烟雾病合并颅内血流相关性动脉瘤的血管内治疗

目的探讨烟雾病合并颅内血流相关性动脉瘤的血管内治疗。方法 2010年1月—2012年3月收治8例烟雾病合并颅内动脉瘤患者,经CT检查证实6例为蛛网膜下腔出血,1例为脑室内出血,1例为缺血症状。对患者行血管内栓塞治疗,其中采用单纯弹簧圈栓塞5例,支架辅助栓塞1例(基底动脉顶宽颈动脉瘤),氰基丙烯酸正丁酯液态胶栓塞1例,1例失败。结果 7个动脉瘤位于Willis环周围,1个动脉瘤位于胼周动脉远段分支动脉。8例中,7例经血管内栓塞治疗成功,动脉瘤栓塞术后5 min复查造影,完全栓塞4例,几乎完全栓塞2例,不完全栓塞1例,术后随访结果良好。结论血管腔内栓塞治疗烟雾病合并颅内动脉瘤安全、有效,对外周动脉型动脉瘤也可予栓塞治疗。     

Endovascular management of basilar artery aneurysms associated with fenestrations

BACKGROUND AND PURPOSE: Arterial fenestrations are associated with saccular aneurysms that are often difficult to treat with open surgical techniques. We evaluated our experience with endovascular treatment of such aneurysms. METHODS: Ten consecutive patients with 11 basilar artery aneurysms associated with fenestrations were treated with coils by means of the endovascular route between November 1994 and February 2000. All patients underwent endovascular embolization by the femoral approach, under general anesthesia. Twelve embolization procedures were perfomed in the 10 patients. RESULTS: Nine proximal and two distal basilar artery fenestration aneurysms were treated successfully. The embolization was complete in 10 of the 11 aneurysms. It was incomplete in one case, and complete occlusion could not be achieved at the second attempt. There was one regrowth at 1-year follow-up, which was successfully treated again. Four of the aneurysms were treated initially with balloon remodeling, whereas one aneurysm with regrowth and one with incomplete occlusion were treated with balloon remodeling at the second embolization procedure. In one case, one limb of the fenestration was sacrificed. CONCLUSION: Endovascular treatment of basilar artery aneurysms associated with fenestrations appears to offer advantages over traditional open surgical techniques.     

Endovascular treatment of basilar tip aneurysms after direct puncture of the vertebral artery.

Basilar aneurysms that are not amenable to standard endovascular treatment via the femoral approach because catheterization is difficult pose a rare but serious problem. We present two cases of basilar tip aneurysms successfully treated by the endovascular route after direct puncture of the right vertebral artery. In both patients, the left vertebral artery was tortuous, small, and irregular, and the ostium of the right vertebral artery was not accessible by the femoral approach.     

Endovascular treatment of cerebral aneurysms associated with arteriovenous malformations

Background and purpose

In univariate survival analysis, coexisting aneurysms was associated with a significantly increased risk of hemorrhage in AVMs. We report here on our clinical experience with AVMs associated with arterial aneurysms that were managed by endovascular treatment.

Methods

To determine the incidence of associated aneurysms, the authors reviewed 366 consecutive patients with AVMs managed between 1999 and 2009. In 86 (23.5%) of these 366 patients, 55 intranidal aneurysms and 40 proximal aneurysms were observed. Targeted endovascular treatment with coils, n-butylcyanoacrylate(NBCA) and Onyx was performed for patients in this series, using a standard protocol. We reviewed the treatment plans, radiological findings and clinical courses of 86 patients suffering AVM associated with aneurysm.

Results

Ninety-five aneurysms in 86 patients with AVMs were enrolled in this study. Hemorrhage was the most frequent presenting symptom (69 patients, 80.2%). Bleeding was caused by an AVM nidus in 44 cases, aneurysm rupture in 20 and an undetermined origin in 5. Four patients were treated for associated aneurysm with coils followed by AVM embolization and 82 patients were treated with NBCA or Onyx embolization. There were total of 3 complications (3.5%) clinically significant complications in this series. Excellent or good outcomes (Glasgow Outcome Scale ≥ 4) were observed in 63 (73.3%) patients at discharge. Neurological deficits (Glasgow Outcome Scale 1–4) were 16.6% at discharge.

