Successful Thrombolysis despite Having an Incidental Unruptured Cerebral Aneurysm

Early interventional embolization in the treatment of cerebral aneurysm rupture

Objective:

To analyze the clinical effectiveness and safety of early interventional embolization in the treatment of ruptured cerebral aneurysm.

Methods:

Eighty-eight patients with cerebral aneurysm rupture who were admitted to the hospital between February 2015 and October 2016 were selected as the research subjects and were randomly divided into a control group (N=44) and an observation group (N=44) using random number table. Patients in the control group were given interventional embolization three days after admission, while patients in the observation group were given interventional embolization within three days after admission. The complete, sub complete and incomplete embolization rates were compared between the two groups. The prognosis of the patients was evaluated using modified Rankin scale and modified Barthel index. The incidences of complications were recorded.

Results:

The complete, sub-complete and incomplete embolization rates of the observation group and control group were significantly different (P<0.05). The modified Rankin score of the observation group was remarkably lower than that of the control group, and the modified Barthel index of the observation group was remarkably higher than that of the control group; the differences had statistical significance (P<0.05). The incidence of complications of the observation group was lower than that of the control group, and the difference had statistical significance (P<0.05).

Conclusion:

Early interventional embolization has satisfactory effect in the treatment of cerebral aneurysm rupture and effectively improve prognosis; hence it is worth promotion in clinical practice.

The risk of intravenous thrombolysis-induced intracranial hemorrhage in Taiwanese patients with unruptured intracranial aneurysm

Background

The presence of an intracranial aneurysm is contraindicated to recombinant tissue plasminogen activator (r-tPA) treatment for acute ischemic stroke. However, it is difficult to exclude asymptomatic intracranial aneurysms by using conventional, noncontrast head computed tomography (CT), which is the only neuroimaging suggested before r-tPA. Recent case reports and series have shown that administering r-tPA to patients with a pre-existing aneurysm does not increase the bleeding risk. However, Asians are known to have a relatively higher bleeding risk, and little evidence is available regarding the risk of using r-tPA on Asian patients with intracranial aneurysms.

Methods

Medical records from the Shuang Ho hospital stroke registration between July 2010 and December 2014 were retrospectively reviewed, and 144 patients received r-tPA. Unruptured intracranial aneurysms were detected using CT, or magnetic resonance or conventional angiography after r-tPA. The primary and secondary outcomes were the difference in overall intracranial hemorrhage (ICH) and symptomatic ICH after r-tPA. The differences were analyzed using Fisher’s exact or Mann–Whitney U tests, and p < 0.05 was defined as the statistical significance.

Results

A total of 144 patients were reviewed, and incidental unruptured intracranial aneurysms were found in 11 of them (7.6%). No significant difference was observed in baseline demographic data between the aneurysm and nonaneurysm groups. Among patients with an unruptured aneurysm, two had giant aneurysms (7.7 and 7.4 mm, respectively). The bleeding risk was not significant different between aneurysm group (2 out of 11, 18%) with nonaneurysm group (7 out of 133, 5.3%) (p = 0.14). None of the patients with an unruptured aneurysm had symptomatic ICH, whereas one patient without an aneurysm exhibited symptomatic ICH.

Conclusions

The presence of an unruptured intracranial aneurysm did not significantly increase the risk of overall and symptomatic ICH in Taiwanese patients after they received r-tPA.

Systemic thrombolysis in acute ischemic stroke patients with unruptured intracranial aneurysms

OBJECTIVE

We sought to determine the safety of IV thrombolysis (IVT) in acute ischemic stroke (AIS) patients harboring unruptured intracranial aneurysm (UIA) in a multicenter study and a comprehensive meta-analysis of available case series.

METHODS

We analyzed prospectively collected data from consecutive AIS patients treated with IVT during a 4-year period at 4 tertiary-care stroke centers. All patients routinely underwent CT or magnetic resonance angiography during hospitalization. The presence of UIA was documented on the basis of neuroradiology reports. Symptomatic intracranial hemorrhage (sICH) was defined as imaging evidence of ICH combined with an increase in NIH Stroke Scale score of ≥4 points. A systematic meta-analysis of case series reporting safety of IVT in AIS with concomitant UIA was conducted according to PRISMA recommendations.

RESULTS

Among 1,398 AIS patients treated with IVT, we identified 42 cases (3.0%) harboring a total of 48 UIAs. The rates of symptomatic and asymptomatic ICH were 2.4% (95% confidence interval [CI] by adjusted Wald method: 0%-12.6%) and 7.1% (95% CI: 1.8%-19.7%), respectively. A total of 5 case series met our inclusion criteria for meta-analysis, and the pooled rate of sICH among 120 IVT-treated AIS patients harboring UIA was 6.7% (95% CI: 3.1%-13.7%). In the overall analysis of 5 case-series studies, the risk ratio of sICH did not differ between AIS patients with and without UIA (risk ratio = 1.60; 95% CI: 0.54-4.77; p = 0.40) with no evidence of heterogeneity across included studies (I(2) = 22% and p = 0.27 for Cochran Q test).

CONCLUSIONS

Our prospectively collected multicenter data, coupled with the findings of the meta-analysis, indicate the potential safety of IVT in AIS patients with UIA.