Clipping of very large or giant unruptured intracranial aneurysms in the anterior circulation: an outcome study

Object Patients with very large or giant unruptured intracranial aneurysms present with ischemic stroke and progressive disability. The aneurysm rupture risk in these patients is extreme—up to 50% in 5 years. In this study the authors investigated the outcome of surgical treatment for these very large aneurysms in the anterior circulation. Methods Clinical data on 62 patients who underwent surgery for unruptured aneurysms (20–60 mm) between 1998 and 2006 were reviewed. Results Complete aneurysm occlusion (100%) was achieved in 90% of cases, near complete occlusion (90–99%) in 5%. The surgical risk in patients younger than 50 years of age was 8% (Glasgow Outcome Scale score of 1 or 3 within 1 year after surgery). In older patients, the risk increased with advancing age. Conclusions The treatment of very large or giant unruptured intracranial aneurysms is hazardous and complex and thus best performed only at major cerebrovascular centers with an experienced team of neurosurgeons, interventional neuroradiologists, neurologists, and neuroanesthesiologists. Surgery, with acceptable risks and excellent occlusion rates, is typically the treatment of choice in patients younger than 50 years of age. In older patients, the benefits of endovascular treatment versus surgery versus no treatment must be carefully weighed individually. Minimizing temporary occlusion and the consequent use of intraoperative angiography may help reduce surgical complications.

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Endoscope-assisted Microsurgery for Intracranial Aneurysms

Neurosurgery ◽

10.1097/00006123-200211000-00004 ◽

2002 ◽

Vol 51 (5) ◽

pp. 1119-1127 ◽

Cited By ~ 57

Author(s):

Chandrasekar Kalavakonda ◽

Laligam N. Sekhar ◽

Pranatartiharan Ramachandran ◽

Peter Hechl

Keyword(s):

Intracranial Aneurysms ◽

Aneurysm Rupture ◽

Parent Artery ◽

Major Advance ◽

Parent Vessel ◽

Anterior Circulation ◽

Intraoperative Angiography ◽

Unruptured Aneurysms ◽

Microsurgical Treatment ◽

Aneurysm Clipping

Abstract OBJECTIVE We discuss the role of the endoscope in the microsurgical treatment of intracranial aneurysms, analyzing its benefits, risks, and disadvantages. METHODS This was a prospective study of 55 patients with 79 aneurysms, treated between July 1998 and June 2001, for whom the endoscope was used as an adjunct in the microsurgical treatment of their lesions. Seventy-one aneurysms were located in the anterior circulation, and eight were located in the posterior circulation. Thirty-seven patients presented with subarachnoid hemorrhage. Eighteen patients had unruptured aneurysms, of whom 5 presented with mass effect, 2 presented with transient ischemic attacks, and 11 were without symptoms. In all cases, the endoscope was used in addition to microsurgical dissection and clipping (sometimes before clipping, sometimes during clipping, and always after clipping), for observation of the neck anatomic features and perforators and verification of the optimal clip position. Intraoperative angiography was performed for all patients after aneurysm clipping. RESULTS In the majority of cases, the endoscope was very useful for the assessment of regional anatomic features. It allowed better observation of anatomic features, compared with the microscope, for 26 aneurysms; in 15 cases, pertinent anatomic information could be obtained only with the endoscope. The duration of temporary clipping of the parent artery was significantly reduced for two patients. The clip was repositioned because of a residual neck or inclusion of the parent vessel during aneurysm clipping in six cases, and the clip position was readjusted because of compression of the optic nerve in one case. One patient experienced a small aneurysm rupture that was directly related to use of the endoscope, but this was easily controlled, with no sequelae. For many patients, the combination of the neuro-endoscope and the micro-Doppler probe made intraoperative angiography redundant. CONCLUSION “Endoscope-assisted microsurgery” is a major advance in the microsurgical treatment of intracranial aneurysms; the endoscope allows better observation of regional anatomic features because of its magnification, illumination, and ability to “look around corners.”

