Stent/coil treatment of very large and giant unruptured ophthalmic and cavernous aneurysms

doi:10.1016/j.surneu.2008.01.025

Surgical Neurology

Volume 71, Issue 1, January 2009, Pages 19-24

https://doi.org/10.1016/j.surneu.2008.01.025 Get rights and content

Abstract

Background

Treatment of VLGUIA remains a challenge. To reduce mass effect and achieve complete occlusion, open surgery has been our favored treatment. However, endovascular therapy is preferred for lesions in the cavernous sinus or for older patients with complicating medical problems. The goal of this study is to investigate outcome of stent and/or coil treatment of VLGUIA.

Methods

Beginning in 2002, the neuroform stent has been available to the University of Texas Southwestern Medical Center in Dallas. Since then until 2006, 15 patients were treated for VLGUIA with stenting and/or coiling at this institution. These 15 patients were used for a retrospective analysis in this study.

Results

Median patient age was 65 years, median aneurysm size was 27 mm (20-37 mm), and median follow-up time was 22 months. Eight aneurysms were localized in the cavernous sinus and 7 at the ophthalmic segment of the internal carotid artery. Four aneurysms were completely occluded (100%); 3 aneurysms, nearly complete (90%-99%); and 8 aneurysms, partial (<90% occlusion). Twelve patients required retreatment. Final GOS was 1 (good recovery) in 11 patients, 2 (moderate disability) in 3 patients, and 3 (severely disabled) in 1 patient. No patient died or deteriorated.

Conclusions

Stent/coil management of VLGUIA is constantly evolving. Current treatment results are promising, with very low morbidity/mortality. Disadvantage is the frequent persistence of residual aneurysm.

Introduction

Unruptured giant intracranial aneurysms remain a challenge for the team of treating physicians. If left untreated, the risk of rupture resulting in the patient's death or disability is as high as 40% to 50% over a 5-year period [21]. Treatment, however, is complicated because of the giant size, partial thrombosis, calcification, and usually presence of a wide neck. Surgical options have been pioneered by CG Drake [6]. Since then, decompression of the aneurysm mass, complete exclusion from circulation, and clip ligation have been our favored treatment, if possible. Endovascular management with optional use of stenting is a newer and less invasive alternative. In light of the small number of very large and giant aneurysms (≥2 cm) and the recent evolution of stents, there are little data about treatment using all modalities available today. Various interventional treatment options are under debate [12], [18]. The goal of the present study is to investigate the outcome of stent and/or coil treatment of unruptured very large and giant intracranial aneurysms ≥2 cm starting at the time the neuroform stents became available.

Section snippets

Patients

Neuroform stents were introduced to our institution in 2002. Chart review revealed 95 patients who were treated for unruptured intracranial aneurysms ≥2 cm at the University of Texas Medical Center in Dallas between 2002 and 2006. Surgery was typically the treatment of choice to reduce the mass effect of the aneurysm. Seventy-four patients underwent surgery as the only treatment. Five patients underwent endovascular parent vessel sacrifice with good outcome. One patient's initial surgery was

Patient and aneurysm characteristics

There was a female predominance with 12 patients (75%); 3 patients were male (25%). The median age was 65 years (13-76 years). All patients presented with vision loss or diplopia attributable to cranial nerve compression by mass effect. Furthermore, 73% complained of headaches. Nine aneurysms were localized on the right side, 6 on the left. Eight aneurysms originated in the cavernous segment of the carotid artery. Seven aneurysms originated from the ophthalmic segment of the carotid artery. The

Discussion

The current study shows stent and/or coil treatment of very large and giant cavernous and ophthalmic aneurysms can be performed safely. Using current stent and coil equipment, morbidity and mortality can be very low. Rupture could be prevented at least during the median follow-up time of 22 months. Disadvantage of the stent/coil therapy is the frequently incomplete occlusion of the aneurysm with need for multiple treatments and follow-up angiography.

Conclusion

Endovascular treatment of giant intracranial aneurysms is constantly evolving as newer stent and coil technology becomes available. Using up-to-date equipment, stent/coil treatment of unruptured giant intracranial aneurysms is promising because it seems to be fairly safe and to cause some protection from rupture. Disadvantage is the often incomplete occlusion with unknown risk of future rupture. We believe stent/coil treatment represents a considerable alternative to surgical treatment of giant

Acknowledgment

We thank Jerri Thomas for her help. We further thank Suzanne “Jorlam” Truex for assistance with the figure.

