Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

Treatment of Paraclinoid Aneurysms With Stent-Assisted Coiling Versus Flow Diversion Techniques: A Systematic Review and Meta-Analysis

BACKGROUND

The stent-assisted coiling (SAC) and flow-diverter stent (FDS) techniques are widely used in the endovascular treatment of paraclinoid aneurysms. This article compares the occlusion rate, periprocedural complications, and clinical outcomes of SAC and FDSs.

METHODS

Between January 2010 and December 2020, a systematic search of electronic databases identified 2283 articles for screening. After the application of inclusion and exclusion criteria, data were extracted for a meta-analysis of the proportions.

RESULTS

Of 23 articles containing 4 comparative studies, 27 cohorts were included, and 1208 patients with 1328 aneurysms were analyzed: In 10 cohorts, 381 (28.7%) patients were treated with SAC, whereas in 17 cohorts, 947 (71.3%) patients were treated with FDSs. In the comparative studies, no significance was observed between the 2 treatments. In the pooled cohorts, complete occlusion was achieved in 85% of aneurysms after treatment with FDSs (95% CI: 0.81-0.88, I2=34.7%) and 76% after treatment with SAC (95% CI: 0.70-0.81, I2=16.6%); the subgroup analysis was statistically significant (P=0.003). New visual complications were observed in 5% of the FDS-treated group (95% CI: 0.02-0.09, I2=76.9%) and in 1% of the SAC-treated group (95% CI: 0.00-0.02, I2=0%); the subgroup analysis was statistically significant (P=0.018). Other observational indices, including total procedure-related complications; hemorrhagic, thrombotic, and ischemic complications; permanent morbidities, and favorable neurological outcomes, showed no statistical significance between the groups.

CONCLUSION

Compared with SAC, treatment with FDSs may have a higher complete occlusion rate at follow-up. The similarly low rates for procedure-related complications and permanent morbidities indicate that both treatments are safe. A higher rate of new visual complications was noted in the FDS-treated group. Further research is required for direct comparisons along with a complete ophthalmological examination.

Improvement in cranial nerve palsies following treatment of intracranial aneurysms with flow diverters: Institutional outcomes, systematic review and study-level meta-analysis

BACKGROUND

Cranial nerve (CN) palsies are rare presenting symptoms of intracranial aneurysms. Our objectives were to report our institutional outcomes and study-level meta-analysis summarizing rates of improvement and identifying factors associated with recovery from CN symptoms after flow diversion.

METHODS

We conducted a retrospective review of our institutional database for patients with intracranial aneurysms presenting with CN palsies who underwent treatment with flow diversion between 2015 and 2023. Systematic review of the literature was performed using Medline, EMBASE, Cochrane, as well as manual citation searches. Random effects meta-analysis was used.

RESULTS

Thirteen of 136 studies were included in the meta-analysis and were combined with our institutional data. The pooled rate of improvement in any CN palsies following flow diversion was 71 % (95 %CI, 60 %-82 %, n=322). Patients presenting with CN II deficits were less likely to improve following treatment compared to other CN deficits (pooled OR [pOR] 0.32, 95 %CI, 0.16-0.63, n=224). The pooled rate of clinical improvement was 53 % in CNII deficits (95 %CI, 42 %-65 %, n=80) and 80 % in other CN deficits (95 %CI, 71 %-88 %, n=106). An increased rate of improvement was associated with acute intervention (pOR 9.12, 95 % CI, 2.26-36.73, n = 71) and radiographic aneurysm occlusion (pOR 5.29, 95 %CI, 1.66-16.90, n=118).

CONCLUSIONS

Flow diversion improves CN palsy outcomes in patients with symptomatic intracranial aneurysms. The lower rate of improvement in visual acuity compared to other CN deficits may point to a different mechanism of injury or potential recoverability in these patients.

Stent-assisted coiling of unruptured paraclinoid aneurysms with wide neck or unfavorable dome-to-neck ratio: Results of ventral wall vs dorsal wall with propensity score matching analysis

OBJECTIVE

This study aimed to evaluate the clinical safety and efficacy of stent-assisted coil embolization of unruptured wide-necked paraclinoid aneurysms based on the projection distribution.

METHODS

Between November 2015 and September 2020, 267 unruptured paraclinod aneurysms in 236 patients were identified with a wide neck or unfavorable dome-to-neck ratio and treated with stent-assisted coiling technique. The classification of this segment aneurysms was simplified to the dorsal group (located on the anterior wall) and ventral group (Non-dorsal). Following propensity score matching analysis, the clinical and radiographic data were compared between the two groups.

RESULTS

Among 267 aneurysms, 186 were located on the ventral wall and 81 were on the dorsal wall. Dorsal wall aneurysms had a larger size (p < .001), wider neck (p = .001), and higher dome-to-neck ratio (p = .023) compared with ventral wall aneurysms. Propensity score-matched analysis found that dorsal group had a significantly higher likelihood of unfavorable results in immediate (residual sac, 39.4% vs. 18.2%, p = .007) and follow-up angiography (residual sac, 14.8% vs. 1.9%, p = .037) compared with ventral group, with significant difference in recurrence rates (9.3% vs. 0%, p = .028). The rates of procedure-related complications were not significantly different, but one thromboembolic event occurred in the dorsal group with clinical deterioration.

