弹簧圈栓塞治疗颅内微小动脉瘤及中长期随访

目的评价弹簧圈栓塞治疗颅内微小动脉瘤（VSCAs）的有效性及稳定性。方法 19例患者（20枚VSCAs）接受血管内弹簧圈栓塞治疗。对其中9枚动脉瘤使用单纯弹簧圈栓塞,9枚使用支架辅助弹簧圈栓塞,2枚使用球囊辅助弹簧圈栓塞。根据DSA表现,将栓塞程度分为完全栓塞、次全栓塞和部分栓塞。术后进行中长期随访并收集DSA及临床结果。结果所有VSCAs均获成功栓塞。术后即刻DSA显示,20枚VSCAs中5枚为完全栓塞,9枚为次全栓塞,6枚为部分栓塞。1~2年随访DSA示20枚VSCAs均完全栓塞,未发现动脉瘤复发及弹簧圈脱出、移位。临床随访显示所有患者均未出现动脉瘤再次破裂出血及神经系统缺血症状。结论血管内弹簧圈栓塞治疗VSCAs有效、稳定;中长期随访证实次全及部分栓塞的患者可发展为完全栓塞。     

Endovascular treatment of blood blister-like aneurysms of the internal carotid artery

OBJECT: Because of its thin wall, an aneurysm arising from the posterior wall of the internal carotid artery (ICA), the so-called blood blister-like aneurysm (BBA), is difficult to manage surgically and is often associated with high morbidity and mortality rates. The authors treated these aneurysms endovascularly. In this paper, they present angiographic and clinical results obtained in patients with ICA BBAs treated endovascularly. METHODS: In seven patients with ICA BBAs who presented with subarachnoid hemorrhage, a total number of 12 endovascular treatments were performed, including seven endosaccular coil embolizations (four conventional, two stent-assisted and one balloon-assisted procedure) in four patients and five endovascular ICA trapping procedures in five patients. Repeated endovascular treatments were undertaken in four patients. In two patients, the endovascular treatment was performed after failure of surgical treatment (one case of rebleeding after clip placement and one aneurysmal regrowth after wrapping). A balloon occlusion test (BOT) was performed in all patients prior to ICA trapping. All four patients treated by endosaccular coil embolization showed aneurysmal regrowth. Neither stents nor balloons helpfully prevented aneurysmal regrowth. Of these four patients, two experienced rebleeding. These two patients remained vegetative at the last follow-up examination. After the BOT, ICA trapping was performed with coils and balloons without complication in five patients; excellent outcomes were achieved in all cases but one in which the patient had been in poor neurological condition due to rebleeding after surgical clip therapy. CONCLUSIONS: All ICA BBAs that were treated by endosaccular coil embolization exhibited regrowth of the aneurysm. Some of the lesions rebled. The majority of patients who underwent ICA trapping experienced excellent outcomes. Based on the authors' experiences, they suggest that ICA trapping including the lesion segment should be considered as a first option for definitive treatment if a BOT reveals satisfactory results. Regarding trapping methods, endovascular treatment may be preferred because of its convenience and safety.     

Endovascular treatment for basilar tip aneurysms

The aim of this study was to analyze the effect of endovascular treatment of basilar (BA) tip aneurysms. The authors performed a retrospective analysis of 79 aneurysms of the BA tip that had been treated using endovascular coil embolization for the last 11 years. Fifty-six patients were women, and 23 were men. The average age of the patients was 63.7 years (range, 35-83 year). The average maximum diameter of the aneurysms was 8.0 mm (range, 2-30 mm). Forty-seven patients (60%) presented with acute subarachnoid hemorrhage (SAH), 1 patient (1%) had an unruptured aneurysm with mass effect, and 31 patients (39%) had incidental aneurysms. Immediate anatomic outcomes demonstrated complete occlusion (CO) in 53 aneurysms (67%), residual neck (RN) in 22 aneurysms (28%), and residual aneurysm (RA) in 4 aneurysms (5%). One patient died from rebleeding 6 hours after the embolization. Another patient suffered from rebleeding 6 years after the initial embolization, and was successfully treated with re-embolization. Four patients suffered from asymptomatic P1 occlusion. No symptomatic complication was observed in the unruptured group. Retreatment was performed in 5 patients, including 4 broad-neck large ruptured aneurysms and 1 giant thrombosed aneurysm. Angiographic and clinical results have been improving in recent cases in this study. Technical advances such as highly compliant balloon remodeling microcatheter and 3D-reconstructed digital angiography contributed to this improvement. Our results indicate that endovascular treatment of BA tip aneurysm is safe and effective. The long-term stability after coil embolization is still a matter of concern. Further improvement is expected.     

Progressive perianeurysmal edema induced after endovascular coil embolization. Report of three cases and review of the literature

The authors report three cases of progressive vasogenic brain edema surrounding a cerebral aneurysm after endovascular coil embolization. In all three cases embolization was incomplete due to the aneurysms' large sizes and wide necks. Follow-up magnetic resonance imaging revealed de novo vasogenic brain edema surrounding the aneurysms 3 to 6 months after the initial treatment. The edema progressed in parallel with regrowth of the aneurysms. All three aneurysms were deep in the brain parenchyma and showed intramural enhancement, suggesting hemorrhage or inflammation. Each patient underwent a second embolization for the aneurysm regrowth, which resulted in improvement of the edema. Based on the findings in these cases and review of the literature, it is suggested that incomplete occlusion of larger aneurysms that are deep within the brain may lead to a disorganized intraluminal thrombosis, aneurysm pulsing, and intramural hemorrhage or inflammation, all of which are associated with brain edema following aneurysm recanalization and regrowth. It should be kept in mind that incomplete embolization of larger aneurysms may cause such malignant change and that this complication may occur after endovascular treatment.     

Embolization of cerebral aneurysms with a liquid embolus,EVAL mixture: Report of three cases

Summary Embolization of three surgically difficult cerebral aneurysms was performed using our newly developed non-adhesive embolic material, EVAL mixture (ethylene vinyl alcohol copolymer). Conventional embolic materials such as detachable balloons or microcoils were not used because of a large or irregular aneurysmal neck. After temporary occlusion of the parent artery with a superselective balloon catheter, the EVAL mixture was slowly injected through a microcatheter placed in the aneurysm or parent artery. The locations of the aneurysms were anterior communicating artery, basilar artery-posterior cerebral artery and basilar artery-anterior inferior cerebellar artery (BA-AICA). One aneurysmal occlusion and 2 parent artery occlusions were performed. Patients had no persistent deficits. The patient with the BA-AICA aneurysm associated with an arteriovenous malformation died of rupture of the residual AVM due to haemodynamic change 2 weeks after embolization. In selected and limited cases, embolization of surgically difficult cerebral aneurysms using EVAL mixture was more effective and safer than embolization using conventional embolic materials such as balloons and microcoils.     

颅内后循环动脉瘤的血管内介入治疗

目的总结颅内后循环动脉瘤的特点,探讨其血管内介入治疗的临床疗效。方法回顾性分析40例行血管内介入治疗的颅内后循环动脉瘤患者的临床和影像学资料、介入治疗过程,观察期效果及术后随访结果。结果 40例患者共发现42个后循环动脉瘤,均完成血管内介入治疗,其中8个行单纯弹簧圈栓塞,28个行支架辅助栓塞,1个行Onyx胶栓塞,5个动脉瘤及载瘤动脉同时闭塞。术后即刻DSA造影显示动脉瘤完全栓塞30个,近全栓塞6个,部分栓塞6个。术后6个月随访DSA造影显示动脉瘤完全栓塞36个,近全栓塞4个,部分栓塞1个。患者出院时行改良Rankin量表(mRS)评分,0分35例,1分3例,2分1例,1例死亡为6分;出院后3~6个月随访mRS评分0分38例,1分1例,无动脉瘤复发及新发神经功能障碍病例。结论颅内后循环动脉瘤具有特殊的临床与影像学表现,且复杂动脉瘤较为常见,对于颅内后循环动脉瘤,血管内介入治疗是一种安全有效的治疗方法。     

