Patient Information
• Female, 65Y
Complaint
• Sudden headache with projectile vomiting for 5h+
• The patient had a sudden severe headache with projectile vomiting several times when defecating 5 hours ago, and had no symptoms such as alalia, disturbance of consciousness, convulsion and limb movement disorder
Physical examination
• Normal consciousness, cooperation during physical examination, round and equal pupils, D=3mm, reactive to light, limb muscle strength level 5, low muscular tension, stiff neck, Klinefelter's syndrome positive
Previous history
• Good physical health, no history of hypertension, diabetes, etc.
Pre-operative imaging
CT scan
· Subarachnoid hemorrhage
CTA
· Aneurysm at the origin of right posterior communicating artery
· Persistent left trigeminal artery
Preopreative evaluation
Diagnosis: Rupture of right posterior communicating artery aneurysm with Subarachnoid hemorrhage
· Craniotomy clipping or intracavitary embolization?
· Simple embolization or stent-assisted embolization?
· Stent liberation method?
· Antiplatelet strategy: Preoperative load or tirofiban administered after operation?
Preoperative angiography
DSA:
· “horn-like” aortic arch
· Thin bilateral vertebral artery
· Persistent left trigeminal artery
· Right posterior communicating artery aneurysm
· Small and irregular aneurysm
· Underdeveloped P1 on the right
Tumor radiography:
· Aneurysm size 2.6mm×2.1mm
· Boot-shaped
· Distal vesicle-ruptured aneurysm
· Aneurysm originates from the posterior communicating artery
· Thick posterior communicating artery
· Forming an acute angle with proximal internal carotid
· P1 has no shadow on the right
Treatment decision
• Embolize aneurysm with stent-assisted coil
• Protect posterior communicating artery
• Stent liberation method: Posterior communicating — internal carotid or posterior communicating (fishtailing)
• Antiplatelet strategy: Continuously pump tirofiban after operation, followed by bridging of dual anti-platelet drug
Treatment material
• 6F ENVOY support catheter
Microcatheter: Frepass® TJMC16 (stent) TJMC14 (coil system for embolism)
Guiding wires: Traxcess TM 14
Stent: Enterprise 4.5mm×22mm
Coil system for embolism: Perdenser® coil system for embolism
(2mm×40mm, 2mm×20mm, 1.5mm×20mm, 1.5mm×20mm, 1.5mm×40mm)
Procedure
Place the stent microcatheter:
· The stent microcatheterization is super-selected to the distal end of the posterior cerebral artery through the posterior communicating artery
· Big angle →the stent headend is “J” shaped
· Adopt loop technology
Place the stent microcatheter:
· Shape the microcatheter according to posterior communicating artery aneurysm
Embolize with stent-assisted coil
· Basket coil (2mm×40mm) liberates 2-3 loops
· Slowly liberate the stent
· The stent tail is implanted by “fishtailing” — the tail is whipped to the posterior communicating artery orifice
· Use tirofiban for anti-platelet treatment
· Liberate three coils (2mm×20mm, 1.5mm×20mm and 1.5mm×20mm) in sequence
Aneurysm neck rupture:
· After packing of the last coil, the radiography shows spill-over of contrast agent at the aneurysm neck
· Neutralize heparin and stop taking tirofiban
· Embolize with a 1.5mm×40mm coil at the aneurysm neck
· The final radiography → shows no spill-over of contrast agent
· Dyna CT shows no obvious hematoma and cerebral hernia
· Continue anti-platelet treatment
After Operation
1 d after operation
• The blood is mostly absorbed, only a small amount of residue, no cerebral infarction
5 d after operation
• The blood is completely absorbed, no cerebral infarction
Email Us: