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.

Endovascular Treatment of Small Ruptured Intracranial Aneurysms (<5 mm) : Long-term Clinical and Angiographic Outcomes and Related Predictors.

PURPOSE: To investigate the long-term clinical and angiographic outcomes and their related predictors in endovascular treatment (EVT) of small (<5 mm) ruptured intracranial aneurysms (SRA). METHODS: The study retrospectively reviewed patients with SRAs who underwent EVT between September 2011 and December 2016 in two Chinese stroke centers. Medical charts and telephone call follow-up were used to identify the overall unfavorable clinical outcomes (OUCO, modified Rankin score ≤2) and any recanalization or retreatment. The independent predictors of OUCO and recanalization were studied using univariate and multivariate analyses. Multivariate Cox proportional hazards models were used to identify the predictors of retreatment. RESULTS: In this study 272 SRAs were included with a median follow-up period of 5.0 years (interquartile range 3.5-6.5 years) and 231 patients with over 1171 aneurysm-years were contacted. Among these, OUCO, recanalization, and retreatment occurred in 20 (7.4%), 24 (12.8%), and 11 (7.1%) patients, respectively. Aneurysms accompanied by parent vessel stenosis (AAPVS), high Hunt-Hess grade, high Fisher grade, and intraoperative thrombogenesis in the parent artery (ITPA) were the independent predictors of OUCO. A wide neck was found to be a predictor of recanalization. The 11 retreatments included 1 case of surgical clipping, 6 cases of coiling, and 4 cases of stent-assisted coiling. A wide neck and AAPVS were the related predictors. CONCLUSION: The present study demonstrated relatively favorable clinical and angiographic outcomes in EVT of SRAs in long-term follow-up of up to 5 years. THE AAPVS, as a morphological indicator of the parent artery for both OUCO and retreatment, needs further validation.

Lower miR-143/145 and higher matrix metalloproteinase-9 levels in circulation may be associated with intracranial aneurysm formation and rupture: A pilot study.

OBJECTIVES: We analyzed the relationship between plasma miR-143/145 and serum MMP-9 in patients with unruptured or ruptured intracranial aneurysms (IAs) to identify new biomarkers for predicting rupture in IAs. PATIENTS AND METHODS: We prospectively enrolled 24 consecutive patients, including seven patients without IAs as a control group, nine patients with unruptured IAs, and eight patients with ruptured IAs (enrolled within 3 days after rupture). Plasma miR-143/145 and MMP-9 were measured in blood samples collected from the femoral artery. Spearman ρ values were used for correlation analyses. RESULTS: The level of plasma miR-143/145 in patients with ruptured IAs was significantly lower than that of the control group. Moreover, patients with ruptured IAs had a significantly higher level of serum MMP-9 compared with that in patients with unruptured IAs and in control patients. A lower level of plasma miR-143 was significantly correlated with a lower level of plasma miR-145 (Spearman ρ = 0.771; P < 0.0001). CONCLUSION: These findings showed that a lower of plasma miR-143/145 is potentially associated with IA formation, while higher serum MMP-9 levels may be associated with IA rupture and could serve as a useful biomarker for the evaluation of IA rupture.

Number of Cigarettes Smoked Per Day, Smoking Index, and Intracranial Aneurysm Rupture: A Case-Control Study.

BACKGROUND AND PURPOSE: We aimed to investigate the effect of smoking on the risk of intracranial aneurysm (IA) rupture (IAR), specifically relationship between the number of cigarettes smoked per day (CPD) or smoking index and the risk of IAR. METHODS: We performed a single-center case-control study of consecutive patients evaluated or treated for IA at our institution from June 2015 to July 2016. Cases were patients with a ruptured IA. Two age- and sex-matched controls with an unruptured IA were included per case. Conditional logistic regression models were used to assess the relationship between both the CPD and smoking index (CPD × years of smoking) and IAR. RESULTS: The study population included 127 cases of IAR and 254 controls. The higher IAR risk was associated with cigarette smoking (both current and former) (OR, 2.3; 95% CI, 1.1-4.8; P = 0.029). Our subgroup analysis of smokers revealed a significant association between IAR risk and current smoking (OR, 2.8; 95% CI, 1.2-6.3; P = 0.012), current heavy smoking (CPD ≥ 20) (OR, 3.9; 95% CI, 1.4-11.0; P = 0.007), and a smoking index ≥800 (OR, 11.4; 95% CI, 2.3-24.5; P = 0.003). Former smoking was not significantly associated with IAR (OR, 1.1; 95% CI, 0.3-4.0; P = 0.929). CONCLUSION: A dose-response relationship has been noted for intensity and duration of smoking consumption and increased risk of IAR. As smoking is modifiable, this finding is important to managing patients with IAs to quit or reduce smoking prior to life-threatening subarachnoid hemorrhage.

