PMC8769445_01
(A) Left internal carotid angiogram after 7 days of SAH, 3 years prior, showing the left distal ACA, Acom, and left internal carotid-Pcom aneurysms. (B) Post-embolization of the left distal ACA aneurysm. (C) CTA showing the small intracerebral hematoma including the dome of the distal ACA aneurysm. ACA: anterior cerebral artery, Acom: anterior communicating artery, CTA: computed tomography angiography, Pcom: posterior communicating artery, SAH: subarachnoid hemorrhage.
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F1
Because the small right frontal hematoma involved the aneurysmal dome, the origin of bleeding was confirmed to be the distal ACA aneurysm (Fig. 1).
(A) MRA, 3 years prior. (B) MRA, 6 months prior. (C) Three-dimensional digital subtraction angiogram, 6 months prior. The arrows demonstrate an aneurysmal bleb growing on the wall of the Acom aneurysm. MRA: magnetic resonance angiography.
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F2
SAC was scheduled due to enlargement of the wide-necked Acom aneurysm (Fig. 2), which was noticed around 6 months ago.
(A) Pre-embolization of the Acom aneurysm. (B) Deployment of Enterprise2 VRD and a first coil. (C) In-stent thrombosis and occlusion of the Acom and right ACA following the insertion of the fifth coil. (D) Recanalization of the Acom and right ACA, and extravasation from the Acom aneurysm, following the administration of 480000 U urokinase. (E, F) CT scan following the intravenous administration of protamine sulfate, showing right frontal hematoma draining into the right lateral ventricle. ACA: anterior cerebral artery, VRD: vascular reconstruction device.
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F3
Fremont, CA, USA) were inserted into the aneurysm and the volume embolization ratio was calculated as 27.1%. Following the insertion of the fifth coil, an angiogram revealed in-stent thrombosis and occlusion of the Acom and right ACA (Fig. 3). Acom and right ACA, and it gradually decreased to 135/80 mmHg during the continuous infusion of urokinase. Although the angiogram revealed no recanalization after the infusion of 180000 U urokinase, recanalization of the Acom and right ACA, accompanied by extravasation around the Acom aneurysm (Fig. 3), was observed on completing the administration of 480000 U urokinase. A brain computed tomography (CT) scan revealed a right frontal intra-cerebral hematoma that drained into the lateral ventricles (Figs. 3E and 3F).
(A, B) Left internal carotid angiogram after 1 year, showing the complete obliteration of the Acom aneurysm and no in-stent stenosis along the left A1 and right A2 segments. The left internal carotid-Pcom aneurysm was also treated using SAC. SAC: stent-assisted coiling.
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F4
An angiogram after 1 year of endovascular treatment (Fig. 4) confirmed the complete occlusion of the Acom aneurysm and good recanalization of the Acom and right ACA without any in-stent stenosis.