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Paediatric intracranial vascular malformations are rare and different from adult ones in vascular anatomy, pathophysiology, and symptoms. Their impact on the brain and their symptoms will differ in the antenatal period, in neonates, infants, and children. Clinical presentation includes seizures, focal neurological deficit, haemorrhage, congestive heart failure, hydrovenous disorder, and developmental delays. These malformations are thus associated with a poor prognosis if left untreated. Therefore, aggressive management is generally recommended and must be performed by a multidisciplinary team with extensive experience. Endovascular treatment is the first-choice treatment for most paediatric intracranial vascular malformations. Indication and timing for treatment should be decided on the basis of a careful assessment of neurological symptoms, growth and development, cardiac and other systemic manifestations, and imaging of the malformation and the brain tissue. WHAT THIS PAPER ADDS: Paediatric intracranial vascular malformations are rare, but their prognosis is poor if left untreated. Improved clinical, anatomical, and pathophysiological understanding of these complex lesions has improved prognosis. [ABSTRACT FROM AUTHOR]

Purpose: Wide-neck bifurcation intracranial aneurysms (WNBA) with a branch incorporated in the aneurysm base remain difficult to treat by embolization. We aim to report our long-term follow-up of stent-assisted coiling (SAC) in this subgroup of patients. Methods: This study was approved by our local ethical committee. A retrospective review of our prospectively maintained database identified all patients treated in our institution by SAC for a WNBA with a branch incorporated in the aneurysm base. Technical issues, immediate, long-term outcomes were evaluated. Results: Between 2007 and 2015, 49 patients with 53 intracranial aneurysms (IAs) (52 unruptured, 1 ruptured) were identified and successfully treated. No morbidity/mortality occurred. The incorporated branch was preserved in all patients but one who was treated during a vasospasm phase. At the first 6-month imaging control, the branch was patent. Immediate occlusion was near-complete in 11/53 aneurysms (20.8%), neck remnant in 20/53 aneurysms (37.7%), and incomplete in 22/53 aneurysms (41.5%). Available imaging follow-up of 47 IAs, ranging from 3 to 84 months (mean 26 months ± 19.6 months), showed 27 progressive thrombosis (57.4%), 17 stable occlusions (36.2%), 1 minor recanalization (2.1%), and 2 significant recanalizations that were retreated (4.3%). The latest imaging control showed 30 near-complete occlusions (63.8%), 13 neck remnants (27.7%), and 4 incomplete occlusions (8.5%). Conclusion: Stent-assisted coiling is safe and effective for the treatment of WNBA with a branch incorporated in the aneurysm base. Despite poor immediate anatomical results, long-term follow-up shows a high rate of progressive thrombosis achieving adequate and stable occlusion in most patients. [ABSTRACT FROM AUTHOR]

Introduction: The Leo stent was the first retrievable stent for endovascular treatment of intracranial aneurysms (IAs). We report our experience with this device with emphasis on very long-term follow-up. Methods: This study was approved by authors' ethical committee. A retrospective review of our prospectively maintained database identified all patients treated for a saccular IA with this stent in our institution. Technical issues and immediate and long-term outcomes (at least 12 months) were evaluated. Results: Between 2004 and 2015, 50 patients with 52 IAs were identified. In two patients, the stent could not safely be placed (failure rate = 3.8%). Among 48 treated patients with 50 IAs, there were 44 women and 4 men (mean age, 53 years). Mean aneurysm diameter was 7.2 mm. All IAs but six were wide-necked. There was no immediate morbidity or mortality. Anatomical results included 76% complete occlusions, 22% neck remnants, and 2% incomplete occlusions. Mean follow-up was 50.2 months (range, 12-139 months). Two patients had delayed TIAs but long-term morbidity rate remained = 0%. At follow-up, occlusion was stable in 68% IAs, showed thrombosis in 12%, and recanalization in 20% IAs. Complementary treatment was required in 8% IAs. Final results showed 70% complete occlusions, 24% neck remnants, and 6% incomplete occlusions. Asymptomatic stent occlusion and significant stenosis occurred in one and two cases, respectively. Conclusion: The Leo stent is safe and effective for treatment of wide-necked saccular IAs. Very long-term results show high rates of adequate and stable occlusion. Moreover, the stent is well tolerated. [ABSTRACT FROM AUTHOR]

