Rupture of giant vertebrobasilar aneurysm following flow diversion: mechanical stretch as a potential mechanism for early aneurysm rupture

Fox, Benjamin D.; Humphries, William; Doss, Vinodh T; Hoit, Daniel; Elijovich, Lucas; Arthur, Adam S

doi:10.1136/neurintsurg-2014-011325.rep

Cited by 39 publications

(28 citation statements)

References 9 publications

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“…Nearly half of the previous reports have hypothesized that inflammation may be the main cause of early IA rupture. 2,4,5,8,9,13 Other putative mechanisms have implicated thrombolysis allowing for recanalization of an IA aneurysm and altered flow conditions within its lumen that may lead to its rupture. 10 Others have identified that rupture is caused by mechanical stress associated with either thrombus growth or changes in inflow and hemodynamics, reduced flow within the aneurysm, and then altering pressure in the weakened aneurysm wall.…”

Section: Discussionmentioning

confidence: 99%

Early Rupture of a Giant Basilar Artery Aneurysm after LEO Stenting: Case Report and Review of the Literature

Strange

Kienzler

Muehleisen

et al. 2020

J Neurol Surg A Cent Eur Neurosurg

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Background Advances in the endovascular armamentarium, such as flow diversion and stenting devices, provide treatment options for posterior circulation intracranial aneurysms (IAs) with complex angioarchitecture. Delayed IA rupture following flow diversion is a rare but often fatal complication. Giant IAs likely pose a higher risk because of the extensive clot formation and its suspected detrimental effect on the aneurysmal wall. However, mechanisms that lead to delayed rupture are poorly understood, and few cases provide thorough documentation of macroscopic and histologic findings. Clinical Presentation After our 60-year-old patient with a giant basilar aneurysm underwent treatment with a LEO stent, the postoperative clinical course remained uneventful until day 4 when he suffered an unexpected fatal subarachnoid hemorrhage (SAH). Autopsy demonstrated extensive hemorrhage, large intraluminal thrombus, and ruptured IA wall. The aneurysm, which ruptured linearly, was completely filled with a clot that seemed to have outgrown the thin aneurysm wall. Histologic specimens revealed thinning and degenerative changes of the aneurysm's wall, and sparse neutrophilic and histiocytic inflammatory infiltrate adjacent to the rupture site, a finding consistent with recently published cases of IA rupture. Conclusions Our case report highlighting the clinical course and autopsy findings of a fatal SAH shortly after stenting this giant basilar artery aneurysm adds to the few previously reported fatal cases of IA rupture after endovascular treatment. Our macroscopic and histologic findings suggested that multimodal changes of inflammation, wall sheer tress (mechanical), and recanalization were involved.

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Section: Discussionmentioning

confidence: 99%

Early Rupture of a Giant Basilar Artery Aneurysm after LEO Stenting: Case Report and Review of the Literature

Strange

Kienzler

Muehleisen

et al. 2020

J Neurol Surg A Cent Eur Neurosurg

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“…The mechanisms of postoperative rupture of IAs following flowdiversion treatment have been explored on the basis of clinical, morphologic, clinicopathologic, and hemodynamic characteristics. 5,8,22,23 However, most studies were case reports or included many confounding factors, such as differing locations and sizes of aneurysms. In the present study, we adjusted for and matched these confounding factors with an aim of investigating the hemodynamic risk factors for postoperative rupture.…”

Section: Discussionmentioning

confidence: 99%

“…The incidence of subarachnoid hemorrhage after flow-diverter placement has been reported as high as 4.0%. [5][6][7][8][9][22][23][24] Kulcsar et al 8 analyzed risk factors of delayed-ruptured aneurysms before and after flow-diversion treatment to understand the mechanisms leading to delayed rupture during the healing process. They proposed 4 clinical risk factors for delayed rupture: large and giant aneurysms, symptomatic aneurysms, saccular aneurysms with an aspect ratio of .1.6, and inertia-driven inflow.…”

Section: Potential Delayed Ruptured Mechanism Of Aneurysm After Flow mentioning

confidence: 99%

Hemodynamic Analysis of Postoperative Rupture of Unruptured Intracranial Aneurysms after Placement of Flow-Diverting Stents: A Matched Case-Control Study

