Angiographic and clinical results in 316 coil-treated basilar artery bifurcation aneurysms

Bypass and flow reduction for complex basilar and vertebrobasilar junction aneurysms

BACKGROUND

Giant aneurysms of the vertebral and basilar arteries are formidable lesions to treat.

OBJECTIVE

To evaluate the long-term outcomes of patients with vertebrobasilar aneurysms treated with extracranial-intracranial bypass and flow reduction.

METHODS

We retrospectively reviewed a prospective database of aneurysms cases treated between December 1993 and August 2011.

RESULTS

Eleven patients (8 male, 3 female) with 12 aneurysms were treated. There were 3 basilar apex aneurysms, 2 aneurysms of the basilar trunk, and 7 vertebrobasilar junction aneurysms. There were 5 saccular and 7 fusiform aneurysms. All patients underwent extracranial-intracranial bypass and vessel occlusion. Flow was reversed or reduced by complete (n = 6) or partial occlusion of the basilar artery (n = 3) or by occlusion of the vertebral arteries distal to the posterior inferior cerebellar artery (n = 3). Postoperatively (mean follow-up, 71.6 months; range, 4-228; median, 49 months), the bypass patency rate was 92.3% (12/13). The perioperative mortality rate for the initial treatment was 18.2% (2/11). In 4 cases, the aneurysms continued to grow and required further treatment; after re-treatment, 3 of these patients died. Of the initial 11 patients, 6 were treated successfully and 5 died. The mean preoperative modified Rankin Scale score was 2.1 (range, 1-3; median, 2). At last follow-up for all patients, the mean modified Rankin Scale score was 3.45 (range, 1-6; median, 3) and 2.5 (range, 1-4; median, 2.5) for the 6 long-term survivors.

CONCLUSION

Vertebrobasilar aneurysms are challenging lesions with limited microsurgical or endovascular options. Despite aggressive surgical treatment, the long-term outcome remains poor for most patients.

Endovascular treatment of intracranial aneurysms with detachable coils: correlation between aneurysm volume, packing, and angiographic recurrence

BACKGROUND AND PURPOSE

The relationship between dense packing and incidence of angiographic recurrence after endovascular treatment of intracranial aneurysms has been shown but remains controversial. We retrospectively analyzed intracranial aneurysms treated with detachable coils to determine the relation between aneurysm volume, packing, and recurrence.

METHODS

We reviewed 221 aneurysms in 199 patients who underwent endovascular coiling using detachable coils from November 2009 to December 2011. Aneurysm volumes were determined using three-dimensional images obtained from rotational angiography. Aneurysm packing was defined as the ratio between the volume of coils inserted and the volume of aneurysm. At follow-up, angiographic results were dichotomized into presence or absence of recurrence. The relationship between aneurysm volume to fill, packing, and angiographic recurrence was determined by multivariable logistic regression.

RESULTS

Follow-up angiography (mean follow-up 8.8 months) revealed recurrence in 14.5% of the aneurysms studied in our series. Recurrent aneurysms had a mean packing of 15.1% while stable aneurysms (non-recurrent) had a mean packing of 23.7%. Multivariable logistic regression analysis showed that aneurysm volume and packing were significantly associated with angiographic recurrence. Large volume aneurysms (>600 mm(3)) were found to have a higher incidence of recurrence than those with small volumes (OR=30.49, p<0.001). Compared with those with high packing (≥20%), the less packed aneurysms (<20%) had a higher incidence of recurrence (OR=29.01, p=0.002). There was no significant difference between aneurysm location, clinical presentation, stent assistance, duration of follow-up, and recurrence.

CONCLUSIONS

Coiling large volume (>600 mm(3)) intracranial aneurysms are more likely to have a recurrence than small ones. High packing (≥20%) provides better protection against recurrence of the aneurysm.

Safety and efficacy of endovascular treatment of basilar tip aneurysms by coiling with and without stent assistance: a review of 235 cases

BACKGROUND

Endovascular therapy is now the preferred treatment option for basilar tip aneurysms (BTAs).

OBJECTIVE

To compare the safety and efficacy of common endovascular techniques in the treatment of BTAs.

METHODS

A retrospective review was conducted of 235 patients with BTAs treated with endovascular means in our institution between 2004 and 2011. Categorization was based on the presence and type of stent assistance (none, single, and Y stenting). The rates of perioperative complications, recanalization, rehemorrhage, and retreatment were analyzed.

