Predictors of Periprocedural Complications and Angiographic Outcomes of Endovascular Therapy for Large and Giant Intracranial Posterior Circulation Aneurysms

Endovascular treatment of ruptured basilar artery trunk aneurysms: complications and long-term outcomes

OBJECT

Treatment of ruptured basilar artery trunk (BAT) aneurysms is challenging, and is associated with high complication and mortality rates. Herein, we analyzed the complications, long-term outcomes, and outcome predictors of endovascular treatment for ruptured BAT aneurysms.

METHODS

Between January 2011 and July 2023, 36 patients with 36 ruptured BAT aneurysms underwent endovascular treatment at our institution. The postprocedural complications and clinical and angiographic outcomes were subsequently reviewed, and the risk factors for postprocedural complications were evaluated.

RESULTS

All 36 aneurysms in 36 patients were treated successfully. The median clinical follow-up time was 47.0 (IQR: 10.5, 84.5) months. Overall, complications occurred in 10 (27.8%) patients, including 3 (8.3%) deaths. Ischemic events occurred in seven (19.4%) patients, while three (8.3%) patients had shunt-dependent hydrocephalus, of whom one (2.8%) patient had both shunt-dependent hydrocephalus and ischemic events. The cumulative survival rates at 3 and 5 years were 94.1% and 87.8%, respectively. The cumulative 3- and 5-year complication-free survival rates were 75.0% and 70.0%, respectively. Multivariate Cox regression analysis revealed that diabetes mellitus (HR:8.76, 95%CI:2.35-32.69, p=0.001), and Glasgow coma scale score ≤ 12 before the procedure (HR:5.04, 95%CI:1.40-18.12, p=0.013) were associated with overall postprocedural complications. The complete aneurysm occlusion rate was 61.5% at a median angiography follow-up time of 6.0 (IQR: 5.0, 6.0) months.

CONCLUSIONS

Endovascular treatment is a safe and feasible option for treating ruptured BAT aneurysms. The rate of favorable outcomes at the final follow-up was satisfactory. However, postprocedural complications, particularly ischemic events, should be carefully considered.

Endovascular Treatment for Ruptured Intracranial Posterior Circulation Aneurysms: Complications and Clinical Outcomes

OBJECTIVE

To analyze the complications and long-term follow-up results of endovascular treatment for ruptured intracranial posterior circulation aneurysms and identify outcome predictors.

METHODS

A total of 194 patients with ruptured intracranial posterior circulation aneurysms treated at our center between January 2014 and June 2023 were included in this retrospective analysis. Factors influencing complications during hospitalization and clinical and angiographic outcomes were analyzed.

RESULTS

Complications occurred in 57 patients (29.4%) during hospitalization. The median clinical follow-up time was 46.5 (interquartile range 26.0-65.3) months, with favorable outcomes observed in 81.4% (158/194) and unfavorable outcomes in 18.5% (36/194) of cases, resulting in an overall mortality rate of 11.9% (23/194). The overall 1-year and 5-year complication-free survival rates were 76.4% and 70.7%, respectively. The overall 1-year and 5-year overall survival rates were 89.5% and 85.4%, respectively. Multifactorial analysis revealed that involvement of the basilar artery (P = 0.032) and perioperative external ventricular drainage (P < 0.001) were independent risk factors for complications during hospitalization, while advanced age (P = 0.030), poor World Federation of Neurosurgical Societies grade (P = 0.003), and use of closed cell design laser cut stents (P = 0.041) were independent risk factors for unfavorable outcomes during follow-up. Among the survivors, angiography follow-up was available for 139 patients, with a follow-up rate of 81.3% (139/171) and a median follow-up time of 8 months (interquartile range 6-12). During this period, 9 patients experienced aneurysm recanalization, and the complete occlusion rate was 85.6% (119/139).

