Guglielmi Detachable Coil Embolization Research Articles

The Natural History of Coiled Cerebral Aneurysms Stratified by Modified Raymond-Roy Occlusion Classification

The natural history and long-term durability of Guglielmi detachable coil (GDC) embolization is still unknown. We hypothesize a stepwise decrease in durability of embolized cerebral aneurysms as stratified by the Modified Raymond-Roy Classification (MRRC). First-time GDC-embolized cerebral aneurysms were retrospectively reviewed from 2004 to 2015. Loss of durability (LOD) was defined by change in aneurysm size or patency seen on serial radiographic follow-up. Kaplan-Meier survival analysis was performed to evaluate embolization durability. Multivariate Cox regression modeling was used to assess baseline aneurysm and patient characteristics for their effect on LOD. A total of 427 patients with 443 aneurysms met the inclusion criteria. Overall, 89 (21%) aneurysms met LOD criteria. Grade 1 aneurysms had statistically significantly greater durability than did all other MRRC grades. Grade 3b aneurysms had significantly worse durability than did all other aneurysm grades. There was no difference in durability between grade 2 and 3a aneurysms. Of aneurysms with LOD, 26 (29%) experienced worsening of MRRC grade. Thirty-five (24%) initial MRRC grade 2, 72 (45%) initial MRRC grade 3a, and 6 (22%) initial MRRC grade 3b aneurysms progressed to MRRC grade 1 without retreatment. In our multivariate analysis, only initial MRRC grade was statistically significantly associated with treatment durability (P < 0.001). MRRC grade is independently associated with first-time GDC-embolized cerebral aneurysm durability. Achieving MRRC grade 1 occlusion outcome is significantly associated with greater long-term GDC durability. Although few aneurysms experience further growth and/or recanalization, most incompletely obliterated aneurysms tend to remain stable over time or even progress to occlusion. Grading scales such as the MRRC are useful for characterizing aneurysm occlusion but may lack sensitivity and specificity for characterizing changes in aneurysm morphology over time.

Cavernous Sinus Thrombosis

Cavernous sinus thrombosis (CST) is a rare diagnosis although must be included in the differential of headache. CST is either infectious or aseptic. Aseptic thrombosis usually occurs secondary to trauma or is post surgical. Sinusitis appears to be the most common cause for septic CST. Otitis media, facial cellulitis (located medial third paranasal) and odontogenic infections are also commonly implicated. Cavernous sinus thrombosis (CST) is a rare phenomenon that requires clinical suspicion and emergent imaging for correct diagnosis. Mycotic aneurysm is a rare complication of cavernous sinus thrombosis and may be treated with antibiotics, carotid ligation, internal carotid artery balloon occlusion, or Guglielmi detachable coil (GDC) embolization.

Application of Guglielmi Detachable Coils in Embolization of Iatrogenic Renal Hemorrhage

This study aims to evaluate the application value of Guglielmi detachable coils (GDCs) in the embolization of iatrogenic renal hemorrhage. Twelve iatrogenic renal hemorrhage patients who failed conservative treatment were randomly treated by superselective transcatheter arterial embolization (TAE) with GDCs, gelatin sponge, and microcoil embolization, respectively. The efficacy of treatment, damage to renal function, and renal infarct size were observed. Embolizations were successful in all patients on the first attempt. Hematuria disappeared completely after the surgery; no recurrence of hemorrhage and no abnormal renal function were observed during the follow-up period. Postoperative angiography revealed that patients treated with GDC embolization had minimum renal infarcts. In summary, while superselective TAE provides a safe and effective therapy in patients with iatrogenic renal hemorrhage, the application of GDCs can better prevent the loss of normal renal tissue after embolization.

Abstract No. 255 - The triple coaxial system in gdc embolization with the voltage detach technique

