RESUMO
Endovascular treatment has been acknowledged as an effective treatment for intracranial aneurysms, showcasing favorable clinical outcomes and providing robust protection against rebleeding and rupture. Notably, during the endovascular procedure, significant complications include intraprocedural aneurysmal rupture (IAR) induced by microcatheters, microguidewires, or spring coils, along with thromboembolic events, significantly escalating patient mortality and disability. Current approaches against for IARs involve various strategies such as heparin reversal, compression of the common carotid artery or upstream soft guidewire to mitigate blood flow, management of intracranial pressure and blood pressure, and balloon-assisted or unassisted rapid dense embolization of the aneurysm. Nevertheless, these measures may prove insufficient in halting hemorrhage, especially in scenarios where additional coils cannot be added for dense embolization due to inherent limitations. In this context, we introduce a novel strategy for the prompt, safe, and effective cessation of aneurysm bleeding, which involves injecting an appropriate quantity of Onyx into the aneurysm through a microcatheter while safeguarded by an aneurysm-carrying arterial braided stent. Initially, we attempted dense embolization by filling multiple coils. However, in cases where continued coil filling proved unfeasible or failed to sufficiently prevent contrast agent extravasation, we opted for Onyx injection into the aneurysm. Utilizing Onyx effectively prevented further blood extravasation without adversely impacting the aneurysm-carrying artery or distal vessels, leading to favorable prognoses for all patients. This article delineates our embolization strategy, highlighting the efficacy and safety of Onyx injection as an alternative or complementary measure in managing complications arising from endovascular coil embolization.
Assuntos
Aneurisma Roto , Dimetil Sulfóxido , Embolização Terapêutica , Aneurisma Intracraniano , Polivinil , Humanos , Embolização Terapêutica/métodos , Aneurisma Roto/terapia , Polivinil/uso terapêutico , Aneurisma Intracraniano/terapia , Masculino , Procedimentos Endovasculares/métodos , Feminino , Pessoa de Meia-Idade , Resultado do Tratamento , TantálioRESUMO
Current approaches for localized intravascular treatments rely on using solid implants, such as metallic coils for embolizing aneurysms, or on direct injection of a therapeutic agent that can disperse from the required site of action. Here, we present a fluid-based strategy for localizing intravascular therapeutics that leverages surface tension and immiscible fluid interactions, to allow confined and focal treatment at brain aneurysm sites. We first show, computationally and experimentally, that an immiscible phase can be robustly positioned at the neck of human aneurysm models to seal and isolate the aneurysm's cavity for further treatment, including in wide-neck aneurysms. We then demonstrate localized delivery and confined treatment, by selective staining of cell nuclei within the aneurysm cavity as well as by hydrogel-based embolization in patient-specific aneurysm models. Altogether, our interfacial flow-driven strategy offers a potential approach for intravascular localized treatment of cardiovascular and other diseases.
Assuntos
Aneurisma Intracraniano , Aneurisma Intracraniano/terapia , Humanos , Embolização Terapêutica/métodosRESUMO
This study aimed to evaluate the radiation doses (peak skin dose (PSD) and bilateral lens dose) for each interventional neuroradiology procedure. A direct measurement system consisting of small radiophotoluminescence glass dosimeter chips and a dosimetry cap made of thin stretchable polyester was used for radiation dosimetry. The mean PSDs for each procedure were 1565 ± 590 mGy (simple technique coil embolization (STCE) cases), 1851 ± 825 mGy (balloon-assisted coil embolization (BACE) cases), 2583 ± 967 mGy (stent-assisted coil embolization (SACE) cases), 1690 ± 597 mGy (simple flow-diverter stenting (FDS) cases), and 2214 ± 726 mGy (FDS + coiling cases). The mean PSD was higher in SACE cases than in STCE, BACE, and simple FDS cases. Moreover, the PSD exceeded 2000 mGy and 3000 mGy in 46 (67.6%) and 19 (27.9%) SACE cases, respectively. The left lens doses for each procedure were 126 ± 111 mGy (STCE cases), 163 ± 152 mGy (BACE cases), 184 ± 148 mGy (SACE cases), 144 ± 60 mGy (simple FDS cases), and 242 ± 178 mGy (FDS + coiling cases). The left lens dose in SACE cases was higher than that in STCE cases and exceeded 500 mGy in 3 (4.4%) patients. In FDS + coiling cases, the mean PSD and left lens dose were 2214 ± 726 mGy and 242 ± 178 mGy, respectively. The left lens dose was higher than that in the STCE and BACE cases, with two (15.4%) patients receiving doses >500 mGy in FDS + coiling cases. The detailed data obtained in this study are expected to contribute to the promotion of radiation dose optimization.
Assuntos
Aneurisma Intracraniano , Doses de Radiação , Radiografia Intervencionista , Humanos , Aneurisma Intracraniano/terapia , Masculino , Feminino , Pessoa de Meia-Idade , Embolização Terapêutica , Idoso , Radiometria , Adulto , Cristalino/efeitos da radiação , NeurorradiografiaRESUMO
The role of a low-profile visualized intraluminal support stent (LVIS) and Enterprise in the treatment of unruptured intracranial aneurysms is well established. Although previous studies have investigated one single type of stent for the treatment of ruptured intracranial aneurysms (RIA), the safety and efficacy between the two types of stents has not been fully explored. Herein we conducted a study to compare the outcomes of the two stents for treatment of RIA. This is a prospective registry database of aneurysmal subarachnoid hemorrhage (aSAH) patients admitted to a single institution between 2018 and 2021. We collected patient baseline information, secondary complications, follow-up angiographic data, long-term prognostic outcomes, and conducted propensity score matching (PSM) analysis with 1:1 ratio and a multivariable logistic regression to compare the outcomes of the two types of stents. A total of 231 patients with RIAs were included in this study, with 108 treated using the LVIS device and 123 treated using the Enterprise device. Before PSM analysis, only the incidence of poor prognosis after 12 months was higher in the Enterprise group comparing to the LVIS group (20% vs. 10%, P = 0.049). After PSM analysis, there was a higher occurrence of delayed cerebral ischemia (DCI) in the Enterprise group compared to the LVIS group (odds ratio [OR] 3.95, 95% confidence interval [CI] [1.20-13.01], P = 0.024). However, no significant difference in prognosis was observed after PSM adjustment. Furthermore, subgroup analysis revealed that patients with female (P = 0.019), hypertension (P = 0.048), and anterior circulation aneurysms (P = 0.019) receiving the Enterprise device had a higher risk of DCI. The overall efficacy of LVIS and Enterprise in the treatment of RIA is comparable, while the incidence of DCI in the LVIS group is lower than that in the Enterprise group after PSM analysis. Registration number: NCT05738083 ( https://clinicaltrials.gov/ ).
Assuntos
Aneurisma Roto , Embolização Terapêutica , Aneurisma Intracraniano , Pontuação de Propensão , Stents , Humanos , Aneurisma Intracraniano/terapia , Feminino , Masculino , Aneurisma Roto/terapia , Pessoa de Meia-Idade , Embolização Terapêutica/métodos , Embolização Terapêutica/instrumentação , Idoso , Adulto , Resultado do Tratamento , Estudos de Coortes , Procedimentos Endovasculares/métodos , Hemorragia Subaracnóidea/terapiaRESUMO
Despite advancements in neurosurgical techniques, subarachnoid hemorrhage(SAH) caused by the rupture of a partially thrombosed intracranial giant aneurysm remains a challenging clinical entity. This report describes the successful treatment of an 80-year-old male patient with SAH due to a ruptured, partially thrombosed intracranial giant aneurysm. The patient underwent a staged endovascular strategy using a flow diverter. The patient presented with SAH secondary to a ruptured, partially thrombosed intracranial giant aneurysm located at the C2 portion of the internal carotid artery and involving the origin of the posterior communicating artery(Pcom). Imaging revealed a dorsomedial rupture point on the aneurysm. A two-stage endovascular intervention(IVR) was performed. The first stage involved coil embolization aimed at covering the rupture point. Following the resolution of the vasospasm and the acute phase of SAH, the second stage involved the deployment of a pipeline embolization device. Digital subtraction angiography performed one month after the second stage IVR demonstrated a significant reduction in aneurysm filling, with preserved flow to the Pcom artery. We will discuss the technical details and rationale behind the staged endovascular approach in this complex case.
