Treatment of complex intracranial pathologies with transcirculation endovascular approaches

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Colocación del paciente en cefalostato magnetocompatible y posicionamiento de la RMi bajo la mesa quirúrgica. B. Posición elevada para llevar a cabo exploración. C. Polos de imán 0,15T (27cm) con detalle del coil colocado sobre región quirúrgica. D. Exploración basal vs. exploración final con resección completa." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sonia Tejada Solís, Cristian de Quintana Schmidt, Josep Gonzalez Sánchez, Ignacio Fernández Portales, Marta del Álamo de Pedro, Victor Rodríguez Berrocal, Ricardo Díez Valle" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Sonia" "apellidos" => "Tejada Solís" ] 1 => array:2 [ "nombre" => "Cristian" "apellidos" => "de Quintana Schmidt" ] 2 => array:2 [ "nombre" => "Josep" "apellidos" => "Gonzalez Sánchez" ] 3 => array:2 [ "nombre" => "Ignacio" "apellidos" => "Fernández Portales" ] 4 => array:2 [ "nombre" => "Marta" "apellidos" => "del Álamo de Pedro" ] 5 => array:2 [ "nombre" => "Victor" "apellidos" => "Rodríguez Berrocal" ] 6 => array:2 [ "nombre" => "Ricardo" "apellidos" => "Díez Valle" ] 7 => array:1 [ "colaborador" => "Grupo de trabajo de la SENEC" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2529849620300010" "doi" => "10.1016/j.neucie.2020.02.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849620300010?idApp=UINPBA00004B" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147319301009?idApp=UINPBA00004B" "url" => "/11301473/0000003100000004/v1_202007010644/S1130147319301009/v1_202007010644/es/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1130147319301198" "issn" => "11301473" "doi" => "10.1016/j.neucir.2019.11.001" "estado" => "S300" "fechaPublicacion" => "2020-07-01" "aid" => "409" "copyright" => "Sociedad Española de Neurocirugía" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Neurocirugia. 2020;31:165-72" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 17 "formatos" => array:2 [ "HTML" => 6 "PDF" => 11 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "Investigación clínica" "titulo" => "Tratamiento neuroendoscópico de quistes aracnoideos en edad pediátrica. Resultados de una serie de 20 pacientes" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "165" "paginaFinal" => "172" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Neuroendoscopic treatment of arachnoid cysts in the paediatric population. Series results for 20 patients" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1842 "Ancho" => 505 "Tamanyo" => 142758 ] ] "descripcion" => array:1 [ "es" => "Caso 11. A) TAC craneal sin contraste, axial: vemos colecciones extraaxiales bilaterales en la parte frontal. B) RM coronal en T2. RM de control después un mes del tratamiento endoscópico mediante CC con artefacto de flujo en secuencia T2. C) RM axial en T2. Artefacto de flujo hacia cisternas de la base." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jorge Linares Torres, Bienvenido Ros López, Sara Iglesias Moroño, Guillermo Ibáñez Botella, Ángela Ros Sanjuán, Miguel Ángel Arráez Sánchez" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Jorge" "apellidos" => "Linares Torres" ] 1 => array:2 [ "nombre" => "Bienvenido" "apellidos" => "Ros López" ] 2 => array:2 [ "nombre" => "Sara" "apellidos" => "Iglesias Moroño" ] 3 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Ibáñez Botella" ] 4 => array:2 [ "nombre" => "Ángela" "apellidos" => "Ros Sanjuán" ] 5 => array:2 [ "nombre" => "Miguel Ángel" "apellidos" => "Arráez Sánchez" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2529849620300022" "doi" => "10.1016/j.neucie.2020.02.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849620300022?idApp=UINPBA00004B" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147319301198?idApp=UINPBA00004B" "url" => "/11301473/0000003100000004/v1_202007010644/S1130147319301198/v1_202007010644/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Clinical Research" "titulo" => "Treatment of complex intracranial pathologies with transcirculation endovascular approaches" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "173" "paginaFinal" => "183" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Michael A. Silva, Alfred P. See, Samir Sur, Mohammad A. Aziz-Sultan" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Michael A." "apellidos" => "Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Alfred P." "apellidos" => "See" "email" => array:1 [ 0 => "alfredpsee@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Samir" "apellidos" => "Sur" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Mohammad A." "apellidos" => "Aziz-Sultan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Neurosurgery, Jackson Memorial Hospital, University of Miami, Miami, FL, USA" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de enfermedades intracraneales complejas con enfoques endovasculares de transcirculación" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0035" "etiqueta" => "Fig. 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1967 "Ancho" => 2500 "Tamanyo" => 735122 ] ] "descripcion" => array:1 [ "en" => "Case 6. (A) Lateral DSA demonstrated a previously treated cerebellar AVM associated with a 3.7mm aneurysm affecting a feeding vessel (white arrowhead). (B) The aneurysm was not amenable to cannulation despite multiple attempts with the microcatheter (white arrowhead). Attention was then turned to the 1.5mm left ICA blister aneurysm seen on lateral DSA (C, black arrowhead). After deployment of a stent across the aneurysm neck, two coils were deployed (D, white arrowhead) and lateral DSA (E) showed a coil mass within the aneurysm sac (white arrowhead) and occlusion without residual filling." ] ] ] "textoCompleto" => "IntroductionIn the decades since the inception of endovascular neurosurgery, new devices and techniques have greatly expanded the breadth and complexity of pathologies amenable to endovascular treatment. While endovascular techniques carry their own set of risks, endovascular neurosurgery has gained an increasingly prominent role in the treatment of many aneurysms. Endovascular techniques have effectively treated patients who are not candidates for open surgery. Studies have shown equivalent or improved outcomes for endovascular treatment of selected unruptured aneurysms compared to clipping,<a class="elsevierStyleCrossRefs" href="#bib0095">1–3</a> with mixed data for ruptured aneurysms.<a class="elsevierStyleCrossRefs" href="#bib0110">4,5</a> In addition to aneurysm treatment, stroke care has been similarly revolutionized by endovascular techniques as a result of mechanical thrombectomy.<a class="elsevierStyleCrossRefs" href="#bib0120">6,7</a>Although the role of endovascular neurosurgery has grown, some lesions remain difficult to treat endovascularly due to difficulty cannulating sharply angled, highly tortuous, or extremely distal vessels. Diminished catheter control in these settings may affect the completeness of embolization. However, there are some lesions thought not to be suitable for endovascular treatment that may be amenable to treatment with unconventional, transcirculation endovascular approaches to the circle of Willis. There have been several prior reports of alternative anatomical endovascular approaches.<a class="elsevierStyleCrossRefs" href="#bib0130">8–14</a> This case series demonstrates the use of several transcirculation techniques to treat challenging lesions that otherwise would have been deemed inappropriate for endovascular therapy.Illustrative casesCase 1A 23-year-old man with a history of subtotal meningioma resection at age 8 presented with signs of increased intracranial pressure and was found to have recurrence of the tumor. An MRI was performed and demonstrated a tumor in the Sylvian fissure over 8cm in size enveloping the MCA branches and ICA terminus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B). A diagnostic angiogram was performed, which showed a hypervascular tumor with supply from the MCA and the recurrent artery of Huebner (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Given the hypervascular nature of the large tumor and particular parasitization of deep pial vessels beyond the reach of the skull base microsurgical approach during the beginning of the case, embolization was considered helpful for safer resection.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>During multidisciplinary discussion, our team reviewed the typical strategy of surgical devascularization; specifically, our center focuses on isolating the tumor from the dural supply during surgical approaches. However, in the unusual case of pial parasitization, as we see in this case, the pial supply also needs to be disconnected before the tumor is devascularized. In some tumors, this is safely accomplished during the microsurgical approach. However, in this case, the size of the tumor and position of the pial supply suggested a challenging reach whether with an orbito-craniotomy and subfrontal approach or an interhemispheric approach. Therefore, the endovascular team pursued a focal pedicular embolization of the pial supply. Penetration within the tumor bulk was not indicated and not pursued because the standard microsurgical devascularization would complement the endovascular technique without the need for deep penetration of tumor capillaries by embolisate.On angiography, the right recurrent artery of Huebner, a major feeding vessel of the tumor, was seen to have an acutely angled takeoff from the right A1 that would have been difficult to catheterize from the ipsilateral side. However, the patient had a fenestrated anterior communicating artery that provided a more direct access to the right recurrent artery of Huebner via the left A1. A Marathon (ev3 Covidien, Plymouth MN) microcatheter was advanced from the left A1 across the superior branch of the fenestrated anterior communicating artery into the right A1 and recurrent artery of Huebner (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). Embolization of the feeding vessel was achieved with Onyx (ev3 Covidien, Plymouth, MN) injection under biplane angiography. The lateral MCA feeding vessels were catheterized and injected with Onyx directly from the ipsilateral side under single-plane angiography following the craniotomy. Postembolization fluoroscopy demonstrated successful embolization of the feeding vessels and Onyx cast throughout the tumor (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>E and F). The patient made a full neurologic recovery after completion of tumor resection with an estimated blood loss of 400mL and was discharged on postoperative day 3. At latest follow-up, the patient has returned to their highly intensive work.This case demonstrates an approach across the ACoA to embolize a tumor with liquid embolisate.Case 2A 61-year-old woman with a history of smoking, hypertension, and migraines with worsening posterior headaches and left-sided incoordination was found to have a 2cm left intracranial vertebral artery aneurysm at an outside hospital. An embolization procedure was attempted at the outside hospital, but was aborted due to inability to visualize the posterior inferior cerebellar artery (PICA). Although the right vertebral artery was catheterized, it terminated in the right PICA. Review of these images suggested an anterior