PulseRider Use in Ruptured Basilar Apex Aneurysms

Endovascular Treatment of Wide-Neck Bifurcation Aneurysm: Recent Trends in Coil Embolization with Adjunctive Technique

Wide-neck bifurcation aneurysms (WNBAs) are sometimes challenging to treat. During endovascular treatment, it is important to prevent coil deviation and preserve normal vessels. Adjunctive balloon- and stent-assisted techniques have been developed. A meta-analysis of endovascular treatments of WNBAs revealed that only 40% of patients had complete occlusion. Recently, novel devices have been developed to expand the range of treatment options. Flow-diverter stents and intra-aneurysmal flow disruption devices do not require coils; however, coil embolization remains the standard procedure used by many neurointerventionists. This review describes the recent trends in adjunctive techniques for supporting coil embolization for WNBAs. We referred to literature on balloon-assisted techniques, stent-assisted techniques, Y-stenting, PulseRider, Barrel stents, Comaneci temporary stents, pCONUS, and eCLIPs. These reports showed that adequate embolization rates were generally greater than 80%, and the complete occlusion rate was as high as 94.6%. All devices had a relatively high occlusion rate; however, it may be inaccurate to simply compare each device because of the heterogeneity of the studies. It is important to select the best treatment for each individual case by considering not only literature-based efficacy and safety but also patient background, aneurysm characteristics, and operator experience.

Risk factors for recanalization of basilar tip aneurysm after endovascular treatment: a retrospective cohort study

OBJECTIVES

Endovascular treatment (EVT) of basilar tip aneurysms (BTAs) is arduous because of the lesions' angioarchitecture and the relatively high recanalization rate after EVT. In this study, we aimed to report the clinical characteristics of BTAs and evaluate the incidence of and risk factors for recanalization.

METHODS

One hundred twenty-five patients with BTAs (11 ruptured, 114 unruptured) treated with EVT between 2009 and 2019 at one institution were retrospectively reviewed. Among them, 113 patients were included in statistical analyses. The anatomical parameters of the aneurysms and clinical data were analyzed. Univariate (chi-square test and t-test) and multivariate (multiple logistic regression) analyses were performed to identify risk factors for recanalization.

RESULTS

        Recanalization of the BTA occurred in 15 patients (13.3%). One patient (0.9%) was retreated endovascularly. The mean follow-up duration was 49.8 months. Neck size, posterior cerebral artery (PCA) angle, maximum diameter, and the rupture rate differed significantly between the recanalization and non-recanalization groups (P=.007, P<.001, P=.006, and P=.048, respectively). The maximum diameter (odds ratio, 1.483 per mm; 95% confidence interval, 1.145-1.919; P=.003) and PCA angle (odds ratio, 1.020 per degree; 95% confidence interval, 1.001-1.039; P=.036) were independently associated with recanalization.

CONCLUSIONS

Of all investigated BTAs, 96.8% were wide-neck aneurysms. The recanalization rate of BTAs after EVT was 13.3%. The PCA angle and maximal aneurysmal diameter were independently associated with recanalization; no associations were observed regarding vertebral artery dominance or modality of treatment. As such, BTA patients with wide PCA angles should be carefully monitored over time.

Y-stent assisted coiling of ruptured wide neck intracranial aneurysm in the acute phase

BACKGROUND

The objective of the present study is to analyze the outcomes of patients with subarachnoid hemorrhage (SAH) in the acute phase after treatment with Y-stent-assisted coiling (YSAC) embolization.

METHODS

This retrospective study assessed of 30 patients with acutely ruptured wide-neck aneurysms following YSAC treatment between April 2013 and October 2019. The demographic data, aneurysm occlusion grade, procedural and periprocedural complications, and clinical outcomes were assessed.

RESULTS

The procedure was completed in 30 cases (90.1%) and technical failure occurred in 3 cases (9.1%). Immediate control angiography revealed that total occlusion Raymond-Ray Class 1 (RR1) was achieved in 21 (70%), neck filling (RR2) in eight (26.6%) and sac filling (RR1) in one (3.3%) aneurysm. Upon angiographic follow-up, RR1 occlusion was observed in 15 (71.4%) patients, RR2 in three (14.3%) patients and RR3 in three (14.3%) patients. In-stent thrombus developed in five (16.6%) patients; procedural ischemic events were observed in four (13.3%) patients; and two (6.6%) patients were symptomatic. A periprocedural asymptomatic intracranial hemorrhage was detected in two patients. At discharge, 17 (56.6%) patients were in good clinical condition, six (20%) were in a severe disability condition, and seven (23.3%) patients had died. At the final follow-up visit (mean: 18.9 months), 16 (76,2%) of 21 patients were in a good clinical condition and five (23.8%) had severe disabilities.

