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Pedro Lylyk, Angel Ferrario, Boris Pabón, Carlos Miranda, and Gustavo Doroszuk

Object. The authors report their experience with the use of the Neuroform Microdelivery System for intravascular reconstruction. They assess the technical feasibility of the system, the efficacy of the combined application of stent and detachable coils, and the follow-up findings.

Methods. Fifty patients found to harbor a complex wide-necked intracranial aneurysm were selected for the study. Different strategies were chosen and the performance and technical success of the device were evaluated. Stent placement was recorded as optimal or suboptimal with respect to the stent position. Clinical and angiographic follow-up examinations were obtained.

Forty-six patients with 48 intracranial aneurysms were treated, leading to a technical success rate of 92%. Forty-two lesions were located in the anterior circulation. In every case the dome/neck ratio was less than 2 and the mean aneurysm size in these patients was 8.8 mm. The most frequent clinical presentation was subarachnoid hemorrhage in 48% of cases. Stent placement was optimal in 81.2% of cases and suboptimal in 18.8%. In 31% of cases, the investigators encountered difficulties in placing the Neuroform stent. Clinical follow up was recorded in all patients and angiographic follow up was obtained in 63%. There were no cases of repeated hemorrhage. In a single case in which only the stent was implanted progressive thrombosis was identified during the follow-up period. The procedure-related morbidity and mortality rates were 8.6 and 2.1%, respectively.

Conclusions. On the basis of the results, the authors conclude that the Neuroform self-expanding stent is a flexible and useful device that can be readily and safely maneuvered through tortuous intracranial vessels, enabling the endovascular treatment of complex wide-necked aneurysms. Early in the authors' experience, stent delivery presented difficulties; however, a second generation of devices has resolved this limitation. Although the early results are promising, the long-term benefit of this technique has to be proved by angiographic and clinical follow-up examinations.

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Pedro Lylyk, José E. Cohen, Rosana Ceratto, Angel Ferrario, and Carlos Miranda

Object. The authors investigated the feasibility, safety, and short-term outcome of stent treatment for intracranial aneurysms, stenoses, and dissections.

Methods. One hundred twenty-three consecutive patients with intracranial saccular, dissecting, and fusiform aneurysms, atherosclerotic lesions, and dissections were selected for intracranial stent implantation with or without adjunctive coil placement. One hundred eleven patients (mean age 47 years, range 3–73 years) underwent stent treatment; 12 patients (9.8%) were not treated. These 111 patients were divided into four groups: in Group 1 there were 62 patients with saccular aneurysms; Group 2 included nine patients (10 lesions) with dissecting or fusiform aneurysms; in Group 3 there were 36 patients with symptomatic intracranial atheromatous stenoses of more than 50%; and Group 4 included four patients with symptomatic intracranial dissections. All patients underwent computerized tomography scanning and/or magnetic resonance imaging and cerebral digital subtraction angiography preoperatively. Of the 72 aneurysms in Groups 1 and 2, 59 (82%) were treated with combined endovascular stent implantation and endosaccular coil placement. In 67 aneurysms (93%) we achieved complete or nearly complete obliteration. All patients with arterial narrowing achieved residual stenoses of less than 30% postangioplasty. One patient required repeated angioplasty. The morbidity rate in the series was 10.9% and the mortality rate was 6.3%.

Conclusions. These findings indicate that stent treatment is feasible and seems to be an effective modality for arterial reconstruction. This versatile tool allows the treatment of a wide variety of challenging intracranial lesions.

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Pedro Lylyk, José E. Cohen, Rosana Ceratto, Angel Ferrario, and Carlos Miranda

Object. With the recent development and refinement of endovascular stents, the significant potential for these devices in the treatment of wide-necked dissecting and fusiform aneurysms has become apparent. In this article the authors report on the use of stents and coils to treat dissecting and fusiform vertebral artery (VA) aneurysms.

