Category Archives: Vascular

Endovascular Cerebral Aneurysm Repair Market By Medtech Ventures

Endovascular Cerebral Aneurysm Repair MarketEndovascular Cerebral Aneurysm Repair Market

Endovascular Cerebral Aneurysm Repair Market
By Medtech Ventures
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Product Description

The global market for endovascular cerebral aneurysm repair (ECAR) devices has surpassed the $1 billion mark and currently stands at US$1.1 billion. The market, which has experienced explosive growth over the previous decade, has matured at the current level of technology. In its purest form, the endovascular cerebral aneurysm repair market consists of three broad categories of minimally invasive devices; embolic coils, intracranial stents and access devices. When used alone, or in combination, they allow the intervening physician to use the patient’s arteries as highways to deliver intended therapies, in the form of coils or stents, to the aneurysm location within the patient’s brain. The delivery procedure is performed under real-time visual guidance from high-powered imaging machines in a neurointerventional suite. The endovascular cerebral aneurysm repair market experienced a phenomenal growth phase that saw revenue rise over ten folds in just over a decade, from less than $100 million in 2000 to its current level of $1.1 billion. Current market leaders are seeking cost reductions and profit maximization through consolidation and moving production to lower cost jurisdictions. However, new research in endothelial biology is ushering in a new breed of biotech startups in search for disease modifying molecular targets, which could, theoretically, disrupt the market before the end of this decade. Medtech Ventures’ Endovascular Cerebral Aneurysm Repair Market Report is an exclusive update to the recently changed global landscape of this market. It provides a brief, but thorough, analysis of the market with profiles of leading participant and a solid forecast to 2020.


Product Details

  • Published on: 2014-06-01
  • Original language: English
  • Binding: Paperback
  • 34 pages

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About the Author
Medtech Ventures is a forward looking think tank and virtual startup accelerator specialized in the medical technology industry. We offer our clients a broad portfolio of services revolving around the concept of “Virtual Incubation”. We help with idea evaluation, opportunity sizing, technology assessment, market analysis as well as perception management and venture capital sourcing and finance. We also publish brief market insight & niche opportunity reports targeted at senior executives in the medical technology field.


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Top Read: Simvastatin in aneurysmal subarachnoid haemorrhage (STASH): a multicentre randomised phase 3 trial.

Lancet Neurol. 2014 May 15. pii: S1474-4422(14)70084-5. doi: 10.1016/S1474-4422(14)70084-5. [Epub ahead of print]

Simvastatin in aneurysmal subarachnoid haemorrhage (STASH): a multicentre randomised phase 3 trial.

Abstract

BACKGROUND:

The benefit of statins in patients with acute aneurysmal subarachnoid haemorrhage is unclear. We aimed to determine whether simvastatin 40 mg could improve the long-term outcome in patients with this disorder.

METHODS:

In this international, multicentre, randomised, double-blind trial, we enrolled patients aged 18-65 years with confirmatory evidence of an aneurysmal subarachnoid haemorrhage and presenting less than 96 h from ictus from 35 acute neurosurgical centres in nine countries. Patients were randomly allocated (1:1) to receive either simvastatin 40 mg or placebo once a day for up to 21 days. We used a computer-generated randomisation code to randomise patients in every centre by blocks of ten (five simvastatin, five placebo). Participants and investigators were masked to treatment assignment. The primary outcome was the distribution of modified Rankin Scale (mRS) score obtained by questionnaire at 6 months. Analyses were done on the intention-to-treat population. This trial has been completed and is registered with Current Controlled Trials, number ISRCTN75948817.

