Morphological predictors of intraprocedural rupture during coil embolization of ruptured cerebral aneurysms: do small basal outpouchings carry higher risk?

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Object

This study aimed to investigate morphological predictors of intraprocedural rupture (IPR) during coil embolization of ruptured cerebral aneurysms.

Methods

A retrospective analysis was conducted in 322 consecutive patients with ruptured cerebral aneurysms who were treated with coil embolization over an 8-year period from January 2005 to December 2012. The authors analyzed all available data with emphasis on morphological characteristics of the aneurysm as shown on baseline angiography in relation to IPR. Regarding aneurysm morphology, the authors classified patients according to multilobulation, presence of a daughter sac, and presence of a small basal outpouching (SBO).

Results

The incidence of IPR was 4.8% (16 of 332). In terms of aneurysm configuration, the presence of multilobulation (100.0% [16 of 16] in the IPR group vs 89.2% [282 of 316] in the non-IPR group, p = 0.388) and daughter sac (75.0% [12 of 16] in the IPR group vs 59.2% [187 of 316] in the non-IPR group, p = 0.208) were not significantly associated with IPR. However, SBO, found in 9% (30 of 332) of the study population, was significantly associated with IPR (56.3% [9 of 16] in the IPR group vs 6.7% [21 of 316] in the non-IPR group, OR 18.06, p < 0.0001).

Conclusions

Based on the authors' data, the more general groups of multilobulation and daughter sac were not significantly associated with IPR, although the more specific subgroup with an SBO was. More confirmation studies on these results are required, but they point to the possibility that SBO (with its possible connection to basal rupture) is an important morphological risk factor for IPR during coiling. In addition, future comparison of coiling and clipping treatment for ruptured aneurysms associated with an SBO seems necessary.

Abbreviations used in this paper:ACA = anterior cerebral artery; ACoA = anterior communicating artery; CTA = CT angiography; DSA = digital subtraction angiography; ICA = internal carotid artery; IPR = intraprocedural rupture; mRS = modified Rankin Scale; PCoA = posterior communicating artery; SBO = small basal outpouching; WFNS = World Federation of Neurosurgical Societies.

Abstract

Object

This study aimed to investigate morphological predictors of intraprocedural rupture (IPR) during coil embolization of ruptured cerebral aneurysms.

Methods

A retrospective analysis was conducted in 322 consecutive patients with ruptured cerebral aneurysms who were treated with coil embolization over an 8-year period from January 2005 to December 2012. The authors analyzed all available data with emphasis on morphological characteristics of the aneurysm as shown on baseline angiography in relation to IPR. Regarding aneurysm morphology, the authors classified patients according to multilobulation, presence of a daughter sac, and presence of a small basal outpouching (SBO).

Results

The incidence of IPR was 4.8% (16 of 332). In terms of aneurysm configuration, the presence of multilobulation (100.0% [16 of 16] in the IPR group vs 89.2% [282 of 316] in the non-IPR group, p = 0.388) and daughter sac (75.0% [12 of 16] in the IPR group vs 59.2% [187 of 316] in the non-IPR group, p = 0.208) were not significantly associated with IPR. However, SBO, found in 9% (30 of 332) of the study population, was significantly associated with IPR (56.3% [9 of 16] in the IPR group vs 6.7% [21 of 316] in the non-IPR group, OR 18.06, p < 0.0001).

Conclusions

Based on the authors' data, the more general groups of multilobulation and daughter sac were not significantly associated with IPR, although the more specific subgroup with an SBO was. More confirmation studies on these results are required, but they point to the possibility that SBO (with its possible connection to basal rupture) is an important morphological risk factor for IPR during coiling. In addition, future comparison of coiling and clipping treatment for ruptured aneurysms associated with an SBO seems necessary.

Intraprocedural rupture (IPR) during coil embolization of ruptured cerebral aneurysms has been reported as an often devastating complication, with incidence rates ranging from 1% to 8% and high mortality rates up to 40%.1–3,6,7,10,11,13,17,18,20,21,23,24 Although there has been some investigation into the risk factors of IPR during coil embolization, most studies have focused on epidemiological factors, background medical conditions, size and location of aneurysms, and technical aspects.1,2,6,7,10,11,13,18–21,23,25 Few studies to date have investigated IPR in relation to morphological configurations of aneurysms.

