Aneurysm Rupture In Patients Research Articles

Endovascular complications: Antiplatelet management for flow diversion

Up to 3−5% of the general population is affected by cerebral aneurysms that are associated with both modifiable as well as non-modifiable risk factors ranging from familial to acquired neurovascular conditions. The initial treatment option was aneurysm clipping and evolved to including primary or adjuvant endovascular treatment. Aneurysm re-rupture, although rare, can have devastating consequences such as intracranial bleeding and carotidcavernous fistula. Emergent surgery in view of delayed aneurysm rupture in patients maintained on dual antiplatelet therapy presents with the need to carefully assess the procedure-related risk factors and evaluate the patients’ platelet function. With the advent of novel technology, flow diverters came into play. These devices utilize the deployment of metallic stents into the parent artery that serves the diversion of blood flow away from the pouching aneurysm. Despite their efficacy, flow diverter insertion and catheter manipulation come with a risk of developing ischemia and stroke, hemorrhage and aneurysm re-rupture, in-stent thrombosis and stenosis, and aneurysmal occlusion amongst other complications. The prospect of thromboembolic events necessitates the use of aggressive antiplatelet regimen with the dual antiplatelet regimen utilizing clopidogrel and aspirin used most frequently. Prasugrel and Ticagrelor have been shown to be superior to Clopidogrel in terms of thromboembolic consequences in cardiovascular literature. Given their potential benefit over the current standard of treatment in this patient population, more extensive randomized-controlled studies are warranted for the evaluation of the efficacy and non-inferiority of Prasugrel and Aspirin or Ticagrelor and Aspirin to Clopidogrel and Aspirin.

Risk factors of rupture and mortality for intracranial aneurysms associated with moyamoya disease: a multicenter retrospective study.

The aim of this study was to analyze the risk factors for aSAH and subsequent death in patients with MMD. Chinese Multi-Center Cerebral Aneurysm Database (CMAD) is a multicenter study registered in China. From 2016 to 2021, 181 patients with MMD in CMAD. Logistic regression analysis was used to identify risk factors for intracranial aneurysm rupture. Univariate and multivariate Cox regression were used to risk factors associated with ruptured intracranial aneurysm patients with MMD follow-up events (death). Cumulative survival was described using the Kaplan‒Meier technique. Of 11,686 IA patients, 181 (1.5%) had MMD. In the study, 158 patients with MMD were enrolled. There were 53 ruptured aneurysms and 105 unruptured aneurysms. In multivariate analysis, age (≥ 60years OR 2.350 [1.008-5.478]), location (middle cerebral artery OR5.431 [1.347-21.889]; posterior circulation arteries OR 3.189 [1.110-9.163]) and aneurysm size (≥ 5mm OR 2.855 [1.274-6.397], P = 0.011) were associated with intracranial aneurysm rupture in patients with MMD. In the 2-year follow-up time of aSAH patients, 44% (22/50) had favorable outcomes, 14% (7/50) had unfavorable outcomes and 42% (21/50) had death. Hypertension (HR 6.643 [1.620-27.244], P = 0.009) and Hunt-Hess grade (H&H grade IV HR 14.852 [3.151-70.011], P = 0.001; H&H grade V HR 17.697 [3.046-102.842], P = 0.001) were associated with increased mortality. In contrast, both ST (HR 0.168 [0.031-0.921], P = 0.04) and ET (HR 0.289 [0.087-0.957], P = 0.042) achieved good results. This study showed that the proportion of MMD in IA patients was approximately 1.5% (181/11686). For patients with cerebral ischemia on admission, revascularization may prevent the rupture of intracranial aneurysms. Age ≥ 60years, location, and aneurysm size ≥ 5mm were associated with IA rupture. Further analysis showed that being located in the middle cerebral artery was the most relevant risk factor for rupture. Patients with ruptured IA who underwent ST or ET had better clinical outcomes and survival than those who underwent CT; however, hypertension and poor initial Hunt-Hess grade were independent predictors of death.

Predictors of intraoperative intracranial aneurysm rupture in patients with subarachnoid hemorrhage: a retrospective analysis.

