Endovascular Management Of Intracranial Aneurysms Research Articles

Perianeurysmal vasogenic oedema (PAVO): A single centre 10-year retrospective review.

Perianeurysmal Vasogenic Oedema (PAVO) is a rare but important complication of endovascular treatment of intracranial aneurysms. Many potential risk factors have been identified including age, aneurysm size, aneurysm location, immunological profile, type of coil used, diabetes, hypertension, and smoking. PAVO can cause persistent post-procedural symptoms, subsequently increasing post-embolization morbidity. A 10-year retrospective review was conducted between 2011 and 2021 at Royal Preston Hospital, Preston, UK. We identified 8 patients that fit our inclusion criteria. This included 6 (75%) females and 2 (25%) males. The mean age was 64. All patients had anterior circulation aneurysms with the middle cerebral artery (MCA) being the most common site. The mean aneurysm size was 12mm. Our patients were managed with a range of endovascular techniques. One patient had pre-treatment PAVO while 7 patients had post-embolization PAVO. Five patients were symptomatic, and 3 cases were asymptomatic with only radiological evidence of PAVO. Five patients were managed with varying courses of dexamethasone. PAVO resolution was achieved in 4 cases. The oedema significantly improved in 3 cases, but transiently progressed in 1 case. PAVO is a rare but important complication of endovascular management of intracranial aneurysms. We have shown that patients can be effectively managed with steroids with resultant oedema regression and symptomatic improvement. Many risk factors have been associated with PAVO, but further research is needed to better understand their role in PAVO development and help develop other therapeutic options.

High-frequency optical coherence tomography for endovascular management of cerebral aneurysms.

Endovascular management of intracranial aneurysms has become the mainstay of treatment in recent years; however, retreatment rates remain as high as 1 in 5. High-frequency optical coherence tomography (HF-OCT) is an emerging imaging modality for the assessment, treatment and follow-up of cerebral aneurysms. EMBASE and SCOPUS databases were searched for studies relating to the management of intracranial aneurysm with OCT. A combination of keywords were used including 'cerebral aneurysm', 'intracranial aneurysm', 'high-frequency optical coherence tomography', 'optical coherence tomography', and 'optical frequency domain imaging'. There were 23 papers included in this review. For the assessment of intracranial aneurysm, OCT was able to accurately assess aneurysm morphology as well as detailed analysis of arterial wall layers. During IA treatment, OCT was used to assess and troubleshoot stent placement to optimise successful isolation from the circulation. In the follow-up period, endothelial growth patterns were visualised by OCT imaging. OCT shows promise for the treatment of IAs at all stages of management. Due to the novel development of HF-OCT, there is limited longitudinal data in human studies. Further research in this area is required with a focus specifically on long-term treatment outcomes in humans.

Trends in Dual Antiplatelet Therapy Use for Neurointerventional Procedures for the Management of Intracranial Aneurysms.

The use of periprocedural dual antiplatelet therapy (DAPT) has significantly evolved along with innovations in the endovascular management of intracranial aneurysms. Historically, aspirin and clopidogrel have been the most commonly employed regimen due to its safety and efficacy. However, recent studies highlight the importance of tailoring DAPT regimens to individual patient characteristics which may affect clopidogrel metabolism, such as genetic polymorphisms. In the present report, a systematic review of the literature was performed to determine optimal antiplatelet use with flow diverting stents, intracranial stents, intrasaccular devices, and stent-assisted coiling. Studies were analyzed for the number of aneurysms treated, DAPT regimen, and any thromboembolic complications. Based on inclusion criteria, 368 studies were selected, which revealed the increasing popularity of alternative DAPT regimens with the aforementioned devices. Thromboembolic or hemorrhagic complications associated with antiplatelet medications were similar across all medications. DAPT with ticagrelor, tirofiban, or prasugrel are effective and safe alternatives to clopidogrel and do not require enzymatic activation. Further clinical trials are needed to evaluate different antiplatelet regimens with various devices to establish highest-level evidence-based guidelines and recommendations.

