Saccular intracranial aneurysm coiling: experience in department of neurology, Ain-Shams University

ABSTRACT

Subarachnoid hemorrhage is a devastating type of stroke associated with 45% case fatality and 30% long-term dependency in survivors. Ruptured aneurysms should be treated early [within 24 to 72 hours] because the risk of subsequent rupture is high. Options for treatment include surgical clipping and endovascular coilings which is less invasive. Endovascular coiling has been proven to be effective and safer than clipping in most ruptured and unruptured intracranial aneurysms. We performed endovascular coiling for ruptured saccular aneurysm [presenting with acute subarachnoid hemorrhage, Hunt and Hess grade I-IV] and for asymptomatic aneurysms [>/= 7 mm in the anterior circulation or patients < 60 y old or with personal or family history of subarachnoid hemorrhage]. All patients underwent clinical assessment together with Hunt and Hess scale [H and H scale] and modified Rankin Scale [mRS] upon discharge. Patients also performed CT scan brain +/- CSF analysis. Then six vessels digital subtraction cerebral angiography [DSA] was done followed by endovascular coiling of the aneurysm. Follow up by mRS and MRA brain or DSA was done after 6 months and then yearly till 5 years. We included our first 60 saccular aneurysms [57 patients with 60 aneurysms] for whom endovascular coiling was done. Fifty seven of our patients [95%] had ruptured aneurysm while 3 [5%] had unruptured aneurysms [asymptomatic]. Fifty five aneurysms [91.7%] were small [< 10 mm] and only 5 [8.3%] were between 11-15 mm. Thirty three [55%] had narrow neck while 27 [45%] had a wide neck. We succeeded to achieve total occlusion of the aneurysm in 49/60 cases [81.6%], neck remnant was left in 6 cases [10%], incomplete occlusion was done in two cases [3.3%]. In 3 cases [5%] we failed to occlude the aneurysm. Balloon remodling and coiling was used in 6 patients [10%] while self-expandable stent and coiling was used in two patient [3.3%]. We faced 3 clinical complications [5%] that resulted in neurologic deficit. During long-term follow up [mean 31 +/- 20.4 months] for the surviving patients, none of the treated aneurysms suffered from rebleeding. MRA or angiography follow up for up to 5 years revealed persistent total occlusion in 37/42 patients [88%], stable neck remnant in 3/42 patients [7.1%] for whom no further treatment was required and major aneurysm recurrence in 2/42 patients [4.7%]. Endovascular coiling is a less invasive alternative to surgical clipping. For patients in good as well as poor clinical condition with ruptured or unruptured aneurysms of either the anterior or posterior circulation, there is firm evidence that if the aneurysm is considered suitable for surgical clipping and endovascular treatment, coiling is associated with a better outcome: