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Published in May 19, 2023
Right M1 dissecting aneurysm incorporating lenticular arteries
Xiaolong Zhang

Case Review


History


• 53 y/o, male

• Suffered from dizziness accompanied with left superior limb numbness for a month. Local hospital MRA revealed a right M1 segment dissecting aneurysm. 
• Medical history：HTN for 7 years，well controlled. No DM. Lacunar infarction without sequalae.
• Personal history：Smoking for 35 years, 3 packs per day. No drinking.
• NE:(-).


Figure 1. T2 Flair shows scattered small infarctions. 



Figure 2. Multi-model MRI shows a right M1 dissecting aneurysm with partial enhanced aneurysmal wall. 


Video 1. Angiography confirms a right MCA dissecting aneurysm incorporating lenticular arteries (red arrow). 


1

Strategy


SAC (Stent-assisted coiling)-Decrease recurrence rate

• Saddle shaped embolization for neck region reconstruction
• Stent remodeling of the parent artery angle 
Large coil technique-Preserve lenticular arteries arising from the neck region

2

Operation



Figure 3. Measurement. 



Video 2. General heparinization.6F guiding catheter. A Prowler plus microcatheter was advanced to the M2 branch guided by a Synchro-2 microwire. An Echelon-10 microcatheter with a straight tip was navigated to the aneurysmal sac. Microplex-10 4mm*10cm coil was selected for framing which was unsatisfactory. 



Video 3. A Solitaire 4*20mm stent was deployed via the Prowler Plus microcatheter. 


Figure 4 GIF. A successful coil framing was made by the Microplex-10 4mm*10cm after stent deployment. At the same time, the tip of the coiling microcatheter was pushed out of the aneurysmal sac. 



Figure 5 GIF. The tip of the coiling microcatheter was renavigated to the aneurysmal sac guided by a microwire. 



Figure 6 GIF. Six coils were inserted into the aneurysmal sac. Hypersoft 3mm*8cm (1), Hypersoft 1.5mm*4cm (2), Hypersoft 2mm*3cm (1) ,Target 360 2mm*3cm (1), Target 360 2mm*4cm (1). But post-coiling angiography shows thrombosis in the parent artery and suspected hemorrhage.



Figure 7 GIF. Repeated angiography shows no hemorrhage. 



Figure 8 GIF. Dyna CT also confirms no hemorrhage.



Figure 9 GIF. After given Tirofiban 16ml and Nimodipine 1ml via the guiding catheter, the angiography shows complete dissolution of the thrombus and patent lenticular arteries arising from the neck region of the aneurysm. 


3

Post-operation


• No neurologic deficit.

• Medications: Clopidogrel 75mg qd for three months, Aspirin 100mg qd until next follow up, anti-hypertensive medicine.

4

Follow up



Figure 10 GIF. Seven-month follow up angiography shows densely packing of the aneurysm with parent artery patent. 



Figure 11. Compared with span and post treatment angiography, follow up angiography shows the parent artery angle increases from 129.2 degrees to 165.0 degrees. 


4

Summary


• Indications: aneurysm wall enhancement and ischemic symptoms

• Treatment strategy: Stent-assisted coiling with large coil technique for protecting perforators and avoid recurrence (Rivet Coiling).
• Suspicious intra-operative complication: re-performing angiography and Dyna CT should be performed firstly.
• Increased parent artery angle after SAC may contribute to the good outcome. 
• Long-term DSA follow up (2-3 year) was scheduled.


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