The fate of cranial neuropathy after flow diversion for carotid aneurysms

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OBJECT

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.

ABBREVIATIONSCN = cranial nerve; PED = Pipeline Embolization Device.
Article Information

Contributor Notes

Correspondence Benjamin Brown, Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224. email: brown.benjamin1@mayo.edu.INCLUDE WHEN CITING Published online October 16, 2015; DOI: 10.3171/2015.4.JNS142790.Disclosure The authors report the following: Dr. Lopes: consultant for Covidien. Dr. Rawk: stock ownership in Blockade Medical. Dr. Ringer: consultant for Covidien, MicroVention, and Stryker. Dr. Arthur: consultant for Covidien, Codman, Stryker, MicroVention, Penumbra, and Sequent. Dr. Hoit: consultant for Covidien. Dr. Snyder: support of non-study-related clinical or research effort from Boston Scientific, Cordis, Endtex, Medtronic, Abbott Vascular, ev3, Toshiba, Micrus, Zimmer, EPI, Guidant, Kerberos and Primus; stock ownership in Boston Scientific, Access Closure, and Niagara Gore Medical; financial interest in Cordis, Endotex, Micrus, and EPI; and consultant for Medtronic, Abbott Vascular, ev3, Toshiba, Micrus, and Zimmer; and Primus. Dr. Siddiqui: stock ownership in Hotspur, Intratech Medical, StimSox, Valor Medical, Blockade Medical, Lazarus Effect, Pulsar Vascular, and Medina Medical; consultant for Codman & Shurtleff, Inc., Covidien Vascular Therapies, Guidepoint Global Consulting, Penumbra Inc., Stryker, Pulsar Vascular, MicroVention, Lazarus Effect, Blockade Medical, and Reverse Medical; speakers’ bureau for Codman & Shurtleff; advisory board of Codman & Shurtleff, Covidien Neurovascular, ICAVL, and Medina Medical; honoraria from Abbott Vascular and Codman & Shurtleff. Dr. Levy: ownership in Intratech Medical Ltd. and Blockade Medical LLC; National PI for SWIFT Prime Trials for Covidien and Carotid Training Sessions for Physicians for Abbott; and legal opinion as an expert witness for Renders Medical. Dr. Hopkins: consultant for Boston Scientific, Cordis, Abbott Vascular, Covidien; direct stock ownership in Boston Scientific, Valor Medical, Claret Medica, Inc., Augmenix, Endomation, Silk Road, Ostial, Apama, StimSox, Photolitec, ValnTx, Ellipse, Axria, NextPlain, and MedinaMed; research grant from Toshiba; speakers’ bureau for Abbott Vascular and Toshiba; honoraria from Cordis, Memorial HealthCare System, Complete Conf. Management, and Covidien; and board position for Claret Medical. Dr. Mocco: Consultant for Lazarus effect, Reverse, Pulsar, Edge Therapeutics, and Medina; and investor in Blockade Medical and Medina; and advisory board for Codman Neurovascular. Dr. Hanel: consultant for Covidien, Stryker, and Codman; stock ownership in Blockade; and scientific advisory board for Medina.

© AANS, except where prohibited by US copyright law.

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