Spontaneous Disappearance of Unruptured Intracranial Aneurysm: A Case Report

Spontaneous resolution or thrombosis of giant or ruptured intracranial aneurysms is occasionally reported. However, spontaneous resolution of unruptured aneurysms without any intervention is extremely rare. Recently, we encountered a case of spontaneous resolution of a small unruptured aneurysm of the anterior communicating artery. We describe this rare case and discuss the mechanism of resolution with a review of the related literature.

Safety and Efficacy of Endovascular Embolization of Ruptured Intracranial Aneurysms within 72 hours of Subarachnoid Hemorrhage

Purpose The purpose of the study was to investigate the safety and efficacy of endovascular embolization of ruptured intracranial aneurysms within 72 hours of subarachnoid hemorrhage (SAH). Materials and methods Patients with intracranial aneurysms treated with embolization were divided into group A (n = 277), patients with ruptured aneurysms treated within 72 hours of SAH; group B (n = 138), patients with ruptured aneurysms treated beyond 72 hours; and group C (n = 93), patients with unruptured aneurysms. Results Embolization was successful in all but four patients (99.2%). The periprocedural complication rate was 36.2% in group B, significantly (p < 0.05) greater than that in group A (24.5%) or group C (11.8%). The rebleeding rate was 9.7% (6/62 patients) in groups A and B after embolization and only 0.3% (1/346 patients) in aneurysms with total or subtotal occlusion. Of these three groups of patients, 69.7% in group A, 58.7% in group B, and 76.3% in group C achieved Glasgow Outcome Scale (GOS) score of 5 or modified Rankin Scale (mRS) score of 0– to 1 at discharge. A significant difference (p < 0.05) existed in the clinical outcome between the three groups. The percentages of patients without deficits (GOS 5 or mRS 0–1) and slight disability (mRS 2) were 80.2% in group A, 81.2% in group B, and 96.7% in group C. The mortality rate was 4.3% (12/277 patients) in group A and 7.2% (10/138 patients) in group B with no significant (p = 0.21) difference. Follow-up was performed at 3 to 54 months (mean 23.2), and the recanalization rate was 28.6% (32/112 patients) in group A, 22.4% (11/49 patients) in group B, and 28.6% (16/56 patients) in group C, with no significant differences (p = 0.15). Hydrocephalus occurred in 30.5% (39/128 patients) in group B, which was significantly (p < 0.01) greater than that in group A (9.4%) or group C (2.2%). Conclusion Early embolization of ruptured cerebral aneurysms within 72 hours of rupture is safe and effective and can significantly decrease periprocedural complications compared with management beyond 72 hours. Timely management of cisternal and ventricular blood can reduce hydrocephalus incidence and improve prognosis.

Propensity score-adjusted analysis on stent-assisted coiling versus coiling alone for ruptured intracranial aneurysms

Stent-assisted coiling (SAC) for ruptured intracranial aneurysms (RIAs) remains controversial due to an inherent risk of potential thromboembolic and hemorrhagic complications. We compared SAC and coiling alone for the management of RIAs using propensity score-adjustment. Sixty-four patients treated by SAC and 220 by stand-alone coiling were retrospectively reviewed and compared using inverse probability of treatment weighting (IPTW) with propensity scores. Functional outcome, procedure-related and overall complications and angiographic results were analyzed. Aneurysms treated by SAC had a larger diameter, a wider neck and were more frequently located at the posterior circulation. SAC had a higher risk for thromboembolic complications (17.2% vs. 7.7%, p = 0.025), however, this difference did not persist in the IPTW analysis (OR 1.2, 95% CI 0.7–2.3, adjusted p = 0.458). In the adjusted analysis, rates of procedural cerebral infarction (p = 0.188), ventriculostomy-related hemorrhage (p = 0.584), in-hospital mortality (p = 0.786) and 6-month favorable functional outcome (p = 0.471) were not significantly different between the two groups. SAC yielded a higher complete occlusion (80.0% vs. 67.2%, OR 3.2, 95% CI 1.9–5.4, p < 0.001) and a lower recanalization rate (17.5% vs. 26.1%, OR 0.3, 95% CI 0.2–0.6, p < 0.001) than stand-alone coiling at 6-month follow-up. In conclusion, SAC of large and wide-necked RIAs provided higher aneurysm occlusion and similar clinical outcome, when compared to stand-alone coiling.

