Headache following intracranial neuroendovascular procedures.

AIMS: Predicting who will develop post-procedure headache (PPH) following intracranial endovascular procedures (IEPs) would be clinically useful and potentially could assist in reducing the excessive diagnostic testing so often obtained in these patients. Although limited safety data exist, the use of triptans or dihydroergotamine (DHE) often raise concern when used with pre/post-coiled aneurysms. We sought to determine risk factors for PPH following IEP, to evaluate the utility of diagnostic testing in patients with post-coil acute headache (HA), and to record whether triptans and DHE have been used safely in this clinical setting. METHODS: We conducted a retrospective chart review of adult patients undergoing IEPs. Bivariate analyses were conducted to compare patients who did and did not develop PPH. RESULTS: We reviewed records pertaining to 372 patients, of whom 263 underwent intracranial coil embolizations, 21 acrylic glue embolizations, and 88 stent placements. PPH occurred in 72% of coil patients, 33% of glue patients, and 14% of stent patients. Significant risk factors for post-coil HA were female gender, any pre-coil HA history, smoking, and anxiety/depression. A pre-stent history of HA exceeding 1 year's duration, and smoking were risk factors for post-stent HA. A pre-glue history of HA exceeding 1 year was the only risk factor for post-glue HA. In the small subgroup available for study, treatment with triptans or DHE was not associated with adverse events in pre/post-coiled aneurysms. Diagnostic testing was low yield. CONCLUSIONS: Occurrence of PPH was common after IEPs and especially so with coiling and in women, smokers, and those with anxiety/depression, and was often of longer duration than allowed by current International Classification of Headache Disorders-II criteria. The yield of diagnostic testing was low, and in a small subgroup treatment with triptans or DHE did not cause adverse events in pre/post-coiled aneurysms. Prospective studies are needed to confirm these findings.

Combined surgical and endovascular approach to a complex dural arteriovenous fistula involving the superior sagittal sinus and torcula.

A complex dural arteriovenous fistula (dAVF) may require complex treatment strategies to achieve successful obliteration. We describe a combined open surgical and endovascular approach to a dAVF involving the superior sagittal sinus (SS) and torcula. A 68-year-old male with Factor V Leiden mutation presented with altered mental status from venous hypertension secondary to a complex, high-flow Borden III dAVF with internal carotid and bilateral external carotid artery feeders draining into the SS and torcula. Because the venous channel to the recipient SS at the point of convergence of the AV shunting was not accessible transfemorally due to venous stenosis, a surgical strategy using a midline burrhole for direct catheterization of the SS was devised. A balloon was inflated in the sinus during arterial embolization. This technique was effective in achieving embolization of multiple arterial feeders via a single vessel injection. Covered Atrium iCasts were introduced in a telescoping fashion after angioplasty of the posterior SS-torcular junction in an attempt to functionally occlude further AV shunting. Postembolization angiography revealed greatly diminished AV shunting with improved intracranial transit time and retrograde cortical venous drainage. The patient was maintained on anticoagulation and made a complete recovery following the intervention; however, he subsequently deteriorated acutely, and died on postprocedure day 4. This case illustrates the difficulties associated with treating a complex AVF, describes a temporizing solution, and reports a potential complication from placing a covered stent in the SS.

An analysis of inflation times during balloon-assisted aneurysm coil embolization and ischemic complications.

