MR angiography of saccular aneurysms after treatment with Guglielmi detachable coils: preliminary experience.

PURPOSETo review our experience using MR angiography to assess the cerebral vasculature after aneurysmal treatment with Guglielmi detachable coils (GDCs).METHODSForty three-dimensional time-of-flight MR angiographic studies were performed in 23 patients after endovascular aneurysmal therapy with GDCs. Digital subtraction angiographic (DSA) studies were evaluated retrospectively for the following findings: parent artery patency, branch vessel patency, residual flow within the aneurysm, and residual aneurysmal neck. The MR angiographic examinations were inspected for the same findings, as well as for the degree of signal loss surrounding the coil mass. Clinical histories were reviewed to determine the impact of MR angiographic findings on therapy.RESULTSPatency status of the parent artery was correctly identified on 25 of 26 MR angiographic examinations with DSA confirmation. Thirty-four of 37 patent branch vessels were identified by MR angiography. Residual neck was correctly identified in seven studies of six aneurysms, with no false-negative or false-positive results. Intraaneurysmal flow was correctly identified in five of eight studies of six aneurysms with residual flow shown by DSA. Artifact and hemorrhage mimicked residual flow in two of 18 MR angiographic studies of aneurysms with no residual flow shown by DSA. In eight patients, MR angiography provided clinically useful information that affected therapy.CONCLUSIONSMR angiography can identify flow within an aneurysm after treatment with GDCs as well as in the adjacent parent and branch vessels. This technique may be a useful adjunct to DSA in some clinical situations.     

Aneurysms of the posterior cerebral artery: classification and endovascular treatment

BACKGROUND AND PURPOSE: We present a retrospective review of our experience in the endovascular treatment of posterior cerebral artery (PCA) aneurysms. We detail the anatomic location of these aneurysms, the technique of endovascular treatment, morphologic results, and clinical outcome. We also discuss the segmental anatomy of the PCA as it relates to the various neurologic deficits that may result from occlusion of the parent artery. METHODS: From 1993 to 1998, 20 patients (12 female, eight male; mean age, 44 yrs) harboring a PCA aneurysm were treated via an endovascular approach. One patient had two aneurysms, comprising a total of 21 lesions. Fourteen (66%) of 21 aneurysms were saccular in nature, five (24%) were giant serpentine aneurysms, and two (10%) were posttraumatic. All aneurysms were treated using Guglielmi detachable coils (GDC) either by selective obliteration of the aneurysm sac or by parent artery occlusion. RESULTS: Fourteen (66%) of the 21 aneurysms were successfully treated with preservation of the parent artery. In the remaining seven (33%), the parent artery was permanently occluded. The overall complication rate in this series was 15%, with a permanent morbidity rate of 10% and a 0% mortality rate. CONCLUSION: Aneurysms of the PCA are rare compared with other locations in the intracranial circulation. Saccular PCA aneurysms can be treated effectively, by use of GDC, to obliterate the aneurysm yet preserve the parent artery. Fusiform and giant serpentine aneurysms of the PCA can effectively be treated by permanent occlusion of the parent artery; in these cases, thorough knowledge of the PCA segmental anatomy is crucial in order to select the site of occlusion and to avoid major neurologic deficits.     

Three-dimensional time-of-flight MR angiography in the evaluation of intracranial aneurysms treated with Guglielmi detachable coils

BACKGROUND AND PURPOSE: Intravascular treatment of intracranial aneurysms is a relatively new therapeutic technique and long-term controlled angiographic trials are needed to assess persistence of aneurysm occlusion. Our purpose was to evaluate the effectiveness of 3D time-of-flight (3D-TOF) MR angiography as a noninvasive screening tool in the follow-up of cerebral aneurysms treated with Guglielmi detachable coils (GDCs). METHODS: Forty-nine patients with 50 intracranial aneurysms previously treated with GDCs were studied with both DSA and 3D-TOF MR angiography. In 14 cases, a second follow-up examination was performed, for a total of 64 aneurysms evaluated. In 25 aneurysms, both pre- and postcontrast MR angiographic studies were obtained. RESULTS: In seven of 64 aneurysms, the MR angiographic studies were considered to be unreliable owing to the presence of artifacts that obscured part of the parent artery and did not allow an accurate evaluation of the aneurysm neck. These seven aneurysms, however, all were shown to be completely occluded at digital subtraction angiography (DSA). In the remaining 57 aneurysms, DSA revealed complete occlusion in 39 and the presence of residual patency in 18, whereas MR angiography showed complete occlusion in 38 and residual patency in 19. Enhanced MR angiography proved to be useful in evaluating residual patency in large and giant aneurysms and in better depicting the distal branch arteries. CONCLUSION: Although artifacts related to the presence of coils are evident on a considerable number of imaging studies, our findings indicate that MR angiography is useful in the evaluation of residual patency of cerebral aneurysms treated with GDCs and may eventually prove valuable in the follow-up of those cases in which a good initial correlation with DSA was demonstrated.     

