Neuroradiology

, Volume 56, Issue 12, pp 1079–1086 | Cite as

Thromboembolic events associated with single balloon-, double balloon-, and stent-assisted coil embolization of asymptomatic unruptured cerebral aneurysms: evaluation with diffusion-weighted MR imaging

  • Tomoji Takigawa
  • Kensuke Suzuki
  • Yoshiki Sugiura
  • Ryotaro Suzuki
  • Issei Takano
  • Nobuyuki Shimizu
  • Yoshihiro Tanaka
  • Akio Hyodo
Interventional Neuroradiology

Abstract

Introduction

The introduction of the balloon remodeling and stent-assisted technique has revolutionized the approach to coil embolization for wide-neck aneurysms. The purpose of this study was to determine the frequency of thromboembolic events associated with single balloon-assisted, double balloon-assisted, and stent-assisted coil embolization for asymptomatic unruptured aneurysms.

Methods

A retrospective review was undertaken by 119 patients undergoing coiling with an adjunctive technique for unruptured saccular aneurysms (64 single balloon, 12 double balloon, 43 stent assisted). All underwent diffusion-weighted imaging (DWI) within 24 h after the procedure.

Results

DWI showed hyperintense lesions in 48 (40 %) patients, and ten (21 %) of these patients incurred neurological deterioration (permanent, two; transient, eight). Hyperintense lesions were detected significantly more often in procedures with the double balloon-assisted technique (7/12, 58 %) than with the single balloon-assisted technique (16/64, 25 %, p = 0.05). Occurrence of new lesions was significantly higher with the use of stent-assisted technique (25/43, 58 %) than with the single balloon-assisted technique (p = 0.001). Symptomatic ischemic rates were similar between the three groups. The increased number of microcatheters was significantly related to the DWI abnormalities (two microcatheters, 15/63 (23.8 %); three microcatheters, 20/41 (48.8 %) (p = 0.008); four microcatheters, 12/15 (80 %) (p = 0.001)).

Conclusion

Thromboembolic events detected on DWI related to coil embolization for unruptured aneurysms are relatively common, especially in association with the double balloon-assisted and stent-assisted techniques. Furthermore, the number of microcatheters is highly correlated with DWI abnormalities. The high rate of thromboembolic events suggests the need for evaluation of platelet reactivity and the addition or change of antiplatelet agents.

Keywords

Unruptured aneurysm Coil embolization Balloon-assisted technique Stent-assisted technique Diffusion-weighted imaging 

Notes

Ethical standards and patient consent

We declare that all human and animal studies have been approved by the Ethical Review Board at Dokkyo Medical University Koshigaya Hospital, Koshigaya, Japan and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. We declare that all patients gave informed consent prior to inclusion in this study.

Conflict of interest

We declare that we have no conflict of interest.