RESULTS

A total of 147 patients were treated with coil embolization and 88 patients with stent-assisted coiling (72 single stents, 16 Y stents). Thromboembolic complications occurred in 6.8% of patients in both groups. There was no associated mortality. Angiographic follow-up (mean, 23.5 months) was available in 172 patients (77.1%). Stented patients had significantly lower recanalization (17.2% vs 38.9%; P=.003) and retreatment (7.8% vs 27.8%; P=.002) rates compared with nonstented patients. Four rehemorrhages (2.7%) occurred in the coiled group, whereas none were noted in the stented group (P=.3). In paired comparisons, lower recanalization (8.3% vs 19.2%; P=.21) and retreatment (0% vs 9.6%; P=.19) rates were seen in the Y-stent group compared with the single-stent group. Thromboembolic complications occurred in 6.9% and 6.2% of patients in the single-stent and Y-stent groups, respectively (P=.91). In multivariate analysis, larger aneurysms, nonstented aneurysms, incomplete initial occlusion, and subarachnoid hemorrhage were predictors of aneurysm recanalization.

CONCLUSION

Stent-assisted coiling has significantly lower recurrence, retreatment, and rehemorrhage rates than coiling alone for the treatment of BTAs. Y stenting has the highest efficacy with low complication rates.

Review of 2 decades of aneurysm-recurrence literature, part 1: reducing recurrence after endovascular coiling

SUMMARY

Angiographic recurrence following endovascular therapy is an indirect measure of the potential for hemorrhage. Because patients and physicians consider recurrence to be a suboptimal outcome with some chance of future hemorrhage, much effort has been expended to reduce the incidence of recurrence. The literature regarding aneurysm recurrence following endovascular therapy, spanning 2 decades, is extensive. We will review and summarize the effort to reduce recurrence following endovascular treatment of cerebral aneurysms.

Superior hypophyseal artery aneurysms have the lowest recurrence rate with endovascular therapy

BACKGROUND AND PURPOSE

Given the challenges posed by surgical clipping, endovascular techniques have been increasingly used to treat SHA aneurysms. The purpose of this study was to assess the safety and efficacy of endovascular techniques in the treatment of SHA aneurysms.

MATERIALS AND METHODS

Medical charts and initial and follow-up angiograms were reviewed retrospectively for all patients treated with endovascular procedures at our institution between January 2006 and February 2011.

RESULTS

We identified 87 patients with SHA aneurysms who were treated with endovascular techniques. Of these patients, 79 were women and only 8 were men (90.8% female predominance). Thirty-five patients were treated with coil embolization; 45, with stent-assisted coiling; 4, with balloon-assisted coil embolization; and 3, with a flow-diversion technique. Minor complications occurred in 2 patients (2.2%). None of the patients had a major complication. The mortality and permanent morbidity rates related to the procedure were 0%. Imaging follow-up was available for 89.4% of patients (DSA in 65, MRA in 11 patients) at a mean time point of 10.4 months (range, 6-60 months). Of the 76 patients with available follow-up, 3 patients had a recurrence (3.9%) and only 1 required further intervention (1.3%). Stent-assisted coiling was associated with lower recurrence rates than simple coil embolization.

CONCLUSIONS

SHA aneurysms have the lowest recurrence rate with endovascular treatment compared with aneurysms in other locations by using historical data. Because of its safety and efficacy, endovascular therapy should be considered the procedure of choice for the treatment of SHA aneurysms.

Complex basilar artery aneurysms treated using surgical basilar occlusion: a modern case series

Object

Complex aneurysms of the basilar artery (BA) apex can be successfully treated using surgical occlusion of the proximal BA. Since the introduction of the Guglielmi detachable coil in 1991, the focus on treating BA aneurysms has been on using endovascular techniques. Outcomes with endovascular techniques have been less than optimal for large and complex aneurysms. The authors therefore report on their current 22-year experience with surgical BA occlusion for complex BA aneurysms and long-term outcome.

Methods

Fifteen patients underwent surgical BA occlusion at Columbia University Medical Center for complex basilar apex aneurysms between 1987 and 2009. The clinical records of each patient were reviewed for details of presentation, hospital course, operative intervention, and outcome.

