Neuroform Atlas Stent Treatment for 533 Intracranial Aneurysms in a Large Chinese Cohort: Complication Risk Factor Analysis

Neuroform Atlas Stent Treatment for 533 Intracranial Aneurysms in a Large Chinese Cohort: Complication Risk Factor Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Neuroform Atlas Stent Treatment for 533 Intracranial Aneurysms in a Large Chinese Cohort: Complication Risk Factor Analysis Shibao Chen, Huibin Kang, Dili Wang, Yan Li, Jamali Aikeba, Yabo Li, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3754137/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Jun, 2024 Read the published version in BMC Neurology → Version 1 posted 4 You are reading this latest preprint version Abstract Purpose The newest generation Neuroform Atlas stent™ (by Stryker, Fremont, California)represents a recent advance in cerebral laser-cut microstents for the treatment of intracranial wide-necked aneurysms and the postoperative complications have been observed in cases among Western populations.We assessed predictors of complications, morbidity, and unfavorable outcomes in a large cohort of patients with aneurysm treated with Neuroform Atlas stent in China. Methods This retrospective study included subjects treated with the Atlas stent in China from November 2020 to January 2022. Results A total of 522 consecutive patients (mean age, 58.9 ± 9.9 years; female, 65.3% [341/522]) with 533 aneurysms were included in the study. In the early postoperative period, neurological morbidity rate was 7.3% (38/522); ischaemic stroke rate was 5.0% (26/522); aneurysm rupture subarachnoid hemorrhage rate was 2.3% (12/522); MRS score deterioration rate was 5.4% (28/522). Mortality rate were 0.8% (4/522) in the postoperative period. Neurologic morbidity at follow-up period were 1.2% (6/486). In multi-factor prediction, cerebral infarction, Hunt-Hess Grade (3–5), procedure duration, stent length and coil protrusion into the parent artery were found to be independent predictors of neurologic morbidity. Procedure duration, stent length and coil protrusion into the parent artery were found to be independent predictors of neurological mRS score deterioration. Conclusion The incidence of SCA (stent-assisted coiling)-related complications with the Atlas stent in this study was comparable to that in the Western population. We identified procedure duration and stent length as novel independent predictors of SCA-related ischemic stroke, neurologic morbidity, and mRS score deterioration among the Chinese population. Intracranial Aneurysms Neuroform Atlas Stent Treatment Complication Risk Factor Introduction The treatment of Intracranial aneurysms using SAC has been practiced for over 20 years. SAC has shown better occlusion rates compared to coiling alone, and flow diversion has achieved occlusion rates of up to 80% with an acceptable safety profile.[ 1 – 3 ] However, the use of stents in coiling is associated with a higher complication rate compared to coiling or balloon-assisted coiling. A recent meta-analysis of low-profile stents reported a procedure-related complication rate of 12.4%[ 4 ]. At present, A large number of studies have been published on procedure-related complications using intracranial stents, such as Neuroform (Stryker, Kalamazoo, MI, USA), Enterprise (Codman,Raynham,MA,USA), Solitaire (Covidien, Irvine, CA, USA) and LVIS (MicroV ention, T ustin, California),etc.[ 5 ] However, There are only limited reports of complications associated with the newest generation of the widely used Neuroform Atlas stent. which was approved by the U.S. Food and Drug Administration in May 2019. Approved for use in China in October 2020. To our knowledge, This is the largest cohort retrospective study of procedure-related complications with the recently introduced small-size Atlas stent. Methods Ethics approval, Participants and Study design We conducted a retrospective evaluation of 522 patients with 533 intracranial aneurysms, including both ruptured and unruptured cases, who were treated with the Neuroform Atlas stent between November 2020 and January 2022 in China. The study protocol underwent review and approval by the Institutional Review Board. The informed consent process was waived due to the retrospective nature of the study design. Patient demographic data, including gender, age, hypertension, diabetes, hyperlipidemia, cerebral infarction, cardiac disease, smoking, alcohol abuse, presentation, Hunt-Hess Grade, previous treatment, CYP2C19 genotyping, platelet aggregation test (PAgT), collagen arachidonic acid (AA), and adenosine diphosphate (ADP), were collected by reviewing the medical charts. The parameters related to the characteristics of aneurysms extracted from digital subtraction angiography (DSA) include aneurysm size, neck size, aneurysm width, aneurysm height, parent artery diameter, Size ratio(SR), Aspect ratio༈AR༉, Height/width ratio༈HW༉, Aneurysm form, Aneurysm location. reviewed aneurysm size definitions reported in the literature and the most commonly cited definition was “maximal dimension of the aneurysmal dome.[ 6 , 7 ] Neck size is defined as the maximum neck diameter, Aneurysm width is defined as Maximal longitudinal diameter of dome parallel with neck plane, Aneurysm height size is defined as the maximum neck diameter, SR is defined asMaximal aneurysm height/parent vessels mean diameter,AR is defined as Maximal distance from neck to aneurysm dome/maximal neck width,HW is defined as Maximal distance from neck to aneurysm dome/maximal width of dome orthogonal to maximal height.Aneurysm form includes saccular and non-saccular. Aneurysm location (anterior or posterior circulation). The anterior circulation was divided into the proximal and distal anterior circulation. The proximal anterior circulation was defined as arteries from the beginning of the internal carotid artery to the bifurcation of the internal carotid artery, including the ophthalmic artery, arterial segment in the cavernous sinus, posterior communicating artery, superior hypophyseal artery and posterior carotid wall. The distal anterior circulation was defined as the arteries branching from the internal carotid artery, including the anterior and middle cerebral arteries.[ 8 ] The posterior circulation divided into the Vertebral-Basilar and Other vessels in the posterior circulation(the posterior cerebral artery, posterior inferior cerebellar artery, anterior inferior cerebellar artery and the superior cerebellar artery). The study endpoints included pre- and early postoperative (< 30 days) functional outcomes (modified Rankin Scale [mRS] score), Complications related to AS treatment in the early postoperative period and during last clinical follow-up (3 to 17 months, mean 9.7 months). Multivariate analysis was performed to identify risk factors for complications. Procedural details Electively treated patients took clopidogrel 75 mg and aspirin 100 mg daily at least five days before the procedure.A Platelet aggregation test and CYP2C19 genotyping test were performed to ensure a good response to clopidogrel. Patients were switched from clopidogrel to Ticagrelor (loading dose of 180 mg and a daily maintenance of 90 mg twice daily) if they were hypo-responders to clopidogrel. All patients were prescribed 75 mg of clopidogrel daily for 12 weeks and 100 mg of aspirin daily for at least 12 months, after the procedure. Patient Follow-up and End Points Patients were scheduled for clinical follow-up at an interval of 3mo, and 6 mo with the neurointerventionalist. At every clinical followup, functional outcome was assessed using the modified Rankin scale (mRS); scores ranging from 0 to 2 were regarded as favorable. Follow-up radiological examination at 6 mo was performed primarily with DSA. Aneurysm occlusion was graded using the modified Raymond-Roy-occlusion-outcome (MRRC) on the final control run and on follow-up angiograms.[ 9 ] Neurological complications were predefined as the composite of the following complications: spontaneous aneurysm rupture, ipsilateral intracranial hemorrhage, ischemic stroke, parent artery stenosis, and cranial neuropathy. We defined the degree of ischemic stroke according to changes in the National Institutes of Health Stroke Scale [NIHSS] score: minor neurological stroke was defined as an NIHSS score change ≤ 4, lasting less than 7 days, imaging confirmed; transient ischemia attacks (TIA) were defined as transient neurological deficits without confirmatory imaging; and major ischemic stroke was defined as changes in NIHSS score > 4, lasting more than 7 days, with confirmatory imaging[ 10 ]. Poor functional outcomes were evaluated according to a deteriorated modified Rankin scale (mRS) score, which we defined as the mRS score preoperation vs the mRS score early postoperation or during follow-up. Statistical Analysis Univariate analysis of discrete data was performed using Chi square or Fisher exact test. T-test were conducted to determine differences between parametric dependent variables. For continuous data with deviation from normality, including analysis of scores or ranked data,nonparametric tests were utilized. We performed multivariate logistic analysis of the predictors of neurological complications to independent risk factors. All analyses were performed with SPSS version 25 (IBM Corp., Armonk, NY, USA). Results Baseline characteristics Demographic and baseline characteristics are presented in Table 1 . A total of 522 patients with 533 aneurysm were treated using the Neuroform Atlas Stent. Mean age was 58.9 ± 9.9 years and 341(65.3%) patients were female. Co-morbidities included hypertension 337(64.6%), diabetes 83(15.9%), hyperlipidemia 150(28.7%), cerebral infarction 89(17.0%), cardiac disease 43(8.2%), peripheral venous thrombosis 4 (0.8%) and renal insufficiency 6(1.1%). Patients were symptomatic in 238(45.6%) of patients, incidental in 188 (36.0%), and 96 (18.4%) of patients had SAH. Twenty-five(4.8%) aneurysms were treated by clipping or coiling. Table 1 Baseline characteristics of 522 patients treated with the Neuroform Atlas Stent: Characteristic Frequency (N = 522) Total number of aneurysms treated with the Neuroform Atlas Stent 533 Patients with multiple aneurysms 157 (30.0%) Female 341 (65.3%) Age(years) 58.9 ± 9.9 Comorbidities Hypertension 337 (64.6%) Diabetes 83 (15.9%) Hyperlipidaemia 150 (28.7%) Cerebral infarction 89 (17.0%) Cardiac disease 43(8.2%) Peripheral venous thrombosis 4 (0.8%) Renal insufficiency 6(1.1%) Smoking Never 402(77.0%) Previous 55 (10.5%) Current 65(12.5%) Alcohol abuse Never 448 (85.8%) Previous 35 (6.7%) Current 39 (7.5%) Presentation Incidental 188 (36.0%) Symptomatic 238(45.6%) Current SAH 96 (18.4%) Hunt-Hess Grade I-II 72/96 (75%) Ⅲ-IV 24/96 (25%) Previous treatment(coiling/stent) 25 (4.8%) CYP2C19 genotyping* 362 (69.3%) Fast metabolism 163 (45.0%) Intermediate metabolism 152 (42.0%) Slow metabolism 47 (13%) Preoperative coagulation test # Prothrombin time(s) 11.09 ± 1.20 International standard ratio 0.98 ± 0.11 Platelet aggregation test & Collagen arachidonic acid(%) 10.01 ± 7.74 Adenosine diphosphate(%) 34.20 ± 13.99 Homocysteine † (µmol/L) 12.57 ± 5.65 Data are shown as n (%) or the mean ± SD. *153 patients did not have CYP2C19 genotyping reported. #12 patients did not have preoperative blood coagulation reported. & 121 patients did not have platelet aggregation test reported. † 121 patients did not have homocysteine reported. Aneurysm characteristics Aneurysm characteristics are presented in Table 2 . Mean aneurysm size, neck size, and parent artery diameter were 5.45 ± 2.69 mm, 4.04 ± 1.66 mm, and 2.66 ± 0.72 mm, respectively. The size ratio,aspect ratio and height/width ratio of aneuryms were 1.71 ± 0.99, 1.12 ± 0.45 and 0.97 ± 0.34, respectively.The morphology of aneurysms was saccular in 395 (74.1%) and non saccular in 138 (25.9%). The majority of occlusions were located in anterior circulation (proximal 152 (28.5%) and distal 304 (57.1%)), 77 (14.4%) in the posterior circulation including 57 (10.6%) located in the vertebral-basilar artery and 20 (3.8%) in the vertebral artery and other posterior circulation . Table 2 Aneurysm characteristics (N = 533) Characteristic Frequency Aneurysm morphologies Average aneurysm size (maximum aneurysm length ,mm) 5.45 ± 2.69 Average neck size(mm) 4.04 ± 1.66 Average width size(mm) 4.69 ± 2.30 Average height size (mm) 4.34 ± 2.40 Average parent artery diameter(mm) 2.66 ± 0.72 Size ratio 1.71 ± 0.99 Aspect ratio 1.12 ± 0.45 Height/width ratio 0.97 ± 0.34 Aneurysm form Saccular 395 (74.1%) Non saccular 138 (25.9%) Location Anterior circulation 456 (85.6%) Anterior circulation proximal 152 (28.5%) Anterior circulation distal 304 (57.1%) Posterior circulation 77 (14.4%) Vertebral-Basilar 57 (10.6%) Other vessels in the posterior circulation* 20 (3.8%) Data is shown as n (%) or the mean ± SD. *Other arteries location on posterior circulation including the posterior cerebral artery, posterior inferior cerebellar artery, anterior inferior cerebellar artery and the superior cerebellar artery. Treatment details, angiographic, and clinical outcomes Treatment details and angiographic and clinical outcomes are presented in Table 3 . The diameter and length of Atlas stent were 3.37 ± 0.55mm and 18.34 ± 3.55mm, respectively. A Total of 21 (3.9%) aneurysms were treated by multiple NeuroForm Atlas Stents and 512 (96.1%) aneurysms were treated by single NeuroForm Atlas stent. Only one aneurysm(0.2%) received single Atlas stent treatment. Thirty three(6.2%) aneurysms with preoperative parent artery stenosis.The mean procedure duration was 152.83 ± 42.40 mins. Events of coil protrusion into parent arteries after Atlas stent Treatment were in 18 (3.4%) aneurysms.At last follow-up for each patient, the total occlusion rate was 74.5% (397/533). mRS 0–2 before the Atlas stent implant was 502 (96.2%), and mRS 3–6 was 20 (3.8%); mRS 0–2 at follow-up was 483 (92.5%) and mRS 3–6 was 39 (7.5%). Table 3 Treatment details of 533 aneurysms Procedural characteristics Frequency(N = 533 aneurysms) NeuroForm Atlas Stent size Diameter (mm) 3.37 ± 0.55 Length (mm) 18.34 ± 3.55 Multiple NeuroForm Atlas Stent used 21 (3.9%) Single NeuroForm Atlas Stent used 512 (96.1%) Blood thinners Preoperative aspirin/clopidogrel > 3 days 439/522 (84.1%) Preoperative statin > 7days 111/522 (21.3%) Preoperative anticoagulant (Warfarin/ Rivaroxaban) > 7days 5/522 (1.0%) Pre-operation parent artery stenosis 33 (6.2%) Coil protrusion 18 (3.4%) Treatment Stent-assisted coiling 532 (99.8%) Stent 1 (0.2%) Aneurysm occlusion status † (Immediate postoperative) Complete occlusion 397 (74.5%) Incomplete occlusion 136 (25.5%) Procedure duration(mins) # 152.83 ± 42.40 Clinical outcomes MRS score Preoperative mRS score 0–2 502/522 (96.2%) 3–6 20/522 (3.8%) Postoperative mRS score (< 30 d) 0–2 483/522 (92.5%) 3–6 39/522 (7.5%) Data are shown as n (%), n/N (%), or the mean ± SD. * The total number of NeuroForm Atlas Stents used was 554. # Records of operative duration were missing for 81 patients. † Each Aneurysm was evaluated using the Raymond–Roy occlusion classification (RROC) and dichotomized as occluded ( I ) or residual ( II / Ⅲ ). Morbidity, mortality, complications rate, and functional outcome Table 4 presents the study outcomes. There were 36 patients lost to clinical follow-up. Major ischemic stroke occurred in 2.1% (11/522) of patients in the early post-operative period and 0.2% (1/486) in the follow-up period). Minor stroke and/or TIA occurred in 2.9% (15/522) in the early post-operative period and 0.8% (4/486) in the follow-up period. DAR occurred in 2.3% (12/522) of patients in the early post-operative and 0.2% (1/486) in the follow-up period. The rate of Distal intraparenchymal hemorrhage(DIPH) was 0.2% (1/522) in the early postoperative period and 0% during the follow-up period. Neurologic morbidity occurred in 7.3% (38/522) in the early postoperative period and 1.2% (6/486) during the follow-up period. Acute thrombosis in stents in the early postoperative period occurred in 2.3% (12/522) versus 0.0% at the follow-up. Encephalopathy caused by contrast occurred in 0.6% (3/522) in the early postoperative period and 0% at the follow-up period. The mortality rate was 0.6% (3/522) in the early postoperative period and 0.2% (1/486) at the follow-up period. Poor functional outcome(MRS score deterioration) was observed in 5.4% (28/522) and 0.8% (4/486) in the early postoperative and the follow-up, respectively. Table 4 Morbidity, mortality, complications, and functional outcomes in the postoperative period Variable Early postoperative period (< 30 days) (N = 522) Follow-up period (3–17 months)(N = 486) # Major ischaemic stroke 11 (2.1%) 1(0.2%) TIA/minor stroke 15 (2.9%) 4(0.8%) DAR 12 (2.3%) 1(0.2%) DIPH 1 (0.2%) 0 Neurologic morbidity* 38(7.3%) 6(1.2%) Stent acute thrombosis 12 (2.3%) 0 Contrast Encephalopathy 3 (0.6%) 0 Mortality 3(0.6%) 1 (0.2%) Artery stenosis 2(0.4%) 2(0.4%) Epilepsy 1 (0.2%) 1 (0.2%) MRS score deterioration † 28 (5.4%) 4(0.8%) Data are shown as n (%). # There were 36 patients lost to clinical follow-up. * Numbers do not sum across categories and subcategories because some patients experienced > 1 event. † MRS score deterioration = Postoperative mRS score (< 30 d) /(3–17 mo)- Preoperative mRS score. Predictors of stroke Multivariate analyses for predictors of ischemic stroke, TIA, and minor stroke during the entire study duration are presented in Supplementary Table 1. At the study, cerebral infarction (OR = 4.324, P = 0.001), Hunt-Hess Grade (3–5) (OR = 2.741, P = 0.001), procedure duration(OR = 1.011, P = 0.005), stent length(OR = 1.197, P = 0.002) and coil protrusion (OR = 6.177, P = 0.004) were independent predictors of ischemic stroke. Predictors of delayed aneurysmal rupture (DAR) On multivariate analysis, cardiac disease (OR = 6.575, P = 0.004) and incomplete occlusion of immediate postoperative (OR = 5.078, P = 0.006) were independent predictors of DAR (Supplementary Table 2). Predictors of neurologic morbidity On multivariate analysis, cerebral infarction(OR = 2.869, P = 0.009), Hunt-Hess Grade (3–5)( OR = 2.408, P = 0.001), Procedure duration( OR = 1.010, P = 0.003), stent length( OR = 1.134, P = 0.010) and coil protrusion( OR = 3.941, P = 0.025) were independent predictors of neurologic morbidity (Supplementary Table 3). Predictors of stent acute thrombosis at the early postoperative period On multivariate analysis, preoperative