Assuntos
Aneurisma Roto , Procedimentos Endovasculares , Aneurisma Intracraniano , Humanos , Masculino , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/terapia , Idoso de 80 Anos ou mais , Aneurisma Roto/cirurgia , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/terapia , Procedimentos Endovasculares/métodos , Embolização Terapêutica/métodos , Angiografia Digital , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/cirurgia , Hemorragia Subaracnóidea/terapia , Resultado do TratamentoRESUMO
For treating ruptured cerebral aneurysms, it is important to understand the setup and basic technique of coil embolization. Safe and effective embolization relies on preoperative considerations that determine the treatment strategy, guide the optimization of the therapeutic environment, and help in the selection of appropriate device systems. Moreover, during aneurysmal embolization, basic techniques for microcatheter shaping and navigation, safe coil introduction, and precise use of occlusion balloons are indispensable. Microcatheter shaping should be based on three-dimensional digital subtraction angiography findings as well as the axes of the parent artery and aneurysm. The operator must understand the advantages and disadvantages of the two methods for navigating the microcatheter into the aneurysm. Furthermore, it is essential to preoperatively simulate and understand the approaches for managing aneurysmal embolization-related complications, such as intraoperative aneurysmal rupture and thromboembolism. Mastery of these steps is mandatory before undertaking embolization of ruptured cerebral aneurysms.
Assuntos
Aneurisma Roto , Embolização Terapêutica , Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/terapia , Aneurisma Intracraniano/diagnóstico por imagem , Embolização Terapêutica/métodos , Aneurisma Roto/terapia , Aneurisma Roto/diagnóstico por imagem , Angiografia Digital , Angiografia CerebralRESUMO
Background: Using two case reports of adult women with moyamoya disease presenting with intracranial hemorrhage from ruptured aneurysms on moyamoya collateral vessels, we aim to demonstrate the potential for effective endovascular treatment navigated by CT angiography, digital subtraction angiography, and flat panel CT. Case 1 Presentation: A 45-year-old female patient with sudden onset of headache, followed by somnolency. CT scan showed a four-ventricle hematocephalus caused by a 27 × 31 × 17 mm hematoma located in the left basal ganglia. Angiography revealed a 3 mm aneurysm on hypertrophic lenticulostriate artery bridging the M1 occlusion. Selective catheterization and distal embolisation with acrylic glue was done. Case 2 Presentation: A 47-year-old woman was admitted for a sudden onset of severe headache, CT scan showed four-ventricle hematocephalus. A 4 mm aneurysm on the collateral vessel-anterior chorioidal artery bridging the closure of the terminal segment of the internal carotid artery was diagnosed as the source of bleeding. Selective catheterization and distal embolisation with acrylic glue was done. Conclusions: Selective embolisation of ruptured aneurysms on moya moya collaterals is a simple, effective, and safe procedure when relevant microcatheters are used with imaging software navigation such as 3D DSA, 3D road map and flat-panel CT.
Assuntos
Aneurisma Roto , Procedimentos Endovasculares , Doença de Moyamoya , Humanos , Feminino , Pessoa de Meia-Idade , Doença de Moyamoya/complicações , Doença de Moyamoya/terapia , Aneurisma Roto/terapia , Aneurisma Roto/complicações , Procedimentos Endovasculares/métodos , Aneurisma Intracraniano/terapia , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/diagnóstico por imagem , Embolização Terapêutica/métodos , Angiografia Digital/métodos , Tomografia Computadorizada por Raios XRESUMO
Regarding intracranial aneurysm treatment, the clip versus coil debate remains inconclusive and lacking studies in Brazil. To examine trends in the management of intracranial aneurysms in Brazil over time, both ruptured and unruptured. A descriptive and exploratory study was conducted based on data of neurovascular procedures for aneurysm treatment using the Brazilian Public Health System database (DATASUS). The variables analyzed were the number of procedures, mortality rates, length of hospital stays, and global costs of hospitalization, from 2010 to 2019. Temporal trend analysis and statistical comparisons were conducted to assess changes over time and differences between the treatment options. The mean annual number of aneurysm treatments with endovascular embolization was 2206.30 (± 309.5), with a non-significant increasing trend (B = 55.66; p = 0.104). Conversely, microsurgical clipping exhibited a significant decreasing trend (B = -69.97; p < 0.001) with a mean of 1133.1 (± 223.12) procedures. The mortality rate associated with clipping procedure was higher in the period, with a mean difference of 5.23 (± 0.39); ([CI95%: 4.36; 6.10]; p < 0.001) and showed an increase trend, while embolization showed a stable trend. The length of in-hospital stay remained stable for clipping but increased for embolization. Costs associated with clipping increased over time, whereas costs for embolization decreased. This study highlights a significant shift in the treatment of aneurysm towards Endovascular Embolization. Despite higher costs, endovascular procedures were associated with lower mortality rates and shorter hospital stays. These findings provide valuable insights into aneurysm treatment patterns and indicators in a middle-income country's Public Health System.
