RESUMO
BACKGROUND: Treatment of small-caliber vessel lesions using flow diverters remains challenging because of vasculature's narrow luminal diameter and tortuosity. This in turn makes navigation and delivery of conventional devices with standard microcatheters more difficult. The Silk Vista Baby (SVB, Balt) flow diversion device was designed for ease of use in vessels with a smaller diameter, distal lesions, and 0.017 â³ microcatheter delivery systems. OBJECTIVE: To report the outcomes of the SVB device on the treatment of posterior inferior cerebellar artery (PICA) aneurysms. METHODS: Databases from different centers were retrospectively reviewed for PICA aneurysms treated with SVB. Demographic information, clinical presentation, radiographic characteristics, procedural complications, and immediate postprocedure outcomes were obtained. RESULTS: Fourteen patients harboring 15 true PICA aneurysms were treated between January 2019 and June 2021. Nine were female (n = 9/14; 64.2%), and the mean age was 51 ± 14.9 years. Most patients had previously ruptured aneurysms, treated by another endovascular technique. Six aneurysms were located distally (n = 6/15; 40%). The mean neck size was 3 mm (SD 1.35, range 2.5-5 mm), whereas the mean PICA diameter was 1.6 mm (SD 0.26, range 1.5-1.7 mm). The mean length of follow-up was 6 months (SD 8.28, range 4.5-16 months). Treatment-related adverse events included 1 case of transient hypoesthesia. Two additional events were reported, but adjudicated as unrelated to the procedure. Complete occlusion, measured as Raymond-Roy class I, was achieved in all cases. CONCLUSION: The SVB device was safely and effectively used in the treatment of PICA aneurysms. The smaller delivery system profile reduces the risk of procedure complications and creates new treatment options for distal lesions.
Assuntos
Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Adulto , Idoso , Cerebelo/irrigação sanguínea , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/etiologia , Aneurisma Intracraniano/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Seda , Resultado do Tratamento , Artéria VertebralRESUMO
BACKGROUND: Cavernous hemangiomas arising in the extraaxial space are rarely encountered, often mimicking other more common pathologies. Furthermore, multiple coexisting lesions and posterior fossa involvement are scarcely reported. Herein, we present the case of a patient with concurrent frontal bone and posterior fossa extraaxial cavernous hemangiomas. We also review the challenges associated with the diagnosis and management of these entities. CASE DESCRIPTION: An otherwise healthy 41-year-old gentleman presented with a 7-month history of a progressive right forehead mass. Imaging demonstrated a right frontal bone mass and an incidentally noted transverse sinus-based mass. The patient opted for surgical resection of both lesions. A right frontal craniotomy was performed to remove the bony lesion, followed by a suboccipital approach for the dural-based mass. There were no significant complications intraoperatively, and gross total resection was achieved for both lesions. Final pathology for each was consistent with cavernous hemangioma. CONCLUSIONS: Extraaxial cavernous hemangiomas are uncommon clinical entities that are challenging to distinguish from other diseases. If intraoperative complications can be avoided, treatment with surgical resection often offers excellent patient outcomes.
Assuntos
Neoplasias Ósseas/cirurgia , Osso Frontal/cirurgia , Hemangioma Cavernoso/cirurgia , Neoplasias Primárias Múltiplas/cirurgia , Seios Transversos/cirurgia , Adulto , Neoplasias Ósseas/patologia , Osso Frontal/patologia , Hemangioma Cavernoso/patologia , Humanos , Achados Incidentais , Imageamento por Ressonância Magnética , Masculino , Doenças Raras , Tomografia Computadorizada por Raios X , Seios Transversos/patologia , Resultado do TratamentoRESUMO
BACKGROUND: Massive epistaxis from rupture of an intracavernous internal carotid artery aneurysm is a potentially fatal event. Although rare, this presentation is seen most often in patients after trauma or iatrogenic injury secondary to transsphenoidal surgery or radiation therapy. CASE DESCRIPTION: We present our unusual case of a patient with no significant risk factors who had recurrent epistaxis owing to a ruptured true cavernous internal carotid artery aneurysm. The patient was treated initially with coil embolization followed by placement of a Pipeline embolization device. The patient had complete resolution of her bleeding events. A follow-up arteriogram performed 14 months later confirmed aneurysm obliteration, with parent artery preservation and no evidence of in-stent stenosis. CONCLUSIONS: Our case highlights the importance of evaluating for intracranial pathological conditions in patients who present with refractory epistaxis. In selected patients, the use of flow-diversion technology as an adjunct or alternative to primary coil embolization for treatment should be considered.
