Risk factors for angiographic recurrence after treatment of unruptured intracranial aneurysms: Outcomes from a series of 178 unruptured aneurysms treated by regular coiling or surgery

Risk factors for recanalization after coil embolization for cerebral aneurysms: importance of the first coil and prediction model

BACKGROUND

Endovascular coil embolization for cerebral aneurysms is a well-established treatment; however, postoperative recanalization remains a risk. This study aimed to clarify risk factors for cerebral aneurysm recanalization after coil embolization and to develop a predictive model for assessing risks.

METHODS

This retrospective study included patients with cerebral saccular aneurysms who underwent initial coil embolization at our hospital in Tokyo, Japan between 2012 and 2023. The following cases were excluded: follow-up of <1 year, re-treatment and use of bioactive coils. Outcomes included aneurysm characteristics and postoperative Raymond-Roy Occlusion Classification (RROC). Univariate and multivariate Cox proportional hazards models were used to identify independent predictors. A simplified risk score was constructed using LASSO logistic regression and β-coefficients from multivariable analysis. Internal validity was assessed by bootstrap resampling. External validation was performed using an independent cohort and model performance was evaluated in terms of discrimination and calibration.

RESULTS

Among the 150 patients with aneurysms, 79 were analyzed after applying exclusion criteria. Multivariate analysis identified four independent predictors of recanalization: rupture status, aneurysm size ≥7 mm, RROC without class I, and first volume embolization ratio <8 %. These variables were incorporated into an integer-based risk score ranging from 0 to 7. The model demonstrated strong discrimination in the internal validation cohort (C-statistic: 0.89), which remained acceptable in the external validation cohort (C-statistic: 0.81, 95 % CI: 0.74-0.89). Risk stratification showed increasing recanalization rates of 1.8 %, 13.5 %, and 41.5 % in low- (0-2), intermediate- (3-4), and high-risk (5-7) groups, respectively. Calibration in the external cohort showed slight overestimation of risk in high-score patients.

CONCLUSION

This study identified four significant risk factors for recanalization after coil embolization and proposed a practical, externally validated risk score. The model provides clinically relevant risk stratification and may support individualized follow-up strategies.

Interdependence of First-coil and Global volume embolization ratios (VERs) calculated by Sim&Size in predicting aneurysm occlusion outcomes

BackgroundCoil embolization is a standard therapeutic approach for intracranial aneurysms. Recurrence risk during follow-up is not negligible, with inadequate packing density identified as a potential risk factor. This study aims to identify patient- and procedure-related factors contributing to recurrence.MethodsWe retrospectively enrolled consecutive patients with unruptured intracranial aneurysms treated only with coils between January 2021 and December 2022. Aneurysms were included if 3D-rotational angiography and follow-up imaging were available. For each patient, the volume embolization ratio (VER) was computed using Sim&Size® (Sim&Cure, France) for both the framing coil (First-coil VER) and the entire coiling procedure (Global VER). Patient demographics and aneurysm characteristics were also recorded. Follow-up imaging classified patients into adequate- or inadequate-occlusion groups. Multivariate analyses assessed independent factors associated with recurrence.ResultsSeventy-nine unruptured aneurysms from 79 patients were included. At follow-up, n = 69 (87%) demonstrated adequate occlusion, defined as modified Raymond-Roy classification I-II. Adequate- and inadequate-occlusion groups differed in First-coil (13.5 ± 5.5% vs 7.1 ± 4.0% respectively, P = .002) and Global VER (24.5 ± 6.8% vs 17.3 ± 5.7% respectively, P = .004). Posterior aneurysm location (P = .013), aneurysm height (P = .007), and neck diameter (P = .018) were significantly associated with recurrence. In multivariate analysis, Global- (P = .029) and First-coil VER (P = .025) remained significant risk factors for recurrence, with their interaction term being statistically significant as well (P = .020).ConclusionsFirst-coil and Global VER computed using Sim&Size® are predictive of aneurysm occlusion at follow-up. These results highlight the potential value of virtual simulation in optimizing coil packing density to improve mid- to long-term occlusion outcomes.

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.

The white-collar sign after Neuroform Atlas stent-assisted coil embolization of unruptured intracranial aneurysms

PURPOSE

Although stent-assisted technique is expected to help provide a scaffold for neointima formation at the orifice of the aneurysm, not all aneurysms treated with stent-assisted technique develop complete neointima formation. The white-collar sign (WCS) indicates neointimal tissue formation at the aneurysm neck that prevents aneurysm recanalization. The aim of this study was to explore factors related to WCS appearance after stent-assisted coil embolization of unruptured intracranial aneurysms (UIAs).

