Flow diversion for internal carotid artery aneurysms with compressive neuro-ophthalmologic symptoms: clinical and anatomical results in an international multicenter study

BackgroundScientific data on the safety and efficacy of flow diverter stents (FDS) for the treatment of unruptured internal carotid artery (ICA) aneurysms with compressive neuro-ophthalmological symptoms are scarce. We studied this subject in a retrospective international multicenter series, pooling data of 9 tertiary care neurointerventional departments.ObjectiveTo investigate, in a retrospective, multicentric cohort of patients presenting with visual or oculomotor symptoms attributed to a compressive carotid artery in an unruptured intracranial aneurysm, the safety and efficacy profiles of FDS, by analyzing neuro-opthalmologic symptom evolution following FDS placement, complications, and aneurysm obliteration rates.MethodsAll patients treated since 2015 with a FDS for an unruptured aneurysm of the ICA with signs of compressive cranial nerve symptoms (CN II, III, IV, VI) were included.ResultsWe treated 55 patients with 55 aneurysms; 21 (38.2%) patients had oculomotor and 15 (27.3%) visual symptoms only; 19 (34.5%) presented with a combination of both. Treatment-related morbidity/mortality occurred in 7.2% and 3.6%, respectively. At last imaging follow-up (13.1±10.5 months) rates of complete aneurysm occlusion, neck remnant, and aneurysm remnant were 72%, 14%, and 14%, respectively. At last clinical follow-up after 13±10.5 months, 19/51 (37.3%) patients had recovered completely and 18/51 (35.3%) had recovered at least partially from their neuro-ophthalmological symptoms. In multivariable models, a longer delay between symptom onset and treatment was associated with higher odds for incomplete recovery and lower odds for any improvement (aOR 1.03 (95% CI 1.01 to 1.07), p=0.047 and 0.04 (0–0.81), p=0.020). Incomplete recovery was independently associated with older age and fusiform aneurysms.ConclusionFDS are effective to treat patients with compressive aneurysms of the ICA causing neuro-ophthalmological symptoms, especially when treatment is initiated early after symptom onset, and aneurysm occlusion is adequate. However, serious complications are not rare.

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Unruptured intracranial aneurysms in children: 18 years’ experience in a tertiary care pediatric institution

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.4.peds18703 ◽

2019 ◽

Vol 24 (2) ◽

pp. 184-189 ◽

Cited By ~ 1

Author(s):

Daniel-Alexandre Bisson ◽

Peter Dirks ◽

Afsaneh Amirabadi ◽

Manohar M. Shroff ◽

Timo Krings ◽

...

Keyword(s):

Carotid Artery ◽

Natural History ◽

Internal Carotid Artery ◽

Intracranial Aneurysms ◽

Internal Carotid ◽

Tertiary Care ◽

Unruptured Intracranial Aneurysms ◽

History Of ◽

Mean Size

OBJECTIVEThere are little data in the literature on the characteristics and natural history of unruptured intracranial aneurysms in children. The authors analyzed their experience with unruptured intracranial aneurysms in the pediatric population at their tertiary care pediatric institution over the last 18 years. The first objective was to assess the imaging characteristics and natural history of these aneurysms in order to help guide management strategies in the future. A second objective was to evaluate the frequency of an underlying condition when an incidental intracranial aneurysm was detected in a child.METHODSThe authors conducted a Research Ethics Board–approved retrospective review of incidental intracranial aneurysms in patients younger than 18 years of age who had been treated at their institution in the period from 1998 to 2016. Clinical (age, sex, syndrome) and radiological (aneurysm location, type, size, thrombus, mass effect) data were recorded. Follow-up imaging was assessed for temporal changes.RESULTSSixty intracranial aneurysms occurred in 51 patients (36 males, 15 females) with a mean age of 10.5 ± 0.5 years (range 9 months–17 years). Forty-five patients (88.2%) had a single aneurysm, while 2 and 3 aneurysms were found in 3 patients each (5.8%). Syndromic association was found in 22 patients (43.1%), most frequently sickle cell disease (10/22 [45.5%]). Aneurysms were saccular in 43 cases (71.7%; mean size 5.0 ± 5.7 mm) and fusiform in the remaining 17 (28.3%; mean size 6.5 ± 2.7 mm). Thirty-one aneurysms (51.7%) arose from the internal carotid artery (right/left 1.4), most commonly in the cavernous segment (10/31 [32.3%]). Mean size change over the entire follow-up of 109 patient-years was a decrease of 0.6 ± 4.2 mm (range −30.0 to +4.0 mm, rate −0.12 ± 9.9 mm/yr). Interval growth (2.0 ± 1.0 mm) was seen in 8 aneurysms (13.3%; 4 saccular, 4 fusiform). An interval decrease in size (8.3 ± 10.7 mm) was seen in 6 aneurysms (10%). There was an inverse relationship between aneurysm size and growth rate (r = −0.82, p < 0.00001). One aneurysm was treated endovascularly with internal carotid artery sacrifice.CONCLUSIONSUnruptured pediatric intracranial aneurysms are most frequently single but can occur in multiples in a syndromic setting. None of the cases from the study period showed clinical or imaging signs of rupture. Growth over time, although unusual and slow, can occur in a proportion of these patients, who should be identified for short-term imaging surveillance.

