Endovascular Treatment of Intracranial Aneurysms

Recurrence rate of intracranial aneurysms: a systematic review and a meta-analysis comparing craniotomy and endovascular coiling

Patients with intracranial aneurysm (IA) are at high risk of cerebral hemorrhage, which is associated with high mortality. Craniotomy or interventional endovascular coiling are common treatment methods in clinical practice, depending on the patient's condition. However, the recurrence rate of IA after either method remains unclear. This meta-analysis was conducted to study the relationship between different treatment regimens and IA recurrence. PubMed, CNKI, Web of Science, Wan Fang, and VIP databases were used to identify studies on "intracranial aneurysm," "craniotomy," "endovascular coiling," and "recurrence rate." Included studies adhered to rigorous screening and diagnostic criteria, and statistical models were applied based on homogeneity testing. This study encompassed 28 articles, including five on craniotomy and 23 on endovascular coiling, published between 2007 and 2022; among 1,448 cases treated with craniotomy, 20 experienced recurrences (recurrence rate: 1.4%, 95% CI: 0.2%), while among 5,975 cases treated with endovascular coiling, 872 cases experienced recurrence (recurrence rate: 14.6%, 95% CI: 14%, 20%). High heterogeneity (87%) was observed in the endovascular coiling, likely due to differences in patient demographics and aneurysm characteristics. For IAs, although endovascular coiling has advantages in terms of lower trauma and faster recovery, its high recurrence rate warrants closer post-treatment monitoring. Despite being more invasive, Craniotomy may be preferable in specific cases, such as when treating aneurysms with complex shapes or challenging locations. Treatment choice should be individualized, and future advancements in endovascular coiling technologies may help reduce recurrence rates.

Analysis of Current Evidence in the Endovascular Treatment of Intracranial Aneurysms: A Systematic Review and Proposal for a Reporting Guideline to Enhance Reproducibility and Comparability of Surgical and Clinical Outcomes

BACKGROUND AND OBJECTIVES

Endovascular therapy (EVT) has recently become the most widely used treatment method for intracranial aneurysms (IAs). However, the literature on this topic is heterogeneous, with studies assessing and reporting surgical and clinical outcomes in different ways, lacking standardization. We aimed to evaluate the quality of these studies and propose a reporting guideline focusing on essential elements to ensure reproducibility and comparability.

METHODS

After Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we searched Medline, Embase, Cochrane Library, and Web of Science databases. Eligible studies were observational or randomized, reported clinical and/or surgical outcomes of EVTs for IAs, included over 200 patients, and were published in English between January 1, 2022, and January 1, 2024. Studies were assessed focusing on key domains: (1) reporting on the baseline characteristics of the patient sample, (2) assessment and reporting on imaging methods and aneurysm characteristics, (3) reporting on pivotal concepts definitions, (4) reporting on operator(s) and staff characteristics, (5) reporting on anesthetic protocol, (6) reporting on antiaggregant and anticoagulation therapy, (7) reporting on surgical details, (8) assessing and reporting clinical and surgical outcomes, and (9) reporting retreatment details.

RESULTS

Thirty-nine studies comprising 79 604 patients were included. Our assessment revealed substantial gaps in the literature on EVTs for IAs, including deficiencies across all domains. An EndoIAs Reporting Guideline was developed, consisting of 74 items distributed across 10 domains, focusing on key surgical and clinical outcomes.

CONCLUSION

Substantial deficiencies were identified in data collection and outcomes reporting in the available literature on EVT for IAs, thereby impeding comparability and reproducibility and hindering the building of cumulative evidence. The aim of the proposed EndoIAs Reporting Guideline was to address these fundamental aspects and has the potential to enhance the reproducibility and comparability of future studies, thereby fostering the building of cumulative and reliable evidence of EVT for IAs.

