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Follow-up of patients after aneurysm embolotherapy with coils

Follow-up of patients after aneurysm embolotherapy with coils. L Pyysalo,, L Keski-Nisula, T Niskakangas, V Kahara, J Öhman Tampere University Hospital, Tampere Finland. 617 patients with aneurysms treated 1992 – 1999 200 aneurysms in 185 patients were coiled

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Follow-up of patients after aneurysm embolotherapy with coils

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  1. Follow-up of patients after aneurysm embolotherapy with coils L Pyysalo,, L Keski-Nisula, T Niskakangas, V Kahara, J Öhman Tampere University Hospital, Tampere Finland

  2. 617 patients with aneurysms treated 1992 – 1999 200 aneurysms in 185 patients were coiled Clinical and angiographic outcome studied in 2007 - 2008 Follow-up 8 – 16 years after the initial coiling (or re-coiling) Mean follow-up time 11 years Patients and methods

  3. Patients and methods • 109 (/185) patients coiled after SAH and • 76 (/185) patients unruptured aneurysms • 122 patients still alive for delayed follow-up • Clinical outcome evaluated in 116 (95%) • MRI/MRA in 77 (63%) patients with 84 aneurysms

  4. Patients and methods • Glasgow Outcome Score (I –V) • -by clinical evaluation (77) or by phone interview (39) • MRA with non-contrast 3D-TOF and cross-sectional MRI (T1, Flair, T2*) • The same head-coil (1-channel) and the same (upgraded) 1.5T magnet (GE Signa) in follow-up as in the initial post-treatment MRAs (concurrently with the primary DSA or within one year) • (Kähärä et al.,AJNR Sept 1999)

  5. Methods • Three readers for all angiograms (diagnostic, procedural and follow-up) • Consensus statement of the occlusion grade: • 1) complete, 2) neck remnant, 3) incomplete • Initial aneurysm size, dome/neck ratio, location, coil packing density (”loose” or ”dense”)

  6. Results • In ruptured aneurysms the primary coil packing denser in DSA than in unruptured aneurysms (0.04). • No difference in achieved occlusion grades between ruptured and unruptured aneurysms in primary DSA. • In follow-up more ”incomplete” occlusions in MRA in the unruptured aneurysms (0.03). • Re-treatment provided for 25% ruptured and 21% unruptured aneurysms, mainly within six months

  7. Angiographic results Initial occlusion grade* Occlusion in follow-up Complete: 38 38 Neck remnant: 19 22 Incomplete: 27 23 (5/15% ruptured) Total: 84 83 (1 not diagnostic) • *Includes the grades achieved also after recoilings

  8. Stability in follow-up • Stable occlusion grade: 50 (ruptured/unr 20+30) • Occlusion improvement: 14(ruptured/unr 7+7) • Occlusion worsening: 19 (ruptured/unr 7+12) • Total 83 (34+49)

  9. Clinical outcome Ruptured Unruptured Total GOS V: 34 31 65 GOS IV: 12 16 28 GOS III: 13 9 22 GOS II: 1 0 1 GOS I: 0 0 0 Total 60 56 116 In only 3 patients without haemorrhage the poor outcome was related to aneurysm

  10. Clinical outcome – (re)bleedings • Alltogether 10 haemorrhages • - 1/75 unruptured (giant) aneurysm bled after 7 y • - 9/109 rebleedings in SAH patients • - except one rebled patient the others (9) died • - only 3 of rebled aneurysms were monitored by MRA (elderly, vegetative, lost to follow-up etc.) • - 5 initially as ”incomplete”, 3 ”neck remnants” (DSA) • Annual rebleeding rate 1.3 % in ruptured and • bleeding rate 0.1% in unruptured aneurysms

  11. Summary • Primarily: 38(46%) complete and 27(32%) incomplete • Follow-up: 38(46%) complete and 23(27%) incomplete • Annual rebleeding 1.3% (0.1% for unruptured) • - barely platinum coils were used - no stents, bioactive coils, balloon assistance etc. in the 1990`s • Conclusion: Coiled aneurysms remain relatively stable in long-term follow-up

  12. Angiographic results - stability • 20 (59%) aneurysms stable in SAH patients • 6 (18%) remnant growth and 1 recurrence (?) • 7 (21%) occlusion progression • In unruptured aneurysms: • 6 stable • 6 remnant growth and 6 recurrences (?) • 7 occlusion progression

  13. MRA results in follow-up • Complete occlusion in 18 (53%)+20 (40%) = 38 • Neck remnant: 11/32%+11/22% = 22 • Incomplete occlusion in 5/15% + 18/38% = 23 • Ruptured in bold

  14. Clinical outcome • Patients with unruptured aneurysms: • GOS 5: 55% (31) • GOS 4: 29% (16 patients) • GOS 3: 16% (9 patients were ”dependent”) • Only in 3 patients poor outcome was related to aneurysm

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