Search

Background: In patients with mild strokes the risk-benefit ratio of endovascular treatment (EVT) for tandem lesions has yet to be evaluated outside of current guideline recommendations. This study investigates the frequency as well as procedural and safety outcomes in daily clinical practice., Methods: Using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) we analyzed patients with anterior circulation stroke due to tandem-lesions and mild deficits. These patients were defined as ≤5 on the National Institutes of Health Stroke Scale (NIHSS). Recanalization was assessed with the modified Thrombolysis in Cerebral Infarction Scale (mTICI). Early neurological and long-term functional outcomes were assessed with the NIHSS change and modified Rankin scale (mRS), respectively. Safety assessment included periprocedural complications and the rate of symptomatic intracerebral hemorrhage (sICH)., Results: A total of 61 patients met the inclusion criteria and were treated endovascularly for tandem lesions. The median age was 68 (IQR:59-76) and 32.9% (20) were female. Patients were admitted to the hospital with a median NIHSS score of 4 (IQR:2-5) and a median Alberta Stroke Programme Early CT Score (ASPECTS) of 9 (IQR:8-10). Successful recanalization (mTICI 2b-3) was observed in 86.9% (53). NIHSS decreased non-significantly (p=0.382) from baseline to two points (IQR:1-9) at discharge. Excellent (mRS≤1) and favorable (mRS≤2) long-term functional outcome at 90-days was 55.8% (29) and 69.2% (36), respectively. Mortality rates at 90-days were 9.6% (5) and sICH occurred in 8.2% (5)., Conclusions: EVT for tandem lesions in patients with mild anterior circulation stroke appears to be feasible but may lead to increased rates of sICH. Further studies comparing endovascular with best medical treatment (BMT) especially investigating the risk of periprocedural hemorrhagic complications, are needed., Competing Interests: Competing interests: J. Fiehler: research support from the German Ministry of Science and Education (BMBF), German Ministry of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions-/Förderbank (IFB), Medtronic, Microvention, Philips, Stryker; consultancy appointments; Acandis, Bayer, Boehringer Ingelheim, Cerenovus, Covidien, Evasc Neurovascular, MD Clinicals, Medtronic, Medina, Microvention, Penumbra, Route92, Stryker, Transverse Medical; stock holdings for Tegus, JNIS Associate Editor.F. Dorn: Associate Editor for JNIS and JCM; Research funding from Cerenovus/ Johnson&Johnson; Consulting for Cerenovus, Balt, Cerus Endovascular; Speaker, Acandis, Stryker; Payment for expert testimony for Cerenovus; Advisory Board Cerenovus.T. Faizy: Eppdata GmbH; German Research Foundation Scholarship Grant.L. Meyer: Compensation as a speaker for Balt Prime.G. Broocks: Compensation as a speaker for Balt PrimeL. Kellert: AstraZeneca, Bayer Vital, Boehringer Ingelheim, Bristol-Meyer-Squibb, Daiichi Sankyo, and Pfizer K. Feil: Intramurale AKF Förderung UKT; Böhringer Ingelheim LEXI; Pfizer.H. Kniep: Permanent consultant with Eppdata GmbH, Hamburg, Germany; Anonymous funding for participating at ESMINT congress 2022 (travel, accommodation).G. Thomalla: EU: TENSION trial, EU: PRECIOUS trial, German Innovation Fund: StroCare, Acandis, Stryker, Alexion, Amarin, Bayer, Boehringer Ingelheim BristolMyersSquibb/Pfizer, Daiichi Sankyo, ESO board of directors, DGN guideline writing group, (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: Acute ischemic stroke due to basilar artery occlusion (BAO) causes the most severe strokes and has a poor prognosis. Data regarding efficacy of endovascular thrombectomy in BAO are sparse. Therefore, in