Abstract
OBJECTIVE
To demonstrate the curative reconstruction of a giant circumferential basilar trunk aneurysm using the Pipeline embolization device (PED) (Chestnut Medical Technologies, Inc., ...Menlo Park, CA) alone, without embolization coils.
METHODS
A 13-year-old female patient was referred for the treatment of a 4-cm, partially thrombosed, circumferential midbasilar trunk aneurysm. Her presenting symptoms included headache, nystagmus, and left upper-extremity ataxia. Open surgical and conventional endovascular treatment options were thought to be of unacceptably high risk and unlikely to achieve a definitive treatment. The patient underwent PED treatment under a Food and Drug Administration compassionate use exemption.
RESULTS
An endovascular construct was built across the affected segment of the basilar trunk with 7 serially placed, telescoping PEDs, which bridged the 29-mm aneurysm neck. Completion angiography demonstrated considerably decreased flow into the aneurysm, with stasis persisting into the venous phase of angiography. No technical complications were encountered. No new neurological symptoms were evident, and the patient's original presenting symptoms resolved completely within 24 hours after the procedure. She was discharged on postoperative Day 3. Computed tomography performed on postoperative Day 5 demonstrated no change in the size of the collective aneurysm-thrombus mass. Conventional angiography performed on postoperative Day 7 showed anatomic reconstruction of the basilar artery and complete occlusion of the circumferential aneurysm. The patient remains neurologically normal.
CONCLUSION
The PED provides a safe and definitive constructive treatment option for large, giant, and fusiform/circumferential aneurysms. The PED can achieve complete aneurysm occlusion without embolization coils. When applied judiciously, the PED may be used safely in vascular segments that give rise to eloquent perforators.
The Neuroform microstent, a flexible, self-expanding, nitinol stent specifically designed for use in the cerebral vasculature, became available in North America for aneurysm treatment in November ...2002. The present report details our experience with the Neuroform stent over the past 2 years, with an emphasis on evolving treatment strategies and treatment durability at initial (3-6 mo) follow-up.
All patients included in this report were registered in a prospectively maintained database. We assessed the clinical history, indications for stent use, aneurysm dimensions, technical details of the procedures, degree of aneurysm occlusion, angiographic and clinical findings at follow-up, and complications.
Over a 20-month period, 64 patients with 74 aneurysms were treated with 86 Neuroform stents. Of 64 patients, 16 (25%) were treated in the context of subarachnoid hemorrhage (8 acute, 7 subacute, 1 remote). Indications for stent use included broad aneurysm neck (n = 51 stents; average neck, 5.1 mm; aneurysm size, 8.2 mm), fusiform/dissecting morphology (n = 17), salvage/bailout for coils prolapsed into the parent vessel (n = 7), and giant aneurysm (n = 11). Sixty-one aneurysms were stented and coiled with complete or near complete (>95%) occlusion in 28 patients (45.9%) and partial occlusion (<95%) in 33 patients (54%). Follow-up angiographic (n = 43) or magnetic resonance angiographic (n = 5) data (average follow-up, 4.6 mo; median, 4 mo; range, 1.5-13 mo) for 48 aneurysms (46 patients) after stent-supported coil embolization demonstrated progressive thrombosis in 25 patients (52%), recanalization in 11 patients (23%) (8 of whom were retreated), and no change in 12 patients (25%). Follow-up angiography in 5 additional patients with dissecting aneurysms treated with stents alone demonstrated interval vascular remodeling with decreased aneurysm size in all patients. Delayed, severe, in-stent stenosis was observed in 3 patients, 1 of whom was symptomatic and required angioplasty and subsequently superficial temporal artery-to-middle cerebral artery bypass surgery. Using the second-generation Neuroform2 delivery system (n = 53), very few technical problems with stent delivery and deployment have been encountered (n = 2).
The Neuroform stent facilitates adequate embolization of complex cerebral aneurysms, which would not otherwise be amenable to endovascular therapy. Initial follow-up data indicate favorable progressive thrombosis and recanalization rates for aneurysms after Neuroform stent-assisted embolization. These advantages of stenting were most evident for small aneurysms with wide necks.
Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. The aim of this scientific statement is to review the current state of evidence on the ...diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional.
Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge.
Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery-artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard.
CD is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.
