Raymond-Roy Classification Research Articles

Safety and Efficacy of the Pipeline Embolization Device Use in the Outside Circle of Willis Located Intracranial Aneurysms: A Single-Center Experience

Background: The use of Pipeline Embolization Device (PED) is approved by the US Food and Drug Administration (FDA) to treat aneurysms located between the petrous and superior hypophyseal segments of the internal carotid artery. The purpose of this study is to evaluate the feasibility and efficacy of treating aneurysms outside the FDA approved anatomical locations. Furthermore, we analyze the safety of our antiplatelet protocol. Methods: Data on all patients treated with PED at our center from March 2015 to December 2017 were reviewed. Only patients with aneurysms treated with PED as off label use were included. Procedural complications and long-term functional outcome measured by modified Rankin Scale (mRS) were recorded. Tirofiban maintenance infusion was administered intravenously after PED deployment. None of the patients had platelet function testing. Results: A total of 36 patients harboring 36 aneurysms were included in the study. Mean age was 58.2 years ±14.6. Nineteen were women (52.8%) and most aneurysms were unruptured (80.6%). There were no intraoperative complications. Five patients experienced postoperative complications – 4 ischemic strokes and one groin hematoma. None led to any significant disability at follow-up. Thirty-one patients (86.1%) achieved an mRS of 0–2 at follow-up. A Raymond-Roy classification of 1 was achieved in 78.9% of patients. Conclusion: The use of PED to treat aneurysms located outside the circle of Willis is feasible and effective. Our novel antiplatelet protocol did not require platelet function assay testing and did not lead to a higher rate of thrombo-embolic events compared to what has been previously reported.

Transradial approach to embolization of a basilar aneurysm: a clinical case and literature review

The study objective is to present a clinical case of using transradial access for embolization of an aneurysm of the basilar artery (BA) bifurcation. Materials and methods. A patient, 67 years old, sought medical help at the I.I. Dzhanelidze Saint Petersburg Research Institute of Emergency Medicine complaining of headaches. Computed angiography of the brain had shown a large aneurysm of the BA with an absolutely wide neck. Embolization of the aneurysm using stent assistance (Y-stenting) was performed with access through the radial artery. The results were compared to data from scientific literature (about 16 cases).Results. Aneurysm embolization level was II or IIIb per the modified Raymond–Roy classification was performed. No complications were observed, blood flow in the radial artery was preserved. The patient was released on day 2 after the surgery. No signs of blood flow through the aneurysm were observed during control selective cerebral angiography 12 months later. According to literature data, transradial access is preferable only with pathology of the vertebrobasilar system, especially if standard access is impossible to form due to atherosclerotic damage of the femoral artery, angling of the aortic arch, and pathological vessel tortuosity.Conclusion. Routine use of transradial access in surgery of pathologies of the cerebral flow is not justifiable. But in some cases, this alternative access can be more effective and safer compared to the standard access. The main advantages of this access are reduced rate of complications of arterial access and possibility of early patient activization.

Endovascular Treatment of Superior Cerebellar Artery Aneurysms.

To present our experience on superior cerebellar artery (SCA) aneurysms treated with embolization by using current endovascular techniques. All SCA aneurysms treated by our endovascular team since 2013 were retrospectively evaluated. Clinical information and angiographic findings on presentation, during treatment and on follow-up were noted. Endovascular treatment was the primary treatment method for SCA aneurysms during the study period. Twenty three patients (15 female, 8 male) with a mean age of 50.6 years, 12 of whom with subarachnoid hemorrhage were treated. Treatments included coiling (56%), stent assisted coiling, stentriever assisted coiling, Y stent assisted coiling and flow diversion with either flow diverter placement or telescopic stenting. Two patients died secondary to consequences of subarachnoid hemorrhage. The outcome of 1 patient was Modified Rankin Scale (mRS) 3 and the outcome of remaining 20 patients was mRS 0. The rates of aneurysm occlusion according to Raymond-Roy classification were: class 1 in 11 patients, class 2 in 6 patients and class 3 in 2 patients on a mean follow-up of 15.3 months. Only one patient required retreatment. Current endovascular techniques are able to address the high rate of recanalization and retreatment of SCA aneurysms which are currently the major drawbacks associated with primary coiling when compared with surgical treatment. It remains to be shown if use of these latest techniques are associated with increased risk of thromboembolic events.

