Endovascular embolization of branch-incorporated cerebral aneurysms

Objectives The aim of this study was to examine the feasibility, technique, and clinical and angiographic outcomes of endovascular coiling to treat a cerebral aneurysm with a branch incorporated into the aneurysmal wall. Methods From 2012 to 2016, 25 patients with 26 cerebral aneurysms having a branch incorporated into the aneurysm (9 unruptured, 17 ruptured) were treated to prevent rupture or re-bleeding from the sac while preserving the incorporated branch by using single-catheter ( n = 18), balloon-remodeling ( n = 4), stent-assisted coiling ( n = 3), or double-catheter ( n = 1) techniques. Results Endovascular coiling was conducted in 26 procedures without angiographic occlusion of the incorporated branch. Post-embolization angiography revealed near-complete occlusion ( n = 8; 30.7%), neck remnant ( n = 13; 50%), and incomplete occlusion ( n = 5; 19.3%) aneurysms. Thromboembolisms were observed in four (15.4%) patients during or after the procedure. A procedure-related neurological deficit was observed in one (3.8%) patient. When patients with a preictal modified Rankin Scale (mRS) score of 3 presenting with grade 5 subarachnoid hemorrhage were excluded, all patients had favorable outcomes (mRS 0–2). Six (23.1%) recurrent aneurysms were observed during follow-up, five of which were treated endovascularly at 5–22 months without complication. The location of an aneurysm at the ICA-posterior communicating artery associated with the dominant-type posterior communicating artery was significantly associated with recurrence ( p = 0.041). Conclusions Cerebral aneurysms with an incorporated branch were safely treated using conventional endovascular coiling. However, treatment durability was unsatisfactory, especially for dominant-type ICA-posterior communicating artery aneurysms.

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Mid-term Results of Endovascular Coiling of Wide-Necked Aneurysms Using Double Stents in a Y Configuration

Neurosurgery ◽

10.1227/neu.0b013e318214abbd ◽

2011 ◽

Vol 69 (2) ◽

pp. 421-429 ◽

Cited By ~ 68

Author(s):

Alejandro M. Spiotta ◽

Rishi Gupta ◽

David Fiorella ◽

Vivekananda Gonugunta ◽

Bjorn Lobo ◽

...

Keyword(s):

Initial Treatment ◽

Cerebral Aneurysms ◽

Endovascular Coiling ◽

Thromboembolic Complications ◽

Endovascular Management ◽

Spontaneous Thrombosis ◽

Complete Occlusion ◽

Neck Recurrence ◽

Mid Term Results

Abstract BACKGROUND: Double stenting in a Y configuration may be used to treat a subset of wide-necked aneurysms not amenable to reconstruction with a single stent. OBJECTIVE: We studied the feasibility, safety, and mid-term angiographic outcome of patients treated using this technique. METHODS: A retrospective review was undertaken of all coil embolizations of wide-necked aneurysms using double stents in a Y configuration. RESULTS: Nineteen patients were identified from 2002 to 2010 (14 women, 5 men) with a mean age of 57.4 years. Stents were deployed in a Y configuration achieving complete occlusion (5/19), residual neck (5/19), and residual aneurysm filling (9/19). Angiographic follow-up was available for a mean of 16 months, and clinical follow up was available for a mean of 21.4 months. The incidence of complications at the initial treatment was 6 of 19 (31.6%), and delayed thromboembolic complications occurred in 2 of 19 (10.5%). An angiographic neck recurrence requiring retreatment developed in only 1 of the patients in whom complete occlusion was obtained with the initial treatment. Spontaneous thrombosis and complete occlusion on follow-up imaging were found in 6 patients in whom initial neck or aneurysm filling was observed. Ultimately, 12 of the aneurysms (63.2%) were completely occluded on follow-up angiography. CONCLUSION: Y-stent reconstruction enables the endovascular management of otherwise complex, wide-necked cerebral aneurysms and can be performed safely in experienced hands with satisfactory mid-term results, even in cases requiring retreatment.

