Complementary management of partially occluded aneurysms by using surgical or endovascular therapy

2002 ◽  
Vol 97 (4) ◽  
pp. 843-850 ◽  
Author(s):  
Siamak Asgari ◽  
Arnd Doerfler ◽  
Isabel Wanke ◽  
Beate Schoch ◽  
Michael Forsting ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Intracranial Aneurysms ◽  
Endovascular Embolization ◽  
Content Type ◽  
Aneurysm Neck ◽  
Surgical Clip ◽  
Clip Application ◽  
Detachable Coils ◽  
Partially Occluded ◽  
Fine Print

Object. The authors present a series of patients in whom partially occluded aneurysms were retreated using complementary surgical or endovascular therapy. Methods. During a period of 18 months, 301 patients with intracranial aneurysms were treated using either clip application (171 patients) or endovascular embolization with Guglielmi Detachable Coils ([GDCs] 130 patients). Routine posttreatment angiography studies revealed residual aneurysms in 21 of these patients, nine of whom were retreated using an endovascular or surgical method, with a mean treatment latency of 1.2 months. Four patients underwent primary surgical clip application, whereas five patients experienced GDC packing first. Among patients in the surgical group, the residual aneurysm neck was small and total elimination of the aneurysm was achieved by packing in GDCs. In patients in the endovascular group the authors incompletely packed the aneurysm because of its wide neck or fusiform component in two patients, perforation of a very small aneurysm in one patient, and coil dislocation in another patient. Typical coil compaction occurred in one case. Complete clip application was achieved in all patients. There was no complication in any patient due to the second treatment modality. Final outcome was excellent or good in six and fair in three. Conclusions. Following clip application or endovascular embolization of intracranial aneurysms, the use of complementary surgical or endovascular management is successful and associated with low morbidity.

Association of an irregularly shaped anterior choroidal aneurysm with CREST syndrome

2004 ◽  
Vol 101 (5) ◽  
pp. 854-857 ◽  
Author(s):  
Richard A. Zoumalan ◽  
Bernard R. Bendok ◽  
Richard J. Parkinson ◽  
John Sorin ◽  
Allan M. Burke ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Treatment Options ◽  
Crest Syndrome ◽  
Content Type ◽  
Aneurysm Neck ◽  
Migraine Headaches ◽  
Surgical Clip ◽  
Clip Application ◽  
Anterior Choroidal ◽  
Fine Print

✓ The authors present the case of a 50-year-old woman with a history of CREST syndrome (calcinosis, Raynaud phenomenon, esophageal motility disorders, sclerodactyly, and telangiectasia), a variant of scleroderma, who was incidentally found to have an irregular intracranial aneurysm. The patient presented with migraine headaches. A magnetic resonance image of the brain obtained during the headache workup revealed a right posterior carotid artery wall aneurysm in the region of the anterior choroidal artery (AChA). On digital subtraction angiograms, the lesion measured 3.5 mm at its largest diameter. Because of the irregular shape of the aneurysm, the patient's relatively young age, and the potential for further aneurysm growth due to collagen disease, surgical clip application was recommended following a discussion of available treatment options. At surgery, the aneurysm was identified as bilobed and broad based, and the AChA was found to be associated with the aneurysm neck. Satisfactory clipping of the aneurysm was achieved with preservation of the parent vessels. An association of CREST syndrome with intracranial aneurysms has only been reported once before. This case is presented to draw attention to the possibility of a pathophysiological connection between CREST syndrome and intracranial aneurysms and to postulate a possible mechanism whereby this condition may result in aneurysm formation. The association of aneurysms with other pathological collagen-related conditions is well known, and literature relevant to a possible connection between CREST syndrome and aneurysms is reviewed and discussed.

