Basilar tip aneurysm: endovascular treatment with Guglielmi detachable coils--midterm results

Posterior Circulation Aneurysms

Posterior circulation aneurysms have a higher tendency to rupture and become symptomatic in comparison to anterior circulation aneurysms. Current treatment modalities for aneurysms in these locations vary widely including microsurgical clipping, trapping with bypass, wrapping, and various endovascular methods such as coiling, balloon or stent-assisted coiling, flow diversion, and vessel sacrifice, among others.Overall, surgical versus endovascular treatment of posterior circulation aneurysms continue to be a controversial topic in cerebrovascular neurosurgery. At our center, multi-disciplinary assessments including surgeons capable of both endovascular and microsurgical treatments of these aneurysms are employed to guide the treatment strategies. As advancements in both fields are made, this will continue to be a topic for debate. Anatomy and individual patient's characteristics will dictate the correct approach and therefore proficiency in the microsurgical techniques required to treat these aneurysms will continue to be both relevant and important.

A comparison between magnetic resonance angiography at 3 Teslas (time-of-flight and contrast-enhanced) and flat-panel digital subtraction angiography in the assessment of embolized brain aneurysms

PURPOSE

To compare the time-of-flight and contrast-enhanced- magnetic resonance angiography techniques in a 3 Tesla magnetic resonance unit with digital subtraction angiography with the latest flat-panel technology and 3D reconstruction in the evaluation of embolized cerebral aneurysms.

INTRODUCTION

Many embolized aneurysms are subject to a recurrence of intra-aneurismal filling. Traditionally, imaging surveillance of coiled aneurysms has consisted of repeated digital subtraction angiography. However, this method has a small but significant risk of neurological complications, and many authors have advocated the use of noninvasive imaging methods for the surveillance of embolized aneurysms.

METHODS

Forty-three aneurysms in 30 patients were studied consecutively between November 2009 and May 2010. Two interventional neuroradiologists rated the time-of-flight-magnetic resonance angiography, the contrast-enhanced-magnetic resonance angiography, and finally the digital subtraction angiography, first independently and then in consensus. The status of aneurysm occlusion was assessed according to the Raymond scale, which indicates the level of recanalization according to degrees: Class 1: excluded aneurysm; Class 2: persistence of a residual neck; Class 3: persistence of a residual aneurysm. The agreement among the analyses was assessed by applying the Kappa statistic.

RESULTS

Inter-observer agreement was excellent for both methods (K = 0.93; 95 % CI: 0.84-1). Inter-technical agreement was almost perfect between time-of-flight-magnetic resonance angiography and digital subtraction angiography (K = 0.98; 95 % CI: 0.93-1) and between time-of-flight-magnetic resonance angiography and contrast-enhanced-magnetic resonance angiography (K = 0.98; 95% CI: 0.93-1). Disagreement occurred in only one case (2.3%), which was classified as Class I by time-of-flight-magnetic resonance angiography and Class II by digital subtraction angiography. The agreement between contrast-enhanced-magnetic resonance angiography and digital subtraction angiography was perfect (K = 1; 95% CI: 1-1). In three patients, in-stent stenosis was identified by magnetic resonance angiography but not confirmed by digital subtraction angiography.

CONCLUSION

Digital subtraction angiography and both 3T magnetic resonance angiography techniques have excellent reproducibility for the assessment of aneurysms embolized exclusively with coils. In those cases also treated with stent remodeling, digital subtraction angiography may still be necessary to confirm eventual parent artery stenosis, as identified by magnetic resonance angiography.

Endovascular therapy for selected (most non-surgical) intracranial aneurysms in a Brazilian University Hospital

OBJECTIVE: The objective of this study was to evaluate technical, clinical and angiographic results of a nonsurgical series of intracranial aneurysms treated by endovascular approach at Hospital das Clínicas of Medical School of Ribeirão Preto - University of São Paulo. METHOD: Between August 2005 and November 2008, 137 aneurysms in 106 patients were endovascularly treated. Of these, 101 were unruptured in 75 patients and 36 aneurysms in 31 patients were treated during the acute phase. The data were prospectively studied. RESULTS: Sixty three aneurysms (46%) were treated with coils alone, 52 (38%) with balloon remodeling, 15 (10.9%) with stent remodeling, and 7 (5.1%) with therapeutic occlusion of the internal carotid artery. Six clinical complications (5.7%) were related to the procedures, 3 (2.8%) transitory and 3 (2.8%) permanent. Angiographic follow-up was available for 97 aneurysms (70.8%), clinical monitoring for 77 patients (72.6%) and telephone contact for 97 (91.5%). CONCLUSION: The technical, clinical and angiographic results found in this study are similar to those reported in the literature

