Abciximab in patients with ruptured intracranial aneurysms

Abstract

Background and purpose: Experience with intravenous abciximab to manage thromboembolism during treatment of ruptured intracranial aneurysms is limited. We present our experience in 13 patients.

Methods: We retrospectively reviewed all patients with thromboembolic complications during endovascular management of ruptured intracranial aneurysms. Thromboembolic complications were treated with intravenous abciximab. We recorded patient and aneurysm demographics, aneurysm occlusion, drug therapy, complications, and outcomes.

Results: World Federation of Neurological Surgeons Grades were 1 or 2 in 11 patients (85%). Median time from diagnostic angiography to treatment was 1 day. Ten (77%) aneurysms involved the anterior or posterior communicating artery, and one each occurred in the posterior inferior cerebellar artery, middle cerebral artery, and basilar regions. Eleven aneurysms were <10 mm. Five were incompletely occluded (0%-90% treated) at the time of the complication. Thromboembolic complications were at the coil-ball/parent-artery interface in nine patients (69%). Two were associated with coil-loop prolapse; one was prophylactically treated without evidence of thromboembolism. Five patients (38%) had distal complications; one also had a proximal thrombus. All patients received an intravenous bolus of abciximab (5-10 mg in 92%) without infusion. Postprocedural recanalization was complete in eight (62%) and partial in four (31%). Eleven patients (85%) had a Glasgow Outcome Scale score of 1 at 3 months. One had a poor outcome (GOS4). One died following additional coiling after abciximab administration, though this intervention was uneventful in three others.

Conclusion: Abciximab completely or partially treated thromboembolic complications arising during coiling of ruptured aneurysms. Further coiling should be performed with extreme caution and needs to be decided on a patient-by-patient basis.

Fig 1.

Anteroposterior oblique views, selective right ICA injection. A, Right PCOM aneurysm in association with fetal-type PCA after the insertion of six coils. Image shows minor projection of coils into the terminal ICA (arrow), which demonstrates spasm. Contrast material irregularly fills the proximal ACA, with nonvisualization of the distal ACA. These findings are consistent with thrombus (arrowhead). B, Immediately after the intravenous injection of abciximab 20 mg, the A1 segment of the ACA (arrowhead) is completely recanalized. Minor filling defect in the proximal A2 (arrow) dissipated shortly afterward.

Fig 2.

Anteroposterior views. A and B, Selective right ICA injection after the insertion of three coils. Before abciximab treatment (A), thrombus is seen at the neck of the aneurysm (arrowhead) and in the proximal right A2 segment of the right anterior cerebral artery (arrow). After abciximab (B), improvement in both is noted. C and D, Selective injection after the insertion of five coils and aneurysm rupture. In C, thrombus (arrow) is present in the distal A1 segment and ACOM, with adjacent extravasation of contrast material (arrowhead). After heparin reversal, repeat angiogram in D demonstrates aneurysm occlusion, cessation of extravasation, and absence of thrombus, but marked vasospasm is present.