Elsevier

Surgical Neurology

Volume 70, Issue 1, July 2008, Pages 30-35
Surgical Neurology

Aneurysm-Rainbow Team/Helsinki
Endovascular treatment of very small intracranial aneurysms

https://doi.org/10.1016/j.surneu.2007.05.059Get rights and content

Abstract

Background

The treatment of very small cerebral aneurysms with maximal diameter less than 3 mm remains a challenge for endovascular and surgical treatment. Endovascular treatment of these lesions may be difficult and associated with high risk of complications because of their small size. Our purpose was to assess the feasibility and results of endovascular treatment of these lesions.

Methods

We conducted a retrospective review of our experience and results of endovascular treatments for a series of 11 consecutive patients with 11 very small aneurysms. Of 11 aneurysms, 10 were acutely ruptured, and 1 was unruptured with a previous subarachnoid hemorrhage from another aneurysm. Aneurysms were located at the internal carotid artery (n = 4), the anterior communicating artery (n = 6), and the vertebral artery (n = 1). Seven patients were treated with coil embolization, and remodeling technique was used in 1 case. Three cases underwent intravascular stent implantation. Coil packing was done after in 2 of 3 aneurysms, and stent implantation alone was used in the remaining aneurysm.

Results

Coil embolization and stent deployment were carried out without difficulty in all cases. Coil packing was not available after stent implantation in 1 case for unsuccessful navigation of microcatheter into the aneurysm sac. Immediate angiograghy demonstrated complete occlusion in 10 cases and nearly complete occlusion in 1 case with stent implantation alone. No stent thrombosis and aneurysmal rupture was encountered during treatment. With the exception of 1 patient (Hunt and Hess grade 4) who died of pneumonia 4 weeks after treatment, no clinical evidence of neurologic deterioration and hemorrhagic complication was seen during the follow-up period in the remaining 10 patients. Follow-up angiography for 3 to 12 months (mean, 5.3 months) was available in 6 (60%) of 10 surviving patients, and no aneurysm recanalization was found.

Conclusions

Endovascular treatment may be a feasible and effective therapeutic alternative for very small aneurysms. The long-term efficacy and durability of endovascular treatment for these lesions remains to be determined in a large series.

Introduction

With the development of endovascular devices and techniques recently, endovascular treatment has became a standard method for the treatment of intracranial aneurysms. However, for very small aneurysms with maximal diameter less than 3 mm, safety and efficiency of endovascular treatment is still controversial. Direct clipping is also limited because these aneurysms are often thin-walled and carry the risks of narrowing or tearing the parent vessel during clipping [14]. In the present study, we retrospectively reviewed our endovascular management of very small aneurysms in 11 patients, with an assessment of its efficacy and safety.

Section snippets

Population

From October 2001 to August 2006, 11 very small aneurysms with maximal diameter of 3 mm or less from 11 consecutive patients were included in this study. Another case with very small AcomA aneurysm, despite having been initially chosen for embolization, was not included in this series because microcatheter could not be navigated through the anterior cerebral artery with severe vasospasm.

As shown in Table 1, the patient group consisted of 3 female and 8 male patients with a mean age of 43 years

Endovascular treatment

Microcatheters were successfully inserted into aneurysms sac in 6 AcomA aneurysms (Fig. 1) and 1 VA-PICA aneurysm, and the aneurysms were completely obliterated with only 1 (4 aneurysms) or 2 (3 aneurysms) coils.

In 2 of the 3 patients chosen for stent-assisted procedures, we were capable of introducing the microdelivery stent systems to the desired location and deploying the stents without displacement in the first session. In the remaining patient with bilateral supraclinoid ICA aneurysms, the

Discussion

It has been reported that ruptured small aneurysms may cause even more extensive SAH than larger aneurysms [18]. Unruptured small aneurysms with a previous hemorrhage from another aneurysm were suggested to have much higher risk of rupture than those without previous hemorrhage. Consequently, effective treatment is usually pursued for those lesions. Forget et al [5] reviewed 245 cases of ruptured aneurysms and found that 86 cases (35%) were smaller than 5 mm, of which anterior communicating

Conclusion

Endovascular treatment may be a feasible and effective therapeutic alternative for very small aneurysms. The long-term efficacy and durability of endovascular treatment of these lesions remains to be determined in a large series.

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