Midterm outcome of partially thrombosed intracranial aneurysms treated with guglielmi detachable coils

Successful shrinkage of a recurrent partially thrombosed symptomatic large basilar tip aneurysm using a Target 3D Coil

Background

Standalone coil embolization is often less effective for partially thrombosed intracerebral aneurysms (PTIA) because of the risk of frequent recurrence if the coil migrates into the thrombus. This report describes a case of PTIA at the basilar tip in which simple coil embolization using a Target 3D Coil resulted in sustained remission without recurrence during long-term follow-up.

Case Description

The patient was a 63-year-old male who presented with right oculomotor nerve palsy after having undergone direct surgery for a basilar artery aneurysm 15 years earlier. Recurrence with partial thrombosis of the basilar artery aneurysm was diagnosed. Target 3D Coil embolization with frame construction in the aneurysmal sac was performed, resulting in the complete disappearance of the aneurysm and improvement of the oculomotor nerve palsy. Magnetic resonance imaging at five years postoperatively confirmed that the thrombus had completely disappeared, and there was no recurrence of the aneurysm. The closed loops in the Target 3D Coil may have contributed to the cohesive mass of coils remaining in the sac of the PTIA, potentially leading to healing.

Conclusion

The characteristics of the Target 3D Coil may have prevented migration of the coil into the thrombus, potentially contributing to the successful resolution of the aneurysm.

Single-Center Case Series of Simple Proximal Clipping for Large Thrombosed Vertebral Artery Aneurysms: Preservation of Perforating Arteries and Long-Term Outcomes

BACKGROUND

Surgical proximal parent artery occlusion (PAO) is one of the treatments for partially thrombosed vertebral artery aneurysms (PTVAs). However, whether long-term changes in size and perforating arteries through the blind end can be truly preserved remain unknown.

OBJECTIVE

To evaluate the efficacy and safety of surgical proximal PAO for PTVAs, focusing on the transition in size and preservation of perforating arteries.

METHODS

We retrospectively reviewed 14 consecutive cases of unruptured large PTVAs. The cases were treated with surgical proximal PAO without trapping or thrombectomy. Preservation of the perforating arteries was confirmed through intraoperative indocyanine green video angiography. The aneurysm size was evaluated by measuring the maximum diameter on axial T2-weighted magnetic resonance images. Post-treatment outcomes were assessed using the modified Rankin Scale at the last follow-up examination.

RESULTS

Thirteen patients (excluding 1 with morbidity) had a mean follow-up time of 33.2 months (range, 12-60 months) and a mean reduction rate of 71% (range, 32%-95%). Only 1 patient (7.2%) experienced postoperative stroke, and 13 patients (92.8%) showed no worsening of the modified Rankin Scale score at the final follow-up examination. The symptoms were improved in 5 of the 6 symptomatic patients (83.3%). In 10 patients (71.4%), a perforating branch that could not be identified on preoperative imaging was identified intraoperatively.

CONCLUSION

Surgical proximal PAO without trapping or thrombectomy for PTVAs allows long-term reduction of aneurysm size and improves treatment safety by preserving the perforating artery, especially in cases wherein direct reconstruction is not feasible.

Surgical Resection and Clipping of an Atherosclerotic Partially Calcified Middle Cerebral Artery Trifurcation Aneurysm with Clipping of an Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

