Endovascular Treatment Of Unruptured Intracranial Aneurysms Research Articles

Propofol-Based Anesthesia Maintenance and/or Volatile Anesthetics during Intracranial Aneurysm Repair: A Comparative Analysis of Neurological Outcomes

Background: Volatile and intravenous anesthetics have substantial effects on physiological functions, notably influencing neurological function and susceptibility to injury. Despite the importance of the anesthetic approach, data on its relative risks or benefits during surgical clipping or endovascular treatments for unruptured intracranial aneurysms (UIAs) remains scant. We investigated whether using volatile anesthetics alone or in combination with propofol infusion yields superior neurological outcomes following UIA obliteration. Methods: We retrospectively reviewed 1001 patients who underwent open or endovascular treatment for UIA, of whom 596 had short- and long-term neurological outcome data (modified Rankin Scale) recorded. Multivariable ordinal regression analysis was performed to examine the association between the anesthetic approach and outcomes. Results: Of 1001 patients, 765 received volatile anesthetics alone, while 236 received propofol infusion and volatile anesthetics (combined anesthetic group). Short-term neurological outcome data were available for 619 patients and long-term data for 596. No significant correlation was found between the anesthetic approach and neurologic outcomes, irrespective of the type of procedure (open craniotomy or endovascular treatment). The combined anesthetic group had a higher rate of ICU admission (p < 0.001) and longer ICU and hospital length of stay (LOS, p < 0.001). Similarly, a subgroup analysis revealed longer ICU and hospital LOS (p < 0.0001 and p < 0.001, respectively) in patients who underwent endovascular UIA obliteration under a combined anesthetic approach (n = 678). Conclusions: The addition of propofol to volatile anesthetics during UIA obliteration does not provide short- or long-term benefits to neurologic outcomes. Compared to volatile anesthetics alone, the combination of propofol and volatile anesthetics may be associated with an increased rate of ICU admission, as well as longer ICU and hospital LOS.

172 Health Inequities in Access to Treatment for Unruptured Intracranial Aneurysms in the United States over 20 Years

INTRODUCTION: Literature suggests that minority racial and ethnic groups have lower treatment rates for unruptured intracranial aneurysms (UIA). It is uncertain how these disparities have changed across time. METHODS: The National Inpatient Sample (NIS) database was queried using diagnostic and procedural codes for adult patients who underwent open surgical or endovascular treatment for UIA. Aneurysmal SAH patients were used as a substitute control for patients with intracranial aneurysms that progressed to hemorrhage before intervention. A multivariable logistic regression model was constructed using patient factors and hospital factors to identify predictors of treatment. RESULTS: A total of 213,350 UIA patients and 173,375 aSAH patients from 2000-2019 were included in the final analysis. After adjusting for covariates, Black patients (0.715, 95% CI 0.699-0.730), Hispanic patients (0.734, 95% CI 0.717-0.751) and other racial/ethnic minority patients (0.633, 95% CI 0.617-0.651) had lower odds of intervention for UIA compared to White patients with UIA. Medicare patients had higher odds of treatment than private insurance patients while Medicaid and the uninsured patients had lower odds. Non-White/Hispanic females (0.697, 95% CI 0.646-0.752) and males (0.602, 95%CI 0.556-0.651) had lower treatment odds than their white counterparts, irrespective of insurance status. Multivariable regression analysis revealed that the treatment odds of Black patients improved over time, while other minority group patients had variable treatment odds over time. CONCLUSIONS: This analysis of NIS data from 2000 to 2019 demonstrates disparities in treatment for UIA across race, sex, insurance status, and hospital factors. The persistence of inequalities over time requires attention in order to target improvement.