METHODS

A total of 59 UIAs treated with a Neuroform Atlas stent were retrospectively analyzed. The WCS was identified on digital subtraction angiography (DSA) 1 year after coil embolization. The cohort was divided into WCS-positive and WCS-negative groups, and possible predictors of the WCS were explored using logistic regression analysis.

RESULTS

The WCS appeared in 20 aneurysms (33.9%). In the WCS-positive group, neck size was significantly smaller (4.2 (interquartile range (IQR): 3.8-4.6) versus 5.4 (IQR: 4.2-6.8) mm, p = .006), the VER was significantly higher (31.8% (IQR: 28.6%-38.4%) versus 27.6% (IQR: 23.6%-33.8%), p = .02), and the rate of RROC class 1 immediately after treatment was significantly higher (70% vs 20.5%, p < .001) than in the WCS-negative group. On multivariate analysis, neck size (odds ratio (OR): 0.542, 95% confidence interval (CI): 0.308-0.954; p = .03) and RROC class 1 immediately after treatment (OR: 6.99, 95% CI: 1.769-27.55; p = .006) were independent predictors of WCS appearance.

CONCLUSIONS

Smaller neck size and complete occlusion immediately after treatment were significant factors related to WCS appearance in stent-assisted coil embolization for UIAs using the Neuroform Atlas stent.

Supraorbital keyhole approach for paraclinoid aneurysms clipping: A case series with literature review

Background

Paraclinoid aneurysms (PcAs) are challenging aneurysms due to the complexity of their relation to the surrounding bony and neurovascular structures. Although over the past decade, their management strategy has shifted from transcranial to endovascular approaches; here, we try to revolve around a subcategory to which minimal invasive supraorbital keyhole (SOK) surgery is feasible depending on specific radiological criteria with a literature review.

Methods

A group of unruptured PcAs was managed surgically, with a subset that was clipped through the SOK approach. They were selected by preoperative simulation images using 3D computed tomography (CT) angiography (CTA). We also conducted an extensive literature review based on a database available on PubMed and Google Scholar, the yielded cases from the literature review plus our cases were analyzed according to six parameters including their size, location, dome direction, need for clinoidectomy and proximal cervical control, and surgical outcome.

Results

From February 2009 to August 2022, 49 cases of unruptured PcAs were managed by clipping, and of these, four cases were clipped by the SOK approach, in addition, four cases were yielded through the literature review. The sizes of the PcAs ranged from 3 to 8 mm. Their location fluctuated from anterior to the superomedial wall and their domes pointed superiorly except for one which points posteriorly. Six of eight cases required anterior clinoidectomy, the outcome was uneventful.

Conclusion

A subset of unruptured PcAs are amenable to SOK with criteria such as unruptured small aneurysm (<10 mm) and projected superiorly. These characteristics can be determined preoperatively using CTA.

Predictors of recurrence and complications for the endovascular treatment of unruptured middle cerebral artery aneurysm: A high-volume center experience over 12 years

OBJECT

To assess the safety and efficacy of endovascular treatment (EVT) of unruptured middle cerebral artery (MCA) aneurysms in a retrospective cohort in a high-volume center. Predictors of complications and recurrence were determined.

METHODS

Retrospectively reviewed our database of prospectively collected information for all patients with unruptured MCA aneurysms that were treated by endovascular approach from March 2008 to December 2020. A multivariate analysis was conducted to identify predictors of complications and recurrence.

RESULTS

Three hundred and fifty-one patients with 370 unruptured MCA aneurysms underwent EVT were included in this study. Seventy-three aneurysms (19.7%) were treated by coiling without stent, 297 (80.3%) with stent-assisted coiling. The procedures were performed with a technical success rate of 100%. Procedure-related neurological complications occurred in 15 patients (4.1%), including 1 patient died from post-procedural stent thrombosis. Age ≥ 65 years (P = 0.039; OR = 3.400; 95% CI, 1.065-10.860) and aneurysm size ≥ 5 mm (P = 0.009; OR = 15.524; 95% CI, 1.988-121.228) were significantly associated with ischemic complications of EVT. Three hundred and six aneurysms were (87.2%) completed image follow-up (235 DSA and 71 CE-MRA). The median angiographic follow-up time were 7.0 ± 4.3 months (range from 1 to 88 months). Follow-up angiograms showed that 249 aneurysms (81.4%) were completed occluded, 29 aneurysms (9.5%) were improved, 17 aneurysms (5.6%) were stable, and 11 aneurysms (3.6%) were recanalized and 10 of them accepted retreatments. Aneurysm size ≥ 10 mm was a predictor of recanalization (P = 0.004; OR = 11.213; 95% CI, 2.127-59.098) and stent-assisted coiling can significantly reduce recanalization (P = 0.004; OR = 0.105; 95% CI, 0.023-0.479).

