Silk Vista Baby for the Treatment of Complex Posterior Inferior Cerebellar Artery Aneurysms.

BACKGROUND: Treatment of small-caliber vessel lesions using flow diverters remains challenging because of vasculature's narrow luminal diameter and tortuosity. This in turn makes navigation and delivery of conventional devices with standard microcatheters more difficult. The Silk Vista Baby (SVB, Balt) flow diversion device was designed for ease of use in vessels with a smaller diameter, distal lesions, and 0.017 ″ microcatheter delivery systems. OBJECTIVE: To report the outcomes of the SVB device on the treatment of posterior inferior cerebellar artery (PICA) aneurysms. METHODS: Databases from different centers were retrospectively reviewed for PICA aneurysms treated with SVB. Demographic information, clinical presentation, radiographic characteristics, procedural complications, and immediate postprocedure outcomes were obtained. RESULTS: Fourteen patients harboring 15 true PICA aneurysms were treated between January 2019 and June 2021. Nine were female (n = 9/14; 64.2%), and the mean age was 51 ± 14.9 years. Most patients had previously ruptured aneurysms, treated by another endovascular technique. Six aneurysms were located distally (n = 6/15; 40%). The mean neck size was 3 mm (SD 1.35, range 2.5-5 mm), whereas the mean PICA diameter was 1.6 mm (SD 0.26, range 1.5-1.7 mm). The mean length of follow-up was 6 months (SD 8.28, range 4.5-16 months). Treatment-related adverse events included 1 case of transient hypoesthesia. Two additional events were reported, but adjudicated as unrelated to the procedure. Complete occlusion, measured as Raymond-Roy class I, was achieved in all cases. CONCLUSION: The SVB device was safely and effectively used in the treatment of PICA aneurysms. The smaller delivery system profile reduces the risk of procedure complications and creates new treatment options for distal lesions.

Multiple Extraaxial Cavernous Hemangiomas: Rare Entity.

BACKGROUND: Cavernous hemangiomas arising in the extraaxial space are rarely encountered, often mimicking other more common pathologies. Furthermore, multiple coexisting lesions and posterior fossa involvement are scarcely reported. Herein, we present the case of a patient with concurrent frontal bone and posterior fossa extraaxial cavernous hemangiomas. We also review the challenges associated with the diagnosis and management of these entities. CASE DESCRIPTION: An otherwise healthy 41-year-old gentleman presented with a 7-month history of a progressive right forehead mass. Imaging demonstrated a right frontal bone mass and an incidentally noted transverse sinus-based mass. The patient opted for surgical resection of both lesions. A right frontal craniotomy was performed to remove the bony lesion, followed by a suboccipital approach for the dural-based mass. There were no significant complications intraoperatively, and gross total resection was achieved for both lesions. Final pathology for each was consistent with cavernous hemangioma. CONCLUSIONS: Extraaxial cavernous hemangiomas are uncommon clinical entities that are challenging to distinguish from other diseases. If intraoperative complications can be avoided, treatment with surgical resection often offers excellent patient outcomes.

Delayed Pipeline Embolization of a Ruptured True Internal Carotid Artery Aneurysm Presenting with Epistaxis: Case Report and Review of the Literature.

BACKGROUND: Massive epistaxis from rupture of an intracavernous internal carotid artery aneurysm is a potentially fatal event. Although rare, this presentation is seen most often in patients after trauma or iatrogenic injury secondary to transsphenoidal surgery or radiation therapy. CASE DESCRIPTION: We present our unusual case of a patient with no significant risk factors who had recurrent epistaxis owing to a ruptured true cavernous internal carotid artery aneurysm. The patient was treated initially with coil embolization followed by placement of a Pipeline embolization device. The patient had complete resolution of her bleeding events. A follow-up arteriogram performed 14 months later confirmed aneurysm obliteration, with parent artery preservation and no evidence of in-stent stenosis. CONCLUSIONS: Our case highlights the importance of evaluating for intracranial pathological conditions in patients who present with refractory epistaxis. In selected patients, the use of flow-diversion technology as an adjunct or alternative to primary coil embolization for treatment should be considered.

Multicenter Study of Pipeline Flex for Intracranial Aneurysms.

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.

Endovascular Recanalization of Symptomatic Intracranial Arterial Stenosis Despite Aggressive Medical Management.

