Mechanically Induced Vasospasm and Postoperative Cerebral Infarction after Coil Embolization of Unruptured Cerebral Aneurysms in Anterior Circulation

Incidence and Outcome of Peri-interventional Vasospasm During Endovascular or Microsurgical Treatment of Unruptured Intracranial Aneurysms

BACKGROUND

Peri-interventional vasospasm (PIVS) is associated with high risk of delayed cerebral vasospasm (DCVS), delayed cerebral ischemia, and poor outcome after aneurysmal subarachnoid hemorrhage. However, the incidence rate associated with treatment of unruptured intracranial aneurysm (UIA) remains unclear.

OBJECTIVE

To define the incidence and clinical significance of PIVS in UIA repair based on intraoperative/peri-interventional digital subtraction angiography.

METHODS

A consecutive series of 205 patients who underwent UIA treatment by means of microsurgical clipping (n = 109) or endovascular coil embolization (n = 96) was assessed for the occurrence of PIVS. In all cases, PIVS was detected, measured, and classified using intraoperative/peri-interventional digital subtraction angiography. Severity of PIVS, association of PIVS with the development of DCVS, and neurological outcome were analyzed.

RESULTS

Intraoperative PIVS was present in n = 14/109 (13%) patients with microsurgical clipping. Of these, caliber irregularities were mild (n = 10), moderate (n = 3), and severe (n = 1). In endovascularly treated patients, 6/96 (6%) developed PIVS, which were either mild (n = 3) or moderate (n = 3). Management in all cases included immediate intensive blood pressure management and application of topical papaverine or intra-arterial nimodipine immediately on detection of PIVS. No patient developed DCVS or lasting neurological deficits attributable to PIVS.

CONCLUSION

This series revealed a relatively high overall incidence of PIVS (10%). However, no association of PIVS with the development of DCVS or poor outcome was found. In contrast to ruptured intracranial aneurysms, PIVS in unruptured intracranial aneurysms-if immediately and adequately addressed-seems to be benign and without sequelae for patient's functional outcome.

Cerebral ischemia after treatment of posterior communicating artery aneurysms: clipping versus coiling

Objection

This study aimed to compare the incidence of cerebral ischemia and outcomes between surgical clipping and endovascular coiling in patients with posterior communicating artery (PCoA) aneurysms.

Methods

Clinical and imaging data of patients with at least one PCoA aneurysm who underwent surgical clipping or endovascular coiling in our institution from January 2017 to December 2019 were analyzed.

Results

Three hundred sixty-three aneurysms in 353 patients were included for analysis, 257 in the clipping group, and 106 in the coiling group. The groups did not differ in terms of baseline characteristics. The incidence of postoperative cerebral ischemia (23.35% vs. 11.32%, p = 0.029) was higher in the clipping group. The proportion of patients with a modified Rankin Scale score ≥ 2 was significantly higher in the clipping group at discharge (35.80% vs. 15.09%; p < 0.05) but not six months after discharge (15.56% vs. 8.49%; p > 0.05). In the clipping group, the mean age was significantly higher in patients who developed cerebral ischemia than in those who did not. In the coiling group, modified Fisher grade and incidence of fetal PCoA were significantly higher in patients who developed ischemia.

Conclusion

The incidence of postoperative cerebral ischemia was higher after PCoA aneurysm clipping than after coiling. The causes and characteristics of postoperative cerebral ischemia after PCoA clipping and coiling are different; therefore, treatment should be selected accordingly.