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

History of endovascular surgery: personal accounts of the evolution

Endovascular therapy has continuously evolved since it was first described in 1904. It was first used as a technique to inject particles to follow the flow into vascular lesions, and from the mid-seventies on, microballoons were developed to reach targets in the arterial vascular tree. Arteriovenous malformations were approached with catheters, the tip mounted by calibrated leak balloons. The embolizing material injected was cyanoacrylate labeled with Lipiodol (Lafayette Pharmacal, Lafayette, IN), a technique that is similar to what we use today. Flow-guided microballoons placed and detached in brain aneurysms eventually became unstable, making reperfusion and rupture possible. With the introduction of guidewire-supported microcatheters, controlled navigation in the endovascular tree became possible, allowing the injection of particles, liquid embolizing agents, or free coils. In 1991, detachable coils became available and brought new therapeutic concepts. Having learned that detachable coils could not be used to treat aneurysms, which were difficult to treat surgically, the neurosurgical community accepted this new technology primarily for patients in poor condition following aneurysmal subarachnoid hemorrhage. Increased experience led to better clinical results, and Guglielmi detachable coiling therapy began to be accepted also for patients with posterior circulation aneurysms. Recent controlled trials and new technologies improving the endovascular feasibility have raised the acceptance of endovascular therapy for brain aneurysms. The elegance of the endovascular approach was an important argument for this technology from its inception, but in early years, restricted endovascular efficacy limited the efficiency of embolizations. Increasing experience and exploding new technologies have made endovascular techniques not only safer but also as effective as microsurgery. The number of vascular pathologies where microsurgery is the only option is decreasing, and training in vascular neurosurgery may become the privilege of specialized centers in the future.

RESULTS OF MICROSURGICAL CLIPPING OF 50 HIGH COMPLEXITY BASILARAPEX ANEURYSMS

OBJECTIVE

Complex basilar aneurysms (large size, wide base, low bifurcation, and dysmorphic posteriorly projecting domes) frequently fail endovascular treatment. We report our experience using the pretemporal transzygomatic transcavernous approach with 50 complex basilar aneurysms.

METHODS

Using the pretemporal transcavernous route, opening the occulomotor trigone, and removing the anterior clinoid and the posterior clinoid when necessary, a wide exposure of the interpeduncular fossa is achieved. Temporary clips are applied to a perforator-free zone of the basilar trunk, proximal to the superior cerebellar artery. Complexity criteria in the 50 aneurysms included large or giant size in 27 patients, wide dysmorphic base in 18 patients, low bifurcation in 21 patients, posteriorly projecting dome in 11 patients, and dolichoectasia of the apex in three patients.

RESULTS

Twenty-five patients presented with subarachnoid hemorrhage. There were 14 men and 36 women between the ages of 32 and 76 years (mean, 52.2 yr). Forty-nine aneurysms (98%) were successfully clipped. There was no procedure-related mortality. Two patients died (one from delayed bowel ischemia and one from a vasospasm-related complication). There were three ischemia-related events, two of which were procedure-related (medial thalamic lacunar infarct, superior cerebellar distribution ischemia) and one which was a third distal middle cerebral cardiac embolus after stopping Coumadin (DuPont Pharmaceuticals, Wilmington, DE) for atrial fibrillation. Transient partial or complete occulomotor palsies occurred in all patients with full recovery as the rule, except in one patient. At discharge, Glascow Outcome Scale scores were 4 or 5 in 88% of the patients. At the 6-month follow-up examination, Rankin Outcome Scale scores were 0 to 2 in 92% of the patients.

CONCLUSION

Our experience reintroduces microsurgery as a safe and more durable treatment option for the management of complex basilar apex aneurysms that tend to have a higher rate of failure with endovascular therapy.

Delayed coil migration from a small wide-necked aneurysm after stent-assisted embolization: case report and literature review

INTRODUCTION

We present a previously unreported complication following the treatment of a patient with two small, wide-necked, posterior communicating artery aneurysms.

METHODS

Endovascular embolization of one aneurysm was performed using a stent-assisted technique. Follow-up angiography 5 months later revealed that a coil had escaped the confinement of the stent and migrated distally without occluding any arterial branches or causing symptoms. This case report demonstrates that although a rare occurrence, a coil can break loose from the stent.

DISCUSSION

We discuss the potential mechanisms of this phenomenon and review the literature on stent-assisted aneurysm coiling in order to raise awareness of this event when embolizing small, wide-necked aneurysms with a stent-assisted technique.

Rerupture following endovascular treatment for dissecting aneurysm of distal anterior inferior cerebellar artery with parent artery preservation: retreatment by parent artery occlusion with Guglielmi detachable coils

Distal anterior inferior cerebellar artery (AICA) aneurysms are rare and most cases have been treated surgically by clipping, wrapping or trapping. We recently treated this 20-year-old male patient by an endovascular technique. At first, he was treated by intra-aneurysmal embolisation with parent artery preservation. But he presented with rerupture 1 month after embolisation. Follow-up angiography revealed the regrowth of the aneurysm, which was considered as a dissecting aneurysm. We performed occlusion of the AICA just proximal to the aneurysm to prevent fatal rebleeding. He gradually improved and his level of consciousness fully recovered. At 2 year follow up, he had no neurological deficits. We suggest that embolisation of distal AICA aneurysm with parent artery occlusion may be safe and a simple method in the treatment of distal AICA aneurysms.

Acceleration of Aneurysm Healing by Hollow Fiber Enabling the Controlled Release of Basic Fibroblast Growth Factor

OBJECTIVE

The objective of this study was to develop an embolization material of hollow fiber combined with gelatin hydrogel for the controlled release of basic fibroblast growth factor (bFGF). We examined feasibility of the material in embolization healing aneurysm by bFGF-induced tissue organization.

METHODS

An aneurysm was prepared at the common carotid artery of 60 rabbits by the end-to-side anastomosis of jugular venous pouch. The hollow fibers combined with or without 100 microg free bFGF or gelatin hydrogel incorporating 0, 10, 50, or 100 microg bFGF were applied to the aneurysm. Tissue appearance or histological observation was performed 1, 2, 3, and 6 weeks after application to evaluate the area embolized by fibrous organization in the aneurysm and the neointima formation at the aneurysm orifice.

RESULTS

When applied with the hollow fibers combined with gelatin hydrogel containing 100 microg bFGF, the aneurysm was histologically occupied by fibrous tissue newly formed 3 weeks later, whereas neointima was formed at the aneurysm orifice. The histological area occupied by fibrous tissue was significantly larger than that of hollow fibers combined with 100 microg bFGF. No influence of bFGF dose on the aneurysm healing by the fibers combined with hydrogels incorporating bFGF was observed.

CONCLUSION

Local, controlled release of bFGF from the hollow fibers combined with gelatin hydrogel incorporating bFGF accelerated the aneurysm healing by tissue organization.

