Neurosurgery Blog


Daily bibliographic review of the Neurosurgery Department. La Fe University Hospital. Valencia, Spain

Flow diverter devices in ruptured intracranial aneurysms

J Neurosurg 128:1037–1043, 2018

In this single-center series, the authors retrospectively evaluated the effectiveness, safety, and midterm follow-up results of ruptured aneurysms treated by implantation of a flow diverter device (FDD).

METHODS The records of 17 patients (12 females, 5 males, average World Federation of Neurosurgical Societies score = 2.9) who presented with subarachnoid hemorrhage (SAH) due to the rupture of an intracranial aneurysm treated with an FDD were retrospectively reviewed. Of 17 ruptured aneurysms, 8 were blood blister–like aneurysms and the remaining 9 were dissecting aneurysms. The mean delay between SAH and treatment was 4.2 days. Intraprocedural and periprocedural morbidity and mortality were recorded. Clinical and angiographic follow-up evaluations were conducted between 6 and 12 months after the procedure.

RESULTS None of the ruptured aneurysms re-bled after endovascular treatment. The overall mortality rate was 12% (2/17), involving 2 patients who died after a few days because of complications of SAH. The overall morbidity rate was 12%: 1 patient experienced intraparenchymal bleeding during the repositioning of external ventricular drainage, and 1 patient with a posterior inferior cerebellar artery aneurysm developed paraplegia due to a spinal cord infarction after 2 weeks. The angiographic follow-up evaluations showed a complete occlusion of the aneurysm in 12 of 15 surviving patients; of the 3 remaining cases, 1 patient showed a remnant of the aneurysm, 1 patient was retreated due to an enlargement of the aneurysm, and 1 patient was lost at the angiographic follow-up.

CONCLUSIONS FDDs can be used in patients with ruptured aneurysms, where conventional neurosurgical or endovascular treatments can be challenging.

Aneurysm wall enhancement on magnetic resonance imaging as a risk factor for progression of unruptured vertebrobasilar dissecting aneurysms after reconstructive endovascular treatment

J Neurosurg 128:747–755, 2018

The recurrence rate of vertebrobasilar dissecting aneurysms (VBDAs) after reconstructive endovascular treatment (EVT) is relatively high. The aneurysm wall enhancement on high-resolution MRI (HRMRI) reportedly predicts an unsteady state of an intracranial aneurysm. The authors used HRMRI to investigate the relationship between wall enhancement on HRMRI and progression of VBDAs after reconstructive EVT.

METHODS From January 2012 to December 2015, patients with an unruptured VBDA who underwent reconstructive EVT were enrolled in this study. Preoperative enhanced HRMRI was performed to evaluate radiological characteristics. The relationships between aneurysm wall enhancement and various potential risk factors were statistically analyzed. Follow-up angiographic examination was performed with digital subtraction angiography and conventional HRMRI. Cox regression analysis was performed to identify predictors of VBDA progression after reconstructive EVT.

RESULTS Eighty-two patients (12 women and 70 men, mean age 53.48 ± 9.23 years) with 83 VBDAs were evaluated in the current study. The average maximum diameter of the VBDAs was 11.30 ± 7.90 mm. Wall enhancement occurred in 43 VBDAs (51.81%). Among all 83 VBDAs, 62 (74.70%) were treated by stent-assisted coil embolization and 21 (25.30%) by stenting alone. The mean duration of imaging follow-up among all 82 patients was 10.55 months (range 6–45 months), and 15 aneurysms (18.07%) exhibited progression. The statistical analysis indicated no significant differences in age, sex, risk factors (high blood pressure, smoking, diabetes mellitus, and a high cholesterol level), VBDA stage, or VBDA size between enhanced and unenhanced VBDAs. Univariate Cox regression analysis showed that both the maximum diameter of the VBDAs and wall enhancement were associated with recurrence (p < 0.05). Multivariate Cox proportional hazard regression analysis showed that the maximum diameter of the VBDAs and wall enhancement on HRMRI were independent risk factors for aneurysm progression (p < 0.05).

CONCLUSIONS Aneurysm size and wall enhancement on HRMRI can predict the progression of VBDAs after reconstructive EVT.

Medina® Embolization Device for the Treatment of Intracranial Aneurysms

Neurosurgery 82:155–162, 2018

The Medina Embolization Device (MED) is a new concept device that combines the design of a detachable coil and the one of an intrasaccular flow disruption device.

