Does stent-assisted coiling still have a place in the management of intracranial aneurysms?

Treatment of a giant terminal internal carotid artery aneurysm in a 10-year-old child by flow diversion: long-term outcome and lessons learned

A 28-mm diameter and partially thrombosed intracranial aneurysm was found in a 10-year-old boy on an MRI for non-specific headaches. The large neck incorporated the left internal carotid artery (ICA) termination and proximal middle cerebral artery. Treatment was planned to prevent further growth and rupture. Because of the difficult anatomy, a braided stent was first placed across the aneurysm neck as a scaffold to allow for the placement of a flow-diverting stent after its endothelialisation. However, severe stent-induced endothelial hyperplasia was encountered when the flow diverter was inserted. This resulted in a transient ICA occlusion during the procedure before flow was restored by angioplasty. As a result, the patient suffered a mild transient dysphasia but permanent loss of vision in the left eye. All antiplatelet medications were stopped 1 year after the procedure without problem. The aneurysm has remained fully occluded in the 7 years since.

Stent-Assisted Coiling of 501 Wide-Necked Intracranial Aneurysms: A Single-Center 8-Year Experience

BACKGROUND

Stent-assisted coiling has expanded the treatment of complex wide-necked intracranial aneurysms. We present our experience with stent-assisted coiling, with an emphasis on procedure-related neurologic complications and the incidence of angiographic recurrence.

METHODS

A total of 480 patients with 501 aneurysms who were treated with stent-assisted coiling between January 2007 and December 2014 were reviewed retrospectively. Baseline characteristics, procedure-related complications, angiographic follow-up results, and clinical outcomes were statistically analyzed.

RESULTS

Among the 480 patients, 423 (88%) were treated electively and 57 (11%) were treated in the context of subarachnoid hemorrhage. There were 22 (4.58%) overall procedure-related complications, which caused death in 4 patients (0.83%) and morbidity in 4 patients (0.83%). In a logistic regression analysis, the complications differed significantly among the patients with hypertension (odds ratio [OR], 2.85; 95% confidence interval [CI], 1.09-7.48; P = 0.03), patients with aneurysms treated with coiling before stenting (OR, 3.07; 95% CI, 1.07-8.81; P = 0.04), and patients treated with multiple stents (OR, 4.96; 95% CI, 1.02-24.07; P = 0.04). Angiographic follow-up was available for 396 patients (83.4%) for a mean of 13 months. The rates of recanalization and retreatment were 13.9% and 3.5%, respectively. In a logistic analysis, larger aneurysm size and initial incomplete aneurysm occlusion were predictors of recanalization. Clinical follow-up was available for 406 patients (85.6%) for a mean of 44.8 months, and 399 patients (98.3%) achieved a Glasgow Outcome Scale score of 5.

CONCLUSIONS

Stent-assisted coiling appears to be a safe and effective option for treating complex wide-necked aneurysms. Higher complication rates are associated with coiling before stenting, use of multiple stents, and hypertension. Stent delivery before coil deployment reduces the risk of procedural complications. Larger aneurysm size and initial incomplete occlusion are associated with aneurysm recanalization.

Long-term angiographic outcome of stent-assisted coiling compared to non-assisted coiling of intracranial saccular aneurysms

AIM

To compare angiographic result at long-term follow-up, and rates of progressive occlusion, recurrence, and retreatment of stent-assisted coiled (SAC) and non-assisted coiled (NAC) intracranial saccular aneurysms.

METHODS

Retrospective evaluation of department records identified 260 patients with 283 saccular intracranial aneurysms who had long-term angiographic follow-up (more than 12 months) and were successfully treated with SAC (89 aneurysms) or NAC (194 aneurysms) at the University Hospital Center Zagreb from June 2005 to July 2012. Initial and control angiographic results in both groups were graded using Roy/Raymond scale, converted to descriptive terms, and the differences between them were evaluated for statistical significance. A multivariate analysis was performed to identify factors related to progression of aneurysm occlusion and recurrence at follow-up, and those related to aneurysm retreatment.

RESULTS

There were more progressively occluded aneurysms in SAC group (38 of 89 aneurysms, 42.7%) than in NAC group (46 of 194, 23.7%) (P=0.002), but there were no significant differences in the rates of recanalization, regrowth, and stable result. Multivariate logistic regression identified the use of stent as the most important factor associated with progressive occlusion (P=0.015, odds ratio 2.22, 95% confidence interval 1.17-4.21), and large aneurysm size and posterior circulation location as most predictive of aneurysm recurrence and retreatment.

CONCLUSION

The use of stent is associated with delayed occlusion of initially incompletely coiled aneurysms during follow-up, but does not reduce the rate of recurrence and retreatment compared to coiling alone. Long-term angiographic follow-up is needed for both SAC and NAC aneurysms.