inferior cerebellar artery (AICA)–PICA complex on the left. The patient was transferred to our institution for further evaluation and endovascular intervention.On exam the patient was found to have left-sided upper extremity dysmetria. The decision was made to proceed with angiography and attempt at flow diversion of the left vertebral artery to treat the large left intracranial vertebral artery aneurysm. The left femoral artery was cannulated and angiography revealed a 14mm fusiform dissecting aneurysm affecting the left vertebral artery at the PICA origin (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Initial attempts to advance the catheter across the aneurysm neck were unsuccessful. Use of a balloon-bounce technique involving inflation of a balloon within the aneurysm sac<a class="elsevierStyleCrossRef" href="#bib0165">15</a> also failed to advance the catheter beyond the aneurysm. Importantly, the right vertebral artery did not contribute to the basilar circulation. The left vertebral artery injection demonstrated bilateral SCA opacification but no significant contribution to the supratentorial circulation, suggesting robust posterior communicating artery supply. The right internal carotid artery injection demonstrated a fetal-type configuration with a posterior communicating artery >2mm in diameter. A transcirculation approach was attempted: the microcatheter was applied in a retrograde fashion via the posterior communicating artery into the basilar artery and left vertebral artery (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). However, this was also unsuccessful in traversing the aneurysm. Although the microwire was able to traverse the aneurysm, there was inadequate wire purchase in either case to allow the microcatheter to follow. The decision was made to abort the procedure and perform vertebral artery sacrifice at a later date.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>In a subsequent procedure, the left femoral artery was again cannulated and a 4mm×7mm balloon was advanced into the left vertebral artery proximal to the aneurysm. After the balloon was inflated, serial neurologic testing demonstrated no neurologic change, this was further evaluated with the blood pressure artificially depressed to 2/3 of baseline using a nitroprusside infusion. Following the successful balloon test occlusion, a microcatheter was advanced into the aneurysm sac. Eight coils were deployed, and the enlarging coil mass was allowed to extend into the parent vessel to sacrifice the left vertebral artery (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C). At most recent follow-up of 5 months, the patient had made a full neurologic recovery and MRA demonstrated complete occlusion of the aneurysm.This case demonstrates an unsuccessful approach across the PCoA from the anterior circulation into the posterior circulation to traverse a large vertebral artery aneurysm with flow diversion.Case 3A 72-year-old female prior smoker with hypertension and a family history of fatal brain aneurysm rupture presented with recurrent CSF rhinorrhea. A cerebral angiogram demonstrated an incidental wide-necked 12mm×19mm left cavernous carotid aneurysm (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A), and the patient failed a BTO during the procedure. Given the size of the aneurysm and the patient's family history of aneurysmal rupture, the decision was made to proceed with aneurysm embolization using multiple telescoping Pipeline embolization devices (PEDs). At the time of treatment, flow diversion was increasingly applied, but the technology was not fully mature. The longer stents that are currently available were not yet available. Therefore, the treatment plan was overlapping flow diverters in a telescoping fashion.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Using a triaxial system (6Fr 80cm SHTL [Cook] within the left common carotid artery, Penumbra 070 115cm [Penumbra] within the distal petrous segment, and Marksman 135cm [Medtronic]), the first PED (4.25mm×20mm) was successfully deployed in the supraclinoid ICA just proximal to the anterior choroidal artery, covering the distal aneurysm neck. Although the microcatheter maintained access across the first PED, due to vessel tortuosity, the microcatheter would not track further distally. This was inadequate support for deployment of the second telescoping PED. Contralateral femoral access and a 5Fr Envoy within the left ICA were applied to attempt secondary catheterization across the PED with an SL-10 microcatheter with multiple microwires (Synchro®, Transend® [Stryker], Neuroscout®, Agility® [Codman DePuy Synthes, Raynham, MA], and Headliner 012 [Terumo, Tokyo, Japan]), but this was unsuccessful. As an adjunct, a 25mm×50cm framing coil was deployed to provide buttressing support to the PED within the aneurysm. Ultimately, this resulted in herniation of the Marksman® microcatheter into the aneurysm with no access across the first PED.Alternative access across the stent was accomplished by a transcirculation approach. With a 5Fr Envoy guide catheter in the RICA, the SL-10 microcatheter was advanced from the RICA to the right A1, through the anterior communicating artery, and into the left A1 and LICA. It was then advanced through the first PED and positioned in the aneurysm. A Marksman microcatheter and Synchro microwire were positioned within the aneurysm via the left ICA. Within the SL-10 (right side approach), An Ev3 Amplatz goose neck microsnare was advanced into the aneurysm and captured the Synchro microwire from the Marksman microcatheter (left side approach) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B and C). The microsnare was retracted to advance the Marksman beyond the PED into the left carotid terminus (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>D).After repositioning the Marksman in the M1 using a microwire, a second PED (5mm×20mm) was loaded onto the Marksman. The second PED was positioned with the distal end at the midpoint of the first PED and deployed to span the rest of the exposed aneurysm neck, successfully reconstructing the parent vessel. Due to a kink in the PED construct, the Marksman was serially advanced and retracted over the guidewire to relieve the kink. This resulted in un-telescoping of the stents and discontinuity between the two PEDs, necessitating deployment of an additional PED. The Marksman, which remained distal to the gap, was advanced into the M1 segment in preparation for additional stent placement. A third PED (5mm×20mm) was advanced across the gap and deployed to regain complete vessel reconstruction (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>A and B). An angiogram performed at the conclusion of the procedure demonstrated successful flow diversion and contrast stagnation within the left cavernous carotid aneurysm (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>C and D).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>Two years following the procedure, follow-up angiography demonstrated near-complete occlusion of the aneurysm with a 3mm region of residual filling. At 4 years, the patient remained asymptomatic and, given their age and clinical stability over 4 years, the decision was made not to pursue further angiography.This case demonstrates an approach across the ACoA to embolize an aneurysm with a complex multi-device flow diverting stent construct.Case 4A 53-year-old woman presented with SAH and catheter angiography demonstrated two LICA supraclinoid aneurysms, a 3mm saccular superior hypophyseal aneurysm and a 2mm anterolateral LICA aneurysm that was presumed to be the source of SAH (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>A). A left ICA BTO was performed, demonstrating a patent anterior communicating artery and adequate filling of the left MCA from the posterior communicating artery.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>In preparation for balloon-assisted Onyx® 500 (Medtronic, Minneapolis, MN) embolization, the patient received 650mg aspirin and 450mg clopidogrel. Despite support with a 65cm reinforced 6Fr sheath and a 6Fr Envoy guide catheter within the distal internal carotid artery, a 90° steam-shaped Echelon 10 microcatheter and multiple microwires (Synchro® and Transend® [Stryker], and Agility® [Codman DePuy Synthes, Raynham, MA]) were unable to catheterize the aneurysm. An alternative approach via the vertebral artery and posterior communicating artery was designed: A 5Fr Envoy catheter within the left vertebral artery allowed navigation of an Echelon 10 microcatheter via the posterior communicating artery and into the aneurysm. The retrograde access to the intracranial ICA provided an optimal trajectory into the aneurysm compared to the microcatheter position destabilized after taking the anterior cavernous genu (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>B). The 7mm×30mm Hyperglide balloon was applied in an anterograde fashion via the right internal carotid artery to assist in administration of the Onyx® 500.After Onyx® embolization, an Enterprise 4.5mm×20mm stent was deployed across the aneurysm neck to prevent Onyx migration. Postoperative angiography demonstrated complete occlusion of the aneurysm (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>C and D). Treatment of the other aneurysm was deferred. At 2-week follow-up, angiography demonstrated complete occlusion with no recanalization of the LICA aneurysm. At one month, the patient had made a full neurologic recovery.Although the Onyx® 500 embolisate is less frequently applied in the current era, catheter stability remains a consideration in coil embolization. Surgery was also considered in this case; indeed, advanced techniques have been described to effectively clip very small (<3mm) aneurysms.<a class="elsevierStyleCrossRef" href="#bib0170">16</a> However, in this case, endovascular treatment was favored given the challenge of clipping such a small aneurysm. Once retrograde access to the aneurysm was achieved without difficulty, endovascular treatment became feasible and Onyx embolization was attempted and successful. In the current era, endovascular treatment of this lesion with a PED would likely have been favored over Onyx embolization. The available technology at the time obligated an unconventional endovascular approach. This case demonstrates a posterior-to-anterior approach across the PCoA to embolize a challenging aneurysm.Case 5Before the era of mechanical thrombectomy, a 58-year-old woman with a heavy smoking history presented with vision loss in the right eye and was found to have a right retinal artery occlusion. Brain MRI demonstrated a right parietotemporal infarct (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>A) and a CTA showed right ICA occlusion (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>B). The RICA occlusion was thought to be secondary to thrombosis, but the chronicity of the clot was not known. The patient acutely progressed with a left facial droop and left hemiparesis with an National Institutes of Health stroke scale of 15. CTA showed a right MCA occlusion. tPA was administered less than 1.5h after onset of the facial droop and the patient was brought to the angiography suite for thrombectomy at 2.5h after symptom onset.