1. Unruptured Aneurysms
Pipeline
Onyx
Coils
Jawad F. Kirmani, MD

2. CREDITS Adnan Qureshi, MD
For content and some of the power point slides

4. Pathophysiology of aneurysm rupture

7. GDC delivery into the aneurysm sac

8. Thrombogenesis during GDC embolization-
Electrothrombosis - - -
Platinum -
Electrolysis
Stainless steel
Electric charge

9. Different size and shapes of GDC

10. Unstable GDC in broad neck aneurysms
Cath
ICA

11. Balloon Stent/Coil Occlusion
GDC
Aneurysm
Aneurysm
ACA
Balloon
Cath
GDC
Cath
MCA
ICA

12. Stent-assisted GDC placement

13. Histological appearance
GDC intermingled with thrombus with subsequent organization

14. Gross morphology
Damiani

15. Histological Appearance

16. Histological Appearance

17. Basilar apex aneurysm
Pre-procedure
Post-procedure

18. Middle cerebral artery aneurysm
Pre-procedure [lateral]
Post-procedure [AP]

19. A. Before Coil Treatment
Internal carotid artery aneurysm
 A. Before Coil Treatment
 B. After Coil Treatment

20. Internal Carotid Artery Aneurysm
Cruz

21. Balloon assisted GDC embolization
Cruz

22. Balloon assisted GDC embolization
Cruz

23. Dissecting vertebral artery aneurysm
Ward

24. Stent assisted GDC embolization
Ward

25. Who to treat?
All ruptured intracranial aneurysms should be considered.
All unruptured intracranial aneurysms >10mm should be considered.
Unruptured intracranial aneurysms >2mm that are symptomatic may be considered.
Unruptured intracranial aneurysms>5 mm in patients with family history of subarachnoid hemorrhage or intracranial aneurysms or previous rupture of another aneurysm.

26. Tools for estimating the
Life-time risk of rupture
&
Effect of intervention on life-expectancy

27. Unruptured aneurysms Increasing numbers being diagnosed
45% - 80% of patients with ruptured aneurysm may die
Not all rupture
Treatment morbidity 0-16%; mortality 0-25%
Treat those at high risk of rupture

28. ISUIA 2003 Prospective Multi-centre
1692 patients did not have treatment
Selection bias
Not randomised
Aneurysms < 2mm not included
Mean duration of follow-up was 4.5 years
Patients who subsequently underwent treatment excluded from analysis
Included only North America and Europe

29. ISUIA, 2003
The best we have
Findings of ISUIA (2003), could be incorporated into the global view of UIA
Considered along with other data pertaining to the patient

30. Objective Tools for calculating rapidly at: Neurovascular MDT meetings
Clinics

31. Method
Cumulative risk (%) = 100 x {1- [(1-annual risk)/100]^years}

32. Maths of Probability Annual risk of no-rupture = 98% 2 1.96 100 98
Annual risk of rupture = 2%
Annual risk of no-rupture = 98% 2
1.96
100
100 × 0.98 98
100 × 0.98 × 0.98
96.4
100 × 0.98 × 0.98 × 0.98
Chance of non-rupture =
100 × (risk of no-rupture) years
Chance of rupture = 100 – chance of no-rupture

33. Calculation: Simple Vs Actual
1% annual risk over 10 years 10
9.6
3 % annual risk over 20 years 60 46

34. Updated ISUIA (2003)
4060 patients were assessed-1692 did not have aneurysmal repair, 1917 had open surgery, and 451 had endovascular procedures.
5-year cumulative rupture rates for patients who did not have a history of subarachnoid haemorrhage with aneurysms located in internal carotid artery, anterior communicating or anterior cerebral artery, or middle cerebral artery were 0%, 2. 6%, 14 5%, and 40% for aneurysms less than 7 mm, 7-12 mm, mm, and 25 mm or greater, respectively, compared with rates of 2 5%, 14 5%, 18 4%, and 50%, respectively, for the same size categories involving posterior circulation and posterior communicating artery aneurysms.

