Radiological demonstration of rupture of a carotid aneurysm during cerebral angiography. Case report

Severe intracranial bleedings during endovascular procedures: outcome of surgically treated patients

OBJECTIVE

Severe intracranial bleedings (SIBs) during endovascular procedures (EPs) are accompanied by acute intracranial hypertension and brain herniation signs. The purpose of this study was to determine the effectiveness of urgent surgical management and its related patient outcome in cases with such a fatal complication.

METHOD

Medical records were reviewed retrospectively for the last 750 patients treated in our department in the past 12 years with acute non-traumatic intracranial bleeding, who underwent a diagnostic or therapeutic EP. Patients with a severe intra-procedural bleeding episode undergoing urgent surgical management (within 30 minutes after bleeding) were analysed.

RESULTS

Fourteen of 750 patients with ruptured vascular malformations presented a new SIB during EP. In nine patients, this occurred during initial angiography, two during aneurysm coiling, two during balloon angioplasty and one during arteriovenous malformation (AVM) embolization. The neurological condition 6 months later was good (independents patients) in seven cases with only a mild disability in two of them. Two patients showed a severe disability. Four patients died without recovering their consciousness. One patient presented a satisfactorily course but died weeks later owing to a pulmonary embolism.

CONCLUSION

Despite the fatal spontaneous prognosis of severe intracranial bleeding occurring during endovascular diagnostic or therapeutic procedures, a favorable outcome can be expected if an appropriated treatment was set within 30 minutes of the bleeding.

Causes and management of aneurysmal hemorrhage occurring during embolization with Guglielmi detachable coils

OBJECT

The purpose of this review is to describe the incidence, causes, management, and outcome of aneurysmal hemorrhage that occurred in patients during endovascular treatment with the Guglielmi detachable coil (GDC) system.

METHODS

At the authors' institution between September 1991 and August 1995, more than 200 patients were treated using GDCs for intracranial aneurysms. The first 200 patients treated in this fashion were reviewed and all who experienced new subarachnoid hemorrhage (SAH) during the procedure were identified. Angiographic studies were also reviewed and patients were contacted for longer-term follow up when possible. Four patients who experienced intraprocedural SAH were identified. The causes of hemorrhage were believed to be perforation of the aneurysm by the guidewire in one patient, perforation by the microcatheter in a second, and perforation by the delivery wire in a third. The fourth patient had a hemorrhage during injection of contrast material for control angiographic studies after placement of the final coil. One patient died, but the other three experienced no neurological symptoms or recovered without acquiring additional deficits. Overall a procedural hemorrhage rate of 2% was seen, with permanent morbidity and mortality rates of 0% and 0.5%, respectively.

CONCLUSIONS

Although SAH during endovascular treatment of intracranial aneurysms remains a significant risk, its incidence is low and a majority of patients can survive without serious sequelae.

Aneurysmal rupture during angiography

The aim of the present study was to analyze the clinical data on rebleeding in cerebral aneurysms during angiography and to evaluate the importance of the time interval between the latest rupture and angiography. Fourteen personal cases and 202 patients reported in the literature are reviewed. Rebleeding during angiography occurred most often (78%) on Day O; 89% bled when angiography was performed within 6 hours of the latest rupture. The prognosis in such ruptures was poor, with a mortality of 79%. Intentional delay in angiography of at least 6 hours from the latest rupture is recommended if the associated hematoma is not large.

Rerupture of intracranial aneurysms during angiography

We analyzed 70 patients (64 from the literature and 6 of our own cases) who had suffered from rerupture of their aneurysms during angiography. When these cases are compared with those who had suffered rupture of their aneurysms only once and a rerupture, which did not coincide with angiography, they were clinically distinguished by a higher Hunt-Hess grade, a higher rate of IC aneurysms, less operability, far miserable outcome and concentration of aneurysmal rerupture within three hours after the initial subarachnoid haemorrhage. It is suggested waiting at least 3 hours after SAH before performing angiography and to use digital subtraction angiography in order to prevent aneurysmal rerupture during angiography.

Transcranial Doppler sonography within 12 hours after subarachnoid hemorrhage

Twenty-one patients were subjected to repeated assessment of cerebral blood flow velocities by means of transcranial Doppler sonography (TCDS) during the first 12 hours after subarachnoid hemorrhage (SAH). In 19 patients the study was performed following the first SAH, and in two after early rebleeds. Flow velocities did not indicate an early phase of arterial narrowing in any case. Following the first TCDS assessment, flows were evaluated repeatedly in the 19 survivors. Increased flow velocities suggesting arterial narrowing or vasospasm occurred only after a delay of at least 4 days. The results of this study favor the restoration of normal velocity patterns in surviving patients and do not indicate that an acute phase of vasospasm exists either immediately after or in the first 12 hours after SAH.

