Stent and flow diverter assisted treatment of acutely ruptured brain aneurysms

2018 ◽  
Vol 10 (9) ◽  
pp. 851-858 ◽  
Author(s):  
José E Cohen ◽  
J Moshe Gomori ◽  
Ronen R Leker ◽  
Sergey Spektor ◽  
Hosni Abu El Hassan ◽  
...  
Keyword(s):  
Acute Phase ◽  
Antiplatelet Agents ◽  
Flow Diverter ◽  
Thromboembolic Complications ◽  
Inclusion Criteria ◽  
Unruptured Aneurysms ◽  
Ruptured Aneurysms ◽  
Aneurysm Occlusion ◽  
Clinical Records

ObjectiveWe present our experience with stent techniques in the management of acutely ruptured aneurysms, focusing on aneurysm occlusion rates, intraprocedural complications, and late outcomes.MethodsWe retrospectively reviewed the clinical records of patients treated by stent techniques during the early acute phase of aneurysmal rupture, from June 2011 to June 2016. Patients who underwent stenting for the management of unruptured aneurysms, or in a delayed fashion for a ruptured lesion, were excluded.Results47 patients met inclusion criteria, including 46 with subarachnoid hemorrhage (SAH). There were 27 men and 20 women, mean age 38 years (range 23–73). They harbored 71 aneurysms, including 56 treated in the acute phase. Aneurysmal dome and neck width averaged 4.7 mm (range 1.7–12.1) and 3.2 mm (range 1.5–7.1), respectively. Single stent techniques were used in 39 patients and dual stent techniques in 17. External ventricular drains (EVDs) were placed before embolization in 35 patients (92%) and after in 3. Intraprocedure thromboembolic complications due to a hyporesponse to antiplatlets in 4 patients (8.5%) were successfully managed with intra-arterial antiplatelet agents. In 45 surviving patients (96%), there was complete aneurysm occlusion at the 9–12 month follow-up in 26/29 aneurysms treated by stent-assisted coiling (90%), in 2/3 aneurysms treated by flow diverter-assisted coiling (66%), and in 19/22 aneurysms treated by flow diverter alone (86%); 42/45 patients (93%) presented with a modified Rankin Scale score of 0–2.ConclusionStenting techniques in ruptured aneurysms can be performed with good technical success; however, procedural thromboembolic complications related to the antiplatelet strategy merit investigation. EVD placement before stenting must be considered.

Flow diversion treatment for acutely ruptured aneurysms

2019 ◽  
Vol 12 (3) ◽  
pp. 283-288 ◽  
Author(s):  
Michelle F M ten Brinck ◽  
Maike Jäger ◽  
Joost de Vries ◽  
J André Grotenhuis ◽  
René Aquarius ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Flow Diverter ◽  
Poor Clinical Outcome ◽  
Good Clinical Outcome ◽  
Ruptured Aneurysms ◽  
Secondary Endpoints ◽  
Aneurysm Occlusion ◽  
Occlusion Rate ◽  
Ruptured Intracranial Aneurysms

Background and purposeFlow diverters are sometimes used in the setting of acutely ruptured aneurysms. However, thromboembolic and hemorrhagic complications are feared and evidence regarding safety is limited. Therefore, in this multicenter study we evaluated complications, clinical, and angiographic outcomes of patients treated with a flow diverter for acutely ruptured aneurysms.MethodsWe conducted a retrospective observational study of 44 consecutive patients who underwent flow diverter treatment within 15 days after rupture of an intracranial aneurysm at six centers. The primary end point was good clinical outcome, defined as modified Rankin Scale score (mRS) 0–2. Secondary endpoints were procedure-related complications and complete aneurysm occlusion at follow-up.ResultsAt follow-up (median 3.4 months) 20 patients (45%) had a good clinical outcome. In 20 patients (45%), 25 procedure-related complications occurred. These resulted in permanent neurologic deficits in 12 patients (27%). In 5 patients (11%) aneurysm re-rupture occurred. Eight patients died resulting in an all-cause mortality rate of 18%. Procedure-related complications were associated with a poor clinical outcome (mRS 3–6; OR 5.1(95% CI 1.0 to 24.9), p=0.04). Large aneurysms were prone to re-rupture with rebleed rates of 60% (3/5) vs 5% (2/39) (p=0.01) for aneurysms with a size ≥20 mm and <20 mm, respectively. Follow-up angiography in 29 patients (median 9.7 months) showed complete aneurysm occlusion in 27 (93%).ConclusionFlow diverter treatment of ruptured intracranial aneurysms was associated with high rates of procedure-related complications including aneurysm re-ruptures. Complications were associated with poor clinical outcome. In patients with available angiographic follow-up, a high occlusion rate was observed.

