Intraprocedural Rupture Research Articles

Safety and effectiveness of Neuroform Atlas stent-assisted coil embolization for ruptured intracranial aneurysms.

The treatment outcomes of ruptured intracranial aneurysms using the Neuroform Atlas stent were evaluated. This study represents a retrospective review that included patients who underwent endovascular treatment for ruptured aneurysms at a single institution. Between January 2018 and September 2022, endovascular treatments including simple coiling or Neuroform Atlas stent-assisted coil embolization were performed in 191 patients with ruptured intracranial aneurysms. Intraprocedural rupture was observed in 11 (8.7%) patients in the Simple Coiling (SC) group, which was slightly higher than that in 4 (6.3%) patients in the Neuroform Atlas stent-assisted coiling (NASAC) group (p=0.241). However, Thromboembolic event (TEE) was slightly more prevalent in the NASAC group, with 4 (6.3%) cases as compared to the 5 (3.9%) cases in the SC group (p=0.235). The retreatment rate was slightly higher in the SC group, with 19 (26.4%) patients as compared to the 10 patients (22.2%) in the NASAC group (p=0.342). The use of the Neuroform Atlas stent (NAS) for ruptured aneurysms might be safe and effective.

Onyx prevents the bleeding of ruptured aneurysms during interventional embolization.

Endovascular treatment has been acknowledged as an effective treatment for intracranial aneurysms, showcasing favorable clinical outcomes and providing robust protection against rebleeding and rupture. Notably, during the endovascular procedure, significant complications include intraprocedural aneurysmal rupture (IAR) induced by microcatheters, microguidewires, or spring coils, along with thromboembolic events, significantly escalating patient mortality and disability. Current approaches against for IARs involve various strategies such as heparin reversal, compression of the common carotid artery or upstream soft guidewire to mitigate blood flow, management of intracranial pressure and blood pressure, and balloon-assisted or unassisted rapid dense embolization of the aneurysm. Nevertheless, these measures may prove insufficient in halting hemorrhage, especially in scenarios where additional coils cannot be added for dense embolization due to inherent limitations. In this context, we introduce a novel strategy for the prompt, safe, and effective cessation of aneurysm bleeding, which involves injecting an appropriate quantity of Onyx into the aneurysm through a microcatheter while safeguarded by an aneurysm-carrying arterial braided stent. Initially, we attempted dense embolization by filling multiple coils. However, in cases where continued coil filling proved unfeasible or failed to sufficiently prevent contrast agent extravasation, we opted for Onyx injection into the aneurysm. Utilizing Onyx effectively prevented further blood extravasation without adversely impacting the aneurysm-carrying artery or distal vessels, leading to favorable prognoses for all patients. This article delineates our embolization strategy, highlighting the efficacy and safety of Onyx injection as an alternative or complementary measure in managing complications arising from endovascular coil embolization.

Outcomes and predictors of intraprocedural rupture in patients with cerebral aneurysm.

Intraprocedural rupture (IPR) is a devastating complication of cerebral aneurysm treatment. While several studies have investigated its risk factors and clinical impact, further research with larger populations is warranted. We retrospectively reviewed data from 4,039 patients with 4,233 cerebral aneurysms treated at our institution between January 2009 and December 2018. Multivariate logistic regression with stepwise elimination was performed to identify the independent risk factors of IPR. Unfavorable clinical outcome was defined as a Modified Rankin Scale (mRS) ≥ 3 points at 3months post-treatment. IPR occurred in 61 (1.44%) of the 4,233 aneurysms. Multivariate analysis showed that previously ruptured aneurysms (odds ratio [OR] 3.182; 95% confidence interval [CI] 1.851-5.470; p < 0.001), surgical clipping (OR 3.598; 95% CI 1.894-6.836; p < 0.001), and higher aspect ratio (OR 1.310; 95% CI 1.032-1.663; p = 0.024) were independent risk factors for IPR. Patients with IPR had significantly higher rates of unfavorable clinical outcomes (mRS ≥ 3) compared to those without (18.0% vs. 3.3%, p < 0.001). However, within the ruptured aneurysm subgroup, the rate of unfavorable outcomes did not differ significantly between IPR and non-IPR groups (22.7% vs. 19.2%, p = 0.594). Ruptured aneurysms, surgical clipping, and higher aspect ratio were independently associated with IPR. IPR significantly increased the risk of unfavorable clinical outcomes regardless of treatment approach, except in the subgroup of ruptured aneurysms.

