Low-profile visualized intraluminal support stent for the endovascular treatment of traumatic intracranial internal carotid artery pseudoaneurysms

Optimal treatment strategies for traumatic intracranial internal carotid artery (ICA) pseudoaneurysms are controversial. The low-profile visualized intraluminal support (LVIS) device is a braided stent with a metal coverage rate between traditional laser cut stents and flow diversion devices. We report here our therapy strategy using the LVIS stent-assisted coiling for treatment of traumatic intracranial ICA pseudoaneurysms. Patients with traumatic intracranial ICA pseudoaneurysms treated by the LVIS stent-assisted coiling in our center between January 2015 and June 2021 were reviewed. The complications, radiographic, and clinical outcomes of these patients were analyzed. A total of 12 patients with 12 pseudoaneurysms were included. The mean maximum aneurysm diameter was 6.2?±?3.1 mm. Nine patients had a subarachnoid hemorrhage; five patients with Hunt-Hess grade III and four patients with grade IV. All procedures were successfully performed without intraoperative complications. Immediate postoperative angiogram showed that six (50%) aneurysms were Raymond grade 1, four (33.3%) were grade 2, and two (16.7%) were grade 3. Postoperative multiple cerebral infarction occurred in two patients because of vasospasm. Of the ten patients with angiographic follow-up (mean, 29.9 months), two received additional coiling because of recanalization of the pseudoaneurysm, and all aneurysms were completely obliterated at the last examination of the patients. During the clinical follow-up period (mean, 26.8 months), the overall mortality and morbidity were 25% (3/12) and 8.3% (1/12), respectively. LVIS stent-assisted coiling was a feasible approach for the treatment of traumatic ICA pseudoaneurysms.

     

Endovascular treatment of very small intracranial aneurysms

BACKGROUND: The treatment of very small cerebral aneurysms with maximal diameter less than 3 mm remains a challenge for endovascular and surgical treatment. Endovascular treatment of these lesions may be difficult and associated with high risk of complications because of their small size. Our purpose was to assess the feasibility and results of endovascular treatment of these lesions. METHODS: We conducted a retrospective review of our experience and results of endovascular treatments for a series of 11 consecutive patients with 11 very small aneurysms. Of 11 aneurysms, 10 were acutely ruptured, and 1 was unruptured with a previous subarachnoid hemorrhage from another aneurysm. Aneurysms were located at the internal carotid artery (n = 4), the anterior communicating artery (n = 6), and the vertebral artery (n = 1). Seven patients were treated with coil embolization, and remodeling technique was used in 1 case. Three cases underwent intravascular stent implantation. Coil packing was done after in 2 of 3 aneurysms, and stent implantation alone was used in the remaining aneurysm. RESULTS: Coil embolization and stent deployment were carried out without difficulty in all cases. Coil packing was not available after stent implantation in 1 case for unsuccessful navigation of microcatheter into the aneurysm sac. Immediate angiography demonstrated complete occlusion in 10 cases and nearly complete occlusion in 1 case with stent implantation alone. No stent thrombosis and aneurysmal rupture was encountered during treatment. With the exception of 1 patient (Hunt and Hess grade 4) who died of pneumonia 4 weeks after treatment, no clinical evidence of neurologic deterioration and hemorrhagic complication was seen during the follow-up period in the remaining 10 patients. Follow-up angiography for 3 to 12 months (mean, 5.3 months) was available in 6 (60%) of 10 surviving patients, and no aneurysm recanalization was found. CONCLUSIONS: Endovascular treatment may be a feasible and effective therapeutic alternative for very small aneurysms. The long-term efficacy and durability of endovascular treatment for these lesions remains to be determined in a large series.     

