Microstent-assisted coiling for wide-necked intracranial aneurysms.

OBJECTIVE: To describe the results, technical feasibility, efficacy and challenges encountered in our preliminary experience using a self-expandable microstent, optimized for intracranial use, as an adjunct in the endovascular treatment of wide-necked aneurysms. METHODS: Only broad-necked aneurysms (dome-to-neck ratio < or = 2, or an isolated neck size > 4.5 mm) were treated with Neuroform microstent from July 2003 to May 2004. The techniques used for stent deployment were either parallel or sequential. Angiographic results were recorded immediately for all patients and classified as Class 1 (complete occlusion), Class 2 (neck remnant) or Class 3 (sac remnant) by three interventional neuroradiologists not involved in the procedure. Follow-up angiography at six months was obtained for one case. Modified Rankin Score scale was assessed for all patients. RESULTS: Seventeen intracranial aneurysms in a total of 18 patients were treated (mean age, 52.2 yr). Eight patients (44.4%) presented with acute subarachnoid hemorrhage. Eleven aneurysms (61.1%) were in the posterior circulation. Average dome size was 10.2 mm (range, 3.7-19.8 mm) and average neck size was 5.36 mm (range, 3.0-10.0 mm). Six out of seven aneurysms of the anterior circulation were approached with parallel technique. Eight aneurysms of the posterior circulation were approached with sequential technique. Average number of coils deployed was 9.64 (range, 4-23 coils). Eleven aneurysms (64.8%) resulted in Class 1 and/or Class 2. One technical failure was observed. Technical complications were recognized in four patients (23.5%), all of them with unruptured aneurysms in the anterior circulation. Two patients (11.7%) presented transient immediate clinical complications. One patient (5.8%) had minor permanent neurological complication. Neither major clinical complications nor death were encountered. Favorable clinical outcome (Modified Rankin Scale score 0-2) was observed in 88.2% of the patients (average follow-up time, 4.72 months). CONCLUSIONS: Absence of major permanent complications and satisfactory immediate obliteration degree in our preliminary experience indicates that microstent-assisted coiling technique is useful for the minimally invasive treatment of broad-necked complex aneurysms that are not ideal for conventional endovascular treatment and are at a high risk for conventional surgical treatment.

Limitations and technical considerations of endovascular treatment in neonates with high-flow arteriovenous shunts presenting with congestive heart failure: report of two cases.

CASE REPORT: We report two neonatal patients with high-flow intracranial or cervical arteriovenous (AV) shunts who presented with congestive heart failure and were successfully managed with endovascular treatment. One with vein of Galen malformation with body weight of only 2.0 kg is, to our knowledge, the smallest neonate successfully treated with endovascular treatment. The other neonate is, to our knowledge, the first vertebro-vertebral fistula patient presenting with heart failure and treated successfully with endovascular treatment. CONCLUSION: Even in neonates, endovascular treatment is the procedure of choice for high-flow AV shunts presenting with progressive congestive heart failure resistant to medical management. We discuss limitations and technical considerations of endovascular treatments in small neonates with high-flow AV shunts and congestive heart failure.