Hemorrhagic Complications Related to the Stent-Remodeled Coil Embolization of Intracranial Aneurysms

Abstract OBJECTIVE To evaluate the postprocedural hemorrhagic complications associated with stent-remodeled coil embolization of intracranial aneurysms. METHODS From the database of 163 cases of stent-remodeled therapy for wide-neck intracranial aneurysms, patients who showed intracranial hemorrhagic complications on follow-up brain imaging were selected. The initial presentation, antithrombotic medication, hemorrhagic type, location, amount, association with ventriculostomy, symptomatic involvement, and outcome were assessed. RESULTS Ten patients (6.1%) developed intracranial hemorrhagic complications (range; 0–422 days; mean; 56 days). The hemorrhagic complication rate was higher in patients with acute subarachnoid hemorrhage (20%, 6 of 30 patients) than in patients with unruptured aneurysms (3%, 4 of 133 patients). Nine of the 10 patients were on dual-antiplatelet therapy at the time of hemorrhage development. Seven of the hemorrhages developed in patients with ventriculostomies (intraparenchymal, n = 4; subdural hematoma, n = 3). Three patients who did not receive a ventriculostomy also developed intracranial hemorrhage (n = 1) or intraparenchymal hemorrhage (n = 2). Hemorrhagic transformation in the recently infarcted brain tissue seemed to be the cause of nonventriculostomy related intraparenchymal hemorrhage. The hemorrhages were accompanied by symptomatic aggravation in 6 of 10 cases, with 5 cases resulting in moribund clinical outcome. CONCLUSION Postprocedural intracranial hemorrhage may be a risk of stent-remodeled therapy while the patient is on dual-antiplatelet medication. Extra caution is warranted especially in patients with acute subarachnoid hemorrhage requiring ventriculostomy or with underlying recent brain infarction.

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Comparison of stent-assisted and no-stent coil embolization for safety and effectiveness in the treatment of ruptured intracranial aneurysms

Journal of Neurosurgery ◽

10.3171/2019.5.jns19988 ◽

2020 ◽

Vol 133 (3) ◽

pp. 814-820 ◽

Cited By ~ 2

Author(s):

Haewon Roh ◽

Junwon Kim ◽

Heejin Bae ◽

Kyuha Chong ◽

Jong Hyun Kim ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

High Risk ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Viable Option ◽

Safety And Efficacy ◽

Ruptured Aneurysms ◽

Hemorrhagic Complications ◽

Acute Subarachnoid Hemorrhage ◽

Ruptured Intracranial Aneurysms

OBJECTIVEThe safety of the stent-assisted coil embolization (SAC) technique for acutely ruptured aneurysms has not been established yet. SAC is believed to be associated with a high risk of thromboembolic and hemorrhagic complications in acute subarachnoid hemorrhage (SAH). The aim of this study was to evaluate the safety and efficacy of the SAC technique in the setting of acutely ruptured aneurysm.METHODSA total of 102 patients who received endovascular treatment for acute SAH between January 2011 and December 2017 were enrolled. The SAC technique was performed in 38 of these patients, whereas the no-stent coil embolization (NSC) technique was performed in 64. The safety and efficacy of the SAC technique in acute SAH was evaluated as compared with the NSC technique by retrospective analysis of radiological and clinical outcomes.RESULTSThere were no significant differences in clinical or angiographic outcomes between the SAC and NSC techniques in patients with acute SAH. The rate of ventriculostomy-related hemorrhagic complications was higher in the SAC group than that in the NSC group (63.6% vs 12.5%; OR 12.25, 95% CI 1.78–83.94, p = 0.01). However, all these complications were asymptomatic and so small that they were only able to be diagnosed with imaging.CONCLUSIONSRuptured wide-necked aneurysms could be effectively and safely treated with the SAC technique, which showed clinical and angiographic outcomes similar to those of the NSC technique. Hence, the SAC technique with dual-antiplatelet drugs may be a viable option even in acute SAH.

