Delayed Cranial Nerve Palsy After Coiling of Carotid Cavernous Sinus Aneurysms

Onset-to-treatment time and aneurysmal regression predict improvement of cranial neuropathy after flow diversion treatment in patients with symptomatic internal carotid artery aneurysms

BACKGROUND

Although flow diversion plays a pivotal role in treating internal carotid artery aneurysms presenting with cranial neuropathy, predictors of symptom improvement have not been established.

OBJECTIVE

To investigate improvement of symptoms after flow diversion treatment in patients with internal carotid artery aneurysms causing cranial neuropathy, with sufficient follow-up period. Additionally, to examine factors associated with improvement of symptoms.

METHODS

This retrospective multicenter study examined patients with unruptured internal carotid artery aneurysms presenting with cranial neuropathy who were treated using flow diversion and followed up for at least 12 months. Study outcomes were transient worsening of symptoms and symptom status 12 months after treatment. Patient and aneurysm characteristics were statistically analyzed.

RESULTS

Seventy-seven patients were included. Data needed for outcome analysis were available for 66 patients. At the 1-, 3-, 6-, 12-month, and last follow-ups, the proportion of patients with resolved or improved symptoms was 26% (20/77), 51% (39/77), 74% (57/77), 83% (64/77), and 79%(62/77), respectively. Symptom onset-to-treatment time <6 months (OR=24.2; 95% CI 3.09 to 188.84; p=0.002) and aneurysmal regression (OR=23.1; 95% CI 1.97 to 271.75; p=0.012) were significantly associated with symptom improvement. Transient symptom worsening and worse symptoms at 12 months occurred in 19/77 (25%) and 2/77 (3%) patients, respectively.

CONCLUSIONS

The rate of cranial neuropathy symptom improvement after flow diversion increased over the first 12 months after treatment, but not thereafter. Treatment within 6 months of symptom onset and aneurysmal regression were predictors of symptom improvement.

Hydrogel versus Bare Platinum Coils in Patients with Large or Recurrent Aneurysms Prone to Recurrence after Endovascular Treatment: A Randomized Controlled Trial

BACKGROUND AND PURPOSE

Some patients are at high risk of aneurysm recurrence after endovascular treatment: patients with large aneurysms (Patients Prone to Recurrence After Endovascular Treatment PRET-1) or with aneurysms that have previously recurred after coiling (PRET-2). We aimed to establish whether the use of hydrogel coils improved efficacy outcomes compared with bare platinum coils.

MATERIALS AND METHODS

PRET was an investigator-led, pragmatic, multicenter, parallel, randomized (1:1) trial. Randomized allocation was performed separately for patients in PRET-1 and PRET-2, by using a Web-based platform ensuring concealed allocation. The primary outcome was a composite of a residual/recurrent aneurysm, adjudicated by a blinded core laboratory, or retreatment, intracranial bleeding, or mass effect during the 18-month follow-up. Secondary outcomes included adverse events, mortality, and morbidity (mRS > 2). The hypothesis was that hydrogel would decrease the primary outcome from 50% to 30% at 18 months, necessitating 125 patients per group (500 for PRET-1 and PRET-2).

RESULTS

The trial was stopped once 250 patients in PRET-1 and 197 in PRET-2 had been recruited because of slow accrual. A poor primary outcome occurred in 44.4% (95% CI, 35.5%-53.2%) of those in PRET-1 allocated to platinum compared with 52.5% (95% CI, 43.4%-61.6%) of patients allocated to hydrogel (OR, 1.387; 95% CI, 0.838-2.295; P = .20) and in 49.0% (95% CI, 38.8%-59.1%) in PRET-2 allocated to platinum compared with 42.1% (95% CI, 32.0%-52.2%) allocated to hydrogel (OR, 0.959; 95% CI, 0.428-1.342; P = .34). Adverse events and morbidity were similar. There were 3.6% deaths (1.4% platinum, 5.9% hydrogel; P = .011).

