Endovascular Reconstruction with the Neuroform Stent as Monotherapy for the Treatment of Uncoilable Intradural Pseudoaneurysms

Neurosurgery ◽  
2006 ◽  
Vol 59 (2) ◽  
pp. 291-300 ◽  
Author(s):  
David Fiorella ◽  
Felipe C. Albuquerque ◽  
Vivek R. Deshmukh ◽  
Henry H. Woo ◽  
Peter A. Rasmussen ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Platelet Inhibition ◽  
Parent Vessel ◽  
Current Series ◽  
Vascular Segment ◽  
Initial Procedure ◽  
Acute Subarachnoid Hemorrhage ◽  
History Of ◽  
Neuroform Stent

Abstract OBJECTIVE: Intradural pseudoaneurysms have a malignant natural history and can be difficult to treat if parent vessel deconstruction is not feasible. These lesions often involve a long arterial segment and lack a defined saccular component that would safely accommodate the introduction of embolization coils. The current report describes the successful endovascular treatment of these lesions using a strategy of Neuroform stent reconstruction. METHODS: A retrospective review of the prospectively maintained Neuroform databases from our two institutions identified all intracranial aneurysms treated with the Neuroform stent alone, without embolization coils. The clinical charts, procedural data, and angiographic results were reviewed. RESULTS: Over a 38-month study period (10/02–2/06), 266 aneurysms were treated with the Neuroform stent. Of these, 10 were small “uncoilable” intradural pseudoaneurysms associated with subarachnoid hemorrhage. These lesions were treated using a strategy of endovascular stent reconstruction of the diseased vascular segment with one or more Neuroform stents (without concomitant coil embolization). Seven pseudoaneurysms were treated in the context of acute or subacute subarachnoid hemorrhage, and three were associated with a remote history of subarachnoid hemorrhage. Periprocedural complications occurred in two patients (clinically silent, intraprocedural thromboembolic event successfully treated with intra-arterial abciximab, symptomatic postprocedural stent thrombosis with successful thrombolysis, and excellent neurological recovery). Both complications occurred in patients with ruptured aneurysms and could be attributed to inadequate platelet inhibition at the time of the initial procedure. Follow-up conventional angiographic examinations were available for all 10 patients with pseudoaneurysms (1–18.5 mo; average, 9.0 mo). In nine cases, the aneurysms improved at follow-up, with either complete (n = 5) or near complete (n = 4) resolution. In one case, short-term follow-up (1 mo) demonstrated no significant change. No patient has rehemorrhaged after treatment. CONCLUSION: Endovascular Neuroform stent reconstruction represents an optimal strategy for the management of intradural pseudoaneurysms that require a constructive treatment strategy and are too small to accommodate the introduction of embolization coils. Nine out of 10 patients in the current series treated with this strategy demonstrated some degree of endovascular remodeling with either complete (n = 5) or partial (n = 4) angiographic resolution at follow-up. No rehemorrhages were encountered. Adequate antiplatelet therapy, even in the setting of acute subarachnoid hemorrhage, is prerequisite for the avoidance of thromboembolic complications.

scholarly journals Intracranial Hemorrhage Secondary to a Delayed Cerebral Pseudoaneurysm Rupture 18 Years after Cranial Trauma

2019 ◽  
Vol 11 (3) ◽  
pp. 325-329
Author(s):  
Mikel Terceño ◽  
Sebastià Remollo ◽  
Yolanda Silva ◽  
Saima Bashir ◽  
Carlos Castaño ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Clinical Outcome ◽  
Previous History ◽  
Complete Recovery ◽  
Good Clinical Outcome ◽  
Intracranial Hematoma ◽  
Cranial Trauma ◽  
History Of ◽  
Etiological Study

We report the case of a 38-year-old male with a previous history of severe cranial trauma and subsequent large subdural and subarachnoid hemorrhage on whom an emergent hematoma evacuation was performed with a good outcome and follow-up. Despite a good clinical evolution, the patient experienced a further intracranial hematoma 18 years after the trauma, with severe aphasia and mild right hemiparesis. After complete etiological study, two cranial pseudoaneurysms were observed in the cerebral angiography. Endovascular treatment was successfully completed, achieving full embolization without complications. No rebleeding was detected during follow-up. The patient had a good clinical outcome at 3 months and achieved complete recovery. Cranial pseudoaneurysm rupture is a rare cause of intracerebral hemorrhage, especially if the trauma occurs years before the bleeding.

