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.

Hyperglycemia, excess weight, and history of hypertension as risk factors for poor outcome and cerebral infarction after aneurysmal subarachnoid hemorrhage

2005 ◽  
Vol 102 (6) ◽  
pp. 998-1003 ◽  
Author(s):  
Seppo Juvela ◽  
Jari Siironen ◽  
Johanna Kuhmonen
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Infarction ◽  
Patient Outcomes ◽  
Plasma Glucose ◽  
Clinical Condition ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Content Type ◽  
Poor Outcome ◽  
History Of ◽  
Fine Print

Object. Stress-induced hyperglycemia has been shown to be associated with poor outcome after aneurysmal subarachnoid hemorrhage (SAH). The authors prospectively tested whether hyperglycemia, independent of other factors, affects patient outcomes and the occurrence of cerebral infarction after SAH. Methods. Previous diseases, health habits, medications, clinical condition, and neuroimaging variables were recorded for 175 patients with SAH who were admitted to the hospital within 48 hours after bleeding. The plasma level of glucose was measured at admission and the fasting value of glucose was measured in the morning after aneurysm occlusion. Factors found to be independently predictive of patient outcomes at 3 months after SAH onset and the appearance of cerebral infarction were tested by performing multiple logistic regression. Plasma glucose values at admission were found to be associated with patient age, body mass index (BMI), history of hypertension, clinical condition, amount of subarachnoid or intraventricular blood, shunt-dependent hydrocephalus, outcome variables, and the appearance of cerebral infarction. When considered independently of age, clinical condition, or amount of subarachnoid, intraventricular, or intracerebral blood, the plasma glucose values at admission predicted poor outcome (per millimole/liter the odds ratio [OR] was 1.24 with a 95% confidence interval [CI] of 1.02–1.51). After an adjustment was made for the amount of subarachnoid blood, the clinical condition, and the duration of temporary artery occlusion during surgery, the BMI was found to be a significant predictor (per kilogram/square meter the OR was 1.15 with a 95% CI of 1.02–1.29) for the finding of cerebral infarction on the follow-up computerized tomography scan. Hypertension (OR 3.11, 95% CI 1.11–8.73)—but not plasma glucose (OR 1.06, 95% CI 0.87–1.29)—also predicted the occurrence of infarction when tested instead of the BMI. Conclusions. Independent of the severity of bleeding, hyperglycemia at admission seems to impair outcome, and excess weight and hypertension appear to elevate the risk of cerebral infarction after SAH.

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.

Bioabsorbable polymeric material coils for embolization of intracranial aneurysms: a preliminary experimental study

2001 ◽  
Vol 94 (3) ◽  
pp. 454-463 ◽  
Author(s):  
Yuichi Murayama ◽  
Fernando Viñuela ◽  
Satoshi Tateshima ◽  
Joon K. Song ◽  
Nestor R. Gonzalez ◽  
...  
Keyword(s):  
Polymeric Material ◽  
Intracranial Aneurysms ◽  
Blood Clot ◽  
Fibrous Tissue ◽  
Clinical Manifestations ◽  
Embolic Agent ◽  
Parent Artery ◽  
Content Type ◽  
Fine Print

Object. A new embolic agent, bioabsorbable polymeric material (BPM), was incorporated into Guglielmi detachable coils (GDCs) to improve long-term anatomical results in the endovascular treatment of intracranial aneurysms. The authors investigated whether BPM-mounted GDCs (BPM/GDCs) accelerated the histopathological transformation of unorganized blood clot into fibrous connective tissue in experimental aneurysms created in swine. Methods. Twenty-four experimental aneurysms were created in 12 swine. In each animal, one aneurysm was embolized using BPM/GDCs and the other aneurysm was embolized using standard GDCs. Comparative angiographic and histopathological data were analyzed at 2 weeks and 3 months postembolization. At 14 days postembolization, angiograms revealed evidence of neck neointima in six of eight aneurysms treated with BPM/GDCs compared with zero of eight aneurysms treated with standard GDCs (p < 0.05). At 3 months postembolization, angiograms demonstrated that four of four aneurysms treated with BPM/GDC were smaller and had neck neointima compared with zero of four aneurysms treated with standard GDCs (p = 0.05). At 14 days, histological analysis of aneurysm healing favored BPM/GDC treatment (all p < 0.05): the grade of cellular reaction around the coils was 3 ± 0.9 (mean ± standard deviation) for aneurysms treated using BPM/GDCs compared with 1.6 ± 0.7 for aneurysms treated using GDCs alone; the percentage of unorganized thrombus was 16 ± 12% compared with 37 ± 15%, and the neck neointima thickness was 0.65 ±0.26 mm compared with 0.24 ±0.21 mm, respectively. At 3 months postembolization, only neck neointima thickness was significantly different (p < 0.05): 0.73 ± 0.37 mm in aneurysms filled with BPM/GDCs compared with 0.16 ± 0.14 mm in aneurysms filled with standard GDCs. Conclusions. In experimental aneurysms in swine, BPM/GDCs accelerated aneurysm fibrosis and intensified neck neointima formation without causing parent artery stenosis or thrombosis. The use of BPM/GDCs may improve long-term anatomical outcomes by decreasing aneurysm recanalization due to stronger in situ anchoring of coils by organized fibrous tissue. The retraction of this scar tissue may also decrease the size of aneurysms and clinical manifestations of mass effect observed in large or giant aneurysms.

