Endovascular Treatment of Internal Carotid Artery Aneurysms with Guglielmi Coils (GDC)

Abstract

This paper evaluates the result of endovascular treatment in aneurysms arising in the internal carotid artery, intracranial tract, using Guglielmi detachable coils. We selected one years, from November 1995 to November 1996 in which we used GDC to breat 26 patients with intracranial aneurysm; 14 of them in the carotid siphon. Patients' ages ranged from 29 to 77 years (9 women and 5 men). Following, the Yasargil classification we divided the aneurysmal origin into: ICA lateral site (posterior communicating artery), 7 cases; ICA inferior site, 3; ACI medial distal site, 1; ICA bifurcation site, 3. Regarding size, the aneurysm was: small in 7 patients, medium in 6 and large in 1. The occlusion percentage was total in 9 patients, sub-total in 4, partial in 1.

The clinical presentation was with subarachnoid haemorrhage in 11 patients (6 of them were treated within 3 days from the onset of symptoms); in three of them aneurysm detection was occasional (real occasional in 2, occasional in 1). All 14 patients were evaluated on discharge with the Glasgow Outcome Scale (GOS) modified, according to the Guglielmi proposals: 10 out of 14 patients had an excellent GOS with no deaths.

All treatment was performed in anaesthesia with heparin infusion 5000 Ul ev in bolus + 1000 Ul each hour); the heparin infusion was suspended 12 hours after the treatment and then paediatric Aspirin or Fraxiheparin was administered for 4–5 days. No perforation of the aneurysmal sac occurred during treatment or cerebral haemorrhage due to the catheter positioning. In one patient with H-H IIIa, with a wide neck aneurysm and siphon dysplasia rebleeding occurred 21 days after treatment requiring prompt surgery; on discharge the GOS was fair. Regarding thrombo-embolic complications, one patient with H-H grade IIIa, had a hypodense ischaemic lesion, in a temporoparietal site ipsilateral to the aneurysm, without associated symptoms.

Another patient, with IIIa H-H grade, presented a thromboembolic complication after treatment; the CT scan revealed multiple hypodense lesions in sub- and supratentorial sites; the GOS was poor on discharge with associated permanent neurological deficit. No patient died as a direct of the treatment. The radiation dose to patient and operator should not be underestimated: in our experience we had three cases of transient localised alopecia.

The angiographic controls after treatment, at discharge and after 3–6 months, showed persistent occlusion; in one case of sub-total occlusion, total occlusion was achieved by re-do surgery. The GOS remained stable at 3–6 months after treatment in patients with an excellent result; one patient with GOS fair at discharge reached an excellent result; the other two patients with GOS poor and fair have improved during time reaching a fair and good outcome respectively.