Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding

OBJECT: During a 5-year period 317 patients presenting with aneurysmal subarachnoid hemorrhage were successfully treated by coil embolization within 30 days of hemorrhage. The authors followed patients to assess the stability of aneurysm occlusion and its longer-term efficacy in protecting patients against rebleeding. METHODS: Patients were followed for 6 to 65 months (median 22.3 months) by clinical review, angiography performed at 6 months posttreatment, and annual questionnaires. Stable angiographic occlusion was evident in 86.4% of small and 85.2% of large aneurysms with recurrent filling in 38 (14.7%) of 259 aneurysms. Rebleeding was caused by aneurysm recurrence in four patients (between 11 and 35 months posttreatment) and by rupture of a coincidental untreated aneurysm in one patient. Annual rebleeding rates were 0.8% in the 1st year, 0.6% in the 2nd year, and 2.4% in the 3rd year after aneurysm embolization, with no rebleeding in subsequent years. Rebleeding occurred in three (7.9%) of 38 recurrent aneurysms and in one (0.4%) of 221 aneurysms that appeared stable on angiography. CONCLUSIONS: Periodic follow-up angiography after coil embolization is recommended to identify aneurysm recurrence and those patients at a high risk of late rebleeding.     

Treatment of basilar artery bifurcation aneurysms by using Guglielmi detachable coils: a 6-year experience

OBJECT: The authors retrospectively analyzed the results of their 6-year experience in the treatment of basilar artery (BA) bifurcation aneurysms by using Guglielmi detachable coils (GDCs). METHODS: This analysis involved 45 BA tip aneurysms in 16 men and 29 women who ranged in age from 23 to 78 years (mean 50 years). Seventy-five percent of the aneurysms had ruptured and 25% remained unruptured. Of the group whose aneurysms hemorrhaged, 14 patients were Hunt and Hess Grade I or II and 20 were Hunt and Hess Grades III to V; 32 patients were treated within 2 weeks of their subarachnoid hemorrhage (SAH). Initially, treatment with GDCs was limited to poor-grade high-risk patients who refused surgery or patients in whom surgery proved unsuccessful. Later in the study, good-grade patients with narrow-necked aneurysms were also treated using GDCs. The length of clinical follow up ranged from 1 to 72 months (average 27.4 months) in the 37 surviving patients. In 33 of the 45 aneurysms treated with coil placement, good to excellent results were achieved. There were 12 poor results (27%) including one in a patient from the non-SAH group who suffered a thrombotic complication due to an underlying vasculitis. Eight deaths were recorded in this group of 45 patients. One of these deaths was caused by a complication related to anesthesia, one by unknown causes, and six resulted from complications of the disease. One patient rebled on the 2nd day after the endovascular procedure. The mortality and permanent morbidity rates directly related to the intervention were 2.2% and 4.4%, respectively. Angiographic studies obtained immediately postintervention demonstrated 99 to 100% occlusion in 30 (67%) of the aneurysms; nine (20%) were more than 90% occluded; and six (13%) were less than 90% occluded by the GDCs. Follow-up angiograms were obtained in 31 patients between 2 and 72 months after coil placement. Nineteen (61%) of the follow-up angiograms revealed stable results (that is, no change from initial treatment). Twelve of the 31 showed coil compaction, but only eight of these lesions could accept additional coils. In large aneurysms recanalization was seen in 57%, and some of the larger lesions required as many as four embolizations (mean 1.7) to achieve optimal occlusion. When small-necked aneurysms were analyzed as a subset, a stable angiographic result was seen in 92%. CONCLUSIONS: Use of GDCs led to excellent clinical and angiographic results in the majority of patients with BA tip aneurysms included in this limited follow-up study. Rebleeding was encountered in one of the 34 previously ruptured BA aneurysms treated with GDCs, and no hemorrhages have been documented in the 11 unruptured aneurysms treated with GDCs in this series. Long-term follow-up studies are necessary before it is possible to compare adequately the treatment of aneurysms with coil placement to the gold standard of aneurysm clipping.     

Intentional neck-plastic incomplete clipping followed by coil embolization for broad-necked distal BA aneurysms]

OBJECTIVE: We report three patients with broad-necked distal basilar artery (BA) aneurysms treated with intentional incomplete clipping followed by endovascular occlusion using Guglielmi detachable coils. METHODS: The location of the aneurysms was BA bifurcation in one patient and BA-superior cerebellar artery (SCA) in two. One patient presented with acute subarachnoid hemorrhage and two patients had incidental aneurysms. In two patients, endovascular treatment was thought to be difficult considering the morphology of the aneurysms and surgical treatment was performed as the first choice of treatment. One patient with a BA-SCA aneurysm underwent endovascular treatment using a remodelling technique first. However, it was impossible to place the coil preserving SCA, so surgical treatment was performed. In all patients, the attempt to pursue complete clipping was considered to be accompanied with high risks of morbidity, so neck-plastic incomplete clipping was performed intentionally. One to six days after the surgery, coil embolization was performed. RESULTS: In all patients, complete occlusion of the aneurysms was achieved and all patients had excellent clinical outcomes. CONCLUSION: Intentional neck-plastic incomplete clipping followed by endovascular coiling may be a useful treatment option for patients with broad-necked distal BA aneurysms.     

Angiographic and clinical results in 316 coil-treated basilar artery bifurcation aneurysms

OBJECT: The aim of this study was to analyze the effect of the endovascular treatment of basilar artery (BA) bifurcation aneurysms and to compare the results with those published by other neuroendovascular teams. METHODS: The authors performed a retrospective analysis of 316 aneurysms of the BA bifurcation that had been treated using endovascular coil occlusion between November 6, 1992, and February 12, 2005. After the initial embolization procedure, a 90 to 100% occlusion rate was achieved in 86% of the aneurysms. No complication was evident in 80% of the lesions, although periprocedural aneurysm rupture (3.2%) and thromboembolic events (12.3%) were the most frequent complications. Clinical outcome according to the Glasgow Outcome Scale (GOS) was a score of 5 or 4 in 77%, 3 in 11%, 2 in 5%, and 1 in 7% of patients. Initial follow-up angiography studies were obtained in 56% of patients at a mean of 19 months posttreatment and demonstrated a 90 to 100% occlusion rate in 70%. No recurrence was seen on 65% of the aneurysms. Coil compaction was evident on 24% of the follow-up angiograms. A second treatment was performed on 48 aneurysms (15%) a mean of 27 months after the first therapeutic session and resulted in 90 to 100% occlusion in 83% of the lesions. Complications were encountered in 19% of the aneurysms. Rupture did not occur during any of the procedures. Clinical outcome was rated as GOS Score 5 or 4 in 83% of the patients and Grade 3 in 17%. During a cumulative clinical follow up of 821 years in 237 patients, 182 patients (81%) were independent (GOS Score 5 or 4), 33 (14%) were dependent (GOS Score 3), eight (3%) were in a vegetative state, and two (1%) had died. Clinical outcome was significantly worse after previous aneurysm rupture and following procedural complications. CONCLUSIONS: These results are within the range of published data for coil treatment of BA tip aneurysms and confirm both the safety and efficacy of this endovascular treatment method.     

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.     

Endovascular coil placement compared with surgical clipping for the treatment of unruptured middle cerebral artery aneurysms: a consecutive series.

