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45 Stroke
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Cerebral Angiography: Aneurysms
JosephJ.Gemmete andJuliusGriauzde
Pathophysiology
A cerebral aneurysm is an abnormal outpouching of a diseased intracranial artery. Most cerebral aneurysms are
asymptomatic and remain undetected until the time of rupture. Autopsy reports have shown that intracranial aneurysms
are present in 5% of the population [1]. The most common
initial presentation of a cerebral aneurysm is subarachnoid
hemorrhage (SAH). An abrupt onset of a severe headache of
atypical quality (“the worst headache of my life”) is the classic presentation of SAH; this may be associated with nausea
and vomiting, brief loss of consciousness, a focal neurological decit, seizure, or meningismus [2].
46
order, then immediate family members have up to a 17% incidence of having an aneurysm [4]. Other risk factors for the
development of a cerebral aneurysm include cigarette smoking,
cocaine use, hypertension, certain blood infections, head injury,
and heavy consumption of alcohol (Table46.1) [5].
Cerebral aneurysms are classied by location, size, and
width of the neck. Location is dened by the vessel of origin.
Morphological types of cerebral aneurysm include saccular,
fusiform, and dissecting. Cerebral aneurysms based on size
are classied accordingly:
Small: 2–7mm in diameter
Medium: 7–12mm in diameter
Large: 13–24mm in diameter
Giant: ≥ 25mm in diameter
Key Point
The most common presentation for a cerebral aneurysm is subarachnoid hemorrhage.
Several medical conditions are associated with the development of cerebral aneurysms, including systemic lupus erythematous, Takayasu disease, giant cell arteritis, autosomal polycystic
kidney disease, type IV Ehlers-Danlos syndrome, Marfan syndrome, bromuscular dysplasia, type 1 neurobromatosis,
hereditary hemorrhagic telangiectasia, coarctation of the aorta,
and alpha1-antitrypsin [3]. Genetics also plays a role in the formation of cerebral aneurysms. If two rst-degree relatives in a
family have a cerebral aneurysm, with no connective tissue dis-
J. J. Gemmete (*)
Department of Radiology and Neurosurgery,
University of Michigan Hospitals, Ann Arbor, MI, USA
e-mail: gemmete@med.umich.edu
J. Griauzde
Department of Radiology, University of Michigan Hospitals,
Ann Arbor, MI, USA
e-mail: jgriauz@med.umich.edu
SAH is classied according to ve grades according to
the Hunt-Hess scale, as follows [6]:
Grade I: asymptomatic, mild headache, slight nuchal rigidity
Grade II: moderate-to-severe headache, nuchal rigidity, no
neurological decit other than cranial nerve palsy
Grade III: drowsiness/confusion and/or mild focal neuro-
logical decit
Grade IV: stupor, moderate-to-severe hemiparesis
Grade V: coma, decerebrate posturing
The Fisher grading system is commonly used to predict
the risk of cerebral vasospasm within 5days after SAH based
on the amount of blood shown on initial CT scans [7]. The
Fisher grading system is as follows:
Grade 1: No subarachnoid or intraventricular blood visualized.
Grade 2: Diffuse thin layer of blood less than 1mm thick
(interhemispheric or ambient cisterns).
Grade 3: Localized clots and/or layers of blood greater than
1mm thick. No intraventricular hemorrhage.
Grade 4: Intracerebral or intraventricular clot with diffuse or
absent blood in basal cisterns.
© Springer International Publishing AG, part of Springer Nature 2018
N. A. Keefe et al. (eds.), IR Playbook, https://doi.org/10.1007/978-3-319-71300-7_46
513
514
J. J. Gemmete and J. Griauzde
Table 46.1 Risk factors predisposing to cerebral aneurysm formation
Category Examples
Comorbid medical conditions Autoimmune conditions
Genetics First-degree relatives
Medical, social, and
environmental factors
Inammatory vasculopathies
Connective tissue disorders
Autosomal polycystic kidney
disease
Neurobromatosis type 1
Hereditary hemorrhagic
telangiectasia
Cigarette smoking
Cocaine use
Heavy alcohol consumption
Hypertension
Blood infections
Head trauma
Clinical Indication
A cerebral aneurysm is usually identied on a CTA or MRA
of the brain obtained for another clinical indication (such as
a stroke work-up) or in a patient presenting with SAH.History
and physical should be obtained with a detailed neurological
examination. A head CT/CTA or brain MRI/MRA is obtained
prior to treatment to evaluate for intraluminal thrombus
within the aneurysm, atherosclerotic disease, and the vascular anatomy prior to treatment. Cerebral angiography with
3D imaging is necessary to show the location, size, shape,
and neck of the aneurysm. All patients with SAH secondary
to aneurysm should be treated with surgical clip placement
or endovascular coiling provided this is feasible.