Abstract 1122‐000074: EnterpriseTM 1 versus EnterpriseTM 2 Stent‐Assisted Coiling in Treating Ruptured Intracranial Aneurysms: A Real‐World Study

Introduction : Enterprise TM 2 is an innovative, self‐expandable nitinol stent system used in stent‐assisted coiling (SAC) for treating intracranial aneurysms and was formally introduced into clinical use since 2018 in China in replace of Enterprise TM 1, the first‐generation stent being used for a decade. There is a lack of evidence to compare Enterprise TM 1 with Enterprise TM 2 in the real‐world setting. The objective of this study was to investigate clinical effectiveness and safety in treating ruptured intracranial aneurysms (RIA) with Enterprise TM 2 stent (E2 group) versus Enterprise TM 1 stent (E1 group) in China. Methods : We conducted a retrospective analysis of an electronic medical record database at Yijishan hospital of Wannan Medical College. Patients included were those diagnosed with RIA and underwent SAC procedure with Enterprise TM 1 stent or Enterprise TM 2 stent from January 2013 to November 2020 with at least one follow‐up visit post discharge. Main outcomes were immediate complete occlusion (ICO) rate (Raymond‐Roy Occlusion Classification), patient functional outcomes (modified Rankin Score (mRS)), and perioperative procedural‐related complications, operating time and length of stay (LOS) and recurrence rate. Student’s t‐test was used for continuous variables and the Chi‐Square test or Fisher Exact test was used for categorical variables to test significance where appropriate. Factors associated with perioperative procedural‐related complications were explored by logistic regression. Aneurysm recurrence rate was estimated using the Life Table method. Results : A total of 361 eligible patients (E2 group = 91; E1 group = 270) were included in the analysis. There were no differences in demographic characteristics between E2 and E1 groups (mean age: 59.9 vs. 58.4 years; male gender: 27.5% vs. 29.3%). The stent deployment was successful in all patients in both groups. ICO was similar (E2 vs. E1: 79.1% vs.75.1%, P = 0.629) and most of patients achieved good function outcomes (mRS< = 2) at discharge (E2 vs. E1: 77.8% vs. 81.1%, P = 0.592). Overall, E2 group had a lower perioperative procedural‐related complication rate compared with E1 (7.7% vs.16.4%, P = 0.042). After controlling for age and underlying severity of disease (presence of hypertension, Hunt‐Hess Scale, Fisher Grade, and size and height of aneurysms), patients in E2 group had a significantly lower risk of perioperative procedural‐related complications compared with those receiving E1 (OR = 0.35; 95% CI: 0.14‐0.88). The operating time was significantly shorter (165.7± 51.6 vs.190.3±79.6 minutes, P = 0.006) in E2 vs. E1 group. While LOS was also shorter in E2 group (16.7±9.7 vs.19.2±12.6 days), the difference was not statistically significant (P = 0.082). By six‐month post discharge, patients receiving E2 had similar good functional outcomes and aneurysm recurrence compared with those in E1 group (80.2% vs. 81.9%; 13.3% vs. 14.9%, respectively). Conclusions : Compared with the Enterprise TM 1, Enterprise TM 2 had similar clinical effectiveness but with a lower perioperative procedural‐related complication risk. Use of E2 also appeared to be associated with improved clinical efficiency with shorter operating time in treating patients with RIA. The application of Enterprise TM 2 stent demonstrated encouraging clinical benefits in treating RIA in China.

Safety and efficacy of intravenous tirofiban for stent-assisted coiling in acutely ruptured intracranial aneurysms: A single center experience

Background There have been few reports on the use of tirofiban in ruptured intracranial aneurysms and the results were conflicting. However, the safety and efficacy of optimal dosage and the reasonable treatment course of tirofiban have not been determined. Objective To determine the safety and efficacy of a new protocol for its prophylactic tirofiban application during the endovascular treatment of ruptured intracranial aneurysms with no oral antiplatelet medications. Methods This retrospective study was based on 105 patients with ruptured aneurysms who underwent stent-assisted coiling at our institution between August 2017 and July 2020. Intravenous tirofiban was administered to patients after stent deployment. Tirofiban was administered as an intravenous bolus (5 µg/kg) over a 3 min period immediately after stent deployment, followed by a 0.06–0.08 µg/kg/min maintenance infusion for 12–24 h. Dual oral antiplatelet therapy was overlapped with half the tirofiban dose 2 h before the cessation of the tirofiban infusion. Cases of intracranial hemorrhage or thromboembolism were recorded. Results This study included a total of 105 patients with ruptured intracranial aneurysms, who underwent stent-assisted coiling. In terms of clinical severity, a presenting Hunt–Hess clinical-grade I was observed in 47 (44.8%) cases, grade II in 19 (18.1%) cases, grade III in 30 (28.6%) cases, grade IV in 6 (5.6%) cases, and grade V in 3 (2.9%) cases. None of the patients showed a newly developed tirofiban-related intracerebral hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, or ventriculostomy-related hemorrhage. There were 3 (2.8%) patients who had thromboembolic complications. Conclusions We have determined a new protocol for prophylactic intraoperative tirofiban during the endovascular treatment of ruptured intracranial aneurysms with no oral antiplatelet medications. In our study, tirofiban showed a low risk of hemorrhagic or thromboembolic complications. Tirofiban appears to be a safe and alternative during the stent-assisted coiling of ruptured intracranial aneurysms.