Endovascular Treatment of Ruptured Intracranial Aneurysms and Intra‐Procedural Re‐Rupture

Introduction Intra‐procedural re‐rupture (IPRR) during endovascular treatment of previously ruptured intracranial aneurysms is a rare but life‐threatening event with limited consolidated evidence. This paper aims to review and synthesize available literature on the incidence, risk factors, procedural contributors, and clinical outcomes of IPRR. Methods A systematic search of PubMed and Scopus was conducted through April 2025 following PRISMA guidelines. Studies reporting on IPRR in ruptured aneurysms treated with coiling techniques were included. Data were extracted on aneurysm characteristics, procedural factors, complications, and outcomes. Results A total of 24 studies comprising 11,431 intracranial aneurysms were included, with an overall intra‐procedural re‐rupture (IPRR) incidence of 3.4%. IPRR occurred most frequently in very small aneurysms (<3.5 mm) and in the anterior communicating artery (45% of cases). The dominant procedural triggers were first‐coil perforation (69%) and microcatheter or guidewire manipulation (31%). Patient comorbidities frequently associated with IPRR included hypertension (43%) and smoking (41%). Clinical outcomes were poor: mortality reached 12%, and only 58% achieved favorable recovery, while angiographic follow‐up demonstrated complete occlusion in just 24% of cases. Complications following IPRR included vasospasm (30%), hydrocephalus (19%), thromboembolic events (17%), and intracerebral hemorrhage (12%). Conclusion IPRR, though infrequent, is associated with disproportionately high morbidity and mortality. Risk awareness, careful technique—especially during early device deployment—and targeted preventive strategies are essential to improve outcomes in this high‐risk group.