Treatment Of Cerebral Aneurysms Research Articles

Immediate and long-term results after microsurgical clipping of ruptured aneurysms in acute period of hemorrhage

To evaluate the immediate and long-term results after microsurgical treatment of cerebral aneurysms in acute period of hemorrhage; to analyze functional results and long-term outcomes, including higher mental functions and return to previous work. The study included 517 patients in acute period of subarachnoid hemorrhage between 2019 and 2022. Severity of hemorrhage was assessed using the Hunt-Hess scale while the Fisher scale was valuable to estimate dimensions of hemorrhage and predictions for vasospasm. All patients underwent microsurgical clipping of aneurysms. We assessed clinical status and outcomes immediately after microsurgical clipping, within 2 weeks, 1, 3, 6 and 12 months after surgery. The Modified Glasgow Outcome Scale, Modified Rankin Scale (mRS), EQ-5D-3L Quality of Life Questionnaire, Mini-Mental State Examination MMSE and Hamilton Anxiety Rating Scale were used. After 1 month, mRS score 0 was observed in 22% of patients, score 1 - 17%, score 2 - 19.4%, score 3 - 6.2%, score 4 - 2.6%, score 5 - 1% of patients. Mortality rate was 6.4%. After 12 months, mRS score 0, 1, 2, 3 and 4 was observed in 67%, 15%, 8%, 3% and 0.4% of patients, respectively. After 12 months, 39 (8.3%) patients did not return to previous work. Among 427 (91.7%) patients who returned to previous work, 20% returned to work after 3 months, 65% after 6 months and 15% after 9 months. Short-term and long-term functional outcomes vary significantly. There were significantly better mRS scores in long-term period compared to early period. Analysis of immediate and long-term results after hemorrhage will allow us to determine the most important predictors of adverse functional outcomes, assess the prevalence, characteristics, modifiable risk factors and consequences of hemorrhage.

Comparison of the hemocompatibility of neurovascular flow diverters with anti-thrombogenic coatings

Despite the continual progress in technology, thromboembolic complications still occur following endovascular treatment of cerebral aneurysms and remain the primary contributor to morbidity and mortality. Thus, coating the surfaces of blood-contacting flow diverters may reduce thrombus-related complications in clinical use. In this study, the hemocompatibility of different commercially available flow diverters Pipeline Flex Embolization Device with Shield Technology (Medtronic), the p64 MW HPC (Phenox), and the DERIVO 2heal (Acandis) was investigated using an in vitro blood circulation model. The DERIVO 2 flow diverter was included in this study as an uncoated device. The markers of coagulation (thrombin-antithrombin complex (TAT)), thrombocytes (β-thromboglobulin (β-TG)), inflammation (PMN elastase), and complement system (SC5b-9, C3a, and C5a) activation were detected by enzyme-linked immunosorbent assay (ELISA). In addition to blood cell counts and hemolysis, thrombogenicity was determined using scanning electron microscopy. Flow diverters with anti-thrombogenic coatings resulted in significantly lower activation of coagulation (TAT) and platelets (β-TG) and lower adhesion of platelets compared with the uncoated DERIVO 2 flow diverter. There were no significant differences between the coated flow diverters in terms of TAT and β-TG levels, as well as platelet adhesion. However, significantly lower activation of the complement system (SC5b-9 and C5a) was observed for the DERIVO 2heal flow diverter in comparison with the Pipeline Flex Shield and the p64 MW HPC flow diverters emphasizing the improved hemocompatibility of the fibrin/heparin-coated DERIVO 2heal flow diverter.