CONCLUSIONS

Traditional stent-assisted coiling can be given preference in paraclinoid aneurysms located on the ventral wall. The relatively high rate of recurrence in dorsal wall aneurysms with stent assistance may require other treatment options.

Risk factors for intraoperative in-stent thrombosis during stent-assisted coiling of paraclinoid aneurysms

Objectives

To identify independent risk factors for intraoperative in-stent thrombosis (IST) in paraclinoid aneurysms (PAs).

Methods

172 PA patents undergoing stent-assisted coiling (SAC) were divided into an IST group (n = 12) and a non-IST group (n = 160). Clinical characteristics, aneurysm morphologies, and laboratory parameters were measured. We performed independent t tests (for normally distributed data) or non-parametric tests (for non-normally distributed data) to compare continuous parameters. Multivariate logistic regression analysis with a stepwise forward method was conducted to determine independent risk factors. Receiver operating characteristic curves were generated, and the Delong test was employed for comparisons.

Results

Independent risk factors for IST included size ratio (SR) (p < 0.001, odds ratio [OR] = 3.909, confidence interval [CI] = 1.925-7.939), adenosine diphosphate (ADP) inhibition (p = 0.028, OR = 0.967, CI = 0.938-0.996), and reaction time (R) (p = 0.006, OR = 0.326, CI = 0.147-0.725). The combined factors (SR, ADP inhibition, and R) exhibited area under the curves of 0.870, 0.720, 0.716, and 0.697, with cutoff values of 2.46, 69.90%, and 4.65, respectively.

Conclusion

The SR, ADP inhibition, and R values were independent risk factors for the IST in the PAs undergoing SAC. For PAs with a large SR, surgeons could prepare for long-term dual antiplatelet therapy before SAC.

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.

Endovascular and microsurgical management of blister aneurysms: a multi-centre review

Blister aneurysms (BA) are high-risk cerebrovascular lesions accounting for 1% of intracranial aneurysms. The defective vessel wall and broad-based neck make this clinical entity difficult to treat, with high rates of re-rupture and mortality in patients presenting with acute subarachnoid haemorrhage. Blister aneurysms pose substantial challenges for both endovascular and microsurgical management. The objective of this study is to evaluate endovascular and microsurgical outcomes in intracranial blister aneurysm management across two tertiary hospitals. A review of two tertiary hospitals with a systematic imaging database search for term of "blister" in modalities from January 2010 to October 2022 was conducted. Operation reports were screened for the 5-year period since cerebral angiogram reports transitioned to surgical database. Identified reports were screened and reviewed for confirmed diagnosis by consultant neuroradiologist. A total of 21 cases of blister aneurysms managed at respective facilities were included. Sixteen cases (76%) were managed endovascularly. Four cases (19%) were managed surgically-2 with primary clipping, and 2 wrap and clipping. One case was managed conservatively (5%). Clinical outcomes were discharge disposition, aneurysm exclusion and post-operative complications. BAs have challenging considerations with high mortality and morbidity. Endovascular treatment offers a less invasive modality with lower rates of intraoperative rupture and morbidity. Mortality rates and patients discharged home were comparable. Commencement of dual anti-platelet therapy was safe in patients with flow diversion stents despite sub-arachnoid blood volume. Management of blister aneurysms is complex. Endovascular treatment shows promise for acute management but careful collaborative consideration of antithrombotic regime and requirement for further surgery should be considered.

Visualization balloon occlusion-assisted technique in the treatment of large or giant paraclinoid aneurysms: A study of 17 cases series

Objective

Although balloon-assisted techniques are valuable in aneurysm clipping, repeated angiography and fluoroscopy are required to understand the location and shape of the balloon. This study investigated the value of visualization balloon occlusion-assisted techniques in aneurysm hybridization procedures.

Methods

We propose a visualization balloon technique that injects methylene blue into the balloon, allowing it to be well visualized under a microscope without repeated angiography. This study retrospects the medical records of 17 large or giant paraclinoid aneurysms treated by a visualization balloon occlusion-assisted technique in a hybrid operating room. Intraoperative surgical techniques, postoperative complications, and immediate and long-term angiographic findings are highlighted.

Results

All 17 patients had safe and successful aneurysm clipping surgery with complete angiographic occlusion. Under the microscope, the balloon injected with methylene blue is visible through the arterial wall. The position and shape of the balloon can be monitored in real time without repeated angiography and fluoroscopic guidance. Two cases of intraoperative visualization balloon shift and slip into the aneurysm cavity were detected in time, and there were no cases of balloon misclipping or difficult removal. Of 17 patients, four patients (23.5%) experienced short-term complications, including pulmonary infection (11.8%), abducens nerve paralysis (5.9%), and thalamus hemorrhage (5.9%). The rate of vision recovery among patients with previous visual deficits was 70% (7 of 10 patients). The mean follow-up duration was 32.76 months. No aneurysms or neurological deficits recurred among all patients who completed the follow-up.

Conclusion

Our study indicates that microsurgical clipping with the visualization balloon occlusion-assisted technique seems to be a safe and effective method for patients with large or giant paraclinoid aneurysms to reduce the surgical difficulty and simplify the operation process of microsurgical treatment alone.

