Discussion

I think this is a chronic RICA dissection with a partially calcified old pseudoaneurysm. I'm leaning towards sacrifice of the RICA proximal to the aneurysm using GDC. Our NS doesn't feel that there's a good neurosurgical solution. We would have liked to maximize our chances of success at sacrifice with an STA bypass, but there was no R STA. Although the collaterals don't look all that robust, I would thing they are fairly viable due to the chronic stenosis of the RICA. I don't think stent/coil is viable here due to the anticoagualtion that would be needed in the face of rupture, the short distal landing zone, and the size of the tear in the ICA.  What would you do?

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Follow-Up

Obviously, I decided against carotid sacrifice in favor of partial, protective coiling. I did that mainly because I became unconvinced that the ACOM was robust enough. I suspect that the patient died as a result of diffuse cerebral edema with resulting downward herniation, perhaps exacerbated by hypoxia caused by neurogenic pulmonary edema.

Your Comments

 

For a minute there I thought you were actually going to try to coil that!  I agree that carotid sacrifice is the ideal solution; but this thing (and it does look like a pseudoaneurysm - that is a very unhealthy vessel segment) appears to arise from the segment containing the P-comm or above it.  Hopefully there is enough cross-flow from the A-comm.  Did you try a cross-compression while injecting the left?  I agree something needs to be done since it has bled.  There's really NO STA?  Not even something a graft could be tied into?

I guess I'm not sure why you believe this to be a dissection rather
than just a giant aneurysm.  Why is that?  Is there a history that you
know that would predispose the patient to this?  Does he have
Ehlers-Danlos or Marfan's syndrome?  The short distal landing zone isn't a problem: go out into the MCA if
the neck is really that wide.  When I looked at it, I wasn't sure that
you're dealing with a wide-necked aneurysm.  Since the thing never
seems to fill completely, I am unsure just what the neck does look
like. Bottom line: unless you need to sacrifice the ICA, you might be able to
get away with just coiling the living hell out of it--with or without a
stent to help out.

Very interesting case.  If it was an acute pseudoaneurysm, I would
agree that it likely would be best to just sacrifice the rica.  The
calcification and delayed aneurysm opacification, however, suggests to
me the possibility of satisfactorily repairing the vessel.  I would
probably attempt a staged procedure: initially coiling the aneurysm (it
may require balloon assist), and, later stenting once you feel he is
past any issues related to vasospasm or hydrocephalus, and it is safe
to place him on plavix.  If you end up stenting down the road, I would
probably recommend positioning the distal end of the stent within the
proximal M1 segment.  I don't envision any problem jailing the right A1
in the subacute period with the patient on adequate antiplatelet
coverage. The concern I have about up front ica occlusion,- is that if you want
to preserve collateral support through the rpcom, the aneurysm would need
to be coiled anyway to prevent its filling through the post-occlusion
inflow from the communicating segment.
Of course, if things got out of hand, I wouldn't hesitate to close the
ica.

I think the analysis is sound.  However sacrifice of the ICA with poor
collaterals in the face of impending spasm would not be my first
choice.My recommendation would be to do a high flow bypass from the ICA in the
neck to the MCA

Pretty big!!!!
Looks like no option to sacrifice ICA
.The neck must be smaller then it seems that only from dye pattern flow
Just do your coiling, Neuroform can be very helpfull
Do not wait this baby is primed to pop again!!!!!!!!!
Would love to tango with this one
Let me know