STENT REMODELING TECHNIQUE FOR COILING OF RUPTURED WIDE-NECK CEREBRAL ANEURYSMS: CASE REPORT

Neurosurgery ◽  
2009 ◽  
Vol 65 (5) ◽  
pp. E1007-E1008 ◽  
Author(s):  
Demetrius K. Lopes ◽  
Kalani Wells
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Aneurysms ◽  
Artery Aneurysm ◽  
Anterior Communicating Artery ◽  
Parent Vessel ◽  
Aneurysm Neck ◽  
Acute Subarachnoid Hemorrhage ◽  
The Right ◽  
Wide Neck ◽  
Cordis Corporation

Abstract OBJECTIVE To describe a novel stent remodeling technique for the coiling of ruptured wide-neck cerebral aneurysms. CLINICAL PRESENTATION A 46-year-old man presented with acute subarachnoid hemorrhage (Hunt and Hess grade IV), intracerebral hemorrhage, and hydrocephalus. Cerebral angiography revealed a wide-neck small anterior communicating artery aneurysm. Conventional coiling was not successful because of coil instability and compromise of the dominant anterior cerebral artery. TECHNIQUE A 6-French shuttle sheath (Cook Medical, Indianapolis, IN) was advanced from a right femoral approach into the right common carotid artery. To protect the parent vessel during coiling without compromising blood flow, a Prowler Select Plus catheter (Cordis Corporation, Bridgewater, NJ) was navigated across the aneurysm neck. Subsequently, an Enterprise stent (22-mm length; Cordis Corporation) was partially deployed across the aneurysm's wide neck. It was very important to watch the distal markers of the stent and lock the stent delivery wire to the Prowler Select Plus with a hemostatic valve once the stent was halfway deployed. This maneuver was essential to prevent further deployment of the stent. The SL-10 microcatheter and Synchro 14 wire (Boston Scientific, Natick, MA) were carefully navigated to the aneurysm passing through the partially deployed stent. Coils were then delivered to the aneurysm using the stent as a scaffold. After coiling, the SL-10 microcatheter was removed and the stent was recaptured into the Prowler Select Plus catheter. During the recapture, there was initial resistance. This was easily overcome after deploying the stent a little more before resheathing. During the procedure, the patient received 2000 U of heparin after the first coil was detached in the aneurysm. CONCLUSION The stent remodeling technique is a novel endovascular technique that can be used to treat ruptured wide-neck aneurysms and maintain patency of parent vessels, avoiding the use of antiplatelet therapy in acute subarachnoid hemorrhage.

Republished: Subarachnoid hemorrhage then thrombosis of posterior inferior cerebellar artery dissection: is early surgical exploration warranted?

2015 ◽  
Vol 8 (6) ◽  
pp. e22-e22
Author(s):  
Nikita G Alexiades ◽  
Jason A Ellis ◽  
Philip M Meyers ◽  
E Sander Connolly
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Posterior Inferior Cerebellar Artery ◽  
Definitive Treatment ◽  
Artery Dissection ◽  
Acute Thrombosis ◽  
Cerebellar Artery ◽  
History Of ◽  
Diseased Vessel ◽  
Vessel Thrombosis

The natural history of spontaneous cerebral artery dissection and thrombosis remains uncertain. Concurrent subarachnoid hemorrhage further complicates the therapeutic approach. Thus the best strategy for managing patients with acute vessel thrombosis in the setting of subarachnoid hemorrhage is unclear. Here we present a case of spontaneous posterior inferior cerebellar artery dissection presenting with subarachnoid hemorrhage and acute thrombosis. Although the patient was initially managed conservatively, angiographic follow-up demonstrated recanalization of the diseased vessel, necessitating definitive treatment. Thus we propose that angiographic follow-up is necessary in the management of patients with subarachnoid hemorrhage in association with apparent vessel thrombosis.

