Clinical and angiographic outcome after Guglielmi detachable coil embolization of intracranial aneurysms

Background: Between July 1997 and April 2001, forty patients underwent Guglielmi detachable coil (GDC) embolization of intracranial aneurysms at Wellington Hospital. Methods: The clinical notes and imaging were reviewed retrospectively. Results: Complete initial occlusion was achieved in 28 patients (70%). Eleven patients (27.5%) had small residual neck (>90% occlusion) and one patient (2.5%) had substantial filling of the aneurysm. Follow up angiographic assessment was obtained in 28 patients (70%) of whom 24 patients (85.7%) had no recurrence or stable residual neck and four patients (14.3%) had recurrence or enlargement of the residual neck. Stable occlusion was achieved in 100% of small and medium sized aneurysms and 50% of large and giant aneurysms. Technical complications occurred in 10% including aneurysms perforated in two patients (5%) and presumed parent artery occlusion in another two (5%). Conclusions: The findings of the present study demonstrate the safety of GDC embolization. The initial clinical grade at presentation strongly predicted the clinical outcome. Although the number of patients in this study is small, there is evidence that the angiographic outcome is better for small and medium sized aneurysms. Our results are comparable to other published series.     

Follow-up angiography of intracranial aneurysms treated with endovascular placement of Guglielmi detachable coils

OBJECTIVE: The success of endovascular treatment of intracranial aneurysms with Guglielmi detachable coils (GDCs) is dependent on the long-term exclusion of the aneurysm from the circulation. We reviewed our experience with the long-term angiographic follow-up monitoring of aneurysms that had been treated with GDCs. METHODS: All patients whose aneurysms had been treated with GDCs between January 1995 and August 1999 and who subsequently underwent follow-up angiography at 6 months or more were included in this study. We reviewed all of the angiographic findings, to determine the percentage of aneurysm occlusion on the initial angiograms and on the last available follow-up angiograms. The categories of aneurysm occlusion used were 100%, >or=95%, and less than 95% occlusion. RESULTS: One hundred thirty patients with 141 aneurysms underwent 143 endovascular coiling procedures and subsequently underwent angiographic follow-up monitoring of 6 months or more. There were 102 female and 28 male patients. The mean angiographic follow-up period was 16.7 months (range, 6-62 mo). The initial rates of occlusion were 100% for 56 aneurysms (39%), >or=95% for 65 aneurysms (46%), and less than 95% for 22 aneurysms (15%). Recurrence of one aneurysm (1.8%) was observed. Of the 87 aneurysms that were incompletely occluded initially, there was progressive thrombosis in 40 (46%), stable neck remnants in 23 (26%), and enlargement of the residual neck in 24 (28%). The final occlusion rates, determined on the last available angiograms, were 100% for 88 aneurysms (61%), >or=95% for 31 aneurysms (22%), and less than 95% for 24 aneurysms (17%). No patient experienced repeat or new subarachnoid hemorrhage more than 6 months after the initial treatment. CONCLUSION: Late angiographic follow-up monitoring of aneurysms that have been treated with GDCs demonstrates the durability of the treatment. Aneurysms with large residual neck remnants were subjected to further treatment, whereas aneurysms with small residual neck remnants remain under observation.     

Predictors of angiographic changes in neck remnants of ruptured cerebral aneurysms treated with Guglielmi detachable coils

The angiographic changes in neck remnants of ruptured cerebral aneurysms treated with Guglielmi detachable coils (GDCs) were evaluated in the acute stage to analyze the important radiological and clinical factors. The clinical and radiological data of 37 patients with a residual neck of a ruptured cerebral aneurysm treated with GDC were reviewed. The angiographic changes on follow-up angiography were classified into three groups: recanalization of the neck remnant, progressive thrombosis, and unchanged. The effects of the clinical and angiographic findings, such as patient age, follow-up period, type of aneurysm (terminal type or side wall type), dome diameter, neck size, dome/neck ratio, obliteration rate, and volume embolization ratio were investigated. Recanalization of the neck remnant was observed in 18 of 37 cases, progressive thrombosis in nine, and unchanged in 10. The type of aneurysm, dome diameter, neck size, and volume embolization ratio were correlated with changes in the neck remnant. The aneurysm dome diameter and type of aneurysm were independent predictive factors for the recanalization of neck remnants on follow-up angiography. Dome diameter of less than 4.5 mm and volume embolization ratio of more than 31% in side wall aneurysms were likely to lead to progressive thrombosis.     

