Silk arterial reconstruction for intracranial aneurysms.

Multicentric french study on 51 consecutive patients.

Jérôme Berge, Alain Bonafé, Hervé Brunel, Emmanuel Chabert, Jean Gabrillargues, Kristof Kadziolka, Xavier Barreau, Laurent Pierrot,

Vincent Dousset.

Neuroradiology Departments:Bordeaux, Montpellier, Marseille, Clermont-Ferrand, Reims,

France

Aims

• Classify indications for new flow diverters– Regarding localisation of the aneurysm– Regarding aneurysm size and neck width– Without any scientific litterature in 2009 !

• Evaluate morbi-mortality of Silk stent on a retrospective multicentric group.

• Evaluate angiographic occlusion rate in post-procedure and at 6 months.

How can we justify to take risk on a non ruptured aneurysm ?

• 3 criteria to take into account:– Patient age

• Life expectancy• endovascular acces faisability

– aneurysm symptomatic or not ?• Seizures• Nerve palsy or compressive syndrom

– Rupture rate associated with aneurysm• Risk factors

– Regrowth of a previous treated aneurysm– Smoker, elevated blood pressure, history of SAH,

• size and localisation of aneurysm

Population• I.S.U.I.A. study (2003)

– Cumulated rupture rate at 5 years• In a patient without history of SAH

Lancet. 2003 Jul 12;362(9378):103-10.Unruptured intracranial aneurysms: natural history, clinical outcome, and

risks of surgical and endovascular treatment.Wiebers DO …… « International Study of Unruptured Intracranial Aneurysms Investigators ».

Cumulated rupturerate at 5 years < 7 mm 7-12 mm 13-24 mm > 24 mm

INTRA - CAVERNOUS CAROTID 0% 0% 0,61% 1%

ICA / MCA / ACom 0% 2,60% 14,50% 40%

Vertebral / Basilar / PCA 2,50% 14,50% 18,40% 50%

Patients

• data from 5 centers on a 1 year period • 51 patients (10 M + 41 F): average = 53 years old• Average diameter of the sac = 18,1 mm• Non ruptured IC aneurysms : 15 fusiforms, 34

sacciforms and 2 dissecting aneurysms.• 11 regrowth post embolisation after SAH• Clinical data:• 23 asymptomatic patients• 28 patients with compressive symptoms.

– Cavernous sinus: 15 patients upon 22 C.C. aneurysms– Brainstem: 4 patients upon 7 vertebro-basilar aneurysms– Optic nerve and chiasma: 9 sur 19 ophtalmic aneurysms

Distribution of patients /size and localization of the aneurysm

5 years rupture rate /Included patients number < 7 mm

5 patients7-12 mm11 patients

13-24 mm22 patients

> 24 mm13 patients

INTRA – CAVERNOUS CAROTID

22 patients0%

1 patient0%

3 patients0,61%

9 patients1%

9 patients

ICA / MCA / ACom 22 patients

0%4 patients

2,60%5 patients

14,50%10 patients

40%3 patients

Vertebral / Basilar / PCA7 patients

2,50%0 patient

14,5%3 patients

18,4%3 patients

50%1 patient

Why did we treat small carotid aneurysms ?

• None of them were symptomatic on the optic nerve• 9 carotid ophtalmic aneurysms < 12 mm

– 2 recanalisatons of previous treated aneurysms– 4 dysplastic carotids with 2 to 5 aneurysms– 1 case had associated ruptured aneurysm

Methods

• 51 endovascular procedures:– 33 cases with 1 Silk

• 5 with previous regrowth after Neuroform + coils– 6 cases with 2 silk– 10 cases with Silk + coils,

• 2 cases with coils in controlateral feeder– Opposite ACA on ACom aneurysm, opposite vertebral artery

• 1 case with 2 Silk and coils– 2 cases: Silk with poor deployment

• Requiring use of a Neuroform or Enterprise stent

Angiographic resultsKamran-Byrne classification 2010 (Plos One) :

Grade 5 = Parentarteryocclusion

Silk final control 0 12 13 15 6

5(3 strokes

and 2 asympto)

at6

months

0 0 6 3 37 5

88%

at 6 months : 5 stenoses at 50%: (all asymptomatic)

Clinical results • Acute morbidity  : 5 strokes

– 2 cases: poor deployment of the FD Stent– 3 cases: thrombosis of the stent and embolic events

• Delayed morbidity:– 19 post procedure inflammatory adverse events.

• (see other communication)– 2 TIA at 3 months when Plavix was stopped– 3 bleeding complications : (day 14, 3 and 4 months)

• 1 patient died (rebleeding at 3 months)• 2 carotid-cavernous fistula (day 14 and 4 months)

– With successfull endovascular treatment• Rupture happened on occluded prooved aneurysms

Mortality at 6 months = 1 / 51 patient (2 %)Permanent morbidity = 5 strokes / 51 patients (9,8%)

Distribution of morbi-mortality regarding localisation

5 years rupture rate /Included patients number < 7 mm

5 patients7-12 mm11 patients

13-24 mm22 patients

> 24 mm13 patients

INTRA – CAVERNOUS CAROTID

22 patients

0%1 patient

0

0%3 patients1 stroke

0,61%9 patients1 stroke

1%9 patients1 stroke

2 CC fistula

ICA / MCA / ACom 22 patients

0%4 patients

0

2,60%5 patients

0

14,50%10 patients

1 stroke(died)

40%3 patients1 stroke

Vertebral / Basilar / PCA7 patients

2,50%0 patient

0

14,5%3 patients

0

18,4%3 patients

0

50%1 patient

0

Discussion about complications:• 6 parent artery occlusions

– 5 cases of Flow Diverter poor delivery– use of Neuroform or Entreprise stents in 2 patients– One case of resistance to clopidogrel

– 5 occured in the carotid siphon and 1 MCA– Responsible for: 4 strokes

2 asymptomatic occlusions• 5 strokes on carotid siphon aneurysms:

• 3 on carotid cavernous aneurysms• 2 on carotid ophtalmic aneurysms• 1 on MCA

– 1 resistance to clopidogrel

• All this events were related with delivery of the SILK stent on a tight curved artery > 90°

Conclusion

• Flow diversion is a promising technique for the treatment of giant or broad neck aneurysms.

• Acute stroke is the main risk:– Related to poor deployment in curved arteries– Or resistance to antiplatelet treatment.

• Transient compressive syndrom and delayed bleeding risk remain ununderstood challenges.

No conflict of interest declared