Stent-assisted coiling in acutely ruptured intracranial aneurysms: a qualitative, systematic review of the literature

Safety and efficacy of stent-assisted coiling ruptured intracranial aneurysms: A single-center experience

Objectives

Endovascular coiling is a minimally invasive method to manage intracranial aneurysms. However, patients who undergo stent-assisted coiling (SAC) for acutely ruptured intracranial aneurysms need dual antiplatelet treatment. We reported our experience and outcomes of SAC for ruptured intracranial aneurysm.

Materials and Methods

We retrospectively collected data on procedure-related complications, rates of aneurysm rebleeding and recurrence, and clinical outcomes of patients with ruptured aneurysms managed by SAC over 2 years.

Results

Among the 17 patients included in this study, there were 14 (82.4%) women and 3 (17.6%) men, with a mean age of 58.59 years (standard deviation = 13.57; range: 40-82 years). There were no periprocedural hemorrhagic complications and no aneurysm rebleeding before discharge. However, two patients developed acute brain infarction because of symptomatic vasospasm. Linear regression revealed significant associations of posterior circulation involvement with the Glasgow Outcome Score and modified Rankin Scale (mRS) at discharge and 6 months after. Besides, Hunt and Hess grade ≥3 has a significant association with mRS at discharge, 6 months, and 1 year after.

Conclusion

SAC for ruptured aneurysm was technically feasible and did not carry an additional risk of postoperative aneurysm rebleeding secondary to antiplatelet treatment. Moreover, it had relatively low rates of aneurysm regrowth and coil compaction. Therefore, it can be a safe and effective endovascular treatment for acutely ruptured intracranial aneurysm.

Different antiplatelet regimens for stenting versus coiling for acutely-ruptured cerebral aneurysms

To investigate the safety, efficacy and risk factors for complications of stenting with optional coiling versus coiling alone for acutely ruptured cerebral aneurysms (ARCAs) using different antiplatelet schemes, 2021 patients were prospectively enrolled into the stenting group (n = 967) and the coiling group (n = 1054). Four different antiplatelet regimens were used. The clinical and treatment data were analyzed and compared. In the stenting group, the common antiplatelet regimen was applied in 259 patients (26.8%), loading regimen in 210 (21.7%), intravenous tirofiban regimen in 240 (24.8%), and premedication free regimen in 258 (26.7%). The aneurysm occlusion degrees in the coiling vs. stenting group were not significantly (P > 0.05) different after treatment. Complications occurred in 168 (15.94%) and 171 (17.68%) patients in the coiling and the stenting group, respectively. Fifteen (1.55%) patients experienced stent-related ischemic complications. The only significant (P < 0.05) independent protective factor for complete occlusion was stent-assisted coiling in the stenting group but aneurysm daughter sac in the coiling group. Significant (P < 0.05) independent risk factors for poor mRS (3-6) were posterior circulation aneurysms and neurological bleeding complications in the stenting group and neurological complications in the coiling group. In the stenting group, the only independent risk factor was parent artery stenosis for neurological complications, Raymond grade III for neurological ischemic complications, and the ice cream technique for total complications in the stenting group. In conclusion, different antiplatelet schemes can be safely and efficiently used for intracranial stenting with optional coiling as compared with coiling alone for ARCAs.

Comparative Analysis of Stent-Assisted Versus Non-Stent-Assisted Coiling in the Management of Ruptured Intracranial Aneurysms: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically evaluate the safety and efficacy of SAC compared to non-SAC in the treatment of RIA, integrating evidence from high-quality studies to guide clinical practice.

METHODS

A meta-analysis was conducted to compare SAC with coiling alone and BAC in the treatment of RIA. Primary outcomes were immediate and follow-up aneurysm occlusion rates, along with perioperative hemorrhagic and ischemic complication rates.

RESULTS

A total of thirteen retrospective cohort studies were included, comprising 3,086 patients, with 1,078 in the SAC group and 2,008 in the non-SAC group. The immediate complete occlusion rates were similar between the SAC and non-SAC groups (59.1% vs. 61.4%; RR = 1.00; 95% CI [0.94, 1.07]; p = 0.92). However, the SAC group demonstrated a significantly higher long-term complete occlusion rate (61.3% vs. 40.6%; RR = 1.44; 95% CI [1.22, 1.69]; p < 0.001). The incidence of ischemic complications was greater in the SAC group (12.2% vs. 10.0%; RR = 1.68; 95% CI [1.37, 2.07]; p < 0.001), as was the incidence of hemorrhagic complications (7.3% vs. 5.1%; RR = 1.55; 95% CI [1.15, 2.08]; p = 0.004). Perioperative mortality was also elevated in the SAC group (6.7% vs. 6.8%; RR = 1.37; 95% CI [1.00, 1.88]; p = 0.048), with a non-significant trend towards higher long-term mortality (9.8% vs. 9.2%; RR = 1.35; 95% CI [0.98, 1.87]; p = 0.068). Functional outcomes at discharge (76.0% vs. 71.0%; RR = 0.97; 95% CI [0.92, 1.02]; p = 0.237), six months (57.8% vs. 60.8%; RR = 0.93; 95% CI [0.81, 1.07]; p = 0.296), and at the last follow-up (RR = 1.01; 95% CI [0.97, 1.06]; p = 0.592) were comparable between the two groups.

CONCLUSIONS

SAC significantly improves long-term occlusion rates for RIA compared to non-SAC, despite a higher incidence of complications. Careful patient selection and optimization of antiplatelet therapy may enhance the safety and efficacy of SAC for RIA treatment.

Safety and effectiveness of Neuroform Atlas stent-assisted coil embolization for ruptured intracranial aneurysms

OBJECTIVE

The treatment outcomes of ruptured intracranial aneurysms using the Neuroform Atlas stent were evaluated.

METHODS

This study represents a retrospective review that included patients who underwent endovascular treatment for ruptured aneurysms at a single institution. Between January 2018 and September 2022, endovascular treatments including simple coiling or Neuroform Atlas stent-assisted coil embolization were performed in 191 patients with ruptured intracranial aneurysms.

RESULTS

Intraprocedural rupture was observed in 11 (8.7%) patients in the Simple Coiling (SC) group, which was slightly higher than that in 4 (6.3%) patients in the Neuroform Atlas stent-assisted coiling (NASAC) group (p=0.241). However, Thromboembolic event (TEE) was slightly more prevalent in the NASAC group, with 4 (6.3%) cases as compared to the 5 (3.9%) cases in the SC group (p=0.235). The retreatment rate was slightly higher in the SC group, with 19 (26.4%) patients as compared to the 10 patients (22.2%) in the NASAC group (p=0.342).

CONCLUSIONS

The use of the Neuroform Atlas stent (NAS) for ruptured aneurysms might be safe and effective.

Feasibility of single antiplatelet therapy after stent assisted coiling for ruptured intracranial aneurysms

OBJECT

We retrospectively analyzed clinical data to evaluate the safety and efficacy of single antiplatelet therapy (SAPT) after stent-assisted coil embolization (SAC) for ruptured cerebral aneurysms.

METHODS

In total, 176 stent-assisted coil embolization procedures were investigated. Among them, 77 ruptured and 99 unruptured aneurysms were grouped and compared respectively. In the ruptured group, only SAPT (aspirin) was administered after the procedure. Meanwhile, in the unruptured group, dual antiplatelet therapy (DAPT) (aspirin and clopidogrel) was administered before and after the procedure following standard guidelines. We compared both groups in regards to thromboembolic complications by analyzing post procedural diffusion-weighted images (DWI), hyperacute thrombosis during the procedure, and post-procedural symptoms.

RESULTS

The single antiplatelet therapy ruptured intracranial aneurysm (SAPT-RIA) group had 77 saccular aneurysms (62 ICA, 3 MCA, 4 ACA, 8 posterior circulation) with a mean diameter of 8.07 mm. The dual antiplatelet therapy unruptured intracranial aneurysm (DAPT-UIA) group had 99 aneurysms (81 ICA, 5 MCA, 3 ACA, 10 posterior circulation) with a mean diameter of 6.32 mm. DWI positivity rates were similar between groups, but hyperacute thrombosis was higher in the SAPT-RIA group (10.4%) compared to none in the DAPT-UIA group. Each group had one symptomatic complication.

CONCLUSIONS

SAPT could be a viable option for the peri-procedural management of SAC in acutely ruptured cases.

Strategies and outcomes of endovascular treatment of posterior inferior cerebellar artery aneurysms: a single center experience

To explore safe and reliable strategies and outcomes of endovascular procedures in the treatment of posterior inferior cerebellar artery (PICA) aneurysms. Retrospectively reviewed and analyzed the cases of PICA aneurysms that undergone endovascular therapy from July 2017 through January 2022 in our neurosurgical center, as well as outcomes of long-term follow-up. Total 24 cases were enrolled. Majority of the PICA aneurysms (87.5%, 21/24) presented initially with subarachnoid hemorrhage (SAH) and only 3 cases were not ruptured when they were clinically diagnosed as PICA aneurysms. The patients were endovascularly given either aneurysm occlusion with selective coils (12 cases), embolization of aneurysms and parent arteries (7 cases: 3 cases with coils and 4 cases with Onyx liquid embolic agent), or stent-assisted coiling of the aneurysms (5 cases). One patient, who had comorbidity of intracranial hemorrhage and severe cerebral vasospasm, declined further post-surgery therapy, and discharged from the hospital with anticipation of poor outcome. The rest 23 patients were followed up for 3-24 months with a recurrence rate of 17.4% (4/23). Endovascular procedure of embolizing PICA aneurysms with selective coils or stent-assisted coils is feasible, safe, and reliable. Simplified embolization of the aneurysms or occlusion of the parent artery is recommended as the first choice for the ruptured and bleeding PICA aneurysms.

Clinical Outcomes of Clipping and Coil Embolization for Ruptured Intracranial Aneurysms Categorized by Region and Hospital Size: A Nationwide Cohort Study in Korea

BACKGROUND

To analyze the outcomes of clipping and coiling for ruptured intracranial aneurysms (RIAs) based on data from the National Health Insurance Service in South Korea, with a focus on variations according to region and hospital size.

