Detection of ischemia in endovascular therapy of cerebral aneurysms: a perspective in the era of neurophysiological monitoring

A prospective study was performed to evaluate the efficacy of neurophysiological monitoring (NPM) techniques in the detection of ischemic changes that may be seen during endovascular treatment of cerebral aneurysms. Sixty three patients underwent NPM during first-stage endovascular treatment of cerebral aneurysms. The endovascular procedures included coil embolization (26 patients), balloon-remodeling coiling (16 patients), stent-assisted coiling (ten patients), balloon-stent-assisted coiling (nine patients), and balloon test occlusion (two patients). NPM included electroencephalography, somatosensory evoked potentials, and brain stem auditory evoked potentials, depending on the location of the aneurysm and its associated vascular territory. NPM changes were seen in three patients (4.8%), and the procedures were altered immediately. No neurological changes were found postendovascularly. Ten patients demonstrated abnormal angiographic findings without concurrent NPM changes, of which five patients developed visual disturbance or hemiparesis. It is concluded that NPM is a valuable monitoring tool for endovascular treatment of cerebral aneurysms.     

Results of surgical management for posterior cerebral artery aneurysms: 7-year experience in the endovascular era

Purpose  

Unlike most posterior circulation aneurysms, posterior cerebral artery (PCA) aneurysms can be surgically approached, we believe, without significant technical difficulty or procedural morbidity. We report our recent experience to assess procedural complications and clinical outcomes for PCA aneurysms.     

Complications of endovascular treatment of cerebral aneurysms

BACKGROUND: The International Subarachnoid Aneurysm Trial has indicated that endovascular management of acutely ruptured aneurysms may be superior to surgery. Clearly poor results ensue from both forms of treatment, and some of these are because of technical complications (not just poor patient status). This observational study was performed to determine the complications associated with the endovascular treatment of ruptured and unruptured cerebral aneurysms. METHODS: Prospective data were gathered on 118 patients undergoing 126 endovascular treatment sessions for 126 nontraumatic cerebral aneurysms (30% unruptured) over a 3-year period. The average age was 51 years (range, 12-85 years). Females comprised 75% of the population treated. RESULTS: Good outcomes were achieved with 71% of the procedures (59% for subarachnoid hemorrhage [SAH]; 97% for unruptured). No bleeding or rebleeding occurred from treated aneurysms. Vessel or aneurysm perforation occurred in 11 cases and led to adverse outcome in 3 (3%). Thromboembolic complications were felt to cause cerebral infarction in 8 cases (6%). The risk of vessel/aneurysm rupture or thromboembolic stroke was greater in patients with SAH. Eight attempts to coil (6%) were initially unsuccessful. Two of these were later successfully coiled and others had surgery. None of the failed attempts led to clinical deterioration. Balloon-assisted coiling (BAC) was not associated with an increased complication rate. CONCLUSIONS: Vessel perforation and thromboembolic stroke are significant risks of endovascular treatment, especially after SAH. In our hands, however, BAC does not add to this risk.     

Anaesthesia for endovascular management of cerebral aneurysms

Subarachnoid haemorrhage due to rupture of cerebral aneurysms is a multisystem disease. Treatment of the condition in the past has relied on craniotomy and clipping of the aneurysm to prevent a recurrent haemorrhage. There is now emerging evidence to suggest that endovascular treatment of cerebral aneurysms may reduce the morbidity associated with open surgery. The anaesthetic management of interventional neuroradiology also creates new challenges due to the novel approach to treatment. Anaesthetists need to be familiar with this procedure and the management of potential complications. This review provides an overview such considerations.     

