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Fenestrated vertebrobasilar junction-related aneurysms (fVBJ-AN) are uncommon and endovascular management strategies have become the first options for the treatment of these lesions. This clinical study aimed to report our experience in the endovascular management of these lesions and to review the literature. We retrospectively reviewed 10 consecutive patients harboring 12 fVBJ-AN between January 2007 and December 2014. The demographic, angiographic and clinical data were reviewed. Additionally, a literature review was performed. Endovascular management strategies were successfully applied in all 10 patients. Post-procedural angiograms indicated total occlusion in eight (66.7%) aneurysms, a residual neck in one (8.3%) aneurysm, and three residual aneurysms (25%). No procedure-related complications were observed. Follow-up angiograms were obtained in eight patients and revealed nine occluded aneurysms and one improved aneurysm; two patients were lost to angiographic follow-up. Clinical follow-ups were obtained in all patients (until July 2015), and the modified Rankin Scale scores at 69.5 months (range 17–101 months) of follow-up were 0 in eight patients and 1 in two patients. Endovascular management strategies provided a high occlusion rate and an acceptable complication rate and are thus efficacious in the treatment of fVBJ-AN. Further studies are necessary to validate the utility of these treatments due to the low incidence of fVBJ-AN. [ABSTRACT FROM AUTHOR]

Background: To evaluate the safety and effectiveness of stent placement for ruptured or unruptured middle cerebral artery (MCA) aneurysms in a larger number. Methods: Between October 2003 and December 2012, data for 70 patients with 72 complex MCA aneurysms treated with stents at our institution were retrospectively collected and analyzed. Results: Eighty-five stents were successfully deployed in this series. However, failure of followed coiling was encountered in 2 (2.8%) tiny aneurysms of them. Of the 63 aneurysms treated with stent-assisted coiling, complete occlusion was achieved in 22 (34.9%), neck remnant in 15 (23.8%), and residual sac in 26 (36.5%). Of the 9 aneurysms treated with stent alone, the results were contrast stasis in 3 aneurysms and no change in 6. Procedure-related complications occurred in 9 (12.5%) procedures, including 7 of 27 (25.9%) with ruptured aneurysms and 2 of 45 (4.4%) with unruptured aneurysms, which resulted in 1 death and 5 disabilities. Univariate and multivariate analyses show that ruptured aneurysm is an independent factor for the outcome of these patients (odds ratio, 7.35; 95% confidence interval, 1.35-40.0). Angiographic follow-up results (mean, 10.5 ± 8.8 months) showed that 72.1% (44 of 61) were completely occluded, 4.9% (3 of 61) recurred, and others were stable or had improved. Intrastent stenosis was observed in 1 (1.6%) patient, which was managed conservatively. During a clinical follow-up period ranging from 7 to 113 months (mean, 33.0 ± 22.4 months), 1 disabled patient died from severe pneumonia, whereas the clinical status of the others had improved or was stable. Procedure-related morbidity/mortality during the follow-up for the ruptured and unruptured groups were 3.7%/3.7% and 0/0, respectively. Conclusions: Our study shows that stent placement for the treatment of certain wide-neck MCA aneurysms is feasible, safe, and effective. However, stent placement for acutely ruptured MCA aneurysms harbors a much higher complication rate. [Copyright &y& Elsevier]

Abstract: Stent-assisted coiling is now the preferred treatment option for wide-necked basilar artery bifurcation aneurysms (BABA). However, the optimal choice of specific treatment strategies is still not well documented. In this paper, based on the “two-neck” theory of BABA, we classified the stent-assisted coiling treatment of BABA into three types: unilateral stent-assisted coiling, unilateral stent plus contralateral microcatheter or microwire-assisted coiling, and bilateral stent-assisted coiling. We assessed the feasibility and effectiveness of different stent-assisted coiling strategies for the treatment of BABA. Twenty-three BABA patients treated with stent-assisted coiling between May 2003 and September 2012 were included. Of the 23 aneurysms, 16 were treated with unilateral stent-assisted coiling, two were treated with unilateral stent and microcatheter or microwire-assisted coiling, and five were treated with bilateral stent-assisted coiling. All 23 BABA were successfully embolized, with a technical success rate of 100%. According to the Raymond classification, the immediate procedural outcome was grade I in nine patients, grade II (neck residue) in four patients and grade III (body filling) in 10 patients. The rate of procedure-related complications was 4.3% (1/23), where intra-operative hemorrhage occurred during coiling due to rupture of the aneurysm. Of the 23 patients, 16 (69.6%) had angiographic follow-up. The mean follow-up duration was 13.5months (range 1–46months). Angiographic follow-up showed complete occlusion in 10 patients (62.5%), improvement in two patients (12.5%), stability in three patients (18.7%), and recanalization in one patient (6.25%). The various stent-assisted coiling strategies available at present are feasible and effective for the treatment of wide-necked BABA. [Copyright &y& Elsevier]

