Subsequent bleeding from ruptured intracranial aneurysms treated by wrapping or coating: a review of the long-term results in 47 cases

Noncurative microsurgery for cerebral aneurysms: a systematic review and meta-analysis of wrapping, residual, and recurrence rates

OBJECTIVE

Microsurgery for cerebral aneurysms is called definitive, yet some patients undergo a craniotomy that results in noncurative treatment. Furthermore, the overall rate of noncurative microsurgery for cerebral aneurysms is unclear. The objective of this study was to complete a systematic review and meta-analysis to quantify three scenarios of noncurative treatment: aneurysm wrapping, postclipping remnants, and late regrowth of completely obliterated aneurysms.

METHODS

A PRISMA-guided systematic literature review of the MEDLINE and Cochrane Library databases and meta-analysis was completed. Studies were included that detailed rates of aneurysm wrapping, residua confirmed with imaging, and regrowth after confirmed total occlusion. Pooled rates were subsequently calculated using a random-effects model. An assessment of statistical heterogeneity and publication bias among the included studies was also completed for each analysis, with resultant I2 values and p values determined with Egger's test.

RESULTS

Sixty-four studies met the inclusion criteria for final analysis. In 41 studies, 573/15,715 aneurysms were wrapped, for a rate of 3.5% (95% CI 2.7%-4.2%, I2 = 88%). In 43 studies, 906/13,902 aneurysms had residual neck or dome filling, for a rate of 6.4% (95% CI 5.2%-7.6%, I2 = 93%). In 15 studies, 71/2568 originally fully occluded aneurysms showed regrowth, for a rate of 2.1% (95% CI 1.2%-3.1%, I2 = 58%). Together, there was a total rate of noncurative surgery of 12.0% (95% CI 11.5%-12.5%). Egger's test suggested no significant publication bias among the studies. Meta-regression analysis revealed that the reported rate of aneurysm wrapping has significantly declined over time, whereas the rates of aneurysm residua and recurrence have not significantly changed.

CONCLUSIONS

Open microsurgery for cerebral aneurysm results in noncurative treatment approximately 12% of the time. This metric may be used to counsel patients and as a benchmark for other treatment modalities. This investigation is limited by the high degree of heterogeneity among the included studies.

Outcome of a Blood Blister-Like Aneurysm Treated by Clip-Reinforced Wrapping Technique Using Y-Shaped Temporalis Fascia for Perforator Protection

BACKGROUND

The optimal approach of blood blister-like aneurysms (BBAs) is debated. Wrapping has been reported to be an effective strategy, but artificial materials have often been used. In addition, perforator protection is difficult using this technique. In this case, we report a ruptured BBA of the left internal carotid artery (ICA) treated with a clip-reinforced wrapping technique using Y-shaped autologous temporalis fascia to protect the posterior communicating artery (PComA). The outcome was favorable.

CASE DESCRIPTION

A 48-year-old woman was admitted for subarachnoid hemorrhage. Digital subtraction angiography (DSA) revealed a BBA located opposite the PComA origin. A frontotemporal craniotomy was performed. The temporalis fascia was isolated from the temporalis muscle, and then tailored into a Y shape for the PComA to pass through. The diseased segment and the BBA were then wrapped by the Y-shaped temporalis fascia circumferentially. Two clips were applied to the fascia to reinforce the wrapping to fit snugly enough around the parent artery subsequently. DSA and computed tomography angiography scan postoperation showed that the BBA had not recurred, the supraclinoid segment of the left ICA had reconstructed well, and the PComA was unobstructed. The patient recovered without any sequelae during the 1-year follow-up period.

CONCLUSIONS

A clip-reinforced wrapping technique using Y-shaped temporalis fascia may be an effective method for treating BBAs located opposite the PComA origin. Long-term follow-up and large sample size studies, however, are necessary to validate this approach.

The Special Considerations in the Surgical Management of Proximal Anterior Cerebral Artery Aneurysms

BACKGROUND

Proximal anterior cerebral artery (A1) aneurysms are difficult to clip because of their frequent proximity to perforators, location behind the parent artery, or adherence to surrounding structures.

METHODS

We retrospectively reviewed a consecutive series of patients with A1 aneurysms and report the clinical status, radiologic findings, treatment methods, and outcome.

RESULTS

This series included 19 male and 12 female patients with a mean age of 50 years. The morphology of the A1 aneurysms was fusiform in 2 patients and saccular in the remaining 29 patients. Multiple aneurysms were presented in 9 patients (29.0%). On admission, 26 patients (83.9%) presented with subarachnoid hemorrhage, 3 of whom had an additional intracerebral hematoma. All surgeries were performed with a standard pteriomal craniotomy. The mean Glasgow Outcome Scale score at final follow-up was 4.8 (interquartile range, 5, 5), with 26 patients (83.9%) rated as 5. The mean follow-up time was 38.5 months (range, 12-60 months).

