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.

Accuracy of CT angiography for detecting ruptured intracranial aneurysms

Background

Digital subtraction angiography (DSA) is invasive, costly and unavailable in many South African hospitals; however, it remains the gold standard for imaging intracranial aneurysms. CT angiography (CTA) is a non-invasive and readily available screening tool prior to DSA.

Objectives

This study aimed to evaluate the diagnostic performance of CTA in detecting ruptured intracranial aneurysms using DSA as the reference standard and to determine the effect of aneurysm size and location on CTA sensitivity.

Method

A retrospective analysis of CTA and DSA data from reports of patients suspected to have aneurysmal subarachnoid haemorrhage (SAH) at Chris Hani Baragwanath Academic Hospital between January 2017 and June 2020.

Results

Conventional DSA detected aneurysms in 94 out of 115 patients; while of these, CTA detected 75 and missed 19. The CTA sensitivity, specificity and accuracy was 80%, 43% and 73%, respectively. The CTA sensitivity for aneurysms < 3 mm and 3 mm - 5 mm in size was 30% and 81.5%, respectively (p = 0.024). Sensitivity of CTA for posterior communicating artery (PComm) aneurysms was 56% and lower than other major anterior circulation locations (83% - 91%) (p = 0.045).

Conclusion

The CTA diagnostic efficiency was lower than previously reported, with even lower sensitivity for aneurysms < 3 mm and for those arising from the PComm. Thus, CTA should remain a screening tool prior to DSA in all local patients suspected to have aneurysmal SAH.

Contribution

Larger, prospective studies are required to accurately define the role of CTA in diagnosing intracranial aneurysms in a developing country with limited resources.

Comparison of microsurgical clipping with intravascular interventional embolization in the treatment of ruptured aneurysms and risk factors for intraoperative rupture and bleeding

OBJECTIVE

To investigate the effectiveness of microsurgical clipping compared with intravascular interventional embolization in the treatment of ruptured aneurysms and the risk factors for intraoperative rupture and bleeding.

METHODS

The data of 116 patients with ruptured aneurysms admitted to the People's Hospital of China Three Gorges University from January 2020 to March 2021 were collected for retrospective analysis. Among them, 61 cases with microsurgical clipping were classified as the control group (CG), and the rest 55 with intravascular interventional embolization were the observation group (OG), and the treatment effects in the two groups were compared. The general conditions of operation (operation time, postoperative hospital stay and intraoperative blood loss) were compared between the two groups. The intraoperative rupture of cerebral aneurysm during operation was counted, and the incidence of complications between the groups was compared. Risk factors affecting intraoperative rupture of cerebral aneurysms were analyzed by logistic regression.

RESULTS

The total clinical treatment efficiency was dramatically higher in the OG than that in the CG (P<0.05). The operative time, postoperative hospital stays, and intraoperative bleeding were all higher in the CG than those in the OG (all P<0.001). There was no statistical difference in the incidence of wound infection, hydrocephalus, and cerebral infarction between the two groups (all P>0.05). However, the incidence of intraoperative rupture was markedly higher in the CG than that in the OG (P<0.05). Multifactorial logistic regression analysis revealed that history of subarachnoid hemorrhage, history of hypertension, large diameter of aneurysm, irregular morphology, and anterior communicating artery aneurysm were independent risk factors for intraoperative rupture in patients.

CONCLUSION

Intravascular interventional embolization for middle cerebral artery aneurysm rupture is a less invasive procedure with faster recovery time, and history of subarachnoid hemorrhage, history of hypertension, large diameter of aneurysm, irregular morphology, and anterior communicating artery aneurysm are independent risk factors affecting patients with intraoperative rupture.

FRED Jr stent for acute flow diversion in ruptured cerebral aneurysms arising from small-caliber vessels: a clinical case series

OBJECTIVE

Treatment of ruptured aneurysms arising from small-caliber (< 2.5 mm) or distal vessels beyond the circle of Willis is considered challenging with all treatment modalities. Recently, the Flow Re-Direction Endoluminal Device Junior (FRED Jr) stent, designed for flow diversion in small arteries, was approved in the United States for the treatment of nonruptured aneurysms. Here, the authors report their experience using this device in the setting of subarachnoid hemorrhage (SAH).

METHODS

Clinical and radiological records of patients sustaining SAH treated with a FRED Jr stent between June 2020 and October 2022 were reviewed. Treatment course, including antiplatelet therapy, external ventricular drain (EVD) management, and vasospasm, and clinical outcomes were analyzed. Angiographic results were assessed according to the O'Kelly-Marotta (OKM) grading scale.

