Endovascular treatment of fusiform cerebral aneurysms with the Pipeline Embolization Device

2014 ◽  
Vol 120 (4) ◽  
pp. 945-954 ◽  
Author(s):  
Stephen J. Monteith ◽  
Asterios Tsimpas ◽  
Aaron S. Dumont ◽  
Stavropoula Tjoumakaris ◽  
L. Fernando Gonzalez ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Cerebral Aneurysms ◽  
Morbidity And Mortality ◽  
Complex Nature ◽  
Stent Deployment ◽  
Pipeline Embolization Device ◽  
Aneurysm Occlusion ◽  
The Mean

Object Despite advances in surgical and endovascular techniques, fusiform aneurysms remain a therapeutic challenge. Introduction of flow-diverting stents has revolutionized the treatment of aneurysms with wide necks and of complex morphology. The authors report their experience with the endovascular treatment of fusiform aneurysms using the Pipeline Embolization Device. Methods A retrospective review of 146 patients with cerebral aneurysms treated with the Pipeline Embolization Device between June 2011 and January 2013 was performed. Twenty-four patients were identified as having fusiform aneurysms. Twenty-four aneurysms in these 24 patients were treated. The mean patient age was 59 years. There were 9 men and 15 women. Angiographic and clinical data (including the modified Rankin Scale [mRS] score) were recorded at the time of treatment and at follow-up. The aneurysms were located in the internal carotid artery in 8 patients (33.3%), middle cerebral artery in 8 patients (33.3%), anterior cerebral artery in 1 patient (4%), and vertebrobasilar circulation in 7 patients (29%). The aneurysms were smaller than 10 mm in 3 patients, 10–25 mm in 16 patients, and larger than 25 mm in 5 patients. The mean largest dimension diameter was 18 mm. Results Stent deployment was successful in all cases. The minor procedural morbidity was 4% (1 case). Morbidity and mortality related to aneurysm treatment were 4.2% and 4.2%, respectively. The mean mRS scores preoperatively and at clinical follow-up (median 6.0 months, mean 6.9 months) were 0.71 and 1.2, respectively (91.7% presented with an mRS score of 2 or better, and 79.2% had an mRS score of 2 or better at the 6.0-month follow-up). At clinical follow-up, 82.6% of patients were stable or had improved, 13.0% worsened, and 4.2% had died. Twenty-two (91.7%) of 24 patients had follow-up angiography available (mean follow-up time 6.3 months); 59% had excellent angiographic results (> 95% or complete occlusion), 31.8% had complete aneurysm occlusion, 27.3% had greater than 95% aneurysm occlusion, 18.2% had a moderate decrease in size (50%–95%), 4.5% had a minimal decrease in size (< 50%), 13.6% had not changed, and 4.5% had an increase in size. Conclusions This series demonstrates that endovascular treatment of fusiform cerebral aneurysms with flow diversion was a safe and effective treatment. Procedural complications were low. Long-term morbidity and mortality rates were acceptable given the complex nature of these lesions.

The Use of the Pipeline Embolization Device in the Management of Recurrent Previously Coiled Cerebral Aneurysms

Neurosurgery ◽  
2015 ◽  
Vol 77 (5) ◽  
pp. 692-697 ◽  
Author(s):  
Badih Daou ◽  
Robert M. Starke ◽  
Nohra Chalouhi ◽  
Stavropoula Tjoumakaris ◽  
Jean Khoury ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Cerebral Aneurysms ◽  
Good Clinical Outcome ◽  
Cerebral Angiogram ◽  
Pipeline Embolization Device ◽  
Aneurysm Occlusion ◽  
The Mean ◽  
Mean Time ◽  
Aneurysm Coiling

