Pipeline flow diversion of ruptured blister aneurysms of the supraclinoid carotid artery using a single-device strategy.

OBJECTIVE Ruptured blister aneurysms remain challenging lesions for treatment due to their broad, shallow anatomy and thin, fragile wall. Historical challenges with both open microsurgical approaches and intrasaccular endovascular approaches have led to increased use of flow diversion for management of these aneurysms. However, the optimum paradigm, including timing of treatment, use of dual antiplatelet therapy, and number of flow-diverter devices to use remains unknown. The authors describe their experience with ruptured blister aneurysms treated with flow diversion at their institution, and discuss rates of rebleeding and number of devices used. METHODS All patients presenting with subarachnoid hemorrhage from a ruptured blister aneurysm and treated with Pipeline flow diversion were identified. Patient demographic data, clinical status and course, need for external ventricular drain (EVD), timing of treatment, and angiographic details and follow-up were recorded. RESULTS There were 13 patients identified (11 women and 2 men), and 4 had multiple aneurysms. Two aneurysms were treated on initial angiography, with average time to treatment of 3.1 days for the remainder, after discussion with the family and institution of dual antiplatelet therapy. Device placement was technically successful in all patients, with 2 patients receiving 2 devices and the remainder receiving 1 device. There was 1 intraoperative complication, of a wire perforation causing intracerebral hemorrhage requiring decompressive craniectomy. Three patients had required EVD placement for management of hydrocephalus. There was no rebleeding from the target lesion; however, one patient had worsening intraventricular hemorrhage and another had rupture of an unrecognized additional aneurysm, and both died. Of the other 11 patients, 10 made a good recovery, with 1 remaining in a vegetative state. Nine underwent follow-up angiography, with 5 achieving complete occlusion, 2 with reduced aneurysm size, and 2 requiring retreatment for aneurysm persistence or enlargement. There were no episodes of delayed rupture. CONCLUSIONS Pipeline flow diversion is a technically feasible and effective treatment for ruptured blister aneurysms, particularly in good-grade patients without hydrocephalus. Patients with a worse grade on presentation and requiring EVDs may have higher risk for bleeding complications and poor outcome. There was no rebleeding from the target lesion with use of a single device in this series.

Anterior spinal artery syndrome in a patient with vasospasm secondary to a ruptured cervical dural arteriovenous fistula.

BACKGROUND: Spinal dural arteriovenous fistulas (DAVF) in the cervical spine are known to cause subarachnoid hemorrhage. Vasospasm after rupture of a DAVF, however, has not previously been reported. CASE PRESENTATION: A 48-year-old woman who presented with the sudden onset of altered mental status. Imaging demonstrated extensive subarachnoid hemorrhage and spinal DAVF at C1 to C2. The patient underwent a suboccipital craniotomy for DAVF ligation. On post-operative day three, she began having acute weakness in all her extremities with proprioception and vibration preserved, whereas pain and temperature sensation was lost. An angiogram demonstrated bilateral vertebral artery vasospasm with no filling of the anterior spinal artery. Bilateral angioplasty of the vertebral arteries was performed successfully and post-angioplasty, the right vertebral artery was filling the anterior spinal artery. The patient clinically improved. She subsequently required treatment with n-butyl cyanoacrylic acid (nBCA) embolization and gamma knife radiosurgery to achieve obliteration of the lesion. CONCLUSIONS: For patients with subarachnoid hemorrhage of unknown origin, differential diagnosis should include DAVF. This patient also presented with vasospasm in the context of ruptured DAVF, a complication previously unreported in the literature. This finding suggests that close monitoring for vasospasm after rupture of DAVF is warranted.

Improvement in Visual Symptomatology after Endovascular Treatment of Cavernous Carotid Aneurysms: A Multicenter Study.

INTRODUCTION: Aneurysms arising from the cavernous internal carotid artery (CCAs) pose technical challenges for surgical management and such patients are frequently referred for endovascular treatment. These aneurysms often produce a variety of neurological deficits, primarily those related to oculoparesis. Our purpose was to determine the visual and neurological outcome of patients with treated CCAs. METHODS: We reviewed the medical records and angiograms for patients who underwent endovascular treatment for CCAs at three academic medical centers. The following outcomes were analyzed: angiographic assessment, visual improvement and outcome at 3 months using Glasgow Outcome Scale (GOS). RESULTS: Thirty-four patients (mean age 54.7 years) were treated for CCAs. The mean aneurysm size was 14.2 mm (range: 3-45 mm), and fourteen patients (41.2%) required stent assistance. Twenty-one aneurysms (61.8%) were completely occluded; nine aneurysms (26.6%) had near-complete occlusion; 4 aneurysms (11.8%) had partial occlusion. Seven patients (20.6%) required retreatment. Fifteen of the 34 patients (44.1%) presented with visual symptoms, while only eight patients had residual visual symptomatology at follow-up (44.1% vs. 23.5%; p=0.02). Patients that presented with visual symptoms (N=15) had a mean aneurysm size of 24.5 mm, while those without visual symptoms (N=19) had a size of 7.5 mm (p=0.001). Follow-up GOS was good (4-5) in 29 patients (90.6%). No thromboembolic complications were observed. One patient died (3.1%) of an unrelated cause. CONCLUSIONS: Most patients in this multicenter series improved or remained stable after treatment. The results of this study indicate that endovascular treatment may improve the outcome of visual symptoms in patients with large cavernous aneurysms with low periprocedural morbidity. COMPETING INTERESTS: MJA is a consultant for Stryker and Codman. AC receives a Cordis Endovascular Fellowship Training Grant and a Stryker Endovascular Neurosurgery Post-graduate Fellow Grant. JUSTIFICATION OF AUTHORSHIP: Dr. Drazin: Conception and Design, Drafting the Article and Critically Revising the Article Dr. Choulakian: Analysis and Interpretation of Data and Drafting the Article Dr. Nuno: Analysis and Interpretation of Data Dr. Gandhi: Analysis and Interpretation of Data and Drafting the Article Dr. Edgell: Analysis and Interpretation of Data and Drafting the Article Dr. Alexander: Critically Revising the Article and Conception and Design.