OBJECTIVE: To evaluate the feasibility, safety, and 6- to 9-mo effectiveness of this new device for the treatment of intracranial wide-necked aneurysms.

METHODS:Twelve patients (10 females,meanage=56 yr)with 13 wide-necked intracranial aneurysms (3 ruptured; 10 unruptured) were treated by means of the MED from January 2015 to October 2015. In 15% of the cases, MEDs were used in a standalone fashion; in 85% of the cases, additional regular coils were used. Adjunctive compliant balloon was used in 4 of 13 cases (31%). Procedure-related complications were systematically recorded; discharge and 6- to 9-mo follow-up modified Rankin Scale was assessed. Angiographic follow-up was performed with a mean delay of 5.5 ± 1.7 mo. Occlusion rate was evaluated in postprocedure and at midterm follow-up using the Roy–Raymond scale.

RESULTS: The deployment of the MED was feasible in all cases. No perforation was recorded. One case of thromboembolic complication was observed in a ruptured anterior communicating artery aneurysm, without any clinical consequence at follow-up. Grade A occlusion rate was 61.5% in postprocedure and 83% at 6-mo follow-up. Two cases (17%) of recanalization were documented angiographically.

CONCLUSION: The MED is a new generation device combining the design of a detachable coil and an intrasaccular flow disruption device. According to our early experience, this device is safe and provides a satisfactory occlusion rate at angiographic follow-up of 6mo.


Comparison of endovascular and microsurgical management of 208 basilar apex aneurysms

J Neurosurg 127:1342–1352, 2017

The deep and difficult-to-reach location of basilar apex aneurysms, along with their location near critical adjacent perforating arteries, has rendered the perception that microsurgical treatment of these aneurysms is risky. As a result, these aneurysms are considered more suitable for treatment by endovascular intervention. The authors attempt to compare the immediate and long-term outcomes of microsurgery versus endovascular therapy for this aneurysm subtype.

METHODS A prospectively maintained database of 208 consecutive patients treated for basilar apex aneurysms between 2000 and 2012 was reviewed. In this group, 161 patients underwent endovascular treatment and 47 were managed microsurgically. The corresponding records were analyzed for presenting characteristics, postoperative complications, discharge status, and Glasgow Outcome Scale (GOS) scores up to 1 year after treatment and compared using chi-square and Student t-tests.

RESULTS Among these 208 aneurysms, 116 (56%) were ruptured, including 92 (57%) and 24 (51%) of the endovascularly and microsurgically managed aneurysms, respectively. The average Hunt and Hess grade was 2.4 (2.4 in the endovascular group and 2.2 in the microsurgical group; p = 0.472). Postoperative complications of cranial nerve deficits and hemiparesis were more common in patients treated microsurgically than endovascularly (55.3% vs 16.2%, p < 0.05; and 27.7% vs 10.6%, p < 0.05, respectively). However, aneurysm remnants and need for retreatment were more common in the endovascular than the microsurgical group (41.3% vs 2.3%, p < 0.05; and 10.6% vs 0.0%, p < 0.05, respectively). Stent placement significantly reduced the need for retreatment. Rehemorrhage rates and average GOS score at discharge and 1 year after treatment were not statistically different between the two treatment groups.

CONCLUSIONS Patients with basilar apex aneurysms were significantly more likely to be treated via endovascular management, but compared with those treated microsurgically, they had higher rates of recurrence and need for retreatment. The current study did not detect an overall difference in outcomes at discharge and 1 year after either treatment modality. Therefore, in a select group of patients, microsurgical treatment continues to play an important role.

A New Aneurysm Occlusion Classification after the Impact of Flow Modification

Classification of angiographic results after endovascular treatment with any technique

AJNR Am J Neuroradiol 37:19 –24

A new classification is proposed for cerebral aneurysms treated with any endovascular technique, for example, coiling with or without adjunctive devices, flow diversion, intrasaccular flow modifiers, or any combination of the above.

Raymond-Roy Occlusion Classification is expanded with novel subgroups such as class 1 represents complete occlusion and is subdivided if a branch is integrated to, or originated from, the aneurysm sac; class 2 represents neck filling; class 3 represents incomplete occlusion with aneurysm filling as in the previous classification; and class 4 describes the immediate postoperative status after extra- or intrasaccular flow modification treatment. A new concept, “stable remodeling,” is included as class 5, which represents filling in the neck region that stays unchanged or reduced, as shown with at least 2 consecutive control angiographies, at least 6 months apart, for not <1 year, or the remodeled appearance of a dilated and/or tortuous vessel in continuation with the parent artery without sac filling.

