We report the safety and midterm effectiveness of endovascular treatment of unruptured aneurysms in our institution. Fifty aneurysms in 48 patients were included in this study. The overall rate of adverse events related to the treatment was 6%.
Thromboembolic complications and intraoperative rupture were encountered in 2 (4%) and 1 (2%), respectively.
The procedure-related morbidity rate was 2% (1 case) and there were no procedure-related deaths. Evaluation of the postoperative anatomic results indicated complete occlusion (CO) in 30 aneurysms (60%), neck remnants (NR) in 12 aneurysms (24%), and dome filling (DF) in 8 aneurysms (16%). On the otherhand, the latest follow-up magnetic resonance angiography with source images, indicated CO in 26 aneurysms (68%), NR in 6 aneurysms (16%), and DF in 6 aneurysms (16%), respectively. The recurrence rate of the embolized aneurysm is relatively low, and there was no bleeding after endovascular treatment during the follow-up period.
Our results are comparable to those of previous reports in the literature. Endovascular treatment of unruptured aneurysms is safe and effective, with low morbidity and mortality rates.
We evaluated the radiologic and clinical outcome of unruptured intracranial aneurysms treatment by using double microcatheters into the aneurysm. Between October 2006 and December 2009, 30 patients with 30 aneurysms were treated, including 12 patients treated by using double microcatheters and 18 patients treated by using a single microcatheter. The volume embolization ratio (VER) ―percentage of the coil volume occupying the aneurysmal lumen―was used as an index to evaluate the radiologic results. The VER of aneurysms treated with double-microcatheter technique was 25.2±4.8%, and the VER of aneurysms treated with the single-microcatheter technique was 21.6±3.9% (P<0.05). There was 1 ischemic complication in the single-microcatheter technique group, and no complications in the double-microcatheter technique group. Although in the aneurysms with a long aneurysmal diameter/short aneurysmal diameter (L/S) ratio less than 1.5, there were no significant differences between the 2 groups, in the aneurysms with a L/S ratio of 1.5 or greater, the VER of aneurysms treated with the double-microcatheter technique was 27.6±4.3%, and the VER of aneurysms treated with single-catheter technique was 19.7±3.4% (P<0.05). The advantage of the double-microcatheter technique is that placing 2 microcatheters into the aneurysm allowed 2 coils to achieve a stable coil configuration before either coil was detached.
The double microcatheter technique is an effective and safe treatment for unruptured aneurysms.
The incidence of aneurysmal subarachnoid hemorrhage (SAH) increases with age. Aged patients of SAH are thought to have higher risk for complications and poorer prognosis. We retrospectively reviewed the consecutive medical records of ruptured intracranial aneurysm patients over 75 years old (y/o), who were admitted to our hospital, where endovascular treatment was adopted as the first option between April 2004 and July 2010. Thirty-eight patients (6 males and 32 females) ranging from 75 to 90 (average 82.1) y/o were enrolled. They were divided into a course observation (CO) group (n=7), clipping (CL) group (n=13) and coil embolization (CE) group (n=18). Among these 3 groups, we evaluated the clinical characteristics, Hunt & Kosnik (H&K) grade on admission, and modified Rankin Scale (mRS) and Glasgow Outcome Scale (GOS) 3 months after ictus as the outcomes. Furthermore, we analyzed the main cause leading to unfavorable outcomes.
According to the location of radically treated aneurysms, all MCA aneurysms were clipped and all VBA aneurysms were coil embolized, while ACoA aneurysms were more likely to be treated with coil embolization. Although it was necessary in some cases to alter the approach route from trans-femoral to trans-brachial or trans-carotid due to atherosclerotic tortuosity, every coil embolization was successful without procedure-related complications. Moreover, neither re-rupture nor re-growth requiring further treatment occurred during follow-up period (range, 6 months–6 years).
Among the CL group and CE group, 20 (64.5%) of 31 resulted in mRS 3–6 despite aggressive treatment. However, the results of the CO group were much worse than those of the CL group and CE group. All 7 patients in the CO group died of primary brain damage (PBD) 3, re-rupture 3, pneumonia 1, respectively. There was no significant difference between the CL group and CE group in age distribution or H&K grade. Nevertheless, the proportion of mRS 0 and 1 in the CE group was larger than that in the CL group (44.4% vs. 23.1%), although there was no statistical difference. No vegetative survival (V) was found in this study, so we regarded severely disabled (SD) and dead (D) as unfavorable outcomes. There were 6 SD and 3 D of 13 in the CL group, whereas there were 7 SD and 3 D of 18 in the CE group. As the main cause of unfavorable outcomes, PBD, systematic complications such as pneumonia, pre-existing comorbidities etc. were named, but above all, vasospasm was strongly correlated with SD in the CL group (4 of 6) compared with the CE group (2 of 7).
