Differences in the angiographic evaluation of coiled cerebral aneurysms between a core laboratory reader and operators: results of the Cerecyte Coil Trial

A core-lab adjudicated analysis of single-stent assisted coiling of wide-neck bifurcation aneurysms

BACKGROUND AND PURPOSE

Core-lab adjudicated data regarding the efficacy of the single-stent assisted aneurysm coiling technique 'L-stenting' are lacking. We present a multicenter, core-lab adjudicated study evaluating the safety and effectiveness of single-stent assisted coiling in the treatment of wide-neck bifurcation aneurysms (WNBAs).

METHODS

Consecutive patients who underwent L-stenting for WNBAs at three academic institutions between 2015 and 2019 were included in this retrospective study. Clinical safety and efficacy outcomes were gathered from the patient chart, and angiographic imaging was evaluated by core lab analysis. Safety and efficacy outcomes were summarized and predictors of safety and efficacy were calculated.

RESULTS

Of 128 patients treated, 124 had angiographic outcome data at last follow-up. Of those, 110 had adequate (core-lab adjudicated modified Raymond Roy (mRR) score of 1 or 2) occlusion (88.7%). During follow-up, 19 patients (14.8%) required retreatment. There were 17 complications experienced in 12 patients: intraoperative (n=8, 6.25%), perioperative (n=5, 3.9%), or delayed (n=6; n=4 attributed to device/procedure, 3.1%). Significant predictors of complete occlusion were smaller aneurysm size and use of the jailing technique (P=0.0276). Significant predictors of retreatment were larger size, neck size, and larger dome to neck ratio (P=0.0008).

CONCLUSION

This study provides multicenter, core-lab adjudicated angiographic data regarding the efficacy of single-stent assisted coiling for WNBAs. This study acts as a validated comparator for future studies investigating novel devices or techniques for treating this challenging subgroup of aneurysms.

Evaluation of flow diverters for cerebral aneurysm therapy: recommendations for imaging analyses in clinical studies, endorsed by ESMINT, ESNR, OCIN, SILAN, SNIS, and WFITN

BACKGROUND

Multiple studies and meta-analyses have described the technical and clinical outcomes in large cohorts of aneurysm patients treated with flow diverters (FDs). Variations in evaluation methodology complicate making comparisons among studies, hinder understanding of the device behavior, and pose an obstacle in the assessment of further advances in FD therapy.

METHODS

A multidisciplinary panel of neurointerventionalists, imaging experts, and neuroradiologists convened with the goal of establishing consensus recommendations for the standardization of image analyses in FD studies.

RESULTS

A standardized methodology is proposed for evaluating and reporting radiological outcomes of FD treatment of intracranial aneurysms. The recommendations include general imaging considerations for clinical studies and evaluations of longitudinal changes, such as neointimal lining and stenosis. They cover standards for classification of aneurysm location, morphology, measurements, as well as the assessment of aneurysm occlusion, wall apposition, and neck coverage. These reporting standards further define four specific braid deformation patterns: foreshortening, fish-mouthing, braid bump deformation, and braid collapse, collectively termed 'F2B2'.

CONCLUSIONS

When widely applied, standardization of methods of measuring and reporting outcomes will help to harmonize the assessment of treatment outcomes in clinical studies, help facilitate communication of results among specialists, and help enable research and development to focus on specific aspects of FD techniques and technology.

FRED X flow diverter for the treatment of intracranial aneurysms: Two-center experience and mini-review of the literature

OBJECTIVE

The flow re-direction endoluminal device (FRED) is a safe and effective treatment option for intracranial aneurysms. The novel FRED X features an antithrombotic surface coating ("X Technology") on an otherwise unmodified stent design. This two-center study evaluates the clinical safety and efficacy of FRED X and compares it to the literature.

METHODS

Consecutive patients treated between 2020 and 2023 were retrospectively reviewed for aneurysm characteristics, procedural details and complications, and angiographic outcomes. A mini-review of the literature for FRED X clinical trials was performed and results were pooled using a random effects model.

RESULTS

Thirty-four patients (mean age 56 years) were treated for 34 aneurysms. The mean aneurysm size was 7.7 ± 5.0 mm, 7 (21%) were ruptured, 6 (18%) were recurrent after previous treatment, 11 (32.3%) were located in the posterior circulation, and 4 (12.5%) had non-saccular morphology. All procedures were technically successful and no balloon angioplasty was required. There was 1 (2.9%) symptomatic complication (a transient ischemic attack) and no procedural morbidity or mortality. Technical asymptomatic events included 1 procedural stent occlusion that was reopened with thrombectomy and 3 cases of vasospasm. Complete and adequate occlusion rates were 68% (19/28) and 89% (25/28) at a mean follow-up time of 6 months, respectively. The results of this study are comparable to previous FRED X studies.

CONCLUSIONS

The results demonstrate a high feasibility and procedural safety of the FRED X with adequate mid-term occlusion rates. Long-term and comparative studies are needed to evaluate the full potential of the FRED X.

Systematic Review and Meta-Analysis of Endovascular Therapy Effectiveness for Unruptured Saccular Intracranial Aneurysms

Background

Currently, endovascular treatment of intracranial aneurysms (ICAs) is limited by low complete occlusion rates. The advent of novel endovascular technology has expanded the applicability of endovascular therapy; however, the superiority of novel embolic devices over the traditional Guglielmi detachable coils (GDCs) is still debated. We performed a systematic review of literature that reported Raymond-Roy occlusion classification (RROC) rates of modern endovascular devices to determine their immediate and follow-up occlusion effectiveness for the treatment of unruptured saccular ICAs.

Methods

A search was conducted using electronic databases (PUBMED, Cochrane, ClinicalTrials.gov, Web of Science). We retrieved studies published between 2000-2022 reporting immediate and follow-up RROC rates of subjects treated with different endovascular ICA therapies. We extracted demographic information of the treated patients and their reported angiographic RROC rates.

Results

A total of 80 studies from 15 countries were included for data extraction. RROC rates determined from angiogram were obtained for 21,331 patients (72.5% females, pooled mean age: 58.2 (95% CI: 56.8-59.6), harboring 22,791 aneurysms. The most frequent aneurysm locations were the internal carotid artery (46.4%, 95% CI: 41.9%-50.9%), the anterior communicating artery (26.4%, 95% CI: 22.5%-30.8%), the middle cerebral artery (24.5%, 95% CI:19.2%-30.8%) and the basilar tip (14.4%, 95% CI:11.3%-18.3%). The complete occlusion probability (RROC-I) was analyzed for GDCs, the Woven EndoBridge (WEB), and flow diverters. The RROC-I rate was the highest in balloon-assisted coiling (73.9%, 95% CI: 65.0%-81.2%) and the lowest in the WEB (27.8%, 95% CI:13.2%-49.2%). The follow-up RROC-I probability was homogenous in all analyzed devices.

Conclusions

We observed that the coil-based endovascular therapy provides acceptable rates of complete occlusion, and these rates are improved in balloon-assisted coils. Out of the analyzed devices, the WEB exhibited the shortest time to achieve >90% probability of follow-up complete occlusion (~18 months). Overall, the GDCs remain the gold standard for endovascular treatment of unruptured saccular aneurysms.

Comparative Analysis of the Low-Profile Acclino Stent and the Enterprise Stent for the Treatment of Unruptured Intracranial Aneurysms

OBJECTIVE

In preliminary studies, advanced intracranial stents appear to have a favorable safety profile for intracranial aneurysm treatment. This dual-center study is a head-to-head comparison of the low-profile Acandis Acclino stent (a third-generation stent) and the first- and second-generation Enterprise stent.

