Frailty is a Predictor of Increased Readmissions and Increased Postoperative Complications After Elective Treatment of Unruptured Aneurysms

INTRODUCTION

Frailty is a state of decreased physiologic reserve associated with adverse treatment outcomes across surgical specialties. We sought to determine whether frailty affected patient outcomes after elective treatment (open microsurgical clipping or endovascular therapy [EVT]) of unruptured cerebral aneurysms (UCAs).

METHODS

The National Readmissions Database was queried from 2010 to 2014 to identify patients who had a known UCA and underwent elective clipping or EVT. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty indicator tool. Multivariable exact logistic regression analyses were conducted to assess the associations between frailty and the primary outcome variables of 30- and 90-day readmissions, complications, length of stay (LOS), and patient disposition.

RESULTS

Of 18,483 patients who underwent elective treatment for UCAs, 358 (1.9%) met the criteria for frailty. After adjusting for patient- and hospital-based factors, frailty (30-day: odds ratio [OR], 1.55; 95% confidence interval [CI], 1.11-2.17; P = 0.01; 90-day: OR, 1.47; 95% CI, 1.05-2.06; P = 0.02) and clipping versus EVT (30-day: OR, 2.12; 95% CI, 1.85-2.43; P < 0.000; 90-day: OR, 1.80; 95% CI, 1.59-2.03; P < 0.0001) were associated with increased readmission rates. Furthermore, frailty was associated with an increased rate of complications (surgical: OR, 2.91; 95% CI, 2.27-3.72; P < 0.0001; neurological: OR, 3.04; 95% CI, 2.43-3.81; P < 0.0001; major: OR, 2.75; 95% CI, 1.96-3.84; P < 0.0001), increased LOSs (incidence rate ratio, 3.08; 95% CI, 2.59-3.66; P < 0.0001), and an increased rate of nonroutine disposition (OR, 3.94; 95% CI, 2.91-5.34; P < 0.0001).

CONCLUSIONS

Frailty was associated with an increased likelihood of 30- and 90-day readmissions after elective treatment of UCAs. Frailty was notably associated with several postoperative complications, longer LOSs, and nonroutine disposition in the treatment of UCAs.

Mechanical compression management of the right middle cerebral artery inferior trunk using a stent during coil embolization of middle cerebral artery aneurysms: A case report and literature review

Endovascular coil embolization is a minimally invasive, rapid, and effective method for the treatment of intracranial aneurysms. However, complications associated with coil embolization, such as intraoperative aneurysm rupture or arterial occlusion, should be promptly managed during the procedure to avoid catastrophic consequences. This study presents a case of mechanical compression management of the right middle cerebral artery (MCA) inferior trunk during coil embolization for bilateral MCA aneurysms. The inferior trunk of the right MCA was abruptly occluded due to mechanical compression during coil embolization of the right MCA bifurcation aneurysm. A Solitaire AB stent (4 ​× ​20 mm, Covidien/Medtronic, Dublin, Ireland) was implanted in the inferior trunk of the right MCA after tirofiban was injected via a microcatheter, and the right inferior trunk was recanalized. The patient also underwent coil embolization of the left MCA bifurcation aneurysm, without any complications. It is crucial to recognize compressive occlusion of adjacent aneurysm branches to avoid severe complications during intracranial aneurysm embolization. Stent placement is a rescue treatment option for recanalization of an occluded artery.

A Unique Technique to Adjust Snare Position for Coil Retrieval in Tortuous Vessel During Aneurysm Coil Embolization: A Technical Case Report

OBJECTIVE

Although snares are useful devices to retrieve an intravascular foreign body, the control of snares is often difficult. We present a safe and effective technique to adjust snare position in the tortuous vessel for coil retrieval during endovascular coil embolization.

METHODS

We describe a case of a protruding coil during coil embolization that was successfully retrieved using a unique technique to adjust snare position and discuss additional intraprocedural bailout strategies for retrieving a coil during endovascular coil embolization.

RESULTS

The patient was a 44-year-old female with unruptured right internal carotid artery (ICA) aneurysm that had grown over a 1.5-year period. Coil embolization was performed. After detachment of final coil and microcatheter removal, the final coil protruded into the ICA and floated. Coil retrieval using a snare was attempted, but the snare could not be placed around the coil tail and coil retrieval could not be achieved. The following technique was used to allow adjustment of snare position. First, a microguidewire and a microcatheter were guided into the M2 and M1 segment of the middle cerebral artery as monorail guides of the snare, respectively. Next, the snare was advanced over the microcatheter. Around C2 segment of the ICA, the microcatheter and the snare were manipulated as a unit. Thus, the snare could be placed around the protruding coil tail and the coil was retrieved successfully.

