Specifics of endovascular embolization for cerebral aneurysmsin the acute period of subarachnoid hemorrhage

Abstract

Aim – to assess the benefits of modern methods for endovascular occlusion of ruptured cerebral aneurysms in the acute period of subarachnoid hemorrhage (SAН). Materials and methods. Medical records of patients undergoing treatment in the acute period of aneurysmal SAН between 2010–2021 were analyzed. 2 groups were formed: I – the use of standard surgical catheters, minimal use of adjunctive techniques for aneurysm embolization (2010–2016), II – routine use of triaxial access systems, intraarterial infusion of nimodipine, active use of adjunctive techniques for aneurysm embolization, intraoperative antiplatelet therapy immediately after aneurysm occlusion – 500 mg of solution Acelysin administrated intravenously (2017–2021). The severity of SAН according to the Hunt–Hess, Fisher scales, the treatment outcome according to the modified Rankin Scale (mSR), the location and size of aneurysms and intraoperative complications were analyzed. Results. There were 156 observations in group I, 91 – in group II. The median age was 48.26 years in group I, 51.44 years – in group II. On the basis of gender status, there was a majority of women in both groups. Aneurysms of the anterior cerebral-anterior communicating artery complex predominated in both groups; the internal carotid artery was the second most frequent localization. The severity of SAН according to the generally accepted scales (Hunt–Hess, Fisher) did not differ significantly. Coil embolization was used in 100 % of cases, balloon-assisted coiling was used in 6.48 % in group I and in 14.80 % – in group II, stent-assisted coiling – in 2.56 % and 9.30 %, respectively, distal access catheter with the triaxial system was not used in group I and it was performed in 57.4 % of cases in group II. Pharmacoangioplasty using nimodipine solution was used in 16.6 % in group I and in 22.2 % in group II. Intravenous drip infusion of 0.5 g Acelysin was performed immediately after aneurysm occlusion in 22.2 % of cases in group II. Intraoperative aneurysm rupture was observed in 5.1 % in group I and in 1.1 % in group II. Distal coil migration or into the maternal artery occurred in 6.41 % in group I and in 2.20 % in group II. Thromboembolic complications were noted in 7.69 % and in 2.20 %, respectively. The mean value of dysfunction degree on mSR amounted to 2.27 in group I and 1.45 – in group II. A good treatment outcome (mRS score 1–2) was defined in 71.2 % of observations in group I and in 87.9 % – in group II. The death rate was 12.82 % and 7.62 %, respectively. Conclusions. Routine use of triaxial access systems and intraarterial pharmacoplasty with nimodipine allow adequate prevention of mechanically induced vasospasm during catheterization of the aneurysm cavity. The triaxial access system stability provides better control of the microguidewire and microcatheters reducing the risk of aneurysmal wall perforation during catheterization. The use of adjunctive techniques for embolization of ruptured cerebral aneurysms in the acute period of SAH and prophylactic infusion of Acelysin solution after aneurysm occlusion significantly reduces the incidence of thromboembolic complications. The earliest possible occlusion of a ruptured cerebral aneurysm is not only the prevention of re-rupture, but also expands the possibilities of intensive care for preventing secondary complications of SAH.

Keywords

• endovascular embolization
• complications
• subarachnoid hemorrhage