Comparison of Flow Diversion and Coiling for the Treatment of Unruptured Intracranial Aneurysms

Introduction Flow diversion is an effective treatment modality for intracranial aneurysms but is associated with ischemic and hemorrhagic complications. Patients treated with flow diversion require dual antiplatelet therapy and subsequent platelet function tests. At our institution, Thromboelastography with Platelet Mapping (TEG-PM) is the test of choice. The primary objective of this study was to identify TEG parameters that are predictive of postoperative complications in patients treated with elective flow diversion. Methods This was a retrospective study of 118 patients with unruptured intracranial aneurysms treated with flow diversion. Data was collected via chart review. Bivariate analyses were performed to identify significant variables in patients who suffered an ischemic stroke or a groin hematoma. ROC curves were constructed for the TEG parameters with statistical significance. Bivariate analyses were repeated using dichotomized TEG results. Results Patients who experienced a symptomatic ischemic stroke had a history of stroke (p value = 0.007), larger aneurysm neck width (p value = 0.017), and a higher alpha angle (p value = 0.013). Cut off point for ischemic complication is 63° on ROC curve with a sensitivity of 100% and specificity of 65%. Patients who experienced a groin hematoma were no different from their healthy peers but had a lower alpha angle (p value = 0.033). Cut off point for hemorrhagic complication is 53.3° with a sensitivity of 82% and specificity of 67%. Conclusion The Alpha Angle parameter of TEG-PM has a sizeable predictive ability for both ischemic complications of the central nervous system and hemorrhagic complications of the access site after elective flow diversion.

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Outcomes following aneurysmal coil embolization with intentionally shortened low-profile visible intraluminal support stent deployment

The Neuroradiology Journal ◽

10.1177/19714009211026925 ◽

2021 ◽

pp. 197140092110269

Author(s):

Kenji Yatomi ◽

Yumiko Mitome-Mishima ◽

Takashi Fujii ◽

Kohsuke Teranishi ◽

Hidenori Oishi ◽

...

Keyword(s):

Fluid Dynamics ◽

Computational Fluid Dynamics ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Perioperative Complications ◽

Flow Diversion ◽

Stent Deployment ◽

Coverage Ratio ◽

Low Profile ◽

Unruptured Intracranial Aneurysms

Purpose Among all stents available for neuroendovascular therapy, the low-profile visible intraluminal support stent bears the highest metal coverage ratio. We deployed a low-profile visible intraluminal support stent with a delivery wire or/and microcatheter system push action to shorten the low-profile visible intraluminal support stent and thus achieve a flow diversion effect. We report our single-institution experience with the use of low-profile visible intraluminal support stents for intentionally shortened deployment (shortening group) and non-shortened deployment (non-shortening group) for unruptured intracranial aneurysms. Methods We retrospectively reviewed the medical records of 130 patients with 131 intracranial aneurysms who were treated with low-profile visible intraluminal support stent-assisted coil embolization from February 2016–January 2019. All perioperative complications were noted. Every 6 months, we re-examined the patients with cerebral angiography or magnetic resonance angiography. The outcomes of aneurysm occlusion were evaluated by the modified Raymond–Roy occlusion classification. We used the finite element method and computational fluid dynamics to investigate the hemodynamics after shortened low-profile visible intraluminal support stent deployment. Results Immediately after treatment, the modified Raymond-Roy occlusion classification was significantly better in the shortening group than in the non-shortening group ( p<0.05). The latest angiographic outcomes showed the same tendency. Hemodynamic analysis by computational fluid dynamics suggested an adequate flow diversion effect with the use of our intentional shortening method. Conclusions Stent-assisted coil embolization using this technique showed good results of a high complete occlusion rate and low complication rate. These findings suggest that shortened low-profile visible intraluminal support stent deployment yields a flow diversion effect and may lead to early intra-aneurysmal thrombus formation.

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Analysis of cerebrovascular aneurysm treatment cost: retrospective cohort comparison of clipping, coiling, and flow diversion

Neurosurgical FOCUS ◽

10.3171/2018.1.focus17775 ◽

2018 ◽

Vol 44 (5) ◽

pp. E3 ◽

Cited By ~ 12

Author(s):

Spencer Twitchell ◽

Hussam Abou-Al-Shaar ◽

Jared Reese ◽

Michael Karsy ◽

Ilyas M. Eli ◽

...

