Gerhard Bavinzski

Clinical and angiographic results of endosaccular coiling treatment of giant and very large intracranial aneurysms: a 7-year, single-center experience.

OBJECTIVE To evaluate whether the objectives of surgical treatment, i.e., prevention of aneurysmal rebleeding, relief of aneurysmal mass effect, and prevention of embolic complications, are met by endosaccular coiling treatment applied to giant and very large wide-necked aneurysms. METHODS Thirty patients with 31 giant or very large aneurysms were considered to show unacceptable risk/benefit ratios for open surgery and were treated using the Guglielmi detachable coil (GDC) method between 1992 and 1998. RESULTS With endosaccular GDC treatment, 73.3% of the population experienced excellent to good recoveries (Glasgow Outcome Scale scores of 4 or 5), with a 13.3% procedure-related morbidity rate and a 6.7% procedure-related mortality rate. Two hemorrhaging episodes occurred after GDC treatment (annual bleeding rate, 2.5%; 2 hemorrhaging episodes/79.2 patient-yr). Symptoms related to aneurysmal mass effect were improved for 45.5% of the patients presenting with signs of neural compression. Among 23 patients with 24 aneurysms who were available for angiographic follow-up assessment, complete or nearly complete occlusion was observed for 17 aneurysms (71%; angiographic follow-up period, 24.3 +/- 19.6 mo, mean +/- standard deviation). A single total embolization served as definitive treatment for only 12.5% of the giant aneurysms and 31% of the very large aneurysms. CONCLUSION Endosaccular GDC treatment of giant and very large aneurysms was accomplished with procedure-related morbidity and mortality rates comparable to those for open surgery performed by experts. However, because coil stability was unsatisfactory, we suggest that the GDC method should currently be reserved for individuals who are considered poor candidates for open surgery.

Chronic shunt-dependent hydrocephalus after early surgical and early endovascular treatment of ruptured intracranial aneurysms.

OBJECTIVE The goal of this study was to document the influence of the treatment method (early surgery versus early endovascular treatment) on the development of chronic shunt-dependent hydrocephalus in a series of 242 patients treated within 7 days after aneurysmal subarachnoid hemorrhage (SAH). METHODS The following parameters were prospectively recorded in a computerized database and retrospectively analyzed for association with chronic shunt-dependent hydrocephalus: 1) Hunt and Hess grade, 2) Fisher computed tomographic grade, 3) incidence of repeat SAH, 4) aneurysm location, and 5) treatment method (early surgery versus early endovascular treatment). RESULTS Forty of 187 patients (21.4%) who survived the SAH and its neurological and/or medical sequelae underwent definitive shunting for treatment of chronic hydrocephalus. The rate of shunt dependency was positively correlated with a higher Hunt and Hess grade (P < 0.001), a higher Fisher computed tomographic grade (P = 0.003), the occurrence of intraventricular hemorrhage (P < 0.001), repeat SAH (P = 0.003), and aneurysms arising at the anterior communicating artery (P < 0.001). CONCLUSION The results of the present study indicate that the treatment method used does not affect the risk of the later development of chronic shunt-dependent hydrocephalus (early surgery, 23.2% [29 of 125]; early endovascular treatment, 17.7% [11 of 62]; P = 0.45).

Endovascular Treatment of Unruptured Intracranial Aneurysms With Guglielmi Detachable Coils Short- and Long-Term Results of a Single-Centre Series

