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Table of Contents    
ORIGINAL ARTICLE
Year : 2019  |  Volume : 67  |  Issue : 4  |  Page : 1062-1065

Endovascular Nuances in Management of Multiple Intracranial Aneurysms


1 Department of Neurosurgery, GB Pant Hospital, New Delhi, India
2 Department of Anaesthesia, GB Pant Hospital, New Delhi, India

Date of Web Publication10-Sep-2019

Correspondence Address:
Dr. M N Tejus
2684/1, 6th Main, 13th Cross, V.V Mohalla, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.266249

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 » Abstract 


Background: Endovascular treatment of aneurysm is the accepted standard of treatment. Multiple intracranial aneurysms are frequently detected due to advances in imaging.
Objective: The purpose of this study was to determine aneurysm properties, management strategies, and outcome of patients with multiple intracranial aneurysms managed by endovascular approach.
Materials and Methods: Data of all patients with multiple intracranial aneurysms who were managed at our institute over a period of 1 year were retrospectively studied. Data of 20 consecutive patients with single aneurysm who were endovascularly managed during the same study period were also collected. Patient demographics, intraprocedural radiation exposure, hardware used, and clinical and angiographic outcome at discharge were analyzed.
Results: A total of 112 patients with intracranial aneurysm were managed during the study period, of which 11 patients had multiple intracranial aneurysms, with a total of 23 aneurysms. Incidence was more among females (63.6%). Proximal of multiple aneurysms ruptured more commonly (63.6%), and internal carotid artery (ICA) bifurcation was the most common site (45.4%). Of the 23 aneurysms, 18 were coiled. Seven patients had good outcome and it was found to be influenced by preoperative Hunt and Hess scale. Based on Raymond–Roy grading, 17 of 18 aneurysms (94.4%) were completely coiled; angiographic outcome was comparable in both the groups. Patients with multiple aneurysm had statistically significant high radiation exposure (4.5 vs 3.8 m SV) as compared to patients with single aneurysm (P < 0.05), but had low stochastic effect. In patients with aneurysm involving different arterial compartment, 66.2% required change of microcatheter.
Conclusion: Single-stage treatment of multiple aneurysm can be achieved with good outcome. Even though radiation exposure is high while treating multiple aneurysm as compared to single aneurysm cases, its stochastic risks are low.


Keywords: Catheter fatigue, multiple aneurysms, radiation exposure, single stage coiling
Key Message: Multiple intracranial aneurysms can be successfully treated using endovascular technique in a single stage by identifying raptured aneurysm, use of appropriate hardware.


How to cite this article:
Tejus M N, Singh D, Jagetia A, Singh H, Tandon M, Chawla R, Ganjoo P. Endovascular Nuances in Management of Multiple Intracranial Aneurysms. Neurol India 2019;67:1062-5

How to cite this URL:
Tejus M N, Singh D, Jagetia A, Singh H, Tandon M, Chawla R, Ganjoo P. Endovascular Nuances in Management of Multiple Intracranial Aneurysms. Neurol India [serial online] 2019 [cited 2019 Nov 13];67:1062-5. Available from: http://www.neurologyindia.com/text.asp?2019/67/4/1062/266249




The incidence of multiple intracranial aneurysms has increased in the past few years. Detection rate have increased due to advances in imaging technique. For instance reported incidence of multiple intracranial aneurysms is approximately 19–34% in patients who present with subarachnoid hemorrhage (SAH).[1],[2] Endovascular intervention for unruptured intracranial aneurysm is currently accepted as the standard treatment.[1],[3],[4] In India, based on autopsies, prevalence of intracranial aneurysms ranges from 0.2% to 10.3%, however, incidence of multiple aneurysms is not exactly known.[5] Multiple aneurysms most commonly involve internal carotid artery territory followed by middle cerebral artery and then posterior circulation.[6] In these patients, sometimes it is difficult to detect aneurysm, which has bled. It is assumed that outcome of patients with multiple intracranial aneurysms is poor compared to those with single aneurysm.[7]

The main objective of this study is to determine aneurysm properties, management strategies, and outcome in management of patients with multiple intracranial aneurysms by endovascular approach.