Risk Factors for Growth of Unruptured Intracranial Aneurysms: Follow-up Study by Serial 0.5–T Magnetic Resonance Angiography

Neurosurgery ◽  
2006 ◽  
Vol 58 (6) ◽  
pp. 1047-1053 ◽  
Author(s):  
Nobuhiko Miyazawa ◽  
Iwao Akiyama ◽  
Zentaro Yamagata
Keyword(s):  
Risk Factors ◽  
Subarachnoid Hemorrhage ◽  
Family History ◽  
Unruptured Aneurysms ◽  
Logistic Analysis ◽  
Aneurysm Size ◽  
History Of ◽  
Aneurysm Growth ◽  
Independent Risk Factors

Abstract OBJECTIVE: The independent risk factors for aneurysm growth were retrospectively investigated in 130 patients with unruptured aneurysms who were followed up by 0.5–T serial magnetic resonance angiography with stereoscopic images. METHODS: Age, sex, site of aneurysm, size of aneurysm, multiplicity of aneurysms, type of circle of Willis, length of follow-up period, cerebrovascular event, hypertension, diabetes, hyperlipidemia, smoking habit, and family history of subarachnoid hemorrhage were investigated using multiple logistic analysis. RESULTS: Fourteen patients (16 aneurysms) among the 130 patients (159 aneurysms) showed aneurysm growth (10.8%) during follow-up of 10 to 69 months (mean 29.3 ± 10.5 mo). Multiple logistic analysis disclosed that location on the middle cerebral artery (odds ratio [OR] 0.08, P < 0.01), multiplicity of aneurysms (OR 68.5, P < 0.01), aneurysm size of 5 mm or larger (OR 1.17, P = 0.05), and family history of subarachnoid hemorrhage (OR 10.9, P < 0.01) were independent risk factors. CONCLUSION: Location on the middle cerebral artery, multiplicity, aneurysm size of 5 mm or larger, and family history of subarachnoid hemorrhage are independent risk factors for aneurysm growth. These results may help to determine the treatment choice for unruptured aneurysms.

Abstract 2884: Angiographic Lumen Changes From Oversized Neuroform Stent Implantation

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Marc A Lazzaro ◽  
Omar Katib ◽  
Behrad Golshani ◽  
Osama O Zaidat
Keyword(s):  
Stent Implantation ◽  
Neointimal Hyperplasia ◽  
Vessel Diameter ◽  
Radial Force ◽  
Lumen Diameter ◽  
Paired Data ◽  
Parent Vessel ◽  
Landing Zone ◽  
Neuroform Stent

Introduction: The effect of oversized intracranial stent implantation, and the potential for excessive neointimal hyperplasia from the resulting chronic outward radial force, has not been previously reported. We sought to compare the angiographic narrowing associated with implantation of oversized Neuroform stents overlapping vessels of different diameters. Methods: We reviewed an aneurysm database and identified patients treated with stent-assisted coil embolization involving stent placement overlapping a vessel size transition. Patient demographics and lesion characteristics were extracted from chart review. A submillimeter digital caliper was used for angiogram measurement of lumen diameter at four sites ( figure ). The relationship between lumen diameter and stent oversizing was compared with student’s t-test and Pearson’s correlation. Results: Twenty vessels were identified in 18 patients, providing 80 paired data points. Mean age was 52 years (SD 12), with mean follow-up time of 8 months (SD 6). The distribution of vessel transitions included BA to PCA (n = 8), A1 to A2 or M1 to M2 (n = 8), ICA to ACA or MCA (n = 3), and Vertebral artery to PICA (n = 1). Stent diameter ranged from 3 mm to 4.5 mm, and the average oversizing in the smaller diameter parent vessel landing-zone was 1.75 mm (range 0.8 to 2.9 mm) greater than the vessel diameter. The mean change in lumen size from pre-stent implantation to follow-up was not significantly different for any of the four sites; the proximal end-stent decreased by 5.5% (SD 19.7), proximal mid-stent increased by 7.3% (SD 18.8), distal mid-stent increased by 14.7% (SD 13.8), and the distal end-stent decreased by 0.9% (SD 13.1). Stent oversizing by less than a factor of 1.65 resulted in a mean lumen loss of 4.1% (SD 15.6), while oversizing by greater than a factor of 1.65 resulted in a mean lumen gain of 11.1% (SD = 17.2), (p = 0.006). Conclusions: These data suggest oversized Neuroform stent implantation within the intracranial vasculature does not lead to increased stenosis. Stent oversizing by a factor of 1.65 or more leads to significant persistent luminal gain. The non-significant trend toward lumen loss at the stent tines suggests diminished radial force or greater neointimal hyperplasia at these sites, however persistent luminal gain from the oversized stent radial force likely predominates over any neointimal hyperplasia. Figure . A NF stent overlapping the M1 and M2 segments (A, tines indicated by white arrows). Four points of measurement (B), proximal tines (1.), mid-stent in proximal landing zone (2.), mid-stent in distal landing zone (3.), and distal tines (4.).

