Article Type : Case Report
Authors : Jian-Mei Wang and Xiao-Dong Wang
Keywords : Aneurysm interventional therapy; Polycystic kidney
Aneurysm formation is multifactorial, and
specific risk factors are associated with the incidence and rupture of
aneurysms. The prevalence of aneurysms in people without comorbidities was 2%,
the mean age was 50 years, and 33% were male [1], while several other
literature showed that the risk of aneurysm rupture was 1%-2.3% [2-3]. In addition to common smoking, alcohol
consumption, hypertension, etc. [4-6], autosomal genetic diseases, polycystic
kidney, Ehler-Danlos syndrome, myofibrodysplasia, Finnish and Japanese people,
and female patients are generally at higher risk for aneurysm incidence,
growth, and rupture [7]. Our research group recently admitted a patient with
multiple intracranial aneurysms, and after evaluation, it was considered that
the patient had a high rupture rate, so we adopted endovascular embolization
therapy, that is, the spring coil filled with baskets.
In recent years, the vast majority of cerebral aneurysm
patients have been treated with one of two reconstruction methods: craniotomy
microsurgical occlusion of the tumor bearing artery reconstruction, or
intracapsular treatment, in which the detachable spring coil is placed into the
aneurysm sac to generate thrombus, so that the aneurysm can be excluded from
the intravascular treatment outside the tumor bearing artery circulation.
However, endovascular techniques for the treatment of brain aneurysms offer a
less invasive option than surgical clamping. Coil embolization of aneurysms at
specific sites has fewer complications. In particular, after the Guglielmi
detachable coil (GDC) was approved by the U.S. Food and Drug Administration
(FDA) in 1995, the results of the International aneurysmal Subarachnoid
Hemorrhage Test (ISAT) gave coil a wide acceptance for the treatment of
ruptured and unruptured aneurysms [8-9].
A 67-year-old female patient visited the
cerebrovascular clinic with "headache for 10 days". The patient had
episodic dizziness 10 days ago without obvious inducement, and could improve
after rest. Not accompanied by nausea, vomiting, no limb movement disorders,
blind objects, ptosis. She was admitted to a local hospital 10 days ago. CTA
indicated anterior communicating aneurysm and left internal carotid artery C7
aneurysm, and no special treatment was given in the hospital (Figure 1). In
order to further diagnose and treat the cause of aneurysms, he was treated in
our department, and "intracranial aneurysms" was included in the ward
in the outpatient department. The patient had severe hypertension with a blood
pressure of up to 170/100mHg on oral medication. The physical examination
showed no obvious abnormal signs. However, CTA indicated anterior communicating
aneurysms and left internal carotid artery C7 aneurysm (Figure 1). In order to
further clarify the aneurysm morphology, we completed the evaluation and
performed DSA angiography under local anesthesia. DSA indicated that the left
internal carotid artery C7 segment aneurysm, anterior communicating artery
aneurysm, tortuous vertebral artery (Figure 2). Two days later, after rigorous
adaptation evaluation, we performed "stent-assisted aneurysm embolization
with spring coil". The surgical records are as follows: The anesthesiologist
gave the patient general anesthesia, the patient was supine, the inguinal area
was disinfected, the sheet was laid, left femoral artery puncture was
performed, 8F arterial sheath was implanted, 6F long sheath with 0.035 guide
wire was sent into 5F multifunctional catheter, left internal carotid artery
angiography showed cystic aneurysm at the anterior communicating artery, C7
segment of the internal carotid artery cystic aneurysm (Figure 2).
The anterior communicating aneurysm was a 4×5mm cystic
aneurysm, and the internal carotid artery C7 segment showed a 13×14mm aneurysm
with multiple ascus. 6F intermediate catheter was sent to the left internal
carotid artery petrosal segment, Y valve and double tee were connected,
contrast agent and heparin saline were connected respectively, cerebral
angiography and 3D-DSA were performed, and the working Angle was selected.