anticoagulant (Warfarin/ Rivaroxaban) > 7 days (OR = 0.101, P < 0.0001) was protective for the formation of in-stent acute thrombosis. And size ratio( OR = 1.596, P = 0.005) and coil protrusion ( OR = 15.060, P = 0.001) were independent predictors of stent acute thrombosis in the early postoperative period (Supplementary Table 4). Predictors of poor functional outcome in the early postoperative period On multivariate analysis, independent predictors of poor functional outcome included procedure duration (OR = 1.789, P = 0.020), stent length (OR = 1.153, P = 0.021) and coil protrusion(OR = 6.451, P = 0.004) (Supplementary Table 5). Discussion The data from our study indicate that the use of Neuroform Atlas stent for treating aneurysms is associated with a favorable safety profile, with acceptable rates of morbidity and mortality. The neurological morbidity rate was 7.3% at the early postoperative period and 1.2% at follow-up period. The rates of complications during the early postoperative period were as follows: ischemic stroke (5.0%), DAR (2.3%), DIPH (0.2%), stent acute thrombosis (2.3%), and mortality (0.6%). During the follow-up period, the rates were as follows: ischemic stroke (1.0%), DAR (0.2%), DIPH (0%), stent acute thrombosis (0%), and mortality (0.2%). Approximately 86% of the major adverse events, particularly ischemic stroke, DIPH and DAR, occurred in the early postoperative period in our study. Finally, patients of mRS score deterioration at the early postoperative period and follow-up, at rates of 5.4% and 0.8%, respectively.Importantly, this study identified that procedure duration, stent length as novel independent predictors of SCA-related ischaemic stroke, neurologic morbidity and mRS score deterioration in the postoperative period. Ischaemic stroke and stent acute thrombosis complications The rate of major ischaemic stroke complications(2.1%) and stent thrombosis occurred (2.3%) in the our study was comparable to the periprocedural major ischaemic stroke rate of 2.9% and stent thrombosis 1.1% reported for a systematic review and meta-analysis by Lynch et al.[ 11 ] Similarly, a multicenter analysis of 128 aneurysms in 128 patients found that the rate of symptomatic thromboembolic stroke was 2.3%.[ 12 ] The rate of thromboembolic events of NeuroForm Atlas stents were lower than that found in a meta-analysis of the LVIS device (4.9%), Neuroform (6.7%) and Enterprise (5.9%) stents[ 13 , 14 ]. However, there are remarkably few studies regarding the risk factors related to ischemic stroke and stent thrombosis in Atlas stents. In our study, the majority of major ischaemic strokes occurred within the early postoperative period; cerebral infarction, Hunt-Hess Grade (3–5), procedure duration, stent length and coil protrusion were independent predictors of ischemic stroke. And preoperative anticoagulant (Warfarin/ Rivaroxaban) > 7 days was protective for the formation of in-stent acute thrombosis. Size ratio and coil protrusion were independent predictors of stent acute thrombosis in the early postoperative period. Russo et al. [ 15 ] found that the formation of stent thrombosis mostly occurs in the postoperative period, which may be related to the deposition of protein membranes after stent implantation[ 16 ]. Therefore, it is important to prioritize early antiplatelet therapy. Prolonged procedure duration and multiple operative procedures may result in endothelial damage due to repeated stent adjustments, which can increase the risk of ischemic stroke[ 8 ]. Patients with subarachnoid hemorrhage (SAH) are in a hypercoagulable state and are more susceptible to thromboembolism [ 17 ]. Longer stents have the potential to obstruct collateral circulation, resulting in reduced or blocked blood flow, leading to ischemic stroke. Additionally, coil herniation into the parent artery can impede blood flow, contributing to ischemic stroke.[ 18 ] DAR and DIPH Lynch et al. [ 11 ] reported an incidence of 1.4% for intraprocedural rupture or vessel dissection, and 1.0% for periprocedural or early hemorrhage. In a multicenter postmarket analysis, 2 patients (1.6%) experienced hemorrhagic complications, with one occurring during the procedure and the second during postoperative follow-up. [ 12 ] In comparison, our study demonstrated a slightly higher rate of DAR (2.5%), with 92% of DARs occurring in the early postoperative period. Cardiac disease and incomplete occlusion immediately after the procedure were identified as independent predictors of DAR during the early postoperative period. In our study, only one patient experienced DIPH events during the early postoperative period. Incomplete occlusion immediately after the procedure may result in acute thrombosis within the aneurysm. Kulcsar et al[ 19 ] hypothesized that the rapid formation of an intraluminal thrombus could trigger protease secretion, de-endothelialization, and leukocyte infiltration of the aneurysm wall, leading to weakened wall integrity and eventual aneurysm rupture. Functional outcomes Sweid et al. reported that 91.8% of patients achieved a favorable clinical outcome (mRS 0–2), with a mortality rate of 1.4%.[ 9 ] Hanel et al.[ 20 ] reported 2 unrelated deaths occurring beyond 30 days post-procedure, and at 1 year, 84.4% (27/32) of patients had a modified Rankin Score of 0 to 2. In our study, the mortality rate during the early postoperative period was 0.6%, and at the follow-up period, it was 0.2%. Poor functional outcome (MRS score deterioration) was observed in 5.4% and 0.8% during the early postoperative and follow-up periods, respectively, which aligns with the previously reported findings. Additionally, our study identified procedure duration, stent length, and coil protrusion as independent predictors of poor functional outcome, which are associated with complications related to ischemic stroke. Overall, this study demonstrated that procedure duration and stent length are novel independent predictors of SCA-related ischemic stroke, neurologic morbidity, and deterioration in mRS score during the postoperative period. Our study offers predictive factors to evaluate the risk of complications in Chinese patients with intracranial aneurysms treated with the Atlas stent. Limitations The limitations of this study are inherent to its single-center, retrospective design, which introduces potential biases. Additionally, the relatively short follow-up duration may have resulted in an underestimation of the complications rate. Conclusion The incidence of SCA(stent-assisted coiling)-related complications with Neuroform Atlas stent in this study was similar to that in the Western population. We found that procedure duration, stent length as novel independent predictors of SCA-related ischaemic stroke, neurologic morbidity and mRS score deterioration in the postoperative period in a Chinese population. Abbreviations SCA stent-assisted coiling mRS Modified Rankin scale SR Size ratio AR Aspect ratio HW Height/width ratio DAR Delayed aneurysm rupture DIPH Distal intraparenchymal hemorrhage TIA Transient ischemic attack SAH Subarachnoid hemorrhage DSA Digital subtraction angiography OR Odds ratio Declarations Ethics approval and consent to participate In accordance with the Declaration of Helsinki, the study protocol underwent review and approval by the People's Hospital of Bayingoleng Mongolia Autonomous Prefecture Institutional Review Board. The informed consent process was waived by People's Hospital of Bayingoleng Mongolia Autonomous Prefecture Institutional Review Board due to the retrospective nature of the study design. Consent for publication I confirm that these papers are original, the other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in these articles. All authors have no ethical issues and conflicts of interest, and complete contact information for the corresponding author. All authors have read and approved the submitted manuscript, the manuscripts have not been submitted elsewhere nor published elsewhere in whole or in part. Availability of data and materials All authors make sure that all data and materials as well as software application support our published claims and comply with field standards. Competing interests The other authors have no actual or potential conflict of interest in relation to this article. Funding No funding was received for conducting this study. Authors' contributions Yuhua Guan and Yisen Zhang contributed to the study conception and design. Material preparation, data collection and analysis were performed by Shibao Chen, Dili Wang, Yan Li, Jamali Aikebaier and Yabo Li. The first draft of the manuscript was written by Huibin Kang and all authors commented on previous versions of the manuscript. 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J Neuroradiol. 2021;48(6):479–85. 10.1016/j.neurad.2020.02.006 . Epub 2020/03/25. Simon C, Palmaz JC, Sprague EA. Protein interactions with endovascular prosthetic surfaces. J Long Term Eff Med Implants. 2000;10(1–2):127–41. 10.1615/jlongtermeffmedimplants.v10.i12.110 . Epub 2000/08/18. Rajajee V, Brown DM, Tuhrim S. Coagulation abnormalities following primary intracerebral hemorrhage. J Stroke Cerebrovasc Dis. 2004;13(2):47–51. 