BACKGROUND AND PURPOSE: The introduction of balloon remodeling has revolutionized the approach to coiling of wide-neck aneurysms. We studied the effects of balloon inflation during coil embolization on ischemic complications. METHODS: A retrospective review was undertaken of the most recent 147 patients undergoing balloon remodeling for unruptured intracranial aneurysm coil embolization at a single institution (81 balloon, 66 unassisted). All underwent postprocedural MRI. RESULTS: Among patients in the "balloon" group, the mean total inflation time was 18 minutes (range, 1-43), a mean number of inflations of 4 (range, 1-9), a mean maximum single inflation time of 7 minutes (range, 1-19), a mean reperfusion time of 2.2 minutes between inflations, and an average procedure time of 2 hours and 10 minutes. Asymptomatic diffusion-weighted imaging abnormalities were detected on postprocedural MRI in 21.5% of patients and symptomatic lesions were identified in 3.8%. Both silent and symptomatic ischemic rates were similar in the internal control group. Patients with ischemic findings were older and more likely have diabetes; no differences were found with respect to total balloon inflation time, number of inflations, maximum inflation time, or reperfusion times. CONCLUSIONS: We found no significant relationship between balloon inflation practices and ischemic events. Older and diabetic patients were more likely to have ischemic events develop.

Mechanical thrombectomy for acute stroke with the alligator retrieval device.

BACKGROUND AND PURPOSE: Recanalization of occluded vessels in acute ischemic stroke is associated with improved outcome. Devices that can quickly and safely remove thrombus and promote recanalization are useful in the management of these patients. The Alligator retrieval device, developed for endovascular foreign body retrieval, may also be useful for thrombus removal. METHODS: Seven patients with acute ischemic stroke (aged 31 to 88 years) who underwent intra-arterial therapy with the Alligator retrieval device at our center are presented. RESULTS: The Alligator retrieval device was able to retrieve the thrombus in 5 of 7 cases with good to excellent recanalization seen and was unsuccessful in 2 of 7 patients. Complete recanalization was obtained in one of 7 patients and near complete recanalization obtained in 4 of 7 patients. Three of the 7 patients had good outcome at 3 months and 3 of 7 patients died within 30 days of treatment. CONCLUSIONS: The Alligator retrieval device was successfully able to remove thrombus in the majority of cases. It appears to have increased success in proximal occlusions in relatively straight segments. In properly selected cases, it may be a useful device in intra-arterial stroke management.

Prehemorrhage statin use and the risk of vasospasm after aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Aneurysmal SAH is often followed by delayed ischemic deficits attributable to cerebral vasospasm. Recent studies suggest a positive impact of statin therapy on the incidence of vasospasm. This study was designed to assess whether a history of prior use of statin therapy was associated with a lower risk of vasospasm in patients with SAH. METHODS: We performed a comprehensive retrospective review of patients with aneurysmal SAH between 1997 and 2004. Clinical demographics and imaging data for all patients were reviewed, and a logistic regression analysis was performed to identify the predictors of cerebral vasospasm, defined as a combination of clinical signs with radiographic confirmation. RESULTS: Three hundred eight patients were included. Mean age was higher in the group receiving statins (64 +/- 12 vs 54 +/- 12 years). Hunt and Hess scores and treatment modality were not significantly different between the groups. Vasospasm was observed in 31% of patients not taking a statin (n = 282) vs 23% taking a statin (n = 26), without achieving statistical significance. Discontinuation of the statin did not affect risk of vasospasm. CONCLUSIONS: Use of a statin prior to an aneurysmal SAH trended to reduce the incidence of subsequent vasospasm, without achieving statistical significance.

Benign angiopathy of the central nervous system presenting with intracerebral hemorrhage.

BACKGROUND: Primary central nervous system vasculitis has traditionally been described as an aggressive condition, with significant morbidity and mortality. A subgroup of patients has been identified who have a similar clinical presentation, but with a benign course. This syndrome of BACNS is successfully treated with low-dose steroids and calcium-channel blockers. Histologic confirmation, when performed, is normal. METHODS: Intracerebral hemorrhage is a rare presenting finding in the setting of BACNS. We present 2 patients with acute onset of headache and neurologic impairment secondary to an ICH. RESULTS: Cerebral angiography showed characteristic findings of diffuse vasculitis. Both patients were subjected to biopsy and both failed to reveal evidence of vasculitis. CONCLUSION: This report is the first to document the normal histologic features of BACNS in the setting of an ICH. Although these angiographic changes are similar to vasculitis, these processes can be differentiated on clinical grounds, which is of vital importance as the treatment and clinical course of BACNS is more benign. Furthermore, the presence of an ICH in the setting of vasoconstriction seen on angiography may represent a novel feature in some patients with BACNS and is not necessarily a harbinger of the more malignant PCNSV.

