Y-stenting with braided stents for wide-neck intracranial bifurcation aneurysms. A single-center initial experience.

INTRODUCTION: The treatment of wide-neck bifurcation aneurysms is still challenging despite the use of new techniques, such as Y-stenting, the waffle-cone technique and intrasaccular flow disrupters, in recent years. Moreover, the use of flow diverter stents in bifurcation aneurysms has been proposed by several teams, although the results remain controversial. This study aims to evaluate the feasibility and efficacy of Y-stent assisted coiling of bifurcation aneurysms with braided stents. METHODS: We retrospectively reviewed all patients in whom Y-stenting with braided stents had been performed in our center. Six patients were identified and analyzed. Technical success, complications, angiographic outcomes, procedural data, and follow-up controls are reported here. This study was approved by our local ethical committee. RESULTS: Technical success was achieved in all procedures. Overall procedure-related morbidity and mortality was 0%. In the immediate post-treatment angiography, adequate occlusion (neck remnant or total occlusion) was observed in all patients. Short- and long-term follow-up angiography showed adequate occlusion of the aneurysms. CONCLUSIONS: In this small, retrospective single-center analysis we showed that Y-stent assisted coiling with braided stents is a safe and feasible technique. Moreover, it has a high immediate occlusion rate and very good long-term stability.

The PHASES score: To treat or not to treat? Retrospective evaluation of the risk of rupture of intracranial aneurysms in patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: The PHASES score was formulated to predict the 5-year risk of rupture for intracranial aneurysms. We retrospectively analyzed all patients treated in our institution for aneurysmal SAH and applied the PHASES score to estimate the probable predicted risk of bleeding in this group of patients. METHODS: Between February 2015 and August 2018, all patients with aneurysmal SAH were retrospectively analyzed and the PHASES score was applied. A total of 155 patients were included with a mean age of 53.8years, including 60 males and 95 females. RESULTS: Of our patients 110 (70.9%) had a PHASES score of below or equal to 5, with a hemorrhagic risk of up to 1.3% over 5years. If we analyze the patients with a risk of below 2% this figure increases to 122 patients (78.7%). Of these 99.3% were European and 0.6% were Japanese (1 patient). In 86 patients (55.4%), the aneurysm was smaller than 5mm and in 10 patients (6.4%) the aneurysm was located in the posterior circulation. CONCLUSION: Of our patients 78.7% had less than a 2% 5-year rupture risk based on their PHASES score, highlighting the discrepancy of the rupture risk calculated with the PHASES score when hypothetically applied to this group of patients. In the hypothetical scenario that our patients had unruptured aneurysms, our retrospective analysis shows that the PHASES score may only provide a weak tool for clinicians to use in the decision-making process as to whether or not to treat these aneurysms.

How to differentiate intracranial atherosclerotic disease or vasospasms after mechanical thrombectomy. Be patient or vasodilator is the secret?

Here we describe a successful mechanical thrombectomy (MT) for acute large vessel occlusion in stroke treatment with one passage (thrombolysis in cerebral infarction, TICI 3). Immediately after the withdrawing of the stent retriever, a narrowing of the middle cerebral artery was diagnosed. The rate of vasospasms during this procedure can be as higher as 41% (range from 6-41%). Here we describe our protocol when a narrowing of the artery is visualized after a stent retriever is withdrawn. A patient presented in our emergency room with National Institute of Health Stroke Scale (NIHSS) of 21, Alberta Stroke Program Early CT Score (ASPECTS) 8, computed tomography angiography revealed occlusion of the M1 segment and MT was indicated. One passage TICI Ⅲ was achieved. After that, the image showed a narrowing of the artery. We present one case of a spasm after stent retriever technique for MT, we injected vasodilator and the artery became normal in a few minutes differentiating between atheromatous stenosis and vasospasm. We present a technical note that can help to make the differentiation of vasospasm or atheromatous disease after MT with the stent retriever technique.

Is the retrograde access for endovascular treatment of a traumatic carotid cavernous fistula associated with dissection of the ipsilateral carotid possible?

This is a case demonstrating a combined traumatic lesion of the internal carotid artery (dissection and a carotid cavernous fistula [CCF]) in a patient who was beaten during a robbery and, while trying to escape, was hit by a vehicle. Endovascular approach for the treatment was chosen using the retrograde access from the vertebral artery to the cavernous sinus by posterior communicating (Pcom) artery due to the occlusion of the ipsilateral internal carotid. Because the artery access by the internal carotid was impossible, retrograde approach by vertebral artery and Pcom artery was done to treat the direct CCF. A patient presented with left hemiplegia and proptosis, chemosis, right eye ptosis. Computed tomography (CT) and CT angiography revealed a CCF of the right carotid. An arterial retrograde endovascular approach by the vertebral artery was used for CCF occlusion with coils. We present a rare case of a combined traumatic cerebrovascular lesion, right carotid artery dissection and a right direct CCF treated by a retrograde endovascular approach by the vertebral artery through the Pcom artery to reach the fistula point and achieved a complete cure of the CCF.

