Special Issue Article

Novel technologies in the treatment of

intracranial aneurysms
Scott L. Zuckerman1, Ilyas M. Eli2, Peter J. Morone1, Michael C. Dewan1,
J. Mocco1
1
Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA, 2Vanderbilt
University School of Medicine, Nashville, TN, USA

The treatment of intracranial aneurysms has undergone precipitous expansion since the first detachable
coils were used less than two decades ago. With rapidly expanding technology comes the need to keep all
involved parties informed. The objective of our review is to provide a comprehensive, succinct overview of
novel paradigms and devices used to treat intracranial aneurysms. We have divided these new
technologies into: (1) coils, (2) flow diverters, (3) adjunctive balloon devices, and (4) stents.
Keywords: Intracranial aneurysm, Treatment, Coil, Flow diversion, Balloon, Stent

Introduction and Drug Administration (FDA), and since then over

Intracranial aneurysms are abnormal outpouchings
of cerebral arteries. Most are saccular, or berry
shaped, and approximately 85% occur throughout
the Circle of Willis.1 Aneurysm locations include:
anterior communicating artery (35%), posterior
communicating artery (30%), middle cerebral artery
bifurcation (25%), basilar artery (5%), internal
carotid artery terminus, superior cerebellar artery
(SCA), and posterior inferior cerebellar artery
(PICA).1,2 Size is classified as: small (X , 5 mm),
medium (5 # X , 15 mm), large (15 # X , 25 mm),
giant (25 # X , 50 mm), or supergiant (X §
50 mm).1,3 Rare morphologies and subtypes include:
dissecting, fusiform, traumatic, mycotic, atheroma-
tous, or blood blister type.1
The most devastating presentation of an intracra-
nial aneurysm is subarachnoid hemorrhage (SAH).
The incidence of aneurysmal SAH (aSAH) is between
6 and 9 per 100 000 individuals, with approximately
30 000 new cases of aSAH reported in the U.S. each
year.4,5 Mortality approaches 50%, with fewer than
60% of survivors returning to independent living.6
Treatment of intracranial aneurysms has under-
gone drastic change in recent decades. Endovascular
coiling has emerged as a safe, durable, and minimally
invasive alternative to traditional clip ligation since
its inception almost 20 years ago. In 1995, the first
Guglielmi detachable coil was approved by the Food
Correspondence to: J Mocco, Department of Neurological Surgery,
Vanderbilt University Medical Center, T-4224 Medical Center North,
Nashville, TN 37232-2380, USA. Email: j.mocco@vanderbilt.edu
300 000 patients have been treated with detachable
coils.2,7–9,10 In the last 15 years, endovascular tech-
niques for the treatment of intracranial aneurysms
have evolved at a rapid pace.11,12
The goal of this review is to describe novel
technologies in the treatment of intracranial aneur-
ysms. Our manuscript is not meant to discuss in-depth
technical considerations for each technology; we
reserve that for experts and investigations devoted
solely to each device. Rather, we hope to provide
a comprehensive, concise overview of several new,
exciting devices in cerebral aneurysm treatment. We
have divided these instruments into: (1) coils, (2) flow
diverters, (3) adjunctive balloon devices, and (4) stents.
Coils
Since the early 1990s, coil embolization has become
the preferred method of treatment for obliteration of
intracranial aneurysms.13,14 However, despite major
strides in morbidity, aneurysm reopening remains a
concern.15 A recent meta-analysis across 41 studies
involving 8,161 coiled aneurysms revealed a 20%
recurrence rate. Early coils were made of low-density
platinum, which was thought to be one of the main
reasons for recurrence, leading to low-density aneur-
ysm packing.16,17
In the area of novel coil technology, we plan
to discuss three developments: (1) Hydrocoils, spe-
cifically Hydrosoft, Hydroform, and Hydrofill,
(2) Variable Range Fill Coils (VFC), and (3) Pe-
numbra 400 Coils.

ß W. S. Maney & Son Ltd 2014

368 DOI 10.1179/1743132814Y.0000000318 Neurological Research 2014 VOL . 36 NO . 4

Figure 1 Classes of HydroCoil: (A) HydroCoil Embolic System; (B.) HydroSoft coil; (C) HydroFrame coil; (D) HydroFill coil.
Hydrocoils
To bolster coil-packing density, hydrogel covered
platinum coils have been introduced. Early HydroCoils
were made with an expansile hydrogen gel that was
designed to improve volumetric filling of the aneurysm
lumen compared to platinum, non-expanding coils,
shown in Fig. 1A. Hydrogel-coated coils are stiffer
than naked coils, which is thought to contribute to
decreased rates of recurrence and compaction.16,18 The
original Hydrocoil is the HydroCoil Embolic System
(HES) (Microvention Terumo, Aliso Viejo, CA,
USA). HydroCoil Embolic System is a platinum,
helical coil covered with a hydrogen polymer, with an
overcoil to enhance durability and ensure uniform
expansion. After inserted into the aneurysmal sac,
the hydrogel quickly expands to fill the lumen in
approximately 20 minutes. The hydrogel remains soft
and compliant to decrease risk of rupture.19 An in vivo
model of a ruptured cerebral aneurysm showed that
hydrocoils compared to bare platinum coils had higher
initial occlusion rates and greater seal at the aneurysm
rupture site after expansion.20
In a human study comparing 57 platinum coil
treated aneurysms to 60 hydrogel-coated coil treated
aneurysm, Gaba et al.18 found improved volumetric
packing density with decreased total coil length in the
hydrogel group. In the landmark study, hydrogel-
coated coils versus bare platinum coils for the
endovascular treatment of intracranial aneurysms
(HELPS) trial, published in the Lancet, a randomized
trial across 24 centers in seven countries compared
249 hydrocoil-treated patients to 250 standard
platinum-treated group.21 Though their primary end
Zuckerman et al. Novel aneurysm technologies
point of improved long-term outcomes was not
statistically different between groups (P 5 0.13), there
were significantly fewer major angiographic recur-
rences in the hydrogel group (P 5 0.049). Despite
significant promise, concerns remain. Reports have
arisen of aseptic meningitis in patients treated with
Hydrocoils; speculation at a possible inflammatory
response has been suggested as the underlying
etiology.22
Below, we will expand on each of the following
types of hydrocoils, all part of the HES: Hydrsoft,
HydroForm, and HydroFill.19
Hydrosoft
The HydroSoft (Microvention Terumo, Aliso Viejo,
CA, USA) contains a platinum coil outside, with an
inner-core of hydrogel, and a stretch resistant
filament.16 Compared to the original HydroCoil, the
HydroSoft is softer, contains less hydrogel, and swells
more slowly, without time restrictions, seen in
Fig. 1B. The Hydrosoft coil was developed to over-
come the limitations of its predecessor, the original
Hydrocoil, as a finishing coil to be deployed at the
aneurysm neck in order to prevent aneurysmal
recurrence through its inherent properties of volume
expansion.23 Several key studies have evaluated its
efficacy and safety.
