Diffusion-weighted imaging lesions after intracranial aneurysm treatment with Pipeline Flex and Pipeline Flex with Shield technology: a retrospective cohort analysis

BACKGROUND

The Pipeline Flex embolization device with Shield technology (PED Shield) is the first flow diverter for brain aneurysm treatment approved in the United States using surface-modified technology. The effect of PED Shield on decreasing perioperative diffusion-weighted imaging positive (DWI+) hits, as a marker for in-human decrease thrombogenicity, is unclear.

OBJECTIVE

To determine if the number of periprocedural DWI+ lesions differs between patients with an aneurysm treated with PED Flex and PED Shield.

METHODS

This retrospective study compares the outcomes of consecutive patients with an aneurysm treated with PED Flex and PED Shield. The primary outcome of interest was the occurrence of DWI+ lesions. We also assessed potential predictors of DWI+ lesions and compared the outcomes between on-label and off-label treatment indications.

RESULTS

89 patients were included, 48 (54%) treated with PED Flex and 41 (46%) with PED Shield. After matching, the incidence of DWI+ lesions was 61% and 62% for the PED Flex and PED Shield groups, respectively. Results were consistent across each model with no significant differences in DWI+ lesions between treatment groups, and effect sizes ranging from OR=1.08 (95% CI 0.41 to 2.89) after propensity score matching to OR=1.84 (95% CI 0.65 to 5.47) after multivariable regression. Multivariable models demonstrated reduced DWI+ lesions with balloon-assisted therapies and posterior circulation treatment, while a significant linear relationship was encountered with fluoroscopy time.

CONCLUSION

There was no significant difference in the incidence of perioperative DWI+ lesions between patients with an aneurysm treated with PED Flex and PED Shield. Larger cohorts are likely needed to demonstrate differences between the devices.

Considering Psychological and Cognitive Factors in Interventional Neuroradiology: A Systematic Literature Review

BACKGROUND

Interventional neuroradiology is a relatively recent discipline that diagnoses and treats cerebral vascular diseases. However, specific literature on cognitive and psychological domains of patients undergoing interventional neuroradiology procedures is limited.

PURPOSE

Our aim was to review the existent literature on cognitive and psychological domains in patients undergoing interventional neuroradiology procedures to raise clinicians' awareness of their mental status.

DATA SOURCES

Articles were searched in PubMed, EMBASE, and Scopus from 2000 to 2022 using terms such as "interventional neuroradiology," "psychology," and "cognition" according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

STUDY SELECTION

Of 1483 articles in English, 64 were included and analyzed. Twelve focused on psychological aspects; 52, on cognitive ones.

DATA ANALYSIS

Regarding psychological aspects, it appears that early psychological consultations and "nonpharmacologic" strategies can impact the anxiety and depression of patients undergoing endovascular procedures. Regarding cognitive aspects, it appears that endovascular treatment is safe and generates similar or even fewer cognitive deficits compared with analogous surgical procedures.

DATA SYNTHESIS

Among the 12 articles on psychological aspects, 6/12 were retrospective with one, while 6/12 were prospective. Among the 52 articles on cognitive aspects, 7/54 were retrospective, while 45/52 were prospective.

LIMITATIONS

The main limitation derives from the inhomogeneity of the cognitive and psychological assessment tools used in the articles included in our analysis.

CONCLUSIONS

Our review highlights the need to include cognitive and psychological assessments in clinical practice in case patients eligible for interventional neuroradiology procedures. In the future, much more research of and attention to cognitive and psychologic aspects of neurovascular disease is needed. Systematic incorporation of strategies and tools to access and address pre, peri-, and postprocedural psychological and cognitive components could have major benefits in patient satisfaction, recovery, and the success of endovascular practice.

Trends in the Age of Patients Treated for Unruptured Intracranial Aneurysms from 1990 to 2020

BACKGROUND

The decision for treatment for unruptured intracranial aneurysms (UIAs) is often difficult. Innovation in endovascular devices have improved the benefit-to-risk profile especially for elderly patients; however, the treatment guidelines from the past decade often recommend conservative management. It is unknown how these changes have affected the overall age of the patients selected for treatment. Herein, we aimed to study potential changes in the average age of the patients that are being treated over time.

METHODS

A systematic search of the literature was performed to identify all studies describing the age of the UIAs that were treated by any modality. Scatter diagrams with trend lines were used to plot the age of the patients treated over time and assess the presence of a potential significant trend via statistical correlation tests.

