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Neuroradiology |
1 From the Service de Neuroradiologie Interventionnelle et Fonctionnelle, Fondation Adolphe de Rothschild, 25-29 rue Manin, 75940 Paris Cedex 19, France. Received June 8, 2004; revision requested August 20; revision received December 20; accepted January 21, 2005. Address correspondence to J.M. (e-mail: jmoret{at}fo-rothschild.fr).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS: This retrospective study had institutional review board approval, and informed consent was obtained. One hundred fifty-four MCA aneurysms in 142 patients were intended to be treated. Complications, patient clinical outcomes, and immediate postprocedural and follow-up angiography results were retrospectively evaluated.
RESULTS: One hundred forty-nine (96.8%) of 154 MCA aneurysms (72 ruptured, 77 unruptured) were occluded with coils in 137 patients (99 women and 38 men; age range, 28–76 years; mean, 48 years). Thromboembolic events occurred in 20 (13.4%) and aneurysm perforation occurred in seven (4.7%) of 149 procedures. Endovascular treatment (EVT) was performed without complications for 121 (81.2%) of the treated aneurysms. For ruptured aneurysms, the treatment-related mortality rate was 6% (four of 72 aneurysms) and the treatment-induced permanent morbidity rate was 1% (one aneurysm). For unruptured aneurysms, the treatment-induced mortality rate was 1% (one of 77 aneurysms) and the procedure-related permanent morbidity rate was 3% (two aneurysms). One hundred five (70.5%) of the 149 aneurysms were examined with follow-up angiography at least once. Recurrences were found for 21 (20%) of the 105 aneurysms that were followed up for a cumulative period of 1564 months (mean, 15 months). Of these 21 recurrent aneurysms, 10 increased in size in the interval between follow-up angiography examinations and 11 remained stable. A second treatment was required for 12 aneurysms, and a third treatment was required for one. After repeat EVT, total aneurysm occlusion was attained for nine aneurysms, and a residual neck was seen in two aneurysms. One recurrent aneurysm was surgically clipped. The nine other aneurysms with small recurrences were not candidates for additional treatment.
CONCLUSION: EVT of MCA aneurysms with coils can be successfully performed without inducing neurologic deficits in most patients with ruptured or unruptured aneurysms.
© RSNA, 2005
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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For each patient, a member of the neurointervention team (M.P., C.M., L.S., A.W., or J.M.) prospectively recorded the following: demographic data, findings at clinical presentation (including Hunt and Hess grade in case of hemorrhage), source of hemorrhage, therapeutic interventions performed, treatment-related complications, immediate patient outcome, and patient outcome at follow-up. The number of MCA aneurysms treated endovascularly from February 1998 to December 2002 was recorded retrospectively (A.I.). Immediate anatomic results and results at angiographic follow-up were recorded in a retrospective manner by a neurosurgeon (A.I.).
Aneurysm Classification
In this retrospective study, the analysis of aneurysm characteristics (location and dome and neck sizes) was performed by a senior neurosurgeon (A.I., who had 9 years of experience) on the basis of precise measurements made on three-dimensional angiograms. Aneurysms were classified according to their location (whether before, at, or beyond the MCA division).
EVT Technique
The timing of EVT relative to the date of the subarachnoid hemorrhage (SAH) was prospectively recorded for all patients who had hemorrhage at presentation. All aneurysm embolizations were performed with detachable coils by using a femoral or a bifemoral 6-F access sheath or sheaths. (Bifemoral access was used when the balloon-remodeling technique was performed [4].) The use of the remodeling technique was noted in a prospective manner. All procedures were performed with general anesthesia and full anticoagulation (5000 IU of heparin given as an intravenous bolus injection, followed by continuous infusion of 2500–3000 IU per hour). Anticoagulation therapy was aimed at keeping the activated clotting time during catheterization and coil deposition at two to three times above the normal value (100 seconds). In addition, in all patients with no history of SAH within the previous 4 weeks, 250 mg of aspirin were given intravenously as a single dose at the beginning of the procedure. Heparin was discontinued after embolization in the majority of patients.
