Endovascular Treatment of 429 Anterior Communicating Artery Aneurysms Using Bare-Platinum Coils : Clinical and Radiologic Outcomes at the Long-term Follow-up

Computer-assisted microcatheter shaping for intracranial aneurysm embolization: evaluation of safety and efficacy in a multicenter randomized controlled trial

BACKGROUND

This study aimed to evaluate the efficacy, stability, and safety of computer-assisted microcatheter shaping (CAMS) in patients with intracranial aneurysms.

METHODS

A total of 201 patients with intracranial aneurysms receiving endovascular coiling therapy were continuously recruited and randomly assigned to the CAMS and manual microcatheter shaping (MMS) groups. The investigated outcomes included the first-trial success rate, time to position the microcatheter in aneurysms, rate of successful microcatheter placement within 5 min, delivery times, microcatheter stability, and delivery performance.

RESULTS

The rates of first-trial success (96.0% vs 66.0%, P<0.001), successful microcatheter placement within 5 min (96.04% vs 72.00%, P<0.001), microcatheter stability (97.03% vs 84.00%, P=0.002), and 'excellent' delivery performance (45.54% vs 24.00%, P<0.001) in the CAMS group were significantly higher than those in the MMS group. Additionally, the total microcatheter delivery and positioning time (1.05 minutes (0.26) vs 1.53 minutes (1.00)) was significantly shorter in the CAMS group than in the MMS group (P<0.001). Computer assistance (OR 14.464; 95% CI 4.733 to 44.207; P<0.001) and inflow angle (OR 1.014; 95% CI 1.002 to 1.025; P=0.021) were independent predictors of the first-trial success rate. CAMS could decrease the time of microcatheter position compared with MMS, whether for junior or senior surgeons (P<0.001). Moreover, computer assistance technology may be more helpful in treating aneurysms with acute angles (p<0.001).

CONCLUSIONS

The use of computer-assisted procedures can enhance the efficacy, stability, and safety of surgical plans for coiling intracranial aneurysms.

A single-center comparative study with large sample size on stent-assisted coiling versus coiling alone for the ruptured anterior communicating artery aneurysms: Analysis of safety, efficacy, and prognosis based on propensity score matching

OBJECTIVE

To compare the safety, efficacy, and prognosis of stent-assisted coiling (SAC) versus coiling alone (CA) in the treatment of ruptured anterior communicating artery aneurysms (ACoAAs).

METHODS

The clinical and follow-up data of ruptured ACoAAs treated with endovascular treatment in our center from January 2011 to January 2021 were retrospectively collected. Patients were divided into an SAC group and a CA group based on whether stents were used, after which the two groups were matched for propensity scores. The general clinical data, embolization effect, perioperative complications, clinical, and follow-up results after matching were compared.

RESULTS

A total of 354 patients were enrolled, of whom 147 patients (41.5%) received SAC and the rest received CA. Comparison baseline of two groups showed that patients with a larger diameter, wide neck, irregular morphology, and anterior direction were more likely to receive SAC. After propensity score matching, 113 patients were included in each group. Immediately postoperative angiography results showed that the complete embolization rate of patients in the SAC group was significantly lower than that in the CA group (62.8% vs. 76.1%, p = 0.03). There were no significant differences between the two groups in the incidence of perioperative complications, mortality, poor prognosis at discharge or follow-up, mid-term complete occlusion rate and recurrence rate.

CONCLUSION

The stent-assisted treatment of ruptured ACoAAs did not increase the risk of perioperative complications or the probability of poor prognosis, indicating that SAC treatment of ruptured ACoAAs is safe and feasible and has a reliable mid-term cure rate.

Intra-procedural complications, success rate, and need for retreatment of endovascular treatments in anterior communicating artery aneurysms: a systematic review and meta-analysis

