Utility of flow diverters in treatment of acutely ruptured uncoilable aneurysms of the posterior circulation of the brain

PurposeAim of this study is to evaluate safety and efficacy of flow diverters (FDs) in treatment of acutely ruptured posterior circulation aneurysmsMaterials and methodsDatabases of three participating institutions were retrospectively scanned for patients in whom FD placement was attempted for treatment of acutely ruptured vertebrobasilar aneurysms. An interval of 14 days or fewer between the latest ictus and treatment was used as inclusion criterion. Patients with dolichoectasia of vertebrobasilar arteries were excluded. If necessary, adjunctive techniques including coiling or stenting were utilized. Clinical outcomes were graded using mWFNS (modified World Federation of Neurosurgical Societies Scale) and mRS (modified Rankin Scale). Aneurysmal occlusion was defined as Raymond-Roy Class 1. Spearman's (rho) test was used to assess the correlation between variables. Univariate and multivariate logistic regression were used to assess outcomes.Results31 patients (25 women, mean age: 52.7 +/- 15.2) harboring 32 aneurysms (16 non-saccular, mean size: 11.4 +/- 7 mm) were included. Mean number of FDs used was 1.22 +/- 0.42. In six cases, adjunctive coiling and in five cases, apposing stent placement were used. Overall mortality rate and procedure-related mortality rates were 22.5% (7/31) and 9.6% (3/31), respectively. At a mean imaging follow-up of 17.2 +/- 12.6 months, total occlusion was achieved in 22 aneurysms (91.6%). Univariate analysis showed that mortality was positively correlated with vasospasm (rho = 0.600, p < 0.05), higher mWFNS Scale (rho = 0.685, p < 0.05), higher modified Fischer Score (rho = 0.609, p < 0.05), higher mRS (rho = 0.594, p < 0.05) on admission and negatively correlated with saccular morphology (rho = -0.529, p < 0.05). Multivariate logistic regression identified mWFNS on admission as a significant predictor. (OR: 7.148, 95% CI 1.777-28.758, p: 0.01). Adjunctive coiling positively correlated with aneurysm occlusion. (rho = 0.522, p < 0.05).ConclusionThe procedure-related morbidity and mortality is not negligible. However, the risks and efficacy associated with FDs are acceptable, especially when adjunctive coiling is possible, given the lack of treatment alternatives

Cerebrovascular complications of transorbital penetrating intracranial injuries

BACKGROUND: Cerebrovascular trauma secondary to transorbital intracranial penetrating injury (TIPVI) is rare. Relatively benign initial presentation may mask the underlying life-threatening vascular injury in transorbital intracranial penetrations. The aim of this study was to evaluate clinical features and endovascular treatment of TIPVI. METHODS: Six patients with angiographic documentation of TIPVI in subacute/chronic phase were reviewed retrospectively. Five were treated endovascularly; however endovascular treatment was aborted in one and conservative management was pursued. RESULTS: Except for one case presenting with vision loss and mild stroke, no significant neurologic deficit was present. Vascular lesions included two cases of carotid-cavernous fistulas, three traumatic aneurysms of cavernous carotid, anterior and middle cerebral arteries and a unique case of coalescing cavernous aneurysms following a through-and-through injury in which the aneurysms united within the thrombosed cavernous sinus on follow up. Fistulas were treated with covered stents, aneurysms with parent artery occlusion or flow diverters. All patients had uneventful recoveries. CONCLUSION: TIPVI may present in a delayed fashion after a seemingly benign presentation. A high index of suspicion is critical to rule out TIPVI with vascular imaging. Transcatheter angiographic techniques allow for both diagnosis and treatment of TIPVI with favorable results

Angiographic Morphometry of Internal Carotid Artery Circulation in Turkish Children

AIM: Knowledge of cerebrovascular morphology is integral in planning neuroendovascular interventions, especially for procedures involving placement of stents, flow diverters or stentrievers. There is insufficient data on angiographic normative values of cerebral circulation in the pediatric age group since angiograms are uncommonly performed in children except for arteriovenous malformations in which arterial dimensions are larger than normal. We aimed to measure the diameters of internal carotid circulation (ICC) arteries on digital subtraction angiograms of pediatric patients and determine the growth trends. MATERIAL and METHODS: This is a retrospective cross-sectional study measurements of ICC arteries of 64 pediatric patients (4- 122 months) with retinoblastoma undergoing intra-arterial chemotherapy. RESULTS: Petrous, cavernous, supraclinoid and choroidal segments of internal carotid artery (ICA) and anterior cerebral artery (ACA) diameters had significant correlation with age. Most of the growth was noted in the first 36-48 months of life. Middle cerebral artery (MCA) diameter did not show significant correlation with age. 87% of the adult diameter of the MCA was attained in the first 6 months of life. ICC arteries reached 81% to 99% of adult sizes in the first 48 months of life. On the contrary, the main iliac artery was only 59% of the adult diameter at this age group. CONCLUSION: Use of current intracranial stents in children appears tolerable due to the growth pattern of ICC arteries. Based on this data, the current armamentarium of intracranial stents or stent-like devices is sufficient to cover the need in the pediatric population