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Thromboelastography (TEG) results are predictive of ischemic and hemorrhagic complications in patients with unruptured intracranial aneurysms treated with flow diversion

Interventional Neuroradiology ◽

10.1177/15910199211025917 ◽

2021 ◽

pp. 159101992110259

Author(s):

Kainaat Javed ◽

Santiago R Unda ◽

Ryan Holland ◽

Adisson Fortunel ◽

Rose Fluss ◽

...

Keyword(s):

Ischemic Stroke ◽

Intracranial Aneurysms ◽

Statistical Significance ◽

Alpha Angle ◽

Flow Diversion ◽

P Value ◽

Hemorrhagic Complication ◽

Unruptured Intracranial Aneurysms ◽

Hemorrhagic Complications ◽

Groin Hematoma

Introduction Flow diversion is an effective treatment modality for intracranial aneurysms but is associated with ischemic and hemorrhagic complications. Patients treated with flow diversion require dual antiplatelet therapy and subsequent platelet function tests. At our institution, Thromboelastography with Platelet Mapping (TEG-PM) is the test of choice. The primary objective of this study was to identify TEG parameters that are predictive of postoperative complications in patients treated with elective flow diversion. Methods This was a retrospective study of 118 patients with unruptured intracranial aneurysms treated with flow diversion. Data was collected via chart review. Bivariate analyses were performed to identify significant variables in patients who suffered an ischemic stroke or a groin hematoma. ROC curves were constructed for the TEG parameters with statistical significance. Bivariate analyses were repeated using dichotomized TEG results. Results Patients who experienced a symptomatic ischemic stroke had a history of stroke (p value = 0.007), larger aneurysm neck width (p value = 0.017), and a higher alpha angle (p value = 0.013). Cut off point for ischemic complication is 63° on ROC curve with a sensitivity of 100% and specificity of 65%. Patients who experienced a groin hematoma were no different from their healthy peers but had a lower alpha angle (p value = 0.033). Cut off point for hemorrhagic complication is 53.3° with a sensitivity of 82% and specificity of 67%. Conclusion The Alpha Angle parameter of TEG-PM has a sizeable predictive ability for both ischemic complications of the central nervous system and hemorrhagic complications of the access site after elective flow diversion.

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Mean hemoglobin concentration after acute subarachnoid hemorrhage and the relation to outcome, mortality, vasospasm, and brain infarction

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2014.08.026 ◽

2015 ◽

Vol 22 (3) ◽

pp. 530-534 ◽

Cited By ~ 17

Author(s):

Marco Stein ◽

Lisa Brokmeier ◽

Johannes Herrmann ◽

Wolfram Scharbrodt ◽

Vanessa Schreiber ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Brain Infarction ◽

Hemoglobin Concentration ◽

Acute Subarachnoid Hemorrhage ◽

Outcome Mortality

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Early experience with a novel net temporary bridging device (Cascade) to assist endovascular coil embolization of intracranial aneurysms

Journal of Neurosurgery ◽

10.3171/2019.11.jns192477 ◽

2020 ◽

pp. 1-9

Author(s):

Alejandro Tomasello ◽

David Hernandez ◽

Laura Ludovica Gramegna ◽

Sonia Aixut ◽

Roger Barranco Pons ◽

...

Keyword(s):

