Outcomes after aneurysm rupture during endovascular coil embolization

OBJECTIVE: Intracranial aneurysm rupture during placement of Guglielmi detachable coils has been reported, but the management and consequences of this event have not been extensively described. We present our experience with this feared complication and report possible neuroradiological and neurosurgical interventions to improve outcomes. METHODS: We retrospectively reviewed the records for 701 patients with 734 intracranial aneurysms that were treated with endovascular coiling, during a 6-year period, in the metropolitan Minneapolis-St. Paul (Minnesota) area. This analysis revealed 10 cases of perforation during coiling. The management and outcomes were recorded, and the pertinent literature was reviewed. RESULTS: All 10 cases involved previously ruptured aneurysms. This complication occurred sporadically and was not observed in the first 100 cases. Perforation occurred during microcatheterization of the aneurysm in two cases and during coil deposition in eight cases. Seven of the perforated aneurysms were located in the anterior circulation and three in the posterior circulation. Six of the 10 patients made good or fair recoveries; all three patients with posterior circulation lesions died immediately after rehemorrhage. Elevated intracranial pressure (ICP) was noted for all five patients with intraventricular catheters in place. Bilateral pupil dilation and profound hemodynamic changes were noted for eight patients. Coiling was rapidly completed, and total or nearly total occlusion was achieved in all cases. Emergency ventriculostomy was performed to rapidly reduce increased ICP for two patients, both of whom made good recoveries. Hemodynamic and angiographic factors after perforation, such as prolonged systemic hypertension, persistent dye extravasation after deployment of the first Guglielmi detachable coil, and persistent prolongation of contrast dye transit time (suggesting ongoing ICP elevation), were correlated with poor outcomes. CONCLUSION: Previously ruptured aneurysms seem to be more susceptible to endovascular treatment-related perforation than are unruptured lesions. Worse prognoses are associated with iatrogenic rupture during coiling of posterior circulation lesions, compared with those in the anterior circulation. When perforation is recognized, the definitive treatment seems to be reversal of anticoagulation therapy and completion of Guglielmi detachable coil embolization. Immediate neurosurgical intervention is limited in these cases and focuses on decreasing ICP via emergency ventriculostomy. However, these measures may be life-saving, and neurosurgical assistance must be readily available during treatment of these cases.     

颅内动脉瘤弹簧圈栓塞治疗术中动脉瘤再破裂的防治

目的颅内动脉瘤在弹簧圈栓塞过程中发生破裂是最可怕的术中并发症之一，本文探讨处理、预防这一并发症的初步经验。方法2002年4月-2006年12月，共有153例患有颅内动脉瘤的患者在我院接受了可脱卸弹簧圈栓塞治疗，其中141例患者曾有过动脉瘤破裂引起蛛网膜下腔出血史。5例有动脉瘤破裂出血史的患者术中再次发生动脉瘤破裂。术中动脉瘤再破裂时，常规使用鱼精蛋白中和肝素，并设法用弹簧圈尽快填塞动脉瘤腔。微导丝引起动脉瘤破裂时，尽量保持微导丝不动，微导管尽快送到瘤腔中进行填塞治疗。若微导管引起破裂而微导管头端位于瘤壁外蛛网膜下腔时，微导管且勿退入瘤腔内，应将弹簧圈经微导管送入蛛网膜下腔一部分后，再将微导管头撤入瘤腔内，继续弹簧圈填塞。若弹簧圈引起破裂，要将弹簧圈完全或部分送出去，将破裂口堵住后，调整微导管头端位置继续弹簧圈填塞。结果在接受动脉瘤栓塞治疗的153例患者中，141例曾有过动脉瘤破裂引起蛛网膜下腔出血，治疗中5例发生了术中再破裂，占动脉瘤破裂引起蛛网膜下腔出血的3．5％，总发生率为3．3％。1例破裂由导丝引起，1例由微导管引起，1例由弹簧圈过度填塞引起，弹簧圈穿孔1例，其余1例由微导管和弹簧圈共同引起。2例死亡，死亡率占术中破裂的40％，占总例数的1．3％；1例患者出院时遗留有右下肢瘫痪，其余2例患者无残留神经系统并发症。结论动脉瘤栓塞术中动脉瘤的再破裂是一少见、威胁生命但又不可避免的事件。应该立即采取妥善措施以挽救患者生命、改善预后、降低可怕并发症的发生。如处理恰当，多数术中动脉瘤破裂的患者能够存活，无后遗症。     

Stereotactic aspiration of a brain stem hematoma

A medical student developed a progressive mesencephalic lesion found to be cystic in nature by computed tomographic (CT) scanning. Stereotactic aspiration of a pontomesencephalic hematoma was carried out twice, and the patient recovered. Angiography and CT scanning demonstrated a vascular lesion compatible with a venous angioma.     

