Multi-center Clinical Analysis Of Stent-assisted Coil Embolization For Treatment Of Acute Intracranial Ruptured Wide-necked Aneurysms

BackgroundIntracranial aneurysm rupture is that most important cause of non-traumatic subarachnoid hemorrhage,account for about 85 percent,and has high morbidity,disability rate and mortality rate.It is a critical and severe disease requiring timely intervention to improve the prognosis in clinical practice.The International Aneurysmal Subarachnoid Hemorrhage Trial and the Barrow Ruptured Aneurysm Trial have shown that endovascular intervention is superior to microsurgical clipping for the treatment of intracranial ruptured aneurysms in prognostic outcomes.Stent-assisted coil embolization has been widely used for the treatment of unruptured intracranial wide-necked aneurysms.Whereas,there are lots of controversy about whether it is still applicable to the treatment of ruptured intracranial wide-necked aneurysms,even though the blood is in a hypercoagulable state in the acute stage of hemorrhage and drugs can not be prepared in advance.In addition,the application of antiplatelet drugs throughout the endovascular treatment is a key measure to prevent perioperative ischemic complications.Clinically,there is a certain consensus on the perioperative use plan of antiplatelet drugs for stent-assisted coil embolization of intracranial unruptured aneurysms.Double antiplatelet therapy is performed continuously before operation to confirm that the platelet inhibition rate reaches the standard before the operation.However,there are many disputes on the perioperative use plan of antiplatelet drugs for stent-assisted coil embolization of intracranial ruptured aneurysms.How to reduce the risk of thromboembolism without increasing the risk of aneurysm re-rupture and bleeding remains an important topic to be solved urgently.ObjectiveTo investigate the safety and effectiveness of stent-assisted coil embolization of acute intracranial ruptured wide-necked aneurysms,the safety of different antiplatelet drug regimens during the perioperative period,and the risk factors affecting perioperative complications and prognosis.MethodsPerspective study,the clinical data of 417 patients with intracranial ruptured wide-necked aneurysms treated with stent-assisted coil embolization in neurosurgical centers of four hospitals from June 2017 to January 2020 were included.Descriptive study,the total occlusion(Raymond grade I)rate was used to assess its effectiveness,the favourable prognosis rate(mRS≤2 points),the perioperative complication rate and mortality rate were used to assess its safety.Cohort study,according to the different antiplatelet drug regimens adopted by patients during the perioperative period,they were divided into the the loaded clopidogrel combined with aspirin group,loaded clopidogrel group and tirofiban group.The clinical baselines were compared,then the differences in the incidence of ischemic and hemorrhagic complications of introperative and perioperative period,the unfavourable prognosis rate of three days after operation and discharge from hospital,mortality rate among the three groups were analyzed.Case-control study,univariate Logistic binary regression analysis and multivariate binary Logistic regression analysis were used to analyze the risk factors and independent risk factors influencing the perioperative procedure related complications and clinical prognosis of the patients.Result351 cases(84.2%)were of Raymond grade I,44 cases(10.6%)were of Raymond grade II,22 cases(5.2%)were of Raymond grade III;360 cases(86.3%)were discharged with mRS≤2 points,57 cases(13.7%)were discharged with mRS≥3 points;Perioperative complications occurred in a total of 44 cases(10.6%),including 29 cases(7.0%)of ischemic complications,15 cases(3.6%)of hemorrhagic complications;and 4 cases(1%)of death.There was no significant difference(P>0.05)in clinical baseline among the clopidogrel loaded combined with aspirin group(212 cases),clopidogrel loaded group(87 cases)and tirofiban group(118 cases).There were 5 cases(5.7%),12 cases(5.7%)and 1 case(0.8%)of intraoperative thromboembolism.The difference was statistically significant(χ2=6.317,P=0.042).The rates of intraoperative aneurysm re-rupture bleeding were 1 case(1.2%),6 cases(2.8%),and 1 cases(0.8%)respectively.The perioperative ischemic complications were 7 cases(8.0%),15 cases(7.1%),and 7 cases(5.9%)respectively.The perioperative hemorrhagic complications were 1 case(1.1%),9 cases(4.2%),and 5 cases(4.2%)respectively.There were 15 cases(17.2%),38 cases(17.9%)and 19 cases(16.1%)with unfavourable prognosis on the three days after operation respectively.There were 9 cases(10.3%),31 cases(14.6%)and 17 cases(14.4%)with unfavourable prognosis after discharge from hospital.There were 1 case(1.1%),2 cases(0.9%)and 1 case(0.8%)with died respectively.The statistical differences were not significant(P>0.05).Univariate and multivariate binary Logistic regression analysis showed that the patient had diabetes(OR:5.596,95%CI:1.824～17.170,P=0.003),preoperative Hunt-Hess grade 3(OR:4.340,95%CI:1.425～13.218,P=0.01),preoperative Hunt-Hess grade 4(OR:3.875,95%CI:2.099～21.633,P=0.037),preoperative Hunt-Hess grade 5(OR:15.818,95%CI:3.701～67.613,p<0.001)were independent risk factors for perioperative surgery-related complications.Univariate binary Logistic regression analysis showed that differences in age(OR:3.011,P<0.001),aneurysm location(OR:2.116,P=0.03),the number of stents(OR:3.460,P=0.011)and preoperative Hunt-Hess classification(Hunt-Hess grade 3 OR:11.512,P<0.001;Hunt-Hess grade 4 OR:41.3,P<0.001;Hunt-Hess grade 5 OR:37.76,P<0.001)had statistical significance for the clinical prognosis.Multivariate binary Logistic regression analysis showed that the patient was≥60 years old(OR:3.407,95%CI:1.620～7.166,P=0.001),preoperative Hunt-Hess grade 3(OR:11.445,95%CI:3.584～36.547,P<0.001),preoperative Hunt-Hess grade 4(OR:88.951,95%CI:14.519～544.948,P<0.001),preoperative Hunt-Hess grade 5(OR:64.949,95%CI:12.809～329.325,P<0.001)and the insert of multiple stents(OR:4.709,95%CI:1.215～18.248,P=0.025)were independent risk factors for prognosis.ConclusionApplication of stent-assisted coil embolization in the treatment of acute intracranial ruptured wide-necked aneurysms is safe and effective.Tirofiban can significantly reduce the risk of thromboembolism formation during the operation without increasing the risk of aneurysm re-rupture bleeding,which is safe as a perioperative antiplatelet drug regimen.Patients with diabetes and preoperative Hunt-Hess≥3 grade are prone to perioperative complications.Patients with age≥60 years old,preoperative Hunt-Hess≥3 grade,and the insert of multiple stents are prone to unfavourable clinical prognosis.