Treatment of ruptured complex and large/giant ruptured cerebral aneurysms by acute coiling followed by staged flow diversion

OBJECT Flow-diversion treatment has been shown to be associated with high rates of angiographic obliteration; however, the treatment is relatively contraindicated in the acute phase following subarachnoid hemorrhage (SAH) as these patients require periprocedural dual antiplatelet therapy. Acute coiling followed by flow diversion has emerged as an intriguing and feasible treatment option for ruptured complex and giant aneurysms. In this study the authors report outcomes and complications of patients with ruptured aneurysms undergoing coiling in the acute phase followed by planned delayed flow diversion. METHODS This case series includes patients from 2 institutions. All patients underwent standard endovascular coiling in the acute phase after SAH with the intention and plan to proceed with flow diversion at a later date. Outcomes studied included angiographic occlusion, procedure-related complications, and long-term clinical outcome as measured using the modified Rankin Scale. RESULTS A total of 31 patients underwent coiling in the acute phase with the intention to undergo flow diversion at a later date. The mean aneurysm size was 15.8 ± 7.9 mm. Of the 31 patients undergoing coiling, 4 patients could not undergo further flow-diverter therapy: 3 patients (9.7%) died of complications of subarachnoid hemorrhage and 1 patient had permanent morbidity as a result of perioperative ischemic stroke (3.1%). Twenty-seven patients underwent staged placement of flow diverters after adequate recovery. The median time to treatment was 16 weeks. There was one case of aneurysm rebleeding following coil treatment. There were no cases of permanent morbidity or mortality resulting from flow-diverter treatment. Twenty-four patients underwent imaging follow-up; 18 of these patients had aneurysms that were completely or nearly completely occluded (58.1% on an intent-to-treat basis). At last follow-up (mean 18.3 months), 25 patients had mRS scores ≤ 2 (80.6% on an intent-to-treat basis). CONCLUSIONS Staged treatment of ruptured complex and giant intracranial aneurysms with coiling in the acute phase and flow-diverter treatment following recovery from SAH is both safe and effective. In this series, no cases of rebleeding occurred during the interval between coiling and flow diversion. This strategy should be considered as a valid option in patients presenting with these challenging ruptured aneurysms.

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Endovascular Treatment of Middle Cerebral Artery Aneurysms

Neurosurgery ◽

10.1227/neu.0b013e318201d7f4 ◽

2011 ◽

Vol 68 (2) ◽

pp. 397-402 ◽

Cited By ~ 49

Author(s):

Waleed Brinjikji ◽

Giuseppe Lanzino ◽

Harry J. Cloft ◽

Alejandro Rabinstein ◽

David F. Kallmes

Keyword(s):

Endovascular Treatment ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Case Series ◽

Endovascular Coiling ◽

Consecutive Case ◽

Treatment Rate ◽

Mortality And Morbidity ◽

Ruptured Aneurysms

Abstract BACKGROUND: Middle cerebral artery (MCA) aneurysms are often considered unsuitable for endovascular coiling because of unfavorable morphological features. With improvements in endovascular techniques, several series have detailed the results and complications of endovascular treatment of MCA aneurysms. OBJECTIVE: We performed a systematic review of published series on endovascular treatment of MCA aneurysms including our experience. METHODS: We conducted a computerized MEDLINE search of the literature on endovascular treatment of MCA aneurysms. Only studies examining a consecutive case series of MCA aneurysms were included. We then extracted information regarding intraprocedural complications, procedural mortality and morbidity, immediate and long-term angiographic outcomes, and re-treatment rate. Analysis was done including 40 MCA aneurysms treated at our institution. RESULTS: Twelve studies including our institution's consecutive case series were included. Approximately 50% of the aneurysms presented as ruptured. Intraprocedural rupture rate in unruptured aneurysms was 1.7% (95% confidence interval [CI] = 0.7%-3.6%) compared with 4.8% (95% CI = 3.1%-7.4%) for ruptured aneurysms (P = .02). The risk of early postprocedural hemorrhage was 1.1% (95% CI = 0.5%-2.5%) for ruptured aneurysms. Overall procedure-related permanent morbidity and mortality were 5.1% and 6.0% for unruptured and ruptured aneurysms, respectively. The overall rate of complete or near-complete obliteration at angiographic follow-up was 82.4%. CONCLUSION: Endovascular treatment of MCA aneurysms is feasible and effective in selected cases. The combined periprocedural mortality and morbidity is not negligible (5.1%) and the overall rate of complete or near-complete angiographic obliteration at follow-up approaches 82%.

