Endovascular Coiling Of Aneurysm Research Articles

Glycoprotein IIb/IIIa inhibitors in the treatment of thromboembolic events related to endovascular treatment of cerebral aneurysms-systematic review and meta-analysis.

Thromboembolism complication is considered the most common complication associated with the treatment of endovascular. This systematic review and meta-analysis aimed to assess the studies investigating the effect of glycoprotein IIb/IIIa inhibitor agents on thromboembolic complications during endovascular aneurysm coiling. This systematic review investigated the outcome of the use of three glycoprotein IIb/IIIa inhibitor agents (ie abciximab, tirofiban, and eptifibatide) on the thromboembolic complications during endovascular aneurysm coiling. The electronic databases of PubMed, Web of Science, Scopus, and Medline were searched up to 25 June 2021, using the keywords "Abciximab," "Tirofiban," and "Eptifibatide" incombination with "Thromboembolism Complication," "Aneurysms," and "Endovascular Aneurysm Coiling." A total of 21 articles were found to be eligible and included in this review. The rates of complete and partial recanalization were estimated to be 56% and 92% in patients who underwent abciximab and tirofiban therapy, respectively. Rupture aneurysms were found in the majority of patients. In general, the mortality rate of the patients treated for thromboembolic complications during endovascular treatment of cerebral aneurysms with glycoprotein IIb/IIIa inhibitors was found to be 4.8% (CI 95%:0.027-0.067; p < .005). The average remission rate in studies investigating thromboembolism was 91% (CI 95%:0.88-0.95, I2 : 65.65/p < .001). Based on the obtained results, a higher mean rate of complete recanalization by eptifibatide was found in studies in which abciximab or tirofiban were used, compared to other mentioned agents. Moreover, the amount of hemorrhage was reported to be less after using tirofiban rather than abciximab.

Recurrent Foreign Body Reactions to Neuroendovascular Polymers—A Clinicopathologic Case Study

Objective We provide histopathologic and neuroimaging evidence of recurrent foreign body reactions in a patient following separate stent-assisted coiling of two contralateral intracranial aneurysms a decade apart. Background Stent-assisted endovascular coiling for wide-neck cerebral aneurysms introduces permanent foreign materials into the cerebral vasculature. While foreign body reactions after endovascular coiling are increasingly reported in the literature, compelling histopathologic data remains very limited. Design/Methods Electronic medical record review for clinical details and neuroimaging. Histopathology was extensively reviewed with a neuropathologist. Results A 37-year-old woman presents with left arm weakness. Magnetic resonance imaging (MRI) shows numerous enhancing lesions with large multifocal T2 FLAIR changes in the right hemisphere. An extensive vascular, infectious, autoimmune, and neoplastic workup returns negative. Months earlier, she had undergone stent-assisted coiling of a right internal carotid artery (ICA) aneurysm. A decade prior, she had presented with focal right-sided seizures after coiling of a left ICA aneurysm; MRI brain at the time revealed two enhancing lesions in the left hemisphere of unclear etiology. A brain biopsy is performed, and histopathology reveals multifocal, chronic micro-abscesses characterized by collections of neutrophils surrounded by a rim of multinucleated giant cells and histiocytes which are in turn rimmed by fibrosis and granulation tissue. Staining is negative for neoplastic changes and infectious organisms. Rare filamentous structures are identified in association with the giant cells; these resemble coil polymers described in the endovascular literature and are highly suspicious for inducing a neuroinflammatory foreign body reaction. She improves following glucocorticoid treatment, and repeat imaging shows substantial reduction in parenchymal abnormalities. Conclusions Foreign body reactions are an uncommon complication of endovascular aneurysm coiling and can manifest as an embolic inflammatory phenomenon. These neuroinflammatory reactions are driven by endovascular polymers and responsive to glucocorticoid treatment. Heightened awareness can facilitate earlier diagnosis and treatment, with prompt neuroimmunology consultation for repeat endovascular procedures.

Flow diverter manages very small aneurysm of the internal carotid artery.