Assuntos
Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Tempo de Internação , Instrumentos Cirúrgicos , Humanos , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/terapia , Brasil , Embolização Terapêutica/métodos , Procedimentos Endovasculares/tendências , Procedimentos Endovasculares/métodos , Procedimentos Neurocirúrgicos/tendências , Aneurisma Roto/cirurgia , Aneurisma Roto/terapia , Masculino , Feminino , Pessoa de Meia-Idade , Resultado do Tratamento , MicrocirurgiaRESUMO
BACKGROUND: The optimal treatment strategy for elderly patients with ruptured intracranial aneurysms (IAs) remains controversial. We evaluated a national, multihospital database to compare the outcomes of aggressive treatment and medical management for those patients. METHODS: We performed a retrospective analysis of 2665 elderly patients with ruptured IAs admitted to 11 hospitals in China. Patients were divided into three age groups (60-69, 70-79, and 80 years or older). Multiple logistic regression was used to estimate the odds ratio for favorable and unfavorable outcomes. RESULTS: Patients between 60 and 69 years old undergoing endovascular treatment (EVT) had significantly decreased morbidity (13.7% versus 19.7% and 29.9%), compared to those who underwent clipping and medical management, similar mortality to patients who underwent clipping (3.6% versus 2.6%), and decreased mortality (3.6% versus 8.7%) to patients who underwent medical management. Coiled patients 70 to 79 years old had lower morbidity (21.3% versus 33.8%) and mortality (2.8% versus 11.3%) compared to patients who underwent medical management and similar mortality (21.3% versus 27.2%) and mortality (2.8% versus 4.8%) to patients who underwent clipping. Multivariate logistic regression analysis demonstrated that factors associated with discharge status were age, poor mFisher grade, poor WFNS grade, hypertension, diabetes, smoking, aneurysms 4 mm or larger, and middle cerebral artery aneurysms. CONCLUSIONS: Elderly patients treated with EVT had significantly less morbidity and mortality than those treated with clipping and medical management. A comprehensive assessment of the general state of elderly patients and IAs characteristic may help us to predict patients' prognosis.
Assuntos
Aneurisma Roto , Procedimentos Endovasculares , Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/terapia , Aneurisma Intracraniano/mortalidade , Idoso , Aneurisma Roto/cirurgia , Pessoa de Meia-Idade , Feminino , Masculino , Estudos Retrospectivos , Idoso de 80 Anos ou mais , Resultado do Tratamento , China/epidemiologia , Procedimentos NeurocirúrgicosRESUMO
Management of wide-necked aneurysms in cavernous ICA has significantly evolved in the endovascular era, with flow diverters and stent-assisted coiling being an effective modality. It is vital to select the type of stent according to the arterial anatomy, hemodynamics, and device characteristics. We report a catastrophic complication of laser-cut stent used for SAC of cavernous ICA aneurysm performed at another center 5 years back, presenting with regrowth and massive life-threatening epistaxis managed successfully. In tortuous angulated anatomy, laser-cut stents are difficult to place, poorly visible, and the device opening is uncertain. Unlike braided stents, laser-cut stents do not provide flow diversion effect, stent migration, and buckling phenomena are more likely to occur with laser-cut stents. We intend to discuss the technical fallacies behind using laser-cut stents in such case scenarios and the optimal treatment approach for such cases with an attitude to learn from such complications.
