Joshua W Osbun

Reduced Efficacy of the Pipeline Embolization Device in the Treatment of Posterior Communicating Region Aneurysms with Fetal Posterior Cerebral Artery Configuration

BACKGROUNDnAneurysms at the origin of the posterior communicating artery (PcommA) have been demonstrated to be effectively treated with the pipeline embolization device (PED). Much less is known about the efficacy of the PED for aneurysms associated with a fetal posterior cerebral artery (fPCA) variant.nnnOBJECTIVEnTo study PED treatment efficacy of PcommA aneurysms, including fPCA aneurysms.nnnMETHODSnA prospectively maintained university database of aneurysm patients treated with the PED was retrospectively reviewed. Demographics, treatment details, and imaging were reviewed for all PcommA and fPCA aneurysms.nnnRESULTSnOut of a total of 285 patients treated with PED, 50 patients (mean age 57.5 ± 12.2 yr, 42 females) with unruptured PcommA (9 fPCA) aneurysms were identified. Mean follow-up duration was 14.0 ± 11.6 mo (48 patients). Roy-Raymond class I occlusion on follow-up magnetic resonance or catheter angiography (mean time 11.7 ± 6.8 mo) was achieved in 30 patients (62.5%), class II occlusion in 11 patients (22.9%) and class III occlusion in 7 patients (14.5%). The PcommA was occluded in 56% of patients without any clinical symptoms. No deaths or permanent neurological complications occurred. In fPCA aneurysms, class I occlusion was seen in 1 patient, class 2 occlusion in 2 patients, and class III occlusion in 6 patients. Multivariate analysis revealed an independent association between incomplete occlusion and fPCA configuration (OR 73.65; 95% CI: 5.84-929.13; P = .001).nnnCONCLUSIONnThe PED is a safe and effective treatment for PcommA aneurysms, although fetal anatomy should increase consideration of traditional endovascular techniques or surgical clipping.

Pipeline Embolization of Posterior Communicating Artery Aneurysms Associated with a Fetal Origin Posterior Cerebral Artery

BACKGROUND AND PURPOSEnFlow diversion may have advantages in the treatment of posterior communicating artery (PComA) aneurysms associated with a fetal origin posterior cerebral artery (PCA), which can be challenging to treat with conventional techniques. However, a PComA incorporated into the aneurysm may prevent or delay aneurysm occlusion. Also, coverage of a fetal origin PCA risks infarction of a large vascular territory. The purpose of this study was to examine the safety and effectiveness of using the Pipeline Embolization Device (PED) to treat PComA aneurysms associated with a fetal origin PCA.nnnPATIENTS AND METHODSnRetrospective review of PComA aneurysms associated with a fetal origin PCA treated with the PED at two neurovascular centers was performed. Periprocedural complications and clinical and angiographic outcomes were reviewed.nnnRESULTSnSeven female patients underwent a total of seven PED procedures to treat seven PcomA aneurysms associated with a fetal origin PCA. The symptomatic complication rate was 14% (1/7) per patient and 13% (1/8) per procedure. Angiographic follow up was obtained for 6 of 7 aneurysms. Follow-up DSA at 5-7 months after treatment demonstrated complete occlusion of 17% (1/6) of aneurysms. One aneurysm was retreated with a second PED and occlusion was demonstrated 36 months after the second treatment, yielding an overall complete occlusion rate of 33% (2/6).nnnCONCLUSIONSnPED treatment was largely ineffective at treating PComA aneurysms associated with a fetal origin PCA, and should only be considered when conventional treatment options, including microsurgical clipping, are not feasible.

Endovascular Treatment of Posterior Inferior Cerebellar Artery Aneurysms with Flow Diversion

BACKGROUNDnFlow diversion is a viable alternative for treatment of wide-neck and fusiform aneurysms originating from the posterior inferior cerebellar artery (PICA), but coverage of the PICA and vertebral perforating arteries may be a concern. The aim of this study was to examine procedural, clinical, and angiographic outcomes of patients with PICA aneurysms treated with the Pipeline Embolization Device.nnnMETHODSnRetrospective review was performed of PICA aneurysms treated with the Pipeline device at 3 neurovascular centers, including periprocedural complications and clinical and angiographic outcomes.nnnRESULTSnIn 16 procedures, 14 PICA aneurysms were treated with the Pipeline device. These included 11 saccular aneurysms with a mean size of 7.4 mm (range, 2.0-11.1 mm) and 3 fusiform aneurysms with a mean diameter of 6.1 mm (range, 5.0-8.0 mm) and mean length of 10.3 mm (range, 6.0-15.0 mm). One patient developed a PICA territory infarct with mild leg weakness that resolved in <7 days. Overall complication rate was 7% (1/14) per patient and 6% (1/16) per procedure. Mean duration of clinical follow-up was 13.5 months (range, 3 weeks to 61.7 months), with all patients returning to baseline functional status. Complete or near-complete aneurysm occlusion was achieved in 58% (7/12) of cases with angiographic follow-up (mean, 15 months; range, 4-61 months). All covered PICAs remained patent.nnnCONCLUSIONSnFlow diversion of PICA aneurysms is a safe and viable treatment option when traditional endovascular options are unlikely to preserve parent vessel patency.