It is estimated within the western population that 10%-13% of patients possess multiple intracranial aneurysms¹ and are linked to certain risk factors. Thrombotic aneurysms are a rare subgroup of complex aneurysms characterized by an organized intraluminal thrombus.^2,3 They differ from typical saccular aneurysms in terms of morphology, natural history, symptomatology, and difficulty in treatment with conventional strategies.^2,4 The risk of rupture is poorly characterized and assumed to be comparable with that of nonthrombotic aneurysms.² A subset of thrombotic aneurysms can be treated surgically with conventional clipping, and direct clipping has been associated with the best surgical outcome.² Despite its safety, endovascular treatment is associated with a high risk of recurrence and retreatment compared with surgical treatment,⁵ with recanalization rates up to 5× higher compared with nonthrombosed aneurysms.^6,7 A 64-year-old male presented with headaches and dizziness for 6 months. He was neurologically intact. Imaging revealed a calcified thrombosed right middle cerebral artery aneurysm and an anterior communicating artery aneurysm, both of which underwent clipping. The patient consented to the procedure. Preservation of blood flow in branch arteries in thrombosed aneurysms is challenging. Thrombectomy and clip reconstruction in such cases can occlude the branch vessels, compromising blood flow. Achieving adequate proximal control and meticulous dissection of the branches is necessary before reconstruction. We present a 2-dimensional video demonstrating the surgical steps of clipping and reconstruction of the giant thrombosed middle cerebral artery aneurysm. Complete occlusion was achieved, and the patient tolerated the operation well with an uneventful postoperative course.

Coil embolization with overlapping horizontal low-profile stents to treat a giant thrombosed fetal posterior cerebral artery aneurysm using contralateral approach through anterior communicating artery: Case report

Background

The treatment of internal carotid artery (ICA) - posterior communicating artery aneurysms (ICPC aneurysms) is challenging when a fetal posterior cerebral artery (PCA) arises from the saccular neck. This complex angioarchitecture renders endovascular approaches difficult. Giant thrombosed IC-PC aneurysms are also hard to treat by endovascular coiling because its flow-diversion effect is insufficient.

Case Description

We report the first case of a ruptured giant thrombosed IC-PC aneurysm associated with a fetal PCA that was successfully treated by coil embolization with retrograde overlap horizontal stenting using low-profile stents introduced through the contralateral ICA. The aneurysm was completely occluded and follow-up MRI scans demonstrated the reduction of the aneurysmal size.

Conclusion

Our technique is advantageous because low-profile stents can be used to treat lesions not accessible with flow-diverter stents due their presence in complex angioarchitectures, and overlap stenting may have flow-diversion effects that can result in the complete occlusion of giant thrombosed aneurysms.

The Fate of Partially Thrombosed Intracranial Aneurysms Treated with Endovascular Intervention

Objective

The fate of partially thrombosed intracranial aneurysms (PTIAs) is not well known after endovascular treatment. The authors aimed to analyze the treatment outcomes of PTIAs.

Methods

We retrospectively reviewed the medical records of 27 PTIAs treated with endovascular intervention between January 1999 and March 2018. Twenty-one aneurysms were treated with intraluminal embolization (ILE), and six were treated with parent artery occlusion (PAO) with or without bypass surgery. Radiological results, clinical outcomes and risk factors for major recurrence were assessed.

Results

The initial clinical status was similar in both groups; however, the last status was better in the ILE group than in the PAO group (p=0.049). Neurological deterioration resulted from mass effect in one case and rupture in one after ILE, and mass effect in two and perforator infarction in one after PAO. Twenty cases (94.2%) in the ILE group initially achieved complete occlusion or residual neck status. However, 13 cases (61.9%) showed major recurrence, the major causes of which included coil migration or compaction. Seven cases (33.3%) ultimately achieved residual sac status after repeat treatment. In the PAO group, all initially showed complete occlusion or a residual neck, and just one case ultimately had a residual sac. Two cases showed major recurrence, the cause of which was incomplete PAO. Aneurysm wall calcification was the only significantly protective factor against major recurrence (odds ratio, 36.12; 95% confidence interval, 1.85 to 705.18; p=0.018).

Conclusion

Complete PAO of PTIAs is the best option if treatment-related complications can be minimized. Simple fluoroscopy is a useful imaging modality because of the recurrence pattern.

