Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils

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✓ In a multicenter study, 120 patients with intracranial aneurysms presenting a high surgical risk were treated using electrolytically detachable coils and electrothrombosis via an endovascular approach. The results of treatment in patients with posterior fossa aneurysms (42 patients with 43 aneurysms) are presented. The most frequent clinical presentation was subarachnoid hemorrhage (24 cases). The clinical follow-up periods ranged from 1 week to 18 months. Complete aneurysm occlusion was obtained in 13 of 16 aneurysms with a small neck and in four of 26 wide-necked aneurysms. A 70% to 98% thrombosis of the aneurysm was achieved in 22 of 26 aneurysms with a wide neck and in three of 16 small-necked aneurysms. One aneurysm could not be treated due to a technical complication. Two cases required postprocedural surgical clipping of a residual aneurysm.

One patient (originally in Hunt and Hess Grade V) experienced procedural rupture of the aneurysm requiring an emergency parent artery occlusion. He eventually died 5 days later. Another patient (originally in Grade IV) had coil migration and posterior cerebral artery territory ischemia. A third patient developed a permanent neurological deficit (hemianopsia) after complete occlusion of a wide-necked basilar bifurcation aneurysm. One patient, harboring an inoperable giant basilar bifurcation aneurysm, died from aneurysm bleeding 18 months after partial occlusion.

Overall morbidity and mortality rates related to treatment were 4.8% (two cases) and 2.4% (one case), respectively (2.6% and 0% if considering only patients in Hunt and Hess Grades I, II, and III).

It is suggested that this technique is a viable alternative in the management of patients with posterior fossa aneurysms associated with high surgical risk. Longer angiographic and clinical follow-up study is necessary to determine the long-term efficacy of this recently developed endovascular occlusion technique. Close postoperative angiographic and clinical monitoring of patients with wide-necked subtotally occluded aneurysms is mandatory to check for potential aneurysmal recanalization, regrowth, and rupture.

Article Information

Address reprint requests to: Guido Guglielmi, M.D., Dipartimento di Scienze Neurologiche, Neuroangiografia Terapeutica, Universita' di Roma, Viale dell'Universita' 30/a, 00185 Roma, Italy.

© AANS, except where prohibited by US copyright law.

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Figures

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    Diagram of the Guglielmi detachable coil (GDC) and of the modified version of the Tracker microcatheter. A = diameter of the circular memory; B = the distal portion, a platinum coil (0.010 or 0.015 in. in diameter and 4 to 40 cm in length if straightened); C = microsolder connecting the platinum coil to the stainless steel delivery wire; D = detachable area; E = proximal (platinum) marker on the GDC; F = Teflon lamination; G = GDC shaft (diameter 0.010 in.); H = catheter tip marker; I = catheter proximal marker; J = catheter shaft.

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    Case 13. Left: Vertebral angiogram, lateral view, demonstrating a small vertebrobasilar junction aneurysm (long arrow). The residual portion of another (partially clipped) vertebrobasilar junction aneurysm is also visible (short arrow). Right: Arteriogram obtained 3 months after occlusion of the first aneurysm with two Guglielmi detachable coils (GDC's) (14 cm total length), and immediately after occlusion of the second (residual) aneurysm with one 4-cm long GDC. Both aneurysms are completely occluded while the normal arteries have been preserved.

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    Case 16. A: Right vertebral angiogram, anteroposterior view, demonstrating a giant vertebrobasilar junction aneurysm. B: Left vertebral angiogram demonstrating the giant aneurysm. C: Right vertebral angiogram performed 3 days after deposition of 10 Guglielmi detachable coils (0.015 in. in diameter, total length 4 m). Most of the aneurysm has undergone thrombosis. The distal vascular tree is now visible. D: Left vertebral angiogram obtained 8 days after coil deposition and immediately after balloon occlusion of the right vertebral artery. The right posterior inferior cerebellar artery (long arrow) is filling from the left. The (subtracted) meshwork of coils is barely visible (short arrows). Permanent occlusion of the right vertebral artery was performed to lessen the jet effect of the arterial flow in the residual aneurysm.

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    Case 17. A: Vertebral angiogram, lateral view, demonstrating a large basilar bifurcation aneurysm. B: Intra-aneurysmal angiogram obtained while performing catheterization of the aneurysm with a modified version of a Tracker-18 microcatheter. Angiography was performed to determine proper positioning of the microcatheter tip (long arrow) and in an attempt to determine the size of the neck by comparing the position of the microcatheter (inflow zone at the neck) with the outflow. Note the contrast material depicting the flow pattern within the aneurysm (two short arrows). C: Plain skull x-ray film showing the network of coils placed within the aneurysm (total coil length 1.95 m). Coils both 0.010 in. and 0.015 in. in diameter were used in this case. D: Immediate postembolization vertebral angiogram showing the aneurysm completely occluded and the parent vessel preserved.

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    Case 19. Left: Vertebral angiogram, anteroposterior view, showing a large inoperable vertebrobasilar junction aneurysm, irregular in shape. Right: Angiogram made after two embolization procedures using four coils with an overall length of 90 cm. In spite of loose packing, most of the aneurysm is occluded. The posttreatment clinical course was uneventful. (Procedure performed at the University of Wisconsin, Madison, Wisconsin.)

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    Case 21. Left: Vertebral angiogram, lateral-oblique view, showing a small posterior inferior cerebellar artery aneurysm (arrow). Right: Vertebral angiogram taken after intra-aneurysmal deposition and detachment of two coils (total length 18 cm) via a modified Tracker-10 microcatheter. The aneurysm is completely occluded. (Procedure performed at New York University, New York, New York.)

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    Case 7. A and B: Vertebral angiograms, anteroposterior (A) and lateral (B) views, showing a small basilar bifurcation aneurysm. C and D: The 14-month postocclusion follow-up angiograms showing persistence of complete aneurysm occlusion. (Angiogram courtesy of Drs. L. Chi and J. Bello, Montefiore Hospital, New York, New York.)

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