References

  1. 1.
    Guglielmi G, Viñuela F, Sepetka I, Macellari V (1991) Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: electrochemical basis, technique, and experimental results. J Neurosurg 75:1–7PubMedCrossRefGoogle Scholar
  2. 2.
    Geremia G, Haklin M, Brennecke L (1994) Embolization of experimentally created aneurysms with intravascular stent devices. AJNR Am J Neuroradiol 15:1223–1231PubMedGoogle Scholar
  3. 3.
    Moret J, Cognard C, Weill A, Castaings L, Rey A (1997) Reconstruction technic in the treatment of wide-neck intracranial aneurysms. Long-term angiographic and clinical results. Apropos of 56 cases. J Neuroradiol 24:30–44PubMedGoogle Scholar
  4. 4.
    Albayram S, Selcuk H, Kara B, Bozdag E, Uzma O, Kocer N, Islak C (2004) Thromboembolic events associated with balloon-assisted coil embolization: evaluation with diffusion-weighted MR imaging. AJNR Am J Neuroradiol 25:1768–1777PubMedGoogle Scholar
  5. 5.
    Cottier JP, Pasco A, Gallas S, Gabrillargues J, Cognard C, Drouineau J, Brunereau L, Herbreteau D (2001) Utility of balloon-assisted Guglielmi detachable coiling in the treatment of 49 cerebral aneurysms: a retrospective, multicenter study. AJNR Am J Neuroradiol 22:345–351PubMedGoogle Scholar
  6. 6.
    Lefkowitz MA, Gobin YP, Akiba Y, Duckwiler GR, Murayama Y, Guglielmi G, Martin NA, Viñuela F (1999) Balloon-assisted Guglielmi detachable coiling of wide-necked aneurysma: part II—clinical results. Neurosurgery 45:531–538PubMedCrossRefGoogle Scholar
  7. 7.
    Malek AM, Halbach VV, Phatouros CC, Lempert TE, Meyers PM, Dowd CF, Higashida RT (2000) Balloon-assist technique for endovascular coil embolization of geometrically difficult intracranial aneurysms. Neurosurgery 46:1397–1407PubMedCrossRefGoogle Scholar
  8. 8.
    Nelson PK, Levy DI (2001) Balloon-assisted coil embolization of wide-necked aneurysms of the internal carotid artery: medium-term angiographic and clinical follow-up in 22 patients. AJNR Am J Neuroradiol 22:19–26PubMedGoogle Scholar
  9. 9.
    Lanterna LA, Tredici G, Dimitrov BD, Biroli F (2004) Treatment of unruptured cerebral aneurysms by embolization with Guglielmi detachable coils: case-fatality, morbidity, and effectiveness in preventing bleeding—a systematic review of the literature. Neurosurgery 55:767–775PubMedCrossRefGoogle Scholar
  10. 10.
    Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R, International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group (2002) International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:1267–1274PubMedCrossRefGoogle Scholar
  11. 11.
    Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr, Piepgras DG, Forbes GS, Thielen K, Nichols D, O’Fallon WM, Peacock J, Jaeger L, Kassell NF, Kongable-Beckman GL, Torner JC, International Study of Unruptured Intracranial Aneurysms Investigators (2003) Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:103–110PubMedCrossRefGoogle Scholar
  12. 12.
    Pelz DM, Lownie SP, Fox AJ (1998) Thromboembolic events associated with the treatment of cerebral aneurysms with Guglielmi detachable coils. AJNR Am J Neuroradiol 19:1541–1547PubMedGoogle Scholar
  13. 13.
    Qureshi AI, Luft AR, Sharma M, Guterman LR, Hopkins LN (2000) Prevention and treatment of thromboembolic and ischemic complications associated with endovascular procedures: part II—clinical aspects and recommendations. Neurosurgery 46:1360–1376PubMedCrossRefGoogle Scholar
  14. 14.
    Pierot L, Spelle L, Vitry F, ATENA Investigators (2008) Immediate clinical outcome of patients harboring unruptured intracranial aneurysms treated by endovascular approach: results of the ATENA study. Stroke 39:2497–2504PubMedCrossRefGoogle Scholar
  15. 15.
    Soeda A, Sakai N, Sakai H, Iihara K, Yamada N, Imakita S, Nagata I (2003) Thromboembolic events associated with Guglielmi detachable coil embolization of asymptomatic cerebral aneurysms: evaluation of 66 consecutive cases with use of diffusion-weighted MR imaging. AJNR Am J Neuroradiol 24:127–132PubMedGoogle Scholar