[Acutely ruptured intracranial aneurysms treated with GDC coils. Results from a single center over a period of 5 years]

PURPOSE

We prospectively reviewed the clinical results of acutely ruptured cerebral aneurysms treated with GDC over a 5 year period, in order to characterize death and dependency factors.

METHODS

Between 1997 and 2002, 229 patients (254 aneurysms treated, 140 females, 89 males; mean age: 51 years) with aneurysmal subarachnoid hemorrhage were treated with GDC (Boston Scientific Neurovascular, Fremont, CA) once the anatomical conditions of feasibility had been achieved. Over 90% of the aneurysms treated (mean size: 5,8 mm) were located in the anterior circulation. The anterior communicating artery complex (87 cases), the posterior aspect of the internal carotid artery (65 cases), and the middle cerebral artery (49 cases) were most commonly treated.

RESULTS

At the end of the initial hospitalization period, 14 patients (6.1%) died. Major procedural complications were associated with perforation of the aneurysmal sac in 9 patients (3.9%), thromboembolic events in 10 patients (4.3%) which resulted in 2 deaths (0.8%) and permanent neurologic morbidity in 7 patients (3%). The univariate analysis demonstrated no correlation between death and time-to-treatment, the topography of the aneurysm, or the occurrence of treatment related complications. The results of the logistical regression model demonstrated that the clinical score upon entry, and the occurrence of delayed ischemia were the only independent factors correlated with patient death. The prognostic factors affecting the degree of sequellae identified by the logistical regression model were the clinical score upon admission, age, treatment related complications, and pulmonary complications.

CONCLUSIONS

Endovascular treatment of ruptured anterior circulation aneurysms with GDC, including MCA aneurysms, is associated with low morbidity and allows good overall outcomes in patients with subarachnoid hemorrhage. A better understanding of dependency factors associated with endovascular coiling will foster further technical advances in order to improve the treatment of small and medium sized ruptured aneurysms.

Endovascular Treatment of Ruptured Aneurysms Associated With Fenestrated Basilar Artery-Two Case Reports-

Two patients with ruptured aneurysm associated with fenestrated basilar artery (BA) were treated using the endovascular approach. Angiography showed these patients had different types of BA bifurcation. One type had two points of bifurcation and a bridging artery in the BA fenestration, with the aneurysm at the bifurcation of the right loop of the fenestration. The aneurysm had different appearances on right and left vertebral angiograms. The other type had only one point of bifurcation, and the appearance of this aneurysm was similar on both angiograms. To ensure successful embolization, bilateral vertebral angiography should be performed for complete assessment of the morphological characteristics of aneurysm associated with fenestrated BA.

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.

Outcome of surgical clipping for ruptured, low-grade, anterior circulation cerebral aneurysms: should clipping be omitted after International Subarachnoid Aneurysm Trial?

BACKGROUND

A recent randomized trial for ruptured aneurysm resulted in poorer outcomes for the surgical group than the endovascular group. However, the surgical results seemed to be worse than could be expected for experienced neurosurgeons in Japan. We therefore analyzed our own surgical results and evaluated them for a comparison with the trial results.

METHODS

Data on patients with ruptured, small, anterior circulation aneurysms in good clinical condition (World Federation of Neurological Surgeons grade I or II) and treated with surgical clipping were obtained from various discharge databases for 1997 to 2001, and their outcomes were analyzed in a retrograde fashion.

RESULTS

Of the total of 487 patients, 17.6% showed a poor outcome (modified Rankin Scales 3-6) at discharge, and after 1 year, 6.1% remained in poor clinical condition. However, fewer patients were in poor condition both at discharge and after 1 year compared with the surgical and endovascular results for patients entered in the International Subarachnoid Aneurysm Trial. Complete occlusion of the aneurysm was attained in 93.6% of our patients. Rebleeding from the treated aneurysm occurred in 0.6%, and there was no rebleeding after 1 year.

CONCLUSIONS

Surgical clipping is a safe and reliable treatment and can be the first choice for small ruptured aneurysms of the anterior circulation with a good grade.

Treatment of unruptured cerebral aneurysms by embolization with guglielmi detachable coils: case-fatality, morbidity, and effectiveness in preventing bleeding--a systematic review of the literature

OBJECTIVE

Guglielmi detachable coils (GDCs) increasingly are being used to treat unruptured cerebral aneurysms (UCAs). We systematically reviewed the literature to assess the case-fatality and permanent morbidity rates of GDC embolization of UCAs and the postembolization bleeding rate.

METHODS

Through a MEDLINE search of the English, Italian, and French literature from January 1990 through December 2002, we retrieved studies on GDC embolization of aneurysms and extracted data on UCAs. Inclusion criteria were: 1) attempted GDC embolization of at least five consecutive patients with UCAs, 2) reported percentage of at least either case-fatality or permanent morbidity rate or crude data allowing an independent calculation. When data on UCAs could not be characterized with certainty among data on other, different lesions, the study was rejected.

RESULTS

We included 30 studies. One thousand three hundred seventy-nine patients were available for the calculation of the case-fatality rate, 794 for the permanent morbidity rate, and 703 for the bleeding rate. The case-fatality rate was 0.6% (95% confidence interval, 0.2-1%), the permanent morbidity rate was 7% (95% confidence interval, 5.3-8.7%), and the bleeding rate was 0.9% per year (95% confidence interval, 0.41-1.4%). Only incompletely coiled UCAs of 10 mm or more accounted for the bleeding events. Morbidity decreased from 8.6% to 4.5% (P < 0.05) when the midyear of study (average calendar year of treatment) was 1995 or later.

CONCLUSION

GDC embolization of UCAs is relatively safe, and the outcome is progressively improving. Partial embolization of UCAs of 10 mm or more is unlikely to provide an acceptable protection. Most of the source publications suffer from methodological weaknesses. Prospective studies with longer follow-up periods are needed to definitively assess the effectiveness of GDCs on UCAs.

Surgical Clipping of Complex Basilar Apex Aneurysms: A Strategy for Successful Outcome Using the Pretemporal Transzygomatic Transcavernous Approach

OBJECTIVE:

Complex basilar apex aneurysms (large size, wide and complex neck, tortuous parent vessels) continue to pose a challenge in treatment. Endovascular treatment has a high risk of recanalization, and surgical treatment is limited by the space and time necessary to achieve safe clipping. To overcome these obstacles, a modification of previously reported approaches was developed. The pretemporal transzygomatic transcavernous approach and a clipping strategy were used in the treatment of 21 high-complexity basilar apex aneurysms.

METHODS:

By use of the pretemporal route, the zygomatic notch was widened, the anterior clinoid was removed, the cavernous sinus was partially exposed, and the oculomotor nerve was mobilized. The depth of the field was widened by further cavernous exposure and the removal of the posterior clinoid. Temporary clips were applied to the basilar trunk perforator-free zone to preserve visualization of the aneurysm neck and perforators and to maintain collateral flow to the brainstem.

