GDC血管内栓塞治疗颅内动脉瘤

目的 探讨电解可脱性弹簧圈（GDC）血管内栓塞治疗颅内动脉瘤的疗效和技术要点。方法 对31例动脉瘤患者应用微导管技术,通过数字减影全脑血管造影,采用GDC作动脉瘤囊内填塞治疗。结果 31例31枚动脉瘤中28枚瘤腔完全闭塞,3枚95％闭塞。术后30例临床痊愈;1例死亡;病死率3．2％。术中并发动脉瘤再破裂出血1例;术后弹簧圈末端逸出1例。术后随访0．5～3年均无再出血。结论 GDC血管内栓塞治疗颅内动脉瘤疗效可靠,早期栓塞及有效的术后处理是提高治愈率的重要方法。     

颅内动脉瘤电解可脱性弹簧圈栓塞术后随访观察

目的　评价颅内动脉瘤电解可脱性弹簧圈 (GDC)栓塞治疗的中、远期疗效。方法　采用GDC栓塞 131例共 134枚颅内动脉瘤 ,其中前交通动脉瘤 39枚 ,后交通动脉瘤 4 5枚 ,颈内动脉虹吸段动脉瘤 19枚 ,大脑中动脉瘤 14枚 ,大脑前动脉瘤 3枚 ,后循环动脉瘤 9枚 ,其他部位 5枚。宽颈动脉瘤 (瘤颈宽度 >4mm或瘤体颈比率 <2 ) 39枚 ,狭颈动脉瘤 79枚 ,瘤颈显示不清者 16枚。栓塞术后 15个月内随访DSA ,以与栓塞后即时DSA比较其变化。结果　在 39枚宽颈动脉瘤和 79枚狭颈动脉瘤中 ,完全、近完全闭塞者分别为 30枚 (76 92 % )和 75枚 (94 94 % ) ,两者差异有非常显著性意义(χ2 =8 6 4 3,P <0 0 1)。栓塞后即时完全、近完全闭塞的 118枚动脉瘤中 ,术后不同时期随访DSA显示均无变化 ;栓塞后即时部分疏松填塞的 16枚动脉瘤中 ,随访DSA显示动脉瘤缩小者 3枚 ,无变化者4枚 ,再开放扩大者 9枚。结论　GDC致密、完全栓塞颅内动脉瘤的近、中期疗效肯定 ,但定期随访行DSA检查是必要的 ,尤其是部分疏松填塞者 ,对于复发的病例 ,可再行GDC栓塞     

Marker alignment for Guglielmi detachable coil embolization: practical considerations

BACKGROUND AND PURPOSE: Aneurysm embolization is not without risk: numerous technical aspects are considered before, during, and after the procedure. The purpose of this study was to show the position of the detachment zone of a Guglielmi detachable coil (GDC) with respect to the catheter tip for various microcatheters and marker alignments. METHODS: Six types of commonly used microcatheters were tested (Excel-14, Excelsior, FasTracker-10, Prowler-10, Prowler-14, and Rebar-14). First, the catheter markers and the distance from the catheter tip to the distal end of the proximal and distal markers of each catheter were compared. Second, the coil maker was aligned with the catheter marker. Third, the distal 3 cm of the microcatheter was modified by random shaping, with or without steaming. Last, marker alignment was tested with resterilized microcatheters (ethylene oxide gas sterilization). RESULTS: The length of the catheter marker and the distance between the catheter tip and the distal end of the proximal and distal catheter markers varied among the microcatheters. Sometimes, they varied even within the same microcatheter type. When a GDC was advanced until the proximal end of the marker on the delivery wire was exactly distal to the proximal catheter marker, the coil detachment zone was positioned at approximately 1.0 to 1.5 mm outside the catheter tip. Steaming or shaping of the distal 3 cm of the microcatheters resulted in the GDCs protruding more from the catheter tip. Resterilization also had an effect of marker distance shortening. Microcatheters were easily stretched by usual handling, such as removing a shaping mandrel from the catheter tip. CONCLUSION: Our study shows that proper marker alignment is influenced by many factors, including microcatheter type, steaming, shaping, sterilization, and manual handling.     

Guglielmi detachable coil embolization of a giant midbasilar aneurysm in a 19-month-old patient

We present the case of a 19-month-old patient with tuberous sclerosis who developed a giant aneurysm of the midbasilar artery. Multiple Guglielmi detachable coils were used to fill and occlude the aneurysm and the involved segment of the basilar artery. After the procedure, the child had transient peripheral fifth cranial nerve palsy and no permanent neurologic deficits.     

Transarterial embolization of a direct carotid cavernous fistula with Guglielmi detachable coils.

