Feasibility, procedural morbidity and mortality, and long-term follow-up of endovascular treatment of 321 unruptured aneurysms

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.

European Stroke Organisation (ESO) guidelines on management of unruptured intracranial aneurysms

Unruptured intracranial aneurysms (UIA) occur in around 3% of the population. Important management questions concern if and how to perform preventive UIA occlusion; if, how and when to perform follow up imaging and non-interventional means to reduce the risk of rupture. Using the Standard Operational Procedure of ESO we prepared guidelines according to GRADE methodology. Since no completed randomised trials exist, we used interim analyses of trials, and meta-analyses of observational and case-control studies to provide recommendations to guide UIA management. All recommendations were based on very low evidence. We suggest preventive occlusion if the estimated 5-year rupture risk exceeds the risk of preventive treatment. In general, we cannot recommend endovascular over microsurgical treatment, but suggest flow diverting stents as option only when there are no other low-risk options for UIA repair. To detect UIA recurrence we suggest radiological follow up after occlusion. In patients who are initially observed, we suggest radiological monitoring to detect future UIA growth, smoking cessation, treatment of hypertension, but not treatment with statins or acetylsalicylic acid with the indication to reduce the risk of aneurysm rupture. Additionally, we formulated 15 expert-consensus statements. All experts suggest to assess UIA patients within a multidisciplinary setting (neurosurgery, neuroradiology and neurology) at centres consulting >100 UIA patients per year, to use a shared decision-making process based on the team recommendation and patient preferences, and to repair UIA only in centres performing the proposed treatment in >30 patients with (ruptured or unruptured) aneurysms per year per neurosurgeon or neurointerventionalist. These UIA guidelines provide contemporary recommendations and consensus statement on important aspects of UIA management until more robust data come available.

Feasibility and Safety of Transradial Aneurysm Embolization: A Systematic Review and Meta-Analysis

OBJECTIVE

Use of the transradial access (TRA) approach for neuroendovascular procedures has been increasing in recent years. Our aim is to assess the feasibility, success rate, and complications associated with TRA for intracranial aneurysm embolization.

METHODS

PubMed, Scopus, and Embase were systematically searched for studies using TRA for intracranial aneurysm embolization. Random-effects models were used to obtain pooled rates of procedural success and complications.

RESULTS

Twenty-four studies comprising 1283 (85.9%) TRA and 122 (8.2%) distal TRA aneurysm embolization procedures were included. The pooled success rate of the 18 studies in the meta-analysis was 93.5% (95% confidence interval [CI], 91.1%-95.8%). The pooled thromboembolic complication rate was 0.5% (95% CI, 0.1%-0.9%), the hemorrhagic complication rate was 0.5% (95% CI, 0.1%-0.9%), and the access site complication rate was 0.8% (95% CI, 0.3%-1.3%). One study (4.3%) used exclusively a 7-French guide catheter, and most used a 6-French guide catheter (22 of 23 studies, 95.7%), which was further incorporated as part of a triaxial configuration through a sheathless 8-French system in 4 studies (17.4%), 7-French guide catheter in 2 studies (8.7%), and 8-French sheath in 1 study (4.3%). The embolization techniques used were flow diverter placement in 451 cases (39.1%), coiling in 376 (32.6%), stent-assisted coiling in 127 (11.0%), balloon-assisted coiling in 104 (9.0%), Woven EndoBridge system in 50 (4.3%), and flow diverter placement plus coiling in 42 (3.6%).

CONCLUSIONS

Treating intracranial aneurysms using various embolization techniques through TRA is feasible and associated with low access site and intraoperative complications.

Aspect Ratio Is Associated with Recanalization after Coiling of Unruptured Intracranial Aneurysms

The rate of recanalization after coil embolization for unruptured intracranial aneurysms (UIAs) is reported to occur around 11.3%-49%. This study aims to investigate the factors that influence the recanalization after coil embolization for UIAs in our institution. We retrospectively investigated 307 UIAs in 296 patients treated at our institution between April 2004 and December 2016. The stent-used cases were excluded. Cerebral angiography and 3D time-of-flight magnetic resonance angiography (TOF MRA) were used for evaluation of the postoperative occlusion status. Volume embolization ratio (VER), aneurysmal size, neck width, and aspect ratio (AR) were compared between the recanalized and non-recanalized groups. The mean follow-up period ranged from 6 to 172 months (mean: 79.0 ± 39.8 months). Recanalization was noted in 78 (25.4%) aneurysms, and 19 (6.2%) aneurysms required retreatment. There was no aneurysmal rupture during the follow-up period. Univariate analysis showed that the aneurysm size (p < 0.001), neck width (p < 0.001), AR (p = 0.003), and VER (p = 0.012) were associated with recanalization. Multivariate logistic regression analysis showed that the AR (p =0.004) and VER (p =0.015) were significant predictors of recanalization. To summarize, a higher AR and a lower VER could lead to recanalization after coil embolization of UIAs. Careful follow-up is required for coiled aneurysms with these features.

Long-term outcomes of endovascular simple coiling versus neurosurgical clipping of unruptured intracranial aneurysms: A systematic review and meta-analysis

BACKGROUND

Previous studies on ruptured intracranial aneurysms have shown favourable long-term outcomes of patients undergoing endovascular coiling compared to neurosurgical clipping. We aimed to evaluate if these results also apply to patients with unruptured intracranial aneurysms (UIAs).