 » Materials and Methods Top


This is a hospital-based retrospective study. Details of patients with intracranial aneurysms who were managed by endovascular and surgical methods over a period of 1 year (from December 2014 to November 2015) were reviewed. Patients with two or more intracranial aneurysms were included in the study [Figure 1]. Multiple aneurysms were then classified as “same compartment” aneurysms or “different compartment” aneurysms. Multiple aneurysms in the same artery or in the distal branches of the same artery were classified as “same compartment aneurysms.” For example, a case with multiple aneurysms in the same internal carotid artery territory, aneurysm left internal carotid artery, and left middle cerebral artery were categorized as “same compartment aneurysms” [Figure 2]. A case with aneurysm in the right internal carotid artery and another aneurysm in the left middle cerebral artery were classified as “different compartment aneurysms.” The following parameters were collected: clinical, angiographic outcome, radiation dose, and hardware used. Ruptured aneurysm was confirmed on digital subtraction angiography by the presence of irregular outline and presence of blood in the adjacent cistern. Clinical outcome at discharge was assessed using the modified Rankin Scale (mRS) score. Immediate post-embolization angiography of each aneurysm was assigned to the 3 categories, as suggested by Raymond et al.; class 1 = complete obliteration, class 2 = residual neck, and class 3 = residual aneurysm. The stock of hardware needed during the procedure was also determined, namely, number of catheters and guidewires used per procedure. Parameters collected were compared with 20 consecutive single ruptured aneurysm patients who were managed by endovascular intervention during the same study period. Statistical analysis was performed using Fisher's test. P value less than 0.05 was considered significant.
Figure 1: Precoiling and postcoiling angiography, anteroposterior view, showing complete obliteration of aneurysm involving left Middle cerebral artery and anterior cerebral artery

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Figure 2: Completion angiogram obtained postcoiling of left internal carotid artery and middle cerebral artery aneurysm, demonstrates complete occlusion of aneurysms with normal flow through parent vessel

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 » Results Top


Clinical data

A total of 112 patients with aneurysm were managed at our institute for a period of 1 year. Of this, 84 patients were managed by endovascular techniques. Eleven patients (9.8%) (4 males, 7 females) with multiple intracranial aneurysms were managed in 1 year. All 11 patients had at least 1-ruptured intracranial aneurysm. Of the 11 patients, 7 patients had Hunt and Hess grade-1 (63.6%), 3 (27.2%) were grade-2, and one was grade-4 (9%) at presentation. Ten patients had Modified Fischer's grade of 3 and one patient was grade 4. Internal carotid artery bifurcation aneurysm was the most commonly ruptured aneurysm of multiple aneurysms, seen in 5 out of 11 cases (45.4%) [Table 1].
Table 1: Patient characteristics, radiation dose, clinical outcome, and occlusion rate

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There were 23 aneurysms in the 11 patients. Four patients had “multiple compartment aneurysms” and 7 patients had “single compartment aneurysms.” In all 7 cases with single compartment aneurysms, the proximal aneurysm had ruptured. Eighteen aneurysms in 9 patients were managed by endovascular intervention. In all patients, ruptured aneurysm was coiled first. Two patients were not coiled. One patient had temporal hematoma associated with aneurysm and was managed surgically. In another patient due to tortuous vessels, endovascular procedure was abandoned and the patient was planned for surgical clipping. However, the patient died due to rebleed before definitive intervention. In one patient, a ruptured middle cerebral artery aneurysm was clipped at another hospital and the associated PICA (posterior inferior cerebellar artery) aneurysm was coiled 4 months later at our hospital. One patient had 3 aneurysms, all in the same internal carotid artery. Of the 20 cases in the control group, 12 were females and 8 were males. Sixteen cases had Modified Fisher's grade of 3, 2 cases had grade 2, and 2 cases had grade 4.

In all cases, ruptured aneurysm was coiled first. Outcome and occlusion rate between the two groups were not statistically significant. mRS 0 was seen in 70% of the patients in the single aneurysm group vs 78% in the multiple aneurysm group. There were two deaths in both the groups. Based on Raymond–Roy grading, 17 of 18 aneurysms (94.4%) in the multiple aneurysm group were completely coiled; one patient had residual neck on immediate postprocedure angiography [Table 1]. Eighteen of the 20 aneurysms (90%) in the control group had no residual neck in the postprocedure angiogram. There was no significant difference in in occlusion rates among the two groups.

Procedure-related data

Mean duration of procedure in multiple aneurysm group was 195 minutes as compared 170 minutes among single aneurysm cases. Patients with multiple aneurysm had statistically significant high radiation exposure (4.5 vs 3.8 mSv) as compared to patients with single aneurysm (P < 0.05) [Table 1]. Three patients had aneurysm involving different arterial compartment, of which two (66.2%) required change of microcatheter [Table 2]. Loss of microcatheter compliance and torque while coiling first aneurysm required a change in the microcatheter assembly.
Table 2: Microcatheters used for coiling multiple aneurysm

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 » Discussion Top


Annual incidence of multiple intracranial aneurysms at our institute is 9.8%. All multiple aneurysms admitted to our hospital were ruptured, 9 of the 11 (82%) patients with multiple aneurysms were managed by endovascular intervention. Complete coiling of aneurysm Raymond class-1 was seen in 88% of patients as compared to 81.7% in study by Keun et al. and 66% in the ISAT trial.[2],[7],[8] Seven of the 9 patients (78%) had good outcome with mRS-0, death or dependence (mRS 3–6) in 22.2% as compared to 23.6% in the ISAT trial. The two most frequent complications of aneurysm coiling are thromboembolic complications and intraoperative rupture, with incidence being 13.3% and 3.7%, respectively, for ruptured aneurysm.[9] In our series, we did not have any intraoperative rupture, and 2 patients had middle cerebral artery infarct following procedure who recovered with medical management and physiotherapy (22.2%). Radiation exposure in intervention suit has both deterministic effects and stochastic effects.[10] There is significant difference in the effective dose of radiation between single and multiple aneurysm groups. However, the highest effective dose value of 5.45 mSv in our multiple aneurysm group is known to cause very low stochastic risks.[11]

