Krzysztof Kadziolka

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.

Follow-up of intracranial aneurysms treated by flow diverter: comparison of three-dimensional time-of-flight MR angiography (3D-TOF-MRA) and contrast-enhanced MR angiography (CE-MRA) sequences with digital subtraction angiography as the gold standard

Background and purpose Follow-up of intracranial aneurysms treated by flow diverter with MRI is complicated by imaging artifacts produced by these devices. This study compares the diagnostic accuracy of three-dimensional time-of-flight MR angiography (3D-TOF-MRA) and contrast-enhanced MRA (CE-MRA) at 3 T for the evaluation of aneurysm occlusion and parent artery patency after flow diversion treatment, with digital subtraction angiography (DSA) as the gold standard. Materials and methods Patients treated with flow diverters between January 2009 and January 2013 followed by MRA at 3 T (3D-TOF-MRA and CE-MRA) and DSA within a 48 h period were included in a prospective single-center study. Aneurysm occlusion was assessed with full and simplified Montreal scales and parent artery patency with three-grade and two-grade scales. Results Twenty-two patients harboring 23 treated aneurysms were included. Interobserver agreement using simplified scales for occlusion (Montreal) and parent artery patency were higher for DSA (0.88 and 0.61) and CE-MRA (0.74 and 0.55) than for 3D-TOF-MRA (0.51 and 0.02). Intermodality agreement was higher for CE-MRA (0.88 and 0.32) than for 3D-TOF-MRA (0.59 and 0.11). CE-MRA yielded better accuracy than 3D-TOF-MRA for aneurysm remnant detection (sensitivity 83% vs 50%; specificity 100% vs 100%) and for the status of the parent artery (specificity 63% vs 32%; sensitivity 100% vs 100%). Conclusions At 3 T, CE-MRA is superior to 3D-TOF-MRA for the evaluation of aneurysm occlusion and parent artery patency after flow diversion treatment. However, intraluminal evaluation remains difficult with MRA regardless of the sequence used.

Outcome after mechanical thrombectomy using a stent retriever under conscious sedation: Comparison between tandem and single occlusion of the anterior circulation

BACKGROUND AND PURPOSE In acute ischemic stroke patients, internal carotid artery/middle cerebral artery (ICA/MCA) occlusion in tandem predicts a poor outcome after systemic thrombolysis. This study aimed to compare outcomes after mechanical thrombectomy for tandem and single occlusions of the anterior circulation. MATERIALS AND METHODS This prospective study included consecutive patients with acute ischemic stroke of the anterior circulation who had undergone mechanical thrombectomy performed with a stent retriever under conscious sedation within 6h of symptom onset. Data on clinical, imaging and endovascular findings were collected. In cases of tandem occlusion, distal thrombectomy (retrograde approach) was performed first whenever possible. Tandem and single occlusions were compared in terms of functional outcome and mortality at 3 months. RESULTS From May 2010 to April 2012, 42 patients with acute ischemic stroke attributable to MCA and/or ICA occlusion were treated. Eleven patients (26.2%) presented with tandem occlusions and 31 patients (73.8%) had a single anterior circulation occlusion. Baseline characteristics were similar between the two groups. Recanalization status also did not differ significantly (P=0.76), but patients with tandem occlusions had poorer functional outcomes (18.2% vs. 67.7% for single occlusions; P=0.01), a higher mortality rate at 3 months (45.5% vs. 12.9%, respectively; P=0.03) and more symptomatic intracranial hemorrhages at 24h (9.7% vs. 0%, respectively; P=0.01). A high rate of early proximal re-occlusion or severe residual stenosis (66%) was also observed in the tandem group. CONCLUSION Tandem occlusions had poor clinical outcomes after mechanical thrombectomy compared with single occlusions. The retrograde approach (treatment of distal occlusion first) used in patients under conscious sedation may have contributed to these poor outcomes.