RESULTS:

Twenty-one high-complexity basilar apex aneurysms, 11 of which caused subarachnoid hemorrhage, were treated. Twenty (95%) were successfully clipped (Glasgow Outcome Scale scores, 4 or 5 in 90.5% at discharge; Rankin Disability Score, 1 in 90.5% at 1-yr follow-up). Complications were transient oculomotor palsy in all patients, small thalamic infarct in one patient, and cerebrospinal fluid leak in another. There was no surgical mortality. Delayed follow-up angiography in 19 of the 21 patients showed no residual aneurysm.

CONCLUSION:

We report the largest series of a unique, challenging group of complex basilar apex aneurysms treated with the pretemporal transzygomatic transcavernous approach, which provided improved safety of clipping by 1) increased visualization of the basilar apex and perforator arteries, 2) improved maneuverability of clip application, 3) a safer perforator-free location, and 4) preservation of brainstem collateral flow.

Evaluation of the Stability of Small Ruptured Aneurysms with a Small Neck after Embolization with Guglielmi Detachable Coils: Correlation between Coil Packing Ratio and Coil Compaction

OBJECTIVE:

Because it is difficult to predict the compaction of Guglielmi detachable coils (GDCs) after endovascular surgery for aneurysms, we studied the relationship between the coil packing ratio and compaction. Here, we propose a simple method for the preoperative estimation of coil compaction. Using follow-up angiograms, we studied the timing and degree of coil compaction in small terminal and side-wall aneurysms with narrow necks.

METHODS:

We studied 62 patients with acute ruptured intracranial aneurysms that were small (&lt;10 mm), had a small neck (&lt;4 mm), and were coil embolized with GDC-10s. The aneurysmal volume was calculated using the equation V = 4/3π(a/2) × (b/2) × (c/2), where a, b, and c are the aneurysmal height, length, and width in millimeters, respectively. The coil volume was calculated using the equation V = π(p/2)2 × l × 10, where p represents the GDC-10 coil diameter (0.25 mm) and l is the coil length. We recorded the maximum prospective coil length, L, as that corresponding with the volume of packed coils occupying 30% of the aneurysmal volume. Therefore, L was calculated as L (cm) = 0.3 × a × b × c, and the coil packing ratio was expressed as packed coil length/L × 100. Angiographic follow-up studies were generally performed at 3 months and 1 and 2 years after endovascular surgery. We considered coil compaction exceeding 2 mm as major compaction and recorded minor compaction when it was less than 2 mm of the empty reappeared space in the embolized aneurysm. Aneurysmal location was recorded as terminal or side wall.

RESULTS:

Of the 62 patients, 16 (25.8%) manifested angiographic coil compaction (10 minor and 6 major compactions); the mean coil packing ratio was 51.9 ± 13.4%. The mean coil packing ratio in the other 46 patients was 80.5 ± 20.2%, and the difference was statistically significant (P &lt; 0.01). In all 6 patients with major compaction, the mean packing ratio was less than 50% and all underwent re-embolization after a mean of 24.9 ± 1.1 months. The 10 patients with minor compaction were conservatively treated, and the degree of compaction did not change during a mean period of 24 months. We detected 93.8% of the compactions within 12 months of coil placement. The aneurysm was of the terminal type in 5 of the 6 patients with major coil compaction.

CONCLUSION:

In patients who underwent embolization with GDC-10s of aneurysms that were small and had a small neck, the optimal coil packing ratio could be identified with the formula 0.3 × a × b × c. The probability of coil compaction was significantly higher when the coil packing ratio was less than 50%. To detect coil compaction after embolization, follow-up angiograms must be examined regularly for at least 12 months. To detect major coil compaction in patients with terminal type aneurysms, angiographic follow-up should not be shorter than 24 months.

Emergency Extracranial-to-Intracranial Bypass after Thromboembolic Occlusion of the Middle Cerebral Artery Following GDC Embolization of a Ruptured ACoA Aneurysm

SUMMARY

We report a case of thromboembolic occlusion of the middle cerebral artery after endovascular treatment of a ruptured anterior communicating artery aneurysm. When fibrinolytic therapy failed to recanalize the occluded vessel, an emergency extracranial-to-intracranial bypass was performed. This intervention rescued our patient from cerebral infarction. This case demonstrates the importance of the offering this procedure at neurointerventional centers.

Endovascular therapy versus surgical clipping for basilar artery bifurcation aneurysm: retrospective analysis of 117 cases

OBJECTIVE

The purpose of this study was to retrospectively evaluate and compare the feasibility, indication and limitations of two treatment options, clipping and coil embolization, for basilar artery (BA) bifurcation aneurysms.

MATERIALS AND METHODS

During the last 13 years, 117 patients with 117 BA bifurcation aneurysms were treated exclusively with direct surgery until February 1997, and with either direct surgery or coil embolization therapy since March 1997. Of them, 76 (65%) aneurysms were treated with direct clipping and 41 (35%) were treated with Guglielmi detachable coils (GDCs) embolization. The 76 surgically clipped aneurysms were analyzed on the basis of the pre-operative angiograms as to whether coil embolization would be feasible or not if each case had been attempted. The 41 embolized aneurysms, on the other hand, were analyzed as to whether clipping surgery would be feasible or not if it had been attempted.

RESULTS

In the total 117 aneurysms, complete coil obliteration was judged to be possible and simple in 61 (52%) aneurysms, possible with complex techniques (difficult) in 29 (25%) and impossible in 27 (23%). Whereas, complete obliteration with direct clipping was judged to be simple in 66 (57%) aneurysms, difficult in 38 (32%) and impossible in the remaining 13 (11%). Linear correlation as to the technical difficulty was found in 61 (52%) aneurysms, but 14 (12%) had marked discrepancy between the two methods. Of the 76 patients treated with clipping surgery, 17 (22%) were left with some post-operative neurological deficits, and in six out of the 17 aneurysms, embolization might have been simple. There were complications in two patients; one procedure-related and the other with late re-bleeding due to aneurysmal re-growth, in the embolization, group.

CONCLUSIONS

Endovascular therapy is an effective alternative for treating BA bifurcation aneurysms, although a quarter of the cases cannot be obliterated completely. It is important to select a suitable treatment option in each case depending on the patient's condition and the angiographical features of each aneurysm as well as the characteristics of the two methods.

Endovascular coil occlusion of 1811 intracranial aneurysms: early angiographic and clinical results

OBJECTIVE

We sought to evaluate the early angiographic and clinical outcomes of the first session of endovascular coil occlusion of a large number of patients with intracranial aneurysms treated by five neurointerventionalists during a decade at a single center.

METHODS

We performed retrospective analyses of pre- and postprocedural angiographic studies and early clinical outcomes. Enrolled patients underwent endovascular treatment of intracranial aneurysms with detachable coils.

