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Research ArticleNeurointervention
Open Access

Surpass Flow Diverter for Treatment of Posterior Circulation Aneurysms

C.A. Taschner, S. Vedantham, J. de Vries, A. Biondi, J. Boogaarts, N. Sakai, P. Lylyk, I. Szikora, S. Meckel, H. Urbach, P. Kan, R. Siekmann, J. Bernardy, M.J. Gounis and A.K. Wakhloo
American Journal of Neuroradiology March 2017, 38 (3) 582-589; DOI: https://doi.org/10.3174/ajnr.A5029
C.A. Taschner
aFrom the Department of Neuroradiology (C.A.T., S.M., H.U., J.B.), Medical Centre–University of Freiburg, Freiburg, Germany
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S. Vedantham
bDepartment of Radiology (S.V.)
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J. de Vries
eDepartment of Neurosurgery (J.d.V., J.B.), Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
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A. Biondi
fDepartment of Neuroradiology and Endovascular Therapy (A.B.), University of Besançon, Besançon, France
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J. Boogaarts
aFrom the Department of Neuroradiology (C.A.T., S.M., H.U., J.B.), Medical Centre–University of Freiburg, Freiburg, Germany
eDepartment of Neurosurgery (J.d.V., J.B.), Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
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N. Sakai
gDepartment of Neurosurgery (N.S.), Kobe City Medical Center General Hospital, Kobe, Japan
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P. Lylyk
hDepartment of Neurosurgery (P.L.), Equipo de Neurocirugía Endovascular Radiología Intervencionista, Buenos Aires, Argentina
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I. Szikora
iNational Institute of Neurosciences (I.S.), Budapest, Hungary
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S. Meckel
aFrom the Department of Neuroradiology (C.A.T., S.M., H.U., J.B.), Medical Centre–University of Freiburg, Freiburg, Germany
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H. Urbach
aFrom the Department of Neuroradiology (C.A.T., S.M., H.U., J.B.), Medical Centre–University of Freiburg, Freiburg, Germany
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P. Kan
jDepartment of Neurosurgery (P.K.), Baylor College of Medicine, Houston, Texas
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R. Siekmann
kDepartment of Neuroradiology (R.S.), Klinikum Kassel, Kassel, Germany.
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J. Bernardy
aFrom the Department of Neuroradiology (C.A.T., S.M., H.U., J.B.), Medical Centre–University of Freiburg, Freiburg, Germany
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M.J. Gounis
cNew England Center for Stroke Research (M.J.G.)
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A.K. Wakhloo
dDivision of Neuroimaging and Intervention (A.K.W.), Departments of Radiology, Neurology, and Neurosurgery, University of Massachusetts Medical School, Worcester, Massachusetts
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    Fig 1.

    A 51-year-old woman presenting with Hunt and Hess grade 4 subarachnoid hemorrhage from a previously diagnosed fusiform aneurysm of the basilar trunk. A, Unenhanced CT scan shows diffuse SAH (arrowheads). The arrow indicates the partially thrombosed, fusiform aneurysm. B, The 3D reconstruction image shows a fusiform aneurysm (arrowhead) of the basilar artery with saccular components (arrow). C, Angiogram after placement of a Surpass FD (arrowhead) from the P1 segment of the right PCA to the midbasilar level. Additional coils were implanted. Note filling of the aneurysm (arrow). D, The 6-month follow-up angiogram shows complete occlusion of the aneurysm (arrow) and some intimal hyperplasia along the flow diverter (arrowhead). The mRS had changed from 2 before the SAH to 4 during follow-up. The clinical deterioration was most likely related to the SAH. No new infarcts occurred in the posterior circulation after implantation of the flow diverter.

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    Fig 2.

    A 29-year-old man presenting with headaches and mild ataxia (mRS 1). A, Sagittal T2-weighted image shows a 32-mm vertebrobasilar junction aneurysm (arrowhead) compressing the medulla. B, Axial T1-weighted image with contrast shows the saccular aneurysm (arrow) and the 2 vertebral arteries (arrowheads) joining the aneurysm. C, The 3D reconstruction image shows a wide-neck (arrow) vertebrobasilar aneurysm with additional dysplastic segments (arrowhead) along the course of the basilar artery. D, Angiogram after placement of 2 Surpass FDs from the midbasilar level to the right vertebral artery. Additional coils were implanted (arrow). The distal segment of the left vertebral artery is occluded with coils (arrowhead). The patient was extubated 2 hours after the treatment and presented with paraplegia and respiratory insufficiency. E, Axial diffusion-weighted MR image (b=1000) reveals a medullar infarct (arrow) within the vascular territory of the left anteromedial group of medullary arteries, most likely related to the voluntary occlusion of the left vertebral artery. F, The 6-month follow-up angiogram shows complete occlusion of the aneurysm (arrow). The left posterior cerebral artery is occluded (arrowhead). The time-of-flight MR angiography shows good collateral filling of the left posterior cerebral artery via the left posterior communicating artery (not shown). Clinically, the patient has improved. He now presents with a mild hemiparesis, slightly slurred speech, and ataxia (mRS 3).

