Intraprocedural Rupture During Endovascular Treatment of Intracranial Aneurysm: Clinical Results and Literature Review

doi:10.1016/j.wneu.2018.03.040

World Neurosurgery

Volume 114, June 2018, Pages e605-e615

https://doi.org/10.1016/j.wneu.2018.03.040 Get rights and content

Highlights

•
Small aneurysm size and ACoA aneurysm is related with IPR during endovascular treatment of intracranial saccular aneurysm.
•
IPR incidence was 7.5% (6/80) in ruptured aneurysms and 2.5% (4/155) in unruptured aneurysms.
•
Understanding the mechanism of IPR in each stage and careful device manipulation are important to avoid IPR.

Objective

Intraprocedural rupture (IPR) during endovascular treatment of cerebral aneurysm is the most feared complication, with high morbidity and mortality. The aim of this study was to estimate the incidence and risk factors of IPR during endovascular treatment of ruptured and unruptured cerebral aneurysms.

Methods

A total of 235 intracranial aneurysms (80 ruptured and 155 unruptured) in 219 patients who received endovascular treatment in our institution between January 2010 and December 2016 were enrolled in our study. Demographic and radiologic data were analyzed to evaluate risk factors of IPR. We conducted a literature review to estimate the incidence of IPR according to rupture status and aneurysm location.

Results

Ten patients (6 ruptured, 4 unruptured) experienced IPR during endovascular treatment. The IPR incidence was 7.5% in ruptured and 2.5% in unruptured aneurysms. Aneurysm size (smaller than 3.58 mm) and anterior communicating artery aneurysm were independent risk factors for IPR. According to the literature review, the overall IPR incidence was 4.47% (393/8791) in ruptured and 1.43% (145/10,131) in unruptured aneurysms.

Conclusions

Independent risk factors for IPR during endovascular treatment of intracranial aneurysm were aneurysm size and anterior communicating artery aneurysm. Ruptured aneurysms showed a higher tendency toward IPR than did unruptured aneurysms.

Introduction

Intraprocedural rupture (IPR) is one of the most feared complications in endovascular treatment of cerebral aneurysm. The incidence of IPR during endovascular treatment is lower than that of surgical clipping but has a higher rate of morbidity and mortality.¹ Since electronically detachable coils came into use in 1991², endovascular treatment has evolved with experience, the development of softer coils, and advanced microcatheter devices. Adjuvant treatments, such as stent-assisted or balloon-assisted coiling, made it possible to treat various aneurysm morphologies.

Previous studies reported IPR rates of 0%–16.1% during endovascular treatment of ruptured intracranial aneurysm.1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 The IPR rate has been reported to be lower in unruptured aneurysms in the range of 0%–4.0%.3, 9, 10, 15, 16, 17, 18, 19, 20, 21, 22, 23, 28, 29, 33, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46 Understanding the mechanism and risk factors of IPR and efforts to avoid this serious complication are important to improve the prognosis. Small aneurysm size, anterior communicating artery (ACoA) aneurysm, presence of small basal outpouching, and ruptured aneurysm have previously been reported to be IPR risk factors.29, 31, 47

The aim of this study was to evaluate the IPR incidence and risk factors during endovascular treatment of intracranial saccular aneurysm. Furthermore, a literature review was conducted to analyze the IPR incidence according to the rupture status and aneurysm location.

Section snippets

Patient Selection

From January 2010 to December 2016, 361 consecutive cerebral aneurysms were treated with an endovascular procedure at our institution. Among these patients, nonsaccular aneurysms (n = 66), unruptured paraclinoid aneurysms that were not definitely intracranial (n = 43), remnant aneurysms after clipping (n = 6), coil compaction (n = 8), aborted coil (n = 2), and glue embolization (n = 1) were excluded from the study. In total, 235 intracranial aneurysms (80 ruptured and 155 unruptured) in 219