Concurrent lymphocytic hypophysitis and pituitary adenoma. Case report and review of the literature.

Lymphocytic hypophysitis (LyH) is an uncommon intrasellar lesion characterized by lymphocytic infiltration of the adenohypophysis. Evidence suggests that the cause is autoimmune, and the symptoms are usually related to either a mass effect or endocrine dysfunction. Lymphocytic hypophysitis has been described rarely in the setting of other simultaneous pathological processes that involve the pituitary and sella turcica, and is postulated to arise from an intrinsic inflammatory response. The authors report the case of a 43-year-old woman who presented with a 2-month history of galactorrhea and pseudohyperprolactinemia secondary to a 10-mm lesion within an enlarged pituitary gland. She was nulliparous and had no contributory medical history. Serial neuroimaging performed over a 2-year period demonstrated lesion growth, and visual deficits had developed; together these warranted surgical intervention. A transsphenoidal resection was performed. Microscopic and immunohistopathological examinations revealed a nonsecreting pituitary adenoma with concurrent lymphocytic adenohypophysitis. This is the first documented case of LyH in the setting of a null-cell pituitary adenoma. The authors review the related literature and outline potential mechanisms for the concurrent development of LyH and a pituitary adenoma.

Multiple overlapping stents as monotherapy in the treatment of 'blister' pseudoaneurysms arising from the supraclinoid internal carotid artery: a single institution series and review of the literature.

BACKGROUND: The 'blister-type' aneurysm is one of the most devastating cerebrovascular lesions. Flow diversion with stent reconstruction is an emerging treatment and has shown promising initial results. OBJECTIVE: To evaluate the experience of one institution using stent reconstruction for pseudoaneurysms of the supraclinoid internal carotid artery and to compare with a review of the literature. METHODS: A retrospective review from one institution identified eight patients with 'blister' aneurysms over a 47-month period. The Raymond scale was used to classify the aneurysms. Clinical data were obtained using the modified Rankin Scale (mRS) and the National Institute of Health Stroke Scale. A literature review was performed and compared with our results. Clinical and angiographic data were obtained. RESULTS: After treatment, two aneurysms were Raymond class 1 (25%) and six were class 3 (75%). Of the class 3 aneurysms, two required retreatment, three (50%) progressed to complete occlusion and three (50%) had persistent aneurysm filling. Clinical data revealed two patients with mRS score of 0 (25%), five with mRS score of 1 (62.5%) and one with mRS score of 2 (12.5%). From the literature review, residual filling was evident in nine patients (64.3%) and complete occlusion in four (28.6%). On follow-up angiography, nine (64.3%) were occluded, two (14.3%) had residual neck filling and one (7.1%) had persistent aneurysm filling. Thirteen patients (92.9%) had an mRS score of 2 or better. Combining the available experience, patients demonstrated either improvement (n=9, 41%) or stability (n=11, 50%). Only two (9%) had progression requiring retreatment. CONCLUSIONS: Endovascular stent remodeling of 'blister-type' aneurysms is a safe and effective strategy.

Trends in device-assisted aneurysm treatment at a single high-volume tertiary care center.

