FD stent placement is a promising therapy for challenging intracranial aneurysms. Long-term evaluations about angiographic and morphologic results are still missing. This is the aim of this ...multicenter series.
We report our experience and 1-year FU in a retrospective chart review of 65 consecutive subjects with 77 unruptured or recanalized aneurysms that were treated with Silk FD stents at 6 centers in France. Both angiographic and clinical results were recorded before treatment and at 6 and 12 months after treatment. At the 12-month FU, relationships between angiographic aneurysm occlusion and shrinkage of the thrombosed aneurysm sac were evaluated.
Stent deployment was achieved in 64 cases (98.5%) and failed in 1 case (1.5%). Seven misdeployments of the Silk stent caused the occlusion of 6 parent arteries. Overall acute/subacute procedural morbidity was 7.7%, and mortality was zero. Delayed complications were observed in 10.9% of subjects. At the 6-month FU, permanent morbidity was 7.8% and mortality was 3%. Complete occlusion occurred within 6 months in 68% of aneurysms and within 12 months after treatment in 84.5% of aneurysms. At the 12-month FU, in angiographically complete occluded aneurysms, MR imaging/CT analysis showed the complete disappearance of the thrombosed aneurysm in 30% of cases and partial shrinkage in 52%; furthermore, thrombosed aneurysms were stable in 11% of cases and enlarged in 7%.
The Silk stent is an effective tool for the treatment of challenging aneurysms because it allows complete occlusion in most cases 1 year after treatment. Permanent morbidity was 7.8%, and mortality was 3%.
Clopidogrel is routinely used to decrease ischemic complications during neurointerventional procedures. However, the efficacy may be limited by antiplatelet resistance.
Our aim was to analyze the ...efficacy of prasugrel compared with clopidogrel in the cerebrovascular field.
A systematic search of 2 large databases was performed for studies published from 2000 to 2018.
According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting treatment-related outcomes of patients undergoing neurointerventional procedures under prasugrel, and studies comparing prasugrel and clopidogrel.
Random-effects meta-analysis was used to pool the overall rate of complications, ischemic and hemorrhagic events, and influence of the dose of prasugrel.
In the 7 included studies, 682 and 672 unruptured intracranial aneurysms were treated under prasugrel (cases) and clopidogrel (controls), respectively. Low-dose (20 mg/5 mg; loading and maintenance doses) prasugrel compared with the standard dose of clopidogrel (300 mg/75 mg) showed a significant reduction in the complication rate (OR = 0.36; 95% CI, 0.17-74,
= .006; I
= 0%). Overall, the ischemic complication rate was significantly higher in the clopidogrel group (40/672 = 6%; 95% CI, 3%-13%; I
= 83% versus 16/682 = 2%; 95% CI, 1%-5%; I
= 73%;
= .03). Low and high loading doses of prasugrel were associated with 0.6% (5/535; 95% CI, 0.1%-1.6%; I
= 0%) and 9.3% (13/147; 95% CI, 0.2%-18%; I
= 60%) intraperiprocedural hemorrhages, respectively (
= .001), whereas low and high maintenance doses of prasugrel were associated with 0% (0/433) and 0.9% (2/249; 95% CI, 0.3%-2%; I
= 0%) delayed hemorrhagic events, respectively (
= .001).
Retrospective series and heterogeneous endovascular treatments were limitations.
In our study, low-dose prasugrel compared with clopidogrel premedication was associated with an effective reduction of the ischemic events with an acceptable rate of hemorrhagic complications.
The safety and efficacy of reconstructive and deconstructive endovascular treatments of very large/giant intracranial aneurysms are not completely clear.
Our aim was to compare treatment-related ...outcomes between these 2 techniques.
A systematic search of 3 data bases was performed for studies published from 1990 to 2017.
We selected series of reconstructive and deconstructive treatments with >10 patients.
Random-effects meta-analysis was used to analyze occlusion rates, complications, and neurologic outcomes.
Thirty-nine studies evaluating 894 very large/giant aneurysms were included. Long-term occlusion of unruptured aneurysms was 71% and 93% after reconstructive and deconstructive treatments, respectively (
= .003). Among unruptured aneurysms, complications were lower after parent artery occlusion (16% versus 30%,
= .05), whereas among ruptured lesions, complications were lower after reconstructive techniques (34% versus 38%). Parent artery occlusion in the posterior circulation had higher complications compared with in the anterior circulation (36% versus 15%,
= .001). Overall, coiling yielded lower complication and occlusion rates compared with flow diverters and stent-assisted coiling. Complication rates of flow diversion were lower in the anterior circulation (17% versus 41%,
< .01). Among unruptured lesions, early aneurysm rupture (within 30 days) was slightly higher after reconstructive treatment (5% versus 0%,
= .08) and after flow diversion alone compared with flow diversion plus coiling (7% versus 0%).
