Predictors and Outcomes of Intraprocedural Rupture in Patients Treated for Ruptured Intracranial Aneurysms: The CARAT Study

Department of Neurology, University of California San Francisco, San Francisco, CA 94143-0114, USA.
Stroke (Impact Factor: 5.72). 06/2008; 39(5):1501-6. DOI: 10.1161/STROKEAHA.107.504670
Source: PubMed


Intraprocedural rupture (IPR) is a well known complication of intracranial aneurysm treatment. Risks and predictors of IPR and its impact on outcome have not been clearly established.
Potential predictors of IPR were evaluated in patients treated in the Cerebral Aneurysm Rerupture After Treatment (CARAT) study using multivariate logistic regression with stepwise elimination stratified by treatment modality. Periprocedural death or disability was defined as death or a change of >or=2 points on the Modified Rankin Scale at discharge compared to before treatment.
IPR occurred in 14.6% of 1010 patients (299 coiled, 711 clipped): 19% with clipping and 5% with coiling (P<0.001). Among those clipped, 31% with IPR had periprocedural death or disability compared to 18% without IPR (P=0.001); among those coiled, 63% with IPR had periprocedural death or disability compared to 15% without IPR (P<0.001). Overall, coronary artery disease and initial lower Hunt and Hess Grade were independent predictors of IPR. For those undergoing coiling, independent predictors of IPR were Asian race, black race, COPD, and lower initial Hunt and Hess Grade. Among those undergoing clipping, hyperlipidemia and lower initial Hunt and Hess Grade were both independent predictors of IPR.
IPR was common in patients undergoing treatment of ruptured aneurysms, particularly with surgical clipping. The frequency of IPR with new disability was similar in the surgical and endovascular treatment groups. Coronary artery disease, hyperlipidemia, race, COPD, and lower Hunt and Hess Grade were associated with greater risk of IPR, which may reflect differences in vessel fragility but requires further confirmation.