CONCLUSIONS

This technique may be widely adapted for various situations when using a snare.

Trends and Outcomes of Endovascular Embolization and Surgical Clipping for Ruptured Intracranial Aneurysms: A Propensity-Matched Study of 1332 Patients in the United States

OBJECTIVE

To describe recent trends in treatment and outcomes of endovascular coil embolization and microsurgical clipping treatment strategies for ruptured intracranial aneurysms.

METHODS

Using International Classification of Diseases, Tenth Revision, codes, 1332 propensity-matched patients >18 years old who underwent coiling or clipping were identified. Patient demographics, baseline characteristics, comorbidities, and clinical outcomes were evaluated within 1 year postoperatively. Pooled and individual studies of the International Classification of Diseases codes investigated differences in clinical outcomes owing to aneurysm location. Outcomes were mortality, intensive care, surgical complications, hydrocephalus, and vasospasm.

RESULTS

After propensity matching for baseline characteristics and comorbidities, 666 patients were included in the coiling and clipping cohorts. There was no significant difference in 1-year mortality between cohorts. However, incidence of intensive care, surgical/medical complications, and vasospasm was significantly lower in the pooled coiling cohort (P = 0.02, P = 0.03, and P = 0.014) compared with the clipping cohort within 1 year postoperatively. Additionally, individual International Classification of Diseases code analysis revealed that coiling of anterior communicating artery aneurysms was associated with significantly fewer surgical/medical complications and hydrocephalus (P = 0.0008 and P = 0.015) and coiling of posterior communicating artery aneurysms was associated with substantially less vasospasm treatment (P = 0.034) compared with the respective clipping cohorts.

CONCLUSIONS

Analysis revealed no difference in 1-year mortality between coiling and clipping. Clinical outcomes, including intensive care, surgical complications, and vasospasm, favored coiling regardless of aneurysm location. Patients with coiling of anterior communicating artery aneurysms had significantly less hydrocephalus and patients with coiling of posterior communicating artery aneurysms had substantially less vasospasm treatment within 1 year compared with the clipping cohort.

Endovascular embolization versus surgical clipping in a single surgeon series of basilar artery aneurysms: a complementary approach in the endovascular era

Background

Currently, most basilar artery aneurysms (BAAs) are treated endovascularly. Surgery remains an appropriate therapy for a subset of all intracranial aneurysms. Whether open microsurgery would be required or utilized, and to what extent, for BAAs treated by a surgeon who performs both endovascular and open procedures has not been reported.

Methods

Retrospective analysis of prospectively maintained, single-surgeon series of BAAs treated with endovascular or open surgery from the first 5 years of practice.

Results

Forty-two procedures were performed in 34 patients to treat BAAs—including aneurysms arising from basilar artery apex, trunk, and perforators. Unruptured BAAs accounted for 35/42 cases (83.3%), and the mean aneurysm diameter was 8.4 ± 5.4 mm. Endovascular coiling—including stent-assisted coiling—accounted for 26/42 (61.9%) treatments and led to complete obliteration in 76.9% of cases. Four patients in the endovascular cohort required re-treatment. Surgical clip reconstruction accounted for 16/42 (38.1%) treatments and led to complete obliteration in 88.5% of cases. Good neurologic outcome (mRS ≤ 2) was achieved in 88.5% and 75.0% of patients in endovascular and open surgical cohorts, respectively (p = 0.40). Univariate logistic regression analysis demonstrated that advanced age (OR 1.11[95% CI 1.01–1.23]) or peri-procedural adverse event (OR 85.0 [95% CI 6.5–118.9]), but not treatment modality (OR 0.39[95% CI 0.08–2.04]), was the predictor of poor neurologic outcome.

Conclusions

Complementary implementation of both endovascular and open surgery facilitates individualized treatment planning of BAAs. By leveraging strengths of both techniques, equivalent clinical outcomes and technical proficiency may be achieved with both modalities.

