Flow-diversion panacea or poison?

Endovascular therapy is now the treatment of choice for intracranial aneurysms (IAs) for its efficacy and safety profile. The use of flow diversion (FD) has recently expanded to cover many types of IAs in various locations. Some institutions even attempt FD as first line treatment for unruptured IAs. The most widely used devices are the pipeline embolization device (PED), the SILK flow diverter (SFD), the flow redirection endoluminal device (FRED), and Surpass. Many questions were raised regarding the long-term complications, the optimal regimen of dual antiplatelet therapy, and the durability of treatment effect. We reviewed the literature to address these questions as well as other concerns on FD when treating IAs

Dural Arteriovenous Malformations: A Review of the Literature and a Presentation of the JHN Series

Dural arteriovenous malformations (DAVMs), also known as dural arteriovenous fistulas, are arteriovenous shunts from a dural arterial supply to a dural venous channel, typically supplied by pachymeningeal arteries and located near a major venous sinus.1 The etiology of these lesions is not fully understood. DAVMs in the pediatric population are associated with structural venous abnormalities ,2 but the majority of DAVMs are thought to be acquired. Different etiologies have been implicated in this phenomenon, namely: sinus thrombosis, trauma or surgery.2–

Endovascular Treatment of Cerebral Mycotic Aneurysm: A Review of the Literature and Single Center Experience

The management of mycotic aneurysm has always been subject to controversy. The aim of this paper is to review the literature on the intracranial infected aneurysm from pathogenesis till management while focusing mainly on the endovascular interventions. This novel solution seems to provide additional benefits and long-term favorable outcomes

Redefining Onyx HD 500 in the Flow Diversion Era

We report the largest US case series results using Onyx HD-500 (EV3), a new liquid embolic agent, in the successful treatment of 21 patients with wide-neck intracranial aneurysms (mean size 4.5 mm), which are at increased risk of incomplete occlusion or recanalization with standard endovascular intervention utilizing detachable platinum coils. All aneurysms were located in the anterior circulation, and three aneurysms presented as acute subarachnoid hemorrhages. Complete aneurysm occlusion was present in 19 of 21 patients (90%). On six-month followup, one patient with an initially small residual neck progressed to total occlusion. Aneurysm recanalization was not detected in any patients on mean follow up of 8.9 months in 11 patients. Four patients experienced transient neurologic deficits in the immediate postoperative period and one in a delayed fashion. Embolization with the liquid embolic agent Onyx appears to be a safe and effective endovascular modality of treatment for wide-neck aneurysms or recurrent aneurysms that had previously failed treatment with detachable coils

The ARUBA Trial: How Should We Manage Brain AVMs?

BACKGROUND Brain arteriovenous malformations (bAVMs) are abnormal shunts that bypass the capillary bed and directly divert blood from the arterial to the venous circulation, without exchanging nutrients or dissipating the arterial blood pressure. They are thought to be congenital vascular lesions that occur during the late stages of fetal development, however the exact pathogenesis has not been elucidated yet.1 History of hemorrhage, small AVM size, high arterial feeding blood pressure, and deep venous drainage are the main risk factors that increase the likelihood of AVM rupture. According to the American Stroke Association, 1 in 200-500 people have an AVM, while 25% of AVM patients experience seizures and 50% of patients suffer intracranial hemorrhage (ICH) at some point in their lives.2 Also, 5-15% of AVM patients experience severe headaches because of the increased intracranial pressure and a similar percentage of patients exhibit neurological deficits.1 With the advent of noninvasive imaging, AVMs are being detected at an early, unruptured stage, but the optimal course of action for preventing future complications still remains uncertain. The ARUBA trial strove to determine whether medical management or interventional therapy has a better long-term outcome for patients with unruptured AVMs. While it provides important data, limitations in its study design raise doubts concerning the generalizability of its findings. The study planned to include 800 patients who were to be followed for a minimum of five and a maximum of seven years.3 They were randomly assigned to one of two groups, the interventional therapy and medical management group. Patients in the medical management group received only pharmacological therapy for the medical symptoms that they experienced (unless they developed hemorrhage or infarction, in which case they were switched into the other group). Patients in the interventional therapy group received endovascular surgery, microsurgery, or radiosurgery, with or without pharmacological therapy depending on their concurrent medical conditions. The primary hypothesis was that medical management is more effective in the treatment of patients with unruptured bAVMs, the primary endpoint was death or stroke, the secondary endpoint was the quality of life, while the functional outcome status was measured using the Rankin scale.3 Previous studies had shown that early interventional treatment in patients with ruptured bAVMs is necessary and patients did not have major future clinical problems.3 Interventional therapy includes endovascular surgery, which aims to occlude the nidus by delivering liquid embolics or embolic coils via a catheter, microsurgical resection of the AVM, or radiosurgery that induces a vascular injury response resulting in AVM obliteration within 1 or 2 years.1 A multimodal therapy that involves more than one of these interventional procedures can also be performed on certain patients. Furthermore, medical management was shown to be very effective in treating unruptured bAVMs as indicated by the very low rate of future hemorrhage. Yet, based on data from the Columbia University Medical Center, interventional treatment of ruptured AVMs had a significantly greater likelihood of hemorrhage and/or clinical impairment (Rankin score ≥2) than medical management of unruptured AVMs. It is thus imperative to compare the effectiveness of the two methods of treatment only on patients with unruptured bAVMs, since patients who present with an ICH have an already much higher risk of experiencing a subsequent ICH (hazard ratio of 3.6).4 The ARUBA trial is the first study comparing medical management to surgical care on patients with unruptured bAVMs and a Rankin score less than two.

