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Ruptured ACA (A1) aneurysm - diagnosis and treatment

Case contributed by Yaïr Glick
Diagnosis certain

Presentation

Syncope with head trauma.

Patient Data

Age: 65 years
Gender: Female

Extensive subarachnoid hemorrhage involving all basal cisterns and the pituitary fossa; right frontal and left frontoparietal sulci, including bilateral frontal parafalcine sulci; bilateral Sylvian cistern and fissure; all four ventricles (small amount); premedullary cistern, foramen of Magendie, and foramina of Luschka.
No fracture.
Right frontal scalp hematoma and periorbital hematoma.

Saccular aneurysm measuring 5.5 mm in length x 5 mm in diameter from the posterior wall of the left A1 at its origin.

Pre-angiography CTA

ct

Magnified 3D reconstructions from a CTA done in preparation for the therapeutic angiography, showing the left A1 aneurysm with a "nipple" at its tip.

Under general anesthesia - puncture of right femoral artery, laying of 6F sheath. Therapeutic catheterization included placement of Envoy MPC leading catheter in the upper cervical left internal carotid artery (LICA). An Eclipse 6x12 mm balloon was placed in the left A1 segment, with the Hyrid 12/14 DA guide lying in the left A2 segment. Placement of Echelon 10 catheter in the aneurysmal sac and introduction of 4 coils: Axium 3d 5 mm x 15 cm; Target 360 Soft 5x10; Target 360 3x6; Target 360 2 x 4 cm; while alternately inflating and deflating the balloon - balloon-assisted coiling. Done under full heparinization. Closure of puncture site with Angioseal 6F.

Case Discussion

Dizziness leading to syncopy, with head trauma. History of Hypertension, obesity, and smoking. On arrival to the ED, she scored 14/15 on the Glasgow Coma Scale (GSC) on account of closed eyes.
Non-contrast CT head showed massive subarachnoid hemorrhage, left convexity sulci more extensive than right. The extent of the hemorrhage could not be attributed solely to the relatively mild trauma and was highly suggestive of a ruptured aneurysm. She returned for a CT angiogram, which pinpointed the aneurysm to the origin of the A1 segment of the left ACA. She was promptly transferred to the neurointerventional suite at a tertiary hospital, where the aneurysm was embolized with coils to a satisfactory occlusion.

Special acknowledgment goes to Dr. Guy Raphaeli, neurologist and interventional neuroradiologist.

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