Endovascular Surgery of Cerebral Aneurysms

Foreword
Preface
Acknowledgment
Contents
About the Editor
1: Pathophysiology of Cerebral Aneurysms
1.1 Introduction
1.2 Structure of the Cerebral Arteries
1.3 Formation of Intracranial Aneurysms
1.3.1 Hemodynamic Factors and Associated Structural Changes
1.3.2 Genetic Factors
1.3.3 Molecular Changes
1.3.4 Hormonal Changes Related to Aneurysm Formation and Rupture
1.4 Risk Factors Associated with Formation and Rupture of Cerebral Aneurysms
1.4.1 Conventional Risk Factors
1.4.2 Innate Risk Factors
1.4.3 Acquired Risk Factors
1.5 Common Risk Factors for Cerebral Aneurysm Rupture
References
2: Aneurysmal SAH Induced Vasospasm: Pathogenesis and Management
2.1 Introduction
2.2 Delayed Cerebral Vasospasm
2.3 The Pathophysiological Changes After SAH
2.3.1 Understanding Early Brain Injury
2.4 What Leads to Vaso Constriction?
2.4.1 Endothelin 1 (The Physiological Vasoconstrictor)
2.4.2 Nitric Oxide (The Physiological Vasodilator)
2.4.3 Inflammatory Changes Leading to Apoptosis
2.4.4 The Ischemic Insult
2.4.5 Free Oxygen Radicals
2.4.6 Is Vasospasm All About Cerebral Vasculature?
2.5 Diagnosis of Vasospasm
2.6 Management Options for Vasospasm
2.6.1 Trials on Targeted Substrates
2.6.1.1 Lipid Peroxidation Inhibitors
2.6.2 Role of Endothelin-1 Antagonist
2.6.3 Is There Any Role of Statins?
2.6.4 Augmenting NO Activity
2.6.5 Sildenafil Citrate
2.6.5.1 Nascent NO Donors
2.6.5.2 Magnesium Sulfate
2.7 Treatment Regime for SAH/Vasospasm
2.7.1 Optimizing Physiological Disruption
2.7.1.1 Catecholamine Surge and Increased Sympathetic Activity
2.7.1.2 Controlling Body Temperature
2.7.1.3 Electrolyte Management
2.7.1.4 Maintaining Cerebral Perfusion
2.7.1.5 Calcium Channel Antagonists
2.7.1.6 Nimodipine
2.7.2 Strategies to Reduce Blood Load in Subarachnoid Space
2.7.2.1 Lumbar Drain
2.7.2.2 Cisternal Lavage and Local Thrombolytics
2.7.3 Intrathecal Treatment Options
2.7.3.1 Intrathecal Thrombolysis
2.7.3.2 Intrathecal Nicardipine
2.7.4 Endovascular Intervention for Vasospasm
2.7.5 Role of Intra-arterial Pharmacotherapy
2.7.5.1 Intra-arterial Nimodipine
2.7.5.2 Papaverine
2.7.5.3 Milrinone
2.7.5.4 Balloon Angioplasty
2.8 Conclusion
References
3: History of Endovascular Surgery of Cerebral Aneurysms
3.1 Introduction
3.2 Middle Ages
3.3 Twentieth Century Era
References
4: Drugs in Neurovascular Intervention
4.1 Introduction
4.2 Fibrinolytic Agents
4.2.1 Alteplase
4.2.2 Tenecteplase
4.3 Antiplatelet Agents
4.3.1 Aspirin
4.3.2 ADP Antagonists/P2Y12 Inhibitors
4.3.3 GP IIb/IIIa Inhibitors
4.3.4 Phosphodiesterase Inhibitors
4.4 Anticoagulating Agents
4.5 Treatment of Vasospasm: (Chemical Angioplasty)
4.6 Radial Artery Cocktail
4.7 Statins (Hypolipidemic Therapy)
References
5: Current Devices and Uses
5.1 Introduction
5.1.1 The Guglielmi Detachable Coil System (GDC)
5.1.2 Balloon Assisted Coiling (BAC)
5.1.3 Stent-Assisted Coiling (SAC)
5.1.4 Flow Diverters
5.1.5 Flow Disrupters
5.1.6 Hybrids and Other Novel Devices
5.2 Conclusion
References
6: Neuroendovascular Management of Wide-Neck Bifurcation Aneurysms
6.1 Background
6.2 Three Types of Bifurcation Aneurysms
