The safety and efficacy of flow-diversion treatment of MCA aneurysms have not been well-established.
Our aim was to evaluate angiographic and clinical outcomes after flow diversions for MCA ...aneurysms.
A systematic search of PubMed, MEDLINE, and Embase was performed for studies published from 2008 to May 2017.
According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we selected studies with >5 patients describing angiographic and clinical outcomes after flow-diversion treatment of MCA aneurysms.
Random-effects meta-analysis 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.
The implantation of flow-diverter stents for the treatment of ruptured intracranial aneurysms required further investigation.
Our aim was to analyze the outcomes after flow diversion of ruptured ...intracranial aneurysms.
A systematic search of 3 databases was performed for studies published from 2006 to 2018.
According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies (from 2010 to 2018) reporting acutely ruptured intracranial aneurysms treated with flow diversion.
Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, rebleeding, and factors influencing the studied outcomes.
We included 20 studies evaluating 223 patients with acutely ruptured intracranial aneurysms treated with flow-diverter stents. Immediate angiographic occlusion was obtained in 32% (29/86; 95% CI, 15.4%-48%; I
= 79.6%) of aneurysms, whereas long-term complete/near-complete aneurysm occlusion was 88.9% (162/189; 95% CI, 84%-93.5%; I
= 20.9%) (mean radiologic follow-up of 9.6 months). The treatment-related complication rate was 17.8% (42/223; 95% CI, 11%-24%; I
= 52.6%). Complications were higher in the posterior circulation (16/72 = 27%; 95% CI, 14%-40%; I
= 66% versus 18/149 = 11.7%; 95% CI, 7%-16%; I
= 0%) (
= .004) and after treatment with multiple stents (14/52 = 26%; 95% CI, 14%-45%; I
= 59%) compared with a single stent (20/141 = 10%; 95% CI, 5%-15%; I
= 0%) (
= .004). Aneurysm rebleeding after treatment was 4% (5/223; 95% CI, 1.8%-7%; I
= 0%) and was higher in the first 72 hours.
Small and retrospective series.
Flow-diversion treatment of ruptured intracranial aneurysms yields a high rate of long-term angiographic occlusion with a relatively low rate of aneurysm rebleeding. However, treatment is associated with a complication rate of 18%. When coiling or microsurgical clipping are not feasible strategies, anterior circulation ruptured aneurysms can be effectively treated with a flow-diversion technique, minimizing the number of stents deployed. Given the 27% rate of complications, flow diversion for ruptured posterior circulation aneurysms should be considered only in selected cases not amenable to other treatments.
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.
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.
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.
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.
The safety and efficacy of treatment with self-expandable braided stents (LEO and LVIS) required further investigation.
Our aim was to analyze the outcomes after treatment with braided stents.
A ...systematic search of 3 databases was performed for studies published from 2006 to 2017.
According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting patients treated with LEO or LVIS stents.
Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, and neurologic outcomes.
Thirty-five studies evaluating 1426 patients treated with braided stents were included in this meta-analysis. Successful stent delivery and complete aneurysm occlusion were 97% (1041/1095; 95% CI, 95%-98%) (I
= 44%) and 88.3% (1097/1256; 95% CI, 85%-91%) (I
= 72%), respectively. Overall, treatment-related complications were 7.4% (107/1317; 95% CI, 5%-9%) (I
= 44%). Ischemic/thromboembolic events (48/1324 = 2.4%; 95% CI, 1.5%-3.4%) (I
= 27%) and in-stent thrombosis (35/1324 = 1.5%; 95% CI, 0.6%-1.7%) (I
= 0%) were the most common complications. Treatment-related morbidity was 1.5% (30/1324; 95% CI, 0.9%-2%) and was comparable between the LEO and LVIS groups. Complication rates between the anterior (29/322 = 8.8%; 95% CI, 3.4%-12%) (I
= 41%) versus posterior circulation (10/84 = 10.5%; 95% CI, 4%-16%) (I
= 0%) and distal (30/303 = 8%; 95% CI, 4.5%-12%) (I
= 48%) versus proximal aneurysms (14/153 = 9%; 95% CI, 3%-13%) (I
= 46%) were comparable (
> .05).
Limitations were selection and publication biases.
In this analysis, treatment with the LEO and LVIS stents was relatively safe and effective. The most common complications were periprocedural thromboembolisms and in-stent thrombosis. The rate of complications was comparable among anterior and posterior circulation aneurysms, as well as for proximal and distally located lesions.