this study, we performed an analysis of the therapy of patients with BAO in routine clinical practice., Methods: Patients enrolled between June 2015 and December 2019 in the German Stroke Registry-Endovascular Treatment (GSR-ET) were analyzed. Primary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3), substantial neurological improvement (≥8-point National Institute of Health Stroke Scale [NIHSS] score reduction from admission to discharge or NIHSS score at discharge ≤1), and good functional outcome at 3 months (modified Rankin Scale [mRS] score of 0-2)., Results: Out of 6635 GSR-ET patients, 640 (9.6%) patients (age 72.2 ± 13.3, 43.3% female) experienced BAO (median [interquartile range] NIHSS score 17 [8, 27]). Successful reperfusion was achieved in 88.4%. Substantial neurological improvement at discharge was reached by 45.5%. At 3-month follow-up, good clinical outcome was observed in 31.1% of patients and the mortality rate was 39.2%. Analysis of mTICI3 versus mTICI2b groups showed considerable better outcome in those with mTICI3 (38.9% vs. 24.4%; p = 0.005). The strongest predictors of good functional outcome were intravenous thrombolysis (IVT) treatment (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.76-5.23) and successful reperfusion (OR 4.92, 95% CI 1.15-21.11), while the effect of time between symptom onset and reperfusion seemed to be small., Conclusions: Acute reperfusion strategies in BAO are common in daily practice and can achieve good rates of successful reperfusion, neurological improvement and good functional outcome. Our data suggest that, in addition to IVT treatment, successful and, in particular, complete reperfusion (mTICI3) strongly predicts good outcome, while time from symptom onset seemed to have a lower impact., (© 2023 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Background: Endovascular treatment (ET) in orally anticoagulated (OAC) patients has not been evaluated in randomized clinical trials and data regarding this issue are sparse., Methods: We analyzed data from the German Stroke Registry-Endovascular Treatment (GSR-ET; NCT03356392, date of registration: 22 Nov 2017). The primary outcomes were successful reperfusion defined as modified thrombolysis in cerebral infarction (mTICI 2b-3), good outcome at 3 months (modified Rankin scale [mRS] 0-2 or back to baseline), and intracranial hemorrhage (ICH) on follow-up imaging at 24 h analyzed by unadjusted univariate and adjusted binary logistic regression analysis. Additionally, we analyzed mortality at 3 months with adjusted binary logistic regression analysis., Results: Out of 6173 patients, there were 1306 (21.2%) OAC patients, 479 (7.8%) with vitamin K antagonists (VKA) and 827 (13.4%) with non-vitamin K antagonist oral anticoagulation (NOAC). The control group consisted of 4867 (78.8%) non-OAC patients. ET efficacy with the rates of mTICI 2b-3 was similar among the three groups (85.6%, 85.3% vs 84.3%, p = 0.93 and 1). On day 90, good outcome was less frequent in OAC patients (27.8%, 27.9% vs 39.5%, p < 0.005 and < 0.005). OAC status was not associated with ICH at 24 h (NOAC: odd's ratio [OR] 0.89, 95% confidence interval [CI] 0.67-1.20; VKA: OR 1.04, CI 0.75-1.46). Binary logistic regression analysis revealed no influence of OAC status on good outcome at 3 months (NOAC: OR 1.25, CI 0.99-1.59; VKA: OR 1.18, CI 0.89-1.56) and mortality at 3 months (NOAC: OR 1.03, CI 0.81-1.30; VKA: OR 1.04, CI 0.78-1.1.37)., Conclusions: ET can be performed safely and successfully in LVO stroke patients treated with OAC. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov . Unique identifier: NCT03356392.

[Figure: see text].