In recent years, intracranial aneurysms have been widely treated with endovascular methods. The anterior communicating artery (Acom) is the most common site of intracranial aneurysms. Despite its effectiveness, endovascular interventions can be associated with various intra-procedural and post-procedural complications. A systematic review of the literature was performed through PubMed, Embase, Scopus, and Web of Sciences databases up to March 18, 2022. The pooled rates of intra-procedural complications, mortality, procedure-related morbidities, the immediate and late aneurysm occlusion, and also the necessity for retreatment were calculated by applying random-effects models. A total of 41 articles with 4583 patients were included in the meta-analysis. The pooled rate of overall intra-procedural complications was 9.6% (95% CI: 7.7 to 11.8%). The initial rupture status and also type of EVT procedure did not affect the overall complication rate. The pooled rate of intra-procedural thrombosis, aneurysm rupture, coil prolapse, and early aneurysm rebleeding were 6.1% (95% CI: 4.5 to 8.2%); 4.2% (95% CI: 3.4 to 5.2%), 4.7% (95% CI: 3.2 to 6.7%), and 2.2% (95% CI: 1.5 to 3.2%), respectively. Our analysis showed that intra-procedural mortality occurred in 1.7% (95% CI: 1.1 to 2.5%) and procedure-related permanent morbidities in 3.3% (95% CI: 2.3 to 4.7%) of patients. Endovascular methods achieved complete and near to complete aneurysm occlusion (Raymond-Roy occlusion classification 1 and 2) in 89.2% (95% CI: 86.4 to 92.5%) of cases post-procedure, and 9.5% (95% CI: 7.3 to 12.4%) of patients needed retreatment due to recanalization in follow-ups. Endovascular treatment can serve as an acceptable method for Acom aneurysms. However, improved endovascular treatment equipment and new techniques provide more satisfactory outcomes for complicated cases.

Topographical Analysis of Aneurysm Wall Enhancement With 3-Dimensional Mapping

BACKGROUND

Aneurysm wall enhancement has been identified as a potential biomarker for aneurysm instability. Enhancement has been determined by different approaches on 2D multiplanar views. This study describes a new method to quantify enhancement through 3D heatmaps and histograms.

METHODS

A custom algorithm was developed using orthogonal probes extending from the aneurysm lumen into the wall to create 3D heatmaps and histograms of wall enhancement on 7T-MRI. Three quantitative metrics for general, specific, and focal wall enhancement were generated from the histograms.

RESULTS

Thirty-two aneurysms were analyzed and classified based on 3D heatmaps and histograms. Larger aneurysms were more enhancing (Spearman's r=0.472, p=0.006), and had more heterogeneous enhancement (Spearman's r=0.557, p<0.001) than smaller aneurysms. Patterns of enhancement differed between saccular, fusiform, and thrombosed aneurysms. Fusiform aneurysms were larger (p=0.015) and had more heterogenous enhancement compared to saccular aneurysms. Fusiform aneurysms had more areas of focal enhancement (p<0.001) and right skewed histograms (p=0.003).

CONCLUSIONS

The 3D analysis of aneurysm wall enhancement provides topographic data of the entire aneurysm wall. New metrics developed based on this method showed that large and fusiform aneurysms have heterogenous enhancement.

Multicenter Retrospective Registry of Anterior Communicating Artery Aneurysms with Endovascular Therapy (MACAARET): safety and efficacy study according to morphological considerations and spatial orientations

AIM

To analyse the safety and efficacy parameters of endovascular treatment of anterior communicating artery (ACoA) aneurysms, according to their morphological considerations and three-dimensional orientation in a multicentric registry.

MATERIALS AND METHODS

A retrospective analysis was undertaken of a prospective database of consecutive patients that underwent endovascular embolisation for ACoA aneurysm in four high-volume neuroradiology interventional departments. The study has been registered in ClinicalTrial.gov. Data were collected regarding the clinico-demographic variables of the patients, anatomical variations of the circle of Willis, morphological considerations and spatial orientation of ACoA aneurysms were recorded. Safety and efficacy variables were also recorded. Associations between anatomical variations of the circle of Willis, morphological considerations, and spatial orientation of the ACoA aneurysms and safety and efficacy variables were assessed.

RESULTS

Data from 122 consecutive patients were collected in the MACAARET study (mean age (±SD) was 55 (±14) and 50.8% (62/122) were male). One hundred and five patients (86.1%) presented with subarachnoid haemorrhage (SAH). ACoA aneurysms with a neck size of >4 mm had less chance of having successful endovascular treatment than those of ≤4 mm (19.8% versus 46.7%; p=0.002) and were also more likely to recanalise during follow-up (61.5% versus 19.5%; p=0.003). Moreover, ACoA aneurysms with an aspect ratio of >1.7 had more chance of having immediate therapeutic success than those with a ratio of ≤1.7 (70.7% versus 44.8%; p=0.012). There were no other associations between the anatomical variables of the ACoA aneurysms and the safety-efficacy variables.

CONCLUSION

ACoA aneurysms are suitable for both endovascular and microsurgical approaches, but more data are required to determine which is the best approach regarding the morphological and spatial orientation of the aneurysm and the anatomical variations of the circle of Willis.