Postprocedure ischemic events after treatment of intracranial aneurysms with Guglielmi detachable coils

OBJECT: Ischemic stroke or transient ischemic attack (TIA) may occur after the treatment of intracranial aneurysms with Guglielmi detachable coils (GDCs). The purpose of the present study is to investigate possible risk factors for thromboembolic events and to determine their frequency and time course. METHODS: The records of 178 consecutive patients with 193 treated intracranial saccular aneurysms were reviewed. A total of 159 GDC procedures were performed to treat 143 aneurysms in 133 of those patients who were in good neurological condition, allowing clinical detection of postprocedure ischemic events (TIA or stroke). The association of clinical, anatomical, and pharmacological factors with intraprocedure intraarterial thrombus and with postprocedure ischemic events was investigated by using uni- and multivariate analyses. Thrombus protruding into the parent artery was noted during six of 159 GDC procedures, resulting in a clinical deficit in one patient. No factor was associated with intraprocedure intraarterial thrombus. Ten postprocedure ischemic events occurred in nine patients. Seven events occurred within 24 hours, and three events occurred between 24 hours and 58 days. Aneurysm diameter and protruding coils were significant independent predictors of postprocedure ischemic events in multivariate analysis (both p = 0.02). The actuarial risk of stroke was 3.8%. CONCLUSIONS: Larger aneurysm diameter and protruding loops of coils are associated with postprocedure ischemic events after GDC placement. It is unlikely that GDC-treated aneurysms retain thromboembolic potential beyond 2 months.     

Problems involved in endovascular embolization of intracranial aneurysms with three-dimensional Guglielmi detachable coils

We experienced nine cases of intracranial aneurysms which were treated with three-dimensional Guglielmi detachable coils (3D-GDC). 3D-GDC is useful in the construction of the initial frame for the embolization of aneurysms, but it also has certain disadvantages for achieving successful treatment. Nine patients with nine intracranial aneurysms were treated with 3D-GDC for initial framing from October, 1999 to September, 2000 at the National Cardio-Vascular Center, Japan. Angiographically complete and successful occlusion was performed in only three patients. Four patients developed parent artery stenosis due to small loops of the 3D-GDC protruding from the aneurysm. Two patients experienced incomplete occlusion because small loops of the 3D-GDC caused cells to form in the framing, and additional coils could not be inserted into some cells. 3D-GDC is useful as an initial framing coil, but we should be careful when placing additional coils into an aneurysm because we cannot predict the effect of the small loops of 3D-GDC on the embolization of aneurysms.     

Assessment of transcranial color-coded duplex sonography for the surveillance of intracranial aneurysms treated with Guglielmi detachable coils

OBJECTIVE: We sought to evaluate the sensitivity and specificity of transcranial color-coded duplex sonography (TCCS) and the effect of an ultrasonographic contrast agent in the long-term surveillance of intracranial aneurysms treated with Guglielmi detachable coils. METHODS: Forty-six studies were obtained in patients with intracranial aneurysms treated with coils. All studies were obtained within 2 months of surveillance digital subtraction angiograms, which was adopted as the standard for observing aneurysm refilling. For 34 of the studies, imaging was performed both before and after infusing an ultrasonographic contrast agent (Levovist). The remaining 12 studies were unenhanced. Aneurysms were described either as being fully occluded or as having residual flow. The degree of residual flow was quantified as minor, moderate, or extensive. The operator was blinded to the results of digital subtraction angiography during TCCS assessment. RESULTS: TCCS correctly identified 19 of 20 aneurysms with complete occlusion (sensitivity, 95%; specificity, 84%). TCCS also identified all 16 of the clinically relevant aneurysms with either moderate or extensive residual flow visualized on digital subtraction angiograms and 5 aneurysms only after contrast enhancement (sensitivity, 100%; specificity, 97%). The overall accuracy of TCCS in identifying clinically relevant aneurysms was 85% without contrast enhancement and 96% with contrast enhancement. CONCLUSION: Contrast-enhanced TCCS shows promise as a noninvasive imaging method for the surveillance of coiled intracranial aneurysms.     

