Endovascular treatment of wide-neck intracranial aneurysms using a microcatheter protective technique: results and outcomes in 75 aneurysms

Endovascular Treatment of Intracranial Aneurysms Using a Microcatheter Protection

PURPOSE

Stent protective or balloon remodeling techniques have enabled coil embolization of complexly configured aneurysms. Still, the utility of such methods may be limited in some small-caliber and/or inherently tortuous lesions. The present study was conducted to examine the efficacy of microcatheter protection (MCP) when applied in these circumstances.

METHODS

This retrospective review included 432 patients with 452 intracranial aneurysms subjected to MCP between April 2001 and January 2021. All available medical records and radiologic data were analyzed, focusing on strategic, safety, and efficacy aspects of the procedures.

RESULTS

In a majority (255/452, 56.4%) of cases, MCP was applied throughout entire coiling procedures, as opposed to coil framing (137/452, 30.3%) or filling/finishing (60/452, 13.3%) only. Lesions of the middle cerebral artery (54.9%) predominated, followed by anterior (12.4%) and posterior (11.1%) communicating artery aneurysms. Stent protection was also used occasionally (46/452, 10.2%). Procedural morbidity was low (3/432, 0.7%), limited to symptomatic thromboembolism and procedural leakage, and there were no deaths. Occlusion was successfully achieved by MCP in 424 aneurysms (93.8%). During the follow-up period (mean, 43.4 ± 30.4 months), satisfactory occlusion was documented in 406 of 440 (92.3%) aneurysms.

CONCLUSION

MCP is feasible and safe for coil embolization of intracranial aneurysms, in conjunction with multicatheter, balloon, or stenting techniques. MCP may have merit in small-sized or tortuous lesions not amenable to balloon or stent usage, often eliminating the need for stenting altogether.

Parent Artery Complex Coil Protection for Side-Branched Wide-Neck Aneurysms

This study aimed to validate the usefulness of parent artery complex coil protection for the treatment of wide-neck, side-branched, and ruptured aneurysms. A microcatheter was first introduced into the aneurysmal sac, and another microcatheter was introduced into the parent artery or near the orifice of the branch artery. A framing coil was deployed partially from the first microcatheter, and a protection coil was deployed from the second microcatheter to prevent protrusion of the first framing coil to the parent artery and side branches. After the first framing coil insertion, the protection coil was withdrawn to confirm the stability of the framing coil and blood flow. The procedures with this technique were successful for 3 patients. Parent artery complex coil protection can be an effective and safe coil embolization technique for the preservation of parent and side branch arteries and an alternative method for emergent ruptured cases.

Microcatheter-Assisted Protection of the Posterior Inferior Cerebellar Artery During Parent Artery Sacrifice of a Vertebral Artery Dissecting Aneurysm

Branch vessel occlusion is a major cause of stroke in parent artery sacrifice (PAS) for vertebral artery dissecting aneurysms (VADA). There is now an increasing trend towards preservation of branch vessels during PAS. Stents are commonly employed to achieve this but bring with it the attendant risks of future thrombosis and lifelong antiplatelet use. Although a microcatheter protection technique has been utilised in branch artery protection of wide-necked saccular aneurysms, it has rarely been described in PAS for VADAs. We describe the use of a dual microcatheter technique in the protection and remodelling of the posterior inferior cerebellar artery (PICA) during PAS of the vertebral artery, which also served as a temporary scaffold to support placement of the coils during the embolisation process.

[New trends in the treatment of bifurcation aneurysms]

CLINICAL ISSUE

Intracranial aneurysms most commonly occur at bifurcation sites. In case of dealing with broad based aneurysms, the risk of accidental vessel occlusion during embolization should not be underestimated. Therefore, several devices are available, e.g. WEB device and barrelsStent. Besides that, a special technique gives the opportunity to place two stents into each other or next to each other into both branches of a bifurcation. Over 300 patients included in 18 studies were treated with Y‑stenting (e.g., Medline/Embase) showing a good clinical outcome in 92%. A complete occlusion was achieved in 91%. The rate of neurologic deficits was 4%, the procedure-caused mortality was 2%. Furthermore, 12% of the patients sustained a stroke during the intervention. Ruptured aneurysm was found in 19%.

CONCLUSION

All in all, a high occlusion rate and a low rate of mortality and stroke were shown by using Y‑stenting.

[Endovascular Treatment of Cerebral Aneurysms: Technical Options in Coil Embolization]

Since the endosaccular coil embolization technique was introduced as an alternative for treating selected patients with aneurysms, it has become a mainstay of treatment for cerebral aneurysms. In lesions with a neck larger than the aneurysmal body, an irregular shape, or arterial branches incorporated within the sac, endovascular treatment using detachable coils are traditionally contraindicated because of technical difficulties. Coil embolization has evolved as a result of both the development of related devices and the introduction of technical improvements using various devices. Use of various technical and device options can make endovascular treatment of cerebral aneurysms safer and can widen the treatment indications. Various technical options, including the technical modification of device-assisted techniques, will be presented, and the related practical points will be discussed in this issue.