FINDINGS:

Between Jan 6, 2007, and Feb 1, 2013, apart from the period between May 15, 2009, and Feb 8, 2011, when recruitment was on hold, 803 patients were randomly assigned to receive either simvastatin 40 mg (n=391) or placebo (n=412). All patients were included in the intention-to-treat population. 782 (97%) patients had outcome data recorded at 6 months, of whom 560 (72%) were classed as having a favourable outcome, mRS 0-2 (271 patients in the simvastatin group vs 289 in the placebo group). The primary ordinal analysis of the mRS, adjusted for age and World Federation of Neurological Surgeons grade on admission, gave a common odds ratio (OR) of 0·97, 95% CI 0·75-1·25; p=0·803. At 6 months, we recorded 37 (10%) deaths in the simvastatin group compared with 35 (9%) in the placebo group (log-rank p=0·592). 70 (18%) serious adverse events were reported in the simvastatin group compared with 74 (18%) in the placebo group. No suspected unexpected serious adverse reactions were reported.

INTERPRETATION:

The STASH trial did not detect any benefit in the use of simvastatin for long-term or short-term outcome in patients with aneurysmal subarachnoid haemorrhage. Despite demonstrating no safety concerns, we conclude that patients with subarachnoid haemorrhage should not be treated routinely with simvastatin during the acute stages.

FUNDING:

British Heart Foundation.

Update: Anterior choroidal artery (AchA)

Anterior choroidal artery (AchA)

J.Sales-Llopis

Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain

Anatomically, the cisternal segment of the AChA originates from the posterolateral wall of the internal carotid artery (ICA), runs along the lateral recess of the basal cistern, attaches itself to the optic tract, which is follows to reach the crural cisternbefore entering the choroidal fissure.

Microdissection of 100 hemispheres from human cadavers were performed in order to study the anatomic characteristics of the anterior choroidal artery (AChA). One AChA per hemisphere was found. In 98% of hemispheres the AChA arose from the internal carotid artery (ACI) 2.4mm distal to the origin of the posterior communicating artery (ACoP) and 4.7mm proximal to the carotid bifurcation. One or more perforating branches arose from communicating segment of ACI in 29% of hemispheres. The average calibre of the cisternal portion was 0.9mm and the plexal portion 0.7mm. The most frequent branches of the cisternal portion pass to the optic tract, cerebral peduncle, uncus and lateral geniculate body. Anastomosis were found between branches of the AChA and posterior cerebral artery, ACoP, middle cerebral artery and ACI 1).

Origin

An ectopic origin was observed in 4% of cases. The intracisternal segment of the anterior choroidal a. forms a neurovascular bundle with the optic tract and basal v. Most of its intraparenchymatous branches arise from the cisternal segment, while branches supplying the optic tract, lateral geniculate body and thalamus arise from the intraplexual segment. Constant anastomoses exist with the vertebrobasilar system, specially the postero-lateral choroidal and posterior cerebral aa. 2).

Segments

Both parts of the cisternal segment of the AChA come into surgical view during surgeries for different pathologies in and around theperimesencephalic cisterns. However, attending to the artery’s genu and defining pre- and postoptic parts during surgery may help the surgeon locate the origin and eventual course of these perforators, and even estimate the terminal areas of supply of most of the perforating arteries. The proposed classification system os Tanriover et al. can prove helpful in planning any operative procedure along the crural cistern and may reduce the probability of inadvertent injury to perforating branches of the cisternal segment.

The cisternal segment of the AChA was divided into pre- and postoptic parts that meet at the artery’s genu, the most medial extension point of the cisternal segment where the artery makes an abrupt turn after passing under the optic tract. The preoptic part of the AChA extended from its origin at the inferomedial side of the internal carotid artery to the artery’s genu, which is commonly located just inferomedial to the initial part of the optic tract. The postoptic part coursed within the crural cistern and extended from the genu to the inferior choroidal point. The genu of the AChA was 8 mm medial to the artery’s origin and was located medial to the optic tract in 13% of the hemispheres. The postoptic part was longer than the preoptic part in all hemispheres and had more perforating arteries supplying critical deep structures (preoptic 3.4 per hemisphere vs postoptic 4.6 per hemisphere), and these results were statistically significant (p = 0.01). At the preoptic part, perforating arteries arose from the superolateral portion of the artery and coursed laterally; at the postoptic part, perforators arose from the inferomedial portion of the artery and coursed medially. Perforating arteries from both segments passed most commonly to the optic tract, followed by the anterior segment and apex of uncus in the preoptic part and the cerebral peduncle in the postoptic part. 3).