METHODS

Patients who underwent stent-assisted coiling with either the Enterprise or the Acclino stent for unruptured aneurysms during an 8-year period were enrolled and compared for complications, clinical outcomes, and angiographic results. Primary outcome measures were ischemic stroke rate and mid-term complete occlusion rate. Propensity score adjustment was performed to account for small differences between the groups.

RESULTS

Enterprise and Acclino stents were used in 48 cases each. The overall rate of thrombotic complications was higher in the Enterprise group than in the Acclino group (20.8% vs. 4.2%, HR: 6.6, 95%CI: 2.2-20.0, P = 0.01, adjusted P < 0.01), which translated into a higher rate of major ischemic stroke after Enterprise treatment (6.3% vs. 0%, HR: 2.1, 95%CI: 1.8-2.4, P = 0.08, adjusted P < 0.01). Mid-term and long-term angiographic follow-up showed complete occlusion rates of 83.3% and 75.0% for Enterprise and 89.2% and 75.9% for Acclino (both P > 0.05). Retreatment rates were 10.4% in the Enterprise group and 4.2% in the Acclino group (P = 0.42, adjusted P = 0.10).

CONCLUSIONS

The results indicate a favorable safety profile of the Acclino over the Enterprise, justifying the use of advanced stent systems in clinical practice. However, further comparative studies of the Acclino and other competing stent systems are needed to draw a definitive conclusion on the state of stent-assisted coiling.

Endovascular treatment for isolated posterior cerebral artery occlusion stroke in the MR CLEAN registry

BACKGROUND

Endovascular treatment (EVT) is standard of care in anterior circulation large vessel occlusions. In posterior circulation occlusions, data on EVT in isolated posterior cerebral artery (PCA) occlusions are limited, although PCA occlusions can cause severe neurological deficit.

OBJECTIVE

To describe in a prospective study the clinical manifestations, outcomes, and safety of EVT in isolated PCA occlusions.

METHODS

We used data (2014-2017) from the MR CLEAN Registry, a nationwide, prospective cohort of EVT-treated patients in the Netherlands. We included patients with acute ischemic stroke (AIS) due to an isolated PCA occlusion on CT angiography. Patients with concurrent occlusion of the basilar artery were excluded. Outcomes included change in National Institutes of Health Stroke Scale (ΔNIHSS) score, modified Rankin Scale (mRS) score 0-3 after 90 days, mortality, expanded Thrombolysis in Cerebral Infarction (eTICI), and periprocedural complications.

RESULTS

Twenty (12%) of 162 patients with posterior circulation occlusions had an isolated PCA occlusion. Median age was 72 years; 13 (65%) were women. Median baseline NIHSS score was 13 (IQR 5-21). Six (30%) patients were comatose. Twelve patients (60%) received IVT. Median ΔNIHSS was -4 (IQR -11-+1). At follow-up, nine patients (45%) had mRS score 0-3. Seven (35%) died. eTICI 2b-3 was achieved in 13 patients (65%). Nine patients (45%) had periprocedural complications. No symptomatic intracranial hemorrhages (sICH) occurred.

CONCLUSIONS

EVT should be considered in selected patients with AIS with an isolated PCA occlusion, presenting with moderate-severe neurological deficits, as EVT was technically feasible in most of our patients and about half had good clinical outcome. In case of lower NIHSS score, a more conservative approach seems warranted, since periprocedural complications are not uncommon. Nonetheless, EVT seems reasonably safe considering the absence of sICH in our study.

SMART Registry: Safety and Performance of the Penumbra SMART COIL System for Patients With Intracranial Aneurysms 4 mm and Smaller

BACKGROUND

The Penumbra SMART COIL System includes a novel generation of embolic coils composed of complex and WAVE shape properties with varying levels of softness.

OBJECTIVE

To assess safety and efficacy of the SMART COIL System through a 1-year follow-up in patients with small intracranial aneurysms.

METHODS

This subset analysis of the SMART Registry, a prospective, multicenter study, includes patients with small intracranial aneurysms (≤4 mm) treated with the SMART COIL System. Registry end points include retreatment rates through 1 year, procedural device-related serious adverse events, and adequate occlusion postprocedure.

RESULTS

Of 905 enrolled patients with aneurysms, 172 (19.0%) had small (≤4 mm) aneurysms (75.6% female; mean age 57.2 ± 13.4 years). 30.8% (53/172) of small aneurysms were ruptured, of which 50.9% (27/53) had Hunt and Hess ≥3. 79.5% (132/166) were wide-necked. Stent-assisted coiling and balloon-assisted coiling were performed in 37.2% (64/172) and 22.1% (38/172) of patients, respectively. The mean packing density for very small aneurysms was 44.9 (SD 25.23). Raymond Class I and Class II were achieved in 89.5% (154/172) postprocedure and 97.2% (137/141) at 1 year. The retreatment rate through 1 year was 5.6% (8/142), and the recanalization rate was 7.1% (10/141). The periprocedural device-related serious adverse event rate was 2.9% (5/172). Intraprocedural aneurysm rupture occurred in 0.8% of patients.

CONCLUSION

This analysis suggests that the SMART COIL System is safe and efficacious in small aneurysms with satisfactory occlusion rates and low rates of rupture or rerupture. At 1 year, patients had low retreatment rates and good clinical outcomes.

Angiographic Follow-Up for Small Ruptured Intracranial Aneurysm Treated by Endovascular Treatment : Follow-Up Plan and Long-Term Follow-Up Results

Objective

Although endovascular treatment for intracranial aneurysms is considered effective and safe, its durability is still debated. Also, few studies have described angiographic follow-up plan after endovascular treatment of intracranial aneurysm, especially in ruptured cases. Hence, we report the long-term results of follow-up angiography protocol.

Methods

Radiological records of 639 cases of coil embolization with ruptured aneurysms from March 2003 to December 2016 were retrospectively reviewed. Patients who received treatment of a saccular aneurysm less than 7 mm resulted with near complete occlusion were included. Two hundred thirty-eight aneuryms which received the follow-up angiography at least once were enrolled. We classified four periods of follow-up as follows : post-treatment 1 year (defined as the first period), from 1 to 2 years (the second period), 2 to 5 years (the third period), and over 5 years (long-term).

Results

We identified 14 cases (6.4%) of recurrence from 218 aneurysms in follow-up angiography in the first period. Among 143 aneurysms in the second period, five cases (3.5%) of recurrence were identified. There were no findings suspicious of recanalization in 97 patients in the third period. Of the total 238 cases, there were 19 recurrences, for a recurrence rate of 8.0%. Six (31.6%) out of 19 recurrences showed a tendency toward repeat recurrences even after additional treatment. Twenty-eight received long-term follow-up over 5 years and there was no recurrence.

Conclusion

Most of the recurrence were found during the first and the second year. We suggest that at least one digital subtraction angiography examination may be necessary around post-treatment 2 years, especially in ruptured cases. If the angiographic results are favorable at 2 years post-treatment, long-term result should be favorable.

Long-term clinical and angiographic outcome of the Woven EndoBridge (WEB) for endovascular treatment of intracranial aneurysms

The Woven EndoBridge (WEB) is a well-established device for endovascular treatment of wide-necked bifurcation aneurysms. The objective was to evaluate the long-term angiographic outcome of the WEB and to identify factors that influence aneurysm occlusion. Patient, aneurysm and procedural characteristics of 213 consecutive patients treated with the WEB at three German tertiary care centers between 2011 and 2020 were retrospectively reviewed. Aneurysm occlusion was determined immediately after the procedure, at mid-term (≤ 12 months) and at long-term (> 12 months) follow-up. Among 182 included aneurysms (mean diameter: 7.0 ± 2.4, mean neck width: 4.3 ± 1.6 mm), 29.7% were ruptured. The novel WEB 17 was used in 41.8%, and 11.0% were treated in combination with coiling and/or stenting. Complete and adequate occlusions were observed in 101/155 (65.2%) and 133/155 (85.8%) at mid-term, respectively, and in 59/94 (62.8%) and 87/94 (92.6%) at long-term follow-up (median: 19 months), respectively. Among 92 patients available for both mid- and long-term follow-up, occlusion was stable in 72.8%, improved in 16.3% and worsened in 10.9%. There were no major recurrences leading to aneurysm remnants between mid- and long-term follow-up. Retreatment was performed in 10/155 (6.5%) during mid-term and in 1/94 (1.0%) during long-term follow-up. The WEB provides durable aneurysm occlusion at the long-term. Nevertheless, follow-up imaging is necessary to identify late recurrences that may occur in around 10%.

