Midterm prevention of rebleeding by Guglielmi detachable coils in ruptured intracranial aneurysms less than 10 mm

Clinical Neurology and Neurosurgery 108 (2006) 163–167

Midterm prevention of rebleeding by Guglielmi detachable coils in ruptured intracranial aneurysms less than 10 mm Takuya Kawabe a , Hiroshi Tenjin a,∗ , Yasuhiro Hayashi a , Kiyoto Kakita b , Satoshi Kubo c a c

Department of Neurosurgery, Kyoto Prefectural Yosanoumi Hospital, 481, Otokoyama, Iwatakicho, Yosagun, Kyotofu 629-2261, Japan b Department of Neurosurgery, Kyoto First Red Cross Hospital, 15-749, Honmachi, Higashiyamaku, Kyoto 605-0981, Japan Department of Neurosurgery, Kyoto Second Red Cross Hospital, Kamazadori, Marutamachi Agaru, Kamigyoku, Kyoto 602-8026, Japan Received 23 November 2004; received in revised form 28 April 2005; accepted 24 May 2005

Abstract The midterm effects of coil embolization for ruptured aneurysm remain unknown. We investigated the prevention of rebleeding by GDC in ruptured aneurysms. Between March 1998 and April 2003, we treated 38 ruptured aneurysms measuring less than 10 mm in diameter. The patients were followed for a median of 37.3 months. During the follow-up term, aneurysms treated by coil embolization did not develop rebleeding after 1 month. We conclude that an embolized aneurysm measuring 10 mm or less remains quite stable over 3 years. © 2005 Elsevier B.V. All rights reserved. Keywords: Midterm follow-up; Ruptured aneurysm; Guglielmi detachable coil

1. Introduction Endovascular treatment of ruptured aneurysms using Guglielmi detachable coils (GDC) has been established as an alternative to surgical clipping. The International Subarachnoid Aneurysmal Trial (ISAT) [1] published in October 2002 showed that in patients with a ruptured intracranial aneurysm, for which endovascular coiling and surgical clipping were the therapeutic options, the outcome at 1 year was significantly better with endovascular coiling. The data also suggest that the short-term risks of rebleeding from the treated aneurysm are low following either treatment. However, the durability of GDC embolization over 1 year in ruptured aneurysms remains unknown. The treatment guidelines for subarachnoid hemorrhage in Japan [2] suggest that coil embolization is not the first indication for ruptured aneurysms because the long-term outcome of coil embolization is not yet known. In this study, we investigated whether or not GDC embolization prevented rebleeding over 1 year. We treated ruptured cerebral aneurysms with GDC embolization and ∗

Corresponding author. Tel.: +81 75 781 3641; fax: +81 75 781 5144. E-mail address: [email protected] (H. Tenjin).

0303-8467/$ – see front matter © 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.clineuro.2005.05.009

present our data here with a discussion of the prevention of rebleeding over 1 year, focussing on aneurysms measuring less than 10 mm in diameter.

2. Patients and methods Between March 1998 and April 2003, 92 patients with subarachnoid hemorrhage were treated in our institution. Fifty-one had direct surgery and 41 had coil embolization. This study focuses on 38 aneurysms measuring less than 10 mm in diameter (Table 1). We separated large aneurysms measuring more than 11 mm in diameter (Table 2), because poor treatment results have already been reported for large aneurysms [3–5]. The profiles of cases less than 10 mm were as follows: 24 coil embolizations were performed for anterior circulation aneurysms and 14 coil embolizations for posterior circulation aneurysms (Table 3). The mean age of the patients was 70.5 years (range 48–90). Coil embolization was performed in seven patients over 80 years of age (Table 4). We evaluated the preoperative state using Hunt & Kosnik (H&K) grading, which does not consider attendant circumstance. Six H&K grade II, 20 grade III, 7 grade IV, and 5 grade V patients

T. Kawabe et al. / Clinical Neurology and Neurosurgery 108 (2006) 163–167

164 Table 1 Summary of cases less than 10 mm Age

74 76 65 62 76 66 80 74 64 65 55 55 48 75 72 57 76 77 69 66 59 68 65 64 88 70 76 90 76 84 89 76 84 87 70 65 62 58

