Case Review
History
• 43-year-old female.
• Present history: Found SAH in 2016 and underwent simple coil embolization of left A2 aneurysm with a daughter sac. Two-year follow up angiography in 2019 showed the aneurysm relapse.
• PE: (-).
Figure 1 GIF. Two-year follow-up angiography shows a post-embolization left A2 bifurcation aneurysm with irregular neck relapse.
1
Treatment strategy
• Re-embolization with stent-assisted coiling.
Figure 2 GIF. 3d-reconstruction.
2
Operation
Figure 3. Measurement.
Figure 4 GIF. 6F Envoy DA. Prowler Plus microcatheter was navigated to the left A3.
Figure 5 GIF. Solitarie 4*20mm was deployed in the parent artery.
Figure 6 GIF. Rotational angiography was performed to find a working projection for coiling.
Figure 7 GIF. A Microplex-10 4mm*10cm coil was inserted for framing. Then general heparinization and Tirofiban (Xinweining) 10ml were administrated.
Figure 8 GIF. One Hypersoft 3mm*8cm coil,one Hypersoft 3mm*4cm coil,one Hypersoft 2mm*6cm coil.
Figure 9 GIF. After inserting a Hypersoft 2mm*4cm coil, the microcatheter tip was pushed out of the aneurysm sac.
Video 1. The microcatheter tip was re-navigated to the aneurysm sac guided by the microwire.
Video 2. One Hypersoft 1mm*3cm coil,one Hypersoft 1mm*2cm coil.
Figure 10 GIF. Post-operative angiography shows intact of intracranial vessels. Tirofiban (Xinweining) 5ml and Nimodipine 1ml were administrated.
Figure 11. Post-operative CT shows contrast medium retention in the left hemisphere.
Figure 12. Post-operative multi-mode high resolution MRI.
3
Post-operation
• No neurologic deficit or peri-operative complication.
• Medication: Aspirin 100mg qd, Clopidogrel 75mg qd (stop after 3 months).
Figure 13. No evident change of the parent artery angle is noted after simple coiling embolization of the aneurysm.
Figure 14. After stent implantation of relapsed aneurysm, the parent artery angle increased immediately, which increased significantly after embolization and during follow up. No evident aneurysm recurrence is noted during follow up. 5 year DSA follow up was scheduled. None medication.
4
Summary
• Simple coiling embolization without parent artery angle remodeling may contribute to aneurysm relapse.
• After stent-assisted coiling of relapsed aneurysm, parent artery angle remodeling by Solitaire stent converted an apical aneurysm to a sidewall aneurysm, reducing the recurrence risk of the relasped aneurysm.