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Contrast Enhancement Hyperdensity After Endovascular Coiling of Intracranial Aneurysms

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Contrast Enhancement Hyperdensity After Endovascular Coiling of Intracranial Aneurysms Published November 26, 2007 as 10.3174/ajnr.A0844 Contrast Enhancement Hyperdensity After ORIGINAL RESEARCH Endovascular Coiling of Intracranial Aneurysms J.L. Brisman BACKGROUND AND PURPOSE: Endovascular coil embolization is used increasingly to treat cerebral M. Jilani aneurysms. The purpose of our study was to quantify the incidence of CT-detectable abnormalities after aneurysm coiling and map the radiographic and clinical progression. J.S. McKinney MATERIALS AND METHODS: We reviewed the radiographic and clinical sequelae of 30 consecutive patients with aneurysms who underwent endosaccular coiling followed by head CT scans. Patients with CT abnormalities received follow-up scans at 4 to 6 hours and 20 to 25 hours. Contrast enhancement was defined as CT hyperdensities with progressive resolution over 25 hours and a Hounsfield unit (HU) of less than 70. The incidence of CT abnormalities was recorded and correlated with amount of contrast used, use of antiplatelet agents, procedure time, and clinical sequelae. RESULTS: Seven patients (23%) had new hyperdensities on CT scan. Four showed gyral hyperattenu- ation; 1 showed basal ganglia hyperattenuation, and 2 showed a combination of these patterns. All were asymptomatic and were consistent with contrast enhancement, with complete resolution in 5 of 7 and partial resolution in 2 of 7 by 20 to 25 hours. Antithrombotic or antiplatelet medication was continued in all cases. The amount of contrast used (P ϭ .014) and the use of antiplatelet medication (P ϭ .029) were statistically correlated with the presence of hyperattenuation after aneurysm coiling, whereas the length of the procedure was not (P ϭ .162). CONCLUSION: Contrast enhancement, unlike contrast extravasation, is a fairly common and clinically benign finding after aneurysm coiling. The enhancement resolves by 25 hours in most cases, regard- less of the continuation of antithrombotic or antiplatelet therapy. ndovascular embolization of intracranial aneurysms (IA) paper to study the correlation of antiplatelet use with new CT Ewith coils has become an increasingly accepted technique findings after coiling and to address whether continued use is INTERVENTIONAL of therapy that is now the preferred method of treating IAs in safe when a new abnormality is encountered. We reviewed our some centers.1 Although the safety and efficacy of this tech- series of 30 consecutively treated aneurysms by using nique are now well documented, as the technology continues Guglielmi detachable coils (GDC; Boston Scientific) or Neu- to grow additional questions arise. Newer devices, in particu- roform stent-assisted coiling and a protocol of perioperative lar, the Neuroform stent (Boston Scientific, Natick, Mass), CT scan imaging. have facilitated the treatment of wide-necked aneurysms but require the use of potent antiplatelet agents such as aspirin and Patients and Techniques ORIGINAL RESEARCH clopidogrel. Increased safety of coiling may be attributed to the use of prophylactic agents against thrombus formation, Procedural Protocol 2 such as heparin, aspirin, clopidogrel, and eptifibatide, and the The Institutional Review Board granted us permission to review the use of successful treatments for thromboembolic phenomena, charts of 30 consecutive patients who had undergone endovascular namely abciximab, heparin, clopidogrel, eptifibatide, and coiling of intracranial aneurysms at the New Jersey Neuroscience In- 3 aspirin. stitute. All coiling procedures were performed by the senior author Few studies on the results of imaging in the acute period (J.L.B.), and all patients underwent head CT scanning without con- 4-7 after coiling have been published, and only 1 other report trast immediately after the procedure. If the CT scan showed evidence has looked at a consecutive series of patients who underwent for either a hemorrhage or other hyperattenuation (other than the 4 head CT scans immediately after coiling. In contrast to the artifact related to the coils or to previously identified intracranial report in which CT scans were not performed beyond 4 to 6 blood in the case of patients presenting with hemorrhage), repeat CT hours postprocedure, we have extended the imaging evalua- scanning was obtained in 4 to 6 hours. If that CT scan continued to tion to 20 to 25 hours. Given the increased use of antithrom- show the new abnormality, a third scan was obtained at 20 to 25 botic and antiplatelet agents, it would be important to know hours. the rate of perioperative hemorrhage or other CT-scan abnor- malities, symptomatic or not, such that decisions can be made CT Scanning and Interpretation regarding continuation of such medication. This is the first All patients underwent head CT scanning using a LightSpeed Pro16 (GE Healthcare, Milwaukee, Wis) with a 5-mm section thickness and Received June 5, 2007; accepted after revision August 8. sections from the vertex through the foramen magnum. Each CT scan