Results

Postoperatively, all patient encounters were recorded at discharge, at the 1-month and 1-year follow-up evaluations, and at long-term outcome. Twelve (80%) of 15 patients experienced no new postoperative neurological deficits. Three patients presenting with severe neurological impairment (modified Rankin Scale [mRS] score > 3) made excellent recoveries (mRS Scores 1–2) at long-term follow-up. One patient died, 1 suffered a stroke during the postoperative angiogram which resulted in hemiparesis, and 1 suffered internuclear ophthalmoplegia which resolved by the 1-month follow-up. Long-term follow-up occurred at an average of 3 ± 4.5 years, ranging from 2 months (for a recently treated patient) to 18 years. The average mRS score at long-term follow-up was 1 ± 1.5. No patient experienced postoperative hemorrhage, rebleeding, or delayed neurological deterioration.

Conclusions

Surgical occlusion of the BA is an effective treatment option offering a high rate of angiographic cure in a single procedure for patients with complex BA aneurysms. The ability to surgically perform point occlusion of the BA without impairment of brainstem perforators, while maintaining collateral blood flow to the posterior circulation branch vessels, may provide an advantage compared with endovascular treatments.

Cardiac standstill for cerebral aneurysms in 103 patients: an update on the experience at the Barrow Neurological Institute. Clinical article

OBJECT

The aim of this study was to clarify the surgical indications, risks, and long-term clinical outcomes associated with the use of deep hypothermic circulatory arrest for the surgical treatment of intracranial aneurysms.

METHODS

The authors retrospectively reviewed 105 deep hypothermic circulatory arrest procedures performed in 103 patients (64 females and 39 males, with a mean age of 44.8 years) to treat 104 separate aneurysms. Patients' clinical histories, radiographs, and operative reports were evaluated. There were 97 posterior circulation aneurysms: at the basilar apex in 60 patients, midbasilar artery in 21, vertebrobasilar junction in 11, superior cerebellar artery in 4, and posterior cerebral artery in 1. Seven patients harbored anterior circulation aneurysms. Two additional patients harbored nonaneurysmal lesions.

RESULTS

Perioperatively, 14 patients (14%) died. Five patients (5%) were lost to late follow-up. At a mean long-term follow-up of 9.7 years, 65 patients (63%) had the same or a better status after surgical intervention, 10 (10%) were worse, and 9 (9%) had died. There were 19 cases (18%) of permanent or severe complications. The combined rate of permanent treatment-related morbidity and mortality was 32%. The mean late follow-up Glasgow Outcome Scale score was 4, and the annual hemorrhage rate after microsurgical clipping during cardiac standstill was 0.5%/year. Ninety-two percent of patients required no further treatment of their aneurysm at the long-term follow-up.

CONCLUSIONS

Cardiac standstill remains an important treatment option for a small subset of complex and giant posterior circulation aneurysms. Compared with the natural history of the disease, the risk associated with this procedure is acceptable.

Defining the risk of retreatment for aneurysm recurrence or residual after initial treatment by endovascular coiling: a multicenter study

OBJECTIVE

Endovascular treatment of intracranial aneurysms is less invasive than surgical repair but poses a higher risk for aneurysm recurrence, which may necessitate retreatment, thus adding to the long-term risk. Cerebrovascular neurosurgeons from 8 institutions in the United States and Puerto Rico collaborated to assess the risk of retreatment for residual or recurrent aneurysms after the initial endovascular coiling.

METHODS

Data were prospectively recorded for 311 patients with coiled intracranial aneurysms who underwent 352 retreatment procedures after angiographic or clinical recurrence (hemorrhage after initial coiling). Results analyzed included procedural complications and procedure-related morbidity. Morbidity was classified as major (modified Rankin scale score > 3) or minor, and temporary (<30 days) or permanent (>30 days).

RESULTS

Retreatment mortality was 0.85% per procedure and 0.96% per patient. Treatment-related rates were 0.32% per patient (0.28% per procedure) for permanent or temporary major disability; 1.29% for permanent minor disability (1.14% per procedure); and 1.61% for temporary minor disability (1.42% per procedure). Total risk for death or permanent major disability was 1.28% per patient and 1.13% per procedure.

CONCLUSION

Retreatment poses a low risk for patients with recurrences of intracranial aneurysms after initial coiling; this risk is smaller than that posed by the initial endovascular therapy. The risk of disability associated with retreatment for aneurysm recurrence after coiling must be considered prospectively in the choice of treatment but with the recognition that its effects are low in the overall management risk.