Keyword(s):

Health Care ◽

Intracranial Aneurysms ◽

Flow Diverter ◽

Flow Diversion ◽

High Quality ◽

Total Cost ◽

Cost Drivers ◽

Discharge Disposition ◽

Unruptured Intracranial Aneurysms ◽

Care Costs

OBJECTIVEWith the continuous rise of health care costs, hospitals and health care providers must find ways to reduce costs while maintaining high-quality care. Comparing surgical and endovascular treatment of intracranial aneurysms may offer direction in reducing health care costs. The Value-Driven Outcomes (VDO) database at the University of Utah identifies cost drivers and tracks changes over time. In this study, the authors evaluate specific cost drivers for surgical clipping and endovascular management (i.e., coil embolization and flow diversion) of both ruptured and unruptured intracranial aneurysms using the VDO system.METHODSThe authors retrospectively reviewed surgical and endovascular treatment of ruptured and unruptured intracranial aneurysms from July 2011 to January 2017. Total cost (as a percentage of each patient’s cost to the system), subcategory costs, and potential cost drivers were evaluated and analyzed.RESULTSA total of 514 aneurysms in 469 patients were treated; 273 aneurysms were surgically clipped, 102 were repaired with coiling, and 139 were addressed with flow diverter placements. Middle cerebral artery aneurysms accounted for the largest portion of cases in the clipping group (29.7%), whereas anterior communicating artery aneurysms were most frequently involved in the coiling group (30.4%) and internal carotid artery aneurysms were the majority in the flow diverter group (63.3%). Coiling (mean total cost 0.25% ± 0.20%) had a higher cost than flow diversion (mean 0.20% ± 0.16%) and clipping (mean 0.17 ± 0.14%; p = 0.0001, 1-way ANOVA). Coiling cases cost 1.5 times as much as clipping and flow diversion costs 1.2 times as much as clipping. Facility costs were the most significant contributor to intracranial clipping costs (60.2%), followed by supplies (18.3%). Supplies were the greatest cost contributor to coiling costs (43.2%), followed by facility (40.0%); similarly, supplies were the greatest portion of costs in flow diversion (57.5%), followed by facility (28.5%). Cost differences for aneurysm location, rupture status, American Society of Anesthesiologists (ASA) grade, and discharge disposition could be identified, with variability depending on surgical procedure. A multivariate analysis showed that rupture status, surgical procedure type, ASA status, discharge disposition, and year of surgery all significantly affected cost (p < 0.0001).CONCLUSIONSFacility utilization and supplies constitute the majority of total costs in aneurysm treatment strategies, but significant variation exists depending on surgical approach, rupture status, and patient discharge disposition. Developing and implementing approaches and protocols to improve resource utilization are important in reducing costs while maintaining high-quality patient care.

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Residuals, recurrences and re-treatment after endovascular repair of intracranial aneurysms: A retrospective methodological comparison

Interventional Neuroradiology ◽

10.1177/1591019919867841 ◽

2019 ◽

Vol 26 (1) ◽

pp. 45-54 ◽

Cited By ~ 3

Author(s):

Jens J Froelich ◽

Nicholas Cheung ◽

Johan AB de Lange ◽

Jessica Monkhorst ◽

Michael W Carr ◽

...

Keyword(s):

Endovascular Treatment ◽

Medical Records ◽

Intracranial Aneurysms ◽

Aneurysm Rupture ◽

Flow Diversion ◽

Unruptured Aneurysms ◽

Ruptured Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

Methodological Comparison

Objective Incomplete aneurysm occlusions and re-treatment rates of 52 and 10–30%, respectively, have been reported following endovascular treatment of intracranial aneurysms, raising clinical concerns regarding procedural efficacy. We compare residual, recurrence and re-treatment rates subject to different endovascular techniques in both ruptured and unruptured intracranial aneurysms at a comprehensive state-wide tertiary neurovascular centre in Australia. Methods Medical records, procedural and follow-up imaging studies of all patients who underwent endovascular treatment for intracranial aneurysms between July 2010 and July 2017 were reviewed retrospectively. Residuals, recurrences and re-treatment rates were assessed regarding initial aneurysm rupture status and applied endovascular technique: primary coiling, balloon- and stent-assisted coiling and flow diversion. Results Among 233 aneurysms, residual, recurrence and re-treatment rates were 27, 11.2 and 9.4%, respectively. Compared with unruptured aneurysms, similar residual and recurrence (p > .05), but higher re-treatment rates (4.5% vs. 19%; p < .001) were found for ruptured aneurysms. Residual, recurrence and re-treatment rates were: 13.3, 16 and 12% for primary coiling; 12, 12 and 10.7% for balloon-assisted coiling; 14.9, 7.5 and 4.5% for stent-assisted coiling; 91.9, 0 and 5.4% for flow diversion. Stent-assistance and flow-diversion were associated with lower recurrence and re-treatment rates, when compared with primary- and balloon-assisted coiling (p < .05). Conclusions Residuals and recurrences after endovascular treatment of intracranial aneurysms are less common than previously reported. Stent assistance and flow diversion seem associated with reduced recurrence- and re-treatment rates, when compared with primary- and balloon-assisted coiling. Restrained use of stents in ruptured aneurysms may be a contributing factor for higher recurrence/retreatment rates compared to unruptured aneurysms.