Three-dimensional volume rendering for magnetic resonance angiography in the screening and preoperative workup of intracranial aneurysms

1996 ◽  
Vol 85 (6) ◽  
pp. 1050-1055 ◽  
Author(s):  
Philippe P. Maeder ◽  
Reto A. Meuli ◽  
Nicolas de Tribolet
Keyword(s):  
Magnetic Resonance ◽  
Volume Rendering ◽  
Intracranial Aneurysms ◽  
Mr Angiography ◽  
Three Dimensional ◽  
Time Of Flight ◽  
Conventional Angiography ◽  
Content Type ◽  
Aneurysm Neck ◽  
Fine Print

✓ This study was undertaken to evaluate the capacity of three-dimensional (3-D) time-of-flight (TOF) magnetic resonance (MR) angiography with VoxelView (VV) 3-D volume rendering to detect and characterize intracranial aneurysms and to compare this rendering technique with that of maximum intensity projection (MIP). Forty patients with a total of 53 intracranial aneurysms (10 giant and subgiant, 43 saccular) were consecutively admitted to University Hospital, Lausanne, Switzerland, and investigated with 3-D TOF MR angiography. Source images of the 43 saccular aneurysms were processed with both MIP and VV. The aneurysm detection rate of the two techniques and their ability to characterize features of an aneurysm, such as its neck and its relation to the parent vessel, were compared. Intraarterial digital subtraction angiography was used as the gold standard to which these techniques could be compared and evaluated. Four aneurysms, less than 3 mm in size, were missed using MIP compared to three missed using VV. The representation of aneurysmal morphology using VV was superior to that found using conventional angiography in nine cases, equal in 16 cases, and inferior in seven cases. The representation of the aneurysm neck using VV was superior to MIP in 21 cases, equal in 17 cases, and inferior in one case; it was superior to that shown using conventional angiography in 10 cases, equal in 18 cases, and inferior in four cases. Time-of-flight MR angiography in conjunction with both MIP and VV 3-D reconstruction was able to visualize all aneurysms that were larger than 3 mm. Compared to MIP, VV provides a better definition of the aneurysm neck and the morphology of saccular aneurysms, making VV valuable for use in a preoperative diagnostic workup.

Detachable balloon embolization therapy of posterior circulation intracranial aneurysms

1989 ◽  
Vol 71 (4) ◽  
pp. 512-519 ◽  
Author(s):  
Randall T. Higashida ◽  
Van V. Halbach ◽  
Leslie D. Cahan ◽  
Grant B. Hieshima ◽  
Yoshifumi Konishi
Keyword(s):  
Basilar Artery ◽  
Intracranial Aneurysms ◽  
Posterior Circulation ◽  
Parent Artery ◽  
Parent Vessel ◽  
Detachable Balloon ◽  
Content Type ◽  
Aneurysm Neck ◽  
Balloon Embolization ◽  
Fine Print

✓ Treatment of complex and surgically difficult intracranial aneurysms of the posterior circulation is now being performed with intravascular detachable balloon embolization techniques. The procedure is carried out under local anesthesia from a transfemoral arterial approach, which allows continuous neurological monitoring. Under fluoroscopic guidance, the balloon is propelled by blood flow through the intracranial circulation and, in most cases, can be guided directly into the aneurysm, thus preserving the parent vessel. If an aneurysm neck is not present, test occlusion of the parent vessel is performed and, if tolerated, the balloon is detached. Twenty-six aneurysms in 25 patients have been treated by this technique. The aneurysms have involved the distal vertebral artery (five cases), the mid-basilar artery (six cases), the distal basilar artery (11 cases), and the posterior cerebral artery (four cases). The aneurysms varied in size and included three small (< 12 mm), 15 large (12 to 25 mm), and eight giant (> 25 mm). Fifteen patients (60%) presented with hemorrhage and 10 patients (40%) with mass effect. In 17 cases (65%) direct balloon embolization of the aneurysm was achieved with preservation of the parent artery. In nine cases (35%), because of aneurysm location and size, occlusion of the parent vessel was performed. Complications from therapy included three cases of transient cerebral ischemia which resolved, three cases of stroke, and five deaths due to immediate or delayed aneurysm rupture. The follow-up period has ranged from 2 months to 43 months (mean 22.5 months). In cases where posterior circulation aneurysms have been difficult to treat by conventional neurosurgical techniques, intravascular detachable balloon embolization may offer an alternative therapeutic option.

