[Endovascular treatment of ischemic strokes : outcomes and practical issues]. / Intégration de la thrombectomie mécanique dans le traitement de l'AVC ischémique en phase aiguë : rôle et mise en oeuvre.

INTRODUCTION: Ischemic stroke is a leading cause of disability and death due to brain arterial occlusion and subsequent ischemia. Acute treatment aims to recanalize the occluded artery as soon as possible. Treatment to achieve recanalization of the occluded artery has evolved during the last couple of years. First therapeutic improvement : intra-veinous thrombolysis (IV rt-PA) was the first validated treatment to achieve reduction in ischemic stroke morbi-mortality. However, rt-PA is efficient in the first hours of stroke onset and for small calibers occluded vessels. Second therapeutic improvement : since 2015, mechanic thrombectomy in combination with IV rt-PA or alone, extended acute ischemic stroke treatment to large vessel occlusions that are responsible for most death and disability in stroke patients, and this, in a time window less restrictive than the 4,5hours after which the rt-PA is no longer effective. Discussion and practical issues : the aim of acute ischemic stroke treatment is to recanalize as soon as possible the occluded vessel to preserve as much viable brain tissue as possible. Here, we propose to base stroke work-up on injected brain computed tomography : before the contrast is injected, brain CT is sufficient for rt-PA infusion decision, then contrast injection can be made within another vein while rt-PA is injected to select patients with proximal occlusion in need of thrombectomy.

INTRODUCTION: L'accident vasculaire cérébral ischémique (AVCi) est une cause majeure de handicap et de mortalité dû à l'occlusion d'une artère cérébrale et à l'ischémie du territoire d'aval. Pendant la phase aiguë, le principe du traitement vise à recanaliser le plus rapidement possible l'artère occluse. Ces traitements ont considérablement évolué ces dernières années. Première révolution thérapeutique : l'injection IV d'un traitement thrombolytique (rt-PA) a permis, en phase aiguë, de diminuer le handicap et la mortalité liés à l'AVCi. Cependant, le rt-PA n'est efficace que dans les heures qui suivent le début des symptômes et pour des vaisseaux occlus de petit calibre. Seconde révolution thérapeutique : depuis 2015, la thrombectomie mécanique, combinée ou non au rt-PA IV, a permis d'étendre les possibilités de recanalisation aux vaisseaux de gros calibre dont les occlusions sont responsables de la majorité des décès et des handicaps sévères, et ce, dans un intervalle de temps moins restrictif que les 4h30 au-delà de laquelle la rt-PA n'est plus efficace. Discussion et mise en oeuvre pratique : l'objectif du traitement de l'AVCi en phase aiguë est de recanaliser le plus rapidement l'artère occluse pour préserver un maximum de tissu cérébral viable. Nous utilisons le CT-scan cérébral comme méthode diagnostique : à blanc, il permet de décider l'administration de rt-PA IV ; après injection de produit de contraste, l'angioscanner et le scanner de perfusion permettent de sélectionner les patients éligibles pour une thrombectomie sans retarder l'injection du rt-PA.

[Not Available]. / Résultats du traitement radiochirurgical Gamma Knife des malformations artério-veineuses cérébrales.

Gamma Knife treatments of arteriovenous malformations (AVM) are performed for about 40 years. This article presents the results of 123 patients treated for a brain AVM at the Gamma Knife Center ULB-Hôpital Erasme. Radiosurgical treatment is proposed following multidisciplinary discussion of the best therapeutic strategy based on specific parameters of the AVM. Gamma Knife irradiation was achieved for an AVM residue after endovascular embolization for 84% of patients, after microsurgery for 7% of patients, or after previous radiosurgical irradiation for 6% of patients. The whole volume of the nidus was irradiated in a single session for all patients. A mean margin dose of 22.3 Gy was delivered to the nidus, which had a mean volume of 3.3 cc. The maximum dose ranged from 30 Gy to 50 Gy (mean 44.1 Gy). All patients were prospectively followed after treatment with serial angio-MR and/or conventional angiography. A retrospective analysis shows complete obliteration of the AVM for 109 patients (89%) after 6 to 52 months (mean 32 months). For 14 patients the nidus was only partially obliterated from the radiosurgical procedure; for 9 patients a second irradiation was performed with subsequent complete occlusion of the AVM in all cases. So, 118 of 123 patients (96%) irradiated by Gamma Knife in 1 or 2 sessions were cured. Four patients bled after irradiation and before complete occlusion of the AVM, with neurological deficit for 2 patients. Transient neurological symptoms develop after treatment for 12 patients (10%), associated with postradic edema treated with corticoids. Permanent neurological worsening occurred in 5 patients (4%). Gamma Knife treatment of cerebral arteriovenous malformations is a highly efficient and low-risk therapy when used by a multidisciplinary team.