Pitfalls of endovascular treatment for cerebral aneurysms]

Seventeen cases of unclippable aneurysms were treated by the endovascular balloon technique. Nine of them involved the anterior circulation, and eight involved the posterior circulation. Eleven of them were treated by parent artery occlusion with detachable balloons. Three were treated by endosaccular balloon embolization, and three cases combined with AVMs were occluded using ethylene vinyl alcohol copolymer (EVAL) including feeding arteries of the AVMs. Embolic complications occurred in one case of an IC bifurcation giant aneurysm treated by parent artery occlusion. Ischemic complications also appeared in two cases of aneurysms treated by endosaccular balloon embolization. In one case, the thrombus in the aneurysm propagated into the parent artery and occluded it later. In another case, the displaced balloon had obliterated the parent artery 6 hours after the embolization. Parent artery occlusion is a safe way to treat internal carotid giant aneurysms. However, endosaccular treatment still has some problems, i.e., 1) maintaining the balloon's position to preserve the parent artery, 2) balloon migration into the clot, 3) rupture of the aneurysm during or after treatment. Our studies indicate that endosaccular balloon embolization is still a high risk procedure and should be used only in selected cases, until new embolic agents, such as detachable coils, become available.     

Rebleeding after endovascular embolization of ruptured cerebral aneurysms

This study retrospectively reviewed 227 patients with ruptured solitary cerebral aneurysm who underwent endovascular embolization with detachable coils between March 1997 and March 2006 to establish the incidence of rebleeding after endovascular treatment for ruptured cerebral aneurysm and identify the risk factors. The site and size of the aneurysm, the interval between treatment and rebleeding, and the outcome were investigated in six of the 227 patients (2.6%) who rebled after treatment. Four patients had large or giant aneurysms located on the internal carotid artery at the origin of the posterior communicating artery. The interval between treatment and rebleeding was less than 1 year in four patients (mean 394.2 days). Two patients died, and the survivors had modified Rankin Scale scores of 0, 2, 3, and 4. Re-embolization was performed in four patients and no further bleeding occurred during the mean follow-up period of 1.9 years after re-treatment. Patients with giant aneurysms of the internal carotid artery are at increased risk for rebleeding. Re-treatment should be considered if there is conventional and/or magnetic resonance angiographic evidence of dome filling. Patients with ruptured cerebral aneurysms must be followed up with diagnostic imaging closely during the first 12 months post-embolization because rebleeding frequently occurs within 1 year after initial treatment. Re-embolization is safe and effective in patients with recurrent hemorrhage from aneurysms previously embolized with detachable coils.     

Open surgical repair of descending thoracic aortic aneurysms in the endovascular era: a 9-year single-center study

The purpose of this study was to present a single center's experience with elective treatment of descending thoracic aortic aneurysms (DTAAs) in the endovascular era. From July 1997 to May 2005, we operated on 173 patients for DTAA. A total of 52 patients (30.1%) underwent endovascular stent-graft repair (group I). Endovascular repair was carried out exclusively in high-surgical risk patients in whom preoperative spinal cord arteriography usually demonstrated that the origin of the Adamkiewicz artery was located outside the zone to be covered by the stent graft. The remaining 121 patients (69.9%) underwent open surgical repair (group II), with partial cardiopulmonary bypass in 78 cases (64.5%) and deep hypothermic circulatory arrest in 43 (35.5%). The two treatment groups differed significantly with regard to age, prevalence of chronic obstructive pulmonary disease, number of aneurysms involving the upper segment or full length of the descending thoracic aorta, and percentage of patients in whom spinal cord arteriography was either deemed unnecessary or demonstrated that the origin of the Adamkiewicz artery was located within the coverage zone. In-hospital mortality was 15.4% (8/52) in group I vs. 5.0% (6/121) in group II (p = 0.02). Five deaths after endovascular repair were due to technical causes. All neurological deficits due to spinal cord ischemia (9/121, 7.4%) including 3.3% of irreversible flaccid paraplegia occurred in group II (p = 0.04). The findings of this study show that open surgical repair achieves excellent results when high-risk surgical candidates are recommended for endovascular repair. However, since preoperative spinal cord arteriography was a selection criterion for endovascular repair, the improvement in mortality was accompanied by a concentration of spinal cord ischemic complications in the patients having open surgical repair. The high mortality associated with endovascular repair in our series should decrease as deployment skill and endovascular technology improve.     

