Stent-assisted coiling of complex middle cerebral artery aneurysms: initial and midterm results

Low incidence of hemorrhagic complications both during and after surgical procedures in patients maintained on prasugrel single antiplatelet therapy

BACKGROUND AND PURPOSE

Prasugrel (Pra) is a third-generation thienopyridine that inhibits platelet aggregation via irreversible blockade of P2Y12 receptors. While several published studies have examined the use of Pra and acetylsalicylic acid (ASA) in coronary and neurovascular stenting procedures, there is only anecdotal evidence regarding the use of Pra as single antiplatelet therapy (SAPT) in open surgical procedures. This topic has become important because previous studies have revealed that neurovascular devices with antithrombotic coatings can be implanted using non-invasive procedures in patients maintained on Pra SAPT.

MATERIAL AND METHODS

Patients who underwent open surgery under Pra SAPT between March 2020 and February 2022 were evaluated retrospectively. Adequate platelet inhibition both before and after the procedures was verified in all patients using Multiplate (Roche Diagnostics) and VerifyNow (Accriva) tests. Intraoperative and postoperative hemorrhagic events were recorded based on reviews of the procedure reports and interviews with the surgeons.

RESULTS

The study enrolled 21 patients who underwent 23 open surgical procedures while maintained on Pra SAPT. The procedures included one extirpation of a brain arteriovenous malformation, seven extra-intracranial bypass surgeries, four ventriculoperitoneal shunts, one eye enucleation for an intractable orbital infection, two gastrostomies, one bone flap reinsertion after craniectomy, one decompressive craniectomy, one case requiring cranial surgical wound care, one colporrhaphy, one transurethral resection of urinary bladder cancer, two tumor oophorectomy/hysterectomy procedures, and one aneurysm clipping. None of the 23 procedures resulted in excessive intraoperative or postoperative hemorrhage.

CONCLUSION

In a small retrospective series of patients who required antiplatelet therapy for neurovascular indications, Pra SAPT resulted in no significant increase in the incidence of perioperative and postoperative hemorrhagic complications.

Bifurcated Aneurysm Location Predicts In-Stent Stenosis After Neuroform-EZ Stent-Assisted Coiling for Intracranial Aneurysm

Background and Purpose

The Neuroform EZ stent system (Boston Scientific Corporation, Fremont, CA, United States) is a fourth-generation intracranial aneurysm stent designed specifically for the cerebrovasculature to support aneurysm treatment. In this study, we analyzed our consecutive series of patients with aneurysm treated with the Neuroform EZ stent, with special attention to the occurrence of in-stent stenosis (ISS).

Methods

A retrospective review of our center's electronic database was conducted to identify all patients with intracranial aneurysms who underwent aneurysm treatment with the Neuroform EZ stent between January 2016 and October 2018. Patients with at least one digital subtraction angiography (DSA) follow-up in our hospital were enrolled in this study. In-stent stenosis (ISS) was graded as mild (<2–5%), moderate (25–50%), or severe (>50%).

Results

The study included 114 patients (78 women, 68.4%; median age 57.2 ± 9 years) with a total of 116 aneurysms. Of the 116 lesions, 20 were identified with ISS (17.2%) at a mean follow-up of 6.9 ± 1.7 months, and ISS was mild in 30% (6/20), moderate in 50% (10/20), and severe in 20% (4/20). No patients were symptomatic or required further intervention. Patients who developed ISS were younger than those without ISS (52.6 ± 7.8 vs. 57.9 ± 9; p = 0.016). The proportion of aneurysms located at the artery bifurcation was significantly higher in patients with stenosis than located at the sidewall artery (37.9 vs. 10.3%; p = 0.002). In the multivariable analysis, the patients' age (OR = 0.94; 95% CI 0.88–0.998; p = 0.02) and bifurcated aneurysm location (OR = 4.59; 95% CI 1.54–13.67; p = 0.006) were independent predictors of ISS.

Conclusions

In this retrospective study, the incidence of ISS after Neuroform EZ stent placement was 17.2%, and all the ISS cases were asymptomatic. Patients with younger age and bifurcated aneurysm location are more likely to develop ISS. Although Neuroform EZ stent is particularly suitable for bifurcated aneurysms, the ISS for this location should be focused upon.

Safety, Efficacy, and Durability of Stent-Assisted Coiling Treatment of M2 (Insular) Segment MCA Aneurysms

BACKGROUND AND PURPOSE

Most distal MCA aneurysms are located within the insular segment, which lies between the limen insulae and circular sulcus. However, experience is limited in the microsurgical and endovascular management of insular segment MCA aneurysms. In this multicenter retrospective case series, we aimed to investigate the safety, efficacy, and durability of stent-assisted coiling for treatment of insular segment MCA aneurysms.

MATERIALS AND METHODS

A retrospective review was performed to identify patients with insular MCA aneurysms that were treated with stent-assisted coiling. The technical success of the procedures and the initial and follow-up clinical and angiographic outcomes were assessed. Periprocedural and delayed complications were reviewed.

RESULTS

Twenty-seven aneurysms in 27 patients with a mean age of 53.3 (SD,11.3) years were included. The mean size of the aneurysms was 6.3 (SD 2.6) mm. Endovascular procedures were successfully performed in all patients. Immediate postprocedural angiography revealed complete aneurysm occlusions in 81.5%. Periprocedural complications developed in 7.4% without causing permanent morbidity. A delayed thromboembolic complication resulted in a minor permanent morbidity in 1 patient (3.7%). There was no mortality. The mean duration of angiographic follow-up was 19.5 (SD, 9.8)  months. The last follow-up examinations showed complete occlusion in 92.6%. During the follow-up period, none of the treated aneurysms showed recanalization.

CONCLUSIONS

The results of this study demonstrate that stent-assisted coiling with a low-profile self-expandable stent is a feasible and relatively safe technique for endovascular treatment of insular segment complex MCA aneurysms. Additionally, it provides an effective and durable treatment for insular MCA aneurysms.

Efficacy and safety of endovascular therapy versus surgical clipping for patients with unruptured middle cerebral artery bifurcation aneurysms

This study aims to evaluate the efficacy and safety of endovascular therapy versus neurosurgical clipping carried out for patients with unruptured middle cerebral artery bifurcation aneurysms (MCABAs). Patients diagnosed with MCABAs were enrolled in this prospective study according to the inclusion and exclusion standard. Enrolled patients were divided into a study group (endovascular therapy) and a control group (neurosurgical clipping), with 65 cases in each group. In terms of efficacy, we found that the proportion of Glasgow Outcome Scale (GOS) grade 1 after treatment in the study group was significantly higher than in the control group (p<0.001), while the proportion of GOS grades 2, 3, and 4 after treatment was significantly lower in the study group than in the control group (p<0.05). The postoperative brain injury indicators neuron-specific enolase and S100β in the study group were significantly lower than in the control group (p<0.001), and the postoperative life activity score of patients in the study group was significantly higher than in the control group (p<0.001). In terms of safety, the postoperative hospital stay of patients in the study group was significantly shorter than in the control group (p<0.001), and the incidence rate of postoperative pulmonary and intracranial infections in the study group was significantly lower than in the control group (p<0.05). Endovascular therapy for patients with unruptured MCABAs may be effective in improving outcomes and has better safety profile compared with neurosurgical clipping, but may increase the risk of postoperative recurrence.

Safety and Long-Term Efficacy Outcomes for Endovascular Treatment of Wide-Neck Bifurcation Aneurysms of the Middle Cerebral Artery: Insights From the SMART Registry

Introduction

Wide-necked middle cerebral artery bifurcation aneurysms pose specific challenges to endovascular management. Surgical clipping remains the standard treatment approach for these aneurysms in many centers. While recent data suggests the endovascular treatment may be comparable, a prospective datapoint has been lacking.

