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Endovascular Treatment of Intracranial Aneurysms

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PanVascular Medicine

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Abstract

Endovascular treatment has become the mainstay of treatment for most ruptured and many unruptured cerebral aneurysms. The key evidence for this development is presented.

The equipment and procedures for standard unassisted coiling of cerebral aneurysms are presented as an overview in a quick to reference list fashion. Major complications and preventive measures are also presented. Adjunctive considerations such as anesthesia, anticoagulation, and post-procedural care are similarly covered. Illustrative figures are provided throughout the text along with key references.

Then the simpler assist techniques for aneurysm coiling are covered – balloon-remodeling (in some detail) and double-microcatheter approach.

In the second section of the chapter, reconstructive approaches to the treatment of complex aneurysms are covered. These are stents (including multiple-stent approaches), flow diverters, and intrasaccular flow disruption devices. The indications for the use of such devices are discussed and overview of the evidence for their use provided within the text. Practical technical considerations specific to the use of these devices are presented. Again, complications are discussed for each class of device.

In the final section of the chapter, deconstructive and combined endovascular therapy options are discussed along with occlusion testing. The procedural and technical aspects of parent vessel occlusion are presented along with key management tips. A brief overview of combined approaches is given at the end of the chapter.

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Notes

  1. 1.

    Road maps (trace-subtract fluoroscopy) are produced when a peak bolus is automatically traced over the area in view when contrast is administered under fluoroscopy. The resulting image shows a vascular structure as if it were completely filled: the reference image or “road map.” Subsequent fluoroscopy shows the progress of the intervention over this reference image. The road map image can be faded in/out for enhanced viewing. Run exposure can be performed without losing the road map image, saving contrast and X-ray dose. In addition, the subtracted fluoroscopy can be re-masked to compensate for movement.

  2. 2.

    SmartMask™ (or equivalent) simplifies road mapping procedures by overlaying fluoroscopy with a selected reference DSA image on the live monitor. The reference and fluoro images can be adjusted to preference.

Abbreviations

Angiography:

Imaging of blood vessels

Bifurcation:

Vessel branching point

Bypass:

Surgical implantation of a vascular graft to circumvent an abnormality

Deconstructive:

Aneurysm treatment where the vessel that the aneurysm arises off is occluded

Embolize:

To deliver an intravascular object/substance to occlude/treat a lesion

Endovascular:

Within the blood vessels (intra-arterial in this case)

Fusiform:

Dilatation of whole vessel segment rather than a pouch of it (saccular)

Intrasaccular:

Within the lumen of an aneurysm sac

Intravascular:

Within a blood vessel

Ischemia:

Lack of adequate blood (oxygen) supply

Mycotic:

Of infective origin

Pseudoaneurysm:

Definitions vary, but it lacks all the wall layers of a usual saccular aneurysm

Reconstructive:

Cerebral aneurysm treatment where patency of parent vessel is maintained

Serpentine:

Particularly tortuous fusiform type of aneurysm

Stent:

Metal tube placed within a blood vessel to reconstruct it

WEB:

Abbreviation for “woven endobridge device”

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Authors and Affiliations

  1. Newcastle University Institute of Neuroscience, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK

    Prof. Phil White

  2. Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK

    Dr. Johann duPlessis MBChB, FRCR

  3. Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Level 6 Leazes Wing, NE1 4LP, Newcastle upon Tyne, UK

    Prof. Phil White, Vijay Jayakrishnan MB, BS, MD, FRCR & Dipayan Mitra MB, BS, MD, FRCR (Consultant Interventional Neuroradiologist)

Authors
  1. Prof. Phil White
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  2. Dr. Johann duPlessis MBChB, FRCR
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  3. Vijay Jayakrishnan MB, BS, MD, FRCR
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  4. Dipayan Mitra MB, BS, MD, FRCR
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Correspondence to Phil White .

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Editors and Affiliations

  1. Akademisches Lehrkrankenhaus MLU, Bitterfeld-Wolfen, Germany

    Peter Lanzer

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White, P., duPlessis, J., Jayakrishnan, V., Mitra, D. (2014). Endovascular Treatment of Intracranial Aneurysms. In: Lanzer, P. (eds) PanVascular Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-37393-0_92-1

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