scholarly journals Angiographic assessment of the efficacy of flow diverter treatment for cerebral aneurysms

2019 ◽  
Vol 25 (6) ◽  
pp. 655-663 ◽  
Author(s):  
Chander Sadasivan ◽  
Ronak Dholakia ◽  
Lissa Peeling ◽  
Philipp Gölitz ◽  
Arnd Doerfler ◽  
...  
Keyword(s):  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Post Treatment ◽  
Flow Diversion ◽  
Data Set ◽  
Predictive Values ◽  
Density Curve ◽  
Aneurysm Occlusion ◽  
Time Density ◽  
Flow Diverters

Background The recent growth of neuro-endovascular treatment has rekindled interest in the use of angiographic techniques for flow assessment. Aneurysm treatment with flow diverters is particularly amenable to such analysis. We analyze contrast time–density curves — recorded within aneurysms before (pre) and immediately after (post) flow diverter implantation to estimate six-month treatment outcomes. Methods Fifty-six patients with 65 aneurysms were treated with flow diverters at two institutions. A region of interest was drawn around the aneurysm perimeter in image sequences taken both pre and post angiography, and the temporal variation in grayscale intensity within the aneurysm (time–density curve) was recorded. Eleven parameters were quantified from each time–density curve. Aneurysm occlusion status was recorded six months post treatment. The change in parameters from pre to post treatment was statistically evaluated between aneurysm occluded and non-occluded groups. Results Of the 11 parameters, eight were significantly different before and immediately after flow diversion. Considering the entire data set, none of the parameters was statistically different between the occluded and non-occluded groups. However, subgroup analyses showed that four variables were significantly different between the aneurysm occluded and non-occluded groups. The sensitivity of these variables to predict aneurysm occlusion at six months ranged from 60% to 89%, while the specificity ranged from 55% to 70%. Conclusions Device-induced intra-aneurysmal flow alterations quantified by simple aneurysmal time–density curves can potentially be used to predict long-term outcomes of flow diversion. Large multi-center studies will be required to confirm these findings. Patient-to-patient variability in coagulation may need to be incorporated for clinically relevant predictive values.

scholarly journals 2D parametric contrast time-density analysis for the prediction of complete aneurysm occlusion at six months’ post-flow diversion stent

2020 ◽  
Vol 26 (4) ◽  
pp. 468-475 ◽  
Author(s):  
Ahmed E Hussein ◽  
Meghana Shownkeen ◽  
Andre Thomas ◽  
Christopher Stapleton ◽  
Denise Brunozzi ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Density Ratio ◽  
Area Under The Curve ◽  
Cerebral Aneurysms ◽  
Flow Diversion ◽  
Aneurysm Occlusion ◽  
Occlusion Rate ◽  
Time Density

Objective Indications for the treatment of cerebral aneurysms with flow diversion stents are expanding. The current aneurysm occlusion rate at six months ranges between 60 and 80%. Predictability of complete vs. partial aneurysm occlusion is poorly defined. Here, we evaluate the angiographic contrast time-density as a predictor of aneurysm occlusion rate at six months’ post-flow diversion stents. Methods Patients with unruptured cerebral aneurysms proximal to the internal carotid artery terminus treated with single flow diversion stents were included. 2D parametric parenchymal blood flow software (Siemens-Healthineers, Forchheim, Germany) was used to calculate contrast time-density within the aneurysm and in the proximal adjacent internal carotid artery. The area under the curve ratio between the two regions of interests was assessed at baseline and after flow diversion stents deployment. The area under the curve ratio between completely vs. partially occluded aneurysms at six months’ follow-up was compared. Results Thirty patients with 31 aneurysms were included. Mean aneurysm diameter was 8 mm (range 2–28 mm). Complete occlusion was obtained in 19 aneurysms. Younger patients ( P = 0.006) and smaller aneurysms ( P = 0.046) presented higher chance of complete obliteration. Incomplete occlusion of the aneurysm was more likely if the area under the curve contrast time-density ratio showed absolute ( P = 0.001) and relative percentage ( P = 0.001) decrease after flow diversion stents deployment. Area under ROC curve was 0.85. Conclusion Negative change in the area under the curve ratio indicates less contrast stagnation in the aneurysm and lower chance of occlusion. These data provide a real-time analysis after aneurysm treatment. If validated in larger datasets, this can prompt input to the surgeon to place a second flow diversion stents.