Stent-assisted coiling of cerebral aneurysms using the Y-stenting technique: a systematic review and meta-analysis

BACKGROUND

Bifurcation aneurysms can be treated with stent-assisted coiling using two stents in a Y-configuration. We aim to investigate the angiographic and clinical outcomes of Y-stent constructs for the treatment of intracranial aneurysms.

METHODS

A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE databases was conducted based on PRISMA guidelines. The study selection was performed using the 'Ryyan' application. Our analysis included 18 studies with 327 patients. Inclusion criteria were: articles published from January 2000 to November 2017, English language, including cerebral aneurysms treated via Y-stenting, and ≥5 cases with radiographic/clinical outcomes. Technical notes, editorials, reviews, and animal studies were excluded. A random-effect meta-analysis was performed on angiographic and clinical outcomes, including aneurysm occlusion, modified Rankin Scale, neurological outcome, and procedure-related mortality. 95% CIs and event rates were estimated. Statistical heterogeneity was assessed using I² statistics.

RESULTS

The procedure-related good outcome rate was 92% and complete occlusion rate was 91%. The permanent neurological deficit rate was 4% and procedure-related mortality was 2%. The procedure-related stroke rate was 12%. A total of 28/146 (19%) patients had ruptured aneurysms. At long-term follow-up, overall stroke rate was 9% in patients with unruptured aneurysm. The mortality rate was higher in cases with ruptured aneurysms than in those with unruptured aneurysms (18% vs 0.8%; p<0.001).

CONCLUSIONS

Y-stenting for bifurcation aneurysms yields a high rate of complete occlusion and low rates of mortality and stroke. Careful patient selection is needed.

Dual microcatheter coil embolization of acutely ruptured wide-necked intracranial aneurysms

The dual microcatheter technique is an alternative treatment for stent-assisted coiling in acutely ruptured wide-necked aneurysms because of no antiplatelet therapy. We assessed the safety and efficacy of this technique in ruptured wide-necked aneurysms. Between March 2008 and March 2016, 56 acutely ruptured aneurysms were treated with the dual microcatheter technique. The angiographic results, treatment-related complications, and clinical outcome were documented. Angiographic follow-up was available in 37 patients at a mean of 20.6 months (6 to 81 months). On the postembolization angiograms, 27 (48.2%) aneurysms showed complete occlusion (Raymond 1), 15 (26.8%) showed neck remnant (Raymond 2), and 14 (25.0%) showed body remnant (Raymond 3). Treatment-related complications occurred in seven patients (12.5%) and six patients remained asymptomatic. The permanent complication rate was 1.8% (1/56). A good outcome (modified Rankin Scale (mRS) score, 0-2) was observed in 64.3% of patients at the time of discharge. Five patients had died, all of the sequelae of subarachnoid hemorrhage. The overall mortality rate was 8.9% (5/56); however, the treatment-related mortality rate was 0%. Of the 37 aneurysms for which angiographic follow-up was available, 21 (56.8%) aneurysms demonstrated recanalization. Five aneurysms with recanalization were retreated endovascularly. There was one aneurysm re-rupture on follow-up and it rebled 21 months after the initial procedure. The dual microcatheter technique is a safe and effective treatment for acutely ruptured wide-necked aneurysms due to low treatment-related complication and mortality rate. However, the high rate of postembolization incomplete occlusion and recanalization remains as the main challenge.

Endovascular treatment of irregular and complicated intracranial aneurysms with coils using double microcatheter technique

Embolisation of irregular and complicated aneurysms is a great challenge for neuroradiologists. To overcome possible complications of endovascular treatment of these type of aneurysms, methods such as intracranial stents, balloon remodelling, and the double microcatheter technique have been developed. The aim of the study was to report our preliminary experience with endovascular treatment of irregular and complicated intracranial aneurysm with coils using double microcatheter technique, and evaluation of its feasibility and clinical advantages. In this retrospective study, 37 cases diagnosed with irregular and complicated intracranial aneurysms and treated using double microcatheter method from July, 2013 to May, 2015, were followed up for six months after discharge. All the aneurysms were successfully embolized using the double microcatheter technique. Immediate post-embolization angiography showed no residual contrast filling in 35 cases, and residual filling in 2 cases. At discharge, according to the modified Rankin Scale score, all the patients recovered without any complications or death. A follow-up of 24 cases with digital subtraction angiography for 6 months revealed no recanalization. In conclusion, the double microcatheter technique for irregular intracranial aneurysms is effective and simple with few complications.

Endovascular Coiling of Wide-Neck and Wide-Neck Bifurcation Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

We present the results of a systematic review and meta-analysis examining outcomes of endovascular coiling of wide-neck and wide-neck bifurcation aneurysms with and without stent assistance. The aim of our study was to assess angiographic and clinical outcomes.

MATERIALS AND METHODS

We performed a comprehensive literature search for all articles on the endovascular coiling of wide-neck and wide-neck bifurcation aneurysms. Studies meeting our inclusion criteria and abstracted data were selected by 2 independent reviewers. Primary outcomes were >6-month complete or near-complete angiographic occlusion, aneurysm recanalization, and aneurysm retreatment. Secondary outcomes included initial complete or near-complete occlusion, long-term good neurologic outcome, procedure-related morbidity, and procedure-related mortality. Data were analyzed by using random-effects meta-analysis.

