endovascular

Anterior communicating artery aneurysm endovascular treatment complications

Anterior communicating artery aneurysm endovascular treatment complications

Intraprocedural aneurysm rupture and thrombus formation are serious complications during coiling of ruptured intracranial aneurysms, and they more often occur in patients with anterior communicating artery aneurysms.

It is associated with a high rate of complete angiographic occlusion. However, the procedure-related permanent morbidity and mortality are not negligible for aneurysms in this location 1).

Delgado Acosta et al. from Hospital Universitario Reina Sofía aimed to report the characteristics of patients suffering intra- or peri-procedural ruptures during embolization of cerebral aneurysms.

Between March 1994 and October 2021, 648 consecutive cerebral aneurysms were treated by the endovascular procedure. Medical records were reviewed retrospectively with emphasis on procedure description, potential risk factors, and clinical outcomes related to intra- or peri-procedural rupture.

Of the 648 patients, 17 (2.6%) suffered an intra- or peri-procedural hemorrhagic event. The most common location was the anterior communicating artery. There was no significant difference between previously ruptured and unruptured aneurysms in the incidence of bleeding. In four patients, bleeding was evident within 24 h after the procedure. The clinical evolution at three months was poor and only four patients presented a positive evolution. There were 11 deaths (64.71%). Balloon remodeling was associated with an increased frequency of ruptures, while stenting was a safer treatment.

Aneurysm rupture during endovascular therapy is unpredictable, and its occurrence can be devastating. The incidence is quite low although the outcome is frequently poor. Early detection and proper management, including prompt occlusion of the aneurysm, are important to achieve a positive outcome. Anterior communicating artery aneurysms and those treated with balloon catheters have a higher incidence of rupture. A small number of ruptures of uncertain origin occur that go unnoticed in digital subtraction angiograms 2).

The immediate and long-term outcomes, complications, recurrences and the need for retreatment were analyzed in a series of 280 consecutive patients with anterior communicating artery aneurysms treated with the endovascular technique. From October 1992 to October 2001 280 patients with 282 anterior communicating artery aneurysms were addressed to our center. For the analysis, the population was divided into two major groups: group 1, comprising 239 (85%) patients with ruptured aneurysms and group 2 comprising of 42 (15%) patients with unruptured aneurysms. In group 1, 185 (77.4%) patients had a good initial pre-treatment Hunt and Hess grade of I-III. Aneurysm size was divided into three categories according to the larger diameter: less than 4 mm, between 4 and 10 mm and larger than 10 mm. The sizes of aneurysms in groups 1 and 2 were identical but a less favorable neck to depth ratio of 0.5 was more frequent in group 2. Endovascular treatment was finally performed in 234 patients in group 1 and 34 patients in group 2. Complete obliteration was more frequently obtained in group 2 unlike a residual neck or opacification of the sac that were more frequently seen in group 1. No peri-treatment complications were recorded in group 2. In group 1 the peri-treatment mortality and overall peri-treatment morbidity were 5.1% and 8.1% respectively. Eight patients (3.4%) in group 1 presented early post treatment rebleeding with a mortality of 88%. The mean time to follow-up was 3.09 years. In group 1, 51 (21.7%) recurrences occurred of which 14 were minor and 37 major. In group 2, eight (23.5%) recurrences occurred, five minor and three major. Two patients (0.8%) presented late rebleeding in group 1. Twenty-seven second endovascular retreatments were performed, 24 (10.2%) in group 1 and three (8.8%) in group 2, seven third endovascular retreatments and two surgical clippings in group 1 only. There was no additional morbidity related to retreatments. Endovascular treatment is an effective method for the treatment of anterior communicating artery aneurysms allowing late rebleeding prevention. Peri-treatment rebleeding warrants caution in anticoagulation management. This is a single center experience and the follow-up period is limited. Patients should be followed-up in the long-term as recurrences may occur and warrant additional treatment 3).

Prolonged anterograde amnesia and disorientation after anterior communicating artery aneurysm coil embolization 4)

LVIS stent-assisted coiling for ruptured wide-necked ACoA aneurysms was safe and effective, with a relatively low rate of perioperative complications and a high rate of complete occlusion at follow-up 5)

1)

Fang S, Brinjikji W, Murad MH, Kallmes DF, Cloft HJ, Lanzino G. Endovascular treatment of anterior communicating artery aneurysms: a systematic review and meta-analysis. AJNR Am J Neuroradiol. 2014 May;35(5):943-7. doi: 10.3174/ajnr.A3802. Epub 2013 Nov 28. PMID: 24287090; PMCID: PMC7964525.
2)

Delgado Acosta F, Bravo Rey I, Jiménez Gómez E, Saucedo VR, Toledano A, Oteros Fernández R. Intra- or peri-procedural rupture in the endovascular treatment of intracranial aneurysms. Acta Neurol Scand. 2022 Aug 17. doi: 10.1111/ane.13686. Epub ahead of print. PMID: 35975464.
3)

Finitsis S, Anxionnat R, Lebedinsky A, Albuquerque PC, Clayton MF, Picard L, Bracard S. Endovascular treatment of ACom intracranial aneurysms. Report on series of 280 patients. Interv Neuroradiol. 2010 Mar;16(1):7-16. doi: 10.1177/159101991001600101. Epub 2010 Mar 25. PMID: 20377974; PMCID: PMC3277962.
4)

Al-Atrache Z, Friedler B, Shaikh HA, Kavi T. Prolonged anterograde amnesia and disorientation after anterior communicating artery aneurysm coil embolisation. BMJ Case Rep. 2019 Jul 30;12(7). pii: e230543. doi: 10.1136/bcr-2019-230543. PubMed PMID: 31366616.
5)

Xue G, Liu P, Xu F, Fang Y, Li Q, Hong B, Xu Y, Liu J, Huang Q. Endovascular Treatment of Ruptured Wide-Necked Anterior Communicating Artery Aneurysms Using a Low-Profile Visualized Intraluminal Support (LVIS) Device. Front Neurol. 2021 Jan 28;11:611875. doi: 10.3389/fneur.2020.611875. PMID: 33584512; PMCID: PMC7876256.

terior communicating artery aneurysm endovascular treatment complications

Anterior communicating artery aneurysm endovascular treatment

Anterior communicating artery aneurysm endovascular treatment

Endovascular treatment has been increasingly performed due to the fact that it is less likely to cause high dysfunction compared to surgery and the treatment has been improved. The International Subarachnoid Aneurysm Trial reported anterior communicating artery aneurysms to comprise 45.4% of cerebral aneurysms on which both endovascular treatment and surgery are suitable. The use of the endovascular treatment for anterior communicating artery aneurysms is expected to increase in the future 1).

With regard to the endovascular technique, firstly, many Anterior communicating artery aneurysm (AcoA aneurysms) have very small sacs, which makes it difficult to distinguish between the aneurysm neck and the microcatheter selection, leading to a few disadvantages.

The standard coil embolization technique is limited by its inability to occlude wide necked aneurysms. Stent deployment across the aneurysm neck supports the coil mass inside the aneurysmal sac, and furthermore, has an effect on local hemodynamic and biologic changes

In the cases of Choi et al., 17 of 112 aneurysms (15%) had very small sacs, and 15 of these patients (88%) were treated with surgical clipping 2).

The second disadvantage of endovascular treatment for AcoA aneurysms is poor controllability and track-ability due to arterial morphology and the acute angle during the endovascular procedure. Moret et al., 3) reported that the main causes of failure to embolize were loops in the cervical and intracranial vessels despite using the cervical approach when necessary and acute angle changes of the posterior projection of the aneurysm 4).

Furthermore, the lumen of the AcoA is relatively small, and remodeling neck techniques using balloons or stents is particularly difficult when treating wide neck or complex aneurysms Safe and complete endovascular occlusion of these aneurysms usually requires the assistance of combined approaches using balloons and stents in an individually tailored strategy 5).

The treatment modality of AcoA aneurysms is affected more by anatomic factors than other aneurysms. However, optimal treatment for AcoA aneurysms cannot be determined by any one anatomic characteristic; rather, all of the morphological features and clinical factors must be considered.

