Recurrent Intracranial Aneurysms Research Articles

Efficacy and safety of flow diverters in retreatment of recurrent intracranial aneurysms-A systematic review and meta-analysis.

Treatment of recurrent intracranial aneurysms after their initial therapy has been a significant challenge in the field of neurointervention. Recently flow diverters stents are widely used for treating intracranial aneurysms. In this systematic review and meta-analysis, we assessed the safety and efficacy of flow diverter in treating recurrent or recanalized intracranial aneurysms. This meta-analysis is reported following the PRISMA 2020 guidelines. We conducted a systematic review of literature in the PubMed, Embase, Web of Sciences, and Scopus databases. Pooled prevalence and the corresponding 95% are calculated from extracted data using a random-effect model. The systematic literature search included 21 studies involving 411 patients, with 135 (32.8%) being male and 276 (67.2%) being females with a total number of 447 aneurysms. The overall rate of adequate occlusion was 90.67% (95% CI: 84.23%-94.65%), and the rates were comparable between the surgery (93.48%), coiling (91.78%), and stenting (85.77%) groups. The overall pooled rate of complete occlusion was 81.80 (95% CI: 71.14%-89.13%). On doing a subgroup analysis, the complete occlusion rates were 89.68%, 84.39%, and 73.47% for the surgery, coiling, and stenting groups, respectively. The overall mortality rate and achieving modified Rankin scale score of 0-2 was 1.28% (95% CI: 0.45%-3.64%) and (95% CI: 89.92%-97.84%), respectively. No significant heterogeneity is noted in the included studies. Flow diverter stents are an effective and safe method for retreating recurrent or residual intracranial aneurysms with a high rate of complete and adequate occlusion. The rate of mortality, intracerebral hemorrhage, and overall and procedural complications following using flow diverters for intracranial aneurysms is low.

Microsurgical management of recurrent intracranial aneurysm after endovascular treatment: a series of 60 consecutive patients

OBJECTIVE The aim of this study was to evaluate the morbidity associated with microsurgical treatment in patients with a recurrent aneurysm to improve their surgical management. METHODS From 2012 to 2022, among the 3128 patients with ruptured or unruptured intracranial aneurysms managed at the authors’ institution, 954 patients were treated by a microsurgical procedure. Of these 3128 patients, 60 consecutive patients (6.3%) who had a recurrent microsurgically treated aneurysm after previous endovascular treatment were included in this study. Additional microsurgical treatment was considered in case of progressive remnant growth or significant aneurysm recurrence. Intraoperative and postoperative complications were noted. Early (< 7 days) and long-term clinical and radiological monitoring were performed. Good functional outcome was considered as a modified Rankin Scale score < 3. RESULTS The mean age at initial treatment was 45 years (range 26–65 years). The mean delay between the first treatment and microsurgical treatment of the recurrence was 64 months (range 2 days–296 months). The mean size of the fundus recurrence was 5 mm, and the mean size of the neck recurrence was 4.6 mm. Five patients (8.3%) presented with subarachnoid hemorrhage associated with rupture of the recurrent aneurysm. Three patients died (6%) of aneurysm rupture and/or intensive care complications. The total morbidity rate associated with the microsurgical procedure was 14.5% (8/55) in patients with unruptured recurrent aneurysms. Among these patients, postoperative definitive complications (ischemic lesions) directly related to the microsurgical procedure were present in 3 patients (5.5%). Intraoperative rupture was recorded in these 3 patients. In the 54 surviving patients with unruptured recurrent aneurysms, good functional outcome was noted in 49 (91%). Poor functional outcome was significantly associated with intraoperative rupture. CONCLUSIONS Microsurgery remains an effective therapeutic option for recurrent intracranial aneurysms. However, in the authors’ experience, postoperative morbidity is higher than in patients with nonrecurrent aneurysms. Therefore, a pretherapeutic multidisciplinary evaluation is mandatory to reduce the potential morbidity associated with the retreatment as much as possible. When endovascular occlusion of the aneurysm requires both stenting and coiling, alternative microsurgical treatment should be carefully evaluated, as microsurgical clipping will become much more challenging in cases of aneurysm recurrence.