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Increased rupture risk in small intracranial aneurysms associated with methamphetamine use

Interventional Neuroradiology ◽

10.1177/1591019920959534 ◽

2020 ◽

pp. 159101992095953

Author(s):

Dylan Noblett ◽

Lotfi Hacein-Bey ◽

Ben Waldau ◽

Jordan Ziegler ◽

Brian Dahlin ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Significant Risk ◽

Retrospective Chart Review ◽

Anterior Circulation ◽

Unruptured Aneurysms ◽

Methamphetamine Use ◽

Aneurysm Size ◽

Unruptured Intracranial Aneurysms ◽

History Of

Background Aneurysmal subarachnoid hemorrhage (SAH) is the most common cause of nontraumatic SAH. Current guidelines generally recommend observation for unruptured intracranial aneurysms smaller than 7 mm, for those are considered at low risk for spontaneous rupture according to available scoring systems. Objective We observed a tendency for SAH in small intracranial aneurysms in patients who are methamphetamine users. A retrospective, single center study to characterize the size and location of ruptured and unruptured intracranial aneurysms in methamphetamine users was performed. Materials and methods Clinical characteristics and patient data were collected via retrospective chart review of patients with intracranial aneurysms and a history of methamphetamine use with a specific focus on aneurysm size and location. Results A total of 62 patients were identified with at least one intracranial aneurysm and a history of methamphetamine use, yielding 73 intracranial aneurysms (n = 73). The mean largest diameter of unruptured aneurysms (n = 44) was 5.1 mm (median 4.5, SD 2.5 mm), smaller than for ruptured aneurysms (n = 29) with a mean diameter of 6.3 mm (median 5.5, SD 2.5 mm). Aneurysms measuring less than 7 mm presented with SAH in 36.5%. With regard to location, 28% (n = 42) of anterior circulation aneurysms less than 7 mm presented with rupture, in contrast to 70% (n = 10) of posterior circulation aneurysms which were found to be ruptured. Conclusions Methamphetamine use may be considered a significant risk factor for aneurysmal SAH at a smaller aneurysm size than for other patients. These patients may benefit from a lower threshold for intervention and/or aggressive imaging and clinical follow-up.

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Natural history of unruptured intracranial aneurysms: probability of and risk factors for aneurysm rupture

Journal of Neurosurgery ◽

10.3171/jns/2008/108/5/1052 ◽

2008 ◽

Vol 108 (5) ◽

pp. 1052-1060 ◽

Cited By ~ 105

Author(s):

Seppo Juvela ◽

Matti Porras ◽

Kristiina Poussa

Keyword(s):

Risk Factors ◽

Intracranial Aneurysms ◽

Smoking Status ◽

Significant Risk ◽

Significant Risk Factor ◽

Aneurysm Rupture ◽

Unruptured Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

History Of

Object The authors conducted a study to investigate the long-term natural history of unruptured intracranial aneurysms and the predictive risk factors determining subsequent rupture in a patient population in which surgical selection of cases was not performed. Methods One hundred forty-two patients with 181 unruptured aneurysms were followed from the 1950s until death or the occurrence of subarachnoid hemorrhage or until the years 1997 to 1998. The annual and cumulative incidence of aneurysm rupture as well as several potential risk factors predictive of rupture were studied using life-table analyses and Cox's proportional hazards regression models including time-dependent covariates. The median follow-up time was 19.7 years (range 0.8–38.9 years). During 2575 person-years of follow up, there were 33 first-time episodes of hemorrhage from previously unruptured aneurysms, for an average annual incidence of 1.3%. In 17 patients, hemorrhage led to death. The cumulative rate of bleeding was 10.5% at 10 years, 23% at 20 years, and 30.3% at 30 years after diagnosis. The diameter of the unruptured aneurysm (relative risk [RR] 1.11 per mm in diameter, 95% confidence interval [CI] 1–1.23, p = 0.05) and patient age at diagnosis inversely (RR 0.97 per year, 95% CI 0.93–1, p = 0.05) were significant independent predictors for a subsequent aneurysm rupture after adjustment for sex, hypertension, and aneurysm group. Active smoking status at the time of diagnosis was a significant risk factor for aneurysm rupture (RR 1.46, 95% CI 1.04–2.06, p = 0.033) after adjustment for size of the aneurysm, patient age, sex, presence of hypertension, and aneurysm group. Active smoking status as a time-dependent covariate was an even more significant risk factor for aneurysm rupture (adjusted RR 3.04, 95% CI 1.21–7.66, p = 0.02). Conclusions Cigarette smoking, size of the unruptured intracranial aneurysm, and age, inversely, are important factors determining risk for subsequent aneurysm rupture. The authors conclude that such unruptured aneurysms should be surgically treated regardless of their size and of a patient's smoking status, especially in young and middle-aged adults, if this is technically possible and if the patient's concurrent diseases are not contraindications. Cessation of smoking may also be a good alternative to surgery in older patients with small-sized aneurysms.