Structure

The anterior choroidal artery serves structures in the telencephalon, diencephalon, and mesencephalon:

choroid plexus of the lateral ventricle and third ventricle

optic chiasm and optic tract

internal capsule

lateral geniculate body

globus pallidus

tail of the caudate nucleus

hippocampus

amygdala

substantia nigra

red nucleus

crus cerebri

Clinical significance

The full extent of the damage caused by occlusion of the anterior choroidal artery is not known. However, studies show that the interruption of blood flow from this vessel can result in hemiplegia on the contralateral (opposite) side of the body, contralateral hemihypoesthesia, and homonymous hemianopsia. These symptoms are thought to arise from ischemic damage to the posterior limb of the internal capsule, thalamus, and optic chiasm/optic tract. However, the posterior limb of the internal capsule also receives lenticulostriate arteries from the Middle Cerebral Artery, thus creating partially redundant supply.

Angiography

1) Ferreira A, Braga FM. [Microsurgical anatomy of the anterior choroidal artery]. Arq Neuropsiquiatr. 1990 Dec;48(4):448-53. Review. Portuguese. PubMed PMID: 2094191.
2) Morandi X, Brassier G, Darnault P, Mercier P, Scarabin JM, Duval JM. Microsurgical anatomy of the anterior choroidal artery. Surg Radiol Anat. 1996;18(4):275-80. PubMed PMID: 8983106.
3) Tanriover N, Kucukyuruk B, Ulu MO, Isler C, Sam B, Abuzayed B, Uzan M, Ak H, Tuzgen S. Microsurgical anatomy of the cisternal anterior choroidal artery with special emphasis on the preoptic and postoptic subdivisions. J Neurosurg. 2014 May;120(5):1217-28. doi: 10.3171/2014.1.JNS131325. Epub 2014 Mar 14. PubMed PMID: 24628614.

Long-term, serial screening for intracranial aneurysms in individuals with a family history of aneurysmal subarachnoid haemorrhage: a cohort study.

Individuals with two or more first-degree relatives who have had aneurysmal subarachnoid haemorrhage (aSAH) have an increased risk of aneurysms and aSAH. We investigated the yield of long-term serial screening for intracranial aneurysms in these individuals.

In a cohort study, we reviewed the results of screening of individuals with a positive family history of aSAH (two or more first-degree relatives who had had aSAH or unruptured intracranial aneurysms) done at the University Medical Centre Utrecht (Utrecht, Netherlands) between April 1, 1993, and April 1, 2013. Magnetic resonance angiography or CT angiography was done from age 16-18 years to 65-70 years. After a negative screen, we advised individuals to contact us after 5 years, but did not actively call them for repeated screening. We recorded familial history of ruptured and unruptured intracranial aneurysms, smoking history, hypertension, previous aneurysms, screening dates, and screening results. We identified risk factors for positive initial and follow-up screens with univariable and multivariable regression analysis.

We identified aneurysms in 51 (11%, 95% CI 9-14) of 458 individuals at first screening, in 21 (8%, 5-12) of 261 at second screening, in seven (5%, 2-11) of 128 at third screening, and three (5%, 1-14) of 63 at fourth screening. Five (3%, 95% CI 1-6) of 188 individuals without a history of aneurysms and with two negative screens had a de-novo aneurysm in a follow-up screen. Smoking (odds ratio 2·7, 95% CI 1·2-5·9), history of previous aneurysms (3·9, 1·2-12·7), and familial history of aneurysms (3·5, 1·6-8·1) were significant risk factors for aneurysms at first screening in the multivariable analysis. History of previous aneurysms was the only significant risk factor for aneurysms at follow-up screening (hazard ratio 4·5, 1·1-18·7). Aneurysms were identified in six (5%, 95% CI 2-10) of 129 individuals who were screened before age 30 years. One patient developed a de-novo aneurysm that ruptured 3 years after the last negative screen.
INTERPRETATION:
In individuals with a family history of aSAH, the yield of long-term screening is substantial even after more than 10 years of follow-up and two initial negative screens. We advocate long-term serial screening in these individuals, although the risk of aSAH within screening intervals is not eliminated.
FUNDING:
The Dutch Heart Foundation1