Assuntos
Aneurisma Intracraniano , Stents , Humanos , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/terapia , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/instrumentação , Artéria Carótida Interna/cirurgia , Masculino , Pessoa de Meia-Idade , FemininoRESUMO
The management of superior cerebellar aneurysms is still controversial. Although several techniques are available, the deep localization of the lesion and the limited number of cases increase the complexity of decision-making for optimal treatment. Only a few cases of dissecting and fusiform aneurysms of the superior cerebellar artery (SCA) are described in the literature, many of which are without long follow-ups. The study aims to offer an exhaustive retrospective analysis of patients affected by SCA fusiform and dissecting aneurysms treated at our institution from 2008 to 2023, highlighting outcomes and complications. Moreover, a comprehensive narrative review was performed. A total of seven patients were treated at our institution. After a title and abstract screen, fifty-five papers met the criteria for inclusion in the review. In our case series, conservative treatment was proposed as the first therapeutic option in four cases (57.1%), while endovascular treatment (EVT) was in three cases (42.9%). A good recovery was observed in 66% of patients presenting with subarachnoid hemorrhage (SAH), while every patient without SAH achieved a good clinical outcome. A poor outcome was observed only in one patient with a dissecting aneurysm causing SAH, who also suffered a pontine infarction. In the literature review, conservative treatment was proposed as a first therapeutic option in eleven cases (16.6%), open microsurgical techniques in 19 patients (28.8%), and EVT in 31 patients (46.9%). Fatal outcome was documented in five patients (7.5%), all characterized by the rupture of the vascular lesion, while 6.1% of cases had non-fatal poor outcomes.
Assuntos
Dissecção Aórtica , Cerebelo , Procedimentos Endovasculares , Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/terapia , Aneurisma Intracraniano/cirurgia , Masculino , Feminino , Pessoa de Meia-Idade , Resultado do Tratamento , Dissecção Aórtica/terapia , Dissecção Aórtica/cirurgia , Cerebelo/irrigação sanguínea , Idoso , Adulto , Procedimentos Endovasculares/métodos , Estudos Retrospectivos , Hemorragia Subaracnóidea/terapia , Hemorragia Subaracnóidea/cirurgiaRESUMO
AIM OF STUDY: To retrospectively assess the occurrence and consequences of subarachnoid haemorrhages (SAH) caused by ruptured intracranial aneurysms (RIA), particularly focusing on the treatment outcomes of small aneurysms treated with either endovascular embolisation or surgical intervention. MATERIAL AND METHODS: We retrospectively analysed data from 408 patients (144 males and 264 females) who were hospitalised between 2013 and 2022 at the Department of Neurosurgery and Neurology in University Hospital Nr 2 in Bydgoszcz, Poland. Clinical conditions at admission, assessed using the Glasgow Coma Scale, Hunt-Hess scale (H-H), modified Rankin scale (mRS), as well as age and sex, were recorded. Additionally, aneurysm data including size, localisation, and the method and outcome of endovascular or surgical treatment were examined. RESULTS: Among the 408 patients hospitalised due to SAH, the most common localisation of the 375 RIAs was the anterior communicating artery (AcomA) complex (111 cases, 29.6%), followed by the medial cerebral artery (MCA) (95 cases, 25.3%), internal carotid artery (ICA) (94 cases, 25%), and the vertebrobasilar complex (consisting of the basilar artery (BA) - 25 cases, vertebral artery (VA) - 13 cases, anterior inferior cerebellar artery (AICA) - one case, and posterior inferior cerebellar artery (PICA) - four cases), which accounted for 43 SAH cases (11.46%). In 33 cases, neither RIA nor a haemorrhage source was identified, or arteriography showed no cerebral arteries contrast flow. Among the examined group of 375 RIAs, 45 (12%) were microaneurysms (≤ 3 mm), 35 (9%) were small aneurysms (3 ≤ 5 mm), 89 (24%) were medium-sized (5 ≤ 7 mm), and 151 (40%) were large aneurysms (> 7 mm), serving as the source of SAH. A better outcome was significantly associated with lower initial H-H grade (p < 0.001), higher GCS (p < 0.001), lower mRS at admission (p < 0.001), younger age (p < 0.001), smaller size (≤ 3 mm) (p < 0.001), and endovascular treatment (p < 0.001). CONCLUSIONS: In this series, over 21% of patients suffered from SAH resulting from ruptured small aneurysms (≤ 5 mm), with 12% specifically attributed to ruptured very small aneurysms (≤ 3 mm), despite large aneurysms (> 7 mm) being the most prevalent source of bleeding in 40% of cases. A worse prognosis was primarily associated with the severity of SAH, reflected in poorer clinical status at admission and older age. Endovascular embolisation was found to be effective and associated with better outcomes compared to surgical treatment.