Flow diversion treatment for giant intracranial serpentine aneurysms

Background

Giant serpentine aneurysms (GSAs) are among the most complex and challenging type of intracranial aneurysms. Surgical clipping, bypass, or endovascular parent artery occlusion has been the main treatment of GSAs in the past. However, studies on flow diversion (FD) are limited. Therefore, we reported our experience with patients with GSAs treated with FD.

Methods

Patients with GSAs treated with FD from 2012 to 2020 in our single center were retrospectively reviewed. Angiographic outcomes were graded according to the O’Kelly–Marotta scale as complete occlusion (D), trace filling (C), entry remnant (B), or aneurysm filling (A). Clinical outcomes were assessed using the modified Rankin scale (mRS) score. We also collected the patients’ treatment details and perioperative complications.

Results

Thirteen patients with 14 aneurysms were included, including three in the anterior circulation and 11 in the posterior circulation. Grades B–D were found in 72.7% (8/11) of the GSAs. Good prognosis (mRS score, 0–2) was found in 66.7% (8/12) and 50.0% (6/12) of the patients at the 6-month and latest follow-up, respectively. Parent artery occlusion was found in three cases of GSAs. Five postoperative complications were observed, including two minor complications and three major complications.

Conclusion

Although reconstructive treatment with FD could be considered as one of the treatment strategies for patients with both anterior and posterior circulation GSAs, however, the risk of complications and parent artery occlusion should be considered.

Partial medial clinoidectomy with optic canal roof drilling for clipping of ophthalmic artery aneurysms: how I do it

BACKGROUND

Clipping of ophthalmic artery (OA) aneurysms present one of the treatment strategies for long-term disease management. Existing surgical techniques primarily require extra/intradural removal of the anterior clinoid process, carrying a higher risk of infection, damage to surrounding structures or technical complications.

METHODS

We present the technique of minimally invasive partial medial clinoidectomy with the unroofing of the optic canal for surgical clipping of OA aneurysms, and besides its pros and cons, we also discuss proper technical indications.

CONCLUSION

The partial medial clinoidectomy improves manoeuvrability around the paraclinoid region, provides better protection for adjacent structures and renders excellent treatment outcome.

A novel endovascular treatment for true ophthalmic aneurysms: A case report

Introduction

Cerebral aneurysms located along the internal carotid artery at the origin of the ophthalmic artery can be treated through open surgery or endovascular technique. The former affords more certainty of aneurysm obliteration, while the latter poses less risk to vision. Flow diversion is an increasingly accepted treatment for side-wall carotid aneurysms, although location at the branch point of the ophthalmic artery is known to moderate occlusion outcomes.

Case presentation

We present a case of a middle-aged female patient with a morphologically irregular 4-mm ophthalmic artery aneurysm (OphA) and a smaller superior hypophyseal artery (SHA) aneurysm whose successful and uncomplicated obliteration by flow diversion with adjunctive coiling was predicted via a balloon test occlusion (BTO). BTO was employed prior to stent placement to confirm a) ophthalmic artery distal collateralization with external carotid artery (ECA) branches and b) preserved arterial flow in the retina visualized via fundoscopy. At 1 year following angiography, the patient had no postoperative deficits and benefitted from complete occlusion of the OphA and SHA.

Conclusion

OphAs constitute a complex surgical disease that is historically associated with high visual morbidity. We present a novel advanced endovascular technique of BTO followed by flow diversion with adjunctive coiling that successfully obliterated an OphA while preserving vision.

Endovascular treatment of aneurysms of the paraophthalmic segment of the internal carotid artery: Current status

The paraophthalmic segment of the internal carotid artery (ICA) originates from the distal border of the cavernous ICA and terminates at the posterior communicating artery. Aneurysms arising from the paraophthalmic segment represent ~5–10% of intradural aneurysms. Due to the advent of endovascular treatment (EVT) techniques, specifically flow-diverting stents (FDSs), EVT has become a good option for these aneurysms. A literature review on EVT for paraophthalmic segment aneurysms is necessary. In this review, we discuss the anatomy of the paraophthalmic segment, classification of the paraophthalmic segment aneurysms, EVT principle and techniques, and prognosis and complications. EVT techniques for paraophthalmic segment aneurysms include coil embolization, FDSs, covered stents, and Woven EndoBridge devices. Currently, coiling embolization remains the best choice for ruptured paraophthalmic segment aneurysms, especially to avoid long-term antiplatelet therapy for young patients. Due to the excessive use of antiplatelet therapy, unruptured paraophthalmic segment aneurysms that are easy to coil should not be treated with FDS. FDS is appropriate for uncoilable or failed aneurysms. Other devices cannot act as the primary choice but can be useful auxiliary tools. Both coiling embolization and FDS deployment can result in a good prognosis for paraophthalmic segment aneurysms. The overall complication rate is low. Therefore, EVT offers promising treatments for paraophthalmic segment aneurysms. In addition, surgical clipping continues to be a good choice for paraophthalmic segment aneurysms in the endovascular era.

Flow Diversion for ICA Aneurysms with Compressive Neuro-Ophthalmologic Symptoms: Predictors of Morbidity, Mortality, and Incomplete Aneurysm Occlusion

BACKGROUND AND PURPOSE

Flow diversion is an effective treatment for aneurysms of the ICA with compression-related neuro-ophthalmologic symptoms, especially when treatment is initiated early after symptom onset and aneurysm occlusion is complete. However, non-negligible complication rates have been reported. Our aim was to identify risk factors for morbidity/mortality and incomplete aneurysm occlusion.

