Endovascular treatment of ruptured intracranial aneurysms: factors affecting midterm quality anatomic results: analysis in a prospective, multicenter series of patients (CLARITY)

Contrast-Enhanced and Time-of-Flight MRA at 3T Compared with DSA for the Follow-Up of Intracranial Aneurysms Treated with the WEB Device

BACKGROUND AND PURPOSE

Imaging follow-up at 3T of intracranial aneurysms treated with the WEB Device has not been evaluated yet. Our aim was to assess the diagnostic accuracy of 3D-time-of-flight MRA and contrast-enhanced MRA at 3T against DSA, as the criterion standard, for the follow-up of aneurysms treated with the Woven EndoBridge (WEB) system.

MATERIALS AND METHODS

From June 2011 to December 2014, patients treated with the WEB in our institution, then followed for ≥6 months after treatment by MRA at 3T (3D-TOF-MRA and contrast-enhanced MRA) and DSA within 48 hours were included. Aneurysm occlusion was assessed with a simplified 2-grade scale (adequate occlusion [total occlusion + neck remnant] versus aneurysm remnant). Interobserver and intermodality agreement was evaluated by calculating the linear weighted κ. MRA test characteristics and predictive values were calculated from a 2 × 2 contingency table, by using DSA data as the standard of reference.

RESULTS

Twenty-six patients with 26 WEB-treated aneurysms were included. The interobserver reproducibility was good with DSA (κ = 0.71) and contrast-enhanced-MRA (κ = 0.65) compared with moderate with 3D-TOF-MRA (κ = 0.47). Intermodality agreement with DSA was fair with both contrast-enhanced MRA (κ = 0.36) and 3D-TOF-MRA (κ = 0.36) for the evaluation of total occlusion. For aneurysm remnant detection, the prevalence was low (15%), on the basis of DSA, and both MRA techniques showed low sensitivity (25%), high specificity (100%), very good positive predictive value (100%), and very good negative predictive value (88%).

CONCLUSIONS

Despite acceptable interobserver reproducibility and predictive values, the low sensitivity of contrast-enhanced MRA and 3D-TOF-MRA for aneurysm remnant detection suggests that MRA is a useful screening procedure for WEB-treated aneurysms, but similar to stents and flow diverters, DSA remains the criterion standard for follow-up.

Stent-assisted coiling and balloon-assisted coiling in the management of intracranial aneurysms: A systematic review & meta-analysis

BACKGROUND

Stent-assisted coiling and balloon-assisted coiling are well-established minimally invasive techniques for treatment of intracranial aneurysms. The aim of this study was to use meta-analysis methods to compare clinical outcomes of aneurysms treated with stent-assisted coiling versus balloon-assisted coiling.

METHODS

We searched for two-arm prospective studies and retrospective studies that compared the clinical outcomes in patients that received stent-assisted or balloon-assisted aneurysm treatment. Database search was performed through May 2015. Odds ratios (OR) with 95% confidence intervals (CI) were used to compare the clinical outcomes in patients that underwent either stent-assisted or balloon-assisted coiling for intracranial aneurysms management.

RESULTS

Complete occlusion rates at the end of the coiling procedure were similar between patients that received stent-assisted and balloon-assisted aneurysm treatment (OR=0.763, 95% CI=0.47 to 1.23, P=0.270). However, complete occlusion rates were higher with stent-assisted coiling at 6months or later after the procedure (OR=1.82, 95% CI=1.21 to 2.74). The overall complication rates and retreatment rates in patients with recurrence were similar between stent-assisted and balloon-assisted aneurysm treatments.

CONCLUSION

Stent-assisted coiling achieved better complete occlusion rates of aneurysms at 6months or later after the procedure compared to balloon-assisted coiling, without being associated with a higher risk of intraprocedural complications and retreatment.

Efficacy of Pre-procedural Rehydration against Thromboembolic Complications for Ruptured Aneurysm Embolization

Objective

To report effects of the pre-procedural rehydration for reduce thromboembolic complications in acute phase aneurysmal subarachnoid hemorrhage coil embolization.

