Guglielmi detachable coil embolization for ruptured lower-midbasilar trunk aneurysms – a report of five cases

Detachable coil embolization currently plays an essential role for patients with ruptured basilar artery aneurysms, even though it may have an unfavorable outcome and there may be some technical problems of embolization. We describe Guglielmi detachable coil (GDC) embolization for five ruptured lower-mid basilar trunk aneurysms, using a variety of techniques. The patients' ages ranged from 61 to 78 years; Hunt and Kosnik grade was distributed from 2 to 4, and three patients were found to have fenestrations of the lower basilar arteries. All patients underwent aneurysmal embolization at the subacute or chronic stage. The transfemoral route was used in three patients – one of whom, with a wide-necked aneurysm, was treated by the balloon remodeling technique. The transbrachial approach was chosen for the fourth patient, while vertebral artery origin exposure followed by a direct puncture was achieved in the fifth. All patients were assessed with 80–100 % aneurysmal obliteration. No patient re-bled after the embolization. Small cerebellar infarction, possibly due to embolism from the obliterated aneurysmal sac, occurred 11 days after the treatment. Of the five patients, four achieved a good recovery, and one became severely disabled. Ruptured basilar trunk aneurysms can be successfully treated with GDC embolization. In addition to the routine transfemoral route, the transbrachial route, direct vertebral artery puncture, and balloon remodeling technique are also useful for the embolization of this location of aneurysm. Received: 16 November 2000/Accepted: 13 March 2001     

Aneurysms of the vertebrobasilar junction: incidence, clinical presentation, and outcome of endovascular treatment

BACKGROUND AND PURPOSE: The aim of this retrospective study was to report the incidence, clinical presentation, and midterm clinical and imaging results of endovascular treatment of 10 aneurysms of the vertebrobasilar junction. MATERIALS AND METHODS: Between January 1995 and January 2007, 2112 aneurysms were treated in our institution. Ten aneurysms in 10 patients were located on the vertebrobasilar junction and 7 aneurysms (70%) were associated with proximal basilar fenestration. There were 5 men and 5 women, ranging from 29 to 75 years of age. Nine aneurysms presented with subarachnoid hemorrhage, and one was a giant partially thrombosed aneurysm with mass effect on the brain stem. RESULTS: Nine ruptured aneurysms were treated by primary coil occlusion. One giant unruptured aneurysm was initially treated with bilateral vertebral artery occlusion, 2 months later followed by selective coil occlusion of the remaining aneurysm lumen via the posterior communicating artery. At imaging follow-up of 6-30 months in 7 patients, all aneurysms were adequately occluded. In 2 patients, the vertebrobasilar junction and distal vertebral arteries (including the aneurysm) thrombosed completely on follow-up without clinical sequelae. CONCLUSION: Vertebrobasilar junction aneurysms are rare, with an incidence of 0.5% of treated aneurysms at our institution. Vertebrobasilar junction aneurysms are frequently associated with proximal basilar fenestration. Most patients present with subarachnoid hemorrhage. Endovascular treatment is effective and safe in excluding the aneurysms from the circulation.     

Endovascular treatment of basilar and ICA termination aneurysms: effects of the use of HydroCoils on treatment stability in a subgroup of patients prone to a higher recurrence rate