Thrombus formation and structure and the evolution of mass effect in intracranial aneurysms treated by balloon embolization: emphasis on MR findings

This study was designed to further assess the capabilities of MR as a tool for the diagnostic evaluation of patients with giant intracranial aneurysms, to determine MR's ability to define the degree of thrombosis present within giant aneurysms before and after treatment with balloon occlusion, and to delineate the MR characteristics of both spontaneous and induced thrombus within giant aneurysms. Nine patients with unclippable intracranial aneurysms treated by parent artery occlusion with detachable balloons were evaluated with MR, angiography, and CT. Pretreatment and posttreatment MR studies were evaluated for their ability to (1) define the size, configuration, and anatomic relationships of an aneurysm; (2) detect and characterize thrombus within an aneurysm; and (3) determine if treatment successfully caused complete aneurysm thrombosis. MR imaging does not replace angiography in either the pretreatment or the posttreatment evaluation of patients with giant intracranial aneurysms. Thrombus formation and dissolution is a complex, dynamic process. Active thrombus in incompletely thrombosed aneurysms differs from isolated organizing thrombus in completely thrombosed aneurysms. Induced and spontaneous thrombi differ in mechanisms of formation and in composition; their MR characteristics are also different. Reduction in mass effect is common after complete thrombosis of giant intracranial aneurysms.     

Giant Serpentine Intracranial Aneurysm: A Case Report

The authors present a case of giant serpentine aneurysm (a partially thrombosed aneurysm containing tortuous vascular channels with a separate entrance and outflow pathway). Giant serpentine aneurysms form a subgroup of giant intracranial aneurysms, distinct from saccular and fusiform varieties, and in this case, too, the clinical presentation and radiographic features of CT, MR imaging and angiography were distinct.     

Transcranial color-coded Doppler sonography of intracranial aneurysms before and after endovascular occlusion with Guglielmi detachable coils.

BACKGROUND AND PURPOSEOur purpose was to evaluate the ability of transcranial color-coded Doppler sonography (TCCD) to 1) identify Guglielmi detachable coils (GDCs) within intracranial aneurysms, 2) show endovascular aneurysmal occlusion and patency of parent and branch arteries, 3) determine the flow velocities within parent arteries and major branches before and after treatment, and 4) assess persistence of aneurysmal occlusion.METHODSThe sonographic appearance of GDCs was established experimentally by TCCD (2 to 2.5 MHz), which was then performed in 40 patients with 43 aneurysms occluded by GDCs. The patency of parent arteries and major branches was assessed qualitatively and compared with the immediate posttherapeutic angiographic appearance in every patient. Flow velocities were selectively measured and compared before and after treatment in 21 parent arteries and 24 major branches. Follow-up TCCD studies performed in 26 patients were compared with angiographic (16 cases) and MR angiographic (10 cases) findings for signs of recanalization of the treated aneurysms.RESULTSThe GDCs were identified experimentally and in the patients as hyperechoic structures of the size and shape, and in the location of, the treated aneurysm in 41 of 43 cases. TCCD in accordance with angiography showed a lack of flow in 42 aneurysms and the presence of flow signal in one large aneurysm. Patency of the parent artery was shown in 40 aneurysms and in all branches. Follow-up TCCD showed the coils unchanged in 23 of 26 cases. In three large aneurysms, TCCD indicated recanalization and reappearance of a flow signal separate from the parent artery.CONCLUSIONTCCD is a reliable, noninvasive means to assess parent artery and major branch patency and to reveal a lack of hemodynamic compromise in the vicinity of aneurysms after endovascular therapy. On follow-up examinations, TCCD was able to detect signs of aneurysmal recanalization.     