INTRODUCTION: Device developments and evolution in technique over the past decade make the treatment of aneurysms which were previously considered poor candidates for coiling more feasible. The authors describe their experience treating aneurysms at a single high-volume tertiary care center, focusing particularly on the use of adjunctive devices. METHODS: A retrospective review was undertaken of all the aneurysms treated at the Cleveland Clinic between 2003 and 2010. RESULTS: A total of 1455 aneurysms were treated (45% subarachnoid hemorrhage). In 2003, aneurysms were treated equally with clipping (49.6%) and coiling (50.4%). Over the 8-year period reviewed there was a decline in the percentage of aneurysms treated surgically. By 2010, 25.5% of aneurysms were treated surgically and 74.5% by endovascular coiling. Among aneurysms that were coiled there was an increase in the cases treated with adjuncts including balloon remodeling and stents. The most dramatic increase in the relative proportion of a single method was the more widespread use of the combined 'balloon stent' technique. Initially used in 12% of stent-assisted cases, it is currently employed in 35.4% of cases. CONCLUSIONS: Significant changes in practice trends for aneurysm treatment have been observed at a single high-volume tertiary care center over the past decade. Although these changes are multifactorial, they are explained in part by institutional comfort level with the adoption of adjunctive techniques, with a growing number of aneurysms treated with balloon remodeling and the 'balloon stent' technique.

Patterns of aneurysm recurrence after microsurgical clip obliteration.

BACKGROUND: Microsurgical clip obliteration remains a time-honored and viable option for the treatment of select aneurysms with very low rates of recurrence. OBJECTIVE: We studied previously clipped aneurysms that were found to have recurrences to better understand the patterns and configurations of these rare entities. METHODS: A retrospective review was performed of 2 prospectively maintained databases of aneurysm treatments from 2 institutions spanning 14 years to identify patients with recurrence of previously clipped intracranial aneurysms. RESULTS: Twenty-six aneurysm recurrences were identified. Three types of recurrence were identified: type I, proximal to the clip tines; type II, distal; and type III, lateral. The most common type of recurrence was that arising distal to the clip tines (46.1%), and the least frequently encountered recurrence was that arising proximal to the tines (19.2%). Laterally located recurrences were found in 34.6% of cases. CONCLUSION: We describe 3 different patterns of aneurysm recurrence with respect to clip application: those occurring proximal, distal, or lateral to the clip tines.

ε-Aminocaproic acid in angiographically negative subarachnoid hemorrhage patients is safe: a retrospective review of 83 consecutive patients.

BACKGROUND: ε-Aminocaproic acid (EACA) has been used to reduce the rate of cerebral aneurysm rerupture before definitive treatment. In centers administering EACA to patients with a subarachnoid hemorrhage (SAH), patients eventually diagnosed with angiographically negative subarachnoid hemorrhage (ANSAH) may also initially receive EACA, perhaps placing them at increased risk for ischemic complications. OBJECTIVE: To evaluate the effect of short-term EACA on outcomes and secondary measures in patients with ANSAH. METHODS: We conducted a retrospective study of 454 consecutive SAH patients over a 2-year period under a current protocol for EACA use. Patients were excluded if a source for the SAH was discovered, yielding a total of 83 ANSAH patients. The patients were assigned to groups that did or did not receive EACA. The primary end points of the study were ischemic complications, pulmonary emboli, vasospasm, ventriculoperitoneal shunting rates, and outcomes. RESULTS: Statistical analysis yielded no significant difference between the 2 arms with respect to any of the end points: vasospasm (P = .65), deep vein thrombosis (P = .51), pulmonary embolism (P = 1.0), stroke (P = 1.0), myocardial infarction (P = 1.0), and ventriculoperitoneal shunt (P = .57). There was no statistically significant outcome difference using the modified Rankin Scale (P = .30). CONCLUSION: Short-term (<72 hour) application of EACA does not result in an increase in adverse events in patients with ANSAH.

Merci retrievers as access adjuncts for reperfusion catheters: the grappling hook technique.

