J Cerebrovasc Endovasc Neurosurg.  2015 Sep;17(3):209-216. 10.7461/jcen.2015.17.3.209.

Rebleeding of Ruptured Intracranial Aneurysms in the Immediate Postoperative Period after Coil Embolization

• Chang SH
• Shin HS
• Lee SH
• Koh HC
• Koh JS

• KMID: 2069245
• DOI: http://doi.org/10.7461/jcen.2015.17.3.209

Abstract

OBJECTIVE
Early rebleeding after coil embolization of ruptured intracranial aneurysms is rare, however serious and fatal results of rebleeding have been reported. We studied the incidence and angiographic and clinical characteristics of rebleeding of ruptured aneurysms occurring in the immediate postoperative period after coil embolization.
MATERIALS AND METHODS
We analyzed patients who had aneurysmal subarachnoid hemorrhage and underwent coil embolization. Patients with dissecting aneurysms, blood blister-like aneurysms, fusiform aneurysms, and pseudoaneurysms were excluded. This study included 330 consecutive patients. The clinical and radiological data of 7 of these patients with acute rebleeding after coil embolization were reviewed.
RESULTS
The incidence of rebleeding of ruptured aneurysms after coil embolization was 2.1% (7/330), and all cases of rebleeding occurred in the immediate postoperative period within 3 days after coiling. The radiological characteristics were as follows: anterior communicating artery (ACoA) aneurysm (71.4%, 5/7); presence of intracerebral hemorrhage (ICH, 71.4%, 5/7); dome-to-neck ratio < 2 (42.9%, 3/7); presence of bleb (42.9%, 3/7); and subtotal occlusion of aneurysm after coiling (14.3%, 1/7). A thrombolytic agent was administered in 1 patient and continued anticoagulation was performed in 2 patients. Rebleeding patients showed a very poor outcome (Glasgow Outcome Scale 1, 85.7%, 6/7).
CONCLUSION
The prognosis of early rebleeding was very poor. Location of aneurysms on ACoA, the unilateral hypoplasia of A1 segment, presence of ICH and bleb, and adverse events during the procedure were probably associated with early rebleeding of ruptured intracranial aneurysms in the immediate postoperative period after coil embolization.

Keyword

Coil embolization, Intracranial aneurysm, Rebleeding; subarachnoid hemorrhage

MeSH Terms

Aneurysm
Aneurysm, Dissecting
Aneurysm, False
Aneurysm, Ruptured
Arteries
Blister
Cerebral Hemorrhage
Embolization, Therapeutic*
Humans
Incidence
Intracranial Aneurysm*
Postoperative Period*
Prognosis
Subarachnoid Hemorrhage

Figure

• 

  Fig. 1 A case with discrepancies in the aneurysm size and morphology between computed tomography angiography (CTA) and three-dimensional rotational angiography (3DRA) findings. (A) Brain CT shows a large amount of subarachnoid hemorrhage (SAH) in the basal cistern, interhemispheric fissure, and both Sylvian fissures. (B) CTA shows an elongated anterior communicating artery aneurysm with a small neck diameter of 1.44 mm and a large neck-to-dome diameter of 3.57 mm. The dome-to-neck ratio of the aneurysm is 2.47. (C, D) Digital subtraction angiography and 3DRA performed after CTA show a small saccular aneurysm with a dome-to-neck ratio of 1.83 (neck diameter, 1.22 mm; neck-to-dome diameter, 2.24 mm). (E) The aneurysm is secured by coil embolization using 3 detachable coils, with no neck and lumen remnants. (F) Compared to immediate postoperative brain CT, brain CT performed 8 h after coil embolization shows increased SAH in the left Sylvian fissure, interhemispheric fissure, and basal cistern with newly developed intraventricular hemorrhage.

• 

  Fig. 2 A case of rebleeding of anterior communicating artery (ACoA) aneurysms after successful coil embolization. (A) Brain computed tomography (CT) of a 58-year-old male shows dense subarachnoid hemorrhage. (B) Computed tomography angiography (CTA) shows a saccular aneurysm of the ACoA (arrow). Cerebral digital subtraction angiography (DSA) and three-dimensional rotational angiography (3DRA) show 2 ACoA aneurysms. (C, D) A large aneurysm in the superior direction (arrowhead), and (E, F) a small aneurysm in the anterior direction (arrowhead). (G, H) Both aneurysms are successfully obliterated with detachable coils, and there is no definite evidence of neck and lumen remnants. Because a coil loop protrudes into the ACoA (arrow), continued anticoagulation therapy with intravenous low-molecular-weight heparin is performed. After the sudden presentation of comatose mentality, brain CT shows increased subarachnoid hemorrhage (SAH) in the basal cistern. (I) Contrast leakage from the ACoA aneurysm in the anterior direction is confirmed on follow-up DSA (arrowhead). (J) Additional coil embolization secures the reruptured aneurysm.

