Flow Diverter Placement Research Articles

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.

Comparative evaluation of brain perfusion with ASL and DSC MRI following intracranial vascular flow diverter stent replacement.

The objective of this study was to asses brain perfusion parameters and ischemic changes following treatment of aneurysm with flow diverters with two different perfusion MRI technique (Arterial spin labeling and DSC MRI), and to compare the results and effectiveness of these two methods. The prospective data was collected from patients with aneurysm who treated with flow diverters. MR examinations, including diffusion-weighted imaging (DWI), ASL, and DSC perfusion MRI, were conducted before and after treatment within the first week and at 6 months. Perfusion parameters of territory area and contralateral side were measured and analyzed by statistically. The relationships between ASL and DSC parameters were analyzed by using Sperman's correlation analysis. A total of 14 cases of aneurysms in 11 patients treated successfully with endovascular flow diverter stent placement. Pretreatment and post treatment (within first week and 6 months) MRI images were evaluated. Asymptomatic randomly distributed millimetric restricted diffusion foci were observed in 8 of all patients. There was no statistically difference between pre and post treatment perfusion parameters (p > 0.05). A statistically significant correlation was found between variable ASL CBF, and the variables of DSC CBF and TTP. Notwithstanding the fact that flow diverters change flow dynamics in aneurysm sac, there is no any perfusion abnormality in the territory area. Asymptomatic randomly distributed diffusion restricted foci in the both cerebral hemisphere can be observed. ASL and DSC MRI are effective for evaluation of brain perfusion.

Factors influencing early obliteration during flow diverter treatment of cerebral aneurysms: Establishment of an early obliteration inhibition score.

This retrospective study aimed to investigate factors associated with inhibition of early aneurysm obliteration after flow diverter (FD) treatment. We also created the early obliteration inhibition (EOI) score for pre-operative evaluation. We examined 110 cerebral aneurysms in 104 patients who underwent FD treatment. The following parameters were investigated: age, sex, symptoms, aneurysm location and type, maximum aneurysm diameter, parent vessel diameter, neck diameter, and dome-neck ratio. We also noted aneurysm location relative to the curvature of the parent artery and any branches arising from the aneurysm dome. Procedural factors such as FD diameter and length, number of FDs placed, type of FD, and use of adjunctive coiling were also investigated. Aneurysm obliteration was evaluated using digital subtraction angiography 3 months after the procedure. Adequate obliteration was defined as grade C or D on the O'Kelly-Marotta scale. The following factors inhibited early obliteration: 1) extradural location, 2) saccular aneurysm, 3) aneurysm neck located at the outer convexity of the parent artery, and 4) arterial branch arising from the aneurysm dome. Odds ratios were used to create an EOI score. Receiver operating characteristic curve analysis showed that the optimal cut-off EOI score for adequate obliteration was 1.5 (area under the curve, 0.81; 95% confidence interval, 0.73-0.9; sensitivity, 0.9; specificity, 0.57). The EOI score, which is based on factors that inhibit early obliteration, may predict early treatment outcomes of FD placement.

Effect of Platelet Function Testing Guidance on Clinical Outcomes for Patients with Intracranial Aneurysms Undergoing Endovascular Treatment.