Guo et al.16 conducted a head-to-head analysis
and compared 75 aneurysms embolized with the
HydroSoft coil versus 66 volume- and shape-matched
aneurysms treated with the traditional HES. The
HydroSoft led to decreased rates of retreatment and
was more suitable for the final coil. There was no
Neurological Research 2014 VOL . 36 NO . 4 369
Zuckerman et al. Novel aneurysm technologies
difference between the two coils in average total coil
length per aneurysm, packing density, and length of
hospital stay. The authors believed the mechanism
for improved outcomes with the HydroSoft was due
to coil expansion at the neck of the aneurysm, leading
to a reduced neck remnant and decreased chance of
recurrence. Further supporting its role as a final coil,
in a canine bifurcation aneurysm model, researchers
packed nine aneurysms with HydroCoils and finished
each with a HydroSoft. The aneurysm necks were
able to be packed with the HydroSoft coil, despite
an average neck size of 7 mm. Furthermore, the
HydroSoft induced neointima formation at the
aneurysm neck.24
In a larger, retrospective study across three centers,
authors explored perioperative safety of the Hydrosoft
coil and its purpose as the finishing coil.23 In 141
aneurysms, 79 (56%) were completely embolized, 40
(28%) had residual neck, 21 (15%) had residual dome,
and in one case, the Hydrosoft coil could not be
deployed. Procedural morbidity and mortality was
2.1% and 1.4%, respectively, and no complications
were directly attributed to the Hydrosfot coils. The
incidence of aneurysmal rupture, cerebral hemor-
rhage, ischemic event, vasospasm, and hydrocephalus
were comparable to the contemporary literature.
Perhaps the best evidence to date is a prospective
multi-institutional series of 127 aneurysms in 120
patients treated with HydroSoft coils has demon-
strated good results. Immediately after coiling, Park
et al.25 reported 69% aneurysm occlusion, 20%
residual neck, and 12% residual sac. Six out of 127
patients (4.7%) had complications, including bleeding
and thromboembolism. At 6 months, the overall
recanalization rate was 3/105 aneurysms (3%), with
two major and one minor recanalization.
After a small number of preliminary studies, the
HydroSoft seems to perform better than traditional
platinum coils with comparable rates of complica-
tions to similar coils. Its use as a finishing coil gives
it a unique advantage when treating wide-necked
aneurysms.
HydroFrame
The HydroFrame (Microvention Terumo, Aliso
Viejo, CA, USA) is a framing hydrocoil used for
aneurysm embolization, shown in Fig. 1C. The
delivery system is similar to a platinum coil with
simple coil detachment. Similar to other hydrocoils,
upon exposure to blood, the hydrogel core expands
and increases the diameter of the coil. The hope is to,
by using a framing hydrocoil, place more hydrogel at
the neck.
By developing a less rigid, and less time-dependent
framing coil that still includes the hydrogel technol-
ogy, manufacturers believe that aneurysms will still
370 Neurological Research 2014 VOL . 36 NO . 4
be able to receive the benefits of hydrogel based
embolization, but without the greater difficulty of use
that was associated with the first generation hydro-
coil. Furthermore, one hopes that this benefit will
result in better clinical outcomes. However, much
more research and clinical experience is needed before
any such conclusions can be made.
HydroFill
Thye HydroFill (Microvention Terumo, Aliso Viejo,
CA, USA) is the newest of the three hydrocoils. The
device is similar to its ancestors, HydroSoft and
HydroFrame, in its platinum overcoil and hydrogel.
However, the HydroFill has a hydrogel core under-
neath a platinum overcoil, and the hydrogel core
swells through the platinum coil, causing aneurysmal
obstruction and subsequent obliteration, seen in
Fig. 1D.
Killer et al.26 compared the new HydroFill
technology to the older HydroSoft and platinum
coils in a rabbit model. Despite reduced post-
treatment angiographic occlusion in the HydroFill
group compared to the HydroSoft and platinum coil
groups, the HydroFill group showed increased
volumetric filling, higher rates of stable occlusion at
follow-up, and increased rates of neointima and
thrombus formation. In a small series of 14 ruptured
and unruptured human aneurysms, Speirs et al.27
reported their clinical experience with the HydroFill.
Immediate angiographic occlusion was seen in 100%
of the cases, packing density ranged from 13% to
135%, and immediate complication rates were 1/11
(9%). Long-term follow-up showed complete occlu-
sion in 12/14 (86%) aneurysms. Due in large part to
its recent development, little data exist about the
HydroFill.
In conclusion with regards to hydrocoils, the
prospective, randomized, international, multi-center
trial currently enrolling patients to evaluate hydrocoil
efficacy and safety is called the hydrogel endovascular
aneurysm treatment (HEAT) Trial. The study’s goal
is to test the effectiveness of hydrocoil embolization
system compared to the current standard bare
platinum coils. Two of the three hydrocoils men-
tioned – hydrosoft and hydroframe – are being
evaluated in the study. There are over 29 centers
enrolling patients and the study is housed at
Northwestern University. The study began in 2011
and hopes to enroll approximately 600 patients.
Versatile Range Fill Coils
Versatile range fill coils (Microvention, Tustin, CA,
USA) allow for a single coil to fill a range of
aneurysm diameters. Instead of stocking 18 different
coils for 3–20 mm aneurysms, VFC devices allow
four coils to fulfill that 18 mm range: 3–6 mm, 6–
10 mm, 10–15 mm, and 15–20 mm.28 The coil is

Figure 2 Alternate coils: (A) Versatile Range Fill Coils; (B)
Penumbra 400.
designed with complex loops, that provide stability,
and waves that allow for coil distribution and
increased packing density, as seen in Fig. 2A.
This technology has great tential to save costs and
minimize sizing difficulty, where several coils may be
used to find the perfect fit. One of the primary
criticisms of coil technology is the high inherent
implant cost associated with its use.29,30 It is
possible that the advent of coils such as the VFC,
which may treat a broader range of aneurysms with
a lower carrying cost, could provide a significant
advance in the efficiency and cost of aneurysm
treatment. We found no published data validating
the use of VFC.
