PMC8769466_01
(A) Non-contrast head CT scan demonstrating diffuse subarachnoid hemorrhage predominantly in the left carotid cistern. (B) Three-dimensional CT scan showing an irregular dilatation in the left ACA across the A1-A2 segments (arrow). (C) Digital subtraction angiogram showing the recurrent artery of Heubner originating from the A1-A2 junction (arrow). (D) Digital subtraction angiogram showing enlargement of the A1 segment on postoperative day 8 (arrow). (E) In-stent stenting using LVIS Jr. 3.5 x 23 mm was performed. The proximal end of the stent showed insufficient expansion. (F) Postoperative three-dimensional rotational angiogram showing the enlarged portion (arrow). ACA: anterior cerebral artery, CT: computed tomography.
nmccrj-8-841-g001.jpg
PMC8769466_01_nmccrj-8-841-g001.jpg
F1
A 67-year-old woman presented with severe subarachnoid hemorrhage, World Federation of Neurosurgical Society grade IV, and neuroimaging demonstrated a fusiform dilatation in the left ACA between the A1 and A2 segments (Fig. 1A and B). Endovascular treatment was selected to prevent ischemic complications, particularly involving perforating branches such as the recurrent artery of Heubner originating from the A1-A2 junction (Fig. 1C). The proximal end of the stent was insufficiently expanded, but blood flow showed no problem (Fig. 1D-1F). CTA on day 12 showed further enlargement of the bleb (Fig. 2A and 1B), so the administration of aspirin was discontinued.
(A, B) Digital subtraction angiograms on postoperative day 15 showing additional enlargement of the aneurysm. (C, D) Digital subtraction angiograms on postoperative day 22 showing thrombosis and shrinkage. (E, F) Digital subtraction angiogram on postoperative day 53 showing additional enlargement of the aneurysm. Contrast pooling in the aneurysm was observed. The microcatheter was navigated to the inflow of the aneurysm using the balloon catheter as a counter wall. Two coils were deployed into the aneurysm. (G) Digital subtraction angiograms on postoperative day 63 showing that the thrombosis of the bleb had progressed further, and the distal neck area was partially filled with contrast medium, but the tip of the bleb was not visualized. (H) Axial three-dimensional CT angiogram at 9 months after the final intervention showing thrombosis and shrinkage of the extra-stent component including the bleb (arrow). CT: computed tomography.
nmccrj-8-841-g002.jpg
PMC8769466_01_nmccrj-8-841-g002.jpg
F2
CTA on day 12 showed further enlargement of the bleb (Fig. 2A and 1B), so the administration of aspirin was discontinued. Follow-up angiography on day 22 showed progression of the thrombosis at the extra-stent component including the bleb (Fig. 2C and 2D). Additional coil embolization with the trans-cell approach was performed (Fig. 2E). After careful follow-up, angiography on day 63 showed that thrombosis of the bleb had progressed further, and the distal neck area was partially filled with contrast medium, but the tip of the bleb was not visualized (Fig. 2F and 2G). CTA at 9 months after the final intervention showed thrombosis and shrinkage of the extra-stent component including the bleb (Fig. 2H).
Time course of aneurysm volume changes and antiplatelet drug dosage. Volume on the vertical axis relates to the non-thrombosed portion of the aneurysm. Volume measurement used thin slice data collected by CTA or rotational angiography processed on a workstation (Synapse Vincent; Fujifilm Medical, Tokyo, Japan). The volume was measured by tracing the contrast area outside the stent in the axial plane. CTA: computed tomography angiography.
nmccrj-8-841-g003.jpg
PMC8769466_01_nmccrj-8-841-g003.jpg
F3
The chronological courses of the aneurysm volume and the antiplatelet management are shown in Fig. 3.