We describe a modified stent-assisted coiling technique, named the semi-deployment technique, in the endovascular treatment of wide-neck aneurysms. Thirty-one consecutive patients with 31 wide-necked or fusiform intracranial aneurysms were treated with the semi-deployment technique. The technical feasibility of the procedure, procedure-related complications, angiographic results, clinical outcome and follow-up angiography were evaluated. In every case, the semi-deployment technique was successfully deployed. Immediate angiography demonstrated complete occlusion in 24 cases (77.4%), neck remnant in four cases (12.9%), and incomplete occlusion in three cases (9.7%). Procedural-related morbidity occurred in one patient (3.2%) but no procedural-related mortality. A favorable clinical outcome (Modified Ran-kin Scale score 0-2) was observed in 90.3% of the patients (average follow-up time, 23.1 months). No rehemorrhage of treated aneurysms occurred. Angiography follow-up was obtained in 22 cases (71.0 %). Three aneurysms (13.6 % of the follow-up angiograms) demonstrated recanalization. No delayed coil or stent migration was found. One patient had in-stent stenosis as a delayed complication. We found that the semi-deployment technique was helpful in the treatment of wide-neck aneurysms.
intracranial aneurysm, stent, endovascular embolization, therapeutic
The use of balloon remodeling technique for coil embolization has developed into a safe alternative to stent assisted coil embolization for wide-necked aneurysms. Dual antiplatelet therapy when a stent is placed for assistance in the treatment of ruptured aneurysms is of concern. There are cases in which a single balloon seems insufficient to protect from coil herniation, like when two vessels are in the proximity of the side of the aneurysm neck. Techniques using two balloons for remodeling have been described; however, dual vascular access may be required. A case is presented in which a ruptured basilar tip wide-necked aneurysm was treated with a single balloon, using a sequential sidelong balloon remodeling technique. Complete embolization of the aneurysm was achieved maintaining patency of bilateral posterior cerebral arteries.
Endovascular treatment of intracranial aneurysms by coiling has become an accepted alternative to surgical clipping1. In cases of wide-necked and sidewall aneurysms, selective embolization is difficult because of the risk of coil protrusion into the parent vessel. The use of three-dimensional coils, stents2, and balloon remodeling have all aided the attempt to adequately manage such lesions. However, compared with sidewall aneurysms, bifurcation aneurysms are more challenging from an endovascular standpoint. Because of their specific anatomy and hemodynamics, the tendency to recur and rerupture is higher. Several authors have reported successful treatment of these complex and wide-necked bifurcation aneurysms by using Y-configured dual stent-assisted coil embolization3,4, the double microcatheter technique5, a more compliant balloon remodeling technique6, the TriSpan neck-bridge device7, or the waffle cone technique8. We describe two cases of wide-necked bifurcation aneurysms in which the waffle cone technique was used for coil embolization. The waffle cone technique was first described in 2006; however, the small number of published cases and the lack of follow-up prevent one from assessing this technique's durability and the probability of recanalization. We report the cases of two patients harboring unruptured wide-necked bifurcation aneurysms that were treated and followed-up for six months.
aneurysm, bifurcation, embolization, stent
We report a case of a 55-year-old man carrying two unruptured internal carotid artery (ICA) wide-neck aneurysms.
In the same session, the smaller aneurysm was treated by coils using the remodeling technique and the large aneurysm was treated by stent-assisted coil embolization. During the stent-assisted procedure for the large aneurysm, the microcatheter tip moved from the aneurysm into the parent artery causing a prolapse of some coil loops into the vessel lumen.
The distal part of the coil was tangled within the stent's struts, therefore, in order to introduce the entire coil, an attempt was made to withdraw the prolapsed loops of the coil within the microcatheter and concomitantly repositioning the microcatheter into the residual aneurysm neck through the stent struts. However this maneuver was unsuccessful.
