A Novel Grading Scale for the Angiographic Assessment of Intracranial Aneurysms Treated Using Flow Diverting Stents

Flow diverting stents are emerging as a treatment option for difficult intracranial aneurysms. Current grading scales for assessment of angiographic outcomes following aneurysm treatment do not apply to aneurysms treated by flow diversion. We propose a novel grading scale based on the degree of angiographic filling and contrast stasis. This scale will facilitate communication and standardize reporting of outcomes following flow diversion treatments.

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Utilization of a Novel, Multi-Durometer Intracranial Distal Access Catheter: Nuances and Experience in 110 Consecutive Cases of Aneurysm Flow Diversion

Interventional Neurology ◽

10.1159/000456086 ◽

2017 ◽

Vol 6 (1-2) ◽

pp. 90-104 ◽

Cited By ~ 13

Author(s):

Geoffrey P. Colby ◽

Li-Mei Lin ◽

Risheng Xu ◽

Narlin Beaty ◽

Matthew T. Bender ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Flow Diversion ◽

Technical Success ◽

Anterior Circulation ◽

Patient Demographics ◽

Aneurysm Treatment ◽

Vessel Injury ◽

Wide Range ◽

Neurological Morbidity ◽

Coaxial Catheter

Background: Coaxial catheter support systems provide a safe and stable foundation in endovascular treatment of intracranial aneurysms. Increasingly, robust distal intracranial support is sought during complex neurointerventions. The AXS Catalyst 5 distal access catheter (Cat5) is a new intracranial catheter designed for improved trackability and stability. We report the first experience using Cat5 for aneurysm treatment by flow diversion. Methods: A single-center aneurysm database was reviewed for cases of aneurysm treatment with the Pipeline embolization device (PED) that utilized Cat5. Data were collected for patient demographics, aneurysm characteristics, procedural details, catheter positions, vessel tortuosity, and catheter related complications. Results: One hundred and ten cases of aneurysm flow diversion were successfully performed using Cat5. Patient age ranged from 21 to 86 years (mean 57 ± 12.5 years) with 84% women. Aneurysm size ranged from 2 to 28 mm (mean 5.7 ± 5.0 mm), with 97% in the anterior circulation. Twenty-four aneurysms (22%) were located beyond the ICA termination. Significant cervical carotid tortuosity was present in 26% of cases, and moderate to severe cavernous tortuosity (cavernous grade ≥2) in 45% of cases. Cat5 was tracked to the intended distal position in all cases with 100% technical success of PED implantation. No iatrogenic catheter-related vessel injury occurred, and major neurological morbidity occurred in 1 patient (1%). Summary: The Cat5 is a novel, multi-durometer cranial distal access catheter designed for use in tri-axial systems. We have demonstrated the utility of Cat5 in 110 successful cases of flow diversion with a wide range of complexity. This catheter is a new tool in the neurointerventionalist's armamentarium to achieve robust and atraumatic distal access.

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Cognitive outcomes after unruptured intracranial aneurysm treatment with flow diversion

Journal of Neurosurgery ◽

10.3171/2019.9.jns191910 ◽

2021 ◽

Vol 134 (1) ◽

pp. 33-38 ◽

Cited By ~ 2

Author(s):

Kathryn Wagner ◽

Aditya Srivatsan ◽

Alina Mohanty ◽

Visish M. Srinivasan ◽

Yasir Saleem ◽

...

Keyword(s):