Stent-assisted coil emboilization of ruptured intracranial aneurysms: A retrospective multicenter review.

BACKGROUND: The purpose of this study is to retrospectively review our experience with stent-assisted embolization of patients with an acutely ruptured cerebral aneurysm. METHODS: Medical records and imaging were reviewed for 36 patients who underwent stent-assisted embolization of a ruptured cerebral aneurysm. RESULTS: Seventeen patients (47%) received a preprocedural loading dose of clopidogrel and five patients (14%) received an intraprocedural dose of clopidogrel. The remaining 14 patients (36%) were treated with antiplatelet therapy following the procedure. Six (17%) stent related intraprocedural thromboembolic complications were encountered; four of these resolved (one partial, three complete) following treatment with abciximab and/or heparin during the procedure. Five of the six thromboembolic events occurred in patients who were not pretreated with clopidogrel (P = 0.043). Two patients in this series (6%) had a permanent thrombotic complication resulting in mild hemiparesis in one patient, and hemianopsia in the second. No procedure related hemorrhagic complications occurred in any patient. One patient had a spontaneous parenchymal hemorrhage contralateral to the treated aneurysm discovered 10 days after treatment. Twenty-eight patients (78%) had a Glasgow Outcome Score of 4 or better at discharge. Seven of 21 patients (33%) with angiographic follow-up required further treatment of the coiled aneurysm. CONCLUSION: Stent-assisted coil embolization is an option for treatment of ruptured wide neck ruptured aneurysms and for salvage treatment during unassisted embolization of ruptured aneurysms but complications and retreatment rates are higher than for routine clipping or coiling of cerebral aneurysms. Pretreatment with clopidogrel appears effective in reducing thrombotic complications without significant increasing risk of hemorrhagic complications.

Body weight: a risk factor for subtherapeutic antithrombotic therapy in neurovascular stenting.

BACKGROUND: Patients with cervical carotid and intracranial stenting are routinely premedicated with antithrombotic agents, clopidogrel and aspirin (ASA), and intraprocedurally with heparin. The levels of antithrombotic therapy necessary for these neurovascular therapies have yet to be well defined. METHOD: A retrospective review of 52 patients who underwent neurovascular stenting procedures was carried out. Measurements obtained intraoperatively included: activating clotting time, antiplatelet inhibition (from Accumetrics) recorded as ASA reaction units (ARU), P2Y12 reaction units (PRU), baseline (BASE), and percentage inhibition. Percentage P2Y12 platelet inhibition <20% and ARU >550 were defined as suboptimal clopidogrel and ASA responses, respectively. RESULTS: 52 patients (mean age 62.6 years) underwent stent implantation for wide necked aneurysms (28, 54%), symptomatic intracranial stenosis (13, 25%) and cervical carotid stenosis (11, 21%). Mean ARU assays were 463.0 ± 84.7. The response was suboptimal in seven patients. For clopidogrel, the mean BASE, PRU and percentage inhibition were 374.0± 54.9, 279.5 ± 78.5 and 30.7% ± 22.6%, respectively. 19 patients (36.5%; p<0.01) showed suboptimal responses for percentage inhibition. Multivariate analysis showed that body weight (82.0 ± 11 vs 73.6 ± 14 kg; p =0.04) and body mass index were significant predictors (OR 1.18, 95% CI 1.01 to 1.18; p =0.003) in the suboptimal group. One case of intraprocedural thrombosis (2%) was observed in the suboptimal group and no cases were seen in the therapeutic group. CONCLUSION: Data obtained in this study suggest a suboptimal clopidogrel response in patients with greater body weight and body mass index. Adjusted dosing according to weight may help achieve adequate therapeutic platelet inhibition and reactivity while decreasing thromboembolic complications.

Moyamoya disease in children with congenital dwarfing conditions.