EXPERT AND CLINICAL ASSESSMENT OF DEFICIENCIES IN PROVIDING CARE TO PATIENTS WITH TRAUMATIC BRAIN INJURY AND HEMORRHAGIC STROKE DUE TO THE RUPTURE OF CEREBRAL ANEURYSM

Introduction. The relevance of conducting this study is determined by the necessity to create organizational conditions and optimize the clinical-diagnostic aspect of medical care for patients with traumatic brain injury (TBI) and acute stroke. This aims to improve patients' quality of life by enhancing the effectiveness of medical care provision in Ukraine. This improvement is based on identifying the causes and analyzing deficiencies in medical care for these conditions.
 The aim of the research is to investigate the specificity of deficiencies in providing medical care to patients with isolated traumatic brain injury and acute hemorrhagic stroke due to the rupture of cerebral arterial aneurysms based on a retrospective analysis of medical documentation, as well as the results of patient treatment in cases of discrepancies between clinical and forensic diagnoses concerning the primary, concomitant diseases, and their complications.
 Materials and methods. Clinical assessment of the results of providing care to patients with traumatic brain injury and stroke was conducted through a retrospective analysis of medical documentation of patients who were hospitalized with these pathologies. The applied methods include clinical and laboratory investigations of homeostasis and metabolism parameters, and instrumental techniques.
 Results. In the identified influence of the timing of the operation (within the first few days) and the breakthrough of blood in the subarachnoid space of the brain, including with intracranial hemorrhage as a result of a re-rupture of a cerebral arterial aneurysm, on the risk of lethal outcomes of surgical treatment, a rationale for searching ways to optimize therapeutic tactics in this category of patients was provided. This includes identifying defects and shortcomings in the organizational aspect of medical care.
 Conclusions. Based on the analysis and identification of the most informative factors influencing the results of surgical treatment of cerebral aneurysms, a prediction system has been developed that allows calculating the probability of its outcome. The application of the forecast is advisable to consider in the prevention and timely detection of possible deficiencies in providing medical care to patients with stroke.

Comparative cost analysis of endovascular and open approaches for elective treatment of middle cerebral artery aneurysms

Background Intracranial aneurysms of the middle cerebral artery can be treated using several open surgical and endovascular approaches. Given the growing evidence of clinical equipoise between these various treatment strategies, there is a need to assess the costs associated with each. Methods Cost of aneurysm treatment was divided into two categories for comparison. “Initial cost” comprised the total in-hospital expenses for initial aneurysm treatment and “total cost” comprised initial aneurysm treatment and all expenses relating to readmission due to treatment-related complications, prescribed catheter angiograms for monitoring of treatment stability, and any retreatments needed for a given aneurysm. The open surgical group was subdivided into a pterional approach group and a lateral supraorbital (LSO) approach group for. Results Median initial cost was $37,152 (IQR $31,318–$44,947) for aneurysms treated with the pterional approach, $29,452 (IQR $27,779–$32,826) for aneurysms treated with the LSO approach, and $19,587 (IQR $14,125–$30,521) for aneurysms treated with endovascular approaches. The median total cost was $39,737 (IQR $33,891–$62,259) for aneurysms treated with the pterional approach, $31,785 (IQR $29,513–$41,099) for aneurysms treated with the LSO approach, and $24,578 (IQR $18,977–$34,547) for aneurysms treated with endovascular approaches. Analysis of variance test demonstrated variance across groups for both initial and total cost ( p = 0.004, p = 0.008, respectively). In our subsequent analysis, initial cost and total cost were higher in the pterional group than the endovascular group ( p = 0.003 and p = 0.006, respectively). Conclusions Endovascular treatment of elective aneurysms has a significantly lower cost than open surgical treatment with the pterional approach, but not with the LSO approach. For aneurysms not amenable to endovascular treatment, a minimally invasive LSO approach carries a lower cost burden than a pterional approach.

Impact of Diplopia and Ptosis From Lingering Third Nerve Palsy After Treatment of Cerebral Aneurysms.

