OBJECTIVE:With a globally aging population, it is imperative to develop specific treatment strategies for intracranial aneurysms in the elderly. However, the optimal management of intracranial ...aneurysms in the elderly remains controversial, particularly for the unruptured aneurysms. Although endovascular treatment is increasingly being used for the management of aneurysms, large endovascular series in the elderly population are relatively lacking, especially with regard to the unruptured aneurysms. We present our single-center endovascular experience in treating intracranial aneurysms in 63 consecutive patients 70 years of age and older.
METHODS:Between November 1998 and December 2003, among a total of 990 patients with intracranial aneurysms treated endovascularly at our center, 63 patients (6%) were 70 years of age or older. Forty-one patients presented with subarachnoid hemorrhage (SAH), and 22 presented with symptomatic unruptured aneurysms. A total of 84 aneurysms were detected in these 63 patients. Only those responsible for either the subarachnoid hemorrhage or clinical symptoms (68 aneurysms) were treated. The aneurysm characteristics, endovascular procedures and techniques, angiographic and clinical outcomes, and complications were reviewed.
RESULTS:Selective embolization failed in three aneurysms (4%). In the remaining 65 aneurysms, complete occlusion was achieved in 33 aneurysms (51%), neck remnant was observed in 17 aneurysms (27%), and residual aneurysmal filling was observed in six aneurysms (9%). Parent vessel occlusion was used in the treatment of nine aneurysms (13%). Thirteen procedure-related complications occurred (19%), six of which resulted in clinical complications (9%). Nine deaths (14%) occurred; three (5%) were directly related to the endovascular procedures, and six (9%) were related to the medical complications of SAH. The remaining 54 patients had a mean clinical follow-up time of 13 months (range, 1–47 mo). Ninety-one percent (20 out of 22) of the patients with unruptured aneurysms and 89% (25/28) of the patients with low-grade (Hunt and Hess Grade I and II) ruptured aneurysms achieved excellent outcomes (modified Rankin Scale score, 0–1), whereas 77% (10 out of 13) of the patients with high-grade (Hunt and Hess Grade ≥ III) ruptured aneurysms either died or had very poor outcomes (modified Rankin Scale score, 4–5). Angiographic follow-up (mean, 11 mo; range, 3–38 mo) was obtained in 34 of the 54 living patients (63%). Two aneurysms demonstrated minor changes that required no further treatment (5%). Five aneurysms showed major recurrences (17%), all of which were successfully retreated endovascularly.
CONCLUSION:The elderly patients should merit strong consideration for endovascular treatment of both ruptured and symptomatic unruptured intracranial aneurysms. However, in elderly patients with high-grade subarachnoid hemorrhage, morbidity and mortality rates remain high.
Hyperperfusion syndrome is a rare but well-described complication after endarterectomy or stenting in the carotid circulation.
A 66-year-old man who had vertebrobasilar insufficiency refractory to ...medical treatment because of an intracranial right side vertebral stenosis was referred to our institution for endovascular treatment. Stenting was performed, and after 24 hours, he became extremely agitated, and this was followed by a period of apathy without focal neurological deficits. MRI showed bilateral thalamic hemorrhage.
To our knowledge, this is the first report of hyperperfusion syndrome with hemorrhagic presentation after intracranial vertebral artery stenting.
To describe a variant of the stent-assisted coiling technique in the endovascular treatment of aneurysms with a dome-to-neck ratio less than 1.5.
This technique, named the stentjack technique, ...consisted of the deployment of a first coil before the delivery of a self-expandable stent across the aneurysm neck without detachment. Once the stent was deployed, the first coil was detached.
This maneuver enabled us to constrain the coil loops within the sac before detachment of the first coil, a coil that is often critical when dealing with broad-neck aneurysms. We successfully treated three patients harboring wide-neck aneurysms.
We found that the stentjack technique was helpful in the treatment of selective aneurysms with a dome-to-neck ratio smaller than 1.5.
The Brazilian public health system determines a quantity of coils allowed to treat a cerebral aneurysm. The goal of this paper was to determine the number of coils necessary to treat an aneurysm ...based on size.
All patients harboring an aneurysm treated by endovascular approach between 1999 and 2003 were reviewed.