Intraoperative cerebral aneurysm rupture (IOR) is a common phenomenon with a frequency of around 19%. Research regarding IOR lacks an analysis of its predictors. We retrospectively examined all saccular aneurysms, in 198 patients with subarachnoid hemorrhage, surgically treated from 2013 to 2019. Operative reports, patient histories, blood test results, discharge summaries, and radiological data were reviewed. IOR was defined as any bleeding from the aneurysm during surgery, preceding putting a clip on its neck, regardless of how trivial. The frequency of IOR was 20.20%. Patients with IOR had higher aneurysm dome size (9.43 ± 8.39mm vs. 4.96 ± 2.57mm; p < 0.01). The presence of blood clot on the aneurysm dome was significantly associated with IOR (12.50% vs. 2.53%; p < 0.01). We also associated lamina terminalis fenestration during surgery (7.50% vs. 21.52%; p = 0.04) and multiple aneurysms (5.00% vs. 18.35%; p = 0.038) with a lower risk of IOR. Glucose blood levels were also elevated in patients with IOR (7.47 ± 2.78mmol/l vs. 6.90 ± 2.22mmol/l; p = 0.04). Multivariate analysis associated that urea blood levels (OR 0.55, 0.33 to 0.81, p < 0.01) and multiple aneurysms (OR 0.04, 0.00 to 0.37, p = 0.014) were protective factors against the occurrence of IOR. Large dome size of an aneurysm, a blood clot on the aneurysm dome and elevated glucose blood levels can be IOR predictive. Lamina terminalis fenestration, the appearance of multiple aneurysms, and high urea blood levels may be associated with a lower risk of such an event.

Understanding intent to treat analyses: An important lesson from the international cooperative study on the timing of aneurysm surgery

Background and purposeIntent-to-treat analyses (ITT) are the best way to analyze randomized clinical trials because they preserve the benefits of randomization: to provide an unbiased assessment of relative treatment effects. Yet they play a more fundamental role, which can be demonstrated with observational studies. MethodsWe use a hypothetical RCT to explain why ITT analyses are more appropriate to analyze RCT results. We review the International Cooperative Study on the Timing of Aneurysm Surgery (ICSTAS), a landmark observational study on the management of ruptured aneurysm patients. We discuss the impact of the ICSTAS lesson on the interpretation of future observational studies using Big Data. ResultsPer-protocol (or as-treated) analyses can be misleading: The ICSTAS study provided ‘as-treated’ results clearly in favour of delayed surgery, while overall management or ITT results showed no difference between early and delayed surgery. A contemporary RCT showed that early surgery was best. ICSTAS’ lesson is that observational studies can provide misleading results when intent-to-treat categories are not predefined in the first place. ConclusionIntent-to treat analyses are the most appropriate way to analyze data, whether from randomized trials or observational studies. This observation has momentous consequences. A science of medical practice is impossible without predefined questions regarding optimal care.

Understanding how to move from dogmatic to outcome-based neurosurgical care: Lessons from past surgical studies on ruptured aneurysm patients

BackgroundThe role research can play in neurosurgical care is poorly understood. The result is that inappropriate methods are frequently used in clinical research, and unverifiable neurosurgical care is widely practised. MethodsWe review the research questions and the methods used in two landmark studies on the surgical treatment of ruptured aneurysms. We then compare the explanatory approach with the more appropriate pragmatic approach, and explain the difference by analogy with the ancient medical dispute between dogmatists and empiricists. ResultsThe International Cooperative study on the timing of aneurysm surgery was dogmatic or rationalistic: medical care is based on reason; research aims to gain theoretical knowledge, explanations and generalizations to be used as reasons to act in practice. But practice based on case-by-case reasoning is haphazard and unverifiable. The Finnish randomized trial was more empirical in spirit: reliable knowledge is to be found in repeated clinical experience. A reliable treatment is one proven to provide verifiably better outcomes in a trial integrated into practice. ConclusionVerifiable outcome-based neurosurgical care will be possible with the integration of pragmatic trials into everyday practice.

