Coil embolization of paraclinoid aneurysms should be simple, safe, and effective considering the benign nature of the aneurysm. Here, we present a microcatheter stabilization technique using a partially inflated balloon for the treatment of paraclinoid aneurysms.
This retrospective study included 58 patients who underwent balloon-assisted coiling (BAC) for unruptured paraclinoid aneurysms at a tertiary neuro-intervention center between January 2019 and March 2020. We applied a technique to stabilize the microcatheter’s position using the modified BAC technique in paraclinoid aneurysms showing various projections around the ophthalmic curve of the internal carotid artery. The basic concept of the technique is to place a partially inflated balloon just distal to the aneurysm neck and support the distal curve of the microcatheter using the proximal bottom of the balloon. Immediate radiological outcomes were analyzed, and clinical outcomes were evaluated with modified Rankin Scale (mRS) scores.
The BAC was successfully performed in 51 of 58 patients (88%). We treated the remaining 7 patients by switching to stent-assisted coiling. We obtained a 37% mean packing density resulting in favorable occlusion in all 58 aneurysms (complete occlusion in 35 and residual neck in 23). There were no intraprocedural thromboembolic or hemorrhagic events except one that revealed an asymptomatic infarction after the procedure (1.7%). Magnetic resonance angiography follow-up was performed in 37 patients at an average of 11.8 months, in which 11 minor recurrences (29.7%) were found. There was no major recurrence nor retreatment. The mRS score was 0 in all patients during a mean follow-up of 17.7 months (range, 12–25 months).
The modified balloon-assisted coiling technique using a partially inflated balloon was safe and effective and could serve as an option for treating paraclinoid aneurysms.
Paraclinoid aneurysms are generally defined as intracranial aneurysms that arise from an ophthalmic segment of the internal carotid artery (ICA) between the roof of the cavernous sinus and the origin of the posterior communicating artery [
Balloon-assisted coil embolization has been used for aneurysms in various locations and has also been applied in paraclinoid aneurysms [
After Institutional Review Board approval, a retrospective review of patients treated with coil embolization at our institution was performed. Between January 2019 and March 2020, a total of 267 patients underwent endovascular treatment for unruptured, paraclinoid ICA aneurysms. Of these, 139 (52%) received stent-assisted coiling, 58 were balloon-assisted (22%), and 66 (25%) were simply coiled. We included the 58 patients who underwent coil embolization using a balloon in this study. The participants consisted of 46 women and 12 men, with an average age of 53 years (range, 33–69 years). The treatment strategy was discussed by neurointerventionist and was based on each patient’s risk factors. Flow diversion was not considered in this study because the government insurance does not cover a flow diverter for an aneurysm less than 15 mm in size in our country [
Aneurysm location and projection were evaluated using a 3D rotational angiography from a biplane angiography system (Artis Zee; Siemens Healthcare, Forchheim, Germany). Paraclinoid aneurysms were defined as aneurysms arising at the ICA from the level of the ophthalmic artery to the supraclinoid ICA below the posterior communicating artery (PcomA) origin, which extends from the estimated distal border of the anterior genu of the cavernous carotid artery to the ostium of the PcomA [
The aneurysms were categorized into four groups according to the origin and projection. Aneurysms in the superior group originated from the superior wall (dorsal wall) and projected superiorly or superomedially. Aneurysms in the medial group originated from the medial wall and projected medially or inferomedially. Aneurysms in the inferior group originated from the inferior wall (ventral or posterior wall) and projected inferiorly or posteroinferiorly. Aneurysms in the lateral group originated from the lateral wall and projected laterally or superolaterally. In our study, most of the aneurysms originating from the ophthalmic artery were categorized into the superior group (57.1%), but in some cases, they were also categorized into the medial (28.6%) or lateral (14.3%) group depending on the location of the origin. We considered the categorization of aneurysm direction as critical because the vector of energy contained in a microcatheter curve during coil introduction tended to be affected by the direction of the aneurysm from the ICA lumen.
According to the institutional protocol, the size, volume, and dome-to-neck ratio of the aneurysms were obtained from a routine measurement by radiological technologists. Wide-neck aneurysms were defined as those with a dome-to-neck ratio of <1.6 [
Forty-eight procedures (83%) were performed with the patient under general anesthesia, while ten procedures (17%) were initiated with conscious sedation and local anesthesia. All patients were pretreated with 100 mg of aspirin and 75 mg of clopidogrel daily for 5 days before the procedure. If the P2Y12 reaction units value indicated that the patient was resistant to clopidogrel, tailored medication with low-dose prasugrel was used instead [
We already described the loop microcatheter technique for paraclinoid aneurysms [
Even if the aneurysm seemed to have a neck, introduced coils were sometimes not securely contained within the aneurysm because of a weak neck, which allowed the wall forming the aneurysm neck to be easily opened by the protrusion of the frame coil (
During retrieval of the microcatheter at the end of the coil embolization, the last inserted coil or some coil loops may protrude out of the aneurysm because of the hooking effect of the tightly looped microcatheter tip. This inadvertent effect can be prevented by point ballooning of the ovoid balloon catheter at the microcatheter tip. This point inflation allowed for safe retrieval of microcatheter and kept the degree and time of lumen occlusion minimal even if the full inflation was required.
