPT were 0.983, 95% confidence interval 0.968-0.993 and 0.831, 95% confidence interval 0.705-0.923, respectively. The parameter rDensitymax showed a strong correlation with the American Society of Interventional and Therapeutic Neuroradiology collateral grading system score (r of Spearman correlation test = 0.869, P < 0.001) and mRS at 3 months (partial correlation coefficient = 0.616, P = 0.009), whereas ΔPT_average did not. A cut-off point of 0.224 in rDensitymax predicted a favorable clinical outcome with high sensitivity and specificity. CONCLUSIONS: The relative maximum contrast density of MCA territory on 2-dimensional DSA measured by parametric imaging technique appears to be a simple and reliable metric for the assessment of leptomeningeal collaterals in cases of acute MCA occlusion.

Stepwise stent deployment technique for tandem intracranial aneurysms: a review of 21 cases.

OBJECTIVES: We performed this study to report our experience using a stepwise stent deployment technique for the treatment of tandem intracranial aneurysms. METHODS: Patients with intracranial tandem aneurysms that were treated with a stepwise stent deployment technique between May 2009 and June 2013 were retrospectively reviewed. RESULTS: Twenty-one patients with 42 tandem aneurysms were identified (11 men, 10 women), with a mean age of 53.7 years (range, 17-82 years). Subarachnoid haemorrhage was confirmed in 12 patients using computed tomography at onset. Complete occlusion was achieved in 20 of the aneurysms (47.6%) after the procedure, neck remnant in 9 (21.4%), and aneurysm remnant in 13 (31.0%). The perioperative complications included in-stent thrombosis in one case and vasospasm in two cases, none of which left a permanent neurological deficit. The modified Rankin Scale (mRS) score at discharge was 0-2 in 20 cases and 3 in one case. The follow-up angiograms available for 17 patients showed complete occlusion in 26 aneurysms, improved in 4, and stable in 4. All of the patients had mRS scores of 0-1 during the clinical follow-up period. CONCLUSIONS: The stepwise stent deployment technique is feasible and helpful in the treatment of intracranial tandem aneurysms. KEY POINTS: • Treating wide-necked intracranial aneurysms with stent-assisted coiling is preferable. • Tandem wide-necked intracranial aneurysms can be treated with a single stent. • Stepwise stent deployment is technically feasible for embolizing tandem intracranial aneurysms.

Treatment of ruptured vertebral artery dissecting aneurysms distal to the posterior inferior cerebellar artery: stenting or trapping?

PURPOSE: The treatment of ruptured vertebral artery dissecting aneurysms (VADAs) continues to be controversial. Our goal was to evaluate the safety, efficacy, and long-term outcomes of internal trapping and stent-assisted coiling (SAC) for ruptured VADAs distal to the posterior inferior cerebellar artery (supra-PICA VADAs), which is the most common subset. METHODS: A retrospective review was conducted of 39 consecutive ruptured supra-PICA VADAs treated with internal trapping (n = 20) or with SAC (n = 19) at our institution. The clinical and angiographic data were retrospectively compared. RESULTS: The immediate total occlusion rate of the VADAs was 80 % in the trapping group, which improved to 88.9 % at the follow-ups (45 months on average). Unwanted occlusions of the posterior inferior cerebellar artery (PICA) were detected in three trapped cases. Incomplete obliteration of the VADA or unwanted occlusions of the PICA were detected primarily in the VADAs closest to the PICA. In the stenting group, the immediate total occlusion rate was 47.4 %, which improved to 100 % at the follow-ups (39 months on average). The immediate total occlusion rate of the VADAs was higher in the trapping group (p < 0.05), but the later total occlusion was slightly higher in the stenting group (p > 0.05). CONCLUSIONS: Our preliminary results showed that internal trapping and stent-assisted coiling are both technically feasible for treating ruptured supra-PICA VADAs. Although not statistically significant, procedural related complications occurred more frequently in the trapping group. When the VADAs are close to the PICA, we suggest that the lesions should be treated using SAC.

Overlapping stents for blood blister-like aneurysms of the internal carotid artery.

OBJECTIVE: Blood blister-like aneurysms (BBAs) are unique due to their high risk of recurrent bleeding associated with their fragile neck. The best treatment for BBAs is still controversial. This paper sought to evaluate the safety and efficacy of stent-assisted coiling and subsequent overlapping stents (SAC+OS) in the treatment of BBAs. METHODS: Fifteen consecutive patients with ruptured BBAs managed with SAC+OS were enrolled in this study. The clinical characteristics, procedural data, angiographic outcome, and follow-up results were reviewed. RESULTS: SAC+OS were successfully performed in all 15 cases. The instant angiographic result was total occlusion in 6 cases, residual neck in 7 cases, and residual aneurysm in 2 cases. Angiographic follow-ups revealed total occlusion in all 6 cases treated by triple or quadruple stents, and 6 of 9 cases treated by double stents. Major recanalization was detected in 3 cases treated by double stents. The modified Rankin Scale score at 4-52 months follow-up (23.8 months on average) was 0 in 6 cases, 1 in 8 cases, and 3 in one case. CONCLUSION: Stent-assisted coiling and subsequent overlapping stents are feasible and safe for BBAs. It can be helpful to further decrease the risk of recanalization with more stents. Early angiographic follow-up within 2 weeks is recommended.

Application of endovascular coiling and subsequent Onyx 34 embolization in anterior communicating artery aneurysms with adjacent hematoma.