Flow-diverter stents in the early management of acutely ruptured brain aneurysms: effective rebleeding protection with low thromboembolic complications

2021 ◽  
pp. 1-8
Author(s):  
José E. Cohen ◽  
J. Moshe Gomori ◽  
Samuel Moscovici ◽  
Andrew H. Kaye ◽  
Yigal Shoshan ◽  
...  
Keyword(s):  
Thrombus Formation ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Complication Rates ◽  
Imaging Data ◽  
Total Occlusion ◽  
Early Management ◽  
Ruptured Aneurysms ◽  
Aneurysm Occlusion

OBJECTIVE Flow-diverter stents (FDSs) are not generally used for the management of acutely ruptured aneurysms with associated subarachnoid hemorrhage (SAH). Herein, the authors present their experience with FDSs in this scenario, focusing on the antiplatelet regimen, perioperative management, and outcome. METHODS The authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured aneurysms and associated SAH from July 2010 to September 2018 who had received an FDS implant as stand-alone treatment within 4 days after diagnosis. The protocol with the use of flow diversion in these patients includes a low threshold for placement of external ventricular drains before stenting, followed by the administration of aspirin and clopidogrel with platelet testing before stent implantation. With this approach, the risk of hemorrhage and stent-related thrombus formation is limited. Demographic, clinical, technical, and imaging data were analyzed. RESULTS Overall, 76 patients (61% females, mean age 42.8 ± 11.3 years) met the inclusion criteria. FDS implantation was performed a median of 2 days after diagnosis. On average, 1.05 devices were used per procedure. There was no procedural mortality directly attributed to the endovascular intervention. Procedural device-related clinical complications were recorded in a total of 6 cases (7.9%) and resulted in permanent neurological morbidity in 2 cases (2.6%). There was complete immediate aneurysm occlusion in 11 patients (14.5%), and persistent aneurysm filling was seen in 65 patients (85.5%). Despite this, no patient presented with rebleeding from the target aneurysm. There was an excellent clinical outcome in 62 patients (81.6%), who had a 90-day modified Rankin Scale score of 0–2. Among the 71 survivors, total or near-total occlusion was observed in 64/67 patients (95.5%) with a 3- to 6-month angiographic follow-up and in all cases evaluated at 12 months. Five patients (6.6%) died during follow-up for reasons unrelated to the procedure or new hemorrhage. CONCLUSIONS Flow diversion is an effective therapeutic strategy for the management of select acutely ruptured aneurysms. Despite low rates of immediate aneurysm occlusion after FDS implantation, the device exerts an important protective effect. The authors’ experience confirmed no aneurysm rerupture, high rates of delayed complete occlusion, and complication rates that compare favorably with the rates obtained using other techniques.

scholarly journals Treatment of ruptured complex and large/giant ruptured cerebral aneurysms by acute coiling followed by staged flow diversion

2016 ◽  
Vol 125 (1) ◽  
pp. 120-127 ◽  
Author(s):  
Waleed Brinjikji ◽  
Mariangela Piano ◽  
Shanna Fang ◽  
Guglielmo Pero ◽  
David F. Kallmes ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Acute Phase ◽  
Case Series ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Endovascular Coiling ◽  
Ruptured Aneurysms ◽  
Permanent Morbidity ◽  
Intent To Treat