Aneurysmal subarachnoid haemorrhage: overall outcome and incidence of early recurrent haemorrhage despite a policy of acute stage operation

A series of 480 patients who were alive upon admission following an aneurysmal subarachnoid haemorrhage (SAH) is reported. These patients represented 40% of the total Swedish incidence during a 3-year period. The three neurosurgical referral centres covering this population had a similar policy of early diagnosis and acute state surgery in all patients considered of having a potential to survive without permanent disabling cerebral malfunction. At 2-year follow up 45% showed a good neurological recovery, the morbidity was 25% and the mortality was 30%. Some more lives might have been saved with an improved ultra-early referral system since there were 21 initially good-to-fair risk patients (4% of the total SAH population) who rebled fatally before surgery and within 48 h. For comparison, in the Kingdom of Denmark, with a general policy of delayed operation, out of 1076 patients who were alive upon admission, 27.5% made a good recovery, while the morbidity was 27%, and the mortality was 45.5%.

Rupture of intracranial vascular lesions during arteriography

Four cases with ruptured intracranial vascular lesions during angiography and confirmed radiologically are presented to emphasise a dangerous complication of the procedure.

Rupture of intracranial aneurysms and ventricular opacification during carotid angiography

Two cases of rupture of intracranial aneurysms and opacification of the lateral ventricles occurring during carotid angiography are reported and X-rays of the haemorrhage from the aneurysms are presented. Though the possibility of this complications remains a real one, the early use of this valuable procedure should not be precluded.

Rupture of an intracranial aneurysm of the carotid artery with ventricular visualization during angiography

Rupture of an aneurysm during angiography, with extravasation of blood and contrast medium into the ventricular system occurs rarely. We wish to add one personal observation to those few cases already published. Haemorrhage from an aneurysm of the internal carotid artery recurred during angiography in a 52-year-old comatose man. Through extravasation of blood and contrast medium into the ventricles these became fully visible on the X-ray screen. The question of a direct causal relationship between angiography and rupture of an aneurysm, the frequency and risk of this coincidence and mortality are discussed. Since computerised tomography now precedes angiography in cases of subarachnoid haemorrhage, complications arising from angiography could be reduced by proper timing.

Angiographic extravasation of contrast medium in a case of ruptured arteriovenous malformation

A case with angiographic extravasation of contrast medium from ruptured vessels in an arteriovenous malformation is reported and a review of the literature presented.

Intracranial extravasation of contrast medium during carotid angiography

The results of 5184 carotid angiograms were reviewed and five cases of intracranial extravasation of contrast medium were found. In two cases an aneurysm ruptured during angiography and extravasation into the subarachnoid space was seen. In one case medium leaked from an angiomatous malformation into the subdural space. The fourth case was a patient who had suffered closed head trauma. Here extravasation was seen deep within the brain. The fifth case illustrates two forms which extravasation from meningeal arteries may take. The incidence and prognostic significance of this finding in different conditions are discussed.

Contrast medium extravasation from aneurysmal rupture during cerebral angiography

The radiographic demonstration of contrast medium extravasation from a rupturing intracranial aneurysm is rare. We have detected this occurrence a mere thrice in 15 years, a period in which angiography was routinely used for the investigation of subarchnoid haemorrhage. We have added these three cases to 14 others that were previously reported in the literature and summarised the total. There does not appear to be a common aetiological factor, though further experimental studies on intracaratid pressures distal to the site of injection seem to be warranted. Ventricular opacification during cerebral angiography occurred in five of the 17 cases: in our most recent case the contrast medium outlined intraventricular haematomata, a finding not hitherto reported in the literature and a feature of prognostic significance. Mortality in this series was extremely high and in excess of that usually found either with an aneurysmal re-bleed or an intracerebral haematoma or both. However, although a combination of these two lesions is notoriously hazardous, perhaps the added insult of the contrast medium extravasation is the cause for the inordinately high fatality rate. Only three of the 17 cases survived, two of whom had a significant residual neurological deficit.

Extravasation of contrast material into subdural space from internal carotid aneurysm during angiography. Case report

✓ A case of multiple aneurysms is reported in which rupture of the internal carotid aneurysm occurred during carotid angiography, opacifying the subdural space. The patient recovered and was successfully treated by clipping of the aneurysm neck.