Treatment of wide-necked intracranial aneurysms with a self-expanding stent system: initial clinical experience

BACKGROUND AND PURPOSE: Currently available stents for intracranial use usually are balloon-expandable coronary stents that carry the risk of damaging a dysplastic segment of the artery, with potential vessel rupture. We assessed the technical feasibility and efficacy of the combined application of a flexible, self-expanding neurovascular stent and detachable coils in the management of wide-necked intracranial aneurysms in humans. METHODS: Four consecutive patients with a wide-necked intracranial aneurysm were treated with a combined approach that consisted of delivery of a flexible self-expanding neurovascular stent through a microcather to cover the neck of the aneurysm and subsequent filling of the aneurysm with coils through the stent interstices. The aneurysms were located at the internal carotid artery (n=2) and the basilar tip encroaching the P1 segment (n=2). Previous attempts with conventional endosaccular coil packing alone failed in all cases. RESULTS: Stent placement in the desired position with complete or nearly complete occlusion of the aneurysms was feasible in all patients. In one patient, aneurysm perforation with the microcatheter occurred and necessitated ventricular drainage, which led to a large parenchymal and intraventricular hemorrhage because of the strong anticoagulation regimen. Six-month follow-up demonstrated no focal neurologic sequelae in any of the patients, except slight memory dysfunction in the patient with bleeding. CONCLUSION: Preliminary data demonstrate that this extremely flexible stent is technically easy to deploy and can be easily and safely maneuvered through severely tortuous vessels, enabling the treatment of intracranial wide-necked aneurysms. The combination of endovascular reconstruction of the parent vessel with use of a self-expanding stent followed by coil embolization offers a promising therapeutic alternative for wide-necked aneurysms not amenable to coil embolization alone. Although immediate angiographic results are promising, long-term angiographic and clinical follow-up is essential to determine permanent vessel patency and aneurysm occlusion rate.     

Neuroform颅内支架辅助栓塞宽颈颅内动脉瘤的初步经验

目的　报道我科使用Neuroform支架辅助可脱式弹簧圈栓塞宽颈脑动脉瘤的初步经验。方法　 2 2例 2 4枚宽颈颅内动脉瘤采用Neuroform支架和弹簧圈进行栓塞 ,其中急性破裂动脉瘤 19枚、未破裂动脉瘤 5枚。结果　支架均成功地释放 ,支架置入后的造影未发现有瘤内造影剂滞留的血流动力学改变。 10 0 %闭塞动脉瘤 18枚 ,90 %以上闭塞 5枚 ,1枚伴发的未破裂小型宽颈动脉瘤在支架置入后微导管无法超选 ,载瘤动脉均通畅。有 2枚动脉瘤虽有支架阻挡 ,但仍有部分弹簧圈畔进入载瘤动脉。所有患者没有出现与支架置入有关的症状性缺血性并发症。 17例造影随访中 ,有 1例在 3个月复查时发现再通 ,进行 2次栓塞完全闭塞动脉瘤 ,其余未见复发 ,结论　Neuroform颅内支架使用安全有效 ,适合于宽颈颅内动脉瘤的支架辅助弹簧圈栓塞 ,特别适合于迂曲的脑血管 ;其径向支撑力较差 ,在输送微导管时应防止其移位 ;其支架网眼较大 ,对血流动力学改变不明显 ,致密填塞是重要的 ,在输送弹簧圈时仍应防止弹簧圈畔进入载瘤动脉 ;术前、术后抗血小板药物的应用以及术后严格的系列造影随访是必要的。     

Stent-assisted coil embolization of wide-necked renal artery bifurcation aneurysms

PURPOSE: To report preliminary results of stent-assisted coil embolization in the treatment of wide-necked renal artery bifurcation aneurysms. MATERIALS AND METHODS: Four patients (three women, one man; mean age, 54 years; range, 49-67 y) with wide-necked renal artery aneurysms were treated with dedicated neurointerventional self-expanding nitinol stent-assisted coil embolization during a 2-year period. The stent was delivered over the neck of the aneurysm, after which the aneurysm was filled with detachable coils through a microcatheter placed into the aneurysm through the stent mesh. RESULTS: Stent delivery and coil embolization was successfully completed in all cases. Complete aneurysm occlusion without coil protrusion or arterial flow compromise was obtained in all patients. A small peripheral subsegmental renal infarction necessitating no therapy was registered in one patient on postembolization computed tomography. At follow-up angiography 1 year after embolization, no aneurysm recanalization or arterial obstruction was registered. CONCLUSIONS: Our preliminary experience indicates that stent-assisted coil embolization is technically feasible and effective for the exclusion of challenging renal artery bifurcation aneurysms without the sacrifice of any branch arteries.     