Purpose A new microcatheter with a 1.9-Fr non-tapered tip has recently become available and this new microcatheter can be inserted into a 2.7-Fr. microcatheter. It is called the triple co-axial system, and it has been reported that this system contributes to super selective catheterization in transcatheter arterial chemoembolisation for hepatocellular carcinoma. Recently, we attempted coil embolization by the triple co-axial system using 0.010-inch Guglielmi detachable coils (GDC). However, usually a two-marker microcatheter is required to detach GDC, but this 1.9-Fr. no-taper microcatheter has only one marker. To solve this problem, we attempted to find the detach point by watching the change of voltage. We name it voltage detach technique. The aim of this study was to describe this new technique, and evaluate its technical feasibility and clinical efficacy. Materials and Methods Nineteen patients, 14 males and 5 females, with a median age of 62 years (range, 37-89 years) underwent this procedure. The reason for undergoing GDC embolization was gastrointestinal bleeding in 5, traumatic bleeding in 3, recanalization of pulmonary arteriovenous malformation in 3, and other disease in 8. The medical records and imaging of the procedures were reviewed, and technical success rate, clinical success rate, and complications were evaluated. The technical success was defined as successful delivery and detachment of GDC, and clinical success as immediate post-embolic complete cessation of blood flow confirmed by digital subtraction angiography. Results Totally, 138 GDC were used, and 19 arteries were embolized. The technical success rate was 93% (129/138). In 6 of 9 failed cases, the stack of GDC inside of the microcatheter occurred, and in 3 of 9 failed cases, incorrect connection of GDC cable occurred. The clinical success rate was 95% (18/19). One failed case died during the procedure because of blood loss. There were no major complications related to this procedure. Conclusion Triple co-axial system in GDC embolization with voltage detach technique appeared to be safe and effective.

Delayed emergence from anesthesia resulting from posterior cerebral artery infarction after Guglielmi detachable coil embolization

In the treatment of unruptured intracranial aneurysms, Guglielmi detachable coil (GDC) embolization is a good alternative to surgical clipping which requires invasive surgery [1]. The authors experienced a delayed emergence from anesthesia in a post anesthesia care unit (PACU) after GDC embolization of an unruptured intracranial aneurysm under general anesthesia. We report a case of a thromboembolism at the Lt. posterior cerebral artery detected on an angiogram that was immediately performed after a neurologic deficit was detected in the patient. A 70-year-old male (169 cm, 74 kg) was admitted for the treatment of a 6 mm unruptured basilar top aneurysm that had been incidentally found during a work up for lung cancer. He was on hypertension and diabetes mellitus medications and had taken aspirin with clopidogrel for 5 days prior to the procedure. Routine laboratory tests were unremarkable and he did not have any neurologic deficit on admission. Bispectral index monitoring was added to the routine monitoring and general anesthesia was induced with intravenous propofol 120 mg, alfentanil 400 μg and rocuronium 50 mg. After tracheal intubation, deep anesthesia was maintained with 6% desflurane in 50% oxygen with nitrous oxide to secure immobil ity during the procedure. Phenylephrine was continuously infused to compensate for the hypotension. There was no remark able event during the procedure. Glycopyrrolate 0.4 mg and neostigmine 1.5 mg were administered after the completion of the procedure. The patient was extubated after confirmation that the bispectral index had reached 80 and self respiration had sufficiently recovered. The patient opened his eyes when his name was called. The proce dure took 45 minutes and the total anesthesia time was 70 minutes. The total dosage of rocuronium was 60 mg. In the PACU, oxygen supplementation of 5 L/min with a facial mask was sufficient to maintain the SpO 2 at 100%, but the patient could not obey commands and looked uncomfortable while breathing. The blood pressure and heart rate were stable and the tympanic membrane temperature was 35.8 o C. To rule out the possibility of incomplete recovery from the neuromuscular blocking agent, additional glycopyrrolate 0.2 mg and neostigmine 1.0 mg were injected intravenously. Muscle relaxation was monitored with an electrical stimulator by applying the

Comparison of lumbar drainage and external ventricular drainage for clearance of subarachnoid clots after Guglielmi detachable coil embolization for aneurysmal subarachnoid hemorrhage

ObjectiveSubarachnoid clots play an important role in development of delayed vasospasm after subarachnoid hemorrhage (SAH). The purpose of this study was to compare clearance of subarachnoid clots using external ventricular drainage (EVD) or lumbar drainage (LD) after Guglielmi detachable coil (GDC) embolization for aneurysmal SAH. MethodsThe subjects were 51 treated with GDC coil embolization for aneurysmal Fisher group 3 SAH within 72h of ictus. Software-based volumetric quantification of the subarachnoid clots was performed on CT scans and the hemoglobin (Hb) level was measured in CSF drained from each catheter. ResultsClearance of subarachnoid clots was more rapid in patients treated with LD (n=34) compared to those treated with EVD (n=17). The Hb level in CSF was significantly higher in the LD group on Days 4–5 after onset of SAH (P<0.05), but was higher in the EVD group on Days 8–9. The incidence of symptomatic vasospasm did not differ between the two groups. The rate of occurrence of a new low density area on CT scans was higher in patients treated with EVD, but not significantly higher than the rate in the LD group. ConclusionGDC embolization followed by lumbar drainage accelerates the reduction of subarachnoid clots, but EVD may contribute to stasis of hemorrhage within subarachnoid spaces.