METHODS

Embase, PubMed, and Cochrane Library were systematically searched for all studies reporting long-term (≥3 years) follow-up after coiling or clipping of UIAs. Thirteen studies involving 16,622 coiled patients and 13,606 clipped patients were included. Short-term outcome was defined as death ≤30 days after treatment. Long-term outcomes (>3 years) included all-cause mortality, morbidity (defined as modified Rankin Score 3-5 or Glasgow Outcome Score 2-3), cerebrovascular accident, intracerebral haemorrhage, additional repairs, and lost to follow-up. We calculated relative risk (RR), incidence and mortality rates (IR and MR), together with incidence and mortality rate ratio (IRR and MRR).

RESULTS

Patients treated with simple coiling had lower short-term mortality than clipped patients (RR = 0.62 (95%CI 0.42-0.91)), but this difference disappeared after long-term follow-up ((MRR) = 0.89 (95%CI: 0.78-1.02). Coiled patients had higher retreatment rates than clipped patients (IRR = 1.70 (95%CI 1.50-1.93)).

CONCLUSIONS

This systematic review and meta-analysis reports benefits and drawbacks of simple coiling versus neurosurgical clipping of UIAs. Future studies with longer follow-up time should account for differences in coiling techniques and confounding factors such as size and location of UIAs.

Neuroform Atlas stent in treatment of iatrogenic dissections of extracranial internal carotid and vertebral arteries: a single-centre experience

AIM OF THE STUDY

To present our experience in the treatment of iatrogenic dissections of extracranial internal carotid and vertebral arteries with the Neuroform Atlas stent.

MATERIALS AND METHODS

Between January 2017 and February 2018 we treated iatrogenic dissections of three internal carotid arteries and three vertebral arteries. These iatrogenic dissections occurred during the endovascular treatment of ruptured and unruptured intracranial aneurysms. The indication for stenting was haemodynamically significant, flow-limiting dissection with threatening flow arrest. In all six cases, the dissections were treated by placement of Neuroform Atlas stents in the dissected segments of internal carotid or vertebral arteries. Deployment of the stent was followed by the usual dual antiplatelet regimen.

RESULTS

Single or multiple Neuroform Atlas stents were deployed without any technical difficulties, and blood flow was restored immediately after placement of the stents in all six cases. Midterm follow-up (6-8 months) showed complete reconstruction of the shape and lumen of all treated arteries, with negligible intimal hyperplasia.

CONCLUSION

Our results indicate that a favourable outcome can be achieved by treating iatrogenic dissections of extracranial internal carotid and vertebral arteries with the Neuroform Atlas stent.

Spot fluoroscopy: a novel innovative approach to reduce radiation dose in neurointerventional procedures

Background

Increased interest in radiation dose reduction in neurointerventional procedures has led to the development of a method called “spot fluoroscopy” (SF), which enables the operator to collimate a rectangular or square region of interest anywhere within the general field of view. This has potential advantages over conventional collimation, which is limited to symmetric collimation centered over the field of view.

Purpose

To evaluate the effect of SF on the radiation dose.

Material and Methods

Thirty-five patients with intracranial aneurysms were treated with endovascular coiling. SF was used in 16 patients and conventional fluoroscopy in 19. The following parameters were analyzed: the total fluoroscopic time, the total air kerma, the total fluoroscopic dose-area product, and the fluoroscopic dose-area product rate. Statistical differences were determined using the Welch’s t-test.

Results

The use of SF led to a reduction of 50% of the total fluoroscopic dose-area product (CF = 106.21 Gycm², SD = 99.06 Gycm² versus SF = 51.80 Gycm², SD = 21.03 Gycm², p = 0.003884) and significant reduction of the total fluoroscopic dose-area product rate (CF = 1.42 Gycm²/min, SD = 0.57 Gycm²/s versus SF = 0.83 Gycm²/min, SD = 0.37 Gycm²/min, p = 0.00106). The use of SF did not lead to an increase in fluoroscopy time or an increase in total fluoroscopic cumulative air kerma, regardless of collimation.

Conclusion

The SF function is a new and promising tool for reduction of the radiation dose during neurointerventional procedures.

Endovascular treatment of unruptured posterior circulation intracranial aneurysms

BACKGROUND AND PURPOSE

Endovascular treatment of unruptured posterior circulation intracranial aneurysms (UPCIAs) is limited in the International Study of Unruptured Intracranial Aneurysms (ISUIA). The aim of this study is to evaluate the periprocedural morbidity, mortality, and midterm clinical and angiographic follow-ups of endovascular treatment of UPCIAs.

MATERIALS AND METHODS

Retrospective analysis of all patients treated in a 2-year period (89 patients: 10-78 years of age, mean: 45.5 ± 14.3/92 UPCIAs). Fifty-eight aneurysms were found incidentally, 12 in association with mass effect symptoms and 22 with stroke.

RESULTS

A clinical improvement or stable outcome was achieved in 84 patients (94.4%). The two cases of permanent morbidity included a patient with paralysis and another patient with hemianopia. One patient died after treatment of a giant fusiform vertebrobasilar aneurysm. In one patient, the aneurysm ruptured during treatment, resulting in death. Another patient suffered a fatal aneurysm rupture 4 days after treatment. Giant size (P = 0.005) and mass effect presentation (P = 0.029) were independent predictors of unfavorable outcomes in UPCIAs. Angiographic follow-up was available in 76 of the 86 surviving patients (88.4%) with a mean of 6.8 months (range: 1-36 months). Recanalization in six patients (7.9%) at 3 months, 4 months, 4 months, 24 months, and 36 months required retreatment in three patients. In-stent stenosis of >50% was found in three patients.

CONCLUSION

Endovascular therapy is an attractive option for UPCIAs with stable midterm outcome. However, the current endovascular option seems to have a limitation for the treatment of the aneurysm with giant size or mass effect presentation.