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Flow Diversion Endovascular Treatment Improves Headaches in Patients with Unruptured Intracranial Aneurysms

World Neurosurgery ◽

10.1016/j.wneu.2020.04.206 ◽

2020 ◽

Vol 140 ◽

pp. e140-e147

Author(s):

Georgios A. Maragkos ◽

Sarah Cordell ◽

Santiago Gomez-Paz ◽

Laura E. Dodge ◽

Mohamed M. Salem ◽

...

Keyword(s):

Endovascular Treatment ◽

Intracranial Aneurysms ◽

Flow Diversion ◽

Unruptured Intracranial Aneurysms

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Letter to the Editor Regarding “Flow Diversion Endovascular Treatment Improves Headaches in Patients with Unruptured Intracranial Aneurysms”

World Neurosurgery ◽

10.1016/j.wneu.2021.03.145 ◽

2021 ◽

Vol 151 ◽

pp. 302

Author(s):

Adrian Safa

Keyword(s):

Endovascular Treatment ◽

Intracranial Aneurysms ◽

Flow Diversion ◽

Letter To The Editor ◽

Unruptured Intracranial Aneurysms

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Editorial: What is the future of the endovascular treatment of intracranial aneurysms?

Endovascular Neuroradiology ◽

10.26683/2304-9359-2020-2(32)-12-20 ◽

2020 ◽

Vol 32 (2) ◽

pp. 12-20

Author(s):

Laurent Pierot

Keyword(s):

Endovascular Treatment ◽

Intracranial Aneurysms ◽

New Technologies ◽

Flow Diversion ◽

Treatment Modalities ◽

Flow Disruption ◽

Complex Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

Number Of Patients ◽

The Future

Intracranial aneurysms rapture is a common cause of mortality or morbidity worldwide. For this reason, in case of rupture, early treatment of the aneurysm is mandatory. The evaluation of unruptured intracranial aneurysms continue to increased due to the improvements in invasive and non-invasive neuroimaging. Securing of this life-threatening condition, considering all demographical and procedural factors is necessary for improving treatment results and patients outcome. The endovascular treatment has become frontline therapy of cerebral aneurysms treatment during the last 20 years, and without a doubt its recent advances shifted this boundary even further. Nowadays endovascular armamentarium continues to grow rapidly. Neuro-interventional procedures have tremendously improved their efficiency and continue to improve device’s safety. However some types of aneurysms are not really easy to treat with ordinary endovascular technique as it can result in devastating consequence, Firstly, it is not always applicable to complex aneurysms or very large neck aneurysms. Secondly, durability of the of the aneurysm occlusion is not guaranteed in all cases even after usage of the remodeling technique or regular stenting. New devices are introduced to decrease these limits. Two new innovative techniques that are increasingly used for endovacular occlusion of the complex aneurysms are flow diversion and intrasaccular flow disruption. The objective of this review is to provide a comprehensive overview of novel paradigms and latest research of flow diversion and intrasaccular flow disruption devices, its current application, limitation and future prospective. The obvious advantages of these new technologies proved progressive expansion of their utilization to the extent that they will ultimately replace standard coiling in an increasing number of cases going forward. The future of the endovascular treatment of intracranial aneurysms is bright. Fast gro-wing improvement in vascular access, treatment modalities and device delivery continue to increase number of patients with intracranial aneurysms treated with endovascular approach versus surgical clipping.

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Resolution of Diminished Olfactory Sensation After Treatment of Bilateral Ophthalmic Segment Aneurysms With Flow Diversion

Neurosurgery ◽

10.1227/neu.0000000000000127 ◽

2013 ◽

Vol 74 (2) ◽

pp. E226-E229 ◽

Cited By ~ 4

Author(s):

Prashant S. Kelkar ◽

Mohamad R. Chaaban ◽

Beverly C. Walters ◽

Bradford A. Woodworth ◽

John P. Deveikis ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Intracranial Aneurysms ◽

