Safety and Effectiveness of Stent-Assisted Coil Embolization for Ruptured Intracranial Aneurysm

Background: It has been conclusively established that intracranial aneurysms measuring a diameter below 7 mm pose a minimal risk of rupture. Conversely, those exhibiting irregular morphology or featuring the presence of a sac necessitate a more stringent and rigorous management approach. Objective: The primary aim of this study is to delve into the morphological features of ruptured aneurysms situated in distinct regions of the brain. Furthermore, we endeavor to assess the degree of safety and efficacy associated with stent-assisted embolization as a treatment modality for these ruptured aneurysms. Methods: This retrospective study encompassed a cohort of 467 patients who presented with intracranial ruptured aneurysms and were diagnosed through a combination of computed tomography (CT) and digital subtraction angiography (DSA) at Nanfang Hospital of Southern Medical University, spanning from January 2009 to December 2019. The following clinical parameters were meticulously recorded: aneurysm height, width, neck measurements, immediate Raymond grade assessments, and any perioperative complications experienced. Results: Within the study population, the average dimensions of ruptured aneurysms were found to be 4.26 ± 2.10 mm (width), 4.86 ± 2.38 mm (height), and 4.04 ± 1.87 mm (neck). Categorically, the most prevalent types of aneurysms were 170 cases of anterior communicating artery aneurysms (accounting for 36.4%), followed by 161 cases of posterior communicating artery aneurysms (34.5%), 56 cases of middle cerebral artery aneurysms (12.0%), 13 cases of anterior cerebral artery aneurysms (2.8%), 45 cases of paraclinoid aneurysms (9.6%), 6 cases of superior pituitary artery aneurysms (1.3%), 7 cases of anterior choroidal artery aneurysms (1.5%), and 9 cases of vertebrobasilar artery aneurysms (2.0%). Notably, 18 patients (3.9%) presented with ruptured aneurysms coexisting with ascus. Regarding treatment approaches, 228 cases (48.8%) underwent stent-assisted embolization, 234 cases (50.1%) received coils embolization, and 5 cases (1.1%) were treated with the dual-catheter technique. Immediately post-treatment, 422 patients (90.4%) attained a Raymond Class I status, with a procedure-related complication rate of 0.9%. Importantly, no statistically significant differences were observed in the incidence of perioperative complications across the three distinct treatment groups (P = 0.505). Conclusion: The outcomes of this study affirm the safety and efficacy of stent-assisted embolization as a treatment modality for ruptured aneurysms.

Diagnosis of ruptured superior mesenteric artery aneurysm mimicking a pancreatic mass

Aneurysms and pseudoaneurysms of the superior mesenteric artery are potentially lethal and should be treated as urgently as possible.In a 52-year-old man with occasional epigastric pain,we accidentally discovered a superior mesenteric artery aneurysm that was ruptured with spontaneous tamponade in the uncinate process and in the head of the pancreas.The ruptured aneurysm had a heterogeneous appearance due to its thrombotic and hemorrhagic content,and it simulated a voluminous mass in the head and uncinate process of the pancreas,associated with mild dilatation of the main pancreatic duct.Recent advances in multidetector computed tomography and magnetic resonance imaging have enabled radiologists to develop a correct diagnosis of mesenteric aneurysms and pseudoaneurysms of the visceral branches of the abdominal aorta,and to differentiate this diagnosis from that of pancreatic or peripancreatic masses;angiography is currently used to confirm a diagnosis and to develop therapeutic treatments.

Modeling on monitoring the growth and rupture assessment of saccular aneurysms

The unpredictable rupture of saccular aneurysms especially of the intracerebral aneurysm is a knotty problem that always results in high mortality. Traditional diagnosis of medical images, which gives the aneurysm size and compares with a speculated critical size from clinical statistics, was demonstrated inadequate to forecasting rupture. Here, we propose a new detecting strategy that uses a dielectric elastomer （DE） capacitance sensor to monitor the growth of saccular aneurysms and deliver both the wall stress and geometric parameters, Based on the elastic growth theory together with the finite deformation analyses, the correlation between the real-time output capacitance of the DE sensor and the wall stress and/or geometry of an aneurysm is derived. Compared to clinic statistics and biomechanics simulations, the wall stress and geometric size may be used as combined indicators to assess the rupture risk of a saccular aneurysm, Numerical results show that an output relative capacitance of 30 indicates a high risk of rupture, Finally, the sensitivity and resolution of the DE sensor are proved adequately high for monitoring the growth state and evaluating the rupture risk of a saccular aneurysm.