Introduction: Aneurysms superiorly located on the proximal segment of the middle cerebral artery (PMCAA) are rare and challenging to treat. No information is available regarding their management by endovascular approach. The aim of this study was to report our experience with endovascular treatment (EVT) of PMCAA. Methods: A retrospective review of our prospectively maintained database identified all PMCAA treated in our institution. The clinical charts, procedural data, and angiographic results were reviewed. Results: From April 2004 to December 2011, 17 patients were identified including six who presented with subarachnoid hemorrhage (SAH) and 11 with an unruptured PMCAA. All aneurysms were small (<6 mm) and had a branch arising from the neck or the sac, and 15/17 were wide-necked. All patients were successfully treated by balloon-assisted coiling ( n = 10), stent-assisted coiling ( n = 5), and coiling ( n = 2). No technical or clinical complication occurred. Fifteen patients showed an excellent clinical outcome, and two kept a slight or a significant deficit that were both SAH-related. Immediate anatomical outcome includes nine complete occlusions and eight neck remnants. Imaging follow-up in 11 patients (mean = 21, range, 6 to 60 months) showed stable or improved results in all cases. Conclusion: Our study is the first reported series of patients with PMCAA treated by selective embolization. It suggests that EVT is a safe and effective alternative to surgery for the management of PMCAA. Balloon- or stent-assisted coiling are needed in most cases because of PMCAA morphological characteristics. [ABSTRACT FROM AUTHOR]

Objective: To report our preliminary experience with the Pipeline flow-diverter stent for the endovascular treatment (EVT) of intracranial aneurysms. Methods: Between September 2009 and October 2010, 20 patients with 27 fusiform or wide-necked unruptured aneurysms were included and treated by Pipeline stent placement alone. Technical issues, immediate findings, delayed complications, and clinical and imaging follow-up at three and six months were assessed. Results: EVT was successfully performed in all patients. Clinical outcome was excellent in all but one patient who died. This latter patient developed a massive infarct due to a delayed stent thrombosis. Other complications without permanent deficit included one perimesencephalic subarachnoid hemorrhage and one retroperitoneal hematoma. Minor technical issues without clinical consequence were encountered in nine patients and included stent migration, stent misplacement, unanticipated stent shortening, and the impossibility to recapture the distal coil tip of the supporting device. Angiographic follow-up in 19 patients with 25 aneurysms showed 21 complete occlusions, one neck remnant, and three incomplete occlusions. No significant parent artery stenosis was seen. Conclusion: This study shows that the Pipeline stent is useful for EVT of fusiform and wide-necked intracranial aneurysms. Moreover, the stent is well tolerated with a low rate of intra-stent stenosis at short-term follow-up. However, technical improvements are needed to ensure safe and precise use of the device. [ABSTRACT FROM AUTHOR]

Stent-assisted coiling (SAC) is an alternative to surgical clipping for the treatment of wide-necked intracranial aneurysms (IA). However, little information is available concerning the long-term results of this treatment. The aim of this study was to report the long-term clinical and anatomical findings in 32 patients with 34 wide-necked IA treated by SAC. A retrospective review of our prospectively maintained database identified all patients followed up for wide-necked IA treated by SAC. The clinical charts, procedural data, and angiographic results were reviewed. Thirty-two patients with 34 IA were identified including 25 asymptomatic patients, four with cranial nerve palsies, two with a subarachnoid hemorrhage, and one with transient ischemic attacks. Mean aneurysm size was 10.2 mm (range 3.5 to 26 mm). Embolization was successful in all patients and no procedure-related neurological morbidity or mortality was observed. Immediate anatomical results included nine complete occlusions (26.5%), two neck remnants (6%), and 23 incomplete occlusions (67.5%). Mean imaging follow-up of 20 months showed 18 further thrombosis (53%) and 16 stable results (47%). Finally, 27 aneurysms were completely occluded (79%), three had a neck remnant (9%), and four were incompletely occluded (12%). Asymptomatic and nonsignificant in-stent stenosis occurred in seven patients (22%). SAC is safe and effective for the treatment of wide-necked IA. Despite unsatisfying immediate aneurysm occlusion, the adjunctive effect of the stent is stabilizing or significantly improving long-term anatomical results. [ABSTRACT FROM AUTHOR]

Aneurysms of the proximal segment of the anterior cerebral artery (A1A) are rare and challenging to treat. No information is available regarding their management by endovascular approach. The aim of this study was to report our experience with endovascular treatment (EVT) of A1As. A retrospective review of our prospectively maintained database identified all A1As treated in our institution. The clinical charts, procedural data, and angiographic results were reviewed. From April 2004 to August 2008, eight patients were identified and presented with an unruptured A1A. All aneurysms but one were <3 mm in diameter and two aneurysms had a perforator at the neck. Surgery was performed in two patients with an aneurysm <2 mm. Six patients were treated by selective embolization including five patients with balloon-assisted coiling (BAC) and/or via a retrograde approach from the contralateral side through the anterior communicating artery. These adjunctive techniques were used to safely catheterize the sac or to protect a branch at the neck. All patients showed an excellent clinical outcome. A complete aneurysm occlusion was obtained in all but one patient. Follow-up imaging in four patients showed stable results. EVT of A1As is feasible and associated with good clinical and anatomical results. Because of their location, small size, and close relationship with perforators, EVT frequently requires the use of BAC and/or a retrograde approach. Our results suggest that EVT is an alternative therapeutic option to surgical clipping if the aneurysm size is compatible with selective embolization. [ABSTRACT FROM AUTHOR]