WEB-DL Endovascular Treatment of Wide-Neck Bifurcation Aneurysms: Long-Term Results in a European Series.

BACKGROUND AND PURPOSE: Flow disruption with the WEB-DL device has been used safely for the treatment of wide-neck bifurcation aneurysms. The stability of aneurysm occlusion after this treatment was evaluated in the short and midterm, but not in the long term. This retrospective multicenter European study is the continuation of an already published series dealing with short- and midterm anatomic results and analyzes long-term data in patients treated with the WEB-DL. MATERIALS AND METHODS: Twelve European neurointerventional centers initially participated in the study. In addition to data collected for the initial publication, images obtained at long-term follow-up were collected and independently analyzed by the same experienced interventional neuroradiologist. RESULTS: Of the initial 45 patients, 26 (20 women and 6 men; 35-73 years of age; mean, 55.2 ± 10.6 years; median, 55.5 years) with 26 aneurysms treated with the WEB-DL device had long-term follow-up (median, 27.4 months). Three of 26 patients (11.5%) were retreated between short- and midterm follow-up, and none, between mid- and long-term follow-up. Long-term aneurysm occlusion in the 19 patients treated with the WEB only and not retreated during follow-up was complete occlusion in 13/19 patients (68.4%), including aneurysms with opacification of the proximal recess in 9/19 patients (47.4%), neck remnant in 3/19 patients (15.8%), and aneurysm remnant in 3/19 patients (15.8%). In all patients (100.0%), aneurysm occlusion was stable between midterm and long-term follow-up. CONCLUSIONS: The results suggest that WEB treatment of wide-neck bifurcation aneurysms offers long-term stable occlusion.

Intrasaccular Flow Disruption in Acutely Ruptured Aneurysms: A Multicenter Retrospective Review of the Use of the WEB.

BACKGROUND AND PURPOSE: Use of the WEB intra-aneurysmal flow-disruption device in unruptured wide-neck bifurcation aneurysms has proven safety and efficacy. However, ruptured aneurysms are underrepresented in existing studies. This retrospective multicenter study describes the use of the WEB in patients with a ruptured intracranial aneurysm. MATERIALS AND METHODS: Ten centers contributed to this study. Clinical and procedural data of 47 patients with 52 aneurysms were analyzed retrospectively together with follow-up angiographies. RESULTS: There were 37 anterior and 15 posterior circulation aneurysms with a neck size of ≥4 mm in 49 of 52 (94%) aneurysms; 45 (87%) aneurysms were <10 mm, and 2 were partially thrombosed. Successful placement of the WEB was possible in every case. Adjunctive devices were used in 8 of 52 (15%) aneurysms. Thromboembolic events were observed in 4 of 52 (8%) patients. Adverse events occurred in 15 patients with 16 aneurysms, 9 of which were potentially related to the WEB procedure (3 thromboembolic events, 5 protrusions, and 1 perforations; 2 perforations were caused by the wire or catheter), but none had a clinical impact. Four patients were retreated. Short-term follow-up in 25 of 39 patients revealed complete occlusion in 15 of 25 (60%), 5 of 25 (20%) with residual neck, and 5 of 25 (20%) with residual aneurysm filling. Short- to midterm imaging in 9 of 25 patients revealed complete occlusion in 5 (55.6%), residual neck in 2 (22%), and residual aneurysm filling in 2 (22%). Of 47 patients, 23 (49%) had an mRS score of 0, 1, or 2; 13 (28%) had an mRS score of 3 or 4; and none had an mRS score of 5 at discharge. CONCLUSIONS: This retrospective series showed good procedural safety, feasibility, and stability of midterm occlusion in ruptured wide-neck bifurcation aneurysms.

