Simple coiling using single or multiple catheters without balloons or stents in middle cerebral artery bifurcation aneurysms

Woven endobridge embolization versus microsurgical clipping for unruptured wide-neck cerebral aneurysms on middle cerebral artery bifurcation

Woven EndoBridge (WEB) is an endovascular treatment for wide-neck bifurcation aneurysms (WNBAs). This study aimed to clarify the efficacy and safety of the WEB comparing to clipping for treating the middle cerebral artery (MCA) WNBAs. For the matched analysis, we designed a retrospective, tertiary, single-center study including 288 MCA WNBAs treated with WEB (n = 37) or clipping (n = 251). Inverse probability of treatment weighting (IPTW) for the main analysis and 1:2 propensity score matching for the sensitivity analysis were used to adjust for aneurysm geometric parameters. Morbidity, major complications, and aneurysm occlusion grade were assessed at 1 year. In the IPTW analysis, no significant difference was observed in morbidity (2.1% vs. 1.6%, odds ratio [OR]: 1.34, p = 0.776) and major complications (3.3% vs. 3.1%, OR: 1.08, p = 0.926). Adequate aneurysm occlusion was achieved in 76.1% of the WEB group and 97.4% of the clipping group (OR: 0.09, p < 0.001). In line with the main analysis, the 1:2 propensity score matching analysis revealed no significant difference in the morbidity (OR: 2.00, 95% CI: 0.13-31.98, p = 0.624). This study supports that microsurgical clipping still requires to play a vital role, but WEB could be an alternative option for WNBAs in the MCA.

Flow Diversion for the Treatment of Middle Cerebral Artery Aneurysms

The invention of flow diverting stents (FDS) is a novel milestone in the field of endovascular aneurysm therapy, promoting physiological healing of the vessel segment contrary to prior deconstructive treatment strategies, such as coiling. The effects of FDS are based on changes in flow patterns, segmental wall stabilization, and the growth of a neointima. Although flow diversion is already well established for cerebral aneurysms in proximal segments, peripheral locations remain challenging. Especially the middle cerebral artery (MCA) with its predominance of non-collateralized perforators and functional end arteries that supply the eloquent areas of the brain is of major concern.The literature was reviewed for flow diversion of the MCA and antiplatelet therapy.Resulting from the special anatomical characteristics of the MCA, FDS implantation in this territory is completely different from the proximal vessel segments. Still, flow diversion represents an effective endovascular strategy, especially in otherwise non-accessible or sufficiently treatable lesions. However, the risk of ischemic adverse events might be increased. Special attention to the individual decision regarding device selection, antiplatelet regimen, and exact definition of the proximal and distal landing zone considering the jailed side branches is essential for a good angiographic and clinical outcome. · MCA aneurysms can be sufficiently treated by FDS.. · The anatomic and hemodynamic characteristics of the MCA result in an increased risk of thromboembolism.. · Individual device selection and antiplatelet regimen are essential for treatment success.. · Schüngel M, Wohlgemuth WA, Elolf E et al. Review: Flow Diversion for the Treatment of Middle Cerebral Artery Aneurysms. Rofo 2025; DOI 10.1055/a-2343-0046.

Embolization of unruptured wide-necked aneurysms at the MCA bifurcation using the Neuroform atlas stent-assisted coiling: a two-center retrospective study

Background

The management of middle cerebral artery (MCA) aneurysms remains a controversial topic, and MCA aneurysms have traditionally been treated primarily by surgical clipping. The Neuroform Atlas Stent™ (NAS, available from Stryker Neurovascular, Fremont, California) represents the latest generation of intracranial stents with improved stent delivery system capabilities.

Objective

This study aims to investigate the safety, feasibility and efficacy exhibited by NAS in treating unruptured aneurysms at the MCA bifurcation.

Methods

This was a two-center retrospective study involving 42 patients with unruptured wide-necked aneurysms (WNAs) of the MCA treated with the NAS from October 2020 to July 2022.

