Routine Cerebral Angiography after Surgery for Saccular Aneurysms: Is It Worth It?

Abstract OBJECTIVE: The objective of this study was to determine whether an angiographically proven rate of saccular intracranial aneurysm occlusion after surgical clipping suggests that postoperative angiography should continue to be used routinely or should be supplanted by intraoperative angiography. These data also should establish a basis for comparing surgery with new endovascular methods of treatment. METHODS: During a 3.5-year period, a consecutive series of 622 patients (955 aneurysms, 808 of which were surgically clipped) who underwent postoperative angiography were studied retrospectively. This series comprised 493 ruptured and 315 unruptured aneurysms. RESULTS: Complete aneurysm closure was achieved in 88% of aneurysms, a neck remnant was discovered in 9%, and a fundus remnant was revealed in 3%. Of 493 ruptured aneurysms, 86% were completely occluded. Of 315 unruptured aneurysms, 91% were completely occluded. The results for clipping of complex aneurysms, i.e., posterior circulation or large to giant aneurysms, were significantly inferior to those for small and anterior circulation aneurysms. In one-third of the large and giant aneurysms, a part of the base was left intentionally because of calcifications or strong wall or to prevent occlusion of any branches. In the series, a significant 5% complication rate of major vessel occlusion was detected. CONCLUSION: Our retrospective analysis revealed that ruptured, posterior circulation, and large/giant aneurysms are more prone to incomplete clipping. Therefore, these aneurysms require postoperative if not intraoperative evaluation with angiography. Many clippings of anterior circulation aneurysms experience unexpected failures, which suggests that intraoperative angiography could be beneficial. This series, which has no selection bias, can be used as a basis to compare the results of other series reporting surgical or endovascular treatment.

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Parent vessel occlusion after Pipeline embolization of cerebral aneurysms of the anterior circulation

Journal of Neurosurgery ◽

10.3171/2016.9.jns152638 ◽

2017 ◽

Vol 127 (6) ◽

pp. 1333-1341 ◽

Cited By ~ 4

Author(s):

Matthew B. Potts ◽

Maksim Shapiro ◽

Daniel W. Zumofen ◽

Eytan Raz ◽

Erez Nossek ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Parent Artery ◽

Parent Vessel ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Complex Aneurysms ◽

Aneurysm Size ◽

Parent Vessel Occlusion ◽

Anterior Circulation Aneurysms

OBJECTIVEThe Pipeline Embolization Device (PED) is now a well-established option for the treatment of giant or complex aneurysms, especially those arising from the anterior circulation. Considering the purpose of such treatment is to maintain patency of the parent vessel, postembolization occlusion of the parent artery can be regarded as an untoward outcome. Antiplatelet therapy in the posttreatment period is therefore required to minimize such events. Here, the authors present a series of patients with anterior circulation aneurysms treated with the PED who subsequently experienced parent vessel occlusion (PVO).METHODSThe authors performed a retrospective review of all anterior circulation aneurysms consecutively treated at a single institution with the PED through 2014, identifying those with PVO on follow-up imaging. Aneurysm size and location, number of PEDs used, and follow-up digital subtraction angiography results were recorded. When available, pre- and postembolization platelet function testing results were also recorded.RESULTSAmong 256 patients with anterior circulation aneurysms treated with the PED, the authors identified 8 who developed PVO after embolization. The mean aneurysm size in this cohort was 22.3 mm, and the number of PEDs used per case ranged from 2 to 10. Six patients were found to have asymptomatic PVO discovered incidentally on routine follow-up imaging between 6 months and 3 years postembolization, 3 of whom had documented “delayed” PVO with prior postembolization angiograms confirming aneurysm occlusion and a patent parent vessel at an earlier time. Two additional patients experienced symptomatic PVO, one of which was associated with early discontinuation of antiplatelet therapy.CONCLUSIONSIn this large series of anterior circulation aneurysms, the authors report a low incidence of symptomatic PVO, complicating premature discontinuation of postembolization antiplatelet or anticoagulation therapy. Beyond the subacute period, asymptomatic PVO was more common, particularly among complex fusiform or very large–necked aneurysms, highlighting an important phenomenon with the use of PED for the treatment of anterior circulation aneurysms, and suggesting that extended periods of antiplatelet coverage may be required in select complex aneurysms.