Endovascular Treatment of Posterior Cerebral Artery Aneurysms With Flow Diversion: Case Series and Systematic Review

BACKGROUNDnFlow diversion of posterior cerebral artery (PCA) aneurysms has not been widely reported, possibly owing to concerns regarding parent vessel size and branch vessel coverage.nnnOBJECTIVEnTo examine the safety and effectiveness of PCA aneurysm flow diverter treatment.nnnMETHODSnRetrospective review of PCA aneurysms treated with the Pipeline Embolization Device (PED; Medtronic Inc, Dublin, Ireland) at 3 neurovascular centers, including periprocedural complications and clinical and angiographic outcomes. Systematic review of the literature identified published reports of PCA aneurysms treated with flow diversion. Rates of aneurysm occlusion and complications were calculated, and outcomes of saccular and fusiform aneurysm treatments were compared.nnnRESULTSnTen PCA aneurysms in 9 patients were treated with the PED. There were 2 intraprocedural thromboembolic events (20%), including 1 symptomatic infarction and 1 delayed PED thrombosis. Eight of 10 patients returned to or improved from their baseline functional status. Complete aneurysm occlusion with parent vessel preservation was achieved in 75% (6/8) of cases at mean follow-up of 16.7 mo. Eleven of 12 (92%) major branch vessels covered by a PED remained patent. Including the present study, systematic review of 15 studies found a complete aneurysm occlusion rate of 88% (30/34) and complication rate of 26% (10/38), including 5 symptomatic ischemic strokes (13%; 5/38). Fusiform aneurysms more frequently completely occluded compared with saccular aneurysms (100% vs 70%; P = .03) but were associated with a higher complication rate (43% vs 9%; P = .06).nnnCONCLUSIONnThe safety and effectiveness profile of flow diverter treatment of PCA aneurysms may be acceptable in select cases.

Isolated Internal Carotid Artery Thrombus and Cerebral Infarction in a Patient with Necrotizing Pancreatitis: Case Report

Isolated internal carotid artery (ICA) thrombus in the absence of underlying atherosclerotic disease is a rare entity. We report a case of a patient presenting with right arm weakness, slurred speech, and altered mental status in the setting of acute on chronic pancreatitis. The patient was found to have scattered left cerebral hemisphere cortical infarctions, and catheter angiography confirmed the presence of intraluminal left ICA thrombus, with no evidence of atherosclerotic disease in the cervical or intracranial vasculature. Further workup also demonstrated the presence of anemia of chronic disease. The patient was initiated on anticoagulation, and follow-up imaging demonstrated a complete resolution of the left ICA thrombus. In the reported case, coagulopathy in the setting of acute on chronic pancreatitis was presumably the primary etiology. Anemia of chronic disease, related to a proinflammatory state, may also play a contributory role.

Treatment of pediatric intracranial aneurysms: case series and meta-analysis

Background There are limited outcome data to guide the choice of treatment in pediatric patients with cerebral aneurysms. Objective To describe our institutional experience treating pediatric patients with cerebral aneurysms and to conduct a meta-analysis of available studies to provide the best current evidence on treatment related outcomes. Methods We identified pediatric patients with cerebral aneurysms evaluated or treated at our institution using a comprehensive case log. We also identified studies to include in a meta-analysis through a systematic search of Pubmed, SCOPUS, EMBASE, and the Cochrane Database of Systematic Reviews. As part of both the local analysis and meta-analysis, we recorded patient characteristics, aneurysm characteristics, management, and outcomes. Statistical analysis was performed using Fisher’s exact test and the two tailed Student’s t test, as appropriate. Results 42 pediatric patients with 57 aneurysms were evaluated at our institution, and treatment specific outcome data were available in 560 patients as part of our meta-analysis. Endovascular and surgical treatments yielded comparable rates of favorable outcome in all children (88.3% vs 82.7%, respectively, P=0.097), in children with ruptured aneurysms (75% vs 83%, respectively, P=0.357), and in children with unruptured aneurysms (96% vs 97%, respectively, P=1.000). Conclusion Endovascular and surgical treatment yield comparable long term clinical outcomes in pediatric patients with cerebral aneurysms.

