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BackgroundThe pipeline embolization device (PED) is approved for the treatment of large aneurysms of the proximal internal carotid artery (ICA). Its off-label application in treating aneurysms located specifically at the ICA terminus (ICA-T) has not been studied.MethodsWe conducted a retrospective chart review of patients from 2011 to 7 treated with PEDs. Out of 365 patients, 10 patients with ICA-T aneurysms were included. Patient demographics, procedural information, follow-up imaging, and clinical assessments were recorded.ResultsMean age was 46.9 years (± 8.8), and 6 (60%) patients were women. The mean maximum diameter of the aneurysms treated was 14.7 mm (± 10.7) and the mean neck diameter was 9.3 mm (± 6.6). Reasons for presentation included six incidental findings, one acute subarachnoid hemorrhage (SAH), and three patients with prior SAH. Kamran–Byrne Occlusion Scale scores for the treated aneurysms were as follows: three class IV (complete obliteration), four class III (ConclusionThe PED has potential for treating ICA-T aneurysms not amenable to conventional treatment strategies. Further studies are warranted to confirm the long term outcomes.

BackgroundThere are limited outcome data to guide the choice of treatment in pediatric patients with cerebral aneurysms.ObjectiveTo describe our institutional experience treating pediatric patients with cerebral aneurysms and to conduct a meta-analysis of available studies to provide the best current evidence on treatment related outcomes.MethodsWe identified pediatric patients with cerebral aneurysms evaluated or treated at our institution using a comprehensive case log. We also identified studies to include in a meta-analysis through a systematic search of Pubmed, SCOPUS, EMBASE, and the Cochrane Database of Systematic Reviews. As part of both the local analysis and meta-analysis, we recorded patient characteristics, aneurysm characteristics, management, and outcomes. Statistical analysis was performed using Fisher’s exact test and the two tailed Student’s t test, as appropriate.Results42 pediatric patients with 57 aneurysms were evaluated at our institution, and treatment specific outcome data were available in 560 patients as part of our meta-analysis. Endovascular and surgical treatments yielded comparable rates of favorable outcome in all children (88.3% vs 82.7%, respectively, P=0.097), in children with ruptured aneurysms (75% vs 83%, respectively, P=0.357), and in children with unruptured aneurysms (96% vs 97%, respectively, P=1.000).ConclusionEndovascular and surgical treatment yield comparable long term clinical outcomes in pediatric patients with cerebral aneurysms.

Background Thromboembolic complications sustained during neuroendovascular procedures can result in postoperative infarcts if not promptly recognized and treated. Treatment commonly involves glycoprotein IIb/IIIa inhibitors such as abciximab. We aimed to retrospectively review angiographic and clinical outcomes following abciximab administration for thromboembolic complications at our institution. Methods Neuroendovascular cases with thromboembolic complications treated with abciximab over a 132 month period were identified using a search of a comprehensive, prospectively maintained case log and all angiography records for the terms “abciximab” or “ReoPro.” Intraoperative intra-arterial (IA) administration typically involved slow infusion of 10 mg abciximab over 5 to 10 minutes. Intraoperative intravenous (IV) administration 0.25 mg/kg abciximab. Postoperative IV infusion typically involved 10 mcg/min infusion of abciximab. All relevant clinical notes and neuroimaging were reviewed. Results Of 19,566 neuroendovascular procedures performed during the review period, 48 (0.25%) involved abciximab administration for thromboembolic complications. 65% (31/48) involved IA administration, 21% (10/48) were IV only, and 15% (7/48) were combined IA and IV. Intraoperative treatment was supplemented with postoperative abciximab infusion in 13% (6/48) patients. Angiographic improvement was seen in 92% (44/48) cases, including 65% (31/48) with complete angiographic resolution (Figure 1). Only 8% (4/48) cases failed to improve angiographically. Angiographic outcomes were similar in patients who received IA, IV, or combined IA and IV administration of abciximab intraoperatively (p = 0.58), or patients who did or did not receive continuous IV infusion of abciximab postoperatively (p = 0.11). Postoperative infarction was seen in 20% (5/25), 44% (4/9), and 67% (4/6) following IA, IV, and combined IA and IV abxicimab, respectively (p = 0.06) (Figure 1). The rate of postoperative infarction was 33% (2/6) in patients who received continuous IV infusion of abciximab postoperatively and 32% (11/34) in those who did not (p = 1.00). Postoperative infarction developed in 8% (2/24) patients with complete angiographic improvement, compared to 69% (11/16) in patients with partial or no improvement (p Conclusion Abciximab administration is an effective method of treating thromboembolic complications of neuroendovascular procedures. Angiographic outcomes were not appreciably different between different routes of abciximab administration. Infarction was least common in patients treated with IA abciximab; the addition of postoperative abciximab infusion did not affect the rate of infarction. No or partial angiographic improvement was associated with significantly higher rates of postoperative infarction than complete angiographic improvement. Disclosures A. Kansagra: None. T. Madaelil: None. D. Cross: None. C. Moran: 2; C; Medtronic Neurovascular. 3; C; Medtronic Neurovascular. C. Derdeyn: None.

