A recent article published by Dr Robert Willinsky and colleagues from Toronto is noteworthy and an excellent addition to the literature on the subject of endovascular treatment of ruptured aneurysms. This is one of the largest series on this subject and addresses, amongst other things, the important issue of rebleeding after endovascular repair.

In this large series, the rehemorrhage rate after embolization was 2.1%. The risk of rebleeding was 1.6% in the first 30 days, decreasing to 0.7% after this time. The authors use a protocol of imaging the ruptured aneurysms with enhanced MRA at the time of discharge, followed by another MRA relatively early at 2-3 months to detect early recanalization/regrowth of aneurysms. Interestingly, the rebleeding rate from initially completely coiled aneurysms was similar to those with neck and body remnants. Therefore, their approach is not to strive for a “perfect” angiographic result that tends to increase the complication rates. They did not specifically comment on the issue of use of stents (and associated antiplatelet therapy) in the setting of ruptured aneurysms and whether or not any of the rebleeds occurred in the context of stent assisted coil embolization.

The complication, recanalization and retreatment rates presented are similar to other large series. As would be expected, their complication rates have steadily decreased with time concurrent with improvements in endovascular catheter and coil technology as well as increasing experience with this technique. There are many excellent suggestions throughout the manuscript relating to optimal treatment approach towards ruptured aneurysms as well as follow-up after therapy. It is very interesting to read how these approaches have evolved over the last 14 years at the authors’ institution. This article is vitally important in furthering our understanding of endovascular therapy of ruptured aneurysms.

Reference
Willinsky RA, Peltz J, da Costa L, et al.  Clinical and Angiographic Follow-up of Ruptured Intracranial Aneurysms Treated with Endovascular Embolization.  AJNR Am J Neuroradiol, first published March 25, 2009 as doi:10.3174/ajnr.A1488.