PURPOSE: The aim of this study was to evaluate the stability of occlusion of terminal bifurcation aneurysms after embolization with hydrogel-coated coils. METHODS: Of 35 bifurcation aneurysms, 34 were treated with hydrogel-coated coils in combination with platinum coils, and 1 was treated with hydrogel-coated coils only. Aneurysms were located at the basilar tip in 17 patients, and the internal carotid artery (ICA) bifurcation in 18 patients. The patient population consisted of 20 women and 15 men with ages ranging from 21 to 65 years. The aneurysm was found in 16 patients on presentation for subarachnoid hemorrhage, and in 19 patients the finding was incidental. Of the 35 aneurysms, 25 were small, 9 were large and 1 was giant. The giant aneurysm was located at the basilar tip and showed partial thrombosis. All except two basilar tip aneurysms were treated with balloon assistance. The remaining two basilar tip aneurysms were embolized with the assistance of an aneurysmal neck bridge device. RESULTS: The mean percentage occluded aneurysm volume for all devices was in the range 34-100%. Follow-up angiograms were obtained at 1 year in 6 patients, 2 years in 11 patients, and 3 years in 18 patients. Angiograms obtained immediately after embolization demonstrated a Raymond class 1 occlusion in 29 patients (82.9%) and a Raymond class 2 occlusion in 6 patients (17.1%). In four of these six patients follow-up angiograms demonstrated regrowth with resultant Raymond class 3 occlusion. In the other two patients, Raymond class 2 occlusion remained stable on follow-up angiograms. In patients who had a Raymond class 1 occlusion on the angiogram obtained immediately after embolization, no regrowth was seen on the follow-up angiograms. The overall recanalization rate was 11.4% (three large, one giant) at 6 months. Retreatment was not considered in three of these patients and they were to be followed; the other patient was retreated. CONCLUSION: Our initial procedural data demonstrate that higher volumetric occlusion was achieved with hydrogel-coated coils and the long-term follow-up results showed a favorably low recanalization rates among the terminal bifurcation aneurysms.     

Balloon-assisted coil embolization of wide-necked aneurysms of the internal carotid artery: medium-term angiographic and clinical follow-up in 22 patients

BACKGROUND AND PURPOSE: The management of broad-necked cerebral aneurysms by Guglielmi detachable coils (GDCs) is technically challenging owing to a variety of factors, including difficulty in defining the aneurysm/parent vessel interface angiographically and problems in achieving complete occlusion, later predisposing the aneurysm to regrowth/recanalization. We sought to determine whether the use of intraluminal balloons to remodel the parent vessel/aneurysm interface during GDC embolization would provide a safe means of improving the efficacy of endovascular treatment of broad-necked aneurysms. METHODS: Twenty-two saccular aneurysms of the internal carotid artery were treated with GDCs by using balloon remodeling techniques. All aneurysms were characterized by wide necks or were small with unfavorable neck/fundus ratios and required balloon assistance for coil embolization. Patients were followed up both clinically and angiographically. RESULTS: By using a microcatheter-mounted nondetachable balloon to provide a temporary barrier across the aneurysmal neck, we were able to deploy GDCs safely within a variety of aneurysms. Among the 22 patients treated, aneurysmal occlusion on follow-up angiography (mean, 19 months) was found in 17 of 20 patients (two patients died and no follow-up studies were available). Observed or suspected thromboembolic events occurred in four of 22 patients, resulting in one permanent deficit. Twenty of the 22 patients had good to excellent clinical outcomes. CONCLUSION: Although balloon-assisted coiling of cerebral aneurysms requires manipulation of a second microcatheter and an inflatable balloon, increasing its technical complexity, we believe that this method has utility in treating broad-necked aneurysms and small aneurysms that are otherwise suboptimally managed by conventional GDC deployment.     

Primary treatment of ruptured blood blister-like aneurysms with stent-assisted coil embolization: report of two cases

Blood blister-like aneurysms (BBAs) are among the most hazardous cerebrovascular aneurysms to treat; microsurgical treatment of these small, wide-necked, and exceptionally fragile aneurysms place patients at significant risk of morbidity or mortality. We report two cases of ruptured BBAs attempted to be treated for the first time with stent-assisted coil embolization solely and review the current literature on treatment options. Our patients underwent stent-assisted coil embolization of the aneurysms in the acute stage of subarachnoid hemorrhage (SAH). One patient was successfully treated without procedure-related complications. The other patient died after surgical internal carotid artery (ICA) occlusion, carried out after intraoperative rerupture of the aneurysm during the endovascular treatment. In the successful case, 8-month and 19-month follow-up angiograms demonstrated incomplete (>90%) occlusion with residual filling of the aneurysm neck, which did not need additional coil embolization. Even though stent-assisted coil embolization of ruptured BBAs in the acute stage appears to be a technically feasible treatment option, the present stent-related endovascular technology has potentially hazardous drawbacks.     

