Endovascular Treatment of Intracranial Aneurysms

doi:10.1016/S0025-6196(12)61068-4

Mayo Clinic Proceedings

Volume 69, Issue 3, March 1994, Pages 272-285

https://doi.org/10.1016/S0025-6196(12)61068-4 Get rights and content

Objective

To examine the techniques, reported experiences, and advantages and disadvantages associated with the endovascular treatment of intracranial aneurysms.

Design

We review the endovascular techniques used for the treatment of intracranial aneurysms and the sequelae of subarachnoid hemorrhage, which have evolved during the past 10 years.

Material and Methods

Two broad categories of endovascular therapy for intracranial aneurysms are described: occlusion of the parent artery and preservation of the parent artery by selective occlusion of the aneurysm with balloons or metallic coils. The Mayo protocol for testing tolerance of patients before permanent balloon occlusion of the parent artery is described, as are the types of aneurysms most amenable to this treatment. In addition, use of balloon angioplasty for cerebral vasospasm after subarachnoid hemorrhage is reviewed.

Results

Recent improvements in microcatheter technology have facilitated the safe navigation of percutaneously introduced catheters in the intracranial circulation and selective catheterization of intracranial aneurysms. Surgically difficult aneurysms are now being treated with endovascular techniques more frequently than in the past. Early results from animal experiments and human trials have shown that selective occlusion of aneurysms with metallic coils may have a role in the treatment of intracranial aneurysms. Balloon angioplasty of symptomatic cerebral vasospasm has demonstrated improvement in neurologic function in approximately 70% of patients.

Conclusion

As technology continues to improve and as greater experience is obtained, interventional neuroradiologists will continue to have an increasingly important role in the treatment of intracranial aneurysms.

Section snippets

BALLOON OCCLUSION OF THE PARENT ARTERY

Often, in patients with aneurysms at increased risk for complications of surgical clipping, the aneurysm can be occluded with endovascular techniques, and the parent vessel can be preserved. Some aneurysms with wide necks and ectatic and fusiform aneurysms are unamenable to selective occlusion and are treated with detachable-balloon occlusion of the parent vessel.8, 9, 10, 11, 12, 13 Before the parent vessel (either the cervical internal carotid artery or the vertebral artery) that is harboring

Detachable Balloons.

Endovascular treatment of intracranial aneurysms was initially limited to balloon occlusion of the parent artery. Advancements in balloon and catheter technology, digital subtraction angiography, fluoroscopy with road-mapping capabilities, and liquid solidifying agents for balloons have allowed treatment of aneurysms with well-defined necks by selective positioning of detachable balloons within the aneurysmal sac in an attempt to induce permanent thrombosis of the sac and preserve the parent

BALLOON ANGIOPLASTY OF VASOSPASM

A discussion of the endovascular treatment of aneurysms would be incomplete without mentioning the role of endovascular techniques for cerebral vasospasm after subarachnoid hemorrhage.

Among patients who survive the initial hemorrhage, 30% will have symptomatic cerebral vasospasm that results in a delayed ischemic deficit.56, 57 Initial therapy to prevent or to modify a delayed ischemic deficit attributable to vasospasm includes the administration of nimodipine, a calcium channel antagonist.

CONCLUSION

The endovascular techniques used for the treatment of intracranial aneurysms and the sequelae of subarachnoid hemorrhage have evolved rapidly during the past decade, and they continue to evolve. Neurosurgical clipping of the neck of the aneurysm remains the therapy of choice; however, in some patients, endovascular techniques may be the best treatment because of the poor condition of the patient or the characteristics of the aneurysm. As technology continues to improve and as greater experience

REFERENCES (67)

A Berenstein et al.
Transvascular treatment of giant aneurysms of the cavernous carotid and vertebral arteries: functional investigation and embolization
Surg Neurol
(1984)
JM Eskridge et al.
Transluminal angioplasty for treatment of vasospasm
Neurosurg Clin North Am
(1990 Apr)
JL Chason et al.
Berry aneurysms of the circle of Willis: results of a planned autopsy study
Neurology
(1958)
EM Housepian et al.
A systematic analysis of intracranial aneurysms from the autopsy file of the Presbyterian Hospital: 1914 to 1956
J Neuropathol Exp Neurol
(1958)
WE Stehbens
Aneurysms and anatomical variation of cerebral arteries
Arch Pathol
(1963)
LH Phillips et al.
The unchanging pattern of subarachnoid hemorrhage in a community
Neurology
(1980)
HP Adams et al.
Early management of aneurysmal subarachnoid hemorrhage: a report of the Cooperative Aneurysm Study
J Neurosurg
(1981)
FA Serbinenko
Catheterization and occlusion of major cerebral vessels and prospects for the development of vascular neurosurgery
Vopr Neirokhir
(1971)
FA Serbinenko
Balloon catheterization and occlusion of major cerebral vessels
J Neurosurg
(1974)
G Debrun et al.
Giant unclippable aneurysms: treatment with detachable balloons
AJNR Am J Neuroradiol
(1981)

AJ Fox et al.

Use of detachable balloons for proximal artery occlusion in the treatment of unclippable cerebral aneurysms

J Neurosurg

(1987)

RT Higashida et al.

Endovascular detachable balloon embolization therapy of cavernous carotid artery aneurysms: results in 87 cases

J Neurosurg

(1990)

RT Higashida et al.

Intracranial aneurysms: interventional neurovascular treatment with detachable balloons—results in 215 cases

Radiology

(1991)

A Aymard et al.

Endovascular occlusion of vertebral arteries in the treatment of unclippable vertebrobasilar aneurysms

J Neurosurg

(1991)

RS Hillman

Vitamin B₁₂, folic acid, and the treatment of megaloblastic anemias

SB Peterman et al.

Improved detection of cerebral hypoperfusion with internal carotid balloon test occlusion and ^99mTc-HMPAO cerebral perfusion SPECT imaging

AJNR Am J Neuroradiol

(1991)

LH Monsein et al.

Assessing adequacy of collateral circulation during balloon test occlusion of the internal carotid artery with ^99mTc-HMPAO SPECT

AJNR Am J Neuroradiol

(1991)

DA Eckard et al.

Temporary balloon occlusion of the carotid artery combined with brain blood flow imaging as a test to predict tolerance prior to permanent carotid sacrifice

AJNR Am J Neuroradiol

(1992)

H Yonas et al.

Internal carotid balloon test occlusion does require quantitative CBF [letter]

AJNR Am J Neuroradiol

(1992)

Tarr RW, Jungreis CA, Pentheny S, Horton JA. Complications of preoperative balloon test occlusion of the internal...

J Rogg et al.

The acetazolamide challenge: imaging techniques designed to evaluate cerebral blood flow reserve

AJNR Am J Neuroradiol

(1989)

JM Eskridge

The challenge of carotid occlusion

AJNR Am J Neuroradiol

(1991)

GB Hieshima et al.

A detachable balloon for therapeutic transcatheter occlusions

Radiology

(1981)

RT Higashida et al.