Gudelj M, et al.

Endovascular Treatment of Intracranial Aneurysms: Initial

Experience in a Low-Volume Center. Journal of the Belgian Society of
Radiology. 2020; 104(1): 19, 1–5. DOI: https://doi.org/10.5334/jbsr.1918

ORIGINAL ARTICLE

Endovascular Treatment of Intracranial Aneurysms:

Initial Experience in a Low-Volume Center
Maxime Gudelj*, Pierre-Julien Bruyère*, Malek Tebache*, Laurent Collignon* and
Boris Lubicz†

Objective: Endovascular treatment (EVT) is the first-line treatment for ruptured and unruptured
intracranial aneurysms (IA). EVT may be performed by interventional neuroradiologist (INR) with different
levels of experience. This study aimed at evaluating clinical and anatomic results of IA embolisations
performed by a INR with a short experience.
Materials and Methods: Within a 26-month period, 35 IA embolisations were managed by a young INR,
26 of these IA being ruptured. Different EVT techniques were used: coiling alone, stent-assisted coiling
and remodeling techniques. Initial angiographic results, clinical outcomes and mid-term anatomic results
were evaluated.
Results: Out of 35 procedures, there were seven per-procedural complications leading to one ischemic
stroke and one death. Immediate post-procedural complete occlusion was obtained in 91% of procedures
(32/35). Good clinical results (modified Rankin Scale Score of 0 or 1) were obtained in 79% of patients
(26/33). In a mean follow-up time of 9.5 months, stable occlusion was shown in 88% of IA (21/24).
Conclusion: This study suggests that IA embolisation may be performed by a recently trained INR with
good clinical and anatomical outcomes.

Keywords: Intracranial aneurysms; endovascular therapy; education; follow-up

Introduction Materials and Methods

The prevalence of intracranial aneurysms (IA) in the Population
general population is approximately 2–6% with an Between October 2016 and December 2018, we
estimated annual rupture risk of 0.7% [1]. Endovascular retrospectively identified in our database all the patients
treatment (EVT) has been proved to be the first-line treated for an IA in the radiology department. All
treatment for ruptured and unruptured IA because clinical and imaging data were prospectively collected.
it is associated with a lower morbidity and mortality Conventional digital subtraction angiography (DSA) was
compared to the neurosurgical clipping. Interventional performed in all our patients. Besides, 3D rotational
neuroradiologists (INR) have to follow an elite training angiography was obtained in each case in order to fully
in order to obtain good outcomes. Nevertheless, this understand the morphology and size of the aneurysm and
training is poorly defined in the literature. INRs may the parent artery. Aneurysms were classified according
work in low-volume or high-volume centers, respectively to their morphology (saccular or fusiform) and their size.
defined as less or equal or more than 50 cases/year [2]. They were considered as small (<10 mm), large (10–25
Few data are available over results of IA embolisations mm) or giant (>25 mm). We also classified the neck as
performed by recently trained INR who work in a low- wide if the neck/sac ratio was ≥0.7 or if the neck was
volume center. The aim of our study is to report the early >4 mm.
experience of a recently trained INR (<3-year experience) Seventy-eight patients were identified with 89 IA.
working in a low-volume center. We evaluate the initial Ninety-five EVT procedures were performed because
angiographic results, clinical outcome and mid-term of 6 of the 89 treated IA reopened over time and were
anatomic results. re-treated. Out of the 95 procedures, 60 were performed
by a senior INR with a 15-year experience (B.L.) while 35
were managed by a young neuroradiologist with a three-
year experience (P.B.). These two patient groups are not
* CHR de la Citadelle, Liège, BE comparable as the senior neuroradiologist handled a
Hopital Erasme, BE
†
majority of unruptured IA with most of them having a
Corresponding author: Maxime Gudelj (maxgudelj@gmail.com) complex configuration. The young INR treated a greater
Art. 19, page 2 of 5 Gudelj et al: Endovascular Treatment of Intracranial Aneurysms

