Thromboembolic Events Associated with Balloon-Assisted Coil Embolization: Evaluation with Diffusion-Weighted MR Imaging

Sait Albayram; Hakan Selcuk; Batuhan Kara; Erhan Bozdag; Omer Uzma; Naci Kocer; Civan Islak

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Fig 1.
Right vertebral AP arteriograms obtained in a 40-year-old woman with severe headache and a right SCA aneurysm.
A, Image shows a wide-necked aneurysm of the right SCA. Distal portion of the SCA and its branches are seen clearly.
B, Immediate postembolization image shows nearly complete aneurysmal occlusion with coils, with a minimal neck remnant around the right SCA orifices. Distal portion of the SCA and its branches (arrows) are not seen clearly because of thromboembolic events during the procedure.
C and D, Images from a second procedure. Image in C shows wide-necked aneurysmal recurrence of the right SCA 3 months after the first procedure. Immediate postembolization image in D shows nearly complete aneurysmal occlusion with coils, with minimal neck remnant around the right SCA orifices (arrow). Right SCA (arrowheads) is not seen clearly because of resistant thromboembolic event during the procedure.
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Fig 2.
Images obtained in a 34-year-old man with SAH (grade 2) and a right SCA aneurysm.
A, Right vertebral AP arteriogram shows a large, wide-necked aneurysm of the right SCA.
B, Unsubtracted view shows the inflated microballoon at the neck of aneurysm (arrow) and microcatheter delivering the coil into the aneurysm (arrowhead).
C, Immediate postembolization right vertebral AP arteriogram shows complete aneurysmal occlusion with coils. Distal portion of SCA and its branches are seen clearly without thromboembolic phenomena.
D and E, DW image(D) and ADC map (E) 4 hours after the procedure show ischemic areas in the right and left SCA territories (arrows).

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TABLE 1:

Summary of clinical and aneurysmal data

Procedure/Age (y)/Sex	Presentation	Location of Aneurysm	Size of Aneurysm (mm)	Diameter of Neck (mm)	Dome-to-Neck Ratio	Balloon Inflation Location	Occlusion of Orifice	Occlusion Rate	Alternate Collateral Circulation	Angiographic Thromboembolic Phenomena During Procedure
1/54/M	Headache	L ICA paraophtalmic	3	3	1	C3	OA	Complete	ACoA	No
2/40/F	Headache	R SCA	8	4	2	Distal basilar artery	Bil PCA and SCA	Subtotal occlusion	R PCoA	R SCA
3/60/F	Headache	R ICA paraophtalmic	8	4	2	C2–C3	OA, PCoA	Complete	ACoA	No
4/57/F	Headache	L ICA cavernous segment	14	10	1.4	C4	None	Complete	ACoA	No
5/52/F	Headache	R ICA paraophtalmic	7	4	1.75	C2	OA	Complete	ACoA	No
6/39/M	SAH grade 3	R SCA	8	5	1.6	Distal basilar artery	Bil PCA and SCA	Complete	R PCoA	No
7/34/M	SAH grade 2	R SCA	15	6	2.5	Distal basilar artery	Bil PCA and SCA	Complete	Not applicable	No
8/39/M	Incidental	L ICA paraophtalmic	7	5	1.4	C3	OA	Complete	AcoA, L PCoA	No
9/34/F	SAH grade 1	L ICA Hypophsyeal	4	4	1	C2–C3	OA	Complete	ACoA	No
10/57/F	SAH grade 2	L ICA paraophtalmic	5	4	1.25	C2–C3	PCoA, AChoA	Failed	AcoA, L PCoA	Thrombosis in ICA
11/52/F	SAH grade 1	L ICA paraophtalmic	5	4	1.25	C2–C3	OA	Complete	ACoA	No
12/37/M	Regrowth	L ICA paraophtalmic	8	6	1.3	C2–C3	OA	Complete	L PCoA	No
13/52/F	Incidental	R ICA hypophsyeal	4	3	1.3	C2–C3	OA	Complete	ACoA, R PCoA	No
14/40/F	Regrowth	R SCA	10	4	2.5	Distal basilar artery	Bil PCA and SCA	Subtotal occlusion	R PCoA	Occlusion of R SCA
15/64/F	SAH grade 2	Basilary Tip	7	7	1	Distal basilar artery	Bil PCA and SCA	Nearly complete	Not applicable	No
16/45/F	SAH grade 1	Basilary Tip	4	4	1	Distal basilar artery	R PCA-Bil SCA	Nearly complete	Bil. PCoA	No
17/59/F	Headache	L ICA paraophtalmic	3	3	1	C2–C3	PCoA	Complete	ACoA, L PCoA	No
18/40/F	Regrowth	R SCA	4	4	1	Distal basilar artery	Bil PCA-L SCA	Complete	R PCoA	No
19/63/F	Regrowth	R ICA paraophtalmic	4	3	1.30	C2	None	Complete	ACoA	No
20/67/F	Headache	L ICA Bifurcation	7	5	1.40	C1–M1 Segment	Lenticulostriat	Complete	ACoA, PCoA	No

