Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

Abstract

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.

Variation of Mass Effect After Using a Flow Diverter With Adjunctive Coil Embolization for Symptomatic Unruptured Large and Giant Intracranial Aneurysms

“…Previous studies have revealed the feasibility and safety of using only a PED without coils. These studies indicate that the PED can effectively divert blood flow from large or giant aneurysms and can shrink the sac size during thrombosis, relieving the mass effect and even resolving the compressional symptoms (8, 9, 18). However, use of a PED alone may increase the risk of rupture after the intervention, especially for large or giant aneurysms, because the occlusion occurs over a delayed period (11, 12).…”

“…The Pipeline embolization device (PED; ev3 Neurovascular, Irvine, CA, USA), which is one of the FDs that has been approved by the Food and Drug Administration, is the most commonly used FD at our center. Because of the excellent flow diverting force, the quantity of coils can be decreased during the intervention, making it possible to reduce the size of the aneurysm; the aneurysm may thus physically shrink by avoiding dense packing of the coil in the aneurysm (6–9). Numerous studies have revealed shrinkage of aneurysms and recovery of compressive cranial nerve symptoms following PED placement in cerebral aneurysms; however, almost all of these studies involved the use of a PED without coils (7–9).…”

“…Because of the excellent flow diverting force, the quantity of coils can be decreased during the intervention, making it possible to reduce the size of the aneurysm; the aneurysm may thus physically shrink by avoiding dense packing of the coil in the aneurysm (6–9). Numerous studies have revealed shrinkage of aneurysms and recovery of compressive cranial nerve symptoms following PED placement in cerebral aneurysms; however, almost all of these studies involved the use of a PED without coils (7–9). In other research, the complete absence of coils was found to be associated with a risk of delayed rupture; therefore, for giant aneurysms, it may be safer to use a PED with an appropriate quantity of loosely packed coils (10–12).…”

The future of open vascular neurosurgery: perspectives on cavernous malformations, AVMs, and bypasses for complex aneurysms

“…Flow diverters now dominate the treatment of cavernous and paraclinoidal internal carotid artery (ICA) aneurysms, and off-label use extends beyond the supraclinoid ICA. 15,61 Intra-aneurysmal flow diverters have been developed for bifurcation aneurysms. 3 What remains for microsurgery are complex aneurysms, defined as those with wide necks, large size, dolichoectatic morphology, intraluminal thrombus, previous endovascular therapy, or atherosclerotic walls.…”

Lower limb weakness with gyrus rectus hematoma: an unusual presentation of paraclinoid aneurysm; a case report with review of literature

“…However, newer endovascular techniques using flow diverters and pipeline embolisation device have shown promising results in terms of improvement of visual symptoms, obliteration rate, complications and recurrence and may play a greater role in future in treatment of paraclinoid aneurysms [8]. However, financial constraints and availability of infrastructure for coiling will continue to be a major hurdle for these endovascular techniques particularly in developing countries around the world.…”