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.     

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

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

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

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

Parent vessel Guglielmi detachable coil herniation during wide-necked aneurysm embolization: treatment with intracranial stent placement: two technical case reports

OBJECTIVE AND IMPORTANCE: Despite recent advances in technology, parent vessel coil herniation occasionally complicates successful Guglielmi detachable coil embolization, particularly in wide-necked aneurysms. We report endovascular stent deployment performed in two patients specifically to treat this complication. CLINICAL PRESENTATION: Two patients underwent Guglielmi detachable coil embolization of cavernous segment aneurysms. Both developed coil herniation into the internal carotid artery. In one patient, the herniation occurred during the initial procedure; in the other, it was discovered in a delayed fashion during a follow-up examination for ocular symptoms. INTERVENTION: In both patients, endovascular stent deployment was performed to isolate the herniated portion of the coil from the internal carotid lumen. Follow-up angiography at 6 months demonstrated no aneurysm recanalization and no stenosis of the parent internal carotid artery in the stented region in either patient. CONCLUSION: The use of intraluminal stents has been reported to be a helpful technical adjunct to the conventional endovascular treatment of aneurysms and balloon angioplasty. One additional indication for the use of this technology is sequestering herniated coils from the lumen of the parent artery to reduce potential embolic or occlusive sequelae.     

水解微弹簧圈栓塞治疗颅内动脉瘤(附10例报告)

目的 探讨水解微弹簧圈（microplex coilsystem ＆ hydrocoil embolicsystem．MCS ＆ HES）栓塞治疗颅内动脉瘤的疗效。方法 10例颅内动脉瘤患者，均在静脉全麻下股动脉穿刺行全脑血管造影，采用MCS＆HES水解微弹簧圈栓塞治疗。结果 8例患者动脉瘤完全栓塞，90％栓塞2例，其中1例结合Neuroform支架栓塞，1例予球囊辅助。随访1～16个月，部分栓塞的1例复发。结论 水解微弹簧圈栓塞治疗颅内动脉瘤效果确切，手术安全，并发症少，复发率低。     

Stent salvage for parent vessel coil herniation during intracranial aneurysm embolization

Background: Despite accumulated experience and improved understanding of the tools, endovascular treatment of cerebral aneurysms still has risks associated with the technique itself and with the specificity of the pathology treated. An important risk is parent vessel Guglielmi detachable coil herniation. Here we review and illustrate our experiences in using a stent to manage this complication. Methods: We reviewed our experiences in 142 intracranial aneurysm embolizations over a four and a half year period and identified 13 cases with intravascular stent deployment. Three cases were unique in using a stent for salvage of coil herniation into the parent vessel. Results: We reported these cases and reviewed the literature for the management of parent vessel coil herniation. Conclusion: Parent vessel coil herniation was an uncommon but important complication of endovascular coiling of intracranial aneurysm. Intravascular stent placement provided a tool to sequester herniated coils from the lumen of the parent artery to minimize thromboembolic complications and restore flow.     

Percutaneous intracranial stent placement for aneurysms

OBJECT: Intracranial stent placement combined with coil embolization is an emerging procedure for the treatment of intracranial aneurysms. The authors report their results using intracranial stents for the treatment of intracranial aneurysms. METHODS: A prospectively maintained database was reviewed to identify all patients with intracranial aneurysms that were treated with intracranial stents. Ten lesions, including eight broad-based aneurysms and two dissecting aneurysms, were treated in 10 patients. Four lesions were located in the cavernous segment of the internal carotid artery, two at the vertebrobasilar junction, two at the basilar trunk, one at the basilar apex, and one in the intracranial vertebral artery. Attempts were made to place stents in 13 patients, but in three the stents could not be delivered. Altogether, intracranial stents were placed in 10 patients for 10 lesions. Results that were determined to be satisfactory angiographically were achieved in all 10 lesions. Two patients suffered permanent neurological deterioration related to stent placement. In two patients, the aneurysm recurred after stent-assisted coil embolization. In one case of recurrence a second attempt at coil embolization was successful, whereas in the second case of recurrence parent vessel occlusion was required and well tolerated. CONCLUSIONS: Intracranial stents can be a useful addition to coil embolization by providing mechanical, hemodynamic, and visual benefits in the treatment of complex, broad-based aneurysms.     

