Benjamin Mine

Endovascular WEB flow disruption in middle cerebral artery aneurysms: preliminary feasibility, clinical, and anatomical results in a multicenter study.

BACKGROUND The endovascular treatment of middle cerebral artery (MCA) aneurysms with unfavorable anatomy (wide neck, unfavorable morphology) is frequently challenging. Flow disruption with the WEB is a potentially interesting endovascular treatment for this type of aneurysm. OBJECTIVE To report in a multicenter series the preliminary treatment experience of MCA aneurysms with flow disruption by the WEB. METHODS Thirty-three patients with 34 MCA aneurysms were treated with the WEB in 5 European centers. The ability to successfully deploy the WEB, procedure- and device-related adverse events, morbidity and mortality of the treatment, and short-term angiographic follow-up results were analyzed. RESULTS Most treated aneurysms were unruptured (85.3%) and were between 5 and 10 mm (85.3%) with a neck size ≥  4 mm (88.2%). The treatment failed in 1 of the 34 aneurysms (2.9%) owing to a lack of appropriate device size. Treatment was performed exclusively with the WEB in 29 of 33 aneurysms (87.9%). Additional treatment (coiling and/or stenting) was used in 4 of 33 aneurysms (12.1%). Mortality of the treatment was 0.0% and morbidity was 3.1% (intraoperative rupture with modified Rankin Scale score of 3 at the 1-month follow-up). In short-term follow-up (range, 2-12 months), adequate occlusion (total occlusion or neck remnant) was observed in 83.3% of aneurysms. CONCLUSION WEB flow disruption seems to be a promising technique for the treatment of complex MCA aneurysms, particularly those with a wide neck or unfavorable dome-to-neck ratio.

WEB-DL Endovascular Treatment of Wide-Neck Bifurcation Aneurysms: Short- and Midterm Results in a European Study

Short- and midterm results of endovascular aneurysm treatment with the new WEB-DL device were assessed in 45 patients from 12 European centers. Of these, 42 aneurysms were unruptured and most were located either in the MCA bifurcation or the posterior circulation. Adequate occlusion was observed in 81% and 90% of aneurysms at 6 and 13 months, respectively. Results suggest that WEB endovascular treatment of wide-neck bifurcation aneurysms offers stable occlusion in a class of aneurysms that are historically unstable. BACKGROUND AND PURPOSE: Flow disruption with the WEB-DL device has been used safely for the treatment of wide-neck bifurcation aneurysms, but the stability of aneurysm occlusion after this treatment is unknown. This retrospective multicenter European study analyzed short- and midterm data in patients treated with WEB-DL. MATERIALS AND METHODS: Twelve European neurointerventional centers participated in the study. Clinical data and pre- and postoperative short- and midterm images were collected. An experienced interventional neuroradiologist independently analyzed the images. Aneurysm occlusion was classified into 4 grades: complete occlusion, opacification of the proximal recess of the device, neck remnant, and aneurysm remnant. RESULTS: Forty-five patients (34 women and 11 men) 35–74 years of age (mean, 56.3 ± 9.6 years) with 45 aneurysms treated with the WEB device were included. Aneurysm locations were the middle cerebral artery in 26 patients, the posterior circulation in 13 patients, the anterior communicating artery in 5 patients, and the internal carotid artery terminus in 1 patient. Forty-two aneurysms were unruptured. Good clinical outcome (mRS < 2) was observed in 93.3% of patients at the last follow-up. Adequate occlusion (complete occlusion, opacification of the proximal recess, or neck remnant) was observed in 30/37 patients (81.1%) in short-term follow-up (median, 6 months) and in 26/29 patients (89.7%) in midterm follow-up (median, 13 months). Worsening of the aneurysm occlusion was observed in 2/28 patients (7.1%) at midterm follow-up. CONCLUSIONS: The results suggest that the WEB endovascular treatment of wide-neck bifurcation aneurysms offers stable occlusion in a class of aneurysms that are historically unstable. Additionally, our data show that opacification of the WEB recess can be delineated from true neck or aneurysm remnants.

Silk Flow-Diverter Stent for the Treatment of Intracranial Aneurysms: A Series of 58 Patients with Emphasis on Long-Term Results

