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.     

Endovascular occlusion of intracranial vessels for curative treatment of unclippable aneurysms: report of 16 cases

Among 121 intracerebral aneurysms presenting at one institution between 1984 and 1989, 16 were treated by endovascular means. All 16 lesions were intradural and intracranial, and had failed either surgical or endovascular attempts at selective exclusion with parent vessel preservation. The lesions included four giant middle cerebral artery (MCA) aneurysms, one giant anterior communicating artery aneurysm, six giant posterior cerebral artery aneurysms, one posterior inferior cerebellar artery aneurysm, one giant mid-basilar artery aneurysm, two giant fusiform basilar artery aneurysms, and one dissecting vertebral artery aneurysm. One of the 16 patients failed an MCA test occlusion and was approached surgically after attempted endovascular selective occlusion. Treatment involved pretreatment evaluation of cerebral blood flow followed by a preliminary parent vessel test occlusion under neuroleptic analgesia with vigilant neurological monitoring. If the test occlusion was tolerated, it was immediately followed by permanent occlusion of the parent vessel with either detachable or nondetachable balloon or coils. The follow-up period ranged from 1 to 8 years. Excellent outcomes were obtained in 12 cases with complete angiographic obliteration of the aneurysm and no new neurological deficits and/or improvement of the preembolization symptoms. Four patients died: two related to the procedure, one secondary to rupture of another untreated aneurysm, and the fourth from a postoperative MCA thrombosis after having failed endovascular test occlusion. The angiographic, clinical, and cerebral blood flow criteria for occlusion tolerance are discussed.     

Treatment selection for ruptured aneurysm and outcomes: clipping or coil embolization

The International Subarachnoid Aneurysm Trial has shown that coil embolization achieves a better outcome for aneurysms treatable by either clipping or coil embolization. However, many ruptured aneurysms are hardly treatable by either clipping or coil embolization. Selection of either clipping or coil embolization will affect the treatment outcome for ruptured aneurysms. The relationship between patient selection and treatment outcome in a so-called "regional center hospital" in Japan must be clarified. This study included 113 patients with ruptured intracranial saccular aneurysms measuring less than 10 mm. Selection criteria for coil embolization were principally paraclinoid or posterior circulation aneurysm, Hunt and Hess grade IV or over, and patient age 75 years or older. Other aneurysms were principally treated by clipping. Aneurysms with a dome/neck ratio of less than 1.5, distorted aneurysms, Hunt and Hess grades I-III, patient age 74 years or younger, and middle cerebral artery aneurysm were actively treated by clipping. A few exceptional indications were considered in detail. Low invasiveness coil embolization is better than clipping to obtain good neurological outcome for patients with perforators difficult to dissect, aneurysms difficult to dissect due to previous open surgery, and aneurysms requiring bilateral open surgery, despite the slightly higher rebleeding rate in coil embolization. Overall outcomes were modified Rankin Scale (mRS) 0-2 in 82 of 113 patients (73%) and mRS 3-6 in 31 (27%). Appropriate selection of clipping or coil embolization can achieve acceptable treatment outcomes for ruptured aneurysm.     

大脑中动脉瘤的血管内介入治疗

【摘要】〓大脑中动脉瘤是常见的颅内动脉瘤,大脑中动脉解剖关系特殊,其动脉瘤破裂较其他幕上动脉瘤产生的临床症状更加严重,预后更差。随着介入治疗技术的不断发展,世界上很多医疗中心已经将介入栓塞治疗作为动脉瘤的首选治疗方式。然而,大脑中动脉动脉瘤治疗方式尚存争议,选择合适的病例进行治疗是首要的问题。     

