Intracranial aneurysms: endovascular treatment with mechanical detachable spirals in 60 aneurysms

“Corrosion” of Tungsten Spirals. A Disturbing Finding

Very long-term (more than 30 months after treatment) skull plain films of patients treated with Mechanical Detachable Spirals “MDS” (tungsten) for intracranial aneurysm or dural fistula by venous approach, showed a decreasing level of radiopacity of the spirals suggesting that this material was resorbing with time. To date, all the aneurysms selectively treated with “MDS” which were followed-up by angiography more than 30 months after treatment (three cases) showed recanalization. The recanalization was proportional to degree of the “corrosion”.

Alternative Detachment Technique for Electrically Detachable Coils: Rescue From an Unintended Complication

BACKGROUND

Embolization of intracranial aneurysms with the use of detachable coils has become the most widely used therapy for this condition. However, unexpected device failure can lead to critical complications.

OBJECTIVE

To describe an alternative detachment technique for various electrically detachable coils (eg, Target of Stryker Neurovascular, Presidio and Microphere of Codman Neurovascular, and MicroPlex and Hydrocoil of MicroVention Terumo) that can be used when standard troubleshooting techniques are not effective and the physician is not able to remove a coil.

METHODS

The alternative detachment method involved the restoration of the current pathway with the use of an alligator clip wire and the distal end of a new coil delivery wire of the same type. The detachment mechanism used in this method is the same as that normally used for each system.

RESULTS

We found that this alternative maneuver was both feasible and reproducible. Moreover, an electrically detachable coil was successfully detached with the use of this method, especially when detachment failure was the result of distal delivery wire and connector damage. No additional complications were noted.

CONCLUSION

An alternative detachment technique involving the reconstruction of the electric circuit could be a safe method of rescue in the potentially risky situation caused by detachment failure during embolization of cerebral aneurysms with electrically detachable coils.

Clinical and radiologic results of endovascular coil embolization for cerebral aneurysm in young patients

Purpose

This study is an overview of the clinical and radiologic outcomes of endovascular coil embolization for cerebral aneurysm in patients aged 40 years and younger.

Materials and Methods

Between January 2008 and June 2011, 218 aneurysms were treated using endovascular coil embolization and followed up with cerebral angiography at least six months later. Twenty-one aneurysms occurred in patients aged 40 years and younger, while 197 occurred in 179 patients older than 40 years. The clinical and radiologic results were retrospectively analyzed and compared between the two groups using the modified Rankin scale scores and the modified Raymond scale.

Results

Follow-up cerebral angiography revealed two (9.5%) major and two (9.5%) minor recanalized aneurysms in patients aged 40 years and younger, and six (3.0%) major and 35 (17.7%) minor recanalized aneurysms in patients older than 40 years. However, the differences between the groups were not statistically significant. The preoperative and postoperative mean modified Rankin scale scores at time for follow-up angiography were 1.14 and 0.19 respectively for patients aged 40 years and younger, and 1.30 and 0.30 respectively for patients older than 40 years.

Conclusion

The younger patients had clinically favorable outcomes with tolerable angiographic follow-up results. More regular and long-term imaging follow-up is required for younger patients due to their longer life expectancy.

Endovascular management of intracranial aneurysms

Data from our clinical series and others supports the idea that endovascular coil embolization is a reliable form of treatment for both ruptured and unruptured cerebral aneurysms. This form of treatment appears from preliminary data to be protective against subarachnoid hemorrhage. Although not likely to replace open surgery, the continued advancements in technology and supportive clinical data will allow endovascular therapy to become a more durable mode of treatment.

Long-term follow-up of 1036 cerebral aneurysms treated by bare coils: a multicentric cohort treated between 1998 and 2003

BACKGROUND AND PURPOSE

The endovascular treatment (EVT) of cerebral aneurysms has experienced a revolution since 1991 with the introduction of platinum coil technology. During the past 10 years, there has been significant study of the feasibility of this technique, and clinical results of EVT have been published. The long-term durability of Guglielmi detachable coil (GDC) embolization of cerebral aneurysms still remains unknown. The purpose of this study was to evaluate the stability of anatomic occlusion of aneurysms and to assess the rate of recanalization and retreatment of these aneurysms.

MATERIALS AND METHODS

Between January 1998 and December 2003, 1036 aneurysms (804 ruptured and 232 nonruptured) were treated consecutively with GDC coils in 5 neuroradiology centers. Procedural feasibility, acute angiographic occlusion results, morbidity, and mortality associated with this technique were assessed. All patients were regularly followed by digital subtraction angiography and MR imaging each year after treatment.

RESULTS

Initial acute angiographic results in 1036 aneurysms demonstrated total occlusion in 731 patients (70.5%), subtotal occlusion in 252 (24.3%), incomplete occlusion in 20 (1.9%), and failures in 33% (3.3%) aneurysms. A remodeling technique was used in 10%. A second procedure was performed for 72 aneurysms (7%). The total aneurysm follow-up time was 49,923 months (4160.25 aneurysm-years). The retreatment period was either in the months following initial treatment in aneurysms incompletely occluded or in years due to recanalization or de novo aneurysms. Fewer than 5 patients rebled during 10 years of follow-up. Long-term follow-up angiograms were obtained in 899 aneurysms, with 646 total, 230 subtotal, and 23 incomplete results.

CONCLUSIONS

Long-term follow-up of cerebral aneurysms is necessary to depict recanalization. Only 7% of the aneurysms were retreated. Use of bare coils gives a good long-term level of occlusion.

Mechanical detachment of Guglielmi detachable coils after failed electrolytic detachment: rescue from a technical complication

OBJECTIVE

We describe the mechanical detachment of 2 Guglielmi detachable coils (GDC) that had been placed in a ruptured aneurysm and that failed to detach by electrolysis.