  16. 16.
    Rordorf G, Bellon RJ, Budzik RE Jr, Farkas J, Reinking GF, Pergolizzi RS, Ezzeddine M, Norbash AM, Gonzalez RG, Putman CM (2001) Silent thromboembolic events associated with the treatment of unruptured cerebral aneurysms by use of Guglielmi detachable coils: prospective study applying diffusion-weighted imaging. AJNR Am J Neuroradiol 22:5–10PubMedGoogle Scholar
  17. 17.
    Cronqvist M, Wirestam R, Ramgren B, Brandt L, Nilsson O, Säveland H, Holtås S, Larsson EM (2005) Diffusion and perfusion MRI in patients with ruptured and unruptured intracranial aneurysms treated by endovascular coiling: complications, procedural results, MR findings and clinical outcome. Neuroradiology 47:855–873PubMedCrossRefGoogle Scholar
  18. 18.
    Derdeyn CP, Cross DT 3rd, Moran CJ, Brown GW, Pilgram TK, Diringer MN, Grubb RL Jr, Rich KM, Chicoine MR, Dacey RG Jr (2002) Postprocedure ischemic events after treatment of intracranial aneurysms with Guglielmi detachable coils. J Neurosurg 96:837–843PubMedCrossRefGoogle Scholar
  19. 19.
    Shapiro M, Babb J, Becske T, Nelson PK (2008) Safety and efficacy of adjunctive balloon remodeling during endovascular treatment of intracranial aneurysms: a literature review. AJNR Am J Neuroradiol 29:1777–1781PubMedCrossRefGoogle Scholar
  20. 20.
    Brooks NP, Turk AS, Niemann DB, Aagaard-Kienitz B, Pulfer K, Cook T (2008) Frequency of thromboembolic events associated with endovascular aneurysm treatment: retrospective case series. J Neurosurg 108:1095–1100PubMedCrossRefGoogle Scholar
  21. 21.
    Ross IB, Dhillon GS (2005) Complications of endovascular treatment of cerebral aneurysms. Surg Neurol 64:12–19PubMedCrossRefGoogle Scholar
  22. 22.
    Lubicz B, Lefranc F, Bruneau M, Balériaux D, De Witte O (2008) Balloon-assisted coiling of intracranial aneurysms is not associated with a higher complication rate. Neuroradiology 50:769–776PubMedCrossRefGoogle Scholar
  23. 23.
    Spiotta AM, Bhalla T, Hussain MS, Sivapatham T, Batra A, Hui F, Rasmussen PA, Moskowitz SI (2011) An analysis of inflation times during balloon-assisted aneurysm coil embolization and ischemic complications. Stroke 42:1051–1055PubMedCrossRefGoogle Scholar
  24. 24.
    Ishibashi T, Murayama Y, Saguchi T, Ebara M, Irie K, Takao H, Abe T (2006) Thromboembolic events during endovascular coil embolization of cerebral aneurysms. Interv Neuroradiol 12(Suppl 1):112–116PubMedCentralPubMedGoogle Scholar
  25. 25.
    Altay T, Kang HI, Woo HH, Masaryk TJ, Rasmussen PA, Fiorella DJ, Moskowitz SI (2011) Thromboembolic events associated with endovascular treatment of cerebral aneurysms. J Neurointerv Surg 3:147–150PubMedCrossRefGoogle Scholar
  26. 26.
    Earnest F 4th, Forbes G, Sandok BA, Piepgras DG, Faust RJ, Ilstrup DM, Arndt LJ (1984) Complications of cerebral angiography: prospective assessment of risk. AJR Am J Roentgenol 142:247–253PubMedCrossRefGoogle Scholar
  27. 27.
    Raymond J, Guilbert F, Weill A, Georganos SA, Juravsky L, Lambert A, Lamoureux J, Chagnon M, Roy D (2003) Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke 34:1398–1403PubMedCrossRefGoogle Scholar
  28. 28.
    Schneider PA, Silva MB Jr, Bohannon WT, Kasirajan K, Caps MT, Nelken N, Santana D (2005) Safety and efficacy of carotid arteriography in vascular surgery practice. J Vasc Surg 41:238–245PubMedCrossRefGoogle Scholar
  29. 29.
    Kerber CW, Cromwell LD, Drayer BP, Bank WO (1978) Cerebral ischemia. I. Current angiographic techniques, complications, and safety. AJR Am J Roentgenol 130:1097–1103PubMedCrossRefGoogle Scholar
  30. 30.
    Mani RL, Eisenberg RL, McDonald EJ Jr, Pollock JA, Mani JR (1978) Complications of catheter cerebral arteriography: analysis of 5,000 procedures. I. Criteria and incidence. AJR Am J Roentgenol 131:861–865PubMedCrossRefGoogle Scholar