RESULTS

Nine patients at a median age of 62 (range 27-75) years were included. The median Hunt and Hess grade was II (IQR I) and the median modified Fisher grade was 4 (IQR 1). Aneurysm morphology types included saccular (6 patients), blister (1 patient), and dissecting (2 patients), and the aneurysms were located at the anterior communicating artery complex (n = 3) at the A2/A3 (n = 3), M2/M3 (n = 1), V4 (n = 1), and P2 (n = 1) arterial segments. All stents were deployed successfully with no intraprocedural complications. Postoperatively, no rebleeding events were encountered. Vasospasm therapy was initiated in 6 patients, and no symptomatic EVD-related hematomas were observed. Postoperative ischemic events were encountered in 2 patients. The median 3-month modified Rankin Scale score was 2 (IQR 1) for the 7 surviving patients, and 3-month radiographic follow-up revealed OKM grade D in 4 of 7 patients.

CONCLUSIONS

Flow diversion using the FRED Jr stent is feasible as a potential treatment strategy for acutely ruptured aneurysms arising from small-caliber vessels. The complication profile reported in this series is comparable to those of historical microsurgical cohorts, and effective protection was conferred by this treatment modality. Therefore, our small cohort provides a glimpse into a new tool for successfully achieving acute flow diversion for this subset of difficult-to-treat aneurysms.

Utility of low-profile visualized intraluminal support (LVIS™) stent for treatment of acutely ruptured bifurcation aneurysms: A single-center study

Objective

Stent-assisted coiling has been increasingly used in the treatment of intracranial aneurysms. However, its application in ruptured bifurcation aneurysms remains controversial and challenging. This study aimed to present the safety and feasibility of low-profile visualized intraluminal support (LVIS™, LVIS, and LVIS Jr.) stent for acutely ruptured bifurcation aneurysms.

Methods

A total of 41 patients with acutely ruptured intracranial aneurysms arising at the bifurcation were treated with LVIS™ stent-assisted coiling in our hospital between January 2017 and December 2021. The clinical data and angiographic results of the patients were analyzed.

Results

Among these patients, all stents were successfully implanted. According to the immediate angiographic results, 29 aneurysms (70.7%) were completely occluded. Intraoperative thrombosis and hemorrhage occurred in two and one cases, respectively. No post-operative thrombosis or rebleeding events were observed. The clinical follow-up of all patients revealed that 38 (92.7%) cases had favorable outcomes (modified Rankin scale: 0-2). The angiographic results available for the 36 patients during the follow-up period revealed complete occlusion was achieved in 30 patients (83.3%) and residual neck in six patients.

Conclusion

The LVIS™ stent-assistant coiling is a safe and feasible option for acutely ruptured bifurcation aneurysms. Further studies with a prospective design, a larger sample size, and long-term follow-up are needed to validate these findings.

Impact of Ruptured Aneurysm Circulation on Mortality: A Nationwide Inpatient Sample Analysis

OBJECTIVE

This study investigates the effect of aneurysm circulation on mortality and patient outcomes after aneurysmal subarachnoid hemorrhage (SAH) within the United States.

METHODS

A retrospective cohort study was conducted using the Nationwide Inpatient Sample (NIS), a part of the Healthcare Cost and Utilization Project (HCUP), with ICD-10 codes for non-traumatic SAH between 2015-2016. Aneurysms were stratified as either anterior or posterior circulation. Multivariate logistic regression was used to find the impact of selected variables on the odds of mortality.

RESULTS

The NIS reported 1,892 cases of non-traumatic SAH within the study period that were predominantly anterior circulation (82.6%), female (68.6%), white (57.7%), with mean age of 59.07 years, and in-hospital mortality of 21.4%. Anterior circulation aneurysms were associated with lower severity of initial illness (p = 0.014) but higher likelihood of vasospasm (p = 0.0006) than those of the posterior circulation. In a multivariate logistic regression analysis, mortality was associated with posterior circulation aneurysms (OR: 1.42; CI 95% 1.005-20.10, p = 0.047), increasing age (OR: 1.035; 95% CI 1.022-1.049; p < 0.0001), and shorter hospital stays (OR: 0.7838; 95% CI 0.758-0.811; p < 0.0001). Smoking history (OR: 0.825; 95% CI 0.573-1.187, p > 0.05) and vasospasm (OR: 1.005; 95% CI 0.648-1.558; p > 0.05) were not significantly associated with higher odds of mortality.