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Competitive flow diversion of multiple P1 aneurysms: proposed classification

BMJ Case Reports ◽

10.1136/bcr-2019-015581 ◽

2020 ◽

Vol 13 (6) ◽

pp. e015581

Author(s):

Mark Alexander MacLean ◽

Thien J Huynh ◽

Matthias Helge Schmidt ◽

Vitor M Pereira ◽

Adrienne Weeks

Keyword(s):

Subarachnoid Hemorrhage ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Cerebral Artery ◽

Internal Carotid ◽

Posterior Cerebral Artery ◽

Flow Diversion ◽

Endovascular Coiling ◽

Ruptured Aneurysms ◽

The Right

We report the case of a patient with subarachnoid hemorrhage and three aneurysms arising from the posterior communicating artery (Pcomm)-P1 complex, treated with endovascular coiling and competitive flow diversion. The largest and likely ruptured Pcomm aneurysm was treated with traditional coiling. Two smaller potentially ruptured aneurysms arose from the distal right posterior cerebral artery (PCA) P1 segment. After a failed attempt to treat with conventional flow diversion across the PCA-P1 segment, the P1 aneurysms were successfully treated with competitive flow diversion distal to the PCA-P1 segment from Pcomm to the P2 segment. Over 12 months, competitive flow diversion redirected flow to the right PCA territory via the internal carotid artery-Pcomm-P2, reducing the size of the PCA-P1 segment and obliterating the P1 aneurysms. Competitive flow diversion treatment should be considered for aneurysms occurring at the circle of Willis when traditional methods are not feasible. Herein, we introduce a novel classification for competitive flow diversion treatment.

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Coil Embolization of Unruptured Middle Cerebral Artery Aneurysms

Neurosurgery ◽

10.1227/neu.0b013e3182035fdc ◽

2011 ◽

Vol 68 (2) ◽

pp. 346-354 ◽

Cited By ~ 33

Author(s):

Byung Moon Kim ◽

Dong Ik Kim ◽

Sung Il Park ◽

Dong Joon Kim ◽

Sang Hyun Suh ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Primary Treatment ◽

Aneurysm Rupture ◽

Endovascular Coiling ◽

Unruptured Aneurysms ◽

Permanent Morbidity ◽

Middle Cerebral Artery Aneurysms

Abstract BACKGROUND: Since the International Subarachnoid Aneurysmal Trial, endovascular coiling has been increasingly used as primary treatment option for ruptured or unruptured aneurysms that are feasible for coiling. OBJECTIVE: To evaluate the feasibility and clinical and angiographic outcomes of coiling for unruptured middle cerebral artery aneurysms. METHODS: The records of 70 consecutive patients with 76 unruptured middle cerebral artery aneurysms who underwent coiling were retrospectively evaluated. RESULTS: Thirty-one aneurysms were treated by single-catheter, 18 by multicatheter, 11 by balloon-assisted, 13 by stent-assisted, and 3 by a combination of multicatheter and balloon-assisted techniques. Coiling was accomplished in 75 but failed in 1 aneurysm. One patient died of consequences of subarachnoid hemorrhage occurring 9 hours after coiling. One intraprocedural aneurysm rupture occurred, which was controlled by further coil insertions and left no sequelae. There were 1 cortical infarction and 1 basal ganglia infarction, both of which recovered completely. Treatment-related permanent morbidity and mortality rates were 0% and 1.4%, respectively. Postembolization control angiography revealed 40 complete, 30 neck remnant, and 5 incomplete occlusions. Clinical follow-up was available in all patients (mean, 25 months; range, 7-105 months). There was no subarachnoid hemorrhage during follow-up, but 1 death resulting from acute myocardial infarction occurred 3 months after coiling. None of the surviving patients had any neurological deterioration. Follow-up angiography was available in 69 aneurysms at 6 to 24 months (mean, 12 months). Three major and 6 minor recurrences were detected. All 3 major recurrent aneurysms were re-treated by coiling without any complications. CONCLUSION: Most unruptured middle cerebral artery aneurysms could be safely treated by coiling with acceptable short-term to midterm outcomes. Our results warrant further study with a longer follow-up period in a larger population.