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Characteristics and surgical treatment of dolichoectatic and fusiform aneurysms

Journal of Neurosurgery ◽

10.3171/jns.1996.84.2.0185 ◽

1996 ◽

Vol 84 (2) ◽

pp. 185-193 ◽

Cited By ~ 189

Author(s):

John A. Anson ◽

Michael T. Lawton ◽

Robert F. Spetzler

Keyword(s):

Cerebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Posterior Circulation ◽

Small Subset ◽

Consecutive Series ◽

Anterior Circulation ◽

Initial Development ◽

Posterior Circulation Aneurysms ◽

Surgical Treatments ◽

Anterior Circulation Aneurysms

✓ Dolichoectatic and fusiform aneurysms represent a small subset of cerebral aneurysms and are often among the most difficult to treat. A consecutive series of 40 patients with 41 of these two types of aneurysms is presented, including their clinical characteristics and surgical treatments. Common to all aneurysms was the pathological involvement of a length of blood vessel with separate inflow and outflow sites (nonsaccular). However, dolichoectatic aneurysms have markedly different symptoms and surgical treatments depending on their location in either the anterior or posterior circulation. Anterior circulation aneurysms involved the petrous internal carotid artery (ICA) in one, the supraclinoid ICA in three, the middle cerebral artery in 13, and the anterior cerebral artery in four patients. Posterior circulation aneurysms involved the basilar artery in 13, the vertebral artery in six, and the posterior inferior cerebellar artery in one patient. Various surgical procedures were performed, including direct clipping, trapping with bypass, proximal occlusion, resection with reanastomosis, transposition, aneurysmorrhaphy with thrombectomy, and wrapping. There was no surgical mortality in the patient series, and treatment was effective in many patients. Overall, outcome at late follow up was good (Glasgow Outcome Scale scores 1–2) in 78% of patients. Patients with anterior circulation aneurysms had better outcomes than patients with posterior circulation aneurysms, with good outcomes in 90% and 65% of the cases, respectively. Dolichoectatic and giant serpentine aneurysms may develop from smaller fusiform aneurysms and represent a spectrum of the same pathological entity. Arterial dissection may also play a role in the initial development of these aneurysms.

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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 118: Diffusion Lesion Volume Reduction after Recanalization Therapy for Anterior Circulation Stroke with Major Vessel Occlusion: Analysis from the RESCUE-Japan Registry Study

Stroke ◽

10.1161/str.45.suppl_1.118 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Mikito Hayakawa ◽

Hiroshi Yamagami ◽

Kazunori Toyoda ◽

Yuji Matsumaru ◽

Yukiko Enomoto ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Volume Reduction ◽

Lesion Volume ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Nihss Score ◽

Median Baseline ◽

Point Reduction ◽

Major Vessel

Objective: Although Diffusion-weighted imaging (DWI) lesions are commonly irreversible, DWI lesion volume reduction (DVR) is occasionally observed. We investigated clinical significance and predictors of DVR in acute stroke patients with major vessel occlusion receiving recanalization therapy (RT). Methods: The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan registry prospectively registered 1,442 stroke patients with major vessel occlusion who were admitted to 84 Japanese stroke centers within 24 hours after onset from July 2010 to June 2011. We retrospectively analyzed all patients with the internal carotid artery or middle cerebral artery (M1 or M2 segments occlusions receiving RT and undergoing MRI both on admission and at 24 hours after onset from the registry. We defined DVR as a 1 or more-point reduction of the DWI-Alberta Stroke Program Early CT Score (ASPECTS), and CT-DWI mismatch (CTDM) as a 2 or more-point lower DWI-ASPECTS than CT-ASPECTS on admission. Reperfusion was defined as TICI grade 2b-3 on catheter angiography or modified Mori grade 3 on MRA immediately after RT. Dramatic recovery (DR) was defined as a 10 or more-point reduction or a total NIHSS score of 0-1 at 24 hours, and favorable outcome (FO) defined as a mRS score 0-2 at 3 months. Results: A total of 390 patients (215 men, 72 years old,) was included. Median baseline NIHSS score was 16 (IQR 10-19) and median baseline DWI-ASPECTS was 8 (6-9). CTDM was seen in 92 patients (28%) on admission. Intravenous thrombolysis and endovascular therapy were performed in 246 patients (63%) and 223 patients (57%), respectively. Reperfusion was obtained in 170 patients (51%). DVR was seen in 51 patients (13%). Eighty-eight patients (23%) obtained DR and 158 patients (41%) achieved FO. On multivariate analyses, DVR was significantly related to DR (OR 3.8, 95%CI 1.5-10) and FO (4.6, 1.8-12). CTDM was an independent predictor of DVR (OR 2.5, 95% CI 1.1-5.8). Conclusions: DVR was significantly related to DR and FO. CTDM is a rough predictor of DVR of which area is considered as a “DWI-bright” ischemic penumbra, and might be a useful marker to identify the adequate candidates for RT in spite of relatively large DWI lesions.

