血管重建治疗颅内宽颈动脉瘤1例

颅内动脉瘤的血管内治疗有了很大的发展,特别是电解可脱卸弹簧圈（GDC）的运用,使介入治疗成为动脉瘤除夹闭手术之外的一项可靠治疗手段。但对于宽颈动脉瘤仍然无能为力,而血管内支架的运用使这种动脉瘤的介入治疗成为可能。本文报道联合应用颅内专用支架和弹簧圈,成功对1例宽颈颈内动脉海绵窦段动脉瘤患者实施介入栓塞治疗。     

Solitaire AB支架辅助弹簧圈栓塞治疗颅内宽颈动脉瘤36例

目的 探讨Solitaire AB支架辅助弹簧圈栓塞治疗颅内宽颈动脉瘤的经验和疗效.方法 2010年5月至2011年3月使用Solitaire AB支架辅助弹簧圈栓塞治疗颅内宽颈动脉瘤患者36例39个动脉瘤,其中动脉瘤破裂出血15例.动脉瘤位于前交通动脉1个,颈内动脉后交通段13个,眼动脉段13个,海绵窦段4个,椎动...     

Neuroform自膨式支架结合弹簧圈栓塞颅内宽颈动脉瘤

目的 探讨Neuroform自膨式支架结合弹簧圈治疗颅内宽颈动脉瘤的安全性、术中并发症、近中期疗效和应用前景.方法 采用Neuroform支架结合弹簧圈栓塞治疗25例27枚颅内宽颈动脉瘤.动脉瘤位于颈内动脉海绵窦段3枚,眼动脉1枚,后交通动脉18枚,前交通动脉2枚,大脑中动脉M1段1枚,大脑中动脉分义部1枚,基底动脉干1枚.其巾2例患者为多发动脉瘤,绝对宽颈(瘤颈>4 mm)动脉瘤21枚,相对宽颈6枚,瘤颈/瘤体均大于0.7.结果 4枚采用NeuroformⅡ代自膨式支架结合弹簧圈栓塞治疗,其余均采用NeuroformⅢ代支架结合弹簧罔栓塞治疗.25例26枚支架均成功到位释放,1例多发动脉瘤患者置入2枚支架.7枚动脉瘤完全栓塞(100%),9枚几乎完全栓寒(95%～99%),11枚不完全栓塞(95%以下).2例术中出血;2例术中支架内血栓形成,其中1例术后遗留肢体偏瘫,另1例死亡;1例术中弹簧圈尾端从支架网孔突入颈内动脉,术后出现一过性脑缺血表现,其余患者均恢复良好出院.临床随访24例,随访期1～32个月,平均10.8个月.3例术后3～6个月血管造影随访,其中1例后交通动脉瘤患者同侧大脑前动脉闭塞,大脑中动脉主干血栓形成;另2例原有瘤颈残留者无变化.结论 在栓塞颅内宽颈动脉瘤时应用Neurolform自膨式支架结合弹簧圈技术,使弹簧圈无法突入载瘤动脉,可提高柃塞致密度,安全、疗效好.     

血管内支架结合电解可脱弹簧圈治疗颅内动脉瘤

目的 初步总结使用血管内支架结合电解可脱卸弹簧圈（GDC）治疗颅内梭形及宽颈动脉瘤的体会,探讨其适应证、方法、疗效及并发症。方法 5例颅内梭形动脉瘤及12例宽颈动脉瘤,首先将冠脉支架跨动脉瘤颈放置,通过支架的网孔将微导管送入动脉瘤腔,继续填塞GDC。结果 13例动脉瘤致密填塞,3例大部分填塞,1例支架未能送入颅内而单用弹簧圈部分栓塞,载瘤动脉通畅,临床效果优良。结论 联合使用支架及微弹簧圈是治疗颅内梭形及宽颈动脉瘤的有效方法,远期疗效需进一步随访。     

血管内支架结合GDC栓塞治疗基底动脉顶端宽颈动脉瘤

目的 报道应用血管内支架结合电解可脱卸弹簧圈栓塞治疗1例未破裂的基底动脉顶端宽颈动脉瘤的经验及结果。方法 将球囊膨胀型血管内支架跨动脉瘤瘤颈部位置入并准确释放后，微导管超选进入动脉瘤内填塞弹簧圈。结果 支架成功的置入，支架近端在基底动脉，远端在大脑后动脉近段，动脉瘤得到次全栓塞(90％以上)，载瘤动脉及毗邻的侧支血管保持通畅，患者恢复满意。结论 血管内支架结合弹簧圈栓塞治疗基底动脉顶端宽颈动脉瘤是可行的，支架植入对侧支血管血流无明显影响。     

