Rebleeding of Ruptured Intracranial Aneurysms in the Immediate Postoperative Period after Coil Embolization

Evaluation of Early Recurrence after Coil Embolization for Ruptured Anterior Communicating Artery Aneurysms

Objective

We retrospectively examined the risk factors for early recurrence in patients with ruptured anterior communicating artery (AcomA) aneurysms who underwent coil embolization.

Methods

Forty-four patients with ruptured AcomA aneurysms who underwent coil embolization between January 2012 and June 2021 were included. Patient backgrounds, anatomical features, intraoperative anticoagulation, and radiological findings before and after treatment were reviewed retrospectively. Univariate analysis was performed separately for each item investigated in the early recurrence (ER) and non-early recurrence (NER) groups. Additionally, the relationship between changes in embolic status (Raymond-Roy classification [RRC]) from immediately after surgery to 2 weeks later and severity of disease was investigated.

Results

Re-treatment was performed in a total of 8 (18.2%) cases. Two cases were detected and treated in the chronic phase with no re-rupture. In the ER group, 6 (13.6%) cases had RRC class 3 filling without evidence of coil compaction on digital subtraction angiography performed 2 weeks after the initial embolization, and were re-treated. The mean intraoperative activated clotting time (ACT; p = 0.0226; NER median 189.5 s, ER median 149 s), contralateral A1 diameter (p = 0.0264; NER median 0.85 mm, ER median 0.26 mm), and volume embolization rate (VER; p = 0.02, NER median 35.57%, ER median 20.86%) were significantly lower in the ER group. The more severe the Hunt and Hess grade, the worse the embolic condition (RRC) tended to be after 2 weeks (p = 0.0339).

Conclusion

In this study, factors such as low intraoperative ACT, low VER, contralateral A1 hypoplasia, and condition severity may be associated with early recurrence after acute coil embolization for ruptured AcomA aneurysms.

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.

Causal Effect Estimation on Imaging and Clinical Data for Treatment Decision Support of Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage is a medical emergency of brain that has high mortality and poor prognosis. Causal effect estimation of treatment strategies on patient outcomes is crucial for aneurysmal subarachnoid hemorrhage treatment decision-making. However, most existing studies on treatment decision-making support of this disease are unable to simultaneously compare the potential outcomes of different treatments for a patient. Furthermore, these studies fail to harmoniously integrate the imaging data with non-imaging clinical data, both of which are useful in clinical scenarios. In this paper, we estimate the causal effect of various treatments on patients with aneurysmal subarachnoid hemorrhage by integrating plain CT with non-imaging clinical data, which is represented using structured tabular data. Specifically, we first propose a novel scheme that uses multi-modality confounders distillation architecture to predict the treatment outcome and treatment assignment simultaneously. With these distilled confounder features, we design an imaging and non-imaging interaction representation learning strategy to use the complementary information extracted from different modalities to balance the feature distribution of different treatment groups. We have conducted extensive experiments using a clinical dataset of 656 subarachnoid hemorrhage cases, which was collected from the Hospital Authority Data Collaboration Laboratory in Hong Kong. Our method shows consistent improvements on the evaluation metrics of treatment effect estimation, achieving state-of-the-art results over strong competitors. Code is released at https://github.com/med-air/TOP-aSAH.

Coil Embolization with Subsequent Subacute Flow Diversion Before Hospital Discharge as a Treatment Paradigm for Ruptured Aneurysms

BACKGROUND

Subtotal coil embolization followed by subsequent flow diversion is often pursued for treatment of acutely ruptured aneurysms. Owing to the need for anti-platelet therapy, the optimal time of safely pursuing flow diversion treatment has not been fully elucidated. In this study, we aim to demonstrate the safety and feasibility of staged treatment of acutely ruptured aneurysms with early coil embolization followed by flow diversion prior to discharge.

METHODS

A retrospective study to evaluate clinical outcomes of patients who presented with aneurysmal subarachnoid hemorrhage and underwent coil embolization followed by subacute flow diversion treatment during the same hospitalization.