Third nerve palsies (TNPs) may not resolve after intervention for intracranial aneurysms that have compressed the nerve. The disability related to this lingering condition has not been assessed with the support of patient self-report. A single-institutional retrospective study of patients with TNP who had undergone interventions for intracranial aneurysms. We used residual primary-position diplopia, a narrow zone of single binocular vision, and vision-obscuring ptosis to divide TNP recovery into complete, incomplete nondisabling, and incomplete disabling outcomes based on medical record documentation and patient self-report derived from telephonic interviews. In a cohort of 33 patients, 13 (39%) had complete TNP recovery. There were 11 patients (33%) with lingering visual disability from diplopia or ptosis present before ophthalmic interventions. Of the 6 patients who underwent ophthalmic interventions, visual disability was relieved in only 2 patients, leaving 9 patients (27%) with lingering impairment in instrumental activities of daily living. Telephonic interviews of 23 patients (70% of the cohort) confirmed that the outcome criteria we applied were accurate in assessing visual disability in 17 patients (74%). Univariate analysis using the Fisher exact test showed that aneurysmal clipping as a treatment modality was the only clinical feature associated with a favorable TNP outcome. In applying a novel method of assessing disability, this study showed that more than one-quarter of patients undergoing procedures for brain aneurysms had lingering disability from third nerve palsy-associated diplopia or ptosis, despite later ophthalmic interventions. Patient self-report gleaned from telephonic interviews was valuable in largely validating the assessment method derived from medical records and in revealing differences between physician and patient estimation of disability.

Safety and efficacy of endovascular versus microsurgical treatment of unruptured wide-necked middle cerebral artery aneurysms: a propensity score-matched analysis of the NeuroVascular Quality Initiative Quality Outcomes Database Cerebral Aneurysm Registry.

Unruptured, wide-necked middle cerebral artery (WN-MCA) aneurysms have traditionally been considered ideal candidates for microsurgery (MS), although endovascular treatment (EVT) has dramatically increased in popularity with the advent of novel devices such as intrasaccular flow disruptors. The purpose of this study was to evaluate the safety and efficacy of MS versus EVT for unruptured WN-MCA aneurysms. The NeuroVascular Quality Initiative Quality Outcomes Database (NVQI-QOD) Cerebral Aneurysm Registry, a multiinstitutional, prospectively collected procedural database, was queried for cases of unruptured WN-MCA aneurysms treated with MS or EVT between 2015 and 2022. A wide neck was defined as an aneurysm neck ≥ 4 mm or a dome/neck ratio ≤ 2. Demographics and aneurysm characteristics were queried. Propensity score matching (PSM) was utilized to match aneurysm size, number of aneurysms treated, patient age, and aneurysm status. Safety outcomes were evaluated including intraoperative and postoperative complication rates. Aneurysm occlusion status and clinical outcomes using the modified Rankin Scale (mRS) score at discharge and the last follow-up were also assessed. Of 671 unruptured MCA aneurysms, 319 were wide necked. Thirty cases were excluded, as the aneurysm had been previously treated. Two hundred eighty-nine operations (203 EVT, 86 MS) in 282 patients satisfied inclusion criteria. After PSM, there were 86 operations in each group for analysis. The mean aneurysm width was 5.0 (EVT) versus 4.9 mm (MS; p = 0.285). Safety data showed similar intraoperative (7.0% EVT vs 3.5% MS, p = 0.496) and postoperative (4.7% vs 7%, p = 0.746) complication rates. The MS patients were more likely to have complete aneurysm occlusion at discharge (90.4% vs 58.8%, p < 0.001). In a limited subset of patients (52.9%) for whom outcome data were available, the EVT patients were more likely to have an mRS score 0 at discharge (50/59 [84.7%] vs 29/54 [53.7%], p < 0.0003] and at the last follow-up (36/55 [65.5%] vs 13/36 [36.1%], p = 0.006). This study describes a large, modern cohort of propensity score-matched patients who underwent treatment of unruptured WN-MCA aneurysms. Safety data on intraoperative and postoperative complication rates were similar in both treatment groups. MS was more likely to result in complete aneurysm occlusion at discharge. In a subset of patients with available outcome data, EVT was associated with better functional outcomes at discharge and the last follow-up. Given the lack of complete follow-up data and rates of retreatment, these results should be interpreted cautiously.

