Small Residual Neck Research Articles

Clipping of Unruptured Anterior Choroidal Artery Aneurysms Together with Small Branches: Safety Confirmation Using Intraoperative Indocyanine Green Video-Angiography and Intraoperative Neurophysiological Monitoring

In treating anterior choroidal artery (AChA) aneurysms, preserving the AChA main trunk is of course necessary to prevent postoperative ischemic complications. However, in practice, complete occlusions are often limited by small branches. We aimed to demonstrate that even in cases where complete occlusion of the AChA aneurysm is complex due to small branches, complete occlusion can be safely achieved using indocyanine green video-angiography and intraoperative neurophysiological monitoring (IONM). We performed a retrospective review of all unruptured AChA aneurysms surgically treated at our institution from 2012 to 2021. All available surgical videos were reviewed to find AChA aneurysms clipped with small branches; clinical and radiological data were collected for these cases. Among 391 cases of unruptured AChA aneurysms treated surgically, 25 AChA aneurysms were clipped with small branches. AChA-related ischemic complications occurred in 2 cases (8%) without retrograde indocyanine green filling to the branches. These 2 cases had changes in IONM. There were no ischemic complications in the remaining cases with retrograde indocyanine green filling to the branches and no change in IONM. During an average follow-up of 47months (12-111months), a small residual neck was observed in 3 cases (12%) and recurrence or progression of the aneurysm was observed in only 1 case (4%). The surgical treatment of AChA aneurysms carries the risk of devastating ischemic complications. Even in cases where complete clip ligation seems impossible due to small branches associated with AChA aneurysms, complete occlusion can be safely achieved using indocyanine green video-angiography and IONM.

Treatment of complex intracranial pathologies with transcirculation endovascular approaches

ObjectThe breadth and complexity of neurovascular pathologies treated with endovascular neurosurgery has expanded dramatically in recent years. Many aneurysms remain difficult to treat safely. Transcirculation (contralateral and/or retrograde) approaches through the circle of Willis are useful alternatives for treating challenging lesions endovascularly. Here, we present a series of patients treated with unconventional transcirculation techniques. MethodsA total of six patients were treated: four patients with five aneurysms, one patient with an MCA stroke, and one patient with a meningioma requiring preoperative embolization were initially thought not to be amenable to endovascular treatment. The decision was made to treat these patients with transcirculation approaches. All patients were treated by one interventionist. One aneurysm was located in the cavernous internal carotid artery (ICA), one in the vertebral artery, two in the paraclinoid ICA, and one in a cerebellar AVM feeder vessel were treated. ResultsFive of six patients (83%) made a full neurologic recovery. Three aneurysms were treated to complete occlusion, one aneurysm was left with small residual neck filling, and one aneurysm was not able to be treated. One patient underwent mechanical thrombectomy of a middle cerebral artery (MCA) embolus and MCA filling was restored after treatment. One patient underwent complete embolization of the deep vascular supply of a meningioma. ConclusionsAlthough many neurovascular pathologies remain unsuitable for endovascular treatment, transcirculation approaches can allow for safe, successful treatment of challenging lesions in select patients.

Treatment of complex intracranial pathologies with transcirculation endovascular approaches.

The breadth and complexity of neurovascular pathologies treated with endovascular neurosurgery has expanded dramatically in recent years. Many aneurysms remain difficult to treat safely. Transcirculation (contralateral and/or retrograde) approaches through the circle of Willis are useful alternatives for treating challenging lesions endovascularly. Here, we present a series of patients treated with unconventional transcirculation techniques. A total of six patients were treated: four patients with five aneurysms, one patient with an MCA stroke, and one patient with a meningioma requiring preoperative embolization were initially thought not to be amenable to endovascular treatment. The decision was made to treat these patients with transcirculation approaches. All patients were treated by one interventionist. One aneurysm was located in the cavernous internal carotid artery (ICA), one in the vertebral artery, two in the paraclinoid ICA, and one in a cerebellar AVM feeder vessel were treated. Five of six patients (83%) made a full neurologic recovery. Three aneurysms were treated to complete occlusion, one aneurysm was left with small residual neck filling, and one aneurysm was not able to be treated. One patient underwent mechanical thrombectomy of a middle cerebral artery (MCA) embolus and MCA filling was restored after treatment. One patient underwent complete embolization of the deep vascular supply of a meningioma. Although many neurovascular pathologies remain unsuitable for endovascular treatment, transcirculation approaches can allow for safe, successful treatment of challenging lesions in select patients.