RESULTS

In total, 38 studies including 2446 patients with 2556 aneurysms were included. For all wide-neck aneurysms, immediate complete or near-complete occlusion rate was 57.4% (95% CI, 48.1%-66.8%). Follow-up near-complete occlusion rate was 74.5% (95% CI, 68.0%-81.0%). Recanalization and retreatment rates were 9.4% (95% CI, 7.1%-11.7%) and 5.8% (95% CI, 4.1%-7.5%), respectively. Long-term good neurologic outcome was 91.4% (95% CI, 88.5%-94.2%). For wide-neck bifurcation aneurysms, initial complete or near-complete occlusion rate was 60.0% (95% CI, 42.7%-77.3%), long-term complete or near-complete occlusion rate was 71.9% (95% CI, 52.6%-91.1%), and the recanalization and retreatment rates were 9.8% (95% CI, 7.1%-12.5%) and 5.2% (95% CI, 1.9%-8.4%), respectively.

CONCLUSIONS

Our study of angiographic and clinical outcomes for patients with wide-neck aneurysms demonstrates that endovascular coiling with or without stent-assisted coiling is safe, with low rates of perioperative morbidity and mortality. Initial and long-term angiographic outcomes were generally satisfactory, but not ideal. These data provide some baseline comparisons against which emergent technologies can be assessed.

Efficacy and Safety of the Woven EndoBridge (WEB) Device for the Treatment of Intracranial Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Intrasaccular flow diverters are increasingly being used in the treatment of wide-neck and bifurcation aneurysms. We performed a systematic review and meta-analysis of existing literature on the Woven EndoBridge device in the treatment of intracranial aneurysms.

MATERIALS AND METHODS

A comprehensive literature search was performed through October 1, 2015. We extracted information on baseline aneurysm and patient characteristics. Outcomes studied included immediate and midterm (>3 month) angiographic outcomes (complete occlusion as well as adequate occlusion, defined as complete occlusion or neck remnant), aneurysm retreatment, intraoperative rupture, perioperative morbidity and mortality, thromboembolic complications, and treatment failure. Meta-analysis was performed by using the random-effects model.

RESULTS

Fifteen uncontrolled series were included in this analysis, including 565 patients with 588 aneurysms, of which 127 were ruptured. Initial complete and adequate occlusion rates were 27% (95% CI, 15%-39%) and 59% (95% CI, 39%-78%), respectively. Midterm complete and adequate occlusion rates after a median of 7 months were 39% (95% CI, 26%-52%) and 85% (95% CI, 78%-91%), respectively. Perioperative morbidity and mortality rates were 4% (95% CI, 1%-8%) and 1% (95% CI, 0%-2%), respectively. Midterm adequate occlusion rates for ruptured aneurysms were 85% (95% CI, 67%-98%), compared with 84% (95% CI, 72%-94%) for unruptured aneurysms (P = .89). Patients with ruptured aneurysm had similar rates of perioperative morbidity to patients with unruptured aneurysm (2%; 95% CI, 0%-26% versus 2%; 95% CI, 0%-6%, respectively; P = .35).

CONCLUSIONS

Early evidence derived from uncontrolled studies suggests that Woven EndoBridge treatment has a good safety profile and promising rates of adequate occlusion, especially given the complexity of aneurysms treated. Further prospective clinical trials are needed to confirm these results and better define the risks and benefits of use of the Woven EndoBridge device in treating wide-neck and wide-neck bifurcation aneurysms.

Endovascular treatment of distal posterior inferior cerebellar artery aneurysms

Objective:

To assess the feasibility and results of endovascular treatment for ruptured distal posterior inferior cerebellar artery (PICA) aneurysms.

Methods:

We retrospectively reviewed our experience and results with endovascular treatments for a series of 13 consecutive patients with ruptured distal PICA aneurysms at the Southwest Hospital, Chongqing, China, treated between June 2011 and January 2015. Therapeutic considerations, intraoperative complications, and results were evaluated.

Results:

Endovascular embolization was performed in all 13 patients including selective coiling (4), stent-assisted coiling (2), microcatheter-assisted coiling (1), coiling without adjunctive techniques (1), and parent artery occlusion (5). Planed stent deployment failure occurred in one patients resulting from marked stenosis at the origin of the PICA; the patient’s existing partial Wallenberg’s syndrome became worse after treatment. Another 2 patients treated with parent artery occlusion recovered well without developing obvious neurological deficits, although a small cerebellar infarction of the distal PICA was observed. No patient experienced post procedural hemorrhage during the follow-up period (8-46 months; mean, 26.8 months).

Conclusion:

Distal PICA aneurysms can be managed effectively with various endovascular methods. Protective strategies using a stent or microcatheter for preserving the patency of the proximal PICA segment are a viable treatment option in reducing the potential risk of brain stem ischemia in selected patients.

