Pipeline versus Tubridge in the treatment of unruptured posterior circulation aneurysms

Background To compare the safety and efficacy of pipeline embolization device(PED)and Tubridge flow diverter(TFD)for unruptured posterior circulation aneurysms.Methods Posterior aneurysm patients treated with PED or TFD between January,2019,and December,2021,were retrospectively reviewed.Patients’demographics,aneurysm characteristics,treatment details,complications,and follow-up information were collected.The procedural-related complications and angiographic and clinical outcome were compared.Results A total of 107 patients were involved;PED was applied for 55 patients and TFD for 52 patients.A total of 9(8.4%)procedural-related complications occurred,including 4(7.3%)in PED group and 5(9.6%)in TFD group.During a mean of 10.3-month angiographic follow-up for 81 patients,complete occlusion was achieved in 35(85.4%)patients in PED group and 30(75.0%)in TFD group.The occlusion rate of PED group is slightly higher than that of TFD group.A mean of 25.0-month clinical follow-up for 107 patients showed that favorable clinical outcome was achieved in 53(96.4%)patients in PED group and 50(96.2%)patients in TFD group,respectively.No statistical difference was found in terms of procedural-related complications(p=0.737),occlusion rate(p=0.241),and favorable clinical outcome(0.954)between groups.Conclusions The current study found no difference in complication,occlusion,and clinical outcome between PED and TFD for unruptured PCAs.

Resolution of Symptoms after Parent Artery Occlusion Treatment for Giant Cavernous Carotid Artery Aneurysms

Background and Objective: Giant cavernous carotid artery aneurysms (CCAAs) often produce a variety of neurological deficits, primarily those related to ophthalmoplegia/paresis and headache. This study was designed to evaluate the resolution of symptoms after parent artery occlusion (PAO) treatment for giant CCAAs. Methods: We retrospectively reviewed a series of 17 consecutive giant CCAAs treated with PAO treatment. All patients were evaluated by balloon occlusion test (BOT) before treatment. Patients who could tolerate BOT were treated by PAO. The following outcomes were analyzed: angiographic assessment, evolution of symptoms and outcome at clinical follow-up using modified Rankin Scale (mRS). Results: A total number of 17 giant CCAAs were treated by PAO. The initial post-procedure and follow-up angiogram revealed complete occlusion in all patients, no new lesion was detected. Periprocedural infarcts occurred in 1 patient (5.9%). Procedure-related mortality and morbidity were 0% and 5.9%, respectively. At mean 31.8 months clinical follow-up, symptoms had disappeared in 7 (41.2%) of the patients, partially improved in 5 (29.4%), remained unchanged in 4 (23.5%) and worsened in 1 (5.9%) of cases. Sixteen (94.1%) patients presented a good clinical outcome (mRS 0 - 1). Conclusion: Most patients in our series improved or remained stable after PAO. The results of this study indicate that PAO can improve the outcome of those symptomatic giant CCAAs if BOT can be tolerated.

Role of endovascular embolisation for curative treatment of intracranial non- Galenic pial arteriovenous fistula

Background and purpose The safety and effectiveness of endovascular treatment for non-Galenic pial arteriovenous fistula(NGPAVF)is inadequately known.The aim of this study is to explore the role of endovascular embolisation for curative treatment of NGPAVF.Materials and methods Patients with NGPAVF underwent endovascular treatment from January 2011 to November 2019 in our institution were retrospectively reviewed.Demographics,clinical information,treatment details and clinical outcomes were collected.Factors associated with clinical outcomes were statistically analysed.Results Twenty patients were included,with a total of 22(2 patients have 2 fistulas)lesions.A total of 25 procedures were performed and 5 patients underwent 2 procedures.Follow-up ranged from 3 to 84 months(mean=34.5 months).Thirteen(59.1%)lesions in 12(60.0%)patients acquired immediate occlusion after initial treatment(immediately occluded group)and follow-up confirmed the complete obliteration.A total of 17(77.3%)lesions in 15(75.0%)patients were cured at last follow-up.The maximal diameter of feeding arteries(p=0.04)and the maximal diameter of the varix(p=0.01)in immediately occluded group was smaller than non-immediately occluded group.The number of feeding artery(p=0.004)and the maximal diameter of the varix(p<0.001)were much smaller in curative group than non-curative group.Seven patients suffered procedure-related complications.No patients had an increased Modified Rankin Scale(mRS)and all patients had favourable clinical outcome(mRS≥2)at last follow-up.Conclusions Endovascular therapy plays an important role in curative treatment of NGPAVF.Patients with less feeding arteries and small varix may be easier to be cured by endovascular embolisation.