Abstract BACKGROUND: The biggest downside of cerebral aneurysm coiling is the high rates of recurrence and retreatments. With the increasing number of aneurysm recurrences after failed coiling procedures, the best retreatment strategy remains unknown. OBJECTIVE: To assess the efficacy and safety of the Pipeline Embolization Device (PED) in the treatment of recurrent previously coiled aneurysms. METHODS: Thirty-three patients who underwent treatment with the PED of a recurrent previously coiled aneurysm were retrospectively identified. Efficacy was assessed in terms of angiographic occlusion at the latest cerebral angiogram, recurrence and retreatment rates after PED placement, and clinical outcome at the latest follow-up. Safety was assessed by looking at the complications, morbidity, and mortality after PED treatment. RESULTS: The mean patient age was 53 years. The mean percent recurrence from coiling to PED placement was 34%. The mean time from coiling to PED placement was 40 months. PED treatment resulted in complete aneurysm occlusion in 76.7% of patients and near-complete aneurysm occlusion (≥90%) in 10%, for a total rate of complete and near-complete aneurysm occlusion of 86.7%. All patients, including those with incomplete aneurysm occlusion, had a significant reduction in aneurysm size. Two aneurysms required another retreatment after PED placement (6.2%). Ninety-seven percent of patients had a good clinical outcome. Complications were observed in 1 patient (3%), who suffered an intracerebral hemorrhage. There were no mortalities. CONCLUSION: The use of the PED in the management of recurrent, previously coiled aneurysms is safe and effective in achieving aneurysm occlusion.

Use of the Pipeline embolization device for recurrent and residual cerebral aneurysms: a safety and efficacy analysis with short-term follow-up

2016 ◽  
Vol 9 (12) ◽  
pp. 1208-1213 ◽  
Author(s):  
Anna Luisa Kühn ◽  
Katyucia de Macedo Rodrigues ◽  
J Diego Lozano ◽  
David E Rex ◽  
Francesco Massari ◽  
...  
Keyword(s):  
Intimal Hyperplasia ◽  
Cerebral Aneurysms ◽  
Device Performance ◽  
Anterior Circulation ◽  
Pipeline Embolization Device ◽  
Safety And Efficacy ◽  
Efficacy Analysis ◽  
Unruptured Intracranial Aneurysms ◽  
Aneurysm Occlusion

ObjectiveEvaluation of the safety and efficacy of the Pipeline embolization device (PED) when used as second-line treatment for recurrent or residual, pretreated ruptured and unruptured intracranial aneurysms (IAs).MethodsRetrospective review of our database to include all patients who were treated with a PED for recurrent or residual IAs following surgical clipping or coiling. We evaluated neurological outcome and angiograms at discharge, 6- and 12-months’ follow-up and assessed intimal hyperplasia at follow-up.ResultsTwenty-four patients met our inclusion criteria. Most IAs were located in the anterior circulation (n=21). No change of preprocedure modified Rankin Scale score was seen at discharge or at any scheduled follow-up. Complete or near-complete aneurysm occlusion on 6- and 12-month angiograms was seen in 94.4% (17/18 cases) and 93.3% (14/15 cases), respectively. Complete or near-complete occlusion was seen in 100% of previously ruptured and 85.7% (6/7 cases) and 83.3% (5/6 cases) of previously unruptured cases at the 6- and 12-months’ follow-up, respectively. One case of moderate intimal hyperplasia was observed at 6 months and decreased to mild at the 12-months’ follow-up. No difference in device performance was observed among pretreated unruptured or ruptured IAs.ConclusionsTreatment of recurrent or residual IAs with a PED after previous coiling or clipping is feasible and safe. There is no difference in device performance between ruptured or unruptured IAs.

Predictive factors of incomplete aneurysm occlusion after endovascular treatment with the Pipeline embolization device

2020 ◽  
Vol 132 (5) ◽  
pp. 1598-1605 ◽  
Author(s):  
Georgios A. Maragkos ◽  
Luis C. Ascanio ◽  
Mohamed M. Salem ◽  
Sricharan Gopakumar ◽  
Santiago Gomez-Paz ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Predictive Factors ◽  
Cohort Analysis ◽  
Multivariable Analysis ◽  
Pipeline Embolization Device ◽  
Unruptured Aneurysms ◽  
Maximal Diameter ◽  
Aneurysm Occlusion ◽  
Incomplete Occlusion