Conclusion

Endovascular treatment can be adequately used for cerebral aneurysms associated with AVMs as an adjunct to microsurgery and radiosurgery.     

Endovascular treatment of basilar tip aneurysms with Guglielmi detachable coils: predictors of immediate and long-term results with multivariate analysis 6-year experience

PURPOSE: To analyze anatomic and clinical results and factors predictive of outcome in treatment of basilar tip aneurysms with Guglielmi detachable coils (GDCs). MATERIALS AND METHODS: During 6 years, 55 unselected consecutive saccular aneurysms in 53 patients (mean age, 47 years) were treated with GDC occlusion. Forty-one (75%) aneurysms were ruptured (Hunt-Hess and Fisher grades were assigned in patients); 14 (25%), unruptured. Clinical and angiographic evaluations were performed 6 months after treatment and during follow-up (mean follow-up, 2 years). Multivariate analysis was used to determine factors predictive of outcome. RESULTS: GDC occlusion was a success in 52 (95%) aneurysms, a failure in two (4%), and not attempted in one (2%). Occlusion at final follow-up, evaluated in 44 aneurysms, was complete in 34 (77%), near complete in four (9%), and incomplete in six (14%). At 6-12 months, mean aneurysmal occlusion rate significantly worsened because of revascularization (P <.001) but improved at final follow-up because of reembolization in 10 aneurysms (P =.009); it remained stable (P =.351) between initial and final follow-up. Multivariate binary logistic regression indicated that before treatment started, aneurysmal neck size was the only independent predictor of initial occlusion rate (P =.002) and revascularization (P =.004). After the initial procedure, sac size and initial occlusion rate were independent predictors of revascularization (P =.004 and.008, respectively), irrespective of neck size. Occlusion rate at 6-12-month follow-up was the only independent predictor of that at final follow-up (P =.021), regardless of shape of aneurysm. Overall morbidity was 2% (one of 51); mortality, 6% (three of 51). Mortality correlated significantly with Hunt-Hess grade 4 at admission (P =.003) and incidence of vasospasm (P =.058). CONCLUSION: GDC occlusion proved to be a safe effective therapeutic alternative to surgery in patients with ruptured or unruptured basilar tip aneurysms. Morphologic and clinical factors were respectively identified as predictors of the optimal anatomic and clinical outcomes.     

Thrombosis in giant basilar tip aneurysms during coil embolization.

Two patients with giant basilar tip aneurysms underwent coil embolization, one with both platinum fiber and platinum Guglielmi detachable coils and the other with Guglielmi detachable coils only. In both cases, spontaneous intraaneurysmal thrombosis occurred outside the coil mass, presumably a result of disruption of the intraaneurysmal flow pattern.     

电解可脱性铂弹簧圈栓塞治疗颅内动脉瘤

目的:探讨电解可脱性铂弹簧圈（GDC）栓塞治疗颅内动脉瘤应用效果。方法:在局麻或神经安定镇痛麻和肝素抗凝下,使用Seldingers技术,经Tracker微导管放置GDC栓塞颅内动脉瘤。结果:成功栓塞18例患者的20个颅内动脉瘤,其中18个为100％栓塞,1个为95％,另1个为90％ 95％栓塞者为宽颈动脉瘤。而90％栓塞者为 Hunt分级Ⅳ级,存在严重脑血管痉挛,经解痉治疗效果不好,而放弃继续栓塞。无并发症及死亡。结论:GDC是栓塞颅内动脉瘤较理想材料,具有安全可靠,效果确切,适合颅内动脉瘤的治疗,尤其适合栓塞危险性较大的动脉瘤。     

Intraorbital ophthalmic artery aneurysm associated with basilar tip saccular aneurysm

We present a rare case of intraorbital ophthalmic artery aneurysm found incidentally, together with a ruptured aneurysm of the tip of the basilar artery. The intraorbital aneurysm was asymptomatic, and no treatment was offered. Angiographic control was recommended to detect any progression. Treatment may be indicated for documented enlargement or significant mass effect of the aneurysm.     

