Evolving role of endovascular treatment for MCA bifurcation aneurysms: case series of 184 aneurysms and review of the literature

Clinical Outcomes of Endovascular Coil Embolization for Ruptured Middle Cerebral Artery Aneurysms

Objective

Middle cerebral artery (MCA) aneurysms are difficult to treat with coil embolization (CE) due to their location and shape, but the number of CE-treated MCA has gradually increased as treatment techniques have improved. However, the outcomes of CE for ruptured MCA aneurysms are poorly understood. This study aimed to evaluate the outcomes of CE for ruptured MCA aneurysms.

Methods

We retrospectively analyzed the medical records of patients with aneurysmal subarachnoid hemorrhages (aSAH) that were treated with CE between 2013 and 2020, and compared the differences in outcomes depending on aneurysm location.

Results

A total of 468 patients with aSAH were included: 39 patients had ruptured MCA aneurysms (group M), and 429 had ruptured aneurysms at other sites (group O). There were no significant differences between the background characteristics of the 2 groups. Also, there were no significant intergroup differences in occlusion status, the frequency of complications such as ischemia, hemorrhaging, rebleeding, retreatment, or the modified Rankin Scale score at discharge. However, intracerebral hemorrhage (ICH) removal was required significantly more frequently in group M than in group O (10.3% vs. 0.5%, p = 0.0006). By case-matching analysis, there were no significant differences in these outcomes. All MCA cases that needed removal had more than 36 ml of hematoma volume. Logistic regression analysis showed that the existence of ICH at onset was a poor prognostic factor for ruptured MCA aneurysms.

Conclusion

CE for ruptured MCA aneurysms produced acceptable outcomes in selected cases. However, the indications for CE in patients with ICH should be carefully considered.

Coil embolization of the middle cerebral artery bifurcation aneurysms: Feasibility and durability

OBJECTIVE

To evaluate the feasibility and durability of coil embolization for MCAB aneurysms by analyzing clinical and radiological results.

METHODS

From January of 2008 to June of 2018, we treated a total of 1785 aneurysms using coil embolization. The aneurysms were treated by both coiling and stent-assisted coiling. Among these cases, 223 MCAB aneurysms were analyzed retrospectively. Clinical and radiological assessments were conducted at admission, after treatment, at discharge, and at last clinical follow-up.

RESULTS

Coil embolization was performed on 223 MCAB aneurysms in 217 patients. Peri-procedural ischemic, hemorrhagic, and other complications within 30 days after coil embolization occurred at rates of 8.0 %, 8.0 %, and 2.0 %, respectively, in the ruptured group and at 2.9 %, 1.2 %, and 0 %, respectively, in the unruptured group. The overall morbidity and mortality rates associated with complications were 2.3 % and 2.0 %. The cumulative major recurrence rates were 5.1 % at 12 months, 7.1 % at 18 months, and 11.9 % at three years after coil embolization. The mean follow-up period was 33.27 ± 25.48 months. Independent risk factors for major recurrence after coil embolization for MCAB aneurysms were a ruptured aneurysm, initial incomplete occlusion, the aneurysm size, and the neck size.

CONCLUSION

Coil embolization is a good alternative treatment option for MCAB aneurysms compared to surgical clipping. Considering the risk factors for major recurrence, the follow-up angiography should continue up to three years after coil embolization.

Pipeline embolization of complex, wide-necked middle cerebral artery bifurcation aneurysms: A single-center experience

PURPOSE

To evaluate the performance of Pipeline Embolization Device (PED) in complex, wide-necked middle cerebral artery (MCA) bifurcation aneurysms.

METHODS

We performed a retrospective review of patients treated with PED for complex, wide-necked MCA bifurcation aneurysms between August 2016 and March 2021. In addition to demographic data, we collected aneurysmal neck width, dome-to-neck ratio, complications, and clinical and angiographic follow-up. The embolization degree of aneurysms was evaluated by O'Kelly-Marotta (OKM) grading scale, and the prognosis was assessed with the modified Rankin Scale (mRS).

RESULTS

From August 2016 to March 2021, a total of 46 patients with 49 MCA bifurcation aneurysms in our center were enrolled, of whom all received PEDs successfully. The O'Kelly-Marotta (OKM) grading showed that post-procedure 15 patients (32.6%) were grade C, another 8 patients (17.4%) were grade D. Aneurysms with small remnant or complete occlusion were 50%, symptomatic ischemic events occurred in 3 (6.5%), and bleeding events in 1 (2.2%). 41 patients underwent a 6-month angiography follow-up, in which 7 patients (17.1%) remained OKM grade C and 30 patients (73.2%) achieved OKM grade D. Complete occlusion and small remnant aneurysms were up to 90.3%. 40 (97.6%) patients' mRS scores were 0, and 1 (2.4%) patient was 2. No new bleeding and ischemic events occurred during the 6-month.

