Microcirugía y estrategias adyuvantes en el tratamiento de los aneurismas intracraneales

Introducción: El riesgo del ser humano de padecer un aneurisma intracraneal se calcula entre 1-2 %, en el 80 % de los casos su forma de presentación es una hemorragia subaracnoidea. Objetivo: Evaluar la utilidad de diferentes maniobras adyuvantes para facilitar la micro disección y el presillamiento del cuello de los aneurismas intracraneales. Metodología: Se realizó un estudio descriptivo con todos los pacientes admitidos en el servicio de neurocirugía del Hospital "Roberto Rodríguez", en Morón, Ciego de Ávila, Cuba, que presentaron un diagnóstico de aneurisma intracraneal y que fueran intervenidos con técnica de microcirugía para su exclusión de la circulación, en el periodo comprendido entre enero de 1997 y diciembre del 2020. Resultados: 201 pacientes fueron intervenidos, 198 (98,51 %) con aneurismas de la circulación anterior y solo 3 (1,49 %), de la circulación posterior. En total fueron abordados 252 sacos, se utilizaron estrategias adyuvantes al procedimiento convencional para facilitar el acto del presillamiento aneurismático como lo fueron el drenaje espinal continuo, la ventriculostomìa al exterior para drenaje de LCR y monitorización continua de la PIC y de la presión de retracción cerebral, cierre temporal de la arteria madre, succión retrograda descompresión en los aneurismas gigantes. El 74,62 % de los casos se recuperaron sin ningún tipo de síntomas o secuelas y la mortalidad fue del 1,49 %. Discusión: La microcirugía resulta un procedimiento eficaz, con elevado nivel de eficiencia, para el tratamiento de los aneurismas intracraneales en nuestro medio. Las estrategias adyuvantes facilitan la relajación del parénquima, la disección y el presillamiento del cuello aneurismático.

Introduction: The human risk of suffering from an intracranial aneurysm is estimated between 1-2%, in 80% of cases its presentation is a subarachnoid hemorrhage. Objectives: To evaluate the usefulness of different adjunctive maneuvers to facilitate micro dissection and clamping of the neck of intracranial aneurysms. Method: We have carried out a descriptive study including all the patients admitted in the neurosurgery department of "Roberto Rodríguez" Hospital in Moron, Ciego de Avila, Cuba with the diagnosis of intracranial aneurysms who were operated on through microsurgical cliping techniques in the period between january 1997 and december 2020. Results: 201 patients were operated on, 198 (98.51%) with aneurysms of the anterior circulation and only 3 (1.49%), of the posterior circulation. A total of 252 sacs were approached, adjuvant strategies to the conventional procedure were used to facilitate the act of aneurysmal clamping, such as continuous spinal drainage, ventriculostomy to the outside for CSF drainage and continuous monitoring of ICP and brain retraction pressure, temporary closure of the mother artery, retrograde suction decompression in giant aneurysms. 74.62% of the cases recovered without any type of symptoms or sequelae, and mortality was 1.49%. Discussion: Microsurgery is an effective procedure, with a high efficiency index, for the treatment of intracranial aneurysms in our environment. Adjunctive strategies facilitate parenchymal relaxation, dissection, and clamping of the aneurysmal neck.

Factores predictivos de rotura de aneurismas intracraneales

Introducción: Un aneurisma intracraneal roto provoca una hemorragia subaracnoidea. La enfermedad presenta una alta mortalidad y morbilidad. Sin embargo, no todos se rompen. Mejorar la predicción de rotura permitirá un tratamiento quirúrgico preventivo en un grupo de pacientes y evitará una intervención quirúrgica con riesgos en otro grupo de enfermos. Es necesario identificar factores predictivos para mejorar la estratificación del riesgo de rotura y optimizar el tratamiento de los aneurismas intracraneales incidentales. Objetivo: Identificar factores predictivos de rotura de aneurismas intracraneales. Métodos: En una muestra de 152 pacientes espirituanos con aneurismas intracraneales saculares rotos (n = 138) y no rotos (n = 22) y 160 imágenes de angiografía por tomografía computarizada, se realizaron mensuraciones de los índices o factores morfológicos, los cuales se combinaron mediante análisis de regresión logística con variables demográficas y clínicas. Resultados: El grupo de edad con mayor frecuencia de presentación de aneurismas fue el de mayor de 65 años. La muestra estuvo representada, en su gran mayoría, por el sexo femenino. Se identificaron tres factores clínicos y cuatro factores morfológicos estadísticamente significativos, asociados con la rotura. El índice de no esfericidad (p = 0,002 y el sexo femenino (p = 0,02) fueron los de mayor significación estadística. Conclusiones: Se detectaron siete factores predictivos de rotura de aneurismas intracraneales estadísticamente significativos, de los cuales el índice de no esfericidad resultó el de mayor significación.