6.2.1 Saccular Aneurysms
6.2.2 Dissecting Aneurysms
6.2.3 Giant Serpentine Aneurysms
6.3 Neuroendovascular Strategies for Bifurcation Aneurysms
6.4 Coiling
6.5 Double Catheter Technique
6.6 Balloon-Assisted Coiling
6.7 Stent-Assisted Coiling
6.8 Y-stenting Technique
6.9 Intrasaccular Flow Disruptions
6.10 Intralumenal Flow Diversion
6.11 The pCONus Bifurcation Aneurysm Implant
6.12 Salvation Techniques
6.13 Observation for Bifurcation Aneurysms
6.14 Conclusion
References
7: Dual Lumen Balloon-Assisted Coil Embolization
7.1 Rationale for the Use of Double-Lumen Balloon
7.2 Advantages
7.2.1 General Advantages of Balloons
7.2.2 Advantages Specific to Double-Lumen Balloons
7.3 Potential Complications
7.4 Specific Indications
7.5 Available Options for Double-Lumen Balloons
7.6 Technique for Device Preparation (Manufacturer Recommendations)
7.6.1 Ascent Balloon Preparation
7.6.2 Scepter Balloon Preparation
7.7 Device Uses
7.8 Alternative Options
References
8: Blood Blister-Like Aneurysms: Pathogenesis and Endovascular Treatment
8.1 Introduction
8.1.1 Pathogenesis of BBA
8.1.2 Neuroendovascular Strategies
8.2 Conclusions
References
9: Flow Diverter Stents
9.1 Introduction
9.2 Study of the FD Characteristics
9.2.1 Flow Diverters: Braided and Low Porosity Stents
9.2.2 Porosity
9.2.3 Pore Density
9.2.4 Composition
9.2.5 Choice
9.2.6 Implantation
9.2.7 Surface Treatment
9.2.8 Extremities
9.2.9 In Vitro Studies
9.2.10 Computational Fluid Dynamic Studies
9.2.11 Cellular and Tissular Level
9.2.12 Factors Related to Aneurysm Characteristics
9.2.12.1 The Importance of Aneurysm Size and Volume
9.2.12.2 The Importance of a Curve at the FSS or Covered Branch
9.2.12.3 Lateral or Bifurcation Aneurysms and Fusiform Aneurysms
9.2.12.4 The Covered or “Jailed” Branch
9.2.12.5 Factors Related to the Choice of the FD
Compaction of the Flow Diverter by the Operator
9.3 Clinical Studies
9.3.1 Efficacy
9.3.2 Classifications
9.3.2.1 O’Kelly–Marotta (OKM) Classification [103]
9.3.2.2 Kamran–Byrne (KB) Classification [104]
9.3.2.3 Grunwald Classification (SMART) [105]
9.4 Complications
9.4.1 Ischemic
9.4.2 Hemorrhagic
9.5 Antiplatelets Regimen
References
10: The Off-Label Use of Flow Diverter
10.1 Blister-Like Aneurysm
10.2 Distal Circulation Aneurysm
10.3 Previously Treated Aneurysms
10.4 Posterior Circulation Aneurysms
10.5 Acute Ruptured Aneurysms
10.6 Intracranial Dissecting Aneurysms
References
11: Complications of Aneurysm Embolization and Their Management: Basic and Practical Considerations
11.1 Introduction
11.2 Hemorrhagic Complications
11.2.1 Incidence, Risk Factors, and Mechanisms of IOB
11.2.2 Comparison Between the Outcomes of Coiling and Clipping
11.2.3 Results
11.2.3.1 Material and Methods
11.2.3.2 Results
11.2.3.3 Case Presentations
11.2.3.4 Discussion
11.2.4 Management of Hemorrhagic Complications
11.3 Ischemic Complications
11.3.1 General Considerations
11.3.2 Local Thrombus Formation: Angiographic Classifications of Appearance and Management
11.3.2.1 Case Presentation
Case 5 (Fig. 11.5). Grade 1: Microthrombus Formation
Case 6 (Fig. 11.6). Grade 3: Thrombus Formation with Significant Decrease in Blood Flow
