Current update on the randomized controlled trials of intracranial aneurysms

Endovascular coiling has become the primary treatment modality for the treatment of intracranial ruptured aneurysms in many centers. A multicenter randomized controlled trial (RCT), ISAT study, has demonstrated that endovascular coiling of ruptured intracranial aneurysms has benefits over surgical clipping in those patients suitable for either treatment. Because RCT comparing conservative management with surgical clipping and with endovascular coiling have not been performed to date for unruptured intracranial aneurysms, the best management for unruptured aneurysm remains unclear. A RCT is ongoing to answer the question whether active treatment can improve the outcome of patients with unruptured intracranial aneurysms as compared with observation.     

比较手术夹闭和介入栓塞治疗颅内未破裂动脉瘤安全性和有效性的Meta分析

目的比较手术夹闭和介入栓塞治疗颅内未破裂动脉瘤的安全性和有效性。方法计算机检索1990至2018年颅内未破裂动脉瘤的所有临床对照研究。两名研究员分别纳入研究、提取数据、质量评价并应用Rev Man5. 0软件进行数据处理。结果最终纳入21篇文献,病例数109114例。Meta分析结果提示:手术夹闭组动脉瘤闭塞率为88. 2%,平均住院时间7. 7天,均高于介入栓塞组的65. 3%和4. 1天,P 0. 05。介入组患者的短期死亡率和致残率分别为0. 61%和2. 1%,均低于手术组的1. 27%和4. 7%,P 0. 05。介入组患者的1年期死亡率和致残率(2. 5%、2. 5%)均与手术组(2. 2%、1. 8%)无明显差异,P 0. 05。漏斗图未发现发表偏倚。敏感性分析结果一致。结论介入栓塞相比于手术夹闭可缩短患者的住院时间,降低患者的短期不良预后发生率。但是动脉瘤的闭塞率较低,1年期预后与手术夹闭无明显差异。据此推测手术夹闭患者的长期预后可能要好于介入栓塞,手术夹闭更适合于年轻患者。     

Critical appraisal of the International Subarachnoid Aneurysm Trial (ISAT)

The results of the International Subarachnoid Aneurysm Trial (ISAT) drew attention from both scientific and lay press, impacting the management of aneurysm patients significantly. In this review, the ISAT report was analyzed critically and the available literature was scrutinized stratifying the common criticisms as to the weak aspects of this study. The aim of ISAT was to compare the safety and efficacy of endovascular coiling with neurosurgical clipping for aneurysms, which were suitable for both treatments. The results showed a 22.5% relative and 6.9% absolute risk reduction at one year in the disability outcome of patients who were treated with coiling. However, long-term risk of re-bleeding from the treated aneurysms and the risk of repeat procedures was higher in this group also. Lack of angiographic data following the initial treatment and long-term follow-up represents one of the main flaws of this study. The outcome assessment scale, biases regarding patient selection and center participation criteria were further issues of criticism. The results of ISAT are not sufficient to provide a definitive answer as to the superiority of endovascular treatment over microsurgery, although coiling appears to produce less peri-procedural morbidity in a selected group of patients. An optimum outcome assessment should include a universally accepted scale and a detailed long-term angiographic outcome.     

106例颅内复杂动脉瘤的支架应用

目的 总结血管内支架技术辅助弹簧圈治疗颅内复杂动脉瘤的疗效，探讨其技术要点、并发症防治及评估该技术的安全性。方法 回顾性分析106例颅内复杂动脉瘤血管内支架技术应用。单纯支架技术6例，一期支架辅助弹簧圈治疗动脉瘤59例，二期支架结合弹簧圈栓塞动脉瘤40例，一期治疗病例中，先放微导管后放支架28例，先放支架后放微导管31例。结果 106例患者宽颈动脉瘤60例，梭形动脉瘤25例、夹层动脉瘤15例、假性动脉瘤6例。支架无法到位1例，105例第一次栓塞术后即时造影动脉瘤完全栓塞70例(66．7％)，动脉瘤大部分栓塞35例(33．3％)。术中动脉瘤破裂3例，术后脑梗塞4例，支架移位4例。80例3个月至24个月造影随访，动脉瘤消失50例(62．5％)，部分残留30例(37．5％)，其中20例行再次弹簧圈栓塞，完全栓塞15例(75％)。80例两次完全栓塞共65例(82．5％)。临床随访105例病人死亡1例，术后遗留永久性神经功能障碍2例。结论 支架技术辅助微弹簧圈栓塞提高了颅内复杂动脉瘤的近期疗效，是治疗颅内复杂动脉瘤的一种有效方法，但长期疗效尚有待进一步的随访研究。     