References (21)

B. Jennett et al.
Assessment of outcome after severe brain damage
Lancet
(1975)
A. Molyneux et al.
International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial
Lancet
(2002)
D.O. Wiebers et al.
International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment
Lancet
(2003)
M. Bendszus et al.
Endovascular occlusion of aneurysms using a new bioactive coil. A matched pair analysis with bare platinum coils
Stroke
(2007)
R.P. Benitez et al.
Endovascular occlusion of wide-necked aneurysms with a new intracranial microstent (Neuroform) and detachable coils
Neurosurgery
(2004)
B.S. Carter et al.
Selective use of extracranial-intracranial bypass as an adjunct to therapeutic internal carotid artery occlusion
Clin Neurosurg
(2000)
G.M. Debrun et al.
Selection of cerebral aneurysms for treatment using Guglielmi detachable coils: the preliminary University of Illinois at Chicago experience
Neurosurgery
(1998)
E.M. Deshaies et al.
A prospective single-center analysis of the safety and efficacy of the hydrocoil embolization system for the treatment of intracranial aneurysms
J Neurosurg
(2007)
C.G. Drake
Giant intracranial aneurysms: experience with surgical treatment in 174 patients
Clin Neurosurg
(1979)
D. Fiorella et al.
Usefulness of the Neuroform stent for the treatment of cerebral aneurysms: results at initial (3-6-mo) follow-up
Neurosurgery
(2005)

There are more references available in the full text version of this article.

Cited by (57)

