Rupture during treatment of recently ruptured aneurysms with Guglielmi electrodetachable coils.

BACKGROUND AND PURPOSEWe describe four cases of aneurysmal rupture during embolization with Guglielmi electrodetachable coils (GDCs) in an attempt to identify those aneurysms whose rupture during embolization represents a life-threatening risk; our emphasis is on emergency management, in particular, ventriculostomy.METHODSMedical records were reviewed retrospectively for 91 aneurysms treated with GDCs 0 to 21 days after subarachnoid hemorrhage. Rupture was ascertained by the presence of extravascular effusion of contrast medium.RESULTSOf the perforated aneurysms, two involved the anterior communicating artery, one the posterior inferior communicating artery, and one the basilar artery. Only two patients, whose aneurysms were located in the posterior fossa, had major complications (arterial hyperpressure, mydriasis, angiographically documented circulatory arrest or slowing). One of these patients died and the other improved after emergency ventriculostomy.CONCLUSIONAneurysmal perforation during embolization may be accompanied by severe intracranial hypertension, which causes either a decrease or arrest of cerebral perfusion, the duration of which determines clinical outcome. Emergency ventriculostomy (which should be performed in the angiographic suite) is an effective means to reduce intracranial pressure. Recognition of aneurysms associated with a high risk of mortality by rupture in the course of embolization (recently ruptured small aneurysms, posterior fossa aneurysms, associated ventricular dilatation, massive cisternal hemorrhage) and use of proper logistics should ensure the effective management of this devastating complication.     

联合血管内外神经介入技术治疗急性期破裂颅内动脉瘤

目的　评估联合血管内外神经介入技术治疗急性期破裂颅内动脉瘤 (aneurysm ,AN)的疗效。方法　对 4 0例急性破裂期AN采用电解脱弹簧圈栓塞 ,随后穿刺腰蛛网膜下腔 ,导丝导向的微导管在透视下插管至枕大池 ,2h后注入 10万U尿激酶 (UK)溶解血块并经微导管持续引流血性脑脊液。根据CT复查结果决定是否继续注射UK。结果　AN栓塞及枕大池插管均获成功 ,无技术相关并发症 ,术后 3～ 7d时的CT见所有患者脑池内的出血消失。除 1例有一过性症状性脑血管痉挛 (CVS)外 ,其余患者无症状性CVS、所有患者无AN再出血。结论　联合血管内外神经介入技术既闭塞了AN ,又清除了蛛网膜下腔积血 ,可防止再出血和继发性CVS的发生 ,达到了对因、对症治疗的双重目的。     

微导丝辅助技术在颅内动脉瘤栓塞治疗中的应用研究

目的 探讨微导丝辅助的瘤颈成形技术在弹簧圈栓塞治疗颅内动脉瘤中的价值、技术操作要点及临床应用前景。方法 本组包括25例小型宽颈动脉瘤(前交通动脉12例，大脑中动脉分叉部12例，小脑后下动脉瘤1例)。微导管成功超选动脉瘤囊内，将撤出的微导丝再塑形后跨瘤颈部位放置。通过微导管内用电解可脱卸弹簧圈栓塞动脉瘤。结果 25例均获得成功，动脉瘤致密栓塞，载瘤动脉保持通畅，效果满意。短期影像随访16例，动脉瘤无复发。结论 微导丝瘤颈成形术作为小型宽颈动脉瘤治疗技术是安全、经济有效的。     

Effects of Circle of Willis Anatomic Variations on Angiographic and Clinical Outcomes of Coiled Anterior Communicating Artery Aneurysms