International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomized trial

Endovascular detachable coil treatment is being increasingly used as an alternative to craniotomy and clipping for some ruptured intracranial aneurysms, although the relative benefits of these two approaches have yet to be established. We undertook a randomized, multicenter trial to compare the safety and efficacy of endovascular coiling with standard neurosurgical clipping for such aneurysms judged to be suitable for both treatments. We enrolled 2143 patients with ruptured intracranial aneurysms and randomly assigned them to neurosurgical clipping (n = 1070) or endovascular treatment by detachable platinum coils (n = 1073). Clinical outcomes were assessed at both 2 months and at 1 year with interim ascertainment of rebleeds and death. The primary outcome was the proportion of patients with a modified Rankin scale (mRs) score between 3 and 6 (dependency or death) at 1 year. Trial recruitment was stopped by the steering committee after a planned interim analysis. Analysis was per protocol. One hundred and ninety of 801 (23.7%) patients allocated endovascular treatment were dependent or dead at 1 year compared with 243 of 793 (30.6%) of those allocated neurosurgical treatment (P = .0019). The relative and absolute risk reductions in dependency or death after allocation to an endovascular versus neurosurgical treatment were 22.6% (95% CI 8.9-34.2) and 6.9% (2.5-11.3), respectively. The risk of rebleeding from the ruptured aneurysm after 1 year was two per 1276 and zero per 1081 patient-years for patients allocated endovascular and neurosurgical treatment, respectively. In patients with a ruptured intracranial aneurysm, for which endovascular coiling and neurosurgical clipping are therapeutic options, the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling. The data available to date suggest that the long-term risks of further bleeding from the treated aneurysm are low with either therapy, although somewhat more frequent with endovascular coiling.     

Clipping versus coiling for ruptured intracranial aneurysms after the international subarachnoid aneurysm trial. United Kingdom experience

The International Subarachnoid Aneurysm Trial (ISAT) was designed as the first multi-central international prospective randomized trial aiming to compare the safety and efficacy of the 2 available treatments for ruptured intracranial aneurysms; endovascular coiling and surgical clipping. The initial results were published in the Lancet (2002), and it showed clearly a superiority of coiling over clipping in the treatment of ruptured intracranial aneurysms; 22.7% of coiled patients were dependent or dead compared with 30.6% in the surgical group with absolute risk reduction of 6.9%. The results of the ISAT drew huge attention from both scientific authorities and lay media. Despite criticisms, the study has made a significant impact on the treatment of aneurysmal subarachnoid hemorrhage, especially in the United Kingdom and Europe. Since their initial results, the ISAT group has published further papers and updates covering more interesting results regarding the risks of rebleeding, repeat procedures, epilepsy, and the cost effectiveness of both treatments.     

