Natural history, epidemiology and screening of unruptured intracranial aneurysms

The prevalence of intracranial aneurysms is 2.3% (95% CI, 1.7-3.1%); most of these aneurysms are small and located in the anterior circulation. Risk factors are age, female gender, smoking, hypertension, excessive use of alcohol, having one or more affected relatives with SAH and autosomal dominant polycystic kidney disease. Most studies on risk of rupture have methodological weaknesses; an important flaw is that observed risks are recalculated to yearly risks of rupture, assuming a constant risk of growth and rupture of aneurysms. In reality, it is much more likely that aneurysms have long periods of low risk and short periods of high risk of growth and rupture. The overall risk of rupture found in follow-up studies is around 1% per year. Size is the most important risk factor for rupture, with smaller risks for smaller aneurysms. Other risk factors are the site of the aneurysm (higher risk for posterior circulation aneurysms), age, female gender, population (higher risks in Finland and Japan) and, probably also, smoking. There are no good comparisons between clipping and coiling of unruptured aneurysms. Both treatment modalities have a risk of around 6% of complications leading to death or dependence of help for activities of daily living for aneurysms smaller than 10mm. These risks increase with larger size of aneurysms. For clipping, the risk seems to increase with age, for coiling this is less apparent. The efficacy of coiling on the long term is unsettled. In deciding whether or not to treat an aneurysm, life expectancy is a pivotal factor; other important factors are the size and the site of the aneurysm. If the aneurysm is left untreated, follow-up imaging may be considered to detect growth of aneurysms, but the frequency and effectiveness of repeated imaging are unknown.     

Patient and aneurysm factors associated with aneurysm rupture in the population of the ARETA study

Background and purposeIdentifying patients with intracranial aneurysms (IA) who have a high risk of rupture is critical to determine optimal management. ARETA (Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm) is a prospective, multicenter study, dedicated to evaluating endovascular treatment of IA. We aimed to identify factors associated with ruptured status, using this very large series of patients with ruptured and unruptured aneurysms.MethodsSeveral analyses were conducted in the ARETA population: univariate and multivariate analyses in the whole population of patients and aneurysms to determine patient and aneurysm factors associated with aneurysm rupture, as well as a matched pair analysis (based on aneurysm size) conducted in the subgroup of patients with only one aneurysm to analyze the patient and aneurysm factors simultaneously.ResultsFrom December 2013 to May 2015, 1289 patients with 1761 aneurysms were included in ARETA. The multivariate analysis identified four patient factors: elevated blood pressure (EBP), no familial history, single IA, and active smoking, and four aneurysm factors: size ≥ 5 mm, narrow neck, irregular shape, and ACA/Acom location, associated with rupture status. In the matched pair analysis, five risk factors of rupture were identified: no familial history of aneurysm, narrow neck, active smoking, ACA/Acom location, and irregular shape.ConclusionsThe most important patient factors associated with IA rupture are smoking and EBP. Given that size is a well-identified aneurysm factor, narrow neck also seems to be associated with aneurysm rupture. Further studies are needed to confirm this factor and determine underlying mechanisms. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01942512.     

The PHASES score: To treat or not to treat? Retrospective evaluation of the risk of rupture of intracranial aneurysms in patients with aneurysmal subarachnoid hemorrhage

Background and purposeThe PHASES score was formulated to predict the 5-year risk of rupture for intracranial aneurysms. We retrospectively analyzed all patients treated in our institution for aneurysmal SAH and applied the PHASES score to estimate the probable predicted risk of bleeding in this group of patients.MethodsBetween February 2015 and August 2018, all patients with aneurysmal SAH were retrospectively analyzed and the PHASES score was applied. A total of 155 patients were included with a mean age of 53.8 years, including 60 males and 95 females.ResultsOf our patients 110 (70.9%) had a PHASES score of below or equal to 5, with a hemorrhagic risk of up to 1.3% over 5 years. If we analyze the patients with a risk of below 2% this figure increases to 122 patients (78.7%). Of these 99.3% were European and 0.6% were Japanese (1 patient). In 86 patients (55.4%), the aneurysm was smaller than 5 mm and in 10 patients (6.4%) the aneurysm was located in the posterior circulation.ConclusionOf our patients 78.7% had less than a 2% 5-year rupture risk based on their PHASES score, highlighting the discrepancy of the rupture risk calculated with the PHASES score when hypothetically applied to this group of patients. In the hypothetical scenario that our patients had unruptured aneurysms, our retrospective analysis shows that the PHASES score may only provide a weak tool for clinicians to use in the decision-making process as to whether or not to treat these aneurysms.     

