CLIPPING OR COILING FOR MCA ANEURYSM

VIPUL GUPTANEUROINTERVENTION SURGERY, MEDANTA THE MEDICITY

• Long standing debate …

• Likely to continue …

Acknowledgement

CLIPPING OR COILING FOR MCAa

Which one to choose ?

• PROTECTION

• SAFETY (Preservation of parent, branching, and perforating arteries)

My approach …

• Randomized trials• Meta- analysis • Community data • Trends• Our data• Evolution – current status

Lancet 2014

• Independent survival (coiling) – Odds – 1.34

• Rebleeding - likely after coiling (small risk) but disability-free survival was significantly greater in the endovascular group at 10 years

Rebleeding –

extremely

rare after 1 yr

Clipping vs coiling in SAH

N- 472

Poor outcome (1 year)

33.7% (clipping) vs 23.2% (coiling)

2012

Learning from BRAT….Results in good grade-

• 9.4% - coil therapy , 19.8% - surgical clipping

• 23.5% and 30.9%, in the ISAT

• Results have improved dramatically more so in coiling group

• Repeat treatmnet – 10.5 % vs 5%

• Rebleeding – no recurrent hemorrhages in the patients treated with coils is notable. During the 1st year of the ISAT, rehemorrhage occurred in 20 (4.2%) of the patients assigned to the coil embolization group

Stroke Council (AHA) update 2012

Guidelines for the Management of Aneurysmal SAH

Class I recommendation:

“For patients with ruptured aneurysms judged to be technically amenable to both endovascular coiling and microneurosurgical clipping, Endovascular coiling

should be considered.”

• N - 5229 patients, 125 hospitals

• Clipping frequency decreased -27% in 2006 to 21% in 2011.

• With clipping (unfavorable outcome)

– Discharge to long-term care : OR – 1.3 (p-0.0006)

– Ischemic complications: 1.5 (p-0.0009)

– neurologic complications : 1.6 (p-0.00018)

– surgical complications : 1.5 (p-0.024)

AJNR 2014

Ruptured aneurysm 2006 - 27%2011- 21%

Unruptured aneurysm 2001 - 80%2008 - 37%

3 prospective controlled trials, N - 2723 patients.

Meta-analysis - Rate of poor outcome at 1 year was significantly lower in patients

allocated to coil embolization (risk ratio, 0.75; 95% confidence interval, 0.65– 0.87).

Absolute risk reduction of 7.8% and a number needed to treat of 13.

Rebleeding rates within the first month were higher in coil embolization.

AJNR 2013

Retrospective analysis of a prospectively acquired data base.

Ruptured aneurysms – 244

Occlusion – 91.4%

Favorable outcome – 79.4%

Complication – 2.9%

Unruptured (favorable outcome): 97% VS 97.2%

.

Ruptured (favorable outcome): 77.1% Vs 72.1% in favor of coiling

FEASIBILITY AND SUCCESS RATE

• Mortimer et al ( AJNR, 2014): N - 300 MCA ; consecutive

Feasible - 93 %

• Quadros RS et al (AJNR, 2007): N - 55 MCA

Feasible – 91.7%

• Vendrell et al (Radiology, 2009) N -174 MCA

Feasible - 92%

• Suzuki et al (Neurosurgery, 2009); N -115 MCA

Feasible – 93%

91 – 93%

OCCLUSION AND RETREATMENT RATES

Zaidat et al.Neurosurg Clin N Am 25 (2014) 455–469

Feasibility: 95%%Obliteration rates: 83% - 95%Retreatment: 1.8% - 7.6%

MORBIDITY AND MORTALITY AND REBLEEDING RATE

• Mortimer et al ( AJNR, 2014): N - 300 MCA (R – 80%) ; consecutive

M&M - 7.8%

• Vendrell et al (Radiology, 2009) N -174 MCA (R – 59.2%)M&M - 5.7%

• Suzuki et al (Neurosurgery, 2009); N -115 MCA (R – 36%)M&M - 9.9%

M&M – 5.7% to 9.9%

Embolization

Surgery

95%

5%

Good outcome

FND

Mortality

Mgt. outcome in good grade patients- 87.6 % mRS 0-2

Recent data : Between Jan 2006 to Dec 2015, No of MCA aneurysm endovascularly treated has been increased from 55 to 162

Improvements in • Long Sheaths• Guide catheters• Distal access catheters• Microcatheters• Ultrasoft complex Coils• Microcoils (1,1.5,2 mm)• Compliant balloons – 14 wire • Self-expanding stents • Microstents• Flow divertor

What makes unfavorable aneurysmal necks or

morphology to be treated by Endovascular means?

MCA bifurcation incorporating inferior division

Choice of artery …MCA bifurcation incorporating both division

RIGHT MCA BIFURCATION BILOBED ANEURYSM

Blister like aneurysm

Very small aneurysm –

A 16-year-old boy presented with 4-day old SAH (WFNS Grade II)

A B C

DYSPLASTIC BIFURCATION ANEURYSMS –double balloon technique

Fusiform , ? Dissecting aneurysm

Near the neck lobule/rupture

When do we don’t 1.Hematoma 2.Dysplastic3.Clot in aneurysm4.Giant dissecting partially thrombosed5.Distal Fusiform

70 YRS OLD PATIENT PRESENTED WITH RIGHT SYLVIAN FISSURE HEAMTOMASENT FOR CLIPPING

Most probably partially thrombosedWill need stent…. Will recur

56 yr old, ischaemic stroke

53yrs old patient presnted with MRI left temporal lobe hematoma-? tumour bleed / ?vascular

Stent assisted coiling of left MCA residual/

recurrent aneurysm

Distal MCA aneurysm

• Rare (ranged 2–6% cerebral aneurysms).

