Skip to main content
SpringerLink
Log in

Delayed ipsilateral parenchymal hemorrhage following treatment of intracranial aneurysms with flow diverter

  • Interventional Neuroradiology
  • Published:
Neuroradiology Aims and scope Submit manuscript

Abstract

Introduction

The use of flow diverters (FDs) has shown promising results, particularly in the treatment of large or complex intracranial aneurysms. However, some complications can occur both during and after FD treatment, including delayed ipsilateral parenchymal hemorrhage (DIPH). The clinical presentation, etiopathogeny, and management of this complication are not well understood. We report a series of four patients with DIPH and discuss the potential mechanisms and modalities of treatment.

Methods

Four patients treated with FDs and presenting with DIPH were diagnosed in two different centers. Clinical and imaging data were reviewed before and after the procedure. Characteristics of the intraparenchymal hematomas, the modalities of treatment, and clinical course were analyzed.

Results

Intraparenchymal hemorrhage occurred 1 to 4 days after aneurysm treatment with FDs. All hemorrhages were situated in the ipsilateral hemisphere and were anatomically remote from the treated aneurysm. The four patients were treated with emergency surgery (hematoma evacuation). All patients had a favorable clinical outcome (mRS = 1) at midterm evaluation. Follow-up imaging showed good permeability of the FD in all subjects and complete aneurysm occlusion in all patients.

Conclusion

From the literature review, DIPH appears to be more frequent than delayed aneurysm rupture and may be a cause of increasing concern for the use of flow diverters. However, the mechanisms of DIPH are not completely understood. Surgical evacuation of the hematoma seems to be feasible with acceptable safety and good clinical outcomes.

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

Abbreviations

ASA:

Acetylsalicylic acid

DIPH:

Delayed ipsilateral parenchymal hemorrhage

FD:

Flow diverter

ICA:

internal carotid artery

ICH:

Intracerebral hemorrhage

IA:

Intracranial aneurysm

SAH:

Subarachnoid hemorrhage

References

  1. Molyneux A, Kerr R, International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R (2002) International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomized trial. J Stroke Cerebrovasc 11:304–314

    Article  Google Scholar 

  2. Pierot L, Spelle L, Vitry F (2010) ATENA investigators immediate anatomic results after endovascular treatment of unruptured intracranial aneurysms: analysis of the ATENA series. AJNR Am J Neuroradiol 31:140–144

    Article  CAS  PubMed  Google Scholar 

  3. Pierot L, Cognard C, Ricolfi F, Anxionnat R (2010) CLARITY Investigators. Immediate anatomic results after the endovascular treatment of ruptured intracranial aneurysms: analysis in the CLARITY series. AJNR Am J Neuroradiol 31:907–911

    Article  CAS  PubMed  Google Scholar 

  4. Pierot L (2011) Flow diverter stents in the treatment of intracranial aneurysms: where are we? J Neuroradiol 38:40–46

    Article  PubMed  Google Scholar 

  5. Turowski B, Macht S, Kulcsár Z, Hänggi D, Stummer W (2011) Early fatal hemorrhage after endovascular cerebral aneurysm treatment with a flow diverter (SILK-Stent): do we need to rethink our concepts? Neuroradiology 53:37–41

    Article  PubMed  Google Scholar 

  6. Cebral JR, Mut F, Raschi M et al (2011) Aneurysm rupture following treatment with flow-diverting stents: computational hemodynamics analysis of treatment. AJNR Am J Neuroradiol 32:27–33

    Article  CAS  PubMed  Google Scholar 

  7. Kulcsár Z, Houdart E, Bonafé A et al (2011) Intra-aneurysmal thrombosis as a possible cause of delayed aneurysm rupture after flow-diversion treatment. AJNR Am J Neuroradiol 32:20–25

    Article  PubMed  Google Scholar 

  8. Mustafa W, Kadziolka K, Anxionnat R, Pierot L (2010) Direct carotid-cavernous fistula following intracavernous carotid aneurysm treatment with a flow-diverter stent. A case report. Interv Neuroradiol 16:447–450

    CAS  PubMed Central  PubMed  Google Scholar 

  9. Cruz JP, Chow M, O’Kelly C et al (2012) Delayed ipsilateral parenchymal hemorrhage following flow diversion for the treatment of anterior circulation aneurysms. AJNR Am J Neuroradiol 33:603–608

    Article  CAS  PubMed  Google Scholar 

  10. Zsolt Kulcsár, István Szikora (2012) The ESMINT Retrospective Analysis of Delayed Aneurysm Ruptures after flow diversion (RADAR) study. EJMINT Original Article. http://www.ejmint.org/original-article/1244000088. Accessed 29 Oct 2012

  11. Saatci I, Yavuz K, Ozer C, Geyik S, Cekirge HS (2012) Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results. AJNR Am J Neuroradiol 33:1436–1446

