Intracranial hemorrhage associated with stent-assisted coil embolization of cerebral aneurysms: a cautionary report

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  • 1 Department of Neurosurgery and
  • 2 Division of Interventional Neuroradiology, Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
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Object

The introduction of the Neuroform microstent has facilitated the embolization of complex cerebral aneurysms, which were previously not amenable to endovascular therapy. Typically, the use of this stent necessitates the administration of dual antiplatelet therapy to minimize thromboembolic complications. Such therapy may increase the risk of hemorrhage in patients who require concurrent external ventricular drainage and/or subsequent permanent cerebrospinal fluid diversion.

Methods

The authors' neurosurgical database was queried for all patients who underwent stent-assisted coil embolization for cerebral aneurysms and who required an external ventricular drain (EVD) or ventriculoperitoneal (VP) shunt placement for management of hydrocephalus.

Results

Thirty-seven patients underwent stent-assisted coil embolization for intracranial aneurysms at the authors' institution over a recent 2-year period. Seven of these patients required placement of an EVD and/or a VP shunt. Three of the 7 patients suffered an immediate intraventricular hemorrhage (IVH) associated with placement or manipulation of an EVD; 1 experienced a delayed intraparenchymal hemorrhage and an IVH; 1 suffered an aneurysmal rehemorrhage; and the last patient had a subdural hematoma (SDH) that resulted from placement of a VP shunt. This patient required drainage of the SDH and exchange of the valve.

Conclusions

The necessity of dual antiplatelet therapy in the use of stent-assisted coil embolization increases the risk of intracranial hemorrhage and possibly rebleeding from a ruptured aneurysm. This heightened risk must be recognized when contemplating the appropriate therapy for a cerebral aneurysm and when considering the placement or manipulation of a ventricular catheter in a patient receiving dual antiplatelet therapy. Further study of intracranial procedures in patients receiving dual antiplatelet therapy is indicated.

Abbreviations used in this paper: BA = basilar artery; CSF = cerebrospinal fluid; CT = computed tomography; EVD = external ventricular drain; ICA = internal carotid artery; IPH = intraparenchymal hemorrhage; IVH = intraventricular hemorrhage; mRS = modified Rankin Scale; PCA = posterior cerebral artery; PICA = posterior inferior cerebellar artery; SAH = subarachnoid hemorrhage; SCA = superior cerebellar artery; SDH = subdural hematoma; VA = vertebral artery; VP = ventriculoperitoneal.

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Contributor Notes

Address correspondence to: C. Michael Cawley, M.D., Department of Neurosurgery, The Emory Clinic, Suite 6200, 1365-B Clifton Road NE, Atlanta, Georgia 30322. email: charles.cawley@emoryhealthcare.org.
  • 1

    Alfke K, , Straube T, , Dorner L, , Mehdorn H, & Jansen O: Treatment of intracranial broad-neck aneurysms with a new self-expanding stent and coil embolization. AJNR Am J Neuroradiol 25:584591, 2004

    • Search Google Scholar
    • Export Citation
  • 2

    Benitez RP, , Silva MT, , Klem J, , Veznedaroglu E, & Rosenwasser RH: Endovascular occlusion of wide-necked aneurysms with a new intracranial microstent (Neuroform) and detachable coils. Neurosurgery 54:13591368, 2004

    • Search Google Scholar
    • Export Citation
  • 3

    Brisman JL, , Song JK, , Niimi Y, & Berenstein A: Treatment options for wide-necked intracranial aneurysms using a self-expandable hydrophilic coil and a self-expandable stent combination. AJNR Am J Neuroradiol 26:12371240, 2005

    • Search Google Scholar
    • Export Citation
  • 4

    Chapman TW, , Bowley DM, , Lambert AW, , Walker AJ, , Ashley SA, & Wilkins DC: Haemorrhage associated with combined clopidogrel and aspirin therapy. Eur J Vasc Endovasc Surg 22:478479, 2001

    • Search Google Scholar
    • Export Citation
  • 5

    Chow MM, , Woo HH, , Masaryk TJ, & Rasmussen PA: A novel endovascular treatment of a wide-necked basilar apex aneurysm by using a Y-configuration, double-stent technique. AJNR Am J Neuroradiol 25:509512, 2004

    • Search Google Scholar
    • Export Citation
  • 6

    Doerfler A, , Wanke I, , Egelhof T, , Stolke D, & Forsting M: Double-stent method: therapeutic alternative for small wide-necked aneurysms Technical note. J Neurosurg 100:150154, 2004

    • Search Google Scholar
    • Export Citation
  • 7

    Fiorella D, , Albuquerque F, , Han P, & McDougall C: Preliminary experience using the Neuroform stent for the treatment of cerebral aneurysms. Neurosurgery 54:617, 2004

    • Search Google Scholar
    • Export Citation
  • 8

    Fiorella D, , Albuquerque FC, , Deshmukh VR, & McDougall CG: In-stent stenosis as a delayed complication of neuroform stent-supported coil embolization of an incidental carotid terminus aneurysm. AJNR Am J Neuroradiol 25:17641767, 2004

