CC BY
47
UDC 616.13/14:616.831]-007.64-007.251-039.35-073.75
NECESSITY OF FOLLOW-UP CEREBRAL DIGITAL SUBTRACTION ANGIOGRAPHY AFTER ENDOVASCULAR COILING OR MICROSURGICAL CLIPING OF RUPTURED INTRACRANIAL ANEURYSMS TO EXCLUDE DENOVO OR ANEURYSMAL REGROW AND AVOID ITS RUPTURE: REPORT OF 2 CASES
D.J. GUNIA, E.T. EKVTIMISHVILI, G.Z. BASILADZE
High Technology Medical Center, University Clinic, Tbilisi, Georgia
*Conflict of Interest Statement (We declare that we have no conflict of interest).
*Заява про конфл^ штереав (Ми заявляемо, що у нас немае шякого конфлiкту штереав). *Заявление о конфликте интересов (Мы заявляем, что у нас нет никакого конфликта интересов).
*No human/animal subjects policy requirements or funding disclosures.
*Жодний i3 об'екпв дослщження (людина/тварина) не тдпадае тд вимоги пол^ики щодо роз-криття шформацп фiнансування.
*Ни один из объектов исследования не подпадает под политику раскрытия информации финансирования.
*Date of submission — 26.01.19 *Date of acceptance — 13.02.19
*Дата подачi рукопису — 26.01.19 *Дата ухвалення — 13.02.19 *Дата подачи рукописи — 26.01.19 *Дата одобрения к печати — 13.02.19
Objective - to improve treatment results of patients with ruptured brain aneurysms using follow-up cerebral digital subtraction angiography to avoid de novo or aneurismal regrow.
Materials and methods. Analysis of follow-up cerebral digital subtraction angiography and treatment results of two patient (60 and 64-year-old females) with brain anterior communicated artery de novo aneurysm and regrowed aneurysm of an anterior communicated artery after microsurgical clipping.
Results. Two patient underwent endovascular treatment of ruptured brain aneurysms after non follow-up cerebral digital subtraction angiography. In first case de novo aneurysm of anterior communicating artery and in second - regrowed aneurys of anterior communicating artery after surgical clipping. Both patients were discharged from the clinic in I and IV modified Rankin scale.
Conclusions. Digital subtraction angiography follow-up of intracranial aneurysms treated by endovascular or microsurgical approach is important for the detection and prediction for the risk of bleeding (aneurysm recurrence and de novo aneurysm). There exist no guidelines on the frequency of monitoring and imaging modality to adopt and the monitoring is adapted on a case-by-case basis. Digital subtraction angiography is the gold standard for the evaluation of
aneurysmal occlusion after coiling and microsurgical clipping and remains also necessary for evaluating other devices.
Key words: intracranial aneurysm; follow-up digital subtraction angiography; subarachnoid hemorage; de novo aneurysm; aneurismal re-ruprure.
DOI 10.26683/2304-9359-2019-1(27)-12-20
List of abbreviations
AcomA Anterior communicating artery
DSA Digital subtraction angiography
EVT Endovascular treatment
ICA Internal carotid artery
SAH Subarachnoid hemorage
The aim of aneurysm treatment is to prevent the rupture for unruptured aneurysms or rebleeding - for ruptured aneurysms. Endovascular approach has become the first choise of treatment for intracranial aneurysms in the majority of cases in many countries. This minimally invasive approach achieved lower morbidity and mortality rates when compared with surgical management [1]. After endovascular treatment (EVT) ~ 18 % of patients will experience residual aneurysm neck after traditional endovascular coiling, necessitating retreatment in about half of them to maintain long-term protection over bleeding [2]. Despite this issue, low rates of bleeding have been reported after EVT of ruptured aneurysms, and its clinical superiority over surgery seems to be maintained over time according to the long-term clinical follow-up of the International Subarachnoid Aneurysm Trial (ISAT) cohort [3]. In the Cerebral Aneurysm Rerupture after Treatment (CARAT) study, the bleeding rate after coil emboli-zation was 0.11 % (mean follow-up time, 4.4 years), whereas in the International Subarachnoid Aneurysm Trial, the annual risk of bleeding after coil-treated aneurysms was 0.08 %. In a large single-center study, the Barrow Ruptured Aneurysm Trial (BRAT), no bleeding was observed after 6 years in the coiling arm, but 4.6 % of these patients were retreated [4].