Mechanics of formation and rupture of human aneurysm

The mechanical response of the human arterial wall under the combined loading of inflation, axial extension, and torsion is examined within the framework of the large deformation hyper-elastic theory. The probability of the aneurysm formation is explained with the instability theory of structure, and the probability of its rupture is explained with the strength theory of material. Taking account of the residual stress and the smooth muscle activities, a two layer thick-walled circular cylindrical tube model with fiber-reinforced composite-based incompressible anisotropic hyper-elastic materials is employed to model the mechanical behavior of the arterial wall. The deformation curves and the stress distributions of the arterial wall are given under normal and abnormal conditions. The results of the deformation and the structure instability analysis show that the model can describe the uniform inflation deformation of the arterial wall under normal conditions, as well as formation and growth of an aneurysm under abnormal conditions such as the decreased stiffness of the elastic and collagen fibers. From the analysis of the stresses and the material strength, the rupture of an aneurysm may also be described by this model if the wall stress is larger than its strength.

Supraceliac Aortic Clamping for Repair of Ruptured Abdominal Aortic Aneurysm in Patients with Short Aortic Neck Length

Objective: Prompt bleeding control with proximal aortic clamping and subsequent aortic repair are very important for ruptured abdominal aortic aneurysm. However, unsuitable anatomy, such as short aortic neck length, not only disturbs the means to an expeditious repair, but may also increase morbidity and mortality. In the present study, we aimed to evaluate the efficacy of supraceliac aortic clamping for improving surgical outcomes for patients with ruptured abdominal aortic aneurysm, who have a short aortic neck length. Method: Between April 2010 and September 2015, eighteen patients underwent emergent open surgical repair of ruptured abdominal aortic aneurysm. Eight patients with a short aortic neck length underwent supraceliac aortic clamping, and 10 underwent infrarenal aortic clamping. Results: The mean supraceliac aortic clamping time was 30 ± 7 minutes. There was 1 operative death in the infrarenal aortic clamping group due to respiratory failure, and the overall operative mortality was 6%. There were no significant differences between the 2 groups with respect to postoperative complication rates or mortality. Furthermore, there were no significant differences in variables of renal function between the 2 groups, through-out the study period. Conclusion: Supraceliac aortic clamping was associated with minimal mortality and morbidity, but not with harmful effects on postoperative renal function. Thus, supraceliac aortic clamping can be safely applied for ruptured abdominal aortic aneurysm with short aortic neck length.

Clinical Efficacy of Shenmai Injection in the Treatment of Cerebral Vasospasm after Ruptured Aneurysm Surgery

Objective: To investigate the therapeutic effect of Shenmai Injection on postoperative cerebral vasospasm in patients with ruptured aneurysms. Methods: Seventy patients undergoing craniotomy for ruptured aneurysms in our hospital were selected as study subjects and randomly divided into control (n = 33) and research (n = 37) groups, they were treated with nimodipine and nimodipine combined with Shenmai injection after operation. The blood flow velocity in the middle cerebral artery (MCA) before and at 1, 3, 7, 11 and 14 days after surgery and the incidence of cerebral vasospasm during these days were compared, and the GCS scores at 14 days postoperatively and GOS scores at 6 months postoperatively were compared between the two groups. Results: There were no statistically significant differences in the occurrence of cerebral vasospasm, GCS or GOS scores between the two groups (P > 0.05), but the period of postoperative cerebral vasospasm in the study group was significantly shorter than that in the control group. Conclusion: Shenmai injection has the effect of shortening the cycle of occurrence of cerebral vasospasm after the operation of ruptured aneurysms, promoting patients to recover as early as possible and reducing their physical and mental burden.

