Endovascular treatment of giant and large intracranial aneurysms by using a combination of stent placement and liquid polymer injection

Restricted access

Object. The aim of this study was to test the feasibility, safety, and efficacy of a new endovascular method for the treatment of giant intracranial aneurysms. This new method consists of combining a metallic stent with a liquid polymer; the stent is first placed across the neck of the aneurysm to reconstruct a tubular arterial lumen, followed by obliteration of the fundus of the aneurysm with an ethyl vinyl alcohol polymer. During its injection, the liquid polymer is contained within the aneurysm by temporarily inflating an occlusion balloon in the parent artery.

Methods. Eleven patients harboring a giant aneurysm were successfully treated using this procedure. All aneurysms were excluded from the circulation, with preservation of the parent artery. In nine of the 11 patients, the 6-month follow-up angiogram demonstrated no recanalization of the aneurysm. In one patient who had a giant and partially clotted internal carotid artery bifurcation aneurysm, the follow-up angiogram demonstrated minimal recanalization. The complications in this series of patients included one death and one case of transient hemiparesis caused by watershed ischemia.

Conclusions. The initial anatomical results and the clinical outcome in this small series of patients are very encouraging. The mortality and morbidity rates associated with this new endovascular treatment are superior to those associated with surgical clipping of giant aneurysms.

Article Information

Address reprint requests to: Michel E. Mawad, M.D., The Meth odist Hospital—Baylor College of Medicine, Mail Station No. M201A, 6565 Fannin, Houston, Texas 77030. email: mmawad@tmh.tmc.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Artist's rendition detailing the different steps of the endovascular procedure in a giant saccular aneurysm. A: The unexpanded stent is advanced over a guidewire and positioned across the neck of the aneurysm. B: The stent is placed by inflating the balloon to the recommended nominal pressure. C: Once deposited, the stent is embedded in the wall of the artery across the fundus of the aneurysm. D: The microcatheter is introduced into the fundus of the aneurysm throughthe mesh of the expanded stent. E: The balloon used to position the stent is inflated temporarily to seal the aneurysm and occlude the parent artery. F: With theocclusion balloon inflated, the radiopaque polymer is slowly injected inside the fundus of the aneurysm. G: Several small injections of the polymer are made toobliterate the aneurysm completely. H: Once the aneurysm is completely obliterated, the microcatheter and occlusion balloon are withdrawn from the parent artery.

  • View in gallery

    Giant saccular aneurysm of the ICA selected for treatment with a combination of stent placement and polymer injection. A: Right ICA angiogram, frontal view, revealing a giant saccular aneurysm arising from the ophthalmic segment of the ICA. B: Lateral view demonstrating the rather wide neck of the aneurysm. C: The stent is placed across the neck of the aneurysm by inflating the balloon to the recommended nominal pressure. D: Lateral view of the skull obtained following obliteration of the aneurysm, demonstrating the expanded stent in place and the radiopaque polymer filling the lesion. E: Posttreatment CA angiogram, frontal view, demonstrating complete obliteration of the aneurysm and preservation of the parent artery. F: Lateral view of the same angiogram demonstrating good reconstruction of the artery and exclusion of the aneurysm from the circulation. G: Frontal view of the right CA arteriogram obtained 8 months posttreatment, demonstrating persistent and complete obliteration of the aneurysm. H: Lateral view of the angiogram obtained 8 months posttreatment.

  • View in gallery

    Artist's rendition detailing the different steps of the endovascular procedure in a giant fusiform aneurysm. A: The unexpanded stent is advanced over a guidewire and positioned within the fusiform aneurysm along the expected trajectory of the artery. B: The stent is deposited by inflating the balloon to the recommended nominal pressure. C: The microcatheter is then introduced into the fundus of the aneurysm through the mesh of the expanded stent. D: With the balloon temporarily inflated, the polymer is slowly injected into the fundus of the aneurysm. E: The aneurysm is gradually obliterated using several small injections of the polymer. As more polymer is injected, it circumferentially surrounds the stent and obliterates the entire aneurysm. F: Once the polymer has cured completely, the microcatheter and then the occlusion balloon are withdrawn from the parent artery.