387 ICU Utilization in Elective Endovascular Treatment of Unruptured Intracranial Aneurysms

INTRODUCTION: Evidence suggests routine post-operative intensive care unit (ICU) admission in high-risk neurosurgical procedures, including endovascular treatment of unruptured intracranial aneurysms (UIA), may be unnecessary, though current practice patterns are undescribed. We sought to evaluate trends in ICU utilization in patients undergoing elective endovascular repair of UIA in the United States. METHODS: This is a retrospective cohort study utilizing commercial claims from a nationwide longitudinal database of multiple payors in the U.S. (MarketScan) to evaluate ICU use in patients undergoing elective, endovascular repair of UIA between 2005 and 2019. Our initial cohort was defined using diagnosis codes and CPT procedural codes. Patients with ruptured aneurysms were excluded, and the remaining unruptured patients were separated by ICU revenue codes to identify those who were likely admitted to the ICU post-operatively. A combination of diagnosis codes and procedural codes were utilized to evaluate demographics, pre-operative comorbidities, post-procedural complications, and discharge status. Cost analysis was also performed. RESULTS: Of 6218 patients who underwent elective endovascular treatment of UIA, 78.6% (4890) of patients were placed in the ICU post-operatively, and this percentage remained stable over the study period. No differences in age, sex, comorbidity scores, or smoking history were found between patients admitted to the ICU versus those admitted to the floor. ICU utilization was more common in urban locations (p < 0.001). The average total payment was higher in patients admitted to the ICU post-operatively ($46,429 versus $40,552, p < 0.0001). CONCLUSIONS: Almost 80% of patients undergoing elective endovascular repair of UIA are admitted to the ICU postoperatively, despite multiple studies suggesting this practice is unnecessary. Costs are significantly higher in patients utilizing the ICU. Reducing routine ICU use in this subgroup of patients may reduce costs and resource utilization in a safe manner.

Intervals of endovascular treatment for coincidental non-adjacent unruptured aneurysms in patients with symptomatic intracranial atherosclerotic stenosis.

Background and purposeTo explore the safety of endovascular therapy for concomitant non-adjacent unruptured intracranial aneurysms (UIAs) which is incidentally found in severe patients with symptomatic intracranial atherosclerotic stenosis at the same session and different sessions.MethodsPatients between January 2019 to December 2020 were retrospectively reviewed at our institution. Patients with concomitant non-adjacent incidental UIA in severe symptomatic intracranial atherosclerotic stenosis, who underwent endovascular treatment for both lesions were included. They were divided into two groups according to the intervals (The aneurysm was treated at the same session as stenosis or at separated sessions). The demographics, procedure details, complications, and clinical outcomes were compared between groups.ResultsA total of 22 patients were involved. In total, ten patients underwent endovascular treatment for UIA and stenosis at one session and 12 patients at separate sessions. In total, three (13.6%) patients experienced procedural related complications, including 2 (20%) in the one session group and 1(8.3%) in the separate sessions group. Follow-up (Range 6–12, mean = 8.5 months) results showed good clinical outcome in all the patients. There is no statistical significance in terms of complication rate and unfavorable clinical outcome between groups.ConclusionsNon-adjacent concomitant UIA and severe symptomatic intracranial atherosclerotic stenosis will not pose additional endovascular treatment risks. Both simultaneous endovascular management and short intervals between separated procedures are technically feasible and safe.

Safety and Efficacy of Low-dose Prasugrel in the Endovascular Treatment of Unruptured Aneurysms in the Elders (≥ 75Years).

The effectiveness and safety of low-dose prasugrel (PSG) premedication for endovascular treatment of unruptured intracranial aneurysms (UIAs) have been widely reported. In this study, we evaluated the clinical outcomes of elders patients (≥ 75years) treated with PSG. Atotal of 200patients with 209 UIAs who were administered PSG as premedication (20 mg loading and 5 mg maintenance with 100 mg aspirin) between March 2018 and December 2021 were retrospectively enrolled. Among them, 39patients were aged 75years or over (elders group), and 161patients were aged under 75 years (control group). Patients' clinical data were collected, and outcomes were compared between the two groups. Of the 200patients with PSG, 9cases (4.5%) had overall complications (7ischemic, 2hemorrhagic). In the comparison between the elders group and the control group, no significant differences were observed in the overall complication rates (elders group vs. control group; 2.6% vs. 5.0%, P = 1.00). Moreover, the rates of poor clinical outcome were comparable (2.6% vs. 1.2%, P = 0.48). The subgroup analysis of patients with stent-assisted procedures revealed no significant differences in complication rates (0% vs. 1.6%, P = 1.00) or poor clinical outcomes (0% vs. 0%, P = 1.00) during maintenance with aspirin 100 mg or PSG 5 mg. The complication rates in the elders treated with low-dose PSG premedication were similar to those in the control. Low-dose PSG premedication could be prescribed without any additional risk for the endovascular treatment of UIAs in elders patients.