Results

In total, 235 intracranial saccular aneurysms were treated with endovascular coiling. Eighty ruptured and 155 unruptured aneurysms were enrolled. Aneurysm location is presented in Table 1. Ten patients (4.3%) experienced an IPR. The IPR incidence was 7.5% (6/80) in ruptured aneurysms and 2.5% (4/155) in unruptured aneurysms. The most common location was the ACoA (5 ruptured and 2 unruptured), which represents 70% of IPRs. A single IPR occurred in the PCoA (unruptured), MCA (unruptured), and

Discussion

This study showed that ACoA and small aneurysm size were independent risk factors for IPR during endovascular treatment of intracranial saccular aneurysms. Several studies28, 29, 49 have shown that small aneurysm size (<3–5 mm) is a risk factor for IPR. A previous study⁴⁶ showed that small dome size (<5 mm) was associated with IPR in unruptured aneurysms. A meta-analysis⁵⁰ of very small (≤3 mm) intracranial aneurysms showed a higher IPR rate in both unruptured (5.0%) and ruptured aneurysms

Conclusions

The practical incidence of IPR during endovascular treatment of intracranial saccular aneurysm was 7.5% (6/80) in ruptured and 2.5% (4/155) in unruptured aneurysms. Independent risk factors for IPR were ACoA and aneurysm size (<3.58 mm). Understanding the IPR mechanism and carefully manipulating devices in each stage of the procedure can help avoid IPR. Future studies should focus on preventing IPR during endovascular treatment of cerebral aneurysm.

References (55)

P.J. Mitchell et al.
Does small aneurysm size predict intraoperative rupture during coiling in ruptured and unruptured aneurysms?
J Stroke Cerebrovasc Dis
(2013)
D.O. Wiebers et al.
Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment
Lancet
(2003)
S.H. Cho et al.
Intraprocedural rupture of unruptured cerebral aneurysms during coil embolization: a single-center experience
World Neurosurg
(2017)
E. Orrù et al.
Complications of endovascular treatment of cerebral aneurysms
Eur J Radiol
(2013)
L. Elijovich et al.
Predictors and outcomes of intraprocedural rupture in patients treated for ruptured intracranial aneurysms: the CARAT study
Stroke
(2008)
G. Guglielmi et al.
Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: electrochemical basis, technique, and experimental results
J Neurosurg
(1991)
G. Guglielmi et al.
Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: preliminary clinical experience
J Neurosurg
(1991)
J.V. Byrne et al.
Embolisation of recently ruptured intracranial aneurysms
J Neurol Neurosurg Psychiatry
(1995)
L. Pierot et al.
Selective occlusion of basilar artery aneurysms using controlled detachable coils: report of 35 cases
Neurosurgery
(1996)
G.E. Klein et al.
Basilar tip aneurysm: endovascular treatment with Guglielmi detachable coils–midterm results
Radiology
(1997)

H.-K. Park et al.

Periprocedural morbidity and mortality associated with endovascular treatment of intracranial aneurysms

AJNR Am J Neuroradiol

(2005)

M.-H. Li et al.

Prevention and management of intraprocedural rupture of intracranial aneurysm with detachable coils during embolization

Neuroradiology

(2006)

Cited by (34)

