Coiling embolization strategy for medium-to-giant-sized intracranial aneurysms treated with pipeline embolization device: a propensity score-weighted study.

OBJECTIVES: We aim to investigate associations between different coil strategies and outcomes in the aneurysms treated by a pipeline embolization device (PED). METHODS: Patients with medium-to-giant-sized aneurysms treated by PED were included. The total cohort was divided into PED-alone and PED-coiling groups, and the PED-coiling group was further divided into loose and dense packing subgroups. Multivariate logistic analyses and stabilized inverse probability of treatment weighting (sIPTW) were performed to investigate the relationships between coiling strategies and outcomes. Restricted cubic spline (RCS) curves were used to describe the coiling degree and angiographic outcome relationship. RESULTS: A total of 398 patients with 410 aneurysms were included. Aneurysms treated with PED coiling had a lower incomplete occlusion rate (15.3% vs. 30.3%, p = 0.002), higher total perioperative complication rate (14.2% vs. 3.5%, p = 0.001), longer production time (142.14 min vs. 101.26 min, p < 0.001), and higher total cost ($45,158.63 vs. $34,680.91, p < 0.001) than those treated with PED alone. There were no differences in outcomes between the loose and dense packing subgroups. However, the total cost was higher in the dense packing group ($43,787.46 vs. $47,288.32, p = 0.001) than in the loose packing group. The result was still robust in the multivariate and sIPTW analyses. The RCS curves showed "L-shape" relationships between the coil degree and angiographic outcomes. CONCLUSION: Compared with PED alone, PED coiling could improve aneurysm occlusion. However, it could also increase the total complication risk, prolong procedure time, and increase the total cost. Compared with loose packing, dense packing did not enhance the treatment effectiveness but increased the treatment cost. CLINICAL RELEVANCE STATEMENT: The additional treatment effect from coiling embolization declines sharply after a certain point. Specifically, the aneurysm occlusion rate is roughly stable when the coil number is greater than 3 or the total coil length is longer than 150 cm. KEY POINTS: • Compared with pipeline embolization device (PED) alone, PED combined with coiling can improve aneurysm occlusion. • Compared with PED alone, PED combined with coiling increases the total complication risk, cost, and prolongs procedure time. • Compared with loose packing, dense packing did not increase the treatment effectiveness but increased the cost.

Blood inflammatory biomarkers predict in-hospital pneumonia after endovascular treatment of aneurysm in patients with aneurysmal subarachoid hemorrhage.

The systemic inflammatory response index (SIRI) is a well-known marker of systemic inflammation reflecting the body's inflammatory/immune state. The study aimed to evaluate the relationship between the SIRI on admission and aneurysmal subarachnoid hemorrhage (aSAH)-associated pneumonia and compare with other currently used bio-markers. We reviewed 562 successive patients with aneurysmal SAH who underwent endovascular treatment between January 2019 and September 2021. ASAH-associated pneumonia was diagnosed using the modified Centers for Disease Control and Prevention criteria. The SIRI on admission was calculated as monocyte count × neutrophil count / lymphocyte count. Multiple logistic regression models were used for data analysis. A total of 158 (28.11%) patients developed aSAH-associated pneumonia. Using the Multiple logistic regression analysis, a notable dose-response association was found between the elevated SIRI (fourth quartile) and aSAH-associated pneumonia (adjusted odds ratio = 6.759; 95% confidence interval [CI], 3.280-13.930; p < 0.001 [p for trend < 0.001]). The SIRI (0.701, 95% CI: 0.653-0.749) presented a higher area under the curve (AUC) than systemic immune- inflammation index (SII) (0.669, 95% CI: 0.620-0.718) (p = 0.089); neutrophil-to-lymphocyte ratio (NLR) (0.665, 95% CI: 0.616-0.714) (p = 0.035) and platelet-lymphocyte ratio (PLR) (0.587, 95% CI: 0.534-0.641) (p < 0.001). A higher SIRI on admission was associated with aSAH-associated pneumonia, which may guide further clinical trials of prophylactic antibiotic therapy.

Association between higher systemic immune inflammation index (SII) and deep vein thrombosis (DVT) in patients with aneurysmal subarachnoid hemorrhage (aSAH) after endovascular treatment.

