✓ Fifteen patients with high-risk intracranial saccular aneurysms were treated using electrolytically detachable coils introduced via an endovascular approach. The patients ranged in age from 21 to 69 years. The most frequent clinical presentation was subarachnoid hemorrhage (eight cases). Considerable thrombosis of the aneurysm (70% to 100%) was achieved in all 15 patients, and preservation of the parent artery was obtained in 14. Although temporary neurological deterioration due to the technique was recorded in one patient, no permanent neurological deficit was observed in this series and there were no deaths. It is believed that this new technology is a viable alternative in the management of patients with high-risk intracranial saccular aneurysms. It may also play an important role in the occlusion of aneurysms in the acute phase of subarachnoid hemorrhage.
Part 2: Preliminary clinical experience
Guido Guglielmi, Fernando Viñuela, Jacques Dion and Gary Duckwiler
Gordon Tang, C. Michael Cawley, Jacques E. Dion and Daniel L. Barrow
Object. Indications for intraoperative angiography during aneurysm surgery remain unclear. To define its use, the authors report the results of a prospective study in which this modality was used in all patients undergoing surgery for intracranial aneurysms.
Methods. Intraoperative angiography was performed prospectively in the surgical treatment of 517 consecutive aneurysms regardless of the lesion's location, size, or complexity. In 64 (12.4%) of 517 aneurysms intraoperative angiography findings prompted a change in surgical treatment. Residual aneurysm (47%) was the most frequent finding leading to clip revision. In 44% of cases, intraoperative angiography revealed vessel compromise. Surgery for aneurysms of the proximal internal carotid artery (ICA) was the most frequently altered, with lesions located at the superior hypophyseal artery (SHA) and clinoidal region having the highest revision rates, eight (40%) of 20 and eight (44%) of 18, respectively. Aneurysm size predicted the need for revision; giant aneurysms (> 24 mm) underwent revision in nine (29%) of 31 cases, whereas large aneurysms (15–24 mm) were revised in 12 (22%) of 54 cases. In a multivariate logistic regression model, factors related to increased revision rates included the SHA and clinoidal locations, as well as giant and large size. Ninety-five patients underwent both intraoperative and postoperative angiography. Five discrepancies were noted (95% accuracy); four were flow-related and one involved a previously unrecognized residual aneurysm. Complications attributable to intraoperative angiography occurred in 0.4% of cases.
Conclusions. Proximal ICA location and large aneurysm size significantly predicted revision of surgery following intraoperative angiography. Unexpected findings, even in less complex locations, are frequently identified on intraoperative angiography. Low complication rates, high accuracy, and the unexpected need for clip readjustments favor a more widespread use of intraoperative angiography.
Luis M. Tumialán, Y. Jonathan Zhang, C. Michael Cawley, Jacques E. Dion, Frank C. Tong and Daniel L. Barrow
The introduction of the Neuroform microstent has facilitated the embolization of complex cerebral aneurysms, which were previously not amenable to endovascular therapy. Typically, the use of this stent necessitates the administration of dual antiplatelet therapy to minimize thromboembolic complications. Such therapy may increase the risk of hemorrhage in patients who require concurrent external ventricular drainage and/or subsequent permanent cerebrospinal fluid diversion.
The authors' neurosurgical database was queried for all patients who underwent stent-assisted coil embolization for cerebral aneurysms and who required an external ventricular drain (EVD) or ventriculoperitoneal (VP) shunt placement for management of hydrocephalus.
Thirty-seven patients underwent stent-assisted coil embolization for intracranial aneurysms at the authors' institution over a recent 2-year period. Seven of these patients required placement of an EVD and/or a VP shunt. Three of the 7 patients suffered an immediate intraventricular hemorrhage (IVH) associated with placement or manipulation of an EVD; 1 experienced a delayed intraparenchymal hemorrhage and an IVH; 1 suffered an aneurysmal rehemorrhage; and the last patient had a subdural hematoma (SDH) that resulted from placement of a VP shunt. This patient required drainage of the SDH and exchange of the valve.