scholarly journals Endovascular Management for P2 Aneurysms of the Posterior Cerebral Artery

2009 ◽  
Vol 15 (3) ◽  
pp. 341-348 ◽  
Author(s):  
X. Lv ◽  
Y. Li ◽  
C. Jiang ◽  
Z. Wu
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Effective Treatment ◽  
Posterior Cerebral Artery ◽  
Parent Artery ◽  
Endovascular Management ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Presenting Symptoms ◽  
Parent Vessel Occlusion

This study evaluated the outcomes of endovascular management for P2-segment aneurysms. From 2003 to 2008, 14 consecutive patients with P2 aneurysms were treated endovascularly by proximal P2 segment occlusion at our institution. The aneurysms included 12 P2a and two P2p aneurysms. Presenting symptoms were caused by subarachnoid hemorrhage (SAH) in six patients, stroke in five, and isolated headaches in three. Mean follow-up was 14 months. Twelve aneurysms were treated with proximal P2 segment occlusion without parent artery revascularization. Twelve aneurysms were at the P2a and two aneurysms at the P2p. Two patients developed hemianopsia after the procedure and one recovered completely within six months follow-up with one still persistent at 22-month follow-up. Proximal parent vessel occlusion was a relatively safe, effective treatment for P2 aneurysms that posed low risk for early or delayed ischemia or infarction.

Recurrence of a Vertebral Artery Dissecting Pseudoaneurysm after Successful Stent-supported Coil Embolization: Case Report

Neurosurgery ◽  
2003 ◽  
Vol 53 (3) ◽  
pp. 754-761 ◽  
Author(s):  
Christopher I. MacKay ◽  
Patrick P. Han ◽  
Felipe C. Albuquerque ◽  
Cameron G. McDougall
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Neck Pain ◽  
Vertebral Artery ◽  
Coil Embolization ◽  
Artery Aneurysm ◽  
Left Vertebral Artery ◽  
Parent Vessel ◽  
Computed Tomographic ◽  
Computed Tomographic Scan

Abstract OBJECTIVE AND IMPORTANCE Dissecting aneurysms of the intracranial vertebral artery are increasingly recognized as a cause of subarachnoid hemorrhage. We present a case involving technical success of the stent-supported coil embolization but with recurrence of the dissecting pseudoaneurysm of the intracranial vertebral artery. The implications for the endovascular management of ruptured dissecting pseudoaneurysms of the intracranial vertebral artery are discussed. CLINICAL PRESENTATION A 36-year-old man with a remote history of head injury had recovered functionally to the point of independent living. He experienced the spontaneous onset of severe head and neck pain, which progressed rapidly to obtundation. A computed tomographic scan of the head revealed subarachnoid hemorrhage centered in the posterior fossa. The patient underwent cerebral angiography, which revealed dilation of the distal left vertebral artery consistent with a dissecting pseudoaneurysm. INTERVENTION Transfemoral access was achieved under general anesthesia, and two overlapping stents (3 mm in diameter and 14 mm long) were placed to cover the entire dissected segment. Follow-up angiography of the left vertebral artery showed the placement of the stents across the neck of the aneurysm; coil placement was satisfactory, with no residual aneurysm filling. Approximately 6 weeks after the patient's initial presentation, he developed the sudden onset of severe neck pain. A computed tomographic scan showed no subarachnoid hemorrhage, but computed tomographic angiography revealed that the previously treated left vertebral artery aneurysm had recurred. Angiography confirmed a recurrent pseudoaneurysm around the previously placed Guglielmi detachable coils. A test balloon occlusion was performed for 30 minutes. The patient's neurological examination was stable throughout the test occlusion period. Guglielmi detachable coil embolization of the left vertebral artery was then performed, sacrificing the artery at the level of the dissection. After the procedure was completed, no new neurological deficits occurred. On the second day after the procedure, the patient was discharged from the hospital. He was alert, oriented, and able to walk. CONCLUSION We appreciate the value of preserving a parent vessel when a dissecting pseudoaneurysm of the intracranial vertebral artery ruptures in patients with inadequate collateral blood flow, in patients with disease involving the contralateral vertebral artery, or in patients with both. However, our case represents a cautionary note that patients treated in this fashion require close clinical follow-up. We suggest that parent vessel occlusion be considered the first option for treatment in patients who will tolerate sacrifice of the parent vessel along its diseased segment. In the future, covered stent technology may resolve this dilemma for many of these patients.