Endovascular treatment of giant serpentine aneurysms

Giant serpentine aneurysms are fusiform partially thrombosed aneurysms with a separate outflow tract to normal distal cerebral vessels. Three patients with giant serpentine aneurysms of the anterior and middle cerebral arteries were treated with endovascular occlusion of the aneurysmal lumen with coils or glue after balloon test occlusion of the involved vessel. In all 3 patients, leptomeningeal collateral circulation was sufficient to prevent distal ischemia.     

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.     

Endovascular parent artery occlusion in large-giant or fusiform distal posterior cerebral artery aneurysms

Posterior cerebral artery aneurysms are amenable to deconstructive surgical treatment because of the rich collateral supply of the distal posterior cerebral artery. This report retrospectively analyses the outcome of endovascular parent artery occlusion for large or fusiform distal posterior cerebral artery aneurysms. Medical records and cerebral angiograms from two endovascular centres were analysed retrospectively. Eight patients with large or fusiform distal posterior cerebral artery (PCA) aneurysms were treated by endovascular occlusion of the segment of the PCA at the site of the aneurysm. Three of those were treated urgently after acute subarachnoid haemorrhage, the remainder had elective treatment. The clinical and angiographic outcomes in seven patients were assessed at 6 to 12 months. A single case of occipital infarction resulting in permanent homonymous hemianopia was the only permanent complication. Of the remaining patients, six made excellent recoveries and one was lost to follow-up. No recurrence or re-bleeding was noted. Endovascular parent artery occlusion may be an alternative to surgical parent artery occlusion in distal PCA aneurysms which are not convenient for selective endovascular treatment or surgical clipping.     

Endovascular occlusion of intracranial aneurysms with electrically detachable coils: correlation of aneurysm neck size and treatment results.

PURPOSETo devise a method to measure aneurysm neck size on angiographic films, and to correlate the sizes obtained with the extent of endovascular aneurysm occlusion, performed with electrically detachable coils.METHODSThe angiograms of 79 intracranial aneurysms treated by endovascular occlusion using electrically detachable coils were retrospectively analyzed. A method using the average reported caliber of the major intracranial vessels was applied to determine the aneurysm neck sizes on the diagnostic angiograms. The cases were divided into two groups according to neck size, 4 mm being the discriminative value for small and wide necks. The posttreatment angiogram of each case was analyzed to evaluate the degree of occlusion achieved by the technique.RESULTSNecks were successfully measured in 95% of the aneurysms. Complete aneurysm thrombosis was observed in 85% of the small-necked aneurysms and in 15% of the wide-necked aneurysms.CONCLUSIONSAccurate angiographic measurements of neck diameter can be obtained in most aneurysms. The size of an aneurysm neck correlates well with the results of the endovascular treatment. Small-necked aneurysms can be satisfactorily occluded with this technique. In wide-necked aneurysms this technique should be reserved for lesions having a high surgical risk.     

MR angiography with three-dimensional time-of-flight and targeted maximum-intensity-projection reconstructions in the follow-up of intracranial aneurysms embolized with Guglielmi detachable coils.

BACKGROUND AND PURPOSE: Intra-arterial contrast angiographies are generally used to confirm treatment results of endovascular neurointerventions such as aneurysm obliteration. We compared MR angiography with digital subtraction angiography (DSA) as a follow-up technique for the detection of aneurysmal remnant cavities and arterial patency in patients treated for intracranial aneurysms with Guglielmi detachable coils (GDCs). METHODS: In 20 consecutive patients, follow-up MR angiography and routine intra-arterial cerebral angiography were performed on the same day 1 to 7 months (mean, 4.5 months) after embolization with GDCs. MR angiographic data were postprocessed for subvolume maximum intensity projections centered on the region of the treated aneurysm. Hard copies of both imaging studies were interpreted independently in a blinded fashion to record and compare remnant cavities, location of residual flow, and adjacent arterial narrowing, using DSA as the standard of reference. The interpreters also established an occlusion grade for the treated aneurysms as evidenced on DSA images and evaluated MR angiograms for artifactual effects. RESULTS: Overall sensitivity and positive predictive value of MR angiography in revealing aneurysmal remnant cavities were both 90%. Specificity in ruling out a remnant cavity with MR angiography was 91%. One remnant cavity was missed by MR angiography, and in five patients, false adjacent arterial encroachments were reported. CONCLUSION: MR angiography may be useful in the long-term follow-up of successfully treated small and medium-sized aneurysms after concurrent primary verification of their occlusion with DSA.     