Changing paradigm in the management of elderly patients with intracranial aneurysms: An institutional review

Optimal treatment of intracranial aneurysms (IAs) in elderly patients has not yet been well established. We have investigated the clinical and radiological outcomes and predictors of unfavorable outcome of IAs in elderly patients. Radiological and clinical data of 85 elderly patients from 2010 through 2015 were retrospectively reviewed. Significant differences between the groups were determined by a chi-square test. Regression analysis was performed to identify the predictors of unfavorable outcome. Among the 85 patients with IAs, the number of patients with >7 mm size aneurysm (p = 0.01), diabetes mellitus (DM) (p = 0.02), smoking (0.009) and Hunt and Hess grade 4–5 (p = 0.003) was significantly higher in the ruptured group compared to the unruptured group. Similarly, the number of patients who underwent clipping was higher in the ruptured aneurysm group (p = 0.01). The overall clinical outcome was comparatively better in the unruptured group (p = 0.03); however, microsurgical clipping of aneurysms provides a significantly higher rate of complete aneurysmal occlusion (p = 0.008). Overall, there was no significant difference in outcome in respect to treatment approach. In regression analysis, hypertension (HTN), obstructive sleep apnea (OSA), prior stroke, ruptured aneurysms and partial occlusion of aneurysms were identified as predictors of unfavorable outcome of IAs. Intracranial aneurysms in elderly patients reveals that endovascular treatment provides better clinical outcome; however, microsurgical clipping yields higher complete occlusion. Retreatment of residual aneurysms was comparatively more in the coiling group. Practice pattern has shifted from clipping to coiling for aneurysms in posterior circulation but not for aneurysms in anterior circulation.     

Endovascular treatment of ruptured tiny (⩽3 mm) intracranial aneurysms in the setting of subarachnoid hemorrhage: A case series of 20 patients and literature review

Successful endovascular coiling of ruptured tiny saccular intracranial aneurysms (⩽3 mm) is technically challenging and traditionally has been associated with technical failures, as well as morbidity related to thromboembolic events and high intraoperative rupture rates. This study analyzes the feasibility, technical efficacy, and clinical outcomes of coil embolization of ruptured tiny intracranial aneurysms using current coil and microcatheter technology and techniques. We performed a retrospective review of 20 patients with 20 ruptured tiny aneurysms treated with endovascular coil embolization from 2013 to 2016 at a single high-volume academic tertiary care practice. The mean aneurysm size was 2.4 mm (median 2.5 mm, 1–3). Complete occlusion was achieved in 12 of 20 patients (60%), the remaining 7 of 20 patients (35%) had a small neck remnant, and there was 1 failure (5%) converted to microsurgical clipping. Two patients had a failed attempted surgical clip reconstruction and were subsequently coiled. There was 1 intraprocedural rupture (5%) and 1 severe parent artery vasospasm (5%) during coiling. At discharge, 60% of patients were living independently. At follow-up three patients were deceased. Mean angiographic follow-up was 139 days (SD 120). There were no aneurysm recurrences among occluded patients and there were no retreatments among those with neck remnants. Coiling of ruptured aneurysms ⩽3 mm is feasible with high occlusion rates and low complication rates. The availability of softer coils with flexible detachment zones has led to safe and effective endovascular treatment of tiny ruptured aneurysms.     