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.

Effectiveness of neurosurgical clip application in patients with aneurysmal subarachnoid hemorrhage

2002 ◽  
Vol 97 (5) ◽  
pp. 1036-1041 ◽  
Author(s):  
Eva H. Brilstra ◽  
Ale Algra ◽  
Gabriel J. E. Rinkel ◽  
Cornelis A. F. Tulleken ◽  
Jan van Gijn
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Treatment Modalities ◽  
Content Type ◽  
Poor Outcome ◽  
Number Of Patients ◽  
Operative Complications ◽  
Clip Application ◽  
Poor Outcomes ◽  
Fine Print

Object. Neurosurgical clip application is the standard method used to prevent rebleeding in patients with aneurysmal subarachnoid hemorrhage (SAH). The authors assessed the magnitude of the reduction in poor outcomes that accompanies a strategy aimed at surgery. Methods. Three hundred forty-six consecutive patients with aneurysmal SAH were studied. The authors estimated the number of surgically treated patients with good outcomes who would have had poor outcomes as a consequence of rebleeding if clip application had not been performed (A). They also assessed the number of patients whose poor outcomes were exclusively caused by operative complications (B). Without an operation some of these patients would have had poor outcomes because of rebleeding (C). The authors represented the number of patients in whom poor outcome was prevented by surgery with the following formula: A − B + C. They assessed the relationships between baseline characteristics of patients and aneurysms and the likelihood that a patient underwent surgery, the risk of operative complications, and the risk of rebleeding. The absolute reduction in the risk of poor outcome found in patients who undergo surgery was 9.7%. This implies that to prevent a poor outcome in one patient, surgery had to be performed in 10. The relative risk of poor outcome following surgery compared with that after conservative treatment was estimated to be 0.81. Logistic regression analysis showed a statistically significant relationship between patient age older than 65 years and the occurrence of operative complications (odds ratio [OR] 2.49; 95% confidence interval [CI] 1.03–6.03), between age older than 65 years and the likelihood of undergoing surgery (OR 0.12; 95% CI 0.07–0.2), and between a poor clinical condition at admission and the likelihood of undergoing surgery (OR 0.26; 95% CI 0.14–0.47). The authors did not identify any predictive factors for rebleeding when the Cox proportional hazard model was used. Conclusions. The beneficial effect of a treatment strategy in which the goal is surgery is substantial. If new treatment modalities such as embolization with coils are explored, these should carefully be compared with surgery before they are generally introduced.

A proposed parent vessel geometry—based categorization of saccular intracranial aneurysms: computational flow dynamics analysis of the risk factors for lesion rupture

2005 ◽  
Vol 103 (4) ◽  
pp. 662-680 ◽  
Author(s):  
Tamer Hassan ◽  
Eugene V. Timofeev ◽  
Tsutomu Saito ◽  
Hiroaki Shimizu ◽  
Masayuki Ezura ◽  
...  
Keyword(s):  
Risk Factors ◽  
Intracranial Aneurysms ◽  
Aneurysm Rupture ◽  
Flow Dynamics ◽  
Low Flow ◽  
Parent Artery ◽  
Dynamics Analysis ◽  
Content Type ◽  
Computational Flow Dynamics ◽  
Fine Print

Object. The authors created a simple, broadly applicable classification of saccular intracranial aneurysms into three categories: sidewall (SW), sidewall with branching vessel (SWBV), and endwall (EW) according to the angiographically documented patterns of their parent arteries. Using computational flow dynamics analysis (CFDA) of simple models representing the three aneurysm categories, the authors analyzed geometry-related risk factors such as neck width, parent artery curvature, and angulation of the branching vessels. Methods. The authors performed CFDAs of 68 aneurysmal geometric formations documented on angiograms that had been obtained in patients with 45 ruptured and 23 unruptured lesions. In successfully studied CFDA cases, the wall shear stress, blood velocity, and pressure maps were examined and correlated with aneurysm rupture points. Statistical analysis of the cases involving aneurysm rupture revealed a statistically significant correlation between aneurysm depth and both neck size (p < 0.0001) and caliber of draining arteries (p < 0.0001). Wider-necked aneurysms or those with wider-caliber draining vessels were found to be high-flow lesions that tended to rupture at larger sizes. Smaller-necked aneurysms or those with smaller-caliber draining vessels were found to be low-flow lesions that tended to rupture at smaller sizes. The incidence of ruptured aneurysms with an aspect ratio (depth/neck) exceeding 1.6 was 100% in the SW and SWBV categories, whereas the incidence was only 28.75% for the EW aneurysms. Conclusions. The application of standardized categories enables the comparison of results for various aneurysms' geometric formations, thus assisting in their management. The proposed classification system may provide a promising means of understanding the natural history of saccular intracranial aneurysms.

