Michel Piotin

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.

Flow Diverters at and Beyond the Level of the Circle of Willis for the Treatment of Intracranial Aneurysms

Background and Purpose— Flow Diverters (FD) are a new emerging therapy for intracranial aneurysms. Initial reports focused on the treatment of proximally located aneurysms. We report our experience with FDs in the treatment of aneurysms at and beyond the circle of Willis. Methods— We treated 30 aneurysms at and beyond the circle of Willis with FDs (silk and pipeline). Aneurysms were treated with FDs alone in 73.3% (22/30) and with FDs and coils in 23.3% (7/30). One procedure was converted in parent vessel occlusion. Results— Thirty aneurysms (21/30, 70.0% saccular; 7/30, 23.3% fusiform; 2/30, 6.7% blister-like; sizes 1.2–19.6, mean 6.8 mm) were treated in 26 patients (17 women, 9 men; mean age, 49 years) during 27 procedures. Access site complication was noted in 3.7% (1/27). Reversible neurological complications were noted in 7.4% (2/27), permanent neurological complication in 3.7% (1/27). There was no mortality. No aneurysms bled or rebled after treatment. Aneurysms treated with FDs alone were significantly smaller than those treated with FDs and coils (5.7 and 10.0 mm, respectively; P=0.0174). Immediate angiographic occlusion was achieved in 18.2% (4/22) with FDs alone, in 0.0% (0/7) with FDs and coils. Twenty-four aneurysms (80.0%) had been followed (mean, 13 months). Fifteen of 19 aneurysms (78.9%) treated with FDs against 4 of 4 of aneurysms (100%) treated with FDs and coils were occluded. There was no angiographic recurrence of initially totally occluded aneurysms. Conclusions— Aneurysms at and beyond the circle of Willis are amenable to selective treatment with FDs.

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.

CT angiography, MR angiography and rotational digital subtraction angiography for volumetric assessment of intracranial aneurysms. An experimental study

The purpose of our experimental study was to assess the accuracy and precision of CT angiography (CTA), MR angiography (MRA) and rotational digital subtraction angiography (DSA) for measuring the volume of an in vitro aneurysm model. A rigid model of the anterior cerebral circulation harbouring an anterior communicating aneurysm was connected to a pulsatile circuit. It was studied using unenhanced 3D time-of-flight MRA, contrast-enhanced CTA and rotational DSA angiography. The source images were then postprocessed on dedicated workstations to calculate the volume of the aneurysm. CTA was more accurate than MRA (P=0.0019). Rotational DSA was more accurate than CTA, although the difference did not reach statistical significance (P=0.1605), and significantly more accurate than MRA (P<0.00001). CTA was more precise than MRA (P=0.12), although this did not reach statistical significance. Rotational DSA can be part of the diagnosis, treatment planning and support endovascular treatment of intracranial aneurysms. The emerging endovascular treatment techniques which consist of using liquid polymers as implants to exclude aneurysms from arterial circulation would certainly benefit from this precise measurement of the volume of aneurysms.

Effect of Endovascular Contact Aspiration vs Stent Retriever on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion: The ASTER Randomized Clinical Trial

Importance The benefits of endovascular revascularization using the contact aspiration technique vs the stent retriever technique in patients with acute ischemic stroke remain uncertain because of lack of evidence from randomized trials. Objective To compare efficacy and adverse events using the contact aspiration technique vs the standard stent retriever technique as a first-line endovascular treatment for successful revascularization among patients with acute ischemic stroke and large vessel occlusion. Design, Setting, and Participants The Contact Aspiration vs Stent Retriever for Successful Revascularization (ASTER) study was a randomized, open-label, blinded end-point clinical trial conducted in 8 comprehensive stroke centers in France (October 2015-October 2016). Patients who presented with acute ischemic stroke and a large vessel occlusion in the anterior circulation within 6 hours of symptom onset were included. Interventions Patients were randomly assigned to first-line contact aspiration (n = 192) or first-line stent retriever (n = 189) immediately prior to mechanical thrombectomy. Main Outcomes and Measures The primary outcome was the proportion of patients with successful revascularization defined as a modified Thrombolysis in Cerebral Infarction score of 2b or 3 at the end of all endovascular procedures. Secondary outcomes included degree of disability assessed by overall distribution of the modified Rankin Scale (mRS) score at 90 days, change in National Institutes of Health Stroke Scale (NIHSS) score at 24 hours, all-cause mortality at 90 days, and procedure-related serious adverse events. Results Among 381 patients randomized (mean age, 69.9 years; 174 women [45.7%]), 363 (95.3%) completed the trial. Median time from symptom onset to arterial puncture was 227 minutes (interquartile range, 180-280 minutes). For the primary outcome, the proportion of patients with successful revascularization was 85.4% (n = 164) in the contact aspiration group vs 83.1% (n = 157) in the stent retriever group (odds ratio, 1.20 [95% CI, 0.68-2.10]; P = .53; difference, 2.4% [95% CI, −5.4% to 9.7%]). For the clinical efficacy outcomes (change in NIHSS score at 24 hours, mRS score at 90 days) and adverse events, there were no significant differences between groups. Conclusions and Relevance Among patients with ischemic stroke in the anterior circulation undergoing thrombectomy, first-line thrombectomy with contact aspiration compared with stent retriever did not result in an increased successful revascularization rate at the end of the procedure. Trial Registration clinicaltrials.gov Identifier: NCT02523261

“Y” and “X” Stent-Assisted Coiling of Complex and Wide-Neck Intracranial Bifurcation Aneurysms