Direct puncture Onyx embolization of a large calvarial metastasis with intracranial extension: Case report

We report a case of renal cell carcinoma (RCC) metastasis to the calvarium and describe a strategy for percutaneous embolization of hypervascular calvarial tumors with intracranial extension. An elderly patient with history of RCC presented with left-sided weakness. Imaging studies showed a large right frontoparietal calvarial mass with intra- and extracranial extension. The tumor was devascularized by direct puncture tumor embolization using Onyx 18, allowing subsequent operative resection without significant blood loss or the need for flap reconstruction of the scalp. Compared to more common endovascular approaches, direct-needle puncture embolization of transcalvarial masses may offer lower risk of injury to scalp vessels and underlying brain parenchyma.

P-034 Reduced efficacy of the pipeline embolization device in the treatment of posterior communicating region aneurysms with fetal posterior cerebral artery configuration

Introduction Aneurysms at the origin of the posterior communicating artery (PcommA) have been demonstrated to be effectively treated with the Pipeline Embolization Device (PED). Much less is known about the efficacy of the PED for aneurysms associated with a fetal posterior cerebral artery (fPCA) variant. Herein, the largest series of patients with ICA aneurysms at the origin of the PcommA or fPCA treated with the PED is presented. Methods A prospectively maintained university database of aneurysm patients treated with the PED was retrospectively reviewed. Demographics, treatment details, and imaging were reviewed for all PcommA and fPCA aneurysms. Results Out of a total of 285 patients treated with PED, 50 patients (mean age 57.5±12.2 years, 42 females) with unruptured PcommA (9 fPCA) aneurysms were identified. Mean follow-up duration was 14.0±11.6 months (48 patients). Roy-Raymond Class I occlusion on follow up Magnetic Resonance or catheter angiography (mean time 11.7±6.8 months) was achieved in 30 patients (62.5%), Class II occlusion in 11 patients (22.9%) and Class III occlusion in 7 patients (14.5%). The PcommA was occluded in 56% of patients without any clinical symptoms. No deaths or permanent neurological complications occurred. In fPCA aneurysms, Class I occlusion was seen in 1 patient, Class II occlusion in 2 patients, and Class III occlusion in 6 patients (figure 1). Multivariate analysis revealed an independent association between incomplete occlusion and fPCA configuration (OR 73.65; 95%u2009CI [5.84–929.13]; p=0.001). The current literature on flow diversion treatment of fPCA aneurysms was reviewed and added to the current series and found to be associated with a low rate of aneurysm occlusion (5/23 or 22%; table 1). Conclusion PEDs are a safe and effective choice in the treatment of PcommA aneurysms. The presence of fetal anatomy, however, should increase consideration of traditional intra-saccular endovascular techniques or surgical clipping. Longer follow-up is needed to determine the ultimate efficacy of PED treatment for these aneurysms. Abstract P-034 Table 1 Studies evaluating the efficacy of the PED in treating ICA aneurysms at the origin of a fPCA fPCA aneurysms (n) Received adjunctive/previous coiling (n) Mean aneurysm size ± SD (mm) Mean PEDs per patient ± SD Patency of fPCA after PED (n) Mean follow-up (months) Fraction achieving complete aneurysm occlusion Daou, et al. 6 N/A N/A N/A Occluded: 0 Diminished: 3 Patent: 3 6 4/6 Tsang, et al. 4 2 7.67±3.3 1.67±0.6 N/A 21 0/4 Kan, et al. 4 3 N/A 1.50±0.6 N/A 22.5 0/4 Present study 9 4 8.23±3.79 1 Occluded: 1 Patent: 8 11.5 1/9 Abstract P-034 Figure 1 Disclosures A. Roy: None. B. Howard: None. D. Haussen: None. J. Osbun: None. S. Halani: None. S. Skukalek: None. F. Tong: None. R. Nogueira: None. J. Dion: None. C. Cawley: None. J. Grossberg: None.

