Alexandria University Faculty of medicine Neurology Depart

Alexandria University , Faculty of medicine Neurology Depart. Egypt Department of Neuroradiology, Neurocenter University of Freiburg, Germany UNRUPTURED MCA ANEURYSM COILING O Mansour, J Weber and M Schumacher Neuroradiology Depart. Freiburg Univ. Neurology Depart. Alexandria Univ.

Endovascular coiling of MCA aneurysms has shown higher procedural failure rate and less favorable results compared to the treatment of aneurysms at other sites (ISAT group, Lancet 2002; Suzuki S, Neurosurgery 2009) In ruptured MCA aneurysms, subgroup analysis of ISAT in older patients more than 65 years revealed inferiority of coiling to clipping (Ryttlefors M, Stroke 2008)

Elderly patients with ruptured MCA aneurysms benefit more from neurosurgical clipping. M Ryttlefors et al , Stroke 2008

Reasons for less favorable outcome : ICH more often associated with ruptured MCA aneurysms Another hindering factor is what is called the wild morphological gallery of MCA aneurysm

Pretreatment study of morphology in 126 MCA aneurysms

Russian Matroska appearance

Marge simpson head

Dew drop

• In the treatment of unruptured intracranial aneurysms endovascular coiling has shown equal or superior results to clipping (Higashida RT, AJNR 2007) unruptured • But for unruptured MCA aneurysms coiling has been limited, mainly due to the unfavorable aneurysm geometry (wide neck and/or incorporation of a branch into the neck) (Doerfler A , AJNR 2006)

Modified endovascular techniques and devices, such as multi-catheter, balloon-assisted, stent-assisted, or combination of these, permit coiling even of aneurysms having a complex anatomy (Lubicz B, AJNR 2006)

Methods and patients Patients with mild neurological deficit (m. RS, 0 - 2) were included Former SAH from another aneurysm Who accidentally discovered during non hemorrhagic neurological manifestation Between 2001 -2009 retrospectively 70 patients with 76 unruptured MCA aneurysms were included, reviewed and evaluated. 30 men and 40 women aged from 27 to 77 years (mean, 59 years)

RESULTS

Mean age of our cohort was 59 years with IQR ( 27 -77 years) , 30 (42. 9%) patients were male. 80 70 60 50 40 male female 30 20 10 0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627282930313233343536373839 female

Results Table 1: aneurysms measurements and endovascular methods used in occlusion. Aneurysm distribution site(n=75) Treatment methods (n=75) SINGLE CATHETER (n=30 , 40%) Multicatheter (n=18 , 24%) Mean of Aneurysm Sac Size Balloon-assisted (n =11, 14. 7%) Aneurysm neck Stent-assisted (n=13 , 17. 3%) Treatment failure Multi-catheter+ballon (n=3, 4%) 7. 5 mm (range, 3 – 19 mm) Wide neck (n=41, 53. 9%) Narrow neck (n=35, 46. 1%) 1 (1. 4%)

Complication rate was in 1/76 = 1. 4% (perforation and treated without sequlae ) Coiling failed in 1/76 = 1. 3% Failure Rate Mortality Rate Procedural complications Morbidity Rate infarction occurred in relevant MCA territory in 2 patients, but both of them completely recovered at discharge Death rate was in 1/76 = 1. 4% ( SAH consequence permanent morbidity 1/76=1, 4%

Follow-up results No SAH 1 MI death and 1 stroke in basilar artery Clinical follow-up ( avalible in all except 1) Mean 23 months ( IQR 4 -105 months)

Follow-up angiographies at least once at 6 – 24 months (mean, 11 months) period of follow up. Mori et. al. classification 69/75 aneury sm (92%) 3 (4. 3%) major recurrences 6 (8. 6%) minor recurrences retreated by coiling without any complication.

Case 1, catheter-assisted twocatheter technique

Case 2 , stent-assisted coil embolization for both aneurysms

Case 3 , Hyper. Form balloon assisted coiling

DISCUSION

MCA aneurysms should not be allocated solely to clipping but only the large MCA aneurysms in young patients, which are likely to recur

Some limitations are present in this series Small, unruptured MCA aneurysms were treated. (randomized retrospective study) Because of the retrospective nature of this study, another limitation is selection bias Limited number of angiographic followup may have lowered the recurrence rate

• Thank you

Introduction Since intracranial subarachnoid aneurysm trial (ISAT), [1] endovascular coiling has been increasingly used as first treatment option for ruptured or unruptured aneurysms that are feasible for coiling. Intracranial subarachnoid aneurysmal trial (ISAT) proved the superiority of endovascular coiling for the treatment of ruptured intracranial aneurysms over microsurgical clipping.

MCA aneurysm State Of the Art Mangement Rupture d However, for the middle cerebral artery (MCA) aneurysms, endovascular coiling is less likely to be applied as routine agreement

in ruptured MCA aneurysms The most widely accepted theory presumed to be responsible for the inconvenient outcome Hematoma frequently associated with ruptured MCA aneurysm may be a cause of unfavorable outcome of coiling, because coiling itself cannot remove the hematoma.

MCAa Unique Morphology Gallery The aneurysm geometry unfavorable for coiling, which is frequently met in MCA aneurysms, can be another factor.

But other more complicated discrible morphologies could be encounterd

Used modified techqniue

Follow-up angiographies at least once at 6 – 24 months (mean, 11 months) period of follow up. Mori et. al. classification 69/75 aneury sm (92%) 60 (87. 1%) major recurrences 3 (4. 3%) major recurrences 6 (8. 6%) minor recurrences retreated by coiling without any complication.