Wide-necked bifurcation aneurysms (WNBAs) are challenging lesions to treat via both open surgical and endovascular techniques. Presently, there are 3 intrasaccular devices available to address many ...of the limitations of prior techniques, all of which are at different phases of approval for human use around the world. These devices include the Woven EndoBridge (WEB
®
) made by MicroVention, the Artisse™ Embolization Device made by Medtronic, and the Contour Neurovascular System™ made by Cerus Endovascular. Although heterogenous in design, these devices rely on the principle of using fine mesh overlying the aneurysm neck to slow blood inflow, promoting stagnation and thrombosis that ultimately leads to healing across the neck and exclusion from the circulation. While our understanding improves as long-term occlusion rates from these devices continue to be studied, the safety profiles and short-term success rates demonstrated in recent studies provide optimism for these innovative intrasaccular devices for the treatment of WNBAs. In this paper, we review these 3 intra-saccular flow disruption devices for use in WNBAs and summarize recent literature and studies of their effectiveness and safety.
Background Intracranial flow diversion has gained increasing popularity since the approval of the Pipeline Embolization Device (PED). Although it is only approved for use in adult patients, the PED ...has been used to treat aneurysms in pediatric patients. We present the first reported case of the use of a PED in a pediatric patient to treat an unusual fusiform distal anterior cerebral artery aneurysm. Case Description A 12-year-old girl presented with new onset seizures and was found to have a distal left anterior cerebral artery aneurysm. Initially, this was managed conservatively, but follow-up imaging performed 4 months after presentation demonstrated enlargement of the aneurysm. The patient underwent endovascular embolization of her aneurysm with PED. This was successfully performed and the patient recovered from the procedure with no neurologic deficits. Conclusions Follow-up digital subtraction angiography and magnetic resonance angiography at 6 and 12 months, respectively, showed complete occlusion of the aneurysm. We also reviewed the literature on flow diversion for treatment of pediatric intracranial aneurysms.
Cerebral vein and dural venous sinus thromboses (CVST) account for 0.5%–1% of all strokes. Some structural factors associated with a potentially higher risk for developing CVST have been described. ...However, angulation of the dural venous sinuses (DVS) has yet to be studied as a structural factor. The current study was performed because this variable could be related to alterations in venous flow, thus predisposing to a greater risk of CVST development. Additionally, such information could help shed light on venous sinus stenosis (VSS) at or near the transverse‐sigmoid junction. The angulations formed in the different segments of the grooves of the transverse (TS), sigmoid (SS), and superior sagittal sinuses (SSS) were measured in 52 skulls (104 sides). The overall angulation of the TS groove was measured using two reference points. Other variables were examined, such as the communication pattern at the sinuses' confluence and the sinus grooves' lengths and widths. The patterns of communication between sides were compared statistically. The most typical communication pattern at the sinuses' confluence was a right‐dominant TS groove (82.98%). The mean angulations of the entire left TS groove at two different points (A and B) were 46° and 43°. Those of the right TS groove were 44° and 45°. The median angulations of the left and right SSS‐transverse sinus junction grooves were 127° and 124°. The mean angulations of the left and right TS‐SSJsv grooves were 111° (range 82°–152°) and 103° (range 79°–130°). Differentiating normal and abnormal angulations of the DVSs of the posterior cranial fossa can help to explain why some patients are more susceptible to pathologies affecting the DVSs, such as CVST and VSS. Future application of these findings to patients with such pathologies is now necessary to extrapolate our results.
Atherosclerotic steno-occlusive cerebrovascular disease includes extracranial carotid occlusive and intracranial atherosclerotic disease. Despite the negative findings in Carotid Occlusion Surgery ...Study (COSS), many large centers continue to report favorable results for revascularization surgery in select groups of patients. The aim of our study was to perform an updated systematic review to investigate the role of revascularization surgery for atherosclerotic steno-occlusive patients in the modern era.