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Available from: Steven L Giannotta, Feb 05, 2015
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    • "A possible explanation is that vessel wall strength may be altered in the presence of this disease. In addition, the presence of associated risk factors such as smoking and hypertension can also alter vessel wall fragility [9]. Preoperative assessment should include thorough evaluation of CAD and associated risk factors, as these comorbidities carry high risk for both cardiac events and cerebrovascular catastrophe. "
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    ABSTRACT: Despite great advancements in the management of aneurysmal subarachnoid hemorrhage (SAH), outcomes following SAH rupture have remained relatively unchanged. In addition, little data exists to guide the anesthetic management of intraoperative aneurysm rupture (IAR), though intraoperative management may have a significant effect on overall neurological outcomes. This review highlights the various controversies related to different anesthetic management related to aneurysm rupture. The first controversy relates to management of preexisting factors that affect risk of IAR. The second controversy relates to diagnostic techniques, particularly neurophysiological monitoring. The third controversy pertains to hemodynamic goals. The neuroprotective effects of various factors, including hypothermia, various anesthetic/pharmacologic agents, and burst suppression, remain poorly understood and have yet to be further elucidated. Different management strategies for IAR during aneurysmal clipping versus coiling also need further attention.
    Anesthesiology Research and Practice 03/2014; 2014:595837. DOI:10.1155/2014/595837
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    • "The intraprocedural rupture (IPAR) mainly depends upon vessel wall fragility which in turn may be modified by the several comorbidities including coronary artery disease, hyperlipidemia, race, COPD, and lower Hunt and Hess grade (Table 1) [38]. "
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    ABSTRACT: Background: Perioperative aneurysm rupture (PAR) is one of the most dreaded complications of intracranial aneurysms, and approximately 80% of nontraumatic SAHs are related to such PAR aneurysms. The literature is currently scant and even controversial regarding the issues of various contributory factors on different phases of perioperative period. Thus this paper highlights the current understanding of various risk factors, variables, and outcomes in relation to PAR and try to summarize the current knowledge. Method: We have performed a PubMed search (1 January 1991-31 December 2012) using search terms including "cerebral aneurysm," "intracranial aneurysm," and "intraoperative/perioperative rupture." Results: Various risk factors are summarized in relation to different phases of perioperative period and their relationship with outcome is also highlighted. There exist many well-known preoperative variables which are responsible for the highest percentage of PAR. The role of other variables in the intraoperative/postoperative period is not well known; however, these factors may have important contributory roles in aneurysm rupture. Preoperative variables mainly include natural course (age, gender, and familial history) as well as the pathophysiological factors (size, type, location, comorbidities, and procedure). Previously ruptured aneurysm is associated with rupture in all the phases of perioperative period. On the other hand intraoperative/postoperative variables usually depend upon anesthesia and surgery related factors. Intraoperative rupture during predissection phase is associated with poor outcome while intraoperative rupture at any step during embolization procedure imposes poor outcome. Conclusion: We have tried to create such an initial categorization but know that we cannot scale according to its clinical importance. Thorough understanding of various risk factors and other variables associated with PAR will assist in better clinical management as well as patient care in this group and will give insight into the development and prevention of such a catastrophic complication in these patients.
    The Scientific World Journal 11/2013; 2013:396404. DOI:10.1155/2013/396404 · 1.73 Impact Factor
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    ABSTRACT: Background and Purpose: Several unsolved problems in the treatment of cerebral aneurysms remain that could be addressed in a large multicenter registry. The Table for Optimization and Monitoring of Cerebral Aneurysm Therapy (TOMCAT) was launched to monitor the quality of care in the participating centers ( Material and Methods: Case record forms (CRFs) were developed in consensus between neuroradiologists and neurosurgeons. CRFs were collected locally and sent to the Center for Neurologic Studies (“Zentrum für Neurologische Studien” [ZNS]) in Essen, Germany. Initial clinical grade was assessed according to the World Federation of Neurological Surgeons' (WFNS) classification and outcome by the modified Rankin Scale (mRS). An mRS score ≤ 1 was defined as good outcome. After completion of a lead-in phase the database was read out for analysis. Rates of complications and of aneurysm remnants were calculated for anatomic localizations, aneurysm anatomy, and clinical presentation (WFNS). Results: TOMCAT was launched as prospective registry within a single center in 03/2006. With inclusion of more centers, an enrollment rate of 20 patients per month was achieved. A total of 487 patients were included. Complete treatment information was available for 315 (64.7%). In case of completed CRFs, twelve patients were untreated, 278 were treated endovascularly (EVT, among them 86 unruptured aneurysms), and 25 surgically. Stent or balloon remodeling techniques were applied in 3.6% and 3.1% of cases, respectively. Bioactive coils were used in 14.4%. In EVT, the rate of procedural aneurysm perforation was 2.3% (2/86) in unruptured and 4.3% (8/186) in ruptured aneurysms. In unruptured aneurysms the rate of permanent neurologic complications was 3.4%. The rate of residual aneurysms was 14.2%, especially in large and MCA (middle cerebral artery) aneurysms. Conclusion: During the lead-in phase of TOMCAT, a stable enrollment could be established. However, as not all treated patients in the single centers are sent to the central database, only preliminary conclusions can be made. First, there is a low complication rate in unruptured aneurysms. Second, MCA aneurysms still appear to represent a challenge due to high rates of complications and residual aneurysms. Third, no difference was observed in the safety profiles of bare coils and of bioactive coils. An improvement of the data collection is launched with simplified datasets and an alternative electronic submission method together with online analysis tools. Hintergrund und Ziel: Es existieren noch immer verschiedene ungelöste Fragen zur Behandlung von Aneurysmen der hirnversorgenden Gefäße, die nur mit einem großen multizentrischen Register beantwortet werden können. Die „Table for Optimization and Monitoring of Cerebral Aneurysm Therapy“ (TOMCAT) wurde initiiert, um die Qualität der Versorgung in den teilnehmenden Zentren zu untersuchen ( Material und Methodik: In Zusammenarbeit zwischen Neuroradiologen und Neurochirurgen wurden Fallanalysebogen (CRFs) entwickelt. Diese CRFs wurden lokal in den Zentren gesammelt und an das Zentrum für Neurologische Studien (ZNS) in Essen geschickt. Der initiale klinische Grad wurde entsprechend der WFNS-Klassifikation (World Federation of Neurological Surgeons) und das klinische Outcome anhand der modifizierten Rankin-Skala (mRS) charakterisiert (ein mRS-Score ≤ 1 wurde als gutes Outcome definiert). Die Komplikationsraten und die Häufigkeit von Aneurysmaresten wurden für die anatomische Lokalisation, die Aneurysmaanatomie und den WFNS-Grad analysiert. Ergebnisse: Die prospektive Registrierung begann 03/2006 monozentrisch. Mit zunehmendem Einschluss weiterer Zentren wurde eine Einschlussrate von 20 Patienten/Monat erreicht. Insgesamt wurden bis zum Ende der „lead-in phase“ (02/2008) 487 Patienten eingeschlossen. Komplette Informationen über die Behandlung waren zum Analysezeitpunkt in 315 Fällen (64,7%) vorhanden. Nach Informationen der komplett ausgefüllten CRFs waren zwölf Patienten unbehandelt, 278 waren endovaskulär (EVT, davon 86 nicht rupturierte Aneurysmen) und 25 chirurgisch behandelt. Stent- oder Ballon-Remodeling wurde in 3,6% bzw. 3,1% der Fälle durchgeführt. Bioaktive Coils wurden bei 14,4% der Patienten verwendet. Bei EVT betrug die Rate prozeduraler Aneurysmaperforation bei nicht rupturierten Aneurysmen 2,3% (2/86) und bei rupturierten 4,3% (8/186). Bei nicht rupturierten Aneurysmen lag die Rate der permanenten neurologischen Komplikationen bei 3,4%. Die Rate residueller Aneurysmen (14,2%) war bei großen und Mediaaneurysmen besonders hoch. Schlussfolgerung: Während der „lead-in phase“ von TOMCAT wurde eine stabile Einschlussrate erreicht. Da aber nicht alle behandelten Patienten aus den einzelnen Zentren an die Datenbank gemeldet wurden, sind derzeit nur vorläufige Schlussfolgerungen möglich. Es wurde eine geringe Komplikationsrate bei nicht rupturierten Aneurysmen beobachtet. Mediaaneurysmen scheinen bei hohen Raten von Komplikationen und residuellen Aneurysmen nach wie vor eine Herausforderung darzustellen. Es ergaben sich keine Unterschiede im Sicherheitsprofil zwischen unbeschichteten und bioaktiven Coils. Eine Verbesserung der Datenerfassung mit alternativer Möglichkeit der elektronischen Einreichung sowie Online-Analyse- Tools ist eingeleitet.
    Clinical Neuroradiology 07/2008; 18(3):168-176. DOI:10.1007/s00062-008-8021-9 · 2.25 Impact Factor
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