Penumbra 400
The Penumbra 400 (PC 400) (Penumbra, Alameda,
CA, USA) represents a new class of softer, thicker
coils compared to conventional coils, shown in
Fig. 2B. Approved by the FDA in April 2011, the
PC 400 provides between 178% and 400% more
volume per unit length than traditional coils.31 The
coil texture is soft, with three classes approved for
use: standard, soft, and extra soft. These gradations
of softness are determined by the nitinol stretch
resistance wire, and not by the diameter filament
wire, as in conventional coils.31
Mascitelli et al.14 retrospectively compared 16
aneurysms embolized with the PC 400 compared to
79 matched aneurysms treated with conventional coils.
Despite limited numbers, aneurysm embolization with
the PC 400 achieved a higher packing density (36.8%
vs. 28.1%; P , 0.005) with fewer coils per aneurysm
(3.9 vs. 6.1; P , 0.05).14 Favorable results were
achieved with significantly less procedure time and a
trend toward less total coil length. In a similar study,
Milburn et al.31 retrospectively reported results of 40
aneurysms treated with standard coils compared to 18
treated only with PC 400 coils. Mean packing density
was significantly higher and the number of coils was
significantly fewer for the PC 400 group with compar-
able aneurysm occlusion rates. The authors concluded
that the PC 400 system may be more efficient and cost-
effective. Currently, a prospective, multi-institution
Zuckerman et al. Novel aneurysm technologies
study is underway evaluating the PC 400 System, titled
ACE: An Aneurysm Coiling Efficiency Study of the
Penumbra Coil 400 System.32
Flow Diversion
Flow diversion represents a major paradigm shift
in the treatment of intracranial aneurysms. Flow
diverters alter flow dynamics within the aneurysm by
inducing thrombosis and occlusion within the aneur-
ysmal sac, while preserving physiologic flow in the
parent vessel.33,34 In a short period of time, the use of
flow diversion has increased rapidly, and in some
areas has drastically decreased the rates of coil and
stent usage.33
Flow diversion arose from observations of flow
patterns in stented aneurysms, where flow was
redirected away from the aneurysm and toward the
parent artery. These tubular, braided metallic implants
have shown the ability to completely occlude the
aneurysm in a high proportion of cases. Attention has
been refocused away from the aneurysm dome and
toward the neck as a point of intervention.35 The
porosity (amount of metal coverage over the neck) and
pore density (number of pores per area) are important
metrics when altering flow, with lower porosity and
higher pore density being the optimal conditions for
aneurysm occlusion.34 Flow diverters may also be
more beneficial than stents. A recent study utilizing
virtual models found that flow diverters reduced
aneurysmal flow velocity to a much greater degree
than stents.36
Concerns about flow diversion include potential
occlusion of perforating arteries or other important
branches. However, in vitro studies have documented
that there is minimal reduction in collateral flow
when a flow diverter is placed across an aneurysmal
neck and collateral branches.34,37–40 These results
make intuitive sense because flow through collaterals
is driven by a pressure gradient, despite being jailed
by a porous medium. Moreover, further limitations
include inability to treat certain aneurysm geometries,
such as at a bifurcation, and need for dual anti-
platelet therapy immediately after and for months
following treatment.41
Two classes of flow diverters currently exist:
intravascular (within the parent vessel) and intrasac-
cular (within the aneurysmal sac). Instead of being
deployed in the parent vessel, an intrasaccular diverter
is placed entirely within the aneurysm cavity, creating
the same flow-diverting mechanism as the intraluminal
flow diverters.35 The intravascular class includes three
options: (1) pipeline embolization device (PED) (ev3,
Menlo Park, CA, USA; Covidien, Mansfield, MA,
USA), (2) Surpass NeuroEndGraft System (Surpass,
Miramar, FL, USA; Stryker Neurovascular Fremont,
CA, USA), and (3) SILK (Balt Extrusion, Montmorency,
Neurological Research 2014 VOL . 36 NO . 4 371
Zuckerman et al. Novel aneurysm technologies
Figure 3 Intravascular flow diverters: (A) Pipeline Embolization
Device; (B) SURPASS NeuroEndograft System; (C) SILK flow
diverter.
France). The newer class of intrasaccular flow diverters
includes two devices: (1) Woven EndoBridgeTM (WEB)
(Sequent Medical, Aliso Viejo, CA, USA) and (2)
LUNA (NFocus Neuromedical, Palo Alto, CA,
USA).
Pipeline embolization device
Pipeline embolization device has been used inter-
nationally for several years and gained FDA
approval in the U.S. in 2011 for the treatment of
large or giant wide-necked intracranial aneurysms.
Pipeline embolization device consists of a permanent
implant combined with a catheter-based delivery
system.42 The PED implant is a braided, multi-alloy
mesh cylinder woven from Platinum/8% Tungsten
and cobalt chromium nickel alloy wires. The woven
wires of the device provide 30–35% metal coverage of
the arterial wall surface area. The implant is mounted
on a stainless steel guidewire and compressed inside
an introducer sheath, depicted in Fig. 3A. The
delivery system consists of a polytetrafluoroethylene
coated guidewire. The tip and protective coil are
made of platinum–tungsten alloy, the proximal
marker a platinum–iridium alloy, and the distal,
mid and proximal solder joints are a tin–silver
mixture. The protective coil holds PED in a collapsed
state until ready for deployment. Rotating the
proximal guidewire unscrews the coil from the distal
tip PED, allowing it to spontaneously expand into
the parent artery.
372 Neurological Research 2014 VOL . 36 NO . 4
Several authors have documented their experience
with PED.33,43–51 In one of the largest studies to date,
Saatci et al.49 treated 251 aneurysms in 191 patients
using PED. Their event rate was 14.1% with a
permanent morbidity of 1% and mortality at 0.5%.
Their aneurysm occlusion rate was 91.2% at 6 months
and 94.6% at 2 years. Fischer et al.45 treated 96
intracranial aneurysms and five dissections using the
PED, with angiographic follow-up for 90/101 lesions.
Complete occlusion was seen in 47/90 lesions (52%),
morphological improvement in 32/90 (36%), and no
improvement in 11/90 (12%). The authors reported six
complications: one fatal aneurysm rupture, two PED
thrombosis, and three hemorrhages in dependent brain
parenchyma.45 The authors commented that when
using PED, remodeling of an aneurysmal dilation takes
several months and dual anti-platelet treatment is a
necessity. A multi-center, prospective registry from
Australia reported treatment of 57 aneurysms with
PED or PED and coils.47 Overall aneurysm occlusion
rate at 6 months was 85.7%. Despite four TIAs and
one small retinal branch occlusion, permanent neuro-
logic morbidity and mortality was 0% at 6 months.