Platelet function testing has been proposed to better adjust individualized antiplatelet treatment for patients undergoing endovascular treatment for intracranial aneurysms. Its clinical significance needs to be comprehensively evaluated. Our aim was to evaluate the impact of platelet function testing-guided versus standard antiplatelet treatment in patients receiving endovascular treatment for intracranial aneurysms. PubMed, EMBASE, and the Cochrane Library of clinical trials were searched from inception until March 2023. Eleven studies comprising 6199 patients were included. ORs with 95% CIs were calculated using random effects models. The platelet function testing-guided group was associated with a decreased rate of symptomatic thromboembolic events (OR = 0.57; 95% CI, 0.42-0.76; I2 = 26%). No significant difference was found in asymptomatic thromboembolic events (OR = 1.07; 95% CI, 0.39-2.94; I2 = 48%), hemorrhagic events (OR = 0.71; 95% CI, 0.42-1.19; I2 = 34%), intracranial hemorrhagic events (OR = 0.61; 95% CI, 0.03-10.79; I2 = 62%), morbidity (OR = 0.53; 95% CI, 0.05-5.72; I2 = 86%), and mortality (OR = 1.96; 95% CI, 0.64-5.97; I2 = 0%) between the 2 groups. Subgroup analysis suggested that platelet function testing-guided therapy may contribute to fewer symptomatic thromboembolic events in patients who received stent-assisted coiling (OR = 0.43; 95% CI, 0.18-1.02; I2 = 43%) or a combination of stent-assisted and flow-diverter stent placement (OR = 0.61; 95% CI, 0.36-1.02; I2 = 0%) or who changed from clopidogrel to other thienopyridines (OR = 0.64; 95% CI, 0.40-1.02; I2 = 18%), though the difference did not reach statistical significance. Heterogeneous endovascular treatment methods and adjusted antiplatelet regimens were limitations. Platelet function testing-guided antiplatelet strategy significantly reduced the incidence of symptomatic thromboembolic events without any increase in the hemorrhagic events for patients undergoing endovascular treatment for intracranial aneurysms.

Comaneci stent-angioplasty for the optimization of inadequately deployed flow diverter stents.

In endovascular procedures, inadequate deployment of a flow diverter stent is a highly concerning technical complication that can lead to acute parent vessel occlusion and ischaemic events. This study aimed to assess the off-label use of the Comaneci device in managing technical difficulties associated with flow diversion. We conducted an analysis of all flow diverter procedures documented in our prospectively collected database. Our objective was to identify patients with inadequately deployed implants who underwent Comaneci stent-angioplasty. Both Comaneci 17 and Comaneci 21 devices were utilized to address and remediate technical complications related to stent deployment. We reviewed anatomical features, technical details, intraprocedural complications, as well as clinical and angiographic outcomes. Thirty-one Comaneci devices were employed to remediate 31 inadequately deployed flow diverter stents. Successful resolution of technical complications associated with flow diverter placement was achieved in all attempted cases. No clinically significant complications were attributed to the technique, and no mortality was observed during the study. Technical issues arising from flow diverter stent deployment are formidable complications. Familiarity with appropriate corrective manoeuvres is essential to achieve successful outcomes. The Comaneci device can be safely and effectively incorporated into the range of techniques used to rectify inadequately deployed stents.

Ticagrelor washout bridged with GPIIb/IIIa inhibitor infusion to facilitate surgical care following placement of pipeline flow diverters: a case report

Background: Pipeline flow diverters (PFDs) are becoming increasingly common. Antiplatelet medication is required to minimize periprocedural ischemic events. Short-acting GPIIb/IIIa inhibitors are frequently administered intraprocedurally; however, the role of these agents in postprocedural PFD management in the neurocritical care unit (NCCU) has been overlooked.Case Report: A patient with an unruptured internal carotid artery aneurysm presented for PFD placement. PFD placement was complicated by post-procedure intra-PFD thrombosis and hemispheric ischemia. Aspirin and ticagrelor were restarted, and the surgery department consulted for tracheostomy and percutaneous endoscopic gastrostomy-tube placement. Short-half-life GPIIb/IIIa infusions served as bridges to surgery after aspirin and tirofiban washout.Conclusion: NCCU management of complications of PFD placement remains under-researched. The use of long-acting antiplatelet agents post-PFD limits the safe administration of surgical procedures. Bridging with GPIIb/IIIa infusion may facilitate the safe delivery of intensive care in these cases.

Numerical simulation of flow-diverting stent: comparison between branches in bifurcation brain aneurysm.

