Long-Term Follow-up of Aneurysms Treated With Hydrogel-Coated Coils Shows Progressive Thrombosis and Improvement in Raymond-Roy Classification.

BACKGROUND: Coil embolization of aneurysms has been shown to be a safe and effective method of aneurysm treatment. Hydrogel-coated coils were developed as a hybrid embolization device to increase the packing density of a coil mass in an aneurysm and to reduce retreatment and rerupture rates. Previous studies have shown a benefit compared with bare metal coils. OBJECTIVE: To present long-term follow-up of a cohort of patients treated with hydrogel-coated coils to better determine the effectiveness compared with bare platinum coils. METHODS: Between January 2003 and April 2012, we identified patients with both ruptured and unruptured aneurysms coiled at our institution, using some portion of hydrogel-coated coils. Planned follow-up angiography was performed at 6 months, 18 months, and 5 years post-treatment. All imaging was independently adjudicated by a single physician at a separate institution. The results were scored with the modified Raymond-Roy Occlusion Classification. RESULTS: A total of 145 patients with 153 treated aneurysms were included in the study analysis. Immediately after treatment, 49% of aneurysms were classified at Raymond-Roy Occlusion Classification I or II, which improved to 83% by 6 months. This percent plateaued at 18-month and 5-year follow-up, measuring 86% and 90%, respectively. The retreatment rate was 14% over the 5-year period, and there were no rerupture events captured. CONCLUSION: Treatment of intracranial aneurysms with coil embolization using hydrogel-coated aneurysms shows evidence of progressive occlusion, particularly over the first 6 months of follow-up. The retreatment rate is comparable with historical data, and the rerupture rate is low.

Matricidal cavernous aneurysms: a multicenter case series.

BACKGROUND: Cavernous carotid artery aneurysms (CCAs) represent a unique subset of intracranial aneurysms due to their distinct natural history and the anatomy of the cavernous sinus. Enlarging CCAs can cause elastic compression of the parent internal carotid artery (ICA). We suggest defining aneurysms that cause luminal stenosis of their parent vessels as 'matricidal aneurysms.'Though many patients are asymptomatic, presenting symptoms of CCAs include ophthalmoplegia with resulting diplopia, vision changes, pain, ptosis, facial numbness, and cavernous-carotid fistula. Less commonly, patients with CCAs can present with epistaxis, subarachnoid hemorrhage, and-in cases of matricidal aneurysms-ischemia due to stenosis. The proper management of stenosis caused by a matricidal CCA is not well established and may not be intuitive. METHODS: We present a multicenter retrospective case series of patients with matricidal CCAs. RESULTS: Forty patients with matricidal aneurysms presented with both asymptomatic and symptomatic stenosis. These patients were either treated with conservative medical management, coiling, flow diversion, or endovascular sacrifice of the parent artery. Planned treatment modalities were not executed in 11 cases (28% treatment failure rate). Presenting symptoms, patient outcomes, and follow-up data are presented for all cases. CONCLUSION: Matricidal aneurysms require careful consideration and planning. The restricted anatomy of the cavernous sinus can make successful execution of endovascular interventions more difficult. Direct elastic compression of the parent artery does not respond to angioplasty and stenting in the same way atherosclerotic stenosis does. Because of this, planning for the possibility of parent vessel sacrifice is important.

A Pilot Comparison of Multispectral Fluorescence to Indocyanine Green Videoangiography and Other Modalities for Intraoperative Assessment in Vascular Neurosurgery.

BACKGROUND: Digital subtraction angiography (DSA) is the gold standard for vascular imaging, but is not easily integrated into a continuous microsurgical environment. Other available modalities for intraoperative vascular assessment have their own limitations. OBJECTIVE: To investigate multispectral fluorescence (MFL), a new technology based on indocyanine green (ICG) fluorescence, which may provide advantages over current intraoperative imaging modalities. METHODS: Cadaveric intracranial aneurysm models and turkey wing bypasses were created and tested with white light and micro-Doppler ultrasound, indocyanine green videoangiography (ICG-VA), MFL, and DSA in conditions mimicking surgery. Assessments with these modalities were scored by 7 neurosurgeons. RESULTS: DSA was significantly better than other modalities in evaluating the vasculature (P < .0001), but was significantly less ergonomic and efficient (P < .0001). MFL and ICG-VA were not significantly different from each other. Both were significantly better than white light/micro-Doppler ultrasound in assessing occlusion and patency (P ≤ .011), and both were better than DSA in ergonomics and efficiency (P < .0001). CONCLUSION: MFL performs similarly to ICG-VA in a laboratory setting. Further study will be required to determine whether it compares favorably in the operating room. While DSA is the standard for cerebrovascular visualization, MFL and ICG are significantly more ergonomic and efficient.

