Background Recurrence of intracranial aneurysms after endovascular coiling is a serious clinical concern.
Objective We hypothesized that recurrence is associated with aneurysm morphology and flow, as well as the coil intervention and the induced flow modifications.
Methods We collected 52 primary-coiling aneurysm cases that were either occluded (n=34) or recurrent (n=18) at >1 year follow-up. We created aneurysm models from pre-coiling digital subtraction angiographic images, calculated aneurysm morphology, simulated pre-coiling hemodynamics, modeled coil deployment, and obtained post-coiling hemodynamics for each case. We performed univariable analysis on 26 morphologic, treatment-specific, and hemodynamic parameters to distinguish between recurrent and occluded groups, and multivariable analysis to identify independently significant parameters associated with recurrence. Univariable analysis was also performed on ruptured and unruptured aneurysm subcohorts separately to investigate if they shared specific significant parameters.
Results Recurrence was associated with pre-coiling aneurysm morphologic and flow parameters including larger size (maximum dimension and volume), larger neck (diameter, area, and neck-to-parent-artery ratio), and higher flow momentum and kinetic energy. Recurrence was also associated with lower coil packing (packing density and uncoiled volume), higher post-treatment flow (velocity, momentum, and kinetic energy), lower post-treatment washout time, and higher post-treatment impingement force at the neck. Multivariable analysis identified two aneurysmal characteristics (neck diameter and pre-coiling flow kinetic energy), one coil packing parameter (uncoiled volume), and one post-treatment hemodynamic parameter (flow momentum) that were independently associated with recurrence. In ruptured aneurysms, recurrence was associated with larger neck (diameter and area), whereas in unruptured aneurysms, recurrence was associated with larger size (maximum dimension and volume). In both subcohorts, recurrence was associated with higher post-coiling flow momentum and kinetic energy.
Conclusion Recurrence at >1 year after coil treatment is associated with intrinsic aneurysm characteristics, coiling itself, and flow changes induced by coiling. Larger aneurysm size and neck, less coil packing, and higher intra-aneurysmal flow before and after coiling predict recurrence.
- blood flow
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Contributors Study conception and design: RJD, VMT, NP, MW, JMD, AHS, HM. Acquisition of data: all authors. Analysis and interpretation of data: RJD, VMT, NP, MW, HM. Drafting of manuscript: RJD, VMT, NP, HM. Critical revision: all authors. All authors read and approved the final manuscript.
Funding This work was supported by The National Institutes of Health grant number R01NS091075 and by Canon Medical Systems Corporation grant number 17-00832.
Competing interests VMT – Co-founder: Neurovascular Diagnostics, Inc. NP – None. TRP – None. MW – None. EIL – Intratech Medical Ltd., NeXtGen Biologics. Principal investigator: Medtronic US SWIFT PRIME Trials. Honoraria–Medtronic. Consultant–Pulsar Vascular. Advisory Board: Stryker, NeXtGen Biologics, MEDX. Cognition Medical. Other financial support: Abbott Vascular for carotid training sessions. JMD – Stock/Stock Options: Rist Neurovascular, Inc.; Consultancy: Cerevenous, Medtronic; Payment for Lectures Including Service on Speakers Bureaus: Penumbra. AHS – Financial Interest/Investor/Stock Options/Ownership: Amnis Therapeutics, Apama Medical, BlinkTBI, Inc, Buffalo Technology Partners, Inc., Cardinal Health, Cerebrotech Medical Systems, Inc, Claret Medical, Cognition Medical, Endostream Medical, Ltd, Imperative Care, International Medical Distribution Partners, Rebound Therapeutics Corp., Silk Road Medical, StimMed, Synchron, Three Rivers Medical, Inc., Viseon Spine, Inc. Consultant/Advisory Board: Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA, Inc., Cerebrotech Medical Systems, Inc., Cerenovus, Claret Medical, Corindus, Inc., Endostream Medical, Ltd, Guidepoint Global Consulting, Imperative Care, Integra, Medtronic, MicroVention, Northwest University – DSMB Chair for HEAT Trial, Penumbra, Rapid Medical, Rebound Therapeutics Corp., Silk Road Medical, StimMed, Stryker, Three Rivers Medical, Inc., VasSol, W.L. Gore & Associates. National PI/Steering Committees: Cerenovus LARGE Trial and ARISE II Trial, Medtronic SWIFT PRIME and SWIFT DIRECT Trials, MicroVention FRED Trial & CONFIDENCE Study, MUSC POSITIVE Trial, Penumbra 3D Separator Trial, COMPASS Trial, INVEST Trial. HM – Co-founder: Neurovascular Diagnostics, Inc.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.