An attempt to retrieve gently the coil also failed and the coil prematurely detached. For maintaining the patency of the arterial lumen and to reduce the embolic risk, a second stent was used to pin the free coil loops. The rescue stent was positioned within the coil loops and its deployment allowed a circumferential expansion of some loops around the stent perimeter while other loops were flattened against the wall of the artery. The parent artery remained patent at one-year follow-up angiographic study. No clinical complications were observed.
aneurysms, wide-neck, coils, stents
Stent-assisted coiling on intracranial aneurysm has been considered as an effective technique and has made the complex aneurysms amenable to coiling. To achieve reconstruction of intracranial vessels with preservation of parent artery the use of stents has the greatest potential for assisted coiling. We report the results of our experiences in ruptured wide-necked intracranial aneurysms using Y-stent coiling.
From October 2003 to October 2011, 12 patients (3 men, 9 women; mean age, 62.6) harboring 12 complex ruptured aneurysms (3 middle cerebral artery, 9 basilar tip) were treated by Y-stent coiling by using self-expandable intracranial stents. Procedural complications, clinical outcome, and initial and midterm angiographic results were evaluated. The definition of broad-necked aneurysm is neck diameter over than 4 mm or an aneurysm with a neck diameter smaller than 4 mm in which the dome/neck ratio was less than 2.
In all patients, the aneurysm was successfully occluded with no apparent procedure-related complication. There was no evidence of thromboembolic complication, arterial dissection and spasm during procedure. Follow-up studies showed stable and complete occlusion of the aneurysm in all patients with no neurologic deficits.
The present study did show that the Y-stent coiling seemed to facilitate endovascular treatment of ruptured wide-necked intracranial aneurysms. More clinical data with longer follow-up are needed to establish the role of Y-stent coiling in ruptured aneurysms.
Intervention; Stent; Subarachnoid hemorrhage
Endovascular treatment of wide neck intracranial aneurysms is technically difficult and leads to less favorable treatment results and long term outcome. We participated in a multicenter prospective study to evaluate the safety and performance of a new self-expandable nitinol micro stent (Neuroform) in stent assisted coil occlusion of wide neck intracranial aneurysms. Eighteen patients were enrolled in the study in a single center. The anatomy of the target aneurysm and the parent vessel, technical details of the procedure, device functionality, anatomic and clinical results were evaluated. All enrolled aneurysms were either wide necked or showed an unfavorable neck-to-fundus ratio. In 16 out of 18 patients the Neuroform device allowed stent assisted coil occlusion of the aneurysm. The occlusion rate was 95% in eight patients and 100% in eight patients. The two failures were both due to anatomic reasons. Flexibility of the stent, behavior during deployment and subsequent ability to retain coils within the aneurysmal sac were considered as good as or better than the properties of previous balloon expandable stents. No device-related adverse events were encountered. Procedure-related clinical complications occurred in seven patients but caused no severe permanent neurological deficit. The Neuroform neurovascular stenting system is a safe and effective adjunct for the stent-assisted coil occlusion of wide necked intracranial aneurysms. The major advantages of this device are its self-expanding property and very high flexibility which allows safe navigation, easy sizing, as well as accurate positioning of the stent while providing sufficient bridging of the aneurysm neck for subsequent coil placement.
intracranial aneurysm, electrolytically detachable coil, intracranial stent, nitinol, embolization, internal carotid artery, vertebral artery, basilar artery
Introduction: Techniques for coil embolization of wide-neck cerebral aneurysms include the use of stents and temporary occlusion with compliant non-detachable balloons to safely allow dense packing of the aneurysm lumen with detachable coils. We describe the use of a new balloon device for assisting in wide-neck aneurysm coil treatment. Methods: A single institution neuroendovascular database was accessed to identify cases in which the Ascent balloon (Codman Neurovascular, Raynham, MA, USA) was used for aneurysm coil embolization. Clinical, demographic, and angiographic data were obtained through chart review. Results: Eleven cerebral aneurysm cases were treated using the Ascent balloon during the first 12-month period that the new device was available at our institution. Three of the patients presented with ruptured aneurysms. All aneurysms were large (maximum diameter 6 mm or greater), with an average maximum diameter of 9.4 mm, and an average neck diameter of 5.5 mm. Complete occlusion with coil embolization (Raymond class I) was achieved in all cases. The Ascent balloon was successfully positioned across the neck of the aneurysm in nine patients. Conclusion: This initial experience demonstrates the feasibility and immediate outcomes of the coaxial dual-lumen design Ascent balloon catheter used as an assistive device in coil embolization of wide-neck cerebral aneurysms. This device contributes to the growing number of assistive devices for the treatment of complex cerebral aneurysms.
aneurysm embolization; ascent; balloon remodeling; coil
Treatment of wide-necked bifurcation aneurysms often poses procedural and long-term outcome challenges. The initial preclinical experience with the Pulsar Vascular Aneurysm Neck Reconstruction Device (PVANRD) in a canine bifurcation model is described.
