Rescue therapy with stent retrievers for thromboembolism during endovascular treatment of intracranial aneurysms

Exploring the Landscape of Intracranial Aneurysms in South America: A Comprehensive Narrative Review Intracranial Aneurysms in South America

Exploring the landscape of intracranial aneurysms in South America unravels a complex interplay of epidemiological factors, clinical manifestations, and therapeutic challenges. The study methodically conducts a comprehensive literature review spanning the years 2003 to 2023, focusing on English-language articles obtained from diverse databases to elucidate the multifaceted nature of intracranial aneurysms in the region. Results and discussions categorize outcomes into positive domains, emphasizing successful treatments, favorable recoveries, and high survival rates, while also shedding light on negative aspects such as residual aneurysms and complications. The research illuminates significant gaps in pathological typing of intracranial aneurysms and exposes challenges in healthcare accessibility, notably the disparities in neurosurgical resources. Management challenges, including constrained infrastructure access, a neurosurgeon shortage, and gender disparities, are underscored. Transitioning to future prospects, the study advocates for strategic interventions, proposing expanded neurosurgical training, multidisciplinary approaches, improved funding, enhanced access to care, and fostering international collaborations. The study concludes by emphasizing the pivotal role of collaborative efforts, intensified training programs, and global partnerships in propelling intracranial aneurysm management forward in South America, ultimately contributing to enhanced patient outcomes across the region.

Thromboembolism during coiling of intracranial aneurysms: predictors and clinical outcome

Introduction

Thromboembolism is one of the most serious complications associated with coil embolization therapy.

Aim

To identify predisposing factors for thromboembolic complications, as well as to determine whether thromboembolism has an impact on clinical outcome.

Material and methods

From February 2008 to March 2015, 273 consecutive patients were treated at our institution via endovascular coil embolization. Patient medical records were reviewed with an emphasis on procedure description, potential risk factors and clinical outcomes related to thromboembolism. Thromboembolic incidents occurred in 19 (6.9%) cases. Multivariate logistic regression models were used to determine independent predictors of thromboembolism. Clinical outcome was analyzed using the Glasgow Outcome Scale (GOS).

Results

Multivariate analysis showed that subarachnoid hemorrhage was an independent risk factor for thromboembolic complications (p = 0.003; OR = 4.4; 95% CI: 1.67–12.02). The difference in frequency of perioperative mortality (GOS 1) in patients with thromboembolism and without thromboembolism was not statistically significant (p = 0.22). The differences in frequencies of severe disability (GOS 2–3) and moderate to low disability (GOS 4–5) between patients with thromboembolism and without thromboembolism were statistically significant in the general study population (p < 0.05).

Conclusions

Subarachnoid hemorrhage is an independent predictor of thromboembolic complications associated with endovascular coiling of cerebral aneurysms. Thromboembolism is associated with significantly increased risk of morbidity, and it affects to a certain extent the periprocedural mortality.

Mechanical Thrombectomy for Delayed Thrombosis of Pipeline Embolization Device

BACKGROUND

In-stent thrombosis is a potentially dangerous complication of flow diversion for cerebral aneurysms. The optimal management strategy for such thrombosis is not known. Here we present a case of acute ischemic stroke caused by occlusion of a Pipeline Embolization Device (PED) construct placed 18 months earlier for treatment of a fusiform middle cerebral artery aneurysm. This was successfully treated with mechanical thrombectomy with good neurologic outcome.

CASE DESCRIPTION

A 40-year-old woman presented with acute onset of left-sided weakness and occlusion of the right middle cerebral artery harboring a PED construct. Intraarterial glycoprotein IIb/IIIa inhibitor was administered without success. Mechanical thrombectomy was then performed using a stent retriever and aspiration, and the patient was loaded with dual antiplatelet therapy. The patient showed initial neurologic improvement but several hours later demonstrated recurrent symptoms due to reocclusion of the PED construct. This was again treated with mechanical thrombectomy followed by an intravenous P2Y12 inhibitor infusion. She ultimately made an excellent neurologic recovery with persistent patency of the PED construct.

CONCLUSIONS

Mechanical thrombectomy with a stent retriever and aspiration is a therapeutic option for treatment of delayed thrombosis of a flow-diverting stent.