Cerebrovascular complications and granuloma formation after wrapping or coating of intracranial aneurysms with cotton gauze and human fibrin adhesives: results from a single-center patient series over a 5-year period

Clinical article

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Object

Reinforcement of intracranial aneurysms (IAs) by wrapping or coating is a well-established therapeutic approach to those IAs not amenable to any other definitive treatment, but has been associated with complications such as parent artery narrowing, granuloma formation, and ischemic stroke. The goal of this study was to systematically investigate cerebrovascular complications following this procedure.

Methods

The authors' hospital database was searched for all patients who underwent wrapping or coating of IAs with cotton gauze and human fibrin adhesives between October 2006 and October 2011. The follow-up records of these patients were extracted, including regular clinical visits and vascular imaging.

Results

Five hundred sixty-seven patients were treated for IAs over the 5-year period: 303 patients underwent endovascular strategies and 264 underwent craniotomies. Wrapping or coating of IAs was performed in 20 patients (3.5%). Parent artery narrowing occurred in 5 (25%) of the 20 patients and was associated with major ischemic strokes in 4 patients and severe headache in another. Ischemic strokes were associated with parent artery narrowing, which occurred early postoperatively in 2 patients or was a consequence of granuloma formation in 2 patients 1 and 2 months after the procedure, respectively.

Conclusions

These data should add to the awareness of significant cerebrovascular complications following wrapping or coating of IAs with cotton gauze and human fibrin adhesives and indicate that major ischemic strokes need to be included in the risk/benefit considerations during decision making for such treatment strategies. Patients who receive IA wrapping should be monitored and followed up closely for arterial narrowing and granuloma formation.

Abbreviations used in this paper:IA = intracranial aneurysm; MCA = middle cerebral artery; PICA = posterior inferior cerebellar artery; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Markus Beitzke, M.D., Medical University of Graz, Auenbruggerplatz 22, Graz 8036, Austria. email: markus.beitzke@klinikum-graz.at.

Please include this information when citing this paper: published online August 9, 2013; DOI: 10.3171/2013.6.JNS1373.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 11. Representative images from a 68-year-old woman who underwent uneventful clipping and wrapping of a ruptured aneurysm of the right MCA. Left: Computed tomography angiography performed on postoperative Day 7 depicts significant narrowing of the parent artery (arrow) and reduced to absent flow signal in the right MCA branches. Right: Subsequent axial diffusion-weighted MRI shows multiple acute ischemic lesions (arrows).

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    Case 5. Images obtained in a 41-year-old man who underwent uneventful gauze wrapping for an incidental aneurysm at the right MCA trifurcation. A: On readmission 1 month after surgery because of sudden-onset left hemiparesis, axial contrast-enhanced T1-weighted MRI showed an enhancing lesion (arrow) at the site of the wrapped aneurysm. B: Magnetic resonance angiography revealed significant focal arterial narrowing of the right MCA (arrow) proximal to the treated aneurysm and reduced flow in the distal MCA branches. C and D: Axial diffusion-weighted MRI (C) showed multiple hyperintense areas (arrows) in the right MCA territory with reduced signal intensity on corresponding apparent diffusion coefficient maps (arrows, D) consistent with acute ischemic infarctions. E: An unenhanced axial brain CT scan obtained 3 days later because of clinical deterioration revealed a space-occupying right MCA infarction necessitating decompressive hemicraniectomy. Also note the hyperintense lesion at the site of the previously treated MCA aneurysm (arrow) indicating the muslinoma. F: Axial brain CT scan obtained on the 2nd day after decompressive hemicraniectomy. G and H: Computed tomography angiography at the 6-month follow-up (G) illustrated occlusion of the right MCA (arrow), and an axial brain CT scan (H) showed a large defect from MCA infarction.

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    Case 19. Images obtained in a 69-year-old woman who underwent uneventful coating of an incidental left MCA aneurysm. A: Magnetic resonance angiography (3D volume rendering) obtained preoperatively showed the 9-mm aneurysm of the left MCA (arrow), which was not amenable to clipping due to heavy calcifications. B: On readmission due to sudden-onset nonfluent aphasia 2 months after the procedure, axial diffusion-weighted MRI illustrated multiple acute ischemic infarcts (arrows). C and D: Coronal contrast-enhanced T1-weighted MRI revealed a lobulated ring-enhancing mass at the site of the previously treated aneurysm (arrows) consistent with granuloma formation (C), and reduction of the size of the muslinoma (arrows) following 2 weeks of corticosteroid treatment (D). E: Magnetic resonance angiography (3D volume rendering) at the 12-month follow-up without further neurological deterioration depicts occlusion of the left proximal MCA (M1 segment, arrow). F: Note also that MR angiography depicts flow signal in the distal MCA branches (M2, M3) indicating the formation of collateral leptomeningeal vascularization (arrows).

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