Microembolic signal monitoring and the prediction of thromboembolic events following coil embolization of unruptured intracranial aneurysms: diffusion-weighted imaging correlation

Abstract OBJECTIVE: The purpose of this study was to evaluate the frequency and causes of thromboembolic events associated with endovascular embolization of asymptomatic aneurysms. Correlations between radiological findings (aneurysm size, localization, embolization time, number of coils used, as well as patient age) were evaluated with the occurrence of thromboembolic events and clinical findings. METHODS: Sixty-eight patients treated for unruptured intracranial aneurysms (mean age, 49 yr) were evaluated. Hyperintense lesions on diffusion weighted imaging were analyzed in 50 patients. Aneurysm size was 3 to 15 mm. RESULTS: Complete occlusion of the aneurysms was achieved in 55 of 68 (82%). One patient had a transient paresis. There was one infarction and one aneurysm rupture during the procedure with no consecutive neurological symptoms. We found new hyperintense lesions in 21 of 50 (42%) diffusion weighted imaging studies. In 43% of these, there was only one lesion smaller than 2 mm. In 33%, there was more than one lesion less than 2 mm; in 19%, we found a lesion of 2 to 10 mm in size. In one case, a lesion greater than 10 mm occurred. There was no correlation between aneurysm location and the occurrence of lesions or among the number of coils used, the size of the aneurysm, patient age, or embolization time. Mortality rate was 0%, morbidity 4.0%. If the 18 aneurysms where no diffusion weighted imaging was obtained are included, morbidity is 2.9%. CONCLUSION: The high rate of thromboembolic events suggests that heparin is not sufficient to prevent ischemic lesions. An antiplatelet therapy, started before or during intervention, might diminish thrombus formation.

Download Full-text

Cognitive Outcome and Clinically Silent Thromboembolic Events After Coiling of Asymptomatic Unruptured Intracranial Aneurysms

Neurosurgery ◽

10.1227/neu.0b013e3182846f74 ◽

2012 ◽

Vol 72 (4) ◽

pp. 638-645 ◽

Cited By ~ 16

Author(s):

Dong-Hun Kang ◽

Yang-Ha Hwang ◽

Yong-Sun Kim ◽

Geum Ye Bae ◽

Seung Jae Lee

Keyword(s):

Cognitive Deficits ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Cognitive Outcome ◽

Cognitively Impaired ◽

Thromboembolic Events ◽

Cognitive Changes ◽

Focal Neurological Deficit ◽

Unruptured Intracranial Aneurysms ◽

Significant Difference

Abstract BACKGROUND: Thromboembolic events are the most common complication after coiling of unruptured intracranial aneurysms (UIAs). However, it remains unclear whether these clinically silent ischemic lesions (CSILs) have any clinical significance. OBJECTIVE: To evaluate cognitive outcome after coil embolization of asymptomatic UIAs and its relationship with CSILs after the procedure. METHODS: We prospectively enrolled 40 UIA patients who showed no new focal neurological deficit after coil embolization. CSILs were assessed with diffusion-weighted imaging (DWI) within 1 day after the procedure. A battery of neuropsychological tests was performed 3 times: preoperatively and postoperatively at 1 and 4 weeks after coil embolization. RESULTS: The incidence of cognitive impairment after coiling in patients with UIAs was 44% (17 of 39) at 1 week and 19% (7 of 37) at 4 weeks after coil embolization. DWI within 1 day after coil embolization revealed that 60% of patients (24 of 40) showed CSILs. However, no significant difference was found in any mean cognitive scores or in the number of cognitively impaired variables between patients with and without CSILs at weeks 1 and 4. Additional correlation analysis revealed no correlations between the number of CSILs on DWI and the cognitive sum z score at both 1 and 4 weeks. CONCLUSION: Exhaustive neuropsychological evaluation of UIA patients who underwent coil embolization demonstrated recovery or improvements from baseline cognitive function after 4 weeks, although some patients still showed cognitive deficits at 4 weeks after the procedure. However, we found no statistically significant relationship between the presence and number of CSILs on DWI and cognitive changes after the procedure.

Download Full-text

The inhibition rate estimated using VerifyNow can help to predict the thromboembolic risk of coil embolization for unruptured intracranial aneurysms

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017586 ◽

2021 ◽

pp. neurintsurg-2021-017586

Author(s):

Young Deok Kim ◽

O-Ki Kwon ◽

Seung Pil Ban ◽

Yu Deok Won ◽

Jae Seung Bang ◽

...

