Electrocoagulation of a Ruptured A1 Aneurysm

1

Pre-operative

Figure 1A-D. MRA and DSA showed a right parietal lobe AVM fed by right ACA and MCA with multiple flow related aneurysms.

Figure 2. There is also a small irregular aneurysm on right A1 segment(white arrow).

2

Treatment Strategy

1. Embolize the proximal irregular A1 aneurysm.

2. Embolize the aneurysmal dilations inside nidus.

3. The residual nidus could be treated by gamma knife.

3

Operation

PART1

Figure 3A-C. The aneurysm was 1.68x2.42mm(A). The microcatheter tip was advanced to the aneurysm sac after several trials, but the catheter remained unstable due to the tortuous ICA(B). Due to the material shortage, Hypersoft 2mmx3cm was chosen, which was failed to be inserted to the aneurysm(C).

Figure 4. We changed to stent-assisted coiling. After placing the tip of first microcather to the aneurysm sac, the headway was failed to be advanced to the distal part of A1 segment. During the procedure, the tip of first microcatheter punctured the aneurysm wall causing blood leakage.

PART2

Emergency treatment  of Hemorrhagic complication

· Decrease SBP to  <100mmHg

· Dehydration treatment with mannitol and furosemide

· Compress ipsilateral ICA

· Advance a coil to aneurysm sac to block bleeding

· Advance a microwire to aneurysm sac for electrocoagulation

Figure 5A-B. The coil was inserted to the aneurysm sac to block bleeding and the tip of another microwire was advanced to the aneurysm sac for electrocoagulation(A). The coil was retrieved after no more bleeding showed in angiography(B). 

Figure 6 A-C. After pulling the coil to the parent artery, there is still bleeding(A). So the coil reinserted to the parent artery for flow control. The angiography showed the detained contrast agent in aneurysm sac and the thrombus in MCA(B-C).  

Figure 7A. Electrocoagulation was performed several times for blocking bleeding surely. After advancing Hyperform 4x7mm balloon to the parent artery preparing for rebleeding, the previous coil was retrieved.

Figure 8A-B. No aneurysm residue or bleeding(A). The thrombus in right M1 was moved to small distal branches and the collateral circulation was good(B). 

Figure 9A-B. The balloon was retrieved(A). The collateral circulation via Acom was observed(B).

Figure 10. After 20 minutes observation, the angiography showed no remnant of A1 aneurysm and no bleeding. 

Figure 11A-B. The microwire was retrieved slowly(A). After 5 minutes observation, the angiography showed the occlusion of A1 aneurysm and no more thrombus in MCA(B). 

Figure 12A-B. The operation was halted. AVM and MCA aneurysm were left for staged embolization.

4

Postoperative

Figure 13A-C. Immediate post operative CT showed SAH mixed contrast agent.

Figure14 A-C. First-day CT post operation.

5

Summary

· Irregular AVM-flow-related aneurysms should be treated.

· No pre-operative general heparinization in this case prevented the catastrophic hemorrhage.

· High flow of the AVM was difficult to be occluded with thrombus.

· If the bleeding occurred: 

   · neutralized heparin;

   · decreased the systolic pressure;

   · compress the ICA in anterior circulation hemorrhage cases;

· Use the QUICKIEST tool (coil or balloon) to block the blood.

· If repeated trial of stabilize the microcatheter failed, we should change the strategy, otherwise tragedy would occur！

· When an inappropriate coil has stopped hemorrhage temporarily, we should NOT retrieve it immediately, until a backup device (balloon) was navigated adjacent to the aneurysm.

· For the small aneurysm with unstable microcatheter, electrocoagulation + post stenting should be considered as an alternative.