10.1016/j.jstrokecerebrovasdis.2004.01 . Epub 2007/10/02. Shim YS, Park SK, Chung J. Preliminary experience of stent salvage using Neuroform Atlas stent for procedure-related complication during coil embolization of intracranial aneurysms. Clin Neurol Neurosurg. 2020;190:105654. 10.1016/j.clineuro.2019.105654 . Epub 2020/01/07. Kulcsar Z, Houdart E, Bonafe A, et al. Intra-aneurysmal thrombosis as a possible cause of delayed aneurysm rupture after flow-diversion treatment. AJNR Am J Neuroradiol. 2011;32(1):20–5. 10.3174/ajnr.A2370 . Epub 2010/11/13. Hanel RA, Yoon N, Sauvageau E, et al. Neurosurgery. 2021;89(1):102–8. 10.1093/neuros/nyab090 . Epub 2021/04/08. Neuroform Atlas Stent for Treatment of Middle Cerebral Artery Aneurysms: 1-Year Outcomes From Neuroform Atlas Stent Pivotal Trial. Additional Declarations No competing interests reported. Supplementary Files SUPPLEMENTALMATERIAL.docx Cite Share Download PDF Status: Published Journal Publication published 10 Jun, 2024 Read the published version in BMC Neurology → Version 1 posted Editorial decision: Revision requested 07 Feb, 2024 Editor assigned by journal 05 Feb, 2024 Submission checks completed at journal 04 Feb, 2024 First submitted to journal 14 Dec, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3754137","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":271102032,"identity":"b80978b3-dae7-4faa-8155-14cc0d89bd29","order_by":0,"name":"Shibao Chen","email":"","orcid":"","institution":"People's Hospital of Bayingoleng Mongolia Autonomous Prefecture, Xinjiang, China","correspondingAuthor":false,"prefix":"","firstName":"Shibao","middleName":"","lastName":"Chen","suffix":""},{"id":271102033,"identity":"6373faf8-bf57-4693-9b0d-bc5d2bca3d7a","order_by":1,"name":"Huibin Kang","email":"","orcid":"","institution":"Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China","correspondingAuthor":false,"prefix":"","firstName":"Huibin","middleName":"","lastName":"Kang","suffix":""},{"id":271102034,"identity":"2f7eda2f-f687-41c6-9377-83c1640fdb6b","order_by":2,"name":"Dili Wang","email":"","orcid":"","institution":"People's Hospital of Jiangxia District, Wuhan, China","correspondingAuthor":false,"prefix":"","firstName":"Dili","middleName":"","lastName":"Wang","suffix":""},{"id":271102035,"identity":"af4c2c4b-9e8a-4f8e-8743-896ad898a94e","order_by":3,"name":"Yan Li","email":"","orcid":"","institution":"Third people's Hospital of Jinan, Jinan,China","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Li","suffix":""},{"id":271102036,"identity":"04ac7af4-a748-4fc2-8d92-4d086690db72","order_by":4,"name":"Jamali Aikeba","email":"","orcid":"","institution":"People's Hospital of Bayingoleng Mongolia Autonomous Prefecture, Xinjiang, China","correspondingAuthor":false,"prefix":"","firstName":"Jamali","middleName":"","lastName":"Aikeba","suffix":""},{"id":271102037,"identity":"b7b0f192-8d22-4ac9-b764-13061cbcb34e","order_by":5,"name":"Yabo Li","email":"","orcid":"","institution":"People's Hospital of Bayingoleng Mongolia Autonomous Prefecture, Xinjiang, China","correspondingAuthor":false,"prefix":"","firstName":"Yabo","middleName":"","lastName":"Li","suffix":""},{"id":271102038,"identity":"e3b45e84-1ecd-4e10-ab14-721e5892fb40","order_by":6,"name":"Yuhua Guan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYDACCeYDBz5UgFggxg+itLAlPpxxBsRiSzw4s4coLTzGxrxtIBaP8WEONiJ0GNxuMJPgYatN7J/d8+EwAw+DPL/YAQJa7hxIk5DgOZ44487ZDYcLLBgMZ85OIKDlRsIxCQOJY4kNN3I3HJ7Bw5BgcJuglsQ2iQSDY4nzb+Q8OMzDRpSWZGaDAwk1iRtu5DAQp0XyRhrjw4YDB4w33kgzAAayBGG/8N3I/3D477862Xk3kh9/+PDDRp5fmoAWhQNg6jCML4FfOQjIN4CpOsIqR8EoGAWjYOQCAHISUo/ssFrRAAAAAElFTkSuQmCC","orcid":"","institution":"People's Hospital of Bayingoleng Mongolia Autonomous Prefecture, Xinjiang, China","correspondingAuthor":true,"prefix":"","firstName":"Yuhua","middleName":"","lastName":"Guan","suffix":""},{"id":271102039,"identity":"c2a5432e-5e33-41ad-a602-59c5c41f6e43","order_by":7,"name":"Yisen Zhang","email":"","orcid":"","institution":"Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China","correspondingAuthor":false,"prefix":"","firstName":"Yisen","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2023-12-14 14:59:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3754137/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3754137/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12883-024-03695-z","type":"published","date":"2024-06-10T14:49:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58822091,"identity":"f80044da-3a14-44b1-98c2-8dddc88d6430","added_by":"auto","created_at":"2024-06-21 16:30:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":791005,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3754137/v1/c7f71459-35ce-4e62-a469-d720429200a5.pdf"},{"id":50706969,"identity":"2fa68325-550f-4e13-bde9-9bfd14afed8b","added_by":"auto","created_at":"2024-02-06 06:23:00","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":58542,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMENTALMATERIAL.docx","url":"https://assets-eu.researchsquare.com/files/rs-3754137/v1/5d9c8a5dbab94dbfa04a17a2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eNeuroform Atlas Stent Treatment for 533 Intracranial Aneurysms in a Large Chinese Cohort: Complication Risk Factor Analysis\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe treatment of Intracranial aneurysms using SAC has been practiced for over 20 years. SAC has shown better occlusion rates compared to coiling alone, and flow diversion has achieved occlusion rates of up to 80% with an acceptable safety profile.[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] However, the use of stents in coiling is associated with a higher complication rate compared to coiling or balloon-assisted coiling. A recent meta-analysis of low-profile stents reported a procedure-related complication rate of 12.4%[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. At present, A large number of studies have been published on procedure-related complications using intracranial stents, such as Neuroform (Stryker, Kalamazoo, MI, USA), Enterprise (Codman,Raynham,MA,USA), Solitaire (Covidien, Irvine, CA, USA) and LVIS (MicroV ention, T ustin, California),etc.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] However, There are only limited reports of complications associated with the newest generation of the widely used Neuroform Atlas stent. which was approved by the U.S. Food and Drug Administration in May 2019. Approved for use in China in October 2020. To our knowledge, This is the largest cohort retrospective study of procedure-related complications with the recently introduced small-size Atlas stent.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthics approval, Participants and Study design\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective evaluation of 522 patients with 533 intracranial aneurysms, including both ruptured and unruptured cases, who were treated with the Neuroform Atlas stent between November 2020 and January 2022 in China. The study protocol underwent review and approval by the Institutional Review Board. The informed consent process was waived due to the retrospective nature of the study design.\u003c/p\u003e \u003cp\u003ePatient demographic data, including gender, age, hypertension, diabetes, hyperlipidemia, cerebral infarction, cardiac disease, smoking, alcohol abuse, presentation, Hunt-Hess Grade, previous treatment, CYP2C19 genotyping, platelet aggregation test (PAgT), collagen arachidonic acid (AA), and adenosine diphosphate (ADP), were collected by reviewing the medical charts.\u003c/p\u003e \u003cp\u003eThe parameters related to the characteristics of aneurysms extracted from digital subtraction angiography (DSA) include aneurysm size, neck size, aneurysm width, aneurysm height, parent artery diameter, Size ratio(SR), Aspect ratio༈AR༉, Height/width ratio༈HW༉, Aneurysm form, Aneurysm location. reviewed aneurysm size definitions reported in the literature and the most commonly cited definition was \u0026ldquo;maximal dimension of the aneurysmal dome.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Neck size is defined as the maximum neck diameter, Aneurysm width is defined as Maximal longitudinal diameter of dome parallel with neck plane, Aneurysm height size is defined as the maximum neck diameter, SR is defined asMaximal aneurysm height/parent vessels mean diameter,AR is defined as Maximal distance from neck to aneurysm dome/maximal neck width,HW is defined as Maximal distance from neck to aneurysm dome/maximal width of dome orthogonal to maximal height.Aneurysm form includes saccular and non-saccular. Aneurysm location (anterior or posterior circulation). The anterior circulation was divided into the proximal and distal anterior circulation. The proximal anterior circulation was defined as arteries from the beginning of the internal carotid artery to the bifurcation of the internal carotid artery, including the ophthalmic artery, arterial segment in the cavernous sinus, posterior communicating artery, superior hypophyseal artery and posterior carotid wall. The distal anterior circulation was defined as the arteries branching from the internal carotid artery, including the anterior and middle cerebral arteries.