SMART coils for intracranial aneurysm embolization: Follow-up outcomes

The SMART coil (Penumbra Inc., Alameda, CA, USA) is a new microcoil designed to enhance deliverability. Although prior studies have described its perioperative safety and efficacy, the follow-up outcomes after embolization of intracranial aneurysms using SMART coils have not been reported. Therefore, the aim of this retrospective cohort study is to assess the angiographic outcomes at interim follow-up after aneurysm embolization with SMART coils. We reviewed data from consecutive patients with intracranial aneurysms who underwent endovascular treatment using SMART coils between June 2016 and August 2017. Baseline data and follow-up angiographic outcomes using the modified Raymond-Roy classification (MRRC) were recorded. The study cohort comprised 33 patients with 34 aneurysms who underwent SMART coil embolization and had sufficient follow-up data. The mean age was 57 years, and 82% were female. The mean aneurysm maximum diameter and neck width were 6.1 ± 2.2 mm and 3.2 ± 1.2 mm, respectively, and 14.7% of aneurysms were ruptured. The overall complication rate was 12%. Initial mean coil packing density was 26%, and the initial MRRC was I, II, IIIa, and IIIb in 24%, 26%, 35%, and 15%, respectively. At last follow-up (mean duration 7.7 ± 3.2 months), the MRRC was I, II, IIIa, and IIIb in 62%, 26%, 3%, and 9%, respectively. The retreatment rate was 14.7%. The SMART coil is efficacious for the treatment of appropriately selected aneurysms, with an acceptable risk profile. The majority of residual aneurysms after the initial embolization procedure will progress to complete or near-complete occlusion at interim follow-up.

Treatment of Unruptured, Tandem Aneurysms of the ICA with aSingle Flow Diverter.

Intracranial adjacent tandem lesions of the internal carotid artery (ICA) are rare and the optimal treatment strategy is unknown. This study was carried out to determine whether asingle flow diverter stent (FDS) could be successfully used to treat these lesions. The prospectively maintained database was retrospectively carried out to identify patients treated between February 2009 and February 2018 with multiple unruptured, tandem ICA aneurysms and treated with asingle FDS. Demographic data, clinical presentation, aneurysm characteristics, treatment data, clinical result and clinical and radiological follow-up information were recorded. A total of 69patients (62female, 89.8%) with average age 55 ± 14.8 years were identified. In total there were 169aneurysms and the majority of patients (n = 47, 68.1%) had only 2tandem aneurysms. The largest aneurysms measured 7.69 ± 5.3 mm (range 1.5-26 mm) in height, 6.64 ± 4.71 mm (range 1.5-23 mm) in width and the smaller aneurysm measured 2.61 ± 1.32 mm (range 0.8-9.5 mm) in height and 2.32 ± 1.12 mm (range 0.7-8 mm) in width. In 36patients the p64 was used, the PED in 28patients and Surpass in 5patients. Follow-up was available in 54patients (130 aneurysms). At initial follow-up (7.2 ± 4.2months) 45 (83.3%) of the larger aneurysms and 66 (86.8%) of the smaller aneurysms were satisfactorily occluded (Raymond-Roy classification RRC1 or2). At delayed follow-up (18 ± 14.6months) 48 of the larger aneurysms (88.9%) and 71 of the smaller aneurysms (93.4%) were satisfactorily occluded. There were three complications including one death. Asingle FDS can be used to successfully treat multiple tandem aneurysms of the ICA with ahigh rate of aneurysm exclusion and an acceptable risk profile.