Results

The stent was used to treat 42 cases of unruptured WNA at the MCA bifurcation. Endovascular treatment techniques had a 100% success rate. Immediate postoperative angiography found complete aneurysm occlusion in 34 patients (80.9%) (mRRC 1), neck remnant in 7 patients (16.7%) (mRRC 2), and residual aneurysm in 1 patient (2.4%) (mRRC 3). The thromboembolic complication rate was 2.4% (1/42). The follow-up period was 8.7 months on average (3-16 months). The last angiographic follow-up results revealed complete aneurysm occlusion in 39 patients (92.9%) (mRRC 1), neck remnant in 3 (7.1%) patients (mRRC 2), no aneurysm recanalization or recurrence, and no cases of stent intimal hyperplasia. During the latest clinical follow-up, all patients had an mRS score of 0.

Conclusion

Our study demonstrates that the NAS can be applied to treat unruptured WNAs at the MCA bifurcation with favorable safety, feasibility, and efficacy.

Simple endovascular coiling: An effective long-term solution for wide-necked ruptured middle cerebral artery aneurysms? A 10-years retrospective study

BACKGROUND

Endovascular coiling is usually the first line treatment modality for most ruptured intracranial aneurysms. However, there is still some debate as to whether microsurgical clipping or coiling is the treatment of choice for complex wide-necked ruptured middle cerebral artery (MCA) aneurysms. Our aim was to assess the efficacy, safety and longevity of simple endovascular coiling for ruptured MCA aneurysms.

METHODS

This was a single-centre 10 years retrospective study (2008-2019) of all endovascularly treated patients with ruptured MCA aneurysms (n = 148). Patients were treated with simple coiling (n = 111), balloon-assisted coiling (n = 13), dual micro-catheter coiling (n = 19), balloon-assisted and dual micro-catheter coiling (n = 4) and woven endobridge (WEB) device (n = 1). The standard follow-up protocol consisted of Magnetic Resonance angiography at 6, 12 and 24 months. Our primary endpoints were mortality at 2, 12 and 24 months and dependency at discharge. Secondary endpoints included aneurysm occlusion, complications, re-canalisation, rebleeding and retreatment rates.

RESULTS

All-cause mortality at 2, 12 and 24 months was 4.7% (n = 7), 8.1% (n = 12) and 10.8% (n = 16), respectively. 81.3% of patients remained independent in activities of daily livings (ADLs) at the point of discharge. Over a mean follow-up period of 19.7 months, we demonstrated re-bleeding and re-treatment rates of 2.7% (n = 4) and 4.1% (n = 6) respectively. Complete occlusion was achieved in 54% (n = 79) of aneurysms, with recanalisation observed in 18.2% (n = 27) of the patients.

CONCLUSIONS

Our results demonstrate that simple endovascular coiling techniques offer a safe and effective solution in the management of ruptured MCA aneurysms without the requirement for re-treatment either surgically or endovascularly using endoluminal stents or other devices.

Woven EndoBridge versus stent-assisted coil embolization of cerebral bifurcation aneurysms

OBJECTIVE

Stent-assisted coil (SAC) embolization has been the mainstay endovascular treatment for bifurcation aneurysms. The recent introduction of the Woven EndoBridge (WEB) device has presented an alternative endovascular treatment modality for these aneurysms. Direct comparisons of outcomes between these two modalities are limited in the literature. Here, the authors compared the outcomes of bifurcation aneurysms treated with SAC and WEB devices.

METHODS

This retrospective single-center study comprised 148 bifurcation aneurysms that were treated endovascularly with SAC or WEB devices between 2011 and 2019. The primary outcome was complete occlusion of the aneurysm at 6 months on catheter angiography.

RESULTS

The SAC and WEB cohorts comprised 85 and 63 aneurysms, respectively. The baseline characteristics were well balanced after inverse probability weight (IPW) adjustment, except for smoking status. The 6-month complete occlusion rate was higher in the WEB cohort than the SAC cohort (67.4% vs 40.6%; unadjusted OR [95% CI] 3.014 [1.385-6.563], p = 0.005). However, this difference in complete occlusion rates did not remain significant after IPW adjustment and multiple imputations. The neck remnant rate was lower in the WEB cohort than the SAC cohort (20% vs 50%; OR [95% CI] 0.250 [0.107-0.584], p = 0.001), and this difference remained significant after IPW adjustment (OR [95% CI] 0.304 [0.116-0.795], p = 0.015) and multiple imputations.