Materials and Methods

The Penumbra SMART registry, a prospective, multi-center, single-arm outcomes registry of Penumbra coil-treated aneurysms, was queried for endovascularly treated MCA bifurcation aneurysms with wide necks (dome:neck ratio <2 or neck >4 mm). Safety and efficacy outcomes were summarized for ruptured and unruptured aneurysms, including rupture, complication rate, and 1-year occlusion outcomes.

Results

Seventy-two aneurysms across 31 sites were enrolled. Of these, a total of 15 presented as ruptured aneurysms. Serious adverse events were reported in 21 (29.2%) of patients, with 8 (11.1%) attributed to the device/procedure. Immediately postoperatively, 75.0% of cases achieved “adequate” Raymond Roy Class I (40.3%) or II (34.7%) occlusion outcomes. Of the 72 patients treated, 60 (83.3%) underwent follow-up angiography at 1 year, and among these, 95.0% had 1-year occlusion outcomes of Raymond Roy Class I (71.7%) or II (23.3%). A total of 6 aneurysms (10.0%) were required or were planned for retreatment at the last follow-up.

Conclusion

This study represents the most significant prospective sample of endovascularly treated wide-neck MCA bifurcation aneurysms conducted to date. It supports the safety and efficacy of endovascular treatment of these aneurysms.

Endovascular management of middle cerebral artery aneurysms (single-center case series study)

Background

Middle cerebral artery (MCA) aneurysms were usually subjected to treatment by surgery, while endovascular treatment (EVT) was performed only in chosen patients. We assessed the efficacy, safety, and durability in addition to the clinical outcome of EVT when it is regarded as the first-line treatment modality for MCA aneurysms.

Results

We recruited 30 patients with MCA aneurysms who underwent definitive management from July 2017 to July 2018. All those patients were treated endovascularly; 22 patients (73.3%) presented with subarachnoid hemorrhage, and 8 patients (26.7%) had different presentations, including isolated headaches and seizures. EVT was performed for all patients and required the use of a balloon, stent, or double catheter techniques in 13 cases and flow diverter stents alone in two cases. Clinical outcome was assessed by the modified Rankin Scale (mRS) at 3 months. Angiographic follow-up was done by a conventional angiography at 6 months and after 1 year. EVT was efficiently conducted, leading to an outstanding accomplishment (mRS = 1–2) in 29 patients. However, one patient had a thromboembolic complication, followed by death after severe chest infection that was not related to the procedure. Immediate anatomical results included complete aneurysmal occlusion with the establishment of normal cerebral circulation. Angiographic follow-up revealed 24 unchanged occlusions and 5 cases with recanalization that required further treatment.

Conclusion

EVT of MCA aneurysms is a viable treatment option with positive outcomes in most cases. Nevertheless, the employment of long-term imaging follow-up is compulsory for validating such early results, often with respect to anatomical and functional stability.

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.

Stent-Assisted Coiling of Unruptured MCA Aneurysms Using the LVIS Jr. Device: A Multicenter Registry

Purpose: The low-profile visualized intraluminal support junior (LVIS Jr.) is a new generation low-profile braided stent. Our aim was to evaluate the safety and efficacy of the LVIS Jr. in the stent-assisted coiling of unruptured middle cerebral artery (MCA) aneurysms. This was a multicenter retrospective study. Patient demographics, aneurysm characteristics, procedural details, complications, and the results of clinical and imaging follow-up were analyzed. Four centers participated in the study. A total of 162 consecutive patients with 162 unruptured MCA aneurysms were included for the analysis. The mean aneurysm size was 7.6 mm (range 2 to 37 mm) and 97.5% were wide-necked. Immediate postprocedural angiograms showed Raymond-Roy class 1 in 118 (72.8%), class 2 in 23 (14.2%), and class 3 in 21 patients (13%). Periprocedural complications occurred in 14 patients (8.6%). There were no procedure-related deaths. Follow-up imaging at 12–18 months post-procedure showed Raymond–Roy class 1 in 132 (81.5%), class 2 in 17 (10.5%), and class 3 in 13 patients (8%). There were 3 cases of in-stent stenosis (1.9%). All 162 patients had good clinical outcome (mRS score 0–2) at 90 days post-procedure. Stent-assisted coiling of unruptured MCA aneurysms with the LVIS Jr. stent is safe and effective, with high immediate and long-term total occlusion rates.

Impact of aneurysm shape and neck configuration on cerebral infarction during microsurgical clipping of intracranial aneurysms

OBJECTIVE

Cerebral infarction is a significant cause of morbidity and mortality related to microsurgical clipping of intracranial aneurysms. The objective of this study was to determine the impact of aneurysm shape and neck configuration on cerebral infarction after aneurysm surgery.

METHODS

The authors retrospectively reviewed consecutive cases of ruptured and unruptured aneurysms treated with microsurgical clipping at their institution between 2010 and 2018. Three-dimensional reconstructions from preoperative computed tomography and digital subtraction angiography were used to determine aneurysm shape (regular/complex) and neck configuration (regular/irregular). Morphological and procedure-related risk factors for cerebral infarction were identified using univariate and multivariate statistical analyses.

RESULTS

Among 243 patients with 252 aneurysms (148 ruptured, 104 unruptured), the overall cerebral infarction rate was 17.1%. Infarction tended to occur more often in aneurysms with complex shape (p = 0.084). Likewise, aneurysms with an irregular neck had a significantly higher rate of infarction (37.5%) than aneurysms with regular neck configuration (10.1%, p < 0.001). Aneurysms with an irregular neck were associated with a higher rate of intraoperative rupture (p = 0.003) and temporary parent artery occlusion (p = 0.037). In the multivariate analysis, irregular neck configuration was identified as an independent risk factor for infarction (OR 4.2, 95% CI 1.9-9.4, p < 0.001), whereas the association between aneurysm shape and infarction was not significant (p = 0.966).

CONCLUSIONS

Irregular aneurysm neck configuration represents an independent risk factor for cerebral infarction during microsurgical clipping of both ruptured and unruptured aneurysms.

Long-Term Outcomes of the WEB Device for Treatment of Wide-Neck Bifurcation Aneurysms

BACKGROUND AND PURPOSE

Treatment of wide-neck bifurcation aneurysms using endovascular therapy is still challenging even with the development of treatment devices. The purpose of this investigation was to assess the safety and efficacy of treatment with a Woven EndoBridge (WEB) device for wide-neck bifurcation aneurysms.

MATERIALS AND METHODS

All patients treated with a WEB device at our institution between May 2009 and November 2016 were retrospectively evaluated. Clinical and imaging evaluation, aneurysm occlusion status, and modified Rankin scale score were analyzed 1 day after treatment and in the short- (<6 months), mid- (<24 months), and long-term (>24 months) follow-up periods.

RESULTS

Forty-one cases of wide-neck aneurysms were analyzed in this study. Overall, 78.8% of the aneurysms had complete occlusion in the last follow-up, and 19.5% required retreatment with additional endovascular devices. A good clinical outcome (modified Rankin scale: 0-2) was obtained in 95.1% of the patients, and the overall treatment-related morbidity and mortality rates were 2.4% and 0.0%, respectively. The mean follow-up time was 15.3 ± 13.5 months.

CONCLUSIONS

The results obtained in this study suggest that treatment of wide-neck bifurcation aneurysms with a WEB device is feasible with an acceptable safety and efficacy rate.

Flow-T stenting with the Silk Vista Baby and Baby Leo stents for bifurcation aneurysms - A novel endovascular technique

We present the first case using a novel flow diverter, the Silk Vista Baby (Balt, Montmorency, France), in combination with a low-profile braided stent, the Baby Leo (Balt, Montmorency, France), in a T configuration that we term Flow-T. We describe the technical characteristics of the case as well as the early follow-up results. We believe that this combination may provide an alternative to standard T-stenting and alternative to treat bifurcation aneurysms.