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Factors affecting recurrence and management of recurrent cerebral aneurysms after initial coiling

Interventional Neuroradiology ◽

10.1177/1591019919901037 ◽

2020 ◽

Vol 26 (3) ◽

pp. 300-308

Author(s):

Yongfeng Han ◽

Jian Liu ◽

Zhongbin Tian ◽

Ming Lv ◽

Xinjian Yang ◽

...

Keyword(s):

Cerebral Aneurysms ◽

Clinical Results ◽

Factors Affecting ◽

Complete Occlusion ◽

Giant Aneurysms ◽

Procedural Complications ◽

Aneurysm Occlusion ◽

Large And Giant Aneurysms ◽

Incomplete Occlusion

Objective To investigate factors affecting recurrence and effects and safety of endovascular retreatment for aneurysms recurrent after embolization. Methods Among 815 aneurysms treated with embolization, recurrence was in 114 aneurysms (14.0%). Forty-three recurrent aneurysms were managed with re-embolization. Procedural complications, angiographic, and clinical results of retreatment were analyzed. Results Patients with recurrent aneurysms were significantly ( P < 0.01) younger than without recurrence (51.09 ± 10.46 vs. 53.88 ± 9.61 years). Recurrent aneurysms ( n = 114) were significantly ( P = 0.00) greater (11.12 ± 8.35 vs. 5.81 ± 3.44 mm) with a significantly ( P = 0.00) greater neck (4.34 ± 2.26 vs. 2.90 ± 1.44 mm) than without recurrence. The rupture status of aneurysms significantly ( P = 0.00) affected recurrence at follow-up. Significantly ( P = 0.00) more aneurysms without recurrence were treated with advanced embolization techniques (81.0% vs. 62.3%) and got complete occlusion at the first embolization than those with recurrence (93.7% vs. 36.8%). In treating 43 recurrent aneurysms, stent-assisted recoiling was used in 48.8% in the first retreatment and 50% in the second and third retreatment procedures. Angiographic follow-up in 38 (88.4%) cases showed complete or near complete occlusion in 30 aneurysms, with the rest eight aneurysms experiencing a second recurrence (21.1%). Of the eight aneurysms with the second recurrence, five underwent the second endovascular retreatment, with complete aneurysm occlusion achieved in three cases (60%), near-complete occlusion in one (20%), and incomplete occlusion in one case at immediate angiography and six-month follow-up. Procedure-related complications occurred in three patients. Conclusions Endovascular retreatment of recurrent previously coiled aneurysms is safe and effective even though advanced embolization techniques are frequently involved especially for large and giant aneurysms.

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Patency of the posterior communicating artery following treatment with the Pipeline Embolization Device

Journal of Neurosurgery ◽

10.3171/2016.2.jns152544 ◽

2017 ◽

Vol 126 (2) ◽

pp. 564-569 ◽

Cited By ~ 23

Author(s):

Badih Daou ◽

Edison P. Valle-Giler ◽

Nohra Chalouhi ◽

Robert M. Starke ◽

Stavropoula Tjoumakaris ◽

...

Keyword(s):