METHODS

Mechanical detachment was attempted by continuously rotating the delivery wire. The feasibility and reproducibility of this maneuver was tested by conducting additional in vitro tests.

RESULTS

Two GDCs that had been positioned in a ruptured cerebral aneurysm and had failed to detach by electrolysis were separated from the delivery wire by rotating the wire until the weakest segment of the coils broke. GDCs tested in vitro with correct detachment positioning could be separated from the microcatheter tip by approximately 15 rotations of the delivery wire without coil loop movement inside the aneurysm.

CONCLUSION

Mechanical detachment of an electrolytic GDC by rotating the delivery wire until a break occurs can be safely performed in a potentially risky situation caused by detachment failure during GDC embolization of cerebral aneurysms.

Long-term Follow-up Angiography of Intracranial Aneurysms Treated with Cook Detachable Coil System

The long-term outcome of detachable coil embolization of cerebral aneurysms is still unknown. The purpose of this study was to evaluate the stability of the anatomic occlusion of aneurysms treated with the Cook detachable coil system and assess the rate of recanalization and recurrence. A study involving 250 patients with 271 ruptured aneurysms treated with the Cook detachable system between January 1997 and September 2003 who subsequently underwent six month, one year and two year follow-up angiography were enrolled in the study. Angiographic findings were reviewed to determine the percentage of aneurysm occlusion. Long-term follow-up angiograms (at two years) demonstrated complete occlusion in 75% of cases, and subtotal occlusion in 25% of cases. Overall morbidity was 7.3%, aneurysm recurrence 3.2%, and aneurysm re-treatment 3.2%. Recurrent subarachnoid hemorrhage occurred in only one patient. Angiographic follow-up demonstrated the stability and durability of treatment with the Cook detachable coil system.

Long-term results with Matrix coils vs. GDC: an angiographic and histopathological comparison

INTRODUCTION

The aim of the study was to compare standard platinum Guglielmi detachable coils (GDC) with coated platinum coils (Matrix; both Boston Scientific, Fremont, CA) regarding handling, complications, occlusion and recanalization rate after 3 and 6A months.

METHODS

Aneurysms in the right common carotid artery were created in 25 rabbits. The animals were divided into five groups of five animals each. The animals of group 1 (the control group) received no treatment of the induced aneurysms, the animals of groups 2 and 3 (killed at 3 and 6A months) were treated with standard GDC, and the animals of groups 4 and 5 (killed at 3 and 6A months) were treated with Matrix coils.

RESULTS

Histopathological evaluation showed organized thrombus formation and connective tissue with neovascularization around the implanted coils in all the treated groups. The achieved occlusion rates in groups 2 and 3 were identical to those in groups 4 and 5. Thus the long-term results of aneurysm treatment with GDC and Matrix coils show no differences regarding occlusion and recanalization rates. The only noticeable difference was the difference in handling. More force was required to pushing the Matrix coils forward through the microcatheter and there was more friction in coil interaction in the aneurysm.

CONCLUSION

The bioactive coating of the Matrix coil produces no significant benefit in achieving higher occlusion and lower recanalization rates, and the coil is more difficult to handle. Future bioactive coils must be shown to produce significantly better long-term results than GDC and their ease of handling has to be improved.

Endovascular therapy of distal anterior cerebral artery aneurysms-an effective treatment option

BACKGROUND

Surgical treatment of APAs is associated with relatively high morbidity and mortality. The aim of this study was to illustrate the technical achievements of endovascular procedures in the distal anterior cerebral artery area, technical difficulties and how they can be overcome, and the outcome of endovascular treatment of APAs.

METHODS

Between 1997 and 2006, of 49 patients with APAs at our institution, 29 were treated endovascularly (4.1% of all endovascularly treated aneurysms; F:M = 3.8; mean age, 52.8 +/- 11.5 years), and 12 were treated surgically. Twenty-one (72.4%) of the endovascularly treated patients had a subarachnoid hemorrhage. The mean observation period was 25 +/- 22.8 months.

RESULTS

In 27 (93.1%) cases, complete occlusion of the aneurysm was achieved. The intervention led to 5 (17.2%) cases of minor complications with no neurologic deficits: 2 thromboembolisms, 1 local thrombus, 1 occlusion, and 1 recurrent hemorrhage. Mortality related to the intervention was 3.4%. There was no morbidity associated with the elective procedures. The dome-to-neck ratio is the main predictor of reperfusion. The most important factor impairing the outcome in terms of the GOS status is the presence of an intraparenchymal hematoma, followed by thrombembolic complications.

CONCLUSION

Endovascular treatment of APAs is feasible, safe, and effective. Mortality and morbidity are comparable with surgical therapy. An intraparenchymal hematoma has a severe negative influence on the patient's condition after rehabilitation. In these cases, surgical intervention should be considered. In case of incomplete occlusion of the aneurysm, prompt reintervention is required.

Feasibility, procedural morbidity and mortality, and long-term follow-up of endovascular treatment of 321 unruptured aneurysms

BACKGROUND AND PURPOSE

The purpose of our study was to evaluate the technical feasibility, morbidity and mortality, and durability of occlusion of unruptured aneurysms treated with Guglielmi detachable coils (GDCs) with a long-term follow-up.

MATERIALS AND METHODS

Between January 1998 and January 2005, we treated 321 unruptured aneurysms with GDCs in 5 neuroradiologic institutions. During this period, 63% of unruptured aneurysms were treated by endovascular technique. Procedural feasibility, technical complications, morbidity and mortality, and acute and long-term angiographic occlusion were assessed.