Natural history and clinical outcomes in patients with complex intracranial aneurysms: a review of 115 bypass cases and 22 nonsurgical cases

The purpose of this study was to evaluate the natural history of patients with these heterogeneous aneurysms to provide guidance for their treatment. This retrospective analysis was performed at a single institution and included 137 patients with complex intracranial aneurysms who underwent a natural history evaluation. Among the 115 patients who underwent bypass surgery, stroke (n = 39, 33.9%) was the most common clinical symptom followed by progressively severe headaches (n = 25, 21.7%). Of the 104 patients with follow-up information, 87 (83.7%) returned to a normal life within a mean follow-up of 4.17 ± 2.09 years. Ten deaths (9.6%) occurred after a mean of 1.3 ± 0.9 years. Among the 22 patients who selected nonsurgical treatment, mass effect (n = 9, 40.9%) was the most common clinical presentation, and 14 deaths (63.6%) occurred after a mean of 3.3 ± 2.5 years. The modified Rankin scale (mRS) scores of 5 survivors (5/22, 22.7%) progressed from 0-2 at initial presentation to 3-4. Bypass surgical treatment for these aneurysms appears to be effective and can achieve good clinical outcomes without additional limitations related to individual aneurysms despite the impact of recent endovascular techniques on vascular surgery.

Long Term Outcome of In-Stent Stenosis after Stent Assisted Coil Embolization for Cerebral Aneurysm

Objective

The objective of this study was to evaluatelong-term radiologic prognosis and characteristics of in-stent stenosis (ISS) after stent assisted coiling (SAC) for cerebral aneurysm and analyze its risk factors.

Methods

Radiological records of 362 cases of SAC during 10 years were retrospectively reviewed. Patients were included in this study if they had follow-up angiogram using catheter selected angiography at least twice. All subjected were followed up from 12 months to over 30 months. Of 120 patients, 123 aneurysms were enrolled. Patient data including age, sex, aneurysm size, neck size, procedural complication, kinds of stent, ISS associated symptom, ruptured state, location of ISS, degree of ISS, radiologic prognosis of ISS, follow-up period of time, and medical comorbidities such as hypertension, diabetes mellitus (DM), dyslipidemia, and smoking were collected.Statistical comparisons of group clinical characteristics were conducted for the total population.

Results

Among 123 casesof aneurysm, 22 cases (17.9%) of ISS were revealed on follow-up angiography. Multiple stenting was performed in three cases and intra-procedural rupture occurred in two cases. Most cases were asymptomatic and symptomatic stenosis was identified in only one case. Sixteen cases were ruptured aneurysm. Mild stenosis was observed in 11 cases. Moderate stenosis was found in eight cases and severe stenosis was identified in three cases. Mean timing of identification of ISS was 8.90 months. The most common type was proximal type. Most cases were improved or not changed on follow-up angiography. Only one case was aggravated from mild stenosis to occlusion of parent artery. Mean follow-up period was 44.3 months. We compared risk factors and characteristic between ISS group and non-ISS group using univariate analysis. Multiple stenting was performed for three cases (13.6%) of the ISS group and four cases (4.0%) of the non-ISS group, showing no statistical difference between the two groups (p=0.108). Additionally, the proportion of patients who had more than two risk factors among four medical risk factors (hypertension, DM, dyslipidemia, and smoking) was higher in the ISS group than that in the non-ISS group, the difference between the two was not statistically significant either (31.8% vs. 12.9%, p=0.05).

Conclusion

Clinical course and long-term prognosis of ISS might be benign. Most cases of ISS could be improved or not aggravated. Control of medical co-morbidity might be important. To the best of our knowledge, our study had more cases with longer follow-up period of time than other reports.

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.

The pCONUS HPC: 30-Day and 180-Day In Vivo Biocompatibility Results

Background

Endovascular stents are commonly used during neurointerventional procedures; however, the concomitant use of dual anti-platelet treatment (DAPT) can limit their use. There is a need to develop stent coatings that mitigate requirement for DAPT.

Methods

The hydrophilic polymer coating is a novel glycan-based multilayer polymer that inhibits platelet adhesion. After Institutional Animal Care and Use Committee approval, 18 New Zealand white rabbits (mean weight 4.02 ± 0.51 kg) were commenced on DAPT (ASA 10 mg/kg/day and clopidogrel 10 mg/kg/day). A bare nitinol pCONUS and coated pCONUS HPC were implanted into the common carotid arteries of each rabbit. Histological examinations were performed at 30 days (n = 9) and 180 days (n = 8) to assess the acute and chronic inflammatory reactions to the pCONUS HPC. Wilcoxon/Kruskal–Wallis and ANOVA were used with p value < 0.05 considered as significant.

Results

There is no statistically significant difference in inflammation within the intima/media or adventitia at 30 days (p = 0.3901 and p = 1, respectively) or at 180 days (p = 0.144 and p = 1, respectively) between pCONUS and pCONUS HPC cohorts. There is no significant difference in the presence of granulomas or giant cells between the cohorts at either 30 days (p = 1 and p = 0.8363) or 180 days (p = 1.00 and p = 0.149). At 30 days and 180 days, there was near-complete endothelialisation of the stent struts and no significant difference between the pCONUS or pCONUS HPC (p = 0.7832 and p = 0.334, respectively).

Conclusion

pCONUS HPC stents do not elicit an acute or chronic inflammatory response in vivo with no significant difference in the tissue response to bare nitinol pCONUS stents or pCONUS HPC stents.

Evaluation of Acute In-stent Thrombosis during Stent-assisted Coil Embolization of Unruptured Intracranial Aneurysms

Stent-assisted coil embolization (SACE) is used to address wide-necked or complex aneurysms. However, periprocedural and/or late in-stent thrombosis (IST) elicit neurological events. We investigated the incidence and timed the development of acute IST during SACE with braided- or laser-cut stents in a retrospective study. Between May 2013 and April 2018, we evaluated 11 ISTs that occurred in the course of 185 SACE procedures (self-expandable laser-cut stent, n = 128; braided stent, n = 57). The onset of IST was measured from the time of stent placement. All 11 patients with IST were treated with anticoagulants and underwent hypertension induction. Post-procedural neurological events due to IST were also recorded. The implantation of a laser-cut stent elicited IST in 5 of 128 patients (3.9%); braided stent placements resulted in IST in 6 of 57 patients (10.5%) (P = 0.1). The mean stent diameter was significantly smaller in patients with-IST than without IST (3.0 ± 0.9 mm vs. 4.5 ± 0.7 mm, P = 0.007). The mean interval between stent placement and IST onset was 19 ± 7.7 min; it was significantly earlier for braided- than laser-cut stents (17.5 ± 4.1 min vs. 29.0 ± 4.8 min, P = 0.006). All ISTs were resolved during the procedure. Three patients experienced postoperative neurologic events. We recommend the meticulous and prolonged monitoring of images after stent placement because delayed intraoperative IST can occur especially when laser-cut stents are used.

Feasibility and Midterm Outcomes of Endovascular Coil Embolization of an Unruptured Middle Cerebral Artery Aneurysm with an Incorporated Branch

BACKGROUND

Endovascular coiling has emerged as an option for the management of unruptured intracranial aneurysms, which was traditionally treated via surgical clipping. Unlike aneurysms elsewhere, aneurysms of the middle cerebral artery (MCA) have several features that are favorable for surgery. However, endovascular treatment can be difficult for MCA aneurysms, especially if they have incorporated branches. We report the results of coil embolization of incorporated MCA aneurysms.

METHODS

From 2012 to 2017, 129 unruptured aneurysms including 10 incorporated MCA aneurysms were treated. The mean neck, height, and width of the aneurysms were 3.74 ± 1.07, 4.26 ± 1.06, and 3.97 ± 1.03, respectively. The mean aspect ratio, neck/sac width, and sac width/neck were 1.19 ± 0.37, 1.09 ± 0.21, and 0.95 ± 0.18, respectively.

