Hematoma expansion unrelated to rebleeding in ruptured anterior cerebral artery aneurysms treated by early endovascular embolization

Background: Whether hematoma expansion after aneurysmal rupture is always a sign of rerupture remains unclear. Hence, the present study aimed to assess the incidence and risk factors of hematoma expansion unrelated to aneurysmal rerupture after endovascular embolization for ruptured cerebral aneurysms. Methods: We included patients who underwent endovascular embolization for ruptured cerebral aneurysms within 48 h after onset at our institution between January 2009 and February 2014. The medical records of 70 consecutive patients were reviewed and analyzed retrospectively. Results: Hematoma expansion unrelated to aneurysmal rerupture occurred in 7 (10%) of 70 patients. Interestingly, four of seven patients had distal anterior cerebral artery (ACA) aneurysms. The interval from onset to aneurysm coiling was shorter in patients with hematoma expansion than in those without (P = 0.040). Conclusion: Early embolization of ruptured ACA aneurysms might increase the risk of hematoma expansion unrelated to aneurysmal rerupture because the procedures were conducted under systemic anticoagulation. It would be better to refer the patient for direct clipping if the patient has a distal ACA aneurysm with parenchymal hematoma at interhemispheric fissure. Delayed coil embolization, which means around 12–18 h delayed, might be another option for ruptured distal ACA aneurysms to prevent hematoma expansion.

Parent artery stenting as a rescue management for stretched coils during cerebral aneurysms embolization: Report of three cases and review of literature

Background Displacement of a stretched coil into the parent artery during intracranial aneurysm coiling is a challenging situation where the risk of acute intravascular thrombosis might be a life-threatening condition. The usual way of management is coil snaring, yet in some cases, it might not be feasible to retrieve the coil. Parent artery rescue stenting had already been described as a way of management in acutely thrombosed parent arteries during aneurysm coiling. Case reports We present three cases with an inadvertent displacement of the unraveled coils into the parent artery for which rescue stenting was carried out to crush the coil against the vessel wall aiming to eliminate its thrombogenic effect. Our preliminary experience is that rescue stenting of the parent artery for stretched coil could be a convenient effective option particularly in case of failed/risky snaring with no notable immediate or long-term complications. Review and discussion We review the reported cases of stretched coils with or without further unraveling and fracture and discuss the possible consequences, salvage methods, and clinical outcomes. Neurointerventionists should be aware of this complication and get acquainted with bailout strategies.

Stereotactic direct-coiling of aneurysms—a feasibility study

Aim of the study Endovascular coiling has gained worldwide acceptance in the management of intracranial aneurysms. However, not all aneurysms can be coiled. Direct aneurysm puncture with aneurysm thrombosis has been performed, using coils for extracranial aneurysms and iron filings for intracranial aneurysms. Therefore, the feasibility of stereotactic aneurysm coiling with direct aneurysm puncture using Nester-coils was studied in an in vitro model. Methods and findings Twenty-eight aneurysms measuring 9–21 mm in diameters (median 14 mm) were made using 0.1 mm vinyl film that was connected to a monometer with 73 cm of water column. Twenty-three aneurysms were coiled through direct puncture of the aneurysms using a stereotactic frame. Five were coiled using a hand-held probe carrier. Statistical analysis of the data was conducted by data analysis feature of Microsoft Excel. Findings The study showed that needle puncture of the aneurysm and coiling of the aneurysm through the needle can be done with ease and without any significant fluid leak from the puncture site. It also shows that the coil will stay within the aneurysm without entering the neck. The study also shows that this method can be done using free-hand technique. Furthermore, it shows that the probe holder for the needle can also be used as an aneurysm stabilizer and as a tamponade.

Monitoring Radiation Doses during Diagnostic and Therapeutic Neurointerventional Procedures: Multicenter Study for Establishment of Reference Levels

Purpose: To assess patient radiation doses during diagnostic and therapeutic neurointerventional procedures from multiple centers and propose dose reference level (RL).Materials and Methods: Consecutive neurointerventional procedures, performed in 22 hospitals from December 2020 to June 2021, were retrospectively studied. We collected data from a sample of 429 diagnostic and 731 therapeutic procedures. Parameters including dose-area product (DAP), cumulative air kerma (CAK), fluoroscopic time (FT), and total number of image frames (NI) were obtained. RL were calculated as the 3rd quartiles of the distribution.Results: Analysis of 1160 procedures from 22 hospitals confirmed the large variability in patient dose for similar procedures. RLs in terms of DAP, CAK, FT, and NI were 101.6 Gy·cm², 711.3 mGy, 13.3 minutes, and 637 frames for cerebral angiography, 199.9 Gy·cm², 3,458.7 mGy, 57.3 minutes, and 1,000 frames for aneurysm coiling, 225.1 Gy·cm², 1,590 mGy, 44.7 minutes, and 800 frames for stroke thrombolysis, 412.3 Gy·cm², 4,447.8 mGy, 99.3 minutes, and 1,621.3 frames for arteriovenous malformation (AVM) embolization, respectively. For all procedures, the results were comparable to most of those already published. Statistical analysis showed male and presence of procedural complications were significant factors in aneurysmal coiling. Male, number of passages, and procedural combined technique were significant factors in stroke thrombolysis. In AVM embolization, a significantly higher radiation dose was found in the definitive endovascular cure group.Conclusion: Various RLs introduced in this study promote the optimization of patient doses in diagnostic and therapeutic interventional neuroradiology procedures. Proposed 3rd quartile DAP (Gy·cm²) values were 101.6 for diagnostic cerebral angiography, 199.9 for aneurysm coiling, 225.1 for stroke thrombolysis, and 412.3 for AVM embolization. Continual evolution of practices and technologies requires regular updates of RLs.

