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1.  Coil Embolization for Intracranial Aneurysms 
Executive Summary
To determine the effectiveness and cost-effectiveness of coil embolization compared with surgical clipping to treat intracranial aneurysms.
The Technology
Endovascular coil embolization is a percutaneous approach to treat an intracranial aneurysm from within the blood vessel without the need of a craniotomy. In this procedure, a microcatheter is inserted into the femoral artery near the groin and navigated to the site of the aneurysm. Small helical platinum coils are deployed through the microcatheter to fill the aneurysm, and prevent it from further expansion and rupture. Health Canada has approved numerous types of coils and coil delivery systems to treat intracranial aneurysms. The most favoured are controlled detachable coils. Coil embolization may be used with other adjunct endovascular devices such as stents and balloons.
Intracranial Aneurysms
Intracranial aneurysms are the dilation or ballooning of part of a blood vessel in the brain. Intracranial aneurysms range in size from small (<12 mm in diameter) to large (12–25 mm), and to giant (>25 mm). There are 3 main types of aneurysms. Fusiform aneurysms involve the entire circumference of the artery; saccular aneurysms have outpouchings; and dissecting aneurysms have tears in the arterial wall. Berry aneurysms are saccular aneurysms with well-defined necks.
Intracranial aneurysms may occur in any blood vessel of the brain; however, they are most commonly found at the branch points of large arteries that form the circle of Willis at the base of the brain. In 85% to 95% of patients, they are found in the anterior circulation. Aneurysms in the posterior circulation are less frequent, and are more difficult to treat surgically due to inaccessibility.
Most intracranial aneurysms are small and asymptomatic. Large aneurysms may have a mass effect, causing compression on the brain and cranial nerves and neurological deficits. When an intracranial aneurysm ruptures and bleeds, resulting in a subarachnoid hemorrhage (SAH), the mortality rate can be 40% to 50%, with severe morbidity of 10% to 20%. The reported overall risk of rupture is 1.9% per year and is higher for women, cigarette smokers, and cocaine users, and in aneurysms that are symptomatic, greater than 10 mm in diameter, or located in the posterior circulation. If left untreated, there is a considerable risk of repeat hemorrhage in a ruptured aneurysm that results in increased mortality.
In Ontario, intracranial aneurysms occur in about 1% to 4% of the population, and the annual incidence of SAH is about 10 cases per 100,000 people. In 2004-2005, about 660 intracranial aneurysm repairs were performed in Ontario.
Treatment of Intracranial Aneurysms
Treatment of an unruptured aneurysm attempts to prevent the aneurysm from rupturing. The treatment of a ruptured intracranial aneurysm aims to prevent further hemorrhage. There are 3 approaches to treating an intracranial aneurysm.
Small, asymptomatic aneurysms less than 10 mm in diameter may be monitored without any intervention other than treatment for underlying risk factors such as hypertension.
Open surgical clipping, involves craniotomy, brain retraction, and placement of a silver clip across the neck of the aneurysm while a patient is under general anesthesia. This procedure is associated with surgical risks and neurological deficits.
Endovascular coil embolization, introduced in the 1990s, is the health technology under review.
Literature Review
The Medical Advisory Secretariat searched the International Health Technology Assessment (INAHTA) Database and the Cochrane Database of Systematic Reviews to identify relevant systematic reviews. OVID Medline, Medline In-Process and Other Non-Indexed Citations, and Embase were searched for English-language journal articles that reported primary data on the effectiveness or cost-effectiveness of treatments for intracranial aneurysms, obtained in a clinical setting or analyses of primary data maintained in registers or institutional databases. Internet searches of Medscape and manufacturers’ databases were conducted to identify product information and recent reports on trials that were unpublished but that were presented at international conferences. Four systematic reviews, 3 reports on 2 randomized controlled trials comparing coil embolization with surgical clipping of ruptured aneurysms, 30 observational studies, and 3 economic analysis reports were included in this review.
Safety and Effectiveness
Coil embolization appears to be a safe procedure. Complications associated with coil embolization ranged from 8.6% to 18.6% with a median of about 10.6%. Observational studies showed that coil embolization is associated with lower complication rates than surgical clipping (permanent complication 3-7% versus 10.9%; overall 23% versus 46% respectively, p=0.009). Common complications of coil embolization are thrombo-embolic events (2.5%–14.5%), perforation of aneurysm (2.3%–4.7%), parent artery obstruction (2%–3%), collapsed coils (8%), coil malposition (14.6%), and coil migration (0.5%–3%).
Randomized controlled trials showed that for ruptured intracranial aneurysms with SAH, suitable for both coil embolization and surgical clipping (mostly saccular aneurysms <10 mm in diameter located in the anterior circulation) in people with good clinical condition:Coil embolization resulted in a statistically significant 23.9% relative risk reduction and 7% absolute risk reduction in the composite rate of death and dependency compared to surgical clipping (modified Rankin score 3–6) at 1-year.
The advantage of coil embolization over surgical clipping varies widely with aneurysm location, but endovascular treatment seems beneficial for all sites.
There were less deaths in the first 7 years following coil embolization compared to surgical clipping (10.8% vs 13.7%). This survival benefit seemed to be consistent over time, and was statistically significant (log-rank p= 0.03).
Coil embolization is associated with less frequent MRI-detected superficial brain deficits and ischemic lesions at 1-year.
The 1- year rebleeding rate was 2.4% after coil embolization and 1% for surgical clipping. Confirmed rebleeding from the repaired aneurysm after the first year and up to year eight was low and not significantly different between coil embolization and surgical clipping (7 patients for coil embolization vs 2 patients for surgical clipping, log-rank p=0.22).
Observational studies showed that patients with SAH and good clinical grade had better 6-month outcomes and lower risk of symptomatic cerebral vasospasm after coil embolization compared to surgical clipping.
For unruptured intracranial aneurysms, there were no randomized controlled trials that compared coil embolization to surgical clipping. Large observational studies showed that:
The risk of rupture in unruptured aneurysms less than 10 mm in diameter is about 0.05% per year for patients with no pervious history of SAH from another aneurysm. The risk of rupture increases with history of SAH and as the diameter of the aneurysm reaches 10 mm or more.
Coil embolization reduced the composite rate of in hospital deaths and discharge to long-term or short-term care facilities compared to surgical clipping (Odds Ratio 2.2, 95% CI 1.6–3.1, p<0.001). The improvement in discharge disposition was highest in people older than 65 years.
In-hospital mortality rate following treatment of intracranial aneurysm ranged from 0.5% to 1.7% for coil embolization and from 2.1% to 3.5% for surgical clipping. The overall 1-year mortality rate was 3.1% for coil embolization and 2.3% for surgical clipping. One-year morbidity rate was 6.4% for coil embolization and 9.8% for surgical clipping. It is not clear whether these differences were statistically significant.