Neurovascular Neck-Bridging device in treatment of wide-necked splenic artery aneurysms

We report the cases of 2 female patients, 45-year-old and 49-year-old, affected by wide-necked splenic aneurysm. We embolized the 2 lesions assisted by a new scaffolding neurovascular device, the Cascade Net, an innovative –occlusive remodeling device for temporary bridging in endovascular coil embolization of intracranial aneurysms. Visceral artery aneurysms are rare with an estimated prevalence of 2%-3% in imaging series and up to 10% in autopsy series. Most are asymptomatic and their diagnosis is occasionally. Aneurysm spontaneous rupture has been demonstrated in 2%-10% of cases and it can result in significant morbidity and mortality. Conservative management and open repair were the preferred treatment options for many years. Endovascular repair has been increasingly used since 2000; and the most widespread method of treatment has been coiling. Because of tortuosity of the parent artery, wide neck, and unfavorable locations at arterial branch points, 6% of Visceral and renal artery aneurysms VRAA cannot be adequately treated by simple coiling and requires parent artery remodeling through balloon occlusion, stent placement or parent vessel occlusion, leading to, in the latter situation, a compromised organ perfusion. Increasingly, balloon-assisted, and stent-assisted approaches as well as novel scaffolding neurovascular devices such as the Cascade Net, have allowed wide necked aneurysms to be bridged during endovascular treatment with smaller delivery system, averting parent artery occlusion and risk of distal embolization.     

Endovascular treatment of posterior cerebral artery aneurysms using detachable coils

Introduction Aneurysms of the posterior cerebral artery (PCA) are rare, and most of the studies reported in the literature in which the endovascular approach was applied were carried out on a limited number of patients with PCA aneurysms. We retrospectively reviewed our cases of PCA aneurysms – at various locations and of differing shapes – that received endovascular treatment and evaluated the treatment outcome. Methods From January 1996 to December 2006, 13 patients (eight females and five males) with 17 PCA aneurysms (nine fusiform and eight saccular) were treated using the endovascular approach. The age of the patients ranged from 20 to 67 years, with a mean age of 44 years. Of the 13 patients, ten presented with intracranial hemorrhage, and one patient, with a large P2 aneurysm, presented with trigeminal neuralgia; the aneurysms were asymptomatic in the remaining two patients. Results All 13 patients were successfully treated, with only one procedure-related symptomatic complication. Seven patients were treated by occlusion of the aneurysm and parent artery together; five patients, by selective embolization of the aneurysm; one patient, by partial coiling. Although infarctions were found in two patients treated with selective embolization and in three patients treated with parent artery occlusion, only one patient with a ruptured P2 aneurysm treated with parent artery occlusion developed transient amnesia as an ischemic symptom. Conclusion Posterior cerebral artery aneurysms can be treated safely with either occlusion of the aneurysm together with the PCA or with a selective coil embolization. Infarctions may occur after endovascular treatment, but they are rarely the cause of a disabling symptom.     

Endovascular treatment of wide-necked aneurysms by using two microcatheters: techniques and outcomes in 25 patients