David GUNIA
Neurosurgery, Endovascular Neurosurjery Assisted Professor of Neurosurgery, Tbilisi State Medical University, High Technology Medical Center, University Clinic address: Tsinandali str. 9, Tbilisi, Georgia Tel.:+995 599 626-726 E-mail: gunia77@gmail.com https://orcid.org/0000-0001-9103-2048
Typically, the first follow-up after EVT is scheduled 3 to 6 months after the procedure with further follow-up tests in varying intervals depending on the patient - aneurysm cy-toarchitectonical features. A classical scheme will include a 12- to 24-month follow-up and a mid- term follow-up at 3 to 5 years. The post-EVT first year period is crucial because most recurrences occur during this period [5]. The ideal frequency of examinations and length of follow-up is actually not determined, but more frequent follow-up may be indicated in patients harboring risk factors of recurrence (ruptured aneurysms, large aneurysms, wide neck, and incomplete post-operative occlusion). Digital subtraction angiography (DSA) is the gold standard for the evaluation of aneurysmal occlusion after coiling and microsurgical clipping. Because of its high spatial resolution with 3D imaging and dynamic information, DSA allows scoring recurrent flow in the aneurysm. DSA also has the advantage of not being impaired device-related artifacts, meaning that whatever the occlusion device used, coils, stent or clip. However, DSA is an invasive procedure exposing the patient to complications such as cerebral thromboem-bolism (from silent microemboli to transient or permanent neurological deficit in 0.5 % to 3.0 % of procedures), contrast nephtotoxicity or ana-phylactic reaction, ionizing radiation, and hematoma on the puncture site [6].
Objective - to improve treatment results of patients with ruptured brain aneurysms using follow-up cerebral digital subtraction angiography to avoid de novo or aneurismal regrow.
Materials and methods
Two patient underwent endovascular treatment of ruptured brain aneurysms after non follow-up cerebral DSA. In first case de novo aneurysm of anterior communicating artery (AcomA) and in second - regrowed aneurysm of AcomA after surgical clipping.
Case 1
A 60-year-old female was admitted in our clinic with severe headache. 5 years ago she had been operated (endovascular coiling) on a rup-
tured left ICA-supraclinoid segment aneurysm in our institution. On DSA no evidence of other cerebral vascular patologie was found (Fig. 1 and 2). Patient was discharged from the clinic without neurological deficite. Follow-up DSA have not been performed for private reasons. Now neoro-logical examination demonstrated an awake patient with high degree of neck stiffness. Hunt and Hess scale II. A CT-scan showed acute subarachnoid hemorage (SAH) with intraventricular clot - Fisher scale IV (Fig. 3) and patient was moved into cath lab for DSA which identified occlusion of the left ICA aneurysm and de novo Aco-mA aneurysm with diverticulitis on its fundus
Fig. 1. Pre-operative DSA image of the left ICA - supraclinoid segment aneurysm
Fig. 2. Post-coilling DSA image of the left ICA - supraclinoid segment aneurysm
Fig. 3. Acute SAH with intraventricular clot Fisher scale IV
(Fig. 4). On the same day endovascular treatment -occlusion of an aneurysm with balloon remodeling technique (Microvention Scepter XC 4 mm/11 mm) and microcoils (Microvention: Microplex 10 Cosmos 4 mm/8 cm, Microplex 10 Helical Hy-peroft 2 mm/8 cm, Microplex Helical Hypersoft 2 mm/6 cm) was performed without complications (Fig. 5). After two week patient was discharged from the clinic - modified Rankin scale I.
Fig. 4. Pre-operative DSA image of occluded Left ICA aneurysm and ruptured de novo AcomA aneurysm
Fig. 6. Acute SAH with intraventricular clot Fisher scale IV
Case 2
A 64-year-old female was hospitalized in our clinic with severe headache. Hunt and Hess II. A CT-scan and DSA showed: acute SAH with intraventricular clot - Fisher scale IV and multiple (2) aneurysms of AcomA (proximal -2.0 mm and distal - 1.8 mm) (Fig. 6 and 7). Due to difficult cytoarchitectonic of an aneurysms
Fig. 5. Post-coiling DSA image of the ruptured de novo AcomA aneurysm
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Vi it 1
I
iff .. i iL I, (
A
Fig. 7. Multiple aneurysms of AcomA
microsurgical clipping was chosen. In intraoperative report was told that just with one clips both of aneurysms were clipped but no control postoperative DSA was done. Patient underwent standard 3H therapy and was dischardeg from the clinic without complications but after one week patient experienced a sudden onset of
bifrontal headache, lost consciousness and was re-hospitalized in poor condition - Hunt and Hess V. A CT-scan showed acute SAH - intraventricular haemorrhage (Fig. 8).