Intracranial Aneurysms and Vascular Malformations: Diagnosis and Therapy

The first part of our study describes the treatment of our patients with intracranial vascular malformations (aneurysms/AVMF – arteriovenous malformations) in a region of about 500,000 inhabitants. The second part will compare currrent treatment and the changes in treatment (microsurgery, endovascular interventional techniques, etc.) also in relation to topography and demography.

Treatment of intracranial aneurysms with hydrogel coated expandable coils

BACKGROUND

Coiling of intracranial aneurysms with platinum coils sometimes results in relatively poor angiographic results which may be is related to low packing volumes achieved. Hydrogel coated expandable coils (HydroCoil) have been shown to achieve better aneurysm volume filling which may potentially result in lower recanalization rates. Currently there is limited clinical data on their safety and efficacy in aneurysm treatment.

METHODS

We analyzed data from a prospectively collected database on patients treated at the Toronto Western Hospital. The analysis included the patients' characteristics, aneurysm size, packing, procedure related complications, recanalization and clinical outcome.

RESULTS

Twenty-nine aneurysms were treated with HydroCoils only or in combination with other coils. The average calculated filling of the aneurysm volume was 74-76%. On the immediate post treatment angiograms, 44% of the berry type aneurysms were completely obliterated, 33% had a residual neck and, in 20%, a residual aneurysm was seen. Follow-up imaging was available in 23 cases. On imaging follow-up (from 2 days to 11 months) one dissecting aneurysm had recanalized. There were six technical/medical complications with no clinical consequences. Two clinically significant procedural related complications occurred.

CONCLUSIONS

HydroCoils can be used effectively to treat intracranial aneurysms. The volume expansion allows for much greater packing than described for bare platinum coils, which may result in better long-term results. The recanalization rate is low but the limited follow-up does not allow for any conclusion regarding the long-term outcome. The complication rate is similar to larger current series using bare platinum coils.

ENDOVASCULAR COIL EMBOLIZATION OF RUPTURED AND UNRUPTURED POSTERIOR CIRCULATION ANEURYSMS

OBJECTIVE

Treatment of posterior circulation aneurysms poses a great technical challenge for the practicing neurosurgeon. The advent of endovascular techniques has made such treatment more feasible. We report our experience with the endovascular management of ruptured and unruptured posterior circulation aneurysms during the past 10 years.

METHODS

A retrospective analysis was performed on all patients with posterior circulation aneurysms undergoing endovascular treatment at Jefferson Hospital for Neuroscience between July 1995 and December 2005. This yielded 275 patients (67 men and 208 women). The degree of aneurysm occlusion was determined by the operating endovascular neurosurgeon at the time of the procedure. Successful embolization was defined as greater than 95% occlusion of the dome without any coil prolapsing into the parent vessel. Clinical outcome was evaluated using the modified Glasgow Outcome Scale. Clinical follow-up data was obtained for 262 patients (95.3%); the follow-up period ranged from 1 to 94 months (mean, 31.8 mo for procedures performed before 2004 and 13.3 mo for procedures performed during 2004 and 2005). Angiographic follow-up data was obtained for 224 patients (84.8%) for periods ranging from 6 to 94 months (mean, 31.3 mo for procedures performed before 2004 and 13.7 mo for procedures performed during 2004 and 2005).