Two patients (3.5%) had asymptomatic in-construct
stenosis. In some of the largest reported series, initial
outcomes with PED are promising.
In an interesting report addressing cost, Colby
et al.43 evaluated 60 patients with anterior circulation
aneurysm, 30 of which were treated with PED and 30
treated with stent-assisted coiling. Despite having a
larger mean aneurysm size, the cost was significantly
lower in the PED group vs. the stent-coiling group by
$5,700 or 25.7%. PED may represent a cost-saving
strategy.
Despite exciting initial results, we cannot forget
PED is at its genesis. A recent report of two patients
with giant aneurysms treated with PED, both with
initially successful parent vessel reconstruction, high-
lights the caution required when using new technol-
ogy.50 The first patient underwent treatment of a
basilar tip aneurysm alone with PED and subse-
quently underwent early aneurysmal rupture and
fatal brainstem hemorrhage. The second patient with
an M2 MCA aneurysm was treated with two PEDs
and dense coil embolization, and experienced acute
thrombosis of the PED likely due to mass effect and
thrombogenecity of the coil mass.50 Additionally,
significant concern has been raised about the
potential risk of delayed intracerebral hemorrhage,52
as well as other novel complications.53 The science of
flow diversion dynamics is still in its infancy, and
little is known about which aneurysms are best
treated with a single PED vs. multiple flow diverters,
and when to use adjunctive coil embolization.
However, several large case series have documented
safe, effective use of PED with promising outcomes.

Surpass
The Surpass NeuroEndoGraft is a self-expanding flow
diverter constructed of cobalt chromium braids with
platinum–tungsten wires, ranging from 3 to 5 mm in
diameter and 15 to 50 mm in length.54 The implant
is made of cobalt, chromium, and platinum/tungsten,
shaped in a tubular, low porosity mesh, designed to be
flexible and kink resistant, seen in Fig. 3B. The tungsten
is interwoven within the cobalt chromium strands, which
aid in visualization under fluoroscopy. The Surpass
NeuroEndoGraft System includes three components:
Surpass NeuroEndograft, Delivery Catheter, and the
Pusher.55 The Pusher is designed to push the Surpass
NeuroEndoGraft out of the delivery catheter across the
aneurysm neck. The Pusher also stabilizes the position
of the Surpass graft in the delivery catheter. After
deployment, the device expands to the vessel lumen
diameter and directs blood away from the aneurysm.54
The manufacturers recommend choosing a device
that is 10 mm longer than the aneurysm neck. As the
braided device is deployed, it expands. The cells then
morph from long and thin to open and square,
causing the length to shorten. The device foreshortens
from the proximal end.54 Up to two Surpass implants
can be used to treat a single aneurysm.
Animal models show good results when utilizing
similar flow diversion technology to Surpass. An
early swine model with a similar tubular mesh device
demonstrated rerouting of particles as small as 60%
of pore dimension with no significant change to
perfusion ratio of jailed parent artery branches.56 A
rabbit model showed that pore density, rather than
porosity, was the critical factor in aneurysm occlusion.57
Translating to humans, Wakhloo et al.58 evalauted
the Surpass implant in 20 patients. Six-month follow-up
in four patients showed complete or near-complete
occlusion. In two patients, ICA tortuosity prevented
device deployment and lead to alternate treatment. All
perforating arteries covered by the implant – anterior
choroidal, ophthalmic, Pcomm, ACA, and lenticulostri-
ates – remained patent at 15 months. Two patients
experienced thromboembolic events and one underwent
intracranial vessel wire perforation leading to ICH
requiring an open procedure. Despite poor long-term
follow-up outcomes, early data show promise for
treatment of complex aneurysms without coiling.
In the largest human study, De Vries et al.59 used
the Surpass implant in 37 patients with 49 complex,
unruptured aneurysms at a single center. At 6-month
follow-up 29/31 non-bifurcation aneurysms (94%)
showed angiographic complete occlusion, whereas 5/
10 bifurcation aneurysms (50%) were occluded. Four
patients (10.4%) had a TIA, one patient (3%) had a
minor permanent neurologic deficit, and there was no
peri-procedural morbidity or mortality. Also of note,
56 side branches were covered throughout the study,
Zuckerman et al. Novel aneurysm technologies
which included but were not limited to: 15 opthalmic,
13 posterior communicating, and 12 anterior choroidal
arteries. At 6-month angiographic follow-up, all were
patent except for 2/15 ophthalmic arteries (13%) and 4/
13 posterior communicating arteries (31%), which
remained clinically silent, signifying good collateral
blood supply.59 Though the data are limited to one
reasonable case series, The Surpass Intracranial
Aneurysm Embolization System (AES) Pivotal Trial
to Treat Large or Giant Wide Neck Aneurysms
(SCENT Trial) is currently enrolling patients across
15 centers.60 Preliminary results have not been reported.
An important consideration with the Surpass im-
plant, and all flow diverters, is the need for long-term
anticoagulation. Because it is a permanent intravas-
cular device, dual anti-platelet therapy is required for
3–6 months, elevating hemorrhage risk significantly.61
Furthermore, the above-mentioned series calls for a
better strategy at treating bifurcation aneurysms.
SILK
The SILK flow diverter (SFD) is a flexible, self-
expanding device first approved for use in humans in
Europe six years ago. As with other flow diverters, it
is designed to reconstruct laminar flow in the parent
artery, depicted in Fig. 3C.62,63 It is a braided mesh
cylinder with flared ends, made of 48 braided nickel–
titanium (Nitinol) alloy and platinum microfilament
strands, and contains high-coverage mesh after
expansion. The delivery procedure is similar to other
flow diverters, with one advantage, it allows reposi-
tioning and re-sheathing even when up to 90% of the
device has been deployed.62 The one-step action
required for use, obviating the need for coils or
balloons, makes it much less time consuming. In a
simple aneurysm, the entire deployment could take
30 minutes, without significant risk of rupture
because the aneurysm lumen is not entered. Several
studies evaluating SFD have been conducted.
Kojima et al.36 used a computer-based simulation
to model multiple Enterprise stents and two flow
diverters, the SILK and PED. Both the SILK and
PED demonstrated reduced velocity in the aneurysm
sac compared to the stents. Shankar et al.64 retro-
spectively reported their experience with 29 complex
intracranial aneurysms treated with SFD without
adjunctive coils. Complication rate and 30 days
morbidity and mortality were 10% and 5%, respec-
tively. After a total of 263 patient months of clinical
follow-up and 166 patient months of imaging follow-
up, complete aneurysm occlusion with a patent
parent artery was observed in 59% of patients.