Materials and Methods

From January 2009 to December 2013, 190 patients with ruptured aneurysmal subarachnoid hemorrhage (aSAH) treated by coil embolization at our institution were consecutively enrolled in this study. In period 1 (from January 2009 to June 2012, n = 122), pre-procedural fluid was not supplied. In period 2 (from July 2012 to December 2013, n = 68), depending on the state of the patient's body weight and degree of dehydration, intravenous fluid was started with infusion of approximately 7 mL/kg of 0.9 percent saline (minimum 300 to maximum 500 mL) over 30 minutes.

Results

A total of 190 patients were hospitalized due to aSAH and underwent coil embolization for five years between January 2009 and December 2013. Of these, 122 patients underwent coil embolization based on the old protocol before June 2012 (period 1) and 68 underwent the procedure based on the new protocol after the period 2. Neck size, width, maximum diameter of the aneurysm and procedure time were associated with procedure related thromboembolic complications in entire periods (multivariate analysis, p < 0.05, in respectively). The frequency of thromboembolism showed a drastic decrease in period 2 (re-hydration period), from 18.0% (22/123) to 4.4% (3/67), which was also statistically significant (p = 0.007, Chi-square test).

Conclusion

Pre-procedural administration of a sufficient dose of fluid considering the patient's dehydration reduced the frequency of thromboembolism in cases of emergency coil embolization for ruptured aneurysm, without increasing additional specific complications.

Clinical and Anatomical Follow-up in Patients With Aneurysms Treated With the WEB Device: 1-Year Follow-up Report in the Cumulated Population of 2 Prospective, Multicenter Series (WEBCAST and French Observatory)

BACKGROUND

Flow disruption with WEB is an innovative endovascular approach for wide-neck bifurcation aneurysms. Initial series have shown a low complication rate with good efficacy.

OBJECTIVE

To report clinical and anatomical results of the WEB treatment in the cumulated population of WEBCAST (WEB Clinical Assessment of Intrasaccular Aneurysm) and French Observatory series.

METHODS

WEBCAST and French Observatory are single-arm, prospective, multicenter, Good Clinical Practice studies dedicated to the evaluation of WEB treatment. Ruptured and unruptured bifurcation aneurysms located in the basilar artery, middle cerebral artery, anterior communicating artery, and internal carotid artery terminus were included in both studies. Clinical data were independently evaluated. Postoperative, 6-month (in WEBCAST), and 1-year aneurysm occlusion was independently evaluated with a 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant.

RESULTS

The cumulated population was 113 patients (74 female, 65.5%) 33 to 74 years of age with 114 aneurysms with a mean neck size of 5.6 mm. There was no mortality at 1 month, and morbidity was 2.7%. A statistically significant difference in the rate of occurrence of thromboembolic events was observed between the use of any antiplatelet agent and the use of no antiplatelet agent (P < .001). At 1 year, complete aneurysm occlusion was observed in 56.0%, neck remnant in 26.0%, and aneurysm remnant in 18.0%. Worsening of aneurysm occlusion between the procedure and 12 months was observed in 2.0% and between 6 months and 1 year in 7.1%.

CONCLUSION

The analysis in this large cumulated population of studies confirms favorable safety and efficacy of WEB treatment.

Validity of the Meyer Scale for Assessment of Coiled Aneurysms and Aneurysm Recurrence

BACKGROUND AND PURPOSE

Both the Meyer and Raymond scales are commonly used to report angiographic outcomes following coil embolization of intracranial aneurysms. The objectives of this study were the following: 1) to assess the interobserver agreement of the Meyer and Raymond scales, and 2) to evaluate and compare their performance in predicting major recurrence at follow-up.

MATERIALS AND METHODS

A retrospective series of 120 coiled aneurysms was included. Four investigators independently graded DSA images immediately posttreatment and at follow-up according to the Meyer and Raymond scales. On follow-up DSA, readers also evaluated recurrence outcome. Interobserver agreement was assessed via the intraclass correlation coefficient. The ability of posttreatment Meyer and Raymond scales to predict major recurrence was modeled by using logistic regression and assessed by using receiver operating characteristic analysis.

RESULTS

For the Meyer scale, interobserver intraclass correlation coefficients were 0.58 (95% CI, 0.46-0.68) on posttreatment and 0.78 (95% CI, 0.72-0.83) on follow-up evaluations. For the Raymond scale, interobserver intraclass correlation coefficients were 0.50 (95% CI, 0.39-0.61) and 0.69 (95% CI, 0.62-0.76), respectively, for posttreatment and follow-up. The areas under the curve for the receiver operating characteristic analyses regarding the performance to predict major recurrence at follow-up were 0.69 (95% CI, 0.60-0.79) for the Meyer and 0.70 (95% CI, 0.61-0.78) for the Raymond scale.