A new endovascular technique for small anterior choroidal artery aneurysms. A consecutive series using the 3-catheter-protective technique

INTRODUCTION

Endovascular treatment of small anterior choroidal artery (AChA) aneurysms can be challenging, especially if the AChA arises from the sac. Preserving its patency during embolization is as important as obliterating the aneurysm. We describe a variant of the "protective microcatheter technique" (PMT) in a series of six patients with AChA aneurysms where the AChA emerged from the sac.

METHODS

Three different microcatheters (KT) were used. The first microcatheter was placed in the AChA to protect it. A remodeling balloon-catheter was then positioned in the internal carotid artery to stabilize the coils during embolization and to control a potential rupture. The third microcatheter was finally used to coil the aneurysm.

RESULTS

Mean sac size of anterior choroidal artery aneurysms was 2×2×2mm. All aneurysms were successfully occluded. There was neither ischemic complication nor ruptured aneurysm during endovascular treatment. A final angiogram demonstrated AChA patency in all cases.

CONCLUSION

The 3KT-PMT for AChA aneurysms appears to be safe and effective to prevent AChA occlusion during aneurysm coiling, especially when the AChA arises from the sac.

Treatment outcomes of unruptured intracranial aneurysm; experience of 1,231 consecutive aneurysms

BACKGROUND

The aim of this study was to review our experience with surgical clipping and endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs), with a special focus on complications.

METHODS

We retrospectively analyzed clinical and radiological data from patients who underwent surgery or EVT. Surgery was performed by one neurosurgeon, and EVT was performed by two neurointerventionists according to one hybrid neurosurgeon's decision. Adverse events included the following: (1) decline of the modified Rankin Scale (mRS) score from 1 to 2 and (2) any unexpected neurological deficit or imaging finding affecting the prognosis and/or requiring additional procedures, medication, or prolonged hospital stay.

RESULTS

Of the 1231 UIAs in 1124 patients, 625 (50.7 %) aneurysms were treated with surgery, and 606 (49.3 %) aneurysms were treated with EVT. The overall complication rate of UIA treatment was 3.2 %. The rate of adverse events was 2.4 %, and the rates of morbidity and mortality were 0.6 and 0.2 %, respectively. The rates of adverse events, morbidity, and mortality were not significantly different between surgery and EVT. The rate of hospital use for EVT was stationary over the years of the study. Posterior circulation in surgery, large aneurysms (>15 mm) in EVT, and stent- or balloon-assisted procedures in EVT were associated with the occurrence of complications. Poor clinical outcome (mRS of 3-6) was 0.8 % at hospital discharge.

CONCLUSIONS

Both UIA treatment modalities decided by one hybrid neurosurgeon showed low complication rates and good clinical outcomes in this study. These results may serve as a point of reference for clinical decision-making for patients with UIA.

Use of Triple Microcatheters for Endovascular Treatment of Wide-Necked Intracranial Aneurysms: A Single Center Experience

Objective

The dual microcatheter technique is common practice for coil embolization of a wide-necked aneurysm, due to safety and efficacy. However, technical limitations of some complex configurations may necessitate additional microcatheters to bolster coil stability, compact the coil, or for protection. Described herein is a triple microcatheter technique for endovascular management of wide-necked intracranial aneurysms.

Materials and Methods

Data accruing prospectively between January 2006 and October 2014 on simultaneously executed triple microcatheter coil embolization procedures done in 38 saccular aneurysms were reviewed. Clinical and morphological outcomes were assessed, with emphasis on technical aspects of treatment.

Results

The triple microcatheter technique was successfully applied to all 38 saccular aneurysms, involving the posterior communicating artery (n = 13), the middle cerebral artery (n = 10), the basilar tip (n = 7), the anterior cerebral artery (n = 5), and the internal carotid artery (n = 3). Stent protection was added in four patients and balloon remodeling in one. Dual microcatheters (n = 24) were usually deployed to deliver the coil within sacs of aneurysms, with the additional microcatheter used for protection. Otherwise, triple microcatheters were deployed for coil delivery (n = 11) or coils were delivered via a single microcatheter, with dual microcatheters deployed for protection (n = 3). Successful occlusion of aneurysms was achieved in 89.5% of cases, with no procedure-related morbidity or mortality. Stable occlusion was maintained in 72.2% (26/36) of the aneurysms at the final follow-up (mean interval, 30.2 ± 22.7 months).

Conclusion

The outcomes of this limited study suggest that the triple microcatheter technique may be an effective and safe therapeutic option for wide-necked aneurysms, using technical strategies tailored to complex angio-anatomic configurations.

Microcatheter Looping to Facilitate Aneurysm Selection in Coil Embolization of Paraclinoid Aneurysms

Objective

Described herein is a microcatheter looping technique to facilitate aneurysm selection in paraclinoid aneurysms, which remains to be technically challenging due to the inherent complexity of regional anatomy.

Materials and Methods

This retrospective study was approved by our Institutional Review Board, and informed consent was waived. Microcatheter looping method was employed in 59 patients with paraclinoid aneurysms between January 2012 and December 2013. In the described technique, construction of a microcatheter loop, which is steam-shaped or pre-shaped, based on the direction of aneurysms, is mandatory. The looped tip of microcatheter was advanced into distal internal carotid artery and positioned atop the target aneurysm. By steering the loop (via inner microguidewire) into the dome of aneurysm and easing tension on the microcatheter, the aneurysm was selected. Clinical and morphologic outcomes were assessed with emphasis on technical aspects of the treatment.