OBJECTIVEThe Pipeline embolization device (PED) is a routine choice for the endovascular treatment of select intracranial aneurysms. Its success is based on the high rates of aneurysm occlusion, followed by near-zero recanalization probability once occlusion has occurred. Therefore, identification of patient factors predictive of incomplete occlusion on the last angiographic follow-up is critical to its success.METHODSA multicenter retrospective cohort analysis was conducted on consecutive patients treated with a PED for unruptured aneurysms in 3 academic institutions in the US. Patients with angiographic follow-up were selected to identify the factors associated with incomplete occlusion.RESULTSAmong all 3 participating institutions a total of 523 PED placement procedures were identified. There were 284 procedures for 316 aneurysms, which had radiographic follow-up and were included in this analysis (median age 58 years; female-to-male ratio 4.2:1). Complete occlusion (100% occlusion) was noted in 76.6% of aneurysms, whereas incomplete occlusion (≤ 99% occlusion) at last follow-up was identified in 23.4%. After accounting for factor collinearity and confounding, multivariable analysis identified older age (> 70 years; OR 4.46, 95% CI 2.30–8.65, p < 0.001); higher maximal diameter (≥ 15 mm; OR 3.29, 95% CI 1.43–7.55, p = 0.005); and fusiform morphology (OR 2.89, 95% CI 1.06–7.85, p = 0.038) to be independently associated with higher rates of incomplete occlusion at last follow-up. Thromboembolic complications were noted in 1.4% and hemorrhagic complications were found in 0.7% of procedures.CONCLUSIONSIncomplete aneurysm occlusion following placement of a PED was independently associated with age > 70 years, aneurysm diameter ≥ 15 mm, and fusiform morphology. Such predictive factors can be used to guide individualized treatment selection and counseling in patients undergoing cerebrovascular neurosurgery.

scholarly journals The use of single low-profile visualized intraluminal support stent-assisted coiling in the treatment of middle cerebral artery bifurcation unruptured wide-necked aneurysm

2020 ◽  
Vol 26 (4) ◽  
pp. 461-467 ◽  
Author(s):  
Yazhou Yan ◽  
Zhangwei Zeng ◽  
Yina Wu ◽  
Jiachao Xiong ◽  
Kaijun Zhao ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Thromboembolic Event ◽  
Perioperative Complications ◽  
Stent Deployment ◽  
Technical Success Rate ◽  
Hemorrhagic Event ◽  
Low Profile

Objective Endovascular treatment of unruptured wide-necked aneurysms located at the middle cerebral artery bifurcation remains challenging. This study aimed to evaluate the safety and efficacy of endovascular treatment for middle cerebral artery bifurcation unruptured wide-necked aneurysms using a low-profile visualized intraluminal support (LVIS) stent. Methods We retrospectively reviewed all patients with middle cerebral artery bifurcation unruptured wide-necked aneurysms treated using an LVIS device at our institution between October 2014 and December 2018. Clinical presentation, aneurysmal characteristics, technical feasibility, perioperative complications, clinical outcome, and angiographic and clinical follow-up results were evaluated. Results Fifty-seven patients with 57 wide-necked aneurysms arising from the middle cerebral artery bifurcation were identified. The technical success rate of stent deployment was 100%. Immediate postoperative angiograms showed Raymond 1 in 26 aneurysms (45.6%), Raymond 2 in 10 (17.6%), and Raymond 3 in 21 (36.8%). Perioperative complications developed in two patients (3.5%), including one procedure-related hemorrhagic event and one thromboembolic event. The follow-up angiogram was available for 47 aneurysms obtained at an average of 11.7 months (range, 5 to 49 months) after intervention; the latest follow-up angiograms revealed complete occlusion in 37 (78.7%) aneurysms, improvement in three (6.4%), stabilization in five (10.6%), and recanalization in two (4.3%). During the follow-up, one patient was found to have in-stent stenosis and two patients were found to have slow flow or occlusion of the jailed branch. All three of these patients were asymptomatic. No hemorrhagic or thromboembolic events occurred during clinical follow-up. Conclusions Our experience suggests that endovascular treatment of middle cerebral artery bifurcation unruptured wide-necked aneurysms with an LVIS stent is safe and effective, but the effect on branches needs to be further studied.

scholarly journals Endovascular treatment of complex middle cerebral artery aneurysms using TuBridge flow diverters

2020 ◽  
Vol 26 (5) ◽  
pp. 539-546
Author(s):  
Feng Liang ◽  
Yibing Yang ◽  
Lijuan Luo ◽  
Bingye Liao ◽  
Guofeng Zhang ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Flow Diverter ◽  
Grading Scale ◽  
The Mean ◽  
Middle Cerebral Artery Aneurysms ◽  
Flow Diverters ◽  
Stent Stenosis