CONCLUSIONS

EVT is a safe and effective therapeutics for unruptured MCA aneurysms management, and provides durable aneurysm occlusion rate during follow-up. Large MCA aneurysms have higher recurrence and ischemic complications risk after EVT. Stent-assisted coiling can significantly reduce the recurrence rate without increasing the risk of complications.

Radiological follow-up of endovascularly treated intracranial aneurysms: a survey of current practice in the UK and Ireland

PURPOSE

Due to the risk of intracranial aneurysm (IA) recurrence and the potential requirement for re-treatment following endovascular treatment (EVT), radiological follow-up of these aneurysms is necessary. There is little evidence to guide the duration and frequency of this follow-up. The aim of this study was to establish the current practice in neurosurgical units in the UK and Ireland.

METHODS

A survey was designed with input from interventional neuroradiologists and neurosurgeons. Neurovascular consultants in each of the 30 neurosurgical units providing a neurovascular service in the UK and Ireland were contacted and asked to respond to questions regarding the follow-up practice for IA treated with EVT in their department.

RESULTS

Responses were obtained from 28/30 (94%) of departments. There was evidence of wide variations in the duration and frequency of follow-up, with a minimum follow-up duration for ruptured IA that varied from 18 months in 5/28 (18%) units to 5 years in 11/28 (39%) of units. Young patient age, previous subarachnoid haemorrhage and incomplete IA occlusion were cited as factors that would prompt more intensive surveillance, although larger and broad-necked IA were not followed-up more closely in the majority of departments.

CONCLUSIONS

There is a wide variation in the radiological follow-up of IA treated with EVT in the UK and Ireland. Further standardisation of this aspect of patient care is likely to be beneficial, but further evidence on the behaviour of IA following EVT is required in order to inform this process.

Long-term clinical and angiographic outcome of the Woven EndoBridge (WEB) for endovascular treatment of intracranial aneurysms

The Woven EndoBridge (WEB) is a well-established device for endovascular treatment of wide-necked bifurcation aneurysms. The objective was to evaluate the long-term angiographic outcome of the WEB and to identify factors that influence aneurysm occlusion. Patient, aneurysm and procedural characteristics of 213 consecutive patients treated with the WEB at three German tertiary care centers between 2011 and 2020 were retrospectively reviewed. Aneurysm occlusion was determined immediately after the procedure, at mid-term (≤ 12 months) and at long-term (> 12 months) follow-up. Among 182 included aneurysms (mean diameter: 7.0 ± 2.4, mean neck width: 4.3 ± 1.6 mm), 29.7% were ruptured. The novel WEB 17 was used in 41.8%, and 11.0% were treated in combination with coiling and/or stenting. Complete and adequate occlusions were observed in 101/155 (65.2%) and 133/155 (85.8%) at mid-term, respectively, and in 59/94 (62.8%) and 87/94 (92.6%) at long-term follow-up (median: 19 months), respectively. Among 92 patients available for both mid- and long-term follow-up, occlusion was stable in 72.8%, improved in 16.3% and worsened in 10.9%. There were no major recurrences leading to aneurysm remnants between mid- and long-term follow-up. Retreatment was performed in 10/155 (6.5%) during mid-term and in 1/94 (1.0%) during long-term follow-up. The WEB provides durable aneurysm occlusion at the long-term. Nevertheless, follow-up imaging is necessary to identify late recurrences that may occur in around 10%.

Repeated intracerebral hemorrhage after craniotomy for a distal middle cerebral artery aneurysm: A case report

RATIONALE

Distal middle cerebral artery aneurysms are very rare in the clinic, and craniotomy clipping is the better treatment after diagnosis. However, patients can also have repeated acute intracerebral hemorrhage after craniotomy for aneurysm, which has not been previously reported.

PATIENT CONCERNS

A 24-year-old male patient was admitted to our hospital with headache, nausea, and vomiting. He was well before, had no family history of cerebrovascular disease or hypertension, and had no history of trauma.

DIAGNOSES

Computer tomography and digital subtraction angiography of the brain revealed intracranial hematoma and an aneurysm located at the M4 segment of the left middle cerebral artery.

INTERVENTIONS

The patient underwent 2 surgeries to treat the aneurysm, followed by 2 operations for acute cerebral hemorrhage.