Immediate and midterm follow-up results of using an electrodetachable, fully retrievable SOLO stent system in the endovascular coil occlusion of wide-necked cerebral aneurysms

OBJECT: Stent-assisted embolization is an alternative endovascular treatment method for wide-necked intracranial aneurysms. Currently available stents have the limitations of poor radial force, difficult delivery systems, and lack of full retrievability. The authors report on their preliminary experience with the use of a new, fully retrievable, self-expanding neurovascular stent, which has a high radial force and easy delivery system, combined with coil or Onyx embolization for the treatment of wide-necked aneurysms, including 6-month follow-up data. METHODS: Fifteen patients with 18 wide-necked intracranial aneurysms were treated using the SOLO stent system and detachable platinum coils. Aneurysms were located at the posterior communicating artery (seven lesions), midbasilar artery (one lesion), internal carotid artery (ICA) bifurcation (one lesion), ICA-ophthalmic artery segment (eight lesions), and posterior cerebral artery (one lesion). Eleven aneurysms were small, six were large, and one was giant. Only one of these aneurysms was in the acute stage of subarachnoid hemorrhage; balloon remodeling alone failed to keep the coils in the aneurysm sac. RESULTS: Only one stent required retrieving and repositioning after it had been fully deployed, and retrieval was easy and successful. No thromboembolic complication, dissection/rupture, or vasospasm occured during stent placement. Follow-up angiograms obtained at 6 months posttreatment in the 18 aneurysms demonstrated that all stents were patent with no evidence of intimal hyperplasia or stenosis. In all cases but one, 100% lesion occlusion was observed at the 6-month control angiography examination. Only one aneurysm had recanalized. CONCLUSIONS: The fully retrievable self-expandible SOLO stent is a feasible, secure, and effective system with a high radial force and ease of delivery in treating wide-necked intracranial aneurysms in combination with coil embolization.     

Outcome for unruptured middle cerebral artery aneurysm treatment: surgical and endovascular approach in a single center

The rupture of an intracranial aneurysm leads to subarachnoid hemorrhage (SAH). To prevent SAH, unruptured lesions can be treated by either endovascular or microsurgical approach. Due to their complex anatomy, middle cerebral artery (MCA) aneurysms represent a unique subgroup of intracranial aneurysms. Primary objective was to determine radiological and clinical outcomes in patients with middle cerebral artery aneurysms who were interdisciplinary treated by either endovascular or microsurgical approach in a single center. Secondary objective was to determine the impact of the lesions’ angiographic characteristics on treatment outcome. Clinical and radiological data of 103 patients interdisciplinary treated for unruptured MCA aneurysms over a 5-year period were analyzed in endovascular (n?=?16) and microsurgical (n?=?87) cohorts. Overall morbidity (Glasgow Outcome Score <5) after 12-month follow-up was 9 %. There was no significant difference between the two cohorts. Complete or “near complete” aneurysm occlusion was achieved in 97 and 75 % in the microsurgical, respective endovascular cohort. A “complex” aneurysm configuration had a significant impact on complete aneurysm occlusion in both cohorts, however, not on clinical outcome. Treatment of unruptured MCA aneurysms can be performed with a low risk of repair using both approaches. However, the risk for incomplete occlusion was higher for the endovascular approach in this series.     

颅内外动脉狭窄合并颅内动脉瘤同期血管内治疗的效果分析

目的探讨同期治疗颅内外动脉狭窄合并颅内动脉瘤的策略及临床效果。方法回顾性分析2013年4月至2018年9月于北京大学第一医院神经外科行同期血管内治疗的15例颅内外动脉狭窄合并颅内动脉瘤患者的临床资料。男性6例,女性9例,年龄(63.9±9.1)岁(范围:43~79岁);动脉狭窄部位共15处,狭窄程度为75%~95%,其中前循环8处,后循环7处;动脉瘤共17个,最大径(5.3±1.2)mm(范围:3~7 mm),其中前循环动脉瘤11个、后循环动脉瘤6个。患者均行同期动脉狭窄支架成形及动脉瘤栓塞术治疗。记录患者围手术期及术后临床症状、影像学资料及并发症情况。结果15处动脉狭窄均成功置入支架(残余狭窄<30%);17个动脉瘤中,10个行单纯弹簧圈栓塞,7个行支架辅助弹簧圈栓塞,均完全栓塞。围手术期1例患者出现轻微脑梗死症状,其余未发生手术相关并发症。术后随访(43.8±8.2)个月(范围:24~85个月),患者术后6~12个月均复查数字减影血管造影,其中2例出现无症状性支架内再狭窄,所有动脉瘤未见复发。截至末次随访时,患者均未出现颅内出血、缺血性卒中等相关症状。结论颅内外动脉狭窄合并颅内动脉瘤应根据血管狭窄的部位、程度及动脉瘤的大小、形态、位置、数量及两者的位置关系等因素综合分析,制定个体化的治疗策略,给予同期血管内治疗可能是一种安全、有效的治疗方法。     

