Thromboembolic Events Associated with Electrolytic Detachment of Guglielmi Detachable Coils and Target Coils : Comparison with Use of Diffusion-Weighted MR Imaging

DWI-Detected Ischemic Lesions after Endovascular Treatment for Cerebral Aneurysms: An Updated Systematic Review and Meta-analysis

BACKGROUND AND PURPOSE

DWI-detected ischemic lesions are potential complications of endovascular procedures that are performed to treat intracranial aneurysms. We completed a systematic review and meta-analysis to identify the occurrence of DWI-detected ischemic lesions after endovascular treatment for intracranial aneurysms.

MATERIALS AND METHODS

A systematic literature search of PubMed, the Web of Science, EMBASE, and Scopus between January 2000 and June 2022 of post-endovascular procedures for intracranial aneurysm studies was conducted using the Nested Knowledge AutoLit software. The main outcome was DWI-detected ischemic lesions within 5 days of the procedures. Information regarding associated risk factors such as the type of procedure, patient demographics, and aneurysm characteristics was also collected.

RESULTS

Twenty-nine studies with 2686 patients were included. The overall incidence of DWI ischemic lesions was 47.0% (95% CI, 39.6%-55.8%). The highest rate of lesions was seen with flow diversion at 62.4% (95% CI, 48.4%-80.5%), followed by complex procedures at 49.3% (95% CI, 29.5%-82.1%), stent-assisted coiling at 47.5% (95% CI, 34.6%-65.3%), simple coiling at 47.1% (95% CI, 35.7%-62.3%), and balloon-assisted coiling at 37.0% (95% CI, 28.3%-48.4%). The differences among different techniques were not statistically significant; however, there was significant heterogeneity and a significant risk of publication bias among included studies.

CONCLUSIONS

Many patients who undergo endovascular procedures for intracranial aneurysms present with new postprocedural DWI-detected ischemic lesions, regardless of the endovascular procedure used. Future studies and meta-analyses are needed to investigate early and long-term outcomes of such small infarcts.

Diffusion-weighted imaging lesions after endovascular treatment of cerebral aneurysms: A network meta-analysis

Background

Thromboembolism is one of the common complications in endovascular treatments including coiling alone, stent-assisted coiling (SAC), balloon-assisted coiling (BAC), and flow-diverting (FD) stents. Such treatments are widely used in intracranial aneurysms (IAs), which usually present as positive lesions in diffusion-weighted imaging (DWI). Whether these adjunctive techniques increase postprocedural DWI-positive lesions after endovascular treatment remains unclear.

Methods

A thorough electronic search for the literature published in English between January 2000 and October 2022 was conducted on PubMed, Medline, and EMBASE. Eighteen studies (3 cohort studies and 15 case-control studies) involving 1,843 patients with unruptured IAs (UIAs) were included. We performed a frequentist framework network meta-analysis (NMA) to compare the rank risks of cerebral thromboembolism of the above four endovascular treatments. The incoherence test was used to analyze the statistical disagreement between direct and indirect evidence. Funnel plots were used to analyze publication bias.

Results

The incidences of DWI lesions in patients who received FD stents, SAC, BAC, and coiling alone were 66.1% (109/165), 37.6% (299/795), 31.1% (236/759), and 25.6% (236/921). The incidence of DWI lesions in patients who received FD stents was higher than that in patients who received SAC [OR: 2.40; 95% CI (1.15, 5.00), P < 0.05], BAC [OR: 2.62; 95% CI (1.19, 5.77), P < 0.05], or coiling alone [OR: 2.77; 95% CI (1.26, 6.07), P < 0.05]. The incoherence test showed preferable consistency in this NMA. No obvious publication bias was found in the funnel plot.

Conclusion

FD stent placement brings more ischemic lesions identified by DWI than any other procedures for patients with UIA. The characteristics of FD stents may result in a high incidence of DWI lesions.

Clopidogrel response predicts thromboembolic events associated with coil embolization of unruptured intracranial aneurysms: A prospective cohort study

Objective

Periprocedural thromboembolic events are a serious complication associated with coil embolization of unruptured intracranial aneurysms. However, no established clinical rule for predicting thromboembolic events exists. This study aimed to clarify the significance of adding preoperative clopidogrel response value to clinical factors when predicting the occurrence of thromboembolic events during/after coil embolization and to develop a nomogram for thromboembolic event prediction.

