1. XIX Symposium Neuroradiologicum Bologna,Italy 4-9 october 2010 Endovascular treatment of 50 posterior communicating artery aneurysms: overall, perioperative results Endovascular treatment of 50 posterior communicating artery aneurysms: overall, perioperative results E.Cotroneo,R.Gigli,F.Puccinelli;G.Guglielmi E.Cotroneo,R.Gigli,F.Puccinelli;G.Guglielmi Neuroradiologia Diagnostica-Interventistica AO S.Camillo-Forlanini,Roma Neuroradiologia Diagnostica-Interventistica AO S.Camillo-Forlanini,Roma

2. INTRODUCTIONINTRODUCTION Aneurysms of the internal carotid artery (ICA)-PcomA junction are 20 to 30% of all cerebral aneurysms. Until now no studies of endovascular treatment of only ICA-PcomA aneurysms have been published. Aneurysms of the internal carotid artery (ICA)-PcomA junction are 20 to 30% of all cerebral aneurysms. Until now no studies of endovascular treatment of only ICA-PcomA aneurysms have been published. A series of 47 consecutive patients with 50 ICA- PcomA ruptured and unruptured aneurysms has been studied. A series of 47 consecutive patients with 50 ICA- PcomA ruptured and unruptured aneurysms has been studied. The clinical outcome, angiographic results, and complications are presented. The clinical outcome, angiographic results, and complications are presented.

3. Methods Methods A series of 47 consecutive patients harboring one or two (bilateral) PComA aneurysms were treated at our Hospital using the endovascular approach from 2000 to 2009 A series of 47 consecutive patients harboring one or two (bilateral) PComA aneurysms were treated at our Hospital using the endovascular approach from 2000 to 2009 38 (81%) were females and 9 (19%) were males. 38 (81%) were females and 9 (19%) were males. The patients’ ages ranged from 21 to 79, with an average age of 50. The patients’ ages ranged from 21 to 79, with an average age of 50.

4. Methods Methods In 3 patients there were bilateral PComA aneurysms. In 3 patients there were bilateral PComA aneurysms. In 5 patients we needed to perform a second treatment In 5 patients we needed to perform a second treatment The total treatments were 55 in 47 patients. The total treatments were 55 in 47 patients.

5. Small (3-15 mm) Large (15-25 mm) Aneurysm size Aneurysm Characteristics 43 (86%) 7 (14%)

6. Small (≤ 4 mm) Wide (> 4 mm) Neck size Aneurysm Characteristics 40 (80%) 10 (20%)

7. Clinical Presentation Haemorrhage Incidental 41 (82%) 9 (18%)

8. Hunt and Hess grade HH 1 HH 2 HH 3 HH 4 18 (43,9%) 14 (34%) 5 (12%) 4 (9,7%) Clinical Presentation

9. Endovascular treatment of 55 posterior communicating artery aneurysms: overall, perioperative results Technique Used Technique Used All procedures were performed via the transfemoral approach, after induction of general anesthesia and with the patient receiving systemic heparinization. All procedures were performed via the transfemoral approach, after induction of general anesthesia and with the patient receiving systemic heparinization. An embolization was considered to be complete when there was no contrast filling of the dome,body,base or neck of the aneurysm. An embolization was considered to be complete when there was no contrast filling of the dome,body,base or neck of the aneurysm.

10. Endovascular treatment of 55 posterior communicating artery aneurysms: overall, perioperative results A neck remnant was defined as residual filling of the neck of the aneurysm(Raymond 2) A neck remnant was defined as residual filling of the neck of the aneurysm(Raymond 2) An incomplete embolization was indicated by contrast agent in the base and a portion of the body of the aneurysm(Raymond 3) An incomplete embolization was indicated by contrast agent in the base and a portion of the body of the aneurysm(Raymond 3) We never used bioactive coils. We never used bioactive coils. In four cases a balloon coiling technique was performed. In four cases a balloon coiling technique was performed.

11. Treatment results Complete occlusions Neck remnant Residual filling 30 (60%) 19 (38%) 1 (2%)

12. Complete occlusion Neck remnant Residual filling 19 (46,3%)21 (51,2%) 1 (2,4%) % of occlusion in ruptured aneurysms

13. Complete occlusion Neck remnat % of occlusion in unruptured aneurysms 5 (56%) 4 (44%)

14. Overall clinical outcome A permanent new neurological motor- sensory deficit was detected in 3 patients (6,3%), A permanent new neurological motor- sensory deficit was detected in 3 patients (6,3%), 2 patients had periprocedural complications, 2 patients had periprocedural complications, 1 patient suffered a severe vasospasm seven days after treatment with residual partial disability. 1 patient suffered a severe vasospasm seven days after treatment with residual partial disability. Overall, 2 patients (4,2%) died of severe vasospasm seven days after the procedure, both were Hunt and Hess grade IV Overall, 2 patients (4,2%) died of severe vasospasm seven days after the procedure, both were Hunt and Hess grade IV

