Abstract Background High recovery rates after endovascular treatment of TNP-inducing PcomA aneurysms have been reported. However, only few and often small series were reported. The results of the 2 ...available comparative studies are controversial. Choosing clipping or coiling as treatment modality nowadays is still a matter of debate. We report the ophthalmologic outcome of 20 consecutive patients treated by coiling of TNP-inducing PcomA aneurysms. Methods The third nerve function before and after endovascular treatment was assessed and studied retrospectively. Predictive recovery factors known from literature including treatment timing, the degree of preoperative nerve deficit, the association with SAH, coil type, cardiovascular risk factors, and age were analyzed. A review of the literature was performed. Results Eight patients presented initially with complete nerve palsy (40%) and 12 with partial palsy (60%). Eleven patients had SAH. The mean aneurysm size was 7.14 mm; there were no partially thrombosed aneurysms. Of the 20 patients, 19 (95%) recovered. Recovery was complete in 7 patients (35%), partial in 12 patients (60%), and 1 patient remained unchanged (5%). The mean duration of follow-up was 24.7 months. One patient with complete TNP recovered completely after 5 months of coiling. One case of late complete nerve recovery was observed at 20 months. No cases of reoccurrences or worsening of the partial TNP were observed, including patients who developed recanalization of the aneurysmal sac. Clinical presentation with SAH and early management were statistically significant factors that positively influenced nerve recovery ( P = .006549 and P = .015718, respectively). Initial partial TNP seems to influence recovery but did not reach significance ( P = .079899). Conclusion Coiling of PcomA aneurysms is associated with high rates of third nerve function recovery. Complete recovery can be expected even after long periods and in cases of initial complete nerve palsy. The early treatment and the association with SAH seem to promote the nerve recovery.
Background and Purpose- Carotid artery stenting in tandem large vessel occlusion strokes is usually avoided because of the intracranial hemorrhagic risks induced by antiplatelet therapy during ...thrombectomy interventions. This study aimed to evaluate the incidence of hemorrhagic transformation following thrombectomy in large vessel occlusion strokes patients with atherosclerotic cervical carotid occlusion, associated factors, and clinical relevance. Methods- The TITAN (Thrombectomy in Tandem Lesions) collaboration pooled individual data of prospectively collected multicentric thrombectomy databases for consecutive anterior circulation tandem large vessel occlusion strokes patients who underwent thrombectomy. Hemorrhagic infarction (HI) and parenchymal hematoma (PH) were assessed within 24 hours. Results- Among 289 patients with atherosclerotic cause, 66 (24.7%) patients developed HI and 38 (14.2%) PH. Intracranial carotid occlusion, diabetes mellitus, absence of prior intravenous thrombolysis, and complete extracranial carotid occlusion were independent predictors of HI. Similar predictors were found for PH with addition of higher baseline National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score <7. No detrimental effect of HI on 90-day clinical outcome was found. The occurrence of PH was associated with increased mortality rates (adjusted odds ratio, 2.63; 95% CI, 1.05-6.59; P=0.039) and had no detrimental effect on 90-day modified Rankin Scale 0 to 2 (adjusted odds ratio, 0.52; 95% CI, 0.20-1.28; P=0.25). Conclusions- Incidence of PH after tandem large vessel occlusion strokes thrombectomy is equivalent to those reported in the literature data for isolated occlusions. Similar predictors were found for PH and HI within 24 hours, whereas acute carotid artery stenting and antiplatelet therapy were not, suggesting an aggressive endovascular treatment of tandem occlusions.