Abstract 2456: Quantitative Analysis Of Hemorrhage Volume For Predicting Cerebral Vasospasm After Subarachnoid Hemorrhage Between Surgical Clipping And Coil Embolization

Objective: Subarachnoid clots are important in development of delayed vasospasm after subarachnoid hemorrhage (SAH). The purpose of this study was to define the association between the subarachnoid clot volume and the incidence of symptomatic vasospasm (SV) after surgical clipping and embolization with Guglielmi detachable coils (GDCs) for aneurysmal SAH. Methods: The subjects were 155 patients with aneurysmal SAHs that were detected with a CT scan at admission and were treated by surgical clipping (Clip group, n=112) or GDC embolization (Coil group, n=43) within 72 hours of ictus between January 22, 2002 and November 22, 2009. Software-based volumetric quantification of the subarachnoid clot was performed using the voxel count method (AZE Virtual Place Fujin Raijin, AZE Ltd.). Subarachnoid clot was defined as cisternal high density areas with a Hounsfield number from 43 to 90 in the CT scan. Results: SV occurred in 24.1% and 16.3% of the patients in the Clip group (age, 63.5±12.8; male, 33.9%) and the Coil group (age, 63.0±12.6; male, 18.6%), respectively. The area under the ROC curve for subarachnoid clots for SV patients was 0.588 (95% confidence interval: 0.472-0.704; Clip group) and 0.849 (95% confidence interval: 0.714-0.985; Coil group). Using subarachnoid clot volumes of 19.6 ml (Clip group) and 32.1 ml (Coil group) as the cut-off values, the sensitivity and specificity were 89 and 39% (Clip group) and 100 and 61% (Coil group), respectively. A χ 2 test also identified that subarachnoid clots (&gt;19.0 ml) were associated with the development of SV compared to lower blood volumes in the Clip group (≤19.0 ml, p=0.017) and that subarachnoid clots (&gt;32.0 ml) were associated with development of SV compared to lower blood volumes in the Coil group (≤32.0 ml, p=0.03). The hemorrhage volumes of the patients with SV in the Clip group were lower than those in the Coil group at admission (37.7±21.5 vs. 58.5±23.1 ml, p=0.034), on the day after the operation (16.5±14.6 vs. 38.3±17.4 ml, p=0.002), and on Day 3-10 after SAH (5.5±4.1 vs. 11.4±9.3 ml, p=0.017). The hemorrhage volume at admission did not differ significantly between the groups (Clip group: 32.5±22.9 ml, Coil group: 32.8±22.4 ml). Conclusions: A threshold of cisternal hemorrhage volume (&gt;19.0 ml in the Clip group and &gt;32.0 ml in the Coil group) may exist above which patients are very likely to develop SV. Aneurysm surgery itself may be harmful to the brain (brain retraction, use of a temporary clip, and mechanical manipulation of cerebral arteries) and can lead to the onset of cerebral vasospasm.

Age limit for surgical treatment of poor-grade patients with subarachnoid hemorrhage: A project of the Chugoku-Shikoku division of the Japan neurosurgical society

Objective:Management of elderly patients with poor-grade subarachnoid hemorrhage (SAH) remains controversial. The objective of this study was to investigate whether there is an age-dependent difference in the outcome of poor-grade SAH after surgical obliteration of the aneurysm.Methods:Data were reviewed retrospectively for 156 patients with poor-grade aneurysmal SAH at multiple centers in Chugoku and Shikoku, Japan. Patients were divided into age groups of 65-74 and ≥75 years old. Factors influencing a favorable outcome at discharge (Glasgow Outcome Scale, good recovery or moderately disabled) were determined using multivariate logistic regression analyses.Results:A favorable outcome at discharge was achieved in 37 of the 156 patients (23.7%). Advanced age (≥75 years old, P < 0.01), improvement of World Federation of Neurosurgical Societies (WFNS) Grade after admission (P = 0.02), Fisher grade (P < 0.001), and a low density area (LDA) associated with vasospasm on computed tomography (CT) (P < 0.01) were significantly associated with outcome. Multivariate analysis identified advanced age (≥75 years old, P = 0.01), Fisher group 4 (P = 0.002), and a new LDA associated with vasospasm on CT (P = 0.007) as predictors of a poor outcome in elderly patients with poor-grade SAH after surgical obliteration of the aneurysm. WFNS Grade V at admission (P = 0.052) was weakly associated with a poor outcome.Conclusions:Advanced age (≥75 years old), Fisher group 4, and LDA associated with vasospasm on CT were independent predictors of clinical outcome in elderly patients with poor-grade SAH. A favorable outcome in these patients occurred more frequently after Guglielmi detachable coil embolization than after surgical clipping, but without a significant difference.