CONCLUSIONS

The Meyer scale appears consistent and reliable with observer agreement as high or higher than that of the Raymond scale. Performance of both scales in predicting the risk of major recurrence at follow-up is adequate, with no statistical difference between the scales.

HydroCoils Are Associated with Lower Angiographic Recurrence Rates Than Are Bare Platinum Coils in Treatment of "Difficult-to-Treat" Aneurysms: A Post Hoc Subgroup Analysis of the HELPS Trial

BACKGROUND AND PURPOSE

The HydroCoil Endovascular Aneurysm Occlusion and Packing Study was a randomized controlled trial that compared HydroCoils to bare platinum coils. Using data from this trial, we performed a subgroup analysis of angiographic and clinical outcomes of patients with "difficult-to-treat" aneurysms, defined as irregularly shaped and/or having a dome-to-neck ratio of <1.5.

MATERIALS AND METHODS

Separate subgroup analyses comparing outcomes of treatment with HydroCoils to that of bare platinum coils were performed for the following: 1) irregularly shaped aneurysms, 2) regularly shaped aneurysms, 3) aneurysms with a dome-to-neck ratio of <1.5, and 4) aneurysms with a dome-to-neck ratio of ≥1.5. For each subgroup analysis, the following outcomes were studied at the last follow-up (3-18 months): 1) any recurrence, 2) major recurrence, 3) re-treatment, and 4) an mRS score of ≤2. Multivariate logistic regression analysis was performed to determine if the HydroCoil was independently associated with improved outcomes in these subgroups.

RESULTS

Among the patients with an irregularly shaped aneurysm, the HydroCoil was associated with lower major recurrence rates than the bare platinum coils (17 of 66 [26%] vs 30 of 69 [44%], respectively; P = .046). Among the patients with an aneurysm with a small dome-to-neck ratio, the HydroCoil was associated with lower major recurrence rates than the bare platinum coils (18 of 73 [24.7%] vs 32 of 76 [42.1%], respectively; P = .02). No difference in major recurrence was seen between HydroCoils and bare platinum coils for regularly shaped aneurysms (42 of 152 [27.6%] vs 52 of 162 [32.1%], respectively; P = .39) or aneurysms with a large dome-to-neck ratio (41 of 145 [28.3%] vs 50 of 155 [32.3%], respectively; P = .53).

CONCLUSIONS

This unplanned post hoc subgroup analysis found that HydroCoils are associated with improved angiographic outcomes in the treatment of irregularly shaped aneurysms and aneurysms with a dome-to-neck ratio of <1.5. Because this was a post hoc analysis, these results are not reliable and absolutely should not alter clinical practice but, rather, may inform the design of future randomized controlled trials.

WEB-DL Endovascular Treatment of Wide-Neck Bifurcation Aneurysms: Long-Term Results in a European Series

BACKGROUND AND PURPOSE

Flow disruption with the WEB-DL device has been used safely for the treatment of wide-neck bifurcation aneurysms. The stability of aneurysm occlusion after this treatment was evaluated in the short and midterm, but not in the long term. This retrospective multicenter European study is the continuation of an already published series dealing with short- and midterm anatomic results and analyzes long-term data in patients treated with the WEB-DL.

MATERIALS AND METHODS

Twelve European neurointerventional centers initially participated in the study. In addition to data collected for the initial publication, images obtained at long-term follow-up were collected and independently analyzed by the same experienced interventional neuroradiologist.

RESULTS

Of the initial 45 patients, 26 (20 women and 6 men; 35-73 years of age; mean, 55.2 ± 10.6 years; median, 55.5 years) with 26 aneurysms treated with the WEB-DL device had long-term follow-up (median, 27.4 months). Three of 26 patients (11.5%) were retreated between short- and midterm follow-up, and none, between mid- and long-term follow-up. Long-term aneurysm occlusion in the 19 patients treated with the WEB only and not retreated during follow-up was complete occlusion in 13/19 patients (68.4%), including aneurysms with opacification of the proximal recess in 9/19 patients (47.4%), neck remnant in 3/19 patients (15.8%), and aneurysm remnant in 3/19 patients (15.8%). In all patients (100.0%), aneurysm occlusion was stable between midterm and long-term follow-up.