血管内支架治疗颅内动脉瘤

目的：探索使用血管内支架及血管内支架结合电解可脱卸弹簧圈（Guglielmi detachable coil,GDC)治疗颅内梭形及宽颈动脉瘤的可能性。方法：3例椎动脉颅内段梭形动脉瘤及6例宽颈动脉瘤,首先将冠脉支架跨动脉瘤颈放置,通过支架的网孔将微导管送入动脉瘤腔,填入GDC。结果：7例动脉瘤致密堵塞,2例大部堵塞,载瘤动脉通畅,临床效果优良。结论：联合使用支架及微弹簧圈是治疗颅内梭形及宽颈动脉瘤可选择的有效方法之一。     

颅内自膨胀支架结合弹簧圈治疗脑动脉瘤

目的　报道采用自膨胀颅内专用支架 (Neuroform支架 )结合弹簧圈栓塞治疗颅内宽颈动脉瘤 ,初步探讨该支架的特点、短期疗效及应用前景。方法　采用Neuroform支架结合弹簧圈栓塞治疗 32例 34枚颅内宽颈动脉瘤。颈内动脉海绵窦段 3例 ,眼动脉 3例 ,后交通动脉 8例 ,前交通动脉 3例 ,大脑中动脉分叉部 5例 ,椎动脉 6例 ,基底动脉顶端 1例 ,基底动脉干 2例 ,大脑前动脉A3段 1例 ,多发动脉瘤 2例。通过Renegade微导管释放Neuroform支架覆盖动脉瘤瘤颈 ,预先将另一微导管置入动脉瘤腔或将微导管通过支架网孔以弹簧圈栓塞动脉瘤。结果　 31例 34个支架成功到位释放 ,1例基底动脉顶端动脉瘤因支架无法通过狭窄的大脑后动脉而改用BX支架。 3例 1次各置入 2枚支架。 2 4例致密栓塞 ,6例瘤颈残留 ,2例部分栓塞。 1例术中发生支架内血栓 ,死亡 1例 ,其余患者均恢复良好出院。临床随访 30例 ,随访期 1～ 6个月 ,平均 4 .7个月 ,无再出血及血栓栓塞症状发生。 1 1例术后 3个月血管造影随访 :7例致密栓塞的动脉瘤均未显影 ;4例瘤颈残留者 ,2例无变化 ;2例原有瘤颈残留未再显影。结论　Neuroform支架技术上容易操控 ,顺应性好 ,安全性高 ,可以到达颅内较远端的血管 ,大大扩展了支架技术治疗颅内血管病变的应用范围 ,近期     

Solitaire AB支架在辅助栓塞颅内宽颈动脉瘤中的临床应用

目的评价Solitaire AB支架在辅助栓塞颅内宽颈动脉瘤中的临床应用价值。方法应用Solitaire AB支架治疗颅内宽颈动脉瘤25例,其中后交通动脉瘤15枚,眼动脉段动脉瘤4枚,颈内动脉海绵窦段动脉瘤1枚,大脑中动脉瘤1枚,椎动脉动脉瘤4枚。结果 25例中,完全栓塞22例,瘤颈残留1例,部分栓塞2例。术中动脉瘤破裂1例,术后脑积水行脑脊液分流术1例,弹簧圈移位1例。随访未有再出血病例。造影随访12例,复发1例。结论应用Solitaire AB支架在辅助栓塞颅内宽颈动脉瘤具有较高的临床价值,值得临床推广。     

难治性颅内动脉瘤血管内支架治疗的初步结果

目的　总结血管内支架结合电解可脱卸弹簧圈 (GDC)治疗分叉部宽颈动脉瘤及复发动脉瘤的技术及疗效。方法　采用血管内支架结合GDC治疗 5例颅内动脉瘤 ,其中颈内动脉分叉部动脉瘤2例 ,基底动脉宽颈瘤 1例和后交通宽颈动脉瘤复发 2例。 3例支架跨重要侧支血管及穿动脉放置。通过支架上的网孔将微导管送入动脉瘤腔 ,继续GDC填塞。结果　 4例动脉瘤达到致密填塞 ,1例大部填塞 ,载瘤动脉及侧支血管通畅 ,1例术后出现动眼神经麻痹 ,3个月后恢复。影像学随访 3～ 6个月 ,无支架内狭窄。结论　联合使用支架及GDC是治疗分叉部宽颈动脉瘤及复发动脉瘤的有效方法 ,临床应用前景广阔。支架覆盖重要动脉开口并不影响血流。     