Adenosine-Induced Transient Asystole During Surgical Treatment of Basilar Artery Aneurysms

To evaluate the safety and efficacy of adenosine-induced transient asystole (AITA) during surgery for basilar artery aneurysms. All the patients with basilar artery aneurysms operated using AITA at our institute during two years period (August 2013-July 2015) were included in this study. Adenosine was used in 11 patients with 13 basilar artery aneurysms. Seven of these aneurysms were basilar bifurcation aneurysms, four were basilar-superior cerebellar artery junction aneurysms, and two were distal basilar trunk aneurysms. The indications for AITA were narrow corridor for placement of temporary clip in 11 aneurysms, intraop rupture in 1 aneurysm, and circumferential dissection of a large aneurysm in 1. The mean dose of adenosine used for inducing asystole was 19.4 mg (range: 15-30 mg) and the mean total dose of adenosine used was 40.6 mg (range: 18-90 mg). A mean of 2 (range: 1-5) AITAs were required during surgical treatment of these aneurysms. The mean duration of a systole was 27 s (range: 9-76 s). There were no complications related to AITA in these patients except for transient rebound hypertension in one patient. Check angiogram revealed complete obliteration of 11 aneurysms and small residual neck in 2 aneurysms. Modified Rankin Scale at three months of follow-up was 0 in seven patients, 1 in two patients, 4 in one patient, and 6 in one patient. AITA during surgical management of basilar artery aneurysms is a safe and effective technique and has an important role during surgery for these aneurysms.

Intradural “limited drill” technique of anterior clinoidectomy and optic canal unroofing for microneurosurgical management of ophthalmic segment and PCOM aneurysms—review of surgical results

To evaluate the safety and efficacy of intradural "limited drill" technique (ILDT) of anterior clinoidectomy (AC) and optic canal unroofing (OCU) for microneurosurgical management of ophthalmic segment and posterior communicating artery (PCOM) aneurysms. All the patients with ophthalmic segment and PCOM aneurysms who underwent AC and OCU by ILDT for microneurosurgical management of ophthalmic segment and PCOM aneurysms during 4-year period (2013-2016) at our Institute were included in this study. In ILDT of AC and OCU, the use of power drill is restricted to AC only and OCU is done exclusively with 1-mm Kerrison punch. AC and OCU by ILDT were done in 24 patients with 29 ophthalmic segment and 7 PCOM aneurysms. AC and OCU by ILDT helped in mobilization of optic nerve/internal carotid artery (ICA) and provided excellent exposure for all these aneurysms. There was no injury to ICA or optic nerve during drilling. AC and OCU facilitated clip ligation of 34 of these aneurysms. Remaining 2 aneurysms were considered not suitable for clipping. Check angiogram done for 33 aneurysms revealed complete obliteration of 26 aneurysms, very small residual neck in 5 aneurysms, and small residual aneurysm in 2 aneurysms. Deterioration in vision was noted in 1 patient (4.1%). In 6 patients with preoperative visual deficits, significant improvement in vision was noted in 4 patients (4/6-66.6%) after surgery. Good outcome (MRS < 2) was noted in 91.6% (22/24) of these patients. ILDT is a safe and effective technique of AC and OCU which provide good exposure for ophthalmic segment and PCOM aneurysms.

