J Cerebrovasc Endovasc Neurosurg.  2019 Jun;21(2):67-76. 10.7461/jcen.2019.21.2.67.

Endovascular treatment of ruptured tiny aneurysms

• Kim JH
• Choi CH
• Lee JI
• Lee TH
• Ko JK

• KMID: 2465199
• DOI: http://doi.org/10.7461/jcen.2019.21.2.67

Abstract

OBJECTIVE
Endovascular coiling of ruptured tiny aneurysms (RTAs) in the brain has been known to be technically challenging owing to the higher rate of adverse events, such as thromboembolism and intraoperative rupture. The aim of this study was to report our ex-periences of endovascular treatment of RTAs (size, ≤3 mm).
METHODS
From January 2006 to December 2017, 35 RTAs in 35 patients were treated at our institution with an endosaccular coiling. Procedural data and clinical and angiographic results were retrospectively reviewed.
RESULTS
The mean size of the RTAs was 2.53 mm (SD: 0.38). The neck remodeling technique was applied to 14 aneurysms, including stent-assisted coiling (n=7) and balloon-assisted coiling (n=7). Procedure-related complications included intraprocedural rupture (n=2), thromboembolic event (n=1), and early rebleeding (n=2), which needed recoiling. Regarding immediate angiographic control, complete occlusion was achieved in 25 aneurysms (71.4%), small neck remnant in 5 (14.3%), and definite remnant in 5 (14.3%). At the end of follow-up, 31 of the 35 patients (88.6%) were able to function independently. Twenty-two of the 35 patients underwent follow-up conventional angiography (mean, 468 days). Stable occlusion was achieved in 20 of the 22 patients (90.9%), minor recanalization in 1 (4.5%), and major recanalization, which required recoiling, in 1 (4.5%).
CONCLUSION
Our experiences demonstrate that endovascular treatment for RTAs is both feasible and effective. However, periprocedural rebleedings were found to occur more often (11.4%) than what is generally suspected.

Keyword

Endovascular coiling; Cerebral aneurysm; Tiny aneurysm

MeSH Terms

Aneurysm*
Angiography
Brain
Follow-Up Studies
Humans
Intracranial Aneurysm
Neck
Retrospective Studies
Rupture
Thromboembolism

Figure

• 

  Fig. 1 Images of a 73-year-old woman with a ruptured aneurysm of the left A1 segment. (A) Diagnostic angiography demonstrates a 2.8-mm saccular aneurysm (arrow) arising at the left proximal A1. (B) Sceptor C balloon is positioned across the aneurysmal neck to stabilize the microcatheter and prevent intraprocedural rupture at the same time. (C) Owing to the broad-neck configuration of this aneurysm, the coil mass was supported by a Neuroform 3 stent at the end of the procedure. (D) Subtracted image acquired immediately after coiling demonstrate complete occlusion of the aneurysm (arrow) without compromising the parent artery.

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  Fig. 2 Images showing a 2.5-mm ruptured aneurysm of the left anterior communicating artery in a 34-year-old man. (A) Unsubtracted image acquired immediately after simple coiling demonstrating complete aneurysm occlusion. Unsubtracted (B) and subtracted (C) images acquired immediately after rebleeding two weeks later show reopening by enlargement of the aneurysm. (D) Additional coiling was performed.

• 

  Fig. 3 Recanalization requiring re-treatment. (A) A 49-year-old woman with subarachnoid hemorrhage found to have a distal A1 aneurysm (arrow) projecting to the left and measuring 2.9 mm in maximum diameter. (B) Unsubtracted image acquired immediately after simple coiling demonstrating complete aneurysm occlusion. (C) Follow-up angiogram at 14 months shows reopening by enlargement of the aneurysm in diameter and more loosened coil frame. (D) Final image acquired immediately after additional coiling demonstrates complete occlusion of the aneurysm.

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