| Part one Clinical value of three-dimensional digital subtractionangiography(3D DSA) in diagnosis and endovascular treatment of intracranialaneurysms.Objective: To evaluate the value of 3D DSA in diagnosis and endovascular treatmentof intracranial aneurysms.Methods: 3D DSA was performed upon 96 patients with subarachnoidhemorrhage(SAH) before and during endovascular embolization, and clinical value of3D DSA in diagnosis and treatment of intracranial aneurysms was evaluated throughthe comparison between images obtained with 2D DSA and 3D DSA. In the study theimages were analyzed by 3 neuroradiologists or more (two or more with the rank ofprofessional title).Results: 83 patients with 92 aneurysms were detected in 96 cases. 88 aneurysms in79 patients were found out with the method of 2D DSA, and 92 aneurysms in 83patients with 3D DSA. The enlargment or backtracking of normal cerebral vesselswere confirmed by 3D DSA in 2 cases, which were suspected to be aneurysms with2D DSA. 4 aneurysms were detected with 3D DSA, but were not seen with 2D DSA.In 89(96.7%) out of 92 aneurysms , necks of the aneurysms and their relationships with the parent arteries were showed clearly on 3D DSA. However, only 56( 60.9%) were showed clearly on 2D DSA, which demonstrated that there was a significant difference between the two methods ( x ~2=35.433, P<0.001) . The best working view of intravascular embolization was deduced from 3D DSA findings bythe analysis of the aneurysm necks and their relationships with the parent arteries.The measure of blood vessels could be performed precisely with 3D DSA and the method of maximum intensity projection was applied usually. In our study, the tiniest aneurysm detected was 1.2mmX0.8mmX 1.0mm in volume, and the biggest one was 13 mm X 22.5 mmX 18mm.Embolization was performed successfully with the help of 3D DSA in 10 aneurysms which were considered difficult and unsuitable for embolism with 2D DSA. On the contrary, according to 3D DSA images, we gave up embolism considered suitable for curing aneurysms with 2D DSA in 5 aneurysms.During the process of embolization, there were 6 aneurysms in which we could not detect if there was neck remnant after treatment. After using 3D DSA, it was demonstrated that there was neck remnant in 3 aneurysms which were embolized completely with additional coils.Conclusion: 1) 3D DSA can improve the diagnostic accuracy of intracranial aneurysms; 2) Compared with 2D DSA, 3D DSA can depict the aneurysm neck and its relationship with the parent artery more clearly; 3) The feasibility of intracranial aneurysm embolization can be determined by 3D DSA; 4) 3D DSA can be used to select the best working view for embolization; 5) Precise measurement of the aneurysm volume with 3D DSA can be used to choose the proper coils; 6) Assessment of the degree of aneurysm embolization can be determined with 3D DSA accurately.Part two Follow-up study on endovascular embolization of intracranialaneurysmsObjective: To evaluate the short- and long-term efficacy of intracranial aneurysmswith detachable coil embolization, and to explore the necessity of follow-up study onthe recanalization and rebleeding of aneurysms.Methods: The patients of intracranial aneurysms with detachable coil embolizationwere followed up in the recent 8 years. The information of clinical symptom recoveryof the patients was obtained by letters, telephone or clinic services. In some cases, itwas necessary to take CT or MRI during the follow-up study. Follow-up DSA wasperformed during the first 6 months, 6 months to 1 year, 1 to 2 years or longer time after coil placement if patients agreed to accept microtraumatic detection. Three or more neuroradiologists ( two or more with the rank of professional title), made the diagnosis to understand the recurrence of aneurysms and determined the treatment such as embolism again if necessary.Purposes of clinical follow-up was to get the following information: a) the recovery of hemiplegic paralysis, aphasia and headache, etc; b) the recovery of oculomotor never paresis; c) the ability of independent living and working, rates of mutilation and death; d)the incidence of rebleeding.Follow-up DSA was to obtain the following information: a) the recanalization rates of aneurysms; b) the shift and absorption of coils in aneurysms; c) the factors affecting the recurrence of aneurysms after embolization; d) the effects of different materials in endovascular treatment of aneurysms; e) the occlusion of the feeding arteries and the blood supply of brain tissue; f) the incidence of rebleeding after embolizatioin and follow-up DSA images; g) the presence of a new aneurysm on follow-up DSA ; h) the necessity of additional embolization. Results:1. Results of clinical follow-up270 patients (124 male and 146 female patients) were investigated in our study. The mean age of the patients was 49.6 years(range ,17-76 years), the mean follow-up period was 2.5 years (range, 1 months to 7 years).Among 270 patients, 85 patients(31.48%) achieved complete recovery (Rankin score, RS 0). 167 patients(61.85%) were independent, with minor symptoms or neurologic deficits(RS 1-2). 11 patients (4.08%) were significantly disabled (RS 3-5), and 7 patients (2.59%) died.In 3 cases ( 1.11%) the neurological deficits were related to embolization. Among the 7 dead patients, one died of delayed aneurysm rupture, the others died of other diseases.The overall incidence of rebleeding was 0.74% (2 cases) after embolization. One case died, the other obtained complete recovery after additional therapy with GDC.Among 52 cases of posterior communicating artery(PCoA) aneurysms with oculomotor nerve paresis, 48 cases received full neurological rehabilitation in one year, 2 in 1.5 years. 