Endovascular management of intracranial aneurysms at Chris Hani Baragwanath Academic Hospital.

Worldwide, intracranial aneurysms are associated with a high mortality rate. While endovascular management has proven to be the choice of treatment in selected patients, patient demographics and aneurysm characteristics differ between study populations. This study aimed to investigate the profile of patients with intracranial aneurysms who underwent endovascular management in the Interventional Neuroradiology Unit at Chris Hani Baragwanath Academic Hospital. Patient demographics, risk factors, indications, aneurysm characteristics and intra-operative complications were studied. This was a 3-year retrospective study of all adult patients between 01 January 2018 and 31 January 2021. The Chi-square test was used to compare categorical variables. A total of 77 patients were included in this study. The mean age of the patients was 47 ± 11.6 with a male-to-female ratio of 1:1.8. Hypertension was the most reported risk factor in 27% of patients. There was no statistical correlation between the gender groups according to presentation, multiplicity, aneurysmal size dimensions and locations. According to the presentation, there was statistical significance in ruptured intracranial aneurysms (p = 0.020), neck size dimensions less than 4 mm (p = 0.010), and aneurysms located in the internal cerebral artery (ICA) circulation (p = 0.001). The study findings support known parameters including females and anterior circulation aneurysm preponderance, and the low complication risk of endovascular management. Interestingly, intracranial aneurysms presented with rupture at smaller size dimensions. This study provides valuable insights into intracranial aneurysm characteristics and endovascular management efficacy in a resource-limited setting.

ENDOVASCULAR MANAGEMENT OF INTRACRANIAL ANEURYSMS ON DISTAL ARTERIAL BRANCHES: ILLUSTRATIVE CASE SERIES AND LITERATURE RETROSPECTION.

SUMMARYIntracranial aneurysms located on distal arterial branches are sporadic and scarce. They account for 2%-7% of the middle cerebral artery and 0.7%-2.3% of the posterior cerebral artery aneurysms, where they mainly arise distally from the P2-related sites. Such aneurysms usually remain asymptomatic prior to rupture, making their diagnosis and management really demanding. Endovascular treatment comprising of different neurointerventional techniques is becoming the most operational up-to-date routine to approach distal cerebral branch aneurysms. In this single-institution case series, endovascular selective coiling and/or parent vessel occlusion resulted in successful and total aneurysmal exclusion from cerebral circulation, which brought good recovery. Hereby, we present an illustrative case series of distal arterial branch intracranial aneurysms, discussing their possible etiology and various endovascular management modalities. We also provide a literature retrospection concerned with this rare entity. In conclusion, due to their predisposition for rupture, distal branch intracranial aneurysms should be treated early and aggressively. We do believe that endovascular selective coil occlusion is the management method of choice, while parent vessel occlusion (with liquid embolics) is optimal when aneurysmal coiling cannot be achieved, or when distal cortical territory is well vascularized by strong collateral cerebral circulation.

Stents Technique for Endovascular Management of Intracranial Aneurysms

Background: Endovascular detachable coil embolization has become an important method in the management of intracranial aneurysms. However, coil embolization alone may fail to treat some wide-neck aneurysms and other complex anatomy configuration. Herein, we report our experience with and outcome of stent techniques of intracranial aneurysms. Objective: The aim of the study was to evaluate the feasibility safety and efficacy of stent usages either conventional or flow diverting stents in endovascular management of intracranial aneurysms. Patients and Methods: Between October 2011 to May 2018 a prospective study was done on a series of 17 consecutive patients harboring 17 intracranial aneurysms approached with endovascular therapeutic stent techniques, these 17 aneurysms (5 have history of rupture, 29 % and 12 unruptured, 71%), Angiographic and clinical follow-up was obtained in 17 (100%) patients (mean 21 months, range 0.5 to 84). Results: In late follow-up 16 patient (94%) had favorable outcome and 1 patient (6%) had unfavorable outcome, over all Complete occlusion Grade 0 with stent technique was achieved in 10 patients (59%), Grade I in 3 patients (17%), Grade II in 1 patients (6%), Grade III in 1 patient (6%), Grade IV in 1 patient (6%) and Grade V in 1 patient (6%), intraoperative complication was noted in 3 cases (18%) with favorable outcome. Conclusion: Endovascular stent-assisted coiling was a feasible, effective and relatively safe technique for the treatment of broad neck and complex configuration intracranial aneurysms.

