Thromboembolic Events Associated with Coil Protrusion into Parent Arteries after GDC Treatment

Abstract

Aneurysm embolization using Guglielmi detachable coils(GDC) is gaining acceptance as a viable alternative to surgery in the treatment of cerebral aneurysms. During GDC treatment of cerebral aneurysms, thromboembolic events are the most frequent complications. As risk factors of thromboembolic events, large aneurysms, wide-necked aneurysms, use of the balloon-assisted technique and protruding coils into the parent arteries are previously reported. From March, 1997 till August, 2004, 270 consecutive patients were treated with GDC embolization at our institute. Fourteen (5.2%) patients with 14 aneurysms of these 270 patients presented with protruding coils into the parent vessels.

Twelve aneurysms of these 14 aneurysms were small (diameter <10 mm), and two were large (diameter 15 mm). Nine aneurysms had small necks (neck diameter <4 mm), and five had wide necks(neck diameter >4 mm). The fundus-toneck ratio ranged from 1.04 to 2.78, with an average of 1.53.

In this series, ten patients (71%) were treated with balloon-remodelling technique because every patient had either a wide-necked aneurysm or complicated morphologic factors. These 14 aneurysms were divided into two groups according to the mode of coil protrusion, loop type and tail type protrusion. The first coil was protruded in five (36%) cases of 14 patients, four of these five cases presented with the loop type protrusion. The last coil was protruded in seven cases (50%), Five of these seven cases presented with the tail type protrusion. Diffusion-weighted imaging abnormalities were found for seven (50%) of 14 patients within 24 hours of the coiling procedures. Three (21%) of 14 patients showed small lesions (< 5 mm) in the subcortical white matter at the border zone or perforating regions. In four (29%) patients, large territorial infarctions (>5 mm) were detected. Symptomatic complications occurred in four (29%) patients, and all of these four patients presented the loop type protrusion. One patient who had small infarctions experienced minimal deficits (slight motor weakness, quadrantic hemianopsia) after six days postprocedure and fully recovered by discharge after stronger systemic heparinization (24000U, for three days), aspirin (100 mg/day) and Ticlopidine (100 mg/day). Three patients who had large territorial infarctions experienced moderate deficits.

Two patients were treated with stronger systemic heparinization and one with Argatroban (60 mg/day, for two days), and following aspirin (100 mg/day) and Ticlopidine (100 mg/day). Finally, two patiens were discharged with permanent minimal deficits (hypoesthesia only) and one with moderate hemiparesis. The infarctions related to the GDC procedures were more common sequelae in wide-necked aneurysms and coil protrusions, especially loop type protrusion. Although permanent neurological deficits were rare, the high rate of thromboembolic events associated with coil protrusion suggest that more aggressive medical treatment should be considered.

Keywords

coil protrusion thromboembolic events DW imaging

Get full access to this article

View all access options for this article.

References

Guglielmi

Viñuela

: Electrothrombosis of saccular aneurysms via endovascular approach, 2: Preliminary clinical experience. J Neurosurg. 75: 8–14, 1991.

Viñuela

Duckwiler

: Guglielmi detachable coil embolization of acute intracranial aneurysm: Perioperative anatomical and clinical outcome in 403 patients. J Neurosurg 86: 475–482, 1997.

Malisch

Guglielmi

: Intracranial aneurysms treated with Guglielmi detachable coil: Midterm clinical results in a consecutive series of 100 patients. J Neurosurg 87: 176–183, 1997.

Murayama

Viñuela

: Embolization of incidental cerebral aneurysm by using the Guglielmi detachable coil system. J Neurosurg 90: 207–214, 1999.

Qureshi

Suri

: Endovasucular treatment of intracranial aneurysms by using Guglielmi detachable coils in awake patients: Safety and feasibility. J Neurosurg 94: 880–885, 2001.

Pelz

Lownie

: Thromboembolic events associated with treatment of cerebral aneurysms with Guglielmi detachable coils. Am J Neuroradiol 19: 1541–1547, 1998.

Klotzsch

Nahser

: Detection of microemboli distal to cerebral aneurysms before and after therapeutic embolization. Am J Neuroradiol 19: 1315–1318, 1998.

Nelson

Levy

: Balloon-assisted coil embolization of wide-necked aneurysms of the internal carotid artery: Medium-term angiographic and clinical follow-up in 22 patients. Am J Neuroradiol 22: 19–26, 2001.

Rordorf

Bellon

: Silent thromboembolic events associated with the treatment of unruptured cerebral aneurysms by use of Guglielmi detachable coils: Prospective study applying Diffusion-Weighted imaging. Am J Neuroradiol 22: 5–10, 2001.

10.

Workman

Cloft

: Thrombus formation at the neck of cerebral aneurysms during treatment with Guglielmi Detachable Coils. Am J Neuroradiol 23: 1568–1576, 2002.

11.

Derdeyn

Cross

III : Postprocedure ischemic events after treatment of intracranial aneurysms with Guglielmi detachable coils. J Neurosurg 96: 837–843, 2002.

12.

Biondi

Oppenheim

: Cerebral aneurysms treated by Guglielmi detachable coils: Evaluation with diffusion-weighted MR imaging. Am J Neuroradiol 21: 957–963, 2000.

13.

Soeda

Sakai

: Thromboembolic Events Associated with Guglielmi Detachable Coil Embolization of asymptomatic cerebral aneurysms: Evaluation of 66 consecutive cases with use of Diffusion-Weighted MR imaging. Am J Neuroradiol 24: 127–132, 2003.

14.

Soeda

Sakai

: Thromboembolic events associated with Guglielmi detachable coil embolization with use of Diffusion-Weighted imaging. Part II. Detection of the microemboli proximal to cerebral aneurysm. Am J Neuroradiol 24: 2035–2038, 2003.

15.

Albayram

Selcuk

: Thromboembolic events associated with balloon-assisted coil embolization: Evaluation with Diffusion-Weighted MR imaging. Am J Neuroradiol 25: 1768–1777, 2004.