Late rebleeding of ruptured intracranial aneurysms treated with detachable coils

Abstract

Background and purpose: The purpose of this study was to assess the incidence of late rebleeding of ruptured intracranial aneurysms treated with detachable coils.

Patients and methods: A clinical follow-up study was conducted in 393 consecutive patients with a ruptured aneurysm treated with detachable coils between January 1995 and January 2003. Late rebleeding was defined as recurrent hemorrhage from a coiled aneurysm >1 month after coiling. One patient was lost to follow-up. Total clinical follow-up of the 392 patients who were coiled for ruptured cerebral aneurysms was 18,708 months (1559 patient years; median, 48 months; mean, 47.7 months; range, 0-120 months).

Results: Four patients suffered late rebleeding from the coiled aneurysm at 8, 12, 30, and 40 months after coiling, respectively. Two of these patients died. Another patient died of probable rebleeding 4 months after coiling. The incidence of late rebleeding was 1.27% (5/393) and mortality of late rebleeding was 0.76% (3/393). The annual late rebleeding rate was 0.32%, and the annual mortality rate from late rebleeding was 0.19%. During the follow-up period, 53 coiled aneurysms in 53 patients (13%) were additionally treated: 35 aneurysms (8.9%) were additionally treated with coils, 16 aneurysms (4.1%) were additionally clipped, and 2 aneurysms (0.5%) were additionally treated with parent vessel balloon occlusion.

Conclusion: The late rebleeding rate after coiling of ruptured cerebral aneurysms is very low. Follow-up of patients with a coiled aneurysm is mandatory to identify aneurysms that need additional treatment after reopening.

Fig 1.

Flow chart of initial and 6-month angiographic results and additional treatments in 393 patients with a ruptured aneurysm treated with coils.

Fig 2.

Case 1, a 52-year-old man with a giant basilar tip aneurysm. A and B, Giant basilar tip aneurysm partially occluded with coils. Detachment of additional coils failed. B and C, Situation after bypass from the external carotid artery to the right P2 and bilateral vertebral artery occlusion. Only a small part of the neck is opacified with contrast material. Six months later, the patient died of autopsy-confirmed rebleeding.

Fig 3.

Case 2, a 72-year-old woman with a 10-mm ruptured basilar tip aneurysm and rebleeding 12 months after coiling. A and B, Basilar tip aneurysm before (A) and after (B) coiling. Six-month follow-up angiography was refused. C, Angiogram after rebleeding 12 months later. The aneurysm has enlarged and reopened. D, Near-complete occlusion after additional coiling.

Fig 4.

Case 3, a 52-year-old woman with an intraventricular hemorrhage. A and B, Angiograms before (A) and after (B) embolization show complete occlusion of large posterior communicating artery aneurysm. C, Follow-up angiogram 7 months later reveals partial reopening of the base of the aneurysm. D, After additional coiling complete occlusion, 6-month follow-up angiography after second coiling was refused. E and F, Thirty months after second coiling, the patient suffered rebleeding, and angiography showed enlargement and reopening of the aneurysm.

Fig 5.

Case 4, a 76-year-old woman with SAH from a large posterior communicating artery aneurysm. A and B, Frontal (A) and lateral (B) views of carotid angiogram show large posterior communicating artery aneurysm. C and D, After coiling residual filling of the aneurysm. Four months later, she was found deceased, possibly as a result of rebleeding.

Fig 6.

Case 5, a 64-year-old man with a ruptured anterior communicating artery aneurysm. A, Angiogram reveals large anterior communicating artery aneurysm and additional small aneurysms on left posterior communicating artery and middle cerebral artery. B, Near-complete occlusion after coiling. The additional aneurysms were not treated. C, Follow-up angiogram 7 months later demonstrates enlargement of neck remnant. Additional coiling was not performed. D, Angiogram after rebleeding shows further enlargement of neck remnant. E, Angiogram after second coiling and coiling of the posterior communicating artery aneurysm.