Single-centre comparison of procedural complications,clinical outcome,and angiographic follow-up between coiling and stent-assisted coiling for posterior communicating artery aneurysms

Aneurysm recurrence is a principle limitation of endovascular coiling procedures, especially in posterior communicating artery aneurysms, with reported recurrence rates of >30%. The adjunctive use of self-expandable stents has revolutionised the treatment of intracranial aneurysms, especially for complex morphologies, wide necks, or unfavourable dome-to-neck ratios. However, there are limited data concerning a direct comparison between simple coiling and stent-assisted coiling in posterior communicating artery aneurysms. This study aimed to compare the durability and outcomes of coiling versus stent-assisted coiling procedures. Imaging data of patients with posterior communicating artery aneurysms treated with coiling or stent-assisted coiling between January 2008 and October 2012 were retrospectively analysed. The initial angiographic results, procedural complications, and clinical outcomes were assessed at discharge. Imaging follow-up was performed with cerebral angiography. Complete aneurysm occlusion was achieved on initial angiography in 23/56 (41.1%) stent and 83/235 (35.3%) non-stent patients. At the latest follow-up (mean follow-up 14.3 ± 10.4 months for stent and 13.2 ± 9.5 months for non-stent patients), aneurysms had recurred in 5/47 (10.6%) stent and 57/203 (28.1%) non-stent patients (p = 0.014). Procedural complications occurred in 6/56 (10.7%) stent and 27/235 (11.5%) non-stent aneurysms. No rebleeding occurred during clinical follow-up (mean duration, 46.7 months). Recurrence rates at the latest follow-up were significantly lower in patients undergoing stent-assisted coiling than those undergoing simple coiling. Thus, use of the stent-assisted neck remodelling technique in the treatment of wide-necked posterior communicating artery intracranial aneurysms appears to improve the long-term clinical outcome.     

The risk of seizures during the in-hospital admission for surgical or endovascular treatment of unruptured intracranial aneurysms

Few studies detail the risk of in-hospital seizures following elective surgical or endovascular treatment of unruptured intracranial aneurysms (UIA). We compared the peri-procedural seizure incidence for clipping and coiling of UIA. A retrospective cohort study using the Australian National Hospital Morbidity Database from 1998 to 2008 was conducted. Treatment modalities were compared for the combined primary end point related to seizure. Putative risk factors were investigated with univariate and multivariate logistic regression analysis to identify independent predictors of outcome. A total of 5922 hospitalisations for UIA (3098 clipping, 2824 coiling) were identified. Overall, surgery was associated with a 2.7% (95% confidence interval [CI] 2.2–3.4) incidence of peri-operative seizures, compared to a 0.6% (95% CI 0.4–1.0) incidence following endovascular treatment (adjusted odds ratio [OR] 4.40; 95% CI 2.64–7.33; p < 0.001). The incidences of seizures declined over the 11 year study period in both treatment groups, from 4.2% to 2.0% for surgery and from 2.8% to 0.3% for endovascular. Haemorrhagic complication with intracerebral haemorrhage predicted occurrence of a seizure (OR 3.41; 95% CI 1.20–9.66; p = 0.021), whereas endovascular coiling was associated with a better seizure outcome (OR 0.23; 95% CI 0.14–0.39; p < 0.001). Overall, elective surgical treatment of UIA is associated with a higher risk of seizure occurrence compared to endovascular coiling. Contrary to conventional thinking, the risk of seizures following endovascular treatment is not entirely absent. Current recommendations must be considered in relation to the issue of driving after elective intracranial aneurysm treatment.     

Balloon-in-stent assisted coiling for treatment of intracranial overwide and undertall aneurysms

This study reports our experience of balloon-in-stent assisted coiling for the treatment of morphologically unfavorable aneurysms located in the internal carotid artery (ICA). From July 2007 to April 2014, twelve patients with twelve aneurysms located in the ICA were coil embolized by simultaneously using balloon and stent assistance. Five aneurysms were ruptured and seven were unruptured. All the aneurysms were overwide (dome-to-neck ratio ⩽1.2) and undertall (aspect ratio ⩽1.2) anatomically. The procedure-related adverse events, clinical and angiographic results were retrospectively analyzed. Intraprocedural aneurysmal bleeding occurred for one unruptured aneurysm but was stopped immediately after the balloon was inflated. Periprocedural thromboembolism occurred for two ruptured aneurysms, leading to death in one patient and severe neurological deficit for the other one. Procedure-related permanent morbidity and mortality rates were 8.3% (1/12) and 8.3% (1/12). Satisfactory (total and subtotal) occlusion was obtained immediately in 11 (91.7%) cases. Nine aneurysms received digital subtraction angiography follow-up (mean 25.1 months, range 6–55), and all of them except one were totally obliterated. No aneurysmal bleeding occurred during a mean period of 59.1 months, clinical follow-up for eleven patients. Balloon-in-stent assisted coiling might be a therapeutic alternative to prevent growth or rupture of overwide and undertall aneurysms. Nevertheless, it should be used prudently for ruptured ICA aneurysms, for its disadvantage of technical complexity and relatively high rate of adverse events.     