Keyword(s):

Roc Curve ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Multiple Logistic Regression Analysis ◽

Youden Index ◽

Significant Variable ◽

Thromboembolic Events ◽

Inhibition Rate ◽

Thromboembolic Risk ◽

Unruptured Intracranial Aneurysms

BackgroundThe role of the inhibition rate of VerifyNow in assessing the thromboembolic risk of coil embolization for unruptured intracranial aneurysms is unclear.ObjectiveTo carry out a retrospective study to determine whether the inhibition rate could provide additional help in predicting thromboembolic events when it was used for patients with a P2Y12 reaction unit (PRU) level of 220 or lower.MethodsPatients who underwent coil embolization for unruptured aneurysms with an appropriate PRU level (PRU 220 or lower) between January 1, 2015 and December 31, 2018 were analyzed. A total of 954 patients with 1020 aneurysms were included in this study. The primary outcome was the thromboembolic events occurring within 30 days after coil embolization. The receiver operating characteristic (ROC) curve and the area under the curve (AUC) were obtained to determine the quantitative predictive ability of the inhibition rate. The optimal cut-off value was derived using the Youden index.ResultsThromboembolic events developed in 11 patients (1.08% of 1020 procedures). The AUC of the ROC curve was 0.83. The optimal cut-off value of the inhibition rate derived using the maximum Youden index was 22.0%. A sensitivity test using a multiple logistic regression analysis demonstrated that the inhibition rate was a significant variable for predicting thromboembolic events.ConclusionsThe inhibition rate can be used to determine high thromboembolic risks for patients with PRU levels of 220 or lower. The optimal cut-off value of the inhibition rate was 22.0% when the PRU level was 220 or less.

Download Full-text

Antiplatelet Premedication for Stent-Assisted Coil Embolization of Intracranial Aneurysms: Low-Dose Prasugrel vs Clopidogrel

Neurosurgery ◽

10.1093/neuros/nyx591 ◽

2017 ◽

Vol 83 (5) ◽

pp. 981-988 ◽

Cited By ~ 21

Author(s):

Hyun Ho Choi ◽

Jung Jun Lee ◽

Young Dae Cho ◽

Moon Hee Han ◽

Won-Sang Cho ◽

...

Keyword(s):

Coil Embolization ◽

Intracranial Aneurysms ◽

Low Dose ◽

Significant Risk ◽

Cerebral Aneurysms ◽

Significant Risk Factor ◽

Thromboembolic Events ◽

Antiplatelet Medication ◽

Unruptured Intracranial Aneurysms ◽

Significant Difference

Abstract BACKGROUND The use of antiplatelet medications to prevent thrombosis in the treatment of cerebral aneurysms with stents has become widely emphasized. OBJECTIVE To compare low-dose prasugrel with clopidogrel in stent-assisted coil embolization of intracranial aneurysms. METHODS This is a retrospective review of 311 aneurysms from 297 patients who underwent stent-assisted endovascular coil embolization of unruptured intracranial aneurysm between November 2014 and March 2017. Thromboembolic and hemorrhagic adverse events were compared between 207 patients who received low-dose prasugrel (PSG group) and 90 patients who received clopidogrel (CPG group). RESULTS P2Y12 reaction unit (PRU) values were significantly lower in the PSG group (PSG group vs CPG group, 132.3 ± 76.9 vs 238.1 ± 69.1; P < .001); the percentage of inhibition was also statistically higher in the PSG group (54.0 ± 26.0% vs 20.8 ± 18.6%; P < .001). Thromboembolic events occurred less frequently in the PSG group than in the CPG group (0.9% vs 6.4%; P = .01), whereas there was no significant difference in the percentage of hemorrhagic complications (0.5% vs 2.2%; P = .22). In the multivariate analysis, clopidogrel as the antiplatelet medication was the sole significant risk factor for thromboembolism in this series of patients undergoing stent-assisted coil embolization. CONCLUSION Use of low-dose PSG as an antiplatelet premedication is quick, effective, and safe for stent-assisted coil embolization of unruptured intracranial aneurysms. Prasugrel premedication significantly lowered the frequency of thromboembolic events without increasing the risk of hemorrhage.