Repeated Measures ◽

Intracranial Aneurysms ◽

Cognitive Status ◽

Cognitive Outcomes ◽

Flow Diversion ◽

Neurological Deficits ◽

Time Interval ◽

Aneurysm Treatment ◽

Unruptured Intracranial Aneurysms

OBJECTIVEFlow diversion is increasingly used to treat a variety of intracranial aneurysms with good safety and efficacy; however, there is some evidence that this treatment is associated with a larger postoperative ischemic burden on imaging than that with other traditional endovascular modalities. These findings typically do not manifest as neurological deficits, but any subtle effects on cognition remain unknown. In this study, the authors describe the neurocognitive performance of a cohort of patients with unruptured intracranial aneurysms (UIAs) before and after treatment with flow diversion. This is the first report of cognitive outcomes following aneurysm treatment with flow diversion.METHODSThe authors prospectively collected data on cognitive function using the Montreal Cognitive Assessment (MoCA) tool in patients with UIAs who were undergoing endovascular aneurysm treatment with flow diversion between June 2017 and July 2019. Patients completed the MoCA prior to intervention, at the 1-month follow-up after treatment, and again at 6 months after the procedure. All patients with UIAs treated with flow diversion were included regardless of age, aneurysm location, or morphology, unless their functional status precluded completion of the MoCA instrument. A repeated-measures linear mixed-effects model was used to compare preintervention and postintervention cognitive status at the time intervals outlined.RESULTSFifty-one patients with 61 aneurysms underwent endovascular aneurysm treatment with flow diversion (mean age 52.5 years, 90.2% females). There was no difference between baseline and postprocedure MoCA scores at any time interval (p > 0.05). The MoCA scores at baseline, 1 month postprocedure, and 6 months postprocedure were 26.1, 26.2, and 26.6, respectively. There was also no difference between pre- and postprocedure scores on any individual domain of the instrument (visuospatial, naming, attention, language, abstraction, delayed recall, and orientation) at any time interval (p > 0.05). Thirty-four patients had follow-up MRI or CT imaging, 5 of whom showed radiographic changes or ischemia. All patients with follow-up clinical evaluation had a 6-month modified Rankin Scale score ≤ 2.CONCLUSIONSFlow diversion is increasingly used in the treatment of intracranial aneurysms. This study suggests that this treatment may not alter neurocognitive function. Larger patient samples and longer follow-ups with other tests of cognitive functions are needed to confirm these findings.

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Thromboelastography (TEG) results are predictive of ischemic and hemorrhagic complications in patients with unruptured intracranial aneurysms treated with flow diversion

Interventional Neuroradiology ◽

10.1177/15910199211025917 ◽

2021 ◽

pp. 159101992110259

Author(s):

Kainaat Javed ◽

Santiago R Unda ◽

Ryan Holland ◽

Adisson Fortunel ◽

Rose Fluss ◽

...

Keyword(s):

Ischemic Stroke ◽

Intracranial Aneurysms ◽

Statistical Significance ◽

Alpha Angle ◽

Flow Diversion ◽

P Value ◽

Hemorrhagic Complication ◽

Unruptured Intracranial Aneurysms ◽

Hemorrhagic Complications ◽

Groin Hematoma

Introduction Flow diversion is an effective treatment modality for intracranial aneurysms but is associated with ischemic and hemorrhagic complications. Patients treated with flow diversion require dual antiplatelet therapy and subsequent platelet function tests. At our institution, Thromboelastography with Platelet Mapping (TEG-PM) is the test of choice. The primary objective of this study was to identify TEG parameters that are predictive of postoperative complications in patients treated with elective flow diversion. Methods This was a retrospective study of 118 patients with unruptured intracranial aneurysms treated with flow diversion. Data was collected via chart review. Bivariate analyses were performed to identify significant variables in patients who suffered an ischemic stroke or a groin hematoma. ROC curves were constructed for the TEG parameters with statistical significance. Bivariate analyses were repeated using dichotomized TEG results. Results Patients who experienced a symptomatic ischemic stroke had a history of stroke (p value = 0.007), larger aneurysm neck width (p value = 0.017), and a higher alpha angle (p value = 0.013). Cut off point for ischemic complication is 63° on ROC curve with a sensitivity of 100% and specificity of 65%. Patients who experienced a groin hematoma were no different from their healthy peers but had a lower alpha angle (p value = 0.033). Cut off point for hemorrhagic complication is 53.3° with a sensitivity of 82% and specificity of 67%. Conclusion The Alpha Angle parameter of TEG-PM has a sizeable predictive ability for both ischemic complications of the central nervous system and hemorrhagic complications of the access site after elective flow diversion.

