title: The fate of cranial neuropathy after flow diversion for carotid aneurysms.
abstract: OBJECTIVE
  The authors sought to determine whether flow diversion with the Pipeline Embolization Device (PED) can approximate microsurgical decompression in restoring function after cranial neuropathy following carotid artery aneurysms.
  
  
  METHODS
  This multiinstitutional retrospective study involved 45 patients treated with PED across the United States. All patients included presented between November 2009 and October 2013 with cranial neuropathy (cranial nerves [CNs] II, III, IV, and VI) due to intracranial aneurysm. Outcome analysis included clinical and procedural variables at the time of treatment as well as at the latest clinical and radiographic follow-up.
  
  
  RESULTS
  Twenty-six aneurysms (57.8%) were located in the cavernous segment, while 6 (13.3%) were in the clinoid segment, and 13 (28.9%) were in the ophthalmic segment of the internal carotid artery. The average aneurysm size was 18.6 mm (range 4-35 mm), and the average number of flow diverters placed per patient was 1.2. Thirty-eight patients had available information regarding duration of cranial neuropathy prior to treatment. Eleven patients (28.9%) were treated within 1 month of symptom onset, while 27 (71.1%) were treated after 1 month of symptoms. The overall rate of cranial neuropathy improvement for all patients was 66.7%. The CN deficits resolved in 19 patients (42.2%), improved in 11 (24.4%), were unchanged in 14 (31.1%), and worsened in 1 (2.2%). Overtime, the rate of cranial neuropathy improvement was 33.3% (15/45), 68.8% (22/32), and 81.0% (17/21) at less than 6, 6, and 12 months, respectively. At last follow-up, 60% of patients in the isolated CN II group had improvement, while in the CN III, IV, or VI group, 85.7% had improved. Moreover, 100% (11/11) of patients experienced improvement if they were treated within 1 month of symptom onset, whereas 44.4% (12/27) experienced improvement if they treated after 1 month of symptom onset; 70.4% (19/27) of those with partial deficits improved compared with 30% (3/10) of those with complete deficits.
  
  
  CONCLUSIONS
  Cranial neuropathy caused by cerebral aneurysm responds similarly when the aneurysm is treated with the PED compared with open surgery and coil embolization. Lower morbidity and higher occlusion rates obtained with the PED may suggest it as treatment of choice for some of these lesions. Time to treatment is an important consideration regardless of treatment modality.
authors.affiliation: Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida;
authors.forename: Benjamin L
authors.initials: BL
authors.lastname: Brown
authors.affiliation: Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois;
authors.forename: Demetrius
authors.initials: D
authors.lastname: Lopes
authors.affiliation: Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida;
authors.forename: David A
authors.initials: DA
authors.lastname: Miller
authors.affiliation: Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida;
authors.forename: Rabih G
authors.initials: RG
authors.lastname: Tawk
authors.affiliation: Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida;
authors.forename: Leonardo B C
authors.initials: LB
authors.lastname: Brasiliense
authors.affiliation: Department of Neurosurgery, University of Cincinnati, Ohio;
authors.forename: Andrew
authors.initials: A
authors.lastname: Ringer
authors.affiliation: Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida;
authors.forename: Eric
authors.initials: E
authors.lastname: Sauvageau
authors.affiliation: Department of Neurological Surgery, The Ohio State University, Columbus, Ohio;
authors.forename: Ciarán J
authors.initials: CJ
authors.lastname: Powers
authors.affiliation: Semmes Murphey Neurologic and Spine Institute, Semmes Murphey Clinic, Memphis, Tennessee;
authors.forename: Adam
authors.initials: A
authors.lastname: Arthur
authors.affiliation: Semmes Murphey Neurologic and Spine Institute, Semmes Murphey Clinic, Memphis, Tennessee;
authors.forename: Daniel
authors.initials: D
authors.lastname: Hoit
authors.affiliation: Department of Neurosurgery, University of Buffalo, New York;
authors.forename: Kenneth
authors.initials: K
authors.lastname: Snyder
authors.affiliation: Department of Neurosurgery, University of Buffalo, New York;
authors.forename: Adnan
authors.initials: A
authors.lastname: Siddiqui
authors.affiliation: Department of Neurosurgery, University of Buffalo, New York;
authors.forename: Elad
authors.initials: E
authors.lastname: Levy
authors.affiliation: Department of Neurosurgery, University of Buffalo, New York;
authors.forename: L Nelson
authors.initials: LN
authors.lastname: Hopkins
authors.affiliation: Department of Neurosurgery, Louisiana State University, Shreveport, Louisiana;
authors.forename: Hugo
authors.initials: H
authors.lastname: Cuellar
authors.affiliation: Department of Neurosurgery, University of Puerto Rico Medical Sciences, San Juan, Puerto Rico;
authors.forename: Rafael
authors.initials: R
authors.lastname: Rodriguez-Mercado
authors.affiliation: Capital Institute for Neurosciences, Capital Health, Trenton, New Jersey;
authors.forename: Erol
authors.initials: E
authors.lastname: Veznedaroglu
authors.affiliation: Capital Institute for Neurosciences, Capital Health, Trenton, New Jersey;
authors.forename: Mandy
authors.initials: M
authors.lastname: Binning
authors.affiliation: Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee;
authors.forename: J
authors.initials: J
authors.lastname: Mocco
authors.affiliation: National Institute of Medical Sciences and Nutrition, Salvador Zubiran, Mexico City, Mexico; and.
authors.forename: Pedro
authors.initials: P
authors.lastname: Aguilar-Salinas
authors.affiliation: Department of Neurosurgery, Albany Medical Center, Albany, New York.
authors.forename: Alan
authors.initials: A
authors.lastname: Boulos
authors.affiliation: Department of Neurosurgery, Albany Medical Center, Albany, New York.
authors.forename: Junichi
authors.initials: J
authors.lastname: Yamamoto
authors.affiliation: Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida;
authors.forename: Ricardo A
authors.initials: RA
authors.lastname: Hanel
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002339:Carotid Arteries / Q000601:surgery*; D002343:Carotid Artery, Internal / Q000601:surgery; D002548:Cerebral Revascularization / Q000009:adverse effects / Q000379:methods*; D003389:Cranial Nerve Diseases / Q000209:etiology* / Q000601:surgery*; D004621:Embolization, Therapeutic / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications* / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology / Q000401:mortality; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States
keywords: CN = cranial nerve; PED = Pipeline Embolization Device; Pipeline Embolization Device; aneurysm; cranial neuropathy; flow diversion; vascular disorders