Abstract 1122‐000152: Flow Diverter Use in Acutely Presented Dissecting Aneurysms, 2 Years Follow Up of 53 Cases

Introduction : Acute dissecting aneurysms are among the uncommon causes of subarachnoid hemorrhage. Established endovascular treatment options include parent artery occlusion and stent‐assisted coiling, but appear to be associated with an increased risk of ischemic stroke. reconstruction of the vessels with flow diverters is an alternative therapeutic option. Methods : This is a retrospective analysis of 53 consecutive acutely ruptured dissecting aneurysms treated with flow diverters. The primary end point was favorable aneurysm occlusion, defined as OKM C1‐3 and D . Secondary end points were procedure‐related complications and clinical outcome. Results : 23 aneurysms (43.4%%) arose from the intradural portion of the vertebral artery, 10 (18.8%) were located on the posterior inferior cerebellar artery and 3 (5.6%) posterior cerebral artery, 7 (13.2%) MCA, (18.8%) ICA . 45 aneurysms presented by SAH while 8 presented by Ischemic manifestation. Flow diverter placement was technically successful in all cases . immediate postoperative rerupture occurred in two case (3.7%), thromboembolic complications in 3 cases (5.7%). Median clinical follow‐up was 640 days and median angiographic follow‐up was 690 days. ten patients (18.9%) with poor‐grade subarachnoid hemorrhage died in the acute phase. Favorable clinical outcome (modified Rankin scale ≤2) was observed in 27 of 53 patients (51%) and a moderate outcome (modified Rankin scale 3/4) was observed in 12 of 53 patients (22.6%). All aneurysms showed complete occlusion at follow‐up. Conclusions : Flow diverters might be a feasible, alternative treatment option for acutely symptomatic dissecting aneurysms and may effectively prevent rebleeding in ruptured aneurysms.

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The implications of magnetic resonance angiography artifacts caused by different types of intracranial flow diverters

Journal of Cardiovascular Magnetic Resonance ◽

10.1186/s12968-021-00753-0 ◽

2021 ◽

Vol 23 (1) ◽

Author(s):

Batur Halitcan ◽

Sayin Bige ◽

Balci Sinan ◽

Akmangit Ilkay ◽

Daglioglu Ergun ◽

...

Keyword(s):

Magnetic Resonance ◽

Magnetic Resonance Angiography ◽

Predictive Value ◽

Diagnostic Yield ◽

Flow Diverter ◽

Parent Artery ◽

Perfect Agreement ◽

Tof Mra ◽

Flow Diverters

Abstract Background Serial cerebral angiographic imaging is necessary to ensure cerebral aneurysm occlusion after flow diverter placement. Time-of-flight (TOF)-magnetic resonance angiography (MRA) is used for this purpose due to its lack of radiation, contrast media and complications. The comparative diagnostic yield of TOF-MRA for different flow diverters has not been previously analyzed. Purpose To evaluate the diagnostic accuracy of TOF-MRA in cerebral aneurysms treated w divertersith different flow diverters. Materials and Methods Flow-diverted patients whose cerebral follow-up MRA and digital subtraction angiograms (DSA) were obtained within 6 weeks were retrospectively identified. The DSA (as gold standard) and MRA images of these patients were compared by two readers (blinded to both patient data and endovascular procedure data) for residual aneurysms and the status of the parent artery for each type of flow diverter. In a second group of patients, magnetic susceptibility artifacts were manually measured and compared for different FDs. Results Seventy-six patients (85 aneurysms) were included in group one, and 86 patients (95 aneurysms) were included in group 2. TOF-MRA and DSA showed almost perfect agreement for residual aneurysms (κ = 0.88, p < 0.001) (positive predictive value (PPV) = 1.00, specificity = 1.00, negative predictive value (NPV) = 0.89, sensitivity = 0.89). Intermodality agreement (κ = 0.97 vs. κ = 0.74, p < 0.005) and sensitivity (0.97 vs. 0.77, NPV: 0.96 vs. 0.77) were highest with nitinol stents. MRA and DSA showed no agreement for occluded or stenotic parent vessels (κ = 0.13, p = 0.015, specificity = 0.44, NPV = 1.00, sensitivity = 1.00). Specificity was lower in chromium-cobalt based FDs than in nitinol devices (specificity = 0.08 vs. 0.60). Chromium-cobalt stents generated the largest artifacts (p < 0.005). The size of the device-related artifact, in millimeters, increased in respective order, for the Silk, Derivo, Pipeline and Surpass devices. Conclusion Unlike DSA, TOF-MRA is susceptible to dissimilarities between flow diverters. MRA is not well-suited for research studies comparing different flow diverters. Nitinol FDs appear to be advantageous for TOF-MRA follow-up so as not to miss small aneurysm remnants or clinically relevant parent artery stenosis.