Download Full-text

Crescent sign on magnetic resonance angiography revealing incomplete stent apposition: correlation with diffusion-weighted changes in stent-mediated coil embolization of aneurysms

Journal of Neurosurgery ◽

10.3171/2011.4.jns102050 ◽

2011 ◽

Vol 115 (3) ◽

pp. 624-632 ◽

Cited By ~ 48

Author(s):

Robert S. Heller ◽

William R. Miele ◽

Daniel D. Do-Dai ◽

Adel M. Malek

Keyword(s):

Coil Embolization ◽

Diffusion Weighted Imaging ◽

Intracranial Aneurysms ◽

Mr Angiography ◽

Ct Scanning ◽

Thromboembolic Complications ◽

Incomplete Stent Apposition ◽

Crescent Sign ◽

Diffusion Weighted ◽

Closed Cell

Object Few data are available on how closely stents appose the luminal vessel wall in stent-mediated coil embolization of intracranial aneurysms and on the effect of incomplete stent apposition on procedural thromboembolic complications. Methods Postprocedural 3-T MR diffusion-weighted imaging and time-of-flight angiography were obtained in 58 patients undergoing stent-mediated coil embolization of aneurysms using the Enterprise closed-cell and Neuroform open-cell self-expanding intracranial microstents. Results A distinctive semilunar signal pattern, identified using 3-T MR angiography, represented flow outside the confines of the stent struts in patients in whom Enterprise but not Neuroform devices were used. This pattern, designated as the crescent sign, was confirmed to correspond to incomplete stent apposition by use of high-resolution angiographic flat-panel CT scanning revealing flow ingress into and egress out of the isolated luminal wedge. The presence of the crescent sign was seen in 18 of 33 Enterprise-treated but in 0 of 25 Neuroform-treated cases, and was more likely in stents delivered in the tortuous internal carotid artery (p = 0.034). The crescent sign was strongly predictive of ipsilateral postprocedural lesions seen on diffusion-weighted imaging in the entire population (OR 18, 95% CI 4.33–74.8; p < 0.0001). In the Enterprise stent subset, ipsilateral lesions were detected on diffusion-weighted imaging in 15 (45%) of 33 cases; the crescent sign was seen in 12 (80%) of 15 patients with ipsilateral lesions on diffusion-weighted imaging, but in only 6 of 18 patients without lesions (OR 8, 95% CI 1.61–39.6; p = 0.006). Conclusions Incomplete stent apposition is detectable on 3-T MR angiography as a crescent sign, and was found to be highly prevalent in Enterprise closed-cell design stents used to assist coil embolization of aneurysms. Incomplete stent apposition was also associated with periprocedural ipsilateral hyperintense lesions on diffusion-weighted imaging. These results identify an association between incomplete stent apposition and thromboembolic complications in stent-mediated coil embolization of intracranial aneurysms.

Download Full-text

Clopidogrel response predicts thromboembolic events associated with coil embolization of unruptured intracranial aneurysms: A prospective cohort study

PLoS ONE ◽

10.1371/journal.pone.0249766 ◽

2021 ◽

Vol 16 (4) ◽

pp. e0249766

Author(s):

Eiji Higashi ◽

Shoji Matsumoto ◽

Ichiro Nakahara ◽

Taketo Hatano ◽

Akira Ishii ◽

...

Keyword(s):

Cohort Study ◽

Intracranial Aneurysm ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Thromboembolic Event ◽