Microsurgical treatment of paraclinoid aneurysms: A report of 20 cases

Objective To investigate the microsurgical strategy and efficacy of paraclinoid aneurysms. Methods The clinical data of 20 patients with paraclinoid aneurysms were retrospectively reviewed who underwent microsurgical clipping from November 2015 to March 2017 at Neurosurgery Department of the First Affiliated Hospital of Chongqing Medical University. The operative methods included simple clipping and clipping of aneurismal neck and parent artery reconstruction. After the operation, the aneurysm clipping was examined by CTA or DSA, and the Glasgow prognosis score (GOS) was used to evaluate the clinical effect. All patients were followed up by outpatient clinic or telephone, and the GOS scale was used to assess the patient's prognosis. Results All patients achieved satisfactory results. There was no aneurysm recurrence or rebleeding in this series detected by CTA or DSA. Only 1 case of unruptured aneurysm had a small residual neck after treatment. There was no death during the perioperative period. The GOS grade was Ⅴ in 13 cases, Ⅳ in 6 and Ⅲ in 1 at discharge. All patients were followed up for a period of 1-18 months, with an average of 10±6 months. The GOS grade was Ⅴ in 16 cases and Ⅳ in 4 cases. Conclusion Microsurgical clipping of paraclinoid aneurysm seems to be safe and feasible, which could have a favorable outcome. Key words: Intracranial aneurysm; Microsurgery; Treatment outcome

Double-clip technique: An effective clipping technique for small and very small aneurysms.

Background:In this video abstract, we present a double-clip technique for the management of small (≤5 mm) and very small (≤3 mm) aneurysms with a suitable configuration to apply two clips. This is a parallel duplication clipping technique of booster clipping which uses mini-clips that have a smaller closing force compared to standard clips. This technique prevents the slippage of the applied clips, was developed along the career of the senior author (Juha Hernesniemi), and has been previously proved to be safe and effective for aneurysm clipping.Technique:The patient with a familial left small (4 × 3 mm) unruptured paraclinoid aneurysm is placed in the supine position. A left lateral supraorbital approach is performed. After opening the carotid cistern, the aneurysm is discovered under a careful microsurgical dissection. With an exposed aneurysm, cardiac arrest and hypotension produced by adenosine intravenous administration reduces the intravascular and intra-aneurysmatic pressure, and allow us a proximal control of the aneurysm without the use of the conventional temporary clipping (TC). In this regard, quick adenosine cardiac arrest is performed instead of an anterior clinoidectomy and proximal TC, whether the neck of the small paraclinoid aneurysm remains visible, but the space for placing TC is too reduced that may difficult the definitive clipping. According to our experience, the use of adenosine (0.2–0.4 mg/kg/dose) in multiple doses up to 87 mg/patient/surgery did not have any effect on the patient outcome. However, a very close collaboration between the surgeon and the anesthesiologist is required. After vascular control is ensured, an initial definitive mini-clip is applied, and a small residual neck sufficient for application of the second mini-clip is left. A second mini-clip with similar morphology to the first one is applied on the residual neck parallel and running in the same direction to the initial clip. With this, the slippage of the proximal mini-clip is prevented. Moreover, the synergic force of both clips ensures a proper occlusion of the aneurysm. Postoperative computed tomography angiography demonstrated absence of complications.Conclusion:The double-clip technique, a variation of booster clipping is an effective procedure to ensure a proper occlusion of small and very small aneurysms.Videolink:http://surgicalneurologyint.com/videogallery/double-clipping-technique/

Repeated Subarachnoid Hemorrhage Due to a Ruptured Radiation-Induced Aneurysm in a Patient with Suprasellar Germinoma Treated By Radiation Therapy 27 Years Previously: A Case Report

Background: Radiation-induced intracranial aneurysm (RIICA) is a rare complication. From the literature, 74.1% of the reported RIICA ruptured with aneurysmal subarachnoid hemorrhage (SAH), and the mortality rate was 42.3%. Here, we report a case of repeated SAH due to a RIICA after surgical clipping. Case description: A 42-year-old woman presented with SAH. She had undergone radiotherapy for suprasellar germinoma 27 years previously. Digital subtraction angiography (DSA) showed an aneurysm at the anterior wall of the non-branching site of the left internal carotid artery and multiple luminal narrowing. The aneurysm was located within the radiation field, and was not detected by previous DSA. Surgical clipping was performed, but bleeding repeated after 3 months. We performed a second neck clipping and confirmed that the clip had slipped from the neck of the aneurysm. Thirty-nine days after the second operation, DSA revealed an enlargement of residual neck of the aneurysm. Therefore, we performed an endovascular stent-assisted coil embolization of the aneurysm. At the end of the endovascular coiling, the small residual neck of the aneurysm was still observed. The follow-up DSA obtained three weeks after the coil embolization demonstrated enlargement of the residual neck. At 6 months after the first coil embolization, we performed an additional coil embolization which achieved complete obliteration of the aneurysm. Her cranial nerves were intact, and motor and sensory examinations revealed no deficits. Close followup by imaging is in progress. Conclusion: A careful annually follow up, with not only MR imaging but also MR angiography as well, is important for the patients who had a full response to radiation therapy for germinoma in childhood. Special attention must be paid in the treatment of RIICA patients, because of fragility of arterial wall adjacent to the RIICA and the radiation-induced severe atherosclerotic change.