Predictors of Outcome, Complications, and Recanalization of the Solitaire Device

Solitaire Device

Neurosurgery 77:355–361, 2015

The use of mechanical thrombectomy in the management of acute ischemic stroke is becoming increasingly popular.

OBJECTIVE: To identify notable factors that affect outcome, revascularization, and complications in patients with acute ischemic stroke treated with the Solitaire Flow Restoration Revascularization device.

METHODS: Eighty-nine patients treated with the Solitaire Flow Restoration Revascularization device (ev3/Covidien Vascular Therapies, Irvine, California) were retrospectively analyzed. Three endpoints were considered: revascularization (Thrombolysis In Cerebral Infarction), outcome (modified Rankin Scale score), and complications. Univariate analysis and multivariate logistic regression were conducted to determine significant predictors.

RESULTS: The mean time from onset of symptoms to the start of intervention was 6.7 hours. The average procedure length was 58 minutes. The mean NIH Stroke Scale (NIHSS) score was 16 on arrival and 8 at discharge. Of the patients, 6.7% had a symptomatic intracerebral hemorrhage, 16.8% had fatal outcomes within 3 months post-intervention, and 81.4% had a successful recanalization. Thrombus location in the M1 segment of the middle cerebral artery was associated with successful recanalization (thrombolysis in cerebral infarction 2b/3) (P = .003). Of the patients, 56.6% had a favorable outcome (modified Rankin Scale score at 3 months: 0-2). In patients younger than 80 years of age, 66.7% had favorable outcome. Increasing age (P = .01) and NIHSS score (P = .002) were significant predictors of a poor outcome. On multivariate analysis, NIHSS score on admission (P = .05) was a predictor of complications. On univariate analysis, increasing NIHSS score fromadmission to 24 hours after the procedure (P = .05) and then to discharge (P = .04) was a predictor of complications. Thrombus location in the posterior circulation (P = .04) and increasing NIHSS score (P = .04) predicted mortality.

CONCLUSION: The Solitaire device is safe and effective in achieving successful recanalization after acute ischemic stroke. Important factors to consider include age, NIHSS score, and location.

International differences in the management of intracranial aneurysms: implications for the education of the next generation of neurosurgeons

MCA aneurysm

Acta Neurochir 2015, 157,(9):1467-1475

The publication of the International Subarachnoid Aneurysm Trial rapidly changed the management of patients with subarachnoid hemorrhage. The present and perceived future trends of aneurysm management have significant implications for patients and how we educate future cerebrovascular specialists.


To determine present perceived competencies of final-year neurosurgical residents who have just finished their residencies and to relate those to what practitioners from a variety of continents expect of these persons. The goal is to provide a basis for further discussion regarding the design of further educational programs in neurosurgery.


A 55-item questionnaire with 33 questions related to competencies and expectations of competency from final-year residents who have just finished residency was completed by 229 neurosurgeons and neuro-radiologists (81 % response rate) of mixed seniority from 45 countries. We used bivariate and descriptive analyses to determine future trends and geographic differences in cerebral aneurysm management as well as the educational implications on the future.


More North Americans than those from the rest of the world are of the opinion that graduating residents are presently competent to perform basic cerebrovascular procedures like evacuation of a hematoma and clipping a simple 7-mm middle cerebral artery aneurysm. Extremely few graduating neurosurgical residents anywhere are presently capable of performing endovascular techniques for even the most basic of aneurysms. Most of those surveyed also believe that endovascular and open surgical management of aneurysms should be a part of residency training for all residents (70.4 and 88.7 %, respectively).


Our findings have implications for the design of neurosurgical curricula for residents as well as for certification examinations and procedures. Specialty and educational organizations and those responsible for the education of future clinicians who will care for patients with cerebrovascular problems should adjust educational objectives and implement curricula and learning experiences that will ensure that cerebrovascular specialists are capable of providing the best care possible to the patient with an aneurysm, whether that be open surgery or endovascular management. These findings mean that organizations around the world will need to make these adjustments to the education of future specialists.

Endovascular Treatment of 346 Middle Cerebral Artery Aneurysms

MCA aneurysmNeurosurgery 76:54–61, 2015

The endovascular treatment of middle cerebral artery (MCA) aneurysms has been controversial because of the frequency of complex anatomy and the relative ease of surgical clipping in this location.