WEB intrasaccular flow disruptor-prospective, multicenter experience in 83 patients with 85 aneurysms

BACKGROUND AND PURPOSE

The safety and efficacy of WEB flow disruption have been analyzed in small, retrospective series. The object of this study was to evaluate the safety and efficacy of WEB flow disruption in a large, multicenter, prospectively collected population.

MATERIALS AND METHODS

Data from all patients treated with the WEB-DL device between June 2011 and October 2013 in 11 French neurointerventional centers were prospectively collected and retrospectively analyzed. Complications occurring during and after treatment were analyzed as well as morbidity and mortality at 1 month. Aneurysm occlusion status at the last follow-up was analyzed.

RESULTS

Eighty-three patients with 85 aneurysms were included in this series. Technical success was achieved in 77 patients with 79 aneurysms (92.9%). Periprocedural complications were observed in 9 patients (10.8%), leading to permanent neurologic deficits in 3 (3.9%). Morbidity and mortality at 1 month were 1.3% and 0.0%, respectively. Angiographic follow-up was performed for 65/79 aneurysms (82.3%) 3-24 months after treatment (mean, 5.3 months). Complete aneurysm occlusion was observed in 37/65 aneurysms (56.9%); neck remnant, in 23/65 (35.4%); and aneurysm remnant, in 5/65 (7.7%).

CONCLUSIONS

In this large prospective series of patients, WEB flow disruption was a safe and efficient technique.

Predictor's analysis of anterior circulation cerebral infarction after the endovascular treatment of anterior communicating artery aneurysms

BACKGROUND

Despite increasing acceptance of endovascular coiling for treating anterior communicating artery (ACoA) aneurysms, anterior circulation cerebral infarction (ACI) after embolization remains a limitation. With higher incidence, higher morbidity and higher mortality, it is one of the main factors influencing the ACoA aneurysms prognosis. Determining the risk factors leading to ACI after embolization will have clinical significance. Through retrospective case analysis, this study investigated the risk factors related to ACI after embolization in order to provide information to serve the clinical practice.

MATERIALS AND METHODS

A retrospective review was performed of patients who had undergone coiling of ACoA aneurysms from 2008 to 2012. All patients had ruptured prior to the completion of embolization. Cases with acute stroke symptoms without alternative diagnoses after embolization were diagnosed as ACI. A total of 32 risk factors such as age, sex, hypertension, diabetes mellitus, modified Fisher grade, Hunt-Hess grade, ventricular hemorrhage, etc. were analyzed using univariate and logistic regression analysis.

RESULTS

Univariate analysis showed that negative fluid volume balance (P = 0.041 <0.05) and modified Fisher grade (P = 0.049 <0.05) reached statistical significance, suggesting that they might be risk factors for ACI after embolization. Multiple logistic regression analysis showed that modified Fisher grade was significantly associated with ACI after embolization, suggesting that it was an independent risk factor (odds ratios (OR): 4.968, 95% confidence intervals (CI): 1.013-24.360, P = 0.048).

CONCLUSION

Modified Fisher grade is an independent risk factor for ACI after embolization.

Results of Stent-Assisted vs Non-Stent-Assisted Endovascular Therapies in 489 Cerebral Aneurysms

BACKGROUND:

Whether the addition of stenting to intracranial aneurysm coil embolization results in benefit in terms of occlusion rates or additional risk in terms of periprocedural adverse events is not clear.

OBJECTIVE:

To report retrospectively analyzed results of endovascular aneurysm treatment comparing stent-assisted coiling with coiling without stents at our hospital from 2005 to 2009.

METHODS:

In this retrospectively reviewed case series, aneurysms were grouped as intent-to-treat or initially treated with stent-assisted coiling (A) vs coiling alone (B) or as-treated—those that ultimately received a stent (C) or not (D). Complication and occlusion rates were compared between groups. Some patients crossed from group B to C after receiving stent placement at a later treatment following the initial therapeutic modality (without a stent).

RESULTS:

In 459 patients, 489 aneurysms were treated by group as follows: A = 181, B = 308, C = 225, and D = 264. In stent groups (A and C), there were significantly lower frequencies of ruptured aneurysms (A vs B = 11% vs 62%, P &lt; .001; C vs D = 20.4% vs 62.5%, P &lt; .001) and more giant aneurysms (A vs B = 7.3% vs 1.0%, P = .001; C vs D = 5.9% vs 1.1%, P &lt; .001). There was no statistically significant difference in permanent event-related morbidity (A vs B = 4.4% vs 4.2%, P = 1.0; C vs D = 4.4% vs 4.2%, P = 1.0). Average angiographic follow-up after last treatment was 18.2 ± 15 months (median = 14). Higher rates of complete occlusion at last angiographic follow-up were observed in stented aneurysms (A vs B = 64.6% vs 49.7%, P = .001; C vs D = 62.7% vs 48.9%, P = .003).

CONCLUSION:

Stent-assisted aneurysm treatment resulted in higher total occlusion rates than non-stent-assisted treatment, with acceptable, comparable periprocedural event rates.

Surgery for unruptured intracranial aneurysms in the ISAT and ISUIA era

BACKGROUND

The ISAT and ISUIA studies, along with the improvement of endovascular treatment (EVT) have strongly influenced the management of intracranial aneurysms (IAs). We present our experience in the microsurgical treatment of unruptured IAs (UIAs) in this context.

METHODS

We retrospectively reviewed a consecutive series of non-giant UIAs selected for surgery during a five-year period. Patients and aneurysms characteristics, surgical results and outcome assessed by the Glascow Outcome Scale (GOS) at three month follow-up were studied.