Flat panel detector angiographic CT for stent-assisted coil embolization of broad-based cerebral aneurysms

BACKGROUND AND PURPOSE: The purpose of this work was to evaluate angiographic CT (ACT) in the combined application of a self-expanding neurovascular stent and detachable platinum coils in the management of broad-based and fusiform intracranial aneurysms. MATERIALS AND METHODS: Eleven patients harboring wide-necked intracranial aneurysms were treated with a flexible self-expanding neurovascular stent and subsequent aneurysm embolization with platinum microcoils. ACT was performed after the interventional procedure to analyze stent position and the relationship of coils to the stent. Postprocessing included multiplanar reconstructions (MPRs) and maximum intensity projections (MIPs). ACT volume datasets were postprocessed for soft tissue visualization. RESULTS: Accurate stent placement with subsequent coil occlusion of the aneurysms was feasible in all of the patients. Similar to nonsubtracted digital subtraction angiography (DSA) images, radiopaque platinum stent markers showed excellent visibility in ACT as well. The stent struts themselves, hardly visible in nonsubtracted DSA, were visible in MPRs and MIPs of ACT in all of the patients. In aneurysms larger than 10 mm in diameter, accurate stent assessment at the level of the coils was limited due to beam hardening artifacts. Postprocedural ACT in all of the patients did not reveal any evidence of procedure-related intracranial hemorrhage. CONCLUSION: ACT provides cross-sectional, 3D visualization of endovascular stents otherwise hardly visible with plain fluoroscopy. ACT enables us to accurately determine stent position, which may be helpful in complex stent-assisted aneurysm coiling procedures. However, in aneurysms larger than 10 mm in diameter, beam hardening artifacts caused by the endoaneurysmal coil package impair visibility of the stent. Further data are necessary to evaluate the usefulness of ACT in stent-assisted aneurysm coiling.     

Three-dimensional packing with complex orbit coils for the endovascular treatment of intracranial aneurysms

BACKGROUND AND PURPOSE: Endovascular treatment of intracranial aneurysms is too often associated with aneurysm recurrence due to coil compaction. High packing of coils prevents compaction. To increase the packing attenuation, we sought to evaluate the results of selective embolization of aneurysms with complex-shaped coils alone. METHODS: Twenty consecutive patients with an intracranial aneurysm were treated by selective embolization. There were 12 women and eight men, with a mean age of 48 years. Fourteen patients presented with subarachnoid hemorrhage, whereas six were asymptomatic. Mean size of aneurysms was 5 mm (range, 3-11 mm). In all cases, we tried to pack the aneurysm with complex coils only (Orbit, Cordis, Miami Lakes, FL), delivered in a concentric fashion. Remodeling technique was used in two cases of wide-neck aneurysms. Clinical and anatomic outcome were assessed by using the modified Glasgow outcome scale and 6-month MR angiography (MRA). RESULTS: From two to five complex coils were delivered within the aneurysms. Occlusion by using complex coils alone was successful in 16 patients, and resulted in 14 complete occlusions and two neck remnants. In four patients, additional helical Orbit coils or Guglielmi detachable coils were required to complete aneurysm obliteration. No technical complication occurred, and clinical outcome was excellent in 14 cases and good in two. Follow-up MRAs were obtained in all patients and showed only one slight recanalization. CONCLUSIONS: Intracranial aneurysms may be treated by selective embolization with complex coils only. Imaging follow-up at 6 months shows a low rate of coil compaction.     