Stent-assisted embolization was performed. Guided by a microguide wire
(Synchro200), a SL-10 microcatheter was sent to the A2 segment of the contralatory
anterior cerebral artery and the microguide wire was withdrawn. The Echelon10
microcatheter is sent into the aneurysm cavity under the guidance of the
microguide wire, and the Echelon10 microcatheter is inserted into the 3D spring
ring, which shows that the spring ring is unstable, and the Echelon10
microcatheter is partially released by the Atlas 3.0×21mm stent covering the
tumor neck, and the spring ring is continued to be inserted until the
angiography indicates that the aneurysm has not developed. The Echelon10
microcatheter was withdrawn and routine anterolateral and lateral angiography
was performed, indicating that the aneurysm was no longer visible. The right
internal carotid artery, posterior communicating artery and branch were well
developed, and all major vessels were well developed. A SL-10 microcatheter is sent to the M2 segment
of middle cerebral artery in the left C7 segment assisted by stent
embolization, and then the microguide wire is withdrawn. Echelon 10
microcatheter is sent into the aneurysm cavity under the guidance of the
microguide wire, and Echelon10 microcatheter is placed at 12-40 3D. It can be
seen that the spring ring is unstable. Atlas 4.5×30mm stent is given to cover
the neck of the tumor for semi-release, and the spring ring is continued to be
placed until the aneurysm is not developed. The Echelon10 microcatheter was
withdrawn, and conventional anterior-lateral angiography showed that the
aneurysm was no longer developed, and the main vessels were developed well. The
catheter was pulled out, the femoral artery was sutured, the operation was
successful, the tracheal intubation was pulled out after the operation, the
patient was conscious, able to speak, acted as instructed, and returned to the
ward safely.
Intracranial aneurysm is one of the major public
health problems at present. The annual incidence of subarachnoid hemorrhage
caused by spontaneous aneurysm rupture is high, and about 10% of patients die
before arriving at the hospital, while the main factors affecting the
disability rate and mortality of survivors of primary rupture are the risk of
rebleeding and cerebrovascular spasm [10-11]. Since up to 50% of patients with
subarachnoid hemorrhage eventually die from hemorrhage, it is urgent to develop
a set of scientific bleeding risk assessment methods and active intervention
measures. In terms of patient selection, unless a large number of intracerebral
hematoma or inappropriate geometry are involved, embolization of ruptured
aneurysms should be considered. In this regard, surgical splinting or
endovascular treatment should be decided in a multidisciplinary and
multi-professional collaborative manner. Generally speaking, narrow-neck
aneurysms have more suitable geometric shapes, such as patients with arterio-to-neck
ratio greater than 2 are also suitable for filling with spring rings. These
cases are placed in each loop in the lumen sequentially, and are more likely to
stay in the lumen. In contrast, in a wide-necked aneurysm, the spring loop is
more likely to burst into the vessel. Aneurysms with a neck greater than 4mm or
a body neck ratio less than 2 are considered to have an inappropriate shape. In
addition, the types of aneurysms that are not suitable for embolization include
aneurysms involving branch points in the neck of the tumor, and aneurysms whose
anatomical structure is still not defined by 3D angiography (such as aneurysms
involving bifurcated or tripartite segments of the middle cerebral artery). If
an aneurysm embolization is performed under these conditions, the surgical
consequences can be catastrophic. Fortunately, in this case, embolization can
be performed with auxiliary means such as blood flow reconstruction devices
[12]. In this case, the patient underwent prophylactic surgery for an unruptured
aneurysm. In view of the high incidence of aneurysm rupture, our team carefully
evaluated the results and decided to intervene the patient's aneurysm in
advance to prevent the catastrophic consequences caused by rupture and
bleeding. For unruptured aneurysms, we first administer systemic heparinization
and monitor active coagulation time (ACT) at 250-300s. When the guide catheter
is placed in the appropriate position of the tumor carrier artery, a one-time
mass injection of 3000-5000U heparin is given, and 1000U heparin is
supplemented every hour during the operation. But, for ruptured aneurysms. To
be on the safe side, we usually start the whole body heparinization after the
first spring is inserted in the body. If the aneurysm ruptures during surgery,
protamine or platelets and depressing acetate neutralizing heparin or
antiplatelet agents are given, respectively, and the aneurysm is embolized
until complete occlusion occurs. If thromboembolic events occur, additional
heparinization or transarterial thrombolysis is required.
Intracranial aneurysm embolization was initially only
used for the treatment of aneurysms that were not suitable for surgical
clamping. With the conclusion of doctors all over the world, some convincing
evidence gradually suggested that coil embolization was a safe and effective
treatment method to replace traditional craniotomy clamping for suitable
selected cases, and the application opportunity of this technology was
increasing. Endovascular therapy is a feasible alternative treatment for
ruptured or unruptured aneurysms that are difficult or impossible to be treated
surgically due to their size, shape and location.