Types of thromboembolic complications in coil embolization for intracerebral aneurysms and management

Multiple dissecting intracranial and extracranial aneurysms in rheumatoid arthritis: a rare case

A 52 year old female with a history of rheumatoid arthritis (RA) and persistently raised levels of serum rheumatoid factor and cyclic citrunillated peptide, presented with dissecting aneurysms at the right internal carotid artery, and intact aneurysms at the supraclinoid segment and opening of the right opthalmic artery. Coil embolization was performed. The patient developed an ischaemic stroke two days later.Intra and extra-cranial large vessel aneurysms in RA have rarely been reported in the literature. RA patients with persistent systemic inflammation are at increased risk of developing vascular complications and ischaemic stroke. Here, high levels of tissue-deposited immune complexes may have resulted in cerebral artery vasculopathy. Risk stratification for the development of vascular complications, including cranial aneurysms and ischaemic stroke, in RA patients with poorly controlled systemic inflammation, is important; especially when we consider the neurological sequelae associated with dissecting cerebral aneurysms, cerebral infarction and surgical intervention.

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.

Thromboembolism during coiling of intracranial aneurysms: predictors and clinical outcome

Introduction

Thromboembolism is one of the most serious complications associated with coil embolization therapy.

Aim

To identify predisposing factors for thromboembolic complications, as well as to determine whether thromboembolism has an impact on clinical outcome.

Material and methods

From February 2008 to March 2015, 273 consecutive patients were treated at our institution via endovascular coil embolization. Patient medical records were reviewed with an emphasis on procedure description, potential risk factors and clinical outcomes related to thromboembolism. Thromboembolic incidents occurred in 19 (6.9%) cases. Multivariate logistic regression models were used to determine independent predictors of thromboembolism. Clinical outcome was analyzed using the Glasgow Outcome Scale (GOS).

Results

Multivariate analysis showed that subarachnoid hemorrhage was an independent risk factor for thromboembolic complications (p = 0.003; OR = 4.4; 95% CI: 1.67–12.02). The difference in frequency of perioperative mortality (GOS 1) in patients with thromboembolism and without thromboembolism was not statistically significant (p = 0.22). The differences in frequencies of severe disability (GOS 2–3) and moderate to low disability (GOS 4–5) between patients with thromboembolism and without thromboembolism were statistically significant in the general study population (p < 0.05).

Conclusions

Subarachnoid hemorrhage is an independent predictor of thromboembolic complications associated with endovascular coiling of cerebral aneurysms. Thromboembolism is associated with significantly increased risk of morbidity, and it affects to a certain extent the periprocedural mortality.

Cerebral abscesses after endovascular coiling of a paraophthalmic aneurysm: Case report and review of the literature

Background:

Intracranial infections are a rare complication of therapeutic neuroendovascular procedures.

Case Description:

We present a case of a 72-year-old female with multiple unilateral cerebral hemisphere abscesses after endovascular embolization of a right paraophthalmic aneurysm and also provide a comprehensive review of the literature on cerebral abscesses following neurovascular embolization.

Conclusion:

Infection following coil embolization of cerebral aneurysm is rare. However, it is likely to increase in the setting of increased used of neuroendovascular techniques in the future. Therefore, we suggest that extreme care is taken to ensure proper asepsis during embolization, and a high index of suspicion is maintained in patients with predisposing characteristics (large hemorrhage, ischemia, recurrent endovascular procedures, right-to-left shunt, and concomitant infection). Given the fact that the majority of abscesses occurred in patients who have had ruptured aneurysms, we suggest consideration is given to prophylactic intraprocedural intravenous antibiotics use as seen with open aneurysm treatment.

Endovascular coiling vs. surgical clipping for unruptured intracranial aneurysm: A meta-analysis

BACKGROUND

With increasing use of high-resolution imaging of brain, unruptured aneurysms are more and more frequently detected. With the advances in treatment techniques, an increasing number of aneurysms are now occluded using endovascular coiling instead of conventional surgical clipping. However, the better modality for unruptured intracranial aneurysm has been poorly understood.

OBJECTIVE

The objective of this meta-analysis was to compare the outcomes between endovascular coiling and surgical clipping among patients with unruptured intracranial aneurysms.

METHODS

PubMed, Embase, Web of Science, CENTRAL, and SIGLE were electronically searched from January 1, 1990 to March 13, 2012 with no language restriction for randomized or nonrandomized clinical controlled trials. Article screening and data extraction were conducted in duplicate. Results were statistically pooled through Review Manager 5 and StatsDirect 2.7.9.