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Flow-diverter stents in the early management of acutely ruptured brain aneurysms: effective rebleeding protection with low thromboembolic complications

Journal of Neurosurgery ◽

10.3171/2020.10.jns201642 ◽

2021 ◽

pp. 1-8

Author(s):

José E. Cohen ◽

J. Moshe Gomori ◽

Samuel Moscovici ◽

Andrew H. Kaye ◽

Yigal Shoshan ◽

...

Keyword(s):

Thrombus Formation ◽

Flow Diverter ◽

Flow Diversion ◽

Complication Rates ◽

Imaging Data ◽

Total Occlusion ◽

Early Management ◽

Ruptured Aneurysms ◽

Aneurysm Occlusion

OBJECTIVE Flow-diverter stents (FDSs) are not generally used for the management of acutely ruptured aneurysms with associated subarachnoid hemorrhage (SAH). Herein, the authors present their experience with FDSs in this scenario, focusing on the antiplatelet regimen, perioperative management, and outcome. METHODS The authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured aneurysms and associated SAH from July 2010 to September 2018 who had received an FDS implant as stand-alone treatment within 4 days after diagnosis. The protocol with the use of flow diversion in these patients includes a low threshold for placement of external ventricular drains before stenting, followed by the administration of aspirin and clopidogrel with platelet testing before stent implantation. With this approach, the risk of hemorrhage and stent-related thrombus formation is limited. Demographic, clinical, technical, and imaging data were analyzed. RESULTS Overall, 76 patients (61% females, mean age 42.8 ± 11.3 years) met the inclusion criteria. FDS implantation was performed a median of 2 days after diagnosis. On average, 1.05 devices were used per procedure. There was no procedural mortality directly attributed to the endovascular intervention. Procedural device-related clinical complications were recorded in a total of 6 cases (7.9%) and resulted in permanent neurological morbidity in 2 cases (2.6%). There was complete immediate aneurysm occlusion in 11 patients (14.5%), and persistent aneurysm filling was seen in 65 patients (85.5%). Despite this, no patient presented with rebleeding from the target aneurysm. There was an excellent clinical outcome in 62 patients (81.6%), who had a 90-day modified Rankin Scale score of 0–2. Among the 71 survivors, total or near-total occlusion was observed in 64/67 patients (95.5%) with a 3- to 6-month angiographic follow-up and in all cases evaluated at 12 months. Five patients (6.6%) died during follow-up for reasons unrelated to the procedure or new hemorrhage. CONCLUSIONS Flow diversion is an effective therapeutic strategy for the management of select acutely ruptured aneurysms. Despite low rates of immediate aneurysm occlusion after FDS implantation, the device exerts an important protective effect. The authors’ experience confirmed no aneurysm rerupture, high rates of delayed complete occlusion, and complication rates that compare favorably with the rates obtained using other techniques.

