A Comparison of Diffusion-Weighted Imaging Abnormalities Following Balloon Remodeling for Aneurysm Coil Embolization in the Ruptured vs Unruptured Setting

BACKGROUND The prothrombotic milieu seen in subarachnoid hemorrhage (SAH) poses a unique challenge to neurovascular surgeons with regard to device use and microcatheter practice. OBJECTIVE To determine how demographic factors and balloon practices impact diffusion-weighted imaging (DWI) abnormalities and outcomes in patients with SAH compared to those without (non-SAH). METHODS We retrospectively analyzed 77 patients with SAH treated by balloon-assisted coiling in a single institution compared with 81 consecutive patients with unruptured aneurysms treated by balloon-assisted coiling at the same institution. Data were collected with regard to demographic factors, procedural and anatomic considerations, and DWI abnormalities on postprocedural magnetic resonance imaging. RESULTS SAH patients were significantly more likely to have DWI abnormality (75% vs 21%, P < .0001) and had a higher number and volume of DWI (4.0 vs 3.0, P = .0421 and 1.3 vs 0.3 cc, P = .0041) despite similar balloon practices. SAH patients were not more likely to have DWI abnormality in vascular territory distal to the treated aneurysm but had a higher likelihood of DWI in a vascular territory unrelated to the aneurysm (81.5% vs 47.1%, P = .0235). Patients without DWI abnormality were significantly more likely to have a good outcome as defined by modified Rankin Score 0 to 2 (95.6% vs 81.6%, P = .0328). Patients with DWI abnormality more often underwent 4-vessel angiography (70.5% vs 48.0%, P = .0174), but this was not found to be significant on multivariate analysis. CONCLUSION Balloon-assisted coiling does not result in increased incidence of downstream ischemic events in SAH patients compared to non-SAH patients and is safe in this cohort of patients. Other factors, such as 4-vessel angiography of the SAH milieu itself, may predispose patients to a higher rate of ischemic events.