Coil embolization is associated with shorter hospital stay compared to surgical clipping.
For both ruptured and unruptured aneurysms, the outcome of coil embolization does not appear to be dependent on age, whereas surgical clipping has been shown to yield worse outcome for patients older than 64 years.
Angiographic Efficiency and Recurrences
The main drawback of coil embolization is its low angiographic efficiency. The percentage of complete aneurysm occlusion after coil embolization (27%–79%, median 55%) remains lower than that achieved with surgical clipping (82%–100%). However, about 90% of coiled aneurysms achieve near total occlusion or better. Incompletely coiled aneurysms have been shown to have higher aneurysm recurrence rates ranging from 7% to 39% for coil embolization compared to 2.9% for surgical clipping. Recurrence is defined as refilling of the neck, sac, or dome of a successfully treated aneurysm as shown on an angiogram. The long-term clinical significance of incomplete occlusion following coil embolization is unknown, but in one case series, 20% of patients had major recurrences, and 50% of these required further treatment.
Long-Term Outcomes
A large international randomized trial reported that the survival benefit from coil embolization was sustained for at least 7 years. The rebleeding rate between year 2 and year 8 following coil embolization was low and not significantly different from that of surgical clipping. However, high quality long-term angiographic evidence is lacking. Accordingly, there is uncertainty about long-term occlusion status, coil durability, and recurrence rates. While surgical clipping is associated with higher immediate procedural risks, its long-term effectiveness has been established.
Indications and Contraindications
Coil embolization offers treatment for people at increased risk for craniotomy, such as those over 65 years of age, with poor clinical status, or with comorbid conditions. The technology also makes it possible to treat surgical high-risk aneurysms.
Not all aneurysms are suitable for coil embolization. Suitability depends on the size, anatomy, and location of the aneurysm. Aneurysms more than 10 mm in diameter or with an aneurysm neck greater than or equal to 4 mm are less likely to achieve total occlusion. They are also more prone to aneurysm recurrences and to complications such as coil compaction or parent vessel occlusion. Aneurysms with a dome to neck ratio of less than 1 have been shown to have lower obliteration rates and poorer outcome following coil embolization. Furthermore, aneurysms in the middle cerebral artery bifurcation are less suitable for coil embolization. For some aneurysms, treatment may require the use of both coil embolization and surgical clipping or adjunctive technologies, such as stents and balloons, to obtain optimal results.
Information from 3 countries indicates that coil embolization is a rapidly diffusing technology. For example, it accounted for about 40% of aneurysm treatments in the United Kingdom.
In Ontario, coil embolization is an insured health service, with the same fee code and fee schedule as open surgical repair requiring craniotomy. Other costs associated with coil embolization are covered under hospitals’ global budgets. Utilization data showed that in 2004-2005, coil embolization accounted for about 38% (251 cases) of all intracranial aneurysm repairs in the province. With the 2005 publication of the positive long-term survival data from the International Subarachnoid Aneursym Trial, the pressure for diffusion will likely increase.
Economic Analysis
Recent economic studies show that treatment of unruptured intracranial aneurysms smaller than 10 mm in diameter in people with no previous history of SAH, either by coil embolization or surgical clipping, would not be effective or cost-effective. However, in patients with aneurysms that are greater than or equal to 10 mm or symptomatic, or in patients with a history of SAH, treatment appears to be cost-effective.
In Ontario, the average device cost of coil embolization per case was estimated to be about $7,500 higher than surgical clipping. Assuming that the total number of intracranial aneurysm repairs in Ontario increases to 750 in the fiscal year of 2007, and assuming that up to 60% (450 cases) of these will be repaired by coil embolization, the difference in device costs for the 450 cases (including a 15% recurrence rate) would be approximately $3.8 million. This figure does not include capital costs (e.g. $3 million for an angiosuite), additional human resources required, or costs of follow-up. The increase in expenditures associated with coil embolization may be offset partially, by shorter operating room times and hospitalization stays for endovascular repair of unruptured aneurysms; however, the impact of these cost savings is probably not likely to be greater than 25% of the total outlay since the majority of cases involve ruptured aneurysms. Furthermore, the recent growth in aneurysm repair has predominantly been in the area of coil embolization presumably for patients for whom surgical clipping would not be advised; therefore, no offset of surgical clipping costs could be applied in such cases. For ruptured aneurysms, downstream cost savings from endovascular repair are likely to be minimal even though the savings for individual cases may be substantial due to lower perioperative complications for endovascular aneurysm repair.
The two Guidance documents issued by the National Institute of Clinical Excellence (UK) in 2005 support the use of coil embolization for both unruptured and ruptured (SAH) intracranial aneurysms, provided that procedures are in place for informed consent, audit, and clinical governance, and that the procedure is performed in specialist units with expertise in the endovascular treatment of intracranial aneurysms.
For people in good clinical condition following subarachnoid hemorrhage from an acute ruptured intracranial aneurysm suitable for either surgical clipping or endovascular repair, coil embolization results in improved independent survival in the first year and improved survival for up to seven years compared to surgical clipping. The rebleeding rate is low and not significantly different between the two procedures after the first year. However, there is uncertainty regarding the long-term occlusion status, durability of the stent graft, and long-term complications.
For people with unruptured aneurysms, level 4 evidence suggests that coil embolization may be associated with comparable or less mortality and morbidity, shorter hospital stay, and less need for discharge to short-term rehabilitation facilities. The greatest benefit was observed in people over 65 years of age. In these patients, the decision regarding treatment needs to be based on the assessment of the risk of rupture against the risk of the procedure, as well as the morphology of the aneurysm.
In people who require treatment for intracranial aneurysm, but for whom surgical clipping is too risky or not feasible, coil embolization provides survival benefits over surgical clipping, even though the outcomes may not be as favourable as in people in good clinical condition and with small aneurysms. The procedure may be considered under the following circumstances provided that the aneurysm is suitable for coil embolization:
Patients in poor/unstable clinical or neurological state
Patients at high risk for surgical repair (e.g. people>age 65 or with comorbidity), or
Aneurysm(s) with poor accessibility or visibility for surgical treatment due to their location (e.g. ophthalmic or basilar tip aneurysms)
Compared to small aneurysms with a narrow neck in the anterior circulation, large aneurysms (> 10 mm in diameter), aneurysms with a wide neck (>4mm in diameter), and aneurysms in the posterior circulation have lower occlusion rates and higher rate of hemorrhage when treated with coil embolization.
The extent of aneurysm obliteration after coil embolization remains lower than that achieved with surgical clipping. Aneurysm recurrences after successful coiling may require repeat treatment with endovascular or surgical procedures. Experts caution that long-term angiographic outcomes of coil embolization are unknown at this time. Informed consent for and long-term follow-up after coil embolization are recommended.