BACKGROUND AND PURPOSE: The Silk flow-diverter stent is increasingly used to treat complex intracranial aneurysms including wide-neck, fusiform aneurysms. Sparse data are available concerning long-term results of this technique. We report our 5-year experience with Silk stent treatment of intracranial aneurysms. MATERIALS AND METHODS: A retrospective review of our prospectively maintained database identified all patients treated by the Silk stent in 2 institutions. Clinical charts, procedural data, and angiographic results were reviewed. RESULTS: Between July 2009 and May 2014, we identified 58 patients with 70 intracranial aneurysms. Endovascular treatment was successful in 93% of patients with 32 treated with the first-generation Silk stent and 26 with the new Silk+ stent. Mean follow-up in 47 patients was 22 months. Despite an 11% delayed complication rate, overall permanent neurologic morbidity was 5.5%. All complications were seen with the first-generation Silk stent. There was no procedure-related mortality. Long-term anatomic results showed 73% with complete occlusion, 16% with neck remnants, and 11% with incomplete occlusion. No recanalization or retreatment was performed. The midterm intrastent stenosis rate was 57%, of which 60% improved or disappeared, 28% were stable, and 12% led to vessel occlusion. Seventy-four percent of stenosis and all vessel occlusions occurred with the first-generation Silk stent. CONCLUSIONS: Endovascular treatment of complex intracranial aneurysms with the Silk stent is an effective therapeutic option. Despite a high rate of delayed complications with the first-generation stents, the current Silk+ stent appears safer. This treatment achieves a high rate of adequate and stable occlusion at long-term follow-up.

WEB-DL Endovascular Treatment of Wide-Neck Bifurcation Aneurysms: Long-Term Results in a European Series

BACKGROUND AND PURPOSE: Flow disruption with the WEB-DL device has been used safely for the treatment of wide-neck bifurcation aneurysms. The stability of aneurysm occlusion after this treatment was evaluated in the short and midterm, but not in the long term. This retrospective multicenter European study is the continuation of an already published series dealing with short- and midterm anatomic results and analyzes long-term data in patients treated with the WEB-DL. MATERIALS AND METHODS: Twelve European neurointerventional centers initially participated in the study. In addition to data collected for the initial publication, images obtained at long-term follow-up were collected and independently analyzed by the same experienced interventional neuroradiologist. RESULTS: Of the initial 45 patients, 26 (20 women and 6 men; 35–73 years of age; mean, 55.2 ± 10.6 years; median, 55.5 years) with 26 aneurysms treated with the WEB-DL device had long-term follow-up (median, 27.4 months). Three of 26 patients (11.5%) were retreated between short- and midterm follow-up, and none, between mid- and long-term follow-up. Long-term aneurysm occlusion in the 19 patients treated with the WEB only and not retreated during follow-up was complete occlusion in 13/19 patients (68.4%), including aneurysms with opacification of the proximal recess in 9/19 patients (47.4%), neck remnant in 3/19 patients (15.8%), and aneurysm remnant in 3/19 patients (15.8%). In all patients (100.0%), aneurysm occlusion was stable between midterm and long-term follow-up. CONCLUSIONS: The results suggest that WEB treatment of wide-neck bifurcation aneurysms offers long-term stable occlusion.

Intrasaccular flow-diversion for treatment of intracranial aneurysms: the Woven EndoBridge

Endovascular approach is now the first option for the treatment of most intracranial aneurysms (IA). However, remaining limitations are the suboptimal stability of aneurysm occlusion and the treatment of complex IA. The use of conventional and flow diverter stents has partially addressed these limitations. Nevertheless, as intraluminal devices, stents require aggressive antiplatelet therapy and are associated with higher thromboembolic (TE) complication rates. Intrasaccular flow disrupters (IFD) are newly developed braided-wire devices designed to achieve flow disruption at the neck without placing material in the parent vessel and without the need of antiplatelet therapy. First clinical series have shown promising anatomical and clinical results. Our purpose is to describe the available IFD and to review the literature about their efficacy, safety, limitations, and developments.

The pCONus device for the endovascular treatment of wide neck bifurcation aneurysms

Background and purpose The pCONus is a new stent featuring a distal end that opens like a blossoming flower with four petals. The device is implanted in the aneurysm sac at the level of the neck. We report our initial experience in a series of patients treated with this device. Methods This retrospective study was approved by the authors’ ethics committees. 18 patients with 19 unruptured wide neck bifurcation intracranial aneurysms (IA) were treated by pCONus placement and coiling. Technical issues, immediate post treatment angiographic findings, and clinical and imaging follow-up were assessed. Results Embolization was successful in all patients. There were 11 women and 7 men with a mean age of 60 years. Median aneurysm size was 9 mm (range 5.5–25 mm). The device was precisely placed and detached in all cases, allowing for subsequent coiling. Two patients experienced a symptomatic complication, one of which, a thromboembolism, was related to the use of the pCONus. This patient had a slight hand paresis. 16 patients had a normal neurological examination at discharge. Immediate anatomical results were 13 complete occlusions, 2 neck remnants, and 4 incomplete occlusions. Imaging follow-up was obtained in 12 patients (mean 9.5 months, range 2–24 months) and showed 9 stable occlusions and 3 recanalizations, of which 2 were retreated. Conclusions In this initial series of patients, endovascular treatment of wide neck bifurcation IAs with the pCONus was feasible, with acceptable clinical and anatomical outcomes. Further studies are needed to evaluate the indications, safety, and efficacy of this new device.

