Charbel Mounayer

Stent-Assisted Coiling of Intracranial Aneurysms Clinical and Angiographic Results in 216 Consecutive Aneurysms

Background and Purpose— Stent-assisted coiling has expanded the treatment of intracranial aneurysms, but the rates of procedure-related neurological complications and the incidence of angiographic aneurysm recurrence of this novel treatment are not yet well known. We present our experience with stent-assisted coiling with special emphasis on procedure-related neurological complications and incidence of angiographic recurrence. Methods— Clinical and angiographic outcomes of 1137 consecutive patients (1325 aneurysms) coiled with and without stent-assisted coiling technique from January 2002 to January 2009 were retrospectively analyzed. Results— There were 1109 aneurysms (83.5%) treated without and 216 (16.5%) treated with stents (15 of 216; 6.9% balloon-expandable versus 201 of 216; 93.1% self-expandable stents). Stents were delivered after coiling in 55.1% (119 of 216) and before coiling in 44.9% (97 of 216) of the cases. Permanent neurological procedure-related complications occurred in 7.4% (16 of 216) of the procedures with stents versus 3.8% (42 of 1109) in the procedures without stents (logistic regression P=0.644; OR: 1.289; 95% CI: 0.439 to 3.779). Procedure-induced mortality occurred in 4.6% (10 of 216) of the procedures with stents versus 1.2% (13 of 1109) in the procedures without stents (logistic regression P=0.006; OR: 0.116; 95% CI: 0.025 to 0.531). A total of 52.7% (114 of 216) of aneurysms treated with stents have been followed so far versus 69.8% (774 of 1109) of aneurysms treated without stents, disclosing angiographic recurrence in 14.9% (17 of 114) versus 33.5% (259 of 774), respectively (Fisher exact test P<0.0001; OR: 0.3485; 95% CI: 0.2038 to 0.5960). Conclusions— Stents were associated with a significant decrease of angiographic recurrences, but they were associated with more lethal complications compared with coiling without stents.

Dural arteriovenous fistula of the lesser sphenoid wing region treated with Onyx: technical note

A 45-year-old man presented with acute right orbital pain and right-sided headache. Magnetic resonance imaging (MRI) and cerebral angiography revealed a dural arteriovenous fistula (DAVF) of the lesser sphenoid wing region. The lesion was endovascularly treated by transarterial embolization with Onyx (ethyl vinyl alcohol; Micro Therapeutics, Irvine, Calif.). We review some anatomical and therapeutic features involving DAVFs of this region and describe the feasibility of the use of Onyx in the treatment of these lesions.

Endovascular Treatment of Intracranial Aneurysms in the Elderly: Single-Center Experience in 63 Consecutive Patients

OBJECTIVE: With a globally aging population, it is imperative to develop specific treatment strategies for intracranial aneurysms in the elderly. However, the optimal management of intracranial aneurysms in the elderly remains controversial, particularly for the unruptured aneurysms. Although endovascular treatment is increasingly being used for the management of aneurysms, large endovascular series in the elderly population are relatively lacking, especially with regard to the unruptured aneurysms. We present our single-center endovascular experience in treating intracranial aneurysms in 63 consecutive patients 70 years of age and older. METHODS: Between November 1998 and December 2003, among a total of 990 patients with intracranial aneurysms treated endovascularly at our center, 63 patients (6%) were 70 years of age or older. Forty-one patients presented with subarachnoid hemorrhage (SAH), and 22 presented with symptomatic unruptured aneurysms. A total of 84 aneurysms were detected in these 63 patients. Only those responsible for either the subarachnoid hemorrhage or clinical symptoms (68 aneurysms) were treated. The aneurysm characteristics, endovascular procedures and techniques, angiographic and clinical outcomes, and complications were reviewed. RESULTS: Selective embolization failed in three aneurysms (4%). In the remaining 65 aneurysms, complete occlusion was achieved in 33 aneurysms (51%), neck remnant was observed in 17 aneurysms (27%), and residual aneurysmal filling was observed in six aneurysms (9%). Parent vessel occlusion was used in the treatment of nine aneurysms (13%). Thirteen procedure-related complications occurred (19%), six of which resulted in clinical complications (9%). Nine deaths (14%) occurred; three (5%) were directly related to the endovascular procedures, and six (9%) were related to the medical complications of SAH. The remaining 54 patients had a mean clinical follow-up time of 13 months (range, 1–47 mo). Ninety-one percent (20 out of 22) of the patients with unruptured aneurysms and 89% (25/28) of the patients with low-grade (Hunt and Hess Grade I and II) ruptured aneurysms achieved excellent outcomes (modified Rankin Scale score, 0–1), whereas 77% (10 out of 13) of the patients with high-grade (Hunt and Hess Grade ≥ III) ruptured aneurysms either died or had very poor outcomes (modified Rankin Scale score, 4–5). Angiographic follow-up (mean, 11 mo; range, 3–38 mo) was obtained in 34 of the 54 living patients (63%). Two aneurysms demonstrated minor changes that required no further treatment (5%). Five aneurysms showed major recurrences (17%), all of which were successfully retreated endovascularly. CONCLUSION: The elderly patients should merit strong consideration for endovascular treatment of both ruptured and symptomatic unruptured intracranial aneurysms. However, in elderly patients with high-grade subarachnoid hemorrhage, morbidity and mortality rates remain high.

