Felipe C. Albuquerque, David J. Fiorella, Patrick P. Han, Vivek R. Deshmukh, Louis J. Kim and Cameron G. Mcdougall
Intracranial vertebral artery (VA) dissecting aneurysms often present with severe subarachnoid hemorrhage (SAH) and dramatic neurological injury. The authors reviewed the management of 23 cases in an effort to evaluate treatment efficacy and outcomes.
The records of 23 patients who underwent endovascular treatment were reviewed to determine symptoms, type of therapy, complications, and clinical outcomes. All patients were evaluated using records kept in a prospectively maintained database.
Ten men and 13 women (age range 35–72 years; mean age 49 years) were treated over an 8-year period. Twelve patients presented with poor-grade SAH, five with good-grade SAH, three with headache, and two with stroke. The other patient's aneurysm was discovered incidentally. Treatment included coil occlusion of the artery at the aneurysm in 21 patients and stent-assisted coil placement in two. Parent artery sacrifice was successful in all cases, whereas both patients treated with stent-assisted coil insertion suffered recurrences. No patient sustained permanent complications as a result of treatment. Two patients died due to the severity of their original SAH. Findings were normal in 14 patients on follow-up review (including five of the 12 presenting with poor-grade SAH), five had fixed neurological deficits but were able to care for themselves, and one was permanently disabled.
Despite their often aggressive neurological presentation, intracranial VA dissecting aneurysms can be managed safely with coil occlusion of the lesion and/or parent artery. Even patients presenting in poor neurological condition may improve dramatically.
Jeffrey D. Klopfenstein, Robert F. Spetzler, Louis J. Kim, Iman Feiz-Erfan, Patrick P. Han, Joseph M. Zabramski, Randall W. Porter, Felipe C. Albuquerque, Cameron G. McDougall and David J. Fiorella
Whether routine intraoperative angiography is necessary for cerebral aneurysm surgery is currently under debate. In this study the authors prospectively assessed the cerebrovascular surgeon's accuracy in predicting the need for intraoperative angiography.
Between January 2002 and January 2003, 200 consecutive patients (141 female and 59 male patients, mean age 52.8 years) with 235 aneurysms underwent routine intraoperative angiography. Before the operation, the surgeons indicated whether they believed that intraoperative angiography was necessary. Their responses were recorded as “intraoperative angiography necessary” or “intraoperative angiography unnecessary.” Regardless of the response, all patients underwent intraoperative angiography after the aneurysm had been clipped. Changes in treatment resulting from intraoperative angiography were compared with surgeons' preoperative predictions of the need for intraoperative angiography.
Intraoperative angiography was predicted to be necessary in 41 cases (20%) and unnecessary in 159 cases (80%). Its use altered treatment in 14 patients. Seven of these patients were among the group in which intraoperative angiography was deemed necessary and seven were in the group in which it was considered unnecessary. In the latter group, two patients had residual aneurysms, three had parent vessel occlusion, and two had previously undiagnosed aneurysms. Only one patient (0.5%) sustained a major intraoperative complication attributed to angiography.
Given the frequency of significant disease that remains undetected if intraoperative angiography is used on a selective basis and the low complication rate associated with the procedure, the use of intraoperative angiography should be considered in the majority of aneurysm cases.
Daniel H. Sahlein, Mohammad Fouladvand, Tibor Becske, Isil Saatci, Cameron G. McDougall, István Szikora, Giuseppe Lanzino, Christopher J. Moran, Henry H. Woo, Demetrius K. Lopes, Aaron L. Berez, Daniel J. Cher, Adnan H. Siddiqui, Elad I. Levy, Felipe C. Albuquerque, David J. Fiorella, Zsolt Berentei, Miklos Marosfoi, Saruhan H. Cekirge, David F. Kallmes and Peter K. Nelson
Neuroophthalmological morbidity is commonly associated with large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms. The authors sought to evaluate the neuroophthalmological outcomes after treatment of these aneurysms with the Pipeline Embolization Device (PED).
The Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial was an international, multicenter prospective trial evaluating the safety and efficacy of the PED. All patients underwent complete neuroophthalmological examinations both before the PED procedure and at a 6-month follow-up. All examinations were performed for the purpose of this study and according to study criteria.
