Bioactive coils cause headache and fever after endovascular treatment of intracranial aneurysms

Endovascular treatment of intracranial aneurysms: Past and present

Intracranial aneurysm is common in stroke and, once rupturing, will cause disaster to patients. Nowadays, endovascular treatment has become a routine to reduce the risk of intracranial aneurysms rupture. Successive endovascular methods, like balloon-assisted coiling, stent-assisted coiling, and flow diversion, have become new choices for doctors. More and more doctors have been entering this field. Understanding the current general situation is crucial for more medical workers to learn the endovascular treatment of intracranial aneurysms. In the past, many devices and ideas about the treatment of intracranial aneurysms appeared. Although developing unceasingly, endovascular treatment still has some deficiencies to overcome. The advantages and drawbacks of current endovascular methods are discussed.

Trends in the Age of Patients Treated for Unruptured Intracranial Aneurysms from 1990 to 2020

BACKGROUND

The decision for treatment for unruptured intracranial aneurysms (UIAs) is often difficult. Innovation in endovascular devices have improved the benefit-to-risk profile especially for elderly patients; however, the treatment guidelines from the past decade often recommend conservative management. It is unknown how these changes have affected the overall age of the patients selected for treatment. Herein, we aimed to study potential changes in the average age of the patients that are being treated over time.

METHODS

A systematic search of the literature was performed to identify all studies describing the age of the UIAs that were treated by any modality. Scatter diagrams with trend lines were used to plot the age of the patients treated over time and assess the presence of a potential significant trend via statistical correlation tests.

RESULTS

A total of 280 studies including 83,437 UIAs treated between 1987 and 2021 met all eligibility criteria and were entered in the analysis. Mean age of the patients was 55.5 years, and 70.7% were female. There was a significant increasing trend in the age of the treated patients over time (Spearman r: 0.250; P < 0.001), with a 1-year increase in the average age of the treated patients every 5 years since 1987.

CONCLUSIONS

The present study indicates that based on the treated UIA patient data published in the literature, older UIAs are being treated over time. This trend is likely driven by safer treatments while suggesting that re-evaluation of certain UIA treatment decision scores may be of great interest.

Postcoiling syndrome including headache and fever after endovascular cerebral aneurysmal coil embolization: A narrative review

Endovascular cerebral aneurysmal coil embolization is becoming more popular than direct aneurysmal neck clipping due to its noninferiority in long-term outcomes and being less invasive. Neuroradiologists often find postoperative symptoms such as headache and fever after unruptured aneurysmal coil embolization, however, they have not paid much attention because symptoms almost always resolve spontaneously within a few days. Since the concept of this syndrome has not been standardized, we named it postcoiling syndrome (PCS). In this short review, we reviewed the criteria, risk factors, mechanisms, significance, and treatment of PCS based on a few pieces of literature. Almost all literature has regarded that some kind of bioactive reaction might be involved in PCS. Preliminary data showed the possibility of inhibition of PCS by histamine-2 receptor antagonists. PCS also might have the potential of more predictive maker than previously reported risk factors for recurrence after aneurysm coil embolization. Further investigation is needed in the future, including the accumulation of cases, unification of concepts, and mid-to-long-term follow-up.

Advances in Biomaterials and Technologies for Vascular Embolization

Minimally invasive transcatheter embolization is a common nonsurgical procedure in interventional radiology used for the deliberate occlusion of blood vessels for the treatment of diseased or injured vasculature. A wide variety of embolic agents including metallic coils, calibrated microspheres, and liquids are available for clinical practice. Additionally, advances in biomaterials, such as shape-memory foams, biodegradable polymers, and in situ gelling solutions have led to the development of novel preclinical embolic agents. The aim here is to provide a comprehensive overview of current and emerging technologies in endovascular embolization with respect to devices, materials, mechanisms, and design guidelines. Limitations and challenges in embolic materials are also discussed to promote advancement in the field.