RESULTS

Based on the Hunt and Hess grading scale, the patient population included 106 patients (38.5%) with unruptured aneurysms, 43 patients (15.6%) with Grade I aneurysms, 16 patients (5.8%) with Grade II aneurysms, 56 patients (20.5%) with Grade III aneurysms, and 54 patients (19.6%) with Grade IV aneurysms. The locations of the posterior circulation aneurysms included 189 (68.7%) in the basilar apex or posterior cerebral artery, 23 (8.4%) in the basilar trunk/anterior inferior cerebellar artery, 22 (8%) in the superior cerebellar artery, and 41 (14.9%) in the vertebral artery or posterior inferior cerebellar artery. Of the 275 patients, 208 (76%) were women and 67 (24%) were men. The mean age at the time of treatment was 53.9 years (range, 7–90 yr). Of all patients treated, 237 patients (87.8%) had successful embolization (>95% occlusion of the dome). On angiographic follow-up, 55 patients (24.5%) developed recanalization of at least 5%. Retreatment was required in 11 patients (4.9%; 0.01%/patient yr) and rehemorrhage occurred in three patients (1.1%; 0.003%/patient yr). Clinical follow-up was graded using the modified Glasgow Outcome Scale (mGOS) and revealed 229 patients (87.4%) in the mGOS I category, 12 patients (4.6%) in the mGOS II category, eight patients (3%) in the mGOS III category, two patients (0.8%) in the mGOS IV category, and 11 patients (4.2%) were deceased (mGOS V). Clinically significant vasospasm requiring angioplasty occurred in 11 patients (6.5%) with subarachnoid hemorrhage, and 120 patients (71%) with subarachnoid hemorrhage required ventricular shunts. Complications causing clinical morbidity occurred in 14 patients (5.1%) and ranged from postoperative ischemia to recurrent subarachnoid hemorrhage. Of all clinical factors evaluated, Hunt and Hess grade was the strongest predictor of good clinical outcome (P < 0.0001).

CONCLUSION

Endovascular coil embolization of posterior circulation aneurysms is an effective treatment in the short term but is associated with recurrence, which requires close surveillance, possible retreatment, and can, albeit very rarely, lead to rehemorrhage. Future technological advancements such as the development of biologically active coils will be essential in the permanent obliteration of aneurysms.

Giant Intracranial Aneurysms: Endovascular Challenges

THE TREATMENT OF giant aneurysms remains a formidable challenge for endovascular and surgical strategies. The use of endovascular techniques in a deconstructive (e.g., parent vessel occlusion) and reconstructive (e.g., stent coiling) methodology is reviewed. The results of endovascular coiling as a primary therapy for giant aneurysm occlusion have been disappointing. Hunterian strategies have had more success in published series, but recent developments in coil, glue, and stent technology show great promise in allowing parent vessel reconstruction as a primary endovascular target, with acceptable morbidity, mortality, and durability. A literature review of giant aneurysm endovascular treatment strategies was undertaken after 1994, when Guglielmi detachable coils were approved by the Food and Drug Administration. Where possible, follow-up, durability, and occlusion rates are also reviewed.

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.

[Clinical course of a partially thrombosed, symptomatic aneurysm of the basilar artery tip with partial recanalization subsequent to coiling]

A 72-year-old patient was referred to the neuroradiological department for diagnostic angiography. She was suffering from vertigo and double vision. Magnetic resonance imaging performed elsewhere had demonstrated a giant aneurysm of the basilar artery tip 2 cm in diameter. Angiography revealed a large aneurysm with a broad neck that was partially thrombosed, which precluded closure by coiling. Neurosurgical management by clipping also appeared to be unsuitable because of the proximity to the cerebrum. The decision was reached to proceed expectantly by closely monitoring the clinical course. When the aneurysm increased in size in the ensuing weeks, coiling was performed successfully. Angiographic follow-up showed reperfusion of the aneurysm neck and closure was again achieved by repeat coiling. Reperfusion is not a rare complication following coiling and often necessitates renewed intervention.

Microsurgical Treatment of Basilar Apex Aneurysms: Perioperative and Long-term Clinical Outcome

OBJECTIVE

We sought to analyze the perioperative and long-term clinical outcome data for patients with microsurgically treated basilar apex aneurysms.

METHODS

We identified 98 consecutively treated basilar apex aneurysms in patients prospectively enrolled in a cerebral aneurysm database.