Abstract: The endovascular treatment of patients with tiny, wide-necked aneurysms is technically challenging, due to the small volume for microcatheterization and coil stabilization inside the aneurysm sac. We performed a retrospective study to evaluate the feasibility, effectiveness, and safety of stent-assisted embolization for patients with ruptured, tiny, wide-necked posterior communicating artery (PcomA) aneurysms. Between January 2007 and August 2011, 17 tiny, wide-necked PcomA aneurysms that had ruptured were treated at our institution using a modified stent-assisted technique, with delivery of the first coil inside the aneurysm followed by placement of a self-expanding stent via a second microcatheter. All patients were treated successfully using this modified stent-assisted coiling technique. Initial results showed aneurysm occlusion of Raymond Class 1 in 10 patients, Class 2 in four patients, and Class 3 in three patients. The angiographic follow-up results for 13 patients (mean, 12.5months) showed that all aneurysms remained stable or improved, without any in-stent stenosis or recurrence. Of the other four patients, three refused angiography for economic or personal reasons, and one was lost in follow-up. Clinical follow-up of 16 patients for a mean of 23.8months showed no death or rebleeding. These results imply that endovascular treatment of ruptured tiny, wide-necked PcomA aneurysms using our modified stent-assisted coiling technique is safe and feasible. This technique improves the long-term outcomes of these aneurysms by increasing the packing density and diverting the intra-aneurysmal blood flow. [Copyright &y& Elsevier]

Abstract: Dural arteriovenous fistulas (DAVF) of the anterior cranial fossa are often associated with hemorrhage and are usually treated surgically. This clinical study summarizes our preliminary experience in the transarterial embolization of these lesions. We retrospectively reviewed the data for 11 patients with anterior cranial fossa DAVF who underwent transarterial embolization with the Onyx Liquid Embolic System (eV3 Endovascular, Plymouth, MN, USA) at our institute between 2007 and 2011. In four patients, a balloon-assisted technique was used to facilitate superselective catheterization. According to the Cognard classification of DAVF, three fistulas were type III, and the other eight were type IV. DAVF were completely obliterated in 10 patients after treatment via a single ethmoidal artery, but the other patient was not completely cured. No signs of rebleeding or symptom progression were observed at a mean follow-up of 18.5months (range: 2–49months). Transarterial embolization using Onyx is therefore feasible and effective for the management of DAVF of the anterior cranial fossa. [Copyright &y& Elsevier]

Abstract: The treatment of anterior communicating artery (AcomA) wide-necked aneurysms with the Enterprise stent (Codman, Miami Lakes, FL, USA) has not been commonly described, due to the complexity of the vascular anatomy and the small vessels of the AcomA complex. To evaluate the feasibility, effectiveness and safety of Enterprise stent placement in AcomA aneurysms, we performed this retrospective study. Between November 2008 and December 2010, 27 wide-necked AcomA ruptured aneurysms were treated within 72hours of ictus with the Enterprise stent. Data collected and analyzed were: demographic data, morphologic features of the aneurysm, treatment results and follow-up results. Twenty-nine Enterprise stents were successfully deployed in all 27 aneurysms, including Y-configuration stent deployment in two patients. The initial embolization degrees were Raymond class I in 20 patients, class II in five and class III in the other two. The angiographic follow-up of 21 patients (mean, 8.4months) showed that all aneurysms remained stable or improved; there was no in-stent stenosis, recurrence or retreatment. The clinical follow-up of 26 patients (mean, 12.6months) showed that 23 patients displayed no symptoms and no or mild disability; three patients remained with severe or moderately severe disability. The Enterprise stent is feasible and safe for endovascular embolization of wide-necked AcomA ruptured aneurysms. Further follow up is needed to assess the long-term efficacy of Enterprise stent placement in AcomA. [Copyright &y& Elsevier]