Rotational angiography (Integris; Philips, Best, the Netherlands), followed by three-dimensional reconstruction of the native projections, was performed just before the embolization procedure was begun. On the basis of the images generated with the rotational acquisition, one to two working projections (angiographic projections that best delineated the relationship between the aneurysm neck and the parent vessel) that gave the operators the best achievable view of the aneurysm neck were defined. Several authors (M.P., C.M., and L.S., all of whom had 2 years of experience; and A.W. and J.M., who had 3 and 21 years of experience, respectively, at the time patients were first treated in this study) served as the operators. At the end of the procedure, posttherapeutic angiograms in frontal, lateral, and working projections were acquired so that we could rule out any parent artery or branch occlusion. In accordance with our routine practice for all intracranial EVT procedures since 1998, all patients underwent immediate pre- and postoperative computed tomographic (CT) scanning of the head in the angiography room so that any subarachnoid or intraparenchymal (re)bleeding could be detected.
Complications, Clinical Outcome, and Follow-up
For the purpose of this study, procedure-related complications were noted and clinical outcomes were evaluated separately for the ruptured and unruptured aneurysms in a retrospective manner (A.I.) by using patient medical charts. The patients were clinically assessed before and after EVT at the time of discharge from the hospital by any one of the several members of the neurointervention team (M.P., C.M., L.S., A.W., or J.M.)—that is, the clinical assessment was not necessarily performed by the physician who was initially in charge of the EVT. Clinical outcome was determined at the time of the first follow-up angiographic examination or, for the patients who were not followed up at our institution, with a telephone interview. Each patient's outcome was graded according to the modified Rankin scale (5), in which a score of 0 indicates that the patient has no symptoms at all; a score of 1, that the patient has no marked disability despite symptoms; a score of 2, that the patient is able to perform all usual duties and activities; a score of 3, that the patient has moderate disability and requires some help but is able to walk without assistance; a score of 4, that the patient has moderately severe disability, is unable to walk without assistance, and is unable to attend to his or her own bodily needs without assistance; a score of 5, that the patient has severe disability and is bedridden, incontinent, and requires constant nursing care and attention; and a score of 6, that the patient is dead.
Angiographic Results and Follow-up
Aneurysm occlusion at the end of the procedure and at follow-up angiography was considered to be complete when the aneurysm sac and neck were packed and there was no filling of the aneurysm sac by contrast material, near complete when the sac was occluded but a neck remnant either was thought to be present or was obviously present, and incomplete when there was persistent opacification of a sac remnant. Our angiographic follow-up protocol for the MCA aneurysms was the same as the protocol we normally use for other aneurysms: A first follow-up examination was performed during the 1st year after EVT (usually between 3 and 6 months), a 2nd-year follow-up examination was performed between 12 and 18 months after EVT, and a 3rd-year follow-up examination was performed between 24 and 36 months after EVT. Angiographic follow-up consisted of the acquisition of frontal, lateral, and working projections that were determined according to the locations of the patient's bone landmarks as they had been defined during the EVT procedure.
An aneurysm was considered to be recurrent if a previously completely occluded aneurysm was seen to have a partial or even small recanalization of the neck. In addition, an aneurysm was considered to show remnant regrowth if a previously subtotally occluded aneurysm was found to have a neck remnant that had increased in size at follow-up angiography. For the purposes of this study, factors influencing recurrences at angiography (mode of presentation, aneurysm dome and neck sizes, initial angiographic result) were analyzed independently.
Statistical Analysis
The incidence of complications was evaluated against the mode of presentation (ie, whether the aneurysm was ruptured or unruptured at presentation) by using the Fisher exact test. Recurrence rates were evaluated according to the mode of presentation, initial angiographic results, and aneurysm neck size by using the Fisher exact test. Recurrence rates were evaluated according to aneurysm sizes by using the 
2 test for trends. P 
.05 was considered to indicate a statistically significant difference. All statistical tests were performed with InStat software, version 3.06 (GraphPad Software, San Diego, Calif).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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For the purpose of calculating the follow-up period, initial presentation was considered to have occurred at the time of the EVT. Seventy-nine (57.7%) of the 137 patients had SAH at presentation, while the aneurysm was incidentally discovered in 58 (42.3%) patients. Among the 79 patients who had hemorrhage at presentation, 72 (91%) had bleeding from an MCA aneurysm, while seven (9%) had hemorrhaging from an aneurysm at another location. In 22 (31%) of the 72 patients with SAH caused by an MCA aneurysm, the SAH was given a Hunt and Hess grade of I; in 24 (33%) patients, it was given a grade of II; in 17 (24%) patients, it was given a grade of III; in five (7%) patients, it was given a grade of IV; and in four (6%) patients, it was given a grade of V (percentages may not add up to 100% owing to rounding). Ninety-four (69%) of the 137 patients had a single aneurysm, while 43 (31%) patients had multiple aneurysms. Five (12%) of the 43 patients with multiple aneurysms had multiple MCA aneurysms.
