Recent Steps Toward A Reconstructive Endovascular Solution for the Orphaned, Complex-Neck Aneurysm

Abstract OBJECTIVE: The purposes of this article are to summarize recent developments and concerns in endovascular aneurysm therapy leading to the adjunctive use of endoluminal devices, to review the published literature on stent-supported coil embolization of cerebral aneurysms, and to describe our experience with this technique in a limited subgroup of problematic complex aneurysms over a medium-term follow-up period. METHODS: Between January 2003 and June 2004, 28 individuals among 157 patients with cerebral aneurysms we evaluated were identified as harboring aneurysms with exceptionally broad necks. Out of these 28 patients, 16 were treated with a combination of stents and detachable coils, preserving the parent artery. Recorded data included patient demographics, the clinical presentation, aneurysm location and characteristics, procedural details, and clinical and angiographic outcome. RESULTS: Over an 18-month period, 16 patients with large cerebral aneurysms additionally characterized by neck sizes between 7 and 14 mm were treated, using combined coil embolization of the aneurysm with stent reconstruction of the aneurysm neck. Thirteen out of the 16 aneurysms were occluded at angiographic reevaluation between 11 and 24 months (mean angiographic follow-up, 17.5 mo). There were no treatment-related deaths or clinically evident neurological complications. Thirteen patients experienced excellent clinical outcomes, with good outcomes in two patients and a poor visual outcome in one patient (mean clinical follow-up, 29 mo). A single technical complication occurred, involving transient nonocclusive stent-associated thrombus, which was treated uneventfully with abciximab. CONCLUSION: Stent-supported coil embolization of large, complex-neck cerebral aneurysms seems to provide superior medium-term anatomic reconstruction of the parent artery compared with historic series of aneurysms treated exclusively with endosaccular coils. In the near future, increasingly sophisticated endoluminal devices offering higher coverage of the neck defect will likely enable more definitive endovascular treatment of complex cerebral aneurysms and further expand our ability to manipulate the vascular biology of the parent artery.

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Treatment of wide-necked cerebral aneurysms with the Neuroform2 Treo stent

Neurosurgical FOCUS ◽

10.3171/foc.2005.18.2.5 ◽

2005 ◽

Vol 18 (2) ◽

pp. 1-5 ◽

Cited By ~ 33

Author(s):

Sepehr Sani ◽

Kirk W. Jobe ◽

Demetrius K. Lopes

Keyword(s):

Coil Embolization ◽

Intracranial Aneurysms ◽

Cerebral Aneurysms ◽

Technical Difficulty ◽

Neurological Complications ◽

Clinical Effects ◽

Parent Vessel ◽

Cerebral Angiogram ◽

Aneurysm Neck

Object Until recently, wide-necked aneurysms were not considered amenable to treatment with coil embolization. The recent introduction of intracranial stents has provided a method of preventing coil migration out of wide-necked aneurysms. The Neuroform2 Treo is a modification of the Neuroform stent; the new version has a higher metal/artery ratio. The authors' initial experience with the use of this stent in combination with coil embolization to treat wide-necked intracranial aneurysms is reported and technical considerations are discussed. Methods The authors' first 10 consecutive patients with wide-necked intracranial aneurysms were included in this study. Inclusion criteria restricted the group to adult patients with wide-necked intracranial aneurysms (ruptured and unruptured lesions). A wide neck was defined as a dome/neck ratio of less than 2 or a neck that was 4 mm or wider as measured on angiograms. Immediate postprocedure angiography studies were performed to determine successful coil occlusion of the aneurysm as well as patency of the parent vessel. Six-month follow-up angiograms were obtained in all patients. Ten aneurysms with poor dome/neck ratios (< 2) were studied in 10 patients. In all cases the stent was delivered to the aneurysm site and positioned without difficulty. No branch artery compromise was observed. A technical difficulty occurred in one case, with prolapse of a coil into the parent vessel, which was successfully corrected with no adverse clinical effects. There were no clinical or neurological complications associated with endovascular treatment of aneurysms in this series. One patient required further coil embolization because of findings on the 6-month follow-up cerebral angiogram. Conclusions The Neuroform2 Treo navigates similarly to the Neuroform2, with the advantage of increased aneurysm neck coverage. This feature may lower the retreatment rates for wide-necked cerebral aneurysms.