There were 952 aneurysms included. Mean diameter sac was 8.2 mm with 7.9 coils per aneurysm. Out of 462 small aneurysms, mean size was 4.8 mm, with 4.6 coils/aneurysm used. A total of 315 medium aneurysms were treated, mean size was 8.6 mm, with 8.2 coils. Out of 135 large, mean size was 17 mm, with 16.1 coils. Forty giant aneurysms were treated with a mean size of 32 mm and 28.7 coils.
We propose size as a reference to predict the number of coils necessary to treat each aneurysm: one coil for each millimeter of diameter.
Stent-assisted coiling has expanded the treatment of intracranial aneurysms, but the rates of procedure-related neurological complications and the incidence of angiographic aneurysm recurrence of ...this novel treatment are not yet well known. We present our experience with stent-assisted coiling with special emphasis on procedure-related neurological complications and incidence of angiographic recurrence.
Clinical and angiographic outcomes of 1137 consecutive patients (1325 aneurysms) coiled with and without stent-assisted coiling technique from January 2002 to January 2009 were retrospectively analyzed.
There were 1109 aneurysms (83.5%) treated without and 216 (16.5%) treated with stents (15 of 216; 6.9% balloon-expandable versus 201 of 216; 93.1% self-expandable stents). Stents were delivered after coiling in 55.1% (119 of 216) and before coiling in 44.9% (97 of 216) of the cases. Permanent neurological procedure-related complications occurred in 7.4% (16 of 216) of the procedures with stents versus 3.8% (42 of 1109) in the procedures without stents (logistic regression P=0.644; OR: 1.289; 95% CI: 0.439 to 3.779). Procedure-induced mortality occurred in 4.6% (10 of 216) of the procedures with stents versus 1.2% (13 of 1109) in the procedures without stents (logistic regression P=0.006; OR: 0.116; 95% CI: 0.025 to 0.531). A total of 52.7% (114 of 216) of aneurysms treated with stents have been followed so far versus 69.8% (774 of 1109) of aneurysms treated without stents, disclosing angiographic recurrence in 14.9% (17 of 114) versus 33.5% (259 of 774), respectively (Fisher exact test P<0.0001; OR: 0.3485; 95% CI: 0.2038 to 0.5960).
Stents were associated with a significant decrease of angiographic recurrences, but they were associated with more lethal complications compared with coiling without stents.
Abstract We report a 61-year-old male with an intraorbital arteriovenous fistula. Due to the close proximity of the arterial feeder to the central retinal artery, and the tiny calibre of the draining ...branches of the superior ophthalmic vein, transvenous embolization of the fistula by Onyx was preferred. The procedure completely obliterated the shunt and the patient had complete relief of symptoms within 6 months.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Objectives
To establish dose reference levels (RLs) for stroke interventions while carefully analysing the impact of clinical and technical parameters on patient exposure.
Methods
The study ...retrospectively analysed data from 377 stroke patients prospectively collected between 15 October 2015 and 30 March 2017 at a single, level-3 stroke centre equipped with Philips Allura Clarity systems. Local dose RLs were first derived as the 75th percentile of the dose area product (DAP), cumulative air kerma (
K
a,r
), fluoroscopy time (FT) and the number of images (NI). Univariate and multivariate negative binomial regressions were considered for the statistical analysis to investigate the dose variability with clinical and technical parameters such as patient’s age and sex, occlusion removal technique, number of passages, single-plane or biplane equipment, etc.
Results
Local stroke dose RLs were derived in terms of total DAP (162 Gy cm
2
),
K
a,r
(854 mGy), FT (42 min) and NI (559). Gender (relative dose multiplier (RDM) 1.31; 95% CI 1.12–1.45), number of passages (RDM 1.22 per passage; 95% CI 1.10–1.22) and procedure success (RDM 0.52, 95% CI 0.55–0.80) proved to be key parameters affecting patient dose. Meanwhile the statistical analysis did not find any difference in relative dose received by patients owing to age, baseline NIHSS score, occlusion removal technique, posterior circulation, support of an anaesthesiologist or use of biplane equipment.
Conclusions
Stroke dose RLs introduced in this work promote the optimisation of patient doses. Male gender, number of passages and success of recanalisation are independent key parameters affecting patient dose.