CONCLUSIONS

Mortality following aneurysmal SAH is associated with posterior circulation aneurysms, and increasing age, but not smoking history or vasospasm. These findings may be useful for prognostication and counseling patients and families.

Risk of de novo aneurysm formation in patients with a prior diagnosis of ruptured or unruptured aneurysm: systematic review and meta-analysis

OBJECTIVE

De novo aneurysms are rare entities periodically discovered during follow-up imaging. Little is known regarding the frequency with which these lesions form or the time course. This systematic review and meta-analysis was undertaken to estimate the incidence of de novo aneurysms and to determine risk factors for aneurysm formation.

METHODS

The authors searched multiple databases for studies of patients with unruptured and ruptured aneurysms describing the rate of de novo aneurysm formation. The primary outcome was incidence of de novo aneurysm formation. A meta-analysis was performed using a random-effects model. The authors examined the associations of multiple aneurysms, prior subarachnoid hemorrhage, smoking, sex, age at presentation, and hypertension with de novo aneurysm formation.

RESULTS

The meta-analysis included 14,968 aneurysm patients who received imaging follow-up from 35 studies. The overall incidence of de novo aneurysm formation was 2% (95% CI 2%-3%) over a mean follow-up time of 8.3 years. The estimated incidence density was 0.3%/patient-year. There was no statistically significant difference in rates of de novo aneurysm formation between patients who had ruptured aneurysms and those with unruptured aneurysms. In 8 studies, 11.2% of de novo aneurysms were found in patients with ≤ 5 years of follow-up and 88.8% were found at > 5 years. The mean time to rupture for de novo aneurysms was 10 years.

CONCLUSIONS

This systematic review demonstrates that formation of de novo aneurysms is rare. Overall, routine screening for de novo aneurysms is likely to be of low yield and could be performed at time intervals of at least 5 to 10 years.

The impact of size and location on rupture of intracranial aneurysms

Objective:

For effective management of patients with unruptured intracranial aneurysms, prognostic criteria for rupture, of which aneurysm size, location, and multiplicity are key factors. The aim of this study is to determine the correlation between the aneurysm size, location, and multiplicity, and their effect on aneurysmal rupture.

Materials and Methods:

Eighty one patients with diagnosis of intracranial aneurysms were managed at our center from January 2008 through July 2011. The characteristics of aneurysms, such as size, location, multiplicity, and presentation were retrospectively reviewed from their charts and radiological findings.

Results:

Eighty one patients harboring 104 aneurysms were diagnosed, of them 45 were males (55.5%) and 36 were females (44.5%). Seventy-six patients (94%) presented with subarachnoid hemorrhage (SAH) due to ruptured aneurysm. Thirty-three patients who were presented with SAH (43%) had their ruptured aneurysm located at the anterior communicating artery with a mean size 5.8 mm. Most of the small (<7 mm) ruptured aneurysms were located at the anterior communicating artery, distal anterior cerebral arteries, posterior communicating arteries, and internal carotid artery bifurcation (51%, 13%, 11%, and 11%), respectively. There were 24 small unruptured aneurysms, 10 of them (42%) located at the middle cerebral arteries, while only 2 of them (8%) located at the anterior communicating artery.

Conclusions:

The aneurysm size and location play a substantial role in determining the risk of rupture. The most common location of rupture of small aneurysms was the anterior communicating artery, while the middle cerebral artery was the commonest site for small unrupured aneurysms.

Determining the critical size of intracranial aneurysm predisposing to subarachnoid hemorrhage in the Saudi population

Introduction:

Aneurysmal subarachnoid hemorrhage (SAH) is a devastating event with a high rate of morbidity and mortality. With the improvement of diagnostic modalities and the adoption of different screening strategies, more aneurysms are being diagnosed prior to rupture. Based on large multi-center trials, size has become the most important determinant of treatment decisions. Unfortunately, these studies did not take into account the regional and racial variations, challenging the generalizability of their results.

Material and Methods:

We conducted a retrospective analysis on a series of 192 patients harboring 213 aneurysms.

Results:

The critical finding in our study is that the majority of patients presenting with SAH due to ruptured aneurysms are <10 mm in size.

Conclusion:

Decision to treatment of a given unruptured intracranial aneurysm should be individually assessed and not taken from general international literature as this may mistakenly apply factors from one population to another.