A case of internal trapping to a thrombosed giant rapidly growing aneurysm at the posterior cerebral artery

We describe a case of internal trapping including the vasa vasorum for a thrombosed giant rapidly growing posterior cerebral artery aneurysm and performing a detailed analysis. A 48-year-old woman was followed up in our hospital for a thrombosed large posterior cerebral artery aneurysm located in the P2 segment. She initially presented after experiencing a sudden headache on two occasions. Head computed tomography and magnetic resonance imaging indicated a larger aneurysm than before. Digital subtraction angiography with balloon occlusion test was assessed, and internal trapping was sequentially conducted. We detected that the vasa vasorum originated from the posterior temporal artery. Therefore, we embolized the posterior temporal artery including the vasa vasorum using N-butyl-2-cyanoacrylate and Lipiodol. Next, the anterior temporal artery was embolized with N-butyl-2-cyanoacrylate and Lipiodol, posterior temporal artery P3 segment and the aneurysm and finally the proximal P2 segment were embolized with coils. Final vertebral and internal carotid angiography showed complete obliteration of the aneurysm. On the day after the procedure her paresis worsened and she developed left upper quadrantanopia, however was finally discharged with no hemiparesis. We reported a case of a rapidly growing thrombosed giant posterior cerebral artery aneurysm treated by parent artery occlusion including the vasa vasorum with detailed image analysis.

Woven Endobridge (WEB) Device as a Retreatment Strategy After Unsuccessful Surgical Clipping

BACKGROUND

Surgical clipping of intracranial aneurysms is typically robust and durable. However, residual aneurysmal components may be seen after clipping. Furthermore, there may be occasional aneurysmal recurrence. These factors are both clinically relevant because subarachnoid hemorrhage after clipping is a rare but important event. The rationale for any treatment is to substantially decrease the future risk of hemorrhage. Small series have shown coiling as a retreatment strategy after unsuccessful clipping, but none has explored the feasibility of Woven Endobridge (WEB) implantation.

CASE DESCRIPTION

We examined the feasibility of WEB implantation as second-line treatment for wide-necked residual aneurysms after unsuccessful clipping. We also recorded the safety and efficacy in this small series of 6 patients. To determine safety, we measured the modified Rankin Scale score before and after the procedure, and at 2 later time points (mean follow-up, 5 months and 15 months). To determine efficacy, we obtained radiographic aneurysm occlusion outcomes (including WEB Occlusion Scale) at these 2 time points. Four middle cerebral artery and 2 anterior communicating artery complex aneurysms were treated with WEB implantation, showing feasibility in 6/6 cases (100%). Follow-up at 15 months showed no change from preprocedural modified Rankin Scale score and there were no other complications. There was adequate occlusion in 5/6 cases (83%).

CONCLUSIONS

WEB implantation provided a feasible option in this challenging retreatment scenario. This is a small series and prospective data are required to make outcome inferences for this population. Nonetheless, we observed no complications and high adequate occlusion rates.

Flow Diversion for Treatment of Partially Thrombosed Aneurysms: A Multicenter Cohort

BACKGROUND

Partially thrombosed intracranial aneurysms (PTIA) represent a unique subset of intracranial aneurysms with an ill-defined natural history, posing challenges to standard management strategies. This study aims to assess the efficacy of flow diversion in the treatment of this pathology.

METHODS

A retrospective review of patients with flow-diverted PTIA at 6 cerebrovascular centers was performed. Clinical and radiographic data were collected from the medical records, with the primary outcome of aneurysmal occlusion and secondary outcomes of clinical status and complications.

