Procedural complications of coiling of ruptured intracranial aneurysms: incidence and risk factors in a consecutive series of 681 patients

BACKGROUND AND PURPOSE: To report the incidence of procedural complications of coiling of ruptured intracranial aneurysms leading to permanent disability or death in a consecutive series of 681 patients and to identify risk factors for these events. PATIENTS AND METHODS: Between January 1995 and July 2005, 681 consecutive patients with ruptured intracranial aneurysms were treated with detachable coils. Procedural complications (aneurysm rupture or thromboembolic) of coiling leading to death or neurologic disability at the time of hospital discharge were recorded. For patients with procedural complications, odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated for the following patient and aneurysm characteristics: patient age and sex, use of a supporting balloon, aneurysm location, timing of treatment, clinical condition at the time of treatment, and aneurysm size. RESULTS: Procedural complications occurred in 40 of 681 patients (5.87%; 95% CI, 4.2% to 7.9%), leading to death in 18 patients (procedural mortality, 2.6%; 95% CI, 1.6% to 4.2%) and to disability in 22 patients (procedural morbidity, 3.2%; 95% CI, 2.0% to 4.9%). There were 8 procedural ruptures and 32 thromboembolic complications. The use of a temporary supporting balloon was the only significant risk factor (OR, 5.1; 95% CI, 2.3 to 15.3%) for the occurrence of procedural complications. CONCLUSION: Procedural complication rate of coiling of ruptured aneurysms leading to disability or death is 5.9%. In this series, the use of a temporary supporting balloon in the treatment of wide-necked aneurysms was the only risk factor for the occurrence of complications.     

Abciximab for thrombolysis during intracranial aneurysm coiling

Introduction  Thrombotic events are a common and severe complication of endovascular aneurysm treatment with significant impact on patients’ outcome. This study evaluates risk factors for thrombus formation and assesses the efficacy and safety of abciximab for clot dissolution. Materials and methods  All patients treated with abciximab during (41 patients) or shortly after (22 patients) intracranial aneurysm coil embolisation were retrieved from the institutional database (2000 to 2007, 1,250 patients). Sixty-three patients (mean age, 55.3 years, ±12.8) had received either intra-arterial or intravenous abciximab. Risk factors for clot formation were assessed and the angiographic and clinical outcome evaluated. Results  No aneurysm rupture occurred during or after abciximab application. The intra-procedural rate of total recanalisation was 68.3%. Thromboembolic complications were frequently found in aneurysms of the Acom complex and of the basilar artery, whilst internal carotid artery aneurysms were underrepresented. Two patients died of treatment-related intracranial haemorrhages into preexisting cerebral infarcts. Two patients developed a symptomatic groin haematoma. Conclusions  Abciximab is efficacious and safe for thrombolysis during and after endovascular intracranial aneurysm treatment in the absence of preexisting ischaemic stroke.     

Initial experience with the use of intravenous eptifibatide bolus during endovascular treatment of intracranial aneurysms

BACKGROUND AND PURPOSE: Despite systemic heparinization, thromboembolic complications remain a major concern related to endovascular treatment of intracranial aneurysms. We assessed the safety of intravenous eptifibatide administered during aneurysm coiling procedures to prevent such complications. METHODS: From August 2001 to November 2004, 298 coil embolization procedures were performed to treat intracranial aneurysms; eptifibatide was used in 84 endovascular coil embolization procedures to treat 79 aneurysms in 74 patients. We retrospectively reviewed medical charts, radiographic images, and procedure notes to evaluate periprocedural complications related to eptifibatide. RESULTS: The mean age of the 74 patients in our cohort was 55 +/- 9 years (range, 31-84) harboring 79 aneurysms (32 ruptured/47 unruptured). Eptifibatide was given prophylactically in 77 procedures, whereas in 7 procedures, it was given for treatment of a thromboembolic event (visualization of an arterial branch occlusion). A total of 5 (5.9% [total cohort]) bleeding complications related to eptifibatide occurred during 84 procedures. Two patients (2.4% [total cohort]/6.3% [ruptured group]) developed intracerebral hemorrhagic complications exacerbated by eptifibatide. The other 3 (3.6% [total cohort]) patients had groin hematomas requiring blood transfusions but had no surgical intervention. One thromboembolic event occurred in the 77 patients receiving eptifibatide prophylactically. CONCLUSIONS: Intravenous infusion of eptifibatide seems to be safe to administer in patients undergoing endovascular repair of an unruptured cerebral aneurysm. Caution must be used in patients harboring ruptured aneurysms as intracranial bleeding complications may occur. Further study is required to delineate the group of patients most likely to benefit from this therapy.     

