Acute endovascular treatment of ruptured aneurysms in poor-grade patients

We reviewed the 6-month outcome of 45 consecutive patients in poor grade treated acutely by coiling after subarachnoid haemorrhage (SAH). About half had a favourable outcome, a promising result in accordance with some surgical and endovascular reports proposing early aggressive treatment of an aneurysm causing SAH. The poor clinical grade, due to parenchyma damage from the SAH, remains the main prognostic factor, rebleeding from the untreated aneurysm being only one cause of poor outcome. It is therefore difficult to isolate the impact of any treatment of the aneurysm on outcome, and unavoidable selection bias may strongly influence favourable results. Nevertheless, available evidence and the limited invasiveness suggest that acute endovascular treatment is reasonable in these patients.Presented in part at the XVII Symposium Neuroradiologicum, Paris, 2002     

Visualisation of intracranial aneurysms by transcranial duplex sonography

We examined 72 patients with 89 angiographically confirmed intracranial aneurysms, using transcranial colour-coded duplex sonography (TCCD) to determine the location and size of the aneurysm. The patients were admitted for coil embolisation of their aneurysm following subarachnoid haemorrhage or because of a cranial nerve palsy. Using a 2/2.25 MHz transducer, 42 aneurysms (47%) were seen satisfactorily through the temporal bone window or foramen magnum. In 24 cases (27%) image quality was insufficient as a result of a poor bone window, of the aneurysm having a diameter of less than 6 mm or of its being in an unfavourable location. In 23 other cases (26%) it was not possible to detect the aneurysm. Thrombosed structures could be demonstrated using TCCD in 8 of 12 giant intracavernous or basilar artery aneurysms, and in 15 of 19 aneurysms treated by platinum coil embolisation. TCCD offers a noninvasive method for monitoring progressive intra-aneurysmal thrombosis following coil embolisation and for follow-up of patients with untreatable fusiform aeurysms, should this be required. Detection of small aneurysms is limited by spatial resolution and insonation angles.     

Combined endovascular therapy of ruptured aneurysms and cerebral vasospasm

We describe two patients with subarachnoid haemorrhage due to a ruptured intracranial aneurysm and severe symptomatic vasospasm. The aneurysm was occluded with detachable coils followed by intra-arterial infusion of papaverine to treat vasospasm as an one-stage procedure. There was significant resolution of the vasospasm. The long-term clinical outcome in one patient was excellent, the other still has minor deficits. Combined endovascular aneurysm therapy followed by intra-arterial spasmolysis with papaverine is a technically feasable therapeutic alternative in patients with symptomatic vasospasm. Received: 5 November 1999/Accepted: 12 July 2000     

Magnetic resonance signal intensity and volume changes after endovascular treatment of intracranial aneurysms causing mass effect

To determine when and how intracranial aneurysms causing mass effect change following endovascular treatment, we used MRI to assess patients for 2–3 years after the interventional procedure. Nine patients who had aneurysms compressing the surrounding structures underwent endovascular treatment. Proximal occlusion of the parent artery was performed in seven cases, and in two the aneurysm was embolised with microcoils. After embolisation, signal intensity within aneurysms tended to be high on both T1- and T2-weighted images. When there was rapid reduction in size high-signal zones within aneurysms became isointense or gave low signal on T1-weighted images. On T2-weighted images, isointense or low-signal foci appeared within high-signal areas in the aneurysm, giving mixed intensity. In typical cases, the mean volume of the aneurysm fell to approximately 30 % of its initial value 2–12 months after treatment. After this, no additional reduction was observed. The aneurysms which showed little signal intensity change tended to shrink more slowly and to a lesser degree than the more typical cases. Aneurysms which gave high signal on both T1- and T2-weighted images early following embolisation shrank more quickly than those showing little signal change. Received: 24 February 1997 Accepted: 19 June 1997     

Multislice CT angiography in the selection of patients with ruptured intracranial aneurysms suitable for clipping or coiling