Treatment of complex intracranial aneurysms with a telescoping stent technique

Background and Object Complex intracranial aneurysms present a treatment challenge for both open and endovascular modalities of treatment. This report seeks to illustrate a series of patients with aneurysms treated with telescoping stents as a method of flow diversion for small and fusiform intracranial aneurysms.Material and Methods A retrospective evaluation of six patients treated with a telescoping stent technique utilizing available stents (at that time before the pipeline era) for complex cerebral aneurysms between January 2009 and January 2010 was performed. Five patients had dissecting aneurysms and one patient had a small superior hypophyseal artery aneurysm. One of the patients was treated in the setting of a Hunt and Hess grade IV subarachnoid hemorrhage. Follow-up cerebral angiography was performed postprocedure at 6 months.Results At a mean follow-up period of 9 months, all the patients experienced complete or near-complete occlusion (>95%). No periprocedural complications were noted in this series. No episodes of hemorrhage or thromboembolic complications occurred.Conclusions Overlapping Neuroform and Enterprise stents may induce complete thrombosis of intracranial aneurysms and facilitate parent artery remodeling. The use of self-expanding stents is still an adequate treatment modality, especially if there is a need for vessel wall stabilization rather than flow diversion. The technique is also a sufficient alternative in small intracranial aneurysms not readily amenable to open surgical treatment or traditional endovascular coil embolization.     

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.     

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.     

Distal anterior cerebral artery aneurysms: report of 26 cases

Distal anterior cerebral artery (ACA) aneurysms are rare, and constitute approximately 1.5% to 9% of all intracranial aneurysms. They show some unique features compared with other aneurysms in the cerebral circulation and are frequently treated with a different technique. Twenty-six of 364 patients with cerebral aneurysms treated at our department between 1996 and 2004 had distal ACA aneurysms (7.1%). Twenty-three of the 26 patients were treated through an anterior interhemispheric approach and two with a pterional approach. All saccular aneurysms were successfully clipped except one which was embolized after the surgery. The only fusiform aneurysm spontaneously thrombosed and resolved with parent artery occlusion. Two of the 26 patients had multiple aneurysms. The surgical mortality was 8%. Distal ACA aneurysms have higher mortality and morbidity than other anterior circulation aneurysms. They should be aggressively treated even if very small because of the tendency to rupture. Endovascular treatment is an alternative in the management of these aneurysms. The most important factors affecting the outcome are grade on admission and the neurosurgeon's experience.     

Endovascular coil occlusion of 1811 intracranial aneurysms: early angiographic and clinical results

OBJECTIVE: We sought to evaluate the early angiographic and clinical outcomes of the first session of endovascular coil occlusion of a large number of patients with intracranial aneurysms treated by five neurointerventionalists during a decade at a single center. METHODS: We performed retrospective analyses of pre- and postprocedural angiographic studies and early clinical outcomes. Enrolled patients underwent endovascular treatment of intracranial aneurysms with detachable coils. RESULTS: A total of 1811 aneurysms in 1579 patients were treated with coil occlusion. Of these, 90 to 100% occlusion of 86.5% of the aneurysms was achieved. In 82.3% of the procedures, no complications occurred. The clinical outcome profile at primary discharge according to the Glasgow Outcome Scale was as follows: Grade V, 74.6%; Grade IV, 6.7%; Grade III, 11.1%; Grade II, 3.1%; and Grade I, 4.5%. In patients with large aneurysms with wide necks, a lower occlusion rate and an increased complication rate were encountered. The use of three-dimensional and fibered coils resulted in higher occlusion rates. Balloon remodeling and stent deployment increased the complication rate. Previous aneurysm rupture, procedural complications, and vasospasm correlated with poor outcome. Of the patients in poor grade after aneurysm rupture, 42% recovered to Glasgow Outcome Scale Grade IV or V, as opposed to 90% of patients who were treated for unruptured aneurysms. The ischemic complication rate was 9%, and the hemorrhagic complication rate was 3%. The early procedural morbidity rate was 5.3%, and the procedural mortality rate was 1.5%. The management mortality rate was 4.4%. CONCLUSION: These data confirm the safety and efficacy of endovascular coil occlusion for patients with intracranial aneurysms.     

