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Alexandria University , Faculty of medicine Neurology Depart. Egypt. Department of Neuroradiology, Neurocenter University of Freiburg, Germany. O Mansour, J Weber and M Schumacher Neuroradiology Depart. Freiburg Univ. Neurology Depart. Alexandria Univ. Unruptured MCA aneurysm coiling.

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Presentation Transcript
slide1

Alexandria University , Faculty of medicine Neurology Depart. Egypt

Department of Neuroradiology, Neurocenter

University of Freiburg, Germany

O Mansour, J Weber and M Schumacher

Neuroradiology Depart. Freiburg Univ.

Neurology Depart. Alexandria Univ.

Unruptured MCA aneurysm coiling

slide2

Endovascular coiling of MCA aneurysms has shown higher procedural failure rate and less favorable results compared to the treatment of aneurysms at other sites (ISAT group, Lancet 2002; Suzuki S,Neurosurgery 2009)

  • In ruptured MCA aneurysms, subgroup analysis of ISAT in older patients more than 65 years revealed inferiority of coiling to clipping (Ryttlefors M, Stroke 2008)
elderly patients with ruptured mca aneurysms benefit more from neurosurgical clipping
Elderly patients with ruptured MCA aneurysms benefit more from neurosurgical clipping.

M Ryttlefors et al , Stroke 2008

another hindering factor is what is called the wild morphological gallery of mca aneurysm
Another hindering factor is what is called the wild morphological gallery of MCA aneurysm

Reasons for less favorable outcome :

ICH more often associated with ruptured MCA aneurysms

slide9

•In the treatment of unruptured intracranial aneurysms endovascular coiling has shown equal or superior results to clipping (Higashida RT, AJNR 2007)

unruptured

  • But for unruptured MCA aneurysms coiling has been limited, mainly due to the unfavorable aneurysm geometry (wide neck and/or incorporation of a branch into the neck) (Doerfler A , AJNR 2006)
slide10

Modified endovascular techniques and devices, such as multi-catheter, balloon-assisted, stent-assisted, or combination of these, permit coiling even of aneurysms having a complex anatomy (Lubicz B, AJNR 2006)

methods and patients
Methods and patients
  • Patients with mild neurological deficit (mRS, 0 - 2) were included
  • Former SAH from another aneurysm
  • Who accidentally discovered during non hemorrhagic neurological manifestation
  • Between 2001-2009 retrospectively 70 patients with 76 unruptured MCA aneurysms were included, reviewed and evaluated .
  • 30 men and 40 women aged from 27 to 77 years (mean, 59 years)
results1
Results

Table 1: aneurysms measurements and endovascular methods used in occlusion .

Aneurysm distribution site(n=75)

Treatment methods (n=75)

slide15

Coiling failed in 1/76 = 1.3%

Complication rate was in 1/76 = 1.4% (perforation and treated without sequlae )

Death rate was in 1/76 = 1.4% ( SAH consequence

Failure Rate

Mortality

Rate

Procedural complications

Morbidity

Rate

infarction occurred in relevant MCA territory in 2 patients, but both of them completely recovered at discharge

permanent morbidity

1/76=1,4%

follow up angiographies at least once at 6 24 months mean 11 months period of follow up
Follow-up angiographies at least once at 6 – 24 months (mean, 11 months) period of follow up.

69/75 aneurysm (92%)

Mori et. al. classification

3 (4.3%) major recurrences

6 (8.6%) minor recurrences

retreated by coiling without any complication.

slide22

MCA aneurysms should not be allocated solely to clipping but only the large MCA aneurysms in young patients, which are likely to recur

some limitations are present in this series
Some limitations are present in this series
  • Small, unruptured MCA aneurysms were treated. (randomized retrospective study)
  • Because of the retrospective nature of this study, another limitation is selection bias
  • Limited number of angiographic follow-up may have lowered the recurrence rate
introduction
Introduction
  • Since intracranial subarachnoid aneurysm trial (ISAT),[1] endovascular coiling has been increasingly used as first treatment option for ruptured or unruptured aneurysms that are feasible for coiling.
  • Intracranial subarachnoid aneurysmal trial (ISAT) proved the superiority of endovascular coiling for the treatment of ruptured intracranial aneurysms over microsurgical clipping.
mca aneurysm state of the art mangement
MCA aneurysm State Of the Art Mangement

Ruptured

  • However, for the middle cerebral artery (MCA) aneurysms, endovascular coiling is less likely to be applied as routine agreement
in ruptured mca aneurysms
in ruptured MCA aneurysms
  • The most widely accepted theory presumed to be responsible for the inconvenient outcome
    • Hematoma frequently associated with ruptured MCA aneurysm may be a cause of unfavorable outcome of coiling, because coiling itself cannot remove the hematoma.
mcaa unique morphology gallery
MCAa Unique Morphology Gallery
  • The aneurysm geometry unfavorable for coiling, which is frequently met in MCA aneurysms, can be another factor.
follow up angiographies at least once at 6 24 months mean 11 months period of follow up1
Follow-up angiographies at least once at 6 – 24 months (mean, 11 months) period of follow up.

69/75 aneurysm (92%)

60 (87.1%) major recurrences

Mori et. al. classification

3 (4.3%) major recurrences

6 (8.6%) minor recurrences

retreated by coiling without any complication.