A Reappraisal of Anterior Communicating Artery Aneurysms: A Case for Stent-Assisted Embolization.

Wide-necked anterior communicating artery aneurysms represent a subset of lesions with challenging endovascular treatment despite new endoluminal and intrasaccular devices. To assess the long-term clinical and angiographic outcomes of stent-assisted embolization for wide-necked anterior communicating artery aneurysms. Between March 2008 and March 2014, 32 patients with unruptured wide-necked AComm aneurysms were treated using stent-assisted embolization. The Glasgow Outcome Scale was reviewed at the time of discharge and at latest follow-up. Ischemic and hemorrhagic events were also recorded and analyzed. Aneurysm occlusion was evaluated post-intervention and on subsequent follow-up evaluations. Successful stent deployment was achieved in all cases, but in 1 patient the coils could not be contained inside the aneurysm, and the procedure was aborted without complications. The distal segment of the stent was positioned in the ipsilateral A2 in 16 patients, in the contralateral A2 in 15 patients, and in the contralateral A1 in 1 patient. There were no periprocedural thromboembolic or hemorrhagic complications. The rate of major complications was 6%. One patient developed intracranial hemorrhage related to antiplatelet therapy and another had ischemic events due to in-stent stenosis. Angiographic follow-up was available for 26 aneurysms and during a mean follow-up of 22 months, 81% of the lesions were completely occluded and 8% had a small residual neck. The retreatment rate for residual aneurysms was 3%. Our long-term results suggest that stent-assisted embolization for anterior communicating artery aneurysms may be considered an excellent treatment option with an adequate combination of safety profile and effectiveness.

Double-clip technique for the microneurosurgical management of very small (< 3 mm) intracranial aneurysms.

The treatment of very small (≤ 3 mm) aneurysms is technically challenging. Mini-clips used for clipping these small aneurysms have a smaller closing force compared with standard clips. To describe the double-clip technique for very small aneurysms. The double-clip technique, a parallel duplication clipping technique of booster clipping, is used by the senior author for clipping very small aneurysms with morphology suitable for the application of 2 clips. The aneurysm is clipped after application of temporary clip(s), administration of adenosine, or both. An initial mini-clip is applied, leaving a small residual neck sufficient for application of the second mini-clip. A second mini-clip of the same size and shape is applied on the residual neck parallel to the initial clip. The initially applied mini-clip, which is in close contact with the second clip, supports the second clip and prevents its slippage. This technique was retrospectively reviewed over a 13-year period (1997-2009). There were 3246 patients with 4757 aneurysms treated in the same period. The outcomes of 39 patients with 40 very small aneurysms clipped with the double-clip technique were analyzed. None of the patients had technique-related complications. Postoperative angiograms revealed complete aneurysm occlusion of 39 aneurysms and a small residual neck in 1 aneurysm. No parent artery obstruction was observed in the postoperative angiogram. The double-clip technique is a safe and effective variation of booster clipping in the treatment of very small aneurysms with suitable morphology.

Anterior Choroidal Artery Aneurysm Surgery: Ischemic Complications and Clinical Outcomes Revisited