Abstract only Introduction The INSPIRE study collects post‐market data on multiple devices from more than 40 centers world‐wide. One of these devices is the PipelineTM Flex flow diverter with Shield ...TechnologyTM (Pipeline Shield) for the treatment of intracranial aneurysms. The Shield surface modification is designed to enhance endothelization of the device with low thromboembolic risks. We analyze the efficacy and safety outcomes after Pipeline Shield therapy at the 1‐year follow‐up in a large prospective study. Methods INSPIRE is a prospective, multicenter, single arm study. Patients are followed for 1‐year post‐procedure and results are adjudicated by an independent Clinical Events Committee and Imaging Core Laboratory. All patients were treated per their hospital’s standard of care. The primary safety endpoint was neurological death or major stroke in the treated vascular area. The primary efficacy endpoint was complete aneurysm occlusion without significant parent artery stenosis (>50%) or retreatment. For this analysis, the last‐available observation was carried forward to overcome differences between centers’ imaging schedules. Results A total of 537 patients were enrolled, with 504 patients with 488 aneurysms included in the analysis (mean age 53.8±12.2, 77.0% 388/504 female). The majority of aneurysms were located in the ICA (74.2%, 362/488). Of the remaining aneurysms, 16.0% (78/488) were in the anterior circulation and 9.8% (48/488) were in the posterior circulation. The majority of aneurysms were saccular (89.3% 436/488). A total of 47.1% of aneurysms were small (< 7mm, 230/488), 30.9% were medium (7‐< 13 mm, 151/488), 16.8% were large (13‐< 25 mm, 82/488), and 5.1% were giant (> = 25 mm, 25/488). Adjunctive devices were used in 20.9% (102/488) of cases, including balloon (42.2% 19/43), coil (63.7%, 65/102), stent (5.9% 6/102), or flow diverter (9.8% 10/102). At 1‐year post‐procedure, complete occlusion (Raymond Roy Class I) was achieved in 74.9% (326/435) aneurysms. The primary safety endpoint occurred in 2.2% (11/504) patients. The primary endpoint was achieved in 73.2% (290/396) cases; reasons for primary endpoint failure included residual neck (5.8% 23/396), residual aneurysm (19.4% 77/396), stenosis >50% (1.0% 4/396), and re‐treatment (1.5% 6/396). Among ICA aneurysms, complete occlusion was achieved in 78.1% (249/319). The primary safety endpoint occurred in 2.0% (7/356) patients. The primary endpoint was achieved in 77.1% (225/292) cases; reasons for primary endpoint failure among ICA aneurysms included residual neck (5.5% 16/292), residual aneurysm (16.4% 48/292), stenosis >50% (0.7% 2/292), and re‐treatment (1.4% 67/292). Conclusions INSPIRE data suggests good rates of complete occlusion, efficacy, and safety among a large cohort of patients with aneurysms in a variety of challenging locations and sizes treated with the Pipeline Shield device, with adjudication by CEC and Imaging Core Lab ensuring high quality of these data.
Abstract
BACKGROUND: Bifurcation middle cerebral artery (MCA) aneurysms with wide neck are amenable to endovascular coiling with pCONus stent, a recent device dedicated to wide-neck bifurcation ...intracranial aneurysms.
OBJECTIVE: To evaluate the 1-year angiographic follow-up of wide-neck MCA aneurysms treated with pCONus.
METHODS: Forty MCA aneurysms (mean dome size, 7.7 mm; mean neck size, 5.6 mm) coiled with pCONus were retrospectively evaluated. “Recanalization” was defined as worsening, and “progressive thrombosis” was defined as improvement on the Raymond scale.
RESULTS: Angiographic midterm (mean, 11.9 months; range, 3-20) follow-up was obtained in all aneurysms. Retreatment was performed in 9 aneurysms (22.5%) without clinical complications, and postoperative angiographic outcome included 2 complete occlusions and 7 neck remnants. Six aneurysms were followed after retreatment (mean, 8.8 months), and presented complete occlusion in 1 case, neck remnant in 4 cases, and aneurysm remnant in 1 case. Among the 31 aneurysms, follow-up showed complete occlusion in 67.7% (21/31), neck remnants in 29% (9/31), and aneurysm remnants in 3.3% (1/31). Adequate aneurysm occlusion (total occlusion and neck remnant) was obtained in 96.7% (30/31). Among these 31 aneurysms, improvement of the rate of occlusion was observed in 15 aneurysms (48.4%), and recurrence in 2 aneurysms (6.5%). There was no 1-year angiographic recurrence of 3- or 6-month totally occluded aneurysms.
CONCLUSION: pCONus stent allows a safe coiling of wide-neck MCA aneurysms usually considered as surgical with a low recanalization rate for those adequately occluded at 3 to 6 months. Angiographic results improve over time due to progressive aneurysm thrombosis in around 50% of cases.
Abstract Background Intracranial aneurysms in children and adolescents are uncommon; they account for 0.5% to 4.6% of the total intracranial aneurysms cases. Methods A 15-year-old boy presented with ...a 6-month history of occipital headache that worsened over time. A magnetic resonance imaging scan revealed a giant, fusiform aneurysm of the V4 segment of the right vertebral artery with mass effect but no signs of hemorrhage. This lesion was confirmed by the catheter digital subtraction angiography. The posterior inferior cerebellar artery arose from the distal part of the aneurysm. Two flow-diverter devices were implanted in the V4 segment of the right vertebral artery. Follow-up angiograms performed 1 and 2 years after the procedure revealed a total aneurysm occlusion. Conclusion Flow-diverter device implantation may be a viable alternative to parent artery occlusion in a symptomatic, giant, fusiform vertebral artery aneurysm in a child.