Mean cost of SFD was significantly less compared
to presumed cost of stent-assisted coiling.
Two larger series have also been published.
Maimon et al.62 treated 32 aneurysms with 31 SFD
Neurological Research 2014 VOL . 36 NO . 4 373
Zuckerman et al. Novel aneurysm technologies
Figure 4 Intrasaccular flow diverters: (A) and (B) Woven
EndoBridge (WEB) Aneurysm Embolization Device. (C)
LUNA Aneurysm Embolization System.
devices. SILK was successfully deployed in all cases,
no aneurysmal rupture was noted, and complete or
near-complete occlusion was found in 93.3% of
patients. Five patients (17.8%) developed immediate
complications, which were permanent in three
patients (10.7%). All complications occurred in
aneurysms larger than 15 mm. In one of the largest
studies to date, Berge et al. treated 77 aneurysms with
SFD across six European centers. At 6-month follow-
up, permanent morbidity was 7.8% and mortality was
3%. Complete occlusion at 12 months occurred in
84.5% of aneurysms.
Two major disadvantages of the SFD exist: (1) the
need for long-term anti-platelet therapy, ranging
from 3 to 6 months, which is not not unique to
SFD, and (2) low radial resistance, which may require
additional stenting or lead to the SFD falling into the
aneurysmal sac.62 Moreover, there seems to be higher
rate of complications with aneurysms larger than
15 mm. Authors have also recommended a ‘slow
learning curve’ where procedures are gradually per-
formed, learned, and improved over time.62 Overall,
the main advantage of the SILK appears to be the
ability to resheath and reposition in mid-deployment.
Woven EndoBridge
Sequent Medical has designed a new, intra-saccular
flow diverter known as the WEB aneurysm emboliza-
tion device. The device is a metallic mesh construct
placed along the aneurysm wall and across the neck,
meant as stand-alone therapy without adjunctive
coils seen in Fig. 4A and B. The WEB II is the newer
version of the earlier technology, with a double layer
of nitinol mesh compared to a single layer, but overall
the technologies are quite similar and will be referred
to as a single entity hereafter.
The WEB device is comprised of a high density,
braided, two-layer nitinol mesh with proximal and
distal platinum markers that hold the structure in a
globular shell shape.35,41 The wire mesh contains a
consistent pore structure allowing for aneurysm
374 Neurological Research 2014 VOL . 36 NO . 4
ostium coverage between 35% and 45%.35,65,66 The
device is indicated for treatment of saccular aneur-
ysms with a neck-to-dome ratio of #1 and neck
length-to-width ratio of ,2.65 The detachment
system is similar to most coil systems. Once deployed,
the mesh structure provides stent-like adherence to
the aneurysm wall, rather than a smooth, non-
adherent balloon.35 The device is available in three
forms: WEB Dual Layer (DL), WEB Single Layer
(SL), and WEB Single Layer Sphere (SLS).67 The DL
provides rapid intra-procedural stasis in wide-neck
bifurcation aneurysms. The SL and SLS provide
equally rapid stasis in bifurcation and side wall
aneurysms, with lower profiles designed to optimize
navigability.67 The device is not yet approved in the
United States, thus much of the research emanates
from overseas.
Early results have yielded successful endovascular
treatment of cerebral aneurysms.35,65,66,68,69 In an
oral presentation, Strother et al.41 performed com-
putational studies in two human aneurysms, one ICA
sidewall and a basilar apex aneurysm, and compared
the WEB technology to a generic intra-luminal flow
diverter in two human aneurysms. The Sequent WEB
device showed a greater decrease in flow and kinetic
energy entering the aneurysm over the generic intra-
luminal device.41 Also in a platform talk, Lubicz
et al.70 reported the result of an ongoing multi-center,
prospective study in five wide-necked, unruptured
aneurysms (2 MCA bifurcation, one basilar tip, one
vertebral artery, one carotid-ophthalmic) after treat-
ment with WEB placement alone. The WEB device
was successfully placed in 4/5 (80%) patients, result-
ing in immediate occlusion with slight neck remnant
in two cases and major flow reduction in two cases.
No morbidity and mortality was reported in these five
patients.
Larger studies have since been published.66,71 In a
prospective analysis, Lubicz et al.71 utilized the WEB
device to treat 19 patients with 20 unruptured wide-
neck bifurcation aneurysms. Placement failure was
noted in 1/20 aneurysms due to lack of correct device
size. Complete or near-complete occlusion was seen in
14/19 (73.7%) aneurysms, with adjunctive coiling in
four cases, three acute and one at follow-up. Two
patients (10.5%) experienced ischemic events resulting
in significant neurologic deficit. In the largest study
to date, Pierot and colleagues66 reported their early
experience with the WEB device in 33 patients with 34
MCA aneurysms treated across five European centers.
Treatment failed in 1/34 aneurysms (2.9%) due to a
similar sizing issue. The authors used the WEB alone in
29/33 (87.9%) patients and adjunctive coiling and/or
stenting in 4/33 (12.1%). No patient died and morbidity
was 3.1%, a patient with intraoperative rupture. At 2–
12-month follow-up, 83.3% had adequate occlusion.

This study supports a promising technique for the
treatment of complex MCA aneursyms, but results
cannot be extrapolated to aneurysms in other locations.
The WEB device is an exciting new technology.
The major benefit appears to be its suitability for
treating wide-necked aneurysms. Sizing appears to be
the most important factor in achieving success, in
order to create a tight seal along the aneurysm neck.65
Previous authors recommend that the width of the
device should be equal to or greater than the
aneurysm width. Upsizing by 1 mm in some cases
can be too great a jump in size, and 0.5 mm sizes are
expected.71 The WEB device also does not preclude
the use of additional embolization materials. Both of
the largest studies include patients that had adjunc-
tive coiling. A recent case report highlighted standard
balloon-assisted coiling to close a regrown MCA
aneurysm after WEB placement.69 In terms of
embolic risk, preclinical animal studies have shown
the WEB had similar thrombotic potential compared
to conventional intra-saccular coils.62 Limitations
include its initial design for straightforward posterior
circulation; the WEB can be difficult to maneuver
through more tortuous anterior vascular anatomy.65
Second, the device may be less qualified to redirect flow
in irregular or fusiform aneurysms, as the symmetric
geometry can only treat a similarly shaped aneurysm.
Lastly, large studies to establish safety do not exist.
LUNA
The LUNA AES is a self-expandable, round-ovoid
implant and delivery system, seen in Fig. 4C. The
implant is made from a double layer of 72 Nitinol
wire 25 m mesh (144 wires) secured at both proximal
and distal ends and clearly marked with radiopaque
markers.72 Available sizes include 4.5 mm (B)–
8.5 mm (G). The system includes a micro-catheter
shaft with detachment controlled by operator activa-
tion of delivery handle.