Endovascular aneurysm coiling is a minimally invasive method to manage intracranial aneurysms. However, aneurysm coiling may fail in very small aneurysms (VSAs); thus, flow diverter (FD) is recommended as an alternative in these difficult aneurysms. Herein, we report our experience and outcomes of FD to treat VSA of the internal carotid artery (ICA). Over a 3-year period, a total of 70 patients with 87 unruptured VSAs of the ICA were managed by FD. There were 54 men and 16 women, with a mean age of 57 (range, 41-75) years. We retrospectively assessed the clinical data, aneurysm characteristics, and angiographic as well as clinical outcomes of patients treated by FD and compared with larger aneurysms. Fifty aneurysms (58%) were located in the supraclinoid ICA, followed by paraclinoid ICA (n = 31, 36%) and cavernous ICA (n = 6, 7%). Most aneurysms (n = 72, 83%) were between 2 and 3 mm in size. The mean aneurysm size was 2.3 mm (range, 1.5-3 mm). Follow-up angiographic data (mean, 13 months) were available in 54 patients with 68 aneurysms. Successful FD deployment in an ideal position to bride aneurysm was achieved in 86 of 87 aneurysms (99%). Complete obliteration (CO) was achieved in 63 aneurysms (93%). Compared with larger aneurysms (>3 mm), VSAs had the tendency to achieve CO ( p < 0.05) in a midterm follow-up. Two patients (2.8%) had intraprocedural complications, including in-stent thrombosis (n = 1) and distal embolism (n = 1). One patient (1.4%) suffered from mild limb weakness. The use of FD to manage VSA was technically feasible, and the procedure was simpler than those of larger aneurysms. FD stenting of VSAs was confirmed to be effective and safe and had higher CO rate than those in larger aneurysms in a midterm angiographic follow-up.

Prediction of the extent of thrombus formation in the parent artery after endovascular occlusion of a distal anterior cerebral artery aneurysm using computational fluid dynamics

Endovascular coiling of a cerebral aneurysm and coil occlusion of the parent artery have been occasionally performed to treat cerebral aneurysms; however, it is difficult to predict the accurate extent of thrombus formation in the parent artery proximal to the coiled aneurysm and the coil-occluded parent artery preoperatively, and unexpected occlusion of the arterial branches can occur by thrombus extension into or in the parent artery. The authors describe a case of a distal anterior cerebral artery (ACA) aneurysm treated by endovascular parent artery occlusion (PAO) with preoperative computational fluid dynamics (CFD) prediction of the extent of thrombus formation. A 73-year-old woman presented with subarachnoid hemorrhage and an aneurysm that was located on the right pericallosal artery distal to the paracentral artery bifurcation. Endovascular coiling of the aneurysm and the pericallosal artery was planned. In advance of the treatment, CFD was performed to predict the extent of thrombus formation with specific wall shear stress and shear rate thresholds. The hemodynamic results indicated that coiling of the aneurysm resulted in thrombus formation in the pericallosal artery up to just distal to the paracentral artery ostium; therefore, the treatment was implemented according to the CFD prediction. Postoperative digital subtraction angiography revealed that the extent of thrombus formation was consistent with the preoperative CFD prediction. This technique may prevent unexpected occlusion of arterial branches.

Predictors of shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: a pilot study in a single Egyptian institute

BackgroundAcute hydrocephalus can cause neurological deterioration after aneurysmal subarachnoid hemorrhage (aSAH). Predicting which patient would require shunting is challenging.MethodsThis prospective study was conducted upon twenty patients who suffered acute hydrocephalus due to subarachnoid hemorrhage of ruptured aneurysms. Surgical or non-surgical management of hydrocephalus was conducted. Glasgow Coma scale (GCS) was assessed, and hydrocephalus was graded by bicaudate index. Fisher grade was determined from CT scan. Aneurysm site was determined by conventional or CT angiography. Either surgical clipping or endovascular coiling of aneurysms was performed.ResultsInitially, 3 (15%) patients had emergency CSF diversion on admission due to poor GCS on arrival. Initially, the remaining 17 patients were managed conservatively. Five patients did not require any intervention. Twelve patients had external ventricular drainage placement, 4 were weaned, and 8 failed weaning. High bicaudate index (> 0.2) correlated with shunting. Aneurysm site correlated well with shunting (ACoA or PCoA).ConclusionsPatients with fair GCS can be managed conservatively. Any deterioration warrants shifting to CSF diversion. Higher bicaudate index will usually need CSF diversion. The value of Fisher carries no significant value. Aneurysm location (ACoA or PCoA) correlates with an increased incidence of ventriculoperitoneal shunt placement.

