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Objective: In preliminary studies, advanced intracranial stents appear to have a favorable safety profile for intracranial aneurysm treatment. This dual-center study is a head-to-head comparison of the low-profile Acandis Acclino stent (a third-generation stent) and the first- and second-generation Enterprise stent., Methods: Patients who underwent stent-assisted coiling with either the Enterprise or the Acclino stent for unruptured aneurysms during an 8-year period were enrolled and compared for complications, clinical outcomes, and angiographic results. Primary outcome measures were ischemic stroke rate and mid-term complete occlusion rate. Propensity score adjustment was performed to account for small differences between the groups., Results: Enterprise and Acclino stents were used in 48 cases each. The overall rate of thrombotic complications was higher in the Enterprise group than in the Acclino group (20.8% vs. 4.2%, HR: 6.6, 95%CI: 2.2-20.0, P = 0.01, adjusted P < 0.01), which translated into a higher rate of major ischemic stroke after Enterprise treatment (6.3% vs. 0%, HR: 2.1, 95%CI: 1.8-2.4, P = 0.08, adjusted P < 0.01). Mid-term and long-term angiographic follow-up showed complete occlusion rates of 83.3% and 75.0% for Enterprise and 89.2% and 75.9% for Acclino (both P > 0.05). Retreatment rates were 10.4% in the Enterprise group and 4.2% in the Acclino group (P = 0.42, adjusted P = 0.10)., Conclusions: The results indicate a favorable safety profile of the Acclino over the Enterprise, justifying the use of advanced stent systems in clinical practice. However, further comparative studies of the Acclino and other competing stent systems are needed to draw a definitive conclusion on the state of stent-assisted coiling., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Information about the cost-effectiveness of a certain treatment is relevant for decision-making and healthcare providers. This study compares the cost-effectiveness of the novel Woven Endobridge (WEB) for intracranial aneurysm treatment with conventional coiling and stent-assisted coiling (SAC) from the perspective of the German Statutory Health Insurance., Methods: A patient-level simulation was constructed to simulate 55-year-old patients with an unruptured middle cerebral artery aneurysm (size: 3-11 mm) considering WEB treatment, coiling or SAC in terms of morbidity, angiographic outcome, retreatment, procedural and rehabilitation costs and rupture rates. Incremental cost-effectiveness ratios (ICERs) were calculated as costs per quality-adjusted life years (QALYs) and costs per year with neurologic morbidity avoided. Uncertainty was explored with deterministic and probabilistic sensitivity analyses. The majority of data were obtained from prospective multi-center studies and meta-analyses of non-randomized studies., Results: In the base case, lifetime QALYs were 13.24 for the WEB, 12.92 for SAC and 12.68 for coiling. Lifetime costs were 20,440 € for the WEB, 23,167 € for SAC, and 8200 € for coiling. Compared to coiling, the ICER for the WEB was 21,826 €/QALY, while SAC was absolutely dominated by WEB. Probabilistic sensitivity analysis revealed that at a willingness-to-pay of ≥ 30,000 €/QALY, WEB was the preferred treatment. Deterministic sampling showed that the discount rate, material costs and retreatment rates had the largest impact on the ICERs., Conclusion: The novel WEB showed at least comparable cost-effectiveness to SAC for treatment of broad-based unruptured aneurysms. Considering all three modalities, coiling had the least costs; however this modality is often not appropriate for the treatment of wide-necked aneurysms., (© 2023. The Author(s).)