RESULTS

A total of 1811 aneurysms in 1579 patients were treated with coil occlusion. Of these, 90 to 100% occlusion of 86.5% of the aneurysms was achieved. In 82.3% of the procedures, no complications occurred. The clinical outcome profile at primary discharge according to the Glasgow Outcome Scale was as follows: Grade V, 74.6%; Grade IV, 6.7%; Grade III, 11.1%; Grade II, 3.1%; and Grade I, 4.5%. In patients with large aneurysms with wide necks, a lower occlusion rate and an increased complication rate were encountered. The use of three-dimensional and fibered coils resulted in higher occlusion rates. Balloon remodeling and stent deployment increased the complication rate. Previous aneurysm rupture, procedural complications, and vasospasm correlated with poor outcome. Of the patients in poor grade after aneurysm rupture, 42% recovered to Glasgow Outcome Scale Grade IV or V, as opposed to 90% of patients who were treated for unruptured aneurysms. The ischemic complication rate was 9%, and the hemorrhagic complication rate was 3%. The early procedural morbidity rate was 5.3%, and the procedural mortality rate was 1.5%. The management mortality rate was 4.4%.

CONCLUSION

These data confirm the safety and efficacy of endovascular coil occlusion for patients with intracranial aneurysms.

Vertebrobasilar junction aneurysms associated with fenestration: experience of five cases treated with Guglielmi detachable coils

BACKGROUND

Fenestration of vertebrobasilar junction is a rare congenital anomaly and often associated with aneurysm formation. We describe five cases of vertebrobasilar junction aneurysms in four patients associated with fenestration, which were treated with endovascular coil occlusion using Guglielmi detachable coils (GDCs). The importance of preoperative computed tomography (CT) angiography to understand the complex anatomy of fenestration and aneurysm is emphasized.

CASE REPORTS

Three patients presented with subarachnoid hemorrhage and one patient presented with headache only. Among 3 patients with subarachnoid hemorrhage, 1 patient was referred for endovascular coil occlusion after clipping of ruptured distal ACA aneurysm. A six-French guiding catheter was placed in the left vertebral artery via right femoral artery, except for 1 patient who had two vertebrobasilar junction aneurysms with complex anatomic relationship, accessed bilaterally. Five vertebrobasilar junction aneurysms with fenestration were treated with endovascular coil occlusion using GDCs. Postoperative angiography demonstrated successful occlusion of aneurysmal sac with preservation of basilar artery.

CONCLUSIONS

Vertebrobasilar junction aneurysms are frequently associated with fenestrations. In addition to vertebral angiography on both sides, CT angiography may be a valuable tool for better understanding of complex anatomy of aneurysms associated with fenestration. The surgically difficult aneurysms such as vertebrobasilar junction aneurysm with fenestration can be successfully treated with GDCs.

Anévrismes rompus de l’artère communicante antérieure

BACKGROUND AND PURPOSE

The respective roles of endovascular and surgical treatment must be clearly defined in the management of ruptured anterior communicating artery (AcoA) aneurysm. The aim of our study was to report our results, using the aneurysm direction as the main morphological argument to choose between microsurgery and endovascular embolization. Morbidity and mortality, causes of unfavorable outcome and morphological results were also assessed.

PATIENTS AND METHODS

Our prospective study included 119 patients: 89 treated by microsurgery and 30 undergoing embolization with Guglielmi Detachable Coils (GDC). When the aneurysm had an anterior direction (fundus of the aneurysm in front of the pericallosal arteries), we attempted microsurgery. If the fundus of the aneurysm was behind the pericallosal arteries, we selected the most adapted procedure after discussion with the neurovascular team, taking into account the physiological status, treatment risk and neck size. Preoperative status of the patients was assessed according to the Hunt and Hess (HH) classification. Cerebral CT-scan and angiograms were routinely performed after treatment to determine causes of unfavorable outcome (GOS>1) and the morphological results.

RESULT

Overall clinical outcome was excellent (GOS1) for 63.0% of patients, good (GOS2) for 10.1%, fair (GOS3) for 13.4%, poor (GOS4) for 2.5%. The mortality rate was 10.9%. Among the 82 patients in good preoperative grade (HH<or=III), the outcome was excellent in 67 (81.7%); the permanent morbidity (GOS 2-4) and mortality (GOS 5) rate was 18.3%. Among the 37 patients in poor preoperative grade (HH>III), 8 (21.6%) achieved an excellent outcome. However permanent morbidity or death occurred in 15 patients (78.4%). Permanent disability and death were related to initial subarachnoid hemorrhage and were observed 21.3% of patients in the microsurgical group and 30.0% in the endovascular group [Fisher's Exact Test; p=0.33]. Procedure-related permanent disability and death rates were 9.0% for the microsurgical group and 23.3% for the endovascular group (p=0.06) respectively. In the microsurgical group, the only morphologic characteristic which significantly correlated with the occurrence of vessel occlusion was the fundus direction (p=0.03). The difference between endovascular and microsurgical procedures in the achievement of complete occlusion was considered significant (p=0.04).

CONCLUSION

In our experience, the direction of the aneurysm was the main morphological criterion in choosing between microsurgery or endovascular procedure for the treatment of AcoA aneurysm. We propose that microsurgical clipping should be preferred for AcoA aneurysms with anterior direction, and depending on morphological criteria, endovascular packing for those with posterior direction.

Neurological, neuropsychological, and psychosocial outcome following treatment of unruptured intracranial aneurysms: a review and commentary

Thirty studies published between 1977 and 2001 that focus on outcome following unruptured intracranial aneurysm (UIA) treatment are reviewed. Although findings from these studies suggest outcome from UIA treatment is reasonably good (between 5% and 25% morbidity and between 0-7% mortality), many of the complex issues associated with the treatment of UIAs remain controversial. Most of the studies reviewed address outcome in terms of mortality and neurological morbidity. Very few studies exist which include measures of outcome such as cognitive status, psychosocial functioning and quality of life. Given that patients facing treatment tend to be healthy middle-aged adults with many years of active working and social life ahead of them, it is important to take into account the long-term consequences of either harboring an UIA, or having it treated. The small number of studies that include cognitive, psychosocial and quality of life outcomes are reviewed in some detail and suggestions made for improving future UIA outcome research.

Recurrent hemorrhage after initially complete occlusion of intracranial aneurysms

Recurrent hemorrhage in the case of incompletely treated aneurysms is well known. The authors present a series of patients in whom rebleeding occurred in spite of totally occluded aneurysms. During a period of 12 years, 1170 patients with intracranial aneurysms were treated using either clipping (n=727) or coiling (n=443). In 11 of them, intracranial rebleeding occurred, in seven of whom routine post-treatment angiography revealed total aneurysm occlusion before the appearance of rehemorrhage. Further analysis focused on these seven patients. Their recurrent aneurysm ruptures happened with a mean latency of 9.5 months (range 21 h-48 months) from initial treatment. All aneurysms belonged to the anterior circulation. Three patients underwent primary clipping, and four experienced coiling first. The intracranial hemorrhages appeared mainly as intracerebral hematomas. The angiographically documented recurrent aneurysm configurations were caused by clip slippage (n=2), coil compaction (n=3), or coil migration/dislocation (n=1). In one case with primary surgery, clip slippage was possible but not confirmed by intraoperative view, because the patient died before therapeutic intervention. Two patients did not undergo therapy because of their poor clinical condition and died. Four of the remaining patients underwent clipping of the recurrent lesions, and one had recoiling. Final outcome was excellent/good in only two patients. The mainly poor outcome after rebleeding was caused by the high incidence of intracerebral hemorrhage.