OUTCOMES

Despite repeated surgical treatments, the patient had a poor prognosis and eventually died of respiratory and circulatory failure after repeated brain bleeding.

LESSONS

Briefly, it is of great importance to consider the risk factors of cerebral hemorrhage, and provide individualized treatment and psychological counseling for patients with intracerebral hemorrhage.

Risk factors for recanalization of dense coil packing for unruptured cerebral aneurysms in endovascular coil embolization: Analysis of a single center's experience

In coil embolization of cerebral aneurysms, inadequate packing is known to increase the probability of recanalization. Even tightly embolized aneurysms may be recanalized, but predictive factors for recanalization have not been fully investigated. This retrospective study aimed to identify risk factors for recanalization of treated aneurysms with a volume embolization ratio (VER) ≥ 25%. A total of 301 unruptured aneurysms in 248 patients who underwent coil embolization between March 2012 and January 2021 were analyzed. Cases involving dissecting aneurysm, intraluminal thrombosis, parent artery occlusion, intraoperative rupture, re-treatment, rupture the day after surgery, postoperative coil migration, and postoperative parent artery occlusion were excluded due to the inaccuracy of VER. A total of 105 aneurysms (34.9%) treated with VER ≥ 25% were extracted. Clinical features (age, sex, medical history, family history), anatomical features (shape, location, aneurysm size, inflow angle, and volume), procedural features (stent-assisted, Raymond-Roy occlusion classification [RROC] immediately after treatment, re-treatment rate), and follow-up period were compared between Recanalization and Non-recanalization groups. Predictors of recanalization were determined using logistic regression and receiver operating characteristic (ROC) curve analyses. Eleven aneurysms were recanalized. In multivariate analysis, RROC class 3 (odds ratio [OR] 11.0; 95% confidence interval [CI] 2.03-59.4) and aneurysm volume (OR 1.005; 95%CI 1.001-1.008) were independent predictors of recanalization. ROC curve analysis showed optimal cutoff values for aneurysm volume of 69.5 mm³ (sensitivity, 81.8%; specificity, 72.3%). In coil embolization of unruptured aneurysms that VER ≥ 25%, cases with RROC class 3 or high aneurysm volume may be associated with a higher risk of recanalization, and should be carefully followed-up.

Retreatment of previously treated intracranial aneurysm: Procedural complications and risk factors for complications

OBJECTIVE

Intracranial aneurysm (IA) is a frequent vascular malformation that can be managed by endovascular treatment (EVT) or microsurgery. A previously treated IA can recanalize, which may require further treatment. The aim of our study was to evaluate procedural complications related to IA retreatment and their risk factors.

METHODS

All patients retreated for IA between 2007 and 2017 in 4 hospitals were included. We retrospectively reviewed the frequency of procedural complications of IA retreatment, defined as death or≥1-point increase in modified Rankin score 24h after the procedure. We then screened for risk factors of procedural complications by comparing the characteristics of patients with and without complications.

RESULTS

During the inclusion period, 4,997 IAs were treated in our 4 institutions. Of these, 237 (4.7%) were retreated. 29 (12.2%) had≥1 procedural complication. However, severe complications, defined as death or dependency at 1 month, occurred only in 3 patients (1.3%). The only risk factor for complications was microsurgical clipping as retreatment.

CONCLUSIONS

Procedural complications during IA retreatment were frequent but, in most cases, retreatment did not lead to death or severe disability. The only risk factor for complications of IA retreatment was clipping as retreatment. However, the design of the study did not allow any conclusion to be drawn as to the optimal means of aneurysm retreatment, and further studies are needed.

Treatment outcomes of 1-stage clipping of multiple unruptured intracranial aneurysms via keyhole approaches

OBJECTIVE

Complete exclusion of multiple unruptured intracranial aneurysms (UIAs) in one session of intervention may be ideal. However, such situations are not always feasible in terms of treatment modalities and outcomes. The authors aimed to analyze their experience with 1-stage clipping of multiple UIAs.

METHODS

Medical records between March 2013 and December 2018 were retrospectively reviewed, and 111 1-stage keyhole approaches in 110 patients with 261 multiple UIAs were ultimately included in this study. Clinical and radiological outcomes were analyzed, as well as postoperative complications up to 1 month after the surgery and their risk factors.