The decision to treat an intracranial aneurysm with surgical clipping or coil embolization needs to be made jointly by the neurosurgeon and neuro-intervention specialist, based on the clinical status of the patient, the size and morphology of the aneurysm, and the preference of the patient.
The performance of endovascular coil embolization should take place in centres with expertise in both neurosurgery and endovascular neuro-interventions, with adequate treatment volumes to maintain good outcomes. Distribution of the technology should also take into account that patients with SAH should be treated as soon as possible with minimal disruption.
PMCID: PMC3379525  PMID: 23074479
2.  Ruptured Total Intrameatal Anterior Inferior Cerebellar Artery Aneurysm 
Among the distal anterior inferior cerebellar artery (AICA) aneurysms, a unique aneurysm at the meatal loop inside the internal auditory meatus is extremely rare. The authors report a case of surgically treated total intrameatal AICA aneurysm. A 62-year-old female patient presenting with sudden bursting headache and neck pain was transferred to our department. Computed tomography and digital subtraction angiography showed subarachnoid hemorrhage at the basal, prepontine cistern and an aneurysm of the distal anterior inferior cerebellar artery inside the internal auditory meatus. Surgery was performed by retrosigmoid craniotomy with unroofing of the internal auditory meatus. The aneurysm was identified between the seventh and eighth cranial nerve in the meatus and was removed from the canal and clipped with a small straight Sugita clip. After operation the patient experienced transient facial paresis and tinnitus but improved during follow up.
PMCID: PMC4564747  PMID: 26361531
Intrameatal AICA aneurysm; Microsurgery; Facial nerve; Vestibular nerve
3.  Endovascular Treatment for Ruptured Distal Anterior Inferior Cerebellar Artery Aneurysm 
A 42-year-old woman presented with Hunt and Hess grade (HHG) III subarachnoid hemorrhage (SAH) caused by a ruptured left distal anterior inferior cerebellar artery (AICA) aneurysm. Computed tomography showed a thin SAH on the cerebellopontine angle cistern, and small vermian intracerebral hemorrhage and intraventricular hemorrhage in the fourth ventricle. Digital subtraction angiography revealed the aneurysm on the postmeatal segment of left distal AICA, a branching point of rostrolateral and caudomedial branch of the left distal AICA. Despite thin caliber, tortuous running course and far distal location, the AICA aneurysm was obliterated successfully with endovascular coils without compromising AICA flow. However, the patient developed left side sensorineural hearing loss postoperatively, in spite of definite patency of distal AICA on the final angiogram. She was discharged home without neurologic sequela except hearing loss and tinnitus.
Endovascular treatment of distal AICA aneurysm, beyond the meatal loop, is feasible while preserving the AICA flow. However, because the cochlear hair cell is vulnerable to ischemia, unilateral hearing loss can occur, possibly caused by the temporary occlusion of AICA flow by microcatheter during endovascular treatment.
PMCID: PMC3997923  PMID: 24765609
Subarachnoid hemorrhage; Cerebellar artery; Endovascular; Hearing loss
4.  Multiple non-branching dissecting aneurysms of the mid-basilar trunk presenting with sequential subarachnoid hemorrhages 
We describe a rare case of a patient with subarachnoid hemorrhage (SAH) due to a ventral dissecting mid-basilar aneurysm that was treated surgically. One week after surgery, the patient experienced sudden deterioration due to a new SAH caused by the development of a new aneurysm of the basilar trunk distinct from the previously clipped aneurysm.
Case Description:
A 54-year-old woman with acute subarachnoid hemorrhage was found to have a small, broad-based aneurysm arising from the ventral aspect of the mid-basilar artery. This complicated lesion was treated with a microsurgical clipping via a translabyrinthine pre-sigmoidal sub-temporal approach. One week postoperatively, the patient suffered a new SAH and was found to have developed a distinct basilar artery aneurysm. The patient was returned to the Operating Room for microsurgical clipping via the previous craniotomy. After surgery, the patient made a slow, but steady, recovery. She underwent repeated angiographic imaging, demonstrating a stable appearance. Two years post surgery, the patient had returned to work and had no obvious neurological deficit, with the exception of unilateral iatrogenic hearing loss.
We describe a rare case of multiple aneurysms originating in relation to a mid-basilar dissection, resulting in multiple episodes of SAH. These are difficult and dangerous lesions that can be treated with open microsurgical reconstruction or possibly via an endovascular approach. The intricate location of the lesions poses a particular challenge to neurosurgeons attempting to directly treat mid-basilar lesions.
PMCID: PMC3205486  PMID: 22059122
Aneurysm; basilar trunk; dissecting aneurysm; subarachnoid hemorrhage
5.  Posterior inferior cerebellar artery aneurysms: Anatomical variations and surgical strategies 
Posterior inferior cerebellar artery (PICA) aneurysms are associated with multiple anatomical variations of the parent vessel. Complexities in their surgical clipping relate to narrow corridors limited by brain-stem, petrous-occipital bones, and multiple neurovascular structures occupying the cerebellomedullary and cerebellopontine cisterns.
The present study focuses on surgical considerations during clipping of saccular PICA aneurysms.
Setting and Design:
Tertiary care, retrospective study.
Materials and Methods:
In 20 patients with PICA aneurysms, CT angiogram/digital substraction angiogram was used to correlate the site and anatomical variations of aneurysms located on different segments of PICA with the approach selected, the difficulties encountered and the final outcome.
Statistical Analysis:
Comparison of means and percentages.
Aneurysms were located on PICA at: vertebral artery/basilar artery (VA/BA)-PICA (n=5); anterior medullary (n=4); lateral medullary (n=3); tonsillomedullary (n=4); and, telovelotonsillar (n=4) segments. The Hunt and Hess grade distribution was I in 15; II in 2; and, III in 3 patients (mean ictus-surgery interval: 23.5 days; range: 3-150 days). Eight patients had hydrocephalus. Anatomical variations included giant, thrombosed aneurysms; 2 PICA aneurysms proximal to an arteriovenous malformation; bilobed or multiple aneurysms; low PICA situated at the foramen magnum with a hypoplastic VA; and fenestrated PICA. The approaches included a retromastoid suboccipital craniectomy (n=9); midline suboccipital craniectomy (n=6); and far-lateral approach (n=5). At a follow-up (range 6 months-2.5 years), 13 patients had no deficits (modified Rankin score (mRS) 0); 2 were symptomatic with no significant disability (mRS1); 1 had mild disability (mRS2); 1 had moderately severe disability (mRS4); and 3 died (mRS6). Three mortalities were caused by vasospasm (2) and, rupture of unclipped second VA-BA junctional aneurysm (1).