CONCLUSION

Endovascular treatment is feasible and effective for treating ruptured intracranial aneurysms; however, there are still risks of complications and unfavorable clinical outcomes. The involvement of the basilar artery trunk increases the risk of complications, and the use of closed cell design laser cut stents is associated with unfavorable outcomes. Clinicians should be cautious to avoid the risk factors when treating ruptured posterior circulation aneurysms and strive to minimize the occurrence of complications and unfavorable clinical outcomes.

Microsurgical Treatment of a Giant Thrombosed Basilar Artery-Superior Cerebellar Artery Aneurysm With the Aid of Double Bypass Superficial Temporal Artery-Posterior Cerebral Artery and Superficial Temporal Artery-Superior Cerebellar Artery: 2-Dimensional Operative Video

Giant thrombosed posterior circulation aneurysms are rare lesions with a natural history associated with high morbidity and mortality.1-6 The treatment has high risk with either microsurgical or endovascular treatment (ET). While ET allows easier access but high recurrence rate, microsurgical treatment has more difficult access but provides more durable lasting treatment.7-13 A 47-year-old woman presented with left hemiparesis from a right giant thrombosed basilar artery-superior cerebellar artery (BA-SCA) aneurysm buried in the brainstem with surrounding edema. Owing to risk of perforator occlusion and high recurrence rate with ET, we opted for microsurgical clipping with the aid of double protective bypass of superficial temporal artery-posterior cerebral artery (STA-PCA) and STA-SCA. The patient consented to the procedure and publication of her image. Initially, we performed a pterional craniotomy with zygomatic arch removal and exposed the right PCA, right SCA, BA, and aneurysm neck. Then, to perform a safe protective STA-PCA bypass, it was necessary to make a partial temporal lobectomy to avoid injury of a PCA-perforating branch. Subsequently, BA-SCA aneurysm was clipped. After clipping, STA-SCA bypass was performed to prevent possible occlusion of SCA afterward. After initial worsening of left hemiparesis and right oculomotor palsy, the patient recovered with rehabilitation and had no deficits 6 months after surgery. Postoperative imaging confirmed aneurysm exclusion, absence of ischemic lesions, and recovering of brainstem edema. Protective bypasses are a useful technique to improve outcomes in the microsurgical treatment of certain giant posterior circulation aneurysms. This report was approved by the ethics committee of our institution.

Giant cavernous aneurysms occluded by aneurysmal thrombosis, calcification, parent artery occlusion: A case report and review of literature

BACKGROUND

Patients with giant intracranial aneurysms (GIAs) are at a high risk of rupture, morbidity, and mortality even after surgical or endovascular treatment. We described a case of a spontaneously occluded GIA secondary to gradual growth of the GIA, continuously progressed aneurysmal thrombosis, complete aneurysmal calcification and complete occlusion of the parent artery-the right internal carotid artery (RICA).

CASE SUMMARY

A 72-year-old female patient complained of sudden pain in her right eye upon admission to our hospital. She had been diagnosed with a GIA [30 mm (axial) × 38 mm (coronal) × 28 mm (sagittal)] containing an aneurysmal thrombus located in the cavernous sinus segment of RICA diagnosed by magnetic resonance imaging (MRI), enhanced MRI, and magnetic resonance angiography more than 14 years ago. Later, with slow growth of the cavernous carotid GIA, aneurysmal thrombosis progressed continuously, spontaneous occlusion of the RICA, complete aneurysmal calcification, and occlusion of the GIA occurred gradually. She had no history of subarachnoid hemorrhage but missed the chance for endovascular therapy at an early stage. As a result, she was left with severe permanent sequelae from the injuries to the right cranial nerves II, III, IV, V1/V2, and VI.

CONCLUSION

The risk of rupture of the cavernous carotid GIAs was relatively low and possibly further be reduced by the stasis flow and spontaneous occlusion of the parent artery internal carotid artery (ICA) induced by the mass effect of the cavernous carotid GIAs and the extremely rare aneurysmal calcification. However, nowadays, it is advisable to recommend early endovascular treatment for the cavernous carotid GIAs to prevent injuries to the surrounding intracranial nerves and occlusion of the ICA, mainly caused by the mass effect of the cavernous carotid GIAs.