RESULTS

Eighty-five patients underwent 93 surgical procedures to obliterate 113 UIAs. Those were incidental in 89% of the cases and mainly located on the middle cerebral artery (65%). Patients were assigned to surgery according to their medical history (young, previous subarachnoid haemorrhage), aneurysm characteristics (wide neck, branch at the neck, "small" size, associated "surgical" aneurysm) or failure of EVT (5%). Operatively, 48% of UIAs had thin wall or blebs and 71% were occluded with one titanium clip. Thrombectomy or temporary clipping were necessary in 4% and 11% of the cases, three aneurysms peroperatively ruptured, four were deemed unclippable, three paraclinoid UIAs had an intracavernous residue and 16% were wrapped because of a small neck remnant (class 2). The mortality rate was 0% and 4% of the patients experienced a definitive major neurological deterioration. Final GOS was unchanged in 96% of the patients.

CONCLUSIONS

Despite reduction in operative cases and in appropriately selected patients ineligible to EVT, microsurgical clipping of non-giant anterior circulation UIAs can still achieve good outcome with very low mortality and neurological morbidity.

Results of endovascular treatment for intracranial wide-necked saccular and dissecting aneurysms using the Enterprise stent: a single center experience

OBJECTIVE

The aim of the present retrospective study is to compare outcome of the endovascular treatment using the Enterprise stent in intracranial wide-necked saccular and dissecting aneurysms.

METHODS

Forty-six patients with 50 complex intracranial aneurysms admitted between June 2009 and November 2010 were treated using Enterprise stents. Thirty-one aneurysms were wide-necked saccular, 19 aneurysms dissecting. In 48 cases, aneurysms were occluded by stent-assisted coiling; in 2 cases, by stent alone.

RESULTS

Among the aneurysms treated with the Enterprise stent, patient sex, aneurysm location, hypertension history and the immediate angiographic results differed significantly between the saccular and dissecting aneurysm groups. However, recurrence rate, clinical follow-up outcomes did not differ significantly between the saccular and dissecting groups. There was 1 (2%) procedure-related complication, which caused death in the saccular group. At mean 9.1-month follow-up, the result was good in all dissecting cases and good in 30 saccular cases. There was 1 recurrence in each group.

CONCLUSIONS

Enterprise stent is very useful for endovascular embolization of intracranial wide-necked saccular and dissecting aneurysms because it is easy to navigate and place precisely. The overall morbidity and mortality rates were low.

Ocular symptomatology, management, and clinical outcome of a giant intracranial aneurysm

Giant aneurysms of the anterior intracranial circulation are rare, slowly progressive vascular abnormalities, often presenting with neuro-ophthalmological symptoms before they rupture. This is a case of a 55-year-old woman with a double aneurysm of the anterior intracranial circulation, part of which was giant, diagnosed exclusively on the basis of ocular manifestations. We also describe successful management of the case throughout a long follow-up period.

Endovascular therapy of 500 small asymptomatic unruptured intracranial aneurysms

BACKGROUND AND PURPOSE

Although the natural course of UIAs remains unclear, the risk of aneurysmal SAH due to small (<10 mm) asymptomatic UIAs is low. Endovascular therapy for UIAs has increased because of device development and the need for less invasive treatment. We report the results, safety, and efficacy of endovascular therapy of small asymptomatic UIAs.

MATERIALS AND METHODS

A total of 457 patients with 500 small asymptomatic UIAs (maximum diameter < 10 mm) underwent endosaccular coil embolization at Juntendo University Hospital and affiliated hospitals. We retrospectively evaluated the technical feasibility, immediate and short-to-midterm follow-up anatomic results, procedure-related complications, and clinical outcomes.

RESULTS

Endosaccular coil embolization was completed in 481 aneurysms (96.2%) and attempted in 19 (3.8%). Completed aneurysms were treated with the simple (39.5%), balloon-assisted (51.4%), and double-catheter (9.1%) techniques. Immediate angiographic outcomes were CO for 309 (64.2%) aneurysms, RN for 72 (15.0%), and RA for 100 (20.8%). Procedure-related complications occurred in 38 aneurysms (7.6%): 19 ischemic, 11 hemorrhagic, and 8 others. Permanent morbidity and mortality were 0.8% and 0.2%, respectively. Anatomic outcome of 427 aneurysms followed up for >6 months with conventional catheter or MR angiographies showed recanalization in 72 (16.9%) aneurysms, necessitating retreatment in 9.9% (mean, 31.4 months). No patients had aneurysmal SAH during the clinical follow-up period (mean, 34.7 months).

CONCLUSIONS

In this series, endovascular therapy of small asymptomatic UIAs was highly feasible with low morbidity and mortality rates.

Long-term Results of Enterprise Stent-Assisted Coiling of Cerebral Aneurysms

BACKGROUND:

The Enterprise Vascular Reconstruction Device and Delivery System (Cordis; the Enterprise stent) was approved for use in conjunction with coiling of wide-necked aneurysms in 2007. No published long-term aneurysm occlusion or complication data exist for the Enterprise system.

OBJECTIVE:

We compiled data on consecutive patients treated with Enterprise stent-assisted coiling of aneurysms from 9 high-volume neurointerventional centers.

METHODS:

A 9 center registry was created to evaluate large volume data on the delayed safety and efficacy of the Enterprise stent system. Pooled data were compiled for consecutive patients undergoing Enterprise stent-assisted coiling at each institution prior to May 2009.