Stent-assisted coiling (SAC) for ruptured intracranial aneurysms (RIAs) remains controversial due to an inherent risk of potential thromboembolic and hemorrhagic complications. We compared SAC and coiling alone for the management of RIAs using propensity score-adjustment. Sixty-four patients treated by SAC and 220 by stand-alone coiling were retrospectively reviewed and compared using inverse probability of treatment weighting (IPTW) with propensity scores. Functional outcome, procedure-related and overall complications and angiographic results were analyzed. Aneurysms treated by SAC had a larger diameter, a wider neck and were more frequently located at the posterior circulation. SAC had a higher risk for thromboembolic complications (17.2% vs. 7.7%, p = 0.025), however, this difference did not persist in the IPTW analysis (OR 1.2, 95% CI 0.7-2.3, adjusted p = 0.458). In the adjusted analysis, rates of procedural cerebral infarction (p = 0.188), ventriculostomy-related hemorrhage (p = 0.584), in-hospital mortality (p = 0.786) and 6-month favorable functional outcome (p = 0.471) were not significantly different between the two groups. SAC yielded a higher complete occlusion (80.0% vs. 67.2%, OR 3.2, 95% CI 1.9-5.4, p < 0.001) and a lower recanalization rate (17.5% vs. 26.1%, OR 0.3, 95% CI 0.2-0.6, p < 0.001) than stand-alone coiling at 6-month follow-up. In conclusion, SAC of large and wide-necked RIAs provided higher aneurysm occlusion and similar clinical outcome, when compared to stand-alone coiling., (© 2021. The Author(s).)

Objective: Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity. The objective was to evaluate, whether specific morphological aneurysm characteristics could serve as predictive values for aSAH severity, disease-related complications and clinical outcome., Methods: A total of 453 aSAH patients (mean age: 54.9 ± 13.8 years, mean aneurysm size: 7.5 ± 3.6 mm) treated at a single center were retrospectively included. A morphometric analysis was performed based on angiographic image sets, determining aneurysm location, aneurysm size, neck width, aneurysm size ratios, aneurysm morphology and vessel size. The following outcome measures were defined: World Federation of Neurosurgical Societies (WFNS) grade 4 and 5, Fisher grade 4, vasospasm, cerebral infarction and unfavorable functional outcome., Results: Regarding morphology parameters, aneurysm neck width was an independent predictor for Fisher 4 hemorrhage (OR: 1.1, 95%CI: 1.0-1.3, p = 0.048), while dome width (OR: 0.92, 95%CI: 0.86-0.97, p = 0.005) and internal carotid artery location (OR: 2.1, 95%CI: 1.1-4.2, p = 0.028) predicted vasospasm. None of the analyzed morphological characteristics prognosticated functional outcome. Patient age (OR: 0.95, 95%CI: 0.93-0.96, p < 0.001), WFNS score (OR: 4.8, 95%CI: 2.9-8.0, p < 0.001), Fisher score (OR: 2.3, 95%CI: 1.4-3.7, p < 0.001) and cerebral infarction (OR: 4.5, 95%CI: 2.7-7.8, p < 0.001) were independently associated with unfavorable outcome., Conclusions: The findings indicate a correlation between aneurysm morphology, Fisher grade and vasospasm. Further studies will be required to reveal an independent association of aneurysm morphology with cerebral infarction and functional outcome., Competing Interests: Declaration of Competing Interest CK serves as consultant for Acandis GmbH (Pforzheim, Germany) and as proctor for MicroVention Inc./Sequent Medical (Aliso Viejo, CA, USA). The other authors declare that they have no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: Although intracranial aneurysms are increasingly treated endovascularly, microsurgical clipping has been the standard approach for middle cerebral artery (MCA) aneurysms. We compared microsurgical clipping and state-of-the-art endovascular treatment of unruptured MCA bifurcation aneurysms treated at a neurovascular center following a "coil-first" policy., Methods: This single-center study included 148 patients treated for 160 unruptured MCA bifurcation aneurysms. Technical success, complications, clinical outcome, and angiographic results were retrospectively compared., Results: Microsurgical clipping was performed for 120 MCA aneurysms (75%) and endovascular treatment for 40 (25%; conventional coiling: 8, stent-assisted coiling: 16, balloon-assisted coiling: 3, and flow-disruption: 13). Technical treatment success was higher in the clipping group (100%) than