Multivariate Analyses ◽

Univariate Analysis ◽

Cerebral Aneurysms ◽

Posterior Communicating Artery ◽

Pipeline Embolization Device ◽

Factors Associated ◽

Previously Treated ◽

Flow Through ◽

Incomplete Occlusion

OBJECTIVE The Pipeline Embolization Device (PED) has become an effective treatment strategy for some cerebral aneurysms. Concerns regarding the patency of branch arteries have been raised. The objective of this study was to assess the patency of the posterior communicating artery (PCoA) following treatment of PCoA aneurysms using the PED. METHODS All patients with PCoA aneurysms treated with the PED who had angiographic follow-up were retrospectively identified. The patency of the PCoA at follow-up was evaluated by 2 authors who were not involved in the intervention. Univariate and multivariate analyses were performed to identify factors associated with the following: 1) PCoA patency versus no or diminished flow, and 2) PCoA patency and diminished flow versus PCoA occlusion. RESULTS Thirty patients with an angiographic follow-up of 6 months were included. Aneurysm obliteration was achieved in 25 patients (83.3%). The PCoA was patent in 7 patients (23.3%), had diminished flow in 7 patients (23.3%), and was occluded in 16 patients (53.3%). In the univariate analysis of outcome, there was a trend for aneurysms with incomplete occlusion, aneurysms not previously treated, those with presence of a fetal PCoA, and those with an artery coming from the aneurysm to have higher odds of the PCoA remaining patent. In univariate and multivariate analyses of factors associated with outcome, fetal PCoA and presence of an artery coming from the aneurysm were associated with the PCoA remaining open with or without diminished flow. No patients had symptoms related to PCoA occlusion. CONCLUSIONS Occlusion and diminished flow through the PCoA is common following PED treatment of PCoA aneurysms. However, it is clinically insignificant in most cases.

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Endovascular Management of Cerebral Aneurysms of the Posterior Cerebral Artery

Frontiers in Neurology ◽

10.3389/fneur.2021.700516 ◽

2021 ◽

Vol 12 ◽

Author(s):

Xin-Yu Li ◽

Cong-Hui Li ◽

Ji-Wei Wang ◽

Jian-Feng Liu ◽

Hui Li ◽

...

Keyword(s):

Cerebral Artery ◽

Posterior Cerebral Artery ◽

Cerebral Aneurysms ◽

Endovascular Embolization ◽

Good Choice ◽

Parent Artery ◽

Safety And Efficacy ◽

Complete Occlusion ◽

Parent Artery Occlusion

Purpose: To investigate the safety and efficacy of endovascular embolization of cerebral aneurysms at the P1–P3 segments of the posterior cerebral artery (PCA).Materials and Methods: Seventy-seven patients with 77 PCA aneurysms who were treated with endovascular embolization were enrolled, including 35 (45.5%) patients with ruptured aneurysms and 42 (54.5%) with unruptured ones. The pretreatment clinical data and aneurysm occlusion status after treatment and at follow-up were analyzed.Results: All patients were successfully treated endovascularly, including coiling alone in 10 (13.0%) patients, stent-assisted coiling in 18 (23.4%), parent artery occlusion in 25 (32.5%), and pipeline embolization device (PED) in 24 (31.2%). Complete occlusion was achieved in 48 (62.3%) aneurysms, residual neck in 4 (5.2%), and residual aneurysm in the other 25 (32.5%) at the end of embolization. Periprocedural complications occurred in eight patients, including acute thrombosis in seven (9.1%) and intraprocedural subarachnoid hemorrhage in one (1.3%), with the total complication rate of 10.4%. Follow-up was performed in 60 patients (77.9%) for 42 ± 11 months; the mRS score was 0–2 in 55 (91.7%) patients, three in four patients (6.7%), and six in one patient (1.7%). Fifty-three (88.3%) patients (53 aneurysms) had stable or complete occlusion, and seven (11.7%) patients had aneurysm recurrence or residual aneurysm. Among 19 patients treated with PED at follow-up, 15 aneurysms (78.9%) proceeded to complete occlusion while four (21.1%) aneurysms showed residual aneurysm.Conclusion: Endovascular embolization remains a good choice of treatment with high safety and efficacy for posterior cerebral artery aneurysms.

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Adenosine-induced Asystole during AVM Embolization

Clinical Neuroradiology ◽

10.1007/s00062-021-01035-z ◽

2021 ◽

Author(s):

V. Hellstern ◽

P. Bhogal ◽

M. Aguilar Pérez ◽

M. Alfter ◽

A. Kemmling ◽

...

