Endovascular coiling is now the primary treatment approach for ruptured intracranial aneurysms based on evidence from trials like ISAT showing improved outcomes compared to clipping. The presenter's experience with 33 patients with 35 consecutive aneurysms showed high rates of aneurysm occlusion (95%) and good clinical outcomes (87.6% had mRS 0-2) when treated using a protocol-based endovascular approach with neurosurgical and critical care support. Complications were low when meticulous techniques were used along with protocols for management of issues like vasospasm.

1. Consecutive aneurysms treated by endovascular approach-our experience
Talk at ISNR 2014 (annual conference of Indian Society of Neuroradiology, Delhi)
VipulGupta
NeurointerventionalSurgery
(Interventional Neuroradiology)
Institute of Neurosciences
Medantathe Medicity

2. ANEURYSMS-basic facts
•Subarachnoid hemorrhage(SAH).
•One in every 20 strokes , at the prime of ones life (commonly between 40-50yrs).
•Up to 40-50% patients do not survive even for a month mostly because of the reruptureof the aneurysm
•With proper treatment up to 90% of patient who reach hospital before any major damage has happened will lead an independent and productive lifeInitial CT ScanRebleeding after 1 day

3. ISAT
Randomized, prospective,
international trial
Clipping vs coiling
9559 patients screened, 2143 randomized
at 1 year, the difference in the risk of dependency or death between the two groups was 6.9% and the relative risk reduction was 22.6%(in the coiling group)
ISAT follow-up, Lancet 2009-death at 5 years lowerThe Barrow Ruptured Aneurysm TrialCompared clipping vscoiling in SAH patients. Poor outcome -33.7% in clipping vs23.2% in coiling

4. Guidelines for the Management of AneurysmalSAH: Special Writing Group of the Stroke Council, ASA/AHA Stroke 2009
Amenable to both endovascularcoiling andneurosurgical clipping, endovascular coiling canbe beneficial(Class I, Level of Evidence B).
Metanalysis
•Stroke 2013
•AJNR 2013
•Ruptured aneurysms-better outcomesafter endovascular management

5. In the ISAT and BRAT trials only 39.8% and 62.3% percentage of patients respectively were treated by endovascular approach
•Image-guidance (3-D , Dyna-CT)
•Coil, catheter, balloons, stents
•Drugs-aspirin, clopidogrel, abciximab
•Appx. 90% by endovascular
•Intra-arterial vasospasm mgt.
•HELP and Cerecytestudies –mRS0-2 in 87% (80% in ISAT)

6. Coiling as first choice…
Lubicz B et alof 167 patients treated by coiling as first intention, 87.3% coiled, surgery in 12.7% cases.
(Lubicz B, et alEndovascular treatment of intracranial aneurysms as the first thérapeutic option. J Neuroradiol.2007; 34(4):250-9)
Clarity GDC study-405 patients, 19 French centers, coilig-402 cases, 3 –clipping
(Cognard C,et al, Clarity Study Group. Results of embolization used as the first treatment choice in a consecutive nonselected population of ruptured aneurysms: clinical results of the Clarity GDC study. Neurosurgery.2011;69(4):837)
Multicentre series of 705 ruptured intracranial aneurysms, 96.9% feasibility of the endovascular technique was achieved.
(Sophie Gallas, et al. A Multicenter Study of 705 Ruptured Intracranial Aneurysms Treated with Guglielmi Detachable Coils. AJNR Am J Neuroradiol 2005; 26:17230

7. Our protocol
Interventionist part of neurosurgery team
DSA & if possible embolization
Neurolab with 3D, CT
NS ICU monitoring (TCD/CTP).
Vasospasm-IAVD
N-706 (Sept 2014)
Data of consecutive patients

11. Circumferential involvement-End hole

13. Broad neck , dyplastic aneurysms

16. A
B
C

21. large-/giant aneurysms

22. Data
•Retrospective review of 548intracranial aneurysms
•35 aneurysms in 33 patients -F-19, M-14; 30-68 yrs
•Fisher grade III SAH -22 (66.6%)
•H& H grade-I-III -27 (81.8%)
•EVD/ Lumbar drainage-8 (24.2%)
•<14 days of SAH-26(78.7%)
•
•Wide Neck aneurysms -16
•Dissecting and/or blister aneurysms-19
•Single (28) or double overlapping (5) stents with additional coil placement in 26 aneurysms.

25. Parent vessel occlusion-Cavernous ICA, dissecting (VA), small peripheral

26. Fusiform, dissecting aneurysm

28. 38 yr old male patient, 2-day old SAH
Known hypertensive
Clinically grade II
Small Blister/dissecting Friable, continued growth, re-rupture

29. Classical blister aneurysm
34-year M, SAH

31. Very small aneurysms

34. ? Near the neck rupture/lobule

35. Catheter reposition

36. 1-mm coil

37. Branch from aneurysm-Overinflationtechnique

38. Embolization
Surgery
95%
5%
Good outcome
FND
Mortality
Mgt. outcome in good grade patients- 90 % mRS 0-2

39. The ISAT revealed a complete occlusion rate of 66% (584 of 988) in the coiled patients, whereas other case series of ruptured coiled aneurysms revealed complete occlusion rates ranging from 33% to 81%
Occlussion rate…

40. Complications...
Low ischemic complications -analysis, anti-coagulation (ACT), early use of lytic agents like Abciximib (Reopro) to prevent clinical complication.
Cases of rupture-prevention is the key, rapid response (hypotension, reversal of anticoagulation, coil occlusion of the perforation site, and the use of a balloon to temporarily occlude the artery.)

41. overall death or dependency was 18.0%.
ISAT trial -23.7%,
BRAT trial -20.4%
GDC CLARITY study -23.3%
Outcome…

42. 56 yr old, ischaemic stroke

44. CONCLUSION
>90-95%, with good outcomes –87.6% ( Good grade),
Team work (NS, INR, critical care)
Meticulous technique with protocols
Imaging, technological advances in material, team work, management of SAH related complication such as vasospasm
Limitation -these are the initial management outcomes only

45. Thank you