Limitations were selection and publication biases.
Parent artery occlusion allowed high rates of occlusion with an acceptable rate of complications for unruptured, anterior circulation aneurysms. Coiling should be preferred for posterior circulation and ruptured lesions, whereas flow diversion is relatively safe and effective for unruptured anterior circulation aneurysms.
The ability of polymer-modified coils to promote stable aneurysm occlusion after endovascular treatment is not well-documented. Angiographic aneurysm recurrence is widely used as a surrogate for ...treatment failure, but studies documenting the correlation of angiographic recurrence with clinical failure are limited. This trial compares the effectiveness of Matrix(2) polyglycolic/polylactic acid biopolymer-modified coils with bare metal coils and correlates the angiographic findings with clinical failure (ie, target aneurysm recurrence), a composite end point that includes any incident of posttreatment aneurysm rupture, retreatment, or unexplained death.
This was a multicenter randomized noninferiority trial with blinded end point adjudication. We enrolled 626 patients, divided between Matrix(2) and bare metal coil groups. The primary outcome was target aneurysm recurrence at 12 ± 3 months.
At 455 days, at least 1 target aneurysm recurrence event had occurred in 14.6% of patients treated with bare metal coils and 13.3% of Matrix(2) (P = .76, log-rank test) patients; 92.8% of target aneurysm recurrence events were re-interventions for aneurysms that had not bled after treatment, and 5.8% of target aneurysm recurrence events resulted from hemorrhage or rehemorrhage, with or without retreatment. Symptomatic re-intervention occurred in only 4 (0.6%) patients. At 455 days, 95.8% of patients with unruptured aneurysms and 90.4% of those with ruptured aneurysms were independent (mRS ≤ 2). Target aneurysm recurrence was associated with incomplete initial angiographic aneurysm obliteration, presentation with rupture, and a larger aneurysmal dome and neck size.
Tested Matrix(2) coils were not inferior to bare metal coils. Endovascular coiling of intracranial aneurysms was safe, and the rate of technical success was high. Target aneurysm recurrence is a promising clinical outcome measure that correlates well with established angiographic measurements.
Flow diversion for aneurysms beyond the circle of Willis is still debated. Our aim was to evaluate the safety and efficacy of flow diversion treatment of distal anterior cerebral artery aneurysms.
...Consecutive patients with distal anterior cerebral artery aneurysms treated from January 2014 to October 2017 were evaluated retrospectively with prospectively maintained data. Treatment was performed only for unruptured or recanalized aneurysms after coiling. Technical feasibility, procedural complications, aneurysm occlusion (O'Kelly-Marotta grading scale), and clinical outcome were evaluated.
Fifteen patients were included in the study, with 17 distal anterior cerebral artery saccular aneurysms treated with flow-diverter stents. Mean aneurysm size was 4.25 ± 3.9 mm; range, 2-9 mm. Flow diversion was used as retreatment among 6 previously coiled aneurysms (5 ruptured and coiled in the acute phase, and 1 unruptured and recanalized). Stent deployment was technically successful in all cases. During the perioperative period, 1 patient experienced a transient minor stroke (6%), whereas 2 patients reported acute in-stent thrombosis with disabling ischemic complications (13%). Fourteen patients and 16 aneurysms were available during a mean radiologic follow-up of 12 months (range, 3-24 months). Overall, 12 (75%) aneurysms were completely occluded (O'Kelly-Marotta grading scale score D), 1 aneurysm (6%) showed near-complete occlusion (O'Kelly-Marotta grading scale score C), and 3 aneurysms (19%) were incompletely occluded (O'Kelly-Marotta grading scale, score B). All 6 aneurysms previously coiled were completely occluded after flow diversion, whereas 70% of aneurysms treated with flow diverters alone showed complete/near-complete occlusion (O'Kelly-Marotta grading scale C-D). There were no cases of aneurysm rupture, in-stent occlusion, or retreatment during long-term follow-up.
Treatment of distal anterior cerebral artery aneurysms with flow-diverter stents is feasible and effective, with high rates of aneurysm occlusion. Flow diversion plus coiling, in the retreatment of lesions previously coiled, allowed higher rates of occlusion compared with flow diverters alone. However, the risk of ischemic complications is not negligible, and flow-diversion treatment should be evaluated only for aneurysms not amenable to simple coil embolization.
