Incomplete Aneurysm Occlusion Research Articles

Analysis of the effect of platelet function and different doses of ticagrelor after flow diverter treatment of intracranial aneurysms.

Ticagrelor has become the standard drug for the treatment of intracranialaneurysms(IAs) with flow diverters (FDs), but the dosage has not been standardized. The effect of platelet function on clinical and imaging prognosis remains unclear. This study aimed to show the effects of different doses of ticagrelor and platelet aggregation function on the clinical and imaging prognosis after FDs treatment of aneurysms.Patients with IAs and underwent FDs stenting were recruited between July 2019 and June 2023. Logistic regression was performed to assess the predictors of incomplete occlusion and in-stent stenosis (ISS). Linear regression analysis, scatter plot and violin diagram were used to investigate the predictors of maximum platelet aggregation rate induced by ADP (ADP-MPA).The study included 156 patients with 206 aneurysms. There was no significant difference in clinical prognosis and aneurysm occlusion rates between the standard-dose group (ticagrelor, 90mg/bid) and the low-dose group (ticagrelor, 45mg/bid). Multivariable analysis identified the ADP-MPA ≥ ADP-MPA (median) (24.2%) (p = 0.037) as an independent risk factor for incomplete occlusion of aneurysms. In addition, higher ADP-MPA (p = 0.045) was an independent risk factor for ISS. Uric acid level (p = 0.019) was negatively associated with ADP-MPA, whereas age (p = 0.031) and body mass index (BMI) (p = 0.042) were positively associated with ADP-MPA.The differencesofclinical prognosis and aneurysm occlusion rates between the standard-dose group and the low-dose group were not significant for the treatment of aneurysms with FDs. Higher ADP-MPA predicted higher rates of incomplete occlusion and in-stent stenosis. Uric acid level was negatively associated with ADP-MPA, whereas age and BMI were positively associated with ADP-MPA.

Midterm and long-term angiographic outcomes and efficacy analysis of the Pipeline Embolization Device in the treatment of intracranial aneurysms

Objective: To investigate the midterm and long-term efficacy of flow-diverter device in treating intracranial aneurysms (IAs) and analyze its clinical outcomes in anterior circulation aneurysms and posterior circulation aneurysms. Methods: This is a retrospective case series study. The data of 566 intracranial aneurysm patients (681 aneurysms) treated with the flow-diverter device at Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University from January 2018 to January 2021 were retrospectively analyzed. There were 205 males and 361 females, with an age (M(IQR)) of 55 (14) years (range:18 to 77 years). Twelve patients (12 aneurysms) had ruptured aneurysms before surgery, and 75 patients (172 aneurysms) had multiple aneurysms. Preoperative modified Rankin scale (mRS) >2 points in 16 patients.There were 444 patients (552 aneurysms) in the anterior circulation group and 122 patients (129 aneurysms) in the posterior circulation group. Postoperative follow-up was conducted via outpatient visits or telephone calls at 3 to 12 months after the procedure. Baseline aneurysm parameters, surgical information, and imaging and clinical outcomes were collected. Univariate and multivariate Logistic regression analyses were used to identify independent factors associated with long-term incomplete aneurysm occlusion. Results: Intraoperative use of flow diverter-assisted coil embolization was performed in 221 patients (226 aneurysms), and balloon assistance was used in 20 patients (22 aneurysms).The intraoperative rupture rate was 0.5% (3/566), and the intraoperative thrombosis rate was 0.7% (4/566). The in-hospital mortality rate was 1.2% (7/566). Postoperative complications included subarachnoid hemorrhage in 5 patients (0.9%), intracerebral hemorrhage in 2 patients (0.4%), ischemic stroke in 19 patients (3.6%), and transient ischemic attack in 16 patients (3.0%). Imaging follow-up was available for 447 patients (548 aneurysms) with a follow-up duration of (16.7±6.7) months (range:3 to 45 months). Incomplete aneurysm occlusion occurred in 79 patients (95 aneurysms), accounting for 17.3% (95/548). Parent artery stenosis was observed in 63 patients (72 aneurysms), accounting for 13.1% (72/548). Clinical follow-up was available for 530 patients (644 aneurysms) with a follow-up duration of (29.4±11.3) months (range:3 to 54 months). One case of mRS score >2 points was observed in 18 patients, accounting for 3.4% (18/530). Among them, the rate of incomplete occlusion in the anterior and posterior circulation group was 16.9% (76/450) and 19.4% (19/98), respectively, and the rate of parent artery stenosis was 10.9% (49/450) and 23.5% (23/98), respectively; the rate of mRS score>2 points was 2.4% (10/415) and 7.0% (8/115), respectively. Univariate and multivariate Logistic regression analysis showed that aneurysm neck size (β=0.075,OR=1.08, P=0.028) and coil use (β=-1.070, OR=0.034, P=0.001) were independent factors influencing long-term aneurysm occlusion. Conclusions: The flow-diverter device demonstrates good safety and efficacy in the midterm and long-term treatment of overall IAs. However, further research is needed to focus on the midterm and long-term treatment outcomes of aneurysms with relatively wide neck and posterior circulation aneurysms.

