Endovascular Management of Intracranial Aneurysms: Current Experience and Future Advances

Neurosurgery ◽  
2006 ◽  
Vol 59 (suppl_5) ◽  
pp. S3-93-S3-102 ◽  
Author(s):  
Christopher J. Koebbe ◽  
Erol Veznedaroglu ◽  
Pascal Jabbour ◽  
Robert H. Rosenwasser
Keyword(s):  
Endovascular Treatment ◽  
Coil Embolization ◽  
Intracranial Aneurysms ◽  
Early Recognition ◽  
Treatment Method ◽  
Endovascular Embolization ◽  
Interventional Treatment ◽  
Endovascular Management ◽  
The Past

Abstract 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.

scholarly journals Both Surgical Clipping and Endovascular Embolization of Unruptured Intracranial Aneurysms Are Associated With Long-term Improvement in Self-Reported Quantitative Headache Scores

Neurosurgery ◽  
2011 ◽  
Vol 69 (1) ◽  
pp. 128-134 ◽  
Author(s):  
Ankeet A Choxi ◽  
Alia K Durrani ◽  
Robert A Mericle
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Pain Scale ◽  
Endovascular Embolization ◽  
Senior Author ◽  
Dramatic Improvement ◽  
Surgical Clipping ◽  
Unruptured Intracranial Aneurysms ◽  
Before And After

Abstract BACKGROUND: The most common presenting symptom for unruptured intracranial aneurysms (UIAs) is headache (HA). However, most experts believe that UIAs associated with HAs are unrelated and incidental. OBJECTIVE: To analyze the incidence and characterization of HAs in patients with UIAs before and after treatment with either surgical clipping or endovascular embolization. METHOD: We prospectively determined the presence, sidedness, and severity of HAs preoperatively in patients who presented to the senior author with a UIA. A validated, quantitative 11-point HA pain scale was used in all patients. The same HA assessments were performed again on these patients an average of 32.4 months postoperatively. RESULTS: In this study, 92.45% (n = 53) of patents for whom we were able to obtain both a preoperative and postoperative pain score had an improvement in their HAs. The average quantitative HA score was 5.87 preoperatively vs 1.39 postoperatively (P < .001). There was no relationship found between the following: (1) HA severity vs aneurysm size, (2) sidedness of aneurysm vs sidedness of HA, and (3) HA improvement after surgical vs endovascular treatment. CONCLUSION: This study suggests that surgical and endovascular treatment of a UIA is associated with dramatic improvement in self-reported HA score an average of 32.4 months postoperatively.

DOES ANGIOGRAPHIC SURVEILLANCE POSE A RISK IN THE MANAGEMENT OF COILED INTRACRANIAL ANEURYSMS? A MULTICENTER STUDY OF 2243 PATIENTS

Neurosurgery ◽  
2008 ◽  
Vol 63 (5) ◽  
pp. 845-849 ◽  
Author(s):  
Andrew J. Ringer ◽  
Giuseppe Lanzino ◽  
Erol Veznedaroglu ◽  
Rafael Rodriguez ◽  
Robert A. Mericle ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Scale Score ◽  
Intracranial Aneurysms ◽  
Accurate Estimate ◽  
Endovascular Embolization ◽  
Modified Rankin Scale ◽  
Major Morbidity ◽  
Risk Of Hemorrhage ◽  
Aneurysm Coiling

Abstract OBJECTIVE Endovascular treatment of intracranial aneurysms is a less invasive alternative than surgical repair. However, the higher risk of recurrence after coiling necessitates regular angiographic surveillance, which has associated risks. To date, the risk of surveillance angiography has not been quantified in patients with intracranial aneurysms treated by endovascular embolization. METHODS Angiograms performed for the surveillance of coiled intracranial aneurysms in patients treated at 8 institutions were recorded prospectively. Of 3086 patients eligible for surveillance angiography according to each institution's protocol during the study period, 2243 patients (72.7%) underwent this procedure. Data were reviewed retrospectively, including the results of each angiogram, angiographic complications, and morbidity resulting from the procedure. Morbidity was classified as major (modified Rankin Scale score ≥3) or minor (modified Rankin Scale score <3) and as temporary (<30 days) or permanent (≥30 days). RESULTS Of 2814 diagnostic angiograms performed, 12 resulted in complications, including 1 (0.04%) permanent major morbidity, 2 (0.07%) temporary major morbidities, and 9 (0.32%) temporary minor morbidities; 6 of these were access site complications). No mortality or permanent minor morbidity was noted. CONCLUSION In this study, routine angiographic surveillance after endovascular treatment of aneurysms has a very low complication rate (0.43%). Incorporating these initial findings with the rate and risk of recurrent treatment or the risk of hemorrhage after coiling will provide a more accurate estimate of the global long-term risk of aneurysm coiling.

