Comprehensive review of imaging of intracranial aneurysms and angiographically negative subarachnoid hemorrhage

Intracranial aneurysms confer the risk of subarachnoid hemorrhage (SAH), a potentially devastating condition, though most aneurysms will remain asymptomatic for the lifetime of the patient. Imaging is critical to all stages of patient care for those who harbor an unruptured intracranial aneurysm (UIA), including to establish the diagnosis, to determine therapeutic options, to undertake surveillance in patients who elect not to undergo treatment or whose aneurysm(s) portends such a low risk that treatment is not indicated, and to perform follow-up after treatment. Neuroimaging is equally as important in patients who suffer an SAH. DSA remains the reference standard for imaging of intracranial aneurysms due to its high spatial and temporal resolution. As noninvasive imaging technology, such as CTA and MRA, improves, the diagnostic accuracy of such tests continues to increasingly approximate that of DSA. In cases of angiographically negative SAH, imaging protocols are necessary not only for diagnosis but also to search for an initially occult vascular lesion, such as a thrombosed, ruptured aneurysm that might be detected in a delayed fashion. Given the crucial role of neuroimaging in all aspects of care for patients with UIAs and SAH, it is incumbent on those who care for these patients, including cerebrovascular neurosurgeons, interventional neurologists and neuroradiologists, and diagnostic radiologists and neurointensivists, to understand the role of imaging in this disease and how individual members of the multispecialty team use imaging to ensure best practices to deliver cutting-edge care to these often complex cases. This review expounds on the role of imaging in the management of UIAs and ruptured intracranial aneurysms and in the workup of angiographically negative subarachnoid hemorrhage.

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Treatment of Ruptured Intracranial Aneurysms: Comparison of Stenting and Balloon Remodeling

Neurosurgery ◽

10.1227/neu.0b013e31828ecf69 ◽

2013 ◽

Vol 72 (6) ◽

pp. 953-959 ◽

Cited By ~ 20

Author(s):

Rohan Chitale ◽

Nohra Chalouhi ◽

Thana Theofanis ◽

Robert M. Starke ◽

Peter Amenta ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracranial Aneurysms ◽

Dual Antiplatelet Therapy ◽

Multivariable Analysis ◽

Ruptured Aneurysms ◽

Complex Aneurysms ◽

Procedural Complications ◽

Baseline Characteristics ◽

Ruptured Intracranial Aneurysms

Abstract BACKGROUND: Stent-assisted coiling (SAC) and balloon-assisted coiling (BAC) are 2 well-established techniques for the treatment of complex and wide-necked intracranial aneurysms. Most clinicians are reluctant to perform SAC in the setting of subarachnoid hemorrhage because of the need for dual antiplatelet therapy. OBJECTIVE: To compare the safety and efficacy of SAC and BAC in acutely ruptured complex and wide-necked aneurysms. METHODS: Forty-four patients underwent SAC and 40 underwent BAC. Patients treated with SAC received antiplatelet medications. Perioperative adverse events and outcomes at follow-up (mean, 7.4 months) were retrospectively studied. RESULTS: The 2 groups were statistically comparable with respect to all baseline characteristics except for older age in SAC patients (65.6 vs 56.5 years; P = .009). A higher proportion of SAC patients also had poor Hunt and Hess grades (III-V; 70.5% vs 55%; P = .l4). Hemorrhagic, thromboembolic, and overall procedural complications occurred in 6.8%, 11.4%, and 18.2% of the SAC group vs 2.5%, 7.5%, and 10% of the BAC group, respectively (P = .5, P = .6, P = .3, respectively). Favorable outcomes (modified Rankin Scale score 0-2) at follow-up were seen in 61.0% of the SAC group vs 77% of the BAC group (P = .1). In multivariable analysis, after controlling for differences in baseline characteristics, the type of treatment was not a predictor of procedural complications or clinical outcome. CONCLUSION: In this study, procedural complications and clinical outcomes did not differ significantly between SAC and BAC in patients with acutely ruptured aneurysms. SAC may be an acceptable alternative to BAC for complex aneurysms in the acute phase of subarachnoid hemorrhage.