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Treatment of Intracranial Aneurysms Using the New Silk Vista Flow Diverter: Safety Outcomes at Short-Term Follow-Up

Frontiers in Neurology ◽

10.3389/fneur.2021.713389 ◽

2021 ◽

Vol 12 ◽

Author(s):

José M. Pumar ◽

Antonio Mosqueira ◽

Jorge Olier ◽

Claudio Rodriguez-Fernandez ◽

Pedro Vega ◽

...

Keyword(s):

Endovascular Treatment ◽

Cerebral Aneurysms ◽

Flow Diverter ◽

Parent Artery ◽

Short Term ◽

Unruptured Aneurysms ◽

Brain Aneurysms ◽

New Generation ◽

Flow Diverters

Background: Flow diverters are widely used as the first endovascular treatment option for complex brain aneurysms due to their high percentage of occlusion and low morbi-mortality. The Silk Vista device is a new generation of flow diverters designed to facilitate full visibility, improve apposition to the vessel wall, and enhance navigability. Indeed, its greatest advantage is that it enables the easier navigation of stents between 3.5 and 4.75 mm through a 0.021 microcatheter. The objective of this study was to evaluate the safety and effectiveness of Silk Vista systems for treating cerebral aneurysms.Methods: This prospective observational study included 25 consecutive patients with 27 wide-necked unruptured aneurysms treated with SILK Vista who were retrospectively analyzed for safety and efficacy.Results: Endovascular treatment was successfully performed in all patients. The final morbidity and mortality rates were both 0.0%. Short-term (3–5 months) angiographic follow-up revealed 21 complete occlusions and 6 near-complete occlusions. No significant parent artery stenosis was observed.Conclusions: This report demonstrates the efficacy of Silk Vista in treating brain aneurysms, although longer experiences should be carried out to confirm our results.

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Treatment of Dissecting Distal Vertebral Artery (V4) Aneurysms With Flow Diverters

Operative Neurosurgery ◽

10.1093/ons/opx180 ◽

2017 ◽

Vol 15 (1) ◽

pp. 1-9 ◽

Cited By ~ 6

Author(s):

Jacquelyn A Corley ◽

Ali Zomorodi ◽

L Fernando Gonzalez

Keyword(s):