125 Staged Endovascular Treatment of Ruptured Intracranial Aneurysms: Acute Coiling Followed By Delayed Flow Diversion

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 228-228
Author(s):  
Erick Michael Westbroek ◽  
Matthew Bender ◽  
Narlin B Beaty ◽  
Bowen Jiang ◽  
Risheng Xu AB ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Complication Rate ◽  
Coil Embolization ◽  
Intracranial Aneurysms ◽  
Major Complication ◽  
Flow Diversion ◽  
Neurological Deficits ◽  
Major Complication Rate ◽  
Ruptured Intracranial Aneurysms

Abstract INTRODUCTION ISAT demonstrated that coiling is effective for aneurysm treatment in subarachnoid hemorrhage (SAH); however, complete occlusion of wide-necked aneurysms frequently requires adjuvants relatively contraindicated in SAH. As such, a limited “dome occlusive” strategy is often pursued in the setting of SAH. We report a single institution series of coiling of acutely ruptured aneurysms followed by delayed flow diversion for definitive, curative occlusion. METHODS A prospectively collected IRB-approved database was screened for patients with aneurysmal SAH who were initially treated by coil embolization followed by planned flow diversion at a single academic medical institution. Peri-procedural outcomes, complications, and angiographic follow-up were analyzed. RESULTS >50 patients underwent both acute coiling followed by delayed, planned flow diversion. Average aneurysm size on initial presentation was 9.5 mm. Common aneurysm locations included Pcomm (36%), Acomm (30%), MCA (10%), ACA (10%), and vertebral (5%). Dome occlusion was achieved in all cases following initial coiling. Second-stage implantation of a flow diverting stent was achieved in 49/50 cases (98%). Follow-up angiography was available for 33/50 patients (66%), with mean follow-up of 11 months. 27 patients (82%) had complete angiographic occlusion at last follow up. All patients with residual filling at follow-up still had dome occlusion. There were no mortalities (0%). Major complication rate for stage I coiling was 2% (1 patient with intra-procedural aneurysm re-rupture causing increase in a previous ICH). Major complication rate for stage 2 flow diversion was 2% (1 patient with ischemic stroke following noncompliance with dual antiplatelet regimen). Minor complications occurred in 2 additional patients (4%) with transient neurological deficits. CONCLUSION Staged endovascular treatment of ruptured intracranial aneurysms with acute dome-occlusive coil embolization followed by delayed flow diversion is a safe and effective treatment strategy.

scholarly journals Long-Term Follow-up Study of Endovascularly Treated Intracranial Aneurysms

2010 ◽  
Vol 16 (3) ◽  
pp. 231-239 ◽  
Author(s):  
L.M. Pyysalo ◽  
L.H. Keski-Nisula ◽  
T.T. Niskakangas ◽  
V.J. Kähärä ◽  
J.E. Öhman
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Bleeding Rate ◽  
Unruptured Aneurysms ◽  
Ruptured Aneurysms ◽  
Follow Up Study ◽  
Long Term Follow Up ◽  
Rebleeding Rate

Long-term follow-up studies after endovascular treatment for intracranial aneurysm are still rare and inconclusive. The aim of this study was to assess the long-term clinical and angiographic outcome of patients with endovascularly treated aneurysms. The clinical outcome of all 185 patients with endovascularly treated aneurysms were analyzed and 77 out of 122 surviving patients were examined with MRI and MRA nine to 16 years (mean 11 years) after the initial endovascular treatment. Sixty-three patients were deceased at the time of follow-up. The cause of death was aneurysm-related in 34 (54%) patients. The annual rebleeding rate from the treated aneurysms was 1.3% in the ruptured group and 0.1% in the unruptured group. In long-term follow-up MRA 18 aneurysms (53%) were graded as complete, 11 aneurysms (32%) had neck remnants and five aneurysms (15%) were incompletely occluded in the ruptured group. The occlusion grade was lower in the unruptured group with 20 aneurysms (41%) graded as complete, 11 (22%) had neck remnants and 18 (37%) were incomplete. However, only three aneurysms were unstable during the follow-up period and needed retreatment. Endovascular treatment of unruptured aneurysms showed incomplete angiographic outcome in 37% of cases. However, the annual bleeding rate was as low as 0.1%. Endovascular treatment of ruptured aneurysms showed incomplete angiographic outcome in 15% of cases and the annual rebleeding rate was 1,3%.

