Purpose—The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods—A formal literature s...

Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Object. The authors report on their 11 years' experience with embolization of cerebral aneurysms using Guglielmi Detachable Coil (GDC) technology and on the attendant anatomical and clinical outcomes. Methods. Since December 1990, 818 patients harboring 916 aneurysms were treated with GDC embolization at University of California at Los Angeles Medical Center. For comparative purposes, the patients were divided into two groups: Group A included their initial 5 years' experience with 230 patients harboring 251 aneurysms and Group B included the later 6 years' experience with 588 patients harboring 665 aneurysms. Angiographically demonstrated complete occlusion was achieved in 55% of aneurysms and a neck remnant was displayed in 35.4% of lesions. Incomplete embolization was performed in 3.5% of aneurysms, and in 5% occlusion was attempted unsuccessfully. A comparison between the two groups revealed a higher complete embolization rate in patients in Group B compared with that in Group A patients (56.8 and 50....

Guglielmi Detachable Coil embolization of cerebral aneurysms: 11 years' experience

This review integrates eight aspects of cerebrospinal fluid (CSF) circulatory dynamics: formation rate, pressure, flow, volume, turnover rate, composition, recycling and reabsorption. Novel ways to modulate CSF formation emanate from recent analyses of choroid plexus transcription factors (E2F5), ion transporters (NaHCO3 cotransport), transport enzymes (isoforms of carbonic anhydrase), aquaporin 1 regulation, and plasticity of receptors for fluid-regulating neuropeptides. A greater appreciation of CSF pressure (CSFP) is being generated by fresh insights on peptidergic regulatory servomechanisms, the role of dysfunctional ependyma and circumventricular organs in causing congenital hydrocephalus, and the clinical use of algorithms to delineate CSFP waveforms for diagnostic and prognostic utility. Increasing attention focuses on CSF flow: how it impacts cerebral metabolism and hemodynamics, neural stem cell progression in the subventricular zone, and catabolite/peptide clearance from the CNS. The pathophysiological significance of changes in CSF volume is assessed from the respective viewpoints of hemodynamics (choroid plexus blood flow and pulsatility), hydrodynamics (choroidal hypo- and hypersecretion) and neuroendocrine factors (i.e., coordinated regulation by atrial natriuretic peptide, arginine vasopressin and basic fibroblast growth factor). In aging, normal pressure hydrocephalus and Alzheimer's disease, the expanding CSF space reduces the CSF turnover rate, thus compromising the CSF sink action to clear harmful metabolites (e.g., amyloid) from the CNS. Dwindling CSF dynamics greatly harms the interstitial environment of neurons. Accordingly the altered CSF composition in neurodegenerative diseases and senescence, because of adverse effects on neural processes and cognition, needs more effective clinical management. CSF recycling between subarachnoid space, brain and ventricles promotes interstitial fluid (ISF) convection with both trophic and excretory benefits. Finally, CSF reabsorption via multiple pathways (olfactory and spinal arachnoidal bulk flow) is likely complemented by fluid clearance across capillary walls (aquaporin 4) and arachnoid villi when CSFP and fluid retention are markedly elevated. A model is presented that links CSF and ISF homeostasis to coordinated fluxes of water and solutes at both the blood-CSF and blood-brain transport interfaces.

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Multiplicity of cerebrospinal fluid functions: New challenges in health and disease

Animal models of traumatic brain injury (TBI) are used to elucidate primary and secondary sequelae underlying human head injury in an effort to identify potential neuroprotective therapies for developing and adult brains. The choice of experimental model depends upon both the research goal and underlying objectives. The intrinsic ability to study injury-induced changes in behavior, physiology, metabolism, the blood/tissue interface, the blood brain barrier, and/or inflammatory- and immune-mediated responses, makes in vivo TBI models essential for neurotrauma research. Whereas human TBI is a highly complex multifactorial disorder, animal trauma models tend to replicate only single factors involved in the pathobiology of head injury using genetically well-defined inbred animals of a single sex. Although such an experimental approach is helpful to delineate key injury mechanisms, the simplicity and hence inability of animal models to reflect the complexity of clinical head injury may underlie the discrepancy between preclinical and clinical trials of neuroprotective therapeutics. Thus, a search continues for new animal models, which would more closely mimic the highly heterogeneous nature of human TBI, and address key factors in treatment optimization.