METHODS

This study analyzed the one-year mortality rates for patients with RIAs who underwent clipping or coiling in 2018. Coiling was further categorized into non-stent assisted coiling (NSAC) and stent assisted coiling (SAC). Hospitals were classified as tertiary referral general hospitals (TRGHs), general hospitals (GHs), or semi-general hospitals (sGHs) based on size. South Korea's administrative districts were divided into 15 regions for analysis.

RESULTS

In 2018, there were 2,194 (33.1%) clipping procedures (TRGH, 985; GH, 827; sGH, 382) and 4,431 (66.9%) coiling procedures (TRGH, 1,642; GH, 2076; sGH, 713) performed for RIAs treatment. Among hospitals performing more than 20 treatments, the one-year mortality rates following clipping or coiling were 11.2% and 16.0%, respectively, with no significant difference observed. However, there was a significant difference in one-year mortality between NSAC and SAC (14.3% vs. 19.5%, P = 0.034), with clipping also showing significantly lower mortality compared to SAC (P = 0.019). No significant differences in other treatment modalities were observed according to hospital size, but clipping at TRGHs had significantly lower mortality than at GHs (P = 0.042). While no significant correlation was found between the number of treatments and outcomes at GHs, at TRGHs, a higher volume of clipping procedures was significantly associated with lower total mortality (P = 0.023) and mortality after clipping (P = 0.022).

CONCLUSION

Using Korea NHIS data, mortality rates for RIAs showed no significant variation by hospital size due to coiling's prevalence. However, differences in clipping outcomes by hospital size and volume in TRGH highlight the need for national efforts to improve clipping skills and standardization. Additionally, the higher mortality rate with SAC emphasizes the importance of precise indications for its application.

The safety and efficacy of double microcatheter technique in small and tiny ruptured aneurysms: A single center study

OBJECTIVE

Double microcatheter technique (dMC) can be the alternative to Single microcatheter technique (sMC) for challenging cases, but there is lack of studies comparing dMC to sMC especifically for small ruptured aneurysms. Our objective was to compare the safety and efficacy of dMC to sMC in treating small (≤5 mm) and tiny (≤3 mm) ruptured aneurysms.

METHODS

This study focused on 91 out of 280 patients who had ruptured aneurysms and underwent either single or double microcatheter coil embolization. These patients were treated with either single or double microcatheter coil embolization. We divided the patients into two groups based on the procedural method and evaluated clinical features and outcomes. Subgroup analyses were conducted specifically for tiny aneurysms, comparing the two methods, and within the dMC group, we also examined whether the aneurysm was tiny or not. In addition, univariate logistic regression analysis was performed to assess the impact of coil packing density.

RESULTS

The mean values for most outcome measures in the dMC group were higher than those in the sMC group, but these differences did not reach statistical significance (coil packing density, 45.739% vs. 39.943%; procedural complication, 4.17% vs. 11.94%; recanalization, 8.3% vs. 10.45%; discharge discharge modified Rankin Scale (mRS), 1.83 vs. 1.97). The comparison between tiny aneurysms and other sizes within the dMC group did not reveal any significant differences in terms of worse outcomes or increased risk. The only factor that significantly influenced coil packing density in the univariate logistic regression analysis was the size of the aneurysm (OR 0.309, 95% CI 0.169-0.566, p=0.000).

CONCLUSIONS

The dMC proved to be a safe and viable alternative to the sMC for treating small ruptured aneurysms in challenging cases.

Treatment of ruptured intracranial aneurysms using the novel generation of flow-diverters with surface modification: A systematic review and meta-analysis

BACKGROUND

Surface modification of flow diverters (FDs) has been explored as a solution for reducing thrombotic risk of these devices, without necessarily using dual antiplatelet therapy (DAPT). If effective, this could pose a promising alternative for treatment of ruptured aneurysms not amenable to other modalities.

METHODS

We performed a comprehensive search of PubMed, MEDLINE, and Embase databases following Preferred Reporting Items for Systematic reviews and Meta-analyzes guidelines. We included articles reporting use of surface-modified FDs for treatment of ruptured aneurysms. Demographics, subarachnoid hemorrhage (SAH) severity, aneurysm characteristics, devices used, periprocedural complications, angiographic outcomes, and mortality were extracted for sample size-based weighted analysis.

RESULTS

Six studies comprising 59 patients with 64 aneurysms were included. Mean patient age was 56.6 ± 6.3 years and 60.6% (95% confidence interval [CI], 46.7-72.9%) were women. The anterior circulation was the location in 60.4% (95%CI, 45.5-73.5%) of aneurysms; 41.8% of the aneurysms were saccular (95%CI, 29.3-55.4%), 16.7% were fusiform (95%CI, 8.3-30.8%), 29.9% were dissecting (95%CI, 12.8-55.4%), 24.4% were blood-blister (95%CI, 15.2-36.7%), and 5.7% were mycotic (95%CI, 2-15.1%). Poor SAH grade was reported in 46.9% (95%CI, 33.3-60.9%). Adjunctive coiling was used in 33.2% (95%CI, 12.4-63.6%). Periprocedural thromboembolic and hemorrhagic complications occurred in 20% (95%CI, 7.1-45.1%) and 8.8% (95%CI, 3.7-19.5%), respectively. Complete occlusion was achieved in 76.4% (95%CI, 58.1-88.3%); no retreatments during follow-up were reported. Overall mortality was 15.1% (95%CI, 7.7-27.6%). There were no differences between single antiplatelet therapy (SAPT) and DAPT regimens with respect to periprocedural thromboembolic complications (P = 0.09), hemorrhagic (P = 0.834) complications, and mortality (P = 0.312).

CONCLUSION

Surface-modified FD treatment of ruptured aneurysms resulted in high rates of thromboembolic complications and acceptable rates of hemorrhagic complications. A considerable proportion of aneurysms were nonsaccular. Rates of complete occlusion were high and retreatment were low. Importantly, no statistically significant difference was found between SAPT and DAPT with respect to complications and mortality.

Safety and efficacy of stent-assisted coil embolization with periprocedural dual antiplatelet therapy for the treatment of acutely ruptured intracranial aneurysms

PURPOSE

Despite growing evidence for the effectiveness of stent-assisted coil embolization (SAC) in treating acutely ruptured aneurysms, the safety of stent placement in acute phase remains controversial because of concerns for stent-induced thromboembolism and hemorrhagic events attributable to the necessity of antiplatelet therapy. Therefore, we investigated the safety and efficacy of SAC with periprocedural dual antiplatelet therapy (DAPT) compared with the coiling-only technique to determine whether it is a promising treatment strategy for ruptured aneurysms.

METHODS

We retrospectively evaluated 203 enrolled patients with acutely ruptured aneurysms, categorizing them into two groups: SAC and coiling-only groups. Comparative analyses between the two groups regarding angiographic results, clinical outcomes, and procedure-related complications were performed. A subgroup analysis of procedural complications was conducted on patients who did not receive chronic antithrombotic medications to alleviate their influence before hospitalization.

RESULTS

130 (64.0%) patients were treated using the coiling-only technique, whereas 73 (36.0%) underwent SAC. There was a trend to a higher complete obliteration rate (p = 0.061) and significantly lower recanalization rate (p = 0.030) at angiographic follow-up in the SAC group compared to the coiling-only group. Postprocedural cerebral infarction occurred less frequently in the SAC group (8.2%) than in the coiling-only group (17.7%), showing a significant difference (p = 0.044). Although the ventriculostomy-related hemorrhage rate was significantly higher in the SAC group than in the coiling-only group (26.2% vs. 9.3%, p = 0.031), the incidence of symptomatic ventriculostomy-related hemorrhage was comparable. Subgroup analysis excluding patients receiving chronic antithrombotic medications showed similar results.

CONCLUSION

SAC with periprocedural DAPT could be a safe and effective treatment strategy for acutely ruptured aneurysms. Moreover, it might have a protective effect on postprocedural cerebral infarction without increasing the risk of symptomatic hemorrhagic complications.

Treatment of intracranial aneurysms with pipeline embolization device: a single-center experience

Background

Endovascular therapy is the primary treatment modality for intracranial aneurysms (IA). The objective of this study was to assess the effectiveness and safety of a pipeline embolization device (PED) for the treatment of IA.

Methods

This retrospective study was conducted at a single center. Data were collected for all patients who underwent PED treatment at the Fourth Affiliated Hospital of Xinjiang Medical University between December 2018 and January 2022. Clinical characteristics, aneurysm-related characteristics, treatment details, and clinical and imaging outcomes were collected and analyzed.

Results

A total of 60 consecutive patients with 60 IAs were treated with a PED. The mean age of the participants was 61.8 years, with 53% being female. The average size of the aneurysms was 14.7 mm, with 54 located in the anterior circulation and six in the posterior circulation. The median last follow-up time was 13.0 months (range, 11-24 months). All patients underwent final digital subtraction angiography (DSA) for angiographic follow-up, and 50 aneurysms (83.3%) were completely occluded. The overall complication rate was 3.3%, and there were no reported mortalities. Among the 12 cases of ruptured aneurysms, all of which underwent adjunctive coil embolization, the complete occlusion rate was 91.7% with a complication rate of 16.6% [ischemic complication and modified Rankin scale (mRS) deteriorated]. In the 6 cases of posterior circulation aneurysms (2 in the basilar artery), 5 cases achieved complete occlusion and 1 case achieved near-complete occlusion, with no reported complications or mortality.

Conclusions

The use of PEDs appears to be an effective treatment option for IA, demonstrating high occlusion rates and low complication rates. While the application of PEDs for the treatment of ruptured aneurysms did not increase the risk of secondary aneurysm rupture, caution is still warranted due to a higher complication rate. In the treatment of aneurysms of the vertebrobasilar artery using PEDs, this study achieved favorable efficacy outcomes without complications nor patient mortality. However, further studies are needed to validate these findings.

Textbook Outcomes Among Patients with Aneurysmal Subarachnoid Hemorrhage Following Endovascular Treatment

INTRODUCTION

The case fatality rate among patients with aneurysmal subarachnoid hemorrhage (aSAH) has decreased progressively, with numerous patients subjected to contemporary paradigms that minimize the use of agonizing therapeutic processes. The concept of the "Textbook Outcome" (TO), a composite outcome that highlights numerous favorable outcomes, was developed in the context of gastrointestinal tumor surgeries and expeditiously extended across diverse surgical spheres. The aim of this study was to explore the factors hindering the achievement of optimal prognoses in postinterventional aSAH patients, employ textbook outcomes, and establish predictive models.