Critical Care of Brain Reperfusion.

Over the last few decades, the management of acute ischemic stroke has undergone significant advancements with the introduction of intravenous thrombolysis and more recently punctuated by the success of endovascular mechanical thrombectomy trials for large vessel occlusion. These advancements have transformed the practice of neurocritical care. In this review, we present a case-based discussion of common brain reperfusion techniques with an emphasis on complication recognition and management. The article encompasses recent evidence-based recommendations as well as some of our own institutional protocols.

Posterior circulation CT angiography collaterals predict outcome of endovascular acute ischemic stroke therapy for basilar artery occlusion.

INTRODUCTION: The natural history of acute ischemic stroke (AIS) due to basilar artery occlusion (BAO) is poor. Endovascular reperfusion therapy (EVT) improves recanalization rates in patients with emergent large vessel intracranial occlusion. OBJECTIVE: To examine the hypothesis that good collateral patterns identified by pretreatment CT angiography (CTA) might be associated with favorable outcomes after EVT. METHODS: We conducted a retrospective chart review of patients presenting with AIS due to BAO in a tertiary care stroke center during a 4-year period. BAO was diagnosed by CTA in all cases. Admission stroke severity was documented using the National Institute of Health Stroke Scale (NIHSS) score. Pretreatment collateral score for posterior circulation was defined as follows: 0, no posterior communicating artery (PCOM); 1, unilateral PCOM; 2, bilateral PCOM. Favorable outcome was defined as modified Rankin Scale score of 0-2 at 3 months. RESULTS: A total of 21 patients with AIS due to BAO (age range 31-84 years, median admission NIHSS score: 18 points, range 2-38) underwent EVT. Eleven of 21 patients (52.4%) had bilateral PCOMs, while unilateral PCOM was seen in 3 patients (14.3%). Patients with bilateral PCOMs tended (p=0.261) to have less severe stroke at admission than those with absent/unilateral PCOM (median NIHSS score 18 vs 27 points). Neurological improvement during hospitalization (quantified by the median decrease in NIHSS score) and the rate of 3-month functional independence were greater in patients with good collaterals (16 vs 0 points (p=0.016) and 72.7% vs 0% (p=0.001)). CONCLUSIONS: The presence of bilateral PCOMs on pretreatment CTA appears to be associated with more favorable outcomes in BAO treated with EVT.

Separating the wheat from the chaff: region of interest combined with metal artifact reduction for completion angiography following cerebral aneurysm treatment.

INTRODUCTION: Following complicated endovascular or microsurgical treatments, assessment of radiographic outcome can be challenging due to device resolution and metallic artifact. Two-dimensional and three-dimensional angiography can reveal information about flow and aneurysm obliteration, but may be limited by beam hardening, overlapping vessels, and image degradation in the region of metallic implants. In this study, we investigated the combination of a collimated volumetric imaging (volume of interest, VOI) protocol followed by metal artifact reduction (MAR) post-processing to evaluate the correct positioning of stents, flow diverters, coils, and clips while limiting the radiation dose to the patient. METHODS: 9 patients undergoing 10 procedures were included in our study. All patients underwent endovascular or surgical treatment of a cerebral aneurysm involving stents, flow diverting stents, coils, and/or clips followed by either immediate or early postoperative evaluation of our protocol. RESULTS: Image datasets corrected for metallic artifacts (VOI-MAR) were judged to be better-a statistically significant finding-than image datasets only corrected for field of view truncation (VOI alone). Qualitatively, images were more interpretable and informative with regards to device position and apposition to the vessel wall for those cases involving a pipeline, and with regards to encroachment on the parent artery and possible residual aneurysm, in all cases. CONCLUSIONS: VOI acquisition combined with MAR post-processing provides for accurate and informative evaluation of cerebral aneurysm treatment while limiting the radiation dose to patients.

Accuracy of customized miniature stereotactic platforms.

In this study, a new system was evaluated for implanting deep-brain stimulators based on a one-piece platform for each trajectory customized from a preoperative planning image. During surgery, the platform is attached to skull-implanted posts that extend through the scalp. The platform acts as a miniature stereotactic frame to provide guidance for parallel cannulas as they are advanced through a burr hole to the target. Accuracy is determined from a postoperative CT. For each implantation, the distance between the position observed in the postoperative image and the position calculated relative to the platform from the preoperative image is our measure of error. Because this measure incorporates the surgical error of electrode anchoring, brain shift between preoperative and postoperative scanning, and error in the measurement of the position of the electrode in CT, it will tend to overestimate the true error. The mean error was 2.8 mm for 20 implantations. These data reflect favorably the accuracy of this system when compared with others.