Experimental bifurcation vein pouch aneurysms were surgically created in the carotid arteries of eight dogs. Endovascular coiling of the aneurysms with assistance of the PVANRD was performed in all cases with acute performance compared with Y-stenting.
Twelve devices were deployed in the eight cases. Deployment of the devices was straightforward and successfully protected the parent artery and maintained patency of the bifurcation in all cases, despite the use of oversized coils.
The PVANRD is a novel bifurcation stent that facilitates treatment of wide-necked bifurcation aneurysms compared with currently available adjunctive devices.
Aneurysm; wide-necked; reconstruction; device; stent; artery; MRI; CT; vein; thrombectomy; spine; subarachnoid; coil; angioplasty; arteriovenous malformation; flow diverter; spinal cord; navigation; complication; balloon; thrombolysis; stroke
In this paper, we report five cases with acutely ruptured wide-necked aneurysms, which were treated with coil embolization using a balloon or stent-assisted technique. Balloon-assisted coil embolization using Equinox balloon, Commodore balloon, and Hyperform balloon were performed for four patients and stent-assisted coil embolization using BX velocity for one patient. We discuss problems of coil embolization for acutely ruptured wide-necked aneurysms with a balloon or stent-assisted technique.
acutely ruptured wide-necked aneurysms, balloon-assisted coil embolization, stent-assisted coil embolization
The endovascular treatment of very small aneurysms (lesions less than 3 mm in maximum diameter) with wide necks remains a challenge for saccular embolization. We retrospectively analyzed our data using Neuroform stent-assisted coiling for very small supraclinoid aneurysms with wide neck to evaluate the feasibility and efficacy of endovascular treatment of these lesions.
We conducted a review of our experience and results of endovascular treatments in six patients with seven very small aneurysms. All aneurysms were located at the side wall of the supraclinoid segment of the ICA. They were ruptured in two patients and unruptured in four. The technique of stent-assisted coiling was used in all cases with coiling before stenting and additional coils after deployment of the stent in the same session.
All patients were successfully embolized with stent-assisted coiling. The coils were introduced into the lumen for subtotal occlusion in five aneurysms and for partial occlusion in two. During one to two years follow-up angiography, all aneurysms were completely occluded and no recurrence occurred. No complications were observed.
Endovascular stent-assisted coil embolization of supraclinoid very small aneurysms with wide necks is effective and feasible. Subtotal aneurysm occlusion might progress to total occlusion.
supraclinoid aneurysm, very small, stent assisted coiling, follow-up
Endovascular treatment of complex, wide-necked bifurcation cerebral aneurysms is challenging. Intra/extra-aneurysmal stent placement, the “waffle cone” technique, has the advantage of using a single stent to prevent coil herniation without the need to deliver the stent to the efferent vessel. The published data on the use of this technique is limited. We present our initial and follow-up experience with the waffle cone stent-assisted coiling (SAC) of aneurysms to evaluate the durability of the technique. We retrospectively identified ten consecutive patients who underwent SAC of an aneurysm using the waffle cone technique from July 2009 to March 2011. Clinical and angiographic outcomes after initial treatment and follow-up were evaluated.