Silk flow-diverter stent for the treatment of intracranial aneurysms: a series of 58 patients with emphasis on long-term results.

BACKGROUND AND PURPOSE: The Silk flow-diverter stent is increasingly used to treat complex intracranial aneurysms including wide-neck, fusiform aneurysms. Sparse data are available concerning long-term results of this technique. We report our 5-year experience with Silk stent treatment of intracranial aneurysms. MATERIALS AND METHODS: A retrospective review of our prospectively maintained database identified all patients treated by the Silk stent in 2 institutions. Clinical charts, procedural data, and angiographic results were reviewed. RESULTS: Between July 2009 and May 2014, we identified 58 patients with 70 intracranial aneurysms. Endovascular treatment was successful in 93% of patients with 32 treated with the first-generation Silk stent and 26 with the new Silk+ stent. Mean follow-up in 47 patients was 22 months. Despite an 11% delayed complication rate, overall permanent neurologic morbidity was 5.5%. All complications were seen with the first-generation Silk stent. There was no procedure-related mortality. Long-term anatomic results showed 73% with complete occlusion, 16% with neck remnants, and 11% with incomplete occlusion. No recanalization or retreatment was performed. The midterm intrastent stenosis rate was 57%, of which 60% improved or disappeared, 28% were stable, and 12% led to vessel occlusion. Seventy-four percent of stenosis and all vessel occlusions occurred with the first-generation Silk stent. CONCLUSIONS: Endovascular treatment of complex intracranial aneurysms with the Silk stent is an effective therapeutic option. Despite a high rate of delayed complications with the first-generation stents, the current Silk+ stent appears safer. This treatment achieves a high rate of adequate and stable occlusion at long-term follow-up.

WEB-DL endovascular treatment of wide-neck bifurcation aneurysms: short- and midterm results in a European study.

BACKGROUND AND PURPOSE: Flow disruption with the WEB-DL device has been used safely for the treatment of wide-neck bifurcation aneurysms, but the stability of aneurysm occlusion after this treatment is unknown. This retrospective multicenter European study analyzed short- and midterm data in patients treated with WEB-DL. MATERIALS AND METHODS: Twelve European neurointerventional centers participated in the study. Clinical data and pre- and postoperative short- and midterm images were collected. An experienced interventional neuroradiologist independently analyzed the images. Aneurysm occlusion was classified into 4 grades: complete occlusion, opacification of the proximal recess of the device, neck remnant, and aneurysm remnant. RESULTS: Forty-five patients (34 women and 11 men) 35-74 years of age (mean, 56.3 ± 9.6 years) with 45 aneurysms treated with the WEB device were included. Aneurysm locations were the middle cerebral artery in 26 patients, the posterior circulation in 13 patients, the anterior communicating artery in 5 patients, and the internal carotid artery terminus in 1 patient. Forty-two aneurysms were unruptured. Good clinical outcome (mRS < 2) was observed in 93.3% of patients at the last follow-up. Adequate occlusion (complete occlusion, opacification of the proximal recess, or neck remnant) was observed in 30/37 patients (81.1%) in short-term follow-up (median, 6 months) and in 26/29 patients (89.7%) in midterm follow-up (median, 13 months). Worsening of the aneurysm occlusion was observed in 2/28 patients (7.1%) at midterm follow-up. CONCLUSIONS: The results suggest that the WEB endovascular treatment of wide-neck bifurcation aneurysms offers stable occlusion in a class of aneurysms that are historically unstable. Additionally, our data show that opacification of the WEB recess can be delineated from true neck or aneurysm remnants.

WEB device for endovascular treatment of wide-neck bifurcation aneurysms.