Sex

F F F F F F F F M M F M F M F M F F F M M M F M F F F M F F F M F F F F F F

Location

VA union BA SCA BA top IC ant chor VA union AcoA IC PcoA AcoA AcoA BA SCA AC distal AcoA IC PcoA AcoA PCA AC distal MCA VA PICA IC PcoA PCA AC distal BA AICA IC PcoA AcoA IC PcoA BA top AcoA AcoA IC PcoA IC PcoA BA top AC distal AcoA IC PcoA BA top BA top MCA BA top

H&K grade

Coiling after SAH (day)

II III IV V V III III III III III V III III III III II III III IV III III II IV III III IV IV II II III IV III III V IV II V III

3 0 17 0 0 0 0 0 0 0 0 0 0 0 3 1 10 0 0 0 0 9 0 9 1 1 0 1 0 0 0 15 1 0 14 0 0 0

Complication by coiling

Infarction Infarction

Infarction

Rebleeding by tPA Penetration

Angiogrphical results

GOS

Follow-up

Early

Late

Period (month)

Rebleeding

N C C C C N I N N N N C I N C C N I C C N C C C N C N C C N I C C N 90 N C C

G G G G MD MD SD MD G MD G MD MD G G G SD MD V MD SD MD SD MD MD MD SD MD MD SD SD SD MD D D D D D

G MD G G SD MD SD G G G G MD MD G G G D MD V SD SD SD SD MD MD G SD G MD D D MD D

71 62 62 62 60 59 56 56 55 52 52 50 44 43 43 43 39 37 32 32 29 25 23 21 19 18 17 16 15 14 12 9 2 <1 <1 <1 <1 <1

no no no no no no no no no no no no no no no no no no no no no no no no no no no no no no no no no

BA top: basilar artery top aneurysm; VA union: vertebral artery union aneurysm; IC ant chor: internal carotid artery anterior choroidal artery bifurcation aneurysm; BA SCA: basilar artery superior cerebellar artery bifurcation aneurysm; AcoA: anterior communicating artery aneurysm; IC PcoA: IC posterior communicating artery bifurcation aneurysm; PCA: posterior cerebral artery aneurysm; AC dist: anterior cerebral artery distal portion aneurysm; BA AICA: basilar artery anterior inferior cerebellar artery bifurcation aneurysm; MCA: middle cerebral artery bifurcation aneurysm; H&K: Hunt&Kosnik; C: complete occlusion; N: neck remnant; I: incomplete occlusion; early: GOS within 2 months; late: GOS after 3 months.

were treated by coil embolization (Table 5). In 25 patients, embolization was performed within 24 h from onset. The criterion of selection is overall judgement based on the location of aneurysm, age, and neurological grade.

One surgeon selected whether surgery or endovasucluar surgery should be performed in this study. The surgical procedure for coil embolization was as follows: angiography was performed using MULTISTAR TOP (Siemens Medical

Table 2 Summary of cases more than 11 mm Age

65 70 79

Sex

F F M

Location

IC PcoA BA top AC distal

H&K grade

IV I I

Coiling after SAH (day) 0 2 0

Complication by coiling

Angiogrphical GOS results Early

Late

Period (month)

Rebleeding

C N N

SD MD GR

24 24 14

no no no

SD GR GR

Follow-up

T. Kawabe et al. / Clinical Neurology and Neurosurgery 108 (2006) 163–167 Table 3 Location of aneurysms Coil embolization

Clipping

Anterior circulation AcoA ACA ICA MCA

9 4 9 2

15 3 9 23

Posterior circulation BAtop BA SCA VA union VA PICA PCA

6 2 1 2 1 2

1

Table 4 Age distribution

165

We investigated complications of the procedure, shortterm outcome, midterm outcome, and midterm rate of rebleeding. Outcome was accessed using the Glasgow outcome scale, that is, good (G), moderate disability (MD), severe disability (SD), vegetative state (V), and dead (D). On follow-up, angiograms were taken 3–6 months postoperatively and MRA was performed thereafter around every 6–12 months. When last angiography was performed, MRA was examined simultaneously, and then MRA was employed to follow up. Follow-up investigations consisted of direct clinical examination at the outpatient clinic, clinical reports from the referring physician, or telephone calls to the patient or patient’s family. The follow-up period was 37.3 ± 19.0 months (Table 1).