INTRODUCTION: We sought to establish whether CT angiography (CTA) can be applied to the planning and performance of clipping or coiling in ruptured intracranial aneurysms without recourse to intraarterial digital subtraction angiography (IA-DSA). METHODS: Over the period April 2003 to January 2006 in all patients presenting with a subarachnoid haemorrhage CTA was performed primarily. If CTA demonstrated an aneurysm, coiling or clipping was undertaken. IA-DSA was limited to patients with negative or inconclusive CTA findings. We compared CTA images with findings at surgery or coiling in patients with positive CTA findings and in patients with negative and inconclusive findings in whom IA-DSA had been performed. RESULTS: In this study, 224 consecutive patients (mean age 52.7 years, 135 women) were included. In 133 patients (59%) CTA demonstrated an aneurysm, and CTA was followed directly by neurosurgical (n = 55) or endovascular treatment (n = 78). In 31 patients (14%) CTA findings were categorized as inconclusive, and in 60 (27%) CTA findings were negative. One patient received surgical treatment on the basis of false-positive CTA findings. In 17 patients in whom CTA findings were inconclusive, IA-DSA provided further diagnostic information required for correct patient selection for any therapy. Five ruptured aneurysms in patients with a nonperimesencephalic SAH were negative on CTA, and four of these were also false-negative on IA-DSA. On a patient basis the positive predictive value, negative predictive value, sensitivity, specificity and accuracy of CTA for symptomatic aneurysms were 99%, 90%, 96%, 98% and 96%, respectively. CONCLUSION: CTA should be used as the first diagnostic modality in the selection of patients for surgical or endovascular treatment of ruptured intracranial aneurysms. If CTA renders inconclusive results, IA-DSA should be performed. With negative CTA results the complementary value of IA-DSA is marginal. IA-DSA is not needed in patients with negative CTA and classic perimesencephalic SAH. Repeat IA-DSA or CTA should still be performed in patients with a nonperimesencephalic SAH.     

The Amplatzer vascular plug for large vessel occlusion in the endovascular management of aneurysms

The Amplatzer vascular plug (AVP) is derived from the Amplatzer device used in correction of cardiac septal defects. We present a large series of the use of the AVP in the endovascular management of aneurysms. Three patients with a combination of aortic and peripheral aneurysms underwent embolisation with the AVP. Plugs with 10–16 mm diameter were used and delivered using introducer/guiding sheaths. A total of 16 internal iliac arteries, 2 common iliac arteries (CIA), 4 subclavian (SCA) arteries, 1 superior mesenteric (SMA) and 1 popliteal artery were embolised. Successful occlusion with the AVP was achieved in 21 out of 24 vessels (87.5%), of which 18 (75%) occluded immediately and 3 (12.5%) were delayed occlusions. The three patients who are considered to have failed to occlude with the AVP required the use of additional embolic agents. At the end of the 17-month follow-up all 24 target vessels had occluded. Two patients developed persistent buttock claudication, and one had a left hemiparesis. The AVP is useful as an adjunctive device in the management of aneurysms. It has a particular role in embolisation of large-diameter vessels with a short implantation zone. The device is safe and easy to use.     

Endovascular treatment of cerebral aneurysms in elderly patients

We report our experience in the endovascular treatment with detachable platinum coils of ruptured or symptomatic unruptured cerebral aneurysms in 61 patients aged 70–82 years. Complete occlusion was achieved in 38, subtotal in 17 and partial in one. The treatment failed in five patients. Clinical follow-up was performed in all patients for 8 months to 8 years. No bleeding occurred during the follow-up period. Outcome was favourable in 63% of the patients. When we compared the outcome of elderly patients with those of younger age endovascularly treated in the same period of time, we found a significantly higher frequency of poorer outcome in the elderly group (²=9.084; P=0.011). The frequency of favourable outcome in the elderly was significantly lower than in the younger group for H–H IV–V (²=9.299; P=0.010). The most important factor influencing the outcome was not age itself, but primary clinical condition on admission. The therapy of symptomatic aneurysms in elderly patients should not be purely conservative—a direct approach of the aneurysm should be considered. Endovascular treatment whenever possible seems to be a good alternative to surgery.     

颅内动脉瘤破裂早期的血管内栓塞治疗

目的探讨颅内动脉瘤破裂早期血管内栓塞治疗的效果。方法２０例破裂的颅内动脉瘤采取早期血管内治疗技术，用自制的多形钨丝弹簧圈栓塞动脉瘤囊。动脉瘤的位置：前交通动脉（ＡＣｏＡ）７例，后交通动脉（ＰＣｏＡ）６例，中动脉（ＭＣＡ）２例，眼动脉１例，后循环４例。病人分级：ＨｕｎｔＨｅｓＩＩ级３例，ＩＩ级及ＩＶ级各７例，Ｖ级３例。１６例于３天内治疗，其余４例于６天内治疗。结果１８例闭塞９０％以上，其中８例动脉瘤完全闭塞（４０％），２例死亡。术后观察３个月～２年，１５例效果良好，３例残留轻～中度瘫痪，术后随访无一例发生蛛网膜下腔出血（ＳＡＨ）。结论血管内栓塞是治疗颅内动脉瘤急性期破裂的较好方法。     

