Thromboembolic Events Associated with Coil Protrusion into Parent Arteries after GDC Treatment

Abstract

Aneurysm embolization using Guglielmi detachable coils(GDC) is gaining acceptance as a viable alternative to surgery in the treatment of cerebral aneurysms. During GDC treatment of cerebral aneurysms, thromboembolic events are the most frequent complications. As risk factors of thromboembolic events, large aneurysms, wide-necked aneurysms, use of the balloon-assisted technique and protruding coils into the parent arteries are previously reported. From March, 1997 till August, 2004, 270 consecutive patients were treated with GDC embolization at our institute. Fourteen (5.2%) patients with 14 aneurysms of these 270 patients presented with protruding coils into the parent vessels. Twelve aneurysms of these 14 aneurysms were small (diameter < 10 mm), and two were large (diameter 15 mm). Nine aneurysms had small necks (neck diameter < 4 mm), and five had wide necks(neck diameter > 4 mm). The fundus-toneck ratio ranged from 1.04 to 2.78, with an average of 1.53. In this series, ten patients (71%) were treated with balloon-remodelling technique because every patient had either a wide-necked aneurysm or complicated morphologic factors. These 14 aneurysms were divided into two groups according to the mode of coil protrusion, loop type and tail type protrusion. The first coil was protruded in five (36%) cases of 14 patients, four of these five cases presented with the loop type protrusion. The last coil was protruded in seven cases (50%), Five of these seven cases presented with the tail type protrusion. Diffusion-weighted imaging abnormalities were found for seven (50%) of 14 patients within 24 hours of the coiling procedures. Three (21%) of 14 patients showed small lesions (< 5 mm) in the subcortical white matter at the border zone or perforating regions. In four (29%) patients, large territorial infarctions (> 5 mm) were detected. Symptomatic complications occurred in four (29%) patients, and all of these four patients presented the loop type protrusion. One patient who had small infarctions experienced minimal deficits (slight motor weakness, quadrantic hemianopsia) after six days postprocedure and fully recovered by discharge after stronger systemic heparinization (24000U, for three days), aspirin (100 mg/day) and Ticlopidine (100 mg/day). Three patients who had large territorial infarctions experienced moderate deficits. Two patients were treated with stronger systemic heparinization and one with Argatroban (60 mg/day, for two days), and following aspirin (100 mg/day) and Ticlopidine (100 mg/day). Finally, two patiens were discharged with permanent minimal deficits (hypoesthesia only) and one with moderate hemiparesis. The infarctions related to the GDC procedures were more common sequelae in wide-necked aneurysms and coil protrusions, especially loop type protrusion. Although permanent neurological deficits were rare, the high rate of thromboembolic events associated with coil protrusion suggest that more aggressive medical treatment should be considered.