Incomplete stent apposition in Enterprise stent–mediated coiling of aneurysms: persistence over time and risk of delayed ischemic events

Abstract

Incomplete stent apposition of the closed cell-design Enterprise stent following stent-mediated coil embolization of intracranial aneurysms has been associated with increased risk of periprocedural thromboembolic events. In this study, the authors seek to determine the natural history of incomplete stent apposition and evaluate the clinical implications of the phenomenon. Since January 2009, all patients receiving Enterprise stents in the treatment of intracranial aneurysms at the authors' institution have undergone serial 3-T MRI with incomplete stent apposition identified by the crescent sign on multiplanar reconstructions of MR angiograms. Magnetic resonance images and MR angiograms obtained at 3, 9, and 18 months after stent-assisted coil embolization were analyzed along with admission and follow-up clinical medical records. These records were evaluated for any radiographic and clinical, transient or permanent ischemic neurological events. Fifty patients receiving Enterprise stents were eligible for inclusion and analysis in the study. Incomplete stent apposition was identified in postoperative imaging studies in 22 (44%) of 50 patients, with 19 (86%) of 22 crescent signs persisting and 3 (14%) of 22 crescent signs resolving on subsequent serial imaging. Delayed ischemic events occurred in 8 (16%) of 50 cases, and all cases involved patients with incomplete stent apposition. The events were transient ischemic attacks (TIAs) in 5 cases, asymptomatic radiographic strokes in 2 cases, and symptomatic strokes and TIAs in the final case. There were no delayed ischemic events in patients who did not have incomplete stent apposition. Only 1 of the delayed ischemic events (2%) was permanent and symptomatic. The postoperative presence of a crescent sign and persistence of the crescent sign were both significantly associated with delayed ischemic events (p < 0.001 and p = 0.002, respectively). Incomplete stent apposition is a temporally persistent phenomenon, which resolves spontaneously in only a small minority of cases and appears to be a risk factor for delayed ischemic events. Although further follow-up is needed, these results suggest that longer duration of antiplatelet therapy and clinical follow-up may be warranted in cases of recognized incomplete stent apposition.