Endovascular treatment of middle cerebral artery aneurysms: current status and future prospects.

Middle cerebral artery (MCA) aneurysms are complex and widely distributed throughout the course of the MCA. Various types of aneurysms can occur in the MCA. Ruptured as well as unruptured MCA aneurysms may require treatment to avoid bleeding or rebleeding. Currently, clipping is regarded as the first-line choice for the treatment of MCA aneurysms. However, endovascular treatment (EVT) is emerging as an alternative treatment in selected cases. EVT techniques vary. Therefore, it is necessary to review EVT for MCA aneurysms. In this review, the following issues were discussed: MCA anatomy and anomalies, classifications of MCA aneurysms, the natural history of MCA aneurysms, EVT status and principle, deployments of traditional coiling techniques and flow diverters (FDs), and deployments and prospects of intrasaccular flow disruptors and stent-like devices. According to the review and our experience, traditional coiling EVT is still the preferred therapy for most MCA aneurysms. FD deployment can be used in selective MCA aneurysms. Parent artery occlusion (PAO) can be used to treat distal MCA aneurysms. In addition, new devices can be used to treat MCA aneurysms, such as intrasaccular flow disruptors and stent-like devices. In general, EVT is gaining popularity as an alternative treatment option; however, there is still a lack of evidence regarding EVT, and longer-term data are not currently available for most EVT devices.

Hybrid approach in the surgical treatment of multiple cerebral aneurysm in the acute period of rupture

Multiple aneurysms of the cerebral vessels, previously considered a rare pathology, are increasingly being diagnosed due to the development of neurovisualization methods. The proportion of patients with multiple aneurysms of the cerebral vessels ranges from 15 to 45% among all patients with aneurysms. Multiple aneurysms are detected in 25–30% of patients with subarachnoid hemorrhage. Surgical treatment of patients in this group is a relevant problem that requires a comprehensive approach. This article presents a clinical observation of successful treatment of a 58-year-old patient with multiple aneurysms in the acute period of rupture, using microsurgical clipping and endovascular embolization.

A comprehensive simulation framework for predicting the eCLIPs implant crimping into a catheter and its deployment mechanisms

Tubular flow diverters (FDs) represent an important subset of the endovascular treatment of cerebral aneurysms (CAs), acting to reduce aneurysm inflow, eventually resulting in aneurysm thrombosis and occlusion. eCLIPs (product of Evasc Neurovascular Enterprises, Vancouver, Canada), an innovative non-tubular implant causes flow diversion by bridging the neck of bifurcation CAs. However, in a small subset of challenging bifurcation aneurysms with fusiform pathology, the currently available eCLIPs models do not provide sufficient neck bridging resulting in a gap created between the device structure and the aneurysm/artery wall. To overcome this challenge, a new design of the eCLIPs (VR-eCLIPs) was developed by varying the rib length to cover such an inflow gap. To optimize the new product development process, and avoiding expensive and time-consuming iterative manufacture of prototype devices, we have developed a new finite element model to simulate the crimping and expansion processes of the VR-eCLIPs implant, and assess the possibility of plastic deformation. Results indicated that neither eCLIPs nor VR-eCLIPs experience plastic deformation during the crimping process. Upon full expansion, the ribs of VR-eCLIPs interact with the aneurysm and artery wall to cover the inflow gap that exists in certain challenging anatomies. This process serves as a basis to expedite design development prior to prototype manufacturing.