Unruptured intracranial aneurysms

Between 3.6 and 6% of the population harbour an unruptured intracranial aneurysm. Risk of rupture is related to aneurysm site and size and whether or not the patient has already had a subarachnoid haemorrhage (SAH) from another aneurysm. In ISUIA 2, the rupture rate for anterior circulation aneurysms<7mm was 0% per year in patients with no prior SAH, and 0.3% per year in patients with previous SAH; 7-12mm aneurysms, 0.5% per year (both groups); 13-24mm aneurysms, 3% per year; and giant aneurysms 8% per year. Rupture rate for posterior circulation aneurysms is higher at all sizes:<7mm was 0.5% per year in subjects with no prior SAH, 0.7% in those with prior SAH; 7-12mm, 3% per year; 13-24mm, 3.7% per year; and giant aneurysms, 10% per year. Non-invasive tests like contrast enhanced magnetic resonance angiography (MRA) and multislice computed tomographic angiography (CTA) are alternatives to intra-arterial digital subtraction angiography (IADSA) to detect aneurysms. Although these are promising techniques, the quality of data testing their accuracy remains limited and single slice CTA and time-of-flight MRA are poorer at detecting aneurysms<5mm diameter, which account for up to 1/3 of unruptured aneurysms. For ruptured aneurysms, the only large scale randomised controlled trial comparing surgical and endovascular treatment (ISAT) by coiling, resulted in an absolute 8.8% reduction (updated figure as of June 2003 for 1888 patients) in death or dependency at 1 year compared with surgical clipping. For unruptured aneurysms, the best available data so far comparing coiling and clipping is from the prospective (but non-randomised) arm of ISUIA. Elective surgical clipping had combined morbidity and mortality at 1 year of 12.2% versus 9.5% for coiling, although the groups were not matched with more high risk patients in the endovascular treatment cohort. Nevertheless these data are encouraging for future randomised trials of elective coiling versus clipping for asymptomatic aneurysms, in particular as the unproven long-term durability of coiling treatment and the fact that complete aneurysm occlusion is not always achieved remain obstacles to its wider use in unruptured aneurysms. There is an increased risk of SAH in relatives of patients with SAH (highest in those with two or more first degree relatives affected), but most SAH is sporadic and therefore the balance of available evidence indicates that mass screening for aneurysms is not cost effective. There may be a limited role for investigation of high-risk subgroups and ideally such screening should be tested in a randomised trial. The avoidance and active management of vascular risk factors should also be part of the management of at risk subjects.     

Endovascular treatment of ruptured intracranial aneurysms during pregnancy: Is this the best way forward? Case report and review of the literature

Objective and importance

Subarachnoid haemorrhage in pregnancy has traditionally been treated by surgical clipping however lately cases of successful coiling have been reported. Nevertheless, the long-term outcome of coiling is not well known in pregnant women. Mortality due to rebleeding of an incompletely treated aneurysm remains high. Only 15 cases of successful endovascular coiling during pregnancy have been reported so far.

Clinical presentation

We report the case of a pregnant woman who presented with aneurysmal subarachnoid hemorrhage (WFNS Grade III) due to rupture of a right posterior communicating artery aneurysm.

Intervention

The patient underwent endovascular coiling successfully followed by an elective caesarian section and delivery of a healthy baby. However, during the course of a 2-year follow up the patient had suffered two relapses of the coiled aneurysm which required additional treatment. These events have affected her choice of extending her family.

Conclusion

The small risk of recurrence and the potential impact on future pregnancies should be explicitly communicated to patients in cases of endovascular coiling.     

The impact of the international subarachnoid aneurysm trial (ISAT) on the management of aneurysmal subarachnoid haemorrhage in a neurosurgical unit in the UK