Follow-up of intracranial aneurysms treated by embolisation with detachable coils is mandatory to detect a possible recanalisation. The aim of this study was to compare contrast-enhanced magnetic resonance angiography (CE-MRA) with digital substraction angiography (DSA) used to detect aneurysm recanalisation to determine if DSA is still needed during follow-up. From May 2006 to May 2007, 55 patients with 67 aneurysms were treated by endosaccular coiling with ( n = 9) or without ( n = 58) an adjunctive stent. Follow-up imaging protocol included MRA at 6 and 12 months and a DSA at 12 months or earlier if a major recanalisation was identified on the 6-month MRA. Two neuroradiologists independently reviewed MRA images (readers 1 and 2) and two other reviewed DSA images. Follow-up DSA showed stability of the aneurysm occlusion in 52 cases, recanalisation in 14 cases, and further thrombosis in one. On CE-MRA, both readers identified all recanalisations but one (sensitivity of 93%) as they missed a major recanalisation in a 2-mm ruptured aneurysm. There were two false-positive evaluations by reader 1 and three for reader 2. Mean specificity of CE-MRA to detect aneurysm recanalisation was 95.5%. CE-MRA is accurate to detect aneurysm recanalisation after embolisation with detachable coils. CE-MRA may be proposed as first-intention imaging technique for their follow-up. However, its sensitivity and specificity remain inferior to that of DSA and major recurrences may be missed in very small aneurysms. Therefore, a single DSA remains mandatory during the imaging follow-up. [ABSTRACT FROM AUTHOR]

Within the neurosurgical literature on intracranial aneurysms, balloon-assisted coiling (BAC) remains controversial when compared to conventional coiling (CC). The aim of this study was to compare our results with BAC and CC over a 4-year period. Daily interventional neuroradiology has been available since March 2004 in our institution. Between March 2004 and February 2008, 275 patients with 357 aneurysms were treated by an endovascular approach, including 174 patients/204 aneurysms treated by CC (group I) and 80 patients/92 aneurysms treated by BAC (group II). The remaining patients were treated with other endovascular techniques. Indications of BAC were as follow: aneurysms with an unfavourable neck/sac ratio and/or a branch arising from the neck (90.2%), unstable coiling catheter (6.5%), and anticipated aneurysm rupture (3.3%). The clinical charts, procedural data, and angiographic results of groups I and II were compared. BAC was used in 25.8% (92/357) of all embolized aneurysms and it was successful in 83/92 aneurysms (90%). There was no significant difference in the procedure-related morbidity and mortality rates between group I (2.3% and 1.15%, respectively) and group II (2.5% and 1.25%, respectively). Although retreatment was more frequent in group II (13%) than in group I (11%), the difference was not statistically significant ( P = 0.8125). When BAC is used frequently, it is a safe and effective technique that is associated with complication rates comparable to those of CC. Although BAC is not associated with more stable anatomical results, it should be considered as an alternative therapeutic option for the treatment of broad-based intracranial aneurysms. [ABSTRACT FROM AUTHOR]

We report our experience with endovascular treatment (EVT) of circumferential and fusiform intracranial aneurysms by a reconstructive approach with self-expandable stents. A retrospective review of our prospectively maintained database identified all circumferential and fusiform aneurysms treated by a reconstructive endovascular approach over a 3-year period. Clinical charts, procedural data, and angiographic results were reviewed. From April 2004 to May 2007, 13 patients were identified, of whom 12 were asymptomatic and 1 presented with a subarachnoid hemorrhage. Two patients with an aneurysm ≤2 mm were treated by stent-within-stent placement without coiling (group 1). In 11 patients with a larger aneurysm, stenting with subsequent coiling was performed (group 2). In this latter approach, a balloon was temporarily inflated within the stent to ensure safe coil delivery. All patients showed an excellent clinical outcome. Asymptomatic procedural complications occurred in three patients, two with cervical internal carotid artery dissection and one with retroperitoneal hematoma. In patients of group 1, the aneurysm had completely disappeared at 6 months. In patients of group 2, aneurysm occlusion was complete in three and incomplete in eight. Follow-up angiography in 12 patients showed four with further thrombosis, six with stable results, and two with minor recanalization. Circumferential and fusiform intracranial aneurysms may be treated by a reconstructive endovascular approach with self-expandable stents. In small aneurysms, a stent-within-stent technique is effective, whereas stenting and subsequent coiling is indicated in larger aneurysms. This therapeutic protocol is associated with good clinical and anatomical results. [ABSTRACT FROM AUTHOR]