RESULTS

Keyhole approaches included unilateral supraorbital in 87 operations (78.4%), bilateral supraorbital in 12 (10.8%), and others in 12. The mean operative duration was 169.6 minutes (range 80-490 minutes). The highest numbers of aneurysms clipped at once were 2 (73.9%) and 3 (18.9%). Complete exclusion and residual neck of the clipped aneurysms were achieved in 89.3% and 7.3%, respectively. There was no significant difference between pre- and postoperative 1-month neurological states (p = 0.14). The permanent morbidity rate was 1.8% (n = 2), and there were no deaths. Postoperative transient neurological deterioration (TND) with no radiological and electrophysiological abnormalities occurred in 8 operations (7.2%). Hypertension was the only significant risk factor for postoperative TND (adjusted odds ratio 17.03, 95% confidence interval 1.99-2232.24, p = 0.01).

CONCLUSIONS

One-stage clipping of multiple UIAs via keyhole approaches showed satisfactory treatment outcomes with a low permanent morbidity. Patients with chronic hypertension had a high risk of postoperative TND.

Readmission Trends Related to Unruptured Intracranial Aneurysm Treatment

Background and Purpose: Aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality. Prophylactic treatment of the unruptured intracranial aneurysm (UIA) is considered in a select group of patients thought to be at high for aneurysmal rupture. Hospital readmission rates can serve as a surrogate marker for the safety and cost-effectiveness of treatment options for UIAs; we present an analysis of the 30-day rehospitalization rates and predictors of readmission following UIA treatment with surgical and endovascular approaches. Methods: We retrospectively analyzed data from the National Readmission Database (NRD) derived from the Healthcare Cost and Utilization Project for the year 2014. The cohort included patients with a primary discharge diagnosis of a treated unruptured aneurysm. The primary outcome variable was the 30-day readmission rate in open surgical vs. endovascularly treated groups. The secondary outcomes included predictors of readmissions, and causes of 30-day readmissions in these two groups. Results: The 30-day readmission rate for the surgical group was 8.37% compared to 4.87% for the endovascular group. The index hospitalization duration was longer in the surgical group. A larger proportion of the patients readmitted following surgical treatment were hypertensive (76.35, vs. 63.43%), but the prevalence of other medical comorbidities was comparable in the two treatment groups. Conclusions: There is a higher likelihood for 30-day readmission, longer duration of initial hospitalization and a lower likelihood of discharge home following surgical treatment of UIAs when compared to endovascular treatment. These findings, however, do not demonstrate long-term superiority of one specific treatment modality.

Intracranial post-clipping residual or recurrent aneurysms: Current status and treatment options (Review)

Following the clipping of intracranial aneurysms, post-clipping residual or recurrent aneurysms (PCRRAs) can occur. In recent years, the incidence of PCRRAs has increased due to a prolonged follow-up period and advanced imaging techniques. However, several aspects of intracranial PCRRAs remain unclear. Therefore, the present study performed an in-depth review of the literature on PCRRAs. Herein, a summary of PCRRAs that can be divided into the following two categories is presented: i) Those occurring after the incomplete clipping of an aneurysm, where the residual aneurysm regrows into a PCRRA; and ii) those occurring after the complete clipping of an aneurysm, in which a de novo aneurysm occurs at the original aneurysm site. Currently, digital subtracted angiography remains the gold standard for the imaging diagnosis of PCRRAs as it can eliminate metallic clip artifacts. Intracranial symptomatic PCRRAs should be actively treated, particularly those that have ruptured. A number of methods are currently available for the treatment of intracranial PCRRAs; these mainly include re-clipping, endovascular treatment (EVT) and bypass surgery. Currently, re-clipping remains the most effective method used to treat PCRRAs; however, it is a very difficult procedure to perform. EVT can also be used to treat intracranial PCRRAs. EVT methods include coiling (stent- or balloon-assisted) and flow-diverting stents (or coiling-assisted). Bypass surgery can be selected for difficult-to-treat, complex PCRRAs. On the whole, following appropriate treatment, the majority of intracranial PCRRAs achieve a high occlusion rate and a good prognosis.

Management of intracranial aneurysms in France: Place of microsurgery and demography of vascular neurosurgeons

STUDY DESIGN

Observational retrospective survey-based study.

INTRODUCTION

Intracranial aneurysms (IA) can be treated with microsurgery or by endovascular treatments (EVT). EVT have taken an increasingly important part in IA management; the ability of neurosurgical teams to perform such surgery as well as the quality of their training is being questioned. We therefore wanted to assess the proportion of IA treated by microsurgery in France, the demography and caseload of surgeons trained in vascular neurosurgery.

METHODOLOGY

A 60-question survey was sent to the 34 French neurosurgical centers treating IA. Twenty-seven questions dealt with the demography of neurovascular surgeons and caseload. Descriptive data are reported here.