支架辅助GDC治疗颅内动脉瘤术中并发症的防治

目的 回顾总结血管内支架治疗颅内动脉瘤术中并发症，以提高使用血管内支架结合电解可脱卸弹簧圈(GDC)治疗颅内夹层及宽颈动脉瘤的安全性。方法 105例难治性动脉瘤，首先将冠脉支架跨动脉瘤颈放置，通过支架的网孔将微导管送入动脉瘤腔，填入GDC。结果 6例患者术中出现支架移位，1例发生动脉瘤破裂出血，1例发生大脑中动脉穿支出血，1例发生支架塌陷，1例发生颈内动脉夹层动脉瘤，1例弹簧圈突入小脑后下动脉(PICA)起始部，10例发生血管痉挛，经对症处理，预后良好。结论 在支架植入过程中，联合采用多种措施可减少并发症的发生；支架和GDC联合应用治疗颅内夹层及宽颈动脉瘤安全、有效。     

血管内栓塞治疗颅内动脉瘤

目的 总结血管内栓塞治疗颅内动脉瘤经验。方法 股动脉Seldinger穿刺,先后应用MagicBD,Tracker-16,Tracker-10和Cordis 3F/2.5F微导管,送入球囊、不同长度的国产、进口游离微弹簧圈,配用MDS、GDC系统送入不同长度微弹簧圈、治疗颅内动脉海绵窦段动脉瘤5例、后交通动脉瘤1例、颈内动脉C2段动脉瘤3例、椎动脉颅内段动脉瘤3例、大脑后动脉瘤P2段动脉瘤1例,治疗颅内动脉C3－4段假性动脉瘤5例。结果 本组无1例死亡。球囊闭塞颈内动脉海绵窦段动脉瘤5例均痊愈,无并发症;微弹簧圈栓塞治疗动脉瘤栓塞达100％者9例、95％者2例,其中1例因血管痉挛遗留轻瘫,1例因MDS到位后不能顺利解脱导致部分脱垂于颈内动脉和大脑中动脉2cm,遗留轻瘫;5例假性动脉瘤完全治愈;闭塞载瘤动脉及动脉瘤的2例椎动脉完全治愈。结论 颈内动脉海绵窦段动脉瘤只要前、后交通动脉侧支循环代偿良好,可脱球囊闭塞载瘤动脉是安全有效的。微弹簧圈栓塞治疗颅内动脉瘤是一种有发展前途的治疗方法。     

HyperForm remodeling-balloon for endovascular treatment of wide-neck intracranial aneurysms

A new, very compliant remodeling balloon microcatheter has been developed for the treatment of difficult wide-neck intracranial aneurysms (eg, arterial bifurcation or small artery aneurysms). We report selective embolization by the use of the remodeling technique with the HyperForm balloon in 16 consecutive patients with a wide-neck intracranial aneurysm located on an arterial bifurcation or a small artery or both.     

Treatment options for wide-necked intracranial aneurysms using a self-expandable hydrophilic coil and a self-expandable stent combination

The endovascular treatment of wide-necked intracranial aneurysms is evolving. We report our initial experience in treating seven wide-neck intracranial aneurysms by using a new self-expanding stent, the Neuroform, in combination with a new generation of coils that incorporate a self-expandable hydrophilic lining, the HydroCoil.     

Treatment of carotid artery aneurysms with platinum coils: an experimental study in dogs

The objectives of this study were to investigate the consistency, patency, and natural history of a vein graft canine aneurysm model and to determine the effectiveness of various coil designs on inducing aneurysm thrombosis. Twenty-one sacculuslike aneurysms were created in mongrel dogs by anastomosing a vein pouch to the common carotid artery. The model produced wide-neck aneurysms with 100% patency. The canine vein graft aneurysm provided an excellent model for the evaluation of endovascular devices. Three types of specially designed platinum coils were placed in the aneurysms: those with simple curves, those with complex curves, and those with flower petal curves and silk fibers. These coils were placed by the endovascular route by means of microcatheters. Flower petal coils with silk fibers were effective in producing thrombosis of the aneurysms, suggesting that coils of the appropriate design may be useful in the endovascular treatment of aneurysms. The other coil designs evaluated, those with simple and complex curves without silk fibers, demonstrated insufficient thrombogenicity and spatial stability.     