RESULTS

A total of 18 patients are included in our case series. Eight patients presented with Hunt-Hess (H-H) grade 2 bleed, 6 patients with H-H grade 3, and 2 patients each with H-H grade 4 and H-H grade 1. Eight patients required placement of an external ventricular drain on admission. After initial coil embolization, 12 achieved Raymond-Roy grade 2 occlusion, and 6 attained grade 3a/b occlusion. The mean duration between coil embolization and subsequent flow diversion was 9.83 days (range: 1-30). There were no instances of re-hemorrhage between initial coil embolization and subsequent flow diversion treatment. Sixteen patients had a minimum of 6-month follow-up, of which 15 were found to have complete occlusion, and 1 required subsequent clipping.

CONCLUSIONS

Subtotal coil embolization followed by definitive treatment using flow diversion during the same hospitalization is feasible and achieves excellent aneurysm occlusion rates while avoiding dual anti-platelet therapy during the initial hemorrhage period.

Hematoma expansion unrelated to rebleeding in ruptured anterior cerebral artery aneurysms treated by early endovascular embolization

Background:

Whether hematoma expansion after aneurysmal rupture is always a sign of rerupture remains unclear. Hence, the present study aimed to assess the incidence and risk factors of hematoma expansion unrelated to aneurysmal rerupture after endovascular embolization for ruptured cerebral aneurysms.

Methods:

We included patients who underwent endovascular embolization for ruptured cerebral aneurysms within 48 h after onset at our institution between January 2009 and February 2014. The medical records of 70 consecutive patients were reviewed and analyzed retrospectively.

Results:

Hematoma expansion unrelated to aneurysmal rerupture occurred in 7 (10%) of 70 patients. Interestingly, four of seven patients had distal anterior cerebral artery (ACA) aneurysms. The interval from onset to aneurysm coiling was shorter in patients with hematoma expansion than in those without (P = 0.040).

Conclusion:

Early embolization of ruptured ACA aneurysms might increase the risk of hematoma expansion unrelated to aneurysmal rerupture because the procedures were conducted under systemic anticoagulation. It would be better to refer the patient for direct clipping if the patient has a distal ACA aneurysm with parenchymal hematoma at interhemispheric fissure. Delayed coil embolization, which means around 12–18 h delayed, might be another option for ruptured distal ACA aneurysms to prevent hematoma expansion.

Knowledge framework and emerging trends in intracranial aneurysm magnetic resonance angiography: a scientometric analysis from 2004 to 2020

Background

As magnetic resonance angiography (MRA) has been increasingly used in the follow-up of intracranial aneurysms (IAs) as a non-invasive technique, the knowledge framework and areas of research interest in intracranial aneurysms magnetic resonance angiography (IAMRA) change approximately every 10 years. However, few studies have quantitatively analyzed the published literature in this field. In the present study, we used scientometrics to survey the knowledge field, development trends, and research focus of IAMRA with the aim of providing a reference for further study.

Methods

We collected articles on IAMRA published from 2004 (Jan 1, 2004) to 2020 (May 24, 2020). Web of Science Core Collection databases (WoSCCd) including the Science Citation Index Expanded were searched. An experienced staff member from the Department of Radiology at Southern Medical University, assisted in screening articles for relevant articles. We used ArcGIS (a mapping and location analytics platform) to perform geographic visualization. Excel 2016 was used to analyze the literature data, including number of publications, impact factor (IF), and publication year. CiteSpace V was used to conduct a series of literature feature clustering, including author co-citation analysis, reference co-citation analysis (RCA), and burst keywords analysis.

