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      Cerebral aneurysm treatment: modern neurovascular techniques

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          Abstract

          Endovascular treatment of cerebral aneurysm continues to evolve with the development of new technologies. This review provides an overview of the recent major innovations in the neurointerventional space in recent years.

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          Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment.

          David O Wiebers, J P Whisnant, J. Huston … (2003)
          The management of unruptured intracranial aneurysms is controversial. Investigators from the International Study of Unruptured Intracranial Aneurysms aimed to assess the natural history of unruptured intracranial aneurysms and to measure the risk associated with their repair. Centres in the USA, Canada, and Europe enrolled patients for prospective assessment of unruptured aneurysms. Investigators recorded the natural history in patients who did not have surgery, and assessed morbidity and mortality associated with repair of unruptured aneurysms by either open surgery or endovascular procedures. 4060 patients were assessed-1692 did not have aneurysmal repair, 1917 had open surgery, and 451 had endovascular procedures. 5-year cumulative rupture rates for patients who did not have a history of subarachnoid haemorrhage with aneurysms located in internal carotid artery, anterior communicating or anterior cerebral artery, or middle cerebral artery were 0%, 2. 6%, 14 5%, and 40% for aneurysms less than 7 mm, 7-12 mm, 13-24 mm, and 25 mm or greater, respectively, compared with rates of 2 5%, 14 5%, 18 4%, and 50%, respectively, for the same size categories involving posterior circulation and posterior communicating artery aneurysms. These rates were often equalled or exceeded by the risks associated with surgical or endovascular repair of comparable lesions. Patients' age was a strong predictor of surgical outcome, and the size and location of an aneurysm predict both surgical and endovascular outcomes. Many factors are involved in management of patients with unruptured intracranial aneurysms. Site, size, and group specific risks of the natural history should be compared with site, size, and age-specific risks of repair for each patient.
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            Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial.

            Tibor Becske, David F Kallmes, Işil Saatçi … (2013)
            To evaluate the safety and effectiveness of the Pipeline Embolization Device (PED; ev3/Covidien, Irvine, Calif) in the treatment of complex intracranial aneurysms. The Pipeline for Uncoilable or Failed Aneurysms is a multicenter, prospective, interventional, single-arm trial of PED for the treatment of uncoilable or failed aneurysms of the internal carotid artery. Institutional review board approval of the HIPAA-compliant study protocol was obtained from each center. After providing informed consent, 108 patients with recently unruptured large and giant wide-necked aneurysms were enrolled in the study. The primary effectiveness endpoint was angiographic evaluation that demonstrated complete aneurysm occlusion and absence of major stenosis at 180 days. The primary safety endpoint was occurrence of major ipsilateral stroke or neurologic death at 180 days. PED placement was technically successful in 107 of 108 patients (99.1%). Mean aneurysm size was 18.2 mm; 22 aneurysms (20.4%) were giant (>25 mm). Of the 106 aneurysms, 78 met the study's primary effectiveness endpoint (73.6%; 95% posterior probability interval: 64.4%-81.0%). Six of the 107 patients in the safety cohort experienced a major ipsilateral stroke or neurologic death (5.6%; 95% posterior probability interval: 2.6%-11.7%). PED offers a reasonably safe and effective treatment of large or giant intracranial internal carotid artery aneurysms, demonstrated by high rates of complete aneurysm occlusion and low rates of adverse neurologic events; even in aneurysms failing previous alternative treatments.
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              Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils.

              Jean Raymond, François Guilbert, Alain Weill … (2003)
              Our aim in this study was to assess the incidence and determining factors of angiographic recurrences after endovascular treatment of aneurysms. A retrospective analysis of all patients with selective endosaccular coil occlusion of intracranial aneurysms prospectively collected from 1992 to 2002 was performed. There were 501 aneurysms in 466 patients (mean+/-SD age, 54.20+/-12.54 years; 74% female). Aneurysms were acutely ruptured (54.1%) or unruptured (45.9%). Mean+/-SD aneurysm size was 9.67+/-5.91 mm with a 4.31+/-1.97-mm neck. The most frequent sites were basilar bifurcation (27.7%) and carotid ophthalmic (18.0%) aneurysms. Recurrences were subjectively divided into minor and major (ideally necessitating re-treatment). The most significant predictors of angiographic recurrence were determined by logistic regression. These results were confirmed by chi2, t tests, or ANOVAs followed, when appropriate, by Tukey's contrasts. Short-term ( 1 year) follow-up angiograms, in 277 (55%), for a total of 383 (76.5%) followed up. Recurrences were found in 33.6% of treated aneurysms that were followed up and that appeared at a mean+/-SD time of 12.31+/-11.33 months after treatment. Major recurrences presented in 20.7% and appeared at a mean of 16.49+/-15.93 months. Three patients (0.8%) bled during a mean clinical follow-up period of 31.32+/-24.96 months. Variables determined to be significant predictors (P or =10 mm, treatment during the acute phase of rupture, incomplete initial occlusions, and duration of follow-up. Long-term monitoring of patients treated by endosaccular coiling is mandatory.
              Article 0 comments Cited 238 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Stroke Vasc Neurol
                Journal ID (iso-abbrev): Stroke Vasc Neurol
                Journal ID (hwp): svn
                Journal ID (publisher-id): svn
                Title: Stroke and Vascular Neurology
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2059-8696
                Publication date Collection: September 2016
                Publication date (Electronic): 25 October 2016
                Volume: 1
                Issue: 3
                Pages: 93-100
                Affiliations
                [1 ]Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital , Baltimore, Maryland, USA
                [2 ]Department of Neurosurgery, University of California, Irvine School of Medicine, UC Irvine Medical Center , Orange, California, USA
                Author notes
                [Correspondence to ] Dr Li-Mei Lin; limei.lin@ 123456uci.edu
                Article
                Publisher ID: svn-2016-000027
                DOI: 10.1136/svn-2016-000027
                PMC ID: 5435202
                PubMed ID: 28959469
                SO-VID: 41fb54c7-a2a1-47cd-9a11-3a263daa40c0
                Copyright © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
                License:

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                Date received : 19 June 2016
                Date revision received : 26 July 2016
                Date accepted : 28 July 2016
                Categories
                Subject: 1506
                Subject: Review

                Keywords: aneurysm,brain,device,flow diverter,coil
                Data availability:
                Keywords: aneurysm, brain, device, flow diverter, coil

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