Decompressive Hemicraniectomy: Predictors and Functional Outcome In Patients With Ischemic Stroke

BACKGROUND Patients presenting with large ischemic strokes may develop uncontrollable, progressive brain edema that risks compression of brain parenchyma and cerebral herniation.1 Edema that does not respond to medical treatment necessitates decompressive hemicraniectomy (DH) as a life-saving procedure. The functional outcome of patients is uncertain and the patient’s family is presented with the difficult decision of intervention with DH. While the functional outcome of patients is not worsened by DH,2 neurological deficit is likely as a result of initial large-territory ischemia. The correlation of specific clinical variables preceding DH to patient outcome helps inform clinicians and families about prognosis.3 This study identifies an array of clinical variables in patients who underwent DH for ischemic stroke in order to investigate potential predictors of functional outcome. METHOD A total of 1,624 subjects that underwent any type of craniectomy from 2006 to 2014 were retrospectively screened via electronic medical record. The specific selection criterion was DH secondary to ischemic stroke involving the middle cerebral artery (MCA), internal carotid artery (ICA), or both. Subjects were excluded if they underwent craniectomy for any reason other than DH for ischemic stroke; or if the MCA or ICA were not implicated. The clinical variables that were collected may be divided into pre-DH and post-DH. The pre-DH variables involve patient demographics and past medical history, in addition to clinical variables during the period of presentation and clinical management leading up to DH. The post-DH variables describe the in-patient recovery period and discharge status. The primary outcome was functional status assessed by the Modified Rankin Scale (MRS) score at 90 days post-DH. The MRS ranges from 0 (no symptoms) to 6 (death) with intermediate values (1-5) representing increasing functional and cognitive disability

Extending the indications of flow diversion to small, unruptured, saccular aneurysms of the anterior circulation.

BACKGROUND AND PURPOSE: Flow diverters are currently indicated for treatment of large and complex intracranial aneurysms. The purpose of this study was to determine whether the indications of flow diversion can be safely extended to unruptured, small, saccular aneurysms (\u3c10 \u3emm) of the anterior circulation. METHODS: Forty patients treated with the pipeline embolization device (PED) were matched in a 1:4 fashion with 160 patients treated with stent-assisted coiling based on patient age, sex, aneurysm location, and aneurysm size. Procedural complications, angiographic results, and clinical outcomes were analyzed and compared. RESULTS: The rate of periprocedural complications was 5% in the PED group and 3% in the stent-coil group (P=0.7). In multivariable analysis, increasing age was the only predictor of complications. At follow-up, a higher proportion of aneurysms treated with PED (80%) achieved complete obliteration compared with stent-coiled aneurysms (70%) but the difference did not reach statistical significance (P=0.2). In multivariable analysis, increasing aneurysm size and aneurysm location were predictors of nonocclusion. The rate of favorable outcome (modified Rankin Scale, 0-2 and modified Rankin Scale, 0-1) was similar in the PED group and the coil group. CONCLUSIONS: The PED was associated with similar periprocedural risks, clinical outcomes, and angiographic results compared with stent-assisted coiling. These findings suggest that the indications of PED can be safely extended to small intracranial aneurysms that are amenable to conventional endovascular techniques. Larger studies with long-term follow-up are necessary to determine the optimal treatment that leads to the highest rate of obliteration and best clinical outcomes

Paradoxical Worsening of Ocular Symptoms after Spontaneous Closure of a Carotid Cavernous Fistula: Case Report

We report an interesting case of a spontaneous occlusion of a carotid cavernous fistula (CCF) causing a paradoxical worsening of orbital symptoms. A 59-year-old woman presented to our institution with conjunctival injection, raised intraocular pressures (IOP) and mild exophthalmos of her left eye. A digital subtraction angiography (DSA) demonstrated a Type-D CCF draining into the left superior ophthalmic vein (SOV). The patient declined endovascular treatment. She presented 15 months later with acute exacerbation of her orbital signs and symptoms. A DSA showed no evidence of arteriovenous fistula, and a brain MRI was consistent with spontaneous thrombosis of the SOV. At her 2-week clinical assessment, the patient showed clinical improvement and her IOP were within normal limits. Spontaneous thrombosis of the SOV can trigger the obliteration of a CCF with possible paradoxical worsening of orbital symptoms. DSA is the gold standard of diagnosis and management is directed toward decreasing IOP. Introduction We present an interesting case of a type-D carotid cavernous fistula (CCF) that closed spontaneously with a paradoxical worsening of the symptoms due to thrombosis of the superior ophthalmic vein (SOV). The authors also give directives for the management of these extremely rare cases