Treatment of giant intracranial aneurysms: long-term outcomes in surgical versus endovascular management

A 7-year retrospective single-center study on treatment strategy and clinical outcome of giant intracranial aneurysm

BACKGROUND

A giant intracranial aneurysm (GIA) measures ≥ 25 mm and is a rare, challenging condition to treat with a poor prognosis. Selecting the appropriate treatment approach, whether surgical, endovascular, or a combination of both, is crucial for achieving favorable outcomes. However, the unique characteristics of each GIA imply that no single treatment option can be considered optimal universally. This study aimed to evaluate the treatment strategies and clinical outcomes at our center.

METHODS

This retrospective, single-center study conducted between 2012 and 2018, included 20 patients with GIA. We comprehensively reviewed demography, aneurysm characteristics, clinical and radiography data, treatment strategies, and angiography and clinical outcomes.

RESULTS

The average maximum GIA was 29.4 mm (excluding serpentine). Twelve aneurysms were located in the internal carotid artery (ICA); three, anterior cerebral artery; and five, middle cerebral artery. Morphologically, 18 saccular and 2 serpentine aneurysms were observed. Among them, 14 were symptomatic, with 8 presenting with subarachnoid hemorrhage, of which, 5 (62.5 %) were accompanied by intracerebral hemorrhage. Cranial nerve-related symptoms were observed in five ICA aneurysms, and two involved a carotid cavernous fistula. Five patients had multiple aneurysms accompanied by GIA. The treatment modalities varied; eight patients initially underwent surgical treatment. Regarding the number of treatment steps, 14 patients required one step, 4 required two steps, and 2 required three steps. In eight patients, parent artery occlusion (with or without bypass surgery) was the final treatment approach. After 1 year, 70 % of patients achieved a favorable outcome, as indicated by a modified Rankin Scale score ≤ 2.

CONCLUSIONS

Patient-specific treatments are crucial for improving clinical outcomes. Advancements in endovascular treatment have been made owing to the development of new devices. Parent artery occlusion with vascular bypass was a reliable treatment option.

Optimizing resources: financial evaluation of flow diverters versus stent assisted coiling in large and giant cerebral aneurysm management in Brazil public health system

BACKGROUND

Cerebral aneurysms, especially large and giant aneurysms, pose challenges in neurointerventional surgery. Treatment choices involve clinical presentation, aneurysm details, and global resource variations. Neurointerventional methods, while innovative, may be cost restrictive in certain regions. In public healthcare, cost is crucial, notably in countries like Brazil. This study examines the device specific cost estimation of flow diverters (FD) and traditional stent assisted coiling (SAC) for large and giant cerebral aneurysms, providing insights into optimizing neurosurgical interventions within the Brazilian public health system's unique challenges.

METHODS

A comprehensive retrospective analysis was conducted at our medical center of cases of large and giant aneurysms treated between 2013 and 2023. Determination of the estimated number of coils for aneurysms previously treated with FDs at our center was made, with the cost of each case, and the difference between both treatments was calculated.

RESULTS

We investigated the profiles of 77 patients: 40 had large aneurysms (51.9%) and 37 had giant aneurysms (48.1%). Large aneurysms had a mean cost difference of US$274 (standard deviation (SD) $2071), underscoring the device specific cost estimation of FDs over SAC in their treatment. For giant aneurysms, the mean cost difference increased to $6396 (SD $2694), indicating FDs as the more economically sound choice.

CONCLUSION

Our study indicated that, for the treatment of giant aneurysms and some large aneurysms, the FD intervention was more economical than SAC.

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.

Pipeline Embolization device for the treatment of unruptured intracranial saccular aneurysms: a systematic review and meta-analysis of long-term outcomes

INTRODUCTION

The pipeline embolization device (PED) is commonly used for intracranial aneurysm treatment. While its effectiveness for certain types of aneurysms is well-established, its efficacy for saccular aneurysms remains controversial. We aimed to assess the long-term outcomes of PED treatment for unruptured intracranial saccular aneurysms.

METHODS

Systematic review and meta-analysis were conducted following PRISMA guidelines. Studies with at least one year of follow-up after PED treatment for saccular aneurysms were included. The primary endpoint was angiographic aneurysm occlusion at long-term follow-up (≥ 12 months), and the secondary outcome was long-term complications. We conducted a meta-regression analysis to explore potential sources of heterogeneity across studies.

RESULTS

Eleven studies of 797 patients with 963 aneurysms were included. Long-term angiographic occlusion rate was 85% (95% CI, 77-91%; p < 0.01), symptomatic ischemic stroke rate was 1% (95% CI, 0-3%; p < 0.01), rupture rate was 1% (95% CI, 0-2%; p = 0.02), and intracranial hemorrhage (ICH) rate was 0.2% (95% CI, 0-1%; p = 0.11). Meta-regression analysis revealed a non-significant decreasing trend per year for aneurysmal occlusion, ischemic stroke rate, delayed aneurysmal rupture, and ICH.