Clinical Factors Associated with the Risk of Intracranial Aneurysm Rupture in Autosomal Dominant Polycystic Kidney Disease

Background: The occurrence of intracranial aneurysms is higher in patients with autosomal dominant polycystic kidney disease (ADPKD) than in the healthy population. However, research concerning the factors related to the risk of intracranial aneurysm rupture in patients with ADPKD is still insufficient. Objectives: The aim of the study was to investigate the prevalence of intracranial aneurysms and aneurysmal subarachnoid hemorrhage (SAH) and to analyze the systemic factors associated with high-risk aneurysms in patients with ADPKD. Methods: We screened patients who underwent cerebral angiography between January 2007 and May 2017 in the ADPKD registry. Patients were examined for the presence of intracranial aneurysms and subsequently reclassified into 3 groups based on the risk of aneurysmal rupture: the aneurysm-negative (group 1), low-risk aneurysm (group 2), or high-risk aneurysm (group 3). Various systemic factors were compared, and independent factors associated with high-risk aneurysms were analyzed. Results: Among the 926 patients, 148 (16.0%) had intracranial aneurysms and 11 (1.2%) had previous aneurysmal SAH. Patients with intracranial aneurysms were further classified into group 2 (low-risk aneurysms, 15.5%) or group 3 (high-risk aneurysms, 84.5%). Age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.05, p = 0.004), female sex (OR 3.13, 95% CI 1.94–5.0 6, p < 0.001), dolichoectasia (OR 8.57, 95% CI 1.53–48.17, p = 0.015), and mitral inflow deceleration time (DT) (OR 1.01, 95% CI 1.00–1.01, p = 0.046) were independently associated with high-risk aneurysms, whereas hypercholesterolemia (OR 0.46, 95% CI 0.29–0.72, p = 0.001) was negatively associated. Conclusion: In the present study among patients with ADPKD, the prevalence of intracranial aneurysms and aneurysmal SAH was 16 and 1.2%, respectively. Age, female sex, dolichoectasia, and mitral inflow DT were positively associated with high-risk aneurysms, whereas hypercholesterolemia was negatively associated. A subsequent large-scaled longitudinal study is needed to define the plausibility of the clinical parameters.

Aging Patient Population With Ruptured Aneurysms: Trend Over 28 Years.

Given increasing life expectancy in the United States and worldwide, the proportion of elderly patients affected by aneurysmal subarachnoid hemorrhage (aSAH) would be expected to increase. To determine whether an aging trend exists in the population of aSAH patients presenting to our institution over a 28-yr period. A prospectively maintained database of consecutive patients presenting to our institution with subarachnoid hemorrhage between January 1991 and December 2018 was utilized. The 28-yr period was categorized into 4 successive 7-yr quarter intervals. The age of patients was compared among these intervals, and yearly trends were derived using linear regression. The cohort consisted of 1671 ruptured aneurysm patients with a mean age of 52.8 yr (standard deviation=15.0 yr). Over the progressive 7-yr time intervals during the 28-yr period, there was an approximately 4-fold increase in the proportion of patients aged 80 yr or above (P<.001) and an increase in mean patient age from 51.2 to 54.6 yr (P=.002). Independent of this trend but along the same lines, there was a 29% decrease in the proportion of younger patients (<50 yr) from 49% to 35%. On linear regression, there was 1-yr increase in mean patient age per 5 calendar years (P<.001). Analyses of aSAH patients demonstrate an increase in patient age over time with a considerable rise in the proportion of octogenarian patients and a decrease in patients younger than 50 yr. This aging phenomenon presents a challenge to the continued improvement in outcomes of aSAH patients.

Development and validation of a novel nomogram to predict aneurysm rupture in patients with multiple intracranial aneurysms: a multicentre retrospective study

Background and purposeApproximately 15%–45% of patients with unruptured intracranial aneurysms have multiple intracranial aneurysms (MIAs). Determining which one is most likely to rupture is extremely important for treatment decision making...

The effect of neutrophil/lymphocyte ratio and tomography measurements at the time of diagnosis in predicting aneurysm rupture in patients with abdominal aortic aneurysms

The effect of neutrophil/lymphocyte ratio and tomography measurements at the time of diagnosis in predicting aneurysm rupture in patients with abdominal aortic aneurysms

The Impact of Myeloperoxidase in the Rupturing of Cerebral Aneurysms

In this study, we aimed to examine the effect of myeloperoxidase on aneurysm rupture in patients with cerebral aneurysms with and without rupture. The study included 53 patients with subarachnoid hemorrhage operated on due to cerebral aneurysm in our clinic, and 49 patients without subarachnoid hemorrhage. After the operation, the domes taken from the aneurysms were embedded in paraffin blocks and scored after hematoxylin and eosin and immunohistochemical staining was carried out. The myeloperoxidase score was 1 in 29.4% of the patients, 2 in 40.2%, 3 in 12.7%, and 4 in 17.6%. Multiple aneurysms were detected in 24.5% of the patients. The median myeloperoxidase score was higher in patients with bleeding aneurysms than those that did not bleed (3 vs. 1; P< 0.001). In addition, the ratio of patients with a myeloperoxidase score of 2 or above was higher among patients with bleeding aneurysms. In our study, finding myeloperoxidase scores higher in cases of ruptured aneurysms compared with unruptured aneurysms reveals the relationship of myeloperoxidase with ruptured cerebral aneurysms.