The 100 most cited articles in the endovascular management of intracranial aneurysms

IntroductionEndovascular interventions for intracranial aneurysms have evolved substantially over the past several decades. A citation rank list is used to measure the scientific and/or clinical impact of an article. Our...

Anesthetic Considerations for Endovascular Management of Intracranial Aneurysms

Intra cranial aneurysms are acquired lesions responsible for about 80% of non-traumatic sub arachnoid hemorrhage. Treatment of the condition in the past has relied on craniotomy and clipping of the aneurysm to prevent a recurrent hemorrhage. Nowadays endovascular coiling is the best primary treatment. The anesthesia in interventional radiology room has special arrangement and precautions. Intra operative management of endovascular cerebral aneurysm from the start including: arrangement of the room, monitoring, induction, maintenance and emergence of the patients. Post-operative care is very important and good management of potential perioperative complications like: aneurysm rupture, cerebral infarction, cerebral vasospasm, contrast reaction and nephropathy is mandatory. Aim of the Study: reviewing the current medical literature as regards the anesthetic considerations and problems of endo-vascular management of intracranial aneurysm. Conclusion: anesthesia in interventional radiology room should have special arrangements and precautions. Intra operative management of endovascular cerebral aneurysm from the start including: arrangement of the room, monitoring, induction, maintenance and emergence of the patients. Post-operative care plays a key role in mitigating potential perioperative complications like: aneurysm rupture, cerebral infarction, cerebral vasospasm, contrast reaction and nephropathy are mandatory.

Analysis of Multiple Intracranial Aneurysms with Different Outcomes in the Same Patient After Endovascular Treatment

Aneurysm recanalization after coiling, with or without stent assistance, is a major issue in the endovascular management of intracranial aneurysms. Multiple intracranial aneurysms with different outcomes after endovascular treatment may represent a useful disease model in which patient-specific risk factors can be balanced to investigate possible features linked to aneurysm recanalization. In the present study, we evaluated the impact of aneurysm-specific, treatment-related, and hemodynamics-related factors on multiple aneurysms and to explore the reason why one aneurysm recanalized and the other did not. Between 2010 and 2015, 763 multiple intracranial aneurysms in 326 patients were diagnosed by digital subtraction angiography. We retrospectively collected and analyzed 13 pairs of multiple aneurysms with different outcomes (recanalized or stable) in the same patient. Patient-specific models were constructed and analyzed by a computational fluid dynamics method. The virtual stent deployment method was used, and the coils were simulated by a porous medium model. Factors were evaluated for significance with respect to recanalization. Aneurysm size (P= 0.021), neck width (P=0.027), ruptured aneurysms (P= 0.002), reduction ratio of averaged velocity (P= 0.008), and wall shear stress (P= 0.024) were significantly associated with aneurysm recanalization. By contrast, the aneurysm location, all of treatment-related factors (packing density, duration of follow-up, stent use, initial angiographic result) and the reduction ratio of averaged pressure were not significantly associated (P > 0.05). Small aneurysm size and neck width, unruptured aneurysm, and perianeurysmal hemodynamics with marked reduction may be important factors associated with the midterm durability of aneurysm embolization.

Endovascular Management of Intracranial Aneurysms: Advances in Stenting Techniques and Technology.