  • View in gallery

    Giant fusiform aneurysm of the cavernous CA treated with a combination of stent placement and liquid polymer injection. A: Frontal view of an ICA angiogram revealing a giant fusiform aneurysm of the cavernous segment of the CA. B: The corresponding lateral view demonstrating the fusiform nature of the aneurysm, which has no discernible neck. C: The unexpanded stent is advanced over a guidewire and positioned within the fusiform aneurysm along the expected trajectory of the artery. D: The stent is placed by inflating the balloon to the recommended nominal pressure. E: Once deposited, the stent is anchored in the proximal and distal ends of the aneurysm. F: The microcatheter is introduced into the fundus of the aneurysm through the mesh of the expanded stent. The balloon is then temporarily inflated to seal the aneurysm and preserve the inner lumen of the stent. G: With the occlusion balloon inflated, the radiopaque polymer is slowly injected into the aneurysm around the inflated balloon. H: Frontal view of the skull, obtained at the end of the treatment demonstrating the radiopaque cast of the polymer surrounding the stent. I: Frontal view of the posttreatment CA angiogram demonstrating complete obliteration of the aneurysm and preservation of the parent artery. J: Lateral view of the posttreatment angiogram demonstrating complete obliteration of the aneurysm and reconstruction of a normal appearing parent artery. K and L: Frontal (K) and lateral (L) views of the angiogram obtained 6 months posttreatment, demonstrating persistent and complete obliteration of the aneurysm.

References

1.

Arnautovic KIAl-Mefty OAngtuaco E: A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms. Surg Neurol 50:5045201998Arnautovic KI Al-Mefty O Angtuaco E: A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms. Surg Neurol 50:504–520 1998

2.

Auer LMAuer T: Early surgical repair of large intracranial saccular aneurysms. Acta Neurochir 95:95981988Auer LM Auer T: Early surgical repair of large intracranial saccular aneurysms. Acta Neurochir 95:95–98 1988

3.

Ausman JIDiaz FGSadasivan Bet al: Giant intracranial aneurysm surgery: the role of microvascular reconstruction. Surg Neurol 34:8151990Ausman JI Diaz FG Sadasivan B et al: Giant intracranial aneurysm surgery: the role of microvascular reconstruction. Surg Neurol 34:8–15 1990

4.

Drake CG: Giant intracranial aneurysms: experience with surgical treatment in 174 patients. Clin Neurosurg 26:12951979Drake CG: Giant intracranial aneurysms: experience with surgical treatment in 174 patients. Clin Neurosurg 26:12–95 1979

5.

Drake CGPeerless SJ: Giant fusiform intracranial aneurysms: review of 120 patients treated surgically from 1965 to 1992. J Neurosurg 87:1411621997Drake CG Peerless SJ: Giant fusiform intracranial aneurysms: review of 120 patients treated surgically from 1965 to 1992. J Neurosurg 87:141–162 1997

6.

Gewirtz RJAwad IA: Giant aneurysms of the anterior circle of Willis: management outcome of open microsurgical treatment. Surg Neurol 45:4094211996Gewirtz RJ Awad IA: Giant aneurysms of the anterior circle of Willis: management outcome of open microsurgical treatment. Surg Neurol 45:409–421 1996

7.

Gobin YPViñuela FGurian JHet al: Treatment of large and giant fusiform intracranial aneurysms with Guglielmi detachable coils. J Neurosurg 84:55621996Gobin YP Viñuela F Gurian JH et al: Treatment of large and giant fusiform intracranial aneurysms with Guglielmi detachable coils. J Neurosurg 84:55–62 1996

8.

Gruber AKiller MBavinzski Get al: Clinical and angiographic results of endosaccular coiling treatment of giant and very large intracranial aneurysms: a 7-year, single-center experience. Neurosurgery 45:7938041999Gruber A Killer M Bavinzski G et al: Clinical and angiographic results of endosaccular coiling treatment of giant and very large intracranial aneurysms: a 7-year single-center experience. Neurosurgery 45:793–804 1999

9.

Heros RCNelson PBOjemann RGet al: Large and giant paraclinoid aneurysms: surgical techniques, complications and results. Neurosurgery 12:1531631983Heros RC Nelson PB Ojemann RG et al: Large and giant paraclinoid aneurysms: surgical techniques complications and results. Neurosurgery 12:153–163 1983

10.

Hosobuchi Y: Direct surgical treatment of giant intracranial aneurysms. J Neurosurg 51:7437561979Hosobuchi Y: Direct surgical treatment of giant intracranial aneurysms. J Neurosurg 51:743–756 1979

11.

Jennett BBond M: Assessment of outcome after severe brain damage. A practical scale. Lancet 1:4804841975Jennett B Bond M: Assessment of outcome after severe brain damage. A practical scale. Lancet 1:480–484 1975

12.

Kattner KABailes JFukushima T: Direct surgical management of large bulbous and giant aneurysms involving the paraclinoid segment of the internal carotid artery: report of 29 cases. Surg Neurol 49:4714801998Kattner KA Bailes J Fukushima T: Direct surgical management of large bulbous and giant aneurysms involving the paraclinoid segment of the internal carotid artery: report of 29 cases. Surg Neurol 49:471–480 1998

13.