Strong consideration should be given for treatment of
asymptomatic cerebral aneurysms ≥ 7 mm in diameter in
younger patients. The treatment of small incidental intracavernous ICA aneurysms is not generally indicated. For large
symptomatic intracavernous aneurysms, treatment decisions
should be made on an individual basis. Symptomatic unruptured intradural aneurysms of all sizes should be considered
for treatment, with relative urgency for the treatment of
acutely symptomatic aneurysms. In a patient with SAH due
to aneurysm, treatment of coexisting aneurysms of any size
should be considered as these carry an increased risk of
future hemorrhage. Small aneurysms with a daughter sac
(irregular protrusion in the wall of the aneurysm), young
patients, and patients with a positive family history for aneurysms or aneurysmal SAH deserve special consideration for
treatment [8].
performed until there is adequate exposure of the aneurysm
and proximal and distal parent vessels. One or more surgical
clips are then placed across the aneurysm neck to exclude it
from the parent circulation. Current surgical techniques can
routinely achieve complete exclusion of the aneurysm from
the circulation without compromise of the parent vessel in
many patients. Risk factors that may put the patient at an
increased risk of morbidity and mortality from surgical clip
placement include aneurysm size and location, patient age,
and medical condition of the patient.
The rst prospective randomized study comparing surgery or endovascular coiling was performed in Finland
[9]. Technical-related mortality rate was 4% in the surgery group and 2% in the endovascular group. Clinical
outcome at 3 months was not signicantly different
between treatment groups. Numerous studies since that
time have further compared surgical clipping to endovascular coiling. The International Subarachnoid Trial (ISAT)
showed patients with SAH fared better with endovascular
coiling than those with surgical clipping [10]. The Barrow
Ruptured Aneurysm Trial (BRAT) showed similar results
for surgical and endovascular treatment of anterior circulation aneurysms; however, outcomes for posterior circulation aneurysms favored coiling [11]. The ISUIA
unruptured aneurysm study showed an overall morbidity
and mortality at 1 year of 12.2% for the surgical group
and 9.5% for the endovascular group [12]. The CLARITY
trial was a multicenter trial comparing patients treated
with GDC or Matrix coils for ruptured aneurysms [13].
The study concluded that the midterm results between the
two coils were not different.
Interventional Therapy
Genesis ofIR Procedure
In 1991, Guglielmi and colleagues introduced the detachable
coil for treating cerebral aneurysms. The Guglielmi detachable coil (GDC) system (Boston Scientic/Target) received
US Food and Drug Administration approval in 1995.
Aneurysms considered unsuitable for surgery were the initial
candidates for GDC coil embolization.
Indications forChoosing theIR Procedure
Conventional Therapy
Microsurgical clipping of a cerebral aneurysm is the historical denitive standard treatment for a cerebral aneurysm.
During surgery, a craniotomy and microdissection are
Numerous clinical trials have demonstrated that endovascular treatment is preferred over open surgical repair in the following situations: aneurysmal SAH, unruptured cerebral
aneurysms ≥ 2mm in size, poor surgical candidates, posterior circulation aneurysms, and cavernous segment ICA
aneurysms. Relative contraindications to endovascular
46 Cerebral Angiography: Aneurysms
Key Point
Indications for endovascular aneurysm coiling:
• SAH secondary to aneurysm
• Unruptured aneurysm ≥2mm
• Poor surgical candidate
• Posterior circulation aneurysm
• Cavernous ICA aneurysm
515
contrast-induced nephropathy will need to be hydrated prior
to the procedure. Premedication with dual antiplatelet agents
usually is started 5–7 days prior to an elective procedure.
Platelet function activation tests are performed prior to the
procedure, and medication doses are adjusted accordingly
[18]. Preoperative CTA, MRA, or angiogram are obtained
and reviewed to help in treatment planning.
Post-procedural Management
treatment include vascular anatomy not favorable for minimally invasive techniques, signicant atherosclerotic disease
affecting the parent vessel, coagulation disorders, and active
bacterial infection.