Methods

In this prospective, single-center, cohort study, we included 345 patients undergoing elective coil embolization for unruptured intracranial aneurysm. Thromboembolic event was defined as the occurrence of intra-procedural thrombus formation and postprocedural symptomatic cerebral infarction within 7 days. We evaluated preoperative clopidogrel response and patients’ clinical information. We developed a patient-clinical-information model for thromboembolic event using multivariate analysis and compared its efficiency with that of patient-clinical-information plus preoperative clopidogrel response model. The predictive performances of the two models were assessed using area under the receiver-operating characteristic curve (AUC-ROC) with bootstrap method and compared using net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

Results

Twenty-eight patients experienced thromboembolic events. The clinical model included age, aneurysm location, aneurysm dome and neck size, and treatment technique. AUC-ROC for the clinical model improved from 0.707 to 0.779 after adding the clopidogrel response value. Significant intergroup differences were noted in NRI (0.617, 95% CI: 0.247–0.987, p < .001) and IDI (0.068, 95% CI: 0.021–0.116, p = .005).

Conclusions

Evaluation of preoperative clopidogrel response in addition to clinical variables improves the prediction accuracy of thromboembolic event occurrence during/after coil embolization of unruptured intracranial aneurysm.

Silent brain infarction after minimally invasive cardiac surgery with retrograde perfusion

BACKGROUND AND AIM

There is no report on silent brain infarction (SBI) after minimally invasive cardiac surgery (MICS) with retrograde perfusion. Thus, the current study aimed to investigate the incidence of SBI after MICS using magnetic resonance imaging (MRI).

METHODS

This study included 174 patients who underwent MICS with retrograde perfusion between July 2014 and July 2018. Preoperative computed tomography (CT) angiography was routinely performed and vascular pathology was evaluated for patient selection. Postoperative MRI was performed to investigate the occurrence of SBI.

RESULTS

Out of the total 174 patients, 26 (14.9%) presented with SBI. A total of 61 SBI lesions were found in the 26 patients; of these, 34 (56%) SBI lesions were in the right hemisphere and 27 (44%) in the left hemisphere. SBIs were primarily observed in the posterior cerebral artery territory. Multivariate analysis revealed aortic stenosis to be the only risk factor of SBI.

CONCLUSIONS

Retrograde perfusion via femoral cannulation may not increase the incidence of SBI in selected MICS patients based on preoperative CT findings.

Factors other than body weight predicting heparin loading to acquire optimal activated clotting time in endovascular neurointerventions

OBJECTIVES

The aim of this study was to investigate the relationship between the activated clotting time (ACT) and heparin loading based on body weight (BW), and factors other than BW that may contribute to the ACT after heparin loading to establish a more accurate regimen for achieving ACT targets during endovascular neurointerventions.

PATIENTS AND METHODS

Japanese patients who underwent endovascular coiling of unruptured intracranial aneurysms or carotid artery stenting in our institution between January 2014 and November 2017 were enrolled. The ACT was measured before (pre-ACT) and 3 min after heparinization (post-ACT). The correlation between ACT and heparin loading based on BW and factors that may contribute to the ACT after heparin loading were analyzed retrospectively.

RESULTS

A total of 199 cases (109 males, age: 66 ± 12 years) were analyzed. There were positive correlations between the heparin loading per kg of BW and post-ACT, post-ACT - pre-ACT (ΔACT) (Spearman's r = 0.2946, 0.2633, P: <0.0001, 0.0002, respectively). Heparin loading per kg of BW, gender, hematocrit (Ht), estimate glomerular filtration rate (eGFR) were significant confounding factors to ΔACT. The calculated predicted ΔACT based on these significant factors was found to be highly correlated with ΔACT compared with the heparin loading per kg of BW. (Spearman's r = 0.5820, P = <0.0001).

CONCLUSION

Initial BW-based heparin loading is a simple way in endovascular neurointerventions. ACT after heparin loading based on BW has individual differences greatly, it is possible to estimate more accurately the heparin loading for acquiring the optimal ACT considering not only BW but also gender, Ht and eGFR.