Surgical management of unruptured intracranial aneurysms

1994 ◽  
Vol 80 (3) ◽  
pp. 440-446 ◽  
Author(s):  
Robert A. Solomon ◽  
Matthew E. Fink ◽  
John Pile-Spellman
Keyword(s):  
Surgical Management ◽  
Intracranial Aneurysms ◽  
Clinical Decision Making ◽  
Mass Effect ◽  
Endovascular Embolization ◽  
Surgical Morbidity ◽  
Content Type ◽  
Unruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
Fine Print

✓ The surgical management of patients with unruptured intracranial aneurysms continues to be controversial. The criteria for withholding treatment or choosing between endovascular embolization and conventional microsurgery are not well delineated. The present study analyzes the morbidity and mortality that can be expected with modern surgical management of unruptured aneurysms, and therefore serves as a point of reference for clinical decision-making in this group of patients. A total of 202 consecutive operations for attempted clipping of unruptured intracranial aneurysms are reported. Subarachnoid hemorrhage from another aneurysm was the most common presentation (55 cases). Thirty-seven patients presented with headache, 36 with mass effect from the aneurysm, and 19 with embolic events; 11 aneurysms were associated with an arteriovenous malformation, 10 caused seizures, and 34 were incidental findings. Excellent or good outcome was achieved in 100% of patients with aneurysms less than 10 mm in diameter, 95% with aneurysms 11 to 25 mm, and 79% with aneurysms greater than 25 mm. Except for giant basilar aneurysms, size (and not location) of the aneurysm was the key predictor of risk for surgical morbidity. These data may be useful when discussing with patients the risk:benefit ratio of choosing between conservative management, endovascular embolization, and microsurgical clipping.

Causes and management of aneurysmal hemorrhage occurring during embolization with Guglielmi detachable coils

1998 ◽  
Vol 89 (1) ◽  
pp. 87-92 ◽  
Author(s):  
Cameron G. McDougall ◽  
Van V. Halbach ◽  
Christopher F. Dowd ◽  
Randall T. Higashida ◽  
Donald W. Larsen ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Contrast Material ◽  
Significant Risk ◽  
Detachable Coil ◽  
Content Type ◽  
Guglielmi Detachable Coil ◽  
Detachable Coils ◽  
Permanent Morbidity ◽  
Fine Print

Object. The purpose of this review is to describe the incidence, causes, management, and outcome of aneurysmal hemorrhage that occurred in patients during endovascular treatment with the Guglielmi detachable coil (GDC) system. Methods. At the authors' institution between September 1991 and August 1995, more than 200 patients were treated using GDCs for intracranial aneurysms. The first 200 patients treated in this fashion were reviewed and all who experienced new subarachnoid hemorrhage (SAH) during the procedure were identified. Angiographic studies were also reviewed and patients were contacted for longer-term follow up when possible. Four patients who experienced intraprocedural SAH were identified. The causes of hemorrhage were believed to be perforation of the aneurysm by the guidewire in one patient, perforation by the microcatheter in a second, and perforation by the delivery wire in a third. The fourth patient had a hemorrhage during injection of contrast material for control angiographic studies after placement of the final coil. One patient died, but the other three experienced no neurological symptoms or recovered without acquiring additional deficits. Overall a procedural hemorrhage rate of 2% was seen, with permanent morbidity and mortality rates of 0% and 0.5%, respectively. Conclusions. Although SAH during endovascular treatment of intracranial aneurysms remains a significant risk, its incidence is low and a majority of patients can survive without serious sequelae.

Excimer laser—assisted bypass in aneurysm treatment: short-term outcomes

2002 ◽  
Vol 97 (5) ◽  
pp. 1029-1035 ◽  
Author(s):  
Eva H. Brilstra ◽  
Gabriel J. E. Rinkel ◽  
Catharina J. M. Klijn ◽  
Albert van der Zwan ◽  
Ale Algra ◽  
...  
Keyword(s):  
Excimer Laser ◽  
Clinical Condition ◽  
Intracranial Aneurysms ◽  
High Flow ◽  
Parent Artery ◽  
Content Type ◽  
Poor Outcome ◽  
Risk Of Rupture ◽  
Clip Application ◽  
Fine Print

