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Neuroform Atlas stent-assisted coiling of ruptured intracranial aneurysms: A multicenter study - 03/04/20

Doi : 10.1016/j.neurad.2020.02.006 
Riccardo Russo a, , Gianni Boris Bradac b, Lucio Castellan c, Ivan Gallesio d, Diego Garbossa e, Giuseppe Iannucci f, Dikran Mardighian g, Roberto Menozzi h, Antonio Pitrone i, Giuseppe Romano j, Fabrizio Venturi b, Mauro Bergui b
a Department of Surgical Sciences, Radiology Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, corso bramante 88, Turin, Italy 
b Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy 
c Neuroradiology Unit, IRCCS San Martino University Hospital, Genoa, Italy 
d Department of Radiology, Neuroradiological Unit, Azienda ospedaliera “SS Antonio e Biagio e C. Arrigo”, Alessandria, Italy 
e Department of Neuroscience, Neurosurgery Section, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy 
f Neuroradiology Unit, San Bortolo Hospital, Vicenza, Italy 
g Neuroradiology Unit, Spedali Civili di Brescia, Brescia, Italy 
h Interventional Neuroradiology Unit, Azienda Ospedaliera Universitaria, Parma, Italy 
i Neuroradiology Unit, Biomedical Sciences and of Morphologic and Functional Images, AOU Policlinico G. Martino, Messina, Italy 
j Neuroradiology Unit, S. Croce e Carle Hospital, Cuneo, Italy 

Corresponding author.
Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Friday 03 April 2020

Highlights

Stent-assisted coiling of ruptured intracranial aneurysms is a feasible option in selected cases.
Peri- and post-procedural medical treatment regimen is still controversial.
Bail-out AntiGP2b3a are extremely effective in achieving complete flow restoration after stent thrombosis without increasing overall complication rate.

Le texte complet de cet article est disponible en PDF.

Abstract

Purpose

To assess efficacy, safety and to discuss optimal medical therapy of stent-assisted coiling of ruptured intracranial aneurysms.

Methods

Ruptured intracranial aneurysms treated with stent-assisted coiling in eight different institutions were retrospectively reviewed. Medical treatment regimens varied among the centers, mainly regarding heparin administration and post-procedural single or double antiplatelet therapy. Clinical and angiographic results, including complications and outcomes were analyzed and related to the different therapies.

Results

Sixty-one consecutive patients (male/female 23/38), aged 59.1 years (36–86) underwent stent-assisted coiling for ruptured intracranial aneurysm without antiplatelet pre-medication. Intravenous acetylsalicylic acid (ASA) 500mg was administered to all patients immediately after stent deployment. At the same time heparin was given as bolus in 15 patients (24.6%) as part of local protocol. Intravenous glycoprotein 2b/3a inhibitors (antiGP2b3a) were used as bail-out therapy for stent thrombosis. Stent thrombosis occurred in 22 patients (36.1%), of which 4 (6.5%) lead to incomplete and 18 (29.6) to complete occlusion of the stent. Heparin administration had no effect on thrombosis rate. Thrombosis resolution occurred in all cases with intravenous antiGP2b3a (7 tirofiban, 15 abciximab), without increasing overall complication rate. Single antiplatelet therapy with ASA (28 patients, 45.9%) or double antiplatelet therapy including ASA and clopidogrel (33 patients, 54.1%) were administered after procedure, depending on local protocols and on neurointerventionists’ experience. Overall complication rate, including ischemia and hemorrhage was higher in patients in which only ASA was administered (21.4% vs. 12.1%). No late stent thrombosis was seen, regardless of whether a single or double antiplatelet regimen was used. Nevertheless, the small sample size suggests caution in interpreting these results. Moreover, a possible bias may arise from the decision whether to modify the maintenance therapy or not depending on the severity of the intracranial hemorrhage in a case-by-case assessment. At three months, 34 out of 38 patients with HH grade 1-2 (89.4%), and 11 out of 23 with Hunt-Hess grade of 3-4 (47.8%) were independent (Modified Ranking Scale 0-2).

Conclusion

Stent assisted coiling of ruptured intracranial aneurysms is a feasible option when simple coiling is not possible. Optimal medical treatment is still controversial because balance between hemorrhagic and ischemic risks is difficult to evaluate. In our series, heparin bolus had no effect on subsequent stent thrombosis. In all cases peri-operative stent thrombosis was successfully managed using bail-out intravenous antiGP2b3a, which did not increase post-procedural hemorrhage rates. A non-significant trend towards increased complications rate was noticed in patients treated with single antiplatelet therapy versus double antiplatelet therapy.

Le texte complet de cet article est disponible en PDF.

Keywords : Ruptured intracranial aneurysms, Endovascular treatment, Stent-assisted coiling, Optimal medical therapy


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