Surgical Treatment Strategies for Residual or Recurrent Intracranial Aneurysms Following Endovascular Embolization.

To explore how to effectively manage the residual or recurrent intracranial aneurysms after embolization. The authors retrospectively reviewed our experience of endovascular interventional therapy, surgical clipping, and cerebrovascular bypass surgery in the treatment of residual or recurrent aneurysms after embolization at the authors' institution from 2018 to 2022. The Glasgow Outcome Scale of 28 patients after the procedure and at discharge showed that 24 recovered well, 3 had severe disability, and 1 died. During the 24-month follow-up, 26 had a good recovery, 1 suffered from disability, and 1 died. Two cases of aneurysm recurrence were detected, and both were treated through endovascular therapy. Among them, 1 case underwent a repeat endovascular embolization, and 1 case was switched to surgical clipping. No residual aneurysms were observed in the remaining patients who underwent bypass surgery, and their bypass grafts were all patent. Based on the clinical status of patients, aneurysmal characteristics, surgical risk, and possibility of rerupture of aneurysms, an individualized strategy was proposed for residual or recurrent aneurysms after embolization. The use of endovascular interventional therapy or surgical clipping can be safely and effectively managed, and cerebrovascular bypass surgery can effectively manage complex aneurysms.

Woven endo bridge device for recurrent intracranial aneurysms: A systematic review and meta-analysis.

Recurrent intracranial aneurysms present a significant clinical challenge, demanding innovative and effective treatment approaches. The Woven EndoBridge (WEB) device has emerged as a promising endovascular solution for managing these intricate cases. This study aims to assess the safety and efficacy of the WEB device in treating recurrent intracranial aneurysms. We conducted a comprehensive search across multiple databases, including PubMed, Scopus, Embase, and Web of Science, from inception to June 5, 2023. Eligible studies focused on evaluating WEB device performance and included a minimum of five patients with recurrent intracranial aneurysms. The complete and adequate occlusion rates, neck remnant rates, and periprocedural complication rates were pooled using SATA V.17. Our analysis included five studies collectively enrolling 73 participants. Participant ages ranged from 52.9 to 65 years, with 64.4% being female. Aneurysms were wide-necked and predominantly located in the middle cerebral artery, basilar artery, and anterior cerebral artery. Previous treatments encompassed coiling, clipping, and the use of WEB devices. Our study found an overall adequate occlusion rate of 0.80 (95% CI 0.71-0.89), a complete occlusion rate of 0.39 (95% CI 0.28-0.50), and a neck remnant rate of 0.38 (95% CI 0.27-0.48). Periprocedural complications were reported at a rate of 0%, although heterogeneity was observed in this data. Notably, evidence of publication bias was identified in the reporting of periprocedural complication rates. Our findings suggest that the WEB device is associated with favorable outcomes for treating recurrent wide-neck intracranial aneurysms.

Tubridge flow diverter for the treatment of recurrent cerebral aneurysms

Background & Objective: The Tubridge flow diverter is a commonly used device in China for reconstructing the parental artery and occluding complex intracranial aneurysms. However, there is limited experience with the device in treating recurrent intracranial aneurysms. The purpose of this study is to assess the safety and effectiveness of the Tubridge flow diverter in treating recurrent single- coiling aneurysms. Methods: The clinical records of patients with recurrent intracranial aneurysms who were treated with a Tubridge flow diverter were reviewed to show the therapeutic process, occlusion rate, and clinical outcomes associated with this treatment method. Results: Five patients with recurrent aneurysms of the internal carotid artery after singe coiling were included in the study. The recurrent aneurysmal sac had a mean length and width of 8.34/4.30 mm. All five Tubridge flow diverters were implanted without any unfold failure. The last angiographic follow-up showed a complete occlusion rate of 100%. Five branch arteries were covered, and only one branch artery disappeared during follow-up. No cases of cerebral infarction or intracranial hemorrhage were found among the patients. Conclusions: Our initial findings indicate that the Tubridge flow diverter could be a reliable and successful method for treating recurring single-coil aneurysms. We observed that the branch arteries were well-preserved, and no patients experienced cerebral infarction or hemorrhage. However, further research is necessary to establish clear indications and potential complications through a multicenter randomized controlled trial with long-term follow-up.