Two preclinical studies on the LUNA AES system
exist. Using a rabbit model, Kwon et al.73 embolized
12 aneurysms with the LUNA AES and performed
digital subtraction angiography (DSA) pre and 5, 10,
and 30 minutes post-implantation. At 30 minutes
and 1 month, 10/12 (83%) were completely occluded.
At 3 months, 7/8 (88%) aneurysms remained com-
pletely occluded.73 Also at 3 months, microscopic
examination showed 8/8 (100%) aneurysms had tissue
completely covering the devise and neointima forma-
tion across the aneurysm neck. In a separate study
1 year later, Turk et al.74 compared the Luna AES to
a vascular plug vascular plug in seven canines. Each
animal received one LUNA and one vascular plug
device and was evaluated angiographically after
placement. At 28 and 55 days, the LUNA device
provided higher levels of occlusion and durability
Zuckerman et al. Novel aneurysm technologies
than the vascular plug, showing promise for accurate
placement and aneurysm occlusion.
In humans, the LUNA AES for Treatment of
Intracranial Aneurysm–PMCF study is currently
enrolling patients. The trial is a prospective, multi-
center, non-randomized, non-blinded PMCF study
with 12-month follow-up across 30 different sites with
the goal of enrolling 63 patients. In a recent oral
abstract, an update on the trial yielded 15 patients,
with 14 unruptured and 1 ruptured saccular aneur-
ysms.75 In 14/15 (93%) patients, 1 LUNA AES was
deployed per aneurysm. Immediate complete occlu-
sion was seen in 1/14 ((7%) patients, near-complete
occlusion was seen in 9/14 (64%) cases, and no
occlusion seen in 4/14 (29%) patients.75 At 6 months,
2/4 (50%) patients had complete occlusion and the
remaining 2/4 had neck remnants. The authors
concluded promising early results with more long-
term follow-up pending.
Amidst the encouraging results, substantial uncer-
tainties remain. First, only animal data exist with
limited use in humans. The aneurysms created in each
animal study are likely more regular and easier to
treat than complex human aneurysms, that may be
irregular, wide-neck, or fusiform.73 Second, little is
known about precise sizing and positioning of the
device given each aneurysms has a unique 3-dimen-
sional morphology. Third, if incomplete occlusion is
found, the interventionalist may have limited options
for re-treatment, as coil placement into the lumen of
the LUNA will not be possible.73
Adjunctive Balloon Devices
Historically, wide-necked aneurysms are difficult to
treat with coil embolization alone as the sac and neck
are often shaped such that it is difficult to maintain
the coils in the saccular portion. Given the angioarch-
itecture of wide-necked aneurysms, there is a high
risk of progressive coil compaction and coil deposi-
tion into the parent vessel leading to complications
such as thromboembolism and aneurysm recurrence.7
Thus, in order to achieve adequate occlusion of wide-
necked aneurysms, it is often not feasible to perform
coil embolization without an assist device.
Industry has developed numerous solutions to
address the problem of difficult coil placement when
coiling aneurysms with a poor dome-to-neck ratio.
One solution, referred to as balloon remodeling or
balloon-assisted coil embolization (BACE), involves
placing a temporary balloon across the neck of the
aneurysm while concomitantly inserting coils. BACE
for treatment of wide-necked intracranial aneurysms
was introduced in 1997 by Moret and colleagues.76
This technique allows more coils to be inserted into
the aneurysm allowing the neurointerventionalist to
obtain maximum coil density within the sac and neck
Neurological Research 2014 VOL . 36 NO . 4 375
Zuckerman et al. Novel aneurysm technologies
Figure 5 Adjunctive balloon devices: (A) and (B) Scepter
Balloon; (C) and (D) TransForm Balloon.
of the aneurysm. Increased coil density may also
minimize the risk of progressive coil compaction.
Numerous clinical studies have been performed
demonstrating mixed results when looking at the
utility and complication rates of BACE.77–79 In a
prospective study of 757 consecutive patients,
Sluzewski et al.80 demonstrated that BACE generated
a 14% complication rate compared to a 3% complica-
tion rate when using only coil embolization. Recently
multiple new types of balloon assist devices for wide-
necked intracranial aneurysms have been developed.
Examples of this technology include the Scepter C,
Scepter XC, and Transform BACE devices.
Scepter Balloon C & XC
Available in 2012, the Scepter C and Scepter XC
(MicroVention, Tustin, CA, USA) are temporary
occlusion balloon systems that have a double lumen
catheter attached to a low inflation pressure compliant
balloon, depicted in Fig. 5A and B. Both devices use
balloons designed to conform to vessel anatomy and
perform vessel occlusion. The main difference between
the Scepter C and Scepter XC is that the Scepter XC is
more compliant allowing the balloon to conform to
complex vessel anatomies where neck coverage is
difficult to obtain (reference pictures of Scepter C and
Scepter XC). The double lumen catheter can accom-
modate a steerable 0.014-inch guidewire and therefore
allows for coil deployment and balloon inflation using
a single-catheter system.
This technology potentially provides a number of
benefits. The first is the ability to use a 0.014-inch
guidewire. Having a more robust and steerable guide
wire may allow for improved deliverability and better
stability during embolization. Second, the additional
lumen allows the ability to deliver additional technol-
ogies through the balloon itself. These technologies
376 Neurological Research 2014 VOL . 36 NO . 4
may include onyx delivery (to obviate the need for a
long time period of onyx plug development), stent
delivery (as a valuable bail out technique for
failed BACE), and, in certain appropriate cases, coil
delivery. It is thought that the use of single-catheter,
double lumen designs like the Scepter C and XC offer
a potential benefit when compared to the older BACE
devices.81
The Scepter C device has other potential uses than
just assistance in coil embolization of wide-necked
aneurysms. John et al.82 performed a retrospective
case series where the balloon was used to treat
cerebral vasopasm secondary to SAH. Balloon
angioplasty with the Scepter C device was completed
in this cohort of patients. The authors concluded that
while the larger diameter double lumen catheter was
stiffer and less compliant when compared to its
single-catheter counterparts, the Scepter C still had
increased trackability secondary to the incorporation
of a more steerable guidewire.82
While Scepter C and Scepter XC balloon devices
are important tools in the neurointerventionalists
armamentarium and offer promising endovascular
treatment of notoriously difficult to coil wide-necked
aneurysms, their efficacy and long-term outcomes are
still unknown. Further studies with increased number
of patients are needed before it can be concluded that
these devices represent definitive endovascular
improvement in the treatment of wide-necked aneur-
ysms when coil embolization alone is insufficient.