Rupture of intracranial aneurysms during treatment with Guglielmi detachable coils: incidence, outcome, and risk factors

OBJECT: The aim of this study was to assess the incidence and outcome of procedure-related rupture of intracranial aneurysms in patients treated with Guglielmi detachable coils (GDCs) and to identify risk factors for this complication. METHODS: Procedure-related rupture occurred in seven of 264 treated aneurysms in 239 consecutive patients. Aneurysm size, history of previous subarachnoid hemorrhage (SAH) caused by the treated aneurysm, timing of treatment after SAH, and the use of a temporary occlusion balloon in the seven procedures in which rupture occurred were compared with the remaining 257 procedures, and these findings were correlated with data from 13 studies in the literature, in which results of 2030 aneurysm treatments were reported. CONCLUSIONS: Procedure-related rupture of intracranial aneurysms during GDC treatment occurs in 2.5% of cases and is responsible for 1% of treatment-related deaths. Risk factors are as follows: small aneurysm size, previous SAH, and probably the use of a temporary occlusion balloon.     

Impact of Guglielmi detachable coils on outcomes of patients with intracranial aneurysms treated by a multidisciplinary team at a single institution

OBJECT: The goal of this study was to investigate the impact of the introduction of the Guglielmi detachable coil (GDC) therapeutic option on the overall management outcome of intracranial aneurysms. The authors accomplished this by assessing patient morbidity and mortality, inflation-adjusted hospital charges, lengths of stay in the hospital and the intensive care unit (ICU), and treatment efficacy. METHODS: The authors conducted a retrospective analysis of consecutive cases of intracranial intradural aneurysms managed by a single multidisciplinary neurovascular team at a tertiary care, academic referral center during the 24 months preceding the introduction of the GDC procedure (Group I or pre-GDC era, 77 patients) and during the first 24 months after its introduction (Group II or GDC era, 99 patients). Treatment with GDCs was considered for cases of higher clinical grade or poor surgical risk, or in response to patient preference (27 [27%] of 99 patients in Group II). Host and lesion parameters in our cohort were validated against outcome parameters by using univariate and multivariate analyses. The pre-GDC and GDC subgroups of patients were comparable for major disease severity parameters (patient age, lesion location, clinical grade, and hemorrhage severity). There was no significant difference in clinical outcome at 6 months, infarcts on computerized tomography scanning, or aneurysm obliteration rates before and after introduction of GDC treatment. Decreasing trends in duration of hospital and ICU stay and in inflation-adjusted hospital charges occurred well before and thus were unrelated to the introduction of the GDC therapeutic option. CONCLUSIONS: The results of this study do not demonstrate any significant impact of integration of the GDC modality on clinical outcome, mortality, morbidity, or effectiveness of treatment. Ongoing improvements in hospital charges and length of hospital stay appeared unrelated to the introduction of the GDC option.     

