Rebleeding after endovascular embolization of ruptured cerebral aneurysms

Prediction of the difficulty of proximal vascular control using 3D-CTA for the surgical clipping of internal carotid artery-posterior communicating artery aneurysms

OBJECTIVE

During surgical clipping of internal carotid artery (ICA)-posterior communicating artery (PCoA) aneurysms, proximal vascular control (PVC) is difficult to achieve in some cases because of variations in the anatomy of this type of aneurysm and its parent arteries. The authors investigated morphometric features that may be predictive for the necessity of anterior clinoidectomy (ACL) or cervical ICA exposure for PVC.

METHODS

The authors retrospectively reviewed 65 patients with an ICA-PCoA aneurysm treated with clipping during the previous 3 years. The factors considered for assessing the difficulty of attaining PVC included the following: the maximum diameter of the aneurysm; the distance between the tip of the anterior clinoid process (ACP) and the proximal aneurysmal neck; the presence of calcification at the ophthalmic segment of the ICA; and the angles between the communicating segment of the ICA and the ophthalmic segment of the ICA and a line perpendicular to the cranial base, which reflect the tortuosity of the ICA. These parameters were measured based on preoperative CTA results.

RESULTS

In a total of 21 patients (32.3%), PVC was difficult to perform with the usual pterional approach. In 6 patients, temporary artery occlusions (TAOs) were difficult to achieve because of severe atherosclerotic wall changes in the ophthalmic segment of the ICA. For 15 patients, the ACPs overhanging the ophthalmic segment of the ICA obstructed the ability to secure a space for TAO. In the 21 patients with PVC difficulty, ACL alone, cervical ICA exposure alone, and both ACL and cervical ICA exposure were conducted in 6, 8, and 7 patients, respectively. Multivariate analysis with binary logistic regression revealed that the maximum diameter of the aneurysm (p = 0.041), the distance between the proximal neck of the aneurysm and the ACP tip (p = 0.002), and calcification of the ICA ophthalmic segment (p = 0.001) were significant predictive factors for difficulties with PVC. A receiver operating characteristic curve analysis revealed that a distance between the proximal aneurysmal neck and the ACP tip of ≤ 5.4 mm was the best cutoff value for predicting the difficulty of attaining PVC (area under the curve 0.800, sensitivity 80.0%, specificity 80.0%).

CONCLUSIONS

A short distance between the proximal aneurysmal neck and the ACP tip and the presence of calcification at the ophthalmic segment of the ICA on preoperative CTA are helpful for predicting the difficulty of achieving PVC.

Preemptive Medicine for Cerebral Aneurysms

Most of cerebral aneurysms (CAs) are incidentally discovered without any neurological symptoms and the risk of rupture of CAs is relatively higher in Japanese population. The goal of treatments for patients with CAs is complete exclusion of the aneurysmal rupture risk for their lives. Since two currently available major treatments, microsurgical clipping and endovascular coiling, have inherent incompleteness to achieve cure of CAs with some considerable treatment risks, and there is no effective surgical or medical intervention to inhibit the formation of CAs in patients with ruptured and unruptured CAs, new treatment strategies with lower risk and higher efficacy should be developed to prevent the formation, growth, and rupture of CAs. Preemptive medicine for CAs should be designed to prevent or delay the onset of symptoms from CAs found in an asymptomatic state or inhibit the de novo formation of CAs, but we have no definite methods to distinguish rupture-prone aneurysms from rupture-resistant ones. Recent advancements in the research of CAs have provided us with some clues, and one of the new treatment strategies for CAs will be developed based on the findings that several inflammatory pathways may be involved in the formation, growth, and rupture of CAs. Preemptive medicine for CAs will be established with specific biomarkers and imaging modalities which can sensor the development of CAs.

Sixteen-year single-surgeon experience with coil embolization for ruptured intracranial aneurysms: recurrence rates and incidence of late rebleeding

Object

Over a 16-year period, 570 patients presenting with acute aneurysmal subarachnoid hemorrhage were successfully treated using endosaccular coil embolization within 30 days of hemorrhage by a single surgeon. Patients were followed to assess the stability of aneurysm occlusion and its longer-term efficacy in protecting against rebleeding.

Methods

Patients were followed for 6 to 191 months (mean 73.7 months, median 67 months) by clinical review, angiography performed at 6 and 24 months posttreatment, and questionnaires sent via the postal service every 5 years. Late rebleeding was defined as > 30 days after treatment.

Results

Stable angiographic occlusion was evident in 74.5% of small, 72.2% of large, and 60% of giant aneurysms. Recurrent filling was found in 119 (26.3%) of 452 aneurysms. Rebleeding was diagnosed in 9 patients (6 treated aneurysms) and occurred between 2 and 114 months posttreatment. It was due to aneurysm recurrence in 6 patients, rupture of a coincidental untreated aneurysm in 2 patients, and rupture of a de novo aneurysm in 1 patient. Rebleeding occurred in 3 (2.5%) of 119 unstable aneurysms and in 3 (0.9%) of 333 stable aneurysms, as seen on initial follow-up angiography studies. Annual rebleeding rates ranged from 0.2% to 0.6% for all causes and from 0.2% to 0.4% for rebleeding of treated aneurysms. No rebleeding was recorded after the first decade, with 138 patients having more than 10 years of follow-up.

Conclusions

Periodic follow-up with angiographic studies after coil embolization is recommended to identify aneurysm recurrence and patients at a high risk of late rebleeding in the medium term. More frequent follow-up is recommended for patients harboring coincidental unruptured aneurysms.

