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Original Article
Endovascular management of giant aneurysms: An introspection Zhenhai Zhang, Xianli Lv1, Xinjian Yang1, Shiqing M. U.1, Zhongxue Wu1, Chunsen Shen, Ruxiang Xu Affiliated Bayi Brain Hospital, Military General Hospital of Beijing PLA, 1Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
ABSTRACT Aims: To evaluate the outcome of giant intra‑dural aneurysms managed with endovascular techniques. Materials and Methods: We retrospectively reviewed a series of 39 consecutive giant intra‑dural aneurysms. The technical feasibility of endovascular treatment, its complications, the angiographic results and the clinical outcome were assessed. Logistic regression analysis was performed to evaluate for predictors of a poor outcome. Results: Nine patients were left untreated. During a 30 month follow‑up, four of them (44.4%) died and two (22.2%) deteriorated. Thirty aneurysms (12 located in the anterior circulation and 18 located in the posterior circulation) were treated using endovascular methods. Of these, 11 were treated by parent vessel occlusion, 11 by stent‑assisted coiling, one using only coils, six using solely a stent, and, one using both coils and onyx. During a 28 month follow‑up, seven (23.3%) patients died and two (6.7%) patients experienced permanent neurological deficits. The mortality and morbidity in the endovascular group seemed lower than that in the untreated group (P = 0.045, 30% vs. 66.7%). There was no difference in the results of endovascular treatment between giant intra‑dural aneurysms located in the posterior and the anterior circulation. Conclusions: Giant intra‑dural aneurysms, whether treated or not, may have a poor clinical outcome. The outcome following endovascular treatment of these lesions is better than its natural history when left untreated. However, endovascular treatment may often be associated with high complication rates and a low chance of cure. Key words: Endovascular treatment; follow‑up; giant aneurysms; untreated
Introduction Giant aneurysms have a diameter that exceeds 2.5 cm.[1,2] Their natural history, when left untreated, is quite dismal.[3,4] In a prospective study, Drake et al.[5] reported that 15 of the 18 patients with untreated giant aneurysms died or experienced severe morbidity as a direct result of complications caused by the aneurysm. Until recently, very few large series had focused on comparing the outcome in patients who were treated for their giant intra‑dural aneurysms versus those in Access this article online Website: www.neurologyindia.com DOI: 10.4103/0028-3886.156278 PMID: xxxxx
Quick Response Code
whom the aneurysm was left untreated[6,7] The goal of the present study is to investigate the risk factors and outcome of giant intra‑dural aneurysms who were either treated with endovascular techniques or left untreated.
Materials and Methods A total of 39 consecutive patients with a giant intra‑dural aneurysm were enrolled between January 2006 and March 2012 at our center. All patients underwent a cerebral digital subtraction angiography with balloon occlusion test (BOT). Tolerance to test occlusion was assessed by a detailed neurologic examination consisting of evaluation of cranial nerve function, muscle strength and language ability every 5 min or when a deficit was perceived. If the patient tolerated 20 min of normal tension, the balloon was deflated for 10 min and then the test was repeated under hypotension for another 20 min. Hypotension was induced by the infusion of sodium
Address for correspondence: Dr. Zhongxue Wu, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Tiantan, Xili, 6, Dongcheng, Beijing, 100050, China. E‑mail: [email protected]
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Neurology India / March 2015 / Volume 63 / Issue 2
[Downloaded free from http://www.neurologyindia.com on Thursday, May 07, 2015, IP: 61.16.135.116]
Zhang, et al.: Endovascular management of giant aneurysms
nitroprusside (2.5–7.5 mg/kg body weight/min). After the mean arterial pressure was reduced to two‑thirds of the baseline, hypotension was maintained for 20 min provided that the mean arterial blood pressure was not less than 55 mmHg. If the patient tolerated BOT under hypotension, he/she was considered clinically able to tolerate parent vessel occlusion (PVO). The test was terminated immediately if any neurologic deficit developed during test occlusion under normotensive or hypotensive conditions. Patients who could tolerate the BOT were treated by PVO, and those who could not tolerate the BOT were treated using a stent/coil. Peri‑procedure medications When the use of a stent was planned, the patients were pre‑medicated with anti‑platelet therapy consisting of aspirin 100 mg and clopidogrel 75 mg for 3 days before the procedure. After the procedure, clopidogrel (75 mg/day) was recommended for an additional 30 days and aspirin (100 mg/day) was recommended for 6 months. After the PVO, the patients were treated with hypervolemia. Results and outcome evaluation The degree of the aneurysmal occlusion was classified as complete obliteration, neck remnant or incomplete occlusion. The length of the angiographic follow‑up period was 9.3 ± 10.5 months (range, 3–39 months). The clinical follow‑up (6–71 months, 28.2 ± 18.1 months) was assessed by the Modified Rankin Scale (mRS) scores at the last follow up visit or by a telephone call. Statistical analysis Logistic regression analysis was performed to evaluate the association between sex, age (younger than 60 years vs. 60 years and older), clinical presentation, aneurysmal size (