METHODS

We conducted a retrospective review of data from 1270 aSAH patients who received endovascular treatment between 2012 and 2018. We delineated an exemplary TO within the aSAH domain, characterized by favorable clinical results, minimal complications, and the absence of retreatments. This TO-oriented approach is explained within the manuscript.

RESULTS

The findings revealed that preoperative intraventricular hemorrhage (IVH), preoperative Hunt and Hess grade (H&H) ≥ 3, World Federation of Neurosurgical Societies (WFNS) grade ≥ 3, the presence of blebs on the aneurysm, aneurysms situated at branching sites, and non-stent-assisted endovascular intervention were the strongest risk factors for not achieving textbook outcomes (non-"Textbook Outcome" [N-TO]). Decision curve analysis and calibration analyses revealed strong concordance between the predictions of the N-TO nomogram model and the actual observations.

CONCLUSIONS

Treatment Outcomes hold significant practical value in clinical studies of aSAH patients receiving endovascular treatment. The likelihood of N-TOs was predicted by IVH, H&H grade ≥ 3, WFNS grade ≥ 2, presence o f bleb on the aneurysm, and aneurysms located at branching sites.

Ticagrelor Versus Clopidogrel in Endovascular Therapy for Cerebral Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND

Antiplatelet therapy is pivotal in endovascular treatment for intracranial aneurysms. However, there is a lack of studies comparing ticagrelor to clopidogrel in patients with aneurysms undergoing endovascular therapy. Additionally, the existing literature lacks adequate sample size, significant subgrouping, and follow-up, making our study important to cover these gaps.

METHODS

We searched 5 databases to collect all relevant studies. Categorical outcomes were pooled as relative risk (R.R.) with a 95% confidence interval (CI). In the single-arm meta-analysis, outcomes were pooled as proportions and their corresponding 95% CI.

RESULTS

This comprehensive analysis of 18 studies involving 2,427 patients. For thromboembolic events, the pooled (R.R.) did not show significant differences, whether considering overall events. A similar pattern was observed for thromboembolic events stratified by aneurysmal rupture status, with no significant differences in overall events. Hemorrhagic events did not also exhibit significant differences in previously mentioned stratifications. Furthermore, there were no substantial differences in death and mRS (0-2) on discharge between Ticagrelor and Clopidogrel. Single-arm meta-analyses for Ticagrelor demonstrated low rates of thromboembolic events, hemorrhage, death, and favorable mRS scores, with associated confidence intervals (CIs). Main line of endovascular treatment did not significantly affect either thromboembolic or hemorrhagic outcomes with Ticagrelor and Clopidogrel.

CONCLUSIONS

We found no significant differences in key outcomes like thromboembolic events, hemorrhagic events, mortality rates, and favorable mRS (0-2) upon discharge in the studied patients between Ticagrelor and Clopidogrel. Moreover, the single-arm meta-analysis for Ticagrelor revealed low rates of thromboembolic events, hemorrhage, mortality, and high rates of favorable mRS scores.

Flow diversion of ruptured intracranial aneurysms: a single-center study with a standardized antithrombotic treatment protocol

BACKGROUND

The use of antithrombotic medication following acute flow diversion for a ruptured intracranial aneurysm (IA) is challenging with no current guidelines. We investigated the incidence of treatment-related complications and patient outcomes after flow diversion for a ruptured IA before and after the implementation of a standardized antithrombotic medication protocol.

METHODS

We conducted a single-center retrospective study including consecutive patients treated for acutely ruptured IAs with flow diversion during 2015-2023. We divided the patients into two groups: those treated before the implementation of the protocol (pre-protocol) and those treated after the implementation of the protocol (post-protocol). The primary outcomes were hemorrhagic and ischemic complications. A secondary outcome was clinical outcome using the modified Ranking Scale (mRS).

RESULTS

Totally 39 patients with 40 ruptured IAs were treated with flow diversion (69% pre-protocol, 31% post-protocol). The patient mean age was 55 years, 62% were female, 63% of aneurysms were in the posterior circulation, 92% of aneurysms were non-saccular, and 44% were in poor grade on admission. Treatment differences included the use of glycoprotein IIb/IIIa inhibitors (pre-group 48% vs. post-group 100%), and the use of early dual antiplatelets (pre-group 44% vs. 92% post-group). The incidence of ischemic complications was 37% and 42% and the incidence of hemorrhagic complications was 30% and 33% in the pre- and post-groups, respectively, with no between-group differences. There were three (11%) aneurysm re-ruptures in the pre-group and none in the post-group. There were no differences in mortality or mRS 0-2 between the groups at 6 months.

CONCLUSION

We found no major differences in the incidence of ischemic or hemorrhagic complications after the implementation of a standardized antithrombotic protocol for acute flow diversion for ruptured IAs. There is an urgent need for more evidence-based guidelines to optimize antithrombotic treatment after flow diversion in the setting of subarachnoid hemorrhage.

Safety and efficacy of dual antiplatelet drugs for stent-assisted embolization on risk of stroke and prognosis in patients with ruptured intracranial aneurysms: One center results of CIAP-5 clinical trial

BACKGROUND

Although stent-assisted coiling embolization (SAC) has been associated with a higher risk of ischemic and hemorrhagic complications, the use of SAC continues to rise for treating ruptured intracranial aneurysms (RIAs). This study aims to assess the safety and effectiveness of dual antiplatelet therapy (DAPT) in the context of RIAs.

METHODS

We conducted a retrospective analysis at a single center, involving patients with aneurysmal subarachnoid hemorrhage (aSAH) between May 1, 2017 and December 31, 2021. Patients were categorized into two groups: the SAC group and the non-SAC (NSC) group. Patients in the SAC group received DAPT. We compared modified Rankin Scale (mRS) score, along with hemorrhagic and ischemic complications, between the two groups to evaluate the safety and efficacy of DAPT for SAC.

RESULTS

The study included a total of 541 patients, of whom 38 (7.0%) experienced hemorrhagic complications and 48 (8.9%) developed ischemic complications. Additionally, 99 (18.3%) and 84 (15.5%) had poor clinical outcomes at discharge and 6 months, respectively. However, no statistically significant differences were observed between the two groups. Our analysis revealed that aneurysm location in the posterior circulation was a significant risk factor for an unfavorable prognosis when antiplatelet drugs were used following SAC (p = 0.025).

CONCLUSIONS

Administering antiplatelet drugs after SAC for RIAs has demonstrated both safety and effectiveness. However, caution should be exercised when considering this treatment strategy for RIAs located in the posterior circulation due to the potentially elevated risk.

Periprocedural thromboembolic complications of LEO baby stent in endovascular treatment of intracranial aneurysms: Experience in 149 patients

OBJECTIVE

To report periprocedural thromboembolic complications of LEO Baby stent-assisted coiling of wide-necked intracranial aneurysms and to analyze the possible influencing factors.

METHODS

We retrospectively identified 149 patients with aneurysms who underwent LEO Baby stent-assisted embolization between October 2018 and March 2022. Clinical and radiographic data of patients were reviewed to determine whether a thromboembolic event had occurred. Multivariate logistic analysis was performed to identify significant factors associated with thromboembolic events.

RESULTS

Successful stent deployment of the stent was achieved in all patients in the target artery. There were 66 patients (44.3%) with acutely ruptured aneurysms and 83 patients (55.7%) with unruptured aneurysms. Fourteen (9.4%, 95% confidence interval: 4.7%-14.1%) patients were confirmed to have developed a thromboembolic event, including nine patients with acute intraoperative thrombosis and five patients with postoperative thromboembolic events. The rate of thromboembolic events was 6.0% (5/83) in patients with unruptured aneurysms and 13.6% (9/66) in patients with acutely ruptured aneurysms. There was a trend toward an increased rate of thromboembolic events in patients with acute ruptured aneurysms (p = 0.087). Thromboembolic events were significantly associated with the parent-artery diameter (p = 0.010).

CONCLUSIONS

Our study demonstrates a low rate of thromboembolic complications in unruptured aneurysms treated with LEO Baby stent. Thromboembolic events appear to be more common in ruptured aneurysms. A small diameter of the parent artery is associated with an increased risk of thromboembolic complications, and more relevant studies are still needed.

Woven EndoBridge versus stent-assisted coil embolization for the treatment of ruptured wide-necked aneurysms: A multicentric experience

BACKGROUND

The potentially higher risk of hemorrhagic complications is of concern in stent-assisted coiling (SAC) of ruptured wide-necked intracranial aneurysms (IAs). The Woven EndoBridge (WEB) is considered an appealing alternative since antiplatelet therapy is not required. Herein, we aimed to compare the safety and effectiveness of WEB vs. SAC for the treatment of ruptured wide-necked IAs.

METHODS

This was an international cross-sectional study of consecutive patients treated for ruptured wide-neck IAs with WEB or SAC at four high-volume neurovascular centers between 2019 and 2022. Primary and secondary efficacy outcomes were radiographic aneurysm occlusion at follow-up and functional status at last follow-up. Safety outcomes included periprocedural hemorrhagic/ischemia-related complications.

RESULTS

One hundred five patients treated with WEB and 112 patients treated with SAC were included. The median procedure duration of endovascular treatment was shorter for WEB than for SAC (69 vs. 76 min; p = 0.04). There were no significant differences in complete aneurysm occlusion rates (SAC: 64.5% vs. WEB: 60.9%; adjusted OR [aOR] = 0.70; 95%CI 0.34-1.43; p = 0.328). SAC had a significantly higher risk of complications (23.2% vs. 9.5%, p = 0.009), ischemic events (17% vs. 6.7%, p = 0.024), and EVD hemorrhage (16% vs. 0%, p = 0.008). The probability of procedure-related complications across procedure time was significantly lower with WEB compared with SAC (aOR = 0.40; 95%CI 0.20-1.13; p = 0.03).