Safety and Efficacy of Management for Intraprocedural Rupture During Endovascular Treatment for Intracranial Aneurysms.

Although intraprocedural rupture (IPR) is rare, it is a devastating complication of endovascular treatment (EVT) for intracranial aneurysms. Very few studies have been conducted on IPR, and the safety and efficacy of management techniques of IPR have not been investigated. Patients who experienced IPR during EVT between 2013 and 2022 were enrolled from a multicenter observational registry. We examined the safety and efficacy of the management of IPR using imaging markers, including increased hemorrhage and ischemic lesions, which were evaluated using postoperative computed tomography and diffusion-weighted imaging, respectively. Of the 3269 EVTs for intracranial aneurysms, 74 patients who experienced IPR (2.26%) were analyzed. Fifty-five patients (3.36%) experienced IPR among 1636 EVT cases for ruptured aneurysms. Multivariate analysis revealed that increased hemorrhage was significantly associated with poor outcomes (odds ratio [OR], 6.37 [95% CI, 1.00-40.51], P = .050), whereas ischemic lesions were not. Regarding management techniques of IPR, antihypertensive medication use was significantly associated with increased hemorrhage (OR, 14.16 [95% CI, 2.35-85.34], P = .004). Heparin reversal was an independent factor for ischemic lesions (OR, 8.92 [95% CI, 1.54-51.58], P = .014). Although the setting of IPR may be miscellaneous, and optimal management varies depending on individual cases, heparin reversal might be associated with ischemic complications, and its role in the successful hemostasis in IPR during EVT for ruptured aneurysms remains unclear.

Clinical and Hemodynamic Features of Aneurysm Rupture in Coil Embolization of Intracranial Aneurysms.

Intraprocedural rupture (IPR) during coil embolization (CE) of an intracranial aneurysm is a significant clinical concern that necessitates a comprehensive understanding of its clinical and hemodynamic predictors. Between January 2012 and December 2023, 435 saccular cerebral aneurysms were treated with CE at our institution. The inclusion criterion was extravasation or coil protrusion during CE. Postoperative data were used to confirm rupture points, and computational fluid dynamics (CFD) analysis was performed to assess hemodynamic characteristics, focusing on maximum pressure (Pmax) and wall shear stress (WSS). IPR occurred in six aneurysms (1.3%; three ruptured and three unruptured), with a dome size of 4.7 ± 1.8 mm and a D/N ratio of 1.5 ± 0.5. There were four aneurysms in the internal carotid artery (ICA), one in the anterior cerebral artery, and one in the middle cerebral artery. ICA aneurysms were treated using adjunctive techniques (three balloon-assisted, one stent-assisted). Two aneurysms (M1M2 and A1) were treated simply, yet had relatively small and misaligned domes. CFD analysis identified the rupture point as a flow impingement zone with Pmax in five aneurysms (83.3%). Time-averaged WSS was locally reduced around this area (1.3 ± 0.7 [Pa]), significantly lower than the aneurysmal dome (p < 0.01). Hemodynamically unstable areas have fragile, thin walls with rupture risk. A microcatheter was inserted along the inflow zone, directed towards the caution area. These findings underscore the importance of identifying hemodynamically unstable areas during CE. Adjunctive techniques should be applied with caution, especially in small aneurysms with axial misalignment, to minimize the rupture risk.

Endovascular Coiling of Ruptured Tiny Saccular Intracranial Aneurysms: A Systematic Review and Meta-Analysis