RESULTS

Nine cases of incorporated MCA aneurysms were treated using the double microcatheter technique, whereas the triple microcatheter technique was used in 1 case. There were no procedure-related complications. Postcoiling angiograms showed that 4 aneurysms achieved complete occlusion (40%), 5 had a remnant neck (50%), and 1 had a remnant sac (10%). During the follow-up period, (26.0 ± 4.5 months; range, 3-49 months), there were no incidents of recurrence and bleeding. One patient experienced a small cerebral infarction 1 month after the procedure, but it did not lead to any permanent neurologic deficits.

CONCLUSIONS

Branch-incorporated MCA aneurysms can be treated with coil embolization, with few procedural complications and midterm durability with appropriate techniques and devices.

Treatment of Wide-Necked Bifurcation Aneurysms : Initial Results with the pCANvas Neck Bridging Device

Background

Recently, numerous devices dedicated to the treatment of wide-necked aneurysms have become available. We present our initial experience with the pCANvas device and present the technical success rate, clinical outcome and immediate angiographic occlusion rates.

Objective

We sought to determine the efficacy of flow with the pCANvas for the treatment of unruptured intracranial aneurysms.

Methods

We performed a retrospective review of our prospectively collected data to identify patients treated with the pCANvas device between February 2015 and February 2017. The patient demographics, aneurysm characteristics, immediate and delayed clinical and radiographic follow-up data were recorded.

Results

We identified 17 patients (13 female) treated only with the pCANvas device. The average age of the patients was 60.5 ± 13.3 years (range 25–75 years). The average dome width was 7.6 ± 3.2 mm (range 3–15.8 mm), dome height 7.1 ± 3.2 mm (range 3–12.9 mm) and neck width 5.4 ± 3.2 (range 3–16.3 mm). The average aspect ratio was 1.5 ± 0.8 (range 0.6–3.7). At the end of the procedure 15 aneurysms continued complete filling of the aneurysm (Raymond Roy Classification[RRC] 3) with 2 aneurysms showing only filling of the neck of the aneurysm (RRC 2). Early follow-up angiography was available for 16 patients and at this stage 11 aneurysms showed persistent and complete filling of the aneurysm (RRC 3), 5 aneurysms showed complete occlusion of the aneurysm (RRC 1) and 7 aneurysms underwent repeat treatment with coiling.

Conclusion

The early results on the use of the pCANvas are promising; however, longer term follow-up and larger studies are required.

Treatment of Distal Anterior Circulation Aneurysms With the Pipeline Embolization Device: A US Multicenter Experience

BACKGROUND

Utilization of the Pipeline embolization device (PED) to treat distal carotid circulation aneurysms has not been well studied.

OBJECTIVE

To report the collective experience of using PED to treat distal anterior circulation aneurysms.

METHODS

We retrospectively reviewed clinical and radiographic records of all patients who underwent Pipeline embolization of distal anterior circulation aneurysms at 10 US neurosurgical centers between 2011 and 2013.

RESULTS

Twenty-eight patients (mean age 51.7 years; 18 women) with 28 aneurysms were included in the analyses. Fifteen aneurysms were fusiform, 5 dissecting, and 8 saccular. Average aneurysm size was 12.3 mm; 7 were giant. Twenty aneurysms were located along the middle cerebral artery, 6 along the anterior cerebral artery, and 2 along the anterior communicating artery. PED deployment was successful in 27 patients, with coils utilized in 6 cases. Clinical follow-up was available for an average of 10.7 months (range 3-26). Twenty-seven patients had follow-up neurovascular imaging: 21 aneurysms had complete occlusion, 4 had residual neck filling, and 2 had residual dome filling. Periprocedural complications (<30 days) occurred in 3 patients (10.7%), including 1 case of device failure resulting in stroke. Outcomes were good (modified Rankin Scale score 0 to 2) in 27 patients (96.4%) and fair (modified Rankin Scale 3) in 1.

CONCLUSION

PED can be utilized in the treatment of distal anterior circulation aneurysms with difficult anatomy for conventional surgical or endovascular techniques. Larger-scale studies with long-term follow-up are needed to further elucidate the durability of PED treatment and its effect on perforator-rich vascular segments.

ABBREVIATIONS

ACA, anterior cerebral arteryAcomA, anterior communicating arteryDSA, digital subtraction angiographyMCA, middle cerebral arterymRS, modified Rankin scalePED, Pipeline embolization device.

Long term follow-up of bifurcation aneurysms treated with braided stent assisted coiling and complex T- and Y- stent constructs

Background

Stent assisted coil embolization (SACE) of bifurcation aneurysms is challenging. Heterogeneous results have been achieved to date, but largely for laser cut stents. While braided stents offer multiple technical advantages, their long term efficacy has yet to be validated.

Objective

To report the first long term 18 month results for the durability of bifurcation aneurysms treated with braided stents.

Materials and methods

Over a 4 year period, 59 consecutive patients with 60 bifurcation aneurysms underwent elective braided SACE across three Australian neurovascular centers. 17 of these aneurysms underwent T- or Y-shaped stent constructs. All patients had immediate, 6 month and 18 month clinical and radiological follow-up. Radiological assessment was made on modified Raymond–Roy occlusion scores while clinical assessment was based on the modified Rankin Scale. Subgroup analysis of 17 aneurysms treated with multi-stent constructs was conducted.

Results

6 month follow-up data were available for 59 aneurysms and 18 month follow-up data for 58 aneurysms. Satisfactory aneurysm occlusion was achieved in 97% at inception and at 6 months, and 98% at 18 months. Good neurological outcomes were achieved in 95% at 18 months. Similar satisfactory results were achieved with the multi-stent construct cohort. Intraprocedural thromboembolic events were recorded in 5% and delayed events in 2%. Technical complications were found in 5%. All complication rate was 13%.

Conclusion

Braided SACE was safe, efficacious, and durable at the long term 18 month follow-up, including for multi-stent constructs. Preliminary results indicate favorable clinical and radiological outcomes compared with laser cut stents.

Minimally Invasive Transpalpebral ‘‘Eyelid’’ Approach to Unruptured Middle Cerebral Artery Aneurysms

BACKGROUND: Although recent technological advances have led to successful endovascular treatment, middle cerebral artery (MCA) aneurysms are still prone to surgery. Because minimally invasive options are limited and possess several functional and cosmetic drawbacks, a transpalpebral approach is proposed as a new alternative.

OBJECTIVES: To describe and assess surgical results of the minimally invasive transpalpebral approach in patients with MCA aneurysms.

METHODS: The data of 25 patients with unruptured MCA aneurysms from 2013 to 2016 were included in a cohort prospective database. We describe modifications of the approach and technique for MCA aneurysm clipping, in a step-by-step manner. The outcome was based on complications, procedural morbidity and mortality, and clinical and angiographic outcomes.

RESULTS: All procedures were successfully performed in a standardized way, and no major complications related to the new approach were observed. Twenty-two patients were discharged the day after surgery (88%). The majority of aneurysms were 5 to 6 mm in diameter (mean, 7 mm; range 4-21 mm). All patients underwent postoperative angiographic control, which showed no significant residual neck. A 3-mo follow-up was sufficient to show no visible scars with excellent cosmetic results. The mean duration of follow-up was 16 mo.

CONCLUSION: The transpalpebral approach comes as a minimally invasive, safe, definitive, and cosmetically adequate solution for MCA aneurysms at the present time.

One-year Angiographic Results After pCONus Stent-Assisted Coiling of 40 Wide-Neck Middle Cerebral Artery Aneurysms

BACKGROUND: Bifurcation middle cerebral artery (MCA) aneurysms with wide neck are amenable to endovascular coiling with pCONus stent, a recent device dedicated to wide-neck bifurcation intracranial aneurysms.

