Flow diverters have been increasingly used lately in off-label, distal intracranial aneurysm treatments. Our aim was to evaluate the effectiveness of flow diverters in the treatment of middle ...cerebral artery bifurcation aneurysms and to analyze midterm angiographic patterns of regional flow modifications for safety and clinical outcomes.
Consecutive patients treated from January 2010 to December 2014 by the authors by using endovascular flow-diverting stents for MCA bifurcation aneurysms were evaluated retrospectively with prospectively maintained data. All patients had been followed for at least 12 months after treatment, with at least 2 control angiograms; regional flow-related angiographic modifications were registered by using a new angiographic outcome scale for flow diverters. Data were analyzed with emphasis on procedure-related events, angiographic results, and clinical outcome.
Fifty-eight patients were included in the study, with 63 MCA bifurcation aneurysms; 13 of these were large and giant. Pretreatment mRS was 0 for 12 patients (20.7%), 1 for 41 (70.7%), and 2 for 5 patients (8.6%). Six-month control revealed mRS 0-2 for 57 (98.3%) patients and 3 for 1 (1.7%) patient. Procedure-related morbidity and mortality were 8.6% (5/58) and 0%, respectively. From 95% of still circulating immediate postprocedure angiographic outcomes, 68% progressed to aneurysm occlusion at 6 months and 95%, to occlusion at 12 months, with a 0% aneurysm rupture rate.
Flow diverters seem to be an effective treatment alternative for complex MCA bifurcation aneurysms, with reasonable complication rates. Longer angiographic follow-ups are needed to assess the morphologic outcome; immediate subtotal occlusions do not seem to be related to rupture.
Intracranial hemorrhage represents a severe complication of brain arteriovenous malformation treatment. The aim of this cohort was to report the rate of hemorrhagic complications after transvenous ...endovascular embolization and analyze the potential angioarchitectural risk factors as well as clinical outcomes.
During an 11-year period, 57 patients underwent transvenous endovascular embolization. All cases of hemorrhagic complications were identified. We analyzed the following variables: sex, age, hemorrhagic presentation, Spetzler-Martin grade, size of the AVM before the transvenous treatment, number of venous collectors, pattern of drainage, presence of dilated veins, and technical aspects. Univariate and multivariate multiple regression analyses were performed to evaluate the potential risk factors for procedure-related hemorrhagic complications.
Hemorrhagic complications (either intraprocedural or periprocedural) unrelated to a perforation due to micronavigation occurred in 8 (14.0%) procedures. Significant (mRS > 2) and persistent neurologic deficits were present in 2 (3.5%) patients at 6-month control. Larger nidi, especially >3 cm (
= .03), and a larger number of venous collectors have shown a statistically significant correlation with hemorrhagic complications. Only the number of venous collectors was identified as an independent predictor of hemorrhagic complications in the multivariate analysis (OR, 8.7; 95% confidence interval, 2.2-58.2) (
= .006).
Larger nidus sizes and an increased number of venous collectors may increase the risk of hemorrhagic complications when implementing transvenous endovascular treatment of AVMs. The technique is effective and promising, especially with small nidi and single venous collectors.
Multiple technologies have developed the endovascular approach to MCA aneurysms. We assess the safety and the efficacy of a systematic endovascular approach in nonselected patients with MCA aneurysms ...and determine predictors of treatment outcomes.
We analyzed data collected between January 2007 and January 2012 in a prospective clinical registry. All patients with MCA aneurysms treated by means of the endovascular approach were included. A multivariate analysis was conducted to identify predictors of complications, recanalization, and outcome.
A total of 120 patients with 131 MCA aneurysms were included. Seventy-nine patients (65.8%) were treated electively and 41 (34.2%) in the setting of subarachnoid hemorrhage. Thirty-three of 131 aneurysms (25.2%) were treated with simple coiling, 79 aneurysms (60.3%) with balloon-assisted coiling, and 19 aneurysms (14.5%) with stent-assisted coiling. Complications occurred in 13.7% of patients. Stent-assisted coiling was significantly associated with more complications (P = .002; OR: 4.86; 95% CI, 1.60-14.72). At 1 month after treatment, both the permanent morbidity (mRS ≤2) and mortality rates were 3.3%, without any significant difference according to the endovascular techniques. Mean angiographic follow-up was 16.3 months. The rate of recanalization was 15.6% without a statistical difference, according to the technique. Larger aneurysms were a predictor of recanalization (P = .016; OR: 1.183; 95% CI, 1.02-1.36). Retreatment was performed in 10 of 131 aneurysms (7.6%).
Even though stent-assisted coiling significantly increases the risk of procedural complications, endovascular treatment of MCA aneurysms is safe, effective, and provides durable aneurysm closure in nonselected patients.