Assuntos
Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/cirurgia , Artéria Carótida Interna/diagnóstico por imagem , Embolização Terapêutica/métodos , Epistaxe/diagnóstico por imagem , Epistaxe/cirurgia , Doenças das Artérias Carótidas/tratamento farmacológico , Artéria Carótida Interna/cirurgia , Epistaxe/tratamento farmacológico , Feminino , Humanos , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/administração & dosagem , Stents Metálicos Autoexpansíveis , Tempo para o TratamentoRESUMO
BACKGROUND: Treatment of acute cerebrovascular pathology, such as acute ischemic stroke or intracranial aneurysms, presents a challenge if an extracranial or intracranial stent is required; immediate platelet inhibition is vital. To date, there is no standardized approach for antiplatelet inhibition in an acute setting. OBJECTIVE: To report our preliminary experience and lessons learnt using cangrelor in acute neurointervention. METHODS: A single-arm pilot study was performed to assess the safety and efficacy of cangrelor plus aspirin for platelet inhibition in patients who require acute stenting in the setting of neuroendovascular treatment. RESULTS: Eight patients were enrolled between October 2017 and August 2018. Median age was 71 years (53-86). Seven patients were treated in an acute setting according to the stroke protocol at our institution, while one patient was treated for a symptomatic, unruptured aneurysm with flow diversion and coiling. At admission, the median National Institutes of Health Stroke Scale score for the patients with stroke was 12.5 (range 2-22.3). Cangrelor was infused and all patients achieved adequate platelet inhibition (<200 PRU (P2Y12 reaction units)). Six of seven patients with ischemic stroke had a carotid stent placed and one had an intracranial stent deployed in the middle cerebral artery. None of the patients experienced intraprocedural thromboembolic complications, intraprocedural in-stent thrombosis, hemorrhagic complications, or stroke within 24 hours after the intervention. The majority of patients (6/8) had a good clinical outcome at discharge (modified Rankin Scale score 0-2). CONCLUSIONS: Our findings suggest that cangrelor is a promising alternative in acute stenting for the treatment of cerebrovascular pathology. However, further studies with larger samples are required to accurately elucidate its safety and effectiveness in neuroendovascular procedures.
Assuntos
Monofosfato de Adenosina/análogos & derivados , Aspirina/administração & dosagem , Isquemia Encefálica/terapia , Inibidores da Agregação Plaquetária/administração & dosagem , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Stents , Acidente Vascular Cerebral/terapia , Monofosfato de Adenosina/administração & dosagem , Monofosfato de Adenosina/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Aspirina/efeitos adversos , Isquemia Encefálica/diagnóstico por imagem , Quimioterapia Combinada , Procedimentos Endovasculares/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Inibidores da Agregação Plaquetária/efeitos adversos , Stents/efeitos adversos , Acidente Vascular Cerebral/diagnóstico por imagem , Trombectomia/métodos , Resultado do TratamentoRESUMO
BACKGROUND: The optimal management of intracranial arterial stenosis is unclear, particularly in patients who have failed medical management. We report a multicenter real-world experience of endovascular recanalization of intracranial atherosclerotic stenosis refractory to aggressive medical therapy. METHODS: Retrospective multicenter case series of consecutive endovascularly treated patients presenting with symptomatic (transient ischemic attack [TIA] or stroke) intracranial stenosis who had failed medical therapy. Patients were divided into 2 groups: patients with recurrent TIA or stroke despite medical management (group 1) versus patients presenting with a stroke and worsening symptoms (progressive or crescendo stroke) despite medical management (group 2). RESULTS: A total of 101 patients were treated in 8 stroke centers from August 2009 to May 2017. Sixty-nine presented with recurrent TIA or stroke and 32 with stroke and worsening symptoms. Successful recanalization was achieved in 84% of patients. Periprocedural stroke occurred in 3 patients and 2 had a recurrent ischemic stroke at the 90-day follow-up. Symptomatic intraparenchymal hemorrhage secondary to reperfusion injury occurred in 3 patients and 1 had a hemorrhagic stroke after discharge. There were 2 periprocedural perforations that resulted in death. At 90 days, 86% of patients (64/74) did not have a recurrence of stroke and the 90-day cumulative ischemic stroke rate was 6.7% with 90-day mortality of 11.2%. The 90-day favorable outcome (modified Rankin Scale score, ≤2) rate was 77.5%. CONCLUSIONS: Endovascular recanalization of unstable intracranial atherosclerotic stenosis in patients who have failed medical therapy is feasible. Future randomized trials need to determine if recanalization is of any value for this population.