Abstract 044: Endovascular photobiomodulation accelerates the complete healing of intracranial aneurysms treated with flow diverters

Introduction Endovascular treatment of intracranial aneurysms (IA) with use of flow diverters (FD), coils and endosaccular implants has been challenged by incomplete occlusion in up to 50% of the patients, delayed aneurysm recanalization. Other shortcomings include delayed or incomplete aneurysm occlusion in senior population, early spontaneous rupture of large and giant aneurysms as well as continued aneurysm growth despite angiographic occlusion. Photobiomodulation is being used successfully for the treatment of superficial birthmarks. Material and Methods A highly flexible optical microfiber system was developed to deliver laser light through a standard microcatheter. Optimization of delivery technology was carried out in vitro in cerebrovascular/aneurysm replica. Subsequently, the PBM system was assessed using a rabbit elastase aneurysm model. Laser wavelength and energy dose calculations based on aneurysm size were obtained from previous cell culture and animal studies. A total of 85 rabbit elastase aneurysms were treated with PBM followed by coils or flow diverters (test group) or with FD or coil only (control group). Pre‐ and post‐treatment and follow‐up angiograms were compared at 3, 7, and 10 days. Following angiograms, animals were sacrificed and aneurysm and parent artery samples were processed for histology. The PBM system was then used in 11 patients with 12 7‐20 mm wide‐necked large aneurysms. Patients were treated with an FD and endosaccular PBM in 9 aneurysms, while in 3 aneurysms the laser was activated within the parent artery. Depending on IA size, treatment time varied from several to 20 minutes. Results Control samples in experimental studies showed no significant endothelialization at 3 days and still filling the aneurysm. Albeit partial filling, a 3‐day sample treated with PBM showed an amorphous clot filling the aneurysm with early endothelialization of the aneurysm neck and the implant within the parent vessel. At 7‐10 days, FD treated with PBM showed a complete aneurysm occlusion in most of the samples and neck endothelialization, while control aneurysms were still patent with sparse endothelial cells attached to the FD at the aneurysm neck. At 7‐10 days, smooth muscle cell actin and CD 31 positive cells were found in large numbers in samples treated with PBM. Although coil compaction at 10 days was seen in both coiled groups, PBM‐treated samples revealed a high concentration of Fibroblasts and myofibroblasts near the aneurysm wall and a small number of primarily Lymphocytes and Neutrophils inside the thrombus compared to coiled‐only aneurysms. In patients treated with FD and LT, at 7‐30 days follow‐up, a nearly complete occlusion of the aneurysms with neck remnant was found in 6 out of 12 aneurysms. No implant stenosis or intimal hyperplasia was observed. None of the patients experienced any adverse events. Conclusion Our preliminary preclinical study shows that PBM delivered in situ is feasible and applicable in patients treated with FD. PBM may lead to an early and more complete aneurysm occlusion without any added treatment risk. Our technology represents a unique introduction of regenerative medicine into the endovascular therapeutic realm. Adjustment of energy applied and a larger long‐term cohort study are needed.