CONCLUSIONS

The results suggest that WEB treatment of wide-neck bifurcation aneurysms offers long-term stable occlusion.

Survival Analysis of Risk Factors for Major Recurrence of Intracranial Aneurysms after Coiling

Background: Recurrence after intracranial aneurysm coiling is a highly prevalent outcome, yet to be understood. We investigated clinical, radiological and procedural factors associated with major recurrence of coiled intracranial aneurysms. Methods: We retrospectively analyzed prospectively collected coiling data (2003-12). We recorded characteristics of aneurysms, patients and interventional techniques, pre-discharge and angiographic follow-up occlusion. The Raymond-Roy classification was used; major recurrence was a change from class I or II to class III, increase in class III remnant, and any recurrence requiring any type of retreatment. Identification of risk factors associated with major recurrence used univariate Cox Proportional Hazards Model followed by multivariate regression analysis of covariates with P<0.1. Results: A total of 467 aneurysms were treated in 435 patients: 283(65%) harboring acutely ruptured aneurysms, 44(10.1%) patients died before discharge and 33(7.6%) were lost to follow-up. A total of 1367 angiographic follow-up studies (range: 1-108 months, Median [interquartile ranges (IQR)]: 37[14-62]) was performed in 384(82.2%) aneurysms. The major recurrence rate was 98(21%) after 6(3.5-22.5) months. Multivariate analysis (358 patients with 384 aneurysms) revealed the risk factors for major recurrence: age>65 y (hazard ratio (HR): 1.61; P=0.04), male sex (HR: 2.13; P<0.01), hypercholesterolemia (HR: 1.65; P=0.03), neck size ≥4 mm (HR: 1.79; P=0.01), dome size ≥7 mm (HR: 2.44; P<0.01), non-stent-assisted coiling (HR: 2.87; P=0.01), and baseline class III (HR: 2.18; P<0.01). Conclusion: Approximately one fifth of the intracranial aneurysms resulted in major recurrence. Modifiable factors for major recurrence were choice of stent-assisted technique and confirmation of adequate baseline occlusion (Class I/II) in the first coiling procedure.

Silk flow-diverter stent for the treatment of intracranial aneurysms: a series of 58 patients with emphasis on long-term results

BACKGROUND AND PURPOSE

The Silk flow-diverter stent is increasingly used to treat complex intracranial aneurysms including wide-neck, fusiform aneurysms. Sparse data are available concerning long-term results of this technique. We report our 5-year experience with Silk stent treatment of intracranial aneurysms.

MATERIALS AND METHODS

A retrospective review of our prospectively maintained database identified all patients treated by the Silk stent in 2 institutions. Clinical charts, procedural data, and angiographic results were reviewed.

RESULTS

Between July 2009 and May 2014, we identified 58 patients with 70 intracranial aneurysms. Endovascular treatment was successful in 93% of patients with 32 treated with the first-generation Silk stent and 26 with the new Silk+ stent. Mean follow-up in 47 patients was 22 months. Despite an 11% delayed complication rate, overall permanent neurologic morbidity was 5.5%. All complications were seen with the first-generation Silk stent. There was no procedure-related mortality. Long-term anatomic results showed 73% with complete occlusion, 16% with neck remnants, and 11% with incomplete occlusion. No recanalization or retreatment was performed. The midterm intrastent stenosis rate was 57%, of which 60% improved or disappeared, 28% were stable, and 12% led to vessel occlusion. Seventy-four percent of stenosis and all vessel occlusions occurred with the first-generation Silk stent.

CONCLUSIONS

Endovascular treatment of complex intracranial aneurysms with the Silk stent is an effective therapeutic option. Despite a high rate of delayed complications with the first-generation stents, the current Silk+ stent appears safer. This treatment achieves a high rate of adequate and stable occlusion at long-term follow-up.

WEB intrasaccular flow disruptor-prospective, multicenter experience in 83 patients with 85 aneurysms

BACKGROUND AND PURPOSE

The safety and efficacy of WEB flow disruption have been analyzed in small, retrospective series. The object of this study was to evaluate the safety and efficacy of WEB flow disruption in a large, multicenter, prospectively collected population.

