Outcomes after aneurysm rupture during endovascular coil embolization

OBJECTIVE: Intracranial aneurysm rupture during placement of Guglielmi deta chable coils has been reported, but the management and consequences of this event have not been extensively described. We present our experience with this feared complication and report possible neuroradiological and neurosur gical interventions to improve outcomes. METHODS: We retrospectively reviewed the records for 701 patients with 734 intracranial aneurysms that were treated with endovascular coiling, during a 6-year period, in the metropolitan Minneapolis-St. Paul (Minnesota) area. This analysis revealed 10 cases of perforation during coiling. The managem ent and outcomes were recorded, and the pertinent literature was reviewed. RESULTS: All 10 cases involved previously ruptured aneurysms. This complica tion occurred sporadically and was not observed in the first 100 cases. Per foration occurred during microcatheterization of the aneurysm in two cases and during coil deposition in eight cases. Seven of the perforated aneurysm s were located in the anterior circulation and three in the posterior circu lation. Six of the 10 patients made good or fair recoveries; all three pati ents with posterior circulation lesions died immediately after rehemorrhage . Elevated intracranial pressure (ICP) was noted for all five patients with intraventricular catheters in place. Bilateral pupil dilation and profound hemodynamic changes were noted for eight patients. Coiling was rapidly com pleted, and total or nearly total occlusion was achieved in all cases. Emer gency ventriculostomy was performed to rapidly reduce increased ICP for two patients, both of whom made good recoveries. Hemodynamic and angiographic factors after perforation, such as prolonged systemic hypertension, persist ent dye extravasation after deployment of the first Guglielmi detachable co il, and persistent prolongation of contrast dye transit time (suggesting on going ICP elevation), were correlated with poor outcomes. CONCLUSION: Previously ruptured aneurysms seem to be more susceptible to en dovascular treatment- related perforation than are unruptured lesions. Wors e prognoses are associated with iatrogenic rupture during coiling of poster ior circulation lesions, compared with those in the anterior circulation. W hen perforation is recognized, the definitive treatment seems to be reversa l of anticoagulation therapy and completion of Guglielmi detachable coil em bolization. Immediate neurosurgical intervention is limited in these cases and focuses on decreasing ICP via emergency ventriculostomy. However, these measures may be life-saving, and neurosurgical assistance must be readily available during treatment of these cases.