Flow diverter stents with hydrophilic polymer coating for the treatment of acutely ruptured aneurysms using single antiplatelet therapy: Preliminary experience

Background: The use of flow diverter stent (FDS) has limitations in cases of subarachnoid haemorrhage caused by ruptured aneurysm, due to the need for double antiplatelet therapy and the delay in the aneurysm occluding. The p48 MW and the p64 MW (Phenox) are available with Hydrophilic Polymer Coating (HPC), that reduces the risk of thrombus formation. Purpose of this study is to evaluate the safety and efficacy of p48 and p64 MW HPC with single antiplatelet therapy for the acute treatment of ruptured aneurysm. Methods: We retrospectively evaluated all patients treated for acutely ruptured aneurysms with a p48 MW HPC or p64 MW HPC from October 2019 to April 2020 using single antiplatelet therapy. For each patient, we considered demographic and aneurysm-related data, clinical presentation, size and location of the implanted flow diverter stent, intra- and post-procedural complications, aneurysm occlusion. Results: Seven patients were included. The ruptured aneurysms were four saccular, two blister-like and one dissecting, six in the anterior and one in posterior circulation. No intraprocedural stent thrombosis and rebleeding was observed. In two cases the aneurysm is completely excluded, in one patient it was found only neck perfusion, in three cases there were mild reduction of the sac and in one case there was a persistent perfusion. No patients needed retreatment in this series. Conclusion: In our experience, FDS HPC appears a potential treatment option in selected cases. Our study is limited by small population and short-term follow-up. We report our preliminary data, but further investigations are necessary

Treatment of cerebral arteriovenous malformations

Even today, arteriovenous malformations (AVM) are one of the most complex conditions encountered in neurosurgical practice. The difficulty in treatment is not confined to surgical resection of the AVM, but also affects the indications for treatment and the type of appropriate therapy. Each treatment aims at complete exclusion of the AVM. Partial resection has no significant effect on the risk of bleeding. Despite ongoing attempts to devise treatment protocols, each patient presenting an AVM is different and each individual case needs to be assessed by a team familiar with this type of lesion and aware of the percentage risk to the patient in proposing a treatment. A recent evaluation of numerous surgical series demonstrated an operative mortality for AVMs of different sizes at 3.3%. Post-operative angiography only displays complete exclusion of the AVM in 97% of cases. The aim of endovascular treatment is to exclude the nidus. If this is not achieved, the AVM will revascularize sooner or later. Endovascular treatment alone seldom results in complete occlusion of the AVM. Some literature reports describe a high mortality rate linked with endovascular treatment with percentages of around 1.6% with a 12.8% morbidity. In our experience, the morbidity linked to endovascular treatment is below 4%. Complications linked to radiosurgery are extremely rare. The main problem of radiosurgery with LINAC or gamma knife is the possibility of treating only small AVM successfully. From November 1991 to August 2001, AVM were found in 115 cases out of 1137 patients admitted for vascular malformations (10%). Of these, 93 (81%) had supratentorial AVM whereas 22 (19%) had subtentorial lesions. Treatment (surgery, embolisation, radiosurgery or a combination) was carried out in 94 cases (82%). Of the nine patients with non-bleeding AVM who did not receive treatment for various reasons, none experienced haemorrhage in the follow-up period of one to ten years. Of the 94 patients who had had a haemorrhage, 12 presented rebleeding of the AVM (13%). In an overall analysis of our results irrespective of the type of treatment and including untreated patients, 67 out of 115 (59%) were discharged without neurological deficit (good outcome). Overall morbidity was 29%; 14 patients died, giving a mortality rate of 12%. The decision how to treat each individual patients is taken after discussion with neuroradiologists and radiosurgeons. In general, in the cases referred to us, we acted as follows: - In superficial AVM less than 25-30 cm3 in non-eloquent brain areas, the lesion was treated surgically. - In AVM on the mesial face of the hemisphere or involving the cingulate or corpus callosum regions, direct obliteration was performed in six cases whereas three were treated by radiosurgery. - Deep para or intraventricular AVM or caudate nucleus or striocapsulothalamic lesions were usually treated by radiosurgery preceded by partial embolisation. - Small AVM in eloquent areas were treated by radiosurgery whereas large lesions were first treated by embolisation followed by radiosurgery. - AVM close to eloquent areas were usually treated surgically, possibly after endovascular therapy

Metastatic Mediastinal Germ-Cell Tumor and Concurrent COVID-19: When Chemotherapy Is Not Deferrable

This letter to the editor describes the case of a patient with mediastinal germ cell tumor who developed COVID-19 at the end of the first cycle of chemotherapy and continues the discussion on whether it is best to continue or delay administration of chemotherapy with an active COVID-19 infection