Beautiful example of large aneurysm outlined by SAH.
You call the "neck" the "tear". You may be right but you also may be
prejudicing the etiology just by use of a word. This could all be a
saccular aneurysm. The post communicating is abnormal, yet for me that
might suggest an underlying unusual type of vascular disease, neither
the usual saccular  aneurysm nor a simple dissection. The etiology
doesn't make too much difference though for the treatment now of this
case.It seems like the "jet" into the aneurysm is beyond p-comm and at the
level of anterior choroidal. That is how I would classify this aneurysm
as a very large choroidal. With that brings a risk of hemiplegia (or
hemianopsia) as an outcome if anterior choroidal would be occluded.
For me this would be the treatment:
1) Placement of two detachable #9 Goldvalve balloons
2) I puncture both groins and place 2 guiding caths in the neck ICA.
3) I would place the distal balloon just below ophthalmic, on the idea
that we preserve main branches (here ophthalmic collateral potential
and anterior choroidal) while drastically changing the flow forces that
give the jet and keep this aneurysm enlarging.
4) Your advantage over simple surgical cervical carotid clipping is
that the occlusion test can be done with the awake patient. I do the
occlusion test with the detachable balloons in the desired position --
when  90+% have a negative occlusion test one proceeds to immediate
detachment without deflating the test balloon. The latter always comes
with a risk of thromboembolism to the hemisphere, despite heparin.
5) Understanding about your lack of access to a detachable balloon and
need to use GDC (much slower occlusion), I would wonder about having a
microcatether in place at the desired level for GDC, then placement of
a non-detachable balloon in the neck ICA for occlusion test, so that
following a negative occlusion test you can proceed to place successive
GDCs without blood flowing through and around them, reducing
thromboembolic risk.
6) Since you need to do a treatment now, what to do if there is
anything positive with the test?  There is something disturbing
about it -- we started with 10 minutes then 12 then 15, with the idea
that hemodynamic if real would express it self quickly. We then for
emotional reasons increased to 30 minutes. With a minor drift
encountered at 25 minutes, we deflated and did an angiogram showing
distal outflow delay in a few cases, interpreted as emboli. To me a
late event during occlusion testing is more likely to be
thromboembolism than hemodynamic. I still do 30 minutes but I am
frightened of it.
7)  All-in-all, I agree with your plan to do an ICA occlusion. Some of
my notes above deal with my eternal fear of thromboembolism. Most doing
iCA occlusion do not dance around like I do - they just do a test
occlusion, restore the flow for all, and then occlude with whatever
technique they are using at whatever level. For me, for the 90+% of
negative occlusion test, I do not wish to give them the new risk of a
shower of emboli when the temporary balloon is re-inflated.
Good luck.

Guess I'd consider an attempt at primary coiling +/- balloon assistance. It's hard for me to really get a confident idea about the size of the tear/neck on these pictures. CTA might help define it....Is the PCA really "dysplastic" or just distorted by mass effect? The opacifying aneurysm lumen doesn't lie against the PCA on the AP oblique view, but I'll bet the aneurysm wall presses on it...the intervening zone is occupied by thrombus in the peripheral aneurysm lumen. The obvious choice if not for the bleed would be stent assistance....you could take the stent into the M1 so your landing zone might not be all that short. My prediction is that with time we're going to do more stent-assisted coilings with less concern about Plavix/ASA premedication...especially in difficult situations like this...

Consider test occlusion because intra-aneurysmal coiling could pinch
off the supraclinoid carotid.........are the rt pcom and acom intact???

Is she awake enough to perform  balloon test occlusion? without
anti coagulation(which is also what would happen with coils)
If she failed immediately then the choices may be accept a stroke and
goahead or do a more risky procedure with stent(patient and families
choice)please let me know what you do ?

Well, it appears that you have a plan, best of luck.  I just hope you
have enough coils.I am frequently in the minority with these, but my opinion is shaped by
previously working with Art Day.  This is one I would refer for
surgery, to exclude the aneurysm and perform a high flow bypass.  I know Art has
done a couple of these and they had good results.
However if you don't have an Art Day, coiling may be your only option,
but I believe there will be a high recurrence rate.  This may benefit
from one or two Neuroforms over the neck to further promote healing and
decrease the risk of recannalization.  The neuroform could be done in
2-4 weeks after you have Plavix on board.

Wow. This is an ugly case and high-risk all around. In the face of poor
collateral, taking the ica is risky. I would think surgical exploration
with possible clipping/bypass is the best first step. There is a lot of
mass effect there as well. Her risk of another sah is very high without
treatment. Good luc
k.


i agree it is a difficult management question here. what i will do hopefully it will help:
1- make sure no other aneurysm is around ( right vert injection?)
2- balloon test occlusion with SPECT scan so even if you can not examine the patient well.  you can still assess the brain perfusion during the occlusion of the rica
3- if patient pass with occlusion test i will sacrifice the rica
4- if he did not pass i will put the balloon in the rt ica/rtmca coil 70-80 of aneurysm and come back to finish the coiling few weeks/months down the road.

I'm not sure exactly the best way.  If not ruptured, I
would bag the vessel.  With rupture, maybe attempting to coil it, then
waiting to sacrifice when the pt cools off.

Stent-coil with neuroform.

Our neurosurgeons would probably try to reconstruct the RICA with
clips.Let me know the results.