BACKGROUND: The optimal management of intracranial arterial stenosis is unclear, particularly in patients who have failed medical management. We report a multicenter real-world experience of endovascular recanalization of intracranial atherosclerotic stenosis refractory to aggressive medical therapy. METHODS: Retrospective multicenter case series of consecutive endovascularly treated patients presenting with symptomatic (transient ischemic attack [TIA] or stroke) intracranial stenosis who had failed medical therapy. Patients were divided into 2 groups: patients with recurrent TIA or stroke despite medical management (group 1) versus patients presenting with a stroke and worsening symptoms (progressive or crescendo stroke) despite medical management (group 2). RESULTS: A total of 101 patients were treated in 8 stroke centers from August 2009 to May 2017. Sixty-nine presented with recurrent TIA or stroke and 32 with stroke and worsening symptoms. Successful recanalization was achieved in 84% of patients. Periprocedural stroke occurred in 3 patients and 2 had a recurrent ischemic stroke at the 90-day follow-up. Symptomatic intraparenchymal hemorrhage secondary to reperfusion injury occurred in 3 patients and 1 had a hemorrhagic stroke after discharge. There were 2 periprocedural perforations that resulted in death. At 90 days, 86% of patients (64/74) did not have a recurrence of stroke and the 90-day cumulative ischemic stroke rate was 6.7% with 90-day mortality of 11.2%. The 90-day favorable outcome (modified Rankin Scale score, ≤2) rate was 77.5%. CONCLUSIONS: Endovascular recanalization of unstable intracranial atherosclerotic stenosis in patients who have failed medical therapy is feasible. Future randomized trials need to determine if recanalization is of any value for this population.

Safety and efficacy of cangrelor in acute stenting for the treatment of cerebrovascular pathology: preliminary experience in a single-center pilot study.

BACKGROUND: Treatment of acute cerebrovascular pathology, such as acute ischemic stroke or intracranial aneurysms, presents a challenge if an extracranial or intracranial stent is required; immediate platelet inhibition is vital. To date, there is no standardized approach for antiplatelet inhibition in an acute setting. OBJECTIVE: To report our preliminary experience and lessons learnt using cangrelor in acute neurointervention. METHODS: A single-arm pilot study was performed to assess the safety and efficacy of cangrelor plus aspirin for platelet inhibition in patients who require acute stenting in the setting of neuroendovascular treatment. RESULTS: Eight patients were enrolled between October 2017 and August 2018. Median age was 71 years (53-86). Seven patients were treated in an acute setting according to the stroke protocol at our institution, while one patient was treated for a symptomatic, unruptured aneurysm with flow diversion and coiling. At admission, the median National Institutes of Health Stroke Scale score for the patients with stroke was 12.5 (range 2-22.3). Cangrelor was infused and all patients achieved adequate platelet inhibition (<200 PRU (P2Y12 reaction units)). Six of seven patients with ischemic stroke had a carotid stent placed and one had an intracranial stent deployed in the middle cerebral artery. None of the patients experienced intraprocedural thromboembolic complications, intraprocedural in-stent thrombosis, hemorrhagic complications, or stroke within 24 hours after the intervention. The majority of patients (6/8) had a good clinical outcome at discharge (modified Rankin Scale score 0-2). CONCLUSIONS: Our findings suggest that cangrelor is a promising alternative in acute stenting for the treatment of cerebrovascular pathology. However, further studies with larger samples are required to accurately elucidate its safety and effectiveness in neuroendovascular procedures.

Current Status of the PulseRider in the Treatment of Bifurcation Aneurysms: A Systematic Review.

BACKGROUND: The PulseRider is an innovative stent-like device designed for the treatment of intracranial bifurcation aneurysms. The aim of this study was to assess the current evidence on safety and effectiveness of the PulseRider. METHODS: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following databases were searched: PubMed, Ovid MEDLINE, and Scopus. The search strategy consisted of "pulserider," "bifurcation aneurysm," and "endovascular" in both AND and OR combinations. Studies included were original research articles in peer-reviewed journals. The manuscripts were thoroughly examined for study design, outcomes, and results. RESULTS: Three studies were identified describing use of the PulseRider device in the treatment of 63 patients with 63 bifurcation aneurysms. We identified 2 multicenter case series and 1 single-arm clinical trial. The majority of aneurysms treated were located at the basilar tip (37, 58.7%). All devices were successfully deployed, and there were 5 intraoperative complications (7.9%), including 2 intraoperative aneurysm ruptures, 1 vessel dissection, and 2 thrombus formations. Immediate complete aneurysm occlusion was achieved in 61.9% (39/63) of cases and at the 6-month imaging follow-up, 66.7% (42/63) achieved complete aneurysm occlusion. One recanalization was reported in 1 of the multicenter case series within the 6-month follow-up. CONCLUSIONS: The PulseRider is safe and probably effective for the treatment of intracranial bifurcation aneurysms, sometimes not amenable for stent-assisted coiling. However, current evidence is limited to a small sample and short follow-up. In addition, the device has not been compared with other treatment modalities.