Headache improvement after intracranial endovascular procedures in Chinese patients with unruptured intracranial aneurysm: A prospective observational study

The aim of this study was to investigate whether there is a long-term improvement in headache of patients with unruptured intracranial aneurysms (UIAs) treated with intracranial endovascular procedures.Using a prospective design, consecutive patients with UIAs with neuroendovascular treatment from January 2014 to December 2014 were asked to participate. Headache outcomes were established before aneurysm treatment and for 6 months following treatment. Factors associated with different headache outcomes were investigated.Ultimately, 58 patients completed the 6-month follow-up. In total, 29 patients had preoperative headache. Six months after the intracranial endovascular procedure, 13 patients (44.8%) stated that their headaches were relieved after endovascular treatment; headache in 1 patient improved slightly, and 12 reported disappearance of headache and marked improvement. Overall, the mean headache scores of 29 patients improved on the self-reported Numeric Rating Scale (NRS) after endovascular treatment (6.00 vs. 2.30; P < 0.001). Patients with pretreatment tension-type headache, more severe headaches, stent-assisted coiling, and stent implantation of the aneurysm were the important disadvantage for patients in improvement of post-procedure headache.Treatment of UIAs resulted in relief of headaches in about half of patients who had headaches pre-operatively.

Characteristics of Headache After an Intracranial Endovascular Procedure: A Prospective Observational Study

BACKGROUND

Two editions of the International Classification of Headache Disorders (ICHD) diagnostic criteria for "Headache attributed to an intracranial endovascular procedure" have been published, in 2004 and 2013.^1,2 Despite studies that have suggested that the former is not very practical, the ICHD-3 beta did not contain major changes. Moreover, so far no consensus exists regarding characteristics of headache after intracranial endovascular procedure. Thus, there is a need for sound suggestions to improve the ICHD-3 beta diagnostic criteria.

METHODS

Using a prospective design, we identified consecutive patients with unruptured intracranial aneurysms (UIAs) with neuroendovascular treatment from January 2014 to December 2014.

RESULTS

In total, 73 patients were enrolled, and 58 patients ultimately completed the 6-month follow-up. After the procedure, five of the 29 patients (17.2%) with pre-existing headache experienced marked worsening after the procedure, while seven of the 29 patients without prior headache developed new-onset headache post-procedurally. The headaches started within 24 hours, with a mean duration of 24-72 hours. The headaches were moderate to severe. The eligibility of these events to be considered headaches caused by neuroendovascular procedures according to the ICHD-3 beta diagnostic criteria for designation was far from ideal.

CONCLUSIONS

Most cases of markedly worsening headaches and new-onset headaches started within 24 hours and persisted longer than that specified in the ICHD-3 beta diagnostic criteria. Moreover, considering that some items are not very practical, the ICHD-3 beta diagnostic criteria should be revised in the light of recent literature reports.

Headache, cerebral aneurysms, and the use of triptans and ergot derivatives

BACKGROUND

Uncertainty exists regarding the correlation between unruptured cerebral aneurysms and their role in headache etiology. It is also unclear whether surgical endovascular treatment may improve or worsen the headache, and if there are predictable factors for headache outcome such as pre-existing headache features, aneurysm characteristics, or other medical history. There is debate regarding safe treatment of migraine in patients with aneurysms, both before and after endovascular treatments. Particularly, there is hesitancy to use the triptans and ergot derivatives such as dihydroergotamine because of their vasoconstrictive effects and concern for adverse events related to the aneurysm such as aneurysmal instability and rupture.

OBJECTIVE

To review the literature regarding the anatomy, pathophysiology, and association between headache, untreated vs surgically treated aneurysms, and the use of triptans and ergot derivatives for migraine treatment in this setting.

CONCLUSION

Associations between some headaches and aneurysms may exist. Some chronic headaches may respond to surgical aneurysm repair while others may worsen. These associations are undefined by current literature because of variable results, study methods, and limited data. Prospective studies are needed which incorporate pre- and post-procedure headache character and diagnosis, aneurysm characteristics, type of aneurysm repair, associated risk factors for worsening post-procedure headache, and ultimately combining all of these data to better predict headache outcome following surgical aneurysm treatment. Lastly, the caution and avoidance of triptan and ergot derivative use for migraine in the setting of aneurysm is not supported by the current evidence, and much of this concern may be excessive and unwarranted, although more evidence confirming safety is needed.

