Endovascular surgery for very small ruptured intracranial aneurysms

Abstract

Application of endovascular surgery for very small aneurysms is controversial because of technical difficulties and high complication rates. The aim in the present study was to assess treatment results in a series of such lesions at one institution. Since 1997, endovascular surgery has been advocated for very small ruptured aneurysms (< 3 mm in maximum diameter) that fulfill the criterion of a fundus/neck ratio greater than 1.5. Twenty-one patients were treated, for whom the World Federation of Neurosurgical Societies classification before treatment was Grade I in 10, Grade II in two, Grade III in two, Grade IV in five, and Grade V in two. The aneurysm location was the internal carotid artery in four, the anterior communicating artery in 11, the middle cerebral artery in one, and the vertebrobasilar system in five. In all patients, endovascular surgery was performed using Guglielmi detachable coils after induction of general anesthesia. Initially, the presumed volume of the lesions was calculated for each aneurysm. Thereafter, the appropriate coil length was decided according to the volume embolization ratio, as 30 to 40%. In all attempts to obliterate aneurysms a single coil was used. All aneurysms were completely obliterated as confirmed by postembolization angiography, without procedure-related complications. During the follow-up period only one patient needed additional coil embolization for a growing aneurysm. Final outcomes were good recovery in 15 patients, moderate disability in five, and severe disability in one. Appropriate selection of patients and coils, and use of sophisticated techniques allow a good outcome for patients with very small aneurysms.

Coil Embolization of Very Small (2 mm or Smaller) Berry Aneurysms: Feasibility and Technical Issues

“…13 The small size of the aneurysm may be associated with a higher risk for rupture during embolization. 2,3 Review of the English-language literature revealed only 1 study by Suzuki et al, 4 who reported on endovascular treatment of very small aneurysms. However, they studied aneurysms of at least 3 mm with a favorable fundus-to-neck ratio of 1.5.…”

“…2,3 Very few series in the English literature focus on the outcome of embolization of very small aneurysms. Suzuki et al 4 reported on the endovascular treatment of aneurysms less than 3 mm in diameter, with a favorable neck-to-fundus ratio. We report consecutive cases of endovascular coil occlusion of very small cerebral aneurysms with at least one of the aneurysmal dimensions being less than 2 mm.…”

Association of endovascular therapy of very small ruptured aneurysms with higher rates of procedure-related rupture

“…3,11-15,17 Suzuki et al 15 recently published a series describing endovascular treatment of 21 patients with very small ruptured intracranial aneurysms (Յ 3 mm diameter) without procedure-related complications. All patients had to fulfill the criterion of a fundus/ neck ratio Ͼ 1.5 to be treated.…”

Clinical and Angiographic Results of Coiling of 196 Very Small (≤ 3 mm) Intracranial Aneurysms

“…In the International Subarachnoid Aneurysm Trial, such very small aneurysms were not included, and the conclusion that coiling is the preferred treatment does not apply to these very small aneurysms. [1][2][3] In particular, the higher chance of procedural rupture in recently ruptured aneurysms is considered a drawback, and surgery for these very small aneurysms is often advocated. Although the chance of procedural rupture is higher in very small aneurysms, its effect on outcome is unknown: only a few reports focusing on outcome of coiling of very small aneurysms are available.…”