Update on Endovascular Treatment of Cerebrovascular Diseases

Intracranial hemorrhage associated with stent-assisted coil embolization of cerebral aneurysms: a cautionary report

Object

The introduction of the Neuroform microstent has facilitated the embolization of complex cerebral aneurysms, which were previously not amenable to endovascular therapy. Typically, the use of this stent necessitates the administration of dual antiplatelet therapy to minimize thromboembolic complications. Such therapy may increase the risk of hemorrhage in patients who require concurrent external ventricular drainage and/or subsequent permanent cerebrospinal fluid diversion.

Methods

The authors' neurosurgical database was queried for all patients who underwent stent-assisted coil embolization for cerebral aneurysms and who required an external ventricular drain (EVD) or ventriculoperitoneal (VP) shunt placement for management of hydrocephalus.

Results

Thirty-seven patients underwent stent-assisted coil embolization for intracranial aneurysms at the authors' institution over a recent 2-year period. Seven of these patients required placement of an EVD and/or a VP shunt. Three of the 7 patients suffered an immediate intraventricular hemorrhage (IVH) associated with placement or manipulation of an EVD; 1 experienced a delayed intraparenchymal hemorrhage and an IVH; 1 suffered an aneurysmal rehemorrhage; and the last patient had a subdural hematoma (SDH) that resulted from placement of a VP shunt. This patient required drainage of the SDH and exchange of the valve.

Conclusions

The necessity of dual antiplatelet therapy in the use of stent-assisted coil embolization increases the risk of intracranial hemorrhage and possibly rebleeding from a ruptured aneurysm. This heightened risk must be recognized when contemplating the appropriate therapy for a cerebral aneurysm and when considering the placement or manipulation of a ventricular catheter in a patient receiving dual antiplatelet therapy. Further study of intracranial procedures in patients receiving dual antiplatelet therapy is indicated.

Changes in Serum Calcium Levels Associated with Catheter-Based Cerebral Angiography

BACKGROUND AND OBJECTIVE

Digital subtraction angiography is performed with agents such as iodinated contrast and intravenous heparin, which can alter electrolyte levels. If severe enough, these alterations may produce symptoms in patients in the post-procedural period. We performed this study to evaluate serum calcium level changes after cerebral angiography.

MATERIALS AND METHODS

The preangiographic and postangiographic serum calcium levels of 87 patients were reviewed and analyzed. Patients were grouped based on when the postangiographic serum calcium level was drawn in relation to the angiographic procedure (0-6 hours, 6-12 hours, 12-18 hours, and 18-24 hours).

RESULTS

A significant reduction in serum calcium was observed in the 0- to 6-hours, 6- to 12-hours, and 12- to 18-hours groups (P < .05). The differences between the preangiographic and postangiographic serum calcium levels were 0.91 mg/dL, 0.59 mg/dL, and 0.55 mg/dL in the 0- to 6-hours, 6- to 12-hours, and 12- to 18-hours groups, respectively. The difference in the 18- to 24-hours group (0.27 mg/dL) was not statistically significant. None of the patients was clinically symptomatic from this decrease in serum calcium levels.

CONCLUSION

An asymptomatic but significant decrease in serum calcium levels is seen following cerebral angiography. Possible mechanisms include chelation from the contrast agent or intravenous heparin. The reduction in serum calcium is transient, appearing to resolve within 24 hours.