RESULTS:

Two-hundred twenty-nine patients with 229 aneurysms, 32 of which were ruptured aneurysms, were included in the study. Mean clinical and angiographic follow-up was 619.6 ± 26.4 days and 655.7 ± 25.2 days, respectively. Mean aneurysm size was 9.2 ± 0.4 mm. Fifty-nine percent of patients demonstrated 100% coil obliteration and 81% had 90% or higher occlusion at last follow-up angiography. A total of 19 patients (8.3%) underwent retreatment of their aneurysms during the follow-up period. Angiographic in-stent stenosis was seen in 3.4% and thromboembolic events occurred in 4.4%. Overall, 90% of patients who underwent Enterprise-assisted coiling had a modified Rankin Scale score of 2 or less at last follow-up. A poor modified Rankin Scale score was strongly associated with rupture status (P &lt; .001).

CONCLUSION:

Although this study is limited by its retrospective nature, the Enterprise stent system appears to be an effective, safe, and durable treatment for intracranial aneurysms when used in conjunction with coiling.

Efficacy and safety of single versus dual antiplatelet therapy for coiling of unruptured aneurysms

BACKGROUND

Although the efficacy of antiplatelet therapy for coiling of unruptured cerebral aneurysms has been reported, regimens for this therapy are not yet well established. The aim of this retrospective study was to analyze correlations among the modes of antiplatelet use, aneurysmal configuration, coiling methods, and complications to elucidate the optimal antiplatelet therapy for coiling.

METHODS

The study population comprised 154 patients with unruptured aneurysms who underwent coiling with antiplatelet therapy at our institution between 2001 and 2009. The patients were categorized by mode of antiplatelet therapy (single [n = 64] or dual [n = 90]), neck size (wide [n = 80] or narrow [n = 74]), and technique used (simple [n = 42] or adjunctive [n = 112]). The incidences of hemorrhagic/ischemic complications and abnormalities on postprocedural diffusion-weighted magnetic resonance imaging (DWI) in each group were statistically assessed.

RESULTS

Hemorrhagic complications occurred in 1 case (1.5%) with single antiplatelet therapy and in 2 cases (2.2%) with dual antiplatelet therapy. Symptomatic ischemic complications occurred in 5 cases (7.8%) with single therapy and in 4 cases (4.4%) with dual therapy. Abnormalities were detected by DWI in 27 cases (42%) with single therapy and in 31 cases (34%) with dual therapy. No significant difference was found between modes of antiplatelet therapy even when the technique used was taken into account. In cases of wide neck, however, there were significant differences in the rate of symptomatic ischemic complications (single, 21.7%; dual, 3.5%; P = .014) and DWI abnormalities (single, 37.8%; dual, 20.9%; P = .048).

CONCLUSION

Our data suggest that dual antiplatelet therapy may better prevent ischemic complications from coiling for wide-necked aneurysms compared with single antiplatelet therapy.

Endovascular treatment of unruptured intracranial aneurysms

We report the clinical and angiographic results of endovascular treatment of unruptured intracranial aneurysms. Over a three-year period, 80 unruptured aneurysms in 74 patients were electively treated with endovascular management. One aneurysm was diagnosed during investigations for a second ruptured aneurysm, 54 aneurysms were incidentally discovered, 18 aneurysms presented with symptoms of mass effect and seven aneurysms presented with symptoms of brain stem ischemia. Mean size of the 80 unruptured aneurysms was 12.5±8.0 mm (range, 2-39 mm). Thirty-six aneurysms (45%) were small (<10 mm), 38 aneurysms (47.5%) were large (10-25 mm), and six aneurysms (7.5%) were giant (25-39 mm). Forty-eight wide-necked aneurysms (60%) were coiled with the aid of a supporting device. The mortality rate was 1.25%, and the overall morbidity was 1.25%. Of these, one of the patients suffered a stroke, leading to severe disability (1.25%). In one patient, the aneurysm ruptured during treatment, resulting in death. Initial aneurysm occlusion was complete (100%) in 76.25% aneurysms, nearly complete (90%-98%) in 10% aneurysms and incomplete (60%-85%) in 13.75% aneurysms. Follow-up angiography was available in 67 patients with 73 treated aneurysms (91.25%) from one to 36 months (mean 9.3 months); partial reopening occurred in 7.5%, mainly large and giant aneurysms (5.5%). Additional coiling was performed in four aneurysms. There were no complications in additional treatments. At 14.1-month clinical follow-up (range, 2 to 36 months), mRS score was 0 in 78.75% patients, 1 in 10% patients, 2 in 8.75% and 3 in 1.25%. There was no aneurysmal rupture during the follow-up period. Endovascular treatment of unruptured intracranial aneurysms has low procedural mortality and morbidity rates.

Endovascular treatment of ruptured tiny intracranial aneurysms

Endovascular treatment of ruptured tiny intracranial aneurysms (RTIA) is technically challenging. We retrospectively collected and analyzed the clinical data of 51 patients with RTIA who underwent attempted endovascular treatment at our institution between November 2000 and April 2009. Forty-nine patients were successfully treated by coiling alone (29 patients), stent-assisted coiling (11 patients) or stent placement alone (nine patients). Procedural complications occurred in five patients. One patient died from a severe initial hemorrhage and poor clinical condition. At the time of discharge, 44 patients (89.8%) had recovered in good condition (Glasgow Outcome Scale [GOS] score 5), two were moderately disabled (GOS score 4) and two were severely disabled (GOS score 3). Angiographic follow-up (mean follow-up time=14 months) was available for 33 patients, and two were re-treated. None of the 46 patients who were clinically followed up (mean=54.2 months) experienced re-bleeding. Our results suggest that RTIA is not uncommon and can be safely treated endovascularly.