Inflammation contributes to deep vein thrombosis (DVT) formation in patients with aSAH after endovascular treatment. The relationship between systemic immune-inflammatory index (SII) as an inflammatory marker and DVT formation remains unclear. Thus, this study aims to evaluate the association between SII and aSAH-associated DVT following endovascular treatment. We enrolled 562 consecutive patients with aSAH after endovascular treatment at three centers from January 2019 to September 2021. The endovascular treatments included simple coil embolization and stent-assisted coil embolization. Deep venous thrombosis (DVT) was assessed by Color Doppler ultrasonography (CDUS). Multivariate logistic regression analysis was used to establish the model. We assessed the association of the SII, neutrophil-to-lymphocyte ratio (NLR), the systemic inflammatory response index (SIRI), platelet-lymphocyte ratio (PLR), and DVT by using restricted cubic spline (RCS). ASAH-associated DVT was found in 136 (24.20%) patients. Based on the multiple logistic regression analysis, the correlation was found between aSAH-associated DVT and elevated SII (fourth quartile) (adjusted odds ratio = 8.20 [95% confidence interval, 3.76-17.92]; p < 0.001 [p for trend < 0.001]), elevated NLR (fourth quartile) (adjusted odds ratio = 6.94 [95% confidence interval, 3.24-14.89]; p < 0.001 [p for trend < 0.001]), elevated SIRI (fourth quartile) (adjusted odds ratio = 4.82 [95% confidence interval, 2.36-9.84]; p < 0.001 [p for trend < 0.001]), and elevated PLR (fourth quartile) (adjusted odds ratio = 5.49 [95% confidence interval, 2.61-11.57]; p < 0.001 [p for trend < 0.001]). The increased SII was correlated with the formation of aSAH-associated DVT after endovascular treatment.

Association of elevated neutrophil-to-lymphocyte ratio with increased intracranial aneurysm stability scores and aneurysm growth.

BACKGROUND AND PURPOSE: Inflammation involves in the progression of intracranial aneurysms (IAs). However, whether the neutrophil-to-lymphocyte ratio (NLR) as an inflammatory marker links to IAs stability is unidentified. This study was performed to assess the association of the NLR with IAs stability. METHODS: We retrospectively reviewed the medical records of patients diagnosed with unruptured IAs from January 2014 to June 2018. According to the quartiles of the NLR, patients with unruptured IAs were categorized into four groups. We evaluated the association between the NLR and IAs stability scores and IAs growth. Multiple logistic regression models were used in the analysis. RESULTS: A significant dose-response association was found between the NLR with IAs stability scores and IAs growth. After adjustment for potential confounders, an elevated NLR (fourth quartile) was associated with increased PHASES score (>5) (adjusted odds ratio [OR], 2.007; 95% confidence interval [CI], 1.361-2.960; p<0.001 [p for trend <0.001]), increased ELAPSS score (>15) (adjusted OR, 1.581; 95% CI, 1.074-2.328; p=0.020 [p for trend =0.001]), increased JAPAN 3-year rupture risk score (>5) (adjusted OR, 1.512; 95% CI, 1.033-2.215; p=0.034 [p for trend <0.001]), and IAs growth (adjusted OR, 16.759; 95% CI, 3.022-92.928; p=0.001 [p for trend <0.001]). CONCLUSION: An elevated NLR was associated with increased IAs stability scores and IAs growth. The association between NLR and IAs stability need further investigate.

Effects of blood lipids and lipid-modifying drugs on intracranial aneurysms.

BACKGROUND AND PURPOSE: We used two-sample Mendelian randomization (MR) to examine the effects of blood lipids and lipid-modifying drugs on intracranial aneurysm (IA). METHODS: Genetic variants for the effects of high-density lipoprotein cholesterol (HDL-C), apolipoprotein A1, low-density lipoprotein cholesterol (LDL-C), apolipoprotein B, and triglycerides and targets for lipid-modifying drugs were selected from the genome-wide discovery analyses of the UK Biobank. Summary-level data on IAs were obtained from the International Stroke Genetics Consortium. Univariate and multivariate MR analyses were performed. RESULTS: Univariate MR analyses showed that the HDL-C was negatively correlated with IA (odds ratio [OR] = 0.816, 95% confidence interval [CI] = 0.715-0.932, p = 0.003) and ruptured IA (rIA; OR = 0.775, 95% CI = 0.663-0.906, p = 0.001). The multivariate MR-inverse variance weighted analysis showed that the HDL-C was negatively correlated with IA (OR = 0.655, 95% CI = 0.434-0.988, p = 0.043) and rIA (OR = 0.563, 95% CI = 0.347-0.913, p = 0.02), and the LDL-C was negatively correlated with IA (OR = 0.402, 95% CI = 0.191-0.848, p = 0.017) and rIA (OR = 0.376, 95% CI = 0.160-0.883, p = 0.025). Using genetic proxies of known lipid-modifying drugs, we found that the increased HDL-C with cholesterol ester transfer protein proxies was associated with a decreased risk of rIA (OR = 0.852, 95% CI = 0.747-0.973, p = 0.018), and the decreased LDL-C with 3-hydroxy-3-methylglutaryl-coenzyme A reductase proxies was associated with increased risk of IA (OR = 1.772, 95% CI = 1.080-2.908, p = 0.024) and rIA (OR = 1.856, 95% CI = 1.022-3.371, p = 0.042). CONCLUSIONS: Genetically determined HDL-C and LDL-C reduce the risk of IA and rIA. The effects of different lipid-modifying drugs on IA need to be further investigated.