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Pipeline embolization device retraction and foreshortening after internal carotid artery blister aneurysm treatment

Interventional Neuroradiology ◽

10.1177/1591019917722514 ◽

2017 ◽

Vol 23 (6) ◽

pp. 614-619 ◽

Cited By ~ 4

Author(s):

Jeremy J Heit ◽

Nicholas A Telischak ◽

Huy M Do ◽

Robert L Dodd ◽

Gary K Steinberg ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

High Morbidity ◽

Case Description ◽

Digital Subtraction ◽

Pipeline Embolization Device ◽

Aneurysm Occlusion ◽

New Treatment

Background Subarachnoid hemorrhage (SAH) secondary to rupture of a blister aneurysm (BA) results in high morbidity and mortality. Endovascular treatment with the pipeline embolization device (PED) has been described as a new treatment strategy for these lesions. We present the first reported case of PED retraction and foreshortening after treatment of a ruptured internal carotid artery (ICA) BA. Case description A middle-aged patient presented with SAH secondary to ICA BA rupture. The patient was treated with telescoping PED placement across the BA. After 5 days from treatment, the patient developed a new SAH due to re-rupture of the BA. Digital subtraction angiography revealed an increase in caliber of the supraclinoid ICA with associated retraction and foreshortening of the PED that resulted in aneurysm uncovering and growth. Conclusions PED should be oversized during ruptured BA treatment to prevent device retraction and aneurysm regrowth. Frequent imaging follow up after BA treatment with PED is warranted to ensure aneurysm occlusion.

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Neuroophthalmological outcomes associated with use of the Pipeline Embolization Device: analysis of the PUFS trial results

Journal of Neurosurgery ◽

10.3171/2014.12.jns141777 ◽

2015 ◽

Vol 123 (4) ◽

pp. 897-905 ◽

Cited By ~ 29

Author(s):