Mast Cell Promotes the Development of Intracranial Aneurysm Rupture.

Inflammation has emerged as a key component of the pathophysiology of intracranial aneurysms. Mast cells have been detected in human intracranial aneurysm tissues, and their presence was associated with intramural microhemorrhage and wall degeneration. We hypothesized that mast cells play a critical role in the development of aneurysmal rupture, and that mast cells can be used as a therapeutic target for the prevention of aneurysm rupture. Intracranial aneurysms were induced in adult mice using a combination of induced systemic hypertension and a single injection of elastase into the cerebrospinal fluid. Aneurysm formation and rupture were assessed over 3 weeks. Roles of mast cells were assessed using a mast cell stabilizer (cromolyn), a mast cell activator (C48/80), and mice that are genetically lacking mature mast cells (KitW-sh/W-sh mice). Pharmacological stabilization of mast cells with cromolyn markedly decreased the rupture rate of aneurysms (80% versus 19%, n=10 versus n =16) without affecting the aneurysm formation. The activation of mast cells with C48/80 significantly increased the rupture rate of aneurysms (25% versus 100%, n=4 versus n=5) without affecting the overall rate of aneurysm formation. Furthermore, the genetic deficiency of mast cells significantly prevented aneurysm rupture (80% versus 25%, n=10 versus n=8, wild-type versus KitW-sh/W-sh mice). These results suggest that mast cells play a key role in promoting aneurysm rupture but not formation. Stabilizers of mast cells may have a potential therapeutic value in preventing intracranial aneurysm rupture in patients.

Comparison of peak wall stress and peak wall rupture index in ruptured and asymptomatic intact abdominal aortic aneurysms.

Previous studies have suggested that finite element analysis (FEA) can estimate the rupture risk of an abdominal aortic aneurysm (AAA); however, the value of biomechanical estimates over measurement of AAA diameter alone remains unclear. This study aimed to compare peak wall stress (PWS) and peak wall rupture index (PWRI) in participants with ruptured and asymptomatic intact AAAs. The reproducibility of semiautomated methods for estimating aortic PWS and PWRI from CT images was assessed. PWS and PWRI were estimated in people with ruptured AAAs and those with asymptomatic intact AAAs matched by orthogonal diameter on a 1 : 2 basis. Spearman's correlation coefficient was used to assess the association between PWS or PWRI and AAA diameter. Independent associations between PWS or PWRI and AAA rupture were identified by means of logistic regression analyses. Twenty individuals were included in the analysis of reproducibility. The main analysis included 50 patients with an intact AAA and 25 with a ruptured AAA. Median orthogonal diameter was similar in ruptured and intact AAAs (82·3 (i.q.r. 73·5-92·0) versus 81·0 (73·2-92·4) mm respectively; P =0·906). Median PWS values were 286·8 (220·2-329·6) and 245·8 (215·2-302·3) kPa respectively (P =0·192). There was no significant difference in PWRI between the two groups (P =0·982). PWS and PWRI correlated positively with orthogonal diameter (both P < 0·001). Participants with high PWS, but not PWRI, were more likely to have a ruptured AAA after adjusting for potential confounders (odds ratio 5·84, 95 per cent c.i. 1·22 to 27·95; P =0·027). This association was not maintained in all sensitivity analyses. High aortic PWS had an inconsistent association with greater odds of aneurysm rupture in patients with a large AAA.

Multivariable analysis on factors associated with aneurysm rupture in patients with multiple intracranial aneurysms.

