Rebleeding and bleeding in the year following intracranial aneurysm coiling: analysis of a large prospective multicenter cohort of 1140 patients-Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm (ARETA) Study

Three Pillars of Recovery After Aneurysmal Subarachnoid Hemorrhage: A Narrative Review

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurologic disease with high mortality and disability. There have been global improvements in survival, which has contributed to the prevalence of patients living with long-term sequelae related to this disease. The focus of active research has traditionally centered on acute treatment to reduce mortality, but now there is a great need to study the course of short- and long-term recovery in these patients. In this narrative review, we aim to describe the core pillars in the preservation of cerebral function, prevention of complications, the recent literature studying neuroplasticity, and future directions for research to enhance recovery outcomes following aSAH.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Intra-procedural complications, success rate, and need for retreatment of endovascular treatments in anterior communicating artery aneurysms: a systematic review and meta-analysis

In recent years, intracranial aneurysms have been widely treated with endovascular methods. The anterior communicating artery (Acom) is the most common site of intracranial aneurysms. Despite its effectiveness, endovascular interventions can be associated with various intra-procedural and post-procedural complications. A systematic review of the literature was performed through PubMed, Embase, Scopus, and Web of Sciences databases up to March 18, 2022. The pooled rates of intra-procedural complications, mortality, procedure-related morbidities, the immediate and late aneurysm occlusion, and also the necessity for retreatment were calculated by applying random-effects models. A total of 41 articles with 4583 patients were included in the meta-analysis. The pooled rate of overall intra-procedural complications was 9.6% (95% CI: 7.7 to 11.8%). The initial rupture status and also type of EVT procedure did not affect the overall complication rate. The pooled rate of intra-procedural thrombosis, aneurysm rupture, coil prolapse, and early aneurysm rebleeding were 6.1% (95% CI: 4.5 to 8.2%); 4.2% (95% CI: 3.4 to 5.2%), 4.7% (95% CI: 3.2 to 6.7%), and 2.2% (95% CI: 1.5 to 3.2%), respectively. Our analysis showed that intra-procedural mortality occurred in 1.7% (95% CI: 1.1 to 2.5%) and procedure-related permanent morbidities in 3.3% (95% CI: 2.3 to 4.7%) of patients. Endovascular methods achieved complete and near to complete aneurysm occlusion (Raymond-Roy occlusion classification 1 and 2) in 89.2% (95% CI: 86.4 to 92.5%) of cases post-procedure, and 9.5% (95% CI: 7.3 to 12.4%) of patients needed retreatment due to recanalization in follow-ups. Endovascular treatment can serve as an acceptable method for Acom aneurysms. However, improved endovascular treatment equipment and new techniques provide more satisfactory outcomes for complicated cases.

Hemodynamic Analysis of Pipeline Embolization Device Stent for Treatment of Giant Intracranial Aneurysm under Unsupervised Learning Algorithm

To treat large intracranial aneurysms, pipeline embolization device (PED) stent with unsupervised learning algorithms was utilized. Unsupervised learning model algorithm was used to screen aneurysm health big data, find aneurysm blood flow and PED stent positioning characteristic parameters, and guide PED stent treatment of intracranial aneurysms. The research objects were 100 patients with intracranial large aneurysm admitted to X Hospital of X Province from June 2020 to June 2021, who were enrolled into two groups. One group used the prototype transfer generative adversarial network (PTGAN) model to measure mean blood flow and mean vascular pressure and guide the placement of PED stents (PTGAN group). The other group did not use the model to place PED (control group). The PTGAN model can learn feature information from horizontal and vertical directions, with smooth edges and prominent features, which can effectively extract the main morphological and texture features of aneurysms. Compared with the convolutional neural network (CNN) model, the accuracy of the PTGAN model increased by 8.449% (87.452%-79.003%), and the precision increased by 8.347% (91.23%-82.883%). The recall rate increased by 7.011% (87.231%-80.22%), and the F1 score increased by 8.09% (89.73%-81.64%). After the adoption of the PTGAN model, the average blood flow inside the aneurysm body was 0.22 (m/s). After the adoption of the CNN model, the average blood flow inside the aneurysm body was 0.21 (m/s), and the difference was 0.01 (m/s), which was considerable (p < 0.05). Through this research, it was found that the PTGAN model was better than the CNN model in terms of accuracy, precision, recall, and F1 score values. The PTGAN model was better than the CNN model in detecting the average blood flow rate and average blood pressure after treatment, and the blood flowed smoothly. Postoperative complications and postoperative relief were also better than those of the control group. In summary, based on the unsupervised learning algorithm, the PED stent had a good adoption effect in the treatment of intracranial aneurysms and was suitable for subsequent treatment.