Neuroform自膨式支架结合弹簧圈栓塞颅内宽颈动脉瘤

目的 探讨Neuroform自膨式支架结合弹簧圈治疗颅内宽颈动脉瘤的安全性、术中并发症、近中期疗效和应用前景.方法 采用Neuroform支架结合弹簧圈栓塞治疗25例27枚颅内宽颈动脉瘤.动脉瘤位于颈内动脉海绵窦段3枚,眼动脉1枚,后交通动脉18枚,前交通动脉2枚,大脑中动脉M1段1枚,大脑中动脉分义部1枚,基底动脉干1枚.其巾2例患者为多发动脉瘤,绝对宽颈(瘤颈>4 mm)动脉瘤21枚,相对宽颈6枚,瘤颈/瘤体均大于0.7.结果 4枚采用NeuroformⅡ代自膨式支架结合弹簧圈栓塞治疗,其余均采用NeuroformⅢ代支架结合弹簧罔栓塞治疗.25例26枚支架均成功到位释放,1例多发动脉瘤患者置入2枚支架.7枚动脉瘤完全栓塞(100%),9枚几乎完全栓寒(95%～99%),11枚不完全栓塞(95%以下).2例术中出血;2例术中支架内血栓形成,其中1例术后遗留肢体偏瘫,另1例死亡;1例术中弹簧圈尾端从支架网孔突入颈内动脉,术后出现一过性脑缺血表现,其余患者均恢复良好出院.临床随访24例,随访期1～32个月,平均10.8个月.3例术后3～6个月血管造影随访,其中1例后交通动脉瘤患者同侧大脑前动脉闭塞,大脑中动脉主干血栓形成;另2例原有瘤颈残留者无变化.结论 在栓塞颅内宽颈动脉瘤时应用Neurolform自膨式支架结合弹簧圈技术,使弹簧圈无法突入载瘤动脉,可提高柃塞致密度,安全、疗效好.     

可解脱弹簧圈结合游离纤毛铂金弹簧圈栓塞大型颅内动脉瘤

目的 探讨可解脱弹簧圈结合游离纤毛铂金弹簧圈栓塞颅内大型动脉瘤的安全性和有效性。方法 可解脱弹簧圈结合游离纤毛铂金弹簧圈栓塞颅内大型动脉瘤4例，动脉瘤直径14～21mm，首先用可解脱弹簧圈在动脉瘤内成篮，然后用游离纤毛铂金弹簧圈进行篮内填塞，最后再用可解脱弹簧圈进行瘤体及瘤颈的致密栓塞。结果 3个动脉瘤获得完全致密栓塞，1个动脉瘤有瘤颈残留。临床随访3～12个月，无出血及脑缺血性事件发生。结论 可解脱弹簧圈结合游离纤毛铂金弹簧圈是一种可选的栓塞颅内大型动脉瘤安全、有效的方法。     

Combined stent implantation and endosaccular coil placement for treatment of experimental wide-necked aneurysms: a feasibility study in swine.

PURPOSETo assess the feasibility of combining stent implantation in the parent artery with endosaccular coil placement for the treatment of experimentally created wide-necked aneurysms.METHODSWide-necked aneurysms were surgically created on the common carotid artery in 12 swine. A metal stent was endovascularly implanted across each aneurysm neck and its effect documented anigiographically. If the aneurysm remained patent, a microcatheter was introduced into the aneurysm through the stent mesh. Electrically detachable coils were delivered into the aneurysm sac to produce thrombosis.RESULTSAfter stent implantation, one carotid artery thrombosed and two aneurysms spontaneously occluded. In the other 9 cases, coils were deposited through the stent to occlude the aneurysm. Complete aneurysm packing was possible in all 9 cases. The presence of the stent allowed placement of small coils near the aneurysm neck, thus contributing to the safe occlusion of small remnants in the final stages of aneurysm packing.CONCLUSIONThe combination of stent implantation and coil placement is feasible in the treatment of experimental wide-necked saccular aneurysms. The stent maintains patency of the parent artery while allowing aneurysm occlusion by endosaccular coil placement through the stent''s mesh. Occlusion of small aneurysm remnants is possible with no fear of coil hernation or migration into the parent artery. Long-term studies will be necessary before application to treatment of selected intracranial aneurysms.     