Background and Purpose— Purpose of the present study is to evaluate the clinical outcome of endovascular treatment of unruptured intracranial aneurysms and to address the question of long-term stability and protection against future subarachnoid hemorrhage. Methods— Retrospective analysis of all patients treated in a 12-year period (173 patients: age 26 to 76 yr, mean 52.2±10.8/202 aneurysms: size 3 to 50 mm, mean 10.0±8.3). Results— The mortality was 0.5%; the overall morbidity was 3.5%. The most frequent complications were thromboembolic events (10.9%). Of these, 3.0% of patients suffered a stroke, leading to severe disability in 1 patient (0.5%). In 1 patient, the aneurysm ruptured during treatment, resulting in relevant neurological disability. Another patient suffered a fatal aneurysm rupture hours after treatment. The occlusion rate depended on aneurysm and neck size. Follow-up angiography revealed a decrease of the occlusion rate over time. This trend was obvious in all size categories and was most pronounced in giant aneurysms. In 3 patients (1.5%) with partially thrombosed giant aneurysms of the posterior circulation, embolization could not prevent later aneurysm rupture. There were no ruptures of any other aneurysms in the follow-up period (3.7±3.4 yr). Conclusion— Endovascular treatment is a highly safe procedure with low intervention-related morbidity and mortality. Long-term data for nongiant aneurysms showed good protection against rupture in the observation period. In contrast, the risk of rupture for giant aneurysms of the posterior circulation was as high as expected in observational studies.

Treatment of post-traumatic carotico-cavernous fistulae using electrolytically detachable coils : technical aspects and preliminary experience

Abstract We treated six patients with post-traumatic cavernous carotid fistulae by electrothrombosis using Guglielmis new electrolytically detachable coils. The transarterial endovascular route was chosen in five and the transvenous in one case. Exophthalmos, chemosis and/or an audible bruit disappeared immediately after therapy or in the following month in all patients suffering from these symptoms. Third and sixth cranial nerve palsies resolved in three of four patients. Clinical results were excellent in three, good in two and fair in one. In this last patient massive thrombosis of an enormously dilatated superior ophthalmic vein occurred after treatment of a giant longstanding fistula, leading to unilateral visual impairment and increased sixth nerve palsy. In our first patient the intracavernous carotid artery was occluded by balloons after coil embolisation because of improper coil position and the fear of possible thromboembolic events. Angiographic cure was demonstrated in all cases by angiograms 1–6 months after therapy. The characteristics of these new coils are easy use, manoeuvreability and retrievability. They conform ideally to the shape of the vessel lumen to be obliterated and produce practically no trauma to the vessel walls. Furthermore, they can be positioned in the sinus close to the orifice of the fistula. In the last two cases partial occlusion of the fistula was sufficient to initiate the process of complete thrombosis, and delayed, complete occlusion was observed after 1 month. In our opinion this new device is not only a major contribution to treatment of intracranial aneurysms, but may also improve the results of treatment of carotico-cavernous fistulae.

GDC-system embolization for brain aneurysms - location and follow-up.

SummaryGDC (Guglielmi detachable coil)-embolization for the treatment of brain aneurysms was first published by Guglielmi in 1991 [1,2] and has become an integral part of the treatment strategy for cerebral aneurysms in many places around the world. Low morbidity and mortality rates [3] are set against the limited possibilities of aneurysm neck occlusion, especially in large necked aneurysms. Depending on the architecture and on the kind of coil distribution, recanalization of the neck is more or less frequent. Nevertheless, rebleeding rates are low [4]. In our series of 211 brain aneurysms from March 1992 to June 1994, 74 (35%) patients underwent GDC-embolization. 4 patients received combined treatment (GDC-embolization and subsequent surgery). Follow-up angiography was performed on 41 patients (55%) at periods of 6, 12, and 24 months (mean follow-up 8 months). To demonstrate the results in a graphic display, the aneurysms were grouped according to location and size. The analysis of the follow-up results shows the highest occlusion stability in aneurysms of the basilar tip, followed by aneurysms of the PICA origin, the basilar trunk and the PCA. Less stability was obtained in aneurysms of the PCom followed by MCA, Acom and aneurysms of the internal carotid (Cl, ophthalmic). Aneurysms of the posterior circulation show generally better results than those located in the anterior circulation. This makes (in combination with the increased surgical difficulties of aneurysms in the posterior fossa) the GDC-treatment especially useful for posterior circulation aneurysms.