BACKGROUND: Expeditious, stable access in acute ischemic stroke is foundational for mechanical revascularization. Proximal vascular tortuosity and unfavorable anatomy may impede the access necessary for revascularization, particularly when large-caliber catheters are used. We describe an approach using the Merci retriever to gain stable catheter access for aspiration. OBJECTIVE: To assess the technical feasibility of using the Merci retriever system as an access adjunct in acute ischemic stroke and tortuous ophthalmic segment anatomy. METHODS: The acute ischemic stroke database was queried, and 3 patients presenting with acute ischemic stroke and tortuous proximal anatomy who were treated with mechanical thrombectomy and the Merci retriever as an access adjunct were identified. Patient charts and procedure reports were reviewed. RESULTS: In each of the patients, the ophthalmic segment of the internal carotid artery proved difficult to navigate. An appropriately sized Merci retriever was deployed in the M1 segment. Gentle tension on the retriever was applied, altering the angle at which the aspiration catheter navigated the ophthalmic segment, affording rapid access past the ophthalmic artery origin and into the target vessel. The 18 L microcatheter and retriever were withdrawn, followed by aspiration and clot maceration with the Penumbra aspiration system. CONCLUSION: Tortuous proximal anatomy may impede access to an occluded vessel. Use of tension on a deployed Merci retriever straightens the course of the wire, changing the angle that the aspiration catheter makes with the vessel. In the setting of unfavorable anatomy, this technique may be used to advance an aspiration catheter to the target lesion.

Stenting of a symptomatic long-segment extracranial vertebral artery occlusion.

We present a 56-year-old man who presented with bilateral vertebral artery occlusions and recurrent transient ischemic attacks and strokes despite maximal medical therapy. A long-segment extracranial right vertebral occlusion was noted and successfully reconstructed with four drug-eluting stents. The patient has been symptom free for 3 months and does not exhibit restenosis on follow-up angiography. Stenting and angioplasty of a long-segment vertebral artery occlusion is technically feasible in select cases.

Balloon-augmented carotid artery sacrifice with Onyx: a proof of concept study in a swine model.

INTRODUCTION: Carotid sacrifice remains a valuable tool in the treatment of select vascular lesions. Neurointerventionalists have relied on coil embolization as their primary means of carotid sacrifice, a procedure that can be lengthy and expensive with long fluoroscopy times. We investigated a novel technique for carotid sacrifice in a swine model using temporary balloon occlusion to achieve proximal flow arrest in the carotid artery while embolizing the vessel with a liquid embolic agent. METHODS: A total of 10 common carotid artery sacrifices were performed in pigs under fluoroscopic guidance. Various balloons were employed to achieve near total proximal flow arrest to allow an Onyx cast to accumulate in the target vessel. RESULTS: The technique for sacrifice was modified during the experiment with the final procedures yielding successful sacrifice using Onyx through a dimethylsulfoxide-tolerant catheter (Echelon 14) with the assistance of two fibered coils and a 5 mm × 30 mm Hyperglide balloon resulting in a 2.5 cm long cast. CONCLUSION: Carotid artery sacrifice using commercially available non-adhesive liquid embolic agents is feasible with balloon assistance, allowing for reduced radiation and material costs. Coils may be beneficial in providing an anchor point for liquid embolic deposition, as well as reducing the volume of liquid embolysate required to achieve vessel occlusion.

Antithrombotic states and outcomes in patients with angiographically negative subarachnoid hemorrhage.

BACKGROUND: Antithrombotic states are encountered frequently, either because of medical therapy or by preexistent pathological states, and may affect the severity of hemorrhagic strokes such as angiographically negative subarachnoid hemorrhages. OBJECTIVE: To determine the effects of antithrombotic states on the outcomes of patients with angiographically negative subarachnoid hemorrhage by examining data pooled from 2 institutions. METHODS: This is a retrospective review of patients who experienced angiographically negative subarachnoid hemorrhage at 2 institutions over the past 5 years. The patients were grouped into those with and those without an antithrombotic state at time of hemorrhage and were stratified according to presentation, clinical grades, outcomes, need for cerebrospinal fluid diversion, and development of vasospasm. Computed tomography of the head was assessed for bleed pattern and modified Fisher grade. Patients were excluded if a causative lesion was subsequently discovered. RESULTS: There is a statistically significant association between antithrombotic states and poorer presentation, higher Hunt and Hess score, increased amount of subarachnoid hemorrhage, higher modified Fisher grade, increased incidence of vasospasm, hydrocephalus, and poor outcomes as assessed by modified Rankin scale (P < .001). Patients with an antithrombotic state experience worse outcomes even with adjustment for the amount of hemorrhage as assessed by modified Fisher grade (P < .001). CONCLUSION: Patients in an antithrombotic state presenting with angiographically negative subarachnoid hemorrhage present with inferior clinical scores, diffuse hemorrhage patterns, and worse modified Fisher grades and have worse outcomes.

