Prospective Study of Early MRI Appearances following Flow-Diverting Stent Placement for Intracranial Aneurysms

McGuinness, Ben; Memon, Sameer; Hope, J. K. A.

doi:10.3174/ajnr.a4335

Cited by 20 publications

(14 citation statements)

References 19 publications

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“…After incremental aneurysmal thrombosis and formation of a neointima along the FDS mesh, the aneurysm is excluded from intracranial circulation [3]. Although excellent occlusion rates of even challenging aneurysms accompanied by comparatively low procedural complication rates were reported, pathophysiologically yet obscure, delayed ischemic adverse events, despite sufficient platelet function inhibition, remain a concern [4,5,6]. In this regard, FDS-induced hemodynamic insufficiency with subsequent watershed ischemia, neointimal hyperplasia, in-stent stenosis, and secondary device deformations (fish-mouthing, peripheral tapering) were suspected as elicitors in some cases [7,8,9,10,11].…”

Section: Introductionmentioning

confidence: 99%

Delayed Stroke after Aneurysm Treatment with Flow Diverters in Small Cerebral Vessels: A Potentially Critical Complication Caused by Subacute Vasospasm

Schob

Richter

Scherlach

et al. 2019

JCM

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Flow diversion (FD) is a novel endovascular technique based on the profound alteration of cerebrovascular hemodynamics, which emerged as a promising minimally invasive therapy for intracranial aneurysms. However, delayed post-procedural stroke remains an unexplained concern. A consistent follow-up-regimen has not yet been defined, but is required urgently to clarify the underlying cause of delayed ischemia. In the last two years, 223 patients were treated with six different FD devices in our center. We identified subacute, FD-induced segmental vasospasm (SV) in 36 patients as a yet unknown, delayed-type reaction potentially compromising brain perfusion to a critical level. Furthermore, 86% of all patients revealed significant SV approximately four weeks after treatment. In addition, 56% had SV with 25% stenosis, and 80% had additional neointimal hyperplasia. Only 13% exhibited SV-related high-grade stenosis. One of those suffered stroke due to prolonged SV, requiring neurocritical care and repeated intra-arterial (i.a.) biochemical angioplasty for seven days to prevent territorial infarction. Five patients suffered newly manifested, transient hemicrania accompanying a compensatorily increased ipsilateral leptomeningeal perfusion. One treated vessel obliterated permanently. Hence, FD-induced SV is a frequent vascular reaction after FD treatment, potentially causing symptomatic ischemia or even stroke, approximately one month post procedure. A specifically early follow-up-strategy must be applied to identify patients at risk for ischemia, requiring intensified monitoring and potentially anti-vasospastic treatment.

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Section: Introductionmentioning

confidence: 99%

Delayed Stroke after Aneurysm Treatment with Flow Diverters in Small Cerebral Vessels: A Potentially Critical Complication Caused by Subacute Vasospasm

Schob

Richter

Scherlach

et al. 2019

JCM

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“…In the systemic review and meta-analysis by Bond et al , the rate of postprocedural DWI documented ischemic lesions was 45%, 44%, 43%, and 67% after simple coiling, balloon assisted coiling, stent assisted coiling, and flow diversion, respectively 23. Single center studies evaluating silent cerebral ischemia after intracranial aneurysm treatment with the PED reported an asymptomatic cerebral ischemia rate of 50.9–90% 4–11. These studies reported an increased risk of post-PED treatment silent cerebral ischemia with female gender,4 aneurysm size ≥10 mm,5 and age ≥60 6…”

Section: Discussionmentioning

confidence: 99%

“…We hypothesized that management of intracranial aneurysms with the PED-Shield is associated with a lower rate of postprocedural, diffusion weighted imaging (DWI) documented cerebral ischemia than previously reported with the PED 4–11. Hence the purpose of this prospective study was to determine the incidence of cerebral ischemia on postprocedural DWI following PED-Shield treatment of intracranial aneurysms in a single institution cohort of consecutive patients.…”

Section: Introductionmentioning

confidence: 97%

“…However, flow diversion is not without complications, and despite the routine use of antiplatelet medications and preprocedural assessment of individual responses to antiplatelet medication, postprocedural cerebral ischemia remains the most common complication of flow diversion. Acute ischemic stroke and silent cerebral infarctions following PED treatment have been reported at a rate of 2.6–4.7%1–3 and 50.9–90%,4–11 respectively. The association of the latter with delayed intracerebral hemorrhage,5 11 cognitive decline, and vascular dementia remains unclear 12 13…”