Fate of Clots in Patients With Subarachnoid Hemorrhage After Different Surgical Treatment Modality: A Comparison Between Surgical Clipping and Guglielmi Detachable Coil Embolization

Subarachnoid clot is important in the development of delayed vasospasm after subarachnoid hemorrhage (SAH). To compare the clearance of subarachnoid clot and the incidence of symptomatic vasospasm in surgical clipping and embolization with Guglielmi detachable coils for aneurysmal SAH. The subjects were 115 patients with Fisher group 3 aneurysmal SAH on computed tomography scan at admission whose aneurysm was treated by surgical clipping (clip group; n = 86) or Guglielmi detachable coil embolization (coil group; n = 29) within 72 hours of ictus. Software-based volumetric quantification of the subarachnoid clot was performed, and the amount of hemoglobin in drained cerebrospinal fluid was measured. Clearance of the subarachnoid clot on the computed tomography scan was rapid in the clip group until the day after the operation but slow in the coil group (58.9% removed vs 27.8% removed; P = .008). However, postoperative clearance of the clot occurred more rapidly in the coil group. Reduction of the clot until days 3 through 5 did not differ significantly between the 2 groups (72.9% removed vs 75.2% removed). The amount of hemoglobin in the clip group was > 0.8 g/d until day 3 and then gradually decreased (n = 15), but hemoglobin in the coil group remained at > 0.8 g/d until day 5 (n = 17). The incidence of symptomatic vasospasm did not differ between the groups. Subarachnoid clot can be removed directly during surgical clipping, which is not possible with endovascular treatment. However, the percentage reduction of the clot on days 3 through 5 did not differ between the 2 groups.

Preoperative Prediction of Outcome in 283 Poor-Grade Patients with Subarachnoid Hemorrhage: A Project of the Chugoku-Shikoku Division of the Japan Neurosurgical Society

Background: The management of patients with poor-grade subarachnoid hemorrhage (SAH) continues to be controversial. The objective of this study was to examine predictors of outcome of poor-grade SAH after surgical obliteration of the aneurysm. Methods: The study was performed as a retrospective review of 283 patients with poor-grade SAH who underwent surgical obliteration of the aneurysm at multiple centers in Chugoku and Shikoku, Japan. Results: A favorable outcome at discharge was achieved in 97 of the 283 patients (34.3%). Age (p < 0.001), World Federation of Neurosurgical Societies (WFNS) grade V at admission (p = 0.002), improvement in WFNS grade after admission (p = 0.002), Fisher grade (p = 0.039) and a low-density area (LDA) associated with vasospasm on computed tomography (CT; p < 0.001) showed a significant association with outcome. Further analysis of WFNS grades indicated that most patients who only improved to preoperative grade IV from grade V at admission did not have a favorable outcome. Multivariate analysis identified age (especially of ≧65 years; p < 0.001), WFNS grade V (p < 0.001) and LDA associated with vasospasm on CT (p < 0.001) as predictors of a poor outcome, and improvement in WFNS grade (p = 0.001) as a predictor of a favorable outcome after surgical obliteration of the aneurysm. Conclusions: Advanced age, WFNS grade V, improvement in WFNS grade, and LDA associated with vasospasm on CT were found to be independent predictors of clinical outcome, whereas rebleeding, early aneurysm surgery and treatment modality (surgical clipping or Guglielmi detachable coil embolization) were not independently associated with outcome in patients with poor-grade aneurysm.