15. Therefore, the procedure-related morbidity and mortality rates were 4,2 % (2 cases) and 0%, respectively. Therefore, the procedure-related morbidity and mortality rates were 4,2 % (2 cases) and 0%, respectively. In patients with incidental aneurysms or in patients ( 5 ) with re-treatment the procedure-related morbidity- mortality rates were 0% and 0%, respectively. In patients with incidental aneurysms or in patients ( 5 ) with re-treatment the procedure-related morbidity- mortality rates were 0% and 0%, respectively. Procedure Related Deficit

16. Overall Clinical outcome No deficit residual deficit Died 42 (89,3%) 3 (6,3%) 2 (4,2%)

17. DISCUSSION PComA aneurysms usually arise from the ICA at the origin of PcomA PComA aneurysms usually arise from the ICA at the origin of PcomA Some authors localize these aneurysms from the superior aspect of the PcomA along the lateral surface of the ICA. Some authors localize these aneurysms from the superior aspect of the PcomA along the lateral surface of the ICA.

18. DISCUSSION Surgical Series Surgical Series Kyu et al reported on the surgical outcome of 453 PcomA,375 ruptured and 49 unruptured. Kyu et al reported on the surgical outcome of 453 PcomA,375 ruptured and 49 unruptured. Leipzig et al. reported on analysis of intraoperative rupture (IOR) in surgical treatment of 1694 saccular aneurysms, 307 were PcomA Leipzig et al. reported on analysis of intraoperative rupture (IOR) in surgical treatment of 1694 saccular aneurysms, 307 were PcomA, in 28 ( 9.1%) patients they noted an IOR of PcomA aneurysm

19. Surgical Series In all surgical series authors affirm that the PCom artery provides numerous delicate perforating branches. In all surgical series authors affirm that the PCom artery provides numerous delicate perforating branches. The largest branch is the anterior thalomoperforating artery,it supplies the inferior optic chiasm,the optic tract and a portion of the medial hypothalamus and the inferior thalamus The largest branch is the anterior thalomoperforating artery,it supplies the inferior optic chiasm,the optic tract and a portion of the medial hypothalamus and the inferior thalamus

20. Surgical series N patients Good clinical outcome Fair clinical outcome Poor clinical outcome Death Kyu et al. 42386,1%6,6%4,7%2,6% Surgical + Endovascular series N patients GOS 5 GOS 4 GOS 3 GOS 2 GOS 1 Zada G et al. (aneurysms at fetal variant PCA) 3067%17%10%3%3% SURGICAL/ENDOVASCULAR SERIES Surgical series N patients No deficit Minor deficit Major deficit Severe functional impairment Death Leipzig TJ 2826,8%17,9%25%10,7%17,9%

21. DISCUSSION Endovascular series Endovascular series In 2005 Norback O et al. presented the overall clinic and angiographic evaluation in 239 ruptured aneurysms, 68 of 239 ( 28%) were ICA- PcomA aneurysms. In 2005 Norback O et al. presented the overall clinic and angiographic evaluation in 239 ruptured aneurysms, 68 of 239 ( 28%) were ICA- PcomA aneurysms. Clinical outcome was favourable (good recovery and moderate disability) in 53 patients (79%), Clinical outcome was favourable (good recovery and moderate disability) in 53 patients (79%), severe disability in 7 ( 10%), severe disability in 7 ( 10%), poor (persistent vegetative state/death) in 7 (10%). poor (persistent vegetative state/death) in 7 (10%). The multivariate analysis revealed that ICA- PcomA aneurysms location was a significant predictor of favourable outcome. The multivariate analysis revealed that ICA- PcomA aneurysms location was a significant predictor of favourable outcome.

22. Our endovascular series In ruptured aneurysms N patients Good clinical outcome Residual deficit Death Our series 4187,5%7,5%5,0% Endovascular series N patients Favourable clinical outcome Severe disability Poor clinical outcome Norback O et al. 6779%10%10% ENDOVASCULAR SERIES

23. DISCUSSION In our endovascular series all the treatment attempts were successful. In our endovascular series all the treatment attempts were successful. Rotational angiography was always employed before attempting endovascular treatment. Rotational angiography was always employed before attempting endovascular treatment. In two cases neck-to-dome ratio was unfavourable and PCA took off directly from the neck, in these cases coiling was deferred and aneurysms could be clipped under surgical observation. In two cases neck-to-dome ratio was unfavourable and PCA took off directly from the neck, in these cases coiling was deferred and aneurysms could be clipped under surgical observation. Regarding the occlusion rate a complete occlusion was achieved in 30 cases (60%), a neck remnant was detected in 19 cases (38%), and in 1 case (2%) a residual filling of the aneurysm was observed. Regarding the occlusion rate a complete occlusion was achieved in 30 cases (60%), a neck remnant was detected in 19 cases (38%), and in 1 case (2%) a residual filling of the aneurysm was observed. Bioactive coils were never used. Bioactive coils were never used.