OBJECT Flow-diversion treatment has been shown to be associated with high rates of angiographic obliteration; however, the treatment is relatively contraindicated in the acute phase following subarachnoid hemorrhage (SAH) as these patients require periprocedural dual antiplatelet therapy. Acute coiling followed by flow diversion has emerged as an intriguing and feasible treatment option for ruptured complex and giant aneurysms. In this study the authors report outcomes and complications of patients with ruptured aneurysms undergoing coiling in the acute phase followed by planned delayed flow diversion. METHODS This case series includes patients from 2 institutions. All patients underwent standard endovascular coiling in the acute phase after SAH with the intention and plan to proceed with flow diversion at a later date. Outcomes studied included angiographic occlusion, procedure-related complications, and long-term clinical outcome as measured using the modified Rankin Scale. RESULTS A total of 31 patients underwent coiling in the acute phase with the intention to undergo flow diversion at a later date. The mean aneurysm size was 15.8 ± 7.9 mm. Of the 31 patients undergoing coiling, 4 patients could not undergo further flow-diverter therapy: 3 patients (9.7%) died of complications of subarachnoid hemorrhage and 1 patient had permanent morbidity as a result of perioperative ischemic stroke (3.1%). Twenty-seven patients underwent staged placement of flow diverters after adequate recovery. The median time to treatment was 16 weeks. There was one case of aneurysm rebleeding following coil treatment. There were no cases of permanent morbidity or mortality resulting from flow-diverter treatment. Twenty-four patients underwent imaging follow-up; 18 of these patients had aneurysms that were completely or nearly completely occluded (58.1% on an intent-to-treat basis). At last follow-up (mean 18.3 months), 25 patients had mRS scores ≤ 2 (80.6% on an intent-to-treat basis). CONCLUSIONS Staged treatment of ruptured complex and giant intracranial aneurysms with coiling in the acute phase and flow-diverter treatment following recovery from SAH is both safe and effective. In this series, no cases of rebleeding occurred during the interval between coiling and flow diversion. This strategy should be considered as a valid option in patients presenting with these challenging ruptured aneurysms.

scholarly journals Stent-assisted coil embolization of anterior communicating artery aneurysms using the LVIS Jr stent

2018 ◽  
Vol 25 (1) ◽  
pp. 12-20 ◽  
Author(s):  
Alejandro Santillan ◽  
Justin Schwarz ◽  
Srikanth Boddu ◽  
Y Pierre Gobin ◽  
Jared Knopman ◽  
...  
Keyword(s):  
Coil Embolization ◽  
Aneurysm Rupture ◽  
Anterior Communicating Artery ◽  
Technical Failure ◽  
Thromboembolic Complications ◽  
Ruptured Aneurysms ◽  
Neurological Morbidity ◽  
Aneurysm Occlusion

Background and purpose This retrospective study evaluates the safety and mid-term and long-term effectiveness of stent-assisted coil embolization of anterior communicating artery (Acomm) aneurysms treated with the LVIS Jr stent. Materials and methods All patients treated with the LVIS Jr stent for Acomm aneurysms between June 2015 and March 2018 were included in the analysis. Details of the procedure’s periprocedural adverse events, immediate aneurysm occlusion rates, and clinical and angiographic follow-up assessment were collected. Results A total of 25 patients with 25 aneurysms were included. Eighteen aneurysms were found incidentally. Seven patients presented with seven ruptured aneurysms: Six were remotely ruptured and one acutely ruptured. Twenty-four patients were treated successfully and one technical failure is reported. The parent arteries measured 1.4 mm to 2.9 mm in diameter (mean, 2.3 mm). Intraprocedural thromboembolic complications occurred in two patients (8%) and an intraoperative aneurysm rupture in one patient (4%). Immediate complete aneurysm occlusion was noted in 18 out of 25 patients (72%). Clinical follow-up ranged from three months to 36 months (mean, 15.8 months) and the imaging follow-up ranged from two to 35 months (mean, 14.2 months). Complete aneurysm occlusion was achieved in 14 out of 20 patients (70%) at last angiographic follow-up. Of the two patients with in-stent thrombosis, one patient had an acutely ruptured aneurysm and the other patient was treated with an LVIS Jr stent in a Y configuration. Neurological morbidity and mortality rate were 0%. Conclusions Complex, wide-necked Acomm aneurysms can be effectively treated with stent-assisted embolization using LVIS Jr stents.

scholarly journals Angiographic Follow-up of Embolization Using Guglielmi Detachable Coils for Cerebral Aneurysms