RESULTS

Overall technical feasibility of coiling treatment was 94%; 302 aneurysms were treated by endovascular technique. At the end of the initial procedure, acute occlusion was classified as complete in 207 cases (70%), subtotal in 84 cases (26.1%), and incomplete in 11 cases (3.9%). Ischemic complications were observed in 28 patients (9%); 8 patients (2.6%) had perforation of their aneurysms. Treatment-related morbidity was 14.4%, and morbidity with clinical complications was evaluated at 7.7% (n = 23 patients). Five patients (1.7%) died as a result of aneurysm perforation. Final follow-up angiograms, after 9 secondary treatments, demonstrated complete occlusion in 193 patients (69.5%), subtotal in 80 aneurysms (28.5%), and incomplete occlusion in 5 (1.8%). Nineteen patients were lost to follow-up (6.3%).

CONCLUSION

Endovascular coiling with detachable coils is an attractive option for treatment of unruptured aneurysms. This method of treatment is safe with a low rate of complications. Prospective studies with longer follow-up periods are needed to assess the long-term durability of occlusion in unruptured aneurysms.

Endovascular treatment of cerebral aneurysms: a retrospective study of 163 embolized aneurysms

OBJECTIVE: To present the results of cerebral aneurysms treated by endovascular technique. METHOD: Retrospective analysis of patient files of Hospital Geral de Fortaleza, Brazil. RESULTS: We report the results of 163 cerebral aneurysms treated by endovascular techniques from January 2002 to October 2005. Patients with ruptured aneurysms (87.2%), according to Hunt-Hess scale were: 33.7% HH I, 28.4% HH II, 24.1% HH III, 13.8% HH IV. The Fisher scale grade IV was the most common (39.7%). Remodeling, coil embolization, arterial occlusion and histoacryl embolization were the techniques employed. Effective occlusion was achieved in 87.7%, partial occlusion in 5.3% and non-effective occlusion in 7.0% of the patients. Glasgow outcome scale results were: 76.3% GOS 5, 5.0% GOS 4, 5.8% GOS 3, 1.4% GOS 2 and 11.5% GOS 1. CONCLUSION: Endovascular treatment seems to be feasible within Brazilian public health system, with results as good as those obtained in larger international centers.

Endovascular management of intracranial aneurysms: current experience and future advances

OBJECTIVE

The past 15 years have seen a revolution in the treatment of intracranial aneurysms. Endovascular technology has evolved rapidly since the Food and Drug Administration approval of Guglielmi detachable coils in 1995, which now allows successful treatment of most aneurysms. The authors provide a review of their 11-year experience at Jefferson Hospital for Neuroscience with endovascular embolization of intracranial aneurysms and discuss clinical trial outcomes and future directions of this treatment method.

METHODS

The authors reviewed the clinical and angiographic outcomes for 1307 patients undergoing endovascular treatment of intracranial aneurysms. Their analysis focuses on posterior circulation and middle cerebral artery aneurysms, as well as cases of stent-assisted coil embolization. They review their procedural protocol and patient selection criteria for endovascular management.

RESULTS

Several large clinical trials have demonstrated the safety and efficacy of endovascular treatment of intracranial aneurysms. The International Subarachnoid Aneurysm Trial provides Level I evidence demonstrating a significant reduction in disability or death with endovascular treatment compared with surgical clipping. The most common procedural complications include intraprocedural rupture and thromboembolic events; avoidance strategies are also discussed. Vasospasm after subarachnoid hemorrhage causes neurological morbidity and mortality and can be successfully managed by early recognition and interventional treatment with angioplasty, pharmacologic agents, or both.

CONCLUSION

Long-term studies evaluating experience with aneurysm coil embolization during the past decade indicate that this is a safe and durable treatment method. The introduction of stent-assist techniques has improved the management of wide-neck aneurysms. Future technology developments will likely improve the durability of endovascular treatment further by delivering bioactive agents that promote aneurysm thrombosis beyond the coil mass alone. It is clear that endovascular therapy of both ruptured and unruptured aneurysms is becoming a mainstay of practice in this patient population. Although not replacing open surgery, the continued improvements have allowed aneurysms that previously were amenable only to open clip ligation to be treated safely with durable long-term outcomes.

Giant Intracranial Aneurysms: Endovascular Challenges

THE TREATMENT OF giant aneurysms remains a formidable challenge for endovascular and surgical strategies. The use of endovascular techniques in a deconstructive (e.g., parent vessel occlusion) and reconstructive (e.g., stent coiling) methodology is reviewed. The results of endovascular coiling as a primary therapy for giant aneurysm occlusion have been disappointing. Hunterian strategies have had more success in published series, but recent developments in coil, glue, and stent technology show great promise in allowing parent vessel reconstruction as a primary endovascular target, with acceptable morbidity, mortality, and durability. A literature review of giant aneurysm endovascular treatment strategies was undertaken after 1994, when Guglielmi detachable coils were approved by the Food and Drug Administration. Where possible, follow-up, durability, and occlusion rates are also reviewed.

Delayed coil migration from a small wide-necked aneurysm after stent-assisted embolization: case report and literature review

INTRODUCTION

We present a previously unreported complication following the treatment of a patient with two small, wide-necked, posterior communicating artery aneurysms.

METHODS

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.

DISCUSSION

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.

Spiral CT Angiography: Applications in Neurovascular Imaging

BACKGROUND

The advent of Spiral Computed Tomographic (CT) angiography has provided the patients a non-invasive, accurate and fast modality of imaging the vasculature.

METHODS

Spiral CT angiography was performed in 30 patients to evaluate intracranial circulation using standard protocols of data acquisition. The images were processed and reconstructed in 3-dimension to delineate anatomy and pathology accurately.

RESULTS

The study established that CT angiography is an accurate modality for evaluating the intracranial circulation in a variety of abnormalities. It is safe both in terms of being non-invasive and exposure to radiation. It has a distinct advantage over other non-invasive modalities of imaging like MRI in the evaluation of patients with metallic stents and clips.

CONCLUSION

CT angiography has tremendous potential in imaging the intracranial vasculature. It is unquestionably safer than catheter angiography as it avoids arterial puncture and intra-arterial catheter manipulation. It is fast and capable of producing excellent 3-dimensional images of the intracranial vasculature.