There have been extensive studies performed to validate
the use of endovascular coils versus surgical treatment for
unrupturedcerebral aneurysm. The data from these studies
does not show a clear benet for one form of treatment over
the other. In the International Study of Unruptured
Intracranial Aneurysm (ISUIA), adverse outcomes were less
common with endovascular treatment (9.3%) than with surgery (13.7%) [12]. Further studies were performed to compare how different endovascular techniques and devices
affect patient outcomes. Several trials including the HELPS
trial, Cerecyte coil trial, and MAPS trial further evaluated the
use of various different coils for endovascular treatment.
Pierot and colleagues showed that the balloon remodeling
technique provides equivalent safety and better anatomic
results compared with standard coiling [14]. Shapiro and
colleagues performed a comprehensive literature survey of
stent-supported aneurysms coiling [15]. The overall procedure complication rate was 19% with a periprocedural mortality of 2.1%. The 3-year posttreatment follow-up of the
Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial
showed a 93.4% cure rate of large and giant wide-neck aneurysms [16]. Early data from the WEB Intra-saccular Therapy
Study (WEB-IT) showed a high level of procedural safety
and technical success [17].
SAH patients are admitted to the neurointensive care unit
(NICU) to monitor for complications related to SAH.Elective
aneurysms treated with coil embolization are typically
admitted for overnight observation in the NICU.Dual antiplatelet agents are continued for 1week after the procedure
for a simple coil embolization. If an intracranial stent is
placed, dual antiplatelet agents are continued between 3 and
6months (based on multisociety consensus), with the patient
remaining on 81mg of aspirin for life. Patients are seen in
the clinic, typically 1month after the procedure to evaluate
for possible puncture site complications. Repeat imaging is
performed 6months after treatment with a contrast-enhanced
MRA or angiogram to look for signs of aneurysm recurrence
[19, 20]. If aneurysm recurrence is not identied, patients are
followed on a yearly basis. Patients with an aneurysm recurrence are retreated.
Complications
Recent large series report overall complication rates for
endovascular treatment of cerebral aneurysms ranging from
8.4 to 18.9%. Risk factors for complications include SAH,
adjunctive techniques, and small and large aneurysms.
Complications can be categorized into rupture of the aneurysm or parent vessel, procedural thrombus formation, coil
malposition, coil stretching, vessel dissection, ischemic
stroke, and a broken coil [21–23].
Pre-procedural Preparation
Prior to the procedure, a comprehensive physical exam with
emphasis on a detailed neurologic exam should be documented. If the aneurysm is small and asymptomatic, then a
reason for treatment should be placed in the patient’s chart.
Drug allergies, renal function, heparin intolerance, and prior
arterial surgery should be noted. A thorough discussion of
risks and benets of the procedure should be discussed with
the patient and/or health-careprovider. A patient at risk of
Key Point
Procedural complications:
• Aneurysm or parent vessel rupture
• Thrombosis of vessel
• Coil malposition, stretching, or fracture
• Vessel dissection
• Stroke
516
J. J. Gemmete and J. Griauzde
The How To
Before the procedure, most neurointerventional radi-
ologists will obtain a CT/CTA for characterization of
the cerebral aneurysm and vascular anatomy.
1. Most aneurysm coiling will be performed through
the femoral approach. In complicated cases, a bilateral femoral approach may be utilized. A radial
approach may be useful for the treatment of poste-
arch. All procedures are performed under general
anesthesia.
2. For all locations, the Seldinger technique is used to
access the artery of choice (refer to Chap. 8 for
more information). The patient is heparinized to
elective cases. For patients with a ruptured aneu-
placement of framing coils, the patient is given
additional heparin to maintain an ACT range of 250
3.
advanced into the internal carotid artery or vertebral artery.
4. An angiogram is performed to evaluate the cerebral
vascular anatomy and characteristics of the aneurysm. A 3D angiogram is performed in all cases, to
aneurysms. The technique involves placing a nondetachable balloon across the neck of the aneurysm during the placement of embolization coils
46.2).
8. Certain wide-neck and dysplastic aneurysms may
not be amenable to treatment with simple coiling or
balloon remodeling. In such cases, two additional
endovascular techniques are available.
(a)
placed into the aneurysm, and then a stent is
placed across the aneurysm neck; this is called
the jailed microcatheter technique. This is followed by coiling of the aneurysm and then pulling the microcatheter out from behind the stent.