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Embolization of Non-Ruptured Aneurysms

Interventional Neuroradiology ◽

10.1177/15910199990050s117 ◽

1999 ◽

Vol 5 (1_suppl) ◽

pp. 93-96 ◽

Cited By ~ 1

Author(s):

C.F. Dowd ◽

C.C. Phatouros ◽

A.M. Malek ◽

T.E. Lempert ◽

P.M. Meyers ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Three Dimensional ◽

Giant Aneurysm ◽

Epidemiological Data ◽

Anterior Circulation ◽

Unruptured Aneurysms ◽

Aneurysm Neck ◽

Technical Developments ◽

History Of ◽

Anterior Circulation Aneurysms

Options for treatment of intracranial aneurysms have expanded with the advent of the Guglielmi Detachable Cod (GDC) eight years ago. We have reviewed 435 cases of intracranial aneurysms treated at UCSF by endovascular means using the GDC system. Of these, 55% represent anterior circulation aneurysms, and 45% are located in the posterior circulation. Additionally, 55% of the aneurysms presented with subarachnoid hemorrhage (SAH) and 45% were unruptured. Factors which hindered optimal coiling include the following: wide aneurysm neck in relation to the overall aneurysm size, mural thrombus, giant aneurysm, arteries originating from the aneurysm sac, and middle cerebral location. After initial experience was gained, we tended to avoid these aneurysms especially in the non-ruptured group. This may be especially important in light of new epidemiological data suggesting that the natural history of unruptured aneurysms is significantly lower than previously thought. New technical developments which may reduce the risk of treating unruptured aneurysms include the two-dimensional coil, the three-dimensional coil, the balloon-assist technique for wide-necked aneurysms, and combined stent-coil procedures.

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Abstract TP72: Localization of Large Vessel Occlusion (LVO) Stroke in the Posterior Circulation Based on Perfusion Imaging

Stroke ◽

10.1161/str.51.suppl_1.tp72 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Carlo W Cereda ◽

Jeremy Heit ◽

Abid Qureshi ◽

Archana Hinduja ◽

Mikayel Grigoryan ◽

...

Keyword(s):

Perfusion Imaging ◽

Primary Outcome Measure ◽

Posterior Circulation ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Rater Agreement ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Intracranial Vessel ◽

Imaging Results

Introduction: The vascular territory of an occluded large intracranial vessel can be reliably identified by CT or MR perfusion imaging. Furthermore, prior studies have shown that perfusion imaging can reliably predict the specific vessel that is occluded in anterior circulation large vessel strokes. We evaluated whether perfusion imaging can predict the specific vessel occlusion (vertebral, basilar, or posterior cerebral) in posterior circulation strokes. Hypothesis: We hypothesized that the occluded vessel could be inferred from the perfusion imaging results in >80% of patients with an acute stroke due to large vessel occlusion in the posterior circulation using the simultaneous CTA or MRA as the gold standard. Furthermore, the inter-rater agreement between a vascular neurologist and a neuroradiologist would be > 90%. Agreement Coefficients (AC1) were determined. Methods: From a multicenter cohort of consecutive patients with posterior circulation stroke, we included patients with documented occlusion of the Basilar Artery (BA) posterior cerebral Artery (PCA) or vertebral artery (VA) who had perfusion imaging (MRI or CT) processed by RAPID software. Perfusion images were evaluated blinded to the angiography or any other brain imaging results. The primary outcome measure was agreement on LVO location based on the CTA/MRA results. Results: 74 patients were eligible: age 63±2, female 32%, median NIHSS 15 (IQR 5-24). The distribution of large vessel occlusions on CTA/MRA was BA (74%), PCA (14%) and VA (12%). Perfusion imaging was able to correctly predict the occluded vessel in 63 (85%), AC1 = 0.82 (95% CI 0.72-0.92), p<0.001. Interrater agreement (n=41) was high [AC1 = 0.94 (95% CI 0.87-1.0), p < 0.001]. Conclusion: Perfusion imaging can predict the site of vessel occlusion (vertebral, basilar, or posterior cerebral) in posterior circulation strokes with good accuracy and high inter-rater agreement.

