Acute rerupture after coil embolization of ruptured intracranial saccular aneurysms: A literature review

Safety and Efficacy of Management for Intraprocedural Rupture During Endovascular Treatment for Intracranial Aneurysms

BACKGROUND AND OBJECTIVES

Although intraprocedural rupture (IPR) is rare, it is a devastating complication of endovascular treatment (EVT) for intracranial aneurysms. Very few studies have been conducted on IPR, and the safety and efficacy of management techniques of IPR have not been investigated.

METHODS

Patients who experienced IPR during EVT between 2013 and 2022 were enrolled from a multicenter observational registry. We examined the safety and efficacy of the management of IPR using imaging markers, including increased hemorrhage and ischemic lesions, which were evaluated using postoperative computed tomography and diffusion-weighted imaging, respectively.

RESULTS

Of the 3269 EVTs for intracranial aneurysms, 74 patients who experienced IPR (2.26%) were analyzed. Fifty-five patients (3.36%) experienced IPR among 1636 EVT cases for ruptured aneurysms. Multivariate analysis revealed that increased hemorrhage was significantly associated with poor outcomes (odds ratio [OR], 6.37 [95% CI, 1.00-40.51], P = .050), whereas ischemic lesions were not. Regarding management techniques of IPR, antihypertensive medication use was significantly associated with increased hemorrhage (OR, 14.16 [95% CI, 2.35-85.34], P = .004). Heparin reversal was an independent factor for ischemic lesions (OR, 8.92 [95% CI, 1.54-51.58], P = .014).

CONCLUSION

Although the setting of IPR may be miscellaneous, and optimal management varies depending on individual cases, heparin reversal might be associated with ischemic complications, and its role in the successful hemostasis in IPR during EVT for ruptured aneurysms remains unclear.

Multifactorial Assessment of Complication Risks in Embolization for Ruptured Cerebral Aneurysm

Objective

Complications in neuroendovascular therapy for cerebral aneurysm (AN) affect the clinical course of patients. Patient conditions, operating procedures, and operator expertise were highlighted as risk factors for complications. These risk factors often combine and constitute particularly strong risks, resulting in a worsened clinical course. In this study, we performed a multifactorial assessment of complication risks in neuroendovascular therapy.

Methods

We analyzed patient data from the Japanese Registry of NeuroEndovascular Therapy 3, which is a nationwide retrospective cohort study of neuroendovascular procedures conducted between 2010 and 2014. Patients who underwent coil embolization for a ruptured anterior communicating artery (Acom) AN, an internal carotid artery-posterior communicating artery (IC-PC) AN, or basilar artery bifurcation (BA-bif) AN were included in this analysis. Information on 16 explanatory variables and 1 objective variable for each patient was obtained from the dataset as nominal variables. The explanatory variables consisted of patient factors, procedural factors, and an operator factor. The objective variable was whether the following complications occurred: intraprocedural bleeding, postprocedural bleeding, and procedure-related infarction. The specific situations involving multiple risk factors associated with high complication rates were identified using a programmed method. The impact of the absence of a supervising physician was also assessed.

Results

A total of 2971 patients were analyzed. The complication rates for patients with Acom ANs, IC-PC ANs, and BA-bif ANs were 12.9%, 10.2%, and 13.7%, respectively. A total of 15 specific situations were identified as follows: 3 related to an Acom AN, with complication rates ranging from 19.3% to 20.3%; 4 related to an IC-PC AN, with complication rates ranging from 15.6% to 17.9%; and 8 related to a BA-bif AN, with complication rates ranging from 20.6% to 33.3%. In 4 of these situations, the absence of a supervising physician significantly impacted complication rates. For instance, the complication rate for patients with IC-PC AN treated under local anesthesia was 16.0% overall, but it was 23.8% without supervising physicians.

Conclusion

Multifactorial assessment based on patient, procedural, and operator factors provides more reliable risk estimations and will help improve the clinical course.

Clinical Outcomes of Endovascular Coil Embolization for Ruptured Middle Cerebral Artery Aneurysms

Objective

Middle cerebral artery (MCA) aneurysms are difficult to treat with coil embolization (CE) due to their location and shape, but the number of CE-treated MCA has gradually increased as treatment techniques have improved. However, the outcomes of CE for ruptured MCA aneurysms are poorly understood. This study aimed to evaluate the outcomes of CE for ruptured MCA aneurysms.