Objective The cause of pseudotumor cerebri, or benign intracranial hypertension (BIH), is controversial. We report our results from 18 cases of venous sinus stenting (VSS), the largest series in the ...literature, with specific focus on the rate of technical success, amelioration of the subjective symptom of headache, attendant complications, and radiographic patency on follow-up. Methods Review of our prospectively maintained database identified 18 patients who had undergone 19 VSS procedures for the placement of 30 stents in the past 2.5 years. Indications for treatment included a clinical diagnosis of BIH with venographic demonstration of stenosis. Results VSS was technically successful in all patients (100%). No patient suffered a permanent complication. Three patients were lost to follow-up. The remaining 15 patients were followed clinically and asked to rate their headache severity on a scale of 1 to 10 both before and after VSS. Overall, 12 patients (80%) qualified their headaches as better after VSS, two stated that they were the same, and one patient said that they were worse. Of 14 patients who underwent follow-up angiography, all demonstrated normal patency of the stented segments. In one of these patients, stenosis was detected on follow-up in the unstented segment of the sigmoid sinus and jugular bulb. Conclusions VSS is highly effective (80%) in ameliorating headache associated with BIH. The procedure is associated with a high rate of technical success (100%), a low rate of permanent complications (0), and a high rate of stent patency on follow-up angiography (100%).
OBJECT The optimal strategy for use of the Pipeline Embolization Device (PED, ev3 Neurovascular) has not been clearly defined. The authors examined re-treatment rates after treatment with PED alone ...versus PED and adjunctive coil embolization (PED/coil). METHODS The authors retrospectively examined cerebral aneurysms treated with the PED from May 2011 to March 2014. Overall, 133 patients (25 men, 108 women; mean age 60.4 years, range 23-85 years) were treated for 140 aneurysms (mean size 11.8 ± 8.3 mm) requiring 224 PEDs (mean 1.7 PEDs per patient). Sixty-eight patients (13 men, 55 women) were treated with PED alone for 73 aneurysms (mean size 10.6 ± 9.2 mm) and 65 patients (12 men, 53 women) were treated with PED/coil for 67 aneurysms (mean size 12.8 ± 7.4 mm). RESULTS Eight aneurysms in 8 patients were re-treated in the PED-alone cohort versus only 1 aneurysm in 1 patient in the PED/coil cohort for re-treatment rates of 11.8% (8/68) and 1.5% (1/65), respectively (p = 0.03). Two patients in the PED-alone cohort were re-treated due to PED contraction, while the other 6 were re-treated for persistent filling of the aneurysms. The PED/coil patient experienced continued filling of a vertebrobasilar artery aneurysm. No aneurysms in either group ruptured after treatment. CONCLUSIONS Adjunctive coil embolization during flow diversion with the PED resulted in a significantly lower re-treatment rate compared with PED alone, suggesting an added benefit with adjunctive coil embolization. This result may provide the basis for future evaluation with randomized, controlled trials.
Objective Carotid-cavernous fistulas (CCFs) are pathologic arteriovenous shunts between the carotid artery and cavernous sinus. The resulting venous congestion within the cavernous sinus accounts for ...the classic ocular symptoms associated with these lesions. Endovascular treatment of CCFs has evolved over time to include a variety of transarterial and transvenous embolization techniques. The present series comprises our institutional experience with the endovascular treatment of CCF. Methods We reviewed our prospectively maintained clinical database for patients with CCF who were evaluated between December 1995 and August 2012. Clinical and demographic data were extracted from medical records, operative notes, and radiographic reports. Cerebral angiograms were reviewed. Results The study included 100 (42 direct CCF dCCF, 58 indirect iCCF) patients. Of the 42 patients with dCCF, endovascular treatment was possible in 40 (95%), with an overall 8% morbidity and 2% mortality. Before March 2004, dCCFs were primarily treated with the use of detachable balloons. After the withdrawal of detachable balloons from the market, coil embolization emerged as the first-line treatment. It was accomplished either transarterially or transvenously and often incorporated balloon or stent protection of the parent vessel. After initial treatment, 33 patients (82%) exhibited complete obliteration of their fistula, whereas an additional four (10%) patients demonstrated fistula thrombosis on follow-up angiography. Endovas c ular access was achieved in 48 (83%) of the 58 patients with iCCF. In this cohort, the morbidity rate was 8%, and there were no deaths. Transvenous approaches were used to treat 88% of these patients and included both transfemoral venous access to the cavernous sinus and direct access through the ophthalmic veins. Immediate fistula occlusion was observed in 37 (77%) patients, and 1 of the 11 patients with a residual fistula progressed to thrombosis on follow-up. Transarterial embolization alone was used in six cases, and five required combined transvenous/transarterial approaches. Conclusions For dCCF, the lack of availability of detachable balloons led to the adoption of both transarterial and transvenous coil embolization with adjunctive techniques of parent vessel protection. For iCCF, advances in techniques of venous access have facilitated treatment of lesions with restricted venous outflow. Treatment strategies for CCF continue to evolve with advances in endovascular techniques.
