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.

Predicting the Aortic Aneurysm Postoperative Risks Based on Russian Integrated Data

This article describes the results of feature extraction from unstructured medical records and prediction of postoperative complications for patients with thoracic aortic aneurysm operations using machine learning algorithms. The datasets from two different medical centers were integrated. Seventy-two features were extracted from Russian unstructured medical records. We formulated 8 target features: Mortality, Temporary neurological deficit (TND), Permanent neurological deficit (PND), Prolonged (> 7 days) lung ventilation (LV), Renal replacement therapy (RRT), Bleeding, Myocardial infarction (MI), Multiple organ failure (MOF). XGBoost showed the best performance for most target variables (F-measure 0.74–0.95) which is comparable to recent results in cardiovascular postoperative risks prediction.

The ARTISSE intrasaccular device for intracranial aneurysm treatment: short-term, mid-term and long-term clinical and angiographic results

BackgroundThe concept of intra-aneurysmal flow disruption has emerged as a new paradigm for the treatment of primarily bifurcation aneurysms. The purpose of this study was to determine the clinical and angiographic outcomes of patients treated with the new ARTISSE intrasaccular device (ISD).MethodsSelected patients with bifurcation aneurysms that matched the indications of the ARTISSE ISD defined by the manufacturer were treated in a single center. Clinical and angiographic follow-up was conducted at 6 and 36 months. Aneurysm occlusion was assessed using the Raymond–Roy classification scale.ResultsNine subjects with nine unruptured bifurcation aneurysms were enrolled. Mean aneurysm size was 7.2±1.2 mm (range 5.5–9.7 mm). An adequate aneurysm occlusion (defined as a complete occlusion or a neck remnant) was achieved in 6/9 patients (66.7%) at 6 months and 4/7 patients (57.1%) at 36 months follow-up. Two of the nine subjects experienced a major stroke (22.2%), including one on postoperative day 1 due to a procedure-related parent vessel occlusion and subsequent ischemic stroke. The other major stroke occurred within the 36-month follow-up period during treatment of a separate aneurysm with coils, leading to perforation with hemorrhagic stroke causing a permanent neurological deficit.ConclusionThe ARTISSE ISD was successfully deployed in all nine cases. There were, however, several procedure-related complications and results in terms of angiographic aneurysm occlusion were modest.

Combined Pipeline Embolization Device with Endoscopic Endonasal Fascia Lata/Muscle Graft Repair as a Salvage Technique for Treatment of Iatrogenic Carotid Artery Pseudoaneurysm

The incidence of internal carotid artery (ICA) injury associated with endoscopic endonasal approaches to the pituitary is less than 1%. While parent vessel sacrifice has historically been the choice of treatment, vessel-preserving endovascular techniques have been reported. Although flow diversion offers endoluminal reconstruction, its major limitation is the delay in obtaining complete occlusion. We describe the use of a combined Pipeline embolization device (PED) with endoscopic endonasal repair using a fascia lata/muscle graft to treat an iatrogenic ICA pseudoaneurysm and report long-term radiographic follow-up. Further investigation into the utility of directed endoscopic endonasal repair of iatrogenic pseudoaneurysms initially treated with PED is necessary, especially given the need of post-PED anticoagulation and the rate of permanent neurological deficit after ICA sacrifice.

63 The “Brighton Connector”: A Simple, Reproducible and Cost-Effective Technique for Bilateral Antegrade Cerebral Perfusion During Aortic Arch Surgery

Aim Surgery of the aortic arch presents significant technical and physiological challenges. Selective antegrade cerebral perfusion (SACP) during arch surgery has been shown to improve mortality and neurological outcomes in these patients. At our centre, we aimed to develop a safe, reliable, and cost-effective technique to provide bilateral antegrade cerebral perfusion without the need of another pump head. Method We developed our system using equipment that is included in the accessory packaging for the Sorin Xtra cell saver system, which is readily available in cardiac surgical units nationwide, but often discarded as it is not required. An EOPA arterial return cannula and the TRUE FLOW RDB SACP cannula were joined using our novel connection. Results A single surgeon has used the “Brighton Connector” for 6 patients in the last two years. All patients made a satisfactory recovery with a 0% rate of mortality or permanent neurological deficit. Conclusions All components in our circuit are already approved for use in cardiac theatres, and the connection tubing would normally be discarded, making our method cost neutral. We demonstrate through a case series that mortality and neurological outcomes are good and comparable with other techniques.

