Consecutive aneurysms treated by endovascular approach- our experience

Talk at ISNR 2014 (annual conference of Indian Society of Neuroradiology, Delhi)

Vipul GuptaNeurointerventional Surgery(Interventional Neuroradiology)Institute of Neurosciences Medanta the Medicity

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 rerupture of 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 life

Initial CT Scan

Rebleeding after 1 day

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 lower

The Barrow Ruptured Aneurysm Trial

Compared clipping vs coiling in SAH patients. Poor outcome - 33.7% in clipping vs 23.2% in coiling

Guidelines for the Management of Aneurysmal SAH: Special Writing Group of the Stroke Council, ASA/AHA Stroke 2009

Amenable to both endovascular coiling and neurosurgical

clipping, endovascular coiling can be beneficial (Class I, Level

of Evidence B).

Metanalysis

• Stroke 2013

• AJNR 2013

• Ruptured aneurysms- better outcomes

after endovascular management

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 Cerecyte studies – mRS 0-2 in 87% (80% in ISAT)

Coiling as first choice…

Lubicz B et al of 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

Our protocol

Interventionist part of neurosurgery team

DSA & if possible embolization Neuro lab with 3D, CT NS ICU monitoring (TCD/CTP). Vasospasm- IAVD N- 706 (Sept 2014) Data of consecutive patients

Circumferential involvement-End hole

Broad neck , dyplastic aneurysms

A B C

large-/giant aneurysms

Data

• Retrospective review of 548 intracranial 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.

Parent vessel occlusion- Cavernous ICA,

dissecting (VA), small peripheral

Fusiform, dissecting aneurysm

38 yr old male patient, 2-day old SAH

Known hypertensive

Clinically grade II

Small Blister/dissecting Friable, continued growth, re-rupture

Classical blister aneurysm

34-year M, SAH

Very small aneurysms

? Near the neck rupture/lobule

Catheter reposition

1-mm

coil

Branch from aneurysm- Overinflation technique

Embolization

Surgery

95%

5%

Good outcome

FND

Mortality

Mgt. outcome in good grade patients- 90 % mRS 0-2

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…

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.)

overall death or dependency was 18.0%.

ISAT trial - 23.7%,

BRAT trial - 20.4%

GDC CLARITY study - 23.3%

Outcome…

56 yr old, ischaemic stroke

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

Thank you