Intraprocedural retrieval of migrated coils during endovascular aneurysm treatment with the Trevo Stentriever device

Coil migration during endovascular treatment of intracranial aneurysms occurs in 2–6% of cases. As endovascular coiling of aneurysms has become increasingly popular and as endovascular technology continues to rapidly evolve, the prevalence of intraprocedural coil migration will invariably rise. Since coil masses are highly thrombogenic, migration out of the aneurysm sac into the parent artery may result in large territory infarcts which subsequently manifest as significant neurological morbidity. Therefore safe and timely retrieval of migrated coils is essential to avoiding poor angiographic and clinical outcomes. A 66-year-old woman with an unruptured 5 × 3 mm, wide-necked posterior communicating artery aneurysm was referred for endovascular treatment. During coiling with the dual catheter technique, both initially deployed coils dislodged from the aneurysm sac and migrated distally into the middle cerebral artery. After failed retrieval with an Alligator device (Chestnut Medical Technologies, Menlo Park, CA, USA), we used two Trevo devices (Concentric Medical, Mountain View, CA, USA) in succession to successfully retrieve the migrated coils. The aneurysm was then occluded with stent-assisted coil embolization. There were no post-procedural angiographic or clinical complications. The patient was subsequently discharged home without neurological deficit. This case illustrates the first use of the Trevo device for retrieval of migrated coils during endovascular treatment of an intracranial aneurysm to our knowledge. Due to the lack of guidelines defining the standard management of intraprocedural coil migration, current strategies are based on retrospective review of published reports and expert opinion. We present a unique and effective method for endovascular retrieval of displaced coils using a Trevo Stentriever device.     

Outcomes for a case series of unruptured anterior communicating artery aneurysm surgery

Surgical outcomes following repair of unruptured anterior communicating artery (AcomA) aneurysms have not been adequately addressed in the literature. We present our operative experiences in a consecutive series of 103 patients with 115 unruptured AcomA aneurysms. Clinical results, operative complications, angiographic outcomes and prognostic factors associated with surgery are presented. Of the 115 aneurysm repairs attempted, 114 were treated by clipping or excision and suture. One aneurysm, less than 2 mm, was wrapped. Six patients (5.8%; 95% confidence interval [CI], 2.5–12.4) experienced a new permanent neurological deficit. There was no postoperative mortality. Transient morbidity occurred in 11 patients (10.7%; 95% CI, 5.9–18.3), including transient anosmia (four patients), acute postoperative confusion and memory disturbances (four patients), extradural haematoma requiring surgery (two patients) and cerebrospinal fluid rhinorrhea (one patient). Of the 84 aneurysms (73.0%) that had documented postoperative angiography, 82 (97.6%) had complete obliteration of the aneurysm and two (2.4%) had neck remnants (mean angiographic follow-up 28.0 months; range, 1.6–146.4 months). Retreatment was performed in one patient (1.0%). Logistic regression analysis of risk factors revealed that aneurysm size (p < 0.01) was a significant predictor of outcome. There was no incidence of subarachnoid haemorrhage in the 272 person years of follow-up. In the current study, surgical treatment of unruptured AcomA aneurysms resulted in 5.8% morbidity and no mortality. The robustness of aneurysm repair achieved by open microsurgery is an important consideration when considering the option between endovascular and microsurgical treatment for unruptured AcomA aneurysms.     