Methods. Eight consecutive patients harboring eight dissecting aneurysms and one fusiform aneurysm of the VA were succesfully treated using a procedure in which the authors inserted an intravascular stent and secondary endosaccular coils when needed. In all but one patient complete aneurysm occlusion was achieved, and in all cases there was no neurological complication. Follow-up angiography examinations were performed in all patients (mean duration of follow-up angiography review 13.1 months, range 3–42 months). The patients remained stable throughout the clinical follow-up period (mean 14.1 months, range 4–42 months). No rebleeding was recorded.

Conclusions. At present this combined approach represents a reliable and safe alternative for the treatment of VA dissecting aneurysms, especially in patients who cannot tolerate occlusion tests.

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Pedro Lylyk, Fernando Viñuela, Jacques E. Dion, Gary Duckwiler, Guido Guglielmi, Warwick Peacock, and Neil Martin

✓ From September, 1986, to March, 1990, the authors treated 28 children harboring a vein of Galen vascular malformation. Eleven (39.3%) of the patients were neonates, 13 (46.4%) were 1 to 2 years old, and four (14.3%) were more than 2 years old.

Fifteen patients (53.6%) presented with severe congestive heart failure, six (21.4%) had seizures, four (14.3%) had hydrocephalus, and three (10.7%) presented with intraventricular hemorrhage. Based on the Yaşargil classification of malformations, 10 lesions (35.7%) were Type I, seven (25%) were Type II, eight (28.6%) were Type III, and three (10.7%) were Type IV. In 11 patients (39.3%), a combined transfemoral, transarterial, and transvenous embolization of the vein of Galen malformation was performed. A pure transtorcular approach was utilized in eight patients (28.6%), and postembolization surgical clipping of arterial feeders was performed in two cases with intractable congestive heart failure.

Complete anatomical occlusion of the galenic malformation was achieved in 13 patients (46.4%). An immediate postembolization improvement in the patient's clinical status was obtained in 23 (82.1%) of 28 patients and a good long-term clinical outcome was seen in 17 patients (60.7%). Five deaths (17.9%) occurred in this series of 28 patients; three (10.7%) were related to a transtorcular embolization and two (7.1%) to the unchanged natural history of the disease.

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David F. Kallmes, Waleed Brinjikji, Saruhan Cekirge, David Fiorella, Ricardo A. Hanel, Pascal Jabbour, Demetrius Lopes, Pedro Lylyk, Cameron G. McDougall, and Adnan Siddiqui

OBJECTIVE

The authors performed a pooled analysis of 3 studies—IntrePED (International Retrospective Study of the Pipeline Embolization Device), PUFS (Pipeline for Uncoilable or Failed Aneurysms Study), and ASPIRe (Aneurysm Study of Pipeline in an Observational Registry)—in order to assess angiographic outcomes and clinical safety of the Pipeline embolization device (PED).

METHODS

IntrePED was a retrospective study, while PUFS and ASPIRe were prospective studies. For each patient included in these studies, the authors collected baseline demographic data, aneurysm characteristics, and procedural details. The primary outcomes for this combined analysis were clinical outcomes, including neurological morbidity and mortality and major ipsilateral intracranial hemorrhage and ischemic stroke. The secondary outcomes were angiographic occlusion rates, which were available for ASPIRe and PUFS only.

RESULTS

A total of 1092 patients with 1221 aneurysms were included across the 3 studies. The mean aneurysm size was 12.0 ± 7.8 mm and the mean neck size was 6.6 ± 4.8 mm. The major ipsilateral ischemic stroke rate was 3.7% (40/1091). The major ipsilateral intracranial hemorrhage rate was 2.0% (22/1091). The major neurological morbidity rate was 5.7% (62/1091). The neurological mortality rate was 3.3% (36/1091). The combined major morbidity and neurological mortality rate was 7.1% (78/1091). The complete occlusion rates were 75.0% at 180 days (111/148) and 85.5% at 1 year (94/110). The overall aneurysm retreatment rate was 3.0% (33/1091) at a mean follow-up time of 10.2 ± 10.8 months.