Raymond Class I or II occlusion of the aneurysm was achieved in all cases with the waffle cone technique. No intraoperative aneurysm rupture was noted. The parent arteries were patent at procedure completion. Clinical follow-up in nine patients (median 12.9 months) revealed no aneurysm rupture. Two patients had a transient embolic ischemic attack at 18 hours and three months after treatment, respectively. Catheter angiography or MRA at six-month follow-up demonstrated persistent occlusions of aneurysms in seven out of eight patients. Another patient had stable aneurysm occlusion at three-month follow-up study. Our experience in the small series suggests the waffle cone technique could be performed on complex, wide-necked aneurysms with relative safety, and it allowed satisfactory occlusions of the aneurysms at six months in most cases.
waffle cone technique, wide-necked aneurysm, stent-assisted, coiling, endovascular
The optimal management of geometrically complex aneurysms remains challenging. The aim of this retrospective study was to evaluate the safety and feasibility of branch-selective technique (BT) in wide-necked aneurysms with an acute angle branch incorporated into the sac.
Materials and Methods
Eight consecutive patients harboring wide-necked cerebral aneurysms with an incorporated, acute angle branch (mean, 30.4°) underwent coiling over an 18-month period. Dome-to-neck ratio ranged from 0.9 to 1.8 (mean, 1.2). Every procedure utilized BT, i.e., stent- or catheter-assisted coiling through the incorporated branch.
Technical success was achieved in all cases. With the aim to avoid the risk of aneurysmal rupture during struggling intraaneurysmal wire navigation, a 'looping method' and retrograde approach of a preshaped 0.014' microcatheter (C or J) was used for branch access in five cases and a 'looping method' and antegrade approach in one case. In the remaining one, just the C-preshape was enough to directly enter the branch without intraaneurysmal wire navigation. Overall, stent-assisted coiling was performed in seven cases, while catheter-assisted coiling was undertaken in one. The only complication was thrombotic posterior inferior cerebellar artery occlusion in one case, which was recanalized after tirofiban infusion. New neurological deficits were not identified in any cases.
BT seems safe and feasible for wide-necked aneurysms with an acute angle branch incorporated into the sac. The looping method may offer safe access to the incorporated, acute angle branch and should be considered for replacement of the fearful intra-aneurysmal wire navigation.
Endovascular procedures; Intracranial aneurysm; Branch-selective technique
We present a case of stent-assisted coil embolization of a wide-necked renal artery aneurysm performed at our institution. The technique involved a stent being delivered over the neck of the aneurysm. Subsequently a catheter was placed into the aneurysm through the stent mesh and the aneurysm was then filled with detachable coils. Complete aneurysm occlusion was obtained and there was no evidence to suggest renal infarction on a follow-up contrast CT scan 6 months later. Our preliminary experience suggests that stent-assisted coil embolization of wide-necked renal artery aneurysms is a technically challenging but potentially effective renal-sparing endovascular approach.
Renal artery aneurysm; stent; coil embolization
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.
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.
Aneurysm; coil; embolization; enterprise; stent; waffle-cone; wide-necked
We report a patient with a wide-necked aneurysm arising at the bifurcation of the right internal carotid artery and the persistent primitive trigeminal artery (PPTA) treated successfully by Matrix detachable coil occlusion and assisted by a Neuroform intracranial stent. First, a Neuroform self-expanding intracranial stent was delivered via a 5-F Guider Softtip XP and placed as desired, then the aneurysm dome was embolized with two Matrix detachable coils through the interstices of the stent. The aneurysm was 80% occluded angiographically and the parent artery was patent. DSA imaging six months after the procedure showed the aneurysm to be obliterated at angiography and the neck tissue thickness of the aneurysm to be increased, but the parent artery diameter was not impacted. We describe the case in detail and discuss our preliminary experience of using the Neuroform stent and Matrix detachable coils for the treatment of a PPTA wide-necked aneurysm.
persistent primitive trigeminal artery, aneurysm, neuroform intracranial stent, Matrix detachable coil, embolization, endovascular therapy
A prospective study was performed to evaluate the efficacy of neurophysiological monitoring (NPM) techniques in the detection of ischemic changes that may be seen during endovascular treatment of cerebral aneurysms. Sixty three patients underwent NPM during first-stage endovascular treatment of cerebral aneurysms. The endovascular procedures included coil embolization (26 patients), balloon-remodeling coiling (16 patients), stent-assisted coiling (10 patients), balloon-stent-assisted coiling (9 patients), and balloon test occlusion (2 patients). NPM included electroencephalography, somatosensory evoked potentials, and brain stem auditory evoked potentials, depending on the location of the aneurysm and its associated vascular territory. NPM changes were seen in 3 (4.8%) patients and the procedures were altered immediately. No neurological changes were found postendovascularly. Ten patients demonstrated abnormal angiographic findings without concurrent NPM changes, of which 5 patients developed visual disturbance or hemiparesis. It is concluded that NPM is a valuable monitoring tool for endovascular treatment of cerebral aneurysms.