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] The posterior circulation divided into the Vertebral-Basilar and Other vessels in the posterior circulation(the posterior cerebral artery, posterior inferior cerebellar artery, anterior inferior cerebellar artery and the superior cerebellar artery).\u003c/p\u003e \u003cp\u003eThe study endpoints included pre- and early postoperative (\u0026lt;\u0026thinsp;30 days) functional outcomes (modified Rankin Scale [mRS] score), Complications related to AS treatment in the early postoperative period and during last clinical follow-up (3 to 17 months, mean 9.7 months). Multivariate analysis was performed to identify risk factors for complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eProcedural details\u003c/h2\u003e \u003cp\u003eElectively treated patients took clopidogrel 75 mg and aspirin 100 mg daily at least five days before the procedure.A Platelet aggregation test and CYP2C19 genotyping test were performed to ensure a good response to clopidogrel. Patients were switched from clopidogrel to Ticagrelor (loading dose of 180 mg and a daily maintenance of 90 mg twice daily) if they were hypo-responders to clopidogrel. All patients were prescribed 75 mg of clopidogrel daily for 12 weeks and 100 mg of aspirin daily for at least 12 months, after the procedure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePatient Follow-up and End Points\u003c/h2\u003e \u003cp\u003ePatients were scheduled for clinical follow-up at an interval of 3mo, and 6 mo with the neurointerventionalist. At every clinical followup, functional outcome was assessed using the modified Rankin scale (mRS); scores ranging from 0 to 2 were regarded as favorable. Follow-up radiological examination at 6 mo was performed primarily with DSA. Aneurysm occlusion was graded using the modified Raymond-Roy-occlusion-outcome (MRRC) on the final control run and on follow-up angiograms.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eNeurological complications were predefined as the composite of the following complications: spontaneous aneurysm rupture, ipsilateral intracranial hemorrhage, ischemic stroke, parent artery stenosis, and cranial neuropathy. We defined the degree of ischemic stroke according to changes in the National Institutes of Health Stroke Scale [NIHSS] score: minor neurological stroke was defined as an NIHSS score change\u0026thinsp;\u0026le;\u0026thinsp;4, lasting less than 7 days, imaging confirmed; transient ischemia attacks (TIA) were defined as transient neurological deficits without confirmatory imaging; and major ischemic stroke was defined as changes in NIHSS score\u0026thinsp;\u0026gt;\u0026thinsp;4, lasting more than 7 days, with confirmatory imaging[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Poor functional outcomes were evaluated according to a deteriorated modified Rankin scale (mRS) score, which we defined as the mRS score preoperation vs the mRS score early postoperation or during follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eUnivariate analysis of discrete data was performed using Chi square or Fisher exact test. T-test were conducted to determine differences between parametric dependent variables. For continuous data with deviation from normality, including analysis of scores or ranked data,nonparametric tests were utilized. We performed multivariate logistic analysis of the predictors of neurological complications to independent risk factors. All analyses were performed with SPSS version 25 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBaseline characteristics\u003c/p\u003e \u003cp\u003eDemographic and baseline characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 522 patients with 533 aneurysm were treated using the Neuroform Atlas Stent. Mean age was 58.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9 years and 341(65.3%) patients were female. Co-morbidities included hypertension 337(64.6%), diabetes 83(15.9%), hyperlipidemia 150(28.7%), cerebral infarction 89(17.0%), cardiac disease 43(8.2%), peripheral venous thrombosis 4 (0.8%) and renal insufficiency 6(1.1%). Patients were symptomatic in 238(45.6%) of patients, incidental in 188 (36.0%), and 96 (18.4%) of patients had SAH. Twenty-five(4.8%) aneurysms were treated by clipping or coiling.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of 522 patients treated with the Neuroform Atlas Stent:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (N\u0026thinsp;=\u0026thinsp;522)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal number of aneurysms treated with the Neuroform Atlas Stent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e533\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatients with multiple aneurysms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e157 (30.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e341 (65.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge(years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e337 (64.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (15.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperlipidaemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150 (28.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebral infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89 (17.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43(8.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral venous thrombosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal insufficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(1.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmoking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e402(77.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65(12.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlcohol abuse\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e448 (85.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePresentation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncidental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e188 (36.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptomatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e238(45.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent SAH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96 (18.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHunt-Hess Grade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eI-II\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72/96 (75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eⅢ-IV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24/96 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious treatment(coiling/stent)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (4.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCYP2C19 genotyping*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e362 (69.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFast metabolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e163 (45.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate metabolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e152 (42.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlow metabolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative coagulation\u0026nbsp;test\u003c/b\u003e\u003csup\u003e\u003cb\u003e#\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProthrombin time(s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternational standard ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlatelet aggregation test\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026amp;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollagen arachidonic acid(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.01\u0026thinsp;\u0026plusmn;\u0026thinsp;7.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenosine diphosphate(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.20\u0026thinsp;\u0026plusmn;\u0026thinsp;13.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHomocysteine\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e(\u0026micro;mol/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.57\u0026thinsp;\u0026plusmn;\u0026thinsp;5.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eData are shown as n (%) or the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e*153 patients did not have CYP2C19 genotyping reported.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e#12 patients did not have preoperative blood coagulation reported.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u0026amp; 121 patients did not have platelet aggregation test reported.\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e 121 patients did not have homocysteine reported.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAneurysm characteristics\u003c/p\u003e \u003cp\u003eAneurysm characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Mean aneurysm size, neck size, and parent artery diameter were 5.45\u0026thinsp;\u0026plusmn;\u0026thinsp;2.69 mm, 4.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.66 mm, and 2.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72 mm, respectively. The size ratio,aspect ratio and height/width ratio of aneuryms were 1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99, 1.