OBJECTIVE: To present a large single-center experience with the endovascular treatment of MCA aneurysms.

METHODS: The neurointerventional database at our institution was reviewed for all endovascular treatments of MCA aneurysms. Demographics, aneurysm characteristics, treatment modality, intraprocedural hemorrhagic and thromboembolic events, 30-day neurological events, and follow-up angiographic studies were recorded.

RESULTS: From December 1996 to April 2013, 292 patients underwent endovascular treatment of 346 MCA aneurysms. Of these, 341 (98.6%) were successfully completed. Balloon neck remodeling was used in 230 procedures (66.5%). Ninety-five procedures (27.4%) were for ruptured aneurysms. The rate of intraprocedural hemorrhage was 2.6% (9 of 346). The overall rate of intraprocedural thromboembolic events was 13.6% (47 of 346), significantly more common in patients with acute subarachnoid hemorrhage (27.4%; P, .001). The 30-day major (modified Rankin Scale score . 2) neurological event rate was 2.9% (10 of 346), significantly more common in patients with subarachnoid hemorrhage (8.4%) compared with those without (0.8%; P , .001). The rate of complete or near-complete aneurysm occlusion at was 90.6% $ 6 months and 91.8% at $ 2 years, with an average of 24 months of follow-up available for 247 procedures.

CONCLUSION: Endovascular treatment of MCA aneurysms can be safe and effective. However, it is associated with a high asymptomatic thromboembolic event rate that is more frequent in the setting of acute subarachnoid hemorrhage.


The failure of preoperative ethylene-vinyl alcohol copolymer embolization to improve outcomes in arteriovenous malformation management: case series


J Neurosurg 118:969–977, 2013

Ethylene-vinyl alcohol copolymer embolization is increasingly used preoperatively in the resection of brain arteriovenous malformations (AVMs). However, the case for embolization improving the outcome of resection has not been evaluated. In this paper the authors set out to compare outcomes after surgery for brain AVMs in 2 consecutive periods of practice. In the first period, selective embolization was used without the use of ethylene-vinyl alcohol copolymer. In the second period, selective embolization with ethylene-vinyl alcohol copolymer was performed.

Methods. A consecutive case series (prospectively collected data) was retrospectively analyzed. Adverse outcomes were considered to be an outcome modified Rankin Scale score greater than 2 due to embolization or surgery.

Results. A total of 538 surgical cases were included. The percentages of adverse outcomes were as follows: 0.34% for Spetzler-Martin AVMs less than Grade III (1 of 297 cases); 5.23% (95% CI 2.64%–9.78%) for Grade III AVMs (9 of 172 cases); and 17% (95% CI 10%–28%) for AVMs greater than Grade III (12 of 69 cases). There was no improvement in outcomes from the first period to the second period. The adverse outcome for Grade III brain AVMs in the first period was 5.2% (7 of 135 cases) and in the second period (after ethylene-vinyl alcohol copolymer was introduced) it was 5.4% (2 of 37 cases). For AVMs greater than Grade III, the adverse outcome was 12% (6 of 49 cases) in the first period and 30% (6 of 20 cases) in the second period.

Conclusions. Outcomes for brain AVM surgery were not improved by ethylene-vinyl alcohol copolymer embolization. Preoperative embolization of high-grade AVMs with an ethylene-vinyl alcohol copolymer did not prevent those hemorrhagic complications which embolization is hypothesized to prevent based on theoretical speculations but not demonstrated in practice.

Venous Sinus Pulsatility and the Potential Role of Dural Incompetence in Idiopathic Intracranial Hypertension

Neurosurgery 71:877–884, 2012

Idiopathic intracranial hypertension (IIH) remains a poorly understood and therapeutically challenging disease. Enthusiasm has emerged for endovascular therapy with stent reconstruction of dural sinus narrowing; however, a complete understanding of the hydrodynamic dysequilibrium is lacking.

OBJECTIVE: To review and characterize catheter manometry findings including pulsatility changes within the venous sinuses in IIH.

METHODS: Cases of venous sinus stent implantation for IIH were retrospectively reviewed.

RESULTS: Three cases of venous sinus stent implantation for treatment of IIH are reported. All cases demonstrated severe narrowing (>70%) within the transverse sinus and a high pressure gradient across the lesion (>30 mm Hg). Stent implantation resulted in pulsatility attenuation, correction of pressure gradient, and improvement of flow.