Surgical treatment of intracranial aneurysm recurrence after clipping

Surgical treatment of intracranial aneurysm recurrence after clipping

A predictive model for the recurrence of intracranial aneurysms following coil embolization.

This study aimed to identify risk factors for intracranial aneurysms (IAs) recurrence and establish a predictive model to aid evaluation. A total of 302 patients with 312 IAs undergoing coil embolization between September 2017 and October 2022 were divided into two groups based on digital subtraction angiography follow-up. Clinical characteristics, operation-related factors, and morphologies were measured. Cox proportional hazard regression was used to identify the risk factors. Hazard ratios (HRs) were used to score points, and a predictive model was established. The test cohorts consisted of 51 IAs. Receiver operating characteristic curves were generated to determine the cutoff values and area under the curves (AUCs). A Delong test was performed to compare the AUCs. Diameter maximum (D max) (p < 0.001, HR = 1.221), Raymond-Roy occlusion classification (RROC) II or III (p = 0.004, HR = 2.852), and ruptured status (p < 0.001, HR = 7.782) were independent risk factors for the recurrence of IAs. A predictive model was established: D max + 2 * RROC (II or III; yes = 1, no = 0) + 6 * ruptured status (yes = 1; no = 0). The AUC of the predictive model (0.818) was significantly higher than those of D max (0.704), RROC (II or III) (0.645), and rupture status (0.683), respectively (Delong test, p < 0.05). The cutoff values of the predictive model and D max were 9.75 points and 6.65 mm, respectively. The D max, RROC (II or III), and ruptured status could independently predict the recurrence of IAs after coil embolization. Our model could aid in practical evaluations.

Aneurysm Treatment with Woven EndoBridge-17: Angiographic and Clinical Results at 12 Months from a Retrospective, 2-Center Series.

This retrospective, 2-center study investigated the feasibility, safety, and efficacy at 12-month follow-up of the treatment of ruptured, unruptured, and recurrent intracranial aneurysms using the latest generation of the Woven EndoBridge (WEB) device, the WEB-17 system. Aneurysms treated with WEB-17 were extracted from the databases of 2 neurovascular centers. Patients, aneurysm characteristics, complications, and clinical and anatomic results were analyzed. From February 2017 to May 2021, two hundred twelve patients with 233 aneurysms (181/233, 77.7%, unruptured-recurrent, and 52/233, 22.3%, ruptured) were included. High treatment feasibility (95.3%) was reported and was similar in ruptured aneurysms (94.2%) and unruptured-recurrent aneurysms (95.6%) (P = .71) and in typical (95.4%) and atypical (94.7%) locations (P = .70), but it was lower in aneurysms with an angle between the parent artery and main aneurysm axis of ≥45° (90.2%) compared with those with an angle of <45° (97.1%) (P = .03). Global mortality and morbidity were 1.9% and 3.8% at 1 month, respectively, and 4.4% and 1.9% at 12 months, respectively. One-month morbidity (P = .02) and mortality (P = .003) were higher in the ruptured group (10.0% and 8.0%, respectively) compared with unruptured-recurrent group (1.9% and 0.0%, respectively). Overall adequate occlusion (complete occlusion and neck remnant) was 86.3%. The percentage of adequate occlusion was higher (P = .05) in the unruptured-recurrent group (88.5%) compared with the ruptured group (77.5%). The WEB-17 system showed high feasibility for ruptured and unruptured aneurysms, typical and atypical locations, and some aneurysms with an angle of ≥45°. As the most recent generation device, the WEB-17 also demonstrates high safety and good efficacy.

Risk of intracranial aneurysm recurrence after microsurgical clipping based on 3D digital subtraction angiography.