Background The safety and efficacy of the TuBridge flow diverter in treating middle cerebral artery aneurysms remains unknown. In this study, we report our preliminary experience treating complex middle cerebral artery aneurysms using the TuBridge flow diverter. Methods A prospectively maintained database of intracranial aneurysms treated with the TuBridge flow diverter was retrospectively reviewed, and patients with middle cerebral artery aneurysms were included in this study. Demographics, aneurysm features, complications, and clinical and angiographic outcomes were assessed. Evaluation of the angiographic results included occlusion grade of aneurysm (O’Kelly–Marotta grading scale), patency of jailed branch(es), and in-stent stenosis. Results Eight patients with eight middle cerebral artery aneurysms were included in this study. The mean aneurysm size was 11.8 ± 6.8 mm. There were no procedure-related complications and there was no morbidity or mortality at a mean follow-up of 11.3 ± 3.6 months. All patients had follow-up angiograms at a mean of 7.5 ± 4.0 months after surgery. Of the eight patients, there was 1 (12.5%) O’Kelly–Marotta grading scale A, 3 (37.5%) O’Kelly–Marotta grading scale B, 1 (12.5%) O’Kelly–Marotta grading scale C, and 3 (37.5%) O’Kelly–Marotta grading scale D. Of the seven patients with jailed branch, the blood flow of jailed branch was unchanged in 4 (57.1%), decreased in 2 (28.6%), and occluded in 1 (14.3%). In-stent stenosis was mild in 2 (25%) patients and moderate in 1 (12.5%) patient. Conclusion Midterm results suggest that endovascular treatment of middle cerebral artery aneurysms using the TuBridge flow diverter is safe and associated with good outcomes. The TuBridge flow diverter may be an option for complex middle cerebral artery aneurysms that are difficult to treat with either clipping or coiling.

NEUROFORM STENT-ASSISTED COIL EMBOLIZATION OF WIDE-NECK INTRACRANIAL ANEURYSMS

Neurosurgery ◽  
2007 ◽  
Vol 61 (3) ◽  
pp. 460-469 ◽  
Author(s):  
Alessandra Biondi ◽  
Vallabh Janardhan ◽  
Jeffrey M. Katz ◽  
Kimberly Salvaggio ◽  
Howard A. Riina ◽  
...  
Keyword(s):  
Coil Embolization ◽  
Cerebral Aneurysms ◽  
Effective Technique ◽  
Stent Deployment ◽  
Unruptured Aneurysms ◽  
Aneurysm Occlusion ◽  
Neuroform Stent ◽  
Wide Neck

Abstract OBJECTIVE To evaluate the midterm results of intracranial stent-assisted coil embolization in the treatment of wide-necked cerebral aneurysms and to assess the efficacy of various strategies used in stent deployment. METHODS A retrospective study of 42 patients with 46 wide-necked cerebral aneurysms enrolled in a prospective single-center registry of patients treated with a Neuroform stent (Boston Scientific/Target, Fremont, CA), a flexible self-expanding nitinol stent, was performed. Twenty-seven of 46 aneurysms were unruptured aneurysms, 14 were recanalized aneurysms, and five were acutely ruptured. Thirty-nine aneurysms were located in the anterior and seven in the posterior circulation. Mean aneurysm size was 9.8 mm. Stenting before coiling was performed in 13 of 45 aneurysms (29%), coiling before stenting in 27 of 45 aneurysms (60%), and stenting alone in five of 45 aneurysms (11%). The balloon remodeling technique for coiling before stenting was performed in 77% of patients. Angiographic and clinical follow up was available in 31 patients with 33 aneurysms and ranged from 3 to 24 months. RESULTS Neuroform stenting was attempted in 46 wide-necked aneurysms (42 patients). Forty-nine stent sessions were performed, including three poststent retreatments. In 46 of 49 sessions (94%), successful deployment of 47 stents for 45 aneurysms was obtained. In 40 aneurysms treated with stent-assisted coiling, angiographic results showed 14 (35%) aneurysm occlusions, 18 (45%) neck remnants, and eight (20%) residual aneurysms. In five recanalized aneurysms treated with stenting alone, no changes were observed in four (80%) aneurysms and one (20%) neck remnant reduced in size. At angiographic follow-up in 30 aneurysms treated with stent-assisted coiling, there were 17 (57%) aneurysm occlusions, seven (23%) neck remnants, and six (20%) residual aneurysms. In three recanalized aneurysms treated with stent alone, two (67%) neck remnants remained unchanged and one (33%) neck remnant decreased in size. Procedural morbidity was observed in two of 42 patients (4.8%) and one patient died. On clinical follow-up, the modified Rankin Scale score was 0 in 27 patients (87%), 1 in three patients (10%), and 2 (3%) in one patient. No aneurysm bled during the follow-up period. CONCLUSION These results indicate that Neuroform stent-assisted coil embolization is a safe and effective technique in the treatment of wide-necked cerebral aneurysms. Further studies are needed to evaluate the long-term durability of stent-assisted aneurysm occlusion and tolerance to the stent.