RESULTS

Fifty patients with 51 PTIA treated with flow diversion were included. Median age was 56.5 years. Thirty-three (64.7%) aneurysms were saccular and 16 (31.4%) were fusiform/dolichoectatic. The most common location was the internal carotid artery (54.9%) followed by the vertebral and basilar arteries (17.7% and 17.7%, respectively). Last imaging follow-up was performed at a median of 25.1 (interquartile range, 12.8-43) months. Complete occlusion at last radiographic follow-up was achieved in 37 (77.1%) aneurysms. Pretreatment aneurysm thrombosis of >50% was associated with a significantly lower rate of complete aneurysm occlusion (58.8 vs. 87.1%, P = 0.026) with a trend toward better functional outcome (modified Rankin scale <2) at last follow-up in patients with <50% pretreatment aneurysm thrombosis (96.8 vs. 82.4; P = 0.08). Ischemic complications occurred in 5 (9.8%) patients, producing symptoms in 4 (7.8%) and resultant mortality in 2 (4.2%) patients.

CONCLUSIONS

Flow diversion treatment of PTIA has adequate efficacy along with a reasonable safety profile. Aneurysms harboring large amounts of pretreatment thrombus were associated with lower rates of complete occlusion.

High frequency optical coherence tomography assessment of homogenous neck coverage by intrasaccular devices predicts successful aneurysm occlusion

BACKGROUND

High frequency optical coherence tomography (HF-OCT) is a novel intravascular imaging technology developed for use in the cerebral vasculature. We hypothesize that HF-OCT characterization of intrasaccular device neck coverage can prognosticate exclusion of the aneurysm from the circulation.

METHODS

Bifurcation and sidewall aneurysms were made in six dogs. Seven aneurysms were treated with next generation intrasaccular devices (NGID) and four with traditional platinum coils. HF-OCT was performed to interrogate gaps in the neck coverage, coil herniation, or acute thrombus formation. Animals were re-imaged at 7, 30, 90, and 180 days following aneurysm embolization. An automated image processing method segmented the devices at the neck of the aneurysm and quantified neck coverage. The largest coverage gap was used to predict aneurysm occlusion at 180 days.

RESULTS

No difference was found in occlusion rates between the coil and NGID groups (P=0.45). Successful segmentation of the NGID construct was achieved in all cases. A coverage gap >1 mm2 was found to predict failed aneurysm occlusion (P=0.047). This threshold was able to predict all cases of failed occlusion. The average number of devices needed to treat the aneurysm was lower in the NGID group (1.9 vs 6.75, P=0.009). HF-OCT showed strong agreement with scanning electron microscopy (bias 0.0024 mm2 (95% CI -0.0279, 0.0327)).

CONCLUSIONS

HF-OCT enables precise and accurate measurement of coverage gaps at the neck of aneurysms treated with intrasaccular devices in vivo. We provide in vivo evidence that uniform aneurysm neck coverage by intrasaccular devices is critical for aneurysm occlusion.

Factors that determine aneurysm occlusion after embolization with the Woven EndoBridge (WEB)

Background

The Woven EndoBridge (WEB) device is a novel endovascular tool for the treatment of wide-necked intracranial aneurysms.

Objective

To evaluate factors influencing aneurysm occlusion and aneurysm recurrence after WEB embolization.

Methods

A total of 113 patients (mean age 58.9±11.9 years) with 114 aneurysms (mean size 8.6±4.6 mm) were successfully treated with the WEB device at three German tertiary care centers between May 2011 and February 2018. Aneurysm occlusion was evaluated using the Raymond-Roy occlusion classification. We retrospectively collected patient characteristics, anatomical details, and procedural aspects and evaluated their impact on aneurysm occlusion and recurrence.

Results

Of 98 patients available for a 6-month angiographic follow-up, complete occlusion was achieved in 62.2%, neck remnants in 21.4%, and aneurysm remnants in 16.3%. Aneurysm recurrence occurred in 15.3%. Initial partial aneurysm thrombosis, recurrent aneurysms, aneurysm size, and simultaneous treatment by WEB and coil were associated with aneurysm remnants (p<0.05). Initial partial aneurysm thrombosis, increasing aneurysm size, and treatment by WEB and coil also predicted aneurysm recurrence (p<0.05).