Assuntos
Procedimentos Endovasculares/métodos , Arteriosclerose Intracraniana/cirurgia , Ataque Isquêmico Transitório/cirurgia , Acidente Vascular Cerebral/cirurgia , Doença Crônica , Constrição Patológica/tratamento farmacológico , Constrição Patológica/cirurgia , Feminino , Humanos , Arteriosclerose Intracraniana/tratamento farmacológico , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Recidiva , Reoperação/estatística & dados numéricos , Reperfusão/métodos , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
BACKGROUND: The Pipeline Flex (PED Flex; Medtronic, Dublin, Ireland) was designed to facilitate deployment and navigation compared to its previous iteration to reduce the rate of technical events and complications. OBJECTIVE: To assess the neurological morbidity and mortality rates of the PED Flex at 30 d. METHODS: Information from 9 neurovascular centers was retrospectively obtained between July 2014 and March 2016. Data included patient/aneurysm characteristics, periprocedural events, clinical, and angiographic outcomes. Multivariate logistic regression was performed to determine predictors of unfavorable clinical outcome (modified Rankin Scale [mRS] > 2). RESULTS: A total of 205 patients harboring 223 aneurysms were analyzed. The 30-d neurological morbidity and mortality rates were 1.9% (4/205) and 0.5% (1/205), respectively. The rate of intraprocedural events without neurological morbidity was 6.8% (14/205), consisting of intraprocedural ischemic events in 9 patients (4.5%) and hemorrhage in 5 (2.4%). Other technical events included difficulty capturing the delivery wire in 1 case (0.5%) and device migration after deployment in another case (0.5%). Favorable clinical outcome (mRS 0-2) was achieved in 186 patients (94.4%) at discharge and in 140 patients (94.5%) at 30 d. We did not find predictors of clinical outcomes on multivariate analysis. CONCLUSION: The 30-d rates of neurological morbidity and mortality in this multicenter cohort using the PED Flex for the treatment of intracranial aneurysms were low, 1.9% (4/205) and 0.5% (1/205), respectively. In addition, technical events related to device deployment were also low, most likely due to the latest modifications in the delivery system.
Assuntos
Aneurisma Intracraniano/cirurgia , Adulto , Idoso , Angiografia , Feminino , Humanos , Aneurisma Intracraniano/mortalidade , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Alta do Paciente , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: The PulseRider is an innovative stent-like device designed for the treatment of intracranial bifurcation aneurysms. The aim of this study was to assess the current evidence on safety and effectiveness of the PulseRider. METHODS: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following databases were searched: PubMed, Ovid MEDLINE, and Scopus. The search strategy consisted of "pulserider," "bifurcation aneurysm," and "endovascular" in both AND and OR combinations. Studies included were original research articles in peer-reviewed journals. The manuscripts were thoroughly examined for study design, outcomes, and results. RESULTS: Three studies were identified describing use of the PulseRider device in the treatment of 63 patients with 63 bifurcation aneurysms. We identified 2 multicenter case series and 1 single-arm clinical trial. The majority of aneurysms treated were located at the basilar tip (37, 58.7%). All devices were successfully deployed, and there were 5 intraoperative complications (7.9%), including 2 intraoperative aneurysm ruptures, 1 vessel dissection, and 2 thrombus formations. Immediate complete aneurysm occlusion was achieved in 61.9% (39/63) of cases and at the 6-month imaging follow-up, 66.7% (42/63) achieved complete aneurysm occlusion. One recanalization was reported in 1 of the multicenter case series within the 6-month follow-up. CONCLUSIONS: The PulseRider is safe and probably effective for the treatment of intracranial bifurcation aneurysms, sometimes not amenable for stent-assisted coiling. However, current evidence is limited to a small sample and short follow-up. In addition, the device has not been compared with other treatment modalities.