Safety and Efficacy of Intravenous Tirofiban as Antiplatelet Premedication for Stent-Assisted Coiling in Acutely Ruptured Intracranial Aneurysms

BACKGROUND AND PURPOSE:Stent-assisted coiling of intracranial aneurysms requires antiplatelet therapy, typically aspirin and clopidogrel to prevent thromboembolic complications. There is a substantial concern that tirofiban may increase the risk of hemorrhage when used as an antiplatelet premedication in ruptured intracranial aneurysms. Our aim was to evaluate the safety and efficacy of intravenous tirofiban administration, instead of oral dual antiplatelet agents, as an antiplatelet premedication for stent-assisted coiling in patients with acutely ruptured intracranial aneurysms.MATERIALS AND METHODS:We conducted a retrospective review of a data base containing a consecutive series of patients who underwent stent-assisted coiling for acutely ruptured intracranial aneurysms between March 2010 and January 2015. Intravenous tirofiban was administered to all patients before stent-assisted coiling, instead of premedication with loading doses of aspirin or clopidogrel.RESULTS:Forty patients with 41 aneurysms received intravenous tirofiban and underwent stent-assisted coiling. None of the patients had a newly developed intracerebral hemorrhage, subarachnoid hemorrhage, or intraventricular hemorrhage. Intraprocedural aneurysmal rupture occurred in 2 patients (5%). Cerebral infarction developed in 2 patients (5%). Ventriculostomy-related hemorrhage was seen in 2 of 10 patients in whom ventriculostomy was performed before or after coiling. Thirty-four (85%) patients had a good outcome (Glasgow Outcome Score of 4 or 5) at the time of discharge, but 1 patient died of cardiac arrest. None of the patients developed thrombocytopenia, retroperitoneal, gastrointestinal, or genitourinary bleeding related to tirofiban administration.CONCLUSIONS:In our study, tirofiban showed a low risk of symptomatic hemorrhagic or thromboembolic complications. Tirofiban may offer a safe and effective alternative as an antiplatelet premedication during stent-assisted coiling of acutely ruptured intracranial aneurysms.

Results from the International Subarachnoid Aneurysm Trial showed that the endovascular management of intracranial aneurysm is a safe, effective, and sometimes preferable treatment option.¹ However, endovascular treatment of ruptured wide-neck aneurysms is still a challenge to neurointerventionalists because of the controversy surrounding the use of stent placement as an adjuvant therapy for the coiling of acutely ruptured aneurysms, due to the need for antiplatelet medications. Stent-assisted procedures are particularly prone to thromboembolic complications, with a reported rate of thromboembolic events of 7%–15% during stent-assisted coiling.^2–4 Therefore, there is a need for preoperative antiplatelet therapy with optimal anticoagulation during the procedures, even with subarachnoid hemorrhage. However, there is no consensus about when and how patients should be loaded with antiplatelet medication before the procedure.Glycoprotein IIb/IIIa antagonists have attracted attention for the prevention or treatment of thromboembolism during coiling of intracranial aneurysms,^5–7 but the increased risk of intracranial hemorrhage following glycoprotein IIb/IIIa inhibition remains a substantial concern. Moreover, the safety and efficacy data regarding the use of tirofiban in endovascular aneurysm treatment are lacking.The objective of our study was to evaluate the safety and efficacy of intravenous tirofiban, instead of clopidogrel and aspirin, as an antiplatelet premedication for stent-assisted coiling in patients with acutely ruptured intracranial aneurysms.     

Intraarterial administration of Abciximab for thromboembolic events occurring during aneurysm coil placement

BACKGROUND AND PURPOSE: Platelet-derived thrombi may occur during intracranial aneurysm coiling. We report a series of 13 patients treated with intraarterial Abciximab for thrombus formation complicating aneurysm coiling. METHODS: Four patients were treated for acutely ruptured aneurysms. Three procedures consisted of the retreatment of previously coiled aneurysms. Six patients had asymptomatic untreated aneurysms. Abciximab was administered intraarterially through a microcatheter as a bolus of 4-10 mg over a period of 10-20 minutes. All patients underwent postthrombolysis control angiography. They also underwent immediate pre- and postoperative cranial CT. RESULTS: In 10/13 cases, the thrombi developed without coil protrusion into the parent artery. In one case, the thrombus was generated from the guiding catheter and embolized remote from the aneurysm site. In one case, the thrombus developed before any coil placement. In another patient, a coil loop protruded into the parent artery favoring a heightened thrombotic state. Arterial thrombi were totally occlusive in two patients, whereas in the remaining 11 cases, the thrombi were not totally obstructive. Complete recanalization was achieved in 92% (12/13) of cases within 20-30 minutes. Incomplete arterial reopening was noted in one case, in which a thrombus fragment embolized distally, causing cerebral infarction. There were no Abciximab-related intracranial hemorrhages. CONCLUSION: Intraarterial Abciximab was effective in this series for the treatment of thrombotic complications occurring during aneurysm coiling.     