Object. If clip application or coil placement for treatment of intracranial aneurysms is not feasible, the parent vessel can be occluded to induce thrombosis of the aneurysm. The Excimer laser—assisted anastomosis technique allows the construction of a high-flow bypass in patients who cannot tolerate such an occlusion. The authors assessed the complications of this procedure and clinical outcomes after the construction of high-flow bypasses in patients with intracranial aneurysms. Methods. Data were retrospectively collected on patient and aneurysm characteristics, procedural complications, and functional outcomes in 77 patients in whom a high-flow bypass was constructed. Logistic regression analysis was used to quantify the relationships between patient and aneurysm characteristics on the one hand and outcome measures on the other. Fifty-one patients harbored a giant aneurysm, 24 patients suffered from a ruptured aneurysm, and 35 patients from an unruptured symptomatic aneurysm. In 22 patients (29%; 95% confidence interval [CI] 19–40%) a permanent deficit developed from an operative complication. At a median follow-up period of 2.5 months, 25 patients (32%; 95% CI 22–44%) were dependent or had died; in 10 of these patients (13% of all patients; 95% CI 6–23%) operative complications were the single cause of this poor outcome. Univariate analysis demonstrated that a poor clinical condition before treatment (odds ratio [OR] 4.7; 95% CI 1.7–13.3) and a history of cardiovascular disease (OR 4.1; 95% CI 1–16.2) increased the risk of poor outcome. Multivariate analysis demonstrated that only the clinical condition before treatment was significantly related to outcome (OR 4; 95% CI 1.3–11.9). Conclusions. In patients with an intracranial aneurysm that cannot be treated by clip application or coil placement, and in whom occlusion of the parent artery cannot be tolerated, the construction of a high-flow bypass should be considered. This procedure carries a considerable risk of complications, but this should be weighed against the disabling or life-threatening effects of compression, the high risk of rupture, and the substantial chance of poor outcome after the rupture of such aneurysms.

Histological findings in giant aneurysms treated with Guglielmi detachable coils

1995 ◽  
Vol 83 (1) ◽  
pp. 129-132 ◽  
Author(s):  
Andrew J. Molyneux ◽  
David W. Ellison ◽  
James Morris ◽  
James V. Byrne
Keyword(s):  
Endovascular Treatment ◽  
Histological Findings ◽  
Guglielmi Detachable Coils ◽  
Content Type ◽  
Aneurysm Neck ◽  
Giant Aneurysms ◽  
Detachable Coils ◽  
Fine Print

✓ The authors report the pathological and histological findings in two patients with giant partially thrombosed aneurysms who were treated by means of Guglielmi detachable coils with subtotal occlusion of the aneurysms. Autopsies of these patients were performed 2 and 6 months after endovascular treatment. The histological findings revealed coils embedded in largely unorganized thrombus in the aneurysms; there was no clear reduction in size of the aneurysms over the period. There was no evidence of endothelialization of the aneurysm neck demonstrated in either case. The significance of these findings is discussed.

Regrowth of aneurysm sacs from residual neck following aneurysm clipping

1989 ◽  
Vol 70 (4) ◽  
pp. 556-560 ◽  
Author(s):  
Teresa Lin ◽  
Allan J. Fox ◽  
Charles G. Drake
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Recurrent Hemorrhage ◽  
Content Type ◽  
Complete Occlusion ◽  
Aneurysm Neck ◽  
Aneurysm Clipping ◽  
Long Period ◽  
Aneurysm Occlusion ◽  
Fine Print

✓ It is recognized that incomplet treatment of an aneurysm may result in recurrent hemorrhage with serious or fatal consequences. For this reason, patients treated at the authors' institution in whom a large portion of the aneurysm neck or sac remained after application of a clip or ligature have been subjected to reoperation. However, 1- to 2-mm residual necks seen in postoperative angiography have been thought to pose little risk. Some cases of aneurysms recurring from a narrow residual neck after clipping have been reported, and a few instances of recurrent aneurysm have been described after apparently complete occlusion of the neck (as observed angiographically or in the surgeon's judgment). In recent years, a surprising number of cases have been presented in which this seemingly unimportant remnant of the neck dilated over a long period to become a dangerous aneurysm. This finding stresses the importance of complete aneurysm occlusion and of postoperative angiography for the recognition of a residual aneurysm neck. This should be important not only in aneurysm clipping but also in the endovascular treatment of intracranial aneurysms with detachable balloons.