Vertebral Artery ◽

Neurological Deficits ◽

Medication Regimen ◽

Antiplatelet Medication ◽

Average Improvement ◽

Multiple Challenges ◽

Partial Thrombosis ◽

Flow Diverters ◽

Dissecting Aneurysms

Abstract BACKGROUND Dissecting aneurysms of the intracranial vertebral arteries are rare; however, treatment of these presents multiple challenges, including high risk of rebleeding, development of thromboembolic strokes, and progressive partial thrombosis. Flow diverters, such as Pipeline Endovascular Devices (PEDs; Covidien, Medtronic Inc, Dublin, Ireland), have emerged as a potential treatment option. OBJECTIVE To present our experience with patients treated at our institution with PEDs for dissecting distal vertebral artery (V4 segment) aneurysms. METHODS A retrospective search of our prospectively maintained database was performed between January 2014 and December 2016. We queried our database for all patients treated with PED for dissecting aneurysms of the V4 segment. Information was gathered including demographics, the location and morphology of the aneurysm, the clinical presentation, specific form of treatment, complications, antiplatelet medication regimen, and follow-up time. RESULTS There were a total of 9 patients with dissecting V4 aneurysms treated with PED during the study period. All were treated initially with an average of 1.2 PEDs. All patients were followed with at least one repeat diagnostic angiogram and there was no residual aneurysm seen in 8 of 9 cases. In those that presented with neurological deficits, there was an average improvement in modified Rankin Scale of 2.85 points. CONCLUSION PED is a safe and effective tool that can be used to treat ruptured dissecting aneurysms of this specific segment of the posterior circulation, but it does require close management of antiplatelet therapy in the setting of subarachnoid hemorrhage and close angiographic follow-up.

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Abstract 120: Surpass Flow Diverter for Endovascular Treatment of Intracranial Aneurysms - A Multicenter Preliminary Clinical and Angiographic Experience in 161 Patients with 186 Aneurysms

Stroke ◽

10.1161/str.45.suppl_1.120 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Ajay K Wakhloo ◽

Pedro Lylyk ◽

Joost de Vries ◽

Matthew J Gounis ◽

Alexandra Biondi ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Experimental Studies ◽

Flow Diverter ◽

Posterior Circulation ◽

Parent Artery ◽

Anterior Circulation ◽

Neck Size ◽

Wide Range ◽

New Generation

Objective: Validated through experimental studies a new generation of flow diverters (Surpass™ FD) was evaluated for treatment of intracranial aneurysms (IA). We present our multicenter preliminary clinical and angiographic experience. METHODS: To achieve the calculated flow disruption between the parent artery and aneurysm for thrombosis, single FDs were placed endovascularly in parent arteries. Implants measured 2.5-5.3mm in diameter with a length of 10-80mm. Patients were enrolled harboring a wide range large and giant wide-neck, fusiform and multiple small and blister-type aneurysm. Clinical and angiographic follow-up were performed at 1-3, 6, and 12 months. RESULTS: A total of 186 consecutive IA in 161 patients (mean age 57.1 years) were treated at 33 centers. Fifty-three aneurysms were smaller than 5 mm, 64 were 5-9.9mm in diameter, 47 were 10-20mm in diameter, and 22 were larger than 20mm (10.4±0.7mm, neck size 6.0±0.5mm [mean±SEM]) . The aneurysms originated in 63.4% from the internal carotid artery; 22% and 14.5% of the lesions were located in the anterior circulation distal to Circle of Willis and posterior circulation respectively. Technical success was achieved in 182 aneurysms (98%); average number of devices used per aneurysm was 1.05. Permanent morbidity and mortality during the follow-up period of mean 8.4months (range 1-24 months) including periprocedural complications for patients with aneurysms of the anterior circulation were encountered in 5 (3.7%) and 2 (1.5 %) patients respectively and 1 (3.7%) and 4 (14.8%) respectively for patients with aneurysms of the posterior circulation location. One-hundred-ten patients (70.5%) harboring 127 (70.2%) were available for clinical and angiographic follow-up and showed a complete or near complete aneurysm occlusion in 63 (81.8%) of the ICA. Aneurysms of the ICA≥10mm that were completely covered by FD and not previously stent-treated with a minimum of 6 months follow-up available in 16 patients showed a complete obliteration in 81.3% (n=13) and >90% occlusion in remaining 3 patients. CONCLUSION: Preliminary data demonstrate high safety and efficacy of a new generation of FD for a wide range of IA of the anterior and posterior circulation with a single implant.

