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Endovascular treatment of very small intracranial aneurysms: Clinical article
Abstract
Endovascular treatment of very small aneurysms poses a significant technical challenge for endovascular therapists. The authors review their experience with a series of patients who had intracranial aneurysms smaller than 3 mm in diameter.
Between 1995 and 2006, 97 very small aneurysms (defined for purposes of this study as < 3 mm in diameter) were diagnosed in 94 patients who were subsequently referred for endovascular treatment. All patients presented after subarachnoid hemorrhage, which was attributed to the very small aneurysms in 85 patients. The authors reviewed the endovascular treatment, the clinical and angiographic results of the embolization, and the complications.
Five (5.2%) of the 97 endovascular procedures failed, and these patients underwent craniotomy and clip ligation. Of the 92 aneurysms successfully treated by coil embolization, 64 (69.6%) were completely occluded and 28 (30.4%) showed minor residual filling or neck remnants on the immediate postembolization angiogram. Complications occurred in 7 (7.2%) of 97 procedures during the treatment (3 thromboembolic events [3.1%] and 4 intraprocedural ruptures [4.1%]). Seventy-six patients were followed up angiographically; 4 (5.3%) of these 76 showed angiographic evidence of recanalization that required retreatment. The clinical outcomes for the 76 patients were also graded using the Glasgow Outcome Scale. In 61 (80.3%) cases the outcomes were graded 4 or 5, whereas in 15 (19.7%) they were graded 3. Seven patients (7.4%) died (GOS Grade 1), 2 due to procedure-related complications (intraoperative rupture) and 5 due to complications related to the presenting subarachnoid hemorrhage.
Endosaccular coil embolization of very small aneurysms is associated with relatively high rates of intraprocedural rupture, especially intraoperative rupture. With the advent of more sophisticated endovascular materials (microcatheters and microguidewires, soft and ultrasoft coils, and stents) endovascular procedures have become feasible and can lead to a good angiographic outcome.
... Very small aneurysms (VSAs) are defined as saccular aneurysms 3 mm in maximum diameter. Endovascular coil embolization of ruptured cerebral VSAs or BBAs is known to be 5 times more likely to result in procedure-related rupture compared to larger aneurysms [1,6]. ...
... Apart from histopathological differences between, BBAs and wide necked VSAs, both face a similar treatment dilemma. While various opensurgical and endovascular techniques have been suggested as possible treatment, the incidence of intra-operative rupture, and subsequent risk for morbidity and mortality is still high [2,6,7]. Endoluminal reconstruction using flow diversion represents a recently suggested safe treatment alternative for both BBAs and wide necked VSA as it does not require direct manipulation of the aneurysm [8]. ...
... Endoluminal reconstruction using flow diversion represents a recently suggested safe treatment alternative for both BBAs and wide necked VSA as it does not require direct manipulation of the aneurysm [8]. Current data on flow diversion for this application, however, are limited [2,6,8,9]. Here, we report a single center retrospective case series of flow diversion for BBAs and wide necked VSAs and evaluate safety and efficacy. ...
Purpose:
Ruptured blood blisters (BBA) and very small, wide necked aneurysms (VSA) remain challenging lesions to treat due to their small size, wide necks, and thin, fragile walls. In the present study, we reviewed our experience with these aneurysms treated by flow diversion.
Methods:
A total of 18 patients with hemorrhage due to a ruptured BBAs and VSAs, treated with flow diversion between July 2014 and March 2016 were included in this study. We analyzed clinical and radiographic outcomes.
Results:
A total of 12 (66.7%) VSAs and 6 (33.3%) BBAs were treated with flow diversion. Fifteen (83.3%) and three (16.7%) aneurysms were located on the internal carotid artery and the basilar artery, respectively. On admission, a GCS score of 15 and WFNS grade 1 were found in 14 (77.7%) patients, 3 patients had an admission GCS of 13 and WFNS grade 2, one had an admission GCS of 8 and WFNS of 4. Fisher CT grades 2, 3, and 4 were observed in 11 (61.1%), 1 (5.6%), and 6 (33.3%) patients, respectively. Flow diversion was performed on average 5.6 days after onset of hemorrhage. 6 months post-intervention angiography showed complete obliteration of the aneurysms in all patients.
Conclusion:
Our findings indicate that flow diversion in the acute and subacute phase of hemorrhage is a reliable treatment for reducing complications in patients with BBAs and VSAs. In patients with poor clinical presentation it might be reasonable to delay treatment until the first signs of recovery become apparent.
... Endovascular coil embolization of intracranial aneurysms (IAs), including small aneurysms, has become a well-established technique for treatment of IAs since its inception in the early 1990s. Although no consensus exists regarding the definition of small or very small IAs, prior reports on the topic have designated aneurysms under 3 mm in diameter as "very small" and aneurysms under 4, 5, 7, or even 10 mm as "small" [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. The International Study of Unruptured Intracranial Aneurysms initially grouped aneurysms by size below and above 10 mm and later grouped aneurysms by size below and above 7 mm [1,2]. ...
... Small brain aneurysms have posed significant therapeutic challenges during endovascular coiling. Multiple reports demonstrate an intraoperative risk of aneurysm rupture during coiling of around 10% for small lesions and a correspondingly lower risk of larger lesions [7][8][9][10][11][12][13]16,20,27,28] More recent reports, however, demonstrate a more favorable risk profile of coil embolization of small brain aneurysms. For example, Stetler et al and Starke et al demonstrated intraoperative risks of small aneurysm rupture during coiling to be only 1.2% in 2015 and 3.7% in 2013, respectively [14,15] (Table 1). ...
... For example, Stetler et al and Starke et al demonstrated intraoperative risks of small aneurysm rupture during coiling to be only 1.2% in 2015 and 3.7% in 2013, respectively [14,15] (Table 1). Additional reports, while limited in number, also have shown good angiographic and clinical outcomes in the endovascular treatment of small brain aneurysms [13,18,[23][24][25][26]29,30] In 2012, Chalouhi et al. demonstrated similar long-term outcomes between groups of very small ruptured aneurysms randomized to microsurgical repair or endovascular coiling, despite the fact that procedural complications were higher in the microsurgery group [17]. Our results also demonstrate a favorable risk profile associated with coil embolization of small brain aneurysms. ...
Purpose:
The introduction of small, soft, complex-shaped microcoils has helped facilitate the endovascular treatment of small intracranial aneurysms (IAs) over the last several years. Here, we evaluate the initial safety and efficacy of treating small IAs using only Target(®) Ultrasoft(™) coils.
Materials and methods:
A retrospective review of a prospectively maintained clinical database at a single, high volume, teaching hospital was performed from September 2011 to May 2015. IAs smaller than or equal to 5.0 mm in maximal dimension treated with only Target(®) Ultrasoft(™) coils were included.
Results:
A total of 50 patients with 50 intracranial aneurysms were included. Subarachnoid hemorrhage from index aneurysm rupture was the indication for treatment in 23 of 50 (46%) cases, and prior subarachnoid hemorrhage (SAH) from another aneurysm was the indication for treatment in eight of 50 (16%) cases. The complete aneurysm occlusion rate was 70% (35/50), the minimal residual aneurysm rate was 14% (7/50), and residual aneurysm rate was 16% (8/50). One intraoperative aneurysm rupture occurred. Three patients died during hospitalization from clinical sequelae of subarachnoid hemorrhage. Follow-up at a mean of 13.6 months demonstrated complete aneurysm occlusion in 75% (30/40) of cases, near complete occlusion in 15% (6/40) of cases, and residual aneurysm in 10% (4/40) of cases, all four of which were retreated.
Conclusion:
Our initial results using only Target(®) Ultrasoft(™) coils for the endovascular treatment of small intracranial aneurysms demonstrate initial excellent safety and efficacy profiles.
... In the literature, very small intracranial aneurysms are defined as intracranial aneurysms with a diameter smaller than or equal to 3 mm [7][8][9]. Other sources qualify these aneurysms to a group called "baby aneurysms" [10,11]. Unfortunately, the sources do not indicate which dimension is analysed in qualification of the aneurysm into the VSIA group; therefore, in our study, to the VSIA group we qualified aneurysms with any dimension less than 3 mm. ...
... Other complications seen in our centre such as rupture of the aneurysm during surgery are also described in other publications. It was 1.54% in our centre, while in the literature it is described as 3.92% to 4.90% [10,20,23]. Some authors describe how VSIA rupture associated with procedure occurs twice or even five times more than in larger aneurysms [17,24,25]. ...
Purpose:
Very small intracranial aneurysms (VSIAs) may cause many neurological complications and even death. Thanks to technological progress and higher quality of non-invasive neuroimaging methods, these pathologies can be investigated sooner and treated earlier. Due to the controversy surrounding invasive treatment of these pathologies, the aim of the study was to analyse methods of treatment, their outcome, and complications in a group of patients with VSIAs.
Material and methods:
Out of 444 cases of intracranial aneurysms treated in our centre, 65 aneurysms met the radiological criteria of VSIAs. The parameters - width and length of the aneurysm's neck and width, length, and height of the aneurysm's dome - were measured. The analysed parameters were as follows: symptoms upon admission and after treatment, days in hospital, and intraoperative complications. Clinical and radiological intensity of subarachnoid haemorrhage (SAH) was evaluated by using the Hunt-Hess and Fisher scales. The degree of embolisation of the aneurysm after the procedure was assessed using the Montreal Scale. Clinical outcome was assessed by Glasgow Outcome Scale.
Results:
50.77% of VSIAs were treated with endovascular procedures and 49.23% with neurosurgical clipping. SAH was presented in 38.46% of patients with VSIAs. Intraoperative complications were presented in 16.92% of patients with VSIAs, and the most common complication was ischaemic stroke. Stents were used in 51.52% of VSIAs. In 69.70% of embolisation procedures at VSIAs complete obliteration was achieved. The average result in the Montreal Scale was 1.31 (SD = 0.66).
Conclusion:
VSIAs can be treated as effectively and safely as larger aneurysms, by both endovascular and surgical methods.
... Many other case series have reported various estimates of procedural rupture during coil occlusion of very small aneurysms only. Those studies included either exclusively ruptured aneurysms [10][11][12][13][14][15][16], or a mix of ruptured and unruptured ones [17][18][19][20][21][22][23][24]. Their results have been pooled in a meta-analysis [25] which has found that procedural rupture rate reported during endovascular coil occlusion of very small aneurysms published after 2010 was lower than those reported in studies published before 2010. ...
Objective
Procedure-related rupture is one of the most feared complications in treating patients with cerebral aneurysm. The primary aim of this study was to estimate the effect of aneurysm size on procedure-related rupture. We also estimated its effect on peri-procedural thromboembolic events.
Methods
This observational study was conducted using routinely-collected health data on patients admitted for subarachnoid hemorrhage and treated with aneurysm coil occlusion in the CHU de Québec — Enfant-Jésus hospital from January 1st, 2000 until sample size was reached. Patients were identified from the Discharge Abstract Database using the Canadian Classification of Health codes. Assessment of complications was blind to aneurysm size. Logistic regression models were performed to test associations between aneurysm size and procedure-related rupture or peri-procedural thromboembolic events, and between both procedure-related rupture and thromboembolic events and patients' outcomes.
Results
This study included 532 aneurysms treated with coil occlusion in 505 patients. Procedure-related rupture occurred in 34 patients (6.7%) and thromboembolic events in 53 (10.5%) patients. Aneurysms of 2 to 3 mm inclusively were not more significantly associated with procedure-related rupture or thromboembolic events than those larger than 3 mm (OR 1.02, 95% CI: 0.9–1.16, p = 0.78 and OR 1.06, 95% CI: 0.96–1.17, p = 0.3, respectively). However, procedure-related rupture had a significant effect on patient mortality (OR 3.86, 95% CI: 1.42–10.53, p < 0.01).
Conclusions
Very small aneurysm size should not preclude aneurysm coil occlusion. Every measure should be taken to prevent procedure-related rupture as it is strongly associated with higher mortality.
... The smaller size of the aneurysm sac limits the movement of the microcatheter; thus, any unexpected movement during catheter positioning or coil deployment can result in rupture of the aneurysm sac. 10,15 Cases of intraprocedural perforation are generally managed through reversal of anticoagulation followed by coiling of the aneurysm. The placement of a balloon at the side of the IA neck to stop hemorrhage has been advocated; however, the use of additional adjunctive devices during treatment of very small intracranial aneurysms has been associated with increased complication rates in some studies. ...
... The aneurysm was extremely small (The size is 2.9 mm × 2.57 mm) and the risk of re-rupture during coil embolization was high. 5) We used four coils of all only EDC-10 ES. The embolization was finished with complete obliteration confirmed on cerebral angiography. ...
Objective: In the final stage of coil embolization, microcatheter kickback often occurs and it may be difficult to fill the remaining space with a coil. To avoid microcatheter kickback and achieve successful embolization, soft type coils such as ED coil-10 Extra Soft type R (EDC-10ES) are frequently used as a finishing coil. We compared six different brands of finishing coils to evaluate the efficacy of EDC-10ES.Case Presentations: This paper presents a representative case of small cerebral aneurysm treated with only EDC-10 ES coils were presented. Furthermore, to compare the degree of coil softness and microcatheter kickback, we verified the in vitro coil performance of six different brands of finishing coils. The first experiment compared the degree of microcatheter kickback in the final stage of coil embolization and the second experiment tested the softness of the delivery wire.Conclusion: The results verified that EDC-10 ES has less microcatheter kickback in relation to both the coil and delivery wire, compared to the other finishing coils. Consequently, EDC-10 ES was evaluated as a coil with extremely high softness, allowing stable coil placement in the final stage of embolization.
... The smaller size of the aneurysm sac limits the movement of the microcatheter; thus, any unexpected movement during catheter positioning or coil deployment can result in rupture of the aneurysm sac. 10,15 Cases of intraprocedural perforation are generally managed through reversal of anticoagulation followed by coiling of the aneurysm. The placement of a balloon at the side of the IA neck to stop hemorrhage has been advocated; however, the use of additional adjunctive devices during treatment of very small intracranial aneurysms has been associated with increased complication rates in some studies. ...
Background and purpose:
Outcomes of endovascular treatment of very small intracranial aneurysms are still not well-characterized. Recently, several series assessing coil embolization of tiny aneurysms have presented new promising results. Thus, we performed a systematic review and meta-analysis of studies evaluating endovascular treatment of very small intracranial aneurysms.
Materials and methods:
We conducted a computerized search of Scopus, Medline, and the Web of Science for studies on endovascular treatment of very small (≤3 mm in diameter) intracranial aneurysms published between January 1996 and May 2015. Using a random-effects model, we evaluated clinical and angiographic outcomes.
Results:
Twenty-two studies with 1105 tiny aneurysms (844 ruptured and 261 unruptured) endovascularly treated were included. Postoperative and long-term complete occlusion was achieved in 85% (95% CI, 78%-90%) and 91% (95% CI, 87%-94%) of aneurysms, respectively. The recanalization rate was 6% (95% CI, 4%-11%) and retreatment occurred in 7% (95% CI, 5%-9%) of cases. Seventy-nine percent (95% CI, 64%-89%) of patients had good neurologic outcome at long-term follow-up. Intraprocedural rupture occurred in 7% (95% CI, 5%-9%) of the coiling procedures, while thromboembolic complications occurred in 4% (95% CI, 3%-6%).
Conclusions:
Coil embolization of very small intracranial aneurysms can be performed safely and effectively. In the case of unruptured aneurysms, procedure-related complications are not negligible. Patients and providers should consider such risks when engaged in a shared decision-making process.
... They form the main bulk of surgical management after the ISAT study, which promoted endovascular coiling as a first-line treatment in patients with aSAH [6]. According to recent guidelines and data, for patients with MCA aneurysms or with very small and large/giant aneurysms, surgical treatment has tended to yield more favorable results [17][18][19][20][21][22]. However, in cases of vertebra-basilar aneurysms, especially in older patients, endovascular treatment has been gaining widespread acceptance based on several observational studies [23][24][25][26][27][28]. ...
Although there have been a number of studies on changes and trends in the management of aneurismal subarachnoid hemorrhage (aSAH) since publication of the International Subarachnoid Aneurysm Trial (ISAT), no data exist on what category of patients still remains for surgical treatment. Our goal was to investigate the changes that occurred in the characteristics of a population of aSAH patients treated surgically in the post-ISAT period in a single neurosurgical center, with limited availability of endovascular service.
The study included 402 aSAH patients treated surgically in our unit between January 2004 and December 2011. Each year, data regarding number of admissions, age, aneurysm location and size, clinical and radiological presentation, outcome and mortality rates were collected and analyzed.
The annual number of admissions more than halved in the study period (from 69 in 2004 to 32 in 2011). There were no linear trends regarding patients' mean age, clinical presentation and outcomes, but the number of patients in Fisher grade 4 increased and mortality slightly decreased. An unexpected, statistically significant increase occurred in the incidence of anterior communicating artery aneurysms (from 36.2% to 50%) and medium size aneurysms (from 34.7% to 56.2%) treated surgically, with a corresponding decrease in the incidence of middle cerebral artery aneurysms (from 40.5% to 34.3%) and large aneurysms (from 21.7% to 12.5%).
Unexpected trends in characteristics of aSAH patients treated surgically could be related to treatment decision modality. Trend patterns could be properly expressed in the constant availability of endovascular services.
... The treatment decision, surgical coiling versus endovascular coiling, was made primarily based on the findings of the digital subtraction angiography. Surgical treatment was favored over endovascular treatment for patients with the following findings : 1) difficult navigation of the microcatheter into the aneurysm 1,9) , 2) very small (<3 mm) aneurysm 1,4,9) , 3) complex and wide-neck aneurysm requiring Y or X stent-assisted coiling 6,10) , 4) aneurysm with an arterial branch incorporated into the sac 5,8) , 5) fusiform or complex aneurysmal configuration, or 6) aneurysmal compression of an adjacent cranial nerve 11) , as long as the patients had no problems related to surgical accessibility or comorbidity. ...
A cost comparison of the surgical clipping and endovascular coiling of unruptured intracranial aneurysms (UIAs), and the identification of the principal cost determinants of these treatments.
This study conducted a retrospective review of data from a series of patients who underwent surgical clipping or endovascular coiling of UIAs between January 2011 and May 2014. The medical records, radiological data, and hospital cost data were all examined.
When comparing the total hospital costs for surgical clipping of a single UIA (n=188) and endovascular coiling of a single UIA (n=188), surgical treatment [mean±standard deviation (SD) : ₩8,280,000±1,490,000] resulted in significantly lower total hospital costs than endovascular treatment (mean±SD : ₩11,700,000±3,050,000, p<0.001). In a multi regression analysis, the factors significantly associated with the total hospital costs for endovascular treatment were the aneurysm diameter (p<0.001) and patient age (p=0.014). For the endovascular group, a Pearson correlation analysis revealed a strong positive correlation (r=0.77) between the aneurysm diameter and the total hospital costs, while a simple linear regression provided the equation, y (₩)=6,658,630+855,250x (mm), where y represents the total hospital costs and x is the aneurysm diameter.
In South Korea, the total hospital costs for the surgical clipping of UIAs were found to be lower than those for endovascular coiling when the surgical results were favorable without significant complications. Plus, a strong positive correlation was noted between an increase in the aneurysm diameter and a dramatic increase in the costs of endovascular coiling.
... Several authors have demonstrated increased procedural rupture rates associated with coiling very small (≤3 mm) aneurysms [102][103][104][105]. ...
Subarachnoid hemorrhage (SAH) is a potentially lethal disease with high morbidity and mortality. The goal of endovascular intracranial aneurysm treatment of intracranial aneurysms is the prevention of rebleeding after primary SAH, the prevention of SAH in unruptured aneurysms or the alleviation of other symptoms attributable to the aneurysm. Securing ruptured aneurysms improves outcome after SAH, and there is high level evidence that endovascular coiling of ruptured aneurysms offers lower morbidity and mortality than neurosurgical clipping. However, the natural history and treatment of unruptured aneurysms is controversial. Endovascular techniques can be classified into deconstructive arterial sacrifice, and endosaccular and endoluminal reconstruction. Detachable microcoils, arterial stents, detachable balloons and liquid embolic agents are devices used in aneurysm treatment. The most serious neurological risks of endovascular techniques are thromboembolic infarction, aneurysm rupture and arterial dissection. Immediate angiographic outcome is measured by the degree of persistent aneurysm or neck filling and is often classified by the 'modified Montreal' or 'Raymond' system. A better immediate angiographic result is shown to reduce aneurysm recurrence. Immediate residual filling of the aneurysm sac and delayed aneurysm recurrence are both risk factors for repeat SAH. The aim of long-term follow-up is to monitor for aneurysm recurrence, and magnetic resonance angiography is now replacing catheter angiography as the first line follow-up imaging modality.
... In the coiling group, neck diameter and dome size were related to incomplete treatment and rebleeding [25]. Furthermore, a very small size aneurysm (below 3 mm) was related to failure of treatment [29]. ...
An intracranial aneurysm, with or without subarachnoid hemorrhage (SAH), is a relevant health problem. The rupture of an intracranial aneurysm is a critical concern for individual health; even an unruptured intracranial aneurysm is an anxious condition for the individual. The aim of this guideline is to present current and comprehensive recommendations for the management of intracranial aneurysms, with or without rupture.
We performed an extensive literature search, using Medline. We met in person to discuss recommendations. This document is reviewed by the Task Force Team of the Korean Society of Interventional Neuroradiology (KSIN).
We divided the current guideline for ruptured intracranial aneurysms (RIAs) and unruptured intracranial aneurysms (UIAs). The guideline for RIAs focuses on diagnosis and treatment. And the guideline for UIAs focuses on the definition of a high-risk patient, screening, principle for treatment and selection of treatment method.
This guideline provides practical, evidence-based advice for the management of patients with an intracranial aneurysm, with or without rupture.
... 3 4 Nevertheless, endovascular treatment of small intracranial aneurysms is pursued less frequently given that coiling small aneurysms is technically challenging, and initial reports have suggested a higher rate of complications. [5][6][7][8][9][10][11][12] It is believed that the smaller aneurysmal sac leads to a less stable microcatheter position with less room for error when deploying coils, especially when considering an inherent submillimeter inaccuracy of coil design between the coil-pusher interface. 13 These difficulties often lead interventionalists to use newer adjunctive technologies, such as balloon assistance or intracranial stenting in addition to standard microcatheter coiling, to help obtain a more stable microcatheter position. ...
Endovascular treatment of small intracranial aneurysms has historically been technically challenging and has been associated with high rates of complications and intraprocedural rupture. In this study, we compared complication and recurrence rates for treatment of small aneurysms (≤4 mm) versus large aneurysms in the context of the advent of improvements in endovascular techniques and technologies.
A retrospective cohort study was performed to include all patients who underwent coiling of an intracranial aneurysm between 2005 and 2012. Small aneurysms were defined as any aneurysm 4.0 mm or smaller in all dimensions. The primary outcome was a composite outcome of the occurrence of an intraoperative rupture or a perioperative thromboembolic event. The secondary outcome of interest was aneurysm recurrence.
During the study period, 483 patients were treated using endovascular techniques; 85 (17.6%) of these patients had small aneurysms. In the small aneurysm group, there was only one (1.2%) intraoperative rupture, three (3.5%) perioperative thromboembolic events, and 11 (12.9%) incidents of aneurysm recurrence. Both the primary and secondary outcomes of interest were similar in patients presenting with small or large aneurysms. Small aneurysm size was not a risk factor for either the composite primary outcome or aneurysm recurrence in multivariate analysis.
Treatment of small intracranial aneurysms via conventional endovascular coiling techniques is not inferior to endovascular treatment of larger aneurysms based on our single institution experience. While technically challenging, such aneurysms may be treated safely and effectively with acceptable rates of complications and recurrence.
... Neurovascular management of very small aneurysms often imposes challenges for the both the surgical as well as interventional procedures [43]. Interestingly in one study small cerebral aneurysms were associated with larger volume of SAH; however the other factors including patient sex and age, intraparenchymal or intraventricular hemorrhage, multiple aneurysms, history of hypertension, and aneurysm location were not associated with a larger volume of SAH [44,45]. The chances of intraprocedural aneurysm rupture were found to be relatively higher during embolization especially in very small aneurysms. ...
Background:
Perioperative aneurysm rupture (PAR) is one of the most dreaded complications of intracranial aneurysms, and approximately 80% of nontraumatic SAHs are related to such PAR aneurysms. The literature is currently scant and even controversial regarding the issues of various contributory factors on different phases of perioperative period. Thus this paper highlights the current understanding of various risk factors, variables, and outcomes in relation to PAR and try to summarize the current knowledge.
Method:
We have performed a PubMed search (1 January 1991-31 December 2012) using search terms including "cerebral aneurysm," "intracranial aneurysm," and "intraoperative/perioperative rupture."
Results:
Various risk factors are summarized in relation to different phases of perioperative period and their relationship with outcome is also highlighted. There exist many well-known preoperative variables which are responsible for the highest percentage of PAR. The role of other variables in the intraoperative/postoperative period is not well known; however, these factors may have important contributory roles in aneurysm rupture. Preoperative variables mainly include natural course (age, gender, and familial history) as well as the pathophysiological factors (size, type, location, comorbidities, and procedure). Previously ruptured aneurysm is associated with rupture in all the phases of perioperative period. On the other hand intraoperative/postoperative variables usually depend upon anesthesia and surgery related factors. Intraoperative rupture during predissection phase is associated with poor outcome while intraoperative rupture at any step during embolization procedure imposes poor outcome.
Conclusion:
We have tried to create such an initial categorization but know that we cannot scale according to its clinical importance. Thorough understanding of various risk factors and other variables associated with PAR will assist in better clinical management as well as patient care in this group and will give insight into the development and prevention of such a catastrophic complication in these patients.
... This can be due to the lack of microcatheter insertion space and structural limitations of current microcatheters and coils for coiling of very small aneurysms [6] . Ioannidis et al. [13] reported a high frequency of IPR in coiling of very small aneurysms. However, thromboembolism and recanalization had a lower incidence rate in comparison with large coiled aneurysms. ...
Introduction:
Endovascular treatment of aneurysms has been introduced as a less invasive method for decreasing the rate of aneurysm rerupture and subsequent subarachnoid hemorrhage. The outcome and complication rate for endovascular treatment of very small (≤3 mm) and very large (15-25 mm) intracranial aneurysms has been controversial. Here we report our experience with endovascular coiling of very small and very large ruptured aneurysms of the anterior cerebral circulation.