Late rebleeding of ruptured intracranial aneurysms treated with detachable coils

BACKGROUND AND PURPOSE: The purpose of this study was to assess the incidence of late rebleeding of ruptured intracranial aneurysms treated with detachable coils. PATIENTS AND METHODS: A clinical follow-up study was conducted in 393 consecutive patients with a ruptured aneurysm treated with detachable coils between January 1995 and January 2003. Late rebleeding was defined as recurrent hemorrhage from a coiled aneurysm >1 month after coiling. One patient was lost to follow-up. Total clinical follow-up of the 392 patients who were coiled for ruptured cerebral aneurysms was 18,708 months (1559 patient years; median, 48 months; mean, 47.7 months; range, 0-120 months). RESULTS: Four patients suffered late rebleeding from the coiled aneurysm at 8, 12, 30, and 40 months after coiling, respectively. Two of these patients died. Another patient died of probable rebleeding 4 months after coiling. The incidence of late rebleeding was 1.27% (5/393) and mortality of late rebleeding was 0.76% (3/393). The annual late rebleeding rate was 0.32%, and the annual mortality rate from late rebleeding was 0.19%. During the follow-up period, 53 coiled aneurysms in 53 patients (13%) were additionally treated: 35 aneurysms (8.9%) were additionally treated with coils, 16 aneurysms (4.1%) were additionally clipped, and 2 aneurysms (0.5%) were additionally treated with parent vessel balloon occlusion. CONCLUSION: The late rebleeding rate after coiling of ruptured cerebral aneurysms is very low. Follow-up of patients with a coiled aneurysm is mandatory to identify aneurysms that need additional treatment after reopening.     

Neuroform颅内支架辅助栓塞宽颈颅内动脉瘤的初步经验

目的　报道我科使用Neuroform支架辅助可脱式弹簧圈栓塞宽颈脑动脉瘤的初步经验。方法　 2 2例 2 4枚宽颈颅内动脉瘤采用Neuroform支架和弹簧圈进行栓塞 ,其中急性破裂动脉瘤 19枚、未破裂动脉瘤 5枚。结果　支架均成功地释放 ,支架置入后的造影未发现有瘤内造影剂滞留的血流动力学改变。 10 0 %闭塞动脉瘤 18枚 ,90 %以上闭塞 5枚 ,1枚伴发的未破裂小型宽颈动脉瘤在支架置入后微导管无法超选 ,载瘤动脉均通畅。有 2枚动脉瘤虽有支架阻挡 ,但仍有部分弹簧圈畔进入载瘤动脉。所有患者没有出现与支架置入有关的症状性缺血性并发症。 17例造影随访中 ,有 1例在 3个月复查时发现再通 ,进行 2次栓塞完全闭塞动脉瘤 ,其余未见复发 ,结论　Neuroform颅内支架使用安全有效 ,适合于宽颈颅内动脉瘤的支架辅助弹簧圈栓塞 ,特别适合于迂曲的脑血管 ;其径向支撑力较差 ,在输送微导管时应防止其移位 ;其支架网眼较大 ,对血流动力学改变不明显 ,致密填塞是重要的 ,在输送弹簧圈时仍应防止弹簧圈畔进入载瘤动脉 ;术前、术后抗血小板药物的应用以及术后严格的系列造影随访是必要的。     

Complications in Stent-Assisted Endovascular Therapy of Ruptured Intracranial Aneurysms and Relevance to Antiplatelet Administration: A Systematic Review