[Endovascular therapy options for aneurysmal subarachnoid hemorrhage]

Aneurysmal subarachnoid hemorrhaging (ASH) is a severe condition with an acute symptomatic, often with a difficult course and accompanied by many complications. Aneurysms can be detected using computed tomography (CT), magnetic resonance angiography (MRA) and digital subtraction angiography (DSA). Possible therapy options for ASH are surgical clipping and endovascular treatment using platinum coils. The surgical approach is an effective and safe method for avoiding recurrent bleeding.So-called Guglielmi detachable coils, with which aneurysms can be successfully embolized, have been available since 1991. Initially only a few different sizes of platinum coils were available but now complex forms of platinum coils with different lengths and rigidness are available so that many forms of aneurysm can be treated. Broad-based aneurysms, which could previously only be treated by surgery, can now be treated by the so-called balloon remodeling technique or stent-assisted coiling, whereby a balloon or stent is placed in the parent vessel to act as a scaffold for the coil. The results of the ISAT study demonstrated that a better outcome for patients could be achieved by endovascular treatment of aneurysms than by neurosurgical clipping of ruptured aneurysms. For this reason the first option should be endovascular treatment when possible. Asymptomatic aneurysms are being observed increasingly more often and primary treatment should be endovascular when possible. The somewhat higher re-bleeding rate for endovascular treatment could not diminish the better results of the ISAT study even during the 5-year follow-up.

Delayed Thrombosis or Stenosis Following Enterprise-Assisted Stent-Coiling: Is It Safe? Midterm Results of the Interstate Collaboration of Enterprise Stent Coiling

BACKGROUND:

Stent-assisted coiling of intracranial aneurysms with self-expanding stents has widened the applicability of neuroendovascular therapies to those aneurysms previously considered “uncoilable” because of poor morphology. The Enterprise Vascular Reconstruction Device and Delivery System (Cordis) has demonstrated promising initial short-term results. However, the rates of delayed in-stent stenosis or thrombosis are not known.

OBJECTIVE:

To report midterm results of the Enterprise stent system.

METHODS:

A 10-center registry was created to provide a large volume of data on the safety and efficacy of the Enterprise stent system. Pooled data were compiled for consecutive patients undergoing Enterprise stent-assisted coiling at each institution. Available follow-up data were evaluated for the incidence of in-stent stenosis, thrombosis, and aneurysm occlusion.

RESULTS:

In total, 213 patients (176 females) with 219 aneurysms were treated with the Enterprise stent. One hundred ten patients had undergone delayed angiography (≥30 days from stent placement, mean follow-up 174.6 days). Forty percent of patients demonstrated total occlusion with 88% having ≥90% aneurysm occlusion. Six percent of patients had delayed (&gt;30 days) angiographic findings, of which 3% demonstrated significant (≥50%) in-stent stenosis or occlusion. Seven delayed thrombotic events occurred (3%), along with 2 additional immediate periprocedural events. All 7 delayed events were concomitant to cessation of double-antiplatelet therapy.

CONCLUSION:

Midterm occlusion rates are excellent, and stenosis and thrombosis rates are comparable to other available neurovascular stents. Interruption of antiplatelet therapy appears to be a factor in those developing delayed stenosis or thrombosis.

Neurointerventional procedures for unruptured intracranial aneurysms under procedural sedation and local anesthesia: a large-volume, single-center experience

Object

In this paper, the authors' goal was to report the outcome of patients with unruptured intracranial aneurysms undergoing endovascular treatment under conscious sedation (local anesthesia).

Methods

Between November 5, 2001, and February 5, 2009, the authors treated 340 patients with 358 unruptured aneurysms by using neurointerventional procedures at Millard Fillmore Gates Hospital (Buffalo, New York). The data were retrospectively reviewed for periprocedural safety and long-term follow-up.

Results

A total of 496 procedures were performed under local anesthesia. Of those, 370 procedures (74.6%) were completed successfully. In 82 procedures (16.5%), an associated medical or technical event occurred. Forty-four procedures (8.9%) were aborted. Rates of overall procedure-related morbidity and mortality were 1.2% (6 of 496) and 0.6% (3 of 496), respectively. The average hospital stay was 1.5 ± 2.5 days. Long-term follow-up was available in 261 (82.1%) of 318 patients whose procedures were performed with local anesthesia. Of those, 246 patients (94.3%) had a good outcome (modified Rankin Scale score ≤ 2), 6 patients (2.3%) had an unfavorable outcome, not related to the procedure, and 9 patients (3.4%) had a poor outcome (modified Rankin Scale score > 2) as a result of the intervention.

Conclusions

Interventional treatment under conscious sedation (local anesthesia) can be effectively performed in most patients with unruptured intracranial aneurysms and is associated with a short hospital stay and low morbidity and mortality.

An Unusual Case of Coil Migration

Migration of endovascular coils from aneurysms has been reported in the past. However, we report a case where the entire coil mass migrated out of the aneurysm into the anterior cerebral artery with associated doubling of aneurysm diameter in the intervening two weeks period post-coiling.

[Treatment of grade 0 intracranial aneurysms: Retrospective study of 79 cases]

AIM

Without precise international recommendations, despite the advances of the ISUAA study, the superiority of microsurgery or endovascular treatment for unruptured intracranial aneurysm (UIA) over the natural history of this disease has not been proved. In this context, the authors evaluate their experience with the aim of assessing the results and risks of the different therapeutics and comparing them with the natural risk of this disease.

MATERIAL AND METHOD

From January 1993 to July 2000, 79 patients harboring 110 UIAs were treated. These patients were divided retrospectively into two groups. Group A included 45 operated patients. Group B included 37 patients treated with endovascular coiling. The therapeutic choice was not randomized and was approved by a multidisciplinary neurovascular staff.