Extending the stroke treatment window beyond DAWN in patients with very slow progressor type collaterals: How far can we go?

Five trials published in 2015 showed the benefit of endovascular thrombectomy (ET) in patients with stroke and large vessel occlusion, extending the treatment window has become an obsession of all physicians. In 2018, the DAWN and DEFUSE-3 trials showed that, with careful selection of patients, the procedure could be carried out up to 24 hours after symptom onset with good outcomes. In addition, there have been cases where the DAWN criteria were met, and treatment occurred >24 hours after symptom onset. We present the case of a 68-year-old female whose groin puncture occurred 52 hours after the time last known well (TLKW), after neurological worsening of the initial situation, with a large mismatch ratio observed on magnetic resonance imaging, achieving TICI (the Thrombolysis in Cerebral Infarction scale) grade 3 recanalization. Five days after the procedure, the patient was discharged with NIHSS (National Institutes of Health Stroke Scale) score of 3. Some types of collateral circulation (slow progressors and "turtle" progressors, our term for very slow progressors) can extend the treatment window beyond 24 hours of the TLKW but can lead to a hyperperfusion-like syndrome immediately after the ET. Further studies are needed to evaluate the reproducibility of this hypothetical syndrome.

Republished: Spinal arteriovenous malformation without endovascular arterial access: is a combined neurosurgical approach and direct venous puncture an option?

This case report describes a combined neurosurgical and endovascular approach for the treatment of a conus medullaris arteriovenous malformation resulting in considerable improvement in the patient's neurological condition (modified Rankin Scale score 2).

Spinal arteriovenous malformation without endovascular arterial access: is a combined neurosurgical approach and direct venous puncture an option?

This case report describes a combined neurosurgical and endovascular approach for the treatment of a conus medullaris arteriovenous malformation resulting in considerable improvement in the patient's neurological condition (modified Rankin Scale score 2).

Balloon remodeling-assisted Woven EndoBridge technique: description and feasibility for complex bifurcation aneurysms.

BACKGROUND: Woven EndoBridge (WEB) deployment remains challenging in aneurysms with a complex shape or orientation. OBJECTIVE: To show that embolization of wide-neck bifurcation aneurysms using the WEB device balloon remodeling-assisted technique is a feasible and elegant endovascular solution compared with other techniques, such as balloon remodeling or stent-assisted coiling. MATERIALS AND METHODS: 10 cases (10 aneurysms in 9 patients) of balloon remodeling-assisted WEB treatment of unruptured complex bifurcation aneurysms were treated in our institution and retrospectively analyzed. Details of clinical presentations, technical details, perioperative and postoperative complications, and outcomes were collected. Immediate and long-term angiographic results were also evaluated. RESULTS: Aneurysms included six middle cerebral artery aneurysms, one anterior communicating artery aneurysm, one posterior communicating artery aneurysm, one basilar artery aneurysm, and one T-shaped carotid aneurysm. Mean dome width was 6.55 mm, mean neck size 4.5 mm, mean height 4.79 mm, and mean dome-to-neck ratio was 1:1.46. Treatment was performed exclusively with the balloon remodeling-assisted WEB technique in all cases. The device was successfully deployed in every case. Periprocedural thromboembolic or hemorrhagic events did not occur. The modified Rankin Scale score at discharge was 0 for all patients. At mid-term or long-term angiographic follow-up, adequate occlusion was observed in 7 aneurysms from 8 controlled cases (87.5%), and one patient (2 aneurysms) did not have angiographic follow-up. CONCLUSION: The balloon remodeling-assisted WEB technique seems to be a safe and effective solution for endovascular treatment of unruptured wide-neck bifurcation aneurysms with specific complex anatomy. However, further studies are needed to evaluate the rate of complications and long-term efficacy.

Flow diversion treatment of aneurysms of the complex region of the anterior communicating artery: which stent placement strategy should 'I' use? A single center experience.

BACKGROUND: Aneurysms of the anterior communicating artery (ACoA) are difficult to treat with coiling or clipping because of the anatomical variation in this region. Flow diversion represents a feasible treatment, but no consensus exists as to which stent deployment technique is more suitable. METHODS: All patients with ACoA aneurysms treated with flow diverters between April 2014 and November 2018 were retrospectively analyzed. Aneurysm characteristics, follow-up results, and clinical outcome data were recorded, and a new classification comparing the diameters of both A1 segments is proposed: H1=same diameters; H2=<50% difference in diameters; H3= ≥50% difference; and Y=no A1 segment. RESULTS: We analyzed 30 procedures in 30 patients with ACoA aneurysms, including 16 ruptured aneurysms treated with coiling embolization and 4 previously unruptured aneurysms (two Medina and two Woven EndoBridge devices). Adequate aneurysm occlusion occurred in 86.9%; one patient (3.3%) experienced symptomatic ischemic stroke. The global thromboembolic complications for each group were 17.6% (H1), 25% (H2), and 60% (H3). CONCLUSION: Flow diversion treatment in this region is safe, feasible, and effective. The most suitable anatomical configuration for flow diverter treatment seems to be the H1 configuration where the 'I technique' is suitable (from an A1 segment to the ipsilateral A2). There is a tendency that the H3 configuration is not a good indication for flow diverter treatment. However, further studies are needed to evaluate the feasibility of this anatomical classification and the reproducibility of our findings.

