Pedro Aguilar-Salinas

Treatment of complex anterior cerebral artery aneurysms with Pipeline flow diversion: mid-term results

Background The off-label use of flow diverters in the treatment of distal aneurysms continues to be debated. Objective To report our multicenter experience in the treatment of complex anterior cerebral artery aneurysms with the Pipeline embolization device (PED). Methods The neurointerventional databases of the four participating institutions were retrospectively reviewed for aneurysms treated with PED between October 2011 and January of 2016. All patients treated for anterior cerebral artery aneurysms were included in the analysis. Clinical presentation, location, type, vessel size, procedural complications, clinical and imaging follow-up were included in the analysis. Results Twenty patients (13 female) with 20 aneurysms met the inclusion criteria in our study. Fifteen aneurysms were classified as saccular and five as fusiform (mean size 7.3 mm). Thirteen aneurysms were located in the anterior communicating region (ACOM or A1/2 junction), six were A2-pericallosal, and one was located in the A1 segment. Six patients had presented previously with subarachnoid hemorrhage and had their aneurysms initially clipped or coiled. There was one minor event (a small caudate infarct) and one major event (intraparenchymal hemorrhage). Sixteen of the 20 patients had angiographic follow-up (mean 10 months). Eleven aneurysms were completely occluded, one had residual neck, and four had residual aneurysm filling. Conclusions The treatment of complex anterior cerebral artery aneurysms with the PED as an alternative for patients who are not good candidates for conventional methods is technically feasible and safe. Mid-term results are promising but larger series with long-term follow-up are required to assess its effectiveness.

The fate of cranial neuropathy after flow diversion for carotid aneurysms.

OBJECTIVE The authors sought to determine whether flow diversion with the Pipeline Embolization Device (PED) can approximate microsurgical decompression in restoring function after cranial neuropathy following carotid artery aneurysms. METHODS This multiinstitutional retrospective study involved 45 patients treated with PED across the United States. All patients included presented between November 2009 and October 2013 with cranial neuropathy (cranial nerves [CNs] II, III, IV, and VI) due to intracranial aneurysm. Outcome analysis included clinical and procedural variables at the time of treatment as well as at the latest clinical and radiographic follow-up. RESULTS Twenty-six aneurysms (57.8%) were located in the cavernous segment, while 6 (13.3%) were in the clinoid segment, and 13 (28.9%) were in the ophthalmic segment of the internal carotid artery. The average aneurysm size was 18.6 mm (range 4-35 mm), and the average number of flow diverters placed per patient was 1.2. Thirty-eight patients had available information regarding duration of cranial neuropathy prior to treatment. Eleven patients (28.9%) were treated within 1 month of symptom onset, while 27 (71.1%) were treated after 1 month of symptoms. The overall rate of cranial neuropathy improvement for all patients was 66.7%. The CN deficits resolved in 19 patients (42.2%), improved in 11 (24.4%), were unchanged in 14 (31.1%), and worsened in 1 (2.2%). Overtime, the rate of cranial neuropathy improvement was 33.3% (15/45), 68.8% (22/32), and 81.0% (17/21) at less than 6, 6, and 12 months, respectively. At last follow-up, 60% of patients in the isolated CN II group had improvement, while in the CN III, IV, or VI group, 85.7% had improved. Moreover, 100% (11/11) of patients experienced improvement if they were treated within 1 month of symptom onset, whereas 44.4% (12/27) experienced improvement if they treated after 1 month of symptom onset; 70.4% (19/27) of those with partial deficits improved compared with 30% (3/10) of those with complete deficits. CONCLUSIONS Cranial neuropathy caused by cerebral aneurysm responds similarly when the aneurysm is treated with the PED compared with open surgery and coil embolization. Lower morbidity and higher occlusion rates obtained with the PED may suggest it as treatment of choice for some of these lesions. Time to treatment is an important consideration regardless of treatment modality.

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.

Treatment of blood blister aneurysms of the internal carotid artery with flow diversion

Background Blood blister aneurysms (BBA) are a rare subset of intracranial aneurysms that represent a therapeutic challenge from both a surgical and endovascular perspective. Objective To report multicenter experience with flow diversion exclusively for BBA, located at non-branching segments along the anteromedial wall of the supraclinoidal internal carotid artery (ICA). Methods Consecutive cases of BBA located at non-branching segments along the anteromedial wall of the supraclinoidal ICA treated with flow diversion were included in the final analysis. Results 49 patients with 51 BBA of the ICA treated with devices to achieve the flow diversion effect were identified. 43 patients with 45 BBA of the ICA were treated with the pipeline embolization device and were included in the final analysis. Angiographic follow-up data were available for 30 patients (32 aneurysms in total); 87.5% of aneurysms (28/32) showed complete obliteration, 9.4% (3/32) showed reduced filling, and 3.1% (1/32) persistent filling. There was no difference between the size of aneurysm (≤2 mm vs >2 mm) or the use of adjunct coiling and complete occlusion of the aneurysm on follow-up (P=0.354 and P=0.865, respectively). Clinical follow-up data were available for 38 of 43 patients. 68% of patients (26/38) had a good clinical outcome (modified Rankin scale score of 0–2) at 3 months. There were 7 (16%) immediate procedural and 2 (5%) delayed complications, with 1 case of fatal delayed re-rupture after the initial treatment. Conclusions Our data support the use of a flow diversion technique as a safe and effective therapeutic modality for BBA of the supraclinoid ICA.