Y-configured Stent with a Double Microcatheter Technique for Ruptured Complex Basilar Tip Aneurysm. A Case Report

A 79-year-old woman had a sudden onset severe headache and became somnolent. On the first day in the hospital, diagnostic cerebral angiography revealed a small broad-necked basilar tip aneurysm with a bleb near the neck. Due to the unfavorable configuration of aneurysm, we decided to use a Y-configured stent with a double microcatheter technique. Although procedural rupture on the bleb near the neck occurred, perioperative neurological state was not changed and her clinical course was uneventful. Because of the stent, complete packing of the aneurysm was possible, hemodynamic stress at the inflow area was reduced and consequently the chance of rebleeding may decrease. Stenting with a double microcatheter technique can be an effective treatment for highly complex intracranial aneurysms.

Coiling of intracranial aneurysms: a systematic review on initial occlusion and reopening and retreatment rates

BACKGROUND AND PURPOSE

The proportion of incompletely occluded aneurysms after coiling varies widely between studies. To assess overall outcome of coiling, we systematically reviewed the literature to determine initial occlusion, reopening, and retreatment rates of coiled aneurysms according to predefined criteria and subgroups.

METHODS

We searched PubMed and EMBASE (January 1999 to September 2008) for studies of >50 coiled aneurysms. Two reviewers independently extracted data. We grouped studies reporting on only ruptured aneurysms, posterior circulation aneurysms, and studies with large proportions of aneurysms >10 mm to assess possible determinants for incomplete occlusion, reopening, and retreatment.

RESULTS

Forty-six studies totalling 8161 coiled aneurysms met inclusion criteria. Immediately after coiling, 91.2% (95% CI, 90.6% to 91.9%) of the aneurysms were adequately occluded. Aneurysm reopening occurred in 20.8% (95% CI, 19.8% to 21.9%) and retreatment was performed in 10.3% (95% CI, 9.5% to 11.0%). Reopening rate was lower in studies reporting on ruptured aneurysms only compared with all studies (11.4% versus 20.8%; relative risk, 0.55; 95% CI, 0.47 to 0.64) and higher in studies focusing on posterior circulation aneurysms compared with studies with >85% anterior circulation aneurysms (22.5% versus 15.5%; relative risk, 1.5; 95% CI,1.2 to 1.7). Regression analysis showed higher retreatment rates with increasing proportion of aneurysms >10 mm (beta=0.252; 95% CI, 0.073 to 0.432). We could not find a relation between reopening and type of coils used.

CONCLUSIONS

At follow-up, one fifth of all coiled intracranial aneurysms shows reopening of which half is retreated. Possible risk factors for aneurysm reopening are location in the posterior circulation and size >10 mm. To confirm our findings, a meta-analysis on individual well-reported patient data is desirable.

Analysis of clinical and radiological outcomes in microsurgical and endovascular treatment of basilar apex aneurysms

OBJECTIVE

We aimed to analyze clinical and radiological outcomes retrospectively in patients with basilar apex aneurysms treated by coiling or clipping.

METHODS

Outcomes of basilar bifurcation aneurysms were assessed retrospectively in 77 consecutive patients (61 women, 16 men), ranging in age from 25 to 79 years (mean, 53.7 years) from 1999 to 2007.

RESULTS

Forty-nine patients out of 77 patients (63.6%) presented with subarachnoid hemorrhages of the 49 patients treated with coiling, 27 (55.1%) showed complete occlusion of the aneurysm sac. Of these, 13 patients (26.5%) developed coil compaction on angiographic or MRI follow-up, with recoiling required in 9 patients (18.4%). Procedural complications of coiling were acute infarction in nine patients and the bleeding of the aneurysms in six patients. The remaining 28 patients underwent microsurgery: twenty-six of these (92.9%) with microsurgery followed up with conventional angiography. Complete occlusion of the aneurysm sac was achieved in 19 patients (73.1%). Operation-related complications of microsurgery were thalamoperforating artery injuries in three patients, retraction venous injury in two, postoperative epidural hemorrhage (EDH) in one, and transient partial or complete occulomotor palsy in 14 patients. Glasgow Outcome Scores (GOS) were 4 or 5 in 21 of 28 (75%) patients treated with microsurgery at discharge, and at 6 month follow-up, 20 of 28 (70.9%) maintained the same GOS. In comparison, GOS of four or 5 was observed in 36 of 49 (73.5%) patients treated with coiling at discharge and at 6 month follow-up, 33 of 49 patients (67.3%) maintained the GOS from discharge.