Four patients underwent transarterial embolization of a carotid-cavernous fistula with Guglielmi detachable coils; in three cases as the initial form of treatment and in one case after treatment via transarterial balloon embolization failed. The fistulas were 2 to 3 mm in diameter on pretreatment angiograms. Complete obliteration was achieved in two patients; in the other two, minimal residual flow remained immediately after embolization but disappeared by follow-up angiography. One to four coils were used to occlude the fistulas. The internal carotid artery remained patent in all patients, and there were no complications.     

电解可脱弹簧圈栓塞治疗颅内动脉瘤

目的：分析应用电解可脱卸弹簧圈(GDC)栓塞治疗颅内动脉瘤的临床效果。方法：6例因蛛网膜下腔出血或其它神经系统症状入住我科的病人，经CT或(和)MR以及DSA检查证实为颅内动脉瘤，其中左侧后交通动脉3例，右侧后交通动脉1例，前交通动脉1例，C2段1例。瘤体直径在5．0-20．0mm之间。在神经安定 局麻下行动脉瘤栓塞术。先作载瘤动脉造影，明确动脉瘤的大小、形状、体／颈比以及与载瘤动脉的关系。再将微导管和微导丝塑型为相应的形状后经导引导管送至动脉瘤腔中部，选择合适的GDC进行填塞，直至致密填塞。结果：全部病人均一次性栓塞治疗成功，技术成功率为100％。栓塞后即刻行脑血管造影显示动脉瘤腔填塞满意，填充程度均在95％以上。全部病人均无再次出血和并发症产生。结论：GDC栓塞颅内动脉瘤是安全、有效和微创的治疗手段。     

Guglielmi detachable coil extraction: suction generated by pusher-wire withdrawal after coil detachment within an intracranial aneurysm

We present a case of Guglielmi detachable coil extraction into a microcatheter after coil detachment during embolization of a superior hypophyseal artery aneurysm; extraction was a result of the suction generated during pusher-wire withdrawal. Experimental simulations using many coil and microcatheter combinations were used to identify factors that contribute to the likelihood of this phenomenon.     

Guglielmi detachable coil embolization for unruptured aneurysms in nonsurgical candidates: a cost-effectiveness exploration.

PURPOSEWe calculated the incremental cost-utility ratio for Guglielmi detachable coil (GDC) embolization versus no therapy for unruptured intracranial aneurysms considered inappropriate for surgical clipping procedures.METHODSDecision tree and Markov analyses that employ cohort simulation were applied to determine the incremental cost-utility ratio of GDC embolization versus no therapy for unruptured cerebral aneurysms. Clinical values required as input data were estimated from the literature for the following variables: relative frequencies of complete aneurysmal occlusion, partial aneurysmal occlusion, and attempted coiling (no coils detached); morbidity and mortality of GDC embolization; frequency, morbidity, and mortality of spontaneous aneurysmal rupture in untreated and GDC-embolized aneurysms; annual rate of recanalization of GDC-embolized aneurysms; quality of life when knowingly living with untreated or GDG-embolized aneurysms and of living with fixed neurologic deficit; costs of GDC embolization, spontaneous aneurysmal rupture, stroke, and rehabilitation; and discount rate. Cost-utility ratios below $50000 per quality-adjusted life year saved were considered acceptable. Sensitivity analyses were performed for all relevant input variables.RESULTSBaseline input values resulted in acceptable cost-utility ratios for GDC embolization of unruptured intracranial aneurysms. These ratios remained within acceptable limits across wide ranges of various input parameters. Cost-effectiveness was markedly affected by the natural course of unruptured, untreated aneurysms; rates of spontaneous rupture greater than 2% per year resulted in favorable cost-utility ratios that were relatively unaffected by variation in GDC efficacy, while rates of rupture less than 1% per year resulted in unfavorable ratios that were highly dependent on GDC efficacy. Many of the GDC efficacy indexes, such as rate of failed coiling, early recanalization, and progressive aneurysmal thrombosis, have mild effects on the cost-utility ratios. GDC complication rate as well as life expectancy had moderate effects on the analysis. The influence of late aneurysmal recanalization was mild unless high rates of rupture for partially coiled aneurysms were applied. Suboptimal clip placement resulting from the presence of GDC coils within a ruptured aneurysm had no demonstrable consequence on cost-utility ratios.CONCLUSIONSThe single most influential variable determining the cost-effectiveness of GDC embolization in our analysis was the natural course of untreated aneurysms. Other important variables included GDC-related morbidity and life expectancy at the time of GDC embolization.     

Does electrothrombosis occur immediately after embolization of an aneurysm with Guglielmi detachable coils?