RESULTS

Seven studies met our inclusion criteria. The pooled risk ratios (coiling vs. clipping) were 0.59 (95% CI = 0.23-1.54) for death; 0.37 (95% CI = 0.10-1.41) for bleeding; 0.78 (95% CI = 0.38-1.58) for cerebral ischemia; 0.87 (95% CI = 0.70-1.08) for occlusion of aneurysm; 0.53 (95% CI = 0.18-1.52) for independence in daily activities. The pooled rates of death, bleeding, ischemia, occlusion of aneurysm, and mRS no less than 3 were 1% (95% CI = 0-2%), 2% (95% CI = 0-5%), 8% (95% CI = 4-13%), 82% (95% CI = 64-95%), and 5% (95% CI = 1-10%) for endovascular coiling, respectively, and 1% (95% CI = 0-2%), 6% (95% CI = 3-10%), 9% (95% CI = 5-15%), 95% (95% CI = 90-98%), and 8% (95% CI = 3-14%) for surgical clipping, respectively. We failed to evaluate quality of life and cognitive outcome due to insufficient data. Both meta-regression and sensitivity analysis showed consistent results. Furthermore, Begg's test and Egger's test failed to detect publication bias.

CONCLUSION

We suggest that endovascular coiling and surgical clipping bear similar risk ratios of death, bleeding, cerebral ischemia, occlusion of aneurysm, and independence in daily activities and encourage further studies on quality of life and cognitive outcome. However, albeit the results in this meta-analysis are robust, due to great clinical heterogeneity and low quality of studies, the results in this meta-analysis should be interpreted with caution.

Effect of premedication method and drug resistance of antiplatelet agent on periprocedural thromboembolic events during coil embolization of an unruptured intracranial aneurysm

Objective

A retrospective review of premedication method and drug resistance of aspirin and clopidogrel in association with thromboembolic events during and after coil embolization of an unruptured intracranial aneurysm was conducted.

Methods

Our premedication policy for coil embolization of an unruptured intracranial aneurysm has changed from administration of the loading dose before the procedure (i.e. loading group) to repeated administration of the maintenance dose for several days (i.e. preparation group). The loading group (27 patients with 29 aneurysms) and the preparation group (30 patients with 35 aneurysms) were compared for identification of the effect of premedication method on periprocedural thromboembolic events. The results of drug response assays of the preparation group were analyzed with respect to periprocedural thromboembolic events.

Results

No statistically significant difference in incidence of thromboembolic events was observed between the loading group and the preparation group. Analysis of the results of the drug response assay showed high prevalence (56.7%, 73.3%) of clopidogrel resistance and relatively low prevalence (6.7%) of aspirin resistance. Patients who had thromboembolic events tended to have lower responsiveness to both aspirin and clopidogrel than patients without it.

Conclusion

The method of antiplatelet premedication does not affect the rate of periprocedural thromboembolic events in coil embolization for treatment of an unruptured intracranial aneurysm. Nevertheless, considering the high prevalence of drug resistance, it is reasonable to premedicate antiplatelet agents in the preparation method for the drug response assay. Use of a higher dose of aspirin and clopidogrel or addition of an alternative drug (cilostazol or triflusal) can be applied against antiplatelet agent resistance. However, because the hemorrhagic risk associated with this supplementary use of antiplatelet agent has not been well-documented, the hemorrhagic risk and the preventive benefit must be weighed.

Intentional sparing of daughter sac from coil packing in the embolization of aneurysms causing the third cranial nerve palsy : initial clinical and radiological results

OBJECTIVE

Cerebral aneurysms which cause oculomotor nerve [cranial nerve (CN) III] palsy, are frequently found with a daughter sac of the aneurysm dome. We assumed that CN III might be compressed by the daughter sac and it would be more helpful not to fill the daughter sac with coils than vice versa during endosaccular embolization for recovering from CN III palsy, because it may give a greater chance for the daughter sac to shrink by itself later. We reviewed the initial results of our experiences of such cases.

METHODS

Among 9 aneurysms accompanied by CN III palsy, 7 (6 unruptured, 1 ruptured) showed a daughter sac. We tried to fill the main dome completely and spare the daughter sac from coil filling to increase the possibility of decompression. We evaluated the short-term effectiveness of this concept using medical records and angiograms.

RESULTS

After initial embolization, all of CN III palsy caused by unruptured aneurysms (6/6) resolved completely after various periods (3-90 days) of time. No adverse effects were noted during and after the procedures except for one case of harmless coil stretching during coil filling using double microcatheter.

CONCLUSION

During the coil embolization of the cerebral aneurysm causing CN III palsy, sparing the daughter sac from coil packing while tightly packing the main dome, can be helpful in increasing the effectiveness of decompression. However, a long-term follow-up will be required.