Endovascular treatment of PICA aneurysms

Endovascular treatment of aneurysms of the posterior inferior cerebellar artery (PICA) avoids manipulation of the brainstem or lower cranial nerves and should therefore carry a lower risk of neurological morbidity than surgical clipping. We reviewed our experience of 23 patients with PICA aneurysms treated by endovascular occlusion with Guglielmi detachable coils and documented their long-term outcome on follow-up. We observed a 28 day procedure-related neurological morbidity of 13% (3/23 patients). One patient suffered permanent neurological complications. There were no procedure-related deaths. None of our patients suffered a re-bleed from their treated aneurysms. Our series shows endovascular treatment of ruptured PICA aneurysms to be safe and effective.     

Endovascular treatment of visceral aneurysms associated with pancreatitis and a suggested classification with therapeutic implications

PURPOSE: To describe a 10-year experience of endovascular and percutaneous treatment of aneurysms and pseudoaneurysms complicating pancreatitis, and to analyze this experience and propose a classification based on computed tomography (CT) and angiographic findings that has therapeutic implications. This may reduce the rate of recurrent bleeding after surgery or endovascular treatment. MATERIALS AND METHODS: Twenty-three patients with aneurysms or pseudoaneurysms associated with acute pancreatitis were treated by endovascular or percutaneous methods. All underwent CT and angiography. The early development of a simple classification based on the CT and angiographic findings was used to guide treatment decisions. In accordance with this classification, 19 patients were treated by primary coil embolization and four were treated by primary percutaneous thrombin injection. RESULTS: Among the 19 patients treated by primary coil embolization, there were two early recurrences of the pseudoaneurysm. All four patients treated by percutaneous thrombin injection exhibited late recurrences and were successfully treated by percutaneous thrombin injections. Twenty-one patients (91.3%) were alive at 6 months. CONCLUSIONS: Endovascular and percutaneous treatment of aneurysms and pseudoaneurysms complicating pancreatitis is safe and effective and is associated with good outcomes, but careful follow-up is necessary. The decision of which treatment option is most appropriate can be made in accordance with a classification based on CT and angiographic appearance.     

基底动脉顶端破裂动脉瘤的血管内治疗

目的 探讨基底动脉顶端动脉瘤破裂血管内介入治疗的有效性及安全性.方法 收集2001年1月一2009年12月收治的12例基底动脉顶端动脉瘤破裂患者,其中男5例,女7例,年龄21～58岁,回顾性分析其影像学资料、血管内介入治疗方法和结果.结果 9例窄颈动脉瘤行直接栓塞,3例宽颈动脉瘤利用支架辅助栓塞.8例完全栓塞,4例部分...     

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.     

Endovascular treatment of peripheral intracranial aneurysms

BACKGROUND AND PURPOSE: Distally located cerebral aneurysms are difficult to treat with preservation of the parent vessel. We report the angiographic results and clinical outcome for 27 patients with peripheral cerebral aneurysms. METHODS: From January 2000 to June 2005, 27 patients, 13 female and 14 male, presented to our institution with peripheral intracranial aneurysms and were treated endovascularly. None of these aneurysms were mycotic in origin. The age of our patients ranged from 23 to 76 years with a mean age of 53. Twenty of the 27 patients had subarachnoid and/or intracerebral hemorrhage upon presentation. In 5 patients, the aneurysm was an incidental finding. One patient with a fusiform P2 aneurysm presented with cranial nerve III palsy, and another patient with P4 aneurysm had visual disturbances. Locations of the aneurysms were as follows: posterior cerebral artery in 9 patients, superior cerebellar artery in 5 patients, anterior inferior cerebellar artery in 1 patient, posterior inferior cerebellar artery in 5 patients, middle cerebral artery (MCA) in 5 patients, and anterior cerebral artery in 2 patients. RESULTS: Seven patients were treated with selective embolization with Guglielmi detachable coils (GDCs). Nineteen patients with fusiform aneurysms underwent parent artery occlusion (PAO). Fifteen PAOs were performed with coils and 4 with glue. One patient with a MCA aneurysm was found at the time of planned embolization to have spontaneously thrombosed the aneurysm and the distal branch of the MCA, 1 day after the initial diagnostic angiogram. Five patients (5/18 or 27.7%) who underwent PAO developed neurologic deficits. Two patients (2/18 or 11.1%) had permanent neurologic deficits (a visual field defect). CONCLUSION: Our results support that distally located aneurysms can be treated with endovascular PAO in the cases in which selective occlusion of the aneurysmal sac with GDC or surgical clipping cannot be achieved.     