RESULTS

Fifty patients presented with subarachnoid hemorrhage, and 19 aneurysms were giant. Eighty-four of 98 aneurysms were directly clipped. Surgical morbidity was 19.4% for the entire cohort and 8.8% for the unruptured, nongiant subgroup. The most common complication resulting in long-term morbidity was perforator injury. Sixty-seven percent of patients with clipped aneurysms were independent at discharge; this fraction increased to 79.0% at the 3-month follow-up examination. Good long-term outcomes (modified Rankin Scale score ≤2) were achieved in 56 (70%) of 80 cases. The mean Barthel Index of surviving patients was 95.8 ± 15.0 (median = 100, n = 66). Patients with unruptured, nongiant lesions fared considerably better than patients in other cohorts. Ninety-three percent of this subgroup was independent at discharge; this fraction increased to 100% at the 3-month follow-up examination (n = 27). In univariate analyses, poor clinical grade, giant aneurysm size, major operative complications, and operations performed early in the series were associated with worse outcomes. In the multivariate analysis, unruptured giant aneurysm status was found to confer a tremendous risk for poor outcome (risk ratio, 80.0; 95% confidence interval, 8.0–800.7; P < 0.01). Surviving patients were observed for a mean clinical follow-up period of 7.4 ± 3.7 years. The annual rate of postoperative subarachnoid hemorrhage was 0.18% for all clipped aneurysms and 0% for completely clipped lesions.

CONCLUSION

In comparison to data from the existing literature regarding Guglielmi detachable coil embolization of basilar apex aneurysms, the data presented suggest that surgical clipping should be an important component of a multimodality approach to the treatment of patients with basilar apex aneurysms.

Local intra-arterial fibrinolysis of thromboemboli occurring during neuroendovascular procedures with recombinant tissue plasminogen activator

BACKGROUND AND PURPOSE

There is a lack of systematic data regarding local intra-arterial fibrinolysis (LIF) of thromboemboli occurring during neuroendovascular procedures with the use of recombinant tissue plasminogen activator (rtPA). We report our technique for treating LIF of intracerebral thromboemboli occurring during neuroendovascular procedures.

METHODS

Nine of 723 patients (1.2%) who underwent neuroendovascular procedures during the period from January 1997 to September 2002 suffered thromboembolic complications. These patients were treated by LIF with a maximum dose of 0.9 mg rtPA per kilogram body weight. Recanalization was categorized as successful (Thrombolysis in Myocardial Infarction [TIMI] grade 2 or 3) versus unsuccessful (TIMI grade 0 or 1), and clinical outcome was categorized as independent (Rankin Scale score 0 to 2) versus dependent or dead (Rankin Scale score 3 to 6).

RESULTS

The minimum time between thrombus detection and beginning of LIF was 10 minutes, and the maximum time was 90 minutes. Successful recanalization was achieved in 4 of 9 patients (44%). All 9 patients suffered cerebral ischemic infarctions, and none of the patients sustained intracerebral hemorrhage. Two patients (22%) died from malignant brain infarctions. Four patients (44%) remained moderately disabled, and 3 patients (33%) were severely disabled 3 months after LIF.

CONCLUSIONS

Although we used relatively high doses of rtPA, the recanalization rates and clinical outcome of LIF in our patients were not satisfactory. Strategies for the prevention of thromboemboli during neuroendovascular procedures must be improved, and novel fibrinolytic or thrombolytic techniques should be developed.

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.

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.

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.

Helical high-resolution volume-rendered 3-dimensional computer tomography angiography in the detection of intracranial aneurysms

BACKGROUND AND PURPOSE

This study was carried out to determine whether high-resolution 3-dimensional prospective-volume-rendered computed tomographic (CT) angiography can replace conventional intra-arterial digital subtractional angiography in the diagnostic evaluation of patients with an acute subarachnoid hemorrhage (SAH) due to ruptured intracranial aneurysm.

METHODS

Both techniques were performed in 30 consecutive patients within 2 to 12 hours after their admission to the hospital.

RESULTS

In this group of 30 patients, CT angiography with 3-dimensional volume-rendered reconstruction detected 31 aneurysms in 25 patients. Two aneurysms were missed on CT angiography. Conventional angiography detected 33 aneurysms in 27 patients. The authors considered angiograms in 3 patients presenting with SAH as normal. In all cases where an aneurysm was detected on CT angiography, the finding was confirmed by conventional angiography.