Cerebral Aneurysmal Coiling in Virtual Reality ‐ An Overview of Novice Skill Development

Introduction and AimsCerebral endovascular aneurysm coiling is an interventional angiography technique which requires the use of fine motor and visuo‐spatial skills in order to guide tools throughout relevant vascular anatomy and deposit coils within the aneurysm. With the help of quantitatively limited fluoroscopy, coils are established through microcatheter placement in the aneurysm neck and electrolytically detached after their appropriate rotation and positioning. This procedure requires, and is currently limited to, extensive clinical training in the AngioSuite, where trainees are closely supervised by a consultant. This approach, although providing the current gold standard in training, limits the pace of skill development, exposes patients to unnecessary risk and wastes valuable monetary and personnel resources. The development of the skills needed for these procedures can be facilitated by 3D simulator‐based training. Simulation‐based medical education has recently started focusing on personalized training in reducing errors and development of specific skills.The ANGIO Mentor visual‐haptic simulator has been regarded as an effective training tool, increasing performance in diagnostic cerebral angiography, however, this simulator has not been tested thoroughly in its ability to train interventional skills. In particular, the details of the aneurysm coiling process during simulation‐based training have not been assessed.MethodsIn this study, 12 novice medical students were given simulation‐based diagnostic cerebral angiography training until a procedural plateau in performance, established in our previous work (Zaika et al., 2016). Subsequently, they were trained using video tutorials and written instructions to identify, measure and intervene with cerebral aneurysms using endovascular coils. Over the span of 6 sessions, participants were assessed on their procedural pace, coiling quantity and quality, and perforation rates. Concurrently, their spatial ability was assessed using a mental rotations test (MRT) and used in the performance analysis.Results and DiscussionWe found that all individuals were able to perform the procedure faster after 6 sessions, reducing their average time from 42 to 24 minutes. Coil success rate improved over from 82% to 88% and coil packing rate remained consistent at 30% throughout testing. High perforation rate seen at the start of the study showed a trend of decreasing over the latter sessions, however, over half of aneurysms were still being perforated by the novice participants. No change in aneurysm coiling quality was found, with a slight decrease in number of parent artery coil protrusions. High MRT individuals were also better able to establish guider catheter and associate tools prior to coiling. This work identifies the utility of simulation‐based cerebral angiography training in identifying the particular difficulties trainees experience in learning procedural skills, including prevention of perforations, proper positioning and success of coils within the aneurysm.Support or Funding InformationThis research was funded by the Natural Sciences and Engineering Research Council of Canada (NSERC) and the Canadian Institutes of Health Research (CIHR).This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

The Prognosis Factors for Endovascular Coiling of Aneurysm in Patients With Ruptured Intracranial Aneurysm.

The spontaneous subarachnoid hemorrhage caused by aneurysm rupture often leads to a variety of complications. Endovascular coiling is effective in the treatment of ruptured intracranial aneurysm. The authors aim to evaluate the risk factors affecting the prognosis of ruptured intracranial aneurysm in patients who received endovascular coiling treatment successfully. The demographic and clinical data including age, gender, blood pressure, blood glucose, Hunt-Hess grade, and Fisher grade at admission, Glasgow outcome scale 3 months after coiling, and the location, size of the aneurysms, coiling methods, and time of intervention were retrospectively reviewed and analyzed. Multivariate analysis and logistic regression were used for data analysis. The history of diabetes mellitus, Hunt-Hess grade, Fisher classification at admission, timing of intervention, as well as the location and size of the aneurysm were prognostic factors for endovascular coiling therapy in patients with ruptured intracranial aneurysm. The Fisher scores, Hunt-Hess classification, history of diabetes mellitus, timing of the intervention, as well as the location and size of aneurysm were independent risk factors for ruptured intracranial aneurysms in patients who received endovascular coiling treatment successfully, which could highly affect the outcome of coiling therapy.