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Surgically Treated Aneurysms Previously Coiled: Lessons Learned

Neurosurgery ◽

10.1227/01.neu.0000103223.90054.c2 ◽

2004 ◽

Vol 54 (2) ◽

pp. 300-305 ◽

Cited By ~ 47

Author(s):

Erol Veznedaroglu ◽

Ronald P. Benitez ◽

Robert H. Rosenwasser

Keyword(s):

Coil Embolization ◽

Patient Population ◽

Cerebral Aneurysms ◽

Lessons Learned ◽

Anterior Communicating Artery ◽

Unique Problem ◽

Aneurysm Neck ◽

Cerebellar Artery ◽

Patient Groups

Abstract OBJECTIVE Intravascular coil embolization of cerebral aneurysms has proved to be a safe and effective treatment in certain patient groups; however, this treatment is relatively new, and the long-term outcomes are unknown. One of the known complications is refilling of the aneurysm dome, which is seen in follow-up studies. This patient population poses unique technical difficulties for the neurosurgeon. We present a series of 18 patients who underwent surgery for residual aneurysms after coil remobilization. METHODS During a 5-year period, we performed surgery in 18 patients who had previously undergone coil embolization for their aneurysms. Of these aneurysms, four were in the anterior communicating artery, five were in the posterior communicating artery, three were in the internal carotid artery, three were in the posteroinferior cerebellar artery, and three were in the middle cerebral artery. One patient presented with rupture, one presented with acute IIIrd cranial nerve palsy, and the rest of the aneurysms were found on routine follow-up angiograms. Fifteen aneurysms were clipped, and in three patients, they were wrapped because the clip could not be placed adequately. RESULTS There were no major complications in any of the patients, and all had uneventful recoveries. The presence of coils in the aneurysm dome and/or neck made clipping and exposure of the aneurysm neck difficult, resulting in incomplete neck obliteration in three patients. CONCLUSION Operative clipping after previous coil embolization in aneurysms poses a unique problem for neurosurgeons. With the increasing use of coil embolization, this patient population will undoubtedly increase. The neurosurgeon should be aware of the difficulties and pitfalls encountered in these patients.

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Optical coherence tomography: a new method to assess aneurysm healing

Journal of Neurosurgery ◽

10.3171/jns.2005.102.2.0348 ◽

2005 ◽

Vol 102 (2) ◽

pp. 348-354 ◽

Cited By ~ 18

Author(s):

William E. Thorell ◽

Michael M. Chow ◽

Richard A. Prayson ◽

Mark A. Shure ◽

Sung W. Jeon ◽

...

Keyword(s):

Optical Coherence Tomography ◽

Coil Embolization ◽

Imaging Modality ◽

Cerebral Aneurysms ◽

Biological Tissues ◽

Optical Coherence ◽

Content Type ◽

Aneurysm Neck ◽

Fine Print

Object. Aneurysmal subarachnoid hemorrhage affects approximately 10/100,000 people per year. Endovascular coil embolization is used increasingly to treat cerebral aneurysms and its safety and durability is rapidly developing. The long-term durability of coil embolization of cerebral aneurysms remains in question; patients treated using this modality require multiple follow-up angiography studies and occasional repeated treatments. Methods. Optical coherence tomography (OCT) is an emerging imaging modality that uses backscattered light to produce high-resolution tomography of optically accessible biological tissues such as the eye, luminal surface of blood vessels, and gastrointestinal tract. Vascular OCT probes in the form of imaging microwires are presently available—although not Food and Drug Administration—approved—and may be adapted for use in the cerebral circulation. In this study the authors describe the initial use of OCT to make visible the neck of aneurysms created in a canine model and treated with coil embolization. Optical coherence tomography images demonstrate changes that correlate with the histological findings of healing at the aneurysm neck and thus may be capable of demonstrating human cerebral aneurysm healing. Conclusions. Optical coherence tomography may obviate the need for subsequent follow-up angiography studies as well as aid in the understanding of endovascular tissue healing. Data in this study demonstrate that further investigation of in vivo imaging with such probes is warranted.