A Combination Technique of N-butyl-2-cyanoacrylate and Minimal Coils with Flow Control for Parent Artery Occlusion of a Giant Internal Carotid Artery Aneurysm: A Technical Note

Parent artery occlusion for large or giant internal carotid artery aneurysms remains a necessary procedure in the era of flow diverters. Endovascular parent artery occlusion is currently performed using detachable balloons or coils, which are difficult to obtain or costly. At our institution, we have devised a technique for combining n-butyl-2-cyanoacrylate and coils with flow control to solve this problem. Patients who underwent parent artery occlusion for large or giant internal carotid artery aneurysms with a follow-up period of more than 12 months were included. Imaging outcomes were evaluated for complete or incomplete aneurysmal occlusion and with or without aneurysmal shrinkage. The clinical outcome was based on changes in the modified Rankin Scale. Ten patients (ten aneurysms) were included. Their average age and average follow-up period were 68.4 years and 36 months, respectively. Complete occlusion and favorable clinical outcome were observed in all cases. The parent artery occlusion using a combination of coils and n-butyl-2-cyanoacrylate with flow control technique is effective for both imaging and clinical outcomes.

The aneurysm occlusion and recurrence of posterior communicating artery aneurysms following the treatment with the pipeline embolization device.

Despite advancements in treatment modalities such as flow diverters, the optimal management of posterior communicating artery (PComA) aneurysms remains uncertain. While PComA aneurysms treated with the Pipeline Embolization Device (PED) has been reported, the characteristics and progression of incomplete occluded aneurysms remain unclear. Therefore, our study aims to investigate the occlusion status and recurrence rates of PComA aneurysms treated with PED. A retrospective review of consecutive PComA aneurysm patients treated with PED was conducted between January 2015 and December 2020. Only patients with radiological follow-up were included. PComA aneurysms were categorized into incomplete occlusion and complete occlusion group. The primary outcomes included the characteristics of incomplete occlusion at the follow-up angiography. Among 121 PComA aneurysms treated with PED at our institution, 80 aneurysms were eligible in our study. During the follow-up period, 19 (23.8%) aneurysms demonstrated incomplete occlusion. Notably, there were no instances of recurrence among the 80 followed-up cases. Baseline characteristics of patients and aneurysms were comparable between the groups with complete and incomplete occlusion. However, the incomplete occlusion group showed a lower rate of assisted coils embolization (21.2% vs. 55.7%, P = 0.017) and shorter median operative time (91.0 vs. 145.5min, P = 0.039). Differences in functional outcomes, complications, and PComA occlusion status between the groups were not significant. Multivariate analysis revealed the use of coils was associated with lower odds of incomplete PComA aneurysm occlusion (OR 0.01, 95% CI 0.001-0.12; P = 0.001), while aneurysm size was associated with higher odds of incomplete occlusion (OR 1.25, 95% CI 1.10-1.46; P = 0.002). The treatment of PED for PComA aneurysm demonstrated favorable outcomes, with an acceptable rate of incomplete occlusion and no instances of recurrence observed. However, further research is needed to explore the optimal procedural strategy for large-sized PComA aneurysms.

Predictors of occlusion, long-term outcomes, and safety in a cohort of 674 aneurysms treated with the Pipeline embolization device.

By providing a more physiological approach to the treatment of intracranial aneurysms, the Pipeline embolization device (PED) has revolutionized the endovascular treatment of aneurysms. Although there are many flow diverters on the market, the authors report their experience with the PED, the first flow diverter to be approved by the Food and Drug Administration. They aimed to assess the efficacy and safety of PED flow diversion for the treatment of a wide range of aneurysms, as well as to look at factors affecting occlusion. This is a retrospective study of a prospectively maintained database of patients treated with the PED between January 2011 and December 2019. Charts were reviewed for patient, aneurysm, and procedure characteristics. The primary outcomes of interest were complication rates, occlusion outcomes (O'Kelly-Marotta grading scale), and functional outcomes (modified Rankin Scale [mRS]). Secondary outcomes included predictors of incomplete occlusion at 6 and 24 months of follow-up. The study cohort included 581 patients with 674 aneurysms. Most aneurysms (90.5%) were in the anterior circulation and had a saccular morphology (85.6%). Additionally, 638 aneurysms (94.7%) were unruptured, whereas 36 (5.3%) were acutely ruptured. The largest mean aneurysm diameter was 8.3 ± 6.1 mm. Complications occurred at a rate of 5.5% (n = 32). The complete occlusion rate was 89.3% at 24 months' follow-up, and 94.8% of patients had a favorable neurological outcome (mRS score 0-2) at the last follow-up. On multivariate analysis, predictors of incomplete aneurysm occlusion at 6 months were hypertension (OR 1.7, p = 0.03), previous aneurysm treatment (OR 2.4, p = 0.001), and increasing aneurysm neck diameter (OR 1.2, p = 0.02), whereas a saccular morphology was protective (OR 0.5, p = 0.05). Predictors of incomplete occlusion at 24 months were increasing aneurysm neck diameter (OR 1.2, p = 0.01) and previous aneurysm treatment (OR 2.3, p = 0.01). The study findings are corroborated by those of previous studies and trials. The complete occlusion rate was 89.3% at 24 months' follow-up, with 94.8% of patients having favorable functional outcomes (mRS score 0-2). Aneurysm treatment before PED deployment and an increasing aneurysm neck diameter increase the risk of incomplete occlusion at 6 and 24 months.

