Serious Blood-Brain Barrier Disruption after Coil Embolization of Unruptured Intracranial Aneurysm : Report of Two Cases and Role of Immediate Postembolization CT Scan

Coil embolization of the middle cerebral artery bifurcation aneurysms: Feasibility and durability

OBJECTIVE

To evaluate the feasibility and durability of coil embolization for MCAB aneurysms by analyzing clinical and radiological results.

METHODS

From January of 2008 to June of 2018, we treated a total of 1785 aneurysms using coil embolization. The aneurysms were treated by both coiling and stent-assisted coiling. Among these cases, 223 MCAB aneurysms were analyzed retrospectively. Clinical and radiological assessments were conducted at admission, after treatment, at discharge, and at last clinical follow-up.

RESULTS

Coil embolization was performed on 223 MCAB aneurysms in 217 patients. Peri-procedural ischemic, hemorrhagic, and other complications within 30 days after coil embolization occurred at rates of 8.0 %, 8.0 %, and 2.0 %, respectively, in the ruptured group and at 2.9 %, 1.2 %, and 0 %, respectively, in the unruptured group. The overall morbidity and mortality rates associated with complications were 2.3 % and 2.0 %. The cumulative major recurrence rates were 5.1 % at 12 months, 7.1 % at 18 months, and 11.9 % at three years after coil embolization. The mean follow-up period was 33.27 ± 25.48 months. Independent risk factors for major recurrence after coil embolization for MCAB aneurysms were a ruptured aneurysm, initial incomplete occlusion, the aneurysm size, and the neck size.

CONCLUSION

Coil embolization is a good alternative treatment option for MCAB aneurysms compared to surgical clipping. Considering the risk factors for major recurrence, the follow-up angiography should continue up to three years after coil embolization.

Contrast Injection from an Intermediate Catheter Placed in an Intradural Artery is Associated with Contrast-Induced Encephalopathy following Neurointervention

BACKGROUND AND PURPOSE

Contrast-induced encephalopathy can result from neurotoxicity of contrast medium in the affected area. The development of intermediate catheters has allowed guidance of catheters to more distal arteries. This study focused on the association between contrast-induced encephalopathy and contrast injection from an intermediate catheter guided into a distal intradural artery during neurointervention for cerebral aneurysms.

MATERIALS AND METHODS

We retrospectively reviewed 420 consecutive aneurysms in 396 patients who underwent neurointervention for extracranial aneurysms and unruptured intracranial aneurysms at our institution from February 2012 to January 2023. Patients were divided into a group with contrast-induced encephalopathy and a group without. To identify risk factors for contrast-induced encephalopathy, we compared clinical, anatomic, and procedural factors between groups by multivariate logistic regression analysis and stepwise selection.

RESULTS

Among the 396 patients who underwent neurointervention for cerebral aneurysms, 14 (3.5%) developed contrast-induced encephalopathy. Compared with the group without contrast-induced encephalopathy, the group with contrast-induced encephalopathy showed significantly higher rates of patients on hemodialysis, previously treated aneurysms, intradural placement of a catheter for angiography, nonionic contrast medium, and flow-diversion procedures in univariate analyses. Stepwise multivariate logistic regression analysis revealed intradural placement of a catheter for angiography (OR = 40.4; 95% CI, 8.63-189) and previously treated aneurysms (OR = 8.20; 95% CI, 2.26-29.6) as independent predictors of contrast-induced encephalopathy.

CONCLUSIONS

Contrast injection from an intradural artery and retreatment of recurrent aneurysms were major risk factors for contrast-induced encephalopathy. Attention should be paid to the location of the intermediate catheter for angiography to avoid developing contrast-induced encephalopathy.

Contrast-induced Encephalopathy Following Embolization of Intracranial Aneurysms in Hemodialysis Patients