Reduction of ileocolic intussusception under sedation or anaesthesia: a systematic review of complications

BackgroundDespite the increased use of sedation in children undergoing stressful procedures, reduction of ileocolic intussusception (RII) is usually performed on awake children without any form of sedation.ObjectiveTo evaluate the incidence of severe complications of RII under sedation or anaesthesia.DesignA systematic review including English language original articles of any date.PatientsChildren undergoing RII (pneumatic or hydrostatic) under sedation or anaesthesia.Data sourcesOvid Embase, Scopus, PubMed, the Cochrane Database of Systematic Reviews and the internet search engine Google Scholar.Data extractionThree authors independently reviewed each article for eligibility. The Newcastle-Ottawa Scale was used to assess the quality of included studies.Main outcome measuresThe primary outcome was the incidence of intestinal perforation during RII. The secondary outcomes were the incidence of sentinel adverse events defined as death, cardiopulmonary resuscitation, permanent neurological deficit and pulmonary aspiration syndrome.ResultsThe search yielded 368 articles. Nine studies with 1391 cases were included in the analysis. Of the nine studies, six had a score of ≤6 stars in the Newcastle-Ottawa Scale assessment, indicating low-to-moderate quality. Propofol-based sedation was used in 849 (59.2%) cases; 5 (0.6%) had intestinal perforation. Intestinal perforation was not reported in patients who were sedated with other sedatives. One patient had pulmonary aspiration syndrome.ConclusionsAlthough caution remains warranted, current data suggest that the incidence of severe complications due to RII under sedation or anaesthesia is low. Due to the lack of prospective data, it is difficult to ascertain the exact incidence of severe complications.

Similar surgical outcomes of the growing rod technique for treatment of early-onset scoliosis with versus without untreated intraspinal anomalies

OBJECTIVE The aim of this study was to compare the radiological and clinical outcomes of early-onset scoliosis (EOS) patients with or without intraspinal anomalies (IAs) managed with growing rods (GRs), and to evaluate the safety of the GR technique in EOS patients with untreated IAs. METHODS EOS patients undergoing GR placement between August 2008 and July 2017 were retrospectively reviewed. Patients with untreated IAs were classified into the EOS+IA group, and those without IAs into the EOS−IA group. The radiographic parameters including Cobb angle of the major curve, T1–S1 height, and apical vertebral translation were measured, and a detailed assessment of the neurological status was performed at each visit. RESULTS Seventy-six patients with EOS (32 boys, 44 girls) with an average age of 6.5 ± 2.3 years at initial surgery satisfied the inclusion and exclusion criteria, including 28 patients in the EOS+IA group and 48 patients in the EOS−IA group. The radiographic measurements were comparable between groups preoperatively, postoperatively, and at the latest follow-up. One patient in the EOS+IA group experienced sensory deficit in a unilateral lower extremity after initial surgery, and an intraoperative neurophysiological monitoring event was observed in a patient in the EOS−IA group. No permanent neurological deficit was observed in either group. CONCLUSIONS EOS patients with and those without IAs had comparable clinical and radiological outcomes of the GR technique. Repeated lengthening procedures may be safe for EOS patients with untreated IAs.

A Novel Approach to Brachial Plexus Injections: A Technical Report

Background: Brachial plexus injects are common procedures for pain management of the upper limb. Complications from theses injections, however, can be severe leading to permanent neurological deficit. The purpose of this technical report is to introduces a safe novel approach for brachial plexus injections. Case Presentation: A 45-year-old woman with type 2 complex region pain disorder underwent a novel brachial plexus injection. The patient was brought to the operating room where fluoroscopy was used to locate the T2 lamina. A 17-gauge introducer needle was maneuvered through the interlaminar space and into the epidural space. The stylet was removed and a Brevi Kath® (Epimed, Dallas, TX) was passed through the C7-T1 foramen into the brachial plexus region. Contrast was used to ensure proper placement and absence of vascular pickup. The injection was then given, and the catheter withdrawn. The procedure was done without complication and the patient had a 40% reduction in pain symptoms based on a visual analog scale. She was cleared to restart physical therapy. Conclusions: This novel technique approaches the brachial plexus by gaining access to the thoracic epidural space and following the spinal nerves through their respective foramen. The use of fluoroscopy and contrast ensures correct placement of injection. A blunt catheter limits the risk of injury. This approach may benefit patients who have failed standard techniques using local landmarks or those that are not ideal candidates due to previous injury or pre-existing conditions. Key words: Interventional pain, injection, brachial plexus, pain management, fluoroscopy

Long-term Implication of Metronidazole Induced Reversible Cerebellar Toxicity and Peripheral Neuropathy- A Case Report

Metronidazole Induced Encephalopathy (MIE) is rare and serious central nervous system toxicity. A 40-year-old male, on long-term self treatment with metronidazole (cumulative dose: 102 gm) presented with dysarthria, nystagmus, unsteadiness, and numbness in both legs. A Magnetic Resonance Imaging (MRI) scan of the brain revealed a symmetric hyperintensity in both the dentate nuclei of cerebellum on both T2 weighted and Fluid-Attenuated Inversion-Recovery (FLAIR) imaging. Discontinuation of metronidazole resulted in resolution of the imaging findings and clinical improvement occurred within one month. Metronidazole-induced neurotoxicity should be considered in patient who present with cerebellar symptoms and characteristic lesion on MRI in close temporal relation with metronidazole intake and drug should be discontinued to prevent permanent neurological deficit.