Flow Diversion for the Management of Posterior Circulation's Intracranial Aneurysms

The endovascular treatment of posterior circulation aneurysms, although challenging, has been well-established due to various factors that limit the surgical approach in most cases. Flow diversion has also been utilized in the treatment of such aneurysms, although its effectiveness and safety still require evaluation. Numerous studies have examined the outcomes and complication rates in patients treated with FD, resulting in varying findings. This review aimed to summarize the most recent literature concerning the effectiveness of flow diversion devices in posterior circulation aneurysms. Additionally, it highlights reports that compare results in the posterior versus anterior circulation, as well as flow diversion versus stent-assisted coiling.

Conservative Therapy vs. Endovascular Approach for Intracranial Vertebrobasilar Artery Trunk Large Aneurysms: A Prospective Multicenter Cohort Study

Background

Intracranial vertebrobasilar trunk large (≥10 mm) aneurysms (IVBTLAs) are rare and challenging to manage. In this study, we describe the natural prognosis and evaluate the safety and efficacy of endovascular treatment of IVBTLAs compared with conservative therapy.

Methods

This prospective multicenter cohort study included patients with IVBTLAs, who chose either endovascular treatment (endovascular group) or conservative therapy (conservative group) after discussion with their doctors. The primary endpoint was the incidence of serious adverse events (SAEs) related to the target vessel, while secondary endpoints included target vessel-related mortality, major stroke, other serious adverse events, and aneurysm occlusion rate.

Results

In total, 258 patients were referred to our two centers for the management of vertebrobasilar aneurysms, and 69 patients had IVBTLAs. Among them, 51 patients underwent endovascular treatment, and 18 patients received conservative therapy. The incidence of target vessel-related SAEs was 15.7% (8/51) in the endovascular group and 44.4% (8/18) in the conservative group (P = 0.031). The target vessel-related mortality was 2.0% (1/51) in the endovascular group and 38.9% (7/18) in the conservative group (P < 0.001). The cumulative survival rates in the endovascular group and conservative group within 1-year, 3-year, and 5-year were 98.0% vs. 83.3%, P = 0.020; 98.0% vs. 66.7%, P = 0.001; and 98.0% vs. 35.6%, P < 0.001, respectively. Multivariate analysis revealed conservative therapy, giant aneurysm, and ischemic onset as risks factor for SAEs.

Conclusions

Compared with conservative treatment, endovascular treatment of the IVBTLAs may be associated with a lower incidence of SAEs, with higher 1-year, 3-year, and 5-year survival rates. Conservative therapy, giant aneurysm, and ischemic onset were associated with a high risk of SAEs.

Flow Diversion vs. Stent-Assisted Coiling in the Treatment of Intradural Large Vertebrobasilar Artery Aneurysms

Objective

To compare the safety, angiographic, and long-term clinical outcomes of intradural large vertebrobasilar artery (VBA) aneurysms following flow diversion (FD) or conventional stent-assisted coiling (SAC).

Methods

We performed a retrospective study of 66 consecutive patients with intradural large VBA aneurysms between 2014 and 2021 who underwent FD or SAC. Patients' characteristics, postprocedural complications, and clinical and angiographic outcome details were reviewed.

Results

A total of 66 intradural large VBA aneurysms were included, including 42 (63.6%), which were treated with SAC (SAC group) and 24 (36.4%), which were treated with FD (FD group). Clinical follow-up was obtained at the median of 24.0 [interquartile range (IQR) 12.0–45.0] months, with 34 (81.0%) patients achieved the modified Rankin Scale (mRS) ≤ 2 in the SAC group and 21 (87.5%) patients in the FD group. Thirteen (19.7%) patients experienced neurological complications, of which 9 (13.6%) patients first occurred during the periprocedural phase and 4 (6.1%) patients first occurred during follow-up. The overall complication rate and periprocedural complication rate were both higher in the SAC group, but did not reach statistical significance (23.8 vs. 12.5%, P = 0.430; 16.7 vs. 8.3%, P = 0.564). The mortality rates were similar between the groups (11.9 vs. 12.5%). Angiographic follow-up was available for 46 patients at the median of 7 (IQR 6–14) months, with a numerically higher complete occlusion rate in the SAC group (82.1 vs. 55.6%, P = 0.051) and similar adequate aneurysm occlusion rates between the groups (85.7 vs. 83.3%, P = 1.000). In the multivariate analysis, ischemic onset (P = 0.019), unilateral vertebral artery sacrifice (P = 0.008), and older age (≥60 years) (P = 0.031) were significantly associated with complications.

