Laurent Spelle

BACKGROUND AND PURPOSE: Stent-assisted coiling has expanded the treatment of intracranial aneurysms, but the rates of procedure-related neurological complications and the incidence of angiographic aneurysm recurrence of this novel treatment are not yet well known. We present our experience with stent-assisted coiling with special emphasis on procedure-related neurological complications and incidence of angiographic recurrence. METHODS: Clinical and angiographic outcomes of 1137 consecutive patients (1325 aneurysms) coiled with and without stent-assisted coiling technique from January 2002 to January 2009 were retrospectively analyzed. RESULTS: There were 1109 aneurysms (83.5%) treated without and 216 (16.5%) treated with stents (15 of 216; 6.9% balloon-expandable versus 201 of 216; 93.1% self-expandable stents). Stents were delivered after coiling in 55.1% (119 of 216) and before coiling in 44.9% (97 of 216) of the cases. Permanent neurological procedure-related complications occurred in 7.4% (16 of 216) of the procedures with stents versus 3.8% (42 of 1109) in the procedures without stents (logistic regression P=0.644; OR: 1.289; 95% CI: 0.439 to 3.779). Procedure-induced mortality occurred in 4.6% (10 of 216) of the procedures with stents versus 1.2% (13 of 1109) in the procedures without stents (logistic regression P=0.006; OR: 0.116; 95% CI: 0.025 to 0.531). A total of 52.7% (114 of 216) of aneurysms treated with stents have been followed so far versus 69.8% (774 of 1109) of aneurysms treated without stents, disclosing angiographic recurrence in 14.9% (17 of 114) versus 33.5% (259 of 774), respectively (Fisher exact test P<0.0001; OR: 0.3485; 95% CI: 0.2038 to 0.5960). CONCLUSIONS: Stents were associated with a significant decrease of angiographic recurrences, but they were associated with more lethal complications compared with coiling without stents.

PURPOSE: To evaluate the stability of aneurysm occlusion at follow-up angiography after endovascular treatment (EVT) with detachable coils in intracranial berry aneurysms. MATERIALS AND METHODS: A total of 203 berry aneurysms (< 1.5 cm) were treated with EVT. Follow-up angiography at least 3 months later was performed in 169 cases. RESULTS: Complete occlusion of the aneurysm sac and neck was achieved in 148 aneurysms, subtotal occlusion in 18, and incomplete occlusion in three. Recurrence occurred between 3 and 40 months in 20 (14%) of the 148 totally occluded aneurysms. A second treatment was performed in five cases, was scheduled in one, and failed in one. The small neck remnant increased in size but did not require any retreatment in three cases, and the size of the neck remnant remained stable in 10 cases. Remnant regrowth occurred in six of the 18 subtotally occluded aneurysms. A second treatment was performed in three. Of the 169 cases, last follow-up angiography showed total occlusion in 133 cases, subtotal in 30, and incomplete in six. No rebleeding occurred. CONCLUSION: A very small recurrence may be observed at the level of the neck of the aneurysm at long-term follow-up angiography despite achieving total occlusion initially with detachable coils.

BACKGROUND AND PURPOSE: The management of unruptured intracranial aneurysms remains controversial and the results of endovascular treatment are not precisely known because no prospective data exist. The first prospective multicenter study (ATENA) was conducted in Canada and France to determine clinical outcome and risks of this treatment. METHODS: Six hundred forty-nine patients harboring a total of 1100 aneurysms from 27 Canadian and French neurointerventional centers were prospectively and consecutively treated by endovascular coil embolization. Of these, 739 unruptured intracranial aneurysms were treated during 700 procedures. Aneurysms were selectively treated in the great majority of cases (98.4%) with coils alone (54.5%), the balloon remodeling technique (37.3%), or stenting (7.8%). RESULTS: Endovascular treatment failed in 32 aneurysms (4.3%). Technical adverse events with or without clinical modification were encountered in 15.4% of patients and included thromboembolic complications (7.1% per procedure), intraoperative rupture (2.6% per procedure), and device-related problems (2.9% per procedure). Adverse events associated with transient or permanent neurological deficit or death were encountered in 5.4% of cases. The 1-month morbidity and mortality rates were 1.7% and 1.4%, respectively. CONCLUSIONS: Endovascular treatment of unruptured intracranial aneurysms is feasible in a high percentage of cases with low morbidity and mortality rates.