Prospective Comparison of Intraoperative Vascular Monitoring Technologies During Cerebral Aneurysm Surgery

BACKGROUND:Microscope integrated intraoperative near-infrared indocyanine green angiography (ICGA) provides assessment of the cerebral vasculature in the operating field. OBJECTIVE:To prospectively compare the value of ICGA-derived information during cerebral aneurysm surgery with data simultaneously generated from other intraoperative monitoring and vascular imaging techniques. METHODS:Data from 104 patients with 123 cerebral aneurysms who were operated on were prospectively recorded. Results of intraoperative vascular monitoring and descriptions of how this information influenced intraoperative decision making were analyzed. RESULTS:Clip repositioning was necessary in 30 of 123 aneurysms (24.4%) treated. Parent artery occlusion was documented by microvascular Doppler ultrasound in 4 aneurysms. ICGA disclosed parent artery stenoses not detected by sonography in 7 cases. Neuroendoscopy was used in 13 cases of midline aneurysms to confirm perforator patency after clipping, and disclosed aneurysm misclipping undetected by ICGA and digital subtraction angiography in 1 aneurysm. The information from DSA and ICGA corresponded in 120 of 123 aneurysms operated on (97.5 %). In 1 patient, ICGA underestimated a relevant parent artery stenosis detected by digital subtraction angiography. In 2 patients with relevant aneurysmal misclipping, digital subtraction angiography and ICGA led to conflicting results that could be clarified only when both methods were used and interpreted together. CONCLUSION:The intraoperative monitoring and vascular imaging methods compared were complementary rather than competitive in nature. None of the devices used were absolutely reliable when used as a stand-alone method. Correct intraoperative assessment of aneurysm occlusion, perforating artery patency, and parent artery reconstruction was possible in all patients when these techniques were used in combination.

Early Clinical Outcome of Patients with Ruptured Cerebral Aneurysms Treated by Endovascular (GDC) or Microsurgical Techniques. A Single Center Experience.

Over the past 3.5 years 220 patients with aneurysmal subarachnoid hemorrhage were treated in the Department of Neurosurgery University of Vienna Medical School using either endovascular techniques (Guglielmi Detachable Coils) or open craniotomy with aneurysm clipping. A retrospective analysis was undertaken to assess whether any difference in outcome could be correlated with the treatment choice. The patients were stratified as to 1) Hunt and Hess grade at time of treatment, 2) method of treatment, and 3) clinical outcome at 2–4 weeks following treatment. The outcomes in this population of patients were consistent with recent published series regardless of whether the aneurysms were treated with microvascular surgery or endovascular surgery. There was a trend toward better outcome in a relatively small sub-group of patients presenting as Hunt and Hess grade III who were treated by the endovascular method. Guglielmi detachable coils have been available for a relatively short time, and although early results are promising, the ultimate long-term efficacy of the coils will have to be assessed.

Prognostic factor analysis for multiple brain metastases after gamma knife radiosurgery: results in 97 patients.

Stereotactic radiosurgery (SR) is being used with increasing frequency in the treatment of brain metastases. This study provides data from a clinical experience with radiosurgery in the treatment of cases with multiple metastases and identifies parameters that may be useful in the proper selection and therapy of these patients. From January 1993 to April 1997, 97 patients (43 women and 54 men; median age 58 years) suffering from multiple brain metastases (median 3; range 2–4) in MRI scans, received SR with the Gamma Knife. The median dose at the tumor margin was 20 Gy (range 17–30 Gy). Median tumor volume was 3900 cmm (range 100–10 000). Different forms of hemiparesis, focal and generalized seizures, cognitive deficit, headache, dizziness and ataxia had been the predominant neurological symptoms. Major histologies included lung carcinoma (44%), breast cancer (21%), renal cell carcinoma (10%), colorectal cancer (8%), and melanoma (7%).The median survival time was 6 months after SR. The actual one-year survival rate was 26%. In univariate and multivariate analysis, a higher Karnofsky performance rating and absence of extracranial metastases had a significantly positive effect on survival. Local tumor control was achieved in 94% of the patients. Complications included the onset of peritumoral edema (n=5) and necrosis (n=1).SR induces a significant tumor remission accompanied by neurological improvement and, therefore, provides the opportunity for prolonged high quality survival. We conclude that radiosurgical treatment of multiple brain metastases leads to an equivalent rate of survival when compared to the historic experience of patients treated with whole brain radiotherapy. Patients presenting initially with a higher Karnofsky performance rating and without extracranial metastases had a median survival time of nine months. Each such case should therefore be evaluated based on these factors to determine an optimal treatment regimen.