24. DISCUSSION In 3 patients there were bilateral PComA aneurysms. In 3 patients there were bilateral PComA aneurysms. In 5 patients we needed to perform a second treatment because the neck was not completely occluded at the first treatment or,during the follow-up, the sac of the aneurysm was partially recanalized. In 5 patients we needed to perform a second treatment because the neck was not completely occluded at the first treatment or,during the follow-up, the sac of the aneurysm was partially recanalized. In 3 patients aneurysms were found at the origin of the fetal variant posterior cerebral artery. In 3 patients aneurysms were found at the origin of the fetal variant posterior cerebral artery.

25. DISCUSSION FOLLOW-UP FOLLOW-UP Aneurysm Recanalization Aneurysm Recanalization 45 patients underwent angiographic follow-up 12 months after treatment 45 patients underwent angiographic follow-up 12 months after treatment

26. FOLLOW-UP Aneurysm Recanalization we observed 5 cases of aneurysm recanalization (Raymond C). we observed 5 cases of aneurysm recanalization (Raymond C). In all these cases we re-treated the aneurysms,in four out of five with a balloon assisted technique,in one using tridimensional coils. In all these cases we re-treated the aneurysms,in four out of five with a balloon assisted technique,in one using tridimensional coils.

27. FOLLOW-UP Aneurysm Recanalization

28. DISCUSSION In our experience,the most important factors related to aneurysm recanalization were : In our experience,the most important factors related to aneurysm recanalization were : acutely ruptured aneurysms, large size of the aneurysms, large size of the neck; presence of a PCA fetal variant. acutely ruptured aneurysms, large size of the aneurysms, large size of the neck; presence of a PCA fetal variant.

29. DISCUSSION Follow-up Follow-up 34 patients underwent follow-up after one,two,three and four years by MRA. 34 patients underwent follow-up after one,two,three and four years by MRA. 10 patients refused MRA follow-up after the second year. 10 patients refused MRA follow-up after the second year. All the aneurysms studied with MRA at four year follow-up resulted stable,no re-treatment was needed. All the aneurysms studied with MRA at four year follow-up resulted stable,no re-treatment was needed.

30. MRA Follow-up

31. DISCUSSION Clinical follow-up All patients without deficit at discharge (42) were MRS 0 at follow-up (9y-1y) No re-bledding occured

32. DISCUSSION Outcome of oculomotor nerve palsy Outcome of oculomotor nerve palsy Third nervy palsy (TNP) is a well-known clinical presentation associated with posterior communicating artery (PComA) aneurysms. Compression of the oculomotor nerve by the aneurismal sac is considered to be the mechanism. The other possible etiologic mechanism of third nervy palsy is nerve damage at the time of SAH (8). Third nervy palsy (TNP) is a well-known clinical presentation associated with posterior communicating artery (PComA) aneurysms. Compression of the oculomotor nerve by the aneurismal sac is considered to be the mechanism. The other possible etiologic mechanism of third nervy palsy is nerve damage at the time of SAH (8).

33. Outcome of oculomotor nerve palsy Two comparative studies were reported to date. Two comparative studies were reported to date. Chen et al. compared 6 patients who were treated by coiling to 7 patients treated by clipping. The surgical group reported a higher complete recovery rate compared to the coiling group (P =.05). Chen et al. compared 6 patients who were treated by coiling to 7 patients treated by clipping. The surgical group reported a higher complete recovery rate compared to the coiling group (P =.05). Ahn et al. compared 10 patients treated by coiling to 7 patients treated by clipping and they did not find differences in the final outcome in either of the 2 groups. Ahn et al. compared 10 patients treated by coiling to 7 patients treated by clipping and they did not find differences in the final outcome in either of the 2 groups.

34. Outcome of oculomotor nerve palsy In our series we reported 100% complete TNP recovery in 7 patients with ruptured aneurysm, but only one of our patients had initial complete TNP. In our series we reported 100% complete TNP recovery in 7 patients with ruptured aneurysm, but only one of our patients had initial complete TNP. We believe that early treatment of aneurysm 48 – 72 hours from the SAH allows recovery, on the other hand treatment performed later involves a major distress of the oculomotor nerve with partial recovery or no recovery at all. We believe that early treatment of aneurysm 48 – 72 hours from the SAH allows recovery, on the other hand treatment performed later involves a major distress of the oculomotor nerve with partial recovery or no recovery at all.

35. Conclusion From the results of this series and from the review of literature it’s possible to infer that endovascular treatment of PCom A aneurysms has a definite place both in ruptured and unruptured aneurysms. From the results of this series and from the review of literature it’s possible to infer that endovascular treatment of PCom A aneurysms has a definite place both in ruptured and unruptured aneurysms. The inherently low risk of injuring the delicate branches and perforating vessels arising from the PComA makes the endovascular approach,in most cases,the treatment of choice for PComA aneurysms. The inherently low risk of injuring the delicate branches and perforating vessels arising from the PComA makes the endovascular approach,in most cases,the treatment of choice for PComA aneurysms.

36. XIX Symposium Neuroradiologicum Bologna,Italy 4-9 october 2010