CONCLUSIONS

Coiling of large and recurrent aneurysms is safe but often poorly effective according to angiographic results. Hydrogel coiling was not shown to be better than platinum.

Neuroophthalmological outcomes associated with use of the Pipeline Embolization Device: analysis of the PUFS trial results

OBJECT

Neuroophthalmological morbidity is commonly associated with large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms. The authors sought to evaluate the neuroophthalmological outcomes after treatment of these aneurysms with the Pipeline Embolization Device (PED).

METHODS

The Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial was an international, multicenter prospective trial evaluating the safety and efficacy of the PED. All patients underwent complete neuroophthalmological examinations both before the PED procedure and at a 6-month follow-up. All examinations were performed for the purpose of this study and according to study criteria.

RESULTS

In total, 108 patients were treated in the PUFS trial, 98 of whom had complete neuroophthalmological follow-up. Of the patients with complete follow-up, 39 (40%) presented with a neuroophthalmological baseline deficit that was presumed to be attributable to the aneurysm, and patients with these baseline deficits had significantly larger aneurysms. In 25 of these patients (64%), the baseline deficit showed at least some improvement 6 months after PED treatment, whereas in 1 patient (2.6%), the deficits only worsened. In 5 patients (5%), new deficits had developed at the 6-month follow-up, while in another 6 patients (6%), deficits that were not originally assumed to be related to the aneurysm had improved by that time. A history of diabetes was associated with failure of the baseline deficits to improve after the treatment. The aneurysm maximum diameter was significantly larger in patients with a new deficit or a worse baseline deficit at 6 months postprocedure.

CONCLUSIONS

Patients treated with the PED for large and giant ICA aneurysms had excellent neuroophthalmological outcomes 6 months after the procedure, with deficits improving in most of the patients, very few deficits worsening, and few new deficits developing.

Microsurgical Treatment of Previously Coiled Intracranial Aneurysms: Systematic Review of the Literature

OBJECTIVE

To assess indications, complications, clinical outcomes, and technical nuances of microsurgical treatment of previously coiled intracranial aneurysms.

METHODS

A systematic review of the literature was performed using PubMed/MEDLINE and EMBASE databases from January 1990 to December 2013. English-language articles reporting on microsurgical treatment of previously coiled intracranial aneurysms were included. Articles that involved embolization materials other than coils were excluded. Data on aneurysm characteristics, indications for surgery, techniques, complications, angiographic obliteration rates, and clinical outcomes were collected.

RESULTS

The literature review identified 29 articles reporting on microsurgical clipping of 375 previously coiled aneurysms. Of the aneurysms, 68% were small (<10 mm). Indications for clipping included the presence of a neck remnant (48%) and new aneurysmal growth (45%). Rebleeding before clipping was reported in 6% of cases. Coil extraction was performed in 13% of cases. The median time from initial coiling to clipping was 7 months. The angiographic cure rate was 93%, with morbidity and mortality of 9.8% and 3.6%, respectively.

CONCLUSIONS

Microsurgical clipping of previously coiled aneurysms can result in high obliteration rates with relatively low morbidity and mortality in select cases. Considerations for microsurgical strategies include the presence of sufficient aneurysmal tissue for clip placement and the potential need for temporary occlusion or flow arrest. Coil extraction is not needed in most cases.

Resolution of cranial neuropathies following treatment of intracranial aneurysms with the Pipeline Embolization Device

Object

Intracranial aneurysms, especially those of the cavernous segment of the internal carotid artery (ICA), can present with cranial nerve (CN) palsies. The Pipeline Embolization Device (PED) has demonstrated safety and efficacy in the treatment of cerebral aneurysms by flow diversion, but little data exist reporting the outcomes of cranial neuropathies following treatment with the device.

Methods

The prospectively maintained Barrow Neurological Institute's endovascular database was reviewed for all patients treated with the PED after presenting with one or more CN palsies secondary to a cerebral aneurysm since May 2011. Patient charts and digital subtraction angiograms were reviewed to report clinical and angiographic outcomes. Only patients with clinical follow-up were included in the analysis.