Acceleration of aneurysm healing by controlled release of basic fibroblast growth factor with the use of polyethylene terephthalate fiber coils coated with gelatin hydrogel

OBJECTIVE

The aims of this study were to develop an endovascular delivery system containing gelatin hydrogels for the controlled release of basic fibroblast growth factor (bFGF) with the use of polyethylene terephthalate fiber coils and to analyze whether such a system would promote healing in an experimental aneurysm.

METHODS

Carotid aneurysms were constructed in 66 rabbits with venous pouches. The polyethylene terephthalate fiber coils coated with and without gelatin hydrogels with different water volumes containing 0, 10, 50, and 100 microg bFGF were implanted into the aneurysms. Histological specimens were harvested at 1, 2, and 3 weeks and at 6 months after implantation. A histological evaluation was performed while the area occupied by the fibrosis in the aneurysms was calculated.

RESULTS

Three weeks after the application of the coils coated with gelatin hydrogels (95 vol%) containing 100 microg bFGF, all aneurysmal orifices were completely closed with neointima. When the coils coated with gelatin hydrogel (98 vol%) containing 100 microg bFGF were used, the orifices in three of the six aneurysms were closed. In contrast, the orifice of the aneurysm was not obliterated when other materials were used. After implanting the coils coated with gelatin hydrogel (95 vol%) containing 100 microg bFGF more than 3 weeks later, the aneurysm was histologically suffused with fibrous tissue, and the area occupied by fibrosis was significantly larger than that observed in the other groups (P < 0.05).

CONCLUSION

Local, controlled release of sufficient amounts of bFGF with polyethylene terephthalate fiber coils coated with gelatin hydrogel accelerated the organization of aneurysms.

Endovascular treatment of paraclinoid aneurysms: experience with 73 patients

OBJECTIVE

Aneurysms arising from the internal carotid artery in close relation to the clinoid process have been called paraclinoid aneurysms. The surgical management of these aneurysms poses technical challenges, and such patients are frequently referred for endovascular treatment. We reviewed our experience with endovascular coil embolization of paraclinoid aneurysms to evaluate the safety and efficacy of this treatment modality.

METHODS

From December 1993 to May 2002, 70 patients underwent endovascular procedures with detachable coils for 73 paraclinoid aneurysms (8 ruptured, 65 unruptured) at the University of Pittsburgh Medical Center and the University of Texas Southwestern Medical Center. A retrospective review of the medical records, outpatient charts, and operative reports was performed. Angiographic outcome was determined at the end of each procedure and by review of follow-up angiograms. Clinical assessments and outcomes are reported according to the Glasgow Outcome Scale (GOS).

RESULTS

Immediate angiographic outcomes for 73 paraclinoid aneurysms demonstrated complete occlusion in 53 (72.6%), near-complete occlusion in 6 (8.2%), and partial occlusion in 14 (19.2%). Nine aneurysms required more than one coiling session to complete treatment; 8 of these aneurysms required two sessions and 1 required four, for a total of 84 endovascular procedures. Follow-up angiograms could be obtained in 49 patients with 52 paraclinoid aneurysms. During the follow-up period, 6 aneurysms demonstrating partial occlusion and 3 demonstrating near-complete occlusion showed spontaneous progression of thrombosis to complete occlusion. Twelve aneurysms initially demonstrating complete occlusion (5 aneurysms), near-complete occlusion (3 aneurysms), or partial occlusion (4 aneurysms) showed coil compaction requiring retreatment. Of these 12 aneurysms that demonstrated coil compaction, 3 were treated with surgery and 9 with coil repacking. The final angiographic outcomes, determined on the last available follow-up angiograms of 49 aneurysms, excluding 3 surgically clipped aneurysms, showed complete occlusion in 43 (87.8%), near-complete occlusion in 3 (6.1%), and partial occlusion in 3 (6.1%). The angiographic follow-up period ranged from 4 to 54 months (mean, 13.9 mo). Morbidity and mortality rates related to 84 endovascular procedures were 8.3 and 0%, respectively. There were no recurrent or new subarachnoid hemorrhages in 63 patients in whom clinical follow-up could be performed during a mean clinical follow-up period of 14.4 months. The final clinical outcomes demonstrated a GOS score of 5 (good recovery) in 56 patients (88.9%), a GOS score of 4 (moderate disability) in 2 (3.2%), and a GOS score of 3 (severe disability) in 1 (1.6%). Four patients (6.3%) died of unrelated causes. The average period of hospitalization was 17.8 days in patients with acutely ruptured aneurysms and 3.5 days in patients with unruptured or retreated aneurysms.

CONCLUSION

The results of this study indicate that endovascular treatment is a safe and effective therapeutic alternative in ruptured and unruptured paraclinoid aneurysms. The endovascular treatment may also confer a positive impact in terms of the length of hospital stay.

The treatment of symptomatic unruptured aneurysms

The authors analysed 99 cases of symptomatic unruptured aneurysms amongst 427 cases which were collected from a multi-center study of Japanese national hospitals. There were 20 cases of giant aneurysms and 19 cases of posterior fossa aneurysms. Overall postoperative morbidity was 16%, and postoperative morbidity for giant aneurysms was 26%. The treatment of giant aneurysms and posterior fossa aneurysms proved to be very difficult according to our study.

Fatal rupture following intra-aneurysmal embolization for the distal posterior inferior cerebellar artery aneurysm with parent artery preservation

This 70-year-old female was admitted to our hospital 1 day after a sudden consciousness disturbance. Computed tomography (CT) showed subarachnoid hemorrhage (SAH), and angiogram revealed an irregular-shaped aneurysm at the lateral medullary segment of the left posterior inferior cerebellar artery (PICA). The patient was treated by intra-aneurysmal embolization with Guglielmi detachable coil (GDC) with parent artery preservation. Post-operative angiogram showed obliteration of the aneurysm except for the neck remnant, but she presented with rerupture 19 days after the onset and died 3 days later. Postmortem examination revealed massive hematoma around the aneurysm, which compressed medulla oblongata from behind. Histological assessment showed the 'entry' where the aneurysmal wall lacked internal elastic lamina, providing evidence of dissecting aneurysm. The present case suggests that embolization of distal PICA aneurysm with parent artery preservation should be avoided because radiological evaluation may fail to rule out the possibility of dissection, where the aneurysmal wall is affected not only at the 'entry' but also in the adjacent region.

Neurosurgical management of intracranial aneurysms previously treated with endovascular therapy

OBJECTIVE

With the increased use of endovascular therapy, an increasing number of patients with incompletely treated intracranial aneurysms are presenting for further surgical management. This study reviews our experiences with such patients.