血管内治疗大脑前动脉远端动脉瘤

目的观察血管内治疗大脑前动脉远端(DACA)动脉瘤的效果。方法回顾性分析14例接受血管内治疗的DACA动脉瘤患者(共15个动脉瘤),对10个动脉瘤行单纯弹簧圈栓塞、4个动脉瘤行支架辅助下弹簧圈栓塞,1个以Onyx胶栓塞。之后复查DSA,根据Raymond分级评价即刻疗效。术后6个月复查DSA,以改良Rankin量表(mRS)评估预后,mRS评分0~2分为结局良好。结果术后即刻12个动脉瘤Ⅰ级栓塞,3个Ⅱ级栓塞。术中、术后均未发生缺血等并发症。1例术后12 h死于动脉瘤再次破裂出血。术后6个月随访显示1例复发,10例结局良好(mRS评分0~2分),另2例mRS评分分别为3分、4分。结论个体化血管内治疗DACA动脉瘤安全、有效。     

Evaluation of intra-aneurysmal blood flow by digital subtraction angiography: blood flow change after coil embolization

BACKGROUND: The natural course of cerebral aneurysms is related to many factors, and it is very important that intra-aneurysmal blood flow is considered. Our group developed a method that allowed the simultaneous evaluation of blood flow in human cerebral aneurysms using digital subtraction angiography (DSA) with no special devices. The intra-aneurysmal blood flow measurement would also be very useful for coil embolization. Since the Guglielmi detachable coil (GDC) was developed, many patients with cerebral aneurysm have been treated with GDC, but coil compaction has sometimes caused a problem after the coil embolization of a cerebral aneurysm. We believed that an intra-aneurysmal flow measurement would suggest the final result of embolization during the procedure. METHODS: We performed DSA to examine 17 aneurysms in 17 patients. The video signal of serial DSA images was stored on a personal computer, and time-density curves were obtained for each individual pixel. The formula, determined by a two-exponential model, was fitted to the time-density curve 1000 times by least square approximation for each individual pixel. We indirectly substituted the coefficient of the flow-in curve for the blood flow. We were therefore able to display the distribution of intra-aneurysmal blood flow in color. We could compare the blood flow in each portion of the cerebral aneurysm and parent artery during coil embolization. RESULTS: The blood flow k(a) in a small aneurysm was faster than that in a large aneurysm, and it slowed in accordance with the coil embolization. The blood flow in a large aneurysm was sometimes accelerated by incomplete coil embolization. CONCLUSION: We can detect the flow distribution in cerebral aneurysms and the flow change during coil embolization, using existing equipment. Our method would be useful in elucidating the natural history of cerebral aneurysms, treating cerebral aneurysms with coils, and following patients after treatment.     

Scheduled re-entry coil embolization before entry coverage of thoracic endovascular stent grafting for aneurysmal chronic type B aortic dissection

Endovascular treatment for type?B dissections is controversial. This therapy aims at complete occlusion and thrombosis of the false lumen of the aneurysm. We report a case where cessation of flow was achieved using covered stent grafts in conjunction with coil embolization of the false lumen. The use of scheduled coil re-entry embolization of the false lumen before endovascular entry coverage using a stent graft is a novel approach that could become a treatment option for aneurysmal type B dissection.     

Clinical and angiographic outcome of intracranial aneurysms treated with Matrix detachable coils in Chinese patients