Procedural morbidity and mortality of elective coil treatment of unruptured intracranial aneurysms

BACKGROUND AND PURPOSE: To report morbidity, mortality, and angiographic results of elective coiling of unruptured intracranial aneurysms. METHODS: In a 10-year period, 176 unruptured aneurysms in 149 patients were electively treated with detachable coils. Seventy-nine aneurysms were additional to another ruptured aneurysm but were coiled more than 3 months after subarachnoid hemorrhage, 59 aneurysms were incidentally discovered, and 38 aneurysms presented with symptoms of mass effect. Mean size of the 176 unruptured aneurysms was 10.6 mm (median, 8 mm; range, 2-55 mm). One hundred thirteen aneurysms (64%) were small (<10 mm), 44 aneurysms (25%) were large (10-25 mm), and 19 aneurysms (11%) were giant (25-55 mm). Thirty wide-necked aneurysms (17%) were coiled with the aid of a supporting device. RESULTS: Procedural mortality of coiling was 1.3% (2 of 149; 95% confidence interval [CI], 0.7-5.1%), and morbidity was 2.6% (4 of 149, 95% CI, 0.8-7.0%). The 4 patients with permanent morbidity were independent (GOS 4). Initial aneurysm occlusion was complete (100%) in 132 aneurysms, nearly complete (90%-98%) in 36 aneurysms, and incomplete (60%-85%) in 8 aneurysms. Six-month follow-up angiography was available in 132 patients with 154 coiled aneurysms (87.5%); partial reopening occurred in 25, mainly large and giant aneurysms (16.2%). Additional coiling was performed in 22 aneurysms and additional parent vessel occlusion in 1 aneurysm. There were no complications of additional treatments. CONCLUSION: Elective coiling of unruptured intracranial aneurysms has low procedural mortality and morbidity. For the management of unruptured aneurysms, endovascular treatment should be considered.     

Endovascular therapy of idiopathic cavernous aneurysms over 11 years.

PURPOSEWe report our experience with 42 patients with 48 cavernous carotid aneurysms, of whom 32 were treated with endovascular techniques and 10 were managed conservatively.METHODSThe 48 aneurysms were divided into two subgroups by location: 23 were at the C-3 portion of the carotid artery (small, saccular aneurysms with an epidural, partly intracavernous location) and 25 originated at the C4-5 segment (large or giant often fusiform aneurysms with a true intracavernous location). Morphologic features in both groups correlated well with differences in clinical presentation and also influenced therapy. Sixteen of the 25 C4-5 aneurysms (all large or giant) were treated by balloon occlusion of the parent artery, four (with narrow necks) were treated with Guglielmi detachable coils (GDCs), and five were not treated (asymptomatic or minimally symptomatic). Twelve of 13 C-3 aneurysms were treated with GDCs. Ten C-3 aneurysms were not treated.RESULTSOphthalmoplegia resolved or improved in nine of 12 patients treated with parent artery occlusion. All aneurysms treated by carotid occlusion thrombosed. Twelve of the 17 aneurysms treated with GDCs were 100% filled by the coils, four were 80% to 95% filled, and one was only 40% filled. Seven of the 100% filled aneurysms remained completely occluded, two showed slight coil compaction, and in three, follow-up angiography was not available. Among the incompletely filled aneurysms, two remained unchanged, one showed progressive thrombosis, a fourth revealed coil compaction, and in one, follow-up angiography was not available. One thromboembolic stroke and three transient ischemic attacks occurred perioperatively, for a permanent morbidity of 3.5% and a transient morbidity of 9%. There was no mortality. Mean clinical follow-up was 33 months; mean angiographic follow-up of patients treated with GDCs was 11 months.CONCLUSIONSurgically difficult cavernous aneurysms can be obliterated by embolization with excellent clinical results. Detachable coils have become an important endovascular tool, especially for narrow-necked cavernous aneurysms of the C-3 segment, which can be protected against rupture in the subarachnoid space in most cases.     