Results

A total of 1,272 articles on IAMRA published between 2004 and 2020 were included. Of 257 journals, American Journal of Neuroradiology (IF 2018: 3.256) published the most IAMRA articles (109 publications, 8.57%), followed by Journal of Neurosurgery (IF 2018: 4.131, 51 publications, 4.16%), and Neuroradiology (IF 2018: 2.504, 51 publications, 4.01%). Of 56 countries, the USA published the most, with 347 articles [27.28%, IF: 3.14 (average IF of all journals in the country)], followed by Japan (242 articles, 19.03%, IF: 2.38), Germany (135 articles, 10.61%, IF: 3.21), and China (101 articles, 7.94%, IF: 2.86). A total of 1387 institutions published articles, with the Mayo Clinic publishing the most (33 articles, 2.59%), followed by Shanghai Jiao Tong University (25 article, 1.97%), Seoul National University (23 articles, 1.81%), and University Medical Center Utrecht (19 articles, 1.49%). Of 399 authors, Rinkel ranked first with 19 articles, followed by Li MH (18 articles), Uchino A (15 articles), and Saito N (13 articles). Cluster RCA showed that the first cluster was "#0 growth", followed by "#1 Guglielmi detachable coils". Timeline views showed that the time span of "#0 growth" was the closest to today. The modularity value was 0.6971, and the mean silhouette value was 0.5477. According to the burst keyword analysis, "risk factors associated to rupture" was the topic with the strongest burst since 2017. Studies conducted in several countries suggested that age is inversely related to the risk of rupture, which implies the importance of MRA follow-up for patients of different age.

Conclusions

From 2004 to 2020, the number of published IAMRA-related articles gradually increased. The USA and Western Europe lead in the field, with a concentration of cutting-edge talents and high-level scientific research institutions. A synthesis of the clustering results of RCA and burst keyword analysis indicated that unruptured IA growth, stent-assisted coil embolization, and risk factors associated to rupture were the current hotspots in IAMRA research.

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.

Factors related to adverse events during endovascular coil embolization for ruptured cerebral aneurysms

BACKGROUND AND PURPOSE

The risk factors for adverse events for example, intraprocedural rupture (IPR), ischemic complication within 24 hours, and rebleeding after endovascular coil embolization for a ruptured cerebral aneurysm remain unclear. The aim of this study was to identify significant associated risk factors.

METHODS

We retrospectively evaluated data from 5358 patients listed on the Japanese Registry of Neuroendovascular Therapy 3 during 2010-2014.

RESULTS

IPR, ischemic complications, and rebleeding occurred during or after 221 (4.1%), 226 (4.2%), and 63 (1.2%) treatments, respectively. All of the adverse events were significantly associated with the patients' poor outcomes at 30 days. Multivariate analysis revealed the factors independently related to these adverse events as follows: (1) for IPR: female sex, bifurcation type, <5 mm aneurysm, emergent surgery, local anesthesia, a balloon-assisted technique; (2) for an ischemic complication: poor World Federation World Federation of Neurological Societies (WFNS) grade, wide neck, and stent-assisted technique; (3) for rebleeding: poor WFNS grade, bifurcation type, wide neck, and body filling as the initial result.

CONCLUSIONS

Knowledge of the risk factors of endovascular coil embolization and paying attention to them are essential for patients' safe treatment and good outcomes.

A hybrid operating room for combined surgical and endovascular procedures for cerebrovascular diseases: a clinical experience at a single centre

Purpose: To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR). Material and methods: A single-plane DSA system with 3-dimensional rotational angiography (3DRA), cone-beam computed tomography, and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of neurovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorised into five subcategorical procedures according to the dominance of surgical and/or endovascular procedures: intraoperative angiographic evaluation, combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, surgical approach for interventional procedure, and frameless stereotaxic operation. Results: Intraoperative angiography revealed unsatisfactory clipping of intracranial aneurysms in 6 (13.6%) patients and remnant AVMs in 1 (16.7%) patient, which were determined as complete surgical outcome via indocyanine green videoangiography. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial haemorrhage (ICH) were treated by partial embolisation and surgical clipping. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolisation. In 1 (0.8%) complicated case of 103 intra-arterial (IA) thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. Direct puncture of the common carotid artery or vertebral artery was performed to achieve interventional access to treat aneurysm or recanalise vessel occlusions in 7 cases. In 27 cases of ICH, frameless stereotaxic haematoma aspiration was performed using XperGuide® system. All procedures were performed in single sessions without any procedural complications. Conclusion: Hybrid OR with a fully equipped DSA system could provide safe and precise treatment for neurovascular diseases. Hybrid procedures for neurovascular diseases in hybrid OR are a promising new trend.

Four-Year Experience Using an Advanced Interdisciplinary Hybrid Operating Room : Potentials in Treatment of Cerebrovascular Disease

Objective

To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR).