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45 and 0.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34, respectively.The morphology of aneurysms was saccular in 395 (74.1%) and non saccular in 138 (25.9%). The majority of occlusions were located in anterior circulation (proximal 152 (28.5%) and distal 304 (57.1%)), 77 (14.4%) in the posterior circulation including 57 (10.6%) located in the vertebral-basilar artery and 20 (3.8%) in the vertebral artery and other posterior circulation .\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAneurysm characteristics\u003cb\u003e(N\u0026thinsp;=\u0026thinsp;533)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAneurysm morphologies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage aneurysm size (maximum aneurysm length ,mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.45\u0026thinsp;\u0026plusmn;\u0026thinsp;2.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage neck size(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage width size(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.69\u0026thinsp;\u0026plusmn;\u0026thinsp;2.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage height size (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.34\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage parent artery diameter(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSize ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspect ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight/width ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAneurysm form\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaccular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e395 (74.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon saccular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138 (25.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior circulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e456 (85.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior circulation proximal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e152 (28.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior circulation distal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e304 (57.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior circulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (14.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertebral-Basilar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (10.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther vessels in the posterior circulation*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eData is shown as n (%) or the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003cp\u003e*Other arteries location on posterior circulation including the posterior cerebral artery, posterior inferior cerebellar artery, anterior inferior cerebellar artery and the superior cerebellar artery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eTreatment details, angiographic, and clinical outcomes\u003c/h3\u003e\n\u003cp\u003eTreatment details and angiographic and clinical outcomes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The diameter and length of Atlas stent were 3.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55mm and 18.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.55mm, respectively. A Total of 21 (3.9%) aneurysms were treated by multiple NeuroForm Atlas Stents and 512 (96.1%) aneurysms were treated by single NeuroForm Atlas stent. Only one aneurysm(0.2%) received single Atlas stent treatment. Thirty three(6.2%) aneurysms with preoperative parent artery stenosis.The mean procedure duration was 152.83\u0026thinsp;\u0026plusmn;\u0026thinsp;42.40 mins. Events of coil protrusion into parent arteries after Atlas stent Treatment were in 18 (3.4%) aneurysms.At last follow-up for each patient, the total occlusion rate was 74.5% (397/533). mRS 0\u0026ndash;2 before the Atlas stent implant was 502 (96.2%), and mRS 3\u0026ndash;6 was 20 (3.8%); mRS 0\u0026ndash;2 at follow-up was 483 (92.5%) and mRS 3\u0026ndash;6 was 39 (7.5%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTreatment details of 533 aneurysms\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedural characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency(N\u0026thinsp;=\u0026thinsp;533 aneurysms)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNeuroForm Atlas Stent size\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiameter (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMultiple NeuroForm Atlas Stent used\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSingle NeuroForm Atlas Stent used\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e512 (96.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood thinners\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative aspirin/clopidogrel\u0026thinsp;\u0026gt;\u0026thinsp;3 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e439/522 (84.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative statin\u0026thinsp;\u0026gt;\u0026thinsp;7days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111/522 (21.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative anticoagulant (Warfarin/ Rivaroxaban)\u0026thinsp;\u0026gt;\u0026thinsp;7days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/522 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePre-operation parent artery stenosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (6.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCoil protrusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTreatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStent-assisted coiling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e532 (99.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAneurysm occlusion status\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u003c/sup\u003e \u003cb\u003e(Immediate postoperative)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete\u0026nbsp;occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e397 (74.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncomplete\u0026nbsp;occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136 (25.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcedure duration(mins)\u003c/b\u003e\u003csup\u003e\u003cb\u003e#\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e152.83\u0026thinsp;\u0026plusmn;\u0026thinsp;42.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMRS score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative mRS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e502/522 (96.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20/522 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative mRS score (\u0026lt;\u0026thinsp;30 d)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e483/522 (92.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39/522 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are shown as n (%), n/N (%), or the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e* The total number of NeuroForm Atlas Stents used was 554.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e# Records of operative duration were missing for 81 patients.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003eEach Aneurysm was evaluated using the Raymond\u0026ndash;Roy occlusion classification (RROC) and dichotomized as occluded (\u003cb\u003eI\u003c/b\u003e) or residual (\u003cb\u003eII\u003c/b\u003e/\u003cb\u003eⅢ\u003c/b\u003e).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMorbidity, mortality, complications rate, and functional outcome\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents the study outcomes. There were 36 patients lost to clinical follow-up. Major ischemic stroke occurred in 2.1% (11/522) of patients in the early post-operative period and 0.2% (1/486) in the follow-up period). Minor stroke and/or TIA occurred in 2.9% (15/522) in the early post-operative period and 0.8% (4/486) in the follow-up period. DAR occurred in 2.3% (12/522) of patients in the early post-operative and 0.2% (1/486) in the follow-up period. The rate of Distal intraparenchymal hemorrhage(DIPH) was 0.2% (1/522) in the early postoperative period and 0% during the follow-up period. Neurologic morbidity occurred in 7.3% (38/522) in the early postoperative period and 1.2% (6/486) during the follow-up period. Acute thrombosis in stents in the early postoperative period occurred in 2.3% (12/522) versus 0.0% at the follow-up. Encephalopathy caused by contrast occurred in 0.6% (3/522) in the early postoperative period and 0% at the follow-up period. The mortality rate was 0.6% (3/522) in the early postoperative period and 0.2% (1/486) at the follow-up period. Poor functional outcome(MRS score deterioration) was observed in 5.4% (28/522) and 0.8% (4/486) in the early postoperative and the follow-up, respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMorbidity, mortality, complications, and functional outcomes in the postoperative period\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly postoperative period (\u0026lt;\u0026thinsp;30 days) (N\u0026thinsp;=\u0026thinsp;522)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFollow-up period\u003c/p\u003e \u003cp\u003e(3\u0026ndash;17 months)(N\u0026thinsp;=\u0026thinsp;486)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMajor ischaemic stroke\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTIA/minor stroke\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDAR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDIPH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeurologic morbidity*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38(7.