Abstract 1122‐000103: FlowDiverter:A Study Safety and Efficacy in a Consecutive Group of 53 Patient and 60 Aneurysm

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Marcelo Bolcato ◽  
ana Carolina Dalmonico ◽  
Leo Ditzel ◽  
Savio Machareti ◽  
Thiago Yoshida ◽  
...  
Keyword(s):  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Consecutive Series ◽  
Safety And Efficacy ◽  
Grading Scale ◽  
Aneurysm Occlusion ◽  
Occlusion Rate ◽  
Flow Diverters

Introduction : Endovascular flow diverters are increasingly used for the treatment of cerebral aneurysms. We assessed the safety and efficacy of the Flow Diverters in a consecutive series of 53 patients and 60 aneurysms. Methods : Inclusion criteria were wide‐neck, blister‐like, or fusiform aneurysms independent of size, treated with the FRED, PIPELINE and SILK between December 2014 and Junho 2021. Assessment criteria were aneurysm occlusion, manifest ischemic stroke, bleeding, or death. The occlusion rate was assessed at 6 months and 1 year with DSA by using the Raymond classification and the O'Kelly‐Marotta grading scale. Results : Fifty three patients (mean age 54.3 years;81.1% female) with 60 aneurysms were treated with 9 Silk, 38 FREDs and 13 Pipeline. Aneurysm size ranged from 2.5 to 30 mm. Deployment of the Flow diverters was successful in 52 aneurysms. Three patient developed mild stroke symptoms that fully receded within days, 4 patients occlusion total carotid because resistant antiagregation and another patient’s development Swelling syndrome. There has been one death. Initial follow‐up at 6 months showed complete occlusion in 90% of the overall study group and 93,33% at 1 year. Conclusions : The flow diverter is a safe device for the treatment of cerebral aneurysms of various types. Our data reveal high occlusion rates at 6 months and 1 year. Long‐term occlusion rates are expected.

scholarly journals Vertebral artery aneurysms and the risk of cord infarction following spinal artery coverage during flow diversion

2020 ◽  
pp. 1-10
Author(s):  
Adam A. Dmytriw ◽  
Anish Kapadia ◽  
Alejandro Enriquez-Marulanda ◽  
Carmen Parra-Fariñas ◽  
Anna Luisa Kühn ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Flow Diverter ◽  
Thromboembolic Complication ◽  
Flow Diversion ◽  
Cerebellar Artery ◽  
Aneurysm Occlusion ◽  
Aneurysm Diameter ◽  
Flow Diverters

OBJECTIVECoverage of the anterior spinal artery (ASA) ostia is a source of considerable consternation regarding flow diversion (FD) in vertebral artery (VA) aneurysms due to cord supply. The authors sought to assess the association between coverage of the ASA, posterior spinal artery (PSA), or lateral spinal artery (LSA) ostia when placing flow diverters in distal VAs and clinical outcomes, with emphasis on cord infarction.METHODSA multicenter retrospective study of 7 institutions in which VA aneurysms were treated with FD between 2011 and 2019 was performed. The authors evaluated the risk of ASA and PSA/LSA occlusion, associated thromboembolic complication, complications overall, aneurysm occlusion status, and functional outcome.RESULTSSixty patients with 63 VA and posterior inferior cerebellar artery aneurysms treated with FD were identified. The median aneurysm diameter was 7 mm and fusiform type was the commonest morphology (42.9%). During a procedure, 1 (61.7%) or 2 (33.3%) flow diverters were placed. Complete occlusion was achieved in 71.9%. Symptomatic thromboembolic complications occurred in 7.4% of cases and intracranial hemorrhage in 10.0% of cases. The ASA and PSA/LSA were identified in 51 (80.9%) and 35 (55.6%) complications and covered by the flow diverter in 29 (56.9%) and 13 (37.1%) of the procedures, respectively. Patency after flow diverter coverage on last follow-up was 89.2% for ASA and 100% for PSA/LSA, not significantly different between covered and noncovered groups (p = 0.5 and p > 0.99, respectively). No complications arose from coverage.CONCLUSIONSFD aneurysm treatment in the posterior circulation with coverage of ASA or PSA/LSA was not associated with higher rates of occlusion of these branches or any instances of cord infarction.

Flow Diversion in Rabbit Aneurysm Models

2013 ◽  
Author(s):  
Juan R. Cebral ◽  
Fernando Mut ◽  
Marcelo Raschi ◽  
Ramanathan Kadirvel ◽  
David Kallmes
Keyword(s):  
Cerebral Aneurysms ◽  
Flow Diversion ◽  
Complex Aneurysms ◽  
Large Complex ◽  
Aneurysm Occlusion ◽  
The Relationship ◽  
Flow Diverters

Flow diversion treatment of cerebral aneurysms has increasingly been considered, especially for large complex aneurysms with wide necks that are difficult to treat with coils of by clipping. However, the relationship between the hemodynamic environment created immediately after implantation of flow diverters (FD) and the subsequent aneurysm occlusion is poorly understood [1].

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

2018 ◽  
Vol 31 (3) ◽  
pp. 270-279 ◽  
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.