BACKGROUND AND PURPOSE:Despite the increasing use of stent-assisted coiling for ruptured intracranial aneurysms, there is little consensus regarding the appropriate antiplatelet administration for this. The objectives of this systematic review were to provide an overview of complications and their association with the method of antiplatelet administration in stent-assisted coiling for ruptured intracranial aneurysms.MATERIALS AND METHODS:A comprehensive search of the literature in the data bases was conducted to identify studies reporting complications of stent-assisted coiling for ruptured intracranial aneurysms. The pooled event rate of preprocedural thromboembolisms, hemorrhages, and mortality was estimated from the selected studies. Subgroup analyses were performed by the method of antiplatelet administration (pre-, postprocedural, and modified). Meta-analysis was conducted to compare periprocedural complications and mortality between ruptured intracranial aneurysms and unruptured intracranial aneurysms.RESULTS:Of the 8476 studies identified, 33 with 1090 patients were included. The event rates of thromboembolism and intra- and postprocedural hemorrhage were 11.2% (95% CI, 9.2%–13.6%), 5.4% (95% CI, 4.1%–7.2%), and 3.6% (95% CI, 2.6%–5.1%), respectively. Subgroup analyses of thromboembolism showed a statistically significant difference between groups (P < .05). In the preprocedural and modified antiplatelet groups, the risk for thromboembolism in stent-assisted coiling for ruptured intracranial aneurysm was not significantly different from that for unruptured intracranial aneurysm, though this risk of the postprocedural antiplatelet group was significantly higher in ruptured intracranial aneurysms than in unruptured intracranial aneurysms.CONCLUSIONS:On the basis of current evidence, complications of stent-assisted coiling for ruptured intracranial aneurysm may be affected by the method of antiplatelet administration.

Aneurysmal neck remodeling with stents has recently emerged as an effective treatment option. This method is beneficial for treating aneurysms with wide necks or for situations in which coils unexpectedly herniate into the parent vessel, requiring rescue with a device that can reconstrain the coil within the lesion.¹ Currently, various stents specialized for aneurysmal neck remodeling are used during endovascular treatment of intracranial aneurysms. However, physicians are often reluctant to apply stents to acutely ruptured aneurysms due to the necessity of antiplatelet medications. During implantation of stents within an intracranial artery, antiplatelet agents should be administrated and maintained postoperatively to prevent in-stent thrombosis and subsequent ischemic events.² In the setting of acutely ruptured aneurysms, antiplatelet medications may lead to complications such as intraprocedural rebleeding, the need for a ventriculostomy, co-occurrence of an intraparenchymal hematoma, and a high likelihood of future invasive procedures.^3–7Despite the chance of complications, administration of antiplatelet agents is an important element of management when using an intracranial stent, regardless of the presence of an acute aneurysm rupture. The type and/or method of antiplatelet agent might affect the periprocedural complication rate of endovascular aneurysm treatment.^8,9 Despite many previous studies of stent-assisted aneurysm management, no published recommendations or large randomized clinical trials provide a consensus as to the appropriate method of antiplatelet medication in stent-assisted endovascular treatment for ruptured intracranial aneurysms (RIAs). The medication method usually varied depending on the institution or the rationales of clinicians in most published case series. Some review articles suggested a higher risk of complications in endovascular therapy for acutely ruptured aneurysms.^3,10,11 However, these reviews did not analyze independent factors affecting the risk of complications in stent-assisted coiling for RIA, including the application of antiplatelet agents.The purposes of this systematic review were to calculate the accumulated complication risk during stent-assisted coiling for RIA and to assess whether the risk of complications would be affected by the method of antiplatelet administration. This information will guide selection of safer antiplatelet administration for stent-assisted coiling of RIA.     

Endovascular treatment of posterior cerebral artery aneurysms

BACKGROUND AND PURPOSE: The purpose of this study was to report the incidence, clinical presentation, endovascular treatment, and outcome of aneurysms of the posterior cerebral artery (PCA). PATIENTS AND METHODS: Among 1880 aneurysms treated between January 1995 and January 2005, 22 aneurysms (1.2%) in 22 patients were located on the PCA. Ten patients presented with subarachnoid hemorrhage (SAH) from the PCA aneurysm: 2 of these patients had additional visual field deficits and 2 had additional occulomotor palsy. One patient presented with acute occulomotor palsy only. Eleven PCA aneurysms were unruptured: 9 were additional to another ruptured aneurysm and 2 were incidentally discovered. Three aneurysms were >15 mm and the other 19 aneurysms were < or = 8 mm. Eighteen aneurysms were saccular, 2 were fusiform, one was dissecting, and one was mycotic. RESULTS: All aneurysms were successfully treated, 17 with selective occlusion of the aneurysm with coils and 5 with simultaneous occlusion of the aneurysm and parent PCA with coils. There were no complications of treatment. Two patients died of sequelae of SAH shortly after treatment. One patient died 2 months after coiling of an unruptured P1 aneurysm with intramural thrombus of SAH from the same aneurysm. One patient had persistent hemianopsia. In 2 patients with intact visual field in which the parent PCA was occluded, no hemianopsia developed due to sufficient leptomeningeal collateral circulation. CONCLUSION: Aneurysms of the PCA are rare with an incidence in our practice of 1.2% of all types of aneurysms. Clinical presentation is variable with SAH, occulomotor palsy, visual field deficit or a combination. Endovascular treatment with either selective occlusion of the aneurysm or occlusion of the aneurysm together with the parent artery with coils is safe and effective with good clinical results.     

