Final Results of the Prospective Multicenter Excimer Laser-Assisted High-Flow Bypass Study on the Treatment of Giant Anterior Circulation Aneurysms

Neurosurgery ◽  
2019 ◽  
Vol 87 (4) ◽  
pp. 697-703
Author(s):  
Albert van der Zwan ◽  
Peter Vajkoczy ◽  
Sepideh Amin-Hanjani ◽  
Fady T Charbel ◽  
Babu Welch ◽  
...  
Keyword(s):  
Excimer Laser ◽  
The United States ◽  
High Flow ◽  
Neurological Deficits ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Recipient Vessel ◽  
Complex Aneurysms ◽  
Potential Benefits ◽  
Temporary Occlusion

Abstract BACKGROUND Both conventional bypass utilizing temporary recipient vessel occlusion and the excimer laser-assisted nonocclusive anastomosis (ELANA) bypass technique are possible strategies in the treatment of giant aneurysms. These treatments have only been studied in single institutional retrospective studies. The potential advantage of the ELANA technique is the absence of temporary occlusion of major arteries, decreasing the risk of intraoperative ischemia. OBJECTIVE To investigate the risks and potential benefits of high-flow bypass surgery for giant and complex aneurysms of the anterior cerebral circulation. In addition, the effectiveness of the ELANA bypass procedure in the treatment of these aneurysms is determined. METHODS A total of 37 patients were included in 8 vascular neurosurgical centers in the United States, Canada, and Europe. A 30-d postoperative bypass follow-up was studied by using digital subtraction angiography and/or magnetic resonance angiography and computed tomography angiography to assess patency as well as by clinical monitoring in all patients. RESULTS In 35 patients, an ELANA high-flow bypass was performed and the aneurysm treated. Four patients had remaining neurological deficits after 30 d caused by stroke (11.4%). These strokes were not related to the ELANA anastomosis device. CONCLUSION This study does not prove that the ELANA technique has an advantage over conventional bypass techniques, but it appears to be an acceptable alternative to conventional transplanted high-flow bypass in this very-difficult-to-treat patient group, especially in select patients whom cannot be bypassed using conventional means in which temporary occlusion is considered to be not recommended.

Routine Cerebral Angiography after Surgery for Saccular Aneurysms: Is It Worth It?

Neurosurgery ◽  
2004 ◽  
Vol 55 (5) ◽  
pp. 1015-1024 ◽  
Author(s):  
Riku P. Kivisaari ◽  
Matti Porras ◽  
Juha Öhman ◽  
Jari Siironen ◽  
Keisuke Ishii ◽  
...  
Keyword(s):  
Posterior Circulation ◽  
Consecutive Series ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Intraoperative Angiography ◽  
Unruptured Aneurysms ◽  
Giant Aneurysms ◽  
Complex Aneurysms ◽  
Major Vessel ◽  
Anterior Circulation Aneurysms

Abstract OBJECTIVE: The objective of this study was to determine whether an angiographically proven rate of saccular intracranial aneurysm occlusion after surgical clipping suggests that postoperative angiography should continue to be used routinely or should be supplanted by intraoperative angiography. These data also should establish a basis for comparing surgery with new endovascular methods of treatment. METHODS: During a 3.5-year period, a consecutive series of 622 patients (955 aneurysms, 808 of which were surgically clipped) who underwent postoperative angiography were studied retrospectively. This series comprised 493 ruptured and 315 unruptured aneurysms. RESULTS: Complete aneurysm closure was achieved in 88% of aneurysms, a neck remnant was discovered in 9%, and a fundus remnant was revealed in 3%. Of 493 ruptured aneurysms, 86% were completely occluded. Of 315 unruptured aneurysms, 91% were completely occluded. The results for clipping of complex aneurysms, i.e., posterior circulation or large to giant aneurysms, were significantly inferior to those for small and anterior circulation aneurysms. In one-third of the large and giant aneurysms, a part of the base was left intentionally because of calcifications or strong wall or to prevent occlusion of any branches. In the series, a significant 5% complication rate of major vessel occlusion was detected. CONCLUSION: Our retrospective analysis revealed that ruptured, posterior circulation, and large/giant aneurysms are more prone to incomplete clipping. Therefore, these aneurysms require postoperative if not intraoperative evaluation with angiography. Many clippings of anterior circulation aneurysms experience unexpected failures, which suggests that intraoperative angiography could be beneficial. This series, which has no selection bias, can be used as a basis to compare the results of other series reporting surgical or endovascular treatment.