Stent-assisted WEB embolization: aneurysm characteristics, outcome and case report of a WEB delivered through a stent

PURPOSE

Woven Endobridge (WEB) embolization has become a well-established endovascular treatment option for wide-necked bifurcation aneurysms. The objective was to analyse cases that required additional stent-implantation.

METHODS

Images of 178 aneurysms ≤ 11 mm treated by WEB only or by WEB plus stent were retrospectively reviewed, evaluating aneurysm characteristics, procedural specifics, adverse events and angiographic results. Moreover, we report a case of a WEB delivered through a previously implanted stent.

RESULTS

Additional stent implantation was performed in 15 patients (8.4%). Baseline patient and aneurysm characteristics were comparable between both groups. A single stent was used in 12 cases and 2 stents in Y-configuration in 3. Thromboembolic complications occurred more often with stent assistance (33.3% vs. 8.0%, p = 0.002), while ischemic stroke rates were comparable between both groups (0% vs. 1.8%, p = 1.0). Six-month angiographic follow-up showed complete occlusion, neck remnants and aneurysm remnants in 73.4%, 19.4% and 7.3% after WEB only, respectively, and in 66.7%, 20.0% and 16.7% after WEB plus stent, respectively (p = 0.538). A case report shows that WEB deployment through the struts of a previously implanted standard microstent is feasible, even if a VIA 33 microcatheter is needed.

CONCLUSION

In the present study, stent-assisted WEB embolization had a comparable safety and efficacy profile compared to treatment by WEB only. However, stent-assisted WEB embolization requires long-term anti-platelet medication, which annihilates the advantages of the WEB as a purely intrasaccular device.

CLINICAL TRIAL REGISTRATION NUMBER

N/A.

Propensity score-adjusted analysis on stent-assisted coiling versus coiling alone for ruptured intracranial aneurysms

Stent-assisted coiling (SAC) for ruptured intracranial aneurysms (RIAs) remains controversial due to an inherent risk of potential thromboembolic and hemorrhagic complications. We compared SAC and coiling alone for the management of RIAs using propensity score-adjustment. Sixty-four patients treated by SAC and 220 by stand-alone coiling were retrospectively reviewed and compared using inverse probability of treatment weighting (IPTW) with propensity scores. Functional outcome, procedure-related and overall complications and angiographic results were analyzed. Aneurysms treated by SAC had a larger diameter, a wider neck and were more frequently located at the posterior circulation. SAC had a higher risk for thromboembolic complications (17.2% vs. 7.7%, p = 0.025), however, this difference did not persist in the IPTW analysis (OR 1.2, 95% CI 0.7-2.3, adjusted p = 0.458). In the adjusted analysis, rates of procedural cerebral infarction (p = 0.188), ventriculostomy-related hemorrhage (p = 0.584), in-hospital mortality (p = 0.786) and 6-month favorable functional outcome (p = 0.471) were not significantly different between the two groups. SAC yielded a higher complete occlusion (80.0% vs. 67.2%, OR 3.2, 95% CI 1.9-5.4, p < 0.001) and a lower recanalization rate (17.5% vs. 26.1%, OR 0.3, 95% CI 0.2-0.6, p < 0.001) than stand-alone coiling at 6-month follow-up. In conclusion, SAC of large and wide-necked RIAs provided higher aneurysm occlusion and similar clinical outcome, when compared to stand-alone coiling.

Impact of aneurysm morphology on aneurysmal subarachnoid hemorrhage severity, cerebral infarction and functional outcome

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity. The objective was to evaluate, whether specific morphological aneurysm characteristics could serve as predictive values for aSAH severity, disease-related complications and clinical outcome.

METHODS

A total of 453 aSAH patients (mean age: 54.9 ± 13.8 years, mean aneurysm size: 7.5 ± 3.6 mm) treated at a single center were retrospectively included. A morphometric analysis was performed based on angiographic image sets, determining aneurysm location, aneurysm size, neck width, aneurysm size ratios, aneurysm morphology and vessel size. The following outcome measures were defined: World Federation of Neurosurgical Societies (WFNS) grade 4 and 5, Fisher grade 4, vasospasm, cerebral infarction and unfavorable functional outcome.

RESULTS

Regarding morphology parameters, aneurysm neck width was an independent predictor for Fisher 4 hemorrhage (OR: 1.1, 95%CI: 1.0-1.3, p = 0.048), while dome width (OR: 0.92, 95%CI: 0.86-0.97, p = 0.005) and internal carotid artery location (OR: 2.1, 95%CI: 1.1-4.2, p = 0.028) predicted vasospasm. None of the analyzed morphological characteristics prognosticated functional outcome. Patient age (OR: 0.95, 95%CI: 0.93-0.96, p < 0.001), WFNS score (OR: 4.8, 95%CI: 2.9-8.0, p < 0.001), Fisher score (OR: 2.3, 95%CI: 1.4-3.7, p < 0.001) and cerebral infarction (OR: 4.5, 95%CI: 2.7-7.8, p < 0.001) were independently associated with unfavorable outcome.

CONCLUSIONS

The findings indicate a correlation between aneurysm morphology, Fisher grade and vasospasm. Further studies will be required to reveal an independent association of aneurysm morphology with cerebral infarction and functional outcome.

Postmarket American Experience With Woven EndoBridge Device: Adjudicated Multicenter Case Series

BACKGROUND

The Woven EndoBridge (WEB) device was granted premarket approval in the United States following results of the Woven EndoBridge Intrasaccular Therapy (WEB-IT) study. WEB-IT reported excellent adequate angiographic occlusion of treated aneurysms with a high safety profile. These results were achieved, however, in the context of a prospective study with strict inclusion criteria and rigorous training support.

OBJECTIVE

To review early as-practiced clinical experience with the WEB device in the United States.

METHODS

Retrospective review across 6 institutions identified 91 patients undergoing 92 treatment sessions for WEB device placement in treatment of 91 intracranial aneurysms. Details regarding demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed in a multicenter database. Angiograms from the index procedure and follow-up studies were reviewed by a blinded and independent adjudicator.

RESULTS

The middle cerebral, anterior communicating, and basilar artery complexes were the commonly treated locations. Eight patients presented with ruptured aneurysms. A mean of 1.2 devices were introduced per case. Technical failure without deployment of a WEB device occurred in 2% (2/92) of sessions. Complete aneurysm occlusion for patients with imaging follow-up was 49% (mean follow-up of 8 mo). Four aneurysms were retreated. 90% of patients had modified Rankin Scale ≤ 2 at last clinical follow-up with no mortalities.

CONCLUSION

Immediate postmarket experience with the WEB device, newly introduced at American centers, confirms safe procedural use, but long-term efficacy remains unclear. Early challenges include accurate sizing and device selection.

