STENT ASSISTED RECONSTRUCTION OF DIFFICULT ANEURYSMS IN ACUTE SUBARACHNOID HEMORRHAGE: A SINGLE CENTER EXPERIENCE

Vipul GuptaNeurointerventional Surgery

Institute of Neurosciences

Medanta the Medicity, Gurgaon

When?

Aneurysms not amenable to standard coiling, balloon assisted coiling or surgery

Dissecting/fusiform aneurysms

Blister aneurysms

Dysplastic berry aneurysms

Stent…. Flow diversion

Intimal growth- healing

Angle of the artery

Purpose

Antiplatelet therapy External Ventricular drain

Associated intraparenchymal hematoma

Potential for infarction secondary to

vasospasm

High likelihood of future invasive

procedures.

StentSupport at neck

Avoid coil protrusion

Data

• Retrospective review of 548 intracranial aneurysms

• 35 aneurysms in 33 patients -F- 19, M-14; 30-68 yrs

• Fisher grade III SAH - 22 (66.6%)

• H& H grade- I-III - 27 (81.8%)• EVD/ Lumbar drainage - 8 (24.2%)

• <14 days of SAH - 26(78.7%)

•

• Wide Neck aneurysms - 16

• Dissecting and/or blister aneurysms - 19

• Single (28) or double overlapping (5) stents with additional coil placement in 26 aneurysms.

Anti-platelet Regime

Antiplatelets - 2 hours prior to the procedure Ecospirin -300 mg

& Clopidogrel -450mg/Prasugrel -50mg/Ticagrelor 180 mg

Systemic heparinization during procedure

EVD if required, prior to the loading dose.

• Technical complications

• 5 (15.1%) in-stent clots, resolved with I/A Reopro

• 1(2.8%) aneurysm rupture during coiling

• 2 (5.7%)- ICA dissection, placement of stent.

• 2 patients had non fatal parenchymal haemorrhage at the EVD insertion/removal site.

Results

28

2 30

5

10

15

20

25

30

mrs 0-2 mrs 3-5 mrs 6

Good outcome - 28/33 (84.9%)

Management Morbidity - 2/33 (6.1%)

Management Mortality - 3/33 (9.0%)

Mortality and MorbidityPatient Age H

&H

Site Stents Used

MRS at discharge

Death

Patient 1 33/F 2 Left vertebral artery dissecting aneurysm

1 6 Rupture during coiling

Patient 2 53/F 4 Right ICA blister aneurysm

3 6 Meningitis

Patient 3 65/F 3 Right ICA blister aneurysm

1 3( righthemiparesis)

Cardiac arrest while tapping pleural fluid

Patient 4 62/M 4 Basilar artery dissecting aneurysm

2 3 Vision loss due to vitreous hemorrhage

Patient 5 42/M 4 Right ICA blister aneurysm

1 5 Malignant vasospasminfarcts

Classical blister aneurysm

34-year M, SAH

2 overlapping stents

1-year follow-up

Dissecting blister aneurysm –

poor grade

EVD

2-overlapping stents

Had repeated nasal & gastric bleedings (Varices,

Cirrhosis) - Anti-platelets were reduced

Almost complete clinical recovery

Case 3

5 months

Angiogram after 10 days

Case 2

A

D E F

A

B C

Review of literature

Neurosurgery. 2012 Jun;70(6):1415-29; discussion 1429. doi: 10.1227/NEU.0b013e318246a4b1.

Stent-assisted coiling of wide-necked aneurysms in the setting of acute subarachnoid hemorrhage: experience in 65

patients.

Neurosurgery. 2013 Jun;72(6):953-9. doi: 10.1227/NEU.0b013e31828ecf69.

Treatment of ruptured intracranial aneurysms: comparison of stenting and balloon remodeling.

AJNR Am J Neuroradiol. 2011

Aug;32(7):1232-6. doi:

10.3174/ajnr.A2478. Epub 2011 May 5.

Stent-assisted coiling in acutely

ruptured intracranial aneurysms: a

qualitative, systematic review of the

literature.

Conclusion

Our findings demonstrate that stent-assisted coiling is a viable treatment option for these challenging lesions in the setting of an acute SAH.

Hemorrhagic complications secondary to antiplatelet agents, although potentially deadly or debilitating, occurred infrequently.

Thromboembloic complications can be avoided by careful management with antiplatelets.