脑动脉瘤血管内治疗的新技术

本文由美国加州大学尔湾分校医学院医学中心神经外科LI-MEI LIN教授团队执笔,详细总结并分析了近年来脑动脉瘤血管内治疗的重要进展.

Updates in the management of cranial dural arteriovenous fistula

Dural arteriovenous fistula(dAVF)accounts for approximately 10%of all intracranial vascular malformations.While they can be benign lesions,the presence of retrograde venous drainage and cortical venous reflux makes the natural course of these lesions aggressive high risk of haemorrhage,neurological injury and mortality.Endovascular treatment is often the first line of treatment for dAVF.Both transarterial and transvenous approaches are used to cure dAVF.The selection of treatment approach depends on the angioarchitecture of the dAVF,the location,the direction of venous flow.Surgery and,to a lesser extent,stereotactic radiosurgery are used when endovascular approaches are impossible or unsuccessful.

Procedural complexity independent of P2Y12 reaction unit(PRU)values is associated with acute in situ thrombosis in Pipeline flow diversion of cerebral aneurysms

background Acute in situ thrombosis is an ischaemic phenomenon during Pipeline embolisation device(PED)procedures with potentially high morbidity and mortality.There is controversy regarding the role of platelet function testing with P2Y12 assay as a predictor of intraprocedural thromboembolic events.There is limited knowledge on whether procedural complexity influences these events.Methods Data were collected retrospectively on 742 consecutive PED cases at a single institution.Patients with intraprocedural acute thrombosis were compared with patients without these events.results A cohort of 37 PED cases with acute in situ thrombosis(mean age 53.8 years,mean aneurysm size 8.4 mm)was matched with a cohort of 705 PED cases without intraprocedural thromboembolic events(mean age 56.4 years,mean aneurysm size 6.9 mm).All patients with in situ thrombosis received intra-arterial and/or intravenous abciximab.The two groups were evenly matched in patient demographics,previous treatment/subarachnoid hemorrhage(SAH)and aneurysm location.There was no statistical difference in postprocedural P2Y12 reaction unit(PRU)values between the two groups,with a mean of 156 in the in situ thrombosis group vs 148 in the control group(p=0.5894).Presence of cervical carotid tortuosity,high cavernous internal carotid artery grade,need for multiple PED and vasospasm were not significantly different between the two groups.The in situ thrombosis group had statistically significant longer fluoroscopy time(60.4 vs 38.4 min,p<0.0001),higher radiation exposure(3476 vs 2160 mGy,p<0.0001),higher rates of adjunctive coiling(24.3% vs 8.37%,p=0.0010)and higher utilisation of balloon angioplasty(37.8% vs 12.2%,p<0.0001).Clinically,the in situ thrombosis cohort had higher incidence of major and minor stroke,intracerebral haemorrhage and length of stay.Conclusions Predictors of procedural complexity(higher radiation exposure,longer fluoroscopy time,adjunctive coiling and need for balloon angioplasty)are associated with acute thrombotic events during PED placement,independent of PRU values.

Cerebral aneurysm treatment: modern neurovascular techniques

Endovascular treatment of cerebral aneurysm continues to evolve with the development of new technologies.This review provides an overview of the recent major innovations in the neurointerventional space in recent years.

Advances in endovascular aneurysm management: flow modulation techniques with braided mesh devices

Flow diverters and flow disruption technology,alongside nuanced endovascular techniques,have ushered in a new era of treating cerebral aneurysms.Here,we provide an overview of the latest flow modulation devices and highlight their clinical applications and outcomes.

Flow diversion covering the M1 origin as a last resort

Introduction Internal carotid artery termination(ICAT)and proximal A1 aneurysms can be challenging for open surgical clipping or endovascular coiling.Treatment with flow diversion covering the middle cerebral artery(MCA),an end vessel supplying a terminal circulation,has not been reported.Methods A prospective,Institutional Review Board-approved database was analysed for patients with pipeline embolisation device(PED)placement from the anterior cerebral artery(ACA)to the ICA during cerebral aneurysm treatment.Results Nine cases were identified,including five proximal A1,three posterior communicating artery and one ICAT aneurysm locations.Average aneurysm size was 8.3 mm(range 3-17),with 67%saccular and 78%right-sided.Primary indication for treatment was significant dome irregularity(44%),recurrence or enlargement(33%),underlying collagen vascular disorder(11%)and traumatic pseudoaneurysm(11%).Preservation of the ipsilateral ACA(with PED placed in A1)was performed when the anterior communicating artery(67%)or contralateral A1(33%)were absent on angiography.Adjunctive coiling was done in four cases(44%).There was one major stroke leading to mortality(11%)and one minor stroke(11%).Clinical follow-up was 27 months on average.Follow-up digital subtraction angiography(average interval 15 months)showed complete aneurysm obliteration(88%)or dome occlusion with entry remnant(12%).The jailed MCA showed minimal or mild delay(primarily anterograde flow)in 75%of cases and significant delay(reliance primarily on ACA and external carotid artery collaterals)in 25%.Conclusions Covering the MCA with a flow diverting stent should be reserved for select rare cases.Strict attention to blood pressure augmentation during the periprocedural period is necessary to minimise potential ischaemic compromise.