RESULTS

A total of 280 studies including 83,437 UIAs treated between 1987 and 2021 met all eligibility criteria and were entered in the analysis. Mean age of the patients was 55.5 years, and 70.7% were female. There was a significant increasing trend in the age of the treated patients over time (Spearman r: 0.250; P < 0.001), with a 1-year increase in the average age of the treated patients every 5 years since 1987.

CONCLUSIONS

The present study indicates that based on the treated UIA patient data published in the literature, older UIAs are being treated over time. This trend is likely driven by safer treatments while suggesting that re-evaluation of certain UIA treatment decision scores may be of great interest.

Antiplatelet therapy adjustment improved the radiomic characteristics of acute silent cerebral infarction after stent-assisted coiling in patients with high on-treatment platelet reactivity: A prospective study

Background

We aimed to investigate the effects of high on-treatment platelet reactivity (HPR) and antiplatelet therapy adjustment on high-risk radiomic features in patients with antiplatelet therapy adjustment on acute silent cerebral infarction (ASCI) who had unruptured intracranial aneurysms (UIA) after stent placement.

Methods

This single-institution study prospectively included 230 UIA patients who had ACSI after stent placement in our hospital between January 2015 and July 2020. All patients underwent magnetic resonance imaging with diffusion-weighted imaging (MRI-DWI) after stent placement and 1,485 radiomic features were extracted from each patient. The least absolute shrinkage and selection operator regression methods were used for selection of high-risk radiomic features associated with clinical symptoms. In addition, 199 patients with ASCI were classified into three groups: controls without HPR (n = 113), HPR patients with standard antiplatelet therapy (n = 63) and HPR patients with antiplatelet therapy adjustment (n = 23). We compared high-risk radiomic features between three groups.

Results

Of the patients who had acute infarction after MRI-DWI, 31 (13.5%) exhibited clinical symptoms. Eight risk radiomic features associated with clinical symptoms were selected, and the radiomics signature exhibited good performance. In ASCI patients, compared with controls, the radiomic characteristics of ischemic lesion in HPR patients were consistent with the following high-risk radiomic features associated with clinical symptoms: higher gray-level values, greater variance in intensity values, and greater homogeneity. However, the adjustment of antiplatelet therapy in HPR patients modified the high-risk radiomic features, which showed lower gray-level values, less variance in intensity values, and more heterogeneous texture. The radiomic shape feature of elongation showed no notable difference between three groups.

Conclusion

Adjustment of antiplatelet therapy might reduce the high-risk radiomic features of UIA patients with HPR after stent placement.

Diffusion-weighted imaging lesions after endovascular treatment of cerebral aneurysms: A network meta-analysis

Background

Thromboembolism is one of the common complications in endovascular treatments including coiling alone, stent-assisted coiling (SAC), balloon-assisted coiling (BAC), and flow-diverting (FD) stents. Such treatments are widely used in intracranial aneurysms (IAs), which usually present as positive lesions in diffusion-weighted imaging (DWI). Whether these adjunctive techniques increase postprocedural DWI-positive lesions after endovascular treatment remains unclear.

Methods

A thorough electronic search for the literature published in English between January 2000 and October 2022 was conducted on PubMed, Medline, and EMBASE. Eighteen studies (3 cohort studies and 15 case-control studies) involving 1,843 patients with unruptured IAs (UIAs) were included. We performed a frequentist framework network meta-analysis (NMA) to compare the rank risks of cerebral thromboembolism of the above four endovascular treatments. The incoherence test was used to analyze the statistical disagreement between direct and indirect evidence. Funnel plots were used to analyze publication bias.

Results

The incidences of DWI lesions in patients who received FD stents, SAC, BAC, and coiling alone were 66.1% (109/165), 37.6% (299/795), 31.1% (236/759), and 25.6% (236/921). The incidence of DWI lesions in patients who received FD stents was higher than that in patients who received SAC [OR: 2.40; 95% CI (1.15, 5.00), P < 0.05], BAC [OR: 2.62; 95% CI (1.19, 5.77), P < 0.05], or coiling alone [OR: 2.77; 95% CI (1.26, 6.07), P < 0.05]. The incoherence test showed preferable consistency in this NMA. No obvious publication bias was found in the funnel plot.

Conclusion

FD stent placement brings more ischemic lesions identified by DWI than any other procedures for patients with UIA. The characteristics of FD stents may result in a high incidence of DWI lesions.

Reduction of thromboembolic complications during the endovascular treatment of unruptured aneurysms by employing a tailored dual antiplatelet regimen using aspirin and prasugrel

Background

Thromboembolic complications (TECs) are frequent during the endovascular treatment of unruptured aneurysms. To prevent TECs, dual antiplatelet therapy using aspirin and clopidogrel is recommended for the perioperative period. In patients with a poor response, clopidogrel is a risk factor for TECs. To prevent TECs, our study assessed the stratified use of prasugrel.