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.     

Long-term Durability of Coil Embolization for Unruptured Aneurysm after Introduction of the Neck-bridge Stent: Comparison between the Pre-stent Era and the Stent Era

More complex aneurysms can be treated by coil embolization with neck-bridge stent assistance. However, concerns about postprocedural ischemic or hemorrhagic complications remain. In this study, we assessed the long-term durability after introduction of neck-bridge stent in the context of coil embolization for unruptured aneurysm by comparing re-treatment and neurological events between the pre-stent and stent eras. Unruptured aneurysms treated by coil embolization between April 2005 and May 2018 were analyzed retrospectively. We divided cases into two groups: the pre-stent era and the stent era. The cumulative rate of re-treatment and neurological events were assessed and compared. During the period, 177 aneurysms were treated in the pre-stent era and 354 aneurysms were treated in the stent era. The median follow-up was 55 months. In the stent era, the dome/neck (D/N) ratio was significantly lower (P <0.001) and the number of aneurysms located at the posterior circulation was higher (P <0.001). A stent was used in 31.92% of cases in the stent era. The cumulative rate of re-treatment was significantly higher in the pre-stent era than it was in the stent era in univariate and multivariate analyses (P = 0.008, P = 0.008, respectively). The cumulative rate of neurological events was not significantly different between the two groups. The re-treatment rate has been improved without increasing neurological complications after introduction of the neck-bridge stent.     

前循环动脉瘤的介入治疗（附40例分析）

目的 探讨前循环动脉瘤介入栓塞的临床疗效及并发症的处理.方法 对40例前循环动脉瘤患者采用介入栓塞治疗（42枚）,其中颈内动脉动脉瘤2例（2枚）,大脑中动脉动脉瘤18例（20枚）,前交通动脉瘤15例（15枚）,大脑中-后交通动脉动脉瘤5例（5枚）.结果 介入栓塞动脉瘤40例（42个）,栓塞率达100％的36个,95％的5个,90％的1个.随访共37例,3例失访.所有患者均复查头颅CT,原则上要求均复查DSA,但5例因经济原因不愿意复查DSA.32例患者均于出院后6个月复查DSA,2例复发,其中1例弹簧圈向瘤内移位,瘤颈部位复发;复查头颅CTA的患者中1例为90％栓塞,6个月后出现瘤颈少许显影,2例患者均再次使用电解可脱式铂金螺旋圈后达100％栓塞.术后恢复良好.结论 采用电解可脱式铂金螺旋圈治疗前循环动脉瘤效果好、并发症少、恢复快,近期效果显著.     

Ruptured intracranial dissecting aneurysms: management considerations with a focus on surgical and endovascular techniques to preserve arterial continuity