CONCLUSIONS

Y-stent assisted coiling in might be a feasible and promising option for treatment in acute phase in selected wide-necked ruptured intracranial aneurysms.

Neurosurgical management of aneurysms of the vertebrobasilar system: increasing indications for endovascular therapy with a continued role for open microneurosurgery

Aneurysms of the vertebrobasilar system remain among the most challenging subsets of aneurysms to treat with an open surgical approach. Since Charles Drake's pioneering work in the 1960s, several advances in microsurgical techniques have improved outcomes and feasibility in the open surgical management of these aneurysms. In parallel, the field of endovascular neurosurgery has provided several safe and effective treatment options. Multiple trials have suggested that endovascular therapy for aneurysms of the vertebrobasilar system is superior to open surgical management in most cases. In some instances, however, open surgical management likely represents a more effective and durable option relative to endovascular therapy. Therefore, continued training of future cerebrovascular specialists in open surgery of vertebrobasilar aneurysms remains crucial. With widespread utilization of endovascular techniques, however, proper exposure of trainees to such aneurysms is growing increasingly difficult. In this review, we discuss the recent advances in the endovascular management of vertebrobasilar aneurysms while also emphasizing the continued importance of open microneurosurgery in such cases.

Intrasaccular flow disruption (WEB) of a large wide-necked basilar apex aneurysm using PulseRider-assistance

Large, wide-necked basilar apex aneurysms are difficult to treat. Microsurgical clipping can result in neurologic morbidity and mortality. Endovascular treatment often leaves remnants that need retreatment and/or stent placement with dual antiplatelet therapy. The Woven EndoBridge (WEB) is an intrasaccular flow disruption device that can be used without dual antiplatelet therapy. However, the WEB cannot typically be used in large or giant aneurysms > 10 mm because the largest diameter device is the 11 × 9.6 mm single layer sphere (SLS). We present a case in which we use a PulseRider aneurysm neck reconstruction device in the basilar artery to assist in WEB deployment within a 22 mm basilar apex aneurysm with 14 mm neck, thereby permitting aspirin monotherapy postoperatively.

Y-Stenting Versus PulseRider-Assisted Coiling in the Treatment of Wide-Neck Bifurcation Aneurysms: Role of Anatomical Features on Midterm Results

BACKGROUND

Y-stenting is an effective but challenging approach for wide-neck aneurysms. PulseRider (PR) (Pulsar/Cerenovus) is a new device designed to provide scaffolding during coiling but has never been compared with other techniques.

OBJECTIVE

To compare the immediate and 6-mo results of Y-stenting vs PR assisted coiling.

METHODS

A total of 105 consecutive patients were retrospectively divided into 2 groups (73 Y-stenting and 32 PR). All underwent angiographic 6-mo follow-up. We evaluated if some anatomical features could influence treatment results.

RESULTS

The groups were homogeneous. Immediate adequate occlusions as well as complication rates were similar in Y-stenting and PR group (94.5% vs 96.9% and 8.2% vs 6.2%, respectively). At 6 mo, adequate occlusion was 93.1% after Y-stenting and 84.3% after PR (P = .28), complete occlusion was significantly higher after Y-stenting: 90.3% vs 62.5% (P = .0017). Occlusion grade worsening occurred in 6.9% of Y-stenting and 18.7% of PR patients (P = .09).

Neck size was associated with occlusion grade in both groups. Maximal aneurysm size was associated with occlusion grade in the PR group (P = .023) but not in the Y-stenting group (P = .06). After PR, 6-mo occlusion rate was higher in small (&lt; 10 mm) than in large aneurysms (P = .0094); this was not observed after Y-stenting (P = .54).

Location did not significantly affect the mid-term occlusion rate in both the groups. After PR, occlusion was more stable in basilar than anterior or middle cerebral artery aneurysms.

CONCLUSION

Y-stenting and PR are both effective with similar immediate and mid-term results. However, treatment stability seems higher after Y-stenting. Aneurysm size seems to negatively affect PR results.