BACKGROUND: Aneurysm recurrence is an innate problem in endovascular treatment of aneurysms with coils. A coated coil system named Matrix (Boston Scientific Neurovascular, Fremont, CA), covered with a bioabsorbable polymeric material (polyglycolide/lactide copolymer [PGLA]), was developed to accelerate intraaneurysmal clot organization and fibrosis. The purpose of this study was to evaluate the efficacy and safety of the Matrix detachable coils in patients with intracranial aneurysms and aneurysmal recurrence rate. METHODS: In a regional neurosurgical center in Hong Kong, data of patients undergoing endovascular embolization of intracranial aneurysm was collected. In a 20-month period, 42 patients with 44 aneurysms were treated by endovascular embolization using matrix coils alone or mixed with bare platinum coils. Thirty-four patients presented with ruptured aneurysms, and 8 patients presented with unruptured aneurysms. RESULTS: Twenty-five patients (60%) had 6-month follow-up DSA, and 10 patients (24%) had 18-month follow-up DSA. Seven aneurysm recurrences were identified, amounting to 16% for all aneurysms and 14% for ruptured aneurysms. Four patients were treated by repeated embolization, and 2 patients were treated by microsurgical clipping. Two adverse events due to thromboembolism were noted. One 78-year-old lady with poor-grade subarachnoid hemorrhage treated by partial embolization died from rebleed at day 4. Another patient with partial embolization and spontaneous thrombosis of dorsal wall ICA aneurysm died at 2 months with aneurysm recanalization with rerupture. Twenty-six patients achieved favorable outcome (GOS score 4 or 5) at last follow-up. The aneurysm recurrence rate using bare platinum coils of the same center was 11% and 7% for all aneurysms and ruptured aneurysms, respectively. CONCLUSION: Matrix coil embolization was safe, but there was no reduction in aneurysm recurrence using matrix coils alone or mixed with GDCs, compared with GDCs alone.     

Nonoperative management of unruptured visceral artery aneurysms: treatment by transcatheter coil embolization

PURPOSE: To describe our experiences with the treatment of visceral artery aneurysms (VAA) by transcatheter coil embolization and to propose indications for treating VAA by this method. METHODS: We treated 22 patients with VAA by coil embolization; 9 had splenic-, 7 renal-, 4 pancreaticoduodenal arcade-, and 2 proper hepatic artery aneurysms. All nine splenic artery aneurysms patients presented with chronic hepatitis-C; four had hepatocellular carcinoma. Of the seven renal artery aneurysms patients, four were hypertensive and three had rheumatoid arthritis. Both pancreaticoduodenal arcade artery aneurysms patients manifested severe stenosis of the celiac axis. Our transcatheter coil embolization procedure includes coil embolization and coil-packing of the aneurysmal sac, preserving the native arterial circulation. RESULTS: Transcatheter coil embolization with aneurysm packing was technically successful in 16 (72.7%) of the 22 patients and the native arterial circulation was preserved. Postprocedure angiograms confirmed complete disappearance of the VAA. In four of the nine splenic artery aneurysm patients, the native arterial circulation was not preserved. In one renal artery aneurysm patient, stenosis at the aneurysmal neck necessitated placement of a stent before transcatheter coil embolization. Magnetic resonance angiographs obtained during the follow-up period (mean 27 months) demonstrated complete thrombosis of the VAA in all 22 patients. Infarction occurred in one splenic- and two renal artery aneurysms patients; the latter developed flank pain and fever after the procedure. CONCLUSIONS: Transcatheter coil embolization is an effective alternative treatment for patients with saccular and proximal VAA. In particular, the isolation technique using coil embolization is advantageous in splenic artery aneurysm patients.     

Giant celiac artery aneurysm: Treatment by transcatheter coil embolization

Celiac artery aneurysms (CAA) are one of the rarest forms of visceral artery aneurysms. Most patients are a symptomatic at the time of diagnosis and aneurysms are detected incidentally during diagnostic imaging for other diseases. We present the case of a 42-year-old man who had an asymptomatic giant CAA detected incidentally by an abdominal ultrasound investigating an abdominal pain. A contrast enhanced computed tomography angiogram (CTA) revealed a large CAA measuring 7.1 cm × 4.3 cm with extensive collaterals from the superior mesenteric artery (SMA). The aneurysm sac was mostly filled with thrombus with the celiac artery branches occluded. Pre-procedural angiography and transcatheter embolization procedures were performed at the same session. Endovascular exclusion was performed by transcatheter coil embolization and packing of the aneurysm sack. Technical success was achieved by the absence of flow in the aneurysm, and preservation of the native circulation on angiograms obtained just after the transcatheter coil embolization procedure. One week postembolization, a CTA confirmed thrombosis of the aneurysm. The patient returned for a follow-up CTA 3, 6, 12 and 48 months after embolization. The aneurysm was thrombosed and the patient remained a symptomatic. The surgical mode of treatment of CAA is increasingly being replaced by endovascular embolization because of the lower morbidity and mortality and high success rate. The accepted endovascular approach is by coil embolization of the aneurysmal lumen, the proximal and distal aneurysmal neck, or both.     