Balloon-assisted coil placement in wide-necked aneurysms

1997 ◽  
Vol 86 (4) ◽  
pp. 724-727 ◽  
Author(s):  
David I. Levy ◽  
Andrew Ku
Keyword(s):  
Gold Standard ◽  
Intracranial Aneurysms ◽  
Ophthalmic Artery ◽  
Standard Of Care ◽  
Parent Artery ◽  
Guglielmi Detachable Coils ◽  
Initial Attempt ◽  
Content Type ◽  
Detachable Coils ◽  
Fine Print

✓ Saccular intracranial aneurysms are a common and often fatal lesion. Whereas surgical treatment of these aneurysms continues to be the gold standard of care, certain situations arise for which surgery may not be the best option. In some of these cases, electrolytically detachable coils have been proven to provide outcomes superior to those seen for medical management alone. The authors present two cases of ophthalmic artery aneurysms that would not hold the Guglielmi detachable coils on the initial attempt. One aneurysm was 7 mm and one 4 mm, both with wide necks relative to the aneurysm sac. By using a balloon-assisted technique and blocking the parent artery with a nondetachable balloon, the coils could be safely placed in these aneurysms without herniation when the balloon was deflated. Both patients exhibited embolic symptoms after the procedure, one with a mild but permanent deficit. Although this technique requires manipulation of a second microcatheter and balloon, which increases its technical difficulties and is a higher risk procedure than standard coil placement, it has utility in patients who are not candidates for surgery.

Endovascular treatment of mural-type vein of Galen malformations

1998 ◽  
Vol 89 (1) ◽  
pp. 74-80 ◽  
Author(s):  
Van V. Halbach ◽  
Christopher F. Dowd ◽  
Randall T. Higashida ◽  
Peter A. Balousek ◽  
Samuel F. Ciricillo ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Endovascular Therapy ◽  
Vein Of Galen ◽  
Femoral Access ◽  
Content Type ◽  
Complete Closure ◽  
Detachable Coils ◽  
Transvenous Approach ◽  
Fine Print

Object. In this study the authors report on the results of endovascular treatment for mural-type vein of Galen malformations (VGMs) in a group of infants. Methods. Eight children (six infants and two neonates) who suffered from symptoms caused by a mural-type VGM were treated by means of endovascular therapy. Their age at the time of treatment ranged from 13 days to 19 months (mean 7.6 months). Two neonates and three infants who presented with hydrocephalus and increased head circumference, one of whom was stabilized with a shunt, underwent elective closure of the malformations 3, 4, 6, 6, and 13 months later, respectively. Two patients presented with hemorrhage; one had an intraventricular hemorrhage (IVH) on the 1st day of life and one, a 5-month-old infant, suffered a large parenchymal hemorrhage and an IVH; both patients were immediately cured by means of endovascular techniques. One child presented with a seizure and cortical venous drainage that were treated immediately. Eleven separate treatment sessions were conducted; eight via transarterial femoral access and the remaining three via a transvenous approach. Two patients were treated by using transfemoral transvenous embolization with fibered coils, and one patient required a transtorcular transvenous approach to permit complete closure of the fistula with electrolytically detachable coils. The embolic devices used included silk suture emboli (three patients), electrolytically detachable coils (three patients), and fibered platinum coils (seven patients). In seven patients, complete closure was demonstrated on postembolization arteriographic studies. The eighth patient had stagnant flow in a giant 6-cm varix treated with arterial and venous coils but has not yet undergone follow-up studies. Late follow-up arteriography was performed in four patients at times ranging from 11 to 24 months postprocedure. In one patient, thrombosis of the malformation and shrinkage of the varix were confirmed on follow-up computerized tomography scanning. The remaining three patients have not yet undergone follow-up angiographic examination. Two asymptomatic complications occurred, including separation of the distal catheter, which was removed with a snare device, and a single platinum coil that embolized to the lung, producing no symptoms in 101 months of clinical follow up. The follow-up period ranged from 3 to 105 months, with a mean of 52 months. Conclusions. Endovascular therapy is the treatment of choice for mural-type VGMs and offers a high rate of cure with low morbidity.

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