Endovascular treatment of tiny ruptured anterior communicating artery aneurysms

INTRODUCTION: Because of its high complication rate, the endovascular treatment (EVT) of anterior communicating artery (ACoA) aneurysms less than 3 mm in maximum diameter remains controversial. We evaluated EVT of tiny ruptured ACoA aneurysms with Guglielmi detachable coils (GDCs). METHODS: We treated 19 ruptured ACoA aneurysms with a maximum diameter of 相似文献   

Endovascular treatment of anterior communicating artery aneurysms using Guglielmi detachable coils

The aim of this study was to evaluate endovascular treatment of anterior communicating artery aneurysms using Guglielmi detachable coils GDC. To obtain long-term follow-up, we selected patients treated between October 1992 and March 1994. Among the 251 berry aneurysms treated by detachable coils at our institution, 36 were located at the anterior communicating artery and treated with GDC. The most frequent clinical presentation in this group (86 %) was subarachnoid haemorrhage (30 cases). There were 23 aneurysms which were completely and 6 were partially occluded. We did not treat 7 aneurysms. In 3 cases, no endovascular treatment was attempted either because the aneurysmal neck was not clearly distinct from the adjacent, or parent vessels (2 cases), or because the aneurysm sac was too small (1 case). In 4 cases, treatment failed because of atheroma of the cervical and intracranial vessels. Complications were, in the majority of cases, related to clotting (3 cases) with a good outcome in 2 cases and neurological sequelae in 1. In 1 case rupture of the aneurysm occurred during treatment. Endovascular packing was continued until complete occlusion of the aneurysm was achieved and no clinical complication was observed after the treatment. Two patients died as a result of complications of subarachnoid haemorrhage (vasospasm in one case, pulmonary complications in the other). Endovascular treatment using GDC is an efficient technique for treating anterior communicating artery aneurysms even in the acute phase of bleeding. Received: 6 June 1995 Accepted: 25 August 1995     

AngioCT in the management of neurointerventional patients: a prospective,consecutive series with associated dosimetry and resolution data

Introduction Endovascular coiling of intracranial aneurysms carries a risk of complications. Early detection and management of complications can improve clinical outcomes. AngioCT is a new imaging technology enabling CT-like images to be generated on a flat-panel digital subtraction angiography system, which can provide immediate “on angio table” identification and thorough assessment of such complications. We prospectively audited its utility during aneurysm coiling in patients following subarachnoid haemorrhage (SAH). Methods A prospective series of 44 patients with SAH undergoing endovascular coiling with AngioCT was audited for image quality and the influence of the AngioCT on patient management. In a parallel experimental study, radiation doses were measured and image quality parameters on standard phantoms were established. Results In all patients, AngioCT provided adequate diagnostic information. In 40.9% of patients, AngioCT was a substantial or major factor in determining the management immediately after coiling. Using a 10-s high-dose acquisition technique, acceptable image quality could be obtained rapidly with a radiation dose just over half that for a conventional CT scan of the head (35 mGy versus approximately 60 mGy). No patient in this series required conventional CT to clarify the AngioCT appearance. Conclusion AngioCT has many applications in the neurointerventional setting. In particular during coiling, AngioCT provides a rapid way to clarify concerns or identify complications and in some cases was the major factor influencing further patient management immediately after coiling. AngioCT images were judged of adequate quality to be clinically useful in all patients in this series.     

Direct carotid puncture for the endovascular treatment of anterior circulation aneurysms

We report the usefulness of Guglielmi detachable coil (GDC) embolization by direct carotid puncture for anterior circulation aneurysms. For all 27 patients, GDC embolization by direct carotid puncture was safely performed by using a 5F sheath introducer 5 cm long and a Tracker-38 catheter. Neurologic deficits and hemorrhage were not found in any patient during the follow-up period. If the transfemoral approach cannot be applied, GDC embolization should be considered as an alternative method.     