Appraisal of the Flow Diversion Effect Provided by Braided Intracranial Stents

Objective: Comparison of the results of stent-assisted coiling (SAC) with braided stents (BS), flow diverters (FD), and laser-cut stents (LCS) to determine the relative flow-diverting capacity of BS (Leo baby and Accero). Methods: Saccular intracranial aneurysms treated by SAC and FD-assisted coiling were retrospectively evaluated. Aneurysm occlusion, as graded per Raymond-Roy score, was categorized as either recanalization/stable residual filling (Group A; lacking a flow diversion effect) or stable/progressive occlusion (Group B with a "flow diversion effect"). Factors predicting the flow diversion effect were evaluated. Results: Of the 194 aneurysms included, LCS, BS, and FD were used in 70 (36.1%), 86 (44.3%), and 38 (19.6%) aneurysms, respectively. Aneurysms treated by FD were larger, had wider necks, and were located on larger parent arteries (p < 0.01, 0.02, and <0.01, respectively). The mean imaging follow-up duration was 24.5 months. There were 29 (14.9%) aneurysms in Group A and 165 (85.1%) in Group B. Among a spectrum of variables, including sex, age, aneurysm size, neck width, parent artery diameter, follow-up duration, and stent type, the positive predictors for stable/progressive aneurysm occlusion were aneurysm size and placement of an FD or BS (p < 0.01 and p < 0.01, respectively, and were positive predictors over LCS: ORs 6.34 (95% CI: 1.62-24.76) and 3.11 (95% CI: 1.20-8.07), respectively) in multivariate analysis. Conclusions: The placement of BS was a predictor of flow diversion over laser-cut stents. However, the flow diversion effect was approximately half that of FDs, suggesting that BS may only be considered to have some (partial) flow diversion effects

The role of choroidal optical coherence tomography for follow-up of carotid cavernous fistula with anterior drainage

Background To evaluate the role of the choroidal vascularity index (CVI) and the tortuosity index (TI), along with choroidal thickness measurements, in follow-up for anteriorly draining carotid cavernous fistulas (CCF) that would otherwise necessitate an invasive carotid angiogram. Methods In this longitudinal observational study, analysis of enhanced depth imaging spectral domain optical coherence tomography (SD-EDI-OCT) images of 22 patients with angiographically proven unilateral CCF with anterior drainage was performed for subfoveal choroidal thickness (SFCT), central foveal thickness (CFT), CVI and TI. Baseline measurements were compared with those taken at the last visit after occlusion of the fistula. Results Both in the clinically affected and unaffected eyes, there was a significant decrease in CFT (p = 0.015 and p = 0.005, respectively), SFCT (p = 0.000 for both eyes), CVI (p = 0.002 and 0.001, respectively) and all three TI parameters, including inferior (p < 0.001 and p = 0.01, respectively) and superior temporal vein tortuosity index (p = 0.005 and p = 0.02, respectively) as well as total venular tortuosity index (p < 0.001 and p = 0.002, respectively) after successful closure of the fistula compared to first presentation. Changes in all parameters were similar between the D-CCF and I-CCF groups except for CVI. Conclusions In this first study concerning follow-up of anteriorly draining unilateral CCFs by SD-EDI-OCT, we not only demonstrated involvement of the clinically unaffected eye but also showed that, this modality, utilizing CVI and TI together with choroidal thickness measurements, can be used as a readily available, noninvasive first-line followup method for evaluating occlusion of fistulas by endovascular treatment or spontaneous resolution

Retinal and Choroidal Optical Coherence Tomography Findings of Carotid Cavernous Fistula

PURPOSE: To define the retinal and choroidal imaging findings of carotid cavernous fistula (CCF) including central foveal thickness, subfoveal choroidal thickness, choroidal vascularity index (CVI) parameters, and tortuosity indexes (TIs) as compared to a control group (CG)