Parent vessel occlusion after Pipeline embolization of cerebral aneurysms of the anterior circulation

2017 ◽  
Vol 127 (6) ◽  
pp. 1333-1341 ◽  
Author(s):  
Matthew B. Potts ◽  
Maksim Shapiro ◽  
Daniel W. Zumofen ◽  
Eytan Raz ◽  
Erez Nossek ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Parent Artery ◽  
Parent Vessel ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Complex Aneurysms ◽  
Aneurysm Size ◽  
Parent Vessel Occlusion ◽  
Anterior Circulation Aneurysms

OBJECTIVEThe Pipeline Embolization Device (PED) is now a well-established option for the treatment of giant or complex aneurysms, especially those arising from the anterior circulation. Considering the purpose of such treatment is to maintain patency of the parent vessel, postembolization occlusion of the parent artery can be regarded as an untoward outcome. Antiplatelet therapy in the posttreatment period is therefore required to minimize such events. Here, the authors present a series of patients with anterior circulation aneurysms treated with the PED who subsequently experienced parent vessel occlusion (PVO).METHODSThe authors performed a retrospective review of all anterior circulation aneurysms consecutively treated at a single institution with the PED through 2014, identifying those with PVO on follow-up imaging. Aneurysm size and location, number of PEDs used, and follow-up digital subtraction angiography results were recorded. When available, pre- and postembolization platelet function testing results were also recorded.RESULTSAmong 256 patients with anterior circulation aneurysms treated with the PED, the authors identified 8 who developed PVO after embolization. The mean aneurysm size in this cohort was 22.3 mm, and the number of PEDs used per case ranged from 2 to 10. Six patients were found to have asymptomatic PVO discovered incidentally on routine follow-up imaging between 6 months and 3 years postembolization, 3 of whom had documented “delayed” PVO with prior postembolization angiograms confirming aneurysm occlusion and a patent parent vessel at an earlier time. Two additional patients experienced symptomatic PVO, one of which was associated with early discontinuation of antiplatelet therapy.CONCLUSIONSIn this large series of anterior circulation aneurysms, the authors report a low incidence of symptomatic PVO, complicating premature discontinuation of postembolization antiplatelet or anticoagulation therapy. Beyond the subacute period, asymptomatic PVO was more common, particularly among complex fusiform or very large–necked aneurysms, highlighting an important phenomenon with the use of PED for the treatment of anterior circulation aneurysms, and suggesting that extended periods of antiplatelet coverage may be required in select complex aneurysms.

Abstract P544: Automated Artificial Intelligence Based Detection and Location Specification of Large Vessel Occlusion on CT Angiography in Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Agnetha A Bruggeman ◽  
Miou Koopman ◽  
Jazba Soomro ◽  
Albert J Yoo ◽  
Henk A Marquering ◽  
...  
Keyword(s):  
Predictive Value ◽  
Diagnostic Performance ◽  
Ground Truth ◽  
The United States ◽  
Detection Algorithm ◽  
Interrater Agreement ◽  
Large Vessel ◽  
Imaging Data ◽  
Anterior Circulation ◽  
Vessel Occlusion