Internal Carotid ◽

Mass Effect ◽

Flow Diversion ◽

Olfactory Tract ◽

Olfactory Sensation ◽

Unruptured Intracranial Aneurysms ◽

Ophthalmic Segment Aneurysms

Abstract BACKGROUND AND IMPORTANCE: Olfactory tract dysfunction due to an unruptured intracranial aneurysm is rare. We present a case in which a patient with impaired olfaction related to bilateral internal carotid artery aneurysms experienced subjective and quantitative objective improvement of olfactory sensation after treatment of ophthalmic segment aneurysms with flow diversion. CLINICAL PRESENTATION: A 44-year-old woman presented with hyposmia and bilateral ophthalmic segment internal carotid artery aneurysms. The symptom of hyposmia, worsening over a period of several months, was suspected to be due to mass effect from bilateral unruptured ophthalmic segment aneurysms pressing on the olfactory tracts. Each aneurysm was treated with a Pipeline embolization device (PED). Follow-up angiography at 5 months showed occlusion of both aneurysms. The patient experienced subjective improvement in olfaction and complete objective resolution of her hyposmia as measured by the validated University of Pennsylvania Smell Identification Test (UPSIT). CONCLUSION: Intracranial aneurysms causing dysfunction of olfactory sensation due to mass effect upon the olfactory tract can be successfully treated with flow diversion. Flow diversion should be considered as one of the treatment options for patients with cranial nerve dysfunction due to unruptured intracranial aneurysms.

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Stratification of Recanalization for Patients With Endovascular Treatment of Intracranial Aneurysms

Neurosurgery ◽

10.1227/neu.0000000000000651 ◽

2015 ◽

Vol 76 (4) ◽

pp. 390-395 ◽

Cited By ~ 19

Author(s):

Christopher S. Ogilvy ◽

Michelle H. Chua ◽

Matthew R. Fusco ◽

Arra S. Reddy ◽

Ajith J. Thomas

Keyword(s):

Decision Making ◽

Endovascular Treatment ◽

Intracranial Aneurysms ◽

Aneurysm Rupture ◽

Flow Diversion ◽

Comprehensive Model ◽

Patient Centered ◽

Related Factors ◽

Accessible Information ◽

Unruptured Intracranial Aneurysms

Abstract BACKGROUND: With the increasing use of endovascular techniques in the treatment of both ruptured and unruptured intracranial aneurysms, the issue of obliteration efficacy has become increasingly important. OBJECTIVE: To systematically develop a comprehensive model for predicting retreatment with various types of endovascular treatment. METHODS: We retrospectively reviewed medical records that were prospectively collected for 305 patients who received endovascular treatment for intracranial aneurysms from 2007 to 2013. Multivariable logistic regression was performed on candidate predictors identified by univariable screening analysis to detect independent predictors of retreatment. A composite risk score was constructed based on the proportional contribution of independent predictors in the multivariable model. RESULTS: Size (>10 mm), aneurysm rupture, stent assistance, and posttreatment degree of aneurysm occlusion were independently associated with retreatment, whereas intraluminal thrombosis and flow diversion demonstrated a trend toward retreatment. The Aneurysm Recanalization Stratification Scale was constructed by assigning the following weights to statistically and clinically significant predictors: aneurysm-specific factors: size (>10 mm), 2 points; rupture, 2 points; presence of thrombus, 2 points. Treatment-related factors were stent assistance, −1 point; flow diversion, −2 points; Raymond Roy occlusion class 2, 1 point; Raymond Roy occlusion class 3, 2 points. This scale demonstrated good discrimination with a C-statistic of 0.799. CONCLUSION: Surgical decision making and patient-centered informed consent require comprehensive and accessible information on treatment efficacy. We constructed the Aneurysm Recanalization Stratification Scale to enhance this decision-making process. This is the first comprehensive model that has been developed to quantitatively predict the risk of retreatment after endovascular therapy.

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Interest of Flow Diversion Prostheses in the Management of Unruptured Intracranial Aneurysms

International Journal of Vascular Medicine ◽

10.1155/2012/654627 ◽

2012 ◽

Vol 2012 ◽

pp. 1-5 ◽

Cited By ~ 7

Author(s):

Xavier Armoiry ◽

Mélanie Paysant ◽

Daniel Hartmann ◽

Gilles Aulagner ◽

Francis Turjman

Keyword(s):

Intracranial Aneurysms ◽

New Technology ◽

Flow Diversion ◽

Current Status ◽

Metallic Surface ◽

Endovascular Coiling ◽

Surgical Clipping ◽

Unruptured Intracranial Aneurysms ◽

Endovascular Approach ◽

Wide Neck

Flow diversion prostheses represent a new endovascular approach aimed at treating patients with large wide-neck aneurysms. Our objective is to present this new technology, to review the clinical studies on efficacy, and to emphasize its current limits. Flow diversion prostheses consist of a cylinder made of a large number of braided microfilaments providing a large metallic surface when deployed and inducing a blood flow diversion outside the aneurysm. Two different brands are currently available. Clinical data supporting their efficacy are currently limited to six non comparative cohort studies that included between 18 and 107 patients. Procedural implantation was shown to be feasible in more than 90% and safe with a thirty-day mortality between 2.8 and 5.5%. Complete occlusion rates at twelve months varied between 85.7 and 100%. Even though promising, the current status of flow diversion prostheses needs further evaluation with randomized, prospective, clinical trials with comparison to conventional strategies including endovascular coiling or surgical clipping.

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