Direct cervical arterial access for intracranial endovascular treatment

IntroductionTortuous vasculature is a cause of failure of endovascular treatment of intracranial vascular lesions. We report our experience of direct cervical accesses in patients in whom the arterial femoral route was not attainable.MethodsIn this retrospective study, 42 direct punctures of the carotid or the vertebral arteries at the neck were performed in 38 patients. The vessel harboring the intracranial lesion was punctured at the neck above the main tortuosity, a sheath was then positioned under fluoroscopic control to allow a stable access to the intracranial circulation. After the procedure, the sheath was removed and hemostasis was gained either by manual compression or by an arterial closure device (4 of 42, 9%).ResultsThe cervical route allowed access to all intracranial lesions in all 42 procedures. A complication was encountered in six procedures (14%) related to the direct puncture. In 2 of the 42 procedures (4%), a transient vasospasm was encountered. A cervical hematoma formed in 3 of the 42 procedures (7%) after sheath withdrawal (one patient in whom an 8F sheath had been used, required surgical evacuation of a hematoma compressing the upper airways; the other patients did well without surgical evacuation). In the remaining patient (1 of 42 procedures, 2%), a small asymptomatic aneurysm at the puncture site was seen on the follow-up angiogram.ConclusionDirect cervical arterial approaches to accessing the intracranial circulation is effective in patients in whom the femoral route does not allow the navigation and stabilization of guiding catheters.

Treatment of Brain Arteriovenous Malformations by Double Arterial Catheterization with Simultaneous Injection of Onyx: Retrospective Series of 17 Patients

BACKGROUND AND PURPOSE: The use of Onyx in the treatment of intracranial AVMs has increased the cure rate of endovascular embolization compared with the use of liquid adhesive agents. Inadvertent occlusion of the draining veins before the complete exclusion of the nidus constitutes a major risk of bleeding. We report a case series using the technique of double simultaneous arterial catheterization as an approach to achieve the complete exclusion of the nidus before reaching the venous drainage, through a more controlled hemodynamic filling. MATERIALS AND METHODS: Between April 2008 and November 2009, 17 patients with brain AVMs were treated by the DACT. The mean age of the patients was 32.7 years (range, 6–54 years), with 9 females and 8 males. The clinical onset was characterized by intracranial hemorrhage in 8 patients and by seizures in 7. The size of the AVMs ranged from 13 to 54 mm (average, 26.2 mm). The DACT was always used with the objective of curing the AVM. RESULTS: All 17 patients completed the EVT. The average number of sessions conducted was 1.4 (range, 1–3 sessions), with the average injection amount of 6.9 mL of Onyx (range, 2–25.2 mL). Sixteen AVMs (94.1%) were angiographically cured by embolization. Clinical complications occurred in 2 patients (11.7%); 1 of these was permanent (5.9%). No deaths were registered. CONCLUSIONS: This preliminary series shows that the DACT presents satisfactory results when used with curative intent.

Flow-diverting stents for intracranial bifurcation aneurysm treatment.