Although based on a small number of studies, a common assumption to date was that the presence of multilobulation or a daughter sac might indicate a high risk of IPR.13,18,21 However, this assumption may be of limited practical application, because of the pervasiveness of ruptured cerebral aneurysms harboring multilobulation or a daughter sac.

To investigate more specific risk factors for IPR, we focused on basal morphology. If a daughter sac, or bleb, is located near the base of a ruptured aneurysm, it is called a “small basal outpouching” (SBO), and it is a common morphological configuration in cases of basal rupture.8,15 In our experience, cases of SBO tended to have a higher incidence of IPR. Therefore, we hypothesized that the chance of IPR could increase if a ruptured aneurysm contained an SBO where the SBO itself was the rupture point of the aneurysm. Also, we retrospectively analyzed whether multilobulation and daughter sac were genuine risk factors of IPR, or whether SBO, which is a proper subset of both daughter sac and multilobulation, was the predominant risk factor.

The purpose of this study was to investigate morphological predictors of IPR, in the context of angiographic predictors of IPR in general, with specific emphasis on ruptured cerebral aneurysms with an SBO.

Methods

Patient Population

This study included all patients with a ruptured cerebral saccular aneurysm who underwent coil embolization at our center between January 2005 and December 2012. All available patients underwent digital subtraction angiography (DSA) or 3D CT angiography (CTA) before the decision was made between coiling and clipping. If the aneurysm was determined to be amenable to coil embolization and consensus was reached by our cerebrovascular team, coil embolization was immediately performed. Intraprocedural rupture was defined as “the extravasation of contrast material demonstrated on concurrent angiography, regardless of the extrusion of coil, microcatheter, or microguidewire outside the lumen of an aneurysm.”20 Cases of IPR were identified during the coiling procedure by the attending neurosurgeon (D.H.K.) or neurointerventionalist (Y.S.K.), with adjudication by a team of 2 independent physicians (D.H.G. and S.K.B.). Medical records were reviewed to assess all available data related to IPR, including demographic factors, a patient's baseline World Federation of Neurosurgical Societies (WFNS) grade and Fisher grade, a previous history of antiplatelet or anticoagulant medication, and angiographic characteristics of the aneurysm.

Angiographic Characteristics of the Ruptured Aneurysms

All morphological variables, including location, size, aspect ratio, type of lobulation, and SBO, were identified based on 3D CTA using a 64-slice multidetector CT scanner (Aquilion TSX-101A, Toshiba Medical Systems Co.) and DSA using the Allura Xper FD20 (Philips Electronics). Attending physicians (D.H.K. and Y.S.K.) first measured these parameters, and they were independently double-checked by 2 other physicians (D.H.G. and S.K.B.). Aneurysm location was categorized into 4 main groups, namely, the anterior cerebral artery (ACA), the internal carotid artery (ICA), the middle cerebral artery, and the vertebrobasilar system. Then, the ACA group was further categorized into the anterior communicating artery (ACoA), A1 segment (the horizontal part at the proximity of the ACoA), and distal ACAs. The ICA group was subcategorized into the posterior communicating artery (PCoA), the anterior choroidal artery, and other ICAs. The vertebrobasilar system was categorized into the basilar apex and other vertebrobasilar vessels. The size of aneurysm was defined by the maximal length of its aneurysm cavity, and it was determined by direct measurement on 3D CTA and/or 3D reconstructed images obtained from DSA. The aspect ratio was defined as the maximum dimension of the dome to the width of the neck of an aneurysm.22 To make this measurement, the depths and necks of the aneurysms were measured to the nearest millimeter based on the best angiographic projections. The aspect ratio was simply calculated as the aneurysm depth divided by the aneurysm neck width.