Endovascular treatment of a ruptured giant serpentine aneurysm of the superior cerebellar artery in a patient with a Chiari II malformation

We present a case of a ruptured giant serpentine aneurysm (GSA) of the superior cerebellar artery in a patient with a Chiari II malformation. The fusiform aneurysm was successfully treated with endovascular parent artery occlusion of the GSA by using detachable coils.     

The endovascular approach in the management of patients with multiple intracranial aneurysms

To investigate the role of endovascular treatment we performed a retrospective study of our patients with multiple intracranial aneurysms seen in our institution between October 1992 and March 1995. This period was chosen to study a homogeneous group of patients since the appearance of controlled detachable coils, and to obtain the largest number of patients with angiographic follow-up of the aneurysms treated. We studied 53 patients with a total of 128 aneurysms, in 46 of whom we treated 67 aneurysms by the endovascular approach. Of these, 5 aneurysms in 3 patients were treated by occlusion of the parent vessel and 62 aneurysms in 43 patients with coils, 52 with Guglielmi detachable coils and 10 with mechanically detachable spirals. Complete occlusion was obtained in 58 aneurysms, and partial occlusion in 9. The therapy caused permanent neurological deficit in 3 cases (6.5 %), and there was 1 case of rebleeding (incomplete occlusion of the aneurysm). No deaths occurred. All aneurysms were treated in 29 of the 53 patients. Endovascular procedures were used for 16 patients (30 %), surgery was performed in 1 patient (2 %) and the two were combined in 12 (23 %). In 23 of 53 cases (43 %), unruptured aneurysms were left untreated, usually because of their small size. In 1 patient with unruptured aneurysms, the endovascular approach failed and the patient refused surgery. Received: 1 September 1995 Accepted: 12 August 1996     

Predictors of aneurysmal occlusion in the period immediately after endovascular treatment with detachable coils: a multivariate analysis.

BACKGROUND AND PURPOSEComplete intracranial aneurysmal occlusion by endovascular techniques is required for successful treatment and is presumably influenced by several parameters. The purpose of this study was to investigate whether operator experience and angiographic characteristics of intracranial aneurysms correspond to the degree of endovascular occlusion in the period immediately after treatment with Guglielmi detachable coils (GDCs).METHODSPre- and posttreatment angiograms of 72 patients undergoing GDC treatment were reviewed retrospectively. The following angiographic characteristics of the aneurysms were evaluated: largest diameter of the sac, volume, neck size, shape, type, cerebrovascular site, surroundings, and likely direction of aneurysmal inflow as judged by a score developed by measuring aneurysm/parent artery angulation. The chronological sequence in which the aneurysms were treated was used as a measure of operator experience. A chi2-test was used to identify parameters that correlated with outcomes of total (100%) or partial (<100%) occlusion. A multivariate analysis was used to determine the factors most predictive of aneurysmal occlusion at therapy.RESULTSParameters that correlated with the unsatisfactory result of partial occlusion were large aneurysmal diameter, volume, and neck size, more direct inflow (ie, increasingly obtuse aneurysm/parent artery angulation), and early chronological presentation in the series. The three factors most predictive of partial occlusion were large aneurysmal diameter, more direct inflow, and early chronological order of treatment.CONCLUSIONSeveral morphologic features of aneurysms were identified to help predict the immediate outcome of occlusion with GDCs. This study underscores the existence of a steep learning curve associated with GDC use in treating aneurysms and the importance of operator experience in achieving optimal therapeutic results.     

Coiling of very large or giant cerebral aneurysms: long-term clinical and serial angiographic results

BACKGROUND AND PURPOSE: Initial complete occlusion of very large or giant aneurysms often cannot be accomplished, and most will partially reopen over time. This study was performed to assess the clinical and angiographic outcome of patients with very large or giant cerebral aneurysms treated with detachable coils. METHODS: During 6 years, 29 patients with 31 very large or giant (20-55-mm) cerebral aneurysms were initially treated with detachable coils. Nineteen patients presented with subarachnoid hemorrhage (SAH), and eight patients had symptoms of mass effect. One patient had an incidental aneurysm, and one patient had an additional aneurysm. RESULTS: Twenty-three (79%) of 29 patients had a good clinical outcome at a median follow-up of 50 months. One of 19 patients presenting with SAH had repeat bleed (annual rebleeding rate, 1.45%). After initial coiling, seven of 31 aneurysms were incompletely occluded; this rate increased to 20 of 29 aneurysms at 6-month follow-up angiography. After 16 repeat coiling procedures in 13 aneurysms, 12 of 29 aneurysms in surviving patients were still incompletely occluded. After additional treatment other than coiling (parent-vessel occlusion and/or surgery) in eight aneurysms, three of 25 aneurysms in 24 surviving patients were incompletely occluded. Only 13 (42%) of 31 aneurysms had one coiling as a sole therapy. CONCLUSION: Coiling of very large or giant aneurysms can be considered. Long-term clinical outcomes were good in 79% of patients. The stability of the coil mesh over time was poor, requiring repeat coiling, surgery, and/or parent-vessel balloon occlusion in 58% of the aneurysms primarily treated with coils.     