Five independent reviewers performed Preferred Reporting Items for Systematic Reviews and Meta-Analyses–guided literature searches in October 2022 to identify articles reporting clinical outcomes in adult patients undergoing bypass for atherosclerotic steno-occlusive disease. Primary endpoints used were perioperative and long-term ischemic strokes, intracerebral hemorrhage, bypass patency, and favorable clinical outcomes. Study quality was evaluated with Newcastle-Ottawa, JADAD, and the Oxford Center for Evidence-Based Medicine scales.
A total of 6709 articles were identified in the initial search. Of these articles, 50 met the inclusion criteria and were included in the systematic review. A notable increase in the proportion of articles published over the past 10 years was observed. There were 6046 total patients with 4447 bypasses performed over the period from 1978 to 2022. The average length of follow-up was 2.75 ± 2.71 years. The average Newcastle-Ottawa was 6.23 out of 9 stars. There was a significant difference in perioperative stroke (odds ratio OR, 0.65 0.48–0.87; P = 0.004), long-term ischemia (OR, 0.32 0.23–0.44; P < 0.0001), overall ischemia (OR, 0.36 0.28–0.44; P < 0.0001), and favorable outcomes (OR, 3.63 2.84–4.64; P < 0.0001) when comparing pre-COSS to post-COSS time frames in favor of post-COSS.
Based on a systematic review of 50 articles, the existing literature indicates that long-term stroke rates and favorable outcomes for surgical revascularization for steno-occlusive disease have improved over time and are lower than previously reported. Improved patient selection, perioperative care, and surgical techniques may contribute to improved outcomes.
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Flat panel imaging for emergent large vessel occlusion can be acquired prior to mechanical thrombectomy (MT). In this study, we examined patients undergoing MT with computed tomography angiography ...(CTA) to determine agreement on the site of occlusion and CTA collateral score (CS).
Flat Panel CTA (FP-CTA) was acquired before MT. Time between CTA and FP-CTA acquisition, site of occlusion, and CS were reported. Significant CS change was defined as >2-point change, or any change to/from a malignant profile (CS = 0 to CS > 0, or vice versa).
Eleven patients (mean age, 60.8 years; NIHSS, 17; 55.0% female) were included; IV tPA was administered to 7. Intra-reader occlusion site, dichotomous CS, and continuous CS correlation between CTA and FP-CTA were 96.6%, 90.0%, and 86.6%, respectively. Inter-reader correlation for occlusion site was 93% for CTA and 100% for FP-CTA; dichotomous CS correlation was 87% for both CTA and FP-CTA; correlation of continuous CS was 77% for CTA and 87% for FP-CTA.
Standard CTA and FP-CTA have high intra and inter-reader correlation determining site of occlusion and CS in ELVO setting. This angiographic tool may have potential applications for both triage and patient selection.
•FPD imaging may provide an alternative workflow for acute ischemic stroke patients.•FPD-CTA can evaluate the site of intracranial occlusion and collateral status.•We found strong concordance between FPD-CTA and standard CTA on both.•This technique has important implications for triaging patients evaluated for MT.•Patients with known ELVO transferred from outside hospitals may especially benefit.
Abstract
Background
The Pipeline Flex (PED Flex; Medtronic, Dublin, Ireland) was designed to facilitate deployment and navigation compared to its previous iteration to reduce the rate of technical ...events and complications.
OBJECTIVE
To assess the neurological morbidity and mortality rates of the PED Flex at 30 d.
Methods
Information from 9 neurovascular centers was retrospectively obtained between July 2014 and March 2016. Data included patient/aneurysm characteristics, periprocedural events, clinical, and angiographic outcomes. Multivariate logistic regression was performed to determine predictors of unfavorable clinical outcome (modified Rankin Scale mRS > 2).