E-057 Endovascular treatment of posterior cerebral artery aneurysms with the pipeline embolization device

Background and Purpose The Pipeline Embolization Device (PED; Covidien, Irvine, CA) is being increasingly utilized for off-label indications, but has not been widely utilized to treat posterior cerebral artery (PCA) aneurysms. Potential concerns regarding placement of the PED in the PCA include the relatively small parent vessel diameter and coverage of major branch vessels and P1 thalamic perforators. Herein, we report our experience using the PED for the treatment of PCA aneurysms. Materials and Methods Institutional review board approval was obtained to retrospectively review the neurointerventional databases of three high-volume neurovascular centers for PCA aneurysms treated with the PED between January 2012 and January 2016. Demographic information, clinical history, and outcomes were collected from electronic medical records. Procedural details and periprocedural complications were collected from operative reports. Preoperative digital subtraction angiography (DSA) was reviewed to determine aneurysm characteristics and anatomy of surrounding branch vessels. Follow up MR and DSA were reviewed for aneurysm occlusion, stenosis within the PED, and the status of branch vessels covered by the PED. Results The study included 10 PCA aneurysms in 9 patients (3 men, 6 women) with a mean age of 56 years (range, 18–74 years). There were 6 saccular aneurysms with a mean aneurysm size of 12.3u2009mm (range, 7–16u2009mm), and 4 fusiform aneurysms with mean size of 6.2u2009mm (range, 3.9–11.0u2009mm) and mean length of 18.8u2009mm (range, 5–45u2009mm). Eight aneurysms were treated with a single PED, and two aneurysms were treated with two PEDs. The PEDs ranged from 2.5–4.25u2009mm in diameter and 12–35u2009mm in length. Six of 10 PEDs were deployed entirely within the PCA. In two patients, the PED extended from the PCA into the basilar artery, covering the contralateral PCA and both superior cerebellar arteries. There were no deaths. There were two intraprocedural thromboembolic events (20%; 2/10), one of which resulted in symptomatic infarction (10%; 1/10), and one case of delayed PED thrombosis (10%; 1/10). Angiographic follow up was obtained for 9 of 10 aneurysms, including MRA for two patients, DSA for five patients, and DSA at 6 months and CTA at 24 months for one patient. The mean duration of angiographic follow up was 16.7 months (range, 2–33 months). Excluding the case of delayed parent vessel thrombosis, complete aneurysm occlusion was achieved in 75% (6/8) of cases at longest follow up during the study period. There were no instances of in-stent stenosis. All major branch vessels covered by a PED were patent at last angiographic follow. Conclusions PED embolization may be a viable treatment option for select PCA aneurysms that may be considered under appropriate clinical circumstances. Disclosures A. Wallace: None. J. Grossberg: None. J. Delgado Almandoz: None. M. Kamran: None. A. Roy: None. Y. Kayan: None. M. Austin: None. B. Howard: None. C. Moran: 2; C; Medtronic Neurovascular, Microvention. M. Cawley: None. D. Cross: None. J. Dion: None. A. Kansagra: None. J. Osbun: None.