ELAPSS score for prediction of risk of growth of unruptured intracranial aneurysms

Neurology ◽  
2017 ◽  
Vol 88 (17) ◽  
pp. 1600-1606 ◽  
Author(s):  
Daan Backes ◽  
Gabriel J.E. Rinkel ◽  
Jacoba P. Greving ◽  
Birgitta K. Velthuis ◽  
Yuichi Murayama ◽  
...  
Keyword(s):  
Risk Factor ◽  
Subarachnoid Hemorrhage ◽  
Risk Score ◽  
Intracranial Aneurysms ◽  
Cox Regression Analysis ◽  
Unruptured Intracranial Aneurysms ◽  
History Of ◽  
Aneurysm Growth ◽  
Risk Factor Status

Objective:To develop a risk score that estimates 3-year and 5-year absolute risks for aneurysm growth.Methods:From 10 cohorts of patients with unruptured intracranial aneurysms and follow-up imaging, we pooled individual data on sex, population, age, hypertension, history of subarachnoid hemorrhage, and aneurysm location, size, aspect ratio, and shape but not on smoking during follow-up and family history of intracranial aneurysms in 1,507 patients with 1,909 unruptured intracranial aneurysms and used aneurysm growth as outcome. With aneurysm-based multivariable Cox regression analysis, we determined predictors for aneurysm growth, which were presented as a risk score to calculate 3-year and 5-year risks for aneurysm growth by risk factor status.Results:Aneurysm growth occurred in 257 patients (17%) and 267 aneurysms (14%) during 5,782 patient-years of follow-up. Predictors for aneurysm growth were earlier subarachnoid hemorrhage, location of the aneurysm, age >60 years, population, size of the aneurysm, and shape of the aneurysm (ELAPSS). The 3-year growth risk ranged from <5% to >42% and the 5-year growth risk from <9% to >60%, depending on the risk factor status.Conclusions:The ELAPSS score consists of 6 easily retrievable predictors and can help physicians in decision making on the need for and timing of follow-up imaging in patients with unruptured intracranial aneurysms.

scholarly journals CT-visible convexity subarachnoid hemorrhage is associated with cortical superficial siderosis and predicts recurrent ICH

Neurology ◽  
2020 ◽  
pp. 10.1212/WNL.0000000000011052
Author(s):  
Qi Li ◽  
Maria Clara Zanon Zotin ◽  
Andrew D. Warren ◽  
Yuan Ma ◽  
Edip Gurol ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Recurrent Stroke ◽  
Superficial Siderosis ◽  
Amyloid Angiopathy ◽  
Cox Proportional Hazard ◽  
Increased Risk ◽  
History Of ◽  
Cox Proportional Hazard Models ◽  
Cortical Superficial Siderosis

Objective:To investigate whether acute convexity subarachnoid hemorrhage (cSAH) detected on CT in lobar intracerebral hemorrhage (ICH) related to cerebral amyloid angiopathy (CAA) is associated with recurrent ICH.Methods:We analyzed data from a prospective cohort of consecutive acute lobar ICH survivors fulfilling the Boston criteria for possible or probable CAA who had both brain CT and MRI at index ICH. Presence of cSAH was assessed on CT blinded to MRI data. Cortical superficial siderosis (cSS), cerebral microbleeds and white matter hyperintensities were evaluated on MRI. Cox proportional hazard models were used to assess the association between cSAH and the risk of recurrent symptomatic ICH during follow-up.Results:A total of 244 ICH survivors (76.4 ± 8.7 years; 54.5% female) were included. cSAH was observed on baseline CT in 99 patients (40.5%). Presence of cSAH was independently associated with cSS, hematoma volume and pre-existing dementia. During a median follow-up of 2.66 years, 49 patients (20.0%) had a recurrent symptomatic ICH. Presence of cSAH was associated with recurrent ICH (hazard ratio [HR] 2.64; 95% CI 1.46-4.79; p=0.001), after adjusting for age, antiplatelet use, warfarin use, history of previous ICH.Conclusion:cSAH was detected on CT in 40.5% of patients with acute lobar ICH related to CAA and heralds an increased risk of recurrent ICH. This CT marker may be widely used to stratify the ICH risk in patients with CAA.Classification of evidence:This study provides Class II evidence that cSAH accurately predicts recurrent stroke in patients with CAA.

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