Additive Effect of Coexisting Aneurysms Increases Subarachnoid Hemorrhage Risk in Patients With Multiple Aneurysms.

BACKGROUND AND PURPOSE: It remains unclear whether the additive effect of coexisting intracranial aneurysms increases the risk of subarachnoid hemorrhage (SAH) in patients with multiple intracranial aneurysms. We have performed a tentative analysis for the additive effect of coexisting aneurysms. METHODS: This multi-institutional cross-sectional study included 1781 aneurysms from 746 patients with multiple intracranial aneurysms. Using the generalized linear mixed model, we analyzed risk factors associated with individual aneurysm rupture and assessed the additive risk of SAH for each patient. RESULTS: The coexisting aneurysms number was not significantly associated with individual intracranial aneurysm rupture, both in unadjusted and adjusted analyses. Patient-level analysis found that an increased number of coexisting aneurysms was significantly associated with a greater estimated additive risk (P<0.001). Estimated additive risks of patients with 2, 3, and 4 or more coexisting intracranial aneurysms were 25.9%, 31.8%, and 38.1%, respectively, which are comparable to the actual incidence of SAH in those patients (26.6%, 29.5%, and 36.5%, respectively), with a Spearman correlation coefficient of 1.000 (P<0.001). Compared with aneurysm-related factors, the estimated additive effect had better discrimination power for SAH risk, with areas under the receiver operating characteristic curve of 0.821. CONCLUSIONS: We found that a greater number of coexisting aneurysms did not increase rupture risk of individual aneurysms, but the potential additive effect might increase SAH risk in patients with multiple intracranial aneurysms.

External Validation of the PHASES Score in Patients with Multiple Intracranial Aneurysms.

OBJECTIVES: This study sought to assess whether the Population, Hypertension, Age, Size, Earlier Subarachnoid Hemorrhage, Site (PHASES) score can do risk stratification of patients with multiple aneurysms (MIAs). MATERIAL AND METHODS: Patients between January 1, 2016 and January 1, 2019 were recruited retrospectively. The PHASES score was applied to assess the theoretical risk of IA rupture. For patients-level analyses, four modes of the application of the score were used: largest IA PHASES score, highest PHASES score, sum PHASES score, and mean PHASES score. RESULTS: A total of 701 patients with 1673 IAs were included in this study. At aneurysm-level analysis, the average PHASES score was 3.0 ± 3.0 points, with 2.8 ± 3.0 points and 4.1 ± 2.9 points in the unruptured and ruptured groups, respectively (p < 0.001). At the patient-level analysis, for the largest IA PHASES score, the areas under the curves (AUC) was 0.572. The discrimination performance of the largest IA PHASES score decreases as IA number increases, with AUCs were 0.597, 0.518, and 0.450 in the 2 IAs, 3 IAs and, 4 or more IAs subgroups, respectively. For highest PHASES score, sum PHASES score, and mean PHASES score, the AUCs were 0.577, 0.599, and 0.619, respectively. CONCLUSIONS: In this study, PHASES score only serve as a weak tool in decision-making settings for MIAs patients; as such, more accurate models should be developed for MIAs patients and the cumulative effect of MIA may should be considered.

The Minimum Distance May Affect Perioperative Complications and Completed Occlusions of Endovascular Treatment for Tandem Intracranial Aneurysms: A Multi-Institutional Retrospective Study.