Recent Outcomes and Challenges of Artificial Intelligence, Machine Learning, and Deep Learning in Neurosurgery
2024, World Neurosurgery: X
Neurosurgeons receive extensive technical training, which equips them with the knowledge and skills to specialise in various fields and manage the massive amounts of information and decision-making required throughout the various stages of neurosurgery, including preoperative, intraoperative, and postoperative care and recovery. Over the past few years, artificial intelligence (AI) has become more useful in neurosurgery. AI has the potential to improve patient outcomes by augmenting the capabilities of neurosurgeons and ultimately improving diagnostic and prognostic outcomes as well as decision-making during surgical procedures. By incorporating AI into both interventional and non-interventional therapies, neurosurgeons may provide the best care for their patients. AI, machine learning (ML), and deep learning (DL) have made significant progress in the field of neurosurgery. These cutting-edge methods have enhanced patient outcomes, reduced complications, and improved surgical planning.
Intraoperative neuromonitoring as real-time diagnostic for cerebral ischemia in endovascular treatment of ruptured brain aneurysms
2024, Clinical Neurophysiology
To evaluate the diagnostic accuracy of intraoperative neurophysiological monitoring (IONM) during endovascular treatment (EVT) of ruptured intracranial aneurysms (rIA).
IONM and clinical data from 323 patients who underwent EVT for rIA from 2014-2019 were retrospectively reviewed. Significant IONM changes and outcomes were evaluated based on visual review of data and clinical documentation.
Of the 323 patients undergoing EVT, significant IONM changes were noted in 30 patients (9.29%) and 46 (14.24%) experienced postprocedural neurological deficits (PPND). 22 out of 30 (73.33%) patients who had significant IONM changes experienced PPND. Univariable analysis showed changes in somatosensory evoked potential (SSEP) and electroencephalogram (EEG) were associated with PPND (p-values: <0.001 and <0.001, retrospectively). Multivariable analysis showed that IONM changes were significantly associated with PPND (Odd ratio (OR) 20.18 (95%CI:7.40–55.03, p-value: <0.001)). Simultaneous changes in both IONM modalities had specificity of 98.9% (95% CI: 97.1%–99.7%). While sensitivity when either modality had a change was 47.8% (95% CI: 33.9%–62.0%) to predict PPND.
Significant IONM changes during EVT for rIA are associated with an increased risk of PPND.
IONM can be used confidently as a real time neurophysiological diagnostic guide for impending neurological deficits during EVT treatment of rIA.
Early Complications and Outcome After Treatment of Ruptured Aneurysms in Patients with Subarachnoid Hemorrhage–A Post Hoc Analysis of the EARLYDRAIN Trial
2024, World Neurosurgery
Aneurysmal subarachnoid hemorrhage (aSAH) from a ruptured intracranial aneurysm is a severe, life-threatening condition, with high morbidity and mortality. The current treatment often involves surgical clipping or endovascular treatment within the first 24–48 hours. Although there is ample evidence of complications in treating unruptured aneurysms, similar data in patients with acutely ruptured aneurysms are limited. The recently completed EARLYDRAIN trial showed improved neurologic results from lumbar drainage after aneurysm treatment in patients with aSAH. Using this data set, we aim to study the frequency and effects of complications and identify associated risk factors.
A substudy was carried out of the prospective multicenter randomized controlled EARLYDRAIN trial. We analyzed treatment-associated complications (bleeding and/or infarctions) detected on computed tomography on day 1 after aneurysm occlusion. Outcomes were the occurrence of postprocedural complications, secondary infarctions in the acute phase, and the modified Rankin Scale score after 6 months.
The EARLYDRAIN trial recruited 287 patients in 19 centers. Of these patients, 56 (19.5%) experienced a treatment complication. Twenty-five patients (8.7%) experienced postprocedural intracranial hemorrhage and 34 patients (11.8%) experienced a treatment-associated infarction. Patients with a complication showed more secondary infarctions (P = 0.049) and worse neurologic outcomes after 180 days (P = 0.025) compared with patients with no complication. Aneurysm location, rebleeding before the treatment, number of patients recruited per center, and the day of the treatment were independent risk factors for the occurrence of complications.
The present study shows that patients with aSAH frequently experience intervention-associated complications associated with aneurysm occlusion required to prevent recurrent hemorrhage. Consequently, patients with aSAH with treatment-related complications more often experience a worse clinical course and poor outcome.
Braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in patients with unruptured complex intracranial aneurysms
2023, Clinics
Braided and laser-cut stents both are efficacious and safe for coiling intracranial aneurysms. The study aimed to compare outcomes following braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in 266 patients who were diagnosed with unruptured intracranial aneurysms of different types and locations.