CONCLUSIONS

CT angiography with 3-dimensional post-processing is a sensitive, noninvasive method that provides a 3-dimensional view of intracranial vessels and the aneurysm. It is also very useful in planning either surgical or endovascular treatment.

Impact of Guglielmi detachable coils on outcomes of patients with intracranial aneurysms treated by a multidisciplinary team at a single institution

OBJECT

The goal of this study was to investigate the impact of the introduction of the Guglielmi detachable coil (GDC) therapeutic option on the overall management outcome of intracranial aneurysms. The authors accomplished this by assessing patient morbidity and mortality, inflation-adjusted hospital charges, lengths of stay in the hospital and the intensive care unit (ICU), and treatment efficacy.

METHODS

The authors conducted a retrospective analysis of consecutive cases of intracranial intradural aneurysms managed by a single multidisciplinary neurovascular team at a tertiary care, academic referral center during the 24 months preceding the introduction of the GDC procedure (Group I or pre-GDC era, 77 patients) and during the first 24 months after its introduction (Group II or GDC era, 99 patients). Treatment with GDCs was considered for cases of higher clinical grade or poor surgical risk, or in response to patient preference (27 [27%] of 99 patients in Group II). Host and lesion parameters in our cohort were validated against outcome parameters by using univariate and multivariate analyses. The pre-GDC and GDC subgroups of patients were comparable for major disease severity parameters (patient age, lesion location, clinical grade, and hemorrhage severity). There was no significant difference in clinical outcome at 6 months, infarcts on computerized tomography scanning, or aneurysm obliteration rates before and after introduction of GDC treatment. Decreasing trends in duration of hospital and ICU stay and in inflation-adjusted hospital charges occurred well before and thus were unrelated to the introduction of the GDC therapeutic option.

CONCLUSIONS

The results of this study do not demonstrate any significant impact of integration of the GDC modality on clinical outcome, mortality, morbidity, or effectiveness of treatment. Ongoing improvements in hospital charges and length of hospital stay appeared unrelated to the introduction of the GDC option.

Prevention and treatment of thromboembolic and ischemic complications associated with endovascular procedures: Part II--Clinical aspects and recommendations

We reviewed the incidence, risk factors, and clinical features of thromboembolic and ischemic events associated with diagnostic cerebral angiography, endovascular treatment of aneurysms using coils or balloons, angioplasty and stent placement to treat extracranial carotid artery stenosis, and embolization of arteriovenous malformations using glue or other embolic agents. We performed a cumulative analysis to determine the frequency and characteristics of these events and a subset analysis (whenever possible) to determine the benefits of various strategies for complication avoidance. Of the 1,547 patients who underwent Guglielmi detachable coil treatment, thromboembolic events were observed for 127 (8.2%), consisting of asymptomatic events for 12 patients, transient ischemic attacks for 29, and strokes for 86. The outcomes for the 86 patients with strokes were categorized as full recovery for 15, good recovery for 27, partial recovery for 19, no recovery for 11, death for 12, and undetermined outcome for 2. Of the 834 patients who underwent carotid angioplasty and stent placement, thromboembolic events were observed for 73 (8.8%), consisting of transient ischemic attacks for 26 patients and strokes for 47. The outcomes for the patients with strokes were categorized as full recovery for 20, good recovery for 15, partial recovery for 6, no recovery for 2, and death for 4. High rates of thromboembolic events were also observed with balloon occlusion of aneurysms (11%) or parent arteries (19%) and carotid angioplasty alone (5.9%). Arteriovenous malformation embolization was associated with an ischemic event/procedure rate of 9.4%. High rates of thromboembolic and ischemic complications, with subsequent morbidity and death, are associated with most endovascular procedures. Further research and the formulation of standard preventive guidelines may help to reduce these risks and improve the overall success of these procedures.

Endovascular treatment of ruptured posterior circulation cerebral aneurysms. Clinical and angiographic outcomes

BACKGROUND AND PURPOSE

We sought to describe the clinical outcome and angiographic results obtained in the endovascular therapy of ruptured posterior circulation cerebral aneurysms using Guglielmi detachable coils (GDC) over a 7-year period.