MATERIALS AND METHODS

We performed a secondary analysis of a previous publication, which included all patients treated with flow diversion for an unruptured aneurysm of the ICA with compression-related symptoms.

RESULTS

Fifty-four patients with 54 aneurysms (48 women, 88.9%; mean age, 59.2 [SD, 15.9] years; range, 21-86 years) treated with flow diversion were included. We observed morbidity and mortality rates of 7.4% and 3.7%. Increasing age (OR per decade, 3.2; 95% CI, 1.23-8.49; P = .02) and dual-antiplatelet therapy with ticagrelor (OR, 13.9; 95% CI, 1.16-165.97; P = .04) were significantly associated with morbidity/mortality. After a median follow-up of 13.3 [SD, 10.5] months, the rates of complete aneurysm occlusion, neck remnant, and aneurysm remnant were 74%, 14%, and 12%. Incomplete occlusion at follow-up was less frequently observed in aneurysms treated with additional coil embolization (OR, 0.1; 95% CI, 0.01-0.86; P = .04).

CONCLUSIONS

Although a promising treatment for compressive ICA aneurysms, flow diversion carries a relevant risk for complications and incomplete aneurysm occlusion. Our results may help identify patients in which flow diversion may not be the ideal treatment method. Additional coil embolization increased the likelihood of complete aneurysm occlusion at follow-up.

The Safety and Efficacy of Flow Diversion versus Conventional Endovascular Treatment for Intracranial Aneurysms: A Meta-analysis of Real-world Cohort Studies from the Past 10 Years

BACKGROUND

Although the flow diverter has advantages in the treatment of intracranial aneurysms, pooled studies that directly compare it with conventional endovascular treatments are rare.

PURPOSE

Our aim was to compare the safety and efficacy of flow-diverter and conventional endovascular treatments in intracranial aneurysms.

DATA SOURCES

We performed a comprehensive search of the literature using PubMed, EMBASE, and the Cochrane Database.

STUDY SELECTION

We included only studies that directly compared the angiographic and clinical outcomes of flow-diverter and conventional endovascular treatments.

DATA ANALYSIS

Random effects or fixed effects meta-analysis was used to pool the cumulative rate of short- and long-term angiographic and clinical outcomes.

DATA SYNTHESIS

Eighteen studies with 1001 patients with flow diverters and 1133 patients with conventional endovascular treatments were included; 1015 and 1201 aneurysm procedures were performed, respectively. The flow-diverter group had aneurysms of a larger size (standard mean difference, 0.22; 95% CI, 0.03-0.41; P = .026). There was a higher risk of complications in the flow-diverter group compared with the conventional endovascular group (OR, 1.4; 95% CI, 1.01-1.96; P = .045) during procedures. The follow-up angiographic results of flow-diverter treatment indicated a higher rate of complete occlusion (OR, 2.55; 95% CI, 1.70-3.83; P < .001) and lower rates of recurrence (OR, 0.24; 95% CI, 0.12-0.46; P < .001) and retreatment (OR, 0.31; 95% CI, 0.21-0.47; P < .001).

LIMITATIONS

Limitations include a retrospective, observational design in some studies, high heterogeneity, and selection bias.

CONCLUSIONS

Compared with the conventional endovascular treatments, the placement of a flow diverter may lead to more procedure-related complications, but there is no difference in safety, and it is more effective in the long term.

Incomplete occlusion and visual symptoms of peri-ophthalmic aneurysm after treatment with a pipeline embolization device: a multi-center cohort study

OBJECTIVE

Peri-ophthalmic aneurysm is a special type of aneurysm. We assessed the relationship between ophthalmic artery (OA) origin and aneurysm and examined the effect of a pipeline embolization device (PED, Covidien/Medtronic) with or without coils on aneurysm occlusion rate and visual outcomes.

METHODS

We retrospectively analyzed 194 peri-ophthalmic aneurysms in 189 patients among 1171 patients treated with a PED in a Chinese post-market multi-center registry study from November 2014 to October 2019. Peri-ophthalmic aneurysms were defined as carotid-ophthalmic segment aneurysms arising from the internal carotid artery dorsal wall at, or distal to, the OA origin, with a superior or superomedial projection. The relationship between OA origin and the aneurysm was classified as follows: type A, OA originating separate from the aneurysm; type B, OA originating from the aneurysm neck or dome. Patients with aneurysm were divided into the PED-only group and the PED + coils group according to treatment.

RESULTS

The median follow-up time was 6.8 months (range, 5.3-20.2 months). There were 163 occluded aneurysms (84%) and 31 aneurysms with incomplete occlusion (16%). A multivariate analysis showed that type B aneurysm was a risk factor for incomplete occlusion in the PED-only group (odds ratio [OR] 4.854, 95% confidence interval [CI] 1.878-12.548, P = 0.001). Visual symptoms at final follow-up correlated with preoperative visual symptoms (OR 22.777, 95% CI 3.115-166.555, P = 0.002).

CONCLUSIONS

Type B aneurysm is associated with a lower occlusion rate after PED-only treatment. Patients with preoperative visual symptoms should be treated promptly to avoid permanent visual symptoms.

