Leonardo B.C. Brasiliense

Vessel perforation during stent retriever thrombectomy for acute ischemic stroke: technical details and clinical outcomes

Background Vessel perforation during stent retriever thrombectomy is a rare complication; typically only single instances have been reported. Objective To report on a series of patients whose stent retriever thrombectomy was complicated by intraprocedural vessel perforation and discuss its potential mechanisms, rescue treatment strategies, and clinical significance. Methods Cases with intraprocedural vessel perforation, where a stent retriever was used either as a primary treatment approach or as a part of a direct aspiration first pass technique (ADAPT), were included in the final analysis. Clinical data, procedural details, radiographic and clinical outcomes were collected from nine participating centers. Results Intraprocedural vessel perforation during stent retriever thrombectomy occurred in 16 (1.0%) of 1599 cases. 63% of intraprocedural perforations occurred at distal locations. Endovascular rescue techniques (most commonly, intracranial balloon occlusion for tamponade) were attempted in 50% of cases. Procedure was aborted without any rescue attempts in 44% of cases. Mortality during hospitalization and at 3u2005months was 56% and 63%, respectively. 25% of patients achieved good functional outcome at 3u2005months after the procedure. Conclusions Intraprocedural perforations during stent retriever thrombectomy were rare, but when they occurred were associated with high mortality. Perforations most commonly occurred at distal occlusion sites and were often characterized by difficulty traversing the occlusion with a microcatheter or microwire, or while withdrawing the stent retriever. Nevertheless, 25% of patients had a favorable functional outcome, suggesting that in some patients with this complication good neurological recovery is achievable.

Endovascular treatment of middle cerebral artery M2 occlusion strokes: Clinical and procedural predictors of outcomes

BACKGROUND: Patients with strokes from M2 segment middle cerebral artery (MCA) occlusion have been underrepresented in recent randomized trials of endovascular therapy. OBJECTIVE: To better understand the clinical, imaging, and procedural predictors of successful recanalization and clinical outcomes in this population of patients. METHODS: We performed a multicenter retrospective analysis of consecutive patients with acute MCA M2 segment occlusion who underwent thrombectomy with stent retrievers or primary aspiration thrombectomy (including A Direct Aspiration First Pass Technique approach). We correlated clinical and radiographic outcomes with demographic, clinical, and technical characteristics. RESULTS: One hundred and seventeen patients were included in analysis (median admission National Institutes of Health stroke scale [NIHSS] score 15, mean age 67.0 ± 14.5, 42% females). Good clinical outcome at 3 months (modified Rankin scale [mRS] ≤ 2) was achieved in 56% of patients. Treatment beyond 6 h of symptoms onset (P = .69, OR 0.80, 95% CI 0.38‐1.73) and age over 80 (P = .47, OR 0.65, 95% CI 0.25‐1.70) were not predictive of poor outcome. NIHSS > 15 was a strong predictor of clinical outcome, based on mRS distribution at 3 months (P = .0085, OR 0.35, 95% CI 0.16‐0.74). Direct aspiration and primary stent retriever thrombectomy approaches showed similar radiographic and clinical success rates. CONCLUSION: Advanced age and time to treatment beyond 6 h from symptom onset were not predictive of clinical outcome with thrombectomy. NIHSS score above 15 was a strong predictor of outcome. Direct aspiration and primary stent retriever thrombectomy showed similar efficacy.

First US experience with Pipeline Flex with Shield Technology using aspirin as antiplatelet monotherapy

Flow diversion has revolutionised the treatment of intracranial aneurysms, and the Pipeline Embolization Device (PED) remains the only flow diverter (FD) approved in the USA. However, thromboembolic events remain an issue for FDs. Attempting to minimise these incidents, a newer PED has been developed with the use of covalent bonding of phosphorylcholine onto the Pipeline device that has been known as Shield Technology (PED Shield), which in vitro has demonstrated a significant reduction in material thrombogenicity. We report the first US experience of the PED Shield in the treatment of a ruptured fusiform aneurysm located in the right vertebral artery in an attempt to mitigate complications related to the use of dual-antiplatelet therapy and discuss our rationale for using the new FD, using aspirin only as the antiplatelet regimen.