Endovascular treatment with flow diverters of recanalized and multitreated aneurysms initially treated by endovascular approach

Purpose To evaluate the feasibility, safety and efficacy of endovascular treatment with flow diverters in patients with recanalized and multitreated aneurysms in a retrospective, multicenter, single-arm study. Methods The study included 29 patients with 29 recanalized aneurysms who were treated by flow diverters (Silk or Pipeline devices). Pre- and post-procedural complications and morbidity and mortality rates were evaluated and functional outcomes (modified Rankin Score (mRS)) at 1 month (short-term) and 3–4 months (mid-term) were compared with preoperative mRS (before the procedure). Mid-term angiographic follow-up was performed assessing aneurysmal occlusion by the Montreal scale (complete occlusion, neck remnant, aneurysm remnant). Results Placement of the flow diverters was achieved in all patients. Two misdeployments of the flow diverters necessitated balloon dilation in two patients, which was associated with stent delivery in one patient. Permanent morbidity related to treatment was 6.9% (2/29), transient morbidity was 10.3% (3/29) and there were no deaths resulting from the treatment. One patient died from a myocardial infarct 4 weeks after the procedure. 25/29 patients (86.2%) had a good final functional outcome, 26/29 (89.7%) had an unchanged functional outcome and 2/29 patients (6.9%) had clinical worsening. Angiographic follow-up showed complete occlusion in 17/28 patients (60.7%), neck remnants in 6/28 patients (21.4%) and residual aneurysms in 5/28 (17.9%). Conclusions Flow diverter placement is feasible and safe in patients with recanalized and multitreated aneurysms. The procedure is associated with a high percentage of good functional outcomes as well as good mid-term anatomical results (82.1%).

Combined use of a double-lumen remodeling balloon and a low-profile stent in the treatment of intracranial aneurysms (‘remostent’ technique): A technical note

Remodeling technique and stenting represent important options for intracranial aneurysm treatment, and they sometimes need to be combined. The technology of remodeling balloons and stents has recently evolved with the development of the double-lumen remodeling balloon (Scepter and Ascent) and the low-profile stent (LVIS Jr). This report describes our initial experience with and feasibility of the deployment of the low-profile stent through the balloons internal guidewire lumen, thereby reducing the number of manoeuvres by combining remodeling and stenting.

Second-Generation Hydrogel Coils for the Endovascular Treatment of Intracranial Aneurysms: A Randomized Controlled Trial

Background and Purpose— Endovascular embolization of intracranial aneurysms with hydrogel-coated coils lowers the risk of major recurrence, but technical limitations (coil stiffness and time restriction for placement) have prevented their wider clinical use. We aimed to assess the efficacy of softer, second-generation hydrogel coils. Methods— A randomized controlled trial was conducted at 22 centers in France and Germany. Patients aged 18 to 75 years with untreated ruptured or unruptured intracranial aneurysms measuring 4 to 12 mm in diameter were eligible and randomized (1:1 using a web-based system, stratified by rupture status) to coiling with either second-generation hydrogel coils or bare platinum coils. Assist devices were allowed as clinically required. Independent imaging core laboratory was masked to allocation. Primary end point was a composite outcome measure including major aneurysm recurrence, aneurysm retreatment, morbidity that prevented angiographic controls, and any death during treatment and follow-up. Data were analyzed as randomized. Results— Randomization began on October 15, 2009, and stopped on January 31, 2014, after 513 patients (hydrogel, n=256; bare platinum, n=257); 20 patients were excluded for missing informed consent and 9 for treatment-related criteria. Four hundred eighty-four patients (hydrogel, n=243; bare platinum, n=241) were included in the analysis; 208 (43%) were treated for ruptured aneurysms. Final end point data were available for 456 patients. Forty-five out of 226 (19.9%) patients in the hydrogel group and 66/230 (28.7%) in the control group had an unfavorable composite primary outcome, giving a statistically significant reduction in the proportion of an unfavorable composite primary outcome with hydrogel coils—adjusted for rupture status—of 8.4% (95% confidence interval, 0.5–16.2; P=0.036). Adverse and serious adverse events were evenly distributed between groups. Conclusions— Our results suggest that endovascular coil embolization with second-generation hydrogel coils may reduce the rate of unfavorable outcome events in patients with small- and medium-sized intracranial aneurysms. Clinical Trial Registration— URL: https://www.drks.de/drks_web/. Unique identifier: DRKS00003132.

Mechanical thrombectomy "as a rescue treatment" of thromboembolic complications during endovascular treatment of intracranial aneurysms.

Acute thromboembolic periprocedural events during endovascular intracranial aneurysm treatment are mostly treated with intravenous or intra-arterial pharmacological thrombolysis. The present report describes a case of mechanical thrombectomy as a rescue treatment that may be an acceptable alternative to the current strategies. The feasibility and safety of stent retrievers in such a clinical indication are also discussed.

