الفهرس 
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Abstract
Interest in endovascular techniques for treatment of intracranial aneurysms has exploded in the past decade. Not too long ago, endovascular aneurysm occlusion was considered a second-line treatment, but it has rapidly become the primary therapeutic option. The “minimally invasive” nature of this approach allows treatment of an intracranial aneurysm through a small groin incision. This approach is understandably more appealing to patients than open surgery involving craniotomy, brain retraction, and dissection. Other factors favoring the rapid spread of this technology include the ease of endovascular access to surgically difficult and demanding areas, such as basilar trunk or bifurcation, and the ability to visualize angiographically the patency of adjacent vessels during procedure.
Endovascular therapy of intracranial aneurysms generally aims at occlusion or thrombosis of the aneurysm sac. The approaches can be classified into two broad categories. Deconstructive approaches involve occlusion of the parent vessel with resultant stasis of the blood inside the aneurysm. Reconstructive approaches involve selective occlusion of the aneurysm lumen sparing of the parent artery. The method of aneurysm obliteration depends primarily on the site, size, and morphologic features of the aneurysm.
Many factors affect the obliteration rate, but the most important factor is the ratio of the neck of the aneurysm to the fundus. Aneurysms with wide necks, (dome/neck ratio <2), are more challenging than narrow neck aneurysm.
With revolution of endovascular techniques and instruments, wide neck aneurysms can be easily treated now with high success rate. Wide neck aneurysms are now treated with one of five methods:
1) Coils alone.
2) Coiling with Balloon remodeling technique.
3) Stent assisted coiling.
4) Flow diversion (pipeline devices and silk flow diverters).
5) Parent artery occlusion.
Introduction of the newer coils generations allowed dense packing of the aneurysms, which in turn reduced the complication rates, especially the recurrence/retreatment rates seen with the older coil generations. These new coils include, but not limited to, 3-D coils, Hydrocoils, and Bioactive coils.
This study aimed at evaluation of the endovascular treatment of wide neck aneurysms as the first line of treatment measuring the success and complication rates both clinically and Radiologically.
This study was conducted on 82 patients with 115 wide neck aneurysms treated by 109 procedures. We categorized the aneurysms in this series according to their states at time of presentation into ruptured and non-ruptured aneurysms in which we used the five treatment methods.
In coiled aneurysms, our study showed that hydrocoils give more packing density than bare platinum coils. In addition, stent assistance increases the packing density and radiological obliteration rate of the aneurysm more than coiling alone or coiling with balloon remodeling. This is markedly noticed in huge aneurysms and aneurysms with unfavorable geometries.
Based on our results, we classified packing density determining factors into non-modifiable factors, related to the aneurysm, including aneurysm stat and size and modifiable factors, related to treatment, including type of coils and assisting technique if present.
The introduction of flow diverters (pipeline devices) markedly facilitated the endovascular treatment of huge unclippaple aneurysms or aneurysms not amenable for other endovascular treatment modalities.
Parent artery occlusion for treatment of aneurysms is now declining with the development of new techniques and devices especially the flow diverters. However, it still represents a line of endovascular treatment for cerebral aneurysms especially when aneurysms are ruptured, huge, and not amenable for simple coiling or when these aneurysms require stent-assisted coiling or treatment with pipelines while anticoagulation therapy is contraindicated in the patient. In addition, it still represents a cheap option when the patient cannot afford the high prices of the flow diverters or stents.
Endovascular treatment still has its own complications including aneurysmal rupture, rebleeding, thromboembolic manifestations, recurrence/retreatment, and even failure of treatment. However, these complications are now decreasing with the new developments in devices and techniques.
It is our recommendation, based on this study, to use pipeline devices or stent-assisted Hydrogel coiling to treat huge aneurysms or aneurysms with unfavorable geometries and dome/neck ratios.