Increased Concentrations of Atherogenic Proteins in Aneurysm Sac Are Associated with Wall Enhancement of Unruptured Intracranial Aneurysm

Current MR-vessel wall imaging (VWI) of unruptured intracranial aneurysms (UIAs) permits the visualization of wall structures. Aneurysm wall enhancement (AWE) was associated with atherosclerotic remodeling of the aneurysm wall accompanied by infiltration of inflammatory cells, potentially contributing to rupture. This study sought to investigate whether the luminal concentrations of atherosclerotic proteins in the aneurysm sac were associated with increased wall enhancement of UIAs in VWI. Subjects undergoing endovascular treatment for UIAs were prospectively recruited. All subjects underwent evaluation using 3T-MRI including pre/post contrast VWI of the UIAs. Blood samples were collected from the aneurysm sac and the parent artery during endovascular procedures. The presence of AWE was correlated with the delta difference in concentration between the aneurysm sac and the parent artery for each atherosclerotic protein. A total of consecutive 45 patients with 50 UIAs were enrolled. The delta differences of anti-oxidized low-density lipoprotein (LDL) antibody, small dense LDL, and lipoprotein(a) [Lp(a)]were significantly higher in UIAs with AWE compared with those without AWE (767.6 ± 1957.1 versus - 442.4 ± 1676.3 mIU/mL, p = 0.02, 114.8 ± 397.7 versus - 518.5 ± 1344.4μg/mL, p = 0.04, and - 5.6 ± 11.3 versus - 28.7 ± 38.5μg/mL, p = 0.01, respectively). In multivariate logistic regression analysis, the delta Lp(a) was significantly associated with AWE (p = 0.04). Increased concentrations of atherogenic proteins in the aneurysm sac were significantly associated with wall enhancement of UIAs. Future studies examining the effect of medications for atherosclerosis on the atherogenic proteins within the aneurysm sac and hence the wall enhancement are warranted.

Practical Incidence of Complications and Degree of Patient Satisfaction After Endovascular Coil Embolization for Unruptured Intracranial Saccular Aneurysm Based on Patients' Surveys

Endovascular treatment for unruptured intracranial aneurysms (UIAs) has been regarded as second to none management nowadays as the result of its proven efficacy and need for less-invasive treatment. Most researchers have focused on the anatomical outcome after endovascular treatment, so in this study we estimated the real incidence of untoward effect and degree of patients' satisfaction based on s survey. This retrospective study was approved by the institutional review board, and 112 patients treated for saccular UIAs were evaluated among a total of 135 patients. After informed consent was obtained, these patients were sent a questionnaire regarding treatment effectiveness, complications, and patient satisfaction. These data were collected and compared with angiographic and clinical outcome. The response rate was 87.5% (98/112). Intracranial complications occurred in 10 aneurysms (10.2%): 7 ischemic and 3 hemorrhagic strokes. Other complications occurred in 30 patients (30.6%): 17 alopecia, 15 bleeding tendency, and 3 puncture-site complications. Overall, 89 (90.8%) patients reported being satisfied with their treatment. Patient satisfaction was closely correlated with clinically successful outcome of treatment. Ninety percent of patients were satisfied with the results after endovascular treatment of UIAs. Endovascular coil embolization was effective and safe procedure, with high clinical success rate and degree of satisfaction.

Abstract WP120: Readmission Trends Related to Unruptured Intracranial Aneurysm Treatment

