Long-term outcomes of carotid stenting in a single neurovascular center: up to 12-year retrospective analysis with a focus on the influence of comorbidities.

BACKGROUND: The aim of this study was to evaluate long-term outcomes in patients who underwent carotid artery stenting (CAS) for symptomatic or asymptomatic high-grade stenosis. METHODS: A total of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522) underwent CAS at our center between 2009 and 2020. A total of 560 patients or contacts (asymptomatic, n = 316; symptomatic, n = 244) were interviewed by telephone to evaluate long-term outcomes with a mean follow-up of 5 years. Mortality from all causes, myocardial infarction, and stroke, as well as comorbidities influencing their occurrence, including overall survival and stroke-free survival, were examined. RESULTS: The overall survival rate for all-cause mortality was 91.6% at 1 year, 77.1% at 5 years, and 55.7% at 10 years. A total of 39 (6.9%) patients had an ischemic stroke during long-term follow-up. The stroke-free survival rates at 1 year, 5 years, and 10 years were 97.9%, 92.7%, and 86.6%, respectively. Stroke-free survival and overall survival did not differ significantly between the symptomatic and asymptomatic groups (overall survival, p = 0.304; stroke-free survival, p = 0.336). Regular physical activity reduced the risk of stroke and death and was associated with better long-term clinical outcomes. Age at treatment and diabetes mellitus were statistically significantly associated with death during follow-up. CONCLUSION: Long-term follow-up data confirmed the effectiveness and durability of CAS as a therapy option for both symptomatic and asymptomatic patients. In patient selection for CAS, special consideration should be paid to patient age, ability to engage in physical activity, and diabetes mellitus.

Use of a p64 MW Flow Diverter with Hydrophilic Polymer Coating (HPC) and Prasugrel Single Antiplatelet Therapy for the Treatment of Unruptured Anterior Circulation Aneurysms: Safety Data and Short-term Occlusion Rates.

PURPOSE: To assess the safety and short-term occlusion rates in procedures using the p64 MW hydrophilic polymer-coated (HPC) flow diverter (FD) with prasugrel single antiplatelet therapy (SAPT) for the treatment of anterior circulation saccular aneurysms. METHODS: We retrospectively identified patients who underwent treatment of one or more intracranial anterior circulation saccular aneurysms between March 2020 and December 2021 with a p64 MW HPC FD and prasugrel SAPT with verified P2Y12 platelet receptor inhibition. Patients diagnosed with fusiform, dissecting, or recently ruptured aneurysms were excluded. Periprocedural and postprocedural complications, clinical outcomes, and angiographic follow-up results were evaluated. RESULTS: One hundred and two patients with 132 intracranial aneurysms met the inclusion criteria. Previous or concomitant treatments (e.g., coil occlusion) had been performed on 18 of these aneurysms. The technical success rate (i.e., implantation of the intended FD) was 100% with an average of 1.1 devices implanted per patient. Periprocedural and postprocedural complications occurred in 13.6% and 6.8% of these patients, respectively. No mortality or permanent clinical deterioration (i.e., modified Rankin scale score ≥ 3) were reported. Early follow-up digital subtraction angiography revealed aneurysmal occlusion rates of 72.6% and 83.8% at four and nine months, respectively. CONCLUSIONS: The implantation of a p64 MW HPC FD with prasugrel SAPT is safe and results in rapid, reliable and effective aneurysmal occlusion.

Carotid Stenting as Definitive Treatment for Free Floating Thrombus-Review of 7 Cases.