Frailty is a Predictor of Increased Readmissions and Increased Postoperative Complications After Elective Treatment of Unruptured Aneurysms

IntroductionFrailty is a state of decreased physiologic reserve associated with adverse treatment outcomes across surgical specialties. We sought to determine whether frailty affected patient outcomes after elective treatment (open microsurgical clipping or endovascular therapy [EVT]) of unruptured cerebral aneurysms (UCA). MethodsThe National Readmissions Database (NRD) was queried from 2010-2014 to identify patients who had known UCA and underwent elective clipping or EVT. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty indicator tool. Multivariable exact logistic regression analyses were conducted to assess the associations between frailty and primary outcome variables of 30- and 90-day readmissions, complications, length of stay (LOS) and patient disposition. ResultsOut of 18,483 patients who underwent elective treatment for UCA, 358 (1.9%) met the criteria for frailty. After adjusting for patient and hospital-based factors, frailty (30-day: OR 1.55 95% CI 1.11-2.17, p=0.01; 90-day: OR 1.47 95% CI 1.05-2.06, p=0.02) and clipping (vs. EVT) (30-day: OR 2.12 95% CI 1.85-2.43, p<0.000; 90-day: OR 1.80 95% CI 1.59-2.03, p<0.0001) were associated with increased readmission rates. Furthermore, frailty was associated with increased complications (surgical: OR 2.91 95% Cl 2.27-3.72, p<0.0001; neurological: OR 3.04 95% Cl 2.43-3.81, p<0.0001; major: OR 2.75 95% Cl 1.96-3.84, p<0.0001), increased LOS (IRR 3.08 95% Cl 2.59-3.66, p<0.0001) and nonroutine disposition (OR 3.94 95% Cl 2.91-5.34, p<0.0001). ConclusionsFrailty was associated with increased likelihood of 30- and 90-day readmission after elective treatment for UCA. Frailty was notably associated with several postoperative complications, greater LOS, and non-routine disposition in the treatment of UCA.

Endovascular treatment of distal cerebral aneurysms

Background. Due to rare occurrence of distal cerebral aneurysms, there are very few publications devoted to endovascular treatment. Due to current progress in the endovascular surgery, the number of successfully cured patients with distal aneurysms has been increasing recently.Aim. To determine technical capabilities and evaluate results of endovascular treatment of patients with distal intracranial aneurysms.Materials and methods. The work is based on analysis of data of endovascular treatment among 45 patients with distal cerebral aneurysms in two neurosurgical departments of federal medical centers. Of the 45 analyzed cases 30 were without aneurysm rupture and 15 were with rupture.Results. Endovascular treatment of the distal aneurysms made it possible to achieve good treatment results (4–5 points on the Glasgow Outcome Scale (GOS)) in 97.8 % of cases: 5 points on GOS – in 68.9 %, 4 points on GOS – in 28.4 %. One (2.2 %) fatal outcome was obtained. The most frequent methods of embolization were embolization of aneurysm by coils with stent assistance (37.8 %) and installation of a flow-diverter stent (28.9 %). Embolization with only coils (20 %) or occlusion of parent artery (13.3 %) were used less frequently. In 3 out of 6 patients, the occlusion of parent artery was not planned.Conclusion. Development of endovascular surgery and technical capabilities of performing operations in the distal cerebral arteries has made it possible to form a multidisciplinary approach to choosing the optimal method of shutting off the distal aneurysm from the bloodstream, taking into account the modern possibilities of open surgery. This is especially important for patients in serious condition due to ruptured aneurysm.

Long-term Follow-up After Aneurysm Treatment with the Flow Redirection Endoluminal Device (FRED) Flow Diverter

IntroductionThis study focuses on long-term outcomes after aneurysm treatment with either the Flow Re-Direction Endoluminal Device (FRED) or the FRED Jr. to investigate the durability of treatment effect and long-term complications.MethodsThis study is based on a retrospective analysis of a prospectively maintained patient data base. Patients treated with either FRED or FRED Jr. between 2013 and 2017 at our institution, and thus a possibility for ≥ 5 years of follow-up, were included. Aneurysm occlusion rates, recurrence rates, modified Rankin scale score shifts to baseline, and delayed complications were assessed.ResultsIn this study 68 patients with 84 aneurysms had long-term follow-up with a mean duration of 57.3 months and 44 patients harboring 52 aneurysms had a follow-up ≥ 5 years with a mean follow-up period of 69.2 months. Complete occlusion was reached in 77.4% at 2 years and increased to 84.9% when the latest available imaging result was considered. Younger age and the absence of branch involvement were predictors for aneurysm occlusion in linear regression analysis. After the 2‑year threshold, there were 3 reported symptomatic non-serious adverse events. Of these, one patient had a minor stroke, one a transitory ischemic attack and one had persistent mass effect symptoms due to a giant aneurysm, none of these resulted in subsequent neurological disability.ConclusionThis long-term follow-up study demonstrates that the FRED and FRED Jr. are safe and effective for the treatment of cerebral aneurysms in the long term, with high rates of complete occlusion and low rates of delayed adverse events.

