Joseph Gabrieli

Medina® Embolization Device for the Treatment of Intracranial Aneurysms: Safety and Angiographic Effectiveness at 6 Months

BACKGROUND The Medina Embolization Device (MED) is a new concept device that combines the design of a detachable coil and the one of an intrasaccular flow disruption device. OBJECTIVE To evaluate the feasibility, safety, and 6‐ to 9‐mo effectiveness of this new device for the treatment of intracranial wide‐necked aneurysms. METHODS Twelve patients (10 females, mean age = 56 yr) with 13 wide‐necked intracranial aneurysms (3 ruptured; 10 unruptured) were treated by means of the MED from January 2015 to October 2015. In 15% of the cases, MEDs were used in a standalone fashion; in 85% of the cases, additional regular coils were used. Adjunctive compliant balloon was used in 4 of 13 cases (31%). Procedure‐related complications were systematically recorded; discharge and 6‐ to 9‐mo follow‐up modified Rankin Scale was assessed. Angiographic follow‐up was performed with a mean delay of 5.5 ± 1.7 mo. Occlusion rate was evaluated in postprocedure and at midterm follow‐up using the Roy-Raymond scale. RESULTS The deployment of the MED was feasible in all cases. No perforation was recorded. One case of thromboembolic complication was observed in a ruptured anterior communicating artery aneurysm, without any clinical consequence at follow‐up. Grade A occlusion rate was 61.5% in postprocedure and 83% at 6‐mo follow‐up. Two cases (17%) of recanalization were documented angiographically. CONCLUSION The MED is a new generation device combining the design of a detachable coil and an intrasaccular flow disruption device. According to our early experience, this device is safe and provides a satisfactory occlusion rate at angiographic follow‐up of 6 mo.

Erratum to: Double-lumen balloon for Onyx® embolization via extracranial arteries in transverse sigmoid dural arteriovenous fistulas: initial experience.

Transverse-sigmoid dural arteriovenous fistulas (TS DAVFs) can be challenging to treat by endovascular means. Indeed, a total cure of the fistula can only be achieved when complete occlusion of the fistulous point(s) is obtained by penetration of the embolic agent. However, in some cases, especially for transosseous branches from extracranial arteries like the occipital artery (OcA) or the superficial temporal artery (STA), such penetration is usually poor, leading to major proximal reflux and incomplete fistula obliteration. We present three cases of embolization in two patients with TS DAVF through the OcA and/or the STA with Onyx® using a double-lumen balloon (Microvention, Tustin, CA, USA). This technique allows the penetration of the embolic agent in the transosseous branches by forming a counter-pressure with the inflated balloon. This technique may be useful to achieve complete occlusion of TS DAVFs by endovascular means.

Long-term visual outcome in patients treated by flow diversion for carotid-ophthalmic aneurysms

Background Flow-diverter stents (FDSs) are an upgrade in the treatment of intracranial aneurysms. However, complications concerning covered branches have been reported, especially the ophthalmic artery (OA). The purpose of our study was to evaluate the long-term ophthalmic complication rate of carotid-ophthalmic aneurysms (COA) without visual pathways compression, treated by a FDS covering the OA by performing an exhaustive ophthalmic examination. Material and methods Retrospective analysis of a single-center database screening the patients treated from October 2009 to April 2015 for an intracranial aneurysm with a FDS. The patients treated for a non-compressive COA with coverage of the OA by the device were studied (n=30). Among these patients, 15 (50%) were excluded. The remaining 15 patients underwent a systematic and extensive ophthalmic examination at least 2 years after the stent placement by two ophthalmologists. Results Fifteen patients with 16 COAs treated with a FDS were included. Mean follow-up was 4.1±2 years. Six patients (40%), presented ophthalmic complications, including three fugax amauroses (18.8%) and four significant visual field defects (25%). After comparing each eye’s visual field’s patients, we observed a significant difference between the eye on the FDS side compared with the contralateral eye, with a mean deviation of −1.58 dB versus −0.67 dB respectively (P=0.003). Visual acuity was preserved in all patients. Conclusion Patients treated by FDS for COA have a good long-term clinical ophthalmic outcome. However, extensive ophthalmic examination shows a high percentage of minor ophthalmic modifications. Interventional neuroradiologists should be aware of these possible complications when choosing to treat these aneurysms with FDS.

Dual lumen balloon spontaneous inflation during embolization

Balloon-assisted coil (BAC) embolization has gained acceptance during the last years for the treatment of wide-necked intracranial aneurysms. This article presents the case of a 51-year-old female with ruptured posterior communicating artery (PComA) aneurysm treated with balloon-assisted coiling using a dual lumen balloon (Eclipse 2L, Balt Extrusion, Montmorency, France). The procedure went uneventfully; however, the final control digital subtraction angiography (DSA) performed with the power injector showed a “spontaneous” inflation of the dual lumen balloon (balloon half inflated at the end of the run, impossible to deflate). “Spontaneous” inflation of balloons during any intracranial intervention can have detrimental consequences. Therefore, several macroscopic and microscopic tests were performed on the device seeking to determine the mechanism behind this spontaneous balloon inflation. This article describes several potential causes of this inopportune spontaneous balloon inflation and some recommendation are also suggested to avoid its occurrence.