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Comaneci-Assisted Coiling as a Treatment Option for Acutely Ruptured Wide Neck Cerebral Aneurysm: Case Series of 118 Patients

Neurosurgery ◽

10.1093/neuros/nyaa200 ◽

2020 ◽

Author(s):

Alexander Sirakov ◽

Krasimir Minkin ◽

Marin Penkov ◽

Kristian Ninov ◽

Vasil Karakostov ◽

...

Keyword(s):

Cerebral Artery ◽

Coil Embolization ◽

Case Series ◽

Cerebral Aneurysms ◽

Morbidity Rate ◽

Anterior Communicating Artery ◽

Parent Artery ◽

Simultaneous Application ◽

Procedural Complications

Abstract Background Wide-necked cerebral aneurysms in the setting of acute subarachnoid hemorrhage (SAH) remain difficult to treat with endovascular methods despite recent progress in the neuroendovascular field. Objective To evaluate the effectiveness and safety of the Comaneci device (Rapid Medical, Israel) in endovascular coil embolization of acutely ruptured, wide-necked sidewall, or bifurcation cerebral aneurysms. Methods We retrospectively reviewed 45 anterior communicating artery, 24 internal carotid artery, 21 middle cerebral artery bifurcation, 15 anterior cerebral artery, and 13 posterior circulation aneurysms, which were treated using Comaneci-assisted coil embolization from August 2017 to January 2019. We evaluated procedural complications, clinical outcomes, and mid-term angiographic follow-up. Immediate and 90 d-clinical outcome and radiological follow-up were obtained in all patients. Results Comaneci-assisted coil embolization was performed in 118 acutely ruptured aneurysms. The technique was carried out successfully in all cases. Simultaneous application of 2 separated Comaneci devices was performed in 8/118 cases (6.77%). Periprocedural thromboembolic complications related to the device were seen in 7/118 cases (5.93%) and severe vasospasm of the parent artery after manipulation of the Comaneci device occurred in 5/118 cases (4.2%). The procedural-related morbidity rate was 2.54%, and there was no procedural related mortality. Among the available survivors, angiographic follow-ups were obtained at 3 and 6 mo, and complete aneurysmal obliteration was confirmed in 81/112 (72.3%) and 75/112 (66.9%) cases, respectively. Mid-term follow-up reviewed total recanalization rate of 14.28%. Conclusion Comaneci-assisted embolization of wide-necked intracranial aneurysms in patients presenting with acute SAH is associated with high procedural safety and adequate occlusion rates. Furthermore, dual antiplatelet therapy can be safely avoided in this patient group.

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Endovascular Treatment of AICA Flow Dependent Aneurysms

Interventional Neuroradiology ◽

10.1177/159101991201800411 ◽

2012 ◽

Vol 18 (4) ◽

pp. 449-457 ◽

Cited By ~ 6

Author(s):

M. Mahmoud ◽

A. El Serwi ◽

M. Alaa Habib ◽

S. Abou Gamrah

Keyword(s):