OBJECTIVE: To evaluate the 1-year angiographic follow-up of wide-neck MCA aneurysms treated with pCONus.

METHODS: Forty MCA aneurysms (mean dome size, 7.7 mm; mean neck size, 5.6 mm) coiled with pCONus were retrospectively evaluated. “Recanalization” was defined as worsening, and “progressive thrombosis” was defined as improvement on the Raymond scale.

RESULTS: Angiographic midterm (mean, 11.9 months; range, 3-20) follow-up was obtained in all aneurysms. Retreatment was performed in 9 aneurysms (22.5%) without clinical complications, and postoperative angiographic outcome included 2 complete occlusions and 7 neck remnants. Six aneurysms were followed after retreatment (mean, 8.8 months), and presented complete occlusion in 1 case, neck remnant in 4 cases, and aneurysm remnant in 1 case. Among the 31 aneurysms, follow-up showed complete occlusion in 67.7% (21/31), neck remnants in 29% (9/31), and aneurysm remnants in 3.3% (1/31). Adequate aneurysm occlusion (total occlusion and neck remnant) was obtained in 96.7% (30/31). Among these 31 aneurysms, improvement of the rate of occlusion was observed in 15 aneurysms (48.4%), and recurrence in 2 aneurysms (6.5%). There was no 1-year angiographic recurrence of 3- or 6-month totally occluded aneurysms.

CONCLUSION: pCONus stent allows a safe coiling of wide-neck MCA aneurysms usually considered as surgical with a low recanalization rate for those adequately occluded at 3 to 6 months. Angiographic results improve over time due to progressive aneurysm thrombosis in around 50% of cases.

Treatment of Large and Giant Middle Cerebral Artery Aneurysms: Risk Factors for Unfavorable Outcomes

OBJECTIVE

This study aimed to assess the clinical and radiologic outcomes after neurosurgical treatment of large and giant aneurysms of the middle cerebral artery (MCA). In addition, we aimed to identify risk factors for unfavorable outcomes.

METHODS

This retrospective study included 105 patients with 106 large or giant MCA aneurysms treated with neurosurgical methods, including microsurgery and endovascular treatment, over a 15-year period.

RESULTS

The mean aneurysm size was 15.3 ± 7.1 mm. Ten (9.4%) were giant aneurysms. The MCA bifurcation was the most common aneurysm site, followed by the MCA trunk and distal MCA. Aneurysm clipping was the most common treatment method, followed by clipping or trapping with bypass surgery and endovascular treatment. However, acute cerebral infarction was the most common complication (16.0%), poor outcomes (modified Rankin Scale score, 3-6) developed in 12.3% of aneurysms after treatment, and 6.6% of treated aneurysms needed retreatment. Multivariate analysis showed that independent risk factors for acute cerebral infarction after treatment were aneurysms located on the MCA trunk and 2 or more underlying diseases. Initial presentation with subarachnoid hemorrhage and complications during treatment were independent risk factors for poor outcomes. In addition, endosaccular coiling was an independent risk factor for retreatment.

CONCLUSIONS

Neurosurgical management should be considered a priority for large and giant MCA aneurysms because of the high rupture rate and clinical symptoms. However, treatment outcomes remain unsatisfactory. Therefore, tailored management with consideration of risk factors for unfavorable outcomes should be implemented.

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.

Prasugrel versus clopidogrel in stent-assisted coil embolization of unruptured intracranial aneurysms

Background Thromboembolic complications are the main problem in stent-assisted coil embolization of unruptured intracranial aneurysms. The combination of aspirin and clopidogrel is generally used to decrease these complications, but some patients do not respond to clopidogrel and have a higher risk of stent thrombosis. In cardiology, clinical trials have shown that prasugrel reduced the incidence of ischaemic events in patients with acute coronary syndrome compared with clopidogrel but, according to several authors, prasugrel would produce an increased risk of cerebral haemorrhagic complications. Objective The purpose of this study was to determine whether prasugrel would be more effective than clopidogrel in reducing procedural events in patients with an unruptured aneurysm treated endovascularly with coils and stent. Materials and methods Two hundred consecutive patients with intracranial aneurysms were treated using coiling and stenting procedures. The first 100 patients were administered a dual antiplatelet of aspirin and clopidogrel, while the remaining 100 patients were administered a dual antiplatelet of aspirin and prasugrel. In each group data were collected on procedural and periprocedural haemorrhagic and ischaemic complications. Results Aneurysmal occlusion and haemorrhagic complications rates were identical in both groups. The number of thromboembolic events observed in the two groups of our study did not differ significantly, but the prasugrel group included more wide-neck aneurysms and more flow-diverted stents. Moreover, complications in the prasugrel group were more benign, explaining the significant difference in clinical outcomes between the two groups on Day 30. Conclusions Prasugrel reduces the clinical consequences of thromboembolic complications of endovascular treatment with stenting and coiling of unruptured intracranial aneurysms.

Evaluation of Pipeline Flex delivery system for the treatment of unruptured aneurysms

INTRODUCTION

Refinements in endovascular technology have revolutionized the treatment of intracranial aneurysms (IAs) with the development of flow-diversion technology. The first generation of the Pipelin Embolization Device (PED) has demonstrated its safety and efficacy. However, the deployment technique was a difficult task that often led to complex maneuvers. The Pipeline Flex Embolization Device (PED Flex) is the second generation and its introduction has arrived with high expectations due to a completely redesigned delivery system that intends to overcome deployment difficulties seen in the previous generation. Areas covered: Preclinical studies, mechanism of action of flow-diverters, technical aspects and deployment system of the PED Flex, and clinical outcomes with both PED generations. Expert commentary: Flow diversion has allowed us to treat lesions that would be otherwise challenging for surgical clipping or unsuitable for other endosaccular strategies. Although the experience with PED Flex is limited, initial results suggest its safety and short-term efficacy.

"Clip first" policy in management of intracranial MCA aneurysms: Single-centre experience with a systematic review of literature

BACKGROUND

The results of microsurgical treatment for middle cerebral artery (MCA) aneurysms (ANs) have been highly satisfying for decades, notoriously posing a challenge for interventional neuroradiologists. Following the International Subarachnoid Aneurysm Trial (ISAT) study results, most centres across Europe and the USA switched to a "coil first" policy. The purpose of this study is to evaluate and critically review the substantiation of this change.

METHODS

The authors conducted a single-institution retrospective study of MCA AN treatment between January 2000 and December 2013 maintaining a "clip first" policy. The results are supplied with a literature review.

RESULTS

A total of 315 MCA ANs were treated in 288 consecutive patients (209 females, 79 males). Microsurgical treatment was performed for 238 AN patients (116 ruptured, 122 unruptured) and 77 AN patients (46 ruptured, 31 unruptured) who underwent a coiling procedure. Treatment-related morbidity and mortality (MM) for unruptured ANs was 2.8 % in the microsurgical group and 10.3 % in the endovascular group. The percentage of patients with no/minor permanent neurological deficits after SAH in a good initial clinical state (HH 1-2) was 93 % in the microsurgical and 76 % in the endovascular group. A literature review identified 21 studies concerning MCA AN treatment with a specified decision-making algorithm. Microsurgery seemed superior to endovascular management regarding both clinical and radiological outcomes, although several aspects of the analysed reports might appear questionable.

CONCLUSION

Although this study has its inherent limitations, the effect brought about by microsurgical clipping of MCA ANs remains superior to that of endovascular embolisation and it should be sustained as the first treatment choice. The decision about the treatment strategy should be made by a multi-disciplinary team consisting of specialists from both teams, bearing in mind the higher occlusion rate and longevity of the surgical treatment.

