Conservative Therapy vs. Endovascular Approach for Intracranial Vertebrobasilar Artery Trunk Large Aneurysms: A Prospective Multicenter Cohort Study

Background

Intracranial vertebrobasilar trunk large (≥10 mm) aneurysms (IVBTLAs) are rare and challenging to manage. In this study, we describe the natural prognosis and evaluate the safety and efficacy of endovascular treatment of IVBTLAs compared with conservative therapy.

Methods

This prospective multicenter cohort study included patients with IVBTLAs, who chose either endovascular treatment (endovascular group) or conservative therapy (conservative group) after discussion with their doctors. The primary endpoint was the incidence of serious adverse events (SAEs) related to the target vessel, while secondary endpoints included target vessel-related mortality, major stroke, other serious adverse events, and aneurysm occlusion rate.

Results

In total, 258 patients were referred to our two centers for the management of vertebrobasilar aneurysms, and 69 patients had IVBTLAs. Among them, 51 patients underwent endovascular treatment, and 18 patients received conservative therapy. The incidence of target vessel-related SAEs was 15.7% (8/51) in the endovascular group and 44.4% (8/18) in the conservative group (P = 0.031). The target vessel-related mortality was 2.0% (1/51) in the endovascular group and 38.9% (7/18) in the conservative group (P < 0.001). The cumulative survival rates in the endovascular group and conservative group within 1-year, 3-year, and 5-year were 98.0% vs. 83.3%, P = 0.020; 98.0% vs. 66.7%, P = 0.001; and 98.0% vs. 35.6%, P < 0.001, respectively. Multivariate analysis revealed conservative therapy, giant aneurysm, and ischemic onset as risks factor for SAEs.

Conclusions

Compared with conservative treatment, endovascular treatment of the IVBTLAs may be associated with a lower incidence of SAEs, with higher 1-year, 3-year, and 5-year survival rates. Conservative therapy, giant aneurysm, and ischemic onset were associated with a high risk of SAEs.

Flow diverter device placement for cerebral aneurysm is not effective for the patient with parent artery occlusion for contralateral aneurysm

PURPOSE

There have been many reports on the risks of enlargement and rupture of residual aneurysms and de novo aneurysm formation in the contralateral internal carotid artery after parent artery occlusion (PAO). In the present study, we investigated the efficacy of flow diverter device placement (FDDP) for the treatment of contralateral internal carotid artery aneurysms after PAO.

METHODS

After 11 patients, who had bilateral large or giant internal carotid aneurysms, were treated for either side with PAO or FDDP, they underwent FDDP for residual lesions in our hospital between October 2015 and June 2018. The patients were divided into two groups, depending on the prior procedure: PAO or FDDP. The embolic state after subsequent FDDP was evaluated by angiography. The embolic state was graded using the O'Kelly Marotta scale. Patients' characteristics and the embolic state of intracranial aneurysms after FDDP were compared between the two groups.

RESULTS

Comparing patients' characteristics between the PAO group and FDDP group, statistically significant differences were observed in laterality of the lesions and the interval between prior treatment and FDDP for residual aneurysms (p < 0.05). The embolic state at the one-year follow-up revealed that there could be significantly sufficient embolisation in the FDDP group (p < 0.05).

CONCLUSION

When FDDP is performed for the contralateral lesion after PAO treatment, it is difficult to attain sufficient embolisation of intracranial aneurysms because haemodynamic load in this procedure is large compared to that in a regular FDDP.

The Rate of Symptomatic Ischemic Events after Passing Balloon Test Occlusion of the Major Intracranial Arteries: Meta-Analysis

BACKGROUND

Balloon test occlusion is a widely used method for predicting tolerance of vessel occlusion in the treatment of aneurysms, fistulae, and head and neck neoplasms. However, the false-negative rate is variably reported due in part to the diversity of perfusion monitoring methods.

OBJECTIVE

To evaluate the rate of symptomatic ischemic events after a negative balloon test occlusion and determine whether perfusion monitoring methods contribute to differences in these rates.

METHODS

PubMed was systematically searched for studies between 1990 and 2020 that reported rates of ischemic outcomes of parental vessel occlusion in patients who passed balloon test occlusion. A generalized linear mixed model meta-analysis was performed. Results were expressed as the rate of symptomatic ischemic events after parental vessel occlusion without vessel bypass in patients who passed balloon test occlusion.

RESULTS

Thirty-two studies met the inclusion criteria. The overall pooled rate of ischemic events after passing balloon test occlusion was 3.7% (95% confidence interval [CI]: 1.7-7.8). This rate was 3.8% (95% CI: 1.1-12.8) when monitored with angiography, 2.2% (95% CI: 0.4-10.2) when monitored by a form of computed tomography, and 5.3% (95% CI: 1.2-20.4) when monitored by 2 or more methods of perfusion assessment. The complication rate of balloon test occlusion was 0.8% (95% CI: 0.2-2.7).

CONCLUSIONS

Balloon test occlusion results in a low rate of subsequent ischemic events, without conclusive evidence of variation between methods of perfusion assessment. The choice of method should focus on reduction of complication risk, experience of the interventional team, and avoidance of prolonged test occlusion times.