Contrast-induced encephalopathy is a very rare complication associated with endovascular treatment of intracranial aneurysms. Patients with renal dysfunction may be prone to developing contrast medium neurotoxicity as a result of delayed elimination of the contrast medium in renal metabolism. This article focuses on our experience with contrast-induced encephalopathy in patients with end-stage renal disease requiring hemodialysis. The authors retrospectively reviewed five patients diagnosed with contrast-induced encephalopathy who underwent aneurysm coil embolization at their institution from January 2006 to December 2015. During the 10-year period, embolization was performed in 755 cases, among which contrast-induced encephalopathy occurred in five patients (0.66%). Three of the five patients were undergoing dialysis for chronic renal failure (one male and two female; mean age 66.7). Embolization for hemodialysis patients was performed in eight during the same period and the incidence of contrast-induced encephalopathy in hemodialysis patients is quite high in our series (3 of 8; 38%). Procedures were performed in one for recurrence of unruptured anterior-communicating artery aneurysm and in two for unruptured basilar-tip aneurysm. Mean approximately 220 ml of contrast media was used among three hemodialysis patients. All three patients showed an improvement or a control in symptoms soon after hemodialysis. Recovery of neurological symptoms was complete in two and almost normal in one within 1 week after intervention. Contrast-induced encephalopathy should be kept in mind as an expected complication of aneurysm embolization in hemodialysis patients. In hemodialysis patients with contrast-induced encephalopathy, performing hemodialysis is an effective treatment to improve symptoms early.

Acute ischemic stroke mimicking subarachnoid hemorrhage after coronary angioplasty

Use of non-ionic contrast media (CM) in coronary arteriography has been reported to cause transient cortical blindness, confusion, amnesia and very rare focal deficits. We report a 69-year old patient with stable angina pectoris who underwent coronary angioplasty with stent placement due to in-stent thrombosis of the right coronary artery and developed stroke symptoms with radiological suspicion of subarachnoid hemorrhage. No vascular malformations were detected on CT cerebral angiography. Dual antiplatelet treatment was continued. Complete neurological recovery was observed within 48 hours post angiography. As observed with repeated CT scans, sulcal hyperdensities mostly faded after 24 hours and totally disappeared within 7 days when she was discharged home. Our case shows transient neurological symptoms and rapid disappearing of sulcal hyperdensities, suggesting temporary blood brain barrier disruption, consequential cerebral infarction and contrast media extravasation as the main mechanisms which allowed us to treat the patient with dual antiplatelet treatment.

Outcome Differences between Intra-Arterial Iso- and Low-Osmolality Iodinated Radiographic Contrast Media in the Interventional Management of Stroke III Trial

BACKGROUND AND PURPOSE

Intracarotid arterial infusion of nonionic, low-osmolal iohexol contrast medium has been associated with increased intracranial hemorrhage in a rat middle cerebral artery occlusion model compared with saline infusion. Iso-osmolal iodixanol (290 mOsm/kg H2O) infusion demonstrated smaller infarcts and less intracranial hemorrhage compared with low-osmolal iopamidol and saline. No studies comparing iodinated radiographic contrast media in human stroke have been performed, to our knowledge. We hypothesized that low-osmolal contrast media may be associated with worse outcomes compared with iodixanol in the Interventional Management of Stroke III Trial (IMS III).

MATERIALS AND METHODS

We reviewed prospective iodinated radiographic contrast media data for 133 M1 occlusions treated with endovascular therapy. We compared 5 prespecified efficacy and safety end points (mRS 0-2 outcome, modified TICI 2b-3 reperfusion, asymptomatic and symptomatic intracranial hemorrhage, and mortality) between those receiving iodixanol (n = 31) or low-osmolal contrast media (n = 102). Variables imbalanced between iodinated radiographic contrast media types or associated with outcome were considered potential covariates for the adjusted models. In addition to the iodinated radiographic contrast media type, final covariates were those selected by using the stepwise method in a logistic regression model. Adjusted relative risks were then estimated by using a log-link regression model.

RESULTS

Of baseline or endovascular therapy variables potentially linked to outcome, prior antiplatelet agent use was more common and microcatheter iodinated radiographic contrast media injections were fewer with iodixanol. Relative risk point estimates are in favor of iodixanol for the 5 prespecified end points with M1 occlusion. The percentage of risk differences are numerically greater for microcatheter injections with iodixanol.

CONCLUSIONS

While data favoring the use of iso-osmolal iodixanol for reperfusion of M1 occlusion following IV rtPA are inconclusive, potential pathophysiologic mechanisms suggesting clinical benefit warrant further investigation.

Contrast encephalopathy after coiling in the setting of obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is increasingly recognised as a source of perioperative morbidity and mortality. We describe a patient with severe OSA who developed transient contrast encephalopathy after elective coiling of an anterior communicating artery aneurysm. Contrast extravasation led to cerebral oedema, seizures and delirium, which eventually completely resolved. OSA is known to be associated with a proinflammatory state that leads to hypertension, impaired endothelial repair capacity and endothelial dysfunction. Further studies are needed to clarify whether OSA increases the risk of endovascular procedures.