OBJECT: The goal of this study was to delineate the angioanatomical features that determine whether a patient with an unruptured middle cerebral artery (MCA) aneurysm is treated using endovascular coil placement or surgical clipping. METHODS: Thirty consecutive patients harboring 34 unruptured MCA aneurysms were evaluated. Patients with unruptured aneurysms are managed prospectively according to the following protocol: the primary treatment recommendation is endovascular packing with Guglielmi detachable coils (GDCs). Surgical clipping is recommended after failed attempts at coil placement or in the presence of angioanatomical features that contraindicate that type of endovascular therapy. Of 34 unruptured MCA aneurysms, two (6%) were successfully embolized and 32 (94%) were clipped. Of these 32 surgically treated aneurysms, in 11 (34%) an attempt at GDC embolization had failed, whereas in 21 (66%) primary clipping was performed because of unfavorable angioanatomy. Of the 13 aneurysms treated endovascularly, two (15%) were successfully excluded, whereas GDC treatment failed in 11 (85%). An unfavorable dome/neck ratio (< 2) and an arterial branch originating at the aneurysm base were the reasons for embolization failure. CONCLUSIONS: Careful evaluation of the angioanatomy of unruptured aneurysms allows selection of the most appropriate treatment. However, for unruptured MCA aneurysms, surgical clipping appears to be the most efficient treatment option. Series of unruptured aneurysms are ideal for comparing treatment results.     

Intraarterial abciximab for treatment of thromboembolism during coil embolization of intracranial aneurysms: outcome and fatal hemorrhagic complications

OBJECT: Experience with intraarterial abciximab for the treatment of thromboembolism during endovascular coil embolization is limited. The authors report the outcome of intraarterial abciximab use, with an emphasis on fatal hemorrhagic complications. METHODS: Between March 2003 and May 2006, the authors treated 606 aneurysms by using endovascular coil embolization, and in 32 (5.3%) of these aneurysms (31 patients) an intraarterial thrombus developed. Sixteen of these aneurysms were ruptured and the other 16 were unruptured. Arterial thrombi were totally occlusive in 3 and partially occlusive in the remaining 29 cases. Intraarterial abciximab was administered at a concentration of 0.2 mg/ml as a bolus of 4-15 mg over a period of 15-30 minutes. RESULTS: Complete thrombolysis was achieved in 17 (53%) and partial thrombolysis in 15 (47%) of 32 lesions. Twenty-eight patients (90.3%) were asymptomatic after abciximab thrombolysis, but 3 had postprocedural rebleeding that occurred after abciximab treatment; all of these patients had recently experienced an aneurysm rupture. Of these patients, 1 displayed severe thrombocytopenia and the other 2 showed a > 25% reduction in platelet count after abciximab treatment. CONCLUSIONS: Intraarterial abciximab is effective for the treatment of thromboembolic complications that occur during intracranial aneurysm coil insertion. Nevertheless, attention should be paid to prevent potentially fatal complications such as thrombocytopenia and hemorrhage, especially in patients with a ruptured aneurysm.     

Large ophthalmic segment aneurysms with anterior optic pathway compression: assessment of anatomical and visual outcomes after endosaccular coil therapy

OBJECT: The optimal therapy for ophthalmic segment aneurysms with anterior optic pathway compression (AOPC) is undecided. Surgical results have been described, but the results of endovascular coil therapy have not been well documented. METHODS: The authors retrospectively reviewed data obtained in all patients who harbored unruptured ophthalmic segment aneurysms with AOPC who underwent endovascular coil therapy at their institution. They analyzed baseline and outcome visual function, aneurysm features, extent of aneurysm closure, internal carotid artery (ICA) occlusion, additional interventions, and neurological outcome. In 17 patients (16 women), age 38 to 83 years, there were 28 affected eyes. All aneurysms were greater than 10 mm in diameter. In the initial procedures 16 of 17 patients received endosaccular coils and the ICA was preserved; in one patient the aneurysm was trapped and the ICA occluded. Patients then underwent follow up for a mean of 2.90 years (range 1 month-1 1.2 years) after the last procedure. One patient died of subarachnoid hemorrhage (SAH) 1 month postoperatively and thus no follow-up data were available for this case. Vision worsened in six patients, stabilized in four, and improved in six. Twelve patients underwent 13 subsequent procedures, including endovascular ICA occlusion in seven, repeated coil therapy in five, and optic nerve decompression in one; vision improved in 83% of these cases after ICA occlusion. A second patient died of SAH 5 months after repeated coil treatment. At the final follow up, vision had improved in eight patients (50%), stabilized in four (25%), and worsened in four (25%). In 16 patients with follow-up studies, aneurysm closure was complete in eight (50%) and incomplete in eight (50%). CONCLUSIONS: The authors found that in patients with ophthalmic segment aneurysms causing chronic AOPC, endosaccular platinum coil therapy, with ICA preservation, may not benefit vision and that additional procedures may be needed. Evaluation of their results suggests that endovascular trapping of the aneurysm and sacrifice of the ICA appear to result in good visual, clinical, and anatomical outcomes.     