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Role of apoptosis in intracranial aneurysm rupture

Journal of Neurosurgery ◽

10.3171/jns.2004.101.6.1018 ◽

2004 ◽

Vol 101 (6) ◽

pp. 1018-1025 ◽

Cited By ~ 51

Author(s):

Luigi Pentimalli ◽

Andrea Modesti ◽

Andrea Vignati ◽

Enrico Marchese ◽

Alessio Albanese ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Superficial Temporal Artery ◽

Aneurysm Rupture ◽

Terminal Deoxynucleotidyl Transferase ◽

Content Type ◽

Unruptured Aneurysms ◽

Ruptured Aneurysms ◽

Aneurysm Wall ◽

Unruptured Intracranial Aneurysms ◽

Fine Print

Object. Mechanisms involved in the rupture of intracranial aneurysms remain unclear, and the literature on apoptosis in these lesions is extremely limited. The hypothesis that apoptosis may reduce aneurysm wall resistance, thus contributing to its rupture, warrants investigation. The authors in this study focused on the comparative evaluation of apoptosis in ruptured and unruptured intracranial aneurysms. Peripheral arteries in patients harboring the aneurysms and in a group of controls were also analyzed. Methods. Between September 1999 and February 2002, specimens from 27 intracranial aneurysms were studied. In 13 of these patients apoptosis was also evaluated in specimens of the middle meningeal artery (MMA) and the superficial temporal artery (STA). The terminal deoxynucleotidyl transferase—mediated deoxyuridine triphosphate nick-end labeling technique was used to study apoptosis via optical microscopy; electron microscopy evaluation was performed as well. Apoptotic cell levels were related to patient age and sex, aneurysm volume and shape, and surgical timing. Significant differences in apoptosis were observed when comparing ruptured and unruptured aneurysms. High levels of apoptosis were found in 88% of ruptured aneurysms and in only 10% of unruptured lesions (p < 0.001). Elevated apoptosis levels were also detected in all MMA and STA specimens obtained in patients harboring ruptured aneurysms, whereas absent or very low apoptosis levels were observed in MMA and STA specimens from patients with unruptured aneurysms. A significant correlation between aneurysm shape and apoptosis was found. Conclusions. In this series, aneurysm rupture appeared to be more related to elevated apoptosis levels than to the volume of the aneurysm sac. Data in this study could open the field to investigations clarifying the causes of aneurysm enlargement and rupture.

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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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Association between Size and Location with Cerebral Aneurysms Rupture

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v30i3.1838 ◽

1969 ◽

Vol 30 (3) ◽

pp. 190-196

Author(s):

Dan Zimelewicz Oberman

Keyword(s):

Cerebral Aneurysms ◽

Preventive Treatment ◽

Cross Sectional Study ◽

Aneurysm Rupture ◽

High Morbidity ◽

Anterior Circulation ◽

Cross Sectional ◽

Unruptured Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

Significant Difference

Introduction: Aneurysm rupture is the most dangerous complication with high morbidity and mortality rate, greater than 40%. Identifying risk factors for aneurysm rupture is extremely important for selecting patients who may truly benefit from preventive treatment. Objective: The aim of this study was to review our patients with ruptured and unruptured intracranial aneurysms and determine if there was an association between the size and location of aneurysms and their rupture. Methods: A cross-sectional study was performed in adult patients with cerebral aneurysm diagnosed from March 2015 to February 2017. Patients were divided into two groups, one with ruptured aneurysms and the other with unruptured aneurysms. Location according to anterior and posterior circulation was recorded. Size was stratified in three categories: (1) less than 7 mm; (2) between 7-12 mm; and (3) bigger than 13 mm in diameters. Results: During this period 80 patients were diagnosed with cerebral aneurysms. A total of 106 aneurysms were identified, 33 aneurysms were ruptured and 73 were unruptured. The mean sizes were 7.88 ± 6.23 mm and 5.35 ± 3.24 mm, respectively. There was statistically significant differences in aneurysm size (p<0.03) between the ruptured and unruptured group. Logistic regression revealed a higher association of rupture of anterior circulation aneurysm when size was ≥ 4mm (p<0.02). Conclusions: There was a significant difference between the size of ruptured and unruptured aneurysm groups. Anterior circulation aneurysms≥4mm revealed a higher association with rupture. This suggest this location should be evaluated more carefully for preventive treatment.

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Rebleeding and bleeding in the year following intracranial aneurysm coiling: analysis of a large prospective multicenter cohort of 1140 patients—Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm (ARETA) Study

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-015971 ◽

2020 ◽

pp. neurintsurg-2020-015971

Author(s):

Laurent Pierot ◽

Coralie Barbe ◽

Denis Herbreteau ◽

Jean-Yves Gauvrit ◽

Anne-Christine Januel ◽

...