<elsevierMultimedia ident="fig0030"></elsevierMultimedia>Due to the RICA occlusion of unclear chronicity, the decision was made to perform mechanical thrombectomy via the vertebrobasilar system. Access via the left ICA was also considered; however in the setting of RICA occlusion, preservation of the contralateral ICA was deemed paramount and the vertebrobasilar system presented a safer access route. A 6F Envoy [Codman DePuy Synthes, Raynham MA] was advanced into the left vertebral artery. Microcatheterization of the basilar artery (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>C) confirmed occlusion of the right MCA. The microcatheter was then advanced through the right PCoA into the right MCA (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>C) for 5mg of intraarterial tPA and mechanical thrombolysis with a Separator® [Penumbra, Alameda, CA] (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>D). A follow-up angiogram showed filling of the right M1 and superior M2 despite persistent subocclusive stenosis (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>E).At discharge, the patient's neurologic exam was notable for left hemiparesis and left-sided neglect. At one-month follow-up, the patient's left hemiparesis had improved and they were able to ambulate independently with only occasional use of a wheelchair (modified Rankin Scale 3).This case demonstrates a posterior-to-anterior approach across the PCoA to for microcatheter delivery of a pharmacotherapeutic and aspiration thrombectomy.Case 6A 70-year-old man with a history of right cerebellar AVM treated with Gamma Knife® [Elekta, Stockholm, Sweden] radiotherapy 4 years prior who presented with four days of headache and nausea and SAH on CT. Catheter angiography demonstrated the previously treated right cerebellar AVM and a left ICA blister aneurysm measuring 1.5mm with a 4mm neck (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>C). The AVM had a 2×2cm nidus draining into the transverse sinus and vein of Galen, and there was a 3.7×3.3mm SCA feeding artery, which was the first treatment target (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>A). However, this was unsuccessful due to tortuosity of the left vertebral artery and hypoplasia of the right vertebral artery. The left ICA blister aneurysm was successfully treated via stent-assist coiling with an Enterprise stent with complete obliteration of the aneurysm (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>E). Multiple attempts to cross the stent with a Marathon [Medtronic] and -X-pedion 10 [eV3] were unsuccessful, and the AVM was left untreated.<elsevierMultimedia ident="fig0035"></elsevierMultimedia>The following day, the patient was taken back for attempted embolization of the AVM-associated aneurysm. Given the inability to cannulate the AVM feeding artery via the tortuous left VA in the prior procedure, the decision was made to attempt cannulation by crossing the LICA stent and approaching the AVM via the PCoA and P1. Given the interval time for the stent to integrate with the endothelium, traversing the stent was expected to be more successful. A distal access catheter was advanced over a Marathon microcatheter and Mirage wire into the left cavernous ICA just proximal to the stent. Under roadmap guidance, the wire and microcatheter were then successfully advanced across the stent and into the PCoA. Despite successful catheterization of the distal basilar artery, the SCA was unable to be catheterized (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>A and B). It is thought that the multiple turns required to access the basilar artery limited control of the wire and microcatheter. Numerous attempts to cannulate the AVM arterial feeder containing the aneurysm were unsuccessful and endovascular treatment of the feeding artery aneurysm was abandoned. At one-month follow-up, the patient's neurologic exam remained unchanged.<elsevierMultimedia ident="fig0040"></elsevierMultimedia>This case demonstrates an anterior-to-posterior approach across the PCoA with traversal of a closed cell remodeling stent.DiscussionTranscirculation approaches, including bilateral and retrograde techniques, have been shown to be feasible and effective in both the anterior and posterior circulations.<a class="elsevierStyleCrossRefs" href="#bib0130">8–14</a> Moret et al. published their experience using a retrograde approach to treat 12 patients with aneurysms that could not be accessed in an anterograde fashion and would not have been suitable for endovascular treatment without an unconventional approach; they successfully treated 10 of the 12 patients, 9 of which resulted in complete embolization.<a class="elsevierStyleCrossRef" href="#bib0155">13</a> Similarly, Albuquerque et al. reported a series of 18 patients with challenging anatomy treated with several transcirculation techniques, including balloon-assisted and stent-assisted coiling and achieved >95% occlusion in all cases.<a class="elsevierStyleCrossRef" href="#bib0130">8</a> In their series, they reported transcirculation access to lesions by crossing the AcoA in 8 cases, PCoA in 6 cases, and the vertebrobasilar junction in 4 cases, and achieved >95% occlusion in all cases.<a class="elsevierStyleCrossRef" href="#bib0130">8</a> Heye et al. reported 26 cases of PICA aneurysms treated via the contralateral vertebral artery and achieved Raymond–Roy Grade 0 or 1 occlusion in all cases without recurrence.<a class="elsevierStyleCrossRef" href="#bib0145">11</a>Our experience with transcirculation approaches demonstrates the feasibility of the technique for select patients. While many of these cases were treated before new technology expanded treatment options (e.g. Case 4, Case 5), this case series is intended to offer an overview of unconventional access to lesions that are difficult to access. The technological constraints provided a window into transcirculation approaches that would not have been necessary in the modern era. However, understanding the feasibility and safety of these approaches is important for the select cases when they might be necessary, even with more modern devices.Case 4 required an Enterprise stent to secure the Onyx embolisate, obligating the use of antiplatelet therapy in a patient who presented with subarachnoid hemorrhage. These stents may not be better than flow diversion in the setting of SAH. This combination of embolization tools would not be the most common approach to treating this ruptured dissecting aneurysm in the current era. However, this case is a relevant demonstration of transcirculation approaches for more favorable catheter navigation and stability. Furthermore, dissecting aneurysms remain challenging treatment targets even for flow diversion, which has been observed to be refractory to single flow diverters.Cases 4 and 5 describe the treatment of anterior circulation lesions via the posterior circulation due to occlusion or inaccessibility of the ICA. Case 4 was performed in a retrograde fashion, whereas in Case 5 the catheter continued anterograde to perform an MCA thrombectomy. This unconventional technique for treating anterior circulation aneurysms from the posterior circulation via the PCoA can be useful in select patients whose anatomy or pathology prevents access to the anterior circulation via the ICA.<a class="elsevierStyleCrossRefs" href="#bib0130">8,13,17</a>In Case 2, we secured the aneurysm and achieved a good neurologic outcome after treating a patient with a VA aneurysm that could not be accessed from the ipsilateral side. In the anterior circulation, transcirculation approaches via the ACoA or the PCoA proved safe and effective. Case 1 demonstrates a contralateral anterior circulation approach to devascularizing a tumor before resection via a favorable trajectory into the recurrent artery of Huebner. A bilateral approach can also be useful for treating ICA aneurysms, as demonstrated in Case 3 in which a retrograde snare restored ipsilateral catheter positioning to achieve complete PED embolization that otherwise would have been unsuccessful.Our results were not universally successful. In Case 6, we unsuccessfully attempted an anterior-to-posterior approach for the treatment of a cerebellar AVM due to insufficient distal control of the catheter, highlighting that transcirculation approaches may increase the number of turns and tortuosity, which may diminish catheter control. Combined with traversing a stent, the transcirculation approach introduced additional catheter length that reduced the distal catheter control needed to cannulate the posterior circulation aneurysm.Understandably, there is apprehension and skepticism for transcirculation endovascular approaches. A key limitation of transcirculation approaches is that they can increase the necessary catheter length and the number of turns needed to access the target lesion, thus diminishing distal control. This can both impair the ability to cannulate the target lesion (e.g. Case 6) and decrease the adequacy and precision with which stents, coils, thrombectomy devices, or other devices can be deployed (e.g. Case 3). Our imperfect results in these cases may be attributable to the added procedural complexity of transcirculation approaches involving increased catheter lengths, along with the selection bias of only the most challenging lesions being treated with this unconventional approach. Careful selection of patients can help predict which cases may be most affected by poor distal control. Thoughtful discussion about all management options, including endovascular, open surgical, and nonsurgical treatment, should be part of every case, especially when there is concern for limited distal control.Interventionists may also be reluctant to disrupt other vascular territories that are not directly involved in the pathology being treated (e.g. Case 5). However, in many cases this may actually be safer than risky ipsilateral approaches (Case 3 being one such example) or obligating the patient to undergo open surgery. Our case series demonstrates that, while not always entirely successful, attempts to access complex vascular lesions with a transcirculation approach can be both safe and effective in select patients and in the hands of an experienced interventionist. In the hands of various dual-trained providers or multimodality teams, there may be different risk–benefit profiles that lead to different endovascular or microsurgical treatment strategies.