Patients with unruptured complex intracranial aneurysms underwent braided (BSE cohort, n = 125) or laser engraved (LSE cohort, n = 141) stent-assisted embolization.
The deployment success rate was higher for patients of the LSE cohort than those of the BSE cohort (140 [99%] vs. 117 [94%], p = 0.0142). Seventy-one (fifty-seven percentages) and 73 (52%) were coil embolization procedure success rates of the BSE and the LSE cohorts. Periprocedural intracranial hemorrhage was higher in patients of the BSE cohort than those of the LSE cohort (8 [6%] vs. 1 [1%], p = 0.0142). Four (three percentages) patients from the LSE cohort and 3 (2%) patients from the BSE cohort had in-stent thrombosis during embolization. Permanent morbidities were higher in patients of the LSE cohort than those of the BSE cohort (8 [6%] vs. 1 [1%], p = 0.0389). Higher successful procedures (76% vs. 68%) and fewer postprocedural intracranial hemorrhage (0% vs. 5%) and mortality (0% vs. 5%) were reported for patients of the BSE cohort in posterior circulation aneurysmal location than those of the LSE cohort. Laser engraved stent has fewer problems with deployment and may have better periprocedural and follow-up outcomes after embolization.
Braided stent-assisted embolization should be preferred when the aneurysm is present in the posterior circulation.
Safety and efficacy of the SeparGate<sup>TM</sup> balloon-guiding catheter in neurointerventional surgery: A prospective, multicenter, single-arm clinical trial
2022, Journal of Interventional Medicine
To evaluate the safety and efficacy of the SeparGate™ balloon-guiding catheter (BGC) for blocking flow and delivering devices in neurointerventional surgery.
This prospective multicenter single-arm trial enrolled patients who received BGC adjuvant therapy to provide temporary blood flow arrest of the supra-aortic arch arteries and their branch vessels in interventional therapy. The primary endpoint was immediate procedural success rate in flow arrest, device delivery, and withdrawal. The efficacy endpoints were intraoperative product performance, including rigidity, smoothness, fracture resistance of the catheter wall, catheter push performance, compatibility and radiopaque display, integrity, adhesion thrombus after withdrawal and balloon rupture. The safety endpoints were adverse and serious adverse events associated with the test device and serious adverse events resulting in death or serious health deterioration.
A total of 129 patients were included; of them, 128 were analyzed in the full analysis set (FAS) and per protocol set (PPS). Immediate procedural success was achieved in 97.7% of patients with FAS and PPS. The lower bound of the 95% confidence interval was 94.6%, higher than the preset efficacy margin of 94%. Device-related adverse events occurred in 2 (1.6%) cases. One was mild adverse event of vasospasm, which resolved spontaneously. The other was serious adverse event of dissection aggravation, which was treated with stenting angioplasty. No device defects were observed.
In neurointerventional surgery, the SeparGate™ BGC can be used to temporarily block the flow of the supra-aortic arch arteries and their branch vessels and guide the interventional device to the target vascular position.
Intraoperative Aneurysm Rupture: Surgical Experience and the Rate of Intraoperative Rupture in a Series of 1000 Aneurysms Operated on by a Single Neurosurgeon
2021, World Neurosurgery
Citation Excerpt :
In the CARAT (Cerebral Aneurysm Rerupture After Treatment) study,23 these rates were 5% with coiling and 19% with clipping, respectively. The rates of IOR reported by large endovascular series (>100 cases) varies also from 0.4% to 7.7%.39-45 In contrast, as seen in Table 4, the average IOR rate is 16.8% in 22 surgical series.
This study aims to examine the risk factors that can cause intraoperative rupture (IOR), and especially, the role of surgical experience. To our knowledge, this is the first study to analyze the effect of the surgeon's experience on the IOR rate in 2 different perspectives.
A total of 1000 aneurysms in 775 patients were operated on by a single neurosurgeon. The clinical and radiologic data and intraoperative video recordings of all patients were retrospectively analyzed. To evaluate the role of the surgeon's experience on the IOR rate, the aneurysms were divided chronologically into both 5-year periods and each 100 aneurysms. Number, stage, severity, location, management of IORs, and patients' outcomes were determined.
IOR occurred in 55 aneurysms (5.5% per aneurysm). The incidence of IOR decreased gradually in the first 2 groups of 5-year periods (11.4% and 5.9%, respectively). However, in the last 3 groups, the decline remained stable (4%–5%). Considering all groups, this decrease was statistically significant (P = 0.037). When this evaluation was made for each group of 100 aneurysms, similar results were obtained. Mortality also gradually decreased over the years (P = 0.035). Of 8 possible risk factors, rupture status was found to be the only independent predictor for IOR (OR, 8.68; 95% confidence interval, 3.69–20.47; P <0.001).
Increased surgical experience reduces the IOR rate from 10%–11% to 4%–5% after an average of 250 aneurysm operations. However, this rate does not decrease further with more experience. To our knowledge, a learning curve regarding IOR is presented for the first time in the literature.

