Guglielmi detachable coil treatment of ruptured saccular cerebral aneurysms: retrospective review of a 10-year single-center experience

Abstract

Background and purpose: We retrospectively analyzed our results with Guglielmi detachable coils (GDCs) for the endovascular occlusion of acutely ruptured saccular cerebral aneurysms over 10 years.

Methods: Between 1991-2000, 83 patients (mean age, 56.1 years) with aneurysmal subarachnoid hemorrhage were treated with endovascular GDCs. Patients with aneurysms due to trauma or dissection and those with mycotic or fusiform aneurysms were excluded. Mean follow-up in survivors was 19.1 months, and the mean Hunt-Hess grade at admission was 2.2. Angiographic follow-up was performed in 93% of surviving patients (mean interval, 11.6 months). The basilar caput (34 patients) and anterior communicating artery complex (19 patients) were most commonly treated.

Results: Sixty-four patients (77%) had a Glasgow Outcome Scale score (GOS) of 4 or 5, nine (11%) had a score of 2 or 3, and 10 (12%) died. At follow-up, 24 patients (35%) had complete aneurysm occlusion, 18 (26%) had a dog-ear remnant, 24 (35%) had a residual neck, and two (3%) had residual aneurysm filling. No treated aneurysm rebled. Three patients required surgical repair after incomplete endovascular treatment. Two or more GDC occlusion procedures were required in 28 patients (34%). Major procedural complications occurred in two patients (2%), resulting in serious neurologic disability or death.

Conclusion: Endovascular treatment of ruptured cerebral aneurysms with GDCs has low morbidity, and it facilitates good overall outcomes in patients after subarachnoid hemorrhage. The short-term effectiveness of GDC occlusion in preventing aneurysmal rebleeding was excellent. Durability of the treatment in preventing long-term rebleeding as compared with direct surgical clipping warrants further study. Advances in device technology and technique may improve future outcomes.

Fig 1.

Graph depicting patients with ruptured cerebral aneurysms treated with endovascular GDC occlusion by year.

Fig 2.

A 56-year-old man with Hunt-Hess grade 1 subarachnoid hemorrhage. A, Towne-view right vertebral DSA demonstrates an 8-mm basilar caput aneurysm. The aneurysm was treated with seven GDCs measuring a total length of 51 cm. B, Immediate post-treatment Towne-view right vertebral DSA demonstrates total occlusion of the aneurysm. Follow-up angiography obtained 6 months after treatment demonstrated persistent total occlusion of the aneurysm (not shown).

Fig 3.

A 39-year-old man with Hunt-Hess grade 1 subarachnoid hemorrhage. A, Towne-view left vertebral DSA demonstrates a 16-mm basilar caput aneurysm. The aneurysm was treated with seven GDCs measuring a total length of 180 cm. Immediate post-treatment DSA demonstrated a small “dog ear” neck remnant (not shown). B, Towne-view left vertebral DSA obtained 6 weeks post treatment demonstrates slight enlargement of the “dog ear” neck remnant (arrow) at the right base of the aneurysm. C, Towne-view left vertebral DSA obtained immediately after detachment of one GDC measuring 8 cm in the dog ear neck remnant demonstrates occlusion of the neck remnant and total occlusion of the aneurysm.

Fig 4.

A 88-year-old man with Hunt-Hess grade 2 subarachnoid hemorrhage. A, Lateral view right internal carotid DSA demonstrates a 3 × 6-mm anterior choroidal artery aneurysm. Oblique views (not shown) demonstrated direct origin of the anterior choroidal artery from the neck of the aneurysm. Significant atherosclerotic disease involving the cavernous right internal carotid artery and the right middle cerebral artery is also demonstrated. B, Lateral view right internal carotid DSA immediately after detachment of four GDCs measuring a total length of 20 cm demonstrate occlusion of the fundus and dome of the aneurysm. A residual neck remnant (arrow) was intentionally left to preserve the origin of the anterior choroidal artery.

Fig 5.

A 66-year-old woman with Hunt-Hess grade 3 subarachnoid hemorrhage. A, Lateral view left internal carotid DSA demonstrates a 15-mm superior hypophyseal aneurysm. Seven GDCs measuring a total length of 140 cm were detached in the aneurysm. Immediate post-treatment DSA demonstrated persistent opacification of the aneurysm. B, Six-month follow-up lateral view left internal carotid DSA demonstrates a residual aneurysm. The aneurysm was subsequently surgically clipped without complications.

Fig 6.

Graph depicting degree of occlusion at follow-up angiography with respect to initial angiographic result.

Fig 7.

Graph depicting angiographic outcome at longest angiographic follow-up with respect to initial aneurysm size.