PICA aneurysms may present with only IVth ventricular blood without subarachnoid hemorrhage. PICA may have multiple anomalies and its aneurysms may be missed on CT angiograms. Surgical approach is influenced by VA-BA tortuosity and variations in anatomy, location of the VA-BA junction and the PICA aneurysm relative to the brain-stem, and the pattern of collateral supply. The special category of VA-PICA junctional aneurysms and its management; and, the multiple anatomical variations of PICA aneurysms, merit special surgical considerations and have been highlighted in this study.
PMCID: PMC3358952  PMID: 22639684
Anatomical variations; aneurysm; basilar artery; far lateral approach; posterior inferior cerebellar artery; radiology; subarachnoid hemorrhage; suboccipital craniectomy; surgery
6.  Infective endocarditis with cerebrovascular complications: timing of surgical intervention 
Management of infective endocarditis (IE) with cerebrovascular complications is difficult due to absence of concrete evidence. These patients usually have multiple neurological deficits and the optimal timing for cardiac operation remains controversial. The aims of this study were to present cases and discuss the treatment options for IE with cerebrovascular complications. From 1998 to 2010, 51 patients underwent operations for IE at our institution. From a review of medical records, 10 patients (19.6%) with preoperative neurological complications were identified. Data on these 10 patients were analysed. Cerebrovascular complications included cerebral infarction (n = 4, 40.0%), mycotic aneurysm (n = 1, 10.0%), mycotic aneurysm plus cerebral infarction (n = 3, 30.0%), meningitis (n = 1, 10.0%) and mycotic aneurysm with cerebral haemorrhage plus meningitis (n = 1, 10.0%). Of 5 patients having mycotic aneurysms, 3 underwent clipping before cardiac operations. The mean interval from craniotomy to cardiac operations was 26.7 ± 21.8 days. A cardiac operation was performed initially on seven patients. The mean interval from the onset of neurological deficit to cardiac operation was 7.4 ± 9.8 days. The mortality rate was 10.0%. Postoperative deterioration was not observed. Management of IE with cerebrovascular complications should be based on case-by-case multidisciplinary assessment of potential risks and benefits of intracranial and cardiac operations.
PMCID: PMC3420269  PMID: 22108940
Infective endocarditis; Cerebrovascular complications; Surgical intervention
7.  Ruptured Intracranial Mycotic Aneurysm in Infective Endocarditis: A Natural History 
Case Reports in Medicine  2010;2010:168408.
Mycotic aneurysms are a rare cause of intracranial aneurysms that develop in the presence of infections such as infective endocarditis. They account for a small percentage of all intracranial aneurysms and carry a high-mortality rate when ruptured. The authors report a case of a 54-year-old man who presented with infective endocarditis of the mitral valve and acute stroke. He subsequently developed subarachnoid hemorrhage during antibiotic treatment, and a large intracranial aneurysm was discovered on CT Angiography. His lesion quickly progressed into an intraparenchymal hemorrhage, requiring emergent craniotomy and aneurysm clipping. Current recommendations on the management of intracranial Mycotic Aneurysms are based on few retrospective case studies. The natural history of the patient's ruptured aneurysm is presented, as well as a literature review on the management and available treatment modalities.
PMCID: PMC2946581  PMID: 20885918
8.  Comparison of Intraoperative Indocyanine Green Angiography and Digital Subtraction Angiography for Clipping of Intracranial Aneurysms 
Interventional Neurology  2015;3(3-4):129-134.
Residual aneurysm after microsurgical clipping carries a risk of aneurysm growth and rupture. Digital subtraction angiography (DSA) remains the standard to determine the adequacy of clipping. Intraoperative indocyanine green (ICG) angiography is increasingly utilized to confirm optimal clip positioning across the neck and to evaluate the adjacent vasculature.
We evaluated the correlation between ICG and DSA in clipped intracranial aneurysms.
A retrospective study of patients who underwent craniotomy and microsurgical clipping of intracranial aneurysms with ICG for 2 years. Patient characteristics, presentation details, operative reports, and pre- and postclipping angiographic images were reviewed to determine the adequacy of the clipping.
Forty-seven patients underwent clipping with ICG and postoperative DSA: 57 aneurysms were clipped; 23 patients (48.9%) presented with subarachnoid hemorrhage. Nine aneurysms demonstrated a residual on DSA not identified on ICG (residual sizes ranged from 0.5 to 4.3 mm; average size: 1.8 mm). Postoperative DSA demonstrated no branch occlusions.
Intraoperative ICG is useful in the clipping of intracranial aneurysms to ensure a gross patency of branch vessels; however, the presence of residual aneurysms and subtle changes in flow in branch vessels is best seen by DSA. This has important clinical implications with regard to follow-up imaging and surgical/endovascular management.
PMCID: PMC4521193  PMID: 26279659
Digital subtraction angiography; Indocyanine green angiography; Intracranial aneurysm; Aneurysm clipping; Microsurgical clipping
9.  Vascular Anomalies and the Risk of Multiple Aneurysms Development and Bleeding 
Interventional Neuroradiology  2004;8(1):15-20.
The pathogenesis of aneurysmal subarachnoid hemorrhage is still debated and the prognosis remains severe, especially in multiple aneurysms, where the therapeutic management is complex. The aim of this study was to look for vascular anomalies and assess their relationship with aneurysm formation and bleeding in patients with multiple intracranial aneurysms. A prospective angiographical review was performed on 141 patients with multiple intracranial aneurysms seen from 1992 to 2000. Three hundred and fifty three aneurysms were studied. In 88% of the patients vascular anomalies were found.
The most common were: asymmetric caudal basilar fusion (43.2%), variations of the anterior communicating artery (AcoA) complex (31.2%), symmetric caudal basilar fusion (26.2%), antero-inferior cerebellar artery-postero-inferior cerebellar artery (AICA-PICA) (15.6%), extradural origin of the PICA (10.6%), cavernous origin of the ophthalmic artery or dorsal ophthalmic artery (dOPH) (3.5%). Some aneurysm locations were associated with a high rate of vascular anomalies, e.g.: posterior cerebral aneurysm with asymmetric caudal fusion, AcoA aneurysm with AcoA complex variation, basilar tip aneurysm with extradural PICA or symmetric caudal fusion, PI-CA aneurysm with AICA-PICA, para-ophthalmic aneurysm with dOPH. These aneurysm locations bled proportionally more frequently when associated with the related vascular anomaly. In conclusion, these results suggest that vascular anomalies are associated with aneurysm development and bleeding.