If the coiling was not secured by the balloon itself, we switched from a balloon- to stent-assisted coiling method (n=7). For that purpose, we used a stent (NeuroForm Atlas™; Stryker Neurovascular, Fremont, CA, USA) that could be deployed
Technical success was defined as achieving stable microcatheter selection on an aneurysm and sufficient packing of coils without residual aneurysm using a balloon catheter. If a stent was used for any reason during balloon-assisted coiling, it was considered treatment failure regardless of the procedural outcome.
All patients underwent post-procedural magnetic resonance imaging within 24 hours, which included axial diffusion-weighted imaging (DWI) and time-of-flight (TOF) magnetic resonance angiography (MRA). All DWI high signal intensity lesions with decreased ADC (apparent diffusion coefficient) value located in the corresponding vascular territory were classified into acute thromboembolic infarction (larger than 5 mm in maximal diameters) and microembolism (mostly 1–2 mm in size, less than 5 mm) [
The procedural outcome was classified into complete obliteration, residual neck, and residual aneurysm [
The coil shape and position were routinely examined by simple skull radiography at each follow-up visit. An MRA follow-up was performed from 6 months to 2 years after the procedure according to the packing density and location of the aneurysms based on the operator’s decision. A recurrence was defined as any increase in aneurysmal filling on the follow-up MRA. Major recurrence included an aneurysmal recurrence of more than 2 mm, which provided an appropriate cavity for additional coils placement [
A total of 58 patients with 58 unruptured paraclinoid aneurysms (average maximum diameter, 4.7±1.4 mm) were enrolled (
Technical success was achieved in 51 of 58 patients (88%). Balloon-assisted coiling was switched to stent-assisted coiling in 7 patients. The technical failure comprised of three medial group (28.6%), two inferior group (28.6%), and two superior group (42.9%). The mean dome-to-neck ratio was 1.33, which was lower than the overall average. In assessing the immediate results, 35 aneurysms (60.3%) were completely occluded, 23 (39.7%) showed a residual neck, and none showed a residual aneurysm. The mean packing density was 37.1% (range, 26–58%). There was no periprocedural complication.
DWI, which was performed within 24 hours after the procedure, showed positive findings in 14 patients (24%), but no neurologic symptoms were present. Of these, microembolism occurred in 13 patients, and acute thromboembolic infarction was observed in one (1.7%). The acute infarction occurred in the right basal ganglia with a size of 1.3 cm, and there was no neurological symptom or sign until the last follow-up of 7 months, but it was recorded as an ischemic event. All patients showed an mRS score of 0 at a mean follow-up duration of 17.7-months (range, 12–25 months).
MRA follow-up was performed in 37 patients (63.8%) at an average of 11.8 months. Of these, complete occlusion was confirmed in 22 patients (75.8%), and aneurysm neck filling was observed in 7 patients (24.1%). Of the 23 patients with a residual neck initially observed, 10 showed progressive occlusion, 3 of them increased in size, and one remained unchanged. Minor recurrence occurred in 11 of 37 patients (29.7%) who underwent follow-up, of which 8 patients newly discovered neck filling and 3 patients increased the size of the existing residual neck filling. A mean of 5.3 months of radiograph follow-up was performed in 21 patients who had not yet received MRA follow-up. Of these, coil compaction was suspected in one patients on radiographs performed 7 months after the procedure.
Our study showed that the modified balloon-assisted coiling technique for the paraclinoid aneurysms initially resulted in good outcomes. We achieved a 37% mean packing density resulting in complete occlusion and a residual neck in 60% and 40% of the patients. This result may be comparable or better than previous reports reported 67.3–76.8% satisfactory occlusion rates (Raymond scores 1 and 2) of paraclinoid aneurysms on initial angiography [
According to previous literatures, the risk of balloon remodeling technique was not greater than conventional techniques [
The main concept of the modified balloon-assisted coiling technique is to prevent a kick-back of the microcatheter tip from the aneurysm, which may preclude dense packing of the paraclinoid aneurysms [
The advantage of the balloon-assisted coiling over stent is that it can reduce the use of antiplatelet medication, which is particularly beneficial in patients with clopidogrel resistance. In addition, during stent-assisted coiling
We found that the aneurysm neck in a paraclinoid aneurysm was sometimes insufficient to secure the frame coil within the aneurysm even if the neck seemed well-established and not wide relative to the aneurysm body and dome. In those situations, the introduced frame coil was not securely retained in the aneurysm and protruded out of the neck because the neck was not strong enough to keep the coil within the aneurysm. We regarded such a phenomenon as a ‘pseudo-neck,’ which required additional support from a balloon or stent. The modified balloon-assisted coiling technique was also helpful in protecting such pseudo-necks by controlling the position and inflation of the balloon. If the balloon-assisted coiling was unsuccessful, stenting was required.