Results

Through this looping technique, a total of 59 paraclinoid aneurysms were successfully treated. After aneurysm selection as described, single microcatheter technique (n = 25) was most commonly used to facilitate coiling, followed by balloon protection (n = 21), stent protection (n = 7), multiple microcatheters (n = 3), and stent/balloon combination (n = 3). Satisfactory aneurysmal occlusion was achieved through coil embolization in 44 lesions (74.6%). During follow-up of 53 patients (mean interval, 10.9 ± 5.9 months), only one instance (1.9%) of major recanalization was observed. There were no complications related to microcatheter looping.

Conclusion

This microcatheter looping method facilitates safe and effective positioning of microcatheter into domes of paraclinoid aneurysms during coil embolization when other traditional microcatheter selection methods otherwise fail.

Embolisation of internal carotid artery aneurysm using the double microcatheter technique - a case report

Background

A wide-necked aneurysm is defined as the one with a neck greater than 4 mm in diameter. Embolisation of wide-necked aneurysms is a great challenge for neuroradiologists. To overcome possible complications of endovascular treatment of this type of aneurysms, methods like intracranial stents, balloon remodelling, the double microcatheter and the microcatheter protective technique have been developed.

Case Report

We report a case of embolisation of a 63-year-old woman with a wide-necked aneurysm using the double microcatheter technique. Introduction of the second microcatheter into the aneurysm allowed for crossing two coils and prevented protrusion into the parent vessel, which resulted in successful treatment without postprocedural complications. Both postembolic and follow-up angiography showed complete exclusion of the aneurysm.

Conclusions

The double microcatheter technique, owing to creation of a stable coil frame across the neck of the aneurysm, is suitable for treatment of aneurysms with an adverse dome-to-neck ratio. This technique is easy to perform for an experienced neuroradiologist.

Modified coil protection for proper coil frame configuration in wide-necked aneurysms

INTRODUCTION

Although various protective techniques for treating wide-necked intracranial aneurysms currently exist and continue to evolve, their utility may be limited in some lesions with complex configurations, small-caliber channels, or inherently tortuous vascular patterns. Described herein is a modified coil protection technique as a novel adjunct for proper coil frame configuration.

METHODS

Initially, a microcatheter is passed into aneurysmal sac, and the first coil is inserted to build a frame. Inevitably, some coils may abut opposite poles of aneurysms and protrude into parent arteries. Should this happen, a second microcatheter may be placed at the site of coil protrusion, so that a separate and smaller coil may be partially deployed for protection. A framing coil may then be configured within aneurysmal sac, under protection of the secondary coil. Once the first coil is entirely in place, the remainder of second coil is carefully inserted, and additional coil may be inserted as needed via dual microcatheters.

RESULTS

This technique was successfully applied to 23 saccular intracranial aneurysms of internal carotid (n = 8), middle cerebral (n = 6), anterior cerebral (n = 6), and superior cerebellar artery (n = 3), combining stent protection in two patients and balloon remodeling in one. Selective endovascular treatment was effective as a result. Excellent outcomes were achieved in all patients, with no morbidity or mortality directly related to the modified procedure.

CONCLUSION

As suggested by outcomes of this small study, our modified coil protection method may be a safe option if traditional coiling strategies are not feasible, enabling stable coil frame configuration in wide-necked aneurysms.

Improved Endovascular Coiling of Wide-Neck Intracranial Aneurysms in Elderly Patients by Double-Microcatheter Technique

Elderly patients are more susceptible to intracranial aneurysms. However, many of them are poor surgical candidates and often have to undergo endovascular treatment. The purpose of this study was to evaluate the efficacy and safety of double-microcatheter technique as an alternative to a balloon- or stent-assisted techniques for wide-neck aneurysms in elderly patients. A retrospective review of 58 patients with 58 wide-neck aneurysms treated with the double-microcatheter technique between October 2010 and December 2012 was performed. Immediate post-embolization angiograms were evaluated using a conventional angiographic scale, and clinical evaluation was performed using the Glasgow Outcome Scale. Clinical and imaging follow-ups were available in 32 (55%) patients, with a mean of 12.5 months. Post-embolization angiograms demonstrated total occlusion in 46 of 58 (79%) aneurysms, a neck remnant in 7 (13%), and body filling in 5 (8%). The technique-related complication rate was 5% (3/58), and the procedural-related mortality rate was 0. Of the 32 aneurysms with follow-ups, recanalization developed in 3 (9%) aneurysms, and none received re-treatment. Using double-microcatheter technique for embolization of wide-neck intracranial aneurysms is safe and effective in the elderly patients. This technique is feasible and safe for coil embolization of wide-neck aneurysms, especially in cases, which are not suitable for balloon- or stent-assisted techniques.