Current knowledge of recurrence rates after intracranial aneurysm (IA) surgery relies on 2D digital subtraction angiography (DSA), which fails to detect more than 75% of small aneurysm remnants. Accordingly, the discrimination between recurrence and growth of a remnant remains challenging, and actual assessment of recurrence risk of clipped IAs could be inaccurate. The authors report, for the first time, 3D-DSA-based long-term durability and risk factor data of IA recurrence and remnant growth after microsurgical clipping. Prospectively collected data for 305 patients, with a total of 329 clipped IAs that underwent baseline 3D-DSA, were evaluated. The incidence of recurrent IA was described by Kaplan-Meier curves. Risk factors for IA recurrence were analyzed by multivariable Cox proportional hazards and logistic regression models. The overall observed proportion of IA recurrence after clipping was 2.7% (9 of 329 IAs) at a mean follow-up of 46 months (0.7% per year). While completely obliterated IAs did not recur during follow-up, incompletely clipped aneurysms (76 of 329) demonstrated remnant growth in 11.8% (3.4% per year). Young age and large initial IA size significantly increased the risk of IA recurrence. The findings support those in previous studies that hypothesized that completely clipped IAs have an extremely low risk of recurrence. Conversely, the results highlight the significant risk posed by incompletely clipped IAs. Young patients with initial large IAs and incomplete obliteration have an especially high risk for IA recurrence and therefore should be monitored more closely.

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

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

Risk factors for repeated recurrence of cerebral aneurysms treated with endovascular embolization.

PurposeTo explore the risk factors of recurrence after second endovascular embolization of recurrent aneurysms and the characteristics of recurrent refractory aneurysms to help clinical decision-making.Materials and methodsForty-nine patients with recurrent aneurysms who underwent repeated embolization were retrospectively enrolled and divided into the recurrent and non-recurrent group. The risk factors of recurrence, complications and follow-up results of repeated embolization, and characteristics of recurrent refractory aneurysms were analyzed.ResultsAmong the 49 patients with the second embolization, 5 were lost to follow-up, 9 recurred, and 35 did not. Univariate analysis showed that aneurysm size (P = 0.022), aneurysm classification (P = 0.014), and Raymond-Roy grade after the second embolization (P = 0.001) were statistically different between the two groups. Multivariate analysis demonstrated the Raymond-Roy grade as an independent risk factor for the recurrence of aneurysms after the second embolization (P = 0.042). The complication rate after the second embolization was 4%. There were five recurrent refractory aneurysms with an average aneurysm size of 23.17 ± 10.45 mm, including three giant aneurysms and two large aneurysms. To achieve complete or near-complete embolization of the recurrent refractory aneurysms, multiple treatment approaches were needed with multiple stents or flow diverting devices.ConclusionAneurysm occlusion status after the second embolization is an independent risk factor for the recurrence of intracranial aneurysms. Compared with near-complete occlusion, complete occlusion can significantly reduce the risk of recurrence after second embolization. In order to achieve complete or near-complete occlusion, recurrent refractory aneurysms need multiple treatments with the use of multiple stents or flow diverting devices.

Flow diverter retreatment for intracranial aneurysms: A meta-analysis of efficacy and feasibility.

Recurrent intracranial aneurysm carries a risk of rupture and retreatment is often necessary. However, there is no consensus on the best retreatment modality of choice. Flow diverter has emerged as a promising option for this population in recent years. Given its high cost, patient selection to optimize outcomes is very important. To identify patient factors predisposing to failure of flow diverter retreatment. We conducted a systematic search on PubMed, Cochrane Library, Embase, Ovid/Medline, and ClinicalTrial.gov from 2000 to 2021. Studies regarding flow diverter retreatment of recurrent aneurysms were analyzed if they meet the inclusion criteria. A total of twenty-six studies were identified. Among 374 patients retreated with flow diverters, about 0.86 [0.81; 0.92] were successfully occluded and only 0.06 [0.02; 0.10] had unfavorable neurological outcomes. Major complications included intracranial hemorrhage (n = 7), ischemic stroke or thromboembolic event (n = 12), and death (n = 2). In-stent stenosis was reported in 10 of the cases. Saccular aneurysms are associated with a higher occlusion rate while aneurysm location, size, status, and prior treatment modality have no significant impact on retreatment efficacy. We demonstrated that flow diverter is an effective retreatment strategy except in patients with non-saccular aneurysms. It should be considered as a first-line option for patients with recurrent intracranial aneurysm.

Synthetic Time of Flight Magnetic Resonance Angiography Generation Model Based on Cycle-Consistent Generative Adversarial Network Using PETRA-MRA in the Patients With Treated Intracranial Aneurysm.