Management strategy for infectious cerebral aneurysms: report of four cases

The surgical and/or endovascular treatment of four patients with infectious cerebral aneurysm associated with infective endocarditis was reported. Two patients presented with intracerebral hemorrhage. One of them, with large hematoma, was treated surgically and the other, with small hematoma, was treated by endovascular surgery. The third patient, with unruptured aneurysm of the distal anterior cerebral artery, was treated by endovascular parent-artery occlusion without neurological deterioration. The fourth patient, with unruptured aneurysm of the distal middle cerebral artery, was initially treated with antibiotics, resulting in stabilization of the aneurysm. However, three weeks after open heart surgery, the aneurysm ruptured, causing a large cerebral hematoma. Despite prompt evacuation of the hematoma and surgical resection of the aneurysm, this patient remained in a vegetative state. Management strategy of intracranial infective aneurysms is discussed.     

Treatment of giant intracranial aneurysms with saphenous vein extracranial-to-intracranial bypass grafting: indications,operative technique,and results in 29 patients

OBJECTIVE: The treatment of giant intracranial aneurysms is a challenge because of the limitations and difficulty of direct surgical clipping and endovascular coiling. We describe the indications, surgical technique, and complications of saphenous vein extracranial-to-intracranial bypass grafting followed by acute parent vessel occlusion in the management of these difficult lesions. METHODS: Between January 1990 and December 1999, 29 patients with giant intracranial aneurysms underwent 30 saphenous vein bypass grafts followed by immediate parent vessel occlusion. There were 11 men and 18 women with a mean follow-up period of 62 months. Twenty-five patients harbored aneurysms involving the internal carotid artery, 2 had middle cerebral artery aneurysms, and 2 had aneurysms in the basilar artery. Serial cerebral or magnetic resonance angiograms were obtained to assess graft patency and aneurysm obliteration. RESULTS: All 30 aneurysms were excluded from the cerebral circulation, with 28 vein grafts remaining patent. Two patients had graft occlusions: one because of poor runoff and the other because of misplacement of a cranial pin during a bypass procedure on the contralateral side. Other surgical complications included one death from a large cerebral infarction, homonymous hemianopsia from thrombosis of an anterior choroidal artery after internal carotid artery occlusion, and temporary hemiparesis from a presumed perforator thrombosis adjacent to a basilar aneurysm. CONCLUSION: With appropriate attention to surgical technique, a saphenous vein extracranial-to-intracranial bypass followed by acute parent vessel occlusion is a safe and effective method of treating giant intracranial aneurysms. A high rate of graft patency and adequate cerebral blood flow can be achieved. Thrombosis of perforating arteries caused by altered blood flow hemodynamics after parent vessel occlusion may be a continuing source of complications.     

Neurosurgical management of intracranial aneurysms previously treated with endovascular therapy

OBJECTIVE: With the increased use of endovascular therapy, an increasing number of patients with incompletely treated intracranial aneurysms are presenting for further surgical management. This study reviews our experiences with such patients. METHODS: During a 7-year period, 38 patients with 40 intracranial aneurysms who were initially treated with endovascular therapy underwent surgical obliteration of refractory or recurrent lesions. All patients were recorded in a prospective registry, and their clinical data and imaging studies were analyzed retrospectively. RESULTS: Twenty-six anterior and 14 posterior circulation aneurysms were treated. Four aneurysms were on the cavernous internal carotid artery, 13 were on the distal internal carotid artery, 6 were on the anterior communicating artery complex, 2 were on the middle cerebral artery, 3 were on the posteroinferior cerebellar artery, 1 was at the vertebrobasilar junction, 3 were on the superior cerebellar artery, 4 were at the basilar apex, 2 were on the posterior cerebral artery, and 1 was on the distal vertebral artery. Two pseudoaneurysms-one on the petrocavernous segment of the internal carotid artery and one on the distal VA-also were treated. The median time until recurrence was 6 months. Thirty-one aneurysms were clip-ligated, and six were treated with trapping. Three extracranial-intracranial bypasses were performed. One aneurysm was treated with muslin wrapping. Two aneurysms required the use of surgical approaches that involved hypothermic circulatory arrest. Nine aneurysms required coil mass extraction and/or complex vascular reconstruction to complete lesion obliteration. All aneurysms except the single wrapped aneurysm were successfully excluded from the intracranial circulation. Two deaths occurred as a result of the operative procedures, and another patient died as a result of subarachnoid hemorrhage-induced massive myocardial infarction. Ultimately, 86.8% of patients achieved an excellent or good recovery. CONCLUSION: With endovascular therapy assuming an increasing role in the treatment of patients with intracranial aneurysms, more lesions that are refractory to initial treatment will require surgical management. Our experience indicates that good results are attainable, although technical challenges are frequently encountered.     