Methods

Patients who underwent endovascular therapy for unruptured cerebral aneurysms from April 2017 to August 2019 were enrolled in this clinical study and given premedication with aspirin and clopidogrel for 2 weeks prior to the procedure. P2Y12 reaction units (PRU) were measured using the VerifyNow assay on the day before the procedure (tailored group). In subgroups with PRU <240, the clopidogrel dose was maintained (CPG subgroup). In subgroups with PRU ≥240, clopidogrel was changed to prasugrel (PSG subgroup). We compared the occurrence of TECs with retrospective consecutive cases from January 2015 to March 2017 without PRU assessments (non-tailored group). The frequency of TECs within 30 days was assessed as the primary endpoint.

Results

The tailored and non-tailored groups comprised 167 and 50 patients, respectively. TECs occurred in 11 (6.6%) and 8 (16%) patients in the tailored and non-tailored groups (P=0.048), respectively. The HR for TECs was significantly reduced in the tailored group (HR 0.3, 95% CI 0.11 to 0.81); P=0.017) compared with the non-tailored group.

Conclusion

The results suggest that tailored dual antiplatelet therapy medication with PRU significantly reduces the frequency of TECs without increasing hemorrhagic complications.

The Utility of Diffusion-Weighted MRI Lesions to Compare the Effects of Different Heparinization Schemes in Intracranial Aneurysms Treated by Endovascular Intervention

Objective: Heparinization is applied to prevent ischemic complications in the endovascular treatment of intracranial aneurysms, but there is no unified heparinization scheme. Diffusion-weighted imaging (DWI) can be used to evaluate ischemia after endovascular therapy for intracranial aneurysms. The goal of this study is to apply DWI to evaluate the effects of different heparinization schemes on intracranial aneurysms treated with endovascular therapy.

Methods: We retrospectively reviewed 141 patients with 149 aneurysms treated with endovascular interventions from July 2019 to April 2020 at our center, including 96 aneurysms treated with local heparinization and 53 aneurysms treated with systemic heparinization. We collected the basic information of the patients, including age, sex, comorbidities, and aneurysm characteristics, and associated treatment data. New ischemic lesions detected by DWI were categorized belonging to four types. Multivariate logistic regression was used to compare the effects of different heparinization schemes on intracranial aneurysms treated with endovascular therapy.

Results: There were no significant differences in age, sex, hypertension, diabetes, and aneurysm size or location between the two groups. The incidence and distribution types of DWI abnormalities in the local heparinization groups and systemic heparinization groups were not significantly different (P > 0.05). There was a correlation between the laser engraving stent and postoperative DWI abnormalities (P < 0.003). Multivariate logistic regression analysis showed that the laser engraving stent was significantly correlated with postoperative DWI abnormalities (odds ratio, 4.71; 95% CI: 1.51–14.58; P = 0.007).

Conclusion: Compared with systemic heparinization, local heparinization does not increase the incidence of DWI abnormalities after endovascular treatment, and its application in this group of patients is safe and effective.

Cognitive outcomes after unruptured intracranial aneurysm treatment with flow diversion

OBJECTIVE

Flow diversion is increasingly used to treat a variety of intracranial aneurysms with good safety and efficacy; however, there is some evidence that this treatment is associated with a larger postoperative ischemic burden on imaging than that with other traditional endovascular modalities. These findings typically do not manifest as neurological deficits, but any subtle effects on cognition remain unknown. In this study, the authors describe the neurocognitive performance of a cohort of patients with unruptured intracranial aneurysms (UIAs) before and after treatment with flow diversion. This is the first report of cognitive outcomes following aneurysm treatment with flow diversion.

METHODS

The authors prospectively collected data on cognitive function using the Montreal Cognitive Assessment (MoCA) tool in patients with UIAs who were undergoing endovascular aneurysm treatment with flow diversion between June 2017 and July 2019. Patients completed the MoCA prior to intervention, at the 1-month follow-up after treatment, and again at 6 months after the procedure. All patients with UIAs treated with flow diversion were included regardless of age, aneurysm location, or morphology, unless their functional status precluded completion of the MoCA instrument. A repeated-measures linear mixed-effects model was used to compare preintervention and postintervention cognitive status at the time intervals outlined.