Congenital right internal mammary artery to portal vein arteriovenous malformation

Neonatal cases of systemic artery to portal venous system arteriovenous malformations (AVMs) can present unique challenges in terms of diagnosis, management, and treatment. Prompt identification of these AVMs is necessary for minimizing long-term sequelae and optimizing prognosis. Our report describes the diagnosis and successful endovascular coil embolization of a congenital right internal mammary artery (IMA) to portal vein AVM in a young infant initially presenting during routine fetal screening with an incidentally discovered congenital thoracic vascular abnormality.

In vitro evaluation of Pt-coated electrospun nanofibers for endovascular coil embolization

Recently, endovascular coil embolization has been introduced to treat intracranial aneurysms because it has lower morbidity and mortality than surgical clipping. The endovascular coils prevent the extravasation of blood by decreasing the permeability of an aneurysm flow governed by Darcy's law. Here, we developed and explored Pt-coated micro-ropes for potential use as endovascular coils. Electrospinning with subsequent electroplating were employed to fabricate Pt-coated nanofibers, which were tightly twisted to form micro-ropes. The compatibility of Pt micro-ropes with commercial delivery catheters was verified and their performance was experimentally explored in an in vitro experimental model. The developed Pt-coated micro-ropes demonstrated feasibility as efficient and low-cost endovascular coils. STATEMENT OF SIGNIFICANCE: The use of Platinum (Pt)-coated polymer nanofibers to prevent blood extravasation has been demonstrated. These Pt nanofibers were installed within a microfluidic channel, and the resulting reduced permeability was evaluated using a fluid similar to blood. Based on the obtained results, these newly developed nanofibers are expected to decrease the operation cost for aneurysmal subarachnoid hemorrhage (SAH), owing their reduced size and low material cost. Overall, the use of this new material should reduce the operational risk associated with the multiple steps required to place the Pt coils at the SAH site. The compatibility of Pt micro-ropes with commercial delivery catheters was verified and their performance was experimentally explored in an in vitro experimental model. The developed Pt-coated micro-ropes demonstrated feasibility as efficient and low-cost endovascular coils.

Successful endovascular coil embolization of large pseudoaneurysm of ductus arteriosus diverticulum

Background

Pseudoaneurysm of the ductus arteriosus diverticulum, although rare in adults, may have catastrophic consequences if left untreated due to erosion and rupture of the pseudoaneurysm into adjacent thoracic structures. Although thoracic endovascular aortic repair (TEVAR) is the standard treatment method for aneurysm closure of the ductus arteriosus diverticulum, it was not possible in our patient secondary to marked aortoiliac access vessel tortuosity, significant vascular calcific burden, and an abdominal aortic aneurysm. We describe the first reported case of endovascular coil embolization being successfully used as the definite repair of a ductus arteriosus diverticulum pseudoaneurysm.

Case presentation

An 85-year-old man with history of severe coronary arterial disease presented with an enlarging pseudoaneurysm of a ductus arteriosus diverticulum. The diverticulum and thoracic aortic junction demonstrated the typical obtuse angles and wide neck, differentiating it from otherwise similar-appearing diagnostic considerations. Repair was attempted with conventional aortic stent graft but the patient’s infrarenal abdominal aortic aneurysm and his heavily calcified, tortuous iliac vessels could not accommodate the 24Fr introducer sheath necessary for stent graft placement. Therefore, endovascular coil embolization was successfully completed through a 4Fr directional catheter. The patient tolerated the procedure well and was discharged from the hospital in good condition on post-embolization day six.

Conclusions

Endovascular coil embolization is an alternative treatment for ductus arteriosus diverticulum pseudoaneurysm closure in cases where the standard TEVAR method is unsuccessful. Instead of the wide entry point at the aorta we used the junction of the diverticulum and pseudoaneurysm as the “neck” for satisfactory and stable coil placement. Endovascular coil embolization alone may be a viable definitive therapy for occlusion of the ductus pseudoaneurysm component of the diverticulum in cases where complex anatomy or extensive vascular disease makes stent graft repair impractical if not impossible.

Practical Incidence of Complications and Degree of Patient Satisfaction After Endovascular Coil Embolization for Unruptured Intracranial Saccular Aneurysm Based on Patients' Surveys

OBJECTIVE

Endovascular treatment for unruptured intracranial aneurysms (UIAs) has been regarded as second to none management nowadays as the result of its proven efficacy and need for less-invasive treatment. Most researchers have focused on the anatomical outcome after endovascular treatment, so in this study we estimated the real incidence of untoward effect and degree of patients' satisfaction based on s survey.

