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.     

Endovascular treatment of 404 intracranial aneurysms treated with nexus detachable coils: short-term and mid-term results from a prospective,consecutive, European multicenter study

Background

Aneurysm recanalization remains a limitation of endovascular treatment. A new type of bioactive coil, the polyglycolic/polylactic acid-covered platinum microfilaments Nexus coil (ev3/Covidien, Irvine, CA, USA), has been proposed. The objective is to evaluate the safety and short-term and mid-term efficacy of Nexus coils in the endovascular treatment of intracranial aneurysms.

Methods

The ENDECOR (European Nexus Detachable Coil Registry) is the first prospective, consecutive, multicenter non-randomized registry. After providing informed consent, 390 patients (238 women and 152 men; mean age, 51.6 years) with 404 ruptured or unruptured aneurysms were enrolled at 34 centers. Treatment was performed with at least 75 % of coil length as Nexus coils. Clinical and technical complications were systematically reported. An independent core laboratory evaluated angiographic results by using the Raymond Grading Scale.

Results

Complete occlusion was seen in 181 aneurysms (48 %); neck remnant in 86 aneurysms (22 %) and aneurysm remnant in 111 aneurysms (30 %). Technical and clinical complications related to the procedure occurred in 33 patients (8.5 %). At discharge, overall mortality and permanent-morbidity were 4.1 % (16/390) and 5.6 % (14/251), respectively. Angiographic mean follow-up of 13.3 months was obtained in 233 of 390 patients (64.4 %) harboring 247 aneurysms. Recanalization was observed in 44 aneurysms (17.7 %), and progressive thrombosis was observed in 53 aneurysms (21.6 %).

Conclusions

Endovascular treatment of intracranial aneurysms with Nexus coils was associated with low morbidity and mortality rates. Efficacy of Nexus coils was comparable to published series of intracranial aneurysms treated with bare platinum coils, but their efficacy to prevent aneurysm recanalization was not demonstrated.     

Flow visualization of recurrent aneurysms after coil embolization by 3D phase-contrast MRI

Background

Flow patterns in cerebral aneurysms are clinically important. Information on inflow patterns into aneurysms is especially helpful in preventing a recurrence after coil embolization. Computational fluid dynamics (CFD) simulations of patient-specific cerebral aneurysms are feasible and provide information on flow patterns. However, flow visualization by CFD simulations is challenging for recurrent aneurysms after coil embolization because coils make it difficult to obtain precise geometry of the recurrent aneurysms. In this study, we assessed the feasibility of flow visualization of recurrent aneurysms using 3D phase-contrast magnetic resonance imaging (PC-MRI).

Method

Time-of-flight magnetic resonance angiography and 3D PC-MRI were performed in eight cases of recurrent aneurysms after coil embolization. We attempted to visualize flow inside the aneurysms using data of 3D PC-MRI and evaluated the visualization. Additionally, CFD simulations were performed in a single case.

Results

Inflow into aneurysms was visualized in all eight cases (100 %). Flow patterns inside aneurysms were visualized in six cases (75 %), and these were associated with a large size of recurrent aneurysms (mean size, 10.3 mm for visualized cases vs. 4.8 mm for unvisualized cases; p?=?0.046, Mann–Whitney test). Flow patterns were similar between PC-MRI and CFD simulations. PC-MRI was faster and easier for observing inflow patterns than CFD simulations.

Conclusions

This is the first study to demonstrate that flow visualization of recurrent aneurysms by 3D PC-MRI is feasible. This technique may be more practical and easier than CFD simulations, and may provide clinically helpful information.     

Clinical and angiographic outcome of intracranial aneurysms treated with Matrix detachable coils in Chinese patients