CONCLUSIONS

A1 aneurysms are rare but have their own complex characteristics and are difficult to treat. Meticulous analysis of the relevant angiographs is needed for their diagnosis. An important consideration in surgery is the preservation of perforators and prevention of rupture. Wide opening of the sylvian fissure and temporary control of the parent artery can facilitate dissection of the A1 aneurysms dome. Multiple intraoperative monitoring methods, such as microvascular Doppler ultrasonography and somatosensory and motor evoked potential monitoring, can reduce the relevant complications of surgery.

Case Report: Late Sequela of a Muslinoma Involving the Optic Chiasm

An 84-year-old woman presented with 3 months of vertical binocular diplopia and difficulty reading at near. She had a history of bilateral ophthalmic artery aneurysm repair involving use of muslin in the 1990s. The patient then developed bitemporal hemianopsia secondary to muslin-induced inflammation ("muslinoma") extending to the optic chiasm, which required surgical decompression. She had a persistent bitemporal hemianopsia but was stable for two decades after surgery. In 2017, the patient re-presented with double vision. Exam showed a non-paretic diplopia due to a small angle comitant right hypertropia attributed to the retinal hemi-field slide. Repeat imaging showed no new aneurysm or recurrent muslinoma. This case had originally been reported two decades ago and represents the longest duration of recurrent symptoms from muslin-related optochiasmatic arachnoiditis in the English language ophthalmic literature. Clinicians should be aware of the potential of delayed and recurrent symptoms or signs years or even decades after muslin wrapping of aneurysms.

Techniques and Outcomes of Gore-Tex Clip-Wrapping of Ruptured and Unruptured Cerebral Aneurysms

OBJECTIVE

Some aneurysms without a definable neck and associated parent vessel pathology are particularly difficult to treat and may require clipping with circumferential wrapping. We report the largest available contemporary series examining the techniques of Gore-Tex clip-wrapping of ruptured and unruptured intracranial aneurysms and patient outcomes.

METHODS

The presentation, location, and shape of the aneurysm; wrapping technique; outcome at discharge and last follow-up; and any change in the aneurysm at last angiographic follow-up were reviewed retrospectively in 30 patients with Gore-Tex clip-wrapped aneurysms.

RESULTS

Gore-Tex clip-wrapping was used in 8 patients with ruptured aneurysms and 22 patients with unruptured aneurysms. Aneurysms included 23 fusiform, 3 blister, and 4 otherwise complex, multilobed, or giant aneurysms. Of the 30 aneurysms, 63% were in the anterior circulation. The overall mean patient age was 52.5 years (range, 17-80 years). Postoperatively, there were no deaths or worsening of neurologic status and no parent vessel stenoses or strokes. The mean Glasgow Outcome Scale score at last follow-up was 4.7. The mean follow-up time was 42.3 months (median, 37.0 months; range, 3-96 months). There were 105.8 patient follow-up years. Aneurysms recurred in 2 patients with Gore-Tex clip-wrapping. No patients developed rehemorrhage. Overall risk of recurrence was 1.9% annually.

CONCLUSIONS

Gore-Tex has excellent material properties for circumferential wrapping of aneurysms and parent arteries. It is inert and does not cause a tissue reaction or granuloma formation. Gore-Tex clip-wrapping can be used safely for microsurgical management of ruptured and unruptured cerebral aneurysms with acceptable recurrence and rehemorrhage rates.

Techniques and long-term outcomes of cotton-clipping and cotton-augmentation strategies for management of cerebral aneurysms