Endovascular treatment of a giant intracranial aneurysm with a stent-graft

This report describes a giant intracavernous carotid aneurysm successfully treated by the placement of a single covered stent. A 40-year-old woman was admitted with a progressive diplopia in relation with palsy of the IV and VI cranial nerves. Magnetic resonance imaging revealed an intracavernous giant aneurysm located at the bifurcation between the origin of a trigeminal artery and the intracavernous portion of the right internal carotid artery. A covered stent was successfully placed, and complete exclusion of the aneurysm was confirmed at 11-month follow-up angiography. The use of covered stents in intracranial vascular structures can now be a feasible way of treating selected cases of wide-necked intracranial aneurysms.     

Endovascular Treatment of Intracranial Aneurysms with the WEB Device: A Systematic Review of Clinical Outcomes

BACKGROUND AND PURPOSE:Despite the improvement in technology, endovascular treatment of bifurcation intracranial wide-neck aneurysms remains challenging, mainly due to the difficulty of maintaining coils within the aneurysm sac without compromising the patency of bifurcation arteries. The Woven EndoBridge (WEB) device is a recent intrasaccular braided device specifically dedicated to treating such aneurysms with a wide neck by disrupting the flow in the aneurysmal neck and promoting progressive aneurysmal thrombosis.MATERIALS AND METHODS:Using several health data bases, we conducted a systematic review of all published studies of WEB endovascular treatment in intracranial aneurysms from 2010 onward to evaluate its efficacy and safety profile.RESULTS:The literature search identified 6 relevant studies (7 articles) including wide-neck bifurcation aneurysms in ≥80% of cases. Clinical data supporting the efficacy and safety of the WEB are limited to noncomparative cohort studies with large heterogeneity from a methodologic standpoint. The WEB deployment was feasible with a success rate of 93%–100%. Permanent morbidity (mRS of >1 at last follow-up) and mortality were measured at 2.2%–6.7% and 0%–17%, respectively. The adequate occlusion rate (total occlusion or neck remnant) varied between 65% and 85.4% at midterm follow-up (range, 3.3–27.4 months).CONCLUSIONS:Endovascular treatment of bifurcation wide-neck aneurysms with the WEB device is feasible and allows an acceptably adequate aneurysm occlusion rate; however, the rate of neck remnants is not negligible. The WEB device needs further clinical and anatomic evaluation with long-term prospective studies, especially of the risk of WEB compression. Prospective controlled studies should be encouraged.

With the emergence of detachable coils and results of the International Subarachnoid Aneurysm Trial and Barrow Ruptured Aneurysm Trial,^1,2 endovascular coiling has become the first-line option for ruptured intracranial aneurysms. It is also a widely accepted option for unruptured aneurysms that are anatomically suitable for endovascular approaches.³ However, coiling of large and wide-neck intracranial aneurysms is associated with low initial complete obliteration, a high incidence of recanalization (up to 20% at 12 months), and a 10% rate of retreatment.⁴ Promising technologies like flow-diverter stents have the potential to overcome some of the limitations of standard coiling for sidewall aneurysms,^5–7 but the management of large wide-neck bifurcation aneurysms remains challenging. Balloon and stent-assisted techniques have widened the indications for endovascular treatment of aneurysms with a wide neck and/or unfavorable anatomy that were otherwise unsuitable for coiling.^8–10 However, endovascular treatment of such complex intracranial aneurysms requires the use of complex endovascular techniques with double-stent placement in Y and X configurations. Bartolini et al¹¹ suggested that Y and X stent-assisted coiling was associated with a high rate of complications, 10% procedure-related permanent morbidity, and 1% mortality rate.In this context, a new endovascular device, the intrasaccular flow disruptor Woven EndoBridge (WEB; Sequent Medical, Aliso Viejo, California), specifically designed to treat wide-neck bifurcation intracranial aneurysms, has emerged in the past 5 years.^12–14 There is an emerging body of literature on the use of the WEB device, but to our knowledge, no study has specifically reviewed the evidence on its use. We, therefore, performed a literature review of this technique in the management of wide-neck bifurcation intracranial aneurysms. Our specific aims were to evaluate its feasibility, safety, and effectiveness to finally discuss its place in the endovascular treatment of bifurcation intracranial aneurysms.     