We applied 3 classification types for the configuration of the aneurysm. The first type was determined according to the irregularity of the aneurysm contour. Unilobulation was defined as a spherical or elliptical shape without irregularity. Configurations other than unilobulation were considered as multilobulated. The second type was defined according to the presence of a daughter sac. A daughter sac was defined as a secondary aneurysmal sac, or bleb, arising from the primary aneurysmal sac with an interface (aneurysm-bleb boundary) smaller than the largest diameter of the daughter aneurysm, or bleb. The third type was defined according to whether the aneurysm had an SBO or not. An SBO was a prominent daughter sac located near the neck of the aneurysm and defined as a one located in the lower third of an aneurysm, with the lower margin of the outpouching approximating the parent artery of the aneurysm.15

Endovascular Procedures Including Management of IPR and Follow-Up

The endovascular procedure was performed under general anesthesia. An initial bolus of 50 U/kg heparin was generally administered after deployment of the first coil to maintain an activated clotting time at twice the patient's baseline level. Coils were placed until satisfactory aneurysm obliteration was achieved and/or placement of additional coils was not possible. A single or multiple microcatheter technique was primarily considered, and for wide-necked aneurysms, stent or balloon assistance was performed according to operator preferences. When an IPR was encountered, heparin was reversed with protamine sulfate, and coils were rapidly deployed to secure the aneurysm. If needed, emergency ventriculostomy was performed to reduce intracranial pressure.

A CT scan was obtained immediately after the procedure to check the amount of additional bleeding or for hydrocephalus. Immediate neurological worsening was defined as an elevation of WFNS grade of more than 2 points. Long-term functional outcome was evaluated using the modified Rankin Scale (mRS) at 3 months from discharge. At least 1 follow-up angiography study was performed within 6 months for all available patients with IPR.

Statistical Analysis

The data were analyzed using SPSS software, version 9.12 for Windows. The chi-square, Fisher's exact, Wilcoxon rank-sum, and multivariate logistic regression tests were used appropriately for a statistical comparison between the 2 groups. The results were considered significant for probability values < 0.05.

Results

During the study period, a total of 332 patients with a ruptured saccular aneurysm underwent coil embolization. The patient population consisted of 213 women (64.2%) and 119 men (35.8%), with a mean age of 57.3 years (range 14–90 years). An IPR occurred in 16 (4.8%) of 332 patients. There were no statistically significant relationships concerning age, sex, baseline WFNS and Fisher grades, and previous history of antiplatelet or anticoagulant medication between patients with and without IPR shown in statistical analysis (Table 1).

TABLE 1:

Baseline characteristics of patients with and without IPR*

VariableIPR (n = 16)No IPR (n = 316)p Value
sex0.695
 male5 (31.3)114 (36.1)
 female11 (68.8)202 (63.9)
mean age in yrs ± SD56.5 ± 15.157.3 ± 13.40.945
initial Fisher grade0.737§
 10 (0.0)6 (1.9)
 26 (37.5)149 (47.2)
 39 (56.3)130 (41.1)
 41 (6.3)31 (9.8)
initial WFNS grade0.785§
 I7 (43.8)135 (42.7)
 II6 (37.5)109 (34.5)
 III0 (0.0)18 (5.7)
 IV2 (12.5)45 (14.2)
 V1 (6.3)9 (2.9)
previous antiplatelet or anticoagulant medication>0.999§
 no14 (87.5)267 (84.5)
 yes2 (12.5)49 (15.5)

Except age, all values are expressed as number (%).

Chi-square test.

Wilcoxon rank-sum test.

Fisher's exact test.

The aneurysm was located in the ACoA in a significantly larger proportion of patients with IPR (12 of 16, 75%, p = 0.001). Intraprocedural rupture did not occur in posterior circulation aneurysms (Table 2); IPR tended to occur more frequently in smaller aneurysms according to the Wilcoxon rank-sum test (4.3 ± 1.3 mm vs 6.1 ± 3.3 mm, p = 0.012). Additionally, when the size was dichotomized as < 5 mm versus ≥ 5 mm, the class of aneurysms < 5 mm was significantly associated with IPR (p = 0.013). However, there was no statistically significant relationship regarding the aspect ratio between patients with and without IPR (p = 0.202). Configuration analysis showed that multilobulation (100.0% [16 of 16] in the IPR group vs 89.2% [282 of 316] in the non-IPR group, p = 0.388) and the presence of a daughter sac (75.0% [12 of 16] in the IPR group vs 59.2% [187 of 316] in the non-IPR group, p = 0.208) were not significantly different between patients with and without IPR. However, the presence of an SBO, found in 9% (30 of 332) of the study population, was significantly associated with IPR (56.3% [9 of 16] in the IPR group vs 6.7% [21 of 316] in the non-IPR group, OR 18.06, p < 0.0001 [Table 3]). After adjustment in multivariate logistic regression analysis, ACoA location, size (< 5 mm), and SBO were all independent predictors of IPR (p = 0.010, p = 0.028, and p < 0.0001, respectively [Table 4]).