OBJECTIVE To address the challenges of microsurgically treating broad-based, frail, and otherwise complex aneurysms that are not amenable to direct clipping, alternative techniques have been developed. One such technique is to use cotton to augment clipping ("cotton-clipping" technique), which is also used to manage intraoperative aneurysm neck rupture, and another is to reinforce unclippable segments or remnants of aneurysm necks with cotton ("cotton-augmentation" technique). This study reviews the natural history of patients with aneurysms treated with cotton-clipping and cotton-augmentation techniques. METHODS The authors queried a database consisting of all patients with aneurysms treated at Barrow Neurological Institute in Phoenix, Arizona, between January 1, 2004, and December 31, 2014, to identify cases in which cotton-clipping or cotton-augmentation strategies had been used. Management was categorized as the cotton-clipping technique if cotton was used within the blades of the aneurysm clip and as the cotton-clipping technique if cotton was used to reinforce aneurysms or portions of the aneurysm that were unclippable due to the presence of perforators, atherosclerosis, or residual aneurysms. Data were reviewed to assess patient outcomes and annual rates of aneurysm recurrence or hemorrhage after the initial procedures were performed. RESULTS The authors identified 60 aneurysms treated with these techniques in 57 patients (18 patients with ruptured aneurysms and 39 patients with unruptured aneurysms) whose mean age was 53.1 years (median 55 years; range 24-72 years). Twenty-three aneurysms (11 cases of subarachnoid hemorrhage) were treated using cotton-clipping and 37 with cotton-augmentation techniques (7 cases of subarachnoid hemorrhage). In total, 18 patients presented with subarachnoid hemorrhage. The mean Glasgow Outcome Scale (GOS) score at the time of discharge was 4.4. At a mean follow-up of 60.9 ± 35.6 months (median 70 months; range 10-126 months), the mean GOS score at last follow-up was 4.8. The total number of patient follow-up years was 289.4. During the follow-up period, none of the cotton-clipped aneurysms increased in size, changed in configuration, or rebled. None of the patients experienced early rebleeding. The annual hemorrhage rate for aneurysms treated with cotton-augmentation was 0.52% and the recurrence rate was 1.03% per year. For all patients in the study, the overall risk of hemorrhage was 0.35% per year and the annual recurrence rate was 0.69%. CONCLUSIONS Cotton-clipping is an effective and durable treatment strategy for intraoperative aneurysm rupture and for management of broad-based aneurysms. Cotton-augmentation can be safely used to manage unclippable or partially clipped intracranial aneurysms and affords protection from early aneurysm re-rupture and a relatively low rate of late rehemorrhage.

Long-term clinical and angiographic outcomes of wrap-clipping strategies for unclippable cerebral aneurysms

PURPOSE

To evaluate the efficacy and stability of the wrap-clipping methods as a reconstructive strategy in the treatment of unclippable cerebral aneurysms.

MATERIALS AND METHODS

Twenty four patients who had undergone wrap-clipping microsurgery were retrospectively reviewed. Type and morphology of the treated aneurysm, utilized technique for wrap-clip procedure, and clinical outcome with angiographic results at their last follow-up were evaluated.

RESULTS

Of 24 patients, eleven patients had internal carotid artery (ICA) blister-like aneurysms, three had dissecting type aneurysms, and ten had fusiform aneurysms. The follow-up period for the late clinical and angiographic results ranged from 10 to 75 months (mean 35 months). Wrap-clipping was performed in eleven, wrap-holding clipping was in ten, and combination of wrap-clip and wrap-holding clip was in three cases. At the last angiographic follow-up study, twelve aneurysms (50%) were found to have completely healed, and nine aneurysms (38%) were at least stable. However, wrap-holding clip for the elongated blister type of ICA aneurysm was found failed, leading to fatal rebleeding in one case, and two cases of combination of wrap-clip-wrap-holding clip revealed delayed branch occlusion and marked regrowing, respectively.

CONCLUSION

Wrap-clipping strategy could be an easy and safe alternative for unclippable aneurysms. The wrapped aneurysm mostly disappeared, or at least remained stationary, after a long-term period. However, surgeons should be aware of that the wrapped aneurysm might become worse. Therefore, follow-up surveillance for an extended period should be mandatory.

Long-term MRI findings of muslin-induced foreign body granulomas after aneurysm wrapping. A report of two cases and literature review

Muslin-induced foreign body granulomas are rare delayed complications after wrapping of intracranial aneurysms. Few small case series have been reported, with a paucity of documented MRI findings. In addition, there are no reports on long-term radiological appearances or temporal evolution of conservatively managed patients. We thus report on the long-term radiological and clinical follow-up of two patients with asymptomatic muslin-induced foreign body granulomas after wrapping of recurrent middle cerebral arterial aneurysms. Both patients were successfully managed conservatively and remain asymptomatic three and six years after diagnosis of their granulomas. A literature review confirms that MRI features of muslin-induced foreign body granuloma are typical. Features include focal areas of elevated T2 signal with increased diffusion-weighted signal and thin rim enhancement. To the best of our knowledge, this is the first report to confirm that there is a corresponding reduction in apparent diffusion coefficient, as typical in an intracranial abscess. Thus a history of aneurysm wrapping is critical for diagnosis. Accurate clinical recognition of this exuberant inflammatory response will avoid misdiagnosis as pyogenic abscess or tumor and prevent unnecessary or invasive treatment.