Machine Learning Algorithms to Predict the Risk of Rupture of Intracranial Aneurysms: a Systematic Review

PURPOSE

Subarachnoid haemorrhage is a potentially fatal consequence of intracranial aneurysm rupture, however, it is difficult to predict if aneurysms will rupture. Prophylactic treatment of an intracranial aneurysm also involves risk, hence identifying rupture-prone aneurysms is of substantial clinical importance. This systematic review aims to evaluate the performance of machine learning algorithms for predicting intracranial aneurysm rupture risk.

METHODS

MEDLINE, Embase, Cochrane Library and Web of Science were searched until December 2023. Studies incorporating any machine learning algorithm to predict the risk of rupture of an intracranial aneurysm were included. Risk of bias was assessed using the Prediction Model Risk of Bias Assessment Tool (PROBAST). PROSPERO registration: CRD42023452509.

RESULTS

Out of 10,307 records screened, 20 studies met the eligibility criteria for this review incorporating a total of 20,286 aneurysm cases. The machine learning models gave a 0.66-0.90 range for performance accuracy. The models were compared to current clinical standards in six studies and gave mixed results. Most studies posed high or unclear risks of bias and concerns for applicability, limiting the inferences that can be drawn from them. There was insufficient homogenous data for a meta-analysis.

CONCLUSIONS

Machine learning can be applied to predict the risk of rupture for intracranial aneurysms. However, the evidence does not comprehensively demonstrate superiority to existing practice, limiting its role as a clinical adjunct. Further prospective multicentre studies of recent machine learning tools are needed to prove clinical validation before they are implemented in the clinic.

Real-world evaluation of CYP2C19 guided antiplatelet therapy in patients undergoing intracranial aneurysm repair

Aim: To evaluate the feasibility and impact of using CYP2C19 genotype to guide selection of antiplatelet therapy in patients undergoing intracranial aneurysm treatment with a flow diversion stent in a real-world clinical setting.Patients & methods: A single-center, retrospective, observational cohort study was conducted in 112 patients undergoing intracranial aneurysm repair with flow-diversion stenting from 2014 to 2021. Data were abstracted from health records. The frequency of clopidogrel or alternative therapy (ticagrelor or prasugrel) use was compared across CYP2C19 status (intermediate or poor metabolizer [IM/PM] vs. normal, rapid, or ultrarapid metabolizer [NM/RM/UM]).Results: In the study population, CYP2C19 genotype testing was performed on 110 (98.2%) patients; of these, 106 (97.2%) had results available prior to the stent procedure and 28 (25.5%) were IM/PMs. Alternative therapy was used more frequently in IM/PMs compared with NM/RM/UMs (57.1 vs. 8.5%, respectively, p < 0.0001). The frequency of thromboembolic events over 12 months did not significantly differ across clopidogrel-treated IM/PMs, clopidogrel-treated NM/RM/UMs and patients on alternative therapy (p = 0.352); although, event numbers were low.Conclusion: A pre-emptive CYP2C19 genotyping strategy to guide antiplatelet therapy selection in intracranial aneurysm repair patients is feasible in a real-world clinical setting. Larger studies are needed to assess the impact on clinical outcomes.

Knowledge domain and emerging trends in the rupture risk of intracranial aneurysms research from 2004 to 2023

BACKGROUND

Intracranial aneurysms (IAs) pose significant health risks, attributable to their potential for sudden rupture, which can result in severe outcomes such as stroke and death. Despite extensive research, the variability of aneurysm behavior, with some remaining stable for years while others rupture unexpectedly, remains poorly understood.

AIM

To employ bibliometric analysis to map the research landscape concerning risk factors associated with IAs rupture.

METHODS

A systematic literature review of publications from 2004 to 2023 was conducted, analyzing 3804 documents from the Web of Science Core Collection database, with a focus on full-text articles and reviews in English. The analysis encompassed citation and co-citation networks, keyword bursts, and temporal trends to delineate the evolution of research themes and collaboration patterns. Advanced software tools, CiteSpace and VOSviewer, were utilized for comprehensive data visualization and trend analysis.