Microcatheter looping facilitates access to both the acutely angled parent artery and cerebral aneurysms for effective embolization

Aneurysms with an acutely angled parent artery are difficult to access for coiling. This study aimed to investigate the safety and effectiveness of microcatheter looping for embolization of cerebral aneurysms with access difficulty. Ten patients (male:female=5:5) with cerebral aneurysms treated with the microcatheter looping technique were analyzed retrospectively. The parent artery formed an acute angle with the major artery in five aneurysms. The microcatheter was looped into a "α" loop for treatment in the anterior temporal artery aneurysm and a "U" loop in the remaining nine aneurysms. All ten aneurysms were successfully treated with the microcatheter looping technique. The microcatheter tip was successfully navigated into the aneurysm sac and remained stable throughout the embolization process. All aneurysms were occluded with total occlusion in five and near-total occlusion in five, and the parent artery remained patent in all cases. No complications occurred peri-procedurally. The Glasgow Outcome Scale was 5 in all patients before discharge. Follow-up angiography six to 12 months later revealed a good occlusion status of the aneurysms. The microcatheter looping technique is effective when the conventional embolization technique fails to treat cerebral aneurysms with difficult access especially when the parent artery forming an acute angle with the major artery exacerbates difficult access to the aneurysms.

Microguidewire protection of wide-necked aneurysms incorporating orifices of tortuous acute-angled vessels: a novel approach

INTRODUCTION

Protective/remodeling techniques for treating wide-necked intracranial aneurysms are constantly sought. However, their utility may be limited in lesions that incorporate the orifice of acute-angled efferent branch vessels. Furthermore, passage of a protective microcatheter may be challenging if a small branch is extremely tortuous. This study was conducted to explore a novel method of treating wide-necked aneurysms, utilizing microguidewire protection.

METHODS

A microcatheter is first passed into parent artery (proximal to aneurysm) to position a microguidewire proximally in the involved branch. A second microcatheter is then inserted into aneurysmal sac. Advancement of the first microcatheter forces the microguidewire to shift, thus covering aneurysmal neck. A framing coil may then be placed within aneurysmal sac, under microguidewire protection. After completing initial coil insertion, easing of tension on the microcatheter allows separation of protective microguidewire and frame coil, confirming stability of the initial coil.

RESULTS

This technique was applied to 11 intracranial saccular aneurysms of M1 segment (n=6), middle cerebral artery bifurcation (n=4), and anterior communicating artery (n=1) with success, combining stent protection in two patients. Coil embolization was thus facilitated, resulting in excellent outcomes for all patients. No morbidity or mortality was directly related to microguidewire protection.

CONCLUSION

Our small study suggests that microguidewire protection may be a safe alternative, if traditional remodeling or protective options are infeasible due to intrinsic vascular properties. This technique is particularly suited for treatment of wide-necked aneurysms where passage of protective microcatheters into involved branches is not achievable.

Coil embolization in precommunicating (A1) segment aneurysms of anterior cerebral artery

INTRODUCTION

Precommunicating (A1) segment aneurysms of the anterior cerebral artery are rare and often pose technical challenges for coil embolization due to their distinctive configurations. Clinical and radiologic outcomes of treating such aneurysms through endovascular coil embolization are presented herein.

METHODS

Data accruing prospectively from May 2002 to August 2013 yielded 48 patients harboring 50 A1 segment aneurysms, each classified as proximal, middle, or distal by location. Clinical outcome of the patients and morphological outcome of the aneurysms were assessed, with emphasis on technical aspects of treatment.

RESULTS

The aneurysms studied occupied either proximal (n = 39), middle (n = 6), or distal (n = 5). Proximal aneurysms were largely directed posteriorly (80 %), and most (97 %) were devoid of branches. Middle and distal aneurysms were associated with the medial lenticulostriate artery, cortical branches, or fenestrations. The preshaped "S" and steam-shaped "S" microcatheters facilitated aneurysm selection in 60 % of lesions. Single-microcatheter technique was most commonly applied for coil embolization (62 %), followed by balloon protection (16 %). Successful aneurysmal occlusion could be achieved in 76 % of the patients, with no procedure-related morbidity and mortality. At final follow-up (mean interval, 29.9 months), stable aneurysmal occlusion was sustained in 93 % of the patients (40/43).

CONCLUSION

A1 segment aneurysms are amenable to safe and efficacious endovascular coil embolization by adjusting procedural strategy to accommodate distinctive anatomic configurations.

The role of endovascular treatment for ruptured distal anterior cerebral artery aneurysms: comparison with microsurgical clipping

BACKGROUND AND PURPOSE

The purpose of this study was to compare clinical outcomes and treatment-related complications between coiling and clipping for ruptured distal anterior cerebral artery (DACA) aneurysms.

METHODS

Eighty-four consecutive patients (M:F = 36:48; mean 53.8 years) with ruptured DACA aneurysms were treated by either clipping (n = 46, 54.8%) or coiling (n = 38, 45.2%). The clinical outcomes and procedure-related complications were evaluated and compared between the two groups.

