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Contributor:
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Dr. Krishna Kumar
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Consultants:
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Dr. Chris Ekong
Dr. Christopher Wallace
Dr. R Willinsky
Dr. J Max Findlay
Dr. John Wong
Dr. Mike Tymianski
Dr. Fred Gentili
Dr. Renn Holness
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Age: 64
Sex: Female
History: March 30, 2004. Presented in a coma following SAH due to a ruptured ACA aneurysm. CT showed R intracerebral haemorrhage and SAH. Angiogram showed left ACA aneurysm, and a vertebral artery aneurysm at the junction of the superior cerebellar artery.
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Emergency craniotomy and clipping of the ruptured Left ACA aneurysm was done. Patient has recovered slowly over several months. She is now fully alert, orientated and moves all limbs well.
Now what should we do with the unruptured vertebral artery aneurysm?
- Leave it alone?
- Coil it?
- Clip it?
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Chris:
You are right, images are poor quality. I would repeat, especially now that the situation is more elective. CTA might do it - though often less so in the post fossa due to bone artifact. Gado-enhanced MRA would be used at our institution at times, though we remain partial to 3D angio in cases like this. This does not look like an SCA aneurysm as you have labelled it on the web site. Looks like AICA....
Regardless, it looks nasty, and I'd offer treatment. I won't quote stats from the asymptomatic aneurysm trials, as we have already done so several times on this web site (and anyways, I have enough reservations about these publications to continue to interpret with caution). This thing is large enough, has a bleb on it, and is in a patient that has already bled.
A 3D angio would be most helpful to decide how to treat. Though the aneurysm has a wide neck, it may be coilable as it is a side wall aneurysm that might be treated, especially with stent-assisted coiling. On the other hand, if it's incoprorating AICA, or if there are vascular access issues, I would clip this aneurysm.
Hope this helps.
Best,
Mike Tymianski
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Hi Chris,
Not sure if I am seeing the same images as Mike--looks like an irregular, nasty Vert-pica -rysm.
Better images would help esp. 3-D. -I can be sure if it's coilable on these views. Agree treatment indicated.
Renn
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Hi all,
Would first repeat angiogram with 3D reconstructions to better delineate anatomy. Broad-based aneurysm appears to arise from ectatic mid-basilar segment and is distinct from superior cerebellar artery. (Aneurysm seems too distal for AICA segment but repeat angio will help clarify.) Left vertebral artery component to basilar artery seems small or nil due to lack of contrast washout from left side therefore two microcatheter approach (for balloon neck remodelling) will be difficult. I would coil this aneurysm with micro-stent assistance to protect parent vessel from coil herniation.
John H. Wong
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Chris,
This aneurysm may be at the basilar origin and therefore may be associated
with a basilar fenestration. It could also arise from the basilar itself or be at the origin of AICA. A CTA should be done to demonstrate the anatomy if treatment were to be considered.
I would be cautious regarding any treatment in view of her age and the devastating bleed that resulted in a slow recovery. Co-morbidities and her expected life span should be considered as well as her present ability to tolerate an invasive procedure.
Best regards,
Bob
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Agree with rest: better pics & providing she returns home capable of AsDL look to endovascular treatment as primary for this tough location in a 64 year old.
Max
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Kris/Chris:
I think that Mike and John make good points. I suspect that better imaging will show that this is an aneurysm that can be well treated endovascularly. With a history of prior hemorrhage and an irregular posterior fossa aneurysm, I would favor treatment if her clinical condition justifies it.
Sometimes the more rigid coronary stents can be better for this type of aneurysm than the flexible Neuroform stents are. A slight straightening of the parent vessel with the coronary stent can dramatically alter the flow dynamics and contribute to a more durable occlusion.
regards to all,
Cameron
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Dear Mike, Renn, Max, Bob, John & Cam:
We unanimously requested for better images.
Here they are!
Now what?
Chris
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Thanks Chris,
I gather our patient has made a good recovery? If so, then I would certainly consider treatment, endovascular treatment with a stent/coil combination but I would talk to Cam and John about what types. In my hands, I think the natural history (size-wise, location, shape, history of SAH) is probably still better than the risk/morbidity of a microsurgical approach for this lesion in a 65 year old.
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Hi Chris,
The angiogram shows a sidewall aneurysm from the basilar artery - I can't appreciate on the images any small perforating branch(es) originating from the neck. (There is a contralateral SCA microaneurysm of 1-2 mm.) Although the sidewall aneurysm looks "ugly", I would estimate its size to be only about 5 mm. If the patient has recovered enough to lead a quality life and can participate in the decision process, I would offer her coiling with micro-stent assistance. She would have to know however that I suspect the chance of coil compaction and aneurysm recanalization to be high, given the local flow dynamics of the ectatic basilar artery. If she is significantly impaired, I'd probably leave things alone.
Cheers,
John Wong
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Hi Chris,
In follow-up to this case, the patient underwent elective stent-assisted coiling of her aneurysm last month without any technical or clinical complication, and was discharged home in short order. The 8x5 mm aneurysm fundus seemed well-occluded despite its broad 4.3 mm neck, and we left a small estimated 1-millimeter neck remnant.
The only unanticipated issue was that we had to preoperatively deal with exacerbation of the patient's asthma/COPD, that was induced by her daughter-in-law's cats where she was staying in Calgary! She will require close angiographic follow-up to ensure that the aneurysm does not recanalize. I'm hopeful for a good long-term result. I've attached some images for your perusal.
Regards and thanks,
John Wong
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