Background. The present retrospective analysis was undertaken to review an institutional experience with 13 intracranial dissecting aneurysms as source of subarachnoid haemorrhage (SAH) among a total of 585 ruptured intracranial aneurysms. Methods and results. In 6 patients the vertebral artery (VA) was affected, in 2 patients the basilar artery (BA), in 3 the internal carotid (ICA), in 1 the middle cerebral (MCA) and in 1 the postcommunicating (A2) segment of the anterior cerebral artery (ACA). Maintaining arterial patency was aimed at in all patients. Tangential clipping or circumferential wrapping were used as surgical methods. Endovascular stenting and/or coiling was applied in 2 instances. Four of the 6 VA dissecting aneurysms underwent surgical exploration between 1 and 22 days after haemorrhage. Two patients were in WFNS grade V and died subsequently with the aneurysms untreated, one after rehaemorrhage. In the patients with secured VA aneurysms the postoperative course was uncomplicated with the exception of additional caudal cranial nerve injury in 1 instance. Both BA aneurysms were initially treated by endovascular methods. In the first patient incomplete packing with Gugliemi detachable (GDC) coils was achieved. Follow-up angiography 6 months later showed growth and coil compaction and subsequent wrapping with Teflon fibres resulting in angiographic stabilization. The other BA aneurysm was treated by a combination of a coronary stent and GDC coils. The 3 dissecting ICA aneurysms were all explored surgically. In only 1 instance ICA continuity could be preserved by wrapping, in the other 2 cases a major portion of the vessel wall disintegrated upon removal of the surrounding clot. The only ACA dissecting aneurysm, on A2, was successfully treated with a Dacron cuff. In the single patient with a MCA aneurysm, a decision for conservative management was taken, because neither a surgical nor an endovascular solution was seen as a possibility that did not risk occlusion of lenticulostriate branches. The patient suffered a fatal rehaemorrhage 4 weeks later at her home. Conclusions. The reported experience suggests that in Western countries also dissecting aneurysms are an occasional source of SAH. The outcome in our conservatively managed patients confirms the poor prognosis of conservative management. Wrapping and endovascular stent based methods can achieve stabilization of the dissected artery without sacrificing the artery. Results of treatment appear to depend largely on the location of the dissecting aneurysm.     

Complementary management of partially occluded aneurysms by using surgical or endovascular therapy

OBJECT: The authors present a series of patients in whom partially occluded aneurysms were retreated using complementary surgical or endovascular therapy. METHODS: During a period of 18 months, 301 patients with intracranial aneurysms were treated using either clip application (171 patients) or endovascular embolization with Guglielmi Detachable Coils ([GDCs] 130 patients). Routine posttreatment angiography studies revealed residual aneurysms in 21 of these patients, nine of whom were retreated using an endovascular or surgical method, with a mean treatment latency of 1.2 months. Four patients underwent primary surgical clip application, whereas five patients experienced GDC packing first. Among patients in the surgical group, the residual aneurysm neck was small and total elimination of the aneurysm was achieved by packing in GDCs. In patients in the endovascular group the authors incompletely packed the aneurysm because of its wide neck or fusiform component in two patients, perforation of a very small aneurysm in one patient, and coil dislocation in another patient. Typical coil compaction occurred in one case. Complete clip application was achieved in all patients. There was no complication in any patient due to the second treatment modality. Final outcome was excellent or good in six and fair in three. CONCLUSIONS: Following clip application or endovascular embolization of intracranial aneurysms, the use of complementary surgical or endovascular management is successful and associated with low morbidity.     

电解可脱性弹簧圈血管内栓塞颅内动脉瘤的技术及并发症防治

目的总结以电解可脱性弹簧圈(GDC)血管内栓塞治疗颅内动脉瘤的技术要点、并发症及其防治经验。方法采用GDC对168例颅内动脉瘤患者进行动脉瘤囊内栓塞。结果成功栓塞168个动脉瘤,其中100%闭塞的144个,95%闭塞的14个,90%闭塞的10个;全组6例死亡,死亡率3.6%。术中并发动脉瘤破裂3例,脑血管痉挛9例,脑梗死2例,术后弹簧圈末端逸出2例;3例复发者经二次补充GDC栓塞而治愈。随访5~54个月,全组术后均无再出血。结论动脉瘤的血管内治疗应根据病情进行个体化设计,并采用与之相应的栓塞技术才能最大限度的提高动脉瘤栓塞的治愈率、降低并发症。     

Preliminary experience using the Neuroform stent for the treatment of cerebral aneurysms

