5-year Angiographic and Clinical Follow-up of Coil-embolised Intradural Saccular Aneurysms. A Single Center Experience

Abstract

The purpose of the paper is the follow-up of embolised intradural saccular Arterial Aneurysms (AA), excluding giant, dissecting, inflammatory, fusiform or AA associated to BVAM. Since its introduction in 1991, the Guglielmi Detachable Coil has offered protection against aneurysmal rebleeding in the critical few days and months after SAH regardless of the grade. A number of questions remain: is complete angiographic obliteration necessary at first embolisation? What duration of clinical / angiographic follow-up (FU) is required to ensure the risk of haemorrhage has been eliminated? What is the long-term protection against rebleeding? One hundred and two patients with 160 intradural saccular AA embolised before april 1997 were selected for this study. They had at least 5-yrs clinical FU, of which 22 patients had a mid- term (3 years) and 45 patients had a 5-year or more angiographic FU (mean 67,7 months per patient). Twenty-eight embolised AAs with 100% occlusion at 1 year, remained unchanged on the 5-year angiograms. A further 14 patients with complete occlusion at 1 year showed persisting complete occlusion on angiogram at 3-years FU, which in our series means that complete occlusion after the first year post-embolisation implies that the aneurysm will remain completely occluded. All secondary spontaneous thromboses (27.6% of cases), occurred during the first year pos- embolisation. In six patients with subtotal or partial occlusion no change was seen for three consecutive years of FU; none showed later change at 5-year angiography. Below 80% occlusion our series does not provide enough information but we consider the situation instable. No mortality related to the procedure was observed in the unruptured AA group.No bleeding or re-bleeding has occurred since the beginning of our experience (1993) in saccular AA treated by GDC-Coil. Coil-embolisation of properly selected patients is effective in protecting against bleeding or re-bleeding at short and long-term with stable morphological results provided a strict follow-up control is established at short term.

Figure 1

A 39-y-old lady bled from MCA-AA (left parenchimatous haematoma-Fisher IV), with associated unruptured RPcom AA which were embolised in 07/95 and 08/95 respectively (A,B);Note 99-90% occlusion rate of Rpcom AA (mild residual neck) and 80% on LMCA AA (body circulation). Angiograms performed 15-mo later (C,D), 3 years (E,F). Angiograms performed 6 years later (G,H) ilustrate later stability of results when AA kept unchanged for three consecutive years.

Figure 1

A 39-y-old lady bled from MCA-AA (left parenchimatous haematoma-Fisher IV), with associated unruptured RPcom AA which were embolised in 07/95 and 08/95 respectively (A,B);Note 99-90% occlusion rate of Rpcom AA (mild residual neck) and 80% on LMCA AA (body circulation). Angiograms performed 15-mo later (C,D), 3 years (E,F). Angiograms performed 6 years later (G,H) ilustrate later stability of results when AA kept unchanged for three consecutive years.

Figure 1

A 39-y-old lady bled from MCA-AA (left parenchimatous haematoma-Fisher IV), with associated unruptured RPcom AA which were embolised in 07/95 and 08/95 respectively (A,B);Note 99-90% occlusion rate of Rpcom AA (mild residual neck) and 80% on LMCA AA (body circulation). Angiograms performed 15-mo later (C,D), 3 years (E,F). Angiograms performed 6 years later (G,H) ilustrate later stability of results when AA kept unchanged for three consecutive years.

* a 63-year-old man embolised from an unruptured AcoA aneurysm presented a viral and alcoholic cirrhosis; listed to liver transplantation, he died 2 years later due to hepatic insuficiency. * a 45-year-old woman presenting SAH and 4 AA on angiogram, was Eo for 2 AA with immediate 100% and 90% occlusion rate, respectively. She died 10 days later while waiting for neurosurgery for a contralateral MCA AA. At autopsy, it was confirmed that previous embolized AA were intact but MCA aneurysm presented tear of its wall with attached haematoma. ** 1 a 56-year-old man Eo in 1994 from a basilar tip AA died in 09/1998 (4-yrs post Eo) from a massive pulmonary aspiration. 2 a 56-year-old woman with SAH, bled twice within 72 h (the later few minutes before Eo from a basilar tip-AA with a immediate 80% oclusion rate); the patient was Fisher = 4, WFNS = 3 and died 6 days later from a severe vasospasm and generalized infection. 3 a 51-year-old woman Eo from a basilar tip-AA, Fisher = 4, H&H = 2, Eo from a AcomA-AA with a immediate 90% occlusion rate, was neurologically normal 24 h after procedure following by progressive onset of systemic infection, with hypocoagulation state, hypothermia, and refratary arterial hypotension. CT and angiogram failed to demonstrate rebleeding. She died 1 week later from a septicemia. 4 a 41-year-old woman, Fisher = 4, H&H = 2 and severe vasospasm at angiography, Eo from basilar tip-AA and obtained a 80-89% of immediate occlusion rate; 2 days later presented headache with deterioration of her mental status, followed by coma at 4^th post operative day. CT showed no re bleed; presence of diffuse cerebral ischaemia compatible with vasospasm. 5 a 53-year-old woman, Fisher = 4, H&H = 3, WFNS = 3 and severe vasospasm on angiography, was Eo from a MCA-AA with a immediate 80% occlusion rate, with a neurological deterioration at 10^th day post SAH (Glascow Scale = 3/15). CT and angiogram were done: no rebleed was seen but severe ischaemia and vasospasm on MCA territory. She died 2 days later. 6 a 72-year-man, Fisher = 4, H&H = 3, Eo from AcoA-AA with neurologiacal deterioration at 6^th post operative; she was reintubed; CT showed no rebleed. Angiogram showed a diffuse vasospasm and subtotal (95%) occlusion of AA embolised. The patient died at 15^th day from a staphylococcemia and subsequent acute renal insufficiency. 7 a 52-year-old lady died 3 years post Eo due to thyroid carcinoma. + a 73-year-old woman Eo from a ruptured non surgical AcoA-AA, Fisher = 4,WFNS = 4, GS = 6/15, she initially presented cardiac arrest during her SAH; following embolisation she had a fibrinolysis for a throemboembolic event with secondary ICH. She died 1 week later with brain ischaemia secondary to severe vasospasm. *** No rebleeding from a embolised AA during follow-up among patients analysed and treated until 04/1997. However, 01 patient with a large AA treated after this interval of time presented aneurysm recanalisation being recommended re-intervention by endovascular reconstrutive technique after Balloon Test Occlusion or surgical by-pass but the patient refused it, rebled and died few months later.

Figure 2

A 64-year-old lady with multiple unruptured RCarot.-ophthalmic (A) and LPcomA (E) aneurysms (arrows) embolised in 07/96 and 10/97 respectively. A) carotico-ophthalmic AA was embolised achiving (B) immediate complete occlusion; angiographic control showed it unchanged at 3-y (C) and 6-y follow-up (D). C) LPcom AA was embolised with immediate subtotal (99-90%) occlusion (small arrow)of aneurysmal sac (F). Angiogram performed one year later showed spontaneous secundary thrombosis (100%) occlusion (G), unchanged at 5-y FU (H).

Figure 2

A 64-year-old lady with multiple unruptured RCarot.-ophthalmic (A) and LPcomA (E) aneurysms (arrows) embolised in 07/96 and 10/97 respectively. A) carotico-ophthalmic AA was embolised achiving (B) immediate complete occlusion; angiographic control showed it unchanged at 3-y (C) and 6-y follow-up (D). C) LPcom AA was embolised with immediate subtotal (99-90%) occlusion (small arrow)of aneurysmal sac (F). Angiogram performed one year later showed spontaneous secundary thrombosis (100%) occlusion (G), unchanged at 5-y FU (H).

Figure 3

A) a 23-year-old girl had SAH due to left Pcom-AA that was embolised in 10/1996;B) 3 years later the AA kept stable;in 09/2001 the patient rebled and CT showed blood left sided (C);left carotid angiogram (D) showed saccular image (arrowhead) superior and circunjacent to previously cast of embolised aneurysm. Rotational-DSA (E) and 3D-angio (F) confirm de novo AA on Pcom artery supero-medial to previous one. Patient underwent embolisation with immediate complete occlusion of aneurysm (H). Plain X-ray film details two differents embolised aneurysms harboring the same parent vessel (G). Long arrow = lateral AA embolised in 1996;arrowhead = medial de novo AA bled in 2001.

Figure 3

A) a 23-year-old girl had SAH due to left Pcom-AA that was embolised in 10/1996;B) 3 years later the AA kept stable;in 09/2001 the patient rebled and CT showed blood left sided (C);left carotid angiogram (D) showed saccular image (arrowhead) superior and circunjacent to previously cast of embolised aneurysm. Rotational-DSA (E) and 3D-angio (F) confirm de novo AA on Pcom artery supero-medial to previous one. Patient underwent embolisation with immediate complete occlusion of aneurysm (H). Plain X-ray film details two differents embolised aneurysms harboring the same parent vessel (G). Long arrow = lateral AA embolised in 1996;arrowhead = medial de novo AA bled in 2001.