Arterial Bypass in the Treatment of Complex Middle Cerebral Artery Aneurysms: Lessons Learned from Forty Patients

Complex middle cerebral artery (MCA) aneurysms incorporating parent or branching vessels are often not amenable to standard microsurgical clipping or endovascular embolization treatments. We aim to discuss the treatment of such aneurysms via a combination of surgical revascularization and aneurysm exclusion based on our institutional experience. Thirty-four patients with complex MCA aneurysms were treated with bypass and aneurysm occlusion, 5 with surgical clipping or wrapping only, and 1 with aneurysm excision and primary reanastomosis. Bypasses included superficial temporal artery (STA)-MCA, double-barrel STA-MCA, occipital artery-MCA, and external carotid artery-MCA. After bypass, aneurysms were treated by surgical clipping, Hunterian ligation, trapping, or coil embolization. The average age at diagnosis was 46 years. Of the aneurysms, 67% were large and most involved the MCA bifurcation. Most bypasses performed were STA-MCA bypasses, 12 of which were double-barrel. There were 2wound-healing complications. All but 2 of the aneurysms treated showed complete occlusion at the last follow-up. There were 3 hemorrhagic complications, 3 graft thromboses, and 4 ischemic insults. The mean follow-up was 73months. Of patients, 83% reported stable or improved symptoms from presentation and 73% reported a functional status (Glasgow Outcome Scale score 4 or 5) at the latest available follow-up. Cerebral revascularization by bypass followed by aneurysm or parent artery occlusion is an effective treatment option for complex MCA aneurysms that cannot be safely treated by standard microsurgical or endovascular techniques. Double-barrel bypass consisting of 2 STA branches to 2 MCA branches yields adequate flow replacement in most cases.

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

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. 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. 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. 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.

Microsurgical treatment of distal middle cerebral artery aneurysm: A single-center review.

To review the characteristics of distal middle cerebral artery (MCA) aneurysm treated by microsurgery, the detailed surgical options, and the clinical result. We retrospectively reviewed cerebral aneurysm in the M2 and M3 segments of the MCA surgically treated between January 2015 and December 2022. The demographic data, aneurysm-related findings, type of surgical approach, surgical technique, and clinical outcomes of the enrolled patients were analyzed. Sixteen distal MCA aneurysms were treated with microneurosurgery (incidence, 1.0%; female, 12; mean age, 58.1 years; ruptured, three). Twelve aneurysms were in the M2 segment (insular segment), two aneurysms at the M2-M3 junction, and two aneurysms in the M3 segment (opercular segment). Twelve aneurysms were saccular (average size, 4.9 mm; multiplicity, 50%; average aneurysms, 3.0; partially thrombosed, 1; sidewall aneurysm, 2). Three aneurysms were fusiform, of which two were ruptured. Of the ruptured aneurysms, one was a ruptured dissecting aneurysm. The trans-sylvian and trans-sulcal approaches were used in fourteen and two patients, respectively. Neck clipping, wrap clipping, and surgical trapping were performed in twelve, one, and one patient, respectively. Proximal occlusion was performed in one patient. Bypass technique was required in two patients (neck clipping and proximal occlusion). The modified Rankin Score was 6 in the two patients with ruptured aneurysms. The remaining patients did not show further neurological deterioration after microneurosurgery. Distal MCA aneurysms had a high incidence of being diagnosed with multiple other aneurysms and were relatively non-saccular.