Many papers have emphasized the need for a collaborative approach to treatment strategies and have shown varying tendencies toward coiling or clipping 6)

The decision-making process during recent years has become increasingly more based on collaboration. All patient cases are discussed by a team including at least one endovascular specialist, one neurosurgeon, and one neurologist. Those presenting acutely are always routinely reviewed by both a surgeon and an endovascular radiologist.

In the study of Choi et al., correlated 5 clinical factors and 5 anatomical factors related to determining treatment modality with clinical and anatomical outcomes. Of the 5 clinical factors, age was the important factor in both uni and multivariate analysis. Older patients (age, >65 years) had significantly higher odds of being treated with coil embolization vs. clipping (adjusted OR, 3.78; 95% CI, 1.39-10.3; p=0.0093). The anatomical factors that affected initial treatment modality decision included aneurysm size (small or large vs. medium), neck size (<4 vs. ≥4) dome-to-neck ratio (<2 vs. ≥2), vessel incorporation, multiple lobulation, and morphologic score. Among these 5 anatomical factors, small or large size, dome-to-neck ratio <2, vessel incorporation, and morphologic score ≥2 were statistically significant in univariate analysis. In multivariate analysis, only morphologic score was statistically significant.

Patients with more than 2 unfavorable factors were treated with surgical clipping 4.34 times more often than with coil embolization. Furthermore, higher scoring patients had a higher tendency to be treated with surgical clipping

Balloon remodeling

Balloon remodeling should be considered for broad-based complex ACoA aneurysms. This technique provides a high rate of aneurysm occlusion with an acceptable complication profile, and avoids the need for dual antiplatelet therapy. The balloon trajectory will depend on aneurysm morphology and bilateral access may be useful in selected cases 7).

Complications

Intraprocedural aneurysm rupture and thrombus formation are serious complications during coiling of ruptured intracranial aneurysms, and they more often occur in patients with anterior communicating artery aneurysms.

Prolonged anterograde amnesia and disorientation after anterior communicating artery aneurysm coil embolization 8)

1)

Takeuchi M, Uyama A, Matsumoto T, Tsuto K. Endovascular Treatment for Anterior Communicating Artery Aneurysms. Adv Tech Stand Neurosurg. 2022;44:239-249. doi: 10.1007/978-3-030-87649-4_13. PMID: 35107683.
2)

Choi JH, Kang MJ, Huh JT. Influence of clinical and anatomic features on treatment decisions for anterior communicating artery aneurysms. J Korean Neurosurg Soc. 2011 Aug;50(2):81-8. doi: 10.3340/jkns.2011.50.2.81. Epub 2011 Aug 31. PubMed PMID: 22053224; PubMed Central PMCID: PMC3206283.
3)

Moret J, Pierot L, Boulin A, Castaings L, Rey A. Endovascular treatment of anterior communicating artery aneurysms using Guglielmi detachable coils. Neuroradiology. 1996;38:800–805.
4)

Proust F, Debono B, Hannequin D, Gerardin E, Clavier E, Langlois O, et al. Treatment of anterior communicating artery aneurysms : complementary aspects of microsurgical and endovascular procedures. J Neurosurg. 2003;99:3–14.
5)

Cohen JE, Melamed I, Itshayek E. X-microstenting and transmesh coiling in the management of wide-necked tent-like anterior communicating artery aneurysms. J Clin Neurosci. 2013 Nov 28. pii: S0967-5868(13)00496-7. doi: 10.1016/j.jocn.2013.09.003. [Epub ahead of print] PubMed PMID: 24291480.
6)

Cowan JA, Jr, Ziewacz J, Dimick JB, Upchurch GR, Jr, Thompson BG. Use of endovascular coil embolization and surgical clip occlusion for cerebral artery aneurysms. J Neurosurg. 2007;107:530–535.
7)

Moon K, Albuquerque FC, Ducruet AF, Crowley RW, McDougall CG. Balloon remodeling of complex anterior communicating artery aneurysms: technical considerations and complications. J Neurointerv Surg. 2014 Apr 28. doi: 10.1136/neurintsurg-2014-011147. [Epub ahead of print] PubMed PMID: 24778138.
8)

Al-Atrache Z, Friedler B, Shaikh HA, Kavi T. Prolonged anterograde amnesia and disorientation after anterior communicating artery aneurysm coil embolisation. BMJ Case Rep. 2019 Jul 30;12(7). pii: e230543. doi: 10.1136/bcr-2019-230543. PubMed PMID: 31366616.

Timing of endovascular treatment for aneurysmal subarachnoid hemorrhage

Timing of endovascular treatment for aneurysmal subarachnoid hemorrhage

An earlier approach may be relevant for the prevention of rebleeding and improvement of clinical outcome, but several disadvantages should be considered, such as an increased rate of periprocedural complications. Hence, a well-designed randomized controlled trial deems necessary to be able to define the optimal time of treatment. The possibility of treatment concomitant with the initial angiography should also be taken into account in this trial. This fact might represent a benefit favoring coiling over clipping in the prevention of rebleeding, and thus avoiding the inevitable delay necessary for the preparation for surgery 1).

Reviews

2017

To systematically review and meta-analyse the data on impact of timing of endovascular treatment in aneurysmal subarachnoid hemorrhage (SAH) to determine if earlier treatment is associated with improved clinical outcomes and reduced case fatality.

Rawal et al., searched MEDLINE, Cochrane database, EMBASE and Web of Science to identify studies for inclusion. The measures of effect utilised were unadjusted/adjusted ORs. Effect estimates were combined using random effects models for each outcome (poor outcome, case fatality); heterogeneity was assessed using the I2 index. Subgroup and sensitivity analyses were performed to account for heterogeneity and risk of bias.

16 studies met the inclusion criteria. Treatment <1 day was associated with a reduced odds of poor outcome compared with treatment >1 day (OR=0.40 (95% CI 0.28 to 0.56; I2=0%)) but not when compared with treatment at 1-3 days (OR=1.16 (95% CI 0.47 to 2.90; I2=81%)). Treatment at <2 days and at <3 days were associated with similar odds of poor outcome compared with later treatment (OR=1.20 (95% CI 0.70 to 2.05; I2=73%; OR=0.71 (95% CI 0.36 to 1.37; I2=71%)). Early treatment was associated with similar odds of case fatality compared with later treatment, regardless of how early/late treatment were defined (OR=1.80 (95% CI 0.88 to 3.67; I2=34%) for treatment <1 day vs days 1-3; OR=1.71 (95% CI 0.72 to 4.03; I2=54%) for treatment <2 days vs later; OR=0.90 (95% CI 0.31 to 2.68; I2=48%) for treatment <3 days vs later).

In only 1 of the analyses was there a statistically significant result, which favoured treatment <1 day. The inconsistent results and heterogeneity within most analyses highlight the lack of evidence for best timing of endovascular treatment in SAH patients 2).

Case series

Patients with intracranial aneurysms treated with embolization were divided into group A (n = 277), patients with ruptured aneurysms treated within 72 hours of SAH; group B (n = 138), patients with ruptured aneurysms treated beyond 72 hours; and group C (n = 93), patients with unruptured aneurysms.

Embolization was successful in all but four patients (99.2%). The periprocedural complication rate was 36.2% in group B, significantly (p < 0.05) greater than that in group A (24.5%) or group C (11.8%). The rebleeding rate was 9.7% (6/62 patients) in groups A and B after embolization and only 0.3% (1/346 patients) in aneurysms with total or subtotal occlusion. Of these three groups of patients, 69.7% in group A, 58.7% in group B, and 76.3% in group C achieved Glasgow Outcome Scale (GOS) score of 5 or modified Rankin Scale (mRS) score of 0- to 1 at discharge. A significant difference (p < 0.05) existed in the clinical outcome between the three groups. The percentages of patients without deficits (GOS 5 or mRS 0-1) and slight disability (mRS 2) were 80.2% in group A, 81.2% in group B, and 96.7% in group C. The mortality rate was 4.3% (12/277 patients) in group A and 7.2% (10/138 patients) in group B with no significant (p = 0.21) difference. Follow-up was performed at 3 to 54 months (mean 23.2), and the recanalization rate was 28.6% (32/112 patients) in group A, 22.4% (11/49 patients) in group B, and 28.6% (16/56 patients) in group C, with no significant differences (p = 0.15). Hydrocephalus occurred in 30.5% (39/128 patients) in group B, which was significantly (p < 0.01) greater than that in group A (9.4%) or group C (2.2%).

