Endoluminal flow diverters in the treatment of sidewall and bifurcation aneurysm: A systematic review and meta-analysis of complications and angiographic outcomes

Background and aim The use of endoluminal flow diversion in bifurcation aneurysms has been questioned due to the potential for complications and lower occlusion rates. In this study we assessed outcomes of endovascular treatment of intracranial sidewall and bifurcation aneurysms with flow diverters Methods In July 2020, a literature search for all studies utilizing endoluminal flow diverter treatment for sidewall or bifurcation aneurysms was performed. Data were collected from studies that met our inclusion/exclusion criteria by two independent reviewers and confirmed by a third reviewer. Using random-effects meta-analysis the target outcomes including overall complications (hematoma, ischemic events, minor ischemic stroke, aneurysm rupture, side vessel occlusion, stenosis, thrombosis, transient ischemic stroke, and other complications), perioperative complications, and follow-up (long-term) aneurysm occlusion were intestigated. Results Overall, we included 35 studies with 1084 patients with 1208 aneurysms. Of these aneurysms, 654 (54.14%) and 554 (45.86%) were classified as sidewall and bifurcation aneurysm, respectively, based on aneurysm location. Sidewall aneurysms had a similar total complication rate (R) of 27.12% (95% CI, 16.56%–41.09%), compared with bifurcation aneurysms (R, 20.40%, 95% CI, 13.24%–30.08%) (p = 0.3527). Follow-up angiographic outcome showed comparable complete occlusion rates for sidewall aneurysms (R 69.49%; 95%CI, 62.41%–75.75%) and bifurcation aneurysms (R 73.99%; 95% CI, 65.05%–81.31%; p = 0.4328). Conclusions This meta-analysis of sidewall and bifurcation aneurysms treated with endoluminal flow diverters demonstrated no significant differences in complications or occlusion rates. These data provide new information that can be used as a benchmark for comparison with emerging devices for the treatment of bifurcation aneurysms.

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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

Interventional Neuroradiology ◽

10.15274/inr-2014-10047 ◽

2014 ◽

Vol 20 (4) ◽

pp. 428-435 ◽

Cited By ~ 7

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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Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.5.peds19126 ◽

2019 ◽

Vol 24 (5) ◽

pp. 558-571 ◽

Cited By ~ 3

Author(s):

Kartik Bhatia ◽

Hans Kortman ◽

Christopher Blair ◽

Geoffrey Parker ◽

David Brunacci ◽

...

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Case Reports ◽

Meta Analysis ◽

Case Series ◽

Neurological Outcomes

OBJECTIVEThe role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.METHODSUsing PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors’ centers was also included. The primary outcomes were the rate of good long-term (mRS score 0–2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0–1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).RESULTSThe authors’ review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0–2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.CONCLUSIONSMechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1–18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

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Normative distribution of posterior circulation tissue time-to-maximum: Effects of anatomic variation, tracer kinetics, and implications for patient selection in posterior circulation ischemic stroke

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x20982395 ◽

2021 ◽

pp. 0271678X2098239

Author(s):

Adam E Goldman-Yassen ◽

Matus Straka ◽

Michael Uhouse ◽

Seena Dehkharghani

Keyword(s):

Ischemic Stroke ◽

Selection Criteria ◽

Arterial Input Function ◽

Anatomic Variation ◽

Input Function ◽

Posterior Circulation ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Perfusion Time