Optimal microcatheter shaping method customized for a patient-specific vessel using a three-dimensional printer

Objective

In coil embolization of cerebral aneurysms, it is very important to guide microcatheters to the appropriate location in the aneurysm and stabilize them during procedures. To do this, microcatheters need to be properly shaped. In this study, we aim to use a computer application program and a three-dimensional (3D) printer to make a patient-specific shaped microcatheter.

Methods

We simplified, skeletalized, and oversized the existing 3D vascular imaging structures and created the central line structure of the blood vessels. These processes were performed using a computer application program developed by our team. The microcatheters were shaped according to the skeletalized data shape, and the catheterization procedures were simulated using the 3D hollow model of the blood vessel region of interest; the number of hollow models was 10. The compatibility of the microcatheters shaped according to the skeletalized data shape was validated if the microcatheter tip was positioned into the aneurysm.

Results

In all 10 hollow models, the positioning of the microcatheter into the aneurysms was successful following one or two attempts.

Conclusions

When shaping microcatheters during endovascular coil embolization, it may be useful to use central line structures with some expansions customized for a patient-specific vessel using a computer application program and a 3D printer. In the future, it may be necessary to apply this technique to actual patients.

Microsurgical Treatment of Unruptured Anterior Communicating Artery Aneurysms: Approaches and Outcomes in a Large Contemporary Series and Review of the Literature

BACKGROUND

With advances in endovascular techniques, the relative roles of microsurgery and endovascular therapy in the management of intracranial aneurysms have become less clear, and data regarding treatment-specific outcomes are increasingly important.

OBJECTIVE

To describe our experience with microsurgery in a large series of unruptured anterior communicating artery aneurysms (ACOMMAAs) and detail our treatment decision-making process based on individual aneurysm morphology.

METHODS

We retrospectively reviewed unruptured ACOMMAAs treated microsurgically at our center between 1997 and 2018, recording aneurysm size, surgical approach, occlusion rates, neurological outcomes, and complications.

RESULTS

We treated 300 unruptured ACOMMAAs in 300 patients, mean age 49 yr, 180 (60.0%) female, including 245 (81.7%) small, 50 (16.7%) large, and 5 (1.7%) giant aneurysms. Most underwent a pterional approach (253, 84.3%), with orbitozygomatic or anterior interhemispheric approaches in 35 (11.7%) and 12 (4%), respectively. Greater than 95% occlusion was achieved in 284 (94.7%), 90% to 95% occlusion in 13 (4.3%), and 3 (1.0%) underwent wrapping. Serious complications occurred in 3 patients (1.0%) resulting in 2 deaths (0.7%), and minor complications in 12 (4.0%). At final follow-up, good neurological outcome was observed in 297 (99.0%) patients.

CONCLUSION

Given clinical equipoise regarding optimal treatment of unruptured ACOMMAAs, this work provides a benchmark for achievable microsurgical outcomes. Future surgical/endovascular studies should separate results of ruptured and unruptured lesions and describe aneurysm morphology to allow for better comparison of outcomes between treatments. We suggest that open microsurgery represents an important option for select, morphologically complex ACOMMAAs, and that a multidisciplinary approach offers optimal patient outcomes.

Microcatheter shaping using three-dimensional printed models for intracranial aneurysm coiling

Background and purpose

Microcatheterization is an important, but also difficult, technique used for the embolization of intracranial aneurysms. The purpose of this study was to investigate the application of three-dimensional (3D) printing technology in microcatheter shaping.

Methods

Nine cases of internal carotid artery posterior communicating artery aneurysm diagnosed by CT angiography were selected, and 3D printing technology was used to build a 3D model including the aneurysm and the parent artery. The hollow and translucent model had certain flexibility; it was immersed in water and the microcatheter was introduced into the water to the target position in the aneurysm, followed by heating the water temperature to 50°C. After soaking for 5 min, the microcatheter was taken out and the shaping was completed. After sterilization, the shaped microcatheter was used for arterial aneurysm embolization and evaluation was conducted.

Results

Nine cases of microcatheter shaping were satisfactory and shaping the needle was not necessary; no rebound was observed. The microcatheter was placed in an ideal position, and the stent-assisted method was used in three cases of wide-neck aneurysm. There were no complications related to surgery.

Conclusion

A new microcatheter shaping method using 3D printing technology makes intracranial artery aneurysm embolization more stable and efficient.