Clinical and anatomic outcomes after endovascular coiling of middle cerebral artery aneurysms: report on 30 treated aneurysms and review of the literature

BACKGROUND: Endovascular treatment of middle cerebral artery (MCA) aneurysms has not been extensively studied. We report our experience on a select group of patients that underwent coil embolization of an MCA bifurcation aneurysm. METHODS: From August 1999 to January 2005, 29 patients harboring 30 MCA aneurysms were treated with coil embolization. These patients were felt to have favorable characteristics for endovascular therapy including absence of thrombus in the aneurysm, absence of an efferent artery off of the aneurysm, and ability to reconstruct the wide neck with stent reconstruction. We retrospectively reviewed their records and angiographic images to evaluate for technical result and complications. RESULTS: The mean age of our cohort was 59 +/- 13 years with 19 patients presenting with a ruptured aneurysm. Complete obliteration was achieved in 24 (80%) of 30 of aneurysms on postprocedural angiography and no patient showed aneurysm regrowth at 6-month follow-up. Twenty-seven (93%) of 29 patients had no change in baseline neurological function post-embolization. There were two procedural-related complications: one intraprocedural rupture of an aneurysm and one thromboembolic stroke in the ipsilateral MCA territory. CONCLUSIONS: Coil embolization of MCA bifurcation aneurysms has a high rate of complete obliteration with acceptable morbidity in our selected group of patients.     

Review of endovascular stent‐assisted embolization for management of intracranial aneurysms

Objective: This was a retrospective review of the results using stent‐assisted coil embolization for management of intracranial aneurysms. Methods: The records of seven patients treated with stent‐assisted Gugliemi detachable coil (GDC) embolization were retrieved from the authors’ prospectively maintained database. The clinical presentation, site and type of aneurysms, treatment procedure and complications, and outcome of these identified cases were reviewed. Results: Between January 2002 and May 2004, seven patients with intracranial aneurysms, four of which were ruptured, were treated by stent‐assisted GDC embolization. Four aneurysms were located at the anterior circulation and three were at the posterior circulation. The indications for stent use were: giant aneurysm (>2.5 cm), dissecting pseudo‐aneurysm, broad‐necked aneurysm and the need for preservation of important parent arteries or branches. Concerning the technical aspect, all except one had successful stent deployment. One stent dislodged after apparent successful deployment. GDC embolization was continued and the aneurysm was partially occluded. More than 90% occlusion of aneurysm sac was achieved in six aneurysms. Intraoperative complications included over‐coagulation, failure in stent deployment, displacement of stent, coil entrapment and thromboembolism. One patient had added focal neurological deficit after the procedure, and one became vegetative due to an unrelated cause. The patient in whom the stent was dislodged suffered another subarachnoid haemorrhage 4 months later and died. Conclusion: Percutaneous intracranial stent is a new and useful device to assist embolization of cerebral aneurysms that were previously not amenable to endovascular therapy. These preliminary results suggest that this procedure could achieve satisfactory outcomes without significant complications.     

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.     

Balloon-assisted coil placement in wide-necked cerebral aneurysms: preliminary clinical experience

Endovascular treatment of wide-necked cerebral aneurysms with Guglielmi detachable coils (GDCs) has been limited due to coil protrusion into the artery. Seven patients with wide-necked cerebral aneurysms were treated with GDCs with temporary balloon inflation for mechanical protection during coil placement. Transarterial embolization of the aneurysm with GDCs had failed due to coil protrusion into the parent artery. The use of simultaneous temporary balloon protection achieved more dense intra-aneurysmal coil packing, especially in the neck, without compromising the parent artery.     

Coiling of ruptured pericallosal artery aneurysms

OBJECTIVE: To assess the technical feasibility of treating ruptured pericallosal artery aneurysms with detachable coils and to evaluate the anatomic and clinical results. METHODS: Over a period of 27 months, 12 patients with a ruptured pericallosal artery aneurysm were treated with detachable coils. A retrospective review was performed to assess the clinical and angiographic results. The three men and nine women had a mean age of 46.6 years (range, 35-75 yr). Seven patients presented in Hunt and Hess Grade II, three in Grade III, and two in Grade IV. Six patients had a concomitant intracerebral hematoma, and four had at least one additional aneurysm. RESULTS: In all 12 patients, the pericallosal aneurysm could be reached with a microcatheter and the coils delivered. No procedure-related complications occurred. Angiography demonstrated that the initial occlusion was complete in 11 aneurysms and near-complete in 1. At follow-up angiography at 6 months, one aneurysm had become partially recanalized owing to coil compaction. At a mean clinical follow-up of 9.2 months, 11 patients had an excellent outcome and one patient had mild hemiparesis and aphasia. CONCLUSION: Coiling of ruptured pericallosal artery aneurysms can be considered an alternative to surgical clipping.     