The usage of flow-diverting stents in the treatment of intracranial aneurysms is widespread due to their high success and low complication rates. However, their use is still not officially recommended for bifurcation aneurysms, as there is a risk of generating ischemic complications due to the reduced blood flow to the jailed branch. Many works utilize computational fluid dynamics (CFD) to study how hemodynamic variables respond to flow diverter placement, but few seem to use it to verify flow variation between branches of bifurcation aneurysms and to aid in the choice of the best ramification for device placement. This investigation was performed in the present work, by comparing wall shear stress (WSS) and flowrates for a patient-specific scenario of a middle cerebral artery (MCA) aneurysm, considering device placement on each branch. A secondary objective was to follow a methodology that provides fast results, envisioning application to daily medical practice. The device was simplified as a homogeneous porous medium, and extreme porosity values were simulated for comparison. Results suggest that stent placement on either branch is both safe and effective, significantly reducing WSS and flow into the aneurysm while maintaining flow to the different ramifications within acceptable thresholds.

De novo expansion formation in the outer curvature of the internal carotid artery after flow diverter deployment for an infectious cavernous carotid aneurysm: illustrative case.

Infectious aneurysms very rarely occur in the cavernous carotid artery. Recently, treatment by flow diverter implantation with preservation of the parent artery has been the treatment of choice. A 64-year-old woman presented with stenosis at the C5 segment of the left internal carotid artery (ICA), followed by ocular symptoms within 2 weeks, with a de novo aneurysm in the left cavernous carotid artery and wall irregularity with stenosis from the C2 to C5 segments of the left ICA. Antimicrobial therapy was given for 6 weeks, and a Pipeline Flex Shield was implanted. Angiography 6 months after treatment showed complete obliteration of the infectious aneurysm and improvement of the stenosis. However, de novo expansions were formed in the outer curvature of C3 and C4 segments of the ICA where the Pipeline device had been deployed. Aneurysms that develop rapidly and show shape changes over time, accompanied by fever and inflammation, may be associated with an infection. Because of the fragility in the irregular wall of the parent vessel associated with infectious aneurysms, de novo expansion may form in the outer curvature of the parent vessel after flow diverter placement; thus, careful follow-up is necessary.

Surgical Trapping of a Cavernous Carotid Aneurysm Causing Carotid Cavernous Fistula After Flow Diverter Placement: Technical Note and Literature Review

Flow diverter (FD) treatment is a promising therapeutic strategy for intracranial aneurysms such as cavernous carotid aneurysms (CCAs). Direct cavernous carotid fistula (CCF) caused by delayed rupture of FD-treated CCAs has been reported, and endovascular therapy has been used in the literature. Surgical treatment is warranted for patients who have failed or ineligible for endovascular treatment. However, no studies have evaluated surgical treatment to date. Here, this paper presents the first case of direct CCF due to delayed rupture of an FD-treated CCA managed with surgical internal carotid artery (ICA) trapping with bypass revascularization, in which the intracranial ICA with FD placement was successfully occluded with aneurysm clips. A 63-year-old man with a diagnosis of large symptomatic left CCA underwent FD treatment. The FD was deployed from the supraclinoid segment of the ICA distal to the ophthalmic artery to the petrous segment of the ICA. Since angiography 7 months after the FD placement showed progressive direct CCF, left superficial temporal artery-middle cerebral artery bypass followed by ICA trapping was performed. The intracranial ICA proximal to the ophthalmic artery where the FD was placed was successfully occluded using two aneurysm clips. The postoperative course was uneventful. Follow-up angiography 8 months after the surgery confirmed complete obliteration of the direct CCF and CCA. The intracranial artery in which the FD was deployed was successfully occluded with two aneurysm clips. ICA trapping can be a feasible and useful therapeutic option to treat direct CCF caused by FD-treated CCAs.

The Use of Simulation and Deep Learning Models in the Endovascular Treatment of Ruptured Intracranial Aneurysms: A Case Report