INTRODUCTION: The Neuroform microstent-a flexible, self-expandable, microcatheter-delivered, nitinol stent designed for the treatment of cerebral aneurysms-was recently approved for use in patients. We present the results of our initial experience in using the Neuroform stent to treat patients with cerebral aneurysms, with an emphasis on potential applications, technical aspects of deployment, and associated intra- and periprocedural complications. METHODS: The records of all patients treated with the Neuroform stent were entered prospectively into a database. We assessed the clinical history, indications for stent use, aneurysm dimensions, and technical details of the procedures, including any difficulties with stent placement and/or deployment, degree of aneurysm occlusion, and complications. RESULTS: During a 5-month period, 19 patients with 22 aneurysms were treated with the Neuroform stent. Twenty-five stents were deployed. Five patients had multiple stents placed. Five patients had ruptured aneurysms at the time of treatment. The indications for use were broad-necked aneurysms (n = 13; average neck length, 5.1 mm; average aneurysm size, 9 mm), fusiform or dissecting aneurysms (n = 3), salvage and/or bailout (n = 1), and giant aneurysms (n = 2). Technical problems included difficulty in deploying the stent (n = 6), inability to deploy the stent (n = 1), stent displacement (n = 2), inadvertent stent deployment (n = 1), and coil stretching (n = 1). Twenty-one of the 22 aneurysms were treated. Four aneurysms were stented without additional treatment, and 17 aneurysms were stented and coiled. Of the coiled aneurysms, complete or nearly complete (more than 95%) occlusion was achieved in 6 aneurysms, and partial occlusion was achieved in 11. Two clinically significant adverse events occurred, both of which were sequelae of periprocedural thromboembolic complications. One patient died after thrombolysis was attempted. The other patient made an excellent functional recovery after undergoing successful thrombolysis of a thrombosed basilar artery stent. CONCLUSION: The Neuroform stent is a useful device for the treatment of patients with aneurysms that may not otherwise be amenable to endovascular therapy. In the majority of cases, the stent can be deployed accurately, even within the most tortuous segments of the cerebral vasculature. Although delivery and deployment may be technically challenging, clinically significant complications are uncommon.     

Single-center experience with the Neuroform stent for endovascular treatment of wide-necked intracranial aneurysms

Background

Stent-assisted coiling is an accepted endovascular treatment (EVT) for wide-necked intracranial aneurysms. The Neuroform stent (Target Therapeutics, Fremont, Calif) is a flexible nitinol self-expandable stent that was designed to potentially overcome the limitations of balloon expandable coronary stents in the intracranial circulation. The aim of this study was to reenforce the use of this stent for EVT of wide-necked cerebral aneurysms.

Methods

Between March 2005 and March 2008, 24 patients harboring wide-necked cerebral aneurysms were treated with stent reconstruction of the aneurysm neck. Inclusion criteria restricted the group to adult patients with wide-necked intracranial aneurysms (ruptured and unruptured lesions). Immediate postprocedure angiography studies were performed to determine successful coil occlusion of the aneurysm as well as patency of the parent vessel. We assessed the clinical history, aneurysm dimensions, and technical detail of the procedures, including any difficulties with stent placement and deployment, degree of aneurysm occlusion, and complications. Clinical outcome was assessed with the Glasgow Outcome Scale (GOS).

Results

The stent was easily navigated and precisely positioned in 24 of 26 cases. However, technical difficulties occurred in 9 patients, including difficulties in crossing the stents interstice in 6 cases, inadvertent stent delivery (n = 1), and incapacity of stent delivery (n = 1) and incapacity of crossing the neck (n = 1). These latter 2 cases were classified as failures of the stent-assisted technique. A single procedural complication occurred, involving transient nonocclusive intrastent thrombus formation, which was treated uneventfully with abciximab. Seventeen patients experienced excellent clinical outcomes (GOS 5), with good outcomes (GOS 4) in 5 patients and a poor outcome (GOS 3) in 2 patients. There were no treatment-related deaths or neurologic complications (mean clinical follow-up, 12 months). Angiographic results consisted of 17 complete occlusions, 4 neck remnants, and 3 incomplete occlusions.