MATERIALS AND METHODS

Data from all patients treated with the WEB-DL device between June 2011 and October 2013 in 11 French neurointerventional centers were prospectively collected and retrospectively analyzed. Complications occurring during and after treatment were analyzed as well as morbidity and mortality at 1 month. Aneurysm occlusion status at the last follow-up was analyzed.

RESULTS

Eighty-three patients with 85 aneurysms were included in this series. Technical success was achieved in 77 patients with 79 aneurysms (92.9%). Periprocedural complications were observed in 9 patients (10.8%), leading to permanent neurologic deficits in 3 (3.9%). Morbidity and mortality at 1 month were 1.3% and 0.0%, respectively. Angiographic follow-up was performed for 65/79 aneurysms (82.3%) 3-24 months after treatment (mean, 5.3 months). Complete aneurysm occlusion was observed in 37/65 aneurysms (56.9%); neck remnant, in 23/65 (35.4%); and aneurysm remnant, in 5/65 (7.7%).

CONCLUSIONS

In this large prospective series of patients, WEB flow disruption was a safe and efficient technique.

Follow-up of intracranial aneurysms treated by flow diverter: comparison of three-dimensional time-of-flight MR angiography (3D-TOF-MRA) and contrast-enhanced MR angiography (CE-MRA) sequences with digital subtraction angiography as the gold standard

Background and purpose

Follow-up of intracranial aneurysms treated by flow diverter with MRI is complicated by imaging artifacts produced by these devices. This study compares the diagnostic accuracy of three-dimensional time-of-flight MR angiography (3D-TOF-MRA) and contrast-enhanced MRA (CE-MRA) at 3 T for the evaluation of aneurysm occlusion and parent artery patency after flow diversion treatment, with digital subtraction angiography (DSA) as the gold standard.

Materials and methods

Patients treated with flow diverters between January 2009 and January 2013 followed by MRA at 3 T (3D-TOF-MRA and CE-MRA) and DSA within a 48 h period were included in a prospective single-center study. Aneurysm occlusion was assessed with full and simplified Montreal scales and parent artery patency with three-grade and two-grade scales.

Results

Twenty-two patients harboring 23 treated aneurysms were included. Interobserver agreement using simplified scales for occlusion (Montreal) and parent artery patency were higher for DSA (0.88 and 0.61) and CE-MRA (0.74 and 0.55) than for 3D-TOF-MRA (0.51 and 0.02). Intermodality agreement was higher for CE-MRA (0.88 and 0.32) than for 3D-TOF-MRA (0.59 and 0.11). CE-MRA yielded better accuracy than 3D-TOF-MRA for aneurysm remnant detection (sensitivity 83% vs 50%; specificity 100% vs 100%) and for the status of the parent artery (specificity 63% vs 32%; sensitivity 100% vs 100%).

Conclusions

At 3 T, CE-MRA is superior to 3D-TOF-MRA for the evaluation of aneurysm occlusion and parent artery patency after flow diversion treatment. However, intraluminal evaluation remains difficult with MRA regardless of the sequence used.

Is long-term follow-up of adequately coil-occluded ruptured cerebral aneurysms always necessary? A single-center study of recurrences after endovascular treatment

PURPOSE

Aneurysm recurrence following coil occlusion is well recognized. However, there is controversy as to how long these patients should be followed up after coiling to detect reopening. We aimed to identify the rate of late reopening and the risk factors for reopening in a large single-center cohort of ruptured aneurysms that appeared adequately occluded at 6 months. We also aimed to assess whether rates of recurrence have altered over time with improving coil and angiographic technology.

METHODS

Patients treated between 1996 and 2010 were assessed and those with both 6-month initial and subsequent long-term follow-up with either digital subtraction angiography or magnetic resonance angiography were included. Aneurysms were stratified by features such as size, neck width, anatomical location and time of treatment: 1996-2005 (cohort 1) and 2006-2010 (cohort 2). ORs for risk of recurrence were calculated for aneurysm features and rates of recurrence in each cohort were compared using a χ(2) test.

RESULTS

437 patients with 458 adequately occluded aneurysms at 6 months had mean long-term follow-up of 31 months; 57 (12.4%) were large (≥ 10 mm) and 104 (22.7%) were wide-necked (>4 mm). Nine aneurysms (2%) showed significant late anatomical deterioration whereby retreatment was considered or undertaken. The risk was greater for large aneurysms (≥ 10 mm) (OR 15.61, 95% CI 3.79 to 64.33, p=0.0001) or wide-necked aneurysms (>4 mm) (OR 12.70, 95% CI 2.60 to 62.13, p=0.0017). The frequency of significant late anatomical deterioration and retreatment was also less common in those treated in cohort 2 (p<0.05). No completely occluded aneurysm at 6 months demonstrated significant late recurrence.

