Association of endovascular therapy of very small ruptured aneurysms with higher rates of procedure-related rupture

Abstract

Object Procedure-related rupture during endovascular therapy of intracranial aneurysms is associated with a mortality rate of more than one third. Previously ruptured aneurysms are a known risk factor for procedure-related rupture. The objective of this study was to evaluate whether very small, ruptured aneurysms are associated with more frequent intraprocedural ruptures. Methods This was a retrospective cohort study in which the investigators examined consecutive ruptured aneurysms treated with coil embolization at a single institution. The study was approved by the institutional review board. Very small aneurysms were defined as ≤ 3 mm. Procedure-related rupture was defined as contrast extravasation during treatment. Univariate analysis with the Fisher exact test and the Mann–Whitney U test was performed. Results Between August 1992 and January 2007, 682 aneurysms were selectively treated with coils in 668 patients. Procedure-related rupture occurred in 7 (11.7%) of 60 aneurysms ≤ 3 mm, compared with 14 (2.3%) of 622 aneurysms > 3 mm (relative risk 5.2, 95% confidence interval 2.2–12.8; p < 0.001). Among cases with procedure-related rupture, inflation of a compliant balloon was associated with better outcome (Glasgow Outcome Scale Score ≥ 4) compared with patients treated without balloon assistance (5 of 5 compared with 7 of 16; p = 0.05). Death resulting from procedure-related rupture occurred in 8 (38%) of 21 patients, and a vegetative state occurred in 1 patient. Clinical outcome was good in the other 12 patients (57%). Conclusions Endovascular coil embolization of very small (≤ 3 mm) ruptured cerebral aneurysms is 5 times more likely to result in procedure-related rupture compared with larger aneurysms. Balloon inflation for hemostasis may be associated with better outcome in the event of intraprocedural rupture and merits further study.

Coil Embolization of Very Small (2 mm or Smaller) Berry Aneurysms: Feasibility and Technical Issues

“…Nguyen et al 3 reported a fivefold increase in the incidence of rupture during endovascular treatment of aneurysms that were Յ3 mm compared with larger aneurysms. To prevent this complication, careful microcatheter placement at the neck of the aneurysm and use of the soft coil loop to enter the aneurysm were useful.…”

“…13 The small size of the aneurysm may be associated with a higher risk for rupture during embolization. 2,3 Review of the English-language literature revealed only 1 study by Suzuki et al, 4 who reported on endovascular treatment of very small aneurysms. However, they studied aneurysms of at least 3 mm with a favorable fundus-to-neck ratio of 1.5.…”

“…Endovascular treatment of these aneurysms is considered to be technically challenging, and high complication rates have been reported. 2,3 Very few series in the English literature focus on the outcome of embolization of very small aneurysms. Suzuki et al 4 reported on the endovascular treatment of aneurysms less than 3 mm in diameter, with a favorable neck-to-fundus ratio.…”

Clinical and Angiographic Follow-up of Ruptured Intracranial Aneurysms Treated with Endovascular Embolization

“…Other authors have demonstrated an increased risk for perforation in small aneurysms. Nguyen et al 35 recently demonstrated that the risk for rupture increases from 2.3% for aneurysms more 36 We used abciximab (intravenously or intra-arterially) in 27 patients when thrombus was evident during the procedure, and there were no symptomatic thromboembolic events in 93% of these patients. One patient had an ischemic stroke in the motor cortex, and another had a subsequent hemorrhage from the treated aneurysm the following day and underwent craniotomy and clipping.…”

Fatal Avulsion of Choroidal or Perforating Arteries by Guidewires

“…hemorrhagic complications of endovascular treatment of aneurysms occur more frequently with ruptured than unruptured aneurysms 2 , and more readily in small than large ruptured aneurysms 3 . The clinical consequences of these complications vary from one report to another 2,4,5 .…”