TABLE 2:

Location, size, and aspect ratio of aneurysms in patients with and without IPR*

VariableIPR (n = 16)No IPR (n = 316)p Value
location
 ACA
  ACoA12 (75)108 (34.2)
  A11 (6.3)1 (0.3)
  distal ACAs1 (6.3)7 (2.2)
 ICA
  PCoA2 (12.5)102 (32.3)
  AChA0 (0)5 (1.6)
  other ICAs0 (0)19 (6.0)
 MCA0 (0)20 (6.3)
 VB system
  BA0 (0)23 (7.3)
  other VBs0 (0)31 (9.8)
size0.012
 mean ± SD4.3 ± 1.36.1 ± 3.3
 median (range)4.1 (2.7–7.8)5.4 (1.7–26.3)
aspect ratio0.202
 mean ± SD2.0 ± 0.41.9 ± 0.6
 median (range)2.1 (1.3–2.8)1.8 (0.4–5.4)

AChA = anterior choroidal artery; BA = basilar apex; MCA = middle cerebral artery; VB = vertebrobasilar.

Obtained using the Wilcoxon rank-sum test.

Values are expressed as number (%).

TABLE 3:

Classification of aneurysm configuration in patients with and without IPR*

VariableNo. of Patients (%)p Value
IPR (n = 16)No IPR (n = 316)
irregularity of aneurysm
 contour
  unilobulation0 (0.0)34 (10.8)0.388*
  multilobulation16 (100.0)282 (89.2)
daughter sac
 absent4 (25.0)129 (40.8)0.208
 present12 (75.0)187 (59.2)
SBO
 absent7 (43.8)295 (93.4)<0.0001*
 present9 (56.3)21 (6.7)

Fisher's exact test.

Chi-square test.

TABLE 4:

Multivariate logistic regression of the predictors of IPR

VariableUnivariateMultivariate
OR (95% CI)p ValueOR (95% CI)p Value
aneurysm site (ACoA)5.78 (1.82–18.34)0.0015.09 (1.47–17.66)0.010
aneurysm size (<5 mm)3.97 (1.25–12.58)0.0134.11 (1.17–14.49)0.028
aneurysm (SBO present)18.06 (6.12–53.31)<0.000116.32 (5.17–53.54)<0.0001

Detailed data of the 16 patients with IPR are summarized in Table 5. Specifically, 1 case of IPR occurred during microcatheter access, 1 occurred during microguidewire advancement, 3 occurred during an early stage of coiling, and 11 occurred during the final stage of the coiling procedure. All cases of IPR were treated using a single (8 of 16) or double (8 of 16) microcatheter technique. Figure 1 shows radiological findings of 4 typical patients who experienced IPR during embolization near an SBO at the final stage of the procedure.

TABLE 5:

Summary of 16 patients with IPR*

Case No.Age (yrs), SexFisher GradeWFNS GradeLocation of AneurysmHeight/Neck Size (mm)Shape of AneurysmCoiling TechniqueStage of IPRDegree of OcclusionmRS Score at 3 Mos
151, F3IIACoA5.1/2.4ML, DSsingle microcatheterfilling, 2nd of 5 coilsneck remnant0
279, F3IIACoA7.8/3.6ML, SBOdouble microcathetersfilling, 7th of 8 coilsincomplete occlusion6
360, F3VA14.2/1.5ML, SBOdouble microcathetersfilling, 3rd of 4 coilsincomplete occlusion2
463, F2IACoA4.5/2ML, SBOdouble microcathetersfinishing, 4th of 4 coilsneck remnant1
542, M2IACoA4/1.9MLsingle microcatheterfilling, 2nd of 6 coilscomplete occlusion1
623, M2IVACoA3.5/1.3ML, SBOsingle microcatheterfinishing, 4th of 4 coilscomplete occlusion0
772, M2Ipericallosal4.5/1.8ML, SBOsingle microcatheterfilling, 4th of 5 coilsneck remnant1
832, M2IIACoA5/2.3MLdouble microcathetersfinishing, 5th of 5 coilscomplete occlusion1
953, F3IACoA4/2.5ML, SBOdouble microcathetersfinishing, 4th of 4 coilsneck remnant6
1061, F3IIACoA3.3/1.5MLsingle microcatheterfinishing, 3rd of 3 coilscomplete occlusion2
1155, M4IIACoA3.5/2ML, SBOdouble microcathetersmicrocatheter accessneck remnant2
1262, F2IACoA6/3.2ML, DSdouble microcathetersfilling, 7th of 8 coilscomplete occlusion1
1366, F3IPCoA2.7/1.8ML, DSdouble microcathetersfinishing, 3rd of 3 coilsneck remnant2
1445, F3IIACoA3.2/1.8ML, SBOsingle microcathetermicroguidewire advancementcomplete occlusion2
1570, F3IPCoA3.3/2.3ML, DSsingle microcatheterfilling, 1st of 3 coilscomplete occlusion1
1670, F3IVACoA4.5/3.6ML, SBOsingle microcatheterfilling, 5th of 6 coilsneck remnant6