Coil Embolization ◽

Intracranial Aneurysms ◽

Type I ◽

Type Ii ◽

Unruptured Aneurysms ◽

Complete Obliteration ◽

Acute Subarachnoid Hemorrhage ◽

Endovascular Coil Embolization ◽

The Mean

OBJECTIVEThe goal of this study was to evaluate the effectiveness and safety of a new noncompletely occlusive net-assisted remodeling technique in which the Cascade net device is used for temporary bridging of intracranial aneurysms.METHODSBetween July 2018 and May 2019, patients underwent coil embolization with the Cascade net device within 4 centers in Europe. Analysis of angiographic (modified Raymond-Roy classification [MRRC]) and clinical outcomes data was conducted immediately following treatment and at the 6-month follow-up.RESULTSFifteen patients were included in the study (mean age 58 ± 13 years, 11/15 [73.3%] female). Ten patients had unruptured aneurysms, and 5 presented with ruptured aneurysms with acute subarachnoid hemorrhage. The mean aneurysm dome length was 6.27 ± 2.33 mm and the mean neck width was 3.64 ± 1.19 mm. Immediately postprocedure, MRRC type I (complete obliteration) was achieved in 11 patients (73.3%), whereas a type II (residual neck) was achieved in 4 patients (26.7%). Follow-up examination was performed in 7/15 patients and showed stabilization of aneurysm closure with no thromboembolic complications and only 1 patient with an increased MRRC score (from I to II) due to coil compression.CONCLUSIONSInitial experience shows that the use of a new noncompletely occlusive net-assisted remodeling technique with the Cascade net device may be safe and effective for endovascular coil embolization of intracranial aneurysms.

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O-008 Size and location of ruptured intracranial aneurysms in a consecutive series of 588 patients with first-time acute subarachnoid hemorrhage treated endovascularly at a tertiary referral medical center over a 16-year time period

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2012-010455a.8 ◽

2012 ◽

Vol 4 (Suppl 1) ◽

pp. A4.2-A5

Author(s):

J Delgado Almandoz ◽

J Fease ◽

B Crandall ◽

Y Kadkhodayan ◽

J Scholz ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracranial Aneurysms ◽

Medical Center ◽

Consecutive Series ◽

Tertiary Referral ◽

Time Period ◽

Acute Subarachnoid Hemorrhage ◽

First Time ◽

Ruptured Intracranial Aneurysms

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Abstract W P307: Novel Application of Reversible Parental Anti-platelets in Patients with Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/str.46.suppl_1.wp307 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Siddhart Mehta ◽

Mohammed Hussain ◽

Jaskiran Brar ◽

Daniel Korya ◽

Harina Chahal ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Coil Embolization ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Antiplatelet Agents ◽

Endovascular Coiling ◽

International Subarachnoid Aneurysm Trial ◽

Procedural Complications ◽

Acute Subarachnoid Hemorrhage ◽

Comprehensive Stroke Center ◽

Stroke Center

Background and Objective: The International Subarachnoid Aneurysm Trial (ISAT) showed a greater likelihood of survival free 1 year disability in patients undergoing endovascular coiling who were started on antiplatelet agents after SAH compared to ones undergoing neurosurgical clipping. However, data on safety of acute parental antiplatelet agents after aneurysmal coiling is lacking. We report on the safety of IV Eptifibatide (rapidly reversible Glyprotein IIbIIIa inhibitor) on patients presenting with acute subarachnoid hemorrhage undergoing endovascular coiling for aneurysmal embolization. Methods: All the patients from 2009-13 who presented to our university affiliated comprehensive stroke center with aneurysmal subarachnoid hemorrhage and underwent endovascular coiling were included for the study. Patients that received IV Eptifibatide for various reasons including acute need for stent assist coiling after securing the ruptured aneurysm with endovascular coiling were reviewed. Eptifibatide was administered intra-arterially as a 135-μg/kg single-dose bolus, and then continued on intravenous infusion of 0.5-μg/kg/min post-procedurally. Charts were reviewed for all patients to assess for medical/procedural complications including symptomatic and asymptomatic intra- and extra-cranial hemorrhages, groin hematomas, epistaxis and gross hematuria. Results: Of the total of 93 patients treated with coil embolization during this period, 5 patients (mean age 56 years, 20% male [n=1]) received acute intra-procedural Eptifibatide followed by IV infusion for a mean duration of 77 hours (range 20-130 hours). Various reasons for use of Eptifibatide included: stent assist coiling [n=2], multiple stents for flow diversion [n=1], partial coil prolapse [n=1] and vascular lumen flow compromise [n=1]. None of the patients demonstrated symptomatic/asymptomatic hemorrhage, groin hematoma, epistaxis or hematuria. Conclusion: Our results may highlight safety of administering IV Eptifibatide to prevent thrombotic complications after endovascular coil embolization in select patients with aneurysmal subarachnoid hemorrhage. Multicenter prospective trials are warranted to corroborate our findings.

