Hostname: page-component-cc8bf7c57-5wl6q Total loading time: 0 Render date: 2024-12-09T07:20:53.847Z Has data issue: false hasContentIssue false

Microstent-Assisted Coiling for Wide-Necked Intracranial Aneurysms

Published online by Cambridge University Press:  02 December 2014

Marlise Peruzzo dos Santos Souza
Affiliation:
Department of Medical Imaging, St. Michael’s Hospital and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
Ronit Agid
Affiliation:
Department of Medical Imaging, St. Michael’s Hospital and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
Robert A. Willinsky
Affiliation:
Department of Medical Imaging, St. Michael’s Hospital and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
Michael Cusimano
Affiliation:
Department of Medical Imaging, St. Michael’s Hospital and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
Walter Montanera
Affiliation:
Department of Medical Imaging, St. Michael’s Hospital and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
M. Christopher Wallace
Affiliation:
Department of Medical Imaging, St. Michael’s Hospital and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
Karel G. terBrugge
Affiliation:
Department of Medical Imaging, St. Michael’s Hospital and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
Thomas R. Marotta
Affiliation:
Department of Medical Imaging, St. Michael’s Hospital and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

To describe the results, technical feasibility, efficacy and challenges encountered in our preliminary experience using a self-expandable microstent, optimized for intracranial use, as an adjunct in the endovascular treatment of wide-necked aneurysms.

Methods:

Only broad-necked aneurysms (dome-to-neck ratio £2, or an isolated neck size > 4.5 mm) were treated with Neuroform microstent from July 2003 to May 2004. The techniques used for stent deployment were either parallel or sequential. Angiographic results were recorded immediately for all patients and classified as Class 1 (complete occlusion), Class 2 (neck remnant) or Class 3 (sac remnant) by three interventional neuroradiologists not involved in the procedure. Follow-up angiography at six months was obtained for one case. Modified Rankin Score scale was assessed for all patients.

Results:

Seventeen intracranial aneurysms in a total of 18 patients were treated (mean age, 52.2 yr). Eight patients (44.4%) presented with acute subarachnoid hemorrhage. Eleven aneurysms (61.1%) were in the posterior circulation. Average dome size was 10.2 mm (range, 3.7-19.8 mm) and average neck size was 5.36 mm (range, 3.0-10.0 mm). Six out of seven aneurysms of the anterior circulation were approached with parallel technique. Eight aneurysms of the posterior circulation were approached with sequential technique. Average number of coils deployed was 9.64 (range, 4-23 coils). Eleven aneurysms (64.8%) resulted in Class 1 and/or Class 2. One technical failure was observed. Technical complications were recognized in four patients (23.5%), all of them with unruptured aneurysms in the anterior circulation. Two patients (11.7%) presented transient immediate clinical complications. One patient (5.8%) had minor permanent neurological complication. Neither major clinical complications nor death were encountered. Favorable clinical outcome (Modified Rankin Scale score 0-2) was observed in 88.2% of the patients (average follow-up time, 4.72 months).

Conclusion:

Absence of major permanent complications and satisfactory immediate obliteration degree in our preliminary experience indicates that microstent-assisted coiling technique is useful for the minimally invasive treatment of broad-necked complex aneurysms that are not ideal for conventional endovascular treatment and are at a high risk for conventional surgical treatment.

Résumé:

RÉSUMÉ:Objectif:

Décrireles résultats, la faisabilité technique, l’efficacité et les défis rencontrés au cours de nos premières expériences d’utilisation d’un microstent autodéployant adapté pour utilisation intracrânienne dans le traitement endovasculaire des anévrismes à large collet.

Méthodes:

Le microstent Neuroform a été utilisé de juillet 2003 à mai 2004 pour traiter uniquement les anévrismes à large collet (rapport sommet/collet £2, ou un collet >4,5 mm). La technique utilisée pour le déploiement du sent était soit parallèle ou séquentielle. Les résultats angiographiques étaient enregistrés immédiatement pour tous les patients et classifiés par trois neuroradiologistes interventionnels indépendants de l’étude comme suit: classe 1 quand l’occlusion était complète; classe 2 quand il y avait un collet résiduel et classe 3 quand il y avait un sac résiduel. Une angiographie a été faite chez un cas 6 mois après l’intervention. Tous les patients ont été évalués au moyen de l’échelle modifiée de Rankin.