ObjectiveSurgical results for anterior choroidal artery (AChA) aneurysms have previously been reported as unsatisfactory due to inadvertent occlusion of the AChA, while the low incidence of AChA aneurysms hampers the accumulation of surgical experience. The authors reviewed their related surgical experience to document the ischemic complications and surgical outcomes.MethodsIdentification of the AChA at its origin by rigorous visual scrutiny, careful microdissection, and meticulous clip placement to avoid the AChA origin are all crucial surgical maneuvers. A retrospective review of a surgical series of 62 consecutive cases of an AChA aneurysm between 2004 and 2012 was performed.ResultsAll patients, except for five (8.1%) with a small residual neck, showed complete aneurysm obliteration in postoperative angiographic evaluations. There was no incidence of procedure-related permanent AChA syndrome or oculomotor nerve palsy, while three (4.8%) patients suffered from transient AChA syndrome. The clinical outcomes [the 3-month modified Rankin Scale (mRS)] of the patients were related to their preoperative World Federation of Neurologic Surgeons (WFNS) grade. As regards the 3-month mRS, significant differences were found between patients with an unruptured aneurysm (WFNS grade 0; n=20), good-grade subarachnoid hemorrhage (WFNS grade 1-3; n=30), and poor-grade subarachnoid hemorrhage (WFNS grade 4-5; n=4).ConclusionIn surgical treatment of AChA aneurysms, a risk of AChA insufficiency can be minimized by taking every precaution to preserve the AChA patency and intraoperative monitoring. In addition, the surgical outcome is primarily determined by the preoperative clinical state.

Surgical Treatment of Unruptured Intracranial Middle Cerebral Artery Aneurysms: Angiographic and Clinical Outcomes in 143 Aneurysms

ObjectiveThe purpose of this study was to determine the outcomes of surgical clipping in patients with unruptured middle cerebral artery (MCA) aneurysms.MethodsA retrospective single-center database of 125 consecutive patients with 143 small MCA aneurysms (< 10 mm) who underwent surgical clipping was reviewed from January 2007 to December 2010. Clinical outcomes were assessed based on surgery-related complications and follow-up (mean: 17 months) using the modified Rankin scale (mRS). Angiographic outcomes were evaluated by conventional angiography (N = 96) or computed tomography angiography (N = 29) at postoperative weeks 1 and 6.ResultsThere were no cases of mortality. There were three surgery-related complications (intracranial hemorrhage, meningitis and wound infection, respectively). The hemorrhagic event caused transient neurological deficits. All patients showed good clinical outcomes during follow-up (mRS 0-1). There was angiographic evidence of complete occlusion in 137 aneurysms (95.8%), a small residual neck in three aneurysms (2.2%) and partial for three aneurysms. In the three cases with partial clipping, the decision was made preoperatively to leave the residual sac to maintain distal flow, and muscular wrapping was performed.ConclusionOur study demonstrates that surgical clipping of unruptured small MCA aneurysms yields favorable clinical and angiographic outcomes. Aneurysmal clipping can be safely recommended for patients with small unruptured MCA aneurysms.

Redefining Onyx HD 500 in the Flow Diversion Era

We report the largest US case series results using Onyx HD-500 (EV3), a new liquid embolic agent, in the successful treatment of 21 patients with wide-neck intracranial aneurysms (mean size 4.5 mm), which are at increased risk of incomplete occlusion or recanalization with standard endovascular intervention utilizing detachable platinum coils. All aneurysms were located in the anterior circulation, and three aneurysms presented as acute subarachnoid hemorrhages. Complete aneurysm occlusion was present in 19 of 21 patients (90%). On six-month followup, one patient with an initially small residual neck progressed to total occlusion. Aneurysm recanalization was not detected in any patients on mean follow up of 8.9 months in 11 patients. Four patients experienced transient neurologic deficits in the immediate postoperative period and one in a delayed fashion. Embolization with the liquid embolic agent Onyx appears to be a safe and effective endovascular modality of treatment for wide-neck aneurysms or recurrent aneurysms that had previously failed treatment with detachable coils.

Long-term visual outcome and aneurysm obliteration rate for very large and giant ophthalmic segment aneurysms: assessment of surgical treatment