Endovascular surgery using stents for vertebral artery dissecting aneurysms and a review of the literature

The treatment of dissecting aneurysms of the vertebral artery (VA) involving the posterior inferior cerebellar artery (PICA) or presenting with hypoplasia of the contralateral VA is controversial. We describe our experience with 4 ruptured and 2 unruptured VA dissecting aneurysms and discuss the efficacy of endovascular surgery using stents. All patients were male; their mean age was 50.7 years. According to World Federation of Neurological Surgeons (WFNS) grading, 3 of the ruptured aneurysms were grade V, the other was grade I. All patients were successfully treated using stents; in 5 we also coil-embolized the aneurysmal lumen. One aneurysm was treated by the placement of 2 stents covering the dissection site; there was a danger of aneurysmal rupture during coil embolization. No technical complications were encountered although one patient suffered minor rebleeding 5 days post-treatment. Delayed vasospasm occurred in 4 cases. According to the Glasgow Outcome Scale (GOS), at 3 months after treatment 2 patients had made a good recovery, one was moderately disabled, one suffered severe disability, and 2 had died. One death each was due to acute myocardial and brain stem infarction. Endovascular surgery using stents may be a useful treatment in patients in poor condition who manifest dissecting VA aneurysms involving the PICA or hypoplasia of the contralateral VA, especially in the acute period after rupture.     

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.     

Endovascular treatment of basilar artery trunk aneurysms with Guglielmi detachable coils: clinical experience with 41 aneurysms in 39 patients

OBJECT: The authors present a retrospective analysis of their clinical experience in the endovascular treatment of basilar artery (BA) trunk aneurysms with Guglielmi detachable coils (GDCs). METHODS: Between April 1990 and June 1999,41 BA trunk aneurysms were treated in 39 patients by inserting GDCs. Twenty-seven patients presented with subarachnoid hemorrhage, six had intracranial mass effect, and in six patients the aneurysms were found incidentally. Eighteen lesions were BA trunk aneurysms, 13 were BA-superior cerebellar artery aneurysms, four were BA-anterior inferior cerebellar artery aneurysms, and six were vertebrobasilar junction aneurysms. Thirty-five patients (89.7%) had excellent or good clinical outcomes; procedural morbidity and mortality rates were 2.6% each. Thirty-six aneurysms were selectively occluded while preserving the parent artery, and in five cases the parent artery was occluded along with the aneurysm. Immediate angiographic studies revealed complete or nearly complete occlusion in 35 aneurysms (85.4%). Follow-up angiograms were obtained in 29 patients with 31 aneurysms: the mean follow-up period was 17 months. No recanalization was observed in the eight completely occluded aneurysms. In 19 lesions with small neck remnants, seven (36.8%) had further thrombosis, three (15.8%) remained anatomically unchanged, and nine (47.3%) had recanalization caused by coil compaction. In one patient (2.6%) the aneurysm rebled 8 years after the initial embolization. CONCLUSIONS: In this clinical series the authors show that the GDC placement procedure is valuable in the therapeutic management of BA trunk aneurysms. The endovascular catheterization of these lesions tends to be relatively simple, in contrast with more complex neurosurgical approaches. Endosaccular obliteration of these aneurysms also decreases the possibility of unwanted occlusion of perforating arteries to the brainstem.     