scholarly journals Aneurysms with persistent filling after failed treatment with the Pipeline embolization device

2019 ◽  
Vol 130 (4) ◽  
pp. 1376-1382 ◽  
Author(s):  
Badih Daou ◽  
Elias Atallah ◽  
Nohra Chalouhi ◽  
Robert M. Starke ◽  
Jeffrey Oliver ◽  
...  
Keyword(s):  
Cerebral Aneurysms ◽  
Previous Treatment ◽  
Anterior Circulation ◽  
Pipeline Embolization Device ◽  
Aneurysm Size ◽  
Paraclinoid Aneurysms ◽  
Long Term Follow Up ◽  
The Mean ◽  
Anterior Choroidal

OBJECTIVEThe Pipeline embolization device (PED) has become a valuable tool in the treatment of cerebral aneurysms. Although failures with PED treatment have been reported, the characteristics and course of these aneurysms remain a topic of uncertainty.METHODSElectronic medical records and imaging studies were reviewed for all patients treated with the PED between July 2010 and March 2015 to identify characteristics of patients and aneurysms with residual filling after PED treatment.RESULTSOf 316 cases treated at a single institution, 281 patients had a long-term follow-up. A total of 52 (16.4%) aneurysms with residual filling were identified and constituted the study population. The mean patient age in this population was 58.8 years. The mean aneurysm size was 10.1 mm ± 7.15 mm. Twelve aneurysms were fusiform (23%). Of the aneurysms with residual filling, there were 20 carotid ophthalmic (CO) aneurysms (20% of all CO aneurysms treated), 10 other paraclinoid aneurysms (16.4% of all paraclinoid aneurysms), 7 posterior communicating artery (PCoA) aneurysms (21.9% of all PCoA aneurysms), 7 cavernous internal carotid artery (ICA) aneurysms (14.9% of all cavernous ICA aneurysms), 4 vertebrobasilar (VB) junction aneurysms (14.8% of all VB junction aneurysms), and 3 middle cerebral artery (MCA) aneurysms (25% of all MCA aneurysms). Eleven patients underwent placement of more than one PED (21.2%), with a mean number of devices of 1.28 per case. Eight of 12 aneurysms were previously treated with a stent (15.4%). Nineteen patients underwent re-treatment (36.5%); the 33 patients who did not undergo re-treatment (63.5%) were monitored by angiography or noninvasive imaging. In multivariate analysis, age older than 65 years (OR 2.65, 95% CI 1.33–5.28; p = 0.05), prior stent placement across the target aneurysm (OR 2.94, 95% CI 1.15–7.51; p = 0.02), aneurysm location in the distal anterior circulation (MCA, PCoA, and anterior choroidal artery: OR 2.72, 95% CI 1.19–6.18; p = 0.017), and longer follow-up duration (OR 1.06, 95% CI 1.03–1.09; p < 0.001) were associated with incomplete aneurysm occlusion.CONCLUSIONSWhile the PED can allow for treatment of large, broad-necked aneurysms with high efficacy, treatment failures do occur (16.4%). Aneurysm size, shape, and previous treatment may influence treatment outcome.

