1. Follow-up of patients after aneurysm embolotherapy with coils L Pyysalo,, L Keski-Nisula, T Niskakangas, V Kahara, J Öhman Tampere University Hospital, Tampere Finland

2. Patients and methods 617 patients with aneurysms treated 1992 – 1999 200 aneurysms in 185 patients were coiled Clinical and angiographic outcome studied in 2007 - 2008 Follow-up 8 – 16 years after the initial coiling (or re-coiling) Mean follow-up time 11 years

3. Patients and methods 109 (/185) patients coiled after SAH and 76 (/185) patients unruptured aneurysms 122 patients still alive for delayed follow-up Clinical outcome evaluated in 116 (95%) MRI/MRA in 77 (63%) patients with 84 aneurysms

4. 185 patients with embolized aneurysms 122 surviving patients 100 patients included 77 MR-imaged patients 4 patients having contraindications to MRI 19 patients unwilling or unable to participate 22 patients excluded (outside the hospital catchment area) 63 patients deceased

5. Patients and methods Glasgow Outcome Score (I –V) -by clinical evaluation (77) or by phone interview (39) MRA with non-contrast 3D-TOF and cross-sectional MRI (T1, Flair, T2*) The same head-coil (1-channel) and the same (upgraded) 1.5T magnet (GE Signa) in follow-up as in the initial post-treatment MRAs (concurrently with the primary DSA or within one year) (Kähärä et al., AJNR Sept 1999 )

6. Methods Three readers for all angiograms (diagnostic, procedural and follow-up) Consensus statement of the occlusion grade: 1) complete, 2) neck remnant, 3) incomplete Initial aneurysm size, dome/neck ratio, location, coil packing density (”loose” or ”dense”)

7. Results In ruptured aneurysms the primary coil packing denser in DSA than in unruptured aneurysms (0.04). No difference in achieved occlusion grades between ruptured and unruptured aneurysms in primary DSA. In follow-up more ”incomplete” occlusions in MRA in the unruptured aneurysms (0.03). Re-treatment provided for 25% ruptured and 21% unruptured aneurysms, mainly within six months

8. Angiographic results Initial occlusion grade*Occlusion in follow-up Complete: 3838 Neck remnant: 1922 Incomplete: 2723 ( 5/15% ruptured ) Total: 84 83 ( 1 not diagnostic ) * Includes the grades achieved also after recoilings

9. Stability in follow-up Stable occlusion grade: 50 (ruptured/unr 20+30) Occlusion improvement: 14 (ruptured/unr 7+7) Occlusion worsening: 19 (ruptured/unr 7+12) Total 83 (34+49)

10. Clinical outcome Ruptured Unruptured Total GOS V: 34 31 65 GOS IV: 12 16 28 GOS III: 13 9 22 GOS II: 1 0 1 GOS I: 0 0 0 Total 60 56 116  In only 3 patients without haemorrhage the poor outcome was related to aneurysm

11. Clinical outcome – (re)bleedings Alltogether 10 haemorrhages - 1/75 unruptured (giant) aneurysm bled after 7 y - 9/109 rebleedings in SAH patients - except one rebled patient the others (9) died - only 3 of rebled aneurysms were monitored by MRA (elderly, vegetative, lost to follow-up etc.) - 5 initially as ”incomplete”, 3 ”neck remnants” (DSA) Annual rebleeding rate 1.3 % in ruptured and bleeding rate 0.1% in unruptured aneurysms

12. Summary Primarily: 38(46%) complete and 27(32%) incomplete Follow-up: 38(46%) complete and 23(27%) incomplete Annual rebleeding 1.3% (0.1% for unruptured) - barely platinum coils were used - no stents, bioactive coils, balloon assistance etc. in the 1990`s Conclusion: Coiled aneurysms remain relatively stable in long-term follow-up

14. Angiographic results - stability 20 (59%) aneurysms stable in SAH patients 6 (18%) remnant growth and 1 recurrence (?) 7 (21%) occlusion progression In unruptured aneurysms: 6 stable 6 remnant growth and 6 recurrences (?) 7 occlusion progression

15. MRA results in follow-up Complete occlusion in 18 (53%)+20 (40%) = 38 Neck remnant: 11/32%+11/22% = 22 Incomplete occlusion in 5/15% + 18/38% = 23 Ruptured in bold

16. Clinical outcome Patients with unruptured aneurysms: GOS 5: 55% (31) GOS 4: 29% (16 patients) GOS 3: 16% (9 patients were ”dependent”) Only in 3 patients poor outcome was related to aneurysm