BACKGROUND AND PURPOSE: Free floating thrombus (FFT) is a rare condition. The optimal treatment strategy is yet to be determined although medical management with anticoagulation is the mainstay. This article reports experience of treating FFT with carotid stenting. METHODS: A retrospective analysis of a prospectively maintained database was performed to identify all patients with FFT treated with carotid stenting. For each patient the demographic data, clinical presentation, location of the thrombus, type of stent and use of adjunctive devices, e.g. balloon guide catheters, clinical and radiological follow-up information as well as complications were recorded. RESULTS: A total of 7 patients, 4 female, with mean age of 55.6 ± 14.5 years were identified. The median National Institutes of Health Stroke Scale (NIHSS) was 7 (range 0-13) at presentation. Free floating thrombus was seen on the left in the majority of cases (n = 6, 85.7%). None of the patients had intracranial large vessel occlusion. The FFT was located in the CCA in 2 cases (28.6%) and the proximal ICA in the remaining 5 cases (71.4%). The Wallstent was used in 5 patients and a cGuard stent used in 2 patients. In 1 patient 2 overlapping stents were used but a single stent was used in the remaining patients. In 6 cases a distal filter wire was used and in 2 cases a balloon guide catheter was used as embolic protection. There were no intraoperative complications and no cases of distal clot migration or intracranial large vessel occlusion during the procedure. At last follow-up (n = 7) 6 patients were recorded as modified Rankin Scale (mRS) ≤2 and 1 patient was mRS 3. CONCLUSION: Free floating thrombus of the carotid arteries can be managed with stenting.

Mechanical thrombectomy for recurrent large vessel occlusion.

Although mechanical thrombectomy (MT) has been shown in numerous trials to be a successful treatment option for patients with large vessel occlusion (LVO), there is limited information on the safety and effectiveness of the technique in cases of recurrent LVO. To this end, we performed a retrospective review of our prospectively maintained database to identify all patients that had undergone more than one MT procedure January 2008 and January 2018. The data collected on these patients included baseline demographics and any history of diabetes mellitus, hypercholesterolaemia, hypertension, atrial fibrillation or smoking. We also recorded when the symptoms had started, the patient's NIHSS and ASPECT scores, the number of passes taken, the patient's final TICI score, any complications which arose and the patient's mRS at 90 days. Our dataset encompassed 25 patients (of which 17 (68%) were female) who had undergone a total number of 52 MT's. Average age at 1st presentation was 70 ±â€¯12.8 years. The median time between one stroke and the next was 71 days (range 1-1059, IQR 183 days). The majority of the strokes were deemed cardioembolic (86.5%) in origin. There was no significant difference in the procedure times, number of passes or TICI scores. There was a significant difference in the mRS after the 1st and 2nd events (p = 0.014) but no significant difference if the 2nd event occurred contralateral to the 1st event (p = 0.66) (n = 22). It is therefore concluded that recurrent thrombectomy can be safely performed with no significant difference in the technical aspects of the procedure.

Basilar artery perforator aneurysms: Report of 9 cases and review of the literature.

Basilar perforator artery aneurysms (BAPA's) are an under-recognised cause of sub-arachnoid haemorrhage (SAH). We present our single centre experience of BAPA's and review of the literature. We performed a retrospective review of our prospectively maintained database to identify all BAPA's that presented acute SAH between February 2009 and February 2018. We identified 9 patients (male = 7), each with a single aneurysm, and average age 55 ±â€¯9.7 years. All aneurysms were small, 2.1 ±â€¯0.5 mm (range 1-3 mm). Three aneurysms were not detected on initial angiography. Six aneurysms were treated with flow diversion, 3 were managed conservatively. No repeat haemorrhage occurred in the flow diverted patients. One patient treated conservatively suffered a repeat haemorrhage and died (mRS 6). Follow up imaging (n = 7), at average 5.6 months (range 3-12 months), showed complete occlusion in all the flow-diverted aneurysms and no change in one conservatively managed patient. There was no evidence of perforator infarction on the follow-up post treatment imaging. Clinical follow-up data was available in 8 patients, 6 of whom (75%) had a good outcome (mRS ≤ 2). A high index of suspicion is required to diagnose BAPA. Flow diversion can be used to treat BAPA's with acceptable risk of perforator infarction and low risk of repeat haemorrhage.

The Size of Ruptured Intracranial Aneurysms : A 10-Year Series from a Single Center.