Standard endovascular therapy has shown little success in treatment of very large and giant ophthalmic segment aneurysms. We hypothesize that surgical treatment of these aneurysms yields better results in terms of visual function and aneurysm obliteration. The Toronto Brain Vascular Malformation Study Group database was analyzed to retrieve patients treated surgically for very large (>15 mm) and giant aneurysms of the ophthalmic segment of the carotid artery. Preoperative data and postoperative long-term outcomes with specific consideration for visual function and aneurysm obliteration were evaluated. Of the 257 patients with ophthalmic and paraophthalmic aneurysms, 38 patients had very large or giant aneurysms. Twenty-one underwent surgical treatment; 19 had direct clipping; 1 had trapping, and 1 underwent trapping and bypass. Fifteen patients had unruptured and six had ruptured aneurysms. The mean follow-up period was 88 months. Six (28%) aneurysms had a small residual neck remnant. Of the 12 patients with documented preoperative visual deficit, 9 (75%) improved, 2 (16%) remained stable, and 1 (8%) worsened. Two patients had mild to moderate new visual deficit. Thus, the surgery-related visual complications were 14%. Eighteen patients (86%) had a good or excellent outcome (GOS IV and V). Presentation with prior visual deficit and poor neurological function were predictors of worse visual and clinical outcome, respectively (P = 0.02 and 0.01). There is considerable surgery-related risk for optic pathways during treatment of very large and giant ophthalmic segment aneurysms. Surgery, however, seems to be the treatment of choice in terms of overall visual outcome and aneurysm obliteration as compared to the current endovascular results in this subset of patients.

Stability of ruptured intracranial aneurysms treated with detachable coils: is delayed follow-up angiography warranted?

The optimal strategy for monitoring the stability of ruptured intracranial aneurysms following coil embolisation is unclear. The value of delayed follow-up angiography in detecting new recurrences or progression of residual lesions visualised on earlier angiographic studies was determined in the light of the increasing use of non-invasive imaging techniques such as time of flight magnetic resonance angiography (TOF-MRA) for the evaluation of intracranial aneurysm occlusion. Ninety-seven patients with 105 ruptured aneurysms treated with detachable coils in 2005 and 2006 were included. The presence of a residual neck or aneurysm was assessed on catheter angiograms performed at 6 months and 2 years using the Raymond criteria (Class I = completely occluded, class II = small residual neck, class III = aneurysm sac filling). At 6-month follow-up, 32% of class I aneurysms progressed to class II and 6% of these aneurysms required re-treatment. A further 2-year angiogram was obtained in 59 patients with 65 aneurysms. Ninety-six per cent of class I, 100% of the class II and class III aneurysms remained unchanged at 2 years compared to 6 months. In our series, most recurrences were apparent at 6-month follow-up. The vast majority of coiled ruptured aneurysms that were class I or II at 6 months remained stable at 2-year follow-up. In the absence of a residual lesion in the early angiographic study, a further delayed catheter angiogram may not be warranted. The use of non-invasive strategies such as TOF-MRA should be considered.

Acute serious rebleeding after angiographically successful coil embolization of ruptured cerebral aneurysms

The present study investigated the incidence of acute rebleeding after successful coil embolization of a ruptured cerebral aneurysm, including clinical outcomes, and possible mechanisms of the events other than coil compaction and/or incomplete embolization. This study included 591 consecutive patients who presented with aneurysmal subarachnoid hemorrhage, were treated with coil embolization, and whose post-procedural angiography revealed successful embolization. Data were collected retrospectively from six patients who showed acute rebleeding despite that angiographically successful coil embolization was achieved. All clinical, radiological data and intraoperative videos were reviewed to identify causative factors which could have contributed to the occurrence of rebleeding. Incidence of acute rebleeding after successful coil embolization of ruptured cerebral aneurysm was 1.0% (6/591). In all of these six patients, complete angiographic occlusion was achieved except in one case where a small residual neck was intentionally left to avoid compromise of the parent artery. Four of the six patients showed poor clinical courses, either died or recovered with severe disability. Whenever possible, we performed an immediate craniotomy for exploration and additional clipping. Based on intraoperative findings, we hypothesized that uneven distribution of the coil masses and spontaneous resolution of thrombus among the strands of coil (inter-coil-loop thrombolysis) could be possible mechanisms of rebleeding. Acute rebleeding is extremely rare, but is possible as a complication of coil embolization of a ruptured cerebral aneurysm even when a case is angiographically successful. The higher degree of morbidity and mortality is a major concern. Therefore, further investigation to discover risk factors and causative mechanisms for such a complication is sorely needed.