BACKGROUND Although initially considered safe when covering bifurcation sites, flow-diverting stents may provoke thrombosis of side branches that are covered during aneurysm treatment. OBJECTIVE To understand the occurrence and clinical expression of side-branch remodeling in distal intracranial arterial sites after flow diverter deployment by means of correlation of imaging and clinical data. METHODS We analyzed our prospectively collected data on a series of patients treated with flow diverters for intracranial aneurysms at bifurcation sites. From February 2011 to May 2013, 32 patients with 37 aneurysms (anterior communicating artery, 9 [24.3%]; anterior cerebral artery, 5 [13.5%]; middle cerebral artery, 19 (51.4%); terminal internal carotid artery, 4 [10.8%]) were treated. We divided aneurysms into 2 groups based on the side branches covered by the stent during treatment. Group A consisted of cases with side branches that supplied brain territories also receiving a direct collateral supply. Group B consisted of cases in which side branches supplied territories without direct collateral supply. The 2 groups were compared statistically. RESULTS Total exclusion occurred in 97.3% of aneurysms at follow-up. Initial modified Rankin Scale (mRS) score was 0 to 1 for 29 patients (90.6%) and 2 for 3 patients (9.4%). New permanent neurological deficit was reported in 3 patients (9.4%). At the 6-month follow-up, the mRS score was 0 to 1 for 31 patients (96.8%) and 3 for 1 patient (3.2%). Although 78.5% of side branches in group A underwent narrowing or occlusion after 6 months, no new stroke was found on magnetic resonance imaging. CONCLUSION Symptomatic modifications of side branches after flow diverter treatment depend on the extent and type of collateral supply.

Embolisation par voie artérielle de malformations artérioveineuses durales intracrâniennes à l’aide d’ethylvinyl alcool copolymère (Onyx®18)

Resume Objectifs Rapporter notre experience recente dans l’embolisation par voie arterielle des malformations arterio-veineuses durales (MAVD) en utilisant un nouvel agent d’embolisation, l’Onyx®18. Patients et methodes Notre serie inclut 6 patients. La presentation clinique se repartissait en 2 groupes : symptomatologie agressive (n = 4), symptomatologie non agressive (n = 2). La MAVD etait localisee sur le sinus longitudinal superieur (n = 1), sur le sinus transverse (n = 2), dans la region du canal condylien (n = 1), au niveau de la fente sphenoidale (n = 1), et dans la region de la tente du cervelet (n = 1). Le drainage de la MAVD se faisait directement par une veine corticale ou condylienne dans trois cas et par un sinus veineux anatomiquement exclu de la circulation veineuse cerebrale dans trois cas. Resultats Une angiographie cerebrale extensive incluant les deux arteres carotides internes, les deux arteres carotides externes et l’artere vertebrale homo-laterale a la MAVD a ete realisee avant et apres chaque traitement. L’afference arterielle choisie pour l’injection de l’Onyx®18 etait toujours meningee. Chaque traitement consistait en un catheterisme selectif et une injection unique de l’agent embolique. Une exclusion anatomique a pu etre obtenue et demontree par l’angiographie realisee en fin de traitement, dans tous les cas, sans aucune complication clinique post-therapeutique. Conclusion L’utilisation de l’Onyx®18 dans les MAVD est peu risquee. Quand il est injecte dans des conditions optimales, cet agent embolique liquide permet le remplissage de la totalite de la MAVD incluant son drainage veineux cortical ou sinusien apres un catheterisme arteriel unique.

Safety and efficacy of neuroform for treatment of intracranial aneurysms: a prospective, consecutive, French multicentric study.