Ruptured aneurysm of the artery of Adamkiewicz: is conservative management the standard of treatment in the current era?

Spinal aneurysms are rare lesions, and their natural history is not well known. In particular, aneurysms arising from the artery of Adamkiewicz (AA) are an extremely rare phenomenon, and given the lack of solid evidence its management remains unclear. We present the case of a 54-year-old woman with spinal subarachnoid hemorrhage. A spinal angiogram demonstrated a fusiform aneurysm arising from the AA. Based on the location, the absence of evident collateral circulation to the anterior spinal artery, and the available literature supporting spontaneous thrombosis, we opted for conservative management. Fifteen days after the diagnosis, a spinal angiogram demonstrated complete occlusion of the aneurysm with no visualization of the AA. At 10-month follow-up, the patient was able to walk without assistance. Management should be done on a case-by-case basis with the goal of preserving spinal cord perfusion. Similar to previous articles, our report reinforces conservative management as a valid strategy.

Ruptured aneurysm of the artery of Adamkiewicz: is conservative management the standard of treatment in the current era?

Spinal aneurysms are rare lesions, and their natural history is not well known. In particular, aneurysms arising from the artery of Adamkiewicz (AA) are an extremely rare phenomenon, and given the lack of solid evidence its management remains unclear. We present the case of a 54-year-old woman with spinal subarachnoid hemorrhage. A spinal angiogram demonstrated a fusiform aneurysm arising from the AA. Based on the location, the absence of evident collateral circulation to the anterior spinal artery, and the available literature supporting spontaneous thrombosis, we opted for conservative management. Fifteen days after the diagnosis, a spinal angiogram demonstrated complete occlusion of the aneurysm with no visualization of the AA. At 10-month follow-up, the patient was able to walk without assistance. Management should be done on a case-by-case basis with the goal of preserving spinal cord perfusion. Similar to previous articles, our report reinforces conservative management as a valid strategy.

Alarming Internal Carotid Artery Aneurysm Eroding the Sphenoid Sinus.

In rare instances, extradural internal carotid artery aneurysms can present with massive epistaxis, which is often a fatal event. We present the case of a young female with an aneurysm eroding through the sphenoid sinus and whose timely diagnosis resulted in treatment of the aneurysm with coil embolization and satisfactory outcome.

Analysis of Predictors and Probability of Aneurysm Occlusion in the Internal Carotid Artery After Treatment with Pipeline Embolization Device.

BACKGROUND: Although the Pipeline Embolization Device (PED) has proved to be an excellent option for internal carotid artery (ICA) aneurysms, the rate of occlusion remains difficult to predict and factors associated with aneurysm occlusion are not well elucidated. This study aimed to investigate predictors and the rate of occlusion for aneurysms along the ICA. METHODS: A total of 117 saccular ICA aneurysms treated with the PED were studied. Occlusion rates were divided among 4 groups: group A [lesions >10 mm in the proximal ICA (petrous to the superior hypophyseal segments)]; group B (lesions <10 mm in the proximal ICA); group C [lesions >10mm in the distal ICA (posterior communicating segment to the ICA bifurcation)]; and group D (lesions <10 mm in the distal ICA). Predictors of aneurysm occlusion were entered into a multivariate Cox regression analysis. RESULTS: The median time to aneurysm occlusion was 8 months in group A (95% confidence interval [CI], 7.0-9.1), 5.2 months in group B (95% CI, 4.5-6.0), 6.9 months in group C (95% CI, 6.5-7.2), and 10.2 months in group D (95% CI, 6.9-13.6) (P = 0.045). There was a statistically significant difference between the probability of aneurysm occlusion in group B compared with distal ICA aneurysms (P = 0.02). Small proximal ICA aneurysms were more likely to occlude over time compared with other aneurysm groups (hazard ratio, 1.76; 95% CI, 1.07-2.9; P = 0.02). CONCLUSIONS: The rate of occlusion after PED is highest for small proximal ICA aneurysms and the probability of occlusion is lower for distal ICA aneurysms.

Endovascular Treatment of Middle Cerebral Artery M2 Occlusion Strokes: Clinical and Procedural Predictors of Outcomes.