Long-term outcomes of brainstem arteriovenous malformations after different management modalities: a single-centre experience

Objective The aims of this study are to clarify the long-term outcomes of brainstem arteriovenous malformations(AVMs)after different management modalities.Methods The authors retrospectively reviewed 61 brainstem AVMs in their institution between 2011 and 2017.The rupture risk was represented by annualised haemorrhagic rate.Patients were divided into five groups:conservation,microsurgery,embolisation,stereotactic radiosurgery(SRS)and embolisation+SRS.Neurofunctional outcomes were evaluated by the modified Rankin Scale(mRS).Subgroup analysis was conducted between different management modalities to compare the long-term outcomes in rupture or unruptured cohorts.Results All of 61 brainstem AVMs(12 unruptured and 49 ruptured)were followed up for an average of 4.5 years.The natural annualised rupture risk was 7.3%,and the natural annualised reruptured risk in the ruptured cohort was 8.9%.13 cases were conservative managed and 48 cases underwent intervention(including 6 microsurgery,12 embolisation,21 SRS and 9 embolisation+SRS).In the selection of interventional indication,diffuse nidus were often suggested conservative management(p=0.004)and nidus involving the midbrain were more likely to be recommended for intervention(p=0.034).The risk of subsequent haemorrhage was significantly increased in partial occlusion compared with complete occlusion and conservative management(p<0.001,p=0.036,respectively).In the subgroup analysis,the follow-up mRS scores of different management modalities were similar whether in the rupture cohort(p=0.064)or the unruptured cohort(p=0.391),as well as the haemorrhage-free survival(p=0.145).In the adjusted Bonferroni correction analysis of the ruptured cohort,microsurgery and SRS could significantly improve the obliteration rate compared with conservation(p<0.001,p=0.001,respectively)and SRS may have positive effect on avoiding new-onset neurofunctional deficit compared with microsurgery and embolisation(p=0.003,p=0.003,respectively).Conclusions Intervention has similar neurofunctional outcomes as conservation in these brainstem AVM cohorts.If intervention is adopted,partial obliteration should be avoided because of the high subsequent rupture risk.

Embolization of feeding arteries and symptom alleviation of mixed dural-pial arteriovenous malformations

Background: To examine whether embolization of dural or pial blood supply branch is more efficient for symptom alleviation for unruptured mixed dural-pial arteriovenous malformations (DPAVMs). Methods: We retrospectively reviewed 30 DPAVM patients from a database of 425 consecutive cerebral arteriovenous malformation (CAVM) patients who underwent endovascular embolization between January 2010 and December 2015 at our institution. Demographics, angioarchitectural characteristics, endovascular embolization details and patients clinical outcomes were recorded. The modified Rankin Scale (mRS), Engel‘s classification and Visual Analogue pain scale (VAS) were used to assess clinical outcomes. Results: The single center cohort data shows that the incidence of DPAVM is 7.1%. Among the 30 DPAVM patients, 9 (30.0%) are ruptured and 21 (70.0%) are unruptured. Four (19.0%) of the 21 unruptured DPAVM patients are failed to follow-up, leaving 17 to analysis the clinical outcomes. Clinical presentations of the 17 unruptured DPAVM patients are epilepsy (n=10), headache (n=5) and focal neurological dysfunction (n=2). Six patients have DPAVMs occluded via pial blood supply branches, 4 via dural branches and 7 via both pial and dural branches. Unruptured DPAVM patients with nidus occluded via dural blood supply branches, or both pial and dural branches have higher symptom alleviation rate than patients with nidus occluded via pial branches (100%/85.7% vs 66.7%). Conclusions: For DPAVM patients presented with epilepsy, headache and FND, embolization via dural blood supply branches may be more efficient for symptom alleviation. Large cohort study is needed to confirm the generalizability.

