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

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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.

Article Information

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.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 1. Angiographic (A–C) and CT (D) studies demonstrating stent-assisted coil embolization of a BA–SCA aneurysm. The need for dual antiplatelet therapy complicated the subsequent VP shunt placement. An SDH required drainage and a programmable valve was placed after correction of platelet function assays.

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    Case 2. Preoperative anteroposterior angiogram (A) demonstrating a right-sided PCA aneurysm. Postoperative angiograms (B and C) showing near complete, radiographically confirmed occlusion of the aneurysm with stent assistance.

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    Case 4. Angiograms (A–C) and CT scan (D) demonstrating a wide-necked, bilobed BA terminus aneurysm that was successfully embolized with stent assistance. Exchange of a nonfunctioning EVD resulted in IVH.

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    Case 5. A 3D reconstruction (A) of the unruptured wide-necked BA terminus aneurysm in this patient, with the planned path of the Neurostent marked by gray lines. Anteroposterior (B) and lateral (C) angiographic views of the positioned stent and framing coils. Angiogram (D) demonstrating technically successful embolization of the aneurysm. Arrows indicate the position of the stent within the vessel crossing the aneurysm. Axial CT scans (E and F) demonstrating SAH and hydrocephalus the day after the procedure, which required an EVD. This was complicated by further IVH.

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    Case 7. Angiogram (left) and CT scan (right) demonstrating stent-assisted coil embolization of a right-sided PICA aneurysm, with subsequent sacrifice of the VA because of an intraprocedural rupture and IVH.

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