Chronic expanding intracerebral hematoma treated by mini-invasive ultrasonography-guided needle aspiration

Chronic expanding intracerebral hematoma (CEIH) is a rare cerebrovascular disease that behaves as a slowly expanding lesion with a gradual onset of progressive neurological deficit or recurrent seizures. The etiology of the CEIH is still not clear. Even if about a half of these lesions are associated with vascular malformations, the remaining cases are post-traumatic, associated with coagulative disorders or are cryptogenic. Treatment of these lesions is controversary: while some neurosurgeons remove the hematoma with its capsule, others prefer to wait and observe it if the patient is neurologically stable. We discuss the opportunity of treating selected patients bearing a CEIH by means of ultrasonography(US)-guided aspiration in selected patients. A 42-year-old hepatopathic man with coagulation disorders was referred to us with a 2-month history of progressive right-sided weakness, speech disorders and difficulty in swallowing solid foods. Radiological findings supported a CEIH with a thin surrounding capsule. The patient underwent to US-guided aspiration of the lesion with a complete resolution of the hematoma, confirmed intraoperatively by real-time US-control and postoperatively by early and long term neuroradiological controls. US-guided aspiration is a low cost, not time consuming technique, that allows an intraoperative real-time control of the lesion and seems to be an effective alternative to open surgery in cases of CEIHs with a thin capsule.     

Stent salvage for parent vessel coil herniation during intracranial aneurysm embolization

Background: Despite accumulated experience and improved understanding of the tools, endovascular treatment of cerebral aneurysms still has risks associated with the technique itself and with the specificity of the pathology treated. An important risk is parent vessel Guglielmi detachable coil herniation. Here we review and illustrate our experiences in using a stent to manage this complication. Methods: We reviewed our experiences in 142 intracranial aneurysm embolizations over a four and a half year period and identified 13 cases with intravascular stent deployment. Three cases were unique in using a stent for salvage of coil herniation into the parent vessel. Results: We reported these cases and reviewed the literature for the management of parent vessel coil herniation. Conclusion: Parent vessel coil herniation was an uncommon but important complication of endovascular coiling of intracranial aneurysm. Intravascular stent placement provided a tool to sequester herniated coils from the lumen of the parent artery to minimize thromboembolic complications and restore flow.     

Predictors of thromboembolism during coil embolization in patients with unruptured intracranial aneurysm

Objectives

To identify the incidence of thromboembolic complications based on magnetic resonance imaging (MRI) and to explore the potential risk factors for thromboembolism (TE) during the periprocedural period of elective coil embolization for unruptured intracranial aneurysms.

Methods

We retrospectively reviewed all aneurysm cases treated with coil insertion between January 2008 and March 2011. Two hundred eighty-two coiling procedures for unruptured aneurysms were included in this study. The patients’ demographic characteristics were documented and records reviewed for abnormalities in diffusion-weighted imaging (DWI) seen on post-procedure MRI, intraoperative thrombus formation, and clinical signs of stroke.

Results

Overall, there were 87 (30.9 %) procedure-related complications in 282 aneurysms treated: 2 (0.7 %) procedural ruptures, 5 (1.8 %) symptomatic infarctions, and 80 (28.3 %) asymptomatic infarctions. Thromboembolic events during the procedure were observed more often in the the hyperlipidemia group (32/71 aneurysms, 45.1 %) than in the normal lipid profile group (39/196 aneurysms, 25.6 %; p?=?0.002; chi-squre test). The coiling technique and size of the aneurysm were also associated with TE (p?<?0.001 and p?=?0.004).

Conclusion

Hyperlipidemia seems to be associated with a significant increase in the rate of thromboembolic events. In preventive procedures, modifiable risk factors should be managed to reduce complications. Although permanent deficits are rare, the high rate of thromboembolic events suggests that improvements in the technique, such as the addition of antiplatelet agents and the development of new embolic materials, are necessary.     