Daniel H. Sahlein ◽

Mohammad Fouladvand ◽

Tibor Becske ◽

Isil Saatci ◽

Cameron G. McDougall ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid ◽

Prospective Trial ◽

Maximum Diameter ◽

Pipeline Embolization Device ◽

Safety And Efficacy ◽

History Of ◽

International Multicenter ◽

Supraclinoid Internal Carotid Artery

OBJECT Neuroophthalmological morbidity is commonly associated with large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms. The authors sought to evaluate the neuroophthalmological outcomes after treatment of these aneurysms with the Pipeline Embolization Device (PED). METHODS The Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial was an international, multicenter prospective trial evaluating the safety and efficacy of the PED. All patients underwent complete neuroophthalmological examinations both before the PED procedure and at a 6-month follow-up. All examinations were performed for the purpose of this study and according to study criteria. RESULTS In total, 108 patients were treated in the PUFS trial, 98 of whom had complete neuroophthalmological follow-up. Of the patients with complete follow-up, 39 (40%) presented with a neuroophthalmological baseline deficit that was presumed to be attributable to the aneurysm, and patients with these baseline deficits had significantly larger aneurysms. In 25 of these patients (64%), the baseline deficit showed at least some improvement 6 months after PED treatment, whereas in 1 patient (2.6%), the deficits only worsened. In 5 patients (5%), new deficits had developed at the 6-month follow-up, while in another 6 patients (6%), deficits that were not originally assumed to be related to the aneurysm had improved by that time. A history of diabetes was associated with failure of the baseline deficits to improve after the treatment. The aneurysm maximum diameter was significantly larger in patients with a new deficit or a worse baseline deficit at 6 months postprocedure. CONCLUSIONS Patients treated with the PED for large and giant ICA aneurysms had excellent neuroophthalmological outcomes 6 months after the procedure, with deficits improving in most of the patients, very few deficits worsening, and few new deficits developing.

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Flow diverter for endovascular treatment of intracranial mirror segment internal carotid artery aneurysms

Interventional Neuroradiology ◽

10.1177/1591019918792536 ◽

2018 ◽

Vol 25 (1) ◽

pp. 4-11 ◽

Cited By ~ 2

Author(s):

Anna Luisa Kühn ◽

Peter Kan ◽

Visish Srinivasan ◽

David E Rex ◽

Katyucia de Macedo Rodrigues ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Temporal Artery ◽

Flow Diverter ◽

Post Treatment ◽

Pipeline Embolization Device ◽

Device Placement ◽

Aneurysm Occlusion

Background To evaluate the feasibility and efficacy of the pipeline embolization device in the treatment of unruptured intracranial mirror segment aneurysms. Methods Out of a total of 338 subjects, 14 were identified harboring a total of 32 internal carotid artery mirror segment aneurysms that were treated with the pipeline embolization device and were consecutively enrolled into our study. We collected data on patient demographics, modified Rankin scale (mRS) at admission, aneurysm characteristics, clinical outcome at discharge, 3–9 and at 12–18 months as well as angiography results at follow-up. Results Patients’ mean age was 52.9 years; baseline mRS was 0 in all subjects. Pipeline embolization device placement was successful in all cases. Post-treatment mRS remained 0 in 13/14 patients. One patient experienced a small intraparenchymal hemorrhage and subarachnoid hemorrhage, associated with a frontoparietal infarction resulting in right upper extremity weakness and aphasia (post-treatment mRS 3). His mRS evaluation remained stable at the 3–9-month follow-up. Three to 9-month follow-up angiography (13/14 subjects) showed complete aneurysm occlusion in 24/30 aneurysms (80%), near complete and partial occlusion in three of 30 (10%) aneurysms each. At the 9-month follow-up, one patient experienced a complete occlusion of the anterior temporal artery branch but did not present with any clinical deficits. No mRS changes were encountered over a median 6-month follow-up period. Mid-term follow-up angiography (12–18 months) available in eight of 14 subjects showed complete aneurysm occlusion in all patients. Mild intimal hyperplasia was observed in one patient. Conclusions Flow diversion technology can be used for the treatment of unruptured mirror segment aneurysms in selected patients.

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Regrowth of a Large Intracranial Aneurysm after On-Label Use of the Pipeline Embolization Device

Journal of Neurosciences in Rural Practice ◽

10.4103/jnrp.jnrp_273_18 ◽

2019 ◽

Vol 10 (01) ◽

pp. 142-144 ◽

Cited By ~ 2

Author(s):

