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      Closed-Cell Stent-Assisted Coiling of Intracranial Aneurysms: Evaluation of Changes in Vascular Geometry Using Digital Subtraction Angiography

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          Abstract

          Background

          Stent-assisted coil embolization (SACE) plays an important role in the treatment of intracranial aneurysms. The purpose of this study was to investigate geometrical changes caused by closed-cell design stents in bifurcation and sidewall aneurysms.

          Methods

          31 patients with 34 aneurysms underwent SACE with closed-cell design stents. Inflow angle α, determined by aneurysm neck and afferent vessel, and angle between afferent and efferent vessel close to (δ 1), respectively, more remote from the aneurysm neck (δ 2) were graphically determined in 2D angiography projections.

          Results

          Stent assisted coiling resulted in a significant increase of all three angles from a mean value (±SEM) of α = 119° (±6.5°) pretreatment to 130° (±6.6°) posttreatment (P ≤ .001), δ 1 = 129° (±6.4°) to 139° (±6.1°), (P ≤ .001) and δ 2 = 115° (±8.4°) to 126° (±7.5°), (P ≤ .01). Angular change of δ 1 in AcomA aneurysms was significant greater compared to sidewall aneurysms (26°±4.9° versus 8°± 2.3°, P ≤ .05). The initial angle of δ 1 and δ 2 revealed a significantly inverse relationship to the angle increase (δ 1: r = -0.41, P ≤ .05 and δ 2: r = -0.47, P ≤ .01). Moreover, angle δ 1 was significantly higher in unruptured compared to ruptured aneurysms (135°±7.1° versus 103°±10.8°, P ≤ .05).

          Conclusion

          Stent deployment modulates the geometry of the aneurysm-vessel complex, which may lead to favorable hemodynamic changes more similar to unruptured than to ruptured aneurysms. Our findings also suggest that the more acute-angled aneurysm-vessel anatomy, the larger the angular change. Further studies are needed to investigate whether these changes improve the clinical outcome.

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          Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms.

          Raphaël Blanc, Jacques Moret, Eric P. Schmidt … (2009)
          Stent-assisted coiling has expanded the treatment of intracranial aneurysms, but the rates of procedure-related neurological complications and the incidence of angiographic aneurysm recurrence of this novel treatment are not yet well known. We present our experience with stent-assisted coiling with special emphasis on procedure-related neurological complications and incidence of angiographic recurrence. Clinical and angiographic outcomes of 1137 consecutive patients (1325 aneurysms) coiled with and without stent-assisted coiling technique from January 2002 to January 2009 were retrospectively analyzed. There were 1109 aneurysms (83.5%) treated without and 216 (16.5%) treated with stents (15 of 216; 6.9% balloon-expandable versus 201 of 216; 93.1% self-expandable stents). Stents were delivered after coiling in 55.1% (119 of 216) and before coiling in 44.9% (97 of 216) of the cases. Permanent neurological procedure-related complications occurred in 7.4% (16 of 216) of the procedures with stents versus 3.8% (42 of 1109) in the procedures without stents (logistic regression P=0.644; OR: 1.289; 95% CI: 0.439 to 3.779). Procedure-induced mortality occurred in 4.6% (10 of 216) of the procedures with stents versus 1.2% (13 of 1109) in the procedures without stents (logistic regression P=0.006; OR: 0.116; 95% CI: 0.025 to 0.531). A total of 52.7% (114 of 216) of aneurysms treated with stents have been followed so far versus 69.8% (774 of 1109) of aneurysms treated without stents, disclosing angiographic recurrence in 14.9% (17 of 114) versus 33.5% (259 of 774), respectively (Fisher exact test P<0.0001; OR: 0.3485; 95% CI: 0.2038 to 0.5960). Stents were associated with a significant decrease of angiographic recurrences, but they were associated with more lethal complications compared with coiling without stents.
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            Magnitude and role of wall shear stress on cerebral aneurysm: computational fluid dynamic study of 20 middle cerebral artery aneurysms.

            Masaaki Shojima, Marie Oshima, Kiyoshi Takagi … (2004)
            Wall shear stress (WSS) is one of the main pathogenic factors in the development of saccular cerebral aneurysms. The magnitude and distribution of the WSS in and around human middle cerebral artery (MCA) aneurysms were analyzed using the method of computed fluid dynamics (CFD). Twenty mathematical models of MCA vessels with aneurysms were created by 3-dimensional computed tomographic angiography. CFD calculations were performed by using our original finite-element solver with the assumption of Newtonian fluid property for blood and the rigid wall property for the vessel and the aneurysm. The maximum WSS in the calculated region tended to occur near the neck of the aneurysm, not in its tip or bleb. The magnitude of the maximum WSS was 14.39+/-6.21 N/m2, which was 4-times higher than the average WSS in the vessel region (3.64+/-1.25 N/m2). The average WSS of the aneurysm region (1.64+/-1.16 N/m2) was significantly lower than that of the vessel region (P<0.05). The WSSs at the tip of ruptured aneurysms were markedly low. These results suggest that in contrast to the pathogenic effect of a high WSS in the initiating phase, a low WSS may facilitate the growing phase and may trigger the rupture of a cerebral aneurysm by causing degenerative changes in the aneurysm wall. The WSS of the aneurysm region may be of some help for the prediction of rupture.
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              Aneurysm growth occurs at region of low wall shear stress: patient-specific correlation of hemodynamics and growth in a longitudinal study.