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A human brain test bed for research in large vessel occlusion stroke

Journal of Neurosurgery ◽

10.3171/2020.7.jns202278 ◽

2021 ◽

pp. 1-9

Author(s):

Daniel Gebrezgiabhier ◽

Yang Liu ◽

Adithya S. Reddy ◽

Evan Davis ◽

Yihao Zheng ◽

...

Keyword(s):

Human Brain ◽

Mechanical Thrombectomy ◽

Posterior Circulation ◽

Large Vessel ◽

Suction Catheter ◽

Large Vessel Occlusion ◽

Test Bed ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Human Brains

OBJECTIVEEndovascular removal of emboli causing large vessel occlusion (LVO)–related stroke utilizing suction catheter and/or stent retriever technologies or thrombectomy is a new standard of care. Despite high recanalization rates, 40% of stroke patients still experience poor neurological outcomes as many cases cannot be fully reopened after the first attempt. The development of new endovascular technologies and techniques for mechanical thrombectomy requires more sophisticated testing platforms that overcome the limitations of phantom-based simulators. The authors investigated the use of a hybrid platform for LVO stroke constructed with cadaveric human brains.METHODSA test bed for embolic occlusion of cerebrovascular arteries and mechanical thrombectomy was developed with cadaveric human brains, a customized hydraulic system to generate physiological flow rate and pressure, and three types of embolus analogs (elastic, stiff, and fragment-prone) engineered to match mechanically and phenotypically the emboli causing LVO strokes. LVO cases were replicated in the anterior and posterior circulation, and thrombectomy was attempted using suction catheters and/or stent retrievers.RESULTSThe test bed allowed radiation-free visualization of thrombectomy for LVO stroke in real cerebrovascular anatomy and flow conditions by transmural visualization of the intraluminal elements and procedures. The authors were able to successfully replicate 105 LVO cases with 184 passes in 12 brains (51 LVO cases and 82 passes in the anterior circulation, and 54 LVO cases and 102 passes in the posterior circulation). Observed recanalization rates in this model were graded using a Recanalization in LVO (RELVO) scale analogous to other measures of recanalization outcomes in clinical use.CONCLUSIONSThe human brain platform introduced and validated here enables the analysis of artery-embolus-device interaction under physiological hemodynamic conditions within the unmodified complexity of the cerebral vasculature inside the human brain.

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Abstract TP24: Radiological and Symptomatic Hemorrhagic Transformation Post Endovascular Thrombectomy for Both Anterior and Posterior Large Vessel Occlusion Ischemic Stroke - Insights From STAR Collaboration

Stroke ◽

10.1161/str.51.suppl_1.tp24 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Vasu Saini ◽

Reda M Chalhoub ◽

David J McCarthy ◽

Ali M Alawieh ◽

Stephanie H Chen ◽

...

Keyword(s):