METHODS

During a 7-year period, 38 patients with 40 intracranial aneurysms who were initially treated with endovascular therapy underwent surgical obliteration of refractory or recurrent lesions. All patients were recorded in a prospective registry, and their clinical data and imaging studies were analyzed retrospectively.

RESULTS

Twenty-six anterior and 14 posterior circulation aneurysms were treated. Four aneurysms were on the cavernous internal carotid artery, 13 were on the distal internal carotid artery, 6 were on the anterior communicating artery complex, 2 were on the middle cerebral artery, 3 were on the posteroinferior cerebellar artery, 1 was at the vertebrobasilar junction, 3 were on the superior cerebellar artery, 4 were at the basilar apex, 2 were on the posterior cerebral artery, and 1 was on the distal vertebral artery. Two pseudoaneurysms-one on the petrocavernous segment of the internal carotid artery and one on the distal VA-also were treated. The median time until recurrence was 6 months. Thirty-one aneurysms were clip-ligated, and six were treated with trapping. Three extracranial-intracranial bypasses were performed. One aneurysm was treated with muslin wrapping. Two aneurysms required the use of surgical approaches that involved hypothermic circulatory arrest. Nine aneurysms required coil mass extraction and/or complex vascular reconstruction to complete lesion obliteration. All aneurysms except the single wrapped aneurysm were successfully excluded from the intracranial circulation. Two deaths occurred as a result of the operative procedures, and another patient died as a result of subarachnoid hemorrhage-induced massive myocardial infarction. Ultimately, 86.8% of patients achieved an excellent or good recovery.

CONCLUSION

With endovascular therapy assuming an increasing role in the treatment of patients with intracranial aneurysms, more lesions that are refractory to initial treatment will require surgical management. Our experience indicates that good results are attainable, although technical challenges are frequently encountered.

Guglielmi detachable coil embolization of posterior circulation aneurysms: a systematic review of the literature

BACKGROUND

Early multicenter trials of Guglielmi detachable coil embolization of posterior circulations aneurysms have been followed by the publication of numerous single-center experiences. Summary of Review- We performed a MEDLINE literature search and extracted data from single-center reports containing at least 10 posterior circulation aneurysms. Twelve reports (495 aneurysms) were specific to the posterior circulation. Eighty-two percent of aneurysms arose near the basilar apex. Eighty-one percent of patients harbored unruptured aneurysms or presented in good clinical condition. Sixty-three percent of lesions were small, and 41% exhibited a narrow neck. Coil deposition was achieved in 97.6% of cases. Procedural complication and morbidity rates were 12.5% and 5.1%, respectively. Procedural and 30-day mortality rates were 1.4% and 6.7%, respectively. Complete aneurysm occlusion was achieved in 47.6%, near-complete occlusion (90% to 99%) in 43.4%, and incomplete occlusion in 9.0% of cases. There were a total of 52 recurrences (22.2%) in a subset of 234 evaluable patients. Ninety-two percent of these aneurysms exhibited wide necks. The annual risk of subarachnoid hemorrhage after embolization was 0.8%. Eighty-five percent of patients achieved functional independence, while only 5.3% lived dependent lifestyles. The overall mortality rate was 9.8%.

CONCLUSIONS

The published literature approximates a large series of basilar apex aneurysms. Embolization is moderately effective in completely excluding an aneurysm from the posterior circulation. The incidence of recurrence in wide-neck aneurysms and incompletely coiled aneurysms is substantial. Coil embolization is effective in preventing early rebleeding. Its role in the treatment of unruptured aneurysms remains unclear.

Clinical and radiographic outcome in the management of posterior circulation aneurysms by use of direct surgical or endovascular techniques

OBJECTIVE

Posterior circulation aneurysms can be difficult lesions to treat surgically, and they have potential for high morbidity and mortality, particularly in elderly patients or those in poor neurological condition. In an effort to improve outcomes, our combined neurosurgical and neuroendovascular unit has used both surgical clipping and endovascular coiling techniques to treat posterior circulation aneurysms. Patients considered at high risk for surgery were managed with endovascular treatment.

METHODS

From 1990 to 1998, 197 posterior circulation aneurysms in 189 patients were treated in our combined neurovascular unit. Of these aneurysms, 128 were ruptured, 63 were unruptured, and 6 had a distant history of rupture in patients who came to our center for delayed or repeat treatment. A total of 132 aneurysms were treated with surgical clipping (85 ruptured, 46 unruptured, and 1 with distant history of rupture) and 65 aneurysms were treated with endovascular coiling (43 ruptured, 17 unruptured, and 5 with distant history of rupture). Dissecting aneurysms of the vertebral or posteroinferior cerebellar arteries or aneurysms treated with proximal (Hunterian) occlusion were excluded from this analysis. Surgical risk was assessed using a previously described system (Massachusetts General Hospital [MGH] grade), which incorporates age, Hunt and Hess grade, size of lesion, and Fisher grade.

RESULTS

Overall clinical outcomes at 1 year of follow-up were 77.2% excellent or good, 10.2% fair, 4.1% poor, and 8.6% dead. Surgical treatment resulted in 95.6% complete aneurysm occlusion and 4.4% with residual aneurysm after surgical treatment, whereas endovascular treatment resulted in 32.3% complete occlusion, 26.2% with residual aneurysm, and 41.5% with partial occlusion. In most cases, however, treatment with Guglielmi detachable coils (Boston Scientific/Target, Fremont, CA) was performed for palliation rather than complete radiographic occlusion. Outcome was closely associated with MGH grade with either treatment modality. Excellent/good outcomes were achieved in 96, 92.3, 82.9, 46.2, and 0% of surgically treated patients with MGH Grades of 0, 1, 2, 3, and 4, respectively. In comparison, excellent/good outcomes were achieved in 100, 84.2, 61.9, 0, and 50% of endovascularly treated patients with MGH Grades of 0, 1, 2, 3, and 4, respectively.

CONCLUSION

A combined surgical and endovascular approach to posterior circulation aneurysms can achieve good outcomes in high-risk surgical patients treated by use of coiling techniques.

A technique for safe withdrawal of a catheter tip that hooks a coil loop

In cerebral aneurysm embolization with GDCs, coil movement and subsequent coil protrusion or migration may occur during catheter withdrawal. Coil migration or protrusion usually does not produce clinical problems, but sometimes it may do. Because the consequences of coil movement cannot be anticipated exactly, coil motion during a catheter withdrawal makes interventionists nervous. The authors report on a technique for safe withdrawal of a catheter tip that hooks a coil loop using a small soft coil.

Endovascular management of unruptured intracranial aneurysms: does outcome justify treatment?

OBJECTIVE

The appropriate management of unruptured intracranial aneurysms depends on a complete understanding of their natural history and on the risks and efficacy of treatment options. There is little current data on the risks of endovascular therapy for these aneurysms. The aim of this study was to assess outcome of endovascular treatment of unruptured intracranial aneurysms.