PMCID: PMC3572516  PMID: 20594507
multiple intracranial aneurysms, cerebral angiography, vascular anomalies, sub arachnoid hemorrhage, anatomy
10.  Idiopathic Lenticulostriate Artery Pseudoaneurysm Protruding into the Lateral Ventricle: A Case Report 
We report a rare case of an idiopathic pseudoaneurysm causing intraventricular hemorrhage (IVH). A 28-year-old man presented with sudden onset of severe headache. He underwent external ventricular drainage for an isolated IVH in the right lateral ventricle. Digital subtraction angiography (DSA) revealed that the aneurysm (7.5×4.5 mm) arose from the distal part of the medial lenticulostriate artery. Following removal of the external ventricular drainage catheter, the aneurysm decreased in size (4.0×2.3 mm). However, follow-up DSA revealed a slightly enlarged aneurysm (4.2×3.2 mm) with morphologic change. The aneurysm was clipped via the interhemispheric transcallosal approach, but postoperative DSA revealed a residual aneurysm sac beside the clips. Given the risk of rebleeding, a second operation was planned for complete resection of the aneurysm. After revised craniotomy and careful dissection of the caudate nucleus, the aneurysm sac was completely resected. Histopathological examination revealed that the aneurysm was a pseudoaneurysm. The patient recovered without any neurological sequel and was discharged.
To the best of our knowledge, this is the first reported case of an idiopathic lenticulostriate artery pseudoaneurysm protruding into the right lateral ventricle and causing an IVH that was successfully treated with microsurgical resection.
PMCID: PMC3804666  PMID: 24167808
Intraventricular pseudoaneurysm; Intraventricular hemorrhage; Lenticulostriate artery
11.  Analysis of Clinical and Radiological Outcomes in Microsurgical and Endovascular Treatment of Basilar Apex Aneurysms 
We aimed to analyze clinical and radiological outcomes retrospectively in patients with basilar apex aneurysms treated by coiling or clipping.
Outcomes of basilar bifurcation aneurysms were assessed retrospectively in 77 consecutive patients (61 women, 16 men), ranging in age from 25 to 79 years (mean, 53.7 years) from 1999 to 2007.
Forty-nine patients out of 77 patients (63.6%) presented with subarachnoid hemorrhages of the 49 patients treated with coiling, 27 (55.1%) showed complete occlusion of the aneurysm sac. Of these, 13 patients (26.5%) developed coil compaction on angiographic or MRI follow-up, with recoiling required in 9 patients (18.4%). Procedural complications of coiling were acute infarction in nine patients and the bleeding of the aneurysms in six patients. The remaining 28 patients underwent microsurgery: twenty-six of these (92.9%) with microsurgery followed up with conventional angiography. Complete occlusion of the aneurysm sac was achieved in 19 patients (73.1%). Operation-related complications of microsurgery were thalamoperforating artery injuries in three patients, retraction venous injury in two, postoperative epidural hemorrhage (EDH) in one, and transient partial or complete occulomotor palsy in 14 patients. Glasgow Outcome Scores (GOS) were 4 or 5 in 21 of 28 (75%) patients treated with microsurgery at discharge, and at 6 month follow-up, 20 of 28 (70.9%) maintained the same GOS. In comparison, GOS of four or 5 was observed in 36 of 49 (73.5%) patients treated with coiling at discharge and at 6 month follow-up, 33 of 49 patients (67.3%) maintained the GOS from discharge.
Basilar top aneurysms were still challenging lesions based on our series. Endovascular or microsurgery endowed with its inborn risks and procedural complications for the treatment of basilar apex aneurysms individually. Microsurgery provided better outcome in some specific basilar apex aneurysms. For reaching the most favorable outcome, endovascular modality as well as microsurgery was inevitably considered for each specific basilar apex aneurysm.
PMCID: PMC2682118  PMID: 19444348
Aneurysm; Basilar artery; Endovascular; Microsurgery
12.  Seven Intracranial Aneurysms in One Patient: Treatment and Review of Literature 
Before the advent of endovascular coiling, patients with multiple intracranial aneurysms were treated with surgical clipping; however, with the advancements in endovascular technology, intracranial aneurysms can be treated with surgical clipping and/or endovascular coiling. We describe a case of subarachnoid hemorrhage in a patient with 7 intracranial aneurysms. A 45-year-old female developed a sudden headache and left sided hemiparesis. Initial workup showed a subarachnoid hemorrhage in the right Sylvian fissure. Further angiographic workup showed 7 intracranial aneurysms (left and right middle cerebral artery bifurcation, right middle cerebral artery, anterior communicating artery, left posterior communicating artery, right posterior inferior cerebellar artery, and left superior cerebellar artery). The patient underwent two craniotomies for surgical clipping of the anterior circulation aneurysms and endovascular stent-assisted coils for the posterior circulation aneurysms. The need for anti-platelet agents for endovascular treatment of the posterior circulation aneurysms and clinical presentation warranted surgical clipping of the anterior circulation aneurysms prior to endovascular therapy. We describe a case report and decision making for a patient with multiple intracranial aneurysms treated with surgical clipping and endovascular coiling.
PMCID: PMC4495085  PMID: 26157691
Aneurysm; Coiling; Clipping; Subarachnoid hemorrhage; Intracranial
13.  Factors Predicting the Oculomotor Nerve Palsy following Surgical Clipping of Distal Vertebrobasilar Aneurysms: A Single-Institution Experience 
Background The aim of our study was to identify various clinical and radiologic factors that correlate with the oculomotor nerve palsy following clipping of distal vertebrobasilar aneurysms.
Methods A total of 48 patients with 51 aneurysms were included in this retrospective study . Patient's age, gender, size, location, and projection of the aneurysm, preoperative Hunt and Hess (H&H) grade, presence of subarachnoid hemorrhage (SAH), temporary clipping, preoperative third nerve palsy, and Glasgow Outcome Scale were included in the model for analysis.
Results A total of 15 patients (31.25%) developed oculomotor nerve palsy following clipping of basilar apex aneurysms. 38 patients (79.2%) presented with SAH and 35 patients (72.9%) had poor H&H grades at presentation. The size of the aneurysm (p = 0.03), preoperative H&H grade (p = 0.04), preoperative oculomotor nerve dysfunction (p = 0.007), and projection of an aneurysm (p = 0.004) had shown a significant correlation with the oculomotor nerve palsy. The size of the aneurysm (p = 0.030, odds ratio: 0.381; 95% confidence interval, 0.175–0.827] was an independent predictor of postoperative nerve dysfunction.
Conclusion The size of the aneurysm, clinical grade at presentation, and projection of the aneurysm correlated with the oculomotor nerve dysfunction following clipping. These clinical and radiologic parameters can be used to predict the oculomotor nerve outcome.
