Endovascular treatment of acutely ruptured and unruptured aneurysms of the basilar bifurcation

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✓ The surgical treatment of basilar bifurcation aneurysms is difficult and the need for an alternative approach is frequently stated. To assess the efficacy and safety of endovascular treatment of aneurysms located at the basilar bifurcation, the authors prospectively studied angiographic results, clinical results, and complications in 31 patients treated with Guglielmi detachable coils (GDCs). Patients treated acutely after subarachnoid hemorrhage (SAH) were graded according to the Hunt and Hess classification and clinical outcome was determined at 1- and 6-month intervals according to the Glasgow Outcome Scale (GOS).

There were 18 women and 13 men, ranging in age from 34 to 67 years (mean age 48 years). Twenty-three were treated acutely after SAH. Clinical Hunt and Hess grades at presentation were as follows: Grade I, six patients; Grade II, three; Grade III, 11; Grade IV, two; and Grade V, one. The GOS score for the group of patients treated acutely was: GOS I, 18 patients; GOS II, III, and IV, one patient each; and GOS V, two patients. There were seven technical complications in this group, most often asymptomatic, but one patient died after aneurysm rupture during treatment and one had residual diplopia at 4 months. Eight patients were treated for incidental basilar bifurcation aneurysms. One technical complication with no neurological deficit occurred in this group of patients with incidental aneurysms.

Immediate angiographic results were considered to be satisfactory in 94% of patients, with complete obliteration in 42% and residual neck and dog ears in 52%. There was no bleeding episode after treatment during clinical follow-up periods ranging from 3 to 42 months (mean 15.5 months in 29 surviving patients). Angiographic results were available for 27 patients at 6 months and were as follows: 30% of the lesions were completely obliterated, 59% presented some residual neck, and 11% showed some opacification of the aneurysm sac. During the follow-up period of up to 42 months, a total of seven recurrences were noted, necessitating retreatment with GDCs in five patients.

Endovascular treatment of basilar bifurcation aneurysms prevented rebleeding and could be performed without clinically significant complications in 94% of patients. Clinical results after SAH compared favorably with surgical series. Morphological results appear less satisfactory, and long-term angiographic follow-up review is mandatory to detect recurrences.

Article Information

Address reprint requests to: Jean Raymond, M.D., Department of Radiology, Hôpital Notre-Dame, 1560 Sherbrooke Street East, Montréal, Québec, H2L 4M1 Canada.

© AANS, except where prohibited by US copyright law.

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Figures

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    Angiograms of clinical examples and diagrams illustrating classifications of angiographic results following endovascular treatment.

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    Angiograms showing aneurysm rupture during treatment in a 64-year-old patient with Hunt and Hess Grade III after SAH treated at 48 hours. Upper Left: Left vertebral angiogram showing lesion consisting of two small lobulations. Upper Right: Angiogram obtained after occlusion of the larger lobulation. Lower Left: Unsubtracted anteroposterior view obtained during embolization of the second lobulation. A short limb of coil is seen beyond the limit of the aneurysm and there is extravasation of contrast material. Lower Right: Angiogram following systemic injection of protamine and detachment of the same coil. The rupture is sealed and the aneurysm excluded; note moderate spasm. The patient experienced clinical aggravation and died of intracranial hypertension 6 days later.

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    Angiograms showing pathology in a 56-year-old patient with Hunt and Hess Grade II after SAH treated within 24 hours. Upper Left: Right vertebral angiogram showing 10-mm aneurysm with 7-mm neck. Upper Center: Angiogram obtained immediately after treatment with GDCs showing residual aneurysm. Upper Right: Right vertebral angiogram obtained at 6 months showing compaction of coils and increased residual aneurysm; good outcome. Lower Left: Angiogram obtained after retreatment at 6 months showing residual dog ear. Lower Center: Control angiogram obtained at 30 months showing increase in residual neck from minimal compaction of coils at the neck/parent vessel interface. Lower Right: Control angiogram obtained at 45 months showing more coil compaction with increased recurrence.

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    Angiograms showing pathology in a 36-year-old patient with Hunt and Hess Grade I after SAH treated at 24 hours. Left: Right vertebral angiogram showing a small aneurysm with a short and narrow neck. Right: Right vertebral angiogram obtained at 6 months posttreatment showing stable results with complete obliteration; good outcome.

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