CONCLUSION: We report the finding of high venous sinus pulsatility attenuation after stent implantation for dural sinus narrowing and propose the hypothesis that this finding is a marker of advanced dural sinus incompetence. This characteristic may be useful in identifying patients who would benefit from endovascular stent remodeling.

Safety and Efficacy of Endovascular Treatment of Basilar Tip Aneurysms by Coiling With and Without Stent Assistance: A Review of 235 Cases

Neurosurgery 71:785–794, 2012

Endovascular therapy is now the preferred treatment option for basilar tip aneurysms (BTAs).

OBJECTIVE: To compare the safety and efficacy of common endovascular techniques in the treatment of BTAs.

METHODS: A retrospective review was conducted of 235 patients with BTAs treated with endovascular means in our institution between 2004 and 2011. Categorization was based on the presence and type of stent assistance (none, single, and Y stenting). The rates of perioperative complications, recanalization, rehemorrhage, and retreatment were analyzed.

RESULTS: A total of 147 patients were treated with coil embolization and 88 patients with stent-assisted coiling (72 single stents, 16 Y stents). Thromboembolic complications occurred in 6.8% of patients in both groups. There was no associated mortality. Angiographic follow-up (mean, 23.5 months) was available in 172 patients (77.1%). Stented patients had significantly lower recanalization (17.2% vs 38.9%; P = .003) and retreatment (7.8% vs 27.8%; P = .002) rates compared with nonstented patients. Four rehemorrhages (2.7%) occurred in the coiled group, whereas none were noted in the stented group (P = .3). In paired comparisons, lower recanalization (8.3% vs 19.2%; P = .21) and retreatment (0% vs 9.6%; P = .19) rates were seen in the Y-stent group compared with the single-stent group. Thromboembolic complications occurred in 6.9% and 6.2% of patients in the single-stent and Y-stent groups, respectively (P = .91). In multivariate analysis, larger aneurysms, nonstented aneurysms, incomplete initial occlusion, and subarachnoid hemorrhage were predictors of aneurysm recanalization.

CONCLUSION: Stent-assisted coiling has significantly lower recurrence, retreatment, and rehemorrhage rates than coiling alone for the treatment of BTAs. Y stenting has the highest efficacy with low complication rates.

Complications After Treatment With Pipeline Embolization for Giant Distal Intracranial Aneurysms With or Without Coil Embolization

Neurosurgery 71:E509–E513, 2012 DOI: 10.1227/NEU.0b013e318258e1f8

The Pipeline Embolization Device (PED) is a flow diverter designed to treat intracranial aneurysms through endoluminal parent vessel reconstruction. The role of adjunctive coil embolization is unknown.

CLINICAL PRESENTATION: This report details the authors’ experience with the PED in 2 patients with symptomatic, giant distal intracranial aneurysms (1 basilar artery and 1 M1 segment middle cerebral artery). Both patients had successful parent vessel reconstruction. In the first patient, the basilar artery aneurysm was treated with PEDs alone, and the patient experienced early fatal brainstem hemorrhage from aneurysm rupture. In the second patient, the M1 aneurysm was treated with 2 PEDs along with dense coil embolization, with a good initial angiographic result. This patient experienced acute thrombosis of the PED post-procedure, likely related to mass effect and thrombogenicity of the dense coil mass.

CONCLUSION: Flow diversion is an evolutionary step in the treatment of giant intracranial aneurysms. However, complete aneurysm occlusion occurs over a delayed period. The authors recommend placement of coils in addition to PED in the treatment of large or giant distal intracranial aneurysms in an attempt to protect the dome. However, robust packing is to be avoided because it can lead to acute PED thrombotic or compressive occlusion.

Long-term Results of Enterprise Stent-Assisted Coiling of Cerebral Aneurysms

Neurosurgery 71:239–244, 2012 DOI: 10.1227/NEU.0b013e3182571953

The Enterprise Vascular Reconstruction Device and Delivery System (Cordis; the Enterprise stent) was approved for use in conjunction with coiling of wide-necked aneurysms in 2007. No published long-term aneurysm occlusion or complication data exist for the Enterprise system.

OBJECTIVE: We compiled data on consecutive patients treated with Enterprise stent-assisted coiling of aneurysms from 9 high-volume neurointerventional centers.