CONCLUSION

WEB and SAC demonstrated similar obliteration rates at follow-up when used for embolization of ruptured wide-necked IAs. However, SAC showed higher rates of procedure-related complications primarily driven by ischemic events and higher rates of EVD hemorrhage. The overall treatment duration was shorter for WEB than for SAC.

One year clinical outcome of dual anti-platelet therapy with the Novel Ticagrelor plus Aspirin versus Clopidogrel plus Aspirin for Endovascular Intervention of patients with Intracranial Aneurysm: A meta-analysis

BACKGROUND

The use of stents to treat un-ruptured intracranial aneurysms was first approved in the year 2002 in the United States as a Humanitarian Device Exemption. Antiplatelet therapy is mandatory following stent placement. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel has been the first line agents for the prevention of thromboembolic events following neuro-endovascular procedures. However, clopidogrel hypo-responsiveness has often been observed. In this analysis, we aimed to systematically compare one year clinical outcome of DAPT with the Novel Ticagrelor plus Aspirin versus Clopidogrel plus Aspirin for Endovascular Intervention of patients with Intracranial Aneurysm.

METHODS

Online electronic databases were searched from June 2023 till July 2023 for relevant studies which compared DAPT with ticagrelor or clopidogrel for endovascular intervention in patients with intracranial aneurysm. The endpoints which were analyzed were classified into thromboembolic and hemorrhagic events. A fixed and a random effect statistical model were used during data analysis respectively. Risk ratio (RR) with 95 % confidence interval (CI) was used to represent the data following analysis.

RESULTS

Five studies with a total number of 893 participants were included in this analysis. Three hundred and fifty eight (358) participants were assigned to the ticagrelor group whereas 535 participants were assigned to clopidogrel group. Participants' enrollment period ranged from the year 2009 to 2019. Our results showed that during a mean follow-up time period of one year, DAPT with ticagrelor was associated with significantly lower thromboembolic events with RR: 0.33, 95 % CI: 0.16 - 0.68; P = 0.003. In addition, at one year, DAPT with ticagrelor was not associated with any increase in hemorrhagic events (RR: 0.66, 95 % CI: 0.29 - 1.50; P = 0.32) when compared to DAPT with clopidogrel.

CONCLUSION

At one year, DAPT with ticagrelor was associated with significantly lower thromboembolic events without any increase in hemorrhagic events when compared to clopidogrel associated DAPT for endovascular intervention of patients with intracranial aneurysm. However, even though ticagrelor-associated DAPT use appeared to be more effective and safe, this hypothesis should only be confirmed in larger upcoming trials.

Stent-Assisted Coil Embolization of Ruptured Aneurysms in the Acute Stage: Advantages and Disadvantages

Objective

In the acute stage of ruptured cerebral aneurysms, limited devices are available, making the treatment difficult. We aimed to evaluate the outcomes of the coil embolization with stenting for the ruptured cerebral aneurysms in the acute stage.

Methods

We assessed 22 cases treated with stenting among 134 of 169 consecutive patients with subarachnoid hemorrhages undergoing an endovascular treatment between April 2014 and December 2021, of which 134 underwent an embolization during the acute stage. A stent was used in the patients wherein the treatment with the balloon-assisted or double catheter technique was difficult. Stenting was performed under the loading of two or more antiplatelet agents.

Results

The mean age of the patients was 68.9 years, of which five were male and 14 (63.6%) had severe grade (World Federation of Neurosurgeons grade IV, V). The aneurysm site was the anterior communicating artery in four cases, internal carotid artery in nine, middle cerebral artery in two, vertebrobasilar artery in six, and posterior cerebral artery in one. The aneurysm shape was saccular in 13 cases, dissection in seven, and fusiform in two. Stents were used for wide-neck aneurysms in 12 cases, vascular preservation in seven, and rescue in three. The mean maximum diameter was 9.6 mm. The mean neck size was 6.4 mm. Complete occlusion and neck remnant were found in eight and seven cases, respectively. The perioperative complication rate was 45.5% (thromboembolism in five cases, stent occlusion in two, re-bleeding in two, and cerebral hemorrhage in one). The outcomes included modified Rankin Scale 0-2 in seven cases, 4-5 in five, and 6 in nine. Stent-related death occurred in one case. The rate of morbidity and mortality was 18.2%. Although stents were used in the acute stage of rupture, they were used for the right reasons. However, a high rate of complications occurred: two cases of re-bleeding, in which an incomplete occlusion was a factor.

Conclusion

Stent placement in patients with the acute ruptured cerebral aneurysms should be carefully determined and efforts should be made to reduce the embolic and hemorrhagic complications. However, it may be an effective treatment option when other options could be extremely difficult.

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

AIM

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

METHODS

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

Coiling Variations for Treatment of Ruptured Intracranial Aneurysms: A Meta-Analytical Comparison of Comaneci-, Stent-, and Balloon-Coiling Assistance Techniques

BACKGROUND

Wide-necked aneurysms represent a challenge for treatment in the setting of acute subarachnoid hemorrhage. Stent-assisted coiling (SAC) and balloon-assisted coiling (BAC) are well-known techniques for treating wide-necked aneurysms. Comaneci-assisted coiling (CAC) is a newer technique involving temporary stent deployment to assist aneurysm coiling. We aim to present the first meta-analysis comparing these treatments of ruptured aneurysms.

METHODS

Following PRISMA guidelines, PubMed and Embase databases were queried from earliest records to July 2022 for literature reporting SAC, BAC, or CAC of ruptured intracranial aneurysms. A meta-analysis of identified articles was performed.

RESULTS

Of the 571 articles queried, 64 articles were included. One study reported BAC and SAC, 8 reported BAC, 52 reported SAC, and 3 reported CAC. These studies comprised 3153 patients with 3207 ruptured aneurysms treated with CAC (161 patients and aneurysms), BAC (330 patients and aneurysms), and SAC (2662 patients, 2716 aneurysms). Rates of periprocedural thromboembolic or hemorrhagic complications, overall or procedure-related mortality, immediate complete occlusion, retreatment, and length of angiographic follow-up did not differ significantly between SAC and BAC. Periprocedural thromboembolic (P = 0.03) and hemorrhagic (P = 0.01) complication rates were higher with BAC than CAC. Periprocedural thromboembolic (P = 0.03) and hemorrhagic (P < 0.0001) complication rates were higher with SAC than CAC. Complete aneurysm occlusion rates (P = 0.033) were higher with CAC than BAC. No significant differences were present in CAC versus BAC or SAC retreatment rates.

CONCLUSIONS

CAC was associated with lower hemorrhagic and thromboembolic complication rates and demonstrated similar complete occlusion and residual retreatment rates to those for BAC and SAC.

Stent-Assisted Coiling in the Treatment of Unruptured Intracranial Aneurysms: A Randomized Clinical Trial

BACKGROUND AND PURPOSE

Stent-assisted coiling may improve angiographic results of endovascular treatment of unruptured intracranial aneurysms compared with coiling alone, but this has never been shown in a randomized trial.

MATERIALS AND METHODS

The Stenting in the Treatment of Aneurysm Trial was an investigator-led, parallel, randomized (1:1) trial conducted in 4 university hospitals. Patients with intracranial aneurysms at risk of recurrence, defined as large aneurysms (≥10 mm), postcoiling recurrent aneurysms, or small aneurysms with a wide neck (≥4 mm), were randomly allocated to stent-assisted coiling or coiling alone. The composite primary efficacy outcome was "treatment failure," defined as initial failure to treat the aneurysm; aneurysm rupture or retreatment during follow-up; death or dependency (mRS > 2); or an angiographic residual aneurysm adjudicated by an independent core laboratory at 12 months. The primary hypothesis (revised for slow accrual) was that stent-assisted coiling would decrease treatment failures from 33% to 15%, requiring 200 patients. Primary analyses were intent to treat.

RESULTS

Of 205 patients recruited between 2011 and 2021, ninety-four were allocated to stent-assisted coiling and 111 to coiling alone. The primary outcome, ascertainable in 203 patients, was reached in 28/93 patients allocated to stent-assisted coiling (30.1%; 95% CI, 21.2%-40.6%) compared with 30/110 (27.3%; 95% CI, 19.4%-36.7%) allocated to coiling alone (relative risk = 1.10; 95% CI, 0.7-1.7; P  = .66). Poor clinical outcomes (mRS >2) occurred in 8/94 patients allocated to stent-assisted coiling (8.5%; 95% CI, 4.0%-16.6%) compared with 6/111 (5.4%; 95% CI, 2.2%-11.9%) allocated to coiling alone (relative risk = 1.6; 95% CI, 0.6%-4.4%; P  = .38).

CONCLUSIONS

The STAT trial did not show stent-assisted coiling to be superior to coiling alone for wide-neck, large, or recurrent unruptured aneurysms.

Comparison of Neuroform Atlas Stent-Assisted Coiling and Coiling Alone in Ruptured Intracranial Aneurysms: A Propensity Score Matching Analysis

BACKGROUND

Although Neuroform Atlas stent is commonly used in stent-assisted coiling (SAC) to treat ruptured intracranial aneurysms (RIA), its safety and efficacy remain controversial.

OBJECTIVE

To assess the safety and efficacy of SAC using Neuroform Atlas for treating RIA compared with coiling alone by performing a propensity score matching analysis.

METHODS

RIA treated with coiling alone and SAC between January 2017 and May 2021 were retrospectively reviewed. Demographics, periprocedural complication rates, angiographic outcomes, and clinical outcomes of the SAC using Neuroform Atlas group and the coiling-alone group were analyzed with 1:1 propensity score matching.

RESULTS

A total of 375 aneurysms were enrolled, and 274 (63.1%) aneurysms were treated with coiling alone. In total, 101 (26.9%) aneurysms were treated with SAC, and Neuroform Atlas stent was used in 71 aneurysms. In propensity score matching, the SAC using Neuroform Atlas group showed higher incidence of complete occlusion (69.0% vs 56.3%, P = .029), lower rate of recanalization (11.3% vs 25.4%, P = .011), and lesser need for retreatment (7.0% vs 16.9%, P = .016) compared with the coiling-alone group. However, there were no significant differences in periprocedural complications such as intraprocedural thrombosis or postprocedural cerebral infarct between the 2 groups.