A study of correlation of angioarchitecture of intracranial blood vessels with difficulty during endovascular coiling of aneurysms

ObjectiveThe duration and complications of coiling are dependent on several factors. These include experience with the armamentarium and the expertise of the operator. Also, the angioarchitecture of the blood vessel...

E-064 Safety and Efficacy of Balloon-Assisted Coiling of Intracranial Aneurysms: A Single-Center Study

ObjectiveBalloon-assisted coil embolization has become an important adjunct in the endovascular treatment of intracranial aneurysms, particularly those with challenging anatomy. The need for anti-platelet agents when deploying intracranial stents, which...

Navigation of Stents across Communicating Arteries for Aneurysm Embolization

Endovascular coiling of aneurysms crossing the Circle of Willis has been described in small case series. The technical challenges in manipulating a stent across the Circle of Willis lie in negotiating difficult angles and small arteries. We present our experience with treating aneurysms by stent assistance in which the Circle of Willis was crossed to facilitate optimal stent deployment. We retrospectively reviewed the cases in our institution from January 2009 to June 2012 in which the Circle of Willis was traversed to facilitate optimal stent deployment. We measured the diameter of the communicating arteries traversed, caliber of the target arteries in which the stent was deployed and the most acute angle negotiated ("critical angle"). We compare our results with other published series in the literature. Eight patients fulfilled the criteria: 5 males (45-66 years). There were three anterior and five posterior circulation aneurysms. Four of the aneurysms were ruptured. The PCOM was traversed in five cases, the ACOM in three cases. The mean diameter of the communicating artery was 1.17 mm. The mean diameter of target arteries was 1.27 mm. The "critical angle" was 72-147 degrees. In all patients, there was satisfactory obliteration of the aneurysm. There were two cases of minor SAH post procedure. Utilizing the Circle of Willis for optimal stent placement in aneurysm remodeling is technically feasible but challenging. This technique can be performed successfully in patients with acute SAH. The procedural risk must be balanced against potential complications such as SAH.

Intraprocedural retrieval of migrated coils during endovascular aneurysm treatment with the Trevo Stentriever device

Coil migration during endovascular treatment of intracranial aneurysms occurs in 2–6% of cases. As endovascular coiling of aneurysms has become increasingly popular and as endovascular technology continues to rapidly evolve, the prevalence of intraprocedural coil migration will invariably rise. Since coil masses are highly thrombogenic, migration out of the aneurysm sac into the parent artery may result in large territory infarcts which subsequently manifest as significant neurological morbidity. Therefore safe and timely retrieval of migrated coils is essential to avoiding poor angiographic and clinical outcomes. A 66-year-old woman with an unruptured 5×3mm, wide-necked posterior communicating artery aneurysm was referred for endovascular treatment. During coiling with the dual catheter technique, both initially deployed coils dislodged from the aneurysm sac and migrated distally into the middle cerebral artery. After failed retrieval with an Alligator device (Chestnut Medical Technologies, Menlo Park, CA, USA), we used two Trevo devices (Concentric Medical, Mountain View, CA, USA) in succession to successfully retrieve the migrated coils. The aneurysm was then occluded with stent-assisted coil embolization. There were no post-procedural angiographic or clinical complications. The patient was subsequently discharged home without neurological deficit. This case illustrates the first use of the Trevo device for retrieval of migrated coils during endovascular treatment of an intracranial aneurysm to our knowledge. Due to the lack of guidelines defining the standard management of intraprocedural coil migration, current strategies are based on retrospective review of published reports and expert opinion. We present a unique and effective method for endovascular retrieval of displaced coils using a Trevo Stentriever device.