The Use of Flow Diversion in Vessels ≤2.5 mm in Diameter–A Single-Center Experience

Flow diversion has become an accepted treatment strategy for aneurysms; however, there are limited data on the use of these devices in small vessels ≤2.5 mm in diameter. We performed a retrospective review of our prospectively maintained database to identify all patients treated with flow diversion between September 2009 and January 2018. We identified all patients in whom the average parent artery was ≤2.5 mm in diameter. Ruptured aneurysms were excluded from the analysis as were patients who had adjunctive coiling at the time of flow diversion. We identified 29 patients (22 female, 76%) with average age 56.2 ± 15.9 years (range, 21-83 years). Most aneurysms were classified as saccular (n= 21, 72.4%), with 7 fusiform aneurysms (24.2%) and 1 presumed dissecting aneurysm (3.4%). The average parent artery diameter was 2.1 ± 0.37 mm (range, 1.3-2.5 mm). Delayed angiographic follow-up was available for 18 patients at an average of 19.4 months after treatment. Fifteen patients showed Raymond-Roy classification grade 1 occlusion (94%) and 1 patient with complete filling showed Raymond-Roy classification grade 3 (6%). Four patients (13.7%) underwent repeat treatment with implantation of another flow-diverting stent in a telescoping manner. At 90 days, 2 patients had a modified Rankin Scale (mRS) score of 6, 1 from an unrelated cause and 1 from the enlarging compressive dissecting aneurysm and intraparenchymal hemorrhage. All the remaining patients had an mRS score ≤2 at 90 days, with 24 patients (83%) with an mRS score of0. Flow diverters can be implanted into small vessels with a high rate of technical success and good rates of aneurysm occlusion. Dedicated devices to target these vessels should be developed.

Usefulness of contrast-enhanced and TOF MR angiography for follow-up after low-profile stent-assisted coil embolization of intracranial aneurysms.

Low-profile, self-expandable stents are used to treat wide-neck aneurysms located on the smaller distal intracranial arteries. This study aimed to assess the usefulness of time-of-flight (TOF) and contrast-enhanced (CE) magnetic resonance angiography (MRA) for follow-up after LEO Baby stent (LBS)-assisted coil embolization. Twenty-four aneurysms treated with LBS-assisted coil embolization were evaluated. Researchers reviewed TOF MRA and CE MRA images in terms of occlusion and stent patency. Aneurysm occlusion was graded according to Raymond-Roy classification as follows: total occlusion (grade 1), residual neck (grade 2), and residual aneurysm (grade 3). Stent patency was scored as follows: occlusion (1), stenosis (2), and normal (3). Interobserver and intermodality agreement values were determined by weighted kappa (κ) statistics. Intermodality and interobserver values of TOF MRA and CE MRA with digital subtraction angiography (DSA) were perfect (κ = 1.00, p < 0.001) in terms of aneurysm occlusion. Rate of stent occlusion and stenosis in DSA, TOF, and MRA, respectively, were as follows: 0 and 12.5%, 16.6 and 70.8%, and 0 and 62.5%. Intermodality agreement values of TOF MRA and CE MRA with DSA were insignificant in terms of stent patency (κ = 0.065, p = 0.27; κ = 0.158, p = 0.15, respectively). Interobserver agreement was substantial in both TOF MRA (κ = 0.71, p < 0.001) and CE MRA (κ = 0.64, p = 0.001). Both TOF and CE MRA techniques have strong concordance with DSA for the detection of aneurysm occlusion status. CE MRA can be used as a first-line noninvasive imaging modality due to its superiority to TOF MRA with respect to the visualization of in-stent signals.

The LUNA aneurysm embolization system for intracranial aneurysm treatment: short-term, mid-term and long-term clinical and angiographic results

Background and purposeIntrasaccular aneurysm flow disruption represents an emerging endovascular approach to treat intracranial aneurysms. The purpose of this study was to determine the clinical and angiographic outcomes of using...

The second-generation eCLIPs Endovascular Clip System: initial experience.

