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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 2  |  Page : 209-210

Endovascular treatment of ruptured fusiform middle cerebral artery aneurysm


Department of Neuro Intervention, King Edward Memorial Hospital, Pune - 411 011, India

Date of Submission15-Mar-2013
Date of Decision15-Mar-2013
Date of Acceptance23-Mar-2013
Date of Web Publication29-Apr-2013

Correspondence Address:
Lakshmi Sudha Prasanna Karanam
Department of Neuro Intervention, King Edward Memorial Hospital, Pune - 411 011
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.111166

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How to cite this article:
Alurkar A, Karanam LP, Oak S, Sorte S. Endovascular treatment of ruptured fusiform middle cerebral artery aneurysm. Neurol India 2013;61:209-10

How to cite this URL:
Alurkar A, Karanam LP, Oak S, Sorte S. Endovascular treatment of ruptured fusiform middle cerebral artery aneurysm. Neurol India [serial online] 2013 [cited 2019 Aug 17];61:209-10. Available from: http://www.neurologyindia.com/text.asp?2013/61/2/209/111166


Sir,

Intracranial fusiform aneurysms are rare and account for 3-13% of all intracranial aneurysms and are more common in vertebrobasilar circulation. [1] Fusiform aneurysms of middle cerebral artery (MCA) are still rarer [2] and the management of this entity remains controversial. We report a case of endovascular treatment of ruptured fusiform MCA aneurysm.

A 40-year-old male presented with severe headache and right side focal onset seizures. Computed tomography (CT) scan showed subarachnoid hemorrhage (SAH) and left temporal lobe bleed with surrounding mass effect and edema. CT-angiogram (CTA) revealed a fusiform bi-lobed aneurysm of M1 segment of left MCA [Figure 1]. Digital subtraction angiogram (DSA) confirmed the CTA findings. A 1.5 × 6 mm sprinter balloon was placed proximal to the aneurysm in M1 and balloon occlusion test was done followed by hypotensive challenge test [Figure 2]. Patient tolerated the test occlusion well and good pial collaterals were seen filling the left MCA territory from anterior cerebral artery. Endovascular parent vessel occlusion was done with complete packing of the aneurismal sac and proximal M1 [Figure 3]. Postprocedure, patient developed right hemiparesis and motor aphasia. Dopamine infusion was started to maintain mean arterial pressure >110 mmHg and central venous pressure was maintained at 10-12 cm H 2 O by intravenous fluids. His deficit improved over the next few hours. On discharge, he had right upper limb monoparesis (grade 2). At one month follow-up, power in the upper limb improved to grade 4 with no other deficits.
Figure 1: CT scan showing SAH with left temporal bleed and mass effect (a). MR T1 image showing the hypointense lesion with surrounding edema in the left temporal region (b). CT angiogram showing the left MCA fusiform aneurysm (c)

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Figure 2: Digital subraction angiogram showing the fusiform aneurysm of the left middle cerebral artery (a), Balloon occlusion test with sprinter balloon placed in the M1 (b) and good collaterals seen filling the left MCA territory (c)

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Figure 3: Postprocedure angiogram with complete exclusion of the aneurysm (a) with the coil mass in situ (b). CT scan one day postprocedure showing the infarct in the left lenticulostriate territory (c)

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A defect in the internal elastic lamina with increased hemodynamic stress predisposes to the formation of fusiform aneurysm. These aneurysms have unfavorable geometry limiting the treatment options. Shi et al. treated six fusiform aneurysms with superficial temporal artery-MCA bypass followed by occlusion of the aneurysm. [3] Distal revascualrization with proximal occlusion is the other proposed treatment. [2] Reinforcement or wrapping has also been used in these patients with high risk of complications. [2] Advanced endovascular methods like stent-assisted coiling and placement of neuro-dedicated stent in unruptured fusiform aneurysms has been reported. [4],[5] The presence of SAH and bleed in our patient were the limiting factors for such options and hence we have chosen to occlude the aneurysm sac along with proximal vessel by endovascular technique.

 
  References Top

1.Findlay JM, Hao C, Emery D. Non-atherosclerotic fusiform cerebral aneurysms. Can J Neurol Sci 2002;29:41-8.  Back to cited text no. 1
    
2.Day AL, Gaposchkin CG, Yu CJ, Rivet DJ, Dacey RG Jr. Spontaneous fusiform middle cerebral arteryaneurysm: Characteristics and a proposed mechanism of formation. J Neurosurg 2003;99:228-40.  Back to cited text no. 2
    
3.Shi ZS, Ziegler J, Duckwiler GR, Jahan R, Frazee J, Ausman JI, et al. Management of giant middle cerebral artery aneurysms with incorporated branches: Partial endovascular coiling or combined extracranial-intracranial bypass-a team approach. Neurosurgery 2009;65(6 Suppl):121-9.  Back to cited text no. 3
    
4.Jeong SM, Kang SH, Lee NJ, Lim DJ. Stent-assisted coil embolization for the proximal middle cerebral artery fusiform aneurysm. J Korean Neurosurg Soc 2010;47:406-8.  Back to cited text no. 4
    
5.Pumar JM, Lete I, Pardo MI, Vázquez-Herrero F, Blanco M. LEO stent monotherapy for the endovascular reconstruction of fusiform aneurysms of the middle cerebral artery. AJNR Am J Neuroradiol 2008;29:1775-6.  Back to cited text no. 5
    


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