Due to poor condition of the patient and severe angiospasm in both ACAs, she was moved into IC-department. After 3 weeks on control
Fig. 8. Acute SAH - intraventricular haemorrhage
DSA we found that proximal aneurysm of AcomA was successfully clipped but distal aneurysm was partially clipped and has grown up in size (3.5 mm) (Fig. 9). Endovascular coiling was planned on the next day. Intraoperative control DSA showed that active AcomA aneurysm was doppelt in size (6 mm) and instant coiling was performed (Fig. 10 and 11). In Postoperative period communicative hydrocephalus (Fig. 12) was
developed and patient got VP-shunting. After while patient was discharged from the clinic -modified Rankin scale IV.
Discusion
There are few evidence based articles about de novo aneurysms and less about aneurysmal regrowth after microsurgical cliping. Accor-
Fig. 9. Successfully clipped proximal aneurysm of AcomA and partially clipped distal aneurysm which has grown up in size
Fig. 10. Intraoperative DSA showed that active AcomA aneurysm was doppelt in size
w
A & & ®
Fig. 22. Postoperative communicative hydrocephalus
ding to our experience follow-up DSA is recommended for accur diagnose and prevention for the risk of bleeding (aneurysm recurrence and de novo aneurysm).
Conclusions
DSA follow-up of intracranial aneurysms treated by endovascular or microsurgical ap-
proach is important for the detection and prediction for the risk of bleeding (aneurysm recurrence and de novo aneurysm). There exist no guidelines on the frequency of monitoring and imaging modality to adopt and the monitoring is adapted on a case-by-case basis. DSA is the gold standard for the evaluation of aneurysmal occlusion after coiling and microsurgical clipping and remains also necessary for evaluating other devices.
References
1. Cognard C, Pierot L, Anxionnat R, Ricolfi F; Clarity Study Group. Results of embolization used as the first treatment choice in a consecutive non selected population of ruptured aneurysms: clinical results of the Clarity GDC study. Neurosurgery. 2011;69:837-41, discussion 842. doi: 10.1227/NEU.0b013e3182257b30.
2. Ferns SP, Sprengers ME, van Rooij WJ, et al. Coiling of intracranial aneurysms: a systematic review on initial occlusion and reopening and retreat-ment rates. Stroke. 2009;40:e523-e9. doi: 10.1161/ STR0KEAHA.109.553099.
3. Molyneux AJ, Birks J, Clarke A, Sneade M, Kerr RS. The durability of endovascular coiling versus neu-rosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the Inter-
national Subarachnoid Aneurysm Trial (ISAT). Lancet. 2015;385:691-7. doi: 10.1016/S0140-6736(14)60975-2.
4. CARAT Investigators. Rates of delayed rebleeding from intracranial aneurysms are low after surgical and endovascular treatment. Stroke. 2006;37:1437-42.
5. Campi A, Ramzi N, Molyneux AJ, et al. Retreatment of ruptured cerebral aneurysms in patients ran- domized by coiling or clipping in the International Subarach-noid Aneurysm Trial (ISAT). Stroke. 2007;38:1538-44. doi: 10.1161/ STR0KEAHA.106.466987.
6. Pierot L, Cognard C, Anxionnat R, Ricolfi F; CLARITY Investigators. Endovascular treatment of ruptured intracranial aneurysms: factors affecting midterm quality anatomic results: analysis in a prospective, multicenter series of patients (CLARITY). Am J Neuro-radiol. 2012;33:1475-80. doi: 10.3174/ajnr.A3003.
необхвдшсть проведення контрольно! церебрально! диг1тально! субтракц1йно! ангюграфп п1сля ендоваскулярно! оклюз1! або м1крох1рург1чного кл1пування 1нтракран1альних аневризм для виявлення аневризм DE NOVO чи !х подальшого росту для запоб1гання повторним розривам: 2 кл1н1чних випадки д.д. Гуны, e.t. еквт1М1шв1Л1, г.з. басшадзе
Центр високих медичних технологш, Ушверситетська клшша, м. Тбша, Грузiя
Мета роботи - полшшити результати л^вання пащешив з розривом церебральних аневризм шляхом використання контрольно! церебрально! диптально! субтракцшно! анпографп для виявлення аневризм de novo або !х подальшого росту.