OBJECTIVE Treatment of wide-necked intracranial aneurysms is associated with higher recanalization and complication rates; however, the most commonly used methods are not specifically designed to work in bifurcation lesions. To address these issues, the authors describe the evolution in the design and use of the eCLIPs (Endovascular Clip System) device, a novel hybrid stent-like assist device with flow diverter properties that was first described in 2008. METHODS A registry was established covering 13 international centers at which patients were treated with the second-generation eCLIPs device. Aneurysm morphology and rupture status, device neck coverage, coil retention, and procedural and late morbidity and mortality were recorded. For those patients who had undergone successful implantation more than 6 months earlier, the final imaging and clinical follow-up results and need for re-treatment were recorded. RESULTS Thirty-three patients were treated between June 2013 and September 2015. Twenty-five (76%) patients had successful placement of an eCLIPs device; 23 (92%) of these 25 patients had complete data. Eight cases of nondeployment occurred during the 1st year of use, consistent with a learning curve; no failures of deployment occurred thereafter. Two periprocedural transient ischemic attacks and 2 asymptomatic thrombotic events occurred. Twenty-one (91%) of 23 patients underwent follow-up at an average of 8 months (range 3-18 months); 9 (42.9%) of these 21 patients demonstrated an improvement in Raymond grade at follow-up; no cases of worsening Raymond grade were recorded, and 17 (81.0%) patients sustained a modified Raymond-Roy Classification class of I or II angiographic result at follow-up. Two delayed ruptures were recorded, both in previously coiled, symptomatic giant aneurysms where the device was used as a part of a salvage strategy. CONCLUSIONS The second-generation eCLIPs device is a viable treatment option for bifurcation aneurysms. The aneurysm occlusion rates in this initial clinical series are comparable to the initial experience with other bifurcation support devices.

The use of flow diverters to treat small (≤5 mm) ruptured, saccular aneurysms.

Background:There is limited published literature on the use of flow diverting stents (FDS) to treat ruptured intracranial aneurysms in the acute stage. We present our experience of using FDS to treat small (≤5 mm) ruptured aneurysms.Methods:We retrospectively identified all patients with ≤5 mm ruptured aneurysms treated exclusively with FDS between February 2009 and February 2016. We recorded demographic data, the Hunt and Hess score, aneurysm location and size, therapeutic intervention, immediate angiographic and clinical result, and clinical and radiological follow-up information.Results:We identified seven patients (four females) with average age 59.8 ± 10 years (range 48–75). The average aneurysm fundus size was 2.7 ± 0.76 mm (range 1–4 mm). The average time from ictus to treatment was 6.3 days (range 1–14 days) and there were no cases of repeat rupture prior to treatment or intraoperative rupture. Angiographic follow-up was available in five patients. At initial follow-up, aneurysms (100%) were completely occluded raymond roy classification 1 (RRC 1). None of the aneurysms re-ruptured following treatment. Clinically, six patients were discharged with good functional outcome modified Rankin Score (mRS ≤2). There were no mortalities.Conclusion:The use of FDS to treat small, ruptured, saccular aneurysms is feasible; however, the use of FDS should not be considered first-line treatment. Further studies are required to determine the safety and efficacy of the use of FDS in the acute situation.

The pCONus2 Neck-Bridging Device: Early Clinical Experience and Immediate Angiographic Results.

Treating wide-necked aneurysms is challenging for the interventional neuroradiologist. Recently, numerous devices dedicated to the treatment of these aneurysms have become available. We report our early experience using the pCONus2 device and present the technical success rate, clinical outcomes, and immediate angiographic occlusion rates. We performed a retrospective review of prospectively collected data to identify patients treated with the pCONus2 device between February 2015 and February2017. We identified 12 patients (10 females) treated with the pCONus2 device. The average patient age was56.6 ± 15.8 years (range, 13-71 years). The average aneurysm dome width was 8.83 ± 5.3 mm (range, 3.8-20mm), the average dome height was 7.23 ± 4.06 mm (range, 3.36-15 mm), and the average neck width was 5.88 ± 2.92 mm (range, 2.77-11 mm). The angulation of the aneurysm to the parent vessel varied between 0 and 78°(mean, 32.2°). Ten aneurysms were located in the anterior circulation, and 2 were in the posterior circulation. Immediate posttreatment angiography showed 11 aneurysms with modified Raymond-Roy classification (mRRC) grade I occlusion and 1 aneurysm with mRRC grade II occlusion. There were no deaths or hemorrhagic complications. Three patients developed small thrombi during treatment, all of whom were successfully treated with glycoprotein IIb/IIIa antagonists. Early angiographic follow-up data for 6 patients showed adequate aneurysm occlusion in 5 patients and aneurysm recanalization in 1patient. The early results on the use of the pCONus2 device suggest that it can be useful for treating wide-necked aneurysms; however, larger studies with longer-term follow-up data are needed.