CONCLUSIONS

Use of SAC and WEB demonstrated comparable 6-month complete occlusion rates for bifurcation aneurysms. WEB appeared to be associated with a lower rate of neck remnant at 6 and 12 months compared with SAC. WEB was also associated with fewer complications and decreased retreatment rates compared with SAC.

The use of single low-profile visualized intraluminal support stent-assisted coiling in the treatment of middle cerebral artery bifurcation unruptured wide-necked aneurysm

OBJECTIVE

Endovascular treatment of unruptured wide-necked aneurysms located at the middle cerebral artery bifurcation remains challenging. This study aimed to evaluate the safety and efficacy of endovascular treatment for middle cerebral artery bifurcation unruptured wide-necked aneurysms using a low-profile visualized intraluminal support (LVIS) stent.

METHODS

We retrospectively reviewed all patients with middle cerebral artery bifurcation unruptured wide-necked aneurysms treated using an LVIS device at our institution between October 2014 and December 2018. Clinical presentation, aneurysmal characteristics, technical feasibility, perioperative complications, clinical outcome, and angiographic and clinical follow-up results were evaluated.

RESULTS

Fifty-seven patients with 57 wide-necked aneurysms arising from the middle cerebral artery bifurcation were identified. The technical success rate of stent deployment was 100%. Immediate postoperative angiograms showed Raymond 1 in 26 aneurysms (45.6%), Raymond 2 in 10 (17.6%), and Raymond 3 in 21 (36.8%). Perioperative complications developed in two patients (3.5%), including one procedure-related hemorrhagic event and one thromboembolic event. The follow-up angiogram was available for 47 aneurysms obtained at an average of 11.7 months (range, 5 to 49 months) after intervention; the latest follow-up angiograms revealed complete occlusion in 37 (78.7%) aneurysms, improvement in three (6.4%), stabilization in five (10.6%), and recanalization in two (4.3%). During the follow-up, one patient was found to have in-stent stenosis and two patients were found to have slow flow or occlusion of the jailed branch. All three of these patients were asymptomatic. No hemorrhagic or thromboembolic events occurred during clinical follow-up.

CONCLUSIONS

Our experience suggests that endovascular treatment of middle cerebral artery bifurcation unruptured wide-necked aneurysms with an LVIS stent is safe and effective, but the effect on branches needs to be further studied.

Endovascular Treatment of Ruptured Middle Cerebral Artery Aneurysms: A Single-Arm Meta-Analysis and Systematic Review

OBJECTIVE

The use of endovascular treatment for ruptured middle cerebral artery (MCA) aneurysms, which have been more likely to be recommended for neurosurgical clipping because of the complex anatomic configuration, remains controversial. In the present study, the angiographic and clinical outcomes of endovascularly treated ruptured MCA aneurysms were systematically reviewed.

METHODS

Online databases, including Cochrane, Medline, Web of Science, and Embase, were retrospectively and systematically searched. The primary outcomes were the immediate complete occlusion rate, mortality, complication-related mortality, and procedure-related complication rate. Meta-analysis was performed using a random or fixed effect model based on heterogeneity.

RESULTS

A total of 14 studies with 1004 ruptured MCA aneurysms were included. The procedure-related mortality rate at discharge was 1.8% (95% confidence interval [CI], 0.9%-2.7%; I² = 0.0%; P = 0.623). The favorable clinical outcome rate at discharge was 65.4% (95% CI, 54.8%-76.0%; I² = 94.2%; P < 0.001) and had progressively increased to 73.2% (95% CI, 59.9%-86.5%; I² = 80.9%; P < 0.001). The overall complication rate was 22.7% (95% CI, 15.1%-30.3%; I² = 75.5%; P < 0.001).

CONCLUSION

Endovascular treatment of MCA aneurysms was related to a high incidence of procedure-related complications but a low rate of procedure-related mortality. The overall angiographic and clinical outcomes were comparable and warrant further investigation comparing clipping versus coiling for ruptured MCA aneurysms.

Endovascular coiling of proximal middle cerebral artery aneurysms: is it safe and durable?

BACKGROUND

Proximal middle cerebral artery (M1 segment) aneurysms are relatively deeply located in neighboring lenticulostriate arteries, which make them unsuitable for microsurgery. We aimed to investigate the clinical and radiological outcomes of endovascular coiling of M1 segment aneurysms.