In total, 108 patients were treated in the PUFS trial, 98 of whom had complete neuroophthalmological follow-up. Of the patients with complete follow-up, 39 (40%) presented with a neuroophthalmological baseline deficit that was presumed to be attributable to the aneurysm, and patients with these baseline deficits had significantly larger aneurysms. In 25 of these patients (64%), the baseline deficit showed at least some improvement 6 months after PED treatment, whereas in 1 patient (2.6%), the deficits only worsened. In 5 patients (5%), new deficits had developed at the 6-month follow-up, while in another 6 patients (6%), deficits that were not originally assumed to be related to the aneurysm had improved by that time. A history of diabetes was associated with failure of the baseline deficits to improve after the treatment. The aneurysm maximum diameter was significantly larger in patients with a new deficit or a worse baseline deficit at 6 months postprocedure.
Patients treated with the PED for large and giant ICA aneurysms had excellent neuroophthalmological outcomes 6 months after the procedure, with deficits improving in most of the patients, very few deficits worsening, and few new deficits developing.
Tibor Becske, Matthew B. Potts, Maksim Shapiro, David F. Kallmes, Waleed Brinjikji, Isil Saatci, Cameron G. McDougall, István Szikora, Giuseppe Lanzino, Christopher J. Moran, Henry H. Woo, Demetrius K. Lopes, Aaron L. Berez, Daniel J. Cher, Adnan H. Siddiqui, Elad I. Levy, Felipe C. Albuquerque, David J. Fiorella, Zsolt Berentei, Miklós Marosföi, Saruhan H. Cekirge and Peter K. Nelson
The long-term effectiveness of endovascular treatment of large and giant wide-neck aneurysms using traditional endovascular techniques has been disappointing, with high recanalization and re-treatment rates. Flow diversion with the Pipeline Embolization Device (PED) has been recently used as a stand-alone therapy for complex aneurysms, showing significant improvement in effectiveness while demonstrating a similar safety profile to stent-supported coil treatment. However, relatively little is known about its long-term safety and effectiveness. Here the authors report on the 3-year safety and effectiveness of flow diversion with the PED in a prospective cohort of patients with large and giant internal carotid artery aneurysms enrolled in the Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial.
The PUFS trial is a prospective study of 107 patients with 109 aneurysms treated with the PED. Primary effectiveness and safety end points were demonstrated based on independently monitored 180-day clinical and angiographic data. Patients were enrolled in a long-term follow-up protocol including 1-, 3-, and 5-year clinical and imaging follow-up. In this paper, the authors report the midstudy (3-year) effectiveness and safety data.
At 3 years posttreatment, 74 subjects with 76 aneurysms underwent catheter angiography as required per protocol. Overall, complete angiographic aneurysm occlusion was observed in 71 of these 76 aneurysms (93.4% cure rate). Five aneurysms were re-treated, using either coils or additional PEDs, for failure to occlude, and 3 of these 5 were cured by the 3-year follow-up. Angiographic cure with one or two treatments of Pipeline embolization alone was therefore achieved in 92.1%. No recanalization of a previously completely occluded aneurysm was noted on the 3-year angiograms. There were 3 (2.6%) delayed device- or aneurysm-related serious adverse events, none of which led to permanent neurological sequelae. No major or minor late-onset hemorrhagic or ischemic cerebrovascular events or neurological deaths were observed in the 6-month through 3-year posttreatment period. Among 103 surviving patients, 85 underwent functional outcome assessment in which modified Rankin Scale scores of 0–1 were demonstrated in 80 subjects.
Pipeline embolization is safe and effective in the treatment of complex large and giant aneurysms of the intracranial internal carotid artery. Unlike more traditional endovascular treatments, flow diversion results in progressive vascular remodeling that leads to complete aneurysm obliteration over longer-term follow-up without delayed aneurysm recanalization and/or growth.
Clinical trial registration no.: NCT00777088 (clinicaltrials.gov)
Sabareesh K. Natarajan, Paresh Dandona, Yuval Karmon, Albert J. Yoo, Junaid S. Kalia, Qing Hao, Daniel P. Hsu, L. Nelson Hopkins, David J. Fiorella, Bernard R. Bendok, Thanh N. Nguyen, Marilyn M. Rymer, Ashish Nanda, David S. Liebeskind, Osama O. Zaidat, Raul G. Nogueira, Adnan H. Siddiqui and Elad I. Levy
The authors evaluated the prognostic significance of blood glucose level at admission (BGA) and change in blood glucose at 48 hours from the baseline value (CG48) in nondiabetic and diabetic patients before and after endovascular therapy for acute ischemic stroke (AIS).