Results

A total of 127 patients were treated with the PED at the authors' institution after FDA approval. Twentytwo patients presented with cranial neuropathies, for initial inclusion in this study. Of these, 20 had sufficient followup for analysis. Cranial neuropathies included those of CN II, III, V, and VI, with presenting symptoms of diplopia, decreased visual acuity, and facial numbness and/or pain. Thirteen lesions were cavernous segment ICA aneurysms, whereas the remainder included supraclinoid and petrous segment ICA, posterior communicating artery, and basilar trunk aneurysms. At an average clinical follow-up of 9.55 months, 15 patients (75%) had resolution or significant improvement of their cranial neuropathies, and the remaining 5 had stable symptoms. Of the 18 patients with angiographic follow-up, 12 (66.7%) demonstrated complete obliteration or small neck residual, whereas 6 (33.3%) had residual lesion. Patients with complete or near-complete obliteration of their lesion were significantly more likely to demonstrate symptomatic improvement at follow-up (p = 0.009). Two patients with persistent symptoms were eventually treated with microsurgical bypass. Transient complications in this series included 6 (30%) extracranial hemorrhagic complications related to dual-antiplatelet therapy, all of which were managed medically. There was 1 delayed right ICA occlusion following retreatment that led to microsurgical bypass.

Conclusions

Intracranial aneurysms presenting with one or more CN palsies show a high rate of clinical improvement after treatment with the PED. Clinical outcomes must be weighed against the risks and challenges faced with flow diverters. Further research is warranted for patients whose symptoms do not respond optimally to device placement.

Patients prone to recurrence after endovascular treatment: periprocedural results of the PRET randomized trial on large and recurrent aneurysms

BACKGROUND AND PURPOSE

Some patients with large or recurrent aneurysms may be at increased risk of recurrence postcoiling. The Patients Prone to Recurrence after Endovascular Treatment (PRET) trial was designed to assess whether hydrogel coils were superior to platinum coils in these high-risk patients. This article reports periprocedural safety and operator-assessed angiographic results from the PRET trial.

MATERIALS AND METHODS

PRET was a pragmatic, multicenter, randomized controlled trial. Patients had ≥10-mm aneurysms (PRET-1) or a major recurrence after coiling of an aneurysm of any size (PRET-2). Patients were randomly allocated to hydrogel or control arms (any platinum coil) by using concealed allocation with minimization. Assist devices could be used as clinically required. Aneurysms could be unruptured or recently ruptured. Analyses were on an intent-to-treat basis.

RESULTS

Four hundred forty-seven patients were recruited (250 PRET-1; 197 PRET-2). Aneurysms were recently ruptured in 29% of PRET-1 and 4% of PRET-2 patients. Aneurysms were ≥10 mm in all PRET-1 and in 50% of PRET-2 patients. They were wide-neck (≥4 mm) in 70% and in the posterior circulation in 24% of patients. Stents were used in 28% of patients (35% in PRET-2). Coiling was successful in 98%. Adverse events occurred in 28 patients with hydrogel and 23 with platinum coils. Mortality (n=2, unrelated to treatment) and morbidity (defined as mRS>2 at 1 month) occurred in 25 patients (5.6%; 12 hydrogel, 13 platinum), related to treatment in 10 (4 hydrogel; 6 platinum) (or 2.3% of 444 treated patients). No difference was seen between hydrogel and platinum for any of the indices used to assess safety up to at least 30 days after treatment. At 1 month, 95% of patients were home with a good outcome (mRS≤2 or unchanged). Operator-assessed angiographic outcomes were satisfactory (complete occlusion or residual neck) in 339 of 447 or 76.4% of patients, with no significant difference between groups.

CONCLUSIONS

Endovascular treatment of large and recurrent aneurysms can be performed safely with platinum or hydrogel coils.

