Preliminary experience of treating complex middle cerebral artery aneurysms with Pipeline embolization device / 中国脑血管病杂志

Objective To investigate the safety and efficacy of Pipeline embolization device (PED) for the treatment of complex middle cerebral artery aneurysms. Methods From December 2015 to June 2018, 7 patients with complex middle cerebral artery unruptured aneurysms and treated with PED at the Department of Neurosurgery, the Second Affiliated Hospital of Nanchang University were recruited. The clinical and follow-up data were analyzed. The Kamran classification was used to evaluate the immediate effect of aneurysm embolization and the changes of parent artery. At 6 months after operation, the effect of embolization was evaluated by Raymond grading; the modified Rankin scale (mRS) was used to evaluate prognosis: 0 -2 for good prognosis, 3 -6 for poor prognosis, and 6 for death. Results The 7 patients with complex middle cerebral artery aneurysms were successfully treated with one PED, including 2 patients with single PED and 5 combined with coiling. Digital subtraction angiography (DSA) were performed immediately after PED implantation. All had Kamran classification 2a at immediate angiography after embolization. The postoperative mRS score was 0 in 6 patients and 1 in 1 patient. One patient with M1 aneurysm had acute in-stent thrombosis and another one with M1 aneurysm had mini-focal occipital lobe cerebral infarction. All 7 patients were Raymond classification I during postoperative follow-up from 6 to 12 months. Among them, 6 patients had aneurysms total occlusion with patent parent artery. For the remaining one patient, the aneurysm was found slightly residual at the middle cerebral artery bifurcation but was totally occluded with parental artery patent at 12 months. There were no aneurysmal rupture, cerebral parenchymal hemorrhage, and neurological defects in the 7 patients during intraoperative and postoperative follow-up periods (6 to 18 months). Conclusions Embolization of complex cerebral artery aneurysms with PED is effective and safe, but its long-term effect still needs to be validated by longer follow-up results and large sample-sized trials.

Infección de injerto carótido-carotídeo para debranching aórtico: tratamiento con injerto autológo de vena / Infection of a carotid-carotid graft for aortic debranching: treatment with an autologous venous graft

Resumen El uso de prótesis vasculares y dispositivos endovasculares ha permitido tratar muchas patologías que antes no se intervenían dado el gran riesgo quirúrgico, como es el caso de los aneurismas de aorta torácica. Los materiales usados para estas reconstrucciones son muy resistentes y de larga duración, pero son muy sensibles a ser colonizados y presentar infección, lo que genera morbimortalidad considerable. Se presenta el caso de un paciente de 64 años con antecedente de aneurisma del arco aórtico y aorta descendente, tratado en forma extra institucional con prótesis de aorta torácica endovascular y debranchig de las ramas del arco aórtico, con injerto carótido-carotídeo y carótido-subclavio izquierdo en dacrón, por vía pretraqueal, con antecedente de intento de cubrimiento del injerto expuesto con un flap miocutáneo el cual fue fallido por necrosis; ingresó al Hospital Universitario Clínica de San Rafael, con exposición del injerto carótido-carotídeo a nivel cervical, signos locales de infección y sepsis secundaria.

Abstract The use of vascular replacements and endovascular devices has led to the treatment of many conditions that could not be operated on due to a high surgical risk, such as aortic aneurysms. The materials used for these reconstructions are very resistant and durable, but are very susceptible to being colonised and infected, which leads to a considerable morbidity and mortality. The case is presented of a 64 year-old patient with a history of an aortic arch and descending aortic aneurysm. This had been treated in another hospital with a thoracic aortic endovascular repair and debranching of the aortic arch, with carotid-carotid and left carotid-subclavian Dacron graft. The pretracheal route was used, after attempting to cover the exposed graft with a myocutaneous flap that failed due to necrosis. The patient was admitted to the Hospital Universitario Clínica de San Rafael, presenting with a carotid-carotid graft at cervical level, with local signs of infection and secondary sepsis.

Treatment of Giant Intracranial Aneurysms: a Review Based on Experience from 286 Cases / Tratamento dos aneurismas gigantes intracranianos: uma revisão baseada na experiência de 286 casos

Aneurysms are classified as giant when their largest diameter is equal to or greater than 25 mm, which represents approximately 5­7% of intracranial aneurysms. Severe disease with poor natural history presents with 68% mortality in two years and 85% in five years for untreated cases. Thus, in the majority of cases, the patients require treatment, despite the risks of therapeutic options. We discuss the epidemiology, natural history, diagnosis, and treatment of giant aneurysms based on the experience of 286 operations and literature data.