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Republished: Competitive flow diversion of multiple P1 aneurysms: proposed classification

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015581.rep ◽

2020 ◽

Vol 12 (9) ◽

pp. e7-e7

Author(s):

Mark Alexander MacLean ◽

Thien J Huynh ◽

Matthias Helge Schmidt ◽

Vitor M Pereira ◽

Adrienne Weeks

Keyword(s):

Subarachnoid Hemorrhage ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Cerebral Artery ◽

Internal Carotid ◽

Posterior Cerebral Artery ◽

Flow Diversion ◽

Endovascular Coiling ◽

Ruptured Aneurysms ◽

The Right

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Stent and flow diverter assisted treatment of acutely ruptured brain aneurysms

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013742 ◽

2018 ◽

Vol 10 (9) ◽

pp. 851-858 ◽

Cited By ~ 17

Author(s):

José E Cohen ◽

J Moshe Gomori ◽

Ronen R Leker ◽

Sergey Spektor ◽

Hosni Abu El Hassan ◽

...

Keyword(s):

Acute Phase ◽

Antiplatelet Agents ◽

Flow Diverter ◽

Thromboembolic Complications ◽

Inclusion Criteria ◽

Unruptured Aneurysms ◽

Ruptured Aneurysms ◽

Aneurysm Occlusion ◽

Clinical Records

ObjectiveWe present our experience with stent techniques in the management of acutely ruptured aneurysms, focusing on aneurysm occlusion rates, intraprocedural complications, and late outcomes.MethodsWe retrospectively reviewed the clinical records of patients treated by stent techniques during the early acute phase of aneurysmal rupture, from June 2011 to June 2016. Patients who underwent stenting for the management of unruptured aneurysms, or in a delayed fashion for a ruptured lesion, were excluded.Results47 patients met inclusion criteria, including 46 with subarachnoid hemorrhage (SAH). There were 27 men and 20 women, mean age 38 years (range 23–73). They harbored 71 aneurysms, including 56 treated in the acute phase. Aneurysmal dome and neck width averaged 4.7 mm (range 1.7–12.1) and 3.2 mm (range 1.5–7.1), respectively. Single stent techniques were used in 39 patients and dual stent techniques in 17. External ventricular drains (EVDs) were placed before embolization in 35 patients (92%) and after in 3. Intraprocedure thromboembolic complications due to a hyporesponse to antiplatlets in 4 patients (8.5%) were successfully managed with intra-arterial antiplatelet agents. In 45 surviving patients (96%), there was complete aneurysm occlusion at the 9–12 month follow-up in 26/29 aneurysms treated by stent-assisted coiling (90%), in 2/3 aneurysms treated by flow diverter-assisted coiling (66%), and in 19/22 aneurysms treated by flow diverter alone (86%); 42/45 patients (93%) presented with a modified Rankin Scale score of 0–2.ConclusionStenting techniques in ruptured aneurysms can be performed with good technical success; however, procedural thromboembolic complications related to the antiplatelet strategy merit investigation. EVD placement before stenting must be considered.

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Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: complications, aneurysm sac occlusion, reabsorption, recurrence, and jailed branch modification at follow-up

Journal of Neurosurgery ◽

10.3171/2018.7.jns18654 ◽

2019 ◽

Vol 131 (6) ◽

pp. 1751-1762 ◽

Cited By ~ 8

Author(s):

Caterina Michelozzi ◽

Jean Darcourt ◽

Adrien Guenego ◽

Anne-Christine Januel ◽

Philippe Tall ◽

...

Keyword(s):