The generalization of perfusion-based, anterior circulation large vessel occlusion selection criteria to posterior circulation stroke is not straightforward due to physiologic delay, which we posit produces physiologic prolongation of the posterior circulation perfusion time-to-maximum (Tmax). To assess normative Tmax distributions, patients undergoing CTA/CTP for suspected ischemic stroke between 1/2018-3/2019 were retrospectively identified. Subjects with any cerebrovascular stenoses, or with follow-up MRI or final clinical diagnosis of stroke were excluded. Posterior circulation anatomic variations were identified. CTP were processed in RAPID and segmented in a custom pipeline permitting manually-enforced arterial input function (AIF) and perfusion estimations constrained to pre-specified vascular territories. Seventy-one subjects (mean 64 ± 19 years) met inclusion. Median Tmax was significantly greater in the cerebellar hemispheres (right: 3.0 s, left: 2.9 s) and PCA territories (right: 2.9 s; left: 3.3 s) than in the anterior circulation (right: 2.4 s; left: 2.3 s, p < 0.001). Fetal PCA disposition eliminated ipsilateral PCA Tmax delays (p = 0.012). Median territorial Tmax was significantly lower with basilar versus any anterior circulation AIF for all vascular territories (p < 0.001). Significant baseline delays in posterior circulation Tmax are observed even without steno-occlusive disease and vary with anatomic variation and AIF selection. The potential for overestimation of at-risk volumes in the posterior circulation merits caution in future trials.

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Abstract P538: A Detailed Analysis of Intracranial Hemorrhage After Endovascular Treatment in Acute Ischemic Stroke Due to Large Vessel Occlusion in the Escape-NA1 Trial

Stroke ◽

10.1161/str.52.suppl_1.p538 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Johanna Ospel ◽

Michael D Hill ◽

Nima Kashani ◽

Arnuv Mayank ◽

Nishita Singh ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Intraventricular Hemorrhage ◽

Infarct Volume ◽

Prognostic Impact ◽

Vessel Occlusion ◽

Good Outcome

Purpose: We investigated the prevalence and prognostic impact on outcome of any intracranial hemorrhage, hemorrhage morphology, type and volume in acute ischemic stroke patients undergoing mechanical thrombectomy. Methods: Prevalence of intracranial hemorrhage, hemorrhage type, morphology and volume was determined on 24h follow-up imaging (non contrast head CT or gradient-echo/susceptibility-weighted MRI). Proportions of good outcome (mRS 0-2 at 90 days) were reported for patients with vs. without any intracranial hemorrhage. Multivariable logistic regression with adjustment for key minimization variables and total infarct volume was performed to obtain adjusted effect size estimates for hemorrhage type and volume on good outcome. Results: Hemorrhage on follow up-imaging was seen in 372/1097 (33.9%) patients, among them 126 (33.9%) with hemorrhagic infarction (HI) type 1, 108 (29.0%) with HI-2, 72 /19.4%) with parenchymal hematoma (PH) type 1, 37 (10.0) with PH2, 8 (2.2%) with remote PH and 21 (5.7%) with extra-parenchymal/intraventricular hemorrhage. Good outcomes were less often achieved by patients with hemorrhage on follow-up imaging (164/369 [44.4%] vs. 500/720 [69.4%]). Any type of intracranial hemorrhage was strongly associated with decreased chances of good outcome ( adj OR 0.62 [CI 95 0.44 - 0.87]). The effect of hemorrhage was driven by both PH hemorrhage sub-type [PH-1 ( adj OR 0.39 [CI 95 0.21 - 0.72]), PH-2 ( adj OR 0.15 [CI 95 0.05 - 0.50])] and extra-parenchymal/intraventricular hemorrhage ( adj OR 0.60 (0.20-1.78) Petechial hemorrhages (HI-1 and HI-2) were not associated with poorer outcomes. Hemorrhage volume ( adj OR 0.97 [CI 95 0.05 - 0.99] per ml increase) was significantly associated with decreased chances of good outcome. Conclusion: Presence of any hemorrhage on follow-up imaging was seen in one third of patients and strongly associated with decreased chances of good outcome.