OBJECTIVE: Small anterior communicating artery aneurysms with recurrent bleeding and adjacent hematoma may have a high risk of post-operative rebleeding. This clinical study summarizes our preliminary experience with this subset of aneurysms, which were treated with endovascular coiling and subsequent Onyx 34 embolization. METHODS: We retrospectively reviewed the data of 9 patients suffering from small anterior communicating artery aneurysms treated with the combination of coils and Onyx. The clinical characteristics, angiographic outcomes, and follow-up results are reviewed. RESULTS: Endovascular coiling and Onyx embolization were successfully accomplished in all 9 cases. The Raymond scale ratings of the treatments are all class I with the parent arteries kept patent. One patient died of severe brain edema on the 5th post-operative day. The modified Rankin scale (mRS) score for the other 8 patients at follow-ups (6m to 26m, 15.8m on average) was 0 in 5 cases, 1 in 2 cases, and 3 in 1 case. Seven of 8 patients (87.5%) underwent angiographic follow-up that demonstrated persistent durable occlusion with no recanalization. CONCLUSIONS: Endovascular coiling and subsequent Onyx 34 embolization may be effective in treating anterior communicating artery aneurysms with adjacent hematoma. Further studies with larger sample size and adequate follow-up are required to verify its safety and efficacy as well as to evaluate the long-term outcome.

Parent artery reconstruction for large or giant cerebral aneurysms using a Tubridge flow diverter (PARAT): study protocol for a multicenter, randomized, controlled clinical trial.

BACKGROUND: The treatment of large (10-25 mm) or giant (≥25 mm) cerebral aneurysms remains technically challenging, with a much higher complication and recanalization rate than that is observed for smaller aneurysms. The use of a flow diverter seems to facilitate the treatment of this special entity. In a previous single-center prospective study approved by the Ethics Committee and China Food and Drug Administration (CFDA), we obtained promising results, showing remarkable safety and effectiveness for the Tubridge flow diverter. Nevertheless, the previous study may have been limited by biases due to its single-center design and limited number of subjects. Furthermore, although various articles have reported durable results from treating aneurysms using flow diverters, increasing questions have arisen about this form of treatment. Thus, prospective, multiple-center, randomized trials containing more subjects are needed. METHODS/DESIGN: This study is a multicenter, randomized, controlled clinical trial comparing clinical outcomes for patients with unruptured large/giant intracranial aneurysms treated with either conventional stent-assisted coiling or flow diverter implantation. A total of 124 patients who fulfill the inclusion and exclusion criteria will be randomized into either a treatment group or a control group in the ratio of 1:1. The treatment group will receive Tubridge implantation alone or combined with bared coils, and the control group will be treated with stent-assisted coiling (bare coils). The primary endpoint will be the complete occlusion rate at 6-month follow-up. Secondary endpoints include the immediate technique success rate, overall mortality, adverse events (ischemic stroke or intracranial bleeding) within 30 days, 90 days and 1 year post-operation, and the rate of intra-stent stenosis and thrombosis 6 months post-operation. DISCUSSION: This prospective trial may provide more information on the safety and efficacy of the Tubridge flow diverter and may potentially change the strategy for treatment of large or giant aneurysms. TRIAL REGISTRATION: The trial is registered on the Chinese Clinical Trial Registry: ChiCTR-TRC-13003127.

The interaction between stent(s) implantation, PICA involvement, and immediate occlusion degree affect symptomatic intracranial spontaneous vertebral artery dissection aneurysm (sis-VADA) recurrence after reconstructive treatment with stent(s)-assisted coiling.

OBJECTIVES: We aimed to evaluate risk factors of sis-VADAs recurrence after reconstructive treatment based on 113 reconstructed lesions. METHODS: A total of 111 patients (M:F = 68:43; median age, 47 years) with 113 sis-VADAs underwent reconstruction from October 2000 to March 2011, using stent(s) and coils. Treatments and predictors of recurrence were retrospectively analysed. RESULTS: Fifty-eight sis-VADAs underwent single-stent treatment, and the remaining 55 sis-VADAs underwent treatment with 2-4 overlapping stents. Follow-up angiography was available for 94 sis-VADAs 12 -78 months, with recurrence in ten patients, including seven angiographic recurrences and three post-treatment haemorrhagic recurrences. A higher rate of post-treatment recurrence was observed in the single stent group than in the multiple stents group (p = 0.010). The interaction between stent (s) implantation and immediate occlusion degree (odds ratio [OR] =3.152; 95% confidence interval [CI], 1.293-7.686; p = 0.012), between stent (s) implantation and the posterior inferior cerebellar artery (PICA) involvement (OR = 4.607; 95% CI, 1.172-18.113; p = 0.029), and between PICA involvement and immediate occlusion degree (OR = 5.018; 95% CI, 1.263-19.933; p = 0.022) affect recurrence in the reconstructed sis-VADAs. CONCLUSIONS: This single centre cohort study indicated that the interaction effect between stent (s) implantation, PICA involvement, and immediate occlusion degree were closely associated with recurrence after reconstructive treatment of sis-VADA. KEY POINTS: The interaction between stent (s) and immediate occlusion degree affect aneurysmal recurrence. The interaction between stent and PICA involvement affect aneurysmal recurrence. The interaction between PICA involvement and immediate occlusion degree affect aneurysmal recurrence.