The development of new devices, especially controlled detachable coils, has made the endovascular approach one of the modalities for the treatment of intracranial aneurysms. We describe the treatment ...and present the results of 35 patients treated by selective occlusion of basilar artery aneurysms in our department during a period of 2 years (November 1992-November 1994). This period of time was chosen to analyze a homogeneous population treated since the introduction of controlled detachable coils and also to be able to have as many follow-up angiographic controls of the treated aneurysms as possible. The clinical presentation was subarachnoid hemorrhage in 32 patients and transient ischemic attack in 1 patient. In another two patients, the aneurysms were incidentally discovered. The majority of the aneurysms were berry aneurysms. The aneurysms were located at the basilar bifurcation (23 patients), at the basilar tip between the posterior cerebral artery and the superior cerebellar artery (5 patients), on the basilar trunk (3 patients), and at the vertebrobasilar junction (4 patients). Endovascular treatment using coils was achieved in 34 patients, using Guglielmi detachable coils (Target Therapeutics, San Jose, CA) in 29 patients and mechanical detachable spirals (Balt, Montmorency, France) in 5 patients. One patient died during the positioning of the first coil into the aneurysmal sac. Twenty-five of 35 aneurysms (73.5%) were completely occluded. Nine aneurysms (26.5%) were only partially (> 90%) occluded. No subsequent bleeding occurred during the follow-up period. Two patients treated in the acute phase of subarachnoid hemorrhage died days or weeks after endovascular treatment because of complications related to the natural history of subarachnoid hemorrhage (vasospasm in one patient and pulmonary complications in the other). In three patients, clotting occurred during the endovascular procedure. In all three patients, occlusion of the aneurysmal sac was achieved despite clotting. Urokinase was administered to two of the three patients. In the remaining patient, no fibrinolytic therapy was initiated. The clinical outcomes were excellent for all three patients. In this study, the morbidity-mortality rate of the endovascular technique is low (3%). If we include complications related to the subarachnoid bleeding, the morbidity-mortality rate remains low (8.8%) Regarding basilar artery aneurysms, endovascular treatment (selective occlusion by controlled detachable coils) is now useful for some patients, especially those with small aneurysms. However, long-term anatomic follow-up is needed to accurately evaluate the role of this treatment modality in the management of basilar aneurysms.
Introduction
The Woven EndoBridge (WEB) system is an innovative device under evaluation for its capacity to treat wide-neck bifurcation intracranial aneurysms. The purpose of this study is to ...evaluate the use of the different occlusion scales available in clinical practice.
Methods
Seven WEB-experienced neurointerventionalists were provided with 30 angiographic follow-up data sets and asked to grade each evaluation point according to the Bicêtre Occlusion Scale Score (BOSS), firstly based on DSA images only then using additional C-Arm VasoCT analysis. This BOSS evaluation was then converted into the WEB Occlusion Scale (WOS) and into a dichotomized scale (complete occlusion or not). To estimate the inter-rater agreement among the seven raters, an overall kappa coefficient
1
and its standard error (SE) were computed.
Results
Using the five-grade BOSS, raters showed “moderate” agreement (kappa = 0.56). Using the three-grade WOS, agreement appeared slightly better (kappa = 0.59). Strongest inter-rater agreement was observed with a dichotomized version of the scale (complete occlusion or not), which enabled an “almost perfect” agreement (kappa = 0.88). VasoCT consistently enhanced the agreement particularly with regards depicting intra-WEB residual filling.
Conclusion
The WOS is a consistent means to angiographically evaluate the WEB device efficiency. But the five-grade BOSS scale allows to identify aneurysm subgroups with differing risks of recurrence and/or rehemorrhage, which needs to be separated especially at the initial phase of evaluation of this innovative device. The additional use of VasoCT allows better inter-rater agreement in evaluating occlusion and specially in depicting intra-WEB persistent filling.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
Because giant aneurysms (GAs) can be technically difficult to clip, the endovascular approach is becoming increasingly popular. Endovascular treatment of distally located GAs, which often requires ...parent vessel occlusion, is particularly challenging because limited pathways are available for collateral flow. We aimed to determine the outcomes of endovascular attempts to treat GAs downstream from the circle of Willis.
Between 1991 and 1998, 27 patients with 27 distally located very large aneurysms or GAs were evaluated for possible endovascular treatment. Ten underwent selective embolization and 9 were treated with primary parent vessel occlusion, with or without distal bypass. Eight patients could not be treated endovascularly.