BACKGROUND: Aneurysm recurrence is an innate problem in endovascular treatment of aneurysms with coils. A coated coil system named Matrix (Boston Scientific Neurovascular, Fremont, CA), covered with a bioabsorbable polymeric material (polyglycolide/lactide copolymer [PGLA]), was developed to accelerate intraaneurysmal clot organization and fibrosis. The purpose of this study was to evaluate the efficacy and safety of the Matrix detachable coils in patients with intracranial aneurysms and aneurysmal recurrence rate. METHODS: In a regional neurosurgical center in Hong Kong, data of patients undergoing endovascular embolization of intracranial aneurysm was collected. In a 20-month period, 42 patients with 44 aneurysms were treated by endovascular embolization using matrix coils alone or mixed with bare platinum coils. Thirty-four patients presented with ruptured aneurysms, and 8 patients presented with unruptured aneurysms. RESULTS: Twenty-five patients (60%) had 6-month follow-up DSA, and 10 patients (24%) had 18-month follow-up DSA. Seven aneurysm recurrences were identified, amounting to 16% for all aneurysms and 14% for ruptured aneurysms. Four patients were treated by repeated embolization, and 2 patients were treated by microsurgical clipping. Two adverse events due to thromboembolism were noted. One 78-year-old lady with poor-grade subarachnoid hemorrhage treated by partial embolization died from rebleed at day 4. Another patient with partial embolization and spontaneous thrombosis of dorsal wall ICA aneurysm died at 2 months with aneurysm recanalization with rerupture. Twenty-six patients achieved favorable outcome (GOS score 4 or 5) at last follow-up. The aneurysm recurrence rate using bare platinum coils of the same center was 11% and 7% for all aneurysms and ruptured aneurysms, respectively. CONCLUSION: Matrix coil embolization was safe, but there was no reduction in aneurysm recurrence using matrix coils alone or mixed with GDCs, compared with GDCs alone.     

Unruptured non-branching site aneurysms located on the anterior (dorsal) wall of the supraclinoid internal carotid artery: aneurysmal characteristics and outcomes following endovascular treatment

Background

This study was undertaken to evaluate the aneurysmal characteristics and clinico-radiological outcomes of unruptured non-branching site aneurysms located on the anterior (dorsal) wall of the supraclinoid internal carotid artery (ICA).

Methods

The data of 34 patients that underwent endovascular treatment for 36 unruptured ICA anterior wall aneurysms were reviewed. ICA anterior wall aneurysms were defined as aneurysms that projected superiorly from the anterior wall of the ICA ophthalmic (n?=?35) or communicating (n?=?1) segment on lateral angiograms, without any branch vessel relationship. In addition, aneurysmal characteristics and treatment outcomes were compared with those of 60 unruptured aneurysms originating from the posterior (ventral) wall of the ICA ophthalmic segment.

Results

Patients with an ICA anterior wall aneurysm frequently had a mirror aneurysm on the contralateral side (14.7?% versus 3.3?%) or another ICA aneurysm (35.3?% versus 15?%). Two of the 36 ICA anterior wall aneurysms exhibited ICA narrowing suggestive of dissection, and another five had dysplastic ICA dilatation around the neck. Stent-assisted embolization was more frequently performed for ICA anterior wall aneurysms (66.7?% versus 36.7?%) because of unfavorable dome/neck (mean, 1.21) and aspect (mean, 1.15) ratios, and because of microcatheter instability associated with superior aneurysmal projections against the abrupt curvature of the carotid siphon. Procedure-related thromboembolic complications occurred in three patients in the anterior aneurysm group, but no patient deteriorated clinically. Immediate radiological outcomes were more unfavorable for ICA anterior wall aneurysms (residual sac, 36.1?% versus 16.7?%). Nevertheless, rates of recanalization (2.9?% versus 5.2?%) and progressive occlusion (24.7?% versus 8.1?%) during follow-up slightly favored ICA anterior wall aneurysms. Two stent-treated ICA anterior wall aneurysms developed asymptomatic ICA steno-occlusion (8.3?%).

Conclusions

Stent-assisted embolization is safe and effective for the treatment of unruptured ICA anterior wall aneurysms exhibiting unfavorable aneurysmal geometries and projections for coil embolization.     

Endovascular coil embolization of unruptured intracranial aneurysms: a Korean multicenter study

Background and objective

Endovascular coil embolization has been a major treatment modality for unruptured intracranial aneurysms (UIAs) in South Korea. However, there are still few reports on the outcomes of this procedure. We performed a retrospective, multicenter study to determine how safe and effective coiling for UIA has been over the most recent 3 years in South Korea.

Materials and methods

We analyzed a total of 2,180 UIAs in 2,035 patients who were treated by coiling from January 2007 to December 2009 at 22 centers in South Korea, with a focus on patient characteristics, the location and size of the aneurysms, procedural complications, and angiographic and clinical outcomes.