in the endovascular group (92.5%, P = 0.015). Overall, complications occurred in 16.7% for clipping and in 20.0% for endovascular treatment (P = 0.631). Major ischemic stroke rates were 4.2% in the clipping group and 7.5% in the endovascular group (P = 0.414). At 6 months, a favorable outcome was obtained by 99.2% after clipping and 95.0% after endovascular treatment (P = 0.154). The 6-month complete aneurysm occlusion rates were by trend higher in the clipping group (89.2%) than in the endovascular group (75.9%, P = 0.078)., Conclusions: Microsurgical clipping was associated with a higher technical success rate and tendentially higher complete occlusion than endovascular treatment, with no additional morbidity and similar clinical outcome. On the basis of these results, clipping proves to be the standard treatment option for MCA bifurcation aneurysms. However, endovascular treatment represents a safe and efficient alternative treatment option for patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Intrasaccular flow-disruption represents a new paradigm in endovascular treatment of wide-necked bifurcation aneurysms., Objective: To retrospectively compare Woven Endobridge (WEB) embolization with microsurgical clipping for unruptured anterior circulation aneurysms using propensity score adjustment., Methods: A total of 63 patients treated with WEB and 103 patients treated with clipping were compared based on the intention-to-treat principle. The primary outcome measures were immediate technical treatment success, major adverse events, and 6-mo complete aneurysm occlusion., Results: The technical success rates were 83% for WEB and 100% for clipping. Procedure-related complications occurred more often in the clipping group (13%) than the WEB group (6%, adjusted P < .01). However, the rates of major adverse events were comparable in both groups (WEB: 3%, clip: 4%, adjusted P = .53). At the 6-mo follow-up, favorable functional outcomes were achieved in 98% of the WEB embolization group and 99% of the clipping group (adjusted P = .19). Six-month complete aneurysm occlusion was obtained in 75% of the WEB group and 94% of the clipping group (adjusted P < .01)., Conclusion: Microsurgical clipping was associated with higher technical success and complete occlusion rates, whereas WEB had a lower complication rate. Favorable functional outcomes were achieved in ≥98% of both groups. The decision to use a specific treatment modality should be made on an individual basis and in accordance with the patient's preferences., (© Congress of Neurological Surgeons 2020.)

Background: The "weekend effect" describes the assumption that weekend and/or on-call duty admission of emergency patients is associated with increased morbidity and mortality rates. For aneurysmal subarachnoid hemorrhage, we investigated, whether presentation out of regular working hours and microsurgical clipping at nighttime correlates with worse patient outcome., Methods: This is a retrospective review of consecutive patients that underwent microsurgical clipping of an acutely ruptured aneurysm at our institution between 2010 and 2019. Patients admitted during (1) regular working hours (Monday-Friday, 08:00-17:59) and (2) on-call duty and microsurgical clipping performed during (a) daytime (Monday-Sunday, 08:00-17:59) and (b) nighttime were compared regarding the following outcome parameters: operation time, treatment-related complications, vasospasm, functional outcome, and angiographic results., Results: Among 157 enrolled patients, 104 patients (66.2%) were admitted during on-call duty and 48 operations (30.6%) were performed at nighttime. Admission out of regular hours did not affect cerebral infarction (p = 0.545), mortality (p = 0.343), functional outcome (p = 0.178), and aneurysm occlusion (p = 0.689). Microsurgical clipping at nighttime carried higher odds of unfavorable outcome at discharge (OR: 2.3, 95%CI: 1.0-5.1, p = 0.039); however, there were no significant differences regarding the remaining outcome parameters. After multivariable adjustment, clipping at nighttime did not remain as independent prognosticator of short-term outcome (OR: 2.1, 95%CI: 0.7-6.2, p = 0.169)., Conclusions: Admission out of regular working hours and clipping at nighttime were not independently associated with poor outcome. The adherence to standardized treatment protocols might mitigate the "weekend effect."