Fusiform Aneurysm on the Basilar Artery Trunk Treated with Intra-Aneurysmal Embolization with Parent Vessel Occlusion after Complete Preoperative Occlusion Test

Fusiform aneurysms on the basilar artery (BA) trunk are rare. The microsurgical management of these aneurysms is difficult because of their deep location, dense collection of vital cranial nerves, and perforating arteries to the brain stem. Endovascular treatment is relatively easier and safer compared with microsurgical treatment. Selective occlusion of the aneurysmal sac with preservation of the parent artery is the endovascular treatment of choice. But, some cases, particularly giant or fusiform aneurysms, are unsuitable for selective sac occlusion. Therefore, endovascular coiling of the aneurysm with parent vessel occlusion is an alternative treatment option. In this situation, it is important to determine whether a patient can tolerate parent vessel occlusion without developing neurological deficits. We report a rare case of fusiform aneurysms in the BA trunk. An 18-year-old female suffered a headache for 2 weeks. Computed tomography and magnetic resonance image revealed a fusiform aneurysm of the lower basilar artery trunk. Digital subtraction angiography revealed a 7.1×11.0 mm-sized fusiform aneurysm located between vertebrovasilar junction and the anterior inferior cerebellar arteries. We had good clinical result using endovascular coiling of unruptured fusiform aneurysm on the lower BA trunk with parent vessel occlusion after confirming the tolerance of the patient by balloon test occlusion with induced hypotension and accompanied by neurophysiologic monitoring, transcranial Doppler and single photon emission computed tomography. In this study, we discuss the importance of preoperative meticulous studies for avoidance of delayed neurological deficit in the patient with fusiform aneurysm on lower basilar trunk.

Emergency Excision of Cardiac Myxoma and Endovascular Coiling of Intracranial Aneurysm after Cerebral Infarction

Cardiac myxoma is the most common primary tumor of the heart, located mainly in the left atrium. Cerebral embolization or intracranial aneurysm formation as a consequence of left atrial myxomas has been well documented, whereas myxoma embolization causing the combination of cerebral infarction and intracranial myxomatous aneurysm is rare. We report herein, a 67-year-old female with a cardiac myxoma who experienced a left hemispheric embolic ischemic stroke and in addition was found to have right internal carotid artery aneurysm. The patient underwent emergency surgical excision of left atrial myxoma 2 hours after the stroke onset and endovascular coiling of the aneurysm a week later. Although the timing of cardiac surgery is controversial in patients who have had recent ischemic stroke, we recommend immediate resection of cardiac myxoma, if feasible, and early endovascular treatment of associated intracranial myxomatous aneurysms.

Aneurysm Ostium Angle: A Predictor of the Need for Stent as Assistance for Endovascular Aneurysm Coiling in Internal Carotid Artery Sidewall Aneurysms

There is no satisfactory parameter that can predict the need for assistant devices for endovascular aneurysm coiling. Our aim was to evaluate the utility of MOA as a predictor of the need for stent-assisted coiling in ICA sidewall aneurysms. From a retrospective review of an internal data base, 55 consecutive ICA sidewall aneurysms were identified. Thirty-two of the aneurysms were treated by using endovascular techniques. Because 23 of the 55 aneurysms were either untreated or clipped, 3 experienced interventionalists reviewed the 3D images of these aneurysms and then made a decision as to whether stent-assisted coiling would have been required. Thirty-one of the 55 aneurysms would have required stent-assisted coiling, while 24 would not. Neck width, DNR, AR, and MOA were obtained from each aneurysm by using prototype software. These parameters were then correlated with the requirement of stent-assisted coiling. MOA and neck width of aneurysms requiring stent-assisted coiling were significantly larger than those not requiring stent-assisted coiling (P < .001 and <0.001, respectively). Although the DNR and AR of aneurysms requiring stent-assisted coiling were smaller than those not requiring it, the difference was not significant (P = .22 and 0.12, respectively). ROC analysis revealed that MOA was the parameter that best correlated with the need for stent-assisted coiling. Inclusion of MOA with the rest of the parameters significantly increased the predictive performance regarding the need for stent-assisted coiling (P = .005). In this small study, MOA was a useful parameter to predict the need for stent-assisted coiling in ICA sidewall aneurysms. Further prospective study of this parameter for aneurysms at multiple locations is required to determine its ultimate value.