Pointwise encoding time reduction with radial acquisition (PETRA) magnetic resonance angiography (MRA) is useful for evaluating intracranial aneurysm recurrence, but the problem of severe background noise and low peripheral signal-to-noise ratio (SNR) remain. Deep learning could reduce noise using high- and low-quality images. To develop a cycle-consistent generative adversarial network (cycleGAN)-based deep learning model to generate synthetic TOF (synTOF) using PETRA. Retrospective. A total of 377 patients (mean age: 60 ± 11; 293 females) with treated intracranial aneurysms who underwent both PETRA and TOF from October 2017 to January 2021. Data were randomly divided into training (49.9%, 188/377) and validation (50.1%, 189/377) groups. Ultra-short echo time and TOF-MRA on a 3-T MR system. For the cycleGAN model, the peak SNR (PSNR) and structural similarity (SSIM) were evaluated. Image quality was compared qualitatively (5-point Likert scale) and quantitatively (SNR). A multireader diagnostic optimality evaluation was performed with 17 radiologists (experience of 1-18 years). Generalized estimating equation analysis, Friedman's test, McNemar test, and Spearman's rank correlation. P < 0.05 indicated statistical significance. The PSNR and SSIM between synTOF and TOF were 17.51 [16.76; 18.31] dB and 0.71 ± 0.02. The median values of overall image quality, noise, sharpness, and vascular conspicuity were significantly higher for synTOF than for PETRA (4.00 [4.00; 5.00] vs. 4.00 [3.00; 4.00]; 5.00 [4.00; 5.00] vs. 3.00 [2.00; 4.00]; 4.00 [4.00; 4.00] vs. 4.00 [3.00; 4.00]; 3.00 [3.00; 4.00] vs. 3.00 [2.00; 3.00]). The SNRs of the middle cerebral arteries were the highest for synTOF (synTOF vs. TOF vs. PETRA; 63.67 [43.25; 105.00] vs. 52.42 [32.88; 74.67] vs. 21.05 [12.34; 37.88]). In the multireader evaluation, there was no significant difference in diagnostic optimality or preference between synTOF and TOF (19.00 [18.00; 19.00] vs. 20.00 [18.00; 20.00], P=0.510; 8.00 [6.00; 11.00] vs. 11.00 [9.00, 14.00], P=1.000). The cycleGAN-based deep learning model provided synTOF free from background artifact. The synTOF could be a versatile alternative to TOF in patients who have undergone PETRA for evaluating treated aneurysms. 4 TECHNICAL EFFICACY: Stage 1.

Flow Diversion Therapy of Remnant and Recurrent Intracranial Aneurysms Treated Surgically.

To evaluate the safety and efficacy of flow diverter stents (FDSs) for treating remnant or recurrent intracranial aneurysms that were treated surgically. The patients who were treated with FDSs due to remnant or recurrent intracranial aneurysms after microsurgery were included in the study. The patients' demographics, treatment histories, aneurysm features, complications associated with flow diversion, and neurological and angiographic follow-up findings were evaluated. Twenty patients (eight males) with 20 aneurysms were included in the study. Of 20 aneurysms, 18 (90%) were in the anterior, and two (10%) were in the posterior circulation. The initial treatment methods were clipping in 17 (85%) and wrapping in three (15%) aneurysms. The endovascular procedure was successful in all patients. In three patients (15%), periprocedural and postprocedural complications were encountered. No hemorrhagic complications were detected on cone-beam computed tomography. One patient with a basilary aneurysm died because of brain stem ischemia. The total morbimortality was 5%. The mean length of follow-up was 13.7 ± 7.3 months in 18 patients. The first angiographic follow-up (3-6 months) revealed the complete occlusion in 7 of 11 aneurysms (63.6%). By contrast, 16 aneurysms (94.1%) were occluded at the last angiographic follow-up, one aneurysm (5.9%) was still filling. An FDS seems effective, safe, and extremely attractive in treating remnant and recurrent intracranial aneurysms treated surgically.

Risk of intracranial aneurysm recurrence after microsurgical clipping based on three-dimensional digital subtraction angiography

Risk of intracranial aneurysm recurrence after microsurgical clipping based on three-dimensional digital subtraction angiography

Hemodynamic Characteristics Associated with Recurrence of Middle Cerebral Artery Bifurcation Aneurysms After Total Embolization.