METHODS: A 9 center registry was created to evaluate large volume data on the delayed safety and efficacy of the Enterprise stent system. Pooled data were compiled for consecutive patients undergoing Enterprise stent-assisted coiling at each institution prior to May 2009.

RESULTS: Two-hundred twenty-nine patients with 229 aneurysms, 32 of which were ruptured aneurysms, were included in the study. Mean clinical and angiographic follow-up was 619.6 ± 26.4 days and 655.7 ± 25.2 days, respectively. Mean aneurysm size was 9.2 ± 0.4 mm. Fifty-nine percent of patients demonstrated 100% coil obliteration and 81% had 90% or higher occlusion at last follow-up angiography. A total of 19 patients (8.3%) underwent retreatment of their aneurysms during the follow-up period. Angiographic in-stent stenosis was seen in 3.4% and thromboembolic events occurred in 4.4%. Overall, 90% of patients who underwent Enterprise-assisted coiling had a modified Rankin Scale score of 2 or less at last follow-up. A poor modified Rankin Scale score was strongly associated with rupture status (P < .001).

CONCLUSION: Although this study is limited by its retrospective nature, the Enterprise stent system appears to be an effective, safe, and durable treatment for intracranial aneurysms when used in conjunction with coiling.

Factors predicting retreatment and residual aneurysms at 1 year after endovascular coiling for ruptured cerebral aneurysms: Prospective Registry of Subarachnoid Aneurysms Treatment (PRESAT) in Japan

Neuroradiology (2012) 54:597–606. DOI 10.1007/s00234-011-0945-0

Endovascular treatment of cerebral aneurysms includes follow-up imaging to identify aneurysms that may need retreatment. The aim of this study was to determine predictors of incomplete aneurysm occlusion at 1 year after endovascular coiling for ruptured cerebral aneurysms.
Methods In 129 patients of the Prospective Registry of Subarachnoid Aneurysms Treatment cohort, ruptured aneurysms were coiled within 14 days of onset and both initial post-coiling and 1-year follow-up digital subtraction angiography or magnetic resonance angiography were obtained. Factors predicting 1-year incomplete aneurysm occlusion (retreatment within 1-year or residual aneurysms at 1 year) were determined using multivariate logistic regression analyses.
Results One-year incomplete aneurysm occlusion was identified in 59 patients, including ten patients who were retreated within 1-year post-coiling. Dome size ≥7.5 mm (P=0.007, odds ratio (OR)=5.00, 95% confidence interval (CI)=1.55– 16.15), pre-treatment aneurysm re-rupture (P=0.023, OR= 3.50, 95% CI=1.19–10.31), non-small size/small neck aneurysm (dome size, ≥10 mm or neck size, ≥4 mm; P= 0.022, OR=3.26, 95% CI=1.19–8.96), and residual aneurysms on immediate post-coiling angiograms (P=0.017, OR= 1.43, 95% CI=1.07–1.93) significantly predicted incomplete aneurysm occlusion at 1-year post-coiling.
Conclusions In addition to the characteristics of aneurysm and initially incomplete aneurysm occlusion, this study showed pre-treatment aneurysm re-rupture to be a predictor that favors closer imaging follow-ups for coiled aneurysms.

Dural sinus stents for idiopathic intracranial hypertension

J Neurosurg 116:538–548, 2012. DOI: 10.3171/2011.10.JNS101410

The use of unilateral dural sinus stent placement in patients with idiopathic intracranial hypertension (IIH) has been described by multiple investigators. To date there is a paucity of information on the angiographic and hemodynamic outcome of these procedures. The object of this study was to define the clinical, angiographic, and hemodynamic outcome of placement of unilateral dural sinus stents to treat intracranial venous hypertension in a subgroup of patients meeting the diagnostic criteria for IIH.

Methods. Eighteen consecutive patients with a clinical diagnosis of IIH were treated with unilateral stent placement in the transverse-sigmoid junction region. All patients had papilledema. All 12 female patients had headaches; 1 of 6 males had headaches previously that disappeared after weight loss. Seventeen patients had elevated opening pressures at lumbar puncture. Twelve patients had opening pressures of 33–55 cm H2O. All patients underwent diagnostic cerebral arteriography that showed venous outflow compromise by filling defects in the transverse-sigmoid junction region. All patients underwent intracranial selective venous pressure measurements across the filling defects. Follow-up arteriography was performed in 16 patients and follow-up venography/venous pressure measurements were performed in 15 patients.