Flow-diverting stents can be used to treat intracranial aneurysms that are not amenable to treatment with coils. We analyzed ophthalmic consequences due to coverage of the origin of the ophthalmic ...artery by flow-diverting stents for the treatment of internal carotid artery aneurysms.
From April 2009 to April 2013, the clinical and angiographic outcomes of all 28 patients treated for aneurysms with flow-diverting stents covering the origin of the ophthalmic artery were prospectively collected. The origin of the ophthalmic artery in relation to the target aneurysm was classified by using a 4-type classification. A complete ophthalmic examination was performed by a single ophthalmologist 48 hours before and 1 week after covering the ophthalmic artery.
Ophthalmic artery patency was normal at the end of endovascular treatment in 24/28 cases (85.7%). With extensive ophthalmic examinations, 11 patients (39.3%) showed new ophthalmic complications. Patients with the ophthalmic artery originating from the aneurysm sac were at high risk for retinal emboli (4/5, 80%). Patients with the ophthalmic artery originating from the inner curve of the carotid siphon were at high risk for optic nerve ischemic atrophy (3/4, 75%).
This prospective study shows that covering the ophthalmic artery with a flow-diverting stent is not without potential complications. Ophthalmic complications can occur but are often not diagnosed. The anatomic disposition of the ophthalmic artery in relation to the carotid siphon and aneurysm should be clearly understood because some configurations have a higher risk. When not required, covering of the ophthalmic artery by flow-diverting stents should be avoided.
Purpose
In the treatment of wide-necked aneurysms, stenting may be required after balloon-assisted coiling (BAC) for reconstructing the lumen/flow of the parent artery in cases of coil herniation. ...The potential benefits and complications of both techniques remain unclear when used together. Our aim was to assess the safety and long-term angiographic outcomes of stenting after BAC.
Methods
Retrospective review of 87 unruptured wide necked aneurysms (in 80 patients) treated with BAC and requiring stent placement at the final stage of the procedure due to coil prolapse. Aneurysm characteristics, technical issues, clinical records, and MR results were assessed. Post-treatment and follow-up angiograms were evaluated by two independent reviewers and categorized as “stable,” “further thrombosis,” or “recanalization.”
Results
The mean maximum diameter was 9.1 ± 4.7 mm and aspect ratio 1.20 ± 0.47. Complete and near-complete initial occlusion were observed in 53 (60.9%) and 28 (32.2%) of all treated aneurysms, respectively. Angiographic follow-up (80 aneurysms; mean, 34.68 ± 25.26 months) revealed stability and further thrombosis in 92.4% (74/80). Recanalization was observed in six cases (7.5%, 6/83), four of which were retreated. No significantly different outcomes were found in terms of aneurysm size (
p
= 0.641). Transient and reversible procedure-related complications occurred in eight (9.2%), minor permanent deficits in 2.3%, and major deficits, including death, in four cases (4.6%).
Conclusion
Our results suggest that treatment of wide-necked aneuryms with stent placement after BAC yields low recanalization rates and enhanced angiographic outcomes in long-term follow-up.
To analyze the strengths and limitations of the Family Health Strategy from the perspective of health care professionals and the community.
Between June-August 2009, in the city of Vespasiano, Minas ...Gerais State, Southeastern Brazil, a questionnaire was used to evaluate the Family Health Strategy (ESF) with 77 healthcare professionals and 293 caregivers of children under five. Health care professional training, community access to health care, communication with patients and delivery of health education and pediatric care were the main points of interest in the evaluation. Logistic regression analysis was used to obtain odds ratios and 95% confidence intervals as well as to assess the statistical significance of the variables studied.
The majority of health care professionals reported their program training was insufficient in quantity, content and method of delivery. Caregivers and professionals identified similar weaknesses (services not accessible to the community, lack of healthcare professionals, poor training for professionals) and strengths (community health worker-patient communications, provision of educational information, and pediatric care). Recommendations for improvement included: more doctors and specialists, more and better training, and scheduling improvements. Caregiver satisfaction with the ESF was found to be related to perceived benefits such as community health agent household visits (OR 5.8, 95%CI 2.8;12.1), good professional-patient relationships (OR 4.8, 95%CI 2.5;9.3), and family-focused health (OR 4.1, 95%CI 1.6;10.2); and perceived problems such as lack of personnel (OR 0.3, 95%CI 0.2;0.6), difficulty with access (OR 0.2, 95%CI 0.1;0.4), and poor quality of care (OR 0.3, 95%CI 0.1;0.6). Overall, 62% of caregivers reported being generally satisfied with the ESF services.
Identifying the limitations and strengths of the Family Health Strategy from the healthcare professional and caregiver perspective may serve to advance primary community healthcare in Brazil.
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