MR angiography with ultrashort echo time in cerebral aneurysms treated with Guglielmi detachable coils.

We evaluated a time-of-flight three-dimensional MR angiographic sequence with an ultrashort echo time for its ability to characterize the perfusional state of cerebral aneurysms that had been treated with Guglielmi detachable coils and to depict adjacent cerebral arteries. The results were compared with findings at conventional MR angiography and digital subtraction angiography. Adjacent vessels were seen better in 36% of patients imaged with the new technique. Both MR angiographic methods detected residual cerebral aneurysmal perfusion with a tendency to overestimate the patent portion of the aneurysm.     

Cerebral Aneurysm Multicenter European Onyx (CAMEO) trial: results of a prospective observational study in 20 European centers

BACKGROUND AND PURPOSE: This study was designed to investigate the safety and efficacy of the Onyx liquid embolic system in treating a selected population of patients with intracranial aneurysms that presented difficulties for surgical or endovascular alternatives. METHODS: A prospective observational study was conducted in 20 European centers enrolling a consecutive series of 119 patients with 123 aneurysms judged suitable for Onyx treatment. The series consists of findings collected in 97 of 119 patients with 100 of 123 aneurysms, because one center declined to provide data to the study sponsor or allow outside audit. Clinical and angiographic outcomes were recorded at discharge, 3 months, and 12 months. All adverse events and re-treatments were recorded. Seventy-nine aneurysms were large or giant. RESULTS: Twelve-month follow-up angiography findings were available for 71 aneurysms. This angiographic follow-up showed complete occlusion in 56 (79%) aneurysms, subtotal occlusion in nine (13%), and incomplete occlusion in six (8%). Procedure- or device-related permanent neurologic morbidity at final follow-up was present in eight of 97 patients. Seven patients died: two deaths were procedure related; one, disease related; and four, unrelated causes. Seventy-five of the 82 patients alive and with follow-up at 12 months were at Rankin 2 or better status. Delayed occlusion of the parent vessel occurred in nine patients; delayed occlusion was asymptomatic in five and resulted in permanent neurologic deficit in two. CONCLUSION: In selected patients with aneurysms that are unsuitable for coil treatment or in whom previous treatment has failed to occlude the aneurysm, Onyx treatment offers an endovascular alternative. Aneurysm occlusion rates are superior to reported rates of coil occlusion, and treatment morbidity is comparable to that of published prospective data on endovascular results for this subgroup of patients.     

Endovascular treatment of bacterial intracranial aneurysms

We report three patients with bacterial intracranial aneurysms treated by the endovascular approach: two presented with sudden severe neurological deficits after a diagnosis of endocarditis; the other had suspected vasculitis. CT showed an intracerebral haematoma in all cases: angiography revealed bacterial aneurysms of distal branches of the middle cerebral artery in two cases and posterior cerebral artery in one. Because of the patients' condition and the location of the aneurysms, endovascular treatment was considered the fastest and safest treatment. Hyperselective catheterisation of the parent branch, close to the aneurysm, was performed with a microcatheter. A small amount of glue was injected to occlude both the aneurysm and a short segment of the diseased vessel. Follow-up angiography revealed occlusion of the aneurysm in all cases. One patient recovered completely; one recovered over some months, with neurological deficit due to the haematoma. The third patient suddenly worsened and died 9 days after treatment for a contralateral haematoma, due to rupture of a new bacterial aneurysm of the middle cerebral artery. Endovascular occlusion of the aneurysm and parent vessel may be an alternative to surgery in selected, severe cases of deep or distal bacterial intracranial aneurysms.