Guglielmi detachable coil embolization of acute intracranial aneurysm: perioperative anatomical and clinical outcome in 403 patients

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✓ From December 1990 to July 1995, the investigators participated in a prospective clinical study to evaluate the safety of the Guglielmi detachable coil (GDC) system for the treatment of aneurysms. This report summarizes the perioperative results from eight initial interventional neuroradiology centers in the United States. The report focuses on 403 patients who presented with acute subarachnoid hemorrhage from a ruptured intracranial aneurysm. These patients were treated within 15 days of the primary intracranial hemorrhage and were followed until they were discharged from the hospital or died.

Seventy percent of the patients were female and 30% were male. The patients' mean age was 58 years old. Aneurysm size was categorized as small (60.8%), large (34.7%), and giant (4.5%); and neck size was categorized as small (53.6%), wide (36.2%), fusiform (6%), and undetermined (4.2%). Fifty-seven percent of the aneurysms were located in the posterior circulation and 43% in the anterior circulation.

Eighty-two patients were classified as Hunt and Hess Grade I (20.3%), 105 Grade II (26.1%), 121 Grade III (30%), 69 Grade IV (17.1%), and 26 Grade V (6.5%). All patients in this study were excluded from surgical treatment either because of anticipated surgical difficulty (69.2%), attempted and failed surgery (12.7%), the patient's poor neurological (12.2%) or medical (4.7%) status, and/or refusal of surgery (1.2%).

The GDC embolization was performed within 48 hours of primary hemorrhage in 147 patients (36.5%), within 3 to 6 days in 156 patients (38.7%), 7 to 10 days in 71 patients (17.6%), and 11 to 15 days in 29 patients (7.2%). Complete aneurysm occlusion was observed in 70.8% of small aneurysms with a small neck, 35% of large aneurysms, and 50% of giant aneurysms. A small neck remnant was observed in 21.4% of small aneurysms with a small neck, 57.1% of large aneurysms, and 50% of giant aneurysms. Technical complications included aneurysm perforation (2.7%), unintentional parent artery occlusion (3%), and untoward cerebral embolization (2.48%). There was a 8.9% immediate morbidity rate related to the GDC technique. Seven deaths were related to technical complications (1.74%) and 18 (4.47%) to the severity of the primary hemorrhage.

The findings of this study demonstrate the safety of the GDC system for the treatment of ruptured intracranial aneurysms in anterior and posterior circulations. The authors believe additional randomized studies will further identify the role of this technique in the management of acutely ruptured incranial aneurysms.

Article Information

Address reprint requests to: Fernando Viñuela, M.D., Department of Radiology, University of California at Los Angeles, 10833 Le Conte Avenue, Los Angeles, California 90095–1721.

© AANS, except where prohibited by US copyright law.

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Figures

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    Angiograms showing a posterior fossa ruptured aneurysm. Left: Right vertebral angiogram shows a small, saccular posterior inferior cerebellar artery aneurysm with a small neck (closed arrow). Right: Postembolization angiogram shows complete GDC occlusion of the aneurysm (open arrow) with preservation of the posterior inferior cerebellar artery.

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    Angiograms documenting GDC embolization of a postsurgical residual aneurysm. Left: Right internal carotid angiogram demonstrates a residual carotidophthalmic aneurysm proximal to the surgical clip. Right: Three months postembolization, this angiogram shows complete GDC occlusion (arrows) of the residual aneurysm and sparing of right internal carotid artery lumen.

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    Right vertebral angiograms. Left: Anteroposterior Water's view shows a small, saccular basilar tip aneurysm. The neck of the aneurysm and the P1 portions of the posterior cerebral arteries are clearly seen. Right: Same angiographic view after GDC embolization of the ruptured aneurysm shows complete aneurysm occlusion (arrow) and preservation of normal vascular anatomy.

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    Left: Left internal carotid angiogram showing a ruptured saccular posterior communicating aneurysm (straight arrow) and an incidental carotidophthalmic aneurysm (curved arrow). Right: Postembolization angiogram showing a small neck remnant (white arrow) in the posterior communicating aneurysm and a complete carotidophthalmic aneurysm occlusion (curved black arrow).

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    Angiograms documenting postembolization angioplasty of severe symptomatic vasospasm. Upper Left: Lateral right internal carotid angiogram shows a small saccular posterior communicating artery aneurysm (black arrow) with severe vasospasm of the supraclinoid internal carotid artery (white arrows). Upper Right: Postembolization angiogram demonstrates GDC occlusion of the aneurysm (straight arrow) and mechanical angioplasty of the supraclinoid internal carotid artery (curved arrow). Lower Left: Right vertebral angiogram shows severe, diffuse vasospasm involving the distal basilar artery and the proximal posterior cerebral arteries. Lower Right: Vertebral angiogram obtained after mechanical angioplasty demonstrates successful dilation of spastic arteries. The patient exhibited significant clinical improvement after the angioplasty.

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