Endovascular Management of Intracranial Aneurysms: Advances in Stenting Techniques and Technology.

The role of antiplatelet therapy in aneurysm coiling

Neurointerventional surgery offers the potential to deliver remarkable intravascular therapies for various neurovascular diseases and stroke. This approach, however, carries a risk of complications that need to be kept to a minimum. Thromboembolism is one of the most consequential complications of neurointerventional surgery in the treatment of intracranial aneurysms. Both antiplatelet and anticoagulant therapies have shown to reduce the risk of thromboembolism in this setting. In this paper, we review the role of antiplatelet therapy in the endovascular management of intracranial aneurysms. For unruptured aneurysms, the use of antiplatelet agents to pre-medicate patients before and during the procedure appears safe and effective in reducing the thrombotic risk. Abciximab has not been extensively studied, but seems to be safe as a salvage maneuver in the case of thrombus formation even in ruptured aneurysms (when the dome is relatively secure) with low rates of intraprocedure and procedure hemorrhagic complications. Further innovation and research are needed to further reduce thromboembolic risks of aneurysm coiling.

Postępowanie anestezjologiczne podczas endowaskularnego leczenia niepękniętych tętniaków wewnątrzczaszkowych

Endovascular techniques for treatment of intracranial aneurysms are increasingly commonly applied. In general, the procedures are short, require general anaesthesia and complete immobilisation of patients. The aim of the present study was to assess the usefulness of general anaesthesia with propofol and laryngeal mask airway for endovascular management of intracranial aneurysms based on analysis of haemodynamic stability. The study encompassed 26 patients undergoing endovascular treatment of intracranial aneurysms. The mean arterial pressure (MAP), heart rate (HR), bispectral index (BIS), end-tidal CO₂(E(T)CO₂) and haemoglobin saturation with oxygen (SpO₂ ) were determined at eight measurement points: T₁ - before anaesthesia induction, T₂ - after induction, T₃ - after LMA insertion, T₄ - during arteriography, T₅ - during "coiling" , T₆ - at completion of propofol infusion, T₇ - before LMA removal, T₈ - after LMA removal. MAP and HR were found significantly reduced between T₂ and T₁ . To maintain BIS within the range of 40-60, the following propofol infusion rates (in mg kg b.w.⁻¹ h⁻¹ ) were required: T₂ - 4.5 ± 0.3; T₃ - 4.6 ± 0.7; T₄ - 4.5 ± 0.8 and T₅ - 4.4 ± 0.6. E T CO₂ and SpO₂ were not demonstrated to be changed. The mean duration of anaesthesia and of recovery was 64.3 ± 21.8 and 8.9 ± 4.8 min, respectively. General anaesthesia with propofol and LMA ensures suitable conditions for endovascular treatment of intracranial aneurysms.

Intra-Arterial Eptifibatide in the Management of Thromboembolism during Endovascular Treatment of Intracranial Aneurysms: Case Series and a Review of the Literature

Objectives: Thromboembolic complications are well recognized during the endovascular management of intracranial aneurysms. In this study, we present a case series of 40 patients with intraprocedural thrombotic complications who were treated with intra-arterial eptifibatide (IAE), and a review of the literature. Methods: Twenty-five patients with ruptured intracranial aneurysms (RIA), 10 with unruptured intracranial aneurysms (UIA) and 5 with aneurysmal subarachnoid hemorrhage-induced vasospasm (VSP) received IAE for intraprocedural thrombi during endovascular treatment. Rates of recanalization, strokes, and hemorrhagic complications were assessed. Results: Recanalization was achieved in 96% (24/25) of the RIA patients [72% (18/25) complete; 24% (6/25) partial], in 100% (10/10) of the UIA patients [90% (9/10) complete; 10% (1/10) partial], and in 100% (5/5) of the VSP patients [80% (4/5) complete; 20% (1/5) partial]. Strokes following intraprocedural thrombosis were coil-related (20%, 5/25) or stent-related (12%, 3/25) in RIA patients, stent-related (10%, 1/10) in UIA patients, and heparin-induced thrombocytopenia type II-related (60%, 3/5) or vasospasm-related (20%, 1/5) in VSP patients. There were no intracerebral hemorrhagic complications in UIA. Intracerebral hemorrhage was observed in 20% of the RIA patients (5/25), all of whom had received intra-arterial thrombolytics and/or high-dose heparin infusion in addition to IAE; in 12%, this was external ventricular drain-related (3/25), 4% had parenchymal hematoma type 1 (1/25), and 4% parenchymal hematoma type 2 (1/25). One of the 5 VSP patients, who had received argatroban in addition to IAE, had parenchymal hematoma type 1. No clinically significant systemic hemorrhage was observed in this study. Conclusion: Treatment of thromboembolic complications with IAE during endovascular management of aneurysms was effective in achieving recanalization and overall well tolerated in this series.