Keyword(s):

Demographic Data ◽

Clinical Results ◽

Endovascular Embolization ◽

Neurological Deficits ◽

Residual Shunt ◽

Grade 5 ◽

Martin Grade ◽

Grade 3 ◽

Brain Avms

Abstract Background Adenosine induced cardiac standstill has been used intraoperatively for both aneurysm and arteriovenous malformation (AVM) surgery and embolization. We sought to report the results of adenosine induced cardiac standstill as an adjunct to endovascular embolization of brain AVMs. Material and Methods We retrospectively identified patients in our prospectively maintained database to identify all patients since January 2007 in whom adenosine was used to induce cardiac standstill during the embolization of a brain AVM. We recorded demographic data, clinical presentation, Spetzler Martin grade, rupture status, therapeutic intervention and number of embolization sessions, angiographic and clinical results, clinical and radiological outcomes and follow-up information. Results We identified 47 patients (22 female, 47%) with average age 42 ± 17 years (range 6–77 years) who had undergone AVM embolization procedures using adjunctive circulatory standstill with adenosine. In total there were 4 Spetzler Martin grade 1 (9%), 9 grade 2 (18%), 15 grade 3 (32%), 8 grade 4 (18%), and 11 grade 5 (23%) lesions. Of the AVMs six were ruptured or had previously ruptured. The average number of embolization procedures per patient was 5.7 ± 7.6 (range 1–37) with an average of 2.6 ± 2.2 (range 1–14) embolization procedures using adenosine. Overall morbidity was 17% (n = 8/47) and mortality 2.1% (n = 1/47), with permanent morbidity seen in 10.6% (n = 5/47) postembolization. Angiographic follow-up was available for 32 patients with no residual shunt seen in 26 (81%) and residual shunts seen in 6 patients (19%). The angiographic follow-up is still pending in 14 patients. At last follow-up 93.5% of patients were mRS ≤2 (n = 43/46). Conclusion Adenosine induced cardiac standstill represents a viable treatment strategy in high flow AVMs or AV shunts that carries a low risk of mortality and permanent neurological deficits.

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Long-Term Results and Follow-Up Examinations after Endovascular Embolization for Unruptured Cerebral Aneurysms

American Journal of Neuroradiology ◽

10.3174/ajnr.a6101 ◽

2019 ◽

Vol 40 (7) ◽

pp. 1191-1196 ◽

Cited By ~ 1

Author(s):

T. Murakami ◽

T. Nishida ◽

K. Asai ◽

Y. Kadono ◽

H. Nakamura ◽

...

Keyword(s):

Cerebral Aneurysms ◽

Endovascular Embolization ◽

Long Term Results ◽

Unruptured Cerebral Aneurysms

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Stent-Assisted Coiling of Cerebral Aneurysms: A Multicenter Analysis

Neurosurgery ◽

10.1093/neuros/nyz310_668 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Maxim Mokin ◽

Christopher T Primiani ◽

Keaton Piper ◽

David Fiorella ◽

Ansaar Rai ◽

...

Keyword(s):