Procedural morbidity and mortality of elective coil treatment of unruptured intracranial aneurysms

BACKGROUND AND PURPOSE: To report morbidity, mortality, and angiographic results of elective coiling of unruptured intracranial aneurysms. METHODS: In a 10-year period, 176 unruptured aneurysms in 149 patients were electively treated with detachable coils. Seventy-nine aneurysms were additional to another ruptured aneurysm but were coiled more than 3 months after subarachnoid hemorrhage, 59 aneurysms were incidentally discovered, and 38 aneurysms presented with symptoms of mass effect. Mean size of the 176 unruptured aneurysms was 10.6 mm (median, 8 mm; range, 2-55 mm). One hundred thirteen aneurysms (64%) were small (<10 mm), 44 aneurysms (25%) were large (10-25 mm), and 19 aneurysms (11%) were giant (25-55 mm). Thirty wide-necked aneurysms (17%) were coiled with the aid of a supporting device. RESULTS: Procedural mortality of coiling was 1.3% (2 of 149; 95% confidence interval [CI], 0.7-5.1%), and morbidity was 2.6% (4 of 149, 95% CI, 0.8-7.0%). The 4 patients with permanent morbidity were independent (GOS 4). Initial aneurysm occlusion was complete (100%) in 132 aneurysms, nearly complete (90%-98%) in 36 aneurysms, and incomplete (60%-85%) in 8 aneurysms. Six-month follow-up angiography was available in 132 patients with 154 coiled aneurysms (87.5%); partial reopening occurred in 25, mainly large and giant aneurysms (16.2%). Additional coiling was performed in 22 aneurysms and additional parent vessel occlusion in 1 aneurysm. There were no complications of additional treatments. CONCLUSION: Elective coiling of unruptured intracranial aneurysms has low procedural mortality and morbidity. For the management of unruptured aneurysms, endovascular treatment should be considered.     

微导丝辅助技术在颅内动脉瘤栓塞治疗中的应用研究

目的 探讨微导丝辅助的瘤颈成形技术在弹簧圈栓塞治疗颅内动脉瘤中的价值、技术操作要点及临床应用前景。方法 本组包括25例小型宽颈动脉瘤(前交通动脉12例，大脑中动脉分叉部12例，小脑后下动脉瘤1例)。微导管成功超选动脉瘤囊内，将撤出的微导丝再塑形后跨瘤颈部位放置。通过微导管内用电解可脱卸弹簧圈栓塞动脉瘤。结果 25例均获得成功，动脉瘤致密栓塞，载瘤动脉保持通畅，效果满意。短期影像随访16例，动脉瘤无复发。结论 微导丝瘤颈成形术作为小型宽颈动脉瘤治疗技术是安全、经济有效的。     

Onyx联合支架辅助弹簧圈治疗复杂性颅内破裂动脉瘤

目的 探讨应用Onyx联合支架辅助弹簧圈治疗颅内复杂破裂动脉瘤的可行性和疗效.方法 回顾性分析2例应用Onyx联合支架辅助弹簧圈技术方法,进行治疗的颅内复杂破裂动脉瘤.并对Onyx栓塞治疗颅内动脉瘤相关文献进行回顾.结果 应用该技术栓塞治疗2例复杂性颅内动脉瘤(1例为右侧颈内动脉分叉部动脉瘤,1例为颈内动脉前壁复发动脉...     

Balloon-assisted coiling of intracranial aneurysms: evaluation of local thrombus formation and symptomatic thromboembolic complications

BACKGROUND AND PURPOSE: Remodeling balloons are used to assist in endovascular coiling of aneurysms. We evaluated our experience with balloon-assisted coiling (BAC) in an attempt to determine whether this technique increased the rate of thrombus formation or symptomatic thromboembolic complications. MATERIALS AND METHODS: In 3 years, we treated 221 patients with intracranial aneurysms. Statistical analysis was performed to assess whether BAC increased the rate of thrombus formation or symptomatic thromboembolic complications. Patient demographics, aneurysm size, location, neck width, antiplatelet therapy, and rupture status were evaluated. RESULTS: We detected no statistically significant difference in rates of thrombus formation (14% versus 9% with and without BAC, respectively, P=0.35) or symptomatic thromboembolic events (7% versus 5% with and without BAC, respectively, P=0.76), though our power to detect small differences was limited. There was also no correlation with age, sex, rupture status, aneurysm size, or location. There was a significant increase in the rates of thrombus formation (6% versus 16%, P=0.02) and symptomatic thromboembolic complications (3% versus 10%, P=0.04) in aneurysms that were classified as narrow- or wide-necked, respectively. The use of clopidogrel was associated with a decrease in the rate of complications (P=0.01). CONCLUSION: In this series, we detected no significant increase in the rates of either intraprocedural thrombus formation or symptomatic thromboembolic events in patients treated with BAC. Larger studies are required to confirm our observations. Wide-necked aneurysms were independently associated with increased rates of thrombus formation and symptomatic thromboembolic complications, whereas the use of clopidogrel was protective (P=0.01).     