Indications and practical application of strategies in the endovascular management of intracranial aneurysms

Abstract The occlusion of intracranial aneurysms is more successful and stable by properly planning the approach and application of endovascular techniques. The next step is a relentless analysis of the different indications of endovascular treatment, tailoring a strategy suitable for the specific case, and making more rational choices for the management of aneurysms. Indications and strategies according to the analysis of the aneurysmal complex are given, as well as pros and cons of the endovascular technique according to different anatomical locations

E-034 Stent assistance in neurointerventional procedures

IntroductionBalloon assistance for endovascular management of intracranial aneurysms is an established technique. There are possible limitations to this technique related to either anatomical or functional factors (patient intolerance to baloon...

Endovascular management of giant intracranial aneurysms of the posterior circulation

Large size, and location in posterior circulation, both individually portend high risk in the endovascular management of intracranial aneurysms. The purpose of this study was to investigate the outcome of endovascular management of giant posterior circulation aneurysms at our centre. This is a retrospective analysis of 22 consecutive patients with giant posterior circulation aneurysms, who were managed by endovascular techniques between 1997 and 2009. The aneurysms included: Vertebral-6 (27%), basilar or vertebrobasilar - 7 (32%) and nine posterior cerebral artery (PCA) - 9 (41%). There were 14 males and eight females with a mean age of 37 years. Treatment modalities included: Parent vessel sacrifice (PVS), coil embolization, flow reversal, stent-assisted coiling, and telescopic stent placement. Angiographic cure or stasis was achieved in 21 (95%) patients and no recurrence was observed in 17 of the 18 patients who had follow-up. Complications occurred in 9 (41%) patients, death in 4 and morbidity in 5 (3 with good eventual outcome). Overall, good clinical outcome was noted in 16 (73%) patients. The majority of the poor outcomes were observed in the management of basilar/vertebrobasilar aneurysms and flow reversal. Parent vessel sacrifice showed the best outcomes with stable results. Our results suggest that PVS remains the procedure of choice wherever possible and is relatively safe, particularly for giant vertebral and PCA aneurysms. When PVS is not feasible, stent-assisted coiling is a reasonable and safe option and requires follow-up. Management of basilar or vertebrobasilar aneurysms is complicated and still evolving.

Endovascular treatment of intracranial aneurysms in Loeys–Dietz syndrome

BackgroundLoeys–Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by extensive arterial aneurysms. The successful clipping of intracranial aneurysms in patients with LDS has been reported in a...