E-047 Endovascular cerebellar artery sacrifice: clinical outcomes in 28 patients

Background Endovascular treatment of lesions associated with the cerebellar arteries is ideally performed with preservation of cerebellar artery flow, but cerebellar artery sacrifice may sometimes be necessary. Clinical outcomes and complication rates of cerebellar artery sacrifice not well defined. Methods We retrospectively reviewed cases of endovascular sacrifice of the superior cerebellar artery (SCA), posterior inferior cerebellar artery (PICA), and anterior inferior cerebellar artery (AICA) in patients with aneurysms, arteriovenous malformations (AVM), or tumors supplied by the corresponding artery. Baseline modified Rankin Scale (mRS) and pre-procedure acute intracranial hemorrhage hydrocephalus, and/or ventriculostomy were recorded along with diameter of the sacrificed cerebellar artery. Outcomes included new clinical neurological deficits, imaging evidence of cerebellar infarction, worsening hydrocephalus, new EVD placement, and craniectomy within 4 weeks of the procedure. Modified Rankin Scale at discharge and at 3 months was also recorded. Results Of the 28 patients treated with endovascular cerebellar artery sacrifice, 22 had aneurysms, 5 had AVMs, and 1 had a tumor (hemangioblastoma) fed by the sacrificed cerebellar artery. Overall, 16 PICAs, 8 SCAs, and 4 AICAs were sacrificed. The mean vessel diameter was 1.45u2009mm. Twelve patients (42.9%) developed clinical neurological deficits within 4 weeks of the procedure that could be attributed to the occluded vessel. Of these patients, 8 developed imaging evidence of infarction in the corresponding arterial territory within 4 weeks of the procedure. Separately, there were 3 patients that developed imaging evidence of infarction without associated clinical neurological deficits. The mean vessel diameter of patients who developed imaging evidence of infarction was 1.2u2009mm, and the mean vessel diameter of patients who did not develop imaging evidence of infarction was 1.5u2009mm. Ten patients (35.7%) developed worsening hydrocephalus within 4 weeks of the procedure; 6 of these patients required placement of a new EVD. A single patient without worsening hydrocephalus required a new EVD electively after several unsuccessful attempts at weaning the indwelling contralateral EVD. Two patients required craniotomy within 4 weeks of the procedure, one which was planned pre-procedure and the other which was for evacuation of a new acute hematoma secondary to AVM hemorrhage. Six patients (21.4%) died prior to hospital discharge. Sixteen patients (57.1%) made a good recovery at 3 months (mRS ≤2). Mean angiographic follow-up period was 137.7 days (range 0–1169 days). Conclusions Similar to open surgical cerebellar artery sacrifice, endovascular cerebellar artery sacrifice is associated with a high risk of infarction, hydrocephalus, and death. Patient # Age Sex Pathology treated Vessel sacrificed Diameter of sacrificed vessel (in mm) Baseline mRS Pre- ICH? Pre- hydrocephalus? Pre- EVD? Post- Neuro deficit? Post- Imaging evidence of infarct? Post- Worsening hydrocephalus? Post- New EVD? Post-Craniectomy? mRS at discharge mRS at 3u2009months Angio f/u (days) 1 69 F Aneurysm AICA - Left 0.5 0 Yes Yes Yes Yes No Yes Yes No 3 0 311 2 50 F Aneurysm AICA - Right 1 0 Yes Yes Yes Yes No No No No 1 1 1169 3 19 F Aneurysm AICA - Right 1 0 Yes Yes Yes No No No No No 2 1 198 4 66 F Aneurysm PICA - Left 0.7 0 Yes Yes Yes Yes Yes Yes No No 6 6 4 5 66 F Aneurysm PICA - Left 0.8 0 Yes Yes Yes Yes Yes No No No 6 6 7 6 76 F Aneurysm PICA - Left 1 0 Yes Yes Yes Yes Yes No No No 6 6 11 7 61 F Aneurysm PICA - Left 1.1 0 Yes Yes Yes No No No No No 6 6 0 8 72 M Aneurysm PICA - Left 1.6 0 Yes Yes Yes Yes Yes Yes No No 6 6 17 9 45 F Aneurysm PICA - Right 1 0 Yes No No Yes Yes Yes Yes No 4 3 3 10 54 F Aneurysm PICA - Right 1 0 Yes Yes No No No No No No 0 0 562 11 48 M Aneurysm PICA - Right 1.2 0 Yes Yes No Yes Yes Yes No No 1 0 7 12 44 F Aneurysm PICA - Right 1.3 0 Yes Yes Yes No Yes No No No 3 1 8 13 74 F Aneurysm PICA - Right 1.3 0 Yes Yes Yes No No No No No 2 1 136 14 82 F Aneurysm PICA - Right 1.4 0 Yes Yes Yes Yes Yes No No No 6 6 0 15 73 F Aneurysm PICA - Right 1.5 0 Yes Yes Yes No Yes Yes Yes No 4 3 0 16 74 M Aneurysm SCA - Left 0.8 0 No No No Yes No No No No 3 4 0 17 51 F Aneurysm SCA - Left 1 0 Yes No No Yes No No No No 1 0 31 18 55 M Aneurysm SCA - Left 1 1 Yes Yes Yes No No Yes No No 1 1 181 19 44 F Aneurysm SCA - Left 1.1 2 Yes No No No No No No No 2 2 4 20 53 F Aneurysm SCA - Left 1.7 1 No No No Yes Yes No No No 2 0 0 21 65 F Aneurysm SCA - Right 1 0 Yes Yes Yes No Yes No No No 3 1 315 22 48 M Aneurysm SCA - Right 1.7 0 Yes Yes Yes No No Yes Yes No 3 2 94 23 42 M AVM AICA - Right 1.9 0 Yes Yes Yes No No No Yes Yes 5 4 145 24 65 F AVM PICA - Left 1 1 No No No No No No No No 1 1 0 25 56 F AVM PICA - Right 0.3 0 No No No No No Yes Yes No 1 0 0 26 57 F AVM PICA - Right 0.4 0 Yes Yes Yes No No Yes Yes Yes 4 3 0 27 18 F AVM PICA - Right 1.9 0 No No No No No No No No 0 0 589 28 22 M Tumor (hemangioblastoma) SCA - Right * 0 Yes Yes Yes No No No No No 1 1 0 * imaging not available Disclosures M. Austin: None. R. Rimer: None. C. Chou: None. A. Wallace: None. M. Kamran: None. C. Moran: 2; C; Medtronic, Microvention. D. Cross: None. J. Osbun: None. G. Zipfel: 1; C; NIH, AHA. R. Dacey: None. A. Kansagra: None.