CONCLUSION

PED demonstrates high long-term occlusion and low complication rates, suggesting it is a safe and effective treatment option for saccular aneurysms. Additionally, newer devices exhibit reduced thrombogenic profiles and safety with decreasing trends in ICH, ischemic stroke, and delayed aneurysmal rupture.

An overview of decision-making in cerebrovascular treatment strategies: Part II - Ruptured aneurysms

Introduction

Decision-making for the treatment of ruptured aneurysms is an intricate process, which involves several factors. There has been a rapid advancement in endovascular, but also in the surgical treating field of ruptured intracranial aneurysms, with a growing body of evidence for either treatment technique.

Research question

As there is a wide variety of treatment possibilities, it can be hard to understand the intricacies which lie behind the decision-making process for a given aneurysm.

Materials and methods

An overview of the most relevant literature in decision-making on ruptured intracranial aneurysms is given.

Results

Different decision-altering factors were identified, which can be divided into information from the general evidence, to influential factors such as the patient's age, initial presenting status, and aneurysmal factors such as size, morphology and aneurysmal location.

Discussion and conclusion

This review provides an evidence-based overview of the most pertinent literature on these different aspects of decision-making in ruptured aneurysm cases and provides some recommendations after each of these segments. As always, all different aspects of the patient and aneurysmal factors should be taken into consideration before coming to a conclusion, as to obtain the best possible result for an individual patient.

Giant unruptured middle cerebral artery aneurysm revealed by intracranial hypertension: is a systematic decompressive hemicraniotomy mandatory?

Our study aimed to evaluate the postoperative outcome of patients with unruptured giant middle cerebral artery (MCA) aneurysm revealed by intracranial hypertension associated to midline brain shift. From 2012 to 2022, among the 954 patients treated by a microsurgical procedure for an intracranial aneurysm, our study included 9 consecutive patients with giant MCA aneurysm associated to intracranial hypertension with a midline brain shift. Deep hypothermic circulatory flow reduction (DHCFR) with vascular reconstruction was performed in 4 patients and cerebral revascularization with aneurysm trapping was the therapeutic strategy in 5 patients. Early (< 7 days) and long term clinical and radiological monitoring was done. Good functional outcome was considered as mRS score ≤ 2 at 3 months. The mean age at treatment was 44 yo (ranged from 17 to 70 yo). The mean maximal diameter of the aneurysm was 49 mm (ranged from 33 to 70 mm). The mean midline brain shift was 8.6 mm (ranged from 5 to 13 mm). Distal MCA territory hypoperfusion was noted in 6 patients. Diffuse postoperative cerebral edema occurred in the 9 patients with a mean delay of 59 h and conducted to a postoperative neurological deterioration in 7 of them. Postoperative death was noted in 3 patients. Among the 6 survivors, early postoperative decompressive hemicraniotomy was required in 4 patients. Good functional outcome was noted in 4 patients. Complete aneurysm occlusion was noted in each patient at last follow-up. We suggest to discuss a systematic decompressive hemicraniotomy at the end of the surgical procedure and/or a partial temporal lobe resection at its beginning to reduce the consequences of the edema reaction and to improve the postoperative outcome of this specific subgroup of patients. A better intraoperative assessment of the blood flow might also reduce the occurrence of the reperfusion syndrome.

Combined endovascular embolization and decompressive craniectomy for microsurgical resection of giant ruptured distal anterior cerebral artery aneurysm

Giant ruptured distal anterior cerebral artery aneurysms are rare, challenging pathologies that may require a combination of microsurgical and endovascular techniques for optimal treatment [1-9]. We describe the case of a female in her 40 s who presented with a Hunt-Hess 4, Fisher 4 subarachnoid hemorrhage from a multiply ruptured, giant distal anterior cerebral artery aneurysm. The patient underwent coil and n-BCA glue embolization of the aneurysm and its feeding A2 anterior cerebral artery. She subsequently underwent decompressive craniectomy, intracerebral hematoma evacuation, and microsurgical trapping and resection of the aneurysm. Postoperative imaging demonstrated no further aneurysm filling, complete hematoma evacuation, and good decompression. The technical considerations and literature for the combined treatment of large and giant ruptured aneurysms are reviewed. The case presentation, operative nuances, and postoperative course with imaging are reviewed with detailed anatomical diagrams to orient the viewer. The patient consented to the procedure and to the publication of her imaging.

Exploring the latest findings on endovascular treatments for giant aneurysms: a review

Giant intracranial aneurysms represent a very challenging aspect of aneurysmal pathophysiology with very high mortality and morbidity if left untreated. Their variety in clinical presentation (subarachnoid hemorrhage, cranial nerve palsy, etc.) and pathological and imaging properties (location, anatomy, presence of collateral circulation) pose serious questions regarding the best treatment option. Admirable advances have been achieved in surgical techniques, while endovascular modalities with flow diversion techniques have become widely used. However, there is still lack of data regarding whether a single endovascular technique can be the universal treatment for such cases. In this review, we aim to summarize the current funds of knowledge concerning giant intracranial aneurysms and the role of endovascular management in their treatment.