View all citing articles on Scopus

: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

View full text

Original ArticleIntraprocedural Rupture During Endovascular Treatment of Intracranial Aneurysm: Clinical Results and Literature Review

Highlights

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patient Selection

Results

Discussion

Conclusions

J Stroke Cerebrovasc Dis

Lancet

World Neurosurg

Eur J Radiol

Predictors and outcomes of intraprocedural rupture in patients treated for ruptured intracranial aneurysms: the CARAT study

Stroke

Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: electrochemical basis, technique, and experimental results

J Neurosurg

Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: preliminary clinical experience

J Neurosurg

Embolisation of recently ruptured intracranial aneurysms

J Neurol Neurosurg Psychiatry

Selective occlusion of basilar artery aneurysms using controlled detachable coils: report of 35 cases

Neurosurgery

Basilar tip aneurysm: endovascular treatment with Guglielmi detachable coils–midterm results

Radiology

Safety and efficacy of endovascular treatment of acutely ruptured aneurysms

Neurosurgery

Guglielmi detachable coil embolization of acute intracranial aneurysm: perioperative anatomical and clinical outcome in 403 patients. 1997

J Neurosurg

Intracranial berry aneurysms: angiographic and clinical results after endovascular treatment

Radiology

Clinical and angiographic outcomes, with treatment data, for patients with cerebral aneurysms treated with Guglielmi detachable coils: a single-center experience

Neurosurgery

Rupture during treatment of recently ruptured aneurysms with Guglielmi electrodetachable coils

AJNR Am J Neuroradiol

Ruptured intracranial aneurysms: acute endovascular treatment with electrolytically detachable coils–a prospective randomized study

Radiology

Endovascular treatment of ruptured posterior circulation cerebral aneurysms. Clinical and angiographic outcomes

Stroke

Aneurysmal rupture during embolization with Guglielmi detachable coils: causes, management, and outcome

AJNR Am J Neuroradiol

Endovascular treatment of intracranial aneurysms by using Guglielmi detachable coils in awake patients: safety and feasibility

J Neurosurg

Rupture of intracranial aneurysms during treatment with Guglielmi detachable coils: incidence, outcome, and risk factors

J Neurosurg

Outcomes after aneurysm rupture during endovascular coil embolization

Neurosurgery

Endovascular treatment of intracranial aneurysms with Guglielmi detachable coils: analysis of midterm angiographic and clinical outcomes

Stroke

Procedure-related haemorrhage in embolisation of intracranial aneurysms with Guglielmi detachable coils

Neuroradiology

Endovascular coil occlusion of 1811 intracranial aneurysms: early angiographic and clinical results

Neurosurgery

Aneurysmal rupture during coiling: low incidence and good outcomes at a single large volume center

Neurosurgery

Periprocedural morbidity and mortality associated with endovascular treatment of intracranial aneurysms

AJNR Am J Neuroradiol

Prevention and management of intraprocedural rupture of intracranial aneurysm with detachable coils during embolization

Neuroradiology

Original Article
Intraprocedural Rupture During Endovascular Treatment of Intracranial Aneurysm: Clinical Results and Literature Review