Single-center experience of surgical and endovascular treatment of ruptured intracranial aneurysms

BACKGROUND AND PURPOSE

ISAT provided valuable data on patient outcome after endovascular coiling and surgical clipping of ruptured aneurysms. The purpose of this study was to retrospectively review the ≥1-year outcome (in terms of survival, independence, and rebleeding) of patients who were treated in a routine clinical setting.

MATERIALS AND METHODS

Records of patients presenting with an SAH from a ruptured aneurysm between 2000 and 2008 were reviewed. The 403 patients who met the inclusion criteria harbored 443 treated aneurysms; 173 were managed surgically and 230 by endovascular means. Mean clinical follow-up was 33.9 months (range, 12-106 months).

RESULTS

The pretreatment clinical condition according to the HH was significantly better in the surgically treated patients (P = .018). Death occurred in 11.6% after surgery and in 17.4% after endovascular treatment (P = .104). Of the surviving patients in the surgical and endovascular groups, 80.3% and 87.2%, respectively, were able to live independently with grades 0-2 on the mRS (P = .084). Complete aneurysm occlusion was achieved significantly more often after surgical treatment (P < .001). Rebleeding occurred in 3.1% and 2.3% of the patients after surgical treatment and endovascular coiling, respectively. The occurrence of a residual aneurysm at the end of a coiling procedure was significantly related to the frequency of rebleeding (P = .007).

CONCLUSIONS

The management of patients with intracranial aneurysms in a routine clinical setting shows good and comparable rates of mortality and independence. Coiling results in lower rates of complete aneurysm occlusion. Postcoiling angiography showing a residual aneurysm is a good predictor of the risk of rebleeding.

A review of the management of posterior communicating artery aneurysms in the modern era

Background:

Technical advancements have significantly improved surgical and endovascular treatment of cerebral aneurysms. In this paper, we review the literature with regard to treatment of one of the most common intra-cranial aneurysms encountered by neurosurgeons and interventional radiologists.

Conclusions:

Anterior clinoidectomy, temporary clipping, adenosine-induced cardiac arrest, and intraoperative angiography are useful adjuncts during surgical clipping of these aneurysms. Coil embolization is also an effective treatment alternative particularly in the elderly population. However, coiled posterior communicating artery aneurysms have a particularly high risk of recurrence and must be followed closely. Posterior communicating artery aneurysms with an elongated fundus, true posterior communicating artery aneurysms, and aneurysms associated with a fetal posterior communicating artery may have better outcome with surgical clipping in terms of completeness of occlusion and preservation of the posterior communicating artery. However, as endovascular technology improves, endovascular treatment of posterior communicating artery aneurysms may become equivalent or preferable in the near future. One in five patients with a posterior communicating artery aneurysm present with occulomotor nerve palsy with or without subarachnoid hemorrhage. Factors associated with a higher likelihood of recovery include time to treatment, partial third nerve deficit, and presence of subarachnoid hemorrhage. Both surgical and endovascular therapy offer a reasonable chance of recovery. Based on level 2 evidence, clipping appears to offer a higher chance of occulomotor nerve palsy recovery; however, coiling will remain as an option particularly in elderly patients or patients with significant comorbidity.

Vernet's syndrome caused by large mycotic aneurysm of the extracranial internal carotid artery after acute otitis media--case report

An 85-year-old man presented with a rare large aneurysm of the extracranial internal carotid artery (ICA) due to acute otitis media manifesting as Vernet's syndrome 2 weeks after the diagnosis of right acute otitis media. Angiography of the right extracranial ICA demonstrated an irregularly shaped large aneurysm with partial thrombosis. The aneurysm was treated by proximal ICA occlusion using endovascular coils. The ICA mycotic aneurysm was triggered by acute otitis media, and induced Vernet's syndrome as a result of direct compression to the jugular foramen. Extracranial ICA aneurysms due to focal infection should be considered in the differential diagnosis of lower cranial nerve palsy, although the incidence is thought to be very low.

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.

Clinical and angiographic follow-up of ruptured intracranial aneurysms treated with endovascular embolization

BACKGROUND AND PURPOSE

Endovascular embolization is a well-established treatment of ruptured intracranial aneurysms, but concern about its long-term stability and its ability to prevent rehemorrhage are still present. We evaluated the long-term clinical and angiographic follow-up of patients with ruptured cerebral aneurysms treated with coiling, focusing on rehemorrhage and changes in aneurysm morphologic features.

MATERIALS AND METHODS

A total of 377 patients with ruptured aneurysms that were treated with endovascular approaches at our institution between 1994 and 2008 were reviewed. Clinical and angiographic data were analyzed from a prospectively collected data base.

RESULTS

There were 377 patients with 391 ruptured aneurysms treated for 14 years. Good outcome (Glasgow Outcome Score [GOS], 5) was achieved in 74% of patients, moderate disability or poor outcome in 18%, and 8.8% died. Permanent morbidity or mortality from procedural complications occurred in 2.9%. Complete follow-up was available for 85% of surviving patients, with mean follow-up of 22.3 months. Re-treatment was required in 11% (31 patients). Eight (2.1%) patients had rebleeding, 6 (1.6%) in the hospital within 30 days of treatment, 5 in the first 48 hours. Follow-up imaging was available in 276 aneurysms in 270 patients. Recanalization occurred in 56 of 276 aneurysms (20.3%) regardless of the initial angiographic result, but the risk was higher if a body remnant was left (chi2, 11.791; P = .0006).

CONCLUSIONS

Long-term clinical and angiographic follow-up demonstrates the efficacy of endovascular treatment of ruptured intracranial aneurysms. Rebleeding after treatment is rare, with the greatest risk during the first 48 hours after treatment. Initial angiographic results are not a useful predictor of clinical outcome or rehemorrhage.