Introduction: The treatment of choice for Unruptured intracranial aneurysms (UICA) is dependent on assessment of several factors including aneurysm size, location, and morphology, along with patient's life expectancy and comorbid conditions. Although multiple studies have deliberated upon the efficacy of surgical and endovascular aneurysm treatment for UICA, the rate of readmission with either technique has not been specifically studied. Methods: We used the Nationwide Readmission database to assess the readmission trends related to various treatment approaches for UICA. The treatment approaches were subdivided into four groups; surgical clipping group and three endovascular approach groups (coil embolization, stent assisted coil embolization and only stent placement groups). All four groups were compared for the characteristics of index hospitalizations and top causes of readmissions. Results: We identified 3533 patients treated with clipping and 4134 (3865 coil embolization, 192 only stent placement and 76 stent assisted coil embolization) patients treated with endovascular approach. Thirty day readmission rate (30RR) was significantly higher with surgical clipping compared to the three endovascular approach groups (8.37% Vs 4.77%, p<0.01). Lower rates of home discharge disposition were observed during index hospitalization (73.8% Vs. 91.4%, p<0.01) and during readmission (53.3% Vs. 72.56%, p<0.01) amongst the clipping group compared to the endovascular groups. Major causes of readmission amongst clipping groups included intracranial hemorrhage (12.9%) and post operative infections (10.5%), Major causes of readmission amongst endovascular group included ischemic cerebrovascular event (21.3%) and headaches (8.6%). Conclusion: Patients undergoing endovascular treatment for UICA are less likely to be readmitted and more likely to be discharged home compared to surgical clipping. Given the complex decision making with consideration of anatomic and patient factors for UICA treatment, these findings do not necessarily prove the general superiority of the endovascular approach but do suggest that when a UICA can be safely treated with either technique, the endovascular approach might reduce the chances of readmission.

Risk Factors for Intraprocedural Rupture in the Endovascular Treatment of Unruptured Intracranial Aneurysms: A Single-Center Experience with 1232 Procedures

Intraprocedural rupture (IPR) is a rare complication that can occur during endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs). However, it universally leads to poor outcomes if not properly managed. In the present study, we sought to illuminate the risk factors for IPR during EVT of UIAs. The data from patients with UIAs who had undergone EVT in our center from January 2010 to March 2017 were retrospectively collected and reviewed. Univariate analysis and multivariate logistic analysis were performed to analyze the risk factors for IPR. A total of 1232 patients with 1312 unruptured aneurysms were included in the present study. IPR occurred in 11 patients (0.9%). Univariate analysis showed that cardiac comorbidities, irregular morphology, and location at the anterior communicating artery (AcomA) were significantly associated with the development of IPR (P < 0.05). In addition, stent placement was related to a lower risk of IPR compared with no stent placement (P= 0.024). The multivariate analysis showed that cardiac comorbidities (odds ratio [OR], 6.320; P= 0.016), irregular morphology (OR, 9.562; P= 0.001), and location on the AcomA (OR, 6.971; P= 0.006) were independent risk factors for IPR. The occurrence rate of IPR was relatively low. Cardiac comorbidities, irregular morphology, and location on the AcomA are independent risk factors for IPR. Stents and flow diverters are safe and feasible in treating UIA, with a significantly low risk of IPR.

Abstract TP81: Intraprocedural Neurological Deficit in Treatment of Unruptured Aneurysm Under Local Anesthesia

Background: It is widely known that the advantage of endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) under local anesthesia (LA) is that neurologic evaluation of the patient during procedure can be performed unlike general anesthesia. However, there have been no literature about intraprocedural neurological deficit and their outcomes. Purpose: This study was performed to identify the causes and outcomes of intraprocedural neurological deficit in EVT under LA. Methods: We retrospectively evaluated the medical and radiologic data of 1068 UIAs (1050 patients) who underwent coil embolization from 2008 to 2016. Results: A total of 1015 procedure (1000 patients) were performed under LA. Intraprocedural neurological deficits were observed in 63 patients (6.3%). The causes were intraprocedural rupture in 13 (1.3%), thromboembolism in 16 (1.6%), intolerance against the balloon or guiding catheter in 19 (1.9%) and reduction of blood flow in 15 patients (1.5%) (thrombus formation in 12 and coil protrusion in 3 patients). The managements of coil protrusion were stent placement in 2 (66%) or balloon inflation in 1 procedure (33%) and those of intolerance were aborting procedures in 3 (16%), stent placement in 4 (21%) or simple technique without balloon catheter in 9 procedures (47%). Of the patients with intraprocedural deficits, 58 patients (92%) had good outcomes and 5 patients (8%) had poor outcomes. Conclusion: The morbidity rate in EVT of UIAs can be reduced by appropriate management of intraprocedural neurological deficit under LA.

Local Anesthesia for Endovascular Treatment of Unruptured Intracranial Aneurysms: Feasibility, Safety, and Periprocedural Complications.

