Journal List > J Cerebrovasc Endovasc Neurosurg > v.17(4) > 1089322

J Cerebrovasc Endovasc Neurosurg. 2015 Dec;17(4):331-333. English.
Published online December 31, 2015.
© 2015 Journal of Cerebrovascular and Endovascular Neurosurgery
Endovascular Management of Intracranial Aneurysms: Advances in Stenting Techniques and Technology
Dale Ding
Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.

Correspondence to Dale Ding. Department of Neurosurgery, University of Virginia Health System, P.O. Box 800212 Charlottesville, VA 22908, USA. Tel: 1-434-924-2203, Fax: 1-434-982-5753, Email:
Received April 19, 2014; Revised February 21, 2015; Accepted December 16, 2015.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Keywords: Endovascular procedures; Flow diversion; Intracranial aneurysm; Stents; Stroke; Subarachnoid hemorrhage


I have read, with interest, a recently published article in the Journal of Cerebrovascular and Endovascular Neurosurgery by Kim et al. titled 'A Self-expanding Nitinol Stent (Enterprise) for the Treatment of Wide-necked Intracranial Aneurysms: Angiographic and Clinical Results in 40 Aneurysms'.23) The authors report their outcomes with Enterprise (Codman, Raynham, MA, USA) stent-assisted coil embolization (SACE) of 40 wide-necked intracranial aneurysms in 39 patients. The mean neck width was 5.6 mm, and 30% were located in the posterior circulation. At the initial treatment, the rates of Raymond class 1, 2 and 3 angiographic outcomes were 20%, 15%, and 65%, respectively. The rate of overall complications was 12.5%, and the rate of symptomatic complications was 2.5%. The modified Rankin Scale (mRS) score was 3 or higher in six patients (15.4%), although four of the six patients (66.7%) presented with subarachnoid hemorrhage (SAH). Of the 18 patients with available angiographic follow-up (mean duration 11.3 months, range 6 to 23 months), the rates of Raymond class 1, 2, and 3 outcomes were 72.2%, 22.2%, and 5.6%, respectively. Of note, 11 of 16 aneurysms with neck or sac remnants at initial treatment progressed to complete occlusion at follow-up (68.8%), and only one of those aneurysms developed recanalization (6.3%). Additionally, there were no cases of in-stent stenosis at follow-up. In the following discussion, we highlight recent advances in endovascular stenting techniques and technologies for the treatment of intracranial aneurysms.

Wide-necked (dome to neck ratio < 2 or neck width ≥ 4 mm) or large (diameter ≥ 10 mm) aneurysms are difficult to treat with endovascular coiling alone.30) Intracranial stents significantly expanded the endovascular armamentarium by providing a scaffold for coil support and promoting endothelialization across the neck of large, wide-necked aneurysms.27) An analysis of 552 aneurysms (508 patients) treated with SACE, 91% electively and 9% in the setting of SAH, reported a 7% procedural complication rate.3) After a mean follow-up of 26 months, the aneurysm recanalization and retreatment occurred in 12% and 6%, respectively. The past few years have seen a transition from the use of stenting techniques from SACE, such as was used in the present series, to flow-diverting stents, such as the Pipeline Embolization Device (PED; ev3 Neurovascular, Irvine, CA, USA) and SILK stent (Balt Extrusion, Montmorency, France).1), 15), 16), 17), 18), 20), 25) A matched cohort study comparing PED flow diversion to coiling (including coiling alone, SACE, and balloon-assisted coiling) large, unruptured saccular aneurysms reported a significantly higher occlusion rate in the PED cohort (86% vs. 41%, p < 0.001), with similar rates of complications and favorable outcome (modified Rankin Scale score 0-2).

A meta-analysis of 1,654 aneurysms (1,451 patients) treated with flow diverters reported complete occlusion in 76%, ischemic stroke in 6%, procedural morbidity in 5%, mortality in 4%, and postoperative subarachnoid hemorrhage, intraparenchymal hemorrhage, and perforator infarction each in 3%.2) Patients with posterior circulation aneurysms were significantly more prone to ischemic stroke (p < 0.0001) and perforator infarction (p < 0.0001) compared to those with anterior circulation aneurysms. An international, multicenter retrospective cohort study of 906 aneurysms (793 patients) treated with the PED at 17 centers reported a combined neurological morbidity and mortality rate of 8%, which was highest in posterior circulation aneurysms (16%) and lowest in internal carotid artery aneurysms < 10 mm in diameter (5%).22) The overall rates of ischemic stroke, intracranial hemorrhage, and spontaneous aneurysm rupture were 5%, 2%, and 0.6%, respectively. Although our understanding of the typical complication profile of flow diversion is becoming more established, the optimal management of uncommon complications remains poorly defined.11), 19), 21)