A 5-Year Follow-Up after Endovascular Treatment of 402 Intracranial Aneurysms-A Single-Centre Experience

The aim of our study was to evaluate the early and long-term clinical and morphological outcomes of the endovascular treatment of ruptured and non-ruptured intracranial aneurysms in a cohort of patients from a single centre. We retrospectively analysed the treatment outcomes of 402 endovascularly treated intracranial aneurysms with an average follow-up of 5.5 years. All included patients were treated with endovascular techniques (coil, stent or both). We analysed patient demographics, risk factors for an aneurysm rupture, aneurysm characteristics, and clinical and angiographic complications and outcomes. We analysed and compared the data from the two groups, ruptured aneurysms (RAs) and unruptured aneurysms (UAs), separately. Out of the 318 patients included, a good early clinical outcome was achieved in 78.5% of RAs and in 95.3% of UAs. No complications occurred in 87.71% of patients with UAs and in 80.45% with RAs. The periprocedural rupture rate for UAs and RAs was 0.8% and 2.2%, respectively. The rate of thromboembolic events was 4.8 and 8% for UAs and RAs, respectively. A retreatment due to the recanalisation was required in 9.21% of patients with UAs and in 16.66% of patients with RAs. The results from our centre showed an overall favourable clinical outcome with acceptable periprocedural complications for both RAs and UR aneurysms and proved the endovascular method as safe and effective in the treatment of intracranial aneurysms.

Thrombectomy for delayed thromboembolism in a recurrent cerebral aneurysm previously treated with coiling: A case report

RATIONALE

Giant intracranial aneurysms pose a significant threat due to high mortality rates upon rupture, prompting interventions such as neurosurgical clipping or endovascular coiling.

PATIENT CONCERNS

We present a rare case involving a 47-year-old female with a history of successfully treated ruptured giant intracranial aneurysms. Six months post-surgical clipping, she developed symptoms of acute ischemic stroke, prompting the decision for neurosurgical coiling and stent-assisted aneurysm coil embolization due to recurrent intracranial aneurysms.

DIAGNOSES

Subsequently, occlusion occurred at the previously implanted stent site during embolization, necessitating exploration of alternative therapeutic options. Digital subtraction angiography confirmed stent occlusion in the right middle cerebral artery.

INTERVENTIONS

Despite an initial unsuccessful attempt using a direct aspiration first-pass technique, the patient underwent successful mechanical thrombectomy with a retrievable stent, leading to successful reperfusion. This study aims to highlight the challenges and therapeutic strategies in managing delayed cerebral vascular occlusion following stent-assisted coil embolization, emphasizing the significance of exploring alternative interventions to enhance patient outcomes.

OUTCOMES

The patient achieved successful reperfusion, and the study underscores the importance of recognizing and addressing delayed cerebral vascular occlusion after stent-assisted coil embolization for recurrent cerebral aneurysms.

LESSONS

Our findings suggest that retrievable stent mechanical thrombectomy may serve as a viable therapeutic option in challenging scenarios, emphasizing the need for further exploration of alternative interventions to enhance patient care.

Flow Diverter Stenting for Symptomatic Intracranial Internal Carotid Artery Aneurysms: Clinical Outcomes and Factors for Symptom Improvement

Flow diverter (FD) stenting is expected to improve cranial nerve symptoms caused by aneurysms via the theoretical reduction of the mass effect by promoting spontaneous thrombosis through the flow diversion effect. However, the factors involved in symptom improvement after treatment remain unclear. This study was performed to identify factors for symptom improvement after FD stenting and the symptom improvement rate of each impaired cranial nerve. We retrospectively evaluated 33 patients who underwent FD stenting for symptomatic internal carotid artery aneurysms at our institution from January 2016 to June 2021. Twenty-three (69.7%) patients had resolved or improved symptoms after 1 year of treatment. The optic nerve was affected in 12 patients; the oculomotor nerve, in 16; the trigeminal nerve, in 2; and the abducens nerve, in 13. There was no statistically significant difference in the symptom improvement rate of each impaired cranial nerve. The patients were classified into the improved and nonimproved groups based on their symptoms after 1 year of treatment, and the factors related to the symptoms were analyzed. The time from onset to treatment was significantly shorter in the improved group than in the nonimproved group (197.1 and 800 days, respectively; p = 0.023). There were no significant differences in age, aneurysm diameter, adjunctive coil embolization, partial thrombosis, change in mass diameter on magnetic resonance imaging, or aneurysm occlusion rate on angiography between the two groups. These results suggest that early treatment after the onset of aneurysm-induced cranial neuropathies increases the likelihood of symptom improvement.