Sole stenting with large cell stents for very small ruptured intracranial aneurysms

Spontaneous subarachnoid hemorrhage caused by ruptured aneurysm of basilar trunk perforator: a case report and literature review

Background

Aneurysm of basilar perforator was rarely reported in the literature. It is difficult to treat due to its small size and deep-seated location. Excessive treatment may cause complications that resulted from ischemic events of parent perforators. Therefore, it is important to make clinical strategy for such patients to improve the prognosis.

Case presentation

One case, who presented as spontaneous subarachnoid hemorrhage, despite the negative result in computed tomography angiography firstly, was diagnosed angiographically as a ruptured aneurysm of the basilar perforator. A good clinical outcome of the case was achieved during the follow-up after conservative observation for 2 months, as well as the disappearance of previous lesion from angiography.

Conclusions

Aneurysm located at perforator of basilar trunk was rare and difficult to treat. Conservative observation for certain cases with periodic angiography follow-up was considered in order to prevent the patients from potential iatrogenic effects.

Stent-Assisted Coil Embolization of Ruptured Blood Blister-Like Aneurysm of the Basilar Artery: A Case Report and Literature Review

Objective

Blood blister-like aneurysms (BBA) often develop on the anterior wall of the internal carotid artery, and few cases have been reported at other sites. We report a case of stent-assisted coil embolization in the acute phase for a ruptured BBA of the basilar artery.

Case Presentation

A 53-year-old woman underwent emergency stent-assisted coil embolization for subarachnoid hemorrhage due to a ruptured BBA in the main trunk of the basilar artery. Seven months after the operation, cerebral angiography confirmed no recurrence and a good clinical course.

Conclusion

Stent-assisted coil embolization for BBA may be one treatment option.

Intra-aneurysmal pressure changes during stent-assisted coiling

We aimed to examine aneurysm hemodynamics with intra-saccular pressure measurement, and compare the effects of coiling, stenting and stent-assisted coiling in proximal segments of intracranial circulation. A cohort of 45 patients underwent elective endovascular coil embolization (with or without stent) for intracranial aneurysm at our department. Arterial pressure transducer was used for all measurements. It was attached to proximal end of the microcatheter. Measurements were taken in the parent artery before and after embolization, at the aneurysm dome before embolization, after stent implantation, and after embolization. Stent-assisted coiling was performed with 4 different stents: LVIS and LVIS Jr (Microvention, Tustin, CA, USA), Leo (Balt, Montmorency, France), Barrel VRD (Medtronic/ Covidien, Irvine, CA, USA). Presence of the stent showed significant reverse correlation with intra-aneurysmal pressure–both systolic and diastolic—after its implantation (r = -0.70 and r = -0.75, respectively), which was further supported by correlations with stent cell size–r = 0.72 and r = 0.71, respectively (P<0.05). Stent implantation resulted in significant decrease in diastolic intra-aneurysmal pressure (p = 0.046). Systolic or mean intra-aneurysmal pressure did not differ significantly. Embolization did not significantly change the intra-aneurysmal pressure in matched pairs, regardless of the use of stent (p>0.05). In conclusion, low-profile braided stents show a potential to divert blood flow, there was significant decrease in diastolic pressure after stent placement. Flow-diverting properties were related to stent porosity. Coiling does not significantly change the intra-aneurysmal pressure, regardless of packing density.

Safety and efficacy of endovascular treatment of ruptured tiny cerebral aneurysms compared with ruptured larger aneurysms

PURPOSE

To investigate the effect and safety of endovascular embolization of tiny aneurysms (≤3 mm) within 72 h of subarachnoid hemorrhage compared with larger ones.

MATERIALS AND METHODS

Patients with intracranial aneurysms treated with endovascular embolization within 72 h were retrospectively enrolled and divided into group A (n = 33) with ruptured tiny aneurysms (≤3 mm) and group B (n = 244) with ruptured larger aneurysms (>3 mm). The clinical and angiographic data before and after embolization were analyzed.

RESULTS

Most tiny aneurysms were located at the posterior communicating artery (36.4%) followed by anterior communicating artery (18.2%). The stent-assisted coiling technique was used mostly in group A with 18 stents deployed (51.5%), but only 24 (9.8%) patients had stent-assisted coiling in group B, with the stent-assisted coiling technique more significantly (P < 0.001) frequently used in group A. No significant (P > 0.05) difference existed in the total, subtotal and incomplete occlusion of aneurysms in two groups. The procedure-related complication rate was not significantly (P > 0.05) different between groups A (24.2%) and B (17.0%). At discharge, no significant (P > 0.05) difference existed in the neurological abnormality between the two groups. Follow-up was performed in 64.5% (20/31) in group A and 75.6% (177/234) in group B. No significant (P > 0.05) difference existed in the aneurysm recurrence rate, deaths, and prognosis.