Clinical Information ◽

Thromboembolic Events ◽

Unruptured Intracranial Aneurysm ◽

Clinical Model ◽

Unruptured Intracranial Aneurysms

Objective Periprocedural thromboembolic events are a serious complication associated with coil embolization of unruptured intracranial aneurysms. However, no established clinical rule for predicting thromboembolic events exists. This study aimed to clarify the significance of adding preoperative clopidogrel response value to clinical factors when predicting the occurrence of thromboembolic events during/after coil embolization and to develop a nomogram for thromboembolic event prediction. Methods In this prospective, single-center, cohort study, we included 345 patients undergoing elective coil embolization for unruptured intracranial aneurysm. Thromboembolic event was defined as the occurrence of intra-procedural thrombus formation and postprocedural symptomatic cerebral infarction within 7 days. We evaluated preoperative clopidogrel response and patients’ clinical information. We developed a patient-clinical-information model for thromboembolic event using multivariate analysis and compared its efficiency with that of patient-clinical-information plus preoperative clopidogrel response model. The predictive performances of the two models were assessed using area under the receiver-operating characteristic curve (AUC-ROC) with bootstrap method and compared using net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Results Twenty-eight patients experienced thromboembolic events. The clinical model included age, aneurysm location, aneurysm dome and neck size, and treatment technique. AUC-ROC for the clinical model improved from 0.707 to 0.779 after adding the clopidogrel response value. Significant intergroup differences were noted in NRI (0.617, 95% CI: 0.247–0.987, p < .001) and IDI (0.068, 95% CI: 0.021–0.116, p = .005). Conclusions Evaluation of preoperative clopidogrel response in addition to clinical variables improves the prediction accuracy of thromboembolic event occurrence during/after coil embolization of unruptured intracranial aneurysm.

Download Full-text

Thromboembolic Events during Endovascular Coil Embolization of Cerebral Aneurysms

Interventional Neuroradiology ◽

10.1177/15910199060120s117 ◽

2006 ◽

Vol 12 (1_suppl) ◽

pp. 112-116 ◽

Cited By ~ 10

Author(s):

T. Ishibashi ◽

Y. Murayama ◽

T. Saguchi ◽

M. Ebara ◽

K. Irie ◽

...

Keyword(s):

Risk Factors ◽

Adverse Event ◽

Coil Embolization ◽

Diffusion Weighted Imaging ◽

Cerebral Aneurysms ◽

Thromboembolic Events ◽

Diffusion Weighted ◽

Endovascular Coil Embolization ◽

Intracerebral Aneurysm

Thromboembolic events was most important adverse event for coil embolization for intracerebral aneurysm. The present study investigated possible risk factors for thromboembolic events during coil embolization using diffusion-weighted imaging (DWI), comparing unruptured and ruptured lesions.

Download Full-text

Ticagrelor versus Clopidogrel in Stent-assisted Coil Embolization of Unruptured Intracranial Aneurysms

10.21203/rs.3.rs-288126/v1 ◽

2021 ◽

Author(s):

Shuo-Chi Chien ◽

Ching-Chang Chen ◽

Chun-Ting Chen ◽

Alvin Yi-Chou Wang ◽

Po-Chuan Hsieh ◽

...

Keyword(s):

Ischemic Stroke ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Hemorrhagic Stroke ◽

Systemic Review ◽

Bleeding Tendency ◽

Thromboembolic Events ◽

Hemorrhagic Event ◽

Unruptured Intracranial Aneurysms ◽

One Year

Abstract Background: In order to prevent thromboembolic events, dual antiplatelet therapy (DAPT) is widely used in stent-assisted coil embolization (SACE) for unruptured intracranial aneurysms (UIAs). Compared to clopidogrel associated with aspirin, knowledge of the safety and efficacy of ticagrelor are lacking in large studies to this date.Methods: A retrospective cohort study from January 2016 to December 2018 with at least one year follow in a single institution and systemic review.Results: Altogether 153 patients with UIA receiving SACE were separated into two groups: 113 patients receiving clopidogrel plus aspirin and 40 patients receiving ticagrelor plus aspirin. Acute in-stent thrombosis events were noted in 2 patients in the clopidogrel group (1.77%) and none in the ticagrelor group (0%). Another 1 patient (0.88%) in the clopidogrel group had an early ischemic stroke (<3 months). Delayed ischemic stroke was noted in 6 patients (5.31%) in the clopidogrel group and 3 patients (7.50%) in the ticagrelor group. There was no major hemorrhagic event in either group. The two groups had no significant differences with regard to ischemic stroke or hemorrhagic stroke.Conclusion: Compared to the clopidogrel based regimen, ticagrelor can reduce thromboembolic events without increasing bleeding tendency for stent-assisted coil embolization of unruptured intracranial aneurysms. Ticagrelor plus aspirin is a safe and effective alternative option for SACE.

Download Full-text

Is Clopidogrel Premedication Useful to Reduce Thromboembolic Events During Coil Embolization for Unruptured Intracranial Aneurysms?

Neurosurgery ◽

10.1227/neu.0b013e3181efe3ef ◽

2010 ◽

Vol 67 (5) ◽

pp. 1371-1376 ◽

Cited By ~ 41

Author(s):

Hyun-Seung Kang ◽

Moon Hee Han ◽

Bae Ju Kwon ◽

Cheolkyu Jung ◽

Jeong-Eun Kim ◽

...