              Nancy Young, R T Higashida, Loic Boussel … (2008)
              Evolution of intracranial aneurysmal disease is known to be related to hemodynamic forces acting on the vessel wall. Low wall shear stress (WSS) has been reported to have a negative effect on endothelial cells normal physiology and may be an important contributor to local remodeling of the arterial wall and to aneurysm growth and rupture. Seven patient-specific models of intracranial aneurysms were constructed using MR angiography data acquired at two different time points (mean 16.4+/-7.4 months between the two time points). Numeric simulations of the flow in the baseline geometries were performed to compute WSS distributions. The lumenal geometries constructed from the two time points were manually coregistered, and the radial displacement of the wall was calculated on a pixel-by-pixel basis. This displacement, corresponding to the local growth of the aneurysm, was compared to the time-averaged wall shear stress (WSS TA) through the cardiac cycle at that location. For statistical analysis, radial displacement was considered to be significant if it was larger than half of the MR pixel resolution (0.3 mm). Mean WSS TA values obtained for the areas with a displacement smaller and greater than 0.3 mm were 2.55+/-3.6 and 0.76+/-1.5 Pa, respectively (P<0.001). A linear correlation analysis demonstrated a significant relationship between WSS TA and surface displacement (P<0.001). These results indicate that aneurysm growth is likely to occur in regions where the endothelial layer lining the vessel wall is exposed to abnormally low wall shear stress.
              Article 0 comments Cited 106 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Utpal Sen: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 13 April 2016
                Publication date Collection: 2016
                Volume: 11
                Issue: 4
                Electronic Location Identifier: e0153403
                Affiliations
                [1 ]Abteilung für Diagnostische und Interventionelle Neuroradiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
                [2 ]Acandis GmbH & Co. KG, Pforzheim, Germany
                University of Louisville, UNITED STATES
                Author notes

                Competing Interests: Mr. Klopp is employed by Acandis GmbH & Co. KG, Pforzheim, Germany. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials. The other authors have no conflict of interest.

                Conceived and designed the experiments: EB SP DK. Performed the experiments: EB DK SP. Analyzed the data: EB DK SP. Contributed reagents/materials/analysis tools: JSK CZ DK. Wrote the paper: EB SP JG JK JSK SP.

                Article
                Publisher ID: PONE-D-16-02335
                DOI: 10.1371/journal.pone.0153403
                PMC ID: 4830582
                PubMed ID: 27073908
                SO-VID: 7353c92b-df6e-4bd5-ad47-9e53fd69e108
                Copyright © © 2016 Beller et al
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 18 January 2016
                Date accepted : 29 March 2016
                Page count
                Figures: 5, Tables: 1, Pages: 11
                Funding
                The authors have no support or funding to report.
                Categories
                Subject: Research Article
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Vascular Diseases
                Subject: Aneurysms
                Subject: Medicine and Health Sciences
                Subject: Hematology
                Subject: Hemodynamics
                Subject: Medicine and Health Sciences
                Subject: Cardiovascular Medicine
                Subject: Cardiovascular Imaging
                Subject: Angiography
                Subject: Medicine and Health Sciences
                Subject: Diagnostic Medicine
                Subject: Diagnostic Radiology
                Subject: Cardiovascular Imaging
                Subject: Angiography
                Subject: Research and Analysis Methods
                Subject: Imaging Techniques
                Subject: Diagnostic Radiology
                Subject: Cardiovascular Imaging
                Subject: Angiography
                Subject: Medicine and Health Sciences
                Subject: Radiology and Imaging
                Subject: Diagnostic Radiology
                Subject: Cardiovascular Imaging
                Subject: Angiography
                Subject: Biology and Life Sciences
                Subject: Anatomy
                Subject: Body Fluids
                Subject: Blood
                Subject: Blood Flow
                Subject: Medicine and Health Sciences
                Subject: Anatomy
                Subject: Body Fluids
                Subject: Blood
                Subject: Blood Flow
                Subject: Biology and Life Sciences
                Subject: Physiology
                Subject: Body Fluids
                Subject: Blood
                Subject: Blood Flow
                Subject: Medicine and Health Sciences
                Subject: Physiology
                Subject: Body Fluids
                Subject: Blood
                Subject: Blood Flow
                Subject: Medicine and Health Sciences
                Subject: Hematology
                Subject: Blood
                Subject: Blood Flow
                Subject: Biology and Life Sciences
                Subject: Anatomy
                Subject: Cardiovascular Anatomy
                Subject: Blood Vessels
                Subject: Arteries
                Subject: Medicine and Health Sciences
                Subject: Anatomy
                Subject: Cardiovascular Anatomy
                Subject: Blood Vessels
                Subject: Arteries
                Subject: Biology and Life Sciences
                Subject: Anatomy
                Subject: Cardiovascular Anatomy
                Subject: Blood Vessels
                Subject: Arteries
                Subject: Carotid Arteries
                Subject: Medicine and Health Sciences
                Subject: Anatomy
                Subject: Cardiovascular Anatomy
                Subject: Blood Vessels
                Subject: Arteries
                Subject: Carotid Arteries
                Subject: Physical Sciences
                Subject: Physics
                Subject: Classical Mechanics
                Subject: Mechanical Stress
                Subject: Shear Stresses
                Subject: Medicine and Health Sciences
                Subject: Hematology
                Subject: Blood Coagulation
                Subject: Coagulation Disorders
                Subject: Thrombosis
                Subject: Medicine and Health Sciences
                Subject: Cardiovascular Medicine
                Subject: Cardiovascular Diseases
                Subject: Coagulation Disorders
                Subject: Thrombosis
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Thrombosis
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