CONCLUSION

Early embolization of tiny cerebral aneurysms within 72 h of subarachnoid hemorrhage is safe and effective compared with ruptured large aneurysms treated in the same manner.

Rerupture of a Blister Aneurysm After Treatment With a Single Flow-Diverting Stent

BACKGROUND AND IMPORTANCE

As the use of flow-diverting stents (FDSs) for intracranial aneurysms expands, a small number of case reports have described the successful treatment of blister aneurysms of the internal carotid artery with flow diversion. Blister aneurysms are uncommon and fragile lesions that historically have high rates of morbidity and mortality despite multiple treatment strategies. We report a case of rebleeding after treatment of a ruptured blister aneurysm with deployment of a single FDS.

CLINICAL PRESENTATION

A 29-year-old man presented with subarachnoid hemorrhage and a ruptured dorsal variant internal carotid artery aneurysm. Despite a technically successful treatment with a single FDS, a second catastrophic hemorrhage occurred during the course of his hospitalization.

CONCLUSION

This case highlights the risk of hemorrhage during the period after deployment of a single FDS. Ruptured aneurysms, especially of the blister type, are at risk for rehemorrhage while the occlusion remains incomplete after flow diversion.

ABBREVIATIONS

FDS, flow-diverting stentICA, internal carotid arterySAH, subarachnoid hemorrhage.

Should we treat aneurysms in perforator arteries from the basilar trunk? Review of 49 cases published in the literature and presentation of three personal cases

Basilar trunk perforator artery aneurysms are rare. Their diagnosis and treatment are difficult, controversial, and challenging. Analysis of 52 cases (49 documented in the literature and three personal cases) clearly shows a re-bleeding rate of 15% in patients whose aneurysm has not been occluded and 0% in treated patients ( p < 0.05). The most effective treatment, and the one that presents the least complication, is double-stenting across the basilar trunk.

Flow Diversion with Low-Profile Braided Stents for the Treatment of Very Small or Uncoilable Intracranial Aneurysms at or Distal to the Circle of Willis

BACKGROUND AND PURPOSE

The endovascular treatment of aneurysms located at or distal to the circle of Willis and not amenable to coiling remains a challenge. We report our experience with flow-diversion treatment using low-profile braided stents as a stent monotherapy procedure for treating distally located very small or uncoilable aneurysms.

MATERIALS AND METHODS

We retrospectively reviewed our data bases to identify patients with aneurysms located at or distal to the circle of Willis who were treated with stent monotherapy using low-profile braided stents. The immediate and follow-up angiographic findings and clinical status of the patients were assessed.

RESULTS

Twenty aneurysms in 19 patients were included in the study. The mean size of the aneurysms was 4.7 ± 2.4 mm. Patients were treated via telescopic implantation of 2 stents for 11 aneurysms; single-stent placement was used for the remaining aneurysms. The technical success rate was 95%. We observed a technical complication in 1 case (5.3%) and a late ischemic event in another (5.3%). The final angiographies during a mean follow-up of 14.7 months showed complete aneurysm occlusion in 73.7%. The complete occlusion rate of the aneurysms treated with telescopic stent placement was 81.8%. The modified Rankin scale scores of all patients at the last follow-up were between 0 and 2.

CONCLUSIONS

Flow diversion with low-profile braided stents as a stent monotherapy procedure for very small or uncoilable intracranial aneurysms located at or beyond the circle of Willis is a promising, relatively safe, and durable endovascular procedure.