Methods:
Patients were included in the study if the maximum dimension of the intracranial ruptured aneurysm was reported to be ≤3 mm or 15-25 mm and if the aneurysm was within the anterior cerebral circulation. The largest dimension was calculated using CT angiography and was confirmed by digital subtraction angiography. Endovascular coiling was performed using Guglielmi detachable coils. All patients underwent follow-up contrast MR angiography every 6 months.
Results:
A total of 40 cases (18 females and 22 males) were included in this single-center study. Twenty-one very small and 19 very large ruptured aneurysms were analyzed. Preprocedural Hunt and Hess grades were determined. Endovascular coiling was performed successfully in most cases (97.5%), with unsuccessful coiling in 1 patient with a very small ruptured aneurysm. In the very small aneurysm group, the most common location was the anterior communicating artery and, in the large aneurysm group, the most common location was the middle cerebral artery (MCA) bifurcation. The mean follow-up time was 15.08 months (range: 6-30 months). The 6th month modified Rankin scale (mRS) values for very small aneurysm cases were 0 (no symptoms at all) in 16 cases (76.2%) and 1 (no significant disability despite symptoms) in 5 cases (23.80%). For the very large aneurysm cases, the mRS values were 1 in 2 cases (10.5%), 2 in 7 cases (36.8%), 3 in 6 cases (31.6%), 4 in 3 cases (15.8%) and 6 in 1 case (died due to vasospasm 72 h later; 5.2%). The immediate complications that were observed were MCA branch occlusion in 1 very small aneurysm patient and early vasospasms in 3 very large aneurysm patients. The late complication that was observed was recanalization in 1 very small aneurysm case (1/21, 4.76%) and in 5 very large aneurysm cases (5/18, 27.77%).
Conclusion:
Endovascular treatment of very small aneurysms is an effective method of treatment with acceptable immediate and long-term outcomes. Immediate and long-term complications were more prevalent in very large ruptured aneurysms.
... This study led to a substantial change in the treatment of cerebral aneurysms despite continued controversy regarding the durability and long-term efficacy of coil treatment for preventing rebleeding (6). In the last decade, endovascular coil embolization has become the treatment of choice for most ruptured cerebral aneurysms (7,8). ...
Purpose:
We aimed to report our 13-year experience with the embolization of ruptured cerebral aneurysms using detachable coils and postembolization angiographic and clinical results.
Materials and methods:
Between June 1998 and September 2011, 481 patients with ruptured aneurysms were referred for endovascular treatment with detachable coils at our center. The technical feasibility, procedural complications, morbidity, mortality, and initial angiographic and clinical results were evaluated.
Results:
Endovascular treatment was successful in 95.6% of the patients. Postembolization angiography showed complete occlusion in 63.4%, a neck remnant in 30.8%, and incomplete occlusion in 5.8% of the aneurysms. A total of 331 patients were followed up. The overall angiographic results showed stable occlusion in 234 aneurysms (70.7%) and recurrence in 97 aneurysms (29.3%). During the follow-up period, stable angiographic occlusion was evident in 75% of the small, 61% of the large, and 38.5% of the giant aneurysms. Complications during the coiling procedure occurred in 75 procedures (15.6%). Ischemic complications were observed in 33 procedures (6.9%), and perforation of the aneurysm during the coiling occurred in 12 cases (2.5%). Five (41.7%) of 12 patients who had perforation during coiling died. The overall procedure-related morbidity and mortality were 5.6% and 2%, respectively. During the follow-up period, two patients (0.4%) had early rebleeding. None of the patients showed late rebleeding. In the follow-up, the retreatment rate was 12.6%.
Conclusion:
Our data confirm the feasibility, safety, and efficacy of endovascular coil embolization in patients with ruptured cerebral aneurysms.
Background
Endovascular coiling of small, intracranial aneurysms remains controversial and difficult, despite advances in technology.
Methods
We retrospectively reviewed data for 62 small aneurysms (<3.99 mm) in 59 patients. Occlusion rates, complications rates, and coil packing densities were compared between subgroups based upon coil type and rupture status.
Results
Ruptured aneurysms predominated (67.7%). Aneurysms measured 2.99 ± 0.63 mm by 2.51 ± 0.61 mm with an aspect ratio of 1.21 ± 0.34 mm. Brands included Optima (Balt) (29%), MicroVention Hydrogel (24.2%), and Penumbra SMART (19.4%) coil systems. Average packing density was 34.3 ± 13.5 mm ³ . Occlusion rate was 100% in unruptured aneurysms; 84% utilized adjuvant devices. For ruptured aneurysms, complete occlusion or stable neck remnant was achieved in 88.6% while recanalization occurred in 11.4%. No rebleeding occurred. Average packing density ( p = 0.919) and coil type ( p = 0.056) did not impact occlusion. Aspect ratio was smaller in aneurysms with technical complications ( p = 0.281), and aneurysm volume was significantly smaller in those with coil protrusion ( p = 0.018). Complication rates did not differ between ruptured and unruptured aneurysms (22.6 vs. 15.8%, p = 0.308) or coil types ( p = 0.830).
Conclusion
Despite advances in embolization devices, coiling of small intracranial aneurysms is still scrutinized. High occlusion rates are achievable, especially in unruptured aneurysms, with coil type and packing density suggesting association with complete occlusion. Technical complications may be influenced by aneurysm geometry. Advances in endovascular technologies have revolutionized small aneurysm treatment, with this series demonstrating excellent aneurysm occlusion especially in unruptured aneurysms.
Objective
To investigate the safety and efficacy of Neuroform Atlas stent-assisted coiling for the treatment of tiny wide-necked intracranial aneurysms and evaluate risk factors associated with procedure-related complications.
Methods
We retrospectively examined 46 patients with 46 tiny wide-necked aneurysms who were treated using Atlas stent-assisted coiling at our institution from August 2020 to May 2022. Patient and aneurysm characteristics, procedural details, procedure-related complications, and angiographic and clinical outcomes were analyzed.
Results
A total of 10 patients presented with aneurysmal rupture. Atlas stent placement was successful in all patients. Angiography immediately after the procedure showed complete occlusion in 38 patients (82.6%), neck remnant in 7 (15.2%), and partial occlusion in 1 (2.2%). The mean angiographic follow-up was 8.4 months (range, 6–16). At the last follow-up, angiography showed complete occlusion in 41 patients (89.1%) and neck remnant in 5 (10.9%). No aneurysm recurrence or in-stent stenosis occurred. Incidence of procedure-related complications was 10.8% (intraprocedural aneurysm rupture, two cases; acute thrombosis, two cases; and coil migration, one case); only one patient (2.2%) experienced procedural neurological morbidity. The mean clinical follow-up was 9.7 months. A favorable outcome was achieved in 45 patients (97.8%). In univariate logistic regression analysis, aneurysm size (odds ratio, 4.538; P = 0.045) was significantly associated with procedure-related complications. However, multivariate analysis found no independent risk factors.
Conclusion
Atlas stent-assisted coiling of tiny wide-necked intracranial aneurysms is feasible and effective. Outcomes and occlusion rates are favorable and morbidity is low. The complication rate may be higher in larger tiny aneurysms.
Objective:
The ULTRA Registry is a national multicenter prospective study designed to assess aneurysm occlusion rates and safety profiles of the Target Ultra and Nano coils in the treatment of small intracranial aneurysms (IAs).
Methods:
Patients with small (≤ 5 mm) ruptured and unruptured IAs were treated exclusively with Target Ultra and Nano coils. The primary endpoints were the initial rate of complete or near-complete aneurysm occlusion, aneurysm recurrence, and need for retreatment. Secondary endpoints were device- and procedure-related adverse events, hemorrhage from the coiled aneurysm at any time during follow-up, and clinical outcomes.
Results:
The ULTRA Registry included 100 patients with a mean ± SD age of 56 ± 11.6 years, of whom 75 were women and 48 presented after aneurysm rupture. The mean aneurysm size was (3.5 ± 0.9) × (2.8 ± 0.9) × (3.0 ± 1.0) mm, and the mean packing density was 34.4% ± 16.7%. Posttreatment complete or near-complete occlusion reported by an independent imaging core laboratory was seen in 92% of patients at baseline and in 87%, 87%, and 83% of patients at first, second, and final follow-up, respectively. At first, second, and final follow-up, 10%, 11%, and 15%, respectively, of patients were deemed to require retreatment. There were three procedural-related ischemic strokes and one intracranial hemorrhage from wire perforation of a parent artery not involved by the aneurysm. There were no coil-related adverse events, including no intraoperative aneurysm ruptures and no known aneurysm ruptures after coiling.
Conclusions:
This assessment of aneurysm occlusion rates and safety profiles in ULTRA Registry study participants demonstrates excellent safety and efficacy profiles for Target Ultra and Nano coils in the treatment of small IAs.
The scope of this technical note is to report our experience with balloon remodeling for wideneck aneurysms and balloon angioplasty of post-subarachnoid hemorrhage vasospasm using the novel Scepter Mini balloon (SMB). Five cases were treated with balloon remodeling for aneurysmal subarachnoid hemorrhage, 2 of which were additionally treated with angioplasty due to post-bleeding vasospasm. All patients had their aneurysm located on parent vessels with a diameter smaller than 2 mm. Complete occlusion was noted in all aneurysms, and the patients had no short-term complications attributed to the catheterization. Additionally, we confirm the previously reported smooth navigation of the balloon through vessels with tortuous anatomy without catheter-induced vasospasm. Based on our experience, the SMB can be a safe and efficient device for applying the balloon remodeling technique for distally located wide-neck aneurysms and distal balloon angioplasty.
With the advent of new endovascular devices, open surgery is becoming less popular for the treatment of intracranial aneurysms. However, in many situations it maintains material advantages and should therefore be considered among the tenable treatment options. This chapter discusses the specific indications for considering surgery as an option due to evidence that surgery yields a better outcome or because equipoise remains regarding the best treatment strategy. The different clinical situations presented include morphological aneurysm characteristics (wide-neck, giant size, fusiform shape, thrombotic, small size and blister aneurysms), the presence of multiple aneurysms, aneurysms causing neural compression or epilepsy, patient’s age, aneurysm location (middle cerebral and anterior communicating aneurysms), and aneurysm recurrence after endovascular treatment.KeywordsIntracranial aneurysmClippingBypassFlow diverterCoilingStentingWoven EndoBridge device
Endovascular coil embolization of very small aneurysms (＜ 3 mm in maximum diameter) remains challenging and requires scrupulous attention to detail during treatment to overcome technical difficulties and mitigate high complication rates. We focused on techniques for positioning microcatheters into aneurysms.
In principle, we placed a balloon microcatheter across or proximal to the aneurysm neck and adopted a microcatheter that is usually shaped with steam according to the three-dimensional relationship of the vascular structure. If the angle between the long axis of the aneurysm and that of the parent artery is approximately 90°, we pulled back the microcatheter from the distal site to place the catheter in the aneurysm. In cases where the long axis of the aneurysm is nearly parallel to that of the parent artery, we often adopt the catheterization technique using of a preceding coil loop or, in anatomically inevitable cases, a preceding micro guidewire.
In this case report, we have described our endovascular coil embolization technique for very small aneurysms, focusing on the method of positioning the microcatheter into the aneurysm.
Background
To investigate the discrepancy between two-dimensional digital subtraction angiography and three-dimensional rotational angiography for small (<5 mm) cerebral aneurysms and the impact on decision making among neuro-interventional experts as evaluated by online questionnaire.
Materials and methods
Eight small (<5 mm) ruptured aneurysms were visually identified in 16 image sets in either two-dimensional or three-dimensional format for placement in a questionnaire for 11 invited neuro-interventionalists. For each set, two questions were posed: Question 1: “Which of the following is the preferred treatment choice: simple coiling, balloon remodeling or stent assisted coiling?”; Question 2: “Is it achievable to secure the aneurysm with pure simple coiling?” The discrepancies of angio-architecture parameters and treatment choices between two-dimensional-digital subtraction angiography and three-dimensional rotational angiography were evaluated.
Results
In all eight cases, the neck images via three-dimensional rotational angiography were larger than two-dimensional-digital subtraction angiography with a mean difference of 0.95 mm. All eight cases analyzed with three-dimensional rotational angiography, but only one case with two-dimensional-digital subtraction angiography were classified as wide-neck aneurysms with dome-to-neck ratio < 1.5. The treatment choices based on the two-dimensional or three-dimensional information were different in 56 of 88 (63.6%) paired answers. Simple coiling was the preferred choice in 66 (75%) and 26 (29.6%) answers based on two-dimensional and three-dimensional information, respectively. Three types of angio-architecture with a narrow gap between the aneurysm sidewall and parent artery were proposed as an explanation for neck overestimation with three-dimensional rotational angiography.
Conclusions
Aneurysm neck overestimation with three-dimensional rotational angiography predisposed neuro-interventionalists to more complex treatment techniques. Additional two-dimensional information is crucial for endovascular treatment planning for small cerebral aneurysms.
Objective
In our series, endovascular coiling with Target® Nano™ coils (Stryker Neurovascular, Fremont, CA, USA) with diameters of 1 or 1.5 mm exhibited favorable technical feasibility in the treatment of small cerebral aneurysms (< 4 mm). However, little is known about the recurrence of small cerebral aneurysms treated using Target® Nano™ coils. We investigated recurrence following the treatment of small cerebral aneurysms using Target® Nano™ coils.
