Skip to main content

Advertisement

SpringerLink
Log in

Timing of Thrombosis in Embolization of Unruptured Intracranial Aneurysms

Tirofiban as Rescue Treatment

  • Original Article
  • Published:
Clinical Neuroradiology Aims and scope Submit manuscript

Abstract

Purpose

Thrombosis is one of the main complications of endovascular treatment for unruptured intracranial aneurysms (UIA). This article reports the timing and initial location of thrombosis and prognosis after the use of tirofiban for performing coil embolization for UIA.

Methods

This study retrospectively collected 1686 cases of intracranial aneurysms treated with coil embolization from January 2013 to February 2018. Ruptured cases were excluded. The presumed causes and timing of thrombosis, the response after tirofiban administration and the modified Rankin scale (mRS) score at 3 months were reviewed.

Results

Of the 26 patients 76% were female and middle cerebral artery and basilar artery aneurysms accounted for 7 cases. The initial location of thrombosis was related to the stent (n = 14, 53.8%) or coil (n = 12, 46.2%). Of the patients 19 (73.1%) developed thrombosis during the procedure, and 5 patients (19.2%) developed it within 1 day of the procedure. Median duration between the thrombotic procedure and initial thrombosis was 38.5 min, 12 patients were symptomatic but more than half completely recovered after using tirofiban. Good clinical outcome (mRS 0–2) was seen in 92.3%. In the subgroup analysis, median time from the first thrombotic procedure to initial thrombosis within 1 day was 38.0 min (stent-related group) and 35.0 min (coil-related group, p = 0.651).

Conclusion

In most cases of embolization for UIA, thrombosis requiring the use of tirofiban occurs intraprocedurally or on the first day after the procedure. Careful observation of thrombosis during the procedure is important and tirofiban should be used for a better outcome even if the infarction progresses.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Grunwald IQ, Papanagiotou P, Politi M, Struffert T, Roth C, Reith W. Endovascular treatment of unruptured intracranial aneurysms: occurrence of thromboembolic events. Neurosurgery. 2006;58:612–8.

    Article  Google Scholar 

  2. Naggara ON, White PM, Guilbert F, Roy D, Weill A, Raymond J. Endovascular treatment of intracranial unruptured aneurysms: systematic review and meta-analysis of the literature on safety and efficacy. Radiology. 2010;256:887–97.

    Article  Google Scholar 

  3. Song J, Kim BS, Shin YS. Treatment outcomes of unruptured intracranial aneurysm; experience of 1,231 consecutive aneurysms. Acta Neurochir (Wien). 2015;157:1303-10; discussion 1311.

    Article  Google Scholar 

  4. Hwang G, Jung C, Park SQ, Kang HS, Lee SH, Oh CW, Chung YS, Han MH, Kwon OK. Thromboembolic complications of elective coil embolization of unruptured aneurysms: the effect of oral antiplatelet preparation on periprocedural thromboembolic complication. Neurosurgery. 2010;67:743–8.

    Article  Google Scholar 

  5. Hwang G, Huh W, Lee JS, Villavicencio JB, Villamor RB Jr, Ahn SY, Kim J, Chang JY, Park SJ, Park NM, Jeong EA, Kwon OK. Standard vs modified antiplatelet preparation for preventing thromboembolic events in patients with high on-treatment platelet reactivity undergoing coil embolization for an unruptured Intracranial aneurysm: a randomized clinical trial. JAMA Neurol. 2015;72:764–72.

    Article  Google Scholar 

  6. Yi HJ, Gupta R, Jovin TG, Tayal A, Genevro J, Gologorsky Y, Horowitz M. Initial experience with the use of intravenous eptifibatide bolus during endovascular treatment of intracranial aneurysms. AJNR Am J Neuroradiol. 2006;27:1856–60.

    CAS  PubMed  Google Scholar 

  7. Brown RD Jr., Broderick JP. Unruptured intracranial aneurysms: epidemiology, natural history, management options, and familial screening. Lancet Neurol. 2014;13:393–404.

    Article  Google Scholar 

  8. Algra AM, Lindgren A, Vergouwen MDI, Greving JP, van der Schaaf IC, van Doormaal TPC, Rinkel GJE. Procedural clinical complications, case-fatality risks, and risk factors in endovascular and neurosurgical treatment of unruptured Intracranial aneurysms: a systematic review and meta-analysis. JAMA Neurol. 2019;76:282-93.

    Article  Google Scholar 

  9. Arias EJ, Patel B, Cross DT 3rd, Moran CJ, Dacey RG Jr, Zipfel GJ, Derdeyn CP. Timing and nature of in-house postoperative events following uncomplicated elective endovascular aneurysm treatment. J Neurosurg. 2014;121:1063–70.