TransForm
The TransForm device is Stryker Neurovascular’s
occlusion balloon catheter designed to assist embo-
lization of intracranial aneurysms. Among the newest
technologies, TransForm received FDA approval for
clinical use in January 2013.83
TransForm, like other balloon devices, is a flexible
catheter-based device designed to maneuver into
targeted cerebral vessels and deploy across the neck
of an aneurysm, temporarily excluding it from its
parent vessel(s), seen in Fig. 5C and D. Additionally,
it can be used to treat vasospasm serving to
temporarily inflate stenotic vessels as a form of
cerebral angioplasty. It is 0.014 inches guidewire-
compatible, comprised of a single-lumen catheter
with a hydrophilic coating. Marketed in two forms as
either Compliant (Fig. 1) or Super Compliant
(Fig. 2), the former adopts a longer, more cylindrical
shape, while the latter is a more spherical and less
rigid structure. Consequently, the Compliant catheter
is available in lengths up to 30 mm (10–30 mm) and
diameters between 3 and 5 mm, while the Super
Compliant catheter is available with lengths between
5 and 15 mm but with a diameter up to 7 mm (3–
7 mm).84

Unlike older balloon designs, TransForm is
manufactured with micro-fabrication slits to allow
rapid inflation and vessel occlusion (Fig. 3). Once
inflated across the neck of the aneurysm, a separate
intrasaccular catheter may deploy permanent coils
limited to the aneurysm itself by the balloon
wall.84
Due to its recent emergence as an approved device,
at the time of this manuscript’s completion no peer-
reviewed publications of TransForm’s clinical results
exist. Remaining questions are whether the advan-
tages offered by this more maneuverable single-lumen
device outweigh the versatility offered by its dual-
lumen counterpart, the Scepter C/XC. It is concei-
vable that neither is outright superior but rather that
each has its unique role in the treatment of lesions
that are themselves heterogeneous. Regardless, objec-
tive conclusions loom as the field of neurointerven-
tional surgery awaits data on the safety and efficacy
of one if its newest technologies.
Stents
The advent of stent-assisted-coiling (SAC) with self-
expanding stents has allowed neurointerventionalists to
treat wide-necked aneurysms formerly deemed untrea-
table. Self-expandable stents are versatile with several
advantages compared to older treatments. Originating in
the field of cardiology,85 the use of stents migrated to
neurosurgical intervention in the late 1990s, but not
without trepidation.86,87 Coronary vasculature is sur-
rounded by stiff myocardium, whereas intracranial
vessels are free floating in CSF. Could the same
technology be transferred to more delicate anatomy?
After the use of cerebrovascular SAC was reported
in animals in 1994,88 Higashida et al., in 1995, became
the first to describe the use of an intravascular stent to
support coil embolization in humans.89 These micro-
stents are flexible, self-expanding metal entities that
utilize a micro-catheter delivery system.90 They act as a
support mechanism under the aneurysm to prevent
coil prolapse into the parent vessel. Advantages of
self-expandable stents include improved coil neck
coverage, increased packing density within the aneur-
ysm,91 successful flow diversion,90 and rigid scaffolding
for orifice endothelialization.92 Additionally, grow-
ing evidence suggests that these stents may have
flow-remodeling effects that lead to aneurysm
obliteration.93,94 There are currently two commonly
used stents: (1) Neuroform and (2) Enterprise stents.
Both technologies have comparable safety profile,
specifically, similar rates of in-stent stenosis and
thromboembolic complications.95–98
In 2002, the Neuroform microstent (Boston
Scientific, Natick, MA, USA) became the first self-
expanding stent designed specifically for intracranial
use.99 It is a nitinol stent with an open-cell design.
Zuckerman et al. Novel aneurysm technologies
Neuroform stents have undergone numerous improve-
ments to allow for better stability and maneuverability
for optimal stent delivery.99 The five iterations are
known as Neuroform 1, 2, 2 Treo, 3, and 3 EZ.100 In
one of the largest patient series, Fiorella et al.96 treated
284 patients with 302 aneurysms using the Neuroform
stent over 42 months. Eighty patients (48.2%) had
aneurysm thrombosis, 40 (24.1%) were unchanged, 46
(27.7%) had recanalization. Twenty-five ischemic
strokes (8.8%) and eight (2.8%) neurovascular deaths
were seen. The authors concluded that although
Neuroform aids in treatment of wide-necked aneur-
ysms, complete occlusion was low and significant
complications occurred.
The Enterprise stent (Cordis, Miami Lakes, FL,
USA) was FDA approved in 2007 and is a newer
flexible nitinol stent also designed for endovascular
treatment of intracranial wide-necked aneurysms. The
Enterprise stent was approved for use in coil emboliza-
tion of aneurysms with wide neck (§4 mm) or poor
dome-to-neck ratios (,2). The stent also has a fixed
closed-cell design. The specific design of the Enterprise
allows the stent to be partially deployed, recaptured,
and redeployed as needed. A long-term retrospective
follow-up study concluded the Enterprise stent as an
effective, safe, and durable treatment with coiling for
intracranial aneurysms.95 Additionally, Mocco et al.98
used the Enterprise for SAC in 141 patients with 142
aneurysms and found a 76% rate of §90% occlusion
with a 6% temporary morbidity, 2.8% permanent
morbidity, and 2% mortality (0.8% unruptured, 12%
ruptured).
Both the Neuroform and Enterprise stent systems
overall have comparable safety profile, specifically,
similar rates of in-stent stenosis and throm-
boembolic complications.95,96 Stent-assisted-coiling
of intracranial aneurysms with self-expanding stents
has allowed an alternative neuro-endovascular
option to those aneurysms previously regarded as
‘uncoilable’.97
Despite large gains, new stent-technologies are on
the horizon to address challenging aneurysms such as
double-barrel stents, Pulsar vascular aneurysm neck
reconstruction device (PVANRD) (Pulsar Vascular,
San Jose, CA, USA), and the similar Pulse-Rider
System (Pulsar Vascular), and the Barrell Stent.101–
103
We describe each new stent below.
Double-barrel stents
Double-barrel stents is a technique of placing two
self-expandable stents (Neuroform or Enterprise)
that are aligned in a side-by-side configuration across
the orifice of the aneurysm, depicted in Fig. 6A. They
function as bridge for optimal support at the base of
the aneurysm to enable coil embolization.104,105
Different configurations of the double-barrel stents
Neurological Research 2014 VOL . 36 NO . 4 377
Zuckerman et al. Novel aneurysm technologies
Figure 6 Novel stent techniques and devices: (A) Double-
barrel stenting. (B) Pulsar Vascular Aneurysm Neck
Reconstruction/Pulse-Rider.
exist ranging from X-configuration, Y-configuration,
and T-configuration.