Simple Coiling versus Stent-Assisted Coiling of Paraclinoid Aneurysms: Radiological Outcome in a Single Center Study.

ObjectiveParaclinoid aneurysms are a group of aneurysms arising at the distal internal carotid artery. Due to a high incidence of small, wide-necked aneurysms in this zone, it is often challenging to achieve complete occlusion when solely using detachable coils, thus stent placement is often required. In the present study, we aimed to investigate the effect of stent placement in endovascular treatment of paraclinoid aneurysms.MethodsData of 98 paraclinoid aneurysms treated by endovascular approach in our center from August 2005 to June 2016 were retrospectively reviewed. They were divided into two groups: simple coiling and stent-assisted coiling. Differences in the recurrence and progressive occlusion between the two groups were mainly analyzed. The recurrence was defined as more than one grade worsening according to Raymond-Roy Classification or major recanalization that is large enough to permit retreatment in the follow-up study compared to the immediate post-operative results.ResultsComplete occlusion was achieved immediately after endovascular treatment in eight out of 37 patients (21.6%) in the stent-assisted group and 18 out of 61 (29.5%) in the simple coiling group. In the follow-up imaging studies, the recurrence rate was lower in the stent-assisted group (one out of 37, 2.7%) compared to the simple coiling group (13 out of 61, 21.3%) (p=0.011). Multivariate logistic regression model showed lower recurrence rate in the stent-assisted group than the simple coiling group (odds ratio [OR] 0.051, 95% confidence interval [CI] 0.005–0.527). Furthermore there was also a significant difference in the rate of progressive occlusion between the stent-assisted group (16 out of 29 patients, 55.2%) and the simple coiling group (10 out of 43 patients, 23.3%) (p=0.006). The stent-assisted group also exhibited a higher rate of progressive occlusion than the simple coiling group in the multivariate logistic regression model (OR 3.208, 95% CI 1.106–9.302).ConclusionUse of stents results in good prognosis not only by reducing the recurrence rate but also by increasing the rate of progressive occlusion in wide-necked paraclinoid aneurysms. Stent-assisted coil embolization can be an important treatment strategy for paraclinoid aneurysms when considering the superiority of long term outcome.

Erratum. The second-generation eCLIPs Endovascular Clip System: initial experience.

OBJECTIVE Treatment of wide-necked intracranial aneurysms is associated with higher recanalization and complication rates; however, the most commonly used methods are not specifically designed to work in bifurcation lesions. To address these issues, the authors describe the evolution in the design and use of the eCLIPs (Endovascular Clip System) device, a novel hybrid stent-like assist device with flow diverter properties that was first described in 2008. METHODS A registry was established covering 13 international centers at which patients were treated with the second-generation eCLIPs device. Aneurysm morphology and rupture status, device neck coverage, coil retention, and procedural and late morbidity and mortality were recorded. For those patients who had undergone successful implantation more than 6 months earlier, the final imaging and clinical follow-up results and need for re-treatment were recorded. RESULTS Thirty-three patients were treated between June 2013 and September 2015. Twenty-five (76%) patients had successful placement of an eCLIPs device; 23 (92%) of these 25 patients had complete data. Eight cases of nondeployment occurred during the 1st year of use, consistent with a learning curve; no failures of deployment occurred thereafter. Two periprocedural transient ischemic attacks and 2 asymptomatic thrombotic events occurred. Twenty-one (91%) of 23 patients underwent follow-up at an average of 8 months (range 3-18 months); 9 (42.9%) of these 21 patients demonstrated an improvement in Raymond grade at follow-up; no cases of worsening Raymond grade were recorded, and 17 (81.0%) patients sustained a modified Raymond-Roy Classification class of I or II angiographic result at follow-up. Two delayed ruptures were recorded, both in previously coiled, symptomatic giant aneurysms where the device was used as a part of a salvage strategy. CONCLUSIONS The second-generation eCLIPs device is a viable treatment option for bifurcation aneurysms. The aneurysm occlusion rates in this initial clinical series are comparable to the initial experience with other bifurcation support devices.

