Aneurysmal rupture during embolization with Guglielmi detachable coils: causes, management, and outcome

Abstract

Background and purpose: Aneurysmal rupture during endovascular treatment is one of the most feared complications of endovascular aneurysm therapy. The purpose of this study was to determine the frequency, causes, management, and outcome of aneurysmal rupture that occurred during treatment with Guglielmi detachable coils (GDCs) in an unselected series of patients with ruptured cerebral aneurysms.

Methods: Between July 1997 and December 2000, we treated 164 acutely ruptured cerebral aneurysms with GDCs. All charts were reviewed, and patients with aneurysmal rupture occurring during embolization were identified.

Results: Five patients had an intraprocedural aneurysmal rupture. In one patient, rupture was due to guidewire perforation of the wall. In two patients, the microcatheter itself perforated the aneurysm. In another two patients, rupture occurred during placement of the first coil. Endovascular packing was continued in all patients. One patient died as a result of the aneurysmal rupture. No negative long-term effects were observed in the remaining four patients. In summary, we observed intraprocedural aneurysmal rupture in 3% of our patients, with a mortality rate of 20% and no long-term morbidity.

Conclusion: Aneurysmal rupture during endovascular treatment with GDCs is a rare event; clinical severity may be variable. Embolization of the aneurysm can be continued in most cases, and most patients with treatment-related subarachnoid hemorrhage survive without serious sequelae.

fig 1.

Case 1. A, Lateral projection arteriogram of the left internal carotid artery reveals a posterior communicating artery aneurysm. B, Lateral projection arteriogram of the left internal carotid artery, obtained immediately after aneurysm rupture that occurred after placement of the first coil, shows the rupture and massive extravasation of contrast material. C, Selective angiogram obtained via the microcatheter. D, Axial view CT scan obtained after clip placement in the aneurysm shows massive brain edema and contrast agent in the subarachnoid space.

fig 2.

Case 2. A, Frontal projection arteriogram of the left vertebral artery shows a basilar tip aneurysm. B, Frontal projection arteriogram of the right vertebral artery, obtained after placement of two GDCs, reveals slight extravasation of contrast material (magnification). C, Frontal projection arteriogram of the left vertebral artery shows complete embolization of the basilar artery tip aneurysm. D, Axial view CT scan depicts slight extravasation of contrast agent and blood.

fig 3.

Case 3. A, Frontal projection arteriogram of the right internal carotid artery shows a small, caudally oriented anterior communicating artery aneurysm. B and C, Arteriograms of the right internal carotid artery, obtained after placement of one GDC, show that the coil partially protrudes into the subarachnoid space. D, Axial CT scan, obtained before endovascular treatment, shows SAH and extravasation of contrast material after aneurysm perforation. E, Axial CT scan, obtained after endovascular treatment, shows SAH and extravasation of contrast material after aneurysmal perforation. F, Control angiogram, obtained 4 wk after endovascular treatment, reveals the aneurysm remnant.

fig 4.

Case 5. A–C, Frontal projection arteriograms of the right internal carotid artery show an anterior communicating artery aneurysm before and after placement of three GDCs, with complete occlusion of the aneurysm. D and E, Time-of-flight MR angiograms, obtained 2 d after endovascular treatment, confirm complete occlusion and do not reveal any thrombosed portions of the aneurysm.