METHODS

A retrospective analysis was performed of 112 patients evaluated at the University of California at San Francisco Medical Center between June 1991 and August 1998. The Hunt-Hess grade at presentation of treated patients was I in 26 patients (24%), II in 24 (22%), III in 27 (25%), IV in 24 (22%), and V in 8 (7%). Clinical follow-up for the total population was achieved in 104 of 109 patients (96%), with a mean duration of 13.1 months. Angiographic follow-up for the subset excluding parent vessel occlusion cases was obtained in 93% of cases, with a mean duration of 7.2 months.

RESULTS

Technical success, defined as the ability to catheterize and embolize the aneurysm with GDC, was achieved in 109 of 112 of cases (97%). The mean angiographic occlusion rate, or projected area of the aneurysm occluded by the coils, for all 110 successfully treated aneurysms was 94.6%. At latest clinical follow-up, 81 of 109 patients (74%) achieved good recovery with Glasgow Outcome Scale (GOS) score of I, 10 of 109 (9%) were moderately (GOS II) and 5 of 109 (5%) were severely (GOS III) disabled, 1 of 109 (1%) remained in a vegetative state (GOS IV), and 12 of 109 (11%) were dead. Of the subset of 77 patients with Hunt-Hess grades I to III, 68 (88%) achieved a good clinical outcome (GOS I). A statistically significant correlation was demonstrated between Hunt-Hess grade at presentation and final GOS outcome score (chi(2)=41.4, P<0.0005). Procedure-related permanent morbidity was 2.8% (3/109 patients). Repeated hemorrhage was observed in a single patient (0.9%) with a partially treated aneurysm.

CONCLUSIONS

The observed favorable outcome and low morbidity in this group of high-risk patients point to GDC embolization as an effective method for the endovascular management of patients with ruptured posterior circulation aneurysms.

Endovascular occlusion of basilar bifurcation aneurysms with electrolytically detachable coils

OBJECT

To describe the clinical and angiographic results of endovascular occlusion of basilar bifurcation aneurysms with electrolytically detachable coils, and to identify factors which should be considered in deciding upon surgical or endovascular treatment.

METHODS

We report our experience with 40 patients in whom occlusion of basilar bifurcation aneurysms with electrolytically detachable coils was attempted. All patients underwent superselective angiography and attempted embolization with Guglielmi detachable coils (GDCs). Angiographic and clinical results were prospectively recorded. Twenty-eight aneurysms presented with subarachnoid hemorrhage (SAH), 2 were symptomatic and 10 were incidental.

RESULTS

Coils were not placed in 10 patients (25%) because of unfavorable anatomy. Complete aneurysm occlusion was achieved at the time of the initial procedure in 13 (32.5%), small neck remnants were present in 13 (32.5%), and in 4 (10.0%) there was obvious residual contrast filling of the aneurysm body. Of 23 patients successfully coiled after SAH, 20 were Grade 1 to 3 and 3 were grade 4 or 5 at the time of treatment. Eighteen (78%) made a good recovery. Procedural mortality was 2.5% and permanent morbidity was 7.5%. There were no permanent complications in patients with unruptured aneurysms. Complete aneurysm occlusion was possible in 10 (56%) of 18 aneurysms with small necks and 3 (14%) of 22 with large necks. Follow-up angiography in 25 of 28 surviving patients (mean, 12 months) demonstrated stability of all completely occluded aneurysms. Incompletely coiled aneurysms had variable results on follow-up angiograms: 15.4% improved, 69.2% worsened, and 15.4% were stable. No aneurysm bled after treatment during clinical follow-up averaging 22 months.

CONCLUSIONS

Endovascular treatment of basilar bifurcation aneurysms appears to prevent early aneurysm rebleeding with acceptable rates of morbidity and mortality, but long-term follow-up is required.

Patient outcome after endovascular treatment of intracranial aneurysms with reference to microsurgical clipping

OBJECTIVES

Endovascular treatment of intracranial aneurysms with Guglielmi detachable coils (GDC) has found growing acceptance worldwide, and partially replaced conventional microsurgery. In this study clinical and angiographical results of embolization are reviewed. In addition, long-term neuropsychological patient outcome with reference to surgery is assessed. Indications for screening and follow-up of the patients as limitations and recent achievements of aneurysm embolization are discussed.