Comparison of Recanalization and In-Stent Stenosis Between the Low-Profile Visualized Intraluminal Support Stent and Enterprise Stent-Assisted Coiling for 254 Intracranial Aneurysms.

OBJECTIVE: To compare the rates of recanalization and in-stent stenosis between the Enterprise (EP) and low-profile visualized intraluminal support (LVIS) stent deployments for intracranial aneurysms (IAs), and the factors associated therein. METHODS: Between June 2014 and July 2016, 142 patients with a total of 161 IAs were treated by LVIS stent-assisted coiling and 111 patients with a total of 142 IAs were treated by EP stent-assisted coiling at our institution. Procedure-related complications, angiographic follow-up results, and clinical outcomes were analyzed statistically. RESULTS: The rates of initially complete and near-complete IA occlusion immediately after the procedure were similar in the LVIS and EP groups (94.3% vs. 89.9%; P = 0.275). On follow-up, complete and near-complete occlusion rates and recanalization rates were also similar in the 2 groups (96.6% vs. 92.1%; P =0.330 and 8.0% vs. 13.5%; P = 0.245, respectively). On logistic regression analysis, a higher size ratio (SR) was significantly associated with the recanalization of aneurysms in the EP group, but not in the LVIS group. The rate of moderate to severe in-stent stenosis was lower in the LVIS group (10.2%) than in the EP group (16.8%), but the difference was not statistically significant (P = 0.198). CONCLUSIONS: Our data show acceptable rates of complete and near-complete occlusion with both the LVIS and EP stents. LVIS stents were associated with lower rates of recanalization and in-stent stenosis, but the difference was not significant. Higher SR (≥2) was a significant predictor of recanalization in IAs treated with EP stents, but not in those treated with LVIS stents.

The Siesta Habit is Associated with a Decreased Risk of Rupture of Intracranial Aneurysms.

BACKGROUND: Previous studies have examined an association between the siesta habit and hypertension, as well as coronary heart disease. However, the relationship between a siesta and the risk of rupture of an intracranial aneurysm (IA) has not yet been established. We aimed to investigate the effects of a siesta on the risk of rupture of IAs. METHODS: We prospectively enrolled consecutive patients diagnosed with IAs at our hospital between January 2016 and December 2016. Univariate and multivariate logistic regression analysis were performed to identify independent risk factors associated with IA rupture. RESULTS: We studied 581 consecutive patients with 514 unruptured and 120 ruptured aneurysms. Univariate analysis demonstrated that hypertension, hyperlipidemia, diabetes mellitus, cigarette smoking, location, size, as well as shape and aspect ratio were associated with the risk of rupture of IAs. Multivariate analysis identified hypertension [odds ratio (OR) 1.68, 95% confidence interval (CI) 1.03-2.73], hyperlipidemia (OR 0.25, 95% CI 0.08-0.72), current cigarette smoking ≥20 cigarettes/day (d) (OR 3.48, 95% CI 1.63-7.47), siesta (siesta time <1 h, OR 0.49, 95% CI 0.24-0.98 and siesta time ≥1 h, OR 0.32, 95% CI 0.19-0.57), location of largest aneurysm on the anterior communicating and internal carotid-posterior communicating artery (PCOM) (anterior communicating artery OR 16.27, 95% CI 7.40-35.79 and PCOM OR 11.21, 95% CI 5.15-24.43), and size of aneurysm ≥7 mm (OR 2.19, 95% CI 1.21-3.97) as independent strong risk factors associated with risk of aneurysm rupture. CONCLUSION: In the present study, we found that a habitual siesta is a new predictive factor to assess the risk of rupture of an IA. We found the siesta habit may reduce the risk of aneurysm rupture. We also found that hypertension, hyperlipidemia, cigarette smoking, location, and size of aneurysm were associated with the risk of rupture of IAs.

Passive Smoking Is Not Associated with Risk of Intracranial Aneurysm Rupture in Nonsmoking Women.