Conclusions

The Neuroform stent is very useful for EVT of wide-necked intracranial aneurysms because it is easy to navigate and to deploy accurately. In most cases, the stent can be deployed precisely, even in very tortuous carotid siphons. Although in some cases delivery and deployment was challenging, clinically significant complications were not observed.     

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.     

颅内外动脉狭窄合并颅内动脉瘤同期血管内治疗的效果分析

目的探讨同期治疗颅内外动脉狭窄合并颅内动脉瘤的策略及临床效果。方法回顾性分析2013年4月至2018年9月于北京大学第一医院神经外科行同期血管内治疗的15例颅内外动脉狭窄合并颅内动脉瘤患者的临床资料。男性6例,女性9例,年龄(63.9±9.1)岁(范围:43~79岁);动脉狭窄部位共15处,狭窄程度为75%~95%,其中前循环8处,后循环7处;动脉瘤共17个,最大径(5.3±1.2)mm(范围:3~7 mm),其中前循环动脉瘤11个、后循环动脉瘤6个。患者均行同期动脉狭窄支架成形及动脉瘤栓塞术治疗。记录患者围手术期及术后临床症状、影像学资料及并发症情况。结果15处动脉狭窄均成功置入支架(残余狭窄<30%);17个动脉瘤中,10个行单纯弹簧圈栓塞,7个行支架辅助弹簧圈栓塞,均完全栓塞。围手术期1例患者出现轻微脑梗死症状,其余未发生手术相关并发症。术后随访(43.8±8.2)个月(范围:24~85个月),患者术后6~12个月均复查数字减影血管造影,其中2例出现无症状性支架内再狭窄,所有动脉瘤未见复发。截至末次随访时,患者均未出现颅内出血、缺血性卒中等相关症状。结论颅内外动脉狭窄合并颅内动脉瘤应根据血管狭窄的部位、程度及动脉瘤的大小、形态、位置、数量及两者的位置关系等因素综合分析,制定个体化的治疗策略,给予同期血管内治疗可能是一种安全、有效的治疗方法。     

支架植入术联合弹簧圈栓塞治疗颅内复杂动脉瘤

目的探讨应用新型颅内支架植入联合弹簧圈栓塞术治疗颅内复杂动脉瘤的疗效。方法对26例30个颅内复杂动脉瘤行支架植入术弹簧圈栓塞术,术后6～24个月进行随访。结果术后即刻疗效：24个复杂动脉瘤完全栓塞,4个次全栓塞（栓塞95%以上）,2个不完全栓塞;所有支架位置满意,载瘤动脉通畅。随访2例动脉瘤复发,未见支架移位、塌陷、狭窄,载瘤动脉通畅、光滑。结论颅内支架植入联合弹簧圈栓塞术治疗颅内复杂动脉瘤安全有效;应根据动脉瘤的具体情况来选择具体技术。     

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.     

An aneurysm located at a fenestration of the vertebrobasilar junction successfully treated with Guglielmi detachable coils

A 35-year-old female developed a subarachnoid hemorrhage from an aneurysm located at the fenestration of the vertebrobasilar (VB) junction. The patient was treated with Guglielmi detachable coils (GDCs). The aneurysm was successfully occluded using 8 coils despite the fact that 2 major complications occurred during the procedure: perforation of the aneurysm with a coil and thrombosis of the parent artery. The GDC that had perforated the aneurysm was left and remained partially in the subarachnoid space, and embolization was continued. The thrombus was mechanically crushed and dissolved. Forty days postoperatively, the patient was discharged home with minimal sequelae. VB junction fenestration is present in 35.5%-70% of VB junction aneurysms, but fenestration of the VB junction is sometimes overlooked on selective angiography. Careful pre-operative assessment is needed for aneurysms at the VB junction. The international subarachnoid aneurysm trial (ISAT) found that endovascular treatment was superior to surgery in the management of ruptured aneurysms. Nevertheless, thromboembolic complications and perforation are associated with coil embolization. Thus, care should be taken to avoid these complications, and it is indispensable to have appropriate treatment options immediately available to deal with them should they occur.