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Published on : Mar 14, 2014
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Slide 1 - Unruptured MCA aneurysm coiling O Mansour, J Weber and M Schumacher Neuroradiology Depart. Freiburg Univ. Neurology Depart. Alexandria Univ. Department of Neuroradiology, Neurocenter University of Freiburg, Germany Alexandria University , Faculty of medicine Neurology Depart. Egypt
Slide 2 - Endovascular coiling of MCA aneurysms has shown higher procedural failure rate and less favorable results compared to the treatment of aneurysms at other sites (ISAT group, Lancet 2002; Suzuki S,Neurosurgery 2009) In ruptured MCA aneurysms, subgroup analysis of ISAT in older patients more than 65 years revealed inferiority of coiling to clipping (Ryttlefors M, Stroke 2008)
Slide 3 - Elderly patients with ruptured MCA aneurysms benefit more from neurosurgical clipping. M Ryttlefors et al , Stroke 2008
Slide 4 - Another hindering factor is what is called the wild morphological gallery of MCA aneurysm ICH more often associated with ruptured MCA aneurysms Reasons for less favorable outcome :
Slide 5 - Pretreatment study of morphology in 126 MCA aneurysms
Slide 6 - Russian Matroska appearance
Slide 7 - Marge simpson head
Slide 8 - Dew drop
Slide 9 - • In the treatment of unruptured intracranial aneurysms endovascular coiling has shown equal or superior results to clipping (Higashida RT, AJNR 2007) unruptured But for unruptured MCA aneurysms coiling has been limited, mainly due to the unfavorable aneurysm geometry (wide neck and/or incorporation of a branch into the neck) (Doerfler A , AJNR 2006)
Slide 10 - Modified endovascular techniques and devices, such as multi-catheter, balloon-assisted, stent-assisted, or combination of these, permit coiling even of aneurysms having a complex anatomy (Lubicz B, AJNR 2006)
Slide 11 - Methods and patients Patients with mild neurological deficit (mRS, 0 - 2) were included Former SAH from another aneurysm Who accidentally discovered during non hemorrhagic neurological manifestation Between 2001-2009 retrospectively 70 patients with 76 unruptured MCA aneurysms were included, reviewed and evaluated . 30 men and 40 women aged from 27 to 77 years (mean, 59 years)
Slide 12 - results
Slide 13 - Mean age of our cohort was 59 years with IQR ( 27-77 years) , 30 (42.9%) patients were male.
Slide 14 - Results Table 1: aneurysms measurements and endovascular methods used in occlusion . Treatment methods (n=75) Aneurysm distribution site(n=75)
Slide 15 - Coiling failed in 1/76 = 1.3% Death rate was in 1/76 = 1.4% ( SAH consequence Complication rate was in 1/76 = 1.4% (perforation and treated without sequlae ) infarction occurred in relevant MCA territory in 2 patients, but both of them completely recovered at discharge permanent morbidity 1/76=1,4% Failure Rate Procedural complications Mortality Rate Morbidity Rate
Slide 16 - Follow-up results
Slide 17 - Follow-up angiographies at least once at 6 – 24 months (mean, 11 months) period of follow up. 69/75 aneurysm (92%) 6 (8.6%) minor recurrences 3 (4.3%) major recurrences retreated by coiling without any complication. Mori et. al. classification
Slide 18 - Case 1, catheter-assisted two-catheter technique
Slide 19 - Case 2 , stent-assisted coil embolization for both aneurysms
Slide 20 - Case 3 , HyperForm balloon assisted coiling
Slide 21 - discusion
Slide 22 - MCA aneurysms should not be allocated solely to clipping but only the large MCA aneurysms in young patients, which are likely to recur
Slide 23 - Some limitations are present in this series Small, unruptured MCA aneurysms were treated. (randomized retrospective study) Because of the retrospective nature of this study, another limitation is selection bias Limited number of angiographic follow-up may have lowered the recurrence rate
Slide 24 - Thank you
Slide 25 - Introduction Since intracranial subarachnoid aneurysm trial (ISAT),[1] endovascular coiling has been increasingly used as first treatment option for ruptured or unruptured aneurysms that are feasible for coiling. Intracranial subarachnoid aneurysmal trial (ISAT) proved the superiority of endovascular coiling for the treatment of ruptured intracranial aneurysms over microsurgical clipping.
Slide 26 - MCA aneurysm State Of the Art Mangement However, for the middle cerebral artery (MCA) aneurysms, endovascular coiling is less likely to be applied as routine agreement Ruptured
Slide 27 - in ruptured MCA aneurysms The most widely accepted theory presumed to be responsible for the inconvenient outcome Hematoma frequently associated with ruptured MCA aneurysm may be a cause of unfavorable outcome of coiling, because coiling itself cannot remove the hematoma.
Slide 28 - MCAa Unique Morphology Gallery The aneurysm geometry unfavorable for coiling, which is frequently met in MCA aneurysms, can be another factor.
Slide 29 - But other more complicated discrible morphologies could be encounterd
Slide 30 - Used modified techqniue
Slide 31 - Follow-up angiographies at least once at 6 – 24 months (mean, 11 months) period of follow up. 69/75 aneurysm (92%) 6 (8.6%) minor recurrences 3 (4.3%) major recurrences retreated by coiling without any complication. 60 (87.1%) major recurrences Mori et. al. classification