Materials and Methods
Between January 2012 and November 2013, 143 patients with 148 small cerebral aneurysms (< 4 mm) were included our study. A total of 135 cerebral aneurysms (91.2%) were unruptured; 45 cerebral aneurysms (30.4%) were treated by endovascular coiling using Target® Nano™ coils. Follow-up radiological images were obtained for 132 cerebral aneurysms (89.2%) over a range of 3 to 58 months (mean, 34.3 months; standard deviation, 14.2).
Results
In the group treated with Target® Nano™ coils, radiological outcomes revealed complete occlusion in 33 (73.3%), residual necks in eight (17.8%), and residual sacs in four (8.9%) cases. Follow-up radiological outcomes revealed complete occlusion in 35 (77.8%) and residual necks in four (8.9%) cases that exhibited stable coil masses. In the group that was not treated with Target® Nano™ coils, radiological outcomes revealed complete occlusion in 69 (67%), residual necks in 18 (17.5%), and residual sacs in 16 (15.5%) cases. Follow-up radiological outcomes revealed complete occlusion in 87 (84.5%) and residual necks (5.8%) in six cases that exhibited stable coil masses. No significant differences were observed in the radiological outcomes or follow-up radiological outcomes between the two groups. No recurrences or retreatments occurred in our series.
Conclusion
Endovascular treatment using Target® Nano™ coils may be a robust treatment option for small cerebral aneurysms (< 4 mm).
Neuroendovascular and neurointerventional therapy is a specialty where disseminating personal knowledge and expert opinion is extremely important, owing to the lack of large-scale clinical trials. The management of complications that occur during or immediately after therapeutic interventions is particularly challenging because these can significantly affect patient outcomes. This book presents how various complication scenarios are handled by well-qualified authorities in the field of neurointervention from three disciplines: neurology, neurosurgery, and neuroradiology. Contributors describe their management of these complications, focusing on the common principles that all the specialists agree on, and give tips and tricks for 'bailout' procedures to help get the practitioner out of trouble. The book is well illustrated and covers the full range of neuroendovascular and neurointerventional procedures. The book will appeal to neurointerventionists, neuroradiologists, stroke physicians, neurosurgeons and vascular surgeons for its practical approach to managing these commonly encountered problems.
This study reports our initial clinical experience treating very small intracranial aneurysms using only Target® Nano™ coils.
Background: Surgical clipping is considered the primary option for ruptured small aneurysms (s-AN; 3 mm or less), because coiling has been associated with a relatively high risk of procedural error. With the advent and development of coiling techniques and materials, several studies showed that coiling of a ruptured s-AN can be performed with acceptable risk. However, the best management strategy for a ruptured s-AN remains unknown.
Objective: The aim of this study was to assess the outcomes of ruptured s-ANs in patients who underwent surgical clipping, and to identify the clinical characteristics of these aneurysms.
Patients and Methods: In total, 237 patients who presented with aneurysmal subarachnoid hemorrhage (SAH) between April 2008 and March 2015 were evaluated. Aneurysms were classified as small (≤3.0 mm), medium (3.0 mm ≤ 12.0 mm), large (12.0 mm ≤ 25.0 mm), and giant (≥25.1 mm), based on their largest dimensions. Various factors were analyzed, including the preoperative Hunt and Kosnik grade and Fisher groups, the aneurysmal location, multiplicity, and procedural complications. Clinical outcomes were assessed using the Glasgow Outcome Scale (GOS) at the time of discharge. In the case of multiple aneurysms, we identified the ruptured aneurysm based on its bleeding pattern on computed tomography (CT) or on surgical findings.
Results: In 28 (11.8%) of 237 patients, an s-AN was identified as the lesion responsible for the SAH. The most frequent site of a ruptured s-AN was the anterior communicating artery. In a comparison with larger aneurysms, ruptured s-ANs were significantly more common in the pericallosal artery, internal carotid-anterior choroidal artery, and vertebral-posterior inferior cerebellar artery bifurcation, but less so in the middle cerebral artery. There were no procedure-related complications during the clipping of ruptured s-ANs. The clinical outcomes (GOS) of 28 patients with ruptured s-ANs were as follows: good recovery (GR) 17 (60.7%), moderate disability (MD) 6 (21.4%), severe disability (SD) 0 (0%), vegetative state (V) 1 (3.6%), and death (D) 4 (14.3%). Thus, the overall outcomes of ruptured s-ANs were significantly better compared with outcomes of larger aneurysms: GR 106 (50.7%), MD 48 (23.0%), SD 18 (8.6%), V 7 (3.4%), and D 30 (14.4%). In 43 (18.1%) of 237 patients, multiple aneurysms were identified. The largest aneurysm had not ruptured in 10 (23.3%), and an s-AN had ruptured in 6 (14.0%) of the 43 patients with multiple aneurysms.
Conclusion: Surgical clipping for ruptured s-ANs was not associated with procedural complications, but the overall outcomes were similar to those reported for coiling. Considering its ability to identify correctly the rupture site in cases with multiple aneurysms, surgical clipping remains an invaluable treatment strategy.
Objective:
To evaluate the safety and efficacy of endovascular treatments, including stent-assisted coiling, of very small (≤3 mm), ruptured intracranial aneurysms.
Methods:
Ninety-three endovascularly treated patients with very small ruptured aneurysms were recruited from four high-volume centers between September 2010 and February 2014. Factors influencing procedural complications and outcomes were analyzed.
Results:
Fifty-one (54.8%) aneurysms were treated by stent-assisted coiling, 41 (44.1%) by coiling alone, and 1 (1.1%) by balloon-assisted coiling. Intraprocedural or postprocedural complications occurred in 13 patients (14.0%): coil migration in one , intraprocedural rupture in one, hydrocephalus in six and ischemic event in one. No tested factor was able to predict procedural complications. Angiographic follow-up of 67 aneurysms (72%) revealed recurrence in five patients (7.5%). One recurrent case was treated initially by stent-assisted coiling and the remaining four by coiling alone (p=0.044). Multivariate regression analysis showed that coiling alone was significantly associated with aneurysm recurrence (odds ratio, 13.8; 95% confidence interval, 1.1-175.3; p=0.043).
Conclusions:
Endovascular treatment of very small ruptured aneurysms was safe and effective and was not associated with a high rate of intraprocedural rupture. Treatment using stents significantly lowered the recurrence rate without additional risks.
Aneurysmal subarachnoid hemorrhage (SAH) is a neurological emergency with high risk of neurological decline and death. Although the presentation of a thunderclap headache or the worst headache of a patient's life easily triggers the evaluation for SAH, subtle presentations are still missed. The gold standard for diagnostic evaluation of SAH remains noncontrast head computed tomography (CT) followed by lumbar puncture if the CT is negative for SAH. Management of patients with SAH follows standard resuscitation of critically ill patients with the emphasis on reducing risks of rebleeding and avoiding secondary brain injuries.
Background and objective:
Treatment of very small (≤3mm) wide-necked intracranial aneurysms remains controversial, we investigated the efficacy and safety of stent-assisted coiling of such aneurysms.
Methods:
From September 2008 to December 2012, 112 very small wide-necked intracranial aneurysms in 108 patients were embolized with stent-assisted coiling. We assessed the initial neurological conditions, complications and anatomic results. The follow-up results were evaluated with DSA and mRS.
Results:
Stent deployment was successful in 104 of 108 procedures (96.3%). 11 complications (10.2%) occurred during procedures, including 5 events of aneurysm rupture, 3 events of thromboembolism. The rate of complication, rupture and thromboembolism was not statistically different between the ruptured and unruptured patients (P=0.452, P=0.369, P=1.000, respectively). The initial aneurysmal occlusion was Raymond scale (RS) 1 in 34 patients (31.5%), RS2 in 53 patients (49.1%), and RS3 in 21 patients (19.4%). 79 aneurysms were available for anatomic follow-up of 12-47 months, stable occlusion in 45 aneurysms (57.0%), progressive complete occlusion in 34 aneurysms (43.0%). 95 patients(88.0%) were available for a clinical follow-up of 12-52 months, 92 patients (96.8%) had favorable clinical outcomes (mRS ≤2), 3 patients (3.2%) had morbidity (mRS: 3-5). The morbidity was not statistically different between the ruptured and unruptured patients (P=1.000).
Conclusions:
Stent-assisted coiling of very small wide-necked intracranial aneurysms may be effective and safe. Because of low risk of rupture in such aneurysms, the coiling of unruptured such aneurysms must be selective. The long-term efficacy and safety of coiling such aneurysms remains to be determined in larger prospective series.
Objective:
Based on the use of Nano™ coils, we retrospectively compared the proportion of the coils (≤ 1.5 mm) and packing density in two patient groups with small cerebral aneurysms (< 4 mm diameter) who were treated with or without Nano™ coils.
Materials and methods:
Between January 2012 and November 2013, in 548 cerebral aneurysms treated by endovascular coiling, 143 patients with 148 small cerebral aneurysms underwent endovascular coiling. After March 2013, coiling with Nano™ coils was performed on 45 small cerebral aneurysms (30.4%).
Results:
There were no significant differences in the size and locations of the cerebral aneurysms, the age of the patients, and the procedural modalities between the two groups. The proportion of the coil (≤ 1.5 mm) of the group treated with Nano™ coils (53.6%) was higher than the proportion of the coil (≤ 1.5 mm) of the group treated without Nano™ coils (14.7%) with statistical significance (p < 0.001). The packing density of the group treated with Nano™ coils (31.3 ± 9.69%) was higher than the packing density of the group treated without Nano™ coils (29.49 ± 7.84%), although the difference was not significant. Procedural complications developed in 3 lesions (2 thromboembolisms and 1 carotid dissection) (2.0%). Treatment-related transient neurological deficits due to thromboembolism developed in 1 lesion, which had not been treated with Nano™ coils. There was no treatment-related permanent morbidity or mortality in either of the groups.
Conclusion:
In our series, the small cerebral aneurysms treated with Nano™ coils showed more packing density with no additive procedural risk or difficulty.
Background:
Treatments for intracranial aneurysms mainly include endovascular treatment and craniotomy. Most studies report on large intracranial aneurysms, yet treatments for very small intracranial aneurysms remain controversial. Our purpose was to explore management strategies for ruptured very small intracranial aneurysms.
Methods:
From January 2002 to September 2010, 162 consecutive patients with ruptured very small intracranial aneurysms (≤3mm) were retrospectively analyzed by comparing procedural data, adverse events, additional procedures, and length of hospital stay between management strategies. Modified Rankin Scale (MRS) was assessed at 2 months and at 1 year by a postal questionnaire and telephone interview.
Results:
85 patients (microsurgical group) underwent surgical clipping (79 cases) and wrapping (6 cases), and 77 patients (endovascular group) underwent endovascular therapy including coiling (65 cases), stent-assisted (13 cases) and balloon-assisted (7 cases), stenting (2 cases). At 2 months, a good grade (MRS 0-2) was achieved in 74% of patients in the endovascular group and 69.4% of patients in the microsurgical group. At 1 year, a good grade was achieved 84.9% in the endovascular group and 80% in the microsurgical group. Logistic regression results showed that whichever treatment option was chosen, Hunt-Hess grade, age, cerebral vasospasm, and complications contributed significantly to the prediction of outcome at 2 months.
Conclusions:
Endovascular therapy for ruptured very small intracranial aneurysms was not inferior to surgical clipping and showed a slight trend towards better prognosis.
Objective: To investigate the methods and efficacy of endovascular embolization treatment of ruptured intracranial tiny aneurysms (maximum diameter ≤3 mm). Methods: The data of 45 patients with ruptured intracranial tiny aneurysms (45 aneurysms) were analyzed retrospectively from January 2006 to December 2011. Eleven aneurysms were at the posterior communicating arteries, 29 were at the anterior communicating arteries, 3 were at the A1 segment of the anterior cerebral arteries, and 2 were at the posterior inferior cerebellar arteries. Twenty-eight patients were embolized with coils only, 8 were treated with endovascular stenting and coil embolization, 4 were embolized with balloon-assisted technique, 3 were embolized with double-microcatheter technique, and 2 were treated with endovascular stenting only. Results: Circled digit one 28 patients were achieved dense embolization, 15 were achieved partial embolization, and 2 had successful stent implantation. Circled digit two Intraoperative complications: 1 patient experienced intraoperative bleeding. After continuous dense embolization with coils, the patient recovered well postoperatively. One patient had acute thrombosis of the ipsilateral middle cerebral artery during embolization of anterior communicating artery aneurysm, and it was recanalized after thrombosis. However, head CT showed cortex infarction after the procedure, and he was left hemiplegia. External ventricular drainage was performed in 5 patients with ventricular hematocele. Circled digit three The modified Rankin scale (mRS) scores at discharge: 0-1 in 28 cases, 2 in 14 cases, 3-4 in 2 cases, and 5 in 1 case. Circled digit four 24 patients were followed up with DSA at 6 to 12 months, and none of them had recurrence. The longest follow-up time in 1 case was 6 years. No recurrence was observed with CT angiography. Conclusion: Endovascular embolization is an effective method in the treatment of ruptured intracranial tiny aneurysms. Precise micro-catheter shaping, appropriate coil selection, personalized treatment programs, and reducing complications are the keys to ensuring the efficacy.