DS = daughter sac; ML = multilobulation.

Intraprocedural rupture occurred at the SBO.

Fig. 1.
Fig. 1.

Four typical cases of IPR in relation to SBO. A: Baseline CT scans. B: Cerebral angiograms (working projection view) showing SBO (arrow). C: Cerebral angiograms (working projection view) obtained during IPR, showing leakage of contrast media during coil embolization near an SBO at the final stage of the procedure (arrow). D: Computed tomography scans obtained immediately after the procedure.

According to the results of an immediate postprocedure CT scan, 8 of 16 IPR patients showed a prominent increase in the amount of subarachnoid hemorrhage; however, there was no case of a significant intracranial hematoma collection that required emergency surgical evacuation. Immediate neurological worsening was noted in 3 of 16 patients after IPR (18.8%). One patient died within 48 hours because of a massive subarachnoid hemorrhage and increased intracranial pressure after IPR. The other 2 patients' conditions deteriorated, with changes of WFNS grade from II to V and I to V, respectively, which finally resulted in death in both within a month. The remaining 13 (81.3%) of 16 IPR patients showed good functional recovery (mRS score ≤ 2) at 3 months. Follow-up angiography was done in 12 patients (10 with DSA, and 2 with time-of-flight MR angiography), which resulted in stable occlusion in 5 (41.7%), minor recanalization in 4 (33.3%), and major recanalization in 3 (25%). Two patients with major recanalization underwent add-on coil embolization.

Discussion

Recently, coil embolization has been increasingly used in place of surgical clipping for ruptured cerebral aneurysms.12 However, IPR has continued to be one of the most devastating complications of coiling due to its high mortality and morbidity rates. Therefore, there have been several efforts to identify risk factors for IPR, including epidemiological factors (Asian or African heritage), background medical conditions (including coronary artery disease and hyperlipidemia), and technical considerations (including a microguidewire jump and excessive coil packing).2,6,7,10,11 Regarding the characteristics of the aneurysm, predictors of IPR were thought to include ACoA aneurysm location, smaller size, and presence of a daughter sac or multilobulation (Table 6).1,2,13,18–21,24,25 However, the aforementioned risk factors are not easily applied to real practice (including the treatment decision between clipping and coiling for a ruptured cerebral aneurysm), because ACoA location and smaller size are widely encountered findings, and most ruptured aneurysms harbor a daughter sac or multilobulation.

TABLE 6:

Literature review of IPR during coil embolization of cerebral aneurysms*

Authors & YearNo. of CasesNo. of IPRs (%)Suggested Risk Factors
TotalRuptured/UnrupturedTotalRupturedUnruptured
Raymond & Roy, 19977575/06 (8)6 (8)insufficient experience, smaller aneurysm size
Viñuela et al., 1997403403/011 (2.7)11 (2.7)smaller aneurysm size
Cognard et al., 1998236150/866 (2.5)6 (4)0 (0)insufficient experience, ruptured aneurysm
McDougall et al., 1998200NS4 (2)fluctuation of blood pressure, insufficient experience, pressure wave at contrast injection
Ricolfi et al., 19989191/04 (4.4)4 (4.4)aneurysm morphology (daughter sac), smaller aneurysm size
Vanninen et al., 19995252/03 (5.8)3 (5.8)NS
Doerfler et al., 2001164164/05 (3)5 (3)insufficient experience, smaller aneurysm size, technical aspect (stiffness of microguidewire tip)
Levy et al., 2001274NS6 (2.2)ruptured aneurysm, smaller aneurysm size, technical aspect (balloon assistance, overpacking, oversizing of coils, use of stiffer 3D coil)
Sluzewski et al., 2001264182/827 (2.7)7 (3.8)0 (0)ruptured aneurysm, smaller aneurysm size, technical aspect (balloon assistance)
Tummala et al., 2001734525/20910 (1.4)10 (1.9)0 (0)aneurysm morphology (daughter sac), ruptured aneurysm, smaller aneurysm size, technical aspect (overpacking)
Brisman et al., 2005600414/1866 (1)6 (1.4)0 (0)ACoA location, ruptured aneurysm, smaller aneurysm size
Elijovich et al., 2008299299/016 (5.4)16 (5.4)Asian/black race, COPD, lower baseline Hunt & Hess grade
Nguyen et al., 2008682682/021 (3.1)21 (3.1)very small aneurysm (≤3 mm)
Schuette et al., 2011347277/7018 (5.2)NSNSACoA location, small aneurysm size (≤4 mm)

COPD = chronic obstructive pulmonary disease; NS = not specified.

The major findings of this study were as follows: 1) regarding the presence of a daughter sac or multilobulation, there were no significant differences between the IPR and non-IPR groups (p = 0.208 and p = 0.388, respectively). 2) However, SBOs, namely, daughter sacs, or blebs, located at the base of the aneurysm, were significantly correlated with IPR (p < 0.0001). In detail, 9% (30 of 332) of the study population harbored an SBO, and among them, 30% (9 of 30) were included in the IPR cohort. 3) In terms of aneurysm location and size, our data were consistent with previous investigations, which showed that ACoA location and smaller size were significantly related with IPR (p = 0.001 and p = 0.012 in our study, respectively). 4) ACoA location, size (< 5 mm), and SBO were all independent predictors of IPR after adjustment in multivariate logistic regression (p = 0.010, p = 0.028, and p < 0.0001, respectively).

From the procedural angiographic review, we found that 7 of 16 IPRs occurred at an SBO (6 while finishing coiling near an SBO and 1 involving microcatheter access near an SBO; Table 5). One possible explanation of such findings is as follows. Some SBOs may be the initial rupture site of the aneurysm, like a daughter sac at the dome, and the risk of IPR could increase during the movement of microcatheter or coil positioning near the SBO if the SBO is the rupture site. The dome of an aneurysm is often the rupture site, but the base of an aneurysm also can be the rupture site, albeit infrequently, with an incidence of 2%.4,5 This possibility of basal rupture can be detected occasionally by an angiographic configuration showing a stalk-like narrow neck or SBO.8,14 Recently, Park et al. reported an 8.7% incidence (41 of 471) of SBO in ruptured aneurysms. In the surgical cohort (n = 286), a basal rupture was confirmed in 8 (30.8%) of the 26 cases of a basal outpouching and successfully treated by aneurysm clip placement. In the endovascular cohort (n = 185), 5 (33.3%) of the 15 patients with a basal outpouching developed intraprocedural aneurysm rebleeding, which was most commonly observed with ACoA aneurysms.15

Although treatment outcomes for ruptured cerebral aneurysm patients are continually improving for both treatment modalities (coiling and clipping), there has been a lack of data in cases of basal rupture because of the rarity of its occurrence. The present study solely focused on the outcome of coil embolization, including IPR, in cases of possible basal rupture. We found that the chance of IPR during coiling increased in cases of aneurysms containing an SBO, which could be related to basal rupture.

Another possible concern of coil embolization for a basal ruptured aneurysm is the degree of occlusion at the end of the coiling procedure. Despite recent advances in endovascular coiling devices, complete neck packing of an aneurysm is not easy, occurring in 39%–66% of cases.9,12,16 If a coiling procedure is finished and there is a neck remnant or incomplete embolization, the chance of rebleeding can potentially increase in cases of basal rupture.