Results

Coiling was successful in 98.0 % of the cases (2,137/2,180 aneurysms). Immediate post-procedural angiography demonstrated complete occlusion in 62.6 % (1,337/2,137 aneurysms), residual neck in 32.4 % (692/2,137), and residual sac in 5.0 % (108/2,137) of the cases. The rate of any procedure-related adverse event was 6.9 % (148/2,137 aneurysms). The rates of permanent morbidity and mortality were 1.8 % (39/2,137 aneurysms) and 0.1 % (2/2,137 aneurysms), respectively. Follow-up conventional angiography or MRA at ≥6 months was performed in 85.7 % (1,832/2,137 aneurysms) of cases. Among the eligible aneurysms for follow-up angiographic analysis, major recanalization was noted in 3.9 % (72/1,832 aneurysms, mean follow-up interval, 12 months). Among these, 68 aneurysms (3.7 %) were re-treated. An aneurysm of the middle cerebral artery (MCA) was a risk factor for incomplete occlusion (P?=?0.049) and major recanalization (P?=?0.046). During follow-up, no aneurysmal rupture occurred.

Conclusions

Endovascular coil embolization of UIAs has been an effective preventive modality with low procedure-related morbidity in South Korea.     

Stent salvage using the Enterprise stent for procedure-related complication during coil embolization of ruptured intracranial aneurysms

Background

Despite accumulated experience and improved understanding of the tools, endovascular treatment of intracranial aneurysms continues to have risks linked to the technique itself, and induces procedure-related complications. The purpose of this study was to report our series of stent salvage using the Enterprise stent for procedure-related complication during coil embolization in patients with ruptured intracranial aneurysms.

Methods

Parent artery thrombosis, parent artery dissection, and coil protrusion were considered to be the procedure-related complications. There were 18 consecutive cases (3 unruptured and 15 ruptured aneurysms) with procedure-related complications rescued by the Enterprise stent from December 2008 to December 2011. Follow-up angiography was performed in 14 of the 15 patients with ruptured aneurysms between 6 and 30 months (mean 14.6 months) after the procedure.

Results

The procedure-related complications were parent artery dissection (n?=?1), parent artery thrombosis (n?=?4), and coil protrusion (n?=?10). There was no complication related to delivering or deploying of the Enterprise stent. Initial radiographic results showed 8 cases of complete occlusion and 7 cases of neck remnant. There was no change in the angiographic results during the follow-up periods.

Conclusions

Facing with procedure-related complications during coil embolization of ruptured intracranial aneurysms, the closed-cell designed Enterprise stent might be a useful option for the salvage technique by restoring blood flow and minimizing thromboembolic events.     

Comparison of clinical and radiologic outcomes among stent-assisted,double-catheter,and balloon-assisted coil embolization of wide neck aneurysms

Background

Endovascular treatment of intracranial aneurysms can be technically challenging in cases of wide necks or unfavorable dome-to-neck ratio. Coils deployed without supporting devices may herniate from the aneurysm sac into the parent artery, causing thromboembolic complications or vessel occlusion. Therefore, alternative strategies for managing wide-necked aneurysms have been introduced such as stent-assisted coil embolization (SAC), balloon-assisted coil embolization (BAC), and double-catheter coil embolization (DCC).

Methods

SAC, BAC, or DCC were used to treat 201 patients with 207 wide-neck aneurysms between 2008 and 2013. Initial occlusion rates, recanalization rates, and periprocedural complications were retrospectively evaluated. The mean follow-up periods for SAC, BAC, and DCC were 16.2 months, 11.6 months, and 14.3 months, respectively.

Results

Clinical and anatomical analyses were conducted in 201 patients with 207 anuerysms. Complete occlusion rates of SAC, DCC, and BAC were 63.8 %, 46.7 %, and 63.2 %, respectively, and incomplete occlusion rates were 13.4 %, 15.5 %, 10.5 %, respectively (p value?=?0.798). No rebleeding or hemorrhage occurred after coil embolization. Recanalization rates did not differ among the SAC, DCC, and BAC groups (7.1 % vs. 11.1 % vs. 7.9 %, p value?=?0.696). Statistically insignificant results were observed in the rate of periprocedural complications among SAC, DCC, and BAC (11.0 % vs. 13.3 % vs. 15.8 %, p value?=?0.578).