BackgroundThe safety and efficacy of endovascular coiling of ruptured tiny saccular intracranial aneurysms (IAs) (≤ 3mm) remains unknown. MethodsA comprehensive search of PubMed, Embase, Web of Science, and Scorpus databases up to November 15, 2023 was performed. Pooled prevalence was calculated for occlusion rates, recanalization, retreatment, long-term favorable outcome, and procedure-related complications and mortality. Pooled odds ratios were calculated to compare these outcomes between coiling and stent-assisted coiling (SAC). Results42 studies with 2,174 ruptured tiny saccular IAs treated with coiling were included. The follow-up complete aneurysm occlusion rate was 83.9% (95% CI: 77.2–88.9%). The rates of recanalization and retreatment were 7.7% (95% CI: 5.7–10.2%) and 5.8% (95% CI: 4.5–7.5%). The range of median Hunt and Hess grades was 1.4–2.9 and the favorable outcome rate was 85.6% (95% CI: 81.1–89.2%). The rates of thromboembolism, intraprocedural rupture, and mortality were 4.6% (95% CI: 3.6–5.8%), 5.4% (95% CI: 4.1–7.0%), and 5.6% (95% CI: 4.4–7.2%), respectively. Comparison of coiling and SAC revealed no significant difference, except for a higher likelihood of follow-up complete aneurysm occlusion in SAC (odds ratio [OR] 0.37, 95% CI: 0.17–0.80) and recanalization in the coiling (OR, 3.21 [95% CI, 1.37–7.51]). ConclusionsOur meta-analysis demonstrates that coiling for ruptured tiny saccular IA is a feasible, effective, and safe approach that is associated with favorable clinical outcomes in both the short and long term for patients with mild to moderate Hunt and Hess grades.

Fubuki XF Long Sheath guide catheter use in neuroendovascular procedures: Institutional experience in 60 cases.

Endovascular treatment devices require compatible guide catheters to navigate complex vessels and anatomy. The Fubuki XF Long Sheath guide catheter (Fubuki XF) was developed with a 0.090-inch internal diameter with hydrophilic coating, an atraumatic rounded tip, and enhanced trackability and support with gradual shaft transition zones. We retrospectively analyzed a prospectively maintained database of neuroendovascular patients treated using Fubuki XF at our center (July 2022─May 2023). Baseline/procedural characteristics were collected. Outcomes of interest included technical success (procedure completion with Fubuki XF without alternative guide catheter use) and peri-procedural complications. This study included 60 patients (43.3% [26/60] female; mean age: 69.6 ± 9.7) presenting with stenosis (45.0% [27/60]), unruptured aneurysms (31.7% [19/60]), ruptured aneurysm (1.7% [1/60]), arteriovenous fistula (5.0% [3/60]), arteriovenous malformation (3.3% [2/60]), chronic subdural hematoma (3.3% [2/60]), stroke/emboli (6.7% [4/60]), vasospasm (1.7% [1/60]), or carotid web (5.0% [1/60]). Fubuki XF was used to deliver endovascular treatment devices for stenting (43.3% [26/60]), flow diversion (23.3% [14/60]), embolization (11.7% [7/60]), coiling (10.0% [6/60]), balloon angioplasty (10.0% [6/60]), and mechanical thrombectomy (1.7% [1/60]). The Fubuki XF tip was placed in the internal carotid artery in 38.3% (23/60) of cases. Technical success was achieved in all cases. One V1 non-flow-limiting dissection (not related to Fubuki XF) and one failed closure occurred (1.7% [1/60] each). No iatrogenic strokes or intraprocedural ruptures occurred. We used Fubuki XF to safely and effectively deliver a variety of compatible neuroendovascular devices. Fubuki XF was stable in all cases and locations, and there were no device-related complications or dissections.

A Retrospective Observational Study in Neonates with Transposition of Great Arteries Undergoing Balloon Atrial Septostomy in a Tertiary Care Hospital

Objectives: Transposition of great arteries (TGA) is a common cause of cyanotic newborns. There is an atrioventricular concordance with ventriculoarterial discordance. This parallel circulation is incompatible with life unless communication exists for the inter-circulatory mixing of blood. Balloon atrial septostomy (BAS) is a percutaneously performed interventional procedure in catheterization laboratory, usually in patients with TGA-intact ventricular septum (IVS) to ensure admixture of oxygenated and deoxygenated blood thus improving systemic oxygen delivery, to achieve hemodynamic stability before the definitive procedure (Arterial switch operation), and to determine the risk of intraprocedural complications in neonates undergoing balloon atrial septostomy. Material and Methods: This is a retrospective observational study, which included neonatal patients during a single year. All the data were collected from the medical record section of the hospital. Results: We included 17 neonates with TGA transferred to our center for definite treatment. Six cases were done under sedation and 11 under general anesthesia. The mean age at the time of BAS was 4.8 days. Procedure-related complications occurred in 41% of patients. In one of the cases, difficult airway management made the periprocedural course daunting. Complications included intraprocedural balloon rupture (1 case), transient atrial arrhythmia (4 cases), hypotension (1 case), and pericardial tamponade due to left atrial wall puncture (1 case). Conclusion: BAS is a safe and effective palliative procedure for TGA-IVS, with good immediate results in our institution. Maintaining cardiorespiratory stability, prevention of respiratory depression in a spontaneously breathing neonate, and maintenance of normothermia in the cold temperature of the catheterization laboratory, with eternal vigilance, forms the cornerstone of a successful neonatal outcome.