Although the conditions of 3 of 16 IPR patients immediately deteriorated, leading to death within a month, the remaining 13 patients (81.3%) had an mRS score of 0–2 at 3 months. The success in the latter cases is thought to be the result of a rescue practice for IPR, which included immediate heparin reversal, rapid aneurysm occlusion, and emergency ventriculostomy.1,20,21

The present study has potential limitations. First, this was a single institutional retrospective study, and the numbers of IPR and aneurysms containing an SBO were small; therefore, the results of statistical analysis should be interpreted cautiously and cannot be easily generalized to show whether coiling is worse than clipping in terms of treating a ruptured aneurysm harboring an SBO. Second, all IPR cases in this paper were treated using a single or double microcatheter technique, so the possibility of different outcomes could not be excluded if the cases were treated with stent or balloon assistance. Additionally, it should be noted that alternative microcatheter positioning or coil size may affect results on whether SBO is a risk factor for IPR. Moreover, to provide more objective information about the relatively small incidence of basal rupture, a larger, prospective coiling-to-clipping comparison study is necessary in the near future.

Conclusions

Intraprocedural rupture during coil embolization occurred in 4.8% of patients. We found that the more general groups of multilobulation and daughter sac were not significantly associated with IPR, although the more specific subgroup with an SBO was. This points to the possibility that an SBO is an important morphological risk factor for IPR, but more confirmation studies on these results are required. Additionally, our data support the claim that some IPRs can occur in relation to a basal rupture of an aneurysm, and if ruptured aneurysms carry such risk factors, more attention is required during coil embolization.

Acknowledgments

We thank Won-Gee Lee of Kyungpook National University for his validation of statistical analysis in this study. We also appreciate Wade Martin of Medical Research International for his critical English revision.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Kang, Park. Acquisition of data: Goh. Analysis and interpretation of data: all authors. Drafting the article: Kang, Goh. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Kang. Statistical analysis: Goh. Study supervision: Kang.

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    Nguyen TNRaymond JGuilbert FRoy DBérubé MDMahmoud M: Association of endovascular therapy of very small ruptured aneurysms with higher rates of procedure-related rupture. J Neurosurg 108:108810922008

  • 14

    Park J: Saccular aneurysm with basal rupture angiographically depicted as an aneurysm with stalk-like narrow neck. Report of 2 cases. J Neurosurg 114:106510682011

  • 15

    Park JWoo HKang DHKim YBaik SK: Ruptured intracranial aneurysms with small basal outpouching: incidence of basal rupture and results of surgical and endovascular treatments. Neurosurgery 71:99410022012

  • 16

    Pierot LCognard CRicolfi FAnxionnat R: Immediate anatomic results after the endovascular treatment of ruptured intracranial aneurysms: analysis in the CLARITY series. AJNR Am J Neuroradiol 31:9079112010

  • 17

    Raymond JRoy D: Safety and efficacy of endovascular treatment of acutely ruptured aneurysms. Neurosurgery 41:123512461997

  • 18

    Ricolfi FLe Guerinel CBlustajn JCombes CBrugieres PMelon E: Rupture during treatment of recently ruptured aneurysms with Guglielmi electrodetachable coils. AJNR Am J Neuroradiol 19:165316581998

  • 19

    Schuette AJHui FKSpiotta AMObuchowski NAGupta RMoskowitz SI: Endovascular therapy of very small aneurysms of the anterior communicating artery: five-fold increased incidence of rupture. Neurosurgery 68:7317372011

  • 20

    Sluzewski MBosch JAvan Rooij WJNijssen PCWijnalda D: Rupture of intracranial aneurysms during treatment with Guglielmi detachable coils: incidence, outcome, and risk factors. J Neurosurg 94:2382402001

  • 21

    Tummala RPChu RMMadison MTMyers MTubman DNussbaum ES: Outcomes after aneurysm rupture during endovascular coil embolization. Neurosurgery 49:105910672001

  • 22

    Ujiie HTamano YSasaki KHori T: Is the aspect ratio a reliable index for predicting the rupture of a saccular aneurysm?. Neurosurgery 48:4955032001

  • 23

    Vanninen RKoivisto TSaari THernesniemi JVapalahti M: Ruptured intracranial aneurysms: acute endovascular treatment with electrolytically detachable coils—a prospective randomized study. Radiology 211:3253361999

  • 24

    Viñuela FDuckwiler GMawad M: Guglielmi detachable coil embolization of acute intracranial aneurysm: perioperative anatomical and clinical outcome in 403 patients. J Neurosurg 86:4754821997

  • 25

    Wiebers DOWhisnant JPHuston J IIIMeissner IBrown RD JrPiepgras DG: Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:1031102003

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Article Information

Drs. Kang and Goh contributed equally to this work.