Endovascular treatment of multiple intracranial aneurysms by using Guglielmi detachable coils

OBJECT: The purpose of this paper is to present the authors' experience with Guglielmi detachable coil (GDC) embolization of multiple intracranial aneurysms and to evaluate the results of this therapy in single-stage procedures. METHODS: Clinical and angiographic evaluations were performed in 38 consecutive patients with multiple intracranial aneurysms treated by GDC embolization between March 1990 and October 1997. Twenty-nine patients presented with subarachnoid hemorrhage (SAH), four with mass effect, and five were asymptomatic. These 38 patients harbored 101 aneurysms, 79 of which were treated with GDCs, 14 by surgical clipping, and eight were left untreated. Of the GDC-treated lesions, a complete endovascular occlusion was achieved in 55 aneurysms (70%), and 24 (30%) presented neck remnants. Twenty-five patients (66%) underwent GDC embolization of more than one aneurysm in the first session. Eighteen (86%) of 21 patients with acute SAH underwent treatment for all aneurysms within 3 days after admission (15 of 21 in one session). Follow-up angiographic studies in 30 patients demonstrated an unchanged or improved result in 94% of the aneurysms (59 lesions) and coil compaction in 6% (four lesions). The overall clinical outcome was excellent in 34 patients (89%), good in one (3%), fair in one (3%), and death in two (5%). CONCLUSIONS: Endovascular treatment of multiple intracranial aneurysms, regardless of their location, with GDCs was performed safely in one session, even during the acute phase of SAH. Treatment of all aneurysms in one session protected the patient from rebleeding and eliminated the risk of mistakenly treating only the unruptured aneurysms.     

Initial clinical experience with matrix detachable coils for the treatment of intracranial aneurysms

OBJECT: The Matrix detachable coil is a new bioactive, bioabsorbable coil used in the endovascular embolization of intracranial aneurysms. It has a platinum core covered with a bioactive, bioabsorbable polymer (polyglycolic acid/lactide). The authors report on their initial midterm clinical experience with the first-generation Matrix detachable coil. METHODS: One hundred twelve patients harboring 118 aneurysms were treated using Matrix coils. Forty-nine aneurysms (41.5%) were associated with acute subarachnoid hemorrhage (SAH). Twenty-four lesions (49%) were harbored by patients with Hunt and Hess Grade I, 11 (23.4%) by patients with Grade II, eight (16.3%) by those with Grade III, and six (12.2%) by those with Grade IV. Four aneurysms (3.4%) were harbored by patients who had presented with nonacute SAH. Sixty-five aneurysms (55%) were unruptured. Fifty-seven lesions (48.3%) were small with a small neck, 29 (24.6%) were small with a wide neck, 30 (25.4%) were large, and two (1.7%) were giant. All patients were followed up to obtain angiography and clinical outcome data. Technical complications occurred in six patients: two thromboembolic complications and four aneurysm perforations. Of these six patients, the status of two deteriorated because of aneurysm perforation and another two because of thrombus formation (morbidity 3.6%). There were five deaths--one due to rerupture after embolization. Angiography follow-up studies of 87 aneurysms were obtained. Seventy aneurysms demonstrated progressive occlusion or a stable neck (80.5%), and 17 had some degree of recanalization (19.5%). The aneurysms originally diagnosed as a neck remnant showed a 15% rate of recanalization. CONCLUSIONS: Matrix coils can be delivered into aneurysms with technical complications similar to those encountered using GDCs. Midterm anatomical outcomes to date have shown moderate improvement in the recanalization rate when compared with those realized using the GDC system. Because of the increased friction associated with the first-generation Matrix coil, the packing density in most aneurysms was less than that achieved with GDCs. Prolonged angiography follow-up evaluations are needed to document long-term efficacy.     

Mid-term outcome of intracranial aneurysms treated with HydroSoft coils compared to historical controls treated with bare platinum coils: a single-center experience

Background

HydroSoft (MicroVention, Aliso Viejo, CA), a hydrogel-platinum coil hybrid device, is one of various efforts to overcome recanalization of coiled intracranial aneurysms. The purpose of this study was to evaluate the efficacy and safety of the HydroSoft coils in patients with intracranial aneurysms, and to compare the 12-month outcomes with that of bare platinum coils.