Predicting incomplete occlusion of intracranial aneurysms treated with flow diverters using machine learning models.

Intracranial saccular aneurysms are vascular malformations responsible for 80% of nontraumatic brain hemorrhage. Recently, flow diverters have been used as a less invasive therapeutic alternative for surgery. However, they fail to achieve complete occlusion after 6 months in 25% of cases. In this study, the authors built a tool, using machine learning (ML), to predict the aneurysm occlusion outcome 6 months after treatment with flow diverters. A total of 667 aneurysms in 616 patients treated with the Pipeline embolization device at a tertiary referral center between January 2011 and December 2017 were included. To build the predictive tool, two experiments were conducted. In the first experiment, six ML algorithms (support vector machine [SVM], decision tree, random forest [RF], k-nearest neighbor, XGBoost, and CatBoost) were trained using 26 features related to patient risk factors and aneurysm morphological characteristics, and the results were compared with logistic regression (LR) modeling. In the second experiment, the models were trained using the top 10 features extracted by Shapley additive explanation (SHAP) analysis performed on the RF model. The results showed that the authors' tool can better predict the occlusion outcome than LR (accuracy of 89% for the SVM model vs 62% for the LR model), even when trained using a subset of the features (83% accuracy). SHAP analysis revealed that age, hypertension, smoking status, branch vessel involvement, aneurysm neck, and larger diameter dimensions were among the most important features contributing to accurate predictions. In this study, an ML-based tool was developed that successfully predicts outcome in intracranial aneurysms treated with flow diversion, thus helping neurosurgeons to practice a more refined approach and patient-tailored medicine.

Spontaneous delayed migration or shortening after pipeline embolization device treatment of intracranial aneurysm: incidence, management, and risk factors

BackgroundStudies reporting spontaneous delayed migration or shortening (SDMS) after treatment with the Pipeline Embolization Device (PED) are limited. This study aimed to evaluate the incidence of SDMS after PED treatment,...

Safety and Efficacy of LVIS Jr Stent-assisted Coiling of Intracranial Aneurysms in Small-diameter Parent Arteries : ASingle-center Experience.

To investigate the safety and efficacy of LVIS Jr stent-assisted coiling (SAC) of intracranial aneurysms (IAs) in small-diameter parent arteries and determine the factors influencing incomplete aneurysm occlusion. Clinical and imaging data of 130 patients with IAs in small-diameter parent arteries that were treated with LVIS Jr SAC were retrospectively analyzed. Stent apposition was evaluated by high-resolution flat detector CT, and aneurysm embolization density was evaluated using 2D-DSA. Perioperative complications were recorded. Multivariate logistic regression analyses were performed to determine possible factors for incomplete aneurysm occlusion. In this study, 130 patients (60and 70patients with ruptured and unruptured aneurysms, respectively) were successfully treated with LVIS Jr SAC. Immediate digital subtraction angiography (DSA) showed that the aneurysm occlusion was Raymond-Roy classI, II, IIIa, and IIIb in 93(71.5%), 24(18.5%), 8(6.2%), and 5(3.8%) cases, respectively. There were three cases of acute in-stent thrombosis and two cases of severe vasospasm observed during the perioperative period. The 6‑month follow-up angiograms indicated that complete aneurysm occlusion in 122 patients was 79.5% (97/122). Multivariate logistic regression analyses showed that an aneurysm size > 10.0 mm, parent artery mean diameter < 2.0 mm, and incomplete stent apposition at the aneurysm neck were possible risk factors for incomplete aneurysm occlusion. The LVIS Jr SAC is effective for managing IAs in small-diameter parent arteries. An aneurysm size > 10.0 mm, parent artery mean diameter < 2.0 mm, and incomplete stent apposition at the aneurysm neck are possible risk factors for incomplete aneurysm occlusion.