Conclusions

There were no significant differences in the recurrence rate and periprocedural complication rate, and no rebleeding or aneurysmal rupture after treatment. Sufficient occlusion rates were achieved with SAC, DCC, and BAC. Notably, DCC does not require the use of antiplatelet agents and achieves coil stability without compromising the parent artery or major branch. Thus, we believe that the double-catheter technique was found to be a feasible and safe treatment modality for branching wide-neck aneurysms.     

Coil embolization of overwide and undertall small intracranial aneurysms with double microcatheter technique

Background

Overwide and undertall small intracranial aneurysms remain a challenge for coil embolization. The purpose of this study is to evaluate the feasibility and results of intrasaccular double microcatheter endovascular coil embolization of overwide and undertall small intracranial aneurysms.

Methods

Small (<7 mm), overwide (dome-to-neck ratio [DNR] ≤1.2), and undertall (ASPECT ratio ≤1.2) aneurysms which were treated with double microcatheter technique were selected. For the double microcatheter technique, two microcatheters were selected simultaneously into the aneurysm sac and coil insertion was performed alternatingly. The initial results, ASPECT, DNR ratios, complications, and follow-up results were assessed.

Results

Twenty small (mean, 3.8 mm), overwide (mean DNR, 1.1), and undertall (mean ASPECT, 1.0) aneurysms were treated with the double microcatheter technique. Overall, complete or near complete occlusion was achieved in 19/20 cases. This was achieved with only the double microcatheter technique in 16/20 cases (ASPECT mean, 1.0; DNR mean, 1.1). Adjuvant balloon remodeling was performed in 4/20 cases (ASPECT mean, 0.8; DNR mean, 1.1). The ASPECT ratio was significantly lower in the adjuvant balloon remodeling cases (p?=?0.027). Coiling failed in one patient with both DNR and ASPECT ratio <1.0. Overall, one patient developed a focal visual field defect after the procedure. No other patients developed neurologically significant complications.

Conclusions

Double microcatheter technique may be a safe and effective method for the treatment of overwide and undertall small intracranial aneurysms.     

Various techniques of stent-assisted coil embolization of wide-necked or fusiform artherosclerotic and dissecting unruptured vertebrobasilar artery aneurysms for reducing recanalization: mid-term results

Background

Coil embolization of wide-necked or fusiform vertebrobasilar aneurysms is challenging and tends to involve frequent recanalization.

Purpose

The aim of our study was to evaluate complications and mid-term outcomes of complex vertebrobasilar artery aneurysms after stent-assisted coiling with various techniques.

Methods

We retrospectively evaluated 28 cases of unruptured vertebrobasilar aneurysm treated by stent-assisted coiling.

Results

Forty-four of the 45 stents placed in 28 patients were deployed at the desired location (97.8 %). Single stent-assisted coiling was performed in 14 aneurysms, a stent-within-a-stent (SWS) technique was used in 12 aneurysms, and Y-stent-assisted coiling was employed in four basilar tip aneurysms. Two basilar tip aneurysms treated by single stent-assisted coiling recurred and were retreated by SWS and Y-stent-assisted coiling. Complete embolization was achieved in 19 aneurysms (67.8 %), and remnant neck persisted in eight aneurysms (28.6 %) and remnant aneurysm was noted in one aneurysm (3.6 %). Permanent neurologic deficit (Modified Rankin Scale 1 and 4) was noted in two patients (7.1 %). Angiographic follow-up (mean follow-up period: 20.8 months) was performed in 20 patients. Major recanalization occurred in two basilar tip aneurysms (10 %) and minor compaction was noted in one superior cerebellar artery aneurysm. The remaining 17 aneurysms were stable or improved (85 %).

Conclusions

Complex vertebrobasilar aneurysm embolization with stent-assisted techniques was effective and feasible as a method for reducing recanalization during midterm angiographic follow-up. Large and wide-necked basilar tip aneurysms showed frequent major recanalization, and compact packing with single or Y-stent-assisted coiling is needed to prevent recanalization even if coiling will be done without stenting.     

Feasibility of insertion of a microcatheter through a Y-stent in coil embolization of cerebral aneurysms and its detailed geometry by micro-computed tomography

Background

In Y-stent-assisted coil embolization for cerebral aneurysms, open or closed cell stents are used. Different microcatheters for coil insertion are available. We investigated which microcatheter could be navigated into an aneurysm through a Y-stent with different stents.

