Risk of ventriculostomy-related hemorrhage in patients with acutely ruptured aneurysms treated using stent-assisted coiling

Clinical article

Restricted access

Object

Intracranial stenting has improved the ability to treat wide-neck aneurysms via endovascular techniques. However, stent placement necessitates the use of antiplatelet agents, and the latter may complicate the treatment of patients with acutely ruptured aneurysms who demonstrate hydrocephalus and require ventriculostomy. Antiplatelet agents in this setting could increase the incidence of ventriculostomy-related hemorrhagic complications, but there are insufficient data in the medical literature to quantify this potential risk. The aim of this study was to directly quantify the risk of ventriculostomy-related hemorrhage in patients with acute aneurysmal subarachnoid hemorrhage treated with stent-assisted coiling.

Methods

The authors retrospectively identified 131 patients who underwent endovascular treatment for an acutely ruptured aneurysm as well as ventriculostomy or ventriculoperitoneal (VP) shunt placement. The rate of hemorrhagic complications associated with ventriculostomy or VP shunt insertion was compared between patients who underwent coiling without a stent (Group 1) and those who underwent stent-assisted coiling and dual antiplatelet therapy (Group 2).

Results

One hundred nine ventriculostomies or VP shunt placement procedures were performed in 91 patients in Group 1, and 50 procedures were undertaken in 40 patients in Group 2. The rates of radiographic hemorrhage and symptomatic hemorrhage were significantly higher in Group 2 (32% vs 14.7%, p = 0.02; and 8% vs 0.9%, p = 0.03, respectively). On multivariate analyses, Group 2 had 3.42 times the odds of a radiographic hemorrhage (95% CI 1.46–8.04, p = 0.0048) after adjusting for antiplatelet use prior to admission.

Conclusions

The application of dual antiplatelet therapy in stent-assisted coiling of acutely ruptured aneurysms is associated with an increase in the risk of hemorrhagic complications following ventriculostomy or VP shunt placement, as compared with its use in a coiling procedure without a stent.

Abbreviations used in this paper: SAH = subarachnoid hemorrhage; VP = ventriculoperitoneal.

Article Information

Address correspondence to: David K Kung, M.D., Department of Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, Iowa 52242. email: david-kung@uiowa.edu.

Please include this information when citing this paper: published online October 15, 2010; DOI: 10.3171/2010.9.JNS10445.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Head CT scans of symptomatic ventriculostomy-related hemorrhage in a patient in Group 1 (left) and a patient in Group 2 (right).

  • View in gallery

    Head CT scans of asymptomatic ventriculostomy-related hemorrhage in a patient in Group 1 (left) and a patient in Group 2 (right).

References

  • 1

    Benitez RPSilva MTKlem JVeznedaroglu ERosenwasser RH: Endovascular occlusion of wide-necked aneurysms with a new intracranial microstent (Neuroform) and detachable coils. Neurosurgery 54:135913682004

    • Search Google Scholar
    • Export Citation
  • 2

    Binz DDToussaint LG IIIFriedman JA: Hemorrhagic complications of ventriculostomy placement: a meta-analysis. Neurocrit Care 10:2532562009

    • Search Google Scholar
    • Export Citation
  • 3

    Biondi AJanardhan VKatz JMSalvaggio KRiina HAGobin YP: Neuroform stent-assisted coil embolization of wide-neck intracranial aneurysms: strategies in stent deployment and midterm follow-up. Neurosurgery 61:4604692007

    • Search Google Scholar
    • Export Citation
  • 4

    de Oliveira JGBeck JSetzer MGerlach RVatter HSeifert V: Risk of shunt-dependent hydrocephalus after occlusion of ruptured intracranial aneurysms by surgical clipping or endovascular coiling: a single-institution series and metaanalysis. Neurosurgery 61:9249342007

    • Search Google Scholar
    • Export Citation
  • 5

    de Rooij NKLinn FHvan der Plas JAAlgra ARinkel GJ: Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry 78:136513722007

    • Search Google Scholar
    • Export Citation
  • 6

    Geisler TLanger HWydymus MGöhring KZürn CBigalke B: Low response to clopidogrel is associated with cardiovascular outcome after coronary stent implantation. Eur Heart J 27:242024252006

    • Search Google Scholar
    • Export Citation
  • 7

    Grewe PHDeneke TMachraoui ABarmeyer JMüller KM: Acute and chronic tissue response to coronary stent implantation: pathologic findings in human specimen. J Am Coll Cardiol 35:1571632000

    • Search Google Scholar
    • Export Citation
  • 8

    Hasan DVermeulen MWijdicks EFHijdra Avan Gijn J: Management problems in acute hydrocephalus after subarachnoid hemorrhage. Stroke 20:7477531989

    • Search Google Scholar
    • Export Citation
  • 9

    Higashida RTSmith WGress DUrwin RDowd CFBalousek PA: Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery. Case report and review of the literature. J Neurosurg 87:9449491997