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Endovascular Treatment of Bilateral Intracranial Vertebral Artery Dissecting Aneurysms Presenting With Subarachnoid Hemorrhage

Operative Neurosurgery ◽

10.1227/neu.0b013e31822ed1f0 ◽

2011 ◽

Vol 70 (suppl_1) ◽

pp. ons75-ons81 ◽

Cited By ~ 1

Author(s):

Yong Sam Shin ◽

Byung Moon Kim ◽

Se-Hyuk Kim ◽

Sang Hyun Suh ◽

Chang Woo Ryu ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Endovascular Treatment ◽

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Stent Insertion ◽

Treatment Methods ◽

Cerebellar Artery ◽

Endovascular Methods ◽

Dissecting Aneurysms

Abstract BACKGROUND: Optimal management of bilateral vertebral artery dissecting aneurysms (bi-VDAs) causing subarachnoid hemorrhage (SAH) remains unclear. OBJECTIVE: To investigate the treatment methods and outcomes of bi-VDA causing SAH. METHODS: Seven patients were treated endovascularly for bi-VDA causing SAH. Treatment methods and outcomes were evaluated retrospectively. RESULTS: Two patients were treated with 2 overlapping stents for both ruptured and unruptured VDAs, 2 with 2 overlapping stents and coiling for ruptured VDA and with conservative treatment for unruptured VDA, 1 with internal trapping (IT) for ruptured VDA and stent-assisted coiling for unruptured VDA, 1 with IT for ruptured VDA and 2 overlapping stents for unruptured VDA, and 1 with IT for ruptured VDA and a single stent for unruptured VDA. None had rebleeding during follow-up (range, 15-48 months). All patients had favorable outcomes (modified Rankin Scale score, 0-2). On follow-up angiography at 6 to 36 months, 9 treated and 2 untreated VDAs revealed stable or improved state, whereas 3 VDAs in 2 patients showed regrowth. Of the 3 recurring VDAs, 1 was initially treated with IT but recurred owing to retrograde flow to the ipsilateral posterior inferior cerebellar artery (PICA), the second was treated with single stent but enlarged, and the last was treated with 2 overlapping stents and coiling but recurred from the remnant sac harboring the PICA origin. All 3 recurred VDAs were retreated with coiling with or without stent insertion. CONCLUSION: Bilateral VDAs presenting with SAH were safely treated with endovascular methods. However, endovascular treatment may be limited for VDAs with PICA origin involvement.

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Treatment of Intracranial Aneurysm with Bare Stent Only

Interventional Neuroradiology ◽

10.1177/15910199080140s213 ◽

2008 ◽

Vol 14 (2_suppl) ◽

pp. 75-78 ◽

Cited By ~ 3

Author(s):

Michael Mu Huo Teng ◽

Chao-Bao Luo ◽

Feng-Chi Chang ◽

Harsan Harsan

Keyword(s):

Intracranial Aneurysm ◽

Artery Occlusion ◽

Dissecting Aneurysm ◽

Parent Artery ◽

Fusiform Aneurysm ◽

Surgical Clipping ◽

Parent Artery Occlusion ◽

Typical Treatment ◽

Dissecting Aneurysms

Typical treatment of intracranial aneurysm includes: surgical clipping, intrasacular packing, and parent artery occlusion. The treatment of a fusiform aneurysm is often parent artery occlusion, and keeping patency of the parent artery is difficult. We report our experience in the treatment of 3 cases of intracranial fusiform aneurysm with stent placement inside the parent artery only, without coil packing of the aneurysm lumen. All 3 patients had a non-hemorrhagic dissecting aneurysm in the vertebral artery. They were treated with 2 Helistents, 3 Neuroform stents, and 2 Neuroform stents, respectively. These aneurysms disappeared after treatment at their follow-up angiograms. Treatment with a bare stent may induce obliteration or reduction in the size of some aneurysms. This technique is useful in the treatment of non-hemorrhagic fusiform-shaped aneurysms or non-hemorrhagic dissecting aneurysms to preserve the patency of these parent arteries.

