Endovascular treatment of wide-necked intracranial aneurysms : techniques and outcomes in 15 patients

Abstract

Objective: It is technically difficult to treat wide-necked intracranial aneurysms by the endovascular method. Various tools and techniques have been introduced to overcome the related technical limitations. The purpose of this study was to evaluate the radiologic and clinical results of wide-necked intracranial aneurysm treatment using the endovascular method.

Methods: Fifteen aneurysms in 15 patients were treated by the endovascular method from October 2009 to August 2010. Seven patients presented with subarachnoid hemorrhage (SAH), seven patients had unruptured aneurysms, and one patient had an intracerebral hemorrhage and intraventricular hemorrhage due to an incompletely clipped aneurysm. The mean dome-to-neck ratio was 1.1 (range, 0.6-1.7) and the mean height-to-neck ratio was 1.1 (range, 0.6-2.0). We used double microcatheters instead of a stent or a balloon for the first trial. When we failed to make a stable coil frame with two coils, we used a stent-assisted technique.

Results: All aneurysms were successfully embolized. Eleven aneurysms (73%) were embolized by the double microcatheter technique without stent insertion, and four aneurysms (27%) were treated by stent-assisted coil embolization. One case had subclinical procedure-related intraoperative hemorrhage. Another case had procedure-related thromboembolism in the left distal anterior cerebral artery. During the follow-up period, one patient (7%) had a recanalized aneurysmal neck 12 months after coil embolization. The recurrent aneurysm was treated by stent-assisted coil embolization.

Conclusion: We successfully treated 15 wide-necked intracranial aneurysms by the endovascular method. More clinical data with longer follow-up periods are needed to establish the use of endovascular treatment for wide-necked aneurysm.

Keywords: Embolization; Intracranial aneurysm; Stent.

Figures

Fig. 1

Case 5; a 54-year-old man with subarachnoid hemorrhage (SAH). A : The left internal carotid artery (ICA) angiogram shows the aneurysm before treatment. B : 3D reconstruction image shows a wide-necked posterior communicating artery (PCoA) aneurysm (neck×height×width×length : 4.6×4.3×5.3×6.8 mm). C : Two microcatheters are positioned within the aneurysm. One has a 90° angled distal tip and the other has a J-shaped distal tip. D : First coil (360° Guglielmi detachable coil 4×8 mm) being deployed. E : Second coil (360° Guglielmi detachable coil 3×6 mm) being deployed via another microcatheter. F : Immediately after treatment, a right ICA angiography shows no contrast dye filling of the aneurysm neck or dome, but the patient died of severe vasospasm on the 10th day after coil embolization.

Fig. 2

Case 9; a 63-year-old women with SAH. A : The left vertebral artery angiogram shows the aneurysm before treatment. B : 3D reconstruction image shows wide-necked right superior cerebellar artery aneurysm (neck×height×width×length : 5.0×7.1×5.3×6.2 mm). C : Two microcatheters are positioned within the aneurysm. One has a 45° angled distal tip and the other has a 90° angled distal tip. D : First coil (360° Guglielmi detachable coil 7×15 mm) being deployed. E : Second coil (Microplex coil Complex 5×15 mm) being deployed via another microcatheter. F : Immediately after embolization, angiogram shows compact occlusion of the aneurysmal sac and patent right SCA. There is a small remnant neck around the right SCA. G : Two months after embolization, an angiogram shows no interval change and stable coils. H : Six months after embolization, magnetic resonance angiogram shows no interval change and stable coils.

Fig. 3

Case 14; a 73-year-old women with SAH. A : The left ICA angiogram shows the aneurysm before treatment. B : 3D reconstruction image shows wide-necked PCoA aneurysm (neck×height×width×length : 10.6×6.5×7.2×7.3 mm). C : Neuroform stent (4.5×15 mm) was deployed resulting in jailing two microcatheters. The microcatheters have different distal shapes; one has a 45° angled distal tip and the other has a 90° angled distal tip. D : Two coils (360° Guglielmi detachable coil 6×11 mm, Microplex coil Complex 5×15 mm) being deployed via two microcatheters. E : Immediately after treatment, a left ICA angiography shows residual contrast dye filling the neck to preserve the fetal type PCoA. The dome of the aneurysm is compactly occluded. But, there was a procedure-related thromboembolism at the left distal anterior cerebral artery. F : Two months after embolization, the angiogram showed no interval change and stable coils.