Contour-Assisted coiling with jailed microcatheter May result in better occlusion (CoCoJaMBO) in wide-necked intracranial aneurysms: Proof of principle and immediate angiographic results

Purpose Wide-necked bifurcation aneurysms, partially thrombosed, and recurrences of large and giant aneurysms are challenging to treat. We report our preliminary experience with a Contour-assisted coiling technique and discuss the periprocedural safety, feasibility, and effectiveness of the approach. Methods We retrospectively reviewed consecutive patients who received endovascular treatment for intracranial aneurysms with an intra-aneurysmal flow disruptor (Contour) at two neurovascular centres between October 2018 and December 2020 and identified patients treated with a combination of Contour and platinum coils. Clinical and procedural data were recorded. Results For this analysis, 8 patients (5 female) aged 60.1 ± 9.2 years on average were identified. Three of 8 aneurysms were associated with previous acute subarachnoid hemorrhage (SAH). The mean average dome height was 12.8 ± 7.6 mm, mean maximum dome width 10.3 ± 5.4 mm, and neck width 5.5 ± 2.5 mm. The mean dome-to-neck ratio was 1.9 ± 1.0. Immediate complete occlusion of the aneurysm was seen in 5 of 8 cases. In one SAH patient, a parent vessel was temporarily occluded but could be reopened rapidly. One device detached prematurely without any sequelae. No other procedural adverse events were recorded. Conclusion From this initial experience, Contour with adjunctive coiling is a safe and technically feasible method for endovascular treatment of large, wide-necked, partially thrombosed, recurrent, or ruptured bifurcation aneurysms. Further studies with larger numbers of patients and longer follow-up are needed to confirm our results.

A case of two shunts in the endovascular treatment of type II Abernethy syndrome

Background Abernethy malformation is a rare condition defined by a congenital extrahepatic portosystemic shunt, often leading to absence or hypoplasia of the intrahepatic portal venous system. Although there are no consensus treatment guidelines, interventional techniques now offer minimally invasive treatment options for Abernethy malformations. This case report describes a case of Abernethy Syndrome Type II where the patient had two separate extrahepatic portosystemic shunts treated with endovascular occlusion with two Amplatzer plugs and demonstrates the feasibility of this treatment for this rare condition. This case was in a young adult, adding to the scarce literature of treatment for Abernethy syndrome in the adult population. Case presentation We report a case of a 20-year-old female patient with neurocognitive behavioral difficulty, voracious appetite, and chronic encephalopathy secondary to type II Abernethy malformation with not one, but two extrahepatic portosystemic shunts. The patient had failed medical management and was not a liver transplant candidate. Therefore, she presented to us for an endovascular treatment option. The two shunts were treated with endovascular occlusion using Amplatzer vascular plugs. Following embolization, flow into the hypoplastic portal vein improved with near complete occlusion of flow into the portosystemic shunts, thus restoring blood flow into the native portal system. At 3 month follow up, a CT demonstrated complete occlusion of the two portosystemic shunts, and a portal vein diminutive in caliber. The portal vein measured 7 mm in diameter on both pre and post-procedure CT scans. The total volume of the liver was found to be 843 cm3 on pre-procedure CT & 1191 cm3 on post-procedure CT. Conclusions This report demonstrates the feasibility of using endovascular embolization to treat Abernethy II malformations. The management strategy of Type II Abernethy Syndrome should be to redirect blood flow into the hypoplastic native portal system, allowing for physiologic hepatic metabolism of splanchnic blood, hypertrophy of the portal system, and growth of the liver from the increased trophic flow.

Vena Cava Thrombosis after Congenital Diaphragmatic Hernia Repair: Multivariate Analysis of Potential Risk Factors

