WEB + Coil of a ruptured DACA aneurysm

Witness the delicate management of an 81-year-old woman presenting with subarachnoid hemorrhage and profound neurological deficits. Delve into the nuances of using Sofia 5 Fr-EX and navigating through the Neuron MAX to deploy Scepter XC and VIA 17 for optimal outcomes. Gain invaluable insights into the strategic coil deployment and rapid coiling techniques to address protrusion through the aneurysm.

Case presentation

81 yo woman with subarachnoid hemorrhage
Hunt-Hess Grade 4, modified Fischer 4

Presentation: Sudden altered mental status. Brought to the hospital intubated, GCS 6 T

Exam: Opens eyes to noxious, pupils equal and reactive, withdraws to noxious stimuli, not following commands

Past medical history: Hypertension and hyperlipidemia

Figure 1 - WEB + coil of a ruptured DACA aneurysm

External ventricular drain placed and angiogram performed

Figure 2 - WEB + coil of a ruptured DACA aneurysm

Figure 3 - WEB + coil of a ruptured DACA aneurysm

Figure 4 - WEB + coil of a ruptured DACA aneurysm

Management options

How would you treat this poor grade elderly patient with a broad based DACA aneurysm with a Murphey's excrescence?

Coiling
Stent coiling
Flow diverter
Endosaccular device (WEB, Contour, Artisse)
Microsurgical clipping
Conservative management and/or palliation

Plan for coiling of daughter sac followed by WEB and with balloon protection

8 Fr short femoral sheathNeuron MAX long sheathSofia 5 Fr-EXScepter XC 4 x 11 mmVIA 17 microcatheterSynchro 14 guidewireStryker Target coilsWEB SL 7 x 2 mm

Figure 5 - WEB + coil of a ruptured DACA aneurysm

Plan for coiling of daughter sac with VIA 17

Inadvertent advancement of VIA 17 through the aneurysm sac during withdrawal of the Synchro 14

Figure 6 - WEB + coil of a ruptured DACA aneurysm

Coiling the daughter sac

Rapid coiling without retracting the VIA 17 until a compact coil mass is achieved in the rupture point

Figure 7 - WEB + coil of a ruptured DACA aneurysm

Control angiogram after coiling

Web deployment

No extravasation observed

Figure 8 - WEB + coil of a ruptured DACA aneurysm

Control after WEB SL 7 x 2 mm detached

Figure 9 - WEB + coil of a ruptured DACA aneurysm

Figure 10 - WEB + coil of a ruptured DACA aneurysm

Post-procedure exam unchanged

No new hemorrhage on CT or large stroke on MRI

Control angiogram post bleed day 6

Learning points

Sofia 5 Fr-EX has a large lumen allowing Scepter XC and VIA 17 placement yet small outer diameter allowing satisfactory roadmap/runs through the Neuron MAX
Remove the load on the VIA 17 prior to removal of Synchro 14
In case of protrusion through the aneurysm, rapid coiling without retraction of the microcatheter +/- inflation of Scepter XC balloon
In case of non-detachment of the WEB (sticky WEB)
- Pull slightly on the wire while applying gentle forward force on the VIA 17
- The preferrable morphology in case of sticky WEB is A or B, avoid C

Figure 11 - WEB + coil of a ruptured DACA aneurysm

Clinical Case Contest for SOFIA™'s 10th anniversary