Endovascular treatment of basilar artery trunk aneurysms with Guglielmi detachable coils: clinical experience with 41 aneurysms in 39 patients

OBJECT: The authors present a retrospective analysis of their clinical experience in the endovascular treatment of basilar artery (BA) trunk aneurysms with Guglielmi detachable coils (GDCs). METHODS: Between April 1990 and June 1999,41 BA trunk aneurysms were treated in 39 patients by inserting GDCs. Twenty-seven patients presented with subarachnoid hemorrhage, six had intracranial mass effect, and in six patients the aneurysms were found incidentally. Eighteen lesions were BA trunk aneurysms, 13 were BA-superior cerebellar artery aneurysms, four were BA-anterior inferior cerebellar artery aneurysms, and six were vertebrobasilar junction aneurysms. Thirty-five patients (89.7%) had excellent or good clinical outcomes; procedural morbidity and mortality rates were 2.6% each. Thirty-six aneurysms were selectively occluded while preserving the parent artery, and in five cases the parent artery was occluded along with the aneurysm. Immediate angiographic studies revealed complete or nearly complete occlusion in 35 aneurysms (85.4%). Follow-up angiograms were obtained in 29 patients with 31 aneurysms: the mean follow-up period was 17 months. No recanalization was observed in the eight completely occluded aneurysms. In 19 lesions with small neck remnants, seven (36.8%) had further thrombosis, three (15.8%) remained anatomically unchanged, and nine (47.3%) had recanalization caused by coil compaction. In one patient (2.6%) the aneurysm rebled 8 years after the initial embolization. CONCLUSIONS: In this clinical series the authors show that the GDC placement procedure is valuable in the therapeutic management of BA trunk aneurysms. The endovascular catheterization of these lesions tends to be relatively simple, in contrast with more complex neurosurgical approaches. Endosaccular obliteration of these aneurysms also decreases the possibility of unwanted occlusion of perforating arteries to the brainstem.     

Intracranial aneurysms in patients with internal carotid artery occlusion: management and outcome in 22 cases

Background

There is little information about clinical characteristics, management, and outcome of patients with intracranial aneurysms and internal carotid artery occlusion. We will describe clinical characteristics, treatment and outcome of patients with coexistent internal carotid artery occlusion and intracranial aneurysms.

Methods

We conducted a retrospective chart review of 22 patients (eight males and 14 females) with coexistent internal carotid artery (ICA) occlusion and intracranial aneurysms.

Results

This series includes 14 females and eight males with a mean age of 63 years (range, 49 to 80). These patients harbored a total of 35 aneurysms, which were located on the same side of the ICA occlusion in five cases, on the contralateral side in 20 cases, while in ten cases the aneurysm had a midline location (AcomA 9, Basilar tip 1). Treatment consisted of surgery for eight aneurysms and endovascular embolization for 13 aneurysms. No invasive treatment was recommended for 14 aneurysms (eight patients with single aneurysm). No permanent perioperative or periprocedural complications occurred in the selected group of patients undergoing invasive treatment. At a mean follow-up of 57?months (range, 3–203), no patient had a subarachnoid hemorrhage and three patients had died of causes not related to the aneurysm.

Conclusion

Surgical and endovascular treatment can be accomplished safely in selected patients with coexistent ICA occlusion and intracranial aneurysms. Conservative treatment is a valid alternative, especially in elderly patients or in patients with very small aneurysms, especially if not located along the collateral pathway.     

The role of cerebral revascularization in patients with intracranial aneurysms

Cerebral revascularization offers an important adjunct to parent-vessel ligation in the treatment of large and otherwise inaccessible intracranial aneurysms. Good or excellent outcomes can be expected in approximately 80% of patients. Poor outcomes and ischemic complications were highest in posterior circulation lesions. Cranial neuropathies from mass effect associated with giant aneurysms of the cavernous and intradural internal carotid artery will improve and be cured in the majority of patients treated with universal revascularization approach. In combination with open parent vessel ligation or endovascular occlusion, durable protection from subarachnoid hemorrhage can be achieved.     

