Is endovascular embolization reliable as a long-term cure for ruptured cerebral aneurysms?

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Abstract

BACKGROUND

Ruptured intracranial aneurysms are associated with a high risk of permanent neurological impairment or death. Evidence suggests that detachable coils can be used to treat ruptured aneurysms safely and effectively; however, data regarding their long-term efficacy is sparse.

OBJECTIVE

To determine the frequency of late rebleeding of ruptured intracranial aneurysms after treatment with detachable coils.

DESIGN AND INTERVENTION

In this retrospective study that was conducted over 8 years, 393 consecutive patients (70% female, 30% male) with a ruptured aneurysm were treated with a detachable coil and followed up to determine the incidence of late rebleeding-defined as recurrent hemorrhage from a coiled aneurysm >1 month after coiling. Using angiography, treatment outcomes were classified as complete occlusion (98-100%), near-complete occlusion (90-98%) or incomplete occlusion (<90%). Patients were followed up clinically 6 weeks after initial discharge, and underwent angiographic follow-up at 6 months and 18 months. Further appropriate treatment was undertaken if incomplete occlusion was discovered at any time during the follow-up period. At the time of initial coiling, the mean patient age was 52.9 years (range 25-81 years). In total, 63% of patients were classified as Hunt and Hess (HH) Stroke Scale I-II, 21% were HH III and 16% were HH IV-V. The majority of treated ruptured aneurysms were located in the anterior communicating artery (n = 123), the basilar tip (n = 85) or the posterior communicating artery (n = 68).

OUTCOME MEASURES

The primary outcome was the number of patients to experience late rebleeding after coiling of a ruptured aneurysm. A secondary outcome was the number of patients to require follow-up treatment for aneurysms.

RESULTS

Clinical data was available for 392 of the 393 patients. The total follow-up duration was 18,708 months, or 1,559 patient-years (mean 47.7 months, range 0-120 months). During follow-up, 70 patients (17.8%) died; deaths were attributed to various factors including subarachnoid hemorrhage (n = 23), unrelated causes (n = 21) and procedural complications of coiling (n = 11). Mortality associated with late rebleeding was 0.76% (n = 3), giving an annual late-rebleeding mortality rate of 0.19% (95% CI 0.04-0.60%). The late-rebleeding incidence was 1.27% (n = 5), giving an annual late-rebleed rate of 0.32% (95% CI 0.12-0.78%). The median size of the original aneurysm in patients with late rebleeding was 17 mm, compared with 8 mm in patients without late rebleeding (P = 0.0017). Late rebleeding occurred in 3 of 366 (0.82%) patients with complete initial aneurysm occlusion, and 2 of 27 patients (7.41%) with incomplete initial occlusion (P = 0.04). Additional treatment was required for 53 (13%) coiled aneurysms during the follow-up period. There was no significant difference in the median ages and gender ratios between patients who experienced late rebleeding and those who did not.

CONCLUSION

Coiling of ruptured aneurysms is associated with a very low rate of rebleeding. Angiographic follow-up reveals incomplete initial occluded aneurysms that might require additional treatment.

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