Preventive treatment of unruptured intracranial aneurysms in adult patients with sickle cell anemia: A cohort study

BACKGROUND AND PURPOSE

Intracranial aneurysms are frequent in patients with sickle cell anemia, while subarachnoid hemorrhage is a major cause of death and disability in young adult patients. Several characteristics, such as younger age and smaller size at rupture, may incline therapeutic decision towards exclusion treatments. Clinical guidelines on treatment of unruptured intracranial aneurysms in this population are still missing. We aimed to assess the safety and efficacy of the treatment of unruptured intracranial aneurysm in patients with sickle cell anemia, using an adapted hematological preparation regimen.

PATIENTS AND METHODS

Adult patients with sickle cell anemia and treated unruptured aneurysms by endovascular therapy or neurosurgery were included in this retrospective cohort study. Treatment decision was reached after multi-disciplinary assessment. A pre-operative blood transfusion protocol was undertaken targeting a HbS below 30%. Demographic data, hematological preparation parameters and clinical and radiological outcomes were documented.

RESULTS AND CONCLUSIONS

Twenty-five procedures were performed in 18 patients encompassing 19 aneurysms treated by embolization and 6 by surgery. Median age at treatment was 34 years-old and median aneurysm dome size was 4.4 mm. Immediate aneurysm exclusion rate was 85.7% after endovascular therapy and 100% after neurosurgery. Median follow-up was 6 months, with all patients being asymptomatic at last follow-up. Two transitory ischemic neurological deficits, as well as four cases of iodine-induced encephalopathy were identified after embolization. No complication occurred after surgery. Endovascular therapy by coiling and neurosurgical treatment of unruptured intracranial aneurysms appears to be safe in patients with sickle cell anemia and should be considered given the specific hemorrhagic risk observed in this population. A rigorous hematological preparation, associated with a dedicated peri‑operative protocol and an adequate therapeutic strategy are essential prerequisites.

CTA-Based Patient-Tailored Femoral or Radial Frontline Access Reduces the Rate of Catheterization Failure in Chronic Subdural Hematoma Embolization

BACKGROUND AND PURPOSE

Chronic subdural hematoma embolization, an apparently simple procedure, can prove to be challenging because of the advanced age of the target population. The aim of this study was to compare 2 arterial-access strategies, femoral versus patient-tailored CTA-based frontline access selection, in chronic subdural hematoma embolization procedures.

MATERIALS AND METHODS

This was a monocentric retrospective study. From the March 15, 2018, to the February 14, 2019 (period 1), frontline femoral access was used. Between February 15, 2019, and March 30, 2020 (period 2), the choice of the frontline access, femoral or radial, was based on the CTA recommended as part of the preoperative work-up during both above-mentioned periods. The primary end point was the rate of catheterization failure. The secondary end points were the rate of access site conversion and fluoroscopy duration.

RESULTS

During the study period, 124 patients (with 143 chronic subdural hematomas) underwent an embolization procedure (mean age, 74 [SD, 13] years). Forty-eight chronic subdural hematomas (43 patients) were included during period 1 and were compared with 95 chronic subdural hematomas (81 patients) during period 2. During the first period, 5/48 (10%) chronic subdural hematoma embolizations were aborted due to failed catheterization, significantly more than during period 2 (1/95, 1%; P = .009). The rates of femoral-to-radial (P = .55) and total conversion (P = .86) did not differ between the 2 periods. No significant difference was found regarding the duration of fluoroscopy (P = .62).

CONCLUSIONS

A CTA-based patient-tailored choice of frontline arterial access reduces the rate of catheterization failure in chronic subdural hematoma embolization procedures.

Parent artery occlusion in large, giant, or fusiform aneurysms of the carotid siphon: clinical and imaging results

BACKGROUND AND PURPOSE

Parent artery occlusion has long been considered the reference treatment for large/giant or fusiform aneurysms of the carotid siphon. However, meager recent data exist on this technique, which tends to be replaced by stent-assisted reconstructive techniques. In our department since 2004, we have assessed the safety, efficacy, and complication risk factors of parent artery occlusion by using coils for trapping these aneurysms.

MATERIALS AND METHODS

We determined retrospectively the complication rate, factors associated with the occurrence of an ischemic event, changes in symptoms of mass effect, evolution of the aneurysmal size, and the growth of an additional aneurysm after treatment.

RESULTS

Fifty-six consecutive patients were included, with a median age of 54 years (range, 25-85 years; 92% women), 48% with giant aneurysms and 75% with infraclinoid aneurysms. There was a permanent morbidity rate of 5% exclusively due to ischemia, a zero mortality rate, an aneurysmal retraction rate of 91%, and an improvement rate for pain of 98% and for cranial nerve palsy of 72%, with a median follow-up of >3 years. Para-/supraclinoid topography of the aneurysm (P = .043) and the presence of cardiovascular risk factors (P = .024) were associated with an excessive risk of an ischemic event, whereas the presence of a mural thrombus had a protective role (P = .033).

CONCLUSIONS

In this study, parent artery occlusion by using coils to treat large/giant or fusiform aneurysms of the carotid siphon was safe and effective, especially for giant infraclinoid aneurysms. According to recent meta-analyses, these results suggest that the validation of stent-assisted reconstructive treatments for these aneurysms requires controlled studies with parent occlusion artery.