Background and Purpose: Up to 30% of infective endocarditis (IE) patients have ischemic stroke as a complication. Standard treatment with mechanical thrombectomy (MT) with or without intravenous thrombolysis for large vessel occlusion (LVO) has not been evaluated formally in these patients., Methods: Patients enrolled in the German Stroke Registry-Endovascular Treatment (GSR-ET) between June 2015 and December 2019 were analyzed. Patients with stroke due to IE and patients with cardioembolic stroke and atrial fibrillation (AF) were compared using propensity score matching. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction score = 2b-3. Modified Rankin Scale (mRS) = 0-2 at 3 months indicated good outcome., Results: Of 6635 patients, 55 patients (age = 69.0 ± 13.3 years, 43.6% female, median premorbid mRS (pmRS) = 1, interquartile range [IQR] = 0-1, National Institutes of Health Stroke Scale [NIHSS] = 15, IQR = 10-21) presented with septic embolic stroke due to IE and were compared to 104 patients (age = 66.5 ± 13.4 years, 39.4% female, pmRS = 0, IQR = 0-2, NIHSS = 16, IQR = 10-20) with cardioembolic stroke due to AF. Successful recanalization was achieved in 74.5% of endocarditis patients compared to 87.5% of controls (p = 0.039). Intracranial hemorrhage rates were comparable (30.9% vs. 21.6%, p = 0.175). Good functional outcome was 20.0% in patients with IE compared to 43.3% in matched patients (p = 0.006), with a significantly higher mortality (60.0% vs. 28.8%, p < 0.001). IE was strongly associated with poor outcome (odds ratio [OR] = 0.32, 95% confidence interval [CI] = 0.11-0.87, p = 0.03 for good outcome) and mortality (OR = 4.49, 95% CI = 1.80-10.68, p = 0.001)., Conclusions: Although MT results in high successful recanalization rates with acceptable safety profile, patients with LVO stroke due to IE have poor outcome., (© 2020 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Aim: In acute large vessel occlusions, endovascular therapy (EVT) achieves flow restoration in the majority of cases; however, EVT fails to achieve sufficient reperfusion in a substantial minority of patients. This study aimed to identify predictors of failed reperfusion., Methods: In this study 2211 patients from the German Stroke Registry who received EVT for anterior circulation stroke were retrospectively analyzed. Failure of reperfusion was defined as thrombolysis in cerebral infarction (TICI) grades 0/1/2a, and sufficient reperfusion as TICI 2b/3. In 1629 patients with complete datasets, associations between failure of reperfusion and baseline clinical data, comorbidities, location of occlusion, and procedural data were assessed with multiple logistic regression., Results: Failure of reperfusion occurred in 371 patients (16.8%) and was associated with the following locations of occlusion: cervical internal carotid artery (ICA, adjusted odds ratio, OR 2.01, 95% confidence interval, CI 1.08-3.69), intracranial ICA without carotid T occlusion (adjusted OR 1.79, 95% CI 1.05-2.98), and M2 segment (adjusted OR 1.86, 95% CI 1.21-2.84). Failed reperfusion was also associated with cervical ICA stenosis (>70% stenosis, adjusted OR 2.90, 95% CI 1.69-4.97), stroke of other determined etiology by TOAST (Trial of ORG 10172 in acute stroke treatment) criteria (e.g. nonatherosclerotic vasculopathies, adjusted OR 2.73, 95% CI 1.36-5.39), and treatment given outside the usual working hours (adjusted OR 1.41, 95% CI 1.07-1.86). Successful reperfusion was associated with higher Alberta stroke program early CT score (ASPECTS) on initial imaging (adjusted OR 0.85, 95% CI 0.79-0.92), treatment with the patient under general anesthesia (adjusted OR 0.72, 95% CI 0.54-0.96), and concomitant ICA stenting in patients with ICA stenosis (adjusted OR 0.20, 95% CI 0.11-0.38)., Conclusion: Several factors are associated with failure of reperfusion, most notably occlusions of the proximal ICA and low ASPECTS on admission. Conversely, stent placement in the proximal ICA was associated with reperfusion success.