Long-term follow-up of ruptured intracranial aneurysms treated by microsurgical wrapping with autologous muscle

The purpose of this study is to describe our series of nine unclippable and uncoilable ruptured aneurysms in eight patients treated by microsurgical wrapping with autologous muscle. Records were retrospectively reviewed for rebleeding rate, morbidity and mortality, changes in size or the aneurysm's configurations, and inflammatory reaction. We conducted a Medline search in the post-microsurgical era, excluding patients in whom wrapping was part of the aneurysm treatment in combination with clipping or coiling. The surgically related morbidity was 12.5%. Global mortality rate was 25% due to vasospasm (one case) and rebleeding (one case). Six patients are still alive. Rebleeding rate was 14.3% within 6 months; then, it was zero. Glasgow outcome scale (GOS) score at discharge was 1 and 4 in one patient, respectively, and 5 in the remaining six. Mean clinical follow-up was 126 months. GOS at last follow-up was 4 and 5 in 50% of patients, respectively. Mean mRS score was 0.8 at 2 months, and 2.4 at 12 months. Follow-up MR demonstrated persistence of the aneurysm's sac, without changes in size and configuration. Patients did not describe or exhibit symptoms attributable to complications inherent to the use of muscle. Microsurgical muscle-wrapping of ruptured intracranial aneurysm is safe, is associated with a low rate of acute and delayed postoperative complications and rebleeding, and could be a valid alternative for unclippable and non-amenable to endovascular procedure ruptured aneurysms.

Clinical and angiographic results after treatment with combined clipping and wrapping technique for intracranial aneurysm

OBJECTIVE

There have been numerous follow-up studies of patients who had ruptured or unruptured intracranial aneurysms treated by wrapping technique using various materials have been reported. Our objective was to ascertain whether our particular wrapping technique using the temporalis muscle provides protection from rebleeding and any aneurysm configuration changes in follow-up studies.

METHODS

Clinical presentation, the location and shape of the aneurysm, outcomes at discharge and last follow-up, and any aneurysm configuration changes on last angiographic study were analyzed retrospectively in 21 patients. Reinforcement was acquired by clipping the wrapped temporalis muscle. Wrapping and clipping after incomplete clipping was also done. Follow-up loss and non-angiographic follow-up patient groups were excluded in this study.

RESULTS

The mean age was 53 years (range 29-67), and 15 patients were female. Among 21 patients, 10 patients had ruptured aneurysms (48%). Aneurysms in 21 patients were located in the anterior circulation. Aneurysm shapes were broad neck form (14 cases), fusiform (1 case), and bleb to adjacent vessel (6 cases). Five patients were treated by clipping the wrapped temporalis, and 16 patients by wrapping after partial clipping. The mean Glasgow coma scale (GCS) at admission was 14.2. The mean Glasgow outcome scale (GOS) at discharge was 4.8, and 18 patients were grade 5. The mean period between initial angiography and last angiography was 18.5 months (range 8-44). Aneurysm size was not increased in any of these patients and configuration also did not change. There was no evidence of rebleeding in any of these treated aneurysms.

CONCLUSION

Our study results show that wrapping technique, using the temporalis muscle and aneurysm clip(s), for intracranial aneurysm treatment provides protection from rebleeding or regrowth.

Ruptured fusiform aneurysm of the proximal anterior cerebral artery (A1 segment)

A 42-year-old man presented with a ruptured fusiform aneurysm of the proximal anterior cerebral artery (A(1) segment) manifesting as sudden onset of severe headache. Brain computed tomography revealed subarachnoid hemorrhage in the basal cisterns, and left carotid angiography demonstrated a fusiform aneurysm of the left A(1) segment. He underwent surgery via the left pterional approach. The left A(1) segment exhibited a fusiform configuration. Adequate development of the anterior communicating artery was confirmed. Trapping of the aneurysm was performed. The aneurysm was associated with atherosclerotic changes. The postoperative course was uneventful, and the patient was discharged without neurological deficits 1 month after surgery. Fusiform aneurysm of the A(1) segment is quite rare, and tends to bleed, so must be treated. The atherosclerotic origin indicates long-term follow up to identify subsequent lesions.

Granuloma formation and occlusion of an unruptured aneurysm after wrapping

Excessive granulomatous foreign-body reaction is a very rare complication after wrapping of intracranial aneurysms. The pathogenetic mechanisms underlying this process are unknown. We report on a patient who developed a space-occupying granulomatous abscess after wrapping of an unruptured aneurysm of the M2/M3 bifurcation. The patient underwent revision craniotomy for abscess removal. The aneurysm was explored and found to be completely thrombosed and excluded from the circulation. Exuberant granulomatous foreign-body reaction was pathologically confirmed and Candida parapsilosis was isolated from the pus. The patient underwent an antifungal treatment regimen and recovered with no residual neurological deficits. Our findings support the assumption that a low-grade infectious process might trigger excessive inflammatory reaction after wrapping. We suggest that this process may also result in complete thrombosis of cerebral aneurysms, which is otherwise a rarely observed phenomenon.