Introduction: Fast and accurate detection of large vessel occlusions (LVOs) is crucial in selection of patients for endovascular treatment. We assessed the diagnostic performance and speed of an Artifical Intelligence algorithm for automated LVO detection with a novel feature that specifies the exact level of occlusion. Methods: All Computed Tomography Angiography (CTA) imaging data were analyzed by an automated algorithm for anterior circulation LVOs (internal carotid artery (ICA), M1 or M2 segments of the middle cerebral artery) (StrokeViewer, Nico.lab). Ground truth was established by consensus of two independent neuroradiologist readings. Diagnostic performance was assessed by calculating sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). Performance of the LVO localization feature was assessed by calculating interrater agreement (Cohen’s Kappa) between the algorithm and the expert panel. Results: CTAs from 297 patients referred or directly admitted to a comprehensive stroke center in the United States (mean age 67 years, SD 15; 145 males) were analyzed. One-hundred and fifty-six patients had an anterior circulation LVO. Location of the occlusions was ICA (n=43 [28%]), M1 (n=79 [51%]) and M2 (n=34 [22%]). Sensitivity and specificity for LVO detection were respectively 92% (95% CI, 86.2%-95.5%) and 85% (95% CI, 78.1%-90.5%). NPV and PPV were 90% and 87% respectively. Interrater agreement between the algorithm and the expert observers for LVO location was 0.92 (95% CI, 0.86-0.98). Median upload-to-notification time for all cases was 3 minutes, 34 seconds (minimal 2:28 minutes; maximal 5:03 minutes). Conclusions: Anterior circulation LVOs can be rapidly and accurately detected by an automated LVO detection algorithm with reliable localization of the involved vessel segment. Therefore, the algorithm presented in this study is a suitable screening tool to support diagnosis of LVOs.

Experience in Using the Excimer Laser–Assisted Nonocclusive Anastomosis Nonocclusive Bypass Technique for High-Flow Revascularization

Neurosurgery ◽  
2011 ◽  
Vol 70 (1) ◽  
pp. 49-55 ◽  
Author(s):  
Peter Vajkoczy ◽  
Miikka Korja ◽  
Marcus Czabanka ◽  
Ulf C. Schneider ◽  
Michael Reinert ◽  
...  
Keyword(s):  
Success Rate ◽  
Excimer Laser ◽  
High Flow ◽  
Posterior Circulation ◽  
Parent Artery ◽  
Modified Rankin Scale ◽  
Anterior Circulation ◽  
Intracranial Lesions ◽  
Posterior Circulation Aneurysms ◽  
Intent To Treat

Abstract BACKGROUND The excimer laser–assisted nonocclusive anastomosis (ELANA) technique enables large-caliber bypass revascularization without temporary occlusion of the parent artery. OBJECTIVE To present the surgical experience of 2 bypass centers using ELANA in the treatment of complex intracranial lesions. METHODS Between July 2002 and December 2007, 64 consecutive patients (37 in Germany and 27 in Finland) were selected for high-flow bypass surgery with ELANA. Modified Rankin Scale, a bypass success rate, and the success rate of the laser arteriotomy were assessed. RESULTS In 66 surgeries for 64 intent-to-treat patients, 58 ELANA procedures were completed successfully. A favorable outcome (postoperative modified Rankin Scale score less than or equal to preoperative modified Rankin Scale) at 3 months was achieved in 43 of 56 patients (77%) with anterior circulation lesions (37 of the 43 patients had aneurysms, 4 had ischemia, and 2 received a bypass before tumor removal) and only in 2 of 8 patients (25%) with posterior circulation aneurysms. Perioperative (< 7 days) mortality for anterior and posterior circulation aneurysms was 6% and 50%, respectively. At the 3-month follow-up, 12% and 63% of patients with anterior and posterior circulation aneurysms, respectively, were dead. The success rate of the laser arteriotomy was 70%. Another 14% were retrieved manually after a nearly complete laser arteriotomy. CONCLUSION The ELANA procedure requires a meticulous and careful operative technique. Morbidity and especially mortality rates, usually unrelated to ELANA, are comparable to those of contemporary series of conventional high-flow revascularization operations. This underscores the overall complexity of treating neurovascular pathologies by high-flow bypasses.

scholarly journals An endovascular assisted, nonocclusive cerebral bypass: a technical feasibility study in a rabbit model

2020 ◽  
pp. 1-6
Author(s):  
Alexander Spiessberger ◽  
Fabio Strange ◽  
Basil Erwin Gruter ◽  
Stefan Wanderer ◽  
Daniela Casoni ◽  
...  
Keyword(s):  
Rabbit Model ◽  
High Flow ◽  
Neurological Deficits ◽  
Parent Artery ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Intraoperative Angiography ◽  
Novel Technique ◽  
Bypass Patency ◽  
Parent Vessel Occlusion