• May be infectious aneurysm. (History and workup)

• Microneurosurgical treatment-challenging.

• ET – Effective with high occlusion rate and low complication

• Isuues: Difficult to localize during the operation

Lack of collateral circulation makes their occlusion more demanding.

High rate of ICH and rebleeding demanding Emergency management

AT OUR INSTITUTION

• Neurointerventionalists and open surgeons are Good partners

• Decisions taken in patient interest

• Right of first attempt goes to Neurointerventionalistunless aneurysms are clearly noncoilable

NEW ENDOVASCULAR DEVICES

Y stent-assisted coiling of a MCA aneurysm with double LVIS Jr. microstent

Deployment of the LVIS Jr. microstent in various single- or double-stent configurations safe and effective to assist the treatment of intracranial wide-neck aneurysms

FLOW DIVERTOR PLACEMENT IN M1-M2 BIFURCATION ANEURYSM

Endovascular treatment with FDD is arelatively safe treatment for small MCA aneurysms resulting in a high occlusion rate.The findings of this study suggestthat complete occlusion after endovascular treatment with FDD can be delayed (>6 months)

PED being used to successfully treat a fusiform aneurysm at the M3-M4 junction of the MCA.

LUNA (Covidien Vascular Therapies, Irvine, California, USA)

WOVEN ENDO-BRIDGE (SequentMedical, Aliso Viejo, California, USA)

Cerebral angiography before and after treatment of a MCA aneurysm with the WEB, demonstrating aneurysm obliteration.

Starke RM, et al. Technology developments in endovascular treatment of intracranial aneurysms. J NeuroIntervent Surg 2016;8:135–144.

Early experience withthe Pulse Rider device - Safe and Effective as an adjunct in the treatment of bifurcation aneurysms arising at the basilar apex or carotid terminus

-New pCONus device opens like a blossomingflower inside of the aneurysm to facilitate the waffle cone technique. -In a case with tandem unruptured broadbased MCA bifurcation aneurysms- two pCONusdeployed in Y configuration, offering stable neck coverage for coiling both aneurysms.

-Novel treatment strategy where a mesh delivered through a 0.021 inch microcathetercan be deployed and allow for temporary neck bridging in aneurysm coiling-20 rabbits were studied. Twelve rabbits were treated with the Comaneci device and eight with the Hyperglide balloon.-Conclusions- The Comaneci device is a new adjuvant treatment for bridging of wide necked aneurysms with the advantage of averting flow arrest during deployment.No evidence of significant endothelial damage during deployment in preclinical studies.

Conclusions

Favorable outcomes more likely in institutions that • Treat high volumes of patients with SAH• Offer both Endovascular and open surgery services However – Biplane, 3DRA, Balloon, Stent,FD, Expertsie

essential

Neurointerventionalists and open surgeons should act as partners, not competitors

Consideration for placement of an EVD drain in poor grade patients or in patients with increasing ventricles size before systemic heparinization associated with ET.

At last , Literature values are other teams’ results.

MISCONCEPTION OVER HEMATOMA

• Bias toward hematoma evacuation and clipping in the same session.

• Actually, this approach result in an increased risk of intraoperative aneurysm rupture due to detamponading

• And the hematoma may make access to the aneurysm neck more complex

• Alternatively, performing coiling before evacuationmay provide protection against detamponading

Zaidat et al. Middle Cerebral Artery Aneurysm Endovascular and Surgical TherapiesNeurosurg Clin N Am 25 (2014) 455–469

12 year old boy with history of occasional severe headaches. Also has history of mitral valve prolapse with severe MR . There was no vegetations/thrombus on cardiac valves on 2D echocardiography.

CASE OF MYCOTIC ANEURYSM

Y STENTING FOR LEFT MCA BIFURCATION ANEURYSM

PROS OF ENDOVASCULAR TREATMENT

• Avoid open surgery and less invasive

• Multiple aneurysm in same sitting

• No retraction of the brain

• Less complication

• Do not limited by the operation approaches

• Less in-hospital time and faster recovery

• Not suitable for the reconstruction

of the Endomenbrane of the

arteries- overcome by stent and

flow divertor.

• Most complex aneurysm cases with

incomplete embolization -Residual

and recanalisation

• Higher cost.

CONS OF ENDOVASCULAR TREATMENT

UNRUPTURED ANEURYSM COILING OUTCOME

• In a systematic review of 12 studies of endovascular MCAA coiling, the death and permanent morbidity rate was 5.1% for unruptured aneurysm and 6% for rupturedaneurysm, with an 82.4% rate of completeobliteration

Zaidat et al. Middle Cerebral Artery Aneurysm Endovascular and Surgical TherapiesNeurosurg Clin N Am 25 (2014) 455–469

All studies in English that reported results for adults (‡18 years) with unruptured MCAAs, from 1990 to 2011 were considered for inclusion.26 studies involving 2295 aneurysms treated with clipping or coiling for unruptured MCAAs included for analysis. 1530 aneurysms treated with clipping 765 aneurysms treated with coiling.

1Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston,Massachusetts; 2Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; 3Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas, USAWorld Neurosurg. (2015) 84, 4:942-953.

Endhole technique

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Dr Vipul Gupta

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