Age and stroke severity are inversely correlated with the odds of favorable outcome after ischemic stroke. A previously proposed score for Stroke Prognostication Using Age and NIHSS Stroke Scale ...(SPAN) indicated that SPAN-100-positive patients (ie, age + NIHSS score = 100 or more) do not benefit from IV-tPA. If this finding holds true for endovascular therapy, this score can impact patient selection for such interventions. This study investigated whether a score combining age and NIHSS score can improve patients' selection for endovascular stroke therapy.
The SPAN index was calculated for patients in the prospective Solitaire FR Thrombectomy for Acute Revascularization study: an international single-arm multicenter cohort for anterior circulation stroke treatment by using the Solitaire FR. The proportion with favorable outcome (90-day mRS score ≤2) was compared between SPAN-100-positive versus-negative patients.
Of the 202 patients enrolled, 196 had baseline NIHSS scores. Fifteen (7.7%) patients were SPAN-100-positive. There was no difference in the rate of successful reperfusion (Thrombolysis In Cerebral Infarction 2b or 3) between SPAN-100-positive versus -negative groups (93.3% versus 82.8%, respectively; P = .3). Stroke SPAN-100-positive patients had a significantly lower proportion of favorable clinical outcomes (26.7% versus 60.8% in SPAN-100-negative, P = .01). In a multivariable analysis, SPAN-100-positive status was associated with lower odds of favorable outcome (OR, 0.3; 95% CI, 0.1-0.9; P = .04). A higher baseline Alberta Stroke Program Early CT Score and a short onset to revascularization time also predicted favorable outcome in the multivariable analysis.
A significantly lower proportion of patients with a positive SPAN-100 achieved favorable outcome in this cohort. SPAN-100 was an independent predictor of favorable outcome after adjusting for time to treatment and the extent of preintervention tissue damage according to the Alberta Stroke Program Early CT Score.
The safety and efficacy of flow diversion among distal anterior circulation aneurysms must be proved.
Our aim was to analyze the outcomes after flow diversion among MCA, anterior communicating ...artery, and distal anterior cerebral artery aneurysms.
A systematic search of 3 databases was performed for studies published from 2005 to 2018.
According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting flow diversion of distal anterior circulation aneurysms.
Random-effects meta-analysis was used to pool aneurysm occlusion and complication rates. From the individual patient data, univariate and multivariate analyses were used to test predictors of occlusion and complications.
We included 27 studies (484 aneurysms). The long-term adequate occlusion rate (O'Kelly-Marotta scale, C-D) was 82.7% (295/364; 95% CI, 77.4%-87.9%; I
= 52%). Treatment-related complications were 12.5% (63/410; 95% CI, 9%-16%%; I
= 18.8%), with 5.4% (29/418; 95% CI, 3.2%-7.5%; I
= 0%) morbidity. MCA location was an independent factor associated with lower occlusion (OR = 0.5,
= .03) and higher complication rates (OR = 1.8,
= .02), compared with anterior communicating artery and distal anterior cerebral artery aneurysms. The Pipeline Embolization Device (versus other stents) gave better occlusion rates (OR = 2.6,
= .002), whereas large/giant aneurysms were associated with higher odds of complications (OR = 2.2,
= .03). The rates of occlusion and narrowing of arteries covered by flow-diverter stents were 6.3% (29/283; 95% CI, 3.5%-9.1%; I
= 4.2%) and 23.8% (69/283; 95% CI, 15.7%-32%; I
= 80%), respectively. Symptoms related to occlusion and narrowing of the jailed arteries were 3.5% (6/269; 95% CI, 1.1%-5%; I
= 0%) and 3% (6/245; 95% CI, 1%-4%; I
= 0%), respectively.
We reviewed small and retrospective series.
Flow diversion among distal anterior circulation aneurysms is effective, leading to adequate aneurysm occlusion in 83% of cases. However, this strategy has some limitations among MCA and larger lesions, especially related to the higher rate of complications. Compared with the other devices, the Pipeline Embolization Device seems to be associated with a higher occlusion rate.
Clinical outcome and initial and midterm angiographic results of EVT of complex MCA aneurysms by using the stent-assisted coiling technique were retrospectively evaluated in our center where EVT of ...intracranial aneurysms is the first treatment option.
From November 2003 to October 2009, 49 patients (27 men, 22 women; mean age, 52 ± 12 years) harboring 52 complex unruptured MCA aneurysms (11 ruptured previously and coiled but recanalized and 41 unruptured) were treated by EVT by using self-expandable intracranial stents. Procedural complications, clinical outcome, and initial and midterm angiographic results were evaluated. Initial treatment status and aneurysm sac size were tested as potential risk factors for recurrence.