Clinical Outcomes ◽

Cerebral Aneurysms ◽

Final Analysis ◽

Patient Characteristics ◽

Aneurysm Rupture ◽

Endovascular Coiling ◽

Complete Occlusion ◽

Low Profile ◽

Grade Scale ◽

The Difference

Abstract INTRODUCTION New devices have allowed endovascular stent-assisted coiling for the treatment of cerebral aneurysms. It remains unknown how each type of stent affects the safety, efficacy, and clinical outcomes of the stent-coiling procedure. METHODS This study compared the outcomes of endovascular coiling of cerebral aneurysms using Neuroform (NEU), Enterprise (EP), and Low-profile Vi_sualized Intraluminal Support (LVIS) stents. Cases of aneurysms treated with more than one type of stents (NEU, EP, LVIS) used for coiling of the same lesion (n = 24) or other devices (n = 32) were excluded. Patient characteristics, angiographic results using the Raymond-Roy grade scale (RRGS), clinical outcomes and procedural complications were analyzed in our study. Patients data was retrospectively collected from 6 academic centers. RESULTS A total of 659 patients with 670 cerebral aneurysms treated with stent-assisted coiling (NEU, n = 182; EP, n = 158; LVIS, n = 330) were included in final analysis. Patient characteristics included mean age 56 ? 12 yr old, female prevalence 74% and aneurysm rupture on initial presentation of 19%. The degree of occlusion at baseline angiography was significantly associated with age (P = .002), location by circulation (P = .002), aneurysm size (P = .009), and rupture status (P = .013). We found differences in complete occlusion on baseline imaging, defined as RRGS I, among the three stents: LVIS 64% (210/326); NEU 56% (95/169); EP 48% (68/143); P = .008. The difference of complete occlusion on 10.5 mo (mean) and 8 mo (median) angiographic follow-up was also significant: LVIS 84% (251/299); NEU 78% (117/150); EP 67% (83/123); P = .004. There were 7% (47/670) intraprocedural complications and 11.5% (73/632) postprocedural related complications in our cohort. CONCLUSION There were significant affects based on type of stent used for assisted coiling in the immediate and long-term angiographic outcomes in our cohort. Randomized prospective trials are warranted to compare stent types and clinical outcome.

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Endovascular Coiling of Aneurysm Remnants after Clipping in Patients with Follow-up

Interventional Neuroradiology ◽

10.1177/159101990501100106 ◽

2005 ◽

Vol 11 (1) ◽

pp. 41-48 ◽

Cited By ~ 9

Author(s):

S. Mangiafico ◽

M. Cellerini ◽

G. Villa ◽

F. Ammannati ◽

L. Paoli ◽

...

Keyword(s):

Treatment Strategy ◽

Intracranial Aneurysms ◽

Endovascular Embolization ◽

Endovascular Coiling ◽

Surgical Clipping ◽

Anterior Circulation ◽

Therapeutic Alternative ◽

Relative Safety

The vast majority of intracranial aneurysms can be obliterated completely with surgical clipping. However, postoperative remnants occur in about 4 to 8% of patients who undergo postoperative angiography. Endovascular embolization has been successfully performed in patients with postoperative aneurysm remnant and it may represent a therapeutic alternative to surgical reintervention. Twelve aneurysm remnants after surgical clipping were treated with endovascular embolization using GDC. All aneurysms were located in the anterior circulation. Our experience confirms the feasibility and relative safety of this treatment strategy that may be considered a valid alternative to reintervention.

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Pipeline embolization device for recurrence of previously treated aneurysms

Neurosurgical FOCUS ◽

10.3171/2017.3.focus1744 ◽

2017 ◽

Vol 42 (6) ◽

pp. E8 ◽

Cited By ~ 10

Author(s):

David Dornbos ◽

Constantine L. Karras ◽

Nicole Wenger ◽

Blake Priddy ◽

Patrick Youssef ◽

...

Keyword(s):