Microcatheter is stiff and has longitudinal flexibility and torque. Rotation of the microcatheter at the proximal end is efficiently transmitted along a central axis to the catheter tip. It is likely that there is a loss of this property in the microcatheter when it was used in multiple compartments. This may have necessitated a change in microcatheter in 2 of the 3 (66.7%) multiple compartment aneurysms. Aneurysm rupture is determined by flow dynamics. Flow dynamics of two aneurysms in the same vascular territory are different. Proximal aneurysm has an unsteady pulsatile flow, and at the same time damps a significant amount of this unsteadiness. Because of this damping, the second aneurysm shows a remarkable insensitivity to the pulsatile flow pattern. This difference in flow dynamics can explain the proximal aneurysm rupture in single compartment aneurysms in our series.[12] It is likely that the coiling of the proximal aneurysm removes the damping effect on the distal aneurysm making it prone for rupture. It is justified to coil unruptured aneurysm as the annual bleeding risk of an unruptured aneurysm regardless of previous SAH is 1 to 2.3%, which is even higher in patients with multiple aneurysms.[13] We have coiled rupture of multiple aneurysms in all our cases, and all aneurysms could be coiled in a single sitting.


 » Conclusion Top


The key for successful outcome of patients with multiple intracranial aneurysm are: (1) Coiling ruptured aneurysm first. (2) Preferably coiling all aneurysms in a single sitting to avoid change of flow dynamics in distal aneurysm. (3) Change of microcatheter catheter assembly to coil aneurysms involving different vascular compartments owing to changes in microcatheter properties. Even though radiation exposure is high while treating multiple aneurysm as compared to single aneurysm cases, its stochastic risks is low.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Jeon P, Kim BM, Kim DJ, Kim DI, Suh SH. Treatment of Multiple Intracranial Aneurysm with 1-Stage Coiling. AJNR Am J Neuroradiol 2014;35:1170-3.  Back to cited text no. 1
    
2.
Kaminogo M, Yonekura M, Shibata S. Incidence and outcome of multiple intracranial aneurysms in a defined population. Stroke 2003;34:16-21.  Back to cited text no. 2
    
3.
Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012;43:1711-37.  Back to cited text no. 3
    
4.
Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 2009;40:994-1025.  Back to cited text no. 4
    
5.
Sathyan S, Koshy LV, Balan S, Easwer HV, Premkumar S, Nair S, et al. Association of Versican (VCAN) gene polymorphisms rs251124 and rs2287926 (G428D), with intracranial aneurysm. Meta Gene 2014;2:651-60.  Back to cited text no. 5
    
6.
Singal RK. Medicine Update: Vol. 17. New Delhi: Jaypee digital publication; 2007.  Back to cited text no. 6
    
7.
Oh K, Lim YC. Single-session Coil Embolization of Multiple Intracranial Aneurysms. J Cerebrovasc Endovasc Neurosurg 2013;15:184-90.  Back to cited text no. 7
    
8.
Derdeyn CP, Barr JD, Berenstein A, Connors JJ, Dion JE, Duckwiler GR, et al. The International Subarachnoid Aneurysm Trial: A position statement from the executive committee of the American Society of Interventional and Therapeutic Neuroradiology. AJNR Am J Neuroradiol 2003;24:1404-8.  Back to cited text no. 8
    
9.
Li H, Pan R, Wang H, Rong X, Yin Z, Milgrom DP, et al. Clipping versus coiling for ruptured intracranial aneurysms: A systematic review and meta-analysis. Stroke 2013;44:29-37.  Back to cited text no. 9
    
10.
Partridge J. Radiation in the cardiac catheter laboratory. Heart 2005;91:1615-20.  Back to cited text no. 10
    
11.
Bergeron P, Carrier R, Roy D, Blais N, Raymond J. Radiation doses to patients in neurointerventional procedures. Am J Neuroradiol 1994;15:1809-12.  Back to cited text no. 11
    
12.
Chatziprodromou I, Butty VD, Makhijani VB, Poulikakos D, Ventikos Y. Pulsatile blood flow in anatomically accurate vessels with multiple aneurysms: A medical intervention planning application of computational haemodynamics. Flow Turbul Combust. 2003;71:333-46.  Back to cited text no. 12
    
13.
Solander S, Ulhoa A, Viñuela F, Duckwiler GR, Gobin YP, Martin NA, et al. Endovascular treatment of multiple intracranial aneurysms by using Guglielmi detachable coils. J Neurosurg 1999;90:857-64.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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