Five-year results of randomized bioactive versus bare metal coils in the treatment of intracranial aneurysms: the Matrix and Platinum Science (MAPS) Trial

BACKGROUND

No randomized trial of intracranial aneurysm coiling has compared long-term efficacy of polymer-modified coils to bare metal coils (BMCs). We report 5-year results comparing Matrix² coils to BMCs. The primary objective was to compare the rates of target aneurysm recurrence (TAR) at 12 months. Secondary objectives included angiographic outcomes at TAR or 12 months and TAR at 5 years.

METHODS

A total of 626 patients were randomized to BMCs or Matrix² coils. Detailed methods and 1-year results have been published previously.

RESULTS

Of 580 patients eligible for 5-year follow-up, 431 (74.3%) completed follow-up or reached TAR. Matrix² coils were non-inferior to BMCs (P=0.8) but did not confer any benefit. Core lab reported post-treatment residual aneurysm filling (Raymond III) correlated with TAR (P<0.0001) and with aneurysm hemorrhage after treatment (P<0.008). Repeat aneurysmal hemorrhage after treatment, but before hospital discharge, occurred in three patients treated for acutely ruptured aneurysms. Additionally, two patients treated for unruptured aneurysms experienced a first hemorrhage during follow-up. All five hemorrhages resulted from aneurysms with Raymond III residual aneurysm filling persisting after initial treatment. After 5 years follow-up, 2/626 (0.3%) patients are known to have had target aneurysm rupture following hospital discharge. The annualized rate of delayed hemorrhage after coiling was 2/398/5=0.001 (0.1%) per year for unruptured aneurysms and 0 for ruptured aneurysms.

CONCLUSIONS

After 5 years Matrix² coils were non-inferior to BMCs but no benefit was demonstrated. Post-treatment residual angiographic aneurysm filling (Raymond III) is strongly associated with TAR (P<0.0001) and post-treatment aneurysmal hemorrhage (P=0.008).

The Woven EndoBridge (WEB) Versus Conventional Coiling for Treatment of Patients with Aneurysmal Subarachnoid Hemorrhage: Propensity Score-Matched Analysis of Clinical and Angiographic Outcome Data

OBJECTIVE

Conventional coiling is standard for treatment of ruptured intracranial aneurysms. We compared clinical and angiographic outcomes between intrasaccular flow disruption with the Woven EndoBridge (WEB) and conventional coiling in patients with aneurysmal subarachnoid hemorrhage (aSAH) using a propensity score-matched analysis.

METHODS

This is a retrospective study of consecutive patients with aSAH treated with the WEB or conventional coiling between 2010 and 2019. Baseline characteristics, procedural complications, angiographic results, and functional outcome were compared between both groups.

RESULTS

Fifty-two patients treated with the WEB and 236 patients treated by coiling were included. The WEB group was characterized by a higher patient age (P = 0.024), a wider aneurysm neck (P < 0.001), and more frequent location at the posterior circulation (P = 0.004). Procedural complications were comparable between WEB (19.2%) and coiling (22.7%, P = 0.447). In-hospital mortality rates were higher in the coiling group (WEB: 5.8%, coiling: 17.8%; P = 0.0034). Favorable outcome (modified Rankin scale ≤2) was obtained in 51.3% after WEB embolization and in 55.0% after coiling (P = 0.653). Retreatment was performed in 26.4% of patients after WEB and in 25.8% after coiling (P = 0.935). Propensity score analysis confirmed these results and revealed higher adequate occlusion rates at midterm follow-up for WEB-treated aneurysms (WEB: 93.9%, coiling: 76.2%, P = 0.058).

CONCLUSIONS

Compared with conventional coiling, aSAH patients treated with the WEB have a similar clinical and potentially improved angiographic outcome at midterm follow-up. The WEB might be considered as an alternative to conventional coiling for the treatment of RIAs, in particular for those with wide-necked and thus challenging anatomy.

Stent-Assisted Coiling of Unruptured MCA Aneurysms Using the LVIS Jr. Device: A Multicenter Registry

Purpose: The low-profile visualized intraluminal support junior (LVIS Jr.) is a new generation low-profile braided stent. Our aim was to evaluate the safety and efficacy of the LVIS Jr. in the stent-assisted coiling of unruptured middle cerebral artery (MCA) aneurysms. This was a multicenter retrospective study. Patient demographics, aneurysm characteristics, procedural details, complications, and the results of clinical and imaging follow-up were analyzed. Four centers participated in the study. A total of 162 consecutive patients with 162 unruptured MCA aneurysms were included for the analysis. The mean aneurysm size was 7.6 mm (range 2 to 37 mm) and 97.5% were wide-necked. Immediate postprocedural angiograms showed Raymond-Roy class 1 in 118 (72.8%), class 2 in 23 (14.2%), and class 3 in 21 patients (13%). Periprocedural complications occurred in 14 patients (8.6%). There were no procedure-related deaths. Follow-up imaging at 12–18 months post-procedure showed Raymond–Roy class 1 in 132 (81.5%), class 2 in 17 (10.5%), and class 3 in 13 patients (8%). There were 3 cases of in-stent stenosis (1.9%). All 162 patients had good clinical outcome (mRS score 0–2) at 90 days post-procedure. Stent-assisted coiling of unruptured MCA aneurysms with the LVIS Jr. stent is safe and effective, with high immediate and long-term total occlusion rates.

Long-term Angiographic Results of the Low-profile Acandis Acclino Stent for Treatment of Intracranial Aneurysms : A Multicenter Study

PURPOSE

The low-profile Acandis Acclino is a self-expandable nitinol microstent for stent-assisted coiling of intracranial aneurysms. This article reports long-term clinical and angiographic outcome in a multicenter setting.

METHODS

In this study 98 consecutive patients (mean age 55.4 ± 13.5 years) were treated with the Acclino for 98 aneurysms (28 unruptured, 20 recurrent, 50 ruptured) at 3 German tertiary care centers within a 6-year period. The technical success, complications, clinical outcome and angiographic results were retrospectively analyzed.

RESULTS

The technical success rate was 100% with immediate complete occlusion achieved in 89.8% of the patients. Among 65 patients (66.3%) available for a 6‑month follow-up, complete and near-complete occlusion rates were 92.3% and 98.5%, respectively. In 38 patients (38.8%) with long-term follow-up (mean: 21 months), complete and near-complete occlusion were achieved in 81.2% and 89.5%, respectively. Aneurysm recurrence between mid-term and long-term follow-up was observed in 14.3%. The retreatment rate was 11.3%. There were three thromboembolic events (3.1%), of which one resulted in ischemic stroke (1.0%). For unruptured aneurysms, the procedural and device-related morbidity rates were 2.1% and 0%, respectively.

CONCLUSION

In the present study, the Acclino was associated with a low risk of thromboembolic complications and high aneurysm occlusion rates at long-term follow-up. Due to incomplete angiographic follow-up in this series, prospective studies will be necessary to confirm the results.

Operator Versus Core Lab Adjudication of Reperfusion After Endovascular Treatment of Acute Ischemic Stroke

Background and Purpose- The modified Treatment In Cerebral Ischemia (mTICI) score is the standard method to quantify the degree of reperfusion after endovascular treatment in acute ischemic stroke. In clinical practice, it is commonly assessed by local operators after the procedure. In clinical trials and registries, mTICI is evaluated by an imaging core lab. The aim of this study was to compare operator mTICI with core lab mTICI scores in patients included in the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. Methods- All patients with an intracranial carotid or middle cerebral artery occlusion with anteroposterior and lateral digital subtraction angiography runs were included. Operators determined the mTICI score immediately after endovascular treatment. Core lab neuroradiologists were blinded to clinical characteristics and assessed mTICI scores based on pre- and postintervention digital subtraction angiography. The agreement between operator and core lab mTICI scores and their value in the prediction of outcome (score on modified Rankin Scale at 90 days) was determined. Results- In total, 1130 patients were included. The proportion of agreement between operator and core lab mTICI score was 56% (95% CI, 54%-59%). In 33% (95% CI, 31%-36%), mTICI was overestimated by operators. Operators reported a higher rate of successful reperfusion than the core lab (77% versus 67%; difference 10% [95% CI, 6%-14%]; P<0.001). In 252 (33%) of 763 patients scored as incomplete reperfusion by the core lab (mTICI <3), the local read was mTICI 3. Multivariable logistic regression models containing either core lab scored or operator scored successful reperfusion predicted outcome on the full (C statistic of both models: 0.76) or dichotomized modified Rankin Scale (modified Rankin Scale, 0-2; C statistic of both models: 0.83) equally well. Conclusions- Operators tend to overestimate the degree of reperfusion compared with the core lab although this does not affect the accuracy of outcome prediction.