Assuntos
Aneurisma Roto , Aneurisma Intracraniano , Hemorragia Subaracnóidea , Humanos , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/terapia , Idoso , Adulto , Polônia , Prevalência , Embolização Terapêutica , Procedimentos Endovasculares , Resultado do Tratamento , Idoso de 80 Anos ou maisRESUMO
BACKGROUND AND PURPOSE: Material-specific reconstructions of dual-energy CTA (DECTA) can highlight iodinated contrast, subtract predefined materials, and reduce metal artifact. We present a technique to improve detection of residual aneurysms after endovascular coiling by which iodine-map DECTA (IM-DECTA) reconstructions subtract platinum coil artifacts in MIP images (MIP IM-DECTA) and assess if IM-DECTA offers improved detection over conventional CTA (CCTA) or monoenergetic DECTA. MATERIALS AND METHODS: We included consecutive patients who underwent endovascular aneurysm coiling with follow-up DECTA and DSA within 24 months. DECTA was performed at 80- and 150-kVp tube voltages on a rapid kV-switching single-source Revolution scanner. CCTA and IM-DECTA series were reconstructed. Reference-standard DSA was compared with CCTA, 50- and 70-keV virtual monochromatic DECTA, IM-DECTA, and MIP IM-DECTA. Blinded to DSA data, cross-section images were reviewed in consensus by 3 neurointerventionalists for residual aneurysms and assigned modified Raymond-Roy classifications (mRRC). Sensitivity, specificity, and accuracy of each series is reported relative to DSA, and single-factor ANOVA and pair-wise Spearman correlation coefficients compared the accuracy of each series. Readers provided ROI measurements of HU deviation adjacent to the aneurysm neck for quantitative noise assessment and qualitatively scored each series on a 3-point Likert-style scale ranging from uninterpretable to excellent image quality. RESULTS: Twenty-one patients with 25 coiled aneurysms were included. Mean time from DECTA to DSA was 286 ± 212 days. IM-DECTA and MIP IM-DECTA most sensitively (89% and 90%) and specifically (93% and 93%) detected residual aneurysms relative to CCTA (6% and 86%). Relative to DSA, IM-DECTA and MIP IM-DECTA most accurately detected (92% versus 28% for CCTA) and classified residual aneurysms by mRRC (ρC-CTA = -0.08; ρIM = 0.50; ρIM-MIP = 0.55; P < .001). Reader consensus reported the best image quality at the aneurysm neck with IM-DECTA and MIP IM-DECTA, with 56% of CCTAs considered uninterpretable versus 0% of IM-DECTAs, and image noise was significantly lower for IM-DECTA (27.9 ± 3.6 HU) or MIP IM-DECTA (26.8 ± 3.5 HU) than CCTA (103.2 ± 13.3 HU; P < .001). CONCLUSIONS: MIP IM-DECTA can subtract coil mass artifact and is more sensitive and specific than CCTA for the detection of residual aneurysms after endovascular coiling.
Assuntos
Angiografia por Tomografia Computadorizada , Meios de Contraste , Procedimentos Endovasculares , Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/terapia , Feminino , Masculino , Pessoa de Meia-Idade , Idoso , Procedimentos Endovasculares/métodos , Angiografia por Tomografia Computadorizada/métodos , Sensibilidade e Especificidade , Angiografia Cerebral/métodos , Imagem Radiográfica a Partir de Emissão de Duplo Fóton/métodos , Adulto , Embolização Terapêutica/métodos , Estudos Retrospectivos , Artefatos , Angiografia Digital/métodos , IodoRESUMO
BACKGROUND AND PURPOSE: The Pipeline Embolization Device is a safe and effective treatment option for intracranial aneurysms. The newer Pipeline generations have received structural refinements and a surface modification to improve deliverability, procedural safety, and angiographic outcomes. This multicenter study evaluated the clinical safety and efficacy of the 2 surface-modified Pipeline iterations, Pipeline Vantage and Pipeline Flex with Shield Technology (PFS). MATERIALS AND METHODS: Consecutive patients treated between 2017 and 2023 were retrospectively reviewed for aneurysm characteristics, procedural details, complications, and angiographic outcomes. The safety end point was the rate of procedural and postprocedural major neurologic events occurring during the hospital stay. The efficacy end point was the rate of complete occlusion at last follow-up. RESULTS: One hundred forty-one patients underwent 112 Pipeline Vantage procedures and 32 PFS procedures for 147 aneurysms with a mean size of 8.0 (SD, 5.9) mm (11% ruptured, 16% posterior circulation, 18% nonsaccular morphology). All procedures were technically successful with a mean of 1.2 devices implanted. Balloon angioplasty was required in 20/144 (13.9%) procedures. Major neurologic adverse events occurred in 6/144 (4.2%) procedures (all ischemic stroke), resulting in death in 2 (1.4%) patients. There were no hemorrhagic complications. At a mean of 11 months, complete occlusion was achieved in 85/112 (75.9%) aneurysms, 15/112 (13.4%) had an entry remnant, and 12/112 (10.7%) had an aneurysm remnant. CONCLUSIONS: The results demonstrate high feasibility, procedural safety, and efficacy of the surface-modified Pipeline flow diverters.
