A Big Headache Taken
Successful management of tricky Aneurysm with
A 59-year-old man, non-hypertensive and non-diabetic, visited Nanavati
Super Speciality Hospital with history of severe headache and vomiting
accompanied by spells of unconsciousness. The patient was stabilised
and was then sent for a brain CT scan. The CT scan revealed acute
subarachanoid haemorrhage in the right sylvian fissure. A cerebral
Digital Subtraction Angiography (DSA) was then performed, revealing
a Middle Cerebral Artery (MCA) trifurcation aneurysm (swelling of the
wall of an artery) with a proximal M1 stenosis. The patient was counselled
for an emergent management of aneurysm with Endovascular Coiling.
The major challenges that had to be overcome during this procedure
- Exclusion of the aneurysm, by Endovascular Coiling, and keeping the
3 major distal cortical branches arising from the M2-3
trifurcation patent. Any coil prolapse into these branches would
have led to a major MCA stroke
- A stent placement would be mandatory to achieve desired treatment,
but it was not possible to load the patient with antiplatelets prior
to the procedure as he had already suffered a Subarachnoid
Haemorrhage (SAH) due to the rupture of aneurysm
The state-of-the-art Three Dimensional Rotational Angiography (3DRA)
facility available in Nanavati Super Speciality Hospital reported exact
anatomy of the lesion, and the exact relationship of the MCA branches
with each other, and, with the neck of the aneurysm. It also helped in
choosing the correct size of stent by estimating the length and diameter.
The patient was taken for Endovascular Coiling under general
anaesthesia, via right femoral arterial approach. A balloon catheter
was placed across the neck, and the first successful exclusion of the
aneurysm was achieved with coils.
The patient was then loaded on to the table with dual antiplatelets
(Ecospirin / Brillinta) via ryles tube, which was followed by a
placement of the stent across the desired segment of the MCA branch
so as to cover the neck and keep the branches patent. The final step
was the balloon dilatation of the M1-M2 junction stenosis. The patient
developed vasospasm on day 4 (post SAH sequelae). This was achieved
with an intra-arterial nimodipine infusion.
The patient recovered well and was discharged with modified Rankin
Scale (mRS) 0. At 6 months follow-up, the patient was symptom free
and a check-up of the cerebral angiogram revealed successful exclusion
of aneurysm and normal patency of the M1 segment of MCA.