RESULTS

Twenty-seven centers answered, giving us a response rate of 79.4%. A total of 209 neurosurgeons worked in these centers. Forty-six neurosurgeons were designated as referents in vascular neurosurgery, 47% of them were under 45 years old. Among the centers, 96.3% had at least one surgeon that was a referent in neurovascular surgery. A total of 88 surgeons performed IA surgery, but only 11 operated more than 20 IA per year. Two thousand four hundred and thirty seven unruptured IA were treated every year in these centers, 25% of which by microsurgery. A total of 2727 ruptured IA were treated in these centers, of which 15% were treated by microsurgery. The most common indications for microsurgical treatment of IA were: middle cerebral artery aneurysms, wide-neck intracranial aneurysms, and giant intracranial aneurysms, as well as aneurysms associated with a hematoma for the ruptured ones.

CONCLUSION

Demography of vascular neurosurgeons remains favorable, with a referent neurosurgeon in most centers, who, in half of the cases, is a young practitioner. The percentage of microsurgery in the treatment of IA is low, especially for ruptured ones. The most frequently operated types of intracranial aneurysm correspond to good practice recommendations.

Clip-first policy versus coil-first policy for the exclusion of middle cerebral artery aneurysms

OBJECTIVE

Middle cerebral artery (MCA) aneurysms are a particular subset of intracranial aneurysms that can be excluded by clipping or coiling. A comparison of the results between these two methods is often limited by a selection bias in which wide-neck and large aneurysms are frequently treated with surgery. Here, the authors report the results of two centers using opposing policies in the management of MCA aneurysms: one center used a clip-first policy while the other used a coil-first policy, which limited the selection bias and ensured a good comparison of these two treatment modalities.

METHODS

All patients treated for either ruptured or unruptured MCA aneurysms at one of two institutions between January 2012 and December 2015 were eligible for inclusion in this study. At one center a clip-first policy was applied, whereas the other applied a coil-first policy. The authors retrospectively reviewed the medical records of these patients and compared their clinical and radiological outcomes.

RESULTS

A total of 187 aneurysms were treated during the inclusion period; 88 aneurysms were treated by coiling and 99 aneurysms by clipping. The baseline patient and radiological characteristics were similar between the two groups, but the clinical presentation of the ruptured aneurysm cohort differed slightly. In the ruptured cohort (n = 90), although patients in the coiling group had a higher rate of additional surgery, the complication rate, functional outcome, and risk of death were similar between the two treatment groups. In the unruptured cohort (n = 97), the complication rate, functional outcome, and risk of death were also similar between the two treatment groups, although the risk of discomfort related to the temporal muscle atrophy was higher in the surgical group. Overall, the rate of complete occlusion was higher in the clipping group (84.2%) than in the coiling group (31%), which led to a higher risk in the coiling group of aneurysm retreatment within the first 2 years (p = 0.04).

CONCLUSIONS

Clipping and coiling for MCA aneurysm treatment provide the same clinical outcome for ruptured and unruptured aneurysms. However, clipping provides higher short- and long-term rates of complete exclusion, which in turn decreases the risk of aneurysm retreatment. Whether this lower occlusion rate can have a clinical impact in the long-term must be further evaluated.

Definitive Treatment With Microsurgical Clipping After Recurrence and Rerupture of Coiled Anterior Cerebral Artery Aneurysms

BACKGROUND

The extent of obliteration of ruptured intracranial aneurysms treated with coil embolization has been correlated with the risk of rerupture. However, many practitioners consider that a small neck remnant is unlikely to result in significant risk after coiling.

OBJECTIVE

To report our recent experience with ruptured anterior cerebral artery aneurysms treated with endovascular coiling, which recurred or reruptured, requiring microsurgical clipping for subsequent treatment.

METHODS

Retrospective review of patients with intracranial aneurysms treated at our institution since August 2018. Patient and aneurysm characteristics, initial and subsequent treatment approaches, and outcomes were reviewed.

RESULTS

Six patients were included. Out of those 6 patients, 5 patients had anterior communicating artery aneurysms, and 1 patient had a pericallosal aneurysm. All initially presented with subarachnoid hemorrhage (SAH) and were treated with coiling. Recurrence occurred at a median of 7.5 mo. In 2 cases, retreatment was initially performed with repeat endovascular coiling, but further recurrence was observed. Rerupture from the residual or recurrent aneurysm occurred in 3 cases. In 2 cases, the aneurysm dome recurred; in 1 case, rerupture occurred from the neck. All 6 patients underwent treatment with microsurgical clipping. Follow-up catheter angiography demonstrated a complete occlusion of the aneurysm in all cases with the preservation of the parent vessel.