The aim of the study is to report the feasibility, safety, and outcomes associated with endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) under local anesthesia. Between March 2011 and December 2016, 184 consecutive patients with 198 UIAs were treated with coil embolization under local anesthesia at the author's center. The data about medical comorbidities according to American Society of Anesthesiologists grade, procedural details, and clinical and radiographic outcomes were reviewed. A total of 388 procedures were performed under local anesthesia, and 198 procedures with UIA were included. The mean age was 63.8 ± 12.5 years, and 118 (59.6%) cases had a risk status of American Society of Anesthesiologists class III or IV. Of those 198 procedures, 196 procedures (99.0%) were completed successfully. The overall procedure-related event rate was 5% (10/198). The rates of morbidity and mortality were 0.5% (1 of 198) and 0% at 1 month, respectively. Among the 3 recurred cases (1.5%), two (1%) underwent EVT again. The mean intensive care unit stay was 0.99 ± 0.1 days, and the mean postoperative hospital stay was 3.6 ± 7.2 days. Local anesthesia in the EVT of UIA is feasible and safe. It could be considered as an alternative for the patients with high risk of general anesthesia.

Incidence and Characteristics of Remote Intracerebral Hemorrhage After Endovascular Treatment of Unruptured Intracranial Aneurysms

The purpose of this study was to investigate the incidence and characteristics of remote intracerebral hemorrhage (ICH) after endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs). Between March 2007 and September 2015, 11 patients with remote ICH from a series of 2258 consecutive patients with 2597 UIAs treated via EVT were identified. Baseline demographic characteristics, medical history, radiologic imaging data, characteristics of remote ICH, and clinical outcomes were retrospectively reviewed. The characteristics of patients with remote ICH were compared with those of patients without remote ICH. All hematomas were single lesions located in the subcortical white matter as lobar-type in 9 patients (81.8%) and in the basal ganglia in 2 patients (18.2%). Events occurred mostly within 1 week and up to 3 weeks after EVT. Hematoma was located on the ipsilateral side in 8 patients (72.7%) and in the contralateral side in 3 patients (27.3%). Compared with patients without remote ICH, there were more aneurysms located on the internal carotid artery (ICA) (P=0.041), more patients treated with stents (P<0.001), more patients with hypertension (P = 0.026), and poorer clinical outcomes at discharge (P < 0.001) for patients with remote ICH. The incidence of remote ICH after EVT of UIAs was 0.46%. This event occurred mostly in patients with stents, hypertension, and UIAs on the ICA. It presented mostly as an ipsilateral lobar-type hemorrhage within 1 week after the procedure. This complication should not be neglected because of its poor clinical outcomes.

Abstract WMP25: Periprocedural Predictors of Acute Ischemic Stroke and Mortality in Endovascular Treatment of Unruptured Intracranial Aneurysm

Introduction: Periprocedural risk of ischemic stroke (IS) in patients undergoing endovascular treatment for unruptured intracranial aneurysms (EUIA) can be as high as 40%, with clinically significant strokes occurring in 3-10% of patients. There is limited data on how typical vascular risk factors can increase peri-procedural risk of IS and mortality in patients undergoing EUIA. Methods: We queried the Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS) data between 2004 and 2012. ICD-9 codes 437.3 (intracerebral unruptured aneurysm) and 39.72 (endovascular repair/embolization of head and neck vessel) were used to identify the study population. Multivariate logistic regression model was used to identify independent predictors of IS and mortality after controlling confounders including age, race, sex, atrial fibrillation (Afib), diseases of endocardium, alcohol, smoking, diabetes mellitus, hypertension, use of anticoagulants, use of antiplatelet agents, carotid artery stenosis, atherosclerosis and hyperlipidemia. We also investigated whether Afib, DM, hypertension and hyperlipidemia in possible combinations further increased the risk of IS and mortality. Results: A total of 50,478 EUC cases were identified, of which 10,600 (20.9%) reported an IS event. A total of 661 (0.01%) died of which 115 (17.4%) had an IS event. After controlling for confounders, age &gt;70 (OR 1.521 95% CI 1.145- 2.020, P&lt; 0.01) and diabetes (OR 1.426, 95%CI 1.092-1.861, p 70 (OR 2.472, CI 1.616-3.782, p&lt;.01)and Afib (OR 2.697, CI 1.509-4.819, p&lt;.01) independently increased risk of mortality in endovascular treated patients. A fib, DM, hypertension and hyperlipidemia in different potential combinations did not increase peri-procedural risk of IS and mortality. Conclusions: In patients undergoing EUIA, Age &gt;70 is an independent risk factor for IS and mortality. Diabetes independently increased risk of IS but not mortality; Afib independently increased risk of mortality but not IS.