Résultats:

Dix–sept anévrismes chez 18 patients dont l’âge moyen était de 52,2 ans ont été traités. Huit patients, soit 44,4%, avaient consulté pour une hémorragie sous–arachnoïdienne aiguë. Onze anévrismes, soit 61,1% étaient situés au niveau de la circulation postérieure. La taille moyenne du sommet de l’anévrisme était de 10,2 mm (écart de 3,7 à 19,8 mm) et la taille moyenne du collet était de 5,36 mm (écart de 3,0 à 10,0 mm). La technique parallèle a été utilisée pour traiter six des sept anévrismes situés au niveau de la circulation antérieure et la technique séquentielle pour 8 anévrismes situés au niveau de la circulation postérieure. Le nombre moyen de coils déployés était de 9,64 (écart de 4 à 23 coils). Le résultat du traitement de onze anévrismes (64,8%) a été classifié comme étant de classe 1 et/ou de classe 2. Il y a eu un échec technique et des complications techniques sont survenues chez quatre patients (23,5%), tous des patients qui avaient des anévrismes sans rupture au niveau de la circulation antérieure. Deux patients (11,7%) ont eu des complications cliniques passagères immédiates. Un patient (5,8%) a eu une complication neurologique permanente mineure. Aucune complication clinique majeure ou décès n’ont été observés. 88,2% des patients ont eu une issue favorable (score de 0 à 2, à l’échelle modifiée de Rankin) au cours d’un suivi moyen de 4,72 mois.

Conclusions:

Chez ces patients, nous n’avons pas observé de complications permanentes majeures et nous avons obtenu un degré satisfaisant d’oblitération immédiate. Nos résultats préliminaires indiquent que la technique du coiling avec microstent est utile dans le traitement non effractif des anévrismes complexes à large collet pour lesquels le traitement endovasculaire conventionnel n’est pas idéal et la chirurgie conventionnelle présente un risque élevé.

Type
Original Articles
Copyright
Copyright © The Canadian Journal of Neurological 2014