Evaluation of the Stability of Small Ruptured Aneurysms with a Small Neck after Embolization with Guglielmi Detachable Coils: Correlation between Coil Packing Ratio and Coil Compaction

OBJECTIVE:

Because it is difficult to predict the compaction of Guglielmi detachable coils (GDCs) after endovascular surgery for aneurysms, we studied the relationship between the coil packing ratio and compaction. Here, we propose a simple method for the preoperative estimation of coil compaction. Using follow-up angiograms, we studied the timing and degree of coil compaction in small terminal and side-wall aneurysms with narrow necks.

METHODS:

We studied 62 patients with acute ruptured intracranial aneurysms that were small (<10 mm), had a small neck (<4 mm), and were coil embolized with GDC-10s. The aneurysmal volume was calculated using the equation V = 4/3π(a/2) × (b/2) × (c/2), where a, b, and c are the aneurysmal height, length, and width in millimeters, respectively. The coil volume was calculated using the equation V = π(p/2)2 × l × 10, where p represents the GDC-10 coil diameter (0.25 mm) and l is the coil length. We recorded the maximum prospective coil length, L, as that corresponding with the volume of packed coils occupying 30% of the aneurysmal volume. Therefore, L was calculated as L (cm) = 0.3 × a × b × c, and the coil packing ratio was expressed as packed coil length/L × 100. Angiographic follow-up studies were generally performed at 3 months and 1 and 2 years after endovascular surgery. We considered coil compaction exceeding 2 mm as major compaction and recorded minor compaction when it was less than 2 mm of the empty reappeared space in the embolized aneurysm. Aneurysmal location was recorded as terminal or side wall.

RESULTS:

Of the 62 patients, 16 (25.8%) manifested angiographic coil compaction (10 minor and 6 major compactions); the mean coil packing ratio was 51.9 ± 13.4%. The mean coil packing ratio in the other 46 patients was 80.5 ± 20.2%, and the difference was statistically significant (P < 0.01). In all 6 patients with major compaction, the mean packing ratio was less than 50% and all underwent re-embolization after a mean of 24.9 ± 1.1 months. The 10 patients with minor compaction were conservatively treated, and the degree of compaction did not change during a mean period of 24 months. We detected 93.8% of the compactions within 12 months of coil placement. The aneurysm was of the terminal type in 5 of the 6 patients with major coil compaction.

CONCLUSION:

In patients who underwent embolization with GDC-10s of aneurysms that were small and had a small neck, the optimal coil packing ratio could be identified with the formula 0.3 × a × b × c. The probability of coil compaction was significantly higher when the coil packing ratio was less than 50%. To detect coil compaction after embolization, follow-up angiograms must be examined regularly for at least 12 months. To detect major coil compaction in patients with terminal type aneurysms, angiographic follow-up should not be shorter than 24 months.

Vascular applications of Spiral CT : an initial Experience

Since the clinical introduction of computed tomography (CT) in the mid 1970s, several technological and clinical advances have improved image quality and reduced scanning time. During the past decade technological breakthroughs have ushered in an exciting advance in medical imaging : spiral CT. Spiral CT technology with its high speed and volumetric data acquisition has spawned a new vascular imaging technique - spiral CT angiography which is noninvasive, accurate, faster and less expensive than conventional angiography. We report our experience of having performed 100 CT angiographies with 3-D reconstructions of various vascular territories of the body. Details of technique of data acquisition, methods of 3-D reconstruction and clinical applications are discussed.

Combined Use of Electrolytically and Mechanically Detachable Platinum Coils for Endovascular Treatment of Cerebral Aneurysms

The combined use of Guglielmi detachable coils (GDCs) and newly developed mechanically detachable platinum coils (Detach Coil System: DCS) was evaluated for the endovascular treatment of 10 patients with cerebral aneurysms. The number and total length of detachable coils placed into the aneurysms, the detaching time for each coil, and any technical problems were recorded and evaluated. Sixty GDCs and 60 DCSs were used. The detachment time for the DCS (mean 21 seconds) was faster than that for the GDC (mean 2 minutes 35 seconds). One DCS moved inside the aneurysm during the mechanical detachment maneuver, but was successfully placed. Neither detachment system influenced the behavior of the other system during coil implantation. The DCS includes a useful J-shape coil, whereas the GDC can be detached safely in fragile aneurysms. The DCS is also cheaper. The coil systems complemented one another and the combination optimized cost and operating time.

Spiral versus J-shaped coils for neurovascular embolisation-an in-vitro study

Our purpose was to compare the characteristics of J-shaped detachable platinum coils with those of spiral coils in in-vitro vascular models. J-shaped coils consist of distal semicircular and proximal straight segments, the latter extending for most of the length of the coil. Spiral coils have a helical shape memory and are thus limited in expansion. In in-vitro silicone vascular models simulating intracranial aneurysms and dural arteriovenous fistulae, we compared J-shaped and spiral coils with regard to ease of delivery, anchoring and folding patterns, and stability in various types of vascular lumen. Delivery and retrieval were comparable. In large and irregular aneurysms and venous sinuses, J-shaped coils could form a more complex basket which conformed to the shape of the vascular cavity. The J-shaped coil was always in contact with the vessel wall. In wide-necked aneurysms, coil protrusion was more frequent with J-shaped coils, while spiral coils tended to stay compact and circular. Arteries were occluded in a shorter segment with spiral coils. J-shaped coils were safe and superior for large and irregular aneurysms or sinuses. Spiral coils were preferable for spherical aneurysms and segmental occlusion of arteries.