number of ruptured IA with a more simple morphology. aneurysmal sac) or incomplete occlusion (class 3 – any
During his training period, the young INR has worked residual opacification of the aneurysmal sac). Follow-up
15 months as second-hand operator for a total of 60 cases studies were assigned to three senior neuroradiologists.
and 12 months as a first-hand operator for 115 cases. On these follow-up imaging examinations, anatomical
results were classified as stable (no change of category),
Procedures minor recurrence (changes from class 1 to class 2) or
All 35 procedures were performed on a monoplane major recurrence (changes from class 1 or 2 to class 3).
C-arm system under general anesthesia and systemic
heparinization. Repeated controls of the activated Results
clotting time (ACT) were carried out in order to assess the Population and Procedures
efficiency of systemic anticoagulation. In our protocol, The mean age of these patients was 53 (range 27–71 years)
we use a 5000 IU bolus infusion of heparin followed by a and 20 patients out of 33 (60%) were women. One patient
continuous drip of 1500 IU/h with the aim to double the was treated for three different aneurysms, one ruptured
ACT. At the end of the EVT, heparinization was prolonged and two unruptured. Among 35 IA, 24 were located in the
for 12–24 hours after the procedure. The patient was then anterior circulation while 11 were located in the posterior
transferred to the intensive care unit where his blood circulation. All IA had a small neck, 24 were small and 11
pressure, neurological status and fluid balance were were large. The mean size of these IA was 7.9 mm (range
monitored for 24 hours. 3.5–15 mm). Demographic informations and lesion
The basics of coiling technique for IA occlusion were characteristics are summarized in Table 1. Among the
described by Gugliemi et al. [3]. In most cases, a 6-Fr guiding 35 procedures performed by the young INR, there were
catheter was used (Envoy, Codman, Miami Lakes, FL). In 26 ruptured aneurysms (74%), six unruptured aneurysms
some patients whose cervical vessels were tortuous, a long (17%) and three recanalizations from a previously coiled
6-Fr introducer was preferred (IVA, Balt, Montmorency, aneurysm (9%).
France; or Neuron Max, Penumbra, Alameda, CA; or Cello, All aneurysm embolizations were performed with
Medtronic, Irvine, CA) and was used with an intermediate coils. Out of 35 procedures, five required the use of a
catheter (Sofia, Microvention, Tustin, CA; or Neuron, balloon catheter. In four of them, the aim was to obtain
Penumbra, Alameda, CA). A microcatheter (XT17, Stryker a denser coils packing. In one case, the balloon was
Neurovascular, Fremont, CA; or Prowler Select, Codman, employed because of a per-procedural aneurysm rupture.
Miami Lakes, FL; or Headway Duo or 17, Microvention, Three of these aneurysms were located on the posterior
Tustin, CA) was then used to deliver coils. If needed, the communicating artery, one was located on the carotid-
remodeling technique (Hyperglide Balloon, ev3, Irvine, ophthalmic artery and one was found on the M1 segment
CA) was used [4] or a stent (Lvis Jr, Microvention, Tustin, of the middle cerebral artery. Stent assisted coiling (SAC)
CA or Leo Stent, Balt, Montmorency, France) was employed technique was executed in six cases (5 Lvis Jr and 1 Leo
to secure the aneurysm neck. Every time a stent was stent). In four of these procedures, SAC was carried out
required, for both ruptured or unruptured IA, Clopidogrel as the aneurysm morphology and/or neck/sac ratio were
was administered for one to three months (75 mg/day). considered unfavorable. In the remaining two cases, coils
Moreover, patients had to take Aspirin (160 mg/day) for at protruded in the parent arteries and resulted in thrombus
least six months. formation. Deployment of a stent and administration
of intravenous (IV) abciximab were used to deal with
Clinical Outcomes those issues. This was successful in one case while in
Per-procedural and immediate post-procedural the other, the treatment failed and led to infarction in
complications were recorded. A neurologist examined the left anterior cerebral artery territory. Regarding the
every patient before and after the procedure. Patients were complications of EVT with coiling alone, we noted three
evaluated again one month after EVT during a specialized thrombus formation in the anterior circulation and one
neurology consultation. The modified Rankin Scale (mRS) carotid dissection. Thrombi fully disappeared after IV
score was used for each patient [5, 6]. abciximab injection. The dissection was 1-mm-thick and
10-mm-long, so conservative management was preferred
Anatomical Outcomes and it faded out on further imaging studies without
Immediate post-procedural angiographic acquisitions any clinical repercussion. Overall, there were seven per-
were evaluated for the quality of aneurysm occlusion. The procedural complications (20%) leading to one ischemic
follow-up imaging protocol includes a conventional DSA stroke and one death (see Table 2).
at six months, a DSA associated with a magnetic resonance
imaging angiography (MRA) at 12 months and then a MRA Clinical Outcomes
every year for three years in case of concordance between Among 33 patients, 24 (73%) presented excellent
both techniques. Anatomical results were described by clinical results (mRS = 0). Two patients (6%) admitted
using the Raymond’s classification [7]. The outcome was for ruptured aneurysms kept a slight upper limb paresis
noted as complete occlusion (class 1 – if no contrast filling but remain independent (mRS = 1). One of these two
the aneurysm), neck remnant (class 2 – persistence of patients already had symptoms on admission. Three
any aneurysmal residue but without opacification of the patients (9%) were dependent with mRS scores of 4 or 5.
Gudelj et al: Endovascular Treatment of Intracranial Aneurysms Art. 19, page 3 of 5

