Relationship between haemodynamic changes and outcomes of intracranial aneurysms after implantation of the pipeline embolisation device: a single centre study

Background Intracranial aneurysms are increasingly being treated by the placement of flow diverters; however, the factors affecting the outcome of aneurysms treated using flow diverters remain unclarified. Methods The present study investigated 94 aneurysms treated with pipeline embolisation device placement, and used a computational fluid dynamics method to explore the factors influencing the outcome of aneurysms. Results Seventy-six completely occluded aneurysms and 18 incompletely occluded aneurysms were analysed. Before treatment, inflow jets were found in 13 (72.2%) aneurysms in the incompletely occluded group and 34 (44.7%) in the completely occluded group ( P = 0.292). After deployment of the pipeline embolisation device, inflow jets remained in nine (50%) aneurysms in the incompletely occluded group and nine (11.8%) in the completely occluded group ( P = 0.001). In the incompletely occluded group, regions with inflow jets after treatment corresponded with the patent areas shown on follow-up digital subtraction angiography. The mean reduction ratios of velocity in the whole aneurysm and on the neck plane were lower in the incompletely occluded than in the completely occluded group ( P = 0.003; P = 0.017). Multivariate analysis revealed that the only independent risk factors for incomplete aneurysm occlusion were the reduction ratios of velocity (in the whole aneurysm, threshold 0.362, P = 0.005; on the neck plane, threshold 0.273, P = 0.015). Conclusions After pipeline embolisation device placement, reduction ratios of velocity in the whole aneurysm of less than 0.362 and on the neck plane of less than 0.273 are significantly associated with a greater risk of aneurysm incomplete occlusion. In addition, the persistence of inflow jets in aneurysms is associated with incomplete occlusion in the inflow jet area.

Download Full-text

Predictors of incomplete aneurysm occlusion after treatment with the Pipeline Embolization Device: PREMIER trial 1 year analysis

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-018054 ◽

2021 ◽

pp. neurintsurg-2021-018054

Author(s):

Ricardo A Hanel ◽

Andre Monteiro ◽

Peter K Nelson ◽

Demetrius K Lopes ◽

David F Kallmes

Keyword(s):

Treatment Failure ◽

Intracranial Aneurysms ◽

Side Branch ◽

Maximum Diameter ◽

Complete Occlusion ◽

Unruptured Aneurysms ◽

Aneurysm Occlusion ◽

Incomplete Occlusion ◽

Flow Diverters

BackgroundFlow diverters have revolutionized the treatment of intracranial aneurysms. Nevertheless, some aneurysms fail to occlude with flow diversion. The Prospective Study on Embolization of Intracranial Aneurysms with the Pipeline Device (PREMIER) was a prospective, multicenter and single-arm trial of small and medium wide-necked unruptured aneurysms. In the current study, we evaluate the predictors of treatment failure in the PREMIER cohort.MethodsWe analyzed PREMIER patients who had incomplete occlusion (Raymond-Roy >1) at 1 year angiographic follow-up and compared them with those who achieved Raymond-Roy 1, aiming to identify predictors of treatment failure.Results25 aneurysms demonstrated incomplete occlusion at 1 year. There was a median reduction of 0.9 mm (IQR 0.41–2.43) in maximum diameter between pre-procedure and 1 year measurements, with no aneurysmal hemorrhage. Patients with incomplete occlusion were significantly older than those with complete occlusion (p=0.011). Smoking (p=0.045) and C6 segment location (p=0.005) were significantly associated with complete occlusion, while location at V4 (p=0.01) and C7 (p=0.007) and involvement of a side branch (p<0.001) were significantly associated with incomplete occlusion. In multivariable logistic regression, significant predictors of incomplete occlusion were non-smoker status (adjusted OR 4.49, 95% CI 1.11 to 18.09; p=0.03) and side branch involvement (adjusted OR 11.68, 95% CI 3.84 to 35.50; p<0.0001), while C6 location had reduced odds of incomplete occlusion (adjusted OR 0.29, 95% CI 0.10 to 0.84; p=0.02).ConclusionsThe results of our study are consistent with previous retrospective series and warrant consideration for technique adaptations to achieve higher occlusion rates. Further follow-up is needed to assess progression of aneurysm occlusion and clinical behavior in these cases.

Download Full-text

Flow Diversion for Treatment of Intracranial Aneurysms in Pediatric Patients: Multicenter Case Series

Neurosurgery ◽

10.1093/neuros/nyz380 ◽

2019 ◽

Vol 87 (1) ◽

pp. 53-62

Author(s):

Jacob Cherian ◽

Visish Srinivasan ◽

Michael T Froehler ◽

Jonathan A Grossberg ◽

C Michael Cawley ◽

...