RESULTS

Fifty-one patients with 61 aneurysms underwent endovascular aneurysm treatment with flow diversion (mean age 52.5 years, 90.2% females). There was no difference between baseline and postprocedure MoCA scores at any time interval (p > 0.05). The MoCA scores at baseline, 1 month postprocedure, and 6 months postprocedure were 26.1, 26.2, and 26.6, respectively. There was also no difference between pre- and postprocedure scores on any individual domain of the instrument (visuospatial, naming, attention, language, abstraction, delayed recall, and orientation) at any time interval (p > 0.05). Thirty-four patients had follow-up MRI or CT imaging, 5 of whom showed radiographic changes or ischemia. All patients with follow-up clinical evaluation had a 6-month modified Rankin Scale score ≤ 2.

CONCLUSIONS

Flow diversion is increasingly used in the treatment of intracranial aneurysms. This study suggests that this treatment may not alter neurocognitive function. Larger patient samples and longer follow-ups with other tests of cognitive functions are needed to confirm these findings.

Mechanically Induced Vasospasm and Postoperative Cerebral Infarction after Coil Embolization of Unruptured Cerebral Aneurysms in Anterior Circulation

We occasionally encounter situations which requires retraction of the guiding system or administration of vasodilatory agents for mechanically induced vasospasm (MVS). However, whether MVS is associated with postoperative cerebral infarction has not been reported.To explore factors associated with MVS and to verify how MVS influences procedure outcomes,we reviewed consecutive cases of unruptured aneurysms in the anterior circulation treated with coil embolization between January 2017 and February 2020. Collected data included patients' clinical characteristics, devices, vessel tortuosity, severity of MVS, diameter of the parent vessel, and procedure duration. Significant MVS was defined as a condition necessitating a pause in the procedure. We also counted postoperative diffusion-weighted imaging (DWI) hyperintense spots (DHS). Parameters associated with MVS and postoperative DHS were investigated by multivariate logistic regression.A total of 103 cases met the eligibility criteria, with significant MVS occurring in 21 cases (20.3%), and postoperative DHS (≥3) confirmed in 30 cases (29.1%). Significant MVS was associated only with larger caliber at the tip of the guiding system compared with the parent vessel (p = 0.001). Postoperative DHS was associated with significant MVS (p = 0.002, OR: 5.313; 95% CI: 1.851-15.254).Significant MVS is a predictor of postoperative cerebral ischemia and occurs in patients with smaller caliber of the parent vessel. In patients with high-risk features for MVS, we should avoid navigating the guiding system forcibly through the narrow parent vessel. In other words, it is crucial to place the large-caliber guiding sheath/catheter proximally and only guide distally the intermediate catheter with better trackability.

Outcome Study of the Pipeline Embolization Device with Shield Technology in Unruptured Aneurysms (PEDSU)

BACKGROUND AND PURPOSE

The recently introduced Pipeline Flex Embolization Device with Shield Technology (Pipeline Shield) is the third generation of Pipeline flow-diverter devices. It has a new stent-surface modification, which reduces thrombogenicity. We aimed to evaluate clinical and radiographic (safety and efficacy) outcomes of the Pipeline Shield.

MATERIALS AND METHODS

The 30-day and 1-year mortality and morbidity rates and the 6- and 18-month radiographic aneurysm occlusion outcomes for procedures performed between March 2016 and January 2018 were analyzed. 3D-TOF-MRA was used for follow-up.

RESULTS

Forty-four attempted Pipeline Shield procedures were performed for 41 patients with 44 target aneurysms (total of 52 aneurysms treated). A total of 88.5% of devices were inserted in the anterior circulation, and 11.5%, in the posterior circulation; 49/52 (94.2%) aneurysms were saccular; and 1/52 (1.9%) was fusiform. One (1.9%) aneurysm was an iatrogenic pseudoaneurysm, and 1 (1.9%) was a dissecting aneurysm. Seventy-one percent (35/49) of the saccular aneurysms were wide-neck (neck, >4 mm), 34.6% (18/52) were large (≥10 mm), and 3.8% (2/52) were giant (≥25 mm). The mean aneurysm sac maximal diameter was 9.0 mm, and the mean neck width was 5.0 mm. The cumulative mortality and morbidity rates were 2.3% and 6.8% at 1 year, respectively. The adequate occlusion rate was 78.8% at 6 months and 90.3% at 18 months.

CONCLUSIONS

In this pragmatic and non-industry-sponsored study, the occlusion rates and safety outcomes were similar to those seen in previously published studies with flow-diverter devices and earlier generation Pipeline Embolization Devices.

