• CC: Suffering from right blepharoptosis with double vision and headache for 1 month.• NE: Right ptosis and partial paralysis of right superior rectus. Width of palpebral fissure: R: 4mm, L: 6mm. Bilateral eye movement and light reflex normal.Bilateral pupils normal (2mm).• Med history: Left breast cancer; left lung carcinoma in situ. Meningioma in the parietal region. No HTN or DM.Figure 1. High resolution MRI show a large right ICA aneurysm with significant circumferential aneurysm wall enhancement.
Video 1. Angiography confirms a large right cavernous sinus aneurysm.
Figure 2. Underdeveloped left A1 segment.
1. Due to a high rupture risk and mass effect, such a large aneurysm requires treatment. 2. As the left A1 segment was underdeveloped, the dominant right ICA must be spanserved.3. Pipeline was inadvisable in this case because:• Pipeline implantation may still require coiling, which could induce mass effect.
• More than one Pipeline may be needed to control the flow jet.
• Furthermore, Pipeline has a high risk of long term intra-stent stenosis or occlusion.
4. For a large CS aneurysm, stent assisted or simple coiling technique is the spanferred treatment.
Video 2. General heparinization. Prowler Plus and “C” curve Echelon-10 microcatheters were navigated into the sac.
Video 3. 16 coils were deployed sequentially via Prowler-plus.
Figure 4A. MicroPlex-18 20mm*50cm (4), 18mm*44cm (7), 16mm*39cm (3), 11mm*28cm (2) coils.
Figure 4B. MicroPlex-18 20mm*50cm (4), 18mm*44cm (7), 16mm*39cm (3), 11mm*28cm (2) coils. 依次填入弹簧圈 MicroPlex-18 20mm*50cm (4), 18mm*44cm (7), 16mm*39cm (3), 11mm*28cm (2) 。
Figure 5 GIF. Angiography shows parent artery patent and the intact of intracranial vessels.
Figure 6. Inserting MicroPlex-10 10mm*30cm (4) coils via Echelon-10.
Figure 7 GIF. Angiography shows densely packing of the aneurysm with parent artery patent and intact intracranial vessels. Tirofiban 6ml and Nimodipine 1ml were administrated via the guiding catheter.
Post operation complication
• 24 hours later, right eye paralysis aggravated. Severe headache with nausea and vomiting.• PE: Right eye ptosis worsen with impaired adduction. Right pupil enlarged to 3-4mm and had no light reflex.• Medication: Mannitol 250ml q6h, Methylspandnisolone 120mg, 80mg, 40mg (dosage decreasing over three days), Mecobalamin 0.5mg tid• Four days later, the symptoms and signs improved. Still with left right eye pain and ptosis. Discharge was permitted.• PE: left pupil 2mm with normal light reflex, right pupil 3mm with impaired light reflex. Right eye ptosis with restricted abduction.• Medication: Aspirin 100mg qd po.• CC: Improved right eye ptosis.• Med history: Meningioma in the parietal region remained untreated and continue clinical follow up.• Medicine: Aspirin for one month then stopped.• PE: Right blepharoptosis. Width of palpebral fissure: R: 4mm, L: 6mm. Right eye adduction resisted without light reflex. Right pupil:3.5mm, Left pupil:2mm.
Figure 8. Improved right eye ptosis.
Figure 9 GIF. Follow-up angiography shows no relapse of the aneurysm. Next DSA follow up is scheduled in 3 years.
1. Due to a high rupture risk and mass effect, such a large aneurysm requires treatment. 2. With the left A1 segment underdeveloped, spanservation of the right ICA is paramount.3. Pipeline was inadvisable in this case because:• Pipeline implantation may still require coiling, which could induce mass effect.
• More than one Pipeline may be needed to control the flow jet.
• Furthermore, Pipeline has a high risk of long term intra-stent stenosis or occlusion. For a large CS aneurysm, stent assisted coiling or coiling technique is the primary treatment.
4. Prowler Plus, a stiff micro-catheter, was selected to insert large and stiff coils. （18 系）5. Large coiling technique should reduce the recurrence rate, however mass effect may occur.Mass effect caused by large coil technique will be relieved gradually during long-term follow up. 6. Thrombus formation is the main cause of mass effect.7. FD stenting could be used at the second stage if recanalization occurs, though post-operative stenosis is a concern.