Management of Unruptured Saccular Aneurysms of the M1Segment with Flow Diversion : ASingle Centre Experience.

The optimal strategy for the treatment of M1segment aneurysms has not yet been determined as both standard microneurosurgical and endovascular techniques can pose challenges. We sought to determine the efficacy of flow diverting stents to treat small, unruptured aneurysms of the M1segment. We retrospectively reviewed our database of prospectively collected information for all patients treated with flow diversion for an unruptured saccular aneurysm of the middle cerebral artery (MCA) between February 2009 and February 2016. The relationship to early cortical branches, aneurysm fundus size, number and type of flow diverting stent (FDS), complications and follow-up data were recorded. In total 15patients were identified that matched our inclusion criteria (11female and 4male). The average age of the patients was 58.3years (range 14-76years). All patients had asingle aneurysm affecting the M1segment of the MCA, 10 (66.6%) of which were related to early cortical branches and 10 aneurysms were located on the left (66.6%). The average aneurysm fundus size was 3 mm (range 2-9 mm) and 13 patients had follow-up angiographic studies. In total, 8aneurysms were completely excluded, and 6 remained incompletely occluded (3 modified Raymond-Roy classification [mRRC]II and 3 mRRCIIIa). One patient suffered astroke and another patient had an iatrogenic vessel dissection that was not flow limiting. Flow diversion can be used to treat small, unruptured aneurysms of the M1segment of the MCA and even though side vessel occlusion can occur clinically relevant infarction occurs infrequently.

Validation of the Modified Raymond–Roy classification for intracranial aneurysms treated with coil embolization

BackgroundThe Raymond–Roy Occlusion Classification (RROC) qualitatively assesses intracranial aneurysm occlusion following endovascular coil embolization. The Modified Raymond–Roy Classification (MRRC) was developed as a refinement of this classification scheme, and dichotomizes...

Survival analysis of risk factors for major recurrence of intracranial aneurysms after coiling.

Recurrence after intracranial aneurysm coiling is a highly prevalent outcome, yet to be understood. We investigated clinical, radiological and procedural factors associated with major recurrence of coiled intracranial aneurysms. We retrospectively analyzed prospectively collected coiling data (2003-12). We recorded characteristics of aneurysms, patients and interventional techniques, pre-discharge and angiographic follow-up occlusion. The Raymond-Roy classification was used; major recurrence was a change from class I or II to class III, increase in class III remnant, and any recurrence requiring any type of retreatment. Identification of risk factors associated with major recurrence used univariate Cox Proportional Hazards Model followed by multivariate regression analysis of covariates with P<0.1. A total of 467 aneurysms were treated in 435 patients: 283(65%) harboring acutely ruptured aneurysms, 44(10.1%) patients died before discharge and 33(7.6%) were lost to follow-up. A total of 1367 angiographic follow-up studies (range: 1-108 months, Median [interquartile ranges (IQR)]: 37[14-62]) was performed in 384(82.2%) aneurysms. The major recurrence rate was 98(21%) after 6(3.5-22.5) months. Multivariate analysis (358 patients with 384 aneurysms) revealed the risk factors for major recurrence: age>65 y (hazard ratio (HR): 1.61; P=0.04), male sex (HR: 2.13; P<0.01), hypercholesterolemia (HR: 1.65; P=0.03), neck size ≥4 mm (HR: 1.79; P=0.01), dome size ≥7 mm (HR: 2.44; P<0.01), non-stent-assisted coiling (HR: 2.87; P=0.01), and baseline class III (HR: 2.18; P<0.01). Approximately one fifth of the intracranial aneurysms resulted in major recurrence. Modifiable factors for major recurrence were choice of stent-assisted technique and confirmation of adequate baseline occlusion (Class I/II) in the first coiling procedure.

An update to the Raymond–Roy Occlusion Classification of intracranial aneurysms treated with coil embolization

BackgroundThe Raymond–Roy Occlusion Classification (RROC) is the standard for evaluating coiled aneurysms (Class I: complete obliteration; Class II: residual neck; Class III: residual aneurysm), but not all Class III aneurysms...