BACKGROUND:Utilization of the Pipeline embolization device (PED) to treat distal carotid circulation aneurysms has not been well studied.
OBJECTIVE:To report the collective experience of using PED to ...treat distal anterior circulation aneurysms.
METHODS:We retrospectively reviewed clinical and radiographic records of all patients who underwent Pipeline embolization of distal anterior circulation aneurysms at 10 US neurosurgical centers between 2011 and 2013.
RESULTS:Twenty-eight patients (mean age 51.7 years; 18 women) with 28 aneurysms were included in the analyses. Fifteen aneurysms were fusiform, 5 dissecting, and 8 saccular. Average aneurysm size was 12.3 mm; 7 were giant. Twenty aneurysms were located along the middle cerebral artery, 6 along the anterior cerebral artery, and 2 along the anterior communicating artery. PED deployment was successful in 27 patients, with coils utilized in 6 cases. Clinical follow-up was available for an average of 10.7 months (range 3-26). Twenty-seven patients had follow-up neurovascular imaging21 aneurysms had complete occlusion, 4 had residual neck filling, and 2 had residual dome filling. Periprocedural complications (<30 days) occurred in 3 patients (10.7%), including 1 case of device failure resulting in stroke. Outcomes were good (modified Rankin Scale score 0 to 2) in 27 patients (96.4%) and fair (modified Rankin Scale 3) in 1.
CONCLUSION:PED can be utilized in the treatment of distal anterior circulation aneurysms with difficult anatomy for conventional surgical or endovascular techniques. Larger-scale studies with long-term follow-up are needed to further elucidate the durability of PED treatment and its effect on perforator-rich vascular segments.
ABBREVIATIONS:ACA, anterior cerebral arteryAcomA, anterior communicating arteryDSA, digital subtraction angiographyMCA, middle cerebral arterymRS, modified Rankin scalePED, Pipeline embolization device
The vertebral column is recognized as the most common site for bony metastases in patients with systemic malignancy. Patients with metastatic spinal tumors may present with pain, neurologic deficit, ...or both. Some tumors are asymptomatic and are detected during screening examinations. Treatment options include medical therapy, surgery, and radiation. However, diversity of patient condition, tumor pathology, and anatomical extent of disease complicate broad generalizations for treatment. Historically, surgery was considered the most appropriate initial therapy in patients with spinal metastasis with the goal of eradication of gross disease. However, such an aggressive approach has not been practical for many patients. Now, operative intervention is often palliative, with pain control and maintenance of function and stability the major goals. Surgery is reserved for neurologic compromise, radiation failure, spinal instability, or uncertain diagnosis. Recent literature has revealed that surgical outcomes have improved with advances in surgical technique, including refinement of anterior, lateral, posterolateral, and various approaches to the anterior spine, where most metastatic disease is located. We review these surgical approaches for which a team of surgeons often is needed, including neurosurgeons and orthopedic, general, vascular, and thoracic surgeons. Overall, a multimodality approach is useful in caring for these patients. It is important that clinicians are aware of the various therapeutic options and their indications. The optimal treatment of individual patients with spinal metastases should include consideration of their neurologic status, anatomical extent of disease, general health, age, and quality of life.
OBJECTIVE:In patients who are not candidates for intravenous tissue plasminogen activator, intra-arterial (IA) therapy is an alternative. Current recanalization rates are 50 to 60% for IA ...thrombolysis. Stent-assisted recanalization in the setting of acute stroke after failed thrombolysis may improve recanalization rates.
METHODS:A retrospective analysis was performed of 19 patients treated at two institutions between July 2001 and March, 2005 with intracranial stenting of a vessel resistant to standard thrombolytic techniques. Demographics, clinical, and radiographic presentation and outcomes were studied.