BACKGROUND AND PURPOSE:Anterior communicating artery aneurysms account for one-fourth of all intracranial aneurysms and frequently occur in the context of A1 vessel asymmetry. The purpose of this study was to correlate circle of Willis anatomic variation association to angiographic and clinical outcomes of anterior communicating aneurysm coiling.MATERIALS AND METHODS:The Cerecyte Coil Trial provides a subgroup of 124 cases with anterior communicating artery aneurysms after endovascular coiling. One hundred seventeen of 124 anterior communicating artery aneurysms had complete imaging and follow-up for clinical outcome analysis, stability of aneurysm coil packing, and follow-up imaging between 5 and 7 months after treatment. Clinical outcomes were assessed by the mRS at 6 months.RESULTS:Anterior cerebral artery trunk-dominance was seen in 91 of 124 (73%) anterior communicating artery aneurysms and codominance in 33 of 124 (27%) anterior communicating artery aneurysms. There was no significant difference (P > .5) in treatment success at 5–7 months for anterior communicating artery aneurysms between the anterior cerebral artery trunk-dominant (49 of 86, 57%) and anterior cerebral artery trunk-codominant (19 of 31) groups. Angiographic follow-up demonstrates a statistically significant increase in neck remnants and progressive aneurysm sac filling with the A1 dominant configuration (n = 21, 24% at follow-up versus n = 11, 12% at immediate posttreatment, P = .035). There was no statistically significant difference in clinical outcomes between types of anterior cerebral artery trunk configuration (P > .5).CONCLUSIONS:Anterior communicating artery aneurysms with anterior cerebral artery trunk-dominant circle of Willis configurations show less angiographic stability at follow-up than those with anterior cerebral artery trunk-codominance similar to other “termination” type aneurysms. This supports the hypothesis that anterior cerebral artery trunk-dominant flow contributes to aneurysm formation, growth, and instability after coiling treatment.

The most common site of intracranial aneurysms is the anterior communicating artery (AcomA). AcomA aneurysms account for approximately one-fourth of all intracranial aneurysms.¹ Also very common in the setting of AcomA aneurysms is unilateral anterior cerebral artery trunk (A1) dominance where 1 side supplies both pericallosal artery (A2) arteries, a well-known phenomenon previously shown to be a potent risk factor for AcomA aneurysm formation and rupture.^1–3To what extent vessel dominance influences the long-term result of endovascular packing of these aneurysms with detachable platinum coils and the patients'' clinical outcome is less well known.^4–6 One previous study indicates that vessel dominance is not a major factor in predicting short-term treatment outcome; however, the methodology and definition of vessel dominance as used in this instance was not stated.⁷ Yet, anterior communicating aneurysms are commonly “termination type” with the aneurysm forming with a relatively wide neck at the site of the inferred jet of flowing blood dynamics, with main branches nearly perpendicular to the parent vessel, also commonly seen for basilar tip, internal carotid tip, and middle cerebral bifurcations.⁸The Cerecyte Coil Trial (CCT) was a prospective, randomized, controlled study that entered 500 cases comparing endovascular coiling of ruptured and unruptured cerebral aneurysms with either Cerecyte or bare platinum coils that showed no difference between groups.^9,10 There was an expected large subset of AcomA aneurysms within the CCT cohort (n = 124).⁹ Therefore, data from this trial provided a unique opportunity to obtain a large number of AcomA aneurysm cases for determination of A1 dominance in relation to coiling treatment and angiographic outcomes immediately posttreatment and at follow-up. Our goal was to determine the impact of A1 dominance on treatment success, stability, and clinical outcomes of endovascularly coiled AcomA aneurysms.     

A case of subdural hemorrhage due to ruptured cerebral aneurysm presenting with atypical imaging features

Acute subdural hemorrhage caused by ruptured cerebral aneurysms is rare. Herein, we report an atypical case of subdural hemorrhage caused by ruptured anterior communicating artery aneurysm in a 49-year-old woman. Computed tomography revealed subarachnoid, intracerebral, and subdural hemorrhages. After the treatment with endovascular coiling significantly decreased the patient''s subdural hemorrhage. However, the subdural hemorrhage revealed and became iso-attenuation compared with the white matter on the 11th day, and hypo-attenuation on the 19th day. On the 33rd day, this subdural hemorrhage completely resolved after discontinuation of dual antiplatelet therapy. Due to rapid changes in the radiologic features of SDH, frequent computed tomography scans at least once a week may be needed especially in patients who receive antiplatelet therapy during the vasospasm phase.     

