A Big Headache Taken
Care of

Successful management of tricky Aneurysm with
Endovascular Coiling

THE CASE

A 59-year-old man, non-hypertensive and non-diabetic, visited Nanavati Super Speciality Hospital with history of severe headache and vomiting accompanied by spells of unconsciousness. The patient was stabilised and was then sent for a brain CT scan. The CT scan revealed acute subarachanoid haemorrhage in the right sylvian fissure. A cerebral Digital Subtraction Angiography (DSA) was then performed, revealing a Middle Cerebral Artery (MCA) trifurcation aneurysm (swelling of the wall of an artery) with a proximal M1 stenosis. The patient was counselled for an emergent management of aneurysm with Endovascular Coiling.

The major challenges that had to be overcome during this procedure included:

1. Exclusion of the aneurysm, by Endovascular Coiling, and keeping the 3 major distal cortical branches arising from the M2-3 trifurcation patent. Any coil prolapse into these branches would have led to a major MCA stroke


2. A stent placement would be mandatory to achieve desired treatment, but it was not possible to load the patient with antiplatelets prior to the procedure as he had already suffered a Subarachnoid Haemorrhage (SAH) due to the rupture of aneurysm

The state-of-the-art Three Dimensional Rotational Angiography (3DRA) facility available in Nanavati Super Speciality Hospital reported exact anatomy of the lesion, and the exact relationship of the MCA branches with each other, and, with the neck of the aneurysm. It also helped in choosing the correct size of stent by estimating the length and diameter.

THE PROCEDURE

The patient was taken for Endovascular Coiling under general anaesthesia, via right femoral arterial approach. A balloon catheter was placed across the neck, and the first successful exclusion of the aneurysm was achieved with coils.

The patient was then loaded on to the table with dual antiplatelets (Ecospirin / Brillinta) via ryles tube, which was followed by a placement of the stent across the desired segment of the MCA branch so as to cover the neck and keep the branches patent. The final step was the balloon dilatation of the M1-M2 junction stenosis. The patient developed vasospasm on day 4 (post SAH sequelae). This was achieved with an intra-arterial nimodipine infusion.

THE RESULT

The patient recovered well and was discharged with modified Rankin Scale (mRS) 0. At 6 months follow-up, the patient was symptom free and a check-up of the cerebral angiogram revealed successful exclusion of aneurysm and normal patency of the M1 segment of MCA.

Dr. Abhijeet Soni
Sr. Consultant
Interventional Radiologist
Nanavati Super Speciality
Hospital, Mumbai