{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T03:02:26Z","timestamp":1779678146033,"version":"3.53.1"},"reference-count":48,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2026,5,24]],"date-time":"2026-05-24T00:00:00Z","timestamp":1779580800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Intraprocedural rupture (IPR) during stent-assisted coiling (SAC) after stent deployment can create a narrow and rapidly changing management problem: hemorrhage control, anticoagulation reversal, acute thrombotic occlusion, and postprocedural cerebrospinal fluid diversion may all become urgent within the same clinical sequence. We report a fatal IPR during SAC of an unruptured anterior communicating artery (AComA) aneurysm and use the case as an anchor for a targeted case-based narrative review. A 71-year-old woman underwent SAC for a 5.1-mm posteriorly directed AComA aneurysm with a bleb after treatment for vertebrobasilar ischemia. Fourth-coil insertion produced tactile resistance and contrast extravasation. Protamine reversal and temporary A1 flow control reduced the leak, but filling defects then developed from the internal carotid artery terminus to the A1 and M1 segments, requiring rescue thrombectomy. Computed tomography showed subarachnoid hemorrhage and intraventricular hemorrhage; same-day progression with hydrocephalus required bilateral external ventricular drainage. The patient died on postoperative day 7. This case highlights IPR during SAC as a time-dependent hemorrhagic\u2013thrombotic escalation rather than a single technical event. We propose a staged assistant\u2013operator communication model for risk mapping, rupture recognition, hemostatic-route preservation, thrombotic surveillance, and transition to computed tomography, external ventricular drainage, and intensive care.<\/jats:p>","DOI":"10.3390\/jcm15114056","type":"journal-article","created":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T01:45:08Z","timestamp":1779673508000},"page":"4056","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Case Report: Hemorrhagic\u2013Thrombotic Escalation After Intraprocedural Rupture During Stent-Assisted Coiling: A Case-Based Narrative Review and Staged Communication Model"],"prefix":"10.3390","volume":"15","author":[{"given":"Kosei","family":"Goto","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Fukujukai Adachi Tobu Hospital, Tokyo 121-0816, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7044-9151","authenticated-orcid":false,"given":"Nobuo","family":"Kutsuna","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fukujukai Adachi Tobu Hospital, Tokyo 121-0816, Japan"},{"name":"Department of Stress and Invasiveness Control, Toho University School of Medicine, Tokyo 153-8515, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Takuto","family":"Nishihara","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fukujukai Adachi Tobu Hospital, Tokyo 121-0816, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kotaro","family":"Makita","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fukujukai Adachi Tobu Hospital, Tokyo 121-0816, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,24]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"575","DOI":"10.1177\/1591019920947857","article-title":"Impact and prevention of errors in endovascular treatment of unruptured intracranial aneurysms","volume":"26","author":"Ospel","year":"2020","journal-title":"Interv. Neuroradiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"28","DOI":"10.3174\/ajnr.A6830","article-title":"Enhancing Education to Avoid Complications in Endovascular Treatment of Unruptured Intracranial Aneurysms: A Neurointerventionalist\u2019s Perspective","volume":"42","author":"Goyal","year":"2021","journal-title":"AJNR Am. J. Neuroradiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1136\/neurintsurg-2011-010137","article-title":"A checklist for cerebral aneurysm embolization complications","volume":"5","author":"Chen","year":"2013","journal-title":"J. Neurointerv. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"E59","DOI":"10.3174\/ajnr.A2140","article-title":"A checklist in the event of aneurysm perforation during coiling","volume":"31","author":"Taussky","year":"2010","journal-title":"AJNR Am. J. Neuroradiol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1177\/1591019918758493","article-title":"Complications of endovascular treatment for intracranial aneurysms: Management and prevention","volume":"24","author":"Ihn","year":"2018","journal-title":"Interv. Neuroradiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"497","DOI":"10.1136\/neurintsurg-2012-010430","article-title":"Enhanced staff communication and reduced near-miss errors with a neurointerventional procedural checklist","volume":"5","author":"Fargen","year":"2013","journal-title":"J. Neurointerv. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Aoki, K., Murayama, Y., Tanaka, Y., Ishibashi, T., Irie, K., Fuga, M., Kato, N., Kan, I., Nishimura, K., and Nagayama, G. (2024). Risk factors and management of intraprocedural rupture during coil embolization of unruptured intracranial aneurysms: Role of balloon guiding catheter. Front. Neurol., 15.","DOI":"10.3389\/fneur.2024.1343137"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"435","DOI":"10.2176\/nmc.oa.2018-0131","article-title":"Evaluation of Acute In-stent Thrombosis during Stent-assisted Coil Embolization of Unruptured Intracranial Aneurysms","volume":"58","author":"Nii","year":"2018","journal-title":"Neurol. Med. Chir."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1136\/neurintsurg-2018-013943","article-title":"Stent-assisted coil embolization of anterior communicating artery aneurysms: Safety, effectiveness, and risk factors for procedural complications or recanalization","volume":"11","author":"Choi","year":"2019","journal-title":"J. Neurointerv. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1177\/1591019918798144","article-title":"Stent-assisted coil embolization of anterior communicating artery aneurysms using the LVIS Jr stent","volume":"25","author":"Santillan","year":"2019","journal-title":"Interv. Neuroradiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"3157","DOI":"10.1007\/s10143-022-01853-w","article-title":"Intra-procedural complications, success rate, and need for retreatment of endovascular treatments in anterior communicating artery aneurysms: A systematic review and meta-analysis","volume":"45","author":"Yarahmadi","year":"2022","journal-title":"Neurosurg. Rev."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"568","DOI":"10.1227\/neu.0000000000003126","article-title":"Safety and Efficacy of Management for Intraprocedural Rupture During Endovascular Treatment for Intracranial Aneurysms","volume":"96","author":"Hirai","year":"2025","journal-title":"Neurosurgery"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1016\/j.jclinepi.2017.04.026","article-title":"CARE guidelines for case reports: Explanation and elaboration document","volume":"89","author":"Riley","year":"2017","journal-title":"J. Clin. Epidemiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1186\/s41073-019-0064-8","article-title":"SANRA-a scale for the quality assessment of narrative review articles","volume":"4","author":"Baethge","year":"2019","journal-title":"Res. Integr. Peer Rev."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"374","DOI":"10.1136\/neurintsurg-2017-013110","article-title":"Timing of complications during and after elective endovascular intracranial aneurysm coiling","volume":"10","author":"Klurfan","year":"2018","journal-title":"J. Neurointerv. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"370","DOI":"10.1007\/s00701-024-06262-0","article-title":"Outcomes and predictors of intraprocedural rupture in patients with cerebral aneurysm","volume":"166","author":"Kim","year":"2024","journal-title":"Acta Neurochir."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"The UCAS Japan Investigators (2012). The natural course of unruptured cerebral aneurysms in a Japanese cohort. N. Engl. J. Med., 366, 2474\u20132482.","DOI":"10.1056\/NEJMoa1113260"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1016\/S1474-4422(13)70263-1","article-title":"Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: A pooled analysis of six prospective cohort studies","volume":"13","author":"Greving","year":"2014","journal-title":"Lancet Neurol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2368","DOI":"10.1161\/STR.0000000000000070","article-title":"Guidelines for the Management of Patients with Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals from the American Heart Association\/American Stroke Association","volume":"46","author":"Thompson","year":"2015","journal-title":"Stroke"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1136\/neurintsurg-2017-013156","article-title":"Risk factors for and outcomes of intraprocedural rupture during endovascular treatment of unruptured intracranial aneurysms","volume":"10","author":"Kawabata","year":"2018","journal-title":"J. Neurointerv. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"731","DOI":"10.1227\/NEU.0b013e3182077373","article-title":"Endovascular therapy of very small aneurysms of the anterior communicating artery: Five-fold increased incidence of rupture","volume":"68","author":"Schuette","year":"2011","journal-title":"Neurosurgery"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"531","DOI":"10.3340\/jkns.2021.0283","article-title":"Could A1 Aplasia or Hypoplasia Affect the Morphology and Rupture Risk of Anterior Communicating Artery Aneurysm?","volume":"65","author":"Park","year":"2022","journal-title":"J. Korean Neurosurg. Soc."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"370","DOI":"10.1136\/neurintsurg-2016-012335","article-title":"Predicting intraprocedural rupture and thrombus formation during coiling of ruptured anterior communicating artery aneurysms","volume":"9","author":"Fan","year":"2017","journal-title":"J. Neurointerv. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"iii62","DOI":"10.1136\/neurintsurg-2012-010503","article-title":"Stent assisted embolization of 64 anterior communicating artery aneurysms","volume":"5","author":"Johnson","year":"2013","journal-title":"J. Neurointerv. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"182","DOI":"10.7461\/jcen.2022.E2022.05.003","article-title":"Alterations of vital signs as prognostic factors after intraprocedural rupture of intracranial aneurysms during endovascular treatment","volume":"25","author":"Kim","year":"2023","journal-title":"J. Cerebrovasc. Endovasc. Neurosurg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"177","DOI":"10.1016\/j.wneu.2017.05.147","article-title":"Intraprocedural Rupture of Unruptured Cerebral Aneurysms During Coil Embolization: A Single-Center Experience","volume":"105","author":"Cho","year":"2017","journal-title":"World Neurosurg."},{"key":"ref_27","first-page":"738","article-title":"Management of aneurysm perforation during Guglielmi electrodetachable coil placement","volume":"23","author":"Hirai","year":"2002","journal-title":"AJNR Am. J. Neuroradiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"907","DOI":"10.1007\/s00234-006-0147-3","article-title":"Prevention and management of intraprocedural rupture of intracranial aneurysm with detachable coils during embolization","volume":"48","author":"Li","year":"2006","journal-title":"Neuroradiology"},{"key":"ref_29","first-page":"1059","article-title":"Outcomes after aneurysm rupture during endovascular coil embolization","volume":"49","author":"Tummala","year":"2001","journal-title":"Neurosurgery"},{"key":"ref_30","first-page":"807","article-title":"Rupture of intracranial aneurysms during endovascular coiling: Management and outcomes","volume":"49","author":"Levy","year":"2001","journal-title":"Neurosurgery"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"420","DOI":"10.7461\/jcen.2023.E2023.07.004","article-title":"Correlation between contrast leakage period of procedural rupture and clinical outcomes in endovascular coiling for cerebral aneurysms","volume":"25","author":"Kim","year":"2023","journal-title":"J. Cerebrovasc. Endovasc. Neurosurg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1016\/j.jocn.2018.12.025","article-title":"Intraprocedural rupture management for intracranial aneurysm rupture during coil embolization by manual common carotid artery compression","volume":"62","author":"Chang","year":"2019","journal-title":"J. Clin. Neurosci."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e289","DOI":"10.1016\/j.wneu.2019.10.038","article-title":"Long-term Outcomes After Intraprocedural Aneurysm Rupture During Coil Embolization of Unruptured Intracranial Aneurysms","volume":"134","author":"Yamagami","year":"2020","journal-title":"World Neurosurg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"108837","DOI":"10.1016\/j.clineuro.2025.108837","article-title":"Evaluation of acute intraprocedural thromboembolism risk factors in endovascular treatment of unruptured intracranial aneurysms","volume":"252","author":"Senturk","year":"2025","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1098","DOI":"10.1161\/STROKEAHA.116.016521","article-title":"Ischemic Stroke After Treatment of Intraprocedural Thrombosis During Stent-Assisted Coiling and Flow