Sole stenting of large and giant intracranial aneurysms with self-expanding intracranial stents-limits and complications.
ABSTRACT Intracranial aneurysms may be difficult for endovascular treatment due to size, fusiform shape, or wide neck. In such patients, intracranial stents are used to support the coils in the aneurysm sac, or they may be used as a sole stenting technique to divert the blood flow without coils. The aim of this paper is to contribute to the existing data by reviewing the risks of sole stenting of large and giant aneurysms.
We treated seven patients with nine aneurysms by self-expanding intracranial stents, either by a single or multiple stents in a stent-in-stent configuration. The follow-up was performed by digital subtraction angiography with a mean follow-up time of 6 months.
A positive response to stenting occurred in five out of seven patients (71%) and six out of nine aneurysms (67%). The aneurysms were occluded in two patients, and incomplete results were noted in three patients. The symptoms due to the compression of cranial nerves resolved in four patients (57%). Procedure-related subarachnoid hemorrhage occurred in two out of seven patients (29%), with death of one patient as a result of hemorrhage (14%).
Sole stenting of large and giant aneurysms with self-expanding intracranial stents may be associated with a higher risk than previously reported. The effect of stenting on intra-aneurysmal flow in such aneurysms, even after the placement of multiple overlapping stents, seems to be unpredictable.
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ABSTRACT: Two cases of acutely ruptured cerebral aneurysm of low dome/neck ratio treated by stent-assisted GDC embolization using balloon-expandable coronary stent, and also their long-term follow-up results are reported. After embolization, the basilar trunk aneurysm was completely occluded, and partial occlusion was obtained for the internal carotid (IC)-paraclinoid aneurysm. Oral ticropidine (200 mg/day) was given after the embolization, and no neurological events were seen during long-term follow-up (64–68 months). Follow-up angiograms of the basilar trunk aneurysm at 20 months showed complete occlusion and no in-stent stenosis. Follow-up angiograms of the IC-paraclinoid aneurysm at 52 months showed complete occlusion of the aneurysm, but mild stenosis at the distal end of the stent graft. These cases suggested that stent-assisted GDC embolization is effective for prevention of rebleeding from ruptured aneurysm during long-term observation even with suffi- cient dose of antiplatelets therapy. Caution should be taken on aneurysmal recanalization and parent artery stenosis due to stent deployment during long-term period.12/2007: pages 5-8;
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ABSTRACT: The Pipeline embolization device (PED) (Chestnut Medical Technologies, Inc., Menlo Park, CA) is a new microcatheter-delivered endovascular construct designed to achieve the curative reconstruction of the parent arteries giving rise to wide-necked and fusiform intracranial aneurysms. We present our initial periprocedural experience with the PED and midterm follow-up results for a series of 53 patients. Patients harboring large and giant wide-necked, nonsaccular, and recurrent intracranial aneurysms were selected for treatment. All patients were pretreated with dual antiplatelet medications for at least 72 hours before surgery and continued taking both agents for at least 6 months after treatment. A control digital subtraction angiogram was typically performed at 3, 6, and 12 months. Fifty-three patients (age range, 11-77 years; average age, 55.2 years; 48 female) with 63 intracranial aneurysms were treated with the PED. Small (n = 33), large (n = 22), and giant (n = 8) wide-necked aneurysms were included. A total of 72 PEDs were used. Treatment was achieved with a single PED in 44 aneurysms, with 2 overlapping PEDs in 17 aneurysms, and with 3 overlapping PEDs in 2 aneurysms. The mean time between the treatment and last follow-up digital subtraction angiogram was 5.9 months (range, 1-22 months). Complete angiographic occlusion was achieved in 56%, 93%, and 95% of aneurysms at 3 (n = 42), 6 (n = 28), and 12 (n = 18) months, respectively. The only aneurysm that remained patent at the time of the 12-month follow-up examination had been treated previously with stent-supported coiling. The presence of a preexisting endoluminal stent may have limited the efficacy of the PED reconstruction in this aneurysm. No aneurysms demonstrated a deterioration of angiographic occlusion during the follow-up period (i.e., no recanalizations). No major complications (stroke or death) were encountered during the study period. Three patients (5%), all with giant aneurysms, experienced transient exacerbations of preexisting cranial neuropathies and headache after the PED treatment. All 3 were treated with corticosteroids, and these symptoms resolved within 1 month. Endovascular reconstruction with the PED represents a safe, durable, and curative treatment of selected wide-necked, large and giant cerebral aneurysms. The rate of complete occlusion at the time of the 12-month follow-up examination approached 100% in the present study. To date, no angiographic recurrences have been observed during serial angiographic follow-up.Neurosurgery 05/2009; 64(4):632-42; discussion 642-3; quiz N6. · 2.53 Impact Factor
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ABSTRACT: A series of 32 patients with aneurysms in the cavernous sinus region is presented. All of them have been operated upon through an intradural pterional approach and the aneurysms directly attacked. Only in 6 patients was the complete dissection of the internal carotid artery and of the aneurysm impossible because of the size of the aneurysms. In these cases the aneurysm has been traped by ligation of the internal carotid artery in the neck and its supraclinoid course and at the same time and extracranial intracranial anastomosis performed. One patient died from massive cerebral infarction after a trapping procedure and another died from a transoperative haemorrhage; another two developed a moderate hemiparesis which resolved within the first six postoperative weeks, and in two patients a preoperative severe visual impairment progressed postoperatively to complete visual loss. All others had a complete resolution of their preoperative symptoms and remained well. The advantages and disadvantages of the different approaches to intracavernous carotid artery aneurysms are discussed and the related literature reviewed.Acta Neurochirurgica 02/1988; 91(1-2):25-8. · 1.55 Impact Factor