Procedural Clinical Complications, Case-Fatality Risks, and Risk Factors in Endovascular and Neurosurgical Treatment of Unruptured Intracranial Aneurysms: A Systematic Review and Meta-analysis

Importance

The risk of procedural clinical complications and the case-fatality rate (CFR) from preventive treatment of unruptured intracranial aneurysms varies between studies and may depend on treatment modality and risk factors.

Objective

To assess current procedural clinical 30-day complications and the CFR from endovascular treatment (EVT) and neurosurgical treatment (NST) of unruptured intracranial aneurysms and risk factors of clinical complications.

Data Sources

We searched PubMed, Excerpta Medica Database, and the Cochrane Database for studies published between January 1, 2011, and January 1, 2017.

Study Selection

Studies reporting on clinical complications, the CFR, and risk factors, including 50 patients or more undergoing EVT or NST for saccular unruptured intracranial aneurysms after January 1, 2000, were eligible.

Data Extraction and Synthesis

Per treatment modality, we analyzed clinical complication risk and the CFR with mixed-effects logistic regression models for dichotomous data. For studies reporting data on complication risk factors, we obtained risk ratios (RRs) or odds ratios (ORs) with 95% CIs and pooled risk estimates with weighted random-effects models.

Main Outcomes and Measures

Clinical complications within 30 days and the CFR.

Results

We included 114 studies (106 433 patients with 108 263 aneurysms). For EVT (74 studies), the pooled clinical complication risk was 4.96% (95% CI, 4.00%-6.12%), and the CFR was 0.30% (95% CI, 0.20%-0.40%). Factors associated with complications from EVT were female sex (pooled OR, 1.06 [95% CI, 1.01-1.11]), diabetes (OR, 1.81 [95% CI, 1.05-3.13]), hyperlipidemia (OR, 1.76 [95% CI, 1.3-2.37]), cardiac comorbidity (OR, 2.27 [95% CI, 1.53-3.37]), wide aneurysm neck (>4 mm or dome-to-neck ratio >1.5; OR, 1.71 [95% CI, 1.38-2.11]), posterior circulation aneurysm (OR, 1.42 [95% CI, 1.15-1.74]), stent-assisted coiling (OR, 1.82 [95% CI, 1.16-2.85]), and stenting (OR, 3.43 [95% CI, 1.45-8.09]). For NST (54 studies), the pooled complication risk was 8.34% (95% CI, 6.25%-11.10%) and the CFR was 0.10% (95% CI, 0.00%-0.20%). Factors associated with complications from NST were age (OR per year increase, 1.02 [95% CI, 1.01-1.02]), female sex (OR, 0.43 [95% CI, 0.32-0.85]), coagulopathy (OR, 2.14 [95% CI, 1.13-4.06]), use of anticoagulation (OR, 6.36 [95% CI, 2.55-15.85]), smoking (OR, 1.95 [95% CI, 1.36-2.79]), hypertension (OR, 1.45 [95% CI, 1.03-2.03]), diabetes (OR, 2.38 [95% CI, 1.54-3.67]), congestive heart failure (OR, 2.71 [95% CI, 1.57-4.69]), posterior aneurysm location (OR, 7.25 [95% CI, 3.70-14.20]), and aneurysm calcification (OR, 2.89 [95% CI, 1.35-6.18]).

Conclusions and Relevance

This study identifies risk factors for procedural complications. Large data sets with individual patient data are needed to develop and validate prediction scores for absolute complication risks and CFRs from EVT and NST modalities.

Early diffusion-weighted MRI lesions after treatment of unruptured intracranial aneurysms: a prospective study

OBJECTIVE

Diffusion-weighted MRI was used to assess periprocedural lesion load after repair of unruptured intracranial aneurysms (UIA) by microsurgical clipping (MC) and endovascular coiling (EC).

METHODS

Patients with UIA were assigned to undergo MC or EC according to interdisciplinary consensus and underwent diffusion-weighted imaging (DWI) 1 day before and 1 day after aneurysm treatment. Newly detected lesions by DWI after treatment were the primary end point of this prospective study. Lesions detected by DWI were categorized as follows: A) 1–3 DWI spots < 10 mm, B) > 3 DWI spots < 10 mm, C) single DWI lesion > 10 mm, or D) DWI lesion related to surgical access.