Keyword(s):

Clinical Outcomes ◽

Intracranial Aneurysms ◽

Case Series ◽

Flow Diversion ◽

Pipeline Embolization Device ◽

Patient Demographics ◽

Scale Scores ◽

Treatment Considerations ◽

Device Placement ◽

Aneurysm Occlusion

Abstract BACKGROUND Though the Pipeline Embolization Device (Medtronic) is approved for use in adults 22 yr and older, the high efficacy and long-term durability of the device is attractive for treatment of intracranial aneurysms in younger patients who often have aneurysms less amenable to traditional endovascular treatments. OBJECTIVE To report technical, angiographic, and clinical outcomes in patients aged 21 or below undergoing flow-diversion treatment for intracranial aneurysms. METHODS Retrospective review across 16 institutions identified 39 patients aged 21 or below undergoing 46 treatment sessions with Pipeline Embolization Device placement between 2012 and 2018. A total of 50 intracranial aneurysms were treated. Details regarding patient demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed in a multicenter database. RESULTS A total of 70% of patients were male. Nonsaccular morphology was seen in half of identified aneurysms. Six aneurysms were giant, and five patients were treated acutely after ruptured presentation. Eight patients were younger than 10 yr of age. Complete aneurysm occlusion was seen in 74% of treated aneurysms. Three aneurysms (6%) were retreated. A total of 83% of patients had a modified Rankin Scale scores of ≤2 at last clinical follow-up. There were 2 early mortalities (4.3%) in the immediate postprocedure period because of rerupture of a treated ruptured aneurysm. No recanalization of a previously occluded aneurysm was observed. CONCLUSION Flow-diversion treatment is a safe and effective treatment for intracranial aneurysms in patients younger than 22 yr. Rates of complete aneurysm occlusion and adverse events are comparable for rates seen in older patients.

Download Full-text

EVALUATION OF ONYX HD-500 EMBOLIC SYSTEM IN THE TREATMENT OF 84 WIDE-NECK INTRACRANIAL ANEURYSMS

Neurosurgery ◽

10.1227/01.neu.0000340977.68347.51 ◽

2009 ◽

Vol 64 (5) ◽

pp. E865-E875 ◽

Cited By ~ 45

Author(s):

Ronie L. Piske ◽

Luis H. Kanashiro ◽

Eric Paschoal ◽

Celso Agner ◽

Sergio S. Lima ◽

...

Keyword(s):

Intracranial Aneurysms ◽

High Rate ◽

Anterior Circulation ◽

Complete Occlusion ◽

Aneurysm Occlusion ◽

Incomplete Occlusion ◽

Wide Neck ◽

Small Aneurysms ◽

Platinum Coils

Abstract OBJECTIVE We report our results using Onyx HD-500 (Micro Therapeutics, Inc., Irvine, CA) in the endovascular treatment of wide-neck intracranial aneurysms, which have a high rate of incomplete occlusion and recanalization with platinum coils. METHODS Sixty-nine patients with 84 aneurysms were treated. Most of the aneurysms were located in the anterior circulation (80 of 84 aneurysms), were unruptured (74 of 84 aneurysms), and were incidental. Ten presented with subarachnoid hemorrhage, and 15 were symptomatic. All aneurysms had wide necks (neck >4 mm and/or dome-to-neck ratio <1.5). Fifty aneurysms were small (<12 mm), 30 were large (12 to <25 mm) and 4 were giant. Angiographic follow-up was available for 65 of the 84 aneurysms at 6 months, for 31 of the 84 aneurysms at 18 months, and for 5 of the 84 aneurysms at 36 months. RESULTS Complete aneurysm occlusion was seen in 65.5% of aneurysms on immediate control, in 84.6% at 6 months, and in 90.3% at 18 months. The rates of complete occlusion were 74%, 95.1%, and 95.2% for small aneurysms and 53.3%, 70%, and 80% for large aneurysms at the same follow-up periods. Progression from incomplete to complete occlusion was seen in 68.2% of all aneurysms, with a higher percentage in small aneurysms (90.9%). Aneurysm recanalization was observed in 3 patients (4.6%), with retreatment in 2 patients (3.3%). Procedural mortality was 2.9%. Overall morbidity was 7.2%. CONCLUSION Onyx embolization of intracranial wide-neck aneurysms is safe and effective. Morbidity and mortality rates are similar to those of other current endovascular techniques. Larger samples and longer follow-up periods are necessary.