BACKGROUND AND PURPOSE: The endovascular occlusion of aneurysms with unfavorable configurations such as a broad neck and an important branch from the fundus remains a technical challenge. The purpose of this study was to evaluate the radiologic and clinical results of complicated aneurysm treatment by using two microcatheters. METHODS: Twenty-five aneurysms in 25 patients were treated by using two microcatheters, from August 2001 to February 2004. Fourteen patients presented with a subarachnoid hemorrhage (SAH) and 11 had unruptured aneurysms. The aneurysms were of the basilar top (7), middle cerebral artery bifurcation (4), posterior communicating artery (4), anterior communicating artery (3), superior cerebellar artery (2), ophthalmic artery (2), and one aneurysm of each of cavernous internal carotid artery (ICA), dorsal ICA, and midbasilar artery. In 16 aneurysms (64%), the width of the aneurysm was the same or longer than the height. In 19 (76%), important branches arose from the aneurysm base, and some were even incorporated with the aneurysm fundus. The mean dome (height)-to-neck ratio was 1.23 +/- 0.37 (range, 0.65-2.33), and this was greater than or equal to 1.0 in 19 aneurysms (76%). RESULTS: All aneurysms were successfully embolized. Immediate postembolization angiography showed no residual contrast filling in eight aneurysms (32%), and some residual contrast filling in 16. The aneurysm remnants, however, were intentionally left to preserve important branches in 12 of the 16 aneurysms with incomplete occlusion. Two complications occurred, including one thromboembolic and one coil protrusion, but they were successfully resolved and produced no clinical symptoms. All patients except one showed excellent clinical outcomes. One patient revealed moderate cognitive dysfunction. During the follow-up period, no new bleeding occurred. CONCLUSION: Our experience with 25 cerebral aneurysm patients shows that the technique of using two microcatheters is feasible and safe for coil embolization of aneurysms with unfavorable configurations. Although the lack of angiographic follow-up prevents us from drawing conclusions about its effectiveness as compared with other techniques such as stent placement and balloon-neck protection, we believe that this technique offers a reliable alternative for endovascular therapy of complicated aneurysms.     

Coil Embolization of Pancreaticoduodenal Artery Aneurysms Associated with Celiac Artery Stenosis: Report of Three Cases

Aneurysms of the pancreaticoduodenal artery are rare. Degeneration of pancreaticoduodenal arcade vessels due to these aneurysms is associated with celiac artery stenosis or occlusion. Untreated lesions enlarge progressively and may rupture spontaneously. As the location of aneurysms of pancreaticoduodenal arcade vessels renders their surgical extirpation a challenge, we examined whether endovascular techniques offer a treatment alternative. We report on 3 patients with aneurysms of the pancreaticoduodenal arcade vessels and concomitant celiac artery stenosis/occlusion due to compression by the median arcuate ligament or chronic pancreatitis. All patients were treated by percutaneous coil embolization of the aneurysm. The aneurysmal sac was successfully excluded and the native circulation was preserved. Endovascular surgery can be used to treat these aneurysms safely and permits retention of the native circulation.     

Imaging detection of cerebral artery fenestrations and their clinical correlation with cerebrovascular diseases

ObjectivesCerebral artery fenestrations detected incidentally during computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) are reported to be associated with aneurysmal dilatation, which may cause cerebrovascular diseases, arteriovenous malformations, or, rarely, ischemic symptoms.MethodsWe retrospectively analyzed CTA and MRA of patients with cerebral artery fenestration examined between January 2014 and December 2017. The location, shape, and other associated vascular diseases were described.ResultsTwo hundred eleven cerebral artery fenestrations were found in 208 patients for a detection rate of 1.13% (208/18,360). Basilar artery fenestrations were most common, accounting for 50.2% (106/211). The fenestration was <5 mm in 115 patients (54.5%), 5–10 mm in 63 (29.9%), and ≥10 mm in 33 (15.6%). Forty-one patients had other vascular malformations, including 29 aneurysms. Except for one aneurysm, which was at the site of the fenestration, all other aneurysms were separate from the fenestrations. 26 patients had cerebral infarctions; among them, 11 had cerebral infarctions in the blood supply area of the arterial fenestration.ConclusionsCerebral artery fenestration is an uncommon finding at cerebral imaging, but mostly affects the basilar artery. Cerebral artery fenestrations could be associated with cerebrovascular diseases and malformations, but the present study could not evaluate the cause-to-effect relationship.     