Abstract: Background: Transcranial approaches for transsinusal endovascular therapy of DAVF have been sporadically reported by large craniectomies. Large craniectomies carry nevertheless a risk of postembolization extradural hematoma, reduced by delaying the endovascular procedure. We report a 1-session technique of SIGC for percutaneous transvenous DAVF embolization. Case Description: This 58-year-old woman developed a right-sided cerebellar hematoma in relation with a high-grade left transverse and sigmoid sinus DAVF. The DAVF was fed by branches from the left vertebral artery, left internal, and left external carotid arteries, draining into the transverse sinus with retrograde flow in cortical veins. Transvenous retrograde embolization was not feasible either through the left internal jugular vein because of thrombosis, or through the right one because of torcular septa. During the same anaesthetic session, a 5-cm-length selective craniectomy was shaped under magnetic resonance image guidance navigation according to the left transverse sinus with high-speed drill. Thereafter, back in the angiography room, the transverse sinus was taped and coiled resulting in a complete exclusion of the DAVF. Conclusion: Selective image-guided craniectomy is efficient and safe for direct percutaneous transvenous embolization of DAVF in a single anesthetic session. Leaving bone beside the sinus prevents a parenchymal traumatic puncture. This bone has nevertheless to be drilled to allow an adequate sharp puncture angle. Doing so, postoperative hematoma is prevented by the small bone opening, the natural adherence of the dura matter and the possibility of direct compression. [Copyright &y& Elsevier]

We report a new technique of 'linear' stent-assisted coiling for the endovascular treatment (EVT) of a large and very wide-necked unruptured middle cerebral artery (MCA) bifurcation aneurysm in a 45-year-old man. Two self-expandable stents were delivered within the MCA bifurcation branches with both proximal stent ends facing each other within the MCA bifurcation. Thanks to this linear stents placement, complete aneurysm neck coverage was obtained in order to safely coil the sac. [ABSTRACT FROM AUTHOR]

Abstract External hydrocephalus (EH) is a recognised sub-type of hydrocephalus associated with macrocephaly in infancy. EH is characterised by the enlargement of subarachnoid spaces (so-called subarachnomegaly) with a normal ventricular system on brain imaging. EH is traditionally considered benign and self-limiting, yet its pathophysiology remains puzzling. Mounting evidence for an association between EH and hydrovenous disorders reshapes our understanding of this condition and its management. To our knowledge, we report the first association between EH and dural arteriovenous fistula (dAVF) in a 17-months-old boy. As dAVF may be a life-threatening condition, early diagnosis and optimal treatment are critical. This case epitomises the intricacies of EH’s aetiology and associated conditions requiring careful management. Therefore, we recommend considering MR angiography in EH’s workup and long-term follow-up. Our experience supports the ongoing reconsideration of EH’s presumed benignity. [ABSTRACT FROM AUTHOR]

The editorial comments on the limitations of endovascular treatment (EVT). The author argues that research and experimental use of stent-assisted coiling for conditions such as preventing aneurysm recanalization and aiding vessel wall healing will expand EVT indications as well as the use of stent-assisted techniques for intracranial aneurysm (AI) treatment.

A response by T. Boulanger and colleagues to a letter to the editor about their article "Stenting is improving and stabilising anatomical results of coiled intracranial aneurysms" published online is presented.

Purpose: Embolization of arteriovenous malformations (AVMs) before radiosurgery has been reported to negatively impact the obliteration rate. This study aims to assess treatment outcomes in a series of 190 patients treated by Gamma Knife radiosurgery (GKRS) for previously embolized AVMs. Methods: The institutional database of AVMs was retrospectively reviewed between January 2004 and March 2018. The clinical and radiological data of patients treated with GKRS for previously embolized AVMs were analyzed. Predicting factors of obliteration and hemorrhage following GKRS were assessed with univariate and multivariate regression analyses. Results: The mean AVM size was significantly reduced after embolization (p < 0.001). The obliteration rate was 78.4%. Multivariate analyses showed that a lower Spetzler-Martin grade (p = 0.035) and a higher marginal dose (p = 0.007) were associated with obliteration. Post-GKRS hemorrhages occurred in 14 patients (7.4%). A longer time between diagnosis and GKRS was the only factor associated with post-GKRS hemorrhages in multivariate analysis (p = 0.022). Complications related to the combined treatment were responsible for a new permanent neurological disability in 20 patients (10.5%), and a case of death (0.5%). Conclusions: This study shows that the embolization of AVMs does not have a negative impact on the obliteration rate after radiosurgery. Embolization reduces the AVM size to a treatable volume by GKRS. However, the combined treatment results in an increased complication rate related to the addition of the risks of each treatment modality. [ABSTRACT FROM AUTHOR]

