Delayed hemorrhagic complications after flow diversion for intracranial aneurysms: a literature overview

Abstract

Background Delayed aneurysm rupture and delayed intraparenchymal hemorrhages (DIPH) are poorly understood and often fatal complications of flow diversion (FD) for intracranial aneurysms. The purpose of this study was to identify risk factors for these complications. Materials and Methods We performed a systematic review on post-FD delayed aneurysm rupture and DIPH. For each reported case we collected the following information: aneurysm location, size and rupture status, type of flow-diverter used, timing of the hemorrhage, and neurological outcome. We reported descriptive statistics of patients suffering DIPH and delayed aneurysm rupture to determine if there were any characteristics consistently present among patients with these complications. Results We identified 81 delayed aneurysms ruptures and 101 DIPH. 76.6% (45/58) of the delayed ruptures occurred within one month. The prognosis of delayed ruptures was poor, with 81.3% (61/75) experiencing death or poor neurological outcome. Giant aneurysms accounted for 46.3% of ruptures (31/67). 80.9% (55/68) of these aneurysms were initially unruptured. 17.8% (13/73) of the delayed ruptured aneurysms had prior or concomitant coiling. DIPHs were ipsilateral to the treated aneurysm in 82.2% (60/73) of cases. 86.0% (43/50) of the DIPH occurred within one month after FDS. Combined morbidity/mortality rate was 68.5% (50/73 following DIPH. 23.0% of DIPHs (14/61) occurred in patients with giant aneurysms. Conclusions Our study demonstrates that giant aneurysms represent almost 50% of delayed aneurysm ruptures in the flow-diverter literature. About 20% of delayed ruptures occurred despite associated coiling. A substantial proportion of DIPHs occur early following FDS treatment of giant aneurysms.

Non-ischemic cerebral enhancing lesions secondary to endovascular aneurysm therapy: nickel allergy or foreign body reaction? Case series and review of the literature

“…Several mechanisms have been advanced to explain this complication, including flow alterations related to stent placement and hemorrhagic transformation of ischemic lesions, but these explanations remain controversial [34,35]. As mentioned earlier, Hu et al have identified PVP in fatal DIPHs after EVT of supraclinoid aneurysms with FDSs [21].…”

“…Delayed ipsilateral parenchymal hemorrhage (DIPH) remote from aneurysms is a dreaded complication of FDSs [33,34]. Several mechanisms have been advanced to explain this complication, including flow alterations related to stent placement and hemorrhagic transformation of ischemic lesions, but these explanations remain controversial [34,35].…”

Quantitative Computed Tomographic Volumetry after Treatment of a Giant Intracranial Aneurysm with a Pipeline Embolization Device

“…The incidence of rupture is higher in giant than in small or large aneurysms, and most ruptures occur within 1 month of PED treat-ment 8. Causes of delayed aneurysm rupture include wall shear stress at the aneurysm dome, unfavorable hemodynamic status, and autolysis of the aneurysm wall by thrombosis-induced proteases 91011.…”

Contemporary endovascular and open aneurysm treatment in the era of flow diversion

“…A recent review found that up to 80% of patients who experience a delayed aneurysm rupture or intraparenchymal haemorrhage have a poor clinical outcome or death 21. Nearly half of patients with a delayed rupture had giant aneurysms 21.…”

“…A recent review found that up to 80% of patients who experience a delayed aneurysm rupture or intraparenchymal haemorrhage have a poor clinical outcome or death 21. Nearly half of patients with a delayed rupture had giant aneurysms 21. The exact mechanism behind the delayed haemorrhagic complications has not been established, and haemorrhages have occurred in vascular territories remote from the FDS.…”