CONCLUSIONS

Most aneurysms adequately occluded at 6 months did not show evidence of late recurrence. Large and wide-neck aneurysms are, however, at greater risk of later recurrence.

WEB-DL endovascular treatment of wide-neck bifurcation aneurysms: short- and midterm results in a European study

BACKGROUND AND PURPOSE

Flow disruption with the WEB-DL device has been used safely for the treatment of wide-neck bifurcation aneurysms, but the stability of aneurysm occlusion after this treatment is unknown. This retrospective multicenter European study analyzed short- and midterm data in patients treated with WEB-DL.

MATERIALS AND METHODS

Twelve European neurointerventional centers participated in the study. Clinical data and pre- and postoperative short- and midterm images were collected. An experienced interventional neuroradiologist independently analyzed the images. Aneurysm occlusion was classified into 4 grades: complete occlusion, opacification of the proximal recess of the device, neck remnant, and aneurysm remnant.

RESULTS

Forty-five patients (34 women and 11 men) 35-74 years of age (mean, 56.3 ± 9.6 years) with 45 aneurysms treated with the WEB device were included. Aneurysm locations were the middle cerebral artery in 26 patients, the posterior circulation in 13 patients, the anterior communicating artery in 5 patients, and the internal carotid artery terminus in 1 patient. Forty-two aneurysms were unruptured. Good clinical outcome (mRS < 2) was observed in 93.3% of patients at the last follow-up. Adequate occlusion (complete occlusion, opacification of the proximal recess, or neck remnant) was observed in 30/37 patients (81.1%) in short-term follow-up (median, 6 months) and in 26/29 patients (89.7%) in midterm follow-up (median, 13 months). Worsening of the aneurysm occlusion was observed in 2/28 patients (7.1%) at midterm follow-up.

CONCLUSIONS

The results suggest that the WEB endovascular treatment of wide-neck bifurcation aneurysms offers stable occlusion in a class of aneurysms that are historically unstable. Additionally, our data show that opacification of the WEB recess can be delineated from true neck or aneurysm remnants.

Endovascular treatment of 300 consecutive middle cerebral artery aneurysms: clinical and radiologic outcomes

BACKGROUND AND PURPOSE

There is controversy as to the best mode of treating MCA aneurysms. We report the results of a large endovascular series of patients treated at our center.

MATERIALS AND METHODS

This study was a retrospective analysis of a prospectively acquired data base. All patients with saccular MCA aneurysms treated between November 1996 and June 2012 were included. World Federation of Neurosurgical Societies grade, aneurysm site, size, and aneurysm neck size were recorded, along with clinical outcome assessed with the Glasgow Outcome Scale and radiographic occlusion assessed with the Raymond classification at 6 months and 2.5 years.

RESULTS

A total of 295 patients with 300 MCA aneurysms were treated including 244 ruptured aneurysms (80.7%). The technical failure rate was 4.3% (13 patients). Complete occlusion or neck remnant was achieved in 264 (91.4%). Complications included rupture in 15 patients (5%), thromboembolism in 17 patients (5.7%), and early rebleeding in 3 patients (1%). Overall permanent procedural-related morbidity and mortality were seen in 12 patients (7.8%). Of the ruptured aneurysms, 189 (79.4%) had a favorable clinical outcome (Glasgow Outcome Scale score, 4-5). A total of 33 patients (13.6%) died. On initial angiographic follow-up, aneurysm remnant was seen in 18 aneurysms (8.1%). A total of 13 patients (4.3%) were re-treated.

CONCLUSIONS

Our experience demonstrates that endovascular treatment of MCA aneurysms has an acceptable safety profile with low rates of technical failure and re-treatment. Therefore, coiling is acceptable as the primary treatment of MCA aneurysms.