Follow-up of intracranial aneurysms treated with detachable coils: comparison of gadolinium-enhanced 3D time-of-flight MR angiography and digital subtraction angiography

PURPOSE: To compare three-dimensional (3D) time-of-flight magnetic resonance (MR) angiography with digital subtraction angiography (DSA) in the follow-up of intracranial aneurysms treated with selective endovascular placement of detachable coils. MATERIALS AND METHODS: Sixty-eight consecutive patients with intracranial aneurysms were included in the prospective study. The goal was to evaluate 3D time-of-flight MR angiography versus DSA for the detection of a residual aneurysm neck or residual flow inside the coil mesh. RESULTS: Eighty-one MR angiographic and 83 DSA examinations were performed; 15 patients were examined with both modalities twice. MR angiography was not possible in two patients. In another patient, the quality of MR angiography was not sufficient to assess the treated aneurysm. In 72 of the remaining 80 MR angiographic and DSA examinations, there was good correlation between the two modalities. In 54 cases, neither image type showed remnants or recurrence, but in 18, both showed residual aneurysm. In eight cases, the MR angiographic and DSA results differed. In one of these cases, MR angiography depicted residual aneurysm but DSA depicted an arterial loop. In seven cases, a small (<3-mm) remnant was not detected at MR angiography. CONCLUSION: Because very small aneurysm remnants or recurrences probably are not clinically important, MR angiography is an option for following up intracranial aneurysms treated with detachable coils and may partly replace DSA.     

新型可回撤自膨胀支架在颅内动脉瘤治疗中的应用

目的评价新型可回撤自膨胀支架(LEO)在颅内动脉瘤治疗中的应用价值。方法回顾分析应用LEO支架治疗的43例患者44枚颅内动脉瘤,其中单纯支架治疗16例,支架结合弹簧圈治疗25例,双支架治疗2例,双支架结合弹簧圈治疗1例。并对其进行影像学及临床随访。结果治疗中支架位置调整方便,所有病例支架均成功释放,1例位置欠理想,1例发生急性支架内血栓,随访中1例发生晚期支架内血栓,1例发生内膜过度增生,22枚(50.0%)动脉瘤达即刻致密栓塞,29例获得影像随访的患者中72.4%动脉瘤治愈或较前好转,13.8%动脉瘤稳定,3例夹层动脉瘤发生瘤体短期内增大,2例患者死亡。结论LEO系统具有释放可控性强、简捷安全、可选择型号广泛等优点,在颅内动脉瘤栓塞和管壁重建中有一定优势。     

支架辅助GDC治疗颅内动脉瘤术中并发症的防治

目的 回顾总结血管内支架治疗颅内动脉瘤术中并发症，以提高使用血管内支架结合电解可脱卸弹簧圈(GDC)治疗颅内夹层及宽颈动脉瘤的安全性。方法 105例难治性动脉瘤，首先将冠脉支架跨动脉瘤颈放置，通过支架的网孔将微导管送入动脉瘤腔，填入GDC。结果 6例患者术中出现支架移位，1例发生动脉瘤破裂出血，1例发生大脑中动脉穿支出血，1例发生支架塌陷，1例发生颈内动脉夹层动脉瘤，1例弹簧圈突入小脑后下动脉(PICA)起始部，10例发生血管痉挛，经对症处理，预后良好。结论 在支架植入过程中，联合采用多种措施可减少并发症的发生；支架和GDC联合应用治疗颅内夹层及宽颈动脉瘤安全、有效。     

Platinum coil treatment of complex aneurysms of the vertebrobasilar circulation

Summary Two patients with complex aneurysms of the vertebrobasilar system were treated using platinum coils. During these sessions, 22 coils were placed in a basilar tip aneurysm in a 48-year-old woman. Almost total occlusion of the lumen was achieved, excepted in the area from which the right posterior cerebral artery arose. A large fusiform vertebral artery aneurysm in a 6-year-old boy was treated using 16 coils, which partially occluded the lumen at initial embolization. Follow-up angiography 2 weeks later revealed almost complete occlusion of the lumen with preservation of the vertebral artery. Our experience indicates that coil embolization of complex intracranial aneurysms is an acceptable treatment alternative to surgery or to a detachable balloon.     