Introduction: A ruptured intracranial aneurysm causes a subarachnoid hemorrhage. The disease has high mortality and morbidity. However, not all of them break. Improving the rupture prediction will allow preventive surgical treatment in a group of patients and it will avoid risky surgical intervention in another group of patients. It is necessary to identify predictive factors to improve rupture risk stratification and to optimize treatment of incidental intracranial aneurysms. Objective: To identify rupture predictive factors for intracranial aneurysms. Methods: Measurements of the morphological indices or factors were performed in a sample of 152 patients from Sancti Spiritus with ruptured (n = 138) and unruptured (n = 22) saccular intracranial aneurysms and 160 computed tomography angiography images. They were combined using logistic regression analysis with demographic and clinical variables. Results: The age group with the highest frequency of aneurysm presentation was older than 65. The sample was represented, in its vast majority, by the female sex. Three clinical factors and four statistically significant morphological factors associated with rupture were identified. The non-sphericity index (p = 0.002) and the female sex (p = 0.02) were the most statistically significant. Conclusions: Seven statistically significant predictors of intracranial aneurysm rupture were detected, the non-sphericity index being the most significant.

Clinical application of Neuroform Atlas stent-assisted coiling in the treatment of unruptured wide-neck intracranial aneurysms / 北京大学学报(医学版)

OBJECTIVE@#To assess the safety and efficacy of Neuroform Atlas stent used in treatment of unruptured wide-neck intracranial aneurysms.@*METHODS@#Clinical data of 62 patients with unruptured wide-neck intracranial aneurysms undergoing Neuroform Atlas stent-assisted coiling from August 2020 to September 2021 were retrospectively analyzed. There were 64 aneurysms in those 62 patients. Among them, 25 aneurysms were located at the bifurcation of M1 segment on middle cerebral artery, 16 at the anterior communicating artery, 10 at the C7 segment of internal carotid artery, 5 at the C6 segment of internal carotid artery, 4 at the apex of basilar artery, 3 at the A3 segment of anterior cerebral artery, and 1 at the M2 segment of middle cerebral artery. All the patients underwent Neuroform Atlas stent-assisted coiling, including 49 patients with single stent assisted coiling and 15 patients with dual stents assisted coiling (14"Y"style and 1"X"style). After the procedure, the immediate DSA was performed to evaluate the status of aneurysm occlusion and the parent artery patency. The clinical follow-up was performed 3 months after the operation and evaluated based on the modified Rankin Scale(mRS).DSA image was reviewed at 6 months after operation and Raymond grading scale was used to assess the status of aneurysm occlusion and the parent artery patency.@*RESULTS@#A total of 62 patients with 64 aneurysms were all achieved technical success(100%).The immediate post-procedural Raymond scale was assessed, including Raymond Ⅰ in 57 aneurysms(89.1%, 57/64), Raymond Ⅱ in 6 aneurysms(9.3%, 6/64) and Raymond Ⅲ in 1 aneurysm(1.6%, 1/64). The peri-procedural complications rate was 4.8%(3/62), 2 patients developed intraoperative thrombosis and 1 patient suffered from local subarachnoid hemorrhage. Among them, 55 patients obtained 3 months clinical follow-up after operation and all the patients had good outcomes (mRS≤2), 50 patients with 52 aneurysms were followed up with DSA 6 months after operation, including Raymond Ⅰ in 45 aneurysms(86.5%, 45/52), Raymond Ⅱ in 4 aneurysms(7.7%, 4/52) and Raymond Ⅲ in 3 aneurysms(5.8%, 3/52).@*CONCLUSION@#Neuroform Atlas stent for the treatment of unruptured wide-neck intracranial aneurysms has high safety and good efficacy, and has its advantages over other traditional stents.

Braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in patients with unruptured complex intracranial aneurysms

Abstract Purposes: Braided and laser-cut stents both are efficacious and safe for coiling intracranial aneurysms. The study aimed to compare outcomes following braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in 266 patients who were diagnosed with unruptured intracranial aneurysms of different types and locations. Methods: Patients with unruptured complex intracranial aneurysms underwent braided (BSE cohort, n = 125) or laser engraved (LSE cohort, n = 141) stent-assisted embolization. Results: The deployment success rate was higher for patients of the LSE cohort than those of the BSE cohort (140 [99%] vs. 117 [94%], p = 0.0142). Seventy-one (fifty-seven percentages) and 73 (52%) were coil embolization procedure success rates of the BSE and the LSE cohorts. Periprocedural intracranial hemorrhage was higher in patients of the BSE cohort than those of the LSE cohort (8 [6%] vs. 1 [1%], p = 0.0142). Four (three percentages) patients from the LSE cohort and 3 (2%) patients from the BSE cohort had in-stent thrombosis during embolization. Permanent morbidities were higher in patients of the LSE cohort than those of the BSE cohort (8 [6%] vs. 1 [1%], p = 0.0389). Higher successful procedures (76% vs. 68%) and fewer postprocedural intracranial hemorrhage (0% vs. 5%) and mortality (0% vs. 5%) were reported for patients of the BSE cohort in posterior circulation aneurysmal location than those of the LSE cohort. Laser engraved stent has fewer problems with deployment and may have better periprocedural and follow-up outcomes after embolization. Conclusions: Braided stent-assisted embolization should be preferred when the aneurysm is present in the posterior circulation.