BACKGROUND: Patients with strokes from M2 segment middle cerebral artery (MCA) occlusion have been underrepresented in recent randomized trials of endovascular therapy. OBJECTIVE: To better understand the clinical, imaging, and procedural predictors of successful recanalization and clinical outcomes in this population of patients. METHODS: We performed a multicenter retrospective analysis of consecutive patients with acute MCA M2 segment occlusion who underwent thrombectomy with stent retrievers or primary aspiration thrombectomy (including A Direct Aspiration First Pass Technique approach). We correlated clinical and radiographic outcomes with demographic, clinical, and technical characteristics. RESULTS: One hundred and seventeen patients were included in analysis (median admission National Institutes of Health stroke scale [NIHSS] score 15, mean age 67.0 ± 14.5, 42% females). Good clinical outcome at 3 months (modified Rankin scale [mRS] ≤ 2) was achieved in 56% of patients. Treatment beyond 6 h of symptoms onset (P = .69, OR 0.80, 95% CI 0.38-1.73) and age over 80 (P = .47, OR 0.65, 95% CI 0.25-1.70) were not predictive of poor outcome. NIHSS > 15 was a strong predictor of clinical outcome, based on mRS distribution at 3 months (P = .0085, OR 0.35, 95% CI 0.16-0.74). Direct aspiration and primary stent retriever thrombectomy approaches showed similar radiographic and clinical success rates. CONCLUSION: Advanced age and time to treatment beyond 6 h from symptom onset were not predictive of clinical outcome with thrombectomy. NIHSS score above 15 was a strong predictor of outcome. Direct aspiration and primary stent retriever thrombectomy showed similar efficacy.

Vessel perforation during stent retriever thrombectomy for acute ischemic stroke: technical details and clinical outcomes.

BACKGROUND: Vessel perforation during stent retriever thrombectomy is a rare complication; typically only single instances have been reported. OBJECTIVE: To report on a series of patients whose stent retriever thrombectomy was complicated by intraprocedural vessel perforation and discuss its potential mechanisms, rescue treatment strategies, and clinical significance. METHODS: Cases with intraprocedural vessel perforation, where a stent retriever was used either as a primary treatment approach or as a part of a direct aspiration first pass technique (ADAPT), were included in the final analysis. Clinical data, procedural details, radiographic and clinical outcomes were collected from nine participating centers. RESULTS: Intraprocedural vessel perforation during stent retriever thrombectomy occurred in 16 (1.0%) of 1599 cases. 63% of intraprocedural perforations occurred at distal locations. Endovascular rescue techniques (most commonly, intracranial balloon occlusion for tamponade) were attempted in 50% of cases. Procedure was aborted without any rescue attempts in 44% of cases. Mortality during hospitalization and at 3 months was 56% and 63%, respectively. 25% of patients achieved good functional outcome at 3 months after the procedure. CONCLUSIONS: Intraprocedural perforations during stent retriever thrombectomy were rare, but when they occurred were associated with high mortality. Perforations most commonly occurred at distal occlusion sites and were often characterized by difficulty traversing the occlusion with a microcatheter or microwire, or while withdrawing the stent retriever. Nevertheless, 25% of patients had a favorable functional outcome, suggesting that in some patients with this complication good neurological recovery is achievable.

Evaluation of Pipeline Flex delivery system for the treatment of unruptured aneurysms.

INTRODUCTION: Refinements in endovascular technology have revolutionized the treatment of intracranial aneurysms (IAs) with the development of flow-diversion technology. The first generation of the Pipelin Embolization Device (PED) has demonstrated its safety and efficacy. However, the deployment technique was a difficult task that often led to complex maneuvers. The Pipeline Flex Embolization Device (PED Flex) is the second generation and its introduction has arrived with high expectations due to a completely redesigned delivery system that intends to overcome deployment difficulties seen in the previous generation. Areas covered: Preclinical studies, mechanism of action of flow-diverters, technical aspects and deployment system of the PED Flex, and clinical outcomes with both PED generations. Expert commentary: Flow diversion has allowed us to treat lesions that would be otherwise challenging for surgical clipping or unsuitable for other endosaccular strategies. Although the experience with PED Flex is limited, initial results suggest its safety and short-term efficacy.

Silent ischemic events after Pipeline embolization device: a prospective evaluation with MR diffusion-weighted imaging.

BACKGROUND: The development of ischemic events is relatively common after endovascular interventions, and flow diverters may pose a particular threat owing to their increased technical complexity and high metal content. OBJECTIVE: To investigate the incidence and potential risk factors for thromboembolic lesions after treatment with a Pipeline embolization device (PED). METHODS: This prospective study included a total of 59 patients electively treated with a PED over 12 months. Postprocedural diffusion-weighted imaging sequences of the brain were obtained 24 h after interventions to detect ischemic lesions. Demographic data, aneurysm characteristics, antiplatelet management, and perioperative data were correlated with the rate of ischemic events. RESULTS: The incidence of silent ischemic events after use of a PED was 62.7% (37 patients) and neurological symptoms occurred in 8.1% of affected patients. Development of ischemic events was significantly associated with older patients (≥60 years; p=0.038). Routine use of platelet function assays and newer P2Y12 receptor inhibitors (ticagrelor) were not associated with fewer thromboembolic events. CONCLUSIONS: Thromboembolic events are relatively common after treatment with a PED with an incidence comparable to stent-assisted and conventional coiling but the risk of neurological morbidity from ischemic burden is low. Older patients are at particularly increased risk of thromboembolic events.