Methods

Double Neuroform open-cell stents or double Enterprise closed-cell stents were deployed in Y-configuration in a silicon model of a bifurcation aneurysm. Two endovascular neurosurgeons independently tried to navigate an SL-10 microcatheter for 0.010” coils or a PX Slim microcatheter for 0.020” Penumbra coils into the aneurysm through the Y-stent. In addition, we measured lengths of stent pores of the Y-stents with double Enterprise stents deployed in the model by micro-computed tomography.

Results

It was feasible to navigate an SL-10 microcatheter into the aneurysm through the Y-stent with Enterprise or Neuroform stents. Navigation of a PX Slim microcatheter was feasible in the Y-stents only with Neuroform stents. In the Y-stent with double Enterprise stents, the lengths of the second stent pores were significantly smaller than those of the first stent (0.41?±?0.18 mm vs 0.69?±?0.20 mm; P?=?0.008). The SL-10 microcatheter was smaller than approximately 80 % of the stent pores of the first stent and 30 % of those of the second stent. The PX Slim microcatheter was smaller than 20 % of the stent pores of the first stent and 0 % of those of the second stent.

Conclusions

It was feasible to insert an SL-10 microcatheter into the aneurysm through Y-stents with Enterprise or Neuroform stents. Navigation of a PX Slim microcatheter for 0.020” Penumbra coils was feasible in Y-stents with Neuroform stents, but not with double Enterprise stents. The measurements of stent pores by micro-computed tomography supported this feasibility study. These results may be helpful to select appropriate stents and microcatheters in Y-stent-assisted coil embolization, especially in case of retreatments.     

Endovascular management of a ruptured cavernous carotid artery aneurysm associated with a carotid cavernous fistula with an intracranial self-expanding microstent and hydrogel-coated coil embolization: case report and review of the literature

BACKGROUND: Ruptured CCAs are traditionally treated with endovascular management. Advances in microstent and coil technology have allowed improved intracranial navigation, increased coil packing density, and coil volume expansion to facilitate complete coil embolization of aneurysms/fistulae. We report a case of a ruptured CCA with an associated CCF treated with an intracranial, self-expanding microstent in combination with coil embolization using hydrogel-coated platinum coils. CASE DESCRIPTION: A 50-year-old woman presented with a 7-day history of severe headache and 2 days of progressive left-sided ptosis, ophthalmoplegia, and facial dysesthesias. A cerebral angiogram demonstrated a left ruptured wide-necked CCA with an associated CCF. An intracranial, self-expanding microstent (Neuroform(3), Boston Scientific, Natick, MA) was placed across the aneurysmal neck. The aneurysm was subsequently embolized with hydrogel-coated platinum coils (HydroCoil). A 3-month follow-up angiogram showed complete resolution of arteriovenous shunting with near-complete occlusion of the CCA. The patient's ocular pain and facial dysesthesias resolved completely, with near-complete resolution of ophthalmoplegia. CONCLUSIONS: This case demonstrates near-complete occlusion of a ruptured CCA and obliteration of an associated CCF using endovascular combinational therapy of an intracranial, self-expanding microstent with hydrogel-coated platinum coils. Use of this newer-generation stent-coil combination may allow more complete and durable lesion occlusion because of increased coil packing density and coil volume expansion without the need for parent artery sacrifice or balloon-remodeling techniques, thus avoiding the potential complications of such therapies.     

Peroneal artery pseudoaneurysm – a case report and literature review

Background

Aneurysms of the peroneal artery are infrequent and consist mainly of pseudoaneurysms.

Case presentation

This report describes an unusual case of peroneal pseudoaneurysm developing after thromoboembolectomy with a Fogarty catheter. It was managed successfully using an endovascular technique consisting of selective catheterization and coil embolization. The coils were placed in the peroneal artery, both proximal and distal to the pseudoaneurysm.

Conclusion

Endovascular technique can be successfully used to treat pseudoaneurysms in difficult settings.     

Recovery from oculomotor nerve palsy due to posterior communicating artery aneurysms: results after clipping versus coiling in a single-center series

Background

Oculomotor nerve palsy (ONP) is a common clinical manifestation of ruptured or unruptured posterior communicating artery (PcomA) aneurysms. Although microsurgical clip ligation has been proven a safe and durable treatment, endovascular management is emerging as an increasingly popular alternative. The aim of our study is to compare the recovery rate from ONP and assess the safety and long-term durability of both techniques.