Os Aneurismas são classificados como gigantes quando seu maior diâmetro é igual ou superior a 25 mm e representam aproximadamente de 5 a 7% dos aneurismas intracranianos. Trata-se de patologia grave com história natural ruim apresentando mortalidade de 68% em 2 anos e 85% em 5 anos para casos não tratados. Desta forma, na maioria dos casos, estes pacientes devem ser tratados apesar do alto risco das opções terapêuticas. Neste estudo, discutimos a epidemiologia, a história natural, o diagnóstico e o tratamento desta grave patologia baseado na experiência de 286 pacientes tratados e dados da literatura.

A Case of Endovascular Treatment for Followed by Side to Side Bypass for Vertebral Artery Dissecting Aneurysms Involved Posterior Inferior Cerebellar Artery

Treatment of complex aneurysms usually entails not only direct clipping but also alternative treatment modality. We recently experienced a case of vertebral artery dissecting aneurysm and obtained good treatment outcomes. Our case suggests that the endovascular segmental occlusion with posterior inferior cerebellar artery (PICA) to PICA side anastomosis might be a good treatment option in patients with complex vertebral artery dissecting aneurysms. A 45-year-old woman has a left vertebral dissecting aneurysm with dizziness. Based on the aneurysmal morphology and the involvement of PICA, the patient underwent side to side anastomosis of the PICA. This was followed by the endovascular segmental coil occlusion. The aneurysmal sac was completely obliterated. At a 2-year follow-up, the patient achieved a good patency of both PICA. In conclusion our case suggests that the endovascular segmental occlusion of the parent artery followed by PICA to PICA bypass surgery through a midline suboccipital approach is a reasonable multimodal treatment option in patients with complex vertebral artery dissecting aneurysms.

Arteritis de Takayasu y aneurisma gigante en escolar: Reporte de caso / Takayasu arteritis and giant aneurysm in a school student: A case report

La arteritis de Takayasu es una vasculitis de grandes vasos que afecta a la aorta y sus ramas principales, llevando a estenosis y trombosis, así como a la formación de aneurismas. Se reporta una incidencia global de 2,6 casos por millón por año, siendo baja en niños. La terapia de elección son los corticoides, seguidos de inmunosupresores en casos de resistencia. Se reporta el caso clínico de un paciente con arteritis de Takayasu con formación de aneurisma gigante de la aorta.

Takayasu's arteritis is a vasculitis of large vessels that affects the aorta and its major branches, leading to stenosis and thrombosis, as well as aneurysm formation. An overall incidence of 2.6 cases per million per year has been reported, being lower in children. Corticosteroids are the therapy of choice, followed by immunosuppressants in cases of resistance. We report the case of a patient with Takayasu's arteritis with formation of giant aneurysm of the aorta.

Modified 'Y-Configured Stents with Waffle Cone Technique' for Broad Neck Basilar Top Aneurysm

Stent assisted coiling on intracranial broad neck aneurysm has been considered as an effective technique and has made the complex aneurysms amenable to coiling. However, stent navigation and application themselves often have the problems especially when the parent vessel angle (entrance between afferent and efferent vessel) is over 90 degrees. We report here a case of a ruptured broad neck basilar top aneurysm that was successfully coiled using two self-expandable stents (Enterprise and Neuroform) placed in a fashion of modified Y-configured stents with waffle cone technique.

In-Stent Stenosis of Stent Assisted Endovascular Treatment on Intracranial Complex Aneurysms

OBJECTIVE: To introduce the frequency and segment analysis of in-stent stenosis for intracranial stent assisted endovascular treatment on complex aneurysms. METHODS: A retrospective study was performed in 158 patients who had intracranial complex aneurysms and were treated by endovascular stent application with or without coil embolization. Of these, 102 patients were evaluated with catheter based angiography after 6, 12, and 18 months. Aneurysm location, using stent, time to stenosis, stenosis rate and narrowing segment were analyzed. RESULTS: Among follow-up cerebral angiography done in 102 patients, 8 patients (7.8%) were shown an in-stent stenosis. Two patients have unruptured aneurysm and six patients have ruptured one. Number of Neuroform stents were 7 cases (7.5%) and Enterprise stent in 1 case (11.1%). Six patients demonstrated in-stent stenosis at 6 months after stent application and remaining two patients were shown at 12 months, 18 months, respectively. CONCLUSION: In-stent stenosis can be confronted after intracranial stent deployment. In our study, no patient showed symptomatic stenosis and there were no patients who required to further treatment except continuing antiplatets medication. In-stent stenosis has been known to be very few when they are placed into the non-pathologic parent artery during the complex aneurysm treatment, but the authors found that it was apt to happen on follow up angiography. Although the related symptom was not seen in our cases, the luminal narrowing at the stented area may result the untoward hemodynamic event in the specific condition.