The aneurysm "clip or coil" debate.
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Clinical Trials as Topic↗
Biomedical subjects
J V Byrne
Publications and source records attributed to J V Byrne.
Distal aneurysms of the unpaired ACA: embryologic and therapeutic aspects.
Anatomical variants of the cerebral arteries in general are frequent and due to the complex ontogenesis of these structures. Although encountered in many mammals, a single anterior cerebral artery (ACA) trunk is an infrequent finding in humans with an incidence of 3-5%. This vessel, giving rise to the arteries of both frontal lobes, is subjected to high flow volumes and distal arterial aneurysms have repetitively been encountered, mostly however before the introduction of endovascular treatment strategies. We report on five patients with acute SAH and arterial aneurysms of an unpaired ACA, who underwent coil embolisation. In all cases endovascular treatment using detachable platinum coils resulted in an at least satisfactory degree of aneurysm obliteration without parent artery occlusion or embolic infarcts. All patients had clinical and angiographic follow-up with median follow-up time of 29 months during which no aneurysm regrowth was encountered. In spite of a small patient group our results suggest, that altered flow dynamics due to enlarged single intracranial vessels may predispose to aneurysm formation and that endovascular embolisation is an appropriate treatment option in distal aneurysms of an unpaired ACA.
Embolization, Therapeutic↗
Cerebrovascular malformations.
The lesions to be considered in this course on cerebrovascular malformations are arteriovenous malformations of the brain, cavernous malformations, capillary telangiectasia and dural arteriovenous fistulas.
Cavernous Sinus↗
Assessment of a technique for 2D-3D registration of cerebral intra-arterial angiography.
This study assesses the ability of a computer algorithm to perform automated 2D-3D registrations of digitally subtracted cerebral angiograms. The technique was tested on clinical studies of five patients with intracranial aneurysms. The automated procedure was compared against a gold standard manual registration, and achieved a mean registration accuracy of 1.3 mm (SD 0.6 mm). Two registration strategies were tested using coarse (128 x 128 pixel) or fine (256 x 256 pixel) images. The mean registration errors proved similar but registration of the lower resolution images was 3 times quicker (mean registration times 33 s, SD 13 s for low and 150 s SD 48 s for high resolution images). The automated techniques were considerably faster than manual registrations but achieved similar accuracy. The technique has several potential uses but is particularly applicable to endovascular treatment techniques.
Algorithms↗
Impact of the international subarachnoid aneurysm trial on radiology.
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Embolization, Therapeutic↗
Embolisation of spinal dural arteriovenous fistulae with Onyx.
Surgery is currently the standard treatment for spinal dural arteriovenous fistulae (DAVF). Endovascular embolisation of these lesions using N-butyl cyanoacrylate (NBCA) has a high success rate. Onyx is a new liquid embolic agent whose viscosity makes it suitable for treatment of spinal DAVF where penetration into the proximal radicular vein is required. It is delivered with greater control than NBCA without the necessity for rapid withdrawal of the catheter and may therefore overcome some of the drawbacks of NBCA. We report two patients who underwent Onyx embolisation of spinal DAVF; to our knowledge this is the first such report.
Angiography↗
Direct cervical vertebro-venous fistula with radiculopathy and MRI changes resolving after successful endovascular embolisation: a report of two cases.
We report two cases of rare direct cervical vertebro-venous fistula (VVF) presenting with chronic radiculopathy as part of the symptom complex. We describe the MRI and intra-arterial angiography findings before and after successful embolisation. These demonstrate occlusion of the fistula with collapse and thrombosis of the draining extradural venous plexus and, in one case, resolution of MRI signal abnormality in the cervical spinal cord.
Adult↗
Acute endovascular treatment by coil embolisation of ruptured intracranial aneurysms.
Over 5 years, 317 consecutive patients were treated by coil embolisation within 30 days of aneurysm rupture. Neurological deteriorations were recorded in 35 patients during the first 48 h after treatment. In 21 patients these were due to procedural complications, which occurred in 31 procedures (9.8%). The timing of treatment relative to the last subarachnoid haemorrhage (SAH) was compared in patients treated after 0-2, 3-7, 8-14 and 15-30 days. No correlation was found in the incidence of such deteriorations and treatment periods, nor with patient's outcomes at 6 months. However, patients treated within 6 days of SAH had better outcomes than those treated later. Patients should, therefore, be treated as soon as possible after presentation since the technique appears less susceptible to the adverse effects of vasospasm in the 3-10 day period after SAH.
Adult↗
A computerised relational database for auditing endovascular treatment of patients with intracranial aneurysms.
We describe the development and design of a database for auditing patients with intracranial aneurysms and their endovascular treatment. The database has been used since 1992. Our department's version now contains records of over 800 patients and well over 1,000 aneurysms. The advantages of a relational database for this type of audit are discussed. Copies of the software can be obtained free of charge from the authors.