Selective embolization resulted in only one cure. Two patients died as a result of subarachnoid hemorrhage during the follow-up period. One coil-treated patient, who underwent subsequent spontaneous parent vessel occlusion, and all nine patients treated primarily with parent vessel occlusion were considered cured after their treatments. Only two patients treated with parent vessel occlusion experienced periprocedural ischemia, which did not result in a major deficit in either case. Of the eight patients who could not be treated endovascularly, one succumbed to surgery, four died while being treated conservatively, and three were lost to follow-up monitoring.
Selective aneurysm embolization is usually not curative in these situations. For selected patients, however, endovascular parent vessel occlusion is usually safe and effective in preventing the progression of symptoms and bleeding.
BACKGROUND:Endovascular treatment of intracranial aneurysms can be technically difficult when the neck is wide. The Solitaire AB stent (Covidien, Irvine, California), the only fully retrieved stent, ...assists in the coiling of wide-neck intracranial aneurysms.
OBJECTIVE:To evaluate the mid-term angiographic follow-up of wide-necked aneurysms treated with the Solitaire AB stent.
METHODS:SOLARE (SOLitaire Aneurysm Remodeling) is a consecutive, prospective study conducted in 7 European centers. A core laboratory evaluated the postoperative and mid-term (6 month ± 15 days) angiographic results by using the Raymond classification Scale. Recanalization was defined as worsening, and progressive thrombosis was defined as improvement in the Raymond scale score.
RESULTS:The mean width of the aneurysm sac was 7.5 mm, and the mean diameter of the aneurysm neck was 4.7 mm. Angiographic mid-term follow-up was obtained in 55 of 65 aneurysms (85.9%). Complete occlusion was achieved in 33 aneurysms (60%); a neck remnant was seen in 16 aneurysms (29.1%) and an aneurysm remnant in 6 aneurysms (10.9%). Of 55 aneurysms, recanalization was observed in 8 aneurysms (14.5%), and progressive thrombosis was observed in 17 aneurysms (30.9%). No bleeding or rebleeding was observed during the follow-up period.
CONCLUSION:Stent-assisted coiling of wide-necked intracranial aneurysms was found to be safe and effective with the Solitaire AB stent at 6-month follow-up. Angiographic results improve with time due to progressive thrombosis of the aneurysm.
ABBREVIATIONS:mRS, modified Rankin ScaleSAC, stent-assisted coiling
To report our experience in the treatment of brain arteriovenous malformations (BAVMs) using Onyx (ev3, Irvine, Calif).
From January 1999 to October 2004, 94 patients with BAVMs were treated ...endovascularly in our department. They were 51 (54%) men and 43 (46%) women with a mean age of 32 years. A total of 210 endovascular procedures were performed with Onyx as the sole embolic agent in 88 procedures; Onyx and n-butyl cyanoacrylate (n-BCA) were used in combination in 50 procedures, and n-BCA alone was used in 72 procedures.
The course of endovascular treatment was completed in 53 patients. In 26 patients (49%, 26/53) an angiographic cure was achieved using embolization as the sole therapeutic technique. Seven (13%, 7/53) patients underwent a surgical resection of the residual BAVM nidus, 20 (38%, 20/53) patients underwent radiosurgical treatment after nidal size reduction <2 cm was accomplished by endovascular treatment. Further endovascular treatment was planned in 33 patients, whereas in 5 patients, the continuation of embolization was aborted due to difficult nidus catheterization. Procedure-related permanent neurologic deficits were observed in 8 (8.5%, 8/94) patients. There were 3 procedure-related deaths.
Onyx is suitable for brain BAVM embolizations and allows obtaining higher rates of anatomic cures compared with those obtained previously with other embolic agents.
L'embolisation transveineuse (ETV) des malformations artério-veineuses (MAV) cérébrales est de plus en plus pratiquée. Chez des patients soigneusement sélectionnés, cette approche a montré son ...efficacité. Nous rapportons les résultats de l'ETV chez des patients ayant des MAV inaccessibles par la voie artérielle ou dont le nidus n'a été que peu réduit par celle-ci.
Etude rétrospective des patients porteurs d'une MAV traitée par ETV au centre NEURI (Hôpitaux Bicêtre et Beaujon) entre 2012 et 2022. Le critère de jugement principal était la faisabilité (accès au nidus) et la sécurité (morbi-mortalité) de l'ETV. Les critères de jugement secondaires comprenaient les complications procédurales, le taux d'occlusion complète immédiat et à distance. Les facteurs de risque d’échec et de complication ont été analysés.