Assuntos
Procedimentos Endovasculares/métodos , Aneurisma Intracraniano/cirurgia , Stents Metálicos Autoexpansíveis , Ensaios Clínicos como Assunto/métodos , Procedimentos Endovasculares/instrumentação , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Stents Metálicos Autoexpansíveis/tendências , Resultado do TratamentoRESUMO
Spinal aneurysms are rare lesions, and their natural history is not well known. In particular, aneurysms arising from the artery of Adamkiewicz (AA) are an extremely rare phenomenon, and given the lack of solid evidence its management remains unclear. We present the case of a 54-year-old woman with spinal subarachnoid hemorrhage. A spinal angiogram demonstrated a fusiform aneurysm arising from the AA. Based on the location, the absence of evident collateral circulation to the anterior spinal artery, and the available literature supporting spontaneous thrombosis, we opted for conservative management. Fifteen days after the diagnosis, a spinal angiogram demonstrated complete occlusion of the aneurysm with no visualization of the AA. At 10-month follow-up, the patient was able to walk without assistance. Management should be done on a case-by-case basis with the goal of preserving spinal cord perfusion. Similar to previous articles, our report reinforces conservative management as a valid strategy.
Assuntos
Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/terapia , Tratamento Conservador/normas , Medula Espinal/diagnóstico por imagem , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/terapia , Tratamento Conservador/métodos , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Medula Espinal/irrigação sanguínea , Artéria Vertebral/diagnóstico por imagemRESUMO
In 25 years, the Mongolian army of Genghis Khan conquered more of the known world than the Roman Empire accomplished in 400 years of conquest. The recent revised view is that Genghis Khan and his descendants brought about "pax Mongolica" by securing trade routes across Eurasia. After the initial shock of destruction by an unknown barbaric tribe, almost every country conquered by the Mongols was transformed by a rise in cultural communication, expanded trade, and advances in civilization. Medicine, including techniques related to surgery and neurological surgery, became one of the many areas of life and culture that the Mongolian Empire influenced.
Assuntos
História Medieval , Conhecimento , Neurociências/história , História Antiga , Humanos , Mongólia , Pinturas/históriaRESUMO
In rare instances, extradural internal carotid artery aneurysms can present with massive epistaxis, which is often a fatal event. We present the case of a young female with an aneurysm eroding through the sphenoid sinus and whose timely diagnosis resulted in treatment of the aneurysm with coil embolization and satisfactory outcome.
Assuntos
Doenças das Artérias Carótidas/diagnóstico por imagem , Artéria Carótida Interna/diagnóstico por imagem , Aneurisma Intracraniano/diagnóstico por imagem , Seio Esfenoidal , Adulto , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/terapia , Angiografia Cerebral , Embolização Terapêutica , Procedimentos Endovasculares , Epistaxe/etiologia , Feminino , Granulomatose com Poliangiite/complicações , Humanos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/terapiaRESUMO
Spinal aneurysms are rare lesions, and their natural history is not well known. In particular, aneurysms arising from the artery of Adamkiewicz (AA) are an extremely rare phenomenon, and given the lack of solid evidence its management remains unclear. We present the case of a 54-year-old woman with spinal subarachnoid hemorrhage. A spinal angiogram demonstrated a fusiform aneurysm arising from the AA. Based on the location, the absence of evident collateral circulation to the anterior spinal artery, and the available literature supporting spontaneous thrombosis, we opted for conservative management. Fifteen days after the diagnosis, a spinal angiogram demonstrated complete occlusion of the aneurysm with no visualization of the AA. At 10-month follow-up, the patient was able to walk without assistance. Management should be done on a case-by-case basis with the goal of preserving spinal cord perfusion. Similar to previous articles, our report reinforces conservative management as a valid strategy.