ObjectiveHemodynamic parameters are associated with the recurrence of intracranial aneurysms (IAs). Studies showed that high velocity and wall shear stress (WSS) were associated with IAs recurrence after endovascular treatment; nevertheless, factors such as small sample size, locations of IAs, and types of IAs (ie, sidewall or bifurcation) were neglected. The purpose of this study was to identify the hemodynamic characteristics associated with recurrence of middle cerebral artery bifurcation aneurysms (MCABAs) after total embolization by the method of computer fluid dynamics (CFD).MethodsFollowing inclusion criteria, we included 92 MCABAs treated with coils only after total embolization from January 2014 to January 2019. We segmented into recurrent and non-recurrent groups according to follow-up digital subtraction angiography (DSA). The MCABA models, including pre-operatively and immediate post-operatively, were reconstructed using 3D-DSAs. The hemodynamic parameters pre-operatively and immediately post-operatively between the groups were calculated and analyzed.ResultsThere were no significant differences between the recurrent and non-recurrent groups for spatially averaged wall shear stress (SAWSS), maximum wall shear stress (MWSS), velocity, or oscillatory shear index (OSI) at the neck pre-operatively. In the recurrent group, the WSS (22.02±5.11 vs 37.43±8.27 pa, p < 0.001), MWSS (42.59±17.02 vs 66.98±18.61 pa, p=0.014), velocity (0.86±0.19 vs 1.44±0.61 m/s, p=0.01) preoperatively were significantly higher than postoperative values. By contrast, in the non-recurrent group, the WSS (26.53±8.18 vs 22.29±8.64pa, p=0.002), MWSS (42.71±14.01 vs 37.15±15.56 pa, p=0.013), velocity (1.08±0.43 vs 0.23 (0.52, 0.57) m/s, p < 0.001) postoperatively were significantly lower than preoperative values. The OSI, whether in the recurrent group or the non-recurrent group, did not differ significantly between groups (p=0.79 and p=0.19).ConclusionHigher WSS (SAWSS, MWSS) and flow velocity at the aneurysm neck after embolization might be related to recurrence of bifurcation IAs. These might be applied to clinical post-embolization management for the evaluation of bifurcation IAs recanalization.

Surgical Clipping of Previously Coiled Recurrent Intracranial Aneurysms: A Single-Center Experience.

Objective: This study reviews our experiences in surgical clipping of previously coiled aneurysms, emphasizing on recurrence mechanism of intracranial aneurysms (IAs) and surgical techniques for different types of recurrent IAs.Method: We performed a retrospective study on 12 patients who underwent surgical clipping of aneurysms following endovascular treatment between January 2010 and October 2020. The indications for surgery, surgical techniques, and clinical outcomes were analyzed.Result: Twelve patients with previously coiled IAs were treated with clipping in this study, including nine females and three males. The reasons for the patients having clipping were as follows: early surgery (treatment failure in two patients, postoperative early rebleeding in one patient, and intraprocedural aneurysm rupture during embolization in one patient) and late surgery (aneurysm recurrence in five patients, SAH in one, mass effect in one, and aneurysm regrowth in one). All aneurysms were clipped directly, and coil removal was performed in four patients. One patient died (surgical mortality, 8.3%), 1 patient (8.3%) experienced permanent neurological morbidity, and the remaining 10 patients (83.4%) had good outcomes. Based on our clinical data and previous studies, we classified the recurrence mechanism of IAs into coil compaction, regrowth, coil migration, and coil loosening. Then, we elaborated the specific surgical planning and timing of surgery depending on the recurrence type of IAs.Conclusion: Surgical clipping can be a safe and effective treatment strategy for the management of recurrent coiled IAs, with acceptable morbidity and mortality in properly selected cases. Our classification of recurrent coiled aneurysms into four types helps to assess the optimal surgical approach and the associated risks in managing them.

Endovascular treatment of residual or recurrent intracranial aneurysms after surgical clipping.