References

1. Henkes, H, Bose, A, Felber, S, et al. Endovascular coil occlusion ofintracranial aneurysms assisted by a novel self-expandable nitinol microstent (Neuroform). Intervent Neuroradiol 2002;8(2):107119.CrossRefGoogle Scholar
2. Fiorella, D, Albuquerque, FC, Han, P, McDougall, CG. Preliminaryexperience using the Neuroform stent for the treatment of cerebral aneurysms. Neurosurgery 2004;54(1):616; discussion 16-17.Google Scholar
3. Murayama, Y, Vinuela, F, Tateshima, S, et al. Cellular Responses ofBioabsorbable Polymeric Material and Guglielmi Detachable Coil in Experimental Aneurysms. Stroke 2002;33(4):11201128.CrossRefGoogle ScholarPubMed
4. Johnston, SC, Higashida, RT, Barrow, DL, et al. Recommendationsfor the endovascular treatment of intracranial aneurysms: a statement for healthcare professionals from the Committee on Cerebrovascular Imaging of the American Heart Association Council on Cardiovascular Radiology. Stroke 2002;33(10):25362544.Google Scholar
5. Howington, JU, Hanel, RA, Harrigan, MR, et al. The Neuroformstent, the first microcatheter-delivered stent for use in the intracranial circulation. Neurosurgery 2004;54(1):25.Google Scholar
6. Roy, D, Milot, G, Raymond, J. Endovascular treatment of unrupturedaneurysms. Stroke 2001;32(9):19982004.Google Scholar
7. van Swieten, JC, Koudstaal, PJ, Visser, MC, Schouten, HJ, van Gijn, J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988;19(5):604607.CrossRefGoogle ScholarPubMed
8. Newcommon, NJ, Green, TL, Haley, E, Cooke, T, Hill, MD. Improvingthe assessment of outcomes in stroke: use of a structured interview to assign grades on the Modified Rankin Scale. Stroke 2003;34(2):377378.CrossRefGoogle Scholar
9. Molyneux, A, Kerr, R, Stratton, I, et al. International SubarachnoidAneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002;360(9342):12671274.Google Scholar
10. Hademenos, GJ, Massoud, TF, Turjman, F, Sayre, JW. Anatomical andmorphological factors correlating with rupture of intracranial aneurysms in patients referred for endovascular treatment. Neuroradiology 1998;40(11):755760.CrossRefGoogle Scholar
11. Turjman, F, Massoud, TF, Sayre, J, Vinuela, F. Predictors ofaneurysmal occlusion inthe period immediately after endovascular treatment with detachable coils: a multivariate analysis. AJNR Am J Neuroradiol 1998;19(9):16451651.Google Scholar
12. Debrun, GM, Aletich, VA, Kehrli, P, et al. Selection of cerebralaneurysms for treatment using Guglielmi detachable coils: the preliminary University of Illinois at Chicago experience. Neurosurgery 1998;43(6):12811295; discussion 1296-1287.Google Scholar
13. Hope, JK, Byrne, JV, Molyneux, AJ. Factors influencing successfulangiographic occlusion of aneurysms treated by coil embolization. AJNR Am J Neuroradiol 1999;20(3):391399.Google ScholarPubMed
14. Szikora, I, Guterman, LR, Wells, KM, Hopkins, LN. Combined use ofstents and coils to treat experimental wide-necked carotid aneurysms: preliminary results. AJNR Am J Neuroradiol 1994;15(6):10911102.Google ScholarPubMed
15. Turjman, F, Massoud, TF, Ji, C, et al. Combined stent implantationand endosaccular coil placement for treatment of experimental wide-necked aneurysms: a feasibility study in swine. AJNR Am J Neuroradiol 1994;15(6):10871090.Google Scholar
16. Higashida, RT, Smith, W, Gress, D, et al. Intravascular stent andendovascular coil placement for a ruptured fusiform aneurysm of the basilar artery. Patient report and review of the literature. J Neurosurg 1997;87(6):944949.Google Scholar
17. Lieber, BB, Gounis, MJ. The physics of endoluminal stenting in thetreatment of cerebrovascular aneurysms. Neurol Res 2002;24 (Suppl 1):S33-S42.CrossRefGoogle Scholar
18. Rhee, K, Han, MH, Cha, SH. Changes of flow characteristics bystenting in aneurysm models: influence of aneurysm geometryand stent porosity. Ann Biomed Eng 2002;30(7):894904.CrossRefGoogle Scholar
19. Lylyk, P, Cohen, J, Ceratto, R, Ferrario, A, Miranda, C. [Endovasculartreatment of partially clipped aneurysms]. Medicina (B Aires) 2001;61(1):5762.Google Scholar
20. Lylyk, P, Cohen, JE, Ferrario, A, Ceratto, R, Miranda, C. Partiallyclipped intracranial aneurysm obliterated with combined stent and coil implantation. J Endovasc Ther 2002;9(2):160164.CrossRefGoogle Scholar
21. Lopes, DK, Ringer, AJ, Boulos, AS, et al. Fate of branch arteries afterintracranial stenting. Neurosurgery 2003;52(6):12751278; discussion 1278-1279.Google Scholar
22. Wanke, I, Doerfler, A, Schoch, B, Stolke, D, Forsting, M. Treatment of wide-necked intracranial aneurysms with a self-expanding stent system: initial clinical experience. AJNR Am J Neuroradiol 2003;24(6):11921199.Google ScholarPubMed
23. Phatouros, CC, Sasaki, TY, Higashida, RT, et al. Stent-supported coilembolization: the treatment of fusiform and wide-neck aneurysms and pseudoaneurysms. Neurosurgery 2000;47(1):107113; discussion 113-105.Google Scholar
24. Leon, MB, Baim, DS, Popma, JJ, et al. Aclinical trial comparing threeantithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. N Engl J Med 1998;339(23):16651671.Google Scholar
25. Arandomised, blinded, trial of clopidogrel versus aspirin in patientsat risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996;348(9038):13291339.Google Scholar
26. Bhatt, DL, Bertrand, ME, Berger, PB, et al. Meta-analysis ofrandomized and registry comparisons of ticlopidine with clopidogrel after stenting. J Am Coll Cardiol 2002;39(1):914.Google Scholar
27. Gurbel, PA, Cummings, CC, Bell, CR, et al. Onset and extent ofplatelet inhibition by clopidogrel loading in patients undergoing elective coronary stenting: the Plavix Reduction Of New Thrombus Occurrence (PRONTO) trial. Am Heart J 2003;145(2): 239247.CrossRefGoogle Scholar
28. Henkes, H, Fischer, S, Weber, W, et al. Endovascular coil occlusion of 1811 intracranial aneurysms: early angiographic and clinical results. Neurosurgery 2004;54(2):268280; discussion 280-265.CrossRefGoogle ScholarPubMed
29. Gum, PA, Kottke-Marchant, K, Welsh, PA, White, J, Topol, EJ. Aprospective, blinded determination of the natural history of aspirin resistance among stable patients with cardiovascular disease. J Am Coll Cardiol 2003;41(6):961965.Google Scholar
30. Gurbel, PA, Bliden, KP, Hiatt, BL, O’Connor, CM. Clopidogrel forcoronary stenting: response variability, drug resistance, and the e ffect of pretreatment platelet reactivity. Circulation 2003; 107(23):29082913.Google Scholar
31. Alfke, K, Straube, T, Dorner, L, Mehdorn, HM, Jansen, O. Treatmentof intracranial broad-neck aneurysms with a new self-expanding stent and coil embolization. AJNR Am J Neuroradiol 2004; 25(4):584591.Google Scholar
32. Chow, MM, Woo, HH, Masaryk, TJ, Rasmussen, PA. A novelendovascular treatment of a wide-necked basilar apex aneurysm by using a Y-configuration, double-stent technique. AJNR Am JNeuroradiol 2004;25(3):509512.Google ScholarPubMed
33. Benitez, RP, Silva, MT, Klem, J, Veznedaroglu, E, Rosenwasser, R. Endovascular occlusion of wide-necked aneurysms with a new intracranial microstent (Neuroform) and detachable coils. Neurosurgery 2004;54(6):In Press.Google Scholar