Frequency of cerebral vasospasm in patients treated with endovascular occlusion of intracranial aneurysms.

UNLABELLEDThe purpose of this study was to retrospectively compare a group of 19 patients treated with craniotomy and aneurysmal clipping with a group of 18 patients who were treated via endovascular occlusion with Guglielmi detachable coils in regard to frequency and severity of cerebral vasospasm.METHODSAll patients were treated within 48 hours of ictus. In the endovascular group, nine patients had Hunt and Hess grade I subarachnoid hemorrhage, five patients had grade II aneurysms, and four patients had grade III. According to the Fisher classification, one aneurysm was grade I, nine were grade II, and eight were grade III. Twelve of the aneurysms were on the anterior circulation and seven were on the posterior circulation. In the surgical group, 10 patients had Hunt and Hess grade I hemorrhage, seven had grade II aneurysms, and two had grade III. Nine of these were Fisher grade II and 10 were grade III. Eighteen aneurysms were on the anterior circulation and one was on the posterior circulation. Endovascularly treated patients were medically treated identically to those in the surgical group, with prophylactic volume expansion and hemodilution immediately after endovascular occlusion, except that they also received 48 hours of full heparinization followed by 24 hours of dextran infusion after endovascular occlusion.RESULTSAll four patients in the endovascular group in whom delayed neurologic deficits developed as a result of vasospasm responded to elevation of blood pressure and did not require either mechanical or chemical angioplasty to reverse their symptomatology. In the surgical group, 14 of 19 developed clinical vasospasm, with elevation of their transcranial Doppler velocities, and required maximum triple-H (hypertensive, hypervolemic, hemodilutional) therapy. Three of these patients required mechanical and pharmacologic angioplasty. No surgical complications were incurred as a direct result of the craniotomy. One patient in the endovascular group developed a femoral pseudoaneurysm as a complication of the procedure and postocclusion anticoagulation. No thromboembolic events were noted in this group.CONCLUSIONIn patients with similar Hunt and Hess grades and Fisher grades, preliminary data suggest that the frequency and severity of cerebral vasospasm may be reduced in those treated by endovascular occlusion of their aneurysm as compared with those treated by direct surgical clipping.     

Intra-arterial tirofiban infusion for thromboembolic complication during coil embolization of ruptured intracranial aneurysms

Introduction

Intra-arterial (IA) thrombolytic intervention for acute thrombosis has been challenged due to the risk of bleeding during the endovascular treatment of ruptured aneurysms. We present the results of IA tirofiban infusion for thromboembolic complications during coil embolization in patients with ruptured intracranial aneurysms.

Methods

Thromboembolic events requiring thrombolytic intervention occurred in 39 (10.5%) cases during coil embolization of 372 consecutive ruptured intracranial aneurysms. Maximal aneurysm diameters of 39 patients (mean age, 54.7 ± 13.2 years; 23 female, 16 male) ranged from 2.1 to 13.1 mm (mean, 6.6 ± 3.0 mm). The anterior communicating artery was the most common site (n = 13), followed by the middle cerebral artery (n = 9) and the posterior communicating artery (n = 7). In this series, we used intracranial stents in 10 patients during the procedure. Superselective IA tirofiban infusion through a microcatheter was performed to resolve thrombi and emboli. We assessed the efficacy and safety of IA tirofiban infusion in patients with ruptured aneurysms.

Results

Intraarterially administered tirofiban doses ranged from 0.25 to 1.25 mg (mean, 0.71 ± 0.26 mg). Effective thrombolysis or recanalization was achieved in 34 patients (87.2%), and three patients (7.7%) suffered distal migration of clots with partial recanalization. The rest (5.1%) had no recanalization. Nonconsequent intracerebral hemorrhage occurred in two patients (5.1%) after the procedure. Thromboemboli-related cerebral infarction developed in eight patients, and only two patients remained infarction related disabilities.