CONCLUSIONS

The Pipeline Embolization Device provides a safe and effective treatment alternative for complex, wide-necked MCA aneurysms. A larger number with longer-term follow-up data is needed for further verification.

Double microcatheter reduction using partially deployed Atlas stents in treating a large dysplastic MCA bifurcation aneurysm with Y stent assisted coiling

Treatment of large dysplastic middle cerebral artery (MCA) aneurysms can be challenging.1 2 Catheterization of M2 branches at hyperacute angles often requires an 'around the world' approach/microcatheter reduction, which can be accomplished with rapid pull,3 balloon anchor,4 and stent anchor5 techniques. In this video video 1, Atlas stents (Stryker) are used for double microcatheter reduction along with Y stent assisted coil embolization (Video 1). Steps include (1) catheterization of the more difficult M2 branch with 'around the world' maneuver; (2) reduction/stent deployment; (3) similar catheterization of the second M2 branch; (4) microcatheter reduction/stent deployment; (5) coil embolization (jailed). Important nuances include: (1) low threshold for a staged procedure; (2) awareness of the possibility of stent twisting; (3) jailed coiling. Final views show adequate treatment of the aneurysm dome with stent protection of the dysplastic neck without thromboembolic complications. Given the residual near the base, close angiographic follow-up is important. neurintsurg;16/3/228/V1F1V1Video 1 Technical video demonstrating double stent reduction technique.

Clipping versus coiling for treatment of middle cerebral artery aneurysms: a retrospective Italian multicenter experience

Endovascular treatment has emerged as the predominant approach in intracranial aneurysms. However, surgical clipping is still considered the best treatment for middle cerebral artery (MCA) aneurysms in referral centers. Here we compared short- and long-term clinical and neuroradiological outcomes in patients with MCA aneurysms undergoing clipping or coiling in 5 Italian referral centers for cerebrovascular surgery. We retrospectively reviewed 411 consecutive patients admitted between 2015 and 2019 for ruptured and unruptured MCA aneurysm. Univariate and multivariate analyses of the association between demographic, clinical, and radiological parameters and ruptured status, type of surgical treatment, and clinical outcome at discharge and follow-up were performed. Clipping was performed in 340 (83%) cases, coiling in 71 (17%). Clipping was preferred in unruptured aneurysms and in those showing collateral branches originating from neck/dome. Surgery achieved a higher rate of complete occlusion at discharge and follow-up. Clipping and coiling showed no difference in clinical outcome in both ruptured and unruptured cases. In ruptured aneurysms age, presenting clinical status, intracerebral hematoma at onset, and treatment-related complications were significantly associated with outcome at both short- and long-term follow-up. The presence of collaterals/perforators originating from dome/neck of the aneurysms also worsened the short-term clinical outcome. In unruptured cases, only treatment-related complications such as ischemia and hydrocephalus were associated with poor outcome. Clipping still seems superior to coiling in providing better short- and long-term occlusion rates in MCA aneurysms, and at the same time, it appears as safe as coiling in terms of clinical outcome.

Case Report: Ruptured Middle Cerebral Artery Aneurysm With Intrasylvian Hematoma Successfully Treated by Coil Embolization and Minimally Invasive Puncture and Drainage

Up to one-third (12–35%) of patients with aneurysmal subarachnoid hemorrhage experience intracerebral hematoma. Ruptured middle cerebral artery (MCA) aneurysm with hematoma is usually accompanied by progressive cerebral swelling with poor outcomes; however, it can be successfully treated by coil embolization and minimally invasive puncture and drainage. From February 2012 to March 2019, six surgeries for ruptured MCA aneurysms with intrasylvian hematoma were performed at our clinic. All patients had intracranial hematomas of <30 ml and GCS scores >8. The patients were treated by coil embolization and minimally invasive puncture and drainage. The aneurysms in all patients were completely embolized and the hematomas were mostly removed by minimally invasive puncture. The Glasgow outcome scale (GOS) scores of all patients were more than 4 at discharge when they discharged. Coil embolization and minimally invasive puncture and drainage are viable treatments for ruptured MCA aneurysms with hematomas, especially if the patient is too old, in a complicated state to undergo craniotomy, is unwilling to undergo craniotomy, or is at a greater risk of bleeding 3 days after surgery.

