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José E. Cohen, Juan A. Abdallah, and Miguel Garrote

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Elad I. Levy, Philipp Taussky, Jose E. Cohen, and Peter Kan

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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, 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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José E. Cohen, Gustavo Rajz, Eyal Itshayek, Yigal Shoshan, Felix Umansky, and John M. Gomori

✓ Traumatic intracranial aneurysms are rare complications of closed and penetrating head injuries and may also be related to a variety of neurosurgical procedures. The primary goals in the treatment of patients harboring these lesions are early identification and intervention to prevent bleeding. Traumatic aneurysms are fragile, prone to rupture, and represent a challenging subset of vascular lesions for either surgery or endovascular therapy. Surgical approaches to aneurysms located at the pericallosal arteries are associated with higher rates of morbidity and mortality than approaches to other supratentorial aneurysms. Current endovascular treatment most often involves occlusion of the parent artery with the potential of added morbidity. The authors present their experience in the endovascular management of traumatic and iatrogenic aneurysms of the pericallosal artery achieved by primary coil embolization with parent vessel preservation. For patients harboring traumatic pericallosal aneurysms with favorable anatomical characteristics, in which the morbidity caused by parent vessel occlusion is not acceptable, endosaccular coil placement may be a valuable option.

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José E. Cohen, Shlomo Constantini, John M. Gomori, Mony Benifla, and Eyal Itshayek

The cone artery, or artery of Desproges-Gotteron, is sometimes seen arising from the internal iliac artery. The authors describe a case of a symptomatic perimedullary arteriovenous fistula (AVF) of the conus medullaris in an 8-year-old boy who presented with a protracted history of urinary difficulty and severe sudden-onset right lumbosciatic pain that evolved to severe paraparesis with compromise of the sphincter muscles. The spinal AVF, which was supplied by the cone artery and a thoracic radiculomedullary artery that joined at the fistula site in a large partially thrombosed varix, was completely occluded with Onyx liquid embolic. The patient's clinical condition improved rapidly after embolization. As shown in this patient, urgent endovascular embolization of spinal AVFs can be very rewarding, even in patients with severe neurological presentation. The artery of Desproges-Gotteron appears to be a rare arterial variation. To the authors' knowledge, this is the first pediatric case of a conal AVF supplied by this artery.

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Carlos Candanedo, Marrigje A. de Jong, Avner Michaeli, Samuel Moscovici, José E. Cohen, and Sergey Spektor

Hemifacial spasm (HFS) is a rare presentation of vestibular schwannoma. The authors present their experience with a 27-year-old woman who presented with normal hearing and HFS, which was the single neurological manifestation of an 18-mm vestibular schwannoma. In this challenging situation, the treatment goals were maximal tumor removal with preservation of hearing and facial nerve function and cure of the HFS. The authors achieved these goals, performing complete tumor removal via a retrosigmoid approach, assisted with neurophysiological monitoring and a 45°-angle QEVO endoscope. In the video, they explain the clinical, radiological, and surgical considerations and demonstrate the surgical technique.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID2099

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José E. Cohen, J. Moshe Gomori, Samuel Moscovici, Andrew H. Kaye, Yigal Shoshan, Sergey Spektor, and Ronen R. Leker

OBJECTIVE

Flow-diverter stents (FDSs) are not generally used for the management of acutely ruptured aneurysms with associated subarachnoid hemorrhage (SAH). Herein, the authors present their experience with FDSs in this scenario, focusing on the antiplatelet regimen, perioperative management, and outcome.

METHODS

The authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured aneurysms and associated SAH from July 2010 to September 2018 who had received an FDS implant as stand-alone treatment within 4 days after diagnosis. The protocol with the use of flow diversion in these patients includes a low threshold for placement of external ventricular drains before stenting, followed by the administration of aspirin and clopidogrel with platelet testing before stent implantation. With this approach, the risk of hemorrhage and stent-related thrombus formation is limited. Demographic, clinical, technical, and imaging data were analyzed.