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(1.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStent acute thrombosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eContrast Encephalopathy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMortality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eArtery stenosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEpilepsy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMRS score deterioration\u003c/b\u003e \u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eData are shown as n (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e#\u003c/sup\u003eThere were 36 patients lost to clinical follow-up.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e* Numbers do not sum across categories and subcategories because some patients experienced\u0026thinsp;\u0026gt;\u0026thinsp;1 event.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u003c/sup\u003eMRS score deterioration\u0026thinsp;=\u0026thinsp;Postoperative mRS score (\u0026lt;\u0026thinsp;30 d) /(3\u0026ndash;17 mo)- Preoperative mRS score.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePredictors of stroke\u003c/p\u003e \u003cp\u003eMultivariate analyses for predictors of ischemic stroke, TIA, and minor stroke during the entire study duration are presented in Supplementary Table\u0026nbsp;1. At the study, cerebral infarction (OR\u0026thinsp;=\u0026thinsp;4.324, P\u0026thinsp;=\u0026thinsp;0.001), Hunt-Hess Grade (3\u0026ndash;5) (OR\u0026thinsp;=\u0026thinsp;2.741, P\u0026thinsp;=\u0026thinsp;0.001), procedure duration(OR\u0026thinsp;=\u0026thinsp;1.011, P\u0026thinsp;=\u0026thinsp;0.005), stent length(OR\u0026thinsp;=\u0026thinsp;1.197, P\u0026thinsp;=\u0026thinsp;0.002) and coil protrusion (OR\u0026thinsp;=\u0026thinsp;6.177, P\u0026thinsp;=\u0026thinsp;0.004) were independent predictors of ischemic stroke.\u003c/p\u003e \u003cp\u003ePredictors of delayed aneurysmal rupture (DAR)\u003c/p\u003e \u003cp\u003eOn multivariate analysis, cardiac disease (OR\u0026thinsp;=\u0026thinsp;6.575, P\u0026thinsp;=\u0026thinsp;0.004) and incomplete occlusion of immediate postoperative (OR\u0026thinsp;=\u0026thinsp;5.078, P\u0026thinsp;=\u0026thinsp;0.006) were independent predictors of DAR (Supplementary Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003ePredictors of neurologic morbidity\u003c/p\u003e \u003cp\u003eOn multivariate analysis, cerebral infarction(OR\u0026thinsp;=\u0026thinsp;2.869, P\u0026thinsp;=\u0026thinsp;0.009), Hunt-Hess Grade (3\u0026ndash;5)( OR\u0026thinsp;=\u0026thinsp;2.408, P\u0026thinsp;=\u0026thinsp;0.001), Procedure duration( OR\u0026thinsp;=\u0026thinsp;1.010, P\u0026thinsp;=\u0026thinsp;0.003), stent length( OR\u0026thinsp;=\u0026thinsp;1.134, P\u0026thinsp;=\u0026thinsp;0.010) and coil protrusion( OR\u0026thinsp;=\u0026thinsp;3.941, P\u0026thinsp;=\u0026thinsp;0.025) were independent predictors of neurologic morbidity (Supplementary Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003ePredictors of stent acute thrombosis at the early postoperative period\u003c/p\u003e \u003cp\u003eOn multivariate analysis, preoperative anticoagulant (Warfarin/ Rivaroxaban)\u0026thinsp;\u0026gt;\u0026thinsp;7 days (OR\u0026thinsp;=\u0026thinsp;0.101, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) was protective for the formation of in-stent\u003c/p\u003e \u003cp\u003eacute thrombosis. And size ratio( OR\u0026thinsp;=\u0026thinsp;1.596, P\u0026thinsp;=\u0026thinsp;0.005) and coil protrusion ( OR\u0026thinsp;=\u0026thinsp;15.060, P\u0026thinsp;=\u0026thinsp;0.001) were independent predictors of stent acute thrombosis in the early postoperative period (Supplementary Table\u0026nbsp;4).\u003c/p\u003e \u003cp\u003ePredictors of poor functional outcome in the early postoperative period\u003c/p\u003e \u003cp\u003eOn multivariate analysis, independent predictors of poor functional outcome included procedure duration (OR\u0026thinsp;=\u0026thinsp;1.789, P\u0026thinsp;=\u0026thinsp;0.020), stent length (OR\u0026thinsp;=\u0026thinsp;1.153, P\u0026thinsp;=\u0026thinsp;0.021) and coil protrusion(OR\u0026thinsp;=\u0026thinsp;6.451, P\u0026thinsp;=\u0026thinsp;0.004) (Supplementary Table\u0026nbsp;5).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe data from our study indicate that the use of Neuroform Atlas stent for treating aneurysms is associated with a favorable safety profile, with acceptable rates of morbidity and mortality. The neurological morbidity rate was 7.3% at the early postoperative period and 1.2% at follow-up period. The rates of complications during the early postoperative period were as follows: ischemic stroke (5.0%), DAR (2.3%), DIPH (0.2%), stent acute thrombosis (2.3%), and mortality (0.6%). During the follow-up period, the rates were as follows: ischemic stroke (1.0%), DAR (0.2%), DIPH (0%), stent acute thrombosis (0%), and mortality (0.2%). Approximately 86% of the major adverse events, particularly ischemic stroke, DIPH and DAR, occurred in the early postoperative period in our study. Finally, patients of mRS score deterioration at the early postoperative period and follow-up, at rates of 5.4% and 0.8%, respectively.Importantly, this study identified that procedure duration, stent length as novel independent predictors of SCA-related ischaemic stroke, neurologic morbidity and mRS score deterioration in the postoperative period.\u003c/p\u003e \u003cp\u003eIschaemic stroke and stent acute thrombosis complications\u003c/p\u003e \u003cp\u003eThe rate of major ischaemic stroke complications(2.1%) and stent thrombosis occurred (2.3%) in the our study was comparable to the periprocedural major ischaemic stroke rate of 2.9% and stent thrombosis 1.1% reported for a systematic review and meta-analysis by Lynch et al.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Similarly, a multicenter analysis of 128 aneurysms in 128 patients found that the rate of symptomatic thromboembolic stroke was 2.3%.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] The rate of thromboembolic events of NeuroForm Atlas stents were lower than that found in a meta-analysis of the LVIS device (4.9%), Neuroform (6.7%) and Enterprise (5.9%) stents[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, there are remarkably few studies regarding the risk factors related to ischemic stroke and stent thrombosis in Atlas stents. In our study, the majority of major ischaemic strokes occurred within the early postoperative period; cerebral infarction, Hunt-Hess Grade (3\u0026ndash;5), procedure duration, stent length and coil protrusion were independent predictors of ischemic stroke. And preoperative anticoagulant (Warfarin/ Rivaroxaban)\u0026thinsp;\u0026gt;\u0026thinsp;7 days was protective for the formation of in-stent acute thrombosis. Size ratio and coil protrusion were independent predictors of stent acute thrombosis in the early postoperative period. Russo et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] found that the formation of stent thrombosis mostly occurs in the postoperative period, which may be related to the deposition of protein membranes after stent implantation[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, it is important to prioritize early antiplatelet therapy. Prolonged procedure duration and multiple operative procedures may result in endothelial damage due to repeated stent adjustments, which can increase the risk of ischemic stroke[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Patients with subarachnoid hemorrhage (SAH) are in a hypercoagulable state and are more susceptible to thromboembolism [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Longer stents have the potential to obstruct collateral circulation, resulting in reduced or blocked blood flow, leading to ischemic stroke. Additionally, coil herniation into the parent artery can impede blood flow, contributing to ischemic stroke.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDAR and DIPH\u003c/p\u003e \u003cp\u003eLynch et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] reported an incidence of 1.4% for intraprocedural rupture or vessel dissection, and 1.0% for periprocedural or early hemorrhage. In a multicenter postmarket analysis, 2 patients (1.6%) experienced hemorrhagic complications, with one occurring during the procedure and the second during postoperative follow-up. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn comparison, our study demonstrated a slightly higher rate of DAR (2.5%), with 92% of DARs occurring in the early postoperative period. Cardiac disease and incomplete occlusion immediately after the procedure were identified as independent predictors of DAR during the early postoperative period. In our study, only one patient experienced DIPH events during the early postoperative period. Incomplete occlusion immediately after the procedure may result in acute thrombosis within the aneurysm. Kulcsar et al[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] hypothesized that the rapid formation of an intraluminal thrombus could trigger protease secretion, de-endothelialization, and leukocyte infiltration of the aneurysm wall, leading to weakened wall integrity and eventual aneurysm rupture.