Comparison of clinical and radiologic outcomes among stent-assisted,double-catheter,and balloon-assisted coil embolization of wide neck aneurysms

Background

Endovascular treatment of intracranial aneurysms can be technically challenging in cases of wide necks or unfavorable dome-to-neck ratio. Coils deployed without supporting devices may herniate from the aneurysm sac into the parent artery, causing thromboembolic complications or vessel occlusion. Therefore, alternative strategies for managing wide-necked aneurysms have been introduced such as stent-assisted coil embolization (SAC), balloon-assisted coil embolization (BAC), and double-catheter coil embolization (DCC).

Methods

SAC, BAC, or DCC were used to treat 201 patients with 207 wide-neck aneurysms between 2008 and 2013. Initial occlusion rates, recanalization rates, and periprocedural complications were retrospectively evaluated. The mean follow-up periods for SAC, BAC, and DCC were 16.2 months, 11.6 months, and 14.3 months, respectively.

Results

Clinical and anatomical analyses were conducted in 201 patients with 207 anuerysms. Complete occlusion rates of SAC, DCC, and BAC were 63.8 %, 46.7 %, and 63.2 %, respectively, and incomplete occlusion rates were 13.4 %, 15.5 %, 10.5 %, respectively (p value?=?0.798). No rebleeding or hemorrhage occurred after coil embolization. Recanalization rates did not differ among the SAC, DCC, and BAC groups (7.1 % vs. 11.1 % vs. 7.9 %, p value?=?0.696). Statistically insignificant results were observed in the rate of periprocedural complications among SAC, DCC, and BAC (11.0 % vs. 13.3 % vs. 15.8 %, p value?=?0.578).

Conclusions

There were no significant differences in the recurrence rate and periprocedural complication rate, and no rebleeding or aneurysmal rupture after treatment. Sufficient occlusion rates were achieved with SAC, DCC, and BAC. Notably, DCC does not require the use of antiplatelet agents and achieves coil stability without compromising the parent artery or major branch. Thus, we believe that the double-catheter technique was found to be a feasible and safe treatment modality for branching wide-neck aneurysms.     

Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding

OBJECT: During a 5-year period 317 patients presenting with aneurysmal subarachnoid hemorrhage were successfully treated by coil embolization within 30 days of hemorrhage. The authors followed patients to assess the stability of aneurysm occlusion and its longer-term efficacy in protecting patients against rebleeding. METHODS: Patients were followed for 6 to 65 months (median 22.3 months) by clinical review, angiography performed at 6 months posttreatment, and annual questionnaires. Stable angiographic occlusion was evident in 86.4% of small and 85.2% of large aneurysms with recurrent filling in 38 (14.7%) of 259 aneurysms. Rebleeding was caused by aneurysm recurrence in four patients (between 11 and 35 months posttreatment) and by rupture of a coincidental untreated aneurysm in one patient. Annual rebleeding rates were 0.8% in the 1st year, 0.6% in the 2nd year, and 2.4% in the 3rd year after aneurysm embolization, with no rebleeding in subsequent years. Rebleeding occurred in three (7.9%) of 38 recurrent aneurysms and in one (0.4%) of 221 aneurysms that appeared stable on angiography. CONCLUSIONS: Periodic follow-up angiography after coil embolization is recommended to identify aneurysm recurrence and those patients at a high risk of late rebleeding.     

Emergence of the white-collar sign after coil embolization of cerebral aneurysms

Background

The white-collar sign (WCS) is represented by the formation of neointimal tissue at the level of the aneurysm neck as the successful outcome on follow-up angiography after coil embolization. WCS has been reported only in aneurysms treated with Matrix® coils. This is the first study to report WCS emergence in aneurysms treated with bare platinum coils, and potential factors associated with WCS emergence were evaluated.