Cerebral Aneurysm; Endovascular treatment; Neurophysiological Monitoring
Endovascular treatment of ruptured intracranial aneurysms with detachable coils has proven a favorable alternative to surgical clipping. However, coiling has limitations in the treatment of complex or broad neck aneurysms because of possible coil prolapse or coil migration into the parent vessel and long-term angiographic recurrences. To achieve reconstruction of intracranial vessels with preservation of the parent artery, the use of stents has the greatest potential for assisted coil embolization. Three-dimensional coils and reconstructive techniques such as balloon-assisted remodeling may overcome these problems. But these methods had some drawbacks.
The Neuroform stent is the most recently developed endovascular stent with self-expandable and micro-delivery properties that are specially designed for the treatment of unruptured intracranial broad neck aneurysms.
Aim of the following working is to report a single center experience of stent-assisted coiling on ruptured intracranial aneurysms with assessment of its efficacy and safety, and follow-up findings.
stent-assisted coiling, complex aneurysm, Neuroform stent
To elucidate focal successive histological responses of the neck of wide-necked aneurysm after single stent implantation and stent-assisted coiling, an experimental wide-necked aneurysm model was surgically created in bilateral common carotid arteries of adult dogs. Balloon-expandable porous stents were positioned across the aneurysm necks on both sides. The aneurysm cavity of one side was additionally loosely coiled with Gugliemi detachable coils after stent implantation. The dogs were followed up with ultrasonography and angiography, then sacrificed at two days, one month, and one year and the aneurysm specimen was subjected to macro, micro, and electron microscopic observation. Stent implantation and coiling was successful in eight dogs. This investigation observed that single stent implantation slowed down the blood flow within the aneurysm, but barely induced thrombosis within the aneurysm. There was neointima formation over the stent mesh without thrombus within the aneurysm cavity, but it did not cover the whole aneurysm neck at one year. Aneurysms treated with stent-assisted coiling showed thrombosis within the aneurysms and neointima formation over the whole aneurysm orifice. These results suggest that the neointima could develop over bare stent filament without thrombus within the aneurysm cavity, coils could enhance thrombosis within the aneurysm cavity and facilitate neointima formation over the aneurysm orifice. Stent-assisted coiling may be an alternative option for the treatment of wide-necked aneurysms.
aneurysm embolization, stents, coils, pathology, experimental, dogs
A 30-year-old man was referred in our department for treatment of a midbasilar trunk aneurysm. His presenting symptoms included headache and dizziness. A CT scan at another hospital showed no significant findings whereas a digital subtraction angiogram disclosed a dissecting aneurysm in the midbasilar trunk, and there was severe stenosis in the basilar artery. After discussion, we planned to use stent-assisted-coil embolization technique. During the procedure, a LEO stent (Balt, Montmorency, France) was implanted into the basilar artery across the aneurysm neck, but fearing acute basilar artery occlusion because of stent collapse or thrombus we did not fill coils into the aneurysm.
After the procedure, the completion angiography demonstrated considerably decreased flow into the aneurysm, with stasis persisting into the venous phase of angiography. The patient awoke from general anaesthesia after the procedure and had no additional neurological symptoms, he was discharged three days later and used clopidogrel and aspirin for antiplatelet therapy. Six months later when he was admitted for a recheck, a DSA showed the basilar artery was occluded completely and the aneurysm had disappeared even though the patient remained neurologically normal.
aneurysm, basilar trunk, dissection, LEO stent, occlusion
To evaluate the feasibility and clinical and angiographic outcomes of stent-assisted embolization for complex middle cerebral artery (MCA) aneurysms.
The records of 23 consecutive patients with 24 MCA aneurysms, who underwent stent-assisted embolization of the aneurysm, were retrospectively evaluated.