    Article  CAS  PubMed  Google Scholar 

  12. Becske T, Kallmes DF, Saatci I et al (2013) Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology. doi:10.1148/radiol.13120099

    PubMed  Google Scholar 

  13. Fischer S, Vajda Z, Aguilar Perez M et al (2012) Pipeline embolization device (PED) for neurovascular reconstruction: initial experience in the treatment of 101 intracranial aneurysms and dissections. Neuroradiology 54:369–382

    Article  PubMed Central  PubMed  Google Scholar 

  14. Shannon P, Billbao JM, Marotta T, Terbrugge K (2006) Inadvertent foreign body embolization in diagnostic and therapeutic cerebral angiography. AJNR Am J Neuroradiol 27:278–282

    CAS  PubMed  Google Scholar 

  15. Toyoda K, Yasaka M, Iwade K et al (2008) Bleeding with AntithromboticTherapy (BAT) Study Group. Dual antithrombotic therapy increases severe bleeding events in patients with stroke and cardiovascular disease: a prospective, multicenter, observational study. Stroke 39:1740–1745

    Article  PubMed  Google Scholar 

  16. Hart RG, Tonarelli SB, Pearce LA (2005) Avoiding central nervous system bleeding during antithrombotic therapy: recent data and ideas. Stroke 36:1588–1593

    Article  PubMed  Google Scholar 

  17. Toyoda K, Okada Y, Minematsu K et al (2005) Antiplatelet therapy contributes to acute deterioration of intracerebral hemorrhage. Neurology 65:1000–1004

    Article  CAS  PubMed  Google Scholar 

  18. Ariesen MJ, Claus SP, Rinkel GJ, Algra A (2003) Risk factors for intracerebral hemorrhage in the general population: a systematic review. Stroke 34:2060–2065

    Article  CAS  PubMed  Google Scholar 

  19. Toyoda K, Yasaka M, Uchiyama S et al (2010) Bleeding with Antithrombotic Therapy (BAT) Study Group. Blood pressure levels and bleeding events during antithrombotic therapy: the Bleeding with Antithrombotic Therapy (BAT) Study. Stroke 41:1440–1444

    Article  PubMed  Google Scholar 

  20. Shapiro M, Becske T, Sahlein D, Babb J, Nelson PK (2012) Stent-supported aneurysm coiling: a literature survey of treatment and follow-up. JNR Am J Neuroradiol 33:159–163

    Article  CAS  Google Scholar 

  21. Fifi JT, Brockington C, Narang J et al (2013) Clopidogrel resistance is associated with thromboembolic complications in patients undergoing neurovascular stenting. AJNR Am J Neuroradiol 34:716–720

    Article  CAS  PubMed  Google Scholar 

  22. Goh C, Churilov L, Mitchell P, Dowling R, Yan B (2013) Clopidogrel hyper-response and bleeding risk in neurointerventional procedures. AJNR Am J Neuroradiol 34:721–726

    Article  CAS  PubMed  Google Scholar 

  23. Hussein HM, Emiru T, Georgiadis AL, Qureshi AI (2013) Assessment of platelet inhibition by point-of-care testing in neuroendovascular procedures. AJNR Am J Neuroradiol 34:700–706

    Article  CAS  PubMed  Google Scholar 

  24. Comin J, Kallmes DF (2013) Platelet-function testing in patients undergoing neurovascular procedures: caught between a rock and a hard place. AJNR Am J Neuroradiol 34:730–734

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

We thank the Covidien Neurovascular Clinical and Scientific Communications Team. We gratefully acknowledge the contribution of Rachel Castro, MPH, in manuscript preparation.

Conflict of interest

LP consults for Codman, Covidien, Microvention, Penumbra and Sequent.

Author information

Authors and Affiliations

  1. Department of Neuroradiology, Centres Hospitaliers Universitaires de Reims, Reims, France

    Catherine Tomas, Azzedine Benaissa, Krzysztof Kadziolka & Laurent Pierot

  2. Department of Neuroradiology, Centres Hospitaliers Universitaires de Tours, Tours, France

    Denis Herbreteau

  3. Service de Neuroradiologie, Hopital Maison Blanche, 45, rue Cognacq Jay, 51092, Reims Cedex, France

    Laurent Pierot

Authors
  1. Catherine Tomas
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Azzedine Benaissa
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Denis Herbreteau
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Krzysztof Kadziolka
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Laurent Pierot
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Laurent Pierot.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Tomas, C., Benaissa, A., Herbreteau, D. et al. Delayed ipsilateral parenchymal hemorrhage following treatment of intracranial aneurysms with flow diverter. Neuroradiology 56, 155–161 (2014). https://doi.org/10.1007/s00234-013-1302-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00234-013-1302-2

Keywords

Search

Navigation