Section: Introductionmentioning

confidence: 99%

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Diffusion weighted image documented cerebral ischemia in the postprocedural period following pipeline embolization device with shield technology treatment of unruptured intracranial aneurysms: a prospective, single center study

Pikis

Mantziaris

Mamalis

et al. 2019

J NeuroIntervent Surg

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ObjectiveAcute ischemic stroke and silent cerebral infarctions following pipeline embolization device (PED) treatment of intracranial aneurysms have been estimated to occur in 3–6% and in 50.9–90% of patients respectively. The PED with Shield technology (PED-Shield) incorporates a surface phosphorylcholine polymer to reduce the thrombogenicity of the implant. We sought to determine the incidence of diffusion weighted image (DWI) documented cerebral ischemia after PED-Shield treatment of unruptured intracranial aneurysms.MethodsThis prospective study involved a single center series of consecutive patients treated for an unruptured intracranial aneurysm with the PED-Shield. All participants underwent clinical evaluation on admission, after the procedure, at discharge, and 30 days following treatment. Brain MRI was obtained within 72 hours of the procedure. Ischemic lesions identified on DWI sequences where examined as to their number, size, and location in relation to the procedure.ResultsOver 12 months, 33 patients harboring 38 intracranial aneurysms were treated with the PED-Shield in 36 procedures. Neither mortality nor clinically evident ischemic events were noted in the 30 day postprocedural period. DWI documented, silent cerebral ischemia occurred in six patients (18.18%) after six procedures (16.66%). No statistically significant risk factors for postprocedural silent cerebral ischemia were identified.ConclusionWe demonstrated a reduced rate of silent cerebral infarcts following PED-Shield treatment of intracranial aneurysms than previously reported with other endovascular treatment modalities and with the previous device generations. Further research is necessary to evaluate our results and to identify methods to reduce the incidence of postprocedural cerebral ischemic events.

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“…Several studies have examined IVWM findings after endovascular treatment of IAs. Using standard MRI sequences, it has been identified that IA wall enhancement is common, occurring in 19-66 % of patients treated with endovascular coiling or flow-diversion stents [61][62][63]. Procedural factors, such as the density of coil packing or coil material and IA-specific characteristics, such as IA size or location, influenced the incidence of wall enhancement, but the MRI findings did not predict IA occlusion success, procedural complications, or post-procedure morbidity such as IA rupture.…”

Section: Introductionmentioning

confidence: 99%

Intracranial vessel wall MRI: a review of current indications and future applications

et al. 2016

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Background: Intracranial vessel wall MRI (IVWM) is a new diagnostic imaging approach with the goal of evaluating intracranial vascular pathology by directly visualizing arterial vessel wall abnormalities with MR sequences, preferably at 3 Tesla field strength, that suppress blood and have excellent spatial resolution. Body: The differentiation of intracranial vascular pathology has historically relied on luminal imaging techniques that depict the alteration of flow created by atherosclerotic stenosis or vasospasm. With IVWM, it is possible to identify distinct radiologic findings of the pathology within the intracranial vessel wall itself, ranging from arterial dissection to vasculitis. Futhermore, IVWM imaging characteristics, such as post-contrast enhancement, can elucidate the temporal relationship between imaging findings and clinical pathology; and may predict future behavior of unruptured aneurysms or atherosclerotic plaques. Conclusion: We present a review of the basic IVWM imaging techniques and the relevant published literature on IVWM, with a focus on evidence-based diagnostic indications for IVWM and discussion of the strengths and weaknesses of each indication. Finally, we discuss how IVWM can be used to differentiate between intracranial pathology and future directions for IVWM research.

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Prospective Study of Early MRI Appearances following Flow-Diverting Stent Placement for Intracranial Aneurysms

Cited by 20 publications

References 19 publications

Delayed Stroke after Aneurysm Treatment with Flow Diverters in Small Cerebral Vessels: A Potentially Critical Complication Caused by Subacute Vasospasm

Delayed Stroke after Aneurysm Treatment with Flow Diverters in Small Cerebral Vessels: A Potentially Critical Complication Caused by Subacute Vasospasm

Diffusion weighted image documented cerebral ischemia in the postprocedural period following pipeline embolization device with shield technology treatment of unruptured intracranial aneurysms: a prospective, single center study

Intracranial vessel wall MRI: a review of current indications and future applications

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