Effect of remote ischemic preconditioning on cerebral vasospasm and biomarkers of cerebral ischemia in aneurysmal subarachnoid hemorrhage (ERVAS): A protocol for a randomized, controlled pilot trial

INTRODUCTION:

Cerebral vasospasm is a dreaded complication of aneurysmal subarachnoid hemorrhage (aSAH) predisposing to delayed cerebral ischemia. We intend to study the cerebroprotective effects of remote ischemic preconditioning (RIPC) in patients with aSAH.

MATERIALS AND METHODS:

This is a single-center, prospective, parallel group, randomized, pilot trial, approved by the Institutional Ethics Committee. Patients with aSAH admitted to our hospital for surgical clipping; fulfilling the trial inclusion criteria will be randomized to true RIPC (n = 12) (inflating upper extremity blood pressure cuff thrice for 5 min to 30 mmHg above systolic blood pressure) or sham RIPC (n = 12) (inflating blood pressure cuff thrice for 5 min to 30 mmHg) in 1:1 allocation ratio using a computerized random allocation sequence and block randomization.

RESULTS:

Our primary outcome measure is vasospasm on cerebral angiography and transcranial Doppler study, and concentration of serum S100B and neuron-specific enolase at 24 h after RIPC and on day 7 of ictus. Our secondary outcomes are safety of RIPC, cerebral oxygen saturation, and Glasgow coma score, and extended Glasgow outcome scale scores at discharge and at 1, 3, and 6 months following discharge. Outcome measures will be assessed by an observer blinded to the study intervention.

CONCLUSION:

If our preliminary results demonstrate a beneficial effect of RIPC, this would serve as a clinically applicable and safe preemptive method of protection against cerebral ischemia.

Early diffusion-weighted MRI lesions after treatment of unruptured intracranial aneurysms: a prospective study

OBJECTIVE

Diffusion-weighted MRI was used to assess periprocedural lesion load after repair of unruptured intracranial aneurysms (UIA) by microsurgical clipping (MC) and endovascular coiling (EC).

METHODS

Patients with UIA were assigned to undergo MC or EC according to interdisciplinary consensus and underwent diffusion-weighted imaging (DWI) 1 day before and 1 day after aneurysm treatment. Newly detected lesions by DWI after treatment were the primary end point of this prospective study. Lesions detected by DWI were categorized as follows: A) 1–3 DWI spots < 10 mm, B) > 3 DWI spots < 10 mm, C) single DWI lesion > 10 mm, or D) DWI lesion related to surgical access.

RESULTS

Between 2010 and 2014, 99 cases were included. Sixty-two UIA were treated by MC and 37 by EC. There were no significant differences between groups in age, sex, aneurysm size, occurrence of multiple aneurysms in 1 patient, or presence of lesions detected by DWI before treatment. Aneurysms treated by EC were significantly more often located in the posterior circulation (p < 0.001). Diffusion-weighted MRI detected new lesions in 27 (43.5%) and 20 (54.1%) patients after MC and EC, respectively (not significant). The pattern of lesions detected by DWI varied significantly between groups (p < 0.001). Microembolic lesions (A and B) found on DWI were detected more frequently after EC (A, 14 cases; B, 5 cases) than after MC (A, 5 cases), whereas C and D were rare after EC (C, 1 case) and occurred more often after MC (C, 12 cases and D, 10 cases). No procedure-related unfavorable outcomes were detected.

CONCLUSIONS

According to the specific techniques, lesion patterns differ between MC and EC, whereas the frequency of new lesions found on DWI is similar after occlusion of UIA. In general, the lesion load was low in both groups, and lesions were clinically silent.

Clinical trial registration no.: NCT01490463 (clinicaltrials.gov)

Diffusion-Weighted Imaging-Detected Ischemic Lesions following Endovascular Treatment of Cerebral Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Endovascular treatment of intracranial aneurysms is associated with the risk of thromboembolic ischemic complications. Many of these events are asymptomatic and identified only on diffusion-weighted imaging. We performed a systematic review and meta-analysis to study the incidence of DWI positive for thromboembolic events following endovascular treatment of intracranial aneurysms.

MATERIALS AND METHODS

A comprehensive literature search identified studies published between 2000 and April 2016 that reported postprocedural DWI findings in patients undergoing endovascular treatment of intracranial aneurysms. The primary outcome was the incidence of DWI positive for thromboembolic events. We examined outcomes by treatment type, sex, and aneurysm characteristics. Meta-analyses were performed by using a random-effects model.