    • Search Google Scholar
    • Export Citation
  • 10

    Hoh BLNogueira RGLedezma CJPryor JCOgilvy CS: Safety of heparinization for cerebral aneurysm coiling soon after external ventriculostomy drain placement. Neurosurgery 57:8458492005

    • Search Google Scholar
    • Export Citation
  • 11

    Ingall TJWhisnant JPWiebers DOO'Fallon WM: Has there been a decline in subarachnoid hemorrhage mortality?. Stroke 20:7187241989

    • Search Google Scholar
    • Export Citation
  • 12

    Kassell NFTorner JCHaley EC JrJane JAAdams HPKongable GL: The international cooperative study on the timing of aneurysm surgery. part 1: Overall management results. J Neurosurg 73:18361990

    • Search Google Scholar
    • Export Citation
  • 13

    Katsaridis VPapagiannaki CViolaris C: Embolization of acutely ruptured and unruptured wide-necked cerebral aneurysms using the neuroform2 stent without pretreatment with antiplatelets: a single center experience. AJNR Am J Neuroradiol 27:112311282006

    • Search Google Scholar
    • Export Citation
  • 14

    King SB IIISmith SC JrHirshfeld JW JrJacobs AKMorrison DAWilliams DO: 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol 51:1722092008

    • Search Google Scholar
    • Export Citation
  • 15

    Lee YJKim DJSuh SHLee SKKim JKim DI: Stent-assisted coil embolization of intracranial wide-necked aneurysms. Neuroradiology 47:6806892005

    • Search Google Scholar
    • Export Citation
  • 16

    Lepäntalo AVirtanen KSHeikkilä JWartiovaara ULassila R: Limited early antiplatelet effect of 300 mg clopidogrel in patients with aspirin therapy undergoing percutaneous coronary interventions. Eur Heart J 25:4764832004

    • Search Google Scholar
    • Export Citation
  • 17

    Linn FHRinkel GJAlgra Avan Gijn J: Incidence of subarachnoid hemorrhage: role of region, year, and rate of computed tomography: a meta-analysis. Stroke 27:6256291996

    • Search Google Scholar
    • Export Citation
  • 18

    Maree AOFitzgerald DJ: Aspirin and coronary artery disease. Thromb Haemost 92:117511812004

  • 19

    Molyneux AKerr RStratton ISandercock PClarke MShrimpton J: International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:126712742002

    • Search Google Scholar
    • Export Citation
  • 20

    Molyneux AJKerr RSYu LMClarke MSneade MYarnold JA: International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366:8098172005

    • Search Google Scholar
    • Export Citation
  • 21

    O'Kelly CJKulkarni AVAustin PCUrbach DWallace MC: Shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage: incidence, predictors, and revision rates. Clinical article. J Neurosurg 111:102910352009

    • Search Google Scholar
    • Export Citation
  • 22

    Prabhakaran SWells KRLee VHFlaherty CALopes DK: Prevalence and risk factors for aspirin and clopidogrel resistance in cerebrovascular stenting. AJNR Am J Neuroradiol 29:2812852008

    • Search Google Scholar
    • Export Citation
  • 23

    Reavey-Cantwell JFFox WCReichwage BDFautheree GLVelat GJWhiting JH: Factors associated with aspirin resistance in patients premedicated with aspirin and clopidogrel for endovascular neurosurgery. Neurosurgery 64:8908962009

    • Search Google Scholar
    • Export Citation
  • 24

    Ross IBDhillon GS: Ventriculostomy-related cerebral hemorrhages after endovascular aneurysm treatment. AJNR Am J Neuroradiol 24:152815312003

    • Search Google Scholar
    • Export Citation
  • 25

    Sacco RLWolf PABharucha NEMeeks SLKannel WBCharette LJ: Subarachnoid and intracerebral hemorrhage: natural history, prognosis, and precursive factors in the Framingham Study. Neurology 34:8478541984

    • Search Google Scholar
    • Export Citation
  • 26

    Stapf CMohr JPAneurysms and subarachnoid hemorrhage— epidemiology. Le Roux PDWinn HRNewell DW: Management of Cerebral Aneurysms PhiladelphiaSaunders2004. 183188

    • Search Google Scholar
    • Export Citation
  • 27

    Suarez-Rivera O: Acute hydrocephalus after subarachnoid hemorrhage. Surg Neurol 49:5635651998

  • 28

    Tumialán LMZhang YJCawley CMDion JETong FCBarrow DL: Intracranial hemorrhage associated with stent-assisted coil embolization of cerebral aneurysms: a cautionary report. J Neurosurg 108:112211292008

    • Search Google Scholar
    • Export Citation
  • 29

    Van Belle ETio FOCouffinhal TMaillard LPasseri JIsner JM: Stent endothelialization. Time course, impact of local catheter delivery, feasibility of recombinant protein administration, and response to cytokine expedition. Circulation 95:4384481997

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 282 282 46
Full Text Views 183 150 3
PDF Downloads 131 112 3
EPUB Downloads 0 0 0

PubMed

Google Scholar