Utility of catheter-assisted Guglielmi detachable coiling in the treatment of wide-necked aneurysms

Stent-assisted Coil Placement for the Treatment of 211 Acutely Ruptured Wide-necked Intracranial Aneurysms: A Single-Center 11-Year Experience

PURPOSE

To evaluate the safety and angiographic and clinical outcome of stent-assisted coil placement (SACP) for acutely ruptured wide-necked intracranial aneurysms treated in a single center during an 11-year period.

MATERIALS AND METHODS

According to an institutional review board-approved protocol, the angiographic and clinical data of 211 patients (52 men, 159 women; median age, 56 years; age range, 31-83 years) with acutely ruptured wide-necked intracranial aneurysms (neck > 4 mm and/or dome-to-neck ratio ≤ 2) treated with SACP from September 2000 to December 2011 were reviewed retrospectively. Baseline characteristics, procedure-related complications, angiographic follow-up results, and clinical outcome were analyzed statistically. A Mann-Whitney U test was performed for non-normally distributed continuous variables. A Pearson χ(2) or Fisher exact test was performed for categorical variables. Univariate analysis and logistic regression analysis were performed to determine the association of procedure-related complications and clinical outcome with potential risk factors.

RESULTS

Procedure-related complications occurred in 30 patients (14.2%). They were more common in the anterior communicating artery (26.7%, 12 of 45) and middle cerebral artery bifurcation (40%, four of 10) aneurysms than in aneurysms at other locations (9.0%, 14 of 156). Clinical outcome (median, 33 months) was good in 175 patients (82.9%) with a modified Rankin Scale score of up to 2. Older age (P = .013, odds ratio = 1.054) and higher Hunt and Hess grade (P < .001, odds ratio = 15.876) were independent risk factors for unfavorable outcome. One hundred fifty-two of 190 patients who survived (80%) underwent angiographic follow-up at least once (median, 12 months). The complete occlusion rate improved from an immediate 45.5% to 75.7% at follow-up (115 of 152 patients).

CONCLUSION

Angiographic and clinical outcomes in our series were comparable to those reported by using coil placement alone or balloon-assisted coil placement techniques. SACP for the treatment of acutely ruptured middle cerebral artery bifurcation and anterior communicating artery aneurysms was associated with a significantly higher incidence of complications than was the case for treatment of aneurysms at other locations.

Coil-protected embolization technique for a branch-incorporated aneurysm

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Coil embolization of unruptured middle cerebral artery aneurysms

BACKGROUND

Since the International Subarachnoid Aneurysmal Trial, endovascular coiling has been increasingly used as primary treatment option for ruptured or unruptured aneurysms that are feasible for coiling.

OBJECTIVE

To evaluate the feasibility and clinical and angiographic outcomes of coiling for unruptured middle cerebral artery aneurysms.

METHODS

The records of 70 consecutive patients with 76 unruptured middle cerebral artery aneurysms who underwent coiling were retrospectively evaluated.

RESULTS

Thirty-one aneurysms were treated by single-catheter, 18 by multicatheter, 11 by balloon-assisted, 13 by stent-assisted, and 3 by a combination of multicatheter and balloon-assisted techniques. Coiling was accomplished in 75 but failed in 1 aneurysm. One patient died of consequences of subarachnoid hemorrhage occurring 9 hours after coiling. One intraprocedural aneurysm rupture occurred, which was controlled by further coil insertions and left no sequelae. There were 1 cortical infarction and 1 basal ganglia infarction, both of which recovered completely. Treatment-related permanent morbidity and mortality rates were 0% and 1.4%, respectively. Postembolization control angiography revealed 40 complete, 30 neck remnant, and 5 incomplete occlusions. Clinical follow-up was available in all patients (mean, 25 months; range, 7-105 months). There was no subarachnoid hemorrhage during follow-up, but 1 death resulting from acute myocardial infarction occurred 3 months after coiling. None of the surviving patients had any neurological deterioration. Follow-up angiography was available in 69 aneurysms at 6 to 24 months (mean, 12 months). Three major and 6 minor recurrences were detected. All 3 major recurrent aneurysms were re-treated by coiling without any complications.

CONCLUSION

Most unruptured middle cerebral artery aneurysms could be safely treated by coiling with acceptable short-term to midterm outcomes. Our results warrant further study with a longer follow-up period in a larger population.

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

BACKGROUND AND PURPOSE

The microcatheter protective technique positions an additional microcatheter in the parent or side-branching artery to protect it during coil embolization. The purpose of this study was to describe this method and to evaluate its efficacy and safety as an alternative to a multiple-microcatheter or balloon- or stent-assisted technique for wide-neck aneurysms.

MATERIALS AND METHODS

A retrospective review of 74 patients (43 women; mean age, 59.6 years) with 75 wide-neck aneurysms treated with the microcatheter protective technique between January 2003 and April 2010 was performed. Immediate postembolization angiograms were evaluated by using a conventional angiographic scale, and clinical evaluation was performed by using the GOS. Clinical and imaging follow-up were available in 57 (76%) patients, with a mean of 14.7 months.

RESULTS

Postembolization angiograms demonstrated total occlusion in 45 of 75 (60%) aneurysms, a neck remnant in 17 (22.7%), and body filling in 13 (17.3%). The technique-related complication rate was 17.4% (13/75), and the procedural-related morbidity rate was 1.3% (1/74). All patients, except 3 complicated cases with a GOS of <4, had a GOS of 5 at the end of the study period. Of the 57 aneurysms with follow-up, recanalization developed in 5 (8.8%) aneurysms, and 3 (5.3%) cases of major recanalization were re-treated endovascularly.