Aneurysm Characteristics
Sixteen (10.7%) of the 149 aneurysms treated with EVT were located in the main trunk (M1 segment) of the artery, 122 (81.9%) were located at the first major bifurcation, and 11 (7.4%) were located beyond the major bifurcation. On the basis of measurements performed on the three-dimensional angiograms, aneurysm maximum diameters ranged from 2 to 16 mm (mean, 7 mm ± 3 [standard deviation]), and aneurysm neck sizes ranged from 1 to 9 mm (mean, 3.5 mm ± 1.3). The maximum diameters of the unruptured MCA aneurysms ranged from 3 to 13 mm (mean, 7 mm ± 2). None of the 149 aneurysms had previously been treated with coils.
Results of EVT
Thirty-six (50%) of the 72 ruptured MCA aneurysms were treated within 3 days after the onset of SAH, 33 (46%) were treated within 4–14 days, and three (4%) were treated within 15–28 days. Among the 77 unruptured MCA aneurysms, 68 (88%) were detected at presentation (54 were detected at CT or magnetic resonance examinations performed in the setting of non–SAH-related headaches; six, at an examination performed in the setting of tinnitus; five, at an examination performed in the setting of epileptic seizures; two, at an examination performed in the setting of dizziness; and one, at an examination performed in the setting of polycystic kidney disease), while six (8%) aneurysms were recognized at the time of rupture of another MCA aneurysm and three (4%) were considered to be remnants left behind after a previous surgical clipping.
One hundred forty-three (96.0%) of the 149 treated aneurysms were occluded with bare coils. Four (2.7%) of the treated aneurysms were occluded with Matrix coils (Boston/Target, Fremont, Calif), while HydroCoils (Microvention, Aliso Viejo, Calif) were used in one aneurysm (0.7%) and both Matrix and HydroCoils were used in another (0.7%). Sixty-six (44.3%) aneurysms (25 [35%] of the 72 ruptured aneurysms and 41 [53%] of the 77 unruptured aneurysms) were treated by using the balloon-assisted technique (the so-called balloon-remodeling technique) (Figs 1, 2).
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Aneurysm Perforation
Perforation during EVT was observed in seven (4.7%) of the 149 aneurysms (four [6%] of the 72 ruptured and three [4%] of the 77 unruptured aneurysms). Two of the patients with aneurysm perforation died (one had sustained a previous SAH; the second patient was treated for an incidentally discovered MCA aneurysm). The five other patients had a good recovery despite the aneurysm perforation during EVT. Overall, aneurysm perforation during EVT was fatal for two (1.3%) of 149 aneurysms. Perforation was slightly but not significantly more frequent (P = .714) in ruptured aneurysms.
Thromboembolic Complications
Overall, angiographically documented thromboembolic complications were noted for 20 (13.4%) of the 149 treated aneurysms (13 [18%] of the 72 ruptured and seven [9%] of the 77 unruptured aneurysms). These complications resulted in three (2.2%) deaths, two (1.5%) severe disabilities (modified Rankin scale score, >3), one (0.7%) moderate disability (modified Rankin scale score, 3), and two (1.5%) transient ischemic deficits that resolved within 24 hours. Thromboembolic events were slightly but not significantly more frequent (P = .149) in ruptured aneurysms.
Patient Outcomes
Patients with ruptured MCA aneurysms.—Five (7%) of the 72 patients with ruptured aneurysms died as a consequence of SAH (three died because of the primary brain damage caused by the hemorrhage, and the other two died as a consequence of vasospasm and subsequent cerebral ischemia). Four (6%) patients with ruptured aneurysms died of complications from the treatment (one death was caused by aneurysm perforation, and three deaths were caused by arterial branch occlusions). The overall mortality rate in this group of patients was 12% (nine of 72 patients).
All of the other patients in this group were followed up clinically for at least 3 months after the EVT. Sixty-one (85%) patients experienced good recoveries (modified Rankin scale score, 0–3), one (1%) had severe disabilities in keeping with the consequences of a cerebral infarct secondary to arterial branch occlusion caused by the EVT (modified Rankin scale score, 4), and one (1%) had a transient deficit that resolved within 24 hours after the EVT and was in keeping with the consequences of a thromboembolic MCA branch occlusion.