CONCLUSIONS

Endovascular treatment of intracranial aneurysms with the PED is safe and effective. Angiographic occlusion rates progressed with follow-up. Rates of stroke, hemorrhage, morbidity and mortality, and retreatment were low, especially given the fact that the aneurysms treated were generally large and wide necked.

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Fernando Viñuela, Jacques E. Dion, Gary Duckwiler, Neil A. Martin, Pedro Lylyk, Allan Fox, David Pelz, Charles G. Drake, John J. Girvin, and Gerard Debrun

✓ The authors describe their experience with 101 cerebral arteriovenous malformations (AVM's) treated by endovascular embolization followed by surgical removal. Fifty-three patients presented with intracranial hemorrhage and 35 had seizures. Based on the classification of Spetzler and Martin, two AVM's were Grade I, 13 were Grade II, 26 were Grade III, 43 were Grade IV, and 17 were Grade V, Fifty-six AVM's were in the right hemisphere, 28 were in the left hemisphere, 12 were in the corpus callosum, and five involved the cerebellum. In 50 cases, presurgical obliteration of 50% to 75% of the AVM nidus was achieved by embolization, and in 31 cases this percentage increased to between 75% and 90%. In 97 (96%) patients, complete surgical removal of the AVM was obtained.

Morbidity resulting from preoperative endovascular embolization was classified as mild in 3.9% of the cases, moderate in 6.9%, and severe in 1.98%. The death rate related to embolization was 0.9%. The immediate postsurgical morbidity was classified as mild in 5.9% of the cases, moderate in 10.8%, and severe in 5.9%. The overall long-term morbidity was mild in 5.9% of the cases, moderate in 6.9%, and severe in 1.98%. Two patients (1.98%) died due to intractable intraoperative hemorrhage and two (1.98%) as a result of postsurgical pulmonary complications.

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Guido Guglielmi, Fernando Viñuela, Gary Duckwiler, Jacques Dion, Pedro Lylyk, Alex Berenstein, Charles Strother, Virgil Graves, Van Halbach, Douglas Nichols, Nick Hopkins, Robert Ferguson, and Ivan Sepetka

✓ In a multicenter study, 120 patients with intracranial aneurysms presenting a high surgical risk were treated using electrolytically detachable coils and electrothrombosis via an endovascular approach. The results of treatment in patients with posterior fossa aneurysms (42 patients with 43 aneurysms) are presented. The most frequent clinical presentation was subarachnoid hemorrhage (24 cases). The clinical follow-up periods ranged from 1 week to 18 months. Complete aneurysm occlusion was obtained in 13 of 16 aneurysms with a small neck and in four of 26 wide-necked aneurysms. A 70% to 98% thrombosis of the aneurysm was achieved in 22 of 26 aneurysms with a wide neck and in three of 16 small-necked aneurysms. One aneurysm could not be treated due to a technical complication. Two cases required postprocedural surgical clipping of a residual aneurysm.

One patient (originally in Hunt and Hess Grade V) experienced procedural rupture of the aneurysm requiring an emergency parent artery occlusion. He eventually died 5 days later. Another patient (originally in Grade IV) had coil migration and posterior cerebral artery territory ischemia. A third patient developed a permanent neurological deficit (hemianopsia) after complete occlusion of a wide-necked basilar bifurcation aneurysm. One patient, harboring an inoperable giant basilar bifurcation aneurysm, died from aneurysm bleeding 18 months after partial occlusion.

Overall morbidity and mortality rates related to treatment were 4.8% (two cases) and 2.4% (one case), respectively (2.6% and 0% if considering only patients in Hunt and Hess Grades I, II, and III).

It is suggested that this technique is a viable alternative in the management of patients with posterior fossa aneurysms associated with high surgical risk. Longer angiographic and clinical follow-up study is necessary to determine the long-term efficacy of this recently developed endovascular occlusion technique. Close postoperative angiographic and clinical monitoring of patients with wide-necked subtotally occluded aneurysms is mandatory to check for potential aneurysmal recanalization, regrowth, and rupture.

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010