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Clinical Effects of Dual Antiplatelet Therapy or Aspirin Monotherapy after Acute Minor Ischemic Stroke or Transient Ischemic Attack, a Meta-Analysis

Current Pharmaceutical Design ◽

10.2174/1381612827666210728102459 ◽

2021 ◽

Vol 27 ◽

Author(s):

Francesco Condello ◽

Gaetano Liccardo ◽

Giuseppe Ferrante

Keyword(s):

Ischemic Stroke ◽

Major Bleeding ◽

Transient Ischemic Attack ◽

Hemorrhagic Stroke ◽

Dual Antiplatelet Therapy ◽

Meta Analysis ◽

Stroke Recurrence ◽

Controlled Trials ◽

Minor Ischemic Stroke ◽

Ischemic Attack

Background: Evidence about the use of dual antiplatelet therapy (DAPT) with aspirin and P2Y12 inhibitors in patients with acute minor ischemic stroke or transient ischemic attack (TIA) is emerging. The aim of our study was to provide an updated and comprehensive analysis about the risks and benefits of DAPT versus aspirin monotherapy in this setting. Methods: The PubMed, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov databases, main international conference proceedings were searched for randomized controlled trials comparing DAPT versus aspirin monotherapy in patients with acute ischemic stroke or TIA not eligible for thrombolysis or thrombectomy presenting in the first 24 hours after the acute event. Data were pooled by meta-analysis using a random-effects model. The primary efficacy endpoint was ischemic stroke recurrence, and the primary safety outcome was major bleeding. Secondary endpoints were intracranial hemorrhage, hemorrhagic stroke, and all-cause death. Results: A total of 4 studies enrolling 21,459 patients were included. DAPT with clopidogrel was used in 3 studies, DAPT with ticagrelor in one study. DAPT duration was 21 days in one study, 1 month in one study, and 3 months in the remaining studies. DAPT was associated with a significant reduction in the risk of ischemic stroke recurrence (relative risk [RR], 0.74; 95% confidence interval [CI], 0.67-0.82, P<0.001, number needed to treat 50 [95% CI 40-72], while it was associated with a significantly higher risk of major bleeding (RR, 2.59; 95% CI 1.49-4.53, P=0.001, number needed to harm 330 [95% CI 149-1111]), of intracranial hemorrhage (RR 3.06, 95% CI 1.41-6.66, P=0.005), with a trend towards higher risk of hemorrhagic stroke (RR 1.83, 95% CI 0.83-4.05, P=0.14), and a slight tendency towards higher risk of all-cause death (RR 1.30, 95% CI 0.89-1.89, P=0.16). Conclusions: Among patients with acute minor ischemic stroke or TIA, DAPT, as compared with aspirin monotherapy, might offer better effectiveness in terms of ischemic stroke recurrence at the expense of a higher risk of major bleeding. The trade-off between ischemic benefits and bleeding risks should be assessed in tailoring the therapeutic strategies.

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Abstract WP43: Diffusion and T2 Star Weighted MR Angiography Mismatch Predicts Ischemic Penumbra in the Acute Stage

Stroke ◽

10.1161/str.48.suppl_1.wp43 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Susumu Yamaguchi ◽

Nobutaka Horie ◽

Yohei Tateishi ◽

MInoru Morikawa ◽

Kazuhiko Suyama ◽

...

Keyword(s):