Procedural Clinical Complications, Case-Fatality Risks, and Risk Factors in Endovascular and Neurosurgical Treatment of Unruptured Intracranial Aneurysms: A Systematic Review and Meta-analysis

Importance

The risk of procedural clinical complications and the case-fatality rate (CFR) from preventive treatment of unruptured intracranial aneurysms varies between studies and may depend on treatment modality and risk factors.

Objective

To assess current procedural clinical 30-day complications and the CFR from endovascular treatment (EVT) and neurosurgical treatment (NST) of unruptured intracranial aneurysms and risk factors of clinical complications.

Data Sources

We searched PubMed, Excerpta Medica Database, and the Cochrane Database for studies published between January 1, 2011, and January 1, 2017.

Study Selection

Studies reporting on clinical complications, the CFR, and risk factors, including 50 patients or more undergoing EVT or NST for saccular unruptured intracranial aneurysms after January 1, 2000, were eligible.

Data Extraction and Synthesis

Per treatment modality, we analyzed clinical complication risk and the CFR with mixed-effects logistic regression models for dichotomous data. For studies reporting data on complication risk factors, we obtained risk ratios (RRs) or odds ratios (ORs) with 95% CIs and pooled risk estimates with weighted random-effects models.

Main Outcomes and Measures

Clinical complications within 30 days and the CFR.

Results

We included 114 studies (106 433 patients with 108 263 aneurysms). For EVT (74 studies), the pooled clinical complication risk was 4.96% (95% CI, 4.00%-6.12%), and the CFR was 0.30% (95% CI, 0.20%-0.40%). Factors associated with complications from EVT were female sex (pooled OR, 1.06 [95% CI, 1.01-1.11]), diabetes (OR, 1.81 [95% CI, 1.05-3.13]), hyperlipidemia (OR, 1.76 [95% CI, 1.3-2.37]), cardiac comorbidity (OR, 2.27 [95% CI, 1.53-3.37]), wide aneurysm neck (>4 mm or dome-to-neck ratio >1.5; OR, 1.71 [95% CI, 1.38-2.11]), posterior circulation aneurysm (OR, 1.42 [95% CI, 1.15-1.74]), stent-assisted coiling (OR, 1.82 [95% CI, 1.16-2.85]), and stenting (OR, 3.43 [95% CI, 1.45-8.09]). For NST (54 studies), the pooled complication risk was 8.34% (95% CI, 6.25%-11.10%) and the CFR was 0.10% (95% CI, 0.00%-0.20%). Factors associated with complications from NST were age (OR per year increase, 1.02 [95% CI, 1.01-1.02]), female sex (OR, 0.43 [95% CI, 0.32-0.85]), coagulopathy (OR, 2.14 [95% CI, 1.13-4.06]), use of anticoagulation (OR, 6.36 [95% CI, 2.55-15.85]), smoking (OR, 1.95 [95% CI, 1.36-2.79]), hypertension (OR, 1.45 [95% CI, 1.03-2.03]), diabetes (OR, 2.38 [95% CI, 1.54-3.67]), congestive heart failure (OR, 2.71 [95% CI, 1.57-4.69]), posterior aneurysm location (OR, 7.25 [95% CI, 3.70-14.20]), and aneurysm calcification (OR, 2.89 [95% CI, 1.35-6.18]).

Conclusions and Relevance

This study identifies risk factors for procedural complications. Large data sets with individual patient data are needed to develop and validate prediction scores for absolute complication risks and CFRs from EVT and NST modalities.

Long-Term Neurological and Radiological Results of Consecutive 63 Unruptured Anterior Communicating Artery Aneurysms Clipped via Lateral Supraorbital Keyhole Minicraniotomy

BACKGROUND

Treatments for unruptured anterior communicating artery (AcomA) aneurysm have relatively high morbidity.

OBJECTIVE

To assess the lateral supraorbital keyhole approach for safe and complete clipping of unruptured AcomA aneurysm and evaluate the long-term clinical and radiological outcomes, including cognitive and depressive status.

METHODS

A total of 63 patients (aged 41-79 yr, mean 64 yr) with relatively small AcomA aneurysms clipped via the lateral supraorbital approach were retrospectively analyzed among the 105 AcomA aneurysms treated by clipping from 2005 to 2014. Neurological and cognitive functions were examined by several scales, including the modified Rankin Scale (mRS) and Mini-Mental Status Examination. The depressive state was assessed using the Beck Depression Inventory and Hamilton Depression Scale. The state of clipping was assessed 1 yr and then every few years after the operation by 3-dimensional computed tomography angiography.