Methods

Four-hundred one patients harboring 430 intracranial aneurysms underwent endovascular embolization with the HydroSoft coils. In the control group, 221 patients harboring 253 aneurysms underwent coil embolization with bare platinum coils. The authors compared the degree of occlusion of the aneurysms, packing attenuations, procedural-related complications, and 12-month follow-up results between the two groups.

Results

There were no significant differences of initial angiographic outcomes and procedure-related complications between the HydroSoft-coil group and the bare-coil group. Mean volumetric packing density of the HydroSoft-coil group was significantly higher than that of the bare platinum coil group (36.0?±?8.50 % versus 32.1?±?8.22 %, p?p?=?0.001, Fischer’s exact test). Multivariate Poisson regression revealed that coil embolization using the HydroSoft coil significantly reduces the retreatment rate of coiled aneurysms at 12-month follow-up (adjusted RR, 0.21; 95 % CI, 0.07-0.64; p?=?0.004).

Conclusion

Coil embolization using HydroSoft coils achieves higher volumetric packing density. Twelve-month follow-up data favors HydroSoft coils, with lower retreatment rates.     

Clinical experience with Matrix2 360° coils in the treatment of 100 intracranial aneurysms

BackgroundThe M2-360° is a recent class of aneurysm coil. This device combines the second generation of bioactive copolymer coating, which is intended to promote aneurysm fibrosis, with the “360°” design, which is meant to improve uniformity and density of packing. This study evaluates the safety and angiographic stability of these devices.MethodsThis was a retrospective review of 86 consecutive patients with 100 intracranial aneurysms that were treated using M2-360°s. Follow-up was done at 6 and 12 months.ResultsSeventy-eight aneurysms were coiled solely with M2-360°s, and 22 aneurysms were treated with a combination of coils. In mixed-coil cases, the average percentage of coil volume consisting of M2-360° coils was 78%. Procedure-related neurologic complications occurred in 6 patients (7%). Initial complete occlusion was obtained in 80 aneurysms. Of 76 aneurysms with 6-month angiographic follow-up, 4 (5.3%) revealed further occlusion, 54 (71.1%) were unchanged, and 18 (23.7%) showed recanalization. Of 38 aneurysms with 12-month follow-up, 1 (2.6%) revealed further occlusion, 23 (60.5%) were unchanged, and 14 (36.8%) showed recanalization. Six- and 12-month angiograms showed major recanalization (requiring further coiling) in 3.9% and 15.8% of cases, respectively.ConclusionsThe risk of complications with M2-360°–treated aneurysms is comparable with reports of other coils, indicating that M2-360°s are relatively safe. Although the initial occlusion rate is higher than that in other coiling series, recanalization rates were similar to those obtained with other coil designs. This study does not demonstrate an advantage with M2-360°s.     

Clinical experience with endovascular treatment of aneurysms using Guglielmi detachable coils

Guglielmi detachable coils (GDCs) provide an endovascular means for aneurysm treatment; however, their role has yet to be defined. This article reviews the most recent clinical series regarding efficacy, safety, and clinical outcomes in both the acute and nonacute setting. Successful treatment was possible in the majority of cases and included cases of complete aneurysm obliteration and with only a small neck remnant. Patients with a neck remnant often received additional treatments although some patients went on to complete obliteration without further treatment. Successful treatment provided protection from rebleeding in a follow-up period of 2 years. Success depended on operator experience as well as width of the aneurysm ostium. Recurrence and incomplete obliteration were more common with giant or large aneurysms and aneurysms with a wide base. Major procedurerelated complications predominantly resulted from intraprocedural rupture and thromboembolic events. These could both be treated via endovascular means at the time of the procedure. Thromboembolic events occurred more frequently with acutely ruptured aneurysms, especially aneurysms with a wide base. Vasospasm rates were not found to vary significantly from those found in surgical series when corrected for Fisher grouping. Morbidity and mortality rates as well as Glasgow outcome scores were at least as good as what would be expected from surgery during both the acute and nonacute setting. The papers reviewed indicate that the GDC provides safe and efficacious treatment for most berry aneurysms in both the acute and nonacute setting relative to surgical results.     