METHODS

This retrospective study was approved by the institutional review board, and 112 patients treated for saccular UIAs were evaluated among a total of 135 patients. After informed consent was obtained, these patients were sent a questionnaire regarding treatment effectiveness, complications, and patient satisfaction. These data were collected and compared with angiographic and clinical outcome.

RESULTS

The response rate was 87.5% (98/112). Intracranial complications occurred in 10 aneurysms (10.2%): 7 ischemic and 3 hemorrhagic strokes. Other complications occurred in 30 patients (30.6%): 17 alopecia, 15 bleeding tendency, and 3 puncture-site complications. Overall, 89 (90.8%) patients reported being satisfied with their treatment. Patient satisfaction was closely correlated with clinically successful outcome of treatment.

CONCLUSIONS

Ninety percent of patients were satisfied with the results after endovascular treatment of UIAs. Endovascular coil embolization was effective and safe procedure, with high clinical success rate and degree of satisfaction.

Intra-arterial and Intravenous Tirofiban Infusion for Thromboembolism during Endovascular Coil Embolization of Cerebral Aneurysm

OBJECTIVE

Thromboembolism is the one of the most serious complications that can occur during endovascular coil embolization of cerebral aneurysm. We report on the effectiveness and safety of intra-arterial/intravenous (IA/IV) glycoprotein IIb/IIIa inhibitor (tirofiban) infusion for treating thromboembolism during endovascular coil embolization of cerebral aneurysm.

METHODS

We performed a retrospective analysis of 242 patients with ruptured or unruptured cerebral aneurysms (n=264) who underwent endovascular coil embolization from January 2011 to June 2014. Thromboembolism occurred in 20 patients (7.4%), including 14 cases of ruptured aneurysms and 6 cases of unruptured aneurysms. The most common site of aneurysms was the anterior communicating artery (n=8), followed by middle cerebral artery (n=6). When we found an enlarged thromboembolism during coil embolization, we tried to dissolve it using tirofiban administered via IA and IV loading (5 μg/kg, respectively) for 3-5 minutes followed by IV maintenance (0.08 μg/kg/min) for approximately 4-24 hours.

RESULTS

In 4 of 5 patients with total vessel occlusion, the vessel was recanalized to Thrombolysis in Cerebral Infarction Perfusion Scale (TICI) grade 3, and in 1 patient to TICI grade 2a. In 2 patients with partial vessel occlusion and 13 patients with minimal occlusion, the vessel recanalized to TICI grade 3. Irrelevant intracerebral hemorrhage was noted in 1 patient (5%), and thromboemboli-related cerebral infarction developed in 5 patients (25%), of which only 1 (5%) was symptomatic.

CONCLUSION

IA/IV infusion and IV maintenance with tirofiban appear to be an effective rescue treatment for thromboembolism during endovascular coil embolization in patients with ruptured or unruptured cerebral aneurysms.

A Less Invasive Strategy for Ruptured Cerebral Aneurysms with Intracerebral Hematomas: Endovascular Coil Embolization Followed by Stereotactic Aspiration of Hematomas Using Urokinase

Objective

Aneurysm clipping and simultaneous hematoma evacuation through open craniotomy is traditionally recommended for ruptured cerebral aneurysms accompanied by intracerebral or intrasylvian hemorrhages. We report our experience of adapting a less invasive treatment strategy in poor-grade patients with intracerebral or intrasylvian hemorrhages associated with ruptured cerebral aneurysms, where the associated ruptured cerebral aneurysms were managed by endovascular coil embolization, followed by stereotactic aspiration of hematomas (SRH) using urokinase.

Materials and Methods

We retrospectively analyzed 112 patients with ruptured cerebral aneurysms. There were accompanying intracerebral or intrasylvian hemorrhages in 36 patients (32.1%). The most common site for these ruptured aneurysms was the middle cerebral artery (MCA) (n = 15; 41.6%). Endovascular coil embolization followed by SRH using urokinase was performed in 9 patients (25%).

Results

In these 9 patients, the most common site of aneurysms was the MCA (n = 3; 33.4%); the hematoma volume ranged from 19.24 to 61.68 mL. Four patients who were World Federation of Neurological Surgeons (WFNS) grade-IV on admission, achieved favorable outcomes (Glasgow Outcome Score [GOS] 4 or 5) at 6-months postoperatively. In the five patients who were WFNS grade-V on admission, one achieved a favorable outcome, whereas 4 achieved GOS scores of 2 or 3, 6-months postoperatively. There was no mortality.