CONCLUSION

The use of Neuroform Atlas is safe and effective for SAC in RIA with comparable procedure-related complication rates but better angiographic outcome in comparison with coiling alone.

Stent-assisted coiling vs. coiling alone of ruptured tiny intracranial aneurysms: A contemporary cohort study in a high-volume center

Objective

This study aims to compare the safety and efficacy of stent-assisted coiling (SAC) with those of coiling alone (CA) for the treatment of ruptured tiny intracranial aneurysms.

Methods

We enrolled 245 patients with ruptured tiny intracranial aneurysms treated with coil embolization. Patients were grouped into SAC and CA groups. Baseline characteristics, periprocedural complications, clinical outcomes, and angiographic results were compared between the two groups. In addition, a subgroup analysis was conducted in the SAC group, and patients were regrouped into low-profile visualized intraluminal support (LVIS) and laser-cut groups to compare the perioperative procedure-related complications and clinical and angiographic follow-up outcomes.

Results

All baseline characteristics were equivalent between the two groups except for aneurysm size and dome-to-neck aspect ratio. The rates of overall procedure-related complications, intraprocedural rupture, postoperative early rebleeding, intraprocedural thrombosis, postprocedural thrombosis, and procedure-related mortality were comparable between the two groups (P = 0.105, 0.145, 0.308, 1.000, 1.000, 0.160, respectively). Nevertheless, the rate of hemorrhagic complication in the SAC group was significantly higher (P = 0.023). The angiographic follow-up outcomes showed that the SAC group had a higher complete occlusion rate and lower recurrence rate (88.2 vs. 67.1%, 5.4 vs. 15.2%, P = 0.001). The clinical outcomes at discharge and follow-up between the two groups demonstrated no significant differences (P = 0.192 and P = 0.085, respectively). For subgroup analysis, LVIS stents were associated with a significantly higher rate of complete occlusion (P = 0.014) and a lower rate of intraprocedural rupture (p = 0.021). Moreover, multivariate analysis showed that there were no predictors for the overall, hemorrhagic, and ischemic procedure-related complications, while Raymond class was an independent predictor of retreatment (OR = 3.508, 95% CI 1.168-11.603; P = 0.029).

Conclusion

Stent-assisted coiling may increase the incidence of hemorrhagic events with favorable angiographic results and comparable clinical outcomes compared with stand-alone coiling. Nevertheless, LVIS stent could improve the safety compared with lazer-cut stent. Simultaneously, considering the better long-term effect, LVIS stent-assisted coiling may be a preferable choice for ruptured tiny intracranial aneurysms.

Stent-assisted Coiling vs. Flow Diverter for Treating Blood Blister-like Aneurysms : A Proportion Meta-analysis

PURPOSE

Blood blister-like aneurysms (BBAs) are rare vascular lesions and a therapeutic challenge. Although endovascular treatment of BBA is a promising approach, the optimal treatment remains controversial. The purpose of this study was to compare the safety and efficacy of stent-assisted coiling (SAC) and flow diverter (FD) in the management of BBAs.

METHODS

A proportion meta-analysis including a published series of BBAs treated with endovascular approaches from 2009 to 2020 including SAC and FD was performed by searching English language studies via MEDLINE and EMBASE.

RESULTS

The 32 studies included 16 based on SAC and 16 involving FD. The long-term complete occlusion rate was higher in FD (89.26%, 95% confidence interval, CI 82.93-94.26%, I² = 14.42%) than in SAC (70.26%, 95% CI 56.79-82.13%, I² = 70.60%). The rate of aneurysm recanalization was lower in FD (4.54%, 95% CI 1.72-8.16%, I² = 0%) than in SAC (25.38%, 95% CI 14.44-38.19%, I² = 67.31%). Rates of mortality, favorable functional outcome, procedural complications, and rebleeding showed no differences between the two procedures.

CONCLUSION

In a proportion meta-analysis comparing FD with SAC, the FD was associated with more favorable angiographic outcomes but similar complications and clinical outcomes.

Microcatheter-guided compartment packing of acutely ruptured complex intracerebral aneurysms (ARCIAs): Preliminary experience and technical note

Objective

We present our initial experience using the microcatheter-guided compartment packing (MCP) technique for endovascular embolization of acutely ruptured complex intracerebral aneurysms (ARCIAs) and evaluate the safety, feasibility, and efficiency of this technique.

Methods

This retrospective, single-center study included 28 patients who underwent coil embolization using the MCP technique for ARCIAs at our institution between January 2021 and January 2022. The MCP technique was the placement of microcatheters in different compartments within the aneurysm to deploy the coils simultaneously or sequentially. Patient demographics, aneurysm characteristics, procedural parameters, grade of occlusion, complications, and clinical results were analyzed. The clinical outcomes were evaluated with modified Rankin Scale (mRS) scores.

Results

Of the 28 patients successfully treated with the MCP technique, 24 (85.7%) aneurysms were considered as complete occlusions (Raymond I) based on the immediate postembolization angiogram results. Complications occurred in 2/28 treatments, including guidewire perforation with subarachnoid hemorrhage and cerebral vasospasm-related cerebral infarction. An angiography follow-up demonstrated complete occlusion in 25/28 aneurysms. Twenty-six (92.9%) patients had favorable 90-day outcomes (mRS 0-2) after the endovascular coil embolization.

Conclusion

The MCP technique is simple, safe, and effective, achieving good packing density and initial occlusion rate when used to treat ARCIAs.

Worldwide productivity and research trends of publications concerning stent application in acutely ruptured intracranial aneurysms: A bibliometric study

Background

Stenting is a common clinical practice to treat acutely ruptured intracranial aneurysm (RIA). Although multiple studies have demonstrated its long-term safety and effectiveness, there is currently a lack of bibliometric analysis on stent application in acutely RIA. This study sought to summarize the current status of research in this field and lay a foundation for further study.

Materials and methods

Related publications were searched in the Web of Science Core Collection (WoSCC) database. Data analysis and visualization were performed by R and CiteSpace software.

Results

A total of 275 publications published in English from 1997 to 2022 were included in this study. The growth of publications slowed down. The reference co-citation network identified 13 clusters with a significant network (Q = 0.7692) and convincing clustering (S = 0.9082). The research focus was acutely RIA and the application of stents during interventional procedures. The main trends of research were: (1) development of materials, and (2) safety of stent application in acutely RIA. The United States contributed the most articles, and Jianmin Liu was the most prolific author. Mayo Clinic was the leading institution in this field. Most articles were published in Interventional Neuroradiology.

Conclusions

This study analyzed the research trends, hotspots and frontiers of stent application in acutely RIA. It is our hope that the results obtained could provide useful information to researchers to get a clearer picture about their future research directions in this field.

Comaneci-Assisted Coiling of Wide-Necked Intracranial Aneurysm: A Single-Center Preliminary Experience

BACKGROUND

Wide-necked aneurysms remain challenging for both coiling and microsurgical clipping. They often require additional techniques to prevent coil prolapse into the parent artery, such as balloon- and stent-assisted coiling. Comaneci is an expandable and removable stent that acts as a bridging device and does not interfere with the blood flow of the parent artery.

METHODS

We retrospectively reviewed our institutional radiological and clinical chart of patients treated for saccular intracranial aneurysm via endovascular Comaneci-assisted coiling. The aim of the study was to report our preliminary experience in Comaneci-assisted coiling of wide-necked intracranial aneurysms.

RESULTS

We included 14 patients in the study. Of these, 11 had a ruptured intracranial aneurysm and were treated with Comaneci-assisted coiling. We registered five minor intraprocedural complications and two intraprocedural failures of the device. At one-year follow-up, a satisfying aneurysm occlusion was observed in 85% of the cases.

CONCLUSIONS

Though long-term follow-up data and larger case series are needed, this preliminary study showed the feasibility of the Comaneci-assisted coiling method for both ruptured and unruptured wide-neck intracranial aneurysms, with similar occlusion rates as balloon-assisted coiling. However, we registered high incidence of thromboembolic complications; these were probably related to the lack of heparin administration. The main advantageous application of this technique is likely in cases of ruptured intracranial aneurysms, as there is no need for post-procedural antiplatelet therapy.

Effects of stent-assisted coiling in comparison with flow diversion on intracranial aneurysms

Objective

The aim of this study was to investigate the efficacy and complications of stent-assisted coiling in comparison with flow diversion for wide-necked intracranial aneurysms.

Methods

Patients with wide-necked intracranial aneurysms who were treated with stent-assisted coiling or flow diversion were respectively, enrolled into the stent-assisted coiling or flow diversion treatment group. The clinical and angiographic data were analyzed.

Results

A total of 61 patients with intracranial aneurysms underwent stent-assisted coiling, including 35 (57.4%) female and 26 (42.6%) male patients with 21 (34.4%) ruptured and 40 (65.6%) unruptured aneurysms. Also, 53 patients underwent deployment of flow-diverting devices, including 30 (56.6%) female and 23 (43.4%) male patients with 25 (47.2%) ruptured and 28 (52.8%) unruptured aneurysms. Stent-assisted coiling was performed successfully in 60 patients with 63 stents deployed, and immediate aneurysm occlusion was complete occlusion in 38 (62.3%) aneurysms, residual neck in 12 (19.7%), and residual aneurysm in 10 (16.4%). Procedure-related complications included in-stent thrombosis in three (4.9%) patients, coil protrusion in three (4.9%), and re-rupture of one (1.6%) aneurysm, with a total complication rate of 11.5%. In the flow diversion group, a pipeline embolization device alone was deployed in each of the 24 (45.3%) patients, adjunctive coiling combined with a pipeline device in 29 (54.7%), and double pipeline devices in each of the 6 (11.3%) patients. Immediately after treatment, complete occlusion was achieved in 3 (5.7%) patients with adjunctive coiling, residual neck in 3 (5.7%), and residual aneurysm in 47 (88.7%). Procedure-related complications included aneurysm rebleeding in one patient (1.9%). Clinical and angiographic follow-up was performed 13–49 months (median 29) after the procedure for 49 (80.3%) patients with stent-assisted coiling, with complete aneurysm occlusion in 27 (55.1%) aneurysms, residual neck in 3 (6.1%), residual aneurysm in 5 (10.2%), and recurrence in 14 (28.6%). Follow-up was performed for 14–37 (median 25) months in 45 (84.9%) patients with flow diversion treatment, with complete occlusion in 39 (86.7%) patients, residual neck in 5 (11.1%), residual aneurysm in 1 (2.2%), and no aneurysm recurrence.

