History of a double disease in a ruptured aneurysm

• 58-year-old female patient
• Headache and vomiting since 1 day
• Systemic hypertension for 2 years
• No other comorbidities

Examination

• Conscious and alert
• GCS- E3V4M6.
• No motor deficit, moves all 4 limbs
• Upper functions intact

Plain brain CT

CT angiogram

3D angiogram

2D working angle projection

Lateral projection

Injection after taking Ballast 088 guide catheter showing slow flow in one of the distal M4 branches to the frontoprietal region. Decided to inject tissue plasminogen activator after securing the Acom aneurysm.

Balloon-assited coiling

After second coil

Follow-up angiogram after the second coil showed active contrast extravasation indicating an aneurysm rupture.

Balloon inflated, blood pressure lowered and heparin reversed with protamine sulfate. Second coil repositioned. After detachment, no further bleeding.

Post-coiling CT

The follow-up CT scan showed a hematoma around the aneurysm with contrast along the anterior commissure. Hypodensity in the left frontal lobe with a focal area of loss of grey-white differentiation.

First day postoperative CT scan

Next day CT – Good contrast removal, left frontal lobe - focal area of infract.

Outcomes

• The patient was ventilated for 12 hours after the operation.
• Treated with Nimodipine statins and analgesics.
• Started low dose aspirin and heparin after operation.
• Regained GCS 15/15 after procedure.
• Low verbal production, otherwise no FND.
• Motor and upper functions intact.

• Study the anatomy of the aneurysm thoroughly - understand the weak points and likely rupture points.
• Therapeutic heparinization immediately after vascular access.
• Be prepared to deal with aneurysm rupture intraoperatively, especially with ruptured aneurysms.
  • Inflate the balloon
  • Lower blood pressure
  • Reverse heparin with protamine sulphate
  • Continue to occlude the aneurysm with coils.
• Assess the extent of bleeding and decide on postoperative elective ventilation.
• A localized haematoma around the aneurysm in case of intraoperative rupture is a better prognostic sign.