RESULTS

Procedure-related complications tend to occur more frequently in the clipping (n = 6, 13.0%) than coiling group (n = 1, 2.6%) (P = .121). At discharge, 51 patients (60.7%) had favorable outcomes (Glasgow outcome scale [GOS], 4 or 5). There was no significant difference between the two groups in favorable outcome (63.2% vs. 58.7%; P = .677). Hunt and Hess (HH) grade (P < .001; 95% CI, 3.354-29.609) and treatment modality (P = .044; 95% CI, 1.039-16.325) were independent risk factors for poor outcome (GOS, 1-3).

CONCLUSIONS

Coiling was more favorable to clipping in clinical outcomes and incidence of treatment-related complications for ruptured DACA aneurysms.

Various techniques of stent-assisted coil embolization of wide-necked or fusiform middle cerebral artery aneurysms : initial and mid-term results

Objective

To evaluate the feasibility and clinical and angiographic outcomes of stent-assisted embolization for complex middle cerebral artery (MCA) aneurysms.

Methods

The records of 23 consecutive patients with 24 MCA aneurysms, who underwent stent-assisted embolization of the aneurysm, were retrospectively evaluated.

Results

Fifteen aneurysms were treated with one stent and 8 were treated using more than two stents (5 a stent-within-a-stent, 1 triple stents, and two Y-stent). Angiographically, complete or near complete occlusion was achieved in 15 aneurysms (65.2%), residual neck in five (21.7%), and residual aneurysm in three (13.1%). Five aneurysms demonstrated thrombosis within the stent during the procedure and hospitalization, and were resolved by intraarterial and intravenous Tirofiban injection. Symptomatic thromboembolic complications were developed in five patients and permanent deficits demonstrated in two patients with modified Rankin Scale 1 and 2, respectively. Treatment-related permanent morbidity and mortality rates were 8.3% and 0% with relatively high complication rate. Angiographic follow-up was available in 17 aneurysms at 6-31 months (mean, 13.2 months) and showed stable or improved in 15 (88.2%) and major and minor recurrence in one, respectively.

Conclusion

Complex MCA aneurysms could be treated by stent-assisted coiling and showed lower recanalization rate during mid-term follow-up by effective flow diversion due to various stent-assisted techniques. Our results warrant further study with a longer follow-up period in a larger sample.

Coil-protected embolization technique for a branch-incorporated aneurysm

OBJECTIVE

A small branch-incorporated aneurysm is an aneurysm with a small branch incorporated into the sac or the neck. It is one of the most difficult aneurysms to treat with coil embolization. The aim of this study was to evaluate the safety and effectiveness of the coil-protected embolization technique for small-branch incorporated aneurysm.

MATERIALS AND METHODS

Fourteen aneurysms (2 ruptured and 12 unruptured) in 12 patients (mean age, 56 years, range, 40-73 years; 6 men and 6 women) were treated with the coil-protected embolization technique during the period between February 2007 and October 2011. Clinical and angiographic outcomes were retrospectively evaluated.

RESULTS

All aneurysms were successfully treated without any complications during the procedure. Immediate post-treatment angiographies demonstrated complete or near complete occlusion in 12 and incomplete occlusion in 2 patients. Two patients had a delayed small embolic infarction in the relevant posterior circulation territory and middle cerebral artery territory 10 days and 14 days later, respectively, but both recovered completely or almost completely (modified Rankin scale score [mRS score], 0 and 1, respectively). During the clinical follow-up period (mean, 21 months; range: 2-58 months), all patients reported an mRS score of 0 (n = 10) or 1 (n = 2). Vascular imaging follow-up (catheter angiography: n = 3 and MR angiography: n = 8) was available in 11 aneurysms at 6-12 months. All 11 aneurysms showed complete occlusion except for 1 minor neck recurrence that did not require further treatment.

CONCLUSION

In this series of cases, the coil-protected embolization technique seems to be feasible and effective in the treatment of small-branch incorporated aneurysms.

Coil protection using small helical coils for wide-neck intracranial aneurysms: a novel approach

BACKGROUND AND PURPOSE

A number of remodeling or protective techniques available to treat wide-neck intracranial aneurysms are increasingly being used, provided that the shape/type of aneurysm, vessel diameter, and inherent course of the vessel are conducive to their use. The purpose of this study was to describe a novel method using coil protection for treatment of wide-neck aneurysms.

MATERIALS AND METHODS

This technique involves sequential maneuvers to the aneurysm and affected branch artery. A microcatheter is first introduced into the aneurysmal sac, and another microcatheter is introduced into the entrance of the branch artery, followed by partial deployment of a small helical coil into the branch artery. A framing coil is then placed within the aneurysmal sac, under the protection of the helical coil. After completion of the first coil insertion, the helical coil should be retrieved to confirm the stability of the framing coil. The helical coil can also serve as a filler.

RESULTS

This technique was successfully applied to 12 intracranial saccular aneurysms of the MCA bifurcation (5 patients); anterior communicating artery (3 patients); and A1 and M1 segments, distal ACA, and basilar tip (1 patient each). Selective endovascular treatment was successfully performed and resulted in excellent outcomes in all patients. There were no complications directly related to coil protection.