Intracranial aneurysms in Ghanaian adults

Objective: To document the location, size, and multiplicity of intracranial aneurysms in Ghanaians who have undergone digital subtraction angiography (DSA) at a single centre in Accra, Ghana. Design: We conducted a retrospective observational review of the medical records of all patients diagnosed with intracranial aneurysms on DSA Setting: Patients' medical records at Euracare Advanced Diagnostic and Heart Centre were reviewed between March 2018 and March 2020. Participants: Thirty-one patients were identified with various intracranial aneurysms (IAs) within the study period. Patients' ages, sex, and types of IAs were extracted using a checklist and analysed using Microsoft Excel for Windows 2016. Interventions: None Main outcome measures: The prevalence of types and distribution of intracranial aneurysms. Results: The age range of the patients was 26-76 years, with a mean age of 45.5±14.3 years. The mean age of men and women with IA was 45.5 ±15.9 years and 46.7 51.3±12.9 years, respectively. The most common IAs were located in the posterior communicating artery (PCOM) at 54.8% (95%CI: 36.0, 72.7), followed by the anterior communicating (ACOM), which constituted 32.3% (95%CI: 16.7, 51.4). The majority, 89.2% (33/37) of these aneurysms were less than 7mm in diameter. Single aneurysms were present in 25 (80.6%). Conclusion: The most common IAs were found in the PCOM and ACOM, and IAs tend to rupture at a younger age and smaller size among the Ghanaian adults examined. Early detection and treatment of IAs less than 7mm in diameter is recommended.

Aneurisma de la arteria carótida interna como lesión compresiva de la vía visual / Internal carotid artery aneurysm as a compressive lesion of the visual pathway

El diagnóstico temprano de las lesiones compresivas del nervio óptico adquiere cada vez mayor importancia. La descompresión precoz de este o del quiasma puede resultar una mejora significativa de la función visual, mientras que el diagnóstico erróneo puede ocasionar pérdida visual irreversible, disfunción neurológica o la muerte. Las causas de la compresión de la vía visual anterior son increíblemente variadas. Los meningiomas, los tumores hipofisarios y los aneurismas son las lesiones comúnmente más identificadas como causa de neuropatía óptica compresiva sin edema del disco. Presentamos una paciente femenina de 50 años de edad, quien se sometió a la cirugía de catarata congénita del ojo izquierdo, sin mejoría de la función visual, a lo que se sumó el empeoramiento inespecífico de la calidad visual. La psicofísica visual, la campimetría automatizada y la tomografía de coherencia óptica aportaron hallazgos sugestivos de compresión de la vía visual intracraneal. Se indicó imagen por resonancia magnética de cráneo y órbitas para confirmar la sospecha diagnóstica. La angiografía cerebral demostró la presencia de un aneurisma de la arteria carótida interna, que se trató por vía endovascular con resultados satisfactorios(AU)

The importance of early diagnosis of compressive lesions of the optic nerve is on the increase. Timely decompression of the optic nerve or the optic chiasm may bring about significant visual function improvement, whereas erroneous diagnosis may result in irreversible visual loss, neurological dysfunction or death. The causes of compression of the anterior visual pathway are incredibly varied. Meningiomas, pituitary tumors and aneurysms are the lesions most commonly identified as causes of compressive optic neuropathy without disc edema. A case is presented of a female 50-year-old patient undergoing congenital cataract surgery of her left eye without visual function improvement, alongside unspecific visual quality worsening. Visual psychophysical testing, automated campimetry and optical coherence tomography contributed findings suggestive of intracranial visual pathway compression. Magnetic resonance imaging of the brain and orbits was indicated to confirm the diagnostic suspicion. Cerebral angiography revealed the presence of an internal carotid artery aneurysm which was treated by endovascular procedure with satisfactory results(AU)

Research progress of the risk of rupture of unruptured intracranial aneurysm / 国际外科学杂志

Intracranial aneurysms will lead to subarachnoid hemorrhage, which has a high mortality and morbidity risk. Screening high-risk aneurysms for preventive intervention has a positive effect, considering the widespread presence of unruptured aneurysms in the general population, this article reviews the risk factors of aneurysm rupture from the aspects of epidemiology, pathology, morphology and hemodynamics. In terms of epidemiology, smoking history, hypertension, age, gender and family inheritance are all closely related to the risk of aneurysm rupture. In terms of pathology, inflammation on the wall of intracranial aneurysm may be related to the risk of aneurysm rupture. In imaging, the size of intracranial aneurysms, location, the characteristics of the artery wall and some morphological and hemodynamic parameters can be used as evaluation index of fracture risk factors, at the same time the growth of intracranial aneurysm is one of the high risk indicators, the indicators for us in the future to establish intracranial unruptured aneurysms rupture risk factors evaluation model is of great significance.

Effect of morphological characteristics of aneurysms on the rupture of pericallosal artery aneurysms / 中国脑血管病杂志