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Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding

Neurosurgical FOCUS ◽

10.3171/foc.1999.6.2.2 ◽

1999 ◽

Vol 6 (2) ◽

pp. E2

Author(s):

James V. Byrne ◽

Min-Joo Sohn ◽

Andrew J. Molyneux ◽

B. Chir

Keyword(s):

Subarachnoid Hemorrhage ◽

High Risk ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Aneurysm Embolization ◽

Aneurysm Occlusion ◽

The Stability ◽

Ruptured Intracranial Aneurysms

Object During a 5-year period 317 patients presenting with aneurysmal subarachnoid hemorrhage were successfully treated by coil embolization within 30 days of hemorrhage. The authors followed these cases to assess the stability of aneurysm occlusion and its longer-term efficacy in protecting patients against rebleeding. Methods These cases were followed for 6 to 65 months (median 22.3 months) by clinical review, angiography performed at 6 months posttreatment, and annual postal questionnaires. Conclusions Stable angiographic occlusion was evident in 86.4% of small and 85.2% of large aneurysms with recurrent filling in 38 (14.7%) of 259 aneurysms. Rebleeding was caused by aneurysm recurrence in four patients (between 11 and 35 months posttreatment) and by rupture of a coincidental untreated aneurysm in one patient. Annual rebleeding rates were 0.8% in the 1st year, 0.6% in the 2nd year, and 2.4% in the 3rd year after aneurysm embolization, with no rebleeding in subsequent years. Rebleeding occurred in three (7.9%) of 38 recurrent aneurysms and in one (0.4%) of 221 aneurysms that appeared stable on angiography. Periodic follow-up angiography after coil embolization is recommended to identify aneurysm recurrence and those patients at a high risk of late rebleeding.

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Radiological analysis of subarachnoid hemorrhage from ruptured intracranial aneurysms

Journal of the Korean Radiological Society ◽

10.3348/jkrs.1988.24.1.48 ◽

1988 ◽

Vol 24 (1) ◽

pp. 48

Author(s):

J D Lee ◽

J H Suh ◽

D I Kim

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracranial Aneurysms ◽

Ruptured Intracranial Aneurysms ◽

Radiological Analysis

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Evaluation of the Accero Stent for Stent-Assisted Coiling of Unruptured Wide-Necked Intracranial Aneurysm Treatment with Short-Term Follow-Up

Journal of Clinical Medicine ◽

10.3390/jcm9092808 ◽

2020 ◽

Vol 9 (9) ◽

pp. 2808

Author(s):

Wojciech Poncyljusz ◽

Kinga Kubiak ◽

Leszek Sagan ◽

Bartosz Limanówka ◽

Katarzyna Kołaczyk

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracranial Aneurysms ◽

Clinical Results ◽

Class I ◽

Unruptured Aneurysms ◽

Patient Demographics ◽

Stent Deformation ◽

Unruptured Intracranial Aneurysms ◽

Occlusion Rate

Background: Stent-assisted coiling is an effective method of treating intracranial aneurysms. The aim of the study was to assess the safety and efficacy of the new Accero stent for the treatment of intracranial aneurysms. Materials and Methods: It was a retrospective, single-center study. Eighteen unruptured intracranial aneurysms were treated using the stent-assisted coiling method with the Accero stent. Patient demographics, aneurysm characteristics, procedural parameters, grade of occlusion, complications, and clinical results were analyzed. Follow-up magnetic resonance (MR) was performed 6 months after intervention. Results: Seventeen patients with 18 incidental unruptured aneurysms were electively treated with coiling and the Accero stent. The aneurysms were located on internal carotid artery (ICA), middle cerebral artery (MCA) and basilar artery (BA). All stents were deployed successfully. Immediate complete occlusion rate Raymond-Roy occlusion classification (RROC) class I was achieved in 13 cases and class II in 4 cases. Complications occurred in 2/17 treatments and included guidewire stent perforation with subarachnoid hemorrhage (SAH) and stent deformation. Vascular spasm in the subarachnoid hemorrhage (SAH) patient subsided before discharge. Ninety days after intervention, the modified Rankin Scale (mRS) value was 0. RROC class I was observed in 88.23% of cases in follow-up. Conclusion: The Accero stent provides excellent support for coil mass. It constitutes an efficacious device with good initial occlusion rate for treating wide-necked unruptured intracranial aneurysms.