<a class="elsevierStyleCrossRef" href="#bib0180">18</a>This series of cases further establishes the experience of transcirculation approaches and expands upon the tools and treatments described by other groups. This includes treatment of neoplastic and ischemic pathology as well as application these approaches with new devices such as snares and flow diverters. Although some of the cases apply tools that are declining in use, the generalizability is an important principle demonstrated by those cases.ConclusionsUnconventional transcirculation approaches to treating challenging intracranial aneurysms may add complexity to endovascular neurosurgery. However, in the hands of an interventionist familiar with the neurovascular anatomy, transcirculation approaches to complex lesions in select patients can provide a safe and effective alternative for patients who would otherwise require open surgery or be relegated to medical management alone.Conflict of interestsThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1356717" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Object" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1247799" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1247798" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres1356718" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1247797" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Illustrative cases" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 2" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Case 3" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Case 4" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Case 5" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Case 6" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-06-05" "fechaAceptado" => "2019-10-27" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1247799" "palabras" => array:6 [ 0 => "Endovascular" 1 => "Aneurysms" 2 => "Transcirculation" 3 => "Coiling" 4 => "Pipeline" 5 => "Flow diversion" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1247798" "palabras" => array:17 [ 0 => "MCA" 1 => "ICA" 2 => "AVM" 3 => "ACA" 4 => "A1" 5 => "PICA" 6 => "AICA" 7 => "SCA" 8 => "PCoA" 9 => "CSF" 10 => "PED" 11 => "MRI" 12 => "CT" 13 => "SAH" 14 => "tPA" 15 => "ACoA" 16 => "VA" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1247797" "palabras" => array:6 [ 0 => "Endovascular" 1 => "Aneurismas" 2 => "Transcirculación" 3 => "Helicoidal" 4 => "Pipeline" 5 => "Diversión de flujo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectThe breadth and complexity of neurovascular pathologies treated with endovascular neurosurgery has expanded dramatically in recent years. Many aneurysms remain difficult to treat safely. Transcirculation (contralateral and/or retrograde) approaches through the circle of Willis are useful alternatives for treating challenging lesions endovascularly. Here, we present a series of patients treated with unconventional transcirculation techniques. MethodsA total of six patients were treated: four patients with five aneurysms, one patient with an MCA stroke, and one patient with a meningioma requiring preoperative embolization were initially thought not to be amenable to endovascular treatment. The decision was made to treat these patients with transcirculation approaches. All patients were treated by one interventionist. One aneurysm was located in the cavernous internal carotid artery (ICA), one in the vertebral artery, two in the paraclinoid ICA, and one in a cerebellar AVM feeder vessel were treated. ResultsFive of six patients (83%) made a full neurologic recovery. Three aneurysms were treated to complete occlusion, one aneurysm was left with small residual neck filling, and one aneurysm was not able to be treated. One patient underwent mechanical thrombectomy of a middle cerebral artery (MCA) embolus and MCA filling was restored after treatment. One patient underwent complete embolization of the deep vascular supply of a meningioma. ConclusionsAlthough many neurovascular pathologies remain unsuitable for endovascular treatment, transcirculation approaches can allow for safe, successful treatment of challenging lesions in select patients." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Object" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoLa variedad y la complejidad de las enfermedades neurovasculares tratadas con neurocirugía endovascular ha aumentado drásticamente en los últimos años. Muchos aneurismas continúan siendo difíciles de tratar de forma segura. Los enfoques de transcirculación (contralateral y/o retrógrada) a través del círculo de Willis son alternativas útiles para el tratamiento endovascular de lesiones difíciles. Presentamos una serie de casos de pacientes tratados con técnicas de transcirculación no convencionales. MétodosSe trató a un total de 6 pacientes que inicialmente se creía que no eran aptos para el tratamiento endovascular: 4 pacientes con 5 aneurismas, un paciente con un ictus de la arteria cerebral media (ACM) y un paciente con un meningioma que requería embolización preoperatoria. Se tomó la decisión de tratar a estos pacientes con métodos de transcirculación. Todos los pacientes fueron tratados por un solo especialista. Se localizaron y trataron un aneurisma en el segmento cavernoso de la arteria carótida interna (ACI), otro en la arteria vertebral, 2 en el segmento paraclinoideo de la ACI y otro en una malformación arteriovenosa cerebelosa de un vaso nutriente. ResultadosCinco de los 6 pacientes (83%) alcanzaron una recuperación neurológica completa. Se trataron 3 aneurismas hasta una oclusión completa, un aneurisma se dejó con un pequeño relleno de cuello residual y otro aneurisma no pudo ser tratado. Un paciente fue sometido a una trombectomía mecánica de un émbolo en la ACM y el relleno de la ACM se restauró después del tratamiento. Un paciente se sometió a embolización completa del riego vascular profundo de un meningioma. ConclusionesAunque muchas enfermedades neurovasculares siguen sin ser adecuadas para el tratamiento endovascular, los enfoques de transcirculación pueden permitir el tratamiento seguro y exitoso de lesiones difíciles en pacientes seleccionados." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1650 "Ancho" => 2500 "Tamanyo" => 279663 ] ] "descripcion" => array:1 [ "en" => "Case 1. Coronal (A) and axial (B) computed tomography angiography (CTA) showing the large hypervascular meningioma incorporating the right MCA and ICA. (C) AP conventional angiogram with injection of the right ICA demonstrating feeding vessels from the MCA (white arrow) and recurrent artery of Huebner (white arrowhead). (D) AP angiography showing transcirculation catheterization of the right sided tumor-feeding vessels (white arrow) by crossing the superior branch of the fenestrated anterior communicating artery (white arrowhead). AP (E) and lateral (F) postembolization fluoroscopy demonstrating the embolization cast filling the feeding vessels of the meningioma." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 855 "Ancho" => 2500 "Tamanyo" => 242558 ] ] "descripcion" => array:1 [ "en" => "Case 2. (A) Lateral DSA with preoperative injection of the left vertebral artery demonstrated a 14mm left vertebral artery aneurysm (white arrowhead). (B) AP DSA after dual catheterization via the left vertebral artery (white arrow) and the right ICA (white arrowhead), which was still unable to traverse the aneurysm to allow a flow-diverting stent despite a retrograde approach across the posterior communicating artery from the anterior circulation to the left vertebral artery. (C) Postoperative lateral fluoroscopy shows the coil packing of the aneurysm and left vertebral artery (white arrowhead)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2160 "Ancho" => 2167 "Tamanyo" => 525229 ] ] "descripcion" => array:1 [ "en" => "Case 3. (A) AP 3D angiography reconstruction of 19mm×12mm left cavernous ICA aneurysm. (B) AP DSA showing the distal access catheter traversed into the aneurysm in retrograde fashion via the contralateral (right) ICA (white arrowhead) to access the Marksman catheter (white arrow) within the aneurysm, but unable to select the previously deployed PED. (C and D) Under native fluoroscopy, the microsnare is initially open in C (white arrowhead) and then closes to entrap and pull the microwire (white arrow) from the Marksman catheter (black arrow) and successfully advance the Marksmen across the aneurysm into the distal ICA." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2130 "Ancho" => 2167 "Tamanyo" => 486557 ] ] "descripcion" => array:1 [ "en" => "Case 3, postoperative imaging. Lateral (A) and AP (B) fluoroscopy demonstrated placement of the PED. AP (C) and lateral (D) DSA showed contrast stagnation within the aneurysm sac after PED deployment. There is robust opacification within the aneurysm during late arterial and early capillary phase, after the contrast in the cavernous ICA has begun to wash out." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2145 "Ancho" => 2167 "Tamanyo" => 589063 ] ] "descripcion" => array:1 [ "en" => "Case 4. (A) AP DSA with injection of the left ICA demonstrated an unruptured 3mm superior hypophyseal aneurysm (black arrowhead) and a ruptured 2mm superolateral clinoidal aneurysm (white arrow). (B) Lateral DSA showing cannulation of the left vertebral artery (white arrowhead) for retrograde access to the left ICA. After Onyx embolization of the 2mm anterolateral left clinoidal ICA aneurysm, complete occlusion was observed (arrowhead) on AP fluoroscopy (C) and 3D reconstruction (D)." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 2027 "Ancho" => 2500 "Tamanyo" => 586732 ] ] "descripcion" => array:1 [ "en" => "Case 5. (A) After presenting with right visual loss due to retinal artery occlusion, diffusion-weighted MRI demonstrated a right parietotemporal infarct (white arrowhead) and coronal CTA (B) showed right ICA flow defect suggestive of occlusion (white arrowhead). Due to the right ICA occlusion, access to the MCA was achieved in retrograde fashion via the basilar, as seen on AP DSA (C) with the microcatheter (white arrowhead) advanced through the basilar and into the right posterior communicating artery. The catheter was advanced into the right MCA, as seen on lateral fluoroscopy (D), and mechanical thrombectomy was performed. After thrombectomy, AP DSA demonstrated new filling of the right MCA despite subocclusive embolus (E, white arrowhead)." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Fig. 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1967 "Ancho" => 2500 "Tamanyo" => 735122 ] ] "descripcion" => array:1 [ "en" => "Case 6. (A) Lateral DSA demonstrated a previously treated cerebellar AVM associated with a 3.7mm aneurysm affecting a feeding vessel (white arrowhead). (B) The aneurysm was not amenable to cannulation despite multiple attempts with the microcatheter (white arrowhead). Attention was then turned to the 1.5mm left ICA blister aneurysm seen on lateral DSA (C, black arrowhead). After deployment of a stent across the aneurysm neck, two coils were deployed (D, white arrowhead) and lateral DSA (E) showed a coil mass within the aneurysm sac (white arrowhead) and occlusion without residual filling." ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Fig. 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 1075 "Ancho" => 2167 "Tamanyo" => 421105 ] ] "descripcion" => array:1 [ "en" => "Case 6, second attempt to treat cerebellar AVM aneurysm. (A, lateral DSA; B, AP DSA) Given the tortuosity of the left VA which limited the initial attempt to treat the AVM-associated aneurysm, a transcirculation approach was attempted by advancing a microcatheter through the left ICA stent (from the previously coiled left ICA blister aneurysm, black arrow), across the posterior communicating artery, and into the posterior circulation, demonstrating the cerebellar aneurysm (black arrowhead). After several attempts, the AVM feeder aneurysm could not be cannulated." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.O. Wiebers" 1 => "J.P. Whisnant" 2 => "J. 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Clinical Research

Treatment of complex intracranial pathologies with transcirculation endovascular approaches

Tratamiento de enfermedades intracraneales complejas con enfoques endovasculares de transcirculación

Michael A. Silvaa, Alfred P. Seeb,

Autor para correspondencia

alfredpsee@gmail.com

Corresponding author.