Objectives: To investigate the morphological characteristics of pericallosal artery aneurysms (PAAs) and to analyze the morphological influence factor of PAA rupture. Methods: From January 2013 to May 2017A,40 consecutive patients with PAA admitted to the Department of Neurosurgery,Xuanwu Hospital, Capital Medical University were enrolled retrospectively. They were diagnosed by whole brain vascular DSA before treatment. Forty patients were divided into ruptured group (n = 22 with 22 aneurysms) and the unruptured group (n = 18 with 23 aneurysms). The morphological parameters of the number of aneurysms in two-dimensional or three-dimensional rotational angiography included diameter, height, width, aneurysm neck width,diameter of parent arteries, and inflow angle of aneurysms, and the aspect ratio, size ratio and length-width ratio (aneurysm diameter/aneurysm width) of each aneurysm were further calculated. The aspect ratio was calculated using aneurysm height/aneurysm neck width and aneurysm diameter/aneurysm neck width, respectively, and the size ratio was calculated using aneurysm height/parent artery diameter and aneurysm diameter/parent artery diameter, respectively. The differences of morphological parameters of PAAs were compared and multivariate logistic regression analysis was performed to preliminarily investigate the morphology of influencing factors of PAA rupture. Results: (1) There were no significant differences in age, male, multiple aneurysms, and risk factors for cardiocerebrovascular diseases between the two groups (all P>0.05). (2) The proportion of irregular aneurysms and the length-width ratio of aneurysms in the rupture group were higher than those in the unruptured group. The difference between the groups was statistically significant (90.9% [20/22] ts. 39. 1% [9/23],χ2 =8. 01); 1. 35 ±0. 36 vs. 1. 01 ±0. 22,t= -3. 85; all P 0. 05). (3) Amongthe 45 aneurysms,the proportion of A3 anterior bifurcation aneurysms was 53.3% (24 aneurysms), and the proportion of the ruptured group and unruptured group was 68. 2% (15/22) and 39. 1% (9/23) respectively. There were no significant differences between the groups (χ2 =0. 381,P = 0. 051). (4) The mean length-width ratio in 45 PAAs was 1. 18. using this as the defined value, the length-width ratio was converted into a two-category variable,and the PAA rupture was used as the dependent variable. The univariate analysis of the morphological parameters in the length-width ratio (> 1. 18) and the irregular aneurysm were included in the multivariate logistic regression analysis. The results showed that the length-width ratio was >1.18 (OR,1.84,95% CI 1.42-28. 11,P =0. 016),and irregular aneurysms (OR,2. 06,95% CI 1. 66-37. 11, P = 0. 009) were the independent risk factor for PAA rupture. Conclusions: The ratio of height-length-width of PAAs and the irregular morphology of aneurysms suggest that PAAs are prone to rupture. The evaluation of PAA morphological parameters should be emphasized in clinical practice.

Clinical effect of staged stent-assisted embolization after initial coiling of acute ruptured wide-neck saccular intracranial aneurysms / 中国脑血管病杂志

Objective: To evaluate the safety and efficacy of coiling in the acute phase followed by staged stenting for ruptured wide-neck saccular intracranial aneurysms. Methods: From November 2006 to December 2017, We retrospectively reviewed 58 consecutive patients with acute ruptured wide-neck saccular intracranial aneurysms(58 ruptured wide-neck saccular intracranial aneurysms) who were treated with staged stent-assisted embolization after initial coiling in the Department of Neurosurgery of NO. 971 Hospital of PLA Navy and the Department of Neurosurgery of First Hospital Affiliated to Naval Medical University. Simple coiling embolization was performed in the acute phase, and stent implantation was performed in the second stage. The immediate postoperative and follow-up angiographic results were assessed using the Raymond scale, and the outcome of clinical follow-up was assessed using the modified Rankin Scale(MRS). Results: All 58 patients(58 ruptured wide-neck saccular intracranial aneurysms) were successfully treated with staged stent-assisted embolization. The median interval of staged stenting treatment was 4. 4(4. 1, 4. 9) weeks. No aneurysm rebleeding occurred prior to the staged stenting treatment. During the treatment of staged stenting, coils were used as many as possible for embolization under the mechanical protection of stents in order to achieve complete occlusion. Immediately after stenting, angiography showed 30 aneurysms (51. 7%) with complete occlusion, 22 aneurysms (37. 9%) with neck remnant and 6aneurysms(10. 3%) with residual sac. One patient suffered in-stent thrombosis two hours after stent implantation, which was relieved with the use of tirofiban. When discharging hospital, showing that a total of 46 patients (79.3%) had MRSO-2, 8 patients(13.8%) had MRS 3 and 4 patients(6.9%) had MRS 4. Imaging follow-up ranged 6-35 months (median 16 months), showing 47 aneurysms (81. 0%) with complete occlusion, 7 aneurysms(12. 1%) with residual neck and 4 aneurysms(6. 9%) with residual sac. There was no recurrence, and the parent arteries were patent in all cases. Clinical follow-up ranged 6-36 months(median 18 months), showing that a total of 8 patients(13. 8%) had MRS 0-2 and 50 patients (86. 2%) had MRS 3. There was no new neurological dysfunction or death. Conclusion: Treatment of ruptured wide-neck saccular aneurysms with coiling in the acute phase followed by staged stenting is safe and effective.

Rescue therapy with stent retrievers for thromboembolism during endovascular treatment of intracranial aneurysms / Terapia de resgate com stent para tromboembolismo durante tratamento endovascular de aneurismas intracranianos

ABSTRACT Thromboembolism is the most frequent complication in endovascular treatment of intracranial aneurysms, causing disability and death. As stent retrievers have achieved high rates of arterial recanalization in the management of ischemic stroke, these devices were tested as rescue therapy of thromboembolism during aneurysm embolization. We retrospectively analyzed 10 consecutive patients with transprocedural arterial occlusion, treated with mechanical thrombectomy at a single center. Good angiographic recanalization was achieved in eight cases, mTICI 3, 2b and 2a in five, three and two patients, respectively, without additional complications or any deaths. Five patients showed complete recovery (mRS 0) and all patients showed improvement of disability (average mRS 1.1) over a mean follow-up period of 31 months. Eight patients had good clinical recovery, while two remained with deficits (mRS 3 and 4). The study found that the stent retriever is a valuable, rapid and effective tool for restoring blood flow, improving the safety of endovascular treatment.

