Late reopening of adequately

coiled intracranial aneurysms

frequency and risk factors in 400 patients

with 440 aneurysms

Depts of Neurosurgery and Radiology, AMC Amsterdam

Depts of Neurology and Radiology, UMC Utrecht

Dept of Radiology, St. Elisabeth Ziekenhuis, Tilburg

Dept of Neurosurgery, Slotervaart Ziekenhuis Amsterdam

Depts of Neurosurgery and Radiology, Leiden UMC

Depts of Neurosurgery and Radiology, VUMC Amsterdam

Depts of Neurology and Radiology, Maastricht UMC

All in the Netherlands

Sandra Ferns, on behalf of the LOTUS study group

Background

• Risk reopening1,2

• Information on ‘late’ (>6 mo) reopening sparse

Purpose:

• To determine frequency of late reopening and

possible risk factors

1; Molyneux et al Lancet 2002, 2; Raymond et al, Stroke 2003

Aneurysm occlusion3

complete neck incomplete

remnant

3; Raymond et al, J neurosurg 1997

Methods

LOTUS STUDY

• Design: multicenter prospective follow-up study

• 7 Dutch participating centers with MEC approval– AMC, Amsterdam

– UMC, Utrecht

– St Elisabeth ZH, Tilburg

– VUMC, Amsterdam

– LUMC, Leiden

– Slotervaart ZH, Amsterdam

– MUMC, Maastricht

Methods

PATIENTS

• Inclusion criteria: – age 18-70

– coiling >4.5 years ago

– GOS 4/5

– adequate aneurysm occlusion after 6 months

– no contra-indications for MRA at 3Tesla

• 400 patients

Methods

IMAGING– 3 Tesla MRI, Philips Medical Systems

– T2 weighted imaging

– MOTSA 3D TOF

– Standard MIP and VR 3D reconstructions

EVALUATION– 2 observers

– Suspected incomplete occlusion: compare to initial and 6 month

angiography

Methods

ANALYSES

• Proportion reopening, retreatment

• Risk factors for late reopening– gender

– rupture status

– size ≥ 10 mm

– posterior circulation

– basilar tip

Results

patients

400 participants younger than

571 non-participants

(mean 55 versus 57 yrs, p<0.001)

mean follow-up 6.0 years

(median 5.0, range 4.5-12.9 yrs)

Participation 74%

16%

Results late reopening

• Agreement 421/440 aneurysms; 95.7%

• Reopening:– 11/400 patients (2.8%, 95%CI 1.4-4.9%)

– with 440 aneurysms (2.5%, 95%CI 1.0-4.0%)

• Retreatment:– 3/440 aneurysms (0.7%, 95%CI 0.2-1.5%)

Results risk factors

• Aneurysm size ≥ 10 mm

(OR 5.2, 95% CI 1.3-16.3, p=0.01)

• Location basilar artery tip

(OR 3.9, 95% CI 1.1- 14.6, p=0.04).

3 CASES(Late reopening after adequate coiling at

6 month FU angiography)

1. 49 year-old woman

Ruptured basilar tip aneurysm 12 mm

Directly after coiling 7 m FU 25-8-04

4.7 yrs FU MRA

reopening 3x8 mm

Not retreated

Unfavorable morphology

4.7 yrs FU VR

1. 49 year-old woman

Ruptured basilar tip aneurysm 12 mm

Before embolisation 5 months FU

2. 27 year-old woman

Unruptured additional left carotid tip aneurysm 6 mm

4.5 yrs FU

Reopening 3x3 mm

2. 27 year-old woman

Unruptured additional left carotid tip aneurysm 6 mm

After retreatment4.5 yrs FU DSA4.5 yrs FU VR

3. , 42 year-old woman

Ruptured left PcomA aneurysm 5 mm

Before coiling Directly after coiling 6 month FU

4.9 yrs FU MRA

reopening 4x3mm

No retreatment

Patient refusal

3. ♀, 42 year-old woman

Ruptured left PcomA aneurysm 5 mm

Conclusion

• Yield of long-term (mean 6 years) follow-up MRA of

coiled aneurysms with adequate occlusion at 6

month follow-up angiography is low

– Proportion reopening: 2.5% (11/ 440)

– Retreatment: 0.7% (3/ 440)

LOTUS study group• AMC

S.P. Ferns, PhD student

C.B.L.M. Majoie, radiologist (Principle

investigator)

R. van den Berg, radiologist

M.E.S. Sprengers, radiologist

J.C. van Rijn, radiologist

J.J. Schneiders, PhD student

P.M. Bossuyt, clinical epidemiologist

W.P. Vandertop, neurosurgeon

B.A. Coert, neurosurgeon

• St. Elizabeth Ziekenhuis Tilburg

W.J.J. van Rooij, radiologist

M. Sluzewski, radiologist

• Slotervaart Ziekenhuis

B.J.C.M. Hummelink, neurosurgeon

• UMCU

G.J.E. Rinkel, neurologist

B.K. Velthuis, radiologist

G.A.P. de Kort, radiologist

J.D. Schaafsma, neurologist resident

• VUMC

F. Barkhof, radiologist

J.C.J. Bot, radiologist

• LUMC

P.A. Brouwer, radiologist

M.A. van Walderveen, radiologist

• MUMC

W.H. van Zwam, radiologist

R. van Oostenbrugge, neurologist

Results: late reopeningNo M/F Age Aneurysm

location

Size (mm) Previous

rupture

Size

reopening (mm)

Retreatment

1 F 61 MCA 3 Y 2x1 N*

2 F 54 Basilar tip 5 Y 3x2 N*

3 F 49 Basilar tip 10 Y 5x2 N*

4 M 66 MCA 20 N 6x3 Y

5 F 63 PcomA 7 Y 5x5 Y

6 F 59 ICA tip 12 Y 8x7 N†

7 F 49 Basilar tip 12 Y 8x3 N‡

8 F 27 ICA tip 6 N 3x3 Y

9 F 42 PcomA 5 Y 4x3 N§

10 F 61 SCA 10 Y 9x7 N§

11 F 45 Basilar tip 7 Y 1x2 N*

* Retreatment not judged indicated by multidisciplinary team; † Patient not retreated because of co-morbidity

‡ Patient not retreated because of unfavorable morphology of the aneurysm remnant;

§ Patient refused retreatment

Results: risk factors reopening400 patients/440 aneurysms

with long-term

MRA follow-up

11 patients/ 11 aneurysms

with aneurysm

reopening

OR (95%CI), p

Women 276 (69%) 10 (91%) 4.66 (0.59-36.82), 0.14

Mean age (yrs) 54.5 52.3 -

median, range 55, 23-70 54, 27-66 -

Ruptured aneurysms 344 (78%) 9 (75%) 1.26 (0.27-5.94), 0.77

Mean size (mm) 6.5 8.8 -

median, range 6.0, 2-20 7.5, 3-20 -

Size ≥10 mm 66 (15%) 5 (45%) 5.13 (1.52-17.32), 0.01‡

Intraluminal thrombus 4 (1%) 1 (8%) -

Aneurysm location

Anterior circulation 327 (74%) 6 (55%) -

ACA 143 0 -

MCA 44 2 -

ICA 140 4 -

Posterior circulation 113 (26%) 5 (45%) † 2.51 (0.75-8.38), 0.14

Basilar tip 61 4 † 3.73 (1.06-13.14), 0.04‡