RESULTS

Complete neck clipping was confirmed in 62 aneurysms (98.4%). Perioperative complications occurred in 5 patients (5/63; mild frontalis muscle weakness in 3, anosmia in 1, and meningitis in 1). The mean clinical follow-up period was 5.2 ± 2.1 yr. No patient showed an mRS score more than 2 and all were completely independent in daily life. The depression scores were significantly improved after surgery. The overall mortality was 0% and overall morbidity (mRS score &gt; 2 or Mini-Mental Status Examination score &lt; 24) was 1.6%. All completely clipped aneurysms did not show any recurrence during the mean follow-up period of 4.9 ± 2.1 yr.

CONCLUSION

Lateral supraorbital keyhole approach to clip relatively small unruptured AcomA aneurysm promises less invasive and durable treatment.

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.

Stand-alone coil embolization of anterior communicating artery aneurysms: Efficacy and technical issues

OBJECTIVE

We report our experience with endovascular coiling of anterior communicating artery aneurysms with special consideration of angiographic and clinical outcomes and periprocedural complications.

MATERIALS AND METHODS

The analysis included treatment results of 28 patients with ruptured and unruptured aneurysms. The aneurysm size ranged from 1.8 to 9.8 mm (mean 5.2, SD 1.7). Clinical examinations with the use of modified Rankin Score and angiographic outcomes were evaluated initially post-embolization and at a minimum follow-up of six months.

RESULTS

Initial post-treatment complete and near-complete aneurysm occlusion was achieved in 27 (96%) cases and incomplete occlusion in one (4%) case. Imaging follow-up, performed in 15 (53.6%) patients, showed no change in the degree of occlusion in 11 (73%), coil compaction in one (7%) and progressive occlusion in three (20%) patients. Three (20%) patients underwent a second coil embolization. The procedure-related severe morbidity and mortality rate was 6.4% (2/31). Coil prolapse was present in one (3.2%) case and intraprocedural aneurysm rupture in three (9.6%) cases. The clinical follow-up evaluation achieved in 19 (67.9%) patients showed no change in 17 (89.5%) patients and improvement in two (10.5%) patients.

CONCLUSIONS

Although the efficacy of coil embolization of anterior communicating artery aneurysms is unquestionable and the procedure-related complications are acceptable, they should not be neglected. Further investigations are needed to better understand protective factors, as well as to establish unequivocally appropriate management strategy of these complications.

Stent-assisted coiling versus coiling alone of ruptured anterior communicating artery aneurysms: A single-center experience

OBJECTIVE

Endovascular coiling of anterior communicating artery (ACoA) aneurysms has evolved; however, stent-assisted coiling of ruptured aneurysms remains controversial. We aimed to compare periprocedural complications, angiographic and clinical outcomes after stent-assisted coiling with coiling alone of ruptured ACoA aneurysms.

METHODS

We performed a retrospective review of consecutive 222 patients with ruptured ACoA aneurysms treated with endovascular coiling within 7 days after ictus. Patients were grouped into stent-assisted coiling and coiling alone groups. Baseline characteristics, periprocedural complications, clinical outcomes, and angiographic results were compared between the two groups.

RESULTS

63 (28.4%) patients underwent stent-assisted coiling and 159 (71.6%) underwent coiling alone. There were no statistically significant differences in age, sex, clinical grading and Fisher grade. Larger aneurysms (P=0.002) and wider-neck aneurysms (P<0.001) were more often treated with stent-assisted coiling within 72h (P=0.025). Intraprocedural aneurysm rupture occurred in 6 (9.5%) patients treated with stent-assisted coiling compared with in 5 (3.1%) treated with coiling alone (P<0.048). Thrombus formation occurred in 10 (15.9%) patients after stent-assisted coiling compared with 6 (3.8%) after coiling alone (P=0.002). Stent-assisted coiling achieved a lower rate of immediate occlusion than coiling alone (P=0.045). Postoperative complications, clinical outcomes, and follow-up aneurysm occlusion did not significantly differ.

CONCLUSIONS

Stent-assisted coiling of ruptured ACoA aneurysms was associated with a higher rate of intraprocedural complications and associated with a lower immediate occlusion rate. However, Postoperative complications and clinical outcomes did not differ. Long-term angiographic results require further study.