OBJECT
The highest incidence of olfactory dysfunction following a pterional approach and its modifications for an intracranial aneurysm has been reported in cases of anterior communicating artery (ACoA) aneurysms. The radiological characteristics of unruptured ACoA aneurysms affecting the extent of retraction of the frontal lobe and olfactory nerve were investigated as risk factors for postoperative olfactory dysfunction.
METHODS
A total of 102 patients who underwent a pterional or superciliary keyhole approach to clip an unruptured ACoA aneurysm from 2006 to 2013 were included in this study. Those patients who complained of permanent olfactory dysfunction after their aneurysm surgery, during a postoperative office visit or a telephone interview, were invited to undergo an olfactory test, the Korean version of the Sniffin’ Sticks test. In addition, the angiographic characteristics of ACoA aneurysms, including the maximum diameter, the projecting direction of the aneurysm, and the height of the neck of the aneurysm, were all recorded based on digital subtraction angiography and sagittal brain images reconstructed using CT angiography. Furthermore, the extent of the brain retraction was estimated based on the height of the ACoA aneurysm neck.
RESULTS
Eleven patients (10.8%) exhibited objective olfactory dysfunction in the Sniffin’ Sticks test, among whom 9 were anosmic and 2 were hyposmic. Univariate and multivariate analyses revealed that the direction of the ACoA aneurysm, ACoA aneurysm neck height, and estimated extent of brain retraction were statistically significant risk factors for postoperative olfactory dysfunction. Based on a receiver operating characteristic (ROC) analysis, an ACoA aneurysm neck height > 9 mm and estimated brain retraction > 12 mm were chosen as the optimal cutoff values for differentiating anosmic/hyposmic from normosmic patients. The values for the area under the ROC curves were 0.939 and 0.961, respectively.
CONCLUSIONS
In cases of unruptured ACoA aneurysm surgery, the height of the aneurysm neck and the estimated extent of brain retraction were both found to be powerful predictors of the occurrence of postoperative olfactory dysfunction.
Aneurysmal subarachnoid hemorrhage (SAH) remains an important health issue in the United States. Despite recent improvements in the diagnosis and treatment of cerebral aneurysms, the mortality rate following aneurysm rupture. In those patients who survive, up to 50% are left severely disabled. The goal of preventing the hemorrhage or re-hemorrhage can only be achieved by successfully excluding the aneurysm from the circulation. This article is a comprehensive review by contemporary vascular neurosurgeons and interventional neuroradiolgists on the modern management of cerebral aneurysms.
Copyright © 2015 Elsevier Inc. All rights reserved.
Objective: Endovascular embolization of very small aneurysms (under 3 mm in maximum diameter) is considered to be high risk for aneurysm perforation.
Methods: We compared initial angiographic results of ruptured aneurysms between under 3 mm in diameter (21 cases, small group) and over 3 mm in diameter (85 cases, non-small group), the results of short-term follow-up angiography in the small group were also demonstrated. In the small group, extremely soft coils were mainly used for aneurysmal filing.
Results: The technical success rates in the small and in the non-small groups were 95.2% and 100%, respectively. Initial angiographic results showed that complete occlusion was obtained in 65.0% of the small group and 52.9% of the non-small group. The mean packing densities in the small and non-small groups were 47.1±11.4% and 26.4±9.5%, respectively, showing the packing density in the small group was significantly higher than those in the non-small group (p<0.001). Intra-operative aneurysmal perforation occurred in 14% and 2.4% in the small and non-small groups, respectively (p=0.08), but none resulted in neurological worsening. In the small group, post-operative rerupture occurred in 5%. Follow-up angiography was performed in 12 cases (60%) at 3–12 months after the procedure, and complete occlusion was obtained in 92%.
Conclusion: Endovascular embolization of very small aneurysms is more likely to result in intra-operative aneurysmal perforation compared to larger aneurysms. The use of extremely soft coils could obtain a high packing density, and suitable for repairing these perforations.
This study reports our initial clinical experience treating very small intracranial aneurysms using only Target® Nano™ coils. Retrospective angiographic and clinical analysis was performed on a non-randomized single arm registry of all intracranial aneurysms treated with only Target® Nano™ coils (1 mm and 1.5 mm diameter only) during a 12 month period at two academic hospitals. Fourteen patients with 14 intracranial aneurysms were treated. The maximum diameter of saccular aneurysms treated ranged from 1.5 to 3.5 mm; minimum aneurysm diameter was 1.1 to 2 mm. The immediate complete aneurysm occlusion rate was 86% (12/14), and a small residual within the aneurysm was seen in 14% (2/14) of cases. Packing density from coils ranged between 24% and 83% (mean 51%). The immediate complication rate was 0% (0/14). The angiographic/MR angiography follow-up period was 22 to 70 weeks (mean 37 weeks) with an overall complete occlusion rate of 9/11 (81%), recurrence in 18% (2/11), and lack of follow-up in three cases, two due to death during hospitalization and one procedure not yet due for imaging follow-up. Both patients who died presented with brain aneurysm ruptures prior to treatment. Both recurrences were retreated with repeat coiling procedures. Our initial results using only Target® Nano™ coils for the endovascular treatment of very small intracranial aneurysms have demonstrated initial good safety and efficacy profiles.
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Objective: Endovascular treatment for a very small aneurysm with a diameter less than 3 mm is challenging because of its technical difficulties and high complication rates. The smallest coil diameter available today is 1.0 mm, so we defined an aneurysm with a short axis of less than 1.0 mm and a long axis of less than 3.0 mm as “the ultra small aneurysm.” We present a case of ruptured ultra small aneurysm successfully embolized by a single Target nano coil (1.5 mm×3.0 cm) and discuss about the technical points of the embolization for the ultra small aneurysm.
Case: A 64-year-old woman presented with subarachnoid hemorrhage. Rupture site was an anterior communicating artery aneurysm with a long axis of 2.9 mm and a short axis of 1.0 mm. We performed coil embolization through the triple coaxial guiding system and used manually shaped microcatheter by hot air gun. A single Target nano coil was successfully inserted into the aneurysm from the microcatheter positioned just at the neck of the aneurysm, and the aneurysm was completely obliterated.
Conclusion: Target nano is a highly soft coil and useful for the embolization of a ultra small ruptured cerebral aneurysm.
Objectives: Behavior of the coils and microcatheters during coil ejection from the microcatheter is influenced not only by the characteristic features themselves but also by the properties of delivery wires. Elasticity and bending features of delivery wires of soft coils in five brands (Axium Helix, Deltaplush, ED coil Extrasoft, Galaxy Complex Xtrasoft, Target Ultra) are examined.Methods: Delivery wires are pinched by tweezers at 30 mm or 20 mm proximal from detaching point, and repelling force was measured when the wires were bended to the point of length of 15 mm or 10 mm each. Configurations of bended wires were also investigated.Results: Average repelling force (×10−3N) of Axium, Deltaplush, ED, Galaxy, and Target were 3.822, 4.41, 2.548, 3.136, and 4.018 each in 30 mm group, and 7.105, 9.996, 4.312, 5.488, 6.174 each in 20-mm group, respectively. Wires showed continuous curve in three brands of Axium, ED, and Target, and non-continuous curve with buckle at 10-mm short of detaching point in the remaining Deltaplush and Galaxy coils.Conclusions: To finish coil embolization treatment safely and effectively, coils should be chosen according to proper understanding of characteristic features of each delivery wires.
Object:
While the incidence of a recurrent hemorrhage is highest within 24 hours of subarachnoid hemorrhage (SAH) and increases with the severity of the clinical grade, a recurrent hemorrhage can occur anytime after the initial SAH in patients with both good and poor clinical grades. Therefore, the authors adopted a 24-hour-a-day, formal protocol, emergency treatment strategy for patients with ruptured aneurysms to secure the aneurysms as early as possible. The incidences of in-hospital rebleeding and clinical outcomes were investigated and compared with those from previous years when broadly defined early treatment was used (<3 days of SAH).
Methods:
During an 11-year period, a total of 1224 patients with a ruptured aneurysm were managed using a strategy of broadly defined early treatment between 2001 and 2004 (Period B, n=423), a mixture of early or emergency treatment between 2005 and 2007, and a formal emergency treatment protocol between 2008 and 2011 (Period A, n=442). Propensity score matching was used to adjust the differences in age, sex, modified Fisher grade, World Federation of Neurosurgical Societies (WFNS) clinical grade at admission, size and location of a ruptured aneurysm, treatment modality (clip placement vs coil embolization), and time interval from SAH to admission between the two time periods. The matched cases were allotted to Group A (n=280) in Period A and Group B (n=296) in Period B and then compared.
Results:
During Period A under the formal emergency treatment protocol strategy, the catheter angiogram, endovascular coiling, and surgical clip placement were started at a median time from admission of 2.0 hours, 2.9 hours, and 3.1 hours, respectively. After propensity score matching, Group A showed a significantly reduced incidence of in-hospital rebleeding (2.1% vs 7.4%, p=0.003) and a higher proportion of patients with a favorable clinical outcome (modified Rankin Scale score 0-3) at 1 month (87.9% vs 79.7%, respectively; p=0.008). In particular, the patients with good WFNS grades in Group A experienced significantly less in-hospital rebleeding (1.7% vs 5.7%, respectively; p=0.018) and better clinical outcomes (1-month mRS score of 0-3: 93.8% vs 87.7%, respectively; p=0.021) than the patients with good WFNS grades in Group B.
Conclusions:
Patients with ruptured aneurysms may benefit from a strategy of emergency application of surgical clip placement or endovascular coiling due to the reduced incidence of recurrent bleeding and improved clinical outcomes.
Aneurysm recurrence is a principle limitation of endovascular coiling procedures, especially in posterior communicating artery aneurysms, with reported recurrence rates of >30%. The adjunctive use of self-expandable stents has revolutionised the treatment of intracranial aneurysms, especially for complex morphologies, wide necks, or unfavourable dome-to-neck ratios. However, there are limited data concerning a direct comparison between simple coiling and stent-assisted coiling in posterior communicating artery aneurysms. This study aimed to compare the durability and outcomes of coiling versus stent-assisted coiling procedures. Imaging data of patients with posterior communicating artery aneurysms treated with coiling or stent-assisted coiling between January 2008 and October 2012 were retrospectively analysed. The initial angiographic results, procedural complications, and clinical outcomes were assessed at discharge. Imaging follow-up was performed with cerebral angiography. Complete aneurysm occlusion was achieved on initial angiography in 23/56 (41.1%) stent and 83/235 (35.3%) non-stent patients. At the latest follow-up (mean follow-up 14.3 ± 10.4 months for stent and 13.2 ± 9.5 months for non-stent patients), aneurysms had recurred in 5/47 (10.6%) stent and 57/203 (28.1%) non-stent patients (p = 0.014). Procedural complications occurred in 6/56 (10.7%) stent and 27/235 (11.5%) non-stent aneurysms. No rebleeding occurred during clinical follow-up (mean duration, 46.7 months). Recurrence rates at the latest follow-up were significantly lower in patients undergoing stent-assisted coiling than those undergoing simple coiling. Thus, use of the stent-assisted neck remodelling technique in the treatment of wide-necked posterior communicating artery intracranial aneurysms appears to improve the long-term clinical outcome.
Aim: Previously‐published meta‐analyses have concluded that coil embolization of very small (≤ 3 mm) intracranial aneurysms carry a high risk of procedural rupture, leading to morbidity and mortality. Several case series subsequently questioned the real procedural rupture risk. We therefore carried out an updated meta‐analysis.
Patients and Methods: Computerized EMBASE, MEDLINE and PubMed searches of the literature for reports on the safety and efficacy of treatment of intracranial aneurysms with a maximum dimension of ≤ 3 mm were carried out from January 1990 to January 2011. Statistical analyses were generated using SPSS for Windows Version 15.0 and Comprehensive MetaAnalysis 2.0 for Windows. Results of the meta‐analyses are presented with 95 per cent confidence intervals (CI).
Results: Twelve eligible studies with 637 patients (660 aneurysms) were analysed. Procedural aneurysm rupture occurred in 39 (5.9 per cent) of 660 aneurysm treatments (random‐effect‐weighted average: 7.2 per cent; 95 per cent CI: 5.3–9.6 per cent; Q ‐value: 11; I ² = 4 per cent). Immediate satisfactory occlusion was achieved in 508 (88 per cent) of 579 aneurysm treatments (random‐effect‐weighted average: 84 per cent; 95 per cent CI: 81–87 per cent; Q ‐value: 48; I ² = 81 per cent). Delayed satisfactory occlusion was achieved in 379 (88 per cent) of 433 aneurysm treatments (random‐effect‐weighted average: 82 per cent; 95 per cent CI: 77–86 per cent; Q ‐value: 48; I ² = 83 per cent).
Conclusions: The present findings suggest that coiling of very small intracranial aneurysms is associated with 7.2 per cent procedural aneurysm rupture risk. Further prospective multicenter studies should be carried out in Hong Kong to review the procedural morbidity and mortality.
The purpose of this article is to give an overview of the management of the most common complications encountered during subarachnoid hemorrhage and endovascular treatment of intracranial aneurysms. We reviewed the literature and identified the complications encountered during endovascular treatment of intracranial aneurysms. We report current management strategies of complications associated with subarachnoid hemorrhage and the interventional procedure. Aneurysmal subarachnoid hemorrhage remains a devastating condition, with high mortality and poor outcome among survivors. The successful treatment of intracranial aneurysms requires a multidisciplinary approach and the treating physicians need to be aware of predisposing factors for complications, their frequency, and also their management.
