SUMMARY:The goal of this study was to evaluate the feasibility and efficacy of A1 occlusion at the level of wide necked A1 aneurysms, where there are bilateral patent A1 segments and a patent AcomA. Between 2000 and 2010, 9 patients with wide necked A1 aneurysms were treated by coiling of the aneurysm along with parent vessel occlusion. All aneurysms had a wide neck (Ն4mm). None were treated in the acute phase of a subarachnoid hemorrhage. Three small infarcts were noted on routine post-treatment head CT, 1 of which was symptomatic (transient hemiparesthesia). On control angiogram at 6 months or more, 3 A1 recanalizations were found, 2 of which had a stable small neck recurrence. None of the aneurysms ruptured on follow-up. In this series, parent artery occlusion was effective in treating wide-necked aneurysms arising from the A1 segment in patients with adequate collateral supply.ABBREVIATIONS: A1 ϭ the first segment of the ACA up to the AcomA; A2 ϭ the second segment of the ACA from the AcomA to the genu of the corpus callosum; ACA ϭ anterior cerebral artery; AcomA ϭ anterior communicating artery; c ϭ coiling; Dist ϭ distal third of the A1; DSA ϭ digital subtraction angiography; EVT ϭ endovascular treatment; FU ϭ follow-up; L ϭ left; MD ϭ maximum diameter; Mid ϭ middle third of the A1; MRA ϭ MR angiography; N ϭ neck; OD ϭ oculi dexter (right eye); Prox ϭ proximal third of the A1; R ϭ right; RAH ϭ recurrent artery of Heubner; s ϭ surgery; SAH ϭ subarachnoid hemorrhage P roximal ACA (A1) aneurysms are rare, accounting for 0.8%-3.4% of intracranial aneurysms.1-3 Wide-neck aneurysms, not only those located at A1, can be challenging to treat selectively by using an endovascular approach, and recurrences are more frequent even if treatment is successful. 4 When the patient has adequate collateral vessel pathways (a patent AcomA with an A1 segment on both sides), occlusion of the A1 segment at the level of the aneurysm may be considered. Materials and MethodsWe studied all patients with ACA aneurysms included in our data base and treated by endovascular methods during a 10-year period (January 2000 to January 2010). From this list, all patients treated for an A1 aneurysm by using parent vessel occlusion were selected for a systematic medical record and imaging review.The decision to occlude the parent vessel was always an a priori decision and was made after demonstration of collateral supply of the ACA by the contralateral carotid artery, by using manual compression or balloon-test occlusion. The parent vessel occlusion was never the result of a periprocedural complication.Our strategy consisted of coiling the aneurysm tightly and letting the coils bulge through the neck. Parent vessel occlusion was completed with coils when necessary, with the intention of keeping the occlusion as short as possible. All the procedures were performed with the patient under heparin administration to reach 3 times the baseline of anticoagulation time.With time, our policy regarding antiplatelet therapy changed. We are now administerin...

Background: Unruptured intracranial aneurysms (UIAs) are treated using endovascular treatment or microsurgical clipping. The safety and efficacy of treatments have not been compared in a randomized trial. Methods: We randomly allocated clipping or coiling to patients with 3-25mm UIAs judged treatable both ways. The primary outcome was treatment failure, defined as: initial failure of aneurysm treatment, intracranial hemorrhage or residual aneurysm on one year imaging. Secondary outcomes included neurological deficits following treatment, hospitalization >5 days, overall morbidity and mortality and angiographic results at one year. Results: 136 patients were enrolled from 2010 through 2016 and 134 patients were treated. The one-year primary outcome, available for 104 patients, was reached in 5/48 (10.4% (4.5%-22.2%)) patients allocated surgical clipping, and 10/56 (17.9% (10.0%-29.8%)) patients allocated endovascular coiling (OR: 0.54 (0.13, 1.90), P=0.40). Morbidity and mortality (mRS>2) at one year occurred in 2/48 (4.2% (1.2%-14.0%)) and 2/56 (3.6% (1.0%-12.1%)) patients allocated clipping and coiling respectively. New neurological deficits (15/65 vs 6/69; OR: 3.12 (1.05, 10.57), P=0.031), and hospitalizations beyond 5 days (30/65 vs 6/69; OR: 8.85 (3.22,28.59), P=0.0001) were more frequent after clipping. Conclusions: Surgical clipping led to greater initial treatment-related morbidity than endovascular coiling. At one year, the superior efficacy of clipping remains unproven and in need of randomized evidence.

