Thrombus formation during intracranial aneurysm coil placement: treatment with intra-arterial abciximab

Abstract

Background and purpose: The management of thrombus formation during coil placement in an intracranial aneurysm is important in minimizing periprocedural morbidity and mortality. We report on seven cases in which the primary treatment for thrombus formation during such coil placement was intra-arterial abciximab infusion.

Methods: Clinical and radiologic records of 100 consecutive patients who underwent coil placement in intracranial aneurysms at our institution during a 1-year period were reviewed. We identified seven cases (four ruptured aneurysms, three unruptured aneurysms) in which thrombus formation occurred during the procedure.

Results: Intra-arterial abciximab infusion, up to 5 mg, completely dissolved the thrombus in four of seven patients and almost completely dissolved it in two. In one patient with distal emboli, recanalization was not achieved. In two patients, an intravenous bolus of abciximab without 12-hour infusion was also given adjunctively. In one patient, leakage of contrast material occurred; this was related to the intra-arterial infusion. Clinically, no new neurologic deficits were directly related to the intra-arterial abciximab infusion. Six patients had good clinical outcome, and one patient died.

Conclusion: Relatively low-dose, intra-arterial abciximab infusion can immediately dissolve an acute thrombus that forms during intracranial aneurysm coil placement. Although neither the optimal dose of intra-arterial abciximab nor the need to supplement the intra-arterial infusion with intravenous administration was established, we preliminarily found that low-dose intra-arterial abciximab infusion may be relatively effective and safe in this setting, even in patients with acute subarachnoid hemorrhage.

Fig 1.

Illustrative case 1. A, Right internal carotid artery angiogram, oblique projection, unsubtracted, shows a coil loop protruding into the parent vessel. B, Right internal carotid artery angiogram, oblique projection, subtracted view, shows a filling defect about the coil loop, indicating thrombus formation. Note the decreased antegrade flow into the supraclinoid internal carotid artery. C, Right internal carotid artery angiogram obtained via a microcatheter injection. The image clearly shows the filling defects about the protruded coil loop and more distally. D, After a local, low-dose (2-mg), intra-arterial infusion of abciximab through the microcatheter, thrombus dissolution is documented without evidence of distal thromboembolism.

Fig 2.

Illustrative case 2. A, Nonenhanced CT scan shows subarachnoid hemorrhage and ventricular prominence. B, Right internal carotid artery angiogram, frontal projection, shows a heart-shaped anterior communicating artery aneurysm pointing inferiorly, with filling of both anterior cerebral arteries through the anterior communicating artery. C, Right internal carotid artery angiogram, frontal projection, shows frank extravasation of contrast material during deployment of the first coil. D, Right internal carotid artery angiogram, frontal projection, obtained after coil placement inf the aneurysm shows no further extravasation of contrast agent. However, both anterior cerebral arteries no longer fill. E, Right anterior cerebral artery angiogram, with a manual injection via a microcatheter, lateral projection, shows a paucity of branch filling consistent with extensive thromboembolism. F, Right anterior cerebral artery angiogram, with a manual injection via a microcatheter, lateral projection, after local low-dose intra-arterial infusion of 5 mg of abciximab through the microcatheter, shows recanalization of the anterior cerebral artery branches. G, Right internal carotid artery angiogram, frontal projection, after aneurysm rupture, aneurysm coil placement, and thrombolysis with intra-arterial ReoPro shows no filling of the anterior communicating artery aneurysm and normal filling of both anterior cerebral arteries.