Multislice computerized tomography angiography in the evaluation of intracranial aneurysms: a comparison with intraarterial digital subtraction angiography

OBJECT

The goal of this study was to assess the diagnostic accuracy of computerized tomography (CT) angiography performed with the aid of multislice technology (MSCT angiography) in the investigation of intracranial aneurysms, by comparing this method with intraarterial digital subtraction (IADS) angiography.

METHODS

Fifty consecutive adult patients, who successively underwent MSCT angiography (four rows) and IADS angiography of intracranial vessels, were prospectively identified. The MSCT angiography studies consisted of 1.25-mm slices, with 0.8-mm reconstruction intervals, a pitch of 0.75, and timing determined by a test bolus. Two neuroradiologists, who were blinded to the initial interpretation of the MSCT angiograms as well as to those of the IADS angiograms, independently reviewed the MSCT angiograms for the detection and characterization of intracranial aneurysms. Forty-nine intracranial aneurysms were identified in 40 patients; 33 of these lesions were responsible for subarachnoid hemorrhage. The sensitivity, specificity, and accuracy of MSCT angiography in the detection of intracranial aneurysms were 94.8, 95.2, and 94.9%, respectively, on a per-aneurysm basis and 99, 95.2, and 98.3%, respectively, on a per-patient basis. Interobserver agreement was 98%. There was an excellent correlation between aneurysm size assessed using MSCT angiography and that determined by IADS angiography (slope = 0.916, r = 0.877, p < 0.001); however, 2 mm stood as the cutoff size below which the sensitivity of MSCT angiography was statistically lower. That method displayed great accuracy in characterizing the morphological characteristics of the aneurysm.

CONCLUSIONS

Multislice CT angiography is an accurate and robust noninvasive screening test for intracranial aneurysms. It performs better than that reported for single-slice CT angiography. Introduction of eight- and especially 16-row MSCT angiography will provide further progression through thinner slices, a lower pitch, and a purely arterial phase.

Postprocedure ischemic events after treatment of intracranial aneurysms with Guglielmi detachable coils

OBJECT

Ischemic stroke or transient ischemic attack (TIA) may occur after the treatment of intracranial aneurysms with Guglielmi detachable coils (GDCs). The purpose of the present study is to investigate possible risk factors for thromboembolic events and to determine their frequency and time course.

METHODS

The records of 178 consecutive patients with 193 treated intracranial saccular aneurysms were reviewed. A total of 159 GDC procedures were performed to treat 143 aneurysms in 133 of those patients who were in good neurological condition, allowing clinical detection of postprocedure ischemic events (TIA or stroke). The association of clinical, anatomical, and pharmacological factors with intraprocedure intraarterial thrombus and with postprocedure ischemic events was investigated by using uni- and multivariate analyses. Thrombus protruding into the parent artery was noted during six of 159 GDC procedures, resulting in a clinical deficit in one patient. No factor was associated with intraprocedure intraarterial thrombus. Ten postprocedure ischemic events occurred in nine patients. Seven events occurred within 24 hours, and three events occurred between 24 hours and 58 days. Aneurysm diameter and protruding coils were significant independent predictors of postprocedure ischemic events in multivariate analysis (both p = 0.02). The actuarial risk of stroke was 3.8%.

CONCLUSIONS

Larger aneurysm diameter and protruding loops of coils are associated with postprocedure ischemic events after GDC placement. It is unlikely that GDC-treated aneurysms retain thromboembolic potential beyond 2 months.

Rescue balloon procedure for an emergency situation during coil embolization for cerebral aneurysms. Technical note

In this article the authors describe a rescue balloon procedure for coil implantation in three cases. In each patient, the coil seemed likely to unravel. The coils stretched when attempts were made to remove the partially implanted but trapped device. The inflation of a nondetachable microballoon in front of the aneurysm orifice allowed the surgeons to complete implantation of the coil and to avoid a more forceful and potentially harmful retrieval. This rescue balloon method may be useful for emergency situations, such as coil stretching with or without migration.

Transforming growth factor beta-coated platinum coils for endovascular treatment of aneurysms: an animal study

OBJECTIVE

To test the hypothesis that coating platinum coils with transforming growth factor beta (TGFbeta) would improve the cellular proliferation within experimental aneurysms relative to uncoated coils.

MATERIALS AND METHODS

Elastase-induced saccular aneurysms were created in 12 New Zealand White rabbits. These aneurysms were embolized with platinum coils, either "control" (unmodified) coils or "test" (coated with TGFbeta) coils. Subjects were killed either 2 weeks (n = 3, control; n = 3, test) or 6 weeks (n = 3, control; n = 3, test) after embolization. Aneurysm tissue was embedded in plastic, sectioned, and stained with hematoxylin and eosin. The thickness of tissue covering the coils at the coil-lumen interface was measured by use of a digital microscope, and was compared between groups by use of the Student's t test (P < or = 0.05).

RESULTS

Two-week implantation samples demonstrated mean thickness of tissue overlying TGFbeta-coated coils of 36+/-15 microm and mean thickness of overlying control coils of 3+/-5 microm, indicating significantly thicker tissue growth covering test versus control coils (P = 0.02). Six-week implantation samples demonstrated mean thickness of tissue overlying TGFbeta-coated coils of 86+/-74 microm versus mean thickness overlying control coils of 37+/-6 mu; this difference did not reach statistical significance (P = 0.30). Thickness of tissue covering TGFbeta-coated coils did not change significantly from 2 to 6 weeks (P = 0.31). Tissue thickness over control coils increased significantly between 2 and 6 weeks (P = 0.002).

CONCLUSION

TGFbeta-coated platinum coils undergo earlier cellular coverage than standard platinum coils, but differences in coverage between coated and control coils are no longer present at later time points. These data suggest that improvements in intra-aneurysmal cellular proliferation resulting from coil modifications, although significant in the early postembolization phase, may dissipate over time.