scholarly journals Endovascular Coil Embolization of a Posterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (6) ◽  
pp. E597-E598
Author(s):  
Maureen A Darwal ◽  
Zakaria Hakma ◽  
Mandy J Binning ◽  
Adam Arthur ◽  
Bain Mark ◽  
...  
Keyword(s):  
New York ◽  
Endovascular Treatment ◽  
Coil Embolization ◽  
Intracranial Aneurysms ◽  
Artery Aneurysm ◽  
Posterior Communicating Artery ◽  
International Subarachnoid Aneurysm Trial ◽  
Endovascular Coil Embolization ◽  
Posterior Communicating Artery Aneurysm ◽  
Set Up

Abstract Since the International Subarachnoid Aneurysm Trial,1 endovascular treatment has been the favored treatment for appropriate ruptured intracranial aneurysms. While our endovascular technology has advanced to allow us to treat the majority of intracranial aneurysms, simple coil embolization is still the most common modality. This video demonstrates the fundamentals of aneurysm catheterization and coiling for safe treatment. In addition, the set-up and devices are detailed. This video is to add to the library of basic techniques that will aid a large number of practitioners. This patient consented to endovascular treatment. The video demonstrates endovascular coil embolization of a posterior communicating artery aneurysm in a 76-yr-old female who presented with a subarachnoid hemorrhage. Image of biplane suite in video used courtesy of Siemens Medical Solutions USA, Inc. Illustration at 5:12 reprinted from Yasargil MG, et al, Microneurosurgery IV B, p. 9, Thieme, New York, 1995.

LVIS Blue as a low porosity stent and coil adjuvant

2018 ◽  
Vol 10 (7) ◽  
pp. 682-686 ◽  
Author(s):  
Matthew J Koch ◽  
Christopher J Stapleton ◽  
Scott B Raymond ◽  
Susan Williams ◽  
Thabele M Leslie-Mazwi ◽  
...  
Keyword(s):  
Coil Embolization ◽  
Intracranial Aneurysms ◽  
Posterior Inferior Cerebellar Artery ◽  
Endovascular Embolization ◽  
Superior Cerebellar Artery ◽  
Anterior Communicating Artery ◽  
Aneurysm Neck ◽  
Proximal Internal Carotid Artery ◽  
Cerebellar Artery

IntroductionThe LVIS Blue is an FDA-approved stent with 28% metallic coverage that is indicated for use in conjunction with coil embolization for the treatment of intracranial aneurysms. Given a porosity similar to approved flow diverters and higher than currently available intracranial stents, we sought to evaluate the effectiveness of this device for the treatment of intracranial aneurysms.MethodsWe performed an observational single-center study to evaluate initial occlusion and occlusion at 6-month follow-up for patients treated with the LVIS Blue in conjunction with coil embolization at our institution using the modified Raymond–Roy classification (mRRC), where mRRC 1 indicates complete embolization, mRRC 2 persistent opacification of the aneurysm neck, mRRC 3a filling of the aneurysm dome within coil interstices, and mRRC 3b filling of the aneurysm dome.ResultsSixteen aneurysms were treated with the LVIS Blue device in conjunction with coil embolization with 6-month angiographic follow-up. Aneurysms were treated throughout the intracranial circulation: five proximal internal carotid artery (ICA) (ophthalmic or communicating segments), two superior cerebellar artery, two ICA terminus, two anterior communicating artery, two distal middle cerebral artery, one posterior inferior cerebellar artery, and two basilar tip aneurysms. Post-procedurally, there was one mRRC 1 closure, five mRRC 2 closures, and 10 mRRC 3a or 3b occlusion. At follow-up, all the mRRC 1 and mRRC 3a closures, 85% of the mRRC 3b closures and 75% of the mRRC 2 closures were stable or improved to an mRRC 1 or 2 at follow-up.ConclusionsThe LVIS Blue represents a safe option as a coil adjunct for endovascular embolization within both the proximal and distal anterior and posterior circulation.