Li¹,

Tian²,

Zhu³

et al. 2019

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Postoperative rupture of intracranial aneurysm has been reported as a fatal complication after flow-diverter placement. We assessed several hemodynamic variables to explore risk factors in the postoperative rupture process. MATERIALS AND METHODS:We enrolled 10 patients with intracranial aneurysms, treated with flow diverters between September 2014 and December 2018, who experienced postoperative aneurysm rupture (postoperative aneurysm rupture group). We matched these subjects 1:2 with 20 patients with postoperative unruptured (postoperative unruptured group) intracranial aneurysms based on clinical and morphologic factors. Using computational fluid dynamics, we assessed hemodynamic changes pre-and posttreatment between the 2 groups on a number of qualitative and quantitative parameters. RESULTS:In the postoperative aneurysm rupture group, the proportion of patients with aneurysms with an unstable flow pattern increased to 60.0% after treatment, while the proportion in the postoperative unruptured group decreased to 20.0%, a significant difference between the 2 groups (P = .028). Energy loss in the postoperative unruptured group decreased after treatment but increased in the postoperative aneurysm rupture group. The reduction ratio of energy loss showed a significant difference between the 2 groups (22.73% 6 53.59% for postoperative unruptured versus À158.81% 6 183.95% for postoperative aneurysm rupture, P = .02). Other parameters and changes of pre-and posttreatment hemodynamic parameters showed no significant difference between 2 groups. CONCLUSIONS: Compared with pretreatment, unstable flow pattern and higher energy loss after Pipeline Embolization Device placement for intracranial aneurysm may be the important hemodynamic risk factors related to delayed aneurysm rupture. ABBREVIATIONS: CFD¼ computational fluid dynamics; EL ¼ energy loss; IA ¼ intracranial aneurysm; LSA ¼ low wall shear stress area; OG ¼ occlusion grade; OSI ¼ oscillatory shear index; POR ¼ postoperative ruptured; POU ¼ postoperative unruptured; RRT ¼ relative residual time; TAWSS ¼ time-averaged wall shear stress; WSS ¼ wall shear stress

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“…5 Early aneurysm rupture-especially large and giant aneurysms treated with flow diversion alone-is a dreaded complication. [1][2][3][4] PEDs for large or giant wide-necked intracranial aneurysms have been shown to be successful in treating wide-necked intracranial aneurysms. 2 4-6 Nevertheless, complications such as incomplete obliteration, early postoperative aneurysm rupture, thromboembolism, and intraparenchymal hemorrhage have been reported.…”

Section: Discussionmentioning

confidence: 99%

“…In our patient the Pipeline Flex alone could have been considered, but cases of disastrous early aneurysm ruptures have been reported, especially for large and giant aneurysms treated with flow diversion alone. [1][2][3][4] We therefore used both coils and a flow diverter due to the size of the aneurysm and symptomatic presentation, which would leave the patient more vulnerable to rupture. The ability to recapture and redeploy a flow diverter was felt to be critical because it would allow precise deployment in a position to protect the origin of the PICA while building a coil mass in the aneurysm.…”

Section: Treatmentmentioning

confidence: 99%

Republished: The first North American use of the Pipeline Flex flow diverter

Duckworth

Nickele

Hoit

et al. 2015

J NeuroIntervent Surg

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SUMMARYFlow diversion for the management of intracranial aneurysms represents a paradigm shift in how aneurysms are managed. The Pipeline embolization device (PED) is, to date, the only flow diverter approved for use in the USA by the Food and Drug Administration. Limitations and complications with new treatment strategies are inevitable, and with the PED there have been reports of complications, most commonly with challenging deployments. Once deployment has been initiated, the device is 'one-way'; it can only be deployed further or removed. Yet, situations arise in which the ability to recapture or reposition the device would be advantageous. A second-generation Pipeline has been developed that addresses these concerns. We report the first use in North America of this second-generation Pipeline device: the Pipeline Flex. We discuss our rationale for using the device, our impressions of its operation, and the relevant literature concerning the current state of flow diversion. BACKGROUND

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Rupture of giant vertebrobasilar aneurysm following flow diversion: mechanical stretch as a potential mechanism for early aneurysm rupture

Cited by 39 publications

References 9 publications

Early Rupture of a Giant Basilar Artery Aneurysm after LEO Stenting: Case Report and Review of the Literature

Early Rupture of a Giant Basilar Artery Aneurysm after LEO Stenting: Case Report and Review of the Literature

Hemodynamic Analysis of Postoperative Rupture of Unruptured Intracranial Aneurysms after Placement of Flow-Diverting Stents: A Matched Case-Control Study

Republished: The first North American use of the Pipeline Flex flow diverter

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