Databases, Factual↗
A novel flexible endovascular stent for use in small and tortuous vessels.
We assessed in vivo the mode of delivery, short-term patency and cellular response to a prototype endovascular stent. The stent is designed for delivery through a modified microcatheter and is retrievable with detachment from a delivery wire effected by electrolysis. We successfully deployed 12 stents in a range of sizes from 3-4 mm in straight and angled arteries of pigs. At control angiography 3 and 6 weeks later, nine arteries were patent, two occluded and one narrowed; patency was not related to vessel or stent size. The device shows promise as a stent for intracranial arteries since it can be delivered through microcatheters small enough for intracranial navigation and provides the operator with greater control than currently available self- or balloon-expanded stents.
Animals↗
Glaucoma mimicked by carotid-ophthalmic artery aneurysm: a rare insidious cause of progressive visual loss.
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Adult↗
Effects of timing of coil embolization after aneurysmal subarachnoid hemorrhage on procedural morbidity and outcomes.
OBJECTIVE: To elucidate the effect of treatment timing on procedural clinical outcomes after aneurysmal subarachnoid hemorrhage (SAH) for patients treated by endosaccular coil embolization. METHODS: A group of 327 patients who were consecutively treated, during a 46-month period, for ruptured intracranial aneurysms by coil embolization within 30 days after SAH were evaluated. Outcomes were assessed by comparing immediate pretreatment World Federation of Neurological Surgeons (WFNS) grades, 72-hour posttreatment WFNS grades, and modified Glasgow Outcome Scale scores at 6 months for patients treated within 48 hours (Group 1), 3 to 10 days (Group 2), or 11 to 30 days (Group 3) after SAH. RESULTS: The three interval-to-treatment groups included 33, 38, and 29% of the patients, respectively. Before treatment, 70% of the patients in Group 1, 78% of those in Group 2, and 83% of those in Group 3 were in good clinical grades (i.e., WFNS Grade 1 or 2). After coil embolization, the WFNS grades were either unchanged or improved for 93.5% of the patients in Group 1, 89.5% of those in Group 2, and 91.5% of those in Group 3. After 6 months, 81.3% of the patients in Group 1 experienced good outcomes (modified Glasgow Outcome Scale scores of 1 or 2), as did 84% of those in Group 2 and 80% of those in Group 3. No statistical difference was demonstrated between the three groups when they were compared for these two variables. CONCLUSION: The interval between endovascular treatment and SAH did not affect periprocedural morbidity rates or 6-month outcomes. Coil embolization should therefore be performed as early as possible after aneurysmal SAH, to prevent aneurysmal rerupture.
Adolescent↗
Audit of selected patients with nonfunctioning pituitary adenomas treated without irradiation - a follow-up study.
OBJECTIVE: Non-functioning pituitary adenomas (NFA) are the commonest type of pituitary macroadenoma. Although the initial definitive management of these tumours is almost always trans-sphenoidal surgery, the use of postoperative radiotherapy remains controversial. Radiotherapy has been shown to significantly reduce the risk of tumour regrowth. An audit of patients with NFAs treated with trans-sphenoidal surgery without irradiation was performed at our centre five years ago, and suggested that careful selection and follow-up could avoid the need for adjuvant radiotherapy. We have repeated this audit to assess the longer term effects of this management strategy. METHODS AND PATIENTS: The case notes and imaging of the original cohort of 65 of 73 patients (50 males, mean age 52) who had undergone trans-sphenoidal surgery (TSA) for NFA between July 1979 and 1992, had not received irradiation and were followed up by imaging were reviewed. Tumour regrowth was defined as enlargement of the pituitary tumour. Mean follow-up was 76 months (range 12-173). RESULTS: Pituitary tumour regrowth has occurred in 21 of the 65 patients (32%) during a mean follow-up of 76 months compared with 8/73 (11%) in 1994 (P = 0.002). The tumour regrowth was detected at a mean of 5.4 years (range 2-14 years). Lifetable analysis of the whole unirradiated group showed 82% recurrence free survival at 5 years (95% confidence limits 72-92%), and 56% at 10 years (95% confidence limits 38-74%). Eight (12%) patients required a second surgical procedure (6 TSA and 2 craniotomies). There was no relationship between recurrence and whether a total surgical removal was thought to have been performed. CONCLUSION: Despite careful selection of patients with non-functioning pituitary adenomas, tumour regrowth occurs in a significant proportion. These results show that continued follow-up in these patients is essential as significantly more patients showed evidence of tumour regrowth at this second assessment compared with the 1994 data. Until we are able to predict which tumours are likely to regrow postoperatively, radiotherapy should be considered for all patients with non-functioning pituitary adenomas as even in carefully selected cases, the regrowth rate is approaching 50% at 10 years.
Adenoma↗
Determining x-ray projections for coil treatments of intracranial aneurysms.