Središnja medicinska knjižnica
Pavliša G., Ozretić D., Murselović T., Pavliša G., Radoš M. (2010) Sole
stenting of large and giant intracranial aneurysms with self-expanding
intracranial stents-limits and complications. Acta Neurochirurgica, 152
(5). pp. 763-9. ISSN 0001-6268
University of Zagreb Medical School Repository
Sole stenting of large and giant intracranial aneurysms with self-expanding intracranial
stents – limits and complications
Goran Pavlisa1, David Ozretic1, Tamara Murselovic2, Gordana Pavlisa3, Marko Rados1
1Clinical institute of diagnostic and interventional radiology, University hospital center
Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia
2Clinic of anesthesiology, reanimatology and intensive care, University hospital center
Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia
3Special hospital for pulmonary diseases, Rockefellerova 3, 10000 Zagreb, Croatia
Goran Pavlisa, MD, PhD
Clinical institute of diagnostic and interventional radiology, University hospital center
Kispaticeva 12, 10000 Zagreb
Intracranial aneurysms may be difficult for endovascular treatment due to size, fusiform
shape or wide neck. In such patients, intracranial stents are used to support the coils in the
aneurysm sac, or they may be used as a sole stenting technique to divert the blood flow
without coils. The aim of this paper is to contribute to the existing data by reviewing the
risks of sole stenting of large and giant aneurysms.
We treated 7 patients with 9 aneurysms by self-expanding intracranial stents, either by a
single or multiple stents in a stent-in-stent configuration. The follow-up was performed
by digital subtraction angiography, with a mean follow-up time of 6 months.
A positive response to stenting ocurred in 5 out of 7 patients (71%), and 6 out of 9
aneurysms (67%). The aneurysms were occluded in 2 patients, and incomplete results
were noted in 3 patients. The symptoms due to the compression of cranial nerves
resolved in 4 patients (57%). Procedure-related subarachnoid hemorrhage occurred in 2
out of 7 patients (29%), with death of one patient as a result of hemorrhage (14%).
Sole stenting of large and giant aneurysms with self-expanding intracranial stents may be
associated with a higher risk than previously reported. The effect of stenting on
intraaneurysmal flow in such aneurysms, even after the placement of multiple
overlapping stents, seems to be unpredictable.
Keywords: Intracranial aneurysm; sole stenting; self-expanding stent; large and giant
Endovascular options in the treatment of intracranial aneurysms are expanding by the
recent advances of materials and techniques. Aneurysms which are difficult for treatment
due to wide neck, fusiform shape and incorporation of arterial branches are being treated
by three-dimensional coils, balloon or stent-assisted coiling, parent artery occlusion,
liquid embolics or combinations of these approaches [1,12,21,22,]. Various types of
coronary and intracranial stents are used to support the coils in the aneurysm sac and/or
to promote the thrombosis of the aneurysm and neointimal proliferation at the aneurysm
neck by flow diversion. Stents may be used without coiling for the purpose of aneurysm
thrombosis, in sole stenting technique, with favourable results [4,17,27,28,29,30,31,32],
although serious complications have been described . New devices in forms of stents
with a high-density wire mesh are being investigated and used in daily practice, with a
potentially good compromise between flow diversion and preservation of perforating
arterial branches [13,19]. However, the publications concerning sole stenting include a
relatively small number of patients with limited follow-up time.
We retrospectivelly analyzed our results on 7 patients with large and giant aneurysms
treated by sole stenting with self-expanding intracranial stents. The aim of this paper was
to contribute to the existing data and emphasise possible risks of this technique.
METHODS AND MATERIALS
Indications for treatment were assessed for every patient by neuroradiologist performing
endovascular treatment, vascular neurosurgeon and neurologist. The patients were
referred to endovascular treatment due to the location of aneurysms on cavernous internal
carotid artery (ICA) and basilar artery and their large and giant size, both of which factors
are associated with higher surgical risks [9,25]. Extradural location of aneurysms and
their wide neck or fusiform shape were considered suitable for sole stenting. All the
patients were treated on a single-plane digital angiography system (Axiom Artis FA;
Siemens AG, Erlangen, Germany), by self-expanding stents designed for intracranial
vessels: Enterprise vascular reconstruction device (Codman Neurovascular, Warren, NJ),
LEO Plus stent (Balt Extrusion, Montmorency, France) and Neuroform3 stent (Boston
Scientific, Natick, MA). We aimed to use multiple closed-cell stents in a stent-in-stent
configuration to achieve higher surface area coverage of the aneurysm neck. An open-cell
Neuroform3 stent was placed in one patient, before the introduction of Enterprise and
LEO stents in our practice. The choice between Enterprise and LEO stents was mostly
influenced by their availability in our institution, as were the decisions to place a single
stent in two patients. Pre-procedural dual antiplatelet medication consisted of 75 mg of
clopidogrel daily and 100 mg of acetylsalicylic acid (ASA) daily during 3 days, or a
loading dose of 300 mg of clopidogrel and 325 mg of ASA at least 4 hours before the
procedure. The patients were heparinized during the procedure in order to double the
baseline activated clotting time. The procedures were performed with patients in general