CONCLUSION

Anterior cerebral artery aneurysms may recur after endovascular treatment, and even small neck remnants present a risk of rerupture after an initial SAH. Complete treatment requires a complete exclusion of the aneurysm from the circulation. Even in cases that have been previously coiled, microsurgical clipping can represent a safe and effective treatment option.

Potential Risks and Limited Indications of the Supraorbital Keyhole Approach for Clipping Internal Carotid Artery Aneurysms

Background

Internal carotid artery (ICA) aneurysm may be a good target for supraorbital keyhole clipping. We discuss the surgical indications and risks of keyhole clipping for ICA aneurysms based on long-term clinical and radiologic results.

Methods

This was a retrospective analysis of 51 patients (aged 35–75 years, mean 62 years) with ICA aneurysms (mean 5.8 ± 1.8 mm) who underwent clipping via the supraorbital keyhole approach between 2005 and 2017. Neurologic and cognitive functions were examined by several methods, including the modified Rankin Scale and Mini-Mental Status Examination. The state of clipping was assessed 1 year and then every few years after the operation.

Results

Complete clipping was confirmed in 45 patients (88.2%), dog-ear remnants behind the clip persisted in 4 patients, and wrapping was performed in 2 patients. Mean duration of postoperative hospitalization was 3.4 ± 6.9 days. The mean clinical follow-up period was 6.6 ± 3.2 years. The overall mortality was 0, and overall morbidity (modified Rankin Scale score ≥2 or Mini-Mental Status Examination <24) was 3.9%. Completely clipped aneurysms did not show any recurrence during the mean follow-up period of 6.3 ± 3.1 years, but the 2 (3.9%) aneurysms with neck remnants showed regrowth.

Conclusions

The risk of neck remnant behind the clip blade is a drawback of supraorbital keyhole clipping. The surgical indication requires preoperative simulation and careful checking of the clip blade state is essential.

Evaluation of the yield of post-clipping angiography and nationwide current practice

BACKGROUND

Surgical treatment of intracranial saccular aneurysms aims to prevent (re)hemorrhage by complete occlusion of the aneurysmal lumen. It is unclear whether routine postoperative imaging, to assess aneurysmal occlusion, is necessary since intraoperative assessment by the neurosurgeon may be sufficient. We assessed routine clinical protocols for post-clipping imaging in the Netherlands and determined whether intraoperative assessment of aneurysm clippings sufficiently predicts aneurysm residuals.

METHODS

A survey was conducted to assess postoperative imaging protocols in centers performing clipping of intracranial aneurysms in the Netherlands (n = 9). Furthermore, a retrospective single-center cohort study was performed to determine the predictive value of intraoperative assessment of aneurysm occlusion in relation to postoperative digital subtraction angiography (DSA) findings, between 2009 and 2017.

RESULTS

No center performed intraoperative DSA in a hybrid OR, routinely. Respectively, four (44.4%), seven (77.8%), and three (33.3%) centers did not routinely perform early postoperative imaging, late follow-up imaging, or any routine imaging at all. Regarding our retrospective study, 106 patients with 132 clipped aneurysms were included. There were 23 residuals ≥ 1 mm (17.4%), of which 10 (43.5%) were unexpected. For the presence of these residuals, intraoperative assessment showed a sensitivity of 56.5%, a specificity of 86.2%, a positive predictive value of 46.4%, and a negative predictive value of 90.4%.

CONCLUSIONS

There is lack of consensus regarding the post-clipping imaging strategy in the Netherlands. Since intraoperative assessment is shown to be insufficient to predict postoperative aneurysm residuals, we advocate routine postoperative imaging after aneurysm clipping unless this is not warranted on the basis of patient age, clinical condition, and/or comorbidity.

Flow Diverter Therapy Using a Pipeline Embolization Device for 100 Unruptured Large and Giant Internal Carotid Artery Aneurysms in a Single Center in a Japanese Population

