Safety and effectiveness of LEO stents for dual stent-assisted embolization combined with IA and IV intra-procedural infusion of tirofiban in the treatment of wide-necked intracranial bifurcation aneurysms

Abstract

Objective: To evaluate the safety and efficacy of employing LEO stents in dual stent-assisted embolization (DSAE) for wide-necked intracranial bifurcation aneurysms, and to assess the effectiveness of combined IA and IV intra-procedural infusion of tirofiban in mitigating perioperative complications.

Methods: Clinical data and follow-up images from 562 patients with wide-necked intracranial bifurcation aneurysms treated at First Affiliated Hospital of Army Medical University from 2018-2022 were collected. Among them, 65 received DSAE with LEO stents. The study observed treatment success rates, procedure-related complications, perioperative thromboembolic events (TEs) and hemorrhagic events (HEs), immediate postoperative modified Raymond-Roy classification (mRR), and follow-up imaging. Glasgow Outcome Scale (GOS) at discharge and clinical follow-ups were recorded.

Results: The study enrolled 65 patients (mean age: 56.77 ± 10.07) with wide-necked intracranial bifurcation aneurysms. Among them, 58 had unruptured aneurysms, 7 ruptured (Hunt-Hess II-III). All aneurysms were successfully embolized without significant stent or bleeding complications. Only one case had intraoprative thrombosis; two postoperative ischemic incidents occurred within three days, no severe bleeding events. Immediate imaging showed modified Raymond-Roy classification: mRRC I (92.3%), mRRC II (4.6%), mRRC III b (3.1%). A total of 43 patients were followed up postoperatively with DSA. Among them, 41 patients exhibited mRRC I, while 2 patients exhibited mRRC II. No aneurysm was recanalized. Discharge GOS: GOS 5-60, GOS 4-1, GOS 3-4. One patient, GOS 1, died from lung cancer; others improved.

Conclusion: The utilization of LEO stents for dual stent-assisted embolization of wide-necked intracranial bifurcation aneurysms demonstrated remarkable success and safety, yielding favorable postoperative outcomes and no instances of aneurysm recurrence. The concomitant administration of perioperative antiplatelet medications alongside IA and IV intra-procedural infusion of tirofiban effectively attenuated thromboembolic events (TEs) without concomitant elevations in bleeding risks.

Keywords: antiplatelet protocol; dual stents; efficacy; safety; tirofiban; wide-necked intracranial bifurcation aneurysm.

Figure 1

Flowchart for patient selection.

Figure 2

Intraoperative complications and postoperative follow-up period for embolization of unruptured AcomA patient. (A) A 67-year-old male, diagnosed with an AcomA aneurysm by CTA. (B) Cerebral angiography in the lateral position clearly showed an aneurysm in the AcomA. (C) 3D reconstruction clearly showed that the aneurysm in the AcomA involved both anterior cerebral arteries, and Y-configuration stent-assisted embolization was proposed for the treatment. (D) The right ACA was not visualized by anterior and lateral position angiography during the procedure. (E) Immediate administration of tirofiban was conducted through a guiding catheter and microcatheter, with a gradual sequential injection totaling 23 mL over 3 min. Simultaneously, a peripheral intravenous infusion was maintained at a dosage of 0.1 μg/kg/min. Following the completion of the injection, a subsequent lateral angiography demonstrated successful reperfusion of the anterior cerebral artery. (F) Bilateral ACA was well illuminated by 3D reconstruction in immediate postoperative angiography. (G) The bilateral ACA was well-luminated by CTA one week after surgery. (H) The right ACA was well-illuminated by cerebral angiography at 10 months after surgery.

Figure 3

Admission status and clinical follow-up of all patients. ICH, intracerebral hemorrhage.

Figure 4

Embolization and imaging follow-up of an unruptured left middle cerebral artery (MCA) bifurcation aneurysm. (A) A 57-year-old woman was admitted for treatment of a left middle cerebral artery aneurysm diagnosed by CTA. (B) Orthostatic cerebral angiography revealed a wide-necked bifurcation aneurysm in the left MCA. (C) 3D reconstruction showing the left MCA aneurysm involving three middle cerebral artery branches, and Y-stent-assisted embolization was proposed for treating the aneurysm. (D) Postoperative 3D angiography showing embolization of the aneurysm in the left MCA bifurcation. (E,F) The 3D reconstruction reveals the embolization status of the aneurysm at the bifurcation of the left MCA. The embolization result is classified as mRRC III b, with partial opacification observed in the aneurysmal sac. (G,H) Postoperative orthopantomography and 3D reconstruction demonstrating improvement in the embolization of the aneurysm located in the branch of the left MCA at the seventh month after surgery, with the aneurysm completely and densely embolized to mRRC I.