  1. Bor AS, Rinkel GJ, van Norden J, Wermer MJ. Long-term, serial screening for
    intracranial aneurysms in individuals with a family history of aneurysmal
    subarachnoid haemorrhage: a cohort study. Lancet Neurol. 2014 Apr;13(4):385-92.
    doi: 10.1016/S1474-4422(14)70021-3. Epub 2014 Mar 5. PubMed PMID: 24618352. []

4TH ANNUAL EANS YOUNG NEUROSURGEONS’ MEETING 2014

This year’s Young Neurosurgeons’ Meeting will once again take place at the Royal College of Surgeons of England, at Lincoln’s Inn Fields in London, UK. Registration and more information are available here.

This year’s topic is ‘Challenges for the Vascular Neurosurgeon’.

The meeting will include round tables, presentations and current updates encouraging debate and discussion. We support the opportunity to bring your own cases to what we hope will be a truly interactive meeting.

Programm

Booking Form

Confirmed Faculty

Bernhard Meyer (Munich)

Matthias Raddatz (Sheffield)

Karl Schaller (Geneva)

Raphael Blanc (Paris)

Claudius Thomé (Innsbruck)

Ioannis Fouyas (Edinburgh)

Francois Proust (Rouen)

Ulrich Sure (Essen)

Helmut Bertalanffy (Hannover)

Peter Vajkoczy (Berlin)

Ramez Kirollos (Cambridge)

Richard Kerr (Oxford)

John Downer (Edinburgh)

Alexander Andreou (Athens)

Johannes Woitzik (Berlin)

Andreas Gruber (Vienna)

Jurgen Beck (Bern)

Andre Grotenhuis (Nijmegen)

Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke

Early decompressive hemicraniectomy reduces mortality without increasing the risk of very severe disability among patients 60 years of age or younger with complete or subtotal space-occupying middle-cerebral-artery infarction. Its benefit in older patients is uncertain.

METHODS:

We randomly assigned 112 patients 61 years of age or older (median, 70 years; range, 61 to 82) with malignant middle-cerebral-artery infarction to either conservative treatment in the intensive care unit (the control group) or hemicraniectomy (the hemicraniectomy group); assignments were made within 48 hours after the onset of symptoms. The primary end point was survival without severe disability (defined by a score of 0 to 4 on the modified Rankin scale, which ranges from 0 [no symptoms] to 6 [death]) 6 months after randomization.

RESULTS:

Hemicraniectomy improved the primary outcome; the proportion of patients who survived without severe disability was 38% in the hemicraniectomy group, as compared with 18% in the control group (odds ratio, 2.91; 95% confidence interval, 1.06 to 7.49; P=0.04). This difference resulted from lower mortality in the surgery group (33% vs. 70%). No patients had a modified Rankin scale score of 0 to 2 (survival with no disability or slight disability); 7% of patients in the surgery group and 3% of patients in the control group had a score of 3 (moderate disability); 32% and 15%, respectively, had a score of 4 (moderately severe disability [requirement for assistance with most bodily needs]); and 28% and 13%, respectively, had a score of 5 (severe disability). Infections were more frequent in the hemicraniectomy group, and herniation was more frequent in the control group.

CONCLUSIONS:

Hemicraniectomy increased survival without severe disability among patients 61 years of age or older with a malignant middle-cerebral-artery infarction. The majority of survivors required assistance with most bodily needs. (Funded by the Deutsche Forschungsgemeinschaft; DESTINY II Current Controlled Trials number, ISRCTN21702227.)1

  1. Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M,
    Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger
    J, Hacke W; DESTINY II Investigators. Hemicraniectomy in older patients with
    extensive middle-cerebral-artery stroke. N Engl J Med. 2014 Mar
    20;370(12):1091-100. doi: 10.1056/NEJMoa1311367. PubMed PMID: 24645942. []