64 patients âgés de 33 (25-48) ans ont été inclus. 62 MAV étaient rompues (97%), leur taille était de 16 (10-24)mm, 24 avaient une localisation profonde (38%) et 10 infratentorielles (16%). Bien que 55% des patients aient reçu un traitement préalable, seulement 23% avaient une occlusion nidale >50% avant l'ETV. Celle-ci était réalisable pour 54 patients (84%) et l'occlusion était complète pour 47 patients (87%) et subtotale pour 5 patients (9%). Une occlusion complète immédiate était obtenue pour 73.4% des MAV éligibles à l'ETV. On notait 14 complications per-procédure (25%) et 4 post-procédure (7%), responsables de 3 déficits transitoires (5%), 7 déficits permanents (12%) et 1 décès (2%), soit une morbi-mortalité de 14%. A 12 mois, le taux d'occlusion complète était de 86% (35 patients). Les 19 perdus de vue vivaient à l’étranger et avaient tous une occlusion immédiate complète.
L'ETV permet d'obtenir un taux très élevé de guérison complète chez des patients présentant une MAV inaccessible par voie artérielle ou non éligible à d'autres thérapeutiques, avec un taux de complications comparable aux occlusions par voie artérielle.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
In a rapidly advancing specialty, it is essential to review the recent studies of alternative new treatments and present their efficacy, safety and outcome. We discuss the recent advances in the ...endovascular treatment of cerebral vasospasm following aneurysmal subarachnoid hemorrhage in the past few years with special focus on the literature regarding this subject in the last 18-24 months.
The recent findings are as follows: effect of papaverine on brain oxygen; recent evaluation concerning nimodipine use; combined intraarterial and intravenous use of milrinone; illustration of the numerous recent studies on nicardipine; the safety and efficacy of high-dose intraarterial verapamil; outcome and adverse effects of intraarterial fasudil; transluminal balloon angioplasty; and recent evaluation of its efficacy and evaluation of its prophylactic use.
Endovascular treatment, including intraarterial vasodilators and transluminal balloon angioplasty, has a very important place in the management of symptomatic vasospasm related to aneurysmal subarachnoid hemorrhage. The efficacy of intraarterial vasodilators has been proven. Numerous studies and analysis of different treatments of cerebrovascular vasospasm took place in the past period. This allowed more understanding and evaluation of their outcome, safety and efficacy helping physicians to choose better treatments to adopt. It emphasizes also the aspects that need more study and research.
Woven EndoBridge (WEB) devices are becoming a reliable option for the treatment of wide-neck bifurcation aneurysms, but clear predictive factors are still missing to understand the one in five ...aneurysm remnant rate.
To evaluate occlusion outcomes after WEB treatment to identify potential determinants of aneurysm occlusion.
A single-center database with consecutive aneurysms treated with WEB between July 2012 and October 2021 was reviewed for potential determinants of aneurysm adequate occlusion (defined as a Bicêtre Occlusion Scale Score (BOSS) of 0, 0', 1 or 2), through univariate and multivariable analysis. Patients without angiographic follow-up were excluded.
215 of 247 individual aneurysms were included in the final analysis, of which 59 (27%) were ruptured. Mean age of patients was 56 years (range 23-90 years) and 65% were female. Mean angiographic follow-up was at 18 months (range 3-97 months). Adequate and complete occlusion were achieved in 171/215 (79.5%) and 135/215 (62.8%) of cases, respectively. Aneurysm irregular shape (aOR=0.42, 95% CI 0.20 to 0.88; p=0.02), aneurysm height (aOR=0.79, 95% CI 0.66 to 0.94; p<0.01), and WEB shape modification (aOR=0.98, 95% CI 0.97 to 1.00; p=0.02) were all independent predictors of aneurysm recurrence, whereas the WEB oversizing ratio (WEB width/aneurysm mean width) (aOR=16.4, 95% CI 1.4 to 266.7; p=0.04) was an independent predictor of adequate occlusion.
In this study we demonstrated that a width oversizing strategy of the WEB device was an independent predictor of aneurysm angiographic occlusion. Conversely, aneurysm height, irregular aneurysm, and WEB shape modification were all independent determinants of angiographic aneurysm remnant. These results may help to select aneurysms suitable for the WEB device and WEB sizing.
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