Treatment Of Anterior Circulation Aneurysms Research Articles

Comparison of clinical efficacy and safety between interventional embolization and craniotomy clipping for anterior circulation aneurysms.

To investigate the clinical efficacy and safety of interventional embolization in the treatment of anterior circulation aneurysms. Eighty patients with anterior circulation aneurysms admitted to People's Hospital of Leshan from June 2019 to December 2021 were retrospectively analyzed. According to the different surgical methods, they were divided into two groups: the observation group and the control group. Patients in the observation group were given interventional embolization, while those in the control group were given craniotomy clipping. The surgical efficacy, postoperative neurological function and quality of life, surgical prognosis and surgical complications of the two groups were compared. The intraoperative blood loss and hospitalization time in the observation group were lower than those in the control group (p<0.05). The scores of the Hunt-Hess and modified Rankin scale in the observation group were significantly lower than those in the control group three months after surgery (p<0.05). The good prognosis rate of the observation group was higher than that of the control group (p<0.05). Moreover, the complication rate of the observation group was 12.50%, which was significantly lower than 32.50% in the control group (p<0.05). Interventional embolization shows the advantages of minimally invasive procedures such as shorter operative times and shorter hospital stays. It has better clinical safety because it can significantly improve the neurological function and quality of life of patients, improve the prognosis of patients, and reduce the incidence of complications.

Multiple Pipeline Embolization Devices for the Treatment of Complex Intracranial Aneurysm: A Multi-Center Study.

BackgroundThe Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial primarily demonstrated the safety and efficacy of the implantation of multiple pipeline embolization devices (multi-PEDs) for large/giant intracranial aneurysms. However, no study has focused on when, why, or how to apply multi-PEDs.ObjectiveThe purpose of this study was to investigate the indications and strategies of using multi-PEDs for complex intracranial aneurysms.MethodsPatients who had been treated with two or more PEDs were included in the post-market multicenter registry study from 2014 to 2019, across 14 centers in China. Indications, strategies, perioperative safety, and clinical outcomes were retrospectively analyzed. The modified Rankin scale (mRS) score was used to evaluate clinical outcomes comprehensively, and the O’Kelly–Marotta (OKM) grading scale was used to evaluate aneurysm healing results.ResultsA total of 55 intracranial aneurysms were treated with multi-PEDs. There were 20 fusiform aneurysms with a large range, 25 large/giant saccular aneurysms, six aneurysms with failed treatment, and four aneurysms with greatly varied diameters of the parent artery. The strategies included telescope techniques in 40 patients and overlap techniques in 15 patients. In total, 120 stents were deployed in 55 patients. The operation styles included 25 patients (55.6%) with two PEDs, 21 patients (38.2%) with two PEDs combined with coiling, four patients (7.3%) with three PEDs, four patients (7.3%) with three PEDs combined with coiling, and one patient (1.8%) with four PEDs. Angiography revealed OKM D in two, OKM C in seven, and OKM A and B in 46 cases after surgery. During the perioperative period, eight patients developed neurological dysfunction, three of whom died. A total of thirty-four patients were followed up with digital subtraction angiography for 2–45 (8.2 ± 8.0) months. Angiography revealed OKM D in 26, OKM C in five, and OKM B in three. At the last follow-up, the mRS score was 0–1 in 52 patients.ConclusionThe treatment of anterior circulation aneurysms with multi-PEDs is safe and effective. The implantation of multi-PEDs could be considered for large-scale fusiform aneurysms, large/giant saccular aneurysms with a jet-sign, salvage of failed PED treatments, and in cases where the diameter of the parent artery varies greatly.

Endovascular Treatment of Anterior Circulation Aneurysms With the p64 Flow Modulation Device: Mid- and Long-Term Results in 617 Aneurysms From a Single Center

Endovascular Treatment of Anterior Circulation Aneurysms With the p64 Flow Modulation Device: Mid- and Long-Term Results in 617 Aneurysms From a Single Center

Clinicoradiological profile and outcome of microsurgical clipping of ruptured anterior circulation aneurysms: A single-institute experience

Introduction:Prevalence of intracranial aneurysms is estimated to be from 1% to 5% of population, most of them are small and located in the anterior circulation. The real danger is when an aneurysm ruptures, leading to a subarachnoid hemorrhage (SAH). SAH is a catastrophic event with a mortality rate of 25% to 50%. Permanent disability occurs in nearly 50% of the survivors. Fifteen percent of patients expire before reaching the hospital and 25% die within 24 h. The purpose of our study is to report the clinicoradiological data and outcome of microsurgical clipping of ruptured anterior circulation aneurysms in our center.Materials and Methods:This study included ruptured anterior circulation aneurysms admitted to tertiary care hospital in northern India from January 2018 to June 2020. The final outcome of patients was analyzed with Glasgow Outcome Score (GOS) at the time of discharge from the hospital.Results:A total of 53 patients with ruptured anterior circulation aneurysm underwent microsurgical clipping comprising 25 (47.2%) males and 28 (52.8%) females. The mean neck size of all aneurysms was 3.43 ± 1.66 mm. The mean hospital stay was longer in patients having preoperative intraventricular hemorrhage (IVH) (35.96 ± 27.27 days) and postoperative complications (43.36 ± 29.76 days) compared to patients who did not have IVH (21.10 ± 15.47 days) and postoperative complications (18 ± 6.54 days). P value was ≤0.05. Patients with preoperative hydrocephalus had GOS 3.44 ± 1.20 at discharge compared to nonhydrocephalus who had GOS 4.32 ± 1.07 (P = 0.009). Patients with Intracerebral Hemorrhage (ICH) and non-ICH had GOS 3.31 ± 1.38 and 4.28 ± 1.01, respectively (P = 0.009).Conclusion:Poor outcome at the time of discharge after the surgical treatment of anterior circulation aneurysms was associated with poor world federation of neurological surgeons grade on admission, presence of IVH, hydrocephalus, intracerebral hemorrhage, and postoperative cerebral infarcts.

Endovascular Treatment of Anterior Circulation Aneurysms With the p64 Flow Modulation Device: Mid- and Long-Term Results in 617 Aneurysms From a Single Center.

BACKGROUNDFlow diverters have become an important tool in the treatment of intracranial aneurysms, especially when dealing with difficult-to-treat or complex aneurysms. The p64 is the only fully resheathable and mechanically detachable flow diverter available for clinical use.OBJECTIVETo evaluate the safety and effectiveness of p64 for the treatment of intracranial saccular unruptured aneurysms arising from the anterior circulation over a long-term follow-up period.METHODSWe retrospectively reviewed our prospectively maintained database to identify all patients who underwent treatment for an intracranial saccular (unruptured or beyond the acute hemorrhage phase) aneurysm arising from the anterior circulation with ≥1 p64 between December 2011 and December 2019. Fusiform aneurysms and dissections were excluded. Aneurysms with prior or concomitant saccular treatment (eg, coiling and clipping) were included. Aneurysms with parent vessel implants other than p64 were excluded. Anatomic features, intraprocedural complications, clinical outcome, as well as clinical and angiographic follow-ups were all recorded.RESULTSIn total, 530 patients (388 females; median age 55.9 yr) with 617 intracranial aneurysms met the inclusion criteria. The average number of devices used per aneurysm was 1.1 (range 1-3). Mean aneurysm dome size was 4.8 mm (range 1-27 mm). Treatment-related morbimortality was 2.4%. Early, mid-term, and long-term angiographic follow-up showed complete or near-complete aneurysm occlusion in 76.8%, 89.7%, and 94.5%, respectively.CONCLUSIONTreatment of intracranial saccular unruptured aneurysms of the anterior circulation using p64 is a safe and effective treatment option with high rate of occlusion at long-term follow-up and low morbimortality.

Remote cerebellar hemorrhage after microsurgical treatment of anterior circulation aneurysms: a single centre 8-year experience

Remote cerebellar hemorrhage after microsurgical treatment of anterior circulation aneurysms: a single centre 8-year experience

The Pipeline Embolization Device: Changes in Practice and Reduction of Complications in the Treatment of Anterior Circulation Aneurysms in a Multicenter Cohort.

The Pipeline Embolization Device (PED; Medtronic, Dublin, Ireland) has become an important tool for the treatment of cerebral aneurysms. Since FDA approval, there are ongoing efforts to increase aneurysm occlusion rates and reduce the incidence of complications. To assess aneurysm occlusion and complication rates over time. Retrospective analysis of consecutive anterior circulation aneurysms treated with a single PED between 2011 and 2016 at 3 academic institutions in the US was performed. Factors contributing to changes in aneurysm occlusion and complication rates over time were identified and evaluated. A total of 284 procedures were performed on 321 anterior circulation aneurysms in 284 patients. At a median follow-up of 13 mo (mean 18 mo), complete or near complete occlusion (>90%) was achieved in 85.9% of aneurysms. There was no significant change in aneurysm occlusion rate or procedure length over time. Thromboembolic complication occurred in 8.1% of procedures, and there was a trend toward decreased incidence from 16.3% in 2011/2012 to 3.3% in 2016 (P=.14). Hemorrhagic complications significantly decreased from 8.2% in 2011/2012 to 0 to 1.0% in 2014-2016 (P=.1). We report a notable drop in the rate of hemorrhagic and to a lesser extent thromboembolic complications with increased experience with PED in a multicenter cohort. Multiple factors are believed to contribute to this drop, including the evolved interpretation of platelet function testing, the switching of clopidogrel nonresponders to ticagrelor, and the reduced use of adjunctive coiling.

Treatment of Anterior Circulation Aneurysms in the Internal Carotid Artery With Flow Diverters.

Several studies have shown the efficacy and feasibility of flow diversion for the endovascular treatment of wide-necked and otherwise anatomically challenging intracranial aneurysms (IA). Technological advances have led to successful long-term occlusion rates and a safety profile for flow-diverter stents that parallels other endovascular and open surgical options for these lesions. With growing indications for use of the Pipeline Embolization Device (PED, Medtronic, Dublin, Ireland) to include IAs up to the internal carotid artery (ICA) terminus, understanding the nuances of this technology is increasingly relevant. Furthermore, there is a growing body of literature on the use of flow diversion to treat distal (up to A2, M2, and P2), ruptured, and posterior circulation aneurysms, although these applications are "off-label" at present. In this manuscript, we discuss the expanding role of flow diversion in the ICA and compare this technique with other endovascular options for the treatment of ICA IAs. We also discuss technical nuances of the deployment of flow diverters for the treatment of challenging lesions and in difficult and tortuous anatomy.

Minimally Invasive Aneurysm Clipping: The Extent of the Supraorbital Approach

The supraorbital keyhole craniotomy is a well-established minimally invasive approach for the treatment of intracranial aneurysms. However, the surgical range of exposure using this technique for treatment of intracranial aneurysms has not been studied. We retrospectively reviewed the data of all clipped aneurysm cases using the supraorbital approach (SO) between 2006 and 2016 in our center. Most importantly, we determined the location of the treated aneurysms in the axial 2-dimensional plane, with the anterior clinoid process (ACP) as the point of reference: the ACP to aneurysm distance. Finally, we extracted data on patient age, aneurysm size, size of the craniotomy, length of hospital stay, and surgery-related complications. We included 142 patients for this series. A total of 170 aneurysms were clipped by means of the SO, and in 18 cases multiple aneurysms were treated during the same surgery. The mean aneurysm size was 7 mm (3.5-22 mm) and the mean craniotomy size was 28 mm (19-41 mm). The aneurysm location ranged from 14.4 mm medially to 35 mm laterally, measured with the ipsilateral ACP as the zero reference. Although the SO is conventionally used in the treatment of anterior circulation aneurysms, we were able to treat aneurysms over a range of 50 mm over the skull base. With its low complication risk, relatively short hospital stay, and excellent cosmetic results, SO remains a valuable treatment option for both young and aged patients.

A Comparative Study between Supraorbital Keyhole and Pterional Approaches on Anterior Circulation Aneurysms.

BackgroundMany different conventional approaches such as the frontal and pterional approaches are used to access anterior circulation aneurysms. Recently, the supraorbital approach has been widely applied to the treatment of anterior circulation aneurysms. This study was done to evaluate which approach (pterional or supraorbital) has better outcomes in terms of residual neck post-clipping, cosmetic satisfaction, scar tenderness, complications and functional outcomes.MethodologyA total of 123 patients were recruited into this study, comprising 82 patients who underwent a pterional approach and 41 patients who underwent a supraorbital approach. Computed tomography angiograms, the modified Rankin Scale, and the visual analogue scale were administered at 6 months to look for residual aneurysm, functional outcomes, scar tenderness, and cosmetic satisfaction. Complication data were collected from patients’ case notes.ResultsThe mean operating time for the pterional group was 226 min, compared to supraorbital group, which was 192 min (P = 0.07). Cosmetic satisfaction was significantly higher (P = 0.001) in the supraorbital group. There was no significant difference between the supraorbital and pterional groups’ scar tenderness (P = 0.719), residual aneurysm (P = 0.719), or functional outcomes (P = 0.137), and there was no significant difference between the groups in terms of intra-operative and post-operative complications.ConclusionsThe supraorbital group had better cosmetic outcomes and shorter operating times compared to the pterional group.

8-F balloon guide catheter for embolization of anterior circulation aneurysms: an institutional experience in 152 patients.

ABSTRACTThe use of 8-F balloon guide catheter (BGC) for proximal flow control was previously shown to prevent distal embolic complications during mechanical clot retrieval in patients with acute ischemic stroke. In this retrospective study, the utility of 8-F BGCs for proximal flow control during endovascular coiling of anterior circulation aneurysms was investigated. Patients who underwent endovascular coiling for anterior circulation aneurysms between August 2013 and December 2016 were retrospectively analyzed. Among a total of 152 patients included in this series, 64 patients presented with aneurysmal rupture, whereas the aneurysms were detected incidentally or due to mass effects in the remaining patients. 8-F BGCs were successfully navigated in all patients. The balloon was inflated during navigation in 19 patients. Inflation of the catheter balloon during coil embolization was required in 34 patients; this was performed as an emergency maneuver in six of these patients. Thromboembolic complications occurred in one patient. 8-F BGC can be effectively used for proximal flow control during endovascular treatment of anterior circulation aneurysms. The other advantages included improved navigation of tortuous arterial anatomy, coil stabilization during aneurysmal coiling, and freedom to utilize aneurysmal neck-remodeling balloons for additional adjunctive techniques or to deploy rescue stents. This novel approach might be safely and effectively used in patients undergoing endovascular treatment for anterior circulation aneurysms.

Flow diversion for the treatment of posterior inferior cerebellar artery aneurysms: a novel classification and strategies

BackgroundThe pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, treatment of posterior inferior cerebellar...

A survey of intracranial aneurysm treatment practices among United States physicians

BackgroundRecent surveys have failed to examine cerebrovascular aneurysm treatment practices among US physicians.ObjectiveTo survey physicians who are actively involved in the care of patients with cerebrovascular aneurysms to determine current...

Parent vessel occlusion after Pipeline embolization of cerebral aneurysms of the anterior circulation.

OBJECTIVE The Pipeline Embolization Device (PED) is now a well-established option for the treatment of giant or complex aneurysms, especially those arising from the anterior circulation. Considering the purpose of such treatment is to maintain patency of the parent vessel, postembolization occlusion of the parent artery can be regarded as an untoward outcome. Antiplatelet therapy in the posttreatment period is therefore required to minimize such events. Here, the authors present a series of patients with anterior circulation aneurysms treated with the PED who subsequently experienced parent vessel occlusion (PVO). METHODS The authors performed a retrospective review of all anterior circulation aneurysms consecutively treated at a single institution with the PED through 2014, identifying those with PVO on follow-up imaging. Aneurysm size and location, number of PEDs used, and follow-up digital subtraction angiography results were recorded. When available, pre- and postembolization platelet function testing results were also recorded. RESULTS Among 256 patients with anterior circulation aneurysms treated with the PED, the authors identified 8 who developed PVO after embolization. The mean aneurysm size in this cohort was 22.3 mm, and the number of PEDs used per case ranged from 2 to 10. Six patients were found to have asymptomatic PVO discovered incidentally on routine follow-up imaging between 6 months and 3 years postembolization, 3 of whom had documented "delayed" PVO with prior postembolization angiograms confirming aneurysm occlusion and a patent parent vessel at an earlier time. Two additional patients experienced symptomatic PVO, one of which was associated with early discontinuation of antiplatelet therapy. CONCLUSIONS In this large series of anterior circulation aneurysms, the authors report a low incidence of symptomatic PVO, complicating premature discontinuation of postembolization antiplatelet or anticoagulation therapy. Beyond the subacute period, asymptomatic PVO was more common, particularly among complex fusiform or very large-necked aneurysms, highlighting an important phenomenon with the use of PED for the treatment of anterior circulation aneurysms, and suggesting that extended periods of antiplatelet coverage may be required in select complex aneurysms.

Pentaxial access platform for ultra-distal intracranial delivery of a large-bore hyperflexible DIC (distal intracranial catheter): A technical note

Abstract Background Intracranial access techniques in modern neurointervention are shifting towards more robust access platforms. We present in this report a novel method of navigating a 5 French distal intracranial catheter (DIC) deep within the intracranial circulation in an atraumatic fashion via a pentaxial access system. Methods We retrospectively reviewed all neurointerventions performed at two author institutions identifying all aneurysm treatments where the pentaxial system was used to build the catheter support for intracranial positioning of a 5 French DIC. Procedural data collected include parent artery tortuosity, use of vasodilator, intra-procedural DIC position, and peri-procedural complications. Results The pentaxial access platform provided ultra-distal intracranial navigation of the 5 French DIC in the following 11 neurointerventions for treatment of anterior circulation aneurysms: Pipeline embolization device (PED) for anterior communicating artery (ACom) aneurysm, n = 2; surpass for large internal carotid artery (ICA) aneurysm, n = 4; Woven EndoBridge (WEB) device for ACom aneurysm, n = 5. Mean patient age was 55 ± 11 years (range 40–75 years). Mean aneurysm size was 6.7 mm ± 3.8 mm (range 2–16 mm). Mean fluoroscopy time was 29 ± 16.7 min. Intra-procedural DIC positions achieved included supraclinoid ICA (n = 6), M1 (n = 4), and A1 (n = 1). No significant catheter-related complications occurred. Conclusion Distal intracranial catheters can achieve ultra-distal intracranial positions safely with the pentaxial access platform. This technique is a near no step-off, atraumatic method of navigating a DIC in a stepwise fashion over de-escalating smaller diameter catheters via a microwire. Familiarity with catheter specifications including diameters and length is essential for the success of this system.

Pipeline endovascular device for the treatment of intracranial aneurysms at the level of the circle of Willis and beyond: multicenter experience

Background and purposeThe aim of our study was to evaluate the safety and efficacy of the pipeline endovascular device for the treatment of anterior circulation aneurysms at the level of...

Efficacy and safety of the pterional keyhole approach for the treatment of anterior circulation aneurysms.

Keyhole surgery is partly replacing the standard pterional approach in patients undergoing surgery to treat aneurysms of the anterior circulation. We describe the pterional keyhole approach for the clipping of anterior circulation aneurysms and discuss the efficacy and safety of our keyhole craniotomy procedure. We treated 103 patients with 111 intracranial aneurysms by surgical clipping via the pterional keyhole approach and retrospectively compared the characteristics and clinical outcomes of the keyhole procedure and the standard pterional approach. We also compared the surgical results of the keyhole approach when the operator was an experienced neurosurgeon or a less experienced neurosurgeon guided by an experienced colleague. All keyhole operations were carried out successfully without enlargement of the craniotomy or a change to a different approach. The outcomes of the keyhole and the standard pterional approach in patients with subarachnoid hemorrhage were not significantly different. Favorable outcomes were obtained in patients with unruptured aneurysms treated by either experienced or less experienced surgeons. The pterional keyhole approach offers the same surgical possibilities as conventional pterional approaches for the treatment of anterior circulation aneurysms. It is safe and simple and yields favorable outcomes even if the operators are less experienced neurosurgeons. Careful patient selection and sufficient opening of the sylvian fissure are the key points for good outcomes and the prevention of intraoperative complications.

E-056 Pipeline Endovascular Device for the Treatment of Intracranial Aneurysm at the Level of the Circle of Willis and Beyond: Multicenter Experience

Background and purposeThe aim of our study was to evaluate the safety and eficacy of the Pipeline endovascular device for the treatment of anterior circulation aneurysms at the level of...

Surgical Management of Symptomatic Posterior Circulation Aneurysms

Surgical treatment of posterior circulation aneurysms is more difficult than surgical treatment of anterior circulation aneurysms and poses a greater technical challenge for the practicing neurosurgeon. There are different surgical options available for the surgical treatment of posterior circulation aneurysms despite the use of the pterional approach to anterior circulation aneurysms. We present our surgical experiences with three cases of posterior circulation aneurysms. Three cases of posterior circulation aneurysms were treated by surgical clipping. We preferred pterional approach for posterior cerebral artery aneurysms, infratentorial supracerebellar approach for superior cerebellar aneurysm, and the combined lateral supracerebellar infratentorial retrosigmoid approach for vertebrobasilar junction aneurysm. The morbidity and mortality associated with open surgery for posterior circulation aneurysms are higher because of the location of the aneurysms within the posterior fossa. For neurosurgeons, the surgical treatment of posterior circulation aneurysms can be challenging.

A safety, length of stay, and cost analysis of minimally invasive microsurgery for anterior circulation aneurysms

The aim of our study was to evaluate minimally invasive techniques for the treatment of anterior circulation aneurysms versus standard surgery, and to calculate the impact of these techniques on health resources, length of stay, and treatment costs. A consecutive series of 24 patients with ruptured and 30 with unruptured anterior circulation aneurysms treated with minimally invasive microsurgery (MIM) by the same surgeon was compared with a matched series of standard microsurgeries (SM) conducted for 23 ruptured and 22 unruptured aneurysms. Complication rates, aneurysm obliteration, modified Rankin Scale (mRS) outcomes, length of stay, and treatment costs were assessed. Surgical complications, aneurysm obliteration rates and mRS outcomes were comparable between MIM and SM groups in ruptured and unruptured aneurysm cohorts. MIM resulted in shorter operative times both in unruptured (102.7 ± 4.35 vs 194.7 ± 10.26 min, p < 0.0001) and ruptured aneurysms (124.3 ± 827 vs 209 ± 13.84 min, p < 0.0001). Length of stay was reduced in patients with MIM for unruptured aneurysms (1.55 ± 24 vs 4.28 ± 0.71 days, p < 0.000,1) but not in those with ruptured aneurysms. MIM reduced treatment costs of unruptured aneurysm patients, mainly through reduced utilization of inpatient resources (non-acute bed costs in CAD: 371.2 ± 80.99 vs 1440 ± 224.1, p < 0.0001), whereas costs were comparable in patients with ruptured aneurysms. Minimally invasive surgery is a safe and effective approach for the treatment of ruptured and unruptured aneurysms of the anterior circulation. In patients with unruptured aneurysms, reduced invasiveness and shorter operative times decreased length of stay, which reflects improved patient postoperative recovery. Overall, this translated into bed resource economy and cost reduction.