Coating the wall of an injured intracranial carotid artery during tumor removal with n-butyl-2-cyanoacrylate: technical case report

OBJECTIVE

Carotid artery injury close to the clinoid process is difficult to repair, and is even more so when the vessel is firmly attached to a calcified tumor. We treated a patient with an intraoperative carotid lesion by coating the vessel wall with n-butyl-2-cyanoacrylate (NBCA).

CLINICAL PRESENTATION

A 7-year-old boy was referred to our clinic with a 3-month history of somnolence, apathy, and headache. Neurological examination revealed bitemporal hemianopsia. The cranial magnetic resonance imaging and computed tomographic scans showed a sellar and suprasellar calcified mass with heterogeneous contrast enhancement, a cyst component in the upper part of the tumor displaced upward and back from the mesencephalic and diencephalic structures.

INTERVENTION

The patient underwent a pterional craniotomy. Using a microsurgical technique, the suprasellar part of the craniopharyngioma was removed. In an attempt to dissect the calcified mass from the carotid artery on the right side, the vessel was unintentionally injured, followed by severe bleeding. Temporary occlusion and suturing of the vessel was impossible because of the overlying hard mass. To avoid a permanent occlusion, we decided to coat the injured artery wall with 100% NBCA. For this, 0.5 ml of NBCA was distributed on the surface of the injured segment and surrounding subarachnoid space by injection through a needle. An excellent hemostasis could be obtained immediately after coating. The patient woke up with no new neurological deficits. A digital cerebral angiogram obtained a few days after the procedure did not show vasospasm, stenosis, or pseudoaneurysm in the supraclinoidal segment of the carotid artery. A magnetic resonance angiogram obtained 3 years later showed a normal shape of the internal carotid artery and a stable residual tumor without inflammatory signs. The child is now attending school and is under hormonal therapy.

CONCLUSION

For hemostatic purposes, the technique of coating an injured arterial wall with NBCA may be useful in cases in which a microsuture is impossible and a permanent artery occlusion is unwanted because of a risk of an ischemic stroke. It could serve as a transitory measure until a microsurgical bypass or the balloon test occlusion tolerance allow the trapping of the affected artery.

Long-term clinical and angiographic follow-up of unclippable wrapped intracranial aneurysms

OBJECTIVE

This is the largest contemporary series examining long-term clinical and angiographic follow-up of unclippable wrapped intracranial aneurysms.

METHODS

The presentation, location and shape of aneurysm, wrapping technique, outcome at discharge and last follow-up, and change in aneurysm at last angiographic follow-up were reviewed retrospectively in 74 patients with wrapped or clip-wrapped aneurysms. Patients in whom wrapping was used in conjunction with primary clipping were excluded.

RESULTS

Of the 74 patients, 11 were lost to follow-up. The mean age of the remaining 63 patients (16 males, 47 females) was 56.5 years (range, 13-89 yr). Fifty-one aneurysms were located in the anterior circulation, and 17 were located in the posterior circulation. Fourteen patients presented with a ruptured aneurysm. Seventeen aneurysms were fusiform. Seven aneurysms were clip-wrapped, and 61 were wrapped with cotton. At discharge the Glasgow Outcome Scale (GOS) score was 5 in 54 patients and 4 in 5 patients. Two patients died from their presenting hemorrhage, and one from a medical comorbidity. The mean clinical follow-up was 44.1 months (range, 1-120 mo). One patient under clinical follow-up experienced subarachnoid hemorrhage. The mean angiographic follow-up of 34 patients was 41.8 months (range, 3-120 mo). During this follow-up period, no patient's aneurysm changed in size or configuration.

CONCLUSION

Wrapping or clip-wrapping of unclippable intracranial aneurysms is safe and seems to confer protection against aneurysmal growth or subarachnoid hemorrhage.

That's a Wrap

Muslin-induced optochiasmatic arachnoiditis is a rare complication following surgical repair of an intracranial aneurysm but should be suspected in any delayed visual loss after aneurysm repair in which muslin was used. A 52-year-old male underwent clipping and muslin wrapping of a ruptured aneurysm of an anterior communicating artery. Eight months following surgery, the patient developed progressive visual loss, resulting in a bitemporal hemianopsia. Neuroimaging confirmed a suprasellar mass but no recurrent aneurysm. The patient was treated with prednisone and had significant improvement of his vision. Muslin wrapping of aneurysms should probably be avoided in aneurysms near the optic apparatus.