Introduction The treatment of newborns with congenital diaphragmatic hernia (CDH) is associated with a significant complication rate. Information on major thrombotic complications and their incidence in newborns with CDH is lacking. The aims of our analysis were to evaluate the frequency of vena cava thrombosis and to determine its predictors within a consecutive series of patients with CDH. Materials and Methods We retrospectively analyzed charts of all neonates of our department that underwent CDH repair from 2007 to 2021, focusing on vena cava thrombosis. Vena cava thrombosis was diagnosed sonographically and classified as complete or partial venous occlusion. Complete occlusion was confirmed by cavography. Variables evaluated were CDH side, liver position, central vein line, surgical approach, and extracorporeal membrane oxygenation (ECMO). Univariate and multivariate tests were utilized. Results Among 57 neonates who underwent CDH repair, vena cava thrombosis was diagnosed in 14 (24.6%), seven of whom had complete occlusion of the vena cava. Factors associated with vena cava thrombosis were femoral or saphenous venous catheter (p = 0.044), right sided CDH (p = 0.027) and chylothorax (p < 0.0001). ECMO was not associated with vena cava thrombosis. Seven patients (50%) with vena cava thrombosis were treated interventionally with angioplasty and seven (50%) conservatively with anticoagulation only. Mortality was not higher in patients with compared with patients without vena cava thrombosis. Conclusion The incidence of vena cava thrombosis in newborns with CDH in our series is high. Routine postoperative abdominal sonography focusing on vena cava thrombosis is mandatory in all patients with CDH. Patients who developed vena cava thrombosis were more likely to develop chylothorax after CDH repair. Considering the good outcome of medical therapy of partial vena cava thrombosis, it may be discussed whether low dose anticoagulation may be provided to all newborns with CDH.

Hemodynamic analysis for endovascular treatment in small unruptured intracranial aneurysms: a matched comparison study of flow diverter versus LVIS

Background We compared the treatment of small unruptured intracranial aneurysms (UIAs) with flow diverter and LVIS-assisted coiling to determine the effects of hemodynamic changes caused by different stent and coil packing in endovascular treatment. Methods Fifty-one UIAs in 51 patients treated with pipeline embolization device (PED) were included in this study and defined as the PED group. We matched controls 1:1 and enrolled 51 UIAs who were treated with LVIS stent, which were defined as the LVIS group. Computational fluid dynamics were performed to assess hemodynamic alterations between PED and LVIS. Clinical analysis was also performed between these two groups after the match. Results There was no difference in procedural complications between the two groups (P = 0.558). At the first angiographic follow-up, the complete occlusion rate was significantly higher in the LVIS group compared with that in the PED group (98.0% vs. 82.4%, P = 0.027). However, during the further angiographic follow-up, the complete occlusion rate in the PED group achieved 100%, which was higher than that in the LVIS group (98.0%). Compared with the LVIS group after treatment, cases in the PED group showed a higher value of velocity in the aneurysm (0.03 ± 0.09 vs. 0.01 ± 0.01, P = 0.037) and WSS on the aneurysm (2.32 ± 5.40 vs. 0.33 ± 0.47, P = 0.011). Consequently, the reduction ratios of these two parameters also showed statistical differences. These parameters in the LVIS group showed much higher reduction ratios. However, the reduction ratio of the velocity on the neck plane was comparable between two groups. Conclusions Both LVIS and PED were safe and effective for the treatment of small UIAs. However, LVIS-assisted coiling produced greater hemodynamic alterations in the aneurysm sac compared with PED. The hemodynamics in the aneurysm neck may be a key factor for aneurysm outcome.

Intrasaccular flow disruption for brain aneurysms: a systematic review of long-term outcomes

OBJECTIVE The long-term safety and efficacy of intrasaccular flow disruption (IFD) for the treatment of brain aneurysms remain unclear. With accumulating experience and increasing use of IFD devices, recent studies have provided additional data regarding their outcomes. This review summarizes the long-term outcomes of IFD-treated brain aneurysms. METHODS A systematic literature review was performed on May 23, 2021, in PubMed, Web of Science, and Ovid MEDLINE for aneurysm treatment outcomes with IFD devices. Procedural details, including use of adjunctive devices and complications, were collected. The quality of studies was assessed using the Downs and Black checklist. Angiographic outcomes were classified as complete occlusion, residual neck, and residual aneurysm. Other outcomes included need for retreatment, permanent neurological deficit, and mortality. Pooled analyses were performed. RESULTS The final analysis comprised 1217 patients with 1249 aneurysms from 22 studies. The mean aneurysm diameter and neck width were 6.9 and 4.5 mm, respectively, and 27.6% of aneurysms were ruptured. The complete occlusion rates at 12 months and final follow-up (pooled mean duration 15.7 months) were 50.1% and 58.2%, respectively. Adjunctive devices were used in 6.4% of cases. The rates of hemorrhage, symptomatic infarction, permanent neurological deficit, and mortality were 1.2%, 2.8%, 1.0%, and 2.6%, respectively. CONCLUSIONS IFD is a very safe treatment for appropriately selected brain aneurysms with low complication and neurological deterioration rates. However, complete occlusion is achieved in only half of IFD-treated aneurysms at 1 year with a modest increase beyond this time point. As the majority of the studies were single arm, the pooled data are subject to selection and reporting biases. Future device developments, increased operator experience, and direct comparisons with alternative endovascular strategies and surgical clipping may clarify the role of IFD in aneurysm management.