Abciximab for treatment of thromboembolic complications during endovascular coiling of intracranial aneurysms

BACKGROUND AND PURPOSE: Thromboembolism is a recognized complication occurring during endovascular coil embolization of intracranial aneurysms. Recently, there has been much interest in glycoprotein IIb/IIIa inhibitors to treat such complications, but the evidence is limited. We reviewed our use of one such agent, abciximab, which we commonly administer and believe to be a safe and suitable rescue agent in this setting.MATERIALS AND METHODS: We retrospectively reviewed cases in which abciximab was administered in our institution between 2001 and 2007. Clinical outcome was assessed by the modified Rankin Scale (mRS) at 6 months. Good outcome was defined as no significant clinical sequelae compared with baseline status or clinical improvement (mRS < 2). Poor outcome was defined as no resolution of a new clinical deficit that developed postprocedure at 6 months (mRS > 2). Angiographic appearance of thromboembolic phenomena and posttreatment outcome was assessed with the Thrombolysis in Myocardial Infarction (TIMI) scale.RESULTS: Thirty-eight patients were included, with good outcome observed in 30 (79%) and poor outcome in 8 (21%) patients. Angiographic improvement based on TIMI scoring was seen in 24 (63%) patients, and no improvement was seen in 14 (37%). In 4 patients (11%), good outcome was obtained at 6 months despite no angiographic improvement on TIMI. No cases of intracranial rebleed or additional neurologic deficit following administration of abciximab were encountered.CONCLUSION: In this small retrospective series, abciximab was safe and effective when used as a rescue agent for thromboembolic complications encountered during coiling of intracerebral aneurysms.

Endovascular treatment with detachable coils is, in many instances, the treatment of choice for intracranial aneurysms. Thromboembolism is a frequently reported complication, and one of the most difficult to treat. The reported incidence of hyperacute thromboembolic complications is seen to vary between 3% and 11% in previous case series.^1–3 Results with angioplasty are poor, and the use of thrombolytics has been associated with an increased risk of rebleed. In one series, there was a 10% rebleed rate in patients receiving recombinant tissue plasminogen activator (rtPA) and mechanical clot disruption.⁴ In recent years, there has been an increasing interest in glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors to treat thromboembolic complications in this setting. Abciximab (ReoPro; Eli Lilly, Indianapolis, Ind) is the Fab fragment of the chimeric human-murine monoclonal antibody 7E3. Abciximab binds to the GP IIb/IIIa receptor of human platelets and inhibits platelet aggregation in the early stages of thrombus formation. It is, therefore, reasonable to administer abciximab as soon as possible after the onset of thromboembolism.The therapeutic benefit of abciximab has been proved in coronary catheter intervention,⁵ lending evidence to its use in the treatment of thromboembolic complications encountered during intracranial aneurysm coiling. The current neuroradiology literature consists of several case reports^6–9 and 3 case series comprising 13, 13, and 29 patients, respectively.^10–12 These studies all report a favorable outcome when abciximab is used as a rescue agent in the treatment of thromboembolism, with a low incidence of rebleed. However when used in combination with thrombolytic drugs and mechanical clot disruption, a significant rebleed rate has been demonstrated. This suggests that risk of rebleed may be reduced when abciximab is used alone.We report our experience using abciximab as a rescue agent for thromboembolic complications in 38 patients at a tertiary neurosciences center.     