A novel coating biomaterial for intracranial aneurysms: Effects and safety in extra- and intracranial carotid artery

Methyl-2-cyanoacrylate, a widely used material for coating cerebral aneurysm, was recently withdrawn. The aim of the present study was to develop an alternative coating material for cerebral aneurysm, which is safe, effective and stable within the brain. In the first experiment, an aneurysm model of the common carotid artery was produced in a rabbit by the local application of elastase. The aneurysm produced was covered by no material (Group A), a cellulose cotton sheet and conventional methyl-2-cyanoacrylate (Group B), a newly produced polyglycolic acid felt and fibrin glue (Group C), or a cellulose cotton sheet and fibrin glue (Group D). Histological examination showed that the materials resulted in the formation of tight connective tissue around the artery, and that the material was completely replaced by the connective tissue after 12 weeks. This change was found exclusively in Group C, but not in Group A or the other materials, although a temporary thickening of the intima was also observed at the site of the elastase application in Group C. In Group D, a long-term, marked thickening of the intima was observed. In the second experiment, using an intracranial internal carotid artery from a beagle, the applied polyglycolic acid felt and fibrin glue to the intracranial artery induced the formation of connective tissue around the artery that was completely absorbed 16 weeks after surgery. There were no signs of intimal thickening or of adverse reactions in nervous tissue. The present results suggest that polyglycolic acid felt and fibrin glue is a possible candidate for a safe, effective biomaterial to wrap or coat cerebral aneurysm.

Ruptured de novo thrombotic giant aneurysm induced by ethyl 2-cyanoacrylate: Case report

BACKGROUND

A very rare case of a ruptured aneurysm induced by ethyl 2-cyanoacrylate is reported.

CASE DESCRIPTION

Six years earlier, this 68-year-old woman had undergone microvascular decompression for trigeminal neuralgia during which the left vertebral artery, which compressed the exit zone of the trigeminal nerve, had been detached and fixed to the dura mater of the petrous bone with ethyl 2-cyanoacrylate. Shortly thereafter she underwent microvascular decompression for left-side facial palsy; again ethyl 2-cyanoacrylate was used. Six years later, she suffered a subarachnoid hemorrhage because of rupture of a new aneurysm of the left vertebral artery. She was referred to our hospital where coil embolization was attempted on the day following the insult. However, the left vertebral artery and the aneurysm could not be occluded completely, and she suddenly died 20 days later from rerupture of the aneurysm.

CONCLUSION

This is the first pathologic report of a ruptured de novo aneurysm induced by ethyl 2-cyanoacrylate. We suggest that arterial wall damage by ethyl 2-cyanoacrylate may have contributed to the development of the de novo aneurysm.

Recurrence of a vertebral artery dissecting pseudoaneurysm after successful stent-supported coil embolization: case report

OBJECTIVE AND IMPORTANCE

Dissecting aneurysms of the intracranial vertebral artery are increasingly recognized as a cause of subarachnoid hemorrhage. We present a case involving technical success of the stent-supported coil embolization but with recurrence of the dissecting pseudoaneurysm of the intracranial vertebral artery. The implications for the endovascular management of ruptured dissecting pseudoaneurysms of the intracranial vertebral artery are discussed.

CLINICAL PRESENTATION

A 36-year-old man with a remote history of head injury had recovered functionally to the point of independent living. He experienced the spontaneous onset of severe head and neck pain, which progressed rapidly to obtundation. A computed tomographic scan of the head revealed subarachnoid hemorrhage centered in the posterior fossa. The patient underwent cerebral angiography, which revealed dilation of the distal left vertebral artery consistent with a dissecting pseudoaneurysm.

INTERVENTION

Transfemoral access was achieved under general anesthesia, and two overlapping stents (3 mm in diameter and 14 mm long) were placed to cover the entire dissected segment. Follow-up angiography of the left vertebral artery showed the placement of the stents across the neck of the aneurysm; coil placement was satisfactory, with no residual aneurysm filling. Approximately 6 weeks after the patient's initial presentation, he developed the sudden onset of severe neck pain. A computed tomographic scan showed no subarachnoid hemorrhage, but computed tomographic angiography revealed that the previously treated left vertebral artery aneurysm had recurred. Angiography confirmed a recurrent pseudoaneurysm around the previously placed Guglielmi detachable coils. A test balloon occlusion was performed for 30 minutes. The patient's neurological examination was stable throughout the test occlusion period. Guglielmi detachable coil embolization of the left vertebral artery was then performed, sacrificing the artery at the level of the dissection. After the procedure was completed, no new neurological deficits occurred. On the second day after the procedure, the patient was discharged from the hospital. He was alert, oriented, and able to walk.