    • Search Google Scholar
    • Export Citation
  • 9

    Fiorella D, , Albuquerque FC, , Deshmukh VR, & McDougall CG: Usefulness of the Neuroform stent for the treatment of cerebral aneurysms: results at initial (3–6-mo) follow-up. Neurosurgery 56:11911192, 2005

    • Search Google Scholar
    • Export Citation
  • 10

    Fiorella D, , Albuquerque FC, , Han P, & McDougall CG: Preliminary experience using the Neuroform stent for the treatment of cerebral aneurysms. Neurosurgery 54:617, 2004

    • Search Google Scholar
    • Export Citation
  • 11

    Herbstreit F, & Peters J: Spinal anaesthesia despite combined clopidogrel and aspirin therapy in a patient awaiting lung transplantation: effects of platelet transfusion on clotting tests. Anaesthesia 60:8587, 2005

    • Search Google Scholar
    • Export Citation
  • 12

    Hoh BL, , Nogueira RG, , Ledezma CJ, , Pryor JC, & Ogilvy CS: Safety of heparinization for cerebral aneurysm coiling soon after external ventriculostomy drain placement. Neurosurgery 57:845849, 2005

    • Search Google Scholar
    • Export Citation
  • 13

    Horowitz M, , Levy E, , Sauvageau E, , Genevro J, , Guterman LR, & Hanel R, : Intra/extraaneurysmal stent placement for management of complex and wide-necked- bifurcation aneurysms: eight cases using the waffle cone technique. Neurosurgery 58:4 Suppl ONS-258-262 2006

    • Search Google Scholar
    • Export Citation
  • 14

    Howington JU, , Hanel RA, , Harrigan MR, , Levy EI, , Guterman LR, & Hopkins LN: The Neuroform stent, the first microcatheter-delivered stent for use in the intracranial circulation. Neurosurgery 54:25, 2004

    • Search Google Scholar
    • Export Citation
  • 15

    Hussain MS, , Qureshi AI, , Kirmani JF, , Divani AA, & Hopkins LN: Update on endovascular treatment of cerebrovascular diseases. J Endovasc Ther 11:2 Suppl II32II42, 2004

    • Search Google Scholar
    • Export Citation
  • 16

    Jabbour P, , Koebbe C, , Veznedaroglu E, , Benitez RP, & Rosenwasser R: Stent-assisted coil placement for unruptured cerebral aneurysms. Neurosurg Focus 17:5 E10, 2004

    • Search Google Scholar
    • Export Citation
  • 17

    Lavine SD, , Larsen DW, , Giannotta SL, & Teitelbaum GP: Parent vessel Guglielmi detachable coil herniation during wide-necked aneurysm embolization: treatment with intracranial stent placement: two technical case reports. Neurosurgery 46:10131017, 2000

    • Search Google Scholar
    • Export Citation
  • 18

    Lownie SP, , Pelz DM, & Fox AJ: Endovascular therapy of a large vertebral artery aneurysm using stent and coils. Can J Neurol Sci 27:162165, 2000

    • Search Google Scholar
    • Export Citation
  • 19

    Lylyk P, , Cohen J, , Ceratto R, , Ferrario A, & Miranda C: Endovascular reconstruction of intracranial arteries by stent placement and combined techniques. J Neurosurg 97:13061313, 2002

    • Search Google Scholar
    • Export Citation
  • 20

    Lylyk P, , Cohen J, , Ferrario A, , Ceratto R, & Miranda C: Partially clipped intracranial aneurysm obliterated with combined stent and coil implantation. J Endovasc Ther 9:160164, 2002

    • Search Google Scholar
    • Export Citation
  • 21

    Lylyk P, , Ferrario A, , Pasbon B, , Miranda C, & Doroszuk G: Buenos Aires experience with the Neuroform self-expanding stent for the treatment of intracranial aneurysms. J Neurosurg 102:235241, 2005

    • Search Google Scholar
    • Export Citation
  • 22

    Picker SM, , Kaleta T, , Hekmat K, , Kampe S, & Gathof BS: Antiplatelet therapy preceding coronary artery surgery: implications for bleeding, transfusion requirements and outcome. Eur J Anaesthesiol 24:332339, 2007

    • Search Google Scholar
    • Export Citation
  • 23

    Pivalizza EG, & Gottschalk LI: A response to ‘Spinal anaesthesia despite combined clopidogrel and aspirin therapy in a patient awaiting lung transplantation: effects of platelet transfusion on clotting tests’. Anaesthesia 60:301, 2005

    • Search Google Scholar
    • Export Citation
  • 24

    Ross IB, & Dhillon GS: Ventriculostomy-related cerebral hemorrhages after endovascular aneurysm treatment. AJNR Am J Neuroradiol 24:15281531, 2003

    • Search Google Scholar
    • Export Citation
  • 25

    Wanke I, , Doerfler A, , Schoch B, , Stolke D, & Forsting M: Treatment of wide-necked intracranial aneurysms with a self-expanding stent system: initial clinical experience. AJNR Am J Neuroradiol 24:11921199, 2003

    • Search Google Scholar
    • Export Citation

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