In the subgroup analysis of 71 aneurysms treated with WEB only, initial incomplete occlusion and male sex were associated with aneurysm remnants (p<0.05), while aneurysm height correlated with aneurysm recurrence (p=0.008).

Conclusions

The WEB provides a high rate of adequate occlusion even in a subset of complex wide-necked intracranial aneurysms. Anatomic results tend to be less favourable in large and partially thrombosed aneurysms and after treatment with WEB and coil.

Treatment strategies for recurrent and residual aneurysms after Woven Endobridge implantation

Background

Woven Endobridge (WEB) embolization is a safe and efficient technique for endovascular treatment of intracranial aneurysms. However, the management of aneurysm recurrence after WEB placement has not been well described to date. We present our multicenter experience of endovascular retreatment of aneurysm recurrence after WEB implantation.

Methods

This is a multicenter study of patients who underwent endovascular retreatment after WEB implantation in three German tertiary care centers. Treatment strategies, complications, and angiographic outcome were retrospectively assessed.

Results

Among 122 aneurysms treated with the WEB device, 15 were retreated. Of these, six were initially treated with the WEB only, two were pretreated by coiling, and seven large aneurysms were treated in a multimodality approach. Ten were true aneurysm remnants and five were neck remnants. The reasons for retreatment were WEB migration (n=6), initial incomplete occlusion (n=5), and WEB compression (n=4). Retreatment strategies included coiling (n=4), stent-assisted coiling (n=7), flow diversion (n=3), and placement of an additional WEB (n=1). All procedures were technically successful and there were no procedure-related complications. Among 11 patients available for follow-up after retreatment, three were retreated again. At last angiographic follow-up, available in 11/15 cases at a median of 23 months, complete occlusion was obtained in eight cases and neck remnants in three.

Conclusions

This pilot study shows that endovascular retreatment of recurrent or residual aneurysms after WEB implantation can be done safely and can achieve adequate occlusion rates.

Surgical Clipping of Previously Ruptured, Coiled Aneurysms: Outcome Assessment in 53 Patients

BACKGROUND

Occasionally, previously coiled aneurysms will require secondary treatment with surgical clipping, representing a more complicated aneurysm to treat than the naïve aneurysm. Patients who initially presented with a ruptured aneurysm may pose an even riskier group to treat than those with unruptured previously coiled aneurysms, given their potentially higher risk for rerupture. The objective of this study was to assess the clinical outcomes of patients who undergo microsurgical clipping of ruptured previously coiled cerebral aneurysms. In addition, we present a thorough review of the literature.

METHODS

A total of 53 patients from a single institution who initially presented with a subarachnoid hemorrhage and underwent surgical clipping of a previously coiled aneurysm between December 1997 and December 2014 were studied. Clinical features, hospital course, and preoperative and most recent functional status (Glasgow Outcome Scale score) were reviewed retrospectively.

RESULTS

The mean time interval from coiling to clipping was 2.6 years, and mean follow-up was 5.5 years (range, 0.1-14.7 years). Five patients (9.8%) presented with rebleed prior to clipping. Most patients (79.3%, 42/53) experienced good neurologic outcomes. Most showed no change (81%, 43/53) or improvement (13%, 7/53) in functional status after microsurgical clipping. One patient (2%) deteriorated clinically, and there were 2 mortalities (4%).

CONCLUSIONS

Microsurgical clipping of previously ruptured, coiled aneurysms is a promising treatment method with favorable clinical outcomes.

Endovascular Treatment of Very Large and Giant Intracranial Aneurysms: Comparison between Reconstructive and Deconstructive Techniques-A Meta-Analysis

BACKGROUND

The safety and efficacy of reconstructive and deconstructive endovascular treatments of very large/giant intracranial aneurysms are not completely clear.

PURPOSE

Our aim was to compare treatment-related outcomes between these 2 techniques.

DATA SOURCES

A systematic search of 3 data bases was performed for studies published from 1990 to 2017.