Comparison of a covered stent and pipeline embolization device in intracranial aneurysm: a propensity score matching analysis

BackgroundThe Willis covered stent (WCS) and pipeline embolization device (PED) have partly overlapping therapeutic indications. However, the differences of effect between these two treatments remain unclear.ObjectiveTo compare clinical outcome, angiographic...

Pipeline embolization device dynamics: prediction of incomplete occlusion by elongation from nominal length.

According to benchtop studies, the oversizing of a Pipeline embolization device (PED) relative to the parent artery leads to a significant increase in porosity and potentially compromises aneurysm occlusion as well as transitional zone (TZ) formation around the neck of aneurysms. However, no clinical assessment has been reported. Here this potential was studied by measuring the dynamic changes of PEDs in the clinical time course. The authors retrospectively examined 124 anterior circulation unruptured aneurysms in 114 consecutive patients treated with a PED between July 2015 and December 2020 at their institution. The authors excluded 77 cases of 68 patients with adjunctive coil embolization or multiple stents that could affect the PED dynamics and measurements, and 47 aneurysms in 46 patients were included. Measurements were performed before, immediately after, and 6 months after treatment, and then at intervals of 6 months to 1 year after that for nonocclusion cases. Complete occlusion was achieved in 79.0% and incomplete occlusion in 21.0% at last follow-up. The PED length immediately after deployment was 136% nominal length. A multivariable regression analysis revealed that age (OR 1.11/year; p = 0.02) and PED elongation from nominal length (OR 1.31/mm; p = 0.012) were independently associated with a higher rate of incomplete occlusion at the last follow-up. TZ formation did not affect the occlusion rate. PED elongation from the nominal length is a new predictor of incomplete aneurysm occlusion. The PED showed vascular remodeling by changing its diameter and length in the clinical course. TZ formation was remodeled and did not affect the occlusion rate.

Correlation of Flow Diverter Malapposition at the Aneurysm Neck with Incomplete Aneurysm Occlusion in Patients with Small Intracranial Aneurysms: A Single-Center Experience.

Flow diversion treatment repairs aneurysms by altering the hemodynamics of the aneurysmal sac and providing a scaffold for endothelial cell adhesion. The purpose of this study was to investigate the correlation of flow diverter (FD) malapposition at the aneurysm neck with incomplete occlusion of small intracranial aneurysms (IAs) and investigate other factors that are possibly related to incomplete occlusion. From January 2019 to June 2022, the clinical and imaging data for 153 patients (175 aneurysms) with unruptured small IAs treated with flow diversion were retrospectively analyzed. FD apposition at the aneurysm neck was evaluated by high-resolution conebeam CT (HR-CBCT), and the complete occlusion rate for aneurysms was judged according to the latest follow-up conventional angiography findings (≥6 months). Multivariate logistic regression analysis was used to determine factors associated with incomplete aneurysm occlusion. In total, 159 FDs were implanted in 153 patients. HR-CBCT performed after the deployment revealed FD malapposition at the aneurysm neck in 18 cases. According to the latest follow-up angiograms (average: 9.47 ± 3.35 months), the complete aneurysm occlusion rate was 66.9%. The complete occlusion rates for incomplete and complete stent apposition at the neck were 38.9% (7/18) and 70.1% (110/157), respectively. The results of regression analysis showed that an aneurysm sac with branch vessels (OR, 2.937; P = .018), incomplete stent apposition at the aneurysm neck (OR, 3.561; P = .023), and a large aneurysm diameter (OR, 1.533; P = .028) were positive predictors of incomplete aneurysm occlusion. An aneurysm sac with branch vessels, a large aneurysm diameter, and malapposition at the aneurysm neck significantly affect aneurysm repair after FD stent-only treatment for small IAs.