CONCLUSIONS

Our small study suggests that coil protection can be a safe alternative to traditional remodeling or protective techniques when those techniques have failed or are not possible due to vascular geometry. It is particularly suited for the treatment of wide-neck aneurysms arising from small and acutely angulated branching vessels.

Microcatheter looping technique for coil embolization of complex configuration middle cerebral artery aneurysms

BACKGROUND

Protection techniques using stents or microcatheters allow treatment of aneurysms with complex configurations by coil embolization. However, the application of these techniques is occasionally limited in wide-neck middle cerebral artery (MCA) aneurysms with acute angularity of the efferent branch vessel.

OBJECTIVE

We describe a looping technique for passage of a microcatheter and microwire into the acutely angled efferent branch vessel without navigating the system through the aneurysm lumen.

METHODS

To select the acutely angulated branch, a looped microcatheter was advanced near the orifice of the distal acutely angled branch vessel, followed by microwire passage through the looped microcatheter into the efferent vessel. The microcatheter loop was straightened after the microwire had been sufficiently advanced. The microcatheter was then navigated into the distal branch vessel over the advanced microwire.

RESULTS

A total of 36 wide-neck MCA aneurysms were successfully treated using this looping method. This technique was used to pass the microcatheter for stent protection in 13 patients and for microcatheter protection in 23. The method was most commonly used for aneurysms located at the M1 trunk (n = 21), followed by the MCA bifurcation (n = 15). Complete or near-complete endosaccular occlusion was achieved in 31 aneurysms. There were no complications related to looping the microcatheter.

CONCLUSION

This microcatheter looping technique facilitates safe entry into the distal branch during coil embolization of wide-neck MCA aneurysms incorporating the origins of acutely angulated branches.

Endovascular Treatment of Wide-necked Cerebral Aneurysms with an Acute Angle Branch Incorporated into the Sac: Novel methods of Branch Access in 8 Aneurysms

Purpose

The optimal management of geometrically complex aneurysms remains challenging. The aim of this retrospective study was to evaluate the safety and feasibility of branch-selective technique (BT) in wide-necked aneurysms with an acute angle branch incorporated into the sac.

Materials and Methods

Eight consecutive patients harboring wide-necked cerebral aneurysms with an incorporated, acute angle branch (mean, 30.4°) underwent coiling over an 18-month period. Dome-to-neck ratio ranged from 0.9 to 1.8 (mean, 1.2). Every procedure utilized BT, i.e., stent- or catheter-assisted coiling through the incorporated branch.

Results

Technical success was achieved in all cases. With the aim to avoid the risk of aneurysmal rupture during struggling intraaneurysmal wire navigation, a 'looping method' and retrograde approach of a preshaped 0.014' microcatheter (C or J) was used for branch access in five cases and a 'looping method' and antegrade approach in one case. In the remaining one, just the C-preshape was enough to directly enter the branch without intraaneurysmal wire navigation. Overall, stent-assisted coiling was performed in seven cases, while catheter-assisted coiling was undertaken in one. The only complication was thrombotic posterior inferior cerebellar artery occlusion in one case, which was recanalized after tirofiban infusion. New neurological deficits were not identified in any cases.

Conclusion

BT seems safe and feasible for wide-necked aneurysms with an acute angle branch incorporated into the sac. The looping method may offer safe access to the incorporated, acute angle branch and should be considered for replacement of the fearful intra-aneurysmal wire navigation.

Tuberothalamic artery infarctions following coil embolization of ruptured posterior communicating artery aneurysms with posterior communicating artery sacrifice

BACKGROUND AND PURPOSE

Ischemic complications after coil embolization of the PcomA aneurysms are not thoroughly understood, especially in cases in which the PcomA is sacrificed. Our purpose was to examine the preoperative angiographic features and pattern of postoperative cerebral infarctions exhibited by patients who underwent embolization of ruptured PcomA aneurysms with PcomA sacrifice.

MATERIALS AND METHODS

A retrospective review identified 14 patients with ruptured PcomA aneurysms who underwent embolization of the aneurysms in combination with PcomA sacrifice. Preoperative angiographic data, including the Allcock test, postoperative DWI, and neurologic status, were examined.

RESULTS

Elimination of the aneurysm was complete in all cases. Postoperative DWI indicated 7 cases with infarctions (infarction group) and 7 cases without infarctions (noninfarction group). All patients in the infarction group developed infarctions in the vicinity of the tuberothalamic artery. In all 14 cases, a preoperative Allcock test demonstrated a retrograde filling of the PcomA through the P1 segment. The incidence of negative visualizations of the P1 segment on vertebral angiograms was significantly higher in the infarction group (100%) than in the noninfarction group (0%; P = .00058). The mean PcomA diameters, PcomA/P1 ratios, and aneurysm sizes observed in the infarction group were significantly greater than those in the noninfarction group (P < .05, P < .01, and P < .02, respectively). Tuberothalamic artery infarction caused hemiparesis and memory disturbance, which were associated with unfavorable outcomes.

CONCLUSIONS

After the coil occlusion of ruptured PcomA aneurysms with PcomA sacrifice, tuberothalamic artery infarctions tended to occur in cases exhibiting negative visualization of the P1 segment, even when collateral flow was observed with the Allcock test.