Purpose: Wide-neck bifurcation aneurysms remain challenging for the neurointerventionist and/or neurosurgeon despite many recent advances. The pCONus (Phenox, Bochum, Germany) is an emerging device for endovascular neck protection, we report the first long-term results of this device. Methods: We performed a retrospective analysis of all consecutive intracranial wide-neck bifurcation aneurysms treated with the pCONus. Patients' characteristics were reviewed, procedural complications, angiographic (Roy-Raymond scale) and clinical outcomes were documented. Results: Between January 2016 and September 2019, 43 patients (74% female, median age 56 [49–66] years) with 43 wide-neck bifurcation aneurysms (mean width of 6.8 ± 2.1 mm, dome/neck ratio of 1.3 ± 0.2 and neck of 5.2 ± 1.3 mm) were included. A procedural angiographic complication was reported in five patients (12%), no patient presented a post-operative neurological deficit or long-term complication, mortality rate was 0%. At last follow-up (median of 46.5 months [38.3–51.7]), an adequate occlusion (complete and neck remnant) was observed in 37/43 patients (86%) and an aneurysm remnant in 6/43 (14%). Four patients (9%) needed retreatment. No in-stent stenosis or branch occlusion was depicted. Conclusion: pCONus device provides a safe and efficient alternative for endovascular wide-neck bifurcation aneurysms management, with long-term stability. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the safety and efficacy of the Tigertriever 13 (Rapid Medical, Yoqneam, Israel) stent retriever in acute ischemic stroke (AIS) patients with primary or secondary distal, medium vessel occlusions (DMVO). Methods: We performed a retrospective analysis of all consecutive AIS patients who underwent thrombectomy with the Tigertriever13 for DMVO. Patients' characteristics were reviewed, procedural complications, angiographic (modified thrombolysis in cerebral infarction score [mTICI]) and clinical (modified Rankin Scale [mRS]) outcomes were documented. Results: Between November 2019 and November 2020, 16 patients with 17 DMVO were included (40% female, median age 60 [50–65] years). The Tigertriever13 was used in 11/17 (65%, median NIHSS of 8 [6–15]) primary DMVO and in 6/17 (35%, median NIHSS of 20 [13–24]) cases of secondary DMVO after a proximal thrombectomy. The successful reperfusion rate (mTICI 2b, 2c, 3) was 94% (16/17) for the dedicated vessel. At day 1, CT imaging showed a subarachnoid hemorrhage in 29% of the cases and a parenchymal hematoma in 12%. At 3 months, 65% of the patients (11/17) had a favorable outcome (mRS 0–2). Conclusion: Mechanical thrombectomy using the Tigertriever13 appears to be safe and effective for DMVO. Clinical and anatomical results are in line with those of patients with proximal occlusions. [ABSTRACT FROM AUTHOR]

Good clinical outcome predictors have been emphasized in mechanical thrombectomy (MT) for acute ischemic stroke (AIS) with large vessel occlusion. MT for distal, medium vessel occlusions (DMVO) is still debated. We sought to assess the factors associated with clinical outcome after MT for DMVO. We retrospectively analyzed the data of consecutive patients who underwent MT for a primary DMVO in 1 large academic center and aimed to identify the baseline clinical, imaging, and MT factors associated with good clinical outcome (defined as modified Rankin scale score of 0–2) at 3 months. Between January 2018 and January 2021, 61 patients underwent a MT for an AIS with a primary DMVO. Overall, good clinical outcome was achieved in 56% (34 of 61) of our patients. In multivariate analysis, an older age (odds ratio [OR] 0.89 [95% confidence interval 0.83–0.96], P = 0.003), longer puncture to recanalization time (OR 0.97 [0.93–0.99], P = 0.033), and higher baseline core volume (OR 0.84 [0.75–0.94], P = 0.003) decreased the probability of good clinical outcomes, while a final complete (or near-) recanalization (modified Thrombolysis In Cerebral Infarction [mTICI] score 2c–3) increased the probability of good outcome (OR 14.19 [1.99–101.4], P = 0.008). An older age, a longer puncture to recanalization time, and a higher baseline core volume decreased the probability of good clinical outcomes, while successful recanalization (mTICI 2c–3) was associated with better outcomes after MT for DMVO. [ABSTRACT FROM AUTHOR]

