Self-expandable stent-assisted coiling of wide-necked intracranial aneurysms: a single-center experience

Abstract

Background and purpose: Endovascular treatment of wide-necked aneurysms remains a therapeutic challenge. We conducted this study to evaluate the angiographic results and clinical outcome of patients treated with stent-assisted coiling by using a recently available self-expandable intracranial stent.

Methods: A retrospective review of all patients treated with self-expandable stent-assisted coiling between September 2002 and December 2003 was done. Treatment was attempted in 32 patients with 35 aneurysms. Four of the aneurysms were ruptured. All had either a dome-to-neck ratio less than 2 and/or a neck diameter of 5 mm or larger. Following stent placement, coiling was attempted in 33 of 34 aneurysms. The technical success of the procedure, procedure related complications, and the angiographic results were documented.

Results: In 34 of 35 aneurysms, stent deployment across the neck of the aneurysm was successful. Coiling was performed successfully in 30 of 33 aneurysms. In 20 aneurysms, immediate posttreatment angiography showed either total (17%) or satisfactory (50%) occlusion. Procedure-related mortality occurred in one patient (3.1%). Adverse events occurred in eight patients (25%); in three of them permanent neurologic deficit resulted (9.3%). In six patients, thrombus formation occurred within the stented segments during the procedure and reopro infusion was used. Follow-up angiography was available in 12 (40%) of 30 treated aneurysms.

Conclusion: In our practice use of the self-expandable stent seemed to facilitate endovascular treatment of wide-necked intracranial aneurysms. Difficulty of deployment and stent thrombogenicity are the main drawbacks of the system.

Fig 1.

Schematic illustration of Neuroform-assisted embolization of a wide-necked superior hypophyseal aneurysm. A, Microcatheter containing the stent was positioned over the wire distal to aneurysm location. B, The stent was deployed by holding the stabilizing catheter in a fixed position while the 3F catheter was pulled back. C and D, Interstices of fully expanded stent can easily accommodate microcatheter for coiling. Protrusion of coil loops in to internal carotid artery is prevented by the stent.

Fig 2.

Case 8. A, Pretreatment lateral carotid angiography shows a broad-necked superior hypophyseal aneurysm of the right internal carotid artery. B, Stent delivery system is advanced distal to the aneurysm over microguidewire. Distal marker of the stent delivery catheter, proximal and distal markers of the stent itself within the catheter are visible. C, Lateral fluoroscopic view shows the stent in the cavernous internal carotid artery, covering the orifice of the aneurysm. D, Late arterial phase of lateral carotid angiography obtained after the stent deployment shows contrast extravasation, which is confirmed by CT (E) also. F and G, The second session of embolization performed 3 weeks later failed because of the persistent protrusion of the coils into the internal carotid artery.

Fig 3.

Case 10. A, Left vertebral angiography obtained 6 months after previous surgery shows residual filling of the basilar tip aneurysm and additional right vertebral artery aneurysm close to the origin of the posterior inferior cerebellar artery. Right posteriocerebral artery is supplied by the right carotid circulation via right posterior communicating artery (not shown). B, Fluoroscopic road map image during embolization with balloon remodeling technique and postembolization right vertebral angiogram (C) shows satisfactory occlusion of the aneurysm with small neck remnant, especially on the right side. D, Follow-up angiography 22 months after the embolization reveals recanalization and regrowth of the aneurysm. E, After placement of Neuroform stent extending from the left posterior communicating artery to the distal basilar artery recanalized portion of the aneurysm embolized with multiple coils. F, Proximal and distal markers of second Neuroform stent, placed across the right vertebral artery aneurysm, are seen. After insertion of the first coil into the aneurysm, lumen flow within the right posterior inferior cerebellar artery is diminished. The coil is retracted and embolization is abandoned.

Fig 4.

Case 3. A, Left carotid angiogram obtained after deployment of Neuroform stent shows broad-necked aneurysm originating from the lateral wall of the internal carotid artery at the level of ophthalmic artery. B, Advancement of the first coil in to the aneurysm through interstices of the stent. C, Total occlusion of the aneurysm is seen on postembolization anteroposterior left carotid angiography. D, On lateral view, ill-defined filling defects consistent with significant amount of fresh thrombus is seen within the stented segment of the left internal carotid artery proximal to aneurysm. Partial and complete lysis of the clot is seen on angiograms obtained 15 minutes (E) and 24 hours (F) after starting the intravenous abciximab protocol.