Address correspondence to: Dong-Hun Kang, M.D., Departments of Neurosurgery and Radiology, Kyungpook National University Hospital, 50, Samduk-2-ga, Jung-gu, Daegu, Republic of Korea. email: kdhdock@hotmail.com.

Please include this information when citing this paper: published online June 27, 2014; DOI: 10.3171/2014.5.JNS132107.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Four typical cases of IPR in relation to SBO. A: Baseline CT scans. B: Cerebral angiograms (working projection view) showing SBO (arrow). C: Cerebral angiograms (working projection view) obtained during IPR, showing leakage of contrast media during coil embolization near an SBO at the final stage of the procedure (arrow). D: Computed tomography scans obtained immediately after the procedure.

References

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Cloft HJKallmes DF: Cerebral aneurysm perforations complicating therapy with Guglielmi detachable coils: a metaanalysis. AJNR Am J Neuroradiol 23:170617092002

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Levy EKoebbe CJHorowitz MBJungreis CAPride GLDutton K: Rupture of intracranial aneurysms during endovascular coiling: management and outcomes. Neurosurgery 49:8078132001

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McDougall CGHalbach VVDowd CFHigashida RTLarsen DWHieshima GB: Causes and management of aneurysmal hemorrhage occurring during embolization with Guglielmi detachable coils. J Neurosurg 89:87921998

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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

13

Nguyen TNRaymond JGuilbert FRoy DBérubé MDMahmoud M: Association of endovascular therapy of very small ruptured aneurysms with higher rates of procedure-related rupture. J Neurosurg 108:108810922008

14

Park J: Saccular aneurysm with basal rupture angiographically depicted as an aneurysm with stalk-like narrow neck. Report of 2 cases. J Neurosurg 114:106510682011

15

Park JWoo HKang DHKim YBaik SK: Ruptured intracranial aneurysms with small basal outpouching: incidence of basal rupture and results of surgical and endovascular treatments. Neurosurgery 71:99410022012

16

Pierot LCognard CRicolfi FAnxionnat R: Immediate anatomic results after the endovascular treatment of ruptured intracranial aneurysms: analysis in the CLARITY series. AJNR Am J Neuroradiol 31:9079112010

17

Raymond JRoy D: Safety and efficacy of endovascular treatment of acutely ruptured aneurysms. Neurosurgery 41:123512461997

18

Ricolfi FLe Guerinel CBlustajn JCombes CBrugieres PMelon E: Rupture during treatment of recently ruptured aneurysms with Guglielmi electrodetachable coils. AJNR Am J Neuroradiol 19:165316581998

19

Schuette AJHui FKSpiotta AMObuchowski NAGupta RMoskowitz SI: Endovascular therapy of very small aneurysms of the anterior communicating artery: five-fold increased incidence of rupture. Neurosurgery 68:7317372011

20

Sluzewski MBosch JAvan Rooij WJNijssen PCWijnalda D: Rupture of intracranial aneurysms during treatment with Guglielmi detachable coils: incidence, outcome, and risk factors. J Neurosurg 94:2382402001

21

Tummala RPChu RMMadison MTMyers MTubman DNussbaum ES: Outcomes after aneurysm rupture during endovascular coil embolization. Neurosurgery 49:105910672001

22

Ujiie HTamano YSasaki KHori T: Is the aspect ratio a reliable index for predicting the rupture of a saccular aneurysm?. Neurosurgery 48:4955032001

23

Vanninen RKoivisto TSaari THernesniemi JVapalahti M: Ruptured intracranial aneurysms: acute endovascular treatment with electrolytically detachable coils—a prospective randomized study. Radiology 211:3253361999

24

Viñuela FDuckwiler GMawad M: Guglielmi detachable coil embolization of acute intracranial aneurysm: perioperative anatomical and clinical outcome in 403 patients. J Neurosurg 86:4754821997

25

Wiebers DOWhisnant JPHuston J IIIMeissner IBrown RD JrPiepgras DG: Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:1031102003

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