CONCLUSION

We appreciate the value of preserving a parent vessel when a dissecting pseudoaneurysm of the intracranial vertebral artery ruptures in patients with inadequate collateral blood flow, in patients with disease involving the contralateral vertebral artery, or in patients with both. However, our case represents a cautionary note that patients treated in this fashion require close clinical follow-up. We suggest that parent vessel occlusion be considered the first option for treatment in patients who will tolerate sacrifice of the parent vessel along its diseased segment. In the future, covered stent technology may resolve this dilemma for many of these patients.

Cranial nerve pareses following wrapping of a ruptured dissecting vertebral artery aneurysm: a possible complication of cyanoacrylate glue--case report

A 51-year-old female with a ruptured dissecting vertebral artery aneurysm underwent an uneventful wrapping technique using Biobond-soaked gauze through a unilateral suboccipital transcondyle approach. On the 3rd postoperative day, she developed pareses of the ipsilateral VII through XII cranial nerves. Daily intravenous administration of 300 mg of hydrocortisone was started. This treatment was continued and dosage was tapered until the 10th postoperative day. The cranial nerve pareses deteriorated until the 8th postoperative day, but slowly resolved by 3 weeks after surgery. The patient was discharged with slight hoarseness and dysphasia 5 weeks after surgery. She had only slight hoarseness at 6 months. This complication was probably due to a neural toxic response to the Biobond.

The fate of intracranial microaneurysms treated with bipolar electrocoagulation and parent vessel reinforcement

OBJECTIVE

Although direct clipping remains the treatment of choice for intracranial aneurysms, not all aneurysms can be clipped. This report reviews the results of bipolar coagulation followed by parent vessel reinforcement for the treatment of intracranial microaneurysms (maximal diameter of < or =3 mm), with immediate and delayed postoperative angiographic evaluation in all cases.

METHODS

During a 1-year period, 20 intracranial microaneurysms in 12 patients were treated with bipolar electrocoagulation followed by reinforcement of the parent artery with muslin gauze. All patients underwent intraoperative or immediate postoperative angiographic evaluation, and all underwent follow-up angiographic evaluation approximately 1 year later. No patient was lost to follow-up monitoring.

RESULTS

Microaneurysms involved the middle cerebral artery (eight cases), internal carotid artery (six cases), anterior cerebral/anterior communicating artery (five cases), and superior cerebellar artery (one case). In all cases, the patient was undergoing a craniotomy for clipping of a larger aneurysm, and the microaneurysms were treated concurrently. At the time of the immediate angiographic examinations, 19 of 20 (95%) microaneurysms were no longer visible and 1 was substantially smaller (< 1-mm irregularity on the parent vessel). No patient experienced an adverse event related to microaneurysm treatment. In the 1-year follow-up examinations, there was no angiographic evidence of recurrence in the 19 cases with complete obliteration; the one residual aneurysm remained stable.

CONCLUSION

At 1 year, direct coagulation followed by parent vessel reinforcement seems to provide a satisfactory treatment option for intracranial microaneurysms.

Subarachnoid hemorrhage associated with angiographic "stenotic" or "occlusive" lesions in the carotid circulation

BACKGROUND

It has been assumed that dissecting aneurysms presenting with subarachnoid hemorrhage (SAH) are extremely rare in the carotid circulation. This may be partially attributed to the difficulty in their diagnosis. The documented angiographic findings include arterial narrowing or occlusion. The purpose of the present study is to investigate the origin of SAH associated with "stenotic" or "occlusive" lesions, which might have been categorized into "SAH of unknown origin."

METHODS

Between April 1984 and June 1994, 580 patients underwent thorough angiographic investigation to determine the origin of their nontraumatic SAH. Of these patients, five patients had as the only lesion suspected as the source of SAH a single stenosis or occlusion in the carotid circulation that was revealed at the first angiography performed within 48 hours following the onset. We detail these five patients and discuss the current strategy for the treatment of SAH associated with stenotic or occlusive lesions in the carotid circulation.

RESULTS

Arterial narrowing or occlusion were located in the internal carotid artery (ICA) in two patients, in the middle cerebral artery (MCA) in two patients, and in the posterior communicating artery in one patient. Three patients underwent operation (circumferential wrapping with cotton gauze), and dissecting aneurysms were confirmed in all of them. They all attained good recovery without rebleeding over a long-term period. Two patients died of fatal rebleeding on day 8 and on day 9 while awaiting the second angiography. In one of the patients with ICA stenosis, autopsy revealed a lacerated ICA without a definite saccular aneurysm. In the last patient with M2 occlusion, dissecting aneurysm was strongly suspected from the clinical course.