Multiple intracranial aneurysms (MIA) occur in one-third of patients with intracranial aneurysms (IA), and have been previously associated with an overall worse prognosis. Risk factors for IA formation and rupture in patients with a single IA are well-known. However, risk factors associated with rupture in patients with MIA have been less studied. We performed a retrospective search of patients with MIA identified by computed tomography angiography (CTA) within a 10-year period. Patients with > 1 saccular aneurysm with size ≥ 2.0 mm were included. The location, size, number, and rupture status of the aneurysms were recorded. Patient demographics and cerebrovascular risk factors were obtained from electronic medical records. The primary endpoint of this study was to determine the association of these factors with aneurysmal rupture. The case-fatality rate was evaluated as a secondary outcome. Of the 2957 patients with IA in our CTA database, 425 patients were diagnosed with MIA and were therefore included in our study. A total of 1082 aneurysms were identified. Predictors of increased risk of aneurysmal rupture were age (OR 0.98, 95% CI, 0.96-0.99), size ≥ 5 mm (OR 4.4, 95% CI 2.76-7.0); and location in the anterior communicating artery complex (AcomC) (OR 2.62, 95% CI, 1.46-4.72) or posterior communicating artery (PCOM) (OR 2.66, 95% CI, 1.45-4.87). Younger age, aneurysm size ≥ 5 mm, and location in the AcomC and PCOM were independently associated with aneurysmal rupture in patients with MIA. Identifying these features could help recognize patients who might benefit from early intervention.

Rupture risk assessment for multiple intracranial aneurysms: why there is no need for dozens of clinical, morphological and hemodynamic parameters.

Introduction:A multitude of approaches have been postulated for assessing the risk of intracranial aneurysm rupture. However, the amount of potential predictive factors is not applicable in clinical practice and they are rejected in favor of the more practical PHASES score. For the subgroup of multiple intracranial aneurysms (MIAs), the PHASES score might severely underestimate the rupture risk, as only the aneurysm with the largest diameter is considered for risk evaluation.Methods:In this study, we investigated 38 patients harboring a total number of 87 MIAs with respect to their morphological and hemodynamical characteristics. For the determination of the best suited parameters regarding their predictive power for aneurysm rupture, we conducted three phases of statistical evaluation. The statistical analysis aimed to identify parameters that differ significantly between ruptured and unruptured aneurysms, show smallest possible correlations among each other and have a high impact on rupture risk prediction.Results:Significant differences between ruptured and unruptured aneurysms were found in 16 out of 49 parameters. The lowest correlation were found for gamma, aspect ratio (AR1), aneurysm maximal relative residence time (Aneurysm_RRT_max) and aneurysm mean relative residence time. The data-driven parameter selection yielded a significant correlation of only two parameters (AR1 and the Aneurysm_RRT_max) with rupture state (area under curve = 0.75).Conclusion:A high number of established morphological and hemodynamical parameters seem to have no or only low effect on prediction of aneurysm rupture in patients with MIAs. For best possible rupture risk assessment of patients with MIAs, only the morphological parameter AR1 and the hemodynamical parameter Aneurysm_RRT_max need to be included in the prediction model.

The Prognostic Significance of a Cast Fourth Ventricle in Ruptured Aneurysm Patients With Intraventricular Hemorrhage in the Barrow Ruptured Aneurysm Trial (BRAT).

Ruptured aneurysms causing intraventricular hemorrhage (IVH) are associated with high morbidity. The presence of blood that completely fills the fourth ventricle (cast fourth ventricle, CFV) is thought to be particularly ominous, but studies documenting the outcome of such cases are lacking. To investigate the outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) and CFV. We reviewed 406 patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT, NCT01593267, clinicaltrials.gov); 238 patients with aSAH and IVH were identified, and imaging was reviewed for the presence of CFV. Outcome was evaluated at the 1-yr follow-up. A poor outcome was defined as modified Rankin Scale score>2. CFV was identified in 25 patients. Admission Glasgow Coma Score was lower in CFV patients, 7.8 versus 11.5 (P<.001). At discharge and the 1-yr follow-up, patients with CFV had a greater risk of a poor outcome (P<.001 and P=.002, respectively). In a subgroup analysis of 79 patients with IVH and initial Glasgow Coma Score≤8, almost 50% of the patients with IVH but without CFV had made a good recovery versus 7% of patients with CFV (odds ratio [OR] 15, P=.002). On multivariate analysis, CFV was a greater predictor of a poor prognosis at 1 yr post-aSAH than Hunt and Hess grade>3 (6.4 OR vs 2.9 OR [P<.001], respectively). The presence of CFV is a predictor of poor outcome in patients with aSAH. When compared to other patients with IVH and aSAH, CFV is a stronger predictor of a poor outcome than a poor Hunt and Hess Grade.