Abstract Introduction The current paper presents an examination of the emerging role of deep learning-based simulation software in enhancing preprocedural planning for intracranial aneurysm treatment using flow diverters. Intracranial aneurysms pose significant risk due to their potential rupture leading to life-threatening subarachnoid hemorrhage. Innovative endovascular treatment options like flow diverters, which redirect blood flow and promote healing, are gaining attention. The role of simulation software in optimizing these procedures is becoming increasingly crucial. Case presentation This study involves a 47-year-old female patient diagnosed with an intracranial aneurysm. Through diagnostic angiography and 3D rotational angiography imaging, the complex aneurysm anatomy was determined and the need for flow diverter placement ascertained. The Sim&Size™ software was used to simulate the size and placement of the flow diverter, based on the patient’s specific vascular anatomy. The procedure, including the placement of the flow diverter as per the simulation, was successful. Conclusion The Sim&Size™ simulation software significantly contributes to the enhancement of intracranial aneurysm treatment planning. By providing patient-specific simulations, it improves procedural precision and reduces the risk of complications, thus potentially optimizing patient outcomes. However, the quality of the simulation is contingent on the accuracy of the input data, and it does not account for physiological dynamics. Despite these limitations, this tool represents a promising development in neurointerventional practice.

OUTCOME EVALUATION OF FLOW DIVERTER STENT PLACEMENT IN TREATMENT OF RUPTURED AND UNRUPTURED CEREBRAL ANEURYSMS

Background: Cerebral aneurysms affect about 5% of the population and are associated with high mortality rates and severe complications for families and society. Complex aneurysm types include giant aneurysms, wide - necked aneurysms, blister - like aneurysms, recurrent aneurysms, fusiform aneurysms, and multiple aneurysms, which are difficult to manage with conventional endovascular or surgical methods due to complications such as coil migration and high rates of re - rupture. The development of flow diverter stents has been a breakthrough in recent decades and has been demonstrated to be safe and effective in treating aneurysms. The aim of this study was to evaluate the outcomes of flow diverter stent placement in the treatment of ruptured and unruptured cerebral aneurysms. Methods: This was a descriptive prospective study that followed up on 23 patients diagnosed and treated for cerebral aneurysms with flow - diverter stent intervention at the Stroke Department of Hue Central Hospital from 6/2020 to 6/2022. The follow - up data after 6 months and 12 months were recorded. Results: There were 23 patients (9 males, 14 females) with 28 cerebral aneurysms, with a mean age of 51.7 ± 9.9 years. Aneurysms were predominantly located in the anterior circulation (85.7%) and 14.3% in the posterior circulation. The most common aneurysm type was fusiform (75%), followed by dissecting (17.9%) and blister - like (7.1%). Most aneurysms had wide necks, with a neck - to - dome ratio < 1.5, accounting for 82.1%. Flow diverter stent placement was successfully performed in 91.3% of patients, with 27 stents used. Stents were properly positioned, well - expanded in 88.9%. The complication rate after intervention was 4.3%. Complete aneurysm occlusion rates at 6 to 12 months were 92.9% and 96.4%, respectively. The rate of mild in - stent stenosis without clinical symptoms was 4.3%. The good outcome rate (mRS 0 - 2) was 91.3%. Conclusion: Flow diverter stent is effective and safe with high rate of successful and low procedural complications in the treatment of complex cerebral aneurysms.

Utility of flow diverters in treatment of acutely ruptured uncoilable aneurysms of the posterior circulation of the brain.

Aim of this study is to evaluate safety and efficacy of flow diverters (FDs) in treatment of acutely ruptured posterior circulation aneurysms MATERIALS AND METHODS: Databases of three participating institutions were retrospectively scanned for patients in whom FD placement was attempted for treatment of acutely ruptured vertebrobasilar aneurysms. An interval of 14days or fewer between the latest ictus and treatment was used as inclusion criterion. Patients with dolichoectasia of vertebrobasilar arteries were excluded. If necessary, adjunctive techniques including coiling or stenting were utilized. Clinical outcomes were graded using mWFNS (modified World Federation of Neurosurgical Societies Scale) and mRS (modified Rankin Scale). Aneurysmal occlusion was defined as Raymond-Roy Class 1. Spearman's (ρ) test was used to assess the correlation between variables. Univariate and multivariate logistic regression were used to assess outcomes. 31 patients (25 women, mean age: 52.7 ± 15.2) harboring 32 aneurysms (16 non-saccular, mean size: 11.4 ± 7mm) were included. Mean number of FDs used was 1.22 ± 0.42. In six cases, adjunctive coiling and in five cases, apposing stent placement were used. Overall mortality rate and procedure-related mortality rates were 22.5% (7/31) and 9.6% (3/31), respectively. At a mean imaging follow-up of 17.2 ± 12.6months, total occlusion was achieved in 22 aneurysms (91.6%). Univariate analysis showed that mortality was positively correlated with vasospasm (ρ = 0.600, p < 0.05), higher mWFNS Scale (ρ = 0.685, p < 0.05), higher modified Fischer Score (ρ = 0.609, p < 0.05), higher mRS (ρ = 0.594, p < 0.05) on admission and negatively correlated with saccular morphology (ρ = -0.529, p < 0.05). Multivariate logistic regression identified mWFNS on admission as a significant predictor. (OR: 7.148, 95% CI 1.777-28.758, p: 0.01). Adjunctive coiling positively correlated with aneurysm occlusion. (ρ = 0.522, p < 0.05). The procedure-related morbidity and mortality is not negligible. However, the risks and efficacy associated with FDs are acceptable, especially when adjunctive coiling is possible, given the lack of treatment alternatives.