Moyamoya Syndrome in a Child with HbEβ-Thalassemia

Moyamoya is a progressive cerebrovascular disease associated with stenosis or occlusion of the arteries of the Circle of Willis. It is uncommon in thalassemia. We present a 9-year-old girl, with HbEβ-thalassemia, who presented with headache, vomiting and episodes of transient hemiparesis with complete occlusion internal carotid arteries.

A randomized controlled study comparing microsurgical clipping via the keyhole approach, conventional craniotomy, and endovascular coiling for ruptured anterior circulation aneurysms

Objective: Few prospective randomized controlled studies have investigated the efficacy of endovascular treatment and microsurgical clipping of intracranial aneurysms, especially via microsurgical keyhole approach. We compared the efficacy of three techniques in treating patients with ruptured anterior circulation aneurysms to provide surgeons with a more objective basis for treatment selection. Methods: 150 patients with ruptured anterior circulation aneurysms were randomly assigned to endovascular treatment, conventional craniotomy, and keyhole approach groups. Aneurysm occlusion, surgical time, hospitalization time, hospitalization expenses, and surgical complications were compared between groups. Results: The complete occlusion rates of aneurysms at discharge were 90% in the endovascular group, 94% in the conventional group, and 96% in the keyhole group. No significant differences in complete occlusion rates or Glasgow Outcome Scale scores were found between groups. In the keyhole approach, conventional craniotomy, and endovascular groups, the overall surgical times were 161.78±34.51 min, 201.55±38.79 min, and 85.86±58.57 min, respectively; the hospitalization times were 11.42±6.64 d, 18.03±7.14 d, and 10.57±8.67 d; hospitalization expenses were 10574.25±4154.25 USD, 13214.54±5487.65 USD, and 20134.58±6587.61 USD; and the incidence rates of postoperative complications such as intracranial infection, cerebral vasospasm, hydrocephalus, intracranial hematoma, and epilepsy were 8%, 28%, and 20%. Conclusions: Endovascular coiling and the microsurgical keyhole approach have the advantages of simple execution, time savings, and short hospitalization. Microsurgical clipping of intracranial aneurysms needs to be updated to a minimally invasive procedure to maintain its complementary value with endovascular treatment.Clinical trial registration: The study has been retrospectively registered in clinicaltrial.org (NCT05049564) in Sep. 8th, 2021.

Blister-like aneurysm of the anterior communicating artery treated with only Low-profile Visualized Intraluminal Support Junior stent

Background: Endovascular treatment is becoming a mainstream treatment for blister-like aneurysms in recent years. Blister-like aneurysms are usually located in the internal carotid artery, whereas that of the anterior communicating artery (AcomA) are very rare. We report the first case of blister-like aneurysm of AcomA that was treated solely with a neck bridging stent that resulted in complete occlusion without complication. Case Description: A 50- year- old woman was admitted to our hospital due to a subarachnoid hemorrhage. Digital subtraction angiography showed a very small aneurysm in the dorsal side of the AcomA. We considered it a blister-like aneurysm based on its size and shape. She underwent endovascular treatment under general anesthesia on day 15 after vasospasm period. Dual antiplatelet therapy was administrated 1 week prior. A Low-profile Visualized Intraluminal Support Junior stent was implanted from the left A2 to the right A1, covering the AcomA. The postoperative course was uneventful, and she was discharged with no neurological deficit. The aneurysm remained unchanged on postoperative day 14; however, complete occlusion was achieved 3 months after the treatment. Conclusion: Monotherapy with a neck bridging stent is an effective treatment option for blister-like aneurysms. Treatment with a single stent could achieve complete occlusion especially if the aneurysms occur elsewhere than the internal carotid artery. We should consider immediate additional treatment if the aneurysm grows within 1 month after initial treatment.