Assuntos
Embolização Terapêutica , Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/terapia , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Masculino , Feminino , Pessoa de Meia-Idade , Embolização Terapêutica/instrumentação , Embolização Terapêutica/métodos , Estudos Retrospectivos , Resultado do Tratamento , Idoso , Adulto , Angiografia Cerebral , StentsRESUMO
Flow-diverter stents offer clinicians an effective solution for treating intracranial aneurysms, especially in cases where other devices may be unsuitable. However, strongly deviating success rates among different centres, manufacturers, and aneurysm phenotypes highlight the need for better in-situ studies of these devices. To support research in this area, virtual stenting algorithms have been proposed that, combined with computational fluid dynamics, provide insights into the hemodynamic alterations induced by the device. Yet, many existing algorithms rely on uncertain parameters, such as the forces applied during operation, fail to predict the length of the device after deployment, or lack robust validation steps, raising concerns about their reliability. Therefore, we developed a robust deployment technique that builds upon the geometrical features of the vessel and includes advancements from previous works. The algorithm is detailed and validated against literature examples, in-vitro experiments, and patient data, achieving a mean angular error below 5° in the latter. Furthermore, we describe and demonstrate how the deployed device can be embedded in a computational mesh using open-source tools and anisotropic meshing routines.
Assuntos
Algoritmos , Hemodinâmica , Aneurisma Intracraniano , Modelos Cardiovasculares , Stents , Humanos , Aneurisma Intracraniano/fisiopatologia , Aneurisma Intracraniano/terapia , Aneurisma Intracraniano/cirurgia , Hemodinâmica/fisiologia , Simulação por ComputadorAssuntos
Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/terapia , Aneurisma Intracraniano/cirurgia , Feminino , Resultado do Tratamento , Masculino , Pessoa de Meia-Idade , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Angiografia Cerebral , Artéria Basilar/diagnóstico por imagem , IdosoRESUMO
BACKGROUND AND PURPOSE: Despite the numerous studies evaluating the occlusion rates of aneurysms following WEB embolization, there are limited studies identifying predictors of occlusion. Our purpose was to identify predictors of aneurysm occlusion and the need for retreatment. MATERIALS AND METHODS: This is a review of a prospectively maintained database across 30 academic institutions. We included patients with previously untreated cerebral aneurysms embolized using the WEB who had available intraprocedural data and long-term follow-up. RESULTS: We studied 763 patients with a mean age of 59.9 (SD, 11.7) years. Complete aneurysm occlusion was observed in 212/726 (29.2%) cases, and contrast stasis was observed in 485/537 (90.3%) of nonoccluded aneurysms. At the final follow-up, complete occlusion was achieved in 497/763 (65.1%) patients, and retreatment was required for 56/763 (7.3%) patients. On multivariable analysis, history of smoking, maximal aneurysm diameter, and the presence of an aneurysm wall branch were negative predictors of complete occlusion (OR, 0.5, 0.8, and 0.4, respectively). Maximal aneurysm diameter, the presence of an aneurysm wall branch, posterior circulation location, and male sex increase the chances of retreatment (OR, 1.2, 3.8, 3.0, and 2.3 respectively). Intraprocedural occlusion resulted in a 3-fold increase in the long-term occlusion rate and a 5-fold decrease in the retreatment rate (P < .001), offering a specificity of 87% and a positive predictive value of 85% for long-term occlusion. CONCLUSIONS: Intraprocedural occlusion can be used to predict the chance of long-term aneurysm occlusion and the need for retreatment after embolization with a WEB device. Smoking, aneurysm size, and the presence of an aneurysm wall branch are associated with decreased chances of successful treatment.