Intraarterial injection of colforsin daropate hydrochloride for the treatment of vasospasm after aneurysmal subarachnoid hemorrhage: preliminary report of two cases

We describe two patients with symptomatic vasospasms after aneurysmal subarachnoid hemorrhage who were successfully treated with intraarterial injection of colforsin daropate hydrochloride (HCl). Colforsin daropate HCl is capable of directly stimulating adenylate cyclase, which in turn causes vasorelaxation via elevated intracellular concentrations of cyclic adenosine monophosphate. We suggest that colforsin daropate HCl might be a useful therapeutic tool in treating cerebral vasospasm.     

Filling defect sign in CT diagnosis of ruptured aneurysm

We have encountered a ruptured aneurysm as a filling defect in cisternal blood on CT in patients with acute subarachnoid haemorrhage (SAH), as high-attenuation blood can act as a contrast medium. We term this finding the “filling defect sign”. To evaluate the usefulness of the sign in the diagnosis of a ruptured aneurysm, we retrospectively analysed CT with 10-mm-thick slices obtained within 2 days of onset of SAH in 100 consecutive patients. The sign was observed in 30 of the 100 patients, and in 13 (68 %) of 19 patients with a ruptured aneurysm more than 10 mm in diameter. The filling defect sign is useful in predicting the site of rupture. Received: 30 May 1996 Accepted: 6 September 1996     

Anatomical and morphological factors correlating with rupture of intracranial aneurysms in patients referred for endovascular treatment

The size of intracranial aneurysms is the only characteristic shown to correlate with their rupture. However, the critical size for rupture has varied considerably among previous accounts and remains a point of controversy. Our goal was to identify statistically significant clinical and morphological factors predictive of the occurrence of rupture and aneurysm size in patients referred for endovascular treatment. We retrospectively recorded the following factors from 74 patients who presented with ruptured (40) or unruptured (34) aneurysms: aneurysm morphology (uni/multilobulated), location (anterior/posterior), maximum diameter, diameter of the neck, and the patient's age and sex. We performed stepwise discriminant, and stepwise and logistic regression analysis to identify factors predicting rupture and the size of the aneurysm at rupture. The mean diameter of the ruptured aneurysms was 11.9 ± 6.3 mm, range 3.0–33.0 mm, and that of the unruptured aneurysm 13.5 ± 5.8 mm, range 5.0–30 mm. Stepwise discriminant analysis identified aneurysm morphology (P < 0.001) and location in the intracranial circulation (P < 0.001) as statistically significant factors in predicting rupture. Stepwise regression analysis revealed that aneurysm morphology and the size of the neck were predictors of aneurysm size at rupture. Received: 30 December 1997 Accepted: 28 April 1998     

A computerised relational database for auditing endovascular treatment of patients with intracranial aneurysms

We describe the development and design of a database for auditing patients with intracranial aneurysms and their endovascular treatment. The database has been used since 1992. Our department's version now contains records of over 800 patients and well over 1000 aneurysms. The advantages of a relational database for this type of audit are discussed. Copies of the software can be obtained free of charge from the authors. Received: 16 November 1999/Accepted: 28 February 2000     

Factors influencing the outcome after the operative treatment of cerebral aneurysms of anterior circulation

BACKGROUND: The influence of various factors on the outcome after the operative occlusion of the cerebral aneurysm was to be defined through the retrospective study on 111 surgically treated patients with aneurysm of anterior cerebral circulation. METHODS: Preoperative clinical condition was graded from 0 to V, according to Hunt & Hess. Postoperative outcome, defined as good or bad according to modified Glasgow Outcome Scale, was correlated in homogenous experimental groups with the following factors: gender, age, aneurysmal size, preoperative interval, nimodipine therapy, experience of surgical team and existence of chronic vascular diseases. RESULTS: Surgical outcome was good in 74.4% of males and 71.4% of females (p > 0.05); in 83.3% of patients with and 41.2% of patients without chronic diseases (p < 0.01); in 71.4% of patients underwent early, 83.3% of ones underwent postponed and 85% of those underwent late surgery (p > 0.05); in 81.5% of patients treated by nimodipine and in 41.7% of those untreated by the same drug (p < 0.01); in 78.9% of patients operated by the experienced surgical team and in 40% of those operated by less experienced surgical team (p < 0.01). In patients with both good and bad outcome, the mean age was 50.6 and 47.6 years (p > 0.05), and the mean aneurysmal size was 12.3 mm and 13.3 mm, respectively (p > 0.05). Before rupture, the mean size for aneurysms on the bifurcation of the middle cerebral artery was 14.3 mm, and for posterior communicating artery aneurysms only 9.7 mm (p < 0.05). CONCLUSION: Surgical outcome was significantly influenced by the existence of chronic diseases, nimodipine therapy and experience of surgical team, whereas gender, age, timing for surgery and aneurysmal size were not of significant influence.     