Risk of growth in unruptured intracranial aneurysms: A retrospective analysis

This study sought to define the growth of unruptured intracranial aneurysms, in particular the frequency of growth and the characteristic factors predictive of growth. Two hundred and eight patients with 285 unruptured aneurysms were followed. Electronic records and angiographic films were obtained for measurements of aneurysm size. The mean follow-up duration was 21.8 months (range 1.1–137.3 months). Growth was identified in 95 of the 285 aneurysms (33.3%). The cumulative incidence of growth predicted using the Kaplan-Meier method was 22.7% at 1 year, 35.2% at 2 years, and 47.7% at 3 years. Aneurysm growth was significantly associated with a patient history of excessive alcohol consumption (p = 0.04). A high incidence of growth can be seen in conservatively managed aneurysms with time. Consequently, continual follow-up is recommended to monitor for aneurysmal growth.     

Outcomes for unruptured ophthalmic segment aneurysm surgery

Ophthalmic segment aneurysms present unique technical challenges because of their proximity to the optic nerve and the anterior clinoid process. The current study was performed to examine whether surgery for unruptured ophthalmic segment aneurysms is an effective treatment modality with acceptable complication rates. A consecutive case series (prospectively collected data) was retrospective reviewed for the period between April 1992 and August 2012. Clinical results, operative complications, angiographic outcomes and prognostic factors associated with surgery are presented. Of the 169 patients with 182 unruptured ophthalmic segment aneurysms that were surgically repaired, 11 (6.4%) experienced new permanent neurological deficits, including six instances of complete visual loss. There was one postoperative death (0.6%) related to a middle cerebral artery infarction. Transient morbidity occurred in 18 patients (10.4%), including cerebrospinal fluid rhinorhea (10 patients), oculomotor nerve palsy (four patients) and transient dysphasia (four patients). A total of 142 aneurysms (78.0%) had documented postoperative angiography. Surgical treatment resulted in 135 (95.1%) complete obliterations and seven (4.9%) neck remnants. Retreatment was performed in three patients (1.7%). Logistic regression analysis of risk factors revealed that age (p < 0.02), aneurysm size (p < 0.01) and the use of temporary clipping (p < 0.01) were significant negative predictors of outcome. The risk associated with surgical repairs for unruptured ophthalmic segment aneurysms is no greater than aneurysms in other locations (6.4% morbidity; 0.6% mortality) and no more hazardous than outcomes achieved by alternative therapies. The robustness of aneurysm repair achieved by open microsurgery is an important consideration.     

Importance of independent evaluation of initial anatomic results after endovascular coiling for ruptured cerebral aneurysms

Initial incomplete occlusion is been an important predictor of aneurysm recurrence, rebleeding or retreatment after endovascular coiling. In 129 patients in the Prospective Registry of Subarachnoid Aneurysms Treatment (PRESAT) cohort, ruptured aneurysms were coiled within 14 days of onset, and initial post-coiling and 1-year follow-up aneurysm-occlusion status were evaluated by both local investigators and independent reviewers. The aim of this study was to investigate whether self-reported evaluations of initial aneurysm occlusion by treating physicians predicted incomplete aneurysm occlusion at 1 year after coiling for ruptured cerebral aneurysms as well as that done by independent evaluations. The relationships between self-reported or independent evaluations of initial anatomic results and 1-year incomplete aneurysm occlusion (retreatment within 1 year, or residual aneurysms at 1 year) were determined. Both initial and 1-year aneurysm-occlusion status were judged significantly worse by independent reviewers than by local investigators (p < 0.001). One-year incomplete aneurysm occlusion was identified in 59 patients: 10 patients, including two patients with re-ruptured aneurysms, were retreated and 49 other patients were judged to have residual aneurysms by independent reviewers. On immediate post-coiling angiograms, both residual neck or aneurysm judged by local investigators, and residual aneurysm judged by independent reviewers, were predictive for 1-year incomplete aneurysm occlusion on univariate analyses. However, multivariate analyses found that the initial aneurysm occlusion status judged by independent reviewers (p = 0.02, odds ratio = 2.83, 95% confidence interval = 1.15–6.95), but not by local investigators, was a significant predictor for 1-year incomplete aneurysm occlusion. This study demonstrates the importance of independent evaluations of aneurysm occlusion status for management of coiled aneurysms.     

