Endovascular management of unruptured cerebral aneurysms

Hesham E Masoud MD (Dr. Masoud of Case Western Reserve University School of Medicine has no relevant financial relationships to disclose.)
Thanh Nguyen MD (Dr. Nguyen of Boston Medical Center and Boston University School of Medicine has no relevant financial relationships to disclose.)
Originally released July 10, 2012; expires July 10, 2015
Notice: This article has expired and is therefore not available for CME credit.

Overview

The authors provide an overview of the history of endovascular management of intracerebral aneurysms. The authors review the literature on the natural history of unruptured aneurysms before discussing the factors to be considered when deciding on management, with emphasis placed on the risk-benefit assessment. A brief clinical case is described, including images taken from an actual case. Finally, the endovascular techniques are explained with comments on outcome, prognosis, and special circumstances, such as pregnancy.

Key points

 

• In 2002, the International Subarachnoid Aneurysmal Trial revealed that endovascular coiling was superior to microsurgical clipping in dependency or death at 1 year for patients with ruptured cerebral aneurysms.

 

• When selecting patients for management of unruptured intracranial aneurysms, it is important to consider the natural history to help predict the risk of rupture compared to the risk of surgical clipping or endovascular coiling.

 

• Endovascular coiling aims to stabilize aneurysms at risk for rupture through the placement of coils with the goal of aneurysm occlusion through thrombosis and flow redirection into the normal parent artery.

Historical note and terminology

In 1937, Walter Dandy became the first to treat an intracranial aneurysm by applying a silver clip across the neck of an unruptured internal carotid artery aneurysm, eliminating the communication between the aneurysm and the circulating blood in its parent artery (Guglielmi et al 1991). The first endovascular treatment of an intracranial aneurysm was performed in 1939 using 30 feet of No.34 gauge silver wire placed inside a giant cavernous carotid aneurysm (Werner et al 1941). In 1964, Luessenhop and Velasquez first described intracranial artery catheterization and catheter-based embolization of an intracranial aneurysm (Luessenhop and Velasquez 1964). In 1974, Serbinenko developed a series of balloon-mounted, flow-guided catheters and detachable balloons designed to occlude intracranial vascular lesions (Serbinenko 2007).

Later in 1975, Norlén pioneered the use of early surgical clipping of aneurysms, and this became the standard of care (Norlén unpublished data). However, in 1991, Guglielmi and colleagues published the first description of the use of detachable endovascular platinum coils to induce thrombosis and obliteration of the aneurysm lumen in humans (Guglielmi et al 1991; Louw et al 2001).

In 2002, the International Subarachnoid Aneurysmal Trial (ISAT) revealed that endovascular coiling was superior to microsurgical clipping in dependency or death at 1 year for patients with ruptured cerebral aneurysms (7% absolute risk reduction) (Molyneux et al 2009). Long-term follow-up of the ISAT showed at 5 years 11% mortality for the endovascular coiling group versus 14% in the surgical group. Endovascular coiling has since been increasingly used as a primary treatment option for intracranial aneurysms that are feasible for coiling.

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