Evaluation of Pipeline Flex delivery system for the treatment of unruptured aneurysms

ABSTRACT Introduction: Refinements in endovascular technology have revolutionized the treatment of intracranial aneurysms (IAs) with the development of flow-diversion technology. The first generation of the Pipelin Embolization Device (PED) has demonstrated its safety and efficacy. However, the deployment technique was a difficult task that often led to complex maneuvers. The Pipeline Flex Embolization Device (PED Flex) is the second generation and its introduction has arrived with high expectations due to a completely redesigned delivery system that intends to overcome deployment difficulties seen in the previous generation. Areas covered: Preclinical studies, mechanism of action of flow-diverters, technical aspects and deployment system of the PED Flex, and clinical outcomes with both PED generations. Expert commentary: Flow diversion has allowed us to treat lesions that would be otherwise challenging for surgical clipping or unsuitable for other endosaccular strategies. Although the experience with PED Flex is limited, initial results suggest its safety and short-term efficacy.

Analysis of Predictors and Probability of Aneurysm Occlusion in the Internal Carotid Artery After Treatment with Pipeline Embolization Device

BACKGROUNDnAlthough the Pipeline Embolization Device (PED) has proved to be an excellent option for internal carotid artery (ICA) aneurysms, the rate of occlusion remains difficult to predict and factors associated with aneurysm occlusion are not well elucidated. This study aimed to investigate predictors and the rate of occlusion for aneurysms along the ICA.nnnMETHODSnA total of 117 saccular ICA aneurysms treated with the PED were studied. Occlusion rates were divided among 4 groups: group A [lesions >10 mm in the proximal ICA (petrous to the superior hypophyseal segments)]; group B (lesions <10 mm in the proximal ICA); group C [lesions >10mm in the distal ICA (posterior communicating segment to the ICA bifurcation)]; and group D (lesions <10 mm in the distal ICA). Predictors of aneurysm occlusion were entered into a multivariate Cox regression analysis.nnnRESULTSnThe median time to aneurysm occlusion was 8 months in group A (95% confidence interval [CI], 7.0-9.1), 5.2 months in group B (95% CI, 4.5-6.0), 6.9 months in group C (95% CI, 6.5-7.2), and 10.2 months in group D (95% CI, 6.9-13.6) (Pxa0= 0.045). There was a statistically significant difference between the probability of aneurysm occlusion in group B compared with distal ICA aneurysms (Pxa0= 0.02). Small proximal ICA aneurysms were more likely to occlude over time compared withxa0other aneurysm groups (hazard ratio, 1.76; 95% CI, 1.07-2.9; Pxa0= 0.02).nnnCONCLUSIONSnThe rate of occlusion after PED is highest for small proximal ICA aneurysms and the probability of occlusion is lower for distal ICA aneurysms.

Letter: Rerupture of a Blister Aneurysm After Treatment With a Single Flow-Diverting Stent

To the Editor: We read the recent article by Mazur et al1 with great interest; in this article, the authors described the case of a 29-year-old male who presented with a ruptured internal carotid artery blisterlike aneurysm treated with a single Pipeline Flex (Medtronic, Dublin, Ireland), complicated by aneurysm rupture postoperatively. This report perfectly exemplifies the challenges faced by vascular neurosurgeons in the treatment of blister aneurysms. Despite tremendous advances in microsurgical and endovascular techniques, blister aneurysms still lack a failsafe treatment option.

Current Status of the PulseRider in the Treatment of Bifurcation Aneurysms: A Systematic Review

BACKGROUNDnThe PulseRider is an innovative stent-like device designed for the treatment of intracranial bifurcation aneurysms. The aim of this study was to assess the current evidence on safety and effectiveness of the PulseRider.nnnMETHODSnA systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following databases were searched: PubMed, Ovid MEDLINE, and Scopus. The search strategy consisted of pulserider, bifurcation aneurysm, and endovascular in both AND and OR combinations. Studies included were original research articles in peer-reviewed journals. The manuscripts were thoroughly examined for study design, outcomes, and results.nnnRESULTSnThree studies were identified describing use of the PulseRider device in the treatment of 63 patients with 63 bifurcation aneurysms. We identified 2 multicenter case series and 1 single-arm clinical trial. The majority of aneurysms treated were located at the basilar tip (37, 58.7%). All devices were successfully deployed, and there were 5 intraoperative complications (7.9%), including 2 intraoperative aneurysm ruptures, 1 vessel dissection, and 2 thrombus formations. Immediate complete aneurysm occlusion was achieved in 61.9% (39/63) of cases and at the 6-month imaging follow-up, 66.7% (42/63) achieved complete aneurysm occlusion. One recanalization was reported in 1 of the multicenter case series within the 6-month follow-up.nnnCONCLUSIONSnThe PulseRider is safe and probably effective for the treatment of intracranial bifurcation aneurysms, sometimes not amenable for stent-assisted coiling. However, current evidence is limited to a small sample and short follow-up. In addition, the device has not been compared with other treatment modalities.