Endovascular occlusion of wide-necked aneurysms with a new intracranial microstent (Neuroform) and detachable coils

OBJECTIVE: The long-term durability of the endovascular occlusion of cerebral aneurysms is one of the major factors limiting the more widespread use of this technique. Long-term occlusion of wide-necked aneurysms has improved with new assistive devices that seem to improve aneurysm occlusion while protecting the parent vessel. We report the use of a new intracranial stent--the Neuroform microstent--in the treatment of patients with wide-necked cerebral aneurysms. METHODS: Patients identified as harboring wide-necked intracranial aneurysms were evaluated for stent-assisted coiling. After appropriate anticoagulation was performed, depending on whether the aneurysm was ruptured or unruptured, the Neuroform stent was delivered across the neck of the aneurysm and deployed with a coil pusher. After stent placement, standard coil occlusion of the aneurysm was achieved in the majority of cases. RESULTS: Fifty-six patients were identified as having wide-necked intracranial aneurysms suitable for stent-assisted coiling. A total of 49 aneurysms in 48 patients were treated with this procedure. In eight cases, stent deployment failed. Forty-one of the aneurysms were initially stented, followed by coil placement. Six aneurysms were stented only, and one aneurysm was initially coiled, followed by stent placement. There were five deaths (8.9%), one of which occurred secondary to a stroke after the procedure (1.8%). Four patients (7%) experienced thromboembolic events, three of which were considered to have been secondary to the procedure (5.3%). In addition, there were two femoral pseudoaneurysms. The overall complication rate was 10.7%. Five patients were available for follow-up angiographic evaluation, and their cases are discussed. CONCLUSION: Intracranial stenting may overcome important technical limitations in current endovascular therapy by improving the occlusion of wide-necked aneurysms while protecting the parent vessel.     

Endovascular surgery for very small ruptured intracranial aneurysms. Technical note

Application of endovascular surgery for very small aneurysms is controversial because of technical difficulties and high complication rates. The aim in the present study was to assess treatment results in a series of such lesions at one institution. Since 1997, endovascular surgery has been advocated for very small ruptured aneurysms (< 3 mm in maximum diameter) that fulfill the criterion of a fundus/neck ratio greater than 1.5. Twenty-one patients were treated, for whom the World Federation of Neurosurgical Societies classification before treatment was Grade I in 10, Grade II in two, Grade III in two, Grade IV in five, and Grade V in two. The aneurysm location was the internal carotid artery in four, the anterior communicating artery in 11, the middle cerebral artery in one, and the vertebrobasilar system in five. In all patients, endovascular surgery was performed using Guglielmi detachable coils after induction of general anesthesia. Initially, the presumed volume of the lesions was calculated for each aneurysm. Thereafter, the appropriate coil length was decided according to the volume embolization ratio, as 30 to 40%. In all attempts to obliterate aneurysms a single coil was used. All aneurysms were completely obliterated as confirmed by postembolization angiography, without procedure-related complications. During the follow-up period only one patient needed additional coil embolization for a growing aneurysm. Final outcomes were good recovery in 15 patients, moderate disability in five, and severe disability in one. Appropriate selection of patients and coils, and use of sophisticated techniques allow a good outcome for patients with very small 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。     

Ruptured intracranial dissecting aneurysms: management considerations with a focus on surgical and endovascular techniques to preserve arterial continuity