Method

Total 130 unruptured (female: male ratio, 100: 30; mean age, 60 years) cerebral aneurysms were treated with coil embolization. Embolization status was assessed immediately and 1 year after treatment, and emergence of WCS in follow-up angiography was assessed. We evaluated the association between WCS emergence and aneurysm location, dome diameter, neck diameter, dome-neck ratio, and type of coil used (bare platinum or bioactive).

Results

WCS appeared in nine aneurysms (6.9 %), of which six were treated only with bare platinum coils. Neck diameter was significantly smaller in the WCS-positive group than in the WCS-negative group. The proportion of aneurysms treated with bioactive coils was not significantly different between the groups. Immediate embolization status in the WCS-positive group tended to be slightly better than that in the WCS-negative group. No aneurysmal morphological characteristics other than small neck diameter were associated with WCS emergence.

Conclusions

WCS is not specific to bioactive coil usage. Small neck diameter was significantly associated with WCS emergence in our series. Further investigations to clarify the predictors of WCS will contribute to progress of aneurysmal embolization.     

Clinical usefulness of multi-planar reconstruction images of three-dimensional computed tomographic angiography for internal carotid artery aneurysms

The usefulness of multi-planar reconstruction (MPR) images of three-dimensional computed tomographic angiography (3D-CTA) for the diagnosis of internal carotid artery (ICA) aneurysms is described. Eleven unruptured ICA aneurysms including six cases of IC-cavernous aneurysm, two cases of IC-ophthalmic artery aneurysm, two cases of IC-posterior communicating artery aneurysm and one cases of IC-anterior choroidal artery aneurysm, were examined by magnetic resonance angiography (MRA), digital subtraction angiography (DSA), 3D-CTA and its MPR images. 3D-CTA and DSA were useful to identify the aneurysmal neck in small aneurysms, but it was difficult to identify the aneurysmal neck in small aneurysms by 3D-CTA-MPR images. DSA and MRA were not useful for identifying the aneurysmal neck in aneurysms more than 10 mm in diameter, as a precise viewing of the neck could not be found due to their large size. For large aneurysms, neither was 3D-CTA useful for identifying the aneurysmal neck when their large size and surrounding bony structures overlapped the aneurysmal neck. On the other hand, 3D-CTA-MPR was very useful for identifying the aneurysmal neck without overlapping by surrounding bony structures. 3D-CTA-MPR images clearly visualized the calcification of the wall. 3D-CTA-MPR images are obtained from 3D-CTA source images without any additional stress to the patients, and they are more useful for the diagnosis as well as demonstration of the aneurysmal neck particularly in more than large aneurysms.     

Rupture of intracranial aneurysms during endovascular coiling: management and outcomes

OBJECTIVE: In this study, the incidence, etiologies, and management with respect to clinical outcome of patients with iatrogenic aneurysmal rupture during attempted coil embolization of intracranial aneurysms are reviewed. METHODS: A retrospective analysis was conducted of 274 patients with intracranial aneurysms treated with Guglielmi detachable coils over a 6-year period from 1994 to 2000. Patient medical records were examined for demographic data, aneurysm location, the number of coils deployed preceding and after aneurysmal rupture, the etiology of the rupture, and the clinical status on admission and at the time of discharge. RESULTS: Of 274 patients with intracranial aneurysms treated with coil embolization, six (2%) had an intraprocedural rupture. Of these six, two were women and four were men. The mean age was 67 years (range, 52-85 yr). Mean follow-up time was 8 months (range, 0-25 mo). Aneurysmal rupture resulted from detachment of the last coil in three patients, detachment of the third coil (of four) in one patient, and insertion of the first coil in another patient. In one patient, the aneurysmal rupture was a result of catheter advancement before detachment of the last coil. The Glasgow Outcome Scale score at last follow-up examination was 1 in two patients, 2 in two patients, and 5 in two patients. CONCLUSION: The rate of rupture of aneurysms during coil embolization is approximately 2 to 4%. The clinical outcome may be related to the timing of the rupture and the number of coils placed before rupture. If extravasation of contrast agent is seen, which suggests intraprocedural rupture, further coil deposition should be attempted if safely possible.     