Endovascular treatment of giant or very large intracranial aneurysms with different modalities: an analysis of 20 cases

Introduction The aim of this retrospective study was to evaluate the clinical efficacy and limitations of different endovascular modalities in the treatment of very large and giant intracranial aneurysms. Methods A group of 20 patients with very large and giant intracranial aneurysms treated by endovascular approaches were retrospectively analyzed. Of the 20 patients, 9 had been treated by parent artery occlusion, 8 by coil embolization, and 3 with an intracranial covered stent. Two recurrent aneurysms initially treated with coil embolization were retreated with an intracranial covered stent. Patients were followed for 9–83 months after the procedure. Results Endovascular treatment was technically feasible in all 20 patients. One patient died 7 days after the procedure from rebleeding caused by incomplete aneurysmal occlusion. Immediate postprocedural angiograms showed that complete occlusion was achieved in 11 aneurysms, subtotal occlusion in 7, and incomplete occlusion in 2. The final angiographic results in the other 19 surviving patients confirmed complete occlusion of 15 aneurysms, subtotal occlusion in 3, and incomplete occlusion in 1. Clinical evaluations performed at the final follow-up visit showed an excellent outcome in 11 patients and a good outcome in 8. Conclusion Endovascular treatment of giant intracranial aneurysms with coil embolization is often associated with a low complete occlusion rate and a high recanalization rate, and parent artery occlusion remains a practical option in selected patients. Based on our limited experience, the use of an intracranial covered stent appears to be a relatively simple and safe procedure for occluding very large and giant aneurysms while still maintaining the patency of the parent artery.     

创伤性颈动脉假性动脉瘤病因及诊治探讨

目的对创伤性颈动脉假性动脉瘤病因及血管内栓塞治疗进行探讨。方法对26例患者行数字减影血管造影术(DSA)检查明确诊断，同时行血管内栓塞治疗。5例采用微弹簧圈栓塞，19例采用可脱性球囊行假性动脉瘤开口处颈动脉闭塞，2例采用10％α-氰基丙烯酸正丁酯(NBCA)脑膜中动脉供支栓塞。结果20例栓塞后鼻腔出血停止，其中1例视力下降栓塞后1周视力好转。3例头痛3周后消失。3例颈部包块杂音消失、质软、无搏动。1例死亡。随访6-12个月无一例再次出血，颈部包块消失。结论血管内栓塞是治疗创伤性颈动脉假性动脉瘤有效的方法。     

小脑后下动脉瘤血管内栓塞治疗的初步临床研究

目的 探讨小脑后下动脉(PICA)瘤栓塞治疗的方法及效果.方法 回顾性分析21例PICA瘤经血管内栓塞治疗的临床资料,根据DSA资料估计动脉瘤的解削分段.采取单纯弹簧圈栓塞8例、单纯液体胶栓塞5例、弹簧圈联合液体胶栓塞2例、支架辅助弹簧圈栓塞2例、球囊辅助弹簧圈PICA闭塞4例,用格拉斯哥预后(GOS)评分评估疗效.结果 单纯弹簧圈致密栓塞5例,90%以上栓塞2例,85%栓寒1例;单纯液体胶栓塞的5例及弹簧圈联合液体胶栓塞的2例均达到致密栓塞;支架辅助弹簧圈栓塞的2例90%以上栓塞;球囊辅助弹簧圈完全闭塞载瘤动脉3例,90%以上栓塞1例.术后脑干穿支动脉闭塞导致死亡1例,术后1周新发神经功能障碍1例,其余未见再出血及小脑损害症状.术后随访6～60个月,平均(22±8)个月.COS评分Ⅰ级1例,Ⅱ级1例,Ⅲ级2例,Ⅳ级5例,Ⅴ级12例.结论 根据PICA瘤的解剖分段选择不同的栓塞方法,可取得良好的治疗效果.     

Endovascular therapeutic approach to peripheral aneurysms of the superior cerebellar artery.

Peripheral aneurysms of the superior cerebellar artery may be difficult to treat surgically owing to their inaccessibility and to the frequent inability to preserve the involved parent artery. In fact, for most cases, surgical treatment consists of proximal parent artery occlusion and/or trapping with surgical clips. An equivalent endovascular therapeutic approach to these lesions may be an attractive alternative method of management. We describe two cases of peripheral superior cerebellar artery aneurysms that were treated successfully with endovascular embolization.     