Usefulness of Craniograms in Discriminating Coiled Intracranial Aneurysms Requiring Retreatment

While endovascular coil embolization has become one of the major therapeutic modalities for intracranial aneurysms, long-term imaging follow-up is required because of the higher rate of retreatment compared with surgical clipping. The purpose of this study was to show the usefulness of craniograms to discriminate coiled intracranial aneurysms that required retreatment. Under the study protocol approved by institutional review board, a retrospective review of the medical record was done regarding coil embolization for intracranial aneurysms performed between January 2014 and December 2018. Coil embolization performed as the initial treatment and followed up for more than 1 year without additional treatment, and those performed as retreatment after the initial coil embolization performed at our institution were recruited. Craniograms obtained just after the initial treatment were compared with those obtained just before the additional treatment in the retreated cases and compared with the latest ones in the non-recurrence cases. Correlation between the morphological changes in the coil mass on the craniograms and retreatments was evaluated. During the study period, 288 coil embolization procedures for intracranial aneurysms were performed. From these, 191 treatments that were followed up for more than 1 year without any additional treatments and 30 retreatments were included. Morphological change of the coil mass was observed in 4 of the 191 non-recurrence treatments and 26 of the 30 retreatments, which was significantly correlated with retreatments (p <0.001). Craniogram was a useful modality in following up the coiled intracranial aneurysms to detect those required retreatments.

Safety and Efficacy of the Woven EndoBridge Device for Treatment of Ruptured Intracranial Aneurysms: A Systematic Review and Meta-analysis

BACKGROUND

The Woven EndoBridge device has been increasingly used to treat wide-neck aneurysms, particularly ruptured ones.

PURPOSE

Our aim was to investigate the safety and efficacy of the Woven EndoBridge device in the treatment of ruptured intracranial aneurysms.

DATA SOURCES

All studies evaluating the outcomes of Woven EndoBridge device use in the treatment of ruptured intracranial aneurysms from inception through 2020 were searched on Ovid Evidence-Based Medicine Reviews, EMBASE, MEDLINE, Scopus, and the Web of Science Core Collection.

STUDY SELECTION

Eighteen studies encompassing 487 patients with 496 ruptured aneurysms treated with the Woven EndoBridge device were included.

DATA ANALYSIS

We studied rates of rerupture and retreatment, angiographic outcomes at the last follow-up point, complications, and mortality rates. Data were collected on anticoagulation and antiplatelet use. Meta-analysis was performed using the random effects model.

DATA SYNTHESIS

The rate of late rebleeding was 1.1% (95% CI, 0.1%-2.1%). The treatment-related perioperative complication rate and the overall clinical complication rate were 13.2% (95% CI, 9.2%-17.2%) and 3.2% (95% CI, 1.6%-4.7%), respectively. Thirteen hemorrhagic (2%; 95% CI, 0.8%-3.3%) and 41 thromboembolic (6.8%; 95% CI, 4.6%-9%) complications occurred. Favorable clinical outcomes were achieved in 85% of patients. Procedure-related mortality and overall mortality rates were 2.1% (95% CI, 0.8%-3.3%) and 11.5% (95% CI, 7%-16%), respectively. At last follow-up, an adequate occlusion rate was 87.3% (95% CI, 82.1%-92.4%) and the retreatment rate was 5.1% (95% CI, 3%-7.3%).

LIMITATIONS

Our meta-analysis is limited by selection bias and high heterogeneity.

CONCLUSIONS

This meta-analysis demonstrated the safety and efficacy of the Woven EndoBridge device in the management of ruptured aneurysms, but further studies are needed.

Porous Media Computational Fluid Dynamics and the Role of the First Coil in the Embolization of Ruptured Intracranial Aneurysms

Background: The objective of our project was to identify a late recanalization predictor in ruptured intracranial aneurysms treated with coil embolization. This goal was achieved by means of a statistical analysis followed by a computational fluid dynamics (CFD) with porous media modelling approach. Porous media CFD simulated the hemodynamics within the aneurysmal dome after coiling. Methods: Firstly, a retrospective single center analysis of 66 aneurysmal subarachnoid hemorrhage patients was conducted. The authors assessed morphometric parameters, packing density, first coil volume packing density (1st VPD) and recanalization rate on digital subtraction angiograms (DSA). The effectiveness of initial endovascular treatment was visually determined using the modified Raymond–Roy classification directly after the embolization and in a 6- and 12-month follow-up DSA. In the next step, a comparison between porous media CFD analyses and our statistical results was performed. A geometry used during numerical simulations based on a patient-specific anatomy, where the aneurysm dome was modelled as a separate, porous domain. To evaluate hemodynamic changes, CFD was utilized for a control case (without any porosity) and for a wide range of porosities that resembled 1–30% of VPD. Numerical analyses were performed in Ansys CFX solver. Results: A multivariate analysis showed that 1st VPD affected the late recanalization rate (p < 0.001). Its value was significantly greater in all patients without recanalization (p < 0.001). Receiver operating characteristic curves governed by the univariate analysis showed that the model for late recanalization prediction based on 1st VPD (AUC 0.94 (95%CI: 0.86–1.00) is the most important predictor of late recanalization (p < 0.001). A cut-off point of 10.56% (sensitivity—0.722; specificity—0.979) was confirmed as optimal in a computational fluid dynamics analysis. The CFD results indicate that pressure at the aneurysm wall and residual flow volume (blood volume with mean fluid velocity > 0.01 m/s) within the aneurysmal dome tended to asymptotically decrease when VPD exceeded 10%. Conclusions: High 1st VPD decreases the late recanalization rate in ruptured intracranial aneurysms treated with coil embolization (according to our statistical results > 10.56%). We present an easy intraoperatively calculable predictor which has the potential to be used in clinical practice as a tip to improve clinical outcomes.