Objective: Conventional coiling is standard for treatment of ruptured intracranial aneurysms. We compared clinical and angiographic outcomes between intrasaccular flow disruption with the Woven EndoBridge (WEB) and conventional coiling in patients with aneurysmal subarachnoid hemorrhage (aSAH) using a propensity score-matched analysis., Methods: This is a retrospective study of consecutive patients with aSAH treated with the WEB or conventional coiling between 2010 and 2019. Baseline characteristics, procedural complications, angiographic results, and functional outcome were compared between both groups., Results: Fifty-two patients treated with the WEB and 236 patients treated by coiling were included. The WEB group was characterized by a higher patient age (P = 0.024), a wider aneurysm neck (P < 0.001), and more frequent location at the posterior circulation (P = 0.004). Procedural complications were comparable between WEB (19.2%) and coiling (22.7%, P = 0.447). In-hospital mortality rates were higher in the coiling group (WEB: 5.8%, coiling: 17.8%; P = 0.0034). Favorable outcome (modified Rankin scale ≤2) was obtained in 51.3% after WEB embolization and in 55.0% after coiling (P = 0.653). Retreatment was performed in 26.4% of patients after WEB and in 25.8% after coiling (P = 0.935). Propensity score analysis confirmed these results and revealed higher adequate occlusion rates at midterm follow-up for WEB-treated aneurysms (WEB: 93.9%, coiling: 76.2%, P = 0.058)., Conclusions: Compared with conventional coiling, aSAH patients treated with the WEB have a similar clinical and potentially improved angiographic outcome at midterm follow-up. The WEB might be considered as an alternative to conventional coiling for the treatment of RIAs, in particular for those with wide-necked and thus challenging anatomy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Purpose: Imaging-based selection of stroke patients for endovascular thrombectomy (EVT) remains an ongoing challenge. Our aim was to determine the value of a combined parameter of ischemic core volume (ICV) and the relative degree of cerebral blood flow in the penumbra for morphologic and clinical outcome prediction., Methods: In this Institutional Review Board (IRB)-approved prospective observational study, 221 consecutive patients with large vessel occlusion anterior circulation stroke within 6 hours of symptom onset and subsequent EVT were included between June 2015 and August 2017. Admission computed tomography perfusion was analyzed using automated threshold-based algorithms. Perfusion-weighted ICV (pw-ICV) was calculated by multiplying ICV with the relative cerebral blood flow reduction within the penumbra. Functional outcome was assessed by standardized assessment of the modified Rankin scale (mRS) after 3 months., Results: In multivariate analyses, pw-ICV was significantly associated with final infarction volume (FIV) (β = .38, P < .001) after adjustment for penumbra volume, age, sex and time from symptom onset. In separate multivariate analysis with either pw-ICV or ICV, pw-ICV outperformed ICV for the prediction of FIV (Akaike's information criterion: 1,072 vs. 1,089; conditional variable importance: 1,494 vs. 955). There was also a highly significant association between FIV and clinical outcome as measured by an mRS score of 2 or less (odds ratio per 10 mL = .78, P < .001). Both pw-ICV and ICV were significantly associated with NIHSS improvement (both P<.05)., Conclusion: In EVT-treated stroke patients, pw-ICV outperforms the more commonly used ICV in the prediction of morphological and functional outcome., (© 2020 by the American Society of Neuroimaging.)

Background and Purpose- Stroke etiology drives thrombus composition. We thus hypothesized that endovascular treatment shows different efficacy in cardioembolic versus noncardioembolic large-vessel occlusions (LVOs). Methods- Procedural characteristics, grade of reperfusion, and functional outcome at discharge and 90 days were compared between patients with cardioembolic versus noncardioembolic LVO from the GSR-ET (German Stroke Registry-Endovascular Treatment; n=2589). To determine associations with functional outcome, adjusted odds ratios and 95% CIs were calculated using ordinal multivariable logistic regression models adjusting for potential baseline confounder variables. Results- Endovascular treatment of cardioembolic LVO had a higher rate of successful reperfusion (85.6% versus 81.0%; P =0.002) and a higher rate of complete reperfusion after a single thrombectomy pass (45.7% versus 38.1%; P <0.001) compared with noncardioembolic LVO. Cardioembolic LVO was associated with better functional outcome at discharge (adjusted odds ratio, 1.61 [95% CI, 1.37-1.88]) and 90 days (adjusted odds ratio, 1.29 [95% CI, 1.09-1.53]). In mediation analysis, reperfusion explained 47% of the effect of etiology on functional outcome at discharge. Conclusions- These results provide evidence for higher efficacy of endovascular treatment in cardioembolic LVO compared with noncardioembolic LVO.

