Safety and Efficacy of Stent-assisted Coiling in the Treatment of Unruptured Wide-necked Intracranial Aneurysms: A Single-center Experience

Introduction: Wide-necked intracranial aneurysms (IAs) are complex lesions that may require different microsurgical or endovascular strategies, and stent-assisted coiling (SAC) has emerged as a feasible alternative to treat this subset of aneurysms. Methods: The objective was to assess the rate of complications of unruptured wide-necked IAs treated with SAC. We retrospectively identified patients with unruptured wide-necked IAs treated with SAC. Medical charts, procedure reports, and imaging studies were analyzed. Results: One hundred twenty patients harboring 124 unruptured wide-necked IAs were included. Ninety-two aneurysms (74.2%) were located in the anterior circulation. The median aneurysm size was 7 mm (IQR = 5-10). The immediate complete aneurysm occlusion rate was 29% (36/124). The rate of procedural complications was 3.3 % (4/120), which included 2 intraprocedural aneurysm ruptures, 1 immediate postprocedure aneurysm rupture, and 1 vessel occlusion rescued with an open-cell stent. The median follow-up time was 21 months (IQR = 10.3-40.9). Kaplan-Meier analysis estimated a median time of complete aneurysm occlusion of 6.3 months (95%CI = 3.8-7.8). At 30-day follow-up, 80.7% of patients had a Glasgow Outcome Score (GOS) of 5 and at the latest follow-up 83.9%. Imaging follow-up was available for 102 patients. The rate of complete aneurysm occlusion was 73.5% (75/102), severe in-stent stenosis (>50%) was found in 1% (1/102), the recanalization rate was 6.6% (5/75), and the retreatment rate was 7.8% (8/102). Conclusion: SAC remains a safe and effective technique to treat wide-necked IAs, providing low rate of complications and recanalization with excellent long-term aneurysm occlusion rates.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Treatment of complex anterior cerebral artery aneurysms with Pipeline flow diversion: mid-term results

BACKGROUND: The off-label use of flow diverters in the treatment of distal aneurysms continues to be debated. OBJECTIVE: To report our multicenter experience in the treatment of complex anterior cerebral artery aneurysms with the Pipeline embolization device (PED). METHODS: The neurointerventional databases of the four participating institutions were retrospectively reviewed for aneurysms treated with PED between October 2011 and January of 2016. All patients treated for anterior cerebral artery aneurysms were included in the analysis. Clinical presentation, location, type, vessel size, procedural complications, clinical and imaging follow-up were included in the analysis. RESULTS: Twenty patients (13 female) with 20 aneurysms met the inclusion criteria in our study. Fifteen aneurysms were classified as saccular and five as fusiform (mean size 7.3 mm). Thirteen aneurysms were located in the anterior communicating region (ACOM or A1/2 junction), six were A2-pericallosal, and one was located in the A1 segment. Six patients had presented previously with subarachnoid hemorrhage and had their aneurysms initially clipped or coiled. There was one minor event (a small caudate infarct) and one major event (intraparenchymal hemorrhage). Sixteen of the 20 patients had angiographic follow-up (mean 10 months). Eleven aneurysms were completely occluded, one had residual neck, and four had residual aneurysm filling. CONCLUSIONS: The treatment of complex anterior cerebral artery aneurysms with the PED as an alternative for patients who are not good candidates for conventional methods is technically feasible and safe. Mid-term results are promising but larger series with long-term follow-up are required to assess its effectiveness

Endovascular Thrombectomy Versus Medical Therapy Alone in Patients With Large Core Based on Computed Tomography Perfusion

Background Patients presenting with large vessel occlusion and a large ischemic core (>50 mL) have been consistently undersampled in the major endovascular thrombectomy (ET) trials. As such, equipoise exists as to whether ET is associated with improved outcomes over medical therapy alone in this population. Methods Prospectively collected databases from 4 US centers were reviewed to identify patients with baseline ischemic cores >50 mL based on computed tomography perfusion imaging using RAPID software (iSchemaView), who were treated with ET or medical therapy alone between January 2014 and October 2019. Baseline characteristics, procedural information, and clinical follow‐up data were collected. A matched‐control comparison of these patients was performed. Results A total of 167 patients were included, of whom 92 received medical therapy alone and 75 underwent ET. Seventy‐five pairs were obtained after matching for baseline ischemic core volume, National Institutes of Health Stroke Scale score, and age. Rate of 90‐day good outcome was significantly higher in the ET arm (28.4% versus 4.9%, P=0.002). In univariate analysis of ET patients, the rate of good outcome was significantly higher among patients treated within <6 hours compared with ≥6 hours (44.2% versus 17.4%, P=0.02). Predictors of good outcome included age (P=0.008), ischemic core volume (P=0.01), and time from last known well to groin puncture (P=0.004). Conclusions ET was associated with improved outcomes in patients with large ischemic core based on computed tomography perfusion. This association was more pronounced in patients who present early (<6 hours from last seen well) with an adequate target mismatch. These results may guide the practice until data from ongoing randomized trials become available