Outcome after endovascular therapy of ruptured intracranial aneurysms: morbidity and impact of rebleeding

Five to ten years follow-up after coiling of 241 patients with acutely ruptured aneurysms. A single centre experience

Endovascular treatment has assumed a role of first choice in the management of ruptured intracranial aneurysms. We describe the clinical and morphological data after the treatment of 258 ruptured intracranial aneurysms in 241 patients, in order to evaluate the safety and the efficacy of the endovascular treatment. Two hundred and forty-one patients with saccular ruptured aneurysms were treated at our institution between 2000 and 2005. After the endovascular treatment a clinical and angiographic follow-up was conducted. The clinical follow-up was carried out with a medical examination and telephonic interviews and mRS was used for evaluation. Two hundred and forty-nine acutely ruptured aneurysms were successfully treated and immediately after the endovascular procedure 81.9% of the aneurysms resulted completely occluded, 12.1% had a residual neck and 6% revealed a residual sac. The evolution of each grade was evaluated at six months and two years. During the follow-up we observed five early and one late re-bleedings. Twenty-four patients underwent a second procedure. After the discharge and up to ten years 73.1% of patients had a good clinical outcome (mRS0-1), 8.9% died and the remainder showed moderate-severe disability (mRS2-3). The long-term stability of the anatomical result is a critic-al issue of this approach because eventual re-bleedings may occur even after several months or years. A careful clinical and radiological follow-up for up to two years after the embolization may prevent recurrences but may not be sufficient.

Clinical and angiographic follow-up of ruptured intracranial aneurysms treated with endovascular embolization

BACKGROUND AND PURPOSE

Endovascular embolization is a well-established treatment of ruptured intracranial aneurysms, but concern about its long-term stability and its ability to prevent rehemorrhage are still present. We evaluated the long-term clinical and angiographic follow-up of patients with ruptured cerebral aneurysms treated with coiling, focusing on rehemorrhage and changes in aneurysm morphologic features.

MATERIALS AND METHODS

A total of 377 patients with ruptured aneurysms that were treated with endovascular approaches at our institution between 1994 and 2008 were reviewed. Clinical and angiographic data were analyzed from a prospectively collected data base.

RESULTS

There were 377 patients with 391 ruptured aneurysms treated for 14 years. Good outcome (Glasgow Outcome Score [GOS], 5) was achieved in 74% of patients, moderate disability or poor outcome in 18%, and 8.8% died. Permanent morbidity or mortality from procedural complications occurred in 2.9%. Complete follow-up was available for 85% of surviving patients, with mean follow-up of 22.3 months. Re-treatment was required in 11% (31 patients). Eight (2.1%) patients had rebleeding, 6 (1.6%) in the hospital within 30 days of treatment, 5 in the first 48 hours. Follow-up imaging was available in 276 aneurysms in 270 patients. Recanalization occurred in 56 of 276 aneurysms (20.3%) regardless of the initial angiographic result, but the risk was higher if a body remnant was left (chi2, 11.791; P = .0006).

CONCLUSIONS

Long-term clinical and angiographic follow-up demonstrates the efficacy of endovascular treatment of ruptured intracranial aneurysms. Rebleeding after treatment is rare, with the greatest risk during the first 48 hours after treatment. Initial angiographic results are not a useful predictor of clinical outcome or rehemorrhage.

Intradural saccular aneurysms treated by Guglielmi detachable bare coils at a single institution between 1993 and 2005: clinical long-term follow-up for a total of 1810 patient-years in relation to morphological treatment results

BACKGROUND AND PURPOSE

The aim of this study was to analyze the clinical results of Guglielmi detachable bare coil (GDC) embolization of intradural saccular aneurysms (AAs) at a single center and to relate the morphological results at various time points to the clinical situation.