Intracranial hemorrhage associated with stent-assisted coil embolization of cerebral aneurysms: a cautionary report

OBJECT: The introduction of the Neuroform microstent has facilitated the embolization of complex cerebral aneurysms, which were previously not amenable to endovascular therapy. Typically, the use of this stent necessitates the administration of dual antiplatelet therapy to minimize thromboembolic complications. Such therapy may increase the risk of hemorrhage in patients who require concurrent external ventricular drainage and/or subsequent permanent cerebrospinal fluid diversion. METHODS: The authors' neurosurgical database was queried for all patients who underwent stent-assisted coil embolization for cerebral aneurysms and who required an external ventricular drain (EVD) or ventriculoperitoneal (VP) shunt placement for management of hydrocephalus. RESULTS: Thirty-seven patients underwent stent-assisted coil embolization for intracranial aneurysms at the authors' institution over a recent 2-year period. Seven of these patients required placement of an EVD and/or a VP shunt. Three of the 7 patients suffered an immediate intraventricular hemorrhage (IVH) associated with placement or manipulation of an EVD; 1 experienced a delayed intraparenchymal hemorrhage and an IVH; 1 suffered an aneurysmal rehemorrhage; and the last patient had a subdural hematoma (SDH) that resulted from placement of a VP shunt. This patient required drainage of the SDH and exchange of the valve. CONCLUSIONS: The necessity of dual antiplatelet therapy in the use of stent-assisted coil embolization increases the risk of intracranial hemorrhage and possibly rebleeding from a ruptured aneurysm. This heightened risk must be recognized when contemplating the appropriate therapy for a cerebral aneurysm and when considering the placement or manipulation of a ventricular catheter in a patient receiving dual antiplatelet therapy. Further study of intracranial procedures in patients receiving dual antiplatelet therapy is indicated.     

Endovascular treatment of basilar tip aneurysms using Guglielmi detachable coils: anatomic and clinical outcomes in 73 patients from a single institution

OBJECTIVE: Seventy-three consecutive patients with 75 basilar tip aneurysms were treated with Guglielmi detachable coil (GDC) technology. Their anatomic and clinical outcomes are discussed. METHODS: Seventy-five basilar tip aneurysms were treated with the GDC system at the University of California, Los Angeles Medical Center from 1990 to 1999. The average age of the population was 48.3 years (range, 28-82 yr). Forty-two patients (57.5%) presented with acute subarachnoid hemorrhage, 8 patients (10.9%) had unruptured aneurysms with mass effect, and 23 patients (31.5%) had incidental aneurysms. Thirty-one aneurysms (41.3%) were small with a small neck, 18 (24%) were small with a wide neck, 16 (21.3%) were large, and 10 (13.3%) were giant aneurysms. RESULTS: Immediate anatomic outcomes demonstrated complete or near-complete occlusion in 64 aneurysms (85.3%) and incomplete occlusion in 7 aneurysms (9.3%). Four aneurysms (5.3%) could not be embolized because of anatomic difficulties. Of the 69 patients treated with GDCs, 63 patients (91.3%) remained neurologically intact or unchanged from their initial clinical status. Procedure-related morbidity and mortality were 4.1% and 1.4%, respectively. Long-term follow-up angiograms were obtained in 41 patients with 42 aneurysms. Thirty aneurysms (71.4%) demonstrated complete or near-complete occlusion. One incompletely embolized giant aneurysm ruptured during the follow-up period. CONCLUSION: In contrast to surgical clipping of basilar tip aneurysms, the main technical challenge of the Guglielmi detachable coiling procedure depends on the shape of the aneurysm, not its location. The results of this study indicate that endovascular GDC technology is an appropriate therapeutic alternative in ruptured or unruptured basilar tip aneurysms regardless of patient age, clinical presentation, clinical status, or timing of treatment.     

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.     

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.     