The periprocedural morbidity and mortality associated with stent treatment of unruptured wide-neck intracranial aneurysms was evaluated in 107 patients. The rate of aneurysm recurrence was nearly 10% and retreatment was needed in 4% of patients. The rates of periprocedural and longer term embolic events were 3.7% and 3.0%, respectively. Longer term morbidity and mortality were both 1%. Stent-assisted coiling with the Neuroform system provided a high level of occlusion with low rates of subsequent treatment despite a population of patients with predominantly wide-neck aneurysms. BACKGROUND AND PURPOSE: Endovascular embolization of wide-neck intracranial aneurysms can be technically challenging, especially when the anatomy is complex. Stent reconstruction of the parent artery is commonly used to treat wide-neck and bifurcated aneurysms. The main objective of this study was to investigate the periprocedural and midterm morbidity and mortality results of this procedure. MATERIALS AND METHODS: SENAT is a consecutive, prospective, multicentric study. Patients with unruptured cerebral aneurysms who underwent endovascular treatment with the Neuroform stent system were recruited and recorded. Technical outcomes and complications were also assessed. The midterm anatomic results were re-evaluated at 12–18 months. RESULTS: A total of 113 stents were used to treat the 107 aneurysms in 107 patients. The mean width of the aneurysm sac was 6.2 mm, and the mean diameter of aneurysm neck was 4.5 mm. The complete occlusion rate postprocedure was 66.4%. The rate of progressive occlusion at 12–18 months was 14%, and the rate of recurrence was 9.7%. The rate of subsequent treatment was 4%. The thromboembolic rate in the periprocedural period was 3.7%, and the rate of delayed TE events was 3%. Overall, the mortality rate at 12–18 months was 1%, and the permanent morbidity rate was 1%. CONCLUSIONS: Stent-assisted coiling with the Neuroform stent system provides a high level of occlusion with low rates of subsequent treatment despite a predominant population of patients with wide-neck aneurysms. Morbidity and thromboembolic rates were comparable to studies investigating stand-alone coiling.

Histopathologic Evaluation of Arterial Wall Response to 5 Neurovascular Mechanical Thrombectomy Devices in a Swine Model

BACKGROUND AND PURPOSE: Five commercial devices are available for mechanical thrombectomy in acute ischemic stroke. This study evaluated and compared the resultant arterial damage from these devices. MATERIALS AND METHODS: Wall damage after 4 wall-contact devices (the Merci retriever, Catch thromboembolectomy system, and Solitaire FR revascularization devices of 4 and 6 mm) and 1 aspiration device (the Penumbra System) was evaluated in the superficial femoral arteries of 20 male swine. Each device was tested with and without intraluminal clot. Twenty control vessels were not subjected to any intervention. Acute histopathologic changes were evaluated. RESULTS: In the device samples, endothelial denudation (72.8 ± 29.4% versus 0.9 ± 1.9%, P < .0001), medial layer edema (52 ± 35.9% versus 18.1 ± 27.8%, P = .004), and mural thrombus (5.3 ± 14.2% versus 0%, P = .05) were found to a greater extent compared with the control samples. The aspiration device provoked more intimal layer (100 ± 79.1% versus 58.8 ± 48.9%, P = .27) and medial layer (75 ± 35.4% versus 46.3 ± 34.8%, P = .13) edema than the wall-contact devices. CONCLUSIONS: All devices caused vascular injuries extending into the medial layer. The aspiration device was associated with more intimal and medial layer edema, compared with the wall-contact devices except for the Catch thromboembolectomy system.

Successful transvenous embolization of brain arteriovenous malformations using Onyx in five consecutive patients.

BACKGROUND:There is an increasing application of endovascular treatment for brain arteriovenous malformations (BAVMs) using ethylene vinyl alcohol copolymer (Onyx). Historically, this treatment has been performed using a transarterial approach. OBJECTIVE:To report our experience with transvenous endovascular embolization with Onyx (TVEO). METHODS:Five consecutive patients with BAVMs underwent endovascular TVEO between June 2007 and March 2009 at the Interventional Neuroradiology Department of the University Hospital of Limoges. There were 3 men and 2 women with a mean age of 41.8 years (range, 19-57 years). The clinical presentation included symptoms caused by intracerebral hemorrhage (n = 4) and seizures (n = 1). According to the Spetzler-Martin classification scheme, 3 BAVMs (60%) were grade III, and 2 BAVMs (40%) were grade IV. Four BAVMs (80%) were supratentorial and 1 BAVM (20%) was infratentorial. Immediate and mid-term treatment (6 months) outcomes were angiographically and clinically analyzed according to the modified Rankin Scale. RESULTS:The transvenous approach was used in all patients (100%). The success rate of complete obliteration of the arteriovenous malformation nidus was 80% (4 of 5), confirmed by follow-up angiography performed immediately and at 6 months after TVEO. No procedure-related complications occurred during or after embolization. All patients remained unchanged (modified Rankin Scale score = 0-2) and clinically stable 6 months after TVEO. CONCLUSION:The transvenous approach using Onyx for the management of BAVMs is shown to be an efficient and safe alternative treatment in cases with no other conventional therapeutic choice and when some anatomic considerations are respected.