Results
A total of 205 patients harboring 223 aneurysms were analyzed. The 30-d neurological morbidity and mortality rates were 1.9% (4/205) and 0.5% (1/205), respectively. The rate of intraprocedural events without neurological morbidity was 6.8% (14/205), consisting of intraprocedural ischemic events in 9 patients (4.5%) and hemorrhage in 5 (2.4%). Other technical events included difficulty capturing the delivery wire in 1 case (0.5%) and device migration after deployment in another case (0.5%). Favorable clinical outcome (mRS 0-2) was achieved in 186 patients (94.4%) at discharge and in 140 patients (94.5%) at 30 d. We did not find predictors of clinical outcomes on multivariate analysis.
Conclusion
The 30-d rates of neurological morbidity and mortality in this multicenter cohort using the PED Flex for the treatment of intracranial aneurysms were low, 1.9% (4/205) and 0.5% (1/205), respectively. In addition, technical events related to device deployment were also low, most likely due to the latest modifications in the delivery system.
Recently, an interesting study regarding “Dural sinus septum: an underlying cause of cerebral venous sinus stenting failure and complications.” was published, to our knowledge, being the launching ...point of the clinical/interventional applications of this intraluminal variation. Herein, we wish to highlight paramount anatomical, clinical, and stent placement considerations related to DSS located in the dural venous sinus at the posterior cranial fossa and the interventional complications caused by the presence of this variation during stenting procedures.
Background
Venous thromboembolism (VTE) is a complication that affects approximately 30 % of moderate and severe traumatic brain injury (TBI) patients when pharmacologic prophylaxis is not used. ...Following TBI, specifically in the case of contusions, the safety and efficacy of pharmacologic thromboembolism prophylaxis (PTP) has been studied only in small sample sizes. In this study, we attempt to assess the safety and efficacy of a PTP protocol for TBI patients, as a quality improvement (QI) initiative, in the neuroscience intensive care unit (NSICU).
Methods
Between January 1st and December 31st, 2009, consecutive patients discharged from the University of Wisconsin NSICU after >a 48 h minimum stay were evaluated as part of a QI project. A protocol for the initiation of PTP was designed and implemented for NSICU patients. The protocol did not vary based on type of intracranial injury. The rate of VTE was reported as was heparin-induced thrombocytopenia and PTP-related expansion of intracranial hemorrhage (IH) requiring reoperation. The number of patients receiving PTP and the timing of therapy were tracked. Patients were excluded for persistent coagulopathy, other organ system bleeding (such as the gastrointestinal tract), or pregnancy. Faculty could opt out of the protocol without reason. Using the same criteria, patients discharged during the preceding 6 months, from July 1st to December 31st, 2008, were evaluated as controls as the PTP protocol was not in effect during this time.
Results
During the control period, there were 48 head trauma admissions who met the inclusion criteria. In 22 patients (45.8 %), PTP was initiated at an average of 4.9 ± 5.4 days after admission. During the protocol period, there were 87 head trauma admissions taken from 1,143 total NSICU stays who met criteria. In 63 patients (72.4 %), the care team in the NSICU successfully initiated PTP, at an average of 3.4 ± 2.8 days after admission. All 87 trauma patients were analyzed, and the rate of clinically significant deep venous thrombosis (DVT) was 6.9 % (6 of 87). Three protocol patients (3.45 %) went to the operating room for surgery after the initiation of PTP; none of these patients had a measurable change in hemorrhage size on head CT. The change in percentage of patients receiving PTP was significantly increased by the protocol (
p
< 0.0001); while the average days to first PTP dose trended down with institution of the protocol, this change was not statistically significant.
Conclusion
A PTP protocol in the NSICU is useful in controlling the number of complications from DVT and pulmonary embolism while avoiding additional IH. This protocol, based on a published body of literature, allowed for VTE rates similar to published rates, while having no PTP-related hemorrhage expansion. The protocol significantly changed physician behavior, increasing the percentage of patients receiving PTP during their hospitalization; whether long-term patient outcomes are affected is a potential goal for future study.
