Endovascular Treatment of Intracranial Aneurysms

Abstract

2046I n a recent systematic review and meta-analysis, the overall prevalence of unruptured intracranial aneurysms (IAs) is estimated as 3.2%. 1 The prevalence of IAs is higher in patients with autosomal dominant polycystic kidney disease or a positive family history of IAs of subarachnoid hemorrhage (SAH).1 From the same review, the size of unruptured IAs is <5 mm in 66%, 5 to 9 mm in 27%, and ≥10 mm in 7%; the site of IAs is internal carotid artery, including posterior communicating artery in 42%, middle cerebral artery in 35%, and anterior cerebral artery and anterior communicating artery in 18%.Most IAs are clinically silent until rupture, which is unpredictable and sometimes associated with SAH, intraparenchymal hematoma, and an intraventricular hemorrhage. The case fatality of IA rupture is high (from 27% to 44%), but has decreased during the past 3 decades because of the introduction of improved management strategies, including neurocritical care.2 The International Study of Unruptured Intracranial Aneurysms (ISUIA) showed an increased risk of IA rupture with aneurysm size and for posterior circulation aneurysms. Although treatment of a ruptured aneurysm is accepted as an emergency, indication for treatment of unruptured IAs is still being discussed. Decision for treatment is based on clinical and anatomic factors; among them, the most important being patient's age, family history of IA(s), associated conditions (autosomal dominant polycystic kidney disease), symptomatic aneurysms, aneurysm size, and location. The randomized International Subarachnoid Aneurysm Trial (ISAT) study has clearly demonstrated the superiority of endovascular treatment (EVT) of ruptured aneurysms using coil technology over surgery. 4 Since the publication of these results, EVT has rapidly evolved. Although for unruptured aneurysms a direct comparison between EVT and surgery is not available, EVT has been widely used in this subgroup as well. 5In fact the population presenting with IAs is quite heterogeneous, regarding their status at presentation (ruptured versus unruptured), aneurysm shape (fusiform versus saccular) and location (aneurysm geometry in relationship to parent artery), their size (small/large/giant), the size of their neck (small/ large), and other factors. The heterogeneity illustrates that various approaches have to be considered to treat all types of IAs by EVT. During the past >2 decades, different therapeutic modalities were developed for EVT of IAs, and the goal of the present review is to describe them and to analyze their role in the management of IAs. CoilingEVT of IAs was introduced by use of detachable latex balloons and pushable coils. Because their use was cumbersome and associated with high incidence of periprocedural complications, they were applied in a relatively limited number of patients who were difficult to treat with standard surgery. The development of coils with controlled detachable system was clearly the first important step for widespread use of EVT. 6,7 Initial large series showed accepta...

A Single Pipeline Embolization Device is Sufficient for Treatment of Intracranial Aneurysms

“…2,16,17 Delayed aneurysm rupture after flow diversion occurs in approximately 1.0% of patients, and its mechanism may involve sudden hemodynamic changes in intra-aneurysmal flow patterns or aneurysm wall weakening due to inflammation and proteolytic enzymes within the developing red thrombus. 17 Some have suggested using intraluminal coils or steroids to attenuate the effects of intra-aneurysmal thrombosis, but whether this strategy can reduce the risk of aneurysm rupture remains to be seen. Last, device migration has recently been recognized as a potential, severe complication of flow diversion that can be associated with hemorrhagic or thromboembolic events.…”

WEB Treatment of Intracranial Aneurysms: Clinical and Anatomic Results in the French Observatory

“…[3][4][5][6][7][8][9] Flow disruption is a new endovascular approach, which involves placement of an intrasaccular device (Woven EndoBridge [WEB] aneurysm embolization system; Sequent Medical, Aliso Viejo, California), which modifies the blood flow at the level of the neck and induces aneurysmal thrombosis. The WEB was designed to treat wide-neck and bifurcation aneurysms.…”

Enhancing Brain Lesions after Endovascular Treatment of Aneurysms

“…1,2 The complication rate of this procedure is relatively low 3 and mostly includes thromboembolic events and intraprocedure aneurysm rupture. 4 Less common nonvascular complications exist and include hydrocephalus and perianeurysmal edema.…”