Endovascular Treatment of Intracranial Aneurysms DOUGLAS A. NICHOLS, M.D., FREDRIC B. MEYER, M.D., DAVID G. PIEPGRAS, M.D., PATSY L. SMITH, R.N.  Mayo Clinic Proceedings  Volume 69, Issue 3, Pages 272-285 (March 1994) DOI: 10.1016/S0025-6196(12)61068-4 Copyright © 1994 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 1 Angiograms of 14-year-old boy with palsy of left cranial nerve VI due to 2.5-cm aneurysm of cavernous segment of left internal carotid artery. Lateral (A) and Towne (B) views of left common carotid artery, demonstrating aneurysm. C, Digital subtraction angiogram. Towne view of right common carotid artery obtained during temporary balloon occlusion of left internal carotid artery, demonstrating good collateral opacification of left carotid intracranial circulation through patent anterior communicating artery. D, Digital subtraction angiogram. Towne view of left vertebral artery also obtained during temporary balloon occlusion of left internal carotid artery, demonstrating good collateral opacification of left middle cerebral circulation through patent left posterior communicating artery. Mayo Clinic Proceedings 1994 69, 272-285DOI: (10.1016/S0025-6196(12)61068-4) Copyright © 1994 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 2 Radiographic studies of same patient described in Figure 1. Lateral (A) and Towne (B) radiographs, demonstrating contrast-filled detached No. 17 latex Debrun balloons (black arrows) in proximal cavernous and petrous segments of left internal carotid artery. Note stagnant contrast medium in cavernous carotid aneurysm (curved white arrows). At 6 weeks after balloon occlusion, spin-density-weighted axial magnetic resonance imaging scan (C), demonstrating complete thrombosis of aneurysm (arrow). At 18 months after balloon occlusion, spin-density-weighted axial magnetic resonance imaging scan (D), demonstrating substantial decrease in size of thrombosed aneurysm so that it is no longer apparent. Patient's palsy of left cranial nerve VI had completely resolved at 18-month follow-up clinical examination. Mayo Clinic Proceedings 1994 69, 272-285DOI: (10.1016/S0025-6196(12)61068-4) Copyright © 1994 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 3 Radiographic studies of 70-year-old woman with history of increasing confusion, ataxia, and left hemiparesis. A, Proton-density-weighted axial magnetic resonance imaging scan, demonstrating 4-cm, partially thrombosed aneurysm with associated mass effect resulting in obstructive hydrocephalus. B, Lateral angiogram of right carotid artery, demonstrating that aneurysm (arrow) arises from origin of posterior communicating artery. Note that most of aneurysm is thrombosed and remaining patent portion is approximately 1 cm in maximal diameter. C, Angiogram of left carotid artery obtained immediately after successful detachment of No. 19 latex Debrun balloon filled with hydroxyethylmethacrylate (arrowheads) within aneurysm. D, Computed tomographic scan of head obtained after treatment, demonstrating detached balloon (arrow) within aneurysm. Note relationship of size of balloon to overall size of thrombosed aneurysm. Mayo Clinic Proceedings 1994 69, 272-285DOI: (10.1016/S0025-6196(12)61068-4) Copyright © 1994 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 4 Diagram of Guglielmi detachable platinum coil. A, Helical diameter of coil. B, Length of coil. C, Microsolder connecting distal stainless steel wire to platinum coil. D, Uninsulated segment of distal stainless steel wire. E, Proximal Teflon-insulated stainless steel wire. Mayo Clinic Proceedings 1994 69, 272-285DOI: (10.1016/S0025-6196(12)61068-4) Copyright © 1994 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 5 Occlusion of aneurysm with Guglielmi detachable coil. A, Aneurysm of basilar artery before treatment. B, Microcatheter has been placed inside aneurysm, and first coil has been delivered inside aneurysm but not yet detached. Arrow depicts junction between guidewire and coil. C, Coil has been detached, and guidewire has been withdrawn proximally into microcatheter (arrow). D, Appearance of aneurysm after completion of treatment. Aneurysm is filled and excluded from intracranial circulation by combination of thrombus and multiple coils. Microcatheter is being withdrawn from basilar artery (arrow). Mayo Clinic Proceedings 1994 69, 272-285DOI: (10.1016/S0025-6196(12)61068-4) Copyright © 1994 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 6 Radiographic studies of 39-year-old man with sudden onset of severe headache and decreased level of consciousness. A, Computed tomographic scan of head, demonstrating diffuse subarachnoid hemorrhage, most prominent in region of interpeduncular cistern (arrow). B, Angiogram of left vertebral artery, Towne view, demonstrating aneurysm, 16 mm in maximal diameter, at tip of basilar artery. Aneurysm was treated with Guglielmi detachable coils 48 hours after onset of symptoms. C, Angiogram of left vertebral artery, Towne view, obtained immediately after treatment of aneurysm. Seven coils, a total of 180 cm in length, were detached within aneurysm. Note small portion of base of aneurysm that remains patent after initial treatment (arrow). It was technically impossible to place a coil in remaining patent portion of aneurysm because of its small size. D, Radiograph, unsubtracted Towne view, demonstrating position and configuration of detached coils after initial treatment. E, Angiogram of left vertebral artery, Towne view, obtained 6 weeks after treatment, demonstrating slight interval enlargement of aneurysmal remnant (arrow). (Compare with C.) F, Aneurysmal remnant was successfully treated by detaching a single additional coil, 8 cm in length and 2 mm in diameter. G, Radiograph, unsubtracted Towne view, demonstrating position of additional detached coil (arrow). (Compare with D.) Mayo Clinic Proceedings 1994 69, 272-285DOI: (10.1016/S0025-6196(12)61068-4) Copyright © 1994 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 7 Radiographic studies of 35-year-old man with severe subarachnoid hemorrhage resulting from ruptured aneurysm at tip of basilar artery. A, Computed tomogram of head, demonstrating subarachnoid blood, which is particularly prominent in sylvian fissures (straight arrows) and pontine cistern (curved arrow). B, Lateral angiogram of left vertebral artery, demonstrating bilobed aneurysm, 5 mm in maximal diameter, at tip of basilar artery (arrow). Aneurysm was treated by detaching four Guglielmi coils, a total of 38 cm in length, inside aneurysm. C, Lateral angiogram of left vertebral artery, demonstrating successful coil occlusion of aneurysm (arrow). D and E, Angiograms, Towne view, of right and left common carotid arteries obtained immediately after coil occlusion of aneurysm, demonstrating severe vasospasm involving supraclinoid internal carotid arteries (open arrows), M-1 segments of middle cerebral arteries (solid arrows), A-1 segments of anterior cerebral arteries (large arrowheads), and small cortical branches of distal middle and anterior cerebral arteries (small arrowheads). Supraclinoid internal carotid arteries and M-1 segments of middle cerebral arteries were treated by balloon angioplasty, and then 100 mg of papaverine was infused directly into both internal carotid arteries for 30 minutes. F and G, Angiograms, Towne view, of right and left internal carotid arteries obtained immediately after balloon angioplasty and infusion of papaverine, demonstrating substantial improvement in diameter of vessels treated with angioplasty and also of more distal branches treated with infusion of papaverine. Mayo Clinic Proceedings 1994 69, 272-285DOI: (10.1016/S0025-6196(12)61068-4) Copyright © 1994 Mayo Foundation for Medical Education and Research Terms and Conditions