Methods

We have reviewed the retrospective data concerning twenty-two patients treated at our institution between 2004 and 2012 for PcomA aneurysms with ONP. Seven patients were operated on via a standard pterional approach, and fourteen were treated by endovascular occlusion with coils. One patient was managed conservatively. Pre-treatment and post-treatment severity of ONP was recorded, as well as the duration of symptoms before admission and treatment-related complications.

Results

All seven patients who underwent surgery improved, with six total recoveries and one partial recovery. Among the fourteen patients treated by embolization, thirteen initially recovered, but long-term follow-up revealed three cases of exacerbation of ONP after refilling of the aneurysms. Two of them were clipped, and one embolized. Also, one partially resolved patient underwent a second embolization. No severe complications occurred in either group.

Conclusions

Despite the small number of patients, our study suggests that both surgical clipping and embolization are safe and effective methods in regards to functional recovery (complete ONP recovery in about 85 % of the cases). However, coiling may lead to delayed recurrence of third cranial nerve (CN) palsy at long-term follow-up, requiring additional treatment.     

Packing efficacy of hydrocoil embolic system: in vitro study using ruptured aneurysm model

After endovascular coil embolization of cerebral aneurysms, coil compaction and late aneurysm recanalization have been ever observed. The HydroCoil Embolic System (HES) was developed to improve the packing efficacy of endovascular treatment of cerebral aneurysms. In this study, we evaluate the packing efficacy of HES using a silicone model of ruptured cerebral aneurysm. This silicone model was connected to a pulsatile flow pump and embolized with the initial framing coils followed by hydro coils (n = 3) or bare platinum coils (n = 3). The coils used in the two groups were identical to each other in size and length. In the hydro coil group, continuous outflow from ruptured aneurysm ceased in two out of three cases. On the other hand, in the bare platinum coil group, outflow from the ruptured point slightly decreased but did not stop in all cases. The hydro coil could result in a higher initial occlusion rate of silicone model. In addition, expanded hydrogel possibly sealed the ruptured point directly. Changes in the size of aneurysms were not detected, from which the risk of over-expansion seemed extremely low. The hydro Coil is a safe and feasible device for improving the packing efficacy in endovascular coil embolization.     

Varicocele embolization: Anatomical variations of the left internal spermatic vein and endovascular treatment with different types of coils

Purpose

To present anatomical variations of left internal spermatic vein and a comparison between treatments with hydrogel-coated and non-coated platinum coils in patients with varicocele.

Aneurysmal bone cyst of the mobile spine: the therapeutic role of embolization

Purpose

Our aim is to define the role of embolization in the treatment of aneurysmal bone cyst of the spine in order to include this option in the decision making process.

Methods

From April 2004 to November 2009, seven patients with primary aneurysmal bone cyst of the mobile spine treated by embolization have been prospectively followed-up. All clinical presentations and imagings were recorded. There are many options of embolic agent and techniques used, but all aim to devascularize the tumor. The therapeutic protocol includes: embolization repeated every 8 weeks until the appearance of radiographic signs of healing. Complications, rate of healing and clinical outcome were analyzed.

Results

The number of embolizations varied from one to a maximum of seven without related intra- or post-operative complications. One patient, after four selective arterial embolizations, underwent direct percutaneous injection of embolic agents into the cyst. A clinical and radiographical response was achieved in all patients who were found alive and completely free of disease at mean follow-up of 46 months after last treatment and nobody crossed to surgical option.

Conclusion

Embolization seems to be the first option for spinal aneurysmal bone cyst treatment because of the best cost-to-benefit ratio. It is indicated in intact aneurysmal bone cyst, when diagnosis is certain, when technically feasible and safe and when no pathologic fracture or neurologic involvements are found. If embolization fails, other options for treatment would still be available.     

Predictors of thromboembolism during coil embolization in patients with unruptured intracranial aneurysm

Objectives

To identify the incidence of thromboembolic complications based on magnetic resonance imaging (MRI) and to explore the potential risk factors for thromboembolism (TE) during the periprocedural period of elective coil embolization for unruptured intracranial aneurysms.