RESULTS

Twenty-two studies with 2148 patients and 2268 aneurysms were included. The overall incidence of DWI positive for thromboembolic events following endovascular treatment was 49% (95% CI, 42%-56%). Treatment with flow diversion trended toward a higher rate of DWI positive for lesions than coiling alone (67%; 95% CI, 46%-85%; versus 45%; 95% CI, 33%-56%; P = .07). There was no difference between patients treated with coiling alone and those treated with balloon-assisted (44%; 95% CI, 29%-60%; P = .99) or stent-assisted (43%; 95% CI, 24%-63%; P = .89) coiling. Sex, aneurysm rupture status, location, and size were not associated with the rate of DWI positive for lesions.

CONCLUSIONS

One in 2 patients may have infarcts on DWI following endovascular treatment of intracranial aneurysms. There is a trend toward a higher incidence of DWI-positive lesions following treatment with flow diversion compared with coiling. Patient demographics and aneurysm characteristics were not associated with DWI-positive thromboembolic events.

Predictor and Prognosis of Procedural Rupture during Coil Embolization for Unruptured Intracranial Aneurysm

Objective

The objectives of this study was to determine the incidence and outcomes of procedural rupture (PR) during coil embolization of unruptured intracranial aneurysm (UIA) and to explore potential risk factors.

Methods

This retrospective study evaluated 1038 patients treated with coil embolization between January 2001 and May 2013 in a single tertiary medical institute. PR was defined as evidence of rupture during coil embolization or post procedural imaging. The patient's medical records were reviewed including procedure description, image findings and clinical outcomes.

Results

Twelve of 1038 (1.1%) patients showed PR. Points and time of rupture were parent artery rupture during stent delivery (n=2), aneurysm rupture during filling stage (n=9) and unknown (n=1). Two parent artery rupture and one aneurysm neck rupture showed poor clinical outcomes [modified Rankin Scale (mRs) >2] Nine aneurysm dome rupture cases showed favorable outcomes (mRS ≤2). Location (anterior cerebral artery) of aneurysm was associated with high procedural rupture rate (p<0.05).

Conclusion

The clinical course of a patientwith procedural aneurysm rupture during filling stage seemed benign. Parent artery and aneurysm neck rupture seemed relatively urgent, serious and life threatening. Although the permanent morbidity rate was low, clinicians should pay attention to prevent PR, especially when confronting the anterior cerebral artery aneurysm.

Effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory: a prospective cohort study

BACKGROUND

We prospectively evaluated the effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory.

METHODS

Between March 2012 and June 2013, 56 patients were recruited for this study. Fifty-one patients met the inclusion criteria and were enrolled. Inclusion criteria were as follows: (1) age ≤65 years and (2) planned microsurgery or endovascular surgery for unruptured intracranial aneurysm. Exclusion criteria were as follows: (1) preoperative intelligence quotient <80 (n = 3); (2) initial modified Rankin scale ≥1 (n = 1); (3) loss to follow-up (n = 1). An auditory controlled continuous performance test (ACCPT), word-color test (WCT) and verbal learning test (VLT) were performed before and after (6 months) preventive surgery.

RESULTS

ACCPT (attention), WCT (executive function) and VLT (learning and memory) scores did not change significantly between the pre- and postoperative evaluations. The ACCPT, WCT, total VLT scores (verbal learning) and delayed VLT scores (memory) did not differ significantly between patients undergoing microsurgery and those undergoing endovascular surgery. However, ACCPT, WCT and delayed VLT scores decreased postoperatively in patients with leukoaraiosis on preoperative FLAIR images (OR 9.899, p = 0.041; OR 11.421, p = 0.006; OR 2.952, p = 0.024, respectively).

CONCLUSIONS

Preventive surgery for unruptured intracranial aneurysms did not affect attention, executive function, learning or memory. However, patients with leukoaraiosis on FLAIR images might be prone to deficits in attention, executive function and memory postoperatively, whereas learning might not be affected.

Remote ischemic preconditioning in the prevention of ischemic brain damage during intracranial aneurysm treatment (RIPAT): study protocol for a randomized controlled trial

BACKGROUND

The treatment of intracranial aneurysms may be associated with cerebral ischemia. We hypothesize that pre-interventional remote ischemic preconditioning (RIPC) reduces ischemic cerebral tissue damage in patients undergoing elective intracranial aneurysm treatment.

