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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 5-9

Long-term follow-up of large and giant intracranial aneurysms managed by endovascular techniques: Experience from a tertiary care neurosurgery institute in India


1 Department of Neuro Surgery, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
2 Department of Radiation Oncology, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
3 Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India

Date of Submission22-Aug-2020
Date of Acceptance31-Aug-2020
Date of Web Publication1-Oct-2020

Correspondence Address:
Dr. Gautam Dutta
Department of Neuro Surgery, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvs.jcvs_18_20

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  Abstract 


Introduction: We present our experience of managing large and giant intracranial aneurysms by conventional endovascular techniques. We discuss the long-term clinical and angiographic outcome of coiling of these aneurysms.
Materials and Methods: We assessed a prospectively maintained database of patients with large and giant intracranial aneurysms managed by the endovascular techniques from January 2010 to December 2014. In 412 patients with 468 aneurysms managed during this period, 58 patients with 60 aneurysms were identified as either large or giant. Each patient's records were reviewed with regard to size, location and morphology of the aneurysms, Hunt and Hess grade, occlusion and coiling/recoiling rates. Clinical outcome was assessed using the modified Rankin Scale (mRS) score with score of 0–2 and 3–6 taken as favourable and unfavourable outcome, respectively.
Results: Overall complication rate was 13.8%, and no intraprocedural death was seen. Angiographic and clinical follow-up was available for 49 patients with 49 aneurysms at an average of 28.7 months. Recanalisation rate was 26.5% in this study and of them 38.5% required retreatment. Favourable mRS score (0–2) was seen in 82.6% of ruptured aneurysms and 92.3% in unruptured aneurysms.
Conclusion: Coiling of large and giant aneurysms is a safe and viable option with a very good clinical outcome in the long run. However, long-term clinical and angiographic follow-up is necessary as angiographic results immediately after the procedure may be deceptive.

Keywords: Angiographic follow-up, coiling, endovascular management, intracranial aneurysm


How to cite this article:
Dutta G, Mahajan D, Singh D, Jagetia A, Singh H, Srivastava AK. Long-term follow-up of large and giant intracranial aneurysms managed by endovascular techniques: Experience from a tertiary care neurosurgery institute in India. J Cerebrovasc Sci 2020;8:5-9

How to cite this URL:
Dutta G, Mahajan D, Singh D, Jagetia A, Singh H, Srivastava AK. Long-term follow-up of large and giant intracranial aneurysms managed by endovascular techniques: Experience from a tertiary care neurosurgery institute in India. J Cerebrovasc Sci [serial online] 2020 [cited 2020 Nov 27];8:5-9. Available from: http://www.jcvs.com/text.asp?2020/8/1/5/296922




  Introduction Top


Large (15–25 mm) and giant (>25 mm) aneurysms often present as symptoms of mass effect, and sometimes, fatal hemorrhage and surgical clipping of such aneurysms are often associated with serious morbidity and mortality because of their configuration and occasional location near the cavernous sinus.[1],[2],[3] With the emergence of recent endovascular techniques, the paradigm of management of such aneurysms has largely been shifted from the open surgical approach to the minimally invasive endovascular approach because of higher safety and feasibility.[4],[5] Although the results of endovascular procedures are promising, there is a dearth of long-term follow-up studies in the literature, especially in cases of large and giant aneurysms managed by endovascular means.[6],[7],[8] The C-arm intensifier with digital subtraction angiogram facility was approved in our neurosurgery department in 1998,[9] and ever since, then we are regularly performing the varieties of endovascular procedures. In this article, we present our long-term angiographic results of large and giant aneurysms managed through endovascular means.


  Materials and Methods Top


We evaluated a prospectively maintained database of patients with large and giant aneurysms managed through endovascular means from January 2010 to December 2014 at our institute. In 412 patients, a total of 468 aneurysms were managed by the endovascular technique. Of them, 58 patients with 60 aneurysms were identified as either large or giant (largest diameter more than 15 mm). The decision to manage these aneurysms through endovascular means was primarily made on the basis of morphology and characteristics of the feeder vessels, relationship with the parent vessels, presence of absence of large hematoma and patient preference.