Giant celiac artery aneurysm: Treatment by transcatheter coil embolization

Celiac artery aneurysms (CAA) are one of the rarest forms of visceral artery aneurysms. Most patients are a symptomatic at the time of diagnosis and aneurysms are detected incidentally during diagnostic imaging for other diseases. We present the case of a 42-year-old man who had an asymptomatic giant CAA detected incidentally by an abdominal ultrasound investigating an abdominal pain. A contrast enhanced computed tomography angiogram (CTA) revealed a large CAA measuring 7.1 cm × 4.3 cm with extensive collaterals from the superior mesenteric artery (SMA). The aneurysm sac was mostly filled with thrombus with the celiac artery branches occluded. Pre-procedural angiography and transcatheter embolization procedures were performed at the same session. Endovascular exclusion was performed by transcatheter coil embolization and packing of the aneurysm sack. Technical success was achieved by the absence of flow in the aneurysm, and preservation of the native circulation on angiograms obtained just after the transcatheter coil embolization procedure. One week postembolization, a CTA confirmed thrombosis of the aneurysm. The patient returned for a follow-up CTA 3, 6, 12 and 48 months after embolization. The aneurysm was thrombosed and the patient remained a symptomatic. The surgical mode of treatment of CAA is increasingly being replaced by endovascular embolization because of the lower morbidity and mortality and high success rate. The accepted endovascular approach is by coil embolization of the aneurysmal lumen, the proximal and distal aneurysmal neck, or both.     

The application of near-infrared oximetry to cerebral monitoring during aneurysm embolization: a comparison with intraprocedural angiography

Near-infrared spectroscopy (NIRS) has been used to monitor regional cerebral oxygen saturation (rSO2) in patients at risk of cerebral desaturation during surgical and neurointerventional procedures. However, the quantitative capabilities of the method have been questioned, as has its validation compared with jugular bulb oximetry. Here, we compare NIRS data acquired during coil embolization procedures with incidence of vasospasm as detected from angiography. Thirty-two subarachnoid hemorrhage patients underwent embolization. Bilateral SomaSensor strips (Invos 4100, Somanetics) were affixed to the forehead at constant anatomic positions, avoiding frontal sinuses and scalp hair. Mean arterial pressure, SaO2, end-tidal pCO2, temperature and Hb were held within a narrow range during the procedure. Ipsilateral angiography was performed every 10 to 15 minutes. An independent neuroradiologist classified any vasospasm in the parent vessel as mild (25% baseline), moderate (50%), severe (75%), or total (100%). Of all, 15/32 (46.9%) patients developed spasm; in 2 it was severe or total. There was no significant association between World Federation of Neurological Surgeons grade and baseline rSO2 signal (either ipsilateral or contralateral to the side of the aneurysm) (P=0.598). There was no significant association between side of aneurysm and baseline rSO2 signal (P=0.243). However, episodes of angiographic spasm were strongly associated with reduction in trend ipsilateral NIRS signal (P<0.001); furthermore, the degree of spasm (especially more than 75% vessel diameter reduction) was associated with a greater reduction in same-side NIRS signal (P<0.001) (2-level random effects regression model, Stata 8.2, Stata Corp, TX). NIRS may have a useful role to play in the detection of cerebral desaturation secondary to vasospasm during neuroendovascular procedures.     

Internal iliac occlusion without coil embolization during endovascular abdominal aortic aneurysm repair