RESUMO Tromboembolismo é a complicação mais frequente no tratamento endovascular de aneurismas cerebrais, podendo causar morte ou sequelas. Como os stent retrievers alcançaram altas taxas de recanalização arterial no tratamento do acidente vascular encefálico isquêmico, testamos esses dispositivos para tratar eventos tromboembólicos ocorridos durante a embolização de aneurismas. Foram analisados retrospectivamente 10 pacientes apresentando oclusão arterial transoperatória, tratados com trombectomia mecânica em um único centro. Obtivemos recanalização angiográfica em oito casos, mTICI 3, 2b e 2a em cinco, três e dois pacientes, respectivamente, sem complicações adicionais ou óbito. Cinco casos apresentaram recuperação completa (mRS 0) e todos os pacientes apresentaram melhora dos déficits (mRS médio 1.1) durante acompanhamento médio de 31 meses. Oito pacientes apresentaram boa recuperação clínica, enquanto dois permaneceram com déficits (mRS 3 e 4). O estudo concluiu que stents são uma ferramenta valiosa, rápida e eficaz para restaurar o fluxo sanguíneo, aumentando a segurança do tratamento endovascular.

Surgical Treatment of Posterior Circulation Aneurysms ­ Anatomical Study and Surgical Technique

Posterior circulation aneurysms represent 10­15% of intracranial aneurysms. The diagnosis is usually secondary to subarachnoid hemorrhage due to its initial asymptomatic presentation and higher risk of rupture compared with aneurysms in the anterior circulation. The surgical treatment of posterior circulation aneurysms is complex and challenging for neurosurgeons because of the particular anatomy of the posterior circulation with its close relation to the brainstem and cranial nerves and also because of the depth and narrowness of the surgical approach. Aneurysms from different locations have specific anatomical relationships and surgical approaches for better visualization and dissection. Therefore, a detailed anatomy knowledge of the posterior circulation is mandatory for an individualized preoperative planning and good neurological and angiographic outcomes.We selected the main aneurysm sites on the posterior circulation, such as: posterior inferior cerebellar artery, basilar trunk, basilar bifurcation, posterior cerebral artery (PCA) and superior cerebellar artery for a detailed description of the relevant anatomy related to aneurysm, and the main surgical approaches for its surgical treatment. Furthermore, we performed a literature review with the most recent outcomes regarding to the surgical treatment of posterior circulation aneurysms.

Aneurismas de circulação posterior representam de 10­15% dos aneurismas intracranianos. O diagnóstico, frequentemente, é secundário a hemorragia subaracnoide devido à apresentação assintomática na maioria dos casos e ao alto risco de sangramento comparado com aneurismas da circulação anterior. O tratamento cirúrgico de aneurismas de circulação posterior é complexo e desafiador para os neurocirurgiões devido à anatomia particular da região, profundidade do acesso cirúrgico, e relação intima com o tronco encefálico e os nervos cranianos. Aneurismas de diferentes localizações têm diferentes relações anatômicas e, portanto, acessos cirúrgicos específicos para melhor dissecção e visibilização de estruturas. Logo, um conhecimento detalhado de anatomia é mandatório para planejamento operatório individualizado e bons resultados clinico-radiológicos. Foram selecionadas as principais localizações de aneurismas de circulação posterior: Artéria cerebelar póstero-inferior; tronco de artéria basilar, bifurcação de artéria basilar, artéria cerebral posterior, e artéria cerebelar superior para detalhamento anatômico da anatomia relevante. O estudo objetiva realizar uma revisão da literatura dos principais resultados sobre tratamento cirúrgico de aneurismas de circulação posterior, além de descrever os principais pontos anatômicos relevantes à técnica microcirúrgica.

Treatment of Intracranial Aneurysms with the Pipeline Embolization Device Only: a Single Center Experience / 신경중재치료의학

PURPOSE: The aim of this study was to evaluate the technical feasibility and rate of mid-term occlusion in aneurysms treated solely with the Pipeline Embolization Device (PED) in a German tertiary care university hospital. MATERIALS AND METHODS: Forty-nine non-consecutive intracranial aneurysms underwent endovascular treatment using the PED exclusively between March 2011 and May 2017 at our institution. Primary endpoint was a favorable aneurysm occlusion defined as OKM C1-3 and D (O'Kelly Marotta Scale). Secondary endpoints were retreatment rate and delayed complications. Median follow-up was 200 days. RESULTS: The mean aneurysm size was 7.1 ± 5.3 mm. Forty-four aneurysms were located in the anterior circulation (90%). Ten aneurysms were ruptured (20%). Branching vessels from the sac were observed in 11 aneurysms (22%). Favorable obliteration immediately after PED placement was seen in 13/49 aneurysms (27%), of those nine aneurysms were completely occluded (18%). Angiographic and clinical follow-up was available for 45 cases (92%); 36/45 aneurysms (80%) were occluded completely and 40/45 aneurysms (89%) showed a favorable occlusion result. A branching vessel arising from the aneurysm sac was associated with incomplete occlusion (P < .05). All electively treated patients had good outcome (mRS 0). Three aneurysms (6%) required additional treatment due to aneurysm recurrence. CONCLUSION: In our series, treatment of intracranial aneurysms with the PED was associated with favorable occlusion rates and low complication rates at mid-term follow-up. The presence of branching vessels arising from the aneurysms sac was predictive for an incomplete occlusion.

