الفهرس 
Anatomy of intra-cranial arterial treeOnly 14 pages are availabe for public view
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Abstract
Endovascular management of intracranial aneurysms is the preferred treatment of choice both by clinicians and patients in most cases. The trend to opt for this minimally invasive alternative instead of open surgical techniques became more frequent after the publication of the International Subarachnoid Aneurysm Trial (ISAT).
Wide-neck intracranial aneurysms (when the neck is ≥4 mm, or when the dome/neck ratio <1.5–2) were originally thought to be either untreatable or very challenging to treat by endovascular means because of a variety of factors, which include the difficulty in defining the aneurysm and parent vessel interface angiographically, preventing coil herniation into the parent artery, and problems in achieving complete aneurysmal occlusion that could later predispose to regrowth or recanalization.
The introduction of the balloon remodeling technique and later stents specifically designed for intracranial use has progressively allowed these lesions to be endovascularly treated. Balloon remodeling and stent-assisted coiling techniques were first designed to treat sidewall aneurysms but, with gained experience and further technical refinement, bifurcation complex-shaped wide-neck aneurysms have been treated by coiling enhanced by these techniques.
Most clinicians are reluctant to perform stent-assisted coiling in the situation of subarachnoid hemorrhage because of the need for dual anti platelet therapy and this has made the use of balloon remodeling technique a more prevalent and preferable approach by clinicians in the last several years to treat wide-necked intracranial aneurysms. Balloons have also been shown to help in the tamponade of the vessel in case of intraoperative perforation and are also used for occlusion testing before sacrifice of the vessel.
The balloon remodeling technique consists in the temporary inflation of a non-detachable balloon across the aneurysm neck during each coil placement to avoid inadvertent coil protrusion into the parent artery. At the end of the procedure, the balloon is removed and no device is left in place in the parent vessel (unless stent placement is subsequently performed). Some balloon catheters allow the placement of a stent at the end of the procedure by inserting the stent into the lumen of the balloon microcatheter after withdrawal of the wire.
Nowadays, the most popular compliant remodeling balloon microcatheters are the HyperGlide™ (compatible with 0.010″ microguidewire), the Transform™ C, and the Scepter™ C (both compatible with 0.014″ microguidewires). Balloons compatible with 0.014″ microwire seem more stable than balloon operating on 0.010″ platforms but induce more deformation of the cerebral arteries during navigation. The Scepter™ has two independent lumens, giving to the operator the opportunity to navigate coils or some microstents while the balloon is still inflated.
The most popular supercompliant balloons microcatheters are the HyperForm™ (compatible with 0.010″ microguidewire), the Transform™ SC and the Scepter XC (both compatible with 0.014 microguidewires). These are preferred when balloon is required to accommodate the shape of a complex anatomy without much stress on the vessel wall as for example to protect an arterial branch coming from the aneurysm neck.
The two most frequent and feared complications of the endovascular treatment of intracranial aneurysms are thromboembolic events and aneurysm perforation. The use of an adjunctive balloon for aneurysm coiling has raised some concerns about potential added morbidity over the standard coiling procedure. Yet multiple recent prospective multicenter studies showed that both conventional coiling and balloon assisted coiling techniques had similar safety in terms of perioperative complications and clinical outcome. But the balloon remodeling technique was superior in more than one study in terms of initial and follow-up aneurysm occlusion rates.