METHOD

A retrospective analysis was performed on all unruptured aneurysms treated by Guglielmi detachable (GD) coils at this institution from 1994 to 2000.

RESULTS

Seventy three unruptured aneurysms were treated in 62 patients. There were 52 female and 10 male patients, with a median age of 55.7 years. Clinical background was: subarachnoid haemorrhage due to rupture of an additional aneurysm (40), headache (4), third nerve palsy (four), familial (four), and incidental (10). There were 14 technical failures with no clinical sequelae. Four procedural complications occurred (5.5%, 95% confidence interval (95% CI) 0.3% to 10.9%). One patient had temporary clinical sequelae (1.4%, 95% CI 0% to 2.7%); 79% of treated aneurysms had stable occlusions at follow up, 10.5% showed improved occlusion grade, 10.5% showed some recurrence, and three patients have required retreatment. Follow up modified Glasgow outcome scores were grade 1, 71%; grade 2, 18%; grade 3, 3%; grade 4, 3%. There were no deaths or haemorrhages during the follow up period. Two patients died as a result of complications from subarachnoid haemorrhage.

CONCLUSION

The endovascular treatment of patients with unruptured aneurysms is safe with few clinical or procedural complications. Poor outcomes were only seen in those patients who presented with subarachnoid haemorrhage due to rupture of an aneurysm at another site.

Endovascular therapy for intracranial aneurysms: a historical and present status review

Beginning in the 1960s, neurosurgeons and radiologists have made attempts to treat intracranial aneurysms using nonclip techniques. The evolution of such therapy has included acrylics, metallic particles, balloons, electric current, and nondetachable and detachable coils. This article will chronologically review these various techniques and the papers that reported their results so that the reader can understand how endovascular therapy developed and the position it currently holds in the treatment of intracranial aneurysms.

Rescue balloon procedure for an emergency situation during coil embolization for cerebral aneurysms. Technical note

In this article the authors describe a rescue balloon procedure for coil implantation in three cases. In each patient, the coil seemed likely to unravel. The coils stretched when attempts were made to remove the partially implanted but trapped device. The inflation of a nondetachable microballoon in front of the aneurysm orifice allowed the surgeons to complete implantation of the coil and to avoid a more forceful and potentially harmful retrieval. This rescue balloon method may be useful for emergency situations, such as coil stretching with or without migration.

Follow-up angiography of intracranial aneurysms treated with endovascular placement of Guglielmi detachable coils

OBJECTIVE

The success of endovascular treatment of intracranial aneurysms with Guglielmi detachable coils (GDCs) is dependent on the long-term exclusion of the aneurysm from the circulation. We reviewed our experience with the long-term angiographic follow-up monitoring of aneurysms that had been treated with GDCs.

METHODS

All patients whose aneurysms had been treated with GDCs between January 1995 and August 1999 and who subsequently underwent follow-up angiography at 6 months or more were included in this study. We reviewed all of the angiographic findings, to determine the percentage of aneurysm occlusion on the initial angiograms and on the last available follow-up angiograms. The categories of aneurysm occlusion used were 100%, >or=95%, and less than 95% occlusion.

RESULTS

One hundred thirty patients with 141 aneurysms underwent 143 endovascular coiling procedures and subsequently underwent angiographic follow-up monitoring of 6 months or more. There were 102 female and 28 male patients. The mean angiographic follow-up period was 16.7 months (range, 6-62 mo). The initial rates of occlusion were 100% for 56 aneurysms (39%), >or=95% for 65 aneurysms (46%), and less than 95% for 22 aneurysms (15%). Recurrence of one aneurysm (1.8%) was observed. Of the 87 aneurysms that were incompletely occluded initially, there was progressive thrombosis in 40 (46%), stable neck remnants in 23 (26%), and enlargement of the residual neck in 24 (28%). The final occlusion rates, determined on the last available angiograms, were 100% for 88 aneurysms (61%), >or=95% for 31 aneurysms (22%), and less than 95% for 24 aneurysms (17%). No patient experienced repeat or new subarachnoid hemorrhage more than 6 months after the initial treatment.

CONCLUSION

Late angiographic follow-up monitoring of aneurysms that have been treated with GDCs demonstrates the durability of the treatment. Aneurysms with large residual neck remnants were subjected to further treatment, whereas aneurysms with small residual neck remnants remain under observation.

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.

Guidewire-induced carotid cavernous fistula

SUMMARY

A rare case of carotid cavernous fistula occurring during endovascular embolization of the left carotid cave aneurysm in a 48-year-old female is reported. It was thought to be caused by the tear of a small branch derived from the intracavernous internal carotid artery while the guidewire was passing the sharp posterior bend of the intracavernous internal carotid artery. The left carotid cave aneurysm was completely occluded with five Guglielmi detachable coils assisted by neck plasty technique. It was decided to follow-up the carotid cavernous fistula since it was asymptomatic. Follow-up angiogram performed two weeks later revealed spontaneous obliteration of the carotid cavernous fistula.

Assessment of acutely unsuccessful attempts at detachable coiling in intracranial aneurysms

OBJECTIVE

Guglielmi detachable coiling (GDC) has quickly become the most common endovascular method for the treatment of intracranial aneurysms. Although several published case series describe various authors' successful experiences or complications, few have elaborated on failed attempts. We examined our experience with GDC, and we analyzed all failed attempts at coiling.

METHODS

Patients who underwent endovascular procedures from September 1995 through July 1999 were identified using endovascular case logs and billing records. Patient charts were then reviewed retrospectively for failed attempts at GDC. A treatment failure was defined as an inability to place coils into an aneurysm, a GDC procedure-related complication resulting in death, or an acute rehemorrhage from a coiled aneurysm that indicated a failure of coils to prevent rerupture. Thromboembolic events and other nonfatal sources of morbidity that did not preclude coiling of the aneurysm were analyzed only to the extent that they prevented successful coiling of the aneurysm.

RESULTS

From September 1995 to June 1999, 241 patients underwent GDC embolizations or attempts. In these patients, 35 procedures were unsuccessful, including 7 deaths from intraoperative or postoperative aneurysmal rerupture. Sixteen aneurysms could not be microcatheterized, nine of which were anterior communicating artery aneurysms. Coils from 13 wide-necked aneurysms (average fundus-to-neck ratio, <2) prolapsed into the parent vessel. Three procedures were abandoned when the aneurysms were found to have normal branches filling from the dome, and three additional procedures were abandoned for technical reasons. Five deaths resulted from intraoperative aneurysm rupture, and two patients died postoperatively from rerupture.

CONCLUSION

The number of successful coiling procedures has increased with experience and improved technology. The procedure still involves risks, however, primarily for patients with subarachnoid hemorrhage.