Endovascular occlusion of wide-necked aneurysms with a new intracranial microstent (Neuroform) and detachable coils

OBJECTIVE: The long-term durability of the endovascular occlusion of cerebral aneurysms is one of the major factors limiting the more widespread use of this technique. Long-term occlusion of wide-necked aneurysms has improved with new assistive devices that seem to improve aneurysm occlusion while protecting the parent vessel. We report the use of a new intracranial stent--the Neuroform microstent--in the treatment of patients with wide-necked cerebral aneurysms. METHODS: Patients identified as harboring wide-necked intracranial aneurysms were evaluated for stent-assisted coiling. After appropriate anticoagulation was performed, depending on whether the aneurysm was ruptured or unruptured, the Neuroform stent was delivered across the neck of the aneurysm and deployed with a coil pusher. After stent placement, standard coil occlusion of the aneurysm was achieved in the majority of cases. RESULTS: Fifty-six patients were identified as having wide-necked intracranial aneurysms suitable for stent-assisted coiling. A total of 49 aneurysms in 48 patients were treated with this procedure. In eight cases, stent deployment failed. Forty-one of the aneurysms were initially stented, followed by coil placement. Six aneurysms were stented only, and one aneurysm was initially coiled, followed by stent placement. There were five deaths (8.9%), one of which occurred secondary to a stroke after the procedure (1.8%). Four patients (7%) experienced thromboembolic events, three of which were considered to have been secondary to the procedure (5.3%). In addition, there were two femoral pseudoaneurysms. The overall complication rate was 10.7%. Five patients were available for follow-up angiographic evaluation, and their cases are discussed. CONCLUSION: Intracranial stenting may overcome important technical limitations in current endovascular therapy by improving the occlusion of wide-necked aneurysms while protecting the parent vessel.     

Endovascular treatment of intracranial aneurysms by using Guglielmi detachable coils in awake patients: safety and feasibility.

OBJECT: Embolization of intracranial aneurysms performed using Guglielmi detachable coils (GDCs) is performed with the patient in a state of general anesthesia at most centers. Such an approach does not allow intraprocedural evaluation of the patient's neurological status and carries additional risks associated with general anesthesia and mechanical ventilation. At the authors' institution, GDC embolization of intracranial aneurysms is performed in awake patients after administration of sedative and analgesic agents (midazolam, fentanyl, morphine, and/or hydromorphone). To determine the feasibility and safety of this approach, the authors have retrospectively reviewed their clinical experience. METHODS: The authors reviewed the medical records of all patients in whom GDC embolization for the treatment of intracranial aneurysms was undertaken between February 1, 1990 and October 31, 1999. Clinical presentation, medical comorbidities, anesthetic agents used, intraprocedural complications, and final procedural outcome were recorded for each patient. Guglielmi detachable coil embolization was attempted in the awake patient in 150 procedures. Among 92 procedures for unruptured aneurysms, 75 (82%) were completed without complications. Four procedures were completed with complications. Of the 92 procedures, 13 were aborted due to patient uncooperativeness (one patient), complications (three patients), morphological characteristics of the aneurysm or surrounding vessels that made embolization technically difficult (eight patients), or vasospasm (one patient). Among 58 procedures for ruptured aneurysms, the procedure was completed without complication in 48 cases (83%). The procedure was completed with complications in five cases and two patients required induction of general anesthesia during the procedure. Five procedures were aborted because morphological characteristics of the aneurysm or surrounding vessels made embolization technically difficult (two patients) or because of aneurysm rupture (two patients) or the appearance of a transient neurological deficit (one patient). CONCLUSIONS: Embolization of intracranial aneurysms performed using GDCs in the awake patient appears to be safe and feasible and allows intraprocedural evaluation of the patient. Potential advantages, including decreased cardiopulmonary morbidity rates, shorter hospital stay, and lower hospital costs, still require confirmation by a direct comparison with other anesthetic procedures.