Though there were inherent limitations and biases in this study and the overall results were unsatisfactory, we validated the usefulness of coil embolization for ruptured aneurysm in elderly patients. Because coil embolization was effective against re-rupture, it might be a preferred alternative for aneurysms not amenable to clipping.
Optimum treatment should be considered individually when both microsurgical and endovascular treatment modalities are available. Furthermore, intensive peri-procedural management of patients’ clinical conditions especially focused on preventing vasospasm as well as greater skill in both treatments are important to improve outcomes.
This study seeks to determine how changes in outcomes and causal events are associated with outcome in patients with subarachnoid hemorrhage over time in an aging population. This retrospective study included 587 patients between 1989 and 2008. In that period, the mean age of the patients became older, from 55 to 65 years. Outcomes were assessed using the Glasgow Outcome Scale (GOS). Initial events that preceded unfavorable outcomes (GOS SD and V) and dead were identified. The overall outcome was GR in 36%, MD in 11%, SD in 13%, V in 3% and D in 37%. We compared data during the previous 10-year period from 1989 to 1998 with those during 1999 to 2008. The proportion of the patients over 70 years old increased from 25% to 46%, Hunt & Kosnik Grade V increased from 9% to 24%, and outcomes of SD increased from 9% to 17%. However, no change in the case-fatality rate was observed. As causative events, primary damage accounted for 56% of all cases with unfavorable outcomes and dead, while the rate of vasospasm and systemic complications were significantly decreased.
Among 349 cases (66.3%) that underwent aneurysm obliteration, unfavorable outcomes of SD and V rose twofold to 23.5%, and the fatality rate fell by one-half to 11%. Overall outcome of subarachnoid hemorrhage has not improved. Advances in treatment have saved many patients; however, the increasing number of severe patients without surgical indication offsets the improvement in outcome. Although early surgery and intensive management reduced the rate of fatalities, vasospasm and systemic complications, this may have resulted in increasing unfavorable outcomes.
These findings reflect the conditions associated with an aging population with a long life expectancy and offer a possible model for other rural cities in Japan.
There are 2 kinds of surgical approaches to unruptured anterior communicating artery aneurysm (Acom an): the pterional and interhemispheric approach. Currently, the thoice of approach depends on the surgeon’s preference and experience. In our study, we compared the interrelationship between appropriate surgical approach and dome projection among the following 3 groups: anterior/inferior, superior, and posterior projections. The results showed only aneurysms with anterior/inferior dome projection were suitable for the pterional approach. However, the interhemispheric approach was preferable for aneurysms with all other projections except for anterior/inferior projection.
Surgeons should be familiar with both approaches so they we can select according to dome projection of Acom an.
Indocyanine green (ICG) angiography of cervical carotid artery stenosis was performed and the contrast patterns were analyzed. The subjects were 18 patients who had undergone carotid endarterectomy (CEA) since August 2009. Before arteriotomy, ICG angiography was performed and monitored. One patient who underwent ICG angiography of the cervical vessels during high-flow bypass of a ruptured cerebral aneurysm acted as a control. On ICG angiography of the control patient, the vascular lumen was first filled with ICG, after which the arterial component of the vasa vasorum was slowly contrast-enhanced, followed by contrast enhancement of the venous component, and finally uniform contrast enhancement of the arterial wall. The vasa vasorum were contrast-enhanced in an annular conformation along the short axis of the internal carotid artery. In CEA patients, the arterial component of the vasa vasorum was quickly contrast-enhanced after ICG filling of the vascular lumen, with a non-homogenous vascular network formed by branches of the vasa vasorum at the atheroma site, followed by contrast enhancement of the venous component and, finally, by patchy contrast enhancement of the entire arterial wall. The vasa vasorum were contrast-enhanced in a virtually radiating conformation along the long axis, mainly around the common carotid bifurcation. Similar results were also obtained from analysis of the time-intensity curve with Flow 800.
ICG angiography findings in severe cervical carotid artery stenosis suggested that the vascular structure of the arterial wall had transformed from a normal condition to a pattern of nutrient supply to the atheroma.