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125 Staged Endovascular Treatment of Ruptured Intracranial Aneurysms: Acute Coiling Followed By Delayed Flow Diversion

Neurosurgery ◽

10.1093/neuros/nyx417.125 ◽

2017 ◽

Vol 64 (CN_suppl_1) ◽

pp. 228-228

Author(s):

Erick Michael Westbroek ◽

Matthew Bender ◽

Narlin B Beaty ◽

Bowen Jiang ◽

Risheng Xu AB ◽

...

Keyword(s):

Endovascular Treatment ◽

Complication Rate ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Major Complication ◽

Flow Diversion ◽

Neurological Deficits ◽

Major Complication Rate ◽

Ruptured Intracranial Aneurysms

Abstract INTRODUCTION ISAT demonstrated that coiling is effective for aneurysm treatment in subarachnoid hemorrhage (SAH); however, complete occlusion of wide-necked aneurysms frequently requires adjuvants relatively contraindicated in SAH. As such, a limited “dome occlusive” strategy is often pursued in the setting of SAH. We report a single institution series of coiling of acutely ruptured aneurysms followed by delayed flow diversion for definitive, curative occlusion. METHODS A prospectively collected IRB-approved database was screened for patients with aneurysmal SAH who were initially treated by coil embolization followed by planned flow diversion at a single academic medical institution. Peri-procedural outcomes, complications, and angiographic follow-up were analyzed. RESULTS >50 patients underwent both acute coiling followed by delayed, planned flow diversion. Average aneurysm size on initial presentation was 9.5 mm. Common aneurysm locations included Pcomm (36%), Acomm (30%), MCA (10%), ACA (10%), and vertebral (5%). Dome occlusion was achieved in all cases following initial coiling. Second-stage implantation of a flow diverting stent was achieved in 49/50 cases (98%). Follow-up angiography was available for 33/50 patients (66%), with mean follow-up of 11 months. 27 patients (82%) had complete angiographic occlusion at last follow up. All patients with residual filling at follow-up still had dome occlusion. There were no mortalities (0%). Major complication rate for stage I coiling was 2% (1 patient with intra-procedural aneurysm re-rupture causing increase in a previous ICH). Major complication rate for stage 2 flow diversion was 2% (1 patient with ischemic stroke following noncompliance with dual antiplatelet regimen). Minor complications occurred in 2 additional patients (4%) with transient neurological deficits. CONCLUSION Staged endovascular treatment of ruptured intracranial aneurysms with acute dome-occlusive coil embolization followed by delayed flow diversion is a safe and effective treatment strategy.

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Management of Unruptured Intracranial Aneurysm in Japan

Medical Decision Making ◽

10.1177/0272989x9801800401 ◽

1998 ◽

Vol 18 (4) ◽

pp. 357-364 ◽

Cited By ~ 34

Author(s):

Noriaki Aoki ◽

Takao Kitahara ◽

Tsuguya Fukui ◽

J. Robert Beck ◽

Kazui Soma ◽

...

Keyword(s):

Clinical Trial ◽

Sensitivity Analysis ◽

Glasgow Outcome Scale ◽

Intracranial Aneurysms ◽

University Hospital ◽

Health Providers ◽

Unruptured Intracranial Aneurysm ◽

Unruptured Intracranial Aneurysms ◽

Quality Adjusted Life

The purpose of this study was to analyze the management of individual patients with unruptured intracranial aneurysms (UN-ANs) using a decision-analytic approach. Tran sition probabilities among Glasgow Outcome Scale (GOS) categories were estimated from the published literature and data from patients who had been treated at Kitasato University Hospital. Utilities were obtained from 140 health providers based principally on the GOS. Baseline analysis for a healthy 40-year-old man with an anterior UN-AN less than 10 mm in diameter showed that the quality-adjusted life expectancies for preventive operation and follow-up were 15.34 and 14.66 years, respectively. For a follow-up strategy to be preferred, the annual rupture rate had to be as low as 0.9%. These results were sustained through extensive sensitivity analysis. The results sup port preventive operation for UN-ANs, and identify problems that can be clarified with a well-designed stratified clinical trial. Key words: decision analysis; Markov model; unruptured intracranial aneurysms; Glasgow Outcome Scale; utility; preventive oper ations. (Med Decis Making 1998;18:357-364)