METHODS/DESIGN

This study is a single-center, prospective, randomized, double-blind explorative trial. Patients with an unruptured intracranial aneurysm admitted to Innsbruck Medical University Hospital for coiling or clipping will be consecutively randomized to either the intervention group (= RIPC by inflating an upper extremity blood-pressure cuff for 3 x 5 min to 200 mmHg) or the control group after induction of anesthesia. Participants will be randomized 1:1 to either the preconditioning group or the sham group using a random allocation sequence and block randomization. The precalculated sample size is n = 24 per group. The primary endpoint is the area-under-the-curve concentration of serum biomarkers (S100B, NSE, GFAP, MMP9, MBP, and cellular microparticles) in the first five days after treatment. Secondary endpoints are the number and volume of new ischemic lesions in magnetic resonance imaging and clinical outcome evaluated with the National Institutes of Health Stroke Scale, the modified Rankin Scale, and neuropsychological tests at six and twelve months. All outcome variables will be determined by observers blinded to group allocation. This study was approved by the local institutional Ethics Committee (UN5164), version 3.0 of the study protocol, dated 20 October 2013.

DISCUSSION

This study uses the elective treatment of intracranial aneurysms as a paradigmatic situation to explore the neuroprotective effects of RIPC. If effects are demonstrable in this pilot trial, a larger, prospective phase III trial will be considered.

Microembolism after endovascular coiling of unruptured cerebral aneurysms: incidence and risk factors

OBJECTIVE

The incidence and risk factors of microembolic lesions on MR diffusion-weighted imaging (DWI) were analyzed after the endovascular coiling of unruptured intracranial aneurysms (UIAs).

METHODS

Data obtained from 271 consecutive patients (70 men and 201 women; median age 57 years; range 23-79 years) who presented with UIA for coil embolization between July 2011 and June 2013 were analyzed. Two independent reviewers examined the DWI and apparent diffusion coefficient maps obtained the following day for the presence of restrictive diffusion spots and counted the number of spots. Multivariate analysis was then performed to identify independent risk factors for developing microembolism following the coiling of an aneurysm.

RESULTS

Microembolic lesions were noted in 101 of 271 patients (37.3%). The results of the multivariate analysis showed that the following factors significantly influenced the risk for microembolism: age, diabetes, previous history of ischemic stroke, high-signal FLAIR lesions in the white matter, multiple aneurysms, and the insertion of an Enterprise stent (all ORs > 1.0 and all p values < 0.05). Previously known risk factors such as prolonged procedure duration, aneurysm size, and decreased antiplatelet function did not show any significant influence.

CONCLUSIONS

The incidence of microembolism after endovascular coiling of UIA was not low. Lesions occurred more frequently in patients with vascular status associated with old age, diabetes, and previous stroke. Aneurysm multiplicity and the type of stent used for treatment also influenced lesion occurrence.

Next day discharge after elective intracranial aneurysm coiling: is it safe?

Background

There is a paucity of literature on early discharge after elective aneurysm treatment. We hypothesize that patient discharge on the next day is not associated with an increase in post-discharge adverse events.

Methods

We retrospectively reviewed elective coiling procedures between 2009 and 2013. The primary outcome measure was 30-day adverse events (emergency department visits, readmission or prolonged admission >30 days, and death). We evaluated the association between early and standard discharge for the primary outcome using the Fisher exact test. We also assessed the association of the primary outcome with other patient and technical variables as well as findings on pre-discharge diffusion weighted imaging.

Results

We included 97 patients. Median length of hospital stay (LOS) was 2.52 days, and in 26 patients (26.8%) LOS was <2 days. There was no significant difference in post-discharge adverse outcome rates between early and standard discharge groups (19.2% vs 18.3%; p=1.000). The primary outcome was significantly associated with the use of flow diverters (p=0.0287) and change in modified Rankin Scale category at discharge (p=0.0329). No significant association was noted between the outcome and the other variables including the presence of diffusion restriction pre-discharge (p>0.05).

Conclusions

Patient discharge the next day after elective intracranial aneurysm coiling is not associated with an increase in 30-day adverse outcomes. A prospective study investigating early discharge in elective treatment is warranted.

Trial number

OHSN-REB #20130786-01H.

Incidence and risk factors for diffusion-weighted imaging (+) lesions after intracranial stenting and its relationship with symptomatic ischemic complications

BACKGROUND AND PURPOSE

Little is known about high-signal lesions in magnetic resonance diffusion-weighted imaging (DWI [+]) after stenting for intracranial atherosclerotic stenosis. This study aimed to evaluate the incidence, distribution, risk factors, and clinical implications of DWI (+) after intracranial stenting.

METHODS

A total of 123 patients (male:female=88:35, mean age, 64.1 years) with symptomatic intracranial atherosclerotic stenosis (mean stenosis, 76.1±7.7%) underwent both stenting and poststenting DWI. The incidence, distribution (embolic-alone versus stenosis-associated perforator/mixed), and risk factors of DWI (+) and its relationship with symptomatic ischemic complications (SIC, including stroke or transient ischemic attack) were retrospectively evaluated.

