Neurology India, Vol. 59, No. 3, May-June, 2011, pp. 369-372
Intraprocedural cerebral aneurysm rupture during endovascular coiling
Peizhuo Zang, Chuansheng Liang, Qiang Shi, Yunjie Wang
Department of Neurosurgery, The First Affiliated Hospital of China Medical University, Shenyang, China
Correspondence Address: Peizhuo Zang Department of Neurosurgery, The First Affiliated Hospital of China Medical University, Heping Beier Street, 110001, Shenyang China firstname.lastname@example.org
Date of Submission: 07-Dec-2010
Code Number: ni11111
AbstractBackground : Intraprocedural aneurysm rupture is considered to be one of the most formidable complications of the endovascular treatment of cerebral aneurysms and is associated with high mortality.
Objective : To report the clinical outcomes of cerebral aneurysms that ruptured during endovascular coiling.
Patients and Methods : Over a period of six years, 559 endovascular embolizations were performed in 467 patients, with 507 cerebral aneurysms. Intraprocedural aneurysm rupture occurred in 14 cases (mean aneurysm size, 3.8 mm). Follow-up angiograms, at a minimum of three months post embolization, were available in 11 living patients. Acute and follow-up results were reviewed.
Results : The difference in the rates of aneurysm perforation during endovascular coiling between ruptured and unruptured aneurysms was significant (P < 0.05). There were three (21.4%) deaths related to this complication and three (21.4%) patients developed new deficits (modified Rankin Scale scores 1 to 2). Acute results of embolization were: complete occlusion in eight (57.1%), neck remnant in two (14.3%), and incomplete occlusion in four (28.6%) patients. Long-term follow-up results in 11 living patients were: major recanalization in one (9.1%), minor recanalization in one (9.1%), and stable occlusion in nine (81.8%).
Conclusion : Intraprocedural aneurysm rupture frequently occurs in small aneurysms and appears to be associated with relatively high rates of mortality.
Keywords: Cerebral aneurysm, embolization, rupture
Intraprocedural aneurysm rupture is one of the most formidable complications of the endovascular treatment of cerebral aneurysms. The reported frequency range is from 1.4 to 4.5%. ,,,,,,,, The serious outcomes reported in the meta-analysis  include death in 33% and disability in 5% of the patients. A recent single large-volume center  experience has shown no mortality and a morbidity of 20%. These results have been attributed to the protocol used: heparin reversal, rapid completion of aneurysm obliteration, ventricular drainage, and ready availability of the neurosurgical team. We present the clinical outcomes in patients who have experienced an intraprocedural aneurysm rupture.
Patients and Methods
Between September 2001 and Semptember 2007, 437 consecutive patients with 507 cerebral aneurysms (137 patients with unruptured aneurysms and 370 patients with ruptured aneurysms) have undergone 559 embolization procedures at our institution. Intraprocedural aneurysm perforation occurred in 14 (2.8%) patients with ruptured aneurysms. Demonstration of extra-aneurysmal contrast material from an aneurysm was considered for the definition of aneurysm perforation [Figure - 1]. The age range was between 39 and 75 years (mean, 52.4 years) and there were eight females.
Embolization was performed using a single-microcatheter technique in nine (64.3%) patients, a stent-assisted technique in four (28.6%) patients, and a balloon-remodeling technique in one (7.1%) patient. Only bare coils were used in these patients. The demographic data and aneurysm characteristics are summarized in [Table - 1].
Management of intraprocedural aneurysm rupture
In all the patients, intraprocedural aneurysm rupture resulted from a coil portion during coil placement. When a contrast leak was identified, the following steps were taken: heparin reversal with intravenous protamine sulfate; rapid completion of aneurysm obliteration using the residual segment of the inserted coil, or if possible, with additional coils and ventricular drainage, depending on patient status and neurological deficits. When a microcatheter tip or portion of a coil extruded from an aneurysm, a prepared coil or residual coil portion within the microcatheter was carefully advanced with slight withdrawal of the microcatheter, so that the last coil portion was at least deployed in the aneurysm. This protocol was adopted in all the patients with contrast leak and the result was stoppage of the contrast leakage at the end of the procedure.