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The use of flow diverters to treat aneurysms of the posterior inferior cerebellar artery: Report of three cases

Interventional Neuroradiology ◽

10.1177/1591019918774877 ◽

2018 ◽

Vol 24 (5) ◽

pp. 489-498 ◽

Cited By ~ 16

Author(s):

Pervinder Bhogal ◽

Jorge Chudyk ◽

Carlos Bleise ◽

Ivan Lylyk ◽

Hans Henkes ◽

...

Keyword(s):

Treatment Option ◽

Intraoperative Complications ◽

Posterior Inferior Cerebellar Artery ◽

Endovascular Coiling ◽

Medical Illness ◽

Unruptured Aneurysms ◽

Alternative Treatment Option ◽

Cerebellar Artery ◽

Flow Diverters

Objective The objective of this study was to report our experience on the use of flow diverting stents placed within the posterior inferior cerebellar artery (PICA) as a treatment option for aneurysms of the PICA. Methods Three patients with aneurysms of the PICA, both ruptured and unruptured, underwent treatment of their aneurysms with placement of a single flow diverter in the PICA across the neck of the aneurysm. Adjunctive techniques such as coiling were not used. We present the angiographic and clinical follow-up data. Results The procedure was a technical success in all cases and there were no intraoperative complications. Follow-up data were available for two patients and this showed complete occlusion of the aneurysm with the PICA remaining patent. There was no evidence, either clinical or radiological, of medullary or pontine infarction. One patient died during the follow-up period from an unrelated medical illness (community acquired pneumonia). Conclusion Flow diverters can be successfully placed within the PICA to treat both ruptured and unruptured aneurysms, and they represent an alternative treatment option to endovascular coiling or microscopic neurosurgery.

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Re-treatment of residual aneurysms after flow diversion: An experimental study

The Neuroradiology Journal ◽

10.1177/1971400918763198 ◽

2018 ◽

Vol 31 (3) ◽

pp. 270-279 ◽

Cited By ~ 1

Author(s):

Robert Fahed ◽

Tim E Darsaut ◽

Marc Kotowski ◽

Igor Salazkin ◽

Jean Raymond

Keyword(s):

Flow Diverter ◽

Artery Occlusion ◽

Flow Diversion ◽

Embolic Agent ◽

Parent Artery ◽

Arterial Lumen ◽

Parent Artery Occlusion ◽

Liquid Embolic ◽

Liquid Embolic Agent ◽

Flow Diverters

Aim Flow diverters are increasingly used to treat aneurysms, but treatment is not always effective. The management of aneurysms that fail to occlude following flow diversion is problematic. We aimed to reproduce failures in an animal model and study re-treatment with additional flow diverters alone or with flow diverters and liquid embolic agent. Material and methods Twenty wide-necked aneurysms were created at the carotid-lingual bifurcation in 10 dogs, and were treated with flow diverters 4–6 weeks later. Follow-up angiography was performed at three months. Suitable residual aneurysms were randomly allocated: re-treatment with flow diverters alone ( n = 6), or with the injection of liquid embolic between two layers of flow diverters ( n = 4) or no re-treatment ( n = 2). Angiography was repeated three months later, followed by euthanasia, photography and pathology. Results Patent wide-necked aneurysms were produced in 17/20 attempts (85%); three months after flow diversion there were 15/17 (88%) residual aneurysms. In three cases, re-treatment was not possible because the flow diverter had prolapsed into the aneurysm, leaving 12 aneurysms to study. Re-treated aneurysms showed improved angiographic results at six months (median score of 2; P = 0.03), but residual aneurysms were present in all cases. Parent artery occlusion occurred in two aneurysms treated with flow diverter plus liquid embolic. At pathology, aneurysms were only partially filled with thrombus; leaks through the flow diverters were found in the neointima connecting the arterial lumen to residual aneurysms. Conclusion Re-treatment of residual flow-diverted experimental aneurysms with additional flow diverters did not lead to aneurysm occlusion.