To compare 3T elliptical-centric CE MRA with 3T TOF MRA for the detection and characterization of unruptured intracranial aneurysms (UIAs), by using digital subtracted angiography (DSA) as reference.
Twenty-nine patients (12 male, 17 female; mean age: 62 years) with 41 aneurysms (34 saccular, 7 fusiform; mean diameter: 8.85mm [range 2.0-26.4mm]) were evaluated with MRA at 3T each underwent 3D TOF-MRA examination without contrast and then a 3D contrast-enhanced (CE-MRA) examination with 0.1mmol/kg bodyweight gadobenate dimeglumine and k-space elliptic mapping (Contrast ENhanced Timing Robust Angiography [CENTRA]). Both TOF and CE-MRA images were used to evaluate morphologic features that impact the risk of rupture and the selection of a treatment. Almost half (20/41) of UIAs were located in the internal carotid artery, 7 in the anterior communicating artery, 9 in the middle cerebral artery and 4 in the vertebro-basilar arterial system. All patients also underwent DSA before or after the MR examination.
The CE-MRA results were in all cases consistent with the DSA dataset. No differences were noted between 3D TOF-MRA and CE-MRA concerning the detection and location of the 41 aneurysms or visualization of the parental artery. Differences were apparent concerning the visualization of morphologic features, especially for large aneurysms (>13mm). An irregular sac shape was demonstrated for 21 aneurysms on CE-MRA but only 13/21 aneurysms on 3D TOF-MRA. Likewise, CE-MRA permitted visualization of an aneurismal neck and calculation of the sac/neck ratio for all 34 aneurysms with a neck demonstrated at DSA. Conversely, a neck was visible for only 24/34 aneurysms at 3D TOF-MRA. 3D CE-MRA detected 15 aneurysms with branches originating from the sac and/or neck, whereas branches were recognized in only 12/15 aneurysms at 3D TOF-MRA.
For evaluation of intracranial aneurysms at 3T, 3D CE-MRA is superior to 3D TOF-MRA for assessment of sac shape, detection of aneurysmal neck, and visualization of branches originating from the sac or neck itself, if the size of the aneurysm is greater than 13mm. 3T 3D CE-MRA is as accurate and effective as DSA for the evaluation of UIAs.
L’approche endovasculaire dans le traitement des anévrismes intracrâniens a connu un essor important avec l’introduction des filaments de platine électrolargable en 1991 et surtout la publication des résultats de l’étude ISAT en 2002. La qualité des résultats anatomiques et le taux relativement élevé de récidive demeure encore aujourd’hui le principal frein à un déploiement encore plus important. Cet article se veut une revue des différents facteurs de résultats sous-optimaux après traitement endovasculaire et des développements technologiques visant à pallier à ceux-ci.
Background:
Whether the addition of stenting to intracranial aneurysm coil embolization results in benefit in terms of occlusion rates or additional risk in terms of periprocedural adverse events is not clear.
Objective:
To report retrospectively analyzed results of endovascular aneurysm treatment comparing stent-assisted coiling with coiling without stents at our hospital from 2005 to 2009.
Methods:
In this retrospectively reviewed case series, aneurysms were grouped as intent-to-treat or initially treated with stent-assisted coiling (A) vs coiling alone (B) or as-treated-those that ultimately received a stent (C) or not (D). Complication and occlusion rates were compared between groups. Some patients crossed from group B to C after receiving stent placement at a later treatment following the initial therapeutic modality (without a stent).
Results:
In 459 patients, 489 aneurysms were treated by group as follows: A = 181, B = 308, C = 225, and D = 264. In stent groups (A and C), there were significantly lower frequencies of ruptured aneurysms (A vs B = 11% vs 62%, P < .001; C vs D = 20.4% vs 62.5%, P < .001) and more giant aneurysms (A vs B = 7.3% vs 1.0%, P = .001; C vs D = 5.9% vs 1.1%, P < .001). There was no statistically significant difference in permanent event-related morbidity (A vs B = 4.4% vs 4.2%, P = 1.0; C vs D = 4.4% vs 4.2%, P = 1.0). Average angiographic follow-up after last treatment was 18.2 ± 15 months (median = 14). Higher rates of complete occlusion at last angiographic follow-up were observed in stented aneurysms (A vs B = 64.6% vs 49.7%, P = .001; C vs D = 62.7% vs 48.9%, P = .003).
Conclusion:
Stent-assisted aneurysm treatment resulted in higher total occlusion rates than non-stent-assisted treatment, with acceptable, comparable periprocedural event rates.
OBJECTIVE: To elucidate the effect of treatment timing on procedural clinical outcomes after aneurysmal subarachnoid hemorrhage (SAH) for patients treated by endosaccular coil embolization.
METHODS: A group of 327 patients who were consecutively treated, during a 46-month period, for ruptured intracranial aneurysms by coil embolization within 30 days after SAH were evaluated. Outcomes were assessed by comparing immediate pretreatment World Federation of Neurological Surgeons (WFNS) grades, 72-hour posttreatment WFNS grades, and modified Glasgow Outcome Scale scores at 6 months for patients treated within 48 hours (Group 1), 3 to 10 days (Group 2), or 11 to 30 days (Group 3) after SAH.
RESULTS: The three interval-to-treatment groups included 33, 38, and 29% of the patients, respectively. Before treatment, 70% of the patients in Group 1, 78% of those in Group 2, and 83% of those in Group 3 were in good clinical grades (i.e., WFNS Grade 1 or 2). After coil embolization, the WFNS grades were either unchanged or improved for 93.5% of the patients in Group 1, 89.5% of those in Group 2, and 91.5% of those in Group 3. After 6 months, 81.3% of the patients in Group 1 experienced good outcomes (modified Glasgow Outcome Scale scores of 1 or 2), as did 84% of those in Group 2 and 80% of those in Group 3. No statistical difference was demonstrated between the three groups when they were compared for these two variables.
CONCLUSION: The interval between endovascular treatment and SAH did not affect periprocedural morbidity rates or 6-month outcomes. Coil embolization should therefore be performed as early as possible after aneurysmal SAH, to prevent aneurysmal rerupture.
Patients with subarachnoid haemorrhage due to the rupture of aneurysms unsuitable for craniotomy and clipping have been treated by coil embolisation within three weeks. Sixty nine of 75 consecutive patients were successfully treated. Procedure related complications occurred in 10 patients, resulting in permanent neurological deficits in three and one death (4.8%). The Glasgow outcome scores at six weeks were 53 grade 1, seven grade 2, four grade 3, and five grade 5. These results are comparable with surgical series despite a high proportion of aneurysms in the posterior cerebral circulation.
The aim of this study was to assess the incidence and outcome of procedure-related rupture of intracranial aneurysms in patients treated with Guglielmi detachable coils (GDCs) and to identify risk factors for this complication.
Procedure-related rupture occurred in seven of 264 treated aneurysms in 239 consecutive patients. Aneurysm size, history of previous subarachnoid hemorrhage (SAH) caused by the treated aneurysm, timing of treatment after SAH, and the use of a temporary occlusion balloon in the seven procedures in which rupture occurred were compared with the remaining 257 procedures, and these findings were correlated with data from 13 studies in the literature, in which results of 2030 aneurysm treatments were reported.
Procedure-related rupture of intracranial aneurysms during GDC treatment occurs in 2.5% of cases and is responsible for 1% of treatment-related deaths. Risk factors are as follows: small aneurysm size, previous SAH, and probably the use of a temporary occlusion balloon.
Although attenuated coil packing of intracranial aneurysms is an important goal of endovascular embolization, because of their small size, some aneurysms can only be treated with a single embolization coil. We retrospectively analyzed small aneurysms treated with a single Guglielmi detachable coil (GDC) to determine whether the coil-embolization ratio (CER) is predictive of embolization stability.
The CER was determined for 25 small (<7-mm diameter) intracranial aneurysms, each treated with a single embolization coil. The largest aneurysm dimension, estimated by comparison to anatomic landmarks, was used for volume calculation based on a spherical model. Coil volumes were according to manufacturer specifications. CER was calculated by the formula (coil volume/aneurysm volume) x 100%. Embolization stability was assessed by angiographic follow-up.
The average CER for all aneurysms was 8.2% (SD, 6.5%; range, 0.6%-21.1%). Twelve percent of the aneurysms had a CER >20%. Follow-up angiographic assessment was conducted at an average of 30.8 months after initial treatment. Eighty-four percent of the aneurysms were obliterated. One large (6 x 10 mm) and 3 small (<1 mm) recurrences were identified. The average CER for unchanged aneurysms was 8.0% (SD, 5.9%) and for the recurrent aneurysms was 8.8% (SD, 8.7%), which was not statistically significant.
Small aneurysms treated with a single coil achieved satisfactory stability despite having a low average packing attenuation. CER was not predictive of recurrence in small intracranial aneurysms treated with a single detachable coil.
To report the incidence of procedural complications of coiling of ruptured intracranial aneurysms leading to permanent disability or death in a consecutive series of 681 patients and to identify risk factors for these events.
Between January 1995 and July 2005, 681 consecutive patients with ruptured intracranial aneurysms were treated with detachable coils. Procedural complications (aneurysm rupture or thromboembolic) of coiling leading to death or neurologic disability at the time of hospital discharge were recorded. For patients with procedural complications, odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated for the following patient and aneurysm characteristics: patient age and sex, use of a supporting balloon, aneurysm location, timing of treatment, clinical condition at the time of treatment, and aneurysm size.
Procedural complications occurred in 40 of 681 patients (5.87%; 95% CI, 4.2% to 7.9%), leading to death in 18 patients (procedural mortality, 2.6%; 95% CI, 1.6% to 4.2%) and to disability in 22 patients (procedural morbidity, 3.2%; 95% CI, 2.0% to 4.9%). There were 8 procedural ruptures and 32 thromboembolic complications. The use of a temporary supporting balloon was the only significant risk factor (OR, 5.1; 95% CI, 2.3 to 15.3%) for the occurrence of procedural complications.
Procedural complication rate of coiling of ruptured aneurysms leading to disability or death is 5.9%. In this series, the use of a temporary supporting balloon in the treatment of wide-necked aneurysms was the only risk factor for the occurrence of complications.
Application of endovascular surgery for very small aneurysms is controversial because of technical difficulties and high complication rates. The aim in the present study was to assess treatment results in a series of such lesions at one institution.
Since 1997, endovascular surgery has been advocated for very small ruptured aneurysms (<3 mm in maximum diameter) that fulfill the criterion of a fundus/neck ratio greater than 1.5. Twenty-one patients were treated, for whom the World Federation of Neurosurgical Societies classification before treatment was Grade I in 10, Grade II in two, Grade III in two, Grade IV in five, and Grade V in two. The aneurysm location was the internal carotid artery in four, the anterior communicating artery in 11, the middle cerebral artery in one, and the vertebrobasilar system in five. In all patients, endovascular surgery was performed using Guglielmi detachable coils after induction of general anesthesia. Initially, the presumed volume of the lesions was calculated for each aneurysm. Thereafter, the appropriate coil length was decided according to the volume embolization ratio, as 30 to 40%. In all attempts to obliterate aneurysms a single coil was used.
All aneurysms were completely obliterated as confirmed by postembolization angiography, without procedure-related complications. During the follow-up period only one patient needed additional coil embolization for a growing aneurysm. Final outcomes were good recovery in 15 patients, moderate disability in five, and severe disability in one.
Appropriate selection of patients and coils, and use of sophisticated techniques allow a good outcome for patients with very small aneurysms.
Persisting disability after brain damage usually comprises both mental and physical handicap. The mental component is often the more important in contributing to overall social disability. Lack of an objective scale leads to vague and over-optimistic estimates of outcome, which obscure the ultimate results of early management. A five-point scale is described—death, persistent vegetative state, severe disability, moderate disability, and good recovery. Duration as well as intensity of disability should be included in an index of ill-health; this applies particularly after head injury, because many disabled survivors are young.
OBJECTIVE : To review our experience and examine the size at which aneurysms ruptured in our patient population.
METHODS : Patient charts and angiograms for all patients admitted with a diagnosis of subarachnoid hemorrhage to the Thomas Jefferson/Wills Eye Hospital between April 1996 and March 2000 were reviewed.
RESULTS : Of the 362 cases reviewed, definite measurements of the ruptured aneurysm were obtained in 245. The data clearly showed that most ruptured aneurysms presenting to our institution were less than 10 mm in diameter. We found that, regardless of location on the circle of Willis, 85.6% of all aneurysms presenting with rupture were less than 10 mm. Review by location shows that aneurysms of the anterior communicating artery most often presented with rupture at sizes less than 10 mm (94.4%). A large number of ruptured posterior communicating artery aneurysms also presented at sizes less than 10 mm (87.5%). This trend continued for all aneurysm sites in our review. The incidence of subarachnoid hemorrhage in Western countries is estimated at 10 per 100,000 people per year. Recent reports have indicated that aneurysms less than 10 mm in size are unlikely to rupture.
CONCLUSION : We argue that the risk of small aneurysms rupturing is not insignificant, especially those of the anterior communicating artery. Our findings indicate that surgery on unruptured aneurysms should not be predicated on aneurysm size alone.
Because the long-term security of endovascular treatments remains uncertain, a follow-up study of the patients treated in the International Subarachnoid Aneurysm Trial was performed to compare the frequency, timing, and consequences of aneurysm recurrence.