Fifteen aneurysms were treated with one stent and 8 were treated using more than two stents (5 a stent-within-a-stent, 1 triple stents, and two Y-stent). Angiographically, complete or near complete occlusion was achieved in 15 aneurysms (65.2%), residual neck in five (21.7%), and residual aneurysm in three (13.1%). Five aneurysms demonstrated thrombosis within the stent during the procedure and hospitalization, and were resolved by intraarterial and intravenous Tirofiban injection. Symptomatic thromboembolic complications were developed in five patients and permanent deficits demonstrated in two patients with modified Rankin Scale 1 and 2, respectively. Treatment-related permanent morbidity and mortality rates were 8.3% and 0% with relatively high complication rate. Angiographic follow-up was available in 17 aneurysms at 6-31 months (mean, 13.2 months) and showed stable or improved in 15 (88.2%) and major and minor recurrence in one, respectively.
Complex MCA aneurysms could be treated by stent-assisted coiling and showed lower recanalization rate during mid-term follow-up by effective flow diversion due to various stent-assisted techniques. Our results warrant further study with a longer follow-up period in a larger sample.
Coil embolization; Intracranial aneurysm; Middle cerebral artery; Stent
The authors describe the use of a self-expandable stent in a temporary deployment for treatment of a very wide-neck A1 segment of anterior cerebral artery (ACA) aneurysm following incomplete clipping. A 39-year-old hypertensive man presenting with seizure-like movement underwent computed tomography, which showed acute subarachnoid hemorrhage and an A1 segment of ACA aneurysm with superior and inferior projection. He underwent surgical clipping of the aneurysm, but superior and posterior portion of wide-neck aneurysm remained. We decided to treat the remnant aneurysm using an endovascular modality. After selection of the aneurysm, coil packing was performed assisted by the temporary semi-jailing technique. The Enterprise stent (Cordis Neurovascular, Miami, FL, USA) was deployed and recaptured repeatedly for angiography to ensure safety of the small caliber parent artery. Successful semi-deployment and recapture of the stent allowed subtotal coil occlusion of the aneurysm with good anatomic and clinical results. No complications were encountered. The stent could be recaptured up to the point where the proximal end of the stent marker was aligned with distal marker band of the microcatheter, approximately 70% of the stent length. The temporary semi-jailing technique is feasible for wide-neck aneurysm with small caliber parent artery.
Intracranial aneurysm; Endovascular therapy; Stent; Surgical clipping
Endovascular treatment of wide-necked aneurysms poses a challenge for the endovascular therapist. The Y-stent–assisted technique has been used for stent-assisted coil embolisation for wide-necked bifurcation aneurysms. This technique has been described for basilar tip aneurysms and middle cerebral artery bifurcation aneurysms using Neuroform and Enterprise stents. We report 2 cases of wide-necked bifurcation aneurysms that were treated with Y-stent–assisted coil embolisation using a new, fully retrievable and detachable intracranial stent (Solitaire AB™). We describe the advantages of a fully retrievable and detachable stent and its feasibility of forming a Y configuration.
endovascular techniques; intracranial aneurysm; neurosurgery; stents; therapeutic embolisation
To evaluate the safety and efficacy of stent-assisted coiling of ruptured intracranial wide-necked aneurysms in a setting of acute subarachnoid hemorrhage, without compromising on the antiplatelet regimen.
Forty-two consecutive patients who underwent stent-assisted coiling for ruptured wide-necked intracranial aneurysms from August 2008 to May 2012 were studied. Demographic data like age, sex, Hunt & Hess grade, Fischer scale, and location, and size of the aneurysms were noted. Complications such as aneurysmal rupture, bleeding complications, thromboembolic events, etc. were documented. Also, 30-day and 1-year outcome was measured using modified Rankin scale (mRS).
