Long term follow-up after endovascular treatment for intracranial aneurysms. Bart Emmer, MD, PhD
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1 Long term follow-up after endovascular treatment for intracranial aneurysms Bart Emmer, MD, PhD
2 Coiling 2
3 International Subarachnoid Aneurysm Trial Molyneux et al. Lancet Oct
4 Clipping vs Coiling Coiling Trombo-embolism Perforation (rupture) Vessel damage Parent vessel occlusion Recurrence Clipping Infection Hemorrhage (rupture) Brain tissue damage Side branch occlusion
5 Figure. Kaplan Meier survival curves of nonprocedural rerupture after various degrees of aneurysm occlusion: complete (solid line), small residual neck (long dash), residual neck (dash), and incomplete occlusion (dot-dash). S. Claiborne Johnston et al. Stroke. 2008;39: Copyright American Heart Association, Inc. All rights reserved.
6 Recanalization - migration - growth
7 Follow Up EMC Coiling MRI 6 mnth MRI 18 mnth MRI 36 mnth No residue No residue No residue End Control
8 Riskfactors recurrence Raymond et al. Stroke 2003
9 Riskfactors recurrence Raymond et al. Stroke 2003
10 Modified Raymond Roy Classification (MRRC). Justin R Mascitelli et al. J NeuroIntervent Surg 2015;7: Copyright Society of NeuroInterventional Surgery. All rights reserved.
11 Nomenclature EMC Irregularity Neckremnant Recanalisation Neckremnant
12 Proposed follow-up scheme adapted to the occlusion grade. Sebastien Soize et al. Stroke. 2016;47: Copyright American Heart Association, Inc. All rights reserved.
13 Figure 2. Forest plot proportion of reopening (percent) in studies reporting reopening. Sandra P. Ferns et al. Stroke. 2009;40:e523-e529 Copyright American Heart Association, Inc. All rights reserved.
14 Figure 3. Regression analysis: reopening and retreatment rates in increasing proportions aneurysm size >10 mm. Sandra P. Ferns et al. Stroke. 2009;40:e523-e529 Copyright American Heart Association, Inc. All rights reserved.
15 Recurrence in Coiling Short term (up to 3y) after EVT 20% reopening necessitating retreatment in about half of them Long term follow up of coiling now available
16 A 27-year-old woman with late reopening and retreatment of unruptured left internal carotid artery tip aneurysm. Sandra P. Ferns et al. Stroke. 2011;42: Copyright American Heart Association, Inc. All rights reserved.
17 Late Reopening of Adequately Coiled Intracranial Aneurysms Frequency and Risk Factors in 400 Patients With 440 Aneurysms Ferns et al. Stroke May 2011
18 Late Reopening of Adequately Coiled Intracranial Aneurysms Frequency and Risk Factors in 400 Patients With 440 Aneurysms Ferns et al. Stroke May 2011
19 Barrow Ruptured Aneurysm Trial (BRAT) Spetzler et al. J Neurosurg 2015 Sep; 123(3)
20 Late follow-up >10 y Prospective 10 y after EVT 129 aneurysms 12,4 % late recurrence 6, 4 % recurrence despite Grade I Raymond Score Lecler Radiology 2015
21 Lecler Radiology 2015
22 Late Follow-Up >10 Y Riskfactor: Grade II Raymond score >10 mm De novo aneurysms in 4,1% after 10 years Lecler Radiology 2015
23 Recurrence in Coiling Short term (up to 3y) after EVT 20% reopening Retreatment in about half of them Late re-opening occurs. What are the consequences?
24 Barrow Ruptured Aneurysm Trial (BRAT) 6 year Spetzler et al. J Neurosurg 2015 Sep; 123(3)
25 Figure 2. Survival analysis of index aneurysm retreatment after surgical clipping (dashed line, n=711) and endovascular coil embolization (solid line, n=299). The CARAT Investigators* Stroke. 2006;37: Copyright American Heart Association, Inc. All rights reserved.
26 Recurrence in Coiling Short term (up to 3y) after EVT 20% reopening Retreatment in about half of them Late re-opening occurs. This leads to more retreatment What about late rebleed?
27 Figure 1. Survival analysis of nonprocedural rerupture after surgical clipping (dashed line, n=711) and endovascular coil embolization (solid line, n=299). The CARAT Investigators* Stroke. 2006;37: Copyright American Heart Association, Inc. All rights reserved.
28 Figure 1. Kaplan-Meier plot of cumulative risk of rebleeding from target (treated) aneurysm later than 1 year after subarachnoid haemorrhage Andrew J Molyneux, Jacqueline Birks, Alison Clarke, Mary Sneade, Richard S C Kerr The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT) null, Volume 385, Issue 9969, 2015,
29
30 Recurrence in Coiling Short term (up to 3y) after EVT 20% reopening Retreatment in about half of them Late re-opening occurs. This leads to more retreatment Late rebleed is rare What about long term outcome?
31
32 Recurrence in Coiling Short term (up to 3y) after EVT 20% reopening Retreatment in about half of them Late re-opening occurs. This leads to more retreatment Late rebleed is rare 10 year outcome still in favor of coiling Long term (>5y) follow-up cost-effective?
33 Follow Up EMC? Coiling MRI 6 mnth MRI 18 mnth MRI 36 mnth No Residue No Residue No Residue 10, 15,20 and 25 years?
Endovascular treatment with coils has become an established
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Clinical trial registration no.: NCT (clinicaltrials.gov) https://thejns.org/doi/abs/ / jns161301
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