Background Ruptured aneurysms are prone to high recurrence and retreatment rates with endovascular coiling thus exposing the patient to a higher risk of morbidity and mortality due to retreatments and rupture. Flow diversion treatment has been shown to be associated with high rates of angiographic obliteration, however, it is relatively contraindicated in the acute phase as these patients require periprocedural dual anti-platelet therapy. Acute coiling followed by flow diversion has emerged as a feasible treatment option. In this study we report outcomes and complications of patients with ruptured aneurysms undergoing coiling in the acute phase followed by planned flow diversion.

Materials and methods This prospective case series includes patients from two institutions. All patients underwent standard endovascular coiling in the acute phase after subarachnoid hemorrhage with planned flow-diverter treatment at a later date. Patients were placed on dual antiplatelet therapy prior to flow-diverter treatment. Outcomes studied included angiographic occlusion, procedure related complications, and long term clinical outcome as measured by the modified Rankin Scale (mRS).

Results A total of 31 patients underwent coiling in the acute phase with the intention to undergo flow diversion at a later date. Mean aneurysm size was 15.8 ± 7.9 mm. Initial angiographic occlusion following coil treatment demonstrated complete occlusion in 3 cases (9.7%), near complete occlusion in 13 cases (41.9%) and incomplete occlusion in 15 cases (48.4%). Complications following coiling included two cases (6.5%) of intraoperative rupture with no permanent morbidities or mortality, and 4 cases of ischemic stroke (13.0%) with two cases of permanent morbidity (6.5%). Of the 31 patients receiving coiling, three patients (9.7%) died from complications of subarachnoid hemorrhage and one patient had permanent morbidity (3.1%)

A total of 27 patients underwent staged placement of flow diverters after adequate recovery from the prior subarachnoid hemorrhage. Mean time to treatment was 27 weeks (range 8 days-100 weeks). There were no cases of aneurysm rebleeding between the coiling procedure and the placement of the flow diverter. On pre-procedural angiogram (before flow-diversion), 92.6% of aneurysms were incompletely occluded, and 7.4% of aneurysms were near-completely occluded with residual neck or dog-ear filling. Complications followed flow diverter treatment included two cases of transient ischemic attack (7.4%) and one groin hematoma (3.7%). There was no permanent morbidity or mortality resulting from flow diverter treatment. At last follow-up, 68.2% (15 patients) had aneurysms that were completely occluded, 13.6% (3 patients) had aneurysms that were near-completely occluded, while 18.2% (4 patients) remained with a stable but incompletely occluded aneurysm. At last follow-up (mean 18.3 months), 25 of the 27 patients who completed treatment had excellent outcomes (mRS 0–2).

Conclusions Staged treatment of ruptured complex intracranial aneurysms with coiling in the acute phase and flow diverter treatment following recovery from SAH is both safe and effective. In our series, despite the complexity of the aneurysms treated, limited major morbidity and mortality occurred during the acute phase after rupture. No cases of rebleeding occurred during the interval between coiling and flow diversion. No patients suffered additional morbidity or mortality from flow diverter treatment.

Disclosures W. Brinjikji: None. M. Piano: None. S. Fang: None. G. Pero: None. D. Kallmes: 1; C; Covidien. 2; C; Covidien. L. Quilici: None. L. Valvassori: None. H. Cloft: None. E. Boccardi: None. G. Lanzino: 2; C; Covidien.