PURPOSE: There is a controversy concerning the risk of rupture of small intracranial aneurysms. We sought to determine the size and morphological features of ruptured intracranial aneurysms. MATERIAL AND METHODS: The hospital files and images from all patients referred during one decade (2007-2016) to a specialized neurovascular center were retrospectively reviewed. Neck diameter, fundus depth and width as well as neck width based on catheter angiography were measured. Aneurysm morphology was classified as either regular, lobulated, irregular or fusiform. RESULTS: A total of 694 consecutive patients with aneurysmal subarachnoid hemorrhage (aSAH) were identified (65.9% female, median age 54.3 years). The anterior communicating artery (AcomA) was the most frequent location of ruptured aneurysms. The medians for aneurysm depth, width and neck diameter were 5 mm, 4.5 mm and 3 mm, respectively. A regular contour of the aneurysm sac was found in 19%. CONCLUSION: The majority of aSAH are caused by small intracranial aneurysms. There is no safety margin in terms of small aneurysm size of regular shape without daughter aneurysms. Treatment should also be offered to patients with small, regularly shaped intracranial aneurysms, together with an empirical risk-benefit assessment.

Treatment of Unruptured, Saccular, Anterior Choroidal Artery Aneurysms with Flow Diversion : A Single Centre Experience.

BACKGROUND: The region of the brain supplied by the anterior choroidal artery (AChoA) is exquisitely eloquent. Aneurysms arising at or close to the origin of the vessel are not uncommon and damage or occlusion to the vessel can result in devastating consequences. The optimal treatment strategy is yet to be determined. OBJECTIVE: We sought to determine the efficacy of flow diversion for the treatment of unruptured AChoA aneurysms. METHOD: A retrospective review of our prospectively maintained database was performed to identify all patients with unruptured aneurysms of the AChoA between March 2009 and May 2017. The fundus size, number and type of flow-diverting stent (FD), complications and follow-up data were recorded. RESULTS: We identified 30 patients (60% female), average age 52.8 ± 10.8 years (range 27-73), with 30 aneurysms. The aneurysms were generally small with a mean fundus diameter of 3.4 mm (range 1-7 mm). Early angiographic follow-up data were available for all patients at which point 15 aneurysms were completely occluded (50%). Delayed angiographic follow-up was available in 24 patients and occlusion was seen in 21 patients (87.5%). Of the patients one developed transient ischemic symptoms after interruption of the antiplatelet medication and another patient had a small embolic infarct with transient symptoms in the periprocedural period. CONCLUSION: Flow diversion can be used to successfully treat aneurysms of the AChoA. The treatment carries a high rate of technical and radiological success with a good safety profile.

High-Grade Dural Arteriovenous Fistulas : Use of Kaneka ED Coils with the Marathon Microcatheter for Transvenous Coil Embolization.

BACKGROUND: Dural arteriovenous fistulas (DAVF) are commonly encountered lesions that can be treated both transvenously, transarterially or using a combined approach. OBJECTIVE: Transvenous coil embolization of DAVF is a recognized treatment option but can be challenging. In this context this article presents clinical experience using the Kaneka ED10 ExtraSoft coils in combination with the Marathon microcatheter to treat high grade DAVF. The physical properties of these coils and the microcatheter were also determined. MATERIAL AND METHODS: All patients with high grade DAVF treated with the Marathon and the Kaneka ED COIL ∞10 ExtraSoft coils were retrospectively identified. The clinical presentation, location, grade of the lesion, clinical and radiological follow-up data were recorded. Bench side studies were performed to determine the physical properties of the Marathon catheter in comparison to the SL10 and Headway Duo as well the maximum width of the Kaneka pusher wire in comparison to Hypersoft, Target and Axium Prime coils. RESULTS: A total of 8 patients with 9 DAVF with 3 Cognard 3 and 6 Cognard 4 lesions were identified. All the DAVF's were occluded either at the end of the procedure or on follow-up imaging. On bench side tests the Marathon microcatheter had the most flexible distal tip and distal shaft in comparison to the SL10 and Headway Duo. The proximal shaft of the Marathon was stiffer than the SL10. The Kaneka ED COIL ∞10 ExtraSoft had the smallest distal width and were the only coils tested that could be deployed through a Marathon microcatheter. CONCLUSION: The combination of the Marathon microcatheter and Kaneka ED COIL ∞10 ExtraSoft is useful for the treatment of high grade DAVF.