PURPOSE: When abdominal aortic aneurysms and common iliac artery (CIA) aneurysms undergo concomitant endovascular repair, endograft limb extension into the external iliac artery is often necessary. Usually, the internal iliac artery (IIA) is coil embolized in such a case to prevent endoleak. It has been our practice to coil embolize the IIA only in cases where there is not adequate stent graft seal in the CIA immediately proximal to the IIA origin (effectively sealing the entire IIA origin). In this study, we evaluated the outcomes of this approach. METHODS: We retrospectively reviewed 204 consecutive endovascular abdominal aortic aneurysm repairs at Dartmouth-Hitchcock Medical Center from 1996 to 2001. Computed tomographic angiography with three-dimensional reconstruction was the primary preoperative imaging modality, and the decision to cover the IIA without concomitant coil embolization was based before surgery on the presence of adequate graft oversizing (> or =10% to 15%) in the most distal 5 mm of CIA and 15 mm of proximal external iliac artery, respectively. RESULTS: The IIA was occluded 33 times in 31 patients. In 22 cases (67%), the IIA was covered without coil embolization (COVER group). The remaining 11 patients (33%) with inadequate graft oversizing in the CIA underwent IIA coil embolization (COIL group). The follow-up periods for the COVER and COIL groups were 19 +/- 2 months and 10 +/- 3 months, respectively. All operations in both groups were technically successful without evidence of endoleak at completion angiography. No endoleaks, graft migrations, or aneurysm enlargements were associated with the covered or coiled IIAs during the follow-up period. No clinical sequelae were seen in the COVER group, with the exception of buttock claudication in six patients (27%) that resolved completely in five patients. In the COIL group, five patients (45%) had buttock claudication. In addition, one case of buttock necrosis and one case of ischemic neuropathy occurred in the COIL group. CONCLUSION: Covering the IIA without coiling effectively excluded the CIA aneurysm in every case and was associated with a low incidence rate of complications compared with coil embolization. With detailed preoperative imaging and patient selection, IIA coil embolization may not be necessary in as many as two thirds of patients who need IIA occlusion.     

Case of an internal carotid artery aneurysm complicated with coil protrusion during embolization

Coil migration during cerebral aneurysm embolization is rare, but one of the most troublesome events. A 65-year-old woman was referred to our hospital for the treatment of a cerebral aneurysm. Angiography showed the aneurysm at the C3 portion of the right internal carotid artery. The neck of the aneurysm was wide. A detachable coil was placed into the aneurysm using the balloon neck plasty technique and was detached after confirmation of its stability. However, after detachment, the coil started to migrate. The balloon was inflated to prevent coil migration and another coil was inserted into the aneurysm to stabilize the migrated coil. Finally, the aneurysm was subtotally embolized with 9 coils. The postoperative course was uneventful. Coil migration may occur especially in a wide-neck aneurysm. Appropriate coil selection is important to prevent such migration. Subsequent coil insertion, retrieval of the migrated coil, and stent placement are the treatment options for coil migration.     

A case of primary fibrosarcoma caused by spontaneous intracerebral hematoma]

A rare case of repeated intracerebral hematoma associated with an intracerebral fibrosarcoma is reported. A 43-year-old man was referred to our clinic with headache and vomiting of sudden onset. On admission, he was lethargic. CT revealed a huge intracerebral hematoma in the left temporal lobe with midline shift. Angiography failed to demonstrate any evidence of an intracranial tumor. An operation was performed under the diagnosis of an idiopathic cerebral hematoma. The postoperative course was uneventful and he was discharged without any deficits except for a left upper quadrant homonymous hemianopia. Four and a half months after the first operation, he was readmitted to our clinic with the same symptoms as he had at the first admission. Neuroradiological examination again revealed an intracerebral hematoma in the left temporal lobe. At operation, a pinkish-gray discolored mass at the hematoma wall was found. An intraoperative histological examination of the mass indicated a malignant tumor and the tumor was totally removed. However the patient did not recover from the severe neurological deficits and died 3 months after the second surgery. Histological examinations of the tumor demonstrated a typical fibrosarcoma. Intracerebral primary fibrosarcoma with hemorrhage is quite rare. In such a case with a large hematoma, the presence of a tumor may be obscured on CT scan and angiography. Detailed observation of the hematoma wall using an operating microscope should be performed to allow a correct diagnosis.     

Successful coil embolization of a ruptured gastroduodenal artery aneurysm

Aneurysms of the gastroduodenal artery are rare. Reported here is the case of a 60-year-old woman suffering from the covered rupturing of a twin aneurysm of the gastroduodenal artery. The patient presented herself in the surgical emergency unit with abdominal discomfort. Diagnostics showed free fluid in the abdominal cavity together with anemia of 9.9 g/dL. A computed tomography scan and an angiography revealed the covered rupturing of a twin aneurysm of the gastroduodenal artery, which was treated by endovascular coiling of the gastroduodenal and pancreaticoduodenal arteries. The patient's hemoglobin level remained stable after treatment, and she was released from the hospital after 18 days. Visceral artery aneurysms are rare. Although endovascular therapy is preferred in cases involving active bleeding, surgery remains the primary therapy in those cases in which bleeding becomes uncontrollable.     