Diversion","volume":"48","author":"Adeeb","year":"2017","journal-title":"Stroke"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Li, G., Xing, H., Mao, G., Cai, J., Jin, D., Tian, Y., Zhang, X., and Zhao, B. (2022). Predictors of thromboembolic complications after stent-assisted coiling of acutely ruptured intracranial aneurysms: A retrospective multicenter study. Front. Cardiovasc. Med., 9.","DOI":"10.3389\/fcvm.2022.922858"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"130","DOI":"10.4103\/bc.bc_51_19","article-title":"Treatment of acute thrombosis during stent-assisted coil embolization of ruptured proximal posterior inferior cerebellar artery aneurysm","volume":"6","author":"Li","year":"2020","journal-title":"Brain Circ."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"479","DOI":"10.1093\/neuros\/nyy127","article-title":"External Ventricular Drain and Hemorrhage in Aneurysmal Subarachnoid Hemorrhage Patients on Dual Antiplatelet Therapy: A Retrospective Cohort Study","volume":"84","author":"Hudson","year":"2019","journal-title":"Neurosurgery"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"397","DOI":"10.1007\/s10143-018-0999-0","article-title":"Ventriculostomy-related hemorrhage in patients on antiplatelet therapy for endovascular treatment of acutely ruptured intracranial aneurysms: A meta-analysis","volume":"43","author":"Cagnazzo","year":"2020","journal-title":"Neurosurg. Rev."},{"key":"ref_40","first-page":"544","article-title":"Safety and Efficacy of Ventriculostomy Procedures under Dual Antiplatelet Therapy in Patients Treated with Stent Assisted Coiling in Subarachnoid Hemorrhage","volume":"28","author":"Civi","year":"2018","journal-title":"Turk. Neurosurg."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"35","DOI":"10.5469\/neuroint.2018.01067","article-title":"External Ventricular Drainage before Endovascular Treatment in Patients with Aneurysmal Subarachnoid Hemorrhage in Acute Period: Its Relation to Hemorrhagic Complications","volume":"14","author":"Lim","year":"2019","journal-title":"Neurointervention"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1653","DOI":"10.1016\/j.wneu.2015.07.003","article-title":"Ventriculostomy-Related Hemorrhage After Treatment of Acutely Ruptured Aneurysms: The Influence of Anticoagulation and Antiplatelet Treatment","volume":"84","author":"Bruder","year":"2015","journal-title":"World Neurosurg."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1021","DOI":"10.3171\/2010.9.JNS10445","article-title":"Risk of ventriculostomy-related hemorrhage in patients with acutely ruptured aneurysms treated using stent-assisted coiling","volume":"114","author":"Kung","year":"2011","journal-title":"J. Neurosurg."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1159\/000489709","article-title":"Neurointerventional \u2018Near Morbidity\u2019: A Candid Appraisal of an Early Case Series","volume":"7","author":"Gross","year":"2018","journal-title":"Interv. Neurol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1136\/neurintsurg-2019-015073","article-title":"Evaluation of a modular in vitro neurovascular procedure simulation for intracranial aneurysm embolization","volume":"12","author":"Nawka","year":"2020","journal-title":"J. Neurointerv. Surg."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"123673","DOI":"10.1016\/j.wneu.2025.123673","article-title":"Video-Based Propagation of Tacit Knowledge During Coil Embolization of Intracranial Aneurysms","volume":"195","author":"Nakamura","year":"2025","journal-title":"World Neurosurg."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"350","DOI":"10.2307\/2666999","article-title":"Psychological safety and learning behavior in work teams","volume":"44","author":"Edmondson","year":"1999","journal-title":"Adm. Sci. Q."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"941","DOI":"10.1002\/job.413","article-title":"Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams","volume":"27","author":"Nembhard","year":"2006","journal-title":"J. Organ. Behav."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/11\/4056\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T02:06:34Z","timestamp":1779674794000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/11\/4056"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,24]]},"references-count":48,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["jcm15114056"],"URL":"https:\/\/doi.org\/10.3390\/jcm15114056","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,24]]}}}