Methods

We retrospectively analyzed the medical records of patients with aneurysmal subarachnoid hemorrhages (aSAH) that were treated with CE between 2013 and 2020, and compared the differences in outcomes depending on aneurysm location.

Results

A total of 468 patients with aSAH were included: 39 patients had ruptured MCA aneurysms (group M), and 429 had ruptured aneurysms at other sites (group O). There were no significant differences between the background characteristics of the 2 groups. Also, there were no significant intergroup differences in occlusion status, the frequency of complications such as ischemia, hemorrhaging, rebleeding, retreatment, or the modified Rankin Scale score at discharge. However, intracerebral hemorrhage (ICH) removal was required significantly more frequently in group M than in group O (10.3% vs. 0.5%, p = 0.0006). By case-matching analysis, there were no significant differences in these outcomes. All MCA cases that needed removal had more than 36 ml of hematoma volume. Logistic regression analysis showed that the existence of ICH at onset was a poor prognostic factor for ruptured MCA aneurysms.

Conclusion

CE for ruptured MCA aneurysms produced acceptable outcomes in selected cases. However, the indications for CE in patients with ICH should be carefully considered.

Surgical Treatment Strategies for Residual or Recurrent Intracranial Aneurysms Following Endovascular Embolization

OBJECTIVE

To explore how to effectively manage the residual or recurrent intracranial aneurysms after embolization.

METHODS

The authors retrospectively reviewed our experience of endovascular interventional therapy, surgical clipping, and cerebrovascular bypass surgery in the treatment of residual or recurrent aneurysms after embolization at the authors' institution from 2018 to 2022.

RESULTS

The Glasgow Outcome Scale of 28 patients after the procedure and at discharge showed that 24 recovered well, 3 had severe disability, and 1 died. During the 24-month follow-up, 26 had a good recovery, 1 suffered from disability, and 1 died. Two cases of aneurysm recurrence were detected, and both were treated through endovascular therapy. Among them, 1 case underwent a repeat endovascular embolization, and 1 case was switched to surgical clipping. No residual aneurysms were observed in the remaining patients who underwent bypass surgery, and their bypass grafts were all patent.

CONCLUSION

Based on the clinical status of patients, aneurysmal characteristics, surgical risk, and possibility of rerupture of aneurysms, an individualized strategy was proposed for residual or recurrent aneurysms after embolization. The use of endovascular interventional therapy or surgical clipping can be safely and effectively managed, and cerebrovascular bypass surgery can effectively manage complex aneurysms.

Intra- and post-operative acute hemorrhagic complications of Onyx embolization of brain arteriovenous malformations: A single-center experience

Background

The intra- and post-operative acute (within 72 h) hemorrhagic complications of endovascular treatment (EVT) for a brain arteriovenous malformation (BAVM) are disastrous. Thus, further experiential summaries are required to fully understand them.

Materials and methods

This was a retrospective study of 25 patients with consecutive BAVM who were treated via EVT with Onyx embolization and suffered intra- and post-operative acute hemorrhage. The clinical and imaging data of the patients were recorded, analyzed, and discussed.

Result

Twenty-five patients were aged 11-70 years (mean, 37.2 ± 16.1 years), of whom 12 were female (48%, 12/25). Of the 25 hemorrhagic complications, 17 (68%, 17/25) were intraoperative, and 8 (32%, 8/25) were post-operative and occurred between 1 and 12 h after EVT. Of 17 intraoperative hemorrhages, 13 (76.5%, 13/17) were due to high-pressure Onyx casting. Of eight post-operative hemorrhages, six (75%, 6/8) were attributed to normal perfusion pressure breakthrough. The degree of nidus Onyx embolization was more than 2/3 or complete in seven (87.5%, 7/8) BAVMs. Draining vein occlusion was observed in eight (32%, 8/25) of 25 BAVMs. After hemorrhage, conservative treatment was administered in 12 (48%, 12/25) cases, and surgical management was performed in other cases. There were eight cases of mortality; the remaining 17 patients had follow-up data. Among them, 15 patients had good outcomes, with Glasgow Outcome Scale scores of 5 and 4, accounting for 60% (15/25).