PMCID: PMC4108490  PMID: 25093149
oculomotor nerve; palsy; clipping; vertebrobasilar; aneurysms
14.  True mycotic aneurysm in a patient with gonadotropinoma after trans-sphenoidal surgery 
Immunosuppressive therapy, prolonged antibiotic use, and intrathecal injections are known risk factors for the development of invasive aspergillosis. Central nervous system (CNS) aspergillosis can manifest in many forms, including mycotic aneurysm formation. The majority of the mycotic aneurysms presents with subarachnoid hemorrhage after rupture and are associated with high mortality. Only 3 cases of true mycotic aneurysms have been reported following trans-sphenoidal surgery.
Case Description:
A 38-year-old man was admitted with nonfunctioning pituitary adenoma for which he underwent trans-sphenoidal surgery. Three weeks later, he presented with cerebrospinal fluid (CSF) rhinorrhea and meningitis. He was treated with intrathecal and intravenous antibiotics, stress dose of glucocorticoids, and lumbar drain. The defect in the sphenoid bone was closed endoscopically. After 3 weeks of therapy, he suddenly became unresponsive, and computed tomography of the head showed subarachnoid hemorrhage. He succumbed to illness on the next day, and a limited autopsy of the brain was performed. The autopsy revealed extensive subarachnoid hemorrhage and aneurysmal dilatation, thrombosis of the basilar artery (BA), multiple hemorrhagic infarcts in the midbrain, and pons. Histopathology of the BA revealed the loss of internal elastic lamina and septate hyphae with an acute angle branching on Grocott's methenamine silver stain, conforming to the morphology of Aspergillus.
The possibility of intracranial fungal infection should be strongly considered in any patient receiving intrathecal antibiotics who fails to improve in 1–2 weeks, and frequent CSF culture for fungi should be performed to confirm the diagnosis. Since CSF culture has poor sensitivity in the diagnosis of fungal infections of CNS; empirical institution of antifungal therapy may be considered in this scenario.
PMCID: PMC4697199  PMID: 26759738
Aspergillosis; basilar artery; mycotic aneurysm; pituitary adenoma; subarachnoid hemorrhage; trans-sphenoidal surgery
15.  Comparison of Incidence and Risk Factors for Shunt-dependent Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage Patients 
The objective of this study was to compare the incidence of ventricular shunt placement for shunt-dependent hydrocephalus (SDHC) after clipping versus coiling of ruptured aneurysms.
Materials and Methods
A retrospective review was conducted in 215 patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent surgical clipping or endovascular coiling during the period from May 2008 to December 2011. Relevant clinical and radiographic data were analyzed with regard to the incidence of hydrocephalus and ventriculo-peritoneal shunt (VPS). Patients treated with clipping were assigned to Group A, while those treated with coiling were assigned to Group B.
Of 215 patients (157 clipping, 58 coiling), no significant difference in the incidence of final VPS was observed between treatment modalities (15.3% vs. 10.3%) (p = 0.35). Independent risk factors for VPS for treatment of chronic hydrocephalus were as follows: (1) older than 65 years, (2) poorer Hunt-Hess grade IV and V, (3) Fisher grade III and IV, and (4) particularly initial presence of an intraventricular hemorrhage.
In this study comparing two modalities for treatment of aneurysm, there was no difference in the incidence of chronic hydrocephalus requiring VPS. A significantly higher rate of shunt dependency was observed for age older than 65 years, poor initial neurological status, and thick SAH with presence of initial intraventricular hemorrhage. By understanding these factors related to development of SDHC and results, it is expected that management of aneurysmal SAH will result in a better prognosis.
PMCID: PMC4102754  PMID: 25045646
Acute hydrocephalus; Chronic hydrocephalus; Subarachnoid hemorrhage; Lumbar drain
16.  A review of the management of posterior communicating artery aneurysms in the modern era 
Technical advancements have significantly improved surgical and endovascular treatment of cerebral aneurysms. In this paper, we review the literature with regard to treatment of one of the most common intra-cranial aneurysms encountered by neurosurgeons and interventional radiologists.
Anterior clinoidectomy, temporary clipping, adenosine-induced cardiac arrest, and intraoperative angiography are useful adjuncts during surgical clipping of these aneurysms. Coil embolization is also an effective treatment alternative particularly in the elderly population. However, coiled posterior communicating artery aneurysms have a particularly high risk of recurrence and must be followed closely. Posterior communicating artery aneurysms with an elongated fundus, true posterior communicating artery aneurysms, and aneurysms associated with a fetal posterior communicating artery may have better outcome with surgical clipping in terms of completeness of occlusion and preservation of the posterior communicating artery. However, as endovascular technology improves, endovascular treatment of posterior communicating artery aneurysms may become equivalent or preferable in the near future. One in five patients with a posterior communicating artery aneurysm present with occulomotor nerve palsy with or without subarachnoid hemorrhage. Factors associated with a higher likelihood of recovery include time to treatment, partial third nerve deficit, and presence of subarachnoid hemorrhage. Both surgical and endovascular therapy offer a reasonable chance of recovery. Based on level 2 evidence, clipping appears to offer a higher chance of occulomotor nerve palsy recovery; however, coiling will remain as an option particularly in elderly patients or patients with significant comorbidity.
PMCID: PMC3011114  PMID: 21206898
Cerebral aneurysm; clipping; coiling; posterior communicating artery
17.  Endovascular Treatment of Wide-Necked Intracranial Aneurysms : Techniques and Outcomes in 15 Patients 
It is technically difficult to treat wide-necked intracranial aneurysms by the endovascular method. Various tools and techniques have been introduced to overcome the related technical limitations. The purpose of this study was to evaluate the radiologic and clinical results of wide-necked intracranial aneurysm treatment using the endovascular method.
Fifteen aneurysms in 15 patients were treated by the endovascular method from October 2009 to August 2010. Seven patients presented with subarachnoid hemorrhage (SAH), seven patients had unruptured aneurysms, and one patient had an intracerebral hemorrhage and intraventricular hemorrhage due to an incompletely clipped aneurysm. The mean dome-to-neck ratio was 1.1 (range, 0.6-1.7) and the mean height-to-neck ratio was 1.1 (range, 0.6-2.0). We used double microcatheters instead of a stent or a balloon for the first trial. When we failed to make a stable coil frame with two coils, we used a stent-assisted technique.
All aneurysms were successfully embolized. Eleven aneurysms (73%) were embolized by the double microcatheter technique without stent insertion, and four aneurysms (27%) were treated by stent-assisted coil embolization. One case had subclinical procedure-related intraoperative hemorrhage. Another case had procedure-related thromboembolism in the left distal anterior cerebral artery. During the follow-up period, one patient (7%) had a recanalized aneurysmal neck 12 months after coil embolization. The recurrent aneurysm was treated by stent-assisted coil embolization.
We successfully treated 15 wide-necked intracranial aneurysms by the endovascular method. More clinical data with longer follow-up periods are needed to establish the use of endovascular treatment for wide-necked aneurysm.