Cerebral Aneurysms ◽

Neurological Complications ◽

Artery Occlusion ◽

Endovascular Embolization ◽

Anterior Inferior Cerebellar Artery ◽

Parent Artery ◽

Parent Artery Occlusion ◽

Cerebellar Artery ◽

Liquid Embolic

Peripheral anterior inferior cerebellar artery (AICA) aneurysms are rare, accounting for less than 1% of all cerebral aneurysms. To our knowledge 34 flow-related cases including the present study have been reported in the literature. Three patients harbouring four flow dependent aneurysms were referred to our institution. Two patients presented with subarachnoid hemorrhage, one presented with cerebellar manifestations. They were all treated by endovascular embolization of the aneurysm as well as the parent artery using liquid embolic material. Two cases were embolized using NBCA, Onyx was used in the third case. No bleeding or rebleeding were encountered during the follow-up period which ranged from five to nine months. One patient developed facial palsy, cerebellar symptoms and sensorineural hearing loss. The remaining two cases did not develop any post treatment neurological complications. Endovascular management of flow-dependent AICA aneurysms by parent artery occlusion is feasible and efficient in terms of rebleeding prevention. Post embolization neurological complications are unpredictable. This depends upon the adequacy of collaterals from other cerebellar arteries.

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Angiographic findings of in-stent intimal hyperplasia after stent-assisted coil embolization: are they permanent findings?

Journal of Neurosurgery ◽

10.3171/2015.2.jns142557 ◽

2016 ◽

Vol 124 (2) ◽

pp. 328-333 ◽

Cited By ~ 10

Author(s):

Young Soo Kim ◽

Sang Won Lee ◽

Jeong A Yeom ◽

Chang Hyo Yoon ◽

Seung Kug Baik

Keyword(s):

Stent Implantation ◽

Coil Embolization ◽

Cerebral Aneurysms ◽

Additional Treatment ◽

Parent Artery ◽

Related Factors ◽

Conventional Angiography ◽

Unruptured Aneurysms ◽

Luminal Narrowing

OBJECT Stent-assisted coil embolization for the treatment of intracranial aneurysms has been used widely. This study aimed to investigate the effect of stent implantation in the nonatherosclerotic parent artery with cerebral aneurysms. The authors evaluated luminal changes and the related factors following stent-assisted coil embolization. METHODS This study included 97 patients harboring a total of 99 unruptured aneurysms of the distal internal carotid artery (ICA) who underwent single-stent implantation and more than 1 session of conventional angiography during follow-up (midterm follow-up only, n = 70; midterm and long-term follow-up, n = 29) between January 2009 and April 2014. The luminal narrowing point was measured using a local thickness map (ImageJ plug-in). RESULTS Stent-assisted coil embolization caused dynamic luminal narrowing of approximately 82% of the parent artery diameter on average after 8 months, which was reversed to 91% after 25 months. In addition, luminal narrowing greater than 40% was noticed in 2 (7%) of the 29 patients who experienced spontaneous reversion without additional management during follow-up. Most luminal narrowing changes seen were diffuse. CONCLUSIONS Luminal narrowing after aneurysm stent-assisted coil embolization is a dynamic process and appears to be a spontaneously reversible event. Routine management of luminal narrowing may not cause adverse events that require additional treatment.

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Additional Rescue Stent Placement for Stabilization of a Prolapsed Coil during Stent-Assisted Coil Embolization of a Wide-Neck Intracranial Aneurysm

Interventional Neuroradiology ◽

10.1177/159101990601200309 ◽

2006 ◽

Vol 12 (3) ◽

pp. 257-262 ◽

Cited By ~ 5

Author(s):

N. Sourour ◽

F. Góngora-Rivera ◽

A. Biondi

Keyword(s):