BACKGROUND: Tandem aneurysms (TAs) are a distinct type of multiple intracranial aneurysms (IAs), the treatment strategies for which remain controversial. We aimed to reveal the clinical and angiographic outcomes of endovascular treatment as well as their risk factors in these complex multiple IAs. METHODS: This multicenter, retrospective follow-up study was carried out in 3 hospitals in China. In total, clinical and angiographical data of 137 patients with 145 lesions (7 patients had bilateral lesions) and 315 TAs were collected. The treatment strategies were divided into full or partial treatment, single- or multiple-session treatment, and coiling (including single coiling and stent-assisted coiling)- or flow-diverting stent (FDS) treatment. Perioperative complications, as well as angiographic and clinical outcomes and their risk factors, were analyzed using univariate analysis and a multiple regression model. RESULTS: Of treated TA lesions, 17 (16.0%) perioperative complications were found. Significant differences were found between the single- and multiple-session treatment groups (p = 0.012). At the latest follow-up, there were no significant differences in the modified Raymond Scale scores between different treatment groups. Significant differences were found in the embolization degree between the coiling and FDS groups (p = 0.038) and between the single common stent (without coiling) and the other treatment groups (p < 0.001). In IAs managed by a single LVIS stent (without coiling), 60% achieved improved or completed occlusion. Multivariate regression analysis found that a shorter minimum distance (odds ratio [OR] 5.967, 95% confidence interval [CI] 1.366-26.074; p = 0.018), multiple-session treatment (OR 9.961, 95% CI 1.707-58.127; p = 0.011), and diabetes (OR 8.106, 95% CI 1.928-34.084; p = 0.004) were predictors of perioperative complications, while shorter minimum distance (OR 5.619, 95% CI 1.493-21.152; p = 0.011), greater diameter ratio (OR 3.621, 95% CI 1.014-12.937; p = 0.048), and greater size ratio (OR 2.424, 95% CI 1.007-5.834; p = 0.048) were predictors of low completed occlusion rate. CONCLUSIONS: Both coiling and FDS can be utilized safely and can achieve similar clinical outcomes. FDS and LVIS are recommended for IAs that do not require embolization but cannot be prevented from being covered by stents. A multiple-session treatment may increase the treatment risk, and the minimum distance may affect the incidence of perioperative complications and completed occlusions. Further hemodynamic and prospective studies on such TAs in close proximity to one another are needed.

Procedural Complications and Factors Influencing Immediate Angiographic Results after Endovascular Treatment of Small (<5 mm) Ruptured Intracranial Aneurysms.

BACKGROUND AND OBJECTIVE: There are technical challenges to complete occlusion of small (<5 mm) ruptured intracranial aneurysms (SRAs) using endovascular treatment (EVT). This study analyzed factors influencing immediate angiographic results in SRAs after EVT. MATERIAL AND METHODS: Intraoperative angiograms and medical records of 290 patients, who underwent EVT for SRAs at 2 stroke centers in China between January 2009 and October 2016, were retrospectively reviewed and evaluated. RESULTS: Immediate complete occlusion was achieved in 213 (73.4%) aneurysms. Aneurysms with a smaller aspect ratio, those less than 3 mm in size, irregular shape, small basal outpouching, multiple aneurysms, poorer Hunt and Hess grade, and location of communication arteries demonstrated higher rates of incomplete occlusion, although the differences were not statistically significant. Multivariate logistic regression analysis revealed that SRAs with parent artery stenosis greater than or equal to 50% and lobulation demonstrated a higher incidence of incomplete occlusion. Intra-procedural rupture occurred in 13 (6.1%) patients in the complete occlusion group, and 3 (3.9%) in the incomplete occlusion group (P = .467). Thromboembolic complications occurred in 3 (1.0%) patients, and 4 (1.9%) underwent decompressive craniotomy after EVT, all of whom were in the complete occlusion group. Nine (4.2%) patients in the complete occlusion group and 2 (2.6%) in the incomplete occlusion group (P = .733) experienced intraprocedural vasospasm, with corresponding morbidity and mortality rates of 15.0% and 2.1%, respectively. CONCLUSIONS: Proximal parent artery stenosis greater than or equal to 50% and lobulation were independent predictors of incomplete occlusion in patients with SRAs. Higher rates of intraprocedural rupture, thromboembolic complications, intraprocedural vasospasm, and mortality were found in the complete occlusion group; however, these differences were not statistically significant. Complete occlusion of SRAs may be achieved without additional mortality and perioperative complications.