Flow Diverter ◽

Flow Diversion ◽

Anterior Communicating Artery ◽

Ischemic Complications ◽

Delayed Complications ◽

Permanent Morbidity ◽

Occlusion Rate ◽

The Mean ◽

Weighted Sequences

OBJECTIVEThe purpose of this study is to present the authors’ medium-term results, with special emphasis on complications, occlusion rate of the aneurysm sac (digital subtraction angiography [DSA] and MRI), and the fate of cortical branches and perforating arteries covered (“jailed”) by the flow diverter (FD) stent.METHODSBetween January 2010 and September 2017, 29 patients (14 female) with 30 aneurysms were treated with an FD stent. Twenty-one aneurysms were at the middle cerebral artery bifurcation, 8 were in the anterior communicating artery region, and 1 was a pericallosal artery bifurcation. Thirty-five cortical branches were covered. A single FD stent was used in all patients. Symptomatic and asymptomatic periprocedural and delayed complications were reported. DSA and MRI controls were analyzed to evaluate modification of the aneurysm sac and jailed branches.RESULTSPermanent morbidity was 3.4% (1/29), due to a jailed branch occlusion, with a modified Rankin Scale (mRS) score of 2 at the last follow-up. Mortality and permanent complication with poor prognosis (mRS score > 2) rates were 0%. The mean follow-up time for DSA and MRI (mean ± SD) was 21 ± 14.5 months (range 3–66 months) and 19 ± 16 months (range 3–41 months), respectively. The mean time to aneurysm sac occlusion (available for 24 patients), including stable remodeling, was 11.8 ± 6 months (median 13, range 3–27 months). The overall occlusion rate was 82.1% (23/28), and it was 91.7% (22/24) in the group of patients with at least 2 DSA control sequences. One recanalization occurred at 41 months posttreatment. At the time of publication, at the latest follow-up, 7 (20%) of 35 covered branches were occluded, 18 (51.4%) showed a decreased caliber, and the remaining 10 (28.5%) were unchanged. MRI T2-weighted sequences showed complete sac reabsorption in 7/29 aneurysms (24.1%), and the remaining lesions were either smaller (55.2%) or unchanged (17.2%). MRI revealed asymptomatic and symptomatic ischemic events in perforator territories in 7/28 (25%) and 4/28 (14.3%) patients, respectively, which were reversible within 24 hours.CONCLUSIONSFlow diversion of bifurcation aneurysms is feasible, with low rates of permanent morbidity and mortality and high occlusion rates; however, recurrence may occur. Caliber reduction and asymptomatic occlusion of covered cortical branches as well as silent perforator stroke are common. Ischemic complications may occur with no identified predictable factors. MRI controls should be required in all patients to evaluate silent ischemic lesions and aneurysm sac reabsorption over time.

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Association of Refractory Pain in the Acute Phase After Subarachnoid Hemorrhage with Continued Outpatient Opioid Use

Neurology ◽

10.1212/wnl.0000000000011906 ◽

2021 ◽

pp. 10.1212/WNL.0000000000011906

Author(s):

Matthew N. Jaffa ◽

Jamie E. Podell ◽

Madeleine C. Smith ◽

Arshom Foroutan ◽

Adam Kardon ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Ethnic Minority ◽

Acute Phase ◽

Acute Illness ◽

Minority Status ◽

Opioid Use ◽

Opioid Dose ◽

Refractory Pain ◽

Racial Ethnic

ObjectiveLittle is known about the prevalence of continued opioid use following aneurysmal subarachnoid hemorrhage (aSAH) despite guidelines recommending their use during the acute phase of disease. We sought to determine prevalence of opioid use following aSAH and test the hypothesis that acute pain and higher inpatient opioid dose increased outpatient opioid use.MethodsWe reviewed consecutively admitted aSAH patients from November 2015 through September 2019. We retrospectively collected pain scores and daily doses of analgesics. Pain burden was calculated as area under the pain-time curve. Univariate and multivariable regression models determined risk factors for continued opioid use at discharge and outpatient follow-up.ResultsWe identified 234 aSAH patients with outpatient follow-up. Continued opioid use was common at discharge (55% of patients) and follow-up (47% of patients, median 63 (IQR 49–96) days from admission). Pain burden, craniotomy, and racial-ethnic minority status were associated with discharge opioid prescription in multivariable analysis. At outpatient follow-up, pain burden (OR 1.88, 95% CI 1.5–2.4), depression (OR 3.1, 95% CI 1.1–8.8), and racial-ethnic minority status (OR 2.1, 95% CI 1.1–4.0) were independently associated with continued opioid use while inpatient opioid dose was not.ConclusionContinued opioid use following aSAH is prevalent and related to refractory pain during acute illness, but not inpatient opioid dose. More efficacious analgesic strategies are needed to reduce continued opioid use in patients following aSAH.Classification of evidenceThis study provides Class II evidence that continued opioid use following aSAH is associated with refractory pain during acute illness but not hospital opioid exposure.