Low-Profile Intra-Aneurysmal Flow Disruptor WEB 17 versus WEB Predecessor Systems for Treatment of Small Intracranial Aneurysms: Comparative Analysis of Procedural Safety and Feasibility

BACKGROUND AND PURPOSE

The Woven EndoBridge 17 has recently been introduced to the market for facilitated endovascular treatment of small bifurcation aneurysms (≤7 mm) with low-profile microcatheters. We compared the Woven EndoBridge 17 with its predecessor versions in terms of procedural safety and feasibility.

MATERIALS AND METHODS

This was a multicenter review of aneurysms ranging from 3 to 7 mm treated with the Woven EndoBridge between 2011 and 2019. Aneurysm characteristics, procedural parameters, and complications were retrospectively compared between treatment with the Woven EndoBridge 17 and a control group that was treated with its predecessor versions, using inverse probability of treatment weighting.

RESULTS

Thirty-eight aneurysms treated with a Woven EndoBridge 17 (mean size, 4.9 ± 1.5 mm) and 70 treated with a predecessor version of the Woven EndoBridge 17 (mean size, 5.6 ± 1.4 mm) were included. The predecessor version of the Woven EndoBridge 17 had a higher failure rate (10.3%) than the Woven EndoBridge 17 (0%, P = .05). Additional stent placement was performed more often with the predecessor version of the Woven EndoBridge 17 (10.0%) than with the Woven EndoBridge 17 (2.6%, adjusted P = .005). The predecessor version of the Woven EndoBridge 17 was associated with a higher thromboembolic event rate (14.3%) than the Woven EndoBridge 17 (5.3%, adjusted P = .002). Neurologic complications (Woven EndoBridge 17: 2.6%; predecessor version of the Woven EndoBridge 17: 2.9%, adjusted P = 1.0) and immediate complete aneurysm occlusion rates (Woven EndoBridge 17: 57.9%; predecessor version of the Woven EndoBridge 17: 54.3%, adjusted P = .21) did not differ significantly between groups.

CONCLUSIONS

In the current study, the Woven EndoBridge 17 was associated with a potentially lower thromboembolic event rate than the predecessor version of the Woven EndoBridge 17, without compromising the immediate aneurysm occlusion rate. Long-term clinical and angiographic outcome analysis will be necessary to draw a definite conclusion.

WEB embolization versus stent-assisted coiling: comparison of complication rates and angiographic outcomes

Background

Intrasaccular flow disruption represents a new paradigm in endovascular treatment of wide-necked bifurcation aneurysms.

Objective

To perform a matched case–control study comparing complications and angiographic outcome using the Woven Endobridge (WEB) device and stent-assisted coiling (SAC).

Methods

Sixty-six patients treated with the WEB at three German tertiary care centers were included and matched with 66 patients treated with SAC based on aneurysm location and unruptured/ruptured aneurysm status. Parameters were retrospectively analysed and compared between the treatment groups using inverse probability of treatment weighting (IPTW) with propensity scores.

Results

Procedural complication rates were 12.1% in the WEB group and 21.2% in the SAC group, which was statistically significant after IPTW adjustment (OR=2.2, 95% CI 1.08 to 4.4, p=0.03). Favourable outcome (modified Rankin scale score ≤2) was achieved by 57/66 (86.4%) in the WEB group and 57/66 (86.4%) in the SAC group (p=1.0). At mid-term follow-up, a similar number of aneurysms achieved adequate occlusion (complete occlusion or neck remnant) in the WEB group (93.9%) and in the SAC group (93.9%, p=1.0). Re-treatment was performed in 10.6% after WEB embolization and 12.1% after SAC (p=1.0).

Conclusions

The WEB provides similar mid-term aneurysm occlusion rates to those of SAC, with no additional morbidity and potentially lower complication rates. Long-term outcome analysis will provide a definite conclusion on the use of WEB for intracranial aneurysms.

Endovascular coiling for cerebral aneurysm: single-center experience in Egypt

Background

Endovascular management for cerebral saccular aneurysm has evolved in the last decade with evolution in both equipment and material. Coiling is still the mainstay of cerebral aneurysm endovascular management. In Egypt, practice outcome needs evaluation especially at low-volume centers.

Purpose

To discuss the technical and management outcomes of our first symptomatic and asymptomatic cerebral saccular aneurysm case series treated with simple coiling.

Patients and methods

Clinical, treatment, and outcome variables of consecutive symptomatic and asymptomatic cerebral aneurysm cases treated with simple coiling between January 2011 and June 2016 in one center were analyzed.

Results

In 31 patients, 35 aneurysms were found, 34 aneurysms (97.1%) were treated by endovascular coiling, and only one aneurysm (2.9%) was not fit for endovascular treatment. Total occlusion was achieved in 29 aneurysms (82.9%). Neck remnants were present in 4 aneurysms (11.4%). Partial coiling (incomplete occlusion) was achieved in 1 aneurysm (2.9%). Regarding functional outcome (mRS at discharge), 25 patients had good outcome (mRS = 0, 1, 2, 3) and 6 patients had poor outcome (mRS = 4, 5, 6).

Conclusion

The endovascular coiling could be used as a first-choice option for treatment of saccular cerebral aneurysms at our center despite the low case rate.

Safety and efficacy of the Derivo Embolization Device for the treatment of ruptured intracranial aneurysms

Background

The Derivo Embolization Device (DED) is a novel flow diverter with advanced X-ray visibility, potentially lower thrombogenicity, and an improved delivery system.

Objective

To evaluate the safety and efficacy of the DED for emergency treatment of ruptured intracranial aneurysms.

Methods

Between February 2016 and March 2018, 10 patients (median age 54.5 years, seven women) with 11 aneurysms were treated with the DED at three neurovascular centers. Procedural details, complications, morbidity, and aneurysm occlusion (O’Kelly-Marotta scale, OKM) were retrospectively reviewed.

Results

Among 11 aneurysms treated, there were nine anterior circulation and two posterior circulation aneurysms. Aneurysm morphology was saccular in four cases, dissecting in three, blister-like in three, and fusiform in one. In each case, a single DED was implanted and deployment was technically successful without exception. Adjunctive coiling was performed in two aneurysms. We observed one in-stent thrombosis, presumably due to low response to clopidogrel 4 days after the procedure, which remained with a mild hemiparesis after aspiration thrombectomy. No further thromboembolic or hemorrhagic events occurred. Favorable outcome (modified Rankin scale score ≤2) at last follow-up was achieved in all patients. Among 10 aneurysms available for angiographic follow-up, complete aneurysm occlusion (OKM D) was obtained in nine cases (90.0%).

Conclusions

In this pilot study, endovascular treatment of ruptured intracranial aneurysms with the DED was feasible and not associated with any incidence of rebleeding. Larger series with longer follow-up are warranted to reach a definite conclusion about this device.

