Endovascular Treatment of Intracranial Aneurysms

257 Pages·1998·6.92 MB·English

by  Dr. James V. Byrne MD

Endovascular Treatment
of Intracranial Aneurysms
Springer
Berlin
Heidelberg
New York
Barcelona
Budapest
Hong Kong
London
Milan
Paris
Santa Clara
Singapore
Tokyo
J.V. Byrne· G. Guglielmi
Endovascular
Treatment
of Intracranial
Aneurysms
Foreword by Charles G. Drake
With 98 Illustrations in 188 Parts
Springer
Dr. James V. Byrne, MD, FRCS, FRCR
Radcliffe Infirmary
Woodstock Road
Oxford 0X2 6HE, GB
Guido Guglielmi, MD
Professor
Division of Interventional Neuroradiology
U.C.L.A. Medical Centre
Los Angeles, CA 90095-1721, USA
ISBN-13: 978-3-642-80383-3 e-ISBN-13: 978-3-642-80381-9
001: 10.1007/978-3-642-80381-9
Library of Congress Cataloging-in-Publication Data
Byrne, J. v. (James V.), 1950-. Endovascular treatment of intracranial aneurysms
I J. V. Byrne, G. Guglielmi. p. cm. Includes bibliographical references and index.
1. Intracranial aneurysms - Endoscopic surgery. l. Guglielmi, G. (Guido),
1948-. II. Title. [DNl.M: 1. Cerebral Aneurysm - therapy. 2. Cerebral Aneu
rysm - diagnosis. 3. Embolization, Therapeutic - methods. WL 355 B995e
19981. RD594.2.B95 1998. 617.4'81-dc21. DNLMIDLC for Library of Congress.
97-28768 CIP
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Dedication
To Nella, Marta, Silvia,
To my brother, Nick Byrne
and Juliet, Rowena, Tom, George, and Henry
Foreword
This is the story of endovascular treatment of brain aneu
rysms whose recent rapid evolution from detachable bal
loons to packing with detachable coils is extraordinary. It
prompted a look back over 40 years of my attempts, and
those of others, to find the ideal safe treatment of intra
cranial aneurysms by surgical ( extravascular) means,
which for me came to an end with retirement in 1992
and experience with over 4000 aneurysms.
Although carotid occlusion had been used even in the
last century, intracranial surgery for aneurysm, while be
ginning in the 1930s, was not widely attempted until after
WWII. Those operations done early after bleeding using
only small unremovable silver clips or ligatures resulted
in high morbidity. Then with the safety of delayed opera
tion there was appalling loss of life with rebleeding while
waiting, and measures to prevent early rebleeding were
only modestly successful. That many postoperative cata
strophes were associated with vasospasm was not recog
nized until the early 1960s, and even today this phenom
enon remains a major cause of morbidity.
Surgeons concentrated on techniques to dissect a slack
aneurysm from its branches and perforators and prevent
inadvertent rupture using varying degrees of systemic hy
potension and even hypothermia for a time. Only gradu
ally did operative morbidity decline in these trying early
years, until micro neurosurgery began. Magnified vision
first with loupes in the 1960s and then under the surgical
microscope in the 1970s provided a new operative world
for the surgeon, revealing the most intimate details of thee
origin and relations of the aneurysm to its neighbour-
hood of nervous structures and vessels.
(c
Aneurysm clip design improved rapidly with remova
ble spring clips of many sizes and shapes. The fenestrated
clip solved the problem of the bulbous neck and could be
used in tandem or in parallel to occlude even the widest
aneurysm necks. After 1980, the use of gentle temporary
VIII Foreword
clipping of the parent vessel came into wider use so that
the surgeon had a slack or even collapsed aneurysm with
which to deal. Coupled with new microsurgical tools most
aneurysm necks could be clipped with exquisite accuracy.
Today in experienced hands most nongiant aneurysms in
good condition patients can be obliterated with morbid
ities under 10% even on the basilar circulation.
The first use of an endovascular embolus may have been
that of Brooks of Nashville, who in 1931 introduced a long
thin strip of muscle into the carotid artery for treatment of
a CC fistula; the patient had a good result but a blind eye.
Russian surgeons later used a muscle embolus tethered
with a suture so that it could be retrieved if the bruit per
sisted or weakness resulted. In the excellent historical re
view herein, it is evident that it was not until 1974 when
Serbinenko's use of flow-directed detachable balloons in an
eurysms, AVMs and CC fistulas ignited wide interest and
sent a tremor through the neurosurgical world. We had oc
casionally used the Luessenhop technique since the mid
1970s but it was the arrival on our unit of Gerard Deb
run, who had introduced these balloon techniques in
Paris, which galvanized our interest and collaborative par
ticipation in endovascular approaches. Not surprising was
the decline of enthusiasm for balloon occlusion of the aneu
rysm sac itself, which produced high morbidity from pre
mature detachment and embolization, rupture of the aneu
rysm or the balloon with its contents. Seldom was oblitera
tion of the aneurysm complete since a balloon could not
usually conform to the shape of the sac. Detachable bal
loons have found their niche in proximal parent artery oc
clusion for inoperable aneurysms and in closing CC fistulae.
The evolution of treatment with wire coils was rapid after
the development of wire-guided catheters. It was the ingenu
ity of Guglielmi and his engineer Sepetka that led to tether
ing the coil to the wire so that it could be detached electri
cally only after its placement in the aneurysm seemed ap
propriate and safe; multiple coil placements are usual.
The ease with which catheters could be guided into vir
tually all intracranial arteries was astonishing. But techni
cal failure to enter aneurysms, due to tortuosity of athero
sclerotic vessels or the take off angle of the aneurysm,
may occur in up to 10% of cases. Coil placement is not
without morbidity - mostly thromboembolism and occa
sional rupture of the aneurysm. Surgeons have sympathy