BACKGROUND AND PURPOSE: The WEB is an intrasaccular flow disrupter dedicated to EVT of IA. We report our initial experience in a series of patients treated with this device. MATERIALS AND METHODS: This prospective study was approved by the authors' ethical committees. Nineteen patients with 20 unruptured wide-neck bifurcation IAs were treated by WEB placement. Technical issues, immediate posttreatment angiographic findings, and clinical and imaging follow-up at 3, 6, and 12 months were assessed. RESULTS: Failure of WEB placement occurred in 1 case because of unavailability of a suitably sized device. Embolization was successful in 18 patients with 19 IAs, and it required additional stent placement and/or coiling in 3 cases at the acute phase and in 1 case at follow-up. Two patients experienced a symptomatic complication, and 16 patients had normal neurologic examination findings at discharge. Immediate anatomic outcome showed 1 complete occlusion, 13 near-complete occlusions, and 5 incomplete occlusions. At follow-up, 17 patients had normal neurologic examination findings and 1 retained a hemiparesis. Angiographic controls were obtained in all patients (mean, 6 months), and they showed stable or improved results in all except 4 cases, including 2 complete occlusions, 15 near-complete occlusions, and 2 incomplete occlusions. CONCLUSIONS: In this initial series of patients, EVT of wide-neck bifurcation IAa with the WEB was feasible. Further studies are needed to evaluate the indications, safety, and efficacy of this new technique.

[Aneurysms and other intracranial vascular malformations]. / Les anévrysmes et autres malformations vasculaires intracrâniennes.

The objective is to present the management of patients with aneurysms and other intracranial vascular malformations by interventional neuroradiology (INR) techniques. Interventional neuroradiology is dedicated to the treatment of patients who present with pathologies of the brain, the face, and the spinal cord that are treatable by direct percutaneous or endovascular approaches. Indications of INR have dramatically increased over the last 20 years thanks to innovations in radiological equipments (angio suite, 3D images, etc.) and embolic materials. The endovascular treatment alone is generally curative but sometimes it will be performed before surgery to decrease its risks. Interventional neuroradiology is thus part of several multidisciplinary teams including departments of neurosurgery, neurology, intensive care, anesthesiology, vascular surgery, ENT, etc. We will present the main indication of INR that is the treatment of patients with aneurysms and other intracranial vascular malformations. In conclusion, interventional neuroradiology plays nowadays the main role for the management of patients with neurovascular diseases. Interventional neuroradiology belongs to several multidisciplinary teams and allows to diagnose, to treat, and to follow-up these patients.

The role of interventional neuroradiology in the management of skull base tumours and related surgical complications.

The management of hypervascular skull base tumours is complex and requires a multidisciplinary approach. Skull base surgery may be challenging because of the risk of serious intra-operative bleeding and of potential injuries to lower cranial nerves and/or large cervical vessels. Over the last four decades, advances in neuro-interventional procedures have produced a range of adjunctive endovascular techniques in addition to conventional surgery. Digital subtraction angiography (DSA) allows for a better understanding of tumour vascularisation and its relationship with Surrounding vessels. Tumoural devascularisation and the occlusion of feeding arteries is a useful adjunct to surgery because it allows for the reduction of intra-operative blood loss and induces ischaemic necrosis of the tumour. Finally, surgery-related iatrogenic vascular lesions may be successfully treated with endovascular techniques. Nevertheless, endovascular procedures in the head and neck region are associated with infrequent but potentially serious complications. An extensive and comprehensive knowledge of head and neck vascular anatomy is therefore necessary. This article provides a review of the indications for, and results of, diagnostic, pre-operative and therapeutic endovascular procedures for the management of skull base tumours and related surgical complications.

Solitaire stent for endovascular treatment of intracranial aneurysms: immediate and mid-term results in 15 patients with 17 aneurysms.