Shear Stress Induces Phenotypic Modulation of Vascular Smooth Muscle Cells via AMPK/mTOR/ULK1-Mediated Autophagy.

Phenotypic modulation of vascular smooth muscle cells (VSMCs) is involved in the pathophysiological processes of the intracranial aneurysms (IAs). Although shear stress has been implicated in the proliferation, migration, and phenotypic conversion of VSMCs, the molecular mechanisms underlying these events are currently unknown. In this study, we investigated whether shear stress(SS)-induced VSMC phenotypic modulation was mediated by autophagy involved in adenosine monophosphate-activated protein kinase (AMPK)/mammalian target of rapamycin (mTOR)/Unc-51-like kinase 1 (ULK1) pathway. The results show that shear stress could inhibit the expression of key VSMC contractile genes and induce pro-inflammatory/matrix-remodeling genes levels, contributing to VSMCs phenotypic switching from a contractile to a synthetic phenotype. More importantly, Shear stress also markedly increased the levels of the autophagy marker microtubule-associated protein light chain 3-II (LC3II), Beclin-1, and p62 degradation. The autophagy inhibitor 3-methyladenine (3-MA) significantly blocked shear-induced phenotypic modulation of VSMCs. To further explore the molecular mechanism involved in shear-induced autophagy, we found that shear stress could activate AMPK/mTOR/ULK1 signaling pathway in VSMCs. Compound C, a pharmacological inhibitor of AMPK, significantly reduced the levels of p-AMPK and p-ULK, enhanced p-mTOR level, and finally decreased LC3II and Beclin-1 level, which suggested that activated AMPK/mTOR/ULK1 signaling was related to shear-mediated autophagy. These results indicate that shear stress promotes VSMC phenotypic modulation through the induction of autophagy involved in activating the AMPK/mTOR/ULK1 pathway.

MiR-29b Downregulation Induces Phenotypic Modulation of Vascular Smooth Muscle Cells: Implication for Intracranial Aneurysm Formation and Progression to Rupture.

BACKGROUND/AIMS: Our previous microarray results identified numerous microRNAs (miRNAs), including miR-29b, that were differentially expressed in the serum of intracranial aneurysm (IA) patients. The current study aimed to investigate whether miR-29b downregulation in IA could promote the phenotypic modulation of vascular smooth muscle cells (VSMCs) involved in the pathogenesis of aneurysm by activating ATG14-mediated autophagy. METHODS: First, the levels of miR-29b and autophagy related genes (ATGs) between IA patients and normal subjects were compared. Next, we modified the level of miR-29b via lentivirus particles in the VSMCs and examined the effects of miR-29b on proliferation, migration, and phenotypic modulation of VSMCs from a contractile phenotype to a synthetic phenotype, as well as the levels of autophagy. Finally, the binding of miR-29b to the 3'UTR of ATG14 mRNA and its effects on ATG14 expression were analysed by a luciferase reporter assay and Western blot, respectively. RESULTS: The level of miR-29b was decreased, and autophagy markers were increased in the IA patients compared to that of the normal subjects. Knockdown of miR-29b significantly promoted VSMCs proliferation and migration and, more importantly, induced the phenotypic modulation associated with autophagy activation, whereas miR-29b overexpression showed the opposite effects. The luciferase reporter assay demonstrated that ATG14 was a functional target gene of miR-29b. Notably, knockdown of ATG14 by siRNA apparently abrogated miR-29b inhibition-mediated phenotypic modulation. CONCLUSION: Downregulation of miR-29b induced VSMCs phenotypic modulation by directly activating ATG14-mediated autophagy, which is associated with the formation, growth and rupture of IAs.

Neuroprotective effects of miR-27a against traumatic brain injury via suppressing FoxO3a-mediated neuronal autophagy.