The necessity of dual antiplatelet therapy in the use of stent-assisted coil embolization increases the risk of intracranial hemorrhage and possibly rebleeding from a ruptured aneurysm. This heightened risk must be recognized when contemplating the appropriate therapy for a cerebral aneurysm and when considering the placement or manipulation of a ventricular catheter in a patient receiving dual antiplatelet therapy. Further study of intracranial procedures in patients receiving dual antiplatelet therapy is indicated.
Neil A. Martin, John Bentson, Fernando Viñuela, Grant Hieshima, Murray Reicher, Keith Black, Jacques Dion and Donald Becker
✓ Intraoperative digital subtraction angiography using commercially available equipment was employed to confirm the precision of the surgical result in 105 procedures for intracranial aneurysms or arteriovenous malformations (AVM's). Transfemoral selective arterial catheterization was performed in most of these cases. A radiolucent operating table was used in all cases, and a radiolucent head-holder in most. In five of the 57 aneurysm procedures, clip repositioning was required after intraoperative angiography demonstrated an inadequate result. In five of the 48 AVM procedures, intraoperative angiography demonstrated residual AVM nidus which was then located and resected. In two cases intraoperative angiography failed to identify residual filling of an aneurysm which was seen later on postoperative angiography, and in one case the intraoperative study failed to demonstrate a tiny residual fragment of AVM which was seen on conventional postoperative angiography. Two complications resulted from intraoperative angiography: one patient developed aphasia from cerebral embolization and one patient developed leg ischemia from femoral artery thrombosis. This technique appears to be of particular value in the treatment of complex intracranial aneurysms and vascular malformations.
Richard S. Polin, Mark E. Shaffrey, Mary E. Jensen, Lisa Braden, Robert D. G. Ferguson, Jacques E. Dion and Neal F. Kassell
✓ Carotid-cavernous aneurysms account for between 1.9% and 9.0% of intracranial aneurysms. Entirely intercavernous aneurysms are believed to have a relatively benign course, with cranial nerve findings or headache being the usual initial symptomatology; however, subarachnoid hemorrhage or carotid-cavernous fistula formation can result from rupture. Over the past 15 years endovascular parent artery occlusion has essentially replaced surgical carotid occlusion as the treatment of choice. The authors describe a series of 39 consecutive patients at the University of Virginia Health Sciences Center who underwent endovascular treatment of a carotid-cavernous aneurysm. Aggressive invasive hemodynamic monitoring and maintenance of a state of normo- to mild hypervolemia in the asymptomatic patient was used throughout the periprocedural period. Rapid institution of hypervolemic—hypertensive therapy can reverse early neurological deficits related to hypoperfusion in these patients. Only one individual managed with this protocol developed neurological deficits not reversible with hypertensive-hypervolemic therapy. Heparin therapy was administered for 48 hours after occlusion, with patients receiving subsequent aspirin therapy for 6 months to combat distal embolism secondary to thrombosis. Long-term complications were not seen in patients receiving aneurysm trapping; however, two individuals with proximal carotid occlusion developed late optic neuropathy and one had recurrent transient ischemic attacks that ceased with supraclinoidal carotid clipping.
Pedro Lylyk, Fernando Viñuela, Jacques E. Dion, Gary Duckwiler, Guido Guglielmi, Warwick Peacock and Neil Martin
✓ From September, 1986, to March, 1990, the authors treated 28 children harboring a vein of Galen vascular malformation. Eleven (39.3%) of the patients were neonates, 13 (46.4%) were 1 to 2 years old, and four (14.3%) were more than 2 years old.