Coaxial Access for Microcatheter Stabilization During Aneurysm Coiling: 2-Dimensional Operative Video

Coaxial support is a fundamental technique utilized by neurointerventionalists to optimize distal catheter control within the intracranial circulation. Here we present a 41-yr-old woman with a previously coiled ruptured anterior communicating artery aneurysm with progressive recurrence harboring tortuous internal carotid anatomy to demonstrate the utility of coaxial support. Raymond-Roy classification of initial aneurysm coiling of class 1 resulted as class 3b over the 21 mo from initial treatment.1 The patient consented to stent-assisted coiling for retreatment of this aneurysm. Coaxial support was advanced as distally as possible in the proximal vasculature to improve catheter control, reducing dead space within which the microcatheter could move, decreasing angulations within proximal vasculature, limiting the movement of the native vessels, and providing a surface of lower friction than the endothelium. As the risk of recurrent subarachnoid hemorrhage in previously treated coiled aneurysms approaches 3%, retreatment occurs in 16.4% within 6 yr2 and in 17.4% of patients within 10 yr.3 Rerupture is slightly higher in patients who underwent coiling vs clipping, with the rerupture risk inversely proportional to the degree of aneurysm occlusion,4 further substantiating that coaxial support provides technical advantage in selected patients where additional microcatheter control is necessary for optimal occlusion. Pitfalls of this technique include vasospasm and vascular injury, which can be ameliorated by pretreatment of the circulation with vasodilators to prevent catheter-induced vasospasm. This case and model demonstration illustrates the technique of coaxial access in the stent-assisted coiling of a recurrent anterior communicating artery aneurysm and identification and management of catheter-induced vasospasm.

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID-19 pandemic

BackgroundDuring the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study’s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.MethodsWe conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March–31 May 2020. The prior 1-year control period (1 March–31 May 2019) was obtained to account for seasonal variation.FindingsThere was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI −24.3% to −20.7%, p<0.0001). Embolisation of ruptured aneurysms declined with 1170–1035 procedures, respectively, representing an 11.5% (95%CI −13.5% to −9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI −28.0% to −22.1%, p<0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile.InterpretationThere was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

Abstract 14: Global Impact of the Covid-19 Pandemic on Subarachnoid Hemorrhage

Introduction: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The objective was to examine whether subarachnoid hemorrhage(SAH) hospitalizations and ruptured aneurysm coiling interventions demonstrated similar declines. Methods: We conducted a global, retrospective, observational study across 6 continents, 37 countries, and 140 comprehensive stroke centers. Patients with diagnosis of SAH, ruptured aneurysm coiling interventions, COVID-19 were identified using ICD-10 codes or by prospectively maintained stroke databases. The 3-month cumulative volume, monthly volumes for SAH hospitalizations and ruptured aneurysm coiling procedures were compared for the period before (1-year and immediately before) and during the COVID-19 pandemic (March 1 to May 31, 2020). Results: There was a significant decline in SAH hospitalizations with 2,044 admissions in the 3 months immediately before and 1,585 admissions during the pandemic, representing a decline of 22.5% (95%CI, -24.3 to -20.7, p<0.0001). Embolization of ruptured aneurysms declined with 1,170 to 1,035 procedures, respectively, representing an 11.5%(95%CI, -13.5 to -9.8, p=0.002) drop. Hospitals with higher COVID-19 hospitalization burden demonstrated greater declines in SAH and ruptured aneurysm coiling compared to lower COVID-19 burden. A relative increase in coiling of ruptured aneurysms was noted in low coiling volume hospitals of 41.1% (95%CI, 32.3-50.6, p=0.008) despite a decrease in SAH admissions in this tertile. Conclusions: There was a global decrease in subarachnoid hemorrhage admissions and ruptured aneurysm embolizations during the COVID-19 pandemic. Among low-volume coiling SAH hospitals, there was an increase in the ruptured aneurysm coiling intervention. These findings in SAH are consistent with a global decrease in other emergencies such as stroke and myocardial infarction.*On behalf of the SVIN COVID-19 Collaborators

Management of Thromboembolic Complications During Aneurysm Coiling: 2-Dimensional Operative Video

Thromboembolic complications during aneurysm coiling are rare, with higher rates noted in ruptured aneurysms as patients are not usually premedicated with dual antiplatelet therapy.1,2 Management includes a series of escalating strategies, including medical therapy and intra-arterial thrombolysis.3-6 Additional strategies include mechanical thrombectomy with suction aspiration and stent retrievers.3 Intracranial stenting can be used as a last resource, especially in ruptured cases given the need for dual antiplatelets to prevent stent thrombosis.2 We present the case of a 42-yr-old man with a ruptured left internal carotid artery aneurysm with associated intracranial and intraventricular hemorrhage. The patient was initially presented to an outside facility after he was found in bed unable to speak and with right hemiparesis. The patient consented for surgery and underwent external ventricular drain (EVD) placement for the treatment of obstructive hydrocephalus, followed by diagnostic cerebral angiogram and aneurysm coiling. After the deployment of the last coil, control angiogram showed a small filling defect at the interface between the aneurysm neck and the distal vessel. The patient received intravenous heparin for therapeutic ACT and aspirin load. After progressive enlargement of the thrombus, the patient received intra-arterial glycoprotein (GP) IIB/IIIA inhibitors with a microcatheter positioned proximal to the thrombus. As the thrombus mass continued to enlarge, mechanical thrombectomy with an aspiration catheter was performed twice. Follow-up angiogram 20 min after the second aspiration demonstrated near-complete resolution of the thrombus. The patient recovered from his right hemiparesis, and he was discharged to rehabilitation on POD #21.