2003 ◽  
Vol 9 (1_suppl) ◽  
pp. 47-50 ◽  
Author(s):  
Y. Nakai ◽  
M. Sonobe ◽  
K. Sugita ◽  
Y. Matsumaru
Keyword(s):  
Morphological Changes ◽  
Cerebral Aneurysms ◽  
Guglielmi Detachable Coils ◽  
Complete Occlusion ◽  
Unruptured Aneurysms ◽  
Ruptured Aneurysms ◽  
Detachable Coils ◽  
Aneurysm Occlusion

The purpose of this study is to evaluate the mid or long-term angiographical stability of Guglielmi Detachable Coils (GDC) after embolization for cerebral aneurysms. Between march 1997 and november 2001, 164 aneurysms, including 116 ruptured and 48 unruptured aneurysms, were treated using GDC at Mito National Hospital. Cerebral angiograms over one month after embolization were obtained in 111 aneurysms, including 71 ruptured and 40 unruptured aneurysms. At the time of initial GDC embolization of the 71 ruptured aneurysms, complete occlusion was achieved in 31 aneurysms, neck remnant in 18 aneurysms, and body filling in 22 aneurysms. Morphological changes were observed in 26 aneurysms (37%) in follow-up. Progressive thrombosis was obtained in 12 out of 71 aneurysms, no changes were shown in 45, and recanalizations occurred in 14. In the initial embolization of the 40 unruptured aneurysms, complete occlusion was achieved in 15 aneurysms, neck remnant in five and body filling in 20 aneurysms respectively. Morphological changes were observed in 12 aneurysms (30%), in which 12 aneurysms showed progressive thrombosis and 28 aneurysms were unchanged. There were significant differences of the long-term angiographical stability between ruptured and unruptured aneurysms. Rigorous follow-up angiography is mandatory when complete aneurysm occlusion is not achieved in ruptured aneurysms.

scholarly journals Vessel wall MRI characteristics of endovascularly treated aneurysms: association with angiographic vasospasm

2019 ◽  
Vol 131 (3) ◽  
pp. 859-867 ◽  
Author(s):  
Mahmud Mossa-Basha ◽  
Thien J. Huynh ◽  
Daniel S. Hippe ◽  
Peter Fata ◽  
Ryan P. Morton ◽  
...  
Keyword(s):  
Vessel Wall ◽  
Delayed Cerebral Ischemia ◽  
Flow Diverter ◽  
Unruptured Aneurysms ◽  
Ruptured Aneurysms ◽  
Intracranial Vessel ◽  
Angiographic Vasospasm ◽  
Unruptured Intracranial Aneurysms ◽  
Mri Characteristics

OBJECTIVEThe aim of this paper was to evaluate the association between intracranial vessel wall MRI enhancement characteristics and the development of angiographic vasospasm in endovascularly treated aneurysm patients.METHODSConsecutive cases of both ruptured and unruptured intracranial aneurysms that were treated endovascularly, followed by intracranial vessel wall MRI in the immediate postoperative period, were included. Two raters blinded to clinical data and follow-up imaging independently evaluated for the presence, pattern, and intensity of wall enhancement. Development of angiographic vasospasm was independently evaluated. Delayed cerebral ischemia; cerebral infarct; procedural details; and presence and grade of subarachnoid, parenchymal, and intraventricular hemorrhage were evaluated. Statistical associations were determined on a per–vessel segment and per-patient basis.RESULTSTwenty-nine patients with 30 treated aneurysms (8 unruptured and 22 ruptured) were included in this study. Interobserver agreement was substantial for the presence of enhancement (κ = 0.67) and nearly perfect for distribution (κ = 0.87) and intensity (κ = 0.84) of wall enhancement. Patients with ruptured aneurysms had a significantly greater number of enhancing segments than those with unruptured aneurysms (29.9% vs 7.2%; OR 5.5, 95% CI 2.2–13.7). For ruptured cases, wall enhancement was significantly associated with subsequent angiographic vasospasm while controlling for grade of hemorrhage (adjusted OR 3.9, 95% CI 1.7–9.4). Vessel segments affected by balloon, stent, or flow-diverter use demonstrated greater enhancement than those not affected (OR 22.7, 95% CI 5.3–97.2 for ruptured; and OR 12.9, 95% CI 3.3–49.8 for unruptured).CONCLUSIONSVessel wall enhancement after endovascular treatment of ruptured aneurysms is associated with subsequent angiographic vasospasm.