Endovascular Treatment of Berry Intracranial Aneurysms Using a New Detachable Coil System. (DCS ((R)) - Detachable Coil System Cook)

SUMMARY

We aimed to assess and to demonstrate the efficiency of a new mechanical system in the endovascular treatment of berry intracranial aneurysms. From September 1999 to October 2000, 38 patients with 40 aneurysms experienced selective embolization using Detach Coils (DCS((R)) - Cook). They were 12 men and 26 women, aged 26 to 77 years, mean age 53.4. The clinical status of patients was graded by Hunt and Hess scale: Stage 0: 8 - stage I: 3 - Stage II: 11 - Stage III: 11 - Stage IV: 2 - Stage V: 3. The localization of aneurysms was as follows: internal carotid artery: 11; sylvian artery: 10; anterior communicating artery: 5; anterior cerebral artery A1-A2: 5; intra-cavernous carotid artery: 1; basilar trunk: 5; PICA: 2; posterior cerebral artery: 1. The size of the aneurysms ranged from 2 to 40 mm. For embolization of aneurysms, we utilized 242 coils (mean number 6.05). The shape and size of coils varied as follows: longest J 6.25 - shortest J 4-3 - longest S 10-20 - shortest S 2-2. The mean time of procedure was 43 minutes (max 180 minutes - min 7 minutes). We did not have any technical complications during the . procedure and no immediate rebleeding occurred. Initial follow-up of the patients showed angiographic full occlusion. Detach Coils appear to be a very precise, reliable and rapid system, with high stability during coil detachment (in very small or very giant aneurysms) in the embolization of intracranial aneurysms, with an interesting aspect concerning the low cost of this new mechanical device.

Follow-up of a Patient Treated by the Mechanical Detachable System (MDS) of Tungsten Spirals. Our Experience

SUMMARY

A case is presented of basilar artery aneurysm, to which endovascular treatment was applied, employing the mechanical detachable system (MDS) of tungsten spirals. The aim of the study was to demonstrate spiral disappearance in embolised aneurysm without recanalisation, following a long-term follow-up period - up to 42 months. During the years 1994 to 1999, about 100 intracranial aneurysms and carotidcavernous fistulas were embolised by the use of MDS spirals. In one case, spiral disappearance was noted, that event not, however, affecting the patient's state in any way and confirmed by clinical and radiological evaluations.

Mechanical detachable platinum coil: report of the European phase II clinical trial in 60 patients

PURPOSE

To determine the safety and reliability of the mechanical detachment system of a platinum coil (Detach-18) when used for neurovascular embolization.

MATERIALS AND METHODS

Sixty patients (21 men, 39 women; age range, 26-75 years; mean age, 56.2 years) were treated in seven centers. Ease of introduction of the coil to the microcatheter, effect of coil passage on the microcatheter shape and stability during its delivery, retrievability of the coil before and after the transition zone passed beyond the microcatheter, detachment of the coil, and effect of coil rotation on the microcatheter stability were evaluated. The detachment system itself was evaluated for premature detachment, failure of the coil to detach, detachment time, number of turns, visibility of radiopaque markers, number of coils deployed per patient, and percentage of vessel occlusion obtained. A 0.015-inch-diameter regular coil and a 0.014-inch-diameter soft coil were used.

RESULTS

A total of 1,061 coils were used; 1,009 were detached. The number of coils deployed ranged from four to 104 (mean, 17 coils). The coils passed easily through the microcatheter. The detachment maneuver occurred within 5-25 seconds, with five to 60 turns of the introducing wire. One premature coil detachment occurred without clinical sequela; 100% occlusion of the vessel lumen was achieved in 53 patients; 80%-90%, in four; and 70%-80%, in two. There were no device-related complications.

CONCLUSION

The detachment system was safe and reliable. This is a useful system for coil embolization in neurovascular diseases.

Treating complex nervous system vascular disorders through a "needle stick": origins, evolution, and future of neuroendovascular therapy

In the past few decades, dramatic improvements have occurred in the field of neuroendovascular surgery. Endovascular therapy today is a well-established treatment modality for a variety of cerebrovascular and nonvascular central nervous system diseases. The foundation of this spectacular evolution was laid by the efforts of pioneering visionaries who often worked alone and under difficult, almost impossible, conditions. Ongoing device development and refinement have revolutionized the field at a dizzying, exhilarating pace. With a better understanding of the molecular basis of diseases and further advancements in gene therapy, neuroendovascular techniques have an enormous potential for application to the entire spectrum of central nervous system diseases as a minimally invasive vehicle for the delivery of biological factors.

Subarachnoid haemorrhage: diagnosis, causes and management

The incidence of subarachnoid haemorrhage (SAH) is stable, at around six cases per 100 000 patient years. Any apparent decrease is attributable to a higher rate of CT scanning, by which other haemorrhagic conditions are excluded. Most patients are <60 years of age. Risk factors are the same as for stroke in general; genetic factors operate in only a minority. Case fatality is approximately 50% overall (including pre-hospital deaths) and one-third of survivors remain dependent. Sudden, explosive headache is a cardinal but non-specific feature in the diagnosis of SAH: in general practice, the cause is innocuous in nine out of 10 patients in whom this is the only symptom. CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative. The cause of SAH is a ruptured aneurysm in 85% of cases, non-aneurysmal perimesencephalic haemorrhage (with excellent prognosis) in 10%, and a variety of rare conditions in 5%. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. A poor clinical condition on admission may be caused by a remediable complication of the initial bleed or a recurrent haemorrhage in the form of intracranial haematoma, acute hydrocephalus or global brain ischaemia. Occlusion of the aneurysm effectively prevents rebleeding, but there is a dearth of controlled trials assessing the relative benefits of early operation (within 3 days) versus late operation (day 10-12), or that of endovascular treatment versus any operation. Antifibrinolytic drugs reduce the risk of rebleeding, but do not improve overall outcome. Measures of proven value in decreasing the risk of delayed cerebral ischaemia are a liberal supply of fluids, avoidance of antihypertensive drugs and administration of nimodipine. Once ischaemia has occurred, treatment regimens such as a combination of induced hypertension and hypervolaemia, or transluminal angioplasty, are plausible, but of unproven benefit.