Conclusion

There was a trend toward lower complication rate and lower complete occlusion rate for intradural large VBA aneurysms following FD as compared to SAC. FD and SAC have comparable mortality rates and favorable outcomes. Ischemic onset, unilateral vertebral artery sacrifice, and older age could increase the risk of complications.

The 8-year single-center experience of telescoping flow diverter for complex intracranial aneurysms treatment

OBJECTIVE

Treatment of complex intracranial aneurysms (IAs) is still a challenging thing and this study aims to summarize the experience of telescoping flow diverters (FDs) in treating complex intracranial aneurysms.

METHOD

Between April 2013 to November 2020, 381 IA cases treated by flow diverters (FD) were retrieved from the database of 4988 IA cases, and finally 20 cases treated by telescoping FDs were enrolled for further analysis.

RESULT

Among 20 patients, 15 patients (75.0%) received Tubridge telescoping while 5 patients (25.0%) received PED telescoping. The technical success rate was 100%. The immediate occlusion results were: 7 cases of OKM grade A (35.0%), 11 cases of OKM grade B (55.0%), and 2 cases of OKM grade C (10.0%). No perioperative complications occurred. The clinical follow-up was available in 20 patients (100%) and the follow-up time was 6-96 months. One patient developed massive infarction and the other 19 patients were range between 0 and 2. The angiographic follow-up was available in 17 patients (85%) and the follow-up time was 6-27 months. The occlusion results were: 1 case of OKM grade B (5.9%), 6 cases of OKM grade C (35, 0.3%), and 10 cases of OKM grade D (58.8%). 2 patients (11.8%) developed occlusion of the patent artery.

CONCLUSION

Telescoping flow diverters showed low perioperative complications and high IA occlusion rate when treating complex intracranial aneurysms in follow-up time, which provides an alternative manner beyond conventional strategy for neurosurgeons.

Endovascular Treatment of Large or Giant Basilar Artery Aneurysms Using the Pipeline Embolization Device: Complications and Outcomes

Background

This study aimed to investigate clinical and angiographic outcomes of Pipeline embolization device (PED) treatment of large or giant basilar artery (BA) aneurysms and examine associated factors.

Methods

Clinical and angiographic data of 29 patients (18 men, 11 women) with large or giant BA aneurysms were retrospectively examined. Mean age was 44.1 ± 21.2 years (range, 30–68). Mean aneurysm size was 22.2 ± 8.3 mm (range, 12.0–40.1).

Results

Mean angiographic follow-up was 18.3 ± 3.4 months (range, 4.5–60). The rate of adequate aneurysmal occlusion (O'Kelly–Marotta grade C–D) was 87%. The overall complication rate was 44.8%; most complications (84.6%) occurred in the periprocedural period. Univariable comparison of patients who did and did not develop complications showed significant differences in aneurysm size (p < 0.01), intra-aneurysmal thrombus (p = 0.03), and mean number of PEDs used (p = 0.02). Aneurysm size (odds ratio, 1.4; p = 0.04) was an independent risk factor for periprocedural complications in multivariable analysis. Mean clinical follow-up was 23.5 ± 3.2 months (range, 0.1–65). Nine patients (31%) had a poor clinical outcome (modified Rankin scale score ≥3) at last follow-up, including 7 patients who died. Univariable comparisons between patients with favorable and unfavorable clinical outcomes showed that aneurysm size (p = 0.009) and intra-aneurysmal thrombus (p = 0.04) significantly differed between the groups. Multivariable analysis showed that aneurysm size (odds ratio, 1.1; p = 0.04) was an independent risk factor for poor clinical outcome.

