For the second time, the LINNC seminar is taking place in Singapore with a series of new and exciting cases in the field of interventional neuroradiology (INR). LINNC Seminars offers all of us the opportunity to discuss recent advances in our field as well as share experience and this edition – as Professors J. Moret and L. Spelle said in their opening remarks to the audience and faculty – is no exception!
T. Terada presented the first case of the day, a ruptured dissecting aneurysm of the terminal carotid artery. This was seen to bleed again after a first treatment by laser-cut stent assisted coiling, and was retreated with additional coils and two braided stents. In discussing the case, we learned that while flow diversion is the best treatment option for dissecting aneurysms, this could not be used in this case since flow diverters are only labelled for giant unruptured aneurysms in Japan.
The second case, presented by N. U. Santosh, was a pial arteriovenous malformation which had been successfully treated by glue injection from the arterial side. This was the occasion for Professor J. Moret to remind us of the critical importance in understanding the anatomy of a disease before treating it.
This was also the key message of two of the eight recorded cases from Bicêtre Hospital (France). One was an osteodural malformation of the right sigmoid sinus crossing the midline that had been treated with PHIL injected from the arterial side while the patent superior sagittal, torcular and left sigmoid sinus were protected using a long Copernic balloon. This case illustrated the importance of distinguishing between dural malformations, a pathology of the periosteum and the dura mater, or from leptomeningeal malformations, a pathology of the perivascular subapical spaces.
Another case was of a pericallosal AVM with feeders coming from both the anterior and the posterior circulation. This had been completely dealt with in a single shot treatment with Onyx via the sole access from the pericallosal artery. The obliteration of the draining vein was achieved with this injection, and it was used to reflux into the rest of the nidus, especially those compartments fed by the posterior cerebral artery into its feeders.
Professor J. Moret then presented a very interesting case of a high-flow vertebra-vertebral fistula in a 6-year-old boy treated by reconstructing the left vertebral artery with three Pipeline stents and a coiling of the venous pouch by a previously jailed microcatheter. This proved to be the perfect occasion to discuss antiplatelet treatment in children, consisting of a full dose of aspirin (160 mg) and 0.5 mg/kg of ticagrelor.
The issue of stroke was treated in two industry sponsored symposia and two recorded cases.
P. Mitchell presented a subgroup analysis of the Trevo Retriever registry with patients treated within an extended time-frame. This “DAWN-like” cohort had comparable outcomes to DAWN patients with 55% having an mRS <2. P. Mitchell concluded that the “window” criteria is less suitable for the selection of patients than brain imaging.
N. Manning presented a single center registry on the Sofia intermediate catheter. He concluded with the hypothesis that, since procedure time is shorter, thromboaspiration might be superior to thrombectomy plus BGS. He also pointed to the importance of standardized procedures in clinical practice.
The afternoon saw recorded stroke cases, including one successful thromboaspiration with a Sofia+ and another one demonstrating a successful thrombectomy with a Trevo retriever, both for M1 occlusions.
The treatment of difficult aneurysms was another of the day’s main topics. The morning session’s first recorded case was of a giant terminal carotid aneurysm. This had been treated with a flow diverter from A1 to the syphon after it was shown with an occlusion test that there existed a good cross flow from leptomeningeal collaterals to the MCA territory. A SILK stent was used because of its good navigability.
Professor L. Spelle demonstrated treatment of an MCA branch aneurysm with stent-assisted coiling. He used a laser-cut Atlas stent because its final conformation in tight curves is more predictable than for braided stents.
The next case was a small ruptured blood-blister-like aneurysm of the left anterior choroidal artery also treated with stent-assisted coiling using a braided stent and the jailing of a microcatheter to deliver the coil. The discussion concerning this strategy concluding that flow diversion, in this case, would probably have been an easier and less risky choice.
The last recorded case of the day was a complex treatment of a small basilar tip aneurysm with a WEB device. The device had not been perfectly positioned before detachment, occluding the left PCA. It could not be repositioned after. Here the mistake was not using a balloon from the very beginning of the procedure. This case was rescued using a Lvis Jr stent placed through a Scepter balloon by which the occluded branch could be catheterized.
In the last industry sponsored symposium, Professor A. Arthur shared his experience with the Pipeline Embolization Device.
The day ended with the presentation of a series of cases concerning giant fusiform aneurysms of the basilar artery presented by H-F Wang and S. Lahoti.
Enjoy Singapore….and see you tomorrow for more exciting and informative cases!