Challenges with staged treatment of a ruptured giant aneurysm

HISTORY

• 65 year old female collapsed at work with headache, confusion, altered mental status
• SAH HH 3/WFNS 2

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OPTIONS

• Subtotal coiling followed by flow diversion versus stent-assisted coiling
• Coiling plus flow diversion
• Open surgical clipping
  • Proximal neck exposure needed likely with retrograde suction decompression
  • Potential need for high flow bypass

DELAYED TREATMENT STRATEGY

• Treatment of ruptured complex and large/giant ruptured cerebral aneurysms by acute coiling followed by staged flow diversion. Brinjikji et al., JNS 2016
• ‘Plug and pipe’ strategy for treatment of ruptured intracranial aneurysms. Howard et al., JNIS 2019

SETUP

• 6F femoral sheath
• Benchmark Guide
• Echelon microcatheter
• Synchro select 014 microwire
• Coils – Target XL coils

THROMBUS FORMATION

• Thrombus at parent vessel and in distal MCA branch
• Cangrelor drip initiated
• The use of cangrelor in neurovascular interventions: a multicenter experience. Cortez et al., Neuroradiology 2021
  • Loading dose – 15 micrograms/kg
  • Infusion – 2 micrograms/kg/minute

SUBSEQUENT COURSE

• Cangrelor continued for a few hours
• Delayed CT head revealed a tract hemorrhage that was stable on repeat scans

HOSPITAL COURSE

• EVD was weaned around day 10
• Prior to dc dual antiplatelet therapy was initiated (Aspirin 325 mg and Clopidogrel 75 mg)
  • Discontinued due to subsequent GI bleed
  • Two duodenal ulcers were subsequently found, one of which was treated with clips by the GI service
• Eventually discharged around 1 month after admission on H pylori treatment

COURSE

• Initiated on Aspirin/Clopidogrel after completion of H pylori treatment
• Prolonged course of dapt completed (1 month) to ensure no recurrent GI bleed prior to planned flow diversion

FLOW-DIVERSION SETUP

• 8F femoral sheath
• Neuron-Max Guide
• CAT5 intermediate
• XT-27 microcatheter
• Synchro select 014 microwire
• Asahi 018 soft microwire
• Trevo 4 x 41 for reduction of microcatheter
• Surpass Evolve 4.25 x 25
• Transform 7 x 7 balloon

CHALLENGES

• Navigation required looping through the aneurysm with microcatheter
• Initial attempt with a Synchro 014 microwire and then switched to Asahi 018
• One coil loop was known to be across the microcatheter but given significant difficulty in finding the outflow this was left in place
• Microcatheter reduced with a Trevo 4 x 41 stent retriever

CONCLUSION

• Thrombus formation at the parent vessel can be seen with coiling of large and giant aneurysms – can be recognized at the time of coiling
• Acute flow diversion in the setting of subarachnoid hemorrhage can be done although this does limit flexibility of dual antiplatelet cessation with tract hemorrhage or a GI bleed
• Outflow navigation of microcatheter in the setting of a large coil mass with a giant aneurysm can be challenging