We report a case of cerebral aneurysm rerupture 24 months after initial bleeding and complete occlusion using a WEB device. A middle-aged patient was transferred at our institution because of a recurrent aneurysmal bleeding. The patient was graded WFNS2 and unenhanced CT showed a modified Fisher grade 3 SAH. DSA showed an increased compaction and an evolutive "proximal recess" of the WEB device associated with a small unprotected part of the aneurysm wall and a bleb pointing towards the haemorrhage. Balloon- and stent-assisted coiling was performed, allowing to completely occlude the recurrence. The patient suffered no neurological deficit neither delayed complication and was discharged at day 16. [ABSTRACT FROM AUTHOR]

Purpose: Endovascular treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents requires a prophylactic antiplatelet premedication to avoid thrombo-embolic complications. Guidelines for optimal antiplatelet regimens are poorly defined. The aim of this study is to report our experience using a high dosage antiplatelet premedication regimen for patients with unruptured intracranial aneurysms undergoing endovascular treatment by stent-assisted coiling or flow diverter stents. Methods: From a retrospective analysis of a prospectively maintained database, we collected clinical and angiographic data of 400 procedures in 362 patients treated by stent-assisted coiling or flow diverter stents for 419 unruptured intracranial aneurysms. Descriptive and analytic statistics were performed to report morbidity, mortality, and complication rates and to demonstrate associations between variables and outcomes. Logistic multivariable regression was performed to rule out confounding factors between subgroups. Results: Thrombo-embolic complications occurred in 23/400 procedures (5.75%) and hemorrhagic complications in 19/400 procedures (4.75%). The majority of complications were minor and transient with overall procedure-related morbidity and mortality rates of 1.75% (n = 7/400) and 1.25% (n = 5/400) respectively. The co-existence of multiple cardiovascular risk factors among smoking, hypertension, dyslipidemia, and age > 65 years old was significantly associated with permanent procedure-related morbidity (p = 0.006) and thrombo-embolic complications occurrence (p = 0.034). Age alone was associated with higher permanent morbidity (p = 0.029) and was the only variable associated with higher hemorrhagic complication (p = 0.024). Conclusion: In this study, the use of a high dosage antiplatelet premedication was safe and effective for the treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents. Mortality and morbidity rates compare favorably with the current literature. The thrombo-embolic complications rate is low and most of them were clinically silent. However, the hemorrhagic complications rate was substantial and a significant proportion of them were associated with mortality. [ABSTRACT FROM AUTHOR]

Introduction: Stent-assisted coiling has widened indications and improved stability of endovascular treatment of intracranial aneurysms. However, stent-assisted coiling is usually not used to treat acutely ruptured intracranial aneurysms to avoid antiplatelet therapy. The objective of this study is to evaluate a strategy of staged endovascular treatment of ruptured intracranial aneurysms including coiling at the acute phase with complementary stenting with or without coiling at the subacute phase. Material and methods: Between 2012 and 2017, we retrospectively identified, in our prospectively maintained database, all patients treated for a ruptured intracranial aneurysm based on this staged stenting strategy. Clinical charts and imaging follow-up were analyzed to assess the procedural safety and feasibility as well as clinical and anatomical outcome. Results: We identified 23 patients with 23 intracranial aneurysms including 15 (65.2%) women with a mean age of 50 years (range 24–69 years). No rebleeding occurred during the mean delay of 24.3 days between initial coiling and stenting. All procedures were successful and additional coiling was performed in 5/23 procedures (21.7%). Clinical status was unchanged in all patients. At follow-up, the modified Rankin scale was graded 0 in 19/23 (82.6%), 1 in 2/23 (8.7%), and 2 in 2/23 (8.7%) patients, respectively. The rate of complete occlusion rose from 30.4% before the stenting procedure to 52.2% immediately after and 72.7% at follow-up. Conclusion: This strategy of early staged stenting in selected patients is safe and improves immediate intracranial aneurysm occlusion and long-term stability in this population at high risk of intracranial aneurysm recurrence with coiling alone. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the ability of dual-energy CT angiography (DECTA) in metal artifact reduction in patients with treated intracranial aneurysms by comparing DECTA-based virtual monoenergetic extrapolations (VMEs) and mixed images (MI).Methods: Thirty-five patients underwent prospectively a dual-source DECTA (Somatom Force, Siemens Medical Solutions, Forchheim, Germany) after aneurysm repair. A total number of 40 aneurysms (23 treated by coil embolization and 17 treated by surgical clipping) were analyzed. Mixed images (equivalent to a conventional single-energy CT angiography) were compared to VMEs at 75, 95, and 115 keV. Artifact severity was assessed quantitatively by measuring the mean attenuation value and standard deviation within regions of interest placed in the most hypodense coil or clip artifact area. Artifact severity score and contrast vessel score were also assessed qualitatively by two independent blinded readers.Results: In those aneurysms treated by surgical clipping, quantitative and qualitative analyses showed significant reduction of artifacts on VMEs compared to MI with the best compromise being obtained at 95 keV in order to keep an optimal vessel contrast in the adjacent vessel. In those aneurysms treated by coil embolization, there was no significant reduction of artifacts both on quantitative and qualitative analyses.Conclusion: Dual-source DECTA was helpful in order to reduce clip artifacts on VMEs with the optimal adjacent vessel visualization obtained at 95 keV, whereas this technique was not helpful in aneurysms treated by coiling. [ABSTRACT FROM AUTHOR]