Methods

A single-plane DSA system with 3-dimensional rotational angiography, cone-beam computed tomography (CBCT), and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of cerebrovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorized into three subcategorical procedures : combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, and frameless stereotaxic operation.

Results

Forty-nine of 191 procedures were performed using hybrid techniques. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial hemorrhage (ICH) were treated by partial embolization and surgical clipping. Six cases of ruptured arteriovenous malformation with ICH were treated by Onyx embolization of nidus and subsequent surgical removal of nidus and ICH. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolization. In one (0.8%) complicated case of 103 intra-arterial thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. In 27 cases of ICH, frameless stereotaxic hematoma aspiration was performed using XperGuide^® system (Philips Medical Systems, Best, the Netherlands). All procedures were performed in single sessions without any procedural complications.

Conclusion

Hybrid OR with a fully equipped DSA system could provide precise and safe treatment strategies for cerebrovascular diseases. Especially, we could suggest a strategy to cope flexibly in complex lesions or unexpected situations in hybrid OR. CBCT with real-time navigation software could augment the usefulness of hybrid OR.

‘Plug and pipe’ strategy for treatment of ruptured intracranial aneurysms

Background

Aneurysmal subarachnoid hemorrhage is a potentially devastating condition, and among the first priorities of treatment is aneurysm occlusion to prevent re-hemorrhage. An emerging strategy to treat patients whose aneurysms are not ideal for surgical or endovascular treatment is subtotal coiling followed by flow diversion in the recovery phase or ‘plug and pipe’. However, data regarding the safety and efficacy of this strategy are lacking.

Methods

A retrospective cohort study was performed to evaluate the efficacy and safety of ‘plug and pipe’. All patients with a ruptured intracranial aneurysm intentionally, subtotally treated by coiling in the acute stage followed by flow diversion after recovery, were included. The primary outcome was re-hemorrhage. Secondary outcomes included aneurysm occlusion and functional status. Complications were reviewed.

Results

22 patients were included. No patient suffered a re-hemorrhage, either in the interval between coiling and flow diversion or in follow-up. The median interval between aneurysm rupture and flow diversion was 3.5 months. Roy–Raymond (R-R) class I or II occlusion was achieved in 91% of target aneurysms at the last imaging follow-up (15/22(68%) R-R 1 and 5/22(23%) R-R 2). Complications occurred in 2 (9%) patients, 1 of which was neurological.

Conclusions

Overall, these data suggest that subtotal coiling of ruptured intracranial aneurysms followed by planned flow diversion is both safe and effective. Patients who may most benefit from ‘plug and pipe’ are those with aneurysms that confer high operative risk and those whose severity of medical illness increases the risk of microsurgical clip ligation.

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

Acute rerupture after coil embolization is defined as rerupture within three days after treatment; its prognosis is worse than that of rebleeding at other time periods. However, to date, little is known about complications during the acute phase. Therefore, we used the PubMed database to perform a review of acute rerupture after coil embolization of ruptured intracranial saccular aneurysms and increase our understanding. After reviewing the complications, we found that the cause of acute rerupture is unclear, but the following risk factors are involved: incomplete occlusion of the initial aneurysm, the presence of a hematoma adjacent to a ruptured aneurysm, an aneurysmal outpouching, poor Hunt-Hess grade at the time of treatment, and the location of the aneurysm in an anterior communicating artery. In addition, intraoperative rupture is a non-negligible cause. Acute rerupture after coil embolization mainly occurs within the first 24 hours after the procedure. Brain computed tomography is the gold standard for diagnosing acute rebleeding of a coiled aneurysm. For acute rerupture after coil embolization, prevention is critical, and complete occlusion of the aneurysm in the first session is the best protection against acute rebleeding. In addition, a restricted postembolization anticoagulation strategy is recommended for patients with high-risk aneurysms. For patients with an adjacent hematoma, surgical clipping is recommended. Most patients present no changes immediately after acute rebleeding because of their poor condition. However, surgical or endovascular treatments can be attempted if the patient is in an acceptable condition. Even so, the outcomes are typically unsatisfactory.