Endovascular Treatment Of Ruptured Intracranial Aneurysms

OBJECTIVE:The purpose of this study was to summarize our experience with endovascular treatment of ruptured intracranial aneurysms on immediate and long-term angiographic and clinical results. To report the incidence of procedural complications and to identify risk factors for the events. A comparison between coiling alone and stent-assisted coiling for saccular ruptured aneurysms was conducted focus on the clinical and angiographic results and incidence of procedural complications. The timing of coiling was also discussed.METHODS:a retrospective study of all patients admitted to Chang Hai Hospital with ruptured intracranial aneurysms treated by endovascular techniques from Jan 2001 to Dec 2008. All of patient's documents will be analyzed, including Hunt and Hess grading scale, timing of coiling, coiling strategy, procedural related complication, clinical and angiographic results. Chi-square test and multivariable logistic regression were used by SPSS18.0 statistics software to analysis the risk factors.RESULTS:908 patients harboring 935 intracranial aneurysms were treated. Male 487cases, the average age is 52.1 years old. Hunt and Hess gradeâ…£-V58 cases.830 aneurysms were located in the anterior circulation and 105 in the posterior circulation.104 were fusiform or dissecting aneurysm,341 were wide-necked aneurysm. Acute angiographic results demonstrated total occlusion in 469 cases (50.1%), subtotal occlusion in 252 cases (26.9%), and incomplete occlusion in 214 cases (22.8%). Procedural complications occurred in 89 patients (9.8%), leading to death in5 patients (0.6%) and to disability in 10 patients (1.1%). There were 30 procedural ruptures,39 thromboembolic complications,13 coil herniation,3 coil migration to the distal parent artery and 4 dissection.26 early rebleeding.The clinical outcome profile primary discharge according to mRS was as follow:Grade 0-2, 818(90.1%); Grade 3-5,39(4.3%); Grade 6,51(5.6%). Long-term follow-up angiograms (mean,16.2 months) were obtained in 408 aneurysms (43.6%). Of them, 275 aneurysms (67.4%) demonstrated stable,82 aneurysms (20.1%) demonstrated recanalization,51 aneurysms (12.5%) demonstrated progressive thrombosis. Aneurysms with incomplete occlusion were subjected to recanalization (P=0.000) 603 patients had a mean clinical follow-up time of 36 months (range,l-120mo). mRS,0-2 in 559(92.7%); mRS,3-6 in 44(7.3%); rebleeding3(0.5%). Gender, timing of coiling, the location of aneurysm and packing density were proved to be risk factors for procedural rupture of complications by analysis of single and multiple variables. The location of aneurysm, wide neck or not and the degree of occlusion was the risk factor for the thromboembolic complications. Gender, Hunt-Hess scale, the location of aneurysm, special aneurysms (dissection aneurysms, pseudoaneurysm, blister aneurysms) or not, intracranial hematoma adjacent the ruptured aneurysm and anticoagulant therapy was the risk factor for the procedural rupture of complications.674 aneurysms treated with coil alone (group 1) and 147 aneurysms with stent-assisted coiling (group2). Immediately angiographic results (group 1 demonstrated total occlusion in 391 cases (58.0%), subtotal occlusion in 171 cases (25.4%), and incomplete occlusion in 112 cases (16.6%); total occlusion in 63 cases (42.4%), subtotal occlusion in 37 cases (25.3%), and incomplete occlusion in 47cases (32.3%) in group 2. A total of 32.2%(217 of 674) of aneurysms treated with coil have been followed so far versus 54.5%(80 of 147) of aneurysms treated with stents, The rate of recanalization is 24.4%(53 of 217) and 13.8%(11 of 80), respectively (P=0.045). Disclosing progressive thrombosis in 2.3%(5 of 217) versus 43.8% (35 of 80), respectively (P=0.000). Procedural complications occurred in6.3% (41 of 647) in the procedures without stents versus 10.2%(15 of 147) of the procedures with stents (P=0.098). Procedural complications leading to disability occurred in 0.8%(5 of 647) in the procedures without stents versus 1.4%(2 of 147) of the procedures with stents. Procedural complications leading to death occurred in 0.5%(3 of 647) in the procedures without stents versus 2.0%(3 of 147) of the procedures with stents (P=0.227).The timing of endovascular treatment after subarachnoid hemorrhage was 0 to 3 days for 371 patients,4 to 10 days for 241 patients, great than 10 for 229 patients. Hunt and Hess grading scale Grade 4-5 was as follow:27(7.3%),18(7.5%),16(7.0%), respectively. Procedural complication rates of group 0 to 3 day,4 to 10 days and great than 10 days were 11.9%(44 of 371),9.1%(22 of 241),11.8%(27 of 229), respectively (p=0.539). The initial rate of angiographic total occlusion were for 185(49.9%),132(54.8%),116(50.7%), respectively (p=0.474). The rate of disability at discharge was as follow:group 0 to 3 day,4.0%(15 of 371); 4 to 10 days 5.0%(12 of 241) and great than 10 days 4.8%(11 of 229),p=0.849. The death occurred in 20 (5.4%),15(6.2%),16(7.0%), respectively (p=0.723). No statistical difference was demonstrated between the three groups when they were compared for these variables.CONCLUSIONS:These data confirm the safety and efficacy of endovascular embomlization for patients with ruptured intracranial aneurysm. however, Aneurysm recanalization is still a major limitation of current endovascular therapy. Aneurysms with incomplete occlusion were subjected to recanalization. Follow-up angiography is mandatory after embolization of cerebral aneurysms; procedural complication is related to many risk factors, aneurysms morphology assessment for coiling strategy is important in preventing the onset of adverse events.Stents facilitate adequate embolization of complex cerebral aneurysms, conferred a statistically significant decrease in the rate of angiographic recurrence. Longer follow-up is mandatory to draw more definitive conclusions. The incidence of procedural complications is higher in the stent assisted group, but no statistically significant.The interval between endovascular treatment and SAH did not affect periprocedural morbidity rates or initial angiographic outcomes. Coil embolization should therefore be performed as early as possible after aneurismal SAH, to prevent aneurismal rebleeding.