Early rebleeding after coiling of ruptured cerebral aneurysms: incidence, morbidity, and risk factors

Abstract

Background and purpose: The purpose of this study was to assess the incidence of early rebleeding after coiling of a ruptured cerebral aneurysm, assess the clinical outcome, and identify risk factors for this event.

Methods: Early rebleedings occurred in 6/431 (1.4%) consecutive patients after coiling of a ruptured aneurysm. Clinical condition at the time of treatment, aneurysm location and size, initial aneurysm occlusion, timing of coiling, and the presence of an adjacent intracerebral hematoma in the six patients with early rebleedings were compared with the remaining 425 patients.

Results: Incidence of early rebleeding after coiling of a ruptured aneurysm was 1.4%, and mortality was 100%. Independent risk factors are the presence of an adjacent intracerebral hematoma and small aneurysm size. Dependent risk factors are location on the anterior communicating artery, initial incomplete aneurysm occlusion, and poor clinical condition at the time of treatment.

Conclusion: Early rebleeding after coiling of ruptured aneurysms is a major concern, in particular because the mortality is very high. A more restricted postembolization anticoagulation strategy in high-risk aneurysms may possibly prevent the occurrence of this devastating event.

Fig 1.

Serial angiograms of patient 5, a 53-year-old man in poor clinical condition after SAH. A, Diagnostic angiogram 1 day after SAH, showing a very small aneurysm on the anterior communicating artery with a filling defect (thrombus) in the fundus. The aneurysm was judged to be too small for coil treatment. B, Angiogram 11 days later, showing disappearance of the fundal thrombus and enlargement of the aneurysm lumen. C, Complete occlusion after coiling. D, Angiogram after rebleeding 10 days after coiling, showing further enlargement of the aneurysm lumen with migration of the coils resulting in incomplete aneurysm occlusion. E and F, Subtracted (E) and unsubtracted (F) angiogram after second coiling, showing near-total occlusion. G and H, Subtracted (G) and unsubtracted (H) angiogram after second rebleeding 25 days after second coiling, again showing further enlargement of the aneurysm with migration of the coils.

Fig 2.

Patient 2, a 68-year-old man with HH III SAH. A, CT scan on admission shows small interhemispheric hematoma. B, Angiogram on the day of admission shows small anterior communicating artery aneurysm pointing upward. C, Pre-embolization angiogram 6 days later shows enlargement of the aneurysm thought to be caused by pseudoaneurysm formation. Note vasospasm in anterior and middle cerebral artery. D—F, Lateral views before (D) and after (E and F) coiling, demonstrating a small neck remnant. There are no coils in the pseudoaneurysm. Note stasis of contrast agent in the pseudoaneurysm (F). G and H, CT scan 16 days later, showing rebleeding and hydocephalus.