Distal Endovascular Occlusion for Incomplete Occlusion of Cavernous Carotid Aneurysms after High-flow Bypass and Cervical Internal Carotid Artery Ligation

Internal carotid artery (ICA) ligation for placing a high-flow extracranial-intracranial (EC-IC) bypass is used in patients with aneurysms on the cavernous portion of the ICA. Recanalization and rupture after proximal ICA ligation can occur. We present four patients who underwent endovascular distal ICA occlusion and report our surgical technique and treatment results. We ligated the ICA to place an EC-IC bypass using a radial artery (RA) graft. Failure to obtain spontaneous occlusion in the distal region required endovascular treatment an average of 219 days later. A guide catheter was placed in the common carotid artery, a guide or distal access catheter was introduced in the RA graft from the external carotid artery, and a microcatheter was navigated into the cavernous aneurysm through the RA graft. Using detachable coils, endovascular ICA occlusion was from just distal to the aneurysmal neck to a site proximal to the origin of the ophthalmic artery. Aneurysmal occlusion was completed by endovascular occlusion of the distal ICA. Complications were RA graft stenosis and transient consciousness disturbance due to local subarachnoid hemorrhage. Outpatient follow-up for a mean of 109.5 months revealed no recurrences. Distal occlusion of the ICA through the implanted RA graft is simple and presents a low risk for cerebral infarction due to thrombus formation during the procedure. To treat cavernous carotid aneurysms that do not disappear after placing the EC-IC bypass after ICA ligation at the aneurysmal neck, we offer our procedure as a treatment option.

Hemodynamic nature of black-blood enhancement in long-term coiled cerebral aneurysms.

Vessel wall imaging (VWI) with black-blood (BB) technique can demonstrate aneurysmal enhancement preluding to growth/rupture in treatment-naive cerebral aneurysms. Interestingly, recent works showed that BB enhancement may also occur in endovascularly treated aneurysms, though its meaning is controversial. Hypothesizing a flow-related mechanism of BB enhancement, we explored its relationship with incomplete occlusion status and coil packing density at DSA. We analyzed the subjects undergoing 3T MRI between January 2017 and October 2020 for a previous aneurysmal coiling. All the MRI studies included pre- and post-contrast 3D BB sequences. The presence of intra-aneurysmal pre-contrast BB signal was assessed. BB enhancement (when present) was classified as follows: (1) enhancement at the neck, (2) intrasaccular/intra-coil enhancement, and (3) peripheral enhancement. Coil packing density and aneurysmal occlusion status (according to the modified Raymond-Roy classification, MRRC) were determined on post-treatment DSA and compared with BB findings using generalized linear mixed-effect model and ANOVA. Significant p values were <0.05. Forty-eight aneurysms from 44 patients were eligible for analysis. Pre-contrast BB signal was observed in 50% of the aneurysms and showed a relationship with baseline aneurysmal size. BB enhancement was detectable in 31 aneurysms (65%), being significantly associated with incomplete aneurysmal occlusion and reduced coil packing density at DSA. BB enhancement of coiled aneurysms is related with increasing degrees of post-coiling aneurysmal remnants and with loose coil packing density at DSA. This supports a hemodynamic interpretation of BB enhancement in long-term coiled aneurysms.

Abstract Number ‐ 129: Intracranial Blister Aneurysm Management: An Australian Multi‐Centre Retrospective Analysis