Intra-aneurysmal coil embolization for large or giant carotid artery aneurysms in the cavernous sinus

This study evaluated the effectiveness of intra-aneurysmal coil embolization for large or giant carotid artery aneurysms in the cavernous sinus in seven patients treated by intra-aneurysmal coil embolization from 2001 to 2010. Only one patient showed improved neurological symptoms caused by aneurysmal mass effect during the mean follow-up period of 53.4 ± 27.3 months. Neurological symptoms caused by the aneurysms remained unchanged in two patients, and deteriorated in four. Intra-aneurysmal coil embolization is not considered an effective treatment option for large or giant carotid artery aneurysms in the cavernous sinus.     

Effects of timing of coil embolization after aneurysmal subarachnoid hemorrhage on procedural morbidity and outcomes

OBJECTIVE: To elucidate the effect of treatment timing on procedural clinical outcomes after aneurysmal subarachnoid hemorrhage (SAH) for patients treated by endosaccular coil embolization. METHODS: A group of 327 patients who were consecutively treated, during a 46-month period, for ruptured intracranial aneurysms by coil embolization within 30 days after SAH were evaluated. Outcomes were assessed by comparing immediate pretreatment World Federation of Neurological Surgeons (WFNS) grades, 72-hour posttreatment WFNS grades, and modified Glasgow Outcome Scale scores at 6 months for patients treated within 48 hours (Group 1), 3 to 10 days (Group 2), or 11 to 30 days (Group 3) after SAH. RESULTS: The three interval-to-treatment groups included 33, 38, and 29% of the patients, respectively. Before treatment, 70% of the patients in Group 1, 78% of those in Group 2, and 83% of those in Group 3 were in good clinical grades (i.e., WFNS Grade 1 or 2). After coil embolization, the WFNS grades were either unchanged or improved for 93.5% of the patients in Group 1, 89.5% of those in Group 2, and 91.5% of those in Group 3. After 6 months, 81.3% of the patients in Group 1 experienced good outcomes (modified Glasgow Outcome Scale scores of 1 or 2), as did 84% of those in Group 2 and 80% of those in Group 3. No statistical difference was demonstrated between the three groups when they were compared for these two variables. CONCLUSION: The interval between endovascular treatment and SAH did not affect periprocedural morbidity rates or 6-month outcomes. Coil embolization should therefore be performed as early as possible after aneurysmal SAH, to prevent aneurysmal rerupture.     

Transluminal stent-assisted coil embolization of a vertebral confluence aneurysm: technique report

BACKGROUND: Recent advances in stent technology have allowed for negotiation of often tortuous posterior circulation intracranial vasculature. Stent-assisted coil embolization is a novel treatment for complex wide-necked aneurysms, as stents provide a buttress that allows for coil deposition while preventing coil herniation into the parent vessel lumen. We describe a case of stent-assisted coil embolization of a complex wide-necked vertebral confluence aneurysm. CASE DESCRIPTION: A 61-year-old woman presented with a Hunt-Hess III, Fisher Grade III subarachnoid hemorrhage secondary to a ruptured vertebral confluence aneurysm demonstrated on angiography. The patient underwent emergent angiography and attempted coiling of a vertebral confluence aneurysm. Because of the aneurysm's complex wide neck and the presence of subclavian steal syndrome, the coils repeatedly herniated into the left vertebral and basilar artery lumina. A flexible coronary stent was deployed across the aneurysm neck, preventing coil herniation and allowing for greater coil deposition. The patient tolerated the procedure and underwent repeat coiling 2 months postoperatively because of mild coil compaction. This resulted in 100% occlusion and the patient is neurologically normal except for a sixth nerve palsy which had been present after the hemorrhage. CONCLUSION: Recent advances in stent technology allow negotiation of the tortuous posterior circulation vasculature. Stent-assisted coil embolization of complex, wide-necked vertebral confluence aneurysms may be an alternative intervention for these surgically challenging lesions.