Retroperitoneal hematoma after coil embolization of cerebral aneurysm -A case report-

We present the case of a 57-year-old man who developed retroperitoneal hemorrhage due to unintentional arterial puncture during femoral artery cannulation for Guglielmi detachable coil embolization. On emergence from anesthesia, he developed severe hypotension. Computed tomographic angiogram of the abdomen showed retroperitoneal hematomas around the urinary bladder, liver, and spleen. Because femoral artery cannulation is a common procedure for intravascular embolization in neuroradiologic procedures, Clinicians should be aware of the development of severe hematomas as a consequence of femoral artery puncture.

Complete Visual Recovery after Mycotic Aneurysm Embolization Complicated by Cavernous Sinus Thrombophlebitis

A 62-year-old woman has been suffered from cavernous sinus thrombophlebitis which was confirmed by four-vessel angiography, orbit magnetic resonance imaging, and blood culture. Three weeks after recovery of cavernous sinus thrombophlebitis, right eye proptosis and complete third, fourth, and sixth cranial nerve palsies developed. Best-corrected visual acuity decreased to 20/70 in the right eye. Repeat magnetic resonance imaging demonstrated a 1.5-cm-sized mass in the right cavernous sinus, suspicious for mycotic aneurysm. Amphotericin B supplementation was begun and was followed by successful transarterial Guglielmi detachable coil embolization. Four months later, extraocular movement was normalized, and visual acuity improved to 20/25 in the right eye.

Successful Transarterial Guglielmi Detachable Coil Embolization of Post-Traumatic Fistula between a Posterior Communicating Artery Aneurysm and the Cavernous Sinus

We describe a case of a post-traumatic posterior communicating artery (PCoA) aneurysm-cavernous sinus fistula, which is an extremely rare complication of craniocerebral trauma, successfully treated with endosaccular coil embolization via transarterial route. Endosaccular embolization with Guglielmi detachable coils via transarterial route appears to be a feasible, effective and minimally invasive option for the treatment of post-traumatic fistula between the PCoA aneurysm with a small ostia and the cavernous sinus in the subacute phase.

Long-Term Follow-Up of 1036 Cerebral Aneurysms Treated by Bare Coils: A Multicentric Cohort Treated between 1998 and 2003

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. 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. 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. 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.

Computerized Assessment of Angiographic Occlusion Rate and Coil Density in Embolized Human Cerebral Aneurysms

Computerized methods have been introduced for more objective quantification of angiographic occlusion rate and coil density as parameters of successful embolization. This study aimed 1) to evaluate this new computerized method for angiographic occlusion rating and coil density calculations by comparison with corresponding histometric parameters from retrieved human aneurysms, and 2) to compare the new computerized method with the present standard of subjective angiographic occlusion rating. From 14 postmortem-retrieved human aneurysms, angiographic occlusion rate was determined by contrast medium attenuation-gradient distinction on digital subtraction angiographs after Guglielmi detachable coil (GDC) embolization. Angiographic coil density was calculated, approximating aneurysms as ellipsoid and coils as cylindric volumes. On surface-stained histologic ground sections of the respective aneurysms, the occluded aneurysm area and coil area were measured. Then, we calculated and compared the histometric occlusion rates and coil densities with the corresponding angiographic parameters by using the Wilcoxon paired signed-rank test and the Spearman rank correlation. Computerized angiographic occlusion rates (75%-100%) showed good correlation (r = 0.799; P < .01) with histometric occlusion-rates (61%-100%), resulting in no statistically significant differences (P = .2163). With 5.1% (+/-3.8), the mean difference between computerized angiographic occlusion rates and histometry was substantially lower compared with 10.7% (+/-8.7) mean difference between subjective angiographic estimations and histometry. Calculated angiographic coil density (13%-32%) significantly differed from histometric coil density (8%-35%; P < .05). For recanalized aneurysms, computerized angiographic occlusion rating showed better correspondence with histometry compared with subjective angiographic occlusion rating. Clinical application of this new tool may lead to more objective cutoff values for re-embolization indications. The value of coil density calculations seems limited by the approximation of the aneurysms as ellipsoid volumes.