Assuntos
Embolização Terapêutica , Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/terapia , Aneurisma Intracraniano/cirurgia , Masculino , Feminino , Pessoa de Meia-Idade , Embolização Terapêutica/instrumentação , Embolização Terapêutica/métodos , Estudos Retrospectivos , Resultado do Tratamento , Idoso , Fatores de RiscoRESUMO
BACKGROUND: Pediatric spontaneous intracranial dissecting aneurysms are rare, but systematic studies comparing hemorrhagic and ischemic presentations are lacking. This study addresses gaps in understanding their epidemiology, clinical presentation, management, and outcome. METHODS: A retrospective analysis of 23 pediatric patients with nontraumatic intracranial dissecting aneurysms treated between July 2018 and December 2023 was conducted. Patients were divided into 2 groups based on presentation: hemorrhagic (n = 16) and ischemic (n = 7). Clinical data were analyzed, including demographics, radiologic findings, treatment modalities, and outcomes. RESULTS: Clinical presentations varied, with limb weakness being more prevalent in hemorrhagic cases (P = 0.014), while headache and seizures were more common in ischemic cases. Angiographic analysis revealed distinct patterns, with hemorrhagic cases showing more distal involvement on vessel segments with stenosis and dilatation (pearl string sign). At the same time, the ischemic group exhibited the double-lumen sign. Various treatments, including microsurgery and endovascular techniques, were utilized, with perioperative complications observed, including one mortality in a hemorrhagic case. Multiple regression analysis identified significant risk factors for perioperative complications, namely, the configuration of the dissecting aneurysm (P = 0.016) and the type of presentation (P = 0.0006). Long-term Glasgow Outcome Scores were comparable, but patients with hemorrhagic manifestations experienced prolonged hospital and ICU stays (P = 0.001). CONCLUSIONS: Pediatric intracranial dissecting aneurysms, particularly hemorrhagic cases, are associated with severe neurologic deficits and higher perioperative complications. Despite similar long-term outcomes, hemorrhagic cases require prolonged hospitalization, increasing treatment costs. Optimizing management strategies for pediatric intracranial dissecting aneurysms, especially those with hemorrhagic features, is essential to improve outcomes and reduce healthcare expenditures.
Assuntos
Dissecção Aórtica , Isquemia Encefálica , Procedimentos Endovasculares , Aneurisma Intracraniano , Humanos , Masculino , Feminino , Procedimentos Endovasculares/métodos , Criança , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/epidemiologia , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/terapia , Estudos Retrospectivos , Adolescente , Dissecção Aórtica/cirurgia , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/epidemiologia , Isquemia Encefálica/etiologia , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/cirurgia , Países em Desenvolvimento , Pré-Escolar , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Despite their asymptomatic occurrence, unruptured intracranial aneurysms (UIAs) account for a significant proportion of hospital charges and healthcare resource utilization in the United States. Hospital length of stay (LOS) is a reimbursement metric utilized to incentivize value-based care. Our study identifies predictors of extended LOS (eLOS) after elective treatment of UIAs. METHODS: This was a retrospective study of 525 patients who underwent elective treatment of an UIA at a single institution. Data were collected with regard to demographics, clinical presentation, treatment characteristics, and postoperative outcomes. The primary outcome, eLOS, was defined as hospital stay in the upper quartile of the median (≥75th percentile). Univariate and multivariate analyses were performed to identify factors predictive of eLOS in this cohort. RESULTS: The average age of the cohort was 61.40, standard deviation=11.41. 77.3% of the cohort was female. The median duration of LOS was 2 days (interquartile range: 1-5). 11.6% experienced eLOS (≥5 days). Multivariate logistic regression identified age (OR: 1.04, 95% confidence interval [CI]: 1.01-1.07), coexistent vascular pathology (OR: 21.33, 95% CI: 8.06-56.39), open surgery (OR: 3.93, 95% CI: 1.85-8.34), and postoperative stroke (OR: 11.72, 95% CI: 3.18-43.18) as independent predictors of eLOS. CONCLUSIONS: Our study identified predictors of eLOS that could help promote risk stratification prior to treatment of UIAs. Future research that identifies predictors of long-term outcomes based on treatment modality could help identify ways to improve healthcare resource utilization in this cohort.