Conclusions

Stent-assisted coiling comes with more complications but fewer permanent aneurysm occlusions than flow diverters, and flow diverters are superior to stent-assisted coiling in the treatment of wide-necked intracranial aneurysms, especially in the long-term effect.

Opposite L-configuration double stenting for rupture of an extremely wide-necked anterior communicating artery aneurysm at the acute stage: illustrative case

BACKGROUND

Wide-necked aneurysms can be treated by double stenting in an X- or Y-configuration or by a double waffle-cone technique. However, some aneurysms remain untreatable.

OBSERVATIONS

The rupture of a complex wide-necked anterior communicating artery (AcomA) aneurysm that caused acute subarachnoid hemorrhage (SAH) was treated successfully using double stents with an opposite L-configuration as an alternative to the X-stent technique. The aneurysm involved both A1-A2 junctions in the aneurysm neck with acutely oriented A2 segments of the anterior cerebral artery bilaterally. It was densely packed and completely obliterated angiographically with preserved blood flow by implanting each stent in the ipsilateral A1-A2 bilaterally. Blood flow from the left A1 to the right A2 was confirmed through the AcomA on injection of the left internal carotid artery immediately after the procedure without critical infarction in the subthalamic area. Although the AcomA was not demonstrated by injection of the left internal carotid artery on angiography at 3 months or 1 year later, no cerebral infarction was seen on magnetic resonance images at the final hospital visit.

LESSONS

Opposite L-configuration double stenting was used successfully as rescue stent-assisted coiling for a rupture of a complex wide-necked AcomA aneurysm in a patient with acute SAH.

Efficacy of pipeline embolization device vs. traditional coils in embolization of intracranial aneurysms: A systematic review and meta-analysis

Introduction

In recent years, the Pipeline embolization device (PED) has been widely used in the embolization of intracranial aneurysms, but there are some inconsistent findings on whether its efficacy and safety are superior to those of traditional coils embolization (coils alone, stent-assisted coils and balloon-assisted coils). The purpose of this meta-analysis was to evaluate the safety and efficacy of PED in intracranial aneurysm embolization by comparing with traditional coils.

Methods

We systematically searched PubMed, Embase, Web of Science, and The Cochrane Library databases for randomized controlled trials and observational studies (case-control studies and cohort studies) comparing the efficacy of PED with traditional coils in intracranial aneurysm embolization published before April 1, 2022. The endpoints observed in this meta-analysis were procedure-related intracranial hemorrhage, procedure-related intracranial ischemia, other procedure-related complications (e.g., aneurysm rupture, neurological impairment, etc.), retreatment rate, complete occlusion (100%) of the aneurysm at the last follow-up, and favorable functional outcome (MRS ≤ 2).

Results

A total of 10 studies with a total of 1,400 patients (PED group: 576 and Traditional coils: 824) were included in this meta-analysis. A comprehensive analysis of the included literature showed that the PED group had a higher rate of complete aneurysm occlusion [OR = 2.62, 95% Cl (1.94, 3.55), p &lt; 0.00001] and Lower re-treatment rate [OR = 0.20, 95% Cl (0.12, 0.34 p &lt; 0.00001)] compared with the traditional coil embolization group at the last follow-up. In terms of procedure-related intracranial hemorrhage [OR = 3.04, 95% Cl (1.08, 8.57), p = 0.04] and other procedure-related complications [OR = 2.91, 95% Cl (1.48, 5.57), p = 0.002], the incidence of PED was higher than that of the traditional coil embolization group. Moreover, in terms of favorable functional outcome [OR = 0.4, 95% Cl (0.22, 0.71), p = 0.002] of patients at the last follow-up, the PED group was lower than the traditional coil embolization group. There was no statistically significant between the two groups in terms of surgery-related intracranial ischemia complications [OR = 0.88, 95% Cl (0.47, 1.64), p = 0.68].

Conclusion

PED had higher rates of complete aneurysm occlusion and lower rates of aneurysm retreatment compared with traditional coils, but traditional coils was superior to the PED group in terms of procedure-related intracranial hemorrhage complication and other procedure-related complications (aneurysm rupture, neurological impairment), and favorable functional outcome (mRS ≤ 2). This result still needs to be further confirmed by additional large-sample, multicenter, prospective randomized controlled trials.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022325673.

Feasibility and Safety of Transradial Aneurysm Embolization: A Systematic Review and Meta-Analysis

OBJECTIVE

Use of the transradial access (TRA) approach for neuroendovascular procedures has been increasing in recent years. Our aim is to assess the feasibility, success rate, and complications associated with TRA for intracranial aneurysm embolization.

METHODS

PubMed, Scopus, and Embase were systematically searched for studies using TRA for intracranial aneurysm embolization. Random-effects models were used to obtain pooled rates of procedural success and complications.

RESULTS

Twenty-four studies comprising 1283 (85.9%) TRA and 122 (8.2%) distal TRA aneurysm embolization procedures were included. The pooled success rate of the 18 studies in the meta-analysis was 93.5% (95% confidence interval [CI], 91.1%-95.8%). The pooled thromboembolic complication rate was 0.5% (95% CI, 0.1%-0.9%), the hemorrhagic complication rate was 0.5% (95% CI, 0.1%-0.9%), and the access site complication rate was 0.8% (95% CI, 0.3%-1.3%). One study (4.3%) used exclusively a 7-French guide catheter, and most used a 6-French guide catheter (22 of 23 studies, 95.7%), which was further incorporated as part of a triaxial configuration through a sheathless 8-French system in 4 studies (17.4%), 7-French guide catheter in 2 studies (8.7%), and 8-French sheath in 1 study (4.3%). The embolization techniques used were flow diverter placement in 451 cases (39.1%), coiling in 376 (32.6%), stent-assisted coiling in 127 (11.0%), balloon-assisted coiling in 104 (9.0%), Woven EndoBridge system in 50 (4.3%), and flow diverter placement plus coiling in 42 (3.6%).

CONCLUSIONS

Treating intracranial aneurysms using various embolization techniques through TRA is feasible and associated with low access site and intraoperative complications.

The Effect of Ticagrelor for Endovascular Intervention of Intracranial Aneurysm Patients with or without Clopidogrel Resistant: A Meta-Analysis

Endovascular interventional is an important treatment method for intracranial aneurysms. However, due to the risk of intracranial thrombosis, prophylactic use of antiplatelet drugs is generally required. Clinically, the most commonly used drugs are aspirin and clopidogrel; although the latter can significantly reduce the incidence of thromboembolic complications, there are still some patients with clopidogrel resistance who have ischemic adverse events during antiplatelet therapy. In this study, cohort studies of PubMed, Embase and Cochrane Library Databases were retrieved to compare the efficacy and safety of ticagrelor and clopidogrel in endovascular interventional treatment of intracranial aneurysms. A total of 10 cohort studies involving 1377 patients were included in this study. All patients had intracranial aneurysms and underwent endovascular intervention. Platelet function was measured in four of the studies and switched the patients with clopidogrel resistance to ticagrelor, while the remaining six studies did not test platelet function, but were also treated with ticagrelor or clopidogrel. The results of the study showed that ticagrelor, like clopidogrel, can effectively control thrombotic complications in endovascular interventional patients, and also control the occurrence of ischemic complications in clopidogrel-resistant patients. Ticagrelor, as a novel platelet aggregation inhibitor that can reversibly bind to P2Y12 receptor, can effectively control thromboembolic complications without increasing hemorrhagic complications, and is also effective in patients with clopidogrel resistance.

Comparison of Enterprise stent 2 with 1 in assisting coiling of ruptured aneurysms: a real-world study

Aim: To investigate the effectiveness and safety of the Enterprise 2 (E2) stent versus the Enterprise 1 (E1) stent in treating ruptured intracranial aneurysms (RIAs) in China. Materials & methods: The authors conducted an electronic medical record analysis for patients with RIAs who underwent E1/E2 deployment. The main outcomes were immediate complete occlusion (ICO), patient functional outcomes, complications and aneurysm recurrence. Results: Stent deployment was successful in all patients (E2: 90; E1: 270). ICO and patients with good functional outcomes at discharge were similar between E2 and E1 (80.0% vs 75.1% and 78.7% vs 81.1%, respectively). The E2 group had a significantly lower complication rate compared with the E1 group (7.8% vs 16.4%; odds ratio: 0.36; 95% CI: 0.15-0.91; p = 0.031). By 6 months post-discharge, the two groups had comparable patient functional outcomes and aneurysm recurrence (E2 vs E1: 80.2% vs 81.9% and 13.3% vs 14.9%). Conclusion: Compared with the E1 stent, the E2 stent had similar effectiveness but a lower complication risk in treating RIAs.

Stent-assisted coiling of acutely ruptured cerebral aneurysm: a multicenter prospective registry study (SAVE)

Background

Stent-assisted coiling (SAC) has been reported as a feasible and effective treatment of wide-neck cerebral aneurysms. However, the evidence of SAC of ruptured cerebral aneurysm is lacking. There are no prospective multicenter studies regarding SAC of acutely ruptured aneurysms within 72 hours after subarachnoid hemorrhage. The purpose of the study is to evaluate the safety and efficiency of SAC of acutely ruptured cerebral aneurysms.

Methods

This study is a prospective, multicenter, and observation registry of consecutive patients with acutely ruptured cerebral aneurysms treated with SAC. Acutely ruptured aneurysms were confirmed within 72 h after the onset of the syndrome. This study will enroll at least 300 patients in 7 high-volume tertiary hospitals (more than 150 cerebral aneurysms treated per year). The primary outcomes are treatment-related thromboembolic complications within 30 days of the treatment. The secondary outcomes are any hemorrhagic complications and aneurysm recurrence at 6 months of angiographic follow-up. The clinical outcomes are measured with the Modified Rankin Scale (mRS) at discharge and at the 6 months of follow-up. The favorable outcomes are defined as an mRS of grades 0 and 2.