Pipeline for Distal Cerebral Circulation Aneurysms

Neurosurgery ◽  
2019 ◽  
Vol 85 (3) ◽  
pp. E477-E484 ◽  
Author(s):  
Elias Atallah ◽  
Hassan Saad ◽  
Nikolaos Mouchtouris ◽  
Kimon Bekelis ◽  
Jackson Walker ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Clinical Outcome ◽  
Cerebral Artery ◽  
Cerebral Circulation ◽  
Posterior Inferior Cerebellar Artery ◽  
Good Clinical Outcome ◽  
Multivariable Logistic Regression ◽  
Aneurysm Occlusion ◽  
The Mean

Abstract BACKGROUND Pipeline embolization device (PED; Medtronic, Dublin, Ireland) utilization is not limited to the treatment of giant wide-necked aneurysms. It has been expanded to handle small blisters, fusiforms, and dissecting intracranial aneurysms. OBJECTIVE To report the use of the PED in various off-label distal cerebral circulation (DCC) arteries with a follow-up to assess clinical outcomes. METHODS Between 2011 and 2016, of 437 consecutive patients, 23 patients with aneurysms located in DCCs were treated with PED. Data on patient presentation, aneurysm characteristics, procedural outcomes, postoperative course, and aneurysm occlusion were gathered. To control confounding, we used multivariable logistic regression and propensity score conditioning. RESULTS A total of 437 patients (mean age 52.12 years; 62 women [14.2%]) underwent treatment with PED in our institution. Twenty-three of 437 (5.2%) received a pipeline in a distal artery: 11/23 middle cerebral artery, 6/23 posterior cerebral artery, 3/23 anterior cerebral artery (A1/A2, pericallosal artery), and 3/23 posterior inferior cerebellar artery. Twenty percent of the aneurysms were treated in the past, 10% had previously ruptured, and 5.9% ruptured at presentation to our hospital. The mean aneurysm size was 9.0 ± 6 mm. The mean follow-up was 12 mo (SD = 12.5). In multivariable logistic regression, no associations were found between PED deployment in DCCs and aneurysm occlusion or thromboembolic complications. PED use in DCC was associated with a good clinical outcome. Twenty-two people of 23 (95%) had a good clinical outcome in the latest follow-up. CONCLUSION Treatment of DCC aneurysms with PED is technically challenging mainly because of the small caliber and tortuosity of the parent arteries. The results of this study further support the safety of flow diverters in the treatment of various distal aneurysms.

Important Factors for a Combined Neurovascular Team to Consider in Selecting a Treatment Modality for Patients with Previously Clipped Residual and Recurrent Intracranial Aneurysms

Neurosurgery ◽  
2003 ◽  
Vol 52 (4) ◽  
pp. 732-739 ◽  
Author(s):  
Brian L. Hoh ◽  
Bob S. Carter ◽  
Christopher M. Putman ◽  
Christopher S. Ogilvy
Keyword(s):  
Endovascular Treatment ◽  
Treatment Modality ◽  
Posterior Circulation ◽  
Neurological Deficits ◽  
Parent Vessel ◽  
Surgical Risk ◽  
Fatal Hemorrhage ◽  
The Mean ◽  
Selection Of