Early embolization of ruptured cerebral aneurysms within 72 hours of rupture is safe and effective and can significantly decrease periprocedural complications compared with management beyond 72 hours. Timely management of cisternal and ventricular blood can reduce hydrocephalus incidence and improve prognosis 3).

A database of patients with aneurysmal subarachnoid hemorrhage was analyzed who were confirmed by CT, and underwent endovascular treatment between January 2005 and January 2012,. The patients were grouped into four cohorts according to the timing of treatment: ultra-early cohort (within 24 hours of onset which was confirmed by CT), early cohort (between 24 and 72 hours of onset which was confirmed by CT), intermediate cohort (between 4 and 10 days of onset which was confirmed by CT) and delayed cohort (after 11 days of onset which was confirmed by CT). Patient demographics, aneurysms features and clinical outcomes were analyzed to evaluate safety and efficacy for timing of endovascular treatment among four cohorts. In our series of 664 patients, 269 patients were grouped into ultra-early cohort, 62 patients in early cohort, 218 patients in intermediate cohort, and 115 patients in delayed cohort. The patient demographics, aneurysm characteristics and neurological conditions on admission among groups showed no statistical significance. As a result of the 9-month follow-up with 513 patients, good outcome (mRS<2) was achieved in 78% patients in “ultra-early” cohort compared with that of 57% in the “intermediate” group(p=0.000), whereas other comparisons showed no statistical significance(p<0.05) among the four groups. Dividing the patients with dichotomized mRS into “good outcome” group and “poor outcome” group (mRS<2) at the 9-month follow-up, the results showed lower Hunt-Hess scores (p=0.000) and smaller size of aneurysms (p=.001) which were correlated with the good outcome. Hypertension (p=0.776), age (p=0.327), sex (p=0.551) and location (p=0.901) showed no statistical significance between groups. Endovascular treatment of aneurysmal subarachnoid hemorrhage which was confirmed by CT within 72 hours achieved better outcomes than that confirmed after 72 hours, especially in those patients treated within 24 hours of onset in comparison with patients treated between 4 and 10 days 4).

1)

Matias-Guiu JA, Serna-Candel C. Early endovascular treatment of subarachnoid hemorrhage. Interv Neurol. 2013 Mar;1(2):56-64. doi: 10.1159/000346768. Review. PubMed PMID: 25187768; PubMed Central PMCID: PMC4031770.
2)

Rawal S, Alcaide-Leon P, Macdonald RL, Rinkel GJ, Victor JC, Krings T, Kapral MK, Laupacis A. Meta-analysis of timing of endovascular aneurysm treatment in subarachnoid haemorrhage: inconsistent results of early treatment within 1 day. J Neurol Neurosurg Psychiatry. 2017 Jan 18. pii: jnnp-2016-314596. doi: 10.1136/jnnp-2016-314596. [Epub ahead of print] PubMed PMID: 28100721.
3)

Li XY, Li CH, Wang JW, Liu JF, Li H, Gao BL. Safety and Efficacy of Endovascular Embolization of Ruptured Intracranial Aneurysms within 72 hours of Subarachnoid Hemorrhage. J Neurol Surg A Cent Eur Neurosurg. 2021 Nov 17. doi: 10.1055/s-0041-1731752. Epub ahead of print. PMID: 34788868.
4)

Qian Z, Peng T, Liu A, Li Y, Jiang C, Yang H, Wu J, Kang H, Wu Z. Early timing of endovascular treatment for aneurysmal subarachnoid hemorrhage achieves improved outcomes. Curr Neurovasc Res. 2014 Feb;11(1):16-22. PubMed PMID: 24320010.

Unruptured intracranial aneurysm endovascular treatment

There is no randomized data available to compare the results of surgery versus endovascular treatment of unruptured aneurysms (UIAs) 1).

Unruptured intracranial aneurysm endovascular treatment can be performed with relative safety. The long-term follow-up results of unruptured intracranial aneurysm treatment (UIAs) by means of coil embolization remain unclear.

The efficacy of treatment as compared with observation has not been rigorously documented 2).

The use of coiling relative to surgical clipping of unruptured intracranial aneurysms is associated with decreasing periprocedural morbidity and mortality among patients treated in the United States from 2001 to 2008 3).

Koyanagi et al., from the National Hospital Organization Himeji Medical Center, Kyoto University Graduate School of Medicine, Kobe City Medical Center General Hospital, National Cerebral and Cardiovascular Center, Suita and Kokura Memorial Hospital Japan.

retrospectively analyzed data from cases in which patients underwent coil embolization between 1995 and 2004 at 4 stroke centers. In collecting the late (≥ 1 year) follow-up data, postal questionnaires were used to assess whether patients had experienced rupture or retreatment of a coiled aneurysm or any stroke or had died.

Overall, 184 patients with 188 UIAs were included. The median follow-up period was 12 years (interquartile range 11-13 years, maximum 20 years). A total of 152 UIAs (81%) were followed for more than 10 years. The incidence of rupture was 2 in 2122 aneurysm-years (annual rupture rate 0.09%). Nine of the 188 patients with coiled UIAs (4.8%) underwent additional treatment. In 5 of these 9 cases, the first retreatment was performed more than 5 years after the initial treatment. Large aneurysms were significantly more likely to require retreatment. Nine strokes occurred over the 2122 aneurysm-years. Seventeen patients died in this cohort.

This study demonstrates a low risk of rupture of coiled UIAs with long-term follow-up periods of up to 20 years. This suggests that coiling of UIAs could prevent rupture for a long period of time. However, large aneurysms might need to be followed for a longer time 4).

Bekelis et al., investigated the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm coiling.

Bekelis et al., performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent endovascular coiling for unruptured cerebral aneurysms between 2007 and 2012. To control for confounding, the authors used propensity score conditioning, with mixed effects to account for clustering at the hospital referral region level.

During the study period, there were 11,716 patients who underwent endovascular coiling for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 1186 (10.1%) underwent treatment performed by hybrid neurosurgeons, and 10,530 (89.9%) by proceduralists who performed only endovascular coiling. Multivariable regression analysis with propensity score adjustment demonstrated a lack of association of combined practice with 1-year postoperative mortality (OR 0.84; 95% CI 0.58-1.23), discharge to rehabilitation (OR 1.0; 95% CI 0.66-1.51), 30-day readmission rate (OR 1.07; 95% CI 0.83-1.38), and length of stay (adjusted difference, 0.41; 95% CI -0.26 to 1.09). Higher procedural volume was independently associated with improved outcomes.

In a cohort of Medicare patients, the authors did not demonstrate a difference in mortality, discharge to rehabilitation, readmission rate, and LOS between hybrid neurosurgeons and proceduralists performing only endovascular coiling 5) .

A portfolio of 41 cases of unruptured intracranial aneurysms with angiographic images, along with a short description of the patient presentation, was sent to 28 clinicians (16 radiologists and 12 surgeons) with varying years of experience in the management of unruptured intracranial aneurysms. Five senior clinicians responded twice at least 3 months apart. Nineteen cases (46%) were selected from patients recruited in the Canadian UnRuptured Endovascular versus Surgery trial, an ongoing randomized comparison of coil embolization and clip placement. For each case, the responder was to first choose between 3 treatment options (observation, surgical clip placement, or endovascular coil embolization) and then indicate their level of certainty on a quantitative 0-10 scale. Agreement in decision making was studied using κ statistics.