The BGA and CG48 data were analyzed in 614 patients with AIS who received endovascular therapy at 7 US centers between 2006 and 2009. Data reviewed included demographics, stroke risk factors, diabetic status, National Institutes of Health Stroke Scale (NIHSS) score at presentation, recanalization grade, intracranial hemorrhage (ICH) rate, and 90-day outcomes (mortality rate and modified Rankin Scale score of 3–6 [defined as poor outcome]). Variables with p values < 0.2 in univariate analysis were included in a binary logistic regression model for independent predictors of 90-day outcomes.
The mean patient age was 67.3 years, the median NIHSS score was 16, and 27% of patients had diabetes. In nondiabetic patients, BGA ≥ 116 mg/dl (≥ 6.4 mmol/L) and failure of glucose level to drop > 30 mg/dl (> 1.7 mmol/L) from the admission value were both significant predictors of 90-day poor outcome and death (p < 0.001). In patients with diabetes, BGA ≥ 116 mg/dl (≥ 6.4 mmol/L) was an independent predictor of poor outcome (p = 0.001). The CG48 was not a predictor of outcome in diabetic patients. A simplified 6-point scale including BGA, Thrombolysis in Myocardial Infarction (TIMI) Grade 2–3 Reperfusion, Age, presentation NIHSS score, CG48, and symptomatic ICH (BRANCH) corresponded with poor outcomes at 90 days; the area under the curve value was > 0.79.
Failure of blood glucose values to decrease in the first 48 hours after AIS intervention correlated with poor 90-day outcomes in nondiabetic patients. The BRANCH scale shows promise as a simple prognostication tool after endovascular therapy for AIS, and it merits prospective validation.
J Mocco, Kenneth V. Snyder, Felipe C. Albuquerque, Bernard R. Bendok, Alan S. Boulos, Jeffrey S. Carpenter, David J. Fiorella, Brian L. Hoh, Jay U. Howington, Brian T. Jankowitz, Kenneth M. Liebma N, Ansaar T. Rai, Rafael Rodriguez-Mercado, Adnan H. Siddiqui, Erol Veznedaroglu, L. Nelson Hopkins and Elad I. Levy
The development of self-expanding stents dedicated to intracranial use has significantly widened the applicability of endovascular therapy to many intracranial aneurysms that would otherwise have been untreatable by endovascular techniques. Recent Food and Drug Administration approval of the Enterprise Vascular Reconstruction Device and Delivery System (Cordis) has added a new option for self-expanding stent-assisted intracranial aneurysm coiling.
The authors established a collaborative registry across multiple institutions to rapidly provide largevolume results regarding initial experience in using the Enterprise in real-world practice. Ten institutions (University at Buffalo, Thomas Jefferson University, University of Florida, Cleveland Clinic, Northwestern University, West Virginia University, University of Puerto Rico, Albany Medical Center Hospital, the Neurological Institute of Savannah, and the Barrow Neurological Institute) have provided consecutive data regarding their initial experience with the Enterprise.
In total, 141 patients (119 women) with 142 aneurysms underwent 143 attempted stent deployments. The use of Enterprise assistance with aneurysm coiling was associated with a 76% rate of ≥ 90% occlusion. An inability to navigate or deploy the stent was experienced in 3% of cases, as well as a 2% occurrence of inaccurate deployment. Procedural data demonstrated a 6% temporary morbidity, 2.8% permanent morbidity, and 2% mortality (0.8% unruptured, 12% ruptured).
The authors report initial results of the largest series to date in using the Enterprise for intracranial aneurysm treatment. The Enterprise is associated with a high rate of successful navigation and low occurrence of inaccurate stent deployment. The overall morbidity and mortality rates were low; however, caution should be exercised when considering Enterprise deployment in patients with subarachnoid hemorrhage as the authors' experience demonstrated a high rate of associated hemorrhagic complications leading to death.