WingSpan Stent System in the endovascular treatment of intracranial aneurysms: clinical experience with midterm follow-up results

OBJECT: The WingSpan stent is a new self-expandable neurovascular stent designed for endovascular treatment of intracranial atheromatous lesions. The authors report their experience with the use of this stent for the endovascular treatment of intracranial aneurysms. METHODS: Thirty-seven patients with 40 wide-necked intracranial aneurysms were treated using the WingSpan stent. Twenty-two aneurysms (55%) were small and 18 (45%) were large or giant. In all but 4 aneurysms, embolization was completed by packing the aneurysm sac with platinum coils. In 4 dissecting aneurysms that were fusiform or too small and wide necked to be catheterized, the stent was used alone. In these cases, the stent bridged the aneurysm neck to allow for flow redirection and the potential stent-induced endothelization effect. RESULTS: Follow-up angiograms obtained in 3 of 4 aneurysms, treated with only stent placement, demonstrated aneurysmal thrombosis and parent artery remodeling in 2 patients and moderate decrease in size in 1. Follow-up angiography obtained at 6 months to 1 year in 31 aneurysms after stent-supported coil embolization demonstrated complete occlusion in 23 aneurysms (74.2%) with a progressive thrombosis rate of 66.7% (10 of 15 aneurysms), and a recanalization rate of 16.1%. CONCLUSIONS: In treating wide-necked intracranial aneurysms, the WingSpan Stent System is very flexible, secure, and effective. Its delivery system is very easy and exact in that it exerts higher outward radial force, thus providing an excellent conformability and a strong scaffold to hold the coils in place. It may offer an effective treatment when used alone in some fusiform or very wide-necked, small dissecting aneurysms in which other surgical or endovascular treatment strategies are not deemed feasible.     

Multiple intracranial aneurysms. Endovascular treatment by coils]

The authors report the case of a 30 years-old man presenting with 3 intracranial aneurysms, which were treated by endovascular techniques. The aneurysm responsible for two previous subarachnoid hemorrhages was a giant supracavernous left internal carotid artery aneurysm. Endovascular therapy using coils caused intraoperative rupture which was successfully managed by balloon occlusion of the internal carotid artery. The two other aneurysms (basilar top, and right middle cerebral artery) were small and asymptomatic; complete obliteration of both aneurysms was achieved by selective coils embolization. Persistent occlusion of the three aneurysms was documented ad six months angiographic follow up.     

Combined endovascular stent implantation and coil embolization for the treatment of a vertebro-basilar fusiform aneurysm: technical case report

We describe a case of the combined application of endovascular stent implantation and Guglielmi detachable coil packing for the treatment of a vertebro-basilar fusiform aneurysm and review the literature on stent placement to treat cerebral aneurysms. A 70-year-old female presented with an acute headache from subarachnoid hemorrhage. A fusiform aneurysm with a broad-based neck and dome, measuring 15 mm, involving the union of the vertebral arteries and the proximal basilar artery was demonstrated on cerebral angiography. The aneurysm was judged to be inoperable and treated conservatively. Twelve days later the patient was transferred to our hospital for endovascular therapy. An intravascular stent (MultiLink) was placed across the base of the aneurysm through the right vertebral artery. After this, coil placement in the aneurysm around the stent was performed via a microcatheter guided from the left vertebral artery. After that a microcatheter was guided from the right vertebral artery through the interstices of the stent into the aneurysm, and additional coils were placed. Final angiography showed subtotal occlusion of the aneurysm and excellent blood flow of the parent artery through the stent. There were no new neurological deficits. Neither rerupture nor ischemic event has occurred. The use of stents provides another treatment for managing the difficult entity of intracranial aneurysms.     

