Endovascular coil embolization of ruptured and unruptured posterior circulation aneurysms: Review of a 10-year experience - Commentary

OBJECTIVE: Treatment of posterior circulation aneurysms poses a great technical challenge for the practicing neurosurgeon. The advent of endovascular techniques has made such treatment more feasible. We report our experience with the endovascular management of ruptured and unruptured posterior circulation aneurysms during the past 10 years. METHODS: A retrospective analysis was performed on all patients with posterior circulation aneurysms undergoing endovascular treatment at Jefferson Hospital for Neuroscience between July 1995 and December 2005. This yielded 275 patients (67 men and 208 women). The degree of aneurysm occlusion was determined by the operating endovascular neurosurgeon at the time of the procedure. Successful embolization was defined as greater than 95% occlusion of the dome without any coil prolapsing into the parent vessel. Clinical outcome was evaluated using the modified Glasgow Outcome Scale. Clinical follow-up data was obtained for 262 patients (95.3%); the follow-up period ranged from 1 to 94 months (mean, 31.8 mo for procedures performed before 2004 and 13.3 mo for procedures performed during 2004 and 2005). Angiographic follow-up data was obtained for 224 patients (84.8%) for periods ranging from 6 to 94 months (mean, 31.3 mo for procedures performed before 2004 and 13.7 mo for procedures performed during 2004 and 2005). RESULTS: Based on the Hunt and Hess grading scale, the patient population included 106 patients (38.5%) with unruptured aneurysms, 43 patients (15.6%) with Grade I aneurysms, 16 patients (5.8%) with Grade II aneurysms, 56 patients (20.5%) with Grade III aneurysms, and 54 patients (19.6%) with Grade IV aneurysms. The locations of the posterior circulation aneurysms included 189 (68.7%) in the basilar apex or posterior cerebral artery, 23 (8.4%) in the basilar trunk/anterior inferior cerebellar artery, 22 (8%) in the superior cerebellar artery, and 41 (14.9%) in the vertebral artery or posterior inferior cerebellar artery. Of the 275 patients, 208 (76%) were women and 67 (24%) were men. The mean age at the time of treatment was 53.9 years (range, 7-90 yr). Of all patients treated, 237 patients (87.8%) had successful embolization (>95% occlusion of the dome). On angiographic follow-up, 55 patients (24.5%) developed recanalization of at least 5%. Retreatment was required in 11 patients (4.9%; 0.01 %/patient yr) and rehemorrhage occurred in three patients (1.1%; 0.003%/patient yr). Clinical follow-up was graded using the modified Glasgow Outcome Scale (mGOS) and revealed 229 patients (87.4%) in the mGOS I category, 12 patients (4.6%) in the mGOS II category, eight patients (3%) in the mGOS III category, two patients (0.8%) in the mGOS IV category, and 11 patients (4.2%) were deceased (mGOS V). Clinically significant vasospasm requiring angioplasty occurred in 11 patients (6.5%) with subarachnoid hemorrhage, and 120 patients (71 %) with subarachnoid hemorrhage required ventricular shunts. Complications causing clinical morbidity occurred in 14 patients (5.1%) and ranged from postoperative ischemia to recurrent subarachnoid hemorrhage. Of all clinical factors evaluated, Hunt and Hess grade was the strongest predictor of good clinical outcome (P < 0.0001). CONCLUSION: Endovascular coil embolization of posterior circulation aneurysms is an effective treatment in the short term but is associated with recurrence, which requires close surveillance, possible retreatment, and can, albeit very rarely, lead to rehemorrhage. Future technological advancements such as the development of biologically active coils will be essential in the permanent obliteration of aneurysms.