RESULTS

Between 2010 and 2014, 99 cases were included. Sixty-two UIA were treated by MC and 37 by EC. There were no significant differences between groups in age, sex, aneurysm size, occurrence of multiple aneurysms in 1 patient, or presence of lesions detected by DWI before treatment. Aneurysms treated by EC were significantly more often located in the posterior circulation (p < 0.001). Diffusion-weighted MRI detected new lesions in 27 (43.5%) and 20 (54.1%) patients after MC and EC, respectively (not significant). The pattern of lesions detected by DWI varied significantly between groups (p < 0.001). Microembolic lesions (A and B) found on DWI were detected more frequently after EC (A, 14 cases; B, 5 cases) than after MC (A, 5 cases), whereas C and D were rare after EC (C, 1 case) and occurred more often after MC (C, 12 cases and D, 10 cases). No procedure-related unfavorable outcomes were detected.

CONCLUSIONS

According to the specific techniques, lesion patterns differ between MC and EC, whereas the frequency of new lesions found on DWI is similar after occlusion of UIA. In general, the lesion load was low in both groups, and lesions were clinically silent.

Clinical trial registration no.: NCT01490463 (clinicaltrials.gov)

Diffusion-Weighted Imaging-Detected Ischemic Lesions following Endovascular Treatment of Cerebral Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Endovascular treatment of intracranial aneurysms is associated with the risk of thromboembolic ischemic complications. Many of these events are asymptomatic and identified only on diffusion-weighted imaging. We performed a systematic review and meta-analysis to study the incidence of DWI positive for thromboembolic events following endovascular treatment of intracranial aneurysms.

MATERIALS AND METHODS

A comprehensive literature search identified studies published between 2000 and April 2016 that reported postprocedural DWI findings in patients undergoing endovascular treatment of intracranial aneurysms. The primary outcome was the incidence of DWI positive for thromboembolic events. We examined outcomes by treatment type, sex, and aneurysm characteristics. Meta-analyses were performed by using a random-effects model.

RESULTS

Twenty-two studies with 2148 patients and 2268 aneurysms were included. The overall incidence of DWI positive for thromboembolic events following endovascular treatment was 49% (95% CI, 42%-56%). Treatment with flow diversion trended toward a higher rate of DWI positive for lesions than coiling alone (67%; 95% CI, 46%-85%; versus 45%; 95% CI, 33%-56%; P = .07). There was no difference between patients treated with coiling alone and those treated with balloon-assisted (44%; 95% CI, 29%-60%; P = .99) or stent-assisted (43%; 95% CI, 24%-63%; P = .89) coiling. Sex, aneurysm rupture status, location, and size were not associated with the rate of DWI positive for lesions.

CONCLUSIONS

One in 2 patients may have infarcts on DWI following endovascular treatment of intracranial aneurysms. There is a trend toward a higher incidence of DWI-positive lesions following treatment with flow diversion compared with coiling. Patient demographics and aneurysm characteristics were not associated with DWI-positive thromboembolic events.

Microembolism after endovascular coiling of unruptured cerebral aneurysms: incidence and risk factors

OBJECTIVE

The incidence and risk factors of microembolic lesions on MR diffusion-weighted imaging (DWI) were analyzed after the endovascular coiling of unruptured intracranial aneurysms (UIAs).

METHODS

Data obtained from 271 consecutive patients (70 men and 201 women; median age 57 years; range 23-79 years) who presented with UIA for coil embolization between July 2011 and June 2013 were analyzed. Two independent reviewers examined the DWI and apparent diffusion coefficient maps obtained the following day for the presence of restrictive diffusion spots and counted the number of spots. Multivariate analysis was then performed to identify independent risk factors for developing microembolism following the coiling of an aneurysm.

RESULTS

Microembolic lesions were noted in 101 of 271 patients (37.3%). The results of the multivariate analysis showed that the following factors significantly influenced the risk for microembolism: age, diabetes, previous history of ischemic stroke, high-signal FLAIR lesions in the white matter, multiple aneurysms, and the insertion of an Enterprise stent (all ORs > 1.0 and all p values < 0.05). Previously known risk factors such as prolonged procedure duration, aneurysm size, and decreased antiplatelet function did not show any significant influence.

CONCLUSIONS

The incidence of microembolism after endovascular coiling of UIA was not low. Lesions occurred more frequently in patients with vascular status associated with old age, diabetes, and previous stroke. Aneurysm multiplicity and the type of stent used for treatment also influenced lesion occurrence.