颅内后循环动脉瘤的血管内介入治疗

目的总结颅内后循环动脉瘤的特点,探讨其血管内介入治疗的临床疗效。方法回顾性分析40例行血管内介入治疗的颅内后循环动脉瘤患者的临床和影像学资料、介入治疗过程,观察期效果及术后随访结果。结果 40例患者共发现42个后循环动脉瘤,均完成血管内介入治疗,其中8个行单纯弹簧圈栓塞,28个行支架辅助栓塞,1个行Onyx胶栓塞,5个动脉瘤及载瘤动脉同时闭塞。术后即刻DSA造影显示动脉瘤完全栓塞30个,近全栓塞6个,部分栓塞6个。术后6个月随访DSA造影显示动脉瘤完全栓塞36个,近全栓塞4个,部分栓塞1个。患者出院时行改良Rankin量表(mRS)评分,0分35例,1分3例,2分1例,1例死亡为6分;出院后3~6个月随访mRS评分0分38例,1分1例,无动脉瘤复发及新发神经功能障碍病例。结论颅内后循环动脉瘤具有特殊的临床与影像学表现,且复杂动脉瘤较为常见,对于颅内后循环动脉瘤,血管内介入治疗是一种安全有效的治疗方法。     

Endovascular treatment of basilar artery aneurysms

International experience regarding the treatment of basilar artery aneurysms using the Guglielmi Detachable Coil (GDC) system was reviewed. The four patient series included in this critique were composed of similar numbers of patients who had aneurysms that predominantly involved the basilar artery bifurcation and who presented clinically after a subarachnoid hemorrhage. Consistent results observed between the individual outcome experiences were as follows: (1) complication rates associated with the endovascular treatment of basilar artery aneurysms compared favorably with the historical rates associated with direct surgical clipping; (2) smaller aneurysms in this location could be more safely and completely occluded than their larger counterparts; (3) the endosaccular thrombus produced after GDC placement is a dynamic, rather than permanent, entity; (4) progressive thrombosis, thrombolysis, or compaction of the coil mass — singly or in combination — can account for changes in the extent of aneurysm occlusion observed over time; (5) even if an aneurysm could not be obliterated completely, treatment with GDC coils immediately after subarachnoid hemorrhage appeared to confer a protective effect upon patients compared to the natural history of untreated, ruptured intracranial aneurysms. In summary, these studies support the following conclusions regarding GDC-mediated electrothrombosis for the treatment of aneurysms: (1) aneurysm morphologies that are the most troublesome to treat by a conventional open surgical approach are also the most difficult to treat endovascularly; (2) although a useful therapeutic option for high-risk surgical candidates after aneurysmal hemorrhages, the endovascular treatment of intracranial aneurysms (basilar or otherwise) as more than a temporizing (i.e., not curative) intervention is not yet supported by data; (3) when comparing the complications and expenses associated with open surgical and endovascular therapy for aneurysms, long-term morbidity and cost analyses must incorporate the respective requirements for subsequent angiographic evaluation and repeat treatment sessions to address aneurysm residuals; (4) limited clinical and angiographic follow-up data preclude conclusions regarding the value of endovascular treatment for the management of asymptomatic aneurysms; (5) direct clip ligation of intracranial aneurysms remains the definitive treatment strategy until appropriate prospective, controlled, randomized studies prove otherwise.     

Early endovascular treatment of ruptured cerebral aneurysms in patients in very poor neurological condition

OBJECTIVE: In patients in very poor neurological condition (World Federation of Neurosurgical Societies Grade V) with aneurysmal subarachnoid hemorrhage, early surgery to prevent rebleeding and to allow appropriate treatment of complications is often difficult. The aim of the present study was to evaluate whether early endovascular treatment followed by aggressive proactive treatment of complications (prophylactic hypervolemic hemodilution, hypertensive treatment in the event of systemic hypotension, and appropriate treatment of intracranial hypertension) is an acceptable management strategy for these patients. METHODS: We prospectively studied 11 consecutive patients who presented with acutely ruptured aneurysms and were in very poor neurological condition after resuscitation (World Federation of Neurosurgical Societies Grade V) but did not have a significant intracerebral hemorrhage. These patients received endovascular treatment with Guglielmi detachable coils (Boston Scientific/Target, Fremont, CA). Follow-up consisted of a clinical evaluation based on the Glasgow Outcome Scale. A control angiogram was obtained after 6 months in patients with favorable outcomes to evaluate the occlusion of the aneurysm. RESULTS: There were no deaths or complications directly related to the procedure. Two patients died as a consequence of increased intracranial pressure. The mean follow-up of the surviving patients was 12 months. Two patients had early rebleeding after the coiling and required further treatment. Four patients had good outcomes, two patients were moderately disabled, and three patients were severely disabled. CONCLUSION: This study demonstrates that early endovascular treatment of acutely ruptured cerebral aneurysms in patients evaluated as World Federation of Neurosurgical Societies Grade V allows for aggressive treatment of intracranial hypertension and vasospasm. More than half of the patients had favorable outcomes. Therefore, early endovascular treatment seems to be a valuable alternative to early surgery in patients who present with a very poor clinical grade after subarachnoid hemorrhage. The results of this study are promising but must be interpreted with caution, because a small number of patients were studied.     