Unusual cisternal coil migration in the follow-up period after aneurysm perforation during endovascular coiling

A 61-year-old woman suffered cisternal coil migration in the follow-up period after endovascular coil embolization for a ruptured cerebral aneurysm. She presented with sudden onset of headache. Computed tomography demonstrated diffuse subarachnoid hemorrhage, and cerebral angiography disclosed a left anterior choroidal artery aneurysm. The aneurysm was treated by endovascular embolization with Guglielmi detachable coils. During the embolization procedure, the microcatheter perforated the aneurysm. For direct closure of the perforation site with coils, the microcatheter was withdrawn and coils were deployed partially in the subarachnoid space and partially in the aneurysm sac. The coil mass was spread in the subarachnoid space around the aneurysm immediately after embolization. The patient was discharged with no neurological deficit. Three months later, follow-up radiography demonstrated obvious reduction in the size and compaction of the coil mass. Magnetic resonance angiography and digital subtraction angiography demonstrated stable occlusion of the aneurysm. The coil mass probably spread in the cistern around the aneurysm and was compacted by the shape memory of the coils and pulsation of the brain and vessels, as the subarachnoid clots around the aneurysm had disappeared. This case suggests that cisternal coil migration should be considered in the follow up of intracranial aneurysm treated with detachable coils.     

A loose-packing approach for coil embolization of giant intracranial aneurysm

Endoluminal occlusion of giant intracranial aneurysms with coil embolization is a viable endovascular treatment option alternative to surgical clipping. However, due to the relatively large aneurysm size, the use of embolization coils for giant aneurysms could be great. A loose-packing embolization strategy in which the fundus of the aneurysm is loosely packed while the aneurysm base is tightly packed is presented. Such a coiling strategy is best suited to giant aneurysms of elongated configuration and narrow neck as illustrated in the present case. While the use of the loose-packing approach is recommended for elongated aneurysms with a narrow neck, its use is not to be generalized for aneurysms of other configurations.     

Partially thrombosed vertebral artery aneurysm with wall enhancement treated by stent-assisted coil embolization

A 50-year-old man presented with a 2-month history of dysarthria caused by a partially thrombosed vertebral artery (VA) aneurysm. Magnetic resonance imaging showed enhancement of the thickened wall and angiography detected staining. Stent-assisted coil embolization with protection of the parent artery patency was performed. The patient's clinical course was unremarkable and shrinking of the aneurysm was obtained. The stent-assisted coil embolization promoted intra-aneurysm flow disruption and stabilized the wall environment, suggesting another strategy for the treatment of partially thrombosed VA aneurysm.     

Management of intraprocedural arterial thrombus in cerebral aneurysm embolization with abciximab: technical case report

OBJECTIVE AND IMPORTANCE: Thromboembolic complications after cerebral aneurysm treatment with Guglielmi detachable coils (Boston Scientific/Target, Fremont, CA) are not infrequent; in a University of California, Los Angeles institutional review of 720 treated aneurysms, thromboembolic complications occurred in 2.5% of cases. The development of intraluminal thrombus during the embolization procedure, however, may be diagnosed promptly and treated effectively with appropriate therapy. This report describes the use of intravenously administered abciximab for the treatment of intraprocedural arterial thrombus encountered during the coil embolization of a recently ruptured anterior communicating artery aneurysm. CLINICAL PRESENTATION: A 45-year-old man presented with severe headache 12 days before transfer to our institution. He had no neurological deficits at admission. Previous computed tomography of the brain demonstrated subarachnoid hemorrhage, and magnetic resonance angiography from the other institution demonstrated a 4-mm anterior communicating artery aneurysm. INTERVENTION: The patient underwent Guglielmi detachable coil embolization of the aneurysm under systemic heparinization. During the embolization, however, a thrombus developed in the proximal left A2 segment. The patient was given an intravenous infusion (20 mg) of abciximab for 10 minutes, and within 15 minutes dissolution of the thrombus was observed with no angiographic evidence of distal emboli. After reversal of general anesthesia, the patient exhibited minimal right leg weakness, which resolved within 1 hour. CONCLUSION: Abciximab may be a useful adjunct for endovascular treatment of patients with cerebral aneurysms in whom intraprocedural arterial thrombus is encountered.