METHODS

All intradural saccular AAs treated with GDCs between 1993 and April 2005 were prospectively entered into a database completed by retrospective analysis of charts and images and a long-term clinical outcome questionnaire. In 413 consecutive patients, there were 466 treated AAs, of which 68.7% were ruptured and 31.1% were unruptured.

RESULTS

The periprocedural thromboembolic event rate, retreatment procedures included, was 5.4%, causing permanent neurologic deficits in 2.2% of patients. One patient (0.2%) bled during a mean+/-SD clinical follow-up of 64.3+/-39.9 months (93 AAs were followed up for >8 years and 45 AAs were followed up for >10 years) for a total of 1810 patient-years. The modified Rankin Scale score was 0 in 54.7%, 1 in 21.0%, 2 in 12.1%, 3 in 7.1%, 4 in 2.1%, 5 in 0.3%, and 6 (death from unrelated causes) in 2.7% of patients. If an aneurysm, with or without a remnant, was unchanged for 12 months, then the risk for future morphological loss was 4.8%, whereas if an aneurysm showed a morphological loss during the earlier 12-month interval, the risk for additional late loss was 38.3% (P<0.001, odds ratio=12.4).

CONCLUSIONS

Embolization of saccular AAs entails a prolonged management period. A stable angiographic result during a 12-month interval predicts a low risk for morphological deterioration. This regimen, aiming for a stable angiographic result rather than complete aneurysm occlusion, gives a low rebleed rate and excellent clinical long-term results.

Endovascular treatment of ruptured aneurysms and vasospasm

Despite various criticisms, the International Subarachnoid Aneurysm Trial (ISAT) has provided Class I evidence that endovascular therapy (EVT) results in superior 1-year outcomes, compared with surgical repair of ruptured aneurysms equally amenable to both types of treatment. Although the lower occlusion rates and higher rates of recanalization in aneurysms treated with EVT necessitate serial imaging follow-up, these findings do not seem to translate into unacceptably high rates of rebleeding or retreatment morbidity that outweigh the upfront advantage over surgical clipping. EVT also compares favorably to surgery in the treatment of unruptured aneurysms. A randomized, controlled study similar to ISAT is needed for comparing EVT to surgery. EVT appears to have more limitations of durability in large and giant aneurysms, which warrants further research into stent or liquid embolic-assisted treatment because surgical treatment morbidity is also high. Vasospasm is a frequent and potentially devastating complication of aneurysmal subarachnoid hemorrhage. Angioplasty and intra-arterial drug therapy are effective treatments, with an acceptable morbidity and mortality. Angioplasty is more effective and durable and should be considered early in patients with signs of ischemia refractory to maximal medical therapy.

Rebleeding after endovascular embolization of ruptured cerebral aneurysms

This study retrospectively reviewed 227 patients with ruptured solitary cerebral aneurysm who underwent endovascular embolization with detachable coils between March 1997 and March 2006 to establish the incidence of rebleeding after endovascular treatment for ruptured cerebral aneurysm and identify the risk factors. The site and size of the aneurysm, the interval between treatment and rebleeding, and the outcome were investigated in six of the 227 patients (2.6%) who rebled after treatment. Four patients had large or giant aneurysms located on the internal carotid artery at the origin of the posterior communicating artery. The interval between treatment and rebleeding was less than 1 year in four patients (mean 394.2 days). Two patients died, and the survivors had modified Rankin Scale scores of 0, 2, 3, and 4. Re-embolization was performed in four patients and no further bleeding occurred during the mean follow-up period of 1.9 years after re-treatment. Patients with giant aneurysms of the internal carotid artery are at increased risk for rebleeding. Re-treatment should be considered if there is conventional and/or magnetic resonance angiographic evidence of dome filling. Patients with ruptured cerebral aneurysms must be followed up with diagnostic imaging closely during the first 12 months post-embolization because rebleeding frequently occurs within 1 year after initial treatment. Re-embolization is safe and effective in patients with recurrent hemorrhage from aneurysms previously embolized with detachable coils.