, Samir Sura, Mohammad A. Aziz-Sultanb

a Department of Neurosurgery, Jackson Memorial Hospital, University of Miami, Miami, FL, USA

b Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA

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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Case 6&#46; &#40;A&#41; Lateral DSA demonstrated a previously treated cerebellar AVM associated with a 3&#46;7<span class="elsevierStyleHsp" style=""></span>mm aneurysm affecting a feeding vessel &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41;&#46; &#40;B&#41; The aneurysm was not amenable to cannulation despite multiple attempts with the microcatheter &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41;&#46; Attention was then turned to the 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm left ICA blister aneurysm seen on lateral DSA &#40;C&#44; <span class="elsevierStyleItalic">black arrowhead</span>&#41;&#46; After deployment of a stent across the aneurysm neck&#44; two coils were deployed &#40;D&#44; <span class="elsevierStyleItalic">white arrowhead</span>&#41; and lateral DSA &#40;E&#41; showed a coil mass within the aneurysm sac &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41; and occlusion without residual filling&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In the decades since the inception of endovascular neurosurgery&#44; new devices and techniques have greatly expanded the breadth and complexity of pathologies amenable to endovascular treatment&#46; While endovascular techniques carry their own set of risks&#44; endovascular neurosurgery has gained an increasingly prominent role in the treatment of many aneurysms&#46; Endovascular techniques have effectively treated patients who are not candidates for open surgery&#46; Studies have shown equivalent or improved outcomes for endovascular treatment of selected unruptured aneurysms compared to clipping&#44;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1&#8211;3</span></a> with mixed data for ruptured aneurysms&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4&#44;5</span></a> In addition to aneurysm treatment&#44; stroke care has been similarly revolutionized by endovascular techniques as a result of mechanical thrombectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although the role of endovascular neurosurgery has grown&#44; some lesions remain difficult to treat endovascularly due to difficulty cannulating sharply angled&#44; highly tortuous&#44; or extremely distal vessels&#46; Diminished catheter control in these settings may affect the completeness of embolization&#46; However&#44; there are some lesions thought not to be suitable for endovascular treatment that may be amenable to treatment with unconventional&#44; transcirculation endovascular approaches to the circle of Willis&#46; There have been several prior reports of alternative anatomical endovascular approaches&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8&#8211;14</span></a> This case series demonstrates the use of several transcirculation techniques to treat challenging lesions that otherwise would have been deemed inappropriate for endovascular therapy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Illustrative cases</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 23-year-old man with a history of subtotal meningioma resection at age 8 presented with signs of increased intracranial pressure and was found to have recurrence of the tumor&#46; An MRI was performed and demonstrated a tumor in the Sylvian fissure over 8<span class="elsevierStyleHsp" style=""></span>cm in size enveloping the MCA branches and ICA terminus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A and B&#41;&#46; A diagnostic angiogram was performed&#44; which showed a hypervascular tumor with supply from the MCA and the recurrent artery of Huebner &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; Given the hypervascular nature of the large tumor and particular parasitization of deep pial vessels beyond the reach of the skull base microsurgical approach during the beginning of the case&#44; embolization was considered helpful for safer resection&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">During multidisciplinary discussion&#44; our team reviewed the typical strategy of surgical devascularization&#59; specifically&#44; our center focuses on isolating the tumor from the dural supply during surgical approaches&#46; However&#44; in the unusual case of pial parasitization&#44; as we see in this case&#44; the pial supply also needs to be disconnected before the tumor is devascularized&#46; In some tumors&#44; this is safely accomplished during the microsurgical approach&#46; However&#44; in this case&#44; the size of the tumor and position of the pial supply suggested a challenging reach whether with an orbito-craniotomy and subfrontal approach or an interhemispheric approach&#46; Therefore&#44; the endovascular team pursued a focal pedicular embolization of the pial supply&#46; Penetration within the tumor bulk was not indicated and not pursued because the standard microsurgical devascularization would complement the endovascular technique without the need for deep penetration of tumor capillaries by embolisate&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">On angiography&#44; the right recurrent artery of Huebner&#44; a major feeding vessel of the tumor&#44; was seen to have an acutely angled takeoff from the right A1 that would have been difficult to catheterize from the ipsilateral side&#46; However&#44; the patient had a fenestrated anterior communicating artery that provided a more direct access to the right recurrent artery of Huebner via the left A1&#46; A Marathon &#40;ev3 Covidien&#44; Plymouth MN&#41; microcatheter was advanced from the left A1 across the superior branch of the fenestrated anterior communicating artery into the right A1 and recurrent artery of Huebner &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; Embolization of the feeding vessel was achieved with Onyx &#40;ev3 Covidien&#44; Plymouth&#44; MN&#41; injection under biplane angiography&#46; The lateral MCA feeding vessels were catheterized and injected with Onyx directly from the ipsilateral side under single-plane angiography following the craniotomy&#46; Postembolization fluoroscopy demonstrated successful embolization of the feeding vessels and Onyx cast throughout the tumor &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E and F&#41;&#46; The patient made a full neurologic recovery after completion of tumor resection with an estimated blood loss of 400<span class="elsevierStyleHsp" style=""></span>mL and was discharged on postoperative day 3&#46; At latest follow-up&#44; the patient has returned to their highly intensive work&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This case demonstrates an approach across the ACoA to embolize a tumor with liquid embolisate&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Case 2</span><p id="par0035" class="elsevierStylePara elsevierViewall">A 61-year-old woman with a history of smoking&#44; hypertension&#44; and migraines with worsening posterior headaches and left-sided incoordination was found to have a 2<span class="elsevierStyleHsp" style=""></span>cm left intracranial vertebral artery aneurysm at an outside hospital&#46; An embolization procedure was attempted at the outside hospital&#44; but was aborted due to inability to visualize the posterior inferior cerebellar artery &#40;PICA&#41;&#46; Although the right vertebral artery was catheterized&#44; it terminated in the right PICA&#46; Review of these images suggested an anterior inferior cerebellar artery &#40;AICA&#41;&#8211;PICA complex on the left&#46; The patient was transferred to our institution for further evaluation and endovascular intervention&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">On exam the patient was found to have left-sided upper extremity dysmetria&#46; The decision was made to proceed with angiography and attempt at flow diversion of the left vertebral artery to treat the large left intracranial vertebral artery aneurysm&#46; The left femoral artery was cannulated and angiography revealed a 14<span class="elsevierStyleHsp" style=""></span>mm fusiform dissecting aneurysm affecting the left vertebral artery at the PICA origin &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Initial attempts to advance the catheter across the aneurysm neck were unsuccessful&#46; Use of a balloon-bounce technique involving inflation of a balloon within the aneurysm sac<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> also failed to advance the catheter beyond the aneurysm&#46; Importantly&#44; the right vertebral artery did not contribute to the basilar circulation&#46; The left vertebral artery injection demonstrated bilateral SCA opacification but no significant contribution to the supratentorial circulation&#44; suggesting robust posterior communicating artery supply&#46; The right internal carotid artery injection demonstrated a fetal-type configuration with a posterior communicating artery &#62;2<span class="elsevierStyleHsp" style=""></span>mm in diameter&#46; A transcirculation approach was attempted&#58; the microcatheter was applied in a retrograde fashion via the posterior communicating artery into the basilar artery and left vertebral artery &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; However&#44; this was also unsuccessful in traversing the aneurysm&#46; Although the microwire was able to traverse the aneurysm&#44; there was inadequate wire purchase in either case to allow the microcatheter to follow&#46; The decision was made to abort the procedure and perform vertebral artery sacrifice at a later date&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In a subsequent procedure&#44; the left femoral artery was again cannulated and a 4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>mm balloon was advanced into the left vertebral artery proximal to the aneurysm&#46; After the balloon was inflated&#44; serial neurologic testing demonstrated no neurologic change&#44; this was further evaluated with the blood pressure artificially depressed to 2&#47;3 of baseline using a nitroprusside infusion&#46; Following the successful balloon test occlusion&#44; a microcatheter was advanced into the aneurysm sac&#46; Eight coils were deployed&#44; and the enlarging coil mass was allowed to extend into the parent vessel to sacrifice the left vertebral artery &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#46; At most recent follow-up of 5 months&#44; the patient had made a full neurologic recovery and MRA demonstrated complete occlusion of the aneurysm&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">This case demonstrates an unsuccessful approach across the PCoA from the anterior circulation into the posterior circulation to traverse a large vertebral artery aneurysm with flow diversion&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Case 3</span><p id="par0055" class="elsevierStylePara elsevierViewall">A 72-year-old female prior smoker with hypertension and a family history of fatal brain aneurysm rupture presented with recurrent CSF rhinorrhea&#46; A cerebral angiogram demonstrated an incidental wide-necked 12<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>19<span class="elsevierStyleHsp" style=""></span>mm left cavernous carotid aneurysm &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#44; and the patient failed a BTO during the procedure&#46; Given the size of the aneurysm and the patient&#39;s family history of aneurysmal rupture&#44; the decision was made to proceed with aneurysm embolization using multiple telescoping Pipeline embolization devices &#40;PEDs&#41;&#46; At the time of treatment&#44; flow diversion was increasingly applied&#44; but the technology was not fully mature&#46; The longer stents that are currently available were not yet available&#46; Therefore&#44; the treatment plan was overlapping flow diverters in a telescoping fashion&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Using a triaxial system &#40;6<span class="elsevierStyleHsp" style=""></span>Fr 80<span class="elsevierStyleHsp" style=""></span>cm SHTL &#91;Cook&#93; within the left common carotid artery&#44; Penumbra 070 115<span class="elsevierStyleHsp" style=""></span>cm &#91;Penumbra&#93; within the distal petrous segment&#44; and Marksman 135<span class="elsevierStyleHsp" style=""></span>cm &#91;Medtronic&#93;&#41;&#44; the first PED &#40;4&#46;25<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm&#41; was successfully deployed in the supraclinoid ICA just proximal to the anterior choroidal artery&#44; covering the distal aneurysm neck&#46; Although the microcatheter maintained access across the first PED&#44; due to vessel tortuosity&#44; the microcatheter would not track further distally&#46; This was inadequate support for deployment of the second telescoping PED&#46; Contralateral femoral access and a 5<span class="elsevierStyleHsp" style=""></span>Fr Envoy within the left ICA were applied to attempt secondary catheterization across the PED with an SL-10 microcatheter with multiple microwires &#40;Synchro&#174;&#44; Transend&#174; &#91;Stryker&#93;&#44; Neuroscout&#174;&#44; Agility&#174; &#91;Codman