Remission of migraine after clipping of saccular intracranial aneurysms

BACKGROUND

Unruptured saccular intracranial aneurysm (SIA) is associated with an increased prevalence of migraine, but it is unclear whether this is altered by clipping of the aneurysm. The aim of our study was to determine whether remission rate of migraine and other recurrent headaches was greater in patients with SIA after clipping than in controls.

METHODS

We prospectively studied 87 SIA patients with migraine or other recurrent headaches. They were interviewed about headaches in the preceding year before and 1 year after clipping using a validated semi-structured neurologist conducted interview. The remission rates of migraine and tension-type headache (TTH) in these patients were compared to 92 patients from a headache center. Diagnoses were made according to the ICHD-2.

RESULTS

During 1 year preceding rupture 51 patients with SIA had migraine. During the year after clipping, this was reduced by 74.5% (P < 0.0001). At first encounter, 47 control patients had migraine during the preceding year, and during 1 year of treatment, it was 41, a reduction 12.8% (P > 0.5). The decrease of migraine in SIA patients was significantly higher than in controls: 74.5% vs 12.8% (P < 0.001). A history of TTH was given by 33 patients with SIA during the year preceding rupture and by 44 during 1 year after clipping (P > 0.75). Forty-one control patients had TTH, 27 after 1 year of treatment, a reduction 34.1% (P < 0.05). No factors except clipping of the aneurysm could explain the remission of migraine.

CONCLUSIONS

Migraine prevalence in patients with SIA decreases significantly after clipping. Further comparative studies of migraine after coiling vs clipping in SIA patients are needed.

Incidence and risk factors of postoperative headache after endovascular coil embolization of unruptured intracranial aneurysms

BACKGROUND

Endovascular coil embolization for unruptured intracranial aneurysms (UIAs) has gained popularity because of its low morbidity and mortality in a short-term context. However, Headache is sometimes brought about or worsened after endovascular treatment, and this complaint may lead to perplexing situations, albeit infrequently. The aim of this study is to estimate the practical incidence and risk factors of postoperative headache in patients with endovascular embolization of UIAs.

METHOD

One hundred and thirty patients who underwent endovascular treatment of UIAs between March 2006 and May 2012 were enrolled according to inclusion criteria. From a retrospective chart review, the patients who had worsening or newly developed headache from postoperative day 1 to in-hospital stay were investigated for analyzing risk factors of post-embolization headache. Factors based on patients' demographics, anatomical and radiological features of the lesions, treatment, utilized devices and outcome were investigated, and statistically verified.

RESULTS

Headache occurred or was exacerbated in 32 patients (24.6 %). Of these, 30 patients showed improvement within days, but two patients with previous migraine history complained of intermittent headache over 3 months after the embolization. Univariate comparison between the headache group and the non-headache group showed that internal carotid artery (ICA) segment aneurysm, stent-assisted coiling, and no history of hypertension were associated with post-embolization headache (p < 0.05). However, stent-assisted coiling and no history of hypertension were significantly associated with post-embolization headache in logistic regression analysis (p < 0.05).

CONCLUSIONS

In the current study, stent-assisted coiling and no history of hypertension were important risk factors for headache in patients undergoing endovascular coil embolization for UIAs. Further investigations are still necessary to confirm the correlation of other factors which did not reach statistical significance in post-embolization headache in this limited study.

Headache attributed to cranial or cervical vascular disorders

Cranial or cervical vascular disease is commonly associated with headaches. The descriptions may range from a thunderclap onset of a subarachnoid hemorrhage to a phenotype similar to tension type headache. Occasionally, this may be the sole manifestation of a potentially serious underlying disorder like vasculitis. A high index of clinical suspicion is necessary to diagnose the disorder. Prompt recognition and treatment is usually needed for many conditions to avoid permanent sequelae that result in disability. Treatments for many conditions remain challenging and are frequently controversial due to paucity of well controlled studies. This is a review of the recent advances that have been made in the diagnosis or management of these secondary headaches.