Background: Flow diverters (FDs) are increasingly used for bifurcation aneurysms. Failure of aneurysm occlusion may be caused by residual flow maintaining patency of the jailed branch along with the aneurysm. Methods: Sixteen wide-necked lingual-carotid artery bifurcation aneurysms were created in 8 canines. Patent aneurysms were randomly allocated 4 weeks later to flow diversion combined with jailed branch occlusion using coils and/or Onyx (n=6) or flow diversion alone (n=8). Angiographic results of aneurysm occlusion at three months were scored using an ordinal scale. Pathology specimens were photographed and neointimal coverage estimated. Results: Fourteen aneurysms were patent at one month. FD deployment was successful in all cases, but at 3 month follow-up, 3 devices had prolapsed into the aneurysm. None of the bifurcation aneurysms treated with FD alone were occluded at 3 months. Endovascular branch occlusion combined with flow diversion significantly improved aneurysm occlusion rates (median angiographic score of 2) compared to flow diversion alone (median score of 0: P=0.0137). Flow-limiting parent vessel stenosis was not observed in any arteries. Devices were covered with thick neointima in most cases. Conclusions: Treatment failures following flow diversion of bifurcation aneurysms can be caused by persistent flow to the jailed branch. Branch occlusion combined with flow diversion may improve angiographic occlusion of canine aneurysms.

Background: The Flow diversion in the treatment of Intracranial Aneurysm (FIAT) trial was designed to guide the clinical use of flow diversion. Methods: FIAT proposed randomized allocation flow diversion or standard management (observation, coiling, parent vessel occlusion, or clipping), and a registry of non-randomized patients treated with flow diversion. Primary safety outcome was death or dependency (mRS > 2) at 3 months. Primary efficacy outcome was angiographic occlusion at 3-12 months combined with independent clinical outcome. Results: Of 112 participating patients recruited, 78 were randomized, and 34 received flow diversion within the registry. The study was halted for safety concerns. Twelve of 73 patients (16.4%; CI [9.7% -26.7%]) who were allocated or received flow diversion at any time were dead (n=8) or dependent (n=4) at 3 months or more, crossing a predefined safety boundary. Death or dependency occurred in 5 of 36 patients randomly allocated flow diversion and in 5 of 36 patients allocated standard treatment (13.9%; [6.1%-28.7%]). Efficacy was below hypothesized expectations: 15 of 36 patients (41.7%; [27.1%-57.8%]) randomly allocated flow diversion failed to reach the primary outcome, as compared to 11 of 36 patients allocated standard treatment (30.1%; [18.0%-46.9%]). Conclusions: Flow diversion was not as safe and effective as hypothesized. More randomized trials are needed.

Background: A significant proportion of glioblastoma multiforme (GBM) patients are considered for repeat resection, but evidence regarding best management remains elusive. Methods: An electronic portfolio of MR images of 37 cases of pathologically confirmed recurrent GBM with an accompanying clinical vignette was constructed. Surgical responders from various countries, training backgrounds, and years’ experience were asked for each case to select: their chosen management (repeat surgery, chemotherapy, radiation, or conservative), confidence in recommended management, and whether they would include the patient in a randomized trial that gave a 50% chance of re-operation. Responses were evaluated with kappa statistics and values interpreted according to Landis and Koch (0–0.2, slight; 0.21–0.4, fair; 0.41–0.6, moderate; 0.61–0.8, substantial; 0.81-1.0 perfect agreement). Results: 26 surgeons responded to the survey. Agreement regarding best management of recurrent GBM was slight, even when management options were dichotomized (repeat surgery vs. all others) (k=0.198 (95%CI 0.133-0.276). Country of practice, years’ experience, and training background did not improve agreement. Responders were willing to include more than 70% of patients in a randomized trial. Conclusions: Only slight agreement exists regarding the question of re-operation for patients with recurrent GBM. This supports the need for a randomized controlled trial.