DePuy Synthes&#44; Raynham&#44; MA&#93;&#44; and Headliner 012 &#91;Terumo&#44; Tokyo&#44; Japan&#93;&#41;&#44; but this was unsuccessful&#46; As an adjunct&#44; a 25<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>cm framing coil was deployed to provide buttressing support to the PED within the aneurysm&#46; Ultimately&#44; this resulted in herniation of the Marksman&#174; microcatheter into the aneurysm with no access across the first PED&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Alternative access across the stent was accomplished by a transcirculation approach&#46; With a 5<span class="elsevierStyleHsp" style=""></span>Fr Envoy guide catheter in the RICA&#44; the SL-10 microcatheter was advanced from the RICA to the right A1&#44; through the anterior communicating artery&#44; and into the left A1 and LICA&#46; It was then advanced through the first PED and positioned in the aneurysm&#46; A Marksman microcatheter and Synchro microwire were positioned within the aneurysm via the left ICA&#46; Within the SL-10 &#40;right side approach&#41;&#44; An Ev3 Amplatz goose neck microsnare was advanced into the aneurysm and captured the Synchro microwire from the Marksman microcatheter &#40;left side approach&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B and C&#41;&#46; The microsnare was retracted to advance the Marksman beyond the PED into the left carotid terminus &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>D&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">After repositioning the Marksman in the M1 using a microwire&#44; a second PED &#40;5<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm&#41; was loaded onto the Marksman&#46; The second PED was positioned with the distal end at the midpoint of the first PED and deployed to span the rest of the exposed aneurysm neck&#44; successfully reconstructing the parent vessel&#46; Due to a kink in the PED construct&#44; the Marksman was serially advanced and retracted over the guidewire to relieve the kink&#46; This resulted in un-telescoping of the stents and discontinuity between the two PEDs&#44; necessitating deployment of an additional PED&#46; The Marksman&#44; which remained distal to the gap&#44; was advanced into the M1 segment in preparation for additional stent placement&#46; A third PED &#40;5<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm&#41; was advanced across the gap and deployed to regain complete vessel reconstruction &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A and B&#41;&#46; An angiogram performed at the conclusion of the procedure demonstrated successful flow diversion and contrast stagnation within the left cavernous carotid aneurysm &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>C and D&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Two years following the procedure&#44; follow-up angiography demonstrated near-complete occlusion of the aneurysm with a 3<span class="elsevierStyleHsp" style=""></span>mm region of residual filling&#46; At 4 years&#44; the patient remained asymptomatic and&#44; given their age and clinical stability over 4 years&#44; the decision was made not to pursue further angiography&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">This case demonstrates an approach across the ACoA to embolize an aneurysm with a complex multi-device flow diverting stent construct&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Case 4</span><p id="par0085" class="elsevierStylePara elsevierViewall">A 53-year-old woman presented with SAH and catheter angiography demonstrated two LICA supraclinoid aneurysms&#44; a 3<span class="elsevierStyleHsp" style=""></span>mm saccular superior hypophyseal aneurysm and a 2<span class="elsevierStyleHsp" style=""></span>mm anterolateral LICA aneurysm that was presumed to be the source of SAH &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>A&#41;&#46; A left ICA BTO was performed&#44; demonstrating a patent anterior communicating artery and adequate filling of the left MCA from the posterior communicating artery&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">In preparation for balloon-assisted Onyx&#174; 500 &#40;Medtronic&#44; Minneapolis&#44; MN&#41; embolization&#44; the patient received 650<span class="elsevierStyleHsp" style=""></span>mg aspirin and 450<span class="elsevierStyleHsp" style=""></span>mg clopidogrel&#46; Despite support with a 65<span class="elsevierStyleHsp" style=""></span>cm reinforced 6<span class="elsevierStyleHsp" style=""></span>Fr sheath and a 6<span class="elsevierStyleHsp" style=""></span>Fr Envoy guide catheter within the distal internal carotid artery&#44; a 90&#176; steam-shaped Echelon 10 microcatheter and multiple microwires &#40;Synchro&#174; and Transend&#174; &#91;Stryker&#93;&#44; and Agility&#174; &#91;Codman DePuy Synthes&#44; Raynham&#44; MA&#93;&#41; were unable to catheterize the aneurysm&#46; An alternative approach via the vertebral artery and posterior communicating artery was designed&#58; A 5<span class="elsevierStyleHsp" style=""></span>Fr Envoy catheter within the left vertebral artery allowed navigation of an Echelon 10 microcatheter via the posterior communicating artery and into the aneurysm&#46; The retrograde access to the intracranial ICA provided an optimal trajectory into the aneurysm compared to the microcatheter position destabilized after taking the anterior cavernous genu &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>B&#41;&#46; The 7<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mm Hyperglide balloon was applied in an anterograde fashion via the right internal carotid artery to assist in administration of the Onyx&#174; 500&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">After Onyx&#174; embolization&#44; an Enterprise 4&#46;5<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm stent was deployed across the aneurysm neck to prevent Onyx migration&#46; Postoperative angiography demonstrated complete occlusion of the aneurysm &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>C and D&#41;&#46; Treatment of the other aneurysm was deferred&#46; At 2-week follow-up&#44; angiography demonstrated complete occlusion with no recanalization of the LICA aneurysm&#46; At one month&#44; the patient had made a full neurologic recovery&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Although the Onyx&#174; 500 embolisate is less frequently applied in the current era&#44; catheter stability remains a consideration in coil embolization&#46; Surgery was also considered in this case&#59; indeed&#44; advanced techniques have been described to effectively clip very small &#40;&#60;3<span class="elsevierStyleHsp" style=""></span>mm&#41; aneurysms&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> However&#44; in this case&#44; endovascular treatment was favored given the challenge of clipping such a small aneurysm&#46; Once retrograde access to the aneurysm was achieved without difficulty&#44; endovascular treatment became feasible and Onyx embolization was attempted and successful&#46; In the current era&#44; endovascular treatment of this lesion with a PED would likely have been favored over Onyx embolization&#46; The available technology at the time obligated an unconventional endovascular approach&#46; This case demonstrates a posterior-to-anterior approach across the PCoA to embolize a challenging aneurysm&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Case 5</span><p id="par0105" class="elsevierStylePara elsevierViewall">Before the era of mechanical thrombectomy&#44; a 58-year-old woman with a heavy smoking history presented with vision loss in the right eye and was found to have a right retinal artery occlusion&#46; Brain MRI demonstrated a right parietotemporal infarct &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>A&#41; and a CTA showed right ICA occlusion &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>B&#41;&#46; The RICA occlusion was thought to be secondary to thrombosis&#44; but the chronicity of the clot was not known&#46; The patient acutely progressed with a left facial droop and left hemiparesis with an National Institutes of Health stroke scale of 15&#46; CTA showed a right MCA occlusion&#46; tPA was administered less than 1&#46;5<span class="elsevierStyleHsp" style=""></span>h after onset of the facial droop and the patient was brought to the angiography suite for thrombectomy at 2&#46;5<span class="elsevierStyleHsp" style=""></span>h after symptom onset&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Due to the RICA occlusion of unclear chronicity&#44; the decision was made to perform mechanical thrombectomy via the vertebrobasilar system&#46; Access via the left ICA was also considered&#59; however in the setting of RICA occlusion&#44; preservation of the contralateral ICA was deemed paramount and the vertebrobasilar system presented a safer access route&#46; A 6F Envoy &#91;Codman DePuy Synthes&#44; Raynham MA&#93; was advanced into the left vertebral artery&#46; Microcatheterization of the basilar artery &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>C&#41; confirmed occlusion of the right MCA&#46; The microcatheter was then advanced through the right PCoA into the right MCA &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>C&#41; for 5<span class="elsevierStyleHsp" style=""></span>mg of intraarterial tPA and mechanical thrombolysis with a Separator&#174; &#91;Penumbra&#44; Alameda&#44; CA&#93; &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>D&#41;&#46; A follow-up angiogram showed filling of the right M1 and superior M2 despite persistent subocclusive stenosis &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>E&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">At discharge&#44; the patient&#39;s neurologic exam was notable for left hemiparesis and left-sided neglect&#46; At one-month follow-up&#44; the patient&#39;s left hemiparesis had improved and they were able to ambulate independently with only occasional use of a wheelchair &#40;modified Rankin Scale 3&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">This case demonstrates a posterior-to-anterior approach across the PCoA to for microcatheter delivery of a pharmacotherapeutic and aspiration thrombectomy&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Case 6</span><p id="par0125" class="elsevierStylePara elsevierViewall">A 70-year-old man with a history of right cerebellar AVM treated with Gamma Knife&#174; &#91;Elekta&#44; Stockholm&#44; Sweden&#93; radiotherapy 4 years prior who presented with four days of headache and nausea and SAH on CT&#46; Catheter angiography demonstrated the previously treated right cerebellar AVM and a left ICA blister aneurysm measuring 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm with a 4<span class="elsevierStyleHsp" style=""></span>mm neck &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>C&#41;&#46; The AVM had a 2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm nidus draining into the transverse sinus and vein of Galen&#44; and there was a 3&#46;7<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3&#46;3<span class="elsevierStyleHsp" style=""></span>mm SCA feeding artery&#44; which was the first treatment target &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>A&#41;&#46; However&#44; this was unsuccessful due to tortuosity of the left vertebral artery and hypoplasia of the right vertebral artery&#46; The left ICA blister aneurysm was successfully treated via stent-assist coiling with an Enterprise stent with complete obliteration of the aneurysm &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>E&#41;&#46; Multiple attempts to cross the stent with a Marathon &#91;Medtronic&#93; and -X-pedion 10 &#91;eV3&#93; were unsuccessful&#44; and the AVM was left untreated&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The following day&#44; the patient was taken back for attempted embolization of the AVM-associated aneurysm&#46; Given the inability to cannulate the AVM feeding artery via the tortuous left VA in the prior procedure&#44; the decision was made to attempt cannulation by crossing the LICA stent and approaching the AVM via the PCoA and P1&#46; Given the interval time for the stent to integrate with the endothelium&#44; traversing the stent was expected to be more successful&#46; A distal access catheter was advanced over a Marathon microcatheter and Mirage wire into the left cavernous ICA just proximal to the stent&#46; Under roadmap guidance&#44; the wire and microcatheter were then successfully advanced across the stent and into the PCoA&#46; Despite successful catheterization of the distal basilar artery&#44; the SCA was unable to be catheterized &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>A and B&#41;&#46; It is thought that the multiple turns required to access the basilar artery limited control of the wire and microcatheter&#46; Numerous attempts to cannulate the AVM arterial feeder containing the aneurysm were unsuccessful and endovascular treatment of the feeding artery aneurysm was abandoned&#46; At one-month follow-up&#44; the patient&#39;s neurologic exam remained unchanged&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">This case demonstrates an anterior-to-posterior