O-013 Intra-aneurysmal Flow Disruption: a New Approach for the Endovascular Treatment of Intracranial Aneurysms. French Clinical Experience

Purpose Standard coiling is now the first line approach for the treatment of intracranial aneurysms. However, this technique has some limitations, including treatment of wide-neck and large and giant aneurysms and recanalisations. Therefore, new techniques and devices are needed. The objective of intra-saccular flow disruption is the modification of aneurysmal flow by placing a device in the aneurysm sac. Preliminary clinical experience in French centres is presented. Materials and Methods Computational fluid dynamics and pre-clinical testing (canine cross-over carotid bifurcation model) were used to develop an intra-saccular flow disrupter design, designated as WEB (Sequent, Aliso Viejo, CA).The WEB is a self-expanding, oblate, braided nitinol mesh, composed of an inner and outer braid held together by proximal, middle, and distal radio-opaque markers and creating two compartments: one distal and one proximal.Clinically, 39 patients (27F/12M, age: 37–75 years) harbouring ruptured, unruptured or recanalised aneurysms were treated between June 2011 and January 2013 in 7 French centres, using an intra-aneurysmal flow-disrupter (WEB). Aneurysm location was middle cerebral artery (23 aneurysms), basilar artery (8), internal carotid artery (5), and anterior communicating artery (3). Aneurysm size was 10mm in 5 aneurysms. Neck size was > 4mm in 5 aneurysms and <4mm in 35 cases. Results Clinically, the device was successfully deployed in all but 2 cases. Three thromboembolic events were observed with favourable outcome in both cases (mRS ≤2). No intraoperative rupture was observed. No delayed rupture or remote haematoma was observed. Additional coiling was performed in 4 cases. Mid-term follow-up results are presented. Conclusion Intra-saccular flow disruption using WEB is a completely new endovascular approach to treat some types of aneurysm, particularly wide-neck bifurcation aneurysms. This preliminary clinical experience shows the safety and efficacy of the device when used in appropriately selected cases. Disclosures L. Pierot: 2; C; Sequent. A. Januel: None. H. Raoult: None. L. Spelle: None. C. Papagiannaki: None. H. Desal: None. P. Courtheoux: None. K. Krzysztof Kadziolka1: None. J. Gauvrit: None. J. Moret: None. D. Herbreteau: None. C. Cognard: None.

Œdème périanévrismal postembolisation révélé par des crises épileptiques chez une patiente traitée par des coïls standards. À propos d’un cas et revue de la littérature

bjectifs.— Le but de l’étude et d’obtenir un modèle numérique éaliste de déformation de la paroi anévrysmale à partir de test iomécanique réalisé sur des poches anévrysmales prélevées in vivo u bloc opératoire. atériel et méthode.— Un anévrysme rompu a été prélevé chez un atient de 44 ans, puis conservé suivant un protocole de congélaion conservant les propriétés biomécaniques des tissus, utilisant MSO, isopropanol, à −80 ◦C. Le prélèvement tissulaire découpé en aguette a subi un essai de traction uni-axiale, avec une prétension e 0,05 N, permettant d’obtenir une courbe force/déplacement. ne courbe déformation/contrainte a ensuite été déduite. n logiciel de mécanique avancé a été utilisé pour déterminer le odèle hyperélastique associé au comportement mécanique de la aroi anévrysmale. e modèle à ensuite était reporté sur l’objet 3D maillé de la poche névrysmale prélevée. Les conditions limitées d’entrée (hémodynaiques) ont été appliquées en utilisant la suite logiciel développée ar Aneuryst : Anefuse. ésultats.— La paroi anévrysmale a été mesurée à 1,5 mm épaisseur. a contrainte seuil appliquée qui a générée un détérioration était de ,13 N/MM2. Le test a confirmé un modèle de déformation hyperlastique de type Mooney-Rivlin. La réintroduction du modèle de éformation dans l’objet 3D permet de visualiser une pulsatile réaiste de l’anévrysme au cours du cycle cardiaque. onclusion.— Les travaux de détermination des caractéristiques bioécaniques des poches anévrysmales sont une étape indispensable la précision des modèles mathématique de simulation du risque ndividuel de rupture.