title: Treatment of ruptured complex and large/giant ruptured cerebral aneurysms by acute coiling followed by staged flow diversion.
abstract: OBJECT Flow-diversion treatment has been shown to be associated with high rates of angiographic obliteration; however, the treatment is relatively contraindicated in the acute phase following subarachnoid hemorrhage (SAH) as these patients require periprocedural dual antiplatelet therapy. Acute coiling followed by flow diversion has emerged as an intriguing and feasible treatment option for ruptured complex and giant aneurysms. In this study the authors report outcomes and complications of patients with ruptured aneurysms undergoing coiling in the acute phase followed by planned delayed flow diversion. METHODS This case series includes patients from 2 institutions. All patients underwent standard endovascular coiling in the acute phase after SAH with the intention and plan to proceed with flow diversion at a later date. Outcomes studied included angiographic occlusion, procedure-related complications, and long-term clinical outcome as measured using the modified Rankin Scale. RESULTS A total of 31 patients underwent coiling in the acute phase with the intention to undergo flow diversion at a later date. The mean aneurysm size was 15.8 ± 7.9 mm. Of the 31 patients undergoing coiling, 4 patients could not undergo further flow-diverter therapy: 3 patients (9.7%) died of complications of subarachnoid hemorrhage and 1 patient had permanent morbidity as a result of perioperative ischemic stroke (3.1%). Twenty-seven patients underwent staged placement of flow diverters after adequate recovery. The median time to treatment was 16 weeks. There was one case of aneurysm rebleeding following coil treatment. There were no cases of permanent morbidity or mortality resulting from flow-diverter treatment. Twenty-four patients underwent imaging follow-up; 18 of these patients had aneurysms that were completely or nearly completely occluded (58.1% on an intent-to-treat basis). At last follow-up (mean 18.3 months), 25 patients had mRS scores ≤ 2 (80.6% on an intent-to-treat basis). CONCLUSIONS Staged treatment of ruptured complex and giant intracranial aneurysms with coiling in the acute phase and flow-diverter treatment following recovery from SAH is both safe and effective. In this series, no cases of rebleeding occurred during the interval between coiling and flow diversion. This strategy should be considered as a valid option in patients presenting with these challenging ruptured aneurysms.
authors.affiliation: Departments of 1 Radiology and.
authors.forename: Waleed
authors.initials: W
authors.lastname: Brinjikji
authors.affiliation: Department of Radiology, Hospital Niguarda, Milan; and.
authors.forename: Mariangela
authors.initials: M
authors.lastname: Piano
authors.affiliation: Mayo Medical School, Mayo Clinic, Rochester, Minnesota, Mayo Clinic, Rochester, Minnesota;
authors.forename: Shanna
authors.initials: S
authors.lastname: Fang
authors.affiliation: Department of Radiology, Hospital Niguarda, Milan; and.
authors.forename: Guglielmo
authors.initials: G
authors.lastname: Pero
authors.affiliation: Departments of 1 Radiology and.|Neurologic Surgery and.
authors.forename: David F
authors.initials: DF
authors.lastname: Kallmes
authors.affiliation: Department of Radiology, Hospital Niguarda, Milan; and.
authors.forename: Luca
authors.initials: L
authors.lastname: Quilici
authors.affiliation: Department of Radiology, Hospital Niguarda, Milan; and.
authors.forename: Luca
authors.initials: L
authors.lastname: Valvassori
authors.affiliation: Department of Radiodiagnostics, Gemelli Hospital, Rome, Italy.
authors.forename: Emilio
authors.initials: E
authors.lastname: Lozupone
authors.affiliation: Departments of 1 Radiology and.|Neurologic Surgery and.
authors.forename: Harry J
authors.initials: HJ
authors.lastname: Cloft
authors.affiliation: Department of Radiology, Hospital Niguarda, Milan; and.
authors.forename: Edoardo
authors.initials: E
authors.lastname: Boccardi
authors.affiliation: Departments of 1 Radiology and.|Neurologic Surgery and.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Lanzino
mesh_terms: D000328:Adult; D000368:Aged; D017542:Aneurysm, Ruptured / Q000000981:diagnostic imaging / Q000628:therapy*; D002533:Cerebral Angiography; D015331:Cohort Studies; D004621:Embolization, Therapeutic; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome
keywords: ICA = internal carotid artery; PED = Pipeline Embolization Device; SAH = subarachnoid hemorrhage; WFNS = World Federation of Neurosurgical Societies; aneurysm; coil; flow diverter; mRS = modified Rankin Scale; vascular disorders