https://link.springer.com/content/pdf/10.1602/neurorx.2.3.410.pdf

Animal Models of Head Trauma

Near-infrared oximetry of the brain

Objective We present our initial experience with Guglielmi detachable coils (GDCs). The aim of this study was to determine the criteria for aneurysms, ruptured or unruptured, that are suitable for this technique. The importance of aneurysm geometry and its impact on the final results are discussed. Methods A retrospective analysis of 329 patients with 339 cerebral aneurysms that were treated at the University of Illinois Hospital at Chicago from May 1994 to June 1997 was conducted. One hundred eighty-five patients were treated surgically, and 144 were selected for treatment using GDCs. Of the 144 patients selected for GDC treatment, 55 patients with 55 aneurysms were admitted during the acute phase of subarachnoid hemorrhage and 89 patients with 97 aneurysms had nonruptured aneurysms or were treated after clinical recovery of previously ruptured aneurysms. All procedures were performed with the patients under general anesthesia and with systemic heparinization using live simultaneous biplane roadmapping, with the exception of the first four patients. These patients were treated before the installation of the biplane system. The percentage of aneurysm occlusion was determined at the end of each procedure. Follow-up angiography was scheduled to be performed at 6 months, 1 year, and 2 years after treatment. Patient selection For the initial 25 patients (Group 1), selection for coiling was restricted to nonsurgical candidates or patients in whom coiling was thought to be the best treatment choice, based on medical condition and location of the aneurysm. The geometry of the aneurysm was not considered to be an important factor in the selection for coiling. The remaining patients (Group 2) were selected for coiling based on aneurysm geometry, as determined by pretherapeutic angiography. Aneurysms that were considered to be favorable for coiling included those that had a dome-to-neck ratio of at least 2 and an absolute neck diameter less than 5 mm. Results The initial 25 patients (Group 1) were treated from May 1994 to February 1995. There were high morbidity and mortality rates, with 56% of the treated aneurysms occluded at 6 months. The remaining patients (Group 2) consisted of 119 patients with 123 aneurysms. There was no mortality directly related to the coiling procedure, and permanent morbidity was limited to 1.0%. Three patients (2.5%) developed transient neurological deficits secondary to the procedure, and seven patients (5.8%) experienced periprocedural complications that did not result in neurological sequelae. The morphological results were strongly correlated to the geometry of the aneurysms, with a complete occlusion rate of 72% among the acutely ruptured aneurysms and 80% among the nonacute aneurysms, when patients were selected for treatment based on the geometry of the aneurysms and the dome-to-neck ratio was at least 2. The occlusion rate dropped to 53% when selection was not based on aneurysm geometry and the dome-to-neck ratio was less than 2. A summary of the morphological outcomes for the Group 2 patients shows that 86% of the aneurysms that initially underwent coiling using GDCs were completely occluded (78% by coils alone, 3.0% in conjunction with surgery, and 5.0% with parent artery occlusion). Residual small neck remnants were present in 11% of the Group 2 aneurysms (3.0% were scheduled for surgical treatment of residual neck remnant growths not amenable to further endovascular treatment, and 8% were scheduled for initial 6-mo follow-up examinations). Death resulting from unrelated causes before initial follow-up occurred in 3.0% of the patients. Conclusion These preliminary results suggest that using GDCs is a safe technique resulting in low morbidity and mortality rates for the treatment of intracranial aneurysms in appropriately selected patients. The percentage of complete aneurysm occlusion is related to the density of coil packing, which is strongly dependent on the geometry of the aneurysm. Optim

Selection of cerebral aneurysms for treatment using Guglielmi detachable coils: the preliminary University of Illinois at Chicago experience.