Fifteen patients (53.6%) presented with severe congestive heart failure, six (21.4%) had seizures, four (14.3%) had hydrocephalus, and three (10.7%) presented with intraventricular hemorrhage. Based on the Yaşargil classification of malformations, 10 lesions (35.7%) were Type I, seven (25%) were Type II, eight (28.6%) were Type III, and three (10.7%) were Type IV. In 11 patients (39.3%), a combined transfemoral, transarterial, and transvenous embolization of the vein of Galen malformation was performed. A pure transtorcular approach was utilized in eight patients (28.6%), and postembolization surgical clipping of arterial feeders was performed in two cases with intractable congestive heart failure.
Complete anatomical occlusion of the galenic malformation was achieved in 13 patients (46.4%). An immediate postembolization improvement in the patient's clinical status was obtained in 23 (82.1%) of 28 patients and a good long-term clinical outcome was seen in 17 patients (60.7%). Five deaths (17.9%) occurred in this series of 28 patients; three (10.7%) were related to a transtorcular embolization and two (7.1%) to the unchanged natural history of the disease.
Harry J. Cloft, David F. Kallmes, Michelle H. Kallmes, Jonas H. Goldstein, Mary E. Jensen and Jacques E. Dion
Object. The aim of this study was to determine the prevalence of cerebral saccular aneurysms in patients with carotid artery and/or vertebral artery (VA) fibromuscular dysplasia (FMD).
Methods. A metaanalysis was performed using data from 17 previously reported series of patients with internal carotid artery (ICA) and/or VA FMD that included information on the prevalence of cerebral aneurysms. In addition, the authors retrospectively evaluated their own series of 117 patients with ICA and/or VA FMD to determine the prevalence of cerebral aneurysms. The metaanalysis of the 17 earlier series, which included 498 patients, showed a 7.6 ± 2.5% prevalence of incidental, asymptomatic aneurysms in patients with ICA and/or VA FMD. In the authors' series of patients with FMD, 6.3 ± 4.9% of patients harbored an incidental, asymptomatic aneurysm. When the authors' series was combined with those included in the metaanalysis, the prevalence was found to be 7.3 ± 2.2%. The prevalence of aneurysms in the general population would have to be greater than 5.6% for there to be no statistically significant difference (chi-square test, p < 0.05) when compared with this 7.3% prevalence in patients with FMD.
Conclusions. The prevalence of intracranial aneurysms in patients with cervical ICA and/or VA FMD is approximately 7%, which is not nearly as high as the 21 to 51% prevalence that has been previously reported.
Aaron S. Dumont, Avery J. Evans and Mary E. Jensen
Fernando Viñuela, Jacques E. Dion, Gary Duckwiler, Neil A. Martin, Pedro Lylyk, Allan Fox, David Pelz, Charles G. Drake, John J. Girvin and Gerard Debrun
✓ The authors describe their experience with 101 cerebral arteriovenous malformations (AVM's) treated by endovascular embolization followed by surgical removal. Fifty-three patients presented with intracranial hemorrhage and 35 had seizures. Based on the classification of Spetzler and Martin, two AVM's were Grade I, 13 were Grade II, 26 were Grade III, 43 were Grade IV, and 17 were Grade V, Fifty-six AVM's were in the right hemisphere, 28 were in the left hemisphere, 12 were in the corpus callosum, and five involved the cerebellum. In 50 cases, presurgical obliteration of 50% to 75% of the AVM nidus was achieved by embolization, and in 31 cases this percentage increased to between 75% and 90%. In 97 (96%) patients, complete surgical removal of the AVM was obtained.
Morbidity resulting from preoperative endovascular embolization was classified as mild in 3.9% of the cases, moderate in 6.9%, and severe in 1.98%. The death rate related to embolization was 0.9%. The immediate postsurgical morbidity was classified as mild in 5.9% of the cases, moderate in 10.8%, and severe in 5.9%. The overall long-term morbidity was mild in 5.9% of the cases, moderate in 6.9%, and severe in 1.98%. Two patients (1.98%) died due to intractable intraoperative hemorrhage and two (1.98%) as a result of postsurgical pulmonary complications.