Endovascular Coiling Of Aneurysm Research Articles

Anaesthesia for interventional neuroradiology

Anaesthesia is required for neuroradiological diagnostic procedures such as angiograms, computerized tomography (CT), and magnetic resonance imaging (MRI) or for therapeutic intervention (Table 1). Interventional neurovascular procedures are part of a trend towards minimally invasive neurosurgery, an important development in which has been the introduction of the Guglielmi detachable coil (GDC) for endovascular aneurysm coiling. Evidence that coiling is associated with a better outcome than craniotomy and clipping is moving more procedures out of theatres into the neuroradiology suite. Prolonged procedures, improved patient safety, and optimal conditions for imaging have resulted in a trend towards a greater use of general anaesthesia (GA), especially in aneurysm and arteriovenous malformation (AVM) treatments, while conscious sedation is preferred for cerebral ischaemic disease (carotid stents, angioplasty, and thrombolysis). Though many of the risks encountered in this newer arena are conceptually similar to traditional neurosurgery, important differences in the working environment and practice exist.

Sapphire® platinum detachable coil experience in a tertiary-care facility

The Guglielmi Detachable Coil introduced by the Boston Scientific Corporation has been widely used for endovascular coiling of aneurysm. Recently, Sapphire platinum detachable coils (eV3, Irvine, CA) have been introduced for aneurysm coiling. Herein, we report our clinical experience with the Sapphire coil to evaluate the incidence of coil related complications and the rate of aneurysm occlusion. Consecutive patients who underwent embolization with Sapphire detachable coils were prospectively enrolled from January 2004 to September 2004 and the data were retrospectively analyzed. Patient demographics, including age, gender, presenting symptoms, Hunt and Hess grade, Fisher grade and locations of the vascular anomalies were collected. Additionally, complications associated with the coils and rates of aneurysm occlusion were observed and the data compiled. 29 patients underwent Sapphire coil embolization for intracranial aneurysms. Mean age was 50 +/- 18 (mean +/- SD) years with 81% being females. Aneurysm neck reconstruction was required in 7 cases, 6 with Neuroform stent (5 unruptured aneurysms) and 1 with balloon assistance (ruptured aneurysm). In 7 cases, Sapphire coils were used along with other coils. There were no events of thromboembolism or ruptures of aneurysms during coil embolization. However, multi-diameter coils demonstrated stretching in 4 stent-assisted cases without any adverse consequences. Complete occlusion of the aneurysm was achieved in 79.31% of the patients, neck remnant in 6.89, and partial coiling was achieved in 13.79%. The Sapphire coil could safely be used in the treatment of both ruptured and unruptured aneurysms. However, multi-diameter non-stretch resistant coils may be associated with coil stretching when used in conjunction with a stent. Further study is still required for definitive results.

Endovascular coiling of intracranial aneurysms using bioactive coils: a single-center study

Some degree of recanalization is reported in up to one-third of intracranial aneurysms treated with endovascular coiling. A technical development potentially effective in avoiding recanalization is the Matrix Detachable Coil (MDC), which is covered with a biodegradable polymeric material that enhances intra-aneurysmal clot organization and fibrosis. To report the initial clinical experience of MDC for endovascular aneurysm coiling in a single-center, single-operator, and well-defined population setting. 118 aneurysms in 104 patients (73 with subarachnoid hemorrhage, SAH) were embolized with MDC alone (n = 52) or combined with bare platinum coils (n = 66). Initial aneurysm obliteration was class 1 (complete obliteration) in 45 aneurysms (38.1%), class 2 (residual neck) in 44 (37.3%), and class 3 (residual aneurysm) in 29 (24.6%). Procedure-related morbidity was 4.8%, and mortality 0.96%. Clinical follow-up of 61 patients with SAH (mean 5.9 months, range 1-17 months) showed good outcome (Glasgow Outcome Scale, GOS 4-5) in 39 (63.9%), and poor outcome or death (GOS 1-3) in 22 (36.1%). Imaging follow-up of 73 aneurysms (average 6.5 months, range 1-17 months) showed class 1 in 47 (64.4%), class 2 in 18 (24.7%), and class 3 in eight (10.9%). Recanalization occurred in 11 aneurysms (15%), of which four (5.5%) required re-treatment. This study confirms that aneurysm coiling with MDC is feasible, effective, and safe.

Endovascular Coiling Versus Neurosurgical Clipping for Patients With Aneurysmal Subarachnoid Hemorrhage

Endovascular Coiling Versus Neurosurgical Clipping for Patients With Aneurysmal Subarachnoid Hemorrhage

Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage

Patients who have had an aneurysmal subarachnoid haemorrhage (SAH) are at very high risk of rebleeding if the aneurysm is not treated. The standard treatment for several decades has been surgical clipping of the neck of the aneurysm. In recent years, an alternative, the introduction of detachable coils to occlude the aneurysm, has become more common. To compare the effects of endovascular coiling versus neurosurgical clipping in patients with aneurysmal subarachnoid haemorrhage. We searched the Cochrane Stroke Group Trials Register (last searched in February 2005). In addition we searched MEDLINE (1966 to January 2004) and EMBASE (1980 to January 2004), and contacted trialists. We included randomised trials in which endovascular coiling of aneurysms was compared with neurosurgical clipping in patients with SAH who have proven aneurysm. Two authors independently extracted the data and assessed trial quality. Trialists were contacted to obtain missing information. We identified three randomised trials: two published and one unpublished. The trials included a total of 2272 patients (range per trial: 20 to 2143 patients). Most of the patients were in good clinical condition and had an aneurysm on the anterior circulation. After one year of follow up, the relative risk (RR) of poor outcome for coiling versus clipping was 0.76 (95% confidence interval (CI) 0.67 to 0.88). The absolute risk reduction was 7% (95% CI 4% to 11%). In the worst-case scenario analysis for poor outcome overall, the relative risk for coiling versus clipping was 0.81 (95% CI 0.70 to 0.92) and the absolute risk reduction was 6% (95% CI 2% to 10%). For patients with anterior circulation aneurysm the relative risk of poor outcome was 0.78 (95% CI 0.68 to 0.90) and the absolute risk decrease was 7% (95% CI 3% to 10%). For those with a posterior circulation aneurysm the relative risk was 0.41 (95% CI 0.19 to 0.92) and the absolute decrease in risk 27% (95% CI 6% to 48%). The evidence comes mainly from one large trial. For patients in good clinical condition with ruptured aneurysms of either the anterior or posterior circulation we have firm evidence that, if the aneurysm is considered suitable for both surgical clipping and endovascular treatment, coiling is associated with a better outcome.

Intracranial vascular surgery

To review the recent literature on intracranial vascular surgery, to summarize the main findings, and to discuss the impact of these findings on clinical practice. Three areas of vascular neurosurgery literature have recently generated significant interest, controversy and heated debate: (1) The International Study of Unruptured Intracranial Aneurysms studied the natural history and treatment options of unruptured aneurysms, and reported surprisingly low aneurysm rupture rates for small asymptomatic aneurysms. The study also reported favorable morbidity rates for endovascular treatment compared with surgical treatment of unruptured aneurysms. (2) The International Subarachnoid Aneurysm Trial compared endovascular and surgical treatments for ruptured intracranial aneurysms. The study concluded that the outcome in terms of survival free of disability at one year was significantly better with endovascular coiling. (3) The Intraoperative Hypothermia for Aneurysm Surgery Trial compared intraoperative hypothermia and normothermia for potential neuroprotection during neurovascular procedures. Preliminary results suggest no difference between the treatments. The International Study of Unruptured Intracranial Aneurysms and the International Subarachnoid Aneurysm Trial have provided data on the natural history of unruptured intracranial aneurysms and on the morbidity and mortality of surgical and endovascular treatments for intracranial aneurysms. Although morbidity rates of endovascular therapy compare favorably with those of surgery, long-term data on the efficacy of endovascular coiling of aneurysms are needed to assess the overall risk-benefit ratio of these therapies.

Relevance of Occlusion Test in Endovascular Coiling of Posterior Cerebral Artery (P2 Segment) Aneurysms

P2 segment aneurysms are located on the posterior cerebral artery (PCA) between the junction of the posterior communicating artery with the PCA and the quadrigeminal cisternal part of the PCA. We reviewed our experience with endovascular coiling in such aneurysms. Clinical and pre-procedural data from four patients, referred for endovascular treatment of P2 segment aneurysms, were retrospectively studied for factors influencing post-interventional neurological deficits caused by ischemia of the PCA distal territory. Balloon occlusion was done in three patients and patient tolerance was assessed using clinical and anatomic criteria. Embryologic and anatomic features of the PCA were reviewed. Balloon occlusion test and endovascular coiling of aneurysms was possible in three patients. Control angiogram after embolization showed elimination of aneurysms from the circulation and the distal PCA filled through leptomeningeal anastomoses. One patient deteriorated due to aneurysmal rupture soon after the balloon occlusion test and coiling could not be done. In the other three patients post-intervention CT and MRI images showed PCA territory infarcts in spite of demonstration of good collateral circulation distal to the occluded PCA. In conclusion, P2 aneurysms can be effectively treated by endovascular coiling without a balloon occlusion test. While the balloon occlusion test does not contribute to clinical decision-making it may be associated with potential morbidity and mortality.

Intraarterial Thrombolysis for Thromboemboli Associated with Endovascular Aneurysm Coiling

With the rapidly developing applications of GDC endovascular aneurysm embolization, the recognition and treatment of potential intra-procedural complications is crucial to reducing the morbidity and mortality of this procedure. Thromboembolic complications occur with an incidence of 2-11% with endovascular aneurysm coiling. We describe five cases in which the intraarterial use of thrombolytics was applied to disrupt a fresh clot and recanalize the occluded vessels with variable angiographic and clinical success. Five cases are presented in which thromboembolic complications occurred during or shortly after GDC endovascular aneurysm occlusion. The complication was recognized while depositing coils in two cases, on post-embolization angiogram in one, and a few hours following embolization in two cases in which a new neurologic deficit developed in the ICU. In those cases recognized while the microcatheter was near the aneurysm site, immediate thrombolysis was performed at the site of occlusion. The patients who developed a new neurologic deficit were returned to the endovascular suite and the site of occlusion was noted to be distal to the coiled aneurysm. Clot disruption was performed with the microcatheter before delivering intraarterial thrombolytics. Thromboembolic complications of GDC aneurysm embolization are fortunately rare and can be managed with delivery of thrombolytic therapy at the site of occlusion. Intraarterial thrombolysis of fresh clot caused by GDC aneurysm occlusion can successfully open the occluded vessels but not without serious risk of hemorrhage.