BACKGROUND: Active smoking is a major risk factor for intracranial aneurysm rupture (IAR); however, little is known about the effects of passive smoking on IAR. In China, female passive smoking is widespread and severe. This study aimed to assess whether passive smoking is associated with increased risk of IAR among nonsmoking women. METHODS: We enrolled and retrospectively analyzed 385 consecutive female patients with intracranial aneurysms (IAs; 87 ruptured, 298 unruptured) who were admitted to our center between June 2015 and January 2017. Data on female active smoking, passive smoking, and other factors potentially influencing IAR were precisely compared between ruptured and unruptured IAs. RESULTS: For all aneurysms, when adjusting for potential confounders, current smoking was significantly associated with IAR (odds ratio [OR], 3.31; 95% confidence interval [CI], 1.08-10.20; P = 0.037). Furthermore, bifurcation location (OR, 5.73; 95% CI, 3.27-10.03; P < 0.001) and educational level (OR, 1.90; 95% CI, 1.10-3.28; P = 0.022) significantly increased the risk of IAR. However, for nonsmoking female patients, approximately one fifth of those with IAs were affected by passive smoking; however, passive smoking was not significantly associated with IAR. The results also showed that bifurcation location (OR, 6.21; 95% CI, 3.46-11.15; P < 0.001) and the location of posterior circulation (OR, 3.23; 95% CI, 1.31-7.93; P = 0.011) significantly increased the risk of IAR. CONCLUSIONS: Although active current smoking was strongly associated with aneurysm rupture in female patients, passive smoking was not an independent risk factor for aneurysm rupture in nonsmoking women.

Bifurcation Location and Growth of Aneurysm Size Are Significantly Associated with an Irregular Shape of Unruptured Intracranial Aneurysms.

BACKGROUND AND OBJECTIVE: Previous studies firmly proved that an irregular aneurysmal shape was associated strongly with intracranial aneurysm (IA) rupture, but it is unclear how irregularly shaped IAs form. We aimed to identify the factors related to irregular shape of IAs. METHODS: We retrospectively analyzed of consecutive patients evaluated or treated for IA at our institution from June 2015 to July 2016. According to the imaging morphology of aneurysm, the enrolled patients were divided into irregular and regular group. Demographic data and imaging data of the 2 groups were compared to identify the factors related to aneurismal irregular shape. RESULTS: There were 429 aneurysms (180 irregular and 249 regular aneurysms), including 315 unruptured aneurysms and 114 ruptured aneurysms. Most unruptured aneurysms occurred in the internal carotid arteries (53.3%), anterior communicating artery (10.8%), and posterior communicating artery (10.8%), anterior cerebral artery (5.4%), middle cerebral artery (9.8%), and posterior circulation (9.8%). In univariate analysis, for unruptured aneurysm, irregular aneurysmal shape was significantly related to aneurysm size (P = 0.009), aspect ratio (P = 0.003), size ratio (P = 0.002), and location at the bifurcation (P = 0.009) but not with smoking status, hypertension, hyperlipidemia, or diabetes mellitus. In multivariate logistic analysis, irregular aneurysms occurred mainly in unruptured aneurysms with a larger size (diameter ≥5 mm; odds ratio [OR] 2.106; 95% confidence interval [CI] 1.183-3.749; P = 0.011); location at a bifurcation (OR 2.017; 95% CI 1.191-3.413; P = 0.006), and aspect ratio (≥0.8; OR 4.992; 95% CI 1.318-18.915; P = 0.018). CONCLUSIONS: Location at a bifurcation, an increased aneurysm size, and greater aspect ratio are significant independent factors associated with an irregular shape in unruptured IAs but not with smoking status, hypertension, hyperlipidemia, or diabetes mellitus.

Progressive Occlusion and Recanalization After Endovascular Treatment for 287 Unruptured Small Aneurysms (<5mm): A Single-Center 6-Year Experience.

OBJECTIVE: We aimed to investigate the effect of coiling for small unruptured intracranial aneurysms (UIAs) (<5 mm) on progressive occlusion and recanalization, and the dubious factors related to progressive occlusion and recanalization among UIAs without complete occlusion. METHODS: A total of 264 patients with 287 small UIAs were coiled in our institution between June 2009 and December 2014. All UIAs were divided into small (3-5 mm) and very small (<3 mm) groups, and UIAs without initial complete occlusion were divided into progressive, stable, and recanalization groups. Baseline characteristics, procedure-related complications, angiographic follow-up results, and clinical outcomes were statistically analyzed. RESULTS: Among 287 aneurysms, 211 aneurysms (73.5%) were completely coiled, 3 (1.2%) had intraoperative ruptures, and 12 (4.2%) had perioperative thromboembolic events. Angiographic follow-up was available for 174 patients (65.9%), and the incidence of recanalization was 5.7%. Among 56 aneurysms without complete occlusion, 43 (76.8%) had progressive occlusion and 6 (10.7%) had recanalization. Anatomic results of initial and follow-up between the small and very small groups were similar. On logistic regression analysis, smaller size (<3 mm) without complete occlusion related to recanalization (odds ratio, 8.0, 95% confidence interval 1.3-50.0; P = 0.026). CONCLUSIONS: Our study suggested that coil embolization of small UIAs can achieve a high rate of progressive occlusion and a low rate of recanalization during follow-up. Anatomic results of initial and follow-up between small (3-5 mm) and very small (<3 mm) groups were similar. Smaller size (<3 mm), without complete occlusion, may relate to recanalization.