Self-expandable stent-assisted coiling of wide-necked intracranial aneurysms: a single-center experience

BACKGROUND AND PURPOSE: Endovascular treatment of wide-necked aneurysms remains a therapeutic challenge. We conducted this study to evaluate the angiographic results and clinical outcome of patients treated with stent-assisted coiling by using a recently available self-expandable intracranial stent. METHODS: A retrospective review of all patients treated with self-expandable stent-assisted coiling between September 2002 and December 2003 was done. Treatment was attempted in 32 patients with 35 aneurysms. Four of the aneurysms were ruptured. All had either a dome-to-neck ratio less than 2 and/or a neck diameter of 5 mm or larger. Following stent placement, coiling was attempted in 33 of 34 aneurysms. The technical success of the procedure, procedure related complications, and the angiographic results were documented. RESULTS: In 34 of 35 aneurysms, stent deployment across the neck of the aneurysm was successful. Coiling was performed successfully in 30 of 33 aneurysms. In 20 aneurysms, immediate posttreatment angiography showed either total (17%) or satisfactory (50%) occlusion. Procedure-related mortality occurred in one patient (3.1%). Adverse events occurred in eight patients (25%); in three of them permanent neurologic deficit resulted (9.3%). In six patients, thrombus formation occurred within the stented segments during the procedure and reopro infusion was used. Follow-up angiography was available in 12 (40%) of 30 treated aneurysms. CONCLUSION: In our practice use of the self-expandable stent seemed to facilitate endovascular treatment of wide-necked intracranial aneurysms. Difficulty of deployment and stent thrombogenicity are the main drawbacks of the system.     

Does endoluminal coil embolization cause distension of intracranial aneurysms?

Introduction The aim of the present study was to determine whether intracranial aneurysms are distended after coil embolization and to evaluate the distensibility of ruptured aneurysms treated with endovascular coiling.Methods This was a prospective study of 20 consecutive patients with 22 aneurysms, who presented with a ruptured cerebral aneurysm and were treated with endovascular coiling of the aneurysm in a single institution. A diagnostic digital subtraction angiography (DSA) and a three-dimensional radiographic angiography (3DRA) were performed with bi-plane angiography equipment (Philips V5000) immediately before and after the embolization procedure to detect volume enlargement of the aneurysm after embolization, and the extent of the enlargement. A simulation study with steel spheres was carried out to study the possible error of over-estimation of the postembolization volume due to the beam-hardening artifact.Results There was no procedure-related rupture of the aneurysms. The percentage by volume of solid coil within the coil mass ranged from 15.78% to 82.01% in the present series. All aneurysms showed distension which ranged from 0.09% to 34.23%. The distensibility of the aneurysms was 34.23%. Error due to the beam-hardening artifact was negligible.Conclusion Endoluminal packing of intracranial saccular aneurysms with embolization coils could cause a certain degree of distension in aneurysms treated with coil embolization, with the degree of distension up to 34.2%. Intracranial aneurysms were able to tolerate a certain degree of endoluminal distension without a risk of immediate rupture, even those that had ruptured recently.     

Thrombus formation during intracranial aneurysm coil placement: treatment with intra-arterial abciximab

BACKGROUND AND PURPOSE: The management of thrombus formation during coil placement in an intracranial aneurysm is important in minimizing periprocedural morbidity and mortality. We report on seven cases in which the primary treatment for thrombus formation during such coil placement was intra-arterial abciximab infusion. METHODS: Clinical and radiologic records of 100 consecutive patients who underwent coil placement in intracranial aneurysms at our institution during a 1-year period were reviewed. We identified seven cases (four ruptured aneurysms, three unruptured aneurysms) in which thrombus formation occurred during the procedure. RESULTS: Intra-arterial abciximab infusion, up to 5 mg, completely dissolved the thrombus in four of seven patients and almost completely dissolved it in two. In one patient with distal emboli, recanalization was not achieved. In two patients, an intravenous bolus of abciximab without 12-hour infusion was also given adjunctively. In one patient, leakage of contrast material occurred; this was related to the intra-arterial infusion. Clinically, no new neurologic deficits were directly related to the intra-arterial abciximab infusion. Six patients had good clinical outcome, and one patient died. CONCLUSION: Relatively low-dose, intra-arterial abciximab infusion can immediately dissolve an acute thrombus that forms during intracranial aneurysm coil placement. Although neither the optimal dose of intra-arterial abciximab nor the need to supplement the intra-arterial infusion with intravenous administration was established, we preliminarily found that low-dose intra-arterial abciximab infusion may be relatively effective and safe in this setting, even in patients with acute subarachnoid hemorrhage.     