Incidence and risk factors of postoperative headache after endovascular coil embolization of unruptured intracranial aneurysms.

Endovascular coil embolization for unruptured intracranial aneurysms (UIAs) has gained popularity because of its low morbidity and mortality in a short-term context. However, Headache is sometimes brought about or worsened after endovascular treatment, and this complaint may lead to perplexing situations, albeit infrequently. The aim of this study is to estimate the practical incidence and risk factors of postoperative headache in patients with endovascular embolization of UIAs. One hundred and thirty patients who underwent endovascular treatment of UIAs between March 2006 and May 2012 were enrolled according to inclusion criteria. From a retrospective chart review, the patients who had worsening or newly developed headache from postoperative day 1 to in-hospital stay were investigated for analyzing risk factors of post-embolization headache. Factors based on patients' demographics, anatomical and radiological features of the lesions, treatment, utilized devices and outcome were investigated, and statistically verified. Headache occurred or was exacerbated in 32 patients (24.6 %). Of these, 30 patients showed improvement within days, but two patients with previous migraine history complained of intermittent headache over 3 months after the embolization. Univariate comparison between the headache group and the non-headache group showed that internal carotid artery (ICA) segment aneurysm, stent-assisted coiling, and no history of hypertension were associated with post-embolization headache (p < 0.05). However, stent-assisted coiling and no history of hypertension were significantly associated with post-embolization headache in logistic regression analysis (p < 0.05). In the current study, stent-assisted coiling and no history of hypertension were important risk factors for headache in patients undergoing endovascular coil embolization for UIAs. Further investigations are still necessary to confirm the correlation of other factors which did not reach statistical significance in post-embolization headache in this limited study.

Intracranial Aneurysms: Review of Current Treatment Options and Outcomes

Intracranial aneurysms are present in roughly 5% of the population, yet most are often asymptomatic and never detected. Development of an aneurysm typically occurs during adulthood, while formation and growth are associated with risk factors such as age, hypertension, pre-existing familial conditions, and smoking. Subarachnoid hemorrhage, the most common presentation due to aneurysm rupture, represents a serious medical condition often leading to severe neurological deficit or death. Recent technological advances in imaging modalities, along with increased understanding of natural history and prevalence of aneurysms, have increased detection of asymptomatic unruptured intracranial aneurysms (UIA). Studies reporting on the risk of rupture and outcomes have provided much insight, but the debate remains of how and when unruptured aneurysms should be managed. Treatment methods include two major intervention options: clipping of the aneurysm and endovascular methods such as coiling, stent-assisted coiling, and flow diversion stents. The studies reviewed here support the generalized notion that endovascular treatment of UIA provides a safe and effective alternative to surgical treatment. The risks associated with endovascular repair are lower and incur shorter hospital stays for appropriately selected patients. The endovascular treatment option should be considered based on factors such as aneurysm size, location, patient medical history, and operator experience.

Contributions from the Sheffield Laboratory of Yale College; XIII, On native crystallized terpin

Endovascular coil embolisation is increasingly used to treat unruptured intracranial aneurysms (UIA). Endovascular coil embolisation of UIA is associated with a 5–10% risk of morbidity and nearly zero mortality from the procedure. Complete or near complete occlusion is usually achieved in &gt;90% of cases, and endovascular therapy seems to reduce the risk of future rupture significantly. Specific selection criteria for endovascular embolisation and novel approaches to endovascular treatment of aneurysms are discussed. Endovascular therapy appears to be a safe and effective treatment for selected UIA. Treatment failure rates will probably decrease with greater experience and advances in techniques and devices. Further study with long term follow up, however, is still necessary to characterise the efficacy, durability, and cost efficiency of endovascular treatment of UIA.