RESULTS

Overall, 76 patients (61% females, mean age 42.8 ± 11.3 years) met the inclusion criteria. FDS implantation was performed a median of 2 days after diagnosis. On average, 1.05 devices were used per procedure. There was no procedural mortality directly attributed to the endovascular intervention. Procedural device-related clinical complications were recorded in a total of 6 cases (7.9%) and resulted in permanent neurological morbidity in 2 cases (2.6%). There was complete immediate aneurysm occlusion in 11 patients (14.5%), and persistent aneurysm filling was seen in 65 patients (85.5%). Despite this, no patient presented with rebleeding from the target aneurysm. There was an excellent clinical outcome in 62 patients (81.6%), who had a 90-day modified Rankin Scale score of 0–2. Among the 71 survivors, total or near-total occlusion was observed in 64/67 patients (95.5%) with a 3- to 6-month angiographic follow-up and in all cases evaluated at 12 months. Five patients (6.6%) died during follow-up for reasons unrelated to the procedure or new hemorrhage.

CONCLUSIONS

Flow diversion is an effective therapeutic strategy for the management of select acutely ruptured aneurysms. Despite low rates of immediate aneurysm occlusion after FDS implantation, the device exerts an important protective effect. The authors’ experience confirmed no aneurysm rerupture, high rates of delayed complete occlusion, and complication rates that compare favorably with the rates obtained using other techniques.

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José E. Cohen, J. Moshe Gomori, Samuel Moscovici, Andrew H. Kaye, Yigal Shoshan, Sergey Spektor, and Ronen R. Leker

OBJECTIVE

Flow-diverter stents (FDSs) are not generally used for the management of acutely ruptured aneurysms with associated subarachnoid hemorrhage (SAH). Herein, the authors present their experience with FDSs in this scenario, focusing on the antiplatelet regimen, perioperative management, and outcome.

METHODS

The authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured aneurysms and associated SAH from July 2010 to September 2018 who had received an FDS implant as stand-alone treatment within 4 days after diagnosis. The protocol with the use of flow diversion in these patients includes a low threshold for placement of external ventricular drains before stenting, followed by the administration of aspirin and clopidogrel with platelet testing before stent implantation. With this approach, the risk of hemorrhage and stent-related thrombus formation is limited. Demographic, clinical, technical, and imaging data were analyzed.

RESULTS

Overall, 76 patients (61% females, mean age 42.8 ± 11.3 years) met the inclusion criteria. FDS implantation was performed a median of 2 days after diagnosis. On average, 1.05 devices were used per procedure. There was no procedural mortality directly attributed to the endovascular intervention. Procedural device-related clinical complications were recorded in a total of 6 cases (7.9%) and resulted in permanent neurological morbidity in 2 cases (2.6%). There was complete immediate aneurysm occlusion in 11 patients (14.5%), and persistent aneurysm filling was seen in 65 patients (85.5%). Despite this, no patient presented with rebleeding from the target aneurysm. There was an excellent clinical outcome in 62 patients (81.6%), who had a 90-day modified Rankin Scale score of 0–2. Among the 71 survivors, total or near-total occlusion was observed in 64/67 patients (95.5%) with a 3- to 6-month angiographic follow-up and in all cases evaluated at 12 months. Five patients (6.6%) died during follow-up for reasons unrelated to the procedure or new hemorrhage.

CONCLUSIONS

Flow diversion is an effective therapeutic strategy for the management of select acutely ruptured aneurysms. Despite low rates of immediate aneurysm occlusion after FDS implantation, the device exerts an important protective effect. The authors’ experience confirmed no aneurysm rerupture, high rates of delayed complete occlusion, and complication rates that compare favorably with the rates obtained using other techniques.

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Peter E. Fecci, Ranjith Babu, D. Cory Adamson, and John H. Sampson