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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 59, Num. 3, 2011, pp. 325-326

Neurology India, Vol. 59, No. 3, May-June, 2011, pp. 325-326


Management of minor and major endovascular intraprocedural aneurysm perforations

Mario N Carvi y Nievas

Neurosurgical Clinic, Klinikum Frankfurt-Höchst, Teaching Hospital of the Johann-Wolfgang-Goethe-University, Frankfurt am Main, FFM- Höchst, Germany

Correspondence Address: Mario N Carvi y Nievas Neurosurgical Clinic, Klinikum Frankfurt-Höchst, Teaching Hospital of the Johann-Wolfgang-Goethe-University, Frankfurt am Main, FFM- Höchst Germany

Date of Submission: 17-Jan-2011
Date of Decision: 17-Jan-2011
Date of Acceptance: 17-Jan-2011

Code Number: ni11101

PMID: 21743154

DOI: 10.4103/0028-3886.82700

The optimal management of cerebral aneurysms requires a coordinate interaction between surgeons and interventionalists. [1] In this issue, Zang et al. [2] report their experience with the treatment of cerebral aneurysms that ruptured during endovascular coiling. Their results confirm the previously reported high rates of associated morbidity (21.4%) and mortality (21.4%) related to this complication. These facts make it important to further differentiate this complication in at least two different conditions: the so-called minor vascular perforations where the rupture is only suspected or radiologically detected without the accompanying clinical deterioration from those severe intracranial bleedings, where additional acute clinical deterioration occurs. [3],[4] In cases of severe intracranial bleeding, an increase in intracranial pressure (ICP) with systemic hypertension and bradycardia, and even pupillary dilatation can occur very acutely. [5]

Minor perforations are mostly caused by the guidewire as it is steered into the aneurysm or by the coils themselves disrupting the wall of the thin aneurysm sacs. Fortunately, bleeding in such patients can be usually sealed immediately with the management described by Zang et al. [2] Major perforations followed by severe bleedings are usually related to uncontrolled advance of the microcatheter over the guidewire into the lesion or in cases of excessive packing with coils in an attempt to occlude the neck of some aneurysms. [6],[7] The key to reduce the magnitude of this severe complication is the rapid completion of aneurysm obliteration. Unfortunately, the chances of endovascular obliteration of such intraprocedural major ruptured aneurysms are very limited. Some of the main factors associated with successful obliteration are the personal skills and technical support of the acting interventionalist as well as the location and size of the aneurysm and the magnitude of the perforation. These discrepancies make it important to differentiate asymptomatic perforations during coiling procedures from those with a more severe course. Asymptomatic patients with minor vascular perforations, where the rupture is only radiologically detected are less endangered. However, those patients with severe bleeding require more complex decisions such as, the placement of ventricular drainage, removal of the additional mass-occupying clots, and the surgical decompression of the massive brain swelling. [5],[8],[9] If massive contrast material extravasation occurs or brain herniation signs develop, it seems hopeless to continue with the embolization of the aneurysm. An additional CT scan examination to evaluate the severity of the bleeding, often represents an additional loss of time for such cases. Hematoma location and extension can be surgically documented from the microscopic dissection of the source of bleeding. In case of a major perforation, following a rush individual analysis of associated factors, such as, advanced age, location, and magnitude of the bleeding source, the endovascular procedure must be interrupted. Spontaneously elevated blood pressure should not be drastically reduced before surgery. At this time, a periodical gentle manual compression of the ipsilateral carotid artery in the neck, after catheter removal, accelerates transitory hemostasis in all severe bleeding arising from the anterior circulation. Our initial management includes: (1) acute reversal of the anticoagulation with protamine; (2) atropine (up to 0.5 mg); (3) administration of 20% mannitol solution (0.5 - 1 mg/kg); (4) thiopental bolus (loading dose of 5 mg/kg), and urgent surgical management performed within 30 minutes of bleeding. Finally, suction of the associated intracerebral mass occupying blood clots and emergent extended craniotomy performed within the first 30 minutes, avoiding the use of lobectomy procedures, often save lives, decrease the ICP values, and restore cerebral perfusion in most of these critical affected patients.


1.Carvi y Nievas MN, Hattingen J, Hoellerhage HG. Interdisciplinary treatment selection in acute admitted patients with subarachnoid hemorrhage. Neurol Res 2009;31:582-92.   Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Zang P, Liang C, Shi Q, Wang Y. Intraprocedural cerebral aneurysm rupture during endovascular coiling. Neurol India 2011;59:369-72.  Back to cited text no. 2  [PUBMED]  
3.Peltier J, Nowtash A, Toussaint P, Desenclos C, Deramond H, Le Gars D. Aneurysmal rupture during embolization with Guglielmi detachable coils. Neurochirurgie 2004;50:454-60.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Matsumaru Y, Sonobe M, Nakai Y, Takahashi S, Nose T. Rupture of aneurysms during and after embolization with guglielmi detachable coils. Interv Neuroradiol 2001;22:83-7.  Back to cited text no. 4    
5.Carvi y Nievas M, Haas E, Höllerhage HG. Severe intracranial bleedings during endovascular procedures: Outcome of surgically treated patients. Neurol Res 2007;29:81-90.  Back to cited text no. 5    
6.McDougall CG, Halbach VV, Dowd CF, Higashida RT, Larsen DW, Hieshima GB. Causes and management of aneurysmal hemorrhage occurring during embolization with Guglielmi detachable coils. J Neurosurg 1998;89:87-92.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Solander S, Ulhoa A, Viñuela F, Duckwiler GR, Gobin YP, Martin NA, et al. Endovascular treatment of multiple intracranial aneurysms by using Guglielmi detachable coils. J Neurosurg 1999;90:857-64.  Back to cited text no. 7    
8.Otani N, Takasato Y, Masaoka H, Hayakawa T, Yoshino Y, Yatsushige H, et al. Surgical outcome following decompressive craniectomy for poor-grade aneurysmal subarachnoid hemorrhage in patients with associated massive intracerebral or Sylvian hematomas. Cerebrovasc Dis 2008;26:612-7.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Eleftherios A, Carvi y Nievas MN. Acute management of poor condition subarachnoid hemorrhage patients. Vasc Health Risk Manag 2007;3:1075-82.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]

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