J Cerebrovasc Endovasc Neurosurg.  2022 Sep;24(3):249-256. 10.7461/jcen.2022.E2022.01.002.

Diffusion-weighted imaging-positive lesions following endovascular treatment for ruptured and unruptured aneurysms: Its incidence according to antithrombotic drugs

• Lee SH
• Kim SH
• Jang JH
• Kim YZ
• Kim KH
• Nam TM

• KMID: 2533676
• DOI: http://doi.org/10.7461/jcen.2022.E2022.01.002

Abstract

Objective
Microembolic infarcts are frequently observed on diffusion-weighted imaging (DWI) following endovascular treatment. We investigated DWI-positive lesions and symptomatic ischemic complications (SICs) in patients with ruptured and unruptured aneurysms following coiling and the relationship between DWI-positive lesions and antithrombotic drugs.
Methods
Between January 2016 and December 2020, 83 patients underwent DWI within 48 h following endovascular treatment for ruptured (n=30) and unruptured (n=53) aneurysms.
Results
The overall rate of DWI-positive lesions was 55.4%. There were no significant differences in the occurrence rate (45.3% vs. 43.3%, p=1.000) and the number of lesions (2.7±4.6 vs. 4.0±5.3, p=0.237) between unruptured and ruptured aneurysms. SIC occurred more frequently in patients with ruptured aneurysms than unruptured ones (20.0% vs. 1.9%, p=0.015). The cutoff value of DWI-positive lesions for predicting SIC was 5 (sensitivity 100%, specificity 78.9%). The procedure time was significantly longer in patients with DWI-positive lesions ≥5 than those with DWI-positive lesions <5 (104.1±43.8 vs. 85.1±30.8 min, p=0.030). Patients with DWI-positive lesions <5 were more frequently observed in the postprocedural heparinization group than in the no heparinization group (85.7% vs. 58.5%, p=0.012).
Conclusions
The incidence of DWI-positive lesions did not differ significantly between the ruptured and unruptured aneurysms. However, SIC occurred more frequently in patients with ruptured aneurysms. Longer procedure time is a risk factor for DWI-positive lesions, and postprocedural heparinization seems to reduce the incidence of DWI-positive lesions.

Keyword

Cerebral aneurysm; Endovascular treatment; Diffusion-weighted imaging; Heparinization; Antithrombotic drugs

Reference

1. Bond KM, Brinjikji W, Murad MH, Kallmes DF, Cloft HJ, Lanzino G. Diffusion-weighted imaging-detected ischemic lesions following endovascular treatment of cerebral aneurysms: a systematic review and meta-analysis. AJNR Am J Neuroradiol. 2017; Feb. 38(2):304–9.

2. Choi HH, Cho YD, Han MH, Cho WS, Kim JE, Lee JJ, et al. Antiplatelet premedication-free stent-assisted coil embolization in acutely ruptured aneurysms. World Neurosurg. 2018; Jun. 114:e1152–60.

3. Choi J, Koo Y, Whang K, Cho S, Kim J. Safety of heparin loading during endovascular embolization in patients with aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg. 2021; Feb. 201:106453.

4. Choi SH, Na DL, Chung CS, Lee KH, Na DG, Adair JC. Diffusion-weighted MRI in vascular dementia. Neurology. 2000; Jan. 54(1):83–9.

5. Chung SW, Baik SK, Kim Y, Park J. Thromboembolic events after coil embolization of cerebral aneurysms: prospective study with diffusion-weighted magnetic resonance imaging follow-up. J Korean Neurosurg Soc. 2008; Jun. 43(6):275–80.

6. Hwang G, Huh W, Lee JS, Villavicencio JB, Villamor RB Jr, Ahn SY, et al. Standard vs modified antiplatelet preparation for preventing thromboembolic events in patients with high on-treatment platelet reactivity undergoing coil embolization for an unruptured intracranial aneurysm: a randomized clinical trial. JAMA Neurol. 2015; Jul. 72(7):764–72.

7. Iosif C, Lecomte JC, Pedrolo-Silveira E, Mendes G, Boncoeur Martel MP, Saleme S, et al. Evaluation of ischemic lesion prevalence after endovascular treatment of intracranial aneurysms, as documented by 3-T diffusion-weighted imaging: a 2-year, single-center cohort study. J Neurosurg. 2018; Apr. 128(4):982–91.

8. James RF, Khattar NK, Aljuboori ZS, Page PS, Shao EY, Carter LM, et al. Continuous infusion of low-dose unfractionated heparin after aneurysmal subarachnoid hemorrhage: a preliminary study of cognitive outcomes. J Neurosurg. 2018; May. 1–8.

9. Kang DH, Hwang YH, Kim YS, Bae GY, Lee SJ. Cognitive outcome and clinically silent thromboembolic events after coiling of asymptomatic unruptured intracranial aneurysms. Neurosurgery. 2013; Apr. 72(4):638–45. discussion 45.