CONCLUSION

To prevent early fatal rebleeding, exploratory craniotomy for angiographic stenotic and occlusive lesions associated with SAH may be justified if all underlying conditions are met, because they may likely include dissecting aneurysms: (1) single stenotic or occlusive, (2) surgically accessible, and (3) consistent with the localization of SAH from CT scan.

Aneurysm reinforcement in the anterior circulation

BACKGROUND

Aneurysms are primarily treated with surgical clipping. Unclippable aneurysms are at risk of recurrent bleeding similar to the natural history of ruptured aneurysms. Aneurysm reinforcement with muslin and ethyl 2-cyanoacrylate may provide a safe and useful alternative to reduce the rebleeding rate in those aneurysms found to be unclippable at surgical exploration.

METHODS

We examined a population of 19 patients with aneurysms treated by reinforcement with muslin and ethyl 2-cyanoacrylate. One patient was lost to follow-up. Patients had a mean follow-up of 60 months. The yearly risk of rebleeding was calculated and compared to the natural history of the disease.

RESULTS

Most of the aneurysms were located in the middle cerebral artery or the anterior communicating artery. The two main causes for reinforcement were a wide base aneurysm or the presence of arterial branches originating from or intimately adherent to the dome. Those patients with aneurysms in which reinforcement was used as the primary and only treatment had a risk of rebleeding of 2.95% per year. The group of patients with ruptured aneurysms in which the reinforcement was used to supplement a clip had no rebleeding. When all the patients with ruptured aneurysms are combined, there is a risk of rebleeding of 1.94% per year. Unruptured aneurysms treated with reinforcement had not shown hemorrhage. No complications related to the use of muslin or ethyl 2-cyanoacrylate were found in this study.

CONCLUSION

The reinforcement with muslin and ethyl 2-cyanoacrylate provides some protection in patients with aneurysms for which direct clipping cannot be done and in those clipped cases in which there is a residual neck or dome. This protection is inferior to clipping, but reduces the risk of rebleeding during the first 6 months after the initial hemorrhage. A longer follow-up is needed to determine if it provides better protection for late rebleeding than the natural history of ruptured aneurysms.

Endovascular treatment of basilar tip aneurysms using electrolytically detachable coils

Preliminary experience using electrolytically detachable coils to treat basilar tip aneurysms in 33 patients is described. The most frequent presentation was subarachnoid hemorrhage (SAH) in 23 patients. All patients were referred after neurosurgical assessment and exclusion as candidates for surgical clipping of their aneurysms. At the time of initial treatment complete aneurysm occlusion was achieved in seven (21.2%) of 33 patients. In 17 of the patients (51.5%), greater than 90% but less than 100% aneurysm occlusion was achieved. Angiographic follow up (mean 11.7 months) was available in 19 patients. At follow- up angiography four (21%) of 19 aneurysms were 100% occluded and 12 (63.2%) of 19 were more than 90% but less than 100% occluded. The mean clinical follow-up time in treated patients surviving beyond the initial treatment period is 15 months. One patient suffered major permanent morbidity from thrombosis of the basilar tip region a few hours after coil placement. One patient treated following SAH experienced further hemorrhage 6 months later. No other patient suffered direct or indirect permanent morbidity as a consequence of this method of treatment. The authors believe that this technique is a reasonable alternative for patients who are not candidates for conventional surgical treatment or in whom such treatment has failed. This study's follow-up period is brief and greater experience with long-term follow-up study is mandatory.

Delayed parent artery narrowing occurring months after aneurysm surgery: a complication after aneurysm surgery--technical case report

The authors report two patients with a rare complication of parent artery narrowing that occurred 3 and 6 months after aneurysm surgery. In both cases, the stenosed arteries had been wrapped around their entire circumferences with neurosurgical sponge (cotton linter) and coated with plastic adhesive (cyanoacrylate compounds) and the aneurysmal neck had been clipped. This reinforcement procedure was considered to have caused the unusual delayed arterial narrowing. The importance of avoiding circumferential parent artery wrapping with plastic-adhesive coating is emphasized.

Coating of intracranial aneurysms: a long-term follow-up study of 34 cases

We performed a retrospective follow-up study of 33 patients, with 34 ruptured aneurysms, treated by coating using bio-adhesive polymers. The rebleeding rate after a mean follow-up of 10 years was 18% (6 patients), with 4 cases of early haemorrhage and 2 late rebleedings (late rebleeding rate of 0.7% per year). All rebleedings proved fatal. Coating of the aneurysmal wall provides some protection in patients with "unclippable" aneurysms, but is obviously inferior to clipping, and should be used only in very selected cases.