Middle cerebral artery aneurysm surgery after stent misplacement: A case report

Stent misplacement during endovascular treatment of middle cerebral artery (MCA) aneurysms can cause challenges and be problematic, if clipping becomes necessary. This article reports on a 56-year-old woman with an unruptured, multi-lobulated MCA aneurysm, whom primarily refused surgery; therefore, she was scheduled for stent-assisted coiling. After successful deployment of the stent, it unfortunately then became snagged by the microcatheter and was pulled backwards. The subsequent surgical procedure (i.e. clipping of the MCA aneurysm) was challenging, due to the position of the dislodged stent. Such as misplacement of the stent is rarely documented: It resulted in the difficult handling of a MCA aneurysm. Aneurysms of the MCA should primarily be considered for surgical clipping. In conclusion, an increased risk for eventual surgery should be considered, in cases where endovascular treatments with stents are performed.

LEO Baby Stent Use following Balloon-Assisted Coiling: Single- and Dual-Stent Technique--Immediate and Midterm Results of 29 Consecutive Patients

BACKGROUND AND PURPOSE

We report our preliminary results in terms of safety and efficacy in using the low-profile LEO Baby stent for the treatment of large-neck and complex intracranial aneurysms with balloon-then-stent-assisted coiling and single- or dual-stent-assisted coiling.

MATERIALS AND METHODS

Clinical and radiologic data of all consecutive patients treated at our institution from September 2012 to October 2013 for an intracranial aneurysm by using a LEO Baby stent were retrospectively analyzed. Immediate and midterm clinical and anatomic follow-up of each patient is reported.

RESULTS

Twenty-nine patients with 29 aneurysms were treated with LEO Baby stents at our institution. The mean age of patients was 48 years; 20 patients were women (71%). One patient was treated in the acute phase of a subarachnoid hemorrhage. In 8 procedures, a double-lumen-catheter balloon was used for balloon-then-stent-assisted coiling. In 3 cases, a LEO Baby stent was used in a Y-, T-, and telescopic dual-stent configuration. In 18 cases, a single LEO Baby stent was used. In 2 cases, technical failure to deploy the stent resulted in acute parent artery thrombosis. In 3 further cases, thromboembolic complications occurred intraoperatively. MR imaging and angiographic midterm follow-up showed complete aneurysm occlusion for 96% of the followed patients (27/29). Clinical outcome was favorable for all patients followed up.

CONCLUSIONS

Results obtained in our study by using the LEO Baby stent for balloon-then-stent and single- or dual-stent-assisted coiling of complex and distally located intracranial aneurysms are encouraging. Incomplete or inadequate opening of the device is a potential cause of laminar blood flow alteration and thrombus formation.

pCONus Device for the Endovascular Treatment of Wide-Neck Middle Cerebral Artery Aneurysms

BACKGROUND AND PURPOSE

Endovascular treatment of bifurcation middle cerebral artery aneurysms with a wide neck could be challenging, and many lesions are still treated by a surgical approach. The pCONus is a newly emerging device for wide-neck bifurcation intracranial aneurysms. To date, a single report on the treatment of intracranial aneurysms including all locations has been published. We report our experience with pCONus in the treatment of wide-neck MCA aneurysms.

MATERIALS AND METHODS

MCA aneurysms treated with pCONus in 4 European centers were retrospectively reviewed.

RESULTS

Forty MCA aneurysms (mean dome size, 7.7 mm; mean neck size, 5.6 mm) were treated in 40 patients (mean age, 62 years). Aneurysm coiling was performed after deployment of 1 pCONus in 95% (38/40) of cases and after deployment of 2 pCONus devices in 5% (2/40). No procedural angiographic complications were observed. Reversible neurologic complications were noted in 5% (2/40), and permanent neurologic complication, in 2.5% (1/40) at 1 month. There was no mortality. No aneurysms bled or rebled after treatment. Immediate angiographic results were complete aneurysm occlusion in 25% (10/40), neck remnant in 47.5% (19/40), and aneurysm remnant in 27.5% (11/40). Follow-up (mean, 6.8 months) was available for 33 aneurysms (82.5%). Stable or improved results were observed in all except 3 cases, including 48.5% complete occlusions (16/33), 30.3% neck remnants (10/33), and 21.2% aneurysm remnants (7/33). There was no in-stent stenosis or jailed branch occlusion. There was no angiographic recurrence of initially totally occluded aneurysms.

CONCLUSIONS

MCA aneurysms with a wide neck are amenable to treatment with pCONus.

Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.

Assisted coiling using LEO Baby or LVIS Jr stents: Report of six cases

BACKGROUND AND PURPOSE

Endovascular treatment of broad-neck, complex cerebral aneurysms is a challenging issue. Placement of a stent over the aneurysm neck and secondary coil embolization prevents coil migration and allows dense packing of the coils. Another challenge is represented by distal aneurysms situated in small vessels. In these cases, the use of little stents, which we are going call ministents, could be a good decision. These low-profile intracranial ministents can be deployed into arteries with diameters between 1.5 and 3.10 mm and delivered through microcatheters with an internal diameter of 0.0165 inches, which allows easier navigation in small-sized, delicate vessels. We present six cases of wide-neck aneurysms, with small parental arteries less than 2.5 mm using a low-profile ministent system (LEO Baby and LVIS Jr) plus coil embolization.

MATERIALS AND METHODS

We retrospectively reviewed patients in whom LEO Baby or LVIS Jr stent was used for the treatment of intracranial aneurysms. Five aneurysms were treated during 2013-2014 in our service using the LEO Baby stent and one aneurysm using LVIS Jr. Stent-assisted coil embolization was performed using the jailing technique in all cases. Clinical and angiographic findings, procedural data, and follow-up are reported.

RESULTS

Six consecutive patients were included in this study. Four patients presented with subarachnoid hemorrhage in the subacute-chronic phase and two patients had unruptured aneurysms. Two of the six aneurysms were located at branches of the sylvian artery, one at the basilar artery, two at the anterior communicating artery, and one at the P1-P2 artery. The procedures were successful. Six-month control digital subtraction angiograms were obtained in all cases; they demonstrated complete occlusion of the aneurysms in all instances. All patients had good clinical outcomes on follow-up, as measured with the Glasgow Outcome Scale and Modified Rankin Scale.

CONCLUSIONS

The results of this small study show that the LEO Baby and LVIS Jr ministents could be safe and efficient for endovascular treatment of intracranial broad-neck aneurysms situated in small arteries.

Endovascular treatment of 346 middle cerebral artery aneurysms: results of a 16-year single-center experience

BACKGROUND

The endovascular treatment of middle cerebral artery (MCA) aneurysms has been controversial because of the frequency of complex anatomy and the relative ease of surgical clipping in this location.

OBJECTIVE

To present a large single-center experience with the endovascular treatment of MCA aneurysms.

METHODS

The neurointerventional database at our institution was reviewed for all endovascular treatments of MCA aneurysms. Demographics, aneurysm characteristics, treatment modality, intraprocedural hemorrhagic and thromboembolic events, 30-day neurological events, and follow-up angiographic studies were recorded.

RESULTS

From December 1996 to April 2013, 292 patients underwent endovascular treatment of 346 MCA aneurysms. Of these, 341 (98.6%) were successfully completed. Balloon neck remodeling was used in 230 procedures (66.5%). Ninety-five procedures (27.4%) were for ruptured aneurysms. The rate of intraprocedural hemorrhage was 2.6% (9 of 346). The overall rate of intraprocedural thromboembolic events was 13.6% (47 of 346), significantly more common in patients with acute subarachnoid hemorrhage (27.4%; P < .001). The 30-day major (modified Rankin Scale score > 2) neurological event rate was 2.9% (10 of 346), significantly more common in patients with subarachnoid hemorrhage (8.4%) compared with those without (0.8%; P < .001). The rate of complete or near-complete aneurysm occlusion at was 90.6% ≥ 6 months and 91.8% at ≥ 2 years, with an average of 24 months of follow-up available for 247 procedures.