Note.—Bil indicates bilateral; PCA, posterior cerebral artery.

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TABLE 2:

Summary of technical factors and DWI findings

Procedure	Type of Microballoon	Size of Microballoon (mm)	Microballoon Inflation Time (seconds)		Total Inflation Time (seconds)	Number of Inflations	Keeping Time (seconds)	No. Microcatheter Repositionings	No. of Coil Removal and Repositionings	No. of GDCs	DWI	Lesions
Procedure	Type of Microballoon	Size of Microballoon (mm)	Minimum	Maximum	Total Inflation Time (seconds)	Number of Inflations	Keeping Time (seconds)	No. Microcatheter Repositionings	No. of Coil Removal and Repositionings	No. of GDCs	DWI	Location	Size^*
1	Equinox	4 × 5	60	130	560	6	86	2	2	4	No	None	NA
2	Sentry-10	3.5 × 10	90	180	510	4	53	4	6	6	Yes	R SCA territory	2 × 2 cm
3	Hyperglide	4 × 20	42	147	740	9	119	0	1	5	No	None	NA
4	Hyperglide	4 × 20	20	155	1360	16	150	0	0	15	No	None	NA
5	Sentry-15	3 × 15	10	127	721	15	130	0	2	4	No	None	NA
6	Sentry-10	3.5 × 10	37	81	313	6	77	0	0	4	No	None	NA
7	Sentry-10	3.5 × 10	15	130	778	14	90	4	5	5	Yes	Both SCA territory	R 2 × 2 cm L 5 × 5 mm
8	Sentry-10	3.5 × 10	21	184	625	7	69	0	0	1	No	None	NA
9	Sentry-10	3.5 × 10	13	90	354	8	84	0	1	5	No	None	NA
10	Sentry-10	3.5 × 10	5	117	294	6	160	0	1	NA	No	None	NA
11	Hyperglide	4 × 20	5	378	1866	20	180	0	1	5	No	None	NA
12	Sentry-15	3.5 × 15	20	140	878	15	80	0	0	3	No	None	NA
13	Hyperglide	4 × 20	20	260	1518	11	113	0	1	4	No	None	NA
14	Sentry-10	3.5 × 10	20	110	480	9	101	5	6	4	Yes	Both SCA territory	R 15 × 10 mm, L 10 × 5 mm
15	Sentry-10/15	3.5 × 10/15	15	190	710	8	117	0	0	5	No	None	NA
16	Sentry-10	3.5 × 10	20	255	565	7	107	0	0	7	No	None	NA
17	Sentry-10	3.5 × 10	25	255	630	6	116	0	0	1	No	None	NA
18	Sentry-10	3.5 × 10	20	110	480	9	57	0	0	4	No	None	NA
19	Sentry-15	3.5 × 5	40	120	585	10	85	1	0	5	No	None	NA
20	Sentry-15	3.5 × 5	33	213	1035	11	143	4	5	9	Yes	MCA territory L BG	Multiple scattered