Downloaded from http://jnis.bmj.com/ on June 7, 2015 - Published by group.bmj.com
Hemorrhagic stroke
ORIGINAL RESEARCH
Assisted coiling of saccular wide-necked unruptured intracranial aneurysms: stent versus balloon Arturo Consoli,1 Chiara Vignoli,2 Leonardo Renieri,1 Andrea Rosi,1 Ivano Chiarotti,2 Sergio Nappini,1 Nicola Limbucci,1 Salvatore Mangiafico1 1
Interventional Neuroradiology Unit, Careggi University Hospital, Florence, Italy 2 Department of Radiology, Careggi University Hospital, Florence, Italy Correspondence to Dr Arturo Consoli, Interventional Neuroradiology Unit, Careggi University Hospital, CTO 4th floor, Largo Palagi 1, Firenze 50134, Italy; [email protected] Received 17 September 2014 Revised 5 November 2014 Accepted 7 November 2014
ABSTRACT Background and purpose Assisted coiling with stents or balloons enables a higher percentage of complete occlusions of saccular unruptured intracranial aneurysms to be achieved with a reasonable complication rate. The aim of this study was to compare stent-assisted coiling and the balloon remodeling technique in terms of efficacy, stability, and safety for the treatment of comparable unruptured saccular intracranial aneurysms. Materials and methods 268 patients with 286 saccular unruptured wide-necked intracranial aneurysms were treated at our institution with stent- or balloonassisted coiling and retrospectively reviewed. Statistical analysis was performed to assess significant differences between the two groups. Results The rate of complete occlusion at the end of the procedure was higher with stent-assisted coiling than with balloon-assisted coiling (86.8% vs 78%) and the same results were also observed after 6 months (92.1% vs 77.6%; p=0.05). About 50% of major recurrences occurred in large to giant aneurysms ( p250 s.
Evaluation tools The angiographic result was assessed by an interventional neuroradiologist with 30 years of experience using the Raymond scale (grade I: complete occlusion; grade II: neck remnant; grade III: sac remnant). Intraprocedural, periprocedural, and late adverse events were registered and classified as asymptomatic or clinically symptomatic (with clinical sequelae), which were subdivided into ischemic (thromboembolism or dissection of the parent vessel or any branch visualized during angiographic controls and successively confirmed by CT scan or MRI) and hemorrhagic events (sac or arterial perforation or rupture, confirmed by CT scan or MRI). All patients underwent a CT scan at the end of the procedure in order to evaluate eventual intraprocedural bleeding. After waking, all the patients were transferred to the neurosurgical ward or to the neurosurgical ICU if necessary. The clinical outcome was independently evaluated by a neurologist at discharge and after 6 months. The modified Rankin Scale (mRS) was used to assess clinical outcome, with mRS 0 considered excellent and mRS 1 as a good clinical outcome. Of the 286 aneurysms, 245 (85%) were examined by digital subtraction angiographic evaluation after 6 months to assess eventual recurrences or delayed vascular morphological modifications (late intrastent stenosis). Major recurrences were defined as a change in the angiographic result from complete occlusion (grade I) or neck remnant (grade II) to sac recurrence, while a minor recurrence was defined as the progression from complete occlusion to a limited regrowth of the neck. Patients with a poor clinical outcome (n=3), those who refused further angiographic controls or were lost during follow-up (n=31), patients who died (n=5), and those in whom endovascular treatment failed and were subjected to clipping (n=2) were not included in the results of the angiographic follow-up. Patient age and gender, aneurysm localization ( parent vessel), size and location (bifurcational or wall side), endovascular technique used (RT or stent-assisted coiling), 2
intraprocedural complications, occlusion grade, and clinical outcome were included as variables. Size, location, intraprocedural complications, and occlusion grade were categorized as described previously. The occlusion grade was also categorized as complete or adequate occlusion; both grades I and II of the Raymond scale were included in the adequate occlusions.