Key Points
• Stroke dose RLs derived in terms of total DAP (162 Gy cm
2
), K
a,r
(854 mGy), FT (42 min) and NI (559) will help optimise the radiation safety of patients treated with mechanical thrombectomy.
• Male gender (relative dose multiplier 1.31; 95% CI 1.12–1.45), number of passages (RDM 1.22 per passage; 95% CI 1.10–1.22) and success of recanalisation TICI score > 2b (RDM 0.52, 95% CI 0.55–0.80) are independent key parameters affecting patient dose.
• Stent retriever or aspiration technique showed no significant difference in terms of the dose delivered to the patient; neither technique should be favoured for dosimetric reasons provided that there is no difference regarding clinical outcomes.
"Le mélange des genres" - mixing genres Moret, Jacques
EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology,
05/2012, Volume:
8, Issue:
1
Journal Article
The concept of the flow-diverter stent (FDS) is to induce aneurysmal thrombosis while preserving the patency of the parent vessel and any covered branches. In some circumstances, it is impossible to ...avoid dangerously covering small branches, such as the anterior choroidal artery (AChA), with the stent. In this paper, the authors describe the clinical and angiographic effects of covering the AChA with an FDS.
Between April 2011 and July 2013, 92 patients with intracranial aneurysms were treated with the use of FDSs in the authors' institution. For 20 consecutive patients (21.7%) retrospectively included in this study, this involved the unavoidable covering of the AChA with a single FDS during endovascular therapy. AChAs feeding the choroid plexus were classified as the long-course group (14 cases), and those not feeding the choroid plexus were classified as the short-course group (6 cases). Clinical symptoms and the angiographic aspect of the AChA were evaluated immediately after stent delivery and during follow-up. Neurological examinations were performed to rule out hemiparesis, hemihypesthesia, hemianopsia, and other cortical signs.
FDS placement had no immediate effect on AChA blood flow. Data were obtained from 1-month clinical follow-up in all patients and from midterm angiographic follow-up in 17 patients (85.0%), with a mean length of 9.8 ± 5.4 months. No patient in either group complained of transient or permanent symptoms related to an AChA occlusion. In all cases, the AChA remained patent without any flow changes.
The results of this study suggest that when impossible to avoid, the AChA may be safely covered with a single FDS during intracranial aneurysm treatment, irrespective of anatomy and anastomoses.
OBJECT WEB is an innovative intrasaccular treatment for intracranial aneurysms. Preliminary series have shown good safety and efficacy. The WEB Clinical Assessment of Intrasaccular Aneurysm Therapy ...(WEBCAST) trial is a prospective European trial evaluating the safety and efficacy of WEB in wide-neck bifurcation aneurysms. METHODS Patients with wide-neck bifurcation aneurysms for which WEB treatment was indicated were included in this multicentergood clinical practices study. Clinical data including adverse events and clinical status at 1 and 6 months were collected and independently analyzed by a medical monitor. Six-month follow-up digital subtraction angiography was also performed and independently analyzed by a core laboratory. Success was defined at 6 months as complete occlusion or stable neck remnant, no worsening in angiographic appearance from postprocedure, and no retreatment performed or planned. RESULTS Ten European neurointerventional centers enrolled 51 patients with 51 aneurysms. Treatment with WEB was achieved in 48 of 51 aneurysms (94.1%). Adjunctive implants (coils/stents) were used in 4 of 48 aneurysms (8.3%). Thromboembolic events were observed in 9 of 51 patients (17.6%), resulting in a permanent deficit (modified Rankin Scale mRS Score 1) in 1 patient (2.0%). Intraoperative rupture was not observed. Morbidity (mRS score > 2) and mortality were 2.0% (1 of 51 patients, related to rupture status on entry to study) and 0.0% at 1 month, respectively. Success was achieved at 6 months in 85.4% of patients treated with WEB: 23 of 41 patients (56.1%) had complete occlusion, 12 of 41 (29.3%) had a neck remnant, and 6 of 41 (14.6%) had an aneurysm remnant. CONCLUSIONS The WEBCAST study showed good procedural and short-term safety of aneurysm treatment with WEB and good 6-month anatomical results.
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