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Outcomes following aneurysmal coil embolization with intentionally shortened low-profile visible intraluminal support stent deployment

The Neuroradiology Journal ◽

10.1177/19714009211026925 ◽

2021 ◽

pp. 197140092110269

Author(s):

Kenji Yatomi ◽

Yumiko Mitome-Mishima ◽

Takashi Fujii ◽

Kohsuke Teranishi ◽

Hidenori Oishi ◽

...

Keyword(s):

Fluid Dynamics ◽

Computational Fluid Dynamics ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Perioperative Complications ◽

Flow Diversion ◽

Stent Deployment ◽

Coverage Ratio ◽

Low Profile ◽

Unruptured Intracranial Aneurysms

Purpose Among all stents available for neuroendovascular therapy, the low-profile visible intraluminal support stent bears the highest metal coverage ratio. We deployed a low-profile visible intraluminal support stent with a delivery wire or/and microcatheter system push action to shorten the low-profile visible intraluminal support stent and thus achieve a flow diversion effect. We report our single-institution experience with the use of low-profile visible intraluminal support stents for intentionally shortened deployment (shortening group) and non-shortened deployment (non-shortening group) for unruptured intracranial aneurysms. Methods We retrospectively reviewed the medical records of 130 patients with 131 intracranial aneurysms who were treated with low-profile visible intraluminal support stent-assisted coil embolization from February 2016–January 2019. All perioperative complications were noted. Every 6 months, we re-examined the patients with cerebral angiography or magnetic resonance angiography. The outcomes of aneurysm occlusion were evaluated by the modified Raymond–Roy occlusion classification. We used the finite element method and computational fluid dynamics to investigate the hemodynamics after shortened low-profile visible intraluminal support stent deployment. Results Immediately after treatment, the modified Raymond-Roy occlusion classification was significantly better in the shortening group than in the non-shortening group ( p<0.05). The latest angiographic outcomes showed the same tendency. Hemodynamic analysis by computational fluid dynamics suggested an adequate flow diversion effect with the use of our intentional shortening method. Conclusions Stent-assisted coil embolization using this technique showed good results of a high complete occlusion rate and low complication rate. These findings suggest that shortened low-profile visible intraluminal support stent deployment yields a flow diversion effect and may lead to early intra-aneurysmal thrombus formation.

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Optical coherence tomography for elucidation of flow-diversion phenomena: The concept of endothelized mural thrombus behind reversible in-stent stenosis in flow-diverters

Interventional Neuroradiology ◽

10.1177/15910199211003432 ◽

2021 ◽

pp. 159101992110034

Author(s):

Andre Monteiro ◽

Demetrius K Lopes ◽

Amin Aghaebrahim ◽

Ricardo Hanel

Keyword(s):

Optical Coherence Tomography ◽

Intracranial Aneurysms ◽

Flow Diversion ◽

Optical Coherence ◽

Recurrence Rates ◽

Oct Imaging ◽

Intravascular Optical Coherence Tomography ◽

Stenotic Area ◽

Flow Diverters ◽

Stent Stenosis

Purpose Flow-diverters have revolutionized the endovascular treatment of intracranial aneurysms, offering a durable solution to aneurysms with high recurrence rates after conventional stent-assisted coiling. Events that occur after treatment with flow-diversion, such as in-stent stenosis (ISS) are not well understood and require further assessment. After assessing an animal model with Optical Coherence Tomography (OCT), we propose a concept that could explain the mechanism causing reversible ISS after treatment of intracranial aneurysms with flow-diverters. Methods Six Pipeline Flex embolization devices (PED-Flex), six PED with Shield technology (PED-Shield), and four Solitaire AB devices were implanted in the carotid arteries (two stents per vessel) of four pigs. Intravascular optical coherence tomography (OCT) and digital subtraction angiography (DSA) images obtained on day 21 were compared to histological specimens. Results A case of ISS in a PED-Flex device was assessed with OCT imaging. Neointima with asymmetrical topography completely covering the PED struts was observed. Histological preparations of the stenotic area demonstrated thrombus on the surface of device struts, covered by neointima. Conclusion This study provides a plausible concept for reversible ISS in flow-diverters. Based on an observation of a previous experiment, we propose that similar cases of ISS are related to thrombus presence underneath endothelization, but further experiments focused on this phenomenon are needed. Optical Coherence Tomography will be useful tool when available for clinical use.

