Contour-Assisted coiling with jailed microcatheter May result in better occlusion (CoCoJaMBO) in wide-necked intracranial aneurysms: Proof of principle and immediate angiographic results

Purpose Wide-necked bifurcation aneurysms, partially thrombosed, and recurrences of large and giant aneurysms are challenging to treat. We report our preliminary experience with a Contour-assisted coiling technique and discuss the periprocedural safety, feasibility, and effectiveness of the approach. Methods We retrospectively reviewed consecutive patients who received endovascular treatment for intracranial aneurysms with an intra-aneurysmal flow disruptor (Contour) at two neurovascular centres between October 2018 and December 2020 and identified patients treated with a combination of Contour and platinum coils. Clinical and procedural data were recorded. Results For this analysis, 8 patients (5 female) aged 60.1 ± 9.2 years on average were identified. Three of 8 aneurysms were associated with previous acute subarachnoid hemorrhage (SAH). The mean average dome height was 12.8 ± 7.6 mm, mean maximum dome width 10.3 ± 5.4 mm, and neck width 5.5 ± 2.5 mm. The mean dome-to-neck ratio was 1.9 ± 1.0. Immediate complete occlusion of the aneurysm was seen in 5 of 8 cases. In one SAH patient, a parent vessel was temporarily occluded but could be reopened rapidly. One device detached prematurely without any sequelae. No other procedural adverse events were recorded. Conclusion From this initial experience, Contour with adjunctive coiling is a safe and technically feasible method for endovascular treatment of large, wide-necked, partially thrombosed, recurrent, or ruptured bifurcation aneurysms. Further studies with larger numbers of patients and longer follow-up are needed to confirm our results.

Impact of Intravenous Aspirin Administration on Ventriculostomy-Associated Hemorrhage in Coiled Acute Subarachnoid Hemorrhage Patients

Purpose: Aspirin has beneficial effects on coiling, even in acute subarachnoid hemorrhage, but there is also a perceived risk of increased bleeding and, importantly, a concern regarding ventriculostomy-associated hemorrhage (VAH) in those with complicating hydrocephalus. We aimed to assess the rate and extent of VAH in patients specifically treated with procedural intravenous aspirin during endovascular coiling of ruptured intracranial aneurysms.Materials and Methods: This was a single neurovascular center retrospective observational study of consecutive patients treated over a three-year period. The rate of VAH assessed using computed tomography and clinical outcomes were compared in patients receiving intraprocedural intravenous aspirin loading (n=90) versus those that did not receive the drug (n=40).Results: There was a significantly elevated rate of VAH in patients receiving intravenous aspirin (30% vs. 2.5%, odds ratio 16.7 [95% confidence interval: 2.2–128.0], P<0.0001). The majority of VAH was <10 mm in size (70%) with the largest bleed measuring 20 mm. No hematoma required surgical evacuation. No difference in favorable outcome at discharge was demonstrated. There was no difference in mortality between the 2 groups.Conclusion: Loading with intravenous aspirin during endovascular treatment of ruptured intracranial aneurysms significantly increases the risk of VAH, but most are small with minimal impact on clinical outcome at discharge. Intravenous aspirin should probably be reserved for selected cases but should not be withheld based on risk of VAH.

Nautilus-assisted coil embolization for a complex AcomA wide-necked aneurysm in the setting of acute subarachnoid hemorrhage

Numerous devices and sophisticated strategies have been developed to further increase the number of aneurysms amenable to endovascular treatment.1–4 Despite the superfluity of available neurovascular armamentarium, wide-necked bifurcation aneurysms can still pose a significant technical challenge to the treating clinician.5–7 Neck bridging is a conceptually new approach, which provides increased occlusion rates with lower recurrence and complications rates.8–10 The Nautilus (EndoStream Medical) is an intrasaccular bridging device intended to assist in coil embolization of wide-necked cerebral aneurysms. This CE-marked device, available in various sizes, consists of flexible-layers, and is a nitinol-based, detachable implant. The device is delivered through a standard microcatheter with a minimal 0.0165" inner diameter and is fully radiopaque and completely resheathable.Owing to its unique ‘tornado’ like shape the device entirely reconstructs the aneurysmal neck, which facilitates the following coil embolization. In this video 1, we demonstrate the use of Nautilus - assisted coil embolization for a complex anterior communicating artery (AcomA) wide-necked aneurysm in the setting of acute subarachnoid hemorrhage.Video 1

Cerebral Vasculitis in a COVID-19 Confirmed Postpartum Patient: A Case Report

COVID-19 has primarily been reported as a respiratory illness, but involvement of other organ systems has been reported. We describe a case of a postpartum with COVID-19 who had cerebral vasculitis. The patient presented with headache, blurring of vision, right-sided body weakness, and incoordination. Cranial magnetic resonance imaging (MRI) and angiography (MRA) showed a small acute hemorrhage on the left occipital lobe with associated acute subarachnoid hemorrhage along the parietal and occipital convexities and bilateral moderate to severe narrowing of the cerebral vessels. The patient was discharged asymptomatic. On follow-up, patient had no residual neurologic deficits, and repeat cranial MRI/MRA showed complete resolution of the vasculitis. This report was compatible with the pattern of viral-induced vasculitis and provides support to the mechanism of COVID-19-associated neurologic manifestation.

Abstract MP8: Long Term Angiographic and Clinical Outcomes From 1,000 Aneurysms Treated With the Pipeline Embolization Device

Background and Purpose: Prospective studies have established the safety and efficacy of the Pipeline TM Embolization Device (PED) for the treatment of intracranial aneurysms (IA). Here, we report long-term outcomes from The Pipeline Embolization Devices for the Treatment of Intracranial Aneurysms (PEDESTRIAN) Registry. Methods: This was a retrospective review of prospectively collected data from the PEDESTRIAN registry. Between March 2006 and July 2019, consecutive patients with complex IA were treated with PED at one center in Argentina. Patients with unfavorable anatomy and/or recurrence following previous treatment were included, and those with acute subarachnoid hemorrhage (SAH) were excluded. The primary angiographic endpoint was complete occlusion and long-term stability. Clinical and angiographic follow-up was performed at 3-6 months, 12 months, and yearly thereafter. Results: A total of 835 patients (mean age 55.9±14.7 years; 80% [671/835] female) with 1,000 aneurysms were included. The majority (64.6%) of aneurysms were small (≤10mm), 25.6% were large (11-24mm), and 9.8% were giant (≥25mm). A total of 1,214 PEDs were deployed, with a single device deployed in 84.2% of aneurysms. Follow-up angiography was available for 85.1% of patients with 776 aneurysms at mean 24.6±25.0 months. Complete Raymond Roy I occlusion was demonstrated in 75.8% (588/776) of aneurysms at 12-months, 92.9% (300/323) at 2-4 years, and 96.4% (159/165) at >5 years. During the post-procedural period, mRS remained stable or improved in 96.2% of patients, with stability or improvement in 99.1% of patients in the longer term. The overall major morbidity and neurological mortality rate was 5.8% (44/835), and the all-cause mortality rate was 4.6% (38/835). Conclusions: Endovascular treatment of IA with PED is safe and effective, with rates of complete occlusion, complications, and mortality comparable to previous prospective studies. Serial angiographic follow-up showed high and increasing occlusion rates, with stable occlusion of all cases at 13 years.