There is limited data on outcomes of mechanical thrombectomy for pediatric stroke using modern devices. In this study, we report two cases of pediatric acute ischemic stroke treated with mechanical thrombectomy, both with good angiographic result (TICI 3) and clinical outcome (no neurological deficits at 90 days). In addition, we conducted a literature review of all previously reported cases describing the use of modern thrombectomy devices. Including our two cases, the aggregate rate of partial or complete vessel recanalization was 100% (22/22), and the aggregate rate of favorable clinical outcome was 91% (20/22). This preliminary evidence suggests that mechanical thrombectomy with modern devices may be a safe and effective treatment option in pediatric patients with acute ischemic stroke. Disclosures T. Madaelil: None. A. Kansagra: None. C. Derdeyn: None. D. Cross: None. C. Moran: 2; C; Medtronic Neurovascular.

Background and purpose Flow diversion is an established technique to treat unruptured intracranial aneurysms not amenable to standard endovascular or microsurgical techniques. The suitability of flow diverting devices (FDD) to treat ruptured aneurysms is less clear. Materials and methods An in-depth search of multiple electronic publication databases was performed for reports describing ruptured intracranial aneurysms treated by flow diversion. Clinical and radiological characteristics, interventional details, and outcomes were pooled and analyzed in aggregate. Results The pooled cohort comprised of 126 patients with a mean age of 52.6 ± 12.5 years. Mean Hunt Hess/World Federation of Neurosurgical Societies grading scale at presentation was 2.2 ± 1.2. Treated aneurysms were located in the anterior circulation in 64% (81/126) cases and 36% (45/126) in the posterior circulation. Five distinct aneurysm morphologies were present, including dissecting (28%, 35/125), fusiform (9.6%, 12/125), giant (3.2%, 4/125), blister (37.6%, 47/125), and saccular (21.6%, 27/125) types. Favorable clinical outcome (defined as Modified Rankin Scale (mRS) = 0−2 or Glasgow Outcome Scale (GOS) = 4−5) was achieved in 81.5% (101/124) of treated patients. Unfavorable clinic outcome (defined by mRS = 3−6 or GOS = 1−3) occurred in 18.5% (23/124) of patients. Clinically significant hemorrhagic complications occurred in 5.5% (7/126) of cases, the majority of which were due to aneurysm re-rupture (4.8%; 6/126). Aneurysm size greater than 2cm was associated with a greater risk of re-rupture when compared to aneurysms smaller than 2 cm (p = 0.001). Aneurysm size greater than 7 mm was associated with more unfavorable clinical outcomes (p = 0.03). Conclusion For ruptured aneurysms not amenable to other treatment strategies, the use of flow diversion may allow for reasonably high rates of good clinical outcomes, particularly in small aneurysms. There was a risk of re-rupture in these aneurysms, especially those larger than 2 cm. Disclosures T. Madaelil: None. C. Moran: 2; C; Medtronic Neurovascular. D. Cross: None. A. Kansagra: None.