Endovascular Thrombectomy in Wake-Up Stroke and Stroke with Unknown Symptom Onset.

BACKGROUND AND PURPOSE: Mechanical thrombectomy in acute ischemic stroke within 6 hours of symptom onset is effective and safe. However, in many patients, information on the beginning of symptoms is not available. Patients can be divided into those with wake-up stroke and daytime-unwitnessed stroke. Evidence on outcome and complications after mechanical thrombectomy in wake-up stroke and daytime-unwitnessed stroke is rare. A potential beneficial effect of mechanical thrombectomy in selected patients with wake-up stroke or daytime-unwitnessed stroke is suspected. MATERIALS AND METHODS: We analyzed 1073 patients with anterior circulation stroke undergoing mechanical thrombectomy between 2010 and 2016. Patients with wake-up stroke and daytime-unwitnessed stroke were compared with controls receiving mechanical thrombectomy as the standard of care. We assessed good functional outcome (mRS ≤ 2 at 3 months), mortality rates, and frequencies of symptomatic intracranial hemorrhage. Subgroup analyses tried to detect influences of patient selection via further imaging modalities (MR imaging, CTP; wake-up stroke [advanced], daytime-unwitnessed stroke [advanced]) on outcome and safety. RESULTS: There was no significant difference in good functional outcome between patients with wake-up stroke and controls (35.9% versus 38.3%, P = .625). Outcome in patients with daytime-unwitnessed stroke was inferior compared with controls (27.3%, P = .007). Groups did not differ in all-cause mortality at day 90 (P = .224) and the rate of symptomatic intracranial hemorrhage (P = .292). Advanced imaging improved the frequency of good functional outcome (non-wake-up stroke [advanced] versus wake-up stroke [advanced]: OR, 2.92; 95% CI, 1.32-6.45; non-daytime-unwitnessed stroke [advanced] versus daytime-unwitnessed stroke [advanced]: OR, 2.09; 95% CI, 1.03-4.25) with an additional reduction in all-cause mortality (non-daytime-unwitnessed stroke [advanced] versus daytime-unwitnessed stroke [advanced]: OR, 0.42; 95% CI, 0.20-0.88). CONCLUSIONS: Mechanical thrombectomy in selected patients with wake-up stroke allows a good functional outcome comparable with that of controls. Outcome after mechanical thrombectomy in daytime-unwitnessed stroke seems to be inferior compared with that in controls. Advanced imaging modalities may increase the frequency of good functional outcome in both patients with wake-up stroke and daytime-unwitnessed stroke.

Difference in aneurysm characteristics between ruptured and unruptured aneurysms in patients with multiple intracranial aneurysms.

BACKGROUND: The risk of aneurysmal rupture is dependent upon numerous factors, however, there are inconsistencies in the results between studies, which may be due to confounding factors. This can be avoided by comparing the characteristics of ruptured and unruptured aneurysms within the same patient. We sought to analyze the aneurysm characteristics of patients with acute aneurysmal subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms. METHODS: We reviewed our prospectively maintained institutional database, between 01/10/2007 and 01/01/2017, for all patients with confirmed SAH and >1 aneurysm. We recorded the size, location, and morphology and calculated secondary geometric indices such as bottleneck factor and aspect ratio. RESULTS: During the study period, a total of 694 patients with aneurysmal SAH were admitted to our institution. We identified 113 patients (74.3% female, average age 51.7 ± 12.3). The majority of patients had only one associate unruptured aneurysm (79.6%). The average unruptured aneurysm was 3.1 ± 1.5 mm and the average ruptured aneurysm was 5.7 ± 2.7 mm (P < 0.001). In the multivariate analysis, aneurysm location, aneurysm morphology, and size were independently associated with rupture. A complex aneurysm morphology was the strongest risk factor for rupture (OR, 29.27; 95% CI 14.33-59.78; P < 0.001) with size >7 mm (OR, 17.74; 95% CI 4.07-77.35; P < 0.001), and AcomA location also showing a strong independent association. CONCLUSION: Size plays an important part in determining rupture risk, however, other factors such as location and in particular morphology must also be considered. We believe that the introduction of vessel wall imaging will help to risk stratify aneurysms.