Preliminary report of a hollow-centered balloon for intravascular occlusion of intracranial aneurysms or arteriovenous fistulas

1980 ◽  
Vol 53 (2) ◽  
pp. 262-265 ◽  
Author(s):  
Milton D. Heifetz ◽  
Grant B. Hieshima ◽  
C. Mark Mehringer
Keyword(s):  
Arteriovenous Fistula ◽  
Preliminary Report ◽  
Intracranial Aneurysms ◽  
Giant Aneurysm ◽  
Parent Artery ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Preliminary Study ◽  
Intravascular Occlusion ◽  
Fine Print

✓ A doughnut-shaped balloon has been designed that can be inserted intravascularly by catheter to occlude the orifice of an intracranial berry or giant aneurysm or arteriovenous fistula. The blood in the parent artery can continue to flow uninterrupted through the hole in the balloon. In a preliminary study, an arteriovenous fistula was successfully obliterated in a dog. The technique for placing the balloon is described.

Endovascular treatment of giant and large intracranial aneurysms by using a combination of stent placement and liquid polymer injection

2002 ◽  
Vol 96 (3) ◽  
pp. 474-482 ◽  
Author(s):  
Michel E. Mawad ◽  
Saruhan Cekirge ◽  
Elisa Ciceri ◽  
Isil Saatci
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Parent Artery ◽  
Metallic Stent ◽  
Content Type ◽  
Liquid Polymer ◽  
Arterial Lumen ◽  
Small Series ◽  
Fine Print

Object. The aim of this study was to test the feasibility, safety, and efficacy of a new endovascular method for the treatment of giant intracranial aneurysms. This new method consists of combining a metallic stent with a liquid polymer; the stent is first placed across the neck of the aneurysm to reconstruct a tubular arterial lumen, followed by obliteration of the fundus of the aneurysm with an ethyl vinyl alcohol polymer. During its injection, the liquid polymer is contained within the aneurysm by temporarily inflating an occlusion balloon in the parent artery. Methods. Eleven patients harboring a giant aneurysm were successfully treated using this procedure. All aneurysms were excluded from the circulation, with preservation of the parent artery. In nine of the 11 patients, the 6-month follow-up angiogram demonstrated no recanalization of the aneurysm. In one patient who had a giant and partially clotted internal carotid artery bifurcation aneurysm, the follow-up angiogram demonstrated minimal recanalization. The complications in this series of patients included one death and one case of transient hemiparesis caused by watershed ischemia. Conclusions. The initial anatomical results and the clinical outcome in this small series of patients are very encouraging. The mortality and morbidity rates associated with this new endovascular treatment are superior to those associated with surgical clipping of giant aneurysms.

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.

Predicting outcome following surgical treatment of unruptured intracranial aneurysms: a proposed grading system

1996 ◽  
Vol 84 (1) ◽  
pp. 49-54 ◽  
Author(s):  
Rohit K. Khanna ◽  
Ghaus M. Malik ◽  
Nuzhat Qureshi
Keyword(s):  
Risk Factors ◽  
Surgical Treatment ◽  
Intracranial Aneurysms ◽  
Posterior Circulation ◽  
Content Type ◽  
Unruptured Aneurysms ◽  
Poor Outcome ◽  
Unruptured Intracranial Aneurysms ◽  
Predicting Outcome ◽  
Fine Print

✓ Surgical treatment of unruptured aneurysms is gaining increased support owing to the recently defined poor long-term natural history of these aneurysms. The benefit of treatment ultimately depends on the relative risk of subsequent aneurysm rupture in untreated patients versus the risk of surgery. To identify those patients at a higher risk from surgery, the authors reviewed the management of 172 patients with unruptured intracranial aneurysms treated at their institution. The size of the aneurysms ranged from 3 to 45 mm (mean 13.7 mm). Twenty-two patients (12.8%) had aneurysms in the posterior circulation, and 32 (18.6%) of these were giant aneurysms. Major morbidity occurred in 12 patients (6.9%) and five patients (2.9%) died. Multivariate logistic analysis of several risk factors revealed that aneurysm size and location had an independent correlation with surgical outcome and that patient age approached statistical significance. Patients presenting with ischemic cerebrovascular disease, in particular, did not have a higher risk of a poor outcome. A simple classification for predicting patients at high risk from surgical morbidity and mortality is proposed. Preoperative grading is based on the size and location of the aneurysm and patient's age. The lowest grade is given to young patients with small anterior circulation aneurysms, and the highest grade includes elderly patients with complex giant posterior circulation aneurysms. A retrospective analysis of this classification demonstrated a strong correlation with postoperative outcome. The incidence of poor outcome progressively increased with a higher grade, ranging from 0% in Grade 0 to 66.6% in Grade VI. An analysis of this classification on 50 consecutive surgically treated patients with unruptured aneurysms not included in the analysis also validated the predictive value of this system. Along with predicting outcome, this classification should provide a standardized format for comparison of results from different clinical centers as well as different therapeutic techniques (surgical vs. endovascular) without omission of significant risk factors found to influence outcome.

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