Assuntos
Aneurisma Roto/diagnóstico , Medula Espinal/irrigação sanguínea , Doenças da Coluna Vertebral/diagnóstico , Hemorragia Subaracnóidea/diagnóstico , Aneurisma Roto/diagnóstico por imagem , Angiografia , Tratamento Conservador , Diagnóstico Diferencial , Feminino , Humanos , Pessoa de Meia-Idade , Medula Espinal/diagnóstico por imagem , Doenças da Coluna Vertebral/diagnóstico por imagem , Hemorragia Subaracnóidea/diagnóstico por imagemRESUMO
BACKGROUND: Although the Pipeline Embolization Device (PED) has proved to be an excellent option for internal carotid artery (ICA) aneurysms, the rate of occlusion remains difficult to predict and factors associated with aneurysm occlusion are not well elucidated. This study aimed to investigate predictors and the rate of occlusion for aneurysms along the ICA. METHODS: A total of 117 saccular ICA aneurysms treated with the PED were studied. Occlusion rates were divided among 4 groups: group A [lesions >10 mm in the proximal ICA (petrous to the superior hypophyseal segments)]; group B (lesions <10 mm in the proximal ICA); group C [lesions >10mm in the distal ICA (posterior communicating segment to the ICA bifurcation)]; and group D (lesions <10 mm in the distal ICA). Predictors of aneurysm occlusion were entered into a multivariate Cox regression analysis. RESULTS: The median time to aneurysm occlusion was 8 months in group A (95% confidence interval [CI], 7.0-9.1), 5.2 months in group B (95% CI, 4.5-6.0), 6.9 months in group C (95% CI, 6.5-7.2), and 10.2 months in group D (95% CI, 6.9-13.6) (P = 0.045). There was a statistically significant difference between the probability of aneurysm occlusion in group B compared with distal ICA aneurysms (P = 0.02). Small proximal ICA aneurysms were more likely to occlude over time compared with other aneurysm groups (hazard ratio, 1.76; 95% CI, 1.07-2.9; P = 0.02). CONCLUSIONS: The rate of occlusion after PED is highest for small proximal ICA aneurysms and the probability of occlusion is lower for distal ICA aneurysms.
Assuntos
Doenças das Artérias Carótidas/terapia , Artéria Carótida Interna/diagnóstico por imagem , Estenose das Carótidas/etiologia , Embolização Terapêutica/métodos , Aneurisma Intracraniano/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças das Artérias Carótidas/diagnóstico por imagem , Estenose das Carótidas/diagnóstico por imagem , Angiografia Cerebral/métodos , Angiografia por Tomografia Computadorizada/métodos , Esquema de Medicação , Quimioterapia Combinada , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/administração & dosagem , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Vessel perforation during stent retriever thrombectomy is a rare complication; typically only single instances have been reported. OBJECTIVE: To report on a series of patients whose stent retriever thrombectomy was complicated by intraprocedural vessel perforation and discuss its potential mechanisms, rescue treatment strategies, and clinical significance. METHODS: Cases with intraprocedural vessel perforation, where a stent retriever was used either as a primary treatment approach or as a part of a direct aspiration first pass technique (ADAPT), were included in the final analysis. Clinical data, procedural details, radiographic and clinical outcomes were collected from nine participating centers. RESULTS: Intraprocedural vessel perforation during stent retriever thrombectomy occurred in 16 (1.0%) of 1599 cases. 63% of intraprocedural perforations occurred at distal locations. Endovascular rescue techniques (most commonly, intracranial balloon occlusion for tamponade) were attempted in 50% of cases. Procedure was aborted without any rescue attempts in 44% of cases. Mortality during hospitalization and at 3â months was 56% and 63%, respectively. 25% of patients achieved good functional outcome at 3â months after the procedure. CONCLUSIONS: Intraprocedural perforations during stent retriever thrombectomy were rare, but when they occurred were associated with high mortality. Perforations most commonly occurred at distal occlusion sites and were often characterized by difficulty traversing the occlusion with a microcatheter or microwire, or while withdrawing the stent retriever. Nevertheless, 25% of patients had a favorable functional outcome, suggesting that in some patients with this complication good neurological recovery is achievable.