Microsurgical Clipping versus Advanced Endovascular Treatment of Unruptured Middle Cerebral Artery Bifurcation Aneurysms After a "Coil-First" Policy

OBJECTIVE

Although intracranial aneurysms are increasingly treated endovascularly, microsurgical clipping has been the standard approach for middle cerebral artery (MCA) aneurysms. We compared microsurgical clipping and state-of-the-art endovascular treatment of unruptured MCA bifurcation aneurysms treated at a neurovascular center following a "coil-first" policy.

METHODS

This single-center study included 148 patients treated for 160 unruptured MCA bifurcation aneurysms. Technical success, complications, clinical outcome, and angiographic results were retrospectively compared.

RESULTS

Microsurgical clipping was performed for 120 MCA aneurysms (75%) and endovascular treatment for 40 (25%; conventional coiling: 8, stent-assisted coiling: 16, balloon-assisted coiling: 3, and flow-disruption: 13). Technical treatment success was higher in the clipping group (100%) than in the endovascular group (92.5%, P = 0.015). Overall, complications occurred in 16.7% for clipping and in 20.0% for endovascular treatment (P = 0.631). Major ischemic stroke rates were 4.2% in the clipping group and 7.5% in the endovascular group (P = 0.414). At 6 months, a favorable outcome was obtained by 99.2% after clipping and 95.0% after endovascular treatment (P = 0.154). The 6-month complete aneurysm occlusion rates were by trend higher in the clipping group (89.2%) than in the endovascular group (75.9%, P = 0.078).

CONCLUSIONS

Microsurgical clipping was associated with a higher technical success rate and tendentially higher complete occlusion than endovascular treatment, with no additional morbidity and similar clinical outcome. On the basis of these results, clipping proves to be the standard treatment option for MCA bifurcation aneurysms. However, endovascular treatment represents a safe and efficient alternative treatment option for patients.

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 small (< 5 mm) unruptured middle cerebral artery aneurysms

Purpose

We report our experience with endovascular treatment of these lesions, with special consideration of angiographic and clinical outcomes and periprocedural complications.

Material and methods

The analysis included treatment results of 19 patients with 20 aneurysms. The aneurysm size ranged from 1.9 to 4.7 mm (mean 3.8, SD 0.7). Clinical examinations with the use of modified Rankin Score and angiographic outcomes were evaluated initially postembolisation and at a minimum follow-up of six months.

Results

Initial post-treatment complete and near-complete aneurysm occlusion was achieved in 19 (95%) cases and incomplete occlusion in one (5%) case. Imaging follow-up, performed in 17 (89.4%) patients, showed no change in the degree of occlusion in 16 (94.1%) patients and coil compaction in one (5.9%). There were no retreatment procedures. The procedure-related mortality rate was 5% (1/20) and was associated with intraprocedural aneurysm rupture. There was a case of a clinically silent coil prolapse into the parent artery. The clinical follow-up evaluation achieved in 17 (89.4%) patients showed no change in clinical status in all followed patients.

Conclusions

Endovascular treatment of small unruptured middle cerebral artery aneurysms is feasible and effective. The procedure-related complications are not negligible, especially in terms of the benign natural course of these lesions.

Endovascular treatment of middle cerebral artery aneurysm with a (LVIS) device: Comparison of LVIS stent and non-LVIS stent

Middle cerebral artery (MCA) aneurysm is a serious medical condition mainly occurring in the proximal and bifurcation tracts. Evidence has indicated that endovascular treatment is an effective surgical method for patients with MCA aneurysm. In the present study, the efficacy of endovascular treatment with low-profile visualized intraluminal support (LVIS) stent for MCA aneurysms was evaluated in comparison with that using a non-LVIS stent device. A total of 92 patients who underwent endovascular treatment of MCA aneurysms with LVIS stent or non-LVIS stent were included in the present study. The clinical presentation, aneurysmal characteristics, technical feasibility, procedural complications, as well as angiographic and clinical follow-up results were analyzed. The computed tomography scan demonstrated that endovascular treatment with LVIS stent markedly reduced pre-operative and intra-operative ruptures. It was indicated that endovascular treatment with LVIS stent resulted in less post-operative symptoms and cases of disability according to the modified Rankin scale score. In conclusion, the present outcomes provide evidence that endovascular treatment with an LVIS stent is an efficient method for the treatment of MCA aneurysm.