Nationwide Analysis of Cost Variation for Treatment of Aneurysmal Subarachnoid Hemorrhage.

Background and Purpose- Aneurysmal subarachnoid hemorrhage (aSAH) has a high healthcare cost burden. Methods- We performed a cross-sectional analysis of the costs of clipping and coiling of aSAH using the National Inpatient Sample and Vizient databases. We conducted multiple regression analyses to estimate national costs and study associations between patient demographic, clinical, and hospital factors and treatment costs. Results- We identified 23 324 ruptured aneurysm patients in the National Inpatient Sample (2002-2013) and found mean inflation-adjusted costs for clipping increased 41.0% ($66 358±1354-$93 597±2339), whereas costs for coiling increased 38.9% ($62 972±2657-$87 441±2382). Multivariate analysis showed that age, length of stay, insurance, comorbidities, risk of mortality, and urban teaching hospital status were associated with higher hospital costs for clipping and coiling (all P<0.05). In the Vizient database (2013-2015), costs for clipping and coiling increased 11% and 5%, respectively. Both databases demonstrated that the western United States had the highest health expenditures for aSAH (P<0.05). Conclusions- Findings show substantial cost increases and regional cost disparities for aSAH treatments. Patient and hospital factors copredict higher costs for aSAH procedures. Interhospital and regional cost variations open the door for cost-containment strategic development.

Heroin Use Is Associated with Ruptured Saccular Aneurysms.

While cocaine use is thought to be associated with aneurysmal rupture, it is not known whether heroin use increases the risk of rupture in patients with non-mycotic saccular aneurysms. Our goal was to investigate the association between heroin and cocaine use and the rupture of saccular non-mycotic aneurysms. The medical records of 4701 patients with 6411 intracranial aneurysms, including 1201 prospective patients, diagnosed at the Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016 were reviewed and analyzed. Patients were separated into ruptured and non-ruptured groups. Univariable and multivariable logistic regression analyses were performed to determine the association between heroin, cocaine, and methadone use and the presence of ruptured intracranial aneurysms. In multivariable analysis, current heroin use was significantly associated with rupture status (OR 3.23, 95% CI 1.33-7.83) whereas former heroin use (with and without methadone replacement therapy), and current and former cocaine use were not significantly associated with intracranial aneurysm rupture. In the present study, heroin rather than cocaine use is significantly associated with intracranial aneurysm rupture in patients with non-mycotic saccular cerebral aneurysms, emphasizing the possible role of heroin in the pathophysiology of aneurysm rupture and the importance of heroin cessation in patients harboring unruptured intracranial aneurysms.

Type II Endoleak after Endovascular Aneurysm Repair: Natural History and Treatment Outcomes

The natural history of type II endoleaks and linkage to aneurysm rupture is unclear. Likewise, treatment recommendations are controversial. The aim of this study was to examine the incidence, factors associated with type II endoleaks, and outcomes in an Australia cohort of patients who have undergone endovascular aneurysm repair (EVAR). Data from 693 patients who underwent EVAR between 2009 and 2013 at multiple institutions across Australia were studied. Patients who developed (1) type II endoleak and (2) type II endoleak with sac expansion were compared for preoperative demographics, mortality, sac expansion, aneurysm rupture, and intervention rates. A total of 225 patients developed type II endoleak over a mean follow-up of 1.9years (±1.0years), out of which 133 spontaneously resolved, 37 were untreated unresolved, and 16 underwent intervention. Type I and III endoleaks occurred in 50 and 19 patients, respectively. Smoking (P=0.002) and warfarin (P=0.044) were protective factors for development of type II endoleak, whereas age (P=0.034), right iliac artery tortuosity (P=0.031), and right (P=0.008) and left external iliac diameters (P=0.028) were risk factors for endoleak. Three patients suffered aneurysm ruptures in the entire cohort. All ruptures occurred in type II endoleak patients, of which two occurred after reintervention and in the absence of sac expansion (>5mm). Late type II endoleak occurred in 117 patients, out of which 26 had sac expansion. Of those without late type II endoleak, 25 have sac expansion. There was no statistically significant difference in survival between those with and without type II endoleak. Age (P<0.0001) and smoking (P=0.001) were significant independent predictive factors for survival in this patient sample. Treatment outcomes were encouraging with most cases involving endoleak resolution (15 of 16 patients) and no sac expansion after intervention (0 of 8 patients with complete follow-up info on sac size). Aneurysm rupture in patients with type II endoleak is uncommon in our series. Type II endoleak with sac expansion does not appear to be associated with aneurysm rupture. In this series, most aneurysm ruptures occurred in the absence of documented sac expansion and after reintervention.