MicroRNA-27a (miR-27a) has been reported to be a brain-specific miRNA and aberrantly expressed in the brain suffered from traumatic brain injury (TBI). The present study is designed to investigate the potential role and molecular mechanism of miR-27a in the pathogenesis of TBI. The level of miR-27a in brain was manipulated by intracerebroventricular injection of lentiviral-encoding miR-27a before TBI induction. Real-time PCR was used to detected miR-27a and Forkhead box O3a (FoxO3a) levels in the hippocampus. Then, we evaluated the impact of miR-27a overexpression on neurological function, brain edema, lesion volume and neuronal autophagy after TBI. The blinding of miR-27a to the 3'UTR of FoxO3a mRNA and its effects on FoxO3a translation were analyzed by luciferase reporter assay and Western blot. The downregulation of miR-27a and the increase in FoxO3a level were observed in the hippocampus post-TBI. Overexpression of miR-27a significantly attenuated neurological deficits and brain injury, especially suppressed autophagic activation after TBI. Furthermore, we identified that miR-27a directly targeted the FoxO3a 3'UTR region to reduced FoxO3a protein expression. Knockdown of FoxO3a significantly reversed high levels of autophagy-related genes induced by TBI. Taken together, Overexpression of miR-27a may protect against brain injury via suppressing FoxO3a-mediated neuronal autophagy following TBI.

Risk Score for Neurological Complications After Endovascular Treatment of Unruptured Intracranial Aneurysms.

BACKGROUND AND PURPOSE: Procedure-related neurological complications are common after endovascular treatment of unruptured intracranial aneurysms. We aimed to develop a score to quantify individual patient risk. METHODS: We retrospectively analyzed consecutive patients who underwent endovascular treatment for unruptured intracranial aneurysms between January 2012 and September 2015. After excluding those who lost to follow-up and those with fusiform unruptured intracranial aneurysms, included patients were randomly divided into a derivation group (60%) and a validation group (40%). A neurological complication was defined as any transient or permanent increase in the modified Rankin Scale score after aneurysm embolization. A risk score for neurological complications was derived from multivariable logistic regression analyses in the derivation group and validated in the validation group. RESULTS: Overall, 1060 patients were included (636 in the derivation group and 424 in the validation group). The incidence of neurological complications was 5.5% (95% confidence interval, 3.8%-7.4%). A 3-point risk score (S-C-C) was derived to predict neurological complications (size [≥10 mm=1], core areas [yes=1], and cerebral ischemic comorbidity [yes=1]). The incidence of neurological complications varied from 2.2% in 0-point patients to 25.0% in 3-point patients. The score demonstrated significant discrimination (C-statistic, 0.714; 95% confidence interval, 0.624-0.804) and calibration (McFadden R(2), 0.102) in the derivation group. Excellent prediction, discrimination, and calibration properties were reproduced in the validation group. CONCLUSIONS: One in 20 patients will develop neurological complications after endovascular treatment of unruptured intracranial aneurysms. The S-C-C score may be useful for predicting these adverse outcomes based on variables in daily practice.

Assessment of Risk of Aneurysmal Rupture in Patients with Normotensives, Controlled Hypertension, and Uncontrolled Hypertension.

BACKGROUND: The prevalence of hypertension in patients with intracranial aneurysms has been an increased concern, but it is not well understood if uncontrolled hypertension has impact on aneurysmal rupture. The aim of this study was to determine whether the risk of aneurysmal rupture is higher in uncontrolled hypertensive cohorts than in controlled hypertensive cohorts and normotensive cohorts. METHODS: We retrospectively analyzed the records and angiographies of 456 patients with aneurysms who were treated at our center between June 2013 and June 2014. Three groups of patients were included in the study following the ESH-ESC (European Society of Hypertension-European Society of Cardiology) 2013 guidelines: normotensive group (n = 229), controlled hypertension group (n = 127), and uncontrolled hypertension group (n = 100). Paired comparisons of these 3 groups were analyzed with the Nemenyi test. Multivariate logistic regression analysis was used to exclude the impact of possible confounding factors. RESULTS: The results of the univariate analysis showed that hypertension, smoking, and size of the aneurysms were significantly associated with intracranial aneurysmal rupture (P < .05). The multivariate logistic regression analysis containing clinical and aneurysmal characteristics showed that uncontrolled hypertension, smoking, and aneurysm size were statistically significant predictors of intracranial aneurysmal rupture (P < .05). The paired comparisons of 3 groups showed that the risk of rupture of intracranial aneurysms in the uncontrolled hypertension group was significantly greater than that in the normotensive group (P < .05) and in the controlled hypertension group (P < .05). CONCLUSIONS: Uncontrolled hypertension is associated with increased risk of rupture of intracranial aneurysms. Given that aneurysmal rupture is a potentially fatal-but preventable-complication, these findings are of clinical relevance.

Endovascular treatment of ruptured vertebrobasilar dissecting aneurysms: Review of 40 consecutive cases.

