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  • Staged Endovascular Treatment of Ruptured Intracranial Aneurysms: Acute Coiling Followed By Delayed Flow Diversion

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    Erick Michael Westbroek MD; Matthew Bender MD; Narlin B. Beaty MD; Bowen Jiang MD; Risheng Xu AB AM MD PhD; Jessica K. Campos MD; Rafael Jesus Tamargo MD; Judy Huang MD; Geoffrey P. Colby MD, PhD, FAANS; Alexander L. Coon MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: ISAT demonstrated that coiling is effective for aneurysm treatment in subarachnoid hemorrhage (SAH); however, complete occlusion of wide-necked aneurysms frequently requires adjuvants relatively contraindicated in SAH. As such, a limited “dome occlusive” strategy is often pursued in the setting of SAH. We report a single institution series of coiling of acutely ruptured aneurysms followed by delayed flow diversion for definitive, curative occlusion.

    Methods: A prospectively collected IRB-approved database was screened for patients with aneurysmal SAH who were initially treated by coil embolization followed by planned flow diversion at a single academic medical institution. Peri-procedural outcomes, complications, and angiographic follow-up were analyzed.

    Results: 50 patients underwent both acute coiling followed by delayed, planned flow diversion. Average aneurysm size on initial presentation was 9.5mm. Common aneurysm locations included Pcomm (36%), Acomm (30%), MCA (10%), ACA (10%), and vertebral (5%). Dome occlusion was achieved in all cases following initial coiling. Second-stage implantation of a flow diverting stent was achieved in 49/50 cases (98%). Follow-up angiography was available for 33/50 patients (66%), with mean follow-up of 11 months. 27 patients (82%) had complete angiographic occlusion at last follow up. All patients with residual filling at follow-up still had dome occlusion. There were no mortalities (0%). Major complication rate for stage I coiling was 2% (1 patient with intra-procedural aneurysm re-rupture causing increase in a previous ICH). Major complication rate for stage 2 flow diversion was 2% (1 patient with ischemic stroke following noncompliance with dual antiplatelet regimen). Minor complications occurred in 2 additional patients (4%) with transient neurological deficits.

    Conclusions: Staged endovascular treatment of ruptured intracranial aneurysms with acute dome-occlusive coil embolization followed by delayed flow diversion is a safe and effective treatment strategy.

    Patient Care: Expanding the scope of endovascular management of acutely ruptured intracranial aneurysms

    Learning Objectives: Endovascular management of acutely ruptured aneurysms.


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