Whole-brain CT perfusion combined with CT angiography for ischemic complications following microsurgical clipping and endovascular coiling of ruptured intracranial aneurysms

Ischemic complications associated with microsurgical clipping and endovascular coiling affects the outcome of patients with intracranial aneurysms. We prospectively evaluated 58 intracranial aneurysm patients who had neurological deterioration or presented with poor grade (Hunt-Hess grades III and IV), aneurysm size >13 mm and multiple aneurysms after clipping or coiling. Thirty patients had ischemic complications (52%) as demonstrated by whole-brain CT perfusion (WB-CTP) combined with CT angiography (CTA). Half of these 30 patients had treatment-associated reduction in the diameter of the parent vessels (n = 6), ligation of the parent vessels or perforating arteries (n = 2), and unexplained or indistinguishable vascular injury (n = 7); seven of these 15 (73%) patients suffered infarction. The remaining 15 patients had disease-associated cerebral ischemia caused by generalized vasospasm (n = 6) and focal vessel vasospasm (n = 9); six of these 15 (40%) patients developed infarction. Three hemodynamic patterns of ischemic complications were found on WB-CTP, of which increased time to peak, time to delay and mean transit time associated with decreased cerebral blood flow and cerebral blood volume were the main predictors of irreversible ischemic lesions. In conclusion, WB-CTP combined with CTA can accurately determine the cause of neurological deterioration and classify ischemic complications. This combined approach may be helpful in assessing hemodynamic patterns and monitoring operative outcomes.     

Unruptured intracranial aneurysms

Between 3.6 and 6% of the population harbour an unruptured intracranial aneurysm. Risk of rupture is related to aneurysm site and size and whether or not the patient has already had a subarachnoid haemorrhage (SAH) from another aneurysm. In ISUIA 2, the rupture rate for anterior circulation aneurysms<7mm was 0% per year in patients with no prior SAH, and 0.3% per year in patients with previous SAH; 7-12mm aneurysms, 0.5% per year (both groups); 13-24mm aneurysms, 3% per year; and giant aneurysms 8% per year. Rupture rate for posterior circulation aneurysms is higher at all sizes:<7mm was 0.5% per year in subjects with no prior SAH, 0.7% in those with prior SAH; 7-12mm, 3% per year; 13-24mm, 3.7% per year; and giant aneurysms, 10% per year. Non-invasive tests like contrast enhanced magnetic resonance angiography (MRA) and multislice computed tomographic angiography (CTA) are alternatives to intra-arterial digital subtraction angiography (IADSA) to detect aneurysms. Although these are promising techniques, the quality of data testing their accuracy remains limited and single slice CTA and time-of-flight MRA are poorer at detecting aneurysms<5mm diameter, which account for up to 1/3 of unruptured aneurysms. For ruptured aneurysms, the only large scale randomised controlled trial comparing surgical and endovascular treatment (ISAT) by coiling, resulted in an absolute 8.8% reduction (updated figure as of June 2003 for 1888 patients) in death or dependency at 1 year compared with surgical clipping. For unruptured aneurysms, the best available data so far comparing coiling and clipping is from the prospective (but non-randomised) arm of ISUIA. Elective surgical clipping had combined morbidity and mortality at 1 year of 12.2% versus 9.5% for coiling, although the groups were not matched with more high risk patients in the endovascular treatment cohort. Nevertheless these data are encouraging for future randomised trials of elective coiling versus clipping for asymptomatic aneurysms, in particular as the unproven long-term durability of coiling treatment and the fact that complete aneurysm occlusion is not always achieved remain obstacles to its wider use in unruptured aneurysms. There is an increased risk of SAH in relatives of patients with SAH (highest in those with two or more first degree relatives affected), but most SAH is sporadic and therefore the balance of available evidence indicates that mass screening for aneurysms is not cost effective. There may be a limited role for investigation of high-risk subgroups and ideally such screening should be tested in a randomised trial. The avoidance and active management of vascular risk factors should also be part of the management of at risk subjects.     