3. Results

Age

Coil embolization

Clipping

∼50 51∼60 61∼70 71∼80 >81

1 5 14 11 7

8 17 14 11 1

Engineering Group, Erlangen, Germany). Under general anesthesia, we introduced a 6-Fr sheath into the femoral artery or occasionally the common carotid artery, and heparinized systemically. A 6-Fr catheter was advanced to the parent artery, and the C arm was fixed at an optimal angle that most effectively separated the aneurysmal neck and parent artery. Tracker-10® (Target Therapeutics, Fremont, CA, USA) as a microcatheter, and Dasher® (Target Therapeutics, Fremont, CA, USA) as a microguidewire were usually used. We inserted the first coil to the minor axis of the aneurysmal dome and filled the dome while gradually shortening it. It is best for the aneurysm to be completely embolized, but sometimes the treatment was finished when flow in the aneurysm became sufficiently slowed. Emergency embolization was completed with a second GDC embolization within 1 month in two cases. In two broad neck aneurysms a double catheter technique was used [6]. Spinal drainage, washing out the subarachnoid hemorrhage at the end of the procedure, was inserted after embolization. The grade of embolization was assessed as follows: complete(C), neck remnant (N), and incomplete (I) in accordance with Murayama et al. [7].

Table 5 Preoperative grade H&K grade

Coil embolization

Clipping

II III IV V

6 20 7 5

24 18 4 5

3.1. Patient selection Regarding of the location of aneurysm, compared with clipping, coil embolization was performed frequently for posterior circulation aneurysms (Table 3). Regarding age distribution, the mean age of the patients treated with coils was 70.5 years (range 48–90). The mean age of the clipping cases was 60.2 years (Table 4). Regarding preoperative grade, the coil embolization group had a higher grade than the clipping group (Table 5). 3.2. Complications of coil embolization Morbidity of coil embolization was 7.8% and mortality was 5.3%. Complications developed in five cases. Two patients with a basilar artery top aneurysm died due to coil embolization. One case had intraventricular hemorrhage due to aneurysmal perforation during catheterization. After stopping the hemorrhage, additional coil embolization and ventricle drainage were performed. However, this patient died on the fourteenth day of illness. Another case had posterior cerebral artery occlusion caused by catheterization. After coil embolization without complete packing, thrombolysis using urokinase was performed, but caused aneurysmal rapture. This patient died from rebleeding. Three cases deteriorated due to cerebral infarction. 3.3. Short-term outcome (Table 6) Two Gs, 3 MDs, and 1 D, in grade II patients. Four Gs, 10 MDs, 5 SDs, and 1D in grade III patients. One G, 1 MD, 3 SDs, 1 V, and 1 D in grade IV patients. Two Gs, 1 MD, and 2 Ds in grade V patients, respectively (Table 6). Five patients died within 1 month. Two of these five patients died due to severe vasospasms and one died due to the initial subarchnoid hemorrhage. The other two deaths were caused by complications due to coil embolization.

T. Kawabe et al. / Clinical Neurology and Neurosurgery 108 (2006) 163–167

166

Table 6 Correlation between grade and outcome 3 months after embolization H&K

I II III IV V

GOS G

MD

SD

2 4 1 2

3 10 1 1

5 3

V

1

D 1 1 1 2

GOS: Glasgow outcome scale, G: good, MD: moderate disability, SD: sever disability, V: persistent vegetative state, D: dead H&K: Hunt & Kosnik grading, which does not consider attendant circumstances.

Table 7 Correlation between grade and outcome in midterm follow-up H&K

I II III IV V

GOS G

MD

SD

3 5 2 2

1 7

1 3 2 1

V

D

1

3 1

3.4. Midterm outcome (Table 7) Three Gs, 1 MD, 1 SD and 1 D, in grade II patients. Five Gs, 7 MDs, 3 SDs, and 3Ds in grade III patients. Two Gs, 2 SDs, 1 V, and 1 D in grade IV patients. Two Gs, and 1 SD in grade V patients, respectively. Compared with the shortterm, MD patients had a tendency to improve or worsen in the midterm (Table 7). Cause of mortality in midterm was as follows. Four patients died more than 1 month after treatment. Two cases of cardiac failure, one renal failure, and one lung cancer developed. None of the patients died from subarachnoid hemorrhage follow-up over 1 year. 3.5. Rebleeding in follow-up term (Table 1) Regarding aneurysms less than 10 mm, no patient had rebleeding during the follow-up term. 3.6. Course of large aneurysms (Table 2) Regarding aneurysms more than 11 mm, one aneurysm reopened. That aneurysm was basilar tip aneurysm and invaginated the midbrain, so we do not treat it further. Two other aneurysms more than 11 mm were the same shape after treatment.