Patient data were reclassified by actual treatment performed. Aneurysm and patient characteristics, including occlusion grades, time and type of retreatment, and clinical outcomes, were compared. The relationship between these variables and late retreatment as a surrogate for recurrence was analyzed by means of the Cox proportional hazards model.
Retreatment was performed in 191 of 1096 (17.4%) patients after primary endovascular coiling (EVT) and in 39 of 1012 patients (3.8%) after neurosurgical clipping. After EVT, 97 (8.8%) patients were retreated early and 94 (9.0%) late, 7 (0.6%) after rebleeding and 87 (8.3%) without. The mean time to late retreatment was 20.7 months. After neurosurgical clipping, 30 (2.9%) patients were retreated early and 9 (0.85%) late, 3 (0.3%) after rebleeding and 6 (0.6%) without. The mean time to late retreatment was 5.7 months. The hazard ratio (HR) for retreatment after EVT was 6.9 (95% CI=3.4 to 14.1) after adjustment for age (P=0.001, HR=0.97, 95% CI=0.95 to 0.98), lumen size (P=0.006, HR=1.1, 95% CI=1.03 to 1.18), and incomplete occlusion (P<0.001, HR=7.6, 95% CI=3.3 to 17.5).
Late retreatment was 6.9 times more likely after EVT. Younger age, larger lumen size, and incomplete occlusion were risk factors for late retreatment after EVT. After neurosurgical clipping, retreatments were earlier; whereas EVT retreatments continued to be performed throughout the follow-up period. Short-term follow-up imaging is therefore insufficient to detect recurrences after EVT.
To study the incidence and clinical outcomes of intraoperative aneurysm rupture (IOR) during endovascular coil embolization at a single large volume center and to review the literature on this subject to determine whether IOR rupture rate and mortality correlate with volume of aneurysms treated at a given center and years since the institution of Guglielmi detachable coils as a treatment modality.
We reviewed the aneurysm database at the Center for Endovascular Surgery since its inception (1997-2003) and reviewed 600 consecutively treated intracranial aneurysms in which coiling was attempted. All patients who sustained an IOR were studied. Procedural and follow-up angiograms as well as clinical outcomes were retrospectively reviewed. A literature review was conducted.
Six patients (1.0%) experienced IOR (1.4% in acutely ruptured lesions, 0% in unruptured). All six had presented with diffuse subarachnoid hemorrhage (Fisher Grade 3) and in good clinical grade (Hunt & Hess Grades 1-3). One patient was rendered permanently disabled secondary to delay in controlling the IOR. All others were neurologically unchanged. A review of the literature revealed a trend in correlation between volume of aneurysms treated and IOR rate; no statistically significant correlation was found between volume of aneurysms treated or years since the introduction of GDC technology and IOR rates or mortality.
IOR remains a serious risk of endosaccular coiling of intracranial aneurysms, with aneurysms presenting with subarachnoid hemorrhage at greater risk for this complication. This risk can be minimized with very low associated morbidity and mortality (incidence 1%, 17% morbidity, 0% mortality at our institution).
Persisting disability after brain damage usually comprises both mental and physical handicap. The mental component is often the more important in contributing to overall social disability. Lack of an objective scale leads to vague and over-optimistic estimates of outcome, which obscure the ultimate results of early management. A five-point scale is described--death, persistent vegetative state, severe disability, moderate disability, and good recovery. Duration as well as intensity of disability should be included in an index of ill-health; this applies particularly after head injury, because many disabled survivors are young.
Fifteen patients with high-risk intracranial saccular aneurysms were treated using electrolytically detachable coils introduced via an endovascular approach. The patients ranged in age from 21 to 69 years. The most frequent clinical presentation was subarachnoid hemorrhage (eight cases). Considerable thrombosis of the aneurysm (70% to 100%) was achieved in all 15 patients, and preservation of the parent artery was obtained in 14. Although temporary neurological deterioration due to the technique was recorded in one patient, no permanent neurological deficit was observed in this series and there were no deaths. It is believed that this new technology is a viable alternative in the management of patients with high-risk intracranial saccular aneurysms. It may also play an important role in the occlusion of aneurysms in the acute phase of subarachnoid hemorrhage.
The autopsy files and preparations of unruptured incidental intracranial aneurysms seen at the Montefiore Medical Center between 1951 and 1987 were reviewed. There were 84 patients with 102 unruptured aneurysms in a total of 10,259 autopsies, giving a prevalence of 0.8%. Sixteen of the 84 (19%) had multiple aneurysms. The thickness of walls of aneurysms could be estimated in 78 of 102 aneurysms, and was determined to be either thin or thin and thick in 71 aneurysms. In this study, four noteworthy factors were found: (1) the incidence of unruptured aneurysms was higher in elderly patients aged 60 years or older, and the peak percentage was 1.2% in the seventh decade; (2) aneurysms occurred more frequently in females than males, with a ratio of 53:31; (3) the most common site of aneurysms was the middle cerebral artery; 37 of 102 aneurysms (36%) occurred on it; and (4) the rate of small aneurysms was very high; 50 of 93 aneurysms (54%) were 4 mm or less in diameter, and 33 aneurysms (35%) were 5-9 mm in diameter. However, relationships could not be found between age distribution and location, size, or thickness of walls; between gender and size or thickness of walls; between location and size or thickness of walls; or between size and thickness of walls. Based on published statistics on subarachnoid hemorrhage and this study, the rupture rate of unruptured aneurysms seems to be very low. Although the risk of rupture may be relatively low in small aneurysms, its low risk probably cannot be explained adequately by morphological examination only.
In 47 cases of verified ruptured saccular aneurysm, we investigated the relationship of the amount and distribution of subarachnoid blood detected by computerized tomography to the later development of cerebral vasospasm. When the subarachnoid blood was not detected or was distributed diffusely, severe vasospasm was almost never encounters (1 of 18 cases). In the presence of subarachnoid blood clots larger than 5 X 3 mm (measured on the reproduced images) or layers of blood 1 mm or more thick in fissures and vertical cisterns, severe spasm followed almost invariably (23 of 24 cases). There was an almost exact correspondence between the site of the major subarachnoid blood clots and the location of severe vasospasm. Every patient with severe vasospasm manifested delayed symptoms and signs. Excellent correlation existed between the particular artery in vasospasm and the delayed clinical syndrome. Severe vasospasm involved the anterior cerebral artery in 20 cases and the middle cerebral artery in only 14. As the grading system used is partly subjective, the findings should be regarded as preliminary. The results, if confirmed, indicate that blood localized in the subarachnoid space in sufficient amount at specific sites is the only important etiological factor in vasospasm. It should be possible to identify patients in jeopardy from vasospasm and institute early preventive measures. (Neurosurgery, 6: 1--9, 1980)
Endosaccular packing of inoperable aneurysms with electrolytic platinum coils was performed in 50 patients. Complete embolization of the aneurysms was achieved in 100% of small, 95% of large and 85% of giant aneurysms, with combined procedural and periprocedural morbidity and mortality rates of 6 and 4%, respectively. Follow-up angiography of 42 aneurysms demonstrated some degree of refilling in 17% of small, 19% of large and 50% of giant aneurysms. The risks associated with the procedure were similar in aneurysms of the carotid and vertebrobasilar circulations. This treatment should therefore be considered for all inoperable aneurysms and particularly for aneurysms involving the posterior circulation. Its long-term efficacy remains uncertain.
The balance of risks of treatment for unruptured aneurysms might change if the prognosis after rupture depends on the size of the aneurysm. In a prospective series of patients with subarachnoid hemorrhage in whom aneurysmal size was measured by CT angiography performed on admission, poor outcome occurred more often in patients with large (> or =10 mm) aneurysms (63%) than in patients with small (<10 mm) aneurysms (41%; RR = 1.5; 95% CI 1.0 to 2.2). The relative risk remained essentially the same after adjustment for age, gender, location of the aneurysm, and amount of cisternal blood.
We describe the development and design of a database for auditing patients with intracranial aneurysms and their endovascular treatment. The database has been used since 1992. Our department's version now contains records of over 800 patients and well over 1,000 aneurysms. The advantages of a relational database for this type of audit are discussed. Copies of the software can be obtained free of charge from the authors.
To elucidate the effect of treatment timing on procedural clinical outcomes after aneurysmal subarachnoid hemorrhage (SAH) for patients treated by endosaccular coil embolization.
A group of 327 patients who were consecutively treated, during a 46-month period, for ruptured intracranial aneurysms by coil embolization within 30 days after SAH were evaluated. Outcomes were assessed by comparing immediate pretreatment World Federation of Neurological Surgeons (WFNS) grades, 72-hour posttreatment WFNS grades, and modified Glasgow Outcome Scale scores at 6 months for patients treated within 48 hours (Group 1), 3 to 10 days (Group 2), or 11 to 30 days (Group 3) after SAH.
The three interval-to-treatment groups included 33, 38, and 29% of the patients, respectively. Before treatment, 70% of the patients in Group 1, 78% of those in Group 2, and 83% of those in Group 3 were in good clinical grades (i.e., WFNS Grade 1 or 2). After coil embolization, the WFNS grades were either unchanged or improved for 93.5% of the patients in Group 1, 89.5% of those in Group 2, and 91.5% of those in Group 3. After 6 months, 81.3% of the patients in Group 1 experienced good outcomes (modified Glasgow Outcome Scale scores of 1 or 2), as did 84% of those in Group 2 and 80% of those in Group 3. No statistical difference was demonstrated between the three groups when they were compared for these two variables.
The interval between endovascular treatment and SAH did not affect periprocedural morbidity rates or 6-month outcomes. Coil embolization should therefore be performed as early as possible after aneurysmal SAH, to prevent aneurysmal rerupture.
The authors explore the risk of rupture in aneurysms categorized by size.
A computerized database of 945 patients with aneurysms treated between 1967 and 1987 was retrospectively established. All available clinical and radiological studies were abstracted. Because of the recent interest in the size of intracranial aneurysms in relation to their likelihood of rupture, the database was searched with respect to this parameter. In 390 patients representing 41% of all cases, aneurysms were measured by neuroradiologists at the time of diagnosis. In 78% of the 945 patients there was only one aneurysm, and of the 507 aneurysms that were measured, 60% were solitary. Of all patients, 86% had ruptured aneurysms. The average age of all patients was 47 years, and for those with ruptured aneurysms it was 46 years. Of the ruptured aneurysms, 77% were 10 mm or smaller, compared with 85% of the unruptured aneurysms. It was found that 40.3% of the ruptured aneurysms were on the anterior cerebral artery or anterior communicating artery, compared with 13% of the unruptured aneurysms. None of the cavernous internal carotid artery (ICA) aneurysms were ruptured and 65% of the ophthalmic artery (OphA) aneurysms were. Of the unruptured aneurysms, 15% were located in the cavernous ICA or the OphA. Of the ruptured aneurysms, 29% were on the middle cerebral artery, compared with 36% of the unruptured aneurysms. The mean size of ruptured and unruptured aneurysms showed no statistically significant increase with patient age, although the difference in size between the ruptured and unruptured aneurysms decreased with increasing age. The mean size of all ruptured aneurysms (10.8 mm) was significantly larger than the mean size of all unruptured aneurysms (7.8 mm, p < 0.001); the median sizes were 10 mm and 5 mm, respectively. The size of ruptured aneurysms in patients who died in the hospital was significantly larger than those in the patients who survived (12 mm compared with 9.9 mm, p = 0.004). Symptomatic unruptured aneurysms were significantly larger than incidental unruptured aneurysms (14.6 mm compared with 6.9 mm, p = 0.032), which were, in turn, larger than aneurysms that were unruptured and part of a multiple aneurysm constellation. Both ruptured and unruptured aneurysms were larger in male than in female patients, but not significantly.
Site and patient age, as well as lesion size, may affect the chance of rupture.
The risk of intraprocedural aneurysm perforation in patients with previously ruptured aneurysms tends to be higher than that of patients with previously unruptured aneurysms, but a statistically significant difference has not been shown. Our purpose was to define the rates of occurrence and of morbidity and mortality associated with aneurysmal perforation associated with coil embolization.
A meta-analysis of the results from 17 published retrospective reports of aneurysm perforations complicating therapy with Guglielmi detachable coils (GDCs) was performed. Rates of perforation and associated morbidity and mortality in previously ruptured and unruptured aneurysms were calculated. The mechanism of perforation was noted.
The risk of intraprocedural perforation was significantly higher in patients with ruptured aneurysms compared with patients with unruptured aneurysms (4.1% vs 0.5%; P <.001). The combined risk of permanent neurologic disability and death associated with intraprocedural aneurysm perforation was 38% for ruptured aneurysms and 29% for unruptured aneurysms. The morbidity and mortality rates with perforations caused by coils (39%) and microcatheters (33%) were similar. The morbidity and mortality rate for microguidewire perforations was considerably lower (0%, n = 4) than the rates for coils and microcatheters, but number of cases was too low to indicate statistical significance.
The risk of aneurysm perforation during GDC therapy is much higher in patients with previously ruptured aneurysms than in those with unruptured aneurysms. The morbidity and mortality rates are substantial for perforations caused by coils and microcatheters, whereas they seem to be much lower for perforations caused by microguidewires.
Our aim in this study was to assess the incidence and determining factors of angiographic recurrences after endovascular treatment of aneurysms.
