Introduction: Thromboembolic events causing neurologic deficits are the most common neurologic complication of coiling ruptured aneurysms. Systemic heparinization is sometimes used to avoid thrombosis, though concern exists this could increase the risk of re-rupture or intracerebral hemorrhage. Few studies have examined the impact of systemic heparinization vs. none in coiling of ruptured aneurysms.
Methods: We performed a retrospective review of a prospectively maintained database of all consecutive aneurysmal subarachnoid hemorrhage (SAH) treated with coiling over a 10-year period at our tertiary care center. Operative reports and anesthesia records were searched for use of periprocedural systemic heparinization, as well as parent vessel thrombosis or re-rupture noted intraprocedurally. Patients were classified into those treated with systemic heparinization and those treated without.
Results: We identified 226 patients who underwent coiling of ruptured aneurysms during the study period, including 73 (32%) with periprocedural systemic heparinization and 153 (68%) without. The mean aneurysm size in patients treated with systemic heparinization was 8.3mm, compared to 6.8mm in the no heparin group (p=0.02). Of patients treated with systemic heparinization, 46 (63%) received pre-procedural ventriculostomy placement, compared to 114 (75%) in the no heparin group (p=0.05). Eight patients had intraprocedural parent vessel thrombosis noted during coiling, including 1/73 in the systemic heparin group (incidence rate 1.4%, 95%CI 0.1-6.8) and 7/153 in the no heparin group (incidence rate 4.5%, 95%CI 2.0-9.1, p=0.26). There were three intraoperative re-ruptures, all of which occurred in patients not receiving systemic heparinization, with no intraoperative re-rupture noted in the systemic heparin group.
Conclusions: SAH coiling patients treated with systemic heparinization had larger aneurysms and were less likely to have pre-procedural ventriculostomy placement. Systemic heparin during SAH coiling does not appear to increase re-rupture rate and may decrease thrombotic events, though further studies are needed to demonstrate efficacy.
Patient Care: Significant practice variation exists between practitioners in use of systemic heparin during coiling of ruptured aneurysms; understanding the risks and benefits of either method may inform decision-making.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Discuss parent vessel thrombosis rates for coiling of ruptured aneurysms with and without systemic heparin.
2) Discuss the risk of rehemorrhage with systemic heparin use during coiling of ruptured aneurysms
References: van Rooij WJ, Sluzewski M, Beute GN, Nijssen PC. Procedural complications of coiling of ruptured intracranial aneurysms: incidence and risk factors in a consecutive series of 681 patients. American Journal of Neuroradiology. 2006;27:1498–1501.