The role of ICP monitoring in meningitis

Intracranial pressure (ICP) monitoring has been widely accepted in the management of traumatic brain injury. However, its use in other pathologies that affect ICP has not been advocated as strongly, especially in CNS infections. Despite the most aggressive and novel antimicrobial therapies for meningitis, the mortality rate associated with this disease is far from satisfactory. Although intracranial hypertension and subsequent death have long been known to complicate meningitis, no specific guidelines targeting ICP monitoring are available. A review of the literature was performed to understand the pathophysiology of elevated ICP in meningitis, diagnostic challenges, and clinical outcomes in the use of ICP monitoring.

Carotid Stenosis: Utility of Diagnostic Angiography

OBJECTIVE Carotid artery stenosis is frequently diagnosed through screening tests with noninvasive imaging. Because of differences noted between the various modalities, we sought to investigate our experience comparing noninvasive imaging (ultrasound, computed tomography angiography, magnetic resonance angiography) with invasive imaging (digital subtraction angiography). METHODS In a multicenter retrospective analysis, 249 carotid vessels were reviewed based on angiography with the associated noninvasive imaging. RESULTS Overall, medical or surgical decision management was changed in 43% (107/243) of cases investigated with digital subtraction angiography owing to a discrepancy between the measured percentage stenosis. In patients with potentially treatable carotid stenosis, angiography revealed nonsignificant stenosis 25.7% of the time. CONCLUSIONS Angiography should be considered the confirmatory test for degree of stenosis in certain patients before definitive surgical treatment.

Pipeline Embolization Device Flow Diversion for a Dissecting Ruptured Posterior Cerebral Artery Aneurysm in a Pediatric Patient

BACKGROUND Intracranial aneurysms (IAs) are rare in the pediatric population and are usually considered difficult to treat with traditional microsurgery owing to their complex morphology. Endovascular techniques have become the standard option for treating IAs in adults. More recently, flow diverters, such as the Pipeline embolization device (PED), are being widely adopted for unruptured IAs, with proven safety and efficacy in adults; however, their use in the pediatric population is not well defined. Here we report a pediatric patient with a ruptured posterior cerebral artery (PCA) aneurysm successfully treated with a PED, and provide a review of the literature on the current status of PED use in this subset of patients. CASE DESCRIPTION A previously healthy 4-year old boy presented to the emergency department with a subarachnoid hemorrhage. Magnetic resonance angiography (MRA) suggested a ruptured dissecting aneurysm in the right PCA. After discussing treatment options with the childs parents, off-label use of the PED device was chosen. A single PED device was successfully deployed within 24 hours of onset. At a 6-month follow-up, the patient was fully recovered, with a modified Rankin Scale score of 0, and MRA showed complete occlusion of the aneurysm and patency of the parent vessel. CONCLUSIONS Even though the PED has not received Food and Drug Administration approval to treat IAs in children, the literature reports favorable outcomes with this application. Thus, the PED may be a feasible option for treating challenging cases occurring more frequently in the pediatric population. Further studies in pediatric populations are needed to determine whether this technology is a viable and durable option for treating aneurysms in children.

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.

Three-dimensional printing and neuroendovascular simulation for the treatment of a pediatric intracranial aneurysm: case report

The use of simulators has been described in a variety of fields as a training tool to gain technical skills through repeating and rehearsing procedures in a safe environment. In cerebrovascular surgery, simulation of skull base approaches has been used for decades. The use of simulation in neurointervention to acquire and enhance skills before treating a patient is a newer concept, but its utilization has been limited due to the lack of good models and deficient haptics. The advent of 3D printing technology and the development of new training models has changed this landscape. The prevalence of aneurysms in the pediatric population is much lower than in adults, and concepts and tools sometimes have to be adapted from one population to another. Neuroendovascular rehearsal is a valid strategy for the treatment of complex aneurysms, especially for the pediatric population. The authors present the case of an 8-year-old boy with a fusiform intracranial aneurysm and documented progressive growth, who was successfully treated after the authors rehearsed the placement of a flow diverter using a patient-specific 3D-printed replicator system model.

Wide-neck bifurcation aneurysms of the middle cerebral artery and basilar apex treated by endovascular techniques: a multicentre, core lab adjudicated study evaluating safety and durability of occlusion (BRANCH)

Background and purpose BRANCH (wide-neck bifurcation aneurysms of the middle cerebral artery and basilar apex treated by endovascular techniques) is a multicentre, retrospective study comparing core lab evaluation of angiographic outcomes with self-reported outcomes. Materials and methods Consecutive patients were enrolled from 10 US centres, aged between 18 and 85 with unruptured wide-neck middle cerebral artery (MCA) or basilar apex aneurysms treated endovascularly. Patient demographics, aneurysm morphology, procedural information, mortality and morbidity data and core lab and self-reported modified Raymond Roy (RR) outcomes were obtained. Results 115 patients met inclusion criteria. Intervention-related mortality and significant morbidity rates were 1.7% (2/115) and 5.8% (6/103) respectively. Core lab adjudicated RR1 and 2 occlusion rates at follow-up were 30.6% and 32.4% respectively. The retreatment rate within the follow-up window was 10/115 (8.7%) and in stent stenosis at follow-up was 5/63 (7.9%). Self-reporting shows a statistically significant direction to angiographic RR one outcomes at follow-up compared with core lab evaluation, with OR 1.75 (95% CI 1.08 to 2.83). Conclusion Endovascular treatment of wide-neck MCA and basilar apex aneurysms resulted in a core lab adjudicated RR1 occlusion rate of 30.6%. Self-reported results at follow-up favour better angiographic outcomes, with OR 1.75 (95% CI 1.08 to 2.83). These data demonstrate the need for novel endovascular devices specifically designed to treat complex intracranial aneurysms, as well as the importance of core lab adjudication in assessing outcomes in such a trial.