Endovascular treatment of cerebral aneurysms: An in vitro study with detachable platinum coils and tricellulose acetate polymer

OBJECTIVE

The purpose of our experimental study was to determine the effectiveness of filling the cavity of in vitro aneurysms with detachable platinum coils and the combination of detachable platinum coils and liquid embolic agent.

MATERIALS AND METHODS

Silicone aneurysm models were connected to a circulatory system to simulate arterial flow. A microcatheter was used to introduce detachable coils into the aneurysm cavities. First, platinum coils were introduced until the point of minimal dense packing, indicated by aneurysmal circulatory exclusion. Packing was continued up to maximal dense packing, indicated by protrusion of the coil into the parent artery. Volumetric ratios (coil volume-aneurysm volume) were calculated for minimal and maximal dense packing. Then, after purposeful undercoiling of aneurysm models, a micropump system was used to fill the aneurysm by stepwise injection of tricellulose acetate polymer through the coil mesh until angiographic aneurysm exclusion was completed. The volumetric ratios of maximal packing with coils and tricellulose acetate polymer in relation to the aneurysm volume were calculated.

RESULTS

Maximal dense packing ratios with coils (mean, 32.5%; standard deviation [SD], 3%) were slightly higher than those with the minimal dense packing (mean, 28. 2%; SD, 3%) but were always less than 37%. The ratios of packing with the combined use of coils and tricellulose acetate polymer were greater than 100% (mean, 124.4%; SD, 15%).

CONCLUSION

Knowledge of the volumetric ratio of maximal dense packing was useful for effective filling with coils and tricellulose acetate polymer. The combined use of coils and liquid polymer appeared more effective than the use of coils alone for the complete occlusion of the aneurysm lumen.

Retrieval of malpositioned, dislocated or fractured guglielmi detachable coils from intracranial vessels. A report of seven cases

SUMMARY

Endovascular treatment of intracranial vascular disorders has become common practice, especially treatment of aneurysms with detachable coils. Detachable coils can be utilized with high success rates but technical complications such as misplacement and displacement of coils and/or fractures may occur.We describe our experience with retrieval of coil material utilizing the Lasso retriever (Balt, Montmorency, France) in seven patients.

The Accuracy of Plain Skull X-ray Examination as a Predictor of Recanalization Following Guglielmi Detachable Coil Embolisation in the Treatment of Cerebral Aneurysms

SUMMARY

We evaluated the accuracy of plain skull x-ray series as an imaging modality for the follow-up of cerebral aneurysm recanalization after Guglielmi Detachable Coil (GDC) embolisation. We retrospectively reviewed of 100 consecutive follow-up angiograms and skull x-ray examinations in 78 patients harboring 82 aneurysms and in whom 85 procedures were performed. Angiography was performed between 1 and 54 months (mean: 10.8 months) after embolisation. The skull series (AP, lateral and Towne's projections) were taken at the time of follow-up angiography. Each follow-up angiogram and skull series were compared to the immediate post-coiling, correlating presence or absence of coil compaction on the skull series and recanalization of the aneurysm at angiography. In 97 (97%) examinations, skull x-ray findings correlated with the angiographic findings. In three cases, skull x-ray examination suggested compaction when no recanalization was seen angiographically; in these three cases, the aneurysms were small and found to be more thrombosed than baseline. In no case did angiographic recanalization occur in the absence of compaction on skull series. These findings yield 100% sensitivity, 95% specificity, 93% positive predictive value, 100% negative predictive value and 97% accuracy. The location, size, configuration and neck/dome ratio of the aneurysm were not related to the correlation between angiography and skull x-ray exam. Skull x-ray series is a safe, accurate, and costeffective mode of follow-up for patients with GDC-treated aneurysms. The possibility of it replacing angiography still requires a more comparative skull x-ray modality in follow-up studies.

Endovascular treatment of ruptured posterior circulation cerebral aneurysms. Clinical and angiographic outcomes

BACKGROUND AND PURPOSE

We sought to describe the clinical outcome and angiographic results obtained in the endovascular therapy of ruptured posterior circulation cerebral aneurysms using Guglielmi detachable coils (GDC) over a 7-year period.

METHODS

A retrospective analysis was performed of 112 patients evaluated at the University of California at San Francisco Medical Center between June 1991 and August 1998. The Hunt-Hess grade at presentation of treated patients was I in 26 patients (24%), II in 24 (22%), III in 27 (25%), IV in 24 (22%), and V in 8 (7%). Clinical follow-up for the total population was achieved in 104 of 109 patients (96%), with a mean duration of 13.1 months. Angiographic follow-up for the subset excluding parent vessel occlusion cases was obtained in 93% of cases, with a mean duration of 7.2 months.

RESULTS

Technical success, defined as the ability to catheterize and embolize the aneurysm with GDC, was achieved in 109 of 112 of cases (97%). The mean angiographic occlusion rate, or projected area of the aneurysm occluded by the coils, for all 110 successfully treated aneurysms was 94.6%. At latest clinical follow-up, 81 of 109 patients (74%) achieved good recovery with Glasgow Outcome Scale (GOS) score of I, 10 of 109 (9%) were moderately (GOS II) and 5 of 109 (5%) were severely (GOS III) disabled, 1 of 109 (1%) remained in a vegetative state (GOS IV), and 12 of 109 (11%) were dead. Of the subset of 77 patients with Hunt-Hess grades I to III, 68 (88%) achieved a good clinical outcome (GOS I). A statistically significant correlation was demonstrated between Hunt-Hess grade at presentation and final GOS outcome score (chi(2)=41.4, P<0.0005). Procedure-related permanent morbidity was 2.8% (3/109 patients). Repeated hemorrhage was observed in a single patient (0.9%) with a partially treated aneurysm.