Hemodynamic analysis of intracranial aneurysms using phase-contrast magnetic resonance imaging and computational fluid dynamics

Additional hemodynamic parameters are highly desirable in the clinical management of intracranial aneurysm rupture as static medical images cannot demonstrate the blood flow within aneurysms. There are two ways of obtaining the hemodynamic information-by phase-contrast magnetic resonance imaging (PCMRI) and computational fluid dynamics (CFD). In this paper, we compared PCMRI and CFD in the analysis of a stable patient's specific aneurysm. The results showed that PCMRI and CFD are in good agreement with each other. An additional CFD study of two stable and two ruptured aneurysms revealed that ruptured aneurysms have a higher statistical average blood velocity, wall shear stress, and oscillatory shear index (OSI) within the aneurysm sac compared to those of stable aneurysms. Furthermore, for ruptured aneurysms, the OSI divides the positive and negative wall shear stress divergence at the aneurysm sac.

Safety and efficacy of stent-assisted coiling for acutely ruptured wide-necked intracranial aneurysms:comparison of LVIS stents with laser-cut stents

Background:To compare the safety and efficacy of LVIS stent-assisted coiling with those of laser-cut stent-assisted coiling for the treatment of acutely ruptured wide-necked intracranial aneurysms.Methods:Patients with acutely ruptured wide-necked intracranial aneurysms treated with LVIS stent-assisted coiling(LVIS stent group)and laser-cut stent-assisted coiling(laser-cut stent group)were retrospectively reviewed from January 2014 to December 2017.Propensity score matching was used to adjust for potential differences in age,sex,aneurysm location,aneurysm size,neck width,Hunt-Hess grade,and modified Fisher grade.Perioperative procedure-related complications and clinical and angiographic follow-up outcomes were compared.Univariate and multivariate analyses were performed to determine the associations between procedure-related complications and potential risk factors.Results:A total of 142 patients who underwent LVIS stent-assisted coiling and 93 patients who underwent laser-cut stent-assisted coiling were enrolled after 1:2 propensity score matching.The angiographic follow-up outcomes showed that the LVIS stent group had a slightly higher complete occlusion rate and lower recurrence rate than the laser-cut stent group(92.7%vs 80.6%;3.7%vs 9.7%,P=0.078).The clinical outcomes at discharge and follow-up between the two groups demonstrated no significant differences(P=0.495 and P=0.875,respectively).The rates of intraprocedural thrombosis,postprocedural thrombosis,postoperative early rebleeding,and procedure-related death were 0.7%(1/142),1.4%(2/142),2.8%(4/142),and 2.1%(3/142)in the LVIS stent group,respectively,and 4.3%(4/93),2.2%(2/93),1.1%(1/93),and 3.2%(3/93)in the laser-cut stent group,respectively(P=0.082,0.649,0.651,and 0.683).Nevertheless,the rates of overall procedure-related complications and intraprocedural rupture in the LVIS stent group were significantly lower than those in the laser-cut stent group(5.6%vs 14.0%,P=0.028;0.7%vs 6.5%,P=0.016).Multivariate analysis showed that laser-cut stent-assisted coiling was an independent predictor for overall procedurerelated complications(OR=2.727,P=0.037);a history of diabetes(OR=7.275,P=0.027)and other cerebrovascular diseases(OR=8.083,P=0.022)were independent predictors for ischemic complications,whereas none of the factors were predictors for hemorrhagic complications.Conclusions:Compared with laser-cut stent-assisted coiling,LVIS stent-assisted coiling for the treatment of acutely ruptured wide-necked intracranial aneurysms could reduce the rates of overall procedure-related complications and intraprocedural rupture.

Endovascular coiling versus microsurgical clipping for ruptured intracranial aneurysms:a meta-analysis and systematic review

Background:The purpose of this analysis is to evaluate the current evidence with regard to the effectiveness and safety between coiling and clipping in patients with ruptured intracranial aneurysms(RIAs).Methods:We performed a meta-analysis that compared clipping with coiling between July 2000 and September 2021.PubMed,EMBASE,and the Cochrane Library were searched for related articles systematically.And the treatment efficacy and postoperative complications were analyzed.Results:We identified three randomized controlled trials and thirty-seven observational studies involving 60,875 patients with ruptured cerebral aneurysms.The summary results showed that coiling was related a better quality of life(mRS0-2;OR=1.327;CI=1.093-1.612;p<0.05),a higher risk of mortality(OR=1.116;CI=1.054-1.180;p<0.05),higher rate of rebleeding(RR=1.410;CI=1.092-1.822;p<0.05),lower incidence of vasospasm(OR=0.787;CI=0.649-0.954;p<0.05),higher risk of hydrocephalous(RR=1.143;CI=1.043-1.252;p<0.05),lower risk of cerebral infarction(RR=0.669;CI=0.596-0.751;p<0.05),lower risk of neuro deficits(RR=0.720;CI=0.582-0.892;p<0.05),and a lower rate of complete occlusion(OR=0.495;CI=0.280-0.876;p<0.05).Conclusion:Coiling was significantly associated with a better life quality(mRS0-2),a lower incidence of postoperative complications,and a higher rate of mortality,rebleeding,hydrocephalous,and a lower rate of complete occlusion than clipping.