Forty-four wide-necked aneurysms were treated in 42 patients with stent-assisted coiling from August 2008 to May 2012 in our institution, out of a total of 248 aneurysms treated endovascularly in the same period. All these patients presented with subarachnoid hemorrhage (SAH) with varying grades and were treated in the acute phase, i.e. within 1 week of the ictus. There were 24 males and 18 females in the age group ranging from 12 to 78 years, with a mean of 45 years. Technical success was achieved in 39 patients with complete angiographic cure (93%). Intraprocedural stent thrombosis was seen in two patients, which resolved with intra-arterial bolus of tirofiban, and both the patients did not have any neurological deficit. Rebleed occurred in two patients of which one patient succumbed.
Six patients required external ventricular drain because of worsening hydrocephalus on computed tomography (CT) scan with clinical deterioration. There was one death in our series due to rebleed. Three other patients died in a period of 1 month due to complications not related to the coiling procedure which include vasospasm, pulmonary embolism, and respiratory infection. All the patients were clinically followed up at 1 month, 3 months, 6 months, and 1 year. Also, angiographic follow- up was done at 1 year in 25 patients (72%). All the patients were maintained on clopidogrel 75 mg per day and ecospirin 150 mg per day for a period of 1 year and were advised to continue ecospirin 150 mg per day lifelong.
Even in a setting of acute SAH, stent-assisted coiling can be an effective and safe treatment option with acceptable risks in experienced hands.
Stent-assisted coiling; subarachnoid hemorrhage; wide-necked aneurysm
We evaluated the outcomes of middle cerebral artery bifurcation (MCAB) aneurysms treated with simple coiling using single or multiple catheters without stents or balloons.
This study included 100 patients with 103 MCAB aneurysms who underwent a simple coiling procedure without the adjuvant use of stents or balloons. The angiographic clinical outcomes and recurrence of these aneurysms were evaluated.
Of the 103 aneurysms, 102 (99.0 %) aneurysms were successfully treated with simple coiling. One patient died from the consequences of a procedural aneurysm rupture. The treatment-associated permanent morbidity and mortality rates were 0 and 1.0 %, respectively. Post-coiling angiograms showed 28 complete occlusions (27.2 %), 60 neck remnants (58.3 %), and 14 partial occlusions (13.6 %). A follow-up angiography (median duration, 30 months; range, 3–73 months) was performed in 80 lesions. Recanalisation was found in 28 lesions (35.0 %), of which 6 were complete occlusions, 18 were neck remnants, and 4 were partial occlusions, as determined by post-coiling angiograms. Among these lesions, 14 major recurrences were retreated with coiling (n = 12) and clipping (n = 2) without complications. Age (odds ratio [OR], 0.93; 95 % confidence interval [CI], −0.11 to −0.01; p = 0.03), the presence of a rupture (OR, 3.89; 95 % CI, 0.12 to 2.60; p = 0.03), and a wide aneurysm neck (OR, 6.40; 95 % CI, 0.57 to 3.14; p = 0.005) were significantly associated with the aneurysm recurrence, as determined by multivariable analyses.
Our study suggests that simple coiling of MCAB aneurysms is feasible and safe; however, it has limitations in durability, particularly in ruptured or wide-necked aneurysms and in young patients.
Aneurysm; Coiling; Simple; Middle cerebral artery; Endovascular
Wide-neck intracranial aneurysms remain a challenge to endovascular treatment. We describe our experience in repairing wide-neck aneurysms of the anterior circulation located at arterial branch points using coil embolization assisted by Y-stenting using two Solitaire® stents.
Six wide-neck intracranial aneurysms located on the middle cerebral artery bifurcation 3, pericallosal artery 1, and anterior communicating artery 2 were repaired by Y-stent-assisted coil embolization using two Solitaire® stents. Four cases were incidental findings of aneurysm and two cases were previously treated ruptured aneurysms that had undergone recanalization.
All the cases were successfully treated without complications. Follow-up by digital subtraction angiography and magnetic resonance angiography at six months showed the stents to be patent with no recanalization of the aneurysm sacs.
Repairing wide-neck aneurysms of the anterior circulation by Y-stent-assisted coil embolization using two Solitaire® stents is a simple and safe method of treating complex aneurysms. While the results are promising, larger series with longer term follow-ups are needed to corroborate that this treatment method is superior to other techniques.
wide-neck aneurysm, embolization, Y-stenting technique, closed-cells stent