Subacute rupture of intracavernous carotid artery aneurysm with cavernous sinus thrombophlebitis: Potential diagnostic and therapeutic challenges

We report on a patient with subacute ruptured intracavernous carotid artery aneurysm presenting with nonspecific features of cavernous sinus thrombophlebitis initially, leading to delayed diagnosis. It alerts our awareness of the potential causes and consequences of cavernous sinus thrombophlebitis, in particular in the presence of complicating internal carotid artery aneurysm and hence, the importance of angiographic evaluation. The increased risk of thrombogenic event from coexisting inflammation raises difficulty in endovascular coiling of aneurysm, which would be further aggravated with presence of stent due to potential risk of stent infection from local spread, as demonstrated in our case with complicated parent artery occlusion due to in-stent thrombus formation during the procedure. Adequate antithrombotic therapy at both before and after the procedure is required and regular follow-up is mandatory.

Outcome in Poor Grade Subarachnoid Hemorrhage Patients Treated with Acute Endovascular Coiling of Aneurysms and Aggressive Intensive Care

Patients with poor grade (World Federation of Neurosurgeons (WFNS) Grades 4 and 5) subarachnoid hemorrhage (SAH) were historically considered to have a poor neurological outcome and therefore not traditionally offered aggressive treatment. In recent years there has been increasing evidence that early aggressive treatment of this patient group can result in a good outcome. Aim of this study is to identify the outcome of patients with WFNS Grade-4 and -5 SAH treated acutely with endovascular detachable coil embolization (DCE) and aggressive neurocritical care within our institution. We retrospectively reviewed the records of patients with SAH WFNS Grades 4 and 5 treated with DCE within 7 days of admission between 1st January 2004 and 1st January 2008. Data collected included age, sex, grade SAH, position/number of Aneurysms, coiling complications, time spent on the neurosurgical critical care unit (NCCU), and 6-month outcome assessed by Glasgow outcome scale (GOS). GOS was dichotomized into good outcome (good recovery/moderate disability) and poor outcome (severe disability, vegetative, dead). A total of 193 acute SAH patients were admitted and treated within this time period, of these, 47 patients were classified as poor grade and included: 70% were female and 30% were male. The mean age was 56 years (33-88 years range). A total of 56 aneurysms were noted at angiography, 52 aneurysms were coiled. Complications of SAH Vasospasm was noted in 18 patients (38%), cerebral infarction in 13 patients (28%), seizures in 7 patients (15%), hydrocephalus in 25 patients (53%). Complications of DCE occurred in 2 patients (4% of total) these were an aneurysmal rupture and a peri-procedure thrombosis. Incomplete coiling occurred in another 5 patients (10.6% of total) due to technical difficulties. The median length of stay on the NCCU was 12 days (1-52 days range). Of the 47 poor grade patients coiled, 25 (53%) had a good outcome (good recovery/moderate disability) and 22 (47%) had a poor outcome (severe disability, vegetative, dead) by the time of the 6-month follow-up. Potentially, more than half the patients with WFNS Grade-4 and -5 SAH who are treated aggressively with coil embolization in association with supportive neurocritical care can achieve a good quality neurological outcome. However, it should be anticipated that these patients will spend a significant period of time in neurocritical care.

Microsurgical Clipping of Intracranial Aneurysms following Unsuccessful Endovascular Treatment

The purpose of the current study was to examine the reasons for failed endovascular aneurysm coiling and to determine the outcome of immediate microsurgical clipping. From July 2006 to July 2008, 198 patients underwent endovascular coiling at our institute; among them, ten cases were unsuccessful. All of the patients were diagnosed with intracranial aneurysms (ICAs) by cranial computed tomography angiography (CTA), and all underwent endovascular treatment without digital subtraction angiography (DSA). When endovascular coiling failed, the patients were immediately transferred to the operating room for microsurgical clipping under the same anesthetic. The ten patients were divided into three groups based on the cause of endovascular failure and associated clinical features. The clinical follow-up period was between 6-12 months, and all 10 patients had good outcomes following the surgery. Taken together, the results of this study suggest that immediate microsurgical clipping after failed endovascular coiling is efficient and may provide improved outcomes by preventing rebleeding.