Objective: Cerebral infarction is a significant cause of morbidity and mortality related to microsurgical clipping of intracranial aneurysms. The objective of this study was to determine the impact of aneurysm shape and neck configuration on cerebral infarction after aneurysm surgery., Methods: The authors retrospectively reviewed consecutive cases of ruptured and unruptured aneurysms treated with microsurgical clipping at their institution between 2010 and 2018. Three-dimensional reconstructions from preoperative computed tomography and digital subtraction angiography were used to determine aneurysm shape (regular/complex) and neck configuration (regular/irregular). Morphological and procedure-related risk factors for cerebral infarction were identified using univariate and multivariate statistical analyses., Results: Among 243 patients with 252 aneurysms (148 ruptured, 104 unruptured), the overall cerebral infarction rate was 17.1%. Infarction tended to occur more often in aneurysms with complex shape (p = 0.084). Likewise, aneurysms with an irregular neck had a significantly higher rate of infarction (37.5%) than aneurysms with regular neck configuration (10.1%, p < 0.001). Aneurysms with an irregular neck were associated with a higher rate of intraoperative rupture (p = 0.003) and temporary parent artery occlusion (p = 0.037). In the multivariate analysis, irregular neck configuration was identified as an independent risk factor for infarction (OR 4.2, 95% CI 1.9-9.4, p < 0.001), whereas the association between aneurysm shape and infarction was not significant (p = 0.966)., Conclusions: Irregular aneurysm neck configuration represents an independent risk factor for cerebral infarction during microsurgical clipping of both ruptured and unruptured aneurysms.

Objective: Indocyanine green (ICG) videoangiography (VAG) is an established method for assessment of cerebral blood flow during microsurgical clipping of intracranial aneurysms. FLOW 800 is a surgical microscope-integrated software program that shows the cerebral blood flow in color-coded maps, thus providing semi-quantitative and real-time analysis of ICG data. We aimed to establish reference values for FLOW 800 parameters before and after microsurgical clipping of intracranial aneurysms and to evaluate the potential of FLOW 800 to guide intraoperative decisions., Methods: We retrospectively reviewed 54 patients (mean age, 53.6 ± 11.6 years) who underwent microsurgical clipping for 60 aneurysms and intraoperative evaluation of ICG fluorescence dynamics using FLOW 800 color-coded maps. FLOW 800 data were correlated with patient characteristics, clinical outcomes, and intraoperative decision making., Results: There were no significant differences in FLOW 800 data between ruptured and unruptured aneurysms (P > 0.05). Likewise, the hemodynamic parameters were not significantly different before and after definite clip placement (P > 0.05). However, in 2 cases, analysis of transit times by FLOW 800 analysis showed a hemodynamically significant clip stenosis that might have been missed by conventional ICG-VAG and resulted in adjustment of the clip position. Overall, there was 1 cerebral infarction, which was not related to clip placement., Conclusions: FLOW 800 is a useful adjunct to ICG-VAG for intraoperative assessment of cerebral perfusion and may help to identify hemodynamically relevant clip stenosis. The beneficial impact of FLOW 800 on clinical outcome after microsurgical clipping needs to be confirmed by comparative studies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Previous studies have indicated that lobulated aneurysms are more susceptible to rupture than are single-sac aneurysms. We aimed to determine the angiographic characteristics related to the lobulated shape of unruptured intracranial aneurysms (UIAs) and ruptured (RIAs) intracranial aneurysms., Methods: This is a retrospective analysis of consecutive patients with UIAs (n = 143) and RIAs (n = 190) who underwent digital subtraction angiography at our institution between 2010 and 2017. Patient and aneurysm characteristics were compared between lobulated and regular single-sac aneurysms., Results: Patients with lobulated UIAs were significantly older than were patients with regular aneurysms (56.5 ± 10.7 years vs. 49.3 ± 13.0 years; P = 0.003). In the multivariate analysis, lobulated morphology was significantly related to bifurcation location (69.5% vs. 27.3%; odds ratio [OR], 3.0, 95% confidence interval [CI], 1.2-7.5; P = 0.019), aneurysm size (8.1 ± 3.2 mm vs. 4.9 ± 3.0 mm; OR, 5.4; 95% CI, 1.7-17.8; P = 0.005), and inflow angle (145 ± 27° vs. 114 ± 27°; OR, 2.8; 95% CI, 1.1-7.2; P = 0.031). Bifurcation location (P = 0.031) and larger aneurysm size (P < 0.001) were confirmed as independent characteristics for lobulation in the RIA group. Compared with regular aneurysms, lobulated UIAs were more often allocated to treatment (86.6% vs. 60.3%; P < 0.001) and treated by microsurgical clipping (39.4% vs. 16.4%; P = 0.002)., Conclusions: Bifurcation location, an increased aneurysm size, and a straighter aneurysm inflow angle are independently associated with lobulated aneurysms., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Subarachnoid hemorrhage (SAH) can be associated with a degree of resulting brain damage and subsequent reorganization of the central nervous system. The aim of this study was to evaluate complication rates and clinical outcome in patients with a previous SAH who were treated for a recurrent or an additional, initially unruptured aneurysm., Methods: A retrospective single-center study was conducted for patients who underwent elective treatment by surgical or endovascular means between 2010 and 2018. We compared patients with a previous SAH and without history of SAH in terms of complication rates and functional outcomes (modified Rankin Scale [mRS])., Results: The study population consisted of 337 patients (non-SAH, 270; SAH, 67) who underwent 390 elective procedures for treatment of 443 aneurysms. Procedure-related complications occurred in 13.5% of patients with a previous SAH and in 13.3% of patients without SAH (P = 1.0). At the 6-month follow-up, the morbidity (defined as any increase on the mRS) was comparable between the SAH group (6.7%) and the non-SAH group (7.6%; P = 0.5). Overall favorable outcome (mRS score ≤2) was achieved by 96.6% in the SAH group and 97.3% in the non-SAH group (P = 1.0). Also, in patients with a previous SAH, the choice of clipping or endovascular treatment did not have a significant impact on clinical outcome at the 6-month follow-up., Conclusions: Treatment of recurrent or additional aneurysms in patients with a previous SAH can be performed with acceptable complication rates and morbidity by either surgical or endovascular means., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Microsurgical clipping of aneurysms demands precise spatial understanding of aneurysm morphology and vascular geometry. We analyzed the impact of preoperative three-dimensional (3D) angiographic imaging on clinical and angiographic outcome after clipping of ruptured intracranial aneurysms., Methods: This is a retrospective analysis of consecutive patients who underwent microsurgical clipping during the acute phase of subarachnoid hemorrhage between 2010 and 2017. Surgical planning was made based on two-dimensional (2D) or 3D angiographic images. We retrospectively compared complication rates, morbidity, and angiographic outcome between these 2 groups., Results: A total of 157 patients (mean age: 54.8 ± 13.1 years) were included in the study. Preoperative 3D angiographic imaging was available for 117 cases. The rate of procedure-related ischemia was significantly lower in the 3D group (16.2%) than in the 2D group (35.0%; P = 0.013). In the multivariate analysis, 2D imaging alone remained as independent factor for subsequent brain ischemia (odds ratio: 2.8, 95% confidence interval 1.2-6.6; P = 0.018). Favorable outcome (modified Rankin scale ≤2) was more often attained in the 3D group (70.0%) than in the 2D group (41.9%; P = 0.002). The rate of complete aneurysm occlusion was not significantly different between the 2 groups (P = 0.967)., Conclusions: In our study, accurate operation planning using 3D angiography was associated with a lower ischemic complication rate after clipping of ruptured intracranial aneurysms, which may potentially influence clinical outcome., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Complex aneurysm shape is a predominant risk factor for aneurysm rupture but its impact on clinical outcome after clipping remains unclear. The objective of the present study was to compare complications and morbidity after clipping of unruptured single-sac aneurysms (SSAs) and aneurysms with multiple sacs (MSAs)., Methods: A retrospective, single-center study was conducted for patients that were treated between 2010 and 2018. We analyzed surgical parameters, treatment-related complications, and morbidity, defined as any increase in the modified Rankin scale at 3-month follow-up., Results: We identified 101 patients (mean age: 52.9 ± 10.5 years) that underwent clipping for 57 SSAs and 44 MSAs. The two groups were comparable regarding aneurysm size and neck width. Clipping of MSAs was associated with a longer operation time (p = 0.008) and increased use of intraoperative indocyanine green (p = 0.016) than SSAs. Complications occurred more often in the MSA group (29.5%) than in the SSA group (14.0%; p = 0.057). Morbidity was significantly higher in the MSA group (20.5%) than in the SSA group (3.5%, p = 0.009). In the univariate analysis, the odds of morbidity were 7.1 times greater for MSAs than for SSAs (95% CI 1.4-34.7)., Conclusions: Morbidity after microsurgical clipping is significantly increased in MSAs as compared to SSAs. This may be attributed to a more difficult clip placement with stronger manipulation of the aneurysm dome and the surrounding brain tissue.