(b) The second technique consists of placing the
stent across the neck of the aneurysm and then
navigating a microcatheter through the struts of
the stent into the aneurysm. The aneurysm is
coiled with the stent acting as a barrier to prevent coils from herniating into the parent vessel
46.3).
9. oped to treat wide-neck aneurysms from an endoluminal rather than an endosaccular approach.
These stent-like devices are placed across the neck
of the aneurysm like a conventional stent and are
designed to reconstruct the parent vessel and to
optimal working projection for coiling.
5. If additional stability is needed to treat an aneurysm
(secondary to tortuous anatomy), a triaxial system
consisting of a long sheath introduced into the origin of the great vessel followed by a guide catheter
through the sheath and then a microcatheter and
6. For conventional coiling of a simple saccular aneurysm, a microcatheter is advanced over a microwire
into the aneurysm under road map. Tailored sizes
and shapes of coils are introduced into the aneu-
with contrast or the microcatheter is pushed outside
46.1).
7. The balloon remodeling (aka balloon-assisted
technique) is used for the treatment of wide-neck
aneurysm promotes intra-aneurysmal thrombus
formation and decreases pressure within the aneu-
46.4).
Key Point
ACT=activated clotting time.
Key Point
A road map refers to an angiogram that has been faded
out and set in the background of active uoroscopy, so
it can delineate the vascular anatomy.
46 Cerebral Angiography: Aneurysms
517
Fig. 46.1 A 54-year-old female who presented with an incidentally dis-
covered 6-mm aneurysm during work-up for a headache. (a) Frontal left
internal carotid artery (LICA) angiogram shows a 6-mm diameter aneurysm at the left A1/A2 junction pointing superior with a narrow neck
(black arrow). (b) Frontal LICA angiogram after placement of the rst
coil shows a frame of the aneurysm sac. (c) Frontal LICA angiogram
after placement of an additional three coils within the aneurysm sac
shows thrombosis of the aneurysm. (d) Final frontal LICA angiogram
shows thrombosis of the aneurysm sac with a widely patent left A1,
anterior communicating artery, and bilateral anterior cerebral arteries
518
J. J. Gemmete and J. Griauzde
Fig. 46.2 A 45-year-old female who presented with a Hunt and Hess
grade 3 subarachnoid hemorrhage (SAH) from a rupture aneurysm. (a)
Frontal LICA angiogram shows a wide-neck anterior communicating
artery aneurysm (black arrow). (b) Frontal LICA road map image
shows a balloon across the neck of the aneurysm (black arrow) with a
microcatheter and coil within the aneurysm sac (thick black arrow). (c)
Frontal LICA road map image after placement of the last coil shows a
balloon across the neck of the aneurysm (black arrow) with no compromise of the parent vessel. (d) Final frontal LICA angiogram shows
thrombosis of the wide-neck anterior communicating artery aneurysm
with no compromise of the parent vessel
46 Cerebral Angiography: Aneurysms
519
Fig. 46.3 A 40-year-old female who presented with an incidentally
discovered basilar tip aneurysm for the work-up of tinnitus. (a) Axial
T2-weighted MRI image shows a wide-neck 9-mm diameter basilar
apex aneurysm (black arrow). (b) Frontal left vertebral artery (LVA)
angiogram shows two stents (white arrows) in a Y-conguration across
the neck of the basilar apex aneurysm with a microcatheter in the
aneurysm sac (black arrow). (c) Frontal LVA angiogram after placement of the rst coil within the aneurysm sac shows nice frame of the
aneurysm sac with no compromise of the parent vessel. (d) Final frontal
LVA angiogram shows thrombosis of the aneurysm sac with no compromise of the parent vessel
520
J. J. Gemmete and J. Griauzde
Fig. 46.4 A 72-year-old male who presented with retro-orbital head-
ache from a wide-neck left supraclinoid artery aneurysm. (a) Frontal
LICA angiogram shows a wide-neck 12-mm diameter left supraclinoid
artery aneurysm (black arrow). (b) Spot image shows the ow-diverting
stent (black arrows) with the microcatheter through the stent lumen
(thick black arrow at microcatheter tip), but no coils were required. The
parent catheter is denoted by theradiopaque line at the inferior portion
of the image. (c) Frontal LICA angiogram late in the angiographic run
shows contrast hanging up in the aneurysm. (d) Cone beam CT shows
the ow-diverting stent across the neck of the aneurysm
46 Cerebral Angiography: Aneurysms
521
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