Results. Initial pressure gradients across the filling defects ranged from 10.5 to 39 mm Hg. Nineteen stent procedures were performed in 18 patients. One patient underwent repeat stent placement for hemodynamic failure. Pressure gradients were reduced in every instance and ranged from 0 to 7 mm Hg after stenting. Fifteen of 16 patients in whom ophthalmological follow-up was performed experienced disappearance of papilledema. Follow-up arteriography in 16 patients at 5–99 months (mean 25.3 months, median 18.5 months) showed patency of all stents without in-stent restenosis. Two patients had filling defects immediately above the stent. Four other patients developed transverse sinus narrowing above the stent without filling defects. One of these patients underwent repeat stent placement because of hemodynamic deterioration. Two of the other 3 patients had hemodynamic deterioration with recurrent pressure gradients of 10.5 and 18 mm Hg.

Conclusions. All stents remained patent without restenosis. Stent placement is durable and successfully eliminates papilledema in appropriately selected patients. Continuing hemodynamic success in this series was 80%, and was 87% with repeat stent placement in 1 patient.

Endovascular Treatment of Cervical Giant Perimedullary Arteriovenous Fistulas

Neurosurgery 70:141–149, 2012 DOI: 10.1227/NEU.0b013e31822ec19e

Giant perimedullary arteriovenous fistulas (GPMAVFs) located in the cervical region are a rare pathology with distinctive characteristics.

OBJECTIVE: To evaluate clinical presentation and different endovascular treatment options of cervical GPMAVFs and review previously published data in the literature regarding cervical GPMAVFs.

METHODS: Six patients with cervical GPMAVFs were found in the spinal vascular malformations database of our group collected between 1990 and 2009. Endovascular techniques and treatment outcomes were evaluated and compared with other published series.

RESULTS: Clinical presentations were progressive motor deficit (5 patients), hematomyelia (1 patient), meningeal syndrome (1 patient), and respiratory arrest and gait apraxia (1 patient). Three patients were treated by the transarterial approach. One patient was treated by the transvenous approach due to previous embolizations resulting in a proximal occlusion and preventing a safe transarterial approach. A transvenous approach was used in another patient due to complex arterial anatomy. In 1 patient, direct percutaneous puncture of the venous pouch was necessary because of previous proximal occlusion of the arteries. All embolizations resulted in complete occlusions with clinical improvement, and there was no recanalization during a mean follow-up of 21 months.

CONCLUSION: Transarterial embolization of cervical GPMAVFs is safe and effective when it is done in highly experienced centers. Cervical GPMAVFs that cannot be accessed by the transarterial technique due to their complex angioarchitecture can be treated by transvenous embolization or direct puncture of the venous pouch.

The Barrow Ruptured Aneurysm Trial

J Neurosurg 116:135–144, 2012.DOI: 10.3171/2011.8.JNS101767

The purpose of this ongoing study is to compare the safety and efficacy of microsurgical clipping and endovascular coil embolization for the treatment of acutely ruptured cerebral aneurysms and to determine if one treatment is superior to the other by examining clinical and angiographic outcomes. The authors examined the null hypothesis that no difference exists between the 2 treatment modalities in the setting of subarachnoid hemorrhage (SAH). The current report is limited to the clinical results at 1 year after treatment.

Methods. The authors screened 725 patients with SAH, resulting in 500 eligible patients who were enrolled prospectively in the study after giving their informed consent. Patients were assigned in an alternating fashion to surgical aneurysm clipping or endovascular coil therapy. Intake evaluations and outcome measurements were collected by nurse practitioners independent of the treating surgeons. Ultimately, 238 patients were assigned to aneurysm clipping and 233 to coil embolization. The 2 treatment groups were well matched. There were no anatomical exclusions. Crossing over was allowed, but primary outcome analysis was based on the initial treatment modality assignment. Posttreatment care was standardized for both groups. Patient outcomes at 1 year were independently assessed using the modified Rankin Scale (mRS). A poor outcome was defined as an mRS score > 2 at 1 year. The primary outcome was based on the assigned group; that is, by intent to treat.

