Endovascular aneurysm treatment: a proven therapy

DETERMINING INTRA-ANEURYSMAL FLOW FOR COILED CEREBRAL ANEURYSMS WITH DIGITAL FLUOROSCOPY

Background and Purpose. Aneurysm geometry often dictates the success of coil embolization. A strong hemodynamic force or high intra-aneurysmal flow may indicate a high probability of recanalization. It is necessary to develop a tool that can predict and estimate the level of hemodynamic forces that coils are subject to during the procedure. Methods. A compartment model is developed to estimate the intra-aneurysmal flow after coil embolization from digital fluoroscopy. The model is based on the measured signal intensity curves for the aneurysm and adjacent artery and derives the amount of intra-aneurysmal flow reduction. A clinical case of a carotid aneurysm was used for demonstration of its ability. Results. Intra-aneurysmal flow was reduced by 70% after coil embolization, and the estimated porosity was 60%. Flow reduction was confirmed by computational fluid dynamics simulations that modeled the coiled aneurysm as a porous medium. Conclusion. Intra-aneurysmal flow reduction may be used to predict the outcome of coil embolization or possible aneurysm recurrence. A sustained high intra-aneurysmal flow prohibits complete embolization and allows recanalization of the aneurysm. The compartment model provides a reasonable estimate of intra-aneurysmal flow and hemodynamic forces on the coils.

Intravenous abciximab for parent vessel thrombus during basilar apex aneurysm coil embolization: case report and literature review

BACKGROUND

Parent vessel thrombus formation is a serious complication of intracranial aneurysm embolization. The management of this issue is controversial. Abciximab, a potent platelet inhibitor, has been shown to have thrombolytic effects during coronary interventions. A small number of cases have demonstrated its potential application in neuroendovascular procedures. We review the literature on the management of parent vessel thrombosis during aneurysm coil embolization and report our successful experience with the use of IV abciximab to treat parent vessel thrombus formation related to coil embolization of a basilar apex aneurysm.

CASE DESCRIPTION

A 45-year-old man presented to our center with an incidental basilar apex aneurysm. After being informed of the surgical and endovascular treatment options, he elected to undergo coil embolization of the aneurysm. During the procedure, acute thrombus was noted in the left P1 segment of the posterior cerebral artery. IV abciximab was administered, and an angiogram the following day showed complete dissolution of the clot. The patient had no neurologic sequelae.

CONCLUSIONS

IV abciximab appears to be an effective option in the management of acute parent vessel thrombus encountered during coil embolization of unruptured aneurysms. Sufficient data are lacking regarding its use in the setting of a ruptured aneurysm.

Surgical clipping may lead to better results than coil embolization: results from a series of 101 consecutive unruptured intracranial aneurysms

OBJECTIVE

Recent reports in the literature have described a significant discrepancy in adverse outcomes between coil embolization (CE; 10%) and surgical clipping (SC; 25%) for the management of unruptured intracranial aneurysms (UIA). This discrepancy led us to analyze our experience.

METHODS

In 1996, we designed a prospective study of patients with UIA in which CE was considered the treatment of choice and was performed if the interventional neuroradiologists deemed the aneurysm's fundus-to-neck ratio accessible for CE. SC was performed only if complete CE was unlikely to be achieved or in patients in whom CE already had failed.

RESULTS

CE was performed in 38 patients with at least one UIA (41 UIAs, 83% in the anterior circulation). SC was performed in 39 patients with at least one UIA unsuitable for CE (59 UIAs, including 6 after failed CE, 96.5% in the anterior circulation). For CE, the total obliteration rate was 56.1%, the subtotal was 14.6%, and CE failed in 29.3%. There were transient complications in 10% of the cases and permanent complications in 7.5%. Of the 12 failed CE procedures, 7 (58%) were performed for middle cerebral artery aneurysms. For SC, the total obliteration rate was 93.2%, the subtotal was 1.7%, and SC failed (wrapping) in 5.1%. There were transient complications in 16.3% of the patients and permanent complications in 1.7%. The success rate for CE was similar to that for SC only when CE was used for aneurysms with a fundus-to-neck ratio of at least 2.5.

CONCLUSION

SC can produce better results than CE in patients with UIA of the anterior circulation. CE as a first-line treatment should be reserved for patients with UIAs with a fundus-to-neck ratio of 2.5 or greater.