OBJECTIVETemporary parent vessel occlusion performed to establish a high-flow interpositional bypass carries the risk of infarcts. The authors investigated the feasibility of a novel technique to establish a high-flow bypass without temporary parent vessel occlusion in order to lower the risk of ischemic complications.METHODSIn 10 New Zealand white rabbits, a carotid artery side-to-end anastomosis was performed under parent artery patency with a novel endovascular balloon device. Intraoperative angiography, postoperative neurological assessments, and postoperative MRI/MRA were performed to evaluate the feasibility and safety of the novel technique.RESULTSA patent anastomosis was established in 10 of 10 animals; 3 procedure-related complications occurred. No postoperative focal neurological deficits were observed. The MRI/MRA findings include no infarcts and bypass patency in 50% of the animals.CONCLUSIONSThe authors demonstrated the feasibility of an endovascular assisted, nonocclusive high-flow bypass. Future refinement of the device and technique in an animal model is necessary to lower the complication rate and increase patency rates.

Endovascular Thrombectomy in Acute Ischemic Stroke

2018 ◽  
Author(s):  
A. Elisabeth Abramowicz
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
The United States ◽  
Functional Independence ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Artery Embolism ◽  
Number Of Patients

Endovascular thrombectomy (EVT) for acute ischemic stroke is a new and powerful treatment modality that restores functional independence to many victims. Although it has been proved of value in large-vessel occlusion of the anterior circulation, it is also used in basilar artery embolism. Time to successful reperfusion is a major determinant of recovery. A subset of patients has robust collaterals and will benefit from treatment up to 24 hours after stroke onset; the presence of salvageable brain tissue (penumbra) must be ascertained by specialized imaging. The number of patients who can benefit from EVT is estimated at 100,000/year in the United States alone in more than 300 designated Thrombectomy-Capable Stroke Centers. EVT is a new anesthetic emergency. Anesthesiologists must be actively involved in creating protocol-driven care for acute ischemic stroke patients.

Combined endovascular and microsurgical management of giant and complex unruptured aneurysms

2004 ◽  
Vol 17 (5) ◽  
pp. 1-7 ◽  
Author(s):  
Francisco A. Ponce ◽  
Felipe C. Albuquerque ◽  
Cameron G. McDougall ◽  
Patrick P. Han ◽  
Joseph M. Zabramski ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Intracranial Aneurysms ◽  
Combined Treatment ◽  
Neurological Deficits ◽  
Complex Nature ◽  
Anterior Communicating Artery ◽  
Parent Vessel ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Unruptured Intracranial Aneurysms

Object The purpose of this study was to assess the efficacy and describe the technical features of combined endovascular and microsurgical treatments for complex and giant unruptured intracranial aneurysms. Methods A prospectively maintained database was reviewed to identify all patients with unruptured intracranial aneurysms who were treated with combined techniques. Twenty-one lesions were treated in as many patients: six lesions involved the posterior cerebral artery (PCA); seven the cavernous portion of the internal carotid artery (ICA); two the basilar apex; two the basilar trunk; and one each the anterior communicating artery, anterior cerebral artery, petrous ICA, and cervical ICA. Aneurysms were treated with combined extracranial–intracranial bypass procedures and parent-vessel occlusion, flow redirection, or arterial transposition. Aneurysm occlusion was achieved in 20 patients. In the remaining patient the aneurysm recurred, requiring stent-assisted repeated coil placement. Three patients suffered permanent neurological deficits related to treatment, and three died, two of whom had basilar trunk aneurysms. Conclusions Certain complex aneurysms may be treated optimally by combining endovascular and surgical procedures. A low incidence of complications follows treatment of anterior circulation aneurysms. Treatment of complex posterior circulation aneurysms is associated with a higher incidence of complications, although this likely reflects the more complex nature of these lesions. The risks of this combined treatment strategy are likely lower than the risks associated with the natural history of this subset of aneurysms.