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The Utility of Assessing Neck Acne

Journal of Cutaneous Medicine and Surgery ◽

10.1177/1203475416673051 ◽

2016 ◽

Vol 21 (1) ◽

pp. 82-83

Author(s):

Karishma Desai ◽

Marc Philip Frey ◽

Jerry Tan

Keyword(s):

Treatment Options ◽

The Body ◽

Essential Component ◽

Posterior Neck ◽

Grading Scale ◽

Lower Neck ◽

Grading Scales ◽

Facial Acne

Background: Acne grading is an essential component in establishing treatment options, but little is known on how neck acne should be incorporated into grading scales. Objective: Our objective was to explore the prevalence of neck acne and determine if its own severity category on an acne global grading scale was warranted. Methods: Acne severity was assessed in 6 categories: face, chest, back, anterior upper (AUN), anterior lower neck (ALN), and posterior neck (PN). Results: The overall prevalence of neck acne was 49%. Of these, 44% had AUN acne, 18.5% had ALN acne, and 19.8% had PN acne. AUN and facial acne had a significant correlation ( r = 0.37, P < .05). No correlation was seen amongst other areas. Males presented with a significantly higher severity of AUN (mean [SD], 1.37 [1.09]) than females (mean [SD], 0.52 [0.91]), on average. Conclusions: While neck acne has proven to be common amongst those with acne on other areas of the body, facial acne can be used as a proxy for classification, as neck severity is usually milder.

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125 Staged Endovascular Treatment of Ruptured Intracranial Aneurysms: Acute Coiling Followed By Delayed Flow Diversion

Neurosurgery ◽

10.1093/neuros/nyx417.125 ◽

2017 ◽

Vol 64 (CN_suppl_1) ◽

pp. 228-228

Author(s):

Erick Michael Westbroek ◽

Matthew Bender ◽

Narlin B Beaty ◽

Bowen Jiang ◽

Risheng Xu AB ◽

...

Keyword(s):

Endovascular Treatment ◽

Complication Rate ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Major Complication ◽

Flow Diversion ◽

Neurological Deficits ◽

Major Complication Rate ◽

Ruptured Intracranial Aneurysms

Abstract INTRODUCTION ISAT demonstrated that coiling is effective for aneurysm treatment in subarachnoid hemorrhage (SAH); however, complete occlusion of wide-necked aneurysms frequently requires adjuvants relatively contraindicated in SAH. As such, a limited “dome occlusive” strategy is often pursued in the setting of SAH. We report a single institution series of coiling of acutely ruptured aneurysms followed by delayed flow diversion for definitive, curative occlusion. METHODS A prospectively collected IRB-approved database was screened for patients with aneurysmal SAH who were initially treated by coil embolization followed by planned flow diversion at a single academic medical institution. Peri-procedural outcomes, complications, and angiographic follow-up were analyzed. RESULTS >50 patients underwent both acute coiling followed by delayed, planned flow diversion. Average aneurysm size on initial presentation was 9.5 mm. Common aneurysm locations included Pcomm (36%), Acomm (30%), MCA (10%), ACA (10%), and vertebral (5%). Dome occlusion was achieved in all cases following initial coiling. Second-stage implantation of a flow diverting stent was achieved in 49/50 cases (98%). Follow-up angiography was available for 33/50 patients (66%), with mean follow-up of 11 months. 27 patients (82%) had complete angiographic occlusion at last follow up. All patients with residual filling at follow-up still had dome occlusion. There were no mortalities (0%). Major complication rate for stage I coiling was 2% (1 patient with intra-procedural aneurysm re-rupture causing increase in a previous ICH). Major complication rate for stage 2 flow diversion was 2% (1 patient with ischemic stroke following noncompliance with dual antiplatelet regimen). Minor complications occurred in 2 additional patients (4%) with transient neurological deficits. CONCLUSION Staged endovascular treatment of ruptured intracranial aneurysms with acute dome-occlusive coil embolization followed by delayed flow diversion is a safe and effective treatment strategy.

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