Flow redirection endoluminal device (FRED) for treatment of intracranial aneurysms: A systematic review

2021 ◽  
pp. 159101992110279
Author(s):  
Muhammad Waqas ◽  
Rimal H Dossani ◽  
Modhi Alkhaldi ◽  
Jocelyn Neveu ◽  
Justin M Cappuzzo ◽  
...  
Keyword(s):  
Systematic Review ◽  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
Complication Rates ◽  
Mesh Terms ◽  
Aneurysm Occlusion ◽  
Occlusion Rate ◽  
Layered Flow ◽  
Comparative Safety

Introduction The Flow Redirection Endoluminal Device (FRED; MicroVention) is a dual-layered flow diverter used for the treatment of intracranial aneurysms. The objective of this systematic review was to compile device-related safety and effectiveness data. Methods The literature from January 1, 2013 to April 30, 2021 was searched for studies describing use of the FRED for intracranial aneurysm treatment irrespective of aneurysm location and morphology. The review included anterior and posterior circulation ruptured and unruptured saccular, fusiform or dissection, and blister aneurysms. MeSH terms related to “flow re-direction endoluminal device” and “FRED for aneurysms” were used. Data related to indication, complications, and rates of aneurysm occlusion were retrieved and analyzed. Results Twenty-two studies with 1729 intracranial aneurysms were included in this review. Overall reported morbidity was 3.9% (range 0–20%). Overall procedure-related mortality was 1.4% (range 0–6%). Complication rates fell into 5 categories: technical (3.6%), ischemic (3.8%), thrombotic or stenotic (6%), hemorrhagic (1.5%), and non-neurological (0.8%). The aneurysm occlusion rate between 0 and 3 months (reported in 11 studies) was 47.8%. The occlusion rate between 4 and 6 months (reported in 14 studies) was 73.8%. Occlusion rates continued to increase to 75.1% at 7–12 months (reported in 10 studies) and 86.6% for follow-up beyond 1 year (reported in 10 studies). Conclusion This review indicated that the FRED is a safe and effective for the treatment of intracranial aneurysms. Future studies should directly compare the FRED with other flow diverters for a better understanding of comparative safety and effectiveness among the different devices.

scholarly journals Long-Term Follow-up Study of Endovascularly Treated Intracranial Aneurysms

2010 ◽  
Vol 16 (3) ◽  
pp. 231-239 ◽  
Author(s):  
L.M. Pyysalo ◽  
L.H. Keski-Nisula ◽  
T.T. Niskakangas ◽  
V.J. Kähärä ◽  
J.E. Öhman
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Bleeding Rate ◽  
Unruptured Aneurysms ◽  
Ruptured Aneurysms ◽  
Follow Up Study ◽  
Long Term Follow Up ◽  
Rebleeding Rate

Long-term follow-up studies after endovascular treatment for intracranial aneurysm are still rare and inconclusive. The aim of this study was to assess the long-term clinical and angiographic outcome of patients with endovascularly treated aneurysms. The clinical outcome of all 185 patients with endovascularly treated aneurysms were analyzed and 77 out of 122 surviving patients were examined with MRI and MRA nine to 16 years (mean 11 years) after the initial endovascular treatment. Sixty-three patients were deceased at the time of follow-up. The cause of death was aneurysm-related in 34 (54%) patients. The annual rebleeding rate from the treated aneurysms was 1.3% in the ruptured group and 0.1% in the unruptured group. In long-term follow-up MRA 18 aneurysms (53%) were graded as complete, 11 aneurysms (32%) had neck remnants and five aneurysms (15%) were incompletely occluded in the ruptured group. The occlusion grade was lower in the unruptured group with 20 aneurysms (41%) graded as complete, 11 (22%) had neck remnants and 18 (37%) were incomplete. However, only three aneurysms were unstable during the follow-up period and needed retreatment. Endovascular treatment of unruptured aneurysms showed incomplete angiographic outcome in 37% of cases. However, the annual bleeding rate was as low as 0.1%. Endovascular treatment of ruptured aneurysms showed incomplete angiographic outcome in 15% of cases and the annual rebleeding rate was 1,3%.