Selective endovascular treatment of a traumatic basilar aneurysm after endoscopic third ventriculostomy

A 4-year-old girl suffered intraventricular and subarachnoid hemorrhage during endoscopic third ventriculostomy. Cerebral angiography revealed a traumatic basilar aneurysm secondary to basilar artery injury. The aneurysm was treated with selective endovascular embolization using Guglielmi detachable coils. We review some therapeutic features of traumatic basilar aneurysms after endoscopic third ventriculostomy and describe the feasibility of endovascular selective therapy to manage these lesions successfully.     

Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment.

PURPOSETo define the role of angiography and embolization in the treatment of patients who have arterial injuries during transsphenoidal surgery.METHODSWe retrospectively studied the arterial hemorrhagic complications, their management, and the clinical outcomes that occurred in 21 of the more than 1800 patients who had transsphenoidal surgery for pituitary adenomas.RESULTSOf the 21 patients who had complications, 17 had internal carotid injuries and four had injuries of the sphenopalatine artery. Angiography was performed in 18 patients. Bleeding occurred and was controlled during surgery in 16 cases. Delayed epistaxis occurred in 10 patients, including five whose surgery was uneventful. After internal carotid injury, the most frequent angiographic findings were carotid occlusion (eight patients), stenosis (five patients), and false aneurysms (three patients). Internal carotid balloon occlusion was performed in five patients. No rebleeding occurred in patients who had complete carotid occlusion either from surgical packing or balloon embolization. Two of the patients who had carotid stenosis after surgical packing had delayed epistaxis necessitating balloon occlusion. Injuries to the sphenopalatine artery were successfully treated by surgery (one patient) or by endovascular treatment (three patients) without complication. Three deaths and five permanent deficits were directly related to the arterial injury or its treatment.CONCLUSIONProfuse bleeding during and after transsphenoidal surgery should be investigated by angiography. Lesions of the sphenopalatine arteries are effectively treated by embolization. Internal carotid injuries are best treated by carotid infusion to prevent life-threatening epistaxis.     

Platinum coil treatment of complex aneurysms of the vertebrobasilar circulation

Summary Two patients with complex aneurysms of the vertebrobasilar system were treated using platinum coils. During these sessions, 22 coils were placed in a basilar tip aneurysm in a 48-year-old woman. Almost total occlusion of the lumen was achieved, excepted in the area from which the right posterior cerebral artery arose. A large fusiform vertebral artery aneurysm in a 6-year-old boy was treated using 16 coils, which partially occluded the lumen at initial embolization. Follow-up angiography 2 weeks later revealed almost complete occlusion of the lumen with preservation of the vertebral artery. Our experience indicates that coil embolization of complex intracranial aneurysms is an acceptable treatment alternative to surgery or to a detachable balloon.     

Coil embolization in precommunicating (A1) segment aneurysms of anterior cerebral artery

Introduction

Precommunicating (A1) segment aneurysms of the anterior cerebral artery are rare and often pose technical challenges for coil embolization due to their distinctive configurations. Clinical and radiologic outcomes of treating such aneurysms through endovascular coil embolization are presented herein.

Methods

Data accruing prospectively from May 2002 to August 2013 yielded 48 patients harboring 50 A1 segment aneurysms, each classified as proximal, middle, or distal by location. Clinical outcome of the patients and morphological outcome of the aneurysms were assessed, with emphasis on technical aspects of treatment.

Results

The aneurysms studied occupied either proximal (n?=?39), middle (n?=?6), or distal (n?=?5). Proximal aneurysms were largely directed posteriorly (80 %), and most (97 %) were devoid of branches. Middle and distal aneurysms were associated with the medial lenticulostriate artery, cortical branches, or fenestrations. The preshaped “S” and steam-shaped “S” microcatheters facilitated aneurysm selection in 60 % of lesions. Single-microcatheter technique was most commonly applied for coil embolization (62 %), followed by balloon protection (16 %). Successful aneurysmal occlusion could be achieved in 76 % of the patients, with no procedure-related morbidity and mortality. At final follow-up (mean interval, 29.9 months), stable aneurysmal occlusion was sustained in 93 % of the patients (40/43).

Conclusion

A1 segment aneurysms are amenable to safe and efficacious endovascular coil embolization by adjusting procedural strategy to accommodate distinctive anatomic configurations.     

