BACKGROUND: The off-label use of flow diverters in the treatment of distal aneurysms continues to be debated. OBJECTIVE: To report our multicenter experience in the treatment of complex anterior cerebral artery aneurysms with the Pipeline embolization device (PED). METHODS: The neurointerventional databases of the four participating institutions were retrospectively reviewed for aneurysms treated with PED between October 2011 and January of 2016. All patients treated for anterior cerebral artery aneurysms were included in the analysis. Clinical presentation, location, type, vessel size, procedural complications, clinical and imaging follow-up were included in the analysis. RESULTS: Twenty patients (13 female) with 20 aneurysms met the inclusion criteria in our study. Fifteen aneurysms were classified as saccular and five as fusiform (mean size 7.3 mm). Thirteen aneurysms were located in the anterior communicating region (ACOM or A1/2 junction), six were A2-pericallosal, and one was located in the A1 segment. Six patients had presented previously with subarachnoid hemorrhage and had their aneurysms initially clipped or coiled. There was one minor event (a small caudate infarct) and one major event (intraparenchymal hemorrhage). Sixteen of the 20 patients had angiographic follow-up (mean 10 months). Eleven aneurysms were completely occluded, one had residual neck, and four had residual aneurysm filling. CONCLUSIONS: The treatment of complex anterior cerebral artery aneurysms with the PED as an alternative for patients who are not good candidates for conventional methods is technically feasible and safe. Mid-term results are promising but larger series with long-term follow-up are required to assess its effectiveness

BackgroundTreatment of acute cerebrovascular pathology, such as acute ischemic stroke or intracranial aneurysms, presents a challenge if an extracranial or intracranial stent is required; immediate platelet inhibition is vital. To date, there is no standardized approach for antiplatelet inhibition in an acute setting.ObjectiveTo report our preliminary experience and lessons learnt using cangrelor in acute neurointervention.MethodsA single-arm pilot study was performed to assess the safety and efficacy of cangrelor plus aspirin for platelet inhibition in patients who require acute stenting in the setting of neuroendovascular treatment.ResultsEight patients were enrolled between October 2017 and August 2018. Median age was 71 years (53–86). Seven patients were treated in an acute setting according to the stroke protocol at our institution, while one patient was treated for a symptomatic, unruptured aneurysm with flow diversion and coiling. At admission, the median National Institutes of Health Stroke Scale score for the patients with stroke was 12.5 (range 2–22.3). Cangrelor was infused and all patients achieved adequate platelet inhibition (<200 PRU (P2Y12 reaction units)). Six of seven patients with ischemic stroke had a carotid stent placed and one had an intracranial stent deployed in the middle cerebral artery. None of the patients experienced intraprocedural thromboembolic complications, intraprocedural in-stent thrombosis, hemorrhagic complications, or stroke within 24 hours after the intervention. The majority of patients (6/8) had a good clinical outcome at discharge (modified Rankin Scale score 0–2).ConclusionsOur findings suggest that cangrelor is a promising alternative in acute stenting for the treatment of cerebrovascular pathology. However, further studies with larger samples are required to accurately elucidate its safety and effectiveness in neuroendovascular procedures.

The LVIS Jr is a technically feasible, safe, and effective treatment for wide-necked intracranial aneurysms. Early results are promising but will need to be corroborated with longer-term follow-up.

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The 30-d rates of neurological morbidity and mortality in this multicenter cohort using the PED Flex for the treatment of intracranial aneurysms were low, 1.9% (4/205) and 0.5% (1/205), respectively. In addition, technical events related to device deployment were also low, most likely due to the latest modifications in the delivery system.

Refinements in endovascular technology have revolutionized the treatment of intracranial aneurysms (IAs) with the development of flow-diversion technology. The first generation of the Pipelin Embolization Device (PED) has demonstrated its safety and efficacy. However, the deployment technique was a difficult task that often led to complex maneuvers. The Pipeline Flex Embolization Device (PED Flex) is the second generation and its introduction has arrived with high expectations due to a completely redesigned delivery system that intends to overcome deployment difficulties seen in the previous generation. Areas covered: Preclinical studies, mechanism of action of flow-diverters, technical aspects and deployment system of the PED Flex, and clinical outcomes with both PED generations. Expert commentary: Flow diversion has allowed us to treat lesions that would be otherwise challenging for surgical clipping or unsuitable for other endosaccular strategies. Although the experience with PED Flex is limited, initial results suggest its safety and short-term efficacy.

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Introduction: Wide-necked intracranial aneurysms (IAs) are complex lesions that may require different microsurgical or endovascular strategies, and stent-assisted coiling (SAC) has emerged as a feasible alternative to treat this subset of aneurysms. Methods: The objective was to assess the rate of complications of unruptured wide-necked IAs treated with SAC. We retrospectively identified patients with unruptured wide-necked IAs treated with SAC. Medical charts, procedure reports, and imaging studies were analyzed. Results: One hundred twenty patients harboring 124 unruptured wide-necked IAs were included. Ninety-two aneurysms (74.2%) were located in the anterior circulation. The median aneurysm size was 7 mm (IQR = 5-10). The immediate complete aneurysm occlusion rate was 29% (36/124). The rate of procedural complications was 3.3 % (4/120), which included 2 intraprocedural aneurysm ruptures, 1 immediate postprocedure aneurysm rupture, and 1 vessel occlusion rescued with an open-cell stent. The median follow-up time was 21 months (IQR = 10.3-40.9). Kaplan-Meier analysis estimated a median time of complete aneurysm occlusion of 6.3 months (95%CI = 3.8-7.8). At 30-day follow-up, 80.7% of patients had a Glasgow Outcome Score (GOS) of 5 and at the latest follow-up 83.9%. Imaging follow-up was available for 102 patients. The rate of complete aneurysm occlusion was 73.5% (75/102), severe in-stent stenosis (>50%) was found in 1% (1/102), the recanalization rate was 6.6% (5/75), and the retreatment rate was 7.8% (8/102). Conclusion: SAC remains a safe and effective technique to treat wide-necked IAs, providing a low rate of complications and recanalization with excellent long-term aneurysm occlusion rates.