Clipping versus coiling for intracranial aneurysms

Background and purposeThe aim of this study was to compare results of clipping and coiling for aneurysms of the anterior circle of Willis. Previous studies have not identified a clear superiority of one method over the other.Material and methodsThe study group included 165 consecutive patients. The assessment took into account the risk of death, neurological status according to the scale of the GOS and mRS, the incidence of early complications and quality of life measured by own surveys and questionnaire EORTC QLQ-C30 v. 3.0.ResultsMean follow-up was more than four years. Early and late results of treatment after embolization and clipping for all patients did not differ. Evaluation of patients with bleeding aneurysms demonstrated better outcomes after embolization, however statistical significance was observed only in terms of symptomatic scale score of QLQ-C30 questionnaire (p = 0.02). For patients with non-bleeding aneurysms better outcomes were obtained after clipping, but statistical significance was found only in the early results: more excellent results in GOS score at discharge (p < 0.03) and fewer complications during hospitalization (p = 0.02).ConclusionsResults of treatment after clipping and coiling do not differ in total for all patients, but differ depending on the presence of bleeding. Patients with bleeding aneurysms achieve better outcomes after coiling, and patients with non-bleeding aneurysms achieve better outcomes after clipping.     

Treatment of unruptured intracranial aneurysms with the pipeline embolization device

The pipeline embolization device (PED; ev3 Endovascular, Plymouth, MN, USA) is a flow-diverter used in the endovascular treatment of intracranial aneurysms, particularly those with unfavorable configurations. It causes progressive flow redirection leading to aneurysm thrombosis. This study aimed to present a systematic review of the published literature on the clinical outcomes of PED. A Medline search of the English language literature was performed using the keywords “intracranial aneurysms” and “pipeline embolization device” or “flow diverters”. The inclusion criteria were: n > 10 patients; unruptured aneurysms; documentation of complications; and at least 3 months of follow-up. A total of 13 studies, with 905 patients and 1043 aneurysms, were included. The mean age was 53.8 years, with women comprising 76.3% of patients. The mean aneurysm diameter was 11.1 mm with 37% classed as large aneurysms and 10% classed as giant. The cumulative mortality rate was 2.3%. Seventeen patients had a stroke (1.9%), while 19 (2.0%) had a transient ischemic attack and 21 patients (2.3%) had an intracranial hemorrhage. The two outcome measures were the cumulative event rate (16.7%) and the 6 month aneurysm occlusion rate (79.7%). A funnel plot with study size plotted against the two outcome measures revealed publication bias. Data from recent studies suggest that complication and mortality rates associated with PED may be similar to other contemporary endovascular techniques, with a better 6 month aneurysm occlusion rate. More prospective clinical trials are warranted to further validate these results.     

Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm

Acute intracranial pseudoaneurysms secondary to aneurysmal rupture are a rare entity with no clear evidence-based guidelines for treatment to our knowledge. There are numerous examples of successful treatment of pseudoaneurysms both surgically and endovascularly, the latter mainly within the anterior circulation. Risk of pseudoaneurysm rupture in the acute state during endovascular procedures with subsequent difficulty in controlling the bleeding without sacrificing the feeder artery has led to some reservation in using endovascular treatments more broadly. We report a rare case of a 52-year-old-woman who presented with acute subarachnoid hemorrhage and was found to have a ruptured 5 mm × 8 mm bi-lobulated basilar apex aneurysm on CT angiography. Digital subtraction angiography demonstrated an associated anterior pseudoaneurysm that was formed secondary to the aneurysm rupture. The true aneurysm was successfully coiled with careful avoidance of the pseudoaneurysmal sac. Pseudoaneurysms are frequently identified for the first time during digital subtraction angiography. Recognizing their presence is essential for treatment planning. Acute pseudoaneurysms associated with true aneurysmal rupture can be safely and successfully treated by endovascular coiling of the true aneurysm. Care must be taken to avoid manipulation of the pseudoaneurysmal sac during the embolization.     

Unruptured intracranial aneurysms in patients with transient cerebral ischemic episodes. Optional managements and literature review

Abstract

Clinical experience about the management of patients with an unruptured intracranial aneurysm (UIA) presenting transient cerebral ischemic attacks (TIAs) is usually restricted to a few case reports. Some authors assume that it is safe to perform an endarterectomy without acutely increasing the risk of aneurysm rupture while others reported a post-operative aneurysmal bleeding even for aneurysms smaller than 10 mm between some days and several months after endarterectomy. The aim of this paper is to analyse the factors involved in the particular ischemic episodes, the examination methods to be employed, and the optional management for each individual case on a literature review and own experience-based data.