Abstract: The Cordis Enterprise stent (Cordis Corporation; Miami, FL, USA), is a novel self-expanding, closed-cell, retractable stent with a low profile, good navigability and flexibility, which has been recently introduced into China. We retrospectively analyzed the clinical data of 84 consecutive patients who presented to our institution from December 2008 to June 2009. They had a total of 90 wide-necked or fusiform aneurysms that were treated using Enterprise stents. A total of 97 stents were implanted into the parent arteries without technical failure. A total of 14 aneurysms were stented alone, while the remaining 76 aneurysms were treated using a combination of stent and coils, resulting in complete occlusion of 43 aneurysms, a residual neck in 11 and a residual aneurysm in 22. Procedure-related complications occurred in two patients, which resulted in one procedure-related mortality. The clinical follow-up (1–7months) results demonstrated no neurological deterioration or re-bleeding. The short-term angiographic follow-up (3–6months) results revealed one recurrence and no in-stent stenosis. Our results suggest that the Cordis Enterprise stent is easy to manipulate, and is safe and effective in the treatment of complex intracranial aneurysms. [Copyright &y& Elsevier]

Certain cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) are difficult to access through transarterial or transvenous routes and may necessitate access through direct transorbital puncture of the superior ophthalmic vein (SOV) or the CS. However, to be successful, the accurate design of the puncture route and guidance are crucial. This study aimed to report our preliminary clinical experience using cone-beam computed tomography (CT) with real-time fluoroscopic overlays for image guidance during transorbital needle puncture. Between December 2017 and July 2018, 3 patients with CS DAVFs were treated via a transorbital puncture to establish access to the CS under the guidance of XperGuide planning software either via direct CS puncture or through the SOV. The guidance trajectory was superimposed onto the real-time fluoroscopic image during needle puncture. Once access was established, the CS DAVFs were treated with a combination of liquid embolic materials and coils. Image guidance aided to avoid at-risk structures and treatment resulted in all cases in complete obliteration of the CS DAVFs as verified by control angiography without peri- or postprocedural complications. Endovascular embolization of CS DAVFs via direct transorbital puncture aided by image guidance provided an alternative option when more conventional approaches are deemed not possible. [ABSTRACT FROM AUTHOR]

Background Giant serpentine aneurysms (GSAs) are a subgroup of giant intracranial aneurysms, distinct from saccular and fusiform varieties, that are defined as partially thrombosed giant aneurysms with tortuous internal vascular channel. Clinicopathologic characteristics of middle cerebral artery GSAs have been rarely reported in the literature, with discussion of radiologic characteristics only. We clarify patient clinical and neuroradiologic features and discuss the mechanism of formation and progression. Case Description A 43-year-old woman presented with a GSA arising from the middle cerebral artery. There was a separate inflow and outflow channel of the aneurysm, with the outflow channel feeding the distal branches of the parent artery and supplying normal brain parenchyma. The GSA was treated successfully by aneurysmectomy and superficial temporal artery–middle cerebral artery bypass followed by proximal occlusion and vascular reconstruction. An aneurysm specimen was examined to correlate pathologic findings and morphologic characteristics. Result Pathologic results showed that thickness of the aneurysmal wall was typically increased and varied, and no internal elastic lamina or endothelial lining could be identified. The sac contained thrombi of various ages with recanalizing vessel formation and chronic inflammation infiltration. Intimal hyperplasia and neoangiogenesis in the wall and hyaline degeneration of the media were observed. Vessels coursing in their adventitia showed mucoid changes, which are responsible for the contrast enhancement of the aneurysmal rim on computed tomography scan. Conclusions GSAs are a specific pathologic entity with unique morphologic and pathologic characteristics that can affect intracranial blood vessels. The pathogenic mechanisms are unclear; this report suggests that GSAs may be associated with degeneration of the vascular wall. [ABSTRACT FROM AUTHOR]