Assuntos
Isquemia Encefálica/cirurgia , Artérias Cerebrais/cirurgia , Complicações Intraoperatórias , Stents/efeitos adversos , Acidente Vascular Cerebral/cirurgia , Trombectomia/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico por imagem , Artérias Cerebrais/diagnóstico por imagem , Feminino , Humanos , Complicações Intraoperatórias/diagnóstico por imagem , Complicações Intraoperatórias/etiologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Trombectomia/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Patients with strokes from M2 segment middle cerebral artery (MCA) occlusion have been underrepresented in recent randomized trials of endovascular therapy. OBJECTIVE: To better understand the clinical, imaging, and procedural predictors of successful recanalization and clinical outcomes in this population of patients. METHODS: We performed a multicenter retrospective analysis of consecutive patients with acute MCA M2 segment occlusion who underwent thrombectomy with stent retrievers or primary aspiration thrombectomy (including A Direct Aspiration First Pass Technique approach). We correlated clinical and radiographic outcomes with demographic, clinical, and technical characteristics. RESULTS: One hundred and seventeen patients were included in analysis (median admission National Institutes of Health stroke scale [NIHSS] score 15, mean age 67.0 ± 14.5, 42% females). Good clinical outcome at 3 months (modified Rankin scale [mRS] ≤ 2) was achieved in 56% of patients. Treatment beyond 6 h of symptoms onset (P = .69, OR 0.80, 95% CI 0.38-1.73) and age over 80 (P = .47, OR 0.65, 95% CI 0.25-1.70) were not predictive of poor outcome. NIHSS > 15 was a strong predictor of clinical outcome, based on mRS distribution at 3 months (P = .0085, OR 0.35, 95% CI 0.16-0.74). Direct aspiration and primary stent retriever thrombectomy approaches showed similar radiographic and clinical success rates. CONCLUSION: Advanced age and time to treatment beyond 6 h from symptom onset were not predictive of clinical outcome with thrombectomy. NIHSS score above 15 was a strong predictor of outcome. Direct aspiration and primary stent retriever thrombectomy showed similar efficacy.
Assuntos
Procedimentos Endovasculares/métodos , Infarto da Artéria Cerebral Média/cirurgia , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/cirurgia , Estudos Retrospectivos , Stents/efeitos adversos , Resultado do TratamentoRESUMO
INTRODUCTION: Refinements in endovascular technology have revolutionized the treatment of intracranial aneurysms (IAs) with the development of flow-diversion technology. The first generation of the Pipelin Embolization Device (PED) has demonstrated its safety and efficacy. However, the deployment technique was a difficult task that often led to complex maneuvers. The Pipeline Flex Embolization Device (PED Flex) is the second generation and its introduction has arrived with high expectations due to a completely redesigned delivery system that intends to overcome deployment difficulties seen in the previous generation. Areas covered: Preclinical studies, mechanism of action of flow-diverters, technical aspects and deployment system of the PED Flex, and clinical outcomes with both PED generations. Expert commentary: Flow diversion has allowed us to treat lesions that would be otherwise challenging for surgical clipping or unsuitable for other endosaccular strategies. Although the experience with PED Flex is limited, initial results suggest its safety and short-term efficacy.