Conclusion

IA tirofiban infusion seems to be efficacious and safe for thrombolysis during coil embolization in patients with ruptured intracranial aneurysms.     

Our experience in the diagnosis and treatment of cerebral pseudoaneurysms

ObjectiveTo present our experience in the diagnosis and intravascular treatment of cerebral pseudoaneurysms.Material and methodsWe present 11 pseudoaneurysms (2 traumatic, 2 mycotic, 3 iatrogenic, and 4 with other causes). We analyze the methods and diagnostic criteria, radiological and clinical outcome, the criteria used in making decisions about treatment, the method of treatment, and the complications.ResultsDigital subtraction angiography is the gold standard for the diagnosis of cerebral pseudoaneurysms; the diagnostic criteria in the literature include: aneurysms with early morphological changes and distal aneurysms or proximal aneurysms associated with another distal one, in the context of the right symptoms and signs. In the nine patients treated with endovascular techniques, the treatment objective was achieved and rebleeding did not occur.ConclusionsIn cases with clinical suspicion of a pseudoaneurysm, the patient should undergo angiography. This is especially important in patients with inexplicable cerebral hemorrhage and in those with septicemia. CT angiography and MR angiography have good diagnostic accuracy and can replace conventional angiography. However, the treatment of choice is endovascular and treatment should not be delayed unless access to the pseudoaneurysm is impeded, usually due to severe cerebral vasospasm.     

Horizontal Neuroform stent deployment for a ruptured basilar terminus aneurysm via the posterior communicating artery

The authors describe the endovascular management of a ruptured wide-necked basilar terminus aneurysm with stent-assisted coil technique via posterior communicating collateral vessels from the anterior cerebral circulation. A Neuroform stent was placed horizontally across the neck of the aneurysm with use of the patient's large, patent, posterior communicating artery. This approach allowed for complete endovascular treatment in the setting of acute subarachnoid hemorrhage.     

Giant serpentine aneurysms: radiographic features and endovascular treatment.

PURPOSETo describe the characteristic CT, MR, and angiographic features of giant serpentine aneurysms and discuss their endovascular treatment.METHODSThirteen patients with giant serpentine aneurysms were studied at our institution in the last 3 years. They all underwent CT and MR studies as well as cerebral angiography. More recently, some of the patients were studied with MR angiography. Seven patients had endovascular occlusion of the giant serpentine aneurysms, 3 with N-butyl cyanoacrylate, 2 with Guglielmi detachable coils, and 2 with detachable balloons.RESULTSGiant serpentine aneurysms mimic cerebral neoplasms on CT and MR studies; they are often associated with mass effect and adjacent edema, and they enhance with contrast medium. The cerebral angiogram shows a residual irregular lumen of the partially clotted aneurysm, which continues into normal branches supplying the distal arterial territory. Six patients were treated successfully with an endovascular approach consisting of complete and permanent occlusion of the parent artery.CONCLUSIONGiant serpentine aneurysms from a subgroup of large intracranial aneurysms that have specific CT, MR, and angiographic features, which should be recognized before their treatment. The endovascular treatment of the aneurysm consists of permanent occlusion of the parent artery.     

Continuous intra-arterial infusion of nimodipine during embolization of cerebral aneurysms associated with vasospasm