Flow Diversion for Intracranial Aneurysm Treatment: Trials Involving Flow Diverters and Long-Term Outcomes

Neurosurgery ◽  
2019 ◽  
Vol 86 (Supplement_1) ◽  
pp. S36-S45 ◽  
Author(s):  
Bree Chancellor ◽  
Eytan Raz ◽  
Maksim Shapiro ◽  
Omar Tanweer ◽  
Erez Nossek ◽  
...  
Keyword(s):  
Cerebral Aneurysms ◽  
Flow Diversion ◽  
Long Term Outcomes ◽  
Complex Aneurysms ◽  
Aneurysm Treatment ◽  
Endovascular Methods ◽  
Cure Rates ◽  
Flow Diverters

Abstract Flow diverters (FDs) have changed the management of brain aneurysms; not only for complex aneurysms (giant, fusiform and blister) refractory to conventional therapies, but also for unruptured lesions previously managed by traditional surgical or coil-based endovascular methods. Since 2011 when the PipelineTM Embolization Device (Medtronic) was cleared by the Food and Drug Administration for adults with large or giant wide-neck intracranial aneurysms of the internal carotid artery proximal to the posterior communicating segment, the role of flow diversion for aneurysm treatment has expanded—supported by favorably low complication and high cure rates compared with alternative treatments. Here we review the key clinical trials and the long term outcomes that have demonstrated safety and efficacy of minimized porosity endoluminal devices in the treatment of cerebral aneurysms.

Overview of Different Flow Diverters and Flow Dynamics

Neurosurgery ◽  
2019 ◽  
Vol 86 (Supplement_1) ◽  
pp. S21-S34 ◽  
Author(s):  
Georgios A Maragkos ◽  
Adam A Dmytriw ◽  
Mohamed M Salem ◽  
Vincent M Tutino ◽  
Hui Meng ◽  
...  
Keyword(s):  
Rapid Evolution ◽  
Evidence Base ◽  
Flow Diverter ◽  
Outcome Data ◽  
Flow Diversion ◽  
Comprehensive Overview ◽  
Flow Diverter Devices ◽  
Technical Specifications ◽  
Flow Diverters

Abstract Over the past decade, flow diverter technology for endocranial aneurysms has seen rapid evolution, with the development of new devices quickly outpacing the clinical evidence base. However, flow diversion has not yet been directly compared to surgical aneurysm clipping or other endovascular procedures. The oldest and most well-studied device is the Pipeline Embolization Device (PED; Medtronic), recently transitioned to the Pipeline Flex (Medtronic), which still has sparse data regarding outcomes. To date, other flow diverting devices have not been shown to outperform the PED, although information comes primarily from retrospective studies with short follow-up, which are not always comparable. Because of this lack of high-quality outcome data, no reliable recommendations can be made for choosing among flow diversion devices yet. Moreover, the decision to proceed with flow diversion should be individualized to each patient. In this work, we wish to provide a comprehensive overview of the technical specifications of all flow diverter devices currently available, accompanied by a succinct description of the evidence base surrounding each device.

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

2018 ◽  
Vol 25 (1) ◽  
pp. 4-11 ◽  
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.

scholarly journals Endovascular Treatment of Intracranial Aneurysms in the Flow Diverter Era: Frequency of Use and Results in a Consecutive Series of 550 Treatments in a Single Centre

2014 ◽  
Vol 20 (4) ◽  
pp. 428-435 ◽  
Author(s):  
Willem Jan van Rooij ◽  
Ratna S Bechan ◽  
Jo P. Peluso ◽  
Menno Sluzewski
Keyword(s):  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Consecutive Series ◽  
Complication Rates ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Permanent Neurological Deficit ◽  
Flow Diverters

Flow diverter devices became available in our department in 2009. We considered treatment with flow diverters only in patients with aneurysms not suitable for surgery or conventional endovascular techniques. This paper presents our preliminary experience with flow diverters in a consecutive series of 550 endovascular aneurysm treatments. Between January 2009 and July 2013, 550 endovascular treatments for intracranial aneurysms were performed. Of these, 490 were first-time aneurysm treatments in 464 patients and 61 were additional treatments of previously coiled aneurysms in 51 patients. Endovascular treatments consisted of selective coiling in 445 (80.8%), stent-assisted coiling in 68 (12.4%), balloon-assisted coiling in 13 (2.4%), parent vessel occlusion in 12 (2.2%) and flow diverter treatment in 12 (2.2%). Eleven patients with 12 aneurysms were treated with flow diverters. Two patients had ruptured dissecting aneurysms. One patient with a basilar trunk aneurysm died of acute in stent thrombosis and another patient died of brain stem ischaemia at 32 months follow-up. One patient had ischaemia with permanent neurological deficit. Two aneurysms are still open at up to 30 months follow-up. Flow diversion was used in 2% of all endovascular treatments. Both our own poor results and the high complication rates reported in the literature have converted our initial enthusiasm to apprehension and hesitancy. The safety and efficacy profile of flow diversion should discourage the use of these devices in aneurysms that can be treated with other techniques.

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