Ahead of Print: Stent-Coiling of Ruptured Wide-Necked Aneurysms
Background: Stent-assisted coiling in the setting of subarachnoid hemorrhage remains controversial. Currently, there is a paucity of data regarding the utility of this procedure and the risks of hemorrhagic and ischemic complications.
Objective: To assess the utility of stent-assisted coil embolization and pretreatment with antiplatelet agents in the management of ruptured wide-necked aneurysms.
Methods: A retrospective study of 65 patients with ruptured wide-necked aneurysms treated with stent-assisted coiling. Patients with hydrocephalus or a Hunt and Hess grade >= III received a ventriculostomy prior to endovascular intervention. Patients were treated intraoperatively with 600 mg of clopidogrel and maintained on daily doses of 75 mg of clopidogrel and 81 mg of aspirin. The Glasgow outcome scale (GOS) score was recorded at the time of discharge. We identified major bleeding complications secondary to antiplatelet therapy and cases of in-stent thrombosis that required peri-procedural thrombolysis.
Results: 66.2 % of aneurysms arose within the anterior circulation. 69.2 % of patients presented with hydrocephalus or a Hunt and Hess grade >= III and required a ventriculostomy. A good outcome (GOS of 4 or 5) was achieved in 63.1 % of patients, and the overall mortality rate was 16.9 %. There were 10 (15.38%) major complications associated with bleeding secondary to antiplatelet therapy (5 patients, 7.7 %) or intraoperative in-stent thrombosis (5 patients, 7.7 %). Three (4.6 %) patients suffered a fatal hemorrhage.
Conclusion: Our findings suggest that stent-assisted coiling and routine treatment with antiplatelet agents is a viable option in the management of ruptured wide-necked aneurysms.
From: Stent-Assisted Coiling of Wide-Necked Aneurysms in the Setting of Acute Subarachnoid Hemorrhage: Experience in 65 Patients by Amenta et al.
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In my experience of the remodeling technique in acutely ruptured aneurysms, the balloon-assisted coiling has a lower complication rate than stent-assisted coiling, due to the occuence of parenchymal bleeding secondary antiplatelet therapy with 4.6 % of fatal trombosis. Acute thrombus of stent is another aspect that makes this technique riskier. For these reasons, I don’t agree with the conclusions of this study.
salvatore Mangiafco
March 19, 2012 at 5:19 PM