Extradural anterior clinoidectomy versus endoscopic transplanum-transcavernous approach to the paraclinoid region: quantitative anatomical exposure analysis

BACKGROUND

Transcranial anterior clinoidectomy is a conventional microsurgical approach for treatment of paraclinoid aneurysms. The endoscopic endonasal approach (EEA) is an alternative method for clipping intracranial aneurysms. No analysis has been conducted to anatomically compare approaches with respect to treating paraclinoid aneurysms. The surgical anatomical exposures of the paraclinoid region during transcranial extradural anterior clinoidectomy (EAC) and the endoscopic endonasal transplanum-cavernous approach (EETC) are described and quantitatively assessed.

METHOD

Seven cadaveric heads underwent EAC and EETC. Measurements included the area of exposure, volume of surgical freedom, angle of attack, ophthalmic artery (OphA) origin, and coronal exposure angle of the internal carotid artery (ICA).

RESULTS

The EETC provided a larger area of exposure than the EAC (100.1±24.9 vs 76.1±12.9 mm², p = 0.04). The EAC provided a higher volume of surgical freedom and greater angle of attack than the EETC in all neurovascular parameters, including the OphA, superior hypophyseal artery (SHA), distal ICA, and distal dural ring (all p < 0.001). The OphA origin was intradural in 85.7% and extradural in 14.3% of specimens. With regard to the coronal angle of exposure, the EAC exposed the OphA and SHA in the upper lateral quadrant (67.9±7.8° and 80.6±4.5°, respectively) and the distal ICA in the upper medial and upper lateral quadrants (92±7.5°). The EEA exposed the OphA, SHA, and distal ICA in the upper medial and lower medial quadrants (130.4±10.7°, 68.4±10.8°, and 58±11.4°, respectively).

CONCLUSIONS

The EAC and EETC each offer specific advantages for paraclinoid region exposure. The EAC is appropriate for paraclinoid aneurysms that occur at the dorsolateral surface of the paraclinoid ICA. The EETC is an alternative approach for aneurysms that occur along medial surface of the paraclinoid ICA (e.g., carotid cave and SHA aneurysms). The EETC provides greater surgical exposure to the medial aspect of the paraclinoid ICA.

Flow diversion for internal carotid artery aneurysms with compressive neuro-ophthalmologic symptoms: clinical and anatomical results in an international multicenter study

BACKGROUND

Scientific data on the safety and efficacy of flow diverter stents (FDS) for the treatment of unruptured internal carotid artery (ICA) aneurysms with compressive neuro-ophthalmological symptoms are scarce. We studied this subject in a retrospective international multicenter series, pooling data of 9 tertiary care neurointerventional departments.

OBJECTIVE

To investigate, in a retrospective, multicentric cohort of patients presenting with visual or oculomotor symptoms attributed to a compressive carotid artery in an unruptured intracranial aneurysm, the safety and efficacy profiles of FDS, by analyzing neuro-opthalmologic symptom evolution following FDS placement, complications, and aneurysm obliteration rates.

METHODS

All patients treated since 2015 with a FDS for an unruptured aneurysm of the ICA with signs of compressive cranial nerve symptoms (CN II, III, IV, VI) were included.

RESULTS

We treated 55 patients with 55 aneurysms; 21 (38.2%) patients had oculomotor and 15 (27.3%) visual symptoms only; 19 (34.5%) presented with a combination of both. Treatment-related morbidity/mortality occurred in 7.2% and 3.6%, respectively. At last imaging follow-up (13.1±10.5 months) rates of complete aneurysm occlusion, neck remnant, and aneurysm remnant were 72%, 14%, and 14%, respectively. At last clinical follow-up after 13±10.5 months, 19/51 (37.3%) patients had recovered completely and 18/51 (35.3%) had recovered at least partially from their neuro-ophthalmological symptoms. In multivariable models, a longer delay between symptom onset and treatment was associated with higher odds for incomplete recovery and lower odds for any improvement (aOR 1.03 (95% CI 1.01 to 1.07), p=0.047 and 0.04 (0-0.81), p=0.020). Incomplete recovery was independently associated with older age and fusiform aneurysms.

CONCLUSION

FDS are effective to treat patients with compressive aneurysms of the ICA causing neuro-ophthalmological symptoms, especially when treatment is initiated early after symptom onset, and aneurysm occlusion is adequate. However, serious complications are not rare.

Impact of Anterior Clinoidectomy on Visual Function After Paraclinoid Carotid Artery Aneurysm Surgery: Power-Drill Versus No-Drill Technique

BACKGROUND

Few studies have attempted to make a direct comparison of the risk of visual impairment following extradural anterior clinoidectomy (EAC) with and without the use of a power drill.

OBJECTIVE

To evaluate postoperative visual outcomes between groups of patients with paraclinoid carotid artery aneurysms (PCAAs) who underwent surgical clipping with and without the use of a power drill during EAC.

METHODS

Between January 2010 and November 2019, 90 patients, 7 with ruptured and 83 with unruptured PCAAs, underwent clipping surgery at our hospital. The authors retrospectively analyzed postoperative visual complications from the medical records of these patients.