CONCLUSIONS

The observed favorable outcome and low morbidity in this group of high-risk patients point to GDC embolization as an effective method for the endovascular management of patients with ruptured posterior circulation aneurysms.

Long-term angiographic follow-up of 169 intracranial berry aneurysms occluded with detachable coils

PURPOSE

To evaluate the stability of aneurysm occlusion at follow-up angiography after endovascular treatment (EVT) with detachable coils in intracranial berry aneurysms.

MATERIALS AND METHODS

A total of 203 berry aneurysms (< 1.5 cm) were treated with EVT. Follow-up angiography at least 3 months later was performed in 169 cases.

RESULTS

Complete occlusion of the aneurysm sac and neck was achieved in 148 aneurysms, subtotal occlusion in 18, and incomplete occlusion in three. Recurrence occurred between 3 and 40 months in 20 (14%) of the 148 totally occluded aneurysms. A second treatment was performed in five cases, was scheduled in one, and failed in one. The small neck remnant increased in size but did not require any retreatment in three cases, and the size of the neck remnant remained stable in 10 cases. Remnant regrowth occurred in six of the 18 subtotally occluded aneurysms. A second treatment was performed in three. Of the 169 cases, last follow-up angiography showed total occlusion in 133 cases, subtotal in 30, and incomplete in six. No rebleeding occurred.

CONCLUSION

A very small recurrence may be observed at the level of the neck of the aneurysm at long-term follow-up angiography despite achieving total occlusion initially with detachable coils.

Ruptured intracranial aneurysms: acute endovascular treatment with electrolytically detachable coils--a prospective randomized study

PURPOSE

To compare the use of electrolytically detachable coils versus surgical ligation for the management of acutely ruptured intracranial aneurysm.

MATERIALS AND METHODS

A prospective randomized study included 109 patients with acute (< 72 hours) subarachnoid hemorrhage caused by a ruptured aneurysm (Hunt and Hess grade I-II [n = 67], grade III [n = 26], or grade IV-V [n = 16]). All patients were suitable candidates for both endovascular and surgical treatment and were randomly assigned to undergo coil embolization (n = 52) or surgical ligation (n = 57).

RESULTS

Significantly better primary angiographic results were achieved after surgery in patients with anterior cerebral artery aneurysm (n = 55, P = .005) and after endovascular treatment in those with posterior circulation aneurysm (n = 11, P = .045). No significant differences were seen in middle cerebral artery (n = 19) or internal carotid artery (n = 24) aneurysms. Early rebleeding occurred in one patient after incomplete coil embolization. The technique-related mortality rate was 4% in the surgical group and 2% in the endovascular group. Clinical outcome (Glasgow Outcome Scale score) at 3 months was not significantly different between treatment groups in terms of intended treatment modality. No late rebleedings had occurred at the time of this writing.

CONCLUSION

In selected patients with a recently ruptured intracranial aneurysm, favorable results were achieved by using endovascular treatment. Subsequent acute or late open surgery was sometimes required. The clinical outcome at 3 months was comparable in the endovascular and surgical treatment groups.

Treatment of intracranial aneurysms by embolization with coils: a systematic review

BACKGROUND

Embolization with coils is increasingly used for the treatment of intracranial aneurysms. To assess the percentage of complications, the percentage of aneurysm occlusion, and the short-term outcome, we performed a systematic review of studies on embolization with controlled detachable or pushable coils.

SUMMARY OF REVIEW

To find studies on embolization with coils, we performed a MEDLINE search from January 1990 to March 1997, checked all reference lists of the studies found, performed a Science Citation Index search on Guglielmi, and hand searched recent volumes of 25 journals. Two authors independently extracted data by means of a standardized data extraction form from 48 eligible studies totalling 1383 patients. Permanent complications of embolization with controlled detachable coils occurred in 46 of 1256 patients (3.7%; 95% CI, 2.7% to 4.9%); 400 of 744 aneurysms (54%; 95% CI, 50% to 57%) were completely occluded. By means of weighted linear regression, no relation between baseline characteristics and outcome measurements was found. The results in the prespecified subgroups of patients with a ruptured aneurysm, an unruptured aneurysm, or a basilar bifurcation aneurysm were essentially the same as the overall results.

CONCLUSIONS

Short-term results indicate that embolization with coils is a reasonably safe treatment for patients with an unruptured aneurysm and for patients with aneurysmal subarachnoid hemorrhage. The effectiveness in terms of complete occlusion of the aneurysm is moderate. Randomized trials are warranted to compare surgical clipping with embolization with coils.

Results and Problems on Direct Embolization of Cerebral Aneurysms Using Interlocking Detachable Coils

The clinical results of direct embolization of cerebral aneurysms using interlocking detachable coils (IDCs) were analysed. In 27 patients who underwent direct embolization of the aneurysm, 19 patients (70%) were treated uneventfully. In the other 8 patients, symptomatic or asymptomatic complications occurred; parent artery occlusion in 3 patients, rupture of the aneurysm in 2 patients, distal embolism in 2 patients, and neurological deterioration due to enlargement of the aneurysm after embolization in 1 patient. In 5 of 8 patients in whom complications occurred, neurological deficits disappeared after additional embolizations or thrombolysis therapies. Permanent deficits were observed in 3 of all patients (11%). These deficits were caused by the parent artery occlusion due to protrusion of the detached coil in wide neck aneurysms.

These results suggest that indication of direct embolization of the cerebral aneurysm should be decided according to neck size. Balloon-assisted coil placement in wide-necked aneurysms was useful but unable to prevent protrusion or migration of the coils after balloon withdrawal. Development of a new device, such as a stent for intracranial use, may make it possible.