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Successful management of bilateral internal carotid artery fusiform giant aneurysms in a patient with intimal fibroplasia using multiple flow diverters: With long-term imaging follow up

Interventional Neuroradiology ◽

10.1177/15910199211049129 ◽

2021 ◽

pp. 159101992110491

Author(s):

Jieun Roh ◽

Seung Kug Baik ◽

Jeong A Yeom ◽

Joo-Young Na ◽

Sang-Won Lee

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Flow Diverter ◽

Giant Aneurysms ◽

The Past ◽

Effective Treatment Modality ◽

Flow Diverters

The authors report a rare case of sequentially developed bilateral internal carotid artery (ICA) fusiform giant aneurysms in a patient with pathologically confirmed intimal fibroplasia. Both ICA fusiform aneurysms were treated with multiple flow diverter insertion and were well-managed over the past 5.5 years of follow-up. The development of aneurysms in this rare disease entity appears to be a lifelong process based on the authors’ observations in serial angiographic follow-up studies. Reconstruction therapy using flow-diverting stents in this unique condition may be a safe and effective treatment modality.

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Association between Apolipoprotein E Polymorphism and Clinical Outcome after Ischemic Stroke, Intracerebral Hemorrhage, and Subarachnoid Hemorrhage

Cerebrovascular Diseases ◽

10.1159/000520053 ◽

2021 ◽

pp. 1-10

Author(s):

Wen Pan ◽

Min Zhang ◽

Zhenping Guo ◽

Wenfeng Xiao ◽

Chao You ◽

...

Keyword(s):

Ischemic Stroke ◽

Subarachnoid Hemorrhage ◽

Clinical Outcome ◽

Intracerebral Hemorrhage ◽

Apolipoprotein E ◽

Functional Outcomes ◽

Fixed Effects ◽

Meta Analysis ◽

Fixed Effects Models ◽

Increased Risk

Backgrounds: Previous studies reported inconsistent results regarding associations between apolipoprotein E (APOE) polymorphism and clinical outcomes after ischemic stroke (IS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH). Thus, the study was designed to make a systematic review and meta-analysis regarding the association between APOE polymorphism and clinical outcome after IS, ICH, and SAH. Methods: To identify studies eligible for this meta-analysis, we searched for articles published before August 2021 in the databases (PubMed, Web of Science, and Google Scholar). We used STATA 12.0 software to compute hazard ratios (HRs) and their 95% confidence intervals (CIs) regarding APOE polymorphism and clinical outcome after IS, ICH, and SAH. Results: Meta-analysis showed no significant association between APOE polymorphism and functional outcome after IS with fixed effects models (ε4 carrier vs. non-ε4 carrier: HR, 1.00; 95% CI: 0.83–1.21, I2 = 29.4%, p = 0.183; ε2 carrier vs. non-ε2 carrier: HR, 0.92; 95% CI: 0.72–1.16, I2 = 15.6%, p = 0.307). Meta-analysis showed that ICH patients carrying ε4 allele have increased risk of poor outcome in Caucasian population with fixed effects models (ε4 carrier vs. non-ε4 carrier: HR, 1.75; 95% CI: 1.19–2.57, I2 = 0.0%, p = 0.543). Meta-analysis showed no significant association between APOE polymorphism and functional outcomes after SAH with random effects models (ε4 carrier vs. non-ε4 carrier: HR, 1.51; 95% CI: 0.80–2.84, I2 = 57.1%, p = 0.022). Conclusions: In conclusion, the present study demonstrated APOE ε4 carriers show worse functional outcomes after ICH, but not after IS or SAH. More large-scale studies were critical to explore the association between APOE polymorphism and clinical outcome after IS, ICH, and SAH.

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