Abstract
Purpose
This study aimed to compare the treatment outcomes of large (15–25 mm) and giant (> 25 mm) intracranial aneurysms (IAs), according to different treatment modalities.
Methods
In total, 112 patients with large and giant IAs treated with various treatment modalities between January 2009 and December 2018 were retrospectively reviewed. Clinical and radiological parameters were analyzed and correlated with the treatment modality.
Results
A total of 141 procedures were performed on 112 patients. We initially treated 47 cases with coil embolization, 39 with flow diverter (FD), 13 with direct clipping, and 13 with parent artery occlusion (PAO). Recurrence (46.8%) and retreatment (31.9%) rates were significantly higher in the coiling group (p < 0.001). Complete occlusion rate (36.3%) was significantly lower in the coiling group (p = 0.027). PAO could achieve a high complete occlusion rate (90.9%) with low complication rate (12.5%). The total complication rate was 17%. In the multivariate logistic regression analysis, FD (OR 3.406, p = 0.036) and direct clipping (OR 5.732, p = 0.017) showed a significantly higher complication rate than coiling. The overall mortality rate was 8% (8/139 procedures). At the last follow-up (mean 30.6 ± 26.4 months), 70 of 96 patients (72.9%) showed complete or near-complete occlusion. Good functional outcome (mRS ≤ 2) was observed in 90 of 112 (80.3%) patients at the last follow-up (mean 33.2 ± 30.5 months).
Conclusions
Good clinical and radiologic outcomes with acceptable complication and mortality rates can be achieved by various treatment modalities. The selection of appropriate modality should be individualized based on the angiographic findings and clinical symptoms.
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References
Abud DG, Spelle L, Piotin M, Mounayer C, Vanzin JR, Moret J (2005) Venous phase timing during balloon test occlusion as a criterion for permanent internal carotid artery sacrifice. AJNR Am J Neuroradiol 26:2602–2609
Adeeb N, Griessenauer CJ, Shallwani H, Shakir H, Foreman PM, Moore JM, Dmytriw AA, Gupta R, Siddiqui AH, Levy EI, Snyder K, Harrigan MR, Ogilvy CS, Thomas AJ (2017) Pipeline embolization device in treatment of 50 unruptured large and giant aneurysms. World Neurosurg 105:232–237
Barrow DL, Alleyne C (1995) Natural history of giant intracranial aneurysms and indications for intervention. Clin Neurosurg 42:214–244
Becske T, Brinjikji W, Potts MB, Kallmes DF, Shapiro M, Moran CJ, Levy EI, McDougall CG, Szikora I, Lanzino G, Woo HH, Lopes DK, Siddiqui AH, Albuquerque FC, Fiorella DJ, Saatci I, Cekirge SH, Berez AL, Cher DJ, Berentei Z, Marosfoi M, Nelson PK (2017) Long-term clinical and angiographic outcomes following pipeline embolization device treatment of complex internal carotid artery aneurysms: five-year results of the pipeline for uncoilable or failed aneurysms trial. Neurosurgery 80:40–48
Becske T, Kallmes DF, Saatci I, McDougall CG, Szikora I, Lanzino G, Moran CJ, Woo HH, Lopes DK, Berez AL, Cher DJ, Siddiqui AH, Levy EI, Albuquerque FC, Fiorella DJ, Berentei Z, Marosfoi M, Cekirge SH, Nelson PK (2013) Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology 267:858–868
Brinjikji W, Lanzino G, Cloft HJ, Siddiqui AH, Boccardi E, Cekirge S, Fiorella D, Hanel R, Jabbour P, Levy E, Lopes D, Lylyk P, Szikora I, Kallmes DF (2016) Risk factors for ischemic complications following pipeline embolization device treatment of intracranial aneurysms: results from the IntrePED Study. AJNR Am J Neuroradiol 37:1673–1678
Brinjikji W, Murad MH, Lanzino G, Cloft HJ, Kallmes DF (2013) Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke 44:442–447
Cebral JR, Mut F, Raschi M, Scrivano E, Ceratto R, Lylyk P, Putman CM (2011) Aneurysm rupture following treatment with flow-diverting stents: computational hemodynamics analysis of treatment. AJNR Am J Neuroradiol 32:27–33
Chalouhi N, Tjoumakaris S, Starke RM, Gonzalez LF, Randazzo C, Hasan D, McMahon JF, Singhal S, Moukarzel LA, Dumont AS, Rosenwasser R, Jabbour P (2013) Comparison of flow diversion and coiling in large unruptured intracranial saccular aneurysms. Stroke 44:2150–2154
Dmytriw AA, Phan K, Salem MM, Adeeb N, Moore JM, Griessenauer CJ, Foreman PM, Shallwani H, Shakir H, Siddiqui AH, Levy EI, Davies JM, Harrigan MR, Thomas AJ, Ogilvy CS (2019) The pipeline embolization device: changes in practice and reduction of complications in the treatment of anterior circulation aneurysms in a multicenter cohort. Neurosurgery
Gao X, Liang G, Li Z, Wei X, Cao P (2012) A single-centre experience and follow-up of patients with endovascular coiling of large and giant intracranial aneurysms with parent artery preservation. J Clin Neurosci 19:364–369
Gobin YP, Vinuela F, Gurian JH, Guglielmi G, Duckwiler GR, Massoud TF, Martin NA (1996) Treatment of large and giant fusiform intracranial aneurysms with Guglielmi detachable coils. J Neurosurg 84:55–62
Gruber A, Killer M, Bavinzski G, Richling B (1999) Clinical and angiographic results of endosaccular coiling treatment of giant and very large intracranial aneurysms: a 7-year, single-center experience. Neurosurgery 45:793–803 discussion 803-794