Paraspinal arteriovenous fistula: Stuttgart classification based on experience and a review of the literature.

The term "paraspinal arteriovenous shunts" (PAVSs) summarizes an inhomogeneous variety of rare vascular disorders. PAVSs have been observed as congenital or acquired lesions. The clinical course of PAVSs may be asymptomatic or present with life-threatening symptoms. Based on a collection of individual cases from three institutions and a literature evaluation, we propose the following classification: PAVSs that are part of a genetic syndrome are separated from "isolated" PAVSs. Isolated PAVSs are subdivided into "acquired", "traumatic" and "congenital" without an identifiable genetic hereditary disorder. The subgroups are differentiated by the route of venous drainage, being exclusively extraspinal or involving intraspinal veins. PAVSs associated to a genetic syndrome may either have a metameric link or occur together with a systemic genetic disorder. Again extra-vs intraspinal venous drainage is differentiated. The indication for treatment is based on individual circumstances (e.g. myelon compression, vascular bruit, high volume output cardiac failure). Most PAVSs can be treated by endovascular means using detachable coils, liquid embolic agents or stents and derivates.

[Management of paraophthalmic aneurysms : Review of endovascular treatment strategies]. / Management paraophthalmischer Aneurysmen : Übersicht der endovaskulären Behandlungsstrategien.

BACKGROUND: Aneurysms of the cerebral vessels are relatively common and aneurysms of the ophthalmic segment of the internal carotid artery (ICA) represent approximately 10% of intradural aneurysms. ANATOMICAL ASPECTS: The ophthalmic segment of the ICA extends from the origin of the ophthalmic artery to the origin of the posterior communicating artery. Aneurysms can originate from the ophthalmic artery itself or directly from the ICA at a distance from the ophthalmic artery. The various anatomic configurations can alter the risks of treatment. SURGICAL TREATMENT: Surgical treatment of aneurysms of the ophthalmic segment poses unique challenges for the neurosurgeon, given the deep location and complex nearby structures and optic nerve. The necessity to remove the clinoid process can make the operation technically challenging. ENDOVASCULAR TREATMENT: Endovascular treatment of paraophthalmic aneurysms includes coil occlusion, and also stent- or balloon-assisted coil occlusion. More recently, hemodynamically active flow diverter stents improved the treatment results. CONCLUSION: The management of paraophthalmic aneurysms is associated with specific risks. Careful consideration of the available techniques is necessary before each invention. Coil-occlusion remains the first choice for ruptured paraophthalmic aneurysms. For unruptured paraophthalmic aneurysms flow diversion offers improved results. The overall complication rates of these procedures are low; however, cerebral ischemia, intracranial hemorrhage and visual complications must be considered in advance and the patient must be informed of the risks.

In-stent Stenosis after p64 Flow Diverter Treatment.

PURPOSE: There is limited information available on the incidence of in-stent stenosis (ISS) secondary to the use of flow-diverting stents in the intracranial vasculature. We sought to determine the incidence, severity, and clinical course of ISS on angiographic follow-up after treatment of saccular aneurysms with p64. METHODS: We retrospectively reviewed all patients who underwent treatment of a saccular (ruptured and unruptured) intracranial aneurysm with ≥1 p64 between 2011 and 2015. Fusiform aneurysms and dissections were excluded. Aneurysms with prior or concomitant saccular treatment (e. g., coiling, clipping) were included. Extradural targets and aneurysms with parent vessel implants other than p64 were excluded. ISS was assessed on follow-up angiography and defined as <50% (mild), 50-75% (moderate), or >75% (severe). RESULTS: In total, 205 patients (147 female, 71.7%; median age 57 years), with 223 saccular aneurysms were treated with p64 and had at least 9 months of digital subtraction angiography (DSA) follow-up completed. There was no DSA follow-up available in 8 patients. ISS of any degree at any time was recognized in 65/223 (29.1%) of all target aneurysms. The maximal degree of lumen loss was <50% in 40 lesions (17.9%), 50-75% in 19 lesions (8.5%), and >75% in 6 lesions (2.7%). ISS did not cause a focal neurological deficit in any patient. No progression from stenosis to occlusion was observed. Balloon angioplasty was performed in 1 lesion and was well tolerated. In 56 lesions (84.8%), a significant reduction of ISS occurred spontaneously, 2 mild stenoses remained stable, and for 6 lesions the long-term follow-up is pending. CONCLUSION: Treatment with p64 is associated with an overall rate of 8.5% moderate ISS (50-75%) and 2.7% severe ISS (>75%), which is comparable with the rate of ISS reported in the literature for other flow diverting stents. There is a tendency for ISS to spontaneously improve over time.