Conclusion

If immediate hematoma evacuation is not mandated by clinical or radiological signs of brain herniation, a less invasive strategy, such as endovascular coil embolization followed by SRH using urokinase, may be a good alternative in poor-grade patients with intracerebral or intrasylvian hemorrhages associated with ruptured cerebral aneurysms.

Unruptured internal carotid artery bifurcation aneurysms: general features and overall results after modern treatment

BACKGROUND

Internal carotid artery bifurcation aneurysms (ICAbifAs) present unique challenges to endovascular and surgical operators, and little is known about their natural history. We reviewed our institution's experience with ICAbifAs studying outcomes of surgical and endovascular management and natural history.

METHODS

Consecutive patients with unruptured ICAbifAs evaluated and/or treated over an 8-year interval were studied. Baseline demographics, neurovascular risk factors, aneurysm location and size, clinical presentation, treatment recommendations, and outcomes were prospectively collected and retrospectively analyzed. Continuous variables were compared with Student's t test and categorical variables with Chi-square tests.

RESULTS

Fifty-nine patients with 61 unruptured ICAbifAs were included. Seven aneurysms were treated surgically (11.5 %), 22 underwent endovascular treatment (36 %), and 32 were managed conservatively (52.5 %). In the surgical group, short- and long-term complete aneurysm occlusion rates were 100 % with no cases of perioperative or long-term permanent morbidity or treatment-related mortality. In the endovascular group, two patients (11.7 %) with giant aneurysms had perioperative thromboembolic events with transient morbidity. There was one case of aneurysm rupture at follow-up in a giant aneurysm treated with partial coil embolization. Complete/near-complete occlusion rates were 63 %. There was one case of aneurysm rupture after 114 aneurysm-years of follow-up in the conservative management group (0.89 %/year), but no ruptures were observed in small aneurysms selected for conservative management.

CONCLUSIONS

Unruptured small ICAbifAs have a benign natural history. In patients selected for treatment, excellent results can be achieved in the vast majority of patients with judicious use of endovascular and surgical therapy.

Dual Stent-Assisted Coil Embolization for Fusiform Aneurysm Arising From Persistent Trigeminal Artery

Aneurysms of the persistent trigeminal artery (PTA) trunk are exceptionally rare and have a high risk for rupture. Dual stent placement through each internal carotid and basilar artery for endovascular coil embolization of a fusiform aneurysm arising from the PTA has not been described in the literature. A 44-year-old female with a history of chronic headache was identified to have a fusiform aneurysm arising from medially coursing adult type, Saltzman type 3 PTA trunk. Sacrifice of the PTA trunk inclusive of the aneurysm was performed with dual stent placement through each basilar and internal carotid artery across their respective junctions with the PTA. Six-month follow-up angiography showed complete occlusion of the PTA and the aneurysm. The patient's symptoms resolved. Our case demonstrated that the sacrifice of an adult type, Saltzman type 3 PTA inclusive of an associated fusiform aneurysm is feasible with dual stent-assisted coil embolization.

Early experience with the Penumbra SMART coil in the endovascular treatment of intracranial aneurysms: Safety and efficacy

BACKGROUND

Penumbra SMART coils differ from traditional microcoils used for endovascular coil embolization of intracranial aneurysms (IAs) in that they (1) become progressively softer from their distal to proximal end, rather than being of uniform stiffness, (2) have a tight conformational structure, and (3) have a more robust stretch-resistance platform. These properties aid in preventing microcatheter prolapse and coil herniation during coil deployment and in filling small pockets of the aneurysm sac.

OBJECTIVE/METHODS

To determine the safety and efficacy of this device, the records of 17 consecutive patients with IAs treated with SMART coils were retrospectively analyzed.

RESULTS

Thirteen female and four male patients were identified. Eleven patients presented with subarachnoid hemorrhage, four had recurrent aneurysms, and two had incidentally discovered aneurysms. Twelve aneurysms (two of which were recurrent) were treated with stand-alone coiling, three were treated with stent-assisted coiling, and two with flow diversion with adjuvant coiling. Microcatheter prolapse occurred in one case of a recurrent aneurysm, due to mechanical limitations imposed by a stent placed during prior coiling. Raymond-Roy Occlusion Classification (RROC) I or II occlusion was achieved in 12 aneurysms, including all 10 undergoing primary stand-alone coiling. Of the five RROC III occlusions, two were expected given treatment with flow diversion, while the other three occurred in complex, recurrent aneurysms. One patient suffered a thromboembolic complication of unclear clinical significance.