Results. One year after treatment, 403 patients were available for evaluation. Of these, 358 patients had actually undergone treatment. The remainder either died before treatment or had no identifiable source of SAH. A poor outcome (mRS score > 2) was observed in 33.7% of the patients assigned to aneurysm clipping and in 23.2% of the patients assigned to coil embolization (OR 1.68, 95% CI 1.08–2.61; p = 0.02). Of treated patients assigned to the coil group, 124 (62.3%) of the 199 who were eligible for any treatment actually received endovascular coil embolization. Patients who crossed over from coil to clip treatment fared worse than patients assigned to coil embolization, but no worse than patients assigned to clip occlusion. No patient treated by coil embolization suffered a recurrent hemorrhage.

Conclusions. One year after treatment, a policy of intent to treat favoring coil embolization resulted in fewer poor outcomes than clip occlusion. Although most aneurysms assigned to the coil treatment group were treated by coil embolization, a substantial number crossed over to surgical clipping. Although a policy of intent to treat favoring coil embolization resulted in fewer poor outcomes at 1 year, it remains important that high-quality surgical clipping be available as an alternative treatment modality.

Onyx embolization for the treatment of brain arteriovenous malformations

Acta Neurochir (2011) 153:869–878. DOI 10.1007/s00701-010-0848-6

Onyx has emerged in recent years for the endovascular treatment of brain arteriovenous malformations (AVMs). However, the role of Onyx embolization is still under discussion. We report our initial experiences in the treatment of brain AVMs with Onyx embolization.

Methods Between January 2004 and December 2007, 86 patients with brain AVMs were embolized with Onyx. Clinical presentation included intracerebral hemorrhage in 32 patients, seizures in 25 patients, headaches in 20 patients, neurologic deficits in 3 patients, and in 6 patients the AVM was an incidental finding. According to the Spetzler–Martin scale, three AVMs were grade I, 13 were grade II, 45 were grade III, 19 were grade IV, and 6 were grade V. Seventy-four AVMs were located in eloquent regions.

Results Initial complete obliteration after final embolization was achieved in 16 patients (18.6%), with an average of 80.5% (range, 30–100%) volume reduction. Partial embolization was followed by surgery in 18 patients, whereas 17 AVMs were cured. In 48 patients treated by embolization and radiosurgery, four patients were lost to follow-up. Three-year follow-up angiography was performed on 30 patients and showed complete obliteration after radiosurgery in 23 patients. The remaining 14 patients are awaiting 3-year postradiosurgery results. Embolization-related permanent morbidity was 3.5%, whereas mortality was 1.2%.

Conclusions Although Onyx allows moderate obliteration rates, combined management, such as adjunctive embolization with microsurgery or radiosurgery, may be effective for selected large AVMs.

Endovascular Therapy of Very Small Aneurysms of the Anterior Communicating Artery: Five-fold Increased Incidence of Rupture

Neurosurgery 68:731–737, 2011 DOI: 10.1227/NEU.0b013e3182077373

Intraprocedural rupture is a dangerous complication of endovascular treatment. Small ruptured anterior communicating artery (ACoA) aneurysms and microaneurysms present a challenge for both surgical and endovascular therapies to achieve obliteration. An understanding of the complication rates of treating ruptured ACoA microaneurysms may help guide therapeutic options.

OBJECTIVE: To report the largest cohort of ACoA microaneurysms treated with endovascular therapy over the course of the past 10 years.

METHODS: We performed a retrospective review of 347 ACoA aneurysms treated in 347 patients at Cleveland Clinic and Emory University over a 10-year period. Patient demographics, aneurysmal rupture, size, use of balloon remodeling, patient outcomes, intraprocedural rupture, and rerupture were reviewed.

RESULTS: Rupture rates were examined by size for all patients and subgroups and dichotomized to evaluate for size ranges associated with increased rupture rates. The highest risk of rupture was noted in aneurysms less than 4 mm. Of 347 aneurysms, 74 (21%) were less than 4 mm. The intraprocedural rupture rate was 5% (18/347) for ACoA aneurysms of any size. There was an intraprocedural rupture rate of 2.9% (8/273) among ACoA aneurysms greater than 4 mm compared with 13.5% (10/74) in less than 4-mm aneurysms. Procedural rupture was a statistically significant predictor of modified Rankin score after adjusting for Hunt and Hess grades (HH).

CONCLUSION: ACoA aneurysms less than 4 mm have a 5-fold higher incidence of intraprocedural rerupture during coil embolization. Outcome is negatively affected by intraprocedural rerupture after adjusting for HH grade.

Neurosurgery Department. “La Fe” University Hospital. Valencia, Spain


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