Endovascular Treatment of a Giant Dissecting Aneurysm in an Infant

Introduction The incidence of intracranial aneurysms in the pediatric population is low, and endovascular treatment is becoming a safe and minimally invasive treatment option. In the present study, the occurrence of special features of cerebral aneurysm in children, in comparison to adults, is also described. Case Report A 3-month-old female infant presented with progressive proptosis and divergent strabismus at the right eye, in addition to inconsolable crying. Cerebral resonance, angiotomography and angiography exams demonstrated angiodysplasia in the right internal carotid artery with two large paraclinoid dissecting aneurysms with wide neck. The right internal carotid artery was occluded with coils by endovascular approach, without detriment to the perfusion of the ipsilateral hemisphere and without neurological deficits. The patient achieved good recovery, and a late control angiotomography confirmed the exclusion of the aneurysms. Conclusion Parent artery sacrifice via endovascular approach is an effective therapeutic option, but a long-termfollow-up is necessary to avoid recurrence and bleeding.

Clinical analysis of endovascular interventional treatment of intracranial peripheral aneurysms / 中国脑血管病杂志

Objective To investigate the clinical effect of endovascular interventional treatment of intracranial peripheral aneurysms. Methods From January 2013 to December 2016,the clinical data of 31 patients with intracranial peripheral aneurysm admitted to the Department of Neurosurgery,Anhui Provincial Hospital were analyzed retrospectively.Among them,12 patients had saccular aneurysms,10 had narrow-neck aneurysms,and 2 lacked clear aneurysm necks;19 patients had fusiform aneurysms,they all lacked clear aneurysm necks.Ten patients with narrow-neck saccular aneurysm were treated with coil embolization, of the 2 lacked clear neck saccular aneurysms,1 was treated with stent-assisted coil embolization,1 was treated with coil occlusion of the aneurysm and parent artery;4 patients with fusiform aneurysm were treated with coil occlusion of the aneurysms and parent arteries,11 with fusiform aneurysm were treated with Onyx glue occlusion of the aneurysms and parent arteries,and 4 with fusiform aneurysm were treated with coils in combination with Onyx glue occlusion of the aneurysms and parent arteries.They were followed up for 6 to 36 months after procedure. Results All patients were successfully treated with endovascular intervention,no rebleeding cases were found.Immediate postoperative angiography showed that 11 patients with saccular aneurysm were totally occluded.The aneurysms and parent arteries in 1 patient with saccular aneurysm and 19 with fusiform aneurysm were totally occluded.The aneurysms and parent arteries of 8 patients were occluded with Onyx glue,cranial CT revealed different degrees of cerebral infarction (6 patients without new neurological deficits,2 new neurologic deficits).CT revealed cerebral infarction in 1 patient treated with coils in combination with Onyx glue for occlusion of the aneurysm and parent artery(no new neurologic deficit),other patients did not have cerebral infarction and new neurologic deficits.DSA follow-up revealed aneurysm neck recurrence in 1 patient with saccular aneurysm,no obvious aneurysm recurrence was observed in all other patients. Conclusions Endovascular treatment of intracranial peripheral aneurysms is safe and effective.Choose what specific intervention therapy base on the aneurysm morphology,location, tortuous degree of the parent artery,and the importance of the blood supply area.

Preliminary experiences of Pipeline embolization device for the treatment of complex intracranial aneurysms / 中国脑血管病杂志

Objective To preliminarly investigate the application value of Pipeline embolization device ( PED ) in the endovascular interventional treatment of complex intracranial aneurysms. Methods From July 2015 to October 2016, the clinical data of 10 consecutive patients with complex intracranial aneurysm treated with PED at the Department of Neurosurgery, Guangdong General Hospital were enrolled retrospectively. Their surgical modalities,complications,and imaging findings were analyzed. Results Of the 10 patients,7 were females and 3 were males,their age was 32-68 years ( mean age 54 ± 12 years) . There were 8 patients with internal carotid artery aneurysm,1 with middle cerebral artery aneurysm,and 1 with vertebrobasilar artery aneurysm;there were 2 patients with ruptured aneurysm and 8 with unruptured aneurysm;there were 5 patients with saccular aneurysm ( 2 with wide-necked aneu-rysm) ,3 with fusiform aneurysm,2 with dissecting aneurysm;there were 2 patients with medium aneurysm ( diameter>5-15 mm) ,2 with large aneurysm ( diameter>15-25 mm) ,6 with giant aneurysm ( diameter>25 mm) ,and there were 2 patients with recurrent aneurysm. They were all single aneurysms. Three patients were treated with PED in combination with coil embolization,and 7 patients were treated with PED implantation alone. Nine patients were treated with one PED and 1 was treated with 3 PEDs. The immediate postoperative angiography revealed that the contrast agents in the aneurysm cavities were obviously stranded. One patient died after procedure and 1 had quadriplegia after procedure,and the remaining 8 patients had no PED-related complications. The modified Rankin scale score was 0 in 8 cases,5 in 1 case,and 6 in 1 case on the first post-operative day. They were followed up for 14 to 28 months. Conclusions The different types of intracranial aneurysms treated with PED implantation is relatively safe and effective,but there are also some risks of dis-ability and death. Strictly selecting the indications and developing the individualized treatment strategies are needed.