Therapeutic effect of enterprise stent-assisted embolization for very small ruptured intracranial aneurysms

Enterprise stent has been widespread used in wide-necked intracranial aneurysms and good efficacy has been achieved, but there are few reports on its applications in very small ruptured intracranial aneurysms in literatures. This study aimed to evaluate the safety and efficacy of Enterprise stent-assisted coiling embolization of very small ruptured intracranial aneurysms.We retrospectively reviewed the clinical and imaging data from 37 patients with very small ruptured intracranial aneurysms who had SAC using Enterprise stents performed from February 2012 to July 2016 in our department. Data collected and analyzed included patient demographics, morphologic features of the aneurysm, treatment results, and follow-up results. Clinical outcomes were evaluated by the Glasgow Outcome Scale (GOS).Enterprise stents were successfully implanted in all 37 patients with very small ruptured intracranial aneurysms. Of the 37 individuals, 28 patients exhibited complete occlusion at Raymond grade I, 5 patients exhibited occlusion at Raymond grade II, and 4 patients at Raymond grade III. Procedure-related complications occurred in 3 of 37 patients (8.1%), including 1 case of intraprocedure aneurysm rupture who died from cerebral herniation caused by severe postoperative cerebral ischemia during the hospital stay, and the other 2 complications were acute in-stent thrombosis, and occlusion of parent artery caused by falling-off internal carotid artery plaque, respectively. A total of 36 patients underwent postoperative clinical follow-up visits for 6 to 24 months of which 31 patients recovered (GOS ≥ 4). One patient had hemiplegic paralysis, and no rehemorrhage was found. A total of 25 patients underwent follow-up digital subtraction angiography (DSA) at 3-21 months postintervention, in whom there were 22 cases with complete occlusion, 2 cases with recurrence of aneurysm neck, and 1 case with in-stent restenosis, but there was no patient with neurologic deficits.The Enterprise stent-assisted coiling embolization can be a safe and effective technique for treatment of very small ruptured intracranial aneurysms.

Super-selective coil embolization of a basilar perforator artery aneurysm previously treated by the stent-in-stent technique, using an extremely soft bare coil delivered through a one-marker microcatheter

Background Aneurysms of the perforating arteries arising from the basilar artery trunk are rare and represent a therapeutic challenge. Methods A basilar perforator aneurysm was initially treated by the stent-in-stent technique. Enlargement of the aneurysm was seen on follow up and the sac was secondarily coiled using two extremely soft bare coils, delivered through a one-marker microcatheter. Results At 6 months, the patient had a modified Rankin Scale score of 0 and cerebral arteriography demonstrated complete occlusion of the lesion. Conclusions We describe, as far as we are aware, the first case of basilar perforator aneurysm occlusion using extremely soft bare coils, inserted through the mesh of two stents previously placed in the basilar trunk.

Endovascular Treatment of Ruptured Blister-Like Aneurysms: A Systematic Review and Meta-Analysis with Focus on Deconstructive versus Reconstructive and Flow-Diverter Treatments

BACKGROUND AND PURPOSE

Various endovascular techniques have been applied to treat blister-like aneurysms. We performed a systematic review to evaluate endovascular treatment for ruptured blister-like aneurysms.

MATERIALS AND METHODS

We performed a comprehensive literature search and subgroup analyses to compare deconstructive versus reconstructive techniques and flow diversion versus other reconstructive options.

RESULTS

Thirty-one studies with 265 procedures for ruptured blister-like aneurysms were included. Endovascular treatment was associated with a 72.8% (95% CI, 64.2%-81.5%) mid- to long-term occlusion rate and a 19.3% (95% CI, 13.6%-25.1%) retreatment rate. Mid- to long-term neurologic outcome was good in 76.2% (95% CI, 68.9%-8.4%) of patients. Two hundred forty procedures (90.6%) were reconstructive techniques (coiling, stent-assisted coiling, overlapped stent placement, flow diversion) and 25 treatments (9.4%) were deconstructive. Deconstructive techniques had higher rates of initial complete occlusion than reconstructive techniques (77.3% versus 33.0%, P = .0003) but a higher risk for perioperative stroke (29.1% versus 5.0%, P = .04). There was no difference in good mid- to long-term neurologic outcome between groups, with 76.2% for the reconstructive group versus 79.9% for the deconstructive group (P = .30). Of 240 reconstructive procedures, 62 (25.8%) involved flow-diverter stents, with higher rates of mid- to long-term complete occlusion than other reconstructive techniques (90.8% versus 67.9%, P = .03) and a lower rate of retreatment (6.6% versus 30.7%, P < .0001).

CONCLUSIONS

Endovascular treatment of ruptured blister-like aneurysms is associated with high rates of complete occlusion and good mid- to long-term neurologic outcomes in most patients. Deconstructive techniques are associated with higher occlusion rates but a higher risk of perioperative ischemic stroke. In the reconstructive group, flow diversion carries a higher level of complete occlusion and similar clinical outcomes.