10. Kang DH, Kim BM, Kim DJ, Suh SH, Kim DI, Kim YS, et al. MR-DWI-positive lesions and symptomatic ischemic complications after coiling of unruptured intracranial aneurysms. Stroke. 2013; Mar. 44(3):789–91.

11. Kole MJ, Wessell AP, Ugiliweneza B, Cannarsa GJ, Fortuny E, Stokum JA, et al. Low-dose intravenous heparin infusion after aneurysmal subarachnoid hemorrhage is associated with decreased risk of delayed neurological deficit and cerebral infarction. Neurosurgery. 2021; Feb. 88(3):523–30.

12. Lund C, Nes RB, Ugelstad TP, Due-Tonnessen P, Andersen R, Hol PK, et al. Cerebral emboli during left heart catheterization may cause acute brain injury. Eur Heart J. 2005; Jul. 26(13):1269–75.

13. Mousavi S, Moradi M, Khorshidahmad T, Motamedi M. Anti-inflammatory effects of heparin and its derivatives: a systematic review. Adv Pharmacol Sci. 2015; 2015:507151.

14. Mulloy B, Hogwood J, Gray E, Lever R, Page CP. Pharmacology of heparin and related drugs. Pharmacol Rev. 2016; Jan. 68(1):76–141.

15. Park JC, Lee DH, Kim JK, Ahn JS, Kwun BD, Kim DY, et al. Microembolism after endovascular coiling of unruptured cerebral aneurysms: incidence and risk factors. J Neurosurg. 2016; Mar. 124(3):777–83.

16. Raymond J, Guilbert F, Weill A, Georganos SA, Juravsky L, Lambert A, et al. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke. 2003; Jun. 34(6):1398–403.

17. Schubert GA, Thome C, Seiz M, Douville C, Eskridge J. Microembolic signal monitoring after coiling of unruptured cerebral aneurysms: an observational analysis of 123 cases. AJNR Am J Neuroradiol. 2011; Sep. 32(8):1386–91.

18. Shimamura N, Naraoka M, Matsuda N, Katayama K, Kakuta K, Katagai T, et al. Use of preprocedural, multiple antiplatelet medications for coil embolization of ruptured cerebral aneurysm in the acute stage improved clinical outcome and reduced thromboembolic complications without hemorrhagic complications. World Neurosurg. 2020; Jan. 133:e751–6.

19. Simard JM, Aldrich EF, Schreibman D, James RF, Polifka A, Beaty N. Low-dose intravenous heparin infusion in patients with aneurysmal subarachnoid hemorrhage: a preliminary assessment. J Neurosurg. 2013; Dec. 119(6):1611–9.

20. Simard JM, Tosun C, Ivanova S, Kurland DB, Hong C, Radecki L, et al. Heparin reduces neuroinflammation and transsynaptic neuronal apoptosis in a model of subarachnoid hemorrhage. Transl Stroke Res. 2012; Jul. 3(Suppl 1):155–65.

21. Tokunaga K, Hatano T, Nakahara I, Ishii A, Higashi E, Kamata T, et al. Factors associated with postprocedural diffusionweighted imaging-positive lesions in endovascular treatment for unruptured cerebral aneurysms. World Neurosurg. 2019; Oct. 130:e457–62.

22. van den Bergh WM, Kerr RS, Algra A, Rinkel GJ, Molyneux AJ; ISAT Collaborative Group. Effect of antiplatelet therapy for endovascular coiling in aneurysmal subarachnoid hemorrhage. Stroke. 2009; April. 40(6):1969–72.

23. Vermeer SE, Prins ND, den Heijer T, Hofman A, Koudstaal PJ, Breteler MM. Silent brain infarcts and the risk of dementia and cognitive decline. N Engl J Med. 2003; Mar. 348(13):1215–22.

24. Yamada NK, Cross DT 3rd, Pilgram TK, Moran CJ, Derdeyn CP, Dacey RG Jr. Effect of antiplatelet therapy on thromboembolic complications of elective coil embolization of cerebral aneurysms. AJNR Am J Neuroradiol. 2007; Oct. 28(9):1778–82.

25. Zachariah J, Snyder KA, Graffeo CS, Khanal DR, Lanzino G, Wijdicks EF, et al. Risk of ventriculostomy-associated hemorrhage in patients with aneurysmal subarachnoid hemorrhage treated with anticoagulant thromboprophylaxis. Neurocrit Care. 2016; Oct. 25(2):224–9.

26. Zhang L, Zhou X, Liu Y, Ding C, Wang Y, Yang H. The utility of diffusion-weighted MRI lesions to compare the effects of different heparinization schemes in intracranial aneurysms treated by endovascular intervention. Front Neurol. 2020; Dec. 11:609384.