OBJECTIVE: To review the changes in the management of aneurysmal subarachnoid haemorrhage (SAH) in a single neurosurgical unit in the UK, following the publication of the international subarachnoid aneurysm trial (ISAT). METHODS: The presentation, investigations, treatments and outcome data of all patients admitted with SAH to the neurosurgical unit between February 2001 and May 2003 were prospectively recorded in a database. The total period studied was split in to three blocks, around the time of publication of the ISAT in October 2002 (period 1=February-December, 2001; period 2=January-September, 2002 and period 3=October 2002 to May 2003). RESULTS: Of the 177 patients admitted with presumed SAH, 130 patients with evidence of an aneurysm on angiograms were included in the study. The mean age was 53+/-1 years, 92 (71%) patients were WFNS grade 1 or 2 and 77 (60%) were Fischer grade 2 or 3. These parameters were unchanged over the study period. Overall, 60 patients (46%) underwent a craniotomy for clipping or wrapping of aneurysm, 60 (46%) underwent endovascular embolisation of the aneurysm and 10 patients (8%) were managed conservatively. Over the study periods 1-3, the proportion of patients undergoing open surgery decreased (from 51 to 31%) while endovascular treatment of aneurysms increased (35-68%; p<0.01). Over the same time points there was a non-significant trend towards better Glasgow outcome scores at 6 months follow-up. The management mortality for all WFNS grades of patients with SAH was eight deaths (14%). The mortality in the surgical group was 3 patients (5%) and there were no deaths in the endovascular group. Over the study periods 1-3, there was a decrease in the mean total duration of hospital stay (from 23.6 to 15.5 days; p<0.05) in WFNS grade 1 and 2 patients and this was related to a shorter duration of hospital stay in the endovascular than surgical group of patients (p<0.05). The mean delay in obtaining an angiogram increased over the study periods 1-3 (1.1-2.3 days; p<0.05). CONCLUSIONS: This observational study highlights the changing pattern of management of SAH and the potential difficulties that could be encountered. The proportion of patients undergoing endovascular treatment of aneurysms has increased following the publication of the ISAT study. The associated increase in the delay in obtaining an angiogram may reflect the increased workload encountered by the neuroradiologists.     

Endovascular coiling versus neurosurgical clipping in patients with a ruptured basilar tip aneurysm

OBJECTIVES: To compare endovascular coiling with neurosurgical clipping of ruptured basilar bifurcation aneurysms. METHODS: Patient and aneurysm characteristics, procedural complications, and clinical and anatomical results were compared retrospectively in 44 coiled patients and 44 patients treated by clipping. The odds ratios for poor outcome (Glasgow outcome scale 1, 2, 3) adjusted for age, clinical condition, and aneurysm size were assessed by logistic regression analysis. RESULTS: In the endovascular group, five patients (11%) had a poor outcome v 13 (30%) in the surgical group; the adjusted odds ratio for poor outcome after coiling v clipping was 0.28 (95% confidence interval, 0.08 to 0.99). Procedural complications were more common in the surgical group. Optimal or suboptimal occlusion of the aneurysm immediately after coiling was achieved in 41 patients (93%). Clipping was successful in 40 patients (91%). CONCLUSIONS: The results suggest that embolisation with coils is the preferred treatment for patients with ruptured basilar bifurcation aneurysms.     

The impact of microsurgical clipping and endovascular coiling on the outcome of cerebral aneurysms in patients over 60 years of age

A retrospective study was performed to compare the safety and efficacy in elderly patients of endovascular coiling, with clipping, for cerebral aneurysms. In total, 198 patients over 60 years of age with ruptured intracranial aneurysms were treated by microsurgical clipping (n = 122) or endovascular coiling (n = 76). Endovascular coiling achieved favorable outcome in 88.2% of patients, which was significantly higher than for the microsurgical clipping group. The occurrence of re-bleeding, infarction, and hydrocephalus was similar between the two groups. Intraoperative time for microsurgical clipping was significantly longer than that for endovascular coiling. Length of hospitalization was shorter for the coiling group than for the clipping group. Our results suggest that endovascular coiling should be considered as the first-choice therapy in elderly patients with ruptured aneurysms, as it may reduce duration of both the operation and hospitalization.     

颅内破裂动脉瘤栓塞术后并发脑疝的危险因素分析

目的 探讨颅内破裂动脉瘤血管内栓塞术后发生脑疝的危险因素及预后。方法 回顾性分析2017年5月至2019年5月行血管内治疗的303例颅内破裂动脉瘤的临床资料。结果 26例术后发生脑疝,脑疝发生率为8.58%。多因素logistic回归分析显示入院WFNS分级Ⅳ～Ⅴ级、动脉瘤再次破裂、脑水肿是术后发生脑疝的独立危险因素（P<0.05）。ROC曲线分析显示,对于预测术后发生脑疝的效能：入院WFNS分级Ⅳ～Ⅴ级的曲线下面积（AUC）为0.734(95%CI 0.639～0.829;P<0.001),动脉瘤再破裂的AUC为0.632(95%CI 0.504～0.760;P=0.026),脑水肿的AUC为0.826(95%CI 0.723～0.928;P<0.001);入院WFNS分级Ⅳ～Ⅴ级+动脉瘤再次破裂+脑水肿的AUC为0.897(95%CI 0.819～0.974;P<0.001)。26例脑疝中,8例去骨瓣减压术治疗（4例出院时死亡;4例存活,随访1年,预后良好2例,预后不良2例）,18例未行去骨瓣减压术均死亡。26例脑疝病死率为84.62%。结论 颅内破裂动脉瘤...     

