Anterior Communicating Artery Aneurysm: Rupture with SAH, Endovascular Occlusion with Bare Coils, Early Re-rupture, Poor Clinical Outcome
- 109 Downloads
An 80-year-old female patient was referred with a spontaneous subarachnoid hemorrhage (SAH), graded as Hunt and Hess III, Fisher IV, with a thick clot along the course of the anterior cerebral artery (ACA). The SAH was due to a ruptured anterior communicating artery (AcomA) aneurysm. The irregularly contoured aneurysm was treated with coil occlusion with almost complete exclusion of the aneurysm from blood circulation. The presumed rupture site was identified and occluded with coils. However, the patient suffered an early re-hemorrhage 36 h after the coil treatment and deteriorated clinically. The site of the re-rupture was distinct from that of the first hemorrhage. The aneurysm was subsequently completely filled with further coils. The patient remained in a persistent vegetative state after the second hemorrhage and died three months after the endovascular treatment. Additional cases are also presented which illustrate early re-hemorrhage from the original rupture site. The rare event of an early re-hemorrhage after endovascular coil occlusion of a ruptured intracranial aneurysm is the main topic of this chapter.
KeywordsAcomA aneurysm SAH Coil occlusion Early re-hemorrhage
80-year-old, female, spontaneous SAH, Hunt and Hess III, Fisher IV
Due to the relatively good clinical condition and previously independent status of the patient, the decision was made to treat the aneurysm in order to prevent a second hemorrhage, despite the advanced age of the patient. As the neck-width to sac-width anatomy of the aneurysm was favorable, the neurovascular interdisciplinary team decided on endovascular coil occlusion.
Procedure #1, 10.05.2011: endovascular coil occlusion of a ruptured AcomA aneurysm
Anesthesia: general anesthesia; 1 × 5000 IU unfractionated heparin (Heparin-Natrium, B. Braun) IV, 1 × 1 g thiopental (Trapanal, Nycomed) IV
Access: right common femoral artery, 1 × 8F sheath (Terumo); guide catheter: 1 × 8F SAAD left (Cordis); distal access catheter: 1 × FARGOMAX (Balt Extrusion); microcatheter: 1 × Echelon14 (Medtronic); microguidewire: 1 × Traxcess 0.014″ 200 cm (MicroVention)
Coils: 1 × Deltaplush10 2/6; 1 × Deltaplush10 2/4; 1 × Deltaplush10 2/3; 1 × Deltapaq10 1.5/2; 1 × Deltaplush10 1.5/2; 1 × Deltaplush10 1.5/1 (all Codman)
Duration: 1st–20th DSA run: 170 min; fluoroscopy time: 43 min
Clinical Course and Subsequent Treatments
A repeated angiography 13 days after the initial coil treatment showed loosening of the coil mass at the neck level of the aneurysm with increased filling of the sac. The decision was then taken to re-treat the early recurrence as the risk of a third hemorrhage was judged to be high due to the progressive reperfusion of the sac in the short term.
Procedure #2, 23.05.2011: endovascular re-treatment of progressive reperfusion of a re-ruptured AcomA aneurysm using coil occlusion
Anesthesia: general anesthesia; no further medication was administered
Access: right common femoral artery, 1 × 6F sheath (Terumo); guide catheter: 1 × 6F Guider Softip (Boston); microcatheter: 1 × Headway-17 (MicroVention); microguidewire: 1 × Traxcess 0.014″ 200 cm (MicroVention)
Coils: 1 × MicroPlex10 Hypersoft 2/20 (MicroVention); 1 × Deltaplush10 1.5/10 (Codman)
Duration: 1st–11th DSA run: 140 min; fluoroscopy time: 17 min
The patient remained stuporous throughout the acute phase with non-localizing movements to painful stimuli. She was discharged into an intensive rehabilitation facility and died on August 8, 2011, from the sequelae of the aneurysm ruptures, about three months after the SAH and endovascular aneurysm treatment.
There were no further follow-up examinations carried out.
The endovascular treatment of ruptured cerebral aneurysms has been proven to be safe and effective since its introduction in the early 1990s, an assertion which has been supported by clinical trials in the early twenty-first century (Byrne et al. 1999; Molyneux 2002; Viñuela et al. 2008). The high rates of recanalization, especially after treatment of ruptured aneurysms in the acute phase, were recognized early on but the rates of re-hemorrhage, and the rates of procedural complications associated with retreatments are low (Molyneux et al. 2005; Raymond et al. 2003; Renowden et al. 2008).
A variety of pathomechanisms have to be considered as potentially responsible for aneurysm re-rupture. Ultra-early pretreatment re-rupture of aneurysms is a possibility, and if there is no CT imaging done immediately prior to the endovascular treatment, it can be impossible to determine whether a new hemorrhage has happened before, during, or after the coiling procedure.
The Cerebral Aneurysm Re-rupture After Treatment (CARAT) study reported a 2.2% risk of non-procedural re-rupture in the first year following surgical and endovascular treatment of 706 and 295 patients, respectively. The study demonstrated a significant correlation between the degree of occlusion and the risk of re-rupture (with a cumulative risk of 17.6% for occlusion of less than 70% compared to 1.1% and 2.9% for complete and 91–99% occlusion, respectively). The risk of re-rupture was higher after coil occlusion but did not differ significantly after adjustment for degree of aneurysm occlusion (Johnston et al. 2008).
A study of 431 patients who had been treated with coil occlusion for ruptured aneurysms reported early re-hemorrhage in 6 (1.4%) cases with 100% mortality. A small ruptured aneurysm and the presence of an adjacent hematoma were independent risk factors (Sluzewski and van Rooij 2005). In a study of 1167 consecutive cases of ruptured aneurysms treated with coil embolization, early re-hemorrhage occurred in 13 patients (1.1%) within two weeks and was associated with a high mortality and morbidity rate. The authors recognized incomplete occlusion, antiplatelet and anticoagulation medication, and the presence of parenchymal hemorrhage as possible risk factors of ultra-early re-rupture after coil treatment (Cho et al. 2012).
In this case the mechanism underlying the re-hemorrhage two days after the coil occlusion of the aneurysm remains undefined. Vasospasm as a potential cause of ischemia with secondary hemorrhage into an infarcted brain parenchyma was never confirmed during the acute-phase follow-up. Compromise of the venous drainage by the initial hematoma triggering a second hemorrhage is only a speculative explanation.
- Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R, International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360(9342):1267–74. https://doi.org/10.1016/S0140-6736(02)11314-6.CrossRefPubMedGoogle Scholar
- Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P, International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. 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. 2005;366(9488):809–17. https://doi.org/10.1016/S0140-6736(05)67214-5.CrossRefPubMedGoogle Scholar
- Raymond J, Guilbert F, Weill A, Georganos SA, Juravsky L, Lambert A, Lamoureux J, Chagnon M, Roy D. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke. 2003;34(6):1398–403. https://doi.org/10.1016/S0140-6736(05)67214-5.CrossRefPubMedGoogle Scholar
- Renowden SA, Koumellis P, Benes V, Mukonoweshuro W, Molyneux AJ, McConachie NS. Retreatment of previously embolized cerebral aneurysms: the risk of further coil embolization does not negate the advantage of the initial embolization. AJNR Am J Neuroradiol. 2008;29(7):1401–4. https://doi.org/10.3174/ajnr.A1098.CrossRefPubMedGoogle Scholar