Paediatric aneurysms - Review of endovascular treatment strategies.

Paediatric aneurysms are rare and represent the end result of a variety of different pathological mechanisms. They have a varied presentation and features that are distinct from their adult counterparts. The appropriate management of these aneurysms requires a multi-disciplinary team approach and detailed analysis to deal with the underlying pathology. This can involve the use of coils, adjunctive devices such as neck-bridging devices, flow diverters and liquid embolic agents, as well as microsurgical clipping. In this paper we discuss the different types of aneurysms that can present in the paediatric population and present cases that highlight the entire spectrum of paediatric aneurysmal disease and the different treatment options currently available. Treatment of paediatric intracranial aneurysms requires individualized strategies.

Endovascular treatment of idiopathic intracranial hypertension: retrospective analysis of immediate and long-term results in 51 patients.

PURPOSE: Idiopathic intracranial hypertension (IIH) is a disorder of increased intracranial pressure in the absence of any known causative factor. Sinus stenosis is common in these patients. Stenting of stenotic dural sinuses has gained popularity as a treatment option, since these stenoses may contribute to an obstruction of the venous return, and, thereby may contribute to IIH via an increase in venous sinus pressure. We evaluated the safety and efficacy of endovascular treatment in IIH with venous sinus stenosis. METHODS: Fifty-one patients with IIH underwent stenting. Median age was 40 years. Clinical manifestation was headache in 74.5% of the patients and visual obscurations in 78.5%. Papilledema was present in 50/51 patients (98%), and lumbar puncture documented elevated CSF opening pressure in all but one patient (98%). Sinus stenoses were observed in all patients. RESULTS: Endovascular treatment was successfully performed in all patients. There were no major complications encountered (i.e., live threatening or causing a deterioration of a patient's condition equivalent to mRS 3-6). Improvement or resolution of papilledema was observed in 88% of the patients, and 84% reported improvement or resolution of the headache. Follow-up angiographies were performed in 48 patients at a median interval of 49 months and demonstrated in stent-stenosis or a de novo stenosis in 12 patients, eight of them needed re-treatment. CONCLUSION: Venous sinus stenting is a safe and effective alternative to other invasive treatments (e.g., optic nerve sheath fenestration, CSF diversion) in patients with IIH. The majority of patients have a persistent clinical benefit.

Stent Retriever Thrombectomy of Small Caliber Intracranial Vessels Using pREset LITE: Safety and Efficacy.