Objective: Clinical data on the new Neuroform Atlas stent for treatment of intracranial aneurysms is limited. We report our experience in stent-assisted coiling procedures of complex, predominantly wide-necked aneurysms., Methods: This is a retrospective study of consecutive patients treated with the Neuroform Atlas stent between August 2014 and November 2018 at three German tertiary care centers. We evaluated the complication rate, clinical outcome and angiographic result at mid-term follow-up., Results: Thirty-seven aneurysms (elective: 23, previous subarachnoid hemorrhage: 14) were treated in 37 patients (mean age: 59.4 years, 62.2% females). Stent-assisted coiling was successful in all cases, achieving immediate complete aneurysm occlusion by coiling in 83.8% and neck remnants in 16.2%. At 6-month angiographic follow-up, complete aneurysm occlusion was obtained in 80.8% (21/26), neck remnants in 11.5% (3/26) and aneurysm remnants in 7.7% (2/26). Retreatment was necessary in 7.7%. Ischemic stroke occurred in one patient (2.7%). At 6-month clinical follow-up, procedure-related permanent morbidity was 2.7%., Conclusions: Our results demonstrate that treatment of intracranial aneurysms with the Neuroform Atlas stent is associated with low morbidity and a high aneurysm occlusion rate at mid-term follow-up. Further studies will be necessary to confirm our results., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background and Purpose: The Woven EndoBridge 17 has recently been introduced to the market for facilitated endovascular treatment of small bifurcation aneurysms (≤7 mm) with low-profile microcatheters. We compared the Woven EndoBridge 17 with its predecessor versions in terms of procedural safety and feasibility., Materials and Methods: This was a multicenter review of aneurysms ranging from 3 to 7 mm treated with the Woven EndoBridge between 2011 and 2019. Aneurysm characteristics, procedural parameters, and complications were retrospectively compared between treatment with the Woven EndoBridge 17 and a control group that was treated with its predecessor versions, using inverse probability of treatment weighting., Results: Thirty-eight aneurysms treated with a Woven EndoBridge 17 (mean size, 4.9 ± 1.5 mm) and 70 treated with a predecessor version of the Woven EndoBridge 17 (mean size, 5.6 ± 1.4 mm) were included. The predecessor version of the Woven EndoBridge 17 had a higher failure rate (10.3%) than the Woven EndoBridge 17 (0%, P = .05). Additional stent placement was performed more often with the predecessor version of the Woven EndoBridge 17 (10.0%) than with the Woven EndoBridge 17 (2.6%, adjusted P = .005). The predecessor version of the Woven EndoBridge 17 was associated with a higher thromboembolic event rate (14.3%) than the Woven EndoBridge 17 (5.3%, adjusted P = .002). Neurologic complications (Woven EndoBridge 17: 2.6%; predecessor version of the Woven EndoBridge 17: 2.9%, adjusted P = 1.0) and immediate complete aneurysm occlusion rates (Woven EndoBridge 17: 57.9%; predecessor version of the Woven EndoBridge 17: 54.3%, adjusted P = .21) did not differ significantly between groups., Conclusions: In the current study, the Woven EndoBridge 17 was associated with a potentially lower thromboembolic event rate than the predecessor version of the Woven EndoBridge 17, without compromising the immediate aneurysm occlusion rate. Long-term clinical and angiographic outcome analysis will be necessary to draw a definite conclusion., (© 2019 by American Journal of Neuroradiology.)