BACKGROUND AND PURPOSE: Despite rigorous efforts, cerebral vasospasm remains an important cause of morbidity and mortality in patients who survive their initial subarachnoid hemorrhage. In cases of intracranial ruptured aneurysm associated with vasospasm, we evaluated the effectiveness of combined embolization of an aneurysm and intra-arterial infusion of nimodipine, which continued during the entire procedure.Materials and METHODS: Ten patients with ruptured aneurysms associated with vasospasm who were treated in a single session were reviewed retrospectively. After initial intra-arterial infusion of nimodipine (1–2 mg within 10–15 minutes), they underwent occlusion of the aneurysm with coils under continuous intra-arterial infusion of nimodipine at a dose of 1 mg per hour.RESULTS: Angiography showed severe proximal vasospasm in 1 patient, proximal and distal in 3 patients, and distal in 3 patients. There was also moderate proximal vasospasm in 4 patients, proximal and distal in 1 patient, and distal in 1 patient. Complete occlusion of the aneurysm was achieved in 5 patients, incomplete occlusion in 3 patients, and a small neck remnant in 2 patients. Final angiograms also demonstrated complete clearance of a proximal spasm in 4 patients, and complete clearance of proximal and distal spasms in another 4 patients. Mean initial dose of nimodipine was 1.375 mg, and mean continuous infusion dose was 1.275 mg (mean total dose, 2.65 mg). No medical complications related to extended infusion of nimodipine occurred.CONCLUSION: In this small series, extended intra-arterial infusion of nimodipine up to the end of the embolization procedure was effective and safe in patients with a ruptured aneurysm and associated vasospasm. This technique seems to increase the security of the procedure as well as force further vasorelaxation when the endovascular route is used to treat both the aneurysm and vasospasm in a single step.

The current optimized approach for patients with a ruptured intracranial aneurysm is to secure the aneurysm early (usually within 3–4 days), either surgically or endovascularly, then apply triple-H therapy alone or in combination with intra-arterial chemical or mechanical angioplasty to overcome vasospasm if it is apparent clinically.¹ In cases of an aneurysm of a high clinical grade or accompanying medical problems that preclude an open surgical procedure, in patients who are candidates for open surgery initially but cannot be operated on later for any reason, and because of other obstacles (ie, geographic distance to referral center) that delay initial intervention, an endovascular interventionalist may encounter an aneurysm along with vasospastic cerebral arteries.Here we describe a simple technique that involves both procedures of aneurysmal embolization and intra-arterial infusion of a vasorelaxing drug in such patients with significant vasospasms.     

重症前交通动脉瘤破裂25例疗效分析

目的探讨对于重症前交通动脉瘤破裂患者积极实施探查夹闭手术的必要性及手术的策略和技巧。方法回顾性分析2010年10月至2013年3月河北医科大学第二医院收治的25例重症前交通动脉瘤破裂患者的临床资料,其中给予探查手术治疗16例,保守治疗9例。根据格拉斯哥预后评分（GOS）对两组治疗结果进行分级评定并比较。结果手术治疗组中,前交通动脉瘤16个,瘤直径〈5mm9例,5～15mm5例,15～25mm2例,均予以完全夹闭,并保持载瘤动脉通畅,去除骨瓣减压。根据GOS结果评定,死亡3例（GOS1分）,差4例（GOS2～3分）,良好9例（GOS4～5分）。非手术组均经CT血管造影（CTA）证实为前交通动脉瘤破裂,治疗结果评定：死亡4例（GOS1分）,差4例（GOS2—3分）,良好1例（GOS4—5分）。两组疗效比较差异有统计学意义（P〈0．05）。结论对于重症前交通动脉瘤破裂患者,通过积极的探查手术治疗,可使患者的生存率得到极大提高,预后明显改善。科学正确的手术策略、精巧细致的分离暴露方法对于探查手术的成功至关重要。     