蛛网膜下腔出血患者的MRA和DSA的对照研究

目的：研究ＭＲ血管造影（ＭＲＡ）在蛛网膜下腔出血（ＳＡＨ）患者病因诊断中的应用准确性和可靠性。材料和方法：回顾性分析３３例ＳＡＨ患者的ＭＲＡ资料，并与ＤＳＡ作了对比分析，ＭＲＡ采用三维时间流逝（３Ｄ－ＴＯＦ）法。结果：ＭＲＡ上显示了２６例血管病变中的２２例，包括１５个动脉瘤中的１３个，８例动静脉畸形中的６例和３例血管狭窄闭塞性病变。１个完全血栓形成的右颈内动脉瘤ＭＲＡ上未显示。但常规ＭＲＩ和ＭＲＡ原始图像上显示，ＭＲＡ结合ＭＲＩ和ＭＲＡ原始图像可以对９１％的患者做出正确诊断和评价，动脉瘤和周围血管的关系及ＡＶＭ的供血动脉和畸形结节能在ＭＲＡ上被准确评价。结论：作为一种非损伤性的血管成像方法，ＭＲＡ具有安全、可靠和方便的优点，可以做为常规用于ＳＡＨ患者的筛选检查。     

Outcome of emergency endovascular treatment of large internal iliac artery aneurysms with guidewires

Purpose

Guidewires have been reported as a useful occlusion material for large aneurysms of different locations with good short-term results. In this study we retrospectively evaluate long-term results of emergency embolization technique with guidewires in symptomatic internal iliac artery aneurysm (IIAA) impending rupture.

Patients and methods

In four patients presented with acute abdominal pain, multidetector computed tomography revealed unstable, 7-14 cm large, IIAAs. Two patients were treated with coil embolization of distal branches followed by occlusion of aneurysmal sac with guidewires. In two patients embolization of aneurysmal sac alone was performed.

Results

In three patients complete or near complete occlusion of the aneurysmal sac was achieved and abdominal pain ceased within hours. Two patients treated with embolization of distal iliac artery branches and aneurysmal sac developed claudication that lasted up to 1 year. Their aneurysms remained thrombosed and they were without symptoms until they died 31 and 56 months later of causes unrelated to IIAA. Two patients treated with embolization of the aneurysm alone were free of ischemic symptoms. Because of incomplete embolization of the sac in one patient open surgery treatment in a non-emergency setting was performed. Complete filling of aneurysmal sac was achieved in other patient but 2 years later his aneurysm re-opened and required open surgery treatment.

Conclusion

Embolization of aneurysmal sac of large IIAA with guidewires may be effective for immediate treatment of impending rupture. Long-term results were better when embolization of the aneurysmal sac was combined with embolization of distal IIA branches.     

Emergent endovascular treatment of ruptured vertebral artery dissecting aneurysms

The goal of this study was to evaluate the results of endovascular and surgical treatments for ruptured vertebral artery dissecting aneurysms (VADAs) to determine which treatment is preferable. We evaluated the cases of 25 consecutive patients with ruptured VADAs treated in our institution. From 1992 to 1997, five patients were treated surgically. Since 1998, 20 patients with VADAs have been treated with endovascular therapy. The goal of the treatment was to exclude the aneurysm from the circulation. Among the five patients undergoing surgery, three aneurysms were treated with proximal clipping, one with trapping, and one with dome clipping. None of the patients were treated during the acute stage of rupture. Transient complications occurred in two patients. Of the 20 patients treated through the endovascular approach, 15 were treated within 24 h of rupture, but 12 had rebleeding before treatment. Eighteen aneurysms were occluded, along with the affected vertebral artery (VA), by using detachable coils (internal trapping), and one was occluded with the VA preserved. A stent-assisted occlusion of one aneurysm was done in a patient who had a contralateral hypoplastic VA. In both groups, the outcome of each patient depended greatly on the patients condition before treatment and whether there was rebleeding. No posttreatment bleeding occurred. All procedures were effective, but endovascular treatment was less invasive and easier to use during the acute stage of subarachnoid hemorrhage. Although this report does not describe a controlled study, we found that endovascular treatment is preferable for treating ruptured VADAs in the acute stage.