for radiologists who are faced with these potentially cata
strophic events, in having to deal with them at the end of
a catheter instead of directly. The authors conclude that
the endovascular technique carries less morbidity than)
Foreword IX
conventional craniotomy. However it should be noted that
the overall good outcome in the largest series of coiling
for acute aneurysms (85%) is about the same as early cra
niotomy for ruptured basilar aneurysms. The disappoint
ment is that complete obliteration is seldom possible ex
cept in small necked aneurysms which are so straightfor
ward for surgeons. Even small remnants of an incomple
tely clipped neck are known to enlarge into a new and
dangerous aneurysm. One wonders what will happen over
the years with wholly open ostia or those merely plugged
with wire. Yet medium follow-up over the first few years
in small series has shown little recurrence except in aneu
rysms with necks over 4 mm in diameter.
It is predictable that advances with coil techniques for
the complete obliteration of larger aneurysms will occur,
perhaps with the assistance of balloon packing, stents, or
even endosaccular plastic.
The endovascular approach to the coiling of aneurysms
has an appealing simplicity and will be widely adopted
outside major centres even though plagued with incom
pleteness. If this can be rectified it may become the pre
ferred primary treatment for most intracranial aneurysms
if its morbidity remains low. Until then and in response
to the authors' plea for collaborativecmanagement, I have
suggested that in units where few endovascular proce
dures are done that only the fundus of acutely ruptured
aneurysms be packed with coils down to the waist leaving
the neck open, which could be done with little morbidity.
The patients now safe from early rebleeding could be
tided over their hemorrhagic brain injury even using hy
pertension and angioplasty for vasospasm. Then a month
or so later an operation for clipping completely the re
maining neck could be carried out under a slack healed
brain also with very low morbidity. Such an approach
should accomplish the desirable; prevent rebleeding, and
complete the obliteration of the aneurysm with a com
bined long-term morbidity far less than either technique
alone. Patients with wide necked aneurysms would not
have to face the risk of thromboembolism again when the
enlarging residual sac had to be repacked every fe~
months or years. This approach would not preclude those
few investigating new techniques from continuing their
attempts for more complete endosaccular occlusions.
However, I suspect it will be difficult to stay the hands of
many endovascular radiologists or surgeons who will
want to try for completeness on their own.
Charles G. Drake, O. c., M. n, FRCSC
-
Preface
The collaboration between the two authors that has resulted
in the production of this book began 8 years ago. Dr. Byrne
visited the University of California at Los Angeles at a time
when clinical trials of the Guglielmi detachable coil were
just beginning, and he subsequently imported the technol
ogy to the United Kingdom, performing the first clinical
treatment there in 1992. The authors have worked together
since to establish training programmes for the propagation
of the techniques involved in coil embolisation. As a result,
regular GDC Training Courses have been held in Oxford
and Los Angeles over the last 4 years, and many of the prin
ciples described here owe their origins to the intellectual
discipline needed in such teaching. Because the technology
involves the development and practice of new skills, the
timing of a book such as this is critical. We now feel that
the technology is mature enough for didactic description
but are sensitive to its youth and the need for its continued
critical evaluation.
The authors are however bound by more than a thin
piece of platinum wire. In producing this text we have
drawn on surgical principles learnt in the neurosurgical
training both of us experienced before practising inter
ventional neuroradiology. It was obvious to us that a text
book based on a single technology, such as the Guglielmi
detachable coil, would simply be a technical manual. We
have therefore attempted to present the technology in the
context of its role in the management of patients with in
tracranial aneurysms. Such management has been prac-"
tised by neurosurgeons for the last 60 years and that ex
perience is vital to endovascular therapists coming lately
to the bedside of patients with subarachnoid haemor
rhage. We simply cannot afford not to build on the neuro
surgical heritage. Inevitably, the technical aspects of what
we have written will date, but the principles of operative
surgery which we have tried to bring to the W9rk are vir
tually timeless.
XII Preface
We would like to acknowledge the assistance of Mrs.
Min-Joo Sohn in the preparation of the manuscript, the
medical illustration departments of UCLA Medical Centre
and Oxford University and our respective colleagues for
their help and advice. The hand-drawn illustrations are
the work of Juliet Bailey, who happens to be married to
the English author. We are also most grateful to Dr.
Charles Drake for providing a foreword to the book.
J.V. Byrne
G. Guglielmi