Flow Diversion ◽

High Rate ◽

Endovascular Coiling ◽

Vessel Occlusion ◽

Pipeline Embolization Device ◽

Complete Occlusion ◽

Microsurgical Clipping ◽

Previously Treated ◽

Angiographic Evidence

OBJECTIVEThe utilization of the Pipeline embolization device (PED) has increased significantly since its inception and original approval for use in large, broad-necked aneurysms of the internal carotid artery. While microsurgical clipping and advances in endovascular techniques have improved overall efficacy in achieving complete occlusion, recurrences still occur, and the best modality for retreatment remains controversial. Despite its efficacy in this setting, the role of PED utilization in the setting of recurrent aneurysms has not yet been well defined. This study was designed to assess the safety and efficacy of PED in the recurrence of previously treated aneurysms.METHODSThe authors reviewed a total of 13 cases in which patients underwent secondary placement of a PED for aneurysm recurrence following prior treatment with another modality. The PEDs were used to treat aneurysm recurrence or residual following endovascular coiling in 7 cases, flow diversion in 2, and microsurgical clipping in 4. The mean time between initial treatment and retreatment with a PED was 28.1 months, 12 months, and 88.7 months, respectively. Clinical outcomes, including complications and modified Rankin Scale (mRS) scores, and angiographic evidence of complete occlusion were tabulated for each treatment group.RESULTSAll PEDs were successfully placed without periprocedural complications. The rate of complete occlusion was 80% at 6 months after PED placement and 100% at 12 months in these patients who underwent PED placement following failed endovascular coiling; there were no adverse clinical sequelae at a mean follow-up of 26.1 months. In the 2 cases in which PEDs were placed for treatment of residual aneurysms following prior flow diversion, 1 patient demonstrated asymptomatic vessel occlusion at 6 months, and the other exhibited complete aneurysm occlusion at 12 months. In patients with aneurysm recurrence following prior microsurgical clipping, the rate of complete occlusion was 100% at 6 and 12 months, with no adverse sequelae noted at a mean clinical follow-up of 27.7 months.CONCLUSIONSThe treatment of recurrent aneurysms with the PED following previous endovascular coiling, flow diversion, or microsurgical clipping is associated with a high rate of complete occlusion and minimal morbidity.

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One-year Angiographic Results After pCONus Stent-Assisted Coiling of 40 Wide-Neck Middle Cerebral Artery Aneurysms

Neurosurgery ◽

10.1093/neuros/nyw131 ◽

2017 ◽

Vol 80 (6) ◽

pp. 925-933 ◽

Cited By ~ 21

Author(s):

Benjamin Gory ◽

Marta Aguilar-Pérez ◽

Elisa Pomero ◽

Francis Turjman ◽

Werner Weber ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Endovascular Coiling ◽

Total Occlusion ◽

Complete Occlusion ◽

Neck Size ◽

Clinical Complications ◽

Middle Cerebral Artery Aneurysms ◽

Wide Neck

Abstract BACKGROUND: Bifurcation middle cerebral artery (MCA) aneurysms with wide neck are amenable to endovascular coiling with pCONus stent, a recent device dedicated to wide-neck bifurcation intracranial aneurysms. OBJECTIVE: To evaluate the 1-year angiographic follow-up of wide-neck MCA aneurysms treated with pCONus. METHODS: Forty MCA aneurysms (mean dome size, 7.7 mm; mean neck size, 5.6 mm) coiled with pCONus were retrospectively evaluated. “Recanalization” was defined as worsening, and “progressive thrombosis” was defined as improvement on the Raymond scale. RESULTS: Angiographic midterm (mean, 11.9 months; range, 3-20) follow-up was obtained in all aneurysms. Retreatment was performed in 9 aneurysms (22.5%) without clinical complications, and postoperative angiographic outcome included 2 complete occlusions and 7 neck remnants. Six aneurysms were followed after retreatment (mean, 8.8 months), and presented complete occlusion in 1 case, neck remnant in 4 cases, and aneurysm remnant in 1 case. Among the 31 aneurysms, follow-up showed complete occlusion in 67.7% (21/31), neck remnants in 29% (9/31), and aneurysm remnants in 3.3% (1/31). Adequate aneurysm occlusion (total occlusion and neck remnant) was obtained in 96.7% (30/31). Among these 31 aneurysms, improvement of the rate of occlusion was observed in 15 aneurysms (48.4%), and recurrence in 2 aneurysms (6.5%). There was no 1-year angiographic recurrence of 3- or 6-month totally occluded aneurysms. CONCLUSION: pCONus stent allows a safe coiling of wide-neck MCA aneurysms usually considered as surgical with a low recanalization rate for those adequately occluded at 3 to 6 months. Angiographic results improve over time due to progressive aneurysm thrombosis in around 50% of cases.

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