Safety and efficiency of the fifth generation Woven EndoBridge device: technical note.

BACKROUND: The treatment of wide neck bifurcation aneurysms remains challenging despite the introduction of new techniques (Y stenting, waffle cone technique, or flow diverter stents). The Woven EndoBridge (WEB) device is an innovative solution for this type of cerebral aneurysm. A new WEB 17 is now available and has been designed to offer smaller sized devices to optimize navigability and delivery. METHODS: Between February 2017 and April 2018 all patients treated with the WEB 17 device in our center were retrospectively reviewed. 25 patients with 28 non-ruptured aneurysms were identified and analyzed. Three patients with two aneurysms both treated with the WEB device were identified. RESULTS: The device was successfully deployed in all cases. Procedure related morbidity was 4% and mortality was 0%. In one case, a delayed postprocedural thromboembolic event occurred owing to device protrusion. Technical success, complications, angiographic outcomes, procedural data, and follow-ups are reported. The modified Rankin Scale score at discharge was 0 for 24 patients (96%). At the 3, 6, or 9 month follow-up, angiograms were taken of 21 of the 25 patients (84%) (24 of 28 aneurysms had been controlled); 3 patients (3 aneurysms) did not receive angiographic follow-up at the time of submission of this work. Complete occlusion was achieved in 22 of 24 aneurysms (91.66%), and 2 of 24 aneurysm (8.33%) showed a neck remnant. CONCLUSIONS: The WEB 17 is safe and technically feasible, according to this retrospective single center analysis. For very small bifurcation aneurysms, the WEB 17 seems to have lower complication rates than stent assisted techniques. However, further studies are needed to evaluate the complication rate and long term efficiency.

Cerebral aneurysms associated with human immunodeficiency virus in adults: literature review and new perspectives.

INTRODUCTION: the treatment of human immunodeficiency virus (HIV) infection has been decreasing patient morbidity and mortality by opportunistic infections and, thus, survival has increased. This new reality has been changing the spectrum of diseases affecting such patients. OBJECTIVE: to discuss the association between HIV and the emergence of aneurysmal brain injuries. METHOD: it was performed a literature review using medical database. The following descriptors were searched: "Intracranial Aneurysms and HIV", "Intracranial Aneurysms and Acquired Immunodeficiency Syndrome," "aneurysm and brain and HIV". RESULTS: after performed a literature review, it was observed that the relationship between HIV infection and the formation of aneurysms appears to be real, however, it still lacks data to confirm the pathophysiology of this condition and its best treatment. CONCLUSION: there are new signs and symptoms that should be studied and researched relating HIV with other changes not previously known.

Cerebral aneurysms associated with human immunodeficiency virus in adults: literature review and new perspectives / Aneurismas cerebrais associados ao vírus da imunodeficiência humana em adultos: revisão da literatura e novas perspectivas

SUMMARY Introduction: the treatment of human immunodeficiency virus (HIV) infection has been decreasing patient morbidity and mortality by opportunistic infections and, thus, survival has increased. This new reality has been changing the spectrum of diseases affecting such patients. Objective: to discuss the association between HIV and the emergence of aneurysmal brain injuries. Method: it was performed a literature review using medical database. The following descriptors were searched: "Intracranial Aneurysms and HIV", "Intracranial Aneurysms and Acquired Immunodeficiency Syndrome," "aneurysm and brain and HIV". Results: after performed a literature review, it was observed that the relationship between HIV infection and the formation of aneurysms appears to be real, however, it still lacks data to confirm the pathophysiology of this condition and its best treatment. Conclusion: there are new signs and symptoms that should be studied and researched relating HIV with other changes not previously known.

RESUMO Introdução: o tratamento da infecção pelo vírus da imunodeficiência humana (HIV) tem diminuído a morbidade e a mortalidade por infecções oportunistas nesses pacientes e, portanto, aumentado a sobrevida. Essa nova realidade tem mudado o espectro de doenças que afetam esses pacientes. Objetivo: discutir a associação entre HIV e ocorrência de aneurismas cerebrais. Método: foi realizada revisão da literatura utilizando bancos de dados médicos. Foram pesquisados os seguintes descritores: "HIV e aneurismas intracranianos", "aneurismas intracranianos e síndrome da imunodeficiência adquirida", aneurismas, cérebro e HIV. Resultados: a relação entre a infecção pelo HIV e a formação de aneurismas parece ser real; porém, ainda faltam dados que confirmem a fisiopatologia dessa condição e seu melhor tratamento. Conclusão: existem novos sinais e sintomas, que devem ser estudados e pesquisados, relacionando o HIV com outras alterações previamente desconhecidas.