This document summarizes the experience of a single center in using stent-assisted reconstruction to treat difficult aneurysms in patients presenting with acute subarachnoid hemorrhage. It describes treating 35 aneurysms in 33 patients that were not amenable to standard coiling, balloon-assisted coiling, or surgery. Stent placement was used to support the neck of wide-neck or dissecting/blister aneurysms to avoid coil protrusion. Most patients (28 of 33) had good outcomes, while 2 had management morbidity and 3 died. The results demonstrate stent-assisted coiling is a viable option for challenging aneurysms in acute subarachnoid hemorrhage cases.

1. STENT ASSISTED RECONSTRUCTION
OF DIFFICULT ANEURYSMS IN
ACUTE SUBARACHNOID HEMORRHAGE:
A SINGLE CENTER EXPERIENCE
Vipul Gupta
Neurointerventional Surgery
Institute of Neurosciences
Medanta the Medicity, Gurgaon

2. When?
 Aneurysms not amenable to standard coiling,
balloon assisted coiling or surgery
 Dissecting/fusiform aneurysms
 Blister aneurysms
 Dysplastic berry aneurysms

3. Stent….
 Flow diversion
 Intimal growth- healing
 Angle of the artery

4. Purpose
Antiplatelet therapy
External Ventricular drain
Associated intraparenchymal hematoma
Potential for infarction secondary to
vasospasm
High likelihood of future invasive
procedures.
Stent
Support at neck
Avoid coil protrusion

5. Data
• Retrospective review of 548 intracranial aneurysms
• 35 aneurysms in 33 patients -F- 19, M-14; 30-68 yrs
• Fisher grade III SAH - 22 (66.6%)
• H& H grade- I-III - 27 (81.8%)
• EVD/ Lumbar drainage - 8 (24.2%)
• <14 days of SAH - 26(78.7%)
•
• Wide Neck aneurysms - 16
• Dissecting and/or blister aneurysms - 19
• Single (28) or double overlapping (5) stents with additional
coil placement in 26 aneurysms.

6. Anti-platelet Regime
 Antiplatelets - 2 hours prior to the procedure
 Ecospirin -300 mg
 & Clopidogrel -450mg/Prasugrel -50mg/Ticagrelor 180 mg
 Systemic heparinization during procedure
 EVD if required, prior to the loading dose.
• Technical complications
• 5 (15.1%) in-stent clots, resolved with I/A Reopro
• 1(2.8%) aneurysm rupture during coiling
• 2 (5.7%)- ICA dissection, placement of stent.
• 2 patients had non fatal parenchymal haemorrhage at
the EVD insertion/removal site.

7. Results
28
2 3
0
5
10
15
20
25
30
mrs 0-2 mrs 3-5 mrs 6
Good outcome - 28/33 (84.9%)
Management Morbidity - 2/33 (6.1%)
Management Mortality - 3/33 (9.0%)

8. Mortality and Morbidity
Patient Age H
&
H
Site Stents
Used
MRS at
discharge
Death
Patient 1 33/F 2 Left vertebral
artery
dissecting
aneurysm
1 6 Rupture during coiling
Patient 2 53/F 4 Right ICA
blister
aneurysm
3 6 Meningitis
Patient 3 65/F 3 Right ICA
blister
aneurysm
1 3
( right
hemiparesis)
Cardiac arrest while
tapping pleural fluid
Patient 4 62/M 4 Basilar artery
dissecting
aneurysm
2 3 Vision loss due to
vitreous hemorrhage
Patient 5 42/M 4 Right ICA
blister
aneurysm
1 5 Malignant vasospasm
infarcts

9. Classical blister aneurysm
34-year M, SAH

10. 2 overlapping stents
1-year follow-up

11. Dissecting blister aneurysm –
poor grade
EVD
2-overlapping stents
Had repeated nasal & gastric bleedings (Varices,
Cirrhosis) - Anti-platelets were reduced
Almost complete clinical recovery
Case 3
5 months

12. Angiogram after 10 days
Case 2

16. A
D E F

18. A

19. B C

20. Review of literature
Neurosurgery. 2012 Jun;70(6):1415-29; discussion 1429. doi: 10.1227/NEU.0b013e318246a4b1.
Stent-assisted coiling of wide-necked aneurysms in the setting of acute subarachnoid hemorrhage: experience in 65
patients.
Neurosurgery. 2013 Jun;72(6):953-9. doi: 10.1227/NEU.0b013e31828ecf69.
Treatment of ruptured intracranial aneurysms: comparison of stenting and balloon remodeling.
AJNR Am J Neuroradiol. 2011
Aug;32(7):1232-6. doi:
10.3174/ajnr.A2478. Epub 2011 May 5.
Stent-assisted coiling in acutely
ruptured intracranial aneurysms: a
qualitative, systematic review of the
literature.

21. Conclusion
 Our findings demonstrate that stent-assisted coiling is a
viable treatment option for these challenging lesions in
the setting of an acute SAH.
 Hemorrhagic complications secondary to antiplatelet
agents, although potentially deadly or debilitating,
occurred infrequently.
 Thromboembloic complications can be avoided by
careful management with antiplatelets.