Objective: The Woven EndoBridge (WEB) device is an innovative tool for endovascular treatment of wide-necked bifurcation aneurysms. Numerous studies of primary aneurysm treatment with the WEB device have been reported. We analyzed the safety and efficacy of WEB embolization for recurrent and residual aneurysms., Methods: We performed a retrospective observational study of consecutive patients with initially endovascularly or surgically treated aneurysms and an aneurysm recurrence or remnant retreated with the WEB device at 3 German high-volume neurovascular centers from May 2011 to February 2018. The technical success, complications, and angiographic outcomes were evaluated., Results: Eleven patients (median age, 65 years; 5 women) with 11 aneurysms (median size, 6.8 mm) were identified. The aneurysms were located at the anterior communicating artery in 4, basilar tip in 4, internal carotid artery in 1, middle cerebral artery in 1, and posterior communicating artery in 1 patient. Three aneurysms had been previously clipped and 8 had undergone endovascular therapy. WEB embolization was feasible in 10 patients. Ancillary devices were used for 4 aneurysms. Perforation occurred in 1 aneurysm, which resolved without sequelae. Of the 9 patients available for angiographic follow-up (median follow-up, 6 months), complete and near-complete aneurysm occlusion was achieved in 3 (33%) and 7 patients (78%), respectively. Three patients underwent repeat treatment (33%)., Conclusions: The results of the present study have indicated that WEB embolization of previously treated aneurysms is reasonably safe. However, careful aneurysm selection could be necessary to achieve adequate mid-term occlusion rates., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Stent-retriever thrombectomy (SRT) for acute intracranial large artery occlusion (LAO) may not result in permanent recanalization in rare cases, e.g. due to an underlying stenosis or dissection. In this specific patient group, rescue stent angioplasty (RSA) may be the only treatment option to achieve permanent vessel patency and potentially a good clinical outcome. To date, the experience with RSA is limited., Methods: In this retrospective analysis, interventional and clinical data of patients with acute intracranial LAO of the anterior and posterior circulation who underwent RSA after SRT due to an underlying lesion between 2012-2017 in four neurovascular centers were studied., Results: In this study 34 patients (mean age 67 years) were included whereby 18 patients had anterior circulation LAO and 16 patients posterior circulation LAO. The SRT maneuver count ranged between 1 and 15 (median 2). Indications for RSA were an immediate re-occlusion in 25 (74%), and a persistent high-grade stenosis in 9 patients (26%). The RSA was technically feasible in 33 patients (97%). A mTICI 2b/3 result was obtained in 26 patients (76%). Median onset-to-recanalization time was 248 min (range 80-650 min). After 3 months 10/34 patients (29%) had a good clinical outcome (modified Rankin Scale, mRS 0-2). In detail, 4/18 patients (22%) with anterior circulation LAO and 6/16 patients (38%) with posterior circulation LAO were functionally independent., Conclusion: The use of RSA can be considered for acute intracranial LAO in cases with immediate re-occlusion or high-grade stenosis after SRT alone.

Background: Intrasaccular flow disruption represents a new paradigm in endovascular treatment of wide-necked bifurcation aneurysms., Objective: To perform a matched case-control study comparing complications and angiographic outcome using the Woven Endobridge (WEB) device and stent-assisted coiling (SAC)., Methods: Sixty-six patients treated with the WEB at three German tertiary care centers were included and matched with 66 patients treated with SAC based on aneurysm location and unruptured/ruptured aneurysm status. Parameters were retrospectively analysed and compared between the treatment groups using inverse probability of treatment weighting (IPTW) with propensity scores., Results: Procedural complication rates were 12.1% in the WEB group and 21.2% in the SAC group, which was statistically significant after IPTW adjustment (OR=2.2, 95% CI 1.08 to 4.4, p=0.03). Favourable outcome (modified Rankin scale score ≤2) was achieved by 57/66 (86.4%) in the WEB group and 57/66 (86.4%) in the SAC group (p=1.0). At mid-term follow-up, a similar number of aneurysms achieved adequate occlusion (complete occlusion or neck remnant) in the WEB group (93.9%) and in the SAC group (93.9%, p=1.0). Re-treatment was performed in 10.6% after WEB embolization and 12.1% after SAC (p=1.0)., Conclusions: The WEB provides similar mid-term aneurysm occlusion rates to those of SAC, with no additional morbidity and potentially lower complication rates. Long-term outcome analysis will provide a definite conclusion on the use of WEB for intracranial aneurysms., Competing Interests: Competing interests: CK and FD serve as consultants for Acandis GmbH (Pforzheim, Germany). TL serves as proctor for MicroVention Inc/Sequent Medical (Aliso Viejo, California, USA)., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Woven Endobridge (WEB) embolization is an approved technique for endovascular