Discussion

We will perform a prospective, multicenter, and observational registry study of consecutive patients with wide-neck acutely ruptured cerebral aneurysms to improve the safety strategy of SAC of acutely ruptured cerebral aneurysms.

Trial registration

Chinese Clinic Trial Registry: ChiCTR2000036972; Registration date: Aug 26, 2020

Endovascular Therapy Versus Microsurgical Clipping of Ruptured Wide Neck Aneurysms (EVERRUN Registry): a multicenter, prospective propensity score analysis

OBJECTIVE

Randomized controlled trials have demonstrated the superiority of endovascular therapy (EVT) compared to microsurgery (MS) for ruptured aneurysms suitable for treatment or when therapy is broadly offered to all presenting aneurysms; however, wide neck aneurysms (WNAs) are a challenging subset that require more advanced techniques and warrant further investigation. Herein, the authors sought to investigate a prospective, multicenter WNA registry using rigorous outcome assessments and compare EVT and MS using propensity score analysis (PSA).

METHODS

Untreated, ruptured, saccular WNAs were included in the analysis. A WNA was defined as having a neck ≥ 4 mm or a dome/neck ratio (DNR) < 2. The primary outcome was the modified Rankin Scale (mRS) score at 1 year posttreatment, as assessed by blinded research nurses (good outcome: mRS scores 0-2) and compared using PSA.

RESULTS

The analysis included 87 ruptured aneurysms: 55 in the EVT cohort and 32 in the MS cohort. Demographics were similar in the two cohorts, including Hunt and Hess grade (p = 0.144) and modified Fisher grade (p = 0.475). WNA type inclusion criteria were similar in the two cohorts, with the most common type having a DNR < 2 (EVT 60.0% vs MS 62.5%). More anterior communicating artery aneurysms (27.3% vs 18.8%) and posterior circulation aneurysms (18.2% vs 0.0%) were treated with EVT, whereas more middle cerebral artery aneurysms were treated with MS (34.4% vs 18.2%, p = 0.025). Within the EVT cohort, 43.6% underwent stand-alone coiling, 50.9% balloon-assisted coiling, 3.6% stent-assisted coiling, and 1.8% flow diversion. The 1-year mRS score was assessed in 81 patients (93.1%), and the primary outcome demonstrated no increased risk for a poor outcome with MS compared to EVT (OR 0.43, 95% CI 0.13-1.45, p = 0.177). The durability of MS was higher, as evidenced by retreatment rates of 12.7% and 0% for EVT and MS, respectively (p = 0.04).

CONCLUSIONS

EVT and MS had similar clinical outcomes at 1 year following ruptured WNA treatment. Because of their challenging anatomy, WNAs may represent a population in which EVT's previously demonstrated superiority for ruptured aneurysm treatment is less relevant. Further investigation into the treatment of ruptured WNAs is warranted.

Comparison of Stent-Assisted Coil Embolization Versus Coil Embolization Alone for Ruptured Cerebral Aneurysms with Mild Symptoms: A Single-Clinic Experience

Purpose

To evaluate the safety and efficacy of stent-assisted coil embolization (SAC) in acutely ruptured cerebral aneurysms without severe symptoms, and thus, the usefulness of the stent itself in patients with subarachnoid hemorrhages.

Materials and Methods

From January 2017 to June 2019, 118 patients were treated with coil embolization for acutely ruptured cerebral aneurysms without severe symptoms (Hunt & Hess grade ≤ 3). The periprocedural complications, six-month modified Rankin scores (mRS), and six-month radiologic outcomes were compared between 56 patients with SAC and 62 patients without SAC (non-SAC).

Results

The rate of good clinical outcomes (mRS ≤ 2), as well as the rate of hemorrhagic and ischemic complications, showed no significant difference between the SAC and non-SAC groups. Moreover, compared to the non-SAC group, the SAC group showed a lower recanalization rate on the six-month follow-up angiogram (20% vs. 39.3%, p = 0.001).

Conclusion

Although stent use was not significantly associated with clinical outcomes in coil embolization of ruptured cerebral aneurysms with non-severe symptoms (Hunt & Hess grade ≤ 3), it significantly decreased the rate of recanalization on follow-up cerebral angiograms.

Silk Vista Baby flow diverter stent for ruptured intracranial aneurysms: a retrospective observational study

PURPOSE

Flow diversion changed the approach to complex intracranial aneurysms, leading to a widespread use and a rapid technological evolution. Indeed, indications continued to expand, including ruptured intracranial aneurysms in selected cases. Recently, new devices have been designed specifically to target smaller vessels. Therefore, we conducted a multicenter study to evaluate clinical outcome, complications, and occlusion rate of patients with ruptured aneurysms treated with new generation low profile Silk Vista Baby (SVB) flow diverter stent (FD).

METHODS

We performed a retrospective observational study on consecutive patients who underwent treatment with SVB for ruptured aneurysms at 12 Italian centers. Primary end point was favorable clinical outcome rate, defined as modified ranking score (mRS) of 0-2 at the 3 months. Secondary outcomes were complication rate, aneurysm re-rupture, and complete aneurysm occlusion at last radiological follow-up.

RESULTS

Twenty-five patients were included; at 3 months' follow-up, 19 patients (79.1%) had favorable clinical outcome (mRS 0-2). Three patients (12.5%) died during follow-up. In-stent thrombosis occurred in two cases (8.3%), managed with glycoprotein IIb/IIIA and intra-stent angioplasty, without clinical consequences. In 18 (85.7%) patients, complete occlusion at 3 months was demonstrated. No rebleeding occurred during follow-up. Presentation with unfavorable World Federation of Neurosurgical Societies grading system (WFNS) and posterior circulation location were both significantly correlated with unfavorable clinical outcome (p = 0.005 and p = 0.02).

CONCLUSIONS

Our data suggests that low profile FD treatment of ruptured intracranial aneurysms located distally of the circle of Willis is feasible. New generation low profile FD may represent an alternative option in carefully selected cases.

Unruptured Aneurysmal Shrinkage of the Distal Posterior Inferior Cerebellar Artery Following Stent Jailing of the Arterial Orifice: A Case Report

A 57-year-old woman who presented with a sudden severe headache and subsequently diagnosed with a subarachnoid hemorrhage was referred to our hospital. CTA revealed a large irregularly shaped dissecting aneurysm of the right vertebral artery (VA) and a small round distal aneurysm of the right posterior inferior cerebellar artery (PICA), which originated just proximal to the VA aneurysm. We diagnosed the VA aneurysm as a ruptured aneurysm and performed endovascular treatment the day the patient was hospitalized. Because the left VA was aplastic, stent-assisted coiling was performed to preserve the blood flow of the right VA, following the administration of antiplatelets and heparin. The proximal part of the laser-cut closed-cell stent jailed the orifice of the right PICA. The postoperative course was uneventful, and she was discharged from the hospital 3 weeks later without any neurological deficits. The follow-up VA angiogram revealed complete disappearance of the distal PICA aneurysm 17 months after stent jailing. Flow reduction by stent jailing of the arterial orifice is considered to be the main mechanism of aneurysmal shrinkage. Jailing of the orifice of the cerebral artery using even a low-metal-coverage stent may cause arterial flow reduction, which may shrink a distal aneurysm.

Comaneci plus Balloon-assisted Embolization of Ruptured Wide-necked Cerebral Aneurysms

BACKGROUND AND PURPOSE

Recently, avant-garde combinations of ancillary devices as an adjunct to coil embolization for acutely ruptured and wide-necked cerebral aneurysms have emerged. This study sought to investigate the feasibility, safety and durability of the simultaneous combination of temporary neck-bridging devices plus balloon-assisted coiling (BAC) to treat acutely ruptured and wide-necked cerebral aneurysms.

METHODS

A retrospective review was performed of patients with ruptured and wide-necked intracranial bifurcation aneurysms treated with temporary stent plus balloon-assisted coiling. Anatomical features, technical details, intraprocedural complications, clinical and angiographic results were reviewed. Preprocedural and follow-up clinical statuses were evaluated using the modified Rankin scale (mRS).

RESULTS

A total of 21 patients (mean age 54.5 years, range 37-72 years) were identified. The immediate postprocedural angiography revealed complete aneurysm occlusion in 85.7% (18/21) of the cases. A periprocedural complication developed in 9.5% of the cases. There was no mortality in this study. The permanent morbidity rate was 4.7%. Long-term follow-up angiography was performed in 18 of 21 patients (85.7%) (the mean follow-up period was 21 months). The rate of complete aneurysm occlusion at final follow-up was 89.4%.

CONCLUSION

The results of this study confirmed that temporary stent plus balloon-assisted coiling is a durable and relatively safe endovascular technique for the treatment of ruptured wide-necked bifurcation aneurysms located in both the posterior and anterior cerebral circulation.

Pipeline Embolization Device for the Treatment of Ruptured Intracerebral Aneurysms: A Multicenter Retrospective Study

Background and Purpose: The utilization of flow diversion for ruptured intracerebral aneurysms (IAs) is still limited. We aimed to demonstrate our multicenter experience using the pipeline embolization device (PED) for ruptured IAs that were difficult to treat by clipping and coiling.

Methods: Thirty-eight patients with ruptured IAs who underwent PED treatment from 2015 to 2020 were retrospectively reviewed. Factors associated with procedure-related stroke (ischemic and hemorrhagic) and clinical and angiography outcomes were analyzed.

Results: There were 14 (36.8%) saccular IAs, 12 (31.6%) blister-like IAs, and 12 (31.6%) dissecting IAs. Perforator involvement was noted in 10 (26.3%) IAs. Early PED placement ( ≤ 15 days) and adjunctive coiling treatment were performed in 27 (71.1%) and 22 (57.9%) cases, respectively. The overall rate of stroke-related complications was 31.6% (12/38) (including rates of 10.5% for procedure-related hemorrhagic complications and 15.8% for procedure-related infarction). The mortality rate was 13.2% (5/38), and 84.2% of patients (32/38) had favorable outcomes. Thirty-two (84.2%) patients underwent follow-up angiographic evaluations; of these, 84.4% (27 patients) had complete occlusion and 15.6% had incomplete obliteration. Multivariate analysis revealed that early PED placement was not associated with a high risk of procedure-related stroke or an unfavorable outcome. Adjunctive coiling exhibited an association with procedure-related stroke (p = 0.073). Procedure-related hemorrhagic complications were significantly associated with an unfavorable outcome (p = 0.003). Immediate contrast stasis in the venous phase was associated with complete occlusion during follow-up (p = 0.050).