Acute outcomes were evaluated by control angiography, obtained at the end of the procedure, and long-term follow-up outcomes were determined by the last follow-up angiography. Acute outcomes were classified as complete occlusion, neck remnant, and incomplete occlusion. Long-term follow-up outcomes were classified as stable occlusions, minor aneurysm recanalization was defined as minimal coil compaction at the aneurysm neck, and major recanalization was defined as contrast filling within the aneurysm dome, significant coil loosening or compaction. Two neuroradiologists independently assessed acute and follow-up anatomic outcomes and the conflicting results were resolved by a consensus. The clinical outcomes were assessed using the modified Rankin Scale (mRS) score. 
There was a significant difference in the rates of aneurysm perforation during endovascular coiling, between ruptured and unruptured aneurysms (χ2 = 4.015, P < 0.05). There were three (21.4%) deaths attributable to major intraprocedural aneurysm ruptures. New neurological deficits were noted in three (21.4%) patients at discharge: subarachnoid hemorrhage (Hunt and Hess Grade II / III, weak right hand grip weakness in one; unilateral third nerve palsy in one; and mild gait disturbance in one). One patient, with an mRS score of 3, underwent external ventricular drainage after embolization and developed intraventricular hemorrhage and worsening hydrocephalus. Recurrent hydrocephalus after drain removal required revision of ventricular drainage, and a poorly functioning drain caused uncontrolled hydrocephalus and gait disturbance. Ventriculoperitoneal shunting was performed before discharge. At the three-month follow-up visit, the gait disturbance had improved considerably (mRS 1). These three patients had follow-up visits at three and six months. The mRS scores were 0 in two patients and 1 in one patient.
The acute results were: complete occlusion in eight (57.1%), neck remnant in two (14.3%), and incomplete occlusion in four (28.6%) patients. Mean follow-up period was 4.5 months (range, 3 - 6 months) and the outcomes were: complete occlusion in nine (81.8%), where one of the neck remnants disappeared; minor recanalization in one (9.1%); and major recanalization in one (9.1%). The patient with major recanalization underwent repeat embolization after three months.
Intraprocedural aneurysm rupture usually occurs with aneurysms that rupture and is associated with significant morbidity and morality. Morbidity and mortality may not be avoided even when rapid completion of aneurysm obliteration with coils is achieved. ,,,,,,,,, In our series, intraprocedural aneurysm rupture was 2.8% and the lowest reported rate was 1.7% in the series by Kwon and colleagues.  In our series the mean size of the aneurysm was less than 4 mm and intraprocedural aneurysm rupture occurred in patients with ruptured aneurysms.  In the series by Kwon et al.,  they could not find any relation with the learning curve and no difference between anterior and posterior circulation aneurysms. When there is any suspicion of aneurysm rupture during the procedure, the interventionalist must focus on the measures to prevent contrast leakage, rather than continuing with the procedure to achieve the best anatomic results. The rate of incomplete occlusion in our study is similar to the earlier reported rates, 2.3 to 10.7%. ,
The mortality in this series was 28.6% and similar high mortality rates have been reported in other series. , In the series reported by Ricolfi et al.  two patients developed mydriasis and temporary arrest of cerebral circulation, as shown by the angiography. In both the patients, the extravasation of contrast media was minimal. Raymond and Roy  reported two deaths related to intraprocedural bleeding, one due to raised intracranial pressure and the other following massive cerebral infarction secondary to carotid occlusion. Emergent decompressive craniotomy, evacuation of space occupying hematoma, and acute aneurysm clipping, are some of the options to save life in patients with this complication. 
Copyright 2011 - Neurology India
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