Stent-assisted coiling versus balloon remodeling of wide-neck aneurysms: comparison of angiographic outcomes

BACKGROUND AND PURPOSE

Stent-assisted coiling and balloon-assisted coiling are 2 well-established techniques for treatment of wide-neck intracranial aneurysms. A direct comparative analysis of angiographic outcomes with the 2 techniques has not been available. We compare the angiographic outcomes of wide-neck aneurysms treated with stent-assisted coiling versus balloon-assisted coiling.

MATERIALS AND METHODS

A retrospective review was conducted on 101 consecutive patients treated at our institution, 69 with stent-assisted coiling and 32 with balloon-assisted coiling. Two multivariate logistic regression analyses were performed to determine predictors of aneurysm obliteration and predictors of progressive aneurysm thrombosis at follow-up.

RESULTS

The 2 groups were comparable with respect to all baseline characteristics with the exception of a higher proportion of ruptured aneurysms in the balloon-assisted coiling group (65.6%) than in the stent-assisted coiling group (11.5%, P < .001). Procedural complications did not differ between the stent-assisted coiling group (6%) and the balloon-assisted coiling group (9%, P = .5). The rates of complete aneurysm occlusion (Raymond score 1) at the most recent follow-up were significantly higher for the stent-assisted coiling group (75.4%) compared with the balloon-assisted coiling group (50%, P = .01). Progressive occlusion of incompletely coiled aneurysms was noted in 76.6% of aneurysms in the stent-assisted coiling group versus 42.8% in the balloon-assisted coiling group (P = .02). Retreatment rates were significantly lower with stent-assisted coiling (4.3%) versus balloon-assisted coiling (15.6%, P = .05). In multivariate analysis, stented aneurysms independently predicted both complete aneurysm obliteration and progression of occlusion.

CONCLUSIONS

Stent-assisted coiling may yield lower rates of retreatment and higher rates of aneurysm obliteration and progression of occlusion at follow-up than balloon-assisted coiling with a similar morbidity rate.

Endovascular therapeutic strategies in ruptured intracranial aneurysms

The aim of the present study was to evaluate endovascular techniques used currently which were not available at the time of ISAT inclusion period, such as balloon remodelling and flow-divertion, in order to assess whether these new technologies have improved the endovascular approach outcomes. We present a review of articles, published in major journals, with the aim to evaluate the efficacy and the safety of coiling with balloon remodelling for the treatment of ruptured aneurysms in comparison to coiling performed without such coadjutant techniques. Furthermore, we reviewed publications reporting on the treatment of ruptured aneurysms in the acute phase with the one of the most recent technologies available nowadays: the flow diverting stent. Looking at the recent literature the results regarding ruptured aneurysms treated with balloon assisted coiling (BAC) have shown an improvement in terms of anatomical results and morbi-mortality rates. Case series of ruptured middle cerebral artery (MCA) aneurysms treated by EVT report results similar to those obtained by surgical clipping. Several articles recently report encouraging results in treating ruptured dissecting and blister aneurysms with flow diverters. Questions regarding the best treatment available for ruptured aneurysms are yet to be answered. Hence there is a need for a subsequent trial aiming to answer these unresolved issues.

Pipeline embolization device for intracranial aneurysm: a systematic review

INTRODUCTION

The pipeline embolization device (PED) is a new endovascular stent designed for the treatment of challenging intracranial aneurysms (IAs). Its use has been extended to nonruptured and ruptured IAs of a variety of configurations and etiologies in both the anterior and posterior circulations.

METHODS

We conducted a systematic review of ten eligible reports on its clinical efficacy and safety.

RESULTS

There were 414 patients with 448 IAs. The majority of the IAs were large (40.2 %), saccular or blister-like (78.3 %), and were located mostly in the anterior circulation (83.5 %). The regimens of antiplatelet therapy varied greatly between and within studies. The mean number of the PED used was 2.0 per IA. Deployment was successful in around 95 % of procedures. Aneurysm obliteration was achieved in 82.9 % of IAs at 6-month. The overall incidences of periprocedural intracranial vascular complication rate and mortality rate were 6.3 and 1.5 %, respectively.

CONCLUSION

The PED is a safe and effective treatment for nonruptured IAs. Its use in the context of acute subarachnoid hemorrhage (SAH) should be cautioned. Its main limitations include the need for prolonged antiplatelet therapy, as well as the potential risks of IA rupture and non-IA-related intracerebral hemorrhages (ICH). Future studies should aim at identifying factors that predispose to incomplete obliteration, delayed rupture, and thromboembolic complications.