Background and Purpose The use of flow diverters to treat aneurysms arising from small caliber parent vessels has been reported. This article reports the results of the first in experiences with the p48MW (p48 Movable Wire) in humans, a device specifically designed to target vessels 1.75-3 mm in diameter. Methods This monocentric study retrospectively reviewed the prospectively maintained database to identify all patients treated with the p48MW device between January 2017 and January 2019 at this institution. Patient demographics, aneurysm characteristics, angiographic and clinical follow-up were recorded as well as complications. Results A total of 25 patients (20 female) with an average age of 55 ± 12.9 years (range 34-84) with 25 aneurysms were identified. The majority of the aneurysms was located in the anterior circulation (19/25, 76%). The average aneurysm dome width was 3.98 ± 3.6 mm (range 1.2-13 mm). Complete occlusion was seen in 18/24 (75%) aneurysms with neck remnants in 1/24 (4.2%) and continued aneurysm filling seen in the remaining cases (5/24, 20.8%). Adequate occlusion was seen in 79.2% of aneurysms (Raymond Roy Classification [RRC] grade I or II) during the follow-up period. There was a single technical complication with inappropriate deployment of the first p48MW. There was a single clinical complication (4%); however, the patient made a complete recovery (modified Rankin Scale [mRS] 0) and one patient died secondary to uncontrollable status epilepticus following acute subarachnoid hemorrhage unrelated to the treatment. Conclusion The p48MW is safe and effective for the treatment of aneurysms including those arising from distal vessels.

BACKGROUND Prospective studies have established the safety and efficacy of the PipelineTM Embolization Device (PED; Medtronic) for treatment of intracranial aneurysms (IA). OBJECTIVE To investigate long-term outcomes from the Pipeline Embolization Devices for the Treatment of Intracranial Aneurysms (PEDESTRIAN) Registry. METHODS The PEDESTRIAN Registry data were retrospectively reviewed, which included patients (March 2006 to July 2019) with complex IAs treated with PED. Patients with unfavorable anatomy and/or recurrence following previous treatment were included and excluded those with acute subarachnoid hemorrhage. The primary angiographic endpoint was complete occlusion and long-term stability. Clinical and radiological follow-up was performed at 3 to 6 mo, 12 mo, and yearly thereafter. RESULTS A total of 835 patients (mean age 55.9 ± 14.7 yr; 80.0% female) with 1000 aneurysms were included. Aneurysms varied in size: 64.6% were small (≤10 mm), 25.6% were large (11-24 mm), and 9.8% were giant (≥25 mm). A total of 1214 PEDs were deployed. Follow-up angiography was available for 85.1% of patients with 776 aneurysms at 24.6 ± 25.0 mo (mean). Complete occlusion was demonstrated in 75.8% of aneurysms at 12 mo, 92.9% at 2 to 4 yr, and 96.4% at >5 yr. During the postprocedural period, modified Rankin Scale scores remained stable or improved in 96.2% of patients, with stability or improvement in 99.1% of patients >5 yr. The overall major morbidity and neurological mortality rate was 5.8%. CONCLUSION This study demonstrated high rates of long-term complete aneurysm occlusion, stable or improved functional outcomes, and low rates of complications and mortality. Clinical and angiographic outcomes improved over long-term follow-up, demonstrating that endovascular treatment of IA with PED is safe and effective.

Introduction Twig-like middle cerebral artery configuration (Tw-MCA) is a rare and commonly misdiagnosed vascular anomaly characterized by a plexiform arterial network that replaces the normal M1 segment. The prevalence and clinical relevance of this anomaly is not fully established. Material and methods We sought to explore the prevalence of Tw-MCA in patients clinically referred to digital angiography in a single academic comprehensive endovascular center and evaluated the radiological and clinical findings among patients with hemorrhagic events. Results From 2011 to 2020, a total of 10,234 patients underwent a cerebral angiography at our institution. During this period, 9 (0.088%) Tw-MCAs were identified. Out of these, 5 patients (62.5%) were admitted due to an intracranial hemorrhage. Two patients had a ruptured intracranial aneurysm on the anterior communicating artery, one with multiple brain aneurysms; two patients presented an intraparenchymal hematoma (IPH) due to the presence of a periventricular anastomosis and one patient an intraventricular hemorrhage with unclear origin. Conclusion Tw-MCA is a very rare vascular anomaly associated with hemorrhagic events. Adequate identification of this anomaly is essential in order to avoid misdiagnosis as steno-occlusive disorders.

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