前交通动脉瘤的栓塞治疗

目的　总结 2 62例前交通动脉瘤栓塞治疗的经验。方法　均采用电解可脱卸弹簧圈(guglielmidetachablecoil,GDC)作动脉瘤内栓塞治疗。对双侧A1正常者应用双侧颈动脉置管技术监测栓塞术中载瘤动脉通畅情况 ,对瘤颈累及双侧A2者采用微导管微导丝辅助技术保持载瘤动脉通畅。发生术中出血者予弹簧圈继续栓塞 ,发生术中血栓形成者予尿激酶溶栓。 3 4例颅内多发动脉瘤均同次手术治愈。结果　动脉瘤完全闭塞 160例 ,>90 %闭塞 5 6例 ,<90 %闭塞 4 6例。术中因过度栓塞造成载瘤动脉闭塞 10例 ,术后脑梗死 16例。术中发生血栓形成 3例 ,经溶栓后恢复通畅。术后死于肺部并发症 1例 ,植物生存 1例。随访 190例 ,3～ 6个月行DSA/MRA复查 ,动脉瘤复发行 2次栓塞 8例 ,复发经手术治愈 1例 ,其余治疗结果稳定。结论　GDC栓塞治疗前交通动脉瘤效果好。采用微导管 /微导丝辅助技术可提高致密栓塞率和减少脑梗死并发症发生     

Potential advantages and limitations of the Leo stent in endovascular treatment of complex cerebral aneurysms

Objective

The Leo self-expandable stent is a new retractable stent that is delivered via a conventional catheter. The aim of this study was to evaluate the use of this stent for endovascular treatment of complex aneurysms.

Methods

Twenty-eight complex cerebral aneurysms (27 saccular and 1 fusiform) in 28 patients were treated electively. They were located at the internal carotid artery (17), basilar trunk (3), anterior cerebral artery (1), anterior communicating artery (3), vertebral artery (2) and middle cerebral artery (2). One aneurysm exhibited recanalization after primary endovascular treatment without stent. Clinical outcome was assessed with the modified Glasgow Outcome Scale.

Results

Deployment of Leo stent was successful in 26 lesions, and difficulties in stent positioning due to tortuous cerebral circulation in 2 cases, which were treated with Neuroform stent. Additional coil embolization was performed in 26 lesions. No permanent neurological deficits were encountered consequent to endovascular procedure. Complete or partial occlusion immediately after stent deployment was achieved in all aneurysms. There was no immediate coil embolization was chosen in 3 cases because of subsequent reduced filling of the aneurysms with contrast agent on angiograms. There were 3 asymptomatic parent artery occlusion related to the deployment of the Leo stent, one stent migration. Follow-up revealed patent stents in the remaining cases. No angiographic recurrences arose.

Conclusion

The Leo stent is very useful for endovascular treatment of complex cerebral aneurysms because it is easy to navigate and place precisely. A drawback is that in-stent thrombosis caused by stent placement and stiffer delivery catheters to place larger stents.     

Abciximab in patients with ruptured intracranial aneurysms

BACKGROUND AND PURPOSE: Experience with intravenous abciximab to manage thromboembolism during treatment of ruptured intracranial aneurysms is limited. We present our experience in 13 patients. METHODS: We retrospectively reviewed all patients with thromboembolic complications during endovascular management of ruptured intracranial aneurysms. Thromboembolic complications were treated with intravenous abciximab. We recorded patient and aneurysm demographics, aneurysm occlusion, drug therapy, complications, and outcomes. RESULTS: World Federation of Neurological Surgeons Grades were 1 or 2 in 11 patients (85%). Median time from diagnostic angiography to treatment was 1 day. Ten (77%) aneurysms involved the anterior or posterior communicating artery, and one each occurred in the posterior inferior cerebellar artery, middle cerebral artery, and basilar regions. Eleven aneurysms were <10 mm. Five were incompletely occluded (0%-90% treated) at the time of the complication. Thromboembolic complications were at the coil-ball/parent-artery interface in nine patients (69%). Two were associated with coil-loop prolapse; one was prophylactically treated without evidence of thromboembolism. Five patients (38%) had distal complications; one also had a proximal thrombus. All patients received an intravenous bolus of abciximab (5-10 mg in 92%) without infusion. Postprocedural recanalization was complete in eight (62%) and partial in four (31%). Eleven patients (85%) had a Glasgow Outcome Scale score of 1 at 3 months. One had a poor outcome (GOS4). One died following additional coiling after abciximab administration, though this intervention was uneventful in three others. CONCLUSION: Abciximab completely or partially treated thromboembolic complications arising during coiling of ruptured aneurysms. Further coiling should be performed with extreme caution and needs to be decided on a patient-by-patient basis.     