Assuntos
Embolização Terapêutica/instrumentação , Aneurisma Intracraniano/terapia , Animais , Ensaios Clínicos como Assunto , Humanos , Resultado do TratamentoRESUMO
BACKGROUND: Wide-necked anterior communicating artery aneurysms represent a subset of lesions with challenging endovascular treatment despite new endoluminal and intrasaccular devices. OBJECTIVE: To assess the long-term clinical and angiographic outcomes of stent-assisted embolization for wide-necked anterior communicating artery aneurysms. METHODS: Between March 2008 and March 2014, 32 patients with unruptured wide-necked AComm aneurysms were treated using stent-assisted embolization. The Glasgow Outcome Scale was reviewed at the time of discharge and at latest follow-up. Ischemic and hemorrhagic events were also recorded and analyzed. Aneurysm occlusion was evaluated post-intervention and on subsequent follow-up evaluations. RESULTS: Successful stent deployment was achieved in all cases, but in 1 patient the coils could not be contained inside the aneurysm, and the procedure was aborted without complications. The distal segment of the stent was positioned in the ipsilateral A2 in 16 patients, in the contralateral A2 in 15 patients, and in the contralateral A1 in 1 patient. There were no periprocedural thromboembolic or hemorrhagic complications. The rate of major complications was 6%. One patient developed intracranial hemorrhage related to antiplatelet therapy and another had ischemic events due to in-stent stenosis. Angiographic follow-up was available for 26 aneurysms and during a mean follow-up of 22 months, 81% of the lesions were completely occluded and 8% had a small residual neck. The retreatment rate for residual aneurysms was 3%. CONCLUSION: Our long-term results suggest that stent-assisted embolization for anterior communicating artery aneurysms may be considered an excellent treatment option with an adequate combination of safety profile and effectiveness.
Assuntos
Embolização Terapêutica/métodos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/terapia , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral/instrumentação , Embolização Terapêutica/tendências , Feminino , Seguimentos , Escala de Resultado de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/tendências , Inibidores da Agregação Plaquetária/administração & dosagem , Retratamento/métodos , Retratamento/tendências , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The development of ischemic events is relatively common after endovascular interventions, and flow diverters may pose a particular threat owing to their increased technical complexity and high metal content. OBJECTIVE: To investigate the incidence and potential risk factors for thromboembolic lesions after treatment with a Pipeline embolization device (PED). METHODS: This prospective study included a total of 59 patients electively treated with a PED over 12â months. Postprocedural diffusion-weighted imaging sequences of the brain were obtained 24â h after interventions to detect ischemic lesions. Demographic data, aneurysm characteristics, antiplatelet management, and perioperative data were correlated with the rate of ischemic events. RESULTS: The incidence of silent ischemic events after use of a PED was 62.7% (37 patients) and neurological symptoms occurred in 8.1% of affected patients. Development of ischemic events was significantly associated with older patients (≥60â years; p=0.038). Routine use of platelet function assays and newer P2Y12 receptor inhibitors (ticagrelor) were not associated with fewer thromboembolic events. CONCLUSIONS: Thromboembolic events are relatively common after treatment with a PED with an incidence comparable to stent-assisted and conventional coiling but the risk of neurological morbidity from ischemic burden is low. Older patients are at particularly increased risk of thromboembolic events.
Assuntos
Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/etiologia , Imagem de Difusão por Ressonância Magnética , Embolização Terapêutica/efeitos adversos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Imagem de Difusão por Ressonância Magnética/tendências , Embolização Terapêutica/métodos , Embolização Terapêutica/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes de Função Plaquetária , Estudos Prospectivos , Fatores de Risco , Stents/efeitos adversos , Resultado do TratamentoRESUMO