Current options for treating cerebral aneurysms include surgical clipping and placement of Guglielmi detachable coils (GDCs). The latter system is reported to induce acute aneurysmal occlusion by a mechanism of electrothrombosis. We report our observations in the case of a ruptured aneurysm treated with GDCs and then surgically exposed 2 hours later. The lack of thrombus within the aneurysm and around the coils led us to question the mechanism of action of GDCs.     

Renal aneurysm and arteriovenous fistula. Management with transcatheter embolization

Embolization was performed in six patients with renal artery aneurysms (n = 2) and arteriovenous fistulas (AVF) (n = 5). The aneurysms were observed in one patient with fibromuscular dysplasia and in another with Ehlers-Danlos syndrome. All the AVFs were intraparenchymal and secondary to iatrogenic trauma. Elective embolization was performed in five patients with good clinical results at follow-up between 1 and 9 years. Because of rupture of the aneurysm emergency embolization was attempted without success in the patient with Ehlers-Danlos syndrome, and nephrectomy was carried out. A postembolization syndrome complicated three procedures in which Gelfoam and polyvinyl alcohol were used; in two of these cases unexpected reflux of the particulate material occurred, resulting in limited undesired ablation of the ipsilateral renal parenchyma. Embolization is the most reliable and effective treatment for intrarenal vascular abnormalities since it minimizes the parenchymal damage.     

Tissue response of a small saccular aneurysm after incomplete occlusion with a Guglielmi detachable coil.

A 49-year-old woman had a small saccular aneurysm that was incompletely occluded with a Guglielmi detachable coil (GDC). She died from rupture of another aneurysm 42 days after the treatment. Autopsy for the embolized aneurysm revealed no neoendothelium at the aneurysmal neck, but an organized thrombus was observed limited to the periphery of the aneurysmal lumen. Although isolation of the aneurysm was not apparent, loose embolization with this method may help to reinforce the aneurysmal wall.     

Cook detachable coil embolization of a symptomatic, isolated orbital arteriovenous fistula via a superior ophthalmic vein approach

Isolated arteriovenous fistulas of the posterior orbit occur with exceptional rarity, and their evaluation and management are not well characterized. We describe the clinical presentation and treatment of a spontaneous arteriovenous fistula of the right posterior orbit via a superior ophthalmic vein approach for embolization using platinum detachable coils.This revised version was published online in January 2005 with a correction to the article title.     

Isolated dissecting aneurysm of the left posterior inferior cerebellar artery: endovascular treatment with a Guglielmi detachable coil.

An isolated progressive dissecting aneurysm of the left posterior inferior cerebellar artery (PICA) associated with a persistent trigeminal artery was successfully treated by endovascular occlusion of the proximal PICA with a Guglielmi detachable coil.     

电解可脱卸弹簧圈栓塞颅内动脉瘤

目的 总结２２例颅内动脉瘤电解可脱卸弹簧圈（ＧＤＣ）栓塞治疗,探讨术中操作注意点,手术时机、术中出血、术后再出血的处理。方法 采用ＧＤＣ－１８、ＧＤＣ－１０系统栓塞治疗２２例２４个人动脉瘤。结果 动脉瘤腔完全栓寒６个,栓塞大于９０％６个,栓塞小于９０％２个,１例术后１月半复发,经手术夹闭而愈。全组无死亡。结论颅内动脉瘤的ＧＤＣ栓塞治疗是一较为安全、效果较好的技术。     

Guglielmi detachable coil treatment of a partially thrombosed giant basilar artery aneurysm in a child

We report a partially thrombosed giant of the aneurysm basilar artery with prominent mass effect, diagnosed in an 11 year-old child who presented with neurological deficits due to brain stem compression. After the patent portion of the aneurysm was embolised with Guglielmi detachable coils, remarkable clinical improvement occurred. Angiography demonstrated complete occlusion of the aneurysm and MRI revealed dramatic shrinkage of the aneurysm at 6-month and 1-year follow-up. Received: 24 December 1998/Accepted: 5 May 1999     

Thromboembolic events associated with Guglielmi detachable coil embolization with use of diffusion-weighted MR imaging. Part II. Detection of the microemboli proximal to cerebral aneurysm