Keyword(s):

Coil Embolization ◽

Intracranial Aneurysms ◽

Multiple Logistic Regression Analysis ◽

Control Group ◽

Thromboembolic Events ◽

Unruptured Aneurysms ◽

Female Patients ◽

Unruptured Intracranial Aneurysms ◽

History Of ◽

Independent Risk Factors

Abstract BACKGROUND: Thromboembolism is a common complication related to coil embolization of intracranial aneurysms. OBJECTIVE: To identify factors related to thromboembolic events during coil embolization for unruptured intracranial aneurysms and to evaluate the role of clopidogrel premedication to prevent thromboembolisms. METHODS: Since March 2006, clopidogrel has been administered to patients with unruptured aneurysms before coil embolization (the clopidogrel group) in our institution. The clopidogrel group (416 patients with 485 aneurysms) and the historical control group (140 patients with 159 aneurysms who received no antiplatelet premedication) were compared to find the efficacy of clopidogrel premedication. Various factors, including age, sex, body weight, and medical history of hypertension, diabetes mellitus, hyperlipidemia, smoking, previous stroke, and heart disease, as well as clopidogrel premedication, were analyzed in relationship to the development of a procedure-related thromboembolism. RESULTS: Procedure-related thromboembolic events tended to occur less frequently in the clopidogrel group compared with the control group (7.4% vs 12.6%; P = .05), and clopidogrel premedication could modify the risk in female patients from 11.1% to 5.2% (P = .04). The use of multiple logistic regression analysis identified clopidogrel premedication (P = .03), smoking (P = .002), and hyperlipidemia (P = .02) as significant factors related to the formation of thromboembolism. CONCLUSION: Clopidogrel premedication seems to have a beneficial effect in reducing the number of procedure-related thromboembolisms during coil embolization for unruptured intracranial aneurysms, especially in female patients. Smoking and hyperlipidemia were independent risk factors related to thromboembolism.

Download Full-text

Outcomes following aneurysmal coil embolization with intentionally shortened low-profile visible intraluminal support stent deployment

The Neuroradiology Journal ◽

10.1177/19714009211026925 ◽

2021 ◽

pp. 197140092110269

Author(s):

Kenji Yatomi ◽

Yumiko Mitome-Mishima ◽

Takashi Fujii ◽

Kohsuke Teranishi ◽

Hidenori Oishi ◽

...

Keyword(s):

Fluid Dynamics ◽

Computational Fluid Dynamics ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Perioperative Complications ◽

Flow Diversion ◽

Stent Deployment ◽

Coverage Ratio ◽

Low Profile ◽

Unruptured Intracranial Aneurysms

Purpose Among all stents available for neuroendovascular therapy, the low-profile visible intraluminal support stent bears the highest metal coverage ratio. We deployed a low-profile visible intraluminal support stent with a delivery wire or/and microcatheter system push action to shorten the low-profile visible intraluminal support stent and thus achieve a flow diversion effect. We report our single-institution experience with the use of low-profile visible intraluminal support stents for intentionally shortened deployment (shortening group) and non-shortened deployment (non-shortening group) for unruptured intracranial aneurysms. Methods We retrospectively reviewed the medical records of 130 patients with 131 intracranial aneurysms who were treated with low-profile visible intraluminal support stent-assisted coil embolization from February 2016–January 2019. All perioperative complications were noted. Every 6 months, we re-examined the patients with cerebral angiography or magnetic resonance angiography. The outcomes of aneurysm occlusion were evaluated by the modified Raymond–Roy occlusion classification. We used the finite element method and computational fluid dynamics to investigate the hemodynamics after shortened low-profile visible intraluminal support stent deployment. Results Immediately after treatment, the modified Raymond-Roy occlusion classification was significantly better in the shortening group than in the non-shortening group ( p<0.05). The latest angiographic outcomes showed the same tendency. Hemodynamic analysis by computational fluid dynamics suggested an adequate flow diversion effect with the use of our intentional shortening method. Conclusions Stent-assisted coil embolization using this technique showed good results of a high complete occlusion rate and low complication rate. These findings suggest that shortened low-profile visible intraluminal support stent deployment yields a flow diversion effect and may lead to early intra-aneurysmal thrombus formation.

Download Full-text