One patient (1%) experienced rebleeding after EVT; the aneurysm was considered subtotally occluded after the initial treatment. This patient was one of two patients for whom staged procedures were scheduled because of complex aneurysmal structures. Five days after the first embolization (6 days after SAH), the aneurysm re-bled and was immediately treated with surgical clipping. The patient had a good recovery. No other patient experienced rebleeding after EVT. Overall, the procedure-related permanent morbidity and mortality rates in this group of patients were 1% (one patient) and 6% (four patients), respectively. The rate of mortality and severe disability (modified Rankin scale score, 4–6) at 3 months was 14% (10 of 72 patients).
Patients with unruptured MCA aneurysms.—Two (3%) of the 58 patients who had an unruptured MCA aneurysm alone experienced permanent procedure-related ischemic complications; one patient experienced slight hemiparesis (modified Rankin scale score, 3) after a CT-documented cerebral infarction 13 days after the procedure, and a second patient was severely disabled as a consequence of an angiographically documented MCA branch occlusion (modified Rankin scale score, 4). One (2%) patient died as the consequence of an aneurysm perforation during EVT that caused a temporal lobe hematoma. Three (5%) patients (two of whom had no evidence of arterial branch occlusion on the "control" angiogram acquired at the end of the EVT procedure) experienced transient ischemic deficits; one patient experienced such a deficit 2 hours after the procedure, and the two others experienced such a deficit 2 days after the procedure. The rate of procedure-related morbidity, including transient deficits, was 9% (five of 58 patients). Overall, the procedure-related permanent morbidity and mortality rates in this group of patients were 3% (two patients) and 2% (one patient), respectively. The rate of mortality and severe disability (modified Rankin scale score, 4–6) at 3 months was 3% (two patients).
Patients with an unruptured MCA aneurysm but a ruptured aneurysm at another location.—Seven (5.1%) of the 137 patients had an unruptured MCA aneurysm that was treated during the acute phase of another ruptured aneurysm. One of these patients died of the consequences of vasospasm, but the six others had a good recovery (modified Rankin scale score, 0–2). In this group of patients, the rate of mortality and severe disability (modified Rankin scale score, 4–6) at 3 months was 14% (one of seven patients).
Treatment-induced Complications according to Mode of Presentation
The rates of complication and death in the 137 patients were analyzed depending on the mode of presentation. The rate of treatment-induced complications that had clinical impact (including transient ischemic attacks) was 10% (seven of 72 patients) for ruptured MCA aneurysms and 9% (six of 65 patients) for unruptured MCA aneurysms. There were no statistically significant differences between complication rates according to clinical presentation. Treatment-related death occurred in four (6%) of the 72 patients with a ruptured MCA aneurysm and in one (2%) of the 65 patients with an unruptured MCA aneurysm. This difference was not significant (Table 1).
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Recurrences were observed in 21 (20.0%) of the 105 aneurysms that were followed up during a cumulative period of 1564 months (mean, 15 months ± 12). All 21 recurrences were observed in the first 2 years of follow-up after EVT: 16 during the 1st year and five during the 2nd year. The patients with two of these five recurrences did not undergo 1st-year follow-up angiography. Recurrences were observed between 3 and 24 months (mean, 9 months ± 6). Of these 21 recurrences, 10 increased in size in the time between follow-up angiographic examinations, while the 11 others remained stable. A second treatment was required for 12 of the 21 recurring aneurysms, and a third treatment was required for one of the 12 aneurysms. After a second or third EVT, total aneurysm occlusion was achieved in nine of the 12 re-treated aneurysms, while a residual neck was noted in two aneurysms (Fig 3). One recurrence was surgically clipped. The other nine aneurysms with recurrence were not candidates for a second treatment because these recurrences appeared to be too small for further coil placement.
Factors Influencing Aneurysm Recurrences
Mode of presentation.—The rate of recurrence was 29% (15 of 52 aneurysms) for ruptured and 11% (six of 53 aneurysms) for unruptured aneurysms (Table 2). The difference in the recurrence rate between ruptured and unruptured aneurysms was found to be significant, despite the fact that both ruptured and unruptured aneurysms were treated with coil packing to the same extent.