Wide-neck bifurcation aneurysms of the middle cerebral artery and basilar apex treated by endovascular techniques: a multicentre, core lab adjudicated study evaluating safety and durability of occlusion (BRANCH)

Background and purpose

BRANCH (wide-neck bifurcation aneurysms of the middle cerebral artery and basilar apex treated by endovascular techniques) is a multicentre, retrospective study comparing core lab evaluation of angiographic outcomes with self-reported outcomes.

Materials and methods

Consecutive patients were enrolled from 10 US centres, aged between 18 and 85 with unruptured wide-neck middle cerebral artery (MCA) or basilar apex aneurysms treated endovascularly. Patient demographics, aneurysm morphology, procedural information, mortality and morbidity data and core lab and self-reported modified Raymond Roy (RR) outcomes were obtained.

Results

115 patients met inclusion criteria. Intervention-related mortality and significant morbidity rates were 1.7% (2/115) and 5.8% (6/103) respectively. Core lab adjudicated RR1 and 2 occlusion rates at follow-up were 30.6% and 32.4% respectively. The retreatment rate within the follow-up window was 10/115 (8.7%) and in stent stenosis at follow-up was 5/63 (7.9%). Self-reporting shows a statistically significant direction to angiographic RR one outcomes at follow-up compared with core lab evaluation, with OR 1.75 (95% CI 1.08 to 2.83).

Conclusion

Endovascular treatment of wide-neck MCA and basilar apex aneurysms resulted in a core lab adjudicated RR1 occlusion rate of 30.6%. Self-reported results at follow-up favour better angiographic outcomes, with OR 1.75 (95% CI 1.08 to 2.83). These data demonstrate the need for novel endovascular devices specifically designed to treat complex intracranial aneurysms, as well as the importance of core lab adjudication in assessing outcomes in such a trial.

Safety and efficacy of the Derivo Embolization Device for the treatment of unruptured intracranial aneurysms: a multicentric study

Background

The Derivo Embolization Device (DED) is a novel flow diverter stent that provides increased x-ray visibility, an improved delivery system, and potentially reduced thrombogenicity. The objective of this study was to evaluate the early safety and efficacy of the second-generation DED.

Methods

We retrospectively analyzed all patients with unruptured intracranial aneurysms (UIAs) treated with the DED between November 2015 and December 2017 in three German tertiary care centers. Procedural details, complications, and morbidity within 30 days after treatment, as well as the aneurysm occlusion rates after 6 months (O’Kelly–Marotta scale, OKM), were evaluated.

Results

Implantation of the DED was attempted in 42 patients with 42 aneurysms. All procedures were technically successful. Multiple DEDs were used in three aneurysms (7.2%) and adjunctive coiling in 11 (26.2%). Procedure-related complications occurred in four cases (9.5%) including three thromboembolic events and one aneurysm perforation. The morbidity rate was 2.4% and there was no mortality. One patient suffered an ischemic stroke with persistent aphasia at 30-day follow-up due to a thromboembolic infarct (modified Rankin Scale score 1). Among 33 patients (78.6%) available for angiographic follow-up, complete (OKM D) and favorable (OKM C+D) aneurysm occlusion was obtained in 72.7% (24/33) and 87.9% (29/33), respectively.

Conclusions

Endovascular treatment of UIAs with the DED is associated with high procedural safety and adequate occlusion rates. Examinations at 1- and 2-year follow-up will provide data on the long-term safety and angiographic outcomes of this device.

China Intracranial Aneurysm Project (CIAP): protocol for a prospective cohort study of interventional treatment and craniotomy for unruptured aneurysms

INTRODUCTION

There are two approaches for the treatment of intracranial aneurysm (IA): interventional therapy and craniotomy, both of which have their advantages and disadvantages in terms of treatment efficacy. To avoid overtreatment of unruptured aneurysms (UIA), to save valuable medical resources and to reduce patient mortality and disability rate, it is vital that neurosurgeons select the most appropriate type of treatment to provide the best levels of care. In this study, we propose a refined, prospective, multicentre study for the Chinese population with strictly defined patient inclusion criteria, along with the selection of representative clinical participating centres.

METHODS AND ANALYSIS

This report describes a multicentre, prospective cohort study. As IA is extremely harmful if it ruptures, ethical issues need to be taken into account with regard to this study. Researchers are therefore not able to use randomised controlled trials. The study will be conducted by 12 clinical centres located in different regions of China. The trial recruitment programme begins in 2016 and is scheduled to be completed in 2020. We expect 1500 participants with UIA to be included. Clinical information relating to the participants will be recorded objectively. The primary endpoints are an evaluation of the safety and efficiency of interventional treatment and craniotomy for 6 months after surgery, with each participant completing at least 1 year of follow-up. The secondary endpoint is the evaluation of safety and efficacy of interventional therapy and craniotomy clipping when participants are treated for 12 months. We also address the success of treatment and the incidence of adverse events.

ETHICS AND DISSEMINATION

The research protocol and the informed consent form for participants in this study were approved by the Ethics Committee of Zhujiang Hospital of Southern Medical University (2017-SJWK-001). The results of this study are expected to be disseminated in peer-reviewed journals in 2021.

TRIAL REGISTRATION NUMBER

NCT03133598.

Voxel based analysis of recurrence dynamics in intracranial aneurysms after coiling

BACKGROUND

Understanding aneurysm growth is critical for the appropriate follow-up of patients after coil embolization and the need for retreatment. The purpose of the study was to stratify the growth dynamics of aneurysm recurrences after coiling by volumetric analysis and to determine predictive factors for aneurysm recurrences.

METHODS

Source images of follow-up three-dimensional time of flight MR angiography (ToF-MRA) scans were compared with the first post-interventional ToF-MRA scan and analyzed for residual flow after co-registration using ANALYZE-software. In the event of incomplete occlusion, the residual volume was segmented and calculated. Growth dynamic was determined for each aneurysm after embolization.

RESULTS

We analyzed 326 patients with 345 aneurysms from two centers. Each case had at least two ToF-MRA examinations after endovascular therapy. The mean observation interval was 59 months. Volumetric analysis of 1139 follow-up MRAs revealed that 218/345 aneurysms (63.2%) showed complete occlusion on initial follow-up imaging, and of these 95.0% remained stable. A steady increase in intra-aneurysmal flow was observed in 83/345 (24.1%). Less frequent observations were a steep increase (21/345; 6.1%) and a decrease (27/345; 7.8%). Independent predictors of increasing residual flow were greatest aneurysm diameter, total coil length, and incomplete occlusion.

CONCLUSIONS

Volumetric analysis of registered three-dimensional ToF-MRA follow-up datasets allows the detection of different growth patterns with high precision, avoids the low inter-rater reliability, and represents a promising approach for future studies that include analysis of more complex predictors of residual flow. In cases of aneurysm recurrence after coiling, the major pattern seems to be a steady increase in intra-aneurysmal flow over several months.

How safe and effective are existing treatments for wide-necked bifurcation aneurysms? Literature-based objective performance criteria for safety and effectiveness

Introduction

Wide-necked bifurcation aneurysms (WNBAs) present unique technical challenges for both endovascular and surgical treatments which aim to achieve complete occlusion of the aneurysm without compromising the patency of the incorporated regional parent vessels. We present a meta-analysis of traditional therapies for WNBAs to provide critical benchmarks for safety and effectiveness.

Methods

Following a systematic search of the literature and the application of pre-specified appropriateness criteria, 43 (including 2794 aneurysms treated) and 65 (including 5366 patients treated) references with sufficient detail were identified to include in a meta-analysis of efficacy and safety, respectively. Effectiveness endpoints of both complete and adequate occlusion were assessed. A composite safety endpoint was based upon commonly applied metrics for major adverse events. Fleiss analyses were performed for both effectiveness and safety endpoints for the entire group, and then parsed separately by treatment modality (surgical clipping (SC) or endovascular therapy (EVT)) and location (anterior or posterior circulation).