Cerecyte versus Platinum Coils in the Treatment of Intracranial Aneurysms: Packing Attenuation and Clinical and Angiographic Midterm Results

As modifications are made to coils, monitoring the safety profile, ability to achieve high packing attenuation, and durability of occlusion as compared to the standard bare platinum coils is of paramount importance. We compared packing attenuation, initial occlusion, and recanalization rates between Cerecyte and bare platinum coils in the treatment of ruptured and unruptured cerebral aneurysms. We compared 63 patients (67 aneurysms) treated with Cerecyte coils with 65 patients (70 aneurysms) treated by using bare platinum coils. Results were classified by the Raymond score. Clinical outcomes were assessed by using a modified Rankin Scale. Angiographic and clinical follow-ups were performed routinely at 6 and 12 months after the intervention. In the Cerecyte group, complete occlusion of the aneurysm (grade 1) was accomplished in 49% (33/67), a small residual neck (grade 2) was seen in 21% (14/67), and dome filling (grade 3) was seen in 30% (20/67). In the platinum group, 41% (29/70) were grade 1, 39% (27/70) were grade 2, and 20% (14/70) were grade 3 immediately postembolization. Mean packing attenuation was 43 +/- 28% in the Cerecyte group and 40 +/- 23% in the bare platinum group (P = .68). Twelve-month follow-up data were available for 54% (36/67) of the Cerecyte population and 43% (30/70) of the bare platinum population. There were 5 cases of neck recanalization (11%) in the Cerecyte group and 11 cases (23%) in the bare platinum group (P = .17). No rebleeds were noted in the follow-up period. Cerecyte coils have a satisfactory safety profile. We were able to achieve high packing attenuations and initial occlusion rates similar to those obtainable with platinum coils.

Treatment related morbidity of unruptured intracranial aneurysms: results of a prospective single centre series with an interdisciplinary approach over a 6 year period (1999–2005)

Objectives: To review the angiographic and clinical outcome of patients with unruptured intracranial aneurysm(s) (UIA) with regard to complications and successful obliteration by surgical clipping or endovascular coiling. Methods: Data...

Embolization of wide-necked aneurysms with using three or more microcatheters

A new and relatively simple endovascular technique, in which more than three microcatheters are used for endovascular treatment of cerebral aneurysms for the first time, is described. Eight patients with wide necked aneurysms were successfully treated with detachable coils using the multiple microcatheter technique. Three patients presented with subarachnoid haemorrhage and five were unruptured. The aneurysm locations were superior hypophyseal artery (2), posterior communicating artery (2), middle cerebral artery bifurcation (1), distal anterior cerebral artery (1), basilar artery (1) and vertebral artery (1). The average neck size was 7.4 +/- 2.8 mm (3.5-12 mm), average width of the aneurysms was 10.6 +/- 5.7 mm (6.2-23 mm) and depth was 8.9 +/- 5.8 mm (3-22 mm). Three microcatheters (7 patients) and four microcatheters (1 patient) were introduced and used for coil delivery. Three or four coils were deployed and intermingled to stabilize the whole coil mass as well as to occupy the aneurysmal sac. When a relatively stable coil frame was formed, one coil was detached and subsequent coils were inserted. After the coil mass became more stable, other coils were also detached and all microcatheters were used for subsequent coil deployment. All aneurysms were successfully treated without complications. Postemboilzation angiograms showed no contrast filling in 5 cases (100% occlusion) and a very small residual neck in 3 cases. There was no procedure related complication. The multiple microcatheter technique can be one technical option for the endovascular treatment of wide necked aneurysms.

Delayed exacerbation of third nerve palsy due to aneurysmal regrowth after endovascular coil embolization.

A 72-year-old woman with a painful left third cranial nerve palsy due to a basilar artery aneurysm situated between the superior cerebellar and posterior cerebral arteries was treated with Guglielmi detachable coils (GDCs). Despite a good initial angiographic result with a small residual neck and improvement in the ocular motility and pain, the patient experienced worsening of the third cranial nerve palsy 15 months later. Cerebral angiography confirmed coil compaction with aneurysmal regrowth. A second endovascular coil embolization resulted in complete obliteration of the aneurysm. The patient experienced complete resolution of the pain and partial resolution of the third cranial nerve palsy. In some patients, a small residual aneurysm neck after endovascular embolization therapy with GDCs can result in delayed aneurysmal regrowth due to coil compaction. Clinical manifestations may herald this dangerous regrowth.