Flow diverters (FDs) have been developed for intracranial aneurysms difficult to treat with conventional endovascular therapy and surgical clipping. We reviewed 94 patients with 100 large or giant unruptured internal carotid artery (ICA) aneurysms treated with Pipeline embolization device (PED) embolization from December 2012 to June 2017 at Juntendo University Hospital. The patients’ mean age was 63.4 years (range, 19–88), and there were 90 women 89.4%. Aneurysm locations were: C4 (45), C3 (4), and C2 (51) in ICA segments. Mean aneurysm size and neck width were 16.9 ± 6.8 mm and 8.3 ± 4.4 mm, respectively, in 40 symptomatic and 60 asymptomatic aneurysms. Follow-up catheter angiographies of 85 patients with 90 aneurysms showed no filling in 62 aneurysms (68.9%), entry remnant in 16 (17.8%), subtotal filling in 11 (12.2), and total filling in 1 (1.1%) with a mean follow-up of 10.2 ± 5.6 months. In-stent stenosis occurred in 1 patient and parent artery occlusion in 2 during follow-up. Hemorrhagic complications occurred in 4 (4.3%): delayed aneurysm rupture (2) and intraparenchymal hemorrhage (2). Ischemic complications with neurological symptoms occurred in 2 (2.1%): very delayed device occlusion (1) and intraprocedural distal embolism (1). Eighteen patients (45%) showed improvement in pre-existing cranial nerve dysfunction because of the aneurysm’s mass effect, 3 patients (7.5%) worsened. One patient died of systemic organ failure unassociated with the procedure. Morbidity and mortality rates were 4.3% and 1.1%, respectively. PED embolization for unruptured large and giant ICA aneurysms is safe and efficacious. Physicians should be observant of characteristic risks associated with FD therapy.

Selective compromise of hypoplastic posterior communicating artery variants with aneurysms treatable by coil embolization: clinical and radiologic outcomes

Background

Posterior communicating artery (PcoA) compromise may serve as adjunctive treatment in patients with hypoplastic variants of PcoA who undergo coil embolization of PcoA aneurysms. However, procedural safety and the propensity for later recanalization are still unclear.

Objective

To evaluate clinical and radiologic outcomes of coil embolization in this setting, focusing on compromise of PcoA.

Methods

As a retrospective review, we examined 250 patients harboring 291 aneurysms of hypoplastic PcoAs, all consecutively treated by coil embolization between January 2004 and June 2016. PcoA compromise was undertaken in conjunction with 81 of the treated aneurysms (27.8%; incomplete 53; complete 28). Medical records and radiologic data were assessed during extended monitoring.

Results

During the mean follow-up of 33.9±24.6 months (median 36 months), a total of 107 (36.8%) coiled aneurysms showed recanalization (minor 50; major 57). Recanalization rates were as follows: PcoA preservation 40.5% (85/210); incomplete PcoA occlusion 34.0% (18/53); complete PcoA occlusion 14.3% (4/28). Aneurysms >7 mm (HR 3.40; P<0.01), retreatment for recanalization (HR 3.23; P<0.01), and compromise of PcoA (P<0.01) emerged from multivariate analysis as significant risk factors for recanalization. Compared with PcoA preservation, complete PcoA compromise conferred more favorable outcomes (HR 0.160), whereas incomplete compromise of PcoA fell short of statistical significance. Thromboembolic infarction related to PcoA compromise did not occur in any patient.

Conclusion

PcoA compromise in conjunction with coil embolization of PcoA aneurysms appears safe in hypoplastic variants of PcoA, helping to prevent recanalization if complete occlusion is achieved.

Evaluation of safety, efficacy and clinical outcome after endovascular treatment of aneurysmal subarachnoid hemorrhage in coil-first setting. A 10-year series from a single center

INTRODUCTION

The endovascular treatment (EVT) of ruptured cerebral aneurysms has been widely adopted after the publication of the International Subarachnoid Aneurysm Trial. In this study, we sought to evaluate the safety and efficacy of the EVT for ruptured aneurysms based on 10-year series from a single center with coil-first strategy.

METHODS

All patients with aneurysmal subarachnoid hemorrhage (aSAH) treated between 2007 and 2016 were retrospectively reviewed and divided according to initial treatment into an EVT and a microsurgical clipping (MSC) group. Clinical and radiological findings at presentation, treatment modalities and procedural complications were recorded. The angiographic and clinical outcome was compared between the two groups.

RESULTS

A total of 587 patients with aSAH were reviewed (452 EVT, 135 MSC). There were no significant differences in mean age or the Hunt and Hess grades. Parenchymal hemorrhage (PH) was more frequent in the MSC. Procedure related complications of the acute treatment were recorded in 5.5% and 32% in the EVT and MSC, respectively. The rate of retreatment was 21.9% in the EVT and 5.9% in the MSC. Late rehemorrhage was not observed in either group. There was no significant difference in the clinical outcome between the two treatment groups after adjustment for other prognostic factors.

CONCLUSION

The majority of ruptured intracranial aneurysms can be managed via an endovascular approach in the acute phase with excellent safety profile and good efficacy. Despite the high rate of reperfusion after primary endovascular approach, retreatment has a very low rate of complications and the rate of recurrent hemorrhage is very low.