BACKGROUND AND PURPOSE: The purpose of this study was to document the incidence and radiologic appearance of thromboembolic events during Guglielmi detachable coil (GDC) embolization for asymptomatic basilar artery (BA) bifurcation and BA-superior cerebellar artery (SCA) aneurysms by using diffusion-weighted (DW) MR imaging, with special emphasis on the evidence of thromboembolic events in vascular territories proximal from the treated aneurysm, which cause cerebellar infarction, and to discuss which step of the procedure (aneurysm or catheter manipulation) may play a role for most thromboembolic events. METHODS: Since 1999, 38 asymptomatic BA bifurcation and BA-SCA aneurysms were treated with GDCs at the National Cardiovascular Center. DW studies were performed for 26 patients between 2 and 5 days after GDC embolizations. All DW images were reviewed by two radiologists for depiction of abnormalities. These findings were retrospectively evaluated with clinical and technical factors of thromboembolic events. RESULTS: DW images showed new hyperintense lesions in 18 patients (69%), with seven (27%) incurring neurologic deteriorations. All symptomatic patients fully recovered by discharge. Fourteen (78%) of 18 patients showed new lesions proximal to the treated aneurysm; that is, in the cerebellar hemispheres. In three cases treated with the balloon-assisted technique, new hyperintense lesions were seen. CONCLUSION: In our experience, most thromboembolic events related to the use of the GDC embolization may be caused by catheter manipulation, especially in the case of the balloon-assisted technique. Caution should be exercised in the handling of catheters. Furthermore, a softer and smaller caliber catheter and simple GDC technique should be considered.     

电解可脱卸弹簧圈栓塞颅内动脉瘤

目的：探讨电解可脱卸弹簧圈（GDC）的治疗颅内动脉瘤的手术指征,术前评估方法,技术操作要点、并发症防治、疗效、存在问题及临床应用前景。方法：1998年7月至2000年2月对93例118例颅内动脉瘤患者施行了电解可脱卸弹簧圈栓塞术,其中84例为破裂动脉瘤,按Hunt-Hess分级：Ⅰ级18例,Ⅱ级29例,Ⅲ级25例,Ⅳ级10例,Ⅴ级2例,7例行急性诊栓塞,手DSA动态监视下完成,术后腰椎蛛网膜下腔持续引流,并予以3H（高血容量、高血压、血液释释）治疗。结果：动脉瘤完全闭塞104个（88．14％）,栓塞程度达90％以上11个（9．32％）,栓塞程度在90％以上3个（2．54％）。全组死亡3例（3．23％（）。1例术后1．5个月复发出血经手术夹闭愈,2例术后复查发现瘤颈扩大,经再次填塞复良好。结论短期随访结果表明,GDC栓塞颅内动脉瘤具有微创,安全、效果可的优点,致密填塞动脉瘤疗效可靠,部分填塞可能导致动脉瘤继续扩大,破裂出血,破裂动脉瘤应急诊检塞治疗。术后腰椎蛛网膜下腔持续引流,可明显提高疗效。     

Cerebral aneurysm perforations complicating therapy with Guglielmi detachable coils: a meta-analysis

BACKGROUND AND PURPOSE: The risk of intraprocedural aneurysm perforation in patients with previously ruptured aneurysms tends to be higher than that of patients with previously unruptured aneurysms, but a statistically significant difference has not been shown. Our purpose was to define the rates of occurrence and of morbidity and mortality associated with aneurysmal perforation associated with coil embolization. METHODS: A meta-analysis of the results from 17 published retrospective reports of aneurysm perforations complicating therapy with Guglielmi detachable coils (GDCs) was performed. Rates of perforation and associated morbidity and mortality in previously ruptured and unruptured aneurysms were calculated. The mechanism of perforation was noted. RESULTS: The risk of intraprocedural perforation was significantly higher in patients with ruptured aneurysms compared with patients with unruptured aneurysms (4.1% vs 0.5%; P <.001). The combined risk of permanent neurologic disability and death associated with intraprocedural aneurysm perforation was 38% for ruptured aneurysms and 29% for unruptured aneurysms. The morbidity and mortality rates with perforations caused by coils (39%) and microcatheters (33%) were similar. The morbidity and mortality rate for microguidewire perforations was considerably lower (0%, n = 4) than the rates for coils and microcatheters, but number of cases was too low to indicate statistical significance. CONCLUSION: The risk of aneurysm perforation during GDC therapy is much higher in patients with previously ruptured aneurysms than in those with unruptured aneurysms. The morbidity and mortality rates are substantial for perforations caused by coils and microcatheters, whereas they seem to be much lower for perforations caused by microguidewires.     

Delayed reconfiguration of a Guglielmi detachable coil mass associated with late occlusion of an adjacent aneurysm and parent vessel

We present a case of asymptomatic, progressive, late occlusion of the left superior cerebellar artery (SCA) and an aneurysm arising from the junction of the SCA and basilar artery after embolization of an adjacent aneurysm arising between the left posterior cerebral artery and the left SCA. The delayed occlusion was associated with reconfiguration of the Guglielmi detachable coils at the neck of the treated aneurysm.