Матер1али та методи. Проведено аналiз контрольно! церебрально! дигитально! субтракцшно! анпографп двох пащешив (жiнки вiком 60 i 64 роки) з церебральними аневризмами: в одному випадку - аневризма de novo передньо! сполучно! артерп, в iншому - повторний рют аневризми передньо! сполучно! артерп тсля мiкрохiрургiчного клiпувания.
Результати. Обом пащенткам не проводили контрольну церебральну диптальну субтрак-цiйну ангiографiю в тсляоперацшний перiод пiсля первинного лшування.
Обидвi жiнки надiйшли в клшшу з розривом аневризм. У першому випадку виявлено аневризму de novo передньо! сполучно! артерп. Пащентку прооперовано ендоваскулярним методом. У другому випадку виявлено рецидивуючий рют аневризми передньо! сполучно! артерп тсля хiрургiчного клтування. Пацiентку прооперовано ендоваскулярним методом. Одну пащентку виписано з клшши в сташ I бал за модифшованою шкалою Ренкiна, другу - в сташ IV бали.
Висновки. Контрольна диптальна субтракцшна ангiографiя iнтракранiальних аневризм, рашше пролiкованих ендоваскулярним або мiкрохiрургiчним доступом, мае важливе значення для виявлення i запобiгання ризику повторного крововиливу (рецидив аневризми або аневризма de novo). Не юнуе ч^ких правил або вимог щодо частоти мошторингу та методiв вь зуалiзацi! в пiсляоперацiйний перiод. Мошторинг проводять з урахуванням конкретного випадку. Диптальна субтракцшна ангiографiя е золотим стандартом ощнки та контролю оклюзп
аневризми стралями або !! мiкрохiрургiчного клiпування i необхiдна для ощнки можливосп використання iнших шструмешив.
Ключов1 слова: iнтракранiальна аневризма; контрольна диптальна субтракцшна ангюгра-фiя; субарахно!дальний крововилив; аневризма de novo; повторний розрив аневризми.
необходимость контрольной церебральной дигитальной субтракционной ангиографии после эндоваскулярной окклюзии или микрохирургического клипирования интракраниальных аневризм для выявления аневризм DE NOVO или их последующего роста с целью предотвращения повторных разрывов: 2 клинических случая
Д.Д. ГУНИЯ, Э Т. ЭКВТИМИШВИЛИ, Г.З. БАСИЛАДЗЕ
Центр высоких медицинских технологий, Университетская клиника, г. Тбилиси, Грузия
Цель работы — улучшить результаты лечения пациентов с разрывом церебральных аневризм путем использования контрольной церебральной дигитальной субтракционной ангиографии для выявления аневризм de novo или их последующего роста.
Материалы и методы. Проведен анализ контрольной церебральной дигитальной суб-тракционной ангиографии двух пациентов (женщины в возрасте 60 и 64 года) с церебральными аневризмами: в первом случае - аневризма de novo передней соединительной артерии, во втором - повторный рост аневризмы передней соединительной артерии после микрохирургического клипирования.
Результаты. Обеим пациенткам не проводили контрольную церебральную дигитальную субтракционную ангиографию в послеоперационный период после первичного лечения.
Обе женщины поступили в клинику с разрывом аневризм. В первом случае выявлена аневризма de novo передней соединительной артерии. Пациентка прооперирована эндова-скулярным методом. Во втором случае выявлен рецидивирующий рост аневризмы передней соединительной артерии после хирургического клипирования. Пациентка прооперирована эндоваскулярным методом. Одна пациентка выписана из клиники в состоянии I балл по модифицированной шкале Ренкина, вторая - в состоянии IV балла.
Выводы. Контрольная дигитальная субтракционная ангиография интракраниальных аневризм, ранее леченных эндоваскулярным или микрохирургическим доступом, имеет важное значение для выявления и предотвращения риска повторного кровотечения (рецидив аневризмы или аневризма de novo). Не существует четких правил или требований относительно частоты мониторинга и методов визуализации в послеоперационный период. Мониторинг проводят с учетом конкретного случая. Дигитальная субтракционная ангиография является золотым стандартом оценки и контроля окклюзии аневризмы спиралями или ее микрохирургического клипирования и необходима для оценки возможности использования других инструментов.
Ключевые слова: интракраниальная аневризма; контрольная дигитальная субтракционная ангиография; субарахноидальное кровоизлияние; аневризма de novo; повторный разрыв аневризмы.