scholarly journals Long-term outcomes of coil embolization of unruptured intracranial aneurysms

2018 ◽  
Vol 129 (6) ◽  
pp. 1492-1498 ◽  
Author(s):  
Masaomi Koyanagi ◽  
Akira Ishii ◽  
Hirotoshi Imamura ◽  
Tetsu Satow ◽  
Kazumichi Yoshida ◽  
...  
Keyword(s):  
Coil Embolization ◽  
Intracranial Aneurysms ◽  
Additional Treatment ◽  
Long Term Outcomes ◽  
Unruptured Intracranial Aneurysms ◽  
Risk Of Rupture ◽  
Long Term Follow Up ◽  
Multiple Stroke

OBJECTIVELong-term follow-up results of the treatment of unruptured intracranial aneurysms (UIAs) by means of coil embolization remain unclear. The aim of this study was to analyze the frequency of rupture, retreatment, stroke, and death in patients with coiled UIAs who were followed for up to 20 years at multiple stroke centers.METHODSThe authors retrospectively analyzed data from cases in which patients underwent coil embolization between 1995 and 2004 at 4 stroke centers. In collecting the late (≥ 1 year) follow-up data, postal questionnaires were used to assess whether patients had experienced rupture or retreatment of a coiled aneurysm or any stroke or had died.RESULTSOverall, 184 patients with 188 UIAs were included. The median follow-up period was 12 years (interquartile range 11–13 years, maximum 20 years). A total of 152 UIAs (81%) were followed for more than 10 years. The incidence of rupture was 2 in 2122 aneurysm-years (annual rupture rate 0.09%). Nine of the 188 patients with coiled UIAs (4.8%) underwent additional treatment. In 5 of these 9 cases, the first retreatment was performed more than 5 years after the initial treatment. Large aneurysms were significantly more likely to require retreatment. Nine strokes occurred over the 2122 aneurysm-years. Seventeen patients died in this cohort.CONCLUSIONSThis study demonstrates a low risk of rupture of coiled UIAs with long-term follow-up periods of up to 20 years. This suggests that coiling of UIAs could prevent rupture for a long period of time. However, large aneurysms might need to be followed for a longer time.

Abstract 3956: Outcomes of Patients Undergoing Endovascular Treatment for Mycotic Intracranial Aneurysms

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Saqib A Chaudhry ◽  
M Fareed K Suri ◽  
Adnan I Qureshi
Keyword(s):  
Surgical Treatment ◽  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Multivariate Logistic Regression Analysis ◽  
Primary Treatment ◽  
Endovascular Embolization ◽  
Parent Artery ◽  
Hospital Outcomes ◽  
Aneurysm Wall ◽  
Mycotic Aneurysms

Background: Mycotic intracranial aneurysms are rare with primary treatment focusing on underlying infection to reduce the high mortality rates. Treating these aneurysms remains challenging and obliteration procedures without sacrificing the parent artery often fail due to the fusiform and fragile aneurysm wall. Objective: To determine the outcomes associated with endovascular embolization in patients with mycotic intracranial aneurysms using a large nationally representative sample. Methods: We determined the frequency of endovascular and surgical procedures performed in patients with mycotic intracranial aneurysms and associated in-hospital outcomes using data from the Nationwide Inpatient Survey (NIS) data files from 2002 to 2009. All the in-hospital outcomes were analyzed after adjusting for potential confounders using multivariate logistic regression analysis. Results: Of the 1,915 patients admitted with the diagnosis of infected “mycotic” aneurysms, 83 (4.3%) underwent endovascular embolization, and 59 (3.1%) underwent surgical treatment. In mycotic aneurysms treated with endovascular treatment compared to surgical treatment, discharge outcomes were better with higher rates of minimal disability self-care (40% vs. 23.7% p=0.2436), and lower rates of moderate-severe disability (36% vs. 40% p=0.7874), and in-hospital deaths death (22.9 vs. 35.2 p= 0.3608). After adjusting for age, gender, and hospital teaching status, discharge mortality after endovascular treatment was not inferior to surgical treatment (odds ratio [OR] 1.58, 95% confidence interval [CI] 0.14 - 17.9) or those treated medically (OR 0.56, 95% CI 0.132 - 2.36). Conclusion: Endovascular embolization for mycotic intracranial aneurysms provides comparable outcomes to surgical treatment and should be considered whenever feasible when aneurysm obliteration is indicated.