Download Full-text

Stenting as Monotherapy for Uncoilable Intracranial Aneurysms

Operative Neurosurgery ◽

10.1227/neu.0b013e31827fcaba ◽

2012 ◽

Vol 73 (suppl_1) ◽

pp. ons80-ons85 ◽

Cited By ~ 2

Author(s):

Ketan R. Bulsara ◽

Gregory A. Kuzmik ◽

Ryan Hebert ◽

Vincent Cheung ◽

Charles C. Matouk ◽

...

Keyword(s):

Clinical Condition ◽

Intracranial Aneurysms ◽

Senior Author ◽

Radiographic Outcomes ◽

Effective Option ◽

Good Clinical Condition ◽

Aneurysm Occlusion ◽

Flow Diverters

Abstract BACKGROUND: Small, blister-like aneurysms (BLAs), by virtue of their unique morphology, are difficult to treat with conventional modalities. The use of oversized self-expanding stents as monotherapy for BLAs is a relatively new and promising concept that warrants further investigation. OBJECTIVE: To clarify the role of oversized self-expanding stents as monotherapy for BLAs. METHODS: Five consecutive patients were treated for BLAs with oversized self-expanding stents alone by the senior author (K.R.B.). We report on their clinical and radiographic outcomes. RESULTS: All 5 patients in our series were discharged in good clinical condition. Complete aneurysm occlusion was observed in all patients at the time of most recent radiographic follow-up. Mean follow-up time was 13.6 months (range, 1 month to 4.5 years). CONCLUSION: The use of oversized self-expanding stents to redirect flow away from aneurysms is an effective option for patients with BLAs. This approach represents an alternative to the use of flow diverters.

Download Full-text

Factors affecting recurrence and management of recurrent cerebral aneurysms after initial coiling

Interventional Neuroradiology ◽

10.1177/1591019919901037 ◽

2020 ◽

Vol 26 (3) ◽

pp. 300-308

Author(s):

Yongfeng Han ◽

Jian Liu ◽

Zhongbin Tian ◽

Ming Lv ◽

Xinjian Yang ◽

...

Keyword(s):

Cerebral Aneurysms ◽

Clinical Results ◽

Factors Affecting ◽

Complete Occlusion ◽

Giant Aneurysms ◽

Procedural Complications ◽

Aneurysm Occlusion ◽

Large And Giant Aneurysms ◽

Incomplete Occlusion

Objective To investigate factors affecting recurrence and effects and safety of endovascular retreatment for aneurysms recurrent after embolization. Methods Among 815 aneurysms treated with embolization, recurrence was in 114 aneurysms (14.0%). Forty-three recurrent aneurysms were managed with re-embolization. Procedural complications, angiographic, and clinical results of retreatment were analyzed. Results Patients with recurrent aneurysms were significantly ( P < 0.01) younger than without recurrence (51.09 ± 10.46 vs. 53.88 ± 9.61 years). Recurrent aneurysms ( n = 114) were significantly ( P = 0.00) greater (11.12 ± 8.35 vs. 5.81 ± 3.44 mm) with a significantly ( P = 0.00) greater neck (4.34 ± 2.26 vs. 2.90 ± 1.44 mm) than without recurrence. The rupture status of aneurysms significantly ( P = 0.00) affected recurrence at follow-up. Significantly ( P = 0.00) more aneurysms without recurrence were treated with advanced embolization techniques (81.0% vs. 62.3%) and got complete occlusion at the first embolization than those with recurrence (93.7% vs. 36.8%). In treating 43 recurrent aneurysms, stent-assisted recoiling was used in 48.8% in the first retreatment and 50% in the second and third retreatment procedures. Angiographic follow-up in 38 (88.4%) cases showed complete or near complete occlusion in 30 aneurysms, with the rest eight aneurysms experiencing a second recurrence (21.1%). Of the eight aneurysms with the second recurrence, five underwent the second endovascular retreatment, with complete aneurysm occlusion achieved in three cases (60%), near-complete occlusion in one (20%), and incomplete occlusion in one case at immediate angiography and six-month follow-up. Procedure-related complications occurred in three patients. Conclusions Endovascular retreatment of recurrent previously coiled aneurysms is safe and effective even though advanced embolization techniques are frequently involved especially for large and giant aneurysms.

Download Full-text

Hemodynamic Environment and Occlusion Time of Tandem Intracranial Aneurysms Treated With Flow Diverters

ASME 2012 Summer Bioengineering Conference, Parts A and B ◽

10.1115/sbc2012-80172 ◽

2012 ◽

Author(s):

Fernando Mut ◽

Esteban Scrivano ◽

Pedro Lylyk ◽

Juan R. Cebral

Keyword(s):

Intracranial Aneurysms ◽

Occlusion Time ◽

Aneurysm Occlusion ◽

Flow Diverters ◽

Occlusion Period

The use of flow diverting devices to treat complex intracranial aneurysms difficult to treat with coils and clips has recently received substantial attention. Initial experiences with increasing numbers of patients have been carried out with promising results [1]. However, it is still difficult to predict the outcome and/or the aneurysm occlusion time after treatment with flow diverters. The purpose of this work was to relate the hemodynamic environment created immediately after treatment and the occlusion period of a pair of tandem aneurysms.