BACKGROUND AND PURPOSE: To report our experience in the treatment of brain arteriovenous malformations (BAVMs) using Onyx (ev3, Irvine, Calif). PATIENTS AND METHODS: From January 1999 to October 2004, 94 patients with BAVMs were treated endovascularly in our department. They were 51 (54%) men and 43 (46%) women with a mean age of 32 years. A total of 210 endovascular procedures were performed with Onyx as the sole embolic agent in 88 procedures; Onyx and n-butyl cyanoacrylate (n-BCA) were used in combination in 50 procedures, and n-BCA alone was used in 72 procedures. RESULTS: The course of endovascular treatment was completed in 53 patients. In 26 patients (49%, 26/53) an angiographic cure was achieved using embolization as the sole therapeutic technique. Seven (13%, 7/53) patients underwent a surgical resection of the residual BAVM nidus, 20 (38%, 20/53) patients underwent radiosurgical treatment after nidal size reduction <2 cm was accomplished by endovascular treatment. Further endovascular treatment was planned in 33 patients, whereas in 5 patients, the continuation of embolization was aborted due to difficult nidus catheterization. Procedure-related permanent neurologic deficits were observed in 8 (8.5%, 8/94) patients. There were 3 procedure-related deaths. CONCLUSION: Onyx is suitable for brain BAVM embolizations and allows obtaining higher rates of anatomic cures compared with those obtained previously with other embolic agents.

BACKGROUND: The use of thrombectomy in patients with acute stroke and a large infarct of unrestricted size has not been well studied. METHODS: We assigned, in a 1:1 ratio, patients with proximal cerebral vessel occlusion in the anterior circulation and a large infarct (as defined by an Alberta Stroke Program Early Computed Tomographic Score of ≤5; values range from 0 to 10) detected on magnetic resonance imaging or computed tomography within 6.5 hours after symptom onset to undergo endovascular thrombectomy and receive medical care (thrombectomy group) or to receive medical care alone (control group). The primary outcome was the score on the modified Rankin scale at 90 days (scores range from 0 to 6, with higher scores indicating greater disability). The primary safety outcome was death from any cause at 90 days, and an ancillary safety outcome was symptomatic intracerebral hemorrhage. RESULTS: A total of 333 patients were assigned to either the thrombectomy group (166 patients) or the control group (167 patients); 9 were excluded from the analysis because of consent withdrawal or legal reasons. The trial was stopped early because results of similar trials favored thrombectomy. Approximately 35% of the patients received thrombolysis therapy. The median modified Rankin scale score at 90 days was 4 in the thrombectomy group and 6 in the control group (generalized odds ratio, 1.63; 95% confidence interval [CI], 1.29 to 2.06; P<0.001). Death from any cause at 90 days occurred in 36.1% of the patients in the thrombectomy group and in 55.5% of those in the control group (adjusted relative risk, 0.65; 95% CI, 0.50 to 0.84), and the percentage of patients with symptomatic intracerebral hemorrhage was 9.6% and 5.7%, respectively (adjusted relative risk, 1.73; 95% CI, 0.78 to 4.68). Eleven procedure-related complications occurred in the thrombectomy group. CONCLUSIONS: In patients with acute stroke and a large infarct of unrestricted size, thrombectomy plus medical care resulted in better functional outcomes and lower mortality than medical care alone but led to a higher incidence of symptomatic intracerebral hemorrhage. (Funded by Montpellier University Hospital; LASTE ClinicalTrials.gov number, NCT03811769.).