After successful stent deployment, coiling was performed in 50 aneurysms (96.2%) in 47 patients; however, 2 failures (3.8%) occurred in 2 patients. Ten intrastent clot formations (20%) observed on final control angiography induced 2 permanent moderate disabilities (GOS score = 2). Mortality and permanent neurologic morbidity were 0% and 4.3%, respectively. At a mean period of 14 ± 9 months, among 48 aneurysms in 45 patients eligible for follow-up, 34 complete (71%) and 14 partial treatments (29%) were observed, 7 recurrences (14.6%) occurred, and 5 patients (10.4%) needed retreatment. No aneurysm bleeding or symptomatic intrastent stenosis was observed. Aneurysm sac size ≥7 mm and incomplete initial treatment were associated with more recurrences without a statistically significant difference.
For complex unruptured MCA aneurysms, EVT by using a self-expandable intracranial stent was feasible, safe, and durable and could be considered as the first-option treatment.
Intracranial stent placement assists in the coiling of wide-neck aneurysms and aids in reconstructing and protecting the parent artery. In this study, we analyze our experience in the use of the ...Neuroform system.
Records of patients treated with a Neuroform stent from June 2003 to September 2007 were retrieved from a data base for analysis of population characteristics, occurrence of complications, and acute and midterm angiographic results.
Sixty-eight patients harboring 76 aneurysms located primarily in the anterior circulation were treated. There were 5 cases (6.6%) of clot formation after deployment (1 with a permanent neurologic deficit), 1 case of perioperative stent displacement with hemorrhage, and 5 cases (6.6%) of transient neurologic deficit due to thromboembolic events. The morbidity-mortality rate at discharge was 2.9%. One patient presented with a delayed in-stent thrombosis, and 3 others, with silent stenosis. Twenty-four aneurysms (31.6%) were completely occluded in the initial embolization. However, a marked increase in the occlusion rate was observed, with 44 of the 68 aneurysms (64.7%) examined at the 18-month follow-up and 26 of the 46 aneurysms (56.5%) examined in the 3-year follow-up presenting with complete occlusion. At the end of the study, a neck remnant was present in 6 aneurysms (13%) and a residual sac, in 7 (15.2%). Mean follow-up time was 25.7 months.
The present series demonstrates the relative safety and feasibility of the Neuroform stent-assisted coiling technique, which seems to provide better results over coiling alone for wide-neck aneurysms. Angiographic results improve with time due to progressive thrombosis of the aneurysm.
Flow disruption with the Woven EndoBridge is increasingly used for the treatment of intracranial aneurysms. We examined factors leading to aneurysm occlusion and Woven EndoBridge shape change during ...a midterm follow-up.
Patients with a minimum 12-month angiographic follow-up were included. Through a univariate and multivariate analysis, independent predictors of adequate occlusion (Raymond-Roy 1/Raymond-Roy 2) and Woven EndoBridge shape change (decrease of the height of the device) were assessed.
Eighty-six patients/aneurysms were included. The aneurysm mean size was 5.5 mm (range, 3-11.5 mm). The most common locations were the MCA (43/86 = 50%), basilar tip (13/86 = 15.1%), and anterior communicating artery (12/86 = 14%). Twenty-one patients (21/86 = 24%) had acute SAH. Immediate and long-term Raymond-Roy 1/Raymond-Roy 2 occlusion rates were 49% (42/86) and 80% (68/86), respectively. Woven EndoBridge shape change was detected among 22% (19/86) of cases. At binary logistic regression, wide ostium (≥4 mm) (OR = 0.2; 95% CI, 0.01-1;
= .04) and regular aneurysm morphology (OR = 5.9; 95% CI, 1.4-24;
= .01) were independent factors of incomplete and adequate aneurysm occlusion, respectively. In addition, irregular morphology (OR = 5.4; 95%CI, 1.4-19;
= .01) and a wide ostium (OR = 9.8; 95% CI, 1.6-60;
= .03) significantly increased the probability of the Woven EndoBridge shape change. Decrease of the Woven EndoBridge height was more common among incompletely occluded aneurysms (6/12 = 50% versus 13/74 = 17.5%), but it was not an independent prognosticator of occlusion at the multivariate model.
The likelihood of good occlusion was 5 times lower in the presence of a wide ostium, whereas aneurysms with regular morphology were 6 times more likely to be occluded. Woven EndoBridge shape modification was strongly influenced by the aneurysm shape and ostium size, and it was not independently associated with the angiographic occlusion.
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