Regression Model ◽

Acute Stroke ◽

Intracranial Hemorrhage ◽

Functional Outcomes ◽

Hemorrhagic Transformation ◽

Posterior Circulation ◽

Clinical Severity ◽

Multivariable Logistic Regression Model ◽

Anterior Circulation ◽

Vessel Occlusion

Introduction: Radiological hemorrhagic transformation (rHT) and symptomatic intracranial hemorrhage (sICH) remain a major complication of mechanical thrombectomy (MT) in acute stroke. Our aim is to identify independent predictors of rHT and sICH. Methods: A retrospective multicenter international study across the US and Europe included 2499 patients, 18 years or older, who underwent EVT for acute stroke from 2015-2019. rHT is defined as any intracranial hemorrhage post MT and subgrouped per ECASS II as petechial (HI), parenchymal hematoma without (PH1) and with mass effect (PH2) and subarachnoid hemorrhage (SAH). sICH was defined as presence of PH2 or SAH. Functional outcomes were described using the 90-day modified Rankin score (mRS) as “good” 0-2 or “poor” 3-6. Multivariable logistic regression model was used to identify predictors of rHT and sICH. Results: 600 (24%) had rHT and 145 (5.8%) had sICH. On multivariable regression model, independent predictors for both rHT and sICH were higher admission NIHSS (OR 1.03, p<.001 vs. OR 1.04, p<.001), lower ASPECTS (OR .82, p<.001 vs. OR .83, p<.001) and higher number of thrombectomy attempts (OR 1.08, p.013 vs. OR 1.08, p .014). Patients with hyperlipidemia (OR .77, p .03 vs. OR .75, p.02) or posterior circulation strokes (OR .59, p .013 vs. OR .58, p .01) had significantly lower rates of rHT and sICH. Both rHT and sICH are independently associated with poor functional outcomes (OR .5, p<.001; OR .29, p .006). Conclusion: Compared to posterior circulation, anterior circulation strokes have higher rates of rHT and sICH. Baseline hyperlipidemia is protective for rHT or sICH post MT and this association needs further study. Clinical severity of stroke, poor ASPECTS on admission and higher thrombectomy attempts are associated with higher rates of rHT or sICH. Both rHT and sICH are independently associated with poor functional outcomes.

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Abstract TP42: Equivalent Favorable Outcomes Possible After Thrombectomy for Posterior Circulation Large Vessel Occlusion Compared to Anterior Circulation: The MUSC Experience

Stroke ◽

10.1161/str.49.suppl_1.tp42 ◽

2018 ◽

Vol 49 (Suppl_1) ◽

Author(s):

Ali M Alawieh ◽

Raymond D Turner ◽

Aquilla S Turk ◽

Mohammad I Chaudry ◽

Jonathan Lena ◽

...

Keyword(s):

Posterior Circulation ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion

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Clipping of very large or giant unruptured intracranial aneurysms in the anterior circulation: an outcome study

Journal of Neurosurgery ◽

10.3171/jns.2008.109.12.1012 ◽

2008 ◽

Vol 109 (6) ◽

pp. 1012-1018 ◽

Cited By ~ 42

Author(s):

Erik F. Hauck ◽

Bryan Wohlfeld ◽

Babu Guai Welch ◽

Jonathan A. White ◽

Duke Samson

Keyword(s):

Older Patients ◽

Intracranial Aneurysms ◽

Aneurysm Rupture ◽

Anterior Circulation ◽

Intraoperative Angiography ◽

Unruptured Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

Acceptable Risks ◽

Temporary Occlusion ◽

Aneurysm Occlusion

Object Patients with very large or giant unruptured intracranial aneurysms present with ischemic stroke and progressive disability. The aneurysm rupture risk in these patients is extreme—up to 50% in 5 years. In this study the authors investigated the outcome of surgical treatment for these very large aneurysms in the anterior circulation. Methods Clinical data on 62 patients who underwent surgery for unruptured aneurysms (20–60 mm) between 1998 and 2006 were reviewed. Results Complete aneurysm occlusion (100%) was achieved in 90% of cases, near complete occlusion (90–99%) in 5%. The surgical risk in patients younger than 50 years of age was 8% (Glasgow Outcome Scale score of 1 or 3 within 1 year after surgery). In older patients, the risk increased with advancing age. Conclusions The treatment of very large or giant unruptured intracranial aneurysms is hazardous and complex and thus best performed only at major cerebrovascular centers with an experienced team of neurosurgeons, interventional neuroradiologists, neurologists, and neuroanesthesiologists. Surgery, with acceptable risks and excellent occlusion rates, is typically the treatment of choice in patients younger than 50 years of age. In older patients, the benefits of endovascular treatment versus surgery versus no treatment must be carefully weighed individually. Minimizing temporary occlusion and the consequent use of intraoperative angiography may help reduce surgical complications.

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