Endoluminal flow diverting stents for middle cerebral artery bifurcation aneurysms: multicenter cohort

BackgroundData regarding the safety and efficacy of flow diverting stents (FDS) in the treatment of middle cerebral artery (MCA) bifurcation aneurysms are scarce and limited to small single center series, with particular concern for increased risk of ischemic complications with jailing one of the M2 branches.MethodsProspectively-maintained databases at six North American and European centers were queried for patients harboring MCA bifurcation aneurysms undergoing treatment with FDS (2011–2018). The pertinent clinical and radiographic data were collected and analyzed.Results87 patients (median age 60 years, 69% females) harboring 87 aneurysms were included. The majority of aneurysms were unruptured (79%); 75.9% were saccular with a median maximal diameter of 8.5 mm. Radiographic imaging follow-up was available in 88.5% of cases at a median of 16.3 months post-treatment, showing complete occlusion in 59% and near complete occlusion (90–99%) in 18% of aneurysms. The overall rate of ischemic and hemorrhagic complications was 8% and 1.1%, respectively. Symptomatic and permanent complications were encountered in 5.7% and 2.3% of patients respectively, with retreatment pursued in 2.3% of patients. Jailed branch occlusion was detected in 11.5% of cases, with clinical sequelae in 2.3%. Last follow-up modified Rankin Scale of 0–2 was noted in 96.8% of patients. On multivariate analysis, male sex was the only independent predictor of aneurysmal persistence at last follow-up imaging (p=0.019).ConclusionFDS treatment for MCA bifurcation aneurysms is feasible, with comparable safety and efficacy profiles to other available endovascular options when utilized in carefully selected aneurysms. Jailing of M2 branches was not associated with a higher risk of post-procedural ischemic complications.

Abstract 1122‐000138: De Novo Intracranial Stenosis after Mechanical Thrombectomy with Stent Retrievers

Introduction : Increased vascular damage with the use of stent‐retrievers (SR) has been shown on histopathological analysis of the vascular tissue immediately after mechanical thrombectomy (MT) in animal models. We hypothesized that intraoperative endovascular damage‐intimal injury could result in fibrosis and de novo vascular stenosis (dnVS). The purpose of the study is to identify de novo or worsening intracranial stenosis (wICS) of the treated vessel(s) on patients who underwent MT for the treatment of acute ischemic stroke with SR, on follow‐up vascular imaging (FVI). Methods : This was a retrospective chart review. Patients who underwent MT with SR at two centers from January 2015‐December 2020, who had FVI (CTA, MRA or cerebral angiogram) were included. Patient characteristics, procedural details, timing for FVI and clinical outcomes were collected. Two neuroradiologists reviewed baseline angiograms and FVI to assess for the presence of dnVS or wICS, and graded each stenosis and collateral scores (CS), when stenosis was present. CS were calculated using the multiphase CT angiography collateral score (mCTA). Fischer exact test and Mann‐Whitney U test were used to assess for differences in categorical and continuous variables, respectively. Statistical analysis was performed using SPSS 28.0 (IBM Corp.). Results : Forty‐six patients within this cohort had FVI with 9 patients developing dnVS or wICS in the follow‐up period (19.6%) with a median follow‐up of 113 days. Five of these patients demonstrated a complete occlusion of the target vessel on FVI. Of the remaining 4 patients, mean degree of stenosis was 55%. Only 2 of these patients had underlying stenosis on baseline post‐treatment angiogram: one with 44% stenosis which progressed to 95% in 2 months. Another with mild stenosis that progressed to complete occlusion in 50 days. Adequate revascularization, defined as TICI score >2b was achieved in 88.8% of patients with dnVS or wICS, and in 89.2% of patients with stable FVI. No significant differences were observed in baseline demographics, NIHSS score at presentation or initial ASPECTS. Median number of passes was identical between patients who developed dnVS or wICS (median 1, IQR [1, 2], p = 0.683). Mean CS for dnVS or wICS was 3. No significant differences were observed in discharge or follow‐up NIHSS scores, mRS, mortality, or recurrent stroke or TIA between the two cohorts. Conclusions : MT with SR can be associated with dnVS or wICS in some patients. The number of passes with SR did not seem to have an impact on this. Patients with dnVS or wICS did not have a higher incidence of recurrent stroke or TIA. This could be due to the development of new collaterals in this population. Our study is limited by a small cohort, however, larger studies might be challenging as standardized radiological follow up of these patients has not been implemented.