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After a magical first day, we continued at the same intense pace, bringing to the audience exceptional cases and novel technical solutions!
We started the second day of the meeting with George Mendes from CHUM Monreal Canada with a challenging falcotentorial DAVF complicated by occipital hematoma, a case which, as usual, puts into question the understanding of the anatomy and related pathology of such a complex pathology.
Next, Gustavo Correa from Belo Horizonte presented us with a remarkable case that highlighted an under-valued strategy of “flossing technique” used to cross the false lumen in carotid dissection cases.
The third case of the morning presented by the Bicêtre Team emphasized the usefulness of the venous approach to some AVMs, especially those whose arterial anatomy does not allow us to understand the anatomy nor to inject the embolic fluid as in the case of the vermin AVM presented here.
Thien Huynh then presented an interesting strategy for treatment of a particularly rare condition: anterior condylar confluence CSF-venous fistula. Understanding the anatomy by superimposing MRV C+ with CTM allows precise targeting of the anterior condylar confluence which was masterfully illustrated in this highly educational presentation.
The fourth case of the morning presented by the Bicêtre Team was a ruptured blister-like carotid siphon treated with FD. In the end, a single flow diverter stent was enough to solve the case but the discussions in the room animated the audience and emphasized once again the lack of targeted studies on this issue.
Vitor Mendes Pereira then presented a left M2 occlusion stroke performed by BADASS technique that allowed complete recanalization after 2 passages. When to change the technique is always a challenging decision to take and here, being patient and following protocol of the service, proved to be the winning card.
After coffee break, the recorded case series continued with an AcoM aneurysm embolization with intrasaccular device that proved to be the ideal solution for a large neck aneurysm. Simulation of the device based on 3DRA allows the precise decision of WEB size implanted.
Vitor Mendes Pereira then presented Venous Sinus Stenting for the treatment of debilitating Pulsatile Tinnitus (PT) using a novel venous sinus-dedicated stent, called BOSSTENT (Sonorus NV). He highlighted a few key messages in the treatment planning of this disease, including the importance of performing 3DRA in the venous phase to accurately assess degree of stenosis in the axial plane, which in this case was underrepresented on AP and Lat DSA views,
as well as lack of correlation of PT with venous sinus pressure, dissimilar to IIH. Treatment of associated dehiscence can be coiled by jailing a catheter during stent deployment as well.
Symposium put on stage another hot topic of braid deformation that seems to be more frequent due to new generation FD treatment, data that have been collected in INSPIRE A registry.
The following case presented highlighted how useful an intrasaccular device such as the Contour is for a small aneurysm implanted in the bifurcation of the middle cerebral artery.
The second part of the day started with the difficult case of a ruptured caudate AVM treated by the Bicêtre team via trans arterial approach using Onyx as embolic agent. Endo navigation into the emerging Hubner artery from the left A1 segment coming from the right carotid artery via Acom to have an ideal angle of attack made this case a cut-off for those in the room.
Small aneurysms remain always subject of a controversial topic both in terms of treatment strategy and indication for endovascular treatment, especially when the aneurysm is situated at the origin of the A1 segment. The case presented by the Bicêtre team raised multiple discussions from the audience due to a simple and technically efficient solution with a magnificent long-term result that has proven to be the placement of a stent flow diverter between the origin of the M1 segment and the carotid siphon with coverage of the origin of the A1 segment.
Next case presented was by Mateus Felipe Dos Santos from Sao Paulo Brazil, who presented a challenging case of spinal dural fistula.
The most important tip in this beautiful case presented was to use advanced image on the DSA using the 3D image of 2 different levels and make the overlay with both images (from left T5 and right L2) to better understand the anatomy and to differentiate what is spinal artery and spinal dural vein. Very nice way to use advanced images with 3D and overlay to better understand the anatomy and have a safer procedure.
Next case was Y-stenting with Atlas stent for an AcomA aneurysm of 5,8 mm. We had a great discussion about the indication of a 68 yo patient with an Acom aneurysm. Pr Moret emphasized that age is not a factor to contraindicate the treatment.
After the discussion, we saw how the Y-stent assisted technique can be done without problems using an open cel laser cut stent (Neuroform Atlas) and coils. At the end of the treatment, we saw some clot formation that was solved with tirofiban.
Tudor Jovin also said that maybe the use of tirofiban is more important than heparin in those cases.
A case of stroke by Toronto team lead by Vitor Mendes Pereira highlighted the beauty and simplicity of the large-bore catheter aspiration technique.
Last part of the day started with the challenge of a 19 mm diameter carotid siphon case that has been treated by stent-assisted coiling. Strategy of treatment has been discussed long time and braided stent proved to be a feasible and efficient technique.
Last case of this meeting was presented by Vitor Mendes Pereira and highlighted the management of giant recanalized T-carotid aneurysm that was treated by flow diversion despite challenging catheterisation of M1 segment.
It was a worthy 10th-anniversary edition with high scientific content that can only make us look forward to the next LINNC!
Reported by Cristian Mihalea & Igor Pagiola