INTRODUCTION: The Solitaire stent is the first fully retractable stent for endovascular treatment (EVT) of intracranial aneurysms. The aim of this study was to evaluate its use in a prospective series with mid-term follow-up. METHODS: A retrospective review of our prospectively maintained database identified all patients treated with a Solitaire stent. Clinical charts, procedural data, angiographic results were reviewed. RESULTS: Between June 2008 and September 2009, 15 patients with 17 wide-necked or fusiform aneurysms (16 unruptured/one ruptured) were identified. EVT was successfully performed in all but one patient in whom the stent was removed because it induced flow reduction in the 1.8-mm parent artery. Among 14 treated patients, 13 had an excellent outcome and one had a good outcome. In this latter patient, the first stent could not be delivered and was changed for another one that was successfully deployed. The patient experienced a thrombo-embolic complication 6 hours after EVT and kept a slight hand paresis. In all cases but one, the stent was thus easily navigated and positioned despite a relative poor visibility. Angiographic results included eight complete occlusions, two neck remnants, and six incomplete occlusions. Six-month control in 14 aneurysms showed 13 complete occlusions and one incomplete occlusion. CONCLUSION: The Solitaire stent is useful for EVT of complex intracranial aneurysms because it is fully retractable, easy to navigate and to precisely place. However, it should be used with caution in arteries less than 2mm in diameter.

Endovascular treatment of anterior choroidal artery aneurysms.

INTRODUCTION: Endovascular treatment (EVT) of anterior choroidal artery aneurysms (AChAA) may be challenging because of the close relationship with the parent artery. The aim of this study was to report our experience with EVT of AChAA. METHODS: A retrospective review of our prospectively maintained database identified all AChAA treated by embolization. The clinical charts, procedural data and angiographic results were reviewed. RESULTS: From April 2004-August 2008, 11 patients were identified. Five patients presented with a subarachnoid hemorrhage (SAH) and six patients were asymptomatic. Aneurysms size varied from two to 13 mm (mean size=3.6 mm) and nine had an unfavourable neck/sac ratio (>or=0.7). The anterior choroidal artery was arising from the sac (n=6) or from the neck (n=5). Endovascular treatment consisted of balloon-assisted coiling (n=8), coiling (n=2) and stent-assisted coiling (n=1). No procedural complication occurred and all patients had an excellent outcome except one patient who died because of severe vasospasm 8 days after an uneventful EVT. Immediate angiographic control showed six complete occlusions, one neck remnant and four incomplete occlusions. Follow-up controls (mean=18 months) were obtained in eight patients and showed five stable occlusions and three further thrombosis achieving complete occlusion. CONCLUSION: EVT of AChAA is associated with very good clinical and long-term anatomical results. Because of their small size, unfavourable neck/sac ratio and close relationship with the parent artery, EVT frequently requires the use of adjunctive techniques such as balloon or stent-assisted coiling.

Information on heavy equipments and facilities in Belgium: gamma-knife.

PURPOSE: To explain the principles and indications of gamma knife radiosurgery and to illustrate the correlated neuroimaging features. METHODS AND MATERIAL: Between December 1999 and July 2007, 1620 patients were treated by GK for a large variety of indications (metastasis 26%, vascular malformations 7%, trigeminal neuralgia 14%, pituitary adenoma 3%, primary CNS tumour 8%, other tumours 6%, vestibular schwannoma 19%, meningioma 17%, functional disorders <1%). The patients benefited from MRI follow-ups. RESULTS: MRI is the imaging technique of choice for Gamma knife radiosurgery (GKRS) in almost all indications. Computed Tomography, Digital Subtraction Angiography and Positron Emission Tomography have an additional role in some indications. Significant MRI data is illustrated in most indications. Evaluation of the treatment is mainly performed using MRI follow-up studies. The main features of these MRI follow-ups are described. Stabilisation or shrinking of the lesions volumes was generally observed. T2 relaxation times were also modified in and around the treated target areas, in patients responding to treatment and without any symptomatic complications. Modifications in contrast uptake were also observed in those patients. A few patients presented symptomatic complications associated with T2 signal anomalies. The interpretation of those modifications is discussed. CONCLUSION: MRI is the method of choice for GKRS planning in most indications. Imaging changes after radiosurgery provide the best quality control available to assess the response to radiosurgical treatment and to identify and monitor potential complications.

Endovascular treatment of intracranial aneurysms as the first thérapeutic option.

BACKGROUND AND PURPOSE: To prospectively evaluate the results of endovascular treatment (EVT) of intracranial aneurysms when it is considered as first-intention treatment. METHODS: From April 2004-October 2006, 167 consecutive patients with 202 aneurysms were treated in our institution. Five patients with a ruptured aneurysm with an associated haematoma were excluded. In 162 patients with 197 aneurysms, EVT was considered as first-intention treatment. RESULTS: Surgical clipping was performed in 25 aneurysms (25/197=12.7%) including 22 aneurysms excluded from EVT and three EVT failures. EVT was thus attempted in 144 patients with 175 aneurysms and successfully performed in 141 patients with 172 aneurysms (172/197=87.3%). EVT failure rate was 1.7%. Clinical outcome according to the modified Glasgow Outcome Scale was: Excellent, 81.5%; Good, 7%; Poor or Fair, 3.5%; Death, 8%. Procedural complications occurred in 17 cases (10%). Balloon- or stent-assisted techniques were used in 60 cases (34.9%) and were not associated with higher complication rate. Overall procedural morbidity and mortality rates were 4.2 and 2.1%. Initially, complete occlusion was obtained in 68%, neck remnant in 23%, and incomplete occlusion in 9% of aneurysms. Follow-up (mean 11 months) was obtained in 119 aneurysms and showed major recanalisation--that required re-treatment--in 13 cases (11%) and minor recanalisation in 17 cases (14.3%). CONCLUSION: Our findings suggest that new endovascular techniques allow proposing EVT as first-intention treatment in 87.3% of patients with intracranial aneurysms. This therapeutic strategy is associated with good clinical results. However, anatomical results are not improved and remain the EVT limiting factor.

Sixty-four-row multisection CT angiography for detection and evaluation of ruptured intracranial aneurysms: interobserver and intertechnique reproducibility.

BACKGROUND AND PURPOSE: The purpose of this work was to assess intertechnique and interobserver reproducibility of 64-row multisection CT angiography (CTA) used to detect and evaluate intracranial aneurysms. MATERIALS AND METHODS: From October 2005 to November 2006, 54 consecutive patients with nontraumatic subarachnoid hemorrhage (SAH) underwent both CTA and digital substraction angiography (DSA). Four radiologists independently reviewed CT images, and 2 other radiologists reviewed DSA images. Aneurysm diameter (D), neck width (N), and the presence of a branch arising from the sac were assessed. RESULTS: DSA revealed 67 aneurysms in 48 patients and no aneurysm in 6 patients. Mean sensitivity and specificity of CTA for the detection of intracranial aneurysms were, respectively, 94% and 90.2%. For aneurysms less than 3 mm, CTA had a mean sensitivity of 70.4%. Intertechnique and interobserver agreements were good for the detection of aneurysms (mean kappa = 0.673 and 0.732, respectively) and for the measurement of their necks (mean kappa = 0.753 and 0.779, respectively). Intertechnique and interobserver agreements were excellent for the measurement of aneurysm diameters (mean kappa = 0.847 and 0.876, respectively). In addition, CTA was accurate in determining the N/D ratio of aneurysms and adjacent arterial branches. However, the N/D ratio was overestimated by all of the readers at CTA. CONCLUSION: Sixty-four-row multisection CTA is an imaging method with a good interobserver reproducibility and a high sensitivity and specificity for the detection and the morphologic evaluation of ruptured intracranial aneurysms. It may be used as an alternative to DSA as a first-intention imaging technique in patients with SAH.

Immediate intracranial aneurysm occlusion after embolization with detachable coils: a comparison between MR angiography and intra-arterial digital subtraction angiography.

