H.Ghanaati; M.D. Associate Professor of Radiology Tehran University Of Medical Sciences Outcomes of intracranial aneurysms treated with coils: A six-month follow-up

Introduction Intracranial aneurysms are a major life-threatening problem requiring treatment and coiling may be one preferred procedure. This treatment technique proved to be effective at preventing re-bleeding after aneurysmal rupture and showed an even better clinical outcome in terms of disability-free survival as compared with surgical clipping.

The efficacy of treatment modality is based on both its safety and durability. Some cases with a re-canalized aneurysm are at risk of delayed aneurysm rupture and thus may require further treatment. A choice should be made based on the conditions of a patient and patients with different ethnicities could have various outcomes.

Patient 1-CT and MRA before procedure

Patient 1- Angiography before procedure

Patient1- Procedure

Purpose Regarding a lack of data from Iran, in this study the radiological and clinical outcomes of coiling performed in patients with intracranial aneurysms were evaluated.

Patients and methods In this clinical series, 106 patients with symptomatic intracranial aneurysms admitted for endovascular coil occlusion between 2007 and In 53 cases we had control angiogram after six months..

Initially all patients were evaluated by four-vessel angiography (GE4100 innova flat panel Advantex) to determine shape, size, multiplicity and location of aneurysms and decide about therapeutic protocol. Thereafter, standard techniques of coiling have been done. At first, the 3D coil was induced and thereafter 2D and soft coils were induced in the aneurysm. according to aneurysm condition balloon assisted or stent assisted techniques have been used.

After the procedure, the follow up angiography was carried out and the patients were divided into three groups according to jean Rymand classification: 1.Complete occlusion (relieving the sac and neck of the aneurysm), 2.residual neck (remaining the main arterial defect as a single projection without penetration of contrast media into the sack), 3.residual aneurysm (with penetration of contrast media into the sack).

After six months, angiography was repeated and aneurysm size, neck widening and shape of the aneurysm were evaluated. Finally, the data were analyzed using SPSS (version 16.0).

Results Mean age of the patients was 44.8±14.4 years.

Sex Distribution

Smoking History

Nine subjects (18.4%) had hemorrhage in CT- Scan including:

eighteen patients (33.9%) had positive history of hypertension and 11 subjects (2o.7%) had a positive history of hyperlipidemia. One patient had a history of polycystic kidney disease. Midline shift was seen in two patients (3.7%) and mass effect was present in one (1.8%).

LocationNumberPercent Anterior Cerebral Artery48.2 Anterior Communicating Artery Middle Cerebral Artery36.1 Posterior Cerebral Artery24.1 Posterior Communicating Artery24.1 Internal Carotid Artery Basilar Artery510.2 Posterior Inferior Cerebellar Artery12 Superior Cerebellar Artery12 The aneurysms were located in posterior circulation in 8 patients (16.3%) and in anterior circulation in 41 patients(83.7%).

Aneurysm sac diameter

Neck diameter

Shape

Occlusion (79% Total occlusion immediately after coiling)

complications Six patients (11.3%) experienced some complications During procedure including: Two basilar spasm, one loss of consciousness up to 15 days after procedure, one some blood leakage from sac that was controlled by hyper glide balloon expansion, one some blurred vision in later periods, and one transient paresis of limbs during procedure that was eliminated. There was 3 mortality during 6 months.

After six months 3 patients (5.7%) had new growth, 2 subjects (3.8%) had neck residue, 2 subjects (3.8%) had coil compression, 2 patients (3.8%) had coil stretching, and 4 patients (7.5%) had progressive thrombosis inside aneurysm (incomplete coiling cases). 75.5% of cases showed complete occlusion.

There was no statistical relationship between the complication and shape of aneurysm (p=0.99) The frequency of complications in posterior circulation aneurysms was 25%(2 of 8) while this was 10.3% amoung anterior ones (4 of 39)(p=0.27)

Discussion Our study also showed a good result in a six- month follow-up with a 75.5% of success rate and only three dead patients.

D'Agostino et al performed a clinical experience with Matrix2 360 degrees coils in treatment of 100 intracranial aneurysms.D'Agostino In their study, the Follow-up was done at 6 and 12 months. Initial complete occlusion was obtained in 80 aneurysms (80% success rate). Of 76 aneurysms with 6-month angiographic follow-up, 4 (5.3%) revealed further occlusion, 54 (71.1%) were unchanged, and 18 (23.7%) showed recanalization (76.3% success rate). Of 38 aneurysms with 12-month follow-up, 1 (2.6%) revealed further occlusion, 23 (60.5%) were unchanged, and 14 (36.8%) showed recanalization. Six- and 12-month angiograms showed major recanalization (requiring further coiling) in 3.9% and 15.8% of cases, respectively. Our results in six-month was approximately similar to D'Agostino’s study findings.

Kang et al evaluated short-term outcome of intracranial aneurysms treated with polyglycolic acid/lactide copolymer-coated coils compared to historical controls treated with bare platinum coils in 51 patients. The PGLA-coil group showed comparable data regarding rate of total or near-total occlusion of the aneurysm, incidence procedure-related thromboembolism, and management outcome. Follow-up evaluation revealed recanalization in 14 of 39 aneurysms (major recanalization in 5 [13%] and minor recanalization in 9 [23%]) among the PGLA- coil group and in 29 of 64 aneurysms (major recanalization in 9 [14%] and minor recanalization in 20 [31%]) among the bare-coil group.

It seems that the size (neck and body), shape and location of aneurysm could have some effects on the complication rate and recurrence but unfortunately, in our study, we did not have enough patients to reach a good sample size for assessing this theory.only we proved that the posterior circulation aneurysm have more complication. In this study coil treatment showed successful outcomes in treatment of intracranial aneurysms with low complication rate. So it is recommended to use it as a safe and effective therapeutic modality. In future we will publish result of larger series with longer follow up.

CONCLUSION It seems that the size (neck and body), shape and location of aneurysm could have some effects on the complication rate and recurrence but unfortunately, in our study, we did not have enough patients to reach a good sample size for assessing this theory.only we proved that the posterior circulation aneurysm have more complication. In this study coil treatment showed successful outcomes in treatment of intracranial aneurysms with low complication rate. So it is recommended to use it as a safe and effective therapeutic modality. In future we will publish result of larger series with longer follow up.