Quality of life after treatment of unruptured intracranial aneurysms by neurosurgical clipping or by embolisation with coils. A prospective, observational study

BACKGROUND: Relatively high rates of complications occur after operation for unruptured intracranial aneurysms. Published data on endovascular treatment suggest lower rates of complications. We measured the impact of treatment of unruptured aneurysms by clipping or coiling on functional health, quality of life, and the level of anxiety and depression. METHODS: In three centres, we prospectively collected data on patients with an unruptured aneurysm who were treated by clipping or coiling. Treatment assignment was left to the discretion of the treating physicians. Before, 3 and 12 months after treatment, we used standardised questionnaires to assess functional health (Rankin Scale score), quality of life (SF-36, EuroQol), and the level of anxiety and depression (Hospital Anxiety and Depression Scale). RESULTS: Nineteen patients were treated by coiling and 32 by clipping. In the surgical group, 4 patients (12%) had a permanent complication; 36 of all 37 aneurysms (97%) were successfully clipped. Three months after operation, quality of life was worse than before operation; 12 months after operation, it had improved but had not completely returned to baseline levels. Scores for depression were higher than in the general population. In the endovascular group, no complications with permanent deficits occurred; 16 of 19 aneurysms (84%) were occluded by more than 90%. One patient died from rupture of the previously coiled aneurysm. In the others, quality of life after 3 months and after 1 year was similar to that before treatment. CONCLUSIONS: In the short term, operation of patients with an unruptured aneurysm has a considerable impact on functional health and quality of life. After 1 year, recovery occurs but it is incomplete. Coil embolisation does not affect functional health and quality of life.     

Direct costs of surgical clipping and endovascular coiling of unruptured intracranial aneurysms

BACKGROUND: Unruptured intracranial aneurysms can be preventively treated by surgical clipping or endovascular coiling. We determined in detail the costs of these treatments. METHODS: We included patients who were treated for an unruptured aneurysm between 1997 and 2003. Patients coiled in this period were matched with clipped patients according to the year of treatment, age and gender. Considering clipping and coiling, we compared all pre-admission costs of diagnostic procedures, all costs of treatment, and costs during follow-up including standard angiographic control examinations at 6 and 18 months after coiling. Costs were calculated as the product of the used resources and the costs of these resources. RESULTS: The mean price for clipping was EUR 8,865.42 and that for coiling EUR 10,370.29. The difference was mainly determined by the higher material costs of coiling (EUR 5,300) compared with clipping (EUR 690). Costs of clipping were mainly determined by the need for intensive care facilities (1.2 days after clipping and 0 days after coiling) and the length of hospital stay (10.5 days after clipping and 3.4 days after coiling). After bootstrapping the data, costs of coiling were on average EUR 1,553 (95% confidence interval: EUR 1,539-1,569) higher than those of clipping. CONCLUSIONS: For unruptured intracranial aneurysms, direct in-hospital costs of coiling are on average higher than those of clipping, mostly because of the more expensive coils.     