PMCID: PMC3079106  PMID: 21519497
Intracranial aneurysm; Embolization; Stent
18.  Coexistence of aneurysmal subarachnoid hemorrhage and surgically identified pituitary apoplexy: a case report and review of the literature 
A ruptured aneurysm associated with a pituitary apoplexy is rare. We present the first case report of the coexistence of a ruptured posterior communicating aneurysm with a surgically discovered pituitary apoplexy where the pituitary apoplexy had not been diagnosed by a pre-operative computerized tomography scan.
Case presentation
A 31-year-old right-handed Chinese woman began to experience severe headache, vomiting and blurred vision which continued for two days. On admission to the hospital, a brain computerized tomography scan demonstrated a small amount of increased signal in the basal cisterns; no evidence of intrasellar and suprasellar lesions was seen. The appearance of her brain suggested aneurysmal subarachnoid hemorrhage. She had nuchal rigidity and reduced vision. There was no extra-ocular palsy and no other neurological deficit. Our patient had no stigmata of Cushing’s syndrome or acromegaly. During an interview for further history, she reported normal menses and denied reduced vision.
Cerebral digital subtraction angiography was subsequently performed, which revealed a 6mm left posterior communicating aneurysm. Urgent left pterional craniotomy was performed. The left ruptured posterior communicating artery aneurysm was completely dissected prior to clipping. At surgery, a suprasellar mass was discovered, the tumor bulging the diaphragma sella and projecting anteriorly under the chiasm raising suspicion of a pituitary tumor. The anterior part of the tumor capsule was opened and a necrotic tumor mixed with dark old blood was removed. The appearance suggested pituitary apoplexy.
Histopathology revealed pituitary adenoma with evidence of hemorrhagic necrosis. Our patient made a good recovery.
Our case report proves that pituitary apoplexy can be coexistent with the rupture of a posterior communicating aneurysm. This association should be considered when evaluating any case of aneurysm. A normal computerized tomography scan does not exclude pituitary apoplexy. Pre-operative magnetic resonance imaging interpretation is required if a pituitary apoplexy is suspected. Craniotomy allows a coexisting aneurysm and pituitary apoplexy to be simultaneously treated.
PMCID: PMC4155771  PMID: 24885333
Aneurysm; Pituitary apoplexy; Pituitary adenoma; Subarachnoid hemorrhage
19.  Bony Protuberances on the Anterior and Posterior Clinoid Processes Lead to Traumatic Internal Carotid Artery Aneurysm Following Craniofacial Injury 
Traumatic intracranial aneurysms are rare, comprising 1% or less of all cerebral aneurysms. The majority of these aneurysms arise at the skull base or in the distal anterior and middle cerebral arteries or their branches following direct mural injury or acceleration-induced shearing force. We present a 50-year-old patient in whom subarachnoid hemorrhage (SAH) was developed as a result of traumatic aneurysm rupture after a closed craniofacial injury. Through careful evaluation of the three-dimensional computed tomography and conventional angiographies, the possible mechanism of the traumatic internal carotid artery trunk aneurysm is correlated with a hit injury by the bony protuberances on the anterior and posterior clinoid processes. This traumatic aneurysm was successfully obliterated with clipping and wrapping technique. The possibility of a traumatic intracranial aneurysm should be considered when patient with SAH demonstrates bony protuberances on the clinoid process as a traumatic aneurysm may result from mechanical injury by the sharp bony edges.
PMCID: PMC3070895  PMID: 21494363
Anterior clinoid process; Posterior clinoid process; Traumatic aneurysm; Craniofacial injury
20.  Ruptured peripheral aneurysms in a collateral pathway associated with stenosis of a major cerebral artery: Report of two cases 
While hemodynamic stress can result in aneurysm formation, it rarely contributes to the development of peripheral aneurysms in collateral pathways. We report two patients with ruptured distal aneurysms in a collateral pathway associated with stenosis of a major cerebral artery.
Case Description
A 67-year-old man presented with intracerebral hemorrhage in the right frontal lobe. Digital subtraction angiography (DSA) revealed severe stenosis of the right middle cerebral artery and two aneurysms in the collateral pathway of the right anterior cerebral artery. The ruptured aneurysm was trapped and resected; histologically, it was a true saccular aneurysm. The unruptured aneurysm was clipped and the patient was discharged without additional neurological deficits. The second patient was a 73-year-old woman with subarachnoid hemorrhage. DSA revealed three arterial dilations. On the 7th day of hospitalization, one of the aneurysms in a posterior inferior cerebellar artery–anterior inferior cerebellar artery anastomosis that functioned as a collateral pathway in the presence of severe basilar artery stenosis was found to be enlarged. It was treated by selective aneurysmal coil embolization with parent artery preservation. Her postoperative course was uneventful and she was discharged without any neurological deficits.
We document the successful treatment of two patients with ruptured aneurysms in the peripheral portion of a collateral pathway. We discuss the histology of peripheral aneurysms and present a review of the literature.
PMCID: PMC3130464  PMID: 21748034
Coil embolization; collateral pathway; histology; peripheral aneurysm; posterior inferior cerebellar artery–anterior inferior cerebellar artery anastomosis; true aneurysm
21.  A case of angiographically occult, distal small anterior inferior cerebellar artery aneurysm 
A small aneurysm at an unusual location, such as a distal anterior inferior cerebellar artery (AICA) aneurysm, may conceal as a computed tomography angiography (CTA) and digital subtraction angiography (DSA)-occult aneurysm.
Case Description:
We herein present the case of a patient suffering from a subarachnoid hemorrhage (SAH) with two aneurysms in which the AICA aneurysm was negative by CTA and DSA. CTA demonstrated a right anterior choroidal artery aneurysm, which was revealed to be an unruptured aneurysm after surgical exploration. A small distal AICA aneurysm was detected by 3D rotational angiography (3DRA). The patient fully recovered except for left-side hearing loss four months after the second operation.
We recommend a meticulous diagnosis by 3DRA in patients with SAH in which the distribution is not coincident with a typical aneurysmal location.
PMCID: PMC4462615  PMID: 26110079
Distal anterior inferior cerebellar aneurysm; diagnosis; subarachnoid hemorrhage; 3D rotational angiography; 3D computed tomography angiography
22.  Distal Anterior Inferior Cerebellar Artery Aneurysm Masquerading as a Cerebellopontine Angle Tumor: Case Report and Review of Literature 
Skull Base  2004;14(2):101-106.