Return of visual function after bilateral visual loss following flow diversion embolization of a giant ophthalmic aneurysm due to both reduction in mass effect and reduction in aneurysm pulsation

Large and giant paraclinoid aneurysms are challenging to treat by either surgical or endovascular means. Visual dysfunction secondary to optic nerve compression and its relationship with aneurysm size, pulsation and thrombosis is poorly understood. We present a patient with a giant paraclinoid aneurysm resulting in bilateral visual loss that worsened following placement of a Pipeline Embolization Device and adjunctive coiling. Visual worsening occurred in conjunction with aneurysm thrombosis, increase in maximal aneurysm diameter and new adjacent edema. Her visual function spontaneously improved in a delayed fashion to better than pre-procedure, in conjunction with reduced aneurysmal mass effect, size and pulsation artifact on MRI. This report documents detailed ophthalmologic and MRI evidence for the role of thrombosis, aneurysm mass effect and aneurysm pulsation as causative etiologies for both cranial nerve dysfunction and delayed resolution following flow diversion treatment of large cerebral aneurysms.

Incorporation of extruded coils into the third nerve in association with third nerve palsy

The extrusion of the coil complex outside of the aneurysmal dome is thought to be an important mechanism by which the aneurysm neck and fundus recanalize, but the migration of the coil loops and their incorporation inside vital nervous structures has not been clearly described. We reviewed the medical literature on coil extrusion and migration and report a rare case of third nerve palsy due to direct damage caused by coil loop migration that resolved after surgery. A 25-year-old woman presented with subarachnoid hemorrhage and painful left third nerve palsy. The angiogram revealed a supraclinoid internal carotid aneurysm incorporating the origin of the left posterior communicating artery. Her aneurysm was coiled. The 8 month follow-up angiogram revealed a major recurrence of her aneurysm. It was decided to surgically clip the aneurysm. At surgery, coil loops were found in the subarachnoid space and embedded into the third nerve. At 1 month follow-up she had recovered well, and only had very subtle diplopia upon fatigue. Coil extrusion is a fairly common phenomenon that should be suspected in instances of major aneurysmal recurrence. Surgical treatment is recommended, and special care should be taken when mobilizing the extruded coil mass.

Y-Stent Coiling of Basilar Bifurcation Aneurysms Induces a Dynamic Angular Vascular Remodeling With Alteration of the Apical Wall Shear Stress Pattern

BACKGROUND:

Although wide-necked basilar bifurcation aneurysms are treated with Y-stent coiling, the effect of this intervention on vessel configuration and hemodynamics is unknown.

OBJECTIVE:

To investigate the immediate and delayed effects of Y-stenting using self-expanding microstents on basilar bifurcation architecture and hemodynamics.

METHODS:

Fifteen patients underwent basilar Y-stent coiling and imaging with rotational angiography. Vascular angles were measured between proximal P1 segments of the posterior cerebral arteries (α) and between the basilar artery and each P1 segment (β1,2) in the anteroposterior and γ1,2 sagittal planes. Patient-specific computational fluid dynamic analysis was used to estimate wall shear stress (WSS) changes with treatment.

RESULTS:

In the anteroposterior plane, Y-stenting significantly decreased angle α and increased β angles immediately after stent coiling (P &lt; .05 and P &lt; .01, respectively) in a continued dynamic remodeling that progressed further in later months; sagittal γ angles also decreased (P &lt; .0001). This novel stent-induced geometric progressive remodeling resulted in effective straightening and narrowing of the basilar bifurcation angle α (150.0 degrees vs 113 degrees, P &lt; .0001) with significant correlation (r = 0.39, P &lt; .05) between pretreatment proximal P1 angles and maximal angular change. Computational fluid dynamic analysis showed the angular remodeling led to significant narrowing of the WSS interpeak at the apex, redirecting high WSS away from the neck transition zone with native vessel toward the inert coil mass.

CONCLUSION:

Y-configuration stent coiling induced immediate and, more significantly, a previously undefined delayed cerebrovascular remodeling. This progressive stent-induced angular remodeling alters perianeurysmal hemodynamics, independent of the flow-diverting properties of stent struts, thus shifting the balance of hemodynamic forces affecting aneurysm development and evolution.