Table 1: Population and IAs characteristics.

Ruptured IA (%) Unruptured IA (%) Recanalizations (%)

No. patients 26 5 3
Male/Female 13/13 0/5 0/3
Mean Age (years) 53,3 52 60
mRS Score
0–2 19 4 3
3–5 3 2 0
6 (death) 4 0 0
No. IA 26 (74) 6 (17) 3 (9)
Size
Small (<10 mm) 18 (51) 5 (14) 1 (3)
Large (10–25 mm) 8 (23) 1 (3) 2 (6)
Giant (>25 mm) 0 0 0
Localization
MCA 3 (9) 1 (3) 0
AcomA 14 (40) 2 (5.5) 0
PcomA 5 (14) 2 (5.5) 0
BT 1 (3) 0 2 (5.5)
PICA 1 (3) 0 0
PeriA 0 1 (3) 0
ICA 2 (5.5) 0 1 (3)
Abbreviations: AcomA, anterior communicating artery; PcomA, posterior communicating artery; BT, basilar trunk; MCA, middle
cerebal artery; PICA, posterior inferior cerebellar artery; ICA, Internal carotid artery.

Table 2: Procedural and periprocedural complications.

Patient IA IA size IA Complication Complication Treatment Clinical results

age status (mm) localization treatment efficiency (mRS)

31 R 10 AcomA Carotid dissection Conservative Complete 0

resolution
69 R 10 PcomA Intraprocedural Balloon assisted Inefficient 6 (death)
rupture coiling
56 R 8.5 BT Gail protrusion & Stent & Complete 0
thrombus in the abciximab resolution
parent artery
43 R 7 PcomA Thrombus Abciximab Complete 1
resolution
50 R 6.5 AcomA Thrombus Abciximab Complete 0
resolution
45 R 7 AcomA Thrombus Abciximab Complete 0
resolution
62 R 8 AcomA Coil protrusion & Stent & Inefficient 5 (left frontal
thrombus in the abciximab infarction)
parent artery

Abbreviations: AcomA, anterior communicating artery; PcomA, posterior communicating artery; BT, basilar trunk; R, ruptured
aneurysm.
Art. 19, page 4 of 5 Gudelj et al: Endovascular Treatment of Intracranial Aneurysms

