Interventional

Two-Center Experience in the Endovascular Treatment of Ruptured and Unruptured Intracranial Aneurysms Using the WEB Device: A Retrospective Analysis

Fellows’ Journal Club

The authors performed a retrospective analysis of all ruptured and unruptured aneurysms treated with a WEB device between August 2014 and February 2017. Primary outcome measures included the feasibility of implantation and the angiographic outcome. Secondary outcome measures included the clinical outcome at discharge and procedural complications. One hundred two aneurysms in 101 patients, including 37 (36.3%) ruptured aneurysms, were treated with the WEB device. Implantation was successful in 98 (96.1%) aneurysms. Additional devices (stents/coils) were necessary in 15.3% (15/98) of aneurysms. Delayed aneurysm ruptures have not been observed during the follow-up period to date. They conclude that the WEB device offers a safe and effective treatment option for broad-based intracranial aneurysms without the need for dual antiplatelet therapy.

Predictors of Incomplete Occlusion following Pipeline Embolization of Intracranial Aneurysms: Is It Less Effective in Older Patients?

Editor’s Choice

This was a retrospective analysis of 465 consecutive aneurysms treated with the Pipeline Embolization Device between 2009 and 2016, at 3 academic institutions in the United States. Cases with angiographic follow-up were selected to evaluate factors predictive of incomplete aneurysm occlusion at last follow-up. Older age (more than 70 years), nonsmoking status, aneurysm location within the posterior communicating artery or posterior circulation, greater aneurysm maximal diameter (>21 mm), and shorter follow-up time (<12 months) were significantly associated with incomplete aneurysm occlusion at last angiographic follow-up.

Comparison of Clinical Outcomes of Intracranial Aneurysms: Procedural Rupture versus Spontaneous Rupture

Fellows’ Journal Club

This was a retrospective review of 1340 patients with 1595 unruptured saccular intracranial aneurysms that underwent endovascular coil embolization between February 2010 and December 2014. The clinical outcomes of patients with procedural rupture of saccular intracranial aneurysms were compared with those of 198 patients presenting with spontaneously ruptured aneurysms. Procedural rupture developed in 19 patients, and the morbidity related to procedural rupture was 26.3% with no mortality. Hunt and Hess scale grades and hospitalization days of patients with procedural rupture were equivalent to those of patients presenting with spontaneous aneurysm rupture. In multivariate analysis, spontaneous aneurysm rupture was a significant risk factor for worse clinical outcome. This study showed better clinical outcomes in the procedural-rupture group.

Angioarchitectures and Hemodynamic Characteristics of Posterior Communicating Artery Aneurysms and Their Association with Rupture Status

Editor’s Choice

The authors studied 313 posterior communicating artery aneurysms (145 ruptured, 168 unruptured) with image-based computational fluid dynamics. Aneurysms were classified into different angioarchitecture types depending on the location of the aneurysm with respect to parent artery bifurcation. Ruptured aneurysms had higher, more concentrated, and more oscillatory wall shear stress distributions; stronger and more concentrated inflow jets; and more complex and unstable flow patterns compared with unruptured aneurysms. They conclude that high-flow intrasaccular hemodynamic characteristics, commonly found in bifurcation-type angioarchitectures, are associated with the posterior communicating artery aneurysm rupture status.

Multicenter Experience with FRED Jr Flow Re-Direction Endoluminal Device for Intracranial Aneurysms in Small Arteries

Editor’s Choice

The authors assessed the clinical safety and efficacy of the Flow Re-Direction Endoluminal Device Jr (FRED Jr) dedicated to small-vessel diameters between 2.0 and 3.0 mm in 42 patients with 47 aneurysms. The primary efficacy end point of complete or near complete occlusion was reached at 1 month in 27/41 (66%), at 6 months in 21/27 (78%), and at 12 months in 11/11 (100%) aneurysms.

Influence of Carotid Siphon Anatomy on Brain Aneurysm Presentation

Fellows’ Journal Club

Lateral view DSA images of 692 consecutive patients with intracranial aneurysms treated at the authors’ institution were reviewed and had their angles measured. Data on the location, presentation, and size of the lesions were collected and evaluated by multivariate analysis in relation to the measured angles. Multivariate analysis showed an association between angles of >15.40° and rupture (P = .005), postsiphon location (P = .034), and aneurysm size of >1.001 mm (P = .015). These findings may be associated with the hemodynamic interactions of blood flow and the curvature of the carotid siphon.

The Impact of Conscious Sedation versus General Anesthesia for Stroke Thrombectomy on the Predictive Value of Collateral Status: A Post Hoc Analysis of the SIESTA Trial

Editor’s Choice

Using imaging data from the Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial, the authors assessed collateral status with the score of Tan et al and graded it from absent to good collaterals (0–3). They examined the association of collateral status with 24-hour improvement of the NIHSS score, infarct volume, and mRS at 3 months according to the sedation regimen in a cohort of 104 patients. The sedation mode, conscious sedation or general anesthesia, did not influence the predictive value of collaterals in patients with large-vessel occlusion anterior circulation stroke undergoing thrombectomy in the SIESTA trial.

Acute Basilar Artery Occlusion: Differences in Characteristics and Outcomes after Endovascular Therapy between Patients with and without Underlying Severe Atherosclerotic Stenosis

Fellows’ Journal Club

Sixty-two patients with acute basilar artery occlusion underwent multimodal endovascular therapy with stent-retriever thrombectomy as a first-line endovascular therapy. Patients with underlying intracranial atherosclerotic stenosis underwent additional intracranial angioplasty and stent placement. Underlying intracranial atherosclerotic stenosis was identified at the occlusion site in 15 patients (24.1%). Occlusion in the proximal segment of the basilar artery was more common in patients with intracranial atherosclerotic stenosis (60% versus 6.4%), whereas occlusion in the distal segment was more common in those without it. Patients with and without underlying intracranial atherosclerotic stenosis who underwent endovascular therapy had similar outcomes.

Temporary Stent-Assisted Coil Embolization as a Treatment Option for Wide-Neck Aneurysms

Editor’s Choice

The authors intended to treat 33 aneurysms between January 2010 and December 2015 with temporary stent-assisted coiling, which formed the series for this study. Incidental and acutely ruptured aneurysms were included. Sufficient occlusion was achieved in 97.1% of the cases. In 94%, the stent could be fully recovered. Complications occurred in 5 patients (14.7%). They conclude that temporary stent-assisted coiling is an effective technique for the treatment of wide-neck aneurysms. Safety is comparable with that of stent-assisted coiling and coiling with balloon remodeling.

Large Basilar Apex Aneurysms Treated with Flow-Diverter Stents

Fellows’ Journal Club

The authors report their experience treating basilar apex aneurysms with flow-diverter stents and evaluate their efficacy and safety profile in this specific condition. Of the 175 aneurysms treated with flow-diverter stents at their institution, 5 patients received flow-diverter stents for basilar apex aneurysms. The mean follow-up after stent deployment was 21 months. They conclude that flow diversion is a feasible technique with an efficacy demonstrated at a midterm follow-up, especially in the case of basilar apex aneurysm recurrences after previous endovascular treatments.