Endovascular Treatment and Microsurgical Clipping for the Management of Paraclinoid Intracranial Aneurysms: A Systematic Review and Meta-Analysis
2023, World Neurosurgery
We aimed to compare the efficacy and safety of microsurgical clipping versus endovascular treatment (EVT) for paraclinoid aneurysms.
A systematic search for studies including patients with paraclinoid aneurysms treated with a microsurgical or endovascular technique was conducted in 6 databases from inception to February 2022. Efficacy outcomes included complete angiographic occlusion at last follow-up, favorable functional outcome, and recurrence of the aneurysm. For safety, we assessed a composite of intraoperative and postoperative complications. Data were pooled using a random-effects model.
A total of 95 studies including 6711 patients, 3029 in the surgical group and 3682 in the EVT group were found. Pooled rates of complete occlusion were 94% (95% CI 91%–96%; I² = 0%) in the surgical group and 69% (95% CI 63%–74%; I² = 79%) in the EVT group, respectively. The favorable functional outcome rate was 86% (95% CI 76%–92%; I² = 72%) with surgical treatment and 95% (95% CI 92%–97%; I² = 61%) with EVT. The rate of aneurysm recurrence with surgical treatment was 1% (95% CI 0%–4%; I² = 0%) and 12% (95% CI 9%–16%; I² = 57%) with EVT. The composite safety outcome rate in the surgical group was 24% (95% CI 18%–30%; I² = 90%) and 10% (95% CI 8%–13%; I² = 71%) in the EVT group.
Our findings suggest that microsurgical clipping seems to have a higher efficacy than EVT in terms of angiographic occlusion and aneurysm recurrence; however, EVT seems to be safer in terms of intraoperative and postoperative complications. Considering the heterogeneity and low-level evidence of the data available, further prospective randomized studies are warranted to confirm our findings.
Thromboembolic Events with Enterprise Versus Pipeline: Porcine In Vivo Experiment
2019, World Neurosurgery
Thromboembolic complications are serious adverse events associated with stenting of intracranial aneurysms. For the development of novel devices, currently no practical model exists to evaluate distal embolic events. The purpose of the current study was 2-fold: 1) assess the feasibility of a porcine carotid bifurcation model for in vivo testing of stent thrombogenicity and 2) compare the thrombogenicity of the Enterprise vascular reconstruction device versus the Pipeline embolization device (PED).
Six Yorkshire pigs underwent implantation of size-matched devices across the carotid bifurcation. Each animal received 1 Enterprise and 1 PED contralaterally. Baseline and 2-week follow-up angiography were performed. Images were analyzed including detailed measurements of the rete mirabile, a small-vessel conglomerate supplied by branches of the common carotid artery.
In the absence of thromboembolic events at 2 weeks (n = 8), the perfused rete area measured 134.4 ± 6.9 mm². In the presence of thromboembolic events (n = 4), the perfused rete was reduced to an area covering 37.1 ± 8.6 mm² (P < 0.01). There was no difference in thrombogenicity between Enterprise and PED with a thromboembolic event rate of 33.3% for both devices (P > 0.99).
The swine carotid stent model allows in vivo analysis of device-related thrombogenicity and distal embolic event rates. Size reduction of the perfused rete mirabile indicates the presence of thromboembolic events. Both Enterprise and PED were associated with similar thrombogenicity in this experiment.
Endovascular Treatment of 147 Cases of Cavernous Carotid Aneurysms: A Single-Center Experience
2016, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
One hundred twenty-three patients underwent stent/balloon-assisted coil occlusion, and 17 patients underwent PAO. The occlusion percentage of the aneurysms was evaluated via the angiographic appearance of the aneurysm, which was defined as follows: complete occlusion (100% occlusion), in which no aneurysm sac was residual; nearly complete occlusion (90%-99% occlusion), in which a small portion of the sac was opacified with the contrast medium; and partial occlusion (<90% occlusion), in which the aneurysm sac was opacified.7 Clinical follow-up was available in 131 patients at 1-39 months (mean = 12 months) and was conducted by telephone or out-patient interview.
Cavernous carotid aneurysms (CCAs) are characterized by pain and neuro-ophthalmologic deficits. The optimal treatment remains unclear, especially for asymptomatic CCAs. This study investigated the efficacy of endovascular treatment for CCAs in our center.
Data obtained from patients who underwent endovascular treatment for CCAs from July 2011 to July 2014 were reviewed. A retrospective analysis was conducted regarding the general condition, clinical presentation, aneurysm characteristics, therapeutic strategy, and prognosis of CCA patients.
One hundred forty-seven patients who exhibited 155 CCAs were included, which comprised 46 asymptomatic and 101 symptomatic CCA cases. Forty-eight cases presented with headache, 5 cases presented with subarachnoid hemorrhage, 20 cases presented with diplopia, 38 cases presented with cranial nerve palsy, and 27 cases presented with ischemic stroke. The mean aneurysm sizes were 15.3 ± 12.2 and 8.1 ± 7.1 mm in the symptomatic and asymptomatic groups, respectively. Different treatments were administered: coil occlusion (n = 15), stent/balloon-assisted coil occlusion (n = 123), and parent artery occlusion (PAO) (n = 17). The PAO-treated group exhibited the highest aneurysm occlusion rate. Follow-up data were available for 131 cases, which included 86 symptomatic and 45 asymptomatic cases. There were no deaths. Among the symptomatic patients, 40.7% improved, 58.1% remained stable, and 1.2% worsened; 12 patients exhibited regrowth and 6 patients had repeated endovascular treatment. The asymptomatic patients remained stable, including 5 patients who exhibited regrowth and 2 patients who had repeated endovascular treatment.
Endovascular treatment is safe and effective for CCAs and should be considered in patients with minimal complications, as well as in asymptomatic patients with stable symptoms.
Risk Factors for Visual Impairments in Patients with Unruptured Intradural Paraclinoid Aneurysms Treated by Neck Clipping without Bypass Surgery
2016, World Neurosurgery
Citation Excerpt :