Reference

1. Asgari S, Wanke I, Schoch B, Stolke D. Recurrent hemorrhage after initially complete occlusion of intracranial aneurysms. Neurosurg Rev. 2003; 10. 26(4):269–274. PMID: 12802695.

2. Bavinzski G, Killer M, Gruber A, Reinprecht A, Gross CE, Richling B. Treatment of basilar artery bifurcation aneurysms by using Guglielmi detachable coils: a 6-year experience. J Neurosurg. 1999; 5. 90(5):843–852. PMID: 10223449.

3. Chen H, Li MH. A1 segment hypoplasia accompanied by AcomA aneurysms assessed with magnetic resonance angiography. Surg Radiol Anat. 2014; 5. 36(4):353–357. PMID: 23912562.

4. Cho YD, Lee JY, Seo JH, Kang HS, Kim JE, Kwon OK, et al. Early recurrent hemorrhage after coil embolization in ruptured intracranial aneurysms. Neuroradiology. 2012; 7. 54(7):719–726. PMID: 21969241.

5. Hayashi K, Takahata H, Kitagawa N. Ruptured cerebral aneurysm complicated with rebleeding following thrombolysis during endovascular embolization: two case reports. Neurol Med Chir (Tokyo). 2007; 6. 47(6):261–264. PMID: 17587778.

6. Jartti P, Isokangas JM, Karttunen A, Jartti A, Haapea M, Koskelainen T, et al. Early rebleeding after coiling of ruptured intracranial aneurysms. Acta Radiol. 2010; 11. 51(9):1043–1049. PMID: 20849318.

7. Johnston SC, Dowd CF, Higashida RT, Lawton MT, Duckwiler GR, Gress DR, et al. Predictors of rehemorrhage after treatment of ruptured intracranial aneurysms: the Cerebral Aneurysm Rerupture After Treatment (CARAT) study. Stroke. 2008; 1. 39(1):120–125. PMID: 18048860.

8. Kang DH, Kim YS, Baik SK, Park SH, Park J, Hamm IS. Acute serious rebleeding after angiographically successful coil embolization of ruptured cerebral aneurysms. Acta Neurochir (Wien). 2010; 5. 152(5):771–781. PMID: 20099070.

9. Kluytmans M, van der Grond J, van Everdingen KJ, Klijn CJ, Kappelle LJ, Viergever MA. Cerebral hemody namics in relation to patterns of collateral flow. Stroke. 1999; 7. 30(7):1432–1439. PMID: 10390319.

10. Makoui AS, Smith DA, Evans AJ, Cahill DW. Early aneurysm recurrence after technically satisfactory Guglielmi detachable coil therapy: is early surveillance needed? Case report. J Neurosurg. 2000; 2. 92(2):355–358. PMID: 10659027.

11. Maurer J, Maurer E, Perneczky A. Surgically verified variations in the A1 segment of the anterior cerebral artery. Report of two cases. J Neurosurg. 1991; 12. 75(6):950–953. PMID: 1823542.

12. McDougall CG, Spetzler RF, Zabramski JM, Partovi S, Hills NK, Nakaji P, et al. The Barrow Ruptured Aneurysm Trial. J Neurosurg. 2012; 1. 116(1):135–144. PMID: 22054213.

13. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002; 10. 360(9342):1267–1274. PMID: 12414200.

14. Roy D, Milot G, Raymond J. Endovascular treatment of unruptured aneurysms. Stroke. 2001; 9. 32(9):1998–2004. PMID: 11546888.

15. Sinson G, Bagley LJ, Flamm ES, Hurst RW. Fatal rebleeding following coil embolization of cerebral aneurysms: the role of long-term systemic anticoagulation. Neuroradiology. 2001; 5. 43(5):398–404. PMID: 11396746.

16. Sluzewski M, van Rooij WJ. Early rebleeding after coiling of ruptured cerebral aneurysms: incidence, morbidity, and risk factors. AJNR Am J Neuroradiol. 2005; 8. 26(7):1739–1743. PMID: 16091523.

17. Vanninen R, Koivisto T, Saari T, Hernesniemi J, Vapalahti M. Ruptured intracranial aneurysms: acute endovascular treatment with electrolytically detachable coils-a prospective randomized study. Radiology. 1999; 5. 211(2):325–336. PMID: 10228510.

18. Willinsky RA, Peltz J, da Costa L, Agid R, Farb RI, terBrugge KG. Clinical and angiographic follow-up of ruptured intracranial aneurysms treated with endovascular embolization. AJNR Am J Neuroradiol. 2009; 5. 30(5):1035–1040. PMID: 19299485.