treatment of wide-necked and bifurcation aneurysms. However, the WEB has not yet been routinely used for internal carotid artery (ICA) sidewall aneurysms. In this multicenter study, we evaluate the safety and efficacy of WEB for treatment of these aneurysms., Methods: We reviewed all patients with ICA sidewall aneurysms who were treated with WEB at 3 German neurovascular centers between 2011 and 2018. Technical success, complication rates, and angiographic outcome were retrospectively assessed., Results: Twenty patients (mean age, 56.3 ± 13.0 years) with 20 ICA aneurysms (6 ruptured) were identified. The aneurysms were located at the paraophthalmic segment (n = 10), the posterior communicating artery segment (n = 9), and the anterior choroidal artery segment (n = 1). The mean aneurysm size was 8.1 ± 5.2 mm and 60% were wide-necked. The aneurysms were treated with a single WEB (n = 11) or in combination with coiling and/or stent implantation (n = 7). WEB implantation failed in 2 aneurysms because of a sharp aneurysm angle. There were 1 periprocedural thromboembolic event and 1 in-stent stenosis at follow-up, which remained asymptomatic in both cases. There was no procedure-related morbidity and mortality. At follow-up, complete occlusion was achieved in 76.5%, neck remnants in 17.6%, and aneurysms remnants in 5.9%., Conclusions: The WEB device can be used for treatment of ICA sidewall aneurysms with a high level of procedural safety and a high degree of technical success., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To compare the safety and efficacy between Woven EndoBridge (WEB) embolization and conventional coiling for treatment of unruptured intracranial aneurysms using a propensity score-matched analysis., Methods: Consecutive patients treated with the WEB at 3 German neurovascular centers and with coiling at a single center during 2011 and 2018 were analyzed. Procedure-related complications, clinical outcome, and angiographic results were retrospectively evaluated and compared., Results: Sixty-seven patients treated by coiling and 56 patients treated with the WEB were identified. Significant differences between the 2 groups were observed in patient age (P = 0.048), aneurysm location (P < 0.01), aneurysm size (P = 0.02), and neck width (P < 0.01). The overall complication rate was comparable between the coil group (9.0%) and the WEB group (8.9%, P = 1.0). Favorable outcome (modified Rankin Scale ≤2) was obtained in 98.5% after coiling and 98.2% after WEB treatment. At last available angiographic follow-up, WEB yielded a higher complete aneurysm occlusion rate (87.2%) than coiling (60.8%, P < 0.01). Nine patients in the coil cohort (17.6%) and 2 patients in the WEB cohort (4.3%) underwent retreatment (P = 0.05). After 1:1 propensity score matching, there were no significant differences in complication (P = 1.0) and morbidity rates (P = 1.0), whereas there was a trend toward a higher complete aneurysm occlusion rate after WEB treatment (P = 0.08)., Conclusions: Treatment of unruptured aneurysms with the WEB provides potentially higher aneurysm occlusion rates than conventional coiling while having similar complication rates and no additional morbidity., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Woven Endobridge (WEB) embolization is a safe and efficient technique for endovascular treatment of intracranial aneurysms. However, the management of aneurysm recurrence after WEB placement has not been well described to date. We present our multicenter experience of endovascular retreatment of aneurysm recurrence after WEB implantation., Methods: This is a multicenter study of patients who underwent endovascular retreatment after WEB implantation in three German tertiary care centers. Treatment strategies, complications, and angiographic outcome were retrospectively assessed., Results: Among 122 aneurysms treated with the WEB device, 15 were retreated. Of these, six were initially treated with the WEB only, two were pretreated by coiling, and seven large aneurysms were treated in a multimodality approach. Ten were true aneurysm remnants and five were neck remnants. The reasons for retreatment were WEB migration (n=6), initial incomplete occlusion (n=5), and WEB compression (n=4). Retreatment strategies included coiling (n=4), stent-assisted coiling (n=7 ) , flow diversion (n=3), and placement of an additional WEB (n=1). All procedures were technically successful and there were no procedure-related complications. Among 11 patients available for follow-up after retreatment, three were retreated again. At last angiographic follow-up, available in 11/15 cases at a median of 23 months, complete occlusion was obtained in eight cases and neck remnants in three., Conclusions: This pilot study shows that endovascular retreatment of recurrent or residual aneurysms after WEB implantation can be done safely and can achieve adequate occlusion rates., Competing Interests: Competing interests: CK and FD serve as consultants for Acandis GmbH (Pforzheim, Germany). TL serves as proctor for MicroVention Inc/Sequent Medical (Aliso Viejo, California, USA). The other authors declare that they have no competing interests., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)