RESULTS

Forty-three patients (35.0%) had DWI (+). Middle cerebral artery, smaller distal parent artery, and treatment-related dissection were independent risk factors for DWI (+) (P<0.05). SIC occurred in 4 patients (3.3%), all of whom had DWI (+). Of the patients with DWI (+), neither the number nor the volume of DWI (+) differed significantly between SIC and asymptomatic patients: median number/patient, 3.5 (range, 2-11) versus 2.0 (range, 1-11) and median volume/patient, 329.8 mm(3) (range, 76-883.5 mm(3)) versus 119.5 mm(3) (range, 32.5-873.0 mm(3)). However, SIC occurred more frequently in the stenosis-associated perforator/mixed type (3/11, 27.3%) than in the embolic-alone type (1/32, 3.1%; P<0.05).

CONCLUSIONS

The incidence of DWI (+) after intracranial stenting for intracranial atherosclerotic stenosis was 35.0%. Middle cerebral artery, smaller distal parent artery, and treatment-related dissection were independent risk factors for DWI (+). SIC occurred more frequently in the stenosis-associated perforator/mixed type than in the embolic-alone type.

Triple antiplatelet therapy with addition of cilostazol to aspirin and clopidogrel for Y-stent-assisted coil embolization of cerebral aneurysms

BACKGROUND

Dual antiplatelet therapy for stent-assisted coiling of cerebral aneurysms is essential to prevent thromboembolic complications. There is concern that Y-stent-assisted coiling may increase thromboembolic complications compared with coiling with a single stent. Several reports have demonstrated that cilostazol may improve clopidogrel responsiveness. We investigated whether triple antiplatelet therapy with addition of cilostazol to aspirin plus clopidogrel for Y-stents can prevent thromboembolic events.

METHODS

Between July 2010 and October 2012, we treated 40 consecutive aneurysms with coil embolization using Enterprise stents. At the peri-procedural period, dual antiplatelet agents (100 mg aspirin and 75 mg clopidogrel) were used for the single stent group (n = 36), and triple antiplatelet agents (addition of 200 mg cilostazol) were used for the Y-stent group (n = 4). We evaluated post-operative diffusion-weighted imaging (DWI) and any complications. We assessed the following for statistical analysis: age, sex, aneurysm location, shape, and size, neck size, size of parent vessels, and stent length.

RESULTS

We found two neurological peri-procedural complications: one transient ischemic attack and one infarction. Both complications belonged to the Y-stent group, which was a significant factor of thromboembolic events (P = 0.008). There were no other significant factors related to neurological complications or positive DWI. For subgroup analysis of the single stent group, stent length was significantly longer in positive DWI than negative DWI (P = 0.04). In the follow-up period of 20 ± 8.6 months, there were no symptomatic late complications in any patients.

CONCLUSIONS

Although the number of patients in the Y-stent group is small, this group had a significantly higher risk of thromboembolic complications. While our protocol of a routine dose of dual antiplatelet therapy may be sufficient for single stent therapy, our protocol of a routine dose of triple antiplatelet therapy for Y-stents may not prevent thromboembolic events. This suggests that evaluation of platelet function may be essential, especially for Y-stents.

Endovascular treatment of unruptured A1 segment aneurysms

Aneurysms of the A1 segment of the anterior cerebral artery (A1A) are rare and challenging to treat. Less information is available regarding their management by endovascular approach. We evaluated our experience of endovascular treatment in 15 patients with unruptured A1As. We retrospectively reviewed unruptured A1As treated by embolization at our hospital. The clinical data and angiographic results were reviewed. A special technique involving shaping microcatheter tips was used for catheterization. From September 2009 to December 2012, 15 patients presenting with unruptured A1As were identified. All the patients were treated by selective embolization including five patients with balloon-assisted coiling (BAC) or stent-assisted coiling (SAC). These adjunctive techniques were used to catheterize the sac safely or to protect a branch at the neck. According to the location and direction of the aneurysm, "Z-shaped", "S-Shaped" or "U-Shaped" microcatheter tip shaping was used for microcatheter positioning and stabilization. All patients showed an excellent clinical outcome. A complete aneurysm occlusion was obtained in all the patients. Endovascular treatment of A1As is feasible and associated with good results. Because of their location and close relationship with perforators, endovascular treatment of A1As sometimes requires the use of BAC or SAC. The microcatheter tip shaping technique is very important for coiling. Our results suggest that endovascular treatment is a suitable therapeutic option for unruptured A1As when the aneurysm size is optimal for embolization.