Balloon assistance as a routine adjunct to the endovascular treatment of cerebral aneurysms

BACKGROUND: The technique of BAC is attractive because the balloon theoretically allows for (1) "control" of blood flow in the vessel; (2) improved stability of the microcatheter in the aneurysm; (3) denser packing with coils; and (4) improved delineation of the neck of the aneurysm. The purpose of this communication is to document our outcomes with this technique and help determine if this technique is of benefit. METHODS: Data on all endovascularily treated aneurysms have been gathered prospectively at our institution since March 2000. The first case of BAC was in November 2000. We have become very liberal in our indications, to the point where all aneurysms are considered for BAC. We document here our results obtained over a 1-year period, during which we treated 56 patients with 60 aneurysms in 58 coiling sessions using only bare platinum coils. RESULTS: Balloon-assisted coiling was attempted in 50 (86%) of the 58 coiling sessions. Successful embolizations were achieved in all but 1 patient in whom BAC was attempted. There was one technique-related complication. The packing density for the BAC cases was, on average, 35.7% (median, 34.6%; SD, 14.1%). Follow-up angiography revealed a 13% class 3 recurrence rate. CONCLUSION: With experience, BAC can be used in the endovascular treatment of most cerebral aneurysms. Although complications are associated with its use, we feel that the risk/benefit ratio is favorable. Excellent coil packing density with bare coils is achievable with this technique.     

Fabry disease in the era of enzyme replacement therapy: a renal perspective

Fabry disease, the second most prevalent lysosomal storage disorder after Gaucher disease, is caused by mutations of the gene encoding the lysosomal hydrolase, -galactosidase A. The enzymatic defect is inherited in an X-linked recessive fashion and leads to systemic glycosphingolipid deposition, resulting in profound dysfunction of neurological, renal, cardiac, and cerebrovascular systems. Although symptoms typically appear in childhood in hemizygous males and some heterozygous females, the diagnosis is often delayed or unrecognized, owing to variable presentations and low incidence. The initial phase begins in childhood or adolescence and is characterized by neuropathic pain, angiokeratomas, and ocular deposits. The later phase is distinguished by progressive cardiac, cerebral, and renal involvement, leading to multi-organ dysfunction and death. Recently published clinical trials have demonstrated the efficacy of enzyme replacement therapy in decreasing neuropathic pain and substrate deposition in target organs. Pediatricians have a key role to play in making the diagnosis, so that therapy can be initiated before irreversible tissue injury develops. Further research is required to determine optimal dosing protocols for treatment and to establish whether therapy can retard the progression of organ dysfunction, or even prevent these complications altogether.     

Early and mid-term results of ruptured abdominal aortic aneurysms in the endovascular era in a community hospital

