Endovascular Treatment of Large or Giant Basilar Artery Aneurysms Using the Pipeline Embolization Device: Complications and Outcomes

Clinical Outcomes On Tubridge Flow Diverter in Treatmenting Intracranial Aneurysms: a Retrospective Multicenter Registry Study

PURPOSE

In China, the application of nitinol Tubridge flow diverter (TFD) has become popular for treating intracranial aneurysms (IAs). In this study, we investigated the safety outcomes of the application of TFD for treating IAs in real-world scenarios.

METHODS

We retrospectively analyzed aneurysms treated with TFD in 235 centers throughout China between April 2018 and April 2020. The primary endpoint was the event-free survival rate at 12 months, defined as the occurrence of morbidity (spontaneous rupture, intraparenchymal hemorrhage (IPH), ischemic stroke, and permanent cranial neuropathy) or death. Univariate and multivariate analyses were performed to assess the risk factors. A good outcome was defined as a modified Rankin Score (mRS) of 0-2.

RESULTS

We included 1281 unruptured aneurysms treated with TFD. The overall neurological morbidity and death rates after 12 months were 5.4 and 2.8%, respectively. Ischemic strokes were the most common complication (4.2%, P < 0.001). Cranial neuropathy, IPH, and spontaneous rupture occurred in 0.3%, 0.3%, and 0.5% of aneurysms, respectively. Univariate and multivariate analyses indicated that the male gender, older age, larger aneurysm diameter, and aneurysm located on BA were the independent risk factors for neurologic events. Aneurysm located on BA was the independent risk factor for ischemic strokes. Most patients (1222) had access to the mRS, and 93.2% of them achieved good outcomes.

CONCLUSION

Treatment of IAs with TFD was associated with low morbidity and mortality, most of which were ischemic events. Large posterior aneurysms might be associated with a higher complication rate.

TRIAL REGISTRATION

Retrospectively registered.

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.

Reconstructive endovascular treatment for basilar artery trunk aneurysms: complications and clinical and angiography outcomes

BACKGROUND

Basilar artery trunk aneurysms (BTAs) are rare intracranial aneurysms. We aim to investigate the procedural complications and clinical and angiographic outcomes of BTAs treated with reconstructive endovascular treatment (EVT).

METHODS

We retrospectively reviewed the data of 111 patients with BTAs who underwent reconstructive EVT during 2013-2022. The factors associated with procedural complications and clinical and angiographic outcomes were analyzed.

RESULTS

The study included 81 men and 30 women (median age 60 years). Overall, 26 (23.4%) cases presented with subarachnoid hemorrhage and 85 (76.6%) presented with unruptured aneurysms. Periprocedural ischemic and hemorrhagic complications occurred in 29 (26.1%) and 4 (3.6%) cases, respectively. The rate of favorable clinical outcomes was 83.8% (92/111) and the mortality rate was 14.4% (16/111). Angiographic follow-up data were available for 77/95 (81.1%) survivors; 57 (74.0%) and 20 (26%) aneurysms exhibited complete and incomplete obliteration, respectively. Old age, high Hunt and Hess grades (IV-V), hemorrhagic complications, and increased aneurysm size were independent risk factors for unfavorable clinical outcomes (p<0.05). Increased aneurysm size and incomplete aneurysm occlusion on immediate angiography were independent risk factors for incomplete occlusion during follow-up (p<0.05).

CONCLUSION

Reconstructive EVTs are a feasible and effective treatment for BTAs but are associated with a high risk of ischemic and hemorrhagic complications and a high mortality rate. Larger aneurysms may predict unfavorable clinical outcomes and aneurysm recurrence during follow-up. Hemorrhagic complications may predict unfavorable clinical outcomes, whereas immediate complete aneurysm occlusion may predict total occlusion during follow-up.

A Case Report of a Giant Basilar Artery Aneurysm

Intracranial aneurysms, characterized by the localized dilation of cerebral arteries, pose a substantial risk of rupture, leading to severe consequences. Basilar artery aneurysms, in particular, present unique challenges due to their location and potential impact on vital brainstem structures. Advanced diagnostic imaging has improved the chances of early identification of the condition, enabling timely intervention. We discuss the case of a 54-year-old female with controlled hypertension, who presented with persistent severe headaches and neurological symptoms. Diagnostic investigations revealed a large saccular basilar artery aneurysm measuring 4.7 cm. The aneurysm exerted pressure on the brainstem. After comprehensive discussions, the patient underwent successful flow-diverter stent placement, which led to the gradual resolution of symptoms. The multidisciplinary team closely monitored the patient in the neurointensive care unit. Managing giant basilar artery aneurysms poses significant challenges due to the potentially life-threatening complications associated with it. The success in treating the presented case underscores the importance of a multidisciplinary approach involving neurosurgery, interventional radiology, and critical care in managing these patients.