Angiographic outcome after endovascular therapy for anterior communicating artery aneurysms: correlation with vascular morphological features

Purpose

The purpose of this study is to analyze the effect of morphological features on angiography after endovascular embolization for anterior communicating artery (AcoA) aneurysms.

Materials and methods

We conducted a retrospective case review of 32 consecutive patients (19 males and 13 females) with AcoA aneurysms treated by endovascular coil embolization between February 2003 and August 2011. Mean age was 61?years (range 36?C90?years). Twenty-eight aneurysms were ruptured and 4 were unruptured. We evaluated morphological features included direction of the dome, dome size, dome to neck ratio, presence of irregularity, and angle between A1 segment of the anterior cerebral artery and C1 segment of the internal carotid artery. Immediate angiographic results (complete or incomplete occlusion) and the occurrence of procedural complications (aneurysmal rupture and thromboembolic events) were correlated with morphological features. Fisher??s exact test was used for statistical analysis.

Results

A single factor significantly associated with incomplete occlusion was superior dome direction (p?=?0.037). Other morphological features did not correlate with angiographical results. There was no correlation between morphological features and procedural complications.

Conclusion

Incomplete occlusion after coil embolization for AcoA aneurysms is more common in cases of superior dome direction.     

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     

Fatal rebleeding following coil embolization of cerebral aneurysms: the role of long-term systemic anticoagulation

Embolization of cerebral aneurysms has become a common technique. Its impact on subsequent medical management of the patient is not well known. We report two patients who presented in a poor neurological grade after subarachnoid hemorrhage from posterior communicating artery aneurysms. Both were treated by coil embolization and both developed subclavian vein thrombosis, requiring systemic anticoagulation, initiated 11 and 21 days after embolization, respectively. Both developed a large, fatal intracranial hemorrhage adjacent to the embolized aneurysm in the fourth week of anticoagulation. Systemic anticoagulation of patients who have had a ruptured aneurysm treated by coil embolization may carry a significant risk of rebleeding. Alternate management strategies should be considered in these patients. Received: 21 January 2000 Accepted: 3 October 2000     

Endovascular treatment of middle cerebral artery aneurysms with electrolytically detachable coils

BACKGROUND AND PURPOSE: Middle cerebral artery (MCA) aneurysms often have an unfavorable aneurysm geometry that might limit endovascular therapy. Our purpose was to analyze the feasibility, safety, and efficacy of coil embolization in a consecutive series of MCA aneurysms chosen for endovascular treatment. PATIENTS AND TECHNIQUES: Of 235 MCA aneurysms seen at our institution during the past 5 years, 36 patients harboring 38 MCA aneurysms were primarily selected for coil embolization: 18 patients had an acute subarachnoid hemorrhage (SAH), 16 of which were due to a ruptured MCA aneurysm. SAH was classified according to Hunt and Hess grade: I (5), II (7), III (5), IV (0), and V (1). RESULTS: Complete occlusion could be achieved in 33 of 38 aneurysms. In 5 aneurysms, coil embolization was not performed because of an unfavorable aneurysm geometry with a wide neck or incorporation of adjacent branches (3) or failed because of insecure coil placement (1) or severe vasospasm (1). Procedural complications included coil protrusion into the parent artery (1), and thromboembolic M2 occlusion (5), with recanalization in 4 of 5 cases. Of 8 aneurysms with initial subtotal occlusion, 3 progressed to total occlusion during follow-up. Three aneurysms had to be retreated, and no patient rebled. Glasgow Outcome Scale at 6 months for the patients with SAH (17/18) was good recovery (12), moderate disability (4), severe disability (0), persistent vegetative state (0), and death (1); outcomes for patients with an incidental aneurysm (17/18) were good recovery (16) and moderate disability (1). CONCLUSION: Endovascular coil embolization can be performed safely and effectively in selected MCA aneurysms. Initial subtotal aneurysm occlusion might progress to total occlusion.     