Does the clopidogrel CYP2C19 genotype assay predict postprocedure stenosis in cerebral aneurysms treated with a flow diverter?

Flow diverters have emerged as a popular modality for treating cerebral aneurysms but require dual antiplatelet therapy (DAPT) after placement. Clopidogrel is a common choice but is a prodrug that some patients may not convert into an active metabolite. The CYP2C19 genotype assay is used to predict activation speed; however, limited data exist showcasing whether this genotype accurately predicts postprocedure complications after flow diversion treatment of cerebral aneurysms. Therefore, the authors sought to characterize whether CYP2C19 genotype correlated with the development of postprocedure intimal hyperplasia (stenosis) after flow diverter placement. Medical records were reviewed for patients who underwent flow diverter treatment of cerebral aneurysm at a single academic institution between January 1, 2012, and May 31, 2020. Patient demographics and comorbidities were reviewed alongside CYP2C19 genotype assay, DAPT regimen, and postprocedure angiogram data. Stenosis was defined based on review of angiogram data by two independent physicians. In this review of 120 unique cerebral aneurysms, 102 received DAPT with clopidogrel and 18 received DAPT with an alternative agent. Stenosis was present on 3-month follow-up angiogram for 35/102 (34.3%) aneurysms receiving DAPT with clopidogrel and in 11/18 (61.1%) aneurysms receiving an alternative DAPT regimen (p = 0.031). The CYP2C19 genotype did not correlate with postprocedure stenosis (p = 0.35). Clopidogrel was a significantly more effective DAPT agent for preventing stenosis when compared to nonclopidogrel DAPT regimens. The clopidogrel CYP2C19 genotype did not predict postprocedure stenosis in this cohort of 120 cerebral aneurysms treated with a flow diverter.

Delayed ischemic events with low-dose prasugrel medication for stent-assisted coil embolization in intracranial aneurysm patients.

Much emphasis has been put on the use of antiplatelet medication for the prevention of ischemic events in the treatment of cerebral aneurysms with stent assistance. In this regard, the effectiveness and safety of a low-dose prasugrel regimen during the periprocedural period was recently reported. The purpose of this study was to present the outcomes of patients on low-dose prasugrel regimens during the follow-up period after stent-assisted coil embolization (SACE) of cerebral aneurysms. For the 396 consecutive patients undergoing SACE procedures, low-dose prasugrel therapy (5 mg of prasugrel and 100 mg of aspirin) was recommended for 3 months after the endovascular treatment. The authors performed a retrospective review of a single-center experience focusing on delayed ischemic events beyond 1 month after treatment. The mean follow-up period was 24.6 ± 11.3 months. In this cohort of patients on a low-dose prasugrel regimen, cerebral infarction occurred in 1 patient (0.3%, 95% CI 0%-1.8%) beyond 1 month after SACE. No intracranial hemorrhage occurred. Overall ischemic events occurred in 14 patients (3.5%, 95% CI 2.1%-5.9%), all within 6 months of the coiling procedure. All patients had transient symptoms. The events occurred within 2 months after cessation of prasugrel in 11 patients (78.6%). Prasugrel maintenance for 6 months was found to result in lower ischemic events compared with maintenance for 3 months. For patients undergoing SACE, a low-dose prasugrel regimen was a safe and reliable treatment option for the prevention of delayed ischemic events. Transient ischemic events often occurred within 2 months of stopping prasugrel medication.