RESULTS

The two populations were homogeneous in terms of age and sex. In group A, 12 patients presented early complications (26.6 %), with one death. In group B, 15.6 % of the patients presented an ischemic complication. After 1 year of follow-up, morbidity was 11.4 % in group A and 4.8 % for group B. Angiography found a partial recanalization in 12.5 % of the operated patients and in 33 % of the patients treated with endovascular coiling.

DISCUSSION

Many factors are involved in the therapeutic decision: UIA location and size and individual risks. Progress in both surgery and interventional neuroradiology has led to good results conforming with the data reported in the literature but does not demonstrate the superiority of one technique over another.

Immediate anatomic results after the endovascular treatment of unruptured intracranial aneurysms: analysis of the ATENA series

BACKGROUND AND PURPOSE

A precise analysis of the immediate postoperative anatomic results in a large series of unruptured intracranial aneurysms treated by endovascular approach has not previously been presented. This study aimed to assess the efficacy of endovascular treatment of unruptured intracranial aneurysms in light of immediate postoperative anatomic results in a prospective, multicenter study (the Analysis of Treatment by Endovascular Approach of Nonruptured Aneurysms study; ATENA).

MATERIALS AND METHODS

Postoperative anatomic results from digital subtraction angiography (DSA) were evaluated with the Montreal scale by the treating physician and by 2 anonymous, independent, experienced neuroradiologists.

RESULTS

The analysis included 622 patients (449 women, 173 men; age range, 22-83 years; mean age, 51.2 +/- 11.3 years) harboring 694 aneurysms. Evaluation of the postoperative anatomic results by the 2 independent reviewers indicated total occlusions in 437 aneurysms (63.0%), neck remnants in 156 aneurysms (22.5%), and aneurysm remnants in 101 aneurysms (14.6%). Several factors favorably affected the quality of the aneurysm occlusion with treatment, including patient age (< 65 years old; P < .0001), aneurysm diameter (<or= 6 mm; P = .0049), aneurysm dome-to-neck ratio (> 1.5; P = .0388), and endovascular technique (coiling or remodelling compared with stent placement; P = .0001).

CONCLUSIONS

The endovascular treatment of unruptured aneurysms provided satisfactory postoperative occlusion rates, with a high percentage of complete occlusion or neck remnants (85.4%). Postoperative anatomic results were significantly affected by aneurysm size and neck size, but not aneurysm location.

Selective embolization of unruptured intracranial aneurysms is associated with low retreatment rate

INTRODUCTION

To report long-term imaging findings of 101 patients with 129 unruptured intracranial aneurysms (UIA) treated by embolization.

METHODS

A retrospective review of our prospectively maintained database identified all patients with an UIA treated by embolization with coils only and with a minimal 12-month imaging follow-up. The clinical charts, procedural data, and angiographic results were reviewed.

RESULTS

Between March 2004 and June 2009, 101 patients with 129 UIA were identified (71 women/30 men, mean age = 51.4 years). Ninety-four aneurysms (73%) were large (10-25 mm), and 35 (27%) were small (<10 mm). Aneurysms mean size was 10.7 mm (median, 9 mm; range 3-22 mm); 87 UIA (67.5%) had a small neck (<4 mm or neck/sac ratio < 0.7), and 42 (32.5%) had a wide neck (> or =4 mm or neck/sac ratio > or = 0.7). Selective coiling with bare/coated coils was performed in 125 cases and four cases, respectively. The balloon-assisted technique was used in 47 cases (36.4%). Only one patient experienced a symptomatic complication (thromboembolism) and kept a slight hemiparesis. Immediate results included 77 complete occlusions (59.7%), 45 neck remnants (34.9%), and 7 incomplete occlusions (5.4%). Mean imaging follow-up of 32 months showed 104 stable occlusions (80.6%), 12 further thrombosis (9.3%), 7 major recanalizations (5.4%), and 6 minor recanalizations (4.7%). Retreatment was required in seven wide-necked and/or large aneurysms including four treated with coated coils. No bleeding occurred during follow-up.

CONCLUSION

Selective embolization of UIA is associated with stable long-term anatomical results and low retreatment rate.

Long-term follow-up of 1036 cerebral aneurysms treated by bare coils: a multicentric cohort treated between 1998 and 2003

BACKGROUND AND PURPOSE

The endovascular treatment (EVT) of cerebral aneurysms has experienced a revolution since 1991 with the introduction of platinum coil technology. During the past 10 years, there has been significant study of the feasibility of this technique, and clinical results of EVT have been published. The long-term durability of Guglielmi detachable coil (GDC) embolization of cerebral aneurysms still remains unknown. The purpose of this study was to evaluate the stability of anatomic occlusion of aneurysms and to assess the rate of recanalization and retreatment of these aneurysms.

MATERIALS AND METHODS

Between January 1998 and December 2003, 1036 aneurysms (804 ruptured and 232 nonruptured) were treated consecutively with GDC coils in 5 neuroradiology centers. Procedural feasibility, acute angiographic occlusion results, morbidity, and mortality associated with this technique were assessed. All patients were regularly followed by digital subtraction angiography and MR imaging each year after treatment.

RESULTS

Initial acute angiographic results in 1036 aneurysms demonstrated total occlusion in 731 patients (70.5%), subtotal occlusion in 252 (24.3%), incomplete occlusion in 20 (1.9%), and failures in 33% (3.3%) aneurysms. A remodeling technique was used in 10%. A second procedure was performed for 72 aneurysms (7%). The total aneurysm follow-up time was 49,923 months (4160.25 aneurysm-years). The retreatment period was either in the months following initial treatment in aneurysms incompletely occluded or in years due to recanalization or de novo aneurysms. Fewer than 5 patients rebled during 10 years of follow-up. Long-term follow-up angiograms were obtained in 899 aneurysms, with 646 total, 230 subtotal, and 23 incomplete results.