Non-traumatic neurological emergencies: emergency neuroradiological interventions

This article summarizes recent developments in the growing field of interventional neuroradiology for the treatment of acute cerebrovascular disease. We describe the possibilities in endovascular therapy of acute cerebral aneurysms using electrolytically detachable coils combined with trispan neck bridging devices and stent implantation to occlude acute wide neck aneurysms. Techniques and results of local intra-arterial thrombolytic therapy in acute stroke and central retinal artery occlusion are described and we discuss the potential for rapid, large-burden thrombus removal in cases of internal carotid artery thrombosis by rheolytic thrombectomy, percutaneous transluminal angioplasty and stent implantation. Emergency endovascular therapy using the transvenous approach to treat severe intracranial or intraocular hypertension and multifocal haemorrhagic venous infarction due to cerebral sinus thrombosis or dural fistulas is also described. In cases of acute bleeding of head and neck lesions following trauma, tumours after radiotherapy, arteriovenous malformations, epistaxis or from iatrogenic origin, angiography plays a major role in localizing the source of bleeding and occluding the damaged vessel during the same session using the same endovascular approach.     

1999 ARRS Executive Council Award. Creation of saccular aneurysms in the rabbit: a model suitable for testing endovascular devices. American Roentgen Ray Society

OBJECTIVE: This study developed an animal model of intracranial aneurysms suitable for evaluating emerging endovascular devices for aneurysmal therapy. We characterized the short-, medium-, and long-term attributes of this endovascular technique for saccular aneurysmal creation in the rabbit. MATERIALS AND METHODS: The right common carotid artery was surgically exposed in nine New Zealand white rabbits. Using endovascular techniques, we occluded the origin of the right common carotid artery with a pliable balloon. Elastase was incubated endoluminally in the proximal common carotid artery above the balloon. The common carotid artery was ligated distally. Animals were studied angiographically and sacrificed at 2 weeks (n = 3), 10 weeks (n = 3), and 24 weeks (n = 3) after aneurysm creation. Histology was obtained. RESULTS: Saccular aneurysms formed in eight of the nine rabbits. The aneurysm projected from the apex of an approximately 90 degree curve of the parent vessel, the brachiocephalic artery. Mean aneurysm diameter was 4.5 mm (SD, 1.2 mm), and mean height was 7.5 mm (SD, 1.6 mm). All samples showed thinned elastic lamina and no evidence of inflammation. In four of eight aneurysms, unorganized thrombus was present in the dome of the aneurysm. CONCLUSION: Arterial aneurysms with intact endothelium and deficient elastic lamina were reliably created in an area of high shear stress in New Zealand white rabbits. Three of these aneurysms remained patent for at least 6 months. We found a simple procedure that can be readily applied to the testing of new endovascular devices for a reliable creation of aneurysms in rabbits.     

Treatment of unruptured intracranial aneurysms: decision and cost-effectiveness analysis

PURPOSE: To prospectively perform a decision and cost-effectiveness analysis of surgical and endovascular treatments of unruptured intracranial aneurysms, with incorporation of the results of the prospective International Study of Unruptured Intracranial Aneurysms. MATERIALS AND METHODS: With use of a Markov model, a decision and cost-effectiveness analysis was performed for comparison of surgical or endovascular treatment with no treatment. Twelve clinical scenarios were defined on the basis of aneurysm size and location. Probabilistic sensitivity analyses were performed for 50- and 40-year-old patient cohorts. Treatment was considered to be cost-effective at an incremental cost-effectiveness ratio less than $100,000 per quality-adjusted life-year. RESULTS: In 50-year-old patients, no treatment was the most cost-effective strategy for aneurysms located in the cavernous carotid artery. For aneurysms smaller than 7 mm located in the anterior circulation, no treatment was the most cost-effective strategy. Endovascular treatment was the most cost-effective option for 7-24-mm aneurysms, whereas surgical treatment was the most cost-effective option for aneurysms 25 mm or larger. For aneurysms smaller than 7 mm or 25 mm or larger located in the posterior circulation, no treatment was the most cost-effective strategy. Surgical treatment was the most cost-effective option for 7-12-mm aneurysms, whereas endovascular treatment was the most cost-effective option for 13-24-mm aneurysms. CONCLUSION: For 50-year-old patients, treatment of aneurysms that are small (<7 mm), that are located in the cavernous carotid artery, or that are large (>or=25 mm) and located in the posterior circulation is ineffective or not cost-effective.