Each patient's medical records and angiographic images (both immediate and follow-up) were reviewed with regard to demography, size, location and morphology of the aneurysms, comorbid factors, Hunt and Hess (HandH) grade, occlusion rate, coiling/recoiling angiographic and clinical outcome. Angiographic outcome of each patient was evaluated using the Raymond-Roy occlusion classification as complete obliteration (Class I), residual neck (Class II) and residual aneurysm (Class III). Follow-up angiographic images were obtained at 6 months, 1 year, 3 years and 5 years after the initial procedure. Any recanalisation during follow-up was noted in the surviving patients. Clinical outcome was assessed at discharge and at each follow-up using the modified Rankin Scale (mRS) score with score of 0–2 and 3–6 taken as favourable and unfavourable outcome, respectively.

All the patients in the study group underwent standard endovascular technique under general anaesthesia using 6–7 diagnostic catheter (Cook, Cordis) and 7-F sheath and microguide wires of size 10 and 14 (Transcend Boston Scientific, Agility ev3) along with microcatheters of Prowlers series (Johnson and Johnson, Miami Lakes, FL, USA) as described by us in our previously published article.[10] Initial basket was created in each aneurysm with 3D coils followed by sufficient packing till no contrast was apparent in more than one place inside the aneurysm sac. We used electric (Boston Scientific, Fremont, CA, USA), hydraulic (Microvention) as well as mechanical detachment systems. Stents used in the procedures were either of Solitaire (ev3), Neuroform (Boston Scientific, Natick, MA, USA) and Enterprise (Codman and Shurtleff, Inc., Raynham, MA, USA). We regularly used bolus of 5000 IU heparin immediately after insertion of femoral catheter followed by the infusion of 1000 IU of heparin/500 ml normal saline (0.9%) during the entire procedure. Nimodipine 5 mg/h continuous infusion through intravenous route was also administered throughout the procedure and continued after the procedure to prevent vasospasm.

Statistical analysis

Patient data were presented as the mean and range for continuous variables while frequency for categorical variables. Analysis was done using an unpaired t-test, Fisher test and analysis of variance as appropriate. P < 0.05 was considered as statistically significant. Statistical analysis was done by the SPSS (version 19.0, IBM, Armonk, NY, United States).


  Results Top


Population characteristics

Of the 412 patients managed by endovascular techniques over this time period, 58 patients with 60 aneurysms were identified as having largest diameter of the sac more than 15 mm. Of them, 12 (20%) aneurysms were identified as giant and 48 (80%) aneurysms were large. Of the 58 patients, 20 (34.5%) were male and 38 (65.5%) were female with a mean age of 52.2 years. Thirty-one (53.4%) patients had unruptured aneurysms, whereas 27 (46.6%) patients presented with subarachnoid hemorrhage (SAH). According to HandH grade, 31 (53.4%) patients were in grade 0, 8 (13.8%) were in Grade I, 11 (19%) in Grade II, 3 (5.2%) in Grade III, 4 (6.9%) in Grade IV and 1 (1.72%) in Grade V. 81.7% of the aneurysms were located in anterior circulation while 18.3% in posterior circulation as summarised in [Table 1]. The size of the aneurysms ranged from 15 to 30 mm. There were 51 (85%) saccular aneurysms and 9 (15%) fusiform aneurysms. There was one patient with a multilobulated aneurysm and two with bilobed aneurysm. Ruptured aneurysms (SAH) were more common in the posterior circulation aneurysms than anterior circulation, and this difference was statistically significant (P = 0.03)
Table 1: Location of the aneurysms in this study group

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Initial procedure

Eight aneurysms in this study group were treated by parent vessel occlusion (PVO), 32 aneurysms with coils and rest 20 aneurysms were treated with stent-assisted coiling (SAC). The procedure failed in three (5%) patients and was converted to the open surgical clipping.

No intra-procedural mortality, iatrogenic dissection or aneurysmal rupture occurred in any patient. Overall complication rate was 13.8% seen in eight patients, namely vasospasm and thromboembolism and vasospasm in four and two patients, respectively, leading to ischaemia, coil protrusion in one case and one cranial nerve palsy. The incidence of complication was 6.5% (n = 2) in unruptured aneurysms, whereas it was 22.2% (n = 6) for those with ruptured aneurysms (P = 0.002).

Eleven aneurysms were treated by PVO, 32 aneurysms with primary coils and rest 17 aneurysms were treated with SAC. Excluding the 3 aneurysms with a failed procedure, immediate complete occlusion was accomplished in 40 (70.2%) aneurysms, whereas residual neck was seen in 12 (21%) and residual aneurysm in 5 (8.8%) patients.

mRS score at discharge of 55 patients (excluding 3 patients who underwent surgical clipping) showed favourable outcome with score of 0–2 in 87.3% cases. Unruptured aneurysms showed a favourable outcome (86.2%) compared to ruptured ones (69.2%).