STUDY SELECTION

We selected series of reconstructive and deconstructive treatments with >10 patients.

DATA ANALYSIS

Random-effects meta-analysis was used to analyze occlusion rates, complications, and neurologic outcomes.

DATA SYNTHESIS

Thirty-nine studies evaluating 894 very large/giant aneurysms were included. Long-term occlusion of unruptured aneurysms was 71% and 93% after reconstructive and deconstructive treatments, respectively (P = .003). Among unruptured aneurysms, complications were lower after parent artery occlusion (16% versus 30%, P = .05), whereas among ruptured lesions, complications were lower after reconstructive techniques (34% versus 38%). Parent artery occlusion in the posterior circulation had higher complications compared with in the anterior circulation (36% versus 15%, P = .001). Overall, coiling yielded lower complication and occlusion rates compared with flow diverters and stent-assisted coiling. Complication rates of flow diversion were lower in the anterior circulation (17% versus 41%, P < .01). Among unruptured lesions, early aneurysm rupture (within 30 days) was slightly higher after reconstructive treatment (5% versus 0%, P = .08) and after flow diversion alone compared with flow diversion plus coiling (7% versus 0%).

LIMITATIONS

Limitations were selection and publication biases.

CONCLUSIONS

Parent artery occlusion allowed high rates of occlusion with an acceptable rate of complications for unruptured, anterior circulation aneurysms. Coiling should be preferred for posterior circulation and ruptured lesions, whereas flow diversion is relatively safe and effective for unruptured anterior circulation aneurysms.

Selective microsurgical treatment of giant intracranial aneurysms

Giant intracranial aneurysms are defined as greater than 25mm in diameter. They share the same surgical challenges and strategies as so-called complex aneurysms, sometimes smaller in size but presenting with similar complex anatomy. The surgical difficulties arise from the size of the sack, the presence of intraluminal thrombus, the thickness of the arterial wall, and the complexity of arterial branching on the neck. Preoperative imaging gathers complementary information from magnetic resonance imaging, computed tomographic angiography, and rotational catheter-based angiography with three-dimensional reconstruction including balloon-test occlusion. The therapeutic decision-making needs a multidisciplinary approach including endovascular, neurosurgical and anesthesiological expertises. The microsurgical treatment needs a step-by-step preoperative planning with anticipation of possible pitfalls and alternative strategies. Classical principles of aneurysm surgery have to be tailored to face the difficulties arising from the size of the sack and from the arterial wall calcifications.

WEB as part of a multimodality treatment in complex, large, and partially thrombosed intracranial aneurysms: a single-center observational study of technical success, safety, and recurrence

Introduction

Complex, large, wide-neck aneurysms, but particularly partially thrombosed intracranial aneurysms (PTIAs), have a greater tendency to recanalize after coil occlusion. The Woven Endovascular Bridge (WEB) combines shape memory wires braided to a relatively uniform, dense surface, which may limit its compaction and its incorporation into an existing aneurysm clot and may thus reduce PTIA recurrence.

Objective

To carry out a retrospective analysis of our experience with the WEB as part of a complex treatment in conjunction with other implants to assess the efficacy and safety of this technique.

Methods

Among 43 aneurysms treated with the WEB in our center, eight complex, large, wide-neck aneurysms were treated in conjunction with other implants (additional WEBs, coils, stents, flow diverters). Six of these eight aneurysms were PTIAs. All patients were followed up by DSA between 3½ and 38 months.

Results

All eight (100%) of the complex, large, wide-neck aneurysms were treated successfully and without periprocedural adverse events (0%). At follow-up, the two non-thrombosed aneurysms were completely occluded, but all six PTIAs recurred (75%) and were re-treated. There was no morbidity or mortality in these eight patients.

Conclusions

Treatment of large, complex aneurysms with the WEB in conjunction with other implants was technically successful and safe but did not prevent recurrence of partially thrombosed aneurysms in our center. PTIA re-treatment was possible and not limited by the previously placed WEB.

