Transcript Anterior Communicating Arterial Aneurysm

Anterior Communicating
Arterial Aneurysm
Stent-Assisted Coil
Embolization
By Jessica Birt
Patient History
Age-67 years old
 Gender-Male
 Married-Lives independently with his wife
 Symptoms-Progressive memory loss &
personality changes, constant nausea
associated with a bad taste in his mouth &
general unsteadiness of his gait
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(Medical Records)
ECU Visit At the Portland VA
September 9, 2006
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Head MRI was
performed-with and
without contrast
Contrast-Gadolinium
Scans: (Foramen
magnum to the vertex)
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Sagittal T1
Axial T1,T2
Gradient-echo
DWI
Coronal FLAIR
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Post-Gadolinium scans:
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Axial T1
Coronal T1
Sagittal T1
(Report case# 5967)
Findings from MRI 09-09-06
(Report case #5967)
4.2 x 3 x 2.5cm partially enhancing mass in the
right lateral ventricle, which displaced the
septum pellucidum into the left lateral ventricle
Findings cont.
The heterogeneous enhancement had
corresponding signs of hemorrhage on
the gradient-echo
 No signs of hydrocephalus
 Patient was scheduled for surgery for
October 4th 2006 to remove the tumor
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(Report case#5967)
Surgery October 4th 2006
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The patient
 Biopsy Findings:
underwent an
Core biopsy indicated
interhemispheric
a benign low-grade
ependymal
craniotomy and
neoplasm most
transcallosal
consistent with
resection of the
mixed
intraventricular tumor
(Medical Records)
ependymoma/
subependymoma
(Surgical Pathology)
Post-Operative Report
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Post-Op CT scan done
with and w/o contrast
using 2mm axial images
showed successful
removal of the mass
Expected hemorrhage
did occur in region of
surgical bed
Post-op
pneumocephalus
occurred so a
ventriculostomy tube
was placed
(Report case#3382)
Post Operative Report cont.
The patient was left with
attention/memory deficits as well as leftsided neglect and urinary incontinence
after surgery
 After recovery the patient was sent to
rehab before he was discharged
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(Medical Records)
October 6, 2006
Routine f/u CT to r/o hydrocephalus
 5mm axial images through the brain with
and w/o contrast
 Findings showed a decrease in
pneumocephalus
 HOWEVER there was an incidental
finding which was on image 11
(Report case# 4317)
Findings for CT 10-06-2006
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Nodular density slightly anterior to the region
of the third ventricle measuring 6 x 3mm and
was of uncertain significance. Close attention
to this area on follow-up exams was
suggested
(Report case# 4317)
Follow-up exams
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October 8th, 2006-CT performed using
5mm axial images w/o contrast
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Nodular density was seen again
Retrospective reviewing of pre-surgery
MRI taken 10-03-2006 clearly shows that
it was an artery aneurysm
 Findings were discussed and
angiography was the next step
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(Report case# 40)
Arterial Aneurysm
An out pouching (aneurysm) of an artery.