Decisions to coil were more frequent (n = 612, 53%) than decisions to clip (n = 289, 25%) or to observe (n = 259, 22%). Interjudge agreement was only fair (κ = 0.31 ± 0.02) for all cases and all judges, despite substantial intrajudge agreement (range 0.44-0.83 ± 0.10), with high mean individual certainty levels for each case (range 6.5-9.4 ± 2.0 on a scale of 0-10). Agreement was no better within specialties (surgeons or radiologists), within capability groups (those able to perform endovascular coiling alone, surgical clipping alone, or both), or with more experience. There was no correlation between certainty levels and years of experience. Agreement was lower when the cases were taken from the randomized trial (κ = 0.19 ± 0.2) compared with nontrial cases (κ = 0.35 ± 0.2).

Individuals do not agree regarding the management of unruptured intracranial aneurysms, even when they share a background in the same specialty, similar capabilities in aneurysm management, or years of practice. If community equipoise is a necessary precondition for trial participation, this study has found sufficient uncertainty and disagreement among clinicians to justify randomized trials 6).

For unruptured cerebral aneurysms, an observed perioperative survival advantage for endovascular coiling relative to that for surgical clipping was lost on long-term follow-up, according to data from an administrative database of patients who were not randomly allocated to treatment type. A cost advantage of endovascular treatment was maintained even though endovascularly treated patients were more likely to undergo subsequent hospitalizations for additional aneurysm repair procedures. Rates of aneurysm rupture following treatment were similar in the two groups 7).

Diffusion-weighted MR images (DWI) obtained after endovascular treatment of cerebral aneurysms frequently show multiple high-signal intensity (HSI) dots.

Aspiration of the inner content of the microcatheter right after detachable coil delivery was helpful for the reduction of the incidence of microembolisms after endovascular coil embolization for the treatment of unruptured cerebral aneurysms 8).

References

1)

Darsaut TE, Findlay JM, Raymond J; CURES Collaborative Group. The design of the Canadian UnRuptured Endovascular versus Surgery (CURES) trial. Can J Neurol Sci. 2011 Mar;38(2):236-41. PubMed PMID: 21320826; PubMed Central PMCID: PMC3528784.
2)

Naggara ON, White PM, Guilbert F, Roy D, Weill A, Raymond J. Endovascular treatment of intracranial unruptured aneurysms: systematic review and meta-analysis of the literature on safety and efficacy. Radiology. 2010 Sep;256(3):887-97. doi: 10.1148/radiol.10091982. Epub 2010 Jul 15. Review. PubMed PMID: 20634431.
3)

Brinjikji W, Rabinstein AA, Nasr DM, Lanzino G, Kallmes DF, Cloft HJ. Better outcomes with treatment by coiling relative to clipping of unruptured intracranial aneurysms in the United States, 2001-2008. AJNR Am J Neuroradiol. 2011 Jun-Jul;32(6):1071-5. doi: 10.3174/ajnr.A2453. Epub 2011 Apr 21. PubMed PMID: 21511860.
4)

Koyanagi M, Ishii A, Imamura H, Satow T, Yoshida K, Hasegawa H, Kikuchi T, Takenobu Y, Ando M, Takahashi JC, Nakahara I, Sakai N, Miyamoto S. Long-term outcomes of coil embolization of unruptured intracranial aneurysms. J Neurosurg. 2018 Jan 5:1-7. doi: 10.3171/2017.6.JNS17174. [Epub ahead of print] PubMed PMID: 29303448.
5)

Bekelis K, Gottlieb D, Labropoulos N, Su Y, Tjoumakaris S, Jabbour P, MacKenzie TA. The impact of hybrid neurosurgeons on the outcomes of endovascular coiling for unruptured cerebral aneurysms. J Neurosurg. 2016 Feb 26:1-7. [Epub ahead of print] PubMed PMID: 26918479.
6)

Darsaut TE, Estrade L, Jamali S, Bojanowski MW, Chagnon M, Raymond J. Uncertainty and agreement in the management of unruptured intracranial aneurysms. J Neurosurg. 2014 Jan 3. [Epub ahead of print] PubMed PMID: 24405069.
7)

Gonda DD, Khalessi AA, McCutcheon BA, Marcus LP, Noorbakhsh A, Chen CC, Chang DC, Carter BS. Long-term follow-up of unruptured intracranial aneurysms repaired in California. J Neurosurg. 2014 Jun;120(6):1349-57. doi: 10.3171/2014.3.JNS131159. Epub 2014 Apr 11. PubMed PMID: 24724850.
8)

Kim DY, Park JC, Kim JK, Sung YS, Park ES, Kwak JH, Choi CG, Lee DH. Microembolism after Endovascular Treatment of Unruptured Cerebral Aneurysms: Reduction of its Incidence by Microcatheter Lumen Aspiration. Neurointervention. 2015 Sep;10(2):67-73. doi: 10.5469/neuroint.2015.10.2.67. Epub 2015 Sep 2. PubMed PMID: 26389009.

Update: Middle cerebral artery aneurysm endovascular treatment with Flow Diverter

Middle cerebral artery aneurysm endovascular treatment with Flow Diverter

Flow diverter for middle cerebral artery aneurysm treatment should be considered an alternative when traditional treatment methods are not feasible 1).
When performed in a select treatment group, high rates of aneurysm occlusion and protection against re-rupture can be achieved 2).
Longer angiographic follow-ups are needed to assess the morphologic outcome; immediate subtotal occlusions do not seem to be related to rupture 3).
Findings suggest that complete occlusion after endovascular treatment with FDD can be delayed (>6 months). Ischemic complications may occur as early or delayed, particularly at clopidogrel interruption 4).
The Pipeline Embolization Device provides a safe and effective treatment alternative for wide-neck MCA aneurysms that give rise to a bifurcating or distal branch when other endovascular techniques are thought to be unfeasible or more risky 5).
WEB flow disruption seems to be a promising technique for the treatment of complex MCA aneurysms, particularly those with a wide neck or unfavorable dome-to-neck ratio 6).
For Caroff et al. compared with other available therapeutic options, the flow-diverter stent does not appear to be a suitable solution for the treatment of saccular MCA bifurcation aneurysms 7).
Unsatisfactory occlusion rate in bifurcation aneurysms likely results from residual filling of the aneurysms in cases in which the jailed side branch remains patent 8).

Systematic review and meta-analysis

A systematic search of PubMed, MEDLINE, and Embase was performed for studies published from 2008 to May 2017.
According to the Preferred Reporting Items for Systematic Reviews and MetaAnalyses, Cagnazzo et al. selected studies with >5 patients describing angiographic and clinical outcomes after flow-diversion treatment of MCA aneurysms.
Random-effects metaanalysis was used to pool the following outcomes: aneurysm occlusion rate, procedure-related complications, rupture rate of treated aneurysms, and occlusion of the jailed branches.
Twelve studies evaluating 244 MCA aneurysms were included in this meta-analysis. Complete/near-complete occlusion was obtained in 78.7% (95% CI, 67.8%-89.7%) of aneurysms. The rupture rate of treated aneurysms during follow-up was 0.4% per aneurysm-year. The rate of treatment-related complications was 20.7% (95% CI, 14%-27.5%), and approximately 10% of complications were permanent. The mortality rate was close to 2%. Nearly 10% (95% CI, 4.7%-15.5%) of jailed arteries were occluded during follow-up, whereas 26% (95% CI, 14.4%-37.6%) had slow flow. Rates of symptoms related to occlusion and slow flow were close to 5%.
Small and retrospective series could affect the strength of the reported results.
Given the not negligible rate of treatment-related complications, flow diversion for MCA aneurysms should be considered an alternative treatment when traditional treatment methods are not feasible. However, when performed in this select treatment group, high rates of aneurysm occlusion and protection against re-rupture can be achieved 9).

Case series

2017

Consecutive patients treated from January 2010 to December 2014 by Iosif et al. by using endovascular flow-diverting stents for MCA bifurcation aneurysms were evaluated retrospectively with prospectively maintained data. All patients had been followed for at least 12 months after treatment, with at least 2 control angiograms; regional flow-related angiographic modifications were registered by using a new angiographic outcome scale for flow diverters. Data were analyzed with emphasis on procedure-related events, angiographic results, and clinical outcome.
Fifty-eight patients were included in the study, with 63 MCA bifurcation aneurysms; 13 of these were large and giant. Pretreatment mRS was 0 for 12 patients (20.7%), 1 for 41 (70.7%), and 2 for 5 patients (8.6%). Six-month control revealed mRS 0-2 for 57 (98.3%) patients and 3 for 1 (1.7%) patient. Procedure-related morbidity and mortality were 8.6% (5/58) and 0%, respectively. From 95% of still circulating immediate postprocedure angiographic outcomes, 68% progressed to aneurysm occlusion at 6 months and 95%, to occlusion at 12 months, with a 0% aneurysm rupture rate.
Flow diverters seem to be an effective treatment alternative for complex MCA bifurcation aneurysms, with reasonable complication rates. Longer angiographic follow-ups are needed to assess the morphologic outcome; immediate subtotal occlusions do not seem to be related to rupture 10).

Bhogal et al. retrospectively reviewed there prospectively maintained database to collect information for all patients with unruptured saccular bifurcation MCA aneurysms treated with FDS between January 2010 and January 2016. In addition to demographic data, they recorded the location, aneurysm characteristics, previous treatments, number and type of FDS, complications, and clinical and angiographic follow-up.
The search identified 13 patients (7 males) with an average age of 61.7 years (47-74 years). All patients had a single bifurcation aneurysm of the MCA, and none of the aneurysms were acutely ruptured. The average fundus size of the saccular aneurysms was 3 mm (range 1.5-10 mm). Follow-up studies were available for 12 patients. Based on the most recent follow-up angiograms, six aneurysms (50%) were totally occluded; five aneurysms (41.7%) showed only a small remnant; and one aneurysm (8.3%) remained unchanged. One patient suffered from an ischemic stroke with resultant permanent hemiparesis (mRS 3). In another case, there was an in-stent thrombosis during the intervention, which resolved upon intra-arterial infusion of Eptifibatide (mRS 0). There were no intra-operative vessel or aneurysm ruptures and no mortalities. Angiography of the covered MCA branches showed no change in the caliber or flow of the vessel in six (50%), a reduction in caliber in five (41.7%), and a complete occlusion in one (8.3%). All caliber changes and occlusions of the vessels were asymptomatic.
91.7% of treated MCA bifurcation aneurysms were either completely occluded or showed only a small remnant with a good safety profile. Flow diversion of MCA bifurcation aneurysms should be considered as an alternative treatment strategy when microsurgical clipping or alternative endovascular treatment options are not feasible 11).

2016

Patients with MCAAs were treated by flow diversion if surgical or other endovascular treatment modalities had failed or were deemed likely to fail. Angiographic and clinical outcome of these patients was assessed retrospectively. Aneurysm location on MCA was defined as M1 segment, “true bifurcation” (classical bifurcation of MCA into superior and inferior trunks), “variant bifurcation” (bifurcation of early frontal or early/distal temporal branches), or M2 segment. Aneurysm morphology was classified as saccular versus dissecting/fusiform.
Treatment was attempted in 29 MCAAs. Technical failure rate was 3.4% (1/29). Thirteen of aneurysms were fusiform. Of the bifurcation aneurysms, most (10/16) were the variant type. Overall and procedure-related mortality/permanent morbidity rates were 10.3% (3/29) and 3.5% (1/29). Total occlusion rates (mean angiographic follow-up 10.3 months) for saccular and fusiform aneurysms were 40% and 75%, respectively. In bifurcation aneurysms, occlusion was strongly associated with side-branch occlusion (P < 0.005).
In this series, flow diversion for the treatment of MCAAs was safe, was effective in the treatment of fusiform MCAAs, and was not as effective at mid-term for MCA bifurcation aneurysms. Unsatisfactory occlusion rate in bifurcation aneurysms likely results from residual filling of the aneurysms in cases in which the jailed side branch remains patent 12).

Fourteen patients with 15 aneurysms were included in the study. Ischemic complications, as confirmed by MR imaging, occurred in 6 patients (43%). Procedure-related morbidity and mortality at last follow-up were 21% and 0%, respectively. Angiographic follow-up was available for 13 aneurysms, with a mean follow-up of 16 months. Complete occlusion was obtained for 8 aneurysms (62%).
Compared with other available therapeutic options, the flow-diverter stent does not appear to be a suitable solution for the treatment of saccular MCA bifurcation aneurysms 13).

From February 2010 to December 2013, 14 patients (10 women; mean age 59 years) with 15 small MCA aneurysms were treated with FDD. All procedures were performed with the Pipeline embolization device (PED).
Complete occlusion was obtained in 12/15 aneurysms (80%) and partial occlusion in 3 (20%). Among 13 aneurysms with a side branch, this was patent at the angiographic control in 4 cases, showed decreased filling in 6, and was occluded in 3 (with neurological deficits in 2). All PEDs were patent at follow-up. Post-procedural ischemic complications occurred in 4 (27%) procedures with permanent neurological deficit (modified Rankin score 2) in 3 (21%). No early or delayed aneurysm rupture, no subarachnoid or intraparenchymal hemorrhage and no deaths occurred.
Endovascular treatment with FDD is a relatively safe treatment for small MCA aneurysms resulting in a high occlusion rate. The findings suggest that complete occlusion after endovascular treatment with FDD can be delayed (>6 months). Ischemic complications may occur as early or delayed, particularly at clopidogrel interruption 14).

2014

Twenty-five aneurysms located at the MCA bifurcation (n = 21) or distal (n = 4) were treated. Of these, 22 were small and 3 were large. A single device was used in all but 2. No deaths occurred in the series. All patients had at least 1 control angiographic study, 21 of which were DSA (3-30 months), which showed that 12 of the rising branches were patent whereas 6 were filling in reduced caliber and 3 were occluded asymptomatically. According to the last angiographic follow-up, complete occlusion was revealed in 21 of 25 aneurysms (84%).
The Pipeline Embolization Device provides a safe and effective treatment alternative for wide-neck MCA aneurysms that give rise to a bifurcating or distal branch when other endovascular techniques are thought to be unfeasible or more risky 15).

2013

Thirty-three patients with 34 MCA aneurysms were treated with the Woven EndoBridge (WEB) in 5 European centers. The ability to successfully deploy the WEB, procedure- and device-related adverse events, morbidity and mortality of the treatment, and short-term angiographic follow-up results were analyzed.
Most treated aneurysms were unruptured (85.3%) and were between 5 and 10 mm (85.3%) with a neck size ≥  4 mm (88.2%). The treatment failed in 1 of the 34 aneurysms (2.9%) owing to a lack of appropriate device size. Treatment was performed exclusively with the WEB in 29 of 33 aneurysms (87.9%). Additional treatment (coiling and/or stenting) was used in 4 of 33 aneurysms (12.1%). Mortality of the treatment was 0.0% and morbidity was 3.1% (intraoperative rupture with modified Rankin Scale score of 3 at the 1-month follow-up). In short-term follow-up (range, 2-12 months), adequate occlusion (total occlusion or neck remnant) was observed in 83.3% of aneurysms.
WEB flow disruption seems to be a promising technique for the treatment of complex MCA aneurysms, particularly those with a wide neck or unfavorable dome-to-neck ratio 16).

Case reports

Burrows et al. present the case of an adolescent with a middle cerebral artery (MCA) fusiform aneurysm which recurred following clip reconstruction and bypass. The aneurysm was successfully treated with endovascular flow diversion 17).
1) , 11)

Bhogal P, AlMatter M, Bäzner H, Ganslandt O, Henkes H, Aguilar Pérez M. Flow Diversion for the Treatment of MCA Bifurcation Aneurysms-A Single Centre Experience. Front Neurol. 2017 Feb 2;8:20. doi: 10.3389/fneur.2017.00020. eCollection 2017. PubMed PMID: 28210239; PubMed Central PMCID: PMC5288345.
2) , 9)

Cagnazzo F, Mantilla D, Lefevre PH, Dargazanli C, Gascou G, Costalat V. Treatment of Middle Cerebral Artery Aneurysms with Flow-Diverter Stents: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2017 Oct 5. doi: 10.3174/ajnr.A5388. [Epub ahead of print] PubMed PMID: 28982785.
3) , 10)

Iosif C, Mounayer C, Yavuz K, Saleme S, Geyik S, Cekirge HS, Saatci I. Middle Cerebral Artery Bifurcation Aneurysms Treated by Extrasaccular Flow Diverters: Midterm Angiographic Evolution and Clinical Outcome. AJNR Am J Neuroradiol. 2017 Feb;38(2):310-316. doi: 10.3174/ajnr.A5022. Epub 2016 Dec 15. PubMed PMID: 27979794.
4) , 14)

Briganti F, Delehaye L, Leone G, Sicignano C, Buono G, Marseglia M, Caranci F, Tortora F, Maiuri F. Flow diverter device for the treatment of small middle cerebral artery aneurysms. J Neurointerv Surg. 2016 Mar;8(3):287-94. doi: 10.1136/neurintsurg-2014-011460. Epub 2015 Jan 20. PubMed PMID: 25603808.
5) , 15)

Yavuz K, Geyik S, Saatci I, Cekirge HS. Endovascular treatment of middle cerebral artery aneurysms with flow modification with the use of the pipeline embolization device. AJNR Am J Neuroradiol. 2014 Mar;35(3):529-35. doi: 10.3174/ajnr.A3692. Epub 2013 Sep 26. PubMed PMID: 24072620.
6) , 16)

Pierot L, Klisch J, Cognard C, Szikora I, Mine B, Kadziolka K, Sychra V, Gubucz I, Januel AC, Lubicz B. Endovascular WEB flow disruption in middle cerebral artery aneurysms: preliminary feasibility, clinical, and anatomical results in a multicenter study. Neurosurgery. 2013 Jul;73(1):27-34; discussion 34-5. doi: 10.1227/01.neu.0000429860.04276.c1. PubMed PMID: 23615104.
7) , 13)

Caroff J, Neki H, Mihalea C, D’Argento F, Abdel Khalek H, Ikka L, Moret J, Spelle L. Flow-Diverter Stents for the Treatment of Saccular Middle Cerebral Artery Bifurcation Aneurysms. AJNR Am J Neuroradiol. 2016 Feb;37(2):279-84. doi: 10.3174/ajnr.A4540. Epub 2015 Sep 24. PubMed PMID: 26405085.
8) , 12)

Topcuoglu OM, Akgul E, Daglioglu E, Topcuoglu ED, Peker A, Akmangit I, Belen D, Arat A. Flow Diversion in Middle Cerebral Artery Aneurysms: Is It Really an All-Purpose Treatment? World Neurosurg. 2016 Mar;87:317-27. doi: 10.1016/j.wneu.2015.11.073. Epub 2015 Dec 23. PubMed PMID: 26723288.
17)

Burrows AM, Zipfel G, Lanzino G. Treatment of a pediatric recurrent fusiform middle cerebral artery (MCA) aneurysm with a flow diverter. J Neurointerv Surg. 2013 Nov;5(6):e47. doi: 10.1136/neurintsurg-2012-010478.rep. Epub 2012 Nov 27. PubMed PMID: 23188788.

Acute Ischemic Stroke: Medical, Endovascular, and Surgical Techniques

Acute Ischemic Stroke: Medical, Endovascular, and Surgical Techniques

Acute Ischemic Stroke: Medical, Endovascular, and Surgical Techniques

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This book approaches the topic of management of acute ischemic stroke in an interdisciplinary manner, explaining how best to utilize the methods currently available for medical, surgical, and endovascular care. After an opening section on basics such as pathophysiology, radiological assessment, and pathology, comprehensive and up-to-date information is provided on each of the available therapies, techniques, and practices. Special attention is paid to recent advances in neurointerventional and neurosurgical procedures, with clear description of important technical details.The book includes plentiful high-quality case illustrations and a wealth of practical information that will prove of value in emergency rooms, angiography suites, operating rooms, and intensive care units. It will aid not only neurologists, neurointerventionists, and neurosurgeons, but also all others who are involved in the management of acute ischemic stroke, from radiologists and emergency physicians to healthcare providers.

Product Details

  • Published on: 2017-03-23
  • Original language: English
  • Number of items: 1
  • Dimensions: 10.00″ h x .0″ w x 7.00″ l, .0 pounds
  • Binding: Hardcover
  • 270 pages

Endovascular Neurosurgery Through Clinical Cases

Endovascular Neurosurgery Through Clinical Cases
By Aristotelis P. Mitsos

Endovascular Neurosurgery Through Clinical Cases

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Endovascular neurosurgery is a recently introduced but rapidly evolving medical field, which uses minimally invasive interventions to treat major life-threatening vascular lesions of the Central Nervous System. Although its history counts less than 15 years of worldwide acceptance, it has rapidly displaced the traditional open neurosurgical techniques, being nowadays the first treatment choice for brain aneurysms and vascular malformations. Thus, the experience of each neuroendovascular center and performer is invaluable, offering the base for learning and teaching the new generation of interventionalists as well as for the evolvement of the method itself.
This book presents the basic principles of endovascular neurosurgery starting from clinical cases. Through this close-to-clinical-reality-process, the reader will be able to more thoroughly understand the pathophysiology of the brain and spine vascular lesions as well as the decision-making strategy, related to the indications, endovascular methods and results, finding suggestions and solutions to his/her clinical questions and problems. Besides chapters devoted to CNS vascular embryology and anatomy, clinical cases organized in groups based on the treated lesions are introduced: ruptured and unruptured cerebral aneurysms of the anterior and posterior circulation, side-wall and bifurcation aneurysms, arteriovenous malformations (AVM), dural arteriovenous fistulae (dAVF), arterial stenosis and angioplasty as well as spinal vascular lesions. A separate chapter is devoted to the organization and necessary equipment of the angio room and the department offering neuroendovascular service.
This volume will be of interest to neurosurgeons, interventional neuroradiologists, vascular surgeons, neurologists and ICU physicians as well as health care providers who are involved in the diagnosis and management of the vascular lesions of the brain and spine.

Product Details

  • Published on: 2016-08-19
  • Released on: 2016-08-19
  • Original language: English
  • Number of items: 1
  • Dimensions: 10.00″ h x .46″ w x 7.01″ l, .0 pounds
  • Binding: Paperback
  • 180 pages

Editorial Reviews

Review
“This book presents personal case illustrations of commonly used endovascular procedures for various arteriovenous malformations of the brain and the spine. … It is appropriate for interventional neuroradiologists and neurosurgical trainees as well as established practitioners. It also can be helpful for neurologists and diagnostic neuroradiologists. … The book is handy, to the point, and carries the weight of years of experience.” (Ramsis Farid Ghaly, Doody’s Book Reviews, May, 2015)
From the Back Cover
Endovascular neurosurgery is a recently introduced but rapidly evolving medical field, which uses minimally invasive interventions to treat major life-threatening vascular lesions of the Central Nervous System. Although its history counts less than 15 years of worldwide acceptance, it has rapidly displaced the traditional open neurosurgical techniques, being nowadays the first treatment choice for brain aneurysms and vascular malformations. Thus, the experience of each neuroendovascular center and performer is invaluable, offering the base for learning and teaching the new generation of interventionalists as well as for the evolvement of the method itself.
This book presents the basic principles of endovascular neurosurgery starting from clinical cases. Through this close-to-clinical-reality-process, the reader will be able to more thoroughly understand the pathophysiology of the brain and spine vascular lesions as well as the decision-making strategy, related to the indications, endovascular methods and results, finding suggestions and solutions to his/her clinical questions and problems. Besides chapters devoted to CNS vascular embryology and anatomy, clinical cases organized in groups based on the treated lesions are introduced: ruptured and unruptured cerebral aneurysms of the anterior and posterior circulation, side-wall and bifurcation aneurysms, arteriovenous malformations (AVM), dural arteriovenous fistulae (dAVF), arterial stenosis and angioplasty as well as spinal vascular lesions. A separate chapter is devoted to the organization and necessary equipment of the angio room and the department offering neuroendovascular service.
This volume will be of interest to neurosurgeons, interventional neuroradiologists, vascular surgeons, neurologists and ICU physicians as well as health care providers who are involved in the diagnosis and management of the vascular lesions of the brain and spine.
About the Author
Aristotelis P. Mitsos is a Lt Colonel of Hellenic Army and a Consultant Neurosurgeon with an expertise in Endovascular Neurosurgery. He has a Master of Science Degree from the University of Oxford, UK (2006) in Endovascular Neurosurgery and Interventional Neuroradiology; he is the Head of the Neuroendovascular Department in 401 Athens General Army Hospital, offering neuroendovascular services in more than 150 patients every year.

New Book: Endovascular Surgical Neuroradiology: Theory and Clinical Practice

Endovascular Surgical Neuroradiology: Theory and Clinical Practice

Endovascular Surgical Neuroradiology: Theory and Clinical Practice

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It covers all aspects of neuroendovascular surgery, such as the science of vascular biology to the more advanced clinical applications in acute stroke interventions and Arteriovenous malformations. Written by neurologists, neurosurgeons, and neuroradiologists, this timely text provides readers with a thorough review of all the considerations pertinent to the endovascular treatment of diseases of the cerebrovascular system, spine, head, and neck.
Key Features:

  • Technique chapters include complication avoidance and management
  • High-quality, unique illustrations and up-to-date images guide the reader through clinical concepts and technically challenging procedures
  • Covers topics that are often overlooked but are critical to understanding the dynamics of endovascular treatment, such as the use of anticoagulants or procoagulants and the biophysics of vascular disease
  • Each chapter ends with a Summary which distills and highlights the key takeaways for that topic

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  • Published on: 2014-10-15
  • Original language: English
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  • 590 pages

Update: Pericallosal artery aneurysm endovascular treatment

Pericallosal artery aneurysm endovascular treatment

J.Sales-Llopis
Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain
The initial results of endovascular coiling for pericallosal artery aneurysms were not satisfactory because most aneurysms in this location are small and distally located 1).
Since the recent improvements in endovascular techniques and equipment, pericallosal artery aneurysms have become accessible for endovascular coiling and the results have thus been improving with success rates to be 92.9–100% 2) 3) 4).
Intracranial hemorrhage (ICH) associated with this aneurysm location is not uncommon, and is viewed as a relative contraindication for heparinization and requires management of increased intracranial pressure. Par- ticular attention must be paid to perioperative management and coiling is still considered to be controversial. Thus, these conditions have resulted in under-utilization of endovascular therapy and un- der-representation in coiling trials.
Yamazaki et al. applied endovascular coiling for ruptured pericallosal artery aneurysms, including those associated with ICH, as the first-line treatment.
They consider to be important to refrain from bolus heparin injection during endovascular coiling for cases with concomitant dense hematoma. Otherwise, coil embolization should be postponed until 8 hours after the onset to lower the risk of hematoma enlargement 5).
Endovascular approaches for aneurysms < 3mm in size reportedly have higher risks for intraoperative rupture 6). 7).

Case series

2013

30 consecutive patients with ruptured pericallosal artery aneurysms including those with intracerebral hematoma. Twenty-seven cases of ruptured pericallosal artery aneurysms were successfully embolized with coiling whereas three failures required surgery. Four patients experienced periprocedural complications including thromboembolic event in two and hematoma enlargement after coiling in two. A maximum aneurysm diameter of <3 mm was most strongly associated with failure of endovascular coiling. Of the 27 coil-treated aneurysms, immediate angiographic results showed complete aneurysm occlusion in 19 cases, neck remnant in 6, and residual aneurysm in 2. One patient had a major aneurysm recurrence that was uneventfully reembolized. Sixteen of our 30 patients had good outcomes (modified Rankin scale [mRS] 0-2), 7 had moderate disability (mRS 3), and 4 had severe disability (mRS 4-5) at 3 months after treatment. The management strategy for coiling as the first-intention treatment for ruptured pericallosal artery aneurysms has the potential to become an acceptable alternative to surgical clipping for selected cases, although a larger study population and longer follow-up periods are needed before definitive conclusions can be drawn.
The maximum diameters of our failed cases were < 3 mm while all 22 aneurysms with a maximum diameter ≥ 3 mm were successfully embolized. Therefore, morphologically, they consider the lower limit on pericallosal artery aneurysm diameters difficult to treat by endovascular coiling to be < 3mm since the failure rate was significantly higher than for larger aneurysms.
The overall complication rate was 13.3% (4/30 cases) and independent activities of daily living (mRS 0–2) were achieved in 53.3% (16/30). Two cases experienced thromboembolic complications with one resulting in a moderate permanent deficit and the other in a minor neurological deficit from which the patient fully recovered. Two patients developed hematoma enlargement probably because coil embolization was performed within 8 hours of onset under systemic heparinization. It is, therefore, important to intentionally postpone endovascular coiling in patients with associated ICH until 8 hours after the onset, or to minimize heparinization for patients requiring coil embolization within 8 hours. This may lower the risk of hemorrhagic complications 8).

Parent vessel trapping with Onyx 18/34 offers a simple, safe, and effective means of achieving obliteration of distal challenging aneurysms reported in 3 cases 9).

2012

4 cases treating wide-neck pericallosal artery aneurysms at the bifurcation with Y-configuration stent placement is feasible and effective. This technique may be considered as a therapeutic option for wide-neck aneurysms that pose a difficult technical challenge 10).

2011

32 patients presenting with SAH due to pericallosal aneurysm treated with an endovascular approach were more likely to have a good modified Rankin scale (mRS) (mRS 0-2 vs 3-6) (p=0.028), to make a complete recovery (mRS=0) (p=0.017) and were less likely to die (mRS=6) (p=0.026). Patients with electively treated pericallosal aneurysms did not have statistically significant differences in outcome between surgical and endovascular cohorts. Differences in secondary endpoints did not reach significance. Patients with ruptured pericallosal aneurysms fare better with endovascular therapy, with better chance of complete recovery. Surgical and endovascular treatments of unruptured pericallosal aneurysms have similar results and outcome 11).

2007

Nguyen et al., examined data of 25 patients that were stored in a prospectively collected database for pericallosal artery aneurysms in patients who underwent coil placement between 1992 and 2005. Hemorrhagic and thromboembolic complications as well as clinical and angiographic outcomes were reviewed. Angiographically documented recurrences were classified as minor or major. These lesions were compared with a historical cohort of non-pericallosal artery aneurysms in patients who underwent coil therapy between 1992 and 2002. The known risk factors for recurrence and procedure-related hemorrhagic complications were evaluated in both groups to assess baseline imbalances.
During a 13-year period, 25 pericallosal artery aneurysms were treated with coils in 25 patients. The non-pericallosal artery lesion group included 488 aneurysms of which 344 underwent follow-up imaging. Procedure-related perforations were more frequent for pericallosal artery aneurysms than those in other intradural locations (three of 25 compared with eight of 476, respectively; risk ratio 7.1, 95% confidence interval [CI] 2.1-22.5, p = 0.03). Follow-up imaging studies (obtained at a mean 28 months) were available for 19 patients with pericallosal artery aneurysms. The recurrence rate was not significantly higher in these patients (22.9/100 person-years of observation) than in those with non-pericallosal artery aneurysms (17.9/100 person-years of observation) (incidence rate ratio 1.3, 95% CI 0.6-2.4, p = 0.46).
Pericallosal artery aneurysms were associated with significantly higher periprocedural rupture than non-pericallosal artery lesions. No significant intergroup difference was found for aneurysm recurrence 12).

Case reports

2014

A rare unique case of ruptured fusiform proximal pericallosal artery aneurysm. Endovascular treatment of this type of aneurysm is a feasible method and can be considered as an effective alternative to surgical technique 13).

A 35-year-old with bacterial endocarditis from Streptococcus mitis was diagnosed with a ruptured 3 mm MIA of the pericallosal anterior cerebral artery after episodic diplopia. The MIA was successfully treated with stent-assisted coil embolization utilizing a Neuroform EZ stent (Stryker Neuroendovascular, Kalamazoo, MI, USA). Follow-up magnetic resonance angiography at 3months demonstrated complete aneurysm obliteration, and the patient was neurologically intact. In the literature, a M1 segment middle cerebral artery MIA, bilateral cavernous carotid MIA, and a unilateral cavernous carotid MIA were also successfully treated with Neuroform, Helistent (Hexacath, Rueil-Malmaison, France), and SILK (BALT Extrusion, Montmorency, France) stents, respectively. We present the first patient with a pericallosal MIA treated with stent-assisted coil embolization. Proper treatment of the causative organism with antibiotics minimizes the risk of infectious seeding of the stent. Intracranial stenting may be safely and effectively utilized to treat select cases of MIA 14).

2013

Endovascular treatment of traumatic pericallosal artery aneurysms. A case report 15).

2010

A 54-year-old woman who underwent endovascular treatment in the setting of a massive subarachnoid haemorrhage due to rupture of a dissecting basilar trunk aneurysm treated with stent implantation and coiling. A further saccular aneurysm in the left pericallosal artery disclosed by four-vessel angiography was treated with coiling during the same procedure. Follow-up DSA performed after six months confirmed complete occlusion of both aneurysms and patency of the stent 16).
1) Pierot L, Boulin A, Cataings L, Rey A, Moret J: Endovascular treatment of pericallosal artery aneurysms. Neurol Res 18: 49–53, 1996
2) , 12) Nguyen TN, Raymond J, Roy D, Chagnon M, Weill A, Iancu-Gontard D, Guilbert F. Endovascular treatment of pericallosal aneurysms. J Neurosurg. 2007 Nov;107(5):973-6. PubMed PMID: 17977269.
3) Vora N, Thomas AJ, Gupta R, Gologorsky Y, Panapitiya N, Jovin T, Jankowitz B, Kassam A, Horowitz M. Endovascular treatment of distal anterior cerebral artery aneurysms: technical results and review of the literature. J Neuroimaging. 2010 Jan;20(1):70-3. doi: 10.1111/j.1552-6569.2008.00324.x. Review. PubMed PMID: 19018950.
4) Waldenberger P, Petersen J, Chemelli A, Schenk C, Gruber I, Strasak A, Eisner W, Beer R, Glodny B. Endovascular therapy of distal anterior cerebral artery aneurysms-an effective treatment option. Surg Neurol. 2008 Oct;70(4):368-77. doi:10.1016/j.surneu.2007.07.058. Epub 2008 Mar 4. PubMed PMID: 18291498.
5) , 8) Yamazaki T, Sonobe M, Kato N, Kasuya H, Ikeda G, Nakamura K, Ito Y, Tsuruta W, Nakai Y, Matsumura A. Endovascular coiling as the first treatment strategy for ruptured pericallosal artery aneurysms: results, complications, and follow up. Neurol Med Chir (Tokyo). 2013;53(6):409-17. PubMed PMID: 23803620.
6) Brinjikji W, Lanzino G, Cloft HJ, Rabinstein A, Kallmes DF: Endovascular treatment of very small (3 mm or smaller) intracranial aneurysms: report of a consecutive series and a meta-analysis. Stroke 41: 116–121, 2010
7) skandar A, Nepper-Rasmussen J: Endovascular treatment of very small intracranial aneurysms. Interv Neuroradiol 17: 299–305, 2011
9) Chalouhi N, Tjoumakaris S, Gonzalez LF, Hasan D, Alkhalili K, Dumont AS, Rosenwasser R, Jabbour P. Endovascular treatment of distal intracranial aneurysms with Onyx 18/34. Clin Neurol Neurosurg. 2013 Dec;115(12):2528-32. doi: 10.1016/j.clineuro.2013.10.018. Epub 2013 Nov 1. PubMed PMID: 24239516.
10) Darkhabani ZM, Lazzaro MA, Zaidat OO. Pericallosal artery aneurysm treatment using Y-configuration stent-assisted coil embolization: a report of four cases. J Neurointerv Surg. 2012 Nov;4(6):459-62. doi: 10.1136/neurintsurg-2011-010086. Epub 2012 Jan 12. PubMed PMID: 22247235.
11) Hui FK, Schuette AJ, Moskowitz SI, Spiotta AM, Lieber ML, Rasmussen PA, Dion JE, Barrow DL, Cawley CM. Microsurgical and endovascular management of pericallosal aneurysms. J Neurointerv Surg. 2011 Dec 1;3(4):319-23. doi: 10.1136/jnis.2011.004770. Epub 2011 Mar 1. PubMed PMID: 21990472.
13) Alurkar A, Karanam LS, Oak S, Nayak S. Endovascular treatment of fusiform A2 aneurysm with parent artery occlusion. Surg Neurol Int. 2014 Jul 30;5(Suppl 4):S199-202. doi: 10.4103/2152-7806.137752. eCollection 2014. PubMed PMID: 25184100; PubMed Central PMCID: PMC4138823.
14) Ding D, Raper DM, Carswell AJ, Liu KC. Endovascular stenting for treatment of mycotic intracranial aneurysms. J Clin Neurosci. 2014 Jul;21(7):1163-8. doi: 10.1016/j.jocn.2013.11.013. Epub 2013 Dec 14. Review. PubMed PMID: 24518267.
15) Van Rooij WJ, Van Rooij SB. Endovascular treatment of traumatic pericallosal artery aneurysms. A case report. Interv Neuroradiol. 2013 Mar;19(1):56-9. Epub 2013 Mar 4. PubMed PMID: 23472724; PubMed Central PMCID: PMC3601618.
16) Lazzarotti GA, Cosottini M, Puglioli M. Stenting and coil embolization of a ruptured dissecting basilar artery aneurysm associated with coil embolization of a pericallosal artery aneurysm. A case report. Neuroradiol J. 2010 Apr;23(2):205-11. Epub 2010 Apr 20. PubMed PMID: 24148540.

Endovascular Cerebral Aneurysm Repair Market By Medtech Ventures

Endovascular Cerebral Aneurysm Repair MarketEndovascular Cerebral Aneurysm Repair Market

Endovascular Cerebral Aneurysm Repair Market
By Medtech Ventures
Price: $950.00 cart

Product Description

The global market for endovascular cerebral aneurysm repair (ECAR) devices has surpassed the $1 billion mark and currently stands at US$1.1 billion. The market, which has experienced explosive growth over the previous decade, has matured at the current level of technology. In its purest form, the endovascular cerebral aneurysm repair market consists of three broad categories of minimally invasive devices; embolic coils, intracranial stents and access devices. When used alone, or in combination, they allow the intervening physician to use the patient’s arteries as highways to deliver intended therapies, in the form of coils or stents, to the aneurysm location within the patient’s brain. The delivery procedure is performed under real-time visual guidance from high-powered imaging machines in a neurointerventional suite. The endovascular cerebral aneurysm repair market experienced a phenomenal growth phase that saw revenue rise over ten folds in just over a decade, from less than $100 million in 2000 to its current level of $1.1 billion. Current market leaders are seeking cost reductions and profit maximization through consolidation and moving production to lower cost jurisdictions. However, new research in endothelial biology is ushering in a new breed of biotech startups in search for disease modifying molecular targets, which could, theoretically, disrupt the market before the end of this decade. Medtech Ventures’ Endovascular Cerebral Aneurysm Repair Market Report is an exclusive update to the recently changed global landscape of this market. It provides a brief, but thorough, analysis of the market with profiles of leading participant and a solid forecast to 2020.

Product Details

  • Published on: 2014-06-01
  • Original language: English
  • Binding: Paperback
  • 34 pages

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About the Author
Medtech Ventures is a forward looking think tank and virtual startup accelerator specialized in the medical technology industry. We offer our clients a broad portfolio of services revolving around the concept of “Virtual Incubation”. We help with idea evaluation, opportunity sizing, technology assessment, market analysis as well as perception management and venture capital sourcing and finance. We also publish brief market insight & niche opportunity reports targeted at senior executives in the medical technology field.

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