Endovascular treatment of bacterial intracranial aneurysms

We report three patients with bacterial intracranial aneurysms treated by the endovascular approach: two presented with sudden severe neurological deficits after a diagnosis of endocarditis; the other had suspected vasculitis. CT showed an intracerebral haematoma in all cases: angiography revealed bacterial aneurysms of distal branches of the middle cerebral artery in two cases and posterior cerebral artery in one. Because of the patients' condition and the location of the aneurysms, endovascular treatment was considered the fastest and safest treatment. Hyperselective catheterisation of the parent branch, close to the aneurysm, was performed with a microcatheter. A small amount of glue was injected to occlude both the aneurysm and a short segment of the diseased vessel. Follow-up angiography revealed occlusion of the aneurysm in all cases. One patient recovered completely; one recovered over some months, with neurological deficit due to the haematoma. The third patient suddenly worsened and died 9 days after treatment for a contralateral haematoma, due to rupture of a new bacterial aneurysm of the middle cerebral artery. Endovascular occlusion of the aneurysm and parent vessel may be an alternative to surgery in selected, severe cases of deep or distal bacterial intracranial aneurysms.     

Endovascular treatment of giant serpentine aneurysms

Giant serpentine aneurysms are fusiform partially thrombosed aneurysms with a separate outflow tract to normal distal cerebral vessels. Three patients with giant serpentine aneurysms of the anterior and middle cerebral arteries were treated with endovascular occlusion of the aneurysmal lumen with coils or glue after balloon test occlusion of the involved vessel. In all 3 patients, leptomeningeal collateral circulation was sufficient to prevent distal ischemia.     

Endovascular treatment of splenic artery aneurysms

PURPOSE: To assess the feasibility and effectiveness of endovascular treatment of splenic artery aneurysms (SAAs). MATERIALS AND METHODS: Between May 2000 and June 2003 we treated 11 true SAAs in 9 patients (7 females and 2 males; mean age 58 years), 8 saccular and 3 fusiform, 4 located at the middle tract of the splenic artery, 5 at the distal tract and 2 intra-parenchymal. The diagnosis was performed with colour-Doppler ultrasound and/or CT-angiography; 7 patients were symptomless, 1 had left hypochondriac pain, and 1 had acute abdomen caused by a ruptured SAA. Four SAAs were treated by microcoil embolization of the aneurysmal sac with preservation of splenic artery patency; in 2 cases this was associated with transcatheter injection of N-butyl-2-cyanoacrylate. Four cases were treated by endovascular ligature, with sectoral spleen ischaemia. One ruptured SAA received emergency treatment with splenic artery cyanoacrylate embolization. Two intra-parenchymal SAAs were excluded, one by cyanoacrylate embolization of the afferent artery and the other by transcatheter thrombin injection in the aneurysmal sac. RESULTS: Technical success was observed in all cases (in 10/11 at the end of the procedure; in 1/11 at CT performed 3 days after the procedure). The follow-up (mean 18 months; range 6-36) was performed by colour-Doppler ultrasound and/or CT-angiography 3, 6 and 12 months after the procedure and subsequently once a year; the complete exclusion of the aneurysms was confirmed in 11/11 cases. The complications were: 4 cases of mild left pleuritis; fever and left hypochondriac pain 1 day after the procedure (in the same 4 patients and in one other case); 5 cases of sectoral spleen ischaemia and 1 case of diffuse spleen infarction with partial revascularization by collateral vessels. No alteration of the levels of pancreatic enzymes was found; a transitory increase in platelet count occurred only in the patient with diffuse spleen infarction. CONCLUSIONS: Using different techniques, endovascular treatment is feasible in nearly all SAAs. It ensures good immediate and long term results, and no doubt presents some advantages in comparison to surgical treatment, as it is less invasive and allows the preservation of splenic function.