Conclusion: The PED is a feasible and effective treatment to prevent rebleeding and achieve aneurysm occlusion, but it is associated with a substantial risk of periprocedural hemorrhage and ischemic complications in acute ruptured IAs. Therefore, the PED should be used selectively for acutely ruptured IAs. Additionally, adjunctive coiling might increase procedure-related stroke; however, it may reduce aneurysm rebleeding in acutely ruptured IAs. Patients with immediate contrast stasis in the venous phase were more likely to achieve total occlusion. A prospective study with a larger sample size should be performed to verify our results.

The Woven Endobridge as a treatment for acutely ruptured aneurysms: A review of the literature

The Woven Endobridge (WEB; Microvention, Aliso Viejo, California, USA) is a relatively new device which has been shown to be safe and effective for the treatment of wide necked bifurcation aneurysms in multiple prospective Good Clinical Practice studies. However, the vast majority of aneurysms included in these studies have been unruptured. The aim of this review is to summarise the current evidence available on the treatment of ruptured aneurysms with the WEB.

Safety and efficacy of intravenous tirofiban for stent-assisted coiling in acutely ruptured intracranial aneurysms: A single center experience

BACKGROUND

There have been few reports on the use of tirofiban in ruptured intracranial aneurysms and the results were conflicting. However, the safety and efficacy of optimal dosage and the reasonable treatment course of tirofiban have not been determined.

OBJECTIVE

To determine the safety and efficacy of a new protocol for its prophylactic tirofiban application during the endovascular treatment of ruptured intracranial aneurysms with no oral antiplatelet medications.

METHODS

This retrospective study was based on 105 patients with ruptured aneurysms who underwent stent-assisted coiling at our institution between August 2017 and July 2020. Intravenous tirofiban was administered to patients after stent deployment. Tirofiban was administered as an intravenous bolus (5 µg/kg) over a 3 min period immediately after stent deployment, followed by a 0.06-0.08 µg/kg/min maintenance infusion for 12-24 h. Dual oral antiplatelet therapy was overlapped with half the tirofiban dose 2 h before the cessation of the tirofiban infusion. Cases of intracranial hemorrhage or thromboembolism were recorded.

RESULTS

This study included a total of 105 patients with ruptured intracranial aneurysms, who underwent stent-assisted coiling. In terms of clinical severity, a presenting Hunt-Hess clinical-grade I was observed in 47 (44.8%) cases, grade II in 19 (18.1%) cases, grade III in 30 (28.6%) cases, grade IV in 6 (5.6%) cases, and grade V in 3 (2.9%) cases. None of the patients showed a newly developed tirofiban-related intracerebral hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, or ventriculostomy-related hemorrhage. There were 3 (2.8%) patients who had thromboembolic complications.

CONCLUSIONS

We have determined a new protocol for prophylactic intraoperative tirofiban during the endovascular treatment of ruptured intracranial aneurysms with no oral antiplatelet medications. In our study, tirofiban showed a low risk of hemorrhagic or thromboembolic complications. Tirofiban appears to be a safe and alternative during the stent-assisted coiling of ruptured intracranial aneurysms.

Endovascular treatment of blood blister-like aneurysms of internal carotid artery: Stent-assisted coiling and pipeline flow diversion

OBJECTIVE

To report the stent-assisted coil embolization and flow diversion treatments of blood-blister-like aneurysms based on the theory of acute dissection of the internal carotid artery.

PATIENTS AND METHODS

From July 2016 through July 2020, 27 patients presenting with subarachnoid hemorrhage (SAH) due to rupture of internal carotid artery blood blister-like aneurysms were subjected to endovascular treatment with stent-assisted coiling or Pipeline flow diversion. Clinical outcomes were evaluated using modified Rankin Scale score (mRS).

RESULTS

A proximal stenosis caused by angiopathology adjacent to aneurysms were found on internal carotid artery angiograms in all 27 cases. The angiopathology combining with the aneurysms implement that acute dissection of the supraclinoid segment of the internal carotid artery indicated the pathogenesis of blood blister-like aneurysm formation. All aneurysms were treated successfully with alleviation of the adjacent angiopathology after stenting on angiograms. During 1-12 months, mean 3.5 months, complete aneurysm obliteration without adjacent stenosis were found in 25(92.6%) patients. Two (7.4%) cases of recanalization were retreated with complete obliteration at 1 week and 3 months after initial treatment. Clinical mRS 0 and 1 outcomes were observed in 23(85.2%) patients, mRS 2 in 3(11.1%) patients and mRS 6 in 1(3.7%) not related to aneurysm treatment during follow-up.

CONCLUSIONS

Acute focal dissection of supraclinoid segment of internal carotid artery underlies the development of blood blister-like aneurysm. Stent-assisted coiling and flow diversion treatments constitute appropriate treatment based on the arterial dissection pathology.

Treatment of ruptured intracranial aneurysms with the Woven EndoBridge device: a systematic review

The Woven EndoBridge (WEB) device is a barrel-shaped nitinol mesh deployed within the aneurysmal sac. The absence of metallic mesh in the aneurysm's parent vessel lumen obviates the need for potent antiplatelet therapy, making this device appealing for acutely ruptured aneurysms not amenable to clipping or coiling. To assess the literature regarding WEB treatment of these aneurysms, we performed a comprehensive systematic search of PubMed, MEDLINE, and EMBASE databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Keywords were combined with Boolean operators to increase search sensitivity and specificity ('woven endobridge device' AND 'ruptured'). Nine studies comprising 377 acutely ruptured aneurysms were included. Overall, 82.7% were wide-necked, 85.9% were located in the anterior circulation, and 26.9% of patients presented with poor subarachnoid hemorrhage grade. Intraprocedure and postprocedure complications occurred in 8.4% (95% CI 3.6% to 13.3%) and 1% (95% CI 0% to 2%), respectively. The post-treatment rebleeding rate was 0%. Rates of adequate occlusion (complete occlusion to neck remnant) and retreatment at last follow-up were 84.8% (95% CI 73% to 96.6%) and 4.5% (95% CI 2.2% to 6.8%), respectively. The favorable outcome rate (modified Rankin Scale score 0-2) was 62.2% (95% CI 53% to 71.4%); mortality was 13.6% (95% CI 9.7% to 17.6%). WEB treatment of acutely ruptured aneurysms results in high adequate occlusion rates, low perioperative complication rates, no rebleeding, and low recurrence requiring retreatment. This device is promising for acutely ruptured aneurysms not amenable to clipping or coiling, considering the lower need for antiplatelet regimens during the procedure or follow-up.

Contemporary Treatment of Intracranial Blood Blister Aneurysms - A Systematic Review

INTRODUCTION

Blood blister aneurysms (BBAs) are rare aneurysms affecting non-branched points of intracerebral arteries. Due to their small size and fragility, BBAs are prone to rupture, and can be challenging to diagnose and treat. Several treatment options have been suggested yet there is no consensus regarding the best modality to reduce morbidity and mortality.

MATERIALS AND METHODS

A systematic review of the literature was conducted searching for articles discussing the treatment of BBAs. Inclusion criteria included: articles published between January 2010 and August 2020, English language, with each paper including at least 15 patients. Studies included required detailed reporting of patient demographics, treatment, and patient outcomes (including complications, recurrence, neurologic functional status, and mortality).

RESULTS AND DISCUSSION

A total of 25 studies with 883 patients were included. Most were female (n = 594, 67.3%) and aneurysms were overwhelmingly located in the supraclinoid internal carotid artery (99%). Aneurysms were variable in size and mostly presented with subarachnoid haemorrhage. Endovascular treatment (n = 518, 58.7%) was more common than microsurgery (n = 365, 41.1%) while only 2 patients were managed conservatively. Complications were more common in patients treated microsurgically. Microsurgical procedures had an unfavorable outcome (mRS 4-6, GOS 1-3) rate of 27.8% (n = 100/360) while that of endovascular procedures was 14.7% (n = 70/477). Endovascular procedures had a lower mortality rate than microsurgical interventions (8.4% vs 11%).

CONCLUSION

This review demonstrates that endovascular treatment of blood blister aneurysm has reduced morbidity and mortality when compared with microsurgical treatment. Small sample sizes and substantial study heterogeneity makes strong conclusions difficult.

Stent-Assisted Embolization for Acutely Ruptured Aneurysm

Objective

The purpose of this study was to report the results of stent-assisted embolization performed at our hospital for acutely ruptured aneurysms.

Methods

This study consisted of 19 patients (4 men and 15 women) with acutely ruptured wide neck aneurysm who underwent stent-assisted coil embolization in acute stage between December 2016 and October 2020. Stent-assisted embolization in the acute stage was performed for very wide neck ruptured aneurysm only when balloon-assisted embolization was failed or was thought to be impossible. Factors related to poor clinical outcome were examined.

Results

There were nine internal carotid artery (ICA) aneurysms, four anterior communicating artery (AcomA) aneurysms, three basilar artery (BA) aneurysms, two vertebral artery (VA) aneurysms and one anterior cerebral artery (ACA) aneurysm. The stents used were one Neuroform EZ and 18 Neuroform Atlas (Stryker). The contrast of the bleb disappeared in all cases with obvious bleb. Complete obliteration was achieved in two cases, neck remnant was in ten, and body filling was in seven. Both of the complete obliteration cases developed thrombotic complications. Modified Rankin score of 0-2 was observed in eight patients (good clinical outcome), whereas that of 4-6 was observed in 11 patients (poor clinical outcome). Several factors possibly affected to poor clinical outcome were examined and only age over 80 years was statically different. Complications related to procedure occurred in five patients; two cases of in-stent thrombosis, one case each of MCA perforation, stent occlusion, and coil fracture.

Conclusion

Stent-assisted coil embolization using Neuroform EZ and Neuroform Atlas could be considered as an emergency treatment for acutely ruptured cerebral aneurysms with very wide neck. It is rarely indicated in patients with age over 80 years.