Abstract OBJECTIVE Intracranial residual and recurrent aneurysms can occur after surgical clipping, with risks of growth and rupture. In the past, surgical reoperation, which can be associated with higher risk than the initial operation, was the only available treatment. A combined neurovascular team that uses both surgical and endovascular therapies could maximize efficacy and outcomes while minimizing risks in these difficult cases. The indications for which surgical or endovascular treatment should be used to treat patients with residual or recurrent aneurysms, however, have not been elucidated well. We have reviewed the 10-year experience of our combined neurovascular team to determine in a retrospective manner which factors were important to treatment modality selection for patients with these residual and recurrent lesions. METHODS From 1991 to 2001, the combined neurovascular unit at the Massachusetts General Hospital treated 25 residual and recurrent previously clipped aneurysms (15 had been clipped at other centers). Only patients in whom a clip had been placed were included in the study; patients who did not have a clip placed or whose aneurysms were wrapped or coated were excluded. The radiographic studies and clinical data were reviewed retrospectively to determine the efficacy, outcomes, and factors important to the selection of treatment strategy in these patients. RESULTS The patients' clinical presentations were radiographic follow-up, 17 patients; rehemorrhage, 3; mass effect, 3; and thromboembolism, 2. The mean aneurysm recurrence or residual size was 11 mm (range, 4–26 mm). The mean interval until representation was 6.6 years (range, 1 wk–25 yr). Treatment consisted of: coiling, 11 patients; reclipping, 8; proximal parent vessel balloon occlusion, 2; extracranial-intracranial bypass with coil occlusion of aneurysm and parent vessel, 2; extracranial-intracranial bypass with clip trapping, 1; and extracranial-intracranial bypass with proximal clip occlusion of parent vessel, 1. The mean radiographic follow-up period was 11 months. Complete angiographic occlusion was found in 19 aneurysms (76%), at least 90% occlusion was found in 4 aneurysms (16%), intentional partial coil obliteration was found in 1 fusiform lesion (4%), and intentional retrograde flow was found in 1 fusiform lesion (4%). Clinical outcomes were excellent or good in 19 patients (76%). Twenty-one patients (84%) were neurologically the same after retreatment (13 remained neurologically intact, and 8 had preexisting neurological deficits that did not change). Three patients (12%) had new neurological deficits after retreatment, and one patient (4%) died. There were four complications of retreatment (16%), one of which was a fatal hemorrhage in a patient 1 month after intentional partial coil obliteration of a fusiform vertebrobasilar junction aneurysm. Factors important to the selection of treatment modality were recurrence or residual location (all posterior circulation lesions were treated endovascularly), lesion size (lesions larger than 10 mm were treated endovascularly or with the use of combined techniques), and aneurysm morphology (fusiform and wide-necked lesions were treated endovascularly or with the use of combined techniques). CONCLUSION The proper selection of surgical or endovascular treatment for residual and recurrent previously clipped aneurysms can achieve excellent radiographic efficacy with low mortality. Factors important to the selection of treatment by this combined neurovascular team were posterior circulation location, aneurysm size larger than 10 mm, and fusiform morphology, which were treated endovascularly or with the use of combined techniques because of the higher surgical risk associated with these factors. For aneurysms with lower surgical risk, such as some anterior circulation aneurysms and aneurysms smaller than 10 mm, we prefer to perform a reoperation because of superior radiographic cure without compromising the outcome.

Reduced Efficacy of the Pipeline Embolization Device in the Treatment of Posterior Communicating Region Aneurysms with Fetal Posterior Cerebral Artery Configuration

Neurosurgery ◽  
2017 ◽  
Vol 82 (5) ◽  
pp. 695-700 ◽  
Author(s):  
Anil K Roy ◽  
Brian M Howard ◽  
Diogo C Haussen ◽  
Joshua W Osbun ◽  
Sameer H Halani ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Clinical Symptoms ◽  
Posterior Cerebral Artery ◽  
Neurological Complications ◽  
Class I ◽  
Class Iii ◽  
Pipeline Embolization Device ◽  
Independent Association ◽  
Incomplete Occlusion

Abstract BACKGROUND Aneurysms at the origin of the posterior communicating artery (PcommA) have been demonstrated to be effectively treated with the pipeline embolization device (PED). Much less is known about the efficacy of the PED for aneurysms associated with a fetal posterior cerebral artery (fPCA) variant. OBJECTIVE To study PED treatment efficacy of PcommA aneurysms, including fPCA aneurysms. METHODS A prospectively maintained university database of aneurysm patients treated with the PED was retrospectively reviewed. Demographics, treatment details, and imaging were reviewed for all PcommA and fPCA aneurysms. RESULTS Out of a total of 285 patients treated with PED, 50 patients (mean age 57.5 ± 12.2 yr, 42 females) with unruptured PcommA (9 fPCA) aneurysms were identified. Mean follow-up duration was 14.0 ± 11.6 mo (48 patients). Roy-Raymond class I occlusion on follow-up magnetic resonance or catheter angiography (mean time 11.7 ± 6.8 mo) was achieved in 30 patients (62.5%), class II occlusion in 11 patients (22.9%) and class III occlusion in 7 patients (14.5%). The PcommA was occluded in 56% of patients without any clinical symptoms. No deaths or permanent neurological complications occurred. In fPCA aneurysms, class I occlusion was seen in 1 patient, class 2 occlusion in 2 patients, and class III occlusion in 6 patients. Multivariate analysis revealed an independent association between incomplete occlusion and fPCA configuration (OR 73.65; 95% CI: 5.84-929.13; P = .001). CONCLUSION The PED is a safe and effective treatment for PcommA aneurysms, although fetal anatomy should increase consideration of traditional endovascular techniques or surgical clipping.

Sign in / Sign up

Export Citation Format

Share Document