Statistical analysis A Student t test was used to evaluate differences between the two groups and a χ2 test was used to perform univariate analysis. Binary logistic regression with the backward stepwise method was used to perform multivariate analysis, where the clinical outcome and occlusion grade were set as dichotomous variables as described previously. Variables with a p value
Hemorrhagic stroke
ORIGINAL RESEARCH
Assisted coiling of saccular wide-necked unruptured intracranial aneurysms: stent versus balloon Arturo Consoli,1 Chiara Vignoli,2 Leonardo Renieri,1 Andrea Rosi,1 Ivano Chiarotti,2 Sergio Nappini,1 Nicola Limbucci,1 Salvatore Mangiafico1 1
Interventional Neuroradiology Unit, Careggi University Hospital, Florence, Italy 2 Department of Radiology, Careggi University Hospital, Florence, Italy Correspondence to Dr Arturo Consoli, Interventional Neuroradiology Unit, Careggi University Hospital, CTO 4th floor, Largo Palagi 1, Firenze 50134, Italy; [email protected] Received 17 September 2014 Revised 5 November 2014 Accepted 7 November 2014
ABSTRACT Background and purpose Assisted coiling with stents or balloons enables a higher percentage of complete occlusions of saccular unruptured intracranial aneurysms to be achieved with a reasonable complication rate. The aim of this study was to compare stent-assisted coiling and the balloon remodeling technique in terms of efficacy, stability, and safety for the treatment of comparable unruptured saccular intracranial aneurysms. Materials and methods 268 patients with 286 saccular unruptured wide-necked intracranial aneurysms were treated at our institution with stent- or balloonassisted coiling and retrospectively reviewed. Statistical analysis was performed to assess significant differences between the two groups. Results The rate of complete occlusion at the end of the procedure was higher with stent-assisted coiling than with balloon-assisted coiling (86.8% vs 78%) and the same results were also observed after 6 months (92.1% vs 77.6%; p=0.05). About 50% of major recurrences occurred in large to giant aneurysms ( p250 s.
Evaluation tools The angiographic result was assessed by an interventional neuroradiologist with 30 years of experience using the Raymond scale (grade I: complete occlusion; grade II: neck remnant; grade III: sac remnant). Intraprocedural, periprocedural, and late adverse events were registered and classified as asymptomatic or clinically symptomatic (with clinical sequelae), which were subdivided into ischemic (thromboembolism or dissection of the parent vessel or any branch visualized during angiographic controls and successively confirmed by CT scan or MRI) and hemorrhagic events (sac or arterial perforation or rupture, confirmed by CT scan or MRI). All patients underwent a CT scan at the end of the procedure in order to evaluate eventual intraprocedural bleeding. After waking, all the patients were transferred to the neurosurgical ward or to the neurosurgical ICU if necessary. The clinical outcome was independently evaluated by a neurologist at discharge and after 6 months. The modified Rankin Scale (mRS) was used to assess clinical outcome, with mRS 0 considered excellent and mRS 1 as a good clinical outcome. Of the 286 aneurysms, 245 (85%) were examined by digital subtraction angiographic evaluation after 6 months to assess eventual recurrences or delayed vascular morphological modifications (late intrastent stenosis). Major recurrences were defined as a change in the angiographic result from complete occlusion (grade I) or neck remnant (grade II) to sac recurrence, while a minor recurrence was defined as the progression from complete occlusion to a limited regrowth of the neck. Patients with a poor clinical outcome (n=3), those who refused further angiographic controls or were lost during follow-up (n=31), patients who died (n=5), and those in whom endovascular treatment failed and were subjected to clipping (n=2) were not included in the results of the angiographic follow-up. Patient age and gender, aneurysm localization ( parent vessel), size and location (bifurcational or wall side), endovascular technique used (RT or stent-assisted coiling), 2
intraprocedural complications, occlusion grade, and clinical outcome were included as variables. Size, location, intraprocedural complications, and occlusion grade were categorized as described previously. The occlusion grade was also categorized as complete or adequate occlusion; both grades I and II of the Raymond scale were included in the adequate occlusions.
Statistical analysis A Student t test was used to evaluate differences between the two groups and a χ2 test was used to perform univariate analysis. Binary logistic regression with the backward stepwise method was used to perform multivariate analysis, where the clinical outcome and occlusion grade were set as dichotomous variables as described previously. Variables with a p value