Lawton MTDaspit CPSpetzler RF: Technical aspects and recent trends in the management of large and giant midbasilar artery aneurysms. Neurosurgery 41:5135211997Lawton MT Daspit CP Spetzler RF: Technical aspects and recent trends in the management of large and giant midbasilar artery aneurysms. Neurosurgery 41:513–521 1997

14.

Lawton MTRaudzens PAZabramski JMet al: Hypothermic circulatory arrest in neurovascular surgery: evolving indications and predictors of patient outcome. Neurosurgery 43:10211998Lawton MT Raudzens PA Zabramski JM et al: Hypothermic circulatory arrest in neurovascular surgery: evolving indications and predictors of patient outcome. Neurosurgery 43:10–21 1998

15.

Lawton MTSpetzler RF: Surgical strategies for giant intracranial aneurysms. Acta Neurochir Suppl 72:1411561999Lawton MT Spetzler RF: Surgical strategies for giant intracranial aneurysms. Acta Neurochir Suppl 72:141–156 1999

16.

Lawton MTSpetzler RF: Surgical strategies for giant intracranial aneurysms. Neurosurg Clin N Am 9:7257421998Lawton MT Spetzler RF: Surgical strategies for giant intracranial aneurysms. Neurosurg Clin N Am 9:725–742 1998

17.

Michel WF: Posterior fossa aneurysms simulating tumours. J Neurol Neurosurg Psychiatry 37:2182231974Michel WF: Posterior fossa aneurysms simulating tumours. J Neurol Neurosurg Psychiatry 37:218–223 1974

18.

Morley TPBarr HW: Giant intracranial aneurysms: diagnosis, course, and management. Clin Neurosurg 16:73941969Morley TP Barr HW: Giant intracranial aneurysms: diagnosis course and management. Clin Neurosurg 16:73–94 1969

19.

Origitano TCAnderson DETarassoli Yet al: Skull base approaches to complex cerebral aneurysms. Surg Neurol 40:3393461993Origitano TC Anderson DE Tarassoli Y et al: Skull base approaches to complex cerebral aneurysms. Surg Neurol 40:339–346 1993

20.

Pasqualin ABattaglia RScienza Ret al: Italian cooperative study on giant intracranial aneurysms: 4. Results of treatment. Acta Neurochir 42:65701988Pasqualin A Battaglia R Scienza R et al: Italian cooperative study on giant intracranial aneurysms: 4. Results of treatment. Acta Neurochir 42:65–70 1988

21.

Peerless SJWallace MCDrake CG: Giant intracranial aneurysms in Youmans JR (ed): Neurological Surgery. A Comprehensive Reference Guide to the Diagnosis and Management of Neurosurgical Problemsed 3. Philadelphia: WB Saunders1990 p 1742Peerless SJ Wallace MC Drake CG: Giant intracranial aneurysms in Youmans JR (ed): Neurological Surgery. A Comprehensive Reference Guide to the Diagnosis and Management of Neurosurgical Problems ed 3. Philadelphia: WB Saunders 1990 p 1742

22.

Pia HWZierski J: Giant cerebral aneurysms. Neurosurg Rev 5:1171481982Pia HW Zierski J: Giant cerebral aneurysms. Neurosurg Rev 5:117–148 1982

23.

Pluchino FGiombini SBroggi Get al: Surgical management of giant anterior aneurysm. J Neurosurg Sci 42 (Suppl 1):65691998Pluchino F Giombini S Broggi G et al: Surgical management of giant anterior aneurysm. J Neurosurg Sci 42 (Suppl 1):65–69 1998

24.

Standard SCGuterman LRChavis TDet al: Endovascular management of giant intracranial aneurysms. Clin Neurosurg 42:2672931995Standard SC Guterman LR Chavis TD et al: Endovascular management of giant intracranial aneurysms. Clin Neurosurg 42:267–293 1995

25.

Sundt TM JrPiepgras DGFode NC: Giant intracranial aneurysms. Clin Neurosurg 37:1161541991Sundt TM Jr Piepgras DG Fode NC: Giant intracranial aneurysms. Clin Neurosurg 37:116–154 1991

26.

Symon L: Surgical experience with giant intracranial aneurysms. Acta Neurochir 118:53581992Symon L: Surgical experience with giant intracranial aneurysms. Acta Neurochir 118:53–58 1992

27.

Whittle IRDorsch NWBesser M: Giant intracranial aneurysms: diagnosis, management, and outcome. Surg Neurol 21:2182301984Whittle IR Dorsch NW Besser M: Giant intracranial aneurysms: diagnosis management and outcome. Surg Neurol 21:218–230 1984

28.

Yaşargil MG: Microneurosurgery. New York: Thieme1984Yaşargil MG: Microneurosurgery. New York: Thieme 1984

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 54 54 30
Full Text Views 137 137 8
PDF Downloads 90 90 5
EPUB Downloads 0 0 0

PubMed

Google Scholar