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Research ArticleNeurointervention

The Maze-Making and Solving Technique for Coil Embolization of Large and Giant Aneurysms

T. Ohta, I. Nakahara, R. Ishibashi, S. Matsumoto, M. Gomi, H. Miyata, H. Nishi, S. Watanabe and I. Nagata
American Journal of Neuroradiology April 2015, 36 (4) 744-750; DOI: https://doi.org/10.3174/ajnr.A4198
T. Ohta
aFrom the Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan.
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I. Nakahara
aFrom the Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan.
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R. Ishibashi
aFrom the Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan.
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S. Matsumoto
aFrom the Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan.
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M. Gomi
aFrom the Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan.
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H. Miyata
aFrom the Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan.
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H. Nishi
aFrom the Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan.
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S. Watanabe
aFrom the Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan.
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I. Nagata
aFrom the Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan.
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    Fig 1.

    The concept of the maze-making and solving technique. The microcatheter for larger diameter coils (MC1) is placed in the center of the aneurysm, and the catheter for traditional coils (MC2) is placed following the aneurysmal wall to reach beyond the orifice (A). As many as possible larger diameter coils are inserted (B). Cross-section illustrations reveal random interspaces still left unembolized and the movement of MC2 (C–E). Note the elevation of MC2 by stent placement and the second marker of MC2 buried in larger diameter coils (C). Traditional coils from MC2 fill the dead space left unembolized (D). After sufficient filling, the microcatheter is moved back to follow the wall and finds a new space. Note the altered position of the tip and the course of MC2 (E). If we repeat these dead space–filling and wall-follower methods in a stepwise fashion, the aneurysm is tightly embolized (F).

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    Fig 2.

    Maze-solving algorithms. The dead space–filling algorithm changes a complex maze (A) to a simple path to reach a goal (B). In combination with the dead space–filling algorithm, the wall-follower algorithm can fill all the spaces inside the maze.

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    Fig 3.

    Representative case. Cerebral angiography reveals a left internal carotid artery large aneurysm in anteroposterior (A) and lateral (B) views. The Penumbra Coil 400 makes a maze with random interspaces between the coils (C), which is solved by the addition of traditional coils (D). Postoperative cerebral angiography reveals complete obliteration in anteroposterior (E) and lateral (F) views.

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    Table 1:

    Patient characteristics

    CaseAge/SexPositionaSize (mm)Vol (mL)SymptomsRaymond Class (Immediate)Postoperative CoursePAFollow-Up AG (mo)
    Larger CoilsTotal
    177/FL-ICA (C7)20 × 14 × 151.528None1Cerebral infarction (mild hemiparesis and dysesthesia), mRS 134.541.212
    272/FL-ICA (C4/5)24 × 15 × 73.522Chronic oculomotor nerve palsy2mRS 029.130.412
    355/FR-ICA (C4)17 × 16 × 131.574None2mRS 035.738.819
    455/FL-ICA (C6)25 × 24 × 214.991Progressive visual disturbance2Cerebral infarction (temporary dysarthria), worsening of visual disturbance, mRS 126.432.517
    580/ML-ICA (C7)16 × 12 × 110.865None1mRS 024.64012
    653/FL-ICA (C5)15 × 14 × 110.921None1mRS 020.233.912
    773/FR-ICA (C7)13 × 10 × 90.748None2Transfusion (hemorrhage from puncture site), mRS 029.333.83
    854/FL-ICA (C4/5)22 × 14 × 152.116None1mRS 037.548.63
    • Note:—R indicates right; L, left; PA, packing attenuation; Vol, volume; AG, angiography.

    • ↵a The ICA segments are defined according to the classification of Bouthillier et al.4

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    Table 2:

    Comparison between the maze and the conventional groups

    Maze Group (n = 8)Conventional Group (n = 30)Conventional Group Using Intracranial Stents (n = 15)P Value between Maze Group and Conventional GroupP Value between Maze Group and Conventional Group Using Intracranial Stents
    Age65 ± 11.565.4 ± 13.068.3 ± 13.2.93.56
    Sex (male:female)1:78:223:12.29.41
    Location (ICA:others)8:020:108:7.064.026a
    Packing attenuation (%)37.4 ± 5.926.2 ± 5.627.9 ± 4.6<.01a<.01a
    Maximum diameter (mm)19 ± 4.413.4 ± 3.813.9 ± 5.0<.01a.02a
    Aneurysm volume (mL)2.03 ± 1.401.09 ± 1.521.38 ± 2.12.13.41
    No. of coils33.3 ± 16.115.5 ± 10.118.7 ± 12.4.017a.047a
    Angiographic recurrence0113.036a.26
    Perioperative complications325.31.34
    Periprocedural death or major stroke053.28.26
    Reintervention042.34.41
    • ↵a Significant P value.

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American Journal of Neuroradiology: 36 (4)
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T. Ohta, I. Nakahara, R. Ishibashi, S. Matsumoto, M. Gomi, H. Miyata, H. Nishi, S. Watanabe, I. Nagata
The Maze-Making and Solving Technique for Coil Embolization of Large and Giant Aneurysms
American Journal of Neuroradiology Apr 2015, 36 (4) 744-750; DOI: 10.3174/ajnr.A4198

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The Maze-Making and Solving Technique for Coil Embolization of Large and Giant Aneurysms
T. Ohta, I. Nakahara, R. Ishibashi, S. Matsumoto, M. Gomi, H. Miyata, H. Nishi, S. Watanabe, I. Nagata
American Journal of Neuroradiology Apr 2015, 36 (4) 744-750; DOI: 10.3174/ajnr.A4198
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