Ruptured cavernous sinus aneurysms causing carotid cavernous fistula: incidence, clinical presentation, treatment, and outcome

BACKGROUND AND PURPOSE: In this study, we present our experience with 11 patients with ruptured cavernous sinus aneurysms causing carotid cavernous fistulas (CCFs), to assess the incidence of ruptured cavernous sinus aneurysms causing CCFs and evaluate clinical presentations, treatments, and outcomes. PATIENTS AND METHODS: During a 10-year period, 10 of 689 (1.5%) endovascular-treated ruptured aneurysms were ruptured cavernous sinus aneurysms causing CCF. One additional patient with a CCF died shortly before treatment of intracranial hemorrhage. All patients had audible pulsatile bruit. Exophthalmus, ocular motor palsy, and decreased vision correlated with venous drainage to the superior ophthalmic veins and intracerebral hemorrhage was associated with major cortical venous drainage in 2 patients. RESULTS: Two low-flow CCFs closed spontaneously before treatment with resolution of symptoms; the aneurysms were subsequently treated. Eight CCFs were successfully occluded, 5 by coil occlusion of the aneurysm, one by occlusion of the aneurysm with a balloon, and 2 by simultaneous coil occlusion of the aneurysm and internal carotid artery. There were no complications of treatment. Visual acuity returned to normal in all but one patient, and ophthalmoplegia was cured in 6 of 8 patients. In 2 patients, a remaining abducens palsy was surgically corrected. CONCLUSION: The incidence of CCF by a ruptured cavernous sinus aneurysm was 1.5%. CCF was the presenting symptom in 24.4% of treated symptomatic cavernous sinus aneurysms. Clinical symptoms correlate with venous drainage. Drainage to cortical veins may lead to intracranial hemorrhage. Endovascular treatment with coils is effective in occluding the fistula.     

Intra-arterial tirofiban infusion for thromboembolic complication during coil embolization of ruptured intracranial aneurysms

Introduction

Intra-arterial (IA) thrombolytic intervention for acute thrombosis has been challenged due to the risk of bleeding during the endovascular treatment of ruptured aneurysms. We present the results of IA tirofiban infusion for thromboembolic complications during coil embolization in patients with ruptured intracranial aneurysms.

Methods

Thromboembolic events requiring thrombolytic intervention occurred in 39 (10.5%) cases during coil embolization of 372 consecutive ruptured intracranial aneurysms. Maximal aneurysm diameters of 39 patients (mean age, 54.7 ± 13.2 years; 23 female, 16 male) ranged from 2.1 to 13.1 mm (mean, 6.6 ± 3.0 mm). The anterior communicating artery was the most common site (n = 13), followed by the middle cerebral artery (n = 9) and the posterior communicating artery (n = 7). In this series, we used intracranial stents in 10 patients during the procedure. Superselective IA tirofiban infusion through a microcatheter was performed to resolve thrombi and emboli. We assessed the efficacy and safety of IA tirofiban infusion in patients with ruptured aneurysms.

Results

Intraarterially administered tirofiban doses ranged from 0.25 to 1.25 mg (mean, 0.71 ± 0.26 mg). Effective thrombolysis or recanalization was achieved in 34 patients (87.2%), and three patients (7.7%) suffered distal migration of clots with partial recanalization. The rest (5.1%) had no recanalization. Nonconsequent intracerebral hemorrhage occurred in two patients (5.1%) after the procedure. Thromboemboli-related cerebral infarction developed in eight patients, and only two patients remained infarction related disabilities.

Conclusion

IA tirofiban infusion seems to be efficacious and safe for thrombolysis during coil embolization in patients with ruptured intracranial aneurysms.     

短期加用替罗非班在支架辅助弹簧圈栓塞梭形动脉瘤中的安全性与有效性研究

目的评估支架辅助弹簧圈栓塞梭形动脉瘤术中及术后24 h内,在标准双抗血小板治疗的基础上,短期应用小剂量替罗非班在降低缺血并发症方面的安全性及有效性。 方法回顾分析我中心2015年1月至2020年12月颅内未破裂梭形动脉瘤接受支架辅助弹簧圈栓塞治疗,并在手术过程中及术后24 h内静脉接受替罗非班（0.1 μg/kg/min）预防血小板聚集的患者资料。记录并分析围手术期并发症,动脉瘤栓塞程度及术后3个月随访时的mRS评分。 结果本研究共纳入38例患者,39枚动脉瘤,动脉瘤平均直径（6.4±2.1）mm。其中,26枚动脉瘤接受了单支架辅助弹簧圈栓塞治疗,13枚动脉瘤接受了双支架辅助弹簧圈栓塞治疗。术后即刻78.9%（30/38）的动脉瘤实现完全栓塞;在26例接受脑血管造影复查的患者中,92.3%（24/26）的患者动脉瘤实现完全闭塞。围手术期缺血并发症发生率为7.9%（3/38）;无出血并发症发生。3个月随访的良好预后率为97.4%（37/38） （mRS评分为0~1分）。 结论支架辅助弹簧圈栓塞梭形动脉瘤术中及术后24 h内,静脉加用小剂量替罗非班未增加出血并发症。但是,由于样本量偏少,缺少对比,在降低缺血并发症方面的有效性尚需进一步证实。