Conclusion

In EVT for BAVMs, intra- and post-operative acute hemorrhagic complications are disastrous; only 60% of patients have a good outcome. Therefore, high-pressure Onyx casting or casting too much Onyx at one time to pursue a high degree of nidus embolization should be performed cautiously, and primary draining vein occlusion should be avoided. In short, EVT needs to be performed carefully.

Surgical clipping and endovascular embolization for senile patients with posterior communicating artery aneurysms complicated with oculomotor nerve palsy

OBJECTIVE

To explore the clinical effect of the surgical clipping and endovascular embolization for senile patients with posterior communicating artery aneurysms (PComA) complicated with oculomotor nerve palsy (ONP) and their neurological recovery.

METHODS

A total of 96 senile patients with PComA complicated with ONP admitted to our hospital from May 2018 to May 2019 were selected and assigned into the experimental group and the control group according to the randomization method, with 48 cases in each group. The patients in the control group underwent surgical clipping, whereas the patients in the experimental group received the endovascular embolization. Subsequently, their surgical therapeutic effect, postoperative blood chemistry parameters, the incidence of complications, the recovery of neurological function and prognosis were analyzed and compared.

RESULTS

The operation duration, bleeding volume, respiratory recovery time and the time to extubation were significantly in favor of the experimental group when compared with the control group (P < 0.001); Senile patients in the experimental group had markedly lower levels of blood chemistry parameters than the control group (P < 0.001); The neurological recovery in the experimental group was found to be remarkably better than that in the control group (P < 0.05); The experimental group showed a distinct decrease in the incidence of complications compared to the control group (P < 0.05); A significant difference in good prognosis was observed between the control group and the experimental group (P < 0.05).

CONCLUSION

Endovascular embolization is more effective in the treatment of senile PComA with ONP. It is superior to the traditional surgical clipping, and has a lower incidence of complications, thereby contributing to the better recovery of neurological function and prognosis.

Treatment of experimental aneurysms with a GPX embolic agent prototype: preliminary angiographic and histological results

Background

Recently, liquid embolic agents have emerged for the endovascular treatment of cerebral aneurysms. Here we describe the in vivo performance of a novel liquid embolization agent (GPX Embolic Device).

Methods

Elastase-induced aneurysms were embolized with a GPX prototype under balloon assistance. Digital subtraction angiography was performed pre-deployment and immediately after, and at 5, 10, and 30 min post-deployment in 10 rabbits and at 1 month in 8 rabbits. The early post-deployment intra-aneurysmal flow was graded as unchanged, moderately diminished, or completely absent. At 1 month the status of aneurysm occlusion was evaluated. Adhesion to catheter material and migration of GPX was assessed.

Results

The mean aneurysm neck diameter, width, and height were 3.6±1.0 mm, 3.0±0.8 mm, and 7.4±1.4 mm, respectively. The mean dome-to-neck ratio was 0.9±0.2. Complete stagnation of intra-aneurysmal flow was observed in 9 of 10 aneurysms (90%) within 30 min of device deployment. One aneurysm showed moderately diminished intra-aneurysmal flow at 30 min. At 1 month, 8 aneurysms were completely occluded. There was no evidence of GPX adhesion to the catheter material. Histologically, a leukocyte and foreign body reaction to GPX was detectable 28 days after embolization.

Conclusions

This is the first preclinical study reporting the performance of a protype version of the GPX Embolic Device in a wide-neck aneurysm model. GPX showed promising results by achieving and maintaining high rates of complete angiographic occlusion, but may induce an inflammatory reaction.

Arteriovenous malformation with associated multiple flow-related distal anterior cerebral artery aneurysms: A case report with poor outcomes

Background

Low-grade arteriovenous malformations (AVMs) associated with multiple flow-related distal anterior cerebral artery (DACA) aneurysms are rare occurrences. Here, we present a case of a frontal AVM with three associated DACA aneurysms arising from a single feeder.

Case Description

A 36-year-old male presented to us in the ER with acute-onset dysphasia and altered mental status. Head computed tomography and angiogram showed a spontaneous intracerebral hemorrhage with intraventricular extension and revealed a Spetzler Martin Grade II AVM, being fed by two feeders, with the major feeder from the DACA bearing three flow-related aneurysms. As the patient awaited digital subtraction angiography, his Glasgow Coma Scale dropped and he underwent emergency embolization with Onyx. This was followed by external ventricular drainage. The patient's neurological status did not improve, and he died following a complicated clinical course.