CONCLUSIONS

The microcatheter protective technique is feasible and safe for coil embolization of wide-neck aneurysms, especially in cases that are not suitable for multiple catheter or balloon- or stent-assisted techniques.

A versatile method for treating intracranial wide-neck aneurysms: catheter-assisted technique of three variations

Successful management of aneurysms of complex morphology depends primarily on adjunct use of balloons or stents. However, these two methods are technically demanding and have higher complication rates. As an alternative to these two techniques, we have used a catheter-assisted technique with a number of cases. It is simple, versatile, and less demanding technically. This technique should be considered as an alternative strategy in cases of wide-necked aneurysms.

A surgical case of delayed coil migration after balloon-assisted embolization of an intracranial broad-neck aneurysm: case report

BACKGROUND AND IMPORTANCE

Balloon-assisted coil placement is an important technique for coil embolization of broad-neck aneurysms. With this technique, we can prevent coil migration into a parent artery during a procedure. Complications of intraprocedural coil migration have been reported in the literature. However, delayed coil migration is extremely rare. We present a case of delayed coil migration after balloon-assisted coil embolization and describe our management of this complication.

CLINICAL PRESENTATION

A 59-year-old man presented with hypertension and a tension headache. Clinical evaluation incidentally discovered an unruptured broad-neck aneurysm at the left internal carotid bifurcation. Endovascular embolization of the aneurysm was performed with a balloon-assisted technique. The patient had a transient ischemic attack, and a skull radiograph showed coil migration 3 months after the procedure. We performed an operation to remove the coils and to clip the aneurysm with superficial temporal artery and middle cerebral artery bypass. The patient was discharged without neurological deficit.

CONCLUSION

This is a rare case in which delayed coil migration into the parent artery occurred after balloon-assisted coil embolization, highlighting the importance of surgical management of delayed coil migration.

Is Clopidogrel Premedication Useful to Reduce Thromboembolic Events During Coil Embolization for Unruptured Intracranial Aneurysms?

BACKGROUND:

Thromboembolism is a common complication related to coil embolization of intracranial aneurysms.

OBJECTIVE:

To identify factors related to thromboembolic events during coil embolization for unruptured intracranial aneurysms and to evaluate the role of clopidogrel premedication to prevent thromboembolisms.

METHODS:

Since March 2006, clopidogrel has been administered to patients with unruptured aneurysms before coil embolization (the clopidogrel group) in our institution. The clopidogrel group (416 patients with 485 aneurysms) and the historical control group (140 patients with 159 aneurysms who received no antiplatelet premedication) were compared to find the efficacy of clopidogrel premedication. Various factors, including age, sex, body weight, and medical history of hypertension, diabetes mellitus, hyperlipidemia, smoking, previous stroke, and heart disease, as well as clopidogrel premedication, were analyzed in relationship to the development of a procedure-related thromboembolism.

RESULTS:

Procedure-related thromboembolic events tended to occur less frequently in the clopidogrel group compared with the control group (7.4% vs 12.6%; P = .05), and clopidogrel premedication could modify the risk in female patients from 11.1% to 5.2% (P = .04). The use of multiple logistic regression analysis identified clopidogrel premedication (P = .03), smoking (P = .002), and hyperlipidemia (P = .02) as significant factors related to the formation of thromboembolism.

CONCLUSION:

Clopidogrel premedication seems to have a beneficial effect in reducing the number of procedure-related thromboembolisms during coil embolization for unruptured intracranial aneurysms, especially in female patients. Smoking and hyperlipidemia were independent risk factors related to thromboembolism.

Endovascular coil embolization of aneurysms with a branch incorporated into the sac

BACKGROUND AND PURPOSE

Because of the concern for occlusion of the incorporated branch artery, an aneurysm with a branch incorporated into the sac has been regarded as a contraindication for coiling. The aim of this study is to evaluate the feasibility, techniques, and clinical and angiographic outcomes of coiling for aneurysms with a branch incorporated into the sac.

MATERIALS AND METHODS

The medical records and radiologic studies of 69 patients with 79 aneurysms having a branch incorporated into the sac (26 ruptured, 53 unruptured) were retrospectively reviewed and evaluated.

RESULTS

Coiling was accomplished in 78 aneurysms in 68 patients but was suspended in 1 due to incorporated branch occlusion. The aneurysms were treated by using the following techniques: single-catheter (n = 37), multicatheter (n = 22), balloon-remodeling (n = 7), stent-assisted coiling (n = 6), and combined (n = 7). Postembolization angiography revealed the following: near-complete occlusion in 71 (89.8%), remnant neck in 4 (5.1%), and incomplete occlusion in 4 (5.1%) aneurysms. Procedure-related permanent morbidity and mortality rates were 5.8% (4/69) and 0%, respectively. All patients with unruptured aneurysms had a modified Rankin Scale (mRS) score of 0, except for 1 patient who had an mRS score of 3. Of the 26 patients with ruptured aneurysms, 18 had favorable outcome (mRS 0-2) but 8 had poor outcome (mRS 3-6). Follow-up angiography was available at least once at 6-50 months (mean, 15 months) in 55 aneurysms (69.6%), of which 45 showed stable or improved occlusion; 4, minor recurrences; and 6, major recurrences. All 6 major recurrent aneurysms were retreated without complication by using a single-catheter (n = 1), multicatheter (n = 2), or balloon-assisted technique (n = 3).

CONCLUSIONS

With appropriate techniques, most aneurysms with a branch incorporated into the sac could be safely treated by coiling, with acceptable outcomes.