Cerebral vasospasm following subarachnoid hemorrhage (SAH) causes significant morbidity in a delayed fashion. The authors recently published a new scale that grades the maximum thickness of SAH on ...axial CT and is predictive of vasospasm incidence. In this study, the authors further investigate whether different aneurysm locations result in different SAH clot burdens and whether any concurrent differences in ruptured aneurysm location and maximum SAH clot burden affect vasospasm incidence.
Two hundred fifty patients who were part of a prospective randomized controlled trial were reviewed. Most outcome and demographic variables were included as part of the prospective randomized controlled trial. Additional variables were also collected at a later time, including vasospasm data and maximum clot thickness.
Aneurysms were categorized into 1 of 6 groups: intradural internal carotid artery aneurysms, vertebral artery (VA) aneurysms (including the posterior inferior cerebellar artery), basilar trunk or basilar apex aneurysms, middle cerebral artery aneurysms, pericallosal aneurysms, and anterior communicating artery aneurysms. Twenty-nine patients with nonaneurysmal SAH were excluded. Patients with pericallosal aneurysms had the least average maximum clot burden (5.3 mm), compared with 6.4 mm for the group overall, but had the highest rate of symptomatic vasospasm (56% vs 22% overall, OR 4.9, RR 2.7, p = 0.026). Symptomatic vasospasm occurrence was tallied in patients with clinical deterioration attributable to delayed cerebral ischemia. There were no significant differences in maximum clot thickness between aneurysm sites. Middle cerebral artery aneurysms resulted in the thickest mean maximum clot (7.1 mm) but rates of symptomatic and radiographic vasospasm in this group were statistically no different compared with the overall group. Vertebral artery aneurysms had the worst 1-year modified Rankin scale (mRS) scores (3.0 vs 1.9 overall, respectively; p = 0.0249). A 1-year mRS score of 0-2 (good outcome) was found in 72% of patients overall, but in only 50% of those with pericallosal and VA aneurysms, and in 56% of those with basilar artery aneurysms (p = 0.0044). Patients with stroke from vasospasm had higher mean clot thickness (9.71 vs 6.15 mm, p = 0.004).
The location of a ruptured aneurysm minimally affects the maximum thickness of the SAH clot but is predictive of symptomatic vasospasm or clinical deterioration from delayed cerebral ischemia in pericallosal aneurysms. The worst 1-year mRS outcomes in this cohort of patients were noted in those with posterior circulation aneurysms or pericallosal artery aneurysms. Patients experiencing stroke had higher mean clot burden.
Hemorrhagic origin is unidentifiable in 10%-20% of patients presenting with spontaneous subarachnoid hemorrhage (SAH). While the patients in such cases do well clinically, there is a lack of ...long-term angiographic followup. The authors of the present study evaluated the long-term clinical and angiographic follow-up of a patient cohort with SAH of unknown origin that had been enrolled in the Barrow Ruptured Aneurysm Trial (BRAT).
The BRAT database was searched for patients with SAH of unknown origin despite having undergone two or more angiographic studies as well as MRI of the brain and cervical spine. Follow-up was available at 6 months and 1 and 3 years after treatment. Analysis included demographic details, clinical outcome (Glasgow Outcome Scale, modified Rankin Scale mRS), and repeat vascular imaging.
Subarachnoid hemorrhage of unknown etiology was identified in 57 (11.9%) of the 472 patients enrolled in the BRAT study between March 2003 and January 2007. The mean age for this group was 51 years, and 40 members (70%) of the group were female. Sixteen of 56 patients (28.6%) required placement of an external ventricular drain for hydrocephalus, and 4 of these subsequently required a ventriculoperitoneal shunt. Delayed cerebral ischemia occurred in 4 patients (7%), leading to stroke in one of them. There were no rebleeding events. Eleven patients were lost to followup, and one patient died of unrelated causes. At the 3-year follow-up, 4 (9.1%) of 44 patients had a poor outcome (mRS > 2), and neurovascular imaging, which was available in 33 patients, was negative.
Hydrocephalus and delayed cerebral ischemia, while infrequent, do occur in SAH of unknown origin. Long-term neurological outcomes are generally good. A thorough evaluation to rule out an etiology of hemorrhage is necessary; however, imaging beyond 6 weeks from ictus has little utility, and rebleeding is unexpected.
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