Conclusion

PED treatment of large or giant BA aneurysms is effective and can achieve a satisfactory long-term occlusion rate. However, the treatment complications are not negligible. Aneurysm size is the strongest predictor of perioperative complications and poor clinical outcome.

Endovascular Management of Vertebrobasilar Trunk Artery Large Aneurysms: Complications and Long-Term Results

Objective

To analyze the complications and long-term results of endovascular management of vertebrobasilar trunk large (≥10 mm) aneurysms (VBTLAs) and identify predictors of outcomes.

Methods

Between 2014 and 2020, 6,987 patients with intracranial aneurysms were referred to our center for aneurysm management and 2,224 patients have undergone the endovascular procedures. We retrospectively reviewed the database and identify all the patients with VBTLAs.

Results

A total of 62 VBTLAs were identified. The median aneurysm size was 13.4 mm [interquartile range (IQR) 11.5–18.7]. Among them, 24 aneurysms were treated with overlapping stent techniques, 18 aneurysms were treated with flow diversion, 14 aneurysms were treated with single stent-assisted coiling, and 6 aneurysms were treated with coiling alone. Ten patients were treated with parent artery occlusion or unilateral vertebral artery occlusion. Periprocedural complications were occurred in 7 (11.3%) patients. Clinical follow-up was obtained at the median of 27.5 months (IQR 15.3–58.5). The overall complication rate was 16.1% (10/62), including nine ischemic events and one hemorrhagic event. The combined disability and neurological mortality rate was 12.9% (8/62), with 4 (6.5%) deaths. The favorable outcome rate at follow-up was 87.1% (54/62). The complication-free cumulative survival rates at 1 and 5 years were 86.8 and 82.0%, respectively. The overall cumulative survival rates at 1 and 5 year were 96.5 and 89.8%, respectively. In the multivariate Cox regression analysis, longer procedure time (>115 min) (P = 0.037) and ischemic onset (P = 0.005) predict complications. Angiography follow-up was available for 36 patients at the median of 6.0 months (IQR 6–12), with a complete occlusion rate of 77.8% (28/36). Two (5.6%) aneurysms were recanalized and subsequently received the retreatment. Subgroup analysis did not find any differences in the complete occlusion rate between endovascular strategies.

Conclusion

Endovascular management of VBTLAs has a reasonable safety profile with favorable 5-year cumulative survival rates and imaging outcomes at follow-up. Prolonged procedure and ischemic onset are associated with a high risk of overall complications.

Giant aneurysm of the bilateral vertebrobasilar junction treated by pipeline and coils: A case report and literature review

Giant aneurysm of the posterior circulation is associated with a higher risk of rupture compared with that of the anterior circulation. Furthermore, surgical clipping and interventional embolization for giant aneurysm of the posterior circulation are more difficult and complex to perform. The present study reported on the case of a 26-year-old female who exhibited a giant spherical aneurysm of the vertebrobasilar junction (VBJ) with a maximum diameter of ~35 mm that caused cervical discomfort. In addition, the patient experienced symptoms including left-sided walking and hoarseness caused by the compression of the brainstem and the posterior cranial nerves. The risks associated with performing surgery in this area are high and the prognosis is mainly poor. The patient of the present study was treated using the Pipeline Flex device with coil embolization. As a giant aneurysm of the VBJ simultaneously affects the bilateral vertebral arteries (VAs) and basilar artery, it is a unique condition and the treatment strategy must be personalized. Based on an analysis of the hemodynamic influence on the aneurysm in the present case, the Pipeline was placed through the left VA, the coils were packed through the right VA, and finally, the right VA was proximally occluded. At 7 months after embolization, the patient's modified Rankin scale score was 1 point. Upon analysis of the hemodynamic influence on the aneurysm of the VBJ, the VA with the larger shear force on the wall of the aneurysm was selected for occlusion to simplify the treatment of the aneurysm and to maximize the probability to achieve recovery.