Ching-Jen Chen ◽

M. Rao Patibandla ◽

Min S. Park ◽

M. Yashar Kalani

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Intracranial Aneurysm ◽

Internal Carotid ◽

Pipeline Embolization Device ◽

Complete Occlusion ◽

Residual Component ◽

First Case ◽

Aneurysm Occlusion

ABSTRACTDespite the widespread use of the pipeline embolization device (PED), no complete aneurysm regrowth after its placement has been reported in the literature. We report the first case of aneurysm regrowth after the initial follow-up angiography demonstrating near-complete occlusion of the aneurysm and remodeling of the vessel with on-label PED use for a large 20 mm × 24 mm × 22 mm (width × depth × height) cavernous segment internal carotid artery (ICA) aneurysm. The patient was treated with two overlapping PED (4.5 mm × 20 mm and 5 mm × 20 mm). Follow-up angiogram at 4 months after treatment demonstrated remodeling of the ICA with a small residual component measuring approximately 7 mm × 8 mm × 7 mm. However, at 10 months after treatment, there was a complete regrowth of the aneurysm with interval growth, now measuring 25 mm × 28 mm × 18 mm. Despite the high aneurysm occlusion rates reported with the PED, persistent aneurysm filling and aneurysm regrowth, although rare, should not be overlooked.

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Long-Term Clinical and Angiographic Outcomes Following Pipeline Embolization Device Treatment of Complex Internal Carotid Artery Aneurysms: Five-Year Results of the Pipeline for Uncoilable or Failed Aneurysms Trial

Neurosurgery ◽

10.1093/neuros/nyw014 ◽

2016 ◽

Vol 80 (1) ◽

pp. 40-48 ◽

Cited By ~ 152

Author(s):

Tibor Becske ◽

Waleed Brinjikji ◽

Matthew B. Potts ◽

David F. Kallmes ◽

Maksim Shapiro ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Multicenter Trial ◽

Modified Rankin Scale ◽

Pipeline Embolization Device ◽

Cerebrovascular Events ◽

Scale Scores ◽

Aneurysm Occlusion

Abstract BACKGROUND: Early and mid-term safety and efficacy of aneurysm treatment with the Pipeline Embolization Device (PED) has been well demonstrated in prior studies. OBJECTIVE: To present 5-yr follow-up for patients treated in the Pipeline for Uncoilable or Failed Aneurysms clinical trial. METHODS: In our prospective, multicenter trial, 109 complex internal carotid artery (ICA) aneurysms in 107 subjects were treated with the PED. Patients were followed per a standardized protocol at 180 d and 1, 3, and 5 yr. Aneurysm occlusion, in-stent stenosis, modified Rankin Scale scores, and complications were recorded. RESULTS: The primary endpoint of complete aneurysm occlusion at 180 d (73.6%) was previously reported. Aneurysm occlusion for those patients with angiographic follow-up progressively increased over time to 86.8% (79/91), 93.4% (71/76), and 95.2% (60/63) at 1, 3, and 5 yr, respectively. Six aneurysms (5.7%) were retreated. New serious device-related events at 1, 3, and 5 yr were noted in 1% (1/96), 3.5% (3/85), and 0% (0/81) of subjects. There were 4 (3.7%) reported deaths in our trial. Seventy-eight (96.3%) of 81 patients with 5-yr clinical follow-up had modified Rankin Scale scores ≤2. No delayed neurological deaths or hemorrhagic or ischemic cerebrovascular events were reported beyond 6 mo. No recanalization of a previously occluded aneurysm was observed. CONCLUSION: Our 5-yr findings demonstrate that PED is a safe and effective treatment for large and giant wide-necked aneurysms of the intracranial ICA, with high rates of complete occlusion and low rates of delayed adverse events.

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Pipeline Embolization Device for Treatment of Extracranial Internal Carotid Artery Pseudoaneurysms: A Multicenter Evaluation of Safety and Efficacy

Neurosurgery ◽

10.1093/neuros/nyz548 ◽

2020 ◽

Vol 87 (4) ◽

pp. 770-778

Author(s):

Oluwaseun O Akinduro ◽

Neethu Gopal ◽

Tasneem F Hasan ◽

Emad Nourollah-Zadeh ◽

Kunal Vakharia ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Case Series ◽