Among the many studies conducted on double-barrel
stents, Kan et al.101 reported one case of a 50-year-old
woman with a, unruptured, 7 mm basilar artery
aneurysm that was successfully treated using a dou-
ble-barrel-stent-assisted coiling technique. The lesion
involved both limbs of the basilar fenestration and both
distal vertebral arteries (Fig. 6). A 4.5 mm 6 22 mm
Enterprise stent was deployed from the right limb of the
basilar fenestration into the right distal vertebral artery.
Likewise, a 2.5 mm 6 20 mm Neuroform EZ stent was
deployed from the left limb of the basilar fenestration
into the left distal vertebral artery. The result was a
dense coil embolization of the aneurysm with preserva-
tion of surrounding vasculature.
Long-term outcomes assessing safety and efficacy
as well as durability of double stent deployment was
conducted by Yavuz et al.106 One hundred and
eighty eight patients with 193 aneurysms were
treated with double stent-assisted coiling. Results
demonstrated 98.5% success rate of deployment,
1.1% delayed ischemic stroke, and 0.5% death.
Recanalization occurred in 3.8% for large aneurysms
and 40% for giant aneurysms. Conclusions were that
double stent placements are safe and a feasible
procedure.
Despite promising results, the deployment of two
stents side-by-side has its limitations. Increase in cost
would be incurred with the use of twice the amount
of stents. Furthermore, multiple stents in a vessel
may delay healing and increase the risk for
thrombosis. Finally, considerable skill and experi-
ence are critical requirements for effective imple-
mentation of double-stents because of its associated
complexity.107
Pulsar vascular aneurysm neck reconstruction/
pulse-rider
The PVANRD is a T-shaped permanent implant
designed for bifurcating artery aneurysms, seen in
378 Neurological Research 2014 VOL . 36 NO . 4
Fig. 6B. This 0.002-inch thick nitinol self-expanding
device deploys through a 0.027-inch micro-catheter
and functions as a reconstructive scaffold area. Its
architecture is uniquely designed to maintain patency
of two bifurcation branches while supporting coil
embolization into the aneurysm. Orientation is
achieved by opposing props that align with the
bifurcating branches resulting in proximal ends being
fixated in the proximal parent vessel. This results in a
‘saddle-shaped web’ across the aneurysm neck.
Furthermore, it utilizes four radiopaque markers to
assist in visualization for proper placement of the
device. There is a reduction in the surface area of
PVANRD of approximately 85% compared to other
stents. A proposed benefit is the potential reduction
in duration of anticoagulation prophylaxis against
thrombosis.
Initial studies on PVANRD were performed using
a canine model to assess the ability to support filling
of coils into the aneurysm. Bifurcation aneurysms
were created using the vein pouch aneurysm model
in the carotid arteries of eight dogs.108 Twelve
PVANRD were compared to Y-stenting. All opera-
tors deploying PVANRD had significant experience
with Y-stenting. Results demonstrated ease of
deployment and maintenance of patency of the
bifurcation in all cases with the use of oversized
coils.103 Overall, they reported easier handling of
PVANRD when compared to Y-stenting.
Further studies were conducted, including one in
vitro and one human trial. In vitro aneurysm models
were dedicated to designing PVANRD for optimal
use and safe delivery prior to human testing. The first
human case was reported in a female with an
incidental basilar tip aneurysm. Aneurysm dimen-
sions were 7.3 mm in the neck and 10.3 mm in the
largest diameter. One PVANRD was deployed using
a Marksman micro-catheter with successful place-
ment in the neck of the aneurysm. Post coiling
angiogram confirmed tight packing of the aneurysm
and patency of both PCAs. They concluded that
PVANRD provided excellent support enabling tight
coil packing without any evidence of proximal
migration by pressure from coil mass.109
Pulsar vascular aneurysm neck reconstruction
device is a new addition to the armamentarium
aiding stabilization of coil embolization therapies
currently in existence. Pulsar Vascular is developing a
product in the PVANRD family known as Pulse-
Rider. Pulse-Rider is marketed as a flexible device
that can deploy across varying anatomies in patients
with bifurcated aneurysms. The device has the ability
to be deployed, re-sheathed, and re-deployed for
position adjustment. Granted the novelty of this
device, there is limited information available on this
product. Early phases of development continue

Figure 7 (A) Barrel stent; (B) Wingspan stent; (C) In vivo
Barrel stent.
pending clinical testing and premarket approval.
Pulse-Rider hints at promising uses, but nonetheless
more clinical trials and long-term follow-up are
needed to provide insight into its efficacy and
durability.
Barrel stent
The Barrel Stent (Reverse Medical, Irvine, CA, USA)
is a self-expanding stent that expands in the mid-
portion to facilitate embolization of branching
aneurysms, as depicted in Fig. 7A–C. Often bifurca-
tion aneurysms are the most challenging to treat.
Given the success of compliant balloon technologies
to aid in BACE, Reverse Medical has designed the
Barrel Stent in order to recapitulate the central
expansion seen with compliant balloons to facilitate
similarly excellent results. The Barrel stent expands
significantly in its central point to maximize neck
coverage in branching locations.
As of now clinical data do not exist, however
preclinical studies are ongoing. It will be interesting
to see whether this new take on coil-assist technology
will continue to advance our ability to treat complex
aneurysms.
Conclusion
In summation, the world of endovascular treatment
for intracranial aneurysms has exploded. Since the
first coils were used less than 20 years ago, we have
experienced a rapid acceleration in new paradigms
of treatment, and better yet, we have seen vast
improvement and refinement to devices still in their
infancy. By reviewing the latest concepts and devices
in the treatment of intracranial aneurysms, we hope
to further educate the neurosurgical and neurointer-
ventional community on the rapid, exciting develop-
ments in our field.
Disclaimer Statements
Contributors Dr Mocco is Consultant: Lazarus Effect,
Medina Medical, Pulsar Vascular, Reverse Medical,
Edge Therapeutics. Investor: Blockade Medical, Medina
Medical. Advisory Board: Codman Neurovascular. NIH
Zuckerman et al. Novel aneurysm technologies
Funding: NIH 1U01NS086492-01; NIH 1R01NS
078828-01A1.
Funding This project received no funding.
Conflicts of interest None.
Ethics approval This study required no ethical
approval.
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