Abstract
Background: Despite significant advances in coil embolization of intracranial aneurysms (IA), intra-procedural perforation (IPP) remains a dreaded complication associated with significant morbidity (up to 50%) and mortality (up to38%). Objective: In this study, we sought to analyze all IPP during IA coiling at our center over a 10 year period to determine what characteristics may predict outcome. Methods: This is a retrospective chart review of 1029 consecutive patients who underwent IA coiling from January 2002-May 2012. Variables evaluated included clinical presentation, aneurysm location, morphological aspects and neurological outcomes at discharge. Good outcomes were defined as modified Rankin scale (mRS) 1-3. Results: IPP occurred in 24 patients (2.3% of the cohort). Of all IPP, 83% occurred in previously ruptured IA, 17% in unruptured IA. This corresponded to an overall IPP rate of 4% and 0.8% respectively. Overall morbidity at discharge (mRS 4,5) was 31.8% and mortality 8.3%. Overall, good outcome was noted in 44.4% immediately post-procedure and 68.2% at discharge. Among patients with unruptured IA and those with good Hunt-Hess (HH) grade (1-3), 92% had good outcome at discharge vs. 54.6% with poor HH, p=0.03. Patients with proximal IA (proximal to internal carotid artery bifurcation or close to basilar artery stem) had better discharge outcomes (41.7%) than distal IA (33.3%), p= 0.04; this was statistically significant after controlling for HH in logistic regression analysis. Between 2002-2007, balloon-assisted coiling (BAC) was utilized in only 20% of IPP cases and 2 mortalities were recorded. After 2007, BAC was used in 60% of IPP cases with no subsequent mortalities. Conclusion: It appears that the incidence of IPP is very low, with good outcomes occurring in a significant portion of the patients. Patients with good neurological exam at presentation are likely to have good discharge outcomes despite IPP. Proximal IA are associated with better discharge outcomes: IPP in this location may be easier to control endovascularly. Techniques like BAC allow for prompt hemostasis once IPP occurs, and might reduce mortality rates.
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