Dissecting aneurysms of the distal segment of the posterior cerebral artery: clinical presentation and endovascular management

Backgroud:We aimed to evaluate the clinical presentations and report the acceptable clinical and angiographic outcome of the distal posterior cerebral artery (PCA) dissecting aneurysms with parent artery occlusion (PAO).Methods:From June 2006 to July 2013,26 patients with PCA dissecting aneurysms were planned to be treated via endovascular PAO in our institution.Fourteen patients had ruptured aneurysms,and twelve patients had unruptured aneurysms.The endovascular modalities were the following:1) PAO (n =19),2) palliative embolization (n =5),and 3) proximal PAO (n =2).Glasgow Outcome Scale (GOS) was used to assess the clinical outcome.Results:The procedure was technically successful in all cases.In the PAO and proximal PAO group,all of the immediate angiography showed occlusion of the parent vessel,and follow-up imaging showed no recurrence of the aneurysms.In the palliative embolization group,one of five patients was died of rebleeding after the procedure,and follow-up digital subtraction angiography (DSA) showed the other four aneurysms recurred.Five procedure related complications occurred totally:rebleeding (n =1),hemiparesis (n =2),and hemianopsia (n =2).Conclusion:Dissecting aneurysms are dynamic lesions with variable and unpredictable evolution and a thorough treatment is warranted.Sacrificing the parent artery appears to be well tolerated for distal segment of PCA.We propose that this technique could be the first treatment option in treating dissecting aneurysms in this location.However,palliative occlusion of distal PCA dissecting aneurysms is not an advisable treatment option.

Associations between haemodynamics and wall enhancement of intracranial aneurysm

Background and purpose Previous studies have reported about inflammation processes(IPs)that play important roles in aneurysm formation and rupture,which could be driven by blood flow.IPs can be identified using aneurysmal wall enhancement(AWE)on high-resolution black-blood MRI(BB-MRI)and blood flow haemodynamics can be demonstrated by four-dimensional-flow MRI(4D-flow MRI).Thus,this study investigated the associations between AWE and haemodynamics in unruptured intracranial aneurysms(IA)by combining 4D-flow MRI and high-resolution BB-MRI.Materials and methods Between April 2014 and October 2017,48 patients with 49 unruptured IA who underwent both 4D-flow MRI and high-resolution BB-MRI were retrospectively included in this study.The haemodynamic parameters demonstrated using 4D-flow MRI were compared between different AWE patterns using the Kruskal-Wallis test and ordinal regression.Results The results of Kruskal-Wallis test showed that the average wall shear stress in the IA(WSSavg-IA),maximum through-plane velocity in the adjacent parent artery,inflow jet patterns and the average vorticity in IA(vorticityavg-IA)were significantly associated with the AWE patterns.Ordinal regression analysis identified WSSavg-IA(p=0.002)and vorticityavg-IA(p=0.033)as independent predictors of AWE patterns.Conclusion A low WSS and low average vorticity were independently associated with a high AWE grade for IAs larger than 4 mm.Therefore,WSS and average vorticity could predict AWE and circumferential AWE.

Correlation of periodontal diseases with intracranial aneurysm formation:novel predictive indicators

Background:We investigated whether periodontal diseases,specifically,periodontitis and gingivitis,could be risk factors of the incidence of intracranial aneurysms(IAs).Methods:We performed a case–control study to compare the differences in the periodontal disease parameters of 281 cases that were divided into the IAs group and non-IAs group.All cases underwent complete radiographic examination for IAs and examination for periodontal health.Results:Comparing with those in the non-IAs group,the cases in the IAs group were older(53.95±8.56 vs 47.79±12.33,p<0.001)and had a higher incidence of hypertension(76 vs 34,p=0.006).Univariate logistic regression analysis revealed that age(>50 years)and hypertension were predictive risk factors of aneurysm formation(odds ratio[OR]1.047,95%confidence interval[95%CI]1.022–1.073,p<0.001 and OR 2.047,95%CI 1.232–3.401,p=0.006).In addition,univariate and multivariate logistic regression analyses showed that the parameters of periodontal diseases,including gingival index,plaque index,clinical attachment loss,and alveolar bone loss,were significantly associated with the occurrence of IAs(all p<0.05).For further statistical investigation,the parameters of periodontal diseases were divided into four layers based on the quartered data.Poorer periodontal health condition(especially gingival index>1.1 and plaque index>1.5)had the correlation with IAs formation(p=0.007 and p<0.001).Conclusion:Severe gingivitis or periodontitis,combining with hypertension,is significantly associated with the incidence of IAs.