Flow Diversion for the Treatment of Intracranial Aneurysms in a Peruvian Cohort: Experiences from a Limited-Resource Setting and Barriers to Implementation

Stenting with flow diverter devices (FDDs) has increasingly emerged as a treatment for intracranial aneurysms. The use of FDDs in the developing world has not been described. A retrospective review was performed of a cohort of patients who underwent flow diversion at 4 tertiary-care centers in Lima, Peru between January 2017 and June 2021. Demographics, clinical features, and aneurysm morphology were evaluated. Clinical outcomes were observed 3 months after discharge and occlusion rates were assessed 12 months after treatment. Sixty-nine patients (mean age, 46 ±14.5 years; 17% female) were treated with FDDs; 4% (n= 3) of the treated aneurysms were ruptured. Most aneurysms were saccular (n= 65; 94%), <10 mm in maximum size (n= 60; 87%), and located in the anterior circulation (n= 67; 97%). Minor complications, such as groin hematoma, occurred in 7 cases. No serious complications or deaths occurred. Patients' functional status was excellent (modified Rankin Scale score 0-1) in 99% (n= 66) at discharge and 100% (n= 67) at 3 months. Although some patients were lost to follow-up, complete occlusion was seen in 76% (n= 31) of 41 treated patients at 12 months. We report the largest multicenter experience of FDDs for cerebral aneurysm treatment in Peru, with reasonable outcomes that are comparable to other settings despite various challenges, suboptimal circumstances, and lack of resources.

Comparison of treatment outcomes and complications of coil embolization in elderly and very elderly patients with cerebral aneurysms: a propensity score matching analysis.

This single center study aims to compare the treatment outcomes and procedure-related complications of coil embolization in elderly patients (60-79 years) and very elderly patients (aged 80 years or older) with cerebral aneurysms. Data was collected from 504 elderly patients aged 60 years or older who underwent coil embolization for intracranial aneurysms from 2018 to 2021. The study evaluated patient-related and anatomical factors and assessed various outcomes, comparing results between groups using statistical analysis and propensity score matching. A total of 503 cerebral aneurysms were analyzed from individuals aged 60-79 years (n = 472) and those aged 80 years or older (n = 31). The majority of the aneurysms were unruptured with an average size of 3.5 mm in height and 3.4 mm in width. The patients were compared using 1:1 propensity score matching, and no significant differences were found in factors other than age and aortic elongation. Logistic analysis revealed that being over 80 years old and having a severe aortic arch elongation were identified as risk factors for procedure-related events in both total and unruptured cases. The study compared coil embolization treatment for cerebral aneurysms in patients aged 60-79 and over 80, finding no significant difference in treatment outcomes except for procedure-related events. Procedure-related events were associated with severe aortic arch elongation and being over 80 years old. Coil embolization can be considered safe and effective for patients over 80, but further trials are needed for accurate conclusions.

Utility of follow-up ultra-high-resolution CT angiography with model-based iterative reconstruction after flow diverter treatment for cerebral aneurysms.

Follow-up examinations after flow diverter (FD) treatment for cerebral aneurysms typically involve magnetic resonance imaging (MRI) or digital subtraction angiography (DSA). However, MRI is prone to vascular defects due to metal artifacts from FD, and DSA carries a risk of ischemic complications. In the context of computed tomography angiography (CTA), this study compares the efficacy of ultra-high-resolution CT (UHRCT) and novel reconstruction techniques, such as model-based iterative reconstruction (MBIR), against conventional methods such as filtered back projection (FBP) and hybrid iterative reconstruction (IR), to determine if they are a viable alternative to DSA in clinical settings. A phantom study was conducted with the full-width half-maximum considered as the FD thickness. This study compared three reconstruction methods: MBIR, FBP, and hybrid IR. A clinical study was also conducted with 21 patients who underwent follow-up CTA after FD treatment. The FD's visibility was assessed using a 4-point scale in FBP, hybrid IR, and MBIR compared to cone-beam CT (CBCT) with angiographic systems. In the phantom study, FBP, hybrid IR, and MBIR visualized thinner FD thicknesses and improved detail rendering in that order. MBIR proved to be significantly superior in both the phantom and clinical study. UHRCT with MBIR is highly effective for follow-up evaluations after FD treatment and may become the first-choice modality in the future.