Risk factors and management of intraprocedural rupture during coil embolization of unruptured intracranial aneurysms: role of balloon guiding catheter.

Intraprocedural rupture (IPR) is a serious complication of endovascular coil embolization of unruptured intracranial aneurysms (UIAs). Although outcomes after IPR are poor, methods to prevent subsequent neurological deterioration have not yet been investigated. We evaluated the risk factors and management strategies for IPR, particularly the role of balloon guiding catheters (BGCs) in rapid hemostasis. We retrospectively reviewed all UIA cases treated with coil embolization at three institutions between 2003 and 2021, focusing on preoperative radiological data, operative details, and outcomes. In total, 2,172 aneurysms were treated in 2026 patients. Of these, 19 aneurysms in 19 patients (0.8%) ruptured during the procedure. Multivariate analysis revealed that aneurysms with a bleb (OR: 3.03, 95% CI: 1.21 to 7.57, p = 0.017), small neck size (OR: 0.56, 95% CI: 0.37 to 0.85, p = 0.007), and aneurysms in the posterior communicating artery (PcomA) (OR: 4.92, 95% CI: 1.19 to 20.18, p = 0.027) and anterior communicating artery (AcomA) (OR: 12.08, 95% CI: 2.99 to 48.79, p < 0.001) compared with the internal carotid artery without PcomA were significantly associated with IPR. The incidence of IPR was similar between the non-BGC and BGC groups (0.9% vs. 0.8%, p = 0.822); however, leveraging BGC was significantly associated with lower morbidity and mortality rates after IPR (0% vs. 44%, p = 0.033). The incidence of IPR was relatively low. A bleb, small aneurysm neck, and location on PcomA and AcomA are independent risk factors for IPR. The use of BGC may prevent fatal clinical deterioration and achieve better clinical outcomes in patients with IPR.

Intermediate catheter use is associated with intraprocedural rupture during coil embolization of ruptured intracranial aneurysms: a retrospective propensity score-matched study.

An intermediate catheter (IMC) may pose a risk of intraprocedural rupture (IPR) during coil embolization of ruptured intracranial aneurysms (RIAs), because the pressure on the microcatheter and coil might be more direct. To verify this hypothesis, this study explored whether use of an IMC might correlate with an increased rate of IPR during coil embolization for RIAs. We retrospectively reviewed 195 consecutive aneurysms in 192 patients who underwent initial coil embolization for saccular RIAs at our institution between January 2007 and December 2023. Patients were divided into two groups with aneurysms treated either with an IMC (IMC group) or without an IMC (non-IMC group). To investigate whether IMC use increased the rate of IPR, a propensity score-matched analysis was employed to control for age, sex, maximal aneurysm size, neck size, bleb formation, aneurysm location, proximal vessel tortuosity, balloon-assisted coiling, type of microcatheter, and type of framing coil. Ultimately, 43 (22%) coil embolization used IMC. In univariate analysis, the incidence of IPR was significantly higher in the IMC group compared with the non-IMC group (14.0 vs. 3.3%, p = 0.016). Propensity score matching was successful for pairs of 26 aneurysms in the IMC group and 52 aneurysms in the non-IMC group. The incidence of IPR was still significantly higher in the IMC group than in the non-IMC group (23.1 vs. 3.8%, p = 0.015). No significant differences in the incidences of ischemic complications and IMC-related parent artery dissection were observed between the two groups. When using IMC for coil embolization of RIAs, the surgeons should be more careful and delicate in manipulating the microcatheter and inserting the coils to avoid IPR.