    Article  Google Scholar 

  10. Kameda-Smith MM, Klurfan P, van Adel BA, Larrazabal R, Farrokhyar F, Bennardo M, Gunnarsson T. Timing of complications during and after elective endovascular intracranial aneurysm coiling. J Neurointervent Surg. 2018;10:374–9.

    Article  Google Scholar 

  11. Chalouhi N, Jabbour P, Kung D, Hasan D. Safety and efficacy of tirofiban in stent-assisted coil embolization of intracranial aneurysms. Neurosurgery. 2012;71:710–4.

    Article  Google Scholar 

  12. Cho YD, Lee JY, Seo JH, Kang HS, Kim JE, Jung KH, Han MH. Intra-arterial tirofiban infusion for thromboembolic complication during coil embolization of ruptured intracranial aneurysms. Eur J Radiol. 2012;81:2833–8.

    Article  Google Scholar 

  13. Liang XD, Wang ZL, Li TX, He YK, Bai WX, Wang YY, Zhou GY. Safety and efficacy of a new prophylactic tirofiban protocol without oral intraoperative antiplatelet therapy for endovascular treatment of ruptured intracranial aneurysms. J Neurointervent Surg. 2016;8:1148–53.

    Article  Google Scholar 

  14. Zi-Liang W, Xiao-Dong L, Tian-Xiao L, Liang-Fu Z, Jiang-Yu X, Wei-Xing B, Ying-Kun H, Gang-Qin X, Qiu-Ji S, Li L, Guang F, Zhao-Shuo L. Intravenous administration of tirofiban versus loading dose of oral clopidogrel for preventing thromboembolism in stent-assisted coiling of intracranial aneurysms. Int J Stroke. 2017;12:553–9.

    Article  Google Scholar 

  15. Yoon CH, Lee HW, Kim YS, Lee SW, Yeom JA, Roh J, Baik SK. Preliminary study of tirofiban infusion in coil embolization of ruptured Intracranial aneurysms. Neurosurgery. 2018;82:76–84.

    Article  Google Scholar 

  16. Kang HS, Kwon BJ, Roh HG, Yoon SW, Chang HW, Kim JE, Han MH. Intra-arterial tirofiban infusion for thromboembolism during endovascular treatment of intracranial aneurysms. Neurosurgery. 2008;63:230–7.

    Article  Google Scholar 

  17. Jeon JS, Sheen SH, Hwang G, Kang SH, Heo DH, Cho YJ. Intraarterial tirofiban thrombolysis for thromboembolisms during coil embolization for ruptured intracranial aneurysms. J Cerebrovasc Endovasc Neurosurg. 2012;14:5–10.

    Google Scholar 

  18. Kwon OK, Lee KJ, Han MH, Oh CW, Han DH, Koh YC. Intraarterially administered abciximab as an adjuvant thrombolytic therapy: report of three cases. AJNR Am J Neuroradiol. 2002;23:447–51.

    PubMed  Google Scholar 

  19. Bruening R, Mueller-Schunk S, Morhard D, Seelos KC, Brueckmann H, Schmid-Elsaesser R, Straube A, Mayer TE. Intraprocedural thrombus formation during coil placement in ruptured intracranial aneurysms: treatment with systemic application of the glycoprotein IIb/IIIa antagonist tirofiban. AJNR Am J Neuroradiol. 2006;27:1326–31.

    CAS  PubMed  Google Scholar 

  20. Jeong HW, Jin SC. Intra-arterial infusion of a glycoprotein IIb/IIIa antagonist for the treatment of thromboembolism during coil embolization of intracranial aneurysm: a comparison of abciximab and tirofiban. AJNR Am J Neuroradiol. 2013;34:1621–5.

    Article  CAS  Google Scholar 

  21. Kim SH, Kim TG, Kong MH. Intra-arterial and intravenous tirofiban infusion for thromboembolism during endovascular coil embolization of cerebral aneurysm. J Korean Neurosurg Soc. 2017;60:518–26.

    Google Scholar 

  22. Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. N Engl J Med. 1998;338:1488–97.

  23. Bolognese L, Falsini G, Liistro F, Angioli P, Ducci K, Taddei T, Tarducci R, Cosmi F, Baldassarre S, Burali A. Randomized comparison of upstream tirofiban versus downstream high bolus dose tirofiban or abciximab on tissue-level perfusion and troponin release in high-risk acute coronary syndromes treated with percutaneous coronary interventions: the EVEREST trial. J Am Coll Cardiol. 2006;47:522–8.