RESULTS

Analysis uncovered a total of 3804 publications on IA rupture risk factors between 2006 and 2023. Research interest surged after 2013, peaking in 2023. The United States led with 28.97% of publications, garnering 37706 citations. Notable United States-China collaborations were observed. Capital Medical University produced 184 publications, while Utrecht University boasted a citation average of 69.62 per publication. "World Neurosurgery" published the most papers, contrasting with "Stroke", the most cited journal. The PHASES score from "Lancet Neurology" emerged as a vital rupture risk prediction tool. Early research favored endovascular therapy, transitioning to magnetic resonance imaging and flow diverters. "Subarachnoid hemorrhage" stood out as a recurrent keyword.

CONCLUSION

This study assesses global IA research trends and highlights crucial gaps, guiding future investigations to improve preventive and therapeutic approaches.

Examining the Efficacy, Safety, and Future Prospects of Tirofiban in Managing Myocardial Infarction among Diabetic Patients

BACKGROUND

Myocardial infarction (MI) is a leading cause of death worldwide, particularly in patients with diabetes mellitus (DM). Tirofiban, a platelet GP IIb/IIIa receptor inhibitor, has shown promise as adjunctive therapy in the emergency management of MI in diabetic patients. However, a comprehensive understanding of its use, efficacy, safety, and limitations in this patient population is necessary to optimize treatment strategies and improve patient outcomes.

METHODOLOGY

This review article utilized a systematic approach to gather relevant research articles, clinical trials, and studies on the use of tirofiban in the therapy of MI in diabetic patients. Databases, such as PubMed and Google Scholar, were extensively searched using specific keywords related to tirofiban, MI, DM, STEMI, and antiplatelet therapy. The collected data were carefully examined, summarized, and analyzed to provide an extensive overview of using tirofiban in the management of MI in diabetic individuals.

RESULTS

The analysis of the gathered literature revealed that tirofiban has demonstrated efficacy in improving clinical outcomes, reducing myocardial ischemia-reperfusion injury, and promoting early recovery of heart function in diabetic patients with MI undergoing percutaneous coronary intervention. The fast on- and off-rate and dose-dependent effect of the drug on platelet aggregation contribute to its effectiveness. However, caution should be exercised due to the potential risk of tirofiban-associated thrombocytopenia. Clinical trials and studies have provided evidence- based dosing guidelines, enabling the safe and effective administration of tirofiban in this patient population.

CONCLUSION

Tirofiban, a platelet GP IIb/IIIa receptor inhibitor, shows promise as adjunctive therapy in the emergency management of MI in diabetic patients. It has demonstrated efficacy in improving clinical outcomes, reducing myocardial ischemia-reperfusion injury, and promoting early recovery of heart function. However, healthcare providers should be cautious regarding the potential risk of tirofiban-associated thrombocytopenia. Further research is needed to optimize dosing guidelines, evaluate long-term safety, and fully understand the benefits and limitations of tirofiban in this patient population. The comprehensive insights provided in this review aim to enhance treatment strategies and improve patient outcomes in the emergency management of MI in diabetic individuals.

A novel flow diverter device (Tubridge) for the treatment of intracranial aneurysms: a systematic review and meta-analysis

The flow diverter (FD) device has become a feasible and effective option for treating intracranial aneurysms. This study aimed to evaluate the efficacy and safety of Tubridge FD (TFD) in treating intracranial aneurysms and provide evidence for further research and clinical application. Electronic databases, including PubMed, Web of Science, Embase, and the Cochrane Library from inception to July 31, 2022, were searched. The eligible studies should include TFD investigations in treating intracranial aneurysms. Pooled technical success rate, complete occlusion rate, improvement rate, stable rate, symptom elimination rate, and adverse events rate were calculated with either the fixed-effects model or the random-effects model, depending on the results of tests for heterogeneity. Egger's tests were performed to assess the potential publication bias. A total of 7 studies (145 patients) were included in this study. The pooled technical success rate was 0.98, the complete occlusion rate was 0.79, the improvement rate was 0.21, and the stable rate was 0.05. One included study reported that the surgery-related mortality rate in the Tubridge group was higher than that in the control group (3.66% vs. 1.61%), while the surgery-related morbidity rate in the Tubridge group was 2.4% and that in the control group was 0. Findings of this meta-analysis indicate that TFD manifests promising and effective performance with acceptable adverse events in the treatment of intracranial aneurysms.