4. Discussion In 1991, Guglielmi et al. published a report describing electrically detachable platinum coils (GDC) [8]. Coil

embolization for ruptured aneurysm has become widely accepted [5,9–15]. An international randomized study showed that the outcome of coil embolization is better than that of clipping [1]. However, the study did not describe the long-term outcome. One reason why clipping is regarded as the first indication for ruptured aneurysm is that the long-term outcome of coil embolization is not yet known. To address this, we investigated the effects of coil embolization over 1 year. Regarding complications of coil embolization, Vinuela et al. reported that in their 403 cases, morbidity was 8.9% and mortality was 1.74%, and ischemic complications including parent artery occlusion (3%) and embolism (2.48%) were the most frequent [5]. Rupture during surgery causes severe complications [16,17]. In our cases, the morbidity rate was 7.8% and the mortality rate was 5.3%. Two deaths occurred due to bleeding in the procedure. The others were ischemic complications. Our study showed a similar tendency. Coil embolization may have a disadvantage in treating vasospasms, because the hemorrhage is not directly removed during the embolization procedure. Murayama et al. reported that vasospasm occurred in 23% of patients classified as having Hunt and Hess Grades I to III, and this rate was not inferior to that of clipping [18]. In our cases, vasospasms occurred in 22% of all cases (involving Hunt and Kosnik grade IV and V). We usually insert spinal/ventricle drainage and occasionally add interventional therapy for vasospasm. Our outcome is similar to those of previous studies. The size of the aneurysm is the most important factor in rebleeding after coil embolization. Vinuela et al. reported that neck remnant was observed in 21.4% of small aneurysms and 51.7% of large aneurysms [5]. Byrne et al. reported that rebleeding occurred in 7.9%, and half of those were large aneurysms [3]. Sluzewski et al. also reported rupture cases involving large, incompletely occluded aneurysms [4]. Regarding the shape, a small aneurysm with a small neck/dome ratio is easy to occlude [19,20]. Hayakawa et al. reported that recurrence occurred in only 17% if the neck was small [21]. Consequently, recurrence occurs more often with large, wide-neck aneurysms. In a large aneurysm with a wide neck, the water–hammer effect may work strongly [22]. Therefore, in this study, we focused on aneurysms measuring less than 10 mm, in which outcome is supposed to be good, and examined rupture prevention over 1 year by coil embolization only in small aneurysms measuring less than 10 mm in diameter. As a result, there was no rebleeding after coil embolization for aneurysms measuring less than 10 mm. On the other hand, one aneurysm more than 11 mm reopened. That aneurysm may rebleed. Reports of midterm follow-up after coil embolization have been published previously. Malisch et al. reported that in 104 cases, small aneurysms did not rebleed during a 3.5year follow-up period [23]. Murayama et al. reported that the overall incidence of delayed aneurysm ruptures was 1.6% and 10 of 12 delayed ruptures occurred in large or giant aneurysms [7]. In other words, the delayed rupture rate of

T. Kawabe et al. / Clinical Neurology and Neurosurgery 108 (2006) 163–167

small aneurysms was 0.26%. Batista et al. reported that there was no rebleeding after 3 years [24]. In an article written by Byrne et al., 2 of 212 small aneurysms showed rebleeding after a median of 22.3 months (0.9%) [3]. In our study, there has been no rebleeding during a median follow-up of 37.3 months. The incidence of delayed rupture of small aneurysms after coil embolization can be comparable with that after clipping [25,26].

[11]

[12]

[13]

5. Conclusion [14]

We investigated the prevention of rebleeding after coil embolization over 1 year for ruptured aneurysms measuring less than 10 mm in diameter. None of the patients developed rebleeding during a median of 37.3 months. We conclude that midterm stability of small ruptured aneurysms can be expected after coil embolization.

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