Introduction: The p64 flow diverter (FD) device is a fully resheathable and detachable stent dedicated for endovascular treatment (EVT) of intracranial aneurysms (IAs). We report our mid-term experience with this device. Methods: Between January 2015 and February 2016, we retrospectively identified, in our prospectively maintained database, all patients treated with p64 FDs in two institutions. Independent clinical follow-up was performed by a vascular neurologist. Imaging follow-up included a digitalized subtraction angiography (DSA) at 3, 6, and 12 months and a magnetic resonance angiography (MRA) at 12 months. Results: Thirty-nine patients (22 women/17 men; median age 54 years) with 48 IAs (median aneurysm size 6.2 mm; mean neck size 3.4 mm) were identified. All IAs were saccular and unruptured. Failure of safe stent delivery occurred in 15% of cases (7/48 IAs) which were excluded. Transient neurological morbidity occurred in 2/35 patients (5.7%) including one delayed thromboembolic complication. No permanent morbidity or mortality was encountered. Complete aneurysmal occlusion at 3, 6, and 12 months was 20/30 (66.6%), 18/27 (66.6%), and 24/28 (85.7%), respectively. Intra-stent stenosis was observed in 9/29 patients (31%) and classified as moderate in 4/29 (13.7%) and mild in 5/29 patients (17.2%). These stenoses gradually improved over time, with only mild stenoses being identified at 6 months and at 12 months. Conclusion: In our small case series, the p64 FD stent appears safe and effective for EVT of IAs. A high occlusion rate and a low morbidity rate were observed. [ABSTRACT FROM AUTHOR]

Introduction: The Low-profile Visualized Intraluminal Support (LVIS) Junior stent is dedicated for endovascular treatment of wide-neck intracranial aneurysms located on small-diameter vessels (2-3.5 mm). This study reports midterm clinical and anatomical results of this device. Methods: This study was approved by authors' ethical committees. A retrospective review of our prospectively maintained database identified all patients treated by this stent in three institutions. Technical issues and immediate and mid-term anatomical and clinical outcomes were evaluated. Results: Forty patients (30 women/10 men, mean age of 55 years) with 43 aneurysms were identified. Mean aneurysm diameter was 5.6 mm (range, 2-13 mm). In all patients, treatment was successful and the stent could be precisely placed. There were three procedure-related complications, one stent thrombosis and two aneurysm ruptures, leading to immediate morbidity in one patient. Delayed ischemic events occurred in three patients including two transient attacks and one permanent deficit. The overall permanent morbidity rate was thus 5 %. No mortality occurred. Immediate aneurysm occlusion consisted of 36 complete occlusions (83.7 %), five neck remnants (11.6 %), and two incomplete occlusions (4.7 %). Twenty-seven patients (29 aneurysms) and 11 patients (11 aneurysms) had a 12- and 6-month angiographic follow-up, respectively. Final anatomical results included 36 complete occlusions (90 %) and four neck remnants (10 %). Two minor recanalizations were seen but did not require retreatment. Non-significant intrastent stenosis occurred in 7/40 followed-up cases (17.5 %). Conclusion: The LVIS Junior stent appears safe and effective for endovascular treatment of wide-neck intracranial aneurysms located on small vessels. Midterm results show high rates of adequate and stable occlusion. [ABSTRACT FROM AUTHOR]