RESULTS:Thirteen men and six women with a median baseline National Institutes of Health Stroke Scale (NIHSS) score of 16 (range, 15-22) were included. Eight lesions were located at the internal carotid artery terminus, seven in the M1/M2 segment, and four in the basilar artery. Average time-to-treatment was 210 ± 160 minutes. Overall recanalization rate (Thrombolysis in Cerebral Infarction Grade 2 or 3) was 79%. There were six deathsfive due to progression of stroke and withdrawal of care at the family’s request and one as the result of a delayed carotid injury after tracheostomy. One postoperative asymptomatic intracranial hemorrhage occurred without adverse affect on outcome. Median discharge NIHSS score of surviving patients was 5 (range, 2.5-11.5). Lesions at the internal carotid artery terminus (P < 0.009), older age (P < 0.003), and higher baseline NIHSS score (P < 0.009) were significant negative outcome predictors, as measured by >3 modified Rankin scale score at discharge.
CONCLUSION:Stent-assisted recanalization for acute stroke resulting from intracranial thrombotic occlusion is associated with a high recanalization rate and low intracranial hemorrhage rate. These initial results suggest that stenting may be an option for recalcitrant cerebral arterial occlusions.
Abstract Introduction/
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urpose Flow diversion has allowed cerebrovascular neurosurgeons and neurointerventionalists to treat complex, large aneurysms, previously treated with trapping, bypass, ...and/or parent vessel sacrifice. However, a minority of aneurysms remain that cannot be treated endovascularly, and microsurgical treatment is too dangerous. However, balloon test occlusion (macro and micro), micro WADA testing, ICG, intra-angiography and intra-operative monitoring are all available to clinically test the hypothesis in an individual patient that vessel sacrifice is safe. We describe a dual-institution series of aneurysms successfully treated with parent vessel occlusion (PVO). Materials/
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ethods Prospectively collected database of all endovascular and open cerebrovascular cases performed at Maine Medical Center and Vanderbilt University Medical Center from 2011 to 2013 was screened for patients treated with primary vessel sacrifice. A total of 817 patients were screened and 17 patients were identified who underwent parent vessel sacrifice as primary treatment. Results All 17 patients primarily treated with PVO are described below. Nine patients presented with SAH, and 3/17 involved anterior circulation. Complete occlusion was achieved in 15/17 patients. In the remaining 2 patients, significant reduction in the aneurysm occurred. Modified Rankin Score (mRS) of 0, signifying complete independence, was achieved for 16/17 patients. One patient died due to an extracranial process. Conclusions Parent vessel sacrifice remains a viable and durable solution in select ruptured and unruptured intracranial aneurysms. Many adjuncts are available to aid in the decision making. In this small series patients naturally divided into vertebral dissecting aneurysms, giant aneurysms and small distal aneurysms. Outcomes were favorable in this highly selected group.
The authors reviewed the Mayo Clinic experience with the treatment of hemangiopericytoma in the primary central nervous system (CNS).
A retrospective study of all patients at the Mayo Clinic revealed ...38 who had been treated for hemangiopericytoma in the CNS. Twenty of these patients were diagnosed in the decade between 1990 and 2000; 18 were initially diagnosed and underwent surgery before 1990. In the patients treated since 1990, the 5-year Kaplan-Meier survival rate was 93%. The 5-year disease-free survival rate was 89%. Sixty percent of patients treated with the aid of stereotactic radiosurgery for recurrent disease were alive 4.4 years after their initial treatment. Salvage chemotherapy was not effective. No survival benefit was detected inpatients who had received initial adjuvant external-beam radiation therapy. High-grade tumors recurred 6.7 years earlier than did low-grade lesions (p = 0.004).
The 5-year survival rate in patients with hemangiopericytoma of the CNS has improved at the authors' institution during the last 10 years. Although the reason for this is not entirely clear, the authors suspect that the improved treatment of patients with cancer, a 0% intraoperative mortality rate, and the use of radiosurgery in the treatment of recurrent disease all likely contribute. High-grade tumors recurred statistically significantly earlier than low-grade lesions. Current chemotherapies are ineffective in the treatment of hemangiopericytoma of the CNS.
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