Abstract Number ‐ 140: Transcranial Doppler Emboli Monitoring for Stroke Prevention after Flow Diversion: A Single Center Experience

Introduction Following the favorable clinical and radiographical results of flow diversion, its use has continually expanded for the treatment of complex intracranial aneurysms. The high metal surface of flow diverters (FD) increases the risk of thromboembolic complications. Current emboli monitoring data after FD placement is limited. Transcranial doppler (TCD) offers a non‐invasive evaluation of microembolic signals and might be a valuable tool to prevent ischemic complications. We evaluated the rate of embolic signals and their management after FD implantation. Methods We performed a retrospective, single‐center evaluation of adult patients who underwent a FD procedure with the Pipeline Embolization Device (PED) for unruptured intracranial aneurysms between 2012 and 2016. Covariates included patient demographics, comorbidities, aneurysm characteristics, procedure characteristics, and post‐procedure TCD emboli monitoring (immediate and &gt;12 hours post‐operative). TCD emboli signals were classified as positive (&lt; 15 microembolic signals) and strongly positive (&gt;15 signals). The primary outcome was the rate of symptomatic stroke at 2 and 12 weeks in these patients. Results 105 patients with 132 aneurysms were analyzed. Mean age was 59.7 years, and 78% were females. Mean aneurysm size was 7.8 ± 6.4 mm. Most of them were located in the paraclinoid region (40%). Two PEDs were implanted in 12 (11%) cases and adjunctive coiling was performed in 15 (14%) cases. Microemboli were detected in 11.4% of cases (12/105 patients) after PED deployment. In 5/12 patients, the emboli resolved upon repeat testing with no intervention. In 6/12 patients, further heparinization, additional clopidogrel administration, or change in antiplatelet agents were needed. These treatments reduced the microembolic events. In 1 patient who was clopidogrel‐resistant and a ticagrelor super‐responder, mechanical thrombectomy was necessary due to acute in‐stent thrombosis. There were no symptomatic strokes at 2 and 12 weeks. Conclusions TCD emboli monitoring can be a powerful non‐invasive tool for the early identification and prevention of thromboembolic events after FD implantation. Early detection of microembolic signals offers the possibility to modify postoperative management, avoid silent emboli, and potentially avoid symptomatic strokes.

A challenging case of recurrent and progressive fusiform anterior circulation intracranial aneurysms: illustrative case.

Intracranial fusiform aneurysms are circumferential dilations of cerebral arteries that can lead to complications including ischemic stroke due to vessel occlusion, subarachnoid hemorrhage, or intracerebral hemorrhage. Treatment options for fusiform aneurysms have expanded significantly in recent years. Microsurgical treatment options include proximal and distal surgical occlusion and microsurgical trapping of the aneurysm, usually in association with high-flow bypass procedures. Endovascular treatment options include the placement of coils and/or flow diverters. Here the authors report a case of aggressive surveillance and treatment of a man with multiple progressive, recurrent, and de novo fusiform aneurysms of the left anterior cerebral circulation over 16 years. Because the long-term course of his treatment coincided with the recent expansion of endovascular treatment options, he underwent every type of treatment listed above. This case demonstrates the wide range of therapeutic options for fusiform aneurysms and how the treatment model for these lesions has evolved.