Initial and mid-term results of LEO Baby stent-assisted coiling of intracranial aneurysms located in small arteries: A single-center experience with 131 consecutive patients

Background and purpose

Low-profile intracranial stents such as the LEO Baby stents are considered to be advantageous for the treatment of intracranial aneurysms originating from small arteries. This study aimed to evaluate the initial and mid-term clinical and angiographic results of LEO Baby stents in stent-assisted coiling of intracranial aneurysms with small parent arteries (<2.5 mm).

Methods

We performed a retrospective study to identify 131 patients with aneurysms arising from small parent arteries treated with Leo Baby stent-assisted coiling in a single institution between October 2018 and June 2021. We assessed the immediate and progressive aneurysm occlusion rates, procedure-related complications, and clinical outcomes.

Results

A total of 131 patients with 135 aneurysms were identified, including 65 (48.1%) cases of acutely ruptured aneurysms. Technical success was achieved in all cases (100%). The immediate angiography showed complete occlusion in 111 aneurysms (82.2%), neck remnants in 19 (14.1%), and residual sac in 5 (3.7%). Procedure-related complications occurred in 14 cases (10.3%), including 13 (9.6%) thromboembolic complications and 1 (0.7%) hemorrhagic complication. Six-month follow-up angiography was achieved in 106 (78.5%) aneurysms, which showed complete occlusion in 102 (96.2%) aneurysms, neck remnants in 2 (1.9%), and residual sac in 2 (1.9%). Clinical follow-up was available in all patients with a median duration of 6.8 months, and favorable clinical outcomes (modified Rankin Scale score: 0–2) reached 91.6%. The mortality rate was 4.6%.

Conclusion

Our results demonstrate that stent-assisted coiling of intracranial aneurysms located on small arteries using LEO Baby stents is technically feasible, highly effective, and has midterm durability in aneurysmal occlusion.

Evaluation of stent effect and thrombosis generation with different blood rheology on an intracranial aneurysm by the Lattice Boltzmann method

BACKGROUND AND OBJECTIVE

Treatment of intracranial aneurysms with flow-diverting stents prevents rupture by reducing blood flow and creating thrombosis within the aneurysm. This paper aims to assess the hemodynamic effect of placing stents with different struts (0, 3, 5, 7 struts) on intracranial aneurysms and to propose a simple prediction model of thrombosis zone without any further computational cost.

METHOD

Lattice Boltzmann method with different rheological models (Newtonian, Carreau-Yasuda, KL) of blood are used to study the hemodynamic effect of flow-diverting stents in the aneurysm. Pulsatile flow boundary conditions were applied in the inlet of the artery. The average Reynolds number was resulting Re = 111. The Lagrangian tracking of the particle was developed to assess the intra-aneurysmal blood stagnation. To predict the probable thrombose zone induced by flow-diverting stents, the shear rate threshold is utilized to determine the nodes of fluid to clot.

RESULTS

The results show that the flow patterns into the aneurysmal sac develop a vortex, decreasing after stent placement until disappearance for the stent with seven struts (porosity 71.4%). Velocity, shear rate, shear stress, trajectory, path length, and occlusion rate are compared before and after stent placement. These parameters decrease inversely with the porosity of the stent. The three models yield a closes result of the (velocity, shear rate, occlusion rate). Tracking the fluid-particle trajectory shows that the length of the particle paths decreases with the number of struts causing fluid to slow down and increase, consequently, the residence time into the sac.

CONCLUSION

The flow-diverting stents placement cause the reduction of dynamic flow within aneurysm. The reduction effect is almost the same below five struts (80% of porosity). The results show that, if our objective is restricted to estimating the hemodynamic effect, measured by (velocity, shear rate, occlusion rate), the differences between rheological behavior models are, practically, not significant, and the models can be used indifferently.