CONCLUSION

Basilar top aneurysms were still challenging lesions based on our series. Endovascular or microsurgery endowed with its inborn risks and procedural complications for the treatment of basilar apex aneurysms individually. Microsurgery provided better outcome in some specific basilar apex aneurysms. For reaching the most favorable outcome, endovascular modality as well as microsurgery was inevitably considered for each specific basilar apex aneurysm.

Subtemporal approach to basilar tip aneurysm with division of posterior communicating artery: technical note

The subtemporal approach with division of the posterior communicating artery (PcomA) is described for treating aneurysms of the basilar tip. When the ipsilateral posterior cerebral artery (PCA) interferes with visibility and manipulation around the aneurysm neck and the artery is tethered by the PcomA and not mobilized, the PcomA can be divided near the junction with the PCA. The procedure permits PCA mobilization and exposes the neck of the aneurysm. We applied this procedure to a patient with a ruptured aneurysm of the basilar tip. The postoperative course was uneventful except for transient left oculomotor nerve palsy. Postoperative cerebral angiography and magnetic resonance imaging confirmed the respective disappearance of the aneurysm and no new ischemic lesions. The subtemporal approach allows safer and easier division of the PcomA near the junction to the PCA compared with the pterional approach, and the present procedure is more suitable for the subtemporal approach.

Internal Carotid Bifurcation Aneurysms: Anatomical Features and Outcome of Endovascular Treatment

This study reports the anatomical presentation of internal carotid bifurcation aneurysms and the angiographic results of their endovascular treatment. We treated 17 patients with internal carotid bifurcation aneurysms by endovascular treatment using detachable coils. Follow-ups were conducted for three to 30 months. The pre- and postprocedural anatomical features of the aneurysms, procedural complications, and postprocedural angiographic outcomes were evaluated. The aneurysmal necks were located just above the internal carotid artery bifurcation or at the origins of anterior cerebral artery or the middle cerebral artery. Immediate angiography demonstrated complete occlusion, neck remnant, or residual aneurysms. Post-treatment, two aneurysms that were initially residual spontaneously progressed to complete occlusion, and two large aneurysms that initially demonstrated complete occlusion or neck remnants showed coil compaction and recanalization. Procedural complications occurred in two cases. Endovascular treatment is effective for ruptured and unruptured carotid terminal aneurysms with various anatomical features.

Plical resection in pre-temporal approach for basilar bifurcation aneurysms: preliminary surgical experience and cadaveric study

OBJECT

Although a pre-temporal approach (PA) can provide a wide space for preservation of thalamoperforating atrteries in direct surgery for basilar bifurcation aneurysms (BBAs), it cannot always secure adequate proximal control. The authors described the advantages of plical resection added to PA for BBAs.

METHODS

Between October 1998 and April 2000, eight consecutive patients with BBAs were treated in the neurosurgical department of Kurashiki Central Hospital. Among them, five patients received direct clipping using this method. There were four females and one male, ages ranging from 61 to 77 (mean 70.8 years). Mean aneurysmal size and distance between the in"terclinoidal line and the aneurysmal neck was 4.5 and 9.5 mm, respectively. The operative procedures consisted of the following components; 1) fronto-temporal craniotomy with translocation of orbito-zygomatico-malar bone for PA, 2) preservation of lateral branches of the superficial sylvian veins, 3) resection of plica dural folds to increase the operative field up to the oculomotor nerve (OMN).

RESULTS

Complete clipping was achieved without thalamic infarction or temporal contusion in all patients. Three of the five patients suffered from transient right OMN palsy which recovered within two months after surgery.

CONCLUSION

Plical resection in the pre-temporal approach might be beneficial in the surgical treatment of BBAs when proximal control seems difficult.

Endovascular treatment of basilar and ICA termination aneurysms: effects of the use of HydroCoils on treatment stability in a subgroup of patients prone to a higher recurrence rate

PURPOSE

The aim of this study was to evaluate the stability of occlusion of terminal bifurcation aneurysms after embolization with hydrogel-coated coils.