Endovascular Treatment of Small Anterior Communicating Artery Aneurysms: Safety and Efficacy in a Contemporary Cohort.

Endovascular treatment (EVT) of small anterior communicating artery (ACoA) aneurysms accompanies a high risk of intraprocedural rupture (IR) because of anatomic location and aneurysm orientation. In this study, we aimed to investigate the safety and efficacy of EVT for small ACoA aneurysms in a contemporary cohort. ACoA aneurysms treated at the Medical University of South Carolina between April 2012 and March 2022 were retrospectively analyzed. Periprocedural baseline characteristics, aneurysm size, and clinical and radiological outcomes were collected. Aneurysms were dichotomized into <4 and ≥4 mm in maximum size. The IR rate, favorable occlusion rate (Raymond-Roy I and II), and the favorable outcome defined as modified Rankin Scale 0-2 were compared. A total of 174 patients were identified, of whom 111 (63.8%) were female, and the median age was 57.7 (interquartile range 50.6-69.6) years. 98 (56.3%) aneurysms were ruptured, and 53 (30.5%) were <4 mm. IR was not observed in unruptured ACoA aneurysms, and there was no significant difference in the IR rates between <4 mm and ≥4 mm ruptured aneurysms (6.5% vs 4.5%, P = .65). Favorable occlusion rate and favorable outcome were observed in 94.7% and 78.2% of patients, respectively. EVT of small ACoA aneurysms is safe and effective.

Correlation between contrast leakage period of procedural rupture and clinical outcomes in endovascular coiling for cerebral aneurysms.

Intraprocedural rupture (IPR) is a fatal complication of endovascular coiling for cerebral aneurysms. We hypothesized that contrast leakage period may be related to poor clinical outcomes. This study aimed to retrospectively evaluate the relationship between clinical outcomes and contrast leakage period. Data from patients with cerebral aneurysms treated via endovascular coiling between January 2010 and October 2018 were retrospectively assessed. The enrolled patient's demographic data, the aneurysm related findings, endovascular treatment and IPR related findings, rescue treatment, and clinical outcome were analyzed. In total, 2,859 cerebral aneurysms were treated using endovascular coiling during the study period, with IPR occurring in 18 (0.63 %). IPR occurred during initial frame coiling (n=4), coil packing (n=5), stent deployment (n=7), ballooning (n=1), and microcatheter removal after coiling (n=1). Tear sites included the dome (n=14) and neck (n=4). All IPRs were controlled and treated with coil packing, with or without stenting. Flow arrest of the proximal balloon was not observed. Temporary focal neurological deficits developed in two patients (11.1%). At clinical follow-up, 14 patients were classified as modified Rankin Scale (mRS) 0, three as mRS 2, and one as mRS 4. The mean contrast leakage period of IPR was 11.2 min (range: 1-31 min). Cerebral aneurysms with IPR were divided into late (n=9, mean time: 17.11 min) and early (n=9, mean time: 5.22 min) control groups based on the criteria of 10 min of contrast leakage period. No significant between-group differences regarding clinical outcomes were observed after IPR (p=1). In our series, all patients with IPR were controlled with further coil packing or stenting without proximal balloon occlusion within 31 min of contrast leakage. There was no difference in clinical outcomes when the long contrast leakage period group and short contrast leakage period group were compared.

Endovascular treatment of multiple intracranial aneurysms.