Isolated iliac artery aneurysms: a contemporary comparison of endovascular and open repair

OBJECTIVE: Iliac artery aneurysms are rare but associated with significant morbidity and mortality when ruptured. This study compares recent open and endovascular repairs of iliac aneurysms at a single institution. METHODS: Patients were identified and charts reviewed using ICD-9 and CPT codes for iliac artery aneurysm and open or endovascular repair performed between January 2000 and January 2006. Baseline characteristics, procedure-related variables, and follow-up data were retrospectively reviewed. RESULTS: A total of 71 patients were treated with isolated iliac artery aneurysms. There were 19 open and 52 endovascular repairs. Seven presented with acute ruptures and were treated by open (4) or endovascular (3) repair. Preoperative comorbidities were similar between the two groups. Major perioperative (30 day) complications included three deaths in the open group from cardiovascular complications, all after ruptured aneurysm repair, and one death in the endovascular group (after rupture; one additional perioperative death occurred after 30 days due to colonic infarction) (P = NS). Postoperative complications were less frequent in the endovascular group, although this did not reach statistical significance. The mortality was 50% in the open group and 33% in the endovascular group for patients presenting with a ruptured aneurysm (P = NS). Transfusion requirement was significantly higher in the open group (47%) than in the endovascular group (6%) (P = .03). The mean follow-up was 20 +/- 5 months in the open group and 17 +/- 2 months in the endovascular group (P = NS). Long-term complications included two limb thromboses following repair with a bifurcated stent graft that were treated with thrombolysis plus stenting or a fem-fem bypass. Three endoleaks were identified on postop CT scans, all of which were successfully managed with endovascular techniques. There were no postoperative ruptures or aneurysm-related death. The mean postoperative length of stay was 5.2 +/- 2.3 days (open) and 1.3 +/- 1.0 days (endovascular) (P = .04). CONCLUSIONS: This is the first large, case control study comparing open vs endovascular repair of isolated iliac artery aneurysms. Endovascular repair of iliac artery aneurysms is safe and results in decreased length of stay, lower requirement for perioperative blood transfusion, and similar intermediate term outcomes as open repair.     

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

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.     

DSA杂交手术室“一站式”精准治疗颅内复杂动脉瘤合并脑内血肿

目的探讨DSA杂交手术室"一站式"精准治疗颅内复杂动脉瘤合并脑内血肿的价值。方法对11例颅内复杂动脉瘤合并脑内血肿未发生脑疝患者于发病72 h内行DSA杂交手术室"一站式"精准治疗,术中以DSA评估动脉瘤是否累及载瘤动脉,行DSA引导下颅内外血管搭桥联合动脉瘤孤立术或球囊临时阻断辅助下动脉瘤塑形夹闭治疗,同步清除血肿。实时监测术中治疗情况,记录术中及术后并发症。随访观察术后6个月CTA表现;于出院及末次随访时以格拉斯哥转归评分(GOS)评价疗效,GOS≥4分认为治疗效果良好。结果对5例行颞浅动脉(STA)-大脑中动脉(MCA)搭桥,术中DSA示桥血管通畅,一期行动脉瘤孤立术;6例行动脉瘤塑形夹闭,术中3例误夹穿支血管,1例夹闭不全,调整瘤夹位置后夹闭效果满意。术后并发小灶性脑梗死2例,癫痫1例。出院时、末次随访时治疗效果良好患者均占81.82%(9/11)。术后6个月均未见复发,吻合口及载瘤动脉无狭窄。结论对难以直接夹闭或介入栓塞治疗的颅内复杂动脉瘤合并脑内血肿患者,采用DSA杂交手术室"一站式"精准治疗可获得较好效果。