scholarly journals Metal coverage ratio of pipeline embolization device for treatment of unruptured aneurysms: Reality check

2015 ◽  
Vol 22 (1) ◽  
pp. 42-48 ◽  
Author(s):  
Liang-Der Jou ◽  
Gouthami Chintalapani ◽  
Michel E Mawad
Keyword(s):  
Flow Diverter ◽  
Pipeline Embolization Device ◽  
Unruptured Aneurysms ◽  
Coverage Ratio ◽  
Reality Check ◽  
Local Mean ◽  
Aneurysm Occlusion ◽  
Occlusion Rate ◽  
The Mean ◽  
The Difference

Background and purpose The metal coverage ratio (MCR) of a flow diverter influences the intra-aneurysmal hemodynamics; a high MCR will occlude an aneurysm early, while a low MCR may delay aneurysm occlusion. The true MCR of a pipeline embolization device (PED) could be lower due to oversize, device deformation, or aneurysm location. In this study deviation of the true MCR from the nominal MCR is assessed and whether their difference affects aneurysm occlusion rate is determined. Methods A total of 40 consecutive patients, each of them treated by one PED for their aneurysms at the internal carotid artery (ICA), were retrospectively analyzed. The DynaCT images of these deployed PEDs were used to determine their true dimensions and estimate three MCRs (local, mean, and nominal). These data were compared in two groups of patients who had different aneurysm outcomes at six months. Results The difference in the local MCR between two groups is small, but statistically significant (24.5% vs 21.6%, p = 05). The local MCR is consistently lower than the nominal MCRs (23.2% vs 30.2%, p < 0.001); however, the difference between the mean and local MCRs is small (23.9% vs 23.2%). Conclusions An expectation that a PED can achieve a MCR of 30% may not be reasonable. Device oversize and deformation during deployment lower the local MCR by 5–7%. A lowered MCR affects the aneurysm occlusion rate at six months.

Endovascular treatment of ruptured aneurysms in anterior cerebral circulation with double microcatheter technique

2020 ◽  
Author(s):  
Xintong Zhao ◽  
Jiaqiang Liu ◽  
Huifang Wang ◽  
Zihuan Zhang ◽  
Zhenbao Li
Keyword(s):  
Risk Factors ◽  
Optimal Strategy ◽  
Cerebral Circulation ◽  
Cerebral Aneurysms ◽  
Partial Occlusion ◽  
Ruptured Aneurysms ◽  
Permanent Morbidity ◽  
Clinical Records ◽  
Related Mortality

Abstract Purpose Single coiling may be the optimal strategy for ruptured aneurysms. But assisted techniques may be needed in some aneurysms. The authors report their experience of double microcatheter technique in the treatment of ruptured aneurysms in anterior cerebral circulation. Methods Between 2012 and 2018, 82 patients with ruptured aneurysms in anterior cerebral circulation were treated with double microcatheter technique. The clinical records, angiographic results, procedure-related complications were reviewed. Clinical and angiographic follow-up was performed. Results Completely occlusion, neck remnant and partial occlusion were achieved in 56.6%, 36.1% and 7.2% in the whole procedures, respectively. The overall rate of morbidity was 8.5% (7/82). The rate of permanent morbidity was 3.7% (3/82). Three patients (3.7%) died before discharge. There was no procedure-related mortality. The favorable outcomes were obtained in 75.6% (62/82) of the whole patients at discharge. High Hunt-Hess grade and suffering from craniotomy or EVD were risk factors for clinical outcomes at discharge. Sixty-eight patients received clinical follow-up at a mean interval of 15.75±12.71 months. Favorable outcomes were obtained in 61 (89.7%) patients. Angiographic follow-up was performed in 44 patients at an average of 13.16±13.12 months. The recurrence rate is 34.1%. Seven of them (15.9%) received retreatment. Conclusion Double microcatheter technique is a safe and effective method for treatment of ruptured aneurysms in anterior cerebral aneurysms with low morbidity. Recurrence remains a problem. Patients should be followed up regularly.

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