RESULTS

Among the 85 patients (excluding 3 patients with disturbance of consciousness caused by subarachnoid hemorrhage and 2 patients with preoperative visual disturbance) evaluated, EAC was conducted using a power drill in 64 patients and using a microrongeur in 21 patients. Permanent postoperative visual impairment developed in 14 (21.9%) patients in the drill group: 9 patients had ipsilateral lower nasal quadrant hemianopsia (ILNQH) and 5 patients had ipsilateral visual acuity reduction. Transient ILNQH developed in only 1 patient in the no-drill group. The incidence of permanent postoperative visual impairments was significantly lower in the no-drill group than in the drill group (P = .020). Seventeen (26.6%) patients developed transient oculomotor nerve palsy in the drill group, while no patients developed oculomotor nerve palsy in the no-drill group.

CONCLUSION

EAC using a microrongeur versus a power drill significantly improved visual outcomes after clipping surgery for PCAAs.

Balloon-Assisted Coils Embolization for Ophthalmic Segment Aneurysms of the Internal Carotid Artery

Objective: To explore the role of balloon-assisted coils technique for ophthalmic segment aneurysms (OSAS).

Methods: Clinical data of 30 patients with OSAS were reviewed between December 2017 and December 2018. OSAS were defined as arising from the internal carotid artery (ICA), reaching from the distal dural ring to the origin of the posterior communicating artery. OSAS were classified into four types based on the angiographic findings. The balloon-assisted coils technique was used for the embolization of aneurysms. The duration of balloon inflation cycles, as well as difficulty and complications during the embolization procedure, were recorded. The immediate angiographic results were evaluated according to the Raymond scale. Clinical results were evaluated based on the MRS score. Follow-ups were performed at 18 months post-embolization by DSA or MRA at our institution.

Results: Thirty-two aneurysms in 30 patients were detected by digital subtraction angiography (DSA), which included 30 unruptured and two ruptured cases. The patients with ruptured aneurysms were grade II status according to the Hunt-Hess scale. Three cases were type A, nine cases were type B, 17 cases were type C, and three cases were type D. According to aneurysm size, there were 19 cases of small, 11 cases of medium, two cases of large aneurysm. Thirty-two aneurysms were successfully embolized in 30 patients by balloon-assisted coils technique. The ophthalmic artery could be protected by an engorged balloon in the procedure, especially for type A aneurysms. Considering that type D aneurysm arises from the side-wall of the artery and near to tortuous ICA siphon, the balloon catheter was inflated to stabilize the microcatheter allowing for overinflation when necessary. The average duration of balloon dilatation was 4 min, and the average time was 2.5 times. Raymond class was one in 28 aneurysms and two in four aneurysms according to the immediate post-embolization angiographic results. All the patients achieved good clinical effects, except for one patient who presented with brain ischemia resulting in dizziness and contralateral limb weakness for 10 h due to prolonged temporary clamping of the responsible ICA. The follow-up angiography results were satisfactory at 18 months post-embolization.

Conclusion: OSAS endovascular treatment with balloon-assisted coils has different advantages in a different classification. The technique is safe, effective, and relatively inexpensive, especially for small and medium OSAS.

Endovascular Treatment for Lateral Wall Paraclinoid Aneurysms and the Influence of Internal Carotid Artery Angle

Lateral wall paraclinoid aneurysms (LPA) are a rare type of aneurysm located on the lesser curve side of the internal carotid artery (ICA) bend, at the level of the anterior clinoid process. The objective of this study was to assess the influence of flexion of the ICA on the morphology of aneurysms and outcome of endovascular treatment. Between 2003 and 2018, we treated 643 cases of unruptured paraclinoid aneurysms with endovascular therapy in our institution. Of those cases, aneurysms projecting laterally on preoperative angiography were defined as LPA. The degree of bending of the ICA (ICA angle) was measured and statistically analyzed in relation to the aneurysm characteristics and the occlusion status after treatment. In all, 43 aneurysms were identified. ICA angle was positively correlated with the maximum dome size of the aneurysm (P <0.01) and the aspect ratio (P <0.01), and negatively correlated with the volume coil embolization ratio (P <0.01). Complete occlusion (CO) was achieved in 23 cases (53.5%) immediately after treatment, and in 35 cases (81.4%) at follow-up. The mean ICA angle in the incomplete occlusion group was significantly larger than in the CO group (P = 0.01). Larger ICA angle resulted in recurrence, whereas smaller ICA angle was more likely to obtain progressive thrombosis (P = 0.02). Endovascular treatment for LPA was safe and effective. The degree of flexion of the ICA may contribute to the level of hemodynamic stress on the aneurysm, its morphology, and the embolization effect.

Whether Intracranial Aneurysm Could Be Well Treated by Flow Diversion: A Comprehensive Meta-Analysis of Large-Sample Studies including Anterior and Posterior Circulation

BACKGROUND

Flow diversion (FD) has become a widely adopted treatment method for intracranial aneurysms in the clinic, but a comprehensive meta-analysis of large-sample studies including anterior and posterior circulation is still lacking.

METHODS

The PubMed, Embase, Web of Science, and Cochrane databases were searched between January 1, 2008, and December 1, 2019. A random-effect model was used to calculate the efficacy and safety data as well as 95% confidence intervals (CIs).

RESULTS

The pooled sample size of all included studies was 6695 patients; the mean age was 55.5 years old, with a total of 7406 aneurysms. For efficacy, the complete occlusion rate in angiographic follow-up (AFU) at 6 months was 78% (95% CI, 0.77, 0.80), and the AFU rate at 6-12 months was 90% (95% CI, 0.88, 0.92). For safety, the hemorrhagic event rate was 2%, the ischemic event rate was 5%, and the mortality rate was 3%.