PURPOSE: Few devices are approved for thrombectomy of distal vessel branches, and clinical experience is limited. Here we report our experience with pREset LITE for thrombectomy of small intracranial vessels. METHODS: From an institutional database we selected consecutive patients treated with pREset LITE for an occlusion of small (≤ 2 mm), intracranial target vessels. Recanalization success was measured by applying the modified Thrombolysis In Cerebral Infarction (mTICI) score. To assess safety, we recorded device-related procedural events and potentially device-related hemorrhages on follow-up imaging. Infarcts in the dependent territory served as a measure for efficacy. RESULTS: Of 536 patients treated between August 2013 and March 2015, 76 met the inclusion criteria. pREset LITE was used in 90 branches with an average diameter of 1.6 mm (1.3-2.0 mm). An mTICI score ≥ 2b was achieved in 70.0 %. Procedural events consisted of 5.6 % significant vasospasm, 2.2 % suspected dissections, 2.2 % downstream emboli, and 1.1 % self-limiting extravasations. On posttreatment imaging 2.2 % parenchymal hemorrhages type I (PHI) and 13.3 % focal subarachnoid hemorrhage (SAH) were potentially device related, but all of these events remained asymptomatic. After successful recanalization, 33.3 % developed no ischemia in the dependent territory while 41.7 % developed a partial infarct, and 25 % developed a complete infarct. Successful recanalization significantly increased the chance to develop no or only partial infarct compared with a complete infarction (p = 0.003, p = 0.013). CONCLUSIONS: Thrombectomy of small vessels with pREset LITE is feasible with good recanalization and reasonable safety margins. Successful recanalization significantly reduces the risk of infarction in the dependent territory. The impact on the overall clinical outcome remains to be determined.

Use of the pCONus as an adjunct to coil embolization of acutely ruptured aneurysms.

INTRODUCTION: Coil embolization of ruptured aneurysms has become the standard treatment in many situations. However, certain aneurysm morphologies pose technical difficulties and may require the use of adjunctive devices. OBJECTIVE: To present our experience with the pCONus, a new neck bridging device, as an adjunct to coil embolization for acutely ruptured aneurysms and discuss the technical success, angiographic and clinical outcomes. METHODS: We conducted a retrospective review of our database of prospectively collected data to identify all patients who presented with acute subarachnoid hemorrhage that required adjunctive treatment with the pCONus in the acute stage. We searched the database between April 2011 and April 2016. RESULTS: 21 patients were identified (13 male, 8 female) with an average age of 54.6 years (range 31-73). 8 aneurysms were located at the basilar artery tip, 7 at the anterior communicating artery, 4 at the middle cerebral artery bifurcation, 1 pericallosal, and 1 basilar fenestration. 61.8% patients achieved modified Raymond-Roy classification I or II at immediate angiography, with 75% of patients having completely occluded aneurysms or stable appearance at initial follow-up. There were no repeat aneurysmal ruptures and two device-related complications (no permanent morbidity). Four patients in our cohort died. CONCLUSIONS: Use of the pCONus is safe and effective in patients with acutely ruptured aneurysms and carries a high rate of technical success.

Treatment of posterior circulation non-saccular aneurysms with flow diverters: a single-center experience and review of 56 patients.

BACKGROUND AND PURPOSE: Non-saccular aneurysms of the posterior fossa are an uncommon pathology with no clear treatment strategy. The use of flow-diverting stents (FDS) has had mixed results. We sought to evaluate our experience of FDS for the treatment of this pathology. METHODS: We retrospectively reviewed our database of prospectively collected information for all patients treated only with flow diversion for an unruptured non-saccular aneurysm of the posterior circulation between February 2009 and April 2016. The aneurysms were classified as dolichoectasia, fusiform or transitional, and imaging characteristics including maximal diameter, disease vessel segment, MRI features (intra-aneurysmal thrombus, T1 hyperintensity in the aneurysmal wall, infarctions in the territory of the posterior circulation, and mass effect) were recorded alongside clinical and follow-up data. RESULTS: We identified 56 patients (45 men) with 58 aneurysms. The average age of the patients was 63.5 years. Twenty-two patients were symptomatic from the aneurysms at presentation. The majority of the lesions were vertebrobasilar in location (44.8%) with isolated vertebral lesions representing 29.3% of aneurysms. Transitional aneurysms were the most common (48.2%). The mean maximal diameter of the aneurysms was 11 mm. Angiographic exclusion of the aneurysms was seen in 57.4% of aneurysms with follow-up (n=47). During the follow-up period nine patients died. CONCLUSIONS: Treatment of non-saccular aneurysms of the posterior fossa is technically possible. Early treatment, particularly of the fusiform and transitional subtypes, is recognized, as is treatment prior to the development of symptoms. A 'watch and wait' strategy with regular imaging follow-up could be employed for asymptomatic dolichoectasia.