Introduction Blister aneurysms (BA) are high risk neurovascular lesions that account for 1% of all intracranial aneurysms. The pathology of BAs, with defective vessel wall and broad‐based neck, make this clinical entity particularly difficult to treat. When these aneurysms present with acute subarachnoid haemorrhage there are associated with high rates of re‐rupture and mortality. These pose substantial challenges for both endovascular and microsurgical management. We report a multi‐centre retrospective analysis of BA management in Sydney, Australia, to describe the different surgical and endovascular approaches and the associated clinical outcomes. Methods A multicentre review of two large tertiary hospitals in Sydney with a search for imaging databases were screened for term of “blister” in all head and neck imaging modalities from January 2010 to June 2022. Operation reports were also screened for the 5‐year time period since cerebral angiogramreports transitioned from imaging database to surgical database. All identified reports were manually screened for confirmed diagnosis of blister aneurysm. Results 21 cases with confirmed diagnosis of blister aneurysm that underwent management at respective facilities were included. 16 cases (76%) were managed endovascularly – one with stent‐assisted coiling and 15 with flow diversion stents. 4 cases (19%) were managed surgically – 3 of these were primary clipping, and one wrap and clipping technique. One surgical case was commenced as an endovascular case prior to conversion. One case was managed conservatively (5%). Clinical outcomes were discharge disposition, occlusion of aneurysm and post‐operative complications. Conclusions BAs have challenging therapeutic considerations with a high mortality and morbidity. Endovascular treatment offers a less invasive management option with a trend of lower rates of intraoperative rupture and lower mortality rates. Endovascular therapy had higher rates of retreatment and incomplete aneurysm occlusion on follow up imaging. Patients discharged directly home were comparable between groups. The decision making for blister aneurysms is complex, endovascular treatment shows promise for acute treatment but careful consideration of antithrombotic regime and requirement for EVD insertion or further surgery should be considered.

Reconstructive endovascular treatment for basilar artery trunk aneurysms: complications and clinical and angiography outcomes

BackgroundBasilar artery trunk aneurysms (BTAs) are rare intracranial aneurysms. We aim to investigate the procedural complications and clinical and angiographic outcomes of BTAs treated with reconstructive endovascular treatment (EVT).MethodsWe retrospectively...

Treatment Outcomes of 94 Cases of Pipeline Embolization Device in a Single Center: Predictive Factors of Incomplete Aneurysm Occlusion

This study aimed to report the outcome of an endovascular treatment with a pipeline embolization device (PED) at a single center. We also examined the predictive factors for an incomplete occlusion after the PED placement. The subjects were 94 patients with 109 aneurysms who underwent the PED placement at our single center from June 2015 to September 2022. As treatment outcomes, we investigated the PED placement success rate, perioperative morbidity and mortality, postoperative cranial nerve improvement rate, and the classification of angiographic result at 6 months after the PED placement. Furthermore, the predictors of an incomplete occlusion were investigated in detail. One hundred nine aneurysms locations were: C1 (9), C2 (30), C3 (15), C4 (53), and C5 (2) in the internal carotid artery segments. Perioperative morbidity, including the asymptomatic ones, occurred in 10 cases (10.6%). Among these 10 cases, the modified Rankin Scale (mRS) improved to preoperative mRS after 90 days in 9 cases except 1 case. On the other hand, no perioperative mortality was observed. The postoperative cranial nerve improvement rate was 84.4%, and 61.7% of patients had a complete occlusion in the follow-up angiography, 6 months after the PED placement. Predictive factors for an incomplete occlusion after the PED placement were the elderly aged 70 years or older (P-value = 0.0214), the elderly aged 75 years or older (P-value = 0.0009), and the use of anticoagulants (P-value = 0.0388) in an univariate analysis. Further, the multivariate analysis revealed that the elderly aged 75 years or older was a predictive factor of an incomplete occlusion in this study. We summarized the outcomes of the PED treatment at our single center. In this study, the elderly aged 75 years or older was a predictive factor of an incomplete occlusion after the PED placement.

Effects of Enterprise 2 stent-assisted coil embolization for wide-necked intracranial aneurysms

BackgroundThis study analyzed the safety and efficacy of Enterprise 2 stent-assisted coil embolization for wide-necked intracranial aneurysms by examining stent-vessel apposition, operative complications, embolization outcomes, and clinical outcomes.MethodsWe retrospectively reviewed the medical records of patients with wide-necked intracranial aneurysms who underwent Enterprise 2 stent-assisted coiling in our hospital from November 2018 to October 2019. Intraoperative VasoCT was performed immediately after stent release in a continuous cohort of patients to observe stent-vessel apposition. Patient demographic, clinical, and imaging data were recorded and analyzed.ResultsA total of 106 wide-necked aneurysms in 106 patients were treated. Stent release was successful in all patients. Twenty-one patients were enrolled consecutively for VasoCT scanning, and incomplete stent apposition was observed in 5 (23.8%). Perioperative complications occurred in 10 patients (9.4%): cerebral infarction in 6, intraoperative coil prolapse in 1, puncture site pseudoaneurysm in 1, deep vein thrombosis at multiple sites in 1, and transient brainstem mass effect in 1. Among the 95 aneurysms with angiographic follow-up, embolization was satisfactory (Raymond–Roy classifications I and II) in 89 (93.7%). Hyperlipidemia was an independent risk factor for incomplete aneurysm occlusion. At the last clinical follow-up, seven patients had a poor clinical outcome (modified Rankin Scale score ≥ 3). Independent risk factors for poor outcomes were preoperative subarachnoid hemorrhage at presentation and cerebral infarction.ConclusionEnterprise 2 stent-assisted coiling for treatment of wide-necked intracranial aneurysms showed good safety and efficacy; however, incomplete stent apposition can still occur in vessels with a large curvature. Preoperative subarachnoid hemorrhage at presentation and cerebral infarction are the main reasons for poor clinical outcomes after stent-assisted coil embolization.