  31. 31.
    Eisenberg RL, Bank WO, Hedgcock MW (1980) Neurologic complications of angiography for cerebrovascular disease. Neurology 30:895–897PubMedCrossRefGoogle Scholar
  32. 32.
    Wolfel DA, Lovett BP, Ortenburger AI, Johnson LS, Sommerville DL (1984) Outpatient arteriography: its safety and cost effectiveness. Radiology 153:363–364PubMedCrossRefGoogle Scholar
  33. 33.
    Saint-Georges G, Aube M (1985) Safety of outpatient angiography: a prospective study. AJR Am J Roentgenol 144:235–236PubMedCrossRefGoogle Scholar
  34. 34.
    Gasparyan AY, Watson T, Lip GY (2008) The role of aspirin in cardiovascular prevention: implications of aspirin resistance. J Am Coll Cardiol 51:1829–1843PubMedCrossRefGoogle Scholar
  35. 35.
    Krasopoulos G, Brister SJ, Beattie WS, Buchanan MR (2008) Aspirin “resistance” and risk of cardiovascular morbidity: systematic review and meta-analysis. BMJ 336:195–198PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Patrono C, García Rodríguez LA, Landolfi R, Baigent C (2005) Low-dose aspirin for the prevention of atherothrombosis. N Engl J Med 353:2373–2383PubMedCrossRefGoogle Scholar
  37. 37.
    Tran HA, Anand SS, Hankey GJ, Eikelboom JW (2007) Aspirin resistance. Thromb Res 120:337–346PubMedCrossRefGoogle Scholar
  38. 38.
    Feher G, Feher A, Pusch G, Koltai K, Tibold A, Gasztonyi B, Papp E, Szapary L, Kesmarky G, Toth K (2010) Clinical importance of aspirin and clopidogrel resistance. World J Cardiol 2:171–186PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Lee DH, Arat A, Morsi H, Shaltoni H, Harris JR, Mawad ME (2008) Dual antiplatelet therapy monitoring for neurointerventional procedures using a point-of-care platelet function test: a single-center experience. AJNR Am J Neuroradiol 29:1389–1394PubMedCrossRefGoogle Scholar
  40. 40.
    Snoep JD, Hovens MM, Eikenboom JC, van der Bom JG, Jukema JW, Huisman MV (2007) Clopidogrel nonresponsiveness in patients undergoing percutaneous coronary intervention with stenting: a systematic review and meta-analysis. Am Heart J 154:221–231PubMedCrossRefGoogle Scholar
  41. 41.
    Delgado Almandoz JE, Crandall BM, Scholz JM, Fease JL, Anderson RE, Kadkhodayan Y, Tubman DE (2013) Pre-procedure P2Y12 reaction units value predicts perioperative thromboembolic and hemorrhagic complications in patients with cerebral aneurysms treated with the Pipeline Embolization Device. J Neurointerv Surg 5(Suppl 3):iii3–iii10PubMedCrossRefGoogle Scholar
  42. 42.
    Kang HS, Kwon BJ, Kim JE, Han MH (2010) Preinterventional clopidogrel response variability for coil embolization of intracranial aneurysms: clinical implications. AJNR Am J Neuroradiol 31:1206–1210PubMedCrossRefGoogle Scholar
  43. 43.
    Murthy SB, Shah S, Venkatasubba Rao CP, Bershad EM, Suarez JI (2014) Treatment of unruptured intracranial aneurysms with the pipeline embolization device. J Clin Neurosci 21:6–11PubMedCrossRefGoogle Scholar
  44. 44.
    Tan LA, Keigher KM, Munich SA, Moftakhar R, Lopes DK (2014) Thromboembolic complications with Pipeline Embolization Device placement: impact of procedure time, number of stents and pre-procedure P2Y12 reaction unit (PRU) value. J Neurointerv Surg 19. doi:10.1136/neurintsurg-2014-011111
  45. 45.
    Heller RS, Dandamudi V, Lanfranchi M, Malek AM (2013) Effect of antiplatelet therapy on thromboembolism after flow diversion with the pipeline embolization device. J Neurosurg 119:1603–1610PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Tomoji Takigawa
    • 1
  • Kensuke Suzuki
    • 1
  • Yoshiki Sugiura
    • 1
  • Ryotaro Suzuki
    • 1
  • Issei Takano
    • 1
  • Nobuyuki Shimizu
    • 1
  • Yoshihiro Tanaka
    • 1
  • Akio Hyodo
    • 1
  1. 1.Department of NeurosurgeryDokkyo Medical University Koshigaya HospitalKoshigayaJapan

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