Emergent management of ruptured pericallosal-callosomarginal artery aneurysm using stent-assisted coil embolization

We present a case of a ruptured bilobed pericallosal aneurysm successfully treated with coil embolization through a Neuroform stent. A 48-year-old male presented with subarachnoid hemorrhage (SAH) following rupture of a previously clipped aneurysm at the bifurcation of the pericallosal and callosomarginal arteries, primarily along the pericallosal artery, Hunt and Hess grade 5. After an initial unsuccessful attempt to embolize the wide-neck aneurysm with a detachable coil, a 4×15 Neuroform stent was uneventfully deployed across the aneurysm neck followed by successful coil embolization using detachable coils. We believe this case describes the first successful use of the Neuroform stent to assist in coiling of a wide-neck pericallosal-callosomarginal aneurysm. This case highlights the expanding role of emergency endovascular therapies to manage severe SAH.     

A new self-expanding nitinol stent (Enterprise) for the treatment of wide-necked intracranial aneurysms: initial clinical and angiographic results in 31 aneurysms

Introduction We report the results of a prospective clinical study using a new self-expanding nitinol stent (Enterprise) designed for the treatment of wide-necked intracranial aneurysms. Methods We treated 31 saccular, wide-necked intracranial aneurysms in 30 patients. Ten aneurysms had recanalized after prior endovascular treatment without a stent, and 21 aneurysms had not been treated before. Results Stent deployment was successful in all procedures. Additional coil embolization was performed in all aneurysms. Initial complete angiographic occlusion was achieved in 6 aneurysms, a neck remnant was left in 18 aneurysms and there were 7 residual aneurysms. Angiographic follow-up examinations of 30 lesions after 6 months demonstrated 15 complete occlusions, 8 neck remnants and 7 residual aneurysms. One patient refused the 6-month angiographic follow-up. Spontaneous occlusion of the aneurysm had occurred in 14 patients, and 6 aneurysms showed recanalization. Four of these residual aneurysms were retreated. At the 6-month follow-up, 29 parent arteries were unaffected, whereas two parent vessels demonstrated minor asymptomatic narrowing at the stent site. Two patients experienced one or more possible or probable device-related serious adverse events during the 6-month follow-up period. There was no procedural morbidity or mortality at 6 months after the procedure. Conclusion The reported results demonstrated the safety and feasibility of the Cordis Neurovascular Enterprise stent in the treatment of wide-necked intracranial aneurysms. Initial clinical and angiographic results are favorable. Werner Weber and Martin Bendszus contributed equally to this work.     

双微导管技术在宽颈颅内动脉瘤栓塞中的初步应用经验

目的　评估采用双微导管技术在宽颈颅内动脉瘤栓塞中的初步经验。方法　 6例宽颈动脉瘤在常规方法应用无效后采用双侧股动脉入路 ,把 2支微导管置入动脉瘤腔内 ,由微导管内同时或先后送入弹簧圈 ,待弹簧圈稳定后解脱 ,随后再送入更多的弹簧圈以达到致密填塞。结果　 6例AN成功地栓塞 ,10 0 %闭塞 2个、闭塞 >90 %的 4个。缺血性并发症 1例 ,导致中残。术后 3月时GOS优良 5例、中残 1例。有 5例进行了造影随访 ,无AN复发和再破裂。结论　双微导管技术对于某些复杂的宽颈动脉瘤是一种可供选择的方法。     

Matrix可脱弹簧圈栓塞治疗颅内动脉瘤的临床应用

目的探讨Matrix可脱弹簧圈血管内栓塞治疗颅内动脉瘤的临床价值。方法对56例共61个颅内动脉瘤施行血管内Matrix可脱弹簧圈栓塞治疗,4例宽颈动脉瘤和2例梭形动脉瘤采用Neuroform支架结合Matrix可脱弹簧圈栓塞治疗。结果应用Matrix可脱弹簧圈栓塞成功53例58个动脉瘤,占95.1%;3例因严重血管痉挛导致微导管无法到位而实施动脉瘤夹闭术;2例弹簧圈尾端残留于载瘤动脉,但未导致临床后果;无死亡及严重并发症;53例随访3～12个月无再次出血和并发症。结论Matrix可脱弹簧圈可有效栓塞颅内各部位动脉瘤,术中有明显的促进动脉瘤腔内形成血栓的作用,可以防止再次破裂出血。     