35. Updated ISUIA (2003) < 7 7-12 13-24 ≥25 Group 1 Group 2
Cavernous carotid 3%
6.4%
AC/MC/IC
1.5%
2.6%
14.5%
40%
Post-P comm
2.5%
3.4%
18.4 %
50%
5 year cumulative rupture rate. Wiebers DO et al. Lancet 2003; 362:

36. Annual risk of rupture of unruptured aneurysm
< 7
7-12
13-24
>=25
Group 1
Group 2
Cavernous carotid
0.6
1.3
AC/MC/IC
0.3
0.5
3.1
9.7
Post-P comm
0.7 4 13

37. UCAS
The UCAS study assessed 5720 patients with 6697 aneurysms patients with 3050 aneurysms underwent surgical or endovascular repair, while the remainder received conservative treatment. The follow-up period was 3 months to 9 years with a total of aneurysm-years.

38. UCAS Aneurysm location was categorized into seven groups:
1. Middle cerebral artery
2. Anterior communicating artery
3. Internal carotid artery
4. Internal caotid – posterior communicating artery
5. Basilar tip and basilar – superior cerebellar artery
6. Verterbal arteries, the posterior inferior cerebellar arteries and vertebro-basilar junction
7. Others

39. UCAS The size of the aneurysms was categorized into five groups:mm mm mm mm
5. ≥ 25 mm

40. UCAS
(annual chance of not bleeding) x expected years of life  = risk of hemorrhage

41. UCAS
As compared with aneurysms in the middle cerebral arteries, those in the posterior and anterior communicating arteries were more likely to rupture (hazard ratio, 1.90 [95% CI, 1.12 to 3.21] and 2.02 [95% CI, 1.13 to 3.58], respectively).
Aneurysms with a daughter sac (an irregular protrusion of the wall of the aneurysm) were also more likely to rupture (hazard ratio, 1.63; 95% CI, 1.08 to 2.48).

42. Risk of Intervention Vs natural history
Many factors are involved in management of patients with unruptured intracranial aneurysms. Site, size, and group specific risks of the natural history should be compared with site, size, and age-specific risks of repair for each patient.
The Risk of intervention is immediate
Risk of natural history is distributed over the life-time

45. Need to take into out those who will have a good outcome following rupture

46. Life table Life-expectancy tables for 2001-2003
Constructed abridged life-tables

47. Look-up tables ‘Actuarial-type’ table Gender specific
Calculations performed using Microsoft® Excel®
Table laid out using Adobe® Illustrator CS2® and Adobe® InDesign CS2®

48. ‘Hope’ calculator Life-time risk of rupture of unruptured aneurysms
Effect of intervention on the life-expectancy
Software developed with Macromedia® Flash 8®
Both Windows and Mac compatible

49. 55 year old male with sah with an incidental 5 mm Acomm Aneurysm

50. A 50 year old female with 8 mm rt. PICA aneurysm

51. AVM’s-Background
Arteriovenous Malformations (AVMs) are direct arterial-to-venous shunt without an intervening capillary bed.
Prevalence of Cerebrovascular arteriovenous malformations is between 0.8% to 1.4% in the population
Current Treatments:
Surgery
Radiosurgery
Embolization
Combined Treatment
Arterial Phase
Venous Phase

52. Direct Supply Fistula and Plexiform
AVM Morphology
Direct Supply Plexiform
“En Passage” Plexiform
with Venous aneurysm
Feeding Artery
Draining vein
Direct Supply Fistula and Plexiform

53. Embolic materials Solid agents: Polyvinyl alcohol particles, Fibers,
Microcoils,
Microballoons.
Liquid agents:
I-butyl cyanoacrylate (IBCA)
N-butyl cyanoacrylate (NBCA)
Absolute ethanol. Henkes H. Nahser HC. Berg-Dammer E. Weber W. Lange S. Kuhne D. Endovascular therapy of brain AVMs prior to radiosurgery. Neurol Res 20(6):479-92, 1998 Sep

54. Embolization with NBCA Mixtures
Embolic Agent
NBCA
Visualization
Lipiodol
Ethiodol
Pantopaque
Tantalum
Tungsten
Polymerization
Lipiodol
Ethiodol
Pantopaque
Glacial Acetic Acid

55. Preoperative embolization of AVMs
Decrease the nidus size
Occlude deep, surgically inaccessible or deep arterial feeding vessels to facilitate
Can favorable effect the operative times, intra-operative blood loss, and even neurological outcomes
Complete surgical removal can be achieved in up to 96% of the patients

56. Preoperative embolization of AVMs

57. Pre-radiosurgical intervention for AVMs
Reduce the lesion to less than 3 cm
Obliterate intranidal or venous aneurysms
Radiosurgery produces total occlusion in 65% of the partially embolized AVMs

58. Thank you!