\u003c/p\u003e \u003cp\u003eFunctional outcomes\u003c/p\u003e \u003cp\u003eSweid et al. reported that 91.8% of patients achieved a favorable clinical outcome (mRS 0\u0026ndash;2), with a mortality rate of 1.4%.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Hanel et al.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] reported 2 unrelated deaths occurring beyond 30 days post-procedure, and at 1 year, 84.4% (27/32) of patients had a modified Rankin Score of 0 to 2. In our study, the mortality rate during the early postoperative period was 0.6%, and at the follow-up period, it was 0.2%. Poor functional outcome (MRS score deterioration) was observed in 5.4% and 0.8% during the early postoperative and follow-up periods, respectively, which aligns with the previously reported findings. Additionally, our study identified procedure duration, stent length, and coil protrusion as independent predictors of poor functional outcome, which are associated with complications related to ischemic stroke.\u003c/p\u003e \u003cp\u003eOverall, this study demonstrated that procedure duration and stent length are novel independent predictors of SCA-related ischemic stroke, neurologic morbidity, and deterioration in mRS score during the postoperative period. Our study offers predictive factors to evaluate the risk of complications in Chinese patients with intracranial aneurysms treated with the Atlas stent.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe limitations of this study are inherent to its single-center, retrospective design, which introduces potential biases. Additionally, the relatively short follow-up duration may have resulted in an underestimation of the complications rate.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe incidence of SCA(stent-assisted coiling)-related complications with Neuroform Atlas stent in this study was similar to that in the Western population. We found that procedure duration, stent length as novel independent predictors of SCA-related ischaemic stroke, neurologic morbidity and mRS score deterioration in the postoperative period in a Chinese population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSCA \u0026nbsp; stent-assisted coiling\u003c/p\u003e\n\u003cp\u003emRS\u0026nbsp; \u0026nbsp;Modified Rankin scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSR \u0026nbsp; \u0026nbsp;Size ratio\u003c/p\u003e\n\u003cp\u003eAR \u0026nbsp; \u0026nbsp;Aspect ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHW \u0026nbsp; Height/width ratio\u003c/p\u003e\n\u003cp\u003eDAR \u0026nbsp; \u0026nbsp;Delayed aneurysm rupture\u003c/p\u003e\n\u003cp\u003eDIPH \u0026nbsp; \u0026nbsp;Distal intraparenchymal hemorrhage\u003c/p\u003e\n\u003cp\u003eTIA \u0026nbsp; \u0026nbsp;Transient ischemic attack\u003c/p\u003e\n\u003cp\u003eSAH \u0026nbsp; Subarachnoid hemorrhage\u003c/p\u003e\n\u003cp\u003eDSA \u0026nbsp; Digital subtraction angiography\u003c/p\u003e\n\u003cp\u003eOR \u0026nbsp; \u0026nbsp; Odds ratio\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn accordance with the Declaration of Helsinki, the study protocol underwent review and approval by the People\u0026apos;s Hospital of Bayingoleng Mongolia Autonomous Prefecture Institutional Review Board. The informed consent process was waived by People\u0026apos;s Hospital of Bayingoleng Mongolia Autonomous Prefecture Institutional Review Board due to the retrospective nature of the study design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI confirm that these papers are original, the other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in these articles. All authors have no ethical issues and conflicts of interest, and complete contact information for the corresponding author. All authors have read and approved the submitted manuscript, the manuscripts have not been submitted elsewhere nor published elsewhere in whole or in part.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors make sure that all data and materials as well as software application support our published claims and comply with field standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe other authors have no actual or potential conflict of interest in relation to this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for conducting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYuhua Guan and Yisen Zhang contributed to the study conception and design. Material preparation, data collection and analysis were performed by Shibao Chen, Dili Wang, Yan Li, Jamali Aikebaier and Yabo Li. The first draft of the manuscript was written by Huibin Kang and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLin N, Brouillard AM, Krishna C, et al. Use of coils in conjunction with the pipeline embolization device for treatment of intracranial aneurysms. Neurosurgery. 2015;76(2):142\u0026ndash;9. 10.1227. Epub 2014/09/26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark MS, Kilburg C, Taussky P, et al. Pipeline Embolization Device with or without Adjunctive Coil Embolization: Analysis of Complications from the IntrePED Registry. 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Neuroform Atlas Stent for Treatment of Middle Cerebral Artery Aneurysms: 1-Year Outcomes From Neuroform Atlas Stent Pivotal Trial.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intracranial Aneurysms, Neuroform Atlas Stent, Treatment, Complication, Risk Factor","lastPublishedDoi":"10.21203/rs.3.rs-3754137/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3754137/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe newest generation Neuroform Atlas stent\u0026trade; (by Stryker, Fremont, California)represents a recent advance in cerebral laser-cut microstents for the treatment of intracranial wide-necked aneurysms and the postoperative complications have been observed in cases among Western populations.We assessed predictors of complications, morbidity, and unfavorable outcomes in a large cohort of patients with aneurysm treated with Neuroform Atlas stent in China.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective study included subjects treated with the Atlas stent in China from November 2020 to January 2022.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 522 consecutive patients (mean age, 58.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9 years; female, 65.3% [341/522]) with 533 aneurysms were included in the study. In the early postoperative period, neurological morbidity rate was 7.3% (38/522); ischaemic stroke rate was 5.0% (26/522); aneurysm rupture subarachnoid hemorrhage rate was 2.3% (12/522); MRS score deterioration rate was 5.4% (28/522). Mortality rate were 0.8% (4/522) in the postoperative period. Neurologic morbidity at follow-up period were 1.2% (6/486). In multi-factor prediction, cerebral infarction, Hunt-Hess Grade (3\u0026ndash;5), procedure duration, stent length and coil protrusion into the parent artery were found to be independent predictors of neurologic morbidity. Procedure duration, stent length and coil protrusion into the parent artery were found to be independent predictors of neurological mRS score deterioration.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe incidence of SCA (stent-assisted coiling)-related complications with the Atlas stent in this study was comparable to that in the Western population. We identified procedure duration and stent length as novel independent predictors of SCA-related ischemic stroke, neurologic morbidity, and mRS score deterioration among the Chinese population.\u003c/p\u003e","manuscriptTitle":"Neuroform Atlas Stent Treatment for 533 Intracranial Aneurysms in a Large Chinese Cohort: Complication Risk Factor Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-06 06:22:55","doi":"10.21203/rs.3.rs-3754137/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-02-07T12:58:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-05T10:35:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-05T03:30:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2023-12-14T14:51:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0e6c6a5e-0e80-4c5a-8f50-65c7000f4065","owner":[],"postedDate":"February 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T14:49:11+00:00","versionOfRecord":{"articleIdentity":"rs-3754137","link":"https://doi.org/10.1186/s12883-024-03695-z","journal":{"identity":"bmc-neurology","isVorOnly":false,"title":"BMC Neurology"},"publishedOn":"2024-06-10 14:49:11","publishedOnDateReadable":"June 10th, 2024"},"versionCreatedAt":"2024-02-06 06:22:55","video":"","vorDoi":"10.1186/s12883-024-03695-z","vorDoiUrl":"https://doi.org/10.1186/s12883-024-03695-z","workflowStages":[]},"version":"v1","identity":"rs-3754137","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3754137","identity":"rs-3754137","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}