E-018 Treatment of Ruptured Blood-blister-like Aneurysms in the Subacute Phase: Clinical and Angiographic Outcome

Purpose Ruptured Blood blisterlike (BBL) aneurysms represent a therapeutic challenge. Timing of treatment and technique of choice are still a subject of debate. We report our experience in the endovascular treatment of such lesions in the subacute phase. Methods Between June 2011 and January 2015, 6 ruptured BBL aneurysms were treated at our institution. Four were located in the carotid siphon, 2 in the posterior circulation. Endovascular procedures were carried out between day 7 and day 15 after the hemorrhagic event. One patient was treated surgically. Flow-diverter stents (FDS) were used in 4 cases. Two telescopic laser-cut stents were used in one case. Double antiplatelet therapy was started 4 days before treatment in 1 case and the day of the procedure in the remaining 4 cases. Angiographic follow-up was carried out by MRA and DSA at 1 month, 6 months and 1 year. Results All endovascular procedures were performed without technical difficulties. Antiplatelet treatment was started 4 days prior to procedure in one case and the day of the intervention in the other cases. One patient presented a transient motor deficit at day 1 after treatment. One patient had a peroperative cerebellar ischemia after FDS deployment, despite antiplatelet treatment. One patient treated by surgery had a fatal brain ischemia after peroperative aneurysmal rupture that eventually required clipping of the carotid siphon. Imaging follow was available for the remaining 5 patients. No patent rebled prior to treatment or during follow-up. Three out of five aneurysms were completely occluded at latest follow-up. Conclusion Modern endovascular techniques for the treatment of ruptures BBL aneurysms, including the use of flow-diversion, seem promising. Treatment in the subacute phase may be considered as an option in relation to other clinical issues (patient WFNS grade, risk of rebleed under antiplatelet therapy, ventricular shunting) when pondering overall risks and benefits in patient management. Disclosures F. Di Maria: None. J. Gabrieli: None. B. Bartolini: None. S. Pistocchi: None. J. Chiras: None. N. Sourour: None. F. Clarençon: None.

Rupture of the retrocorporeal artery: a rare cause of spontaneous spinal epidural haematoma.

A 22-year-old man presented with a sudden backache and paraplegia (ASIA = B). Magnetic resonance imaging showed an anterior pan-spinal epidural haematoma. Digital subtraction angiography was performed and ruled out an underlying vascular malformation but showed an active contrast media leakage into the T-4 ventral epidural space with a pattern of pseudo-aneurysm. A rupture of a T-4 retrocorporeal artery was considered as the aetiology, possibly caused by a haemorrhagic sub-adventitial dissection. Treatment consisted in the embolisation of both the pseudo-aneurysm and the parent artery with liquid acrylic glue, followed by neurosurgical decompression in emergency. The patient had totally recovered (ASIA = E) by the 10-month clinical follow-up.

O-029 safety and effectiveness of middle cerebral artery aneurysms treatment (endovascular and surgical): retrospective analysis of a single center series with 362 consecutive patients

Introduction Middle cerebral artery (MCA) aneurysms are eligible for both treatment options (microsurgery and embolization). The purposes of our study were 1) to evaluate the morbi-mortality rate related to endovascular and microsurgical treatments of ruptured and unruptured MCA aneurysms and 2) to study the effectiveness of endovascular and surgical treatments for these aneurysms in terms of recanalization/recurrence and bleeding at short and long terms angiographic and clinical follow-ups. Material and methods Our study is a mono-centric retrospective observational study, reporting clinical and angiographic follow-up of consecutive patients treated for MCA aneurysms (ruptured and unruptured). From 2002 to 2012, 362 consecutive patients were admitted at our institution for the treatment of 390 MCA aneurysms (255 ruptured and 135 unruptured). Among the procedures, 127 aneurysms were treated by endovascular means (32.5%) and 263 (67.5%) by microsurgery. Procedure-related death and complications (major/minor) were systematically assessed. The per-procedural rupture rate was also evaluated. The quality of the aneurysms exclusion was evaluated according to the Roy-Raymond scale in post-procedure and at long term angiographic follow-up (mean delay = 36 months). Results Procedure related death rate was 1.9%. This rate was slightly higher in the group of ruptured aneurysms treated by endovascular (EV) means (3.2% vs 1.2% in the group S [Surgery]), but this difference was not significant (p = 0.23). The procedure-related major complication rate was slightly higher in the group S (5.6% vs 2.4% for the group EV; p = 0.19, non-significant). Minor complications were slightly more frequent in the group S (5.6% vs 4.8% for the group EV), but this difference was also not statistically significant (p = 1). Per-procedure rupture rate was 14.4%; per-procedure ruptures were more frequently observed for ruptured aneurysms treated by microsurgery. During the hospital stay, 69% of the patients with ruptured aneurysms had a favorable outcome (mRS ≤ 3); this rate increased to 72.9% at 6 months and 72.3% at 12 months follow-up. In post-procedure, Roy-Raymond grade A or B occlusion rate was 94.8% for the overall population; this rate was similar for the group S and the group EV (95.6% for the group S vs 92.2% for the group EV; NS). However, long-term angiographic follow-up showed a higher Roy-Raymond grade A or B for the group S (94.2% for the group S vs 78% for the group EV [p Conclusion Both microsurgical and endovascular techniques are safe for the treatment of MCA aneurysms, with an acceptable complication rate (overall morbi-mortality rate: 5.6%). The two techniques allow for a satisfactory exclusion of aneurysm. However, long-term angiographic follow-up showed more stable results for the surgical treatment, but without bleeding/rebleeding event observed during the long-term clinical follow-up for both techniques. Disclosures N. Sourour: 2; C; eV3/Covidien. S. Hallout: None. F. Di Maria: None. A. Nouet: None. J. Gabrieli: None. P. Cornu: None. J. Chiras: None. F. Clarencon: None.