E-008 Endovascular recanalization of intracranial arterial stenosis in patients with medical failure

Introduction The optimal management of intracranial arterial stenosis is unclear in particular in patients who have failed medical management. We now report a multicenter experience of endovascular recanalization of intracranial artherosclerotic stenosis refractory to medical therapy. Methods Retrospective multicenter case series of consecutive endovascularly treated patients presenting with symptomatic (TIA or stroke) who have failed medical therapy. All of the patients were considered to be in the high-risk category with unstable symptomatic intracranial stenosis and progression or recurrence of their symptoms despite the best medical management who required endovascular intervention either with stenting and/or balloon angioplasty. Results Fifty patients presented with recurrent TIAs (n=26) or strokes (n=24) were treated in 5 stroke centers from 2011 to 2017. All patients underwent best medical management in the decision of the stroke neurologist and were enroll in this study only if they had recurrent or progression of symptoms despite their medical therapy. The majority of lesions were located in the M1 segment (15/50). There was one periprocedural vessel perforation resulting in patient death, one case of groin hematoma, one intraprocedure hemorrhage, and one periprocedural stroke. Twelve patients (24%) had restenosis on follow up imaging and 80% (33/41) of patients were symptom free at 90u2009day follow-up. Three patients had a stroke in the territory of the stenosis and 5 patients had recurrent TIAs. Conclusion Endovascular recanalization of unstable intracranial atherosclerotic stenosis who have failed medical therapy is feasible and safe. Disclosures P. Aguilar-Salinas: None. R. Hanel: 1; C; Microvention. 2; C; Medtronic; Stryker; Microvention. 4; C; Blockade Medical. E. Sauvageau: None. D. Lopes: 2; C; Microvention. A. Saied: None. T. Jovin: 2; C; Medtronic. 3; C; Blockade Medical; Silk Road Medical. A. Jadhav: None. L. Kaustubh: None. L. Brasiliense: None. T. Dumont: None. J. Cherian: None. P. Kan: None. A. Aghaebrahim: None.

Specifics of Treatment for Basilar Trunk Artery Aneurysms

Abstract The estimated prevalence of intracranial aneurysms (IAs) in the general population ranges between 2% and 4% based on the radiographic and autopsy studies. The aneurysms of the posterior circulation account for 15% of all IAs and have a higher risk of rupture compared with those located in the anterior circulation. The basilar trunk artery is the segment in between the vertebrobasilar junction up to the superior cerebellar artery and the aneurysms located in this segment are extremely rare, constituting less than 1% of all IAs. In this chapter, we discuss their anatomical features and explore the pathophysiological mechanisms contributing to these lesions. Current evidence regarding surgical and endovascular interventions are examined. Although there is no consensus regarding the optimal treatment for lesions at the basilar trunk, decision is made on a case-by-case basis with extrapolation and assumptions based on results from the treatment for other cerebral aneurysms.

Multicenter Study of Pipeline Flex for Intracranial Aneurysms

BACKGROUNDnThe Pipeline Flex (PED Flex; Medtronic, Dublin, Ireland) was designed to facilitate deployment and navigation compared to its previous iteration to reduce the rate of technical events and complications.nnnOBJECTIVEnTo assess the neurological morbidity and mortality rates of the PED Flex at 30 d.nnnMETHODSnInformation from 9 neurovascular centers was retrospectively obtained between July 2014 and March 2016. Data included patient/aneurysm characteristics, periprocedural events, clinical, and angiographic outcomes. Multivariate logistic regression was performed to determine predictors of unfavorable clinical outcome (modified Rankin Scale [mRS]xa0>xa02).nnnRESULTSnA total of 205 patients harboring 223 aneurysms were analyzed. The 30-d neurological morbidity and mortality rates were 1.9% (4/205) and 0.5% (1/205), respectively. The rate of intraprocedural events without neurological morbidity was 6.8% (14/205), consisting of intraprocedural ischemic events in 9 patients (4.5%) and hemorrhage in 5 (2.4%). Other technical events included difficulty capturing the delivery wire in 1 case (0.5%) and device migration after deployment in another case (0.5%). Favorable clinical outcome (mRS 0-2) was achieved in 186 patients (94.4%) at discharge and in 140 patients (94.5%) at 30 d. We did not find predictors of clinical outcomes on multivariate analysis.nnnCONCLUSIONnThe 30-d rates of neurological morbidity and mortality in this multicenter cohort using the PED Flex for the treatment of intracranial aneurysms were low, 1.9% (4/205) and 0.5% (1/205), respectively. In addition, technical events related to device deployment were also low, most likely due to the latest modifications in the delivery system.