CONCLUSION

Endovascular treatment of MCA aneurysms can be safe and effective. However, it is associated with a high asymptomatic thromboembolic event rate that is more frequent in the setting of acute subarachnoid hemorrhage.

The combined treatment of stenting and surgery in a giant unruptured aneurysm of the middle cerebral artery

BACKGROUND

This case study reports on a combined therapy of stenting and surgery for a giant unruptured middle cerebral artery (MCA) aneurysm with the aim of preserving the patency of the vessel during surgery.

CASE DESCRIPTION

A 51-year-old male presented with a sudden onset of moderate left hemiparesis and dysarthria. Neuro-radiological evaluations showed a giant right unruptured MCA aneurysm without subarachnoid hemorrhage (SAH). The cerebral angiography confirmed the presence of such an aneurysm producing compression of both M2 branches with consequent slowing of the blood flow. Two weeks later, the patient underwent the positioning of an Enterprise stent and inside this, a flow diverter Silk stent. They were placed across the aneurysm and in one of the two M2 branches with the aim of protecting them during surgical manipulation. The patient went immediately to surgery, where the aneurysm was resected and both M2 branches decompressed.

CONCLUSION

The combined placement of the stents allowed safe and successful surgical dissection of the M2 branches and clipping of the aneurysm without interrupting the blood flow.

Flow diverter device for the treatment of small middle cerebral artery aneurysms

PURPOSE

Experience with the endovascular treatment of middle cerebral artery (MCA) aneurysms by flow diverter devices (FDD) is still limited. This study examines the results and complications of FDD for small aneurysms at this location.

METHODS

From February 2010 to December 2013, 14 patients (10 women; mean age 59 years) with 15 small MCA aneurysms were treated with FDD. All procedures were performed with the Pipeline embolization device (PED).

RESULTS

Complete occlusion was obtained in 12/15 aneurysms (80%) and partial occlusion in 3 (20%). Among 13 aneurysms with a side branch, this was patent at the angiographic control in 4 cases, showed decreased filling in 6, and was occluded in 3 (with neurological deficits in 2). All PEDs were patent at follow-up. Post-procedural ischemic complications occurred in 4 (27%) procedures with permanent neurological deficit (modified Rankin score 2) in 3 (21%). No early or delayed aneurysm rupture, no subarachnoid or intraparenchymal hemorrhage and no deaths occurred.

CONCLUSIONS

Endovascular treatment with FDD is a relatively safe treatment for small MCA aneurysms resulting in a high occlusion rate. The findings of this study suggest that complete occlusion after endovascular treatment with FDD can be delayed (>6 months). Ischemic complications may occur as early or delayed, particularly at clopidogrel interruption.

Multiple intracranial aneurysms: endovascular treatment and complications

This study evaluated the results of endovascular embolization of multiple intracranial aneurysms. A retrospective hospital chart and radiograph review were made of all patients with multiple intracranial aneurysms seen between March 2010 and January 2011. Ten patients presented with subarachnoid hemorrhage, four with mass effect, two with brain ischemia and twenty were incidental. These 36 patients harbored 84 aneurysms, 63 of which were treated with endovascular techniques, two by surgical clipping, and 19 were left untreated. Of the coil-treated lesions, a complete endovascular occlusion was achieved in 54 aneurysms (85.7%), and eight (12.7%) presented neck remnants with one (1.6%) stented only. Twenty-six patients (72.2%) underwent coil embolization of more than one aneurysm in the first session. Follow-up angiographic studies in 31 patients demonstrated an unchanged or improved result in 93.0% of the aneurysms (53 lesions) and coil compaction in 7.0% (four lesions). The overall clinical outcome was excellent in 33 patients (91.7%), good in one (2.8%) and fair in two (5.5%). Endovascular techniques may be a particularly suitable method for treating multiple intracranial aneurysms.

"Y" and "X" stent-assisted coiling of complex and wide-neck intracranial bifurcation aneurysms

BACKGROUND AND PURPOSE

Stent-assisted coiling with two stents has been described in some series for the treatment of complex and wide-neck bifurcation aneurysms. Our aim was to report our experience of a stent-assisted coiling technique with double stents in "Y" and "X" configurations, with emphasis on safety, feasibility, and efficacy.

MATERIALS AND METHODS

Clinical and angiographic outcomes of patients for whom the strategic therapeutic option was the stent-assisted coiling technique in a Y or X configuration for neck scaffolding from June 2006 to June 2013 were retrospectively analyzed.

RESULTS

One hundred five aneurysms in 97 patients were treated during 100 consecutive procedures. There were 54.2% (57/105) MCA, 28.6% (30/105) anterior communicating artery, 16.2% (17/105) basilar tip, and 1.0% (1/105) ICA termination aneurysms. A Y stent placement was used to treat 87 aneurysms in 85 procedures; an X stent placement was used to treat 7 aneurysms in 6 procedures, while 9 procedures failed for 11 aneurysms. There were 10.0% (10/100) procedure-related permanent neurologic deficits and 1.0% (1/100) death. The immediate angiographic controls showed a complete occlusion in 47.6% (50/105) of the aneurysms and a partial (neck or sac remnant) occlusion in 52.4% (55/105). To date, 81.0% (85/105) of the aneurysms have been followed up (mean, 17 months) with angiography, disclosing a recanalization in 5.9% (5/85) and an improvement in 42.4% (36/85). At discharge and follow-up, the mRS score was 0 in 83.5% (81/97) of patients, 1 in 4.1% (4/97), 2 in 3.1% (3/97), 3 in 4.1% (4/97), 4 in 3.1% (3/97), and 6 in 2.1% (2/97).

CONCLUSIONS

Y and X stent-assisted coiling of complex and wide-neck intracranial bifurcation aneurysms is an effective technique.

Outcome for unruptured middle cerebral artery aneurysm treatment: surgical and endovascular approach in a single center

The rupture of an intracranial aneurysm leads to subarachnoid hemorrhage (SAH). To prevent SAH, unruptured lesions can be treated by either endovascular or microsurgical approach. Due to their complex anatomy, middle cerebral artery (MCA) aneurysms represent a unique subgroup of intracranial aneurysms. Primary objective was to determine radiological and clinical outcomes in patients with middle cerebral artery aneurysms who were interdisciplinary treated by either endovascular or microsurgical approach in a single center. Secondary objective was to determine the impact of the lesions' angiographic characteristics on treatment outcome. Clinical and radiological data of 103 patients interdisciplinary treated for unruptured MCA aneurysms over a 5-year period were analyzed in endovascular (n = 16) and microsurgical (n = 87) cohorts. Overall morbidity (Glasgow Outcome Score <5) after 12-month follow-up was 9 %. There was no significant difference between the two cohorts. Complete or "near complete" aneurysm occlusion was achieved in 97 and 75 % in the microsurgical, respective endovascular cohort. A "complex" aneurysm configuration had a significant impact on complete aneurysm occlusion in both cohorts, however, not on clinical outcome. Treatment of unruptured MCA aneurysms can be performed with a low risk of repair using both approaches. However, the risk for incomplete occlusion was higher for the endovascular approach in this series.

Stent placement for complex middle cerebral artery aneurysms

BACKGROUND

To evaluate the safety and effectiveness of stent placement for ruptured or unruptured middle cerebral artery (MCA) aneurysms in a larger number.

METHODS

Between October 2003 and December 2012, data for 70 patients with 72 complex MCA aneurysms treated with stents at our institution were retrospectively collected and analyzed.

