Application Of Double Micro Catheter Technique In Wide-necked Intracranial Aneurysms

Background:In recent years, with the rapid development of intervention materials, endovascular treatment(ET) of aneurysms is exhibiting more superiorities such minor invasiveness, rapid recovery, wide surgical indications than craniotomy.The long-term clinic outcomes of ET are also comparable with that of clipping surgery. However, it is still a big challenge for the coils embolization of intracranial wide-neck aneurysms without other assistant devices. Lower complete embolization rate and higher incidence of aneurysm recurrence are reported inSimple coil embolization treated patients. Implanted coils are more likely to escape from aneurysm sac as well. At presently, stent or balloon assisted technique combined with coil embolization are widely used in the treatment of intracranial wide necked aneurysms and better therapeutic effects have been achieved. However, the complex operation procedures as well as the potential stimulus/damage to the vascular wall of stent/balloon assisted technique may limit its application in the treatment of acute ruptured wide neck intracranial aneurysm. Other drawbacks such as incidence of vasospasm, postoperative thrombosis also aggravate this dilemma. Double micro catheter technique seems to be another effective treatment method for the treatment of ruptured wide neck aneurysm during the acute phase. It is easier to implement and with less complications compared with the balloon/stent assisted coil embolizationtechniques.Objective:By analyzing the clinic data of the 22 dual microcatheter techniques treated intracranial neck-wide aneurysm cases(Mar. 2013—Aug. 2014), the surgical indications, efficacy, emblization degree and associated complications were studied.Methods:All the 22 cases of wide-neck aneurysm were treated with dual micro catheter techniques within 3 days after the onset of aneurysm rupture. Patient condition was assessed based on Hunt-Hess grade system preoperatively. Under general anesthesia,aneurysm neck width and aneurysm height were firstly measured with seldinger technique,combined with 3D-DSA. The aneurysm neck width / body width ratio and the relationship between the parent artery carrying blood vessels and aneurysms were also carefully analyzed.Through the guiding 6 F catheter, a micro catheter was placed in aneurysm sac. A standard Guglielmi detachable coils(GDC, GDC-1) was then delivered into the aneurysm sac. After being weaving into a basket, keep it undetached. Another differently shaped micro catheter(compare with the fist one) was introduced into the aneurysm sac from a second Y shape valve connected to the first one. And a second GDC coil(GDC-2) was delivered into aneurysm sac. Based on the aneurysm shape,the two coils are delivered simultaneously, successively or alternately. Detach the coil GDC-2 and deliver another coil if necessary. After complete embolization, detach GDC-1.Results:(1) Radiographic results: All the 22 patients with wide neck aneurysm were successfully treated with double micro catheter techniques. Postoperative immediate angiography indicated that 12 cases(54.5%) were completely embolized; 6 cases were most embolized(27.2%) and 4 cases(18.2%) were partly embolized.(2) Clinical results: 11 of the 17 patients with a preoperative Hunt- Hess grade of I – III showed satisfied prognosis at the time of hospital discharge(with / without mid symptoms such as headach, dizziness etc.). 5 patients were discharged with different degree of disability but were of partial life self-care. The distal part of theparent artery was occluded during the operation in 1 cases of middle cerebral artery aneurysm. Partial recanalization was accquired after immediate urokinase thrombolysis. However, massive cerebral infarction was diagnosed after postoperative CT scan and decompressive craniectomy was performed on the next day. At the time of hospital discharge, the patient was vegetative state with a GCS score of 5 points.One case of posterior communicating artery aneurysm was confirmed a small amount of contrast agent leakage during the emblization, which indicated the rupture of the aneurysm. By rapid coil delivery, the fistula was occluded very well and a good prognosis was obtained when discharge. In the 5 cases of grade IV-V, 1 patient died, 2cases obtained good recovery, with mild to moderate disability or disturbance of consciousness, 2 cases were of moderate disability and part of living ability.(3)Clinical follow-up and imaging follow-up: Three months after hospital discharge, by means of outpatient service or telephone follow-up, 21 cases were assessed with Modified Rankin Scale score: 0 to 3 points in 18 cases and 4 to 5 points in 3 patients. CTA or DSA examination was performed on 16 patients 6-12 months after the operation. Aneurysms were embolized of high dense in 13 cases, 2 patients were confirmed of residual aneurysm neck portion and in 1 case, the coil loop protrude out of the aneurysm neck, but it does not affect the blood supply of parent artery. 1 case was diagnosed aneurysm recurrence.Conclusion: Double micro catheter embolization technique is an effective and safe method in the treatment of acute phase intracranial relative wide neck aneurysm.