Case 7 (Fig. 11.7). Grade 1: Microthrombus Formation
11.3.3 Risk Factors and Considerations
11.4 Delayed Encephalopathy
11.4.1 General Considerations
11.4.2 Case Presentation
11.5 Conclusion
References
12: Clipping in Uncoilable Aneurysms
12.1 Introduction
12.2 Factors for Decision-Making in Coiling or Clipping
12.3 What does the Landmark Trials Say?
12.4 Group I: Uncoilable Aneurysms
12.4.1 Tiny Aneurysm Are Difficult to Coil (Fig. 12.1a, b)
12.4.2 Blood Blister-Like Aneurysm
12.4.3 Wide-Necked Aneurysm (Fig. 12.3a, b)
12.4.4 Bad Contour (Fig. 12.4a, b)
12.4.5 Incorporation of Parent or Branch Arteries (Fig. 12.5a, b)
12.4.6 Large and Giant Aneurysms (Fig. 12.6a–e)
12.4.7 Poor Access (Figs. 12.7a–c and 12.8a, b)
12.4.8 Complex Anatomy (Fig. 12.9 a–d)
12.4.9 Resistant Vasospasm (Fig. 12.10)
12.4.10 Pseudoaneurysms (Fig. 12.11)
12.4.11 Clipping as an Option to Newer Endovascular Techniques When Coiling Is Not Feasible?
12.4.12 Coiling Risks Which Can Be Handled Well by Clipping
12.4.13 Why Clipping Is Better in Specific Cases?
12.5 Group II: Unclippable Aneurysms
12.6 Group III: Both Unclippable and Uncoilable Aneurysms
12.7 Cost of Hospitalization
12.8 Conclusions
References
13: Open Treatment of Cerebral Aneurysms in the Endovascular Age
13.1 Introduction
13.2 General Advantages of Open Surgical Treatment of Aneurysms
13.3 Wide-Neck Aneurysms
13.4 Giant Aneurysms
13.5 Neural Compression
13.6 Epilepsy
13.7 Small Aneurysms
13.8 Blister Aneurysms
13.9 Thrombotic Aneurysms
13.10 Ruptured Aneurysms Presenting with Intracerebral Hemorrhage
13.11 Young Population
13.12 Fusiform Aneurysms
13.13 Multiple Aneurysms
13.14 Middle Cerebral Artery Aneurysms
13.15 Anterior Communicating Artery Aneurysms
13.16 Elderly Population
13.17 Recurrence After Endovascular Treatment
13.18 Future of Open Aneurysm Surgery
13.19 Conclusion
References
14: Recent Advances in Cerebral Aneurysms
14.1 Introduction
14.2 Pathophysiology of Aneurysms-Advanced Concepts
14.3 Advances in Imaging
14.4 Medical Management of Cerebral Aneurysms
14.5 Clipping Versus Coiling
14.6 Advances in Microneurosurgery
14.7 Advances in Endovascular Management of Aneurysms
14.7.1 Advances in Coils
14.7.2 Balloon-Assisted Coiling
14.7.3 Stent-Assisted Coiling
14.7.4 Flow Diverter Devices
14.8 Conclusions
References
15: Microsurgery of Cerebral Aneurysms Not Amenable to Endovascular Therapy
15.1 Introduction
15.2 Operative Techniques
15.2.1 Choice of Operative Approach (Fig. 15.1)
15.3 Anterior Circulation Aneurysms
15.3.1 Orbitozygomatic-Pterional Approach
15.3.2 Interhemispheric Approach
15.4 Posterior Circulation Aneurysms
15.4.1 Orbitozygomatic Approach
15.4.2 Transpetrosal Approaches
15.4.3 Far-Lateral Approach
15.4.4 Combined Approaches
15.5 Vascular Control
15.6 Techniques for Clipping
15.6.1 Aneurysm with Hemorrhagic Presentation
15.6.2 Aneurysm with Ischemic Presentation (Fig. 15.8)
15.6.3 Aneurysm with Mass Effect as There Presentation
15.7 Literature Review
15.8 Conclusion
References
16: Giant Intracranial Aneurysm: Flow Alteration vs Flow Diversion
16.1 Introduction
16.2 Comparison for Outcome: Endovascular Treatment vs. Surgical Bypass
16.2.1 Occlusion, Recurrence and Re-bleeding
16.2.2 Flow Diverter Stent in Posterior Circulation Giant Aneurysm
16.2.3 Pressure Symptoms due to Cranial Nerve Compression
16.2.4 Morbidity and Mortality
16.3 Concepts of Flow Diversion and Flow Alteration
16.4 Surgical Management for GIAs
16.4.1 Clipping with Reconstruction of Vessel Wall
16.4.2 Surgical Bypass
16.4.3 Decision Making in Surgical Bypass
16.4.4 Clinical Tips for Successful Surgical Bypass
16.4.5 Illustrated Case Examples of Surgical Bypass in GIAs
16.4.5.1 Bypass with Proximal Ligation
16.4.5.2 Trapping of Aneurysm with Bypass
16.5 Endovascular Treatment for GIA
16.5.1 Complications of Endovascular Management of GIAs
16.5.2 Comparison Between Management Strategies for Complications and Clinical Outcomes
16.6 Conclusion
References
17: Training Protocols for Neuroendovascular Surgery
17.1 Introduction
17.2 Training Protocols
17.2.1 Europe
17.2.1.1 The Program
17.2.1.2 Requirements/Criteria for Trainees
Percutaneous Treatments
Neuroendovascular Procedures
17.2.1.3 Requirements/Criteria for Institutions
17.2.1.4 Requirements/Criteria for Faculty and the Director of the Program
17.2.2 USA
17.2.2.1 The Program
17.2.2.2 Requirements/Criteria for Trainees
17.2.2.3 Requirements/Criteria for Institutions
17.2.2.4 Requirements/Criteria for Faculty and the Director of the Program
17.2.3 India
17.2.3.1 The Program
17.2.3.2 Requirements/Criteria for Trainees
17.2.3.3 Requirements/Criteria for Institutions
17.2.3.4 Requirements/Criteria for the Program Personnel
17.3 Conclusions
References