Congenital dwarfisms can be associated with a variety of vascular anomalies. Here, we describe 2 patients with congenital dwarfisms who presented with moyamoya syndrome and underwent indirect intracranial revascularization. The pathogenesis of moyamoya syndrome in this population is not well understood, but it is a major cause of stroke and early death in these patients, making their timely diagnosis and management critical.

Mechanical thrombectomy with the penumbra system for treatment of venous sinus thrombosis.

OBJECTIVE: Venous sinus thrombosis can be a fatal condition. When systemic anticoagulation therapy fails or is high risk, endovascular chemical thrombolysis or mechanical thrombectomy may be necessary. We report our experience using the Penumbra system (PS; Penumbra, Alameda, California, USA) in a series of four patients with venous sinus thrombosis. METHODS: Four patients were treated with mechanical thrombectomy using the PS for venous sinus thrombosis. Three of these patients also underwent balloon angioplasty following the PS device. Utility of this technique was evaluated by procedural success, improvement in neurological condition, avoidance of complications and follow-up imaging. RESULTS: Technical success was achieved in all four patients with restoration of flow in the occluded sinuses without the use of chemical thrombolysis. No complications were encountered during the procedure and no postprocedural complications were attributable to the thrombectomy. One patient with glioblastoma died 6 weeks after the procedure. No new intracerebral hemorrhages were caused and there was no exacerbation of pretreatment intracerebral hemorrhages. Follow-up imaging was available in all but one patient to documented continued sinus patency. Neurologic improvement was seen in all patients after thrombectomy. Two patients have returned for outpatient follow-up and both are doing well. CONCLUSION: Endovascular treatment for venous sinus thrombosis with the PS is a safe and efficacious alternative to the other forms of mechanical thrombectomy reported in the literature. Good clinical and radiographic results can be obtained without the need for chemical thrombolysis.

Congenital absence of the common carotid artery in a patient with a ruptured anterior communicating artery aneurysm.

In a 41-year-old woman with a ruptured anterior communicating artery aneurysm, cerebral angiography incidentally showed an absence of the right common carotid artery. The right internal and external carotid artery originated from the ipsilateral inominate artery. The absence of the common carotid artery is extremely rare and association with a ruptured cerebral aneurysm is even less common. A description of the case and review of the literature are reported.

Endosaccular treatment of 113 cavernous carotid artery aneurysms.

OBJECTIVE: Cavernous carotid aneurysms (CCAs) can present with visual symptoms or with subarachnoid hemorrhage (SAH). As surgical treatment of these aneurysms can be technically challenging, endovascular management has emerged as the preferred treatment modality. METHODS: A retrospective review was conducted of 113 patients who underwent endosaccular treatment for CCAs. Presenting symptoms, aneurysm size, use of stent assistance, rate of thromboembolic complications, presence of SAH and angiographic follow-up were reviewed. RESULTS: 29 patients (26%) with CCAs presented with diplopia due to cranial nerve palsies. Mean aneurysm size in this group was 17 mm. Three patients (2.6%) presented with SAH with a mean aneurysm size of 15.3 mm. Mean length of stay for ruptured versus non-ruptured aneurysms was 11.7 and 1.7 days, respectively. Clinically significant thromboembolic complications occurred in four cases (3.5%). Stent assistance was required in 53 cases (47%). Of the 86 patients (76%) returning for follow-up angiography (mean 6.2 months), 58 (75%) had no residual aneurysm and 14 (12%) showed regrowth. Thirteen patients (11.5%) underwent repeat endovascular treatment. CONCLUSIONS: CCAs commonly produce diplopia and cranial nerve palsies when a critical size is reached (mean 17 mm in our series). Aneurysm obliteration with internal carotid artery preservation is the preferred treatment modality and can be accomplished with coil embolization with or without stent assistance. Although recurrence and retreatment can occur, the thromboembolic risk of endovascular treatment is low. Consideration should be given to treatment of asymptomatic CCAs 15 mm or larger due to potential risks of cranial neuropathy and SAH.

NBCA embolization of a ruptured intraventricular distal anterior choroidal artery aneurysm in a patient with moyamoya disease.

Occasionally an aneurysm is the cause of hemorrhage in patients with moyamoya disease (MMD). We present a case of a ruptured intraventricular distal anterior choroidal artery (AChA) aneurysm treated with n-butyl cyanoacrylic acid (nBCA) (Trufill nBCA Liquid Embolic, Codman Neurovascular, Raynham, Massachusetts, USA) embolization in a patient with MMD. There were no procedural complications and at 6 month follow-up she remained neurologically normal. Six month follow-up cerebral angiography showed no residual aneurysm. The endovascular route is an attractive option for many aneurysms associated with MMD as the lesions can be treated without disturbing the moyamoya collaterals. nBCA, delivered through a flow-guided microcatheter, is a good embolic agent choice when the lesion is distal on a small vessel and when distal parent artery occlusion can be tolerated. Intraventricular AChA aneurysms are well suited for this treatment strategy.