Predicting the unpredictable course of events after a Flow Diverter placement

Patient presentation

• 47-year-old male patient
• HTN, Chronic smoker
• HCV reactive, IV drug abuser/ Opium addict
• Sudden onset headache and vomiting, HH2
• On examination :
  • GCS E4V5M6, No focal deficit

B/L wide complex MCA bifurcation and left para-ophthalmic aneurysm

Preferred Approach to be considered:

• Which one likely ruptured?
• Which side to treat FIRST?
• Should both be treated?

Treatment Options to be considered:

• Balloon-assisted coiling?
• Stent-assisted coiling?
• Flow diverter stent ALONE / WITH coiling?
• Surgical clipping?
• Surgical + Endovascular

We considered stent-assisted coiling on right side and coated flow diverter stent for left side in same sitting.

Loaded 2 hours prior with Tablet Ecosprin 150 mg And Tablet Ticagrelor 180 mg

Stent-assisted coiling for right MCA Bifurcation aneurysm

• Clot formation after 5 minutes

Was it related to Smoking/Opium use?

• I/A 5mg Abciximab bolus + 7 mg slow injection over 15-20 minutes was given

Our Patient likely had resistance

1. Should we still do FD stent on left side?
2. Wait for a day or two?
3. Choose alternative options or
4. Leave and treat on follow up

Intervention

• We decided to treat with coated flow diverter stent for left MCA bifurcation aneurysm

On Day 7 since ictus

• Patient developed transient right hemiparesis with complete recovery in 10 minutes
• Underwent Urgent CT followed by check DSA to rule out spasm.
• Severe vasospasm on left side.
• Chemical dilatation with I/A Nimodipine 3mg + Milrinone 8mg over 45-50 min done
• Post-dilatation: FD ? Fish mouthing of proximal end causing migration in ICA

• There was minimal spasm on right side.
• Considering clinical status, spasm and small basal ganglia infarct, option for I/A abciximab was deferred.
• Patient was shifted to ICU with IV Milrinone infusion @ 15ml/hr

Next day morning (Day 8)

• Patient developed right hemiparesis with facial involvement and aphasia.
• GCS – E2M5V1, restless, Power on right side UL 1/5 & LL 2/5
• Underwent check angiography / chemical Dilatation

• Severe vasospasm

Day 8 evening: long segment CLOT

• Post dilatation, patient showed partial improvement in motor power.
• No improvement in speech
• GCS E2M5V1,
• Continued with IV Milrinone infusion @15ml/hr.
• Planned to re-asses and do check DSA in the same day evening

• Patient was having persistent clot formation and spasm on LEFT side only.
• Now, we decided to put an overlapping stent from Left M1 MCA to ICA.

• But, not able to cross wire through ICA

• Limited flow through ACOM

• Retrograde transcirculation navigation across Acom artery across FDS and overlapping laser cut stent placement
• Deployed laser cut self-expanding stent 4.0 x 21 mm from M1 MCA to A1 ACA

• On subsequent runs, spasm improved and clot subsided

• In view of resistant angiographic spasm and clinical deterioration, We decided for continuous I/A chemical dilatation in same sitting.
• I/A Nimodipine 80mg + Milrinone 40mg @ 10-12 drops/min was started.
• Started on Abciximab infusion as per body weight and switched to Prasugrel
• Also started Inj. Enoxaparin 0.6 ml S/C OD.
• Post-procedure CT showed no fresh bleed
• GCS after 1 hour – E3M6dullV3

Day 12, morning

• Patient remained clinically stable throughout continuous dilatation.
• Check DSA done on Day 12, morning
• No CLOT

• Patient remained neurologically same with GCS - E3M6dullV3.
• Patient continued on triple therapy. (Ecosprin 150mg+ Prasugrel 10mg – Inj. Enoxaparin 0.6 S/C OD.
• Check DSA done on next day (Day-13) to assess clot/spasm.

Persistent CLOT formation noted

• We gave Inj. Abciximab 5mg bolus + 7mg slow infusion over 15-20 minutes with subsequent clot resolution.
• Also, Chemical dilatation was done for moderate vasospasm.
• Check DSA done on Day 14 to assess clot/spasm, again.

We decided not to intervene as patient was neurologically stable, CT showed infarcted tissue and good angiographic leptomeningeal collaterals

Treatment options re-visited

• Many variables to be considered in our case:
  • Opium-induced resistance /
  • Resistant Vasospasm /
  • Flow-dynamics /
  • Reaction to heal /
• Also, Flow diverter placement in ruptured settings for distal circulation should be considered.
• Cautious while treating OPIUM addicts with anti-platelets/ anticoagulation.