Abstract WMP30: Circulating MicroRNAs as Potential Novel Diagnostic Biomarkers for Ruptured Intracranial Aneurysm

Background and Objective: MicroRNAs have been shown to regulate in several pathological process of intracranial aneurysms. The study aimed to estimate whether miRNAs have the potential to become novel biomarkers for intracranial aneurysm rupture. Materials and methods Forty-five ruptured intracranial aneurysm patients were enrolled according to the inclusion criteria, meanwhile thirty-five healthy individuals were recruited in this study. Differentially expressed plasma miRNA profiles were screened in five pairs of patients and controls in microarray study. Then validation was performed in the rest of the objects using quantitative real-time PCR assays. Results: Fourteen significantly changed miRNAs were screened out from patients with aneurysms compared with healthy controls. More than three thousand target genes related to these disregulated miRNAs were found and bioinformatic analysis revealed that these miRNA were involved in intracranial aneurysm development and rupture. Ultimately four miRNAs from screening profile and one supplementary miRNA were demonstrated to be significantly altered. Conclusion: We demonstrated that several miRNAs were differentially expressed among ruptured aneurysm patients and healthy participants, and plasma miRNAs may be novel diagnostic biomarkers in intracranial aneurysm rupture.

Antiplatelet therapy for the prevention of peri-coiling thromboembolism in high-risk patients with ruptured intracranial aneurysms

OBJECTIVE The most frequent procedural complication of the endovascular treatment of intracranial aneurysms is a thromboembolic event (TEE); in a subset of patients, such events will cause permanent neurological disability. In patients with unruptured aneurysms, increasing evidence supports the use of periprocedural antiplatelet therapy to prevent TEEs. The object of this study was to evaluate whether patients with ruptured aneurysms and subarachnoid hemorrhage would also benefit from periprocedural antiplatelet therapy. METHODS The authors reviewed a prospective registry of 169 patients with endovascularly treated intracranial aneurysms to delineate angiographic features associated with periprocedural TEEs. They then performed a controlled before-and-after study in 79 patients with ruptured aneurysms who were deemed to be at high risk for TEEs (for example, patients with at least 1 angiographic feature associated with TEEs) to evaluate whether selective aspirin administration would reduce the rate of periprocedural thromboembolism without increasing major hemorrhagic complications. RESULTS Six angiographic features were associated with periprocedural TEEs in the study cohort: wide aneurysm neck, coil or loop protrusion, small parent artery diameter, an incorporated branch, intraprocedural thrombus formation, and intracranial parent vessel atherosclerosis. Aspirin administration to high-risk patients significantly decreased the rate of periprocedural TEEs, from 53.8% in the control group to 10.6% in the aspirin-treated group (p = 0.001). The reduction in TEEs in the aspirin-treated group continued to be statistically significant even when adjusted for age, sex, cardiovascular risk factors (smoking, diabetes, hypertension, dyslipidemia, coronary artery disease), and factors associated with TEEs in other large studies (wide aneurysm neck, aneurysm size ≥ 10 mm), with an adjusted OR of 0.16 (95% CI 0.03-0.8). There were no major systemic hemorrhagic complications, and aspirin did not increase the risk of aneurysm rebleeding, symptomatic intracranial hemorrhage, or major external ventricular drain (EVD)-associated hemorrhage (p = 0.3), though there was an increase in asymptomatic, minor (< 1 cm) EVD-associated hemorrhage in the aspirin-treated group (p = 0.02). CONCLUSIONS The study findings suggest that for ruptured aneurysm patients with high-risk features, antiplatelet therapy can significantly reduce the rate of periprocedural TEE without increasing major systemic or intracranial hemorrhages.