Purpose

To assess efficacy, safety and to discuss optimal medical therapy of stent-assisted coiling of ruptured intracranial aneurysms.

Methods

Ruptured intracranial aneurysms treated with stent-assisted coiling in eight different institutions were retrospectively reviewed. Medical treatment regimens varied among the centers, mainly regarding heparin administration and post-procedural single or double antiplatelet therapy. Clinical and angiographic results, including complications and outcomes were analyzed and related to the different therapies.

Results

Sixty-one consecutive patients (male/female 23/38), aged 59.1 years (36–86) underwent stent-assisted coiling for ruptured intracranial aneurysm without antiplatelet pre-medication. Intravenous acetylsalicylic acid (ASA) 500 mg was administered to all patients immediately after stent deployment. At the same time heparin was given as bolus in 15 patients (24.6%) as part of local protocol. Intravenous glycoprotein 2b/3a inhibitors (antiGP2b3a) were used as bail-out therapy for stent thrombosis. Stent thrombosis occurred in 22 patients (36.1%), of which 4 (6.5%) lead to incomplete and 18 (29.6) to complete occlusion of the stent. Heparin administration had no effect on thrombosis rate. Thrombosis resolution occurred in all cases with intravenous antiGP2b3a (7 tirofiban, 15 abciximab), without increasing overall complication rate. Single antiplatelet therapy with ASA (28 patients, 45.9%) or double antiplatelet therapy including ASA and clopidogrel (33 patients, 54.1%) were administered after procedure, depending on local protocols and on neurointerventionists’ experience. Overall complication rate, including ischemia and hemorrhage was higher in patients in which only ASA was administered (21.4% vs. 12.1%). No late stent thrombosis was seen, regardless of whether a single or double antiplatelet regimen was used. Nevertheless, the small sample size suggests caution in interpreting these results. Moreover, a possible bias may arise from the decision whether to modify the maintenance therapy or not depending on the severity of the intracranial hemorrhage in a case-by-case assessment. At three months, 34 out of 38 patients with HH grade 1-2 (89.4%), and 11 out of 23 with Hunt-Hess grade of 3-4 (47.8%) were independent (Modified Ranking Scale 0-2).

Conclusion

Stent assisted coiling of ruptured intracranial aneurysms is a feasible option when simple coiling is not possible. Optimal medical treatment is still controversial because balance between hemorrhagic and ischemic risks is difficult to evaluate. In our series, heparin bolus had no effect on subsequent stent thrombosis. In all cases peri-operative stent thrombosis was successfully managed using bail-out intravenous antiGP2b3a, which did not increase post-procedural hemorrhage rates. A non-significant trend towards increased complications rate was noticed in patients treated with single antiplatelet therapy versus double antiplatelet therapy.

中文翻译：

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Neuroform Atlas 支架辅助栓塞颅内动脉瘤破裂：一项多中心研究

目的

评估疗效、安全性并讨论支架辅助栓塞颅内动脉瘤破裂的最佳药物治疗。

方法

回顾性审查了在八个不同机构中用支架辅助弹簧圈治疗破裂的颅内动脉瘤。各中心的药物治疗方案各不相同，主要是肝素给药和术后单药或双药抗血小板治疗。分析了临床和血管造影结果，包括并发症和结果，并与不同的治疗方法相关联。

结果

连续 61 名患者（男性/女性 23/38），年龄 59.1 岁（36-86 岁），在没有抗血小板药物治疗的情况下接受了支架辅助栓塞治疗颅内动脉瘤破裂。静脉注射乙酰水杨酸 (ASA) 500 支架展开后立即给予所有患者 mg。同时，作为当地方案的一部分，15 名患者 (24.6%) 以推注形式给予肝素。静脉注射糖蛋白 2b/3a 抑制剂 (antiGP2b3a) 被用作支架血栓形成的救助疗法。22 名患者 (36.1%) 发生支架血栓形成，其中 4 名 (6.5%) 导致支架不完全闭塞，18 名 (29.6) 名导致支架完全闭塞。肝素给药对血栓形成率没有影响。所有静脉注射抗GP2b3a（7 替罗非班，15 阿昔单抗）的病例均发生血栓消退，而总体并发症发生率没有增加。根据当地方案和神经介入医师的经验，在手术后给予 ASA 单次抗血小板治疗（28 名患者，45.9%）或包括 ASA 和氯吡格雷在内的双重抗血小板治疗（33 名患者，54.1%）。仅使用 ASA 的患者的总体并发症发生率更高，包括缺血和出血（21.4% 对 12.1%）。无论使用单药还是双药抗血小板方案，均未观察到晚期支架内血栓形成。然而，小样本量表明在解释这些结果时要谨慎。此外，根据个案评估中颅内出血的严重程度，决定是否修改维持治疗可能会产生偏差。在三个月时，38 名 HH 1-2 级患者中的 34 名 (89.4%) 和 Hunt-Hess 3-4 级患者中的 11 名 (47.8%) 是独立的（修改后的排名量表 0-2）。无论是使用单抗血小板还是双抗血小板方案。然而，小样本量表明在解释这些结果时要谨慎。此外，根据个案评估中颅内出血的严重程度，决定是否修改维持治疗可能会产生偏差。在三个月时，38 名 HH 1-2 级患者中的 34 名 (89.4%) 和 Hunt-Hess 3-4 级患者中的 11 名 (47.8%) 是独立的（修改后的排名量表 0-2）。无论是使用单抗血小板还是双抗血小板方案。然而，小样本量表明在解释这些结果时要谨慎。此外，根据个案评估中颅内出血的严重程度，决定是否修改维持治疗可能会产生偏差。在三个月时，38 名 HH 1-2 级患者中的 34 名 (89.4%) 和 Hunt-Hess 3-4 级患者中的 11 名 (47.8%) 是独立的（修改后的排名量表 0-2）。

结论

当无法进行简单的盘绕时，支架辅助盘绕破裂的颅内动脉瘤是一种可行的选择。最佳药物治疗仍然存在争议，因为出血和缺血风险之间的平衡难以评估。在我们的系列中，肝素推注对随后的支架血栓形成没有影响。在所有病例中，围手术期支架内血栓形成均使用救助式静脉注射抗 GP2b3a 成功控制，并没有增加术后出血率。在接受单一抗血小板治疗与双重抗血小板治疗的患者中观察到并发症发生率增加的非显着趋势。