Patient Outcomes and Cerebral Infarction after Ruptured Anterior Communicating Artery Aneurysm Treatment

BACKGROUND AND PURPOSE:Anterior communicating artery aneurysm rupture and treatment is associated with high rates of dependency, which are more severe after clipping compared with coiling. To determine whether ischemic injury might account for these differences, we characterized cerebral infarction burden, infarction patterns, and patient outcomes after surgical or endovascular treatment of ruptured anterior communicating artery aneurysms.MATERIALS AND METHODS:We performed a retrospective cohort study of consecutive patients with ruptured anterior communicating artery aneurysms. Patient data and neuroimaging studies were reviewed. A propensity score for outcome measures was calculated to account for the nonrandom assignment to treatment. Primary outcome was the frequency of frontal lobe and striatum ischemic injury. Secondary outcomes were patient mortality and clinical outcome at discharge and at 3 months.RESULTS:Coiled patients were older (median, 55 versus 50 years; P = .03), presented with a worse clinical status (60% with Hunt and Hess Score >2 versus 34% in clipped patients; P = .02), had a higher modified Fisher grade (P = .01), and were more likely to present with intraventricular hemorrhage (78% versus 56%; P = .03). Ischemic frontal lobe infarction (OR, 2.9; 95% CI, 1.1–8.4; P = .03) and recurrent artery of Heubner infarction (OR, 20.9; 95% CI, 3.5–403.7; P < .001) were more common in clipped patients. Clipped patients were more likely to be functionally dependent at discharge (OR, 3.2; P = .05) compared with coiled patients. Mortality and clinical outcome at 3 months were similar between coiled and clipped patients.CONCLUSIONS:Frontal lobe and recurrent artery of Heubner infarctions are more common after surgical clipping of ruptured anterior communicating artery aneurysms, and are associated with poorer clinical outcomes at discharge.

Subarachnoid hemorrhage secondary to rupture of a cerebral aneurysm affects 30,000 people in the United States every year and results in significant morbidity and mortality.¹ Clinical outcomes after aneurysm rupture and treatment are influenced by cumulative cerebral infarction burden.^2,3 Furthermore, patients who recover from aneurysm rupture are often left with disabling cognitive deficits that may result in the patient''s dependency on others, which is reflect by higher mRS scores.^4,5 The severity of these cognitive deficits has been correlated to the Hunt and Hess Scale (HHS) grade on admission, older age, aneurysm location, and treatment-related brain injury.^6–8Anterior communicating artery aneurysms (AcomAs) are among the most commonly identified ruptured aneurysms,^9,10 and AcomA rupture and treatment are more strongly associated with cognitive and behavioral deficits relative to other aneurysm locations.^5,11–14 The cause of these neuropsychiatric deficits remains uncertain, but prior studies have suggested ischemic injury to the frontal cortex, ventromedial prefrontal (orbitofrontal) cortex, or striatum as a possible etiology.^15–17Ruptured aneurysms may be successfully treated by microsurgical clipping or endovascular coil embolization.^5,9,18 However, surgical clipping of AcomAs has been associated with more severe cognitive and behavioral deficits and higher rates of patient dependency compared with endovascular coil embolization, which may be caused by retraction injury to the frontal lobe or other causes of cerebral infarction.^{2,5,11,13,14,17,19}Our primary aim was to determine whether there is an increase in frontal lobe or striatum ischemic injury after treatment with surgical clipping compared with coil embolization in patients with ruptured AcomA. Our secondary outcomes were patient mortality and clinical outcome at discharge and at 3 months of follow-up. We therefore characterized patterns of cerebral ischemic injury and patient outcomes after treatment of ruptured AcomA at our neurovascular referral center.