CT血管造影在脑动脉瘤手术和栓塞中的价值

目的评估CT血管造影(CTA)在脑动脉瘤(AN)手术和栓塞中的临床价值.方法回顾211例行CTA检查并进行了手术或栓塞治疗的AN,196例患者同期接受了数字减影血管造影(DSA)检查.所有患者根据CTA的结果确定治疗方案和指导手术或栓塞的进行.结果 7例CTA出现技术性失误,其余CTA影像均被手术或栓塞所证实.CTA发现了DSA漏诊的2例小型AN.CTA提供的AN的部位、瘤体、瘤颈、瘤体/瘤颈比等参数,有利于早期确定治疗方案.66例行夹闭术,依据CTA所模拟的手术入路影像均可顺利找到AN,CTA能有效地提供AN与载瘤动脉、周围分支及颅底骨结构之间的三维关系信息.145例行栓塞治疗,CTA的结果均被DSA所证实,对前交通、基底动脉顶端AN,CTA均准确指导导引导管进入的方向,能清晰显示瘤颈的投射角度和瘤体瘤颈比,辅助确定工作角度和是否需要支架植入.结论 CTA有助于AN治疗方案地迅速确定,为早期治疗提供确切依据和指导信息,对AN手术或栓塞具有重要的价值.     

Interdisciplinary treatment of unruptured intracranial aneurysms: impact of intraprocedural rupture and ischemia in 563 aneurysms

This study was conducted to determine the risk factors and the clinical impact of intraprocedural aneurysm rupture (IAR) and periprocedural ischemia in the treatment of symptomatic and asymptomatic unruptured intracranial aneurysms (UIAs). A single-center retrospective data analysis of 563 UIAs treated between 2000 and 2010 was conducted. Treatment assignment was made on the basis of individual aneurysmal criteria in an interdisciplinary neurovascular conference with attending neurosurgeons, neuroradiologists and neurologists. In 363 microsurgical and 200 endovascular procedures, the permanent morbidity rate was 4.9 and 6 %. The overall mortality rate was 0.7 %—no procedure-related death occurred in microsurgery, and four patients had fatal outcomes after endovascular treatment. IAR occurred in 34 (9.4 %) microsurgical and 8 (4 %) endovascular procedures (p = 0.03). Risk factors for IAR were age, aneurysm diameter, symptomatic aneurysms, hypertension and smoking in microsurgery. IAR was associated with significantly worse outcome at discharge after microsurgical and at discharge and follow-up after endovascular procedures and was followed by fatal outcome in four endovascular cases. Periprocedural ischemia (12.1 vs. 9 %) resulted in significantly worse outcome in both groups. Risk factors for periprocedural ischemia were IAR during microsurgery, aneurysm diameter, symptomatic aneurysms and smoking in either group. Treatment of UIAs can be conducted with an equivalent low rate of permanent morbidity for clipping and coiling—treatment of symptomatic aneurysms elevates the procedural risk. IAR was less frequent during coiling, but was associated with relevant mortality. IAR and periprocedural ischemia represent significant treatment-associated risks, which should be taken into account in interdisciplinary treatment planning and patient counseling.     

Aneurysmal SAH: cognitive outcome and structural damage after clipping or coiling.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (SAH) and surgical clipping of intracranial aneurysms are associated with substantial morbidity and mortality. OBJECTIVE: To compare cognitive outcome and structural damage in patients with aneurysmal SAH treated with surgical clipping or endovascular coiling. METHODS: Forty case-matched pairs of patients with aneurysmal SAH treated by surgical clipping or endovascular coiling were prospectively assessed by use of a battery of cognitive tests. Twenty-three case-matched pairs underwent MRI 1 year after the procedure. Matching was based on grade of SAH on admission, location of aneurysm, age, and premorbid IQ. RESULTS: Both groups were impaired in all cognitive domains when compared with age-matched healthy control subjects. Comparison of cognitive outcome between the two groups indicated an overall trend toward a poorer cognitive outcome in the surgical group, which achieved significance in four tests. MRI showed focal encephalomalacia exclusively in the surgical group. This group also had a significantly higher incidence of single or multiple small infarcts within the vascular territory of the aneurysm, but both groups had similar incidence of large infarcts and global ischemic damage. CONCLUSION: Endovascular treatment may cause less structural brain damage than surgery and have a more favorable cognitive outcome. However, cognitive outcome appears to be dictated primarily by the complications of SAH.     