This study has several limitations. First, the mean MRA follow-up duration was 11.8 months, and the MRA was performed in limited patients (63.8%). Therefore, we could not assess long-term outcomes about aneurysm occlusion or recurrence rate. Further follow-up is required to confirm the long-term effects of our procedure. However, for all patients who did not undergo MRA, both immediate angiography and MRA on the next day confirmed the complete occlusion of the aneurysm. Therefore, the possibility of recurrence was considered low. Second, there may be a potential bias for the selection of the techniques among all paraclinoid aneurysms. The randomized, controlled study may be required to compare the outcomes among different techniques.
In conclusion, we describe a modified balloon-assisted coiling technique employed to successfully treat 51 (88%) of 58 paraclinoid aneurysms. Partial inflation of the balloon to support the curved microcatheter could stabilize the microcatheter tip and improve packing density and outcome result. The technique appears to be safe and effective and could serve as an option for treating paraclinoid aneurysms.
This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (No. 2018R1A2B6003143). The sponsor had no role in the design or conduct of this research.
The Institutional Review Board at our medical center approved this retrospective study (2020-0269) and waived the requirement to obtain written informed consent from the patients.
DCS received an research grant from the Microvention
DCS has been the Editor-in-Chief of the
YS has been the Assistant Editor of the
No other authors have any conflict of interest to disclose.
Concept and design: DCS. Analysis and interpretation: YS, BK, AHA, RGK, and DCS. Data collection: YS, BK, AHA, and RGK. Writing the article: YS and DCS. Critical revision of the article: YS and DCS. Final approval of the article: YS, BK, AHA, RGK, and DCS. Statistical analysis: YS. Obtained funding: DCS. Overall responsibility: DCS.
Concept diagram depicting coiling of the paraclinoid aneurysm using a partially inflated balloon. (A) A loop-shaped microcatheter is introduced into the aneurysm. (B) The coil protrudes out of the aneurysm because of resistance of the coil within the aneurysm and withdrawal of the microcatheter. (C) Coil packing can be accomplished by supporting the microcatheter loop with the partially inflated balloon.
Balloon-assisted coiling for the treatment of a paraclinoid aneurysm. (A) A 4-mm aneurysm with superolateral projection just distal to the anterior genus of the right cavernous internal carotid artery. (B, C) Framing and filling coils are inserted into the aneurysm by supporting the microcatheter with intermittent ballooning (arrows). (D) No contrast filling is seen in the aneurysm on completion angiogram. A tiny opacification within the coil mass was determined as an overlapping ophthalmic artery.
A paraclinoid aneurysm with a relatively well-delineated neck as a pseudo-neck. (A) An internal carotid arteriogram shows an aneurysm at the posterior wall. (B) The aneurysm neck is not resistant to the coils and collapses while introducing the frame coil; thus it is regarded as a pseudo-neck. (C) The coils are contained within the aneurysm
Exchange into stenting after the failure of balloon-assisted coiling. (A) Left internal carotid angiogram shows an aneurysm projecting medially. (B) Despite using a balloon (arrows), the coil protrudes out of the aneurysm. (C) After deploying a stent, the coil is packed in the aneurysm. (D) Complete obliteration of the aneurysm is achieved.
Aneurysm characteristics and treatment outcome
Variable | Value |
---|---|
Aneurysm characteristics | |
Aneurysm group | |
Superior | 6 (10.3) |
Inferior | 24 (41.4) |
Medial | 23 (39.7) |
Lateral | 5 (8.6) |
Size (mm) | |
<3 | 1 (1.7) |
3–5 | 35 (60.3) |
5–7 | 15 (25.9) |
≥7 | 7 (12.1) |
Aneurysm size (mm) | 4.7±1.4 |
Aneurysm volume (mm3) | 47.2±43.9 |
Dome-to-neck ratio | 1.5±0.3 |
Treatment outcome | |
Packing density (%) | 37.1±6.8 |
Immediate results | |
Complete occlusion | 35 (60.3) |
Residual neck | 23 (39.7) |
Residual aneurysm | 0 (0) |
DWI lesions | |
None | 44 (75.9) |
Few microembolism | 10 (17.2) |
Many microembolism | 3 (5.2) |
Asymptomatic Infarction | 1 (1.7) |
Adverse events | |
Ischemic | 1 (1.7) |
Hemorrhagic | 0 (0) |
Follow-up MRA |
|
Minor recurrence | 11 (29.7) |
Major recurrence | 0 (0) |
mRS score of 0 at a recent follow-up | 58 (100) |
Values are presented as number (%) or mean±standard deviation.
DWI, diffusion-weighted image; MRA, magnetic resonance angiography; mRS, modified Rankin Scale.
Available in 37 patients.