Patients presenting superior semicircular canal dehiscence (SSCD) can experience symptoms such as conductive hearing loss, pulsatile tinnitus, autophony, and pressure-induced vertigo. Decreased ...cervical vestibular-evoked myogenic potentials (cVEMPs) thresholds and high-resolution computed tomography (HRCT) of the petrous bone are essential for diagnosis of SSCD syndrome. We report the case of a 43-year-old man suffering from constant right pulsatile tinnitus, intermittent autophony, and unsteadiness induced by physical exercise. An SSCD by the superior petrosal sinus (SPS) was confirmed on the right side by axial HRCT of the temporal bone reformatted in the plane of Pöschl and ipsilateral abnormally low elicited cVEMPs. Treatment options were discussed with the patient since the pulsatile tinnitus progressively became debilitating. Two options were considered: surgery or a new endovascular treatment; the patient chose the latter option. After stenting the right SPS, the intensity of the pulsatile tinnitus dramatically decreased. As there was no complication the patient was discharged at Day 1. The other symptoms improved progressively. By the 60-day follow-up visit the patient only reported a slight tinnitus worsened by physical exercise. Angiographic follow-up at 5 months confirmed the patency of the SPS. Stenting the SPS in patients with SSCD by the SPS appears to be an alternative to the existing surgical treatments.
Coil embolization has become a well-established option for the treatment of intracranial aneurysms. Yet, wide-neck bifurcation aneurysms (WNBAs) remain a challenge. The pCONUS is the first generation ...of a stent-like implant for the bridging of WNBAs to enable coiling. The pToWin study was a prospective, single-arm, multicenter study conducted to analyze the safety and efficacy of the pCONUS in the treatment of WNBAs. The primary effectiveness endpoint was the rate of adequate occlusion of the aneurysm at 3-6 and 7-12 months. The primary safety endpoint was the occurrence of major ipsilateral stroke or neurological death during the follow-up. A total of 115 patients were included. Aneurysm locations were the middle cerebral artery in 52 (45.2%), the anterior communicating artery in 35 (30.4%), the basilar artery in 23 (20%), the internal carotid artery terminus in three (2.6%), and the pericallosal artery in two (1.7%) patients. Treatment was successfully performed in all but one patient. The morbi-mortality rate was 1.9% and 2.3% at 3-6 and 7-12 months, respectively. Of the aneurysms, 75.0% and 65.6% showed adequate occlusion at 3-6 and 7-12 months, respectively. pCONUS offers a safe and reasonably effective treatment of WNBAs, demonstrated by acceptable adequate aneurysm occlusion and low rates of adverse neurologic events.
Contact aspiration has gained growing acceptance in endovascular stroke therapy. The safety and efficacy data of the novel ARC catheter (Medtronic, Irvine, California, USA) used for intracranial ...thrombectomy have been poorly evaluated thus far. We report our preliminary results with the ARC with regard to angiographic reperfusion, duration of thrombectomy, safety, and clinical outcome at 90 days.
In a single-center series including 20 large-vessel occlusion stroke patients who were collected prospectively, we retrospectively evaluated the safety and efficacy profiles of the ARC intracranial catheter for first-line contact aspiration. Successful reperfusion was defined as modified Thrombolysis in Cerebrovascular Infarction (mTICI) scores 2b–3 at final angiogram and functional independence as modified Rankin Scale score 0–2 at 90 days.
Median admission National Institutes of Health Stroke Scale score was 15, and previous intravenous thrombolysis was administered in 12 patients (60%). Proximal occlusion was located in the anterior circulation in 16 patients (80%). Primary aspiration alone was successful in 10 of 15 patients (67%) within a median time of 26 minutes. Overall successful reperfusion was achieved in 16 patients (80%) within a median time of 31 minutes. There were no device-related events. Median National Institutes of Health Stroke Scale score was 2.5 at discharge. Six of 17 patients (35%) were independent, and 6 (35%) died at 90 days. Symptomatic intracerebral hemorrhage occurred in 5%.
In our initial experience, the ARC appears safe and efficient for contact aspiration thrombectomy in large-vessel stroke therapy. However, improvement of its distal navigability needs further development to improve the success of aspiration alone, and large prospective studies are warranted.
Flow-diverter stents are the new promising tools in the treatment of intracranial aneurysms allowing progressive aneurysm occlusion. Here, we report a case where high-resolution magnetic resonance ...imaging showed thrombus at fundus of the aneurysm sac, indicating a progressive intraaneurysmal thrombosis after flow-diverter placement.
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