The endovascular coil embolization of intracranial saccular aneurysms requires a set of specific X-ray images with which to view the aneurysm during coiling. These two-dimensional (2-D) images, known as working projections, should be optimal for measuring the aneurysm sac diameter, inserting the first coil, and checking coil overhang into the surrounding vessels. At present the gantry tilt that produces these images is found by the radiologist by trial and error. In this paper, we present a method for automatically finding the angles that will produce the desired X-ray projections. Our method consists of four steps: 1) finding the location and orientation of the aneurysm neck; (2) labeling the aneurysm sac; 3) determining the optimal tilts for viewing the aneurysm during coiling; and 4) adjusting the optimal tilts for change in the patient orientation between pre-Guglielmi detachable coil (GDC) scanning and the coiling treatment. We discuss these steps and present results of the algorithm applied to pathological examples in the form of simulated X-ray images. A final discussion is given for one example where our results have been applied in a clinical situation.
Algorithms↗
Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding.
OBJECT: During a 5-year period 317 patients presenting with aneurysmal subarachnoid hemorrhage were successfully treated by coil embolization within 30 days of hemorrhage. The authors followed patients to assess the stability of aneurysm occlusion and its longer-term efficacy in protecting patients against rebleeding. METHODS: Patients were followed for 6 to 65 months (median 22.3 months) by clinical review, angiography performed at 6 months posttreatment, and annual questionnaires. Stable angiographic occlusion was evident in 86.4% of small and 85.2% of large aneurysms with recurrent filling in 38 (14.7%) of 259 aneurysms. Rebleeding was caused by aneurysm recurrence in four patients (between 11 and 35 months posttreatment) and by rupture of a coincidental untreated aneurysm in one patient. Annual rebleeding rates were 0.8% in the 1st year, 0.6% in the 2nd year, and 2.4% in the 3rd year after aneurysm embolization, with no rebleeding in subsequent years. Rebleeding occurred in three (7.9%) of 38 recurrent aneurysms and in one (0.4%) of 221 aneurysms that appeared stable on angiography. CONCLUSIONS: Periodic follow-up angiography after coil embolization is recommended to identify aneurysm recurrence and those patients at a high risk of late rebleeding.
Adult↗
Factors influencing successful angiographic occlusion of aneurysms treated by coil embolization.
BACKGROUND AND PURPOSE: Coil embolization of berry aneurysms is a relatively new treatment whose long-term efficacy has yet to be established. The purpose of this study was, first, to attempt to identify factors that might be important in predicting success both at the time of treatment and at the time of follow-up angiography, and, second, to study changes in the aneurysm between treatment and follow-up to determine the frequency of these changes. METHODS: The pretreatment, posttreatment, and follow-up angiograms of the first 63 aneurysms (in 58 patients) treated at our institution between June 1992 and April 1995 were analyzed, and the percentage of occlusion of each aneurysm was calculated. The size of any rest was noted for the posttreatment and follow-up angiograms. Treatment success was defined as a residue of less than 2 mm. Aneurysms were said to have changed if the percentage of occlusion had altered by more than 2.5% or if the difference in rest size was greater than 0.25 mm. Possible factors influencing primary and follow-up success rates were correlated against these calculations. RESULTS: Success rates at treatment and follow-up were 71% and 65%, respectively. No change occurred in 41% of aneurysms, and 20% had a decrease in size of the residue. Twenty-eight percent had coil compaction, and 11% had aneurysmal growth. Neck size was the only significant variable in primary treatment success. Success at follow-up correlated significantly with neck size, initial treatment success, vasospasm at the time of treatment, and clinical presentation. CONCLUSION: Best long-term angiographic results are obtained when the primary treatment is successful, when the aneurysm is small and narrow-necked, when the acutely ruptured aneurysm is treated within 15 days of ictus, and with anterior communicating and basilar-tip aneurysms.
Adolescent↗
The porous, guidewire-directed, detachable aneurysm liner: a new concept in the endovascular treatment of intracranial aneurysms.
A new device for the endovascular treatment of aneurysms is described. It consists of a guidewire-directed porous liner or bag, detachably mounted on a microcatheter and designed to be inserted into an aneurysm and to be filled with detachable coils or other embolic agents. Several prototypes have been made. Preliminary in vitro and in vivo experiments have demonstrated its behavior in relatively wide-necked aneurysms.
Animals↗
Giant fusiform basilar artery aneurysm: endovascular treatment by flow reversal in the basilar artery.
We report a patient presenting with subarachnoid haemorrhage due to rupture of a giant fusiform aneurysm of the proximal basilar artery. The aneurysm was successfully treated by reversing blood flow in the basilar artery by balloon occlusions of both vertebral arteries proximal to the posterior inferior cerebellar artery origins. Substantial thrombosis and regression of the aneurysm was evident 4 months later.
Adolescent↗