Center for Brain Aneurysm Care - Aneurysm Coiling and Flow Diversion Protocol

This is a treatment protocol and guideline for aneurysm coiling and aneurysm flow diversion treatment used by our center.

In general, our philosophy is to treat with balloon assisted coiling first if the anatomy is amenable so as not to commit the patient to long term blood thinner (antiplatelet) therapy. Stent assisted coiling or flow diversion would be reserved for patients with wide neck, large aneurysms, or recurrent aneurysms.

Unruptured Aneurysm

imaging of large carotid terminus aneurysm, prior to treatment

Prior to procedure

  • Each patient should have a baseline head CT or MRI within the last 3 to 6 months prior to intervention.
  • Each patient should be given at least one dose of aspirin 81 or 325 mg, either the morning of the procedure, or the day before. If a stent-assisted coiling placement is envisioned, then aspirin 81 mg po qd AND clopidogrel 75 mg po qd should also be given for at least 3 to 5 days prior to the procedure. If the patient was not given the clopidogrel, or did not take the medication, then a loading dose of clopidogrel 300 mg po qd may be administered prior to procedure.
  • If endovascular flow diversion is envisioned, then aspirin 81 mg po qd AND cloipidogrel 75 mg po qd should be given 7-14 days prior to the procedure. Platelet testing will be performed prior to the procedure.

Post procedure

large carotid terminus aneurysm after treatment with stent-assisted coiling
  • Head CT (no contrast) on every patient the next day to look for silent ischemic complications from intervention.
  • If patient had a stent placed, patient would be discharged on asa 81 mg po qd and clopidogrel 75 mg po qd x 3 months. After 3 months, d/c clopidogrel and continue aspirin indefinitely. Otherwise, no antiplatelet medications required unless otherwise specified by interventionalist.
  • If patient had a flow diverter placed, patient would be discharged on asa 81 mg po qd and clopidogrel 75 mg po qd (or alternative) x 6 months. After 6 months, d/c clopidogrel and continue aspirin indefinitely.
  • Discharge patient at 24 hours.
  • Follow-up with neurointerventionalist at 1 to 3 month clinic follow-up. Neurointerventional team will assess for cerebrovascular risk factors at f/u and modification as necessary. MRA or angiogram to be scheduled in 6-12 months.
  • Patients with flow diverter placement will have follow-up angiogram at 6 months.

Long-term angiographic or MRA follow-up of aneurysm

  • 6 months, 18 months, 3 years, 5 years, 10 years

Ruptured Aneurysm

Post procedure

  • Begin heparin s/c in ICU 12 hours after procedure (unless otherwise specified by interventionalist).
  • Supplemental ASA will be advised to team at the discretion of neurointerventionalist (in general, additional antiplatelet therapy is not needed, unless there was a large aneurysm with large coil mass, or wide neck aneurysm).
  • Head CT (no contrast) on every patient the next day to look for silent ischemic complications from intervention.

At Discharge

  • Follow-up with neurointerventionalist at 2 to 3 month clinic follow-up (INR team will ask Jackie Baptista to schedule).
  • Neurointerventional team will assess for cerebrovascular risk factors at f/u and modification as necessary. Smoking cessation will be emphasized.
  • Catheter angiogram or MRA to be scheduled at 6-12 months.

Long-term angiographic follow-up of aneurysm

  • 6 months, 18 months, 3 years, 5 years, 10 years
  • If patient is difficult access or high risk for angiography, then 3D MRA with TOF
  • If evidence of recanalization, then angiograms may be scheduled at a closer interval.

Physicians performing endovascular aneurysm treatment:

References