CONCLUSION

FD is an effective and safe treatment for intracranial aneurysm with high complete occlusion rate and acceptable complication rate.

Open-cell stent-assisted coiling for the treatment of paraclinoid aneurysms: traditional endovascular treatment is still not out of date

PURPOSE

Before we enter the era of flow diverter stents (FDS), the standard stent-assisted coiling technique is a well-established treatment option for routine paraclinoid aneurysms. We assess the clinical safety and efficacy of stent-assisted coiling with open-cell stent in the treatment of paraclinoid aneurysms and evaluate the association between clinical factors and follow-up aneurysm occlusion.

METHODS

The clinical and radiographic data of 110 consecutive patients with 122 paraclinoid aneurysms treated with open-cell stent between April 2015 and April 2019 were analyzed retrospectively at our center. We assessed the immediate and progressive occlusion rates, complications, and clinical outcome. Multivariate analysis was performed to investigate the risk factors of angiographic incomplete occlusion.

RESULTS

Among 110 patients, stent-assisted coiling was successfully performed in all cases. Four (3.6%) thromboembolic events were reported during the procedure, which resulted in transient morbidity. Immediate angiography demonstrated complete occlusion in 64 (52.5%) aneurysms and no occlusion of ophthalmic artery. Angiographic follow-up at 6 months demonstrated an increase in the complete occlusion rate to 92.9%. No delayed in-stent stenosis was observed, and three aneurysms recurred. Clinical follow-up was completed in 102 patients (92.7%), and favorable outcomes were achieved in 101 (99%) patients at 6 months. Multivariate analysis showed that aneurysm size (p < 0.001) was associated with incomplete aneurysm occlusion at follow-up.

CONCLUSION

Stent-assisted coil embolization with open-cell stents is safe and effective for the treatment of paraclinoid aneurysms and provides progressive occlusion without significant in-stent stenosis events.

The Minimum Distance May Affect Perioperative Complications and Completed Occlusions of Endovascular Treatment for Tandem Intracranial Aneurysms: A Multi-Institutional Retrospective Study

BACKGROUND

Tandem aneurysms (TAs) are a distinct type of multiple intracranial aneurysms (IAs), the treatment strategies for which remain controversial. We aimed to reveal the clinical and angiographic outcomes of endovascular treatment as well as their risk factors in these complex multiple IAs.

METHODS

This multicenter, retrospective follow-up study was carried out in 3 hospitals in China. In total, clinical and angiographical data of 137 patients with 145 lesions (7 patients had bilateral lesions) and 315 TAs were collected. The treatment strategies were divided into full or partial treatment, single- or multiple-session treatment, and coiling (including single coiling and stent-assisted coiling)- or flow-diverting stent (FDS) treatment. Perioperative complications, as well as angiographic and clinical outcomes and their risk factors, were analyzed using univariate analysis and a multiple regression model.

RESULTS

Of treated TA lesions, 17 (16.0%) perioperative complications were found. Significant differences were found between the single- and multiple-session treatment groups (p = 0.012). At the latest follow-up, there were no significant differences in the modified Raymond Scale scores between different treatment groups. Significant differences were found in the embolization degree between the coiling and FDS groups (p = 0.038) and between the single common stent (without coiling) and the other treatment groups (p < 0.001). In IAs managed by a single LVIS stent (without coiling), 60% achieved improved or completed occlusion. Multivariate regression analysis found that a shorter minimum distance (odds ratio [OR] 5.967, 95% confidence interval [CI] 1.366-26.074; p = 0.018), multiple-session treatment (OR 9.961, 95% CI 1.707-58.127; p = 0.011), and diabetes (OR 8.106, 95% CI 1.928-34.084; p = 0.004) were predictors of perioperative complications, while shorter minimum distance (OR 5.619, 95% CI 1.493-21.152; p = 0.011), greater diameter ratio (OR 3.621, 95% CI 1.014-12.937; p = 0.048), and greater size ratio (OR 2.424, 95% CI 1.007-5.834; p = 0.048) were predictors of low completed occlusion rate.

CONCLUSIONS

Both coiling and FDS can be utilized safely and can achieve similar clinical outcomes. FDS and LVIS are recommended for IAs that do not require embolization but cannot be prevented from being covered by stents. A multiple-session treatment may increase the treatment risk, and the minimum distance may affect the incidence of perioperative complications and completed occlusions. Further hemodynamic and prospective studies on such TAs in close proximity to one another are needed.

LATE ANEURYSM RELAPSE AFTER MICROSURGICAL TREATMENT OF MIDDLE CEREBRAL ARTERY ANEURYSM: A CASE REPORT AND LITERATURE REVIEW OF TREATMENT OPTIONS

Recurrence of intracranial aneurysm after initial microsurgical or endovascular treatment is uncommon. Although the exact etiology remains unknown, recurrent aneurysms may be observed in surgical patients with big and multiple aneurysms, arterial hypertension, non-atherosclerotic cerebrovascular arteriopathies, as well as in those with a familial history of the disease. Such recurrence can occur over a wide period ranging from several months to years after the initial aneurysm treatment. Still, the occurrence delayed by more than 20 years is rather unusual. Herein, we present a case of a 70-year-old female patient who developed late intracranial aneurysm relapse 30 years after successful microsurgical clipping of the middle cerebral artery aneurysm. We also provide a brief review of relevant literature, discussing the etiology and pathophysiology of aneurysm reappearance, as well as different treatment options available. In conclusion, one should always consider the possibility of intracranial aneurysm recurrence regardless of the mode and time of primary surgery. In such a case, a multidisciplinary management approach using flow diverting endovascular techniques is advised in selected patients.