Endoscope-integrated ICG technology: first application during intracranial aneurysm surgery

Microscopic indocyanine green videoangiography (mICG-VA) has gained wide acceptance during intracranial aneurysm surgery by lowering rates of incomplete clipping and occlusion of surrounding vessels. However, mICG-VA images are limited to the microscopic view and some deeper areas, including the aneurysm sac/neck posterior side, cannot be efficiently assessed as they are hidden by the aneurysm, clips, or surrounding structures. Contrarily, endoscopes allow a wider area of visualization, but neurosurgical endoscopes to date only provided visual data. We describe the first application of endoscope ICG-integrated technology (eICG) applied in an initial case of anterior communicating artery aneurysm clipping. This new technique provided also relevant information regarding aneurysm occlusion and patency of parent and branching vessels and small perforating arteries. eICG-VA provided additional information compared to mICG-VA by magnifying areas of interest and improving the ability to view less accessible regions, especially posterior to the aneurysm clip. Obtaining eICG sequences required currently the microscope to be moved away from the operating field. eICG-VA was only recorded under infrared illumination which prevented tissue handling, but white-infrared light views could be interchanged instantaneously. Further development of angled endoscopes integrating the ICG technology and dedicated filters blocking the microscopic light could improve visualization capacities even further. In conclusion, as a result of its ability to reveal structures around corners, the eICG-VA technology could be beneficial when used in combination with mICG-VA to visualize and confirm vessel patency in areas that were previously hidden from the microscope.

Stent-assisted coiling of unruptured intracranial aneurysms: Long-term follow-up in 164 patients with 183 aneurysms

PURPOSE Stent-assisted coiling (SAC) is increasingly used to treat complex unruptured intracranial aneurysms (UIA) including wide-necked and fusiform IA. However, few data are available over the long-term results of this technique. We report our 9-year-experience of SAC of UIA. METHODS A retrospective review of our prospectively maintained database identified all patients treated by SAC for an UIA in 2 institutions. The clinical charts, procedural data and angiographic results were reviewed. RESULTS Between 2004 and 2012, we identified 164 patients with 183 UIA. There were 115 women and 49 men with a mean age of 46 years. Embolization was successful in all patients. Procedural morbidity and mortality rates were 2.2% and 0% respectively. Immediate anatomical outcome included 54 complete occlusion (29.5%), 43 neck remnants (23.5%) and 86 incomplete occlusions (47%). Imaging follow-up was available in 137 patients (mean=26 months, range 3 to 99 months) and it showed 104 complete occlusions (75.9%), 23 neck remnants (16.8%) and 10 incomplete occlusions (7.3%). At follow-up, only 3 patients developed a significant intrastent stenosis, one of which was induced by radiosurgery. One of these patients had a symptomatic thrombo-embolic complication 3 years after stent placement. CONCLUSION SAC of complex UIA is effective and associated with low complication rates. Even if immediate anatomical results are relatively unsatisfying, mid- and long-term follow-up show a major improvement with a high rate of adequate occlusion that is stable over time. Moreover, the long-term clinical and angiographic tolerance of intracranial stents is excellent.

A Rare Variant of Persistent Trigeminal Artery: Cavernous Carotid-Cerebellar Artery Anastomosis—A Case Report and a Systematic Review

We report a very rare anomalous anatomic variant of the cavernous internal carotid artery supplying directly the posterior inferior cerebellar artery, with no basilar artery opacification. A systematic review as well as a description of other variants of trigeminal-cerebellar anastomosis is given.

Follow-up of intracranial aneurysms treated by a WEB flow disrupter: a comparative study of DSA and contrast-enhanced MR angiography

Objective To compare contrast-enhanced MR angiography (CE-MRA) and DSA for the follow-up of intracranial aneurysms (IAs) treated with the Woven EndoBridge embolization system DL (WEB DL; Sequent Medical, Aliso Viejo, California, USA). Materials and methods We retrospectively identified all patients treated with a WEB DL between November 2010 and February 2013 in 2 hospitals. The IA occlusion was graded on follow-up CE-MRA and DSA by 4 independent readers and by 2 readers reaching a consensus, respectively. Interobserver agreement for MRA and intertechnique agreement was evaluated by calculating linear weighted κ. Results Fifteen patients with 16 IAs were included. Mean delay between MRA and DSA was 2 months (range 0–16 months). Interobserver agreement for MRA was substantial to almost perfect (κ=0.686–0.921; mean κ=0.809). Intertechnique agreement was moderate to substantial (κ=0.579–0.724; mean κ=0.669). Only three out of five inadequately occluded IAs were detected by MRA. Conclusions CE-MRA is a useful tool for the follow-up of IAs treated with a WEB DL. However, early follow-up with DSA remains mandatory to detect inadequately occluded IAs.