Bilateral blindness following flow diverter placement in a giant thrombosed cavernous carotid aneurysm: illustrative case

The best treatment option for giant intracranial aneurysms (GIAs) is still debated. The authors report a case of a giant thrombosed cavernous carotid artery (CCA) aneurysm for which two sessions of flow diverter (FD) placement failed, leading to bilateral blindness. A 66-year-old man presented to an outside center with a history of rapid-onset right-sided retro-orbital pain, visual deterioration, and restricted eye movements associated with headache, vomiting, and diminished sensations on the right side of the face. He was diagnosed with an unruptured thrombosed giant CCA aneurysm and was treated twice with unsuccessful FDs. At follow-up, he developed blindness in both eyes. After 1.5 years, he presented to the authors' institution with headache, vomiting, and epistaxis, for which he underwent high-flow external carotid artery-M2 segment of the middle cerebral artery bypass grafting using the radial artery as a conduit and ligation of the internal carotid artery in the neck without any added neurological deficits. This dreadful complication of bilateral blindness after being treated with repeated unsuccessful FDs has not been reported in the literature. It could have been avoided if microsurgery had been the primary modality of treatment.

Evaluation of the apposition in unruptured aneurysms treated with flow diverters by optical coherence tomography: Preliminary clinical experience.

The risk of perioperative stroke and the rate of occlusion of long-term aneurysms in the treatment of unruptured aneurysms with flow diverters (FDs) are affected by stent apposition. Optical coherence tomography (OCT) may be an optional technique in evaluating apposition. To explore the feasibility of the OCT imaging technique in evaluating stent apposition in the clinical application of the FD for unruptured aneurysms. OCT and Vaso CT were used in patients with indications for surgery to treat unruptured aneurysms with the FDs, to evaluate the apposition of the FDs after fully released, and to analyze OCT images for FDs apposition and compare with corresponding Vaso CT images. A total of four patients were enrolled, and OCT found malapposition after FDs placement in all four patients, and the maximum gap between the stent and vascular wall ranged from 0.68 to 1.95 mm and the length of malapposition ranged from 1.80 to 7.40 mm. However, Vaso CT found malapposition only in two of the four patients and missed malapposition near aneurysm in all three patients treated by the FD combined with coiling and could not accurately evaluate the maximum gap and the length of the malapposition. The optical coherence tomography technique is a possible approach to evaluate apposition after the treatment of unruptured aneurysms by the FDs.

Combined deconstructive and reconstructive treatment of a giant vertebrobasilar fenestration aneurysm.

Aneurysms associated with a vertebrobasilar fenestration are rare lesions and can grow to a giant size, presenting significant therapeutic challenges. Endovascular treatment of these aneurysms has traditionally been with coiling; however, flow diverter placement within the fenestration arms has recently proven to be a viable treatment strategy. The authors present a case of a giant vertebrobasilar fenestration aneurysm in a patient presenting with a cranial nerve VI palsy. The lesion was treated by using a combination of flow diverter placement and vertebral artery sacrifice. The nuances of flow diversion therapy for these aneurysms and the management of intra- and postoperative complications are discussed. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2256.

Clinical Results of Flow Diverter Treatments for Cerebral Aneurysms under Local Anesthesia.