Coil Embolization ◽

Parent Artery ◽

Aneurysm Neck ◽

Arterial Lumen ◽

Clinical Complications ◽

One Year ◽

Large Aneurysm ◽

Wide Neck ◽

Embolic Risk

We report a case of a 55-year-old man carrying two unruptured internal carotid artery (ICA) wide-neck aneurysms. In the same session, the smaller aneurysm was treated by coils using the remodeling technique and the large aneurysm was treated by stent-assisted coil embolization. During the stent-assisted procedure for the large aneurysm, the microcatheter tip moved from the aneurysm into the parent artery causing a prolapse of some coil loops into the vessel lumen. The distal part of the coil was tangled within the stent's struts, therefore, in order to introduce the entire coil, an attempt was made to withdraw the prolapsed loops of the coil within the microcatheter and concomitantly repositioning the microcatheter into the residual aneurysm neck through the stent struts. However this maneuver was unsuccessful. An attempt to retrieve gently the coil also failed and the coil prematurely detached. For maintaining the patency of the arterial lumen and to reduce the embolic risk, a second stent was used to pin the free coil loops. The rescue stent was positioned within the coil loops and its deployment allowed a circumferential expansion of some loops around the stent perimeter while other loops were flattened against the wall of the artery. The parent artery remained patent at one-year follow-up angiographic study. No clinical complications were observed.

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Anterior Communicating Artery Aneurysm Treatment with the Pipeline Embolization Device: A Single-Center Experience with Long-Term Follow-Up

Interventional Neurology ◽

10.1159/000456552 ◽

2017 ◽

Vol 6 (3-4) ◽

pp. 126-134 ◽

Cited By ~ 5

Author(s):

Ali Sultan-Qurraie ◽

Ahsan Sattar ◽

Wled Wazni ◽

Mazen Noufal ◽

Osama Zaidat

Keyword(s):

Cerebral Aneurysms ◽

Artery Aneurysm ◽

Endovascular Coiling ◽

Anterior Communicating Artery ◽

Parent Artery ◽

Data Set ◽

Pipeline Embolization Device ◽

Aneurysm Neck ◽

Single Center Experience

Introduction: The pipeline embolization device (PED) is increasingly used in the endovascular management of cerebral aneurysms. Longitudinal data regarding safety and benefit of the PED in anterior communicating (ACOM) artery aneurysms are limited and particularly lacking in residual ACOM artery aneurysms. We report the use of the PED in 3 patients with ACOM artery aneurysms who were previously coiled. Methods: Three patients with ACOM artery aneurysms, all previously treated with coiling and with recurrence of the aneurysm neck, were treated with the PED. All obtained follow-up diagnostic cerebral angiograms at either 3 or 6 months. Results: Mean age of patients was 59 years. All patients received cerebral angiograms at a minimum of 3 months after treatment with the PED. Follow-up angiography was performed up to a mean of 10 months at which time point all cases demonstrated complete aneurysm occlusion, without any stenosis in the parent artery. Conclusion: The PED can be safely used for the treatment of ACOM artery aneurysms. Complete aneurysm obliteration can be achieved in cases refractory to endovascular coiling. These findings warrant replication in a larger data set.

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The impact of statin therapy after surgical or endovascular treatment of cerebral aneurysms

Journal of Neurosurgery ◽

10.3171/2019.3.jns183500 ◽

2020 ◽

Vol 133 (1) ◽

pp. 182-189

Author(s):

Tae-Jin Song ◽

Seung-Hun Oh ◽

Jinkwon Kim

Keyword(s):