Management of Residual and Recurrent Aneurysms After Initial Endovascular Treatment

BACKGROUND Coil instability possibly translating into higher delayed rebleeding rates remains a concern in the endovascular management of cerebral aneurysms. OBJECTIVE To report on 127 patients with endovascular aneurysmal remnants who underwent re-treatment over an 18 year period. METHODS Patients presenting with aneurysm residuals >20% of the original lesion, unstable neck remnants, aneurysmal regrowth, or new aneurysmal daughter sacs were treated by an individualized approach, using both endovascular and surgical techniques. RESULTS Seventy-five aneurysmal remnants (59.1%) were treated by further re-embolization. Standard coil embolization was used in 65 cases, stent-protected coiling in 9 cases, and balloon remodeled coiling in 1 case, respectively. Fifty-two (40.9%) aneurysmal remnants were treated surgically. Standard microsurgical clipping was used in 44 patients, parent artery occlusion or trapping under bypass protection in 5 cases, deliberate clipping of the basilar artery trunk in 2 cases, and aneurysm wrapping in one case, respectively. Mechanisms of aneurysm recurrence were coil compaction in 93 cases and regrowth in 34 cases. A single reembolization was sufficient to occlude 78.7% of recurrences from coil compaction, but only 14.3% of recurrences from aneurysm regrowth. CONCLUSION The individualized approach resulted in complete occlusion of 114 aneurysms (89.7%), with neck remnants and residual aneurysms detectable in 11 (8.7%) and 2 (1.6%) cases, respectively. Treatment morbidity was 11.9%, without significant differences between surgical (15.6%) and endovascular (9.3%) patients (P = .09). Recurrences from coil compaction were safely treated by re-embolization, whereas recurrences from aneurysmal regrowth may best be managed surgically when technically feasible.

False aneurysms of the intracavernous carotid artery — Report of 7 cases

SummaryWe present 7 cases of false intracavernous carotid artery aneurysms. Four occurred after trauma and three were caused iatrogenically. Two of the latter occurred in patients with pituitary adenomas, one after transsphenoidal microsurgery and the other after yttrium [YI90] seed implantation into the sella. The third iatrogenic aneurysm was seen shortly after transcavernous tumour surgery.In five of our seven patients massive, delayed, lifethreatening epistaxis was the leading symptom. All traumatic cases were associated with immediate unilateral blindness or blurred vision and with skull base fractures. One of these had a concomitant carotid cavernous fistula. Treatment of choice of our 5 recent cases was permanent balloon occlusion of the intracavernous carotid artery at the level of the lesion. Collateral circulation was evaluated prior to definitive carotid occlusion using a balloon test occlusion. During the balloon test adequate collateral circulation was defined as symmetric angiographic filling of both hemispheres. Awake patients were neurologically examined continuously. In unconscious patients transcranial Doppler sonography, electroencephalographic and somatosensory evoked potential monitoring was used in addition. Intra-operative heparin administration was not reversed with protamin. A postoperative continuous heparin infusion was not found necessary.In our two early cases this technique was not available: In the first case we accomplished aneurysm occlusion by a surgically introduced Fogarty balloon catheter. Our second patient needed surgical trapping of the involved carotid after early unsuccessful attempts of selective aneurysm occlusion, After treatment no further epistaxis occurred. Follow-up angiography showed persistent aneurysm occlusion. The results were excellent in 5 cases and good in 1 case. One patient with bilateral lesions suffered a stroke after occlusion of the second, remaining carotid artery, despite functioning bilateral extra-intracranial bypasses. Four years later there is a mild dysphasia still present in this patient. The mean follow-up time was 75.6 months.