Kallmes DF, Hanel R, Lopes D, Boccardi E, Bonafe A, Cekirge S, Fiorella D, Jabbour P, Levy E, McDougall C, Siddiqui A, Szikora I, Woo H, Albuquerque F, Bozorgchami H, Dashti SR, Delgado Almandoz JE, Kelly ME, Turner R, Woodward BK, Brinjikji W, Lanzino G, Lylyk P (2015) International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. AJNR Am J Neuroradiol 36:108–115
Lanzino G, Crobeddu E, Cloft HJ, Hanel R, Kallmes DF (2012) Efficacy and safety of flow diversion for paraclinoid aneurysms: a matched-pair analysis compared with standard endovascular approaches. AJNR Am J Neuroradiol 33:2158–2161
Lee JY, Cho YD, Kang H-S, Han MH (2020) Healing of aneurysm after treatment using flow diverter stent : histopathological study in experimental canine carotid side wall aneurysm. J Korean Neurosurg Soc 63:34–44
Linskey ME, Jungreis CA, Yonas H, Hirsch WL Jr, Sekhar LN, Horton JA, Janosky JE (1994) Stroke risk after abrupt internal carotid artery sacrifice: accuracy of preoperative assessment with balloon test occlusion and stable xenon-enhanced CT. AJNR Am J Neuroradiol 15:829–843
Lv X, Ge H, He H, Jiang C, Li Y (2017) A systematic review of pipeline embolization device for giant intracranial aneurysms. Neurol India 65:35–38
Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P (2005) International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366:809–817
Nishi H, Ishii A, Satow T, Iihara K, Sakai N (2019) Parent artery occlusion for unruptured cerebral aneurysms: results of the Japanese Registry of Neuroendovascular Therapy 3. Neurol Med Chir (Tokyo) 59:1–9
Nossek E, Chalif DJ, Chakraborty S, Lombardo K, Black KS, Setton A (2015) Concurrent use of the pipeline embolization device and coils for intracranial aneurysms: technique, safety, and efficacy. J Neurosurg 122:904–911
Oishi H, Teranishi K, Yatomi K, Fujii T, Yamamoto M, Arai H (2018) Flow diverter therapy using a pipeline embolization device for 100 unruptured large and giant internal carotid artery aneurysms in a single center in a Japanese population. Neurol Med Chir (Tokyo) 58:461–467
Rouchaud A, Brinjikji W, Lanzino G, Cloft HJ, Kadirvel R, Kallmes DF (2016) Delayed hemorrhagic complications after flow diversion for intracranial aneurysms: a literature overview. Neuroradiology 58:171–177
Sheen JJ, Park W, Kwun BD, Park JC, Ahn JS (2019) Microsurgical treatment strategy for large and giant aneurysms of the internal carotid artery. Clin Neurol Neurosurg 177:54–62
Shin D-S, Carroll CP, Elghareeb M, Hoh BL, Kim B-T (2020) The evolution of flow-diverting stents for cerebral aneurysms; historical review, modern application, complications, and future direction. J Korean Neurosurg Soc 63:137–152
Siddiqui AH, Kan P, Abla AA, Hopkins LN, Levy EI (2012) Complications after treatment with pipeline embolization for giant distal intracranial aneurysms with or without coil embolization. Neurosurgery 71:E509–E513
Sluzewski M, Menovsky T, van Rooij WJ, Wijnalda D (2003) Coiling of very large or giant cerebral aneurysms: long-term clinical and serial angiographic results. AJNR Am J Neuroradiol 24:257–262
Sughrue ME, Saloner D, Rayz VL, Lawton MT (2011) Giant intracranial aneurysms: evolution of management in a contemporary surgical series. Neurosurgery 69:1261–1270 discussion 1270-1261
van der Schaaf IC, Brilstra EH, Buskens E, Rinkel GJ (2002) Endovascular treatment of aneurysms in the cavernous sinus: a systematic review on balloon occlusion of the parent vessel and embolization with coils. Stroke 33:313–318
van Rooij WJ, Sluzewski M (2009) Endovascular treatment of large and giant aneurysms. AJNR Am J Neuroradiol 30:12–18
van Rooij WJ, Sluzewski M, Slob MJ, Rinkel GJ (2005) Predictive value of angiographic testing for tolerance to therapeutic occlusion of the carotid artery. AJNR Am J Neuroradiol 26:175–178
Ye G, Zhang M, Deng L, Chen X, Wang Y (2016) Meta-analysis of the efficiency and prognosis of intracranial aneurysm treated with flow diverter devices. J Mol Neurosci 59:158–167
Zeeshan Q, Ghodke BV, Juric-Sekhar G, Barber JK, Kim LJ, Sekhar LN (2018) Surgery for very large and giant intracranial aneurysms: results and complications. Neurol India 66:1741–1757
Zhou G, Su M, Yin YL, Li MH (2017) Complications associated with the use of flow-diverting devices for cerebral aneurysms: a systematic review and meta-analysis. Neurosurg Focus 42:E17
Zhou G, Su M, Zhu YQ, Li MH (2016) Efficacy of flow-diverting devices for cerebral aneurysms: a systematic review and meta-analysis. World Neurosurg 85:252–262
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This research was funded by the Basic Science Research Program through the National Research Foundation of Korea (NRF) (2019R1F1A1057108).
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Choi, J.H., Lee, K.S., Kim, Bs. et al. Treatment outcomes of large and giant intracranial aneurysms according to various treatment modalities. Acta Neurochir 162, 2745–2752 (2020). https://doi.org/10.1007/s00701-020-04540-1
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DOI: https://doi.org/10.1007/s00701-020-04540-1