scholarly journals Endovascular Treatment of Small Ruptured Intracranial Aneurysms (<5 mm)

2019 ◽  
Vol 30 (4) ◽  
pp. 817-826
Author(s):  
Fei Peng ◽  
Xin Feng ◽  
Xin Tong ◽  
Baorui Zhang ◽  
Luyao Wang ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Cox Proportional Hazards ◽  
Parent Artery ◽  
Parent Vessel ◽  
Fisher Grade ◽  
Wide Neck ◽  
Ruptured Intracranial Aneurysms

Abstract Purpose To investigate the long-term clinical and angiographic outcomes and their related predictors in endovascular treatment (EVT) of small (<5 mm) ruptured intracranial aneurysms (SRA). Methods The study retrospectively reviewed patients with SRAs who underwent EVT between September 2011 and December 2016 in two Chinese stroke centers. Medical charts and telephone call follow-up were used to identify the overall unfavorable clinical outcomes (OUCO, modified Rankin score ≤2) and any recanalization or retreatment. The independent predictors of OUCO and recanalization were studied using univariate and multivariate analyses. Multivariate Cox proportional hazards models were used to identify the predictors of retreatment. Results In this study 272 SRAs were included with a median follow-up period of 5.0 years (interquartile range 3.5–6.5 years) and 231 patients with over 1171 aneurysm-years were contacted. Among these, OUCO, recanalization, and retreatment occurred in 20 (7.4%), 24 (12.8%), and 11 (7.1%) patients, respectively. Aneurysms accompanied by parent vessel stenosis (AAPVS), high Hunt-Hess grade, high Fisher grade, and intraoperative thrombogenesis in the parent artery (ITPA) were the independent predictors of OUCO. A wide neck was found to be a predictor of recanalization. The 11 retreatments included 1 case of surgical clipping, 6 cases of coiling, and 4 cases of stent-assisted coiling. A wide neck and AAPVS were the related predictors. Conclusion The present study demonstrated relatively favorable clinical and angiographic outcomes in EVT of SRAs in long-term follow-up of up to 5 years. THE AAPVS, as a morphological indicator of the parent artery for both OUCO and retreatment, needs further validation.

scholarly journals Early experience with the Penumbra SMART coil in the endovascular treatment of intracranial aneurysms: Safety and efficacy

2016 ◽  
Vol 22 (6) ◽  
pp. 654-658 ◽  
Author(s):  
Christopher J Stapleton ◽  
Collin M Torok ◽  
Aman B Patel
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Thromboembolic Complication ◽  
Flow Diversion ◽  
Long Term Results ◽  
Conformational Structure ◽  
Safety And Efficacy ◽  
Endovascular Coil Embolization ◽  
Male Patients

Background Penumbra SMART coils differ from traditional microcoils used for endovascular coil embolization of intracranial aneurysms (IAs) in that they (1) become progressively softer from their distal to proximal end, rather than being of uniform stiffness, (2) have a tight conformational structure, and (3) have a more robust stretch-resistance platform. These properties aid in preventing microcatheter prolapse and coil herniation during coil deployment and in filling small pockets of the aneurysm sac. Objective/Methods To determine the safety and efficacy of this device, the records of 17 consecutive patients with IAs treated with SMART coils were retrospectively analyzed. Results Thirteen female and four male patients were identified. Eleven patients presented with subarachnoid hemorrhage, four had recurrent aneurysms, and two had incidentally discovered aneurysms. Twelve aneurysms (two of which were recurrent) were treated with stand-alone coiling, three were treated with stent-assisted coiling, and two with flow diversion with adjuvant coiling. Microcatheter prolapse occurred in one case of a recurrent aneurysm, due to mechanical limitations imposed by a stent placed during prior coiling. Raymond-Roy Occlusion Classification (RROC) I or II occlusion was achieved in 12 aneurysms, including all 10 undergoing primary stand-alone coiling. Of the five RROC III occlusions, two were expected given treatment with flow diversion, while the other three occurred in complex, recurrent aneurysms. One patient suffered a thromboembolic complication of unclear clinical significance. Conclusions The Penumbra SMART coil is a safe and effective device for the endovascular treatment of IAs. Follow-up studies are required to establish long-term results.

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