Keyword(s):

Intracranial Aneurysm ◽

Endovascular Treatment ◽

Aneurysm Rupture ◽

Unruptured Aneurysms ◽

Delayed Bleeding ◽

Ruptured Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

Two Factors ◽

Aneurysm Occlusion ◽

Aneurysm Coiling

BackgroundEndovascular treatment is the first line therapy for the management of ruptured and unruptured intracranial aneurysms, but delayed aneurysm rupture leading to bleeding/rebleeding can occur subsequently. ARETA (Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm) is a prospective, multicenter study conducted to analyze aneurysm recanalization. We analyzed delayed bleeding and rebleeding in this large cohort.Methods16 neurointerventional departments prospectively enrolled patients treated for ruptured and unruptured aneurysms between December 2013 and May 2015 (ClinicalTrials.gov: NCT01942512). Participant demographics, aneurysm characteristics and endovascular techniques were recorded. Data were analyzed from participants with ruptured or unruptured aneurysms treated by coiling or balloon-assisted coiling. Rates of bleeding and rebleeding were analyzed and associated factors were studied using univariable and multivariable analyses.ResultsThe bleeding rate was 0.0% in patients with unruptured aneurysms and 1.0% (95% CI 0.3% to 1.7%) in patients with ruptured aneurysms. In multivariate analysis, two factors were associated with rebleeding occurrence: incomplete aneurysm occlusion after initial treatment (2.0% in incomplete aneurysm occlusion vs 0.2% in complete aneurysm occlusion, OR 10.2, 95% CI 1.2 to 83.3; p=0.03) and dome-to-neck ratio (1.5±0.5 with rebleeding vs 2.2±0.9 without rebleeding, OR 0.2, 95% CI 0.04 to 0.8; p=0.03). Modalities of management of aneurysm rebleeding as well as clinical outcomes are described.ConclusionsAneurysm coiling affords good protection against bleeding (for unruptured aneurysms) and rebleeding (for ruptured aneurysms) at 1 year with rates of 0.0% and 1.0%, respectively. Aneurysm occlusion and dome-to-neck ratio are the two factors that appear to play a role in the occurrence of rebleeding.

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Derivo embolization device in the treatment of unruptured intracranial aneurysms: a prospective multicenter study

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016303 ◽

2020 ◽

pp. neurintsurg-2020-016303

Author(s):

Christian A Taschner ◽

Christian Paul Stracke ◽

Franziska Dorn ◽

Krzysztof Bartosz Kadziolka ◽

Kornelia Kreiser ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Multicenter Trial ◽

Morbidity Rate ◽

Major Morbidity ◽

Unruptured Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

Neurological Morbidity ◽

Aneurysm Occlusion

BackgroundFlow diverters (FD) are used regularly for the endovascular treatment of unruptured intracranial aneurysms. We aimed to assess the safety and effectiveness of the Derivo embolization device (DED) with respect to long-term clinical and angiographic outcomes.MethodsA prospective multicenter trial was conducted at 12 centers. Patients presenting with modified Rankin Score (mRS) of 0–1, treated for unruptured intracranial aneurysms with DED were eligible. Primary endpoint was the mRS assessed at 18 months with major morbidity defined as mRS 3–5. Satisfactory angiographic occlusion was defined as 3+4 on the Kamran scale.ResultsBetween July 2014 and February 2018, 119 patients were enrolled. Twenty-three patients were excluded. Ninety-six patients, 71 (74%) female, mean age 54±12.0 years, were included in the analysis. Mean aneurysm size was 14.2±16.9 mm. The mean number of devices implanted per patient was 1.2 (range 1–3). Clinical follow-up at 18 months was available in 90 (94%) patients, resulting in a mean follow-up period of 14.8±5.2 months. At last available follow-up of 96 enrolled patients, 91 (95%) remained mRS 0–1. The major morbidity rate (mRS 3–5) was 3.1% (3/96), major stroke rate was 4.2% (4/96), and mortality was 0%. Follow-up angiographies were available in 89 (93%) patients at a median of 12.4±5.84 months with a core laboratory adjudicated satisfactory aneurysm occlusion in 89% (79/89).ConclusionOur results suggest that DED is a safe and effective treatment for unruptured aneurysms with high rates of satisfactory occlusion and comparably low rates of permanent neurological morbidity and mortality.Trial registrationDRKS00006103

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Direct carotid exposure approach in the treatment of anterior circulation unruptured intracranial aneurysms for elderly patients

Interventional Neuroradiology ◽

10.1177/1591019920987345 ◽

2021 ◽

pp. 159101992098734

Author(s):

Fumiaki Maruyama ◽

Toshihiro Ishibashi ◽

Naoki Kato ◽

Kostadin Karagiozov ◽

Issei Kan ◽

...