Results

Using the above methods, the core laboratory adjusted rate of complete occlusion was 46.3% (standard error 3.6%), 39.8% (3.7%), and 52.5% (9.6%) for all therapies, EVT, and SC, respectively. The rate of adequate occlusion was 59.4% (12.2%), 43.8% (5.3%), and 69.7% (14.3%) for all therapies, EVT, and SC, respectively. The rates of occurrence for pre-specified safety endpoints were 18.7% (2.9%), 21.1% (2.8%), and 24.3% (4.9%) for all therapies, EVT, and SC, respectively.

Conclusions

Conventional therapies for WNBAs are associated with relatively low rates of complete occlusion and peri-procedural complications are not uncommon. As new treatment technologies are investigated, it is important that the available data regarding predicate treatments is understood.

Interrater Agreement in the Radiologic Characterization of Ruptured Intracranial Aneurysms Based on Computed Tomography Angiography

OBJECTIVE

To determine interrater agreement in the initial radiologic characterization of ruptured intracranial aneurysms based on computed tomography angiography (CTA) with special emphasis on the rater's level of experience.

METHODS

One junior and one senior rater of 5 high-volume neurovascular tertiary centers evaluated anonymized CTA images of 30 consecutive patients with aneurysmal subarachnoid hemorrhage. Each rater described location, side, size, and morphology in a standardized manner. Interrater variability was analyzed using intraclass correlation and Fleiss' kappa analysis.

RESULTS

There was a high level of agreement for location (κ = 0.76, 95% confidence interval [CI] 0.74-0.79), side (κ = 0.95, CI 0.91-0.99), maximum diameter (intraclass correlation coefficient [ICC] 0.81, CI 0.70-0.90), and dome (ICC 0.78, CI 0.66-0.88) of intracranial aneurysms. In contrast, a lower level of agreement was observed for aneurysms' neck diameter (ICC 0.39, CI 0.28-0.58), the presence of multiple aneurysms (κ = 0.35, CI 0.30-0.40), and aneurysm morphology (blister κ = 0.11, CI -0.05 to 0.07; fusiform κ = 0.54, CI 0.48-0.60; multilobular, κ = 0.39 CI 0.33-0.45). The interrater agreement in the senior rater group was greater than in the junior rater group.

CONCLUSIONS

Interrater agreement confirms the benefit of CTA as initial diagnostic imaging in ruptured intracranial aneurysms but not for aneurysm morphology and presence of multiple aneurysms. A trend towards greater interrater agreement between more experienced raters was noticed.

GEL THE NEC: a prospective registry evaluating the safety, ease of use, and efficacy of the HydroSoft coil as a finishing device

Background and purpose

The HydroSoft coil was developed as a finishing coil, ideally to be placed along the aneurysm neck to enhance intracranial aneurysm healing. The GEL THE NEC (Gaining Efficacy Long Term: Hydrosoft, an Emerging, New, Embolic Coil) multicenter registry was developed to assess the safety and efficacy of HydroSoft coils in treating intracranial aneurysms. We report angiographic and clinical results of this prospective registry.

Materials and methods

GEL THE NEC was performed at 27 centers in five countries. Patients aged 21–90 years with a ruptured or unruptured aneurysm 3–15 mm in size were eligible for enrollment. The following variables were obtained: demographics/comorbidities, aneurysm geometry, adjunctive devices used, proportion of patients in whom HydroSoft coils were successfully placed, and long-term angiographic outcomes (graded by an independent core laboratory using the Modified Raymond Scale), and procedure-related adverse events. Predictors of good angiographic outcome were studied using χ2 and t-tests.

Results

A total of 599 patients with 599 aneurysms were included in this study. HydroSoft coils were successfully deployed in 577 (96.4%) patients. Procedure-related major morbidity and mortality were 0.5% (3/599) and 1.3% (8/599), respectively. The most common perioperative complications were iatrogenic vasospasm (30/599, 5.0%), thromboemboli (27/599, 4.5%), and aneurysm perforation (16/599, 2.7%). At last angiographic follow-up (mean 9.0±6.3 months), the complete occlusion rate was 63.2% (280/442) and near complete occlusion rate was 25.2% (107/442). The core laboratory read recanalization rate was 10.8% (46/425) and the retreatment rate was 3.4% (20/599).

Conclusions

Endovascular treatment of intracranial aneurysms with HydroSoft coils resulted in complete/near complete occlusion rates of 88% and a major complication rate of 1.8%.

Trial registration number

NCT01000675.

Inter- and Intrarater Agreement on the Outcome of Endovascular Treatment of Aneurysms Using MRA

BACKGROUND AND PURPOSE

Patients treated with coiling are often followed by MR angiography. Our objective was to assess the inter- and intraobserver agreement in diagnosing aneurysm remnants and recurrences by using multimodality imaging, including TOF MRA.

MATERIALS AND METHODS

A portfolio composed of 120 selected images from 56 patients was sent to 15 neuroradiologists from 10 institutions. For each case, raters were asked to classify angiographic results (3 classes) of 2 studies (32 MRA-MRA and 24 DSA-MRA pairs) and to provide a final judgment regarding the presence of a recurrence (no, minor, major). Six raters were asked to independently review the portfolio twice. A second study, restricted to 4 raters having full access to all images, was designed to validate the results of the electronic survey.

RESULTS

The proportion of cases judged to have a major recurrence varied between 16.1% and 71.4% (mean, 35.0% ± 12.7%). There was moderate agreement overall (κ = 0.474 ± 0.009), increasing to nearly substantial (κ = 0.581 ± 0.014) when the judgment was dichotomized (presence or absence of a major recurrence). Agreement on cases followed-up by MRA-MRA was similarly substantial (κ = 0.601 ± 0.018). The intrarater agreement varied between fair (κ = 0.257 ± 0.093) and substantial (κ= 0.699 ± 0.084), improving with a dichotomized judgment concerning MRA-MRA comparisons. Agreement was no better when raters had access to all images.

CONCLUSIONS

There is an important variability in the assessment of angiographic outcomes of endovascular treatments. Agreement on the presence of a major recurrence when comparing 2 MRA studies or the MRA with the last catheter angiographic study can be substantial.

Interobserver variability in the characterization of giant intracranial aneurysms with special emphasis on aneurysm diameter and shape

BACKGROUND

The Giant Intracranial Aneurysm Registry is a multicenter observational trial exclusively focusing on giant intracranial aneurysms (GIA). As no data exist on the interobserver variability in the radiological description of GIA, there is some uncertainty concerning the reliability of the GIA characteristics included in the registry. We have therefore designed a study to test the interobserver variability in the description of the specific GIA characteristics that are examined in the GIA registry.

METHODS

Six different raters analyzed imaging of five GIA concerning GIA location, GIA size, GIA shape, GIA thrombosis, and the presence of perianeurysmal edema. Interobserver variability was examined using intraclass correlation and Fleiss' kappa analysis.

RESULTS

The intraclass correlation coefficient was 0.99 (95 % CI 0.97-1.0) for the largest GIA diameter and 0.98 (95 % CI 0.94-1.0) for the largest GIA diameter in an axial imaging slice. We found perfect interobserver agreement (Fleiss' kappa 1.00) in the characterization of GIA location and the presence of perianeurysmal edema and almost perfect interobserver agreement for GIA thrombosis (Fleiss' kappa 0.86, 95 % CI 0.63-1.00). Only moderate interobserver agreement was found in the description of GIA shape (Fleiss' kappa 0.50, 95 % CI 0.27-0.73).

CONCLUSIONS

While GIA size, location, thrombosis, and the presence of perianeurysmal edema showed excellent interobserver agreement, the description of GIA shape was achieved with only moderate agreement. Data on GIA shape in multicenter studies, like the GIA registry, should therefore be discussed with caution and potentially reassessed in a centralized fashion.