Minimally Conscious State After Ruptured Giant Basilar Aneurysm

To report the clinical and radiologic findings in a case of transient minimally conscious state after rupture and coiling of a giant basilar aneurysm. Case report. Neuroscience intensive care unit. A 44-year-old man who developed a transient minimally conscious state in association with perianeurysmal edema in the rostral brainstem and thalamus after rupture and coiling of a giant basilar artery aneurysm. Correlation of clinical and magnetic resonance imaging findings. A minimally conscious state and bilaterally symmetric vasogenic edema of the rostral brainstem and thalamus developed 2 days after endovascular aneurysm coiling. The clinical and radiologic abnormalities improved significantly and in parallel during the following 4 weeks. Perianeurysmal vasogenic edema in the brainstem and thalamus can develop after rupture and coiling of a giant basilar artery aneurysm. This process can be transient and can produce dramatic alterations in consciousness that later resolve.

Effect of Antiplatelet Therapy for Endovascular Coiling in Aneurysmal Subarachnoid Hemorrhage

Antiplatelets are frequently used during or after endovascular coiling of aneurysm in patients with subarachnoid hemorrhage (SAH). This strategy is based on uncontrolled case series including also patients with unruptured aneurysms or other lesions. We collected data on effectiveness of antiplatelets in patients with SAH. All 43 participating centers in the International Subarachnoid Aneurysm Trial (ISAT) were sent a questionnaire whether they never, sometimes, or always prescribed antiplatelets during or after coiling. Based on individual patient data, the relative risks (RRs) of coiling versus clipping were calculated separately for patients treated in hospitals with standard prescription during or after coiling versus patients treated in hospitals with no standard prescription of antiplatelets. We calculated ratios of RRs for standard versus not standard prescription of antiplatelets during coiling and for standard versus not standard prescription after coiling. Nineteen centers responded, representing 1422 (66%) of the 2143 ISAT patients. Antiplatelets were standard prescribed during coiling in 2 responding centers (8% of coiled patients) and after coiling in 6 centers (24%). For poor outcome at 2 months of coiling versus clipping the RR was 0.82 (95% CI: 0.45 to 1.49) in hospitals with a policy of antiplatelet prescription during coiling versus 0.66 (95% CI: 0.55 to 0.78) in those without such policy (ratio of RR's 1.24, P=0.56). The ratio of RRs for 1-year outcome was 1.01 (P=0.89) for antiplatelet use during coiling and 1.00 (P=0.77) for use after coiling. The results of this study do not support the assumption that antiplatelets during or after endovascular coiling improve outcome in patients with SAH.

Abciximab Is a Safe Rescue Therapy in Thromboembolic Events Complicating Cerebral Aneurysm Coil Embolization

The purpose of this study was to estimate the safety and efficacy of abciximab treatment in combination with prophylactic heparin, acetylsalicylic acid (ASA), and clopidogrel application in cases of thrombus formation complicating endovascular coil embolization in cerebral aneurysms. Thromboembolic incidents during endovascular management of 515 consecutive cerebral aneurysms were observed in 48 cases (9.3%). Eight incidents were observed during embolization of incidental aneurysms (8/174; 4.6%, 95% CI: 2.0 to 8.9%). All patients underwent anticoagulation with heparin and platelet-inhibition with ASA during treatment procedure. In addition, clopidogrel orally was applied 3 days preoperatively in patients with incidental aneurysms. In case of thrombus formation, glycoprotein IIb-IIIa inhibitor abciximab was given in 42 cases. No coagulation-effective rescue treatment was conducted in 5 cases. One patient was treated with r-tPA. End points were infarction on follow-up cranial CT and the rate of intracranial hemorrhages. No infarcts on follow-up CT were observed after treatment with abciximab in 29/42 patients (69.0%, 95% CI: 52.9 to 82.4%). No coagulant rescue therapy was applied in 5 patients because of a small nonocclusive thrombus or good collateral blood supply, showing consecutive infarction on follow-up CT in 3 cases as did the 1 patient treated with r-tPA. No periprocedural bleedings or rebleedings were observed in any case. Abciximab was safe as rescue treatment in cases of thrombus formation during endovascular aneurysm coiling. In our study the use of Abciximab, in combination with prophylactic anticoagulation and antiaggregation, does not lead to additional intracranial hemorrhages or any extracranial bleeding complications.