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Endovascular Treatment of Intracranial Unruptured Aneurysms: A Systematic Review of the Literature on Safety with Emphasis on Subgroup Analyses [Neuroradiology]

To report subgroup analyses of an updated systematic review on endovascular treatment of intracranial unruptured aneurysms (UAs); to compare types of embolic agents, adjunct techniques, and newer devices; and to identify potential risk factors for poor outcomes.

Meta-Analysis of Observational Studies in Epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to prepare this article, and the literature was searched with PubMed and with EMBASE and Cochrane databases. Six eligibility criteria (procedural complications rates; at least 10 patients; saccular, nondissecting UAs; original study published in English or French between January 2003 and July 2011; methodological quality score > 6 [modified Strengthening and Reporting of Observational Studies in Epidemiology criteria]; a study published in a peer-reviewed journal) were used. End points included procedural mortality and unfavorable outcomes (death or modified Rankin Scale, Glasgow Outcome Scale, or World Federation of Neurosurgeons Scale at 1 month scores, all > 2). A fixed-effects model (Mantel-Haenszel) was used for pooled estimates of mortality and unfavorable outcomes; a random-effects model (DerSimonian-Laird) was used in case of heterogeneity.

Ninety-seven studies with 7172 patients (26 studies published July 2008 through July 2011) were included. Sixty-nine (1.8%) of 7034 patients died (fixed-effect weighted average; 99% confidence interval [CI]: 1.4%, 2.4%; Q value, 55.0; I² = 0%). Unfavorable outcomes, including death, occurred in 4.7% (242 of 6941) of patients (99% CI: 3.8, 5.7; Q value, 128.3; I² = 26.8%). Patients treated after 2004 had better outcomes (unfavorable outcome, 3.1; 99% CI: 2.4, 4.0) than patients treated during 2001–2003 (unfavorable outcome, 4.7%; 99% CI: 3.6%, 6.1%; P = .01) or in 2000 and before (unfavorable outcome, 5.6%; 99% CI: 4.7%, 6.6%; P < .001). Significantly higher risk was associated with liquid embolic agents (8.1%; 99% CI: 4.7%, 13.7%) versus simple coil placement (4.9%; 99% CI: 3.8%, 6.3%; P = .002). Unfavorable outcomes occurred in 11.5% (99% CI: 4.9%, 24.6%) of patients treated with flow diversion.

Procedure-related poor outcomes occurred (4.7% of patients), risks decreased, and liquid embolic agents and flow diversion were associated with higher risks.

©RSNA, 2012

Supplemental material:http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12112114/-/DC1

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Closed-Cell Stent for Coil Embolization of Intracranial Aneurysms: Clinical and Angiographic Results [INTERVENTIONAL]

Recanalization is observed in 20–40% of endovascularly treated intracranial aneurysms. To further reduce the recanalization and expand endovascular treatment, we evaluated the safety and efficacy of closed-cell SACE.

Between 2007 and 2010, 147 consecutive patients (110 women; mean age, 54 years) presenting at 2 centers with 161 wide-neck ruptured and unruptured aneurysms were treated by using SACE. Inclusion criteria were wide-neck aneurysms (>4 mm or a dome/neck ratio ≤2). Clinical outcomes were assessed by the mRS score at baseline, discharge, and follow-up. Aneurysm occlusion was assessed on angiograms by using the RS immediately after SACE and at follow-up.

Eighteen aneurysms (11%) were treated following rupture. Procedure-related mortality and permanent neurologic deficits occurred in 2 (1.4%) and 5 patients (3.4%), respectively. In total, 7 patients (4.8%) died, including 2 with reruptures. Of the 140 surviving patients, 113 (80.7%) patients with 120 aneurysms were available for follow-up neurologic examination at a mean of 11.8 months. An increase in mRS score from admission to follow-up by 1, 2, or 3 points was seen in 7 (6.9%), 1 (1%), and 2 (2%) patients, respectively. Follow-up angiography was performed in 120 aneurysms at a mean of 11.9 months. Recanalization occurred in 12 aneurysms (10%), requiring retreatment in 7 (5.8%). Moderate in-stent stenosis was seen in 1 (0.8%), which remained asymptomatic.

This series adds to the evidence demonstrating the safety and effectiveness of SACE in the treatment of intracranial aneurysms. However, SACE of ruptured aneurysms and premature termination of antiplatelet treatment are associated with increased morbidity and mortality.

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Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association [AHA/ASA Guideline]

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH).

A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years.

Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.

aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

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Long-Term Clinical and Imaging Follow-Up of Complex Intracranial Aneurysms Treated by Endovascular Parent Vessel Occlusion

Superior Hypophyseal Artery Aneurysms Have the Lowest Recurrence Rate with Endovascular Therapy

N. Chalouhi  et al

Abstract

BACKGROUND AND PURPOSE: Given the challenges posed by surgical clipping, endovascular techniques have been increasingly used to treat SHA aneurysms. The purpose of this study was to assess the safety and efficacy of endovascular techniques in the treatment of SHA aneurysms.

MATERIALS AND METHODS: Medical charts and initial and follow-up angiograms were reviewed retrospectively for all patients treated with endovascular procedures at our institution between January 2006 and February 2011.

RESULTS: We identified 87 patients with SHA aneurysms who were treated with endovascular techniques. Of these patients, 79 were women and only 8 were men (90.8% female predominance). Thirty-five patients were treated with coil embolization; 45, with stent-assisted coiling; 4, with balloon-assisted coil embolization; and 3, with a flow-diversion technique. Minor complications occurred in 2 patients (2.2%). None of the patients had a major complication. The mortality and permanent morbidity rates related to the procedure were 0%. Imaging follow-up was available for 89.4% of patients (DSA in 65, MRA in 11 patients) at a mean time point of 10.4 months (range, 6–60 months). Of the 76 patients with available follow-up, 3 patients had a recurrence (3.9%) and only 1 required further intervention (1.3%). Stent-assisted coiling was associated with lower recurrence rates than simple coil embolization.

CONCLUSIONS: SHA aneurysms have the lowest recurrence rate with endovascular treatment compared with aneurysms in other locations by using historical data. Because of its safety and efficacy, endovascular therapy should be considered the procedure of choice for the treatment of SHA aneurysms.

Interpretation Errors in CT Angiography of the Head and Neck and the Benefit of Double Reading

Abstract

BACKGROUND AND PURPOSE: CTA provides high-resolution imaging of the head and neck vasculature but also of the soft tissues and bones. This results in a large volume of information to be interpreted. This study examines interpretation errors with head and neck CTAs and assesses whether double reading reduces miss rates.

MATERIALS AND METHODS: Consecutive CTAs of the neck and intracranial circulation were retrospectively identified and reviewed for vascular and nonvascular findings by a consensus of 2 neuroradiologists. The results were compared with the official report. Significant discrepancies were considered those that would have influenced follow-up or management.

RESULTS: We reviewed 503 studies; 144 were originally reported by a staff neuroradiologist alone, 209 by staff and diagnostic radiology resident, and 150 by staff and neuroradiology fellow. Twenty-six significant discrepancies were discovered in 20 studies, corresponding to 4.0% of studies with at least 1 miss, and an overall miss rate per study of 5.2%. There was at least 1 miss in 6.3% of studies interpreted by a staff neuroradiologist alone, 3.3% by staff and resident, and 2.7% by staff and fellow. The miss rate differences were not statistically significant. The most common misses were small aneurysms (50% of misses).