Multiple intracranial aneurysms are difficult to treat. In order to investigate the effect and safety of endovascular treatment for multiple intracranial aneurysms, 54 consecutive patients with 116 multiple intracranial aneurysms treated with endovascular embolization were retrospectively enrolled. Angiography was performed immediately after embolization and at each follow-up. All clinical data were analyzed. Of the 116 aneurysms, 56 (48.3%) were embolized with coiling alone, 19 (16.4%) with stent-assisted coiling, 31 (26.7%) with stenting alone, and 10 (8.6%) with flow diverters plus coiling. After embolization, 31 (27.6%) aneurysms with stenting alone had no apparent change in size, and in the remaining 84 aneurysms, complete occlusion was achieved in 50 aneurysms (59.5%), near-complete occlusion in 26 (31.0%), and incomplete occlusion in 8 (9.5%). Thrombus formation at the aneurysm neck occurred in 3 patients (5.6%), coil protrusion in 2 (3.7%), and intraprocedural rupture in 1 (1.9%), resulting in a total complication rate of 11.1%. Follow-up angiography was performed in 44 (81.5%) patients 6 to 90 months (mean 49) later. Among 50 completely occluded aneurysms, 38 (76%) aneurysms remained completely occluded, and 4 (8%) aneurysms recurred. Among 26 aneurysms with initial near-complete occlusion, 12 (46.2%) aneurysms with neck remnant had progressive thrombosis to complete occlusion, 2 (7.7%) had no change compared with immediate occlusion, and 5 (19.2%) regrew. In conclusion, endovascular embolization with intracranial stenting and coiling is safe and effective and may play an increasingly important role in the management of multiple intracranial aneurysms.

Evaluation of effectiveness and safety of the CorPath GRX robotic system in endovascular embolization procedures of cerebral aneurysms

BackgroundRobotic-assisted neurointervention was recently introduced, with implications that it could be used to treat neurovascular diseases.ObjectiveTo evaluate the effectiveness and safety of the robotic-assisted platform CorPath GRX for treating cerebral...

Coil embolization for ruptured and unruptured very small intracranial aneurysms: A retrospective review of a 10-year single-center experience.

Because of the risk of intraoperative rupture and technical difficulties, coil embolization of very small aneurysms (VSIAs) with a diameter of ≤3 mm is challenging. Herein, we reviewed our treatment strategies and outcomes in performing coil embolization for VSIAs compared to those for larger sized intracranial aneurysms (IAs) with 4 to 4.5 mm. We retrospectively reviewed the data on ruptured and unruptured VSIAs and larger-sized IAs treated with coiling from January 2012 to June 2021. Saccular IAs treated with coil embolization and followed up for at least 6 months with imaging studies were included in the study. Fifty-eight VSIAs (27 subarachnoid hemorrhages [SAH group] and 31 unruptured hemorrhages [URA group]) were identified. The wide-necked VSIAs were significantly more common in the URA group (90.3% vs 63.0%, P = .013). Procedural complications occurred in 8 cases (13.8%): intra-procedural rupture (n = 3), coil prolapse (n = 3), and thromboembolic events (n = 2). Complications were more frequent in the SAH group (P = .020). SAH was an independent risk factor for procedural complications (odds ratio, 11.293 [95% confidence interval: 1.173-108.684], P = .036), and the outcomes were affected by SAH presentation (P = .007) and poor clinical status of SAH (P = .001). When compared with larger IAs (n = 57), there were no significant differences in treatment outcomes, procedural complications, and clinical outcomes. VSIAs ≤ 3 mm in diameter were successfully treated with coil embolization, with reasonable procedure-related complications and treatment outcomes. The safety and efficacy of coil embolization for VSIAs were comparable to those of 4 to 4.5 mm sized IAs in this single-center cohort.

Stent-assisted coiling vs. coiling alone of ruptured tiny intracranial aneurysms: A contemporary cohort study in a high-volume center.