Immediate post-operative aneurysm occlusion after endovascular treatment of intracranial aneurysms with coiling or balloon-assisted coiling in a prospective multicenter cohort of 1189 patients: Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm (ARETA) Study

BACKGROUND

Coiling, including balloon-assisted coiling (BAC), is the first-line therapy for ruptured and unruptured aneurysms. Its efficacy can be clinically evaluated by bleeding/rebleeding rate after coiling, and anatomically evaluated by aneurysm occlusion post-procedure and during follow-up. We aimed to analyze immediate post-coiling aneurysm occlusion and associated factors within the Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm (ARETA) population.

METHODS

Between December 2013 and May 2015, 16 neurointerventional departments prospectively enrolled participants treated for ruptured and unruptured aneurysms (ClinicalTrials.gov: NCT01942512). Participant demographics, aneurysm characteristics, and endovascular techniques were recorded. In patients with aneurysms treated by coiling or BAC, immediate post-operative aneurysm occlusion was independently evaluated by a core lab using a 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant.

RESULTS

Of 1135 participants (age 53.8±12.8 years, 754 women (66.4%)), 1189 aneurysms were analyzed. Treatment modality was standard coiling in 645/1189 aneurysms (54.2%) and BAC in 544/1189 (45.8%). Immediate post-operative aneurysm occlusion was complete occlusion in 57.8%, neck remnant in 34.4%, and aneurysm remnant in 7.8%. Adequate occlusion (complete occlusion or neck remnant) was significantly more frequent in aneurysms with size <10 mm (93.1% vs 86.3%; OR 1.8, 95% CI 1.1 to 3.2; p=0.02) and in aneurysms with a narrow neck (95.8% vs 89.6%; OR 2.5, 95% CI 1.5 to 4.1; p=0.0004). Patients aged <70 years had significantly more adequate occlusion (92.7% vs 87.2%; OR 1.9, 95% CI 1.1 to 3.4; p=0.04).

CONCLUSIONS

Immediately after aneurysm coiling, including BAC, adequate aneurysm occlusion was obtained in 92.2%. Age <70 years, aneurysm size <10 mm, and narrow neck were factors associated with adequate occlusion.

TRIAL REGISTRATION NUMBER

NCT01942512, http://www.clinicaltrials.gov.

Delayed thromboembolic events after coiling of unruptured intracranial aneurysms in a prospective cohort of 335 patients

BACKGROUND

Coiling is the first-line treatment for the management of unruptured intracranial aneurysms (UIAs), but delayed thromboembolic events (TEEs) can occur after such treatment. ARETA (Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm) is a prospective multicenter study conducted to analyze aneurysm recanalization. We analyzed delayed TEEs in the UIA subgroup.

METHODS

Sixteen neurointerventional departments prospectively enrolled patients treated for ruptured and unruptured aneurysms between December 2013 and May 2015. Participant demographics, aneurysm characteristics, and endovascular techniques were recorded. Data were analyzed from participants with UIA treated by coiling or balloon-assisted coiling. We assessed the rates, timing, management, clinical outcomes, and risk factors for delayed TEEs using univariable and multivariable analyses.

RESULTS

The rate of delayed TEEs was 2.4% (95% CI 1.0% to 4.6%) in patients with unruptured aneurysms, with all events occurring in the week following the procedure. In multivariate analysis, two factors were associated with delayed TEEs: autosomal dominant polycystic kidney disease (ADPKD): 20.0% in patients with ADPKD vs 1.9% in patients without ADPKD (OR 27.3 (95% CI 3.9 to 190.2), p=0.0008) and post-procedure aneurysm remnant: 9.4% in patients with post-procedure aneurysm remnant vs 1.6% in patients with adequate occlusion (OR 9.9 (95% CI 1.0 to 51.3), p=0.006). We describe modalities of management as well as clinical outcomes.

CONCLUSIONS

Delayed TEE is a relatively rare complication after coiling of UIAs. In this series, all occurred in the week following the initial procedure. Two factors were associated with delayed TEE: ADPKD and aneurysm remnant at procedure completion.

CLINICAL TRIAL REGISTRATION

NCT01942512.