RESULTS

Eighty-five stents were successfully deployed in this series. However, failure of followed coiling was encountered in 2 (2.8%) tiny aneurysms of them. Of the 63 aneurysms treated with stent-assisted coiling, complete occlusion was achieved in 22 (34.9%), neck remnant in 15 (23.8%), and residual sac in 26 (36.5%). Of the 9 aneurysms treated with stent alone, the results were contrast stasis in 3 aneurysms and no change in 6. Procedure-related complications occurred in 9 (12.5%) procedures, including 7 of 27 (25.9%) with ruptured aneurysms and 2 of 45 (4.4%) with unruptured aneurysms, which resulted in 1 death and 5 disabilities. Univariate and multivariate analyses show that ruptured aneurysm is an independent factor for the outcome of these patients (odds ratio, 7.35; 95% confidence interval, 1.35-40.0). Angiographic follow-up results (mean, 10.5±8.8 months) showed that 72.1% (44 of 61) were completely occluded, 4.9% (3 of 61) recurred, and others were stable or had improved. Intrastent stenosis was observed in 1 (1.6%) patient, which was managed conservatively. During a clinical follow-up period ranging from 7 to 113 months (mean, 33.0±22.4 months), 1 disabled patient died from severe pneumonia, whereas the clinical status of the others had improved or was stable. Procedure-related morbidity/mortality during the follow-up for the ruptured and unruptured groups were 3.7%/3.7% and 0/0, respectively.

CONCLUSIONS

Our study shows that stent placement for the treatment of certain wide-neck MCA aneurysms is feasible, safe, and effective. However, stent placement for acutely ruptured MCA aneurysms harbors a much higher complication rate.

Low-profile Visualized Intraluminal Support device (LVIS Jr) as a novel tool in the treatment of wide-necked intracranial aneurysms: initial experience in 32 cases

BACKGROUND AND PURPOSE

The focus of this study was to determine ease of deployment, safety and effectiveness of the LVIS Jr device.

METHODS

A retrospective analysis was performed of 32 cases comprising 34 aneurysms in which the LVIS Jr device was used for stent-assisted coil embolization of intracranial aneurysms from February to October 2012, including all clinical and angiographic data as well as mid-term follow-up (1-12 months of treatment).

RESULTS

The median age of the patients was 54 years (range 21-76) and 19 (59%) were women. The aneurysms were ruptured in 12/34 cases (35.3%); 26 (76.4%) were located within the anterior circulation and the remaining 8 (23.5%) were located in the posterior circulation. Eleven of the 34 aneurysms (32.3%) were treated with a Y-stent configuration. Immediate total occlusion was observed in 16/34 (47%), near total occlusion (90-95%) in 5/34 (14.7%) and a 'dog ear' or subtotal occlusion in 12/34 (35.2%). A single aneurysm was treated without coil embolization. Complications occurred in 5/34 cases (15%), including two cases of in-stent thrombosis.

CONCLUSIONS

Implantation of the LVIS Jr device as a support device for stent-assisted coil embolization seems to be safe and effective. The LVIS Jr device can also be implanted in a Y-stent configuration, offering a novel technique with a potentially lower risk of thromboembolic complications compared with other devices.

Endovascular and Surgical Treatment of Unruptured MCA Aneurysms: Meta-Analysis and Review of the Literature

Introduction. The best treatment for unruptured middle cerebral artery (MCA) aneurysms is unclear. We perform a meta-analysis of recent publications to evaluate the results of unruptured MCA aneurysms treated with surgical clipping and endovascular coiling. Methods. A PubMed search for articles published between January 2004 and November 2013 was performed. The R statistical software package was used to create a random effects model for each desired incidence rate. Cochran's Q test was used to evaluate possible heterogeneity among the rates observed in each study. Results. A total of 1891 unruptured MCA aneurysms, 1052 clipped and 839 coiled, were included for analysis. The complete occlusion rate at 6–9 months mean follow-up was 95.5% in the clipped group and 67.8% in the coiled group (P < 0.05). The periprocedural thromboembolism rate in the clipping group was 1.8% compared with 10.7% in the aneurysms treated by coiling (P < 0.05). The recanalization rate was 0% for clipping and 14.3% for coiling (P = 0.05). Modified Rankin scores of 0–2 were obtained in 98.9% of clipped patients compared to 95.5% of coiled (NS). Conclusions. This review weakly supports clipping as the preferred treatment of unruptured MCA aneurysms. Clinical outcomes did not differ significantly between the two groups.

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

OBJECTIVE

This study evaluates the role of endovascular therapy for middle cerebral artery (MCA) aneurysms and its evolution over time. We are reporting a large case series of 184 MCA aneurysms and comparative analysis of the literature.

METHODS

This was a retrospective review of a prospectively maintained database including all patients with MCA bifurcation aneurysms embolized between 2000 and 2013. There were 184 aneurysms in 166 patients, with 71 ruptured and 113 nonruptured aneurysms.

RESULTS

Stent assistance was required in 70 cases (38·0%) and 3 cases (1·6%) required 'Y' stenting. The initial rate of total aneurysm occlusion was 59·8% and at delayed follow up was 90·1%. Seven embolizations resulted in thrombo-embolic complications (3·8%), with no cases of aneurysm re-bleeding, wire perforations, or other hemorrhages. Three patients with ruptured aneurysms died of causes unrelated to the embolization, and none with nonruptured aneurysms died in the follow-up period (total mortality 1·6% at 30 days post-procedure). A total of seven aneurysms (3·9%) required retreatment with an average follow up of 41 months. Prior to dedicated aneurysm stents, 68·8% of patients underwent embolization with the remainder surgically treated. Following the introduction of aneurysm stents in 2002, 92·0% of MCA aneurysms treated were embolized.

CONCLUSIONS

During the past decade we have seen a treatment paradigm shift in MCA aneurysm treatment from surgical treatment to endovascular treatment. Developments in 3D angiography, more compliant balloons, dedicated aneurysm stents, complex coils, and antiplatelet therapy regimes have led to this transition for safe and effective management of these patients.

Bypass surgery for complex middle cerebral artery aneurysms: impact of the exact location in the MCA tree

Object

The object of this study was to describe the authors' institutional experience in the treatment of complex middle cerebral artery (MCA) aneurysms necessitating bypass and vessel sacrifice.

Methods

Cases in which patients with MCA aneurysms were treated with a combination of bypass and parent artery sacrifice were reviewed retrospectively.

Results

The authors identified 24 patients (mean age 46 years) who were treated with bypass and parent artery sacrifice. The aneurysms were located in the M1 segment in 7 patients, MCA bifurcation in 8, and more distally in 9. The mean aneurysm diameter was 30 mm (range 7–60 mm, median 26 mm). There were 8 saccular and 16 fusiform aneurysms.

Twenty-one extracranial-intracranial and 4 intracranial-intracranial bypasses were performed. Partial or total trapping (only) of the parent artery was performed in 17 cases, trapping with resection of aneurysm in 3, and aneurysm clipping with sacrifice of an M2 branch in 4.

The mean follow-up period was 27 months. The aneurysm obliteration rate was 100%. No recanalization of the aneurysms was detected during follow-up.

There was 1 perioperative death (4% mortality rate) and 6 cerebrovascular accidents, causing permanent morbidity in 5 patients. The median modified Rankin Scale score of patients with an M1 aneurysm increased from 0 preoperatively to 2 at latest follow-up, while the score was unchanged in other patients. Most of the permanent deficits were associated with M1 aneurysms. Twenty-one patients (88%) had good outcome as defined by a Glasgow Outcome Scale score of 4 or 5.

Conclusions

Bypass in combination with parent vessel occlusion is a useful technique with acceptable frequencies of morbidity and mortality for complex MCA aneurysms when conventional surgical or endovascular techniques are not feasible. The location of the aneurysm should be considered when planning the type of bypass and the site of vessel occlusion. Flow alteration by partial trapping may be preferable to total trapping for the M1 aneurysms.