Multi-Modality Treatment for Intracranial Arteriovenous Malformation Associated with Arterial Aneurysm

Intracranial arteriovenous malformation (AVM) associated with aneurysm has been infrequently encountered and the treatment for this malady is challenging. We report here on our clinical experience with AVMs associated with arterial aneurysms that were managed by multimodality treatments, including clipping of the aneurysm, microsurgery, Gamma-knife radiosurgery (GKS) and Guglielmi detachable coil (GDC) embolization. We reviewed the treatment plans, radiological findings and clinical courses of 21 patients who were treated with GKS for AVM associated with aneurysm. Twenty-seven aneurysms in 21 patients with AVMs were enrolled in this study. Hemorrhage was the most frequent presenting symptom (17 patients : 80.9%). Bleeding was caused by an AVM nidus in 11 cases, aneurysm rupture in 5 and an undetermined origin in 1. Five patients were treated for associated aneurysm with clipping followed by GKS for the AVM and 11 patients were treated with GDC embolization combined with GKS for an AVM. Although 11 associated aneurysms remained untreated after GKS, none of them ruptured and 4 aneurysms regressed during the follow up period. Two aneurysms increased in size despite the disappearance of the AVM nidus after GKS and then these aneurysms were treated with GDC embolization. If combined treatment using microsurgery, GKS and endovascular treatment can be adequately used for these patients, a better prognosis can be obtained. In particular, GKS and GDC embolization are considered to have significant roles to minimize neurologic injury.

Bilateral paramedian thalamic and mesencephalic infarcts after basilar tip aneurysm coiling: role of the artery of Percheron

Aneurysm embolization using Guglielmi detachable coils (GDC) is gaining acceptance as a viable alternative for surgery in the treatment of aneurysms. Recent reports describe a significant rate of thromboembolic complications. Thalamic and midbrain blood supply can arise from complex anatomical variations. The rare variation: "artery of Percheron", is a solitary arterial trunk arising from one of the proximal segments of a posterior cerebral artery and supplies the paramedian thalami and rostral midbrain bilaterally. We describe a patient that underwent elective endovascular treatment for a basilar tip aneurysm using GDC and stents in each PCA; 12 hours later patient was comatose and not following commands. Sequential magnetic resonance imaging (MRI) of brain showed bilateral paramedian thalamic and mesencephalic infarcts presumably secondary to artery of Percheron occlusion. Thromboembolic event related to the use of the GDC embolization and stents is a rare clinical sequelae, but catastrophic. The use of antiplatelets agents should be reinforced in the scenario. When bilateral medial thalamic and midbrain infarcts are found, occlusion of the artery of Percheron should be considered. Angiography may not b helpful and lack of visualization of the artery does not exclude its presence. In this case the MRI findings confirmed the presence of the infarction based on the anatomical distribution.

Transvenous Embolization of Primitive Trigeminal Artery Variant-Cavernous Fistula with Guglielmi Detachable Coils

Here, we present a 32-year-old male with proptosis and chemosis of the left eye following a close head injury. Digital subtraction angiography of the left internal carotid artery showed a left carotid-cavernous fistula (CCF) associated with a primitive trigeminal artery (PTA) variant. The patient was successfully treated with transvenous Guglielmi detachable coils embolization via the inferior petrosal sinus. The PTA variant was preserved without cerebellar or brainstem infarct.

Primary treatment of a blood-blister-like aneurysm of the internal carotid artery with Guglielmi detachable coil embolisation

Blood-blister-like aneurysms (BBAs) are rare but challenging to treat owing to their fragile, thin walls and poorly defined necks. Studies have shown many complications related to this type of aneurysm. In particularly, other authors have reported high rates of complications arising within a few weeks of BBAs treated with primary endovascular coiling. We report a 44-year-old woman with subarachnoid haemorrhage due to a ruptured BBA to demonstrate successful primary treatment with endovascular coiling without complications or regrowth at 6-month follow up.

MECHANICAL DETACHMENT OF GUGLIELMI DETACHABLE COILS AFTER FAILED ELECTROLYTIC DETACHMENT

We describe the mechanical detachment of 2 Guglielmi detachable coils (GDC) that had been placed in a ruptured aneurysm and that failed to detach by electrolysis. Mechanical detachment was attempted by continuously rotating the delivery wire. The feasibility and reproducibility of this maneuver was tested by conducting additional in vitro tests. Two GDCs that had been positioned in a ruptured cerebral aneurysm and had failed to detach by electrolysis were separated from the delivery wire by rotating the wire until the weakest segment of the coils broke. GDCs tested in vitro with correct detachment positioning could be separated from the microcatheter tip by approximately 15 rotations of the delivery wire without coil loop movement inside the aneurysm. Mechanical detachment of an electrolytic GDC by rotating the delivery wire until a break occurs can be safely performed in a potentially risky situation caused by detachment failure during GDC embolization of cerebral aneurysms.