BackgroundThe use of flow diversion to treat intracranial aneurysms has increased in recent years.ObjectiveTo assess the safety and angiographic efficacy of the p64 flow modulation device.MethodsDiversion-p64 is an international, prospective, multicenter, single-arm, study conducted at 26 centers. The p64 flow modulation device was used to treat anterior circulation aneurysms between December 2015 and January 2019. The primary safety endpoint was the incidence of major stroke or neurologic death at 3–6 months, with the primary efficacy endpoint being complete aneurysm occlusion (Raymond-Roy Occlusion Classification 1) on follow-up angiography.ResultsA total of 420 patients met the eligibility criteria and underwent treatment with the p64 flow modulation device (mean age 55±12.0 years, 86.2% female). Mean aneurysm dome width was 6.99±5.28 mm and neck width 4.47±2.28 mm. Mean number of devices implanted per patient was 1.06±0.47, with adjunctive coiling performed in 14.0% of the cases. At the second angiographic follow-up (mean 375±73 days), available for 343 patients (81.7%), complete aneurysm occlusion was seen in 287 (83.7%) patients. Safety data were available for 413 patients (98.3%) at the first follow-up (mean 145±43 days) with a composite morbidity/mortality rate of 2.42% (n=10).ConclusionsDiversion-p64 is the largest prospective study using the p64 flow modulation device. The results of this study demonstrate that the device has a high efficacy and carries a low rate of mortality and permanent morbidity.
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Background: Cerebral vasospasm that occurs after subarachnoid hemorrhage (SAH) can be an important cause of mortality and morbidity for patients successfully operated for a cerebral aneurysm. Methods: Five cases of prompt diagnostic and surgical treatment of a cerebral aneurysm, with important SAH on cerebral computed tomography (CT) at onset, are presented. All patients were admitted in a poor neurological state and developed severe vasospasm. Both, the correct clipping of the aneurysm and the cerebral vasospasm were angiographic demonstrated in all cases. Two patients showed complete obliteration of one carotid artery. Results: Postoperatory, four of the patients were treated with intrathecally administered nimodipine (10mg/50ml). In three cases, the procedure caused the reverse of the vasospasm and clinical improvement of the patients. Their clinical outcomes were very good and were discharged with minimal neurological deficits. In one case, repeated intraarterial administration of nimodipine, showed no reduction of the vasospasm, and no improvement of patient’s clinical status. The patient was conscious, but presented focal neurological deficits (hemiplegia and aphasia). One patient did not benefit from this treatment and had a poor clinical outcome, remaining in a vegetative state. Conclusions: Cerebral vasoconstriction after SAH could be an important obstacle in obtaining very good results in aneurysm surgery. Intra-arterial administration of nimodipine is an important and useful treatment, but good results in reversal severe cerebral vasospasm are not always mandatory.
Nontraumatic intracranial aneurysms have a 2-5% incidence in the population and most are asymptomatic. However, even though the risk of rupture is low, it has a high mortality and morbidity. We report an extremely rare case of concurrently rupture of bilateral nontraumatic carotid-ophthalmic aneurysm complicated with acute bilateral subdural hematoma in a postpartum woman. The imagistic examinations showed two saccular bilateral aneurysm located at the carotid-ophthalmic junction, bilateral basal frontotemporal subdural hematoma, a right frontotemporal intraparenchimatous hematoma and massive cerebral edema. Additionally, the autopsy revealed the location of rupture of both aneurysms, and the presence of recent bilateral thrombi in the lumen of the cervical segment of the internal carotid arteries (as a result of the mechanical occlusion of these arteries due to the massive cerebral edema). In the absence of any medical and antenatal checkups records of the patient, we concluded that in the pathogenesis of the development and rupture of these aneurysms could contributed the following factors: hemodynamic, blood, and arterial wall changes during pregnancy and puerperium, infection, presence of intraluminal aneurysm thrombus. We have suggested the possible pathogenic mechanism for the bilateral subdural hematoma based on the hypothesis of the aneurysm sentinel bleeding, sustained by the patient's symptomatology.
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