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Intracranial Aneurysms in Children with Sickle-Cell Anemia

Blood ◽

10.1182/blood.v120.21.4756.4756 ◽

2012 ◽

Vol 120 (21) ◽

pp. 4756-4756

Author(s):

Manoelle Kossorotoff ◽

Valentine Brousse ◽

David Grevent ◽

Michel Zerah ◽

Olivier Naggara ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Sickle Cell ◽

Sickle Cell Anemia ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Brain Mri ◽

Posterior Circulation ◽

Moyamoya Syndrome ◽

Stenotic Lesion ◽

Concurrent Development

Abstract Abstract 4756 Background: Intracranial aneurysms in sickle-cell anemia (SCA) have been reported in about 50 adult patients, mostly presenting with subarachnoid hemorrhage (SAH). Aneurysms in those patients tend to be multiple (50%), to involve the posterior circulation more frequently than in the general population (33% vs 14%) and to be diagnosed at a younger age. In pediatric SCA patients, SAH has scarcely been reported, without evident link with stenotic cerebral vasculopathy. An associated intracranial aneurysm has only been demonstrated once in a teenager. Case reports: We report the cases of 2 children with sickle-cell anemia (HbSS) with intracranial aneurysms. The first patient was a 5-year old girl with abnormal transcranial Doppler (TCD) screening for cerebral vasculopathy: left middle cerebral artery time-averaged mean velocity (MCA TAMV) 208cm/sec, right MCA TAMV 196cm/sec. She had normal neurological assessment. On her brain MRA, no stenotic lesion was found within the Circle of Willis and the Internal Carotid arteries. A 6mm distal left posterior cerebral artery unruptured saccular aneurysm was observed. The brain MRI revealed a left thalamic lacunar infarction likely due to asymptomatic embolic infarction from the aneurysm. Longitudinal MR imaging showed spontaneous but incomplete thrombotic aneurysm occlusion. The second patient, an 11 year-old boy with slight cognitive delay and normal annual TCD procedures, presented with a non-traumatic SAH. Brain MRI showed several small silent cerebral infarctions in the white matter watershed territories. Brain MRA revealed multiple aneurysms without any stenotic lesion. A ruptured aneurysm was located on the basilar artery termination. Four unruptured aneurysms were found: 3 on the posterior cerebral arteries (1 right, 2 left) and 1 on the ophthalmic artery ostium. Endovascular coil embolization resulted in angiographic occlusion of the 2 accessible aneurysms. Clinical outcome was excellent. Discussion: Hemorrhagic strokes are more frequent than ischemic strokes in young adult SCA patients. Two main mechanisms are described: intracerebral or intraventricular hemorrhage due to major occlusive vasculopathy (moyamoya syndrome) or subarachnoid hemorrhage due to aneurysm rupture or leak. Our pediatric patients have no evidence for moyamoya syndrome. Their intracranial aneurysms bear similar characteristics with adult SCA patients': possibility of multiple aneurysms and posterior circulation involvement. They are observed at a very young age and are associated with mild cerebral vasculopathy: abnormal TCD without MRA stenosis in one case, silent cerebral infarcts without MRA stenosis in the other case. These findings plead for a possible concurrent development of vascular lesions leading either to ischemic or hemorrhagic stroke. This hypothesis is supported by similar histopathological findings in both aneurysms and cerebrovascular occlusive lesions in SCA: intimal hyperplasia, smooth-muscle layer hyalinization and elastic lamina fragmentation. This challenges the supposedly sequential pathophysiology of strokes in SCA, based on the high prevalence of infarctive strokes in children and hemorrhagic strokes in young adults. Conclusion: This report of pediatric intracranial aneurysms, associated with mild cerebral vasculopathy in both patients, supports the hypothesis of a common pathophysiological mechanism and the possible concurrent development of stenotic lesions and dilatations. This is also the first report of successful coil embolization in a pediatric SCA patient. Disclosures: No relevant conflicts of interest to declare.

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