Intraprocedural thrombus formation during coil placement in ruptured intracranial aneurysms: treatment with systemic application of the glycoprotein IIb/IIIa antagonist tirofiban

Abstract

Background and purpose: When using detachable coils to treat intracranial aneurysms, thromboembolism is the most feared and frequently reported complication during or after endovascular therapy. The purpose of this study was to document the therapeutic effect of tirofiban on patency of the parent vessel, rate of rebleedings, and outcome of the patients in the setting of acute subarachnoidal hemorrhage.

Methods: A patient data base was retrospectively reviewed to identify patients in whom thrombus occurred during endovascular treatment of ruptured cerebral aneurysms within a 34-month period and who were treated with tirofiban. All patients underwent anticoagulation with heparin during endovascular treatment procedures. Sixteen patients (age range, 52.9 +/- 10.7 years; 10 women, 6 men) were identified with intraprocedural thrombus formation. The patency of the parent vessel was assessed in a retrospective analysis blinded to outcome. Eight patients received ventriculostomy and had a follow-up CT.

Results: Local nonocclusive thrombus at the coil surface was detected in 5 patients, in all of whom the thrombus was dissolved. In 10 patients, partial or total occlusion of the parent vessel occurred during the intervention; in 8 of these, the vessel was recanalized completely and in 2 drug administration was assisted by mechanical means. In 1 patient, however, the occlusion persisted. No periprocedural rebleedings of the ruptured aneurysm occurred; 3 of 8 ventriculostomies had clinically silent small local bleedings.

Conclusion: The use of tirofiban in the setting of endovascular treatment of ruptured intracranial aneurysms to dissolve platelet aggregation seems relatively safe and effective.

Fig. 1.

This 49-year-old female patient was admitted to the hospital in good clinical condition (WFNS 1). A 5 × 4-mm aneurysm of the basilar tip involving the right superior cerebellar artery (SCA) was found on diagnostic angiography (A). Despite care taken not to compromise the ostium of the SCA with the coil package, the SCA was occluded during the coiling procedure (B). After administration of tirofiban, the vessel reopened within 15 minutes (C). Follow-up angiography 4 months later confirmed patency of the SCA, and the aneurysm remained occluded (D).

Fig. 2.

Local thrombosis controlled by tirofiban. This 56-year-old female patient presented with a subarachnoidal hemorrhage and focal deficits (WFNS 3). Multiple aneurysms were found on diagnostic angiography; however, the pericallosal aneurysm was determined to be the symptomatic one. During the interventional procedure, a local thrombus was detected in the left pericallosal artery (arrow, A). Tirofiban was administered and patency of the vessel was restored (B). Outcome of the patient was excellent; there were no focal or generalized deficits (mRS 0).

Fig. 3.

Extensive thrombosis and thromboembolism in part controlled by tirofiban. This 64-year-old male patient (10) presented with an extensive subarachnoidal hemorrhage (Fisher IV) and suffered a severe rebleeding during transfer from an outside hospital (WFNS V). The bilobar aneurysm of the anterior communicating branch had broad-based contact to the parent vessel (A). Because of the poor clinical status, a surgical approach was excluded. During the interventional procedure, an occlusion of the left pericallosal artery was detected (B). Tirofiban and aspirin were administered; however, patency of the vessel was not restored after 30 minutes. After mechanical assistance with the use of a microwire and various microcatheters (C), the pericallosal artery was partially recanalized (D). However, the patient had focal deficits (mRS 4).