MATERIAL AND METHODS

Angiographical and clinical follow-up of the first 44 patients with 48 GDC-coiled aneurysms are reviewed. Postprocedural clinical, emotional and social (CES) outcome on disability scale as scored from postal questionnaire data is presented and compared to 106 currently operated patients.

RESULTS

In 75% of the embolized aneurysms successful occlusion was achieved, procedural mortality was 2.3% and morbidity 18.2%. Clinical status of all 15 patients with unruptured aneurysms preserved. Of the surviving 29 patients with ruptured aneurysms 12 improved and the rest preserved their clinical status. In 91% of the embolized patients and in 85% of the operated patients CES outcome was categorized as good or excellent. The difference was statistically nonsignificant.

CONCLUSION

Embolization with GDC is a feasible, effective and safe mini-invasive method in small aneurysms with a small neck. However, intentional parent artery occlusion, novel endovascular techniques and embolic agents or supplementary surgery may be necessary in selected cases. Neuropsychological long-term outcome of the patients treated for an intracranial aneurysm does not differ much between GDC embolization and microsurgical clipping.

A comparison between endovascular and surgical management of basilar artery apex aneurysms

OBJECT

The goal of this retrospective study was to evaluate endovascular treatment by means of Guglielmi detachable coils (GDCs) compared with surgical management for basilar artery (BA) apex aneurysms.

METHODS

Forty-one patients presented with saccular BA apex aneurysms with angiographically definable necks that were judged suitable for either treatment. Of 20 patients who underwent surgery and 21 who underwent GDC embolization, 15 (75%) and 11 (52%), respectively, were treated in the acute phase after subarachnoid hemorrhage (SAH). Twenty-four (92%) of the 26 patients presenting with an SAH had a Hunt and Hess Grade III or better. Fifteen patients with unruptured or ruptured aneurysms more than 14 days post-SAH were treated electively. Patients in the endovascular and surgical treatment groups had aneurysms with comparable dimensions and configurations. Overall, 15 (75%) of the surgical patients and 20 (95%) of the patients in whom GDC embolization was performed had a good outcome (Glasgow Outcome Scale score of 4 or 5). Among those patients treated in the acute stage post-SAH, 11 (73%) of the surgical group and 10 (91%) of the endovascular group did well. Fourteen patients treated electively (93%) had good outcomes. There were two deaths (10%) in the surgical group and none in the endovascular group. Patients treated surgically were hospitalized twice as long and incurred twice the expenses of patients who underwent endovascular treatment (p<0.001).

CONCLUSIONS

Endovascular GDC embolization of select BA apex aneurysms may be a competitive alternative to direct surgical clipping. Long-term follow up is needed to better define the natural history of the endovascularly treated aneurysm and to further evaluate the accuracy of these preliminary results.

Aneurysm retreatment after Guglielmi detachable coil and nondetachable coil embolization: report of nine cases and review of the literature

OBJECTIVE

Guglielmi detachable coil embolization of cerebral aneurysms is becoming increasingly used to manage certain intracranial lesions based on aneurysm geometry, patient condition, and patient and surgeon preferences. Aneurysm recurrences or incomplete initial treatments are not uncommon, making repeat treatment necessary using either surgical or endovascular techniques.

METHODS

Between January 1993 and June 1998, 1025 cerebral aneurysms were managed by the authors at a single hospital. One hundred twenty-four of these lesions were treated using Guglielmi detachable coils, and one was managed with nondetachable coils. During the follow-up period, eight patients who underwent embolization at our institution and one who underwent embolization elsewhere received repeat treatment. Five were approached surgically, and four underwent re-embolization. All charts and films were reviewed retrospectively to determine patient outcome and clinical success.

RESULTS

No patient in the subgroup of this clinical study suffered a permanent complication from initial aneurysm coiling, no episodes of subsequent bleeding occurred, and no complications resulted from any subsequent therapies. The anatomic results were excellent, and all aneurysms were totally or near totally obliterated.

CONCLUSION

Subtotal initial coil embolization of aneurysms can be managed safely using a variety of surgical and endovascular techniques. Our approach to this predicament, lessons we have learned, and a review of the literature are herein discussed.