Stents continue to play a crucial role in the treatment of intracranial aneurysms, as well as numerous cerebrovascular disorders.4), 5), 7), 8), 9), 12), 14), 26), 32) Conventional high-porosity stents have given way, in recent years, to low-porosity flow diverters. Our understanding of the indications for SACE and flow diversion continues to evolve as evidence mounts for stent-based techniques and devices. An improved understanding of aneurysm biology may improve our ability to develop and employ emerging stent technologies for the treatment of complex aneurysms.6), 10), 13), 24), 28), 29), 31)


Disclosure:The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

1. Becske T, Kallmes DF, Saatci I, McDougall CG, Szikora I, Lanzino G, et al. Pipeline for Uncoilable or Failed Aneurysms: Results from a Multicenter Clinical Trial. Radiology 2013 Jun;267(3):858–868.
2. Brinjikji W, Murad MH, Lanzino G, Cloft HJ, Kallmes DF. Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke 2013 Feb;44(2):442–447.
3. Chalouhi N, Jabbour P, Singhal S, Drueding R, Starke RM, Dalyai RT, et al. Stent-assisted coiling of intracranial aneurysms: predictors of complications, recanalization, and outcome in 508 cases. Stroke 2013 May;44(5):1348–1353.
4. Chen CJ, Ding D, Starke RM, Mehndiratta P, Crowley RW, Liu KC, et al. Endovascular vs medical management of acute ischemic stroke. Neurology 2015 Dec;85(22):1980–1990.
5. Ding D. Endovascular Mechanical Thrombectomy for Acute Ischemic Stroke: A New Standard of Care. J Stroke 2015 May;17(2):123–126.
6. Ding D. Expanding the boundaries of endovascular aneurysm treatment: emerging technologies for wide-necked bifurcation aneurysms. Acta Neurochir (Wien) 2015 Jun;157(6):1049–1050.
7. Ding D, Chen CJ, Starke RM, Liu KC, Crowley RW. Ophthalmologic course of bilateral abducens nerve palsies after the treatment of idiopathic intracranial hypertension with venous sinus stenting. Neurol Sci 2015 Dec;36(12):2297–2299.
8. Ding D, Chen CJ, Starke RM, Liu KC, Crowley RW. Rapid recovery of bilateral abducens nerve palsies after venous sinus stenting for idiopathic intracranial hypertension. J Neurol Sci 2015 Oct;357(1-2):335–337.
9. Ding D, Liu KC. Applications of stenting for intracranial atherosclerosis. Neurosurg Focus 2011 Jun;30(6):E15.
10. Ding D, Liu KC. Management strategies for intraprocedural coil migration during endovascular treatment of intracranial aneurysms. J Neurointerv Surg 2014 Jul;6(6):428–431.
11. Ding D, Liu KC. Microsurgical extraction of a malfunctioned pipeline embolization device following complete deployment. J Cerebrovasc Endovasc Neurosurg 2013 Sep;15(3):241–245.
12. Ding D, Starke RM, Crowley RW, Liu KC. Role of stenting for intracranial atherosclerosis in the post-SAMMPRIS era. Biomed Res Int 2013;2013:304320.
13. Ding D, Starke RM, Dumont AS, Owens GK, Hasan DM, Chalouhi N, et al. Therapeutic Implications of Estrogen for Cerebral Vasospasm and Delayed Cerebral Ischemia Induced by Aneurysmal Subarachnoid Hemorrhage. Biomed Res Int 2014;2014:727428.
14. Ding D, Starke RM, Durst CR, Crowley RW, Liu KC. Venous stenting with concurrent intracranial pressure monitoring for the treatment of pseudotumor cerebri. Neurosurg Focus 2014 Jul;37 1 Suppl:1.
15. Ding D, Starke RM, Durst CR, Gaughen JR Jr, Evans AJ, Jensen ME, et al. DynaCT imaging for intraprocedural evaluation of flow-diverting stent apposition during endovascular treatment of intracranial aneurysms. J Clin Neurosci 2014 Nov;21(11):1981–1983.