Background. The present retrospective analysis was undertaken to review an institutional experience with 13 intracranial dissecting aneurysms as source of subarachnoid haemorrhage (SAH) among a total of 585 ruptured intracranial aneurysms. Methods and results. In 6 patients the vertebral artery (VA) was affected, in 2 patients the basilar artery (BA), in 3 the internal carotid (ICA), in 1 the middle cerebral (MCA) and in 1 the postcommunicating (A2) segment of the anterior cerebral artery (ACA). Maintaining arterial patency was aimed at in all patients. Tangential clipping or circumferential wrapping were used as surgical methods. Endovascular stenting and/or coiling was applied in 2 instances. Four of the 6 VA dissecting aneurysms underwent surgical exploration between 1 and 22 days after haemorrhage. Two patients were in WFNS grade V and died subsequently with the aneurysms untreated, one after rehaemorrhage. In the patients with secured VA aneurysms the postoperative course was uncomplicated with the exception of additional caudal cranial nerve injury in 1 instance. Both BA aneurysms were initially treated by endovascular methods. In the first patient incomplete packing with Gugliemi detachable (GDC) coils was achieved. Follow-up angiography 6 months later showed growth and coil compaction and subsequent wrapping with Teflon fibres resulting in angiographic stabilization. The other BA aneurysm was treated by a combination of a coronary stent and GDC coils. The 3 dissecting ICA aneurysms were all explored surgically. In only 1 instance ICA continuity could be preserved by wrapping, in the other 2 cases a major portion of the vessel wall disintegrated upon removal of the surrounding clot. The only ACA dissecting aneurysm, on A2, was successfully treated with a Dacron cuff. In the single patient with a MCA aneurysm, a decision for conservative management was taken, because neither a surgical nor an endovascular solution was seen as a possibility that did not risk occlusion of lenticulostriate branches. The patient suffered a fatal rehaemorrhage 4 weeks later at her home. Conclusions. The reported experience suggests that in Western countries also dissecting aneurysms are an occasional source of SAH. The outcome in our conservatively managed patients confirms the poor prognosis of conservative management. Wrapping and endovascular stent based methods can achieve stabilization of the dissected artery without sacrificing the artery. Results of treatment appear to depend largely on the location of the dissecting aneurysm.     

Endovascular treatment of basilar tip aneurysm associated with moyamoya disease--case report

A 58-year-old female was admitted unconscious to a local hospital. Computed tomography demonstrated subarachnoid hemorrhage. Cerebral angiography revealed evidence of moyamoya disease and a saccular aneurysm at the tip of the basilar artery. The patient was transferred to our hospital for embolization of the basilar tip aneurysm. Endovascular embolization was performed using Guglielmi detachable coils (GDCs), and the aneurysm was completely occluded with preservation of the parent artery. No change in the patient's neurological status was seen during and after the procedure. Endovascular treatment using GDCs appears to be particularly suitable for ruptured cerebral saccular aneurysms in patients with moyamoya disease.     

Bypass-surgery and coil-embolisation in the treatment of cerebral giant aneurysms

OBJECTIVE: Operative clipping is the most effective method in the treatment of cerebral giant aneurysms. But about 50% of all giant aneurysms are treatable this way. We want to report about eight patients with giant cerebral aneurysms, which were in our opinion "unclippable" without causing ischaemia in depending brain areas. METHODS: We describe eight cases of giant aneurysms of the pericallosal artery (n = 1) the middle cerebral artery (n = 3), the basilar tip (n = 3) and of the upper part of the basilar artery (n = 1). One patient with an aneurysm of the pericallosal artery was treated with an extra-intracranial saphenous vein bypass saphenous bypass, in three cases of middle cerebral artery aneurysms an extra-intracranial bypass was also done combined with a resection of the aneurysm. The four patients suffering from an aneurysm of the basilar artery got an extra intracranial bypass too followed by an occlusion of the aneurysm with GD-Coils. RESULTS: There was no peri-operative mortality and no severe peri- or postoperative complication. The neurological symptoms of all patients were unchanged after the operation. An angiographic control showed a complete obliteration of the aneurysm and a free running bypass in all cases. CONCLUSION: Bypass surgery and combined bypass surgery and coil embolisation are effective methods in the treatment of giant cerebral aneurysms, which can not be treated by clipping alone.