Is visual evaluation of aneurysm coiling a reliable study end point? Systematic review and meta-analysis

BACKGROUND AND PURPOSE

Angiographic occlusion as a surrogate marker of satisfactory aneurysm treatment is commonly used in clinical trials although some pitfalls have to be considered. To investigate the inter-rater reliability of visual rating of aneurysm occlusion as study end point, we performed a systematic review and meta-analysis.

METHODS

Electronic databases (MEDLINE, EMBASE, PubMed, and the Cochrane Library) were searched up to June 2014. Assessment of risk for bias was based on the Quality Appraisal Tool for Studies of Diagnostic Reliability and the Guidelines for Reporting Reliability and Agreement studies. Inter-rater reliability estimates were pooled across studies using meta-analysis, and the influence of several factors (eg, imaging methods, grading scales, and occlusion rate) was tested with meta-regression.

RESULTS

From 1193 titles, 644 abstracts and 87 full-text versions were reviewed. Twenty-six articles met the inclusion criteria and provided 77 reliability estimates. Twenty-one different rating scales were used, and statistical analysis varied. Mean inter-rater agreement of the pooled studies was substantial (κ=0.65; 95% confidence interval, 0.60-0.69). Reliability varied significantly as a function of imaging methods, grading scales, occlusion rates, and their interaction. Observer agreement substantially increased with increasing occlusion rate in digital subtraction angiography but not in MR angiography. Reliability was higher in studies using 2- or 3-value grading scales than in studies with 4-value grading scales.

CONCLUSIONS

There is significant heterogeneity between studies evaluating the reliability of visual evaluation of aneurysm coiling. On the basis of our analysis, we found that the combination of magnetic resonance angiography, 3-value grading scale, and 2 trained raters seems most promising for usage as surrogate study end points.

HydroCoils reduce recurrence rates in recently ruptured medium-sized intracranial aneurysms: a subgroup analysis of the HELPS trial

BACKGROUND AND PURPOSE

The HydroCoil Endovascular Aneurysm Occlusion and Packing Study (HELPS) was a randomized, controlled trial comparing HydroCoils with bare-platinum coils. The purpose of this study was to perform a subgroup analysis of angiographic and clinical outcomes of medium-sized aneurysms in the HELPS trial.

MATERIALS AND METHODS

Patients with medium-sized aneurysms (5-9.9 mm) were selected from the HELPS trial. Outcomes compared between the HydroCoil and bare-platinum groups included the following: 1) any recurrence, 2) major recurrence, 3) retreatment, and 4) mRS score of ≤2. Subgroup analysis by rupture status was performed. Multivariate logistic regression analysis adjusting for aneurysm neck size, shape, use of adjunctive device, and rupture status was performed.

RESULTS

Two hundred eighty-eight patients with medium-sized aneurysms were randomized (144 in each group). At 15-18 months posttreatment, the major recurrence rate was significantly lower in the HydroCoil group than in controls (18.6% versus 30.8%, P = .03, respectively). For patients with recently ruptured aneurysms, the major recurrence rate was significantly lower for the HydroCoil group than for controls (20.3% versus 47.5%, P = .003), while rates were similar between groups for unruptured aneurysms (16.7% versus 14.8%, P = .80). Multivariate analysis of patients with recently ruptured aneurysms demonstrated a lower odds of major recurrence with HydroCoils (OR = 0.27; 95% CI, 0.12-0.58; P = .0007). No difference in retreatment rates or mRS of ≤2 was seen between groups.

CONCLUSIONS

HydroCoils were associated with statistically significant and clinically relevant lower rates of major recurrence for recently ruptured, medium-sized aneurysms in the HELPS trial. Because this was not a prespecified subgroup analysis, these results should not alter clinical practice but, rather, provide insight into the design of future clinical trials comparing bare platinum with second-generation coils.

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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Aneurysm Recurrence Volumetry Is More Sensitive than Visual Evaluation of Aneurysm Recurrences

PURPOSE

Considerable inter-observer variability in the visual assessment of aneurysm recurrences limits its use as an outcome parameter evaluating new coil generations. The purpose of this study was to compare visual assessment of aneurysm recurrences and aneurysm recurrence volumetry with an example dataset of HydroSoft coils (HSC) versus bare platinum coils (BPC).

METHODS

For this retrospective study, 3-dimensional time-of-flight magnetic resonance angiography datasets acquired 6 and 12 months after endovascular therapy using BPC only or mainly HSC were analyzed. Aneurysm recurrence volumes were visually rated by two observersas well as quantified by subtraction of the datasets after intensity-based rigid registration.

RESULTS

A total of 297 aneurysms were analyzed (BPC: 169, HSC: 128). Recurrences were detected by aneurysm recurrence volumetry in 9 of 128 (7.0 %) treated with HSC and in 24 of 169 (14.2 %) treated with BPC (odds ratio: 2.39, 95 % confidence interval: 1.05-5.48; P = 0.039). Aneurysm recurrence volumetry revealed an excellent correlation between observers (Cronbach's alpha = 0.93). In contrast, no significant difference in aneurysm recurrence was found for visual assessment (3.9 % in HSC cases and 4.7 % in BPC cases). Recurrences were observed in aneurysms smaller than the sample median in 10 of 33 (30.3 %) by aneurysm recurrence volumetry and in 1 of 13 (7.7 %) by visual assessment.

CONCLUSIONS

Aneurysm recurrences were detected more frequently by aneurysm recurrence volumetry when compared with visual assessment. By using aneurysm recurrence volumetry, differences between treatment groups were detected with higher sensitivity and inter-observer validity probably because of the higher detection rate of recurrences in small aneurysms.

Effects of circle of Willis anatomic variations on angiographic and clinical outcomes of coiled anterior communicating artery aneurysms

BACKGROUND AND PURPOSE

Anterior communicating artery aneurysms account for one-fourth of all intracranial aneurysms and frequently occur in the context of A1 vessel asymmetry. The purpose of this study was to correlate circle of Willis anatomic variation association to angiographic and clinical outcomes of anterior communicating aneurysm coiling.

MATERIALS AND METHODS

The Cerecyte Coil Trial provides a subgroup of 124 cases with anterior communicating artery aneurysms after endovascular coiling. One hundred seventeen of 124 anterior communicating artery aneurysms had complete imaging and follow-up for clinical outcome analysis, stability of aneurysm coil packing, and follow-up imaging between 5 and 7 months after treatment. Clinical outcomes were assessed by the mRS at 6 months.

RESULTS

Anterior cerebral artery trunk-dominance was seen in 91 of 124 (73%) anterior communicating artery aneurysms and codominance in 33 of 124 (27%) anterior communicating artery aneurysms. There was no significant difference (P > .5) in treatment success at 5-7 months for anterior communicating artery aneurysms between the anterior cerebral artery trunk-dominant (49 of 86, 57%) and anterior cerebral artery trunk-codominant (19 of 31) groups. Angiographic follow-up demonstrates a statistically significant increase in neck remnants and progressive aneurysm sac filling with the A1 dominant configuration (n = 21, 24% at follow-up versus n = 11, 12% at immediate posttreatment, P = .035). There was no statistically significant difference in clinical outcomes between types of anterior cerebral artery trunk configuration (P > .5).

CONCLUSIONS

Anterior communicating artery aneurysms with anterior cerebral artery trunk-dominant circle of Willis configurations show less angiographic stability at follow-up than those with anterior cerebral artery trunk-codominance similar to other "termination" type aneurysms. This supports the hypothesis that anterior cerebral artery trunk-dominant flow contributes to aneurysm formation, growth, and instability after coiling treatment.