In two of them, this score was already present before the procedure-related morbidity and mortality rates of 3%,
procedure. One patient conserved a moderate paretic respectively. It is quite similar to the rate of procedure-
dysarthria, a severe left hemiplegia with a strong spasticity related complications found in the literature [10, 12].
of the left upper limb and a moderate left hyposensibility. The initial anatomical results are excellent with 100% of
The third patient had a mRS score of 0 on admission but immediate adequate occlusions (class 1 and 2) whereas
EVT was complicated with thrombus formation resulting the rate is around 91–94% in the literature [12]. The
in infarction in the left anterior cerebral artery territory. aneurysmal recurrence rate is also in accordance with
Four patients (12%) died early after EVT. In one of them, previous studies [7, 12]. Regarding the clinical outcome,
aneurysm rupture occurred during the procedure. This good results were observed in 26 patients (79%) with a
patient had a large subarachnoid hemorrhage, grade IV mRS score of 0 or 1 at discharge. One of these patients
according to the modified Fisher Scale [8], and developed was admitted with a mRS score of 5. Three patients (9%)
a vasospasm with cerebellous, frontal, parietal and were dependent with a mRS score of 4 or 5 at discharge
occipital ischemic lesions on MRI studies. Another patient and four patients (12%) were deceased (mRS = 6). These
died from multiple organ failure. clinical results are comparable to those published in
Clarity and ISAT studies [13, 14]. They are slightly better
Anatomical Outcomes than those reported in other studies [12]. This could be
Immediate post-procedural DSAs showed 32 complete explained by the fact that this study does not only include
occlusions (91%) and three neck remnants (9%). The latter ruptured IA but also unruptured IA and recanalizations of
three cases were treated with coiling alone. There was no previously treated IA.
incomplete occlusion in our series. Follow-up imaging This retrospective study bears limitations. First, the
studies were obtained in 23 patients with 24 IAs. Mean group of patients is inhomogeneous as we included
follow-up time was 9.5 months (range 1–18 months). a majority of ruptured IA but also some unruptured
The follow-up imaging could be unavailable for many IA and recanalizations. This could affect the results
reasons such as death (four patients), lost to follow-up presented in this study as we know that these categories
(two patients) or recently performed procedures (four of IA have different biological behaviors. Indeed, a study
patients). demonstrated the lower rigity of the wall in ruptured IA,
Stable occlusions were showed in 21 cases (88%). Minor which can potentially affect recurrence and complication
recurrence was identified in one case (4%) and major rates [15]. On the other hand, procedures were also
recurrence was depicted in two cases (8%). Of these heterogenous, including simple coiling, remodeling
two latter cases, one was a large recanalized basilar tip technique and stent-assisted coiling. Procedure-related
aneurysm that had been previously treated with coils. The complications are influenced by the technique. The
other case was a small ruptured anterior communicating population of our study is quite small and length of the
artery aneurysm. This aneurysm was treated with bare imaging follow-up is limited (only nine patients had
coils and immediate post-procedural DSA showed a neck an imaging exam at 12 months and above). Lastly, our
remnant. There was no rebleeding within the time frame good clinical and anatomical results could partially be
of the follow-up. explained by the absence of giant aneurysms and wide
neck aneurysms.
Discussion
This study illustrates the early experience of a recently Conclusion
trained young INR working in a low-volume center. To This study suggests that a recently trained INR working
our knowledge, this is the first paper dealing with that in a low-volume center can successfully carry out IA
kind of experience in Belgium. There are few studies embolization with morbidity and mortality rates similar to
evaluating learning curves for IA embolizations in the those described in previous studies. Further investigation
literature. One of these studies demonstrated that the risk is needed to confirm these clinical and anatomical results.
of complications significantly decreases with physician
experience in the setting of unruptured aneurysms Competing Interests
treated with coil embolization [9]. The first-year The authors have no competing interests to declare.
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How to cite this article: Gudelj M, Bruyère P-J, Tebache M, Collignon L, Lubicz B. Endovascular Treatment of Intracranial
Aneurysms: Initial Experience in a Low-Volume Center. Journal of the Belgian Society of Radiology. 2020; 104(1): 19, 1–5. DOI:
https://doi.org/10.5334/jbsr.1918

Submitted: 22 August 2019 Accepted: 17 April 2020 Published: 06 May 2020

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