血管内介入栓塞治疗颅内动脉瘤的并发症

目的　着重讨论微弹簧圈栓塞治疗颅内动脉瘤的并发症及其发病机制。方法　回顾总结血管内栓塞治疗颅内动脉瘤 4 8例。结果　 10 0 %闭塞 2 5例、90 %闭塞 18例、80 %闭塞 5例。术后并发症8例 :微弹簧圈移位 2例 ,术中动脉瘤破裂 3例 ,严重血管痉挛 3例 ,死亡 2例。结论　血管内栓塞动脉瘤腔是一种微创、安全、有效治疗动脉瘤的方法。选择正确的技术和方法对改善动脉瘤栓塞治疗效果 ,减少并发症有重要意义。     

Intracranial aneurysms treated with Guglielmi detachable coils: usefulness of 6-month imaging follow-up with contrast-enhanced MR angiography

BACKGROUND AND PURPOSE: This study was undertaken to assess the utility of contrast-enhanced MR angiography at 6 months after endovascular treatment of intracranial aneurysms with Guglielmi detachable coils. METHODS: Contrast-enhanced MR angiography was performed in 47 patients at 6 and 12 months after endovascular treatment of intracranial aneurysms (48 aneurysms). Digital subtraction angiography (DSA) was used as reference and was performed at 12 months after the treatment in all patients. MR angiographs were analyzed independently by two senior radiologists. DSA and MR angiography findings were assigned into one of three categories: complete obliteration, residual neck, or residual aneurysm. RESULTS: All examinations were assessable. Interobserver agreement was judged as very good for contrast-enhanced MR angiography (kappa=0.96), with one discrepancy between examiners. Comparison between MR angiography at 6 months and DSA at 12 months showed an excellent agreement between techniques (kappa=0.93). Two cases of complete occlusion at DSA were misclassified as a residual neck at 6-month MR angiography. All aneurysm recanalizations at DSA already were detected on MR angiography at 6 months. The size of aneurysm recanalization did not increase between both MR angiographs performed at 6 and 12 months. CONCLUSION: Contrast-enhanced MR angiography after selective embolization of intracranial aneurysm seems to predict properly early aneurysm recanalizations.     

电解可脱弹簧圈治疗颅内动脉瘤

目的:探讨电解可脱弹簧圈治疗颅内动脉瘤的临床效果。材料和方法:CT以及DSA检查证实为颅内动脉瘤65例,66个动脉瘤。在神经安定麻醉和全身肝素化的条件下,经Tracker-10或Tracker-18微导管放置电解可脱性弹簧圈对脑动脉瘤患者进行栓塞治疗,手术在DSA动态监视下完成。结果:66个动脉瘤中,瘤体大小为3.5mm×3.8mm~5.4mm×4.5mm。64例栓塞成功,成功率为97%;2例因载瘤动脉严重痉挛而失败(3%),其中100%闭塞48个(72.7%);栓塞程度达95%以上9个(13.6%);90%闭塞7个(10.6%)。术后回访3~24个月,未发现蛛网膜下腔再次出血。结论:电解可脱弹簧圈栓塞颅内动脉瘤具有微创、安全、效果可靠的优点。     

Anatomically conformable, three-dimensional, detachable platinum microcoil system for the treatment of intracranial aneurysms

BACKGROUND AND PURPOSE: The configurations of detachable platinum coils have evolved over the last decade. Our objective was to assess the efficacy of the anatomically conformable three-dimensional (ACT) detachable platinum microcoil in the treatment of intracranial aneurysms. METHODS: A series of 141 patients presented between May 2000 and August 2002 to a single neurointerventionalist for endovascular treatment of intracranial aneurysms. Eight patients were treated at another institute or are now overseas. The remaining 133 patients had 141 aneurysms, which were treated; 110 were ruptured and 31 were unruptured. The clinical conditions and aneurysm locations were recorded. The procedural technique was the same as that used with the Guglielmi detachable coil (GDC) device, though the coil detachment mechanism was unique. The ACT microcoil was used in almost all cases as the initial coil. RESULTS: Complete (100%) occlusion was achieved in 104 (74%) aneurysms. Thirty four (24%) had subtotal occlusion > or = 95%), and three (2%) had incomplete occlusion (<95%). The ACT coil conformed to both spherical and irregularly shaped aneurysms. No procedure-related deaths occurred, and there was no aneurysm rupture related to coil deployment. No postprocedural rebleeding was observed. CONCLUSION: The ACT microcoil device is feasible as an alternative platinum coil device, offering some advantages over other currently available devices.