Suitability of cerebral aneurysms for endovascular treatment: Evolution of criteria with technological developments

With the introduction of electrically detachable coils in 1991 and later the results of the ISAT trial in 2002, endovascular approach became the primary treatment for cerebral aneurysms in many countries. The suboptimal quality of anatomical results and the relatively high rate of aneurysm recurrence after treatment still hamper an even more widespread of the technique. In this paper, we will make a review of the anatomical factors associated with poor anatomical results as well as technological developments aiming at improvement of aneurysm healing.

Endovascular treatment of a large partially thrombosed basilar tip aneurysm

Despite the remarkable developments in neurosurgical and neuro-interventional procedures, the optimal treatment for large or giant partially thrombosed aneurysms with a mass effect remains controversial. The authors report a case of a partially thrombosed aneurysm with a mass effect, which was successfully treated by stent-assisted coil embolization. A 41-year-old man presented with headache. Brain computed tomography depicted an 18×18 mm sized thrombosed aneurysm in the interpeducular cistern. More than 80% of the aneurysm volume was filled with thrombus and the canalized portion beyond its neck measured 6.8×5.6 mm by diagnostic cerebral angiography. Stent-assisted endovascular coiling was performed on the canalized sac and the aneurysm was completely obliterated. Furthermore, most of the thrombosed aneurysm disappeared in the interpeduncular cistern was clearly visualized follow-up brain magnetic resonance imaging conducted at 21 months. The authors report a case of selective coiling of a large, partially thrombosed basilar tip aneurysm.

Endovascular Treatment of Large Intracranial Aneurysms by Neuroform Stent-Assisted Coil Placement

Large intracranial aneurysms represent huge therapeutic challenges for neurosurgeons and endovascular therapists. Since they may involve entire vessels or be irregular in shape, the ratio of complete obliteration of these aneurysms with detachable coils is low and the incidence of recanalisation is very high. So the technique of stent-assisted coil placement was designed for the treatment of large intracranial aneurysms. We report our experience in the treatment of large or complex and wide-necked aneurysms using Neuroform stent-assisted coil placement. Thirty-six patients harboring large intracranial aneurysms were treated by Neuroform stent-assisted coil placement. Thirty-five Neuroform stents were delivered and deployed at the desired location. Of the 35 aneurysms successfully stented, all the aneurysms were occluded with stent-assisted coiling. Twenty-six were totally occluded, four achieved subtotal occlusion, and five incomplete occlusion at the end of the procedure. There were no complications related to the procedure except the migration of stents in two cases. All the patients recovered well. Though Neuroform stent-assisted coil placement may be a favorable technique for treatment of large intracranial aneurysms, further study is necessary to assess the long-term outcome.

Endovascular treatment of giant or very large intracranial aneurysms with different modalities: an analysis of 20 cases

INTRODUCTION

The aim of this retrospective study was to evaluate the clinical efficacy and limitations of different endovascular modalities in the treatment of very large and giant intracranial aneurysms.

METHODS

A group of 20 patients with very large and giant intracranial aneurysms treated by endovascular approaches were retrospectively analyzed. Of the 20 patients, 9 had been treated by parent artery occlusion, 8 by coil embolization, and 3 with an intracranial covered stent. Two recurrent aneurysms initially treated with coil embolization were retreated with an intracranial covered stent. Patients were followed for 9-83 months after the procedure.

RESULTS

Endovascular treatment was technically feasible in all 20 patients. One patient died 7 days after the procedure from rebleeding caused by incomplete aneurysmal occlusion. Immediate postprocedural angiograms showed that complete occlusion was achieved in 11 aneurysms, subtotal occlusion in 7, and incomplete occlusion in 2. The final angiographic results in the other 19 surviving patients confirmed complete occlusion of 15 aneurysms, subtotal occlusion in 3, and incomplete occlusion in 1. Clinical evaluations performed at the final follow-up visit showed an excellent outcome in 11 patients and a good outcome in 8.