CONCLUSIONS

The Penumbra SMART coil is a safe and effective device for the endovascular treatment of IAs. Follow-up studies are required to establish long-term results.

A 54-year-old man with 12 intracranial aneurysms and familial subarachnoid hemorrhage: case report

Unruptured intracranial aneurysms occur in 1-3 % of the general population, and the risk of rupture is generally considered to be low. However, patients with multiple aneurysms and familial predisposition carry a particular risk of subarachnoid hemorrhage (SAH). A 54-year-old hypertensive man underwent screening with a head CT angiography (CTA) because of his comorbidities. CTA revealed multiple bilateral aneurysms around the circle of Willis. At first surgery, seven aneurysms were clipped (BA, ACOM, ICA ×2, and MCA ×3), two of which were detected intraoperatively only. During the second surgery, another three aneurysms were surgically clipped (PCOM and MCA ×2), one of which was detected intraoperatively. Follow-up angiography revealed another two aneurysms. A PCOM aneurysm was treated by coil embolization and a VA aneurysm clipped surgically during a third admission. The patient made an uneventful recovery. However, 4 months after his second surgery, his daughter underwent surgical clipping of a right-sided ICA aneurysm. This case report highlights both the importance of screening of high risk patients with family history of SAH, as well as its limitations, as our patient developed two de novo aneurysms during 6-month follow-up and CTA preoperatively missed three small aneurysms.

Surgical recanalization of distal middle cerebral artery occlusion due to a coil migration during endovascular coil embolization: a case report

Coil migration into the parent artery during endovascular coil embolization is a rare, but life-threatening complication, which can induce thromboembolism and result in poor outcome. A 63-year-old man was referred to Chonbuk National University Hospital emergency center due to migration of a coil for a left middle cerebral artery bifurcation unruptured aneurysm. We performed an emergency craniectomy to remove the coil migrated to the distal M2 branch and thrombus, and aneurysmal neck clipping for his aneurysm. Fortunately, at the six month follow-up, the patient did not show any noticeable neurological sequela. In case of parent artery occlusion due to coil migration an immediate recanalization should be performed by a neurovascular specialist who can provide both surgical treatment and endovascular management in order to prevent severe sequela or even death.

Endovascular Coil Embolization of Distal Anterior Cerebral Artery Aneurysms: Angiographic and Clinical Follow-up Results

Purpose

This study is an overview of the clinical and angiographic outcomes of patients who undergo treatment for distal anterior cerebral artery aneurysms.

Materials and Methods

Between January 2009 and March 2012, 444 cerebral aneurysms were treated using endovascular coil embolization at our institute. Among them, 217 aneurysms were followed-up with angiography at least six months later. Of these, there were 16 distal anterior cerebral artery (ACA) aneurysms in 16 patients. We conducted a retrospective review of clinical and radiological follow-up results of all patients with distal ACA aneurysms. The clinical and angiographic outcomes were assessed using the modified Rankin scale (mRS) and the Raymond classification scale, respectively.

Results

The mean age was 54.7 ± 10.2 years (41-75 years). The mean follow-up period was 20.6 ± 9.64 months (6-37 months). Three patients presented with acute rupture. The average aneurysm size was 4.98 ± 1.39 mm (3.0-8.1 mm), and eight of 16 aneurysms (50%) had aspect ratios < 2.0. All 16 patients presented with complete obliteration immediately after the procedure. However, two patients had procedure-related complications, one with coil extrusion to the subarachnoid space without hemorrhage and one with thromboembolism subsequent to chemical thrombolysis. In the follow-up angiography, one major and five minor recurrences (for a total of six recurrences, 37.5%) were detected. However, the differences between the ACA aneurysm group and others were not statistically significant. Clinical outcomes were good for all of the patients at the time of discharge (mean mRS: 0.25, 0 to 1) and at the follow-ups (mean mRS: 0).

Conclusion

Despite a comparatively high recurrence rate, the endovascular treatment of distal anterior cerebral aneurysms is feasible and has a good clinical outcome.