Endovascualr Treatment of a Cerebral Aneurysm

Case 8 : Contributed by Dr. Kirti Khopkar

Other Cases

Clinical profile: 38 year-old-lady presented with sudden onset headaches ,which were severe and generalized, associated with vomiting, since 7-9 days. The patient was conscious, oriented but drowsy.

A CT scan of the brain showed a subarachnoid haemorrhage (SAH). An MR angiogram revealed an aneurysm at the top of right internal carotid artery A DSA was then performed. This showed a right ICA-top saccular aneurysm which was of subcentimetre size.

Fig 1

The sac was elongated, sausage shaped and tilted to the right side with a wide neck. There was no spasm. The MCA and ACA were well opacified.

There was good cross flow across the circle of Willis. After discussing the various treatment options, endovascular treatment was opted for. This procedure was performed under general anesthesia.

A Tracker10 microcatheter was navigated over a Dasher14 wire and placed into the aneurysm sac. Two GDC 10 coils (6x10, and 4x8 soft) were placed in the aneurysm and detached uneventfully.

While placing the third coil, (4x8 soft) the coil and tip of the microcatheter jumped outside the confines of the aneurysm.

Fig 2

DSA at this time showed significant leak of contrast in the subarachnoid space. Heparin was reversed, the leak sealed off in a few seconds.

Marked arterial spasm ensued . The coil was detached, part of it outside the aneurysm in the subarachnoid space and the catheter was withdrawn into the aneurysm sac.

Control angio done after a few minutes showed obstruction to right ICA flow due to a coil loop, with stagnation of contrast in supraclinoid right ICA .

Heparin infusion was restarted.

A Sentry balloon (15mm) was navigated and inflated across the neck, in right middle cerebral artery (MCA)and supraclinoid ICA. This pushed the coil back in the aneurysm and re-established blood flow in the right MCA through the ICA. Post-angioplasty angiogram showed good flow in right MCA, ACA with occlusion of aneurysm.

Fig 3

Fig 4

On waking up at the end of the procedure patient had headache and left face and upper limb weakness. These recovered over the next few days. She also developed signs of diabetes insipidus which cleared over the next ten days at which time she was discharged. As per our protocol she will be called after three months for a check angiogram.

Discussion:

An aneurysm is an abnormal dilatation of an artery. Intracranial aneurysm rupture is a significant cause of subarachnoid hemorrhage leading to patient morbidity and mortality.

The incidence of intracranial saccular aneurysms is 1 to 5%; the common location being the circle of Willis. In our department we see between 100-150 patients with SAH due to intracranial aneurysm rupture in a year.

Classically they have been treated with surgical clipping. Endovascular therapy has emerged in the 90’s and in many centres world over perform GDC coiling of the intracranial aneurysms as the primary treatment modality.In our institute, endovascular treatment is the automatic choice for posterior circulation aneurysms and is gaining grounds in other locations too.

Guglielmi detachable coils(GDC) are made of soft platinum alloy attached to a stainless steel delivery wire. Coils are electrolitically detached by application of low voltage current. Coils of various softness, helical diameter , and length are available. GDC coils provide complete control at the time of deployment hence allow to be used in critical work such as treatment of aneurysm of the brain.

Parent vessel occlusion (1 to 3%) and embolic episodes (5-10%) are the commoner complications.

Aneurysmal perforation during coiling has been reported in less than 3% of cases. If it happens during the placement of the first or second coil, is often fatal. It is generally believed that the subarachnoid leak which happens when a few coils that have already been detached is less dangerous. It may happen because the exact catheter tip location becomes obscure in the coil mass resulting in possible pushing of the coil on the aneurysm wall or weakness. Anticoagulation has to be reversed immediately and coiling of the aneurysm should be completed.

Aneurysm rupture during open surgery though often results in critical complication or death.