2 cases are under follow-up investigation now, one of which has recovered partly in 3 months after embolization, the other has recovered almost completely within 6 months.2. Results of follow-up DSAFollow-up DSA was performed on 102 cases with 114 aneurysms,the mean angiographic follow-up period was 10.5 months (range, 1 months to 6.5 years).Endovascular embolization was performed in 112 aneurysms. The initial rates of occlusion were 100% for 58 aneurysms(51.79%),^95% for 37 aneurysms (33.04%), and less than 95% for 17 aneurysms (15.17%). In 87( 77.68%) aneurysms, coils were fixed stably after embolization. There were 6( 5.36%) aneurysms which contracted in remaining volume, and 19( 16.96 %) re-opned.Among 112 aneurysms, recanalization was exhibited in 12% (3/25) during the first 6 months after embolization, in 24.5%(13/53) between 7 months and 1 year, in 7.7%(2/26) between 1 and 2 years, and in 12.5% (1/8) more than 2 years.1) .GDC or EDC therapyIn our studies, GDC and EDC were the main material used in 90 aneurysms, and reopening of aneurysms was showed in 14(15.56%).The aneurysms were occluded completely in 49, of which coils were stable in 47 cases, and recanalization was observed in 2(4.08%) aneurysms.The occlusion of ^95% was achieved in 30 aneurysms, of which coils were stable in 20 aneurysms, the visualization reduced in 2 aneurysms (6.67%), and recanalization was exhibited in 26.67%(8/30) of aneurysms.The occlusion of less than 95% was achieved in 11 aneurysms, of which the coils were stable in 6 aneurysms, the visualization reduced in 1(9.09%) aneurysm, and recanalization was exhibited in 4 (36.36%) aneurysms.The difference of the recanalization rates between the above occlusions with different degree were significance( x 2=11.356,v=2, P=0.003<0.01).The initial rates of 100% occlusion in narrow-necked aneurysms were58.23%(46/79), which were obviously higher than those in wide-necked aneurysms(3/l 1, 27.27%, x2=6. 461, P<0.05).The recanalization rates in aneurysms of 10mm or more in diameter were 27.5%(ll/40). which were significantly higher than those(3/50, 6%) of small aneurysms (less thanlOmm in diameter) ( x 2=7.82, PO.01).The recanalization rates of wide-necked aneurysms were 45.45%(5/ll), which were obviously higher than those of with narrow-necked aneurysms (11.39%, 9/97) (x2=6.132,P<0.05).The recanalization rates of PCoA aneurysms were 36.4%(8/22), which were obviously higher than those of anterior communicating artery aneurysms (9.5%, 2/21) (x2=4.337,JP<0.05).The progressive occlusion was observed in 3 aneurysms(3.33%), feeding artery occlusion was found in 2 aneurysms, there was no presence of new aneurysms. Among recurrent aneurysms , 9 aneurysms were re-embolized with GDC in time and were not found to bleed again. Among 5 aneurysms observed continuously, there was one delayed rupture , and recanalization of the aneurysm was exhibited apparently on DSA and re-embolized with GDC.2).MDS therapy18 aneurysms were embolized with MDS, recanalization was exhibited in 5(27.78%).The initial rates of occlusion were 100% for 8 aneurysms, no change in 7 on follow-up DSA ,and 1 (12.5%) re-open aneurysm was observed.The initial rates of occlusion were ^95% for 6 aneurysms ,with stable neck remnants in 4 aneurysms. Recurrence was observed in 2 aneurysms(33.33%).The initial rates of occlusion were less than 95% for 4 aneurysms ,with stable neck remnants in 2, and re-open of aneurysm was observed in 2(50%).MDS made up of wolfram was absorbed in 2 aneurysms.Among 5 re-open aneurysms, 3 aneurysms were re-embolized with GDC, and the others were under follow-up observation.3).Matrix detachable coil therapyIn one aneurysm of 100% occlusion with Matrix detachable coils, recurrence was not observed on follow- up DSA 5 months after embolization. The initial rate of occlusion was ^95% for another aneurysm and the complate occlusion was observed on follow-up DSA 6 months after embolization.4).Neuroform stent combined with Matrix detachable coil therapyTwo wide-necked aneurysms were embolized with Matrix detachable coils and Neuroform stents. Though the initial rates of occlusion were less than 95%, the aneurysms were completely occluded on follow-up DSA between 7 months and 1 year. Conclusions:1.Clinical follow-upl).The method of endovascular embolization to treat intracranial aneurysms is safe and effective.2).Oculomotor never paresis caused by PCoA aneurysms might recover after endovascular embolization.3).The incidence of rebleeding of patients with intracranial aneurysms embolized by microcoils is low, occupied only 0.74% in our groups.2. DSA follow-upl).The recanalization rates of aneurysms in our groups are lower than those reported in foreign pertinent literature.2).The recanalization rates of aneurysms which are 10mm or more in diameter are higher than those of small aneurysms which are less than 10mm in diameter. The recanalization rates of wide-necked aneurysms are higher than those of the narrow-necked aneurysms markedly.3).The recanalization rates of PCoA aneurysms are higher than those of anterior communicating artery aneurysms.4). To obtain long-term stable embolization, dense-packing of the aneurysm is needed.5).GDC and EDC seldom evoke the process of thrombosis. MDS made up of wolfram can be absorbed in vivo.6).Matrix detachable coils can promote the healing of aneurysms and wide-necked aneurysms can be cured with Matrix detachable coils and Neuroform stents.7).Periodic angiographic follow up is essential for aneurysms after embolization, especially in those occluded incompletely.8).Additional coil placement should be performed in recurrent aneurysms. |
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