The United States ◽

Pipeline Embolization Device ◽

Safety And Efficacy ◽

Complete Occlusion ◽

Extracranial Ica

Abstract BACKGROUND There is a paucity of literature regarding treatment options for extracranial pseudoaneurysms of the internal carotid artery (ICA). To date, Pipeline Embolization Device (PED; Medtronic Inc) use for the treatment of extracranial pseudoaneurysms of the ICA has only been reported from single-center case series. OBJECTIVE To evaluate the safety and efficacy of PED for the treatment of extracranial ICA pseudoaneurysms. METHODS This is a multicenter retrospective study involving 6 high-volume tertiary academic institutions in the United States. We analyzed patients with extracranial ICA pseudoaneurysms treated with PED between January 1, 2011, and January 1, 2019. Clinical assessment was performed pre- and postintervention using the modified Rankin Scale (mRS) and National Institution of Health Stroke Scale (NIHSS) at a minimum of 4-mo follow-up. RESULTS A total of 28 pseudoaneurysms with a mean diameter of 17.7 mm (range: 4.1-52.5 mm) were treated with PED in 24 patients at 6 participating centers. The mean age was 52.1 yr (17-73) ± 14.3 with 14 females and 10 males. At a mean of 21-mo (range 4-66 mo) follow-up, complete occlusion was achieved in 89% (n = 25/28), with near-complete occlusion (>90% occlusion) in the remainder. There were no periprocedural complications. Postprocedure NIHSS was 0 in 88% (n = 21/24) and 1 in 12% (n = 3/24) of patients, and mRS was 0 in 83% (n = 20/24) and 1 in 17% (n = 4/24) of patients. CONCLUSION The treatment of extracranial ICA pseudoaneurysms with PED is safe and effective in selected patients. Randomized controlled trials and prospective cohort studies are needed to establish the role of flow diversion for ICA pseudoaneurysms.

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Treatment failure of fetal posterior communicating artery aneurysms with the pipeline embolization device

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-011959 ◽

2015 ◽

Vol 8 (9) ◽

pp. 945-948 ◽

Cited By ~ 32

Author(s):

Peter Kan ◽

Edward Duckworth ◽

Ajit Puri ◽

Greg Velat ◽

Ajay Wakhloo

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Treatment Failure ◽

Internal Carotid ◽

Posterior Cerebral Artery ◽

Flow Diverter ◽

Posterior Communicating Artery ◽

Pipeline Embolization Device ◽

Aneurysm Occlusion

Aneurysms that involve the internal carotid artery and posterior communicating artery junction and incorporate a fetal posterior cerebral artery are known as fetal posterior communicating artery aneurysms. We report the outcomes of four patients with fetal posterior communicating artery aneurysms who underwent treatment with the pipeline embolization device with or without adjunctive coil embolization. In our study, all four patients failed to achieve aneurysm occlusion at the last follow-up evaluation. Based on our results, we currently do not recommend the use of the flow diverter for the treatment of fetal posterior communicating artery aneurysms.

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Long-term stability of fusiform dilatation of the internal carotid artery following surgery adjacent to the circle of Willis: report of 2 cases

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.7.peds20469 ◽

2020 ◽

pp. 1-4

Author(s):

Madeline B. Karsten ◽

R. Michael Scott

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Arachnoid Cyst ◽

Pediatric Patients ◽

Internal Carotid ◽

Imaging Finding ◽

Neurological Status ◽

Suprasellar Region

Fusiform dilatation of the internal carotid artery (FDCA) is a known postoperative imaging finding after craniopharyngioma resection. FDCA has also been reported following surgery for other lesions in the suprasellar region in pediatric patients and is thought to be due to trauma to the internal carotid artery (ICA) wall during tumor dissection. Here, the authors report 2 cases of pediatric patients with FDCA. Case 1 is a patient in whom FDCA was visualized on follow-up scans after total resection of a craniopharyngioma; this patient’s subsequent scans and neurological status remained stable throughout a 20-year follow-up period. In case 2, FDCA appeared after resection and fenestration of a giant arachnoid cyst in a 3-year-old child, with 6 years of stable subsequent follow-up, an imaging finding that to the authors’ knowledge has not previously been reported following surgery for arachnoid cyst fenestration. These cases demonstrate that surgery involving dissection adjacent to the carotid artery wall in pediatric patients may lead to the development of FDCA. On very long-term follow-up, this imaging finding rarely changes and virtually all patients remain asymptomatic. Neurointerventional treatment of FDCA in the absence of symptoms or significant late enlargement of the arterial ectasia does not appear to be indicated.

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