The fate of cranial neuropathy after flow diversion for carotid aneurysms.

OBJECTIVE: The authors sought to determine whether flow diversion with the Pipeline Embolization Device (PED) can approximate microsurgical decompression in restoring function after cranial neuropathy following carotid artery aneurysms. METHODS: This multiinstitutional retrospective study involved 45 patients treated with PED across the United States. All patients included presented between November 2009 and October 2013 with cranial neuropathy (cranial nerves [CNs] II, III, IV, and VI) due to intracranial aneurysm. Outcome analysis included clinical and procedural variables at the time of treatment as well as at the latest clinical and radiographic follow-up. RESULTS: Twenty-six aneurysms (57.8%) were located in the cavernous segment, while 6 (13.3%) were in the clinoid segment, and 13 (28.9%) were in the ophthalmic segment of the internal carotid artery. The average aneurysm size was 18.6 mm (range 4-35 mm), and the average number of flow diverters placed per patient was 1.2. Thirty-eight patients had available information regarding duration of cranial neuropathy prior to treatment. Eleven patients (28.9%) were treated within 1 month of symptom onset, while 27 (71.1%) were treated after 1 month of symptoms. The overall rate of cranial neuropathy improvement for all patients was 66.7%. The CN deficits resolved in 19 patients (42.2%), improved in 11 (24.4%), were unchanged in 14 (31.1%), and worsened in 1 (2.2%). Overtime, the rate of cranial neuropathy improvement was 33.3% (15/45), 68.8% (22/32), and 81.0% (17/21) at less than 6, 6, and 12 months, respectively. At last follow-up, 60% of patients in the isolated CN II group had improvement, while in the CN III, IV, or VI group, 85.7% had improved. Moreover, 100% (11/11) of patients experienced improvement if they were treated within 1 month of symptom onset, whereas 44.4% (12/27) experienced improvement if they treated after 1 month of symptom onset; 70.4% (19/27) of those with partial deficits improved compared with 30% (3/10) of those with complete deficits. CONCLUSIONS: Cranial neuropathy caused by cerebral aneurysm responds similarly when the aneurysm is treated with the PED compared with open surgery and coil embolization. Lower morbidity and higher occlusion rates obtained with the PED may suggest it as treatment of choice for some of these lesions. Time to treatment is an important consideration regardless of treatment modality.

A Reappraisal of Anterior Communicating Artery Aneurysms: A Case for Stent-Assisted Embolization.

BACKGROUND: Wide-necked anterior communicating artery aneurysms represent a subset of lesions with challenging endovascular treatment despite new endoluminal and intrasaccular devices. OBJECTIVE: To assess the long-term clinical and angiographic outcomes of stent-assisted embolization for wide-necked anterior communicating artery aneurysms. METHODS: Between March 2008 and March 2014, 32 patients with unruptured wide-necked AComm aneurysms were treated using stent-assisted embolization. The Glasgow Outcome Scale was reviewed at the time of discharge and at latest follow-up. Ischemic and hemorrhagic events were also recorded and analyzed. Aneurysm occlusion was evaluated post-intervention and on subsequent follow-up evaluations. RESULTS: Successful stent deployment was achieved in all cases, but in 1 patient the coils could not be contained inside the aneurysm, and the procedure was aborted without complications. The distal segment of the stent was positioned in the ipsilateral A2 in 16 patients, in the contralateral A2 in 15 patients, and in the contralateral A1 in 1 patient. There were no periprocedural thromboembolic or hemorrhagic complications. The rate of major complications was 6%. One patient developed intracranial hemorrhage related to antiplatelet therapy and another had ischemic events due to in-stent stenosis. Angiographic follow-up was available for 26 aneurysms and during a mean follow-up of 22 months, 81% of the lesions were completely occluded and 8% had a small residual neck. The retreatment rate for residual aneurysms was 3%. CONCLUSION: Our long-term results suggest that stent-assisted embolization for anterior communicating artery aneurysms may be considered an excellent treatment option with an adequate combination of safety profile and effectiveness.