Object. Reports in the literature have offered discussions of the feasibility, efficacy, and safety of balloon-assisted Guglielmi detachable coil (GDC) placement in wide-necked intracranial aneurysms, which was first described by Jacques Moret as the “remodeling technique.” In this article the authors summarize their results in a subset of aneurysms treated with GDCs using the remodeling technique. Methods. This report contains a retrospective analysis of 72 patients with 75 aneurysms who underwent 79 endovascular procedures performed using the remodeling technique. Morphological outcome was determined at the end of each procedure and by reviewing available follow-up angiograms. Clinical assessments and outcomes are reported using a modified Glasgow Outcome Scale. Coils were placed in 66 (88%) of 75 aneurysms selected for treatment. In eight aneurysms (11%) treatment failures occurred due to the tortuosity of the vessel used to reach the aneurysms or because of balloon inadequacies. Incorporating all avai...

The remodeling technique of balloon-assisted Guglielmi detachable coil placement in wide-necked aneurysms: experience at the University of Illinois at Chicago.

Surgery following endovascular coiling of intracranial aneurysms.

Endovascular treatment of paraclinoid aneurysms.

The study was aimed determine the criteria for treating cerebral aneurysms, ruptured and unruptured, suitable for endovascular Guglielmi detachable coiling (GDC) with least morbidity and mortality. We will discuss the importance of knowledge of the geometry of cerebral aneurysm and its impact on the results of coiling. We have treated 324 patients with cerebral aneurysms at the University of Illinois Hospital from May 1, 1994 to June 1997. During this period 139 patients were treated with GDC and 185 patients were treated surgically. Of 139 patients treated with coils 54 patients with 54 aneurysms were ruptured and the remaining 85 patients with 90 aneurysms were unruptured. For initial 25 patients, the selection of aneurysms for coiling was random and the geometry of the aneurysm was not considered as an important factor in the selection for coiling, however, in the later series of 114 patients with 119 aneurysms were selected for coiling only when the geometry looked favorable in the angiogram. With time we realized that the dome/neck ratio more than or equal to 2/1 and the diameter of the neck not ex-ceeding 5mm were most suitable for coiling. The initial series of 25 patients (May 1994 to February 1995) treated without taking geometry of the aneurysms as an important criteria for coiling led to high morbidity and mortality and less than 50% of these aneurysms were angiographically occluded at 6-month follow-up. In the second series of 114 patients (March 1995 to June 1997) with 119 aneurysms we had 0% mortality related to the coiling and only 1.8% permanent morbidity. We found complete aneurysm occlusion in 78% of the subarachnoid hemorrhage and 76% of unruptured group when the dome/neck ratio was more than or equal to 2/1. However, the occlusion rate dropped to 50% when the dome/neck ratio was less than 2/1. This preliminary experience suggests that GDC is a safe technique with low mortality-morbidity for the treatment of intracranial aneurysms in appropriately selected patients. The percentage of complete occlusion of the aneurysm following tight and dense packing is strongly dependent on the geometry of the aneurysm and we conclude that the best results are achieved when the dome/neck ratio is more than or equal to 2/1.

/pdf/aneurysm-geometry-an-important-criterion-in-selecting-1gkcoblqm2.pdf

Mukesh Misra

Papers

Selection of cerebral aneurysms for treatment using Guglielmi detachable coils: the preliminary University of Illinois at Chicago experience.

The remodeling technique of balloon-assisted Guglielmi detachable coil placement in wide-necked aneurysms: experience at the University of Illinois at Chicago.

Surgery following endovascular coiling of intracranial aneurysms.

Endovascular treatment of paraclinoid aneurysms.

Aneurysm geometry: an important criterion in selecting patients for Guglielmi detachable coiling.