Analysis of influencing factors of the effect of the morphology of unruptured intracranial aneurysms on aneurysm wall enhancement of vascular wall with high-resolution magnetic resonance imaging / 中国脑血管病杂志

Objective To investigate the influencing factor of the morphology of unruptured intracranial aneurysms for aneurysm wall enhancement under the high-resolution magnetic resonance imaging. Methods From January 2015 to December 2016,the clinical and imaging data of 68 consecutive patients with unruptured intracranial aneurysm (86 aneurysms) in Changhai Hospital,the Second Military Medical University were enrolled retrospectively. Vascular wall imaging technology was used to conduct aneurysm scan,and the aneurysm wall enhancement was identified by the imaging features before and after contrast enhancement. They were divided into either an enhancement group ( n=32,34 aneurysms) or a non-enhancement group (n=45,52 aneurysms) according to whether having the abnormal enhancement of aneurysm wall or not ( because some patients also have enhanced aneurysms and non-enhanced aneurysms, the number of cases of the enhanced or not was calculated seperately in both groups ) . Morphological parameters were calculated by 3D image data,including aneurysm size,ratio of height to width,volume ratio, dome-to-neck ratio, transverse length ratio, bottleneck factor, and inflow angle. Univariate and multivariate logistic analyses were used to determine the morphological influence factors of aneurysm wall enhancement. Results (1) A total of 34 (39. 5%) aneurysms had aneurysm wall enhancement and 52 (60. 5％) aneurysms did not have aneurysm wall enhancement. There were no significant differences in sex, age, hypertension,diabetes, smoking, family history of subarachnoid hemorrhage, and aneurysm site in both groups (all P>0. 05). (2) The aneurysm size,ratio of height to width,volume ratio,dome-to-neck ratio, and bottleneck factor in the enhancement group were larger than those of the non-enhancement group. There were significant differences between the 2 groups (9. 19 [6. 54,11. 04] mm vs. 5. 31 [4. 17,7. 37] mm, (1. 18 [1. 01,1. 69] vs. 0. 91 [0. 72,1. 25],(3. 62 [2. 30,4. 63] vs. 2. 18 [1. 37,2. 76],1. 52 [1. 25, 1. 99] vs. 1. 19 [1. 03,1. 51],and 1. 21 [1. 11,1. 69] vs. 1. 05 [0. 94,1. 31],all P<0. 01). The proportion of irregular morphologic aneurysms in the enhancement group was higher than that in the non-enhancement group. There was significant difference between the 2 groups (55. 9％ [19/34] vs. 17. 3％ [9/52],P<0. 01 ) . There were no significant differences in transverse length ratio and inflow angle between the 2 groups (all P>0. 05). (3) Because the ratio of height to width,volume ratio,dome-to-neck ratio,and bottleneck factor were related to the aneurysm size,the aneurysm size,inflow angle,and irregular shape were included in the multivariate logistic regression analysis. The results showed that aneurysm size ( OR,3. 727,95％CI 1. 933-6. 971,P<0. 01) and irregular shape (OR,3. 990,95％CI 1. 219-13. 065,P=0. 022) were the independent risk factors for aneurysm wall enhancement. Conclusions The size and irregular shape of unruptured intracranial aneurysms are the independent risk factors for aneurysm wall enhancement. High-resolution magnetic resonance wall imaging may become an effective and noninvasive imaging method for evaluating the ruptured risk of intracranial aneurysms.

Feasibility, Safety, and Follow-up Angiographic Results of Endovascular Treatment for Non-Selected Ruptured Intracranial Aneurysms Under Local Anesthesia with Conscious Sedation

BACKGROUND: At most centers, general anesthesia (GA) has been preferred for endovascular treatment (EVT) of ruptured intracranial aneurysms (RIAs). In this study, we analyzed procedural results, clinical outcomes, and follow-up angiographic findings for patients undergoing EVT for RIA under local anesthesia (LA) with conscious sedation (CS). METHODS: We retrospectively evaluated 308 consecutive patients who underwent EVT for RIAs at a single institution between June 2009 and February 2017. EVT under LA with CS was considered for all patients with aneurysmal subarachnoid hemorrhage, regardless of Hunt and Hess (HH) scale score. RESULTS: EVT was performed for 320 aneurysms in 308 patients with subarachnoid hemorrhages. The mean patient age was 55.5±12.6 years. Moderate (III) and poor (IV, V) HH grades were observed in 75 (24.4%) and 77 patients (25%), respectively. Complete occlusion immediately after EVT was achieved for 270 (84.4%) of 320 aneurysms. Thromboembolic complications and intraprocedural ruptures occurred in 25 (7.8%) and 14 cases (4.3%), respectively. The morbidity rate at discharge (as defined by a modified Rankin scale score of 3 or greater) was 27.3% (84/308), while the mortality rate was 11.7% (36/308). Follow-up angiographic results were available for 210 (68.1%) of 308 patients. Recanalization was observed in 64 (29.3%) of 218 aneurysms in 210 patients. CONCLUSION: Based on our experience, EVT for RIAs under LA with CS was feasible, regardless of the clinical grade of the subarachnoid hemorrhage. Complication rates and follow-up angiographic results were also comparable to those observed when GA was used to perform the procedure.