CONCLUSIONS

Long-term follow-up of cerebral aneurysms is necessary to depict recanalization. Only 7% of the aneurysms were retreated. Use of bare coils gives a good long-term level of occlusion.

Coiling of intracranial aneurysms: a systematic review on initial occlusion and reopening and retreatment rates

BACKGROUND AND PURPOSE

The proportion of incompletely occluded aneurysms after coiling varies widely between studies. To assess overall outcome of coiling, we systematically reviewed the literature to determine initial occlusion, reopening, and retreatment rates of coiled aneurysms according to predefined criteria and subgroups.

METHODS

We searched PubMed and EMBASE (January 1999 to September 2008) for studies of >50 coiled aneurysms. Two reviewers independently extracted data. We grouped studies reporting on only ruptured aneurysms, posterior circulation aneurysms, and studies with large proportions of aneurysms >10 mm to assess possible determinants for incomplete occlusion, reopening, and retreatment.

RESULTS

Forty-six studies totalling 8161 coiled aneurysms met inclusion criteria. Immediately after coiling, 91.2% (95% CI, 90.6% to 91.9%) of the aneurysms were adequately occluded. Aneurysm reopening occurred in 20.8% (95% CI, 19.8% to 21.9%) and retreatment was performed in 10.3% (95% CI, 9.5% to 11.0%). Reopening rate was lower in studies reporting on ruptured aneurysms only compared with all studies (11.4% versus 20.8%; relative risk, 0.55; 95% CI, 0.47 to 0.64) and higher in studies focusing on posterior circulation aneurysms compared with studies with >85% anterior circulation aneurysms (22.5% versus 15.5%; relative risk, 1.5; 95% CI,1.2 to 1.7). Regression analysis showed higher retreatment rates with increasing proportion of aneurysms >10 mm (beta=0.252; 95% CI, 0.073 to 0.432). We could not find a relation between reopening and type of coils used.

CONCLUSIONS

At follow-up, one fifth of all coiled intracranial aneurysms shows reopening of which half is retreated. Possible risk factors for aneurysm reopening are location in the posterior circulation and size >10 mm. To confirm our findings, a meta-analysis on individual well-reported patient data is desirable.

Endovascular occlusion of intracranial wide-necked aneurysms with stenting (Neuroform) and coiling: mid-term and long-term results

INTRODUCTION

Coiling associated with placement of self-expandable intracranial stents has amplified the treatment of intracranial wide-necked aneurysms, but the durability of this treatment and the existence of delayed recurrence are not yet well known. The purpose of this report is to present our experience with the Neuroform Stent associated with coiling and to evaluate complications, effectiveness, and long-term results of this technique.

METHODS

A retrospective study of 42 patients with wide-necked cerebral aneurysms treated with the Neuroform Stent was performed. Mean aneurysm size was 11.3 mm. Mean neck size was 5.33 mm. All patients were treated with coiling and stenting. Clinical and angiographic follow-up was available in 38 patients (90.5%). The overall follow-up time ranged from 6 months to 5 years (mean, 42 months), but most of the patients (92%) had a follow-up period superior to 1 year.

RESULTS

Successful deployment of 41 stents (97%) was obtained. Permanent procedural morbidity was observed in only one patient (2.4%). Long-term complete aneurysmal occlusion was obtained in 27 patients (71%). Aneurysmal regrowth was observed in four patients (9.5%) on the first control angiogram. After the first control angiogram, no delayed recanalization or regrowth was observed. During the follow-up period, there were no hemorrhagic events, no delayed thrombosis, and no stent displacement.

CONCLUSION

Our results demonstrate the effectiveness of the technique, a small rate of procedural complications, and long-term tolerance of the Neuroform Stent. Despite some evidence of early aneurysmal recurrence, long-term durability of stent-assisted aneurysm occlusion is stable after the first year.

Treatment of intracranial aneurysms with the Enterprise stent: a multicenter registry

OBJECT

The development of self-expanding stents dedicated to intracranial use has significantly widened the applicability of endovascular therapy to many intracranial aneurysms that would otherwise have been untreatable by endovascular techniques. Recent Food and Drug Administration approval of the Enterprise Vascular Reconstruction Device and Delivery System (Cordis) has added a new option for self-expanding stent-assisted intracranial aneurysm coiling.

METHODS

The authors established a collaborative registry across multiple institutions to rapidly provide largevolume results regarding initial experience in using the Enterprise in real-world practice. Ten institutions (University at Buffalo, Thomas Jefferson University, University of Florida, Cleveland Clinic, Northwestern University, West Virginia University, University of Puerto Rico, Albany Medical Center Hospital, the Neurological Institute of Savannah, and the Barrow Neurological Institute) have provided consecutive data regarding their initial experience with the Enterprise.

RESULTS

In total, 141 patients (119 women) with 142 aneurysms underwent 143 attempted stent deployments. The use of Enterprise assistance with aneurysm coiling was associated with a 76% rate of > or = 90% occlusion. An inability to navigate or deploy the stent was experienced in 3% of cases, as well as a 2% occurrence of inaccurate deployment. Procedural data demonstrated a 6% temporary morbidity, 2.8% permanent morbidity, and 2% mortality (0.8% unruptured, 12% ruptured).

CONCLUSIONS

The authors report initial results of the largest series to date in using the Enterprise for intracranial aneurysm treatment. The Enterprise is associated with a high rate of successful navigation and low occurrence of inaccurate stent deployment. The overall morbidity and mortality rates were low; however, caution should be exercised when considering Enterprise deployment in patients with subarachnoid hemorrhage as the authors' experience demonstrated a high rate of associated hemorrhagic complications leading to death.