The versatile distal access catheter: the Cleveland Clinic experience.

BACKGROUND: Vascular access is fundamental to any endovascular intervention. Concentric Medical has developed the Outreach Distal Access Catheter (DAC), which affords stable access at the target vessel modulating the forces at play within the thrombectomy device complex. The DAC is a device with novel access characteristics useful in a host of other types of clinical scenarios. OBJECTIVE: To review our experience with the DAC family of devices, the theory, and method of use. METHODS: A retrospective review of all cases in which the DAC was used during the period 2008 to 2010 was conducted and the cases classified by indication. Catheter-related complications were recorded. The use of the DAC in a variety of settings including intracranial stenting, aneurysm coil embolization, and arteriovenous malformation embolization is described. RESULTS: The DAC was used in 103 procedures performed in 93 patients between August 2008 and February 2010. Indications included acute stroke, treatment of intracranial atherosclerosis, vasospasm therapy, arteriovenous malformation embolization, and aneurysm embolization. In those procedures, 113 catheters were used. No complications directly attributable to DAC use were identified. CONCLUSION: The DAC is useful for gaining access to the cerebral vasculature, especially in patients with significant tortuosity or when re-access of distal vasculature is required multiple times.

Mid-term results of endovascular coiling of wide-necked aneurysms using double stents in a Y configuration.

BACKGROUND: Double stenting in a Y configuration may be used to treat a subset of wide-necked aneurysms not amenable to reconstruction with a single stent. OBJECTIVE: We studied the feasibility, safety, and mid-term angiographic outcome of patients treated using this technique. METHODS: A retrospective review was undertaken of all coil embolizations of wide-necked aneurysms using double stents in a Y configuration. RESULTS: Nineteen patients were identified from 2002 to 2010 (14 women, 5 men) with a mean age of 57.4 years. Stents were deployed in a Y configuration achieving complete occlusion (5/19), residual neck (5/19), and residual aneurysm filling (9/19). Angiographic follow-up was available for a mean of 16 months, and clinical follow up was available for a mean of 21.4 months. The incidence of complications at the initial treatment was 6 of 19 (31.6%), and delayed thromboembolic complications occurred in 2 of 19 (10.5%). An angiographic neck recurrence requiring retreatment developed in only 1 of the patients in whom complete occlusion was obtained with the initial treatment. Spontaneous thrombosis and complete occlusion on follow-up imaging were found in 6 patients in whom initial neck or aneurysm filling was observed. Ultimately, 12 of the aneurysms (63.2%) were completely occluded on follow-up angiography. CONCLUSION: Y-stent reconstruction enables the endovascular management of otherwise complex, wide-necked cerebral aneurysms and can be performed safely in experienced hands with satisfactory mid-term results, even in cases requiring retreatment.

Experience with coil embolization of previously clipped aneurysms presenting with rupture.