Flow diversion for internal carotid artery aneurysms: Impact of complex aneurysm features and overview of outcome

OBJECTIVE

Flow diversion is a popular technique used to treat ordinary small, as well as complex internal carotid artery (ICA) aneurysms. We describe aneurysm occlusion rates, complications and patient outcomes in patients with ICA aneurysms treated with flow diverter stents.

PATIENTS AND METHODS

We identified all consecutive patients with ICA aneurysms that were treated with flow diverter stents between 2014 and 2019 at our institution. We divided the aneurysms into two anatomic subgroups (cavernous and supraclinoid segments). All the imaging studies and medical records were reviewed for relevant features in relation to aneurysms, complications and patient outcomes.

RESULTS

A total of 62 patients with 76 ICA aneurysms (72 unruptured; 4 ruptured) were treated with 70 flow diversion procedures, including six re-treatments. Complete aneurysm occlusion was achieved in 61 % of patients at 6-month follow-up (cavernous 69 %, supraclinoid 58 %), and in 69 % at the latest follow-up (mean of 18 months). Postprocedural intracranial ischemia or hemorrhage was seen in 24 % of patients, including two aneurysm ruptures after flow diversion, and related major long-term functional decline or mortality was seen in 6% of patients. Preprocedural dysfunction of extraocular muscles or vision disturbance improved moderately at best (40-60 %). At the latest follow-up, 54 patients (87 %) were functionally independent (mRS ≤2).

CONCLUSION

Flow diversion for cavernous and supraclinoid ICA aneurysms demonstrated acceptable results, but complex aneurysm features cause uncertainty in predicting aneurysm occlusion probability. Patients should be informed of the non-negligible rate of complications, and of only moderate improvement rate of cranial nerve dysfunctions.

Lower limb weakness with gyrus rectus hematoma: an unusual presentation of paraclinoid aneurysm; a case report with review of literature

Lower limb weakness is usually a feature of ruptured anterior communicating (ACom) aneurysms due to spasm of the anterior cerebral arteries. Paraclinoid aneurysms, in addition to other cardinal features of subarachnoid haemorrhage (SAH), usually present with headache and visual field defects due to compression of the optic pathway. We report a case of left paraclinoid aneurysm presenting with right lower limb weakness and gyrus rectus hematoma without SAH. The aneurysm was long, passing beneath the optic nerve to emerge in the inter-optic cistern, leading to such atypical presentation. The aneurysm was clipped successfully after drilling the clinoid. As per our knowledge, such a clinical presentation of paraclinoid aneurysm has not been reported in the literature till date.

Variation of Mass Effect After Using a Flow Diverter With Adjunctive Coil Embolization for Symptomatic Unruptured Large and Giant Intracranial Aneurysms

Background: Mass effect associated with large or giant aneurysms is an intractable problem for traditional endovascular treatments. Preventing recurrence of aneurysms requires dense coiling, which may aggravate the mass effect. However, the flow diverter (FD) is a new device that avoids the need for dense coiling. This study was performed to investigate whether use of FDs with adjunctive coil embolization can relieve the aneurysmal mass effect and to explore the factors that affect the variation of compressional symptoms.

Methods: We retrospectively evaluated patients with compressional symptoms caused by unruptured aneurysms who underwent endovascular treatment with an FD with adjunctive coil embolization at our center from January 2015 to December 2017. Imaging follow-up included digital subtraction angiography (DSA) ranging from 11 to 14 months and magnetic resonance imaging (MRI) ranging from 24 to 30 months; the former was used to evaluate the intracavitary volume, and the latter was used to measure the variation of the mass effect. Follow-up physical examinations were performed to observe variations of symptoms.

Results: In total, 22 patients with 22 aneurysms were treated by an FD combined with coil embolization. All 22 patients underwent the last clinical follow-up. Regarding compressional symptoms, 12 (54.54%) patients showed improvement, 6 (27.27%) were fully recovered, and 6 (27.27%) showed improvement but with incomplete cranial palsy. However, five (22.72%) patients showed no change, four (18.18%) showed worsening symptoms compared with their preoperative state, and one (4.55%) died of delayed rupture. Seventeen of the 22 patients underwent MRI. Of these 17 patients, the aneurysm shrank in 13 (76.47%) and no significant change occurred in 4 (23.53%). In the multivariate analysis, a short duration from symptom occurrence to treatment (p = 0.03) and younger patient age (p = 0.038) were statistically significant factors benefiting symptom improvement, and shrinkage of the aneurysm was associated with favorable clinical outcomes (p = 0.006).

Conclusions: Use of the FD with adjunctive loose coil embolization might help to alleviate the compressional symptoms caused by intracranial aneurysms. Shrinkage of the aneurysm, a short duration of symptoms, and younger patient age might contribute to favorable outcomes of mass effect-related symptoms.