ObjectiveTotal aneurysm occlusion is crucial for the prevention of rebleeding of a ruptured aneurysm or to avoid rupture of an unruptured lesion. Both surgical and endovascular embolization fail to achieve complete aneurysm occlusion in all the cases. The objective of the study was to establish the safety and efficacy of endovascular treatment for previously clipped residual or recurrent aneurysms.MethodsThis was an observational, retrospective study of patients harboring incompletely occluded intracranial aneurysms after clipping who underwent endovascular treatment. Patients were treated using 4 different techniques: (1) simple coiling, (2) balloon remodeling, (3) stent-assisted coiling, and (4) flow diversion. Analyses were performed to identify predictors of total aneurysm occlusion, recanalization and complications.ResultsBetween May 2010 and September 2018, 70 patients harboring incompletely occluded intracranial aneurysms after clipping met the inclusion criteria in 5 centers. The mean residual aneurysm size was 7.5 mm. Fifty-nine aneurysms were unruptured. Total aneurysm occlusion was achieved in 75.3% of the aneurysms after 1 year. All aneurysms treated with flow diversion revealed complete occlusion according to control angiography. Recanalization was observed in 14.5%. Permanent morbidity and mortality occurred in 2.9% and 1.4% of the patients, respectively.ConclusionsEndovascular treatment of recurrent or residual aneurysms after surgical clipping was safe and efficacious. Flow diversion seems to be associated with better anatomical results. A more rigid study, a larger group of patients, and long-term follow-up are required to provide stronger conclusions about the best approach for residual clipped aneurysms.

Treatment of recurrent and residual aneurysms with the low-profile Acandis Acclino stent: Multi-center review of 19 patients

ObjectiveTo evaluate the safety and efficacy of the low-profile Acandis Acclino microstent for embolization of recurrent and residual intracranial aneurysms. MethodsConsecutive patients treated with the Acclino for aneurysm remnants at three German neurovascular centers were enrolled. The technical success, complications, angiographic and clinical outcome were investigated. ResultsNineteen patients (median age: 53 years) with 19 aneurysm remnants (median size: 5 mm, anterior circulation: 14) were included. Initial aneurysm treatment consisted of stand-alone coiling in 14 cases, stent-assisted coiling in 4 and clipping in 1. Acclino stent-assisted coil embolization was performed technically successfully in all patients. Morbidity occurred in one patient (5.3%) due to aneurysm perforation. At the angiographic follow-up with a median follow-up duration of 21 months (range: 5–37 months), complete occlusion was obtained in 76.9%. The retreatment rate was 7.7%. ConclusionsRetreatment of aneurysm remnants with the Acclino microstent was associated with high aneurysm occlusion rates and acceptable morbidity. Further studies will be necessary to draw a definite conclusion.

The outcomes of recurrent wide-necked intracranial aneurysms treated with the Woven EndoBridge (WEB): A retrospective bicenter study

BackgroundThe Woven EndoBridge (WEB) is a device for the treatment of intracranial wide-necked bifurcation aneurysms. The safety and effectiveness of WEB for intracranial aneurysms have both been evaluated in previous trials. Our aim was to study the outcomes of recurrent intracranial aneurysms (IAs) treated with WEB. MethodsClinical and radiological outcomes of patients with a wide-necked aneurysm recurrence, which was treated with WEB device, were assessed. Imaging follow-up was performed with digital subtraction angiography and/or magnetic resonance angiography. Aneurysm occlusion was determined using by the Raymond-Roy Occlusion Classification (RROC). RROC 1 and RROC 2 were considered as adequate radiological outcome. ResultsTwenty-two patients with 23 recurrent IAs were treated with WEB. Of which, 17 of recurrent IAs (74%) previously treated by coiling, three (13%) by clipping and three (13%) by WEB. The most common location of the recurrent IA was the middle cerebral artery (n = 10, 43%). Endovascular treatment with WEB alone was suitable for 20 recurrent IAs (87%). Ancillary devices were also used: coils in two (9%), and a stent in one (4%). Radiological follow-up results available for all patients (range: 3–60 months; median 24 months). Adequate occlusion (RROC I and II) was achieved in 20 recurrent IAs (87%). A hemorrhagic complication occurred 2 weeks post treatment in one patient (5%). ConclusionsWEB could be an effective treatment with low rates of complications for challenging cases of recurrent wide-necked IAs.