OBJECTIVE Paraclinoid aneurysms represent approximately 5% of intracranial aneurysms (Drake et al. [1968]). Visual impairment, which occurs in 16%-40% of patients, is among the most common presentations of these aneurysms (Day [1990], Lai and Morgan [2013], Sahlein et al. [2015], and Silva et al. [2017]). Flow-diverting stents, such as the Pipeline Embolization Device (PED), are increasingly used to treat these aneurysms, in part because of their theoretical reduction of mass effect (Fiorella et al. [2009]). Limited data on paraclinoid aneurysms treated with a PED exist, and few studies have compared outcomes of patients after PED placement with those of patients after clipping or coiling. METHODS The authors performed a retrospective analysis of 115 patients with an aneurysm of the cavernous to ophthalmic segments of the internal carotid artery treated with clipping, coiling, or PED deployment between January 2011 and March 2017. Postoperative complications were defined as new neurological deficit, aneurysm rupture, recanalization, or other any operative complication that required reintervention. RESULTS A total of 125 paraclinoid aneurysms in 115 patients were treated, including 70 with PED placement, 23 with coiling, and 32 with clipping. Eighteen (14%) aneurysms were ruptured. The mean aneurysm size was 8.2 mm, and the mean follow-up duration was 18.4 months. Most aneurysms were discovered incidentally, but visual impairment, which occurred in 21 (18%) patients, was the most common presenting symptom. Among these patients, 15 (71%) experienced improvement in their visual symptoms after treatment, including 14 (93%) of these 15 patients who were treated with PED deployment. Complete angiographic occlusion was achieved in 89% of the patients. Complications were seen in 17 (15%) patients, including 10 (16%) after PED placement, 2 (9%) after coiling, and 5 (17%) after clipping. Patients with incomplete aneurysm occlusion had a higher rate of procedural complications than those with complete occlusion (p = 0.02). The rate of postoperative visual improvement was significantly higher among patients treated with PED deployment than in those treated with coiling (p = 0.01). The significant predictors of procedural complications were incomplete occlusion (p = 0.03), hypertension, (p = 0.04), and diabetes (p = 0.03). CONCLUSIONS In a large series in which patient outcomes after treatment of paraclinoid aneurysms were compared, the authors found a high rate of aneurysm occlusion and a comparable rate of procedural complications among patients treated with PED placement compared with the rates among those who underwent clipping or coiling. For patients who presented with visual symptoms, those treated with PED placement had the highest rate of visual improvement. The results of this study suggest that the PED is an effective and safe modality for treating paraclinoid aneurysms, especially for patients who present with visual symptoms.
OBJECTIVE Woven EndoBridge (WEB) intrasaccular flow disruptors and stent-assisted coiling (SAC) are viable endovascular treatment options for wide-neck bifurcation intracranial aneurysms (WNBAs). Data directly comparing these two treatment options are limited. The authors aimed to compare radiographic occlusion rates and complication profiles between patients who received WEB and those who received SAC for WNBAs. METHODS Retrospective review of a prospectively maintained cerebrovascular procedural database was performed at a single academic medical center between 2017 and 2021. Patients were included if they underwent WEB embolization or SAC of an unruptured WNBA. SAC patients were propensity matched to WEB-embolized patients on the basis of aneurysm morphology. Complete and adequate (complete occlusion or residual neck remnant) occlusion rates at last angiographic follow-up, as well as periprocedural complications, were compared between the two groups. A cost comparison was performed for a typical 5-mm WNBA treated with WEB versus SAC by using manufacturer-suggested retail prices. RESULTS Thirty-five WEB and 70 SAC patients were included. Aneurysm width, neck size, and dome-to-neck ratio were comparable between groups. Follow-up duration was significantly longer in the SAC group (median [interquartile range] 545 [202–834] days vs 228 [177–494] days, p < 0.001, Mann-Whitney U-test). Complete (66% of WEB patients vs 69% of SAC patients) and adequate (94% WEB vs 91% SAC) occlusion rates were similar between groups at the last available angiographic follow-up (p = 0.744, chi-square test). Complete occlusion rates were comparable on Cox regression analysis after correction for follow-up duration (hazard ratio 1.5, 95% CI 0.8–3.1). Average time to residual aneurysm or neck formation was not statistically different between treatment groups (613 days for SAC patients vs 347 days for WEB patients, p = 0.225, log-rank test). Periprocedural complications trended higher in the SAC group (0% WEB vs 9% SAC, p = 0.175, Fisher exact test), although this finding was not significant. The equipment costs for a typical SAC case were estimated at $18,950, whereas the costs for a typical WEB device case were estimated at $18,630. CONCLUSIONS Midterm complete and adequate occlusion rates were similar between patients treated with WEB and those treated with SAC. Given these comparable outcomes, there may be equipoise in treatment options for WNBAs.
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