Endovascular repair of the basilar artery bifurcation aneurysms (BABA) remains the preferred approach, as clipping is associated with a higher chance of mortality and morbidity. Additionally, surgical clipping is not offered to those with poor grades.
Objectives To determine the perioperative risk and outcomes of patients with ruptured BABA (RBABA) who underwent endovascular repair including those with poor grades.
Methods Consecutive patients who underwent endovascular therapy of RBARA from January 2011 to December 2017 were retrospectively analyzed. Antiplatelet loading regimen: stent assisted coiling; Plavix 75 mg × 4 and chewable baby aspirin 81 mg x4. Coiling; chewable aspirin 81 mg × 4, both cases given at least 4 hours prior. Overpacking and primary coiling cases received additional 300 mg rectal aspiring immediate after the procedure. Heparin was administered for all stent-assisted and primary coiling cases prior to deployment of stent or coil with target 1.5 −2 × 2 baseline ACT. Ruptured primary coiling; heparin was administered after the deployment of first coil. Patients long-term outcome was measure using modified Rankin Scale (mRS).
Results 26 patients with median age 55 (31–71), 21 women, median aneurysm size 11 mm (4–30) and 14 wide-neck underwent repair; primary coiling 17, stent-assisted coiling 9 and 15 required extra ventricular drainage (EVD). For the stent-assisted cases; planned EVD was placed at least 6 hours prior to the procedure for adequate hemostasis, were loaded with aspiring and Plavix at least 2 hours prior for those who can swallow and at least one hour before for those who received crushed loads via nasogastric tube. Presenting H and H grades; I in 7, II in 8, III in 4 and IV in 7. Off 7 patients with H and H IV, 5 demonstrated gradual improvement of their H and H grades after EVD placement. Perioperative stroke developed in one (3.8%) who achieved mRS 3 and EDV related subdural hemorrhage in one (initial grade was IV, not a stent-assisted case, no improvement and died). Immediate complete and near complete aneurysm obliteration in 81% (21; complete 10, near complete 11) and subtotal in 19% (5). 90 days good outcome was observed in 77% (mRS 0 in 16, mRS 1 in 2, mRS 2 in 2) and poor outcome in 19% (mRS 3 in 3, mRS 4 in 2, mRS 6 in 1). Among 7 patients (27%) with H and H IV; 57% (4) had good outcome (mRS 0 in 2, mRS 1 in 2), and 43% (3) had poor outcome (mRS 4 in 2 and mRS 6 in 1). Aneurysm racialized in 9 cases (5 large, 3 giant) including subtotal obliterated cases and those were retreated (5 stent-coil, 4 coiling).
Conclusions Endovascular approach to repair RBABA is associated with low perioperative events and offers good functional outcomes including those who present with poor grades or require acute stent-assisted repair. Presenting poor grades may be related to the location of initial ictus in conjunction with hydrocephalus which may improve after EVD placements. Therefore, endovascular therapy should be offered for all RBABA patients including those present with poor grades. Further studies are required.
Disclosures Y. Lodi: None. V. Reddy: None. S. Javed: None. S. Multani: None. W. Elnour: None. T. Wang: None. A. Hourani: None.
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