Ruptured cerebral aneurysm complicated with rebleeding following thrombolysis during endovascular embolization: two case reports

A 68-year-old woman and a 42-year-old woman presented with subarachnoid hemorrhage due to rupture of cerebral aneurysm. Both patients were treated with endovascular coil embolization. Thromboembolic complications occurred during the procedure and local thrombolysis was performed for recanalization. One patient developed massive rebleeding immediately after the procedure and the other suffered minor hemorrhage adjacent to the embolized aneurysm 2 days later. Local thrombolysis during treatment of ruptured aneurysm by coil embolization carries a significant risk of rebleeding. Prevention of thromboembolic complication by adequate heparinization is important.     

Review of endovascular stent‐assisted embolization for management of intracranial aneurysms

Objective: This was a retrospective review of the results using stent‐assisted coil embolization for management of intracranial aneurysms. Methods: The records of seven patients treated with stent‐assisted Gugliemi detachable coil (GDC) embolization were retrieved from the authors’ prospectively maintained database. The clinical presentation, site and type of aneurysms, treatment procedure and complications, and outcome of these identified cases were reviewed. Results: Between January 2002 and May 2004, seven patients with intracranial aneurysms, four of which were ruptured, were treated by stent‐assisted GDC embolization. Four aneurysms were located at the anterior circulation and three were at the posterior circulation. The indications for stent use were: giant aneurysm (>2.5 cm), dissecting pseudo‐aneurysm, broad‐necked aneurysm and the need for preservation of important parent arteries or branches. Concerning the technical aspect, all except one had successful stent deployment. One stent dislodged after apparent successful deployment. GDC embolization was continued and the aneurysm was partially occluded. More than 90% occlusion of aneurysm sac was achieved in six aneurysms. Intraoperative complications included over‐coagulation, failure in stent deployment, displacement of stent, coil entrapment and thromboembolism. One patient had added focal neurological deficit after the procedure, and one became vegetative due to an unrelated cause. The patient in whom the stent was dislodged suffered another subarachnoid haemorrhage 4 months later and died. Conclusion: Percutaneous intracranial stent is a new and useful device to assist embolization of cerebral aneurysms that were previously not amenable to endovascular therapy. These preliminary results suggest that this procedure could achieve satisfactory outcomes without significant complications.     

Parent Artery Occlusion for Unruptured Cerebral Aneurysms: The Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2

Parent artery occlusion (PAO) is an alternative to surgical clipping or endovascular endosaccular coil embolization for the management of cerebral aneurysms. Most giant and fusiform aneurysms are not amenable to endosaccular coil embolization due to anatomical considerations, such as a broad-neck. However, majority of reports regarding the safety of PAO are based on case series involving a relatively small number of patients. In the present study, a total of 381 consecutive patients with unruptured cerebral aneurysms who were treated with PAO were extracted from the Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and JR-NET2 database, which are nationwide surveys conducted by the Japanese Society of Neuroendovascular Therapy. The mean age of the 381 patients was 58.1 years, and 59.3% were female. The aneurysmal location included the vertebral artery (42%) and the cavernous portion of internal carotid artery (32%). The aneurysm size and shape consisted of fusiform (45%), giant (25%), and large (22%). Symptomatic lesions were present in 59.8% of the population. Technical success was achieved in 98.4%. The 30-day morbidity and mortality rates were 3.1% and 1.0%, respectively. The most frequent procedure-related complication was ischemic stroke, which occurred in 12.9% (distal embolism, 6.0%; branch occlusion, 3.9%). The 30-day morbidity and mortality rates related to ischemic strokes were 2.1% and 0.3%, respectively. PAO for unruptured aneurysms is feasible with a high technical success rate. Peri-procedural management of ischemic stroke is the key to enhance the safety of this treatment option.     