CONCLUSION

Endovascular treatment of giant intracranial aneurysms with coil embolization is often associated with a low complete occlusion rate and a high recanalization rate, and parent artery occlusion remains a practical option in selected patients. Based on our limited experience, the use of an intracranial covered stent appears to be a relatively simple and safe procedure for occluding very large and giant aneurysms while still maintaining the patency of the parent artery.

Additional coiling of previously coiled cerebral aneurysms: clinical and angiographic results

BACKGROUND AND PURPOSE

Some cerebral aneurysms that have been coiled reopen over time and additional treatment should be considered to reduce the risk of recurrent hemorrhage. Our purpose was to assess procedural complications and angiographic results of additional coiling in patients with previously coiled but reopened aneurysms and to evaluate protection against (re)bleeding.

METHODS

We compared procedural complications of initial coiling of 488 aneurysms in 439 patients with those of 53 additional coiling procedures in 41 reopened aneurysms in 40 patients. Angiographic results of additional coiling were assessed. We compared episodes of (re)bleeding in patients with complete or near-complete aneurysm occlusion after additional coiling with those of patients with incomplete aneurysm occlusion at 6-month follow-up angiography who were not additionally treated or who still had incomplete occlusion after additional coiling.

RESULTS

Thirty-five procedural complications occurred in 488 initial coiling procedures, and no complications occurred in 53 additional procedures. Complete or near-complete angiographic occlusion after additional coiling was obtained in 31 (76%) of 41 aneurysms. Rebleeding occurred in two of 29 patients with incomplete aneurysm occlusion but in none of the 31 patients with complete or near-complete occlusion after additional coiling.

CONCLUSION

Additional coiling of previously coiled aneurysms has a low procedural complication rate and leads to sufficient occlusion in most aneurysms. The data indicate that successful additional coiling decreases the risk of rebleeding.

Relation between aneurysm volume, packing, and compaction in 145 cerebral aneurysms treated with coils

PURPOSE

To assess the relation between aneurysm volume, packing, and compaction in cerebral aneurysms treated with coils.

MATERIALS AND METHODS

The volumes of 145 aneurysms that were treated with coils were calculated with biplanar angiographic images and a custom-designed method. Partially thrombosed aneurysms were excluded. Packing was defined as the ratio between the volume of the inserted coils and the volume of the aneurysm and was calculated for all 145 aneurysms. Results at 6-month follow-up angiography were dichotomized into presence or absence of compaction.

RESULTS

Aneurysm volume, packing, and compaction at 6-month follow-up were closely related. Large aneurysm volume was associated with low packing and frequent compaction. High packing prevents compaction. If the aneurysm volume was packed for 24% or more with coils, compaction did not occur in aneurysms with a volume of less than 600 mm(3). In small aneurysms with volumes of less than 200 mm(3), compaction did not occur when packing was above 20%.

CONCLUSION

The common practice of inserting as many coils as possible in cerebral aneurysms is sensible in trying to avoid compaction. In aneurysms with packing of 24% or more, no compaction occurred at 6-month angiographic follow-up. In aneurysms with a volume of more than 600 mm(3), high packing could not be achieved, which resulted in compaction in the majority of aneurysms.

Endovascular Treatment of Cerebral Aneurysms

Balloon occlusion of parent vessel and direct coiling are the two endovascular techniques routinely used and commonly accepted as alternatives to surgery for treatment of the cerebral aneurysm in many patients. Based on our experience and what is reported in the literature, the various aspects concerning techniques, difficulties, risks, are described. In comparison to surgery, the endovascular approach is a relatively new technique, which is still in evolution. To date, there is no objective indication regarding the method to be used in a given case. The experience and attitude of the involved team still play an essential role.