INTRODUCTION: Endovascular coil embolization has an established role alongside microsurgical clipping in the treatment of aneurysms. We studied previously clipped aneurysms that presented as subarachnoid hemorrhage and were treated by coil embolization. METHODS: A retrospective review was performed of two prospectively maintained databases from two institutions (Cleveland Clinic, Emory University) that spanned 12 years. RESULTS: Seven patients were identified (mean age 56.9 years) who had previously undergone surgical clipping for aneurysm obliteration; six (86%) were previously ruptured. Patients presented with aneurysm rupture with a mean time of 11.5 years (range 4 months to 20 years) following surgical treatment. Aneurysm location included anterior communicating artery (n=4), posterior communicating artery (n=1), internal carotid artery terminus (n=1) and anterior choroidal (n=1). Three patients presented in Hunt and Hess (HH) grade 1, one in HH2, two in HH3 and one in HH4. Four of the patients underwent unassisted coil embolization while balloon assistance was employed in three. Angiographic results were as follows: complete occlusion (n=3; 42.9%) and residual neck (n=4; 57.1%). There were no intraprocedural complications. CONCLUSION: Aneurysm rupture following surgical obliteration is a rare event and may occur remote from the initial treatment. Endovascular embolization with or without balloon assistance can be safely employed in cases of aneurysm recurrence rupture following surgical treatment with satisfactory angiographic treatment.

Thromboembolic events associated with endovascular treatment of cerebral aneurysms.

OBJECTIVE: To evaluate the rate of peri-procedural thromboembolic events after the endovascular treatment of cerebral aneurysms. The rate of diffusion-positive lesions was assessed in relation to selected procedural and technical factors. METHODS: 184 patients treated with coil embolization (198 total procedures) between July 2004 and February 2007 were included. In 65, the procedure was coiling alone; in 55, coiling with balloon remodeling; in 48, coiling with Neuroform stenting; and in 30, coiling, Neuroform stenting and balloon remodeling. All patients underwent a routine diffusion weighted magnetic resonance imaging (DWI) within the 72 h after the intervention for the detection of ischemic complications. RESULTS: Regardless of the technique used, thromboembolic complications were more common (p<0.0001) in patients with ruptured aneurysms (33/65, 51%) than in those with unruptured aneurysms (40/133, 30%). Balloon remodeling tended to be associated with a lower rate of DWI positivity than the other techniques. Younger patients (≤60) with unruptured aneurysms had the lowest rates of DWI lesions regardless of the technique used. CONCLUSION: In this study, peri-procedural DWI-positive lesions occurred in approximately one-third of all cases. These were threefold more common in the setting of ruptured aneurysms. Adjunctive devices did not increase the rate of ischemic events. On the contrary, there was a trend toward fewer DWI abnormalities in the procedures in which balloon remodeling was employed. This may, in part, be related to the application of the conglomerate coil mass technique of balloon remodeling.

Endovascular therapy of very small aneurysms of the anterior communicating artery: five-fold increased incidence of rupture.

BACKGROUND: Intraprocedural rupture is a dangerous complication of endovascular treatment. Small ruptured anterior communicating artery (ACoA) aneurysms and microaneurysms present a challenge for both surgical and endovascular therapies to achieve obliteration. An understanding of the complication rates of treating ruptured ACoA microaneurysms may help guide therapeutic options. OBJECTIVE: To report the largest cohort of ACoA microaneurysms treated with endovascular therapy over the course of the past 10 years. METHODS: We performed a retrospective review of 347 ACoA aneurysms treated in 347 patients at Cleveland Clinic and Emory University over a 10-year period. Patient demographics, aneurysmal rupture, size, use of balloon remodeling, patient outcomes, intraprocedural rupture, and rerupture were reviewed. RESULTS: Rupture rates were examined by size for all patients and subgroups and dichotomized to evaluate for size ranges associated with increased rupture rates. The highest risk of rupture was noted in aneurysms less than 4 mm. Of 347 aneurysms, 74 (21%) were less than 4 mm. The intraprocedural rupture rate was 5% (18/347) for ACoA aneurysms of any size. There was an intraprocedural rupture rate of 2.9% (8/273) among ACoA aneurysms greater than 4 mm compared with 13.5% (10/74) in less than 4-mm aneurysms. Procedural rupture was a statistically significant predictor of modified Rankin score after adjusting for Hunt and Hess grades (HH). CONCLUSION: ACoA aneurysms less than 4 mm have a 5-fold higher incidence of intraprocedural rerupture during coil embolization. Outcome is negatively affected by intraprocedural rerupture after adjusting for HH grade.