The treatment of relatively large cerebral aneurysms by direct clipping has been reported to significantly increase operative morbidity. In this article, we introduce a newly conducted surgical technique of aneurysmoplasty, which is most suitable for clipping of these ruptured aneurysms and implies additional methods to prevent surgical injury to surrounding vessels and brain tissues. The main concept of aneurysmoplasty includes tentative clipping in the early stage of aneurysm dissection and reduction in size of aneurysms by low output bipolar-coagulation. These methods are systemically arranged and titrated according to the aneurysm’s size and location.
Transforming large ruptured aneurysms to small unruptured aneurysms apparently improves safety and reliability in clipping procedure by direct inspection around the neck and behind the dome of aneurysms.
The high signal intensity (SI) of diffusion weighted image (DWI) is well correlated with complete brain infarction. High SI of DWI includes reversible and/or irreversible ischemia, and the borderline between them has not been confirmed clearly yet. In this report, we elucidate the clinical borderline of ischemic condition of reversibility concerned with SI of DWI at the acute ischemic stage. MRI data were collected in 15 patients with acute stroke who achieved recanalization within 6 hours from onset. SI was investigated with correlation to the apparent diffusion coefficient (ADC) and ratio to normal location as standard.
An inversed correlation was demonstrated between signal intensity of DWI and ADC. The irreversible borderline was less than 0.56 (10-3 mm2/s) in ADC and it was equal to a signal intensity of more than 175 in DWI. The signal ratio effectively divided infarct and retained when the basic standard site was anatomical contralateral point. The irreversible borderline of the signal ratio was more than 1.4 to the contralateral portion in DWI. This study suggests SI in DWI can be a criterion for ischemic reversibility.
Dural arteriovenous fistulas (DAVFs) in the transverse-sigmoid sinus (TSS) usually flow into the sinus, and sometimes retrograde venous drainage is observed. We experienced a rare variant of DAVF located in the wall of the transverse-sigmoid sinus and draining only into the cortical vein.
A 55-year-old man presenting with pulsating headache was diagnosed as a DAVF and referred to our hospital. The patient had no neurologic deficit, but a pulsating bruit was heard in the right mastoid area. There was no history of head trauma or surgery. Magnetic resonance imaging (MRI) showed many flow void spots around the right temporal lobe. Contrast-enhanced magnetic resonance angiography showed the large dilated vein of Labbé in the early arterial phase. Angiography disclosed a DAVF located in the superior wall of the transverse-sigmoid sinus.
This DAVF drained directly into the right vein of Labbé in a retrograde fashion but not into the transverse-sigmoid sinus. Cerebral venous blood flow was not affected by the DAVF and drained into the ipsilateral transverse-sigmoid sinus. The patient was successfully treated with transarterial glue embolization.
We report a case of true posterior communicating artery (Pcom) aneurysm associated with carotid rete mirabile presenting subarachnoid hemorrhage.
A 77-year-old woman was admitted to our hospital because of disturbance of consciousness. Computed tomography showed subarachnoid hemorrhage. Cerebral angiography demonstrated 2 aneurysms arising from the left Pcom and left posterior cerebral artery (P1–P2 junction). The right carotid angiography demonstrated an abnormal vascular network around the cavernous portion of internal carotid artery (ICA), so-called “carotid rete mirabile.” The right ICA was aplastic and the left ICA was hypoplasic. Two days after onset, coil embolization was performed. As a result, the left P1–P2 junctional aneurysm was almost completely occluded, but it was impossible to occlude the left Pcom aneurysm.
Twenty-four days after onset, neck clipping of the responsible left Pcom aneurysm was carried out through the left subtemporal approach. Postoperatively, the patient experienced temporary left oculomotor nerve palsy but improved. Follow-up angiography revealed disappearance of the left Pcom aneurysm and almost complete obliteration of the left P1–P2 junction aneurysm.
True posterior-communicating artery (PcoA) aneurysms are rare, and usually have no association with the internal carotid artery (ICA) or the posterior cerebral artery. Here we report the case of an 82-year-old woman with severe subarachnoid hemorrhage due to true PCoA aneurysm rupture. Cerebral angiography revealed an aneurysm of the left PCoA itself with superomedial projection. The patient underwent left pterional craniotomy and neck clipping of the aneurysm. Intra-operatively, the aneurysm was not observed on the lateral side of the ICA, although its origin could be seen on the posterolateral wall of the ICA. The aneurysm was approached via the opticocarotid space after removing the anterior clinoid process and opening the carotid dural ring. The aneurysm was completely obliterated and the PCoA was preserved.
True PCoA aneurysms can have a variety of projecting directions, which must be considered when choosing the surgical approach to their treatment.