An exploratory study of intangibles risk disclosure in annual reports of banking companies from the UK, US, Germany and Italy - Some descriptive insights

2013 ◽  
pp. 81-120 ◽  
Author(s):  
Susanne Durst
Keyword(s):  
Intellectual Capital ◽  
Exploratory Study ◽  
The United States ◽  
Annual Reports ◽  
Risk Disclosure ◽  
Related Risk ◽  
Potential Benefits ◽  
Report Data ◽  
Key Drivers ◽  
The Uk

Intangibles are viewed as the key drivers in most industries, and current research shows that firms voluntarily disclose information about their investments in intangibles and their potential benefits. Yet little is known of the risks relating to such resources and the disclosures firms make about such risks. In order to obtain a more balanced and complete picture of firms' activities, information about the risky side of their intangibles is also needed. This exploratory study provides some descriptive insights into intangibles-related risk disclosure in a sample of 16 large banks from the United States (US), United Kingdom (UK), Germany and Italy. Annual report data is analyzed using the three Intellectual Capital dimensions. Study findings illustrate the variety of intangibles-related risk disclosure as demonstrated by the banks involved.

EXPRESS: Stent Retriever Alone vs. Aspiration and Stent-Retriever Combination in Large Vessel Occlusion Stroke: A Matched Analysis

2021 ◽  
pp. 174749302110192
Author(s):  
Mahmoud H Mohammaden ◽  
Diogo C. Haussen ◽  
Leonardo Pisani ◽  
Alhamza Al-Bayati ◽  
Aaron Anderson ◽  
...  
Keyword(s):  
Randomized Clinical Trials ◽  
Functional Independence ◽  
Stent Retriever ◽  
Sensitivity Analyses ◽  
First Line ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Guide Catheter ◽  
First Pass ◽  
Combined Technique

Background Three randomized clinical trials have reported similar safety and efficacy for contact aspiration (CA) and Stent-retriever (SR) thrombectomy. Aim We aimed to determine whether the Combined Technique (SR+CA) was superior to SR alone as first-line thrombectomy strategy in a patient cohort where balloon-guide catheter was universally used. Methods A prospectively maintained mechanical thrombectomy database from January 2018-December 2019 was reviewed. Patients were included if they had anterior circulation proximal occlusion ischemic stroke (intracranial ICA or MCA-M1/M2 segments) and underwent SR alone thrombectomy or SR+CA as first-line therapy. The primary outcome was the first-pass effect (FPE) (mTICI2c-3). Secondary outcomes included modified FPE (mTICI2b-3), successful reperfusion (mTICI2b-3) prior to and after any rescue strategy, and 90-day functional independence (mRS ≤2). Safety outcomes included rate of parenchymal hematoma (PH) type-2 and 90-day mortality. Sensitivity analyses were performed after dividing the overall cohort according to first-line modality into two matched groups. Results A total of 420 patients were included in the analysis (mean age 64.4 years; median baseline NIHSS 16[11-21]). As compared to first-line SR alone, first-line SR+CA resulted in similar rates of FPE (53% vs. 51%,aOR 1.122, 95%CI[0.745-1.691],p=0.58), mFPE (63% vs. 60.4%,aOR1.250, 95%CI[0.782-2.00],p=0.35), final successful reperfusion (97.6% vs. 98%,p=0.75) and higher chances of successful reperfusion prior to any rescue strategy (81.8% vs. 72.5%,aOR 2.033, 95%CI[1.209-3.419],p=0.007). Functional outcome and safety measures were comparable between both groups. Likewise, the matched analysis (148 patient-pairs) demonstrated comparable results for all clinical and angiographic outcomes except for significantly higher rates of successful reperfusion prior to any rescue strategies with the first-line SR+CA treatment (81.8% vs. 73.6%,aOR 1.881, 95%CI[1.039-3.405],p=0.037). Conclusions Our findings reinforce the findings of ASTER-2 trial in that the first-line thrombectomy with a Combined Technique did not result in increased rates of first-pass reperfusion or better clinical outcomes. However, addition of contact aspiration after initial SR failure might be beneficial in achieving earlier reperfusion.

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