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Intracranial Aneurysms
K.A. Hausegger
Dep. of Diagnostic and InterventionalRadiology
Klagenfurt / Austria
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• 72 year- old female
• Sudden devastating head ache
• Somnolent but able to communicate
Ruptured Carotid terminus aneurysmSAH; H+H stage III
Fishergrade III
Risk of re-rupture within 24 hours ≈ 4% Ruptured aneurysms should be treated as early as logically and
technically possible – at least within 72 h after onset of symptoms(we treat ruptured aneurysms within 24 hrs.)
ESO guidelines 2013
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5
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ISAT Trial – Lancet 2005
(2143 patients)
Coiling: 23,5% mortality/morbidity
Clipping: 30.9% mortality/morbidity
higher risk for seizures
The goal of treatment of ruptured aneurysms is toprevent rebleeding
6
In cases where the aneurysm appears to be equally effectively treated either by coiling or clipping, coiling is the preferred treatment (class I, level A)
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Incidental Aneurysms
• Patients have no symptoms
• When is treatment indicated?
• Should the patient be offered an intervention which has an inherent risk?
➢ Potential risk: stroke, SAH, death
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5720 patients – 6697 non-rupt. aneurysms
ISUIA Study - 2003
UCAS Study - 2012
1692 patients – 2686 no-rupt. aneurysms
• 1-year rupture risk➢ 1%
• 5-year rupture risk➢ < 7 mm 0 - 1%➢ 7-12 mm 2,6%➢ 13-24 mm 14,5%➢ > 25 mm 40%
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Pooled data from 4 cohort studiesNature reviews Neurology 2016
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Which incidental aneurysm should be treated?
UIAT score / Neurology 2015Phases score / Lancet
Neurology 2014
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Development of intracranial aneurysms
UIA
• Not congenital
• Likelyhood increased with first degree relative SAB of UIA (PR 3.4)
• PCKD (PR 6.9)
• Connective tissue disease ?
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2002 2019
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Finite Element Analysis-based Approach forprediction of Aneurysm-Prone arterial Segments
Viktor Yu. Dolgov et al.
Journal of Medical and Biological Engineering(2019)
Pedridis et al.; Clinics and Practice 2018
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Treatment of intracranial aneurysms- endoluminal vs. clipping -
• Ruptured Aneurysms: Endoluminal if possible (level I /class A evidence)
• Unruptured Aneurysms: less clear
ISUIA / Evidence based Analysis /Ontario 2006
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Achilles´s heal of Coiling
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Mascitelli JR et al.; J Neurointervent 2015
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Achilles´s heal of Coiling
390 Aneurysms; 2 Rebleedings all in Class IIIb
Mascitelli et al.; J NeuroIntervent Surg 2015
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Limitations of Coiling
• Broad neck aneurysms
• Fusiform aneurysms
• Dissecting aneurysms
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Coiling – What else?
• Balloon supported coil embolisation
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Neurointervention LKH KLU
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Stent assisted Coiling
Neurovascular stents need consequent antiplatelett therapyTirofiban in the acute settingClopidogrel and ASS in the non-acute setting
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Flowdiverter
24
antiplatelett therapyis obligatory
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Flow disrupter - WEB
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Procedure time60 min
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WEB in Klagenfurt
Acom MCA Pcom Basilaris ACI
Patients 32
Age 24-77 Jahre (Mittel 59 a)
Rupture 2
Diameter 4 – 11 mm (Mittel 7.1 mm)
9 16 2 3 2
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Procedure / Technique / FU
• WEB in broadbased aneurysms
• Dual PLAT + Heparin n=6
• Single PLAT+ Heparin n= 24
( 2 ruptured aneurysms)
• Tria-axial system
(6-F Sheath / 70 cm; Navien 5-F; VIA microcatheter)
• MR und MRA before demission
• MRA (CTA)DSA controll after 6 mths.
• Clopidogrel für 3 mths.
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Angiographic results - Exclusionrate
9/19 complete occlusion
Partial occlusion
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Does WEB modify its form?
Clinical experience in treatment of intracranial aneurysms with the WEB device
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Does WEB modify its form?
Ratio 1,2
Diam. 9,7 mm
WEB 10 x 7 mm
Ratio 1 -> 1,1
Diam. 2,6 -> 3,1 mm
WEB 5 x 2 mm
Ratio 1,1 -> 1,5
Diam. 5,1 -> 5,5 mm
WEB 6 x 3 mm
Ratio 1,1 -> 1,3
Diam. 5,8 -> 6,2 mm
WEB 7 x 5 mm
Clinical experience in treatment of intracranial aneurysms with the WEB device
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Ratio 1,1 -> 1,3
Diam. 5,8 -> 6,2 mm
WEB 7 x 5 mm
Clinical experience in treatment of intracranial aneurysms with the WEB device
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Ratio 1,2
Diam. 9,7 mm
WEB 10 x 7 mm
Clinical experience in treatment of intracranial aneurysms with the WEB device
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Are there other important issues?
Clinical experience in treatment of intracranial aneurysms with the WEB device
• Currently we use WEBs in broad based aneurysms
• Seem to be attractive for ruptured aneurysms
• FU controlls are necessary
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Conclusion
• Management of intracranial aneurysms is complex
• Endoluminal techniques are advanced and full of variants
• It may be exspected that the application of artificialintelligence will develop to helpful decison supporttools – indication and technique wise.
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