Conclusion

Multiple DACA aneurysms are a case of both clinical and anatomical rarity and to avoid complications in the clinical course, one must be judicious about the time spent between symptom onset and embolization.

Safety of stent-assisted coiling for the treatment of wide-necked ruptured aneurysm: A systematic literature review and meta-analysis of prevalence

BACKGROUND

Stent-assisted coil embolization of ruptured wide-necked aneurysms is a controversial treatment modality due to concerns on the peri-procedural safety of anti-platelet therapy in the setting of acute subarachnoid hemorrhage. Our aim was to systematically review the literature on stent-assisted coil embolization of acutely ruptured wide-neck aneurysms to calculate the pooled prevalence of clinical outcome, thromboembolic and hemorrhagic complication rates and overall mortality.

METHODS

We searched PubMed and Google Scholar for articles published between 2009 and 2019 and stratified selected articles based on risk of publication bias. Data on thromboembolic and hemorrhagic complications, clinical outcomes and mortality rates were analyzed using quality-effects model and double arcsine transformation.

RESULTS

24 articles were included featuring a total of 1582 patients. Thromboembolic and hemorrhagic complication rates were witnessed in 9.1% [95% CI: 6.0% - 12.7%; I² = 72.8%] and 8.7% [95% CI: 5.4 - 12.6%; I² = 77.2%] of patients, respectively. 245 patients received external ventricular drains, of which 33 (13.5%) had EVD-related hemorrhages. Total complication rate was 20.8% [95% CI: 14.2 - 28.1%; I² = 87.0%]. 57% of aneurysms were completely occluded and a favorable clinical outcome was reported in 74.7% [95% CI: 66.4 - 82.2%; I² = 86.0] of patients. Overall mortality rate came at 7.8% [95% CI: 4.8 - 11.6%; I² = 76.9%].

CONCLUSION

Stent-assisted coiling of ruptured intracranial aneurysm is a technically feasible procedure with controlled thromboembolic complication rate but may be associated with higher hemorrhagic and total complication rates compared to coiling alone. While stent-assisted coiling of ruptured wide-necked aneurysm seems to yield a lower rate of favorable clinical outcome, overall mortality is comparable to that of endovascular coiling alone.

Rebleeding and bleeding in the year following intracranial aneurysm coiling: analysis of a large prospective multicenter cohort of 1140 patients-Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm (ARETA) Study

BACKGROUND

Endovascular treatment is the first line therapy for the management of ruptured and unruptured intracranial aneurysms, but delayed aneurysm rupture leading to bleeding/rebleeding can occur subsequently. ARETA (Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm) is a prospective, multicenter study conducted to analyze aneurysm recanalization. We analyzed delayed bleeding and rebleeding in this large cohort.

METHODS

16 neurointerventional departments prospectively enrolled patients treated for ruptured and unruptured aneurysms between December 2013 and May 2015 (ClinicalTrials.gov: NCT01942512). Participant demographics, aneurysm characteristics and endovascular techniques were recorded. Data were analyzed from participants with ruptured or unruptured aneurysms treated by coiling or balloon-assisted coiling. Rates of bleeding and rebleeding were analyzed and associated factors were studied using univariable and multivariable analyses.

RESULTS

The bleeding rate was 0.0% in patients with unruptured aneurysms and 1.0% (95% CI 0.3% to 1.7%) in patients with ruptured aneurysms. In multivariate analysis, two factors were associated with rebleeding occurrence: incomplete aneurysm occlusion after initial treatment (2.0% in incomplete aneurysm occlusion vs 0.2% in complete aneurysm occlusion, OR 10.2, 95% CI 1.2 to 83.3; p=0.03) and dome-to-neck ratio (1.5±0.5 with rebleeding vs 2.2±0.9 without rebleeding, OR 0.2, 95% CI 0.04 to 0.8; p=0.03). Modalities of management of aneurysm rebleeding as well as clinical outcomes are described.

CONCLUSIONS

Aneurysm coiling affords good protection against bleeding (for unruptured aneurysms) and rebleeding (for ruptured aneurysms) at 1 year with rates of 0.0% and 1.0%, respectively. Aneurysm occlusion and dome-to-neck ratio are the two factors that appear to play a role in the occurrence of rebleeding.