OBJECTIVE: The authors sought to determine whether flow diversion with the Pipeline Embolization Device (PED) can approximate microsurgical decompression in restoring function after cranial neuropathy following carotid artery aneurysms. METHODS: This multiinstitutional retrospective study involved 45 patients treated with PED across the United States. All patients included presented between November 2009 and October 2013 with cranial neuropathy (cranial nerves [CNs] II, III, IV, and VI) due to intracranial aneurysm. Outcome analysis included clinical and procedural variables at the time of treatment as well as at the latest clinical and radiographic follow-up. RESULTS: Twenty-six aneurysms (57.8%) were located in the cavernous segment, while 6 (13.3%) were in the clinoid segment, and 13 (28.9%) were in the ophthalmic segment of the internal carotid artery. The average aneurysm size was 18.6 mm (range 4-35 mm), and the average number of flow diverters placed per patient was 1.2. Thirty-eight patients had available information regarding duration of cranial neuropathy prior to treatment. Eleven patients (28.9%) were treated within 1 month of symptom onset, while 27 (71.1%) were treated after 1 month of symptoms. The overall rate of cranial neuropathy improvement for all patients was 66.7%. The CN deficits resolved in 19 patients (42.2%), improved in 11 (24.4%), were unchanged in 14 (31.1%), and worsened in 1 (2.2%). Overtime, the rate of cranial neuropathy improvement was 33.3% (15/45), 68.8% (22/32), and 81.0% (17/21) at less than 6, 6, and 12 months, respectively. At last follow-up, 60% of patients in the isolated CN II group had improvement, while in the CN III, IV, or VI group, 85.7% had improved. Moreover, 100% (11/11) of patients experienced improvement if they were treated within 1 month of symptom onset, whereas 44.4% (12/27) experienced improvement if they treated after 1 month of symptom onset; 70.4% (19/27) of those with partial deficits improved compared with 30% (3/10) of those with complete deficits. CONCLUSIONS: Cranial neuropathy caused by cerebral aneurysm responds similarly when the aneurysm is treated with the PED compared with open surgery and coil embolization. Lower morbidity and higher occlusion rates obtained with the PED may suggest it as treatment of choice for some of these lesions. Time to treatment is an important consideration regardless of treatment modality.
Assuntos
Artérias Carótidas/cirurgia , Revascularização Cerebral/métodos , Doenças dos Nervos Cranianos/etiologia , Doenças dos Nervos Cranianos/cirurgia , Embolização Terapêutica/métodos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/cirurgia , Procedimentos Neurocirúrgicos/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Artéria Carótida Interna/cirurgia , Revascularização Cerebral/efeitos adversos , Embolização Terapêutica/efeitos adversos , Feminino , Seguimentos , Humanos , Aneurisma Intracraniano/mortalidade , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Resultado do Tratamento , Estados UnidosRESUMO
Many endovascular techniques have been described in recent years for the management of wide necked aneurysms. The Y stent assisted technique has been generally used for coil embolization of wide necked bifurcation aneurysms. This technique was first described for the treatment of basilar tip aneurysms in combination with several different devices, demonstrating encouraging results. We report the results of the first two cases of wide necked basilar tip aneurysms treated with Y stent assisted coil embolization using a new low profile visible intraluminal stent (LVIS Jr; MicroVention, Tustin, California, USA) delivered through a 0.017 inch microcatheter. We also reviewed the literature comparing other endovascular techniques (coiling alone, stent assisted coiling, and Y stent assisted coiling) for wide necked aneurysms. The LVIS Jr device offers a new option for the treatment of these challenging lesions, with clear advantages over currently available intracranial stents. Larger series and long term results are needed to confirm the applicability and durability of this technique/technology.
Assuntos
Prótese Vascular , Embolização Terapêutica/métodos , Aneurisma Intracraniano/terapia , Stents , Idoso , Angiografia Digital , Artéria Basilar/diagnóstico por imagem , Embolização Terapêutica/instrumentação , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagemRESUMO
Revascularization of the extracranial vertebral artery has evolved significantly since the adoption of endovascular techniques. The current neurosurgical armamentarium includes microsurgical and endovascular approaches. The indications for each treatment modality, however, still need to be further delineated. In contrast to carotid artery endarterectomy and carotid artery angioplasty/stenting, there is limited comparative evidence on the efficacy of medical, open, and endovascular treatment of atherosclerotic disease of the extracranial vertebral artery. More recently, drug-eluting stents have gained momentum after high rates of in-stent restenosis have been reported with bare metal stents placed in the vertebral artery. In this article, we discuss the indications, clinical assessment, and surgical nuances of microsurgical and endovascular revascularization for atherosclerotic disease of the extracranial vertebral artery. Despite a general tendency to consider endovascular treatment in the majority of patients, ultimately, open and endovascular revascularization of extracranial vertebral artery should be regarded as complementary therapies and both treatment options need to be discussed in selected patients.