We present the case of a distal anterior inferior cerebellar artery (AICA) aneurysm masquerading as a cerebellopontine angle tumor in a 60-year-old right-handed man with previously undiagnosed polyarteritis nodosa (PAN). The patient presented with a 2-month history of progressive right-sided hearing loss, intermittent severe headache, and sudden onset of complete facial paralysis 3 weeks before admission. Magnetic resonance imaging, including postgadolinium images, showed a 1.2-cm heterogenously enhancing mass that slightly enlarged the right internal auditory canal. A right suboccipital craniotomy was performed, and a partially thrombosed fusiform AICA aneurysm was discovered just anterior to the VII/VIII nerve complex. The aneurysm was trapped and opened, and a thrombectomy was performed. Postoperatively, the patient experienced abdominal pain; liver function tests were abnormal. Investigation revealed a small retroperitoneal hemorrhage and aneurysms of the celiac axis and gastroduodenal arteries. Further investigation revealed an increased erythrocyte sedimentation rate, and a diagnosis of PAN was made. PAN is a well-identified factor in the genesis of peripheral vascular aneurysms. Aneurysms involving the hepatic, renal, coronary, pancreatic, and tibial arteries have been described. PAN is an extremely rare cause of intracranial aneurysm. Patients who present with aneurysms in unusual locations (e.g., distal AICA) should be investigated for vasculopathy and collagen vascular disorders.
PMCID: PMC1151678  PMID: 16145591
Anterior inferior cerebellar artery; aneurysm; peripheral vascular aneurysms; polyarteritis nodosa
23.  Endovascular Coil Embolization After Clipping: Endovascular Treatment of Incompletely Clipped or Recurred Cerebral Aneurysms 
The presence of a cerebral aneurysm remnant after surgical clipping is associated with a risk of regrowth or rupture. For these recurred aneurysms, coil embolization can be considered as a treatment option. We retrospectively reviewed cases of ruptured or regrown aneurysms after clipping treated by endovascular coil embolization.
Materials and Methods
We conducted a retrospective review of patients with ruptured or recurred aneurysm after clipping, who underwent coil embolization between January 1995 and December 2013. We evaluated clinical information and the outcomes of these cases.
Eight patients were treated by endovascular coil embolization after surgical clipping. Six aneurysms were located in the anterior communicating artery, one in the posterior communicating artery, and one in the middle cerebral artery bifurcation. All patients were initially treated by surgical clipping because of a ruptured aneurysm. Aneurysm recurrence at the initial clipping site was detected in all cases. The median interval from initial to second presentation was 42 months. In four patients, aneurysms were detected before rupture and the four remaining patients presented with recurrent subarachnoid hemorrhage. All patients were treated by coil embolization and showed successful occlusion of aneurysms without complications.
Endovascular coil embolization can be a safe and successful treatment option for recurred aneurysms after clipping.
PMCID: PMC4205253  PMID: 25340029
Intracranial aneurysm; Recurrence; Coil embolization; Clipping
24.  Expanding Endovascular Therapy of Very Small Ruptured Aneurysms with the 1.5-mm Coil 
Interventional Neurology  2015;4(1-2):59-63.
Very small ruptured aneurysms (≤3 mm) demonstrate a significant risk for procedural rupture with endovascular therapy. Since 2007, 1.5-mm-diameter coils have been available (Micrus, Microvention, and ev3), allowing neurointerventionalists the opportunity to offer patients with very small aneurysms endovascular treatment. In this study, we review the clinical and angiographic outcome of patients with very small ruptured aneurysms treated with the 1.5-mm coil.
This is a retrospective cohort study in which we examined consecutive ruptured very small aneurysms treated with coil embolization at a single institution. The longest linear aneurysm was recorded, even if the first coil was sized to a smaller transverse diameter. Very small aneurysms were defined as ≤3 mm. Descriptive results are presented.
From July 2007 to March 2015, 81 aneurysms were treated acutely with coils in 78 patients presenting with subarachnoid hemorrhage. There were 5 patients with 3-mm aneurysms, of which the transverse diameter was ≤2 mm in 3 patients. In all 5 patients, a balloon was placed for hemostatic prophylaxis in case of rupture, and a single 1.5-mm coil was inserted for aneurysm treatment without complication. Complete aneurysm occlusion was achieved in 1 patient, residual neck in 2, and residual aneurysm in 2 patients. Aneurysm recanalization was present in 2 patients with an anterior communicating artery aneurysm; a recoiling attempt was unsuccessful in 1 of these 2 patients due to inadvertent displacement and distal coil embolization, but subsequent surgical clipping was successful. Another patient was retreated by surgical clipping for a residual wide-neck carotid terminus aneurysm. One patient died of ventriculitis 3 weeks after presentation; all 4 other patients had an excellent outcome with no rebleed at follow-up (mean 21 months, range 1-62).
The advent of the 1.5-mm coil may be used in the endovascular treatment of patients with very small ruptured aneurysms, providing a temporary protection to the site of rupture in the acute phase. If necessary, bridging with elective clipping may provide definitive aneurysm treatment.
PMCID: PMC4640086  PMID: 26600799
Very small ruptured aneurysms; Endovascular therapy; Coil embolization
25.  Enterprise stent for waffle-cone stent-assisted coil embolization of large wide-necked arterial bifurcation aneurysms 
Large wide-necked arterial bifurcation aneurysms present a unique challenge for endovascular coil embolization treatment. One technique described in the literature deploys a Neuroform stent into the neck of the aneurysm in the shape of a waffle-cone, thereby acting as a scaffold for the coil mass. This case series presents four patients with large wide-necked bifurcation aneurysms treated with the closed-cell Enterprise stent using the waffle-cone technique.
Case Description:
Four patients (59 ± 18 years of age) with large wide-necked arterial bifurcation aneurysms (three basilar apex and one MCA bifurcation) were treated with the waffle-cone technique using the Enterprise stent as a supporting device for stent-assisted coil embolization. Three of the patients presented with aneurysmal subarachnoid hemorrhage (Hunt-Hess 2-3; Fisher Grade 3-4). There was no procedural morbidity or mortality associated with treatment itself. One aneurysm was completely obliterated, and three had small residual necks. One patient developed an area of PCA infarct and visual field cut one month after the procedure and required recoiling of the residual neck. The flared ends of the Enterprise stent remodeled the aneurysm neck by conforming to the shape of the neck without any technical difficulty, resulting in a stable scaffold holding the coils into the aneurysm.
The closed cell construction, flexibility, and flared ends of the Enterprise stent allow it to conform to the waffle-cone configuration and provide a stable scaffold for coil embolization of large wide-necked arterial bifurcation aneurysms. We have had excellent initial results using the Enterprise stent with the waffle-cone technique. However, this technique is higher risk than standard treatment methods and therefore should be reserved for large wide-necked bifurcation aneurysms where Y stenting is needed, but not possible, and surgical clip ligation is not an option.
PMCID: PMC3589841  PMID: 23493649
Aneurysm; coil; embolization; enterprise; stent; waffle-cone; wide-necked

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