 An aneurysm is a localized widening
(dilatation) of an artery, vein, or the heart
 At the area of an aneurysm, there is
typically a bulge and the wall is
weakened and may rupture
 The word "aneurysm" comes from the
Greek "aneurysma" meaning "a
widening.“
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(MedicineNet.com)
Angiography October 25, 2006
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Surgical catheterization of the right common
femoral artery was accessed using a 19-gauge
open-needle
 A 0.035 Benson guide wire was used along
with a 5-French Davis catheter to reach the
selective arteries within the neck and head
 Findings were as expected: ~7mm smoothly
marginated anterior communicating artery
aneurysm which was rather symmetrically
involving the origins of both the left and right
A2 anterior cerebral arteries and was not
ruptured
(Report case# 3674+)
Anterior Communicating Arterial
Aneurysm
3D image of the
cerebral aneurysmTreatment of aneurysm
with coils was
suggested
(Report case# 3674+)
MRI F/U Post Tumor Resection
December 5, 2006
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MRI Sequence through
brain:
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Sagittal T1
Axial T1
Axial T2
Coronal FLAIR
Post-Gadolinium-Axial
and coronal T1
(Report case# 1834)
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Findings
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Indication of reduction
in size of the right
lateral ventricular mass
status post partial
resection
Aneurysm assessed
again showing same
consistency-Coil
embolization was
suggested again and
patient was scheduled
for coiling December
12, 2006
MRI Post Tumor Resection
Compare to MRI taken 09-09-06
Prognosis after MRI taken
12-05-2006
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Regarding the patients prior craniotomy, the
patient stated he was doing well
 Denied any headaches, nausea, vomiting,
visual changes, or any focal deficits
 Wife states he has problems with short-term
memory and bed wetting
 He is able to ambulate with the help of a cane
and seems to be increasing his level of activity
(Discharge summary)
Back to the Hospital for Coil
Embolization- 12-12-06
Stent assisted coil embolization: 1st time EVER performed at the VA
 Stent goes across the neck of the aneurysm to hold the coils
in place inside the aneurysm
 Tiny little wire coils are inserted into the aneurysm using
angiography until its filled
 Coils block the blood flow to the aneurysm preventing rupture
or growth of aneurysm (Neil- angio tech)
(www.inlandvascular.com)
RISKS
Bursting of the aneurysm
 Infection
 Bleeding
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Procedure-Patient Prep
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Patient was pretreated with Plavix and aspirin
Patient was prepped sterilizing the puncture site and covered in a
sterile drape
The patient was then given a general anesthetic
Once again the doctors used a 19-gauge open needle and a
0.035 Benson guide wire to surgically catheterize the right
common femoral artery
A 6-French Shuttle Sheath was placed over the guide wire into
the thoracic aorta
Placement of a coaxial 6.5 French JB 1 catheter was introduced
with a 0.035 Glidwire, and selective catheterization of arteries in
the neck and head was performed for preliminary diagnostic
cerebral arteriography
AP, lateral, magnified views, and 3D spin pictures were taken to
assess the aneurysm
(Report case# 1588+)
Procedure- Stent
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Coaxial placement of a SL-10 microcatheter with a
Fast Dasher Guide wire
Selective catheterization-ipsilateral A1 arterial
segment through the aneurysm to the contralateral A2
arterial segment
An exchange for a 3mm diameter x 20mm length
Neuroform self-expanding stent was positioned across
the aneurysm neck
After re-catheterization of A1 into the aneurysm using
the same SL-10 microcatheter and Transend Guide
wire the stent was deployed trapping the catheter into
the lumen of the aneurysm
Next came the coils
(Report case# 1588+)
Stent Across Neck of Aneurysm
(www.inlandvascular.com)
Placement of coils
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Multiple GDC bare platinum
coils (a 7mm framing coil
followed by numerous
Ultrasoft 0.010 coils) were
used to fill the aneurysm
The coils were packed
generally tight filling the
aneurysm full enough to
block the blood flow, but not
enough to burst it
The catheters were removed
and f/u arteriography in AP,
lat, magnified, and spin 3D
angiography was performed
(Report case# 1588+)
Pre-Coils
Post-Coils
Post-Coils
Prognosis
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Successful sent-assisted coil embolization of
anterior communicating artery aneurysm
Doctor noted it was an excellent angiographic
result without any complications
No evidence of rupture or prolapse of the coil
into the native parent artery
Procedure was done under fluoroscopy and
room time was ~2.5 hrs
175 cc nonionic contrast was used
(Report case# 1588+)
Discharge Summary
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The patient was transferred to the SICU where
he was observed overnight and received
anticoagulation therapy for 24 hours
 He remained neurologically intact and was
discharged to home on 12-13-06 in stable
condition
 Follow-up angiogram will be performed in six
months to access the coils
(Discharge summary)