Thrombus formation at the neck of cerebral aneurysms during treatment with Guglielmi detachable coils

Abstract

Background and purpose: Thromboembolic events are a common source of complications during Guglielmi detachable coil (GDC) treatment of intracranial aneurysms. Thrombus formation at the coil-parent artery interface is not commonly reported but is an important potential source of emboli. We describe nine cases in which thrombus propagated from GDCs into the parent artery during coil therapy of cerebral aneurysms and subsequent treatment of the thrombus.

Methods: A retrospective review of a procedural database was performed to identify cases in which thrombus occurred during GDC treatment of cerebral aneurysms during a 30-month period. All images were reviewed at the time of the procedure. Nine cases of thrombus forming at the coil-parent artery interface and five cases of distal emboli were identified among 210 cases. All patients underwent anticoagulation with heparin during GDC treatment procedures.

Results: Thrombus was identified at the coil-parent artery interface during GDC treatment in nine (4.3%) of 210 cases. In each case, the thrombus was recognized before distal embolic complication occurred and was successfully treated with heparin alone (five patients) or with heparin plus a glycoprotein IIb-IIIa inhibitor (four patients).

Conclusion: Potential clinical complications can be avoided by early recognition of thrombus at the coil-parent artery interface and by administering appropriate medical therapy.

Fig 1.

Images from the case of a 54-year-old female patient with giant ophthalmic artery aneurysm remnant. A, Right internal carotid artery injection, oblique projection. Mask artifact outlines the margin of the dense coil pack filling the giant ophthalmic artery aneurysm. The first coil has been detached within the remnant at the aneurysm base (black arrow). Note GDCs within a previously embolized middle cerebral artery bifurcation aneurysm (arrowhead). B, After completion of the embolization procedure, control angiogram shows a small, poorly marginated, hazy opacity at the coil-parent artery interface, suggesting early thrombus formation (arrow). C, Repeat angiogram obtained 25 minutes later shows marked increase in thrombus burden at the coil surface and in the parent artery. D, Forty minutes after the administration of the abciximab bolus, near-complete resolution of thrombus at the coil surface can be seen.

Fig 2.

Images from the case of a 49-year-old male patient with a basilar tip aneurysm. A, Angiogram of the left vertebral artery, transfacial projection. The basilar tip aneurysm is packed with GDCs (short arrows). A linear filling defect with hazy margins, consistent with thrombus, is present in the distal basilar artery and extends into the right P1 segment (long arrows). B, Angiogram of the left vertebral artery, transfacial projection. After 24 hours of heparin infusion, follow-up angiogram obtained after GDC treatment shows resolution of thrombus. However, there is partial recanalization of the aneurysm centrally.

Fig 3.

Images from the case of a 57-year-old female patient with a superior hypophyseal artery aneurysm. A, Control angiogram of the right internal carotid artery, contralateral transorbital oblique projection. The superior hypophyseal artery aneurysm is tightly packed with GDCs (arrowheads). Thrombus has formed at the coil-parent artery interface, manifesting as a filling defect with a lobular contour with hazy margins (white arrow). B, Control angiogram obtained 10 minutes after the administration of the Integrilin bolus shows resolution of thrombus at the coil-parent artery interface.