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Bilateral subdural hygromas after endovascular coiling for ruptured aneurysmal subarachnoid hemorrhage: an unusual and rare complication

Oxford Medical Case Reports ◽

10.1093/omcr/omab062 ◽

2021 ◽

Vol 2021 (8) ◽

Author(s):

Walid O Ahmed ◽

Shady N Mashhour ◽

Marwa E Abdelfattah

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Rare Complication ◽

Mass Effect ◽

Contralateral Side ◽

Endovascular Coiling ◽

Neurological Assessment ◽

Ruptured Intracranial Aneurysm ◽

Significant Mass Effect

ABSTRACT Subarachnoid hemorrhage (SAH) with subdural hygroma (SH) was rarely reported after endovascular coiling. A 60-year-old male presented with impaired consciousness and convulsions due to SAH from a ruptured aneurysm. It was managed by endovascular coiling 20 h after the onset of symptoms. Serial brain imaging for 2 weeks revealed progressive bilateral SHs, more on contralateral side of leaking aneurysm. Management of SH was discussed in a multidisciplinary setting to be conservative as there was neither significant mass effect nor hydrocephalus. The patient recovered neurologically except for mild dysarthria. The SH persisted for 2 months and then cleared gradually. We concluded that SH may arise and become symptomatic as an unusual sequela of post-coiling of a ruptured intracranial aneurysm, in which the SH can complicate the clinical course of SAH. However, the symptomatic SH may resolve spontaneously and completely without any intervention, but needs meticulous neurological assessment and follow-up.

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WEB device for treatment of posterior communicating artery aneurysms

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017405 ◽

2021 ◽

pp. neurintsurg-2021-017405

Author(s):

Guilherme Aguiar ◽

Jildaz Caroff ◽

Cristian Mihalea ◽

Jonathan Cortese ◽

Jean-Baptiste Girot ◽

...

Keyword(s):

Case Series ◽

Posterior Communicating Artery ◽

Neck Size ◽

Ruptured Aneurysms ◽

Antiplatelet Medication ◽

Woven Endobridge ◽

Web Device ◽

Intraoperative Rupture ◽

Wide Neck

BackgroundWoven EndoBridge (WEB) device treatment of wide-neck bifurcation aneurysms has proved to be safe and effective, but the use of these devices in sidewall aneurysms has been reported only in a small number of case series.ObjectiveTo report our results in a cohort of consecutive patients in whom a WEB device was used as first-line treatment for posterior communicating artery (PComA) aneurysms.MethodsWe conducted a retrospective analysis of a prospectively maintained database of PComA aneurysms treated with a WEB device in our institution from June 1, 2012 to November 15, 2020. Clinical and radiological findings were evaluated at immediate and last follow-up.ResultsA total of 219 aneurysms were treated with a WEB device, including 15 PComA aneurysms in 15 patients, 10 of which were ruptured. Aneurysms were wide necked, with a mean aspect ratio of 1.6 (range 0.7–3.0) and a mean neck size of 4.2 mm (range 2.6–7.4 mm). No intraoperative rupture occurred and only one thromboembolic event was noted. Among the group with at least a 3-month digital subtraction angiography (DSA) follow-up, complete and adequate occlusion were obtained in 54% and 72%, respectively (average follow-up 13 months). Re-treatment was needed for two initially ruptured aneurysms. No procedure-related morbidity or mortality was reported.ConclusionThis series suggests the high safety profile of WEB devices even when used in off-label indications. Treatment with these devices seems to be a valuable strategy for ruptured wide-neck PComA aneurysms, avoiding the need for antiplatelet medication. However, occlusion rates should be investigated in further larger studies.

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