16. Ding D, Starke RM, Evans AJ, Jensen ME, Liu KC. Balloon anchor technique for pipeline embolization device deployment across the neck of a giant intracranial aneurysm. J Cerebrovasc Endovasc Neurosurg 2014 Jun;16(2):125–130.
17. Ding D, Starke RM, Evans AJ, Jensen ME, Liu KC. Endovascular treatment of recurrent intracranial aneurysms following previous microsurgical clipping with the Pipeline Embolization Device. J Clin Neurosci 2014 Jul;21(7):1241–1244.
18. Ding D, Starke RM, Jensen ME, Evans AJ, Kassell NF, Liu KC. Perforator aneurysms of the posterior circulation: case series and review of the literature. J Neurointerv Surg 2013 Nov;5(6):546–551.
19. Ding D, Starke RM, Liu KC. Microsurgical strategies following failed endovascular treatment with the pipeline embolization device: case of a giant posterior cerebral artery aneurysm. J Cerebrovasc Endovasc Neurosurg 2014 Mar;16(1):26–31.
20. Durst CR, Starke RM, Clopton D, Hixson HR, Schmitt PJ, Gingras JM, et al. Endovascular treatment of ophthalmic artery aneurysms: ophthalmic artery patency following flow diversion versus coil embolization. J Neurointerv Surg. 2015 Sep 09;
21. Hu YC, Deshmukh VR, Albuquerque FC, Fiorella D, Nixon RR, Heck DV, et al. Histopathological assessment of fatal ipsilateral intraparenchymal hemorrhages after the treatment of supraclinoid aneurysms with the Pipeline Embolization Device. J Neurosurg 2014 Feb;120(2):365–374.
22. Kallmes DF, Hanel R, Lopes D, Boccardi E, Bonafe A, Cekirge S, et al. International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. AJNR Am J Neuroradiol 2015 Jan;36(1):108–115.
23. Kim ST, Jeong HW, Jeong YG, Heo YJ, Seo JH, Paeng SH. A Self-expanding Nitinol Stent (Enterprise) for the Treatment of Wide-necked Intracranial Aneurysms: Angiographic and Clinical Results in 40 Aneurysms. J Cerebrovasc Endovasc Neurosurg 2013 Dec;15(4):299–306.
24. Liu KC, Ding D, Starke RM, Geraghty SR, Jensen ME. Intraprocedural retrieval of migrated coils during endovascular aneurysm treatment with the Trevo Stentriever device. J Clin Neurosci 2014 Mar;21(3):503–506.
25. Nelson PK, Lylyk P, Szikora I, Wetzel SG, Wanke I, Fiorella D. The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR Am J Neuroradiol 2011 Jan;32(1):34–40.
26. Przybylowski CJ, Ding D, Starke RM, Durst CR, Crowley RW, Liu KC. Evolution of endovascular mechanical thrombectomy for acute ischemic stroke. World J Clin Cases 2014 Nov;2(11):614–622.
27. Shapiro M, Becske T, Sahlein D, Babb J, Nelson PK. Stent-supported aneurysm coiling: a literature survey of treatment and follow-up. AJNR Am J Neuroradiol 2012 Jan;33(1):159–163.
28. Starke RM, Chalouhi N, Ding D, Hasan DM. Potential Role of Aspirin in the Prevention of Aneurysmal Subarachnoid Hemorrhage. Cerebrovasc Dis 2015 May;39(5-6):332–342.
29. Starke RM, Chalouhi N, Ding D, Raper DM, McKisic MS, Owens GK, et al. Vascular smooth muscle cells in cerebral aneurysm pathogenesis. Transl Stroke Res 2014 Jun;5(3):338–346.
30. Starke RM, Durst CR, Evans A, Ding D, Raper DM, Jensen ME, et al. Endovascular treatment of unruptured wide-necked intracranial aneurysms: comparison of dual microcatheter technique and stent-assisted coil embolization. J Neurointerv Surg 2015 Apr;7(4):256–261.
31. Starke RM, Raper DM, Ding D, Chalouhi N, Owens GK, Hasan DM, et al. Tumor necrosis factor-α modulates cerebral aneurysm formation and rupture. Transl Stroke Res 2014 Apr;5(2):269–277.
32. Starke RM, Wang T, Ding D, Durst CR, Crowley RW, Chalouhi N, et al. Endovascular Treatment of venous sinus stenosis in idiopathic intracranial hypertension: complications, neurological outcomes, and radiographic results. ScientificWorldJournal 2015;2015:140408.