Bioabsorbable polymeric material coils for embolization of intracranial aneurysms: a preliminary experimental study

OBJECT

A new embolic agent, bioabsorbable polymeric material (BPM), was incorporated into Guglielmi detachable coils (GDCs) to improve long-term anatomical results in the endovascular treatment of intracranial aneurysms. The authors investigated whether BPM-mounted GDCs (BPM/GDCs) accelerated the histopathological transformation of unorganized blood clot into fibrous connective tissue in experimental aneurysms created in swine.

METHODS

Twenty-four experimental aneurysms were created in 12 swine. In each animal, one aneurysm was embolized using BPM/GDCs and the other aneurysm was embolized using standard GDCs. Comparative angiographic and histopathological data were analyzed at 2 weeks and 3 months postembolization. At 14 days postembolization, angiograms revealed evidence of neck neointima in six of eight aneurysms treated with BPM/GDCs compared with zero of eight aneurysms treated with standard GDCs (p < 0.05). At 3 months postembolization, angiograms demonstrated that four of four aneurysms treated with BPM/GDC were smaller and had neck neointima compared with zero of four aneurysms treated with standard GDCs (p = 0.05). At 14 days, histological analysis of aneurysm healing favored BPM/GDC treatment (all p < 0.05): the grade of cellular reaction around the coils was 3 +/- 0.9 (mean +/- standard deviation) for aneurysms treated using BPM/GDCs compared with 1.6 +/- 0.7 for aneurysms treated using GDCs alone; the percentage of unorganized thrombus was 16 +/- 12% compared with 37 +/- 15%, and the neck neointima thickness was 0.65 +/- 0.26 mm compared with 0.24 +/- 0.21 mm, respectively. At 3 months postembolization, only neck neointima thickness was significantly different (p < 0.05): 0.73 +/- 0.37 mm in aneurysms filled with BPM/GDCs compared with 0.16 +/- 0.14 mm in aneurysms filled with standard GDCs.

CONCLUSIONS

In experimental aneurysms in swine, BPM/GDCs accelerated aneurysm fibrosis and intensified neck neointima formation without causing parent artery stenosis or thrombosis. The use of BPM/GDCs may improve long-term anatomical outcomes by decreasing aneurysm recanalization due to stronger in situ anchoring of coils by organized fibrous tissue. The retraction of this scar tissue may also decrease the size of aneurysms and clinical manifestations of mass effect observed in large or giant aneurysms.

Severe Subarachnoid Hemorrhage With Pulmonary Edema Successfully Treated by Intra-aneurysmal Embolization Using Guglielmi Detachable Coils. Two Case Reports

A 48-year-old male and a 39-year-old female presented with subarachnoid hemorrhage (SAH) due to ruptured anterior communicating artery aneurysms. Both patients were comatose on admission. Chest radiography disclosed pulmonary edema. They were conservatively treated under controlled ventilation, but cardiopulmonary dysfunction persisted over 2 days. The patients were then treated by intra-aneurysmal embolization with Guglielmi detachable coils (GDCs) 2 days after the onset. The postoperative courses were uneventful, and the patients showed full recovery from pulmonary edema and were discharged without neurological deficits. Neurogenic pulmonary edema is one of the serious complications of SAH, and is a leading cause of poor clinical outcome. The favorable outcomes of the present cases suggest that intra-aneurysmal embolization with GDCs is an excellent choice for the patients with severe aneurysmal SAH complicated with pulmonary edema, in whom conventional surgical treatment under general anesthesia is difficult to perform in the acute stage.

Intentional body clipping of wide-necked basilar artery bifurcation aneurysms

OBJECT

Neck clipping or coil embolization cannot always achieve complete neck obstruction in wide-necked basilar artery (BA) bifurcation aneurysms. Clipping of the aneurysm body, leaving a small aneurysm rest, is one clipping method used for this kind of aneurysm to maintain the patency of the posterior cerebral arteries and perforating vessels. However, the long-term efficacy of intentional body clipping has not been well investigated. The authors reviewed their experience with intentional body clipping of wide-necked BA bifurcation aneurysms to determine suitable clipping techniques and the long-term efficacy of the procedure.

METHODS

Complete neck occlusion was abandoned and body clipping intentionally performed in 17 patients with BA bifurcation aneurysms; wrapping of the aneurysm rest was made in seven cases. There were 10 ruptured aneurysms (58.8%), and the size of the aneurysm was larger than 10 mm in 11 patients (64.7%). The width between the clip blades and the base of the aneurysm neck was 1 mm in 11 cases, 2 mm in four, and 3 mm in two. Favorable outcome (Glasgow Outcome Scale [GOS] Score 4 or 5) was obtained in 13 cases (76.5%) and unfavorable outcome (GOS Scores 1-3) in four cases (23.5%). Major causes of unfavorable outcome included injury to perforating arteries and major vessel occlusion following surgical manipulation, in addition to the primary damage caused by subarachnoid hemorrhage. Subarachnoid hemorrhage did not occur during a mean follow-up period of 7.4+/-5.6 years (range 0.7-18.1 years) after treatment.

CONCLUSIONS

Intentional body clipping of wide-necked BA aneurysms proved to be effective to prevent subarachnoid hemorrhage, although injury to perforating arteries remains problematic. The choice of complete neck clipping or body clipping should be established early during the microsurgical procedure to reduce the risk of injury to perforating vessels.

Prospective analysis of aneurysm treatment in a series of 103 consecutive patients when endovascular embolization is considered the first option

OBJECT

The aim of this study was to evaluate prospectively the results of treating cerebral aneurysms with coil embolization (CE) or with surgical clipping when CE was considered the first option.

METHODS

Whenever an aneurysm was to be treated, CE was first considered by our neurovascular team. Surgical clipping was reserved for cases excluded from CE or cases in which CE failed. The study consisted of 103 consecutive patients with 132 aneurysms, of which 127 were treated. Coil embolization was performed using Guglielmi detachable coils, and surgery was performed using Zeppelin clips. Three groups were defined: Group A consisted of 64 aneurysms that were treated by CE (neck/sac ratio < 1:3); Group B, 63 aneurysms that were surgically clipped; and Group C, 12 aneurysms that failed to be satisfactorily (> or = 95%) embolized and were subsequently clipped. The percentages of residual aneurysm were 31.2% in Group A, 1.6% in Group B, and 0% in Group C. The percentages of patients with poor Glasgow Outcome Scale (GOS) scores (GOS Scores 1-3) were 13.3% in Group A, 6.1% in Group B, and 8.3% in Group C. The percentages of poor outcome (GOS Scores 1-3) in patients with good clinical status before treatment were 10.7% in Group A, 0% in Group B, and 8.3% in Group C.

CONCLUSIONS

Even with preselection, CE remains associated with a significant number of treatment failures and poor outcomes, even in patients with good preoperative clinical status. Surgical clipping can offer better results than CE, even for more complex aneurysms of the anterior circulation, especially for those involving the middle cerebral artery cases. However, because CE can be effective and causes less stress and invasiveness for the patient, it should be considered first in aneurysms strictly selected by a neurovascular team.