BACKGROUND AND PURPOSE: Stent-assisted coiling with two stents has been described in some series for the treatment of complex and wide-neck bifurcation aneurysms. Our aim was to report our experience of a stent-assisted coiling technique with double stents in “Y” and “X” configurations, with emphasis on safety, feasibility, and efficacy. MATERIALS AND METHODS: Clinical and angiographic outcomes of patients for whom the strategic therapeutic option was the stent-assisted coiling technique in a Y or X configuration for neck scaffolding from June 2006 to June 2013 were retrospectively analyzed. RESULTS: One hundred five aneurysms in 97 patients were treated during 100 consecutive procedures. There were 54.2% (57/105) MCA, 28.6% (30/105) anterior communicating artery, 16.2% (17/105) basilar tip, and 1.0% (1/105) ICA termination aneurysms. A Y stent placement was used to treat 87 aneurysms in 85 procedures; an X stent placement was used to treat 7 aneurysms in 6 procedures, while 9 procedures failed for 11 aneurysms. There were 10.0% (10/100) procedure-related permanent neurologic deficits and 1.0% (1/100) death. The immediate angiographic controls showed a complete occlusion in 47.6% (50/105) of the aneurysms and a partial (neck or sac remnant) occlusion in 52.4% (55/105). To date, 81.0% (85/105) of the aneurysms have been followed up (mean, 17 months) with angiography, disclosing a recanalization in 5.9% (5/85) and an improvement in 42.4% (36/85). At discharge and follow-up, the mRS score was 0 in 83.5% (81/97) of patients, 1 in 4.1% (4/97), 2 in 3.1% (3/97), 3 in 4.1% (4/97), 4 in 3.1% (3/97), and 6 in 2.1% (2/97). CONCLUSIONS: Y and X stent-assisted coiling of complex and wide-neck intracranial bifurcation aneurysms is an effective technique.

A Direct Aspiration, First Pass Technique (ADAPT) versus Stent Retrievers for Acute Stroke Therapy: An Observational Comparative Study

BACKGROUND AND PURPOSE: Mechanical thrombectomy with stent retrievers is now the standard therapy for selected patients with ischemic stroke. The technique of A Direct Aspiration, First Pass Technique for the Endovascular Treatment of Stroke (ADAPT) appears promising with a high rate of recanalization. We compared ADAPT versus stent retrievers (the Solitaire device) for efficacy and safety as a front-line endovascular procedure. MATERIALS AND METHODS: We analyzed 243 consecutive patients with large intracranial artery occlusions of the anterior circulation, treated within 6 hours with mechanical thrombectomy by either ADAPT or the Solitaire stent. Th primary outcome was complete recanalization (modified TICI ≥ 2b); secondary outcomes included complication rates and procedural and clinical outcomes. RESULTS: From November 2012 to June 2014, 119 patients were treated with stent retriever (Solitaire FR) and 124 by using the ADAPT with Penumbra reperfusion catheters. The median baseline NIHSS score was the same for both groups (Solitaire, 17 [interquartile range, 11–21] versus ADAPT, 17 [interquartile range, 12–21]). Time from groin puncture to recanalization (Solitaire, 50 minutes [range, 25–80 minutes] versus ADAPT, 45 minutes [range, 27–70 minutes], P = .42) did not differ significantly. However, compared with the Solitaire group, patients treated with ADAPT achieved higher final recanalization rates (82.3% versus 68.9%; adjusted relative risk, 1.18; 95% CI, 1.02–1.37; P = .022), though differences in clinical outcomes between the cohorts were not significant. Use of an adjunctive device was more frequent in the ADAPT group (45.2% versus 13.5%, P < .0001). The rate of embolization in new territories or symptomatic hemorrhage did not differ significantly between the 2 groups. CONCLUSIONS: Front-line ADAPT achieved higher recanalization rates than the Solitaire device. Further randomized controlled trials are warranted to define the best strategy for mechanical thrombectomy.

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.

Hemorrhagic Complications after Endovascular Treatment of Cerebral Arteriovenous Malformations

BACKGROUND AND PURPOSE: Intracranial hemorrhage is the most severe complication of brain arteriovenous malformation treatment. We report our rate of hemorrhagic complications after endovascular treatment and analyze the clinical significance and potential mechanisms, with emphasis on cases of delayed hemorrhage after uneventful embolization. MATERIALS AND METHODS: During a 10-year period, 846 embolization procedures were performed in 408 patients with brain AVMs. Any cases of hemorrhagic complications were identified and divided into those related or unrelated to a periprocedural arterial tear (during catheter navigation or catheter retrieval). We analyzed the following variables: sex, age, hemorrhagic presentation, Spetzler-Martin grade, size of the AVM, number of embolized pedicles, microcatheter used, type and volume of liquid embolic agent injected, and the presence of a premature venous occlusion. Univariate and multivariate multiple regression analyses were performed to identify risk factors for hemorrhagic complications. RESULTS: A hemorrhagic complication occurred in 92 (11%) procedures. Forty-four (48%) complications were related to a periprocedural arterial perforation, and 48 (52%) were not. Hemorrhagic complications unrelated to an arterial perforation were located more commonly in the cerebral parenchyma, caused more neurologic deficits, and were associated with worse prognosis than those in the arterial perforation group. Only premature venous occlusion was identified as an independent predictor of hemorrhagic complication in the nonperforation group. Premature venous occlusion was significantly related to the ratio of Onyx volume to nidus diameter. CONCLUSIONS: Higher injected volume of embolic agent and deposition on the venous outflow before complete occlusion of the AVM may account for severe hemorrhagic complications.