Direct surgery for paraclinoid aneurysms is challenging because of the technical difficulties derived from the anatomic complexity and their relation to complex bony structures and the optic apparatus, as well as diversified projections of aneurysm domes.10,11 Endovascular treatment may be a better option for this location given ease of endovascular access, and paraclinoid aneurysms are now frequently referred for endovascular treatment.12-16 However, compared with the surgical technique, endovascular treatment is associated with a lower rate of complete occlusion and more frequent recurrence, and this may be related to many factors, such as aneurysm dimension.17
Although paraclinoid aneurysms are now frequently referred for endovascular treatment, the durability of obliteration is still to be determined. Therefore, direct surgery for paraclinoid aneurysms still remains indispensable. The present study aimed to evaluate the risk factors for the visual impairments in patients with unruptured intradural paraclinoid aneurysms.
The data of 133 patients with 136 aneurysms treated by neck clipping without bypass surgery was evaluated. Visual impairments included decreased visual acuity and visual field defect. The aneurysm was classified into superior projecting aneurysm, ventral projecting aneurysm, and carotid cave aneurysm. Plug-in method was defined as filling interspace, which was formed between the internal carotid artery and the sutured dura in case of detachment of the dural ring.
Postoperative new visual impairments were observed in 30 aneurysms (22%). During the follow-up period (median, 600 days), postoperative new visual impairments continued in 23 aneurysms (17%). Multivariate analysis showed that carotid cave location and plug-in method were related to new visual impairments at 30 days (odds ratio [OR], 2.6; 95% confidence interval [CI] 1.1–6.1; P = 0.031 and OR, 4.1; 95% CI 1.4–12; P = 0.008) and at 6 months (OR, 4.1; 95% CI 1.5–11; P = 0.005 and OR, 3.3; 95% CI 1.1–11; P = 0.045).
The present study showed that carotid cave location and plug-in method during dural closures were related to postoperative continued visual impairments. Neurosurgeons should carefully consider the surgical indication for unruptured carotid cave aneurysms and avoid plug-in methods.
Clinical and radiological outcomes after treatment of unruptured paraophthalmic internal carotid artery aneurysms: A comparative and pooled analysis of single-center experiences
2015, World Neurosurgery
Citation Excerpt :
The MEDLINE search resulted in 1781 articles, of which 168 were considered to be relevant after filtering out duplicates, articles written in a language other than English, and articles not concerning the subject. After reviewing the remaining articles, 33 studies, including our own experience, with 1473 patients harboring 1526 unruptured paraophthalmic aneurysms met the inclusion and exclusion criteria and were included for following pooled-analysis (Figure 1) (1-3, 9, 11, 13-17, 20-22, 24, 25, 27-29, 31-37, 39-41, 44-47). Overall, the aneurysms in 566 patients were treated by clipping, 607 by coiling alone, 206 by stent-assisted coiling, and 94 by flow diversion.
Unruptured paraophthalmic aneurysms present unique challenges, and the ideal management remains unknown.
We performed a pooled analysis of single-center experiences to compare the risks and effectiveness involving patients with unruptured paraophthalmic aneurysms treated with clipping, coiling alone, stent-assisted coiling, and flow-diversion. The MEDLINE database was searched and thirty-three series (including our institutional experience) were included.
Clipping caused more intracranial hemorrhage (ICH) and neurologic complications (NCs) than coiling alone (ICH: odds ratio [OR] = 3.058, P = 0.013; NC: OR = 5.809, P < 0.001), stent-assisted coiling (ICH: P = 0.018; NC: OR = 7.367, P < 0.001), and flow-diversion (ICH: P = 0.006; NC: OR = 16.954, P < 0.001). Clipping also caused more unfavorable visual outcomes than both coiling alone (OR = 3.037, P = 0.001) and stent-assisted coiling (OR = 6.055, P = 0.005). Clipping resulted in a lower reoperation rate than coiling alone in large/giant aneurysm group, which approached statistical significance (OR = 0.133, P = 0.057). Clipping, stent-assisted coiling, and flow-diversion all showed higher occlusion rates compared with coiling alone (OR [clipping vs. coiling alone] = 2.852, P ≤ 0.001; OR [coiling alone vs. stent-assisted coiling] = 0.302, P = 0.003; OR [coiling alone vs. flow-diversion] = 0.400, P = 0.013). Flow-diversion showed comparative complication rate, clinical outcomes, and angiographic result compared with stent-assisted coiling. No significant differences were found among all 4 treatment modalities on mortality and poor outcome.
Endovascular therapies have benefits over surgical clipping in terms of fewer intracranial hemorrhage complications, fewer NCs, and lower unfavorable visual outcome rate. Flow diversion showed comparative safety and effectiveness to stent-assisted coiling, and they both achieved better radiologic results than coiling alone. Further validation by randomized cohort studies is still needed to provide robust evidence.
The Management of Intracranial Aneurysms: Current Trends and Future Directions
2024, Neurology International

View all citing articles on Scopus

View full text

AneurysmStent/coil treatment of very large and giant unruptured ophthalmic and cavernous aneurysms

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Patient and aneurysm characteristics

Discussion

Conclusion

Acknowledgment

Lancet

Lancet

Lancet

Endovascular occlusion of aneurysms using a new bioactive coil. A matched pair analysis with bare platinum coils

Stroke

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

Neurosurgery

Selective use of extracranial-intracranial bypass as an adjunct to therapeutic internal carotid artery occlusion

Clin Neurosurg

Selection of cerebral aneurysms for treatment using Guglielmi detachable coils: the preliminary University of Illinois at Chicago experience

Neurosurgery

A prospective single-center analysis of the safety and efficacy of the hydrocoil embolization system for the treatment of intracranial aneurysms

J Neurosurg

Giant intracranial aneurysms: experience with surgical treatment in 174 patients

Clin Neurosurg

Usefulness of the Neuroform stent for the treatment of cerebral aneurysms: results at initial (3-6-mo) follow-up

Neurosurgery

Aneurysm
Stent/coil treatment of very large and giant unruptured ophthalmic and cavernous aneurysms