approach across the PCoA with traversal of a closed cell remodeling stent&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">Transcirculation approaches&#44; including bilateral and retrograde techniques&#44; have been shown to be feasible and effective in both the anterior and posterior circulations&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8&#8211;14</span></a> Moret et al&#46; published their experience using a retrograde approach to treat 12 patients with aneurysms that could not be accessed in an anterograde fashion and would not have been suitable for endovascular treatment without an unconventional approach&#59; they successfully treated 10 of the 12 patients&#44; 9 of which resulted in complete embolization&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> Similarly&#44; Albuquerque et al&#46; reported a series of 18 patients with challenging anatomy treated with several transcirculation techniques&#44; including balloon-assisted and stent-assisted coiling and achieved &#62;95&#37; occlusion in all cases&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> In their series&#44; they reported transcirculation access to lesions by crossing the AcoA in 8 cases&#44; PCoA in 6 cases&#44; and the vertebrobasilar junction in 4 cases&#44; and achieved &#62;95&#37; occlusion in all cases&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> Heye et al&#46; reported 26 cases of PICA aneurysms treated via the contralateral vertebral artery and achieved Raymond&#8211;Roy Grade 0 or 1 occlusion in all cases without recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Our experience with transcirculation approaches demonstrates the feasibility of the technique for select patients&#46; While many of these cases were treated before new technology expanded treatment options &#40;e&#46;g&#46; Case 4&#44; Case 5&#41;&#44; this case series is intended to offer an overview of unconventional access to lesions that are difficult to access&#46; The technological constraints provided a window into transcirculation approaches that would not have been necessary in the modern era&#46; However&#44; understanding the feasibility and safety of these approaches is important for the select cases when they might be necessary&#44; even with more modern devices&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Case 4 required an Enterprise stent to secure the Onyx embolisate&#44; obligating the use of antiplatelet therapy in a patient who presented with subarachnoid hemorrhage&#46; These stents may not be better than flow diversion in the setting of SAH&#46; This combination of embolization tools would not be the most common approach to treating this ruptured dissecting aneurysm in the current era&#46; However&#44; this case is a relevant demonstration of transcirculation approaches for more favorable catheter navigation and stability&#46; Furthermore&#44; dissecting aneurysms remain challenging treatment targets even for flow diversion&#44; which has been observed to be refractory to single flow diverters&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Cases 4 and 5 describe the treatment of anterior circulation lesions via the posterior circulation due to occlusion or inaccessibility of the ICA&#46; Case 4 was performed in a retrograde fashion&#44; whereas in Case 5 the catheter continued anterograde to perform an MCA thrombectomy&#46; This unconventional technique for treating anterior circulation aneurysms from the posterior circulation via the PCoA can be useful in select patients whose anatomy or pathology prevents access to the anterior circulation via the ICA&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8&#44;13&#44;17</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In Case 2&#44; we secured the aneurysm and achieved a good neurologic outcome after treating a patient with a VA aneurysm that could not be accessed from the ipsilateral side&#46; In the anterior circulation&#44; transcirculation approaches via the ACoA or the PCoA proved safe and effective&#46; Case 1 demonstrates a contralateral anterior circulation approach to devascularizing a tumor before resection via a favorable trajectory into the recurrent artery of Huebner&#46; A bilateral approach can also be useful for treating ICA aneurysms&#44; as demonstrated in Case 3 in which a retrograde snare restored ipsilateral catheter positioning to achieve complete PED embolization that otherwise would have been unsuccessful&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Our results were not universally successful&#46; In Case 6&#44; we unsuccessfully attempted an anterior-to-posterior approach for the treatment of a cerebellar AVM due to insufficient distal control of the catheter&#44; highlighting that transcirculation approaches may increase the number of turns and tortuosity&#44; which may diminish catheter control&#46; Combined with traversing a stent&#44; the transcirculation approach introduced additional catheter length that reduced the distal catheter control needed to cannulate the posterior circulation aneurysm&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Understandably&#44; there is apprehension and skepticism for transcirculation endovascular approaches&#46; A key limitation of transcirculation approaches is that they can increase the necessary catheter length and the number of turns needed to access the target lesion&#44; thus diminishing distal control&#46; This can both impair the ability to cannulate the target lesion &#40;e&#46;g&#46; Case 6&#41; and decrease the adequacy and precision with which stents&#44; coils&#44; thrombectomy devices&#44; or other devices can be deployed &#40;e&#46;g&#46; Case 3&#41;&#46; Our imperfect results in these cases may be attributable to the added procedural complexity of transcirculation approaches involving increased catheter lengths&#44; along with the selection bias of only the most challenging lesions being treated with this unconventional approach&#46; Careful selection of patients can help predict which cases may be most affected by poor distal control&#46; Thoughtful discussion about all management options&#44; including endovascular&#44; open surgical&#44; and nonsurgical treatment&#44; should be part of every case&#44; especially when there is concern for limited distal control&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Interventionists may also be reluctant to disrupt other vascular territories that are not directly involved in the pathology being treated &#40;e&#46;g&#46; Case 5&#41;&#46; However&#44; in many cases this may actually be safer than risky ipsilateral approaches &#40;Case 3 being one such example&#41; or obligating the patient to undergo open surgery&#46; Our case series demonstrates that&#44; while not always entirely successful&#44; attempts to access complex vascular lesions with a transcirculation approach can be both safe and effective in select patients and in the hands of an experienced interventionist&#46; In the hands of various dual-trained providers or multimodality teams&#44; there may be different risk&#8211;benefit profiles that lead to different endovascular or microsurgical treatment strategies&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">This series of cases further establishes the experience of transcirculation approaches and expands upon the tools and treatments described by other groups&#46; This includes treatment of neoplastic and ischemic pathology as well as application these approaches with new devices such as snares and flow diverters&#46; Although some of the cases apply tools that are declining in use&#44; the generalizability is an important principle demonstrated by those cases&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">Unconventional transcirculation approaches to treating challenging intracranial aneurysms may add complexity to endovascular neurosurgery&#46; However&#44; in the hands of an interventionist familiar with the neurovascular anatomy&#44; transcirculation approaches to complex lesions in select patients can provide a safe and effective alternative for patients who would otherwise require open surgery or be relegated to medical management alone&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interests</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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            2 => "Transcirculation"
            3 => "Coiling"
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          "clase" => "abr"
          "titulo" => "Abbreviations"
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            0 => "MCA"
            1 => "ICA"
            2 => "AVM"
            3 => "ACA"
            4 => "A1"
            5 => "PICA"
            6 => "AICA"
            7 => "SCA"
            8 => "PCoA"
            9 => "CSF"
            10 => "PED"
            11 => "MRI"
            12 => "CT"
            13 => "SAH"
            14 => "tPA"
            15 => "ACoA"
            16 => "VA"
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            1 => "Aneurismas"
            2 => "Transcirculaci&#243;n"
            3 => "Helicoidal"
            4 => "Pipeline"
            5 => "Diversi&#243;n de flujo"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Object</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The breadth and complexity of neurovascular pathologies treated with endovascular neurosurgery has expanded dramatically in recent years&#46; Many aneurysms remain difficult to treat safely&#46; Transcirculation &#40;contralateral and&#47;or retrograde&#41; approaches through the circle of Willis are useful alternatives for treating challenging lesions endovascularly&#46; Here&#44; we present a series of patients treated with unconventional transcirculation techniques&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A total of six patients were treated&#58; four patients with five aneurysms&#44; one patient with an MCA stroke&#44; and one patient with a meningioma requiring preoperative embolization were initially thought not to be amenable to endovascular treatment&#46; The decision was made to treat these patients with transcirculation approaches&#46; All patients were treated by one interventionist&#46; One aneurysm was located in the cavernous internal carotid artery &#40;ICA&#41;&#44; one in the vertebral artery&#44; two in the paraclinoid ICA&#44; and one in a cerebellar AVM feeder vessel were treated&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Five of six patients &#40;83&#37;&#41; made a full neurologic recovery&#46; Three aneurysms were treated to complete occlusion&#44; one aneurysm was left with small residual neck filling&#44; and one aneurysm was not able to be treated&#46; One patient underwent mechanical thrombectomy of a middle cerebral artery &#40;MCA&#41; embolus and MCA filling was restored after treatment&#46; One patient underwent complete embolization of the deep vascular supply of a meningioma&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Although many neurovascular pathologies remain unsuitable for endovascular treatment&#44; transcirculation approaches can allow for safe&#44; successful treatment of challenging lesions in select patients&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La variedad y la complejidad de las enfermedades neurovasculares tratadas con neurocirug&#237;a endovascular ha aumentado dr&#225;sticamente en los &#250;ltimos a&#241;os&#46; Muchos aneurismas contin&#250;an siendo dif&#237;ciles de tratar de forma segura&#46; Los enfoques de transcirculaci&#243;n &#40;contralateral y&#47;o retr&#243;grada&#41; a trav&#233;s del c&#237;rculo de Willis son alternativas &#250;tiles para el tratamiento endovascular de lesiones dif&#237;ciles&#46; Presentamos una serie de casos de pacientes tratados con t&#233;cnicas de transcirculaci&#243;n no convencionales&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se trat&#243; a un total de 6 pacientes que inicialmente se cre&#237;a que no eran aptos para el tratamiento endovascular&#58; 4 pacientes con 5 aneurismas&#44; un paciente con un ictus de la arteria cerebral media &#40;ACM&#41; y un paciente con un meningioma que requer&#237;a embolizaci&#243;n preoperatoria&#46; Se tom&#243; la decisi&#243;n de tratar a estos pacientes con m&#233;todos de transcirculaci&#243;n&#46; Todos los pacientes fueron tratados por un solo especialista&#46; Se localizaron y trataron un aneurisma en el segmento cavernoso de la arteria car&#243;tida interna &#40;ACI&#41;&#44; otro en la arteria vertebral&#44; 2 en el segmento paraclinoideo de la ACI y otro en una malformaci&#243;n arteriovenosa cerebelosa de un vaso nutriente&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Cinco de los 6 pacientes &#40;83&#37;&#41; alcanzaron una recuperaci&#243;n neurol&#243;gica completa&#46; Se trataron 3 aneurismas hasta una oclusi&#243;n completa&#44; un aneurisma se dej&#243; con un peque&#241;o relleno de cuello residual y otro aneurisma no pudo ser tratado&#46; Un paciente fue sometido a una trombectom&#237;a mec&#225;nica de un &#233;mbolo en la ACM y el relleno de la ACM se restaur&#243; despu&#233;s del tratamiento&#46; Un paciente se someti&#243; a embolizaci&#243;n completa del riego vascular profundo de un meningioma&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Aunque muchas enfermedades neurovasculares siguen sin ser adecuadas para el tratamiento endovascular&#44; los enfoques de transcirculaci&#243;n pueden permitir el tratamiento seguro y exitoso de lesiones dif&#237;ciles en pacientes seleccionados&#46;</p></span>"