支架后释放技术在颅内宽颈动脉瘤栓塞治疗中的应用

目的探讨支架后释放技术在颅内宽颈动脉瘤栓塞治疗中的安全性、疗效及技术优势。方法回顾分析2007年1月至2009年5月间支架后释放技术（支架输送至载瘤动脉动脉瘤段,先填塞部分弹簧圈后再释放支架）治疗的153例178＂个动脉瘤患者的动脉瘤及载瘤动脉解剖形态,支架植入技术操作程序,临床和造影结果。结果所有动脉瘤均成功植入支架,其中Neuroform支架76枚、Enterprise支架72枚、LEO支架33枚。术后即刻完全栓塞136个动脉瘤（76．4％）,瘤颈残留29个（16．3％）,部分栓塞13个（7．3％）。术中弹簧圈拉丝1例,血栓栓塞并发症1例。平均术后9．3个月后DSA随访74例,MRA随访44例,显示3例动脉瘤再通。结论支架后释放技术是颅内动脉瘤栓塞治疗中的一种重要手段,能显著提高动脉瘤颈覆盖率而达到血管重建目的,使支架治疗技术成功率、安全性和疗效进一步提高。     

Y-Stenting Endovascular Treatment for Ruptured Intracranial Aneurysms : A Single-Institution Experience in Korea

Objective

Stent-assisted coiling on intracranial aneurysm has been considered as an effective technique and has made the complex aneurysms amenable to coiling. To achieve reconstruction of intracranial vessels with preservation of parent artery the use of stents has the greatest potential for assisted coiling. We report the results of our experiences in ruptured wide-necked intracranial aneurysms using Y-stent coiling.

Methods

From October 2003 to October 2011, 12 patients (3 men, 9 women; mean age, 62.6) harboring 12 complex ruptured aneurysms (3 middle cerebral artery, 9 basilar tip) were treated by Y-stent coiling by using self-expandable intracranial stents. Procedural complications, clinical outcome, and initial and midterm angiographic results were evaluated. The definition of broad-necked aneurysm is neck diameter over than 4 mm or an aneurysm with a neck diameter smaller than 4 mm in which the dome/neck ratio was less than 2.

Results

In all patients, the aneurysm was successfully occluded with no apparent procedure-related complication. There was no evidence of thromboembolic complication, arterial dissection and spasm during procedure. Follow-up studies showed stable and complete occlusion of the aneurysm in all patients with no neurologic deficits.

Conclusion

The present study did show that the Y-stent coiling seemed to facilitate endovascular treatment of ruptured wide-necked intracranial aneurysms. More clinical data with longer follow-up are needed to establish the role of Y-stent coiling in ruptured aneurysms.     

Combined Endovascular and Microsurgical Procedures as Complementary Approaches in the Treatment of a Single Intracranial Aneurysm

Objective

Both endovascular coil embolization and microsurgical clipping are now firmly established as treatment options for the management of cerebral aneurysms. Moreover, they are sometimes used as complementary approaches each other. This study retrospectively analyzed our experience with endovascular and microsurgical procedures as complementary approaches in treating a single aneurysm.

Methods

Nineteen patients with intracranial aneurysm were managed with both endovascular and microsurgical treatments. All of the aneurysms were located in the anterior circulation. Eighteen patients presented with SAH, and 14 aneurysms had diameters of less than 10 mm, and five had diameters of 10-25 mm.

Results

Thirteen of the 19 patients were initially treated with endovascular coil embolization, followed by microsurgical management. Of the 13 patients, 9 patients had intraprocedural complications during coil embolization (intraprocedural rupture, coil protrusion, coil migration), rebleeding with regrowth of aneurysm in two patients, residual sac in one patient, and coil compaction in one patient. Six patients who had undergone microsurgical clipping were followed by coil embolization because of a residual aneurysm sac in four patients, and regrowth in two patients.

Conclusion

In intracranial aneurysms involving procedural endovascular complications or incomplete coil embolization and failed microsurgical clipping, because of anatomical and/or technical difficulties, the combined and complementary therapy with endovascular coiling and microsurgical clipping are valuable in providing the best outcome.