Delayed Ipsilateral Parenchymal Hemorrhage Following Flow Diversion for the Treatment of Anterior Circulation Aneurysms

Abstract

BACKGROUND AND PURPOSE:The PED is a flow-diverting stent designed for the treatment of cerebral aneurysms. We report 4 cases of delayed ipsilateral IPH following the technically successful treatment of anterior circulation aneurysms with the PED.

The Efficacy of Flow Diverter Stents in the Treatment of Wide-Necked Intracranial Aneurysms

“…However unknown the mechanism leading to these hemorrhages remains, some factors such as hemorrhagic transformation and use of anti-platelet are alleged as guilty culprits (16)(17)(18). No intraparenchymal hemorrhages were observed in our study although the rates of the hemorrhages were reported to range between 0% and 10% in several studies (16)(17)(18).…”

Prospective Study of Early MRI Appearances following Flow-Diverting Stent Placement for Intracranial Aneurysms

“…Most described parenchymal hemorrhages following flow diversion are supratentorial and result in a severe clinical deficit. 3,5,17 Most interesting, in this case, we had the opportunity of obtaining MR imaging before the brain stem hemorrhage, but it did not show a focus of diffusion restriction or susceptibility effect as a clue to the cause of the hemorrhage. The only caveat was that DWI can fail to detect a small brain stem infarct when performed early after the stroke (day 2 postoperative in this case).…”

“…[1][2][3][4][5] Speculation remains regarding the etiology of both forms of hemorrhage, with an overall hemorrhage risk of 7% in reported series. 6 Delayed parenchymal hemorrhages typically occur on the side of the treated aneurysm and at an incidence in excess of that expected due to dual antiplatelet medication alone and from that reported in prior non-flow-diverting-stent literature.…”

Risk Factors for Hemorrhagic Complications following Pipeline Embolization Device Treatment of Intracranial Aneurysms: Results from the International Retrospective Study of the Pipeline Embolization Device

“…Little is known regarding the exact etiology or risk factors of post-flowdiverter IPH. [7][8][9][10][11][12][13] A number of theories have been proposed, including the use of dual antiplatelet therapy, activation of platelets despite antiplatelet therapy by shearing over the metal surface area and subsequent hemorrhagic transformation of embolic platelet plug-mediated ischemic stroke, hemodynamic perturbations (hypo-or hyperperfusion states) during and immediately after flow-diverter treatment, and embolization of polyvinylpyrrolidone, a compound found in a number of catheters including the Shuttle guide sheath (Cook, Bloomington, Indiana). 10 Using the International Retrospective Study of the Pipeline Embolization Device (IntrePED) registry, we compared the clinical and procedural characteristics of patients who had postoperative IPH and those who did not, to determine which clinical and procedural characteristics were associated with IPH.…”

“…1,3 Spontaneous intraparenchymal hemorrhage (IPH) is one of the most dreaded complications of aneurysm treatment with flow diverters. [7][8][9][10][11][12][13] Although rarely reported after stent-assisted coiling of aneurysms, systematic reviews of flow-diverter treatment suggest that this complication occurs in 2%-4% of patients. Little is known regarding the exact etiology or risk factors of post-flowdiverter IPH.…”