Keyword(s):

Elderly Patients ◽

Intracranial Aneurysms ◽

Anticoagulation Therapy ◽

Anterior Circulation ◽

Unruptured Aneurysms ◽

Activated Clotting Time ◽

Unruptured Intracranial Aneurysms ◽

Vessel Tortuosity ◽

Aneurysm Diameter ◽

Guiding Catheter

Background and purpose The direct carotid exposure approach (DCEA) is a technical option for elderly patients with severe vessel tortuosity due to arteriosclerosis. We evaluated complications related to antiplatelet/anticoagulant management and compared the DCEA to standard transfemoral/transbrachial approaches (TFBA) in the treatment of unruptured intracranial aneurysms for elderly patients. Methods From August 2017 to August 2020, 52 patients (53 procedures) aged over 75 years with unruptured aneurysms in the anterior circulation were treated at our institution. All patients received dual antiplatelet drugs before the procedure. Eleven patients (21.2%) (12 procedures) were treated with the DCEA. The rest were treated with TFBA. The main indication of the DCEA was an unfavorable aortic arch or vessel tortuosity. Complications and the duration of the procedure were compared between the two groups. Results There were no significant differences between the two groups in age, aneurysm location, preoperative antiplatelet use, heparin use, or maximum activated clotting time (ACT) values. All endovascular treatments were successfully performed by DCEA. Among all parameters, the DCEA group had only bigger average aneurysm diameter (14 mm) and higher number of pipeline embolic device (PED) placement (58%). Time to the guiding-catheter placement was not significantly different between the groups (DCEA vs TFBA = 31.0 min vs 24.7 min, p = 0.178).　No significant complications of DCEA, such as subcutaneous hematomas, were observed.　 Conclusion Even with the use of antiplatelet and anticoagulation therapy, the DCEA can be performed safely for unruptured aneurysms in elderly patients.

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Proposal of a follow-up imaging strategy following Pipeline flow diversion treatment of intracranial aneurysms

Journal of Neurosurgery ◽

10.3171/2018.2.jns172673 ◽

2019 ◽

Vol 131 (1) ◽

pp. 32-39 ◽

Cited By ~ 1

Author(s):

Raghav Gupta ◽

Christopher S. Ogilvy ◽

Justin M. Moore ◽

Christoph J. Griessenauer ◽

Alejandro Enriquez-Marulanda ◽

...

Keyword(s):

Digital Subtraction Angiography ◽

Cumulative Incidence ◽

Intracranial Aneurysms ◽

Aneurysm Rupture ◽

Digital Subtraction ◽

Imaging Data ◽

Unruptured Intracranial Aneurysms ◽

Imaging Strategy ◽

Aneurysm Occlusion

OBJECTIVEThere is currently no standardized follow-up imaging strategy for intracranial aneurysms treated with the Pipeline embolization device (PED). Here, the authors use follow-up imaging data for aneurysms treated with the PED to propose a standardizable follow-up imaging strategy.METHODSA retrospective review of all patients who underwent treatment for ruptured or unruptured intracranial aneurysms with the PED between March 2013 and March 2017 at 2 major academic institutions in the US was performed.RESULTSA total of 218 patients underwent treatment for 259 aneurysms with the PED and had undergone at least 1 follow-up imaging session to assess aneurysm occlusion status. There were 235 (90.7%) anterior and 24 posterior (9.3%) circulation aneurysms. On Kaplan-Meier analysis, the cumulative incidences of aneurysm occlusion at 6, 12, 18, and 24 months were 38.2%, 77.8%, 84.2%, and 85.1%, respectively. No differences in the cumulative incidence of aneurysm occlusion according to aneurysm location (p = 0.39) or aneurysm size (p = 0.81) were observed. A trend toward a decreased cumulative incidence of aneurysm occlusion in patients 70 years or older was observed (p = 0.088). No instances of aneurysm rupture after PED treatment or aneurysm recurrence after occlusion were noted. Sixteen (6.2%) aneurysms were re-treated with the PED; 11 of these had imaging follow-up data available, demonstrating occlusion in 3 (27.3%).CONCLUSIONSThe authors propose a follow-up imaging strategy that incorporates 12-month digital subtraction angiography and 24-month MRA for patients younger than 70 years and single-session digital subtraction angiography at 12 months in patients 70 years or older. For recurrent or persistent aneurysms, re-treatment with the PED or use of an alternative treatment modality may be considered.

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