Original Article
Endovascular management of giant aneurysms: An introspection Zhenhai Zhang, Xianli Lv1, Xinjian Yang1, Shiqing M. U.1, Zhongxue Wu1, Chunsen Shen, Ruxiang Xu Affiliated Bayi Brain Hospital, Military General Hospital of Beijing PLA, 1Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
ABSTRACT Aims: To evaluate the outcome of giant intra‑dural aneurysms managed with endovascular techniques. Materials and Methods: We retrospectively reviewed a series of 39 consecutive giant intra‑dural aneurysms. The technical feasibility of endovascular treatment, its complications, the angiographic results and the clinical outcome were assessed. Logistic regression analysis was performed to evaluate for predictors of a poor outcome. Results: Nine patients were left untreated. During a 30 month follow‑up, four of them (44.4%) died and two (22.2%) deteriorated. Thirty aneurysms (12 located in the anterior circulation and 18 located in the posterior circulation) were treated using endovascular methods. Of these, 11 were treated by parent vessel occlusion, 11 by stent‑assisted coiling, one using only coils, six using solely a stent, and, one using both coils and onyx. During a 28 month follow‑up, seven (23.3%) patients died and two (6.7%) patients experienced permanent neurological deficits. The mortality and morbidity in the endovascular group seemed lower than that in the untreated group (P = 0.045, 30% vs. 66.7%). There was no difference in the results of endovascular treatment between giant intra‑dural aneurysms located in the posterior and the anterior circulation. Conclusions: Giant intra‑dural aneurysms, whether treated or not, may have a poor clinical outcome. The outcome following endovascular treatment of these lesions is better than its natural history when left untreated. However, endovascular treatment may often be associated with high complication rates and a low chance of cure. Key words: Endovascular treatment; follow‑up; giant aneurysms; untreated
Introduction Giant aneurysms have a diameter that exceeds 2.5 cm.[1,2] Their natural history, when left untreated, is quite dismal.[3,4] In a prospective study, Drake et al.[5] reported that 15 of the 18 patients with untreated giant aneurysms died or experienced severe morbidity as a direct result of complications caused by the aneurysm. Until recently, very few large series had focused on comparing the outcome in patients who were treated for their giant intra‑dural aneurysms versus those in Access this article online Website: www.neurologyindia.com DOI: 10.4103/0028-3886.156278 PMID: xxxxx
Quick Response Code
whom the aneurysm was left untreated[6,7] The goal of the present study is to investigate the risk factors and outcome of giant intra‑dural aneurysms who were either treated with endovascular techniques or left untreated.
Materials and Methods A total of 39 consecutive patients with a giant intra‑dural aneurysm were enrolled between January 2006 and March 2012 at our center. All patients underwent a cerebral digital subtraction angiography with balloon occlusion test (BOT). Tolerance to test occlusion was assessed by a detailed neurologic examination consisting of evaluation of cranial nerve function, muscle strength and language ability every 5 min or when a deficit was perceived. If the patient tolerated 20 min of normal tension, the balloon was deflated for 10 min and then the test was repeated under hypotension for another 20 min. Hypotension was induced by the infusion of sodium
Address for correspondence: Dr. Zhongxue Wu, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Tiantan, Xili, 6, Dongcheng, Beijing, 100050, China. E‑mail: [email protected]
184
Neurology India / March 2015 / Volume 63 / Issue 2
[Downloaded free from http://www.neurologyindia.com on Thursday, May 07, 2015, IP: 61.16.135.116]
Zhang, et al.: Endovascular management of giant aneurysms
nitroprusside (2.5–7.5 mg/kg body weight/min). After the mean arterial pressure was reduced to two‑thirds of the baseline, hypotension was maintained for 20 min provided that the mean arterial blood pressure was not less than 55 mmHg. If the patient tolerated BOT under hypotension, he/she was considered clinically able to tolerate parent vessel occlusion (PVO). The test was terminated immediately if any neurologic deficit developed during test occlusion under normotensive or hypotensive conditions. Patients who could tolerate the BOT were treated by PVO, and those who could not tolerate the BOT were treated using a stent/coil. Peri‑procedure medications When the use of a stent was planned, the patients were pre‑medicated with anti‑platelet therapy consisting of aspirin 100 mg and clopidogrel 75 mg for 3 days before the procedure. After the procedure, clopidogrel (75 mg/day) was recommended for an additional 30 days and aspirin (100 mg/day) was recommended for 6 months. After the PVO, the patients were treated with hypervolemia. Results and outcome evaluation The degree of the aneurysmal occlusion was classified as complete obliteration, neck remnant or incomplete occlusion. The length of the angiographic follow‑up period was 9.3 ± 10.5 months (range, 3–39 months). The clinical follow‑up (6–71 months, 28.2 ± 18.1 months) was assessed by the Modified Rankin Scale (mRS) scores at the last follow up visit or by a telephone call. Statistical analysis Logistic regression analysis was performed to evaluate the association between sex, age (younger than 60 years vs. 60 years and older), clinical presentation, aneurysmal size (