Angiographic and clinical outcome during follow-up

Six patients were lost in follow-up and excluding the three patients with a failed procedure, angiographic and clinical follow-up was obtained in a total of 49 patients with 49 aneurysms (39 large and 10 giant) for a mean duration of 28.7 months. Over this period of follow-up, 13 (26.5%) aneurysms showed recanalisation [Table 2], and of them, 5 (38.5%) required further management. Of them, 4 were successfully managed by repacking the sac while one required balloon-assisted coiling. For large aneurysms, the recurrence rate was 23% (9 of 39 aneurysms) and for giant aneurysms, the rate was 40% (4 of 10 aneurysms). Multivariate analysis revealed that independent predictors of recurrence are larger aneurysm size (odds ratio [OR] 1.2; confidence interval [CI] 1.04–1.32; P = 0.005), longer follow-up time (OR 2.6; CI 1.12–3.4; P = 0.05) and location in cavernous, paraclinoid and middle cerebral artery (OR 1.08; CI 1.01–1.12; P = 0.004).
Table 2: Recurrence rate with respect to size of the aneurysms

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Clinical outcome was evaluated at follow-up which showed a favourable mRS score (0–2) in 82.6% of ruptured aneurysm cases and 92.3% in unruptured aneurysms [Table 3]. In multivariate analysis, good Huxsnt and Hess grades (OR 0.42; CI; 0.18–0.62; P = 0.003) and smaller aneurysm size (OR 0.82; CI 0.80–0.94; P = 0.02) were the independent positive prognosticators for favourable outcome (mRS 0–2).
Table 3: Modified Rankin Scale score at discharge and follow-up

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  Discussion Top


In this study, we tried to assess outcome with a long-term follow-up and evaluate factors which can be responsible for the recurrence of large and giant aneurysms managed through endovascular means. Sometimes, the initial angiographic and clinical outcome may be deceptive, and suboptimal results are often noticed in the long term.

There are certain factors which are deemed responsible for aneurysm recurrence and overall clinical outcome such as angiographic outcome, SAH grade and aneurysm size following endovascular approach that has been previously described yet coiling is associated with reasonably low morbidity and mortality.[11],[12],[13],[14] These factors affecting the outcome of the procedure have been confirmed by the current study. Impact of location of the aneurysm is debatable as some studies found no such association[8],[15] while some found location in cavernous, paraclinoid and anterior circulation are predictive of recurrence after treatment.[16] The results of this study suggest recurrence is more likely in anterior circulation aneurysms following endovascular procedure; however, larger number of patient cohort is required to conclusively draw this finding.

Endovascular management of large and giant aneurysms is associated with significantly low morbidity and mortality in good HandH grade patients. The current study did not have any intraprocedural mortality, and overall complication rate was 13.8% suggesting coiling of large and giant aneurysms are safe and effective. Parkinson et al.[17] studied giant aneurysms managed by endovascular techniques and found that overall morbidity and mortality are 17% and 8% respectively. Another study found a good clinical outcome of coiling in nearly 80% of these aneurysms.[18] This study indicates that clinical outcome is negatively affected by increasing aneurysm size in multivariate analysis; however, overall outcome and safety profile of endovascular approach in managing such aneurysms remains reasonably favorable.

In this study, follow-up of treated aneurysms revealed quite a significant recurrence rate of 26.5% cases and of them 38.5% required retreatment. A previous study attributed such recurrence to resolution of thrombus, coil migration and inadequate packing of sac.[5] The recurrent cases in our study were successfully managed by recoiling without significant morbidity supporting the findings of another study.[19]

With the recent introduction of flow diversion devices, many large and giant aneurysms are being increasingly managed by pipeline procedures, although the debate remains regarding the best procedure. In one study, the authors reported similar morbidity but higher rate of obliteration with pipeline procedure, however, concluded that long-term follow-up is necessary to prove its superiority over coiling.[19] Moreover, flow diversion has its own inherent complications, and recent studies found that this technique has higher risks than conventional endovascular procedures like stroke or death.[20],[21] These studies indicate that flow diversion is not without significant risks and in cases of acute SAH, flow diversion is not a first option and such ruptured aneurysms are managed either by conventional coiling or clipping. In posterior circulation aneurysms too, flow diversion carries significant morbidity and recurrence rate.[21],[22] Moreover, these devices are costly, and out of reach for most patients, especially in the Indian setup. In our study, posterior circulation aneurysms treated by conventional endovascular techniques carried significantly the lower rate of recurrence compared to anterior circulation in multivariate study supporting the viability of coiling in managing these aneurysms.


