Ruptured serpentine ACA aneurysm & parent artery occlusion

Patient presentation

• 31-year-old male patient, manual worker
• suffering from headaches for a few weeks
• sudden loss of vision in the right eye for a week
• MRI revealed an SAH in the anterior interhemispheric region

Diagnostic MRI

CT angio

Next day, early morning

• Seizures
• Poor sensorium, GCS 8/15
• GCS improved (11/15) after giving anti epileptics
• Left hemiplegia noted
• Kept intubated

Repeat CT

DSA

• Extremely poor immigrant patient
• His place of origin is 5 days away by ambulance
• Cannot afford air ambulance
• Government institutes, 7 hours drive
• Lack of intensive care unite beds in government institutes

Parent artery occlusion with coils

• Enter from left ICA, through Acom, go distally, and the coil behind, from A2-A3 junction,
• Adequate coil packing to prevent filling across Acom and retrograde from distal ACA
• Finally, once the bag is coiled, enter the hypoplastic right A1 ACA from right ICA and occlude it

Issue

• Difficulty entering the Acom from the left side
• Even after pumping nimodipine
• Entry of the wire remained impossible
• After several attempts, a balloon was inflated in A2 ACA left side to direct wire into Acom, but it failed too

Change of plan

• Coming from right hypoplastic A1 ACA (3 mg nimodpine in right A1 ACA, no change in caliber)
• Control angio from left side (as expected, when microcath entered the right ACA, aneurysm filling from right side stopped)

It is impossible to navigate further and enter the A2-A3 junction

 

• Started to coil from the distal end of the aneurysm backwards
• Control angios from left side to see Acom filling
• Control angio from ipsilateral ICA to see if there is any filling posterior cerebral collaterals via Pcom)

• Entry into the bag pointing downwards was not successful
• Check angio showed stasis in the bag
• There was no filling from Acom

Right A1 was coiled

• Patient remained intubated for 24 hrs
• Extubated
• Left lower limb power 0/5
• Continued steroids and anti-edema measures
• Hemodynamic augmentation (nimodipine, fluids and IA BP monitoring)

Around day 5

• Developed drowsiness
• For financial reasons, had to be transferred to a public teaching hospital after re-intubation, after discussion with a consultant neurosurgeon

• Craniectomy or EVD not done, nor spasm assessment, for reasons outside the hospital
• Died after 3 days in intensive care in an outside hospital