Treatment of tiny intracranial aneurysms with guidewire manipulation

Background:Tiny false intracranial rupture aneurysms are particularly rare. It is challenged both to neurosurgery and endovascular treatment.Methods:We present here five rare cases of perforator tiny aneurysms that were diagnosed based on DSA. These patients were found due to SAH, and they decided to treat these aneurysms with endovascular therapy. After numerous attempts, the coiling microcatheter failed to access the aneurysms. As a result, the aneurysms finally were treated with guidewire manipulation.Results:Mean follow-up time was about 10.4 months. The outcomes of the 5 cases were all surprisingly excel ent. The patients were followed up with angiography and telephone till now. No revascularization of aneurysm was found.Conclusions:This paper demonstrated for the first time to our knowledge that tiny false intracranial aneurysm may be treated with guidewire manipulation. While larger studies with long-term follow-up are required to validate these promising results, guidewire manipulation is a new approach worth considering when microcatheter cannot enter aneurysm.

Cell-free microRNA-21: biomarker for intracranial aneurysm rupture

Background:Deregulation of miRNA-21 expression has been reported to be associated with vascular smooth muscle behavior and cytoskeletal stability.This study is aimed to investigate the density of serum miRNA-21 in patients with different phases of intracranial aneurysms(IAs)and explore its warning function for IA rupture.Methods:A total of 16 in 200 IA patients were selected and categorized into 4 groups based on the phase of IA.Microarray study was carried out using serum miRNA and differentially expressed miRNAs were identified.Another 24 samples from a cohort of 360 patients were added and real-time polymerase chain reaction(RT-PCR)was performed on expanded sample size(n=40)for miRNA-21 validation.Potential gene targets of miRNA-21 were screened out from Gene Ontology(GO)database and literatures.Results:Microarray study identified 77 miRNAs with significantly different expression levels between experimental groups and the control group.RT-PCR assays validated significant downregulation of miRNA-21 in experimental groups,among which miRNA-21 expression level of daughter aneurysm group decreased the most.Bioinformatic analyses revealed that several target genes related with miRNA-21 may be involved in IA formation and rupture.Conclusions:This study suggested that miRNA-21 had a protective effect for intracranial vascular wall against remodeling and warning function for intracranial aneurysm rupture.Significant suppression of serum miRNA-21 in IA patients may provide diagnostic clues for aneurysm rupture and guide clinical intervention.

Efficacy and safety of a neurointerventional operation robotic assistance system in cerebral angiography

Background At present,neurointerventional surgery requires angiographers to perform operations in the digital subtraction angiography(DSA)room.Ionising radiation and chronic joint damage are still unavoidable for angiographers.Therefore,we researched and developed a neurointerventional robot-assisted system,which is operated by angiographers in an operating room outside the DSA room.We have conducted a prospective,multicentre,randomised controlled trial to evaluate the safety and efficacy of a robot-assisted system in human cerebral angiography.In the future,this research will provide a platform for the research and development of an intelligent surgical system and bring revolutionary progress in neurointerventional surgery.Methods From December 2020 to December 2021,260 patients were enrolled from three medical centres,who were randomly and equally divided into a robot-assisted system group and a clinical routine cerebral angiography group.The success rate of angiography,the rate of the catheter reaching the target vessel,the operation time,X-ray radiation exposure and the incidence of related adverse events were compared between the two groups.Results A total of 257 patients completed this trial;baseline characteristics of the two groups did not differ significantly.The success rate of angiography in both the control group and the experimental group was 100%.The rate of the catheter reaching the target vessel was 99.23%and 100.00%in the control and experimental groups,respectively.For the control versus experimental groups,the angiographic operation time was 48.59±25.60min versus 47.94±27.49min,respectively;the X-ray radiation dose was 735.01±554.77mGy versus 821.65±705.45mGy,respectively;and the incidence of adverse events was 23.44%versus 22.48%,respectively.No statistical differences were present between the two groups.Conclusion The robot-assisted surgical system is more convenient for cerebral angiography and is as safe and effective as the traditional cerebral angiography.