Methods

We retrospectively reviewed all aneurysm cases treated with coil insertion between January 2008 and March 2011. Two hundred eighty-two coiling procedures for unruptured aneurysms were included in this study. The patients’ demographic characteristics were documented and records reviewed for abnormalities in diffusion-weighted imaging (DWI) seen on post-procedure MRI, intraoperative thrombus formation, and clinical signs of stroke.

Results

Overall, there were 87 (30.9 %) procedure-related complications in 282 aneurysms treated: 2 (0.7 %) procedural ruptures, 5 (1.8 %) symptomatic infarctions, and 80 (28.3 %) asymptomatic infarctions. Thromboembolic events during the procedure were observed more often in the the hyperlipidemia group (32/71 aneurysms, 45.1 %) than in the normal lipid profile group (39/196 aneurysms, 25.6 %; p?=?0.002; chi-squre test). The coiling technique and size of the aneurysm were also associated with TE (p?<?0.001 and p?=?0.004).

Conclusion

Hyperlipidemia seems to be associated with a significant increase in the rate of thromboembolic events. In preventive procedures, modifiable risk factors should be managed to reduce complications. Although permanent deficits are rare, the high rate of thromboembolic events suggests that improvements in the technique, such as the addition of antiplatelet agents and the development of new embolic materials, are necessary.     

Indikationen zur primären oder sekundären Implantation von fenestrierten Stentprothesen beim „hostile AAA neck“

Background

Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) is an established alternative to open reconstruction but is limited by the AAA anatomy. Nevertheless, an increasing number of patients are being treated with EVAR despite the presence of a hostile proximal neck. The aim of this study was to assess whether standard EVAR is safe in patients with a hostile neck or whether fenestrated EVAR (F-EVAR) should primarily be preferred in patients with adverse proximal anatomy or in the presence of aneurysmal degeneration after previous aortic surgery.

Material and methods

This article presents an overview of the literature regarding standard EVAR and F-EVAR for hostile AAA neck and an analysis of our experience with F-EVAR for secondary aneurysms after previous aortic surgery.

Results

Standard EVAR in the presence of adverse proximal anatomy is associated with higher rates of type I endoleaks, a decrease in primary technical success and an increase in aneurysm-related mortality. The F-EVAR procedure is associated with high technical success rates, low 30-day mortality and a low rate of type I endoleaks. Target vessel patency is high. Literature on F-EVAR after previous aortic surgery is sparse. Our experience shows that F-EVAR is feasible and durable after previous aortic surgery, although additional technical challenges are to be expected.

Conclusion

In the presence of a hostile neck standard EVAR should not be regarded as the first choice technique and F-EVAR is a safe and effective treatment option providing long-term durability. The F-EVAR technique has also shown promising results in the treatment of secondary aneurysms; however, further studies are required to confirm the initial good results.     

Hydrogel coil-related delayed hydrocephalus in patients with unruptured aneurysms

OBJECT: Because of high recanalization rates associated with wide-necked intracranial aneurysms treated with bare platinum coils, hydrogel coils (HydroCoil, MicroVention, Inc.) have been developed. Hydrogel coils undergo progressive expansion once exposed to the physiological environment of blood and increase overall aneurysm filling. METHODS: The authors retrospectively reviewed their series of patients with unruptured aneurysms treated between 1998 and 2006 and who underwent placement of bare platinum and hydrogel coils for cerebral aneurysms. They examined the incidence of delayed hydrocephalus as related to coil type. In a subgroup of patients in which preand postprocedure CT and MR imaging studies were available, the authors quantitatively analyzed the ventricular size change after hydrogel coils were placed. RESULTS: Four of 29 patients treated with hydrogel coils developed symptomatic hydrocephalus 2-6 months after the intervention compared with 0 of 26 treated with bare platinum coils alone. The difference in ventricular size between the subgroups in which pre- and postprocedure imaging was performed was found to be statistically significant (p < 0.05). All 4 HydroCoil-treated patients in whom hydrocephalus developed required placement of a shunt. CONCLUSIONS: A 14% incidence (95% confidence interval 3.9-31.7%) of hydrocephalus in patients with unruptured aneurysm undergoing embolization with hydrogel coils was discovered. This incidence is much higher than previously reported. The mechanism by which hydrogel coils may induce hydrocephalus remains poorly understood.