From the Departments of Neurosurgery (J.L.B.) and Neurology (J.S.M.), New Jersey was reviewed by a neuroradiologist, and abnormalities were recorded. Neuroscience Institute, Edison, NJ, and Department of Radiology (M.J.), JFK Medical The neuroradiologist was not blinded to the clinical history. Areas of Center, Edison, NJ. new focal increased attenuation were individually selected by the ra- Please address correspondence to Jonathan L. Brisman, MD, Cerebrovascular and Endo- vascular Neurosurgery, Winthrop University Hospital, 100 Merrick Rd, Suite 128W, Rock- diologist, and the HU was measured. Hyperdensities in which the ville Centre, NY 11570. measured HU were greater than 70 and which persisted at 20 to 25 DOI 10.3174/ajnr.A0844 hours after the procedure were interpreted as hemorrhage and those AJNR Am J Neuroradiol ●:● ͉ ● 2008 ͉ www.ajnr.org 1 Copyright 2007 by American Society of Neuroradiology. Table 1: Patient data of cases with postprocedural CT hyperdensities Stent Perioperative Location of HU HU HU Clinical Sex/Age Treated Aneurysm Assist Antiplatelets Enhancement Postprocedure 4–6 Hours 20–25 Hours Change F/42 Unruptured 6 mm left No Aspirin* Caudate 48 41 N/A None superior hypophyseal M/43 Unruptured 6 mm AcomA No Aspirin† clopidogrel† Caudate/Gyral 46/60 43/41 resolved None M/62 Unruptured 8 mm AcomA No Aspirin† abciximab§ Caudate/Gyral 50/67 40/45 resolved None F/65 Unruptured 5 mm left MCA No Aspirin† clopidogrel† Gyral 59 47 resolved None abciximab‡ F/80 SAH, 5 mm basilar tip Yes Aspirin† clopidogrel† Gyral 53 52 39 None abciximab‡§ F/61 Unruptured 22 mm left Yes Aspirin* clopidogrel* Gyral 47 44 resolved None supraclinoid ICA F/68 Unruptured 7 mm AcomA No Aspirin† Gyral 46 42 resolved None Note:—F indicates female; M, male; SAH, subarachnoid hemorrhage; N/A, not available; AcomA, anterior communicating artery; MCA, middle cerebral artery; ICA, internal carotid artery; HU, Hounsfield units. * Premedication Ն5 days. † Started day of procedure. ‡ Intra-arterial intraoperative. § Intravenous intraoperative and immediately postoperative. less than 70 and that showed progressive resolution for the 20- to 25-hour Results period after the procedure as contrast enhancement hyperattenuation (CEH). This definition of CEH represents a more conservative threshold Preoperative Data than that described in conjunction with CT findings after intra-arterial Of the 30 patients evaluated, there were 23 women and 7 men thrombolysis for acute stroke (HU Ͻ90).8,9 with ages ranging from 32 to 80 years (mean age, 57 years). Sixteen patients presented with hemorrhage. Four patients Data Collection and Analysis underwent stent-assisted coiling. A total of 28 patients had Data collected on the study group included age; sex; presentation; aneu- aneurysms in the anterior circulation with aneurysmal size rysm location and size; amount of contrast used (mL/kg) for the proce- ranging from 2.5 to 22 mm (mean, 7.1 mm). Two patients dure; duration (minutes) of the procedure; number of coils deployed; were premedicated with clopidogrel or aspirin for 5 days, 3 whether a stent was used; location of the hyperattenuation if found; HU patients received aspirin as their baseline medication preoper- of the hyperattenuation at 0 hours, 4 to 6 hours, and 20 to 25 hours; use of atively, and 13 patients received aspirin the day of the proce- heparin, aspirin, clopidogrel, and abciximab; and clinical examination at dure (8 [unruptured] the morning of the procedure and 5 all time points. We performed statistical analysis using the Student t test [subarachnoid hemorrhage] intraoperatively). Eleven pa- and Fisher exact test with significance defined as P Ͻ .05. tients were taking no antiplatelet agents perioperatively. In addition, 6 patients received intra-arterial or intravenous ab- Endovascular Coiling ciximab, all but 1 of whom was also medicated with aspirin or Coiling with use of a biplane fluoroscopic machine with 3D rotational clopidogrel, or both, in the perioperative period. capability was performed with the patients under general anesthesia. CT scans were performed on all patients with CEH at 3 time Iodixanol 320 mgI/mL was the contrast agent used in all patients. points except for 1 patient who did not receive a CT scan at the 20- Most of the contrast was delivered into the vascular territory supply- to 25-hour mark. There were 7 (23%) of 30 patients evaluated ing the target aneurysm. However, all patients underwent 4-vessel who were found to have CEH immediately after coiling. Their angiography at the time of treatment to identify any vascular abnor- clinical presentation, procedural details, and perioperative find- malities and to assess collateral circulation. After the 3D angiography ings are summarized in Table 1. There were 5 women and 2 men was used to select the best working image for coiling and to measure with ages ranging from 42 to 80 years old (mean age, 60 years). the aneurysmal neck and fundus, a 6F guiding catheter was placed Only one of the patients had presented with SAH. Six of the 7 into the cervical region of the vessel of interest, and multiple high- patients had aneurysms in the anterior circulation.
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