Download Full-text

Limitations of Flow Diverters in Posterior Communicating Artery Aneurysms

Brain Sciences ◽

10.3390/brainsci11030349 ◽

2021 ◽

Vol 11 (3) ◽

pp. 349

Author(s):

Michelle F. M. ten Brinck ◽

Luigi Rigante ◽

Viktoria E. Shimanskaya ◽

Ronald H. M. A. Bartels ◽

Frederick J. A. Meijer ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Flow Characteristics ◽

Posterior Communicating Artery ◽

Secondary Treatment ◽

First Line ◽

Aneurysm Occlusion ◽

Permanent Morbidity ◽

Treatment Safety ◽

Flow Diverters ◽

First Line Treatment

Background: Treatment of intracranial aneurysms with flow diverters (FDs) showed promising results. However, a subset of patients treated for posterior communicating artery (PComA) aneurysms has variable occlusion rates. Especially the fetal type-associated PComA aneurysms seemed to respond differently to treatment. We analyze our series of fetal type PComA aneurysms treated with a FD. The literature on this subject is reviewed. Methods: Data from patients treated with FD for all PComA aneurysms at the RadboudUMC Nijmegen were retrospectively analysed. Primary end-point was complete aneurysm occlusion at six months. Secondary end-points were clinical outcome, treatment safety, and results of secondary treatment after non-closure. The results for the fetal PComA aneurysms were compared to the literature. Results: Nineteen consecutive patients harboring 21 PComA aneurysms were treated. Three aneurysms had ipsilateral fetal type PCA (14.3%). Overall, none of the fetal type PcomA aneurysm showed complete occlusion versus 77.8% of the others (p = 0.03). Mortality and permanent morbidity rates were respectively 5.3% and 0%. Conclusions: FD treatment for PComA aneurysm with fetal type circulation seemed to be less effective compared to other types of PComA aneurysms. Flow characteristics at the PComA bifurcation are thought to be causative Alternative strategies should be considered as first line treatment.

Download Full-text

Postoperative occlusion degree after flow-diverter placement with adjunctive coiling: analysis of complications

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017445 ◽

2021 ◽

pp. neurintsurg-2021-017445

Author(s):

Huibin Kang ◽

Bin Luo ◽

Jianmin Liu ◽

Hongqi Zhang ◽

Tianxiao Li ◽

...

Keyword(s):

Ischemic Stroke ◽

Functional Outcomes ◽

Intracranial Aneurysms ◽

Independent Predictor ◽

Flow Diverter ◽

Complete Occlusion ◽

Post Market ◽

Aneurysm Occlusion ◽

Incomplete Occlusion

BackgroundAlthough coiling with a flow diverter may provide immediate dome protection, no studies have evaluated the effect on complications of postoperative occlusion degree immediately postoperatively. The purpose of this study was to determine whether postoperative occlusion degree immediately after flow-diverter placement with adjunctive coiling was associated with complications.MethodsAll patients’ data were collected from the post-market multi-center cohort study of embolization of intracranial aneurysms with a pipeline embolization device (PED) in China (PLUS) registry. We divided patients into those treated with a PED alone (PED-only (PO) group), those treated with a PED with coils and incomplete occlusion (PED + coils + incomplete occlusion (PCIO) group), and those treated with a PED with coils and complete occlusion (PED + coils + complete occlusion (PCCO) group).ResultsWe evaluated 1171 consecutive patients with 1322 aneurysms treated with a PED: 685 aneurysms were treated with PO, 444 with PCIO, and 193 with PCCO. The PCCO group had a higher rate of aneurysm occlusion at the last follow-up than the PCIO and PO groups (P<0.0001). Multivariate analysis of the predictors of ischemic stroke and modified Rankin Scale score (mRS) deterioration showed that PCCO was an independent predictor of ischemic stroke (HR, 2.03; 95% CI, 1.12 to 3.67; P=0.019) and mRS deterioration (HR, 2.59; 95% CI, 1.57 to 4.26; P<0.0001).ConclusionsAlthough postoperative complete occlusion with a PED and adjunctive coiling can increase the rate of aneurysm occlusion, this approach may also increase the risk of ischemic stroke and lead to poor postoperative functional outcomes.

Download Full-text