METHODS

Of 35 bifurcation aneurysms, 34 were treated with hydrogel-coated coils in combination with platinum coils, and 1 was treated with hydrogel-coated coils only. Aneurysms were located at the basilar tip in 17 patients, and the internal carotid artery (ICA) bifurcation in 18 patients. The patient population consisted of 20 women and 15 men with ages ranging from 21 to 65 years. The aneurysm was found in 16 patients on presentation for subarachnoid hemorrhage, and in 19 patients the finding was incidental. Of the 35 aneurysms, 25 were small, 9 were large and 1 was giant. The giant aneurysm was located at the basilar tip and showed partial thrombosis. All except two basilar tip aneurysms were treated with balloon assistance. The remaining two basilar tip aneurysms were embolized with the assistance of an aneurysmal neck bridge device.

RESULTS

The mean percentage occluded aneurysm volume for all devices was in the range 34-100%. Follow-up angiograms were obtained at 1 year in 6 patients, 2 years in 11 patients, and 3 years in 18 patients. Angiograms obtained immediately after embolization demonstrated a Raymond class 1 occlusion in 29 patients (82.9%) and a Raymond class 2 occlusion in 6 patients (17.1%). In four of these six patients follow-up angiograms demonstrated regrowth with resultant Raymond class 3 occlusion. In the other two patients, Raymond class 2 occlusion remained stable on follow-up angiograms. In patients who had a Raymond class 1 occlusion on the angiogram obtained immediately after embolization, no regrowth was seen on the follow-up angiograms. The overall recanalization rate was 11.4% (three large, one giant) at 6 months. Retreatment was not considered in three of these patients and they were to be followed; the other patient was retreated.

CONCLUSION

Our initial procedural data demonstrate that higher volumetric occlusion was achieved with hydrogel-coated coils and the long-term follow-up results showed a favorably low recanalization rates among the terminal bifurcation aneurysms.

RESULTS OF MICROSURGICAL CLIPPING OF 50 HIGH COMPLEXITY BASILARAPEX ANEURYSMS

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Periprocedural morbidity and mortality by endovascular treatment of cerebral aneurysms with GDC: a retrospective 12-year experience of a single center

Despite increasing experience and improved material, endovascular treatment of cerebral aneurysms still has risks linked to the technique itself and to the specificity of the pathology treated. The purpose of this report is to examine procedural technical and clinical negative events, even minimal ones, occurring in this type of treatment. We considered 557 procedures carried out from January 1994 to December 2005 in 533 patients harboring 550 aneurysms. Of the patients, 448 presented with SAH and 85 with unruptured aneurysms. All procedures were performed under general anesthesia. The GDC-10 system was routinely used. Additional devices like the balloon remodeling technique, Trispan and stents were also occasionally used. Every procedural complication occurring during or soon after treatment was registered. Endovascular treatment was completed in 539 out of 557 procedures. There were 18 failures (3.3%). Occlusion of the aneurysm was judged complete in 343 (64%), near complete in 184 (34%) and incomplete in 12 (2%). Procedural complications occurred in 72 (13%) of the cases. The most frequent negative events were thromboembolisms (6.6%) and ruptures (3.9%). Other types (coil migration, transient occlusions of the parent vessel, dissections and early rebleeding) were rarer (2.5%). In the majority of cases there were no clinical consequences. Procedural morbidity and mortality were 1.1 and 1.8%, respectively. Considering the 449 procedures performed in ruptured and the 90 in the unruptured aneurysms separately, morbidity and mortality were 1.1 and 2.2% in the former group and 1.1 and 0% in the latter. Many factors influence the risk of complications. Being progressively aware of this and with increasing experience, the frequency can be limited. Negative events linked to the procedure have more significant serious clinical consequences in patients admitted in a critical clinical condition after SAH, because of the already present changes involving the brain parenchyma and cerebral circulation.

Ruptured Intracranial Aneurysms—Clinical Aspects of Subarachnoid Hemorrhage Management and the International Subarachnoid Aneurysm Trial

The last 14 years has seen a revolution in the management of intracranial aneurysms; endovascular coil treatment has moved from a minority marginal treatment applicable to a few patients in a few centers to become the mainstay of treatment of ruptured intracranial aneurysms. This article highlights new information learned from the International Subarachnoid Aneurysm Trial.