advances in interventional neuroradiology dr james f peerless march 2014
TRANSCRIPT
![Page 1: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/1.jpg)
Advances in Interventional Neuroradiology
Dr James F PeerlessMarch 2014
![Page 2: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/2.jpg)
Introduction
![Page 3: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/3.jpg)
Interventional Radiology
• Endovascular, catheter-based techniques using fluoroscopy and angiography– To diagnose and treat vascular diseases of the CNS
• Examples– diagnostic cerebral angiography– acute endovascular stroke treatment– revascularization of carotid and intracranial stenosis– cerebral aneurysm
![Page 4: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/4.jpg)
The Past
![Page 5: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/5.jpg)
From Small Beginnings
• Catheterisation of arterial cerebral vessels first described in 1931 by French neurologist, Dr Moniz.
• Access limited by size of catheters– Transfemoral and transcarotid approaches
• Treatment options:– Electrothrombosis (1964)– Detachable balloons (1970)– Injection into aneurysm
• Iron• Microspheres
• Microcatheter developed in 1988– Allowed direct probing of aneurysms
![Page 6: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/6.jpg)
Coil Development
• Free coil occlusion– Detachable coils via a delivery wire– Separated with direct current– Guido Gugliemi (UCLA), 1991
• Initially used in non-ruptured posterior aneurysms, poor grade SAH and those unfit for surgery
• Now the treatment of choice, >90%• Electrolysis detachment replaced by
mechanical/pressure devices
![Page 7: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/7.jpg)
Coil Development
![Page 8: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/8.jpg)
The Present
![Page 9: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/9.jpg)
Aneurysms
• Coiling– Bare platinum coils– Bioactive PGA coils
• Increased thrombogeneity and fibrosing induction
• Stenting• Balloon-remodelling and embolisation• Flow-diverters– devices are designed to achieve aneurysm occlusion
through reconstruction of the diseased segment of artery
![Page 10: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/10.jpg)
Aneurysm Treatments
![Page 11: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/11.jpg)
Balloon and Onyx Embolisation
![Page 12: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/12.jpg)
• Collected data in 2143 patients between 1994-2002– Clipped: 1070 (30.6 %)– Coiled: 1073 (23.7 %)
• Follow-up series in 2005 + 2009 conferred a survival benefit of at least seven years
• Increased (small) risk of rebleed• Future bleeds “essentially eliminated”
![Page 13: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/13.jpg)
• Previous small single-centre trials showed promise of bioactive coils
• Bare platinum versus Cerecyte coils• RCT (non-blinded), n = 500• Non-significance demonstrated, but– Increased periprocedural M&M– Poorer 6-month outcome (mRS)
![Page 14: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/14.jpg)
• ATENA Trial, 2010– Data collected in 622 patients in France and
Canada between 2005 & 2006– Coiling and remodelling associated with better
radiological outcomes than stenting– Factors for a favourable outcome• Age < 65• Aneurysm diameter < 6 mm• Dome-neck ratio > 1.5
![Page 15: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/15.jpg)
Brain AVMs• Embolisation techniques
– nBCA• n-butyl-cyano-acrylate
– Onyx licensed in 2005• polymer in organic solvent
• Results from single-centre studies only• Trade-off between long- and short-term gain
– Pierot et al., 2009 (J. Neuroradiol.)• >60% occlusion rates in 73% on 116 patients• 2% mortality, 8% morbidity at one month• Increased risk of recanalisation with reduced occlusion
• Periprocedural morbidity– 12.2%: Hauck et al., 2009 (Am. J Neuroradiol.)– 19.5%: Panagiotopolous et al., 2009 (Am. J Neuroradiol.)
![Page 16: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/16.jpg)
The Future
![Page 17: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/17.jpg)
Future Advances
• Aneurysms– Problems are the same as in the past
• Tricky aneurysms are large with wide necks• Difficult to treat with high recurrence rates
– flow diverters– Bettering the understanding of:
• aneurysm formation, growth, and rupture
• AVMs– New embolisation materials
![Page 18: Advances in Interventional Neuroradiology Dr James F Peerless March 2014](https://reader037.vdocuments.net/reader037/viewer/2022103122/56649cd65503460f9499d416/html5/thumbnails/18.jpg)
Reference
• Schumacher M, Weber J. Aneurysm Treatment – a Neuroradiologic Success Story. Clinical Neuroradiology, 2008;4:203-215
• Gounis J, De Leo III M, Wakhloo A. Advances in Interventional Neuroradiology. Stroke, 2010;41:e81-e87
• Chen M. Interventional Neurology – Recent Advances & New Applications. US Neurology, 2011;7(1):37-40