BACKGROUND AND PURPOSE: To prospectively compare the effectiveness of time-of-flight (TOF) and contrast-enhanced (CE) MR angiography (MRA) with that of digital subtraction angiography (DSA) to assess immediate intracranial aneurysm occlusion after selective embolization. METHODS: From August 2006 to March 2007, 33 consecutive patients with 40 aneurysms were included. Thirty aneurysms were treated by endosaccular coils (group 1). Ten aneurysms were treated by stent placement and subsequent endosaccular coils (group 2). All patients underwent MRA within 24 h after treatment. One senior and one fellow radiologist independently reviewed the MR images, and another senior radiologist reviewed the DSA images. RESULTS: DSA showed 22 complete occlusions, ten residual necks, and eight residual aneurysms. For residual neck detection, there was no difference between TOF-MRA (sensitivity, 80%-80%; specificity, 93.8%-100%, according to both readers) and CE-MRA (sensitivity, 80%-80%; specificity, 100%). For residual aneurysm detection, there was a significant difference between TOF-MRA (sensitivity, 50%-62.5%; specificity, 100%) and CE-MRA (sensitivity and specificity, 100%, according to both readers). In group 2, a residual aneurysm was missed by both readers with TOF-MRA in the same 3 aneurysms. Moreover, both readers judged CE-MRA better than TOF-MRA to assess parent-artery patency in group 2. Interobserver agreement was excellent for TOF-MRA and CE-MRA (kappa=0.9 and 1, respectively). CONCLUSIONS: In our study, both TOF-MRA and CE-MRA had high and comparable sensitivity and specificity for the assessment of immediate aneurysm occlusion after selective embolization, except when a stent-assisted technique was used. In such cases, CE-MRA was superior to TOF-MRA to evaluate aneurysm occlusion and parent-artery patency.

Endovascular treatment of intracranial aneurysms with a branch arising from the sac.

BACKGROUND AND PURPOSE: The endovascular treatment (EVT) of intracranial aneurysms is no more limited by the presence of a branch at the neck or by the neck width. Saccular aneurysms with a branch arising from the sac, however, are mostly candidates for surgery rather than embolization. We prospectively evaluated the feasibility and safety of the EVT in such cases. METHODS: Between May and November 2004, 9 consecutive patients with a saccular aneurysm that presents a branch arising from the sac were treated by embolization. There were 7 women and 2 men (mean age, 58 years). Six patients presented with a subarachnoid hemorrhage (SAH), and 3 were asymptomatic. All patients were treated by selective coiling with (n = 6) or without (n = 3) the remodeling technique. Clinical outcome was assessed with a modified Glasgow Outcome Scale at 3 months. RESULTS: EVT was successfully performed in all patients and resulted in 7 excellent outcomes and 2 deaths related to SAH complications. The arterial branch could be preserved in 7 cases and intentionally occluded in 2. Neither embolic nor ischemic complication occurred in the vascular territory of the involved branch. Angiographic results showed 5 neck remnants, 2 incomplete occlusions, and 2 complete occlusions. No rebleeding occurred. CONCLUSION: Our study, though limited by its small patient population, suggests that saccular intracranial aneurysms with a branch arising from the sac may be treated by endovascular approach with excellent clinical results; however, larger series with long-term follow-up are mandatory to confirm these preliminary results mostly in terms of anatomic stability.

Endovascular treatment of remnants of intracranial aneurysms following incomplete clipping.

We report clinical and angiographic findings in eight patients treated by the endovascular approach for an intracranial aneurysm remnant after incomplete surgical clipping. They were seven women and one man, mean age 38 years (range 14-50 years). In three, the remnant was responsible for a recurrent subarachnoid haemorrhage. All were treated by embolisation of the remnant using Guglielmi detachable coils. In two, a nondetachable balloon was inflated in front of the remnant during coil detachment because of a wide neck. Mean clinical and imaging follow-up was 19 months (range 12-24 months). Immediate angiography showed complete occlusion of the remnant and follow-up clinical examination showed good or excellent recovery in all patients. Imaging follow-up confirmed persistent occlusion of the remnant in all cases.

Giant aneurysms of the internal carotid artery: endovascular treatment and long-term follow-up.

We report the long-term follow-up of 18 patients with giant aneurysms of the internal carotid artery (ICA) referred for endovascular occlusion of the parent vessel. There were 10 aneurysms involving the infra- and/or supraclinoid cavernous segment, six the ophthalmic segment, one the petrous segment and one the bifurcation. One patient who did not tolerate test occlusion was treated medically. Clinical and imaging follow-up were obtained in 16 patients for a mean of 30 months, range 6-80 months. Endovascular treatment led to excellent clinical outcome in 16 patients. One 34-year-old woman, who presented with subarachnoid haemorrhage (SAH), died from bilateral middle cerebral artery infarcts due to severe vasospasm 4 days after treatment. The patient treated medically died from SAH. Long-term imaging follow-up in 16 patients revealed a markedly smaller aneurysm sac in all cases.