PMC8769479_01
CT shows a high-density area at the left parietal lobe (A). Enhanced CT shows an enhancing lesion (white arrow) inside the hematoma (B). Three-dimensional rotation angiography shows a saccular aneurysm (white arrow) of the left posterior parietal artery (C). The frontal view of three-dimensional CT shows a left ventricular assist device (asterisk) and a previous implant (white arrow). The left common carotid artery (black arrow) branches directly from the brachiocephalic artery (D).
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F1
Three weeks after admission, asymptomatic intracranial hemorrhage was detected incidentally in the left parietal lobe (Fig. 1A). Enhanced brain CT showed an enhancing lesion inside the hematoma (Fig. 1B). Subsequently, digital subtraction angiography (DSA) was performed and revealed a saccular aneurysm of the left posterior parietal artery, approximately 2.3 mm in diameter (Fig. 1C). An endovascular procedure via the trans-femoral approach was considered difficult owing to the tortuous anatomy of the origin of the innominate artery and implant of the aortic arch after a past thoracic aortic surgery (Fig. 1D).
Lateral view of the left internal carotid artery angiogram and aneurysm (arrow) (A). Extravasation (arrows) after the introduction of the microcatheter (B). Disappearance of the aneurysm and extravasation after N-butyl 2-cyanoacrylate (NBCA) injection (C). Intraoperative craniogram shows NBCA into the aneurysm (arrow) (D).
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F2
TACTICS (Technocrat Corporation, Aichi, Japan) and a DeFrictor Nano catheter (Medico's Hirata, Osaka, Japan) were coaxially inserted, and the microcatheter was introduced into the proximal side of the aneurysm (Fig. 2A). "While introducing the microcatheter, a wire perforation occurred, and DSA revealed an extravasation from the parent vessel proximal to the aneurysm (Fig. 2B). The extravasation was caused by the manipulation of the parent vessel:speculated of having a pathologically fragile wall:with a microguidewire."
Postoperative CT shows a cast of the N-butyl 2-cyanoacrylate and a small amount of subarachnoid hemorrhage.
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F3
However, a small amount of subarachnoid hemorrhage was detected on a post-operative CT scan (Fig. 3).