Flow diverters (FD) have become the mainstay for the endovascular treatment of unruptured intracranial aneurysms (UIA). Most FD procedures are performed under general anesthesia, and the influence of local anesthesia (LA) on outcomes remains unknown. This study evaluated the results of FD placement under LA. Data of patients treated for FD under LA between August 2016 and January 2022 were analyzed retrospectively. A good outcome was defined as a modified Rankin scale score of 0–2. Major stroke, steno-occlusive events of FD, mortality, and satisfactory aneurysm occlusion were also evaluated. In total, 169 patients undertook 182 treatments (139 [82%) female, mean age 61 ± 11 years). The median maximum aneurysm size was 9.5 mm (interquartile range 6.1-14 mm). A flow re-directed endoluminal device and pipeline embolization device were used in 103 (57%) and 78 (43%) treatments. One patient (0.59%) experienced major stroke, and steno-occlusive events were observed in four patients (2.4%). A good outcome at 90 days was obtained in 164 patients (98%), and one patient died (0.59% mortality). During the median follow-up period of 345 days (interquartile range 176–366 days), satisfactory aneurysm occlusion was observed in 126 of 160 aneurysms (79%). Our results suggest that FD placement under LA is a safe and effective treatment for UIA.

Predictors of Ischemic Complication in Anterior Choroidal Artery Aneurysm Repair

Treatment of anterior choroidal artery (AchoA) aneurysms is challenging because of the risk of artery injury. The objective of the study was to evaluate the incidence and predictors of AchoA infarction in patients who underwent surgical or endovascular procedure. We included 123 patients with AchoA aneurysms treated by surgical clipping (n=62; 50.4%) or endovascular coiling, including flow diverter placement (n=61; 49.6%). The clinical and radiological data were retrospectively analyzed. AchoA infarction was defined as the presence of a hyperintense signal on diffusion-weighted imaging in the area of AchoA, including the posterior limb of the internal capsule. AchoA infarction was detected in 8 cases (6.5%), with similar incidence in both groups (6.5% [4/62] vs. 6.6% [4/61]). It occurred in ruptured aneurysms more frequently than in unruptured aneurysms (14.3% [6/42] vs. 2.5% [2/81], P=0.019). In the surgical group, all 4 affected patients had a non-proximal type AchoA, whereas in the non-infarction group, 9 patients (15.5%) had a non-proximal type AchoA (P=0.001). In the endovascular group, the incidence was higher in patients with ruptured aneurysms (17.3% [4/23] vs. 0% [0/38], P=0.017) and lower in patients with pre-admission antiplatelet therapy (0% [0/39] vs. 18.8% [4/22], P=0.014). Repair of an AchoA aneurysm is associated with the risk of incurring post-procedural AchoA infarction. Surgical clipping and endovascular coiling have similar complication rates, but risk factors specific to each intervention exist. Careful surgical planning to avoid these risk factors in each therapeutic modality may improve patient outcomes.

Feasibility and Safety of Transradial Aneurysm Embolization: A Systematic Review and Meta-Analysis

Use of the transradial access (TRA) approach for neuroendovascular procedures has been increasing in recent years. Our aim is to assess the feasibility, success rate, and complications associated with TRA for intracranial aneurysm embolization. PubMed, Scopus, and Embase were systematically searched for studies using TRA for intracranial aneurysm embolization. Random-effects models were used to obtain pooled rates of procedural success and complications. Twenty-four studies comprising 1283 (85.9%) TRA and 122 (8.2%) distal TRA aneurysm embolization procedures were included. The pooled success rate of the 18 studies in the meta-analysis was 93.5% (95% confidence interval [CI], 91.1%-95.8%). The pooled thromboembolic complication rate was 0.5% (95% CI, 0.1%-0.9%), the hemorrhagic complication rate was 0.5% (95% CI, 0.1%-0.9%), and the access site complication rate was 0.8% (95% CI, 0.3%-1.3%). One study (4.3%) used exclusively a 7-French guide catheter, and most used a 6-French guide catheter (22 of 23 studies, 95.7%), which was further incorporated as part of a triaxial configuration through a sheathless 8-French system in 4 studies (17.4%), 7-French guide catheter in 2 studies (8.7%), and 8-French sheath in 1 study (4.3%). The embolization techniques used were flow diverter placement in 451 cases (39.1%), coiling in 376 (32.6%), stent-assisted coiling in 127 (11.0%), balloon-assisted coiling in 104 (9.0%), Woven EndoBridge system in 50 (4.3%), and flow diverter placement plus coiling in 42 (3.6%). Treating intracranial aneurysms using various embolization techniques through TRA is feasible and associated with low access site and intraoperative complications.