    Article  CAS  Google Scholar 

  24. Kereiakes DJ, Kleiman NS, Ambrose J, Cohen M, Rodriguez S, Palabrica T, Herrmann HC, Sutton JM, Weaver WD, McKee DB, Fitzpatrick V, Sax FL. Randomized, double-blind, placebo-controlled dose-ranging study of tirofiban (MK-383) platelet IIb/IIIa blockade in high risk patients undergoing coronary angioplasty. J Am Coll Cardiol. 1996;27:536–42.

    Article  CAS  Google Scholar 

  25. Pierot L, Spelle L, Vitry F. Immediate clinical outcome of patients harboring unruptured intracranial aneurysms treated by endovascular approach: results of the ATENA study. Stroke. 2008;39:2497–504.

    Article  Google Scholar 

  26. Piotin M, Blanc R, Spelle L, Mounayer C, Piantino R, Schmidt PJ, Moret J. Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms. Stroke. 2010;41:110–5.

    Article  Google Scholar 

  27. Kim B, Kim K, Jeon P, Kim S, Kim H, Byun H, Cha J, Hong S, Jo K. Thromboembolic complications in patients with clopidogrel resistance after coil embolization for unruptured intracranial aneurysms. AJNR Am J Neuroradiol. 2014;35:1786–92.

    Article  CAS  Google Scholar 

  28. Ishihara H, Ishihara S, Niimi J, Neki H, Kakehi Y, Uemiya N, Kohyama S, Yamane F. Risk factors for coil protrusion into the parent artery and associated thrombo-embolic events following unruptured cerebral aneurysm embolization. Interv Neuroradiol. 2015;21:178–83.

    Article  Google Scholar 

  29. Vermeulen M, van Vliet HH, Lindsay KW, Hijdra A, van Gijn J. Source of fibrin/fibrinogen degradation products in the CSF after subarachnoid hemorrhage. J Neurosurg. 1985;63:573–7.

    CAS  PubMed  Google Scholar 

  30. Ikeda K, Asakura H, Futami K, Yamashita J. Coagulative and fibrinolytic activation in cerebrospinal fluid and plasma after subarachnoid hemorrhage. Neurosurgery. 1997;41:344–9.

    Article  CAS  Google Scholar 

  31. Song J, Shin YS. Antiplatelet drug resistance did not increase the thromboembolic events after stent-assisted coiling of unruptured intracranial aneurysm: a single center experience of 99 cases. Neurol Sci. 2017;38:879–85.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea (Republic of)

    Dongwhane Lee

  2. Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 05505, Seoul, Korea (Republic of)

    Deok Hee Lee, Yunsun Song & Dae Chul Suh

  3. Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (Republic of)

    Jung Cheol Park

  4. Department of Radiology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea (Republic of)

    Jae Ho Shin

  5. Department of Neurosurgery, Dankook University Hospital, Cheonan, Korea (Republic of)

    Jaewoo Chung

  6. Department of Neurosurgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea (Republic of)

    Jae Jon Sheen

Authors
  1. Dongwhane Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Deok Hee Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jung Cheol Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jae Ho Shin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yunsun Song
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jaewoo Chung
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jae Jon Sheen
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Dae Chul Suh
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Deok Hee Lee.

Ethics declarations

Conflict of interest

D. Lee, D.H. Lee, J.C. Park, J.H. Shin, Y. Song, J. Chung, J.J. Sheen and D.C. Suh declare that they have no competing interests.

Ethical standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1975 Helsinki declaration and its later amendments or comparable ethical standards. Individual patient consent was waived by Asan Medical Center institutional review board due to retrospective nature of study.

Caption Electronic Supplementary Material

62_2019_873_MOESM1_ESM.docx

Supplementary Figure 1. Flowchart of the patient selection process. Supplementary Figure 2. Distribution of the median time from the first thrombotic material insertion to the recognition of thrombosis in patients with thrombosis within a day and according to the initiating location of thrombosis within a day. Supplementary Table 1. Clinical characteristics and prognosis of patients with thrombosis according to the initiating location of thrombosis within a day of symptoms. Supplementary Table 2. Clinical characteristics and prognosis according to the initiating location of thrombosis regardless of the timing of thrombosis. Supplementary Table 3. Results of the patients who underwent both antiplatelet resistance tests (n=13).

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lee, D., Lee, D.H., Park, J.C. et al. Timing of Thrombosis in Embolization of Unruptured Intracranial Aneurysms. Clin Neuroradiol 31, 125–133 (2021). https://doi.org/10.1007/s00062-019-00873-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00062-019-00873-2

Keywords

Search

Navigation