  Conclusion Top


Our study shows that conventional endovascular procedures are reasonably safe, valid, cost-effective in managing large and giant intracranial aneurysms and associated with a very good clinical outcome. Aneurysm location in anterior circulation, smaller aneurysm size, and good HandH score are predictive of successful outcome. The recurrence rate is 26.5% and retreatment of such cases with coils is a viable measure. Long-term clinical and angiographic follow-up is necessary as initial angiographic results may be deceptive.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Schaller B. Extracranial-intracranial bypass to reduce the risk of ischemic stroke in intracranial aneurysms of the anterior cerebral circulation: a systematic review. J Stroke Cerebrovasc Dis 2008;17:287-98.  Back to cited text no. 3
    
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Lozier AP, Connolly ES Jr., Lavine SD, Solomon RA. Guglielmi detachable coil embolization of posterior circulation aneurysms: A systematic review of the literature. Stroke 2002;33:2509-18.  Back to cited text no. 4
    
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Sluzewski M, Menovsky T, van Rooij WJ, Wijnalda D. Coiling of very large or giant cerebral aneurysms: Long-term clinical and serial angiographic results. AJNR Am J Neuroradiol 2003;24:257-62.  Back to cited text no. 5
    
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Molyneux AJ, Kerr RS, Birks J, Ramzi N, Yarnold J, Sneade M, et al. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the international subarachnoid aneurysm Trial (ISAT): Long-term follow-up. Lancet Neurol 2009;8:427-33.  Back to cited text no. 7
    
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Raymond J, Guilbert F, Weill A, Georganos SA, Juravsky L, Lambert A, et al. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke 2003;34:1398-403.  Back to cited text no. 8
    
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Sharma DP, Singh D, Jagetia A, Singh H, Tandon M, Ganjoo P. Intra procedure rupture of intracranial aneurysm during endovascular coiling: Neurosurgeons' experience and review of the literature. Neurol India 2011;59:690-5.  Back to cited text no. 10
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Thornton J, Debrun GM, Aletich VA, Bashir Q, Charbel FT, Ausman J. Follow-up angiography of intracranial aneurysms treated with endovascular placement of guglielmi detachable coils. Neurosurgery 2002;50:239-49.  Back to cited text no. 11
    
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Fernandez Zubillaga A, Guglielmi G, Viñuela F, Duckwiler GR. Endovascular occlusion of intracranial aneurysms with electrically detachable coils: Correlation of aneurysm neck size and treatment results. AJNR Am J Neuroradiol 1994;15:815-20.  Back to cited text no. 12
    
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Dutta G, Sachdeva D, Singh D, Singh H, Srivastava AK. Mechanical versus electrical detachment of coils in treatment of intracranial aneurysms: Role in sickle cell disease. Neurol Neurochir Pol 2018;52:759-61.  Back to cited text no. 13
    
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Ng P, Khangure MS, Phatouros CC, Bynevelt M, ApSimon H, McAuliffe W. Endovascular treatment of intracranial aneurysms with Guglielmi detachable coils: analysis of midterm angiographic and clinical outcomes. Stroke 2002;33:210-7.  Back to cited text no. 14
    
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Parkinson RJ, Eddleman CS, Batjer HH, Bendok BR. Giant intracranial aneurysms: Endovascular challenges. Neurosurgery 2008;62:1336-45.  Back to cited text no. 17
    
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Renowden SA, Koumellis P, Benes V, Mukonoweshuro W, Molyneux AJ, McConachie NS. Retreatment of previously embolized cerebral aneurysms: The risk of further coil embolization does not negate the advantage of the initial embolization. AJNR Am J Neuroradiol 2008;29:1401-4.  Back to cited text no. 18
    
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Lanzino G, Crobeddu E, Cloft HJ, Hanel R, Kallmes DF. Efficacy and safety of flow diversion for paraclinoid aneurysms: A matched-pair analysis compared with standard endovascular approaches. AJNR Am J Neuroradiol 2012;33:2158-61.  Back to cited text no. 19
    
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Kan P, Siddiqui AH, Veznedaroglu E, Liebman KM, Binning MJ, Dumont TM, et al. Early postmarket results after treatment of intracranial aneurysms with the pipeline embolization device: A U.S. multicenter experience. Neurosurgery 2012;71:1080-7.  Back to cited text no. 21
    
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