Consecutive Aneurysms Treated by Endovascular Approach

1. Consecutive aneurysms treated by endovascular approach-our experience
Talk at ISNR 2014 (annual conference of Indian Society of Neuroradiology, Delhi)
VipulGupta
NeurointerventionalSurgery
(Interventional Neuroradiology)
Institute of Neurosciences
Medantathe Medicity

2. ANEURYSMS-basic facts
•Subarachnoid hemorrhage(SAH).
•One in every 20 strokes , at the prime of ones life (commonly between 40-50yrs).
•Up to 40-50% patients do not survive even for a month mostly because of the reruptureof the aneurysm
•With proper treatment up to 90% of patient who reach hospital before any major damage has happened will lead an independent and productive lifeInitial CT ScanRebleeding after 1 day

3. ISAT
Randomized, prospective,
international trial
Clipping vs coiling
9559 patients screened, 2143 randomized
at 1 year, the difference in the risk of dependency or death between the two groups was 6.9% and the relative risk reduction was 22.6%(in the coiling group)
ISAT follow-up, Lancet 2009-death at 5 years lowerThe Barrow Ruptured Aneurysm TrialCompared clipping vscoiling in SAH patients. Poor outcome -33.7% in clipping vs23.2% in coiling

4. Guidelines for the Management of AneurysmalSAH: Special Writing Group of the Stroke Council, ASA/AHA Stroke 2009
Amenable to both endovascularcoiling andneurosurgical clipping, endovascular coiling canbe beneficial(Class I, Level of Evidence B).
Metanalysis
•Stroke 2013
•AJNR 2013
•Ruptured aneurysms-better outcomesafter endovascular management

5. In the ISAT and BRAT trials only 39.8% and 62.3% percentage of patients respectively were treated by endovascular approach
•Image-guidance (3-D , Dyna-CT)
•Coil, catheter, balloons, stents
•Drugs-aspirin, clopidogrel, abciximab
•Appx. 90% by endovascular
•Intra-arterial vasospasm mgt.
•HELP and Cerecytestudies –mRS0-2 in 87% (80% in ISAT)

6. Coiling as first choice…
Lubicz B et alof 167 patients treated by coiling as first intention, 87.3% coiled, surgery in 12.7% cases.
(Lubicz B, et alEndovascular treatment of intracranial aneurysms as the first thérapeutic option. J Neuroradiol.2007; 34(4):250-9)
Clarity GDC study-405 patients, 19 French centers, coilig-402 cases, 3 –clipping
(Cognard C,et al, Clarity Study Group. Results of embolization used as the first treatment choice in a consecutive nonselected population of ruptured aneurysms: clinical results of the Clarity GDC study. Neurosurgery.2011;69(4):837)
Multicentre series of 705 ruptured intracranial aneurysms, 96.9% feasibility of the endovascular technique was achieved.
(Sophie Gallas, et al. A Multicenter Study of 705 Ruptured Intracranial Aneurysms Treated with Guglielmi Detachable Coils. AJNR Am J Neuroradiol 2005; 26:17230

7. Our protocol
Interventionist part of neurosurgery team
DSA & if possible embolization
Neurolab with 3D, CT
NS ICU monitoring (TCD/CTP).
Vasospasm-IAVD
N-706 (Sept 2014)
Data of consecutive patients

11. Circumferential involvement-End hole

13. Broad neck , dyplastic aneurysms

16. A
B
C

21. large-/giant aneurysms

22. Data
•Retrospective review of 548intracranial aneurysms
•35 aneurysms in 33 patients -F-19, M-14; 30-68 yrs
•Fisher grade III SAH -22 (66.6%)
•H& H grade-I-III -27 (81.8%)
•EVD/ Lumbar drainage-8 (24.2%)
•<14 days of SAH-26(78.7%)
•
•Wide Neck aneurysms -16
•Dissecting and/or blister aneurysms-19
•Single (28) or double overlapping (5) stents with additional coil placement in 26 aneurysms.

25. Parent vessel occlusion-Cavernous ICA, dissecting (VA), small peripheral

26. Fusiform, dissecting aneurysm

28. 38 yr old male patient, 2-day old SAH
Known hypertensive
Clinically grade II
Small Blister/dissecting Friable, continued growth, re-rupture

29. Classical blister aneurysm
34-year M, SAH

31. Very small aneurysms

34. ? Near the neck rupture/lobule

35. Catheter reposition

36. 1-mm coil

37. Branch from aneurysm-Overinflationtechnique

38. Embolization
Surgery
95%
5%
Good outcome
FND
Mortality
Mgt. outcome in good grade patients- 90 % mRS 0-2

39. The ISAT revealed a complete occlusion rate of 66% (584 of 988) in the coiled patients, whereas other case series of ruptured coiled aneurysms revealed complete occlusion rates ranging from 33% to 81%
Occlussion rate…

40. Complications...
Low ischemic complications -analysis, anti-coagulation (ACT), early use of lytic agents like Abciximib (Reopro) to prevent clinical complication.
Cases of rupture-prevention is the key, rapid response (hypotension, reversal of anticoagulation, coil occlusion of the perforation site, and the use of a balloon to temporarily occlude the artery.)

41. overall death or dependency was 18.0%.
ISAT trial -23.7%,
BRAT trial -20.4%
GDC CLARITY study -23.3%
Outcome…

42. 56 yr old, ischaemic stroke

44. CONCLUSION
>90-95%, with good outcomes –87.6% ( Good grade),
Team work (NS, INR, critical care)
Meticulous technique with protocols
Imaging, technological advances in material, team work, management of SAH related complication such as vasospasm
Limitation -these are the initial management outcomes only

45. Thank you