Treatment management and outcomes of unruptured nonsaccular aneurysms are different compared with their saccular counterparts.
Our aim was to analyze the outcomes after flow diversion among ...nonsaccular unruptured lesions.
A systematic search of 3 data bases (2005-2019) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
We included studies reporting flow diversion for nonsaccular unruptured aneurysms of the posterior and distal anterior circulations. Anterior circulation lesions were included if located distal to the petrocavernous and supraclinoid ICA (MCA, A1, anterior communicating artery, A2). Giant dolichoectatic holobasilar lesions were excluded because of their poor treatment outcomes.
Aneurysm occlusion and complication rates were calculated (random effects meta-analysis).
We included 15 studies (213 aneurysms). The long-term adequate occlusion rate was 85.3% (137/168; 95% CI, 78.2%-92.4%; I
= 42.3%). Treatment-related complications were 17.4% (41/213; 95% CI, 12.45%-22.4%; I
= 0%). Overall, 15% (37/213; 95% CI, 10%-20%; I
= 0%) were ischemic events. Procedure-related morbidity was 8% (20/213; 95% CI, 5%-12%; I
= 0%). Fusiform or dissecting types had comparable adequate occlusion (116/146 = 83%; 95% CI, 74%-92%; I
= 48% versus 33/36 = 89%; 95% CI, 80%-98%; I
= 0%;
= .31) and complication rates (35/162 = 17%; 95% CI, 10%-25%; I
= 24% versus 11/51 = 19%; 95% CI, 10%-31%; I
= 0%;
= .72). Aneurysm size (>10 versus ≤10 mm) was independently associated with a higher rate of complications (OR = 6.6; 95% CI, 1.3-15;
= .02). The rate of ischemic events after discontinuation of the antiplatelet therapy was 5% (5/93; 95% CI, 2%-9%; I
= 0%).
Small and retrospective studies were available for this meta-analysis.
Unruptured nonsaccular aneurysms located in the posterior and distal anterior circulations can be effectively treated with flow diversion. Nevertheless, treatment-related complications are not negligible, with about 15% ischemic events and 8% morbidity. Larger size (>10 mm) significantly increases the risk of procedure-related adverse events.
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.
Delayed cerebral ischemia strongly impacts clinical outcome after aneurysmal SAH. The effect of antiplatelet therapy on delayed cerebral ischemia has been described with heterogeneous results. Our ...aim was to analyze the efficacy of antiplatelet therapy on delayed cerebral ischemia and clinical outcome in patients with SAH.
A systematic search of 3 databases was performed for studies published from 1990 to 2019.
According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies comparing the rates of delayed cerebral ischemia and clinical outcomes among patients with SAH with and without antiplatelet therapy.
Random-effects meta-analysis was used to pool the following: delayed cerebral ischemia, mortality, and good outcome rates.
Including 7 studies, 1060 and 1762 patients with SAH were endovascularly or surgically treated with (cases) and without (controls) antiplatelet therapy, respectively. Overall, antiplatelet therapy did not significantly decrease delayed cerebral ischemia rates compared with the control group (219/1060 versus 485/1762, OR = 0.781; 95% CI, 0.46-1.31;
= .33). Among patients treated endovascularly, there was a trend toward lower delayed cerebral ischemia rates after antiplatelet therapy (157/778 versus 413/1410, OR = 0.552; 95% CI, 0.273-1.115;
= .06). Long-term (>2 weeks) antiplatelet therapy tended to be associated with a lower incidence of delayed cerebral ischemia (63/438 versus 96/353, OR = 0.379; 95% CI, 0.12-1.2;
= .06). The good-outcome rate was significantly higher (803/1144 versus 1175/1775, OR = 1.368; 95% CI, 1.117-1.676;
= .002) and the mortality rate was significantly lower (79/672 versus 97/571, OR = 0.656; 95% CI, 0.47-0.91;
= .01) among the antiplatelet therapy group.
Heterogeneity was high for most outcomes.
Overall, the incidence of delayed cerebral ischemia seems not to be significantly reduced among the antiplatelet therapy group. However, delayed cerebral ischemia tended to be lower among subjects with both long-term antiplatelet therapy and endovascular treatment and antiplatelet administration. Poor outcome and mortality rates were significantly reduced among the antiplatelet therapy group.
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