Evaluation of ischemic lesion prevalence after endovascular treatment of intracranial aneurysms, as documented by 3-T diffusion-weighted imaging: a 2-year, single-center cohort study

Abstract

OBJECTIVE Even though published data exist concerning the prevalence of ischemic lesions detected by diffusion-weighted imaging (DWI) following endovascular treatment of intracranial aneurysms, a single-center cross-evaluation of the different endovascular techniques has been lacking. The authors sought to prospectively evaluate the prevalence and clinical significance of ischemic lesions occurring after endovascular treatment of intracranial aneurysms and to compare the safety and effectiveness of a broad spectrum of currently accepted endovascular techniques in a single-center setting. METHODS This was a prospective cohort study involving consecutive patients treated for intracranial aneurysms exclusively by endovascular means, excluding treatments in the acute rupture phase, in a center featuring an endovascular-only treatment policy for intracranial aneurysms. All patients underwent MRI, including a 3-directional DWI sequence, before treatment, 24 hours postprocedure, and 6 months following endovascular embolization. Selective angiography was performed at 6 months' follow-up. RESULTS From January 2012 through December 2013, 164 aneurysms were treated in 128 consecutive patients. Endovascular techniques included coiling (14.6%), balloon-assisted coiling (20.1%), stent-assisted coiling (3.7%), low-profile stent-assisted coiling, flow diversion (38.4%), and very complex treatments (6.1%) involving 2 stents in Y or T configurations. On postprocedure MRI, the rates of occurrence of new DWI-positive lesions were 64.3% for coiling, 54.5% for remodeling, 61.1% for stent-assisted coiling, 53.7% for flow-diverting stents, and 75% for very complex treatments (p = 0.4962). The 6-month procedure-related morbidity and mortality rates were 6.25% and 0%, respectively. At 6 months' follow-up, 93% of the patients had modified Rankin Scale (mRS) scores of 0-2. Very complex treatments offered a higher complete occlusion rate (100%) than all other techniques (66.7%-88.9%). Age and length of procedure were independent factors for DWI lesion occurrence. The diameter of DWI lesions on 24-hour postprocedure MRI was positively correlated with mRS score at discharge. Among the DWI-positive lesions measuring less than 2 mm in diameter on the 24-hour MRI, 44.12% had regressed at 6 months. CONCLUSIONS Procedure-related DWI lesions are far more often encountered in silent forms than they are clinically evident. They do not seem to be significantly correlated with procedure-related complications, nor do they seem to impair clinical outcome, regardless of the endovascular technique. Small lesions (< 2 mm in diameter) may regress within 6 months. The use of the most adapted technique, in terms of aneurysm configuration, results in significant total occlusion rates, with acceptable safety.

Remote ischemic preconditioning for elective endovascular intracranial aneurysm repair: a feasibility study

“…Interestingly, all three patients who were treated with flow diverters in our study had at least one post-procedure DWI lesion while only one patient out of four who was treated with coiling alone had two DWI lesions. These findings are: (a) consistent with recent meta-analysis findings 25 that demonstrated a significantly higher rate of DWI-positive lesions following endovascular flow diversion compared with coiling alone, possibly due to the high ratio of metal coverage in flow diverters that might increase the risk of intra-luminal thrombosis; (b) in contrary to most previous studies 25,28,29 that reported a higher occurrence rate of DWI lesions after endovascular coiling. The low rate of DWI lesions on post-procedure MRI in our patients who were treated with coiling is interesting because it might shed new light on the possible potential neuroprotective benefits of RIPC for the prevention and treatment of stroke in patients who are at high risk of ischemic events.…”

Diffusion weighted image documented cerebral ischemia in the postprocedural period following pipeline embolization device with shield technology treatment of unruptured intracranial aneurysms: a prospective, single center study

“…In the systemic review and meta-analysis by Bond et al , the rate of postprocedural DWI documented ischemic lesions was 45%, 44%, 43%, and 67% after simple coiling, balloon assisted coiling, stent assisted coiling, and flow diversion, respectively 23. Single center studies evaluating silent cerebral ischemia after intracranial aneurysm treatment with the PED reported an asymptomatic cerebral ischemia rate of 50.9–90% 4–11. These studies reported an increased risk of post-PED treatment silent cerebral ischemia with female gender,4 aneurysm size ≥10 mm,5 and age ≥60 6…”

“…We hypothesized that management of intracranial aneurysms with the PED-Shield is associated with a lower rate of postprocedural, diffusion weighted imaging (DWI) documented cerebral ischemia than previously reported with the PED 4–11. Hence the purpose of this prospective study was to determine the incidence of cerebral ischemia on postprocedural DWI following PED-Shield treatment of intracranial aneurysms in a single institution cohort of consecutive patients.…”

“…However, flow diversion is not without complications, and despite the routine use of antiplatelet medications and preprocedural assessment of individual responses to antiplatelet medication, postprocedural cerebral ischemia remains the most common complication of flow diversion. Acute ischemic stroke and silent cerebral infarctions following PED treatment have been reported at a rate of 2.6–4.7%1–3 and 50.9–90%,4–11 respectively. The association of the latter with delayed intracerebral hemorrhage,5 11 cognitive decline, and vascular dementia remains unclear 12 13…”

Angiographic and clinical outcomes of balloon remodeling versus unassisted coil embolization in the ruptured aneurysm cohort of the GEL THE NEC study

“…Albayram et al demonstrated that the risk of thromboembolic events resulting in DWI lesions was not more significant when BACE was used compared with CE 26. In a recent study evaluating the presence of ischemic lesions following endovascular treatment of aneurysms using 3 T DWI, Iosif et al found that the rates of occurrence of new DWI positive lesions were higher for CE and stent assisted coil embolization (SACE) compared with BACE (64.3% for CE, 61.1% for SACE, and 54.5% for BACE) 27. It is not clear if subarachnoid hemorrhage increases the risk of thromboembolic events during BACE due to its prothrombotic milieu.…”