A retrospective analysis of all patients with selective endosaccular coil occlusion of intracranial aneurysms prospectively collected from 1992 to 2002 was performed. There were 501 aneurysms in 466 patients (mean+/-SD age, 54.20+/-12.54 years; 74% female). Aneurysms were acutely ruptured (54.1%) or unruptured (45.9%). Mean+/-SD aneurysm size was 9.67+/-5.91 mm with a 4.31+/-1.97-mm neck. The most frequent sites were basilar bifurcation (27.7%) and carotid ophthalmic (18.0%) aneurysms. Recurrences were subjectively divided into minor and major (ideally necessitating re-treatment). The most significant predictors of angiographic recurrence were determined by logistic regression. These results were confirmed by chi2, t tests, or ANOVAs followed, when appropriate, by Tukey's contrasts.
Short-term (< or =1 year) follow-up angiograms were available in 353 aneurysms (70.5%) and long-term (>1 year) follow-up angiograms, in 277 (55%), for a total of 383 (76.5%) followed up. Recurrences were found in 33.6% of treated aneurysms that were followed up and that appeared at a mean+/-SD time of 12.31+/-11.33 months after treatment. Major recurrences presented in 20.7% and appeared at a mean of 16.49+/-15.93 months. Three patients (0.8%) bled during a mean clinical follow-up period of 31.32+/-24.96 months. Variables determined to be significant predictors (P<0.05) of a recurrence included aneurysm size > or =10 mm, treatment during the acute phase of rupture, incomplete initial occlusions, and duration of follow-up.
Long-term monitoring of patients treated by endosaccular coiling is mandatory.
The management of unruptured intracranial aneurysms is controversial. Investigators from the International Study of Unruptured Intracranial Aneurysms aimed to assess the natural history of unruptured intracranial aneurysms and to measure the risk associated with their repair.
Centres in the USA, Canada, and Europe enrolled patients for prospective assessment of unruptured aneurysms. Investigators recorded the natural history in patients who did not have surgery, and assessed morbidity and mortality associated with repair of unruptured aneurysms by either open surgery or endovascular procedures.
4060 patients were assessed-1692 did not have aneurysmal repair, 1917 had open surgery, and 451 had endovascular procedures. 5-year cumulative rupture rates for patients who did not have a history of subarachnoid haemorrhage with aneurysms located in internal carotid artery, anterior communicating or anterior cerebral artery, or middle cerebral artery were 0%, 2. 6%, 14 5%, and 40% for aneurysms less than 7 mm, 7-12 mm, 13-24 mm, and 25 mm or greater, respectively, compared with rates of 2 5%, 14 5%, 18 4%, and 50%, respectively, for the same size categories involving posterior circulation and posterior communicating artery aneurysms. These rates were often equalled or exceeded by the risks associated with surgical or endovascular repair of comparable lesions. Patients' age was a strong predictor of surgical outcome, and the size and location of an aneurysm predict both surgical and endovascular outcomes.
Many factors are involved in management of patients with unruptured intracranial aneurysms. Site, size, and group specific risks of the natural history should be compared with site, size, and age-specific risks of repair for each patient.
The goal of this study was to determine the relationship between aneurysm size and the volume of subarachnoid hemorrhage (SAH).
One hundred consecutive patients who presented with acute SAH, which was diagnosed on the basis of a computerized tomography (CT) scan within 24 hours postictus and, subsequently, confirmed to be aneurysmal in origin by catheter angiography, were included in this study. The data were collected prospectively in 32 patients and retrospectively in 68. The volume of SAH on the admission CT scan was scored in a semiquantitative manner from 0 to 30, according to a previously published method. The mean aneurysm size was 8.3 mm (range 1-25 mm). The mean SAH volume score was 15 (range 0-30). Regression analysis revealed that a smaller aneurysm size correlated with a more extensive SAH (r(2) = 0.23, p < 0.0001). Other variables including patient sex and age, intraparenchymal or intraventricular hemorrhage, multiple aneurysms, history of hypertension, and aneurysm location were not statistically associated with a larger volume of SAH.
Smaller cerebral aneurysm size is associated with a larger volume of SAH. The pathophysiological basis for this correlation remains speculative.
The authors present two cases of patients with small, acutely ruptured, wide-necked aneurysms of the distal vertebral artery that were not amenable to conventional coil embolization and were instead treated by means of a double-stent method in which one stent was placed inside another. Angiography performed immediately after the procedure revealed a significant reduction in aneurysm filling; total occlusion of the lesion was observed after 7 days and confirmed 6 months later in both aneurysms. By placing one stent inside the other, stent permeability can be reduced, which may result in significant hemodynamic changes with accelerated aneurysm thrombosis. This double-stent method may represent a therapeutic alternative, especially in cases of small, wide-necked aneurysms in which conventional endovascular techniques or stent-supported coil embolization is not considered feasible or is believed to be too dangerous, and surgical treatment is contra-indicated.
A case-control analysis of patients with SAH was performed to compare risk factors and outcomes at 6 months posthemorrhage in patients with a very small aneurysm compared with those with a larger aneurysm.
All patients with SAH who were treated between January 1998 and December 1999 were studied. A very small aneurysm was defined as "equal to or less than 5 mm in diameter." Clinical data and treatment summaries were maintained in an electronic database. The Glasgow Outcome Scale (GOS) score was determined by an independent registrar. One hundred twenty-seven patients were treated. A very small aneurysm was the cause of SAH in 42 patients (33%), whereas 85 (67%) had aneurysms larger than 5 mm (mean diameter 11 mm). There were no differences in demographic variables or medical comorbidities between the two groups. Thick SAH (Fisher Grade 3 or 4) was more common in patients with a very small aneurysm than in those with a larger aneurysm (p = 0.028). One hundred eight patients underwent microsurgery (85%), 15 underwent coil embolization (12%), and four (3%) required both procedures. Vasospasm occurred in nine patients (21%) with very small aneurysms compared with 14 (16%) with larger aneurysms (p = 0.62). Shunt-dependent hydrocephalus occurred in nine patients (21%) with very small aneurysms and in 19 (22%) with larger aneurysms (p = 1). The mean GOS score for both groups was 4 (moderately disabled) at 6 months.
Small aneurysms produce thick SAH more often than larger aneurysms. There is no difference in outcome after SAH between patients with a very small aneurysm and those with a larger aneurysm.
Two types of treatment are being used for patients with ruptured intracranial aneurysms: endovascular detachable-coil treatment or craniotomy and clipping. We undertook a randomised, multicentre trial to compare these treatments in patients who were suitable for either treatment because the relative safety and efficacy of these approaches had not been established. Here we present clinical outcomes 1 year after treatment.
2143 patients with ruptured intracranial aneurysms, who were admitted to 42 neurosurgical centres, mainly in the UK and Europe, took part in the trial. They were randomly assigned to neurosurgical clipping (n=1070) or endovascular coiling (n=1073). The primary outcome was death or dependence at 1 year (defined by a modified Rankin scale of 3-6). Secondary outcomes included rebleeding from the treated aneurysm and risk of seizures. Long-term follow up continues. Analysis was in accordance with the randomised treatment.
We report the 1-year outcomes for 1063 of 1073 patients allocated to endovascular treatment, and 1055 of 1070 patients allocated to neurosurgical treatment. 250 (23.5%) of 1063 patients allocated to endovascular treatment were dead or dependent at 1 year, compared with 326 (30.9%) of 1055 patients allocated to neurosurgery, an absolute risk reduction of 7.4% (95% CI 3.6-11.2, p=0.0001). The early survival advantage was maintained for up to 7 years and was significant (log rank p=0.03). The risk of epilepsy was substantially lower in patients allocated to endovascular treatment, but the risk of late rebleeding was higher.
In patients with ruptured intracranial aneurysms suitable for both treatments, endovascular coiling is more likely to result in independent survival at 1 year than neurosurgical clipping; the survival benefit continues for at least 7 years. The risk of late rebleeding is low, but is more common after endovascular coiling than after neurosurgical clipping.
Although current guidelines for the management of unruptured intracranial aneurysms (IAs) suggest aneurysms larger than 7 mm should be considered for treatment, a significant number of subarachnoid hemorrhages are caused by IAs 7 mm or smaller. Thus, we sought to identify risk factors associated with the rupture of IAs 7 mm or smaller.
We identified 100 patients with subarachnoid hemorrhage resulting from IAs 7 mm or smaller between January 2001 and 2004. Patients were compared with controls (n = 51) with unruptured IAs 7 mm or smaller, diagnosed by conventional angiography or three-dimensional computerized angiography, with respect to aneurysm characteristics (size, location, and age of presentation) and risk factors (hypertension, smoking, cocaine use, and family history).
Hypertensive patients with IAs 7 mm or smaller were 2.6 times more likely to experience rupture (P = 0.01; 95% confidence interval, 1.21-5.53) than patients with normal blood pressure. Posterior circulation aneurysms were 3.5 times more likely to rupture than anterior circulation aneurysms (P = 0.048; 95% confidence interval, 0.95-19.4). After adjustment for location and hypertension, the age of patient on presentation was associated with a trend toward inverse correlation with aneurysmal rupture risk (P = 0.07). Hypertension and posterior location remained significant independent predictors in the logistic regression model.
Among patients with small aneurysms (< or = 7 mm), hypertension, relatively young age, and posterior circulation were significant risk factors for rupture. Given the minimal long-term morbidity and mortality of treatment of unruptured aneurysms in large, tertiary medical centers, management of unruptured aneurysms 7 mm or smaller should be governed by factors other than size, specifically age, history of hypertension, and location.
We present a previously unreported complication following the treatment of a patient with two small, wide-necked, posterior communicating artery aneurysms.
Endovascular embolization of one aneurysm was performed using a stent-assisted technique. Follow-up angiography 5 months later revealed that a coil had escaped the confinement of the stent and migrated distally without occluding any arterial branches or causing symptoms. This case report demonstrates that although a rare occurrence, a coil can break loose from the stent.
We discuss the potential mechanisms of this phenomenon and review the literature on stent-assisted aneurysm coiling in order to raise awareness of this event when embolizing small, wide-necked aneurysms with a stent-assisted technique.
Small intracranial aneurysms with a fundus diameter of 2 - 3 mm may rupture and are therefore potential targets for an endovascular approach in treatment. Currently available coil technology is less than optimal for the treatment of aneurysms within this size range. Even the smallest coils are sometimes too large. If such a minute coil can be introduced into a small aneurysm, the hemodynamic effect and the induced thrombosis are frequently inadequate to occlude the aneurysm sufficiently from the parent artery circulation.
Three technical alternatives for the endovascular treatment of small intracranial aneurysms not suitable for coil occlusion are illustrated with the following three case descriptions.
Stent grafts are usable for the intracranial internal carotid artery and for the V4 segment. The stiffness of the stent and the high expansion pressures are the two major drawbacks. Coaxial deployment of two or more self-expanding porous stents can result in sufficient redirection of the blood flow to induce aneurysmal thrombosis. Deployment of multiple stents, however, may require several treatment sessions in order to allow for the integration of the stents into the vessel wall from session to session. A regular microcatheter can block aneurysmal inflow in aneurysms with a very narrow neck. This allows the occlusion of the aneurysm with an appropriate amount of highly concentrated, rapidly polymerizing glue. Polymer emboli may result from excessive or rapid glue injection.
The available coil technology has inherent limitations in the treatment of very small intracranial aneurysms. Liquid embolic agents and stent-based extrasaccular treatment strategies may provide solutions for these challenging lesions.
The authors of recent reports have suggested that smaller aneurysms are associated with more extensive subarachnoid hemorrhage (SAH), which could potentially presage poor outcome in patients harboring these lesions. The authors reviewed their clinical experience to determine if this theory has a basis in truth.
The authors undertook a retrospective review of a consecutive series of patients with aneurysmal SAH. Computed tomography scans and angiograms were studied to establish SAH scores and aneurysm size.
One hundred thirty-three patients were treated during a 2-year period (January 2003-December 2004). There were 101 female and 32 male patients whose mean age was 56.7 years. The location distribution of aneurysms that bled was as follows: anterior communicating artery (56 cases), posterior communicating artery (34 cases), middle cerebral artery (21 cases), posterior circulation (16 cases), and paraclinoid region (six cases). The mean aneurysm size was 6.2 mm (range 2-26 mm). The mean SAH score was 18.3 (not normally distributed, p < 0.01, D'Agostino-Pearson test). One hundred three patients underwent surgical exploration and placement of an aneurysm clip, 21 underwent deployment of a coil, and two underwent both therapies; seven patients died prior to intervention. No correlation was found between aneurysm size and SAH score (r(s) = -0.023, p = 0.8) or between small aneurysm size and poor Glasgow Outcome Scale score (p = 0.13). In fact, the trend was the opposite. The SAH score did, however, correspond strongly with the admission Hunt and Hess grade (p < 0.0001), indicating the strong correlation between grade and volume of intracranial blood. Outcome was best explained in the multivariate analysis by the following factors: admission Hunt and Hess grade, age, and clinical vasospasm (p < 0.0001) with the proportion of cases correctly classified as 79.7%.
Evaluation of the results in the present clinical series suggests that there is no relation between aneurysm size and volume of subarachnoid blood. The volume of cisternal blood correlates with Hunt and Hess grade but is not an independent determinant of outcome. Outcome is related to the following triad of well-established clinical factors: Hunt and Hess grade, age, and clinical vasospasm.
Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale
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