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            "Tamanyo" => 279663
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; Coronal &#40;A&#41; and axial &#40;B&#41; computed tomography angiography &#40;CTA&#41; showing the large hypervascular meningioma incorporating the right MCA and ICA&#46; &#40;C&#41; AP conventional angiogram with injection of the right ICA demonstrating feeding vessels from the MCA &#40;<span class="elsevierStyleItalic">white arrow</span>&#41; and recurrent artery of Huebner &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41;&#46; &#40;D&#41; AP angiography showing transcirculation catheterization of the right sided tumor-feeding vessels &#40;<span class="elsevierStyleItalic">white arrow</span>&#41; by crossing the superior branch of the fenestrated anterior communicating artery &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41;&#46; AP &#40;E&#41; and lateral &#40;F&#41; postembolization fluoroscopy demonstrating the embolization cast filling the feeding vessels of the meningioma&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 855
            "Ancho" => 2500
            "Tamanyo" => 242558
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Case 2&#46; &#40;A&#41; Lateral DSA with preoperative injection of the left vertebral artery demonstrated a 14<span class="elsevierStyleHsp" style=""></span>mm left vertebral artery aneurysm &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41;&#46; &#40;B&#41; AP DSA after dual catheterization via the left vertebral artery &#40;<span class="elsevierStyleItalic">white arrow</span>&#41; and the right ICA &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41;&#44; which was still unable to traverse the aneurysm to allow a flow-diverting stent despite a retrograde approach across the posterior communicating artery from the anterior circulation to the left vertebral artery&#46; &#40;C&#41; Postoperative lateral fluoroscopy shows the coil packing of the aneurysm and left vertebral artery &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 2160
            "Ancho" => 2167
            "Tamanyo" => 525229
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Case 3&#46; &#40;A&#41; AP 3D angiography reconstruction of 19<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>mm left cavernous ICA aneurysm&#46; &#40;B&#41; AP DSA showing the distal access catheter traversed into the aneurysm in retrograde fashion via the contralateral &#40;right&#41; ICA &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41; to access the Marksman catheter &#40;<span class="elsevierStyleItalic">white arrow</span>&#41; within the aneurysm&#44; but unable to select the previously deployed PED&#46; &#40;C and D&#41; Under native fluoroscopy&#44; the microsnare is initially open in C &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41; and then closes to entrap and pull the microwire &#40;<span class="elsevierStyleItalic">white arrow</span>&#41; from the Marksman catheter &#40;<span class="elsevierStyleItalic">black arrow</span>&#41; and successfully advance the Marksmen across the aneurysm into the distal ICA&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Fig&#46; 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 2130
            "Ancho" => 2167
            "Tamanyo" => 486557
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Case 3&#44; postoperative imaging&#46; Lateral &#40;A&#41; and AP &#40;B&#41; fluoroscopy demonstrated placement of the PED&#46; AP &#40;C&#41; and lateral &#40;D&#41; DSA showed contrast stagnation within the aneurysm sac after PED deployment&#46; There is robust opacification within the aneurysm during late arterial and early capillary phase&#44; after the contrast in the cavernous ICA has begun to wash out&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Fig&#46; 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 2145
            "Ancho" => 2167
            "Tamanyo" => 589063
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Case 4&#46; &#40;A&#41; AP DSA with injection of the left ICA demonstrated an unruptured 3<span class="elsevierStyleHsp" style=""></span>mm superior hypophyseal aneurysm &#40;<span class="elsevierStyleItalic">black arrowhead</span>&#41; and a ruptured 2<span class="elsevierStyleHsp" style=""></span>mm superolateral clinoidal aneurysm &#40;<span class="elsevierStyleItalic">white arrow</span>&#41;&#46; &#40;B&#41; Lateral DSA showing cannulation of the left vertebral artery &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41; for retrograde access to the left ICA&#46; After Onyx embolization of the 2<span class="elsevierStyleHsp" style=""></span>mm anterolateral left clinoidal ICA aneurysm&#44; complete occlusion was observed &#40;<span class="elsevierStyleItalic">arrowhead</span>&#41; on AP fluoroscopy &#40;C&#41; and 3D reconstruction &#40;D&#41;&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Fig&#46; 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 2027
            "Ancho" => 2500
            "Tamanyo" => 586732
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Case 5&#46; &#40;A&#41; After presenting with right visual loss due to retinal artery occlusion&#44; diffusion-weighted MRI demonstrated a right parietotemporal infarct &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41; and coronal CTA &#40;B&#41; showed right ICA flow defect suggestive of occlusion &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41;&#46; Due to the right ICA occlusion&#44; access to the MCA was achieved in retrograde fashion via the basilar&#44; as seen on AP DSA &#40;C&#41; with the microcatheter &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41; advanced through the basilar and into the right posterior communicating artery&#46; The catheter was advanced into the right MCA&#44; as seen on lateral fluoroscopy &#40;D&#41;&#44; and mechanical thrombectomy was performed&#46; After thrombectomy&#44; AP DSA demonstrated new filling of the right MCA despite subocclusive embolus &#40;E&#44; <span class="elsevierStyleItalic">white arrowhead</span>&#41;&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Fig&#46; 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 1967
            "Ancho" => 2500
            "Tamanyo" => 735122
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Case 6&#46; &#40;A&#41; Lateral DSA demonstrated a previously treated cerebellar AVM associated with a 3&#46;7<span class="elsevierStyleHsp" style=""></span>mm aneurysm affecting a feeding vessel &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41;&#46; &#40;B&#41; The aneurysm was not amenable to cannulation despite multiple attempts with the microcatheter &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41;&#46; Attention was then turned to the 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm left ICA blister aneurysm seen on lateral DSA &#40;C&#44; <span class="elsevierStyleItalic">black arrowhead</span>&#41;&#46; After deployment of a stent across the aneurysm neck&#44; two coils were deployed &#40;D&#44; <span class="elsevierStyleItalic">white arrowhead</span>&#41; and lateral DSA &#40;E&#41; showed a coil mass within the aneurysm sac &#40;<span class="elsevierStyleItalic">white arrowhead</span>&#41; and occlusion without residual filling&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "fig0040"
        "etiqueta" => "Fig&#46; 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr8.jpeg"
            "Alto" => 1075
            "Ancho" => 2167
            "Tamanyo" => 421105
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Case 6&#44; second attempt to treat cerebellar AVM aneurysm&#46; &#40;A&#44; lateral DSA&#59; B&#44; AP DSA&#41; Given the tortuosity of the left VA which limited the initial attempt to treat the AVM-associated aneurysm&#44; a transcirculation approach was attempted by advancing a microcatheter through the left ICA stent &#40;from the previously coiled left ICA blister aneurysm&#44; <span class="elsevierStyleItalic">black arrow</span>&#41;&#44; across the posterior communicating artery&#44; and into the posterior circulation&#44; demonstrating the cerebellar aneurysm &#40;<span class="elsevierStyleItalic">black arrowhead</span>&#41;&#46; After several attempts&#44; the AVM feeder aneurysm could not be cannulated&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:18 [
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                  "host" => array:1 [
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                            0 => "G&#46; Fotakopoulos"
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            3 => array:3 [
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                        0 => array:2 [
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                            0 => "I&#46; Van der Schaaf"
                            1 => "A&#46; Algra"
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "R&#46;F&#46; Spetzler"
                            1 => "C&#46;G&#46; McDougall"
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                  "host" => array:1 [
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                      "doi" => "10.3171/2013.3.JNS12683"
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            5 => array:3 [
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                      "titulo" => "Endovascular thrombectomy for acute ischemic stroke&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "J&#46;H&#46; Badhiwala"
                            1 => "F&#46; Nassiri"
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.2015.13767"
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                        "fecha" => "2015"
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            6 => array:3 [
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              "referencia" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "O&#46;A&#46; Berkhemer"
                            1 => "P&#46;S&#46; Fransen"
                            2 => "D&#46; Beumer"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa1411587"
                      "Revista" => array:6 [
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            7 => array:3 [
              "identificador" => "bib0130"
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "F&#46;C&#46; Albuquerque"
                            1 => "L&#46;F&#46; Gonzalez"
                            2 => "Y&#46;C&#46; Hu"
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                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "Revista" => array:5 [
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            8 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "&#8220;Cross-over&#8221; technique for horizontal stenting of an internal carotid bifurcation aneurysm using a new self-expandable stent&#58; technical case report"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "G&#46; Benndorf"
                            1 => "R&#46;P&#46; Klucznik"
                            2 => "D&#46; Meyer"
                            3 => "C&#46;M&#46; Strother"
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                      ]
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                  ]
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                      "Revista" => array:4 [
                        "tituloSerie" => "Neurosurgery"
                        "fecha" => "2006"
                        "volumen" => "58"
                        "numero" => "Suppl&#46;"
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            ]
            9 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "Y&#46;A&#46; Chen"
                            1 => "R&#46;B&#46; Qu"
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5137/1019-5149.JTN.9014-13.0"
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            10 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46; Heye"
                            1 => "C&#46;P&#46; Stracke"
                            2 => "H&#46; Nordmeyer"
                            3 => "M&#46; Heddier"
                            4 => "M&#46; Stauder"
                            5 => "R&#46; Chapot"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/neurintsurg-2014-011417"
                      "Revista" => array:6 [
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                        "volumen" => "7"
                        "paginaInicial" => "824"
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                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bilateral approach for stent-assisted coiling of posterior inferior cerebellar artery aneurysms &#8211; two cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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Información del artículo

ISSN: 11301473
Idioma original: Inglés

DOI:10.1016/j.neucir.2019.10.003

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