Endovascular treatment of unruptured intracranial aneurysms

BACKGROUND AND PURPOSE: Intracranial aneurysms are common, with an overall frequency ranging from 0.8% to 10%. Because prognosis after subarachnoid hemorrhage is still very poor, treatment of unruptured aneurysms, either neurosurgically or endovascularly, has been advocated. However, risk of rupture and subsequent subarachnoid hemorrhage needs to be considered against the risks of elective treatment. We analyzed the technical feasibility, safety, and efficacy of endovascular treatment of a consecutive series of unruptured cerebral aneurysms. METHODS: From July 1997 through December 2000, a total of 76 patients with 82 unruptured cerebral aneurysms were treated at our institution. Endovascular treatment was administered to 39 consecutive patients with a total of 42 unruptured cerebral aneurysms. Thirty-six aneurysms were treated with an endovascular technique; in six patients, the parent artery was occluded to eliminate aneurysmal perfusion. Aneurysms were located either in the anterior (n = 31) or posterior (n = 11) circulation. Eight patients had experienced previous subarachnoid hemorrhage from other aneurysms and were treated electively after complete rehabilitation. Ten patients had neurologic symptoms; in 21 patients, the aneurysm was an incidental finding. Eighteen aneurysms were small (0-5 mm), 11 were medium (6-10 mm), nine were large (11-25 mm), and four were giant (> 25 mm). Occlusion rate was categorized as complete (100%), subtotal (95-99%), and incomplete (< 95%) obliteration. RESULTS: Endovascular treatment was technically feasible for 38 of 42 aneurysms. Complete (100%) or nearly complete (95-99%) occlusion was achieved in 34 of 38 aneurysms. In four aneurysms of the internal carotid artery, only incomplete (< 95%) occlusion was achieved. All patients except one with mild neurologic deficits according to the Glasgow Outcome Scale and one with mild memory dysfunction but no focal neurologic deficit achieved good recovery, resulting in a morbidity rate of 4.8% and a mortality rate of 0%. CONCLUSION: Endovascular embolization of unruptured cerebral aneurysms is an effective therapeutic alternative to neurosurgical clipping and is associated with low morbidity and mortality rates. For the management of unruptured aneurysms, endovascular treatment should be considered.     

Stent-assisted coil embolization of intracranial wide-necked aneurysms

The endovascular treatment of cerebral aneurysms with coils poses significant technical challenges, particularly with respect to wide-necked aneurysms. We present the results of our initial experiences in using a stent for endovascular treatment of aneurysms, with an emphasis on potential applications, technical aspects, and associated complications. Twenty-three wide-necked aneurysms from 22 patients were treated during the 13-month study period. Seven patients presented with subarachnoid hemorrhage. Aneurysms were located at the internal carotid artery (n=14), the vertebral artery (n=3), the basilar artery (n=5), and the middle cerebral artery (n=1). A Neuroform stent² was used for stent-assisted procedures. Premedication with antithrombotic agents was available for unruptured cases. Postprocedural antithrombotic medication was prescribed for all patients. Nineteen aneurysms were primarily stented, followed by coil placement. For five of these aneurysms, stenting was performed subsequent to failure of an attempt to frame with an initial coil. Stenting for the remaining four aneurysms was performed as a rescue procedure to prevent the migration of previously placed coils. Complete occlusion was obtained in ten aneurysms, nearly complete occlusion (95% or more occluded) in 11 aneurysms, and partial occlusion (less than 95% occluded) in one aneurysm. In one aneurysm, we failed to navigate the microcatheter into the aneurysmal sac through the interstices of the stent. Stent thrombosis was noted during the procedure in one patient. Hemorrhagic complication on the 25th day after the procedure was noted in one patient. No procedure-related complications were observed during the procedure or during follow-up in the remaining 20 patients, including seven patients who did not receive antithrombotic agents prior to endovascular treatment owing to recent subarachnoid hemorrhage. To overcome the technical limitation in the coiling of wide-necked aneurysms, stent-assisted coil embolization may be a technically feasible and relatively safe method, even though longer periods of follow-up are required.