Short-term follow-up for unruptured wide-necked intracranial aneurysms treated with Pipeline embolization device / 中国脑血管病杂志

Objective To evaluate the short-term effect of Pipeline embolization device (PED)for the treatment of unruptured wide-necked intracranial aneurysms. Methods From October 2015 to September 2016,15 consecutive patients with unruptured wide-necked intracranial aneurysm (aneurysm neck and aneurysm body ratio ≥0. 5)treated with PED at the Department of Neurosurgery,the Second Affiliated Hospital of Nanchang University were enrolled retrospectively. Their clinical and imaging data were analyzed. Kamran scale was used to evaluate the embolization rate of aneurysms and the changes of the parent arteries. DSA examination was performed again at 6 -12 months after operation. Results Fifteen PED were implanted in 15 patients with unruptured wide-necked intracranial aneurysms,including 13ophthalmic artery aneurysms,1 posterior communicating artery aneurysm,and 1 cavernous sinus aneurysm. The technical success rate was 100% . Immediately after PED implantation,Karman rating of 15 cases were aneurysm grade 2 embolization,parent artery grade A (grade 2a). DSA examination was performed again at 6 - 12 months after operation showed that 14 patients were aneurysm grade 4,parent artery was grade A (grade 4a). One patient (ophthalmic artery aneurysm)underwent the second DSA examinations at 6 and 12 months after operation showed that the residual development of aneurysms. The aneurysm embolization was grade 3, and the parent artery was grade A (grade 3a). No branch artery occlusion was observed. Non of them had neurological deficit. The modified Rankin scale score was 0 in all 15 patients. Conclusion The use of PED in the treatment of unruptured wide-necked intracranial aneurysms has a higher occlusion rate. Its long-term effect still needs further follow-up.

Analysis of influence factors of endovascular complete embolization for intracranial aneurysms / 中国脑血管病杂志

Objective To analyze the influence factors for complete embolization of intracranial aneurysms. Methods The clinical data of 546 inpatients with single intracranial aneurysm underwent interventional embolization at the Department of Neurosurgery,Anhui Provincial Hospital Affiliated to Anhui Medical University from January 2013 to January 2017 were analyzed retrospectively. They were divided into either a complete embolization group (n=255) or a incomplete embolization group (n=291) according to the immediate embolism degree of aneurysms. Single factor,multiple factors logistic regression analyses were used to analyze the factors associated with complete embolization of intracranial aneurysms. Results Univariate analysis showed that there were significant differences in the rupture status,anatomical morphology,Hunt-Hess grade, aneurysm size and neck width, different treatment regimens, and aneurysm angle between the patients in the complete embolism group and the incomplete embolism group ( all P<0. 05). The results of multivariate regression analysis showed that aneurysm size ( OR,0. 344,95%CI 0. 204-0. 578,P<0. 01),aneurysm rupture status (OR,0. 568,95%CI 0. 314-0. 947,P=0. 030), embolism ways (OR,3. 699,95%CI 2. 223-6. 153,P<0. 01),neck width of aneurysm (OR,0. 326, 95%CI 0. 198-0. 539,P=0. 003),aneurysm angle (OR,0. 647,95%CI 0. 451-0. 928,P=0. 018),and aneurysm morphology (OR,1. 689,95%CI 1. 118-2. 552,P =0. 013) were the independent factors of affecting the complete embolization of intracranial aneurysms. Conclusion Tiny, unruptured, narrow-neck, small inclination angle,regular-shaped aneurysms,stent-assisted or balloon-assisted embolization of intracranial aneurysms are easier to embolize the aneurysms completely.

Analysis of influence factors of endovascular complete embolization for intracranial aneurysms / 中国脑血管病杂志

Objective To analyze the influence factors for complete embolization of intracranial aneurysms. Methods The clinical data of 546 inpatients with single intracranial aneurysm underwent interventional embolization at the Department of Neurosurgery,Anhui Provincial Hospital Affiliated to Anhui Medical University from January 2013 to January 2017 were analyzed retrospectively. They were divided into either a complete embolization group (n=255) or a incomplete embolization group (n=291) according to the immediate embolism degree of aneurysms. Single factor,multiple factors logistic regression analyses were used to analyze the factors associated with complete embolization of intracranial aneurysms. Results Univariate analysis showed that there were significant differences in the rupture status,anatomical morphology,Hunt-Hess grade, aneurysm size and neck width, different treatment regimens, and aneurysm angle between the patients in the complete embolism group and the incomplete embolism group ( all P<0. 05). The results of multivariate regression analysis showed that aneurysm size ( OR,0. 344,95%CI 0. 204-0. 578,P<0. 01),aneurysm rupture status (OR,0. 568,95%CI 0. 314-0. 947,P=0. 030), embolism ways (OR,3. 699,95%CI 2. 223-6. 153,P<0. 01),neck width of aneurysm (OR,0. 326, 95%CI 0. 198-0. 539,P=0. 003),aneurysm angle (OR,0. 647,95%CI 0. 451-0. 928,P=0. 018),and aneurysm morphology (OR,1. 689,95%CI 1. 118-2. 552,P =0. 013) were the independent factors of affecting the complete embolization of intracranial aneurysms. Conclusion Tiny, unruptured, narrow-neck, small inclination angle,regular-shaped aneurysms,stent-assisted or balloon-assisted embolization of intracranial aneurysms are easier to embolize the aneurysms completely.