Purpose: Standard coiling is now the first line approach for the treatment of intracranial aneurysms. However, this technique has some limitations, including treatment of wide-neck and large and giant aneurysms and recanalizations. Therefore, new techniques and devices are needed. The objective of intra-saccular flow disruption is the modification of aneurysmal flow by placing a device in the aneurysm sac. Clinical experience with this new technique is analyzed in a series collected in 11 French centers. Materials and Methods: The WEB (Sequent, Aliso Viejo, CA) is a self-expanding, oblate, braided nitinol mesh, composed of an inner and outer braid held together by proximal, middle, and distal radio-opaque markers and creating two compartments: one distal and one proximal. 66 patients (49F/17M, age: 36-75 years) harbouring 68 aneurysms (ruptured: 5, unruptured: 57 or recanalized: 6) were treated between June 2011 and July 2013. Aneurysm location was middle cerebral artery (39 aneurysms), basilar artery (16), anterior communicating artery (7), and internal carotid artery (6). Results: The device was successfully deployed in all but 4 cases (failure rate: 5.9%). Additional coiling was performed in 6 aneurysms, remodeling in 2 cases, and stenting in 1 case. One intraoperative rupture was observed in a ruptured aneurysm (1.5%). Six thromboembolic events (8.8%) were observed with transient clinical worsening and good clinical outcome in 5 cases (mRS ≤2). No delayed rupture or remote hematoma was observed. Finally mortality was 0.0% and morbidity 1.5% (in a patient who both had intraoperative rupture and thromboembolic complication). Anatomical follow-up was obtained in 32 patients 3 to 15 months after the treatment. Total occlusion was obtained in 15/32 aneurysms (46.9%), neck remnant in 14/32 aneurysms (43.8%), and aneurysm remnant in 3/32 aneurysms (9.4%). Conclusion: In the present series reporting the initial clinical experience with intra-saccular flow disruption using WEB in 11 French centers, the feasibility of treatment is high, the safety profile similar to coiling, and anatomical results are quite satisfactory knowing that some neck remnants are in fact just opacification of the proximal recess of the device.
BackgroundPatients receiving standard treatment for chronic subdural hematoma have a high risk of treatment failure. The effect of adjunctive middle meningeal artery embolization on the risk of treatment failure in this population remains unknown.MethodsWe randomly assigned patients with symptomatic chronic subdural hematoma to undergo middle meningeal artery embolization as an adjunct to standard treatment (embolization group) or to receive standard treatment alone (control group). Either surgical or nonsurgical standard treatment had been chosen for each patient before randomization. The primary efficacy outcome was a composite of the following events: recurrent or residual chronic subdural hematoma (measuring >10 mm) at 180 days; reoperation or surgical rescue within 180 days; or major disabling stroke, myocardial infarction, or death from neurologic causes within 180 days. The primary safety outcome was a composite of major disabling stroke or death from any cause within 30 days.ResultsAmong 310 enrolled patients, 149 were randomly assigned to the embolization group and 161 to the control group; 189 patients were to receive surgical standard treatment and 121 nonsurgical standard treatment. The mean age of the patients was 73 years, and 70% were men. In the primary efficacy analysis, a primary-outcome event occurred in 19 of 120 patients (16%) in the embolization group, as compared with 47 of 129 patients (36%) in the control group (odds ratio, 0.36; 95% confidence interval, 0.20 to 0.66; P=0.001). In the primary safety analysis, 4 of 144 patients (3%) in the embolization group and 5 of 166 patients (3%) in the control group either had a major disabling stroke or died within 30 days. Through 180 days, 12 patients (8%) in the embolization group and 9 patients (5%) in the control group had died, with death from neurologic causes occurring in 1 patient (1%) in the embolization group and in 3 patients (2%) in the control group.ConclusionsAmong patients with symptomatic chronic subdural hematoma, adjunctive middle meningeal artery embolization resulted in a lower risk of treatment failure than standard treatment alone, without resulting in an increased incidence of disabling stroke or death in the short term. Further study of longer-term safety outcomes is warranted. (Funded by Balt USA; STEM ClinicalTrials.gov number, NCT04410146.)
Ischemic stroke is a leading cause of death and disability worldwide. Much of the long-term disability occurs in patients with Emergent Large Vessel Occlusion (ELVO). In fact, in these patients, occlusion of a major intracerebral artery results in a large area of brain injury often resulting in