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    Fig 3.

    Summary of statistical analysis. Univariate model results are along the connecting lines; multivariate model (MVM) results are within the box.

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    Fig 4.

    Shift from baseline mRS to mRS at follow-up (n = 52).

Tables

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    Table 1:

    Patient data and characteristics of aneurysms treated with FD

    Characteristics
    Patients (No.)52
    Aneurysms (No.)52
    Women (%)21/52 (41%)
    Mean age (range) (yr)54 (16–79)
    Presentation/indications for treatment (No.) (%)
        Incidental finding/headaches20 (38%)
        Recurrent after coiling/coiling and stenting/failed clipping16 (31%)
        Cranial nerve deficit/mass effect14 (27%)
        Stroke/transient ischemic attack7 (13%)
        Acute SAH7 (13%)
    Baseline mRS (No.)
        mRS 020 (38%)
        mRS 1–218 (35%)
        mRS 3–514 (27%)
    Aneurysm size (n = 51) (%)
        <5 mm4 (8%)
        5–9.9 mm13 (25%)
        10–20 mm17 (33%)
        >20 mm17 (33%)
    Aneurysm neck size (mm)
        Mean (range)17.5 ± 17.7 (2–90)
    Location (No.) (%)
        V4 segment of vertebral artery20 (38%)
        VB junction11 (21%)
        BT15 (29%)
        PCA6 (12%)
    Morphology (No.) (%)
        Wide-neck saccular12 (23%)
        Fusiform/dissecting40 (77%)
    Treatment
        No. of flow diverters1.4 ± 0.7 (range, 1–3)
        No. of additional coiling15 (29%)
    • View popup
    Table 2:

    Patients with fatal outcomesa

    SexAge (yr)Baseline mRSLocationTypeSize (mm)No. of FDsCause of DeathSurvival Time (days)
    M603BTFusiform101Ischemic stroke 48 hr after FD treatment2
    M584BTFusiform551Rupture during placement of the FD7
    M642VB junctionFusiform901Medullary infarct15
    M553BTFusiform393Stable mRS at discharge; acute brain stem infarct50
    M573VB junctionFusiform403Stable mRS at discharge; acute gastrointestinal bleed; clopidogrel was stopped; died of urosepsis170
    M594VB junctionSaccular553Improved mRS at discharge (mRS 3); follow-up DSA at 7 months; aneurysm patent (>50%); at 8 mo, sudden clinical impairment242
    M743BTFusiform282Stable mRS at discharge; died of pneumonia388
    F753VB junctionFusiform302mRS 5 at discharge to a tertiary care facility; died of pneumoniaUnknown
    F651Vertebral arteryFusiform81Stable mRS at discharge; died from complications related to brain tumor treatmentUnknown
    • ↵a All patients had presented with unruptured aneurysms.

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American Journal of Neuroradiology: 38 (3)
American Journal of Neuroradiology
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1 Mar 2017
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C.A. Taschner, S. Vedantham, J. de Vries, A. Biondi, J. Boogaarts, N. Sakai, P. Lylyk, I. Szikora, S. Meckel, H. Urbach, P. Kan, R. Siekmann, J. Bernardy, M.J. Gounis, A.K. Wakhloo
Surpass Flow Diverter for Treatment of Posterior Circulation Aneurysms
American Journal of Neuroradiology Mar 2017, 38 (3) 582-589; DOI: 10.3174/ajnr.A5029

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Surpass Flow Diverter for Treatment of Posterior Circulation Aneurysms
C.A. Taschner, S. Vedantham, J. de Vries, A. Biondi, J. Boogaarts, N. Sakai, P. Lylyk, I. Szikora, S. Meckel, H. Urbach, P. Kan, R. Siekmann, J. Bernardy, M.J. Gounis, A.K. Wakhloo
American Journal of Neuroradiology Mar 2017, 38 (3) 582-589; DOI: 10.3174/ajnr.A5029
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