Statin Therapy ◽

Coil Embolization ◽

Primary Outcome ◽

Cox Regression ◽

Cerebral Aneurysms ◽

Time Dependent ◽

Lipid Lowering ◽

Surgical Clipping ◽

The Impact

OBJECTIVECerebral aneurysms represent the most common cause of spontaneous subarachnoid hemorrhage. Statins are lipid-lowering agents that may expert multiple pleiotropic vascular protective effects. The authors hypothesized that statin therapy after coil embolization or surgical clipping of cerebral aneurysms might improve clinical outcomes.METHODSThis was a retrospective cohort study using the National Health Insurance Service–National Sample Cohort Database in Korea. Patients who underwent coil embolization or surgical clipping for cerebral aneurysm between 2002 and 2013 were included. Based on prescription claims, the authors calculated the proportion of days covered (PDC) by statins during follow-up as a marker of statin therapy. The primary outcome was a composite of the development of stroke, myocardial infarction, and all-cause death. Multivariate time-dependent Cox regression analyses were performed.RESULTSA total of 1381 patients who underwent coil embolization (n = 542) or surgical clipping (n = 839) of cerebral aneurysms were included in this study. During the mean (± SD) follow-up period of 3.83 ± 3.35 years, 335 (24.3%) patients experienced the primary outcome. Adjustments were performed for sex, age (as a continuous variable), treatment modality, aneurysm rupture status (ruptured or unruptured aneurysm), hypertension, diabetes mellitus, household income level, and prior history of ischemic stroke or intracerebral hemorrhage as time-independent variables and statin therapy during follow-up as a time-dependent variable. Consistent statin therapy (PDC > 80%) was significantly associated with a lower risk of the primary outcome (adjusted hazard ratio 0.34, 95% CI 0.14–0.85).CONCLUSIONSConsistent statin therapy was significantly associated with better prognosis after coil embolization or surgical clipping of cerebral aneurysms.

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Stent-assisted coil embolization followed by a stent-within-a-stent technique for ruptured dissecting aneurysms of the intracranial vertebrobasilar artery

Journal of Neurosurgery ◽

10.3171/2009.2.jns081418 ◽

2009 ◽

Vol 111 (1) ◽

pp. 48-52 ◽

Cited By ~ 50

Author(s):

Sang Hyun Suh ◽

Byung Moon Kim ◽

Sung Il Park ◽

Dong Ik Kim ◽

Yong Sam Shin ◽

...

Keyword(s):

Coil Embolization ◽

Therapeutic Option ◽

Direct Consequence ◽

Treatment Method ◽

Dissecting Aneurysm ◽

High Rate ◽

Parent Artery ◽

Vertebrobasilar Artery ◽

Complete Obliteration

Object A ruptured dissecting aneurysm of the vertebrobasilar artery (VBA-DA) is a well-known cause of acute subarachnoid hemorrhage (SAH) with a high rate of early rebleeding. Internal trapping of the parent artery, including the dissected segment, is one of the most reliable techniques to prevent rebleeding. However, for a ruptured VBA-DA not suitable for internal trapping, the optimal treatment method has not been well established. The authors describe their experience in treating ruptured VBA-DAs not amenable to internal trapping of the parent artery with stent-assisted coil embolization (SAC) followed by a stent-within-a-stent (SWS) technique. Methods Eleven patients—6 men and 5 women with a mean age of 48 years and each with a ruptured VBA-DA not amenable to internal trapping of the parent artery—underwent an SAC-SWS between November 2005 and October 2007. The feasibility and clinical and angiographic outcomes of this combined procedure were retrospectively evaluated. Results The SAC-SWS was successful without any treatment-related complications in all 11 patients. Immediate posttreatment angiograms revealed complete obliteration of the DA sac in 3 patients, near-complete obliteration in 7, and partial obliteration in 1. One patient died as a direct consequence of the initial SAH. All 10 surviving patients had excellent clinical outcomes (Glasgow Outcome Scale Score 5) without posttreatment rebleeding during a follow-up period of 8–24 months (mean follow-up 15 months). Angiographic follow-up at 6–12 months after treatment was possible at least once in all surviving patients. Nine VBA-DAs showed complete obliteration; the other aneurysm, which had appeared partially obliterated immediately after treatment, demonstrated progressive obliteration on 2 consecutive follow-up angiography studies. There was no in-stent stenosis or occlusion of the branch or perforating vessels. Conclusions The SAC-SWS technique seems to be a feasible and effective reconstructive treatment option for a ruptured VBA-DA. The technique may be considered as an alternative therapeutic option in selected patients with ruptured VBA-DAs unsuitable for internal trapping of the parent artery.

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