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Blister like aneurysm: a review about its surgical management / Aneurismas blister-like: uma revisão sobre seu manejo cirúrgico

Arquivos Médicos dos Hospitais e da Faculdade de Ciências Médicas da Santa Casa de São Paulo ◽

10.26432/1809-3019.2019.64.2.131 ◽

2019 ◽

Vol 64 (2) ◽

pp. 131

Author(s):

Rodrigo Salmeron de Toledo Aguiar ◽

Guilherme Brasileiro de Aguiar ◽

Rafael Gomes dos Santos ◽

André Freitas Nunes ◽

Renan Maximilian Lovato ◽

...

Keyword(s):

Surgical Management ◽

Intracranial Aneurysms ◽

Surgical Techniques ◽

Vascular Lesion ◽

High Morbidity ◽

Good Efficiency ◽

Treatment Techniques ◽

Pubmed Database ◽

Surgical Methods ◽

Ruptured Intracranial Aneurysms

ABSTRACT Introduction: Blister aneurysms are of uncertain pathogenesis and are a vascular lesion located in the brain. Overall, they represent 0.3% - 1.0% of all intracranial aneurysms and 0.9% - 6.5% of ruptured intracranial aneurysms. They are associated with high morbidity and mortality. Even with the first description being from 1969, there is still debate in the literature about which type of treatment is the best: surgical or endovascular. In this review, we focus on the surgical management. Method: The authors performed a review of available surgical techniques used for blood blister-like aneurysms treatment. Pubmed database was used as search source introducing blister-like aneurysm and blister aneurysms as keywords. The most relevant articles and those that focused on surgical treatment techniques were selected. Discussion: The most used surgical methods are clipping, trapping, wrapping and bypass. As main features of each technique, we can highlight clipping with good efficiency, when there is good neck exposure; trapping being employed in ruptured aneurysm; wrapping for avulsion and bypass that promotes vascularization to the distal territory of the aneurysm. Conclusion: The endovascular method has shown to be promising and efficient. However, different surgical techniques are still being employed based on their efficiency when facing certain surgical scenarios.Keywords: Neurosurgery, Subarachnoid hemorrhage, Intracranial aneurysm, Endovascular proceduresRESUMOIntrodução: Aneurismas cerebrais blister-like são lesões vasculares de patogenia incerta. De modo geral, representam 0.3%-1.0% de todos aneurismas intracranianos e 0.9% - 6.5% dos aneurismas intracranianos que rompem. Estão associados a alta morbimortalidade. Mesmo com a primeira descrição sendo de 1969, ainda há debate na literatura sobre qual tipo de tratamento é o melhor: cirúrgico ou endovascular. Nessa revisão, focamos no tratamento cirúrgico. Métodos: Os autores realizaram uma revisão das técnicas cirúrgicas utilizadas para tratamento de aneurismas blister-like. A plataforma Pubmed foi utilizada para a pesquisa das palavras chaves “blister-like aneurysm” e “blister aneurysm”. Os artigos de maior relevância e aqueles que enfatizam as técnicas cirúrgicas foram selecionados. Discussão: Os métodos cirúrgicos empregados são clipagem, trapping, wrapping e bypass. Quanto às características de cada método, podemos salientar a eficácia da clipagem, quanto melhor for a exposição do aneurisma; o uso do trapping em situações de rompimento do aneurisma; wrapping para casos em que houve avulsão do aneurisma e by-pass que promove a vascularização distal ao aneurisma. Conclusão: O método endovascular tem se mostrado promissor e efetivo. No entanto, as diferentes técnicas cirúrgicas ainda são empregadas e defendidas devido a sua eficiência frente certos cenários cirúrgicos.Descritores: Neurocirurgia, Hemorragia subaracnóidea, Aneurisma intracraniano, Procedimentos endovasculares

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