METHODS

Between January 2003 and December 2014, we retrospectively reviewed the medical records of 52 patients (52 aneurysms) from four institutions who underwent endovascular coiling of M1 segment aneurysms. Patients who underwent clinical and radiologic follow-up for more than a year after the procedure were evaluated.

RESULTS

The aneurysms were located in the early frontal branch, early temporal branch, and lenticulostriate artery in 28, 15, and nine patients, respectively. Endovascular coiling was achieved in 51 cases and failed in one case. Of these 51 cases, 46 (90.2%) and five (9.8%) were non-ruptured and ruptured aneurysms, respectively. Initial angiographic results revealed complete occlusion in 26 (51.0%), residual neck in 16 (31.4%), and residual sac in nine (17.6%) cases. One failed case had a symptomatic procedural complication of thromboembolism. However, there was no permanent morbidity or mortality. Two major recanalization cases (3.9%) were retreated by endovascular coiling. On multivariable logistic regression analysis, aneurysmal recurrence was significantly related to aneurysm height (OR, 1.887; 95% CI, 1.107 to 3.217; p = 0.020), width (OR, 1.836; CI, 1.127 to 2.992; p = 0.015), and neck (OR, 4.017; CI, 1.220 to 13.232, p = 0.022).

CONCLUSION

Endovascular coiling of M1 segment aneurysms appeared to be a feasible treatment option with a relatively low-retreatment rate. Aneurysm size was statistically significantly associated with recurrence.

Coiling Versus Microsurgical Clipping in the Treatment of Unruptured Middle Cerebral Artery Aneurysms: A Meta-Analysis

BACKGROUND

Open microsurgical clipping of unruptured intracranial aneurysms has long been the gold standard, yet advancements in endovascular coiling techniques have begun to challenge the status quo.

OBJECTIVE

To compare endovascular coiling with microsurgical clipping among adults with unruptured middle cerebral artery aneurysms (MCAA) by conducting a meta-analysis.

METHODS

A systematic search was conducted from January 2011 to October 2015 to update a previous meta-analysis. All studies that reported unruptured MCAA in adults treated by microsurgical clipping or endovascular coiling were included and cumulatively analyzed.

RESULTS

Thirty-seven studies including 3352 patients were included. Using the random-effects model, pooled analysis of 11 studies of microsurgical clipping (626 aneurysms) revealed complete aneurysmal obliteration in 94.2% of cases (95% confidence interval [CI] 87.6%-97.4%). The analysis of 18 studies of endovascular coiling (759 aneurysms) revealed complete obliteration in 53.2% of cases (95% CI: 45.0%-61.1%). Among clipping studies, 22 assessed neurological outcomes (2404 aneurysms), with favorable outcomes in 97.9% (95% CI: 96.8%-98.6%). Among coiling studies, 22 examined neurological outcomes (826 aneurysms), with favorable outcomes in 95.1% (95% CI: 93.1%-96.5%). Results using the fixed-effect models were not materially different.

CONCLUSION

This updated meta-analysis demonstrates that surgical clipping for unruptured MCAA remains highly safe and efficacious. Endovascular treatment for unruptured MCAAs continues to improve in efficacy and safety; yet, it results in lower rates of occlusion.

Physiological remodeling of bifurcation aneurysms: preclinical results of the eCLIPs device

OBJECTIVE

Intracranial bifurcation aneurysms are complex lesions for which current therapy, including simple coiling, balloon- or stent-assisted coiling, coil retention, or intrasaccular devices, is inadequate. Thromboembolic complications due to a large burden of intraluminal metal, impedance of access to side branches, and a high recurrence rate, due largely to the unmitigated high-pressure flow into the aneurysm (water hammer effect), are among the limitations imposed by current therapy. The authors describe herein a novel device, eCLIPs, and its use in a preclinical laboratory study that suggests the device's design and functional features may overcome many of these limitations.

METHODS

A preclinical model of wide-necked bifurcation aneurysms in rabbits was used to assess functional features and efficacy of aneurysm occlusion by the eCLIPs device.

RESULTS

The eCLIPs device, in bridging the aneurysm neck, allows coil retention, disrupts flow away from the aneurysm, leaves the main vessel and side branches unencumbered by intraluminal metal, and serves as a platform for endothelial growth across the neck, excluding the aneurysm from the circulation.