Long-term outcomes and dynamic changes of in-stent stenosis after Pipeline embolization device treatment of intracranial aneurysms

BACKGROUND

Flow diverters have revolutionized the treatment of intracranial aneurysms. However, the delayed complications associated with flow diverter use are unknown.

OBJECTIVE

To evaluate the incidence, severity, clinical outcomes, risk factors, and dynamic changes associated with in-stent stenosis (ISS) after treatment with a Pipeline embolization device (PED).

METHODS

Patients who underwent PED treatment between 2015 and 2020 were enrolled. The angiographic, clinical, and follow-up data of 459 patients were independently reviewed by four neuroradiologists to identify ISS. Binary logistic regression was conducted to determine ISS risk factors, and an ISS-time curve was established to demonstrate dynamic changes in ISS after PED implantation.

RESULTS

Of the 459 treated patients, 69 (15.0%) developed ISS. At follow-up, nine patients (2.0%) with ISS demonstrated reversal, while 18 (3.9%) developed parental artery occlusion. A total of 380 patients (82.8%) achieved complete aneurysm occlusion (O'Kelly-Marotta grade D). Patients with posterior-circulation aneurysm (OR=2.895, 95% CI (1.732 to 4.838; P<0.001) or balloon angioplasty (OR=1.992, 95% CI 1.162 to 3.414; P=0.037) were more likely to develop ISS. Patients aged >54 years (OR=0.464, 95% CI 0.274 to 0.785; P=0.006) or with a body mass index of >28 kg/m2 (OR=0.427, 95% CI 0.184 to 0.991; P=0.026) had a lower ISS risk. Intimal hyperplasia initiated by PED placement peaked within 1 year after the procedure, rarely progressed after 12 months, and tended to reverse within 24 months.

CONCLUSIONS

ISS is a common, benign, and self-limiting complication of PED implantation in the Chinese population.

Case report: Covered stent placement to treat delayed aneurysmal rupture after flow diverter-assisted coil embolization

INTRODUCTION

Flow diverter (FD) placement is widely accepted as a treatment for large saccular intracranial aneurysms. Delayed aneurysmal rupture (DAR) after FD placement is potentially catastrophic and difficult to treat. To our knowledge, using a Willis covered stent (WCS) to treat DAR after placement of a Pipeline Flex embolization device (PFED) combined with coiling has not been previously reported.

CASE PRESENTATION

A 49-year-old woman with an incidental asymptomatic large right supraclinoid internal carotid artery aneurysm was treated with PFED placement and adjunctive coiling. DAR causing subarachnoid hemorrhage occurred 11 hours after the procedure. Treatment using a WCS was successful and resulted in a favorable clinical outcome (modified Rankin scale score 2).

CONCLUSION

DAR after FD implantation requires isolation of the aneurysm from the cerebral circulation as soon as possible. WCS placement can achieve this immediately and occlude the aneurysm. We hope our case could provide new idea for similar cases in the future.

Use of flow diverter device in basilar artery for aneurysm treatment: Case series and literature review

Background

Flow diverters (FDs) for the treatment of basilar artery (BA) aneurysms remain controversial. In this study, we report our initial experience of flow diversion for treatment of this pathology.

Methods

Consecutive patients with an aneurysm of the BA that was treated by implantation of the FD were included in our retrospective study. Procedural complications, aneurysm occlusion, and a functional outcome were evaluated. FD placement in BA for aneurysm treatment reported in the literature was also reviewed and summarized.

Results

Sixteen patients with 16 BA aneurysms were treated by FD implantation with (n = 8) or without (n = 8) adjunctive coiling. The Tubridge was used in 13 (81.3%) and Pipeline in 3 (18.8%) procedures. Average aneurysm size was 15.7 mm. Four aneurysms were located at the basilar apex, six at the basilar trunk, and six at the vertebrobasilar junction. Three patients experienced procedural complications (18.8%), including two ischemic strokes and one hydrocephalus, with resultant mortality in one case (6.3%). Median follow-up was 7.7 months and available for 15 aneurysms. Complete/near-complete occlusion was seen in 13 (86.7%) aneurysms.

Conclusion

In our initial experience, flow diversion is feasible and safe in the treatment of BA aneurysms with promising occlusion rates at mid-term follow-up. Larger cohort studies are required to validate these results.