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5 mm), 20% (10 of 51 aneurysms) for aneurysms between 6 and 10 mm in diameter, and 46% (six of 13 aneurysms) for aneurysms with a diameter of 11 mm or greater (Table 3). There was a significant difference among recurrence rates according to the size of the sac.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Thromboembolic complications.—Thromboembolic events (which occurred in 18% of ruptured vs 9% of unruptured MCA aneurysms), however, remained an important problem in the present study. Our rate of thromboembolic events in ruptured MCA aneurysms was substantially higher than the previously reported rate of thromboembolic complications in ruptured cerebral aneurysms of all kinds (13–15). This finding might be explained by the peculiar anatomy of MCA aneurysms, which are located on sometimes complex arterial bifurcations or trifurcations. The fact that we do not routinely administrate antiplatelet agents (eg, aspirin) in the acute setting of SAH may also explain the overincidence of thromboembolic events in the group of patients with ruptured MCA aneurysms.
Patient Outcomes
Ruptured MCA aneurysms.—In the present study, the rate of mortality and severe disability at 3 months was 14% (modified Rankin scale score, 4–6) in the patients with ruptured MCA aneurysms.
The importance of EVT with detachable platinum coils of ruptured intracranial aneurysms has now been firmly established with the publication of results of the International Subarachnoid Aneurysm Trial, or ISAT (16). At the time of their publication, the results of the ISAT, which involved specific treatment selection criteria, indicated that there was a rate of neurologic disability or death of 23.7% at 1 year in the group of patients who underwent EVT, versus a rate of 30.6% in the group of patients who underwent surgical clipping; hence, there was an absolute 6.9% reduction in the rate of death or dependency at 1 year for patients treated with EVT compared with the rate for patients treated with surgical clipping (this increased to an absolute 8.8% reduction, according to figures updated as of June 2003 for 1888 patients). The ISAT did not, however, address the specific issue of patients with ruptured MCA aneurysms, who represented only 303 (14.1%) of the 2143 enrolled patients.
Information regarding the specific outcome of patients with surgically or endovascularly treated ruptured MCA aneurysms is still limited. In 1996, Rinne et al (17) reported the clinical outcome of 438 patients with ruptured MCA aneurysms among a series of 1314 consecutive patients. The authors noted a good recovery rate of 60%, with a morbidity rate of 26% and a mortality rate of 14%; the poor outcomes depended on the multiplicity of aneurysms, the presence of intracerebral hemorrhages accompanying aneurysm ruptures, and the presence of giant aneurysms. However, patients with ruptured MCA aneurysms had surprisingly bad treatment outcomes, despite the good surgical results achieved in patients with good Hunt and Hess grades at presentation, and there were significantly more poor outcomes (Glasgow Outcome Scale score, 3–5) among patients with ruptured MCA aneurysms than among those with any other kind of ruptured anterior circulation aneurysm. Unlike our series, the surgical series of Rinne et al was not affected by selection bias regarding aneurysm size or neck dimension.
Unruptured MCA aneurysms.—In the present study, the overall procedure-related permanent morbidity and mortality rates in patients with unruptured MCA aneurysms were 3% and 2%, respectively. Our rate of procedure-related permanent morbidity is similar to the 5.2% reported by Roy et al (18). On the other hand, Roy et al reported no mortality in their series of 125 unruptured aneurysms treated with coils.
Recently, data from a prospective observational study, the International Study of Unruptured Intracranial Aneurysms, have been published (11). These results show that the surgical management of unruptured aneurysms yields a surprisingly poor clinical outcome (based on the combined modified Rankin scale scores of 3–6 or the cognitive deficits seen at 30-day follow-up), with a combined morbidity and mortality rate of 13.7%. Subgroup analysis according to aneurysm size revealed that the rate of poor clinical outcomes was significantly higher for large and giant aneurysms than for small aneurysms, with a 10% rate of poor outcome for aneurysms 10–24 mm in diameter and an 18% rate of poor outcome for giant aneurysms. Analysis of the angiographic occlusion rates after EVT, however, revealed a complete occlusion rate of only 50% at 1 year. Twenty-five percent of aneurysms were incompletely occluded, and an additional 25% were not occluded at all. Far fewer patients were treated with endovascular (n = 451) than with surgical (n = 1916) means. However, the number of MCA aneurysms that were endovascularly treated was low (n = 54) compared with the number of MCA aneurysms that were surgically treated (n = 650).