OBJECTIVE: Endovascular repair (EVAR) has been increasingly used for ruptured abdominal aortic aneurysms (rAAAs), especially in major academic centers. The goal of this article is to report our results with an EVAR-first approach for rAAA which we adopted in 2001 in our community hospital. METHODS: All consecutive patients who underwent attempted repair for rAAA between February 2001 and July 2006 were analyzed. Only patients with computed tomographic or visual verification of extraluminal blood were included. RESULTS: A total of 40 patients (30 men; mean age, 76.4 +/- 7.2 years; range, 57-89 years) presented with rAAA. Thirty patients underwent attempted EVAR for rAAA, constituting 4.1% of all EVAR cases (n = 738), and 10 patients had attempted open repair. Twenty-one (53%) were transferred from another institution. Computed tomography was performed in 97.5%. On arrival to the emergency department, 43%% were hypotensive (systolic blood pressure <80 mm Hg). Transfemoral balloon occlusion was used in 12 cases (30%; 10 in the EVAR group and 2 in the open group). The length of operation was 128 +/- 35 minutes (range, 77-210 minutes) in EVAR cases. EVAR was completed in 93.3% (iliac anatomy and proximal endoleak caused open conversion in two cases). Out of the 10 open treated cases, 1 was converted to EVAR and survived. The grafts used for EVAR were AneuRx (n = 21), Zenith (n = 5), and Ancure (n = 4), and 97% were bifurcated. Five patients (16.6%) in the EVAR group died within 30 days (four required balloon occlusion). The mean length of stay was 9.1 +/- 6.2 days (range, 4-30 days) in survivors of EVAR. In the EVAR-treated group, two patients died (7 and 9 months; unrelated), and six of the surviving patients (23%) required secondary procedures (five femorofemoral bypasses for limb occlusions and one proximal cuff for a type I endoleak that caused repeat rupture) during a mean follow-up of 13.8 +/- 10.4 months (range, 3-39 months). The mortality rate was 40% (4/10) in patients who underwent open procedures during this period, with an overall mortality rate of 22.5% for all ruptures treated. The difference in 30-day mortality in the EVAR and open groups did not reach statistical significance (17% vs 40%; P = .19). In the entire cohort, hypotension (systolic blood pressure <80 mm Hg) on arrival and loss of consciousness were associated with 30-day mortality. Balloon occlusion was correlated with mortality in the EVAR-treated group (44% vs 4%; P = .019). The multivariate analysis using logistic regression showed that hypotension (odds ratio [OR], 7.4; 95% confidence interval [CI], 1.3-42.0; P = .025), loss of consciousness (OR, 37.5; 95% CI, 3.4-40.8; P = .003), and the need for balloon occlusion (OR, 5.2; 95% CI, 1.8-25.5; P = .042) were correlated with higher perioperative mortality, whereas age greater than 76 years, coronary artery disease, chronic obstructive pulmonary disease, hypertension, diabetes, renal insufficiency, and type of procedure did not. CONCLUSIONS: Our results show that EVAR is feasible with favorable outcomes in patients presenting with rAAA in a busy community hospital. There is a high secondary intervention rate, which can potentially be decreased by ensuring good iliac limb anatomy at the end of the procedure and by a closer follow-up.     

Mesenteric ischaemia after endovascular coiling of ruptured cerebral aneurysms

Summary Three patients were referred to a national neurosurgical centre following CT evidence of subarachnoid haemorrhage. The three patients, who were referred from different institutions within a seven week period, were Fisher grade 3 and WFNS Grade I at all times. Angiography showed a PCOM aneurysm in one case, a ruptured Basilar tip aneurysm and an unruptured ACOM aneurysm in another case, and an ACOM aneurysm in the third case. It was decided that the aneurysms were suitable for endovascular coiling. These patients had unremarkable intraoperative catheterizations and coiling but subsequently deteriorated post-operatively due to mesenteric ischaemia. Two patients required colectomy for mesenteric ischaemia, and the third arrested secondary to sepsis from bowel perforation. We discuss the various causes that may explain this association, and we alert the neurosurgical community for this complication which has not been reported before. Correspondence: Mahmoud Hamdy Kamel, Neurosurgery Department, 4F ward, Royal Victoria Hospital, Belfast, UK.     

血管内治疗大脑前动脉远端动脉瘤

目的观察血管内治疗大脑前动脉远端(DACA)动脉瘤的效果。方法回顾性分析14例接受血管内治疗的DACA动脉瘤患者(共15个动脉瘤),对10个动脉瘤行单纯弹簧圈栓塞、4个动脉瘤行支架辅助下弹簧圈栓塞,1个以Onyx胶栓塞。之后复查DSA,根据Raymond分级评价即刻疗效。术后6个月复查DSA,以改良Rankin量表(mRS)评估预后,mRS评分0~2分为结局良好。结果术后即刻12个动脉瘤Ⅰ级栓塞,3个Ⅱ级栓塞。术中、术后均未发生缺血等并发症。1例术后12 h死于动脉瘤再次破裂出血。术后6个月随访显示1例复发,10例结局良好(mRS评分0~2分),另2例mRS评分分别为3分、4分。结论个体化血管内治疗DACA动脉瘤安全、有效。     

Technical strategy in endovascular treatment of proximal anterior cerebral artery aneurysms

Purpose  

There have been few reports on the endovascular treatment of aneurysms arising from A1 due to their rarity. We report the angiographic results, clinical outcomes, and technical aspects of endovascular treatment for 13 A1 aneurysms in 12 patients.