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.

Treatment of ruptured middle cerebral artery aneurysms by endovascular approach: a single-center experience

PURPOSE

The optimal treatment modalities of ruptured middle cerebral artery aneurysm are still controversial. The objective of this study is to analyze the outcomes of patients with ruptured middle cerebral artery aneurysms treated by endovascular coiling.

MATERIALS AND METHODS

From October 2011 to October 2015, 67 patients with 71 ruptured middle cerebral artery aneurysms received endovascular coiling in our hospital. We retrospectively reviewed the clinical, radiologic records and outcomes.

RESULTS

Of all the 71 aneurysms (67 patients), 42 were treated by coil embolization merely, 27 by stent-assisted coiling and 2 unruptured aneurysms in patients with bilateral middle cerebral artery aneurysms without receiving treatment. Complete occlusion was achieved in 82.6% (57/69) of all the procedures. Each of incomplete and partial occlusion rates was 8.7% (6/69). Intraoperative rupture of aneurysms occurred in two procedures (2.9%). Thrombogenesis occurred in eight procedures (11.6%). Brain infarction occurred in eight patients (11.9%). Post-operative rebleeding occurred in seven patients (10.4%). Sixty-three patients were followed at a mean follow-up of 8.24 ± 7.16 months. The mortality and good outcome rate were 3.2% and 90.5%, respectively. Aneurysm recurrence occurred in 6 (13.3%) of the 45 aneurysms at a mean follow-up of 8.44 ± 7.83 months.

CONCLUSIONS

Endovascular coiling is effective for patients with ruptured middle cerebral artery aneurysms. Individualized treatment should be assessed by experienced specialist. It is essential to perform randomized large trials to confirm the efficiency of endovascular coiling.

Surgical Management of Ruptured Middle Cerebral Artery Aneurysms With Large Intraparenchymal or Sylvian Fissure Hematomas

BACKGROUND:

Craniotomy for hematoma evacuation and aneurysm clipping is the treatment modality of choice for ruptured middle cerebral artery (MCA) aneurysms with intracranial hematomas. Recent literature suggests that endovascular coil embolization followed by hematoma evacuation can be an acceptable alternative.

OBJECTIVE:

To determine neurological outcomes in patients with ruptured MCA aneurysms and intraparenchymal or sylvian fissure hematomas.

METHODS:

The records of 49 patients with ruptured MCA aneurysms with large intracranial hematomas treated with hematoma evacuation and aneurysm clipping between January 2000 and December 2013 were retrospectively reviewed.

RESULTS:

Within this cohort, 35 patients (71.4%) were Hunt and Hess grade IV or V on presentation. The mean hematoma volume was 100.4 ± 77.2 mL. Craniectomy was performed in 40 patients (81.6%). Angiographic vasospasm developed in 15 patients (30.6%). The in-hospital mortality rate was 28.6% (14 patients). At a mean of 25.3 ± 34.0 months follow-up, a good outcome (modified Rankin Scale [mRS] score 0–3) was observed in 18 patients (36.7%). Significant factors associated with poor outcome or death (mRS scores of 4–6) included increasing age (P &lt; .01), increasing Hunt and Hess grade (P = .03), increasing modified Fisher grade (P = .01), presence of intraventricular hemorrhage (P &lt; .01), decreasing percentage of hematoma evacuation (P &lt; .05), need for craniectomy (P &lt;. 01), need for external ventricular drainage (P = .04), and angiographic vasospasm (P = .02).

CONCLUSION:

MCA aneurysm rupture with concomitant large intraparenchymal or sylvian fissure hematoma formation carries a grave prognosis. Simultaneous hematoma evacuation and aneurysm clipping with or without craniectomy can be an effective treatment modality.

General technical considerations for the endovascular management of cerebral aneurysms

Cerebral aneurysms pose a threat to patients because of their risk of rupture causing subarachnoid hemorrhage, and the goal of treatment is the exclusion of the aneurysm from the circulation to prevent bleeding (in the case of unruptured aneurysms) or rebleeding. This article analyzes the general technical factors associated with the endovascular treatment of cerebral aneurysms. It discusses issues with transarterial access; imaging of aneurysm size, morphology, and regional anatomy to determine the endovascular plan; the techniques for the major endovascular aneurysm devices; and periprocedural management issues to reduce potential treatment-related complications.