CONCLUSIONS

The eCLIPs device permits physiological remodeling of the bifurcation.

Role of preliminary registry data in development of a clinical trial for an innovative device: a small but integral piece of a health policy initiative

Establishing a national health policy at a macro level involves the integration of a series of health initiatives across a spectrum of activities, including clinical care. Evaluation of the safety and efficacy of a new medical device ultimately evolves to testing in humans. The pathway to a formal prospective clinical trial includes a stepwise appreciation of pre-clinical data and detailed analysis of data obtained from preliminary registries, where information about appropriate patient selection and use of the device is obtained. Evaluation of procedural and follow-up efficacy and safety data in a preliminary series of cases, chosen to simulate published data, allows the design and conduct of clinical trials that are required to verify preliminary observations, closing the loop on one aspect of modifying health policy decisions.

Flow Diversion for the Treatment of MCA Bifurcation Aneurysms-A Single Centre Experience

Background

Intracranial aneurysms located at the bifurcation of the middle cerebral artery (MCA) can often be challenging for the neurointerventionalist. We aimed to evaluate the efficacy and safety of flow diverting stents (FDS) in the treatment of these aneurysms.

Materials and methods

We retrospectively reviewed our prospectively maintained database to collect information for all patients with unruptured saccular bifurcation MCA aneurysms treated with FDS between January 2010 and January 2016. In addition to demographic data, we recorded the location, aneurysm characteristics, previous treatments, number and type of FDS, complications, and clinical and angiographic follow-up.

Results

Our search identified 13 patients (7 males) with an average age of 61.7 years (47–74 years). All patients had a single bifurcation aneurysm of the MCA, and none of the aneurysms were acutely ruptured. The average fundus size of the saccular aneurysms was 3 mm (range 1.5–10 mm). Follow-up studies were available for 12 patients. Based on the most recent follow-up angiograms, six aneurysms (50%) were totally occluded; five aneurysms (41.7%) showed only a small remnant; and one aneurysm (8.3%) remained unchanged. One patient suffered from an ischemic stroke with resultant permanent hemiparesis (mRS 3). In another case, there was an in-stent thrombosis during the intervention, which resolved upon intra-arterial infusion of Eptifibatide (mRS 0). There were no intra-operative vessel or aneurysm ruptures and no mortalities. Angiography of the covered MCA branches showed no change in the caliber or flow of the vessel in six (50%), a reduction in caliber in five (41.7%), and a complete occlusion in one (8.3%). All caliber changes and occlusions of the vessels were asymptomatic.

Conclusion

In our series, 91.7% of treated MCA bifurcation aneurysms were either completely occluded or showed only a small remnant with a good safety profile. Flow diversion of MCA bifurcation aneurysms should be considered as an alternative treatment strategy when microsurgical clipping or alternative endovascular treatment options are not feasible.

Endovascular and Surgical Treatment of Unruptured MCA Aneurysms: Meta-Analysis and Review of the Literature

Introduction. The best treatment for unruptured middle cerebral artery (MCA) aneurysms is unclear. We perform a meta-analysis of recent publications to evaluate the results of unruptured MCA aneurysms treated with surgical clipping and endovascular coiling. Methods. A PubMed search for articles published between January 2004 and November 2013 was performed. The R statistical software package was used to create a random effects model for each desired incidence rate. Cochran's Q test was used to evaluate possible heterogeneity among the rates observed in each study. Results. A total of 1891 unruptured MCA aneurysms, 1052 clipped and 839 coiled, were included for analysis. The complete occlusion rate at 6–9 months mean follow-up was 95.5% in the clipped group and 67.8% in the coiled group (P < 0.05). The periprocedural thromboembolism rate in the clipping group was 1.8% compared with 10.7% in the aneurysms treated by coiling (P < 0.05). The recanalization rate was 0% for clipping and 14.3% for coiling (P = 0.05). Modified Rankin scores of 0–2 were obtained in 98.9% of clipped patients compared to 95.5% of coiled (NS). Conclusions. This review weakly supports clipping as the preferred treatment of unruptured MCA aneurysms. Clinical outcomes did not differ significantly between the two groups.