We read with interest the case report presented by Willinsky and terBrugge (1) regarding a technique of using a second microcatheter to treat perforation of a ruptured paraophthalmic aneurysm during initial catheterization. Having had experience with a similar situation during endovascular treatment of a cerebral aneurysm, we felt obliged to report on our procedure with some modification and to contribute to the validation of the simple technique to treat a perforation of a cerebral aneurysm.
A 66-year-old man presented with subarachnoid hemorrhage. Angiography showed a 6 × 5 × 4-mm saccular aneurysm of the basilar-superior cerebellar artery. A Fastracker-10 microcatheter (Boston Scientific/Target) was navigated into the aneurismal lumen through a guiding catheter that was placed into the left vertebral artery. When we were attempting to push the remaining 10-mm length of a second coil after successful placement of a first coil, the microcatheter and coil suddenly moved forward and perforated the dome, with the distal part of the coil extending beyond the aneurysm (Fig 1A). Angiography performed immediately after the event showed no apparent extravasation of contrast material. The microcatheter and coil were left in place, and the heparin treatment was promptly reversed. An antihypertensive agent was intravenously administered because the patient had a history of transient systemic hypertension, and his blood pressure was maintained at 80 mm Hg. We decided to pack the aneurysm with a Guglielmi detachable coil via a second microcatheter to minimize extravasation at withdrawal of the original microcatheter and Guglielmi detachable coil. With the help of a second microcatheter placed through the contralateral vertebral artery, we succeeded in packing the aneurysm without removing the original microcatheter (Fig 1B). Although additional minimal subarachnoid hemorrhage was observed, the patient was discharged in good clinical condition.
Several strategies to manage the life-threatening situation have been suggested (1–5). Prompt recognition of the aneurysmal perforation by using the road-mapping technique, immediate reversal of anticoagulation treatment, reducing the systemic blood pressure, and emergency angiography are essential. Immediate treatment decisions should be guided by the results of emergency angiography, with the material perforating the aneurysmal wall temporarily remaining in place.
If the emergency angiogram reveals extravasation, rapid packing of the aneurysm with Guglielmi detachable coils should be performed (2, 3). If the patient manifests an acute increase in intracranial pressure and persistent systemic hypertension despite rapid embolization of the aneurysm, emergency ventriculostomy may be required (4). If, on the other hand, the emergency angiogram shows no or minimal extravasation, some other methods should be considered. Placement of a bridging coil that prevents extravasation through the hole of the aneurysm may be useful (5). The use of a second microcatheter, as described in our case, may be a valuable technique. Willinsky and terBrugge successfully treated the perforation of a paraophthalmic aneurysm by using a second microcatheter. Several conditions were different between our case and the reported case. Because both the microcatheter and the second coil perforated the aneurysm in our case, the size of the hole might have been larger in our case than in theirs. The location of the aneurysm was also different. For the posterior circulation aneurysm, an approach through the contralateral vertebral artery is necessary because the diameter of the vertebral artery is much smaller than that of the carotid artery. If the aneurysm is located in the posterior circulation, we suggest that angiograms of the bilateral vertebral arteries be obtained before the start of endovascular treatment to identify a route for the possible introduction of a second microcatheter.
Images show perforation of the dome and obliteration of the lumen.
A, Frontal scout view obtained immediately after aneurysmal perforation, shows the original microcatheter with the second Guglielmi detachable coil (arrowheads) extending beyond the aneurysm. The arrow indicates the tip of the microcatheter.
B, Angiogram of the left vertebral artery, obtained after final embolization through the second microcatheter (arrowheads), shows complete obliteration of the aneurysmal lumen.
References
- Copyright © American Society of Neuroradiology