The place for remodeling technique and stenting in the endovascular management of intracranial aneurysms: a single-center analysis from 2008 to 2010

The objective of this study was to analyze the place for the balloon remodeling and stenting in the endovascular treatment of intracranial aneurysms as well as the impact of their use on the failure and complications rates. Analysis was conducted in a recent 3-year period (2008-2010) in a single center. A total of 287 aneurysms, harbored by 252 patients (age, 16-87 years; mean, 50.9 ± 13.4 years), were proposed for endovascular treatment. Patient and aneurysms characteristics, modalities of treatment (coiling, remodeling, or stenting), failure rate, and rate of adverse events related to the treatment were analyzed. Treatment failed in 3/287 aneurysms (1.0%). The use of the remodeling technique and stenting increased over time (23.9% and 4.6% in 2008, 39.5% and 14.9% in 2009, and 43.9% and 20.7% in 2010, respectively). The remodeling technique was used in a similar percentage of cases independent of aneurysm characteristics (aneurysm status, location, and size, and neck size), except dome-to-neck ratio. Stenting was more frequently used in unruptured aneurysms, in internal carotid artery aneurysms, and in wide neck aneurysms. The rate of specific adverse events (thromboembolism and intraoperative rupture) was similar in coiling (2.8%), remodeling (6.9%), and stenting (1.1%). The rate of specific adverse events was similar in 2008, 2009, and 2010 (2.3%, 4.4%, and 6.1%, respectively). In the endovascular management of intracranial aneurysms, the large use of the remodeling technique combined with stenting in selected cases enables a low rate of treatment failures without increasing the rate of complications.

Difficult Aneurysms for Endovascular Treatment: Overwide or Undertall?

Aneurysm geometry has been shown to predict the need for adjunctive techniques in the endovascular treatment of intracranial aneurysms. We conducted a systematic retrospective study examining which thresholds of dome-to-neck ratio, maximum neck width, and aspect ratio of intracranial aneurysms best predict the need for adjunctive techniques in endovascular management. One hundred seventy-five consecutive patients who were selected for attempted embolization of 185 intracranial aneurysms were included in this study. Aneurysm dome-to-neck ratio (maximum dome width/maximum neck width), maximum neck width, and aspect ratio (dome height/maximum neck width) were measured on 2D digital subtraction angiography. Statistical analysis was conducted to determine which thresholds of dome-to-neck ratio, maximum neck width, and aspect ratio were most predictive of the need for adjunctive devices in endovascular management of these aneurysms. We demonstrated that 75% of aneurysms with dome-to-neck ratios >1.6 (P < .0001), 75% of aneurysms with aspect ratios >1.6 (P < .0001), and 70% of aneurysms with neck diameters <4.0 mm (P < .0001) did not need adjunctive techniques in their management. Adjunctive techniques were essential to treatment of 80% of aneurysms with dome-to-neck ratios <1.2 (P = .02) and 89% of aneurysms with aspect ratios <1.2 (P < .0001). Multivariate logistic regression analysis demonstrated that aspect ratio was the best predictor of the need for an adjunctive device (P = .0004). Aneurysms with aspect and dome-to-neck ratios >1.6 usually did not require adjunctive techniques. Aneurysms with aspect and dome-to-neck ratios <1.2 almost always required adjunctive techniques. In this single-center series, aspect ratio was the independent predictor of the need for adjunctive techniques in the endovascular management of intracranial aneurysms.

Current trends in endovascular management of intracranial aneurysms (including posterior fossa aneurysms and multiple aneurysms)

Aneurysmal subarachnoid hemorrhage (SAH) is a devastating illness and a major cause of morbidity and mortality.[1] The frequency of aneurysm ranges from 0.4-10%; there is a prevalence of 2.3% in adults without a risk factor for SAH and an annual risk of rupture of 1.9%.[2] Once the aneurysm has bled, there is 15% chance of rebleed in the first few hours, and this is associated with high mortality.[3] Therefore, intracranial aneurysms (IAs) has to be treated surgically or endovascularly. With the publication of the International Subarachnoid Aneurysm Trial (ISAT) results, more and more aneurysms are being treated by endovascular means worldwide.[4] However, each aneurysm should be assessed by an interdisciplinary approach, with the aim being to choose the best option for each patient. Advanced techniques in endovascular therapy have made this modality relatively safe and as effective as surgery in experienced hands.