However, Barker et al (19), after a retrospective cohort study that included 3498 patients who underwent surgical clipping and 421 who underwent endovascular coil placement, reported that there were no significant differences in mortality rates or rates of discharge to long-term facilities whether unruptured aneurysms were treated by clipping or with coil placement. When discharge to short-term rehabilitation was counted as an adverse event, patients who underwent coil placement had significantly better outcomes at the time of hospital discharge than did patients who underwent surgical clipping, but most of the advantage of coil placement was concentrated in patients older than 65 years of age.
Immediate Angiographic Results and Follow-up
EVT is, by nature, less frequently a complete treatment than is surgical clipping of aneurysms. Furthermore, recurrences are clearly more frequent with EVT, even though follow-up angiographic examinations are not frequently performed after surgical clipping (20). It has been shown that occlusion of the aneurysm sac—whether or not a residual neck is left—is sufficient to prevent rebleeding for 98.5% of acutely ruptured aneurysms (21). Conversely, the presence of a residual aneurysm is associated with a 5% rate of rebleeding (15). By extension, when EVT of unruptured aneurysms results in persistent filling of the aneurysm sac, we consider that the patient is not totally protected against bleeding. The reported incidence of residual neck filling at "control" angiography performed after surgical clipping of an aneurysm ranges between 3.8% and 8% (22–25). The incidence of regrowth for aneurysms that were totally occluded after surgical clipping varies from 1.5% (20) to 2.4% (26). In a series of 114 patients with unruptured clipped aneurysms, Tsutsumi et al (27) found a cumulative risk of SAH of 1.4% in 10 years and 12.4% in 20 years.
Factors that have been previously identified as significant predictors of recurrence after coil placement include suboptimal initial angiographic results, treatment after rupture, and aneurysm size (14,28–34). These risk factors of angiographic recurrence have been validated in our study, which focused on MCA aneurysms. In a previous study involving 148 intracranial berry aneurysms that were totally occluded after EVT, Cognard et al (28) found a 16% recurrence rate for MCA aneurysms, a result quite similar to our overall 20.0% rate. The lack of information to date regarding both the rate of residual aneurysm filling or regrowth and the long-term angiographic follow-up of patients with surgically treated MCA aneurysms makes meaningful comparison between surgical treatments and EVT for these lesions difficult or impossible. However, it is likely that aneurysm remnants and recurrences are more frequent after coil placement than after surgical clipping, even if surgical series involving follow-up angiographic examinations are rare (20).
Study Limitations
The purpose of our study was to specifically address the clinical and angiographic outcomes of MCA aneurysms after coil placement. Our series was by definition a selected one because the majority of our patients were referred from other centers, either by neurosurgeons or by neurointerventionists, and only MCA aneurysms that were treated selectively with coils were included. Even though in France EVT is considered the first treatment option for both ruptured and unruptured aneurysms, it is more than probable that many patients with ruptured MCA aneurysms that were surrounded by compressive hematomas were directly treated with surgery and not sent to our institution for EVT. However, lesions for which the primary EVT consisted of parent vessel sacrifice (with or without previous external carotid artery–to–distal MCA surgical bypass) were excluded from our series because the recurrence issue does not apply to this subgroup of aneurysms. The fact that only 70.5% of the treated aneurysms were followed up adds to the limitations of this study.
Conclusion
EVT of MCA aneurysms with coils could be achieved without treatment-induced major neurologic deficit (modified Rankin scale score, 3) in 97% of the patients with unruptured MCA aneurysms and in 93% of the patients with ruptured MCA aneurysms. Advances in device technology and technique may further improve future outcomes. Morphologic findings revealed total obliteration of 77.2% of the aneurysms that were treated with coil placement. A longer follow-up period is necessary to determine the efficacy of EVT of MCA aneurysms with coils. Because coil placement is relatively safe, we propose to compare conservative treatment and EVT for patients with unruptured MCA aneurysms in a randomized large-scale multicenter study.
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FOOTNOTES |
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Abbreviations: EVT = endovascular treatment • MCA = middle cerebral artery • SAH = subarachnoid hemorrhage
Authors stated no financial relationship to disclose.
Author contributions: Guarantors of integrity of entire study, M.P., J.M.; study concepts and design, M.P.; literature research, A.I., M.P.; clinical studies, M.P., C.M., L.S., A.W., J.M.; data acquisition, M.P., C.M., L.S., A.W., J.M.; data analysis/interpretation, A.I., M.P.; statistical analysis, M.P.; manuscript preparation, editing, and revision/review, A.I., M.P.; manuscript definition of intellectual content and final version approval, M.P.
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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