Stent-grafting combined with transcatheter embolization for a ruptured isolated hypogastric artery aneurysm

Rupture of isolated hypogastric artery aneurysm （HAA） is rarely encountered and is associated with a high mortality rate. Conventional surgery can not achieve distal control easily and may cause substantial blood loss, yielding high operative morbidity and mortality. On March 17, 2005, we treated a patient with such a disease successfully by using endovascular stent-grafting combined with transcatheter embolization.

Preliminary experience using transthoracic echocardiography guiding percutaneous closure of ruptured right sinus of Valsalva aneurysm

Background In the 21st century, minimally invasive treatment is one of the main developmental directions of medical sciences. It is well known that the echocardiography plays an important role during interventional treatments of some structural heart diseases. Because the ruptured right sinus of the Valsalva aneurysm （RRSVA） is a rare disease, there were few reports about percutaneous catheter closure of RRSVA. This study aimed to sum up our experience with transthoracic echocardiography （TTE） during percutaneous catheter closure of RRSVA.Methods Five RRSVA cases were treated with percutaneous catheter closure. The whole procedure was guided and monitored by TTE and fluoroscopy. The maximum diameter of the RRSVA was measured by TTE before and after the catheter passed through the rupture site. A duct occluder 2 mm larger than the maximum diameter was chosen. The closure effects were evaluated with TTE and fluoroscopy immediately after the occluding device was deployed. All patients were followed up by TTE for 8 to 30 months.Results Before the catheter passed through the rupture site the maximum diameter of the RRSVA measured with TTE and aortography were （7.9 ±2.1） mm and （7.8 ± 1.8） mm. After the catheter passed through the rupture site the maximum diameter measured with TTE was （11.2 ± 3.2） mm, which was significantly larger than before the procedure （P 〈0.05）. The percutaneous catheter closure was successful in four cases and failed in one. Compared to the aortography the TTE was better at distinguishing residual shunts from aortic valve regurgitation immediately after the occluding device was deployed. There were no complications during 8 to 30 months of follow-up.Conclusion Transthoracic echocardiography can play an important role during percutaneous catheter closure of RRSVA,especially for estimating the size of the RRSVA after the catheter passes through the rupture site, and differentiating residual shunt from aortic valve regurgitation immediately after the occluding device is deployed

Aneurysmal isolated intracerebral hemorrhage and/or intraventricular hemorrhage without subarachnoid hemorrhage: a rare and perplexing scenario in neurosurgical practice

Ruptured aneurysms with a presentation of intracerebral hemorrhage (ICH) and/or intraventricular hemorrhage (IVH)without subarachnoid hemorrhage (SAH) are rarely reported.Issues on the clinical characteristics,mechanism,diagnosis,treatment and prognosis of this rare entity are obscure to us.We present two cases of ruptured aneurysms with a presentation of isolated ICH.A systematic review of the literature was also conducted.There were 21 cases plus our cases.Good recovery was achieved in 10 patients (47.6 ％).Pertaining to location,38 ％ of presenting aneurysms were on the right side,52 ％ were on the left side,and 10 ％ were midline.Anterior circulation aneurysms were identified in 81％ of patients (7 PComA,8 MCA,1 ICA,1 AComA) and posterior in 19 ％ of patients (3 PCA,1 BA).Sizes of the aneurysms ranged from 3 mm to 40 mm (16.21 ± 8.45).Ruptured aneurysms at the main trunks of the Willis cycle with a presentation of isolated ICH and/or IVH without SAH is extremely rare.The cause of this rare entity is multifactorial.The diagnosis and management of this entity pose a great challenge to us.The prognosis was discouraging based on the now available data.