Ischemic Stroke ◽

Contrast Media ◽

Mr Angiography ◽

Acute Stage ◽

The Other ◽

Unknown Etiology ◽

Ischemic Penumbra ◽

Vessel Occlusion ◽

Major Vessel

Background and purpose: T2 star weighted MR angiography (SWAN) can detect hemodynamic insufficiency as hypointensity areas in the medullary or cortical veins. In this study, we investigate whether SWAN in 1.5T MRI can help to detect ischemic penumbra-like lesions in acute ischemic stroke (AIS) patients. Materials and methods: Patients showing acute major vessel occlusion (ICA and MCA) within 4.5 hours from onset were consecutively analyzed with MRI including SWAN, DWI, and MRA. To evaluate ischemic area in SWAN and DWI, modified ASPECT (mASPECTS) were used. SWAN- and DWI- based mASPECTS was calculated, and correlation between DWI-SWAN mismatch and final infarct lesion or outcome was evaluated. Results: Thirty-five patients were included in this study. Of the 35 patients (mean age: 73.5 ± 13.5 years), cardioembolic stroke was confirmed in 26 patients, atherothrombotic stroke was in 4 patients, and the others had unknown etiology. Overall, recanalization was achieved in 23 patients (65%), showing higher mASPECTS in follow up DWI and lower mRS at 90 days than patients with no recanalization ( P =0.037 and P <0.001). Initial SWAN-based mASPECTS and follow-up DWI-based mASPECTS were both significantly higher in atherothrombotic stroke than in cardiogenic stroke ( P =0.016 and P =0.042). Of 12 patients showing no recanalization, DWI-SWAN mismatch was significantly correlated with infarct growth (R 2 =0.6160, P =0.0025). On the other hand, there was no such correlation for patients showing recanalization. Interestingly, initial SWAN-based mASPECTS was significantly correlated with mRS at 90 days (R=-0.38, P =0.037) regardless of recanalization. Conclusions: DWI-SWAN mismatch in 1.5T MRI could show penumbra-like lesions in AIS patients with major vessel occlusion. Low mASPECTS in initial SWAN might predict unfavorable outcome. Assessment of ischemic penumbra from venous side using SWAN can visualize a lesion’s viable tissue and is quite useful without contrast media.

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

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000152 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Ossama Y Mansour ◽

Aser Goma

Keyword(s):

Subarachnoid Hemorrhage ◽

Clinical Outcome ◽

Flow Diverter ◽

Parent Artery ◽

Modified Rankin Scale ◽

Alternative Treatment Option ◽

Increased Risk ◽

Flow Diverters ◽

Dissecting Aneurysms

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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Abstract WP378: Insulin in the Management of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Stroke ◽

10.1161/str.51.suppl_1.wp378 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Christian D Cerecedo Lopez ◽

Alejandra Cantu Aldana ◽

Nirav J Patel ◽

Mohammad A Aziz-Sultan ◽

Kai U Frerichs ◽

...

Keyword(s):

Ischemic Stroke ◽

Glycemic Control ◽

Acute Ischemic Stroke ◽

Glucose Control ◽

Meta Analysis ◽

Severe Hypoglycemia ◽

Tight Glycemic Control ◽

Tight Glucose Control ◽

Random Effects Models

Background: The role of tight glycemic control in the management of acute ischemic stroke remains uncertain. Objective: Our goal is to evaluate the effects of tight glucose control with insulin therapy after acute ischemic stroke. Methods: We searched PubMed, CENTRAL, and EMBASE for randomized controlled trials (RCTs) that evaluated the effects of tight glycemic control (70 - 135 mg/dL) in acute ischemic stroke. Analysis was performed using fixed- and random-effects models. Outcomes were death, independence and modified Rankin Scale (mRS) score at ≥90 days follow-up, and symptomatic or severe hypoglycemia during treatment. Results: Twelve RCTs including 2,734 patients were included. When compared to conventional therapy or placebo, tight glycemic control was associated with similar rates of mortality at ≥90 days follow-up (pooled odds ratio [pOR], 0.99 [95% CI, 0.79 - 1.22], I 2 0%), independence at ≥90 days follow-up (pOR, 0.95 [0.79 - 1.14], I 2 0%) and mRS scores at ≥90 days follow-up (standardized mean difference, 0.014 [-0.15 - 0.17], I 2 0%). In contrast, tight glycemic control was associated with increased rates of symptomatic or severe hypoglycemia during treatment (pOR 5.2 [1.87 - 14.42], I 2 20%). Conclusion: Tight glucose control after acute ischemic stroke is not associated with improvements in mortality, independence or mRS score and leads to higher rates of symptomatic or severe hypoglycemia.

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Overview of Different Flow Diverters and Flow Dynamics

Neurosurgery ◽

10.1093/neuros/nyz323 ◽

2019 ◽

Vol 86 (Supplement_1) ◽

pp. S21-S34 ◽

Cited By ~ 4

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.

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