Objective: Irregular shape is a known risk factor of intracranial aneurysm rupture causing subarachnoid hemorrhage. The objective of this study was to determine the impact of aneurysm shape on intraoperative rupture (IOR) during microsurgical clipping of ruptured aneurysms., Methods: This is a retrospective, single-center study of consecutive patients that underwent clipping between 2010 and 2017. Based on 3-dimensional reconstructions from preoperative computed tomography scan and digital subtraction angiography, aneurysm shape was classified as regular aneurysm (RA) or irregular aneurysm (IRA). Risk factors for IOR were identified using univariate and multivariate statistical analyses., Results: A total of 138 patients with 32 RAs and 102 IRAs were included in the analysis. IRAs had a larger size than RAs (8.3 ± 3.5 vs. 4.6 ± 2.3 mm, respectively; P < 0.001). There were 36 instances of IOR (26.1%). The IOR rate was greater in IRAs than in RAs (31.1% vs. 9.4%, respectively; P = 0.02). In multivariate analysis, IRA shape was the only significant independent risk factor for IOR (odds ratio, 3.9; 95% confidence interval, 1.0-14.6; P = 0.047). Unfavorable outcome (modified Rankin scale score greater than 2) was not significantly associated with aneurysm shape (P = 0.998) and IOR (P = 0.260)., Conclusions: Our results demonstrate that IRA shape is an independent risk factor for IOR. In the analyzed patient cohort, aneurysm shape and IOR had no significant impact on patient prognosis., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Intracranial infectious aneurysms (IIAs) are a rare clinical entity without a definitive treatment guideline. In this study, we evaluate the treatment options of these lesions based on our own clinical experience and review the current knowledge of therapy as portrayed in the literature., Methods: We conducted a single-center retrospective analysis of all patients with an IIA and performed a systematic review of the literature using the MEDLINE database. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950-October 2015) using the following keywords (in combination): 'infectious', 'mycotic', 'cerebral aneurysm', 'intracranial aneurysm'. 1,721 potentially relevant abstracts were identified and 63 studies were selected for full review. The studies were analysed regarding ruptured versus unruptured aneurysms, aneurysm localization and treatment, as well as clinical and radiological outcome., Results: Our institutional series consisted of 6 patients (median age 57 [32-76]) treated between 2011 and 2015. All patients presented with ruptured IIAs located on the middle cerebral artery (MCA, 5 patients) and anterior cerebral artery (ACA, 1 patient). Five patients were treated by clipping and resecting the aneurysm, 1 patient underwent coiling. All patients received antibiotic therapy and 1 patient died. We further identified 814 patients (median age 35.5 [0-81]) in 63 studies. Locations of the aneurysms were mentioned in 55 studies. The most frequent locations of the aneurysms were: MCA (63.5%), posterior cerebral artery (14%), ACA (9.0%) and others (13.5%). Treatment for IIAs was described in 62 studies: antibiotic treatment (56.1%), a combination of antibiotics and surgery (20.9%) or antibiotics and endovascular treatment (23.0%). Outcome was mentioned in 82.4% of the patients with a mortality rate of 16.8%. An evaluation of treatment outcome was limited due to the heterogeneity of patients in the published case series., Conclusion: Antibiotic therapy of patients with IIA is mandatory. However, due to the complexity of the disease and its accompanying comorbidities, a general treatment algorithm could not be defined. Analogous to non-mycotic aneurysms, further treatment decisions require an interdisciplinary approach involving neurosurgeons, interventionists and infectious disease specialists., (© 2016 S. Karger AG, Basel.)