AIMS: To evaluate the safety and efficacy of endovascular intervention in the treatment of ruptured vertebrobasilar dissecting aneurysms (VBDAs) with the aim of developing endovascular treatment standards for this disorder. MATERIALS AND METHODS: The results of 40 consecutive patients with ruptured VBDAs, who were treated with internal trapping (n = 7), stent(s)-assisted coiling (n = 26), and solely stenting (n = 7) from January 2010 to June 2014, were retrospectively reviewed and analyzed. RESULTS: A treatment protocol for the ruptured VBDAs was created and proved to be effective. All 7 patients treated with internal trapping had satisfactory outcomes; none had treatment-related complications, rebleeding, or recanalization after treatment. Of the 26 patients treated with stent-assisted coiling, one patient suffered from an acute in-stent thrombosis during the operation, one had a small cerebral cortical infarction, one had rebleeding, and one had recanalization of his obliterated aneurysm after surgery. Of the seven patients treated solely with stenting, one patient had recanalization and two patients suffered rebleeding, of whom one patient died. CONCLUSIONS: The treatment protocol for ruptured VBDAs proposed in this study proved to be a simple and effective method in selecting the requisite treatment. If a proper endovascular strategy is in place, an effective treatment outcome for ruptured VBDAs can be obtained.

Stent-assisted coiling of very small wide-necked intracranial aneurysms: Complications, anatomical results and clinical outcomes.

BACKGROUND AND OBJECTIVE: Treatment of very small (≤3mm) wide-necked intracranial aneurysms remains controversial, we investigated the efficacy and safety of stent-assisted coiling of such aneurysms. METHODS: From September 2008 to December 2012, 112 very small wide-necked intracranial aneurysms in 108 patients were embolized with stent-assisted coiling. We assessed the initial neurological conditions, complications and anatomic results. The follow-up results were evaluated with DSA and mRS. RESULTS: Stent deployment was successful in 104 of 108 procedures (96.3%). 11 complications (10.2%) occurred during procedures, including 5 events of aneurysm rupture, 3 events of thromboembolism. The rate of complication, rupture and thromboembolism was not statistically different between the ruptured and unruptured patients (P=0.452, P=0.369, P=1.000, respectively). The initial aneurysmal occlusion was Raymond scale (RS) 1 in 34 patients (31.5%), RS2 in 53 patients (49.1%), and RS3 in 21 patients (19.4%). 79 aneurysms were available for anatomic follow-up of 12-47 months, stable occlusion in 45 aneurysms (57.0%), progressive complete occlusion in 34 aneurysms (43.0%). 95 patients(88.0%) were available for a clinical follow-up of 12-52 months, 92 patients (96.8%) had favorable clinical outcomes (mRS ≤2), 3 patients (3.2%) had morbidity (mRS: 3-5). The morbidity was not statistically different between the ruptured and unruptured patients (P=1.000). CONCLUSIONS: Stent-assisted coiling of very small wide-necked intracranial aneurysms may be effective and safe. Because of low risk of rupture in such aneurysms, the coiling of unruptured such aneurysms must be selective. The long-term efficacy and safety of coiling such aneurysms remains to be determined in larger prospective series.

Endovascular management of giant aneurysms: An introspection.

AIMS: To evaluate the outcome of giant intra-dural aneurysms managed with endovascular techniques. MATERIALS AND METHODS: We retrospectively reviewed a series of 39 consecutive giant intra-dural aneurysms. The technical feasibility of endovascular treatment, its complications, the angiographic results and the clinical outcome were assessed. Logistic regression analysis was performed to evaluate for predictors of a poor outcome. RESULTS: Nine patients were left untreated. During a 30 month follow-up, four of them (44.4%) died and two (22.2%) deteriorated. Thirty aneurysms (12 located in the anterior circulation and 18 located in the posterior circulation) were treated using endovascular methods. Of these, 11 were treated by parent vessel occlusion, 11 by stent-assisted coiling, one using only coils, six using solely a stent, and, one using both coils and onyx. During a 28 month follow-up, seven (23.3%) patients died and two (6.7%) patients experienced permanent neurological deficits. The mortality and morbidity in the endovascular group seemed lower than that in the untreated group (P = 0.045, 30% vs. 66.7%). There was no difference in the results of endovascular treatment between giant intra-dural aneurysms located in the posterior and the anterior circulation. CONCLUSIONS: Giant intra-dural aneurysms, whether treated or not, may have a poor clinical outcome. The outcome following endovascular treatment of these lesions is better than its natural history when left untreated. However, endovascular treatment may often be associated with high complication rates and a low chance of cure.