Flow Diversion for ICA Aneurysms with Compressive Neuro-Ophthalmologic Symptoms: Predictors of Morbidity, Mortality, and Incomplete Aneurysm Occlusion.

Flow diversion is an effective treatment for aneurysms of the ICA with compression-related neuro-ophthalmologic symptoms, especially when treatment is initiated early after symptom onset and aneurysm occlusion is complete. However, non-negligible complication rates have been reported. Our aim was to identify risk factors for morbidity/mortality and incomplete aneurysm occlusion. We performed a secondary analysis of a previous publication, which included all patients treated with flow diversion for an unruptured aneurysm of the ICA with compression-related symptoms. Fifty-four patients with 54 aneurysms (48 women, 88.9%; mean age, 59.2 [SD, 15.9] years; range, 21-86 years) treated with flow diversion were included. We observed morbidity and mortality rates of 7.4% and 3.7%. Increasing age (OR per decade, 3.2; 95% CI, 1.23-8.49; P = .02) and dual-antiplatelet therapy with ticagrelor (OR, 13.9; 95% CI, 1.16-165.97; P = .04) were significantly associated with morbidity/mortality. After a median follow-up of 13.3 [SD, 10.5] months, the rates of complete aneurysm occlusion, neck remnant, and aneurysm remnant were 74%, 14%, and 12%. Incomplete occlusion at follow-up was less frequently observed in aneurysms treated with additional coil embolization (OR, 0.1; 95% CI, 0.01-0.86; P = .04). Although a promising treatment for compressive ICA aneurysms, flow diversion carries a relevant risk for complications and incomplete aneurysm occlusion. Our results may help identify patients in which flow diversion may not be the ideal treatment method. Additional coil embolization increased the likelihood of complete aneurysm occlusion at follow-up.

Insufficient Closing Forces of Yasargil Titanium Clips in Two Small Aneurysms Detected with Intraoperative Indocyanine Green Videoangiography.

Aneurysm clips must have adequate closing forces because residual blood flow in clipped aneurysms may result in aneurysm recurrence. Such flow can be intraoperatively detected by visual inspection, microvascular Doppler sonography, indocyanine green videoangiography (ICG-V), angiography, and puncture. We present two patients with ruptured very small middle cerebral artery aneurysms (3 and 2.9 mm). The necks of both aneurysms were microsurgically clipped with Yasargil aneurysm clips without any complications. In both aneurysms, visual inspection suggested complete occlusion, but ICG-V showed persistent residual blood flow between the middle parts of the clip blades.The first patient was treated with a 5.4-mm FT744T clip (closing force of 1.47 N). After the ICG-V finding, a second 3.9-mm FT714T clip (closing force of 1.08 N) was placed on the tips of the already implanted clip to increase the closing forces. Subsequent ICG-V did not show any further residual blood flow. In the second patient, the aneurysm was clipped with an 8.0-mm FE764K clip (closing force of 1.77 N). Intraoperative ICG-V showed persistent residual blood flow within the aneurysmal dome despite complete closure of the clip. The clip was repositioned closer to the parent vessel. Consecutive ICG-V did not show any residual blood flow. Visually undetected incomplete aneurysm occlusion can be revealed with ICG-V. In very small aneurysms, standard closing forces of clips may not be sufficient and complete closure of the clip branches should be intraoperatively validated with ICG-V.