Introduction: Solitaire AB stent-assisted coiling facilitates the endovascular treatment of wide-necked intracranial aneurysms. Solitaire Aneurysm Remodeling is the first prospective, consecutive, European multicentric study whose main objective was to evaluate the safety, short-, and long-term efficacy of the Solitaire AB stent. This first analysis is focused on the short-term results. Methods: After exclusion of one patient, 66 Solitaire AB stents were used to treat via endovascular approach 64 aneurysms (63 patients) in seven European centers. Technical and clinical complications were recorded. A core laboratory evaluated the angiographic efficacy by using the Raymond classification scale. Results: The mean width of aneurysm sac was 7.5 mm, and the mean diameter of aneurysm neck was 4.7 mm. Complete occlusion was achieved in 27 aneurysms (42.2 %); neck remnant was seen in 25 aneurysms (39.1 %) and aneurysm remnant in 12 aneurysms (18.7 %). Technical and clinical complications related to the procedure were encountered in eight patients (12.7 %). Postprocedural modification of the clinical status was observed in one patient (1.6 %). No patients died (0 %); one had a permanent deficit (1.6 %), and one had a transient deficit (1.6 %). Treatment-related mortality was 0 %, and permanent morbidity was 1.6 %. Conclusion: The Solitaire AB stent has an excellent rate of technical success navigation with the absence of dislodgement. The safety and short-term efficacy are comparable to those previously reported with coiling alone. Mid- and long-term follow-up will be required to elucidate the impact of the Solitaire AB stent on recanalization rate. [ABSTRACT FROM AUTHOR]

The need to pursue long-term follow-up in patients treated for a ruptured aneurysm remains debated. New aneurysms development is a crucial element to consider but remains scarcely analyzed especially after a mean follow-up longer than 10 years. Our study was designed to provide rates of newly developed aneurysms in patients who have undergone prior clipping who were not followed with serial imaging. Patients were included if they were (1) treated more than 10 years ago by clipping of a ruptured aneurysm, (2) independent at time of discharge, (3) presently younger than 65 years, and if (4) they agreed to undergo a late digital subtraction angiography (DSA) control or to transmit results of a recent one performed elsewhere. Twenty patients were included with a mean delay between aneurysm treatment and late DSA of 18.0 years (10-26.5 years). Out of these patients, six (30%) harbored new aneuryms. Of these six individuals, four (66.6%) presented multiple aneurysms with a total of 15 newly discovered aneurysms. Aneurysm sizes ranged from 1 to 10 mm. One patient suffered from a de novo aneurysm rupture. Multiple aneurysms at the time of the first hemorrhage were a risk factor in developing de novo aneurysm ( p = 0.0175). In conclusion, based on a 30% rate of new aneurysm formation in patients clipped more than a decade ago, close screening on a very long-term perspective is encouraged. This study suggests aneurysm formation to be a continuous process. [ABSTRACT FROM AUTHOR]

To report long-term imaging findings of 101 patients with 129 unruptured intracranial aneurysms (UIA) treated by embolization. A retrospective review of our prospectively maintained database identified all patients with an UIA treated by embolization with coils only and with a minimal 12-month imaging follow-up. The clinical charts, procedural data, and angiographic results were reviewed. Between March 2004 and June 2009, 101 patients with 129 UIA were identified (71 women/30 men, mean age = 51.4 years). Ninety-four aneurysms (73%) were large (10–25 mm), and 35 (27%) were small (<10 mm). Aneurysms mean size was 10.7 mm (median, 9 mm; range 3–22 mm); 87 UIA (67.5%) had a small neck (<4 mm or neck/sac ratio < 0.7), and 42 (32.5%) had a wide neck (≥4 mm or neck/sac ratio ≥ 0.7). Selective coiling with bare/coated coils was performed in 125 cases and four cases, respectively. The balloon-assisted technique was used in 47 cases (36.4%). Only one patient experienced a symptomatic complication (thromboembolism) and kept a slight hemiparesis. Immediate results included 77 complete occlusions (59.7%), 45 neck remnants (34.9%), and 7 incomplete occlusions (5.4%). Mean imaging follow-up of 32 months showed 104 stable occlusions (80.6%), 12 further thrombosis (9.3%), 7 major recanalizations (5.4%), and 6 minor recanalizations (4.7%). Retreatment was required in seven wide-necked and/or large aneurysms including four treated with coated coils. No bleeding occurred during follow-up. Selective embolization of UIA is associated with stable long-term anatomical results and low retreatment rate. [ABSTRACT FROM AUTHOR]

We report a very rare anomalous anatomic variant of the cavernous internal carotid artery supplying directly the posterior inferior cerebellar artery, with no basilar artery opacification. A systematic review as well as a description of other variants of trigeminal-cerebellar anastomosis is given. [ABSTRACT FROM AUTHOR]