Aneurysm clipping after endovascular treatment with coils: a report of 13 cases

In 1996, Civit et al. (Neurosurgery, 38:955-961, 1996) reported a series of eight patients whose aneurysms were clipped after previous embolization with coils. This paper highlighted the safety of this surgery in second line, with a low complication rate and a favorable outcome. The two major surgical indications were either after deliberate partial occlusion of the aneurysm (N = 3) or partial occlusion after endovascular treatment (N = 3). Reviewing 13 additional patients from 1996 to June 2005, the authors compared the surgical indications and focused on the technical problems of clipping after coiling. Thirteen patients (men = 6, women = 7) with aneurysm clipping following one or more endovascular embolizations have been operated on since 1996. The patients' files were reviewed retrospectively by both a senior consultant neurosurgeon and a neuroradiologist. Demographic data included sex, age at admission, relevant medical history, initial endosaccular treatment and its quality (partial or complete effectiveness), the rationale for surgery, and the complications arising from the different treatments. In addition to the patient's clinical follow-up, angiograms were performed soon after the surgical procedure, 3 months, 1 year, and 5 years after the coiling, respectively. None of the initial endovascular treatments was complete. Surgical indication was related firstly to anatomical particularities of the aneurysm (width of the neck, N = 5; arterial branches from the aneurysm, N = 4; no individualized neck in a small aneurysm, N = 1); secondly to a shift of the coils with delayed aneurysm regrowth and repermeabilization, N = 4; and thirdly to rebleeding, N = 3. All the patients who were operated on underwent complete surgical exclusion of their aneurysm (controlled by angiogram). Twelve out of 13 patients recovered satisfactorily (92.3%), attaining the same neurological state they presented prior to surgery. One patient died after the operation. He had already been in a serious condition because of severe rebleeding following the embolization. Aneurysm clipping following a previous endovascular embolization procedure is a rare, although not so exceptional, indication. It is a safe and effective procedure, probably under-used. Nowadays, "hemostatic" and incomplete embolization of an aneurysm increases the risk of future growth and rebleeding of the residual pouch. An additional aneurysm clipping may therefore be required rapidly after embolization.     

Endovascular treatment of very small intracranial aneurysms

BACKGROUND: The treatment of very small cerebral aneurysms with maximal diameter less than 3 mm remains a challenge for endovascular and surgical treatment. Endovascular treatment of these lesions may be difficult and associated with high risk of complications because of their small size. Our purpose was to assess the feasibility and results of endovascular treatment of these lesions. METHODS: We conducted a retrospective review of our experience and results of endovascular treatments for a series of 11 consecutive patients with 11 very small aneurysms. Of 11 aneurysms, 10 were acutely ruptured, and 1 was unruptured with a previous subarachnoid hemorrhage from another aneurysm. Aneurysms were located at the internal carotid artery (n = 4), the anterior communicating artery (n = 6), and the vertebral artery (n = 1). Seven patients were treated with coil embolization, and remodeling technique was used in 1 case. Three cases underwent intravascular stent implantation. Coil packing was done after in 2 of 3 aneurysms, and stent implantation alone was used in the remaining aneurysm. RESULTS: Coil embolization and stent deployment were carried out without difficulty in all cases. Coil packing was not available after stent implantation in 1 case for unsuccessful navigation of microcatheter into the aneurysm sac. Immediate angiography demonstrated complete occlusion in 10 cases and nearly complete occlusion in 1 case with stent implantation alone. No stent thrombosis and aneurysmal rupture was encountered during treatment. With the exception of 1 patient (Hunt and Hess grade 4) who died of pneumonia 4 weeks after treatment, no clinical evidence of neurologic deterioration and hemorrhagic complication was seen during the follow-up period in the remaining 10 patients. Follow-up angiography for 3 to 12 months (mean, 5.3 months) was available in 6 (60%) of 10 surviving patients, and no aneurysm recanalization was found. CONCLUSIONS: Endovascular treatment may be a feasible and effective therapeutic alternative for very small aneurysms. The long-term efficacy and durability of endovascular treatment for these lesions remains to be determined in a large series.