endovascular management of cerebral aneurysms · exclude aneurysm by placing clip across neck...

Endovascular Management

of Cerebral Aneurysms

Shao-Pow Lin, MD, PhD

Neurointerventional Radiology

Lambert Radiology Medical Group

Cerebral Aneurysms

Weak point in vessel wall that “balloons out” over time

Propensity for hemorrhage

Adapted from Chalouhi et al, Stroke. 2013;44:3613-3622

Risk Factors

For aneurysms:

• Smoking, HTN,

Hyperlipidemia

• Age > 40, Female

• Family history,

congenital disorders

• CNS infection,

Trauma, AVM

For rupture:

• Prior rupture

• Smoking, HTN,

cocaine, meth

• African Americans &

Hispanics > White

Statistics

Statistics

~1 in 50 people have an aneurysm, ~1 in 20 over 50

• Common disease

Ruptures ~30k/yr in US (less than 5% of all stroke)

• Low risk of rupture (1%/yr – most never rupture)

~50% of ruptures are fatal (15% never reach hospital)

~50% of non-fatal ruptures result in permanent

neurological deficit

• High risk of bad outcome

Intracranial Hemorrhage

Epidural

• Trauma, usually fracture

Subdural

• Trauma, spontaneous

(elderly/blood thinners)

Intraparenchymal

(intracerebral)

• HTN, AVM, tumor, trauma

Subarachnoid

• Aneurysm, trauma

SAH Evaluation

SAH = ruptured aneurysm

until proven otherwise

Imaging

• CTA or MRA at minimum

• If negative, catheter

angiography still

recommended

• Up to 20% can be

negative on catheter

angiogram

• Depending on clinical

suspicion, repeat CTA or

angiogram after 1-2 weeks

Aneurysm Work-up

MRA

Non-emergent

screening

CTA

Workhorse for

emergent work-up

Catheter angio

Work-up known

aneurysm/SAH

Ok I found an aneurysm,

now what?

Incidental aneurysm

• Non-emergent consult,

outpatient ok

Symptomatic aneurysm

• New, worsening,

persistent HA or cranial

nerve palsy

• ED, Urgent consult

Subarachnoid hemorrhage

• Emergent consult

Emergent Consult

Why isn’t time critical?

• Brain is not ischemic

• Usually no active

bleeding

• Aneurysm treatment

doesn’t improve status,

but hydrocephalus

treatment can

Why is time still important?

• Highest risk of re-bleed

in first 48 hrs

• Our goal is to treat

within 24 hrs, usually

within 12

Acute Management

Imaging: Non-con CT, CTA

Labs: Coags, BMP, CBC

Control BP

• Nicardipine drip

• SBP < 140

Manage ICP

• Mannitol, Hypertonic saline

• Ventriculostomy

Treat

• Clip (craniotomy)

• Coil (endovascular)

Treatment: Clip or Coil?

CLIP COIL

Approach Craniotomy Endovascular

Anesthesia General General

Goal Exclude aneurysm by

placing clip across neck

Exclude aneurysm by packing the

inside with coils

Preferred

Characteristics

MCA bifurcation,

Complex or wide neck

Basilar tip,

Narrow neck

Follow-up Usually 1 angiogram F/u angiography for several years

What is a “Coil”?

Platinum (mostly) wire:

0.002-0.003 in

Secondary shape “coil”:

0.010 to 0.015 in

Tertiary shape helix,

sphere, etc. 1 mm – 3 cm

Attach to pusher wire with

detachment mechanism

MR Conditional

• Field < 3T

• Gradient < 2500 G/cm

• SAR < 2W/kg in 15 min

Ok for immediate

scanning

41 M

In town for wedding

Acute onset severe HA

with R facial droop

Catheter Angio, LICA

Primary Coiling, ACOM

AP LAT

Subtracted Image

AP LAT

1 Lobe Left…

AP LAT

Complete Occlusion

AP LAT

Outcome

No new neurologic deficits

No vasospasm

D/c home

66 F

In town on vacation

Sudden onset:

• HA

• Neck pain

• LOC, likely seizure

while taking shower

Now awake, oriented

Catheter Angiogram, LICA

AP LAT

Wide Neck PCOM aneurysm

Balloon-Assisted Coiling

Outcome

No new neurologic deficits

No vasospasm

D/c home

39 F

Acute onset HA

SAH dx at OSH

No aneurysm found on

CTA, patient transferred

for higher level of care

CTA

Missed basilar

tip aneurysm

No neck

Wider at base

than dome

What Now?

Clip – not for basilar tip

Primary coiling

• Unlikely to work

Balloon assisted coiling

• Temporary scaffold

Stent assisted coiling

• Permanent scaffold

• Non-ideal because patient has

acute rupture

• Pre-medicated with

ASA/Plavix overnight and

treated first case in AM

Aneurysm Scaffold Devices

Laser cut stents

• Cut from Nitinol, with

tantalum or platinum

markers

• Neuroform, Enterprise

Braided stents

• Nitinol wires with tantalum

markers

• LVIS, Leo

Pulserider

• Nitinol with platinum/iridium

markers

Catheter Angio, Vertebral

AP LAT

“Y” Stent Assistance

Stent to L PCA Stent to R PCA Finish coiling

Outcome

No new neurological deficit

No vasospasm

D/c home

Small recurrence at 6 months,

added coils

51 F

HA

Hypertensive urgency

No hemorrhage

Incidental aneurysm (HA resolved with

lower BP)

Catheter Angio, LICA

Very Wide Neck Aneurysm

Primary coiling – unlikely to work

Balloon assisted coiling – might work

Stent assisted coiling – reasonable option

Flow diversion

• Latest and greatest treatment

What is a Flow Diverter?

Braided stent-like device

Typical (Neuroform/Enterprise) stent

provides approximately 6% coverage

Pipeline, Surpass, Silk and other flow

diverters provide 30+% coverage

Low porosity “diverts” blood away

from aneurysm without need for coils

Pipeline Flow Diverter

48-strand braided mesh

75% Co-Cr, 25% Pt-W

CT: easily visible

MRI safety:

• Conditional up to 3T,

720 G/cm, SAR 4

W/kg

• Ok for immediate

scanning

PED Placed Over Aneurysm

Immediate stasis 6 month f/u

58 F

Acute onset HA,

R sided weakness

SAH Dx at OSH,

transfer for higher

level of care

Awake, oriented

Catheter Angio, LICA

AP LAT

Fusiform MCA Aneurysm

Clip – generally best

option for complex

MCA aneurysm

Primary or balloon

assisted coil – no

Stent assisted coil or

Pipeline embolization

• Need ASA/Plavix

• Would consider if not

ruptured

Post Clipping

AP LAT

Outcome

No new neurological deficit

Full recovery

D/c home

8 Months Later…

Recurrent HA and R sided weakness

What Now?

Parent artery not normal

Re-clip not a good option

Need vessel

reconstruction

Patient pre-medicated

with ASA/Plavix a few

hours prior to Pipeline

assisted coiling

Pipeline and Coils

Outcome

No new neurological deficit

Full recovery

D/c home

3 Month f/u

Take Home Points

Aneurysms are common

Aneurysm rupture

• Low probability, high risk event

Aneurysm treatment depends on:

• Rupture status

• Complexity of aneurysm

• Neck size

• Branch vessels

• Location

GDC coil FDA approved in 1995.

Neurointervention is still a new field!

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