Enterprise stent-assisted coiling for wide-necked intracranial aneurysms during ultra-early (48hours) subarachnoid hemorrhage: a single-center experience in 59 consecutive patients.

BACKGROUND AND OBJECTIVE: Accumulated experience and improvement of stents dedicated to intracranial use have significantly widened the applicability of stent-assisted coiling (SAC) to ruptured wide-necked aneurysms. This retrospective study was designed to evaluate the safety and efficacy of SAC using the Enterprise stent for ruptured wide-necked intracranial aneurysms during ultra-early subarachnoid hemorrhage. METHOD: We reviewed data from 59 consecutive patients with ruptured wide-necked aneurysms who had SAC using the Enterprise stent performed within 48hours of onset. Data collected and analyzed included: patient demographics; morphologic features of the aneurysm; treatment results and follow-up results. Clinical outcomes were evaluated by modified Rankin Scale (mRS). RESULTS: In all 59 cases, SAC using the Enterprise stent was performed successfully, with no significant technical difficulties. Initial angiographic results were: complete occlusion in 38 cases; near occlusion in 17; and partial occlusion in four. Angiographic follow-up of 48 patients showed that 46 (95.8%) remained stable or improved, without regrowth, while regrowth was imaged in two patients. Medium-term clinical follow-up of 54 patients (mean, 26.9months) showed that 88.9% had a good outcome (mRS: 0 in 34; 1 in eight; and 2 in six), and 11.1% poor outcomes (mRS: 3 in four; and 4 in two). CONCLUSION: Enterprise SAC is a safe and viable option for treatment of ruptured wide-necked aneurysms within 48hours of ictus.

[Endovascular treatment of nongalenic cerebral arteriovenous fistulas].

OBJECTIVE: To explore the efficacies of embolization in the treatment of nongalenic cerebral arteriovenous fistula (NCAVF). METHODS: The clinical data of 16 NCAVF patients (14 from Department of Neurointerventional Medicine, Beijing Tiantan Hospital and 2 from Department of Neurosurgery, Second Municipal Hospital of Yulin) undergoing embolization from April 2008 to October 2014 were analyzed retrospectively. Clinical and imaging follow-ups were conducted. RESULTS: Among them, 6 patients were embolized with coils alone and the remainder coil plus Onyx glue. The digital subtraction angiography (DSA) images obtained immediately after embolization showed that complete (n = 12), near-complete (n = 2) and staged (n = 2) occlusions of NCAVFs were achieved. One patient recurred during an imaging follow-up period of 3-24 months. All symptoms and signs were relieved after embolization during a clinical follow-up period of 3-38 months. CONCLUSION: Embolization with coil or coil-assisted Onyx embolization is both feasible and efficacious for NCAVF. Using coils helps to reduce the velocity of blood flow and assists Onyx in embolizing fistulas in patients with high-flow NCAVF.

Onyx embolization of cavernous sinus dural arteriovenous fistulas via direct transorbital puncture under the guidance of three-dimensional reconstructed skull image (reports of six cases).

BACKGROUND: Because of complex angioarchitecture, the transarterial or venous pathway is not feasible for some cavernous sinus dural arteriovenous fistulas (CS DAVFs). We present six cases in which onyx embolization of a CS DAVFs was made possible through direct transorbital puncture. METHODS: In the present study, all patients were penetrated through one third of the medial-lateral of the inferior orbital rim under the guidance of fluoroscopy superimposed on the three-dimensional reconstructed skull image to complete embolization (onyx with or without coils). The records of patient demographics, clinical manifestation, fistula features, procedures, clinical outcome and angiographic outcome were reviewed and analyzed. RESULTS: In our series of six patients, the immediate angiographic result showed complete occlusion in all patients. The six patients experienced retrobulbarhematoma and eye swelling right after embolization, while the swelling significantly subsided after 3-5 days of conservative treatment. During the postoperative angiography and clinical follow-up (4-10 months), one of the patients had decreased visual acuity; the other five patients did not have neurological dysfunction. CONCLUSIONS: Onyx embolization via direct transorbital puncture provides a method to be considered to treat CS DAVFs when the conventional transvenous approaches are inaccessible.