Background
Delayed ipsilateral intraparenchymal haemorrhage is a recently recognised complication
after endovascular flow diversion for intracranial aneurysms. Although the mechanism
of this phenomenon is not understood, one proposed explanation (the windkessel hypothesis)
is that removal of aneurysmal compliance increases distal pulse pressure.
Methods
We present a case of delayed haemorrhage after placement of a Pipeline stent, discuss
the proposed mechanisms, and describe a novel electrical analogue model that was used
to evaluate the likely haemodynamic effect of stent placement.
Results
Model-based analysis suggests that stenting is not likely to produce a significant
change in distal pulse pressure. Moreover, basic fluid dynamics principles suggest
that a local reduction in disturbed flow in the region of the aneurysm could produce
only a minor increase in distal pressure (a few mmHg), which is unlikely to be the
main cause of the observed haemorrhage.
Conclusion
The windkessel hypothesis is unlikely to explain the occurrence of delayed ipsilateral
intraparenchymal haemorrhage after flow diversion; however, other mechanisms involving
altered haemodynamics distal to the treated aneurysm may play a role. Further studies
involving the assessment of haemodynamic changes after flow diversion would be useful
to understand, and eventually mitigate, this currently unpredictable risk.
Keywords
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References
- Delayed ipsilateral parenchymal hemorrhage following flow diversion for the treatment of anterior circulation aneurysms.AJNR Am J Neuroradiol. 2012; 33: 603-608
- Review of reported complications associated with the Pipeline Embolization Device.World neurosurgery. 2012; 77: 403-404
- Delayed intraparenchymal hemorrhage following pipeline embolization device treatment for a giant recanalized ophthalmic aneurysm.Journal of NeuroInterventional Surgery. 2012; 4 (e24–e)
- Aneurysm Rupture Following Treatment with Flow-Diverting Stents: Computational Hemodynamics Analysis of Treatment.AJNR Am J Neuroradiol. 2011; 32: 27-33
- High-resolution CFD detects high-frequency velocity fluctuations in bifurcation, but not sidewall, aneurysms.J Biomech. 2013; 46: 402-407
- Regarding “Aneurysm Rupture Following Treatment with Flow-Diverting Stents: Computational Hemodynamics Analysis of Treatment”.American Journal of Neuroradiology. 2011; 32 (E95–E7)
- An impedance index in normal subjects and in subarachnoid hemorrhage.Ultrasound Med Biol. 1996; 22: 373-382
- Direct numerical simulation of transitional flow in a patient-specific intracranial aneurysm.J Biomech. 2011; 44: 2826-2832
- Hemodynamics for the vascular surgeon.Arch Surg. 1980; 115: 216
- Transcranial color Doppler sonography of basal cerebral arteries in 182 healthy subjects: age and sex variability and normal reference values for blood flow parameters.AJR American Journal of Roentgenology. 1999; 172: 213-218
- Blood Pressure Variability and Organ Damage in a General Population: Results from the PAMELA Study.Hypertension. 2002; 39: 710-714
FDA Executive Summary. FDA Executive Summary - Chestnut Medical Pipeline Embolization Device. 2011.
- The pipeline embolization device for the intracranial treatment of aneurysms trial.American Journal of Neuroradiology. 2011; 32: 34-40
- Histopathological assessment of fatal ipsilateral intraparenchymal hemorrhages after the treatment of supraclinoid aneurysms with the Pipeline Embolization Device: Report of 3 cases.J Neurosurg. 2014; 120: 365-374
- Cerebral hyperperfusion after flow diversion of large intracranial aneurysms.Journal of Neurointerventional Surgery. 2013; 5 (e48–e)
- A 1D arterial blood flow model incorporating ventricular pressure, aortic valve and regional coronary flow using the locally conservative Galerkin (LCG) method.Comm Numer Methods Eng. 2008; 24: 367-417
- Validation of a one-dimensional model of the systemic arterial tree.Am J Physiol Heart Circ Physiol. 2009; 297: H208-H222
- Endografting of the Descending Thoracic Aorta Increases Ascending Aortic Input Impedance and Attenuates Pressure Transmission in Dogs.Eur J Vasc Endovasc Surg. 2006; 32: 129-135
- Revisiting the Risk of Intraparenchymal Hemorrhage following Aneurysm Treatment by Flow Diversion.American Journal of Neuroradiology. 2012; 33: E107
- Haemodynamic consequences of embolizing aneurysms: a transcranial Doppler study.Br J Neurosurg. 1995; 9: 749-758
- Arterial pressure, vascular input impedance, and resistance as determinants of pulsatile blood flow in the umbilical artery.Eur J Obstet Gynecol Reprod Biol. 1999; 84: 119-125
- Ultrastructural morphometry of hypertensive medial damage in lenticulostriate and other arteries.Stroke. 1985; 16: 449-453
Article info
Publication history
Published online: February 17, 2015
Accepted:
February 9,
2015
Received in revised form:
January 20,
2015
Received:
December 19,
2014
Identification
Copyright
© 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
