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Background: No randomized trial of intracranial aneurysm coiling has compared long-term efficacy of polymer-modified coils to bare metal coils (BMCs). We report 5-year results comparing Matrix 2 coils to BMCs. The primary objective was to compare the rates of target aneurysm recurrence (TAR) at 12 months. Secondary objectives included angiographic outcomes at TAR or 12 months and TAR at 5 years., Methods: A total of 626 patients were randomized to BMCs or Matrix 2 coils. Detailed methods and 1-year results have been published previously., Results: Of 580 patients eligible for 5-year follow-up, 431 (74.3%) completed follow-up or reached TAR. Matrix 2 coils were non-inferior to BMCs (P=0.8) but did not confer any benefit. Core lab reported post-treatment residual aneurysm filling (Raymond III) correlated with TAR (P<0.0001) and with aneurysm hemorrhage after treatment (P<0.008). Repeat aneurysmal hemorrhage after treatment, but before hospital discharge, occurred in three patients treated for acutely ruptured aneurysms. Additionally, two patients treated for unruptured aneurysms experienced a first hemorrhage during follow-up. All five hemorrhages resulted from aneurysms with Raymond III residual aneurysm filling persisting after initial treatment. After 5 years follow-up, 2/626 (0.3%) patients are known to have had target aneurysm rupture following hospital discharge. The annualized rate of delayed hemorrhage after coiling was 2/398/5=0.001 (0.1%) per year for unruptured aneurysms and 0 for ruptured aneurysms., Conclusions: After 5 years Matrix 2 coils were non-inferior to BMCs but no benefit was demonstrated. Post-treatment residual angiographic aneurysm filling (Raymond III) is strongly associated with TAR (P<0.0001) and post-treatment aneurysmal hemorrhage (P=0.008)., Competing Interests: Competing interests: SWH: core lab services for Stryker and MicroVention Terumo (money paid to UCSF, over $5K); consulting for Microvention Terumo (money paid to Dr Hetts, under $5K). CGM: consultant for Medtronic and Microvention. JCC: consultant for Stryker. AB: consultant for Stryker, Microvention, Balt, and Phenox. AKW: research grant from Philips Medical; serves as a consultant for Stryker and Phenox; is a stockholder of InNeuroCo, EpiEP, Neural Analytics, Rist, Analytics 4 Life, and ThrombX; and is on the Speakers’ Bureau for SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms) presentations. AG: consultant for Microvention and emeritus consultant at Newcastle upon Tyne Hospitals NHS Trust. CFD: chief adjudicator, Stryker EVOLVE Trial Core Angiography Lab (salary support to department)., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Deployment of a Neuroform microstent (NFM; Boston Scientific/Target, Freemont, California, USA) within acutely angled geometry may result in substantial deformations. This in vitro study was conducted to validate a novel alternative technique, consisting of intentional deployment of a NFM straight on into a terminus aneurysm, by assessing the mechanics, feasibility, and stability of the coils., Methods: Silicon models of wide-neck terminus aneurysms were constructed. Straight-on deployment of a NFM from the afferent vessel into the aneurysm was compared with conventional cross-neck deployment at a right angle position followed by Guglielmi detachable coil embolization simulation. The supporting forces of the two different methods of deployment were compared by the use of side-wall eccentric and en-face compression tests., Results: Straight-on deployment of a NFM at a wide-neck terminus aneurysm was a relatively simple technique compared with cross-neck right angle deployment. Good stability of the coil mass was consistently achieved with adequate preservation of the parent vessel lumen. A larger residual neck space at the side without the stent and much coil mass protruding into the parent vessel were observed in cross-neck stent deployment. Compression tests revealed a larger supporting force of the NFM with straight-on deployment compared with the side-wall radial force (P < 0.05). A potential problem with this technique is the possible inability or difficulty in retrieving a partially deployed coil., Conclusions: Stent-assisted coiling of wide-neck terminus aneurysms with straight-on deployment of NFM consistently achieved a stable NFM-coil complex. The NFM also had a better supporting force in a straight position. Some technical difficulties may be encountered during subsequent coiling. This alternative technique to conventional cross-neck bridging appears to be another strategy for wide-neck terminus aneurysm coiling., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Silicone models of cerebral aneurysm and stroke pathology were produced by copying the images of clinical cases to evaluate the simulation of endovascular procedures. Conventional silicone models, silicone suture models made from separate aneurysm sac and parent artery sutured together, and animal vascular models made from vessels obtained from pigs were made. The models were incorporated in the training system for simulation of endovascular procedures under digital subtraction angiography control using a portable angiography system. The conventional silicone models provided very close reproduction of the aneurysm and vessels, even the fine branches. However, greater resistance or impact was felt, especially when passing the device through curved vessels. Stroke models were insufficiently dilated by percutaneous transluminal angioplasty or stenting. The silicone suture model was useful to avoid damage to models of giant aneurysm or models with small orifices during the lost wax procedure, whereas the projection of domes was somewhat inaccurate. The animal vascular model could not provide accurate aneurysm shape and vessel diameter, although the feel during manipulation was much more realistic.

To our knowledge, the use of transdermal nitroglycerin ointment (Nitropaste) in the setting of intracranial vasospasm has not been described in the peer-reviewed literature. Five patients with intracranial vasospasm induced by subarachnoid hemorrhage were evaluated angiographically both before and after application of Nitropaste. All cases exhibited mild to moderate improvement in the degree of vasospasm. We conclude that Nitropaste is a simple noninvasive technique to reduce intracranial vasospasm.

Objective and Importance: To describe the clinical presentation and endovascular management of peripheral aneurysms of the lateral posterior choroidal artery. Aneurysms in this location are exceptionally rare and optimal treatment may be difficult., Clinical Presentation: Two patients with peripheral aneurysms of the distal portion of the lateral posterior choroidal artery presented with headaches from extensive intraventricular hemorrhage., Intervention: Endovascular surgical therapy by use of superselective n-butylcyanoacrylate embolization of the aneurysm and adjacent distal parent artery was successful in both patients., Conclusion: Patients with peripheral aneurysms of the lateral posterior choroidal artery usually present with intraventricular hemorrhage. They may be difficult to treat by open surgical techniques owing to their intraventricular location and the frequent inability to preserve the parent artery by aneurysm clipping. Instead, it is typical that either proximal parent artery occlusion or aneurysm trapping must be used. An equivalent endovascular surgical technique may be an attractive alternative method of management.