Unexpected complication of stent-assisted aneurysm coiling in presence of complex anatomical variation

• 50 y/F.
• No known comorbidities.
• Sudden onset headache and vomiting.
• GCS = 15/15
• Head CT - grade-4 SAH
• Planned for DSA >

RVA AP

Unexpected complication of stent assisted aneurysm coiling in presence of complex anatomical-2

RVA LAT

Unexpected complication of stent assisted aneurysm coiling in presence of complex anatomical-3

LVA  AP

LVA LAT

RCCA  AP /  RCCA  LAT

RICA  AP

RICA  LAT

SIMULTANEOUS RVA AND LICA RUN

AP

LAT

SIMULTANEOUS RVA AND LICA  3D RA

Unexpected complication of stent assisted aneurysm coiling in presence of complex anatomical-10

ANGIO CT REFORMAT

Summary of angiographic findings

• Ruptured wide-necked basilar tip aneurysm.
• Persistent left-sided trigeminal artery joining the left superior cerebellar artery.
• The right ICA is not visible beyond the ophthalmic artery.
• The left ICA is attenuated after the left PTA.
• The right PCoM is hypertrophied and supplies the right anterior circulation.
• The left anterior circulation fills from the right anterior circulation through ACoM.

• BALLOON-ASSISTED COILING
• STENT-ASSISTED COILING
• FLOW DIVERSION
• INTRASACCULAR DEVICES WITH OR WITHOUT ASSISTANCE

WORKING PROJECTION /  LASER CUT STENT DEPLOYED FROM RIGHT P1 TO BASILAR

POST-COILING CHECK ANGIOGRAM

POST-COILING ANGIO CT

POST-COILING SIMULTANEOUS RVA AND LICA RUN

RVA  AP

LICA  AP

FOLLOW-UP

• Patient was extubated in ICU at POD1.
• MAP kept above 100 mm of Hg.
• ON POD2, developed right hemiparesis.
• CT-left MCA infarct.

RVA AP POD 2

LICA AP POD 2

• After one year of follow-up, the patient has minor weakness in the right upper and lower limbs.
• Complete exclusion of the aneurysm.

• After stent-assisted coiling, there is a preferential redirection of flow into the right hemianterior circulation, and a reduction in flow through the ACoM, compromising the left MCA branches.
• Altering natural physiological variation can always be tricky and should be dealt carefully.
• Understand the anatomy is the most crucial part of any neurointerventional procedure.
• Minute findings and detailed angiographic understanding can help in treating and prognosticating patients.