This study aims to compare the safety and efficacy of stent-assisted coiling (SAC) with those of coiling alone (CA) for the treatment of ruptured tiny intracranial aneurysms. We enrolled 245 patients with ruptured tiny intracranial aneurysms treated with coil embolization. Patients were grouped into SAC and CA groups. Baseline characteristics, periprocedural complications, clinical outcomes, and angiographic results were compared between the two groups. In addition, a subgroup analysis was conducted in the SAC group, and patients were regrouped into low-profile visualized intraluminal support (LVIS) and laser-cut groups to compare the perioperative procedure-related complications and clinical and angiographic follow-up outcomes. All baseline characteristics were equivalent between the two groups except for aneurysm size and dome-to-neck aspect ratio. The rates of overall procedure-related complications, intraprocedural rupture, postoperative early rebleeding, intraprocedural thrombosis, postprocedural thrombosis, and procedure-related mortality were comparable between the two groups (P = 0.105, 0.145, 0.308, 1.000, 1.000, 0.160, respectively). Nevertheless, the rate of hemorrhagic complication in the SAC group was significantly higher (P = 0.023). The angiographic follow-up outcomes showed that the SAC group had a higher complete occlusion rate and lower recurrence rate (88.2 vs. 67.1%, 5.4 vs. 15.2%, P = 0.001). The clinical outcomes at discharge and follow-up between the two groups demonstrated no significant differences (P = 0.192 and P = 0.085, respectively). For subgroup analysis, LVIS stents were associated with a significantly higher rate of complete occlusion (P = 0.014) and a lower rate of intraprocedural rupture (p = 0.021). Moreover, multivariate analysis showed that there were no predictors for the overall, hemorrhagic, and ischemic procedure-related complications, while Raymond class was an independent predictor of retreatment (OR = 3.508, 95% CI 1.168-11.603; P = 0.029). Stent-assisted coiling may increase the incidence of hemorrhagic events with favorable angiographic results and comparable clinical outcomes compared with stand-alone coiling. Nevertheless, LVIS stent could improve the safety compared with lazer-cut stent. Simultaneously, considering the better long-term effect, LVIS stent-assisted coiling may be a preferable choice for ruptured tiny intracranial aneurysms.

Brain aneurysm rupture during mechanical thrombectomy for large vessel occlusion: Technical case series and complication avoidance strategies.

Endovascular therapy became the mainstream treatment for patients with acute stroke due to emergent large vessel occlusion (LVO). With increasing number of interventions, it is not uncommon for incidental vascular pathologies to be found during mechanical thrombectomy. Overall, intracranial aneurysms can occur in up to 4% of the population, but previous studies suggest a slightly higher prevalence of intracranial aneurysms in stroke patients as they may share common risk factors. We report on three patients with acute stroke secondary to LVO undergoing mechanical thrombectomy with brain aneurysms incidentally discovered and discuss the potential implications and technical considerations of performing revascularization in these scenarios. In the first case, a patient treated with stent-retriever and aspiration developed a carotid-cavernous fistula without clinical repercussion. The second case illustrates an internal carotid artery posterior communicating segment aneurysm rupture with a massive subarachnoid hemorrhage. The third case exemplifies an unruptured middle cerebral artery bifurcation aneurysm related to an M2 occlusion managed with a different strategy, avoiding aneurysm rupture. Intraprocedural aneurysm rupture is a potential complication during mechanical thrombectomy, especially when anatomical challenges are present. Interventionalists should be aware of the potential risk and constraints in this setting in order to mitigate adverse events.

Neuroform atlas stent-assisted coiling of tiny wide-necked intracranial aneurysms.

To investigate the safety and efficacy of Neuroform Atlas stent-assisted coiling for the treatment of tiny wide-necked intracranial aneurysms and evaluate risk factors associated with procedure-related complications. We retrospectively examined 46 patients with 46 tiny wide-necked aneurysms who were treated using Atlas stent-assisted coiling at our institution from August 2020 to May 2022. Patient and aneurysm characteristics, procedural details, procedure-related complications, and angiographic and clinical outcomes were analyzed. A total of 10 patients presented with aneurysmal rupture. Atlas stent placement was successful in all patients. Angiography immediately after the procedure showed complete occlusion in 38 patients (82.6%), neck remnant in 7 (15.2%), and partial occlusion in 1 (2.2%). The mean angiographic follow-up was 8.4 months (range, 6-16). At the last follow-up, angiography showed complete occlusion in 41 patients (89.1%) and neck remnant in 5 (10.9%). No aneurysm recurrence or in-stent stenosis occurred. Incidence of procedure-related complications was 10.8% (intraprocedural aneurysm rupture, two cases; acute thrombosis, two cases; and coil migration, one case); only one patient (2.2%) experienced procedural neurological morbidity. The mean clinical follow-up was 9.7 months. A favorable outcome was achieved in 45 patients (97.8%). In univariate logistic regression analysis, aneurysm size (odds ratio, 4.538; P = 0.045) was significantly associated with procedure-related complications. However, multivariate analysis found no independent risk factors. Atlas stent-assisted coiling of tiny wide-necked intracranial aneurysms is feasible and effective. Outcomes and occlusion rates are favorable and morbidity is low. The complication rate may be higher in larger tiny aneurysms.

Periprocedural cerebrovascular complications and 30-day outcomes of endovascular treatment for intracranial vertebral artery dissecting aneurysms.

The authors undertook an evaluation of periprocedural cerebrovascular complications and 30-day outcomes of endovascular treatment for intracranial vertebral artery dissecting aneurysms (IVADAs) and assessed the relevant risk factors. The authors included a series of 195 patients who had undergone endovascular treatment for 198 IVADAs. Clinical data, morphological characteristics, treatment details, and periprocedural cerebrovascular complications including intraprocedural rupture, intraprocedural thrombosis, intracranial hemorrhage (ICH), transient ischemic attack (TIA), and ischemic stroke (IS) were recorded. After evaluation of the 30-day modified Rankin Scale (mRS) scores, the authors applied univariate and multivariate logistic regression analyses to identify the risk factors for complications and 30-day unfavorable clinical outcomes. There were no intraprocedural ruptures, but the authors recorded intraprocedural thrombosis (n = 5), ICH (n = 3), TIA (n = 1), and IS (n = 13), comprising an 11.1% (22/198) complication rate. Multivariate logistic regression analysis indicated that hyperlipidemia (odds ratio [OR] 3.17, 95% confidence interval [CI] 1.20-8.41, p = 0.020), IS history (OR 5.55, 95% CI 1.46-21.01, p = 0.012), and subarachnoid hemorrhage (SAH) (OR 4.48, 95% CI 1.52-13.20, p = 0.007) were risk factors for overall complications, whereas aneurysmal height (OR 0.77, 95% CI 0.61-0.98, p = 0.032) was a protective factor. SAH (OR 6.44, 95% CI 1.54-26.89, p = 0.011) and preprocedural mRS score > 2 (OR 5.07, 95% CI 1.01-25.59, p = 0.049) were independent risk factors for perforator occlusion stroke. Periprocedural cerebrovascular complications (OR 32.09, 95% CI 3.00-343.94, p = 0.004) and preprocedural mRS score > 2 (OR 319.92, 95% CI 30.28-3379.98, p < 0.001) were independent risk factors for 30-day unfavorable clinical outcomes. Hyperlipidemia, IS history, and SAH were independent predictors for overall periprocedural cerebrovascular complications of endovascular treatment for IVADAs, but aneurysmal height was an independent protective factor. SAH and preprocedural mRS score > 2 were independent risk factors for perforator occlusion stroke. Preprocedural mRS score > 2 and periprocedural complications were independent risk factors for 30-day unfavorable clinical outcomes.

Alterations of vital signs as prognostic factors after intraprocedural rupture of intracranial aneurysms during endovascular treatment.

To report our experience with intraprocedural rupture (IPR) of intracranial aneurysms during endovascular treatment and evaluate alterations in vital signs as independent prognostic factors to predict the outcomes of IPR. Between January 2008 and August 2021, 34 patients (8 ruptured and 26 unruptured) were confirmed to have IPR based on our dataset with 3178 endovascular coiling procedures. The patients who underwent additional surgeries related to IPR were classified as the OP group (n=9), while those who did not receive additional surgeries were classified as the non-OP group (n=25). Vital signs were recorded during the procedure by anesthesiologists and analyzed. Of the 34 patients included in this study, eight initially presented with subarachnoid hemorrhage due to a ruptured aneurysm. The clinical outcomes at discharge were significantly different between the two groups (p=0.046). In the OP group, five patients showed favorable outcomes at discharge, while four showed unfavorable outcomes. In the non-OP group, 23 patients showed favorable outcomes at discharge while two patients showed